Colorectal cancer (CRC) genetics carries important clinical implications for the screening, diagnosis, and management of patients and their families. All CRCs should undergo universal tumor screening, preoperatively whenever possible, to assess for mismatch repair deficiency. Additionally, germline genetic testing plays an integral role in diagnosing polyposis and nonpolyposis hereditary CRC syndromes; therefore, understanding genetic testing criteria is critical to identify patients with these syndromes. Management of patients with hereditary CRC syndromes is complex and requires lifelong surveillance and multidisciplinary care to minimize death from cancer and to maximize quality-of-life preservation.

This quality improvement study explores the clinical outcomes, energy use, and related costs before and after implementation of air quality changes in 55 operating rooms.

Endorobotic submucosal dissection (ERSD) using the da Vinci single-port (SP) platform offers high-definition visualization and enhanced precision for the resection of distal colorectal lesions. In contrast, conventional endoscopic submucosal dissection is technically demanding and associated with a steep learning curve. This study aims to evaluate the efficacy, broader applicability, and long-term outcomes of ERSD in a large patient cohort. We retrospectively analyzed 101 patients who underwent ERSD using the da Vinci SP platform between March 2020 and May 2025. Patient demographics, lesion characteristics, procedural details, pathological findings, and long-term follow-up data were reviewed. The primary objectives were to assess intraoperative and postoperative complications, evaluate the feasibility of en-bloc submucosal dissection, and examine the oncological outcomes associated with the ERSD procedure. The median age of the cohort was 62.5 years (IQR: 52–70 years), with 56.4

Management of complex colonic polyps with benign preoperative biopsy findings remains challenging when endoscopic resection is technically difficult or oncologic risk is uncertain. Combined endoscopic–laparoscopic surgery (CELS) offers an organ-preserving alternative to oncologic colectomy (OC), yet clear criteria for intraoperative decision-making are lacking. This study aimed to identify predictors of conversion from CELS to OC and malignant pathology and to develop an intraoperative risk score to guide escalation. A single-center retrospective cohort study included consecutive patients treated between 2014 and 2024 for complex colonic polyps with benign preoperative biopsy findings using an endoscopy-first strategy requiring laparoscopic assistance. The primary endpoint was conversion to OC. Secondary endpoints included pathologic malignancy and ≥ T2 disease. Clinically relevant preoperative and intraoperative variables were analyzed using Firth penalized logistic regression. Internal validation was performed using bootstrap resampling. A 10-point CELS–OC score was derived and integrated into a stepwise operative algorithm. Seventy patients were included, of whom 25 (35.7

AIM:Literature comparing total proctocolectomy with permanent end ileostomy (TPC-EI) and IPAA in patients with UC is sparse. We aimed to (a) elucidate reasons for non-restorative surgery in ulcerative colitis (UC), (b) describe the incidence of perineal wound complications and (c) assess differences in short-term outcomes between groups. We hypothesized that non-restorative surgery was associated with a higher overall complication rate than ileoanal pouch (IPAA). METHODS:We identified a sample of patients with UC who underwent proctectomy (2005-2023) at our institution. The primary endpoint was the overall 30-day complication rate. Odds ratios (ORs) and 95% confidence intervals are presented. RESULTS:A total of 821 patients were included: 689 (83.9%) IPAA and 132 (16.1%) TPC-EI (80% and 52% staged proctectomy, respectively). The most common reasons for TPC-EI over IPAA were patient preference (53%), neoplasia (10.6%), incontinence (9.1%) and obesity (7.6%). Compared with IPAA patients, TPC-EI patients were older, had more comorbidities, and more were receiving biologics. Postoperatively, 18.2% of TPC-EI patients developed perineal wound complications, whereas 4.5% of IPAA patients experienced leaks. The overall 30-day complication rate was higher after TPC-EI (37.1% vs. 19.2%, p < 0.0001); however, after excluding these procedure-specific complications, rates were equivalent (22.7% vs. 17.9%, p = 0.23). In multivariable analysis after propensity score matching, TPC-EI remained a significant predictor of any complication (OR 2.84, 95% CI 1.37-6.08, p = 0.006). CONCLUSIONS:Patient preference was the most common reason for permanent ileostomy in UC. Although short-term complication rates were similar overall, perineal complications occurred in 18% after TPC-EI. These data may inform preoperative counselling when discussing surgical options for UC.

