Room for Improvement: The Impact of Guideline-Recommended Extended Thromboprophylaxis in Patients Undergoing Abdominal Surgery for Colorectal and Anal Cancer at a Tertiary Referral Center

BACKGROUND

Venous thromboembolism occurs in approximately 2% of patients undergoing abdominal and pelvic surgery for cancers of the colon, rectum, and anus and is considered preventable. The American Society of Colon and Rectal Surgeons recommends extended prophylaxis in high-risk patients, but there is low adherence to the guidelines.

OBJECTIVE

This study aims to analyze the impact of venous thromboembolism risk-guided prophylaxis in patients undergoing elective abdominal and pelvic surgeries for colorectal and anal cancers from 2016 to 2021.

DESIGN

This was a retrospective analysis.

SETTING

The study was conducted at a multisite tertiary referral academic health care system.

PATIENTS

Patients who underwent elective abdominal or pelvic surgery for colon, rectal, or anal cancer.

MAIN OUTCOME MEASURES

Receipt of Caprini-guided venous thromboembolism prophylaxis, 90-day postoperative rate of deep vein thrombosis, pulmonary embolism, venous thromboembolism, and bleeding events.

RESULTS

A total of 3504 patients underwent elective operations, of whom 2224 (63%) received appropriate thromboprophylaxis in the inpatient setting. In the postdischarged cohort of 2769 patients, only 2% received appropriate thromboprophylaxis and no thromboembolic events were observed. In the group receiving inappropriate thromboprophylaxis, at 90 days postdischarge, the deep vein thrombosis, pulmonary embolism, and venous thromboembolism rates were 0.60%, 0.40%, and 0.88%, respectively. Postoperative bleeding was not different between the 2 groups.

LIMITATIONS

Limitations to our study include its retrospective nature, use of aggregated electronic medical records, and single health care system experience.

CONCLUSION

Most patients in our health care system undergoing abdominal or pelvic surgery for cancers of the colon, rectum, and anus were discharged without appropriate Caprini-guided venous thromboembolism prophylaxis. Risk-guided prophylaxis was associated with decreased rates of inhospital and postdischarge venous thromboembolism without increased bleeding complications. See Video Abstract .

MARGEN DE MEJORA EL IMPACTO DE LA TROMBOPROFILAXIS RECOMENDADA POR LAS DIRECTRICES EN PACIENTES SOMETIDOS A CIRUGA ABDOMINAL POR CNCER COLORRECTAL Y ANAL EN UN CENTRO DE REFERENCIA TERCIARIO

ANTECEDENTES:El tromboembolismo venoso ocurre en aproximadamente el 2% de los pacientes sometidos a cirugía abdominal y pélvica por cánceres de colon, recto y ano, y se considera prevenible. La Sociedad Estadounidense de Cirujanos de Colon y Recto recomienda una profilaxis prolongada en pacientes de alto riesgo, pero el cumplimiento de las directrices es bajo.OBJETIVO:Este estudio tiene como objetivo analizar el impacto de la profilaxis guiada por el riesgo de tromboembolismo venoso (TEV) en pacientes sometidos a cirugías abdominales y pélvicas electivas por cáncer colorrectal y anal entre 2016 y 2021.DISEÑO:Este fue un análisis retrospectivo.AJUSTE:El estudio se llevó a cabo en un sistema de salud académico de referencia terciaria de múltiples sitios.PACIENTES:Pacientes sometidos a cirugía abdominal o pélvica electiva por cáncer de colon, recto o ano.PRINCIPALES MEDIDAS DE RESULTADO:Recepción de profilaxis de tromboembolismo venoso guiada por Caprini, tasa postoperatoria de 90 días de trombosis venosa profunda, embolia pulmonar, tromboembolismo venoso y eventos de sangrado.RESULTADOS:Un total de 3.504 pacientes se sometieron a operaciones electivas, de los cuales 2.224 (63%) recibieron tromboprofilaxis adecuada en el ámbito hospitalario. En el cohorte de 2.769 pacientes después del alta, solo el 2% recibió tromboprofilaxis adecuada en la que no se observaron eventos tromboembólicos. En el grupo que recibió tromboprofilaxis inadecuada, a los 90 días después del alta, las tasas de trombosis venosa profunda, embolia pulmonar y tromboembolia venosa fueron del 0,60%, 0,40% y 0,88%, respectivamente. El sangrado posoperatorio no fue diferente entre los dos grupos.LIMITACIONES:Las limitaciones de nuestro estudio incluyen su naturaleza retrospectiva, el uso de registros médicos electrónicos agregados y la experiencia de un solo sistema de atención médica.CONCLUSIÓN:La mayoría de los pacientes en nuestro sistema de salud sometidos a cirugía abdominal o pélvica por cánceres de colon, recto y ano fueron dados de alta sin una profilaxis adecuada de TEV guiada por Caprini. La profilaxis guiada por el riesgo se asoció con menores tasas de tromboembolismo venoso hospitalario y dado de alta sin un aumento de las complicaciones de sangrado. (Traducción-Dr. Aurian Garcia Gonzalez ).

Features associated with travel distance for radical cystectomy in Florida: Implications for access to care

INTRODUCTION

Characteristics associated with travel distance for radical cystectomy (RC) remain incompletely defined but are needed to inform efforts to bridge gaps in care. Therefore, we assessed features associated with travel distance for RC in a statewide dataset.

METHODS

We identified RC patients in the Florida Inpatient Discharge dataset from 2013 to 2019. Travel distance was estimated using zip code centroids. The primary outcome was travel >50 miles for RC. Secondary outcomes included inpatient mortality, nonhome discharge, and inpatient complications. U.S. County Health Rankings were included as model covariates. Mixed effects logistic regression models accounting for clustering within hospitals were utilized.

RESULTS

We identified 4,209 patients, of whom 2,284 (54%) traveled <25 miles, 654 (16%) traveled 25 to 50 miles, and 1271 (30%) traveled >50 miles. Patients who traveled >50 miles primarily lived in central and southwest Florida. Following multivariable adjustment, patients traveling >50 miles were less likely to be Hispanic/Latino (odds ratio [OR] 0.35, 95% CI: 0.23-0.51), and more likely to reside in a county with the lowest health behavior (OR 6.48, 95% CI: 3.81-11.2) and lowest socioeconomic (OR 7.63, 95% CI: 5.30-11.1) rankings compared to those traveling <25 miles (all P < 0.01). Travel distance >50 miles was associated with treatment at a high-volume center and significantly lower risks of inpatient mortality, nonhome discharge, and postoperative complications (all P < 0.02).

CONCLUSION

These data identify characteristics of patients and communities in the state of Florida with potentially impaired access to RC care and can be used to guide outreach efforts designed to improve access to care.

The Impact of Caprini Guideline Indicated Venous Thromboembolism Prophylaxis in Colorectal Surgery Patients: Experience of a Single Health System

BACKGROUND

Venous thromboembolism (VTE) is the most common cause of preventable mortality following colorectal surgery (CRS), occurring in about 2% of patients. As a result, prophylaxis including discharge chemoprophylaxis is recommended. While VTE risk assessment tools are available, the consistent adoption and utilization of these tools remains elusive. Our study objectives were to determine the utilization and impact of risk adjusted VTE prophylaxis in CRS patients.

STUDY DESIGN

CRS cases performed between 1/1/2016 and 5/31/2021 were retrospectively analyzed. Caprini score and implemented VTE prophylaxis measures were determined. The primary outcome measure was receiving Caprini guideline indicated VTE prophylaxis. Secondary outcomes included VTE and bleeding. Categorical variables were compared by chi-square and Fisher's exact tests, and continuous variables by Kruskal-Wallis test. Logistic regression models were used to determine predictors of receiving appropriate VTE prophylaxis or experiencing postoperative VTE and bleeding.

RESULTS

10,422 CRS cases were analyzed and 90.6% were high risk for VTE. In-hospital appropriate prophylaxis rates in low, moderate, high, and very high-risk category patients were 91.2%, 56.1%, 61.0%, and 63.1%, respectively. Inpatient VTE was reduced by 75% in those receiving appropriate VTE prophylaxis. At discharge, 5.8% of patients received appropriate prophylaxis, in whom there were no VTE events at 30- and 90 days from discharge. Increasing Caprini score positively correlated with VTE risk in both the inpatient and discharge cohorts, but inversely correlated with the likelihood of receiving appropriate prophylaxis at discharge (OR .31, P <.0001).

CONCLUSION

Caprini guideline indicated VTE prophylaxis in CRS patients reduced VTE events without increasing bleeding complications.

