Effectiveness and Cost of Stenting in Ureteral Injury in Colorectal Surgeries in the US: 2015 - 2019

Background

Intraoperative ureteral injury (IUI) during colorectal surgery can have devastating consequences. This study aimed to assess the clinical and economic impact of pre-operative ureteral stenting in colorectal surgeries.

Methods

A retrospective cohort study was conducted using United States hospital data (October 2015 - December 2019). IUI incidence was examined across selected inpatient surgery types (elective colectomy, enterectomy, proctectomy, enterostomy, other colorectal procedures; emergency colectomy). Stenting effectiveness was evaluated as the difference in IUI and intraoperative detection rates between propensity score-matched groups. The additional hospital cost for stenting was also estimated considering the savings from IUIs that were potentially avoidable or detected by stenting.

Results

In total, 283,549 colorectal surgeries were analyzed. Across surgery types, stent use and IUI incidence ranged from 1.47% - 8.86% and from 0.91% - 2.90%, respectively. Stents were used in 6.75% of elective colectomy cases, where they were associated with an absolute reduction of 1.14 percentage points (95% CI: -1.85 to -1.03) in IUI rate and a 21.6 percentage point reduction in the intraoperative detection rate. Additional hospital costs for stenting ranged from $1,464 - $4,436 across surgery types. Additional results varied by case but were consistent with the colectomy example.

Conclusions

While effective in limited settings, the IUI reduction attributed to stenting and ability to shift IUI detection to the intraoperative setting could not offset the hospital cost of stent placement during colectomy (and colorectal surgery, in general). There thus remains an ongoing need in colorectal surgery for a universal, cost-effective solution to prevent IUI.

Abdominopelvic Surgery: Intraoperative Ureteral Injury and Prophylaxis in the United States, 2015-2019

INTRODUCTION

Preoperative ureteral catheterization/stenting (stenting) and intraoperative diagnostic cystoscopy (cystoscopy) may help prevent or identify intraoperative ureteral injuries (IUIs) during abdominopelvic surgery. In order to provide a comprehensive, single source of data for health care decision makers, this study aimed to catalog the incidence of IUI and rates of stenting and cystoscopy across a wide spectrum of abdominopelvic surgeries.

METHODS

We conducted a retrospective cohort analysis of United States (US) hospital data (October 2015-December 2019). IUI rates and stenting/cystoscopy use were investigated for gastrointestinal, gynecological, and other abdominopelvic surgeries. IUI risk factors were identified using multivariable logistic regression.

RESULTS

Among approximately 2.5 million included surgeries, IUIs occurred in 0.88% of gastrointestinal, 0.29% of gynecological, and 1.17% of other abdominopelvic surgeries. Aggregate rates varied by setting and for some surgery types were higher than previously reported, especially in certain higher-risk colorectal procedures. Prophylactic measures were generally employed at a relatively low frequency, with cystoscopy used in 1.8% of gynecological procedures and stenting used in 5.3% of gastrointestinal and 2.3% of other abdominopelvic surgeries. In multivariate analyses, stenting and cystoscopy use, but not surgical approach, were associated with a higher risk of IUI. Risk factors associated with stenting or cystoscopy, as well as those for IUI, largely mirrored the variables reported in the literature, including patient demographics (older age, non-White race, male sex, higher comorbidity), practice settings, and established IUI risk factors (diverticulitis, endometriosis).

CONCLUSION

Use of stenting and cystoscopy largely varied by surgery type, as did rates of IUI. The relatively low use of prophylactic measures suggests there may be an unmet need for a safe, convenient method of injury prophylaxis in abdominopelvic surgeries. Development of new tools, technology, and/or techniques is needed to help surgeons identify the ureter and avoid IUI and the resulting complications.

Does Completeness of the Mesorectal Excision Still Correlate With Local Recurrence?

BACKGROUND

Total mesorectal excision is the standard surgical procedure for rectal cancer treatment. Several studies have shown a close correlation between the prognosis of patients with rectal cancer and the completeness of the mesorectal specimen.

OBJECTIVE

To assess the correlation between macroscopic assessment of mesorectal excision and long-term oncological outcomes.

DESIGN

Retrospective analysis of an Institutional Review Board-approved database.

SETTINGS

Tertiary referral center.

PATIENTS

Patients with rectal cancer who were operated on between March 2016 and October 2019 were classified into 3 groups based on the mesorectal specimen quality: complete, near complete, and incomplete. Only patients with a follow-up of ≥2 years and without signs of preoperative distant disease were included.

MAIN OUTCOME MEASURES

Relationship between total mesorectal excision and local and distant recurrence rates in patients with rectal cancer.

