Search

BACKGROUND Preoperative steroid use has been associated with worse surgical outcomes. The purpose of this study was to determine whether laparoscopic surgery reduces the risk of septic shock/sepsis among ulcerative colitis patients with preoperative chronic steroid use. METHODS Patients with ulcerative colitis undergoing a total abdominal colectomy were identified from the American College of Surgeons National Surgical Quality Improvement Program (NSQIP) database (2005-2019). Patients were stratified based on preoperative chronic steroid use and operative approach (open versus laparoscopic). The primary outcome was septic shock/sepsis. Multivariable regression models were used to assess the association between laparoscopic surgery and rates of septic shock/sepsis among steroid users and non-steroid users in both the elective and emergent settings. RESULTS Among 8,644 patients undergoing a total abdominal colectomy, 67.1% were steroid users and 32.9% were non-steroid users. Compared with an open approach, elective laparoscopic surgery was associated with lower rates of septic shock/sepsis, albeit with higher readmission rates for both steroid users (15.1% [laparoscopic] vs 12.0% [open], P = .005) and non-steroid users (12.6% [laparoscopic] vs 9.4% [open], P = .019). On adjusted analysis, ulcerative colitis patients with chronic steroid use undergoing an elective laparoscopic total abdominal colectomy demonstrated a reduced risk of septic shock/sepsis compared to open surgery (odds ratio 0.61, 95% confidence interval 0.49-0.76, P < .001). Similar findings were seen among chronic steroid users undergoing emergent laparoscopic procedures (odds ratio 0.54, 95% confidence interval 0.31-0.95, P = .031). CONCLUSION Laparoscopic surgery was associated with a reduced risk of septic shock/sepsis among ulcerative colitis patients with preoperative chronic steroid use, suggesting that minimally invasive surgery may be a promising option among this unique patient population.

Rectal cancer treatment is often multimodal, comprising of surgery, chemotherapy, and radiotherapy. However, the impact of coordination between these modalities is currently unknown. We aimed to assess whether delivery of nonsurgical therapy within same facility as surgery impacts survival in patients with rectal cancer.A patient cohort with rectal cancer stages II to IV who received multimodal treatment between 2004 and 2016 from National Cancer Database was retrospectively analyzed. Patients were categorized into three groups: (A) surgery + chemotherapy + radiotherapy at same facility (surgery + 2); (B) surgery + chemotherapy or radiotherapy at same facility (surgery + 1); or (C) only surgery at reporting facility (chemotherapy + radiotherapy elsewhere; surgery + 0). The primary outcome was 5-year overall survival (OS), analyzed using Kaplan-Meier curves, log-rank tests, and Cox proportional-hazards models.A total of 44,716 patients (16,985 [37.98%] surgery + 2, 12,317 [27.54%] surgery + 1, and 15,414 [34.47%] surgery + 0) were included. In univariate analysis, we observed that surgery+2 patients had significantly greater 5-year OS compared to surgery + 1 or surgery + 0 patients (5-year OS: 63.46% vs 62.50% vs 61.41%, respectively; P= .002). We observed similar results in multivariable Cox proportional-hazards analysis, with surgery + 0 group demonstrating increased hazard of mortality when compared to surgery + 2 group (HR: 1.09; P.001). These results held true after stratification by stage for stage II (HR 1.10; P= .022) and stage III (HR 1.12; P.001) but not for stage IV (P= .474).Greater degree of care coordination within the same facility is associated with greater OS in patients with stage II to III rectal cancer. This finding illustrates the importance of interdisciplinary collaboration in multimodal rectal cancer therapy.