Risk factors for surgical site infections and trends in skin closure technique after diverting loop ileostomy reversal: A multi-institutional analysis

BACKGROUND

Surgical site infections (SSIs) are one of the most common complications following diverting loop ileostomy (DLI) closures. This study assesses SSIs after DLI closure and the temporal trends in skin closure technique.

METHODS

A retrospective review was conducted using the American College of Surgeons National Surgical Quality Improvement Program database for adult patients who underwent a DLI closure between 2012 and 2021 across a multistate health system. Skin closure technique was categorized as primary, primary ​+ ​drain, or purse-string closure. The primary outcome was SSI at the former DLI site.

RESULTS

A SSI was diagnosed in 5.7% of patients; 6.9% for primary closure, 5.7% for primary closure ​+ ​drain, and 2.7% for purse-string closure (p ​= ​0.25). A diagnosis of Crohn's disease, diverticular disease, and increasing operative time were significant risk factors for SSIs. There was a positive trend in the use of purse-string closure over time (p ​< ​0.0001).

CONCLUSIONS

This study identified a low SSI rate after DLI closure which did not vary significantly based on skin closure technique. Utilization of purse-string closure increased over time.

Caprini assessment utilization and impact on patient safety in gynecologic surgery

PURPOSE

Postoperative venous thromboembolism (VTE) can potentially be associated with significant morbidity, mortality, and healthcare costs. The aim of this study was to determine the utilization of Caprini guideline indicated VTE in elective gynecologic surgery patients and its impact on postoperative VTE and bleeding complications.

METHODS

This was a retrospective cohort study of elective gynecologic surgical procedures performed between January 1, 2016, and May 31, 2021. Two study cohorts were generated: (1) those who received and (2) those who did not receive VTE prophylaxis based on Caprini score risk stratification. Outcome measures were then compared between the study cohorts and included the development of a VTE up to 90-days postoperatively. Secondary outcome measures included postoperative bleeding events.

RESULTS

A total of 5471 patients met inclusion criteria and the incidence of VTE up to 90 days postoperatively was 1.04%. Overall, 29.6% of gynecologic surgery patients received Caprini score-based guideline VTE prophylaxis. 39.2% of patients that met high-risk VTE criteria (Caprini > 5) received appropriate Caprini score-based prophylaxis. In multivariate regression analysis, the American Society of Anesthesiologists (ASA) score (OR 2.37, CI 1.27-4.45, p < 0.0001) and Caprini score (OR 1.13, CI 1.03-1.24, p = 0.008) predicted postoperatively VTE occurrence. Increasing Charlson comorbidity score (OR 1.39, CI 1.31-1.47, P < 0.001) ASA score (OR 1.36, CI 1.19-1.55, P < 0.001) and Caprini score (OR 1.10, CI 1.08-1.13, P < 0.001) were associated with increased odds of receiving appropriate inpatient VTE prophylaxis.

CONCLUSION

While the overall incidence of VTE was low in this cohort, enhanced adherence to risk-based practice guidelines may provide more patient benefit than harm to postoperative gynecologic patients.

Continuous Glucose Monitoring for Patients with COVID-19 Pneumonia: Initial Experience at a Tertiary Care Center

OBJECTIVE

Patients hospitalized with COVID-19 and hyperglycemia require frequent glucose monitoring, usually performed with glucometers. Continuous glucose monitors (CGMs) are common in the outpatient setting but not yet approved for hospital use. We evaluated CGM accuracy, safety for insulin dosing, and CGM clinical reliability in 20 adult patients hospitalized with COVID-19 and hyperglycemia.

METHODS

Study patients were fitted with a remotely monitored CGM. CGM values were evaluated against glucometer readings. The CGM sensor calibration was performed if necessary. CGM values were used to dose insulin, without glucometer confirmation.

RESULTS

CGM accuracy against glucometer, expressed as mean absolute relative difference (MARD), was calculated using 812 paired glucometer-CGM values. The aggregate MARD was 10.4%. For time in range and grades 1 and 2 hyperglycemia, MARD was 11.4%, 9.4%, and 9.1%, respectively, with a small variation between medical floors and intensive care units. There was no MARD correlation with mean arterial blood pressure levels, oxygen saturation, daily hemoglobin levels, and glomerular filtration rates. CGM clinical reliability was high, with 99.7% of the CGM values falling within the "safe" zones of Clarke error grid. After CGM placement, the frequency of glucometer measurements decreased from 5 to 3 and then 2 per day, reducing nurse presence in patient rooms and limiting viral exposure.

CONCLUSION

With twice daily, on-demand calibration, the inpatient CGM use was safe for insulin dosing, decreasing the frequency of glucometer fingersticks. For glucose levels >70 mg/dL, CGMs showed adequate accuracy, without interference from vital and laboratory values.

Postoperative Safety Profile of Minimally Invasive Ileocolonic Resections for Crohn's Disease in the Era of Biologic Therapy

BACKGROUND

There is controversy regarding the postoperative outcomes in Crohn's disease [CD] patients exposed to vedolizumab [VDZ] or ustekinumab [UST]. We aimed to describe our surgical outcomes in patients who underwent minimally invasive ileocolonic resection [MIS-ICR] for CD who had preoperative biologic therapy.

METHODS

All consecutive adult patients who had MIS-ICR for CD between 2014 and 2021 at our institution were included. Patients were divided into four groups: VDZ, UST, anti-tumour necrosis factor [anti-TNF], and no biologic group. Timing between the last dose of biologics and surgery was per surgeon's discretion. The primary outcome was intra-abdominal septic complications. Secondary outcomes included all 30-day complications.

RESULTS

A total of 274 patients were identified. Of these, 113 [41.2%] patients had received anti-TNF, 52 [19%] had received UST, and 19 [7%] had received VDZ. There was no difference between the four groups regarding baseline risk factors. There was no difference between the four groups regarding intra-abdominal septic complications [4.4% for no biologic, 5.3% for anti-TNF, 5.8% for UST, and 5.3% for VDZ; p = 0.987], surgical site infection rate, overall 30-day morbidity, overall 30-day readmission, overall surgical and medical complications, urinary tract infection, pulmonary infections, or length of stay. Those results were consistent after a subgroup analysis based on complexity of the disease.

CONCLUSIONS

This retrospective analysis demonstrates an equivalent postoperative safety profile for patients treated with preoperative anti-TNF, VDZ, or UST versus no biologic therapy within 3 months of MIS-ICR for Crohn's disease. Preoperative biologic therapy may not increase complications after minimally invasive ileocolonic resection in Crohn's disease. Further studies with larger sample sizes are needed to confirm results.

The Association Between Mood and Anxiety Disorders with Perioperative Outcomes Following Radical Cystectomy

OBJECTIVE

To identify associations between preoperative psychiatric diagnoses and perioperative outcomes after RC.

METHODS

The Florida Inpatient Data File was used to identify patients who underwent RC from 2013-2019. ICD-10 codes for a mood or anxiety disorder were identified and analyzed as a 3-level variable: neither, one of these, or both. Outcomes included inpatient mortality, non-home discharge, in-hospital complications, and length of stay. Mixed-effects logistic regression (accounting for clustering within hospitals) and negative binomial regression models were utilized.

RESULTS

We identified 4396 RC patients, including 306 (7.0%) with a mood disorder and 389 (8.8%) with an anxiety disorder. After multivariable adjustment, there was no significant association between mood and/or anxiety disorders with mortality or the presence or number of in-hospital complications. However, a mood or anxiety disorder was significantly associated with increased odds of non-home discharge (OR 1.60, 95% CI 1.20-2.14) and longer length of stay (IRR 1.13, 95% CI 1.07-1.19); these associations were also increased among patients with both mood and anxiety disorder diagnoses (non-home discharge OR 2.66, 95% CI 1.61-4.38; length of stay IRR 1.12, 95% CI 1.01-1.24).

CONCLUSION

Patients with mood and/or anxiety disorders undergoing RC had longer length of stay and increased odds of discharge to a non-home facility despite similar risks of perioperative complications. These data suggest an opportunity for perioperative intervention to address these disparities in postoperative outcomes. However, further work is needed to determine the underlying causes of these differences and to develop effective interventions.

Assessment of length of stay and cost of minimally invasive versus open thymectomies in patients with myasthenia gravis in Florida

BACKGROUND

Thymectomy has become a standard component in treatment for myasthenia gravis. The best surgical approach is still subject to debate. Minimally invasive surgery may have a lower mortality and morbidity rate, improved cosmetic results, and equivalent efficacy at improving neurologic symptoms to open approaches. We compared the perioperative outcomes and cost between the two techniques.