RESULTS

A total of 124 patients (35.5% females) were included in the analysis, with a mean age of 58.1 (SD 12) years and a mean BMI of 26.4 (SD 4.59) kg/m². Neoadjuvant chemoradiation was administered to 71% of patients, whereas 13.7% received total neoadjuvant therapy. Restorative procedures were performed in 107 patients (86.3%), whereas 17 patients (13.7%) underwent abdominoperineal resection. The majority of mesorectal excision specimens (87.09%) were complete or near complete. Local recurrence rates were 6.3% (1/16) in the incomplete and 7.4% (8/108) in the complete/near complete group ( p = 0.86). Metachronous distant metastases occurred in 6 patients (37.5%) in the incomplete group and in 24 patients (22.2%) in the complete/near complete group (p = 0.18). Thus, specimen quality did not appear to impact disease-free survival.

LIMITATIONS

Retrospective, single-center study with relatively short follow-up.

CONCLUSIONS

In the era of a multidisciplinary approach and extensive use of neoadjuvant therapy, macroscopic completeness of total mesorectal excision may not be as valuable a prognosticator as in the past. Larger studies with longer follow-ups are needed to clarify these preliminary findings. See Video Abstract at http://links.lww.com/DCR/C129.

LA INTEGRIDAD DE LA ESCISIN MESORRECTAL TODAVA SE CORRELACIONA CON LA RECURRENCIA LOCAL

ANTECEDENTES:La escisión total desl mesorrecto es el estándar de oro para el tratamiento del cáncer de recto. Varios estudios han demostrado una estrecha correlación entre el pronóstico de los pacientes con cáncer de recto y la integridad espécimen mesorrectal.OBJETIVO:Evaluar la correlación entre la evaluación macroscópica de la escisión mesorrectal y los resultados oncológicos a largo plazo en pacientes con cáncer de recto.DISEÑO:Análisis retrospectivo de una base de datos aprobada por el IRB.ENTORNO CLINICO:El estudio se realizó en un centro de referencia terciario de una sola institución.PACIENTES:Todos los pacientes con cáncer de recto operados entre 3/2016-10/2019. Los pacientes se clasificaron en 3 grupos, según la calidad del espécimen mesorrectal: completo, casi completo e incompleto. Solo se incluyeron pacientes con seguimiento >2 años y sin signos de enfermedad a distancia preoperatoria.PRINCIPALES MEDIDAS DE RESULTADO:Identificar la relación entre la escisión mesorrectal total y las tasas de recurrencia local y a distancia en pacientes con cáncer de recto.RESULTADOS:Se incluyeron 124 pacientes (35,5% mujeres) con una edad media de 58,1 años (DE 12) y un índice de masa corporal medio de 26,4 (DE 4,59). Se administró quimiorradiación neoadyuvante al 71% de los pacientes, mientras que el 13,7% recibió terapia neoadyuvante total. Se realizaron procedimientos de restauración en 107 pacientes (86,3%), mientras que 17 pacientes (13,7%) se sometieron a resección abdominoperineal. La mayoría (87,09%) de los especímenes de escisión mesorrectal fueron completas o casi completas. Las tasas de recurrencia local fueron 1/16 (6,3%) en el grupo incompleto y 8/108 (7,4%) en el grupo completo/casi completo ( p = 0,86). Se produjeron metástasis a distancia metacrónicas en 6 pacientes (37,5%) en el grupo incompleto y 24 (22,2%) en el grupo completo/casi completo ( p = 0,18). Por lo tanto, la calidad del espécimen no pareció afectar la supervivencia libre de enfermedad.LIMITACIONES:Estudio retrospectivo de un solo centro con pequeño número de casos y seguimiento relativamente corto.CONCLUSIÓN:En la era de un enfoque multidisciplinario y el uso extensivo de la terapia neoadyuvante, la integridad macroscópica de la escisión total del mesorrecto, puede no ser un pronóstico tan valioso como en el pasado. Se necesitan estudios más amplios con períodos de seguimiento más prolongados para aclarar estos hallazgos preliminares. Consulte Video Resumen en http://links.lww.com/DCR/C129 . (Traducción-Dr. Fidel Ruiz Healy ).

Treatment and outcome trends and predictors of overall survival of rectal melanoma: Analysis of the National Cancer Database

BACKGROUND

We aimed to assess characteristics, treatment, and outcomes of rectal melanoma (RM).

METHODS

This retrospective cohort study looked at patients with RM from National Cancer Database (2004-2019) analyzed characteristics and outcomes of the entire cohort and across three time periods (2004-2009; 2010-2014; 2015-2019). Main outcome measures were change in treatment and survival trends across time periods and overall survival (OS).

