Should I See You Again Soon? A Multispecialty Assessment of the Impact and Burden of Preoperative History and Physical Update Visits

BACKGROUND

Federal regulations require a history and physical (H&P) update performed ≤30 days before a planned procedure. We evaluated the utility and burdens of H&P update visits by determining impact on operative management, suitability for telehealth, and visit time and travel burden.

STUDY DESIGN

We identified H&P update visits performed in our health system during 2019 for 8 surgical specialties. As available, up to 50 visits per specialty were randomly selected. Primary outcomes were a) interval changes in history, exam, or operative plan between the initial and updated H&P notes and b) visit suitability for telehealth, as determined by two independent physician reviewers. Clinic time was captured, and round-trip driving time and distance between patients' home and clinic ZIP codes were estimated.

RESULTS

We identified 8,683 visits and 362 were randomly selected for review. Documented changes were most commonly identified in histories (60.8%), but rarely in physical exams (11.9%) and operative plans (11.6%). 99.2% of visits were considered suitable for telehealth. Median clinic time was 52 minutes (IQR:33.8-78), driving time was 55.6 minutes (IQR:35.5-85.5), and driving distance was 20.2 miles (IQR:8.5-38.4). At the health system level, patients spent an estimated aggregate 7,000 hours (including 4,046 hours of waiting room and travel time) and drove 142,273 miles to attend in-person H&P update visits in 2019.

CONCLUSION

Given their minimal impact on operative management, regulatory requirements for in-person H&P updates should be reconsidered. Flexibility in update timing and modality might help defray the substantial burdens these visits impose on patients.

Evaluating Changes in Surgical Outcomes for Patients With Inflammatory Bowel Disease Following Medicaid Expansion

BACKGROUND

Little is known about the impact of Medicaid expansion on the surgical care of inflammatory bowel disease. We sought to determine whether Medicaid expansion is associated with improved postsurgical outcomes for patients with inflammatory bowel disease undergoing a colorectal resection.

METHODS

We performed a risk-adjusted difference-in-difference study examining postsurgical outcomes for patients ages 26 to 64 with Crohn's disease or ulcerative colitis undergoing a colorectal resection across 15 states that did and did not expand Medicaid before (2012-2013) and after (2016-2018) policy reform. Primary study outcomes included 30-day readmission and postoperative complication.

RESULTS

Study population included 11 394 patients with inflammatory bowel disease that underwent a colorectal resection. States that underwent Medicaid expansion were associated with a rise in Medicaid enrollment following policy reform (11.8% pre-Medicaid expansion vs 19.7% post-Medicaid expansion). Difference-in-difference analysis revealed a statistically significant lower odds of 30-day readmission in patients undergoing a colorectal resection in expansion states following policy reform relative to patients in nonexpansion states prior to reform (odds ratio, 0.56; 95% confidence interval, 0.36-0.86). No changes in odds of postoperative complication were noted across expansion and nonexpansion states.

CONCLUSIONS

Medicaid expansion is associated with a rise in Medicaid enrollment in expansion states following policy reform. There were greater improvements in postoperative outcomes associated with patients in expansion states following policy reform relative to patients in nonexpansion states prior to reform, which may have been related to improved perioperative care and medical management.

Preoperative history and physical update visits offer limited clinical value in colorectal surgery

BACKGROUND

United States regulations require a history and physical (H&P) ≤30 days before planned procedures. We evaluated the impact of H&P update visits in colorectal surgery.

METHODS

Preoperative H&P update visits conducted in colorectal clinics at our institution during 2019 were identified. Two independent reviewers assessed whether update visits identified interval changes to history, exam, or operative plan. Secondary outcomes included visit times, estimated travel times and distances.

RESULTS

For 132 visits, interval changes were identified in 39% of histories, but only 4.2% of exams and 6.8% of operative plans. When plans changed, visit goals could have been accomplished via telehealth in 77.8%. Median clinic and round-trip driving time were 61.5 and 62.2 min, respectively.

CONCLUSIONS

H&P update visits conducted to satisfy the 30-day regulation rarely result in clinically relevant changes yet impose time and travel burdens on patients. Regulations should be revised to provide flexibility in H&P update modalities.

Toward Allyship and Mentorship: Recognition, Relatability, and Respect

Allyship and mentorship are two critical aspects needed not only to promote the growth of success of people around us, but also to advocate for those that are not as fortunate and are often excluded or marginalized. Understanding the distinctions and commonalities between the two, as well as the required interdependence, will go a long way toward ensuring that an impact toward positive change is made in the future.

Impact of Patient Comorbidities on Presentation Stage of Breast and Colon Cancers

BACKGROUND

While patients with multiple comorbidities may have frequent contact with medical providers, it is unclear whether their healthcare visits translate into earlier detection of cancers, specifically breast and colon cancers.

METHODS

Patients diagnosed with stage I-IV breast ductal carcinoma and colon adenocarcinoma were identified from the National Cancer Database and stratified by comorbidity burden, dichotomized as a Charlson Comorbidity Index (CCI) Score of <2 or ≥2. Characteristics associated with comorbidities were analyzed by univariate and multivariate logistic regression. Propensity-score matching was performed to determine the impact of CCI on stage at cancer diagnosis, dichotomized as early (I-II) or late (III-IV).

RESULTS

A total of 672,032 patients with colon adenocarcinoma and 2,132,889 with breast ductal carcinoma were included. Patients with colon adenocarcinoma who had a CCI ≥ 2 (11%, n = 72,620) were more likely to be diagnosed with early-stage disease (53% vs. 47%; odds ratio [OR] 1.02, p = 0.017), and this finding persisted after propensity matching (CCI ≥ 2 55% vs. CCI < 2 53%, p < 0.001). Patients with breast ductal carcinoma who had a CCI ≥ 2 (4%, n = 85,069) were more likely to be diagnosed with late-stage disease (15% vs. 12%; OR 1.35, p < 0.001). This finding also persisted after propensity matching (CCI ≥ 2 14% vs. CCI < 2 10%, p < 0.001).

