Colorectal cancer occurs in a significant portion of patients with hereditary cancer syndromes, including Lynch syndrome (LS), familial adenomatous polyposis (FAP), Peutz-Jeghers syndrome (PJS), and PTEN hamartoma tumor syndrome (PHTS). Given that endoscopic surveillance and treatment alone does not fully prevent CRC in these patients, chemoprevention strategies have been increasingly investigated as adjuncts to endoscopic and surgical management. The most extensively studied agents include aspirin and other non-steroidal anti-inflammatory drugs (NSAIDs), which primarily act through inhibition of cyclooxygenase enzymes. Multiple trials have investigated these drugs in LS and FAP. Emerging strategies include immune checkpoint inhibitors and neoantigen peptide vaccines, which exploit the highly immunogenic tumors in LS, as well as mTOR inhibitors for PJS and PHTS, though human trial data for these medications remain limited. This review summarizes evidence for chemoprevention across hereditary cancer syndromes, highlighting key trials, both published and ongoing.
While familial adenomatous polyposis is one of the most widely recognized adenomatous polyposis syndromes, there are several less common polyposis syndromes that healthcare providers may encounter in practice. We review the epidemiology, pathogenesis, cancer risk and clinical management for serrated polyposis syndrome, MUTYH-associated polyposis, colonic oligopolyposis of unknown etiology, in addition to emerging polyposis syndromes such as polymerase proofreading-associated polyposis, NTHL1-associated polyposis, MSH3-associated polyposis, and GREM1-associated polyposis.
Identification of hereditary colorectal cancer (CRC) predisposition prompts important healthcare considerations for affected individuals and at-risk relatives. Approximately 5–10% of CRC cases are attributable to known hereditary syndromes, with higher prevalence among early-onset cases. Lynch syndrome remains the most common cause, while adenomatous and hamartomatous polyposis syndromes account for additional sources of hereditary CRC risk. Given overlapping phenotypes across syndromes, multi-gene panel testing (MGPT) is essential to establish accurate molecular diagnoses and guide risk stratification, surveillance, and risk-reduction strategies. This narrative review summarizes hereditary CRC and polyposis syndromes, current and emerging strategies for genetic testing, and evolving models of care delivery. Indications for genetic evaluation are outlined based on personal and family history, tumor molecular features, and polyp burden, along with consideration of universal genetic testing in CRC. Emerging diagnostic approaches, such as RNA analysis, assessment of constitutional MLH1 hypermethylation, and evaluation for mosaicism, are introduced as potential options for improved diagnostic yield in patients with unexplained but suggestive clinical presentations. Interpretation of genetic test results is discussed with emphasis on the substantive impact of cascade testing in relatives. Finally, alternative genetic service delivery models, including point-of-care and mainstreaming approaches, are introduced as potential means of enhancing access and scalability of cancer genetics services.
For patients with rectal cancer, neoadjuvant radiotherapy combined with total mesorectal excision surgery has revolutionized treatment, leading to significant improvement in local recurrence and survival. However, functional outcomes (i.e. gastrointestinal, sexual, genitourinary) are compromised by this treatment combination in many patients. Further, pelvic radiotherapy is an important option in patients with rectal cancer recurrence, prostate and gynecologic cancers and is unavailable if used as first line treatment in rectal cancer. As such, emerging use of neoadjuvant chemotherapy demonstrates promise in rectal cancer downstaging and recurrence prevention. In this paper, we will summarize the current evidence supporting radiation sparing strategies in multimodal treatment regimens for patients with rectal cancer.
Ileus is a prevalent and perplexing surgical phenomenon that adds to patient morbidity and hospital length of stay and cost. While many have studied this process, the underlying cause remains elusive, but risk factors have been identified. Additionally, enhanced recovery pathways have been developed to mitigate surgical risk in ileus development. This review will define ileus, and its impact as well discuss potential causes and treatment strategies that have been evaluated.