There is a strong association between hospital volume and surgical outcomes in resectable colorectal cancer. The purpose of our study was to investigate the association between hospital facility type and survival of patients with metastatic colorectal cancer.Adults from the National Cancer Database (2010-2015) with a primary diagnosis of colorectal metastases were included and stratified by facility type: community cancer program, comprehensive community cancer program, and academic/research program. The primary outcome was 5-year overall survival, analyzed using Kaplan-Meier survival curves, log-rank test, and the Cox proportional hazards regression model.Among the 52,958 included patients, 13.72% were treated at a community cancer program, 49.89% at a comprehensive community cancer program, and 36.29% at an academic/research program. A significant increase in the proportion of patients being treated in an academic/research program has been observed from 2010 to 2015. An academic/research program tended to use more chemotherapy with colorectal radical resection and liver or lung resection and immunotherapy with chemotherapy. In adjusted analysis, the academic/research program had decreased risk of mortality in comparison to the community cancer program and the comprehensive community cancer program (hazard ratio 0.90, 95% confidence interval 0.86-0.94; 0.87, 0.85-0.90; each P.001; respectively). Similar results were seen after stratifying by metastatic site and treatment type.The prognosis and overall survival of patients with metastatic disease is better in an academic/research program compared with a community cancer program or a comprehensive community cancer program, with this difference persisting across sites of metastatic disease and treatment types. Further studies are required to validate these results and investigate disparities in the management of metastatic colorectal cancer.

AIM The objective was to assess the effect of three different surgical treatments for T1 rectal tumours, radical resection (RR), open local excision (open LE) and laparoscopic local excision (laparoscopic LE), on overall survival (OS). METHODS Adults from the National Cancer Database (2008-2016) with a diagnosis of T1 rectal cancer were stratified by treatment type (LE vs RR). We assumed that laparoscopic LE equates to transanal minimally invasive surgery (TAMIS) or transanal endoscopic microsurgery. The primary outcome was 5-year OS. Subgroup analyses of the LE group stratified by time period [2008-2010 (before TAMIS) vs 2011-2016 (after TAMIS)] and approach (laparoscopic vs open) were performed. RESULTS Among 10 053 patients, 6623 (65.88%) underwent LE (74.33% laparoscopic LE vs 25.67% open LE) and 3430 (34.12%) RR. The use of LE increased from 52.69% in 2008 to 69.47% in 2016, whereas RR decreased (P

The increased use of minimally invasive surgery in the management of colorectal cancer has led to a renewed focus on how certain factors, such as insurance status, impact the equitable distribution of both laparoscopic and robotic surgery. Our goal was to analyze surgical wait times between robotic, laparoscopic, and open approaches, and to determine whether insurance status impacts timely access to treatment. After IRB approval, adult patients from the National Cancer Database with a diagnosis of colorectal cancer were identified (2010–2016). Patients who underwent radiation therapy, neoadjuvant chemotherapy, had wait times of 0 days from diagnosis to surgery, or had metastatic disease were excluded. Primary outcomes were days from cancer diagnosis to surgery and days from surgery to adjuvant chemotherapy. Multivariable Poisson regression analysis was performed. Among 324,784 patients, 5.9% underwent robotic, 47.5% laparoscopic, and 46.7% open surgery. Patients undergoing robotic surgery incurred the longest wait times from diagnosis to surgery (29.5 days [robotic] vs. 21.7 [laparoscopic] vs. 17.2 [open], p

