George J. Chang

Abstract Background This is the fourth updated Enhanced Recovery After Surgery (ERAS ® ) Society guideline presenting a consensus for optimal perioperative care in colorectal surgery and providing graded recommendations for each ERAS item within the ERAS ® protocol. Methods A wide database search on English literature publications was performed. Studies on each item within the protocol were selected with particular attention paid to meta‐analyses, randomised controlled trials and large prospective cohorts and examined, reviewed and graded according to Grading of Recommendations, Assessment, Development and Evaluation (GRADE) system. Results All recommendations on ERAS ® protocol items are based on best available evidence; good‐quality trials; meta‐analyses of good‐quality trials; or large cohort studies. The level of evidence for the use of each item is presented accordingly. Conclusions The evidence base and recommendation for items within the multimodal perioperative care pathway are presented by the ERAS ® Society in this comprehensive consensus review.

PURPOSE: Fluorouracil/leucovorin as the sole therapy for metastatic colorectal cancer (CRC) provides an overall survival of 8 to 12 months. With an increase in surgical resections of metastatic disease and development of new chemotherapies, indirect evidence suggests that outcomes for patients are improving in the general population, although the incremental gain has not yet been quantified. METHODS: We performed a retrospective review of patients newly diagnosed with metastatic CRC treated at two academic centers from 1990 through 2006. Landmark analysis evaluated the association of diagnosis year and liver resection with overall survival. Additional survival analysis of the Surveillance Epidemiology and End Results (SEER) database evaluated a similar population from 1990 through 2005. RESULTS: Two thousand four hundred seventy patients with metastatic CRC at diagnosis received their primary treatment at the two institutions during this time period. Median overall survival for those patients diagnosed from 1990 to 1997 was 14.2 months, which increased to 18.0, 18.6, and 29.3 months for patients diagnosed in 1998 to 2000, 2001 to 2003, and 2004 to 2006, respectively. Likewise, 5-year overall survival increased from 9.1% in the earliest time period to 19.2% in 2001 to 2003. Improved outcomes from 1998 to 2004 were a result of an increase in hepatic resection, which was performed in 20% of the patients. Improvements from 2004 to 2006 were temporally associated with increased utilization of new chemotherapeutics. In the SEER registry, overall survival for the 49,459 identified patients also increased in the most recent time period. CONCLUSION: Profound improvements in outcome in metastatic CRC seem to be associated with the sequential increase in the use of hepatic resection in selected patients (1998 to 2006) and advancements in medical therapy (2004 to 2006).

IMPORTANCE: Evidence about the efficacy of laparoscopic resection of rectal cancer is incomplete, particularly for patients with more advanced-stage disease. OBJECTIVE: To determine whether laparoscopic resection is noninferior to open resection, as determined by gross pathologic and histologic evaluation of the resected proctectomy specimen. DESIGN, SETTING, AND PARTICIPANTS: A multicenter, balanced, noninferiority, randomized trial enrolled patients between October 2008 and September 2013. The trial was conducted by credentialed surgeons from 35 institutions in the United States and Canada. A total of 486 patients with clinical stage II or III rectal cancer within 12 cm of the anal verge were randomized after completion of neoadjuvant therapy to laparoscopic or open resection. INTERVENTIONS: Standard laparoscopic and open approaches were performed by the credentialed surgeons. MAIN OUTCOMES AND MEASURES: The primary outcome assessing efficacy was a composite of circumferential radial margin greater than 1 mm, distal margin without tumor, and completeness of total mesorectal excision. A 6% noninferiority margin was chosen according to clinical relevance estimation. RESULTS: Two hundred forty patients with laparoscopic resection and 222 with open resection were evaluable for analysis of the 486 enrolled. Successful resection occurred in 81.7% of laparoscopic resection cases (95% CI, 76.8%-86.6%) and 86.9% of open resection cases (95% CI, 82.5%-91.4%) and did not support noninferiority (difference, -5.3%; 1-sided 95% CI, -10.8% to ∞; P for noninferiority = .41). Patients underwent low anterior resection (76.7%) or abdominoperineal resection (23.3%). Conversion to open resection occurred in 11.3% of patients. Operative time was significantly longer for laparoscopic resection (mean, 266.2 vs 220.6 minutes; mean difference, 45.5 minutes; 95% CI, 27.7-63.4; P < .001). Length of stay (7.3 vs 7.0 days; mean difference, 0.3 days; 95% CI, -0.6 to 1.1), readmission within 30 days (3.3% vs 4.1%; difference, -0.7%; 95% CI, -4.2% to 2.7%), and severe complications (22.5% vs 22.1%; difference, 0.4%; 95% CI, -4.2% to 2.7%) did not differ significantly. Quality of the total mesorectal excision specimen in 462 operated and analyzed surgeries was complete (77%) and nearly complete (16.5%) in 93.5% of the cases. Negative circumferential radial margin was observed in 90% of the overall group (87.9% laparoscopic resection and 92.3% open resection; P = .11). Distal margin result was negative in more than 98% of patients irrespective of type of surgery (P = .91). CONCLUSIONS AND RELEVANCE: Among patients with stage II or III rectal cancer, the use of laparoscopic resection compared with open resection failed to meet the criterion for noninferiority for pathologic outcomes. Pending clinical oncologic outcomes, the findings do not support the use of laparoscopic resection in these patients. TRIAL REGISTRATION: clinicaltrials.gov Identifier: NCT00726622.

