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In the pelvis, anatomic complexity and difficulty in visualization and access make surgery a formidable task. Surgeons are prone to work-related musculoskeletal injuries from the frequently poor design and flow of their work environment. This is exacerbated by the strain of surgery in the pelvis. These injuries can result in alterations to a surgeons practice, inadvertent patient injury, and even early retirement. Human factors examines the relationships between the surgeon, their instruments and their environment. By bridging physiology, psychology, and ergonomics, human factors allows a better understanding of some of the challenges posed by pelvic surgery. The operative approach involved (open, laparoscopic, robotic, or perineal) plays an important role in the relevant human factors. Improved understanding of ergonomics can mitigate these risks to surgeons. Other human factors approaches such as standardization, use of checklists, and employing resiliency efforts can all improve patient safety in the operating theatre.

Guidelines recommend adjuvant chemotherapy for stage II colon cancer with high-risk features, but there has been little study on compliance with guidelines. This work sought to evaluate compliance with adjuvant chemotherapy and factors associated with compliance in high-risk stage II colon cancer. This work's hypothesis was that compliance with adjuvant chemotherapy recommendations is low, but improves overall survival when used.The National Cancer Database was reviewed for stage II high-risk colon cancers that underwent curative resection from 2010 to 2017. The cases were stratified into adjuvant chemotherapy and no adjuvant chemotherapy cohorts. A multivariate logistic regression identified factors associated with adjuvant chemotherapy compliance. Propensity-score matching was performed to balance the cohorts and Kaplan-Meier analysis assessed overall survival. The main outcome measures were adjuvant chemotherapy compliance, factors associated with compliance, and overall survival in high-risk stage II colon cancer.A total of 52,609 patients were evaluated, and 23.2% received adjuvant chemotherapy. The factors associated with noncompliance included older age (odds ratio 0.919; 95% confidence interval 0.915-0.922; P.001), Medicaid (odds ratio 0.720; 95% confidence interval 0.623-0.832; P.001) payor, greater comorbidities (odds ratio 0.423; 95% confidence interval 0.334-0.530; P.001), and residing in the Midwest (odds ratio 0.898; 95% confidence interval 0.812-0.994; P = .037). All of the known high-risk features were significantly independently associated with compliance. In a matched cohort, adjuvant chemotherapy significantly improved the 5-year overall survival (78.1% vs 66.6%; P.001).Nationally, there is low compliance with adjuvant chemotherapy in high-risk stage II colon cancer. Despite the low compliance, adjuvant chemotherapy was associated with improved overall survival. Demographic variables were associated with poor compliance, whereas tumor factors were associated with increased compliance. These results highlighted the disparities in care and opportunities to improve outcomes in high-risk stage II colon cancer.

Background Amid increasing awareness of early-onset colorectal cancer (CRC), guidelines in the United States (US) recently lowered the recommended routine CRC screening age from 50 to 45 in average-risk individuals. There are little data on the number of patients in this age group diagnosed with CRC prior to these changes. Our objective was to audit the historic CRC case trends and impact of CRC in the 45-to-50-year-old category prior to new screening recommendations. Methods Colorectal adenocarcinoma cases in 45-to-50-year-old patients were queried from the NCDB (2004–2017). Cases were stratified by sex, race, and site. The disability-adjusted lost years (DALY) and lost earnings were estimated. The average annual percentage changes (AAPC) of CRC incidence were estimated using jointpoint analysis. The main outcome measures were DALY and lost earnings. Secondary outcome measures were the 2004–2017 AAPC and the cumulative incidence of potential CRC cases in the 45-to-50 cohort through 2030 without guideline changes. Results 67,442 CRC patients in the 45-to-50 demographic were identified. The CRC burden resulted 899,905 DALY and $17 billion in lost earnings. The 2004–2017 AAPC was 1.6%, with an estimated 13-year increase of 25%. There were sex-, race-, and anatomic site-specific discrepancies with estimated 13-year increases of 30% for males, 110% for American Indian/ Alaska Natives/ Asian American/ Pacific Islander races, and 31% for rectal cancer by 2030. Conclusion CRC has been steadily increasing in the 45-to-50 age group, with tremendous disability and cost ensuing. There is great potential benefit from lowering the recommended routine CRC screening age to 45. Targeted intervention could ensure the most vulnerable segments benefit from the new guidelines, in both reducing the incidence and improving survivorship in CRC patients. Graphical abstract