BACKGROUND:Temporary fecal diversion (FD) is performed selectively in patients with rectovaginal fistulas (RVFs). This study aimed to identify the factors associated with FD in the treatment of RVF and determine whether FD is associated with increased recurrence-free survival. METHODS:A retrospective review of females who underwent repair of an RVF was performed. Patients were divided into 2 groups based on the use of FD. Recurrence was defined as evidence of RVF on clinical examination or imaging after at least 2 previous follow-ups, with healing noted. RESULTS:A total of 158 patients underwent 424 surgical procedures, of whom 100 (63.3%) underwent FD and 58 (36.7%) did not. Patients were comparable in terms of age, body mass index, diabetes mellitus, smoking history, inflammatory bowel disease history, and fistula etiology. Patients in the FD group required a median of 3 repairs (IQR, 1-5) (P <.005). Interposition flaps were more common in the FD group than in the non-FD group: gracilis flap (13 [13%] vs 2 [3%]; P =.05) and Martius flap (17 [17%] vs 2 [3%]; P =.01). There were no significant differences in healing or recurrence rates. Multivariate analysis revealed an increased number of previous attempted repairs associated with the use of FD (P <.001). The cumulative 5-year Kaplan-Meier cure rates were 72.7% (95% CI, 61.0%-87.0%) in the FD group and 64.3% (95% CI, 48.0%-86.0%) in the non-FD group (P =.38). CONCLUSION:Multiple previous RVF repairs and interposition flap repairs were associated with the use of FD. Selecting high-risk patients for FD before re-repair may allow the recurrence rate to be similar to that of lower-risk nondiverted patients.

Background Cytoreductive surgery (CRS) with hyperthermic intraperitoneal chemotherapy (HIPEC) has been shown to increase survival in select patients with peritoneal metastasis. One point of contention is whether a cholecystectomy should be performed during the index CRS/HIPEC as this may avoid the risk of missing difficult-to-assess gallbladder (GB) tumor involvement and the potential for a higher-risk cholecystectomy in a post-CRS/HIPEC abdomen. We aim to evaluate the practice of cholecystectomy during CRS/HIPEC and analyze the outcomes of concurrent cholecystectomy. Methods Adult patients who underwent CRS with HIPEC across our quaternary care health center were retrospectively reviewed for GB disease pre- or post-CRS/HIPEC or GB intervention at index or post-CRS/HIPEC. Patients with prior cholecystectomy were excluded. Pre-operative variables collected included patient demographics, cancer diagnosis, and surgical history. Operative reports were reviewed for intraoperative GB evaluation, GB interventions, peritoneal cancer index (PCI), and surgeon specialty. Post-CRS/HIPEC GB disease, GB intervention, and associated complications, and mortality were collected. Cholecystectomy pathology reports were reviewed for GB disease and malignant involvement. Results Between 2009 and 2023, a total of 83 patients underwent CRS with HIPEC and met our inclusion criteria (Table 1). 64 patients underwent cholecystectomy at index CRS/HIPEC, with one Clavien-Dindo (CD) grade-I complication. Post-CRS/HIPEC GB intervention was required for 11 out of the 19 remaining patients (58%) which included 8 open cholecystectomies, 1 cholecystostomy tube, and 1 medical-management with 1 CD-IV complication during cholecystectomy. Two of the patients who required open cholecystectomy had preoperative evidence of cholelithiasis. Among the 64 patients who underwent concurrent cholecystectomy and CRS/HIPEC, 28 patients had evidence of malignant gallbladder involvement. Only 12 out of 20 patients with preoperative evidence of gall bladder disease underwent cholecystectomy at time of CRS/HIPEC. Cholelithiasis was the most common preoperative gall bladder disease. The concordance between intra-operative surgeon perspective of GB disease and final pathology was 56%. Patients who underwent cholecystectomy had a lower PCI compared to those who didn’t (p-value 0.014). Conclusion In our study, cholecystectomy performed during CRS/HIPEC has demonstrated minimal complications. Furthermore, cholecystectomy at time of CRS/HIPEC may ensure a more comprehensive removal of cancerous tissue. Cholecystectomy at the time of CRS/HIPEC may decrease the need for further interventions in this complex patient population.

Abstract Continent ileostomy (CI) is a complex procedure performed in patients who require a total proctocolectomy and are not candidates for a J pouch and are willing to avoid wearing an external ileostomy appliance. This procedure was revolutionary in colorectal surgery as it was the first procedure offering an alternative to wearing an external appliance to catch the stool output if the patient lost the colon and rectum. CI has undergone marked evolution in techniques during the last few decades. The CI offers a high quality of life for appropriately selected patients. A major drawback of CI is the need for revision surgery in nearly half of patients in the long-term. Such revision performed in experienced hands provides retention of the continent pouch in 80% and allows patients to maintain an excellent quality of life. This review aims to summarize the historical technique of this complex procedure, complications, and present various scenarios of the current application of CI.