BACKGROUND Minimally invasive surgical techniques are routinely promoted as alternatives to open surgery because of improved outcomes. However, the impact of robotic surgery on certain subsets of the population, such as frail patients, is poorly understood. OBJECTIVE The purpose of our study was to examine the association between frailty and minimally invasive surgical approaches with colon cancer surgery. DESIGN This is a retrospective study of prospectively collected outcomes data. Thirty-day surgical outcomes were compared by frailty and surgical approach using doubly robust multivariable logistic regression with propensity score weighting, and testing for interaction effects between frailty and surgical approach. SETTING Patients undergoing an open, laparoscopic, or robotic colectomy for primary colon cancer, 2012 to 2016, were identified from the American College of Surgeons National Surgical Quality Improvement Program database. PATIENTS Patients undergoing a colectomy with an operative indication for primary colon cancer were selected. MAIN OUTCOME MEASURES The primary outcomes measured were 30-day postoperative complications. RESULTS After propensity score weighting of patients undergoing colectomy, 33.8% (n = 27,649) underwent an open approach versus 34.3% (n = 28,058) underwent laparoscopic surgery versus 31.9% (n = 26,096) underwent robotic surgery. Robotic (OR, 0.53; 95% CI, 0.42-0.69, p < 0.001) and laparoscopic (OR, 0.58; 95% CI, 0.52-0.66, p < 0.001) surgeries were independently associated with decreased rates of major complications. Frailer patients had increased complication rates (OR, 1.56; 95% CI, 1.07-2.25, p = 0.018). When considering the interaction effects between surgical approach and frailty, frailer patients undergoing robotic surgery were more likely to develop a major complication (combined adjusted OR, 3.15; 95% CI, 1.34-7.45, p = 0.009) compared with patients undergoing open surgery. LIMITATIONS Use of the modified Frailty Index as an associative proxy for frailty was a limitation of this study. CONCLUSIONS Although minimally invasive surgical approaches have decreased postoperative complications, this effect may be reversed in frail patients. These findings challenge the belief that robotic surgery provides a favorable alternative to open surgery in frail patients. See Video Abstract at http://links.lww.com/DCR/B163. LOS PACIENTES MAS FRAGILES SOMETIDOS A COLECTOMIA ROBOTICA POR CANCER DE COLON EXPERIMENTAN MAYORES TASAS DE COMPLICACIONES EN COMPARACION CON ABORDAJES LAPAROSCOPICO O ABIERTO: Las tecnicas quirurgicas minimamente invasivas estan frecuentement promovidas como alternativas a la cirugia abierta debido a sus mejores resultados. Sin embargo, el impacto de la cirugia robotica en ciertos subgrupos de poblacion, como el caso de los pacientes endebles, es poco conocido.El proposito de nuestro estudio fue examinar la asociacion entre la fragilidad de los pacientes y el aborgaje quirurgico minimamente invasivo para la cirugia de cancer de colon.Estudio retrospectivo de datos de resultados recolectados prospectivamente. Los resultados quirurgicos a 30 dias se compararon entre fragilidad y abordaje quirurgico utilizando la regresion logistica multivariable doblemente robusta con ponderacion de puntaje de propension y pruebas de efectos de interaccion entre fragilidad y abordaje quirurgico.Los pacientes identificados en la base de datos del Programa Nacional de Mejora de la Calidad Quirurgica del Colegio Estadounidense de Cirujanos, que fueron sometidos a una colectomia abierta, laparoscopica o robotica por cancer de colon primario, de 2012 a 2016.Todos aquellos pacientes seleccionados con indicacion quirurgica de cancer primario de colon que fueron sometidos a una colectomia.Las complicaciones postoperatorias a 30 dias.Luego de ponderar el puntaje de propension de los pacientes colectomizados, el 33.8% (n = 27,649) fue sometido a laparotomia versus el 34.3% (n = 28,058) operados por laparoscopia versus el 31.9% (n = 26,096) operados con tecnica robotica. Las cirugias roboticas (OR 0.53, IC 95% 0.42-0.69, p < 0.001) y laparoscopicas (OR 0.58, IC 95% 0.52-0.66, p < 0.001) se asociaron de forma independiente con una disminucion de las tasas de complicaciones mayores. Los pacientes mas delicados tenian mayores tasas de complicaciones (OR 1.56, IC 95% 1.07-2.25, p = 0.018). Al considerar los efectos de interaccion entre el abordaje quirurgico y la fragilidad, los pacientes mas debiles sometidos a cirugia robotica tenian mas probabilidades de desarrollar una complicacion mayor (OR ajustado combinado 3.15, IC 95% 1.34-7.45, p = 0.009) en comparacion con los pacientes sometidos a cirugia abierta.El uso del indice de fragilidad modificado como apoderado asociativo de la fragilidad.Si bien los abordajes quirurgicos minimamente invasivos han disminuido las complicaciones postoperatorias, este efecto puede revertirse en pacientes labiles. Estos hallazgos desafian la creencia de que la cirugia robotica proporciona una alternativa favorable a la cirugia abierta en pacientes fragiles. Consulte Video Resumen en http://links.lww.com/DCR/B163. (Traduccion-Dr. Xavier Delgadillo).

