Faculty Bibliography

BACKGROUND/UNASSIGNED:Re-recurrent rectal cancer (RRRC) represents a highly complex disease following curative-intent treatment of recurrent rectal cancer (RRC). While management principles for primary and locally recurrent rectal cancer (RRC) have been defined by expert collaborations, no specific guidelines currently outline the perioperative management of RRRC. This systematic review aimed to appraise the reported perioperative strategies and oncological outcomes of patients undergoing curative-intent treatment for RRRC. METHODS/UNASSIGNED:Eligibility criteria, Studies reporting perioperative management and outcomes of adult patients undergoing curative-intent treatment for RRRC were included. Non-English articles, letters, abstracts, and studies lacking surgical or oncological data were excluded. Information sources, The review was conducted according to PRISMA guidelines and registered in PROSPERO (CRD420251244390). MEDLINE (PubMed), Cochrane Library, Web of Science, and Scopus were searched for relevant articles. Risk of bias, Methodological quality was assessed using the Newcastle-Ottawa Scale for cohort studies. Synthesis of results, Given heterogeneity in treatment strategies and outcome reporting, results were synthesized narratively. RESULTS/UNASSIGNED:Included studies, Three retrospective cohort studies comprising 169 patients treated with curative intent surgery for RRRC were included. Synthesis of results, Neoadjuvant therapy was administered in 20-92% of included patients, depending on the previous cumulative radiation dose. Pelvic exenteration was frequently required, with total exenteration performed in 6-20% and sacrectomy in up to 15% of cases; reconstructive procedures were reported in less than 16%. IORT was used in 44-77% of patients in centers where it was available. R0 resection rates ranged from 33% to 62%, with oncological outcomes directly associated with margin status. DISCUSSION/UNASSIGNED:Limitations of evidence, Evidence was limited to retrospective observational studies with small sample sizes, heterogeneous management, and varied institutional resources, precluding meta-analysis. Interpretation, Curative-intent surgery for RRRC is feasible in highly selected patients, with R0 being the principal prognostic determinant of oncological outcome. However, significant variability in perioperative pathways, margin definition, MRI-based classification, and reconstructive strategies underlines the necessity for the development of standardized, consensus-based recommendations to optimize multidisciplinary treatment. SYSTEMATIC REVIEW REGISTRATION/UNASSIGNED:https://www.crd.york.ac.uk/PROSPERO/view/CRD420251244390, identifier CRD420251244390.

BACKGROUND:Minimally invasive surgical techniques have improved outcomes in colorectal surgery, but comparative data on their use in total abdominal colectomy with end ileostomy for inflammatory bowel disease remain limited. This study aimed to compare postoperative outcomes among patients undergoing robotic, laparoscopic, or open total abdominal colectomy for inflammatory bowel disease. METHODS:We performed a retrospective cohort analysis using propensity score matching to control for baseline differences across patients. Data were obtained from the 2022 American College of Surgeons National Surgical Quality Improvement Program, a national surgical outcomes registry. Adult patients who underwent total abdominal colectomy with end ileostomy for ulcerative colitis or Crohn's disease were included. Patients were treated with robotic-assisted, laparoscopic, or open total abdominal colectomy with end ileostomy. The primary outcome was any postoperative complication within 30 days of surgery. Secondary outcomes included operative time, conversion to open surgery, length of hospital stay, 30-day readmission, and other specific postoperative complications such as surgical site infection and renal insufficiency. RESULTS:A total of 581 matched patients were analyzed, including 83 robotic, 415 laparoscopic, and 83 open cases. There were no significant differences in overall 30-day morbidity across groups. Robotic surgery had significantly longer operative time than laparoscopic but not open surgery. Organ space infections and renal complications were more common in the robotic group compared with laparoscopic. Although robotic surgery was associated with shorter hospital stay, it also had the highest 30-day readmission rate. CONCLUSIONS:Robotic total abdominal colectomy demonstrated similar overall morbidity and conversion rates compared with other approaches but was associated with longer operative time, increased complications, and higher readmissions. Further refinement of perioperative protocols and patient selection may improve outcomes.

