Introduction: Dextran sodium sulfate (DSS) is commonly used to induce a murine fulminant colitis model. Hepatocyte growth factor (HGF) has been shown to decrease the symptoms of inflammatory bowel disease (IBD) but the effect of its activator, HGFA, is not well characterized. Arginine reduces effects of oxidative stress but its effect on IBD is not well known. The primary aim is to determine whether HGF and HGFA, or arginine will decrease IBD symptoms such as pain and diarrhea in a DSS-induced fulminant colitis murine model. Methods: A severe colitis was induced in young, male Fischer 344 rats with 4% (w/v) DSS oral solution for seven days; rats were sacrificed on day 10. Rats were divided into five groups of 8 animals: control, HGF (700 mcg/kg/dose), HGF and HGFA (10 mcg/dose), HGF and arginine, and high dose HGF (2800 mcg/kg/ dose). Main clinical outcomes were pain, diarrhea and weight loss. Blinded pathologists scored the terminal ileum and distal colon. Results: DSS reliably induced severe active colitis in 90% of animals (n ¼ 36/40). There were no differences in injury scores between control and treatment animals. HGF led to 1.38 fewer days in pain (p ¼ 0.036), while arginine led to 1.88 fewer days of diarrhea (P ¼ 0.017) compared to controls. 88% of HGFA-treated rats started regaining weight (P 0.001). Discussion/Conclusion: Although treatment was unable to reverse fulminant disease, HGF and arginine were associated with decreased days of pain and diarrhea. These clinical interventions may reduce associated symptoms for severe IBD patients, even when urgent surgical intervention remains the only viable option.

Background Postoperative ileus (POI) is a major cause of morbidity, increased length of stay (LOS) and hospital cost after colorectal surgery. Alvimopan is a l-opioid antagonist used to accelerate upper and lower gastrointestinal function after bowel resection. We hypothesized that alvimopan would reduce LOS in patients undergoing colorectal resection with stoma, a situation that has not been evaluated. Methods A retrospective review (2010–2015) identified 58 patients who underwent colorectal resection for benign or malignant disease with stoma creation and received alvimopan. They were case-matched to 58 non-alvimopan patients based on age, BMI, baseline comorbidities, stoma type created and surgical approach. We compared overall LOS, incidence ofPOI and other postoperative complications. Results There were equal numbers of laparoscopic (N = 18) and open resections (N = 40) in the alvimopan group and non-alvimopan group. There were also equal numbers of patients with an ileostomy (N = 37) or colostomy (N = 21) in each group. Overall, 41 patients underwent resection for malignant disease in the alvimopan group compared to 37 in the non-alvimopan group. There was a significant reduction in median LOS overall (alvimopan 5 (4–7) versus control 6 (4.75–9.25) days, P = 0.03). While the 6-day median LOS was similar for patients undergoing ileostomy creation (P = 0.25), alvimopan patients had a 3-day decreased median LOS that approached statistical significance (P = 0.06). The overall 30-day complication rate was higher in the control group (41.4 vs. 51.7%, P = 0.26), but the readmission rate within 30 days was higher in the alvimopan group (19 vs. 13.8%, P = 0.45). Neither of these differences reached statistically significance. Conclusion The use of alvimopan in patients undergoing colorectal resection with stoma is associated with a significantly shorter LOS, but the increased readmission rate warrants further study. Based on these data, alvimopan should be evaluated in a controlled setting for patients undergoing colorectal resection with colostomy creation.

Background: Intraoperative radiation therapy (IORT) has been proposed as a tool to improve local control in patients with locally advanced primary or recurrent colorectal cancer. Methods: A retrospective review (1999e2015) of all patients undergoing IORT for locally advanced or recurrent colorectal cancer at a single academic center was performed. Patient demographics, oncologic staging, short-term and long-term outcomes were reviewed. Results: There were 77 patients (mean age 63 ± 11 years) identified, of whom 19 had colon cancer, 57 had rectal cancer, and 2 had appendiceal cancers. R0 resection was performed in 53 patients (69%), R1 in 19 (25%) and R2 in 5 (6%). Ten (13%) patients had a local recurrence at 18 ± 14 months and 34 (44%) had a distant recurrence at 18 ± 18 months. Mean survival was 47 ± 41 months. Conclusion: IORT resulted in low local failure rates and should be considered for patients with locally advanced or recurrent colorectal cancers.

Background: Intraoperative radiation therapy (IORT) has been proposed as a tool to improve local control in patients with locally advanced primary or recurrent colorectal cancer. Methods: A retrospective review (1999e2015) of all patients undergoing IORT for locally advanced or recurrent colorectal cancer at a single academic center was performed. Patient demographics, oncologic staging, short-term and long-term outcomes were reviewed. Results: There were 77 patients (mean age 63 ± 11 years) identified, of whom 19 had colon cancer, 57 had rectal cancer, and 2 had appendiceal cancers. R0 resection was performed in 53 patients (69%), R1 in 19 (25%) and R2 in 5 (6%). Ten (13%) patients had a local recurrence at 18 ± 14 months and 34 (44%) had a distant recurrence at 18 ± 18 months. Mean survival was 47 ± 41 months. Conclusion: IORT resulted in low local failure rates and should be considered for patients with locally advanced or recurrent colorectal cancers.