CONCLUSIONS

Patients with more comorbidities are more likely to present with early-stage colon cancers but late-stage breast cancers. This finding may reflect differences in practice patterns for routine screening in these patients. Providers should continue guideline directed screenings to detect cancers at an earlier stage and optimize outcomes.

Exploring ethnic differences in post-discharge patterns of surgical care for older adults admitted with diverticulitis

AIM

We aimed to evaluate ethnic differences in patterns of care following an index nonoperative admission for acute diverticulitis amongst a universally insured patient cohort.

METHODS

We identified nationwide Medicare beneficiaries aged 65.5 years or older hospitalized between 1 July 2015 and 1 November 2017 for nonoperative management of an index admission for diverticulitis. Patients were followed for 1 year to examine patterns of care. Primary categorical outcomes included receipt of an elective operation, emergency operation, nonoperative readmission or no further hospitalizations for diverticulitis. Multinomial regression was performed to determine the association between ethnicity and receipt of each primary outcome category whilst adjusting for potential confounders. We examined the use of percutaneous drainage during the index admission to better understand its association with subsequent care patterns.

RESULTS

Amongst 22 630 study patients, subsequent operative treatment was less common for Black, Hispanic, Asian and American Indian patients relative to White patients. Multinomial logistic regression noted that Black (relative risk 0.40; 95% CI 0.32-0.50) and Asian (relative risk 0.37; 95% CI 0.15-0.91) patients were associated with the lowest relative risk of undergoing an elective interval operation compared to White patients. Black patients were also associated with a 1.43 (95% CI 1.19-1.73) increased risk of requiring subsequent nonoperative readmissions for disease recurrence compared to White patients. The use of percutaneous drainage was higher amongst White patients relative to Black patients (6.9% vs. 4.0%, P value < 0.001).

CONCLUSION

We have identified ongoing inequities in the consumption of medical resources, with White patients being more likely to undergo elective colectomy and percutaneous drainage. Differences in care are not fully alleviated by equal access to insurance.

Trends in infectious complications after partial colectomy for colon cancer over a decade: A national cohort study

BACKGROUND

The American College of Surgeons National Surgical Quality Improvement Program helps participating hospitals track and report surgical complications with the goal of improving patient care. We sought to determine whether postoperative infectious complications after elective colectomy for malignancy improved among participating centers over time.

METHODS

Patients with colon malignancies who underwent elective partial colectomy with primary anastomosis (categorized as low or non-low) were identified from the American College of Surgeons National Surgical Quality Improvement Program database (2011-2019). Thirty-day postoperative infectious complications analyzed by year included superficial, deep, and organ space surgical site infections, urinary tract infection, pneumonia, and sepsis. Trends in patient and treatment characteristics were investigated using log-linear regression along with their association with infectious outcomes.

RESULTS

Of the 78,827 patients identified, 51% were female, and the median age was 68. The majority (84%) underwent partial colectomy without a low anastomosis. There was a decrease in all infectious complications except for organ space infections which increased 35% overall from 2.0 to 2.7% (P = .037), driven by patients without a low anastomosis (1.9%-2.7%, P = .01). There was no change in most patient factors associated with organ space infections, except for a notable increase in American Society of Anesthesiologists class III and IV-V patients over time, both associated with organ space infections (P < .001; P = .002).

CONCLUSION

Infectious complications have decreased significantly overall after colectomy for colon cancer, whereas there has been an increase in organ space infection rates specifically. Although changing patient characteristics may contribute to this observed trend, further study is needed to better understand its etiology to help mitigate this complication.

Impact of the affordable care act's medicaid expansion on presentation stage and perioperative outcomes of colorectal cancer

BACKGROUND AND OBJECTIVES

Medicaid expansion has improved healthcare coverage and preventive health service use. To what extent this has resulted in earlier stage colorectal cancer diagnoses and impacted perioperative outcomes is unclear.

METHODS

This was a retrospective difference-in-difference study using the National Cancer Database on adults (40-64) with Medicaid or no insurance, diagnosed with colorectal adenocarcinomas before (2010-2013) and after (2015-2018) expansion. The primary outcome was early-stage (American Joint Committee on Cancer Stage 0-1) diagnosis. The secondary outcomes were rate of local excision, emergency surgery, postoperative length of stay, rates of minimally invasive surgery, postoperative mortality, and overall survival (OS).

RESULTS

Medicaid expansion was associated with an increase in early-stage diagnoses for patients with colorectal cancers (odds ratio [OR]: 1.28, 95% confidence interval [CI]: 1.15-1.43), an increase in local excision (OR: 1.39, 95% CI: 1.13-1.69), and a decreased rate of emergent surgery (OR: 0.85, 95% CI: 0.75-0.97) and 90-day mortality (OR: 0.75, 95% CI: 0.59-0.97). Additionally, patients in expansion states postexpansion had an improved 5-year OS (hazard ratio: 0.88, 95% CI: 0.83-0.94).

CONCLUSIONS

Insurance coverage expansion may be particularly important for optimizing stage of diagnosis, subsequent survival, and perioperative outcomes for socioeconomically vulnerable patients.

New Operative Reporting Standards: Where We Stand Now and Opportunities for Innovation

BACKGROUND

The American College of Surgeons Commission on Cancer's (CoC) new operative standards for breast cancer, melanoma, and colon cancer surgeries will require that surgeons provide synoptic documentation of essential oncologic elements within operative reports. Prior to designing and implementing an electronic tool to support synoptic reporting, we evaluated current documentation practices at our institution to understand baseline concordance with these standards.