Perineal hernias are an uncommon but clinically significant condition faced by the colorectal surgeon, commonly as a complication following abdominoperineal resection or pelvic exenteration. Clinical presentation varies based on hernia size and contents, often involving gastrointestinal or urinary symptoms. Diagnosis primarily relies on clinical examination and cross-sectional imaging, with computed tomography as the preferred modality in acute settings. Although rare, perineal hernias can result in serious complications, including enterocutaneous fistulas, bowel obstruction, and herniation of pelvic organs. Management requires an individualized surgical approach based on defect size, hernia contents, and patient factors. Abdominal approaches, particularly open approaches, tend to offer lower recurrence rates compared to perineal repairs but are associated with longer recovery times. Mesh reinforcement is generally preferred for large defects, while flap reconstruction remains crucial for radiated or complex surgical fields. Despite advances in technique, recurrence remains a challenge, particularly following primary suture repairs. Reconstructions with synthetic mesh via abdominal or perineal approaches, with or without flaps, may provide the best outcomes.
Postoperative adrenal insufficiency (PAI) leading to refractory hypotension and resultant circulatory collapse is a rare but potentially devastating complication. In this review, we aim to describe the phenomenon of postoperative adrenal insufficiency, clarify approaches to management, and summarize current literature that informs management of perioperative steroids in the colorectal surgery patient population.
Post-operative venous thromboembolism is a significant source of morbidity, mortality, and healthcare cost in patients undergoing colon and rectal surgery. Patients with colorectal disease are particularly vulnerable to venous thromboembolism formation due to the proinflammatory nature of their conditions and subsequent operative trauma. Tailored thromboprophylaxis strategies according to individualized risk assessments as well as use of evidence-based guidelines for venous thromboembolism treatment are essential in minimizing ongoing complications and avoiding post-operative bleeding. This review summarizes current prevention and management guidelines as well as future directions for improving postoperative venous thromboembolism related outcomes in colorectal surgery patients.
Nonhealing perineal wounds remain a significant challenge following abdominoperineal resection (APR) for rectal cancer and other pelvic malignancies. Despite advancements in surgical techniques, wound complication rates remain high, particularly in the context of neoadjuvant chemoradiotherapy and extensive pelvic dissection. This review examines the natural history of perineal wound healing, evaluates closure strategies including primary closure, flap reconstruction, and adjuncts such as omental pedicle flaps, and explores advanced and emerging therapies including hyperbaric oxygen, negative pressure wound therapy, and regenerative medicine. By synthesizing the current literature and highlighting risk factors for poor healing, we provide an evidence-based guide to optimizing outcomes in this complex and often debilitating complication.
Ileus is a prevalent and perplexing surgical phenomenon that adds to patient morbidity and hospital length of stay and cost. While many have studied this process, the underlying cause remains elusive, but risk factors have been identified. Additionally, enhanced recovery pathways have been developed to mitigate surgical risk in ileus development. This review will define ileus, and its impact as well discuss potential causes and treatment strategies that have been evaluated.
Colorectal cancer (CRC) in younger adults poses unique challenges in multiple quality of life domains. There are numerous potential downstream effects of CRC treatments (surgery, chemotherapy, and radiation therapy) that may be felt more deeply by younger patients, not just in physical symptoms but also in emotional, psychological, and social aspects of their lives. Many of these domains overlap, and the effects are difficult to quantify, but healthcare providers need to be aware of the consequences that CRC diagnosis and its treatment can have on younger adults. Herein, we review the quality of life and psychosocial concerns related to young-onset CRC spanning from perceived physical symptoms to stressors in finances, occupation, interpersonal relationships, and fear of cancer recurrence.
Introduction Despite the general decline in rectal cancer diagnoses, early onset rectal cancer (EORC) diagnoses are increasing. Meanwhile, Watch and Wait (WW) surveillance for patients with complete clinical response to neoadjuvant therapy is gaining popularity. While outcomes for WW are good, there may be hesitancy enrolling younger patients. This review aimed to evaluate literature examining WW in EORC patients. Methods A systematic literature review was conducted and full-text, peer-reviewed manuscripts were assessed for eligibility. A single study, “Watch and Wait After a Clinical Complete Response in Rectal Cancer Patients Younger than 50 Years,” by Bahadoer et al. (2021) was identified. Results The study included 199 EORC patients followed for a mean of 3.2 years. Compared to older patients, EORC patients had higher overall survival, and similar rates of disease-free survival and local recurrence. Discussion The results of the identified study are encouraging, however, there is a paucity of data on WW in EORC patients, including not only clinical outcomes but surveillance compliance and barriers that might inform treatment decision-making. Decisions regarding WW in EORC patients should be made on an individual case after thorough discussion with patients.
