BACKGROUND:Multi-disciplinary team (MDT) conferences are used within the realm of colorectal surgery for both benign and malignant disease to assist in both diagnostic workup and to guide treatment. Usually, teams encompass colorectal surgery (CRS), gastroenterology (GE), pathology and radiology. Although it is believed that MDT discussion is associated with improved outcomes, there is a scarcity of evidence regarding the benefit or patient selection criteria among patients with inflammatory bowel disease (IBD). Due to advancements in both medical and surgical management in the management of IBD, clinical decision making may be challenging. Our aim is to identify which patients are currently being presented in MDT meetings and to assess compliance with the MDT's recommendations. METHODS:We conducted a retrospective, observational, multiple campus study including all patients with Crohn's Disease (CD) treated within our system during a twelve-month period. Data was collected from a prospective database of MDT patients and retrospective chart review, including demographics, medical and surgical history, disease course and treatment provided. We compared patients presented at MDT to patients without conference review. Outcomes considered included medical versus surgical management. Analysis included chi square and student t-test, with p < 0.05 considered statistically significant. RESULTS:From September 2022 to September 2023, 766 patients were presented to our hospital system for management of CD disease and 52 patients were reviewed at a multi-disciplinary conference for IBD. On comparison of the two groups, those presented at the conferences were on average younger (43.4 vs. 44.9 years; p < 0.05) and had lower body mass index (BMI) compared to those not presented (23.6 vs. 26.1; p < 0.05). There was no difference in gender (p = 0.55) or race distribution between the two groups (p = 0.07). Surgical intervention was more frequent in patients that were presented in MDT meetings (46.2 % vs. 23.2 %; p < 0.05). CONCLUSION:Multi-disciplinary conferences can be used in IBD and CD disease to guide treatment. Our results suggest a tendency to present younger, lower BMI patients for surgical management of CD disease. Further analysis will target the role of this conference in new diagnoses, in the setting of medical refractory disease or those with multiple prior operative interventions, and in patients who require additional consultants outside of gastroenterology and colorectal surgery. Prospective studies are warranted to establish criteria for presentation of CD Disease patients at MDT conferences.

BACKGROUND:Watch-and-wait management (WW) of rectal cancer is accepted for select patients with a complete clinical response (cCR) to neoadjuvant therapy (NAT). The appropriateness of WW for cancers beyond the reach of digital rectal examination (DRE) and/or with a delayed cCR is unclear. METHODS:In this retrospective multicenter study, tumor palpability and clinical response were determined after NAT. Local regrowth-free survival (LRFS), disease-free survival (DFS), rectal organ preservation (OP), and salvage surgery outcomes were assessed. RESULTS:Among 477 patients, 427 (90%) had palpable tumers, with initial cCR in 389 (91%) and delayed cCR in 38 (9%) patients, respectively, whereas 50 (10%) had nonpalpable tumors, with initial pCR in 38 (76%) and delayed pCR in 12 (24%) patients, respectively (p < 0.01). The 3-year LRFS rate was 81.4% (95% confidence interval [CI], 76.6-86.2%) for palpable tumors and 74.3% (95% CI, 61.0-88.6%) for nonpalpable tumors. The DFS rates were 80.8 % (95 % CI, 75.9-85.7%) and 74.3% (95% CI, 61.0-88.6%), respectively. The 3-year rectal OP rate was 82.7% (95% CI, 77.9-87.5%) and 76.0% (95%, CI, 62.9-89.1%), respectively, with no difference in the survival curves for these three outcomes. (all p > 0.05). The patients with initial cCR or delayed cCR also had no differences in LRFS, DFS, or OP, but the interval to each of these outcomes were decreased with delayed cCR (all p < 0.01). CONCLUSION:Watch-and-wait management of rectal tumors beyond the reach of DRE is appropriate, with oncologic and rectal organ preservation rates that do not differ from patients with palpable tumors. In comparison to cancers with initial cCR, cancers with delayed cCR have accelerated intervals to local regrowth, disease recurrence, and rectal organ loss.