RESULTS

641 patients (58.5% female; mean age: 68.2 ± 13.6 years) were included. OS rate was 26%; median survival duration was 17.9 (IQR: 15.93-20.67) months. There was a significant decrease in the use of chemotherapy (17.3%-6.6%; p = 0.001) and surgery (62.9%-41.8%; p = 0.00004) but increased use of immunotherapy (11.9%-52%; p < 0.001) across time periods. OS was longer in the last time period than in the first two (21.8 vs 16.8 vs 16.5 months; p = 0.09). Surgical excision was an independent predictor of improved OS (HR = 0.266, 95%CI: 0.089-0.789, p = 0.017) whereas older age (HR = 1.039, 95%CI: 1.007-1.072, p = 0.016), positive resection margins (HR = 5.06, 95%CI: 1.902-13.48, p = 0.001) and metastasis (HR = 34.62, 95%CI: 3.973-301.6, p = 0.001) were predictors of poor survival.

CONCLUSIONS

Over time, chemotherapy and surgery have been used less often in the treatment of RM while the use of immunotherapy increased by more than four-fold. Older age, surgical treatment, positive resection margins, and metastasis were predictive of survival of RM.

Outcomes of graciloplasty in the treatment of fecal incontinence: a systematic review and meta-analysis of the literature

BACKGROUND

Patients with refractory fecal incontinence symptoms can be treated with several surgical procedures including graciloplasty. Reported outcomes and morbidity rates of this procedure are highly variable. The aim of this study was to assess continence rate and safety of dynamic and adynamic graciloplasty.

METHODS

PubMed and Google Scholar databases were systematically searched from inception until January 2022 according to preferred reporting items for systematic reviews and meta-analyses (PRISMA) guidelines. Reviews, animal studies, studies with patients < 18 years or < 10 patients, with no success rate reported or non-English text, were excluded. Main outcome measures were overall continence and morbidity rates of each technique.

RESULTS

Fourteen studies were identified, incorporating a total of 450 patients (337 females), published between 1980 and 2021. Most common etiology of incontinence (35.5%-n = 160) was obstetric trauma followed by anorectal trauma (20%-n = 90). The weighted mean rate of continence after dynamic graciloplasty was 69.1% (95% CI 0.53-0.84%, I2 = 90%) compared to 71% (95% CI 0.54-0.87, I2 = 82.5%) after adynamic. Although the weighted mean short-term complication rate was lower in the dynamic group (26% versus 40%), when focusing on complications requiring intervention under general anesthesia, there was a much higher incidence (43.4% versus 10.5%) in the dynamic group. The weighted mean rate of long-term complications was 59.4% (95% CI 0.13-1.04%, I2 = 97.7%) in the dynamic group, almost twice higher than in the adynamic group [30% (95% CI - 0.03 to 0.63), I2 = 95.8%]. Median follow-up ranged from 1 to 13 years.

CONCLUSIONS

Our data suggest that graciloplasty may be considered for incontinent patients. Dynamic graciloplasty may harbor higher risk for reoperation and complications compared to adynamic. The fact that the functional results between adynamic and dynamic graciloplasty are equivalent and the morbidity rate of adynamic graciloplasty is significantly lower reinforce the graciloplasty as an option to treat appropriately selected patients with fecal incontinence.

Financial and Inpatient Burden of Adhesion-Related Small Bowel Obstruction: A Systematic Review of the Literature

BACKGROUND

Postoperative adhesions may occur after >90% of laparotomies and is the most common cause of small bowel obstruction (SBO). Despite the high incidence, there is a lack of data related to financial implications of adhesion-related SBO (ASBO). This systematic literature review of in-hospital costs for treatment of ASBO searched PubMed, Scopus and Google Scholar databases according to PRISMA guidelines. Exclusion criteria were reviews, editorials, clinical vignettes, studies of patients <18 years of age, studies with no English full text and studies assessing adhesiolysis for causes other than SBO or that used extrapolations with economic models. Main outcome measures were financial costs per patient and national costs.

RESULTS

Seven studies, published between 1999 and 2016, incorporating a total of 39 573 patients, were identified. Four were undertaken in European countries, one in the USA, 1 in New Zealand and 1 in Nigeria. Overall national costs regarding treatment of patients with ASBO ranged between $3.468 million and $1.77 billion. Median overall cost in the medical management group was $2371.5 ($1814-$2568) vs $12370 ($4914-$25321) in the surgical group. Median length of stay was 4 (3-7) days for patients conservatively treated and 11.5 (8-16.3) days for patients who underwent surgery. Median length of stay of operated patients on was almost triple that of patients conservatively managed.

