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BACKGROUND: The aim of the study was to assess which aspects of an enhanced recovery programme are associated with better outcomes following laparoscopic colorectal surgery. METHODS: A database of laparoscopic colorectal procedures performed in 2011 was reviewed. Elements of the enhanced recovery programme and compliance were evaluated for short-term (30-day) outcomes. Individual elements included gabapentin, celecoxib, intrathecal analgesia, diet, postoperative fluids, and paracetamol/non-steroidal anti-inflammatory drug pain management. RESULTS: Five hundred and forty-one consecutive procedures were included. Compliance with the enhanced recovery programme elements ranged from 82.4 to 99.3 per cent. Median length of hospital stay was 3 (i.q.r. 2-5) days, with 25.9 per cent of patients discharged within 48 h. Patients without complications had a median length of stay of 3 (i.q.r. 2-4) days if compliant and 3 (3-5) days if not (P < 0.001). Low oral opiate intake (oral morphine equivalent of less than 30 mg) (odds ratio (OR) 1.97, 95 per cent confidence interval 1.29 to 3.03; P = 0.002), full compliance (OR 2.36, 1.42 to 3.90; P < 0.001) and high surgeon volume (more than 100 cases per year) (OR 1.50, 1.19 to 1.89; P < 0.001) were associated with discharge within 48 h. Compliance with the elements of oral intake and fluid management in the first 48 h was associated with a reduced rate of complications (8.1 versus 19.6 per cent; P = 0.001). Median oral opiate intake was 37.5 (i.q.r. 0-105) mg in 48 h, with 26.2 per cent of patients receiving no opiates. CONCLUSION: Compliance with an enhanced recovery pathway was associated with less opiate use, fewer complications and a shorter hospital stay.

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BACKGROUND: Current approaches to the detection of colorectal neoplasia associated with inflammatory bowel disease (IBD-CRN) are suboptimal. AIM: To test the feasibility of using stool assay of exfoliated DNA markers to detect IBD-CRN. METHODS: This investigation comprised tissue and stool studies. In the tissue study, gene sequencing and methylation assays were performed on candidate genes using tissue DNA from 25 IBD-CRNs and from 25 IBD mucosae without CRN. Mutations on p53, APC, KRAS, BRAF or PIK3CA genes were insufficiently informative, but several aberrantly methylated genes were highly discriminant. In the stool study, we evaluated candidate methylated genes (vimentin, EYA4, BMP3, NDRG4) in a prospective blinded study on buffered stools from 19 cases with known IBD-CRN and 35 age- and sex-matched IBD controls without CRN. From stool-extracted DNA, target genes were assayed using quantitative allele-specific real-time target and signal amplification method. RESULTS: IBD-CRN cases included 17 with ulcerative colitis (UC) and two with Crohn's disease (CD); nine had cancer and 10 had dysplasia. Controls included 25 with UC and 10 with CD. Individually, BMP3, vimentin, EYA4 and NDRG4 markers showed high discrimination in stools with respective areas under the ROC curve of 0.91, 0.91, 0.85 and 0.84 for total IBD-CRN and of 0.97, 0.97, 0.95 and 0.85 for cancer. At 89% specificity, the combination of BMP3 and mNDRG4 detected 9/9 (100%) of CRC and 80% of dysplasia, 4/4 (100%) of high grade and 4/6 (67%) of low grade. CONCLUSION: These findings demonstrate the feasibility of stool DNA testing for non-invasive detection of colorectal neoplasia associated with inflammatory bowel disease.

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BACKGROUND AND OBJECTIVE: Standardization of surgical technique helps to reproduce excellent clinical outcomes, especially in teaching institutions. We aim to describe in detail our established approach for oncological right colectomy. TECHNIQUE: The right colon is mobilized in a five-step latero-inferior approach starting off with the terminal ileum, visualizing the duodenum and the head of pancreas. The ascending colon is dissected from the retroperitoneum, and takedown of the hepatic flexure is completed coming retrograde from the transverse colon. Transection of the remaining retroperitoneal attachments completes exposure of the duodenum and mobilization of the right colon. Ileocolic vessels are dissected out and divided close to their origin, and the mesocolon is divided. We then establish intestinal continuity by use of a side-to-side stapled technique. The arms of a linear cutting stapler are inserted via transverse incisions at the anti-mesenteric sides of the terminal ileum and the transverse colon (tenia) and fired. The enterotomy site is closed by removal of the specimen using a second transverse firing of the linear cutting stapler. An important final step is the reinforcement of the anastomotic ends and the crossing of the staple lines; an omental patch and closure of the mesenteric window are optional. CONCLUSION: The suggested standardized five-step lateral-to-medial dissection of the right colon and the three-step side-to-side stapled technique for ileo-colonic anastomosis are easy to learn and to reproduce. Careful adherence to pivotal technical details will help to obtain an optimal oncological outcome and a consistently low leak rate around 2%.