BACKGROUND:Redo ileocolic resection (ICR) for Crohn's disease is technically challenging, and surgeons often debate whether a laparoscopic approach should be attempted given the risk of conversion. We evaluated predictors of conversion and postoperative outcomes following conversion to inform operative decision-making. METHODS:Patients undergoing redo ileocolic resection for Crohn's disease from 2009 to 2021 at a quaternary referral centre were identified from a prospectively maintained database. Cases were categorized as completed laparoscopically, converted or planned open. Predictors of conversion and perioperative outcomes were analysed. RESULTS:Among 436 redo ileocolic resections, 100 were attempted laparoscopically, with a 10% conversion rate. Penetrating disease was significantly associated with conversion. Postoperative outcomes after conversion were comparable to planned open surgery, including overall complications, readmission and reoperation. Length of stay was shorter after completed laparoscopy. CONCLUSIONS:Conversion during laparoscopic redo ileocolic resection is uncommon and primarily driven by penetrating disease. Importantly, outcomes after conversion approximate those of planned open surgery, supporting an initial laparoscopic approach in appropriately selected patients.

Background: Temporary fecal diversion (FD) is performed selectively in patients with rectovaginal fistulas (RVFs). This study aimed to identify the factors associated with FD in the treatment of RVF and determine whether FD is associated with increased recurrence-free survival. Methods: A retrospective review of females who underwent repair of an RVF was performed. Patients were divided into 2 groups based on the use of FD. Recurrence was defined as evidence of RVF on clinical examination or imaging after at least 2 previous follow-ups, with healing noted. Results: A total of 158 patients underwent 424 surgical procedures, of whom 100 (63.3%) underwent FD and 58 (36.7%) did not. Patients were comparable in terms of age, body mass index, diabetes mellitus, smoking history, inflammatory bowel disease history, and fistula etiology. Patients in the FD group required a median of 3 repairs (IQR, 1-5) (P < .005). Interposition flaps were more common in the FD group than in the non-FD group: gracilis flap (13 [13%] vs 2 [3%]; P =.05) and Martius flap (17 [17%] vs 2 [3%]; P =.01). There were no significant differences in healing or recurrence rates. Multivariate analysis revealed an increased number of previous attempted repairs associated with the use of FD (P < .001). The cumulative 5-year Kaplan-Meier cure rates were 72.7% (95% CI, 61.0%-87.0%) in the FD group and 64.3% (95% CI, 48.0%-86.0%) in the non-FD group (P =.38). Conclusion: Multiple previous RVF repairs and interposition flap repairs were associated with the use of FD. Selecting high-risk patients for FD before re-repair may allow the recurrence rate to be similar to that of lower-risk nondiverted patients. (c) 2026 Published by Elsevier Inc. on behalf of Society for Surgery of the Alimentary Tract.

BACKGROUND:Rediversion before redo ileal pouch-anal anastomosis (IPAA) may reduce pelvic inflammation and optimize pouch salvage outcomes. We hypothesized that the 3-stage approach to pouch revision, compared with 2-stage approach, was associated with a lower risk of pouch failure. STUDY DESIGN:This was a single-quaternary referral center retrospective cohort study of a prospectively maintained pouch registry. Patients were stratified into 2 groups: 3-stage redo IPAA, defined as initial rediversion followed by redo IPAA with diverting ileostomy, and finally ileostomy reversal; 2-stage procedures omitted initial rediversion. The primary outcome was redo pouch failure, defined as permanent ileostomy with or without pouch excision. Secondary outcomes included postoperative complications and functional outcomes. RESULTS:A total of 509 patients who underwent redo IPAA between 2000 and 2024 were included: 3-stage (n = 356; 70%) or 2-stage (n = 153; 30%). Most were women (58.3%), with an overall median age of 39 years. Ulcerative colitis (85.6%) was the most common indication for IPAA. After a median follow-up of 3.2 years, redo pouch failure occurred in 19.4% of the 3-stage group vs 32% in the 2-stage group (p = 0.002). On Cox proportional modeling, the 3-stage approach was associated with improved pouch survival (hazard ratio 0.68, 95% CI 0.46 to 0.99; p = 0.04); septic indications were also associated with a higher failure risk (hazard ratio 1.73, 95% CI 1.14 to 2.64; p = 0.01). CONCLUSIONS:The 3-stage approach to redo pouch surgery was associated with lower risk of redo pouch failure than the 2-stage approach. Initial rediversion should be strongly considered in patients presenting with pouch septic complications before pouch revision.