Gold standard management of stage III colon cancer includes surgical resection and adjuvant chemotherapy. Despite improved overall survival with adjuvant chemotherapy in stage III colon cancer, it is reportedly underused in older adults. To date, no contemporary national analysis of adjuvant chemotherapy use and its impact in older adults with stage III colon cancer exists.To assess current use of adjuvant chemotherapy in older adults with stage III colon cancer and determine factors associated with noncompliance.Retrospective cohort study.Conducted using the National Cancer Database.Patients 65 years and older undergoing curative resection for stage III colon adenocarcinomas from 2010-2017.Adjuvant chemotherapy use, factors associated with adjuvant chemotherapy use, and overall survival with and without adjuvant chemotherapy in older adults with pathologic stage III disease.Of 64,608 patients included, 64.3% received adjuvant chemotherapy. Adjuvant chemotherapy was significantly independently associated with improved 1-, 3-and 5-year overall survival versus no adjuvant chemotherapy (92.8%, 75.3%, 62.4% vs. 70.8%, 46.6%, 32.7%; respectively, HR 0.475, 95% CI 0.459-0.492, p0.001). Compared with the no adjuvant chemotherapy cohort, patients who received adjuvant chemotherapy were younger, female, and less co-morbid (p0.001). Factors associated with adjuvant chemotherapy noncompliance included advancing age (OR 0.857, 95% CI 0.854-0.861), lower annual income (OR 0.891, 95% CI 0.844-0.940), open approach (0.730, 95% CI 0.633-0.842), longer length of stay (OR 0.949, 95% CI 0.949-0.954), pathologic stage IIIA (0.547, 95% CI 0.458-0.652), and12.Administrative data source with inherent risks of bias, coding errors, and limitations in the fields available for analysis.Adjuvant chemotherapy significantly improved overall survival but was only used in 64.3% of older adults with stage III colon cancer. Adjuvant chemotherapy noncompliance was seen in the most vulnerable and highest risk patients, including those with greater co-morbidity, lower income, and patients who received open surgery. See Video Abstract at http://links.lww.com/DCR/C125.

BACKGROUND: Fluorescence imaging with indocyanine green is increasingly being used in colorectal surgery to assess anastomotic perfusion, and to detect sentinel lymph nodes.METHODS: In this 2-round, online, Delphi survey, 35 international experts were asked to vote on 69 statements pertaining to patient preparation and contraindications to fluorescence imaging during colorectal surgery, indications, technical aspects, potential advantages/disadvantages, and effectiveness versus limitations, and training and research. Methodological steps were adopted during survey design to minimize risk of bias.RESULTS: More than 70% consensus was reached on 60 of 69 statements, including moderate-strong consensus regarding fluorescence imaging's value assessing anastomotic perfusion and leak risk, but not on its value mapping sentinel nodes. Similarly, although consensus was reached regarding most technical aspects of its use assessing anastomoses, little consensus was achieved for lymph-node assessments. Evaluating anastomoses, experts agreed that the optimum total indocyanine green dose and timing are 5 to 10 mg and 30 to 60 seconds pre-evaluation, indocyanine green should be dosed milligram/kilogram, lines should be flushed with saline, and indocyanine green can be readministered if bright perfusion is not achieved, although how long surgeons should wait remains unknown. The only consensus achieved for lymph-node assessments was that 2 to 4 injection points are needed. Ninety-six percent and 100% consensus were reached that fluorescence imaging will increase in practice and research over the next decade, respectively.CONCLUSION: Although further research remains necessary, fluorescence imaging appears to have value assessing anastomotic perfusion, but its value for lymph-node mapping remains questionable.

BACKGROUND Minimally invasive surgery (MIS) is safe and improves outcomes in older persons with rectal cancer but may be underutilized. As older persons are the largest surgical population, investigation of the current use and factors impacting MIS use is warranted. Our goal is to investigate the trends and disparities that affect utilization of MIS in older persons with rectal cancer. METHODS The National Cancer Database was reviewed for persons 65 years and older who underwent curative resection for rectal adenocarcinoma from 2010 to 2017. Cases were stratified by surgical approach (open or MIS [laparoscopic or robotic]). Univariate analysis compared patient and provider demographics across approaches. Multivariate analysis investigated variables associated with MIS use. Main outcome measures were trends and factors associated with MIS use in older persons. RESULTS Of 31,910 patients analyzed, 51.9% (n = 16,555) were open and 48.1% (n = 15,355) MIS. The MIS cohort was 66.7% (n = 10,236) laparoscopic and 33.3% (n = 5119) robotic. MIS increased from 29% in 2010 (n = 1197; 25% laparoscopic, 4% robotic) to 65% in 2017 (n = 2382; 35% laparoscopic, 30% robotic), likely from annual increases in robotics (OR 1.24/year, p

Robotic colorectal surgery has been touted as a possible way to overcome the limitations of laparoscopic surgery and has shown promise in rectal resections, thus shifting traditional open surgeons to a minimally invasive approach. The safety, efficacy, and learning curve have been established for most colorectal applications. With this and a robust sales and marketing model, utilization of the robot for colorectal surgery continues to grow steadily. However, this disruptive technology still requires standards for training, privileging and credentialing, and safe implementation into clinical practice.