We aimed to assess patient and demographic factors, treatment trends, and survival outcomes of patients with colorectal cancer with metastasis to the liver, lung, or both sites. Differences remain among national guidelines about the optimal management strategy.Adults from the National Cancer Database (2010 to 2015) with a primary diagnosis of colorectal liver, lung, or liver and lung metastases were included and stratified by metastasis site. The primary end point was 5-year overall survival, analyzed using Kaplan-Meier survival curves, log-rank test, and the Cox proportional hazards model.Among 82,609 included patients, 70.42% had liver, 8.74% had lung, and 20.85% had simultaneous liver and lung metastases. Treatment with chemotherapy alone was used the most (21.11%), followed by chemotherapy with colorectal radical resection (CRRR) (19.4%), no treatment (14.35%), CRRR alone (9.03%), and chemotherapy with CRRR and liver/lung resection (8.22%). Patients with lung metastasis had significantly better 5-year overall survival rates than the other 2 metastatic groups (15.99%, 16.70%, and 5.51%; p0.001), even after stratifying by treatment type and adjusting for other factors. Chemotherapy with CRRR and liver/lung resection was associated with the greatest reduction in mortality risk for all sites in both unadjusted (35.15%, 44.52%, and 20.10%; p0.001) and adjusted analyses (hazard ratio 0.42; 95% CI, 0.38 to 0.47; p0.001; hazard ratio 0.31; 95% CI, 0.18 to 0.53; p0.001; and hazard ratio 0.79; 95% CI, 0.62 to 1.01; p = 0.064 for trend), and forgoing treatment or CRRR alone offered the worst overall survival.Patients with metastasis to lung had increased overall survival compared with other sites of metastases, regardless of treatment modality. Combined resection of primary tumor, metastasectomy, and chemotherapy appears to offer the greatest chance of survival.

Background Thoracic epidural analgesia has been shown to be an effective method of pain control. The utility of epidural analgesia as part of an enhanced recovery after surgery protocol is debatable. Objective This study aimed to determine if the use of thoracic epidural analgesia in an enhanced recovery after surgery protocol decreases hospital length of stay or inpatient opioid consumption after elective colorectal resection. Design This is a single-institution retrospective cohort study. Settings The study was performed at a high-volume, tertiary care center in the Midwest. An institutional database was used to identify patients. Patients All patients undergoing elective transabdominal colon or rectal resection by board-certified colon and rectal surgeons from 2013 to 2017 were included. Main outcome measures The main outcome was length of stay. The secondary outcome was oral morphine milligram equivalents consumed during the first 48 hours. Results There were 1006 patients (n = 815 epidural, 191 no epidural) included. All patients received multimodal analgesia with opioid-sparing agents. Univariate analysis demonstrated no difference in length of stay between those who received thoracic epidural analgesia and those who did not (median, 4 vs 5 days; p = 0.16), which was substantiated by multivariable linear regression. Subgroup analysis showed that the addition of epidural analgesia resulted in no difference in length of stay regardless of an open (n = 362; p = 0.66) or minimally invasive (n = 644; p = 0.46) approach. Opioid consumption data were available after 2015 (n = 497 patients). Univariate analysis demonstrated no difference in morphine milligram equivalents consumed in the first 48 hours between patients who received epidural analgesia and those who did not (median, 135 vs 110 oral morphine milligram equivalents; p = 0.35). This was also confirmed by multivariable linear regression. Limitations The retrospective observational design was a limitation of this study. Conclusion The use of thoracic epidural analgesia within an enhanced recovery after surgery protocol was not found to be associated with a reduction in length of stay or morphine milligram equivalents consumed within the first 48 hours. We cannot recommend routine use of thoracic epidural analgesia within enhanced recovery after surgery protocols. See Video Abstract at http://links.lww.com/DCR/A765.

Background The development of high-resolution anoscopy (HRA) has advanced our ability to detect anal dysplasia. Historically, HRA is performed in a clinical setting and subsequent ablation is performed in the clinical setting or operating room. The aim of this study was to determine the most effective venue for the performance of HRA. Methods Following institutional review board (IRB) approval, the correlation between anal cytology and HRA performed in the clinic versus in the operating room was evaluated. Data were extracted from our IRB-approved prospective HRA database over the time period of 2013–2017. Results One hundred twenty-eight HRAs were compared (101 in the clinical setting, 27 in the operating room). There was a statistically significant difference in the correlation between anal cytology and HRA pathology for procedures performed in the clinical setting (55% [56/101]) versus those performed in the operating room (82% [22/27]) (p = 0.014). More biopsies were obtained in the operating room than in the clinic setting (3 vs. 1, p Conclusions Detection rates for anal dysplasia on HRA, are significantly higher when performed in the operating room. To prevent discomfort in the clinical setting, patients with high-grade dysplasia on anal pap testing may benefit from proceeding directly to the operating room for concurrent HRA and ablation.