INTRODUCTION:Transanal Minimally Invasive Surgery (TAMIS) is frequently used to treat rectal lesions that are not amenable to conventional polypectomy or endoscopic resection. Few studies have reported long-term outcomes of TAMIS. This study aims to assess the long-term outcomes in patients who underwent TAMIS for rectal lesions. METHODS:Patients who underwent TAMIS for rectal neoplasms at a tertiary care center between June 2010 and August 2023 were retrospectively reviewed. The assessment of oncological outcomes, reported separately for benign and malignant lesions, was limited to patients with adenomatous polyps, serrated polyps, or adenocarcinomas as indicated in the postoperative histopathology report. The primary outcomes were long-term oncological outcomes, including local recurrence, distant metastasis, mortality, disease-free and overall survival rates. RESULTS:The current study included a total of 208 individuals, of whom 74 (35.6 %) were female, with a median age of 64 (19.3) years. Upon postoperative histopathological examination, adenomatous lesions were identified in 109 (52.4 %) patients, serrated adenoma in 7 (3.4 %) patients, negative pathology in 18 (8.7 %) patients, and adenocarcinoma in 74 (35.5 %) patients. The median follow-up duration was 37 months. During the follow-up period, local recurrence occurred in 1 patient (0.8 %) with benign disease, 16 months after TAMIS. Additionally, recurrence occurred in 8 (9.4 %) patients with malignant disease at a median follow-up of 23.5 months. Distant metastasis was observed in 1 patient (0.8 %) who initially had benign disease seven months after experiencing malignant recurrence. Furthermore, distant metastasis was noted in 5 patients (5.9 %) with malignant disease. No disease-related mortality was recorded during the follow-up period for benign lesions. However, 5 (5.9 %) patients with malignant disease experienced mortality associated with rectal adenocarcinoma. The 3-year disease-free and overall survival rates for patients with malignant disease were 91 % and 96.6 % (p = 0.015), respectively. CONCLUSION:TAMIS is an effective technique for rectal lesions, offering an acceptable short- and long-term oncological outcome for both benign and malignant lesions.

BACKGROUND:Complex perineal fistulas frequently recur after surgery. Hyperbaric oxygen therapy (HBOT) augments tissue oxygenation and may enhance healing. METHODS:In this retrospective matched cohort study, we reviewed 53 consecutive patients who received HBOT during repair of perianal, rectovaginal, or pouch-vaginal fistulas (2012-2024). Each was matched 1:3 to controls treated without HBOT by age, sex, body mass index, and fistula type. Demographics, operative history, healing, recurrence and stoma reversal were compared. Healing was defined as complete clinical closure confirmed at examination. Kaplan-Meier (KM) curves assessed time-to-fistula recurrence. RESULTS:HBOT patients had longer median fistula duration than controls (2.7 vs. 1.5 years, p < 0.001), higher diversion rates (89% vs. 47%, p < 0.001), and were more likely to have undergone more than two prior surgeries (70% vs. 34%, p = 0.001). At 6 months follow-up, 45 (84.9%) patients in the HBOT group achieved fistula healing compared with 122 (76.3%) patients in the control group (p = 0.18). After a median follow-up of 1.4 and 2.7 years for HBOT and non-HBOT groups (p = 0.55), respectively, 4 (9%) HBOT patients and 20 (16.4%) controls developed fistula recurrence (p = 0.38). The Kaplan-Meier estimated recurrence-free survival of healed fistulas was numerically higher with HBOT at 6, 12 and 18 months: 83%, 78% and 74% versus 75%, 68% and 65% (p = 0.20). After stoma reversal, recurrence was lower with HBOT 5.9% versus 26.5% (log rank p = 0.035). Among patients with three or more repairs (n = 90), healing at last follow-up was 85% after HBOT versus 66% in controls (p = 0.04). CONCLUSION:HBOT was associated with lower recurrence after stoma reversal and with more durable healing in fistulas that had already failed multiple prior repairs, without changing stoma reversal rates. These data suggest that HBOT may be a useful adjunct in the reconstructive strategy for complex recurrent perineal fistulas.