AIM:There is increasing adoption of nonoperative management of rectal cancer; however, the extent to which trainees are proficient in nonoperative management is unclear. The aim of this work was to describe the exposure of recent colorectal resident graduates to nonoperative management, their comfort level in assessing clinical responses and their comfort in performing rectal cancer surgeries. METHOD:This was an online survey of Accreditation Council for Graduate Medical Education-certified colorectal surgery residency graduates of training programmes in 2020, 2021 and 2022 utilizing their respective WhatsApp class chat groups. Data on resident comfort in assessing complete or near complete clinical response as part of nonoperative management, adoption in practice and perceived effects on rectal cancer operative experience were collected. RESULTS:Forty five graduates responded, with 83.3% exposed to nonoperative management in training. Eighty five per cent utilize nonoperative management in their own practices and 37.1% felt it had a negative impact on preparing them for rectal cancer surgeries. While 82.4% felt comfortable assessing a complete clinical response, only 61.8% felt comfortable assessing a near complete response. Residents who perceived a positive effect on their training felt more comfortable assessing a complete or near complete response. CONCLUSION:Most recent graduates were exposed to nonoperative management in training and utilize it in practice, although many did not feel comfortable assessing a near complete response. A significant portion felt it had a negative impact on their experience and quantity of rectal cancer surgeries. This suggests a need to improve colorectal resident education in nonoperative management of rectal cancer while simultaneously preserving surgical experience for trainees.

BACKGROUND:The use of a watch-and-wait management strategy after a complete clinical response to neoadjuvant therapy for rectal cancer is increasing. However, insights into implementation, treatments, and outcomes on a national level in the United States are limited. OBJECTIVE:To investigate and report on watch-and-wait management practices and outcomes in the United States. DESIGN:Retrospective study. SETTING:Multicenter. PATIENTS:Patients with stage II or III rectal cancer who underwent intentional watch-and-wait management between January 2015 and August 2022. MAIN OUTCOME MEASURES:Patient and tumor characteristics, neoadjuvant treatment and response, local cancer regrowth and metastasis, salvage surgery, overall survival, and disease-specific survival. RESULTS:Among 545 patients from 33 centers, follow-up was 21 months (range, 9-37). Total neoadjuvant therapy or other types of neoadjuvant therapy were used in 395 (72%) and 150 (28%) patients, respectively. The estimated 3-year local regrowth rate was 23.8% (95% CI, 19.1%-29.4%). Patients with local regrowth had higher distant metastases incidence (14.2% vs 3.5%, p < 0.001). Salvage surgery was performed in 74 of 84 patients (88%) with local regrowth and included rectal resection in 66 patients (89%) and local excision in 8 (11%). Of 64 salvage resections with known pathology results, 58 (91%) were margin-negative. Overall, 3-year overall survival was 94.8% (95% CI, 90.5%-97.2%) and 3-year disease-specific survival was 96.2% (95% CI, 91.8%-98.2%). Patients with and without local regrowth exhibited 3-year overall survival of 83.6% (95% CI, 68.4%-91.9%) and 97.7% (95% CI, 93.3%-99.2%), respectively. LIMITATIONS:Retrospective study. CONCLUSIONS:This multicenter study indicates that the watch-and-wait approach for locally advanced rectal cancer is feasible with acceptable outcomes across a variety of geographical regions and practice settings in the United States. Local regrowth and distant metastasis rates were within published norms and salvage surgery proved effective. See Video Abstract . MANEJO DE ESPERA Y OBSERVACIN DEL CNCER RECTAL EXPERIENCIA DE PACIENTES DEL GRUPO DE INVESTIGACIN DEL CNCER RECTAL DE EE UU:ANTECEDENTES:El uso de una estrategia de manejo de observación y espera después de una respuesta clínica completa a la terapia neoadyuvante para el cáncer de recto está aumentando. Sin embargo, los conocimientos sobre la implementación, los tratamientos y los resultados, a nivel nacional de los Estados Unidos, son limitados.OBJETIVO:Investigar e informar sobre las prácticas y los resultados del manejo de observación y espera en los EE. UU.DISEÑO:Estudio retrospectivo.ESCENARIO:Multicéntrico.PACIENTES:Pacientes con cáncer de recto en estadio II o III que se sometieron a un manejo de observación y espera intencional entre enero de 2015 y agosto de 2022.PRINCIPALES MEDIDAS DE RESULTADOS:Características del paciente y del tumor, tratamiento neoadyuvante y respuesta, recrecimiento local del cáncer y metástasis, cirugía de rescate, supervivencia general y específica de la enfermedad.RESULTADOS:Entre 545 pacientes de 33 centros, el seguimiento fue de 21 meses (rango, 9-37). Se utilizó terapia neoadyuvante total u otros tipos de neoadyuvancia en 395 (72%) y 150 (28%) de los pacientes, respectivamente. La tasa estimada de recrecimiento local a 3 años fue del 23,8% (IC del 95%: 19,1-29,4%). Los pacientes con recrecimiento local tuvieron una mayor incidencia de metástasis a distancia (14,2% frente a 3,5%, p < 0,001). Se realizó cirugía de rescate en 74/84 (88%) pacientes con recrecimiento local e incluyó resección rectal en 66 (89%) y escisión local en 8 (11%). De 64 resecciones de rescate con resultados patológicos conocidos, 58 (91%) fueron márgenes negativos. En general, la supervivencia global a los 3 años fue del 94,8 % (IC del 95 %: 90,5-97,2 %) y la supervivencia específica de la enfermedad a los 3 años del 96,2 % (IC del 95 %: 91,8-98,2 %). Los pacientes con y sin recrecimiento local mostraron una supervivencia global a los 3 años del 83,6 % (IC del 95 %: 68,4-91,9 %) y del 97,7 % (IC del 95 %: 93,3-99,2 %), respectivamente.LIMITACIONES:Estudio retrospectivo.CONCLUSIÓN:Este estudio multicéntrico indica que el enfoque de observación y espera para el cáncer rectal localmente avanzado es factible con resultados aceptables en una variedad de regiones geográficas y entornos de práctica en los EE. UU. Las tasas de recrecimiento local y metástasis a distancia estuvieron dentro de las normas publicadas y la cirugía de rescate resultó eficaz. (Traducción-Dr Yolanda Colorado ).

