Evaluation of Financial Relationships Between US Colorectal Surgery Fellowship Program Directors and Industry

This cross-sectional study evaluates the financial relationships between colorectal surgery fellowship program directors and industry.

External validation of the Codman score in colorectal surgery: a pragmatic tool to drive quality improvement

AIM

The simple six-variable Codman score is a tool designed to reduce the complexity of contemporary risk-adjusted postoperative mortality rate predictions. We sought to externally validate the Codman score in colorectal surgery.

METHODS

The American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) participant user file and colectomy targeted dataset of 2020 were merged. A Codman score (composed of six variables: age, American Society of Anesthesiologists score, emergency status, degree of sepsis, functional status and preoperative blood transfusion) was assigned to every patient. The primary outcome was in-hospital mortality and secondary outcome was morbidity at 30 days. Logistic regression analyses were performed using the Codman score and the ACS NSQIP mortality and morbidity algorithms as independent variables for the primary and secondary outcomes. The predictive performance of discrimination area under receiver operating curve (AUC) and calibration of the Codman score and these algorithms were compared.

RESULTS

A total of 40 589 patients were included and a Codman score was generated for 40 557 (99.02%) patients. The median Codman score was 3 (interquartile range 1-4). To predict mortality, the Codman score had an AUC of 0.92 (95% CI 0.91-0.93) compared to the NSQIP mortality score 0.93 (95% CI 0.92-0.94). To predict morbidity, the Codman score had an AUC of 0.68 (95% CI 0.66-0.68) compared to the NSQIP morbidity score 0.72 (95% CI 0.71-0.73). When body mass index and surgical approach was added to the Codman score, the performance was no different to the NSQIP morbidity score. The calibration of observed versus expected predictions was almost perfect for both the morbidity and mortality NSQIP predictions, and only well fitted for Codman scores of less than 4 and greater than 7.

CONCLUSION

We propose that the six-variable Codman score is an efficient and actionable method for generating validated risk-adjusted outcome predictions and comparative benchmarks to drive quality improvement in colorectal surgery.

Precision cut intestinal slices, a novel model of acute food allergic reactions

BACKGROUND

Food allergy affects up to 10% of the pediatric population. Despite ongoing efforts, treatment options remain limited. Novel models of food allergy are needed to study response patterns downstream of IgE-crosslinking and evaluate drugs modifying acute events. Here, we report a novel human ex vivo model that displays acute, allergen-specific, IgE-mediated smooth muscle contractions using precision cut intestinal slices (PCIS).

METHODS

PCIS were generated using gut tissue samples from children who underwent clinically indicated surgery. Viability and metabolic activity were assessed from 0 to 24 h. Distribution of relevant cell subsets was confirmed using single nucleus RNA sequencing. PCIS were passively sensitized using plasma from peanut allergic donors or peanut-sensitized non-allergic donors, and exposed to various stimuli including serotonin, histamine, FcɛRI-crosslinker, and food allergens. Smooth muscle contractions and mediator release functioned as readouts. A novel program designed to measure contractions was developed to quantify responses. The ability to demonstrate the impact of antihistamines and immunomodulation from peanut oral immunotherapy (OIT) was assessed.

RESULTS

PCIS viability was maintained for 24 h. Cellular distribution confirmed the presence of key cell subsets including mast cells. The video analysis tool reliably quantified responses to different stimulatory conditions. Smooth muscle contractions were allergen-specific and reflected the clinical phenotype of the plasma donor. Tryptase measurement confirmed IgE-dependent mast cell-derived mediator release. Antihistamines suppressed histamine-induced contraction and plasma from successful peanut OIT suppressed peanut-specific PCIS contraction.

CONCLUSION

PCIS represent a novel human tissue-based model to study acute, IgE-mediated food allergy and pharmaceutical impacts on allergic responses in the gut.

Post-operative outcomes in patients with locally advanced colon cancer: a comparison of operative approach

INTRODUCTION

Surgeons may choose an open approach to locally advanced colon cancer (LACC) because of the elevated conversion rate (minimally invasive to open) in these patients (resulting in part from a judgment of the technical feasibility of a minimally invasive approach). Poorer outcomes have been suggested in those requiring conversion from a minimal access to an open approach; however, the influence of conversion has not been studied in LACC. We sought to compare perioperative outcomes in patients with T4aN2 colon cancer undergoing minimally invasive surgery (MIS), planned open (PO), and converted (CN) procedures to evaluate the influence of conversion in this subgroup.

METHODS

A retrospective cohort study was conducted using the NSQIP database. Patients with T4aN2 colon cancer undergoing elective resection were included; rectal/unknown tumor location, and T4b disease were excluded (to ensure homogeneity in surgical management). Patients were divided into cohorts based on approach: PO, MIS, and CN. Summary statistics were compared between groups. Multivariable analysis was conducted for mortality and morbidity outcomes.

RESULTS

1286 cases were included (313 PO, 842 MIS, 131 CN); 10.2% underwent conversion. Those undergoing MIS had a shorter length of stay than those undergoing PO or CN (p < 0.0001). On univariable analysis, CN resulted in increased rates of any complication (p < 0.0001). CN also had a greater rate of anastomotic leak (p = 0.0046) and death (p = 0.05). On multivariable analysis, significant predictors of any complication included age, ASA class, M stage, and approach; however, CN did not increase the risk of complication compared with MIS, whereas PO nearly doubled the risk of complication (OR = 1.98, p = 0.0083). The only significant predictor of mortality on multivariable analysis was age (HR = 1.09, p = 0.0002)-approach was not associated with mortality.

CONCLUSION

PO confers the greatest risk of suffering any complication. Surgical approach was not associated with death. Results of our study challenge the notion that conversion is associated with the worst perioperative outcomes and an MIS approach should be considered in patients with LACC.

Racial disparities in colon cancer survival: A propensity score matched analysis in the United States

BACKGROUND

Black patients are disproportionally impacted by colorectal cancer, both with respect to incidence and mortality. Studies accounting for patient- and community-level factors that contribute to such disparities are lacking. Our objective is to determine if Black compared to White race is associated with worse survival in colon cancer, while accounting for socioeconomic and clinical factors.

METHODS

A retrospective analysis was performed of Black or White patients with nonmetastatic colon cancer in the Surveillance, Epidemiology, and End Results cancer registry between 2008 and 2016. Multivariable Cox regression analysis and propensity-score matching was performed.

RESULTS

A total of 100,083 patients were identified, 15,155 Black patients and 84,928 White patients. Median follow-up was 38 months (interquartile range: 15-67). Black patients were more likely to lack health insurance and reside in counties with low household income, high unemployment, and lower high school completion rates. Black race was associated with poorer unadjusted 5-year cancer-specific survival (79.4% vs 82.4%, P < .001). After multivariable adjustment, Black race was associated with greater 5-year cancer-specific mortality (hazard ratio: 1.19, 95% confidence interval: 1.13-1.25, P < .001) and overall mortality (hazard ratio: 1.12, 95% confidence interval: 1.08-1.16, P < .001). Mortality was higher for Black patients across stages: stage I (hazard ratio: 1.08, 95% confidence interval: 1.08-1.09), stage II (hazard ratio: 1.06, 95% confidence interval: 1.06-1.07), stage III (1.03, 95% confidence interval: 1.03-1.04). Propensity-score matching identified 27,640 patients; Black race was associated with worse 5-year overall survival (67.5% vs 70.2%, P = .003) and cancer-specific survival (79.4% vs 82.3%, P < .001).

CONCLUSIONS

This US population-based analysis confirms poorer overall survival and cancer-specific survival in Black patients undergoing surgery for nonmetastatic colon cancer despite accounting for trans-sectoral factors that have been implicated in structural racism.

Neoadjuvant therapy versus direct to surgery for T4 colon cancer: meta-analysis

BACKGROUND

Despite persistently poor oncological outcomes, approaches to the management of T4 colonic cancer remain variable, with the role of neoadjuvant therapy unclear. The aim of this review was to compare oncological outcomes between direct-to-surgery and neoadjuvant therapy approaches to T4 colon cancer.

METHODS

A librarian-led systematic search of MEDLINE, Embase, the Cochrane Library, Web of Science, and CINAHL up to 11 February 2020 was performed. Inclusion criteria were primary research articles comparing oncological outcomes between neoadjuvant therapies or direct to surgery for primary T4 colonic cancer. Based on PRISMA guidelines, screening and data abstraction were undertaken in duplicate. Quality assessment was carried out using Cochrane risk-of-bias tools. Random-effects models were used to pool effect estimates. This study compared pathological resection margins, postoperative morbidity, and oncological outcomes of cancer recurrence and overall survival.