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BACKGROUND: This study determined survival and recurrence rates following curative resection of rectal cancer without radiotherapy. METHODS: This was a retrospective review of the Mayo Clinic database of patients with rectal cancer treated with curative intent using surgery alone from 1990 to 2006. Patients who received neoadjuvant chemotherapy or radiation therapy and those who had any postoperative radiotherapy were excluded. Details were collected from the database and patient records using a protocol approved by the institutional review board. RESULTS: Some 655 consecutive patients with rectal cancer treated with curative intent using surgery alone were identified; 397 had stage I disease, 125 stage II and 133 stage III. Four hundred and nine patients underwent anterior resection (AR) and 246 abdominoperineal resection (APR). Median follow-up was 62 months. The 5-year rate of local recurrence was 4·3 per cent, disease-free survival 90·0 per cent and cancer-specific survival 91·5 per cent. Stage-specific and all-stage disease-free survival did not differ significantly between AR and APR. The 5-year cumulative local recurrence rate was lower following AR than APR (3·6 versus 5·5 per cent; P = 0·321). There were only two patients with positive margins and type of operation was not significant on multivariable analysis. CONCLUSION: Well-performed, standardized APRs have similar local recurrence to AR. Radiation therapy may not confer much additional benefit.

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BACKGROUND: The Crohn's Disease Activity Index (CDAI) has been used in medical trials with scores <150 indicative of remission. Its value in assessing postoperative recurrence is unknown. The objective of this study was to explore the utility of the CDAI in determining the presence or absence of symptomatic disease recurrence in patients having previously undergone ileocolic resection for Crohn's disease. METHODS: Ninety-three patients underwent clinical and colonoscopic evaluation within 12 months of ileocolic resection. Endoscopic appearance was assessed using the Rutgeerts score (i0-i4). Symptomatic disease recurrence was defined by the composite of symptom severity warranting therapy and an endoscopic score ≥ i2. CDAI scores were calculated. Comparisons were made using the receiver operator curve (ROC). RESULTS: Thirty-nine (42%) patients had recurrent disease (22% symptomatic, 20% endoscopic only) at 12 months. Median CDAI for symptomatic recurrence was 198 (interquartile range [IQR]: 106-293), 80 for asymptomatic subjects (IQR 35-115). The area under the ROC curve for symptomatic disease and CDAI was 0.78 (95% confidence interval [CI] 0.64-0.91). Recurrence was best predicted by a CDAI of ≥ 148 (sensitivity 70%, specificity 81%). A strong linear relationship existed between the CDAI and Inflammatory Bowel Disease Questionnaire (r = 0.82). CONCLUSIONS: The CDAI performs reasonably well in the postoperative setting and 150 appears the best cutpoint for indicating symptomatic disease. However, it is likely not suitable for use as the primary outcome measure. These data suggest that a combination of symptom assessment plus endoscopic evidence of recurrence should remain the gold standard definition for assessing outcomes in postoperative CD trials.

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AIM: A permanent colostomy is considered to have an adverse impact on quality of life (QOL). However, functional outcomes following sphincter preservation also affect QOL. Our aim was to determine differences in QOL of patients undergoing coloanal anastomosis (CAA) or abdominoperineal resection (APR) for distal rectal cancer. METHOD: Eighty-five patients underwent CAA (72 with intestinal continuity and 13 with a stoma because of complications) and 83 patients underwent APR for a distal rectal cancer between 1995 and 2001 at a single institution and responded to our survey. QOL was evaluated using the EORTC QLQ-C30 and QLQ-CR38. RESULTS: Patients with CAA were younger than APR patients (mean age 57 vs 62 years, P < 0.001), but gender distribution, tumour stage and proportion of subjects receiving radiotherapy was not significantly different. Patients undergoing CAA had higher scores (better QOL) for physical functioning; lower scores (fewer symptoms) for fatigue, pain, financial difficulties, weight loss and chemotherapy side effects; and higher scores (more symptoms) for constipation and gastrointestinal symptoms compared with APR patients. CAA patients had higher scores (better QOL) for body image in men but not in women. Sexual functioning scores in men and women were lower (worse QOL) in CAA patients compared with APR patients. CONCLUSIONS: QOL after APR is comparable to sphincter preservation, although there are some differences that need to be considered. QOL and functional results should be taken into account with the oncological outcome when devising management strategy for distal rectal cancer.