Background:Idiopathic myointimal hyperplasia of the mesenteric veins (IMHMV) is a rare condition that poses a diagnostic challenge to surgeons and pathologists alike. Our aim is to describe two cases of IMHMV requiring operative intervention. The challenge going forward is accurately and systematically identifying factors from both a pathologic and clinical perspective that guide timely diagnosis and avoid unnecessary treatment. Case Description:A 37-year-old male with no significant past medical history was evaluated for a two-month history of abdominal pain, constipation, diarrhea and recent bleeding per rectum. Computed tomography (CT) scan revealed abnormal wall thickening with surrounding inflammatory changes and mesenteric edema involving the descending and sigmoid colon as well as the rectum. The patient was taken to the operating room where he underwent a laparoscopic-assisted extended left colectomy with end colostomy. The patient did well postoperatively and was ultimately meeting all goals for discharge by postoperative day 9. A 49-year-old male with a past medical history of hypertension, gastroesophageal reflux and recent coronavirus disease 2019 (COVID-19) infection was admitted to another hospital following several months of colitis of unknown etiology; unresponsive to antibiotics and steroids. CT scan revealed concentric, severe mural thickening and intramural edema of the distal descending colon extending to the rectum consistent with proctocolitis. The patient was taken to the operating room where he underwent a laparoscopic-assisted low anterior resection with end colostomy with findings of an extremely indurated, thickened left colon and rectum. The patient recovered from these additional interventions and was discharged home in stable condition on postoperative day 32. Conclusions:A multidisciplinary team approach to this condition will be vital to administering the appropriate treatment modalities for future cases of IMHMV.

Neoadjuvant therapy has become standard of care for locally advanced rectal cancer patients. It is correlated with improved clinical and pathological outcomes, including significant tumor downstaging and organ preservation in certain patients. Magnetic resonance imaging (MRI), which has become the standard for pre-operative staging, is also used for clinical and pre-operative restaging following pre-operative treatment. In this meta-analysis, we aimed to evaluate the concordance between restaging MRI (following the completion of neoadjuvant therapy) and postoperative pathology result. We conducted a meta-analysis following the PRISMA 2020 guidelines. Two independent reviewers searched PubMed and Google Scholar for studies reporting restaging MRI results compared to pathological outcomes. Outcomes included tumor and nodal staging, circumferential resection margin (CRM) and pathological complete response (pCR). Out of 25,000 studies found on the initial search; 33 studies were included. The studies were published between 2005 and 2023 and included 4100 patients (57.14

