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Objective: The aim of this study was to compare rates and severity of recurrent acute diverticulitis in patients with and without solid organ transplant., Background: Immunocompromised solid organ transplant recipients have been considered higher risk for both recurrence and severity of acute diverticulitis. Current guidelines recommend an individualized approach for colectomy in these patients, but these are based on single-center data., Methods: We identified patients with acute diverticulitis using the Merative MarketScan commercial claims data from 2014 to 2020. Patients were classified by history of solid organ transplant. The primary outcome was recurrence of acute diverticulitis with an associated antibiotic prescription ≥60 days from the initial episode. Secondary outcomes included hospitalization, colectomy, and ostomy in patients with recurrence. Analyses used inverse probability weighting to adjust for imbalances in covariates., Results: Of 170,697 patients with evidence of acute diverticulitis, 442 (0.2%) had a history of solid organ transplantation. In the weighted cohort, among people who had not been censored at 1 year (n=515), 112 (22%; 95% CI: 20%-25%) experienced a recurrence within the first year. Solid organ transplantation was not significantly associated with a risk of recurrence (hazard ratio=1.19; 95% CI: 0.94-1.50). There was also no statistically significant difference in the hospitalization rate for recurrent diverticulitis. Restricting the analysis to hospitalized recurrences, there was no statistically significant difference observed in either length of stay or discharge status., Conclusions: In this national analysis of commercially insured patients with acute diverticulitis we found no statistically significant differences in recurrence between those with and without a history of solid organ transplant. We do not support an aggressive colectomy strategy based on concern for increased recurrence rate and severity in a solid organ transplant population., Competing Interests: The authors report no conflicts of interest., (Copyright © 2023 Wolters Kluwer Health, Inc. All rights reserved.)

Background: National guidelines, including the National Accreditation Program for Rectal Cancer, recommend initiation of rectal cancer treatment within 60 days of diagnosis; however, the effect of timely treatment initiation on oncologic outcomes is unclear. The purpose of this study was to evaluate the impact on oncologic outcomes of initiation of rectal cancer treatment within 60 days of diagnosis., Methods: This was a retrospective review of stage II/III rectal cancer patients performed using the United States Rectal Cancer Consortium, a collaboration of 6 academic medical centers. Patients with clinical stage II/III rectal cancer who underwent radical resection between January 1, 2010 and December 31, 2018 were included. The primary exposure was treatment initiation, defined as either resection or initiation of chemotherapy or chemoradiotherapy, within 60 days of diagnosis. The primary outcome was disease recurrence, and the secondary outcome was all-cause mortality., Results: A total of 1,031 patients meeting inclusion criteria were included in the analysis. Treatment was initiated within 60 days of diagnosis in 830 patients (80.5%) and after 60 days in 201 patients (20.3%). In multivariable logistic regression, older age, non-White race, and residence greater than 100 miles from the treatment center were significantly associated with delay in treatment beyond 60 days. In survival analysis, 167 patients (16.2%) experienced recurrent disease, and 127 patients (12.3%) died of any cause. In an adjusted model accounting for pathologic staging, treatment sequence, distance to care, age, comorbidities, treatment center, and receipt of adjuvant chemotherapy, neither progression-free survival nor all-cause mortality was significantly associated with timely initiation of therapy with hazard ratios of 1.09 (0.70, 1.69) and 1.03 (0.63, 1.66), respectively., Conclusion: This study found no difference in oncologic outcomes with initiation of treatment beyond 60 days., (Copyright © 2021 Elsevier Inc. All rights reserved.)

Objective: This study aims to characterize the extent of geographic variation in elective sigmoid resection for diverticulitis and to identify factors associated with observed variation., Introduction: National guidelines for treatment of recurrent diverticulitis fail to offer strong recommendations for or against surgical intervention. We hypothesize that healthcare market factors will be significantly associated with geographic variation in colon resection for diverticulitis, a discretionary surgical intervention., Methods: We used Center for Medicare Services 100% inpatient Limited Data Set (LDS) files from January 2013 through September 2015 to calculate an observed to expected standardized colon resection ratio for each hospital referral region (HRR). We then analyzed patient, hospital-, and market-level factors associated with variation of colectomy. For each HRR, a Herfindahl-Hirschman index, a measure of market competition, was calculated., Results: A total of 19,557 Medicare patients underwent an elective colon resection for diverticulitis at 2462 hospitals over the study period. Standardized colon resection ratios ranged from 0 in the Tuscaloosa HRR to 3.7 in the Royal Oak, MI HRR. Few patient factors were associated with variation, but a number of hospital factors (size, area, profit status, and critical access designation) all were associated with variation. In an analysis of market factors, increased surgeon density, and decreased market competition were associated with higher predicted rates of colon resection., Conclusion: We observed pronounced variation (excess of 3-fold) in standardized colon resection ratios for recurrent diverticulitis. Surgeon density and hospital level factors were strongly associated with this variation and may be the main drivers of colonic resection for diverticular disease. Further investigation and stronger national guidelines are needed to optimize patient selection for colectomy., Competing Interests: The authors declare no conflict of interests., (Copyright © 2020 Wolters Kluwer Health, Inc. All rights reserved.)

