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Background: Hepatic artery infusion (HAI) is less frequently used in the adjuvant setting for resectable colorectal liver metastasis (CRLM) due to concerns regarding toxicity. Our objective was to evaluate the safety and feasibility of establishing an adjuvant HAI program., Methods: Patients who underwent HAI pump placement between January 2019 and February 2023 for CRLM were identified. Complications and HAI delivery were compared between patients who received HAI in the unresectable and adjuvant settings., Results: Of 51 patients, 23 received HAI for unresectable CRLM and 28 in the adjuvant setting. Patients with unresectable CRLM more commonly had bilobar disease (n = 23/23 vs n = 18/28, p < 0.01) and more preoperative liver metastases (median 10 [IQR 6-15] vs 4 [IQR 3-7], p < 0.01). Biliary sclerosis was the most common complication (n = 2/23 vs n = 4/28); however, there were no differences in postoperative or HAI-specific complications. In the most recent two years, 0 patients in the unresectable group vs 2 patients in the adjuvant group developed biliary sclerosis. All patients were initiated on HAI with no difference in treatment times or dose reductions., Conclusion: Adjuvant HAI is safe and feasible for patients with resectable CRLM. HAI programs can carefully consider including patients with resectable CRLM if managed by an experienced multidisciplinary team with quality assurance controls in place., (Copyright © 2023 International Hepato-Pancreato-Biliary Association Inc. Published by Elsevier Ltd. All rights reserved.)

Background: Hepatic artery infusion pump (HAIP) chemotherapy is an advanced cancer therapy for primary and secondary hepatic malignancies. The risk of concurrent hepatic and/or colorectal operations with HAIP placement is unknown. Our objective was to characterize the short-term outcomes of concurrent surgery with HAIP placement., Methods: The 2005-2017 ACS NSQIP dataset was queried for patients undergoing hepatic and colorectal operations with or without HAIP placement. Outcomes were compared for HAIP placement with different combined procedures. Patients who underwent procedures without HAIP placement were propensity score matched with those with HAIP placement. The primary outcome was 30-day death or serious morbidity (DSM). Secondary outcomes included infectious complications, wound complications, length of stay (LOS), and operative time., Results: Of 467 patients who underwent HAIP placement, 83.9% had concurrent surgery. The rate of DSM was 10.7% for HAIP placement alone, 19.2% with concurrent minor hepatic procedures, 22.1% with concurrent colorectal resection, 23.2% with concurrent minor hepatic plus colorectal procedures, 28.4% with concurrent major hepatic resection, and 41.7% with concurrent major hepatic plus colorectal resection. On matched analyses, there was no difference in DSM, infectious, or wound complications for procedures with HAIP placement compared with the additional procedure alone, but operative time (294.7 vs 239.8 min, difference 54.9, 95% CI 42.8-67.0) and LOS (6 vs 5, IRR 1.20, 95% CI 1.08-1.33) were increased., Conclusions: HAIP placement is not associated with additional morbidity when performed with hepatic and/or colorectal surgery. Decisions regarding HAIP placement should consider the risks of concurrent operations, and patient- and disease-specific factors.