Importance:In March 2023, the National Comprehensive Cancer Network endorsed watch and wait for those with complete clinical response to total neoadjuvant therapy. Neoadjuvant therapy is highly efficacious, so this recommendation may have broad implications, but the current trends in organ preservation in the US are unknown. Objective:To describe organ preservation trends among patients with rectal cancer in the US from 2006 to 2020. Design, Setting, and Participants:This retrospective, observational case series included adults (aged ≥18 years) with rectal adenocarcinoma managed with curative intent from 2006 to 2020 in the National Cancer Database. Exposure:The year of treatment was the primary exposure. The type of therapy was chemotherapy, radiation, or surgery (proctectomy, transanal local excision, no tumor resection). The timing of therapy was classified as neoadjuvant or adjuvant. Main Outcomes and Measures:The primary outcome was the absolute annual proportion of organ preservation after radical treatment, defined as chemotherapy and/or radiation without tumor resection, proctectomy, or transanal local excision. A secondary analysis examined complete pathologic responses among eligible patients. Results:Of the 175 545 patients included, the mean (SD) age was 63 (13) years, 39.7% were female, 17.4% had clinical stage I disease, 24.7% had stage IIA to IIC disease, 32.1% had stage IIIA to IIIC disease, and 25.7% had unknown stage. The absolute annual proportion of organ preservation increased by 9.8 percentage points (from 18.4% in 2006 to 28.2% in 2020; P < .001). From 2006 to 2020, the absolute rate of organ preservation increased by 13.0 percentage points for patients with stage IIA to IIC disease (19.5% to 32.5%), 12.9 percentage points for patients with stage IIIA to IIC disease (16.2% to 29.1%), and 10.1 percentage points for unknown stages (16.5% to 26.6%; all P < .001). Conversely, patients with stage I disease experienced a 6.1-percentage point absolute decline in organ preservation (from 26.4% in 2006 to 20.3% in 2020; P < .001). The annual rate of transanal local excisions decreased for all stages. In the subgroup of 80 607 eligible patients, the proportion of complete pathologic responses increased from 6.5% in 2006 to 18.8% in 2020 (P < .001). Conclusions and Relevance:This case series shows that rectal cancer is increasingly being managed medically, especially among patients whose treatment historically relied on proctectomy. Given the National Comprehensive Cancer Network endorsement of watch and wait, the increasing trends in organ preservation, and the nearly 3-fold increase in complete pathologic responses, international professional societies should urgently develop multidisciplinary core outcome sets and care quality indicators to ensure high-quality rectal cancer research and care delivery accounting for organ preservation.

Center for Colon and Rectal Cancer, Surgical Health Outcomes Consortium, AdventHealth Orlando, Orlando, Florida Supplemental digital content is available for this article. Direct URL citations appear in the printed text, and links to the digital files are provided in the HTML and PDF versions of this article on the journal’s website (www.dcrjournal.com). Funding/Support: None reported. Financial Disclosure: Dr Soliman serves on the Surgeon Advisory Board of Intuitive, is cofounder and CEO of SurgeOn, and is a speaker for ConMed. The patient signed consent for video record. Presented at the Florida Colon and Rectal Surgery Research Meeting, October 15, 2021, and the American Society of Colon and Rectal Surgeons meeting, Tampa, Florida, April 30, 2022. Correspondence: Mark K. Soliman, M.D., AdventHealth Medical Group Colorectal Surgery, Digestive Health and Surgery Institute, Central Florida Division, 2415 N Orange Ave, Suite 102, Orlando FL, 32804. E-mail: [email protected]

Aim: Pelvic exenteration is a radical procedure used to treat locally advanced and/or recurrent pelvic malignancies. Different reconstruction options exist, the most popular being the end colostomy with ileal conduit. The double barrel wet colostomy (DBWC) offers concomitant fecal and urinary diversion through a single stoma, but is infrequently utilized. We aim to review the evidence base of the postoperative complications, long-term oncologic risks and quality of life following creation of a double barrel wet colostomy.Methods: A narrative review of the literature was performed evaluating the DBWC. Patient demographics, perioperative complications, operative variables, long terms oncologic outcomes and quality of life data were extracted. Descriptive statistics were used to define the data.Results: Fourteen articles with a total of 300 patients undergoing DBWC following pelvic exenteration were selected. 41% of malignancies were gastrointestinal in origin while 41.7% were gynecologic and 5.3% genitourinary. 42% of patients experienced at least one complication within in 40 days of surgery, the most common being wound infection (8.7%) and urinary leak (8.3%). There was no evidence of malignancy within the DBWC during long-term surveillance. Quality of life following DBWC is comparable to other reconstructive methods.Conclusion: The DBWC is a well described reconstructive method for urinary and fecal diversion utilizing a single stoma following pelvic exenteration. The short-and long-term outcomes following DBWC are comparable to other reconstructive methods and the quality of life with a DBWC is acceptable. DBWC should remain a readily available option for reconstruction following pelvic exenteration.(c) 2023 Royal College of Surgeons of Edinburgh (Scottish charity number SC005317) and Royal College of Surgeons in Ireland. Published by Elsevier Ltd. All rights reserved.