METHODS

We queried Florida Inpatient Discharge Dataset for patients who underwent thymectomy and had a primary diagnosis of non-thymomatous myasthenia gravis using International Classification of Diseases (ICD)-9 and ICD-10 codes to carry out this retrospective cohort study. The dates ranged between January 1st, 2013, to December 31st, 2018. We compared outcomes of patients who underwent minimally invasive thymectomy versus those who had open thymectomy.

RESULTS

An open approach was used in 108 patients, whereas a minimally invasive approach was used in 40 patients. Minimally invasive surgery group had a shorter length of stay (3.0 vs. 6.0 days, P<0.001) and had a non-significant lower total cost ($18.4K vs. $22.1K, P=0.186). After adjusting for age and Elixhauser score, length of stay for minimally invasive group was 32% (P=0.01) lower compared to the open surgery group.

CONCLUSIONS

Patients who underwent minimally invasive thymectomy for Myasthenia gravis had a significantly shorter length of stay and a lower, although not significant, overall cost.

Risk of malignancy and outcomes of surgically resected presacral tailgut cysts: A current review of the Mayo Clinic experience

AIM

The aim of this study was to describe the surgical management, outcomes and risk of malignancy of presacral tailgut cysts.

METHOD

A retrospective analysis of all patients who underwent resection of tailgut cyst at Mayo Clinic in Arizona, Florida and Minnesota between 2008 and 2020 was performed. Demographics, presentation, evaluation, surgical approach, postoperative complications, pathology and recurrence rates were reviewed.

RESULTS

Seventy-three patients were identified (81% female) with a mean age of 45 years. Thirty-nine patients (53%) were symptomatic, most commonly with pelvic pain (26 patients). Digital rectal examination identified a palpable mass in 68%. Mean tumour size was 6 cm. Resection was primarily performed through a posterior approach (77%, n = 56), followed by a transabdominal approach (18%, n = 13) and a combined approach (5%, n = 4). Six patients underwent a minimally invasive resection (laparoscopic/robotic). Coccygectomy or distal sacrectomy was performed in 41 patients (56%). Complete resection was achieved in 94% of patients. Thirty-day morbidity occurred in 18% and was most commonly wound related; there was no mortality. Malignancy was identified in six patients (8%). For the 30 patients with follow-up greater than 1 year, the median follow-up was 39 months (range 1.0-11.1 years). Local recurrence was identified in three patients and distant metastatic disease in one patient.

CONCLUSION

The rate of malignancy in presacral tailgut cysts based on this current review was 8%. Overall recurrence was 5% at a median of 24 months.

The Effect of Advanced Practice Providers on ACGME Colon and Rectal Surgery Resident Diagnostic Index Case Volumes

OBJECTIVE

Prior to 2015 residents in our Accreditation Council for Graduation Medical Education (ACGME) colon and rectal surgery training program were in charge of managing, with faculty oversight, the outpatient anorectal clinic at our institution. Starting in 2015 advanced practice providers (APPs) working in the division assumed management of the clinic. The effect of APPs on ACGME resident index diagnostic case volumes has not been explored. Herein we examine ACGME case log graduate statistics to determine if the inclusion of APPs into our anorectal clinic practice has negatively affected resident index diagnostic anorectal case volumes.

DESIGN

ACGME year-end program reports were obtained for the years 2011 to 2019. Program anorectal diagnostic index volumes were recorded and compared to division volumes. Analysis of variance (ANOVA) and analysis of covariance (ANCOVA) tests were conducted to assess whether the number of cases per year (for each respective case type) prior to the introduction of APPs into the anorectal clinic (2011-2014) differed from the number of cases per year with the APP clinic in place (2015-2018). A p-value <0.05 was considered statistically significant.

SETTING

Mayo Clinic, Rochester, Minnesota (quaternary referral center).

PARTICIPANTS

Colon and rectal surgery resident year-end ACGME reports (2011-2019).

RESULTS

ANOVAs revealed a marginally significant (p = 0.007) downtrend for hemorrhoid diagnostic codes, and a significant uptrend (p = 0.000) for fistula cases. Controlling for overall division volume, ANCOVA only reveled significance for fistula cases (p = 0.004) with the involvement of APPs.

CONCLUSIONS

At our institution we found the inclusion of APPs into our anorectal clinic practice did not negatively affect colon and rectal surgery resident ACGME index diagnostic anorectal case volumes. Inclusion of APPs into a multidisciplinary practice can promote resident education by allowing trainees to pursue other educational opportunities without hindering ACGME index case volumes.

Ileocolic Resection for Crohn Disease: The Influence of Different Surgical Techniques on Perioperative Outcomes, Recurrence Rates, and Endoscopic Surveillance

Ileocolic resection (ICR) is the most common surgical procedure in Crohn disease (CD). There are many surgical techniques for performing ICRs and subsequent anastomoses. Recurrence of CD after ICR is common, often clinically silent, and thus requires monitoring including periodic use of endoscopy to detect early active disease. There is emerging evidence that surgical approaches may influence CD recurrence. This review explores the various surgical considerations, the data behind each decision, and how these techniques influence subsequent endoscopic surveillance.

Prognostic models for stage I-III esophageal cancer: a comparison between existing calculators

Background

Determining the best approach for esophageal cancer and predicting accurate prognosis are critical. Multiple studies evaluated characteristics associated with overall survival, and several prediction models have been developed. This study aimed to evaluate existing models and perform external validation of selected models.

Methods

A retrospective investigation of a multi-site institutional enterprise for patients with a diagnosis of esophageal cancer between 2013-2014 was performed. Selected survival prediction models included the Roswell Park Comprehensive Cancer Center (RPCCC) calculator, Oregon Health & Science University (OHSU) calculator, and two nomograms published by Shapiro et al. and Sun et al. One-year overall survival, level of agreement, and performance for each model were evaluated.

Results

A total of 104 patients were included and used to assess the prediction models. One-year overall survival was 0.76. Different calculators tended to rank patients similarly; however, they did not agree on predicted overall survival. The least disparity in correlation was observed between OHSU and Shapiro calculators. Shapiro's model achieved the highest performance [area under the curve (AUC) =0.63].

Conclusions

Selected models showed fair results in estimating individual overall survival, although none achieved a high performance. While these tools may support the decision-making process for esophageal cancer patients, their implementation in clinical practice requires improved refinement to optimize their clinical utility.

Patient colon and rectal operative outcomes when treated with immune checkpoint inhibitors

There is limited data about the safety of colorectal surgery after immune checkpoint inhibitors (ICI). We aimed to share our experience about postoperative outcomes of colorectal surgery for patients treated with ICI. Overall, 31 patients were identified, 22 (71%) underwent elective and nine (29%) underwent emergent/urgent surgery. The 30-day Clavien Dindo class ≥ III complication rates were 27.3% (n = 6) for elective and 55.5% (n = 5) for emergent/urgent cases. Four patients underwent emergency surgery for immune-related colonic perforation and developed postoperative septic shock; two died. Considering patients' comorbidities, cancer stage, and surgical complexity, elective colorectal surgery after ICI seems relatively safe. However, emergent/urgent colorectal surgery was associated with high postoperative morbidity. Indeed, colonic perforation in the setting of ICI treatment has a significant risk of postoperative mortality. Therefore, for patients on ICI with any acute abdominal symptoms, surgical consult should be involved, and colon perforation should be ruled out.

Permanent stoma: a quality outcome in treatment of rectal cancer and its impact on length of stay

BACKGROUND

This study aimed to identify socioeconomic predictors of permanent stoma in rectal cancer treatment and examine its association with length of stay at the treatment facility.

METHODS

Rectal cancer patients who underwent elective surgery between January 2015 and December 2018 were identified from the Agency for Health Care Administration Florida Hospital Inpatient Discharge Dataset. Multivariate regression models were utilized to identify demographic and socioeconomic factors associated with receiving a permanent stoma as well as the associated length of stay of these patients.

RESULTS

Of 2630 rectal cancer patients who underwent surgery for rectal cancer, 21% had a permanent stoma. The odds of receiving permanent stoma increased with higher Elixhauser score, metastatic disease, advanced age, having open surgery, residence in Southwest Florida, and having Medicaid insurance or no insurance/self-payers (p < 0.05). Patients with a permanent stoma had a significantly extended stay after surgery (p < 0.001).

CONCLUSIONS

Patients with a permanent stoma following cancer resection were more likely to have open surgery, had more comorbidities, and had a longer length of stay. Having permanent stoma was higher in patients living in South West Florida, patients with Medicaid insurance, and in the uninsured. Additionally, the payer type significantly affected the length of stay.