Background: Surgeons often approach anal fissure with chemical denervation (Botulinum toxin, BT) instead of initial lateral internal sphincterotomy (LIS) due to concerns for long-term incontinence. We evaluated the characteristics and outcomes of patients who received BT or LIS. Methods: We performed a retrospective chart review of patients undergoing LIS and BT for anal fissure between 2009 and 2015. In 2015, a telephone survey was performed to evaluate durability, long-term incontinence and patient satisfaction. Results: Ninety-four patients met criteria: 73 LIS and 21 BT. Age (BT 49 vs. LIS 52) was similar between groups (p ¼ 1.0). Cleveland Clinic Fecal Incontinence (CCFI) score pre-intervention was higher in BT than LIS patients (2.1 vs. 0.4, p ¼ 0.007) with fewer BT patients with perfect continence (50% vs. 88%). Telephone survey response was 61%. Fissure recurrence was significantly higher for BT than LIS patients (36% vs. 9%, p ¼ 0.03). Conclusion: Patients undergoing LIS were less likely to recur. Both LIS and BT patients had some durable changes in continence raising the question of whether there is a safe technique. Summary for table of contents: Anal fissure is a painful condition that when not responding to medical management, often is treated with Botulinum toxin injection or Lateral Internal Sphincterotomy. In this retrospective review and telephone survey, we found that patients who underwent Botulinum toxin injection had worse baseline incontinence than Lateral Internal Sphincterotomy patients and higher recurrence rates. Both patient groups had durable changes in continence, which surgeons must consider when treating patients with anal fissure.

Background: Surgeons often approach anal fissure with chemical denervation (Botulinum toxin, BT) instead of initial lateral internal sphincterotomy (LIS) due to concerns for long-term incontinence. We evaluated the characteristics and outcomes of patients who received BT or LIS. Methods: We performed a retrospective chart review of patients undergoing LIS and BT for anal fissure between 2009 and 2015. In 2015, a telephone survey was performed to evaluate durability, long-term incontinence and patient satisfaction. Results: Ninety-four patients met criteria: 73 LIS and 21 BT. Age (BT 49 vs. LIS 52) was similar between groups (p ¼ 1.0). Cleveland Clinic Fecal Incontinence (CCFI) score pre-intervention was higher in BT than LIS patients (2.1 vs. 0.4, p ¼ 0.007) with fewer BT patients with perfect continence (50% vs. 88%). Telephone survey response was 61%. Fissure recurrence was significantly higher for BT than LIS patients (36% vs. 9%, p ¼ 0.03). Conclusion: Patients undergoing LIS were less likely to recur. Both LIS and BT patients had some durable changes in continence raising the question of whether there is a safe technique. Summary for table of contents: Anal fissure is a painful condition that when not responding to medical management, often is treated with Botulinum toxin injection or Lateral Internal Sphincterotomy. In this retrospective review and telephone survey, we found that patients who underwent Botulinum toxin injection had worse baseline incontinence than Lateral Internal Sphincterotomy patients and higher recurrence rates. Both patient groups had durable changes in continence, which surgeons must consider when treating patients with anal fissure.

Introduction: Abdominoperineal Resection (APR) remains an important option for patients with advanced rectal cancer though some may require multivisceral resection (MVR) in addition to APR. We hypothesized that oncological outcomes would be worse with MVR. Methods: A retrospective review from 2006 to 2015 of 161 patients undergoing APR or MVR for rectal cancer, of whom 118 underwent curative APR or APR with MVR. Perioperative, oncologic and survival metrics were evaluated. Results: There were 82 patients who underwent APR and 36 who underwent MVR. Surgical approach and incidence of complications were similar (All P > 0.05). There was 1 local recurrence in each of the APR and MVR groups at a mean follow-up of 34 and 32 months, respectively. Distant recurrences occurred in 3 APR patients and 4 MVR patients. Conclusions: APR and APR with MVR can be performed with comparable morbidity and oncologic outcomes. Summary For patients with locally advanced or recurrent rectal cancers, abdominoperineal resection remains an important option for curative resection, however some patients may require multivisceral resection in addition to abdominoperineal resection. In our retrospective review of 118 patients who underwent curative resection, we found comparable rates of short-term complications and survival outcomes between patients undergoing abdominoperineal resection alone or in conjunction with a multivisceral resection.