METHODS

Applicable procedures performed between 1 January 2018 and 31 December 2018 were included. Two independent reviewers evaluated sequential operative notes, up to a total of 100 notes, for documentation of required elements. Complete concordance (CC) was defined as explicit documentation of all required CoC elements. Mean percentage CC and surgeon-specific CC were calculated for each procedure. Interrater reliability was assessed via Cohen's kappa statistic.

RESULTS

For sentinel lymph node biopsy, mean CC was 66% (n = 100), with surgeon-specific CC ranging from 6 to 100%, and for axillary dissection, mean CC was 12% (n = 89) and surgeon-specific CC ranged from 0 to 47%. The single surgeon performing melanoma wide local excision had a mean CC of 98% (n = 100). For colon resections, mean CC was 69% (n = 96) and surgeon-specific CC ranged from 39 to 94%. Kappa scores were 0.77, 0.78, -0.15, and 0.78, respectively.

CONCLUSIONS

We identified heterogeneity in current documentation practices. In our cohort, rates of baseline concordance varied across surgeons and procedures. Currently, documentation elements are interspersed within the operative report, posing challenges to chart abstraction with resulting imperfect interrater reliability. This presents an exciting opportunity to innovate and improve compliance by introducing an electronic synoptic documentation tool.

Delphi Consensus on Intraoperative Technical/Surgical Aspects to Prevent Surgical Site Infection after Colorectal Surgery

BACKGROUND

Previous studies have focused on the development and evaluation of care bundles to reduce the risk of surgical site infection (SSI) throughout the perioperative period. A focused examination of the technical/surgical aspects of SSI reduction during CRS has not been conducted. This study aimed to develop an expert consensus on intraoperative technical/surgical aspects of SSI prevention by the surgical team during colorectal surgery (CRS).

STUDY DESIGN

In a modified Delphi process, a panel of 15 colorectal surgeons developed a consensus on intraoperative technical/surgical aspects of SSI prevention undertaken by surgical personnel during CRS using information from a targeted literature review and expert opinion. Consensus was developed with up to three rounds per topic, with a prespecified threshold of ≥70% agreement.

RESULTS

In 3 Delphi rounds, the 15 panelists achieved consensus on 16 evidence-based statements. The consensus panel supported the use of wound protectors/retractors, sterile incision closure tray, preclosure glove change, and antimicrobial sutures in reducing SSI along with wound irrigation with aqueous iodine and closed-incision negative pressure wound therapy in high-risk, contaminated wounds.

CONCLUSIONS

Using a modified Delphi method, consensus has been achieved on a tailored set of recommendations on technical/surgical aspects that should be considered by surgical personnel during CRS to reduce the risk of SSI, particularly in areas where the evidence base is controversial or lacking. This document forms the basis for ongoing evidence for the topics discussed in this article or new topics based on newly emerging technologies in CRS.

Predictive risk-score model for selection of patients with high-risk stage II colon cancer for adjuvant systemic therapy

BACKGROUND

Adjuvant systemic therapy is selectively considered for high-risk stage II colon cancer, but which patients benefit most from adjuvant systemic therapy is unclear.

METHODS

Patients who underwent resection of stage II colon cancer were identified from the National Cancer Database (2010-2016). Risk-factors for decreased overall survival on multivariable analysis were used to establish a predictive risk-score model for all-cause mortality. After propensity matching within each risk group, 5-year overall survival was estimated based on receipt of adjuvant systemic therapy.

RESULTS

Of the 15,241 patients evaluated, 2,857 (18.8%) received adjuvant systemic therapy. Risk factors for decreased overall survival included age >75 (hazard ratio 3.3, P < .001), male sex (hazard ratio 1.2, P < .001), White/Black race (hazard ratio 1.4, P = .020), preoperative carcinoembryonic antigen >3.5 ng/mL (hazard ratio 1.6, P < .001), T4a T-stage (hazard ratio 2.0, P < .001), T4b T-stage (hazard ratio 2.4, P < .001), lymphovascular invasion (hazard ratio 1.2, P = .003), perineural invasion (hazard ratio 1.3, P = .003), and non-R0 proximal/distal resection margins (hazard ratio 1.7, P < .001). An internally validated risk-score model using these factors was developed composed of low-risk (n = 8,489), moderate-risk (n = 4,623), and high-risk (n = 2,129) groups; within each group, 19.9%, 15.7%, and 20.8% of patients, respectively, received adjuvant systemic therapy. After propensity matching, adjuvant systemic therapy was not associated with improved 5-year overall survival for low-risk patients (89.8% vs 88.3%, P = .280), but was for moderate-risk (80.5% vs 70.8%, P < .001), and high-risk (65.2% vs 45.7%, P < .001) patients.

CONCLUSION

A predictive risk-score model incorporating patient and tumor factors identifies a high-risk cohort of stage II colon cancer patients who may benefit from adjuvant systemic therapy, although the minority of these patients appear to be receiving treatment.

The effects of the Affordable Care Act on access and outcomes of colon surgery

BACKGROUND

Insurance status has been strongly associated with both access to and outcomes of colon resection (CRS). Under the Affordable Care Act (ACA), individual states opted to participate in Medicaid expansion (ME) and adopt essential health benefits (EHB).

METHODS

We performed a quasi-experimental difference-in-differences (DID) analysis of 2012-2017 state-level inpatient claims with risk adjustment. We examined frequency of emergent presentation and in-hospital death. Subset analyses were performed by insurance type.