Intravital Microscopy (IVM) in Human Solid Tumors: Novel Protocol to Examine Tumor-Associated Vessels

Background

Intravital microscopy (IVM) allows the real-time, direct visualization of microscopic blood vessels. This pilot clinical trial will elucidate the physical and functional characteristics of vessels associated with solid tumors.

Objective

The main objective of this study is to determine the feasibility of performing IVM in patients with solid tumors during the standard course of surgical resection. IVM will also be performed when vasopressors or fluid boluses are administered during the standard course of the operation.

Methods

This is an open-label, nonrandomized, single-center, pilot study of IVM observation in subjects with solid tumors undergoing surgical resection.

Results

This study was active on January 1, 2019 (NCT03823144) and funded by the Mayo Clinic Florida Cancer Focused Research Team Award. As of September 27, 2020, we had enrolled 20 patients. Accrual period is expected to end by December 31, 2021.

Conclusions

This trial will support the development of interventions to improve patient treatment by extending the application of IVM to the tumor microenvironment. IVM observations during volume and pressor management at the time of surgery may aid in the development of strategies to augment responses to systemic treatments.

International Registered Report Identifier (IRRID)

PRR1-10.2196/15677

The intersection of tumor location and combined bowel preparation: Utilization differs but anastomotic leak risk reduction does not

BACKGROUND AND OBJECTIVE

Whether bowel preparation utilization rates or effectiveness varies based on tumor location is unknown.

METHODS

The 2012-2016 American College of Surgeons National Surgical Quality Improvement Program Colectomy Targeted participant user file was queried for patients undergoing elective colorectal resection for cancer. Bowel preparation was classified as combined, mechanical bowel preparation alone, oral antibiotic alone, or none. Cochran-Armitage tests were used for trend analysis. Multivariable analyses stratified by tumor location were performed for the outcome of anastomotic leak. An additional multivariable model including all tumor locations assessed for interaction between bowel preparation and tumor location on an anastomotic leak.

RESULTS

A total of 29,739 operations were included and the anastomotic leak rate was 1.9% with combined preparation versus 4.0% without preparation. Combined bowel preparation utilization increased over time as tumor location became more distal (both p < .0001). However, the adjusted effect of combined bowel preparation on anastomotic leak risk reduction did not differ by individual tumor location or across all tumor locations (p = .43 for interaction).

CONCLUSION

Though the utilization rate of combined bowel preparation increased as tumor location became more distal, its risk-reducing effect remained similar. Quality improvement initiatives should focus on increased utilization of combined bowel preparation with an emphasis on tumors in the ascending colon.

Factors associated with worse outcomes for colorectal neuroendocrine tumors in radical versus local resections

Background

Colorectal neuroendocrine tumors (NETs) are the most common NETs of the gastrointestinal tract. Due to the rarity, colorectal NETs are understudied and are not clearly understood. Our study sought to identify the factors associated with worse outcomes for colorectal NETs following resection.

Methods

We identified patients diagnosed with colorectal NETs [2004-2014] who underwent resection from the National Cancer Data Base. Non-NETs were excluded. Overall survival (OS) was evaluated using the Kaplan Meier method. Cox proportional hazards and logistic regression models were used to assess factors associated with radical versus local resection, OS and LOS.

Results

A total of 7,967 colon and 11,929 rectal NETs were analyzed. The majority of colon (93.4%) and rectal (89.1%) NETs underwent radical and local resection respectively. The 5-year OS was 69% and 92% for colon and rectal NETs respectively. Older age (OR 1.45, CI 1.37-1.53) and clinical stage 4 (OR 9.91, CI 4.56-21.52) were associated with higher odds for colonic radical resection. Lowest median income quartile (OR 1.41, CI 1.21-1.64) and African Americans (OR 1.26, CI 1.07-1.49) experienced higher mortality for colon and rectal NETs respectively.

Conclusions

Racial minority and low-income patients experience worse outcomes for colorectal NETs following resection.

Influence of surgeon specialty and volume on the utilization of minimally invasive surgery and outcomes for colorectal cancer: a retrospective review

BACKGROUND

Utilization of minimally invasive surgery (MIS) has multiple determinants, one being the specialization of the surgeon. The purpose of this study was to assess the differences in the utilization of MIS, associated length of stay (LOS), and complications for colorectal cancer between colorectal (CRS) and general surgeons (GS). Previous studies have documented the influence of surgical volume and surgeon specialty on clinical outcomes and patient survival following colorectal cancer surgery. It is unclear whether there are differences in the utilization of MIS for colorectal cancer based on surgeon's specialization and how this influences clinical outcomes.

METHODS

Using the 2013-2015 Florida Inpatient Discharge Dataset and the National Plan & Provider Enumeration System, colorectal cancer patients experiencing a colorectal surgery were identified as well as the operating physician's specialty. Mixed-effects regression models were used to identify associations between the use of MIS, complications during the hospital stay, and patient LOS with patient, physician, and hospital characteristics.

RESULTS

There is no difference in the use of MIS, complication, nor LOS between GS and CRS for colorectal cancer surgery. However, physician volume was associated with increased use of MIS (OR 1.26, 95% CI 1.09, 1.46) and MIS was associated with decreases in certain complications as well as reductions in LOS overall (β = - 0.16, p < 0.001) and for each specialty (GS: β = - 0.18, p < 0.001; CRS β = - 0.12, p < 0.001) CONCLUSIONS: Despite the higher amount of proctectomies performed by CRS, no difference in MIS utilization, complication rate, or LOS was found for colorectal cancer patients based on surgeon specialty. While there are some differences in clinical outcomes attributable to specialized training, results from this study indicate that differences in surgical approach (MIS vs. Open), as well as the patient populations encountered by these two specialties, are key factors in the outcomes observed.

Preoperative predictive risk to cancer quality in robotic rectal cancer surgery

BACKGROUND

Circumferential resection margin (CRM) involvement is widely considered the strongest predictor of local recurrence after TME. This study aimed to determine preoperative factors associated with a higher risk of pathological CRM involvement in robotic rectal cancer surgery.

METHODS

This was a retrospective review of a prospectively maintained database of consecutive adult patients who underwent elective, curative robotic low anterior or abdominoperineal resection with curative intent for primary rectal adenocarcinoma in a tertiary referral cancer center from March 2012 to September 2019. Pretreatment magnetic resonance imaging (MRI) reports were reviewed for all the patients. Risk factors for pathological CRM involvement were investigated using Firth's logistic regression and a predictive model based on preoperative radiological features was formulated.

RESULTS

A total of 305 patients were included, and 14 (4.6%) had CRM involvement. Multivariable logistic regression found both T3 >5 mm (OR 6.12, CI 1.35-36.44) and threatened or involved mesorectal fascia (OR 4.54, CI 1.33-17.55) on baseline MRI to be preoperative predictors of pathologic CRM positivity, while anterior location (OR 3.44, CI 0.72-33.13) was significant only on univariate analysis. The predictive model showed good discrimination (area under the receiver-operating characteristic curve >0.80) and predicted a 32% risk of positive CRM if all risk factors were present.

CONCLUSION

Patients with pre-operatively assessed threatened radiological margin, T3 tumors with greater than 5 mm extension and anterior location are at risk for a positive CRM. The predictive model can preoperatively estimate the CRM positivity risk for each patient, allowing surgeons to tailor management to improve oncological outcomes.

Recurrence and Long-Term Survival Following Segmental Colectomy for Right-Sided Colon Cancer in 813 Patients: a Single-Institution Study

BACKGROUND

Controversy exists regarding optimal surgical approach to right-sided colon cancer due to increasing complete mesocolic excision outcome data; yet, scarce long-term surgical and oncologic outcome data from high-volume centers following right segmental resections without complete mesocolic excision make comparisons difficult to interpret. We report long-term outcomes following standard mesocolic excision for right-sided colon adenocarcinoma.

METHODS

A retrospective review of a prospective database was conducted of all consecutive adult patients undergoing surgery for a right-sided colon adenocarcinoma between 2000 and 2007. Demographics, oncologic, operative, and pathologic details are reported. Primary endpoints consisted of overall survival and recurrence. Patients with stage IV and recurrent disease were excluded.

RESULTS

Eight hundred thirteen patients were identified. Majority of tumors were stage II (n = 318, 39%). Adjuvant chemotherapy was administered to 228 patients (28%). Recurrence was observed in 97 patients (12%), at median 1.3 years. Recurrence was most commonly distant (n = 73, 9%). At median follow-up 7.3 years, 5- and 10-year overall survival was 72.4%, and 48.6%, respectively. Five- and 10-year disease-free survival was 67% and 45.8%, respectively. Multivariable analysis demonstrated that TNM stage was a significant predictor of recurrence. For disease-free survival, T stage, and N stage were significant on multivariate analysis. Multivariable predictors of overall survival included age, number of lymph nodes removed, N stage, and adjuvant chemotherapy use.