Background Depression has been linked to increased morbidity and mortality in patients after surgery. The purpose of this study is to investigate the impact of documented depression diagnosis on in-hospital postoperative outcomes of patients undergoing colorectal surgery. Materials and methods Patients from the National Inpatient Sample (2002-2017) who underwent proctectomies and colectomies were included. The outcomes measured included total hospital charge, length of stay, delirium, wound infection, urinary tract infection (UTI), pneumonia, deep vein thrombosis, pulmonary embolism, mortality, paralytic ileus, leak, and discharge trends. Multivariable logistic and Poisson regression analyses were performed. Results Of the 4,212,125 patients, depression diagnosis was present in 6.72% of patients who underwent colectomy and 6.54% of patients who underwent proctectomy. Regardless of procedure type, patients with depression had higher total hospital charges and greater rates of delirium, wound infection, UTI, leak, and nonroutine discharge, with no difference in length of stay. On adjusted analysis, patients with a depression diagnosis who underwent colectomies had increased risk of delirium (odds ratio (OR) 2.11, 95% confidence interval (CI) 1.93-2.32), wound infection (OR 1.08, 95% CI 1.03-1.12), UTI (OR 1.15, 95% CI 1.10-1.20), paralytic ileus (OR 1.06, 95% CI 1.03-1.09), and leak (OR 1.37, 95% CI 1.30-1.43). Patients who underwent proctectomy showed similar results, with the addition of significantly increased total hospital charges among the depression group. Depression diagnosis was independently associated with lower risk of in-hospital mortality (colectomy OR 0.58, 95% CI 0.53-0.62; proctectomy OR 0.72, 95% CI 0.55-0.94). Conclusions Patients with a diagnosis of depression suffer worse in-hospital outcomes but experience lower risk of in-hospital mortality after undergoing colorectal surgery. Further studies are needed to validate and fully understand the driving factors behind this.

It is evident that the use of laparoscopy in the management of rectal cancer has gained popularity in the last few years. It is still, however, not widely accepted as the standard of care. Multiple randomized trials have shown that short-term outcomes and perioperative morbidity and mortality of laparoscopic proctectomy are equivalent to open surgery. However, data regarding long-term oncologic outcomes are still scarce, with only a few randomized trials reporting similar outcomes in both laparoscopic and open group. A more recent trial failed to replicate those results in patients with locally advanced rectal cancer. In this article, we will look at the most recent evidence regarding the use of laparoscopy for patients with rectal cancer. We will also briefly discuss the different approaches and new minimally invasive techniques used in this field, and we will talk about the challenges facing the widespread adoption of laparoscopic surgery in the management of rectal cancer.

The aim of this study is to assess treatment trends and overall survival (OS) in small bowel (SB) and colorectal (CR) gastrointestinal stromal tumors (GIST) with respect to the introduction of imatinib in 2008. Patients diagnosed with SB and CR GIST were identified from the National Cancer Database (2004–2015). The primary outcome was 5- and 10-year OS. Patients were stratified by tumor site, time period (before and after imatinib), and treatment type. OS was analyzed using Kaplan-Meier survival curves, log-rank test, and Cox proportional hazards models. A total of 8441 cases were included (SB 81.66%; CR 18.34%). Radical resection was the most common treatment (SB 42.33%; CR 38.69%). The addition of chemotherapy to radical resection for SB GIST increased between the two time periods (31.76 to 40.43%; p