IMPORTANCE: The overall incidence of colorectal cancer (CRC) has been decreasing since 1998 but there has been an apparent increase in the incidence of CRC in young adults. OBJECTIVE: To evaluate age-related disparities in secular trends in CRC incidence in the United States. DESIGN, SETTING, AND PATIENTS: A retrospective cohort study using the Surveillance, Epidemiology, and End Results (SEER) CRC registry. Age at diagnosis was analyzed in 15-year intervals starting at the age of 20 years. SEER*Stat was used to obtain the annual cancer incidence rates, annual percentage change, and corresponding P values for the secular trends. Data were obtained from the National Cancer Institute's SEER registry for all patients diagnosed as having colon or rectal cancer from January 1, 1975, through December 31, 2010 (N = 393 241). MAIN OUTCOME AND MEASURE: Difference in CRC incidence by age. RESULTS: The overall age-adjusted CRC incidence rate decreased by 0.92% (95% CI, -1.14 to -0.70) between 1975 and 2010. There has been a steady decline in the incidence of CRC in patients age 50 years or older, but the opposite trend has been observed for young adults. For patients 20 to 34 years, the incidence rates of localized, regional, and distant colon and rectal cancers have increased. An increasing incidence rate was also observed for patients with rectal cancer aged 35 to 49 years. Based on current trends, in 2030, the incidence rates for colon and rectal cancers will increase by 90.0% and 124.2%, respectively, for patients 20 to 34 years and by 27.7% and 46.0%, respectively, for patients 35 to 49 years. CONCLUSIONS AND RELEVANCE: There has been a significant increase in the incidence of CRC diagnosed in young adults, with a decline in older patients. Further studies are needed to determine the cause for these trends and identify potential preventive and early detection strategies.

Monson, J. R. T. M.D.; Weiser, M. R. M.D.; Buie, W. D. M.D.; Chang, G. J. M.D.; Rafferty, J. F. M.D.; Buie, W. Donald M.D., Chair; Rafferty, Janice M.D., Co-chair; Guillem, Jose M.D., Council Representative; Boushey, Robin M.D.; Chang, George M.D.; Feingold, Daniel M.D.; Fleshner, Philip M.D.; Genua, Jill M.D.; Hammond, Kerry M.D.; Harb, William M.D.; Hendren, Samantha M.D.; Herzig, Daniel M.D.; Kaiser, Andreas M.D.; Larson, David M.D.; Lee, Sang M.D.; McCormick, James D.O.; Melton-Meaux, Genevieve M.D.; Mills, Steven M.D.; Monson, John M.D.; Moore, Harvey III M.D.; Perry, W. Brian M.D.; Phang, P. Terry M.D.; Rivadeneira, David M.D.; Ross, Howard M.D.; Steele, Scott M.D.; Strong, Scott M.D.; Ternent, Charles M.D.; Varma, Madhulika M.D.; Weiser, Martin M.D.; Wilkins, Kirsten M.D. Standards Practice Task Force of the American Society of Colon and Rectal Surgeons Standards Practice Task Force of the American Society of Colon and Rectal Surgeons Standards Practice Task Force of the American Society of Colon and Rectal Surgeons Standards Practice Task Force of the American Society of Colon and Rectal Surgeons Standards Practice Task Force of the American Society of Colon and Rectal Surgeons Standards Practice Task Force of the American Society of Colon and Rectal Surgeons Standards Practice Task Force of the American Society of Colon and Rectal Surgeons Standards Practice Task Force of the American Society of Colon and Rectal Surgeons Standards Practice Task Force of the American Society of Colon and Rectal Surgeons Standards Practice Task Force of the American Society of Colon and Rectal Surgeons Standards Practice Task Force of the American Society of Colon and Rectal Surgeons Standards Practice Task Force of the American Society of Colon and Rectal Surgeons Standards Practice Task Force of the American Society of Colon and Rectal Surgeons Standards Practice Task Force of the American Society of Colon and Rectal Surgeons Standards Practice Task Force of the American Society of Colon and Rectal Surgeons Standards Practice Task Force of the American Society of Colon and Rectal Surgeons Standards Practice Task Force of the American Society of Colon and Rectal Surgeons Standards Practice Task Force of the American Society of Colon and Rectal Surgeons Standards Practice Task Force of the American Society of Colon and Rectal Surgeons Standards Practice Task Force of the American Society of Colon and Rectal Surgeons Standards Practice Task Force of the American Society of Colon and Rectal Surgeons Standards Practice Task Force of the American Society of Colon and Rectal Surgeons Standards Practice Task Force of the American Society of Colon and Rectal Surgeons Standards Practice Task Force of the American Society of Colon and Rectal Surgeons Standards Practice Task Force of the American Society of Colon and Rectal Surgeons Standards Practice Task Force of the American Society of Colon and Rectal Surgeons Standards Practice Task Force of the American Society of Colon and Rectal Surgeons Standards Practice Task Force of the American Society of Colon and Rectal Surgeons Standards Practice Task Force of the American Society of Colon and Rectal Surgeons Standards Practice Task Force of the American Society of Colon and Rectal Surgeons Author Information