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OBJECTIVE: To evaluate short-term outcomes after construction of synchronous colonic anastomoses without fecal diversion. METHOD: Using a prospective procedural database, all adult general surgery patients who underwent two synchronous segmental colon resections and anastomoses without ostomy at our institution from 1992-2007 were identified. Demographics, operative techniques, and 30-day outcomes are reported. Results are number (percent) of patients or median (interquartile range). RESULTS: Over 15 years, 69 patients underwent double colonic anastomoses [40 males, age 63 (45-76) years, BMI 25.3 (22.9-28.7) kg/m(2)]. Multiple colonic anastomoses were performed in one of every 201 colectomies during the study period (0.5%). The operation was an emergency in two (3%) cases; most cases were clean-contaminated 56 (81%). Ten (17%) cases were laparoscopic-assisted with a 44% conversion rate. Length of stay was seven (5-10) days. Overall 30-day morbidity was 36% including nine (13%) surgical site infections, two (2.9%) intra-abdominal abscesses requiring percutaneous drainage, and one (1.4%) wound dehiscence. There were no anastomotic leaks or fistulas, and two patients (2.9%) died within 30 days from pulmonary sepsis and complications from a distal anastomotic hemorrhage, respectively. CONCLUSIONS: Synchronous colon anastomoses without fecal diversion do not appear to be associated with an increased risk of complications and can be safely constructed in selected patients.

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BACKGROUND: The aim was to evaluate outcomes in patients with ulcerative colitis complicated by primary sclerosing cholangitis (PSC) who required ileal pouch-anal anastomosis (IPAA) and orthotopic liver transplantation (OLT). METHODS: A retrospective analysis was performed of 32 patients undergoing both IPAA and OLT between 1980 and 2006. Data were collected regarding demographics, indication for surgery, postoperative complications, and outcome of IPAA and OLT. RESULTS: Thirty-day mortality after either procedure was nil. The median preoperative Model for End-stage Liver Disease (MELD) score for the group with initial IPAA was 8 (range 6-20) and the postoperative score was 11 (range 6-19). At 1 and 10 years, 32 and 26 of the 32 liver grafts had survived, and 31 and 30 of the 32 pouches, respectively. Fourteen patients require daily medical therapy for chronic pouchitis. At a median follow-up of 3.6 (range 0.2-16.2) years after the second of two procedures, responding patients reported a median of 5.5 stools per day and 2 stools per night. CONCLUSION: IPAA and OLT are feasible and safe in patients requiring both procedures for ulcerative colitis and PSC. Functional outcomes are stable over time, despite an increased risk of chronic pouchitis.

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BACKGROUND: Ileal pouch-anal anastomosis (IPAA) is performed routinely for chronic ulcerative colitis. METHODS: Using data from a prospective database and annual standardized questionnaires, functional outcome, complications and quality of life (QoL) after IPAA were assessed. RESULTS: Some 1885 IPAA operations were performed for chronic ulcerative colitis over a 20-year period (mean follow-up 11 years). The mean age at the time of IPAA was 34.1 years, increasing from 31.2 years (1981-1985) to 36.3 years (1996-2000). The overall rate of pouch success at 5, 10, 15 and 20 years was 96.3, 93.3, 92.4 and 92.1 per cent respectively. Mean daytime stool frequency increased from 5.7 at 1 year to 6.4 at 20 years (P < 0.001), and also increased at night (from 1.5 to 2.0; P < 0.001). The incidence of frequent daytime faecal incontinence increased from 5 to 11 per cent during the day (P < 0.001) and from 12 to 21 per cent at night (P < 0.001). QoL remained unchanged and 92 per cent remained in the same employment. Seventy-six patients were eventually diagnosed with indeterminate colitis and 47 with Crohn's disease. CONCLUSION: IPAA is a reliable surgical procedure for patients requiring proctocolectomy for chronic ulcerative colitis and indeterminate colitis. The clinical and functional outcomes are excellent and stable for 20 years after operation.