RESULTS

Four studies with a total of 43 063 patients met the inclusion criteria. Compared with direct to surgery, neoadjuvant therapy was associated with increased rates of margin-negative resection (odds ratio (OR) 2.60, 95 per cent c.i. 1.12 to 6.02; n = 15 487) and 5-year overall survival (pooled hazard ratio 1.42, 1.10 to 1.82, I2 = 0 per cent; n = 15 338). No difference was observed in rates of cancer recurrence (OR 0.42, 0.15 to 1.22; n = 131), 30-day minor (OR 1.12, 0.68 to 1.84; n = 15 488) or major (OR 0.62, 0.27 to 1.44; n = 15 488) morbidity, or rates of treatment-related adverse effects.

CONCLUSION

Compared with direct to surgery, neoadjuvant therapy improves margin-negative resection rates and overall survival.

Apical lymphadenectomy during low ligation of the IMA during rectosigmoid resection for cancer

Background

Low ligation of the inferior mesenteric artery with preservation of the left colic artery may decrease the risk of colorectal anastomotic ischemia compared to high ligation at its origin. Low ligation leaves apical nodes in situ and is therefore paired with apical lymphadenectomy. We sought to compare relevant oncologic outcomes between high ligation and low ligation plus apical lymphadenectomy in rectosigmoid resection for colorectal cancer.

Methods

We conducted a retrospective cohort study. Patients receiving a rectosigmoid resection for cancer between January 2012 and July 2018 were included. Patients with metastatic disease and those who underwent low ligation without apical lymphadenectomy were excluded. Our primary outcome was nodal yield/metastasis. Secondary outcomes included perioperative complications, local recurrence, and overall survival.

Results

Eighty-four patients underwent high ligation and 89 low ligation plus apical lymphadenectomy (median follow-up 20 months). In the low-ligation group, a median of 2 (interquartile range = 1–3) apical nodes was resected; 4.1% were malignant, increasing pathologic stage in 25% of these patients. There were no differences in nodal yield, complications, anastomotic leak, local recurrence, or overall survival.

Conclusion

No differences were identified between high ligation and low ligation plus apical lymphadenectomy with respect to relevant clinical outcomes. Prospective trial data are needed to robustly establish the oncologic benefit and safety of the low ligation plus apical lymphadenectomy technique.

Impact of BMI on Adverse Events After Laparoscopic and Open Surgery for Rectal Cancer

PURPOSE

The impact of body mass index (BMI) on outcomes after open or laparoscopic surgery for rectal cancer remains unclear. The objective of this retrospective cohort study was to examine the interaction of body mass index and surgical modality (i.e., laparoscopy versus open) with respect to short-term clinical outcomes in patients with rectal cancer.

METHODS

The ACS-NSQIP database (2012-2016) was reviewed for patients undergoing open or laparoscopic surgery for rectal cancer. The primary outcome was 30-day all-cause morbidity. Logistic regression and Cox proportional hazard models were used for analysis.

RESULTS

A total of 16,145 patients were grouped into open (N = 6759, 42%) and laparoscopic (N  = 9386, 58%) cohorts. Patients with higher BMI (p < 0.001) and those undergoing open surgery (p < 0.001) were at increased risk of all-cause morbidity. There was no significant change in the odds ratio of experiencing all-cause morbidity between open and laparoscopic surgery with increasing BMI (p = 0.572). Median length of stay was significantly shorter in the laparoscopy group (4 days vs. 6 days; p < 0.001), at the cost of increased operative time (239 min vs. 210 min, p < 0.001). The difference in operative time between laparoscopy and open surgery did not increase with rising BMI (i.e., ∆37 min vs. ∆39 min at BMI 25 kg/m² vs 50 kg/m², respectively, p = 0.491).

CONCLUSION

BMI may not be a strong modifier for surgical approach with respect to short-term clinical outcomes in patients with obesity and rectal cancer. Laparoscopic surgery was associated with improved short-term clinical outcomes, without much change in the absolute difference in operative time compared with open surgery, even at higher BMIs.

Minimally Invasive Surgical Approaches Are Safe and Appropriate in N2 Colorectal Cancer

BACKGROUND

There is emerging evidence of the oncological safety of minimally invasive surgery in T4 colorectal cancer; however, such support is lacking in N2 disease.

OBJECTIVE

This study aimed to compare oncological and perioperative outcomes of surgical resection for N2 colorectal cancer using an open versus minimally invasive approach.

DESIGN

We conducted a retrospective cohort study using the National Surgical Quality Improvement Program's generic and targeted colectomy data sets.

SETTINGS

Data about surgery for N2 colorectal cancer were obtained regarding North American hospitals participating in the American College of Surgeons National Surgical Quality Improvement Program.

PATIENTS

All patients undergoing elective surgical resection for N2 colorectal cancer in participating hospitals between 2014 and 2018 were selected.

INTERVENTIONS

Surgical resection of N2 colorectal cancer was performed.

MAIN OUTCOME MEASURES

Our primary outcome was nodal yield. Secondary outcomes included perioperative complications and mortality.

RESULTS

A total of 1837 patients underwent open and 3907 patients underwent minimally invasive surgery colectomies for N2 colorectal cancer (n = 5744). Median nodal yield was 20 (interquartile range, 15-27) in the open group and 21 (interquartile range, 16-28) in the minimally invasive group (p < 0.0001); however, nodal harvest between the 2 groups was not significantly different on multivariate analysis. Perioperative complications were higher on univariate analysis in the open surgery group, with respect to key outcomes including anastomotic leak and death (p < 0.001).

LIMITATIONS

This study is limited by its retrospective design and by the fact that the staging data collected by the National Surgical Quality Improvement Program are pathological rather than clinical; however, prior studies found a 97% concordance between pathological and clinical N2 determination.

CONCLUSIONS

Minimally invasive surgery approaches to colorectal cancer with N2 disease result in equivalent nodal harvests compared with open approaches. Our group supports the use of a minimally invasive approach in advanced nodal stage colorectal cancer in the appropriately selected patient. See Video Abstract at http://links.lww.com/DCR/B417.

LOS ABORDAJES QUIRRGICOS MNIMAMENTE INVASIVOS SON SEGUROS Y APROPIADOS EN EL CNCER COLORRECTAL N

ANTECEDENTES:Existe evidencia emergente de la seguridad oncológica de la cirugía mínimamente invasiva en el cáncer colorrectal T4; sin embargo, semenjante apoyo falta en la enfermedad N2.OBJETIVO:comparar los resultados oncológicos y perioperatorios de la resección quirúrgica para el cáncer colorrectal N2 utilizando un abordaje abierto versus mínimamente invasivo.DISEÑO:Realizamos un estudio de cohorte retrospectivo utilizando los conjuntos de datos de colectomía genéricos y específicos del Programa Nacional de Mejoramiento de la Calidad Quirúrgica.AJUSTE:Hospitales de Norte America que participan en el Programa Nacional de Mejoramiento de la Calidad Quirúrgica del Colegio Americano de Cirujanos.PACIENTES:Todos los pacientes sometidos a resección quirúrgica electiva por cáncer colorrectal N2 en los hospitales participantes entre 2014 y 2018.INTERVENCIONES:Resección quirúrgica de cáncer colorrectal N2.PRINCIPALES MEDIDAS DE VOLORACION:Nuestro resultado principal fue el rendimiento nodal. Los resultados secundarios incluyeron complicaciones perioperatorias y mortalidad.RESULTADOS:1837 pacientes fueron sometidos a cirugía abierta y 3907 pacientes fueron sometidos a colectomías de cirugía mínimamente invasiva por cáncer colorrectal N2 (n = 5744). La mediana del rendimiento nodal fue 20 (IQR 15-27) en el grupo abierto y 21 (IQR 16-28) en el grupo mínimamente invasivo (p <0,0001); sin embargo, el rendimiento nodal entre los dos grupos no fue significativamente diferente en el análisis multivariado. Las complicaciones perioperatorias fueron mayores en el análisis univariado en el grupo de cirugía abierta, con respecto a los resultados clave, incluida la fuga anastomótica y la muerte (p <0,001).LIMITACIONES:Este estudio está limitado por su diseño retrospectivo y por el hecho de que los datos de estadificación recopilados por NSQIP son patológicos más que clínicos; sin embargo, estudios previos encontraron una concordancia del 97% entre la determinación patológica y clínica de N2.CONCLUSIONES:Los enfoques de cirugía mínimamente invasiva para el cáncer colorrectal con enfermedad N2 dan rendimientos nodales equivalentes a abordajes abiertos. Nuestro grupo apoya el uso de abordaje mínimamente invasivo en el cáncer colorrectal avanzado en estadio ganglionar en el paciente adecuadamente seleccionado. Consulte Video Resumenhttp://links.lww.com/DCR/B417.

Anastomotic leak after colorectal surgery: does timing affect failure to rescue?