Background: The optimal level of pedicle ligation during proctectomy for rectal cancer, either at the origin of the inferior mesenteric artery or the superior rectal artery, is still debated., Objective: The objective was to determine whether superior rectal artery ligation portends equivalent technical or oncologic outcomes., Design: This was a retrospective analysis of a rectal cancer database (2007-2017)., Settings: The study was conducted at 6 tertiary referral centers in the United States (Emory University, University of Michigan, University of Pittsburgh Medical Center, The Ohio State University Wexner Medical Center, Vanderbilt University Medical Center, and Washington University School of Medicine in St. Louis)., Patients: Patients with primary, nonmetastatic rectal cancer who underwent low anterior resection or abdominoperineal resection were included., Main Outcome Measures: Anastomotic leak, lymph node harvest, locoregional recurrence-free survival, recurrence-free survival, and overall survival were measured., Results: Of 877 patients, 86% (n = 755) received an inferior mesenteric artery ligation, whereas 14% (n = 122) received a superior rectal artery ligation. A total of 12%, 33%, 24%, and 31% were pathologic stage 0, I, II, and III. Median follow-up was 31 months. Superior rectal artery ligation was associated with a similar anastomotic leak rate compared with inferior mesenteric artery ligation (9% vs 8%; p = 1.0). The median number of lymph nodes removed was identical (15 vs 15; p = 0.38). On multivariable analysis accounting for relevant clinicopathologic factors, superior rectal artery ligation was not associated with increased anastomotic leak rate, worse lymph node harvest, or worse locoregional recurrence-free survival, recurrence-free survival, or overall survival (all p values >0.1)., Limitations: This was a retrospective design., Conclusions: Compared with inferior mesenteric artery ligation, superior rectal artery ligation is not associated with either worse technical or oncologic outcomes. Given the potential risks of inadequate blood flow to the proximal limb of the anastomosis and autonomic nerve injury, we advocate for increased use of superior rectal artery ligation. See Video Abstract at http://links.lww.com/DCR/B646., Estudio Del Consorcio De Cncer De Recto De Estados Unidos De Ligadura Baja De La Arteria Mesentrica Inferior Contra Ligadura Alta De La Arteria Mesentrica Inferior Qu Tan Alto Debemos Extendernos: ANTECEDENTES:el nivel óptimo de la ligadura del pedículo en la proctectomía para el cáncer de recto, ya sea en el origen de la arteria mesentérica inferior o en la arteria rectal superior aún no esta definido.OBJETIVO:El objetivo era determinar si la ligadura de la arteria rectal superior pronostica resultados técnicos u oncológicos similares.DISEÑO:Análisis retrospectivo de una base de datos de cáncer de recto (2007-2017).ESCENARIO:el estudio se realizó en seis centros de referencia de tercer nivel en los Estados Unidos (Universidad de Emory, Universidad de Michigan, Centro médico de la Universidad de Pittsburgh, Centro médico Wexner de la Universidad Estatal de Ohio, Centro médico de la Universidad de Vanderbilt y Escuela de Medicina de la Universidad de Washington en St. Louis).PACIENTES:Se incluyeron pacientes con cáncer de recto primario no metastásico que se sometieron a resección anterior baja o resección abdominoperineal.PRINCIPALES VARIABLES ANALIZADAS:Se midió la fuga anastomótica, los ganglios linfáticos recuperados, la sobrevida sin recidiva locorregional, la sobrevida sin recidiva y la sobrevida global.RESULTADOS:De 877 pacientes, en el 86% (n = 755) se realizó una ligadura de la arteria mesentérica inferior, y en el 14% (n = 122) se realizó una ligadura de la arteria rectal superior. El 12%, 33%, 24% y 31% estaban en estadio patológico 0, I, II y III respectivamente. La mediana de seguimiento fue de 31 meses. La ligadura de la arteria rectal superior se asoció con una tasa de fuga anastomótica similar a la ligadura de la arteria mesentérica inferior (9 vs 8%, p = 1,0). La mediana del número de ganglios linfáticos extirpados fue idéntica (15 contra 15, p = 0,38). En el análisis multivariado que tiene en cuenta los factores clínico-patológicos relevantes, la ligadura de la arteria rectal superior no se asoció con una mayor tasa de fuga anastomótica, una peor cosecha de ganglios linfáticos o una peor sobrevida libre de recurrencia locorregional, sobrevida libre de recurrencia o sobrevida global (todos p> 0,1).LIMITACIONES:Diseño retrospectivo.CONCLUSIONES:En comparación con la ligadura de la arteria mesentérica inferior, la ligadura de la arteria rectal superior no se asocia a peores resultados técnicos ni oncológicos. Debido a los riesgos potenciales de un flujo sanguíneo inadecuado del muñon proximal de la anastomosis y la lesión de los nervios autonómicos, proponemos una mayor realización de la ligadura de la arteria rectal superior. Consulte Video Resumen en http://links.lww.com/DCR/B646., (Copyright © The ASCRS 2021.)