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PURPOSE: Perineal hernias are infrequent complications of abdominoperineal operations with estimated historic prevalences (from the era where the perineal wound was left open) ranging from 0.6 to 7 percent. The purpose of this study was to identify the modern prevalence of postoperative perineal hernias, factors that may contribute to their development, and examine the methods of repair. METHODS: The Mayo Clinic patient database (1990-2000) was interrogated for the following data identifiers: incisional hernia, perineal hernia, abdominoperineal resection, proctocolectomy, and partial or total pelvic exenteration. All surviving patients were followed up to December 2005. The retrieved patient data was retrospectively analyzed. RESULTS: Of a total of 3,761 patients who underwent abdominoperineal resection (including nonrestorative proctocolectomy and pelvic exenteration) during the study period, 8 developed a perineal hernia (5 females). The median age at hernia presentation was 76 (range, 69-84) years, representing a median interval of 22 (range, 1-60) months from the original operation. All were smokers (> or =15 pack years) and five had received chemoradiotherapy for their original diagnosis. The commonest prevalence was found in patients who had undergone abdominoperineal resection (5/1,266) or pelvic exenteration (2/1,334). Only 1 of 1,161 patients developed a perineal hernia after proctocolectomy despite most being on perioperative immunosuppression for inflammatory bowel disease. Abdominal exploration and repair was performed in four patients whereas four underwent perineal repair (2 of each with mesh). None have recurred with a median follow-up of 36 (range, 6-60) months. CONCLUSIONS: Perineal hernias are rare complications of abdominoperineal surgery with a more common prevalence after cancer operations. Smoking and chemoradiotherapy, but not corticosteroid immunosuppression, may be factors. The abdominal approach has advantages over the perineal approach, but both are suitable with good medium-term results.

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PURPOSE: The aim of this study was to determine the optimal management of patients with colorectal cancer and abdominal aortic aneurysm in the elective situation. METHODS: All patients with a history of colorectal cancer and abdominal aortic aneurysm between 1986 and July 2000 were identified, and charts of those with concomitant disease were reviewed. RESULTS: A total of 435 patients with available charts were reviewed. Eighty-three patients with concomitant abdominal aortic aneurysm and colorectal cancer were identified. In 64 patients the colorectal cancer was treated first, and 44 of these patients had an abdominal aortic aneurysm less than 5 cm in diameter (average = 3.8 cm). No abdominal aortic aneurysm ruptured in the postoperative period. Median delay to colorectal cancer surgery from diagnosis was four days. Twenty patients with abdominal aortic aneurysm of 5 cm or greater (average = 5.4 cm) were treated for colorectal cancer first. In two of these patients (with abdominal aortic aneurysms sized 5 and 6.4 cm), the abdominal aortic aneurysm ruptured in the early postoperative period. Median delay to colorectal cancer resection was eight days. Twelve patients had both abdominal aortic aneurysm and colorectal cancer treated at the same time. The average size of the abdominal aortic aneurysm was 6.4 cm. Median delay from colorectal cancer diagnosis to resection was 15 days. No documented cases of graft infection occurred in this group; median follow-up was 3.2 years. Seven patients underwent abdominal aortic aneurysm repair before resection of colorectal cancer; in two patients, colorectal cancer was found at the time of resection. The average size of abdominal aortic aneurysm was 6 cm and median delay to treatment of colorectal cancer was 122 days, a statistically significant longer delay than in the other two groups (P < 0.0001). CONCLUSION: In patients with colorectal cancer and abdominal aortic aneurysm of 5 cm or more, treatment of colorectal cancer first may result in life-threatening rupture, whereas treatment of abdominal aortic aneurysm first may significantly delay treatment of colorectal cancer. Concomitant treatment seems to be a safe alternative. If anatomically suitable, the abdominal aortic aneurysm may be considered for endovascular repair followed by a staged colon resection. The presence of an abdominal aortic aneurysm less than 5 cm does not affect colorectal cancer treatment.