CONCLUSIONS

Excellent long-term outcomes from a large cohort of patients with non-metastatic, right colon adenocarcinoma treated by segmental colectomy without complete mesocolic excision are reported. The majority of recurrences were distant.

BRAF-V600E and microsatellite instability prediction through CA-19-9/CEA ratio in patients with colorectal cancer

BACKGROUND

Early identification of colorectal cancer (CRC) patients that are BRAF-V600E mutant and/or microsatellite instability-high (MSI-High), has both prognostic and predictive value. We wanted to highlight an observation of utilizing 2 simple, rapid and universally available lab tests, i.e., carbohydrate cancer antigen 19-9 (CA 19-9) and carcinoembryonic antigen (CEA) tumor markers, the ratio (CA-19-9/CEA) of which can distinctly identify these patients from other molecular subsets of CRC.

METHODS

All patients with metastatic CRC from December 2016 to February 2019 were identified, and included in the study if they had both CA19-9 and CEA tests available. Circulating tumor DNA (ctDNA) testing and tissue genetic testing results were used to categorize patients into BRAF V600E microsatellite stable (MSS), MSI-High, RAS mutant MSS and RAS/RAF wild type CRCs. Kruskal-Wallis test was used to compare the CA19-9/CEA ratio between mutation types and the pairwise p values were adjusted for multiple comparisons with Holm method. For sensitivity analysis, the same analysis was repeated for the mean and median ratio of each patient. All tests were two-sided with alpha level set at 0.05 for statistical significance.

RESULTS

BRAF-V600E MSS CRC patients had a discordantly profound elevation in CA-19-9 levels as opposed to the CEA levels. Patients in the BRAF V600E MSS subset had the highest median CA19-9/CEA ratio versus the least median ratio in MSI-High patients. The median of maximum CA-19-9/CEA ratio was 28.92 (range, 2.76-707.27) in BRAF-V600E MSS patients and 4.06 (range, 0.46-166.74) in MSI-High subset of patients.

CONCLUSIONS

To date, this is the first report utilizing the ratio of tumor markers CA19-9/CEA as a predictive rather than just prognostic tool to identify BRAF-V600E MSS and MSI-High CRC patients.

Racial Disparities in Outcomes Among Asians With Gastric Cancer in the USA

BACKGROUND/AIM

We aimed to evaluate disparities in presentation and treatment of gastric cancer (GC), including time between diagnosis and treatment, based on race, focusing on Japanese patients within the USA.

PATIENTS AND METHODS

The National Cancer Database was queried for patients diagnosed with GC between 2004-2013. Clinical and treatment variables were summarized by race (White, non-Japanese Asian, Japanese). The association between race and overall survival (OS) was evaluated using the log-rank test.

RESULTS

A total of 79,481 patients were included. Japanese patients received surgery the earliest after diagnosis in all stages. Regarding radiotherapy, white patients had the shortest waiting time followed by Asian and Japanese patients. Asian patients had better OS at both 3 and 5 years of follow-up. White patients were associated with the lowest OS.

CONCLUSION

Japanese and Asian GC patients have better OS compared to White patients. Moreover, there were disparities in time to both GC diagnosis and treatment, with Japanese patients being sooner diagnosed and surgically treated, which may ultimately impact patient experience.

Assessing Malnutrition Before Major Oncologic Surgery: One Size Does Not Fit All

BACKGROUND

There are multiple definitions for malnutrition, without evidence of superiority of any one definition to assess preoperative risk. Therefore, to aid in identification of patients that might warrant prehabilitation, we aimed to determine the optimal definition of malnutrition before major oncologic resection for 6 cancer types.

METHODS

The American College of Surgeons NSQIP database was queried for patients undergoing elective major oncologic operations from 2005 to 2017. Nutritional status was evaluated using the European Society for Parenteral and Enteral Nutrition definitions, NSQIP's variable for >10% weight loss during the previous 6 months, and the WHO BMI classification system. Multivariable logistic regression was performed to evaluate the adjusted effect of nutritional status on mortality and major morbidity.

RESULTS

We identified 205,840 operations (74% colorectal, 10% pancreatic, 9% lung, 3% gastric, 3% esophageal, and 2% liver). A minority (16%) of patients met criteria for malnutrition (0.6% severe malnutrition, 1% European Society for Parenteral and Enteral Nutrition 1, 2% European Society for Parenteral and Enteral Nutrition 2, 6% NSQIP, and 6% mild malnutrition), 31% were obese, and the remaining 54% had a normal nutrition status. Both mortality and major morbidity varied significantly between the nutrition groups (both p < 0.0001). An interaction between nutritional status and cancer type was observed in the models for mortality and major morbidity (interaction term p < 0.0001 for both), indicating the optimal definition of malnutrition varied by cancer type.

CONCLUSIONS

The definition of malnutrition used to assess postoperative risk is specific to the type of cancer being treated. These findings can be used to enhance nutritional preparedness in the preoperative setting.

Risk factors for conversion in laparoscopic and robotic rectal cancer surgery

BACKGROUND

The aim of this study was to review risk factors for conversion in a cohort of patients with rectal cancer undergoing minimally invasive abdominal surgery.

METHODS

A retrospective analysis was performed of consecutive patients operated on from February 2005 to April 2018. Adult patients undergoing low anterior resection or abdominoperineal resection for primary rectal adenocarcinoma by a minimally invasive approach were included. Exclusion criteria were lack of research authorization, stage IV or recurrent rectal cancer, and emergency surgery. Risk factors for conversion were investigated using logistic regression. A subgroup analysis of obese patients (BMI 30 kg/m² or more) was performed.

RESULTS

A total of 600 patients were included in the analysis. The overall conversion rate was 9·2 per cent. Multivariable analysis showed a 72 per cent lower risk of conversion when patients had robotic surgery (odds ratio (OR) 0·28, 95 per cent c.i. 0·15 to 0·52). Obese patients experienced a threefold higher risk of conversion compared with non-obese patients (47 versus 24·4 per cent respectively; P < 0·001). Robotic surgery was associated with a reduced risk of conversion in obese patients (OR 0·22, 0·07 to 0·71).

CONCLUSION

Robotic surgery was associated with a lower risk of conversion in patients undergoing minimally invasive rectal cancer surgery, in both obese and non-obese patients.

Is metastasectomy a worthy option?-the role of surgery in metastatic colon cancer to liver and lungs

Background

The role of surgery and metastasectomy is controversial in the treatment of stage IV colon cancer (CC). The aim of this study was to investigate the relationship between primary tumor resection (PTR) with metastasectomy and survival in patients diagnosed with metastatic CC.

Methods

The National Cancer Data Base (NCDB) was retrospectively queried for patients diagnosed with colon adenocarcinoma from 2004 to 2013. Patient demographics, clinical characteristics, and short-term outcomes were collected. Groups were generated based on if surgery was performed and, if so, was metastasectomy involved. Associations between groups were evaluated using Kruskal-Wallis and Pearson Chi-square tests. Overall survival (OS) was summarized using standard Kaplan-Meier methods. The association between surgical group and OS was evaluated using the log-rank test.

Results

Of 31,172 patients, 13,214 (42.4%) had surgery while 17,958 (57.6%) did not. Among these, 81.3% of patients had liver metastases only, while 18.7% of patients had both liver and lung metastases. Median OS was 15.1 months (95% CI: 14.8 to 15.5 months) for the entire cohort. However, median OS was significantly better for those who had surgery (either PTR alone or PTR with metastasectomy) compared to those who did not (21.8 vs. 7.5 months, P<0.001). Patients who received PTR with metastasectomy had worse median OS (20.5 vs. 21.8 months, P=0.035) compared to those who only received PTR (P=0.211).

Conclusions

PTR in select patients diagnosed with metastatic CC provides a remarkable improvement to survival rate. The role of metastasectomy remains controversial as no difference in survival outcomes exists between patients who received it and who did not.

Disparities influencing rates of urgent/emergent surgery for diverticulitis in the state of Florida

BACKGROUND

Patients with diverticulitis have a 20% risk of requiring urgent/emergent treatment. Since morbidity and mortality rates differ between elective and urgent/emergent care, understanding associated disparities is critical. We compared factors associated with treatment setting for diverticulitis and evaluated disparities regarding access to Minimally Invasive Surgery (MIS) and development of complications.