Introduction: Management of retroperitoneal and lateral pelvic lymph nodes (RLPN) in rectal cancer remains unclear. With total neoadjuvant therapy (TNT), more patients have radiologic complete clinical response (rCR). We sought to evaluate the impact of radiographic persistent RLPN after neoadjuvant therapy on survival., Materials and Methods: Patients with rectal adenocarcinoma with isolated RLPN metastasis, who received neoadjuvant therapy before surgery were included from the United States Rectal Cancer Consortium database. Primary outcomes were recurrence-free survival (RFS) and overall survival (OS)., Results: Of 77 patients, all received neoadjuvant therapy, with 35 (46%) receiving TNT. Posttreatment, 33 (43%) had rCR while 44 (57%) had radiographic persistent RLPN. Median number of radiographic positive RLPN was 1 (IQR 1-2). Receipt of TNT was associated with radiographic RLPN rCR (OR 4.77, 95% CI 1.81-12.60, p < .01). However, there was no difference in RFS and OS between patients who achieved rCR or with persistent RLPN (all p > .05)., Conclusions: Radiographic persistence of RLPN was not associated with worse survival in well-selected patients and may not be a reliable indicator of pathological response. TNT may be the preferred management strategy to select patients given its association with rCR. Radiographic persistence of RLPN after preoperative therapy should not necessarily preclude surgery., (© 2021 Wiley Periodicals LLC.)

Background: The American College of Surgeons (ACS) National Surgical Quality Improvement Program Surgical Risk Calculator (ACS Calculator) provides empirically derived, patient-specific risks for common adverse perioperative outcomes. The ACS Calculator is promoted as a tool to improve shared decision-making and informed consent for patients undergoing elective operations. However, to our knowledge, no data exist regarding the use of this tool in actual preoperative risk discussions with patients. Accordingly, we performed a survey to assess (1) whether patients find the tool easy to interpret, (2) how accurately patients can predict their surgical risks, and (3) the impact of risk disclosure on levels of anxiety and future motivations to decrease personal risk., Methods: Patients (N = 150) recruited from a preoperative clinic completed an initial survey where they estimated their hospital length of stay and personal perioperative risks of the 12 clinical complications analyzed by the ACS Calculator. Next, risk calculation was performed by entering participants' demographics into the ACS Calculator. Participants reviewed their individualized risk reports in detail and then completed a follow-up survey to evaluate their perceptions., Results: Nearly 90% of participants desire to review their ACS Calculator report before future surgical consents. High-risk patients were 3 times more likely to underestimate their risk of any complication, serious complication, and length of stay compared to low-risk patients (P < .001). After reviewing their calculated risks, 70% stated that they would consider participating in prehabilitation to decrease perioperative risk, and nearly 40% would delay their surgery to do so. Knowledge of personal ACS risk calculations had no effect on anxiety in 20% and decreased anxiety in 71% of participants., Conclusions: The ACS Calculator may be of particular benefit to high-risk surgical populations by providing realistic expectations of outcomes and recovery. Use of this tool may also provide motivation for patients to participate in risk reduction strategies.