Introduction: Abdominoperineal Resection (APR) remains an important option for patients with advanced rectal cancer though some may require multivisceral resection (MVR) in addition to APR. We hypothesized that oncological outcomes would be worse with MVR. Methods: A retrospective review from 2006 to 2015 of 161 patients undergoing APR or MVR for rectal cancer, of whom 118 underwent curative APR or APR with MVR. Perioperative, oncologic and survival metrics were evaluated. Results: There were 82 patients who underwent APR and 36 who underwent MVR. Surgical approach and incidence of complications were similar (All P > 0.05). There was 1 local recurrence in each of the APR and MVR groups at a mean follow-up of 34 and 32 months, respectively. Distant recurrences occurred in 3 APR patients and 4 MVR patients. Conclusions: APR and APR with MVR can be performed with comparable morbidity and oncologic outcomes. Summary For patients with locally advanced or recurrent rectal cancers, abdominoperineal resection remains an important option for curative resection, however some patients may require multivisceral resection in addition to abdominoperineal resection. In our retrospective review of 118 patients who underwent curative resection, we found comparable rates of short-term complications and survival outcomes between patients undergoing abdominoperineal resection alone or in conjunction with a multivisceral resection.

Enhanced recovery pathways allow for safe discharge and optimal outcomes within 48 hours after ileostomy closure. Unfortunately, some patients undergoing ileostomy closure have prolonged hospital stays. We have shown previously that the Modified Frailty Index can help predict patients who will fail early discharge after laparoscopic colorectal surgery. OBJECTIVE: The purpose of this study was to use the Modified Frailty Index to identify patients who were safe for early discharge after ileostomy closure. DESIGN: This was a retrospective review. SETTINGS: The study was conducted at a tertiary referral center. PATIENTS: Patients who underwent ileostomy closure (2006–2015) were stratified into early (≤48 hours) and late discharge groups. MAIN OUTCOME MEASURES: The Modified Frailty Index, morbidity, and readmission rates were measured. RESULTS: A total of 272 patients undergoing ileostomy closure were evaluated. Overall length of stay was 3.64 days (±3.23 days), with 114 patients (42%) discharged within 48 hours. Sex, age, and ASA scores were similar between early and later discharge groups (p > 0.2). Univariate logistic regression demonstrated that a Modified Frailty Index score of 0 was associated with early discharge (p = 0.03), whereas a Modified Frailty Index score ≤1 and ≤2 were not. There was no significant association between the Modified Frailty Index and complication or readmission rates. Postoperative complications occurred in 39 patients (14.3%), and 1 patient died secondary to an anastomotic leak. Fifteen patients (5.5%) were readmitted within 30 days. Readmission rate within 30 days was 3.2%, with a Modified Frailty Index score of 0, 6.1% for a Modified Frailty Index score of 1, and 5.9% for a Modified Frailty Index score of 2, for which there was not an association based on univariate logistic regression (Modified Frailty Index = 0, p = 0.13; 1, p = 0.55; 2, p = 0.53). LIMITATIONS: The study was limited by nature of being a retrospective review. CONCLUSIONS: Patients undergoing ileostomy closure with a Modified Frailty Index score of 0 are associated with higher rates of discharge within 48 hours of ileostomy closure surgery than those with a higher Modified Frailty Index, without higher readmission rates. This information can be helpful to better manage patient and resource use expectations for the duration of inpatient recovery.

Enhanced recovery pathways allow for safe discharge and optimal outcomes within 48 hours after ileostomy closure. Unfortunately, some patients undergoing ileostomy closure have prolonged hospital stays. We have shown previously that the Modified Frailty Index can help predict patients who will fail early discharge after laparoscopic colorectal surgery. OBJECTIVE: The purpose of this study was to use the Modified Frailty Index to identify patients who were safe for early discharge after ileostomy closure. DESIGN: This was a retrospective review. SETTINGS: The study was conducted at a tertiary referral center. PATIENTS: Patients who underwent ileostomy closure (2006–2015) were stratified into early (≤48 hours) and late discharge groups. MAIN OUTCOME MEASURES: The Modified Frailty Index, morbidity, and readmission rates were measured. RESULTS: A total of 272 patients undergoing ileostomy closure were evaluated. Overall length of stay was 3.64 days (±3.23 days), with 114 patients (42%) discharged within 48 hours. Sex, age, and ASA scores were similar between early and later discharge groups (p > 0.2). Univariate logistic regression demonstrated that a Modified Frailty Index score of 0 was associated with early discharge (p = 0.03), whereas a Modified Frailty Index score ≤1 and ≤2 were not. There was no significant association between the Modified Frailty Index and complication or readmission rates. Postoperative complications occurred in 39 patients (14.3%), and 1 patient died secondary to an anastomotic leak. Fifteen patients (5.5%) were readmitted within 30 days. Readmission rate within 30 days was 3.2%, with a Modified Frailty Index score of 0, 6.1% for a Modified Frailty Index score of 1, and 5.9% for a Modified Frailty Index score of 2, for which there was not an association based on univariate logistic regression (Modified Frailty Index = 0, p = 0.13; 1, p = 0.55; 2, p = 0.53). LIMITATIONS: The study was limited by nature of being a retrospective review. CONCLUSIONS: Patients undergoing ileostomy closure with a Modified Frailty Index score of 0 are associated with higher rates of discharge within 48 hours of ileostomy closure surgery than those with a higher Modified Frailty Index, without higher readmission rates. This information can be helpful to better manage patient and resource use expectations for the duration of inpatient recovery.