Background Clinical fetal weight estimation is a common practice in obstetrics. This study aims to evaluate the accuracy of fetal weight estimation by midwives, and to identify factors that may lead to overestimation or underestimation of fetal weight. Methods A cohort prospective study in a Lebanese university hospital, included weight estimation of singleton pregnancies above 35 weeks. Multiple pregnancies, unclear dating, growth retardation, malformations and stillbirths cases are excluded. The estimated fetal weight is recorded by midwives in a sealed envelope and compared to true weight later. The effects of BMI, weight gain, parity, diabetes, hypertension, neonate’s sex and weight, uterine contractions, rupture of membranes and daytime or nighttime shift on these estimations were assessed. Results One hundred and sixty-six patients were included. Mean birth weight was 3246 ± 362 g. Mean absolute percentage error of weight estimation was 8.5 ± 6.7% (0–30.9%). Estimation was within the correct range of ±10% in 63% of cases. Maternal and fetal factors did not significantly change weight estimation. Fetuses with birth weights more than 4000 tended to be underestimated by midwives. Estimation improved over time (nonsignificant). Conclusions Maternal and fetal factors, except for macrosomia, have limited impact on estimation of fetal birth weight. Macrosomia is challenging because of a consistent tendency of underestimation by midwives.

Molecular markers associated with thyroid malignancy are increasingly being used as differential diagnostic tools for thyroid nodules. However, little has been reported recently regarding the prevalence of these markers in benign lesions. The literature was systematically reviewed to examine studies that reported on the prevalence of these markers in benign thyroid lesions.Appropriate studies published between January 1, 2000, and April 30, 2015, and cataloged in PubMed, Embase, Cochrane, Scopus, and Web of Science databases were searched for by combining different keywords for "thyroid tumor" with both general and specific keywords for "molecular marker" by using "AND" as the Boolean operator. All studies meeting criteria that reported the prevalence of RAS mutations, and RET/PTC and PAX8/PPAR-gamma chromosomal rearrangements in benign thyroid lesions were included for study.A total of 64 articles (including 8162 patients, of whom 42.5% had benign lesions) that met all the study criteria were systematically reviewed and abstracted. Among 35 studies examining RAS mutations, the reported prevalence of RAS mutation in benign lesions ranged from 0% to 48%. In 38 studies examining RET/PTC rearrangements, the prevalence in benign lesions ranged from 0% to 68%. PAX8/PPAR-gamma rearrangements were examined in 27 studies, with the prevalence in benign lesions ranging from 0% to 55%.The presence of these biomarkers and the tremendous variation in reports of their prevalence in benign lesions suggests the need for caution when including these markers in diagnostic decisions. Further understanding of the importance of these markers, as well as newly discovered markers of thyroid malignancy, may be required in order to avoid overtreatment of patients with benign thyroid tumors.

Background The Physician Payment Sunshine Act was implemented to provide transparency to financial transactions between industry and physicians. Under this law, the Open Payments Program (OPP) was created to publicly disclose all transactions and inform patients of potential conflicts of interest. Collaboration between industry and cardiothoracic surgeon-scientists is essential in developing new approaches to treating patients with cardiac disease. The objective of this study is to characterize industry payments to cardiothoracic surgeons as reported by the OPP. Methods We used the first wave of Physician Payment Sunshine Act data (August 2013 to December 2013) to assess industry payments made to cardiothoracic surgeons. Results Cardiothoracic surgeons (n = 2,495) received a total of $4,417,545 during a 5-month period. Cardiothoracic surgeons comprised 0.5% of all persons in the OPP and received 0.9% of total disclosed industry funding. Among cardiothoracic surgeons receiving funding, 34% received payments less than $100, 43% received payments of $100 to $999, 19% received payments of $1,000 to $9,999, 4% received payments of $10,000 to $99,999, and 0.2% received payments of more than $100,000. The median was $181 (interquartile range [IQR]: $60 to $843) and the mean ± SD was $1,771 ± $7,664. The largest payment to an individual surgeon was $159,444. The three largest median payments made to cardiothoracic surgeons by expense category were royalty fees $8,398 (IQR: $536 to $12,316), speaker fees $3,600 (IQR: $1,500 to $8,000), and honoraria $3,344 (IQR: $1,563 to $7,350). Conclusions Among cardiothoracic surgeons who are listed as recipients of nonresearch industry payments, 50% of cardiothoracic surgeons received less than $181. Awareness of the OPP data is critical for cardiothoracic surgeons, as it provides a means to prevent potential public misconceptions about industry payments within the specialty that may affect patient trust.