RESULTS

Among the 73,961 CRS patients, 49.6% were in a state with both ME and EHB, 34.7% presented emergently, and 2.0% died. Adoption of ME and EHB was associated with a significant, 24%, reduction in the likelihood of in-hospital mortality, and no significant change in emergent presentation for CRS.

CONCLUSIONS

The ACA's ME was strongly associated with a decrease in mortality following colon resection among Medicaid beneficiaries. These findings support the adoption of healthcare policies that improve access to insurance.

The volume-outcome relationship in robotic protectectomy: does center volume matter? Results of a national cohort study

BACKGROUND

Utilization of robotic proctectomy (RP) for rectal cancer has steadily increased since the inception of robotic surgery in 2002. Randomized control trials evaluating the safety of RP are in process to better understand the role of robotic assistance in proctectomy. This study aimed to characterize the trends in the use of RP for rectal cancer, and to compare oncologic outcomes with center-level RP volume.

MATERIALS AND METHODS

8107 patients with rectal adenocarcinoma who underwent RP were identified in the National Cancer Database (2010-2015). Logistic regression was used to evaluate associations between center-level volume and conversion to open proctectomy, margin status, lymph node yield, 30- and 90-day post-operative mortality, and overall survival.

RESULTS

The utilization of RP increased from 2010 to 2015. On multivariate regression, lower center-level volume of RP was associated with significantly higher rates of conversion to open, positive margins, inadequate lymph node harvest (≥ 12), and lower overall survival. The present study was limited by its retrospective design and lack of information regarding disease-specific survival.

CONCLUSIONS

This series suggests a volume-outcome relationship association; patients who have robot-assisted proctectomies performed at low-volume centers are more likely to have poorer overall survival, positive margins, inadequate lymph node harvest, and require conversion to open surgery. While these data demonstrate the increased adoption of robot-assisted proctectomy, an understanding of the appropriateness of this intervention is still lacking. As with any new intervention, further information from ongoing randomized controlled trials is needed to better clarify the role of RP in order to optimize patient outcomes.

Functional recovery in senior adults undergoing surgery for colorectal cancer: Assessment tools and strategies to preserve functional status

Colorectal cancer is a widely-recognized aging-associated disease. Recent advances in the care of senior colorectal cancer patients has led to similar cancer-related life expectancy for older patients when compared to their younger counterparts. Recent data suggests that onco-geriatric patients place as much value on maintenance of functional independence and quality of life after treatment as they do on the potential improvements in survival that a treatment might offer. As a result, there has been significant interest in the geriatric literature surrounding the concept of "functional recovery," a multidimensional outcome metric that takes into account several domains, including physical, physiologic, psychological, social, and economic wellbeing. This review introduces the concept of functional recovery and highlights a number of predictors of post-treatment functional trajectory, including several office-based tools that clinicians can use to help guide informed decision making surrounding potential treatment options. This review also highlights a number of validated metrics that can be used to assess a patient's progress in functional recovery after surgery. While the timeline of each individual's functional recovery may vary, most data suggests that if patients are to return to their pre-operative functional status, this could occur up to 6 months post-surgery. For those patients identified to be at risk for post-operative functional decline this review also delineates strategies for prehabilitation and rehabilitation that may improve functional outcomes.

From Burnout to Well-Being: A Focus on Resilience

Burnout is a widespread problem in health care. Factors that contribute to enhancing engagement and building resiliency are widely discussed, but the data supporting these practices are not well understood. Interventions aimed at increasing engagement and promoting resiliency are targeted toward individual practitioners, health care institutions, and national organizations. Knowledge of the data supporting various kinds of interventions is vital to implementing change meaningfully. Prevention of burnout should start early in training with appropriate modeling and input from mentors and should incorporate stress management strategies. The most compelling data for building resilience requires institutions, physicians, and their support staff to align their values to create a mutual culture of wellness and engagement. It is imperative that institutional and national reform allows us as physicians to preserve our relationships with patients and colleagues, while also prioritizing time to reflect and pursue outside interests that recharge and restore.

Minimally Invasive Surgery for Complicated Diverticulitis

Recent guidelines recommend an individualized approach to recurrent uncomplicated diverticulitis, reflecting research showing that non-operative treatment is safe. Thus, the majority of operations for diverticulitis in the future may be for complicated indications. A laparoscopic approach may be used for both acute and chronic complicated diverticulitis in appropriate patients, as described in the American and European guidelines. However, a safe approach to minimally invasive surgery requires recognition when conditions deteriorate or are not suited to laparoscopy as well as knowledge of a variety of technical maneuvers that elucidate difficult anatomy and facilitate resection. Primary anastomosis with or without diversion can be performed safely, and ileostomy reversal is significantly less morbid than Hartmann's (colostomy) reversal. Success in laparoscopy can be achieved with the use of adjunct techniques and technologies, including ureteral stents, hand ports, and hybrid approaches. When completed successfully, a laparoscopic approach has been shown to confer decreased ileus, length of stay, post-operative pain, surgical site infection, and ventral hernia compared to an open approach.

Validation of a coding algorithm for intra-abdominal surgeries and adhesion-related complications in an electronic medical records database

PURPOSE

Epidemiological data on adhesion-related complications following intra-abdominal surgery are limited. We tested the accuracy of recording of these surgeries and complications within The Health Improvement Network (THIN), a primary care database within the UK.

METHODS

Individuals within THIN from 1995 to 2011 with an incident intra-abdominal surgery and subsequent bowel obstruction (SBO) or adhesiolysis were identified using diagnostic codes. To compute positive predictive values (PPVs), requests were sent to treating physicians of patients with these diagnostic codes to confirm the surgery, SBO, or adhesiolysis code. Completeness of recording was estimated by comparing observed surgical rates within THIN to expected rates derived from the Hospital Episode Statistics dataset within England. Cumulative incidence rates of adhesion-related complications at 5 years were compared with a previously published cohort within Scotland.