Background: Venous thromboembolism (VTE) is the most common preventable cause of 30-day post-operative mortality, with many events occurring after hospital discharge. High-level evidence supports post-discharge VTE chemoprophylaxis following abdominal/pelvic cancer resection; however, some studies support a more tailored approach. Our objectives were to (1) identify risk factors associated with post-discharge VTE in a large cohort of patients undergoing colorectal cancer resection and (2) develop a post-discharge VTE risk calculator., Methods: Patients who underwent colorectal cancer resection from 2012 to 2016 were identified from ACS NSQIP colectomy and proctectomy procedure-targeted modules. Multivariable logistic regression was used to identify factors associated with post-discharge VTE. Incorporating pre-operative, intra-operative, and post-operative variables, a post-discharge VTE risk calculator was constructed and validated., Results: Of 51,139 patients, 387 (0.76%) developed post-discharge VTE. Pre-operative factors associated with post-discharge VTE included BMI (e.g., morbidly obese OR 2.27, 95% CI 1.65-3.12 vs. normal BMI), and thrombocytosis (OR 1.41, 95% CI 1.03-1.92). Intra-operative factors included operative time (4-6 h OR 1.56, 95% CI 1.12-2.17; > 6 h, OR 1.85, 95% CI 1.21-2.84, vs. < 2 h), and type of operation (e.g., open partial colectomy OR 1.67, 95% CI 1.30-2.16 vs. laparoscopic partial colectomy). Post-operative factors included anastomotic leak (OR 2.05, 95% CI 1.31-3.21) and post-operative ileus (OR 1.39, 95% CI 1.07-1.79). Using the risk calculator, the predicted probability of post-discharge VTE ranged from 0.04 to 10.29%. On a 10-fold cross validation, the calculator's mean C-Statistic was 0.65., Conclusions: Patient-specific factors are associated with varying rates of post-discharge VTE. We present the first post-discharge VTE risk calculator designed for use at the time of discharge following colorectal cancer resection.

Colorectal cancer (CRC) is diagnosed with colonoscopy and treated with focal therapies. CRC is a good candidate for nanoparticle-mediated photothermal ablation (PTA) therapy. Herein, we developed a near-infrared fluorescent (NIRF) endoscopic image-guided PTA approach using a nanoparticle capable of simultaneously diagnosing and treating CRC. Dual-modal NIR heating and fluorescent gold nanorods (dual-modal GNRs) were synthesized by conjugation of GNRs to an NIRF probe. To validate the translational potential of our approach, a well-characterized transgenic TS4 CRE/APC loxΔ468 colon cancer mouse model was used to carry out NIRF image-guided PTA using our dual-modal GNRs under clinically relevant conditions. Intravenously infused dual-modal GNRs were effectively targeted at colon polyps by immunogenic capturing of the GNRs within tumor-infiltrating innate immune cells. NIRF endoscopic image-guided PTA using the GNRs permitted successful detection and ablation of inflammatory colon polyps. NIRF endoscopy image-guided PTA using dual-modal GNRs can be utilized for diagnosis and treatment of CRC and various inflammatory diseases.

The liver is the second leading site of colorectal cancer metastases, following the lymph nodes. Although metastatic resection for colorectal cancer liver metastases has been shown to improve survival, many patients cannot undergo surgery. Several nonsurgical therapies are available in these situations, however high-quality evidence comparing the effectiveness of these therapies is sparse. Here, we review the currently available evidence in support of nonresectional regional therapies for colorectal metastases to the liver., (© 2019 Wiley Periodicals, Inc.)

Background and Aims: Endoscopic resection (ER) is a safe and effective treatment for nonmalignant complex colorectal polyps (complex polyps). Surgical resection (SR) remains prevalent despite limited outcomes data. We aimed to evaluate SR outcomes for complex polyps and compare SR outcomes to those of ER., Methods: We performed a single-center, retrospective, cohort study of all patients undergoing SR (2003-2013) and ER (2011-2013) for complex polyps. We excluded patients with invasive carcinoma from the SR cohort. Primary outcomes were 12-month adverse event (AE) rate, length of stay (LOS), and costs. SR outcomes over a 3-year period (2011-2013) were compared with the overlapping ER cohort., Results: Over the 11-year period, 359 patients (mean [± SD] age 64 ± 11 years) underwent SR (58% laparoscopic) for complex polyps. In total, 17% experienced an AE, and 3% required additional surgery; 12-month mortality was 1%. Including readmissions, median LOS was 5 days (IQR 4-7 days), and costs were $14,528. When an AE occurred, costs ($25,557 vs $14,029; P < .0001) and LOS (11 vs 5 days; P < .0001) significantly increased. From 2011 to 2013, 198 patients were referred for ER, and 73 underwent primary SR (70% laparoscopic). There was a lower AE rate for ER versus primary SR (10% vs 18%; P = .09). ER costs (including rescue SR, when required) were lower than those of primary SR ($2152 vs $15,264; P < .0001)., Conclusions: AEs occur in approximately one-sixth of patients after SR for complex polyps. ER-accounting for rescue SR caused by malignancy, AEs, or incomplete resection-is associated with markedly lower costs than SR. These data should be used when counseling patients about treatment options for complex polyps., (Copyright © 2016 American Society for Gastrointestinal Endoscopy. Published by Elsevier Inc. All rights reserved.)