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BACKGROUND & AIMS: To determine accuracy of endoscopic ultrasound (EUS) and magnetic resonance imaging (MRI) for evaluation of Crohn's disease perianal fistulas. METHODS: Thirty-four patients with suspected Crohn's disease perianal fistulas were prospectively enrolled in a blinded study comparing EUS, MRI, and examination under anesthesia (EUA). Fistulas were classified according to Parks' criteria, and a consensus gold standard was determined for each patient. Acceptable accuracy was defined as agreement with the consensus gold standard for > or =85% of patients. RESULTS: Three patients did not undergo MRI; 1 did not undergo EUS or EUA; and consensus could not be reached for 1. Thirty-two patients had 39 fistulas (20 trans-sphincteric, 5 extra-sphincteric, 6 recto-vaginal, 8 others) and 13 abscesses. The accuracy of all 3 modalities was > or =85%: EUS 29 of 32 (91%, confidence interval [CI] 75%-98%), MRI 26 of 30 (87%, CI 69%-96%), and EUA 29 of 32 (91%, CI 75%-98%). Accuracy was 100% when any 2 tests were combined. CONCLUSIONS: EUS, MRI, and EUA are accurate tests for determining fistula anatomy in patients with perianal Crohn's disease. The optimal approach may be combining any 2 of the 3 methods.

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PURPOSE: Patients with diverticular disease may present with chronic symptoms but never develop diverticulitis. The purpose of this research was to review the outcome of surgical intervention in this subgroup of patients with atypical "smoldering" diverticular disease. METHODS: Records of 930 patients who underwent sigmoid resection for diverticular disease during a ten-year period at the Mayo Clinic in Rochester, Minnesota, were reviewed. Forty-seven patients (5 percent) fit our inclusion criteria for smoldering diverticular disease and underwent sigmoid colectomy with primary anastomosis. A minimum of 12 months of follow-up was completed in 68 percent of these patients. RESULTS: Evidence of acute or chronic inflammatory changes was present in 76 percent of resected specimens. Complete resolution of symptoms occurred in 76.5 percent, with 88 percent being pain free. CONCLUSIONS: We conclude that the diagnosis and presentation of atypical smoldering diverticular disease is an uncommon and poorly defined entity. However, sigmoid resection in this subgroup of patients is safe and is associated with resolution of symptoms in the majority of cases.

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PURPOSE: Information in the literature regarding salvage treatment for patients with locally recurrent colorectal cancer who have previously been treated with high or moderate dose external beam irradiation (EBRT) is scarce. A retrospective review was therefore performed in our institution to determine disease control, survival, and tolerance in patients treated aggressively with surgical resection and intraoperative electron irradiation (IOERT) +/- additional EBRT and chemotherapy. METHODS AND MATERIALS: From 1981 through 1994, 51 previously irradiated patients with recurrent locally advanced colorectal cancer without evidence of distant metastatic disease were treated at Mayo Clinic Rochester with surgical resection and IOERT +/- additional EBRT. An attempt was made to achieve a gross total resection before IOERT if it could be safely accomplished. The median IOERT dose was 20 Gy (range, 10--30 Gy). Thirty-seven patients received additional EBRT either pre- or postoperatively with doses ranging from 5 to 50.4 Gy (median 25.2 Gy). Twenty patients received 5-fluorouracil +/- leucovorin during EBRT. Three patients received additional cycles of 5-fluorouracil +/- leucovorin as maintenance chemotherapy. RESULTS: Thirty males and 21 females with a median age of 55 years (range 31--73 years) were treated. Thirty-four patients have died; the median follow-up in surviving patients is 21 months. The median, 2-yr, and 5-yr actuarial overall survivals are 23 months, 48% and 12%, respectively. The 2-yr actuarial central control (within IOERT field) is 72%. Local control at 2 years has been maintained in 60% of patients. There is a trend toward improved local control in patients who received > or =30 Gy EBRT in addition to IOERT as compared to those who received no EBRT or <30 Gy with 2-yr local control rates of 81% vs. 54%. Distant metastatic disease has developed in 25 patients, and the actuarial rate of distant progression at 2 and 4 years is 56% and 76%, respectively. Peripheral neuropathy was the main IOERT-related toxicity; 16 (32%) patients developed neuropathies (7 mild, 5 moderate, 4 severe). Ureteral narrowing or obstruction occurred in seven patients. All but one patient with neuropathy or ureter fibrosis received IOERT doses > or =20 Gy. CONCLUSION: Long-term local control can be obtained in a substantial proportion of patients with aggressive combined modality therapy, but long-term survival is poor due to the high rate of distant metastasis. Re-irradiation with EBRT in addition to IOERT appears to improve local control. Strategies to improve survival in these poor-risk patients may include the more routine use of conventional systemic chemotherapy or the addition of novel systemic therapies.