OBJECTIVE:Management of locally invasive colorectal carcinoma at any stage currently involves surgical excision followed by chemoradiotherapy; however, the prognosis is poor, with a 5-year overall survival (OS) of only 5%. Failure to achieve gross-total resection is associated with poorer OS, and patients with residual tumor postresection (R1 or R2 resection) have a median OS of 7 months compared with 23 months in those who undergo resection with negative margins (R0 resection). For tumors that have invaded the sacrum, sacrectomy becomes necessary to achieve R0 resection. The objective of this study was to provide a descriptive multicenter account of resection for locally invasive colorectal carcinoma with sacral invasion, focusing on the association of tumor morphometry with surgical planning and perioperative outcomes. METHODS:Demographic, comorbidity, clinical, tumor-specific, operative characteristic, and outcome data were collected on all patients who underwent resection of colorectal carcinoma with concurrent sacral resection between January 2005 and May 2022. Patients were grouped into those having undergone surgery for purely palliative intent, or those with resection with attempt at local control and dichotomized into level of osteotomy (either proximal or distal to the S2-3 level). RESULTS:Twenty-two patients (median age 50.5 [IQR 43.3-60.0] years, 54.5% female) underwent sacrectomy for colorectal carcinoma. Operative records indicated intent for local control in 14 patients and palliative in the remaining 8 patients. Palliative surgical intent was based primarily on the presence of distant metastases. There was no significant difference in median local progression-free survival between patients undergoing osteotomy proximal to the S2-3 level and those undergoing osteotomy distal to the S2-3 level. CONCLUSIONS:En bloc resection is believed to offer the best local control in patients with locally invasive colorectal carcinoma. The present descriptive series highlights outcomes of en bloc resection with partial or full sacrectomy in patients with tumors showing local extension into the sacrum. Complications are common, most often in the form of wound dehiscence or infection, and many patients require placement in a rehabilitation or intermediate-care facility upon discharge. However, for those with stage III (locally aggressive) disease, median OS exceeds 16 years, suggesting that such aggressive management with en bloc resection may be warranted in properly selected patients.

The use of a closed staple height of less than 3.5 mm in right colon resections remains poorly defined, with limited comparative data against the traditionally used 3.5 mm staplers. To compare rates of anastomotic bleeding and other complications between two staple heights (2.5 mm, white cartridge versus 3.5 mm, blue cartridge) used for intracorporeal isoperistaltic ileocolic anastomosis in robotic right hemicolectomies. This is a retrospective study. The investigation is based on data from a tertiary care center. All patients who underwent a robotic right hemicolectomy or robotic extended right hemicolectomy with an intracorporeal isoperistaltic ileocolic anastomosis for dysplasia or cancer from August 2018 to February 2024. The primary outcome was the anastomotic bleeding rate. A total of 120 patients were included of which 64 patients (53.3%) were female. Group 1 comprised of 52 patients (43.3%) in whom white cartridges were used for ileocolic anastomosis, and group 2 had 68 patients (56.6%) for whom a blue cartridge was used either for the resection of the colon, creation of the anastomosis, or both. A total of 14 patients (11.6%) had anastomotic bleeding. This was managed conservatively with hemodynamic monitoring and blood transfusions in 13 patients (93%), and one patient required a lower endoscopy. The incidence of anastomotic bleeding was almost twice as high in group 2 at 14.7% compared to only 7.6% in group 1 (p = 0.23). No anastomotic leaks were observed in this study. The retrospective nature of the study and inclusion of a single specialized center. The use of staplers with reduced staple height while performing robotic right colon resections may reduce the incidence of bleeding complications without an increase in rates of other complications. Further investigation with large-scale and randomized patient populations is warranted to validate these findings.