METHODS

The Florida Inpatient Discharge Dataset was queried for patients diagnosed with diverticulitis. Three multivariate models were utilized: 1) elective vs urgent/emergent surgery, 2) MIS vs open and 3) presence of complications.

RESULTS

The analysis included 12,654 patients. Factors associated with increased odds of urgent/emergent care included being uninsured or covered by Medicaid, African American, obese, or more comorbid. MIS was associated with reduced odds of complications. Patients treated by high-volume or colorectal surgeons had increased odds of receiving MIS.

CONCLUSIONS

Patients were more likely to receive MIS if they were treated by a colorectal surgeon, or a high-volume surgeon (colorectal, or general surgeon). Additionally, patients that were older, had increased comorbidities, or did not have health insurance were less likely to receive MIS.

Factors Associated With Minimally Invasive Surgery for Colorectal Cancer in Emergency Settings

BACKGROUND

Minimally invasive surgery (MIS) is associated with improved colorectal cancer (CRC) outcomes, but it is used less frequently in emergency settings. We aimed to assess patient-level factors associated with emergency presentation for CRC and the use of MIS in emergency versus elective settings.

METHODS

This retrospective study examined the clinical data of patients who underwent emergency and elective resections for CRC from 2013 to 2015 using the Florida Inpatient Discharge Dataset. Multivariable analyses were performed to assess differences in gender, age, race, urbanization, region, insurance, and clinical characteristics associated with mode of presentation and surgical approach. In-hospital mortality and length of stay by mode of presentation were recorded.

RESULTS

Of 16,277 patients identified, 10,224 (61%) had elective surgery and 6503 (39%) had emergency surgery. Emergency presentations were more likely to be black (14.2% versus 9.5%), Hispanic (18.9% versus 15.4%), Medicaid-insured (9.7% versus 4.2%), and have metastatic cancer (34.4% versus 20.2%) or multiple comorbidities (12.6% versus 4.0%). MIS was the surgical approach in 31.8% of emergency cases versus 48.1% of elective cases. Factors associated with lower odds of MIS for emergencies include Medicaid (odds ratio (OR) 0.79, 95% confidence interval (CI) 0.63-0.99), metastases (OR 0.56, CI 0.5-0.63), and multiple comorbidities (OR 0.53, CI 0.4-0.7). Emergency cases experienced higher in-hospital mortality (3.7% versus 1.0%) and a longer median length of stay (10 d versus 5 d).

CONCLUSIONS

Emergency CRC presentations are associated with racial minorities, Medicaid insurance, metastatic disease, and multiple comorbidities. Odds of MIS in emergency settings are lowest for patients with Medicaid insurance and highest clinical disease burden.

Surgical Care for Women with Endometrial Cancer in Florida

Objective: The goal of this research was to analyze if disparities in route of hysterectomy for endometrial cancer exist in Florida. Materials and Methods: In this retrospective cohort study, Florida inpatient and ambulatory surgery databases (2014-2016) were examined to find cases of patients with endometrial cancer who underwent hysterectomy in the state. Logistic regression models were used to compare patient- and hospital-level factors associated with having minimally invasive surgery (MIS) versus open surgery, and complications in patients having open hysterectomy versus MIS. Results: Overall, 6513 patients met the inclusion criteria. MIS was performed in 81.4% of cases. The odds of using a minimally invasive approach to hysterectomy (vaginal, robotic, or laparoscopic) were significantly lower for black women (odds ratio [OR]: 0.41; 95% confidence interval [CI]: 0.34-0.50) as well as for other non-white patients (OR: 0.64; 95% CI: 0.49-0.84). Patients with Medicaid (OR: 0.42; 95% CI: 0.30-0.59) or Medicare managed care (OR: 0.73; 95% CI: 0.59-0.91), or who received care at a teaching hospital (OR: 0.82; 95% CI: 0.68-0.98) or government hospital (OR: 0.50; 95% CI: 0.38-0.65) were also less likely to receive MIS. Patients receiving care at a high-volume (OR: 1.69; 95% CI: 1.30-2.20) or medium-volume (OR: 3.11; 95% CI: 2.37-4.08) hospital, or patients who were located in the Central (OR: 1.71; 95% CI: 1.17-2.48) or Peninsula (OR: 1.73; 95% CI: 1.17-2.56) regions, compared to the Florida Panhandle, had greater odds of receiving MIS. Conclusions: Although Florida has a high adoption of MIS for treating endometrial cancer, disparities persist. Efforts of state-level entities should focus on improving access to minimally invasive hysterectomy for racial minorities with endometrial cancer.

Trends in the Use of Laparoscopy and Robotics for Colorectal Cancer in Florida

Background: Laparoscopy and more recently robotics are increasingly used for colorectal cancer surgery in the United States. We examined the current trends of minimally invasive surgical resections for colorectal cancer in Florida. Methods: The Florida Inpatient Discharge Dataset was used to examine the clinical data of patients who underwent elective surgery for colorectal cancer during 2013-2015. Multivariate analyses were performed to compare patient characteristics associated with the use of open and minimally invasive surgeries. Results: A total of 10,513 patients were analyzed; 5451 (52%) had open surgery, 4403 (42%) laparoscopy, and 659 (6%) robotic surgery. The rates of minimally invasive surgery (MIS) increased from 46.95% in 2013 to 48.72% in 2015. Among minimally invasive surgical procedures, the use of robotics increased from 9.82% in 2013 to 15.48% in 2015. Metastatic cancer (odds ratio [OR] 0.61, confidence interval [CI] 0.55-0.67), Elixhauser score of 3-5 (OR 0.85, CI 0.76-0.95) or more than 5 (OR 0.78, CI 0.63-0.97), Medicaid insurance (OR 0.73, CI 0.6-0.89), Black race (OR 0.88, CI 0.77-0.99), and rural residence (OR 0.83, CI 0.69-0.99) were associated with lower odds of MIS than open surgery. Conclusions: This study demonstrates that the overall rates of MIS for colorectal cancer in Florida increased from 2013 to 2015. Socially deprived and very sick patient populations with colorectal cancer are less likely to undergo MIS.

Randomized clinical trial of liposomal bupivacaine transverse abdominis plane block versus intrathecal analgesia in colorectal surgery

Background

Transverse abdominis plane (TAP) block is considered an effective alternative to neuraxial analgesia for abdominal surgery. However, limited evidence supports its use over traditional analgesic modalities in colorectal surgery. This study compared the analgesic efficacy of liposomal bupivacaine TAP block with intrathecal (IT) opioid administration in a multicentre RCT.

Methods

Patients undergoing elective small bowel or colorectal resection were randomized to receive TAP block or a single injection of IT analgesia with hydromorphone. Patients were assessed at 4, 8, 16, 24 and 48 h after surgery. Primary outcomes were mean pain scores and morphine milligram equivalents (MMEs) administered within 48 h after surgery. Secondary outcomes included duration of hospital stay, incidence of postoperative ileus and use of intravenous patient-controlled analgesia.

Results

In total, 209 patients were recruited and 200 completed the trial (TAP 102, IT 98). The TAP group had a 1·6-point greater mean pain score than the IT group at 4 h after surgery, and this difference lasted for 16 h after operation. The TAP group received more MMEs within the first 24 h after surgery than the IT group (median difference in MMEs 10·0, 95 per cent c.i. 3·0 to 20·5). There were no differences in MME use at 24 and 48 h, or with respect to secondary outcomes.

Conclusion

IT opioid administration provided better immediate postoperative pain control than TAP block. Both modalities resulted in low pain scores in patients undergoing elective colorectal surgery and should be considered in multimodal postoperative analgesic plans. Registration number: NCT02356198 ( http://www.clinicaltrials.gov).

Impact of enhanced recovery on oncological outcomes following minimally invasive surgery for rectal cancer

BACKGROUND

Oncological outcomes of locally advanced rectal cancer depend on the quality of surgical and oncological management. Enhanced recovery pathways (ERPs) have yet to be assessed for their oncological impact when used in combination with minimally invasive surgery. This study assessed outcomes with or without an ERP in patients with rectal cancer.

METHODS

This was a retrospective analysis of all consecutive adult patients who underwent elective minimally invasive surgery for primary rectal adenocarcinoma with curative intent between February 2005 and April 2018. Both laparoscopic and robotic procedures were included. Short-term morbidity and overall survival were compared between patients treated according to the institutional ERP and those who received conventional care.