CONCLUSIONS

Given the major financial implications of ASBO, further initiatives are needed to avoid operations for SBO when clinically appropriate and minimize delays taking patients with high suspicion of complete SBO to the operating room.

Endorectal advancement flap compared to ligation of inter-sphincteric fistula tract in the treatment of complex anal fistulas: A meta-analysis of randomized clinical trials

BACKGROUND

Rectal advancement flap and ligation of intersphincteric fistula tract are common procedures for treating complex anal fistula. The present meta-analysis aimed to compare the surgical outcomes of advancement flap and ligation of intersphincteric fistula tract.

METHODS

A Preferred Reporting Items for Systematic Reviews and Meta-Analyses-compliant systematic review of randomized clinical trials comparing the ligation of intersphincteric fistula tract and advancement flap was conducted. PubMed, Scopus, and Web of Science were searched through January 2023. The risk of bias was assessed using the Risk of Bias 2 tool and certainty of evidence with the Grading of Recommendations Assessment, Development and Evaluation approach. The primary outcomes were healing and recurrence of anal fistulas, and secondary outcomes were operative time, complications, fecal incontinence, and early pain.

RESULTS

Three randomized clinical trials (193 patients, 74.6% male) were included. The median follow-up was 19.2 months. Two trials had a low risk of bias, and 1 had some risk of bias. The odds of healing (odds ratio: 1.363, 95% confidence interval: 0.373-4.972, P = .639), recurrence (odds ratio: 0.525, 95% confidence interval: 0.263-1.047, P = .067), and complications (odds ratio: 0.356, 95% confidence interval: 0.085-1.487, P = .157) were similar between the 2 procedures. Ligation of intersphincteric fistula tract was associated with a significantly shorter operation time (weighted mean difference: -4.876, 95% confidence interval: -7.988 to -1.764, P = .002) and less postoperative pain (weighted mean difference: -1.030, 95% confidence interval: -1.418 to -0.641, 0.198, P < .001, I² = 3.85%) than advancement flap. Ligation of intersphincteric fistula tract was associated with marginally lower odds of fecal incontinence than advancement flap (odds ratio: 0.27, 95% confidence interval: 0.069-1.06, P = .06).

CONCLUSION

Ligation of intersphincteric fistula tract and advancement flap had similar odds of healing, recurrence, and complications. The odds of fecal incontinence and extent of pain after ligation of intersphincteric fistula tract were lower than after advancement flap.

Can preoperative CT/MR enterography preclude the development of Crohn's disease-like pouch complications in ulcerative colitis patients undergoing J pouch surgery?

AIM

We aimed to determine whether ulcerative colitis patients with preoperative negative computed tomography or magnetic resonance enterography (CTE/MRE) were less likely to develop Crohn's disease-like pouch complications (CDLPC) and establish risk factors and predictors for developing CDLPC.

METHODS

This was a single centre retrospective analysis of patients with ulcerative colitis (UC) and inflammatory bowel disease unclassified (IBDU) who underwent total proctocolectomy with ileal J-pouch between January 2010 and December 2020. The study group comprised patients with negative preoperative CTE/MRE and the control group included patients operated without preoperative CTE/MRE.

RESULTS

A total of 131 patients were divided into the negative CTE/MRE study group (76 [58%] patients) and control group (55 [42%] patients). There were no significant differences in incidence rates (21% vs. 23.6%, p = 0.83), time to developing CDLPC from ileostomy closure (22.3 vs. 23.8 months; p = 0.81), pouchitis rates (23.6% vs. 27.2%; p = 0.68), or pouch failure rates (5.2 vs. 7.2; p = 0.71). Multivariate Cox regression analysis showed backwash ileitis (HR 4.1; p = 0.03, CI: 1.1-15.1), severe pouchitis (HR 3.4; p = 0.039, CI: 1.0-10.9), and history of perianal disease (HR 3.4; p = 0.017, CI: 1.4-39.6) were independent predictors for CDLPC.

CONCLUSIONS

Negative findings on MRE/CTE prior to J-pouch surgery in ulcerative colitis should be interpreted with caution as it is does not reliably exclude or predict development of CDLPC. These patients should be preoperatively counselled concerning the possibility of developing CDLPC regardless of lack of positive findings on preoperative CTE/MRE. Patients with backwash ileitis with a previous history of perianal disease should be informed of the potentially increased risk of developing such complications.

