Despite advances in neoadjuvant and adjuvant therapy, attention to proper surgical technique, and improved pathological staging for both the primary and metastatic lesions, almost half of all colorectal cancer patients will develop recurrent disease. More concerning, this includes ~25% of patients with theoretically curable node-negative, non-metastatic Stage I and II disease. Given the annual incidence of colorectal cancer, approximately 150,000 new patients are candidates each year for follow-up surveillance. When combined with the greater population already enrolled in a surveillance protocol, this translates to a tremendous number of patients at risk for recurrence. It is therefore imperative that strategies aim for detection of recurrence as early as possible to allow initiation of treatment that may still result in cure. Yet, controversy exists regarding the optimal surveillance strategy (high-intensity vs. traditional), ideal testing regimen, and overall effectiveness. While benefits may involve earlier detection of recurrence, psychological welfare improvement, and greater overall survival, this must be weighed against the potential disadvantages including more invasive tests, higher rates of reoperation, and increased costs. In this review, we will examine the current options available and challenges surrounding colorectal cancer surveillance and early detection of recurrence.

Postoperative ileus (POI) is a common complication following colon and rectal surgery, with reported incidence ranging from 10 to 30%. It can lead to increased morbidity, cost, and length of stay. Although definitions vary considerably in the literature, in its pathologic form, it can be characterized by a temporary inhibition of gastrointestinal motility after surgical intervention due to nonmechanical causes that prevents sufficient oral intake. Various risk factors for development of POI have been identified including increasing age, American Society of Anesthesiologists scores 3 to 4, open approach, operative difficulty, operative duration more than 3 hours, bowel handling, drop in hematocrit or need for a transfusion, increasing crystalloid administration, and delayed mobilization. While treatment is expectant and supportive, significant investigations into strategies to mitigate development of POI or shorten its duration have been undertaken with mixed results. There is significant evidence to suggest that a minimally invasive approach and multimodal pain regimens reduce the development of POI. The beneficial effect of chewing gum, alvimopan, and enhanced recovery after surgery protocols may decrease development of POI in selected groups of patients who undergo elective colorectal surgery, and shorten time to return of bowel function, but overall, the data remain inconclusive.

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Readmissions after colorectal resection occur frequently and incur a significant financial burden on the health-care system. Future studies aimed at targeted interventions for high-risk patients may reduce readmissions and curb escalating health-care costs.

Introduction: With the advent of multidisciplinary and multimodality approaches to the management of colorectal cancer patients, there is an increasing need to define how we monitor response to novel therapies in these patients. Several factors ranging from the type of therapy used to the intrinsic biology of the tumor play a role in tumor response. All of these can aid in determining the ideal course of treatment, and may fluctuate over time, pending down-staging or progression of disease. Therefore, monitoring how disease responds to therapy requires standardization in order to ultimately optimize patient outcomes. Unfortunately, how best to do this remains a topic of debate among oncologists, pathologists, and colorectal surgeons. There may not be one single best approach. The goal of the present article is to shed some light on current approaches and challenges to monitoring treatment response for colorectal cancer.Methods: A literature search was conducted utilizing PubMed and the OVID library. Key-word combinations included colorectal cancer metastases, neoadjuvant therapy, rectal cancer, imaging modalities, CEA, down-staging, tumor response, and biomarkers. Directed searches of the embedded references from the primary articles were also performed in selected circumstances.Results: Pathologic examination of the post-treatment surgical specimen is the gold standard for monitoring response to therapy. Endoscopy is useful for evaluating local recurrence, but not in assessing tumor response outside of the limited information gained by direct examination of intra-lumenal lesions. Imaging is used to monitor tumors throughout the body for response, with CT, PET, and MRI employed in different circumstances. Overall, each has been validated in the monitoring of patients with colorectal cancer and residual tumors.Conclusion: Although there is no imaging or serum test to precisely correlate with a tumor's response to chemo- or radiation therapy, these modalities, when used in combination, can aid in allowing clinicians to adjust medical therapy, pursue operative intervention, or (in select cases) identify complete responders. Improvements are needed, however, as advances across multiple modalities could allow appropriate selection of patients for a close surveillance regimen in the absence of operative intervention.

In an equal-access system, young age at presentation (<50 years) was associated with advanced stage and higher recurrence of colorectal cancer, but similar survival in comparison with older patients. Although increased adjuvant therapy use in younger patients may partially account for stage-specific increases in survival, the relative decreased chemotherapy use overall requires further evaluation.

Objectives: On completion of the article, the reader should be able to describe the differences between large volume administrative and clinical databases and to discuss the limitations of using administrative databases for outcomes research.Surgical outcomes research has grown exponentially in the past decade with increased utilization of large-volume administrative and clinical databases. Surgeon, hospital, and regional outcomes are increasingly evaluated with comparison of both patient outcomes (morbidity and mortality) and resource utilization (cost, intensive care unit admissions). External pressures have further fueled outcomes research with the American Board of Surgery requiring surgeons to monitor their own performance, 1 the Joint Commission urging hospitals to demonstrate key surgical safety indicators, 2 and payers implementing pay-for-performance programs. 3Within the field of colon and rectal surgery, large-volume databases are increasingly utilized to study outcomes.4,5 For both outcomes analysis as well as research, these provide multiple potential advantages. Derivation of data from large, heterogeneous populations may result in decreased selection bias and increased study generalizability. 6,7 New surgical interventions 8 and assessment of quality improvement measures may be examined. 9,10 In the era of escalating health care costs, database research lends itself to the assessment of the cost and effectiveness of surgical treatments 11 while permitting investigation of the role of specialty provider and institution characteristics on resource utilization and patient outcomes. Variations at the regional, state, and national level can be assessed and risk models can be created and validated. 12On the other hand, as large-volume databases become increasingly available for research purposes, a clear understanding of the appropriate applications and limitations is necessary. The nuances and complexities of individual databases can be confusing. In this section, we aim to discuss the large-volume databases currently available for outcomes research, outlining database selection, modes of analyses, and inherent limitations. Study DesignClinical research includes the traditional prospective clinical trials, cohort studies, and case-control studies, while outcomes research has now solidified itself as a separate class of clinical research. Subtypes of surgical outcomes research include geographic variations of surgical procedures, volume outcomes analyses, treatment disparities (racial/economic/ age-related), trend analyses, cost-effectiveness studies, and surgical quality/risk adjustment.Appropriate database selection requires a thorough understanding of the individual database, including unique strengths and limitations. The utility of administrative data for assessing surgical quality depends on the measures being studied and how well they are captured in administrative and clinical records. In addition, the initial study design and hypothesis generation is a critical phase to the validity and Abstrac...

Results from a large nationwide database demonstrate that a laparoscopic approach was utilized in an increasing number of UC patients undergoing colectomy and was associated with lower morbidity and mortality, even in more complex procedures, such as TAC and IPAA.