Background Single snapshot imaging of optical properties (SSOP) is a relatively new non-invasive, real-time, contrast-free optical imaging technology, which allows for the real-time quantitative assessment of physiological properties, including tissue oxygenation (StO2). This study evaluates the accuracy of multispectral SSOP in quantifying bowel ischaemia in a preclinical experimental model. Methods In six pigs, an ischaemic bowel segment was created by dividing the arcade branches. Five regions of interest (ROIs) were identified on the bowel loop, as follows: ROI 1: central ischaemic; ROI 2: left marginal; ROI 3: left vascularised; ROI 4: right marginal; and ROI 5: right vascularised. The Trident imaging system, specifically developed for real-time tissue oxygenation imaging using SSOP, was used to image before (T0) and after ischaemia induction. Capillary and systemic lactates were measured at each time point (T0, T15, T30, T45, T60), as well as StO2 values acquired by means of SSOP (SSOP-StO2). Results The mean value of SSOP-StO2 in ROI 1 was 30.08 ± 6.963 and was significantly lower when compared to marginal ROIs (ROI 2 + ROI 4: 45.67 ± 10.02 p = < 0.0001), and to vascularised ROIs (ROI 3 + ROI 5: 48.08 ± 7.083 p = < 0.0001). SSOP-StO2 was significantly correlated with normalised lactates r = − 0.5892 p < 0.0001 and with histology r =− 0.6251 p = 0.0002. Conclusion Multispectral SSOP allows for a contrast-free accurate assessment of small bowel perfusion identifying physiological tissue oxygenation as confirmed with perfusion biomarkers.

Despite recent technological progress in surgical guidance, current intraoperative assessment of tissue that should be removed (e.g., cancer) or avoided (e.g., nerves) is still performed subjectively. Optical imaging is a non-contact, non-invasive modality that has the potential to provide feedback regarding the condition of living tissues by imaging either an exogenously administered contrast agent or endogenous constituents such as hemoglobin, water, and lipids. As such, optical imaging is an attractive modality to provide physiologically and structurally relevant information for decision-making in real-time during surgery. The Trident imaging platform has been designed for real-time surgical guidance using state-of-the-art optical imaging. This platform is capable of dual exogenous and endogenous imaging owing to a unique filter and source combination, allowing to take advantage of both imaging modalities. This platform makes use of a real-time and quantitative imaging method working in the spatial frequency domain, called Single Snapshot imaging of Optical Properties (SSOP). The Trident imaging platform is designed to comply with all relevant standards for clinical use. In this manuscript, we first introduce the rationale for developing the Trident imaging platform. We then describe fluorescence and endogenous imaging modalities where we present the details of the design, assess the performance of the platform on the bench. Finally, we perform the validation of the platform during an in vivo preclinical experiment. Altogether, this work lays the foundation for translating state-of-the-art optical imaging technology to the clinic.

Patient safety and outcomes are directly related to surgical performance. Surgical training emphasizes the importance of the surgeon in determining these outcomes. After training is complete, there is a lack of structured programs for surgeons to audit their skills and continue their individual development. There is a significant linear relationship between surgeon technical skill and surgical outcomes; however, measuring technical performance is difficult. Video-based coaching matches an individual surgeon in practice with a surgical colleague who has been trained in the core principles of coaching for individualizing instruction. It can provide objective assessment for teaching higher-level concepts, such as technical skills, cognitive skills, and decision-making. There are many benefits to video-based coaching. While the concept is gaining acceptance as a method of surgical education, it is still novel in clinical practice. As more surgeons look towards video-based coaching for quality improvement, a consistent definition of the program, goals, and metrics for assessment will be critical. This paper is a review on the status of the video-based coaching as it applies to practicing surgeons.