BACKGROUND AND OBJECTIVES/OBJECTIVE:Little is known about the relationship between neoadjuvant chemotherapy (NAC) and perioperative morbidity for patients undergoing combined resection of rectal cancer and sLM. The purpose of this study is to determine the impact of NAC on 30-day morbidity for patients who undergo combined resection of primary rectal cancer and sLM. MATERIALS AND METHODS/METHODS:A retrospective cohort study of patients undergoing combined resection of primary rectal cancer and sLM between 2016 and 2020 at participating NSQIP hospitals. Multivariate logistic regression models were used to assess the relationship between NAC and 30-day morbidity rates. RESULTS:Among 878 patients who underwent combined resection of primary rectal cancer and sLM, 672 (76.54%) received NAC. There were no significant differences in the rates of 30-day overall morbidity between patients who received NAC and those who did not (37.65% vs. 37.68%, p = 0.95). On adjusted analysis, there was no association between receipt of NAC and rates of overall morbidity (adjusted OR = 1.10, 95% CI 0.78-1.56, p = 0.95). CONCLUSIONS:The receipt of NAC does not appear to be associated with increased perioperative morbidity in patients undergoing combined resection of primary rectal cancer and sLM.

BACKGROUND:The decriminalization of cannabis across the United States has led to an increased number of patients reporting cannabis use prior to surgery. However, it is unknown whether preoperative cannabis use disorder (CUD) increases the risk of postoperative complications among adult colectomy patients. METHODS:Adult patients undergoing an elective colectomy were retrospectively analyzed from the National Inpatient Sample database (2004-2018). To control for potential confounders, patients with CUD, defined using ICD-9/10 codes, were propensity score matched to patients without CUD in a 1:1 ratio. The association between preoperative CUD and composite morbidity, the primary outcome of interest, was assessed. Subgroup analyses were performed after stratification by age (≥50 years). RESULTS:Among 432,018 adult colectomy patients, 816 (0.19%) reported preoperative CUD. The prevalence of CUD increased nearly three-fold during the study period from 0.8/1000 patients in 2004 to 2.0/1000 patients in 2018 (P-trend<0.001). After propensity score matching, patients with CUD exhibited similar rates of composite morbidity (140 of 816; 17.2%) as those without CUD (151 of 816; 18.5%) (p = 0.477). Patients with CUD also had similar anastomotic leak rates (CUD: 5.64% vs. No CUD: 6.25%; p = 0.601), hospital lengths of stay (CUD: 5 days, IQR 4-7 vs. No CUD: 5 days, IQR 4-7) (p = 0.415), and hospital charges as those without CUD. Similar findings were seen among patients aged ≥50 years in the subgroup analysis. CONCLUSIONS:Though the prevalence of CUD has increased drastically over the past 15 years, preoperative CUD was not associated with an increased risk of composite morbidity among adult patients undergoing an elective colectomy.

BACKGROUND/UNASSIGNED:Total neoadjuvant therapy (TNT) is an accepted approach for the management of locally advanced rectal cancer (LARC) and is associated with a decreased risk of development of metastatic disease compared to standard neoadjuvant therapy. However, questions remain regarding surgical outcomes and local control in patients who proceed to surgery, particularly when radiation is given first in the neoadjuvant sequence. We report on our institution's experience with patients who underwent short-course radiation therapy, consolidation chemotherapy, and surgery. METHODS/UNASSIGNED:We retrospectively reviewed surgical specimen outcomes, postoperative complications, and local/pelvic control in a large cohort of patients with LARC who underwent neoadjuvant therapy incorporating upfront short-course radiation therapy followed by consolidation chemotherapy. RESULTS/UNASSIGNED:In our cohort of 83 patients who proceeded to surgery, a complete/near-complete mesorectal specimen was achieved in 90 % of patients. This outcome was not associated with the time interval from completion of radiation to surgery. Postoperative complications were acceptably low. Local control at two years was 93.4 % for all patients- 97.6 % for those with low-risk disease and 90.4 % for high-risk disease. CONCLUSION/UNASSIGNED:Upfront short-course radiation therapy and consolidation chemotherapy is an effective treatment course. Extended interval from completion of short-course radiation therapy did not impact surgical specimen quality.