Robotic and laparoscopic colectomy: propensity score-matched outcomes from a national cancer database

BACKGROUND

Laparoscopic and robotic approaches to colonic cancer surgery appear to provide similar outcomes. The present study aimed to compare short-term and survival outcomes of laparoscopic and robotic colectomy for colonic cancer.

METHODS

This retrospective review of patients with stage I-III colonic cancer who underwent laparoscopic or robotic colonic resection was undertaken using data from the National Cancer Database (2013-2019). Patients were matched using the propensity score matching method. The primary outcome was 5-year overall survival. Secondary outcomes included conversion to open surgery, duration of hospital stay, 30- and 90-day mortality, unplanned readmission, and positive resection margins.

RESULTS

The original cohort included 40 457 patients with stage I-III colonic adenocarcinoma, with a mean(s.d.) age of 67.4(12.9) years. Some 33 860 (83.7 per cent) and 6597 (17.3 per cent) patients underwent laparoscopic and robotic colectomy respectively. After matching, 6210 patients were included in each group. Robotic colectomy was associated with marginally longer overall survival for women, and patients with a Charlson score of 0, stage II-III disease or left-sided tumours. The robotic group had a significantly lower rate of conversion (6.6 versus 11 per cent; P < 0.001) and shorter hospital stay (median 3 versus 4 days) than the laparoscopic group. The two groups had similar rates of 30-day mortality (1.3 versus 1 per cent for laparoscopic and robotic procedures respectively), 90-day mortality (2.1 versus 1.8 per cent), 30-day unplanned readmission (3.7 versus 3.8 per cent), and positive resection margins (2.8 versus 2.5 per cent).

CONCLUSION

In this study population, robotic colectomy was associated with less conversion to open surgery and a shorter hospital stay compared with laparoscopic colectomy.

Systematic review and meta-analysis of randomized clinical trials on the treatment of low anterior resection syndrome

BACKGROUND

We conducted a systematic review of randomized clinical trials on treating low anterior resection syndrome to help inform current practice.

METHODS

This Preferred Reporting Items for Systematic Reviews and Meta-Analyses-compliant systematic review of randomized clinical trials involved different treatments for low anterior resection syndrome. The risk of bias 2 tool was used to assess the risk of bias. The main outcomes were improvement in low anterior resection syndrome after treatment assessed by change in low anterior resection syndrome, fecal incontinence scores, and adverse treatment effects.

RESULTS

After an initial screening of 1,286 studies, 7 randomized clinical trials were included. Sample sizes ranged between 12 to 104 patients. Posterior tibial nerve stimulation was the most frequently assessed treatment in 3 randomized clinical trials. The weighted mean difference between posterior tibial nerve stimulation and medical treatment or sham therapy in follow-up low anterior resection syndrome score (-3.31, P = .157) was insignificant. Transanal irrigation reduced major low anterior resection syndrome symptoms by 61.5% compared with 28.6% after posterior tibial nerve stimulation with a significantly lower 6-month follow-up low anterior resection syndrome score. Pelvic floor training achieved better improvement in low anterior resection syndrome than standard care (47.8% vs 21.3%) at 6 months, but this was not maintained at 12 months (40.0% vs 34.9%). Ramosetron was associated with a greater short-term improvement in major low anterior resection syndrome (23% vs 8%) and a lower low anterior resection syndrome score (29.5 vs 34.6) at 4-weeks follow-up than Kegels or Sitz baths. No significant improvement in bowel function was noted after probiotics use as probiotics and placebo had similar follow-up low anterior resection syndrome scores (33.3 vs 36).

CONCLUSION

Transanal irrigation was associated with improvement in low anterior resection syndrome according to 2 trials, and ramosetron showed promising short-term results in one trial. Posterior tibial nerve stimulation had a marginal benefit compared with standard care. In contrast, pelvic floor training was associated with short-term symptomatic improvement, and probiotics showed no tangible improvement in low anterior resection syndrome symptoms. Firm conclusions cannot be drawn due to the small number of trials published.

Surgical treatment of stomal prolapse: A systematic review and meta-analysis of the literature

AIM

This study aimed to assess success, recurrence, and overall complication rates among different surgical procedures for stomal prolapse.

METHODS

This study was a PRISMA-compliant systematic review. PubMed, Scopus, and Google Scholar were searched until March 2022. Studies that assessed surgical treatments of stomal prolapse in adults were included. The primary outcome was recurrence of stomal prolapse and the secondary outcome was 30-day complications. A random-effect meta-analysis was used to estimate the weighted mean rates of recurrence.