RESULTS

A total of 600 patients underwent minimally invasive surgery, of whom 320 (53·3 per cent) were treated according to the ERP and 280 (46·7 per cent) received conventional care. ERP was associated with less overall morbidity (34·7 versus 54·3 per cent; P < 0·001). Patients in the ERP group had improved overall survival on univariable (91·4 versus 81·7 per cent at 5 years; hazard ratio (HR) 0·53, 95 per cent c.i. 0·28 to 0·99) but not multivariable (HR 0·78, 0·41 to 1·50) analysis. Multivariable analysis revealed age (HR 1·46, 1·17 to 1·82), male sex (HR 1·98, 1·05 to 3·70) and complications (HR 2·23, 1·30 to 3·83) as independent risk factors for compromised overall survival. Disease-free survival was comparable for patients who had ERP or conventional treatment (80·5 versus 84·6 per cent at 5 years respectively; P = 0·272).

CONCLUSION

Treatment within an ERP was associated with a lower morbidity risk that may have had a subtle impact on overall but not disease-specific survival.

Disparities in elective surgery for diverticulitis: Identifying the gap in care

BACKGROUND

Minimally invasive surgery (MIS) in patients with diverticulitis is advantageous relative to open surgery. We aimed to determine disparities associated with MIS access for diverticulitis and post-operative complications.

METHODS

The Florida Inpatient Discharge Dataset was retrospectively queried for patients with diverticulitis undergoing elective surgery between 2013 and 2015. Associations of patient, physician, and hospital characteristics with surgical approach (MIS vs open) and development of complications were calculated in two separate mixed effects logistic regression models.

RESULTS

Of the 5857 patients in the analysis, older, sicker patients, residing in rural areas or with Medicaid insurance had decreased odds of receiving MIS. Being treated by high volume or colorectal surgeons increased the odds of MIS. Decreased complications were present with MIS, in younger, healthier patients, treated by high volume surgeons.

CONCLUSIONS

Disparities in Florida are present in patients undergoing elective diverticulitis surgery. MIS access and complications rates are not equal, and MIS is associated with significantly reduced odds of post-operative complications. Improved access to MIS-trained surgeons is a critical step towards improving surgical outcomes for Floridians.

Impact of Tumor Location and Variables Associated With Overall Survival in Patients With Colorectal Cancer: A Mayo Clinic Colon and Rectal Cancer Registry Study

Background: Our study investigated the demographic characteristics of Mayo Clinic Colon and Rectal Cancer Registry patients and sought to associate tumor location with overall survival.

Methods: Using the cohort of patients seen at Mayo Clinic (Minnesota, Arizona, Florida) from 1972 to 2017, we obtained 26,908 colorectal adenocarcinoma patient records. Overall survival of patients with colorectal cancer was analyzed by sidedness (right vs. left) and location (right vs. left vs. rectum). Kaplan–Meier method was used to analyze all demographic and cancer variables available within the dataset to trace survival over a 35-year period. Subgroups within variables were compared to each other using log-rank test and considered significantly different at P < 0.05. Cox proportional hazards regression model was used to assess impact of tumor location while controlling for age, year of diagnosis, sex, tumor stage, and tumor grade. Cox regression models were used to evaluate the independent effect of cancer location on overall survival after adjusting for age, gender, year of diagnosis, and cancer stage. To further explore the potential interaction effect of cancer location with cancer stage and year of diagnosis, similar multivariable Cox model was fit stratified by cancer stage (1–3 vs. 4) and by year of diagnosis (<1980, 1980–2000, >2000).

Results: Overall survival differed significantly within all variables studied after Kaplan–Meier method analysis (P < 0.0001). Survival was higher in the left-side group when evaluated by tumor sidedness, and rectal cancer patients had the highest median survival (101.3 months). Right-sided cancer patients had the worst prognosis in both tumor location and sidedness analyses, with a median survival of 76.6 months. However, the stratified analysis showed that, the difference in survival between left- and right-sided cancer only existed in late cancer stage (stage 4) patients but not in early cancer stage; therefore, screening for CRC to pick cancer at an early stage can influence overall survival significantly.

Conclusion: These observations confirm some of the previous and recent studies on sidedness of colorectal cancer patients. Our analysis is novel in that it included patients of all stages rather than just stage IV metastatic patients. This initial study provides a platform to investigate more biologic and clinical factors associated with tumor location. Merging this dataset with other available datasets and previously conducted studies within the institution will provide a robust platform for multiple future studies and collaborations. Finally, appropriate screening can result in a decrease in incidence and mortality of CRC.

Body Mass Index and Long-Term Outcomes in Patients With Colorectal Cancer

Background: The association between body mass index (BMI) and colorectal cancer is unique. There are several patient- and tumor-related factors that affect this and associations are not entirely clear. The primary aim of this study is to examine the association between BMI and survival after colorectal cancer diagnosis.

Methods: Among 26,908 Mayo Clinic patients diagnosed with colorectal cancer between 1972 and 2017, 3,799 patients had information on BMI within 6 months prior to cancer diagnosis. Multivariable Cox regression models were used to assess the differences in overall survival between BMI groups in each cancer stage, controlling for age, gender, year of diagnosis, and cancer location. The impact of change of BMI at 30, 60, and 90 days on survival afterwards were also analyzed.

Results: Among 3,799 patients included in the study, there were 29% normal weight, 2% underweight, 36% overweight, and 33% obese patients. With all stages combined together, the overall 5-years survival rates for underweight, normal weight, overweight, and obese patients were 33, 56, 60, and 65%, respectively (p < 0.001). The results show that, the difference in overall survival was not statistically significant when underweight, overweight, and obese patients were compared to normal weight patients in stage 1 and stage 2, although there was a trend that overweight patients had better survival than normal weight group in stage 2 cancer patients (HR = 0.8, p = 0.086). In stage 3 and 4 patients combined, underweight group demonstrated a significant disadvantage (HR = 1.96, p = 0.007) for overall survival compared to the normal weight group. Additionally, post-diagnosis BMI drop more than 10% from either a previous time (HR = 1.88, p = 0.002) or pre-diagnosis time (HR = 1.61, p < 0.001) was associated with worse overall survival after adjusting for baseline variables.

Conclusions: BMI is an important consideration in patients with colorectal cancer. Outcomes are stage-dependent where in some situations obesity maybe an advantage. More importantly, being underweight is a significant negative predictor of outcome. The impact of drop in BMI or weight, on survival of CRC patients, needs to be studied further since this is potentially an actionable variable and a dynamic biomarker that may help improve outcome in these patients.

Stage II-III colon cancer: a comparison of survival calculators

Background

Individualized postoperative survival calculators for patients with cancer can be an aid for predicting prognosis and clinical decision making, such as the use of adjuvant chemotherapy. The aim of this study was to compare existing survival calculators for colon cancer and determine their performance using an independent cohort of patients.

Methods

A retrospective analysis of a multi-site institutional experience was performed on patients diagnosed with stage II-III colon cancer between January 2012 and March 2013. Patient survival rates were estimated using Roswell Park Comprehensive Cancer Center (RPCCC), Memorial Sloan Kettering Cancer Center (MSKCC), and MD Anderson Cancer Center (MDACC) calculators. These calculators vary in the number and breadth of variables that are included. The agreement between selected models was obtained through a scatter plot matrix and related intra-class correlation coefficient (ICC). Calculators' performances were compared using time-dependent receiver operating characteristic (ROC) curves and corresponding area under the curve (AUC) values.

Results

After the application of inclusion and exclusion criteria, a total of 97 patients were included in the analysis. Survival data were available for all patients. Median follow-up was 57.6 months, and the overall 5-year survival rate was 0.74 (95% CI: 0.64-0.82). Overall, the different calculators tended to predict survival similarly (ICC =0.017). However, there was variation among calculator performance with the RPCCC calculator showing the highest performance (AUC =0.913), followed by the MSKCC calculator (AUC =0.803), and the MDACC calculator (AUC =0.644).

Conclusions

Prognostic models incorporating a more comprehensive amount of patient and tumor specific variables may provide a more accurate estimate of individual patient survival rates. These tools can be an actual aid in the clinical practice, allowing physicians to personalize treatment and follow-up for patients with colon cancer.

Disparities in minimally invasive surgery for colorectal cancer in Florida

BACKGROUND

The cost of minimally invasive surgery (MIS) raises potential for racial and social disparities. The aim of this study was to identify the racial, socioeconomic and geographic disparities associated with MIS for colorectal cancer (CRC) in Florida.

METHODS

Using the Florida Inpatient Discharge Dataset, we examined the clinical data of patients who underwent elective resections for CRC during 2013-2015. Multivariable analysis was performed to identify differences in gender, age, race, urbanization, region, insurance and clinical characteristics associated with the surgical approach.