BACKGROUND

Anastomotic leak (AL) is a common complication after colectomy with a relatively high failure to rescue rate (FTR), or death after major complications. There is emerging evidence to suggest an early AL may be associated with increased technical difficulty. Whether the timing of an AL is associated with higher FTR has not been established.

METHODS

Patients who underwent a colectomy between 2012 and 2017 were identified from the American College of Surgeons National Quality Improvement Program (ACS NSQIP database). The primary outcome was FTR after AL. The predictor variable used was day of post-operative leak (POD) categorized into early (POD ≤ 3), intermediate (3 < POD ≤ 20) and late (20 < POD ≤ 30) AL. These POD groups were compared to generate hypotheses to explain any association observed between timing of AL and FTR.

RESULTS

Of 135,539 identified patients, 4613 patients experienced an AL (3.4%) with an overall FTR of 6.4%. FTR differed by timing of AL: early AL was found to have a FTR of 28/195 (12.6%), with a FTR in intermediate AL of 152/2550 (5.6%) and 3/356 (0.8%) in late AL patients (p < 0.0001). When compared by timing of AL, patients differed by sex, pre-operative bowel preparation, de-functioning ostomy rates and re-operation rates (p < 0.05). Controlling for age, ASA, sex, emergency status, operative approach, indication, de-functioning ostomy, re-operation and concurrent procedure, an early AL was found to have a 2.3-fold increased risk of FTR (95% CI 1.38-3.84, p = 0.001), with a late AL having a 0.15-fold decreased risk (95% CI 0.04-0.49, p = 0.002), both compared to an intermediate AL.

CONCLUSION

Early ALs, occurring within three days of surgery, may carry a significant risk of FTR. Given the findings identified here, this may support the use of early detection algorithms and interventions of AL to minimize the risk of FTR.

Racial Disparities in Surgery: A Cross-Specialty Matched Comparison Between Black and White Patients

Objective

To determine if Black race is associated with worse short-term postoperative morbidity and mortality when compared to White race in a contemporary, cross-specialty-matched cohort.

Background

Growing evidence suggests poorer outcomes for Black patients undergoing surgery.

Methods

A retrospective analysis was conducted comprising of all patients undergoing surgery in the National Surgical Quality Improvement Program dataset between 2012 and 2018. One-to-one coarsened exact matching was conducted between Black and White patients. Primary outcome was rate of 30-day morbidity and mortality.

Results

After 1:1 matching, 615,118 patients were identified. Black race was associated with increased rate of all-cause morbidity (odds ratio [OR] = 1.10, 95% confidence interval [CI] 1.08-1.13, P < 0.001) and mortality (OR = 1.15, 95% CI 1.01-1.31, P = 0.039). Black race was associated with increased risk of re-intubation (OR = 1.33, 95% CI 1.21-1.48, P < 0.001), pulmonary embolism (OR = 1.55, 95% CI 1.40-1.71, P < 0.001), failure to wean from ventilator for >48 hours (OR = 1.14, 95% CI 1.02-1.29, P < 0.001), progressive renal insufficiency (OR = 1.63, 95% CI 1.43-1.86, P < 0.001), acute renal failure (OR = 1.39, 95% CI 1.16-1.66, P < 0.001), cardiac arrest (OR = 1.47, 95% CI 1.24-1.76 P < 0.001), bleeding requiring transfusion (OR = 1.39, 95% CI 1.34-1.43, P < 0.001), DVT/thrombophlebitis (OR = 1.24, 95% CI 1.14-1.35, P < 0.001), and sepsis/septic shock (OR = 1.09, 95% CI 1.03-1.15, P < 0.001). Black patients were also more likely to have a readmission (OR = 1.12, 95% CI 1.10-1.16, P < 0.001), discharge to a rehabilitation center (OR = 1.73, 95% CI 1.66-1.80, P < 0.001) or facility other than home (OR = 1.20, 95% CI 1.16-1.23, P < 0.001).

Conclusion and Relevance

This contemporary matched analysis demonstrates an association with increased morbidity, mortality, and readmissions for Black patients across surgical procedures and specialties.

Adequacy of lymph node harvest following colectomy for obstructed and nonobstructed colon cancer

BACKGROUND

Technical and clinical differences in resection of obstructed and non-obstructed colon cancers may result in differences in lymph node retrieval. The objective of this study is to compare the lymph node harvest following resection of obstructed and nonobstructed colon cancer patients.

METHODS

A retrospective analysis utilizing the 2014-2018 NSQIP colectomy targeted data set was conducted. One-to-one coarsened exact matching (CEM) was utilized between patients undergoing resection for obstructed and non-obstructed colon cancer. The primary outcome was the adequacy of lymph node retrieval (LNR, ≥12 nodes).

RESULTS

CEM resulted in 9412 patients. Patients with obstructed tumors were more likely to have inadequate LNR (13.3% vs 8.2%, p < .001) compared to those with nonobstructed tumors. Multivariate analysis demonstrated that patients with obstructing tumors had worse LNR compared to non-obstructed tumors (odds ratio [OR]: 0.74, 95% confidence interval [CI]: 0.62-0.87; p < .005). Increased age (OR: 0.99, 95% CI: 0.098-0.99), presence of preoperative sepsis (OR: 0.70, 95% CI: 0.055-0.90), left-sided and sigmoid tumors compared to right-sided (OR: 0.64, 95% CI: 0.51-0.81; OR: 0.69, 95% CI: 0.58-0.82, respectively), and open surgical resection compared to an minimally invasive surgical approach were associated with inadequate LNR (p < .05).

CONCLUSION

This study demonstrated that resection for obstructing colon cancer compared to non-obstructed colon cancer is associated with increased odds of inadequate lymph node harvest.

Will My Patient Survive an Anastomotic Leak? Predicting Failure to Rescue Using the Modified Frailty Index

IMPORTANCE

Failure to rescue (FTR), or death after major complications, has emerged as a marker of hospital-level quality of care.

OBJECTIVE

To evaluate the predictive performance of the ACS-NSQIP modified frailty index (mFI) in determining FTR following an anastomotic leak (AL) after a colectomy for colorectal cancer.

DESIGN

Retrospective cohort study.

SETTING

Multicenter interrogation of the 2012-2016 American College of Surgeons (ACS) colectomy procedure targeted National Surgical Quality Improvement Program (NSQIP) database.

PATIENTS AND METHODS

A total of 50,944 patients who underwent colectomy for colorectal cancer.

EXPOSURE

Frailty as measured by: (1) Age, ASA, and emergency status (model 1), (2) Age, ASA, emergency status, and mFI (model 2), (3) ACS-NSQIP mortality prediction (model 3).

MAIN OUTCOME AND MEASURE

Primary outcome was FTR after AL.

RESULTS

A total of 1755 patients experienced an AL (3.46%) with a FTR rate of 6.44%. The mean age was 65.6 years (95% CI 65.28-65.58 years), median ASA was 3 (IQR 2-3), 51 patients (2.92%) were partially or totally dependent, 366 (20.86%) were diabetic, 105 (5.98%) had a history of chronic obstructive pulmonary disease (COPD), 32 (1.82%) had a history of congestive heart disease (CHD), and 966 (55.04%) were on hypertensive treatment. The performance of model 1 (AUROC 0.77; 95% CI 0.72-0.81), model 2 (AUROC 0.77; 95% CI 0.73-0.82), and model 3 (AUROC 0.79; 95% CI 0.75-0.83) to predict FTR was not different (p = 0.44).

CONCLUSIONS AND RELEVANCE

Age and ASA remain the most reliable predictors of failure to rescue anastomotic leak after colectomy for colorectal cancer. Addition of the modified frailty index, or all variables collected by NSQIP, did not significantly improve predictive performance.

Current Evidence for Minimally Invasive Surgery During the COVID-19 Pandemic and Risk Mitigation Strategies: A Narrative Review

OBJECTIVE

Our objective was to review the literature surrounding the risks of viral transmission during laparoscopic surgery and propose mitigation measures to address these risks.

SUMMARY BACKGROUND DATA

The SARS-CoV-2 pandemic has caused surgeons the world over to re-evaluate their approach to surgical procedures given concerns over the risk of aerosolization of viral particles and exposure of operating room staff to infection. International society guidelines advise against the use of laparoscopy; however, the evidence on this topic is scant and recommendations are based on the perceived most cautious course of action.

METHODS

We conducted a narrative review of the existing literature surrounding the risks of viral transmission during laparoscopic surgery and balance these risks against the benefits of minimally invasive approaches. We also propose mitigation measures to address these risks that we have adopted in our institution.

RESULTS AND CONCLUSION

While it is currently assumed that open surgery minimizes operating room staff exposure to the virus, our findings reveal that this may not be the case. A well-informed, evidence-based opinion is critical when making decisions regarding which operative approach to pursue, for the safety and well-being of the patient, the operating room staff, and the healthcare system at large. Minimally invasive surgical approaches offer significant advantages with respect to both patient care, and the mitigation of the risk of viral transmission during surgery, provided the appropriate equipment and expertise are present.