RESULTS

Six studies published (111 patients; 103 males) were included. 52 (46.8%) patients had end colostomies, 35 (31.5%) had loop colostomies. Seven procedures were assessed and included local stoma reconstruction (40%), stapled local repair (27%), modified Altemeier technique (10%), mesh strip repair (9%), stoma relocation (6%) redo laparotomy repair (5%), and colectomy and end ileostomy (3%). The weighted mean recurrence rate after local stoma reconstruction was 37.2% (95% CI: -1.8 to 76.3), higher than that after the stapled local repair technique (14.9%; 95% CI: 1.7-28.2). The crude recurrence rate of the modified Altemeier technique was 20%, and of stoma relocation was 66.6%. No recurrence was detected after the mesh strip technique (n = 10). The median follow-up ranged between 7 months and 2.5 years.

CONCLUSION

Several surgical techniques are available to treat stomal prolapse. Local stoma reconstruction may be associated with high rates of recurrence while the stapled local repair and modified Altemeier procedure has relatively low recurrence. Further larger studies are needed to compare the efficacy of these techniques.

Predictors and outcomes of positive surgical margins after local excision of clinical T1 rectal cancer: A National Cancer Database analysis

BACKGROUND

Transanal local excision and the use of specialized platforms has become increasingly popular for early-stage rectal cancer. Predictors and outcomes of positive resection margins following transanal local excision for early-stage rectal cancer have yet to be explored.

METHODS

This was a retrospective analysis of the National Cancer Database of all patients with clinical nonmetastatic node negative T1 rectal adenocarcinoma who underwent transanal local excision from 2004 to 2017. Patients with positive surgical margins were compared to those with negative resection margins to determine factors associated with predictors and outcomes of positive surgical margins after transanal local excision. The main outcome measure was overall survival.

RESULTS

Of 318,548 patients with rectal adenocarcinoma in the National Cancer Database, 9,078 (2.8%) met the inclusion criteria. The positive surgical margins rate was 7.4%. Predictors of positive surgical margins were older age (odds ratio, 1.03; P < .001), higher Charlson comorbidity index (odds ratio, 1.24; P = .004), poorly differentiated carcinomas (odds ratio, 1.89; P < .001), mucinous (odds ratio, 2.36; P = .003) and signet-ring cell carcinomas (odds ratio, 4.7; P = .048). Independent predictors of reduced survival were older age (hazard ratio, 1.062; P < .001), male sex (hazard ratio, 1.214; P = .011), Charlson comorbidity index 3 (hazard ratio, 1.94; P < .001), pathologic T2 (hazard ratio, 1.27; P = .036) and T3 stages (hazard ratio, 1.77; P = .006), poorly differentiated carcinomas (hazard ratio, 1.47; P = .008), and positive surgical margins (hazard ratio, 1.374; P = .018). The positive surgical margins group's median overall survival was significantly shorter (88 vs 159.3 months, P < .001).

CONCLUSION

Positive surgical margins after transanal local excision for early-stage node-negative rectal cancer adversely affects prognosis. Older male patients with higher Charlson comorbidity index scores and poorly differentiated mucinous or signet cell histology tumors are at risk for positive surgical margins. Patient selection according to these suggested criteria may help avoid positive surgical margins.

The importance of surgical resection in the management of rectal sarcoma: A national cancer database analysis of 133 cases

BACKGROUND AND PURPOSE

Rectal sarcomas (RS) are rare malignant tumors with a very poor prognosis. This study aimed to assess the characteristics, treatment, and outcomes of RS in the United States.

METHODS

This study was a retrospective analysis of the National Cancer Database (NCDB) from 2004 to 2019 of patients with a diagnosis of RS. The main outcome measures were overall survival (OS) and its predictors.

RESULTS

133 RS patients (39.1% female) with a mean age of 65.7 ± 15.6 years were included in the study. Mean tumor size was 6.1 ± 3 cm. The crude OS rate was 22.5% and median survival duration was 10.1 (IQR: 3.2-21) months. Factors associated with an improved OS on were private insurance (HR = 0.23, p = 0.001) and undergoing surgery (HR 0.23, p < 0.001), Factors associated with poor survival were age (HR 1.02, p = 0.005), male sex (HR 2.27, p = 0.001), Charlson score of 3 (HR 5.17, p = 0.003), and positive resection margins (HR: 2.64, p = 0.01). Multivariate Cox regression analysis revealed that male sex (HR 2.16, p = 0.04) and positive resection margins (HR 2.31, p = 0.03) were predictors of poor survival whereas surgery was an independent predictor of improved OS (HR 0.321, p < 0.001) CONCLUSIONS: RS is a very rare rectal malignancy with an even poorer prognosis than previously reported. However, undergoing surgery with curative intent while obtaining negative margins may confer better OS.