The incidence of young-onset colorectal cancer (YOCRC) is rising. This patient population often presents with advanced disease and is treated more aggressively, raising unique challenges—particularly regarding fertility and sexual function. This chapter explores the multifaceted impact of YOCRC treatment on fertility and the importance of early reproductive counseling. YOCRC patients frequently undergo multimodal therapy, including chemotherapy, radiation, and surgery—all of which can impair fertility. Chemotherapeutic agents like oxaliplatin and irinotecan are known to be gonadotoxic, with variable long-term effects in both men and women. Pelvic radiation carries high risks for both gonadal failure and uterine or testicular dysfunction. Surgical interventions can damage reproductive organs or alter anatomical and hormonal function, leading to infertility. Fertility preservation methods—including sperm or oocyte cryopreservation, embryo freezing, ovarian transposition, and tissue cryopreservation—offer patients the possibility of future biological parenthood but require early intervention. Additionally, sexual dysfunction is common, driven by nerve damage, radiation effects, anatomical changes, and psychological distress, all of which may further impair reproductive potential. Given that YOCRC patients are often first evaluated by surgeons, it is critical for providers to discuss fertility and sexual health early and refer patients to reproductive specialists. Improved provider awareness and proactive counseling can help preserve future family-building options and enhance quality of life for this growing patient population.
Surgeons are generally familiar with Current Procedural Terminology (CPT (R)) coding for office and operative care, but have less awareness of billing and risk-adjustment around hospitalization and overall costs of care. Hospitals use Diagnosis-Related Groups (DRGs) to designate indications for and complexity of inpatient care. Accountable Care Organizations (ACOs) receive global per capita according to algorithms defined by Hierarchical Condition Categories (HCCs) which estimate individuals' costliness by defined disease states. An understanding of these coding systems and their uses will enable surgeons to properly document the complexity of care they provide patients within rapidly evolving reimbursement and quality assessment programs.
The use of unlisted procedural codes in surgical billing poses risks of under-reimbursement or denial, especially in innovative fields like minimally invasive surgery. These codes are required when procedures lack specific CPT codes, often for new, experimental, or discontinued services. Proper documentation and preparation are crucial to secure reimbursement and reduce risks.Unlisted codes should be compared to reference CPT codes to aid pricing and justification. Detailed documentation must include a description of the procedure, its complexity, necessity, and outcomes. This supports claims and ensures payer collaboration.Reimbursement and RVU negotiations benefit from transparency regarding costs, resource demands, and historical data. Highlighting advanced technologies, specialized teams, or prolonged hospital stays can justify higher rates. For RVU-based models like Medicare, comparing complexity and resource use to reference codes is essential.Preauthorization, appeals, and adherence to payer guidelines remain critical for success, ensuring fair compensation while reflecting the procedure’s true effort and value.
Colon and rectal surgery is commonly performed by both general and colon and rectal surgeons. Guidelines around proper coding and reimbursing can be complicated and difficult to interpret for both surgeons and their coders. The goal of this paper is to review common Current Procedural Terminology (CPT) codes and the proper use of modifiers as they relate to complex open colorectal surgery and multi-disciplinary procedures to facilitate accurate coding.
The use of supplementary codes to adjust primary billing codes that describe surgical services are a source of potential deserved additional revenue. The American Medical Association (AMA) maintains the Current Procedural Technology (CPT (R)) set of codes which include "modifier" codes that are used in addition to primary procedure codes. The Centers for Medicare and Medicaid (CMS) maintains a set of G codes which are part of the Healthcare Common Procedural Coding System (HCPCS). Both sets of codes are complex, extensive and have requirements in appropriate use and documentation, but successful use can improve financial reflection of the full extent of the services provided in colorectal practice. This article explores both CPT (R) modifiers and G codes and provides the reader a summary of the most relevant codes along with their appropriate uses and tips for successful application in practice.
American healthcare policy requires a standard nomenclature(CPT) and valuation process(RUC). We review the makeup of both the CPT panel and advisory panel as well as the processes to create new CPT codes and edit current CPT codes as medical care and technology changes. We describe the RUC panel composition and the processes for determining the valuation of these new or edited CPT codes.