RESULTS

Of the 10,224 patients identified, 5308 (52%) had open surgery and 4916 (48%) had MIS. Females (p = 0.012), Medicare-insured patients (p = 0.001) and residents of South Florida were more likely to undergo MIS. Patients with Medicaid (p = 0.008), metastasis (p < 0.001) or 3-5 comorbidities (p = 0.004) had reduced likelihood of MIS. Hispanic patients in Southwest Florida had reduced likelihood of receiving MIS than whites (p < 0.017). Patients who underwent MIS had significantly reduced LOS (p < 0.001).

CONCLUSIONS

Consistent with national studies, MIS for CRC in Florida is associated with insurance status and geographic location. There are patient-level regional differences for racial disparities in MIS for CRC in Florida.

PROACTIVE PROTOCOL-BASED MANAGEMENT OF HYPERGLYCEMIA AND DIABETES IN COLORECTAL SURGERY PATIENTS

OBJECTIVE

The management of diabetic patients undergoing elective abdominal surgery continues to be unsystematic, despite evidence that standardized perioperative glycemic control is associated with fewer postoperative surgical complications. We examined the efficacy of a pre-operative diabetes optimization protocol implemented at a single institution in improving perioperative glycemic control with a target blood glucose of 80 to 180 mg/dL.

METHODS

Patients with established and newly diagnosed diabetes who underwent elective colorectal surgery were included. The control group comprised 103 patients from January 1, 2011, through December 31, 2013, before protocol implementation. The glycemic-optimized group included 96 patients following protocol implementation from January 1, 2014, through July 31, 2016. Data included demographic information, blood glucose levels, insulin doses, hypoglycemic events, and clinical outcomes (length of stay, re-admissions, complications, and mortality).

RESULTS

Patients enrolled in the glycemic optimization protocol had significantly lower glucose levels intra-operatively (145.0 mg/dL vs. 158.1 mg/dL; P = .03) and postoperatively (135.6 mg/dL vs. 145.2 mg/dL; P = .005). A higher proportion of patients enrolled in the protocol received insulin than patients in the control group (0.63 vs. 0.48; P = .01), but the insulin was administered less frequently (median [interquartile range] number of times, 6.0 [2.0 to 11.0] vs. 7.0 [5.0 to 11.0]; P = .04). Two episodes of symptomatic hypoglycemia occurred in the control group. There was no difference in clinical outcomes.

CONCLUSION

Improved peri-operative glycemic control was observed following implementation of a standardized institutional protocol for managing diabetic patients undergoing elective colorectal surgery.

ABBREVIATIONS

HbA1c = glycated hemoglobin A1c; IQR = interquartile range.

Does obesity impact postoperative outcomes following robotic-assisted surgery for rectal cancer?

INTRODUCTION

Obesity has been identified as a risk factor for both conversion and severe postoperative morbidity in patients undergoing laparoscopic rectal resection. Robotic-assisted surgery (RAS) is proposed to overcome some of the technical limitations associated with laparoscopic surgery for rectal cancer. The aim of our study was to determine if obesity remains a risk factor for severe morbidity in patients undergoing robotic-assisted rectal resection.

PATIENTS

This study was a retrospective review of a prospective database. A total of 183 patients undergoing restorative RAS for rectal cancer between 2007 and 2016 were divided into 2 groups: control (BMI < 30 kg/m²; n = 125) and obese (BMI ≥ 30 kg/m²; n = 58). Clinicopathologic data, 30-day postoperative morbidity, and perioperative outcomes were compared between groups. The main outcome was severe postoperative morbidity defined as any complication graded Clavien-Dindo ≥ 3.

RESULTS

Control and obese groups had similar clinicopathologic characteristics. Severe complications were observed in 9 (7%) and 4 (7%) patients, respectively (p > 0.99). Obesity did not impact conversion, anastomotic leak rate, length of stay, or readmission but was significantly associated with increased postoperative morbidity (29 vs. 45%; p = 0.04) and especially more postoperative ileus (11 vs. 26%; p = 0.01). Obesity and male gender were the two independent risk factors for postoperative overall morbidity (OR 1.97; 95% CI 1.02-3.94; p = 0.04 and OR 2.23; 95% CI 1.10-4.76; p = 0.03, respectively).

CONCLUSION

‎Obesity did not impact severe morbidity or conversion rate following RAS for rectal cancer but remained a risk factor for overall morbidity and especially postoperative ileus.

Palliative Care Use Among Patients With Solid Cancer Tumors: A National Cancer Data Base Study

BACKGROUND

Palliative care has been increasingly recognized as an important part of cancer care but remains underutilized in patients with solid cancers. There is a current gap in knowledge regarding why palliative care is underutilized nationwide.

OBJECTIVE

To identify the factors associated with palliative care use among deceased patients with solid cancer tumors.

METHODS

Using the 2016 National Cancer Data Base, we identified deceased patients (2004-2013) with breast, colon, lung, melanoma, and prostate cancer. Data were described as percentages. Associations between palliative care use and patient, facility, and geographic characteristics were evaluated through multivariate logistic regression.

RESULTS

A total of 1 840 111 patients were analyzed; 9.6% received palliative care. Palliative care use was higher in the following patient groups: survival >24 months (17% vs 2%), male (54% vs 46%), higher Charlson-Deyo comorbidity score (16% vs 8%), treatment at designated cancer programs (74% vs 71%), lung cancer (76% vs 28%), higher grade cancer (53% vs 24%), and stage IV cancer (59% vs 13%). Patients who lived in communities with a greater percentage of high school degrees had higher odds of receiving palliative care; Central and Pacific regions of the United States had lower odds of palliative care use than the East Coast. Patients with colon, melanoma, or prostate cancer had lower odds of palliative care than patients with breast cancer, whereas those with lung cancer had higher odds.

CONCLUSIONS

Palliative care use in solid cancer tumors is variable, with a preference for patients with lung cancer, younger age, known insurance status, and higher educational level.

The Determinants of Palliative Care Use in Patients With Colorectal Cancer: A National Study

BACKGROUND

Palliative care is associated with improved survival and quality of life, but its use among patients with colorectal cancer varies nationwide and the determinants of those variations are not clear.

OBJECTIVE

To determine the factors associated with palliative care use among patients who died of colorectal cancer.

METHODS

Deceased patients treated for colorectal cancer (2004-2013) were identified within the National Cancer Database. Multivariable logistic regression was used to evaluate patient and institutional characteristics associated with palliative care use. Patients were classified based on their length of survival (<6 months, 6-24 months, and 24+ months) to provide timing context.

RESULTS

A total of 287 923 patients were analyzed. Overall, 4.3% of the patients received palliative care. Patients who received palliative care were more likely to be younger, recently diagnosed, treated at academic hospitals, and have stage IV disease. Patients living in Mountain and Pacific regions had higher odds of palliative care receipt than those in the East Coast. Patients without insurance had higher odds of palliative care if they survived <24 months. Insurance coverage through Medicaid was associated with increased palliative care use among patients who survived 6 to 24 months. Patients who survived <6 months and lived >9 miles from the institution received more palliative care.

CONCLUSION

Palliative care use among patients with colorectal cancer is associated with a younger age, a more recent year of diagnosis, insurance status, academic hospitals, and living in Mountain and Pacific regions.

Participation of Colon and Rectal Fellows in Robotic Rectal Cancer Surgery: Effect on Surgical Outcomes

OBJECTIVES

To determine whether involvement of colon and rectal fellows has an effect on short-term surgical and oncological outcomes in robotic rectal cancer surgery.

PATIENTS AND METHODS

From a dataset of 263 robotic-assisted rectal cancer operations, 114 case-matched patients over a 5-year period (January 2010-December 2015) were included in the study. Patients who underwent resection with and without fellow involvement were compared. Cases were matched according to age, body mass index, neoadjuvant therapy, and tumor location. Intraoperative, postoperative, and pathological outcomes were compared between the 2 groups.

RESULTS

There was no difference in tumor grade, type of surgical procedure, presence of an anastomosis, or diverting stoma between groups. In addition, there was no difference in the incidence of intraoperative or postoperative complications between the 2 groups. Estimated blood loss was higher in the fellow group compared to the consultant group (mean difference of 70mL, p = 0.007). For pathological outcomes, there was no difference in surrogate oncological quality indicators, specifically margin positivity and lymph node yield, between the 2 groups. Furthermore, fellow involvement did not adversely affect operative time.

CONCLUSION

This study demonstrates that equivalent short-term surgical and oncological outcomes can be achieved with colorectal fellow participation in the field of robotic-assisted rectal cancer surgery.