Objectives: To assess national adherence with extended venous thromboembolism (VTE) chemoprophylaxis guideline recommendations after colorectal cancer surgery., Background: Postoperative VTE remains a major cause of morbidity and mortality after abdominal cancer surgery. On the basis of the results from randomized controlled trials, since 2007, national guidelines have suggested that these patients be discharged on VTE chemoprophylaxis., Methods: Medicare beneficiaries undergoing open colorectal cancer resections in 2008-2009 were identified using the Medicare Provider Analysis and Review data and limited to those who were enrolled and used Part D for their postoperative prescriptions. Postdischarge use of low-molecular-weight-heparin and other anticoagulants was assessed., Results: A total of 5078 patients underwent open colorectal cancer surgery and met the inclusion criteria. Of these, 77% underwent colectomy and 23% underwent proctectomy. A prescription for an anticoagulant was filled immediately after discharge for 77 (1.5%) patients, and a low-molecular-weight-heparin for 60 (1.2%) patients. On multivariable analysis, patients were more likely to receive postdischarge VTE chemoprophylaxis if undergoing rectal cancer surgery [incidence rate ratio (IRR), 1.83; 95% confidence interval, 1.07-3.12; vs colon], if higher educational status (IRR, 2.20; 95% confidence interval, 1.23-3.95; vs low education), or if they had a higher Elixhauser comorbidity index (IRR, 1.13; 95% confidence interval, 1.01-1.25; vs lower index)., Conclusions: Although VTE remains a major issue after abdominal cancer surgery, only 1.5% of Medicare beneficiaries undergoing colorectal cancer surgery received care consistent with established guidelines for postdischarge VTE chemoprophylaxis. Barriers to adherence must be elucidated to improve the quality of care for abdominal and pelvic cancer surgery patients.

Objectives/background: Colorectal cancer (CRC) can be prevented by routine colonoscopy. CRC screening in special populations, e.g. spinal cord injury and disorders, presents unique barriers and, potentially, a higher risk of complications. We were concerned about potentially higher risks of complications and sought to determine the safety of colonoscopy., Methods: Retrospective observational design using medical record review for 311 patients who underwent 368 colonoscopies from two large VA SCI centers from 1997-2008. Patient demographics and peri-procedural characteristics, including indication, bowel prep quality, and pathological findings are presented. Descriptive statistics are presented., Results: The population was predominantly male and Caucasian, and 199 (64%) had high-level injuries (T6 or above). Median age at colonoscopy was 61 years (interquartile range 53-69). Just <1/2 of the colonoscopies were diagnostic, usually for evidence of rectal bleeding. Although a majority of colonoscopies were reported as poorly prepped, the proportion that were adequately prepped increased over time (from 3.7 to 61.3%, P = <0.0001). Of the 146 polyps removed, 101 (69%) were adenomas or carcinomas. Ten subjects had 11 complications, none of which required surgical intervention., Conclusions: Although providing quality colonoscopic care in this population is labor intensive, the data suggests that it appears safe and therapeutically beneficial. The results indicate that the risk of screening is outweighed by the likelihood of finding polyps. Recognition of the benefit of colonoscopy in this population may have improved bowel prep and reporting over time. Spinal cord injury providers should continue to offer screening or diagnostic colonoscopy to their patients when indicated, while being aware of the special challenges that they face.