The impact of surgical modality on self-reported body image, quality of life and survivorship after anterior resection for colorectal cancer – a mixed methods study

Background

There is growing enthusiasm for robotic and transanal surgery as an alternative to open or laparoscopic surgery for colorectal cancer (CRC). We examined the impact of surgical modality on body image and quality of life (QOL) in patients receiving anterior resection for CRC.

Methods

We used a mixed-methods approach, consisting of a chart review and semistructured interviews with CRC patients, at least 8 months after surgery. We assessed cosmetic outcomes and QOL using validated questionnaires.

Results

Thirty patients were stratified into open (n = 8), laparoscopic (n = 12) and robotic (n = 10) groups. Mean body image scores were significantly higher (i.e., poorer body image) in patients receiving open surgery (mean difference [MD] +5.7 with laparoscopy, p < 0.001). Open surgery was more detrimental to physical function, including strenuous activities, prolonged ambulation and self-care (MD –11.6 with laparoscopy, p = 0.039). Patients receiving laparoscopic surgery reported superior role (MD +27.6 with open surgery, p = 0.002) and social function (MD +13.7 with open surgery, p = 0.042), including the ability to enjoy hobbies, family life and social activities. Surgical modality did not impact emotional and cognitive function or symptoms including genitourinary function, pain and defecation.

Conclusion

The negative impact of open surgery on body image and physical function warrants further educational interventions for patients. The protective effect of laparoscopy on role and function may be associated with “tumour factors” that are unaccounted for in the European Organization for Research and Treatment of Cancer questionnaires. Open surgery is detrimental to body image and physical function in patients receiving anterior resection for CRC. Prospective randomized studies are required to validate these findings.

Nonoperative management (NOM) in rectal cancer: Physician perspectives on offering NOM as standard of care

79

Background: 20% of rectal cancer patients will have a complete clinical response (cCR) following neoadjuvant chemoradiotherapy. Non-operative management (NOM) with close surveillance can spare patients proctectomy and avoid the sequelae of surgery. Patients are interested in and advocate for NOM, whereas oncologists appear to be reluctant to offer this option. We wished to identify the perceptions and barriers that oncologists face when considering NOM. Methods: This qualitative study explored oncologists’ experiences treating rectal cancer and identified their perceptions and values around NOM. Purposive and snowball sampling identified medical, radiation and surgical oncologists’ who treat a high volume of rectal cancer across Canada. Oncologists varied in length/location of practice and gender. Data were collected via semi-structured interviews. Constant comparative analysis identified key concepts. Results: Data saturation was achieved after 40 interviews: 20 surgeons, 12 radiation and 8 medical oncologists. The dominant theme was “NOM is not ready for prime time’. Most oncologists felt that there is insufficient long-term data around NOM and single center studies appear ‘too good to be true’. Physicians voiced concerns about worsening oncologic outcomes in the setting of regrowth, the challenges in determining a cCR and apprehension around patient compliance to surveillance. Some oncologists felt that NOM is limited to a very select population and voiced reluctance in offering it to younger patients or patients with more advanced disease. There was little consideration to improved functional outcomes with NOM. Overall the majority of participants felt that NOM is ‘ trading the benefit of saving the rectum for the uncertainty of an inferior oncologic outcome’. Conclusions: Oncologists felt that NOM should not be offered as a standard of care option following a cCR. Most felt that there is insufficient data supporting NOM and are concerned around worse oncologic outcomes. Patient views of NOM are critically needed to assess if patients value the same outcomes. Additional research is needed to address barriers should patients wish to consider NOM as a treatment option in the setting of a cCR.

Benefits of minimally-invasive surgery for sigmoid and rectal cancer in older adults compared with younger adults: Do older adults have the most to gain?

INTRODUCTION

Randomized trials demonstrated oncologic safety and short-term benefits of laparoscopy. We investigated if the benefit of laparoscopy on short-term outcomes is greater for older adults compared with younger adults.

METHODS

We identified all older (≥70 years old) and younger (<70) adults with primary sigmoid and rectal cancer treated with resection between 2002 and 2018 from an institutional database. We compared 30-day postoperative outcomes using multivariable logistic regression with an interaction term between age group and surgical approach. Primary outcomes were death, major (Clavien-Dindo III-IV) and minor (Clavien-Dindo I-II) complications, and wound complications.

RESULTS

We included 792 patients, 293 (37%) older and 499 (63%) younger. Use of laparoscopy was similar between age groups: 120/293 (41%) older, 204/499 (41%) younger (p = .98). All patients had 30-day follow-up. Compared with open resection, minimally-invasive resection was associated with a greater reduction in deaths in older adults than in younger adults (absolute difference in older adults 7.0% less versus 2.1% less in younger adults; adjusted odds ratio [aOR] older 3.01, 95% confidence interval [CI] 1.31-7.33; aOR younger 0.31, 95% CI 0.05-1.24; interaction p = .01). Similarly, minimally-invasive resection was associated with a greater reduction in major complications in older adults than in younger adults (absolute difference in older adults 6.4% less versus 2.4% less in younger adults; aOR older 1.91, 95% CI 1.07-3.41; aOR younger 0.70, 95% CI 0.34-1.38; interaction p = .03).

CONCLUSIONS

Minimally-invasive compared with open surgery demonstrated a differential benefit on postoperative death and major complications between younger and older adults.

Association Between Adjuvant Chemotherapy and Overall Survival in Patients With Rectal Cancer and Pathological Complete Response After Neoadjuvant Chemotherapy and Resection

Importance

Although American guidelines recommend use of adjuvant chemotherapy in patients with locally advanced rectal cancer, individuals who achieve a pathological complete response (pCR) following neoadjuvant chemoradiotherapy are less likely to receive adjuvant treatment than incomplete responders. The association and resection of adjuvant chemotherapy with survival in patients with pCR is unclear.

Objective

To determine whether patients with locally advanced rectal cancer who achieve pCR after neoadjuvant chemoradiation therapy and resection benefit from the administration of adjuvant chemotherapy.

Design, Setting, and Participants

This retrospective propensity score-matched cohort study identified patients with locally advanced rectal cancer from the National Cancer Database from 2006 through 2012. We selected patients with nonmetastatic invasive rectal cancer who achieved pCR after neoadjuvant chemoradiation therapy and resection.

Exposures

We matched patients who received adjuvant chemotherapy to patients who did not receive adjuvant treatment in a 1:1 ratio. We separately matched subgroups of patients with node-positive disease before treatment and node-negative disease before treatment to investigate for effect modification by pretreatment nodal status.

Main Outcome and Measures

We compared overall survival between groups using Kaplan-Meier survival methods and Cox proportional hazards models.

Results

We identified 2455 patients (mean age, 59.5 years; 59.8% men) with rectal cancer with pCR after neoadjuvant chemoradiation therapy and resection. We matched 667 patients with pCR who received adjuvant chemotherapy and at least 8 weeks of follow-up after surgery to patients with pCR who did not receive adjuvant treatment. Over a median follow-up of 3.1 years (interquartile range, 1.94-4.40 years), patients treated with adjuvant chemotherapy demonstrated better overall survival than those who did not receive adjuvant treatment (hazard ratio, 0.44; 95% CI, 0.28-0.70). When stratified by pretreatment nodal status, only those patients with pretreatment node-positive disease exhibited improved overall survival with administration of adjuvant chemotherapy (hazard ratio, 0.24; 95% CI, 0.10-0.58).

Conclusions and Relevance

The administration of adjuvant chemotherapy in patients with rectal cancer with pCR is associated with improved overall survival, particularly in patients with pretreatment node-positive disease. Although this study suggests a beneficial effect of adjuvant treatment on survival in patients with pCR, these results are limited by the presence of potential unmeasured confounding in this nonrandomized study.

Cost of open and laparoscopic distal gastrectomy: surgeon perceptions versus the reality of hospital spending

BACKGROUND

Rising health care costs have led to increasing focus on cost containment and accountability from health care providers. We sought to explore surgeon awareness of supply costs for open and laparoscopic distal gastrectomy.

METHODS

Surveys were sent in 2015 to surgeons at 8 academic hospitals in Toronto who performed distal gastrectomy for gastric adenocarcinoma. Respondents were asked to estimate the total cost, type and number of disposable equipment pieces required to perform open and laparoscopic distal gastrectomy. We determined the accuracy of estimates through comparisons with procedural invoices for distal gastrectomy performed between Jan. 1, 2011, and Dec. 31, 2015. All values are in 2015 Canadian dollars.