RESULTS

Two hundred seventeen of 245 (89%) questionnaires were returned (180 SBO and 37 adhesiolysis). The PPV of codes for surgery was 94.5% (95%CI: 91-97%). The 88.8% of procedure types were correctly coded. The PPV for SBO and adhesiolysis was 86.1% (95%CI: 80-91%) and 89.2% (95%CI: 75-97%), respectively. Colectomy, appendectomy, and cholecystectomy rates within THIN were 99%, 95%, and 84% of rates observed in national Hospital Episode Statistics data, respectively. Cumulative incidence rates of adhesion related complications following colectomy, appendectomy, and small bowel surgery were similar to those published previously.

CONCLUSIONS

Surgical procedures, SBO, and adhesiolysis can be accurately identified within THIN using diagnostic codes. THIN represents a new tool for assessing patient-specific risk factors for adhesion-related complications and long-term outcomes.

Surveillance after neoadjuvant therapy in advanced rectal cancer with complete clinical response can have comparable outcomes to total mesorectal excision

PURPOSE

While the standard of care for patients with rectal cancer who sustain a complete clinical response (cCR) to chemoradiotherapy (CRT) remains proctectomy with total mesorectal excision, data suggests that non-operative management may be a safe alternative. The purpose of this study is to compare outcomes between patients treated with CRT that attained a cCR and opted for a vigilant surveillance to those of the patients who had a complete pathologic response (cPR) following proctectomy.

METHOD

This is a retrospective review of patients treated for adenocarcinoma of the rectum who achieved either a cCR or a cPR following CRT. Patients with a cCR were enrolled in an active surveillance program which included regularly scheduled exams, proctoscopy, serum carcinoembryonic antigen (CEA), endorectal ultrasound, and cross-sectional imaging. Outcomes were compared to those patients who underwent proctectomy with a cPR. Our primary outcome measures were post-treatment complications, recurrence, and survival.

RESULTS

We reviewed 18 patients who opted for surveillance after cCR and 30 patients who underwent proctectomy after a cPR. No non-operative patients had a documented treatment complication, while 17 patients with cPR suffered significant morbidity. There were two recurrences in the active surveillance group, one local and once distant, both treated by salvage resection with no associated mortality at 54 and 62 months. In the cPR group, one patient had a distant recurrence 24 months after surgery which was managed non-operatively. This patient died of unrelated causes 35 months after surgery.

CONCLUSIONS

Active surveillance can be a safe option that avoids the morbidity associated with proctectomy and preserves oncologic outcomes.

Lower rates of acute gastrointestinal toxicity with pencil beam proton therapy relative to IMRT in neoadjuvant chemoradiation for rectal cancer

696

Background: Preoperative chemoradiotherapy (CRT) is standard treatment for locally advanced rectal cancer (LARC). GI toxicity leading to ED visits, hospitalization, and need for IV hydration remains a management challenge. Previous studies have established volume of bowel receiving low dose radiation (V15) as the strongest predictor of GI toxicity. We have previously shown pencil beam scanned proton therapy (PBSPT) is dosimetrically superior to IMRT in LARC with respect to low dose to the bowel. This studycompares the toxicity of patients treated with PBSPT and IMRT in neoadjuvant treatment of LARC. Methods: A retrospective review was conducted of patients treated at the University of Pennsylvania with neoadjuvant 5-FU or capecitabine CRT. Patient and tumor characteristics, treatment, and toxicity data were collected. PBSPT (50.4 Gy RBE to standard volumes) was delivered using either two opposed lateral fields or posterior oblique fields with a patient supine or prone. These patients were registered on a prospective registry study. IMRT plans were delivered with 7-9 field IMRT or volumetric arc therapy in the supine or prone position. Statistical analysis was performed using STATA v12.0. Results: Between 3/2009 and 6/2014, 39 patients treated with IMRT and 26 patients treated with PBSPT were studied. Continuous-infusion 5-FU was administered in 31 (79%) IMRT patients and 16 (62%) PBSPT patients (p = 0.162); the remainder received capecitabine. PBSPT patients had significantly lower rates of acute Grade ≥ 2 diarrhea, 12% versus 39% with IMRT (p = 0.022). On multivariable analysis incorporating the type of chemotherapy, use of PBSPT remained a significant predictor of lower rate of Grade ≥ 2 diarrhea (OR = 0.20, 95% CI 0.05 - 0.82, p = 0.025). There was also a borderline significant reduction in Grade ≥ 2 fatigue with the use of PBSPT, occurring in 8% versus 29% of IMRT patients, p = 0.057. Conclusions: These preliminary results indicate PBSPT is associated with significant reduction in acute Grade ≥ 2 diarrhea compared to IMRT. PBSPT may play an important role in the treatment of LARC, a disease with high cure rate where radiation toxicity should be minimized.

The impact of complications following open colectomy on hospital finances: a retrospective cohort study

Background

When hospitals suffer financial losses when postoperative complications occur, they may have a direct financial incentive to initiate quality improvement programs. The purpose of this research was to determine the relationship between complications following open colectomy and hospital finances.

Methods

After obtaining Institutional Review Board approval, we conducted a retrospective chart review of 276 open colectomies performed at the Hospital of the University of Pennsylvania. The medical records were manually reviewed for complications that occurred within 30 days after surgery. Financial information, including total, fixed and variable costs, was obtained from the hospital’s cost accounting database. Reimbursement assuming payment by Medicare was calculated. Differences in costs, reimbursements and total margins were analyzed.