Purpose: Timeliness of cancer treatment is an important aspect of health care quality. Veterans Affairs Medical Centers (VAMCs) are expected to treat a growing number of patients with cancer. Our objectives were to examine treatment times from diagnosis to first-course therapy for patients with colon and rectal cancers and assess factors associated with prolonged wait times., Methods: From the VA Central Cancer Registry, patients who underwent colon or rectal resection for cancer from 1998 to 2008 were identified. Time from diagnosis to definitive cancer-directed therapy was measured, and multivariable regression methods were used to determine predictors of prolonged wait times for colon (≥ 45 days) and rectal (≥ 60 days) cancers., Results: From 124 VAMCs, 14,097 patients underwent colectomy, and 3,390 underwent rectal resection for cancer. For colon cancer, the median time to treatment increased by 68% over time (P < .001). From 2007 to 2008, the median time to colectomy was 32 days. Predictors of prolonged wait times included age ≥ 55 years (v < 55 years), time period (2007 to 2008 v 1998 to 2000), black race (v white), marriage status (married v unmarried), high-volume center status (v low volume), and treatment at a different hospital (v same hospital as initial diagnosis; all P < .05). For rectal cancer, the overall median time to first-course treatment increased by 74% (P < .001). From 2007 to 2008, the median time to proctectomy was 47 days. Similar predictors of prolonged wait times were identified for rectal cancer., Conclusion: Time to first treatment has increased for patients with colon and rectal cancers at VAMCs. Patient, tumor, and hospital factors are associated with prolonged time to treatment.

Purpose: To understand signaling pathways that shape inflamed tissue and predispose to cancer is critical for effective prevention and therapy for chronic inflammatory diseases. We have explored phosphoinositide 3-kinase (PI3K) activity in human inflammatory bowel diseases and mouse colitis models., Experimental Design: We conducted immunostaining of phosphorylated AKT (pAKT) and unbiased high-throughput image acquisition and quantitative analysis of samples of noninflamed normal colon, colitis, dysplasia, and colorectal cancer. Mechanistic insights were gained from ex vivo studies of cell interactions, the piroxicam/IL-10(-/-) mouse model of progressive colitis, and use of the PI3K inhibitor LY294002., Results: Progressive increase in densities of pAKT-positive tumor-associated macrophages (TAM) and increase in densities of mast cells in the colonic submucosa were noted with colitis and progression to dysplasia and cancer. Mast cells recruited macrophages in ex vivo migration assays, and both mast cells and TAMs promoted invasion of cancer cells. Pretreatment of mast cells with LY294002 blocked recruitment of TAMs. LY294002 inhibited mast cell and TAM-mediated tumor invasion, and in mice, blocked stromal PI3K, colitis, and cancer., Conclusion: The PI3K/AKT pathway is active in cells infiltrating inflamed human colon tissue. This pathway sustains the recruitment of inflammatory cells through a positive feedback loop. The PI3K/AKT pathway is essential for tumor invasion and the malignant features of the piroxicam/IL-10(-/-) mouse model. LY294002 targets the PI3K pathway and hinders progressive colitis. These findings indicate that colitis and progression to cancer are dependent on stromal PI3K and sensitive to treatment with LY294002., (©2013 AACR.)