RESULTS

Of the 53 surveys sent out, 12 were completed (response rate 23%). Surgeon estimates of total supply costs ranged from $500 to $3000 and from $1500 to $5000 for open and laparoscopic cases, respectively. Estimated supply costs for requested equipment ranged from $464 to $2055 for open cases and from $1870 to $2960 for laparoscopic cases. Invoices for actual equipment yielded a mean of $821 (standard deviation $543) (range $89-$2613) for open cases and $2678 (standard deviation $958) (range $835-$4102) for laparoscopic cases. Estimates of total cost were within 25% of the median invoice total in 1 response (9%) for open cases and 3 (27%) of those for laparoscopic cases.

CONCLUSION

Respondents failed to accurately estimate equipment costs. The variation in true total costs and estimates of supply costs represents an opportunity for intraoperative cost minimization, efficient equipment selection and value-based purchasing arrangements.

Emergency laparoscopic and open repair of incarcerated ventral hernias: a multi-institutional comparative analysis with coarsened exact matching

BACKGROUND

The safety of emergent laparoscopic repair of incarcerated ventral hernias is not well established. The objective of this study was to determine if emergent laparoscopic repair of incarcerated ventral hernias is comparable to open repair with respect to short-term clinical outcomes.

METHODS

Patients undergoing emergency repair of an incarcerated ventral hernia with associated obstruction and/or gangrene were identified using the ACS-NSQIP 2012-2016 dataset. One-to-one coarsened exact matching (CEM) was conducted between patients undergoing laparoscopic and open repair. Matched cohorts were compared with respect to morbidity, mortality, readmission, reoperation, missed enterotomies, and length of stay. Missed enterotomy was defined as any re-operative procedure within 30 days that required resection of large or small bowel segments, based on CPT codes. Multivariate analysis was conducted to determine adjusted predictors of morbidity.

RESULTS

A total of 1642 patients were identified after CEM. Laparoscopic compared to open repair was associated with a lower rate of 30-day wound-morbidity (OR 0.35, 95% CI 0.22-0.57, p < 0.001). Laparoscopic repair was not associated with lower 30-day non-wound morbidity (OR 0.73, 95% CI 0.51-1.06, p = 0.094). Laparoscopic repair was associated with shorter LOS (3.6 days vs. 4.3 days, p = 0.014). A higher rate of missed enterotomies was observed in the laparoscopic cohort (0.7% vs. 0.0%, p = 0.031). There were no group differences with respect to 30-day readmission, reoperation, or mortality.

CONCLUSIONS

Emergency laparoscopic repair of incarcerated ventral hernias is associated with lower rates of wound-morbidity and shorter hospital stays compared to open repair. However, laparoscopic repair is associated with a higher rate of missed enterotomies; a rate which is low and comparable to elective non-incarcerated ventral hernia repairs.

Effect of time to operation on outcomes in adults who underwent emergency general surgery procedure

BACKGROUND

Patients who undergo an emergency procedure have an increase in postoperative morbidity and mortality. Emergency procedures constitute 14.2% of all general surgery procedures and account for 53.5% of deaths. Among this population, time to surgery from arrival to the emergency department (ED) has not been evaluated as an independent risk factor for morbidity and mortality.

MATERIAL AND METHODS

Patients who underwent an emergency general surgery procedure from 2013 to 2015 were identified using a local American College of Surgeons National Surgical Quality Improvement Project (ACS-NSQIP) database. Outcomes of interest included 30-d mortality, all morbidity, and severe morbidity. Multivariate analyses were conducted using a logistic regression model using clinically relevant covariates to determine predictors of the outcome measures.

RESULTS

A total of 974 patients were included in the final analysis. The prolonged median time from ED presentation to OR was predictive of all morbidity (14.3 h versus 13.3 h, P = 0.009) and severe morbidity (13.3 h versus 14.4 h, P = 0.063) on univariate analysis. Time from ED presentation to OR was not predictive of mortality (13.5 h versus 13.6 h, P = 0.474). Multivariate analysis demonstrated an adjusted increased odd of morbidity of 2.3 (95% CI: 1.01-5.24) for priority level A cases within the fourth quartile compared to that of the first quartile of time (P = 0.048).

CONCLUSIONS

This study corroborates with known data that morbidity and mortality increases in patients who are older, have multiple comorbidities, and higher ASA class. Furthermore, the time from ED arrival to the OR is associated with an overall increase in morbidity.

Comparison of two novel staging systems with the TNM system in predicting stage III colon cancer survival

BACKGROUND AND OBJECTIVES

Adaptations of the TNM staging system that incorporate the Lymph Node Ratio (LNR) have been proposed for stage III colon cancer. This study compared the concordance of two novel staging systems and the TNM system with observed survival outcomes in stage III patients.

METHODS

A review of patients who underwent surgery for stage III colon cancer between January 2002 and April 2015 at a tertiary care centre was performed. The Kaplan-Meier method was used to estimate the 5-year overall (OS) and disease free survival (DFS) rates, and the concordance probability was calculated to evaluate the discriminatory power of the staging systems.

RESULTS

Two hundred and sixty-one patients were identified. For TNM stages IIIA, IIIB, and IIIC, 5-year OS was 83.4%, 67.6%, and 38.3%, respectively (P < 0.001). All three staging systems were independently predictive of OS and DFS (P < 0.001). However, the novel staging system by Sugimoto et al¹⁸ was the most favourable prognostic tool, with a concordance of 0.646 for DFS and 0.659 for OS.

CONCLUSIONS

The novel staging system by Sugimoto et al¹⁸ was superior to the TNM system. Incorporating LNR into staging models for node positive colon cancers may improve survival information available to patients and potentially aid treatment decisions.

Tumor platinum concentrations and pathological responses following preoperative cisplatin-containing chemotherapy in gastric or gastroesophageal junction cancer patients

76

Background: Perioperative chemotherapy plus surgical resection is a standard of care for locally advanced gastric or gastroesophageal junction (GEJ) cancers. There is a wide range in tumor response following cisplatin-containing preoperative chemotherapy. We investigated the relationship between tumor platinum levels and pathological tumor responses in gastric or GEJ cancer patients following preoperative chemotherapy. Methods: Tumor and adjacent normal tissues were retrieved. Pathological responses were assessed per standard criteria. Tissue platinum concentrations were determined with high-performance liquid chromatography mass spectrometry. Platinum distribution in tissue components was evaluated with imaging mass cytometry. Tissue collagen content was evaluated using trichrome staining. Results: Ten patients were enrolled in this study. Nine patients received 3 cycles of preoperative chemotherapy and 1 received 2 cycles. The median cumulative cisplatin dose was 166.8 mg/m2 (range: 95.9–181.1 mg/m2). Surgery was performed at a median time of 49 days (range: 28–72 days) after the last cycle of chemotherapy. The mean platinum level in tumor tissue in patients with any response was 893 ± 460 pg, significantly higher than in those with no response [38.8 ± 8.8 pg (p = 0.007)]. The collagen content was significantly higher in patients with any response than in those with no response (37.4 ± 6.8% vs. 11.5 ± 8.6%, p < 0.05). Platinum preferentially bound to collagen. Conclusions: Platinum was detectable in surgical specimens up to 72 days after preoperative chemotherapy. Higher tumor platinum concentration correlated with improved pathological response. Collagen binding potentially explained the high interpatient variability in tumor platinum concentrations.

Knowledge and Perception of Bariatric Surgery Among Primary Care Physicians: a Survey of Family Doctors in Ontario

PURPOSE

The primary objective of this study was to identify Ontario family physicians' knowledge and perceptions of bariatric surgery.

METHODS

The study population included all physicians practicing family medicine in Ontario who were listed in the Canadian Medical Directory. A self-administered questionnaire consisting of 28 questions was developed and validated using a focus group of seven primary care physicians. The questionnaire was distributed to 1328 physicians.

RESULTS

One hundred sixty-five surveys were completed. 8.8 % of physicians did not have any bariatric surgical patients, and 71.3 % had no more than five in their practice. 70.2 % referred no more than 5 % of their morbidly obese patients for surgery. Only 32.1 % had the appropriate equipment and resources to manage obese patients. 92.5 % of physicians would like to receive more education about bariatric surgery. Physicians with no history of referral (n = 21) were earlier into their practices and had less morbidly obese patients than physicians with previous referrals (n = 141). They were also less likely to discuss bariatric surgery with their patients (30 vs. 79.3 %; p < 0.001) and less likely to feel comfortable explaining procedure options (5.6 vs. 33.9 %; p = 0.013) and providing postoperative care (26.7 vs. 64.2 %; p = 0.005). 55.6 % would refer a family member for surgery, compared to 85.4 % of physicians with previous referrals; p = 0.002.

CONCLUSION

There appears to be a knowledge gap in understanding the role of bariatric surgery in the treatment of obesity. There is an opportunity to improve education and available resources for primary care physicians surrounding patient selection and follow-up care. This may improve access to treatment.