Background Neuroendocrine tumors of the small intestine are uncommon, but at the same time they are the most frequent subtype of neuroendocrine tumor in the gastrointestinal system. They originate from enterochromaffin cells, which are involved in the creation of serotonin. This asymptomatic characteristic in the initial presentation is usually why these tumors are discovered at a late stage, sometimes in association with symptomatic metastatic disease. Case Description We present a case-report of a 52-year-old gentleman with a suggestive family history of hereditary cancer syndrome (mother with lung cancer and maternal uncle with colon cancer at the age of 40 years old). The patient was diagnosed with rectal cancer and he received neoadjuvant chemotherapy with short-course radiotherapy followed by a robotic low anterior resection with diverting loop ileostomy. Following closure of his ileostomy, the pathology report of the ileostomy resection specimen showed a 1.1 cm neuroendocrine tumor with negative margins. Conclusions This extraordinary unusual presentation could be very fortuity for the patient, who in every other opportunity just found this neuroendocrine tumor after advanced or maybe metastatic diseases.

AIM:The National Accreditation Program for Rectal Cancer (NAPRC) was developed to improve rectal cancer patient outcomes in the United States. The NAPRC consists of a set of process and outcome measures that hospitals must meet in order to be accredited. We aimed to assess the potential of the NAPRC by determining whether achievement of the process measures correlates with improved survival. METHODS:The National Cancer Database was used to identify patients undergoing curative proctectomy for non-metastatic rectal cancer from 2010 to 2014. NAPRC process measures identified in the National Cancer Database included clinical staging completion, treatment starting <60 days from diagnosis, carcinoembryonic antigen level measured prior to treatment, tumour regression grading and margin assessment. RESULTS:There were 48 669 patients identified with a mean age of 62 ± 12.9 years and 61.3% of patients were men. The process measure completed most often was assessment of proximal and distal margins (98.4%) and the measure completed least often was the serum carcinoembryonic antigen level prior to treatment (63.8%). All six process measures were completed in 23.6% of patients. After controlling for age, gender, comorbidities, annual facility resection volume, race and pathological stage, completion of all process measures was associated with a statistically significant mortality decrease (Cox hazard ratio 0.88, 95% CI 0.81-0.94, P < 0.001). CONCLUSION:Participating institutions provided complete datasets for all six process measures in less than a quarter of patients. Compliance with all process measures was associated with a significant mortality reduction. Improved adoption of NAPRC process measures could therefore result in improved survival rates for rectal cancer in the United States.

Development of enterocutaneous fistula (ECF) remains a challenging complication of gastrointestinal surgery and fistulizing disease processes. Successful management of ECF is dependent on timely diagnosis, effective treatment of resulting intra-abdominal sepsis, wound/nutrition management, and supporting the patient though the perioperative optimization period. When approached in multi-disciplinary setting with teams specializing in ECF/intestinal failure, care is optimized and can allow for patients to have greater independence even with complex wounds. While resolution of the ECF remains the overarching goal, a methodical and stepwise approach to management remains paramount both before and after surgical intervention. This chapter outlines ECF management from initial diagnosis to intra-operative decision making after a patient is deemed a candidate for surgery. Further, it highlights patient-specific considerations that can be overlooked in the big picture view of ECF management. While ECF treatment is challenging, the chance to cure a patient of their fistula is a rewarding experience for the patient and ECF/intestinal failure team members alike.