Background: The American College of Surgeons (ACS) National Surgical Quality Improvement Program (NSQIP) generally has not collected cancer-specific variables. Because increasing numbers of studies are using ACS NSQIP data to study cancer surgery, the objectives of the current study were 1) to examine differences between existing ACS NSQIP variables and cancer registry variables, and 2) to determine whether the addition of cancer-specific variables improves modeling of short-term outcomes., Methods: Data from patients in the ACS NSQIP and National Cancer Data Base (NCDB) who underwent colorectal resection for cancer were linked (2006-2008). By using regression methods, the relative importance of cancer staging and neoadjuvant therapy variables were assessed along with their effects on morbidity, serious morbidity, and mortality., Results: From 146 hospitals, 11,405 patients were identified who underwent surgery for colorectal cancer (colon, 85%; rectum, 15%). The NCDB metastatic cancer variable and the ACS NSQIP disseminated cancer variables agreed marginally (Cohen kappa coefficient, 0.454). For mortality, only the ACS NSQIP disseminated cancer variable and the NCDB stage IV variable were identified as important predictors; whereas the variables stage I through III, tumor (T)-classification, and lymph node (N)-classification were not selected. Cancer stage variables were inconsistently important for serious morbidity (stage IV, T-classification), superficial surgical site infection (N-classification), venous thromboembolism (metastatic cancer), and pneumonia (T-classification). With respect to neoadjuvant therapy, ACS NSQIP and NCDB variables agreed moderately (kappa, 0.570) and predicted superficial surgical site infection, serious morbidity, and organ space surgical site infection. The model fit was similar regardless of the inclusion of stage and neoadjuvant therapy variables., Conclusions: Although advanced disease stage and neoadjuvant therapy variables were predictors of short-term outcomes, their inclusion did not improve the models., (Copyright © 2012 American Cancer Society.)

Background: The US Department of Veterans Affairs (VA) Office of Quality and Performance's July 2009 report detailed the quality of VA colorectal cancer (CRC) care on the basis of 10 quality indicators (QIs). Of 21 Veterans Integrated Service Networks (VISNs), the authors' VISN ranked last or near last on more than half of the QIs. The aim of this study was to compare a national-level assessment of performance with an institutional-level clinical review., Methods: The authors reabstracted all patients seen at surgical hospitals within their VISN during the time period of the Office of Quality and Performance report and reanalyzed their performance on the 10 QIs. A number of quality improvement efforts were also implemented to further boost performance, including the creation of a computerized patient record system CRC order set and quarterly surveillance meetings., Results: After reanalysis of the VISN's QI performance for CRC patients during the time period of the OQP report, the VISN performed 18% better than reported and 2% better than the national average. Since that time, a multidisciplinary CRC committee has implemented quality improvement measures that have further improved QI performance., Conclusions: There is variability between administrative quality assessments and clinically abstracted data. Care must be taken when analyzing QIs at the national level., (Published by Elsevier Inc.)

Bevacizumab (Avastin™; rhuMab VEGF), a monoclonal antibody targeting vascular endothelial growth factor (VEGF), has seen increased use in the perioperative treatment of colorectal and pancreatic cancer. Little is known, however, regarding its impact on surgical outcomes in patients undergoing resection. The objective of this review was to examine if the addition of bevacizumab to existing neoadjuvant regimens increases morbidity after cancer resection., (J. Surg. Oncol. 2010;102:539-542. © 2010 Wiley-Liss, Inc.)

T-regulatory cells (Treg) and mast cells (MC) are abundant in colorectal cancer (CRC) tumors. Interaction between the two is known to promote immune suppression or loss of Treg functions and autoimmunity. Here, we demonstrate that in both human CRC and murine polyposis the outcome of this interaction is the generation of potently immune suppressive but proinflammatory Treg (DeltaTreg). These Treg shut down IL10, gain potential to express IL17, and switch from suppressing to promoting MC expansion and degranulation. This change is also brought about by direct coculture of MC and Treg, or culture of Treg in medium containing IL6 and IL2. IL6 deficiency in the bone marrow of mice susceptible to polyposis eliminated IL17 production by the polyp infiltrating Treg, but did not significantly affect the growth of polyps or the generation of proinflammatory Treg. IL6-deficient MC could generate proinflammatory Treg. Thus, MC induce Treg to switch function and escalate inflammation in CRC without losing T-cell-suppressive properties. IL6 and IL17 are not needed in this process.