Results

Of 276 patient records reviewed, 61 (22%) of the patients experienced postoperative complications. When complications occurred, mean total costs increased from $23,101 to $48,180, fixed costs increased from $14,516 to $30,339 and variable costs increased from $8,535 to $17,848 (P < 0.001 for each comparison); the mean reimbursement increased from $23,231 to $35,651 (P < 0.001); and the total margin decreased from $131 to - $12,528 (P < 0.001). Complications were associated with a more than twofold increase in length of stay in the hospital. Multiple regression modeling indicated similar increases in each of the financial variables and length of stay as a result of postoperative complications. The impact of these complications on each outcome measure was similar in effect for patients in the matched subset of 100 patients.

Conclusion

Our results demonstrate a financial incentive for hospitals to investigate quality improvement measures to prevent postoperative complications and avoid the associated financial losses.

The effect of colorectal cancer screening mandates on access to care and clinical outcomes: a retrospective study of patients undergoing operations of the colon and rectum

INTRODUCTION

Policies that mandate colorectal screening coverage by private insurers are associated with increased use of screening procedures. We seek to understand whether such mandates have improved access to care and short-term operative outcomes for patients undergoing operations of the colon and rectum (OCR).

METHODS

Privately insured OCR patients, ages 50-64, enrolled in the Nationwide Inpatient Sample (NIS) (2000-2009) were identified. Patients were classified as "exposed" if they underwent OCR in a state that implemented a mandate ≥ 2 years before their procedure. Three outcomes were examined: admission source, postoperative complications, and postoperative mortality. Univariate analyses were performed by the use of logistic regression models. Multivariable logistic regression models were developed to evaluate the relationship between exposure status, admission source, postoperative complications, and postoperative mortality, with adjustment for confounders.

RESULTS

We identified 99,405 patients who underwent OCR during the study period. Of these patients, 39% were "exposed," 23% were admitted from the ED, 32% developed a postoperative complication, and 2% died during the admission. After adjusting for confounders, exposed patients were less likely to access OCR through the emergency department (odds ratio 0.87; 95% confidence interval 0.83-0.91) and less likely to develop postoperative complications (odds ratio 0.94; 95% confidence interval 0.89-0.98). There was no detectable difference in postoperative mortality.

CONCLUSION

Implementation of policies mandating coverage of colorectal screening modestly reduced emergent admission for OCR among privately insured patients. Additional studies are required to examine the screening status of patients to determine causality. Remaining states should consider implementing similar policies.

Prevention and management of nonhealing perineal wounds

Complex perineal wounds are at risk for nonhealing. High-risk procedures include proctectomy for Crohn disease, anal cancer and radiated distal rectal cancers. A basic understanding of both patient and procedural risk factors is helpful in planning and executing operative procedures for these conditions and to minimize associated wound complications. Diabetes, obesity, and malnutrition may contribute to wound breakdown and failure to heal. Delaying operative intervention, adding nutritional supplementation, and employing intestinal diversion as well as myocutaneous flaps may help optimize conditions for wound healing.

Biologic determinants of tumor recurrence in stage II colon cancer: validation study of the 12-gene recurrence score in cancer and leukemia group B (CALGB) 9581

PURPOSE

A greater understanding of the biology of tumor recurrence should improve adjuvant treatment decision making. We conducted a validation study of the 12-gene recurrence score (RS), a quantitative assay integrating stromal response and cell cycle gene expression, in tumor specimens from patients enrolled onto Cancer and Leukemia Group B (CALGB) 9581.

PATIENTS AND METHODS

CALGB 9581 randomly assigned 1,713 patients with stage II colon cancer to treatment with edrecolomab or observation and found no survival difference. The analysis reported here included all patients with available tissue and recurrence (n = 162) and a random (approximately 1:3) selection of nonrecurring patients. RS was assessed in 690 formalin-fixed paraffin-embedded tumor samples with quantitative reverse transcriptase polymerase chain reaction by using prespecified genes and a previously validated algorithm. Association of RS and recurrence was analyzed by weighted Cox proportional hazards regression.

RESULTS

Continuous RS was significantly associated with risk of recurrence (P = .013) as was mismatch repair (MMR) gene deficiency (P = .044). In multivariate analyses, RS was the strongest predictor of recurrence (P = .004), independent of T stage, MMR, number of nodes examined, grade, and lymphovascular invasion. In T3 MMR-intact (MMR-I) patients, prespecified low and high RS groups had average 5-year recurrence risks of 13% (95% CI, 10% to 16%) and 21% (95% CI, 16% to 26%), respectively.

CONCLUSION

The 12-gene RS predicts recurrence in stage II colon cancer in CALGB 9581. This is consistent with the importance of stromal response and cell cycle gene expression in colon tumor recurrence. RS appears to be most discerning for patients with T3 MMR-I tumors, although markers such as grade and lymphovascular invasion did not add value in this subset of patients.

Effect of technique on postoperative perineal wound infections in abdominoperineal resection

BACKGROUND

Perineal wound infection (PWI) after abdominoperineal resection causes a burden for patients and health systems. We sought to determine the effect of patient positioning on the incidence of postoperative surgical site infection.

METHODS

We conducted a retrospective cohort study of patients who underwent APR in our hospital system over a 10-year period. Univariate analysis was performed to identify characteristics associated with position and PWI. A logistic model was developed to assess the relationship of position and PWI, with adjustment for confounders.

RESULTS

Patient characteristics were similar for the prone and lithotomy positions. Operative time was less for the prone than for the lithotomy position. The prone position was associated with a reduced risk of PWI. After adjustment for potential confounders, the prone position remained significantly associated with a reduction in PWI.

CONCLUSIONS

Positioning patients in the prone position results in a lower occurrence of postoperative PWI and shorter operative time. We advocate this technique for most indications of APR.