Trends in the Characteristics, Treatment, and Outcomes of Rectal Adenocarcinoma in the US From 2004 to 2019: A National Cancer Database Analysis

Importance

Rectal cancer management has significantly evolved over the last 2 decades.

Objective

This study aimed to evaluate trends in the characteristics, treatment, and outcomes of rectal adenocarcinoma across 16 years.

Design, Setting, and Participants

This retrospective, observational case series study used data from the National Cancer Database (NCDB) to evaluate patients diagnosed with rectal adenocarcinoma from 2004 through 2019. Data analysis was performed from March to May 2022.

Exposures

Trends in the treatment and outcomes of rectal adenocarcinoma in the US between 2004 and 2019 were explored. This period was subdivided into 4 equal periods: 2004-2007, 2008-2011, 2012-2015, and 2016-2019.

Main Outcomes and Measures

Patient and tumor characteristics, treatments, short-term outcomes, and overall survival.

Results

A total of 318 548 patients diagnosed with rectal adenocarcinoma were included in the analysis, 191 369 (60.1%) of whom were males and 127 179 (39.9%%) were females. The mean (SD) age of the patients was 63.5 (13.4) years, and 46 824 patients (14.8%) were younger than 50 years. Among the patients, 10 859 (3.4%) were of Asian race and ethnicity, 28 464 (8.9%) were Black, and 271 236 (85.1%) were White. The percentage of patients younger than 50 years who were diagnosed with rectal cancer increased by 1.5%, from 13.9% in period 1 to 15.4% in period 4. Patients in the last period (2016-2019) presented more often with stages III (36.2% vs 30.2% vs 25.0% vs 23.4%; P < .001) and IV (21.5% vs 19.3% vs 18.1% vs 18.6%; P < .001) disease compared with those in the remaining 3 periods. The use of chemotherapy (36.8% vs 48.1% vs 49.1% vs 47.0%; P < .001) and immunotherapy (0.4% vs 0.2% vs 3.5% vs 6.5%; P < .001) significantly increased across the 4 periods. Although neoadjuvant radiotherapy was used more often across the periods studied (28.6% in period 1 to 34.3% in period 4), the use of adjuvant radiotherapy was reduced by half (12.9% to 6.0%). The median (IQR) time from diagnosis to definitive surgery increased from 95 (15-126) days in period 1 to 128 (47-158) days in period 4. The rate of use of open surgery decreased by half (60.1% in period 2 to 30.1% in period 4), and the use of robotic surgery significantly increased (5.2% in period 2 to 28.4% in period 4). The conversion rate was significantly reduced (11.2% in period 2 to 7.3% in period 4) and the median (IQR) hospital stay decreased by 2 days, from 6 (3-9) days to 4 (2-7) days. The median (IQR) overall survival significantly increased across the periods (from 83.1 months [95% CI, 81.8-84.6 months] in period 1 to 92.1 months [95% CI, 90.2-93.6 months] in period 3; P < .001).

Conclusion and Relevance

The findings of this case series study suggest a treatment trend of increased use of chemotherapy, immunotherapy, sphincter-saving surgery, and minimally invasive surgery. In addition, the time between diagnosis and definitive surgery increased by a median of 33 days. This treatment trend was associated with a significant improvement in the overall survival, reduction in the conversion rate by 3.9%, and a 2-day shorter hospital stay. These findings have major clinical relevance to the management of rectal cancer. The improvements seen in short-term outcomes and survival of patients diagnosed with rectal cancer can probably be attributed to the treatment trends observed. Continued improvement in outcomes warrant further updates in treatments.

Could meeting the standards of the National Accreditation Program for Rectal Cancer in the National Cancer Database improve patient outcomes?

AIM

The National Accreditation Program for Rectal Cancer (NAPRC) was developed to improve rectal cancer patient outcomes in the United States. The NAPRC consists of a set of process and outcome measures that hospitals must meet in order to be accredited. We aimed to assess the potential of the NAPRC by determining whether achievement of the process measures correlates with improved survival.

METHODS

The National Cancer Database was used to identify patients undergoing curative proctectomy for non-metastatic rectal cancer from 2010 to 2014. NAPRC process measures identified in the National Cancer Database included clinical staging completion, treatment starting <60 days from diagnosis, carcinoembryonic antigen level measured prior to treatment, tumour regression grading and margin assessment.

RESULTS

There were 48 669 patients identified with a mean age of 62 ± 12.9 years and 61.3% of patients were men. The process measure completed most often was assessment of proximal and distal margins (98.4%) and the measure completed least often was the serum carcinoembryonic antigen level prior to treatment (63.8%). All six process measures were completed in 23.6% of patients. After controlling for age, gender, comorbidities, annual facility resection volume, race and pathological stage, completion of all process measures was associated with a statistically significant mortality decrease (Cox hazard ratio 0.88, 95% CI 0.81-0.94, P < 0.001).

