Diseases of the colon and rectum
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A positive circumferential resection margin has been associated with a high risk of local recurrence and a decrease in survival in patients who have rectal cancer. ⋯ Circumferential resection margin is an important measurement in rectal cancer pathology, but the correlation to local recurrence is much less than previously stated, probably because of oncological treatment and surgery that respects the mesorectal fascia and, when required, en bloc resections. Circumferential resection margin should not be used as a prognostic marker in the modern multidisciplinary management of rectal cancer.
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There are scant data on the presumed reduction of small-bowel obstruction and incisional hernia rates associated with laparoscopic IPAA. ⋯ Some of the anticipated long-term benefits of laparoscopic IPAA could not be demonstrated in this cohort. The lack of such long-term benefits should be discussed with patients when proposing a laparoscopic approach.
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Local excision for early rectal cancer has gained widespread interest. Currently available imaging modalities have low sensitivity to detect locoregional disease, which may result in understaging and a high risk of recurrence after local excision. ⋯ Even in highly selected patients who undergo surgery for local recurrence after transanal excision of early stage rectal cancer, oncologic outcomes are poor.
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Efforts to improve the quality of surgical care and reduce morbidity and mortality have resulted in outcomes reporting at the service and institutional level. Surgeon-specific outcomes are not readily available. ⋯ Each surgeon was identified as a "high outlier" in at least 1 adverse event category. Comparisons at the annual and 5-year points demonstrated poor concordance between our 100% capture institutional data and the National Surgical Quality Improvement Program data.
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High BMI is often used as a proxy for obesity and has been considered a risk factor for the development of an incisional hernia after abdominal surgery. However, BMI does not accurately reflect fat distribution. ⋯ Visceral obesity, history of inguinal hernia, and location of specimen extraction site are significantly associated with the development of an incisional hernia, whereas BMI is poorly associated with hernia development. These findings suggest that a lateral transverse location is the incision site of choice and that new strategies, such as prophylactic mesh placement, should be considered in viscerally obese patients.