Secular trends in small-bowel obstruction and adhesiolysis in the United States: 1988-2007

BACKGROUND

Postoperative adhesions are common after surgery and can cause small-bowel obstruction (SBO) and require adhesiolysis. The impact that laparoscopy and other surgical advances have had on rates of SBO and adhesiolysis remains controversial. This study examines trends in discharges from US hospitals for SBO and adhesiolysis from 1988 to 2007.

METHODS

We performed an analysis of secular trends for SBO and adhesiolysis, using the National Hospital Discharge Survey. Spearman correlation coefficients were calculated to assess trends over time.

RESULTS

Rates of SBO were stable over time (ρ = .140; P = .28). Adhesiolysis rates were stable over time (ρ = -.18; P = .17), although there were significant downward trends in patients older than age 65 (ρ = -.55; P = .01) and age 15 to 44 (ρ = -.84; P < .01).

CONCLUSIONS

There has been no significant change in overall rates of SBO or adhesiolysis from 1988 to 2007. For adhesiolysis, there were decreasing trends when stratified by age. Further research is required to understand the factors associated with adhesion-related complications.

Acuity and survival in colon cancer surgery

PURPOSE

Reports indicate that up to 40% of patients with colon cancer require nonelective resection, which has been shown to portend worse long-term prognosis compared with elective resection. We used a national database to identify specific preoperative, perioperative, and postoperative factors mediating the acuity-survival relationship in an effort to identify areas of medical practice that can serve as targets for improvement in cancer care.

METHODS

We used the Surveillance, Epidemiology and End Results-Medicare-linked database to identify non-health maintenance organization-enrolled people aged 66 years and older who were diagnosed with stages I to III colon cancer between 1996 and 2003 (N = 30,685). Using stepwise, multivariate Cox regression, disease-specific survival was compared in patients undergoing elective vs nonelective resection. Adjustment for preoperative, perioperative, and postoperative variables was performed to identify factors contributing to the acuity-survival relationship.

RESULTS

Five-year disease-specific survival was 86.3% after elective and 75.4% after nonelective colon resection (hazard ratio, 1.92; P < .001). A significant proportion of this disparity was the result of differences in stage and patient characteristics, particularly age and comorbidity burden, at the time of resection. Differences in adequacy of nodal assessment and the use of surveillance colonoscopy and adjuvant chemotherapy, however, also contributed to the disparity. After adjustment for these factors, the hazard ratio for nonelective resection was 1.30 (P < .001).

CONCLUSION

Nonelective resection of colon cancer is associated with poor long-term prognosis compared with elective resection. Disease-specific survival among patients undergoing nonelective surgery may be improved by addressing insufficient nodal assessment, inadequate follow-up care, and underutilization of appropriate, adjuvant chemotherapy.

Impact of surgical site infections on length of stay and costs in selected colorectal procedures

BACKGROUND

Length of stay (LOS) and inpatient costs for open-abdomen colorectal procedures have not been examined recently. The aim of this study was to determine LOS and costs for several colorectal procedures in the context of factors potentially associated with surgical site infection (SSI).

METHODS

We used a large U.S. hospital database to identify the variables associated with longer LOS and higher costs for colorectal procedures from January 1, 2005, through June 30, 2006. The study population consisted of all patients >18 years, identified via International Classification of Disease, Ninth Revision, procedural codes for elective colorectal surgery. Patient demographics, surgical procedure, and a modified Study of the Efficacy of Nosocomial Infection Control (SENIC) infection risk score were examined using logistic regression as predictors of LOS >or=1 week and cost >or=$15,000. Patients given cefotetan as surgical prophylaxis were compared with patients given cefazolin/metronidazole. Superficial and deep SSIs were considered; intra-abdominal infection was not.

RESULTS

The 25,825 patients were of average age 63 years, with 53% being female and 75% being Caucasian. The overall infection rate was 3.7%. The mean LOS was 7.25 days, and the mean +/- standard deviation total cost per patient $13,746 +/- $13,330. Rates of infection, LOS, and mean hospital costs were all greater for patients with a high SENIC score and increasing disease acuity. Values for these outcome variables were highest for procedures involving stoma formation, followed by operations on the small bowel and large bowel. Variables independently predictive of longer LOS were SSI (odds ratio [OR] 11.74; 95% confidence interval [CI] 9.67, 14.26), age >or=65 years (OR 1.90; 95% CI 1.81, 2.01), and high SENIC score (OR 1.79; 95% CI 1.67, 1.92), whereas Caucasian race (OR 0.86; 95% CI 0.81, 0.91) was predictive of a shorter LOS. Cefazolin/metronidazole was not predictive of a shorter LOS compared with cefotetan (OR 1.06; 95% CI 0.96, 1.17) but was associated with significantly more hospitalizations with costs >or=$15,000 (OR 1.39; 95% CI 1.23, 1.56).

CONCLUSIONS

Length of stay and cost rise proportionally with SENIC score, disease acuity, and patient characteristics such as age. Surgical site infections are significantly and independently associated with LOS and cost and contribute to inpatient morbidity and expense. Cefotetan has limited availability, and substitutions are utilized increasingly. Although equally efficacious in elective colon procedures, cefotetan used as surgical prophylaxis was associated with lower hospitalization costs than cefazolin plus metronidazole.

Resected colorectal cancer among Medicare beneficiaries:adoption of FDG PET

PURPOSE

To investigate early adoption and potential predictors of postoperative utilization of fluorine 18 fluorodeoxyglucose (FDG) positron emission tomography (PET) in patients who underwent colorectal cancer resection between July 2001 and December 2002 (the first 18 months of Centers for Medicare and Medicaid Services [CMS] coverage for FDG PET) and who were observed for 2 years from the date of surgery.