Background Rectal diverticula are a very rare occurrence compared to diverticula of the colon. They are reported to account for only 0.08% of all diverticulosis. Diverticula of the rectum can be caused by congenital or acquired factors. The majority are asymptomatic, diagnosed incidentally, and require no treatment. The low incidence of rectal diverticulosis may be attributed to the unique anatomical structure and physiological environment of the rectum. However, complications can arise and may necessitate surgical or endoscopic treatment. Case Description We report the case of a 72-year-old female with a history of diabetes mellitus, hyperlipidemia, and hypothyroidism who presented to the colorectal surgery clinic with symptoms of constipation of nearly a 50-year duration. The patient underwent an anorectal exam under anesthesia which revealed a 3 cm defect in the left levator muscles with herniated rectal wall. A large left lateral rectal diverticulum was diagnosed during the work-up for pelvic organ prolapse on defecography. She underwent robotic assisted ventral mesh rectopexy and recovered uneventfully. After 1 year of follow-up, the patient is asymptomatic, and the control colonoscopy shows no signs of the rectal diverticulum. Conclusions Rectal diverticula can present in the setting of pelvic organ prolapse and can be safely managed with ventral mesh rectopexy.

BACKGROUND: Multispecialty management should be the preferred approach for the treatment of pelvic floor dysfunction, as there is often multicompartmental prolapse. OBJECTIVE: To assess the safety of combined robotic ventral-mesh rectopexy and either uterine or vaginal fixation for treatment of multicompartmental pelvic organ prolapse at our institution. DESIGN: Retrospective analysis. SETTINGS: Tertiary referral academic center. PATIENTS: All patients who underwent a robotic approach and combined procedure and discussed at a biweekly pelvic floor multidisciplinary team meeting. MAIN OUTCOME MEASURES: Operative time, intraoperative blood loss and complications. Postoperative pelvic organ prolapse quantification score, length of stay, 30-day morbidity, and readmission. RESULTS: From 2018 to 2021, there were 321 operations for patients with multicompartmental prolapse. Mean age was 63.4 years. The predominant pelvic floor dysfunction was rectal prolapse in 170 cases (60%). Pelvic organ prolapse quantification scores were II in 146 patients (53%), III in 121 (44%), and IV in 9 (3%); 315 of the 323 cases included robotic ventral mesh rectopexy (98%). Sacrocolpopexy or sacrohysteropexy was performed in 281 patients (89%). Other procedures included 175 hysterectomies (54%), 104 oophorectomies (32%), 151 sling procedures (47%), 149 posterior repairs (46%), and 138 cystocele repairs (43%). The operative time for ventral mesh rectopexy was 211 minutes and combined pelvic floor reconstruction 266 minutes. Average length of stay was 1.6 days. Eight patients were readmitted within 30 days, 1 with a severe headache and 7 patients with postoperative complications (2.5%): pelvic collection, perirectal collection both requiring radiologic drainage. Four complications required reoperation: epidural abscess, small-bowel obstruction, missed enterotomy requiring resection, and urinary retention requiring sling revision. There were no mortalities. LIMITATIONS: Retrospective single-center study. CONCLUSIONS: A combined robotic approach for multicompartmental pelvic organ prolapse is a safe and viable procedure with a relatively low rate of morbidity and no mortality. This is the highest volume series of combined robotic pelvic floor reconstruction in the literature and demonstrates a low complication rate and short length of stay.

The aim of this meta-analysis is to determine the impact of bariatric surgery on the risk of early-onset colorectal neoplasia. This systematic review was conducted according to PRISMA recommendations. It was registered in the PROSPERO international database. A comprehensive search was conducted in electronic databases (MEDLINE, EMBASE, and Web of Science) for completed studies until May 2022. The Search was made using a mixture of indexed terms and title, abstract and keywords. The search included terms: obese, surgical weight loss intervention, colorectal cancer, and colorectal adenomas. Studies that included bariatric intervention patient’s vs non-surgical obese patients younger than 50 years were considered. Inclusion criteria were patients with BMI more than 35 kg/m2 who underwent a colonoscopy. Studies with follow-up colonoscopy performed in less than 4 years after bariatric surgery and those that evaluated patients with a mean age difference of 5 or more years between groups were excluded. Outcomes analyzed in obese patients with surgical treatment vs control patients included colorectal cancer incidence. From 2008 to 2021, a total of 1536 records were identified. Five retrospective studies that included 48,916 patients were analyzed. Follow-up period ranged from 5 to 22.2 years. 20,663 (42.24

To discuss the evolution to value-based care in surgery, describe defects in value in rectal cancer treatment, and suggest approaches to improve value.