Is quality important to our patients? The relationship between surgical outcomes and patient satisfaction

Background

With greater transparency in health system reporting and increased reliance on patient-centred outcomes, patient satisfaction has become a priority in delivering quality care. We sought to explore the relationship between patient satisfaction and short-term outcomes in patients undergoing general surgical procedures.

Methods

Satisfaction surveys were distributed to patients following discharge from the general surgery service at an academic hospital between June 2012 and March 2015. Short-term clinical outcomes were obtained from the American College of Surgeons National Surgical Quality Improvement Program database. Patients rated their level of satisfaction on a 5-point Likert scale, and ordered logistic regression model was used to determine predictors of high patient satisfaction.

Results

757 patient satisfaction surveys were completed. The mean age of patients surveyed was 52.2 years; 60.0% of patients were female. The majority of patients underwent a laparoscopic procedure (85.9%) and were admitted as inpatients following surgery (72%). 91.5% of patients rated satisfaction of 4–5, and 95.0% said they would recommend the service. The odds of overall satisfaction were lower in patients who had complications (OR: 0.52, 95% CI 0.31 to 0.87) and 30-day readmission (OR: 0.35, 95% CI 0.17 to 0.70). Having elective surgery was associated with higher odds of satisfaction (OR: 1.62, 95% CI 1.07 to 2.47).

Conclusions

We found a significant association between patient satisfaction and both 30-day readmission and the occurrence of postoperative surgical complications. Given this association, further study is warranted to evaluate patient satisfaction as a healthcare quality indicator.

Robotic simultaneous resection of rectal cancer and liver metastases

Surgical resection is the only potential cure for colorectal cancer with synchronous liver metastases (SLM). Simultaneous resection of colorectal cancer and SLM using robotic‐assistance has been rarely reported. We demonstrate that robotic‐assisted simultaneous resection of colorectal cancer and SLMs is feasible, safe, and has potential to demonstrate good oncologic outcomes.

Comparison of robotic and laparoscopic colorectal resections with respect to 30-day perioperative morbidity

BACKGROUND

Robotic surgery has emerged as a minimally invasive alternative to traditional laparoscopy. Robotic surgery addresses many of the technical and ergonomic limitations of laparoscopic surgery, but the literature regarding clinical outcomes in colorectal surgery is limited. We sought to compare robotic and laparoscopic colorectal resections with respect to 30-day perioperative outcomes.

METHODS

The American College of Surgeons National Surgical Quality Improvement Program database was used to identify all patients who underwent robotic or laparoscopic colorectal surgery in 2013. We performed a logistic regression analysis to compare intraoperative variables and 30-day outcomes.

RESULTS

There were 8392 patients who underwent laparoscopic colorectal surgery and 472 patients who underwent robotic colorectal surgery. The robotic cohort had a lower incidence of unplanned intraoperative conversion (9.5% v. 13.7%, p = 0.008). There were no significant differences between robotic and laparoscopic surgery with respect to other intraoperative and postoperative outcomes, such as operative duration, length of stay, postoperative ileus, anastomotic leak, venous thromboembolism, wound infection, cardiac complications and pulmonary complications. On multivariable analysis, robotic surgery was protective for unplanned conversion, while male sex, malignancy, Crohn disease and diverticular disease were all associated with open conversion.

CONCLUSION

Robotic colorectal surgery has comparable 30-day perioperative morbidity to laparoscopic surgery and may decrease the rate of intraoperative conversion in select patients.

Understanding the complexities of shared decision-making in cancer: a qualitative study of the perspectives of patients undergoing colorectal surgery

BACKGROUND

Decisions leading up to surgery are fraught with uncertainty owing to trade-offs between treatment effectiveness and quality of life. Past studies on shared decision-making (SDM) have focused on the physician-patient encounter, with little emphasis on familial and cultural factors. The literature is scarce in surgical oncology, with few studies using qualitative interviews. Our objective was to explore the complexities of SDM within the setting of colorectal cancer (CRC) surgery.

METHODS

An interdisciplinary team developed a semistructured questionnaire. Telephone interviews were conducted with CRC patients in the practice of 1 surgical oncologist. Data saturation was achieved and a descriptive thematic analysis was performed.

RESULTS

We interviewed 20 patients before achieving data saturation. Three major themes emerged. First, family was considered as a crucial adjunct to the patient-provider dyad. Second, patients identified several facilitators to SDM, including a robust social support system and a competent surgical team. Although language was a perceived barrier, there was no difference in level of involvement in care between patients who spoke English fluently and those who did not. Finally, patients perceived a lack of choice and control in decision-making, thus challenging the very notion of SDM.

CONCLUSION

Surgeons must learn to appreciate the role of family as a vital addition to the patient-provider dyad. Family engagement is crucial for CRC patients, particularly those undergoing surgical resection of late-stage disease. Surgeons must be aware of the uniqueness of decision-making in this context to empower patients and families.

Preoperative localization of colorectal cancer: a systematic review and meta-analysis

BACKGROUND

Preoperative colorectal tumor localization is crucial for appropriate resection and treatment planning. As the localization accuracy of conventional colonoscopy is considered to be low, several localization techniques have been developed. We systematically reviewed the tumor localization error rates of several preoperative endoscopic techniques and synthesized information on risk factors for localization errors and procedure-related adverse events.

METHODS

MEDLINE, EMBASE, the Cochrane Library, and the grey literature were searched. Studies were included if they reported tumor localization errors in patients with colorectal cancer undergoing resection with curative intent. Using random-effects models, pooled incidence of tumor localization errors were derived for conventional colonoscopy and colonoscopic tattooing. Due to the lack of comparative studies, a direct comparison of the pooled estimates was performed. Procedure-related adverse events, risk factors for localization errors, and the localization outcomes of other techniques such as colonoscopic clip placement, radioguided occult colonic lesion identification, and the use of magnetic endoscope imaging were also synthesized.

RESULTS

A total of 38 non-randomized controlled and observational studies were included in this review (2578 patients underwent conventional colonoscopy and 643 colonoscopic tattooing). The pooled incidence of localization errors with conventional colonoscopy was 15.4 % (95 % CI 12.0-18.7), whereas that of colonoscopic tattooing was 9.5 % (95 % CI 5.7-13.3), mean difference 5.9 % (95 % CI 0.65-11.14, p = 0.03). Adverse events secondary to tattooing were infrequent, and most were cases of ink spillage. Limited information was available for other localization techniques.

CONCLUSION

Conventional colonoscopy has a higher incidence of localization error compared to colonoscopic tattooing for localization of colorectal cancer. Colonoscopic tattooing is safe and leads to fewer tumor localization errors. Given the widespread adoption of laparoscopic resections for colorectal cancer, routine colonoscopic tattooing should be adopted. However, studies directly comparing different localization techniques are needed.

Preoperative repeat endoscopy for colorectal cancer: What is its role and when is it necessary?

SUMMARY

Many surgeons consider repeat endoscopy to be the standard of care for colorectal cancer; however, its utility in the preoperative setting is not well understood, especially given the lack of standardized guidelines on appropriate tumour localization and colonoscopic reporting. This often results in patients undergoing an unnecessary medical procedure during their preoperative evaluation. We discuss some of the issues surrounding the practice of preoperative repeat endoscopy as well as patient perspectives on the procedure. Our observations suggest that repeat endoscopy in the setting of colorectal cancer surgery may play a role in enabling transition of patient care between the initial endoscopist and the treating surgeon and in improving the patient experience. Patients with operable colorectal cancer appear to understand and support the current use of repeat endoscopy. However, improving preoperative care will require further research and ultimately the development of evidence-based clinical guidelines.

The neutrophil-to-lymphocyte ratio predicts major perioperative complications in patients undergoing colorectal surgery

AIM

The objective of the study was to evaluate the association between the neutrophil-to-lymphocyte ratio (NLR) and the occurrence of perioperative complications in patients undergoing colorectal surgery.

METHOD

A retrospective cohort study was conducted of patients who underwent resection for suspected or confirmed colorectal cancer from 2004 to 2012. Patient cohorts with a high vs low NLR were defined by receiver operating characteristic curve analysis. Univariate and multivariate logistic regression was used to determine whether patients with elevated NLR were more likely to suffer perioperative complications.

RESULTS

In all, 583 patients were included. A preoperative NLR greater than or equal to 2.3 was significantly associated with a major perioperative complication (OR 2.52, 95% CI 1.26-5.01). On multivariate analysis, a high NLR (OR 2.25, 95% CI 1.12-4.52) and Charlson Comorbidity Index ≥ 3 (OR 4.55, 95% CI 2.17-9.56) were significantly related to major morbidity. No relationships were found between an elevated preoperative NLR and complication type, although there was a trend towards the occurrence of anastomotic leakage.