MATERIALS AND METHODS

This HIPAA-compliant study was exempt from institutional review board approval. Informed consent was waived. This was a retrospective cohort study of FDG PET utilization in patients with colorectal cancer following resection between July 1, 2001 and December 31, 2002. Utilization data were drawn from the Surveillance, Epidemiology and End Results-Medicare files during the first 2 years following colorectal surgery. The primary outcome measure was FDG PET utilization. Covariates included disease-, patient-, and hospital-level characteristics, as well as computed tomography (CT) utilization. Univariate and multiple regression analysis were performed.

RESULTS

Of 10630 patients (mean age, 77.5 years) who underwent resection for colorectal cancer during the study period, 1056 (10%) patients underwent at least one FDG PET examination in the 2-year period following surgery. A 41% relative increase in utilization of FDG PET was found among patients who underwent resection early in the study period compared with those who underwent resection late in the study period; this was a significant difference (P < .001). There was no change in CT utilization between these two groups (P = .302). The highest utilization of FDG PET was during the first 6 months following surgery. Significant predictors of higher FDG PET utilization included rectal cancer, later date of initial surgery, higher disease stage, older age, marital status, and lower comorbidity.

CONCLUSION

Substantial growth in utilization of FDG PET within 2 years of surgery was found among patients who underwent surgery during the first 18 months of approved CMS coverage, with the highest rates of utilization occurring within 6 months of surgery and lower rates occurring subsequently over the 2-year period following resection.

Sigmoid Colon Duplication Cysts

Enteric duplication cysts are uncommon congenital anomalies that can occur anywhere along the length of the alimentary tract or nearby organs. Overall, the colon is the least common site of congenital alimentary duplications. Colonic duplication cysts can present with symptoms of diverticulitis and can be confused with acquired giant sigmoid diverticula. We present a case of a sigmoid colon duplication cyst presenting as persistent diverticulitis in an adult male. We review the literature and attempt to differentiate congenital colonic duplication cysts from the more common, acquired giant colonic diverticula.

Sigmoid colon duplication cysts

Enteric duplication cysts are uncommon congenital anomalies that can occur anywhere along the length of the alimentary tract or nearby organs. Overall, the colon is the least common site of congenital alimentary duplications. Colonic duplication cysts can present with symptoms of diverticulitis and can be confused with acquired giant sigmoid diverticula. We present a case of a sigmoid colon duplication cyst presenting as persistent diverticulitis in an adult male. We review the literature and attempt to differentiate congenital colonic duplication cysts from the more common, acquired giant colonic diverticula.

Effect of time interval between surgery and preoperative chemoradiotherapy with 5-fluorouracil or 5-fluorouracil and oxaliplatin on outcomes in rectal cancer

BACKGROUND AND OBJECTIVES

Preoperative chemoradiotherapy for locally advanced rectal cancer is now considered "standard of care." However, the optimal time interval for resection after neoadjuvant therapy is unknown.

METHODS

Between 11/90 and 11/04, 107 patients with rectal adenocarcinoma underwent preoperative chemo/RT at the University of Pennsylvania. Fifty-six percent had LAR and 40% had APR. Chemotherapy consisted of 5-FU/oxaliplatin in 28% and 5-FU in 72% of patients. All patients received preoperative RT.

RESULTS

A longer time interval between chemo/RT and surgery was associated with tumor downstaging (OR 1.24, P = 0.02). A longer time interval was not associated with: nodal downstaging (OR 1.00, P = 0.98); pathologic complete response (PCR) (OR 0.97, P = 0.80); likelihood of performing an LAR (OR 0.90, P = 0.47); improved disease free survival (DFS), local control, or distant control (HR 1.05, P = 0.49; HR 1.14, P = 0.22; HR 1.06, P = 0.52, respectively). The PCR rate was 34.5% in the 5-FU/oxaliplatin/radiation group, and 13.7% in the 5-FU/radiation group. If patients with microscopic CR were excluded, then the PCR rate for 5FU/OX was 21.4% and for 5-FU was 12.2%.

CONCLUSIONS

Time interval between surgery and chemo/RT appeared to have little effect on PCR or LAR rates. Patients receiving 5 FU/oxaliplatin/RT had a high PCR rate. A prospective randomized trial to test superiority of 5 FU/oxaliplatin is warranted.

A Surprising Twist to an Old Problem: Sigmoid Volvulus in a 19-Year-Old Man

Sigmoid volvulus classically presents in the seventh or eighth decade, therefore, diagnosis of sigmoid volvulus in an adolescent may be delayed or missed. This life-threatening diagnosis should be considered in young patients presenting with abdominal pain, nausea, vomiting, and constipation. Intraoperative findings in a 19-year-old man with a sigmoid volvulus highlight the importance of considering further studies, such as an abdominal CT scan, which goes beyond the typical obstruction evaluation in the adolescent patient. When nonoperative management fails to decompress the volvulus, complicating factors should be considered, and laparotomy is indicated to provide definitive treatment for this condition.

A surprising twist to an old problem: sigmoid volvulus in a 19-year-old man

Sigmoid volvulus classically presents in the seventh or eighth decade, therefore, diagnosis of sigmoid volvulus in an adolescent may be delayed or missed. This life-threatening diagnosis should be considered in young patients presenting with abdominal pain, nausea, vomiting, and constipation. Intraoperative findings in a 19-year-old man with a sigmoid volvulus highlight the importance of considering further studies, such as an abdominal CT scan, which goes beyond the typical obstruction evaluation in the adolescent patient. When nonoperative management fails to decompress the volvulus, complicating factors should be considered, and laparotomy is indicated to provide definitive treatment for this condition.