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PURPOSE: Preanastomotic recurrence and stricturing after surgery for ileocolic Crohn's disease is a frequent, unexplained phenomena that may lead to prompt reoperation. The aim of this study was to determine whether a wide-lumen stapled anastomosis (side-to-side, functional end-to-end) provides better outcome than a conventional sutured end-to-end anastomosis METHOD: A case-control comparative analysis of patients with Crohn's disease from two inflammatory bowel disease centers treated with wide-lumen stapled anastomosis and a matched (age and gender) group treated with conventional sutured end-to-end anastomosis was performed. RESULTS: A total of 138 patients with Crohn's disease were treated, 69 with wide-lumen stapled anastomosis and 69 with conventional sutured end-to-end anastomosis. Preoperative therapy, number of previous resections, indication for operation, and length of bowel resected were similar in both groups. Fewer complications occurred after wide-lumen stapled anastomosis (P = 0.048). A total of 55 patients developed recurrent Crohn's disease symptoms, 39 (57 percent) in the conventional sutured end-to-end anastomosis and 16 (24 percent) in the wide-lumen stapled anastomosis group. Median follow-up was 70 and 46 months, respectively. After conventional sutured end-to-end anastomosis 18 reoperations were required, 15 for anastomotic stricture and 3 for fistulization. After wide-lumen stapled anastomosis three reoperations were necessary, two for stricture and one for fistulization. The cumulative reoperation rate for anastomotic recurrence was significantly lower (P = 0.017; log-rank test) for the wide-lumen stapled anastomosis group. CONCLUSION: Wide-lumen stapled anastomosis is as safe as conventional sutured end-to-end anastomosis and results in a lower incidence of symptomatic recurrent Crohn's disease and need for reoperation. Further prospective study of the wide-lumen stapled anastomosis technique is necessary to define the precise role of this operation in patients with Crohn's disease.

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PURPOSE: This study examines the risk factors for developing perianal abscess or fistula formation after ileal pouch-anal anastomosis procedure for chronic ulcerative colitis or familial adenomatous polyposis. METHODS: A total of 1,457 patients with J-pouch, 1,304 (89.5 percent) with chronic ulcerative colitis and 153 (10.5 percent) with familial adenomatous polyposis who had a two-stage procedure without any evidence of previous perianal disease were included in the study. The effect of pouch-to-anal anastomosis type on perianal abscess or fistula formation was evaluated. RESULTS: A total of 108 patients (7.4 percent) had a perianal abscess or fistula after the ileal pouch-anal anastomosis procedure after at least one year of follow-up. No statistically significant difference was identified in fistula formation regarding the age and gender of the patients (P > 0.05), nor did the risk of fistula formation differ significantly between the patients with handsewn vs. stapled anastomoses (P > 0.05). However, patients with a diagnosis of chronic ulcerative colitis, compared with patients with familial adenomatous polyposis, had a statistically higher risk of developing abscess or fistula (P = 0.012). CONCLUSION: The most important risk factor in developing perianal sepsis in long-term patients with ileal pouch-anal anastomosis is the initial disease type. After excluding patients without Crohn's disease, the risk of developing an abscess or fistula was found to be significantly greater in patients with chronic ulcerative colitis compared with patients with familial adenomatous polyposis, and this risk is independent of anastomotic technique.

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Local recurrence rates following resection of rectal cancer with curative intent are extremely variable. An appropriate anatomic dissection of the rectum is essential to accomplish a complete removal of the tumor and has been described since the 1940s. In the last two decades, increased emphasis has been placed on the concept of total mesorectal excision as the fundamental technical step to minimize local recurrence rates. It is currently accepted, however, that complete removal of the mesorectum is not necessary for all rectal cancer cases. On the other hand, measurement of the free radial margins should be routinely performed to evaluate the local aggressiveness of the disease and assess the potential for a curative resection.

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