Background: Resection of T4 colon cancer remains challenging compared to lower T stages. Data on the effect of neoadjuvant radiation to improve resectability and survival are lacking. The purpose of this study is to describe the use and outcomes of neoadjuvant radiation therapy in clinical T4 colon cancer., Methods: Adults with clinical evidence of T4 locally advanced colon cancer were included from the National Cancer Database (2004-2014). Bivariate and multivariable analyses were used to examine the association between neoadjuvant radiation therapy and R 0 resection rate, multivisceral resection, and overall survival., Results: Fifteen thousand two hundred and seven patients with clinical T4 disease who underwent resection were identified over the study period. One hundred ninety-five (1.3%) underwent neoadjuvant radiation therapy. Factors associated with the use of neoadjuvant radiation therapy included younger age, male sex, private insurance, lower Charlson Comorbidity Index score, and treatment at an academic research program. Neoadjuvant radiation therapy was associated with superior R 0 resection rates (87.2% neoadjuvant radiation therapy vs 79.8% no neoadjuvant radiation therapy; P = .009). Five-year overall survival was increased in the neoadjuvant radiation therapy group (62.0% neoadjuvant radiation therapy vs 45.7% no neoadjuvant radiation therapy; P < .001). The benefit of neoadjuvant radiation therapy persisted in a Cox proportional hazards multivariable model containing a number of confounding variables, including comorbidity and postoperative chemotherapy (odds ratio 1.37; 95% confidence interval 1.05-1.77; P = .01). In a subgroup analysis of T4b patients, there was an even greater size effect in adjusted overall survival (odds ratio 1.71; 95% confidence interval 1.07-2.72; P = .02)., Conclusion: Although radiation is rarely used in locally advanced colon cancer, this National Cancer Database analysis suggests that the use of neoadjuvant radiation for clinical T4 disease may be associated with superior R 0 resection rates and improved overall survival. Patients with clinical T4b disease may benefit the most from treatment. Neoadjuvant radiation therapy should be considered on a case-by-case basis in locally advanced colon cancer., (Copyright © 2018 Elsevier Inc. All rights reserved.)

Background: Anal melanoma is a lethal disease, but its rarity makes understanding the behavior and effects of intervention challenging. Local resection and abdominal perineal resection are the proposed treatments for nonmetastatic disease. We hypothesize that there is no difference in overall survival between surgical therapies., Methods: The National Cancer Database (2004-2014) was queried for adults with a diagnosis of anal melanoma who underwent curative resection. Patients with metastatic disease were excluded. Patients were divided into 2 groups based on surgical approach (local resection versus abdominal perineal resection). Unadjusted and adjusted analyses were used to examine the association between surgical approach and R0 resection rate, short-term survival, and overall survival., Results: A total of 570 patients with anal melanoma who underwent resection were identified. The median age was 68 and 59% of patients were female. A total of 383 (67%) underwent local resection. Abdominal perineal resection was associated with higher rates of R0 resection rates (abdominal perineal resection 91% versus local resection 73%; P < .001). Overall 5-year survival for the entire cohort was 20%. There was no significant difference in 5-year overall survival (abdominal perineal resection 21% vs local resection 17%; P = .31). This persisted in a Cox proportional hazard multivariable model (odds ratio 0.84; 95% confidence interval 0.66-1.06; P = .15). Additionally, there was no improvement in overall survival for patients who underwent R0 resection (odds ratio 1.18; 95% confidence interval 0.90-1.56; P = .22)., Conclusion: Anal melanoma has a very poor prognosis, with only 1 of 5 patients alive at 5 years. Although local resection was associated with lower rates of R0 resection, there was no discernable difference in overall survival in both unadjusted and adjusted analysis., (Copyright © 2018 Elsevier Inc. All rights reserved.)

Background: Level one evidence has shown that minimally invasive surgery (MIS) for colon cancer improves short-term outcomes with equivalent long-term oncologic results when compared to open surgery. However, the adoption of MIS for patients with colon cancer has not been universal. The goal of this study is to identify barriers to the use of MIS surgery in colon cancer resection across the United States., Methods: The National Cancer Database was queried for all cases of colonic adenocarcinoma resection from 2010 to 2012. Patients undergoing an MIS approach were compared with those undergoing open surgery (OS). MIS was defined as either robotic or laparoscopic surgery. Patients with metastatic disease, surgery for palliation, or tumors >8 cm were excluded. Multivariable modeling was used to identify variables associated with the use of open surgery., Results: After applying exclusion criteria, 124,205 cases were identified. An MIS approach was used in only 54,621 (44%) patients. In a multivariable model adjusting for stage and tumor size, a number of important factors were associated with decreased odds of a MIS approach including black race (OR .91; p < .0001), lack of insurance (OR .51; p < .0001), lower education (OR .88; p < .0001), lower income (OR .83; p < .0001), treatment at a community program (OR .86; p < .0001), and treatment at a low-volume center (OR .79; p < .0001). Utilization of MIS increased over the study period (2010: 38.7%, 2011: 44.0%, 2012: 49.1%; p < .0001)., Conclusions: MIS approach is utilized in less than half of all colon resections in this national database, which accounts for over 70% of all diagnosed cancers in the US. Significant variability exists among age, race, insurance status, socioeconomic status, region, and facility type. In light of the recognized benefits of the MIS approach, local and national policy should focus on narrowing these disparities and continuing the upward trend of MIS utilization.