CONCLUSION

Preoperative NLR ≥ 2.3 may be a risk factor for major surgical complications following colorectal resection. Further study is needed to validate this threshold and evaluate the clinical implications of these findings.

Discrepancy between gastroenterologists' and general surgeons' perspectives on repeat endoscopy in colorectal cancer

BACKGROUND

A myriad of localization options are available to endoscopists for colorectal cancer (CRC); however, little is known about the use of such techniques and their relation to repeat endoscopy before CRC surgery. We examined the localization practices of gastroenterologists and compared their perceptions toward repeat endoscopy to those of general surgeons.

METHODS

We distributed a survey to practising gastroenterologists through a provincial repository. Univariate analysis was performed using the χ² test.

RESULTS

Gastroenterologists (n = 69) reported using anatomical landmarks (91.3%), tattooing (82.6%) and image capture (73.9%) for tumour localization. The majority said they would tattoo lesions that could not be removed by colonoscopy (91.3%), high-risk polyps (95.7%) and large lesions (84.1%). They were equally likely to tattoo lesions planned for laparoscopic (91.3%) or open (88.4%) resection. Rectal lesions were less likely to be tattooed (20.3%) than left-sided (89.9%) or right-sided (85.5%) lesions. Only 1.4% agreed that repeat endoscopy is the standard of care, whereas 38.9% (n = 68) of general surgeons agreed (p < 0.001). General surgeons were more likely to agree that an incomplete initial colonoscopy was an indication for repeat endoscopy (p = 0.040). Further, 56% of general surgeons indicated that the findings of repeat endoscopy often lead to changes in the operative plan.

CONCLUSION

Discrepancies exist between gastroenterologists and general surgeons with regards to perceptions toward repeat endoscopy and its indications. This is especially significant given that repeat endoscopy often leads to change in surgical management. Further research is needed to formulate practice recommendations that guide the use of repeat endoscopy, tattoo localization and quality reporting.

Baseline Laparoscopic Skill May Predict Baseline Robotic Skill and Early Robotic Surgery Learning Curve

INTRODUCTION

Robotic surgery is associated with a learning curve unique to each trainee. Knowledge about a trainee's baseline skill and learning curve would facilitate the development of a more individualized training curriculum. The aim of our study was to determine whether baseline laparoscopic skill is predictive of one's baseline robotic skill and short-term learning curve.

METHODS

Trainees from four different surgical specialties were included in the study. Each trainee participated in a 4-week, simulation-based robotic surgery basic skills training course. Precourse, baseline laparoscopic and robotic skills were assessed using validated test tasks; a basic peg transfer (PT) and an advanced intracorporeal suturing and knot tying (ISKT) task. Trainee robotic skill was assessed again 1 week postcourse. Each task performance was video recorded and scored by two blinded expert surgeons.

RESULTS

A total of 32 trainees were included; 14 urology, 7 gynecology, 8 thoracic Sx, 3 general Sx. Most (91%) were senior residents or clinical fellows and 50% had no prior robotic experience. There were no differences in baseline laparoscopic and robotic skill related to reported prior robotic experience. Between specialties, no differences were seen on baseline laparoscopic skill and only small differences were seen on baseline robotic skill. Both baseline Lap PT (p = 0.01) and Lap ISKT (p = 0.01) performances correlated with baseline robotic ISKT performance, but not robotic PT scores. Only baseline Lap ISKT performance correlated with postcourse robotic PT (p = 0.01) and ISKT (p < 0.01) performance. Baseline robotic ISKT scores, but not PT scores, correlated with postcourse robotic performance (p = 0.02 for PT, p < 0.01 for ISKT).

CONCLUSIONS

In this study, a trainee's baseline laparoscopic skill correlated with certain baseline robotic skills. Better baseline performance on an advanced, but not basic, laparoscopic and robotic skill task may correlate with a shorter learning curve for basic robotic skills. Further exploration of this finding may yield better training curricula.

Understanding Quality Issues in Your Surgical Department: Comparing the ACS NSQIP With Traditional Morbidity and Mortality Conferences in a Canadian Academic Hospital

INTRODUCTION

Review of surgical complications in traditional morbidity and mortality (M&M) rounds remains an important mechanism to identify and discuss quality-of-care issues. This process relies on case selection by providers; therefore, complications identified for review may differ from those captured in comprehensive quality programs such as the American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP). Additionally, although the ACS NSQIP captures robust data on complications in surgical wards, without strategies to disseminate this information to staff and improve practice, minimal change may result. The objective of this study was to compare complications identified by the ACS NSQIP with those captured in M&M conferences at a large Canadian academic hospital.

METHODS

Retrospective medical record reviews of all patients admitted to the general surgery unit from March 2012 to March 2013 were reviewed. Number and types of complications were recorded for cases that were both submitted and reviewed in M&M rounds and those cases that were submitted but not reviewed. These complications were compared with those extracted from our local ACS NSQIP database.

RESULTS

A total of 1348 general surgical procedures were performed. The ACS NSQIP captured complications in 143 patients compared with 58 patients identified for review in M&M rounds. Both the methods identified similar proportions of major and minor complications (ACS NSQIP 52% major, 48% minor; M&M 58% major, 42% minor). More postoperative deaths were entered into the ACS NSQIP (12) than in M&M conferences (8 reviewed and 2 submitted). The ACS NSQIP identified higher proportions of surgical site infections and readmissions. However, M&M conferences captured additional complications in patients who did not undergo surgery and identified potential quality issues in patients who did not ultimately experience an adverse outcome.

CONCLUSIONS

M&M rounds and the ACS NSQIP provide important and potentially complementary data on surgical quality. Incorporating the ACS NSQIP outcomes data into traditional M&M conferences may help to optimize quality improvement efforts.

Comparison of clinical and economic outcomes between robotic, laparoscopic, and open rectal cancer surgery: early experience at a tertiary care center

BACKGROUND

Robotic surgery has gained popularity in surgical oncology. Rectal cancer surgery, known to be technically challenging, may benefit from robotics in achieving better mesorectal dissection and may contribute to improved perioperative outcomes. The objective of this study was to compare early experience in robotic surgery to conventional approaches with regard to clinicopathologic and economic parameters.

METHODS

A retrospective review using a prospectively maintained database of rectal cancer surgeries performed at a tertiary cancer center from 2007 to 2013 was conducted. These resections included those performed via laparotomy, laparoscopy, and robotic-assisted operations. Perioperative demographic and tumor characteristics were collected, and short-term clinicopathologic outcomes were compared. Additionally, economic variables were evaluated for each patient's episode of care.

RESULTS

Seventy-nine cases were identified. Twenty-six were completed via open approach, 27 laparoscopically, and 26 via robotic assistance. Demographic characteristics were similar between all groups including age, gender, BMI, and Charlson score. Comparison of intraoperative characteristics showed a lower rate of conversion to laparotomy (12 vs. 37%, p = 0.05), and lower estimated blood loss (mean 296 vs. 524 cc, p = 0.04), in the robotic group compared to laparoscopy or open resection. There was no significant difference in quality of total mesorectal excision and number of lymph nodes harvested between the three cohorts. Postoperative complication rate, mean length of stay, 30-day readmission, and 30-day mortality were comparable among the cohorts. Median cost per episode of care was lower in laparoscopic surgery ($11,493), compared to open ($12,558) and robotic approach ($18,273); p = 0.029.

CONCLUSIONS

The findings demonstrate similar perioperative and short-term outcomes between robotic surgery and conventional approaches. Robotic assistance is associated with decreased intraoperative blood loss and fewer conversions, albeit at an increased overall cost. Given these benefits, and as data and experience mature, future study is needed to fully define the value of the robotic approach.

Patient and operational factors affecting wait times in a bariatric surgery program in Toronto: a retrospective cohort study

BACKGROUND

Increasing rates of obesity have led to growing demand for bariatric surgery. This has implications for wait times, particularly in publicly funded programs. This study examined the impact of patient and operational factors on wait times in a multidisciplinary bariatric surgery program.

METHODS

A retrospective study was conducted involving patients who were referred to a tertiary care centre (University Health Network, Toronto Western Hospital, Toronto) for bariatric surgery between June 2008 and July 2011. Patient characteristics, dates of clinical assessments and records describing operational changes were collected. Univariable analysis and multivariable log-linear and parametric time-to-event regressions were performed to determine whether patient and operational covariates were associated with the wait time for bariatric surgery (i.e., length of preoperative evaluation).