CONCLUSION

Participating institutions provided complete datasets for all six process measures in less than a quarter of patients. Compliance with all process measures was associated with a significant mortality reduction. Improved adoption of NAPRC process measures could therefore result in improved survival rates for rectal cancer in the United States.

A National Cancer Database analysis of the predictors of unplanned 30-day readmission after proctectomy for rectal adenocarcinoma: The CCF RETURN-30 Score

BACKGROUND

Unplanned 30-day readmission is common after major surgery, including rectal cancer surgery. The present study aimed to assess the rate and predictors of unplanned 30-day readmission after proctectomy for rectal cancer.

METHODS

This was a retrospective case-control study using data from the National Cancer Database. Patients with non-metastatic rectal cancer who underwent proctectomy were included, and patients who required readmission within 30 days after discharge were compared to patients who were not readmitted in regard to patient and treatment baseline factors to determine the predictors of 30-day readmission after proctectomy. The main outcome measures were the rate and predictors of 30-day unplanned readmission and the impact of readmission on short-term mortality and overall survival.

RESULTS

A total of 55,181 patients (60.9% men) with a mean age of 61.2 years were included. The 30-day readmission rate was 7.07% (95% confidence interval: 6.9-7.3). A Charlson score of 0 (odds ratio: 0.75, P < .001), Medicare insurance (odds ratio: 0.836, P = .04), and private insurance (odds ratio: 0.73, P = .0003) were predictive of a lower likelihood of 30-day readmission, whereas urban living area (odds ratio: 1.18, P = .01), rural living area (odds ratio: 1.65%, P = .0004), neoadjuvant radiation therapy (odds ratio: 1.37, P = .001), pull-through coloanal anastomosis (odds ratio: 1.37, P = .0005), conversion to open surgery (odds ratio: 1.25, P = .001), and hospital stay ≥6 days (odds ratio: 1.02, P < .001) were predictive of a higher likelihood of 30-day readmission. Readmitted patients had a higher rate of 90-day mortality (3.1% vs 2.1%, P < .001) and a lower 5-year overall survival (67.0% vs 72.7%, P < .001) than non-readmitted patients. Using the weighted ORs of the significant predictors of 30-day readmission, a risk score, the Cleveland Clinic Florida REadmission afTer sUrgery for Rectal caNcer in 30 days (RETURN-30) score, was developed.

CONCLUSION

Comorbidities, residence in urban or rural areas, neoadjuvant radiation therapy, pull-through coloanal anastomosis, conversion to open surgery, and extended hospital stay were predictive of a higher risk of 30-day readmission. Patients who were readmitted had a higher rate of 90-day mortality and a lower 5-year overall survival.

Risk factors and predictors of 30-day complications and conversion to open surgery after repeat ileocolic resection of Crohn's disease

BACKGROUND

Repeat ileocolic resection of Crohn's disease (CD) is a challenging procedure that can be followed by a high rate of complications. The present study aimed to identify the factors associated with complications and conversion to open surgery in patients undergoing repeat ileocolic resection for CD.

METHODS

This was a retrospective review of an IRB-approved prospective database of CD patients who underwent elective repeat ileocolic resection between 2011 and 2021. Univariate and multivariate analyses were performed to determine the predictive factors of postoperative complications and conversion to open surgery.

RESULTS

The present study included 65 patients (47.7% male) with a mean age of 52.5 years. 43.1% of patients developed short-term complications, most of which were of Clavien-Dindo class I-II. Longer operative time was found to be an independent predictor of complications (OR 1.016, p = 0.014). The preoperative use of biological therapy was an independent protective factor from complications (OR 0.243, p = 0.016). The only significant risk factor of a longer operation time was higher BMI (OR 3.11, p = 0.044). Overall, 28.1% of laparoscopic procedures were converted to laparotomy. According to bivariate analysis, previous ileocolic open resection (OR 190, p < 0.0001), longer operation time (OR 1.01; p = 0.036), and takedown of incidental fistula of incidental fistula (OR 3.78, p = 0.04) were associated with higher odds of conversion to open surgery.

CONCLUSION

Longer operation time was significantly associated with and predictive of complications after repeat ileocolic resection of CD. Preoperative biological therapy was predictive of a lower rate of complications. Previous ileocolic resection by laparotomy, longer operation time, and takedown of fistula were associated with a higher likelihood of conversion to open surgery.