RESULTS

Of the 1664 patients included in the analysis, 724 underwent surgery with a mean wait time of 440 (standard deviation 198) days and a median wait time of 445 (interquartile range 298-533) days. Wait times ranged from 3 months to 4 years. Univariable and multivariable analyses showed that patients with active substance use (β = 0.3482, p = 0.02) and individuals who entered the program in more recent operational periods (β = 0.2028, p < 0.001) had longer wait times. Additionally, the median time-to-surgery increased over 3 discrete operational periods (characterized by specific program changes related to scheduling and staffing levels, and varying referral rates and defined surgical targets; p < 0.001).

INTERPRETATION

Some patients could be identified at referral as being at risk for longer wait times. We also found that previous operational decisions significantly increased the wait time in the program since its inception. Therefore, careful consideration must be devoted to process-level decision-making for multistage bariatric surgical programs, because managerial and procedural changes can affect timely access to treatment.

Laparoscopic versus open surgery for T4 colon cancer: evaluation of margin status

BACKGROUND

Laparoscopic resection has been considered a relative contraindication for T4 colonic and rectal lesions due to concern over inadequate margins. The objective of this study was to compare planned laparoscopic and open resections of T4 lesions with respect to the positive margin rate.

METHODS

Data were obtained from the American College of Surgeons National Surgical Quality Improvement Program participant use file to perform a retrospective cohort analysis. The study population consisted of patients that underwent a colorectal resection for a primary T4 lesion during 2011 and 2012. A multiple logistic regression analysis was conducted to determine the adjusted odds ratio (OR) of positive margins based on surgical approach. An inverse probability of treatment weighting (IPTW) analysis was used to account for confounding by indication. A sensitivity analysis including only "as-treated" cases was also performed.

RESULTS

The sub-selected population consisted of 455 and 406 patients in the laparoscopic and open group, respectively. In the original cohort, demographic variables were similar. The open group had a higher incidence of comorbidities, metastatic disease, and emergency cases. Laparoscopic surgery was found to be no different than open surgery with respect to positive margin status (OR 1.10, p = 0.54). After IPTW adjustment, surgical approach remained a nonsignificant predictor of positive margins (OR 1.18, p = 0.31). The "as-treated" analysis also showed that surgical approach had no significant effect on the positive margin rate (OR 1.24, p = 0.24).

CONCLUSIONS

Using this large national surgical database, select patients with T4 lesions who underwent planned laparoscopic colorectal resections did not have a significantly higher positive margin rate compared with patients with open operations. Further research is needed to identify the role of laparoscopy in managing T4b lesions before any consensus can be reached regarding its application in locally advanced colon cancer.

Conditional disease-free survival after surgical resection of gastrointestinal stromal tumors: a multi-institutional analysis of 502 patients

IMPORTANCE

Gastrointestinal stromal tumors (GISTs) are the most commonly diagnosed mesenchymal tumors of the gastrointestinal tract. The risk of recurrence following surgical resection of GISTs is typically reported from the date of surgery. However, disease-free survival (DFS) over time is dynamic and changes based on disease-free time already accumulated following surgery.

OBJECTIVES

To assess the comparative performance of established GIST recurrence risk prognostic scoring systems and to characterize conditional DFS following surgical resection of GISTs.

DESIGN, SETTING, AND PARTICIPANTS

A retrospective cohort study of 502 patients who underwent surgery for a primary, nonmetastatic GIST between January 1, 1998, and December 31, 2012, at 7 major academic cancer centers in the United States and Canada.

MAIN OUTCOMES AND MEASURES

Disease-free survival of the patients was classified according to 5 prognostic scoring systems, including the National Institutes of Health criteria, modified National Institutes of Health criteria, Memorial Sloan Kettering Cancer Center GIST nomogram, and American Joint Committee on Cancer gastric and nongastric categories. The concordance index (also known as the C statistic or the area under the receiver operating curve) of established GIST recurrence risk prognostic scoring systems. Conditional DFS estimates were calculated.

RESULTS

Overall 1-year, 3-year, and 5-year DFS following resection of GISTs was 95%, 83%, and 74%, respectively. All the prognostic scoring systems had fair prognostic ability. For all tumor sites, the American Joint Committee on Cancer gastric category demonstrated the best discrimination (C = 0.79). Using conditional DFS, the probability of remaining disease free for an additional 3 years given that a patient was disease free at 1 year, 3 years, and 5 years was 82%, 89%, and 92%, respectively. Patients with the highest initial recurrence risk demonstrated the greatest increase in conditional survival as time elapsed.

CONCLUSIONS AND RELEVANCE

Conditional DFS improves over time following resection of GISTs. This is valuable information about long-term prognosis to communicate to patients who are disease free after a period following surgery.

Adherence to Guidelines for Adjuvant Imatinib Therapy for GIST: A Multi-institutional Analysis

BACKGROUND

Gastrointestinal stromal tumors (GIST) are the most common mesenchymal tumors of the gastrointestinal tract. Adjuvant imatinib therapy improves recurrence-free and overall survival following surgery for patients with high-risk GIST; however, the factors associated with use of adjuvant imatinib therapy are unclear, and adherence to adjuvant imatinib has not been investigated. We sought to determine the clinicopathologic predictors of therapy with adjuvant imatinib following surgical resection for GIST and to determine the utilization of adjuvant imatinib in patients who underwent surgical resection of primary GIST in 2009 or later as recommended by National Comprehensive Cancer network (NCCN) guidelines.

METHODS

A multi-institutional cohort including 171 patients who underwent surgery for primary GIST at seven high-volume cancer centers in the USA and Canada between January 2009-December 2012 was used in this study. Receipt of adjuvant imatinib therapy was ascertained, and factors associated with imatinib therapy were analyzed.

RESULTS

Following surgery for primary GIST, tumor size (<5.0 cm: ref; 5.0-9.9 cm: odds ratio (OR) 2.36, 95 % confidence interval (CI) 0.74-7.55; >10.0 cm: OR 9.15, 95 % CI 2.28-36.75; p = 0.007), mitotic rate (≤5/50 mitoses per 50 high powered field [HPF]: ref; 6-10/50 HPF: OR 24.91, 95 % CI 3.64-170.35; >10/50 HPF: OR 5.80, 95 % CI 3.64-170.35; p < 0.001), and neoadjuvant therapy (OR 9.52; 95 % CI 2.51-36.14; p = 0.001) were associated with receipt of adjuvant imatinib therapy. Overall, 75 % of patients received appropriate treatment, 23 % of patients were undertreated, and 2 % of patients were overtreated as compared to NCCN guidelines. Adjuvant imatinib therapy was administered in only 53 % of patients for which the NCCN guidelines recommended adjuvant therapy.

CONCLUSION

The clinicopathologic factors associated with use of adjuvant imatinib therapy in patients following resection of primary GIST are consistent with established risk factors for recurrence. Adjuvant imatinib therapy remains underutilized in patients with intermediate and high-risk GIST and in patients who receive neoadjuvant therapy. Barriers to adjuvant imatinib therapy in this group of patients needs to be further explored.

Preoperative Neutrophil-to-Lymphocyte Ratio is a Better Prognostic Serum Biomarker than Platelet-to-Lymphocyte Ratio in Patients Undergoing Resection for Nonmetastatic Colorectal Cancer

INTRODUCTION

Current risk stratification tools for patients with colorectal cancer (CRC) rely on final surgical pathology but may be improved with the addition of novel serum biomarkers. The objective of this study was to evaluate the utility of preoperative NLR and PLR in predicting long-term oncologic outcomes in patients with operable CRC.

METHODS

All patients who underwent curative resection for adenocarcinoma at a large tertiary academic hospital were identified. High NLR/PLR was evaluated preoperatively and defined by maximizing log-rank statistics. Recurrence-free survival (RFS) and overall survival (OS) were calculated using the Kaplan-Meier method and compared by the log-rank test. Univariate and multivariable Cox proportional hazard regression was used to identify associations with outcome measures.

RESULTS

A total of 549 patients were included in the study. High NLR (≥2.6) was associated with worse RFS (hazard ratio [HR] 2.03, 95 % confidence interval [CI] 1.48-2.79, p < 0.001) and OS (HR 2.25, 95 % CI 1.54-3.29, p < 0.001). High PLR (≥295) also was associated with worse RFS (HR 1.68, 95 % CI 1.06-2.65, p = 0.028) and OS (HR 1.81, 95 % CI 1.06-3.06, p = 0.028). In the multivariable model, high NLR retained significance for reduced RFS (HR 1.59, 95 % CI 1.1-2.28, p = 0.013) and OS (HR 1.91, 95 % CI 1.26-2.9, p = 0.002). Significantly more patients in the high NLR group were older at diagnosis, had mucinous adenocarcinoma, higher T stage, and advanced cancer stage.

CONCLUSIONS

High preoperative NLR in this series was shown to be a negative independent prognostic factor in patients undergoing surgical resection for nonmetastatic CRC. The prognostic utility of this serum biomarker may help to guide use of adjuvant therapies and patient counselling.