Surgery is a common gateway to opioid-related morbidity. Ambulatory anorectal cases are common, with opioids widely prescribed, but there is limited data on their role in this crisis. We sought to determine prescribing trends, new persistent opioid use rates, and factors associated with new persistent opioid use after ambulatory anorectal procedures.The Optum Clinformatics claims database was analyzed for opioid-naïve adults undergoing outpatient hemorrhoid, fissure, or fistula procedures from January 1, 2010, to June 30, 2017. The main outcome measure was the rate of new persistent opioid use after anorectal cases. Secondary outcomes were annual rates of perioperative opioid fills and the prescription size over time (oral morphine equivalents).A total of 23,426 cases were evaluated: 69.09% (n = 16,185) hemorrhoids, 24.29% (n = 5,690) fissures, and 6.45% (n = 1,512) fistulas. The annual rate of perioperative opioid fills decreased on average 1.2%/year, from 72% in 2010 to 66% in 2017 (P.001). Prescribing rates were consistently highest for fistulas, followed by hemorrhoids, then fissures (P.001). There was a significant reduction in prescription size (oral morphine equivalents) over the study period, with median oral morphine equivalents (interquartile range) of 280 (250-400) in 2010 and 225 (150-375) in 2017 (P.0001). Overall, 2.1% (n = 499) developed new persistent opioid use. Logistic regression found new persistent opioid use was associated with additional perioperative opioid fills (odds ratio 3.92; 95% confidence interval: 2.92-5.27; P.0001), increased comorbidity (odds ratio 1.15; confidence interval: 1.09-1.20; P.00001), tobacco use (odds ratio 1.79; confidence interval: 1.37-2.36; P.0001), and pain disorders (odds ratio, 1.49; confidence interval, 1.23-1.82); there was no significant association with procedure performed.Over 2% of ambulatory anorectal procedures develop new persistent opioid use. Despite small annual reductions in opioid prescriptions, there has been little change in the amount prescribed. This demonstrates a need to develop and disseminate best practices for anorectal surgery, focusing on eliminating unnecessary opioid prescribing.

There is a paradigm shift in surgical training, and new tool and technology are being used to facilitate mastery of the content and technical skills. The transanal procedures for rectal cancer—transanal endoscopic surgery (TES) and transanal total mesorectal excision (TaTME)—have a distinct learning curve for competence in the procedures, and require special training for familiarity with the “bottom-up” anatomy, procedural risks, and managing complex cases. These procedures have been models for structured education and training, using multimodal tools, to ensure safe implementation of TES and TaTME into clinical practice. The goal of this work was to review the current state of surgical education, the introduction and learning curve of the TES and TaTME procedures, and the established and future models for education of the transanal procedures for rectal cancer.

The circumferential resection margin (CRM) is a primary predictor of local recurrence and survival in rectal cancer, and an important consideration in guiding treatment. CRM is usually predicted preoperatively, so optimal management of an unexpected pathologic positive CRM involvement is debatable. We aimed to investigate the postoperative management of T3N0 rectal cancers with a positive pathologic CRM, and the impact of each strategy on survival.The NCDB was reviewed for pathological T3N0 rectal cancer cases from 2010 to 2015, that received neoadjuvant chemotherapy, had surgical resection with pathological clear margins, but a positive pathologic CRM(disease≤2 mm from radial margin). The main outcomes were the incidence, treatment modalities used, and impact of each modality on survival. Univariate analysis evaluated the demographic and provider characteristics across treatment groups. Kaplan-Meier and Cox regression analysis assessed survival and factors associated with overall survival (OS).Of 1607 cases with a positive CRM, 65% (1045) received no adjuvant treatment and 35% (n = 562) received adjuvant chemotherapy (AC). After matching, the 1-, 3-, and 5-year OS rates were 98.5%, 88.6% and 76.6% for AC and 96.9%, 84.6% and 68.4% for with no treatment (p = .027). Factors independently associated with improved OS were treatment at an academic/research facility (p = .009), minimally invasive approach (p = .005), well and moderately differentiated tumor (p .001), absence of perineural invasion (p = .015) and AC administration (p = .047).In T3N0 rectal cancers resected with local clear margins but a positive pathologic CRM, AC improved OS. However, only a third received this option. Further study is needed to investigate the disparities in AC use in these patients with unexpected pathologic results.

BACKGROUND Anorectal cases may be a common gateway to the opioid epidemic. Opioid reduction is inherent in enhanced recovery after surgery (ERAS) protocols, but little work has evaluated ERAS in these cases. OBJECTIVE To determine if ERAS could reduce postoperative opioid utilization in ambulatory anorectal surgery without sacrificing patient pain or satisfaction. METHODS A randomized controlled trial assigned ambulatory anorectal patients to ERAS (experimental) or routine care (surgeon's choice) for pain management (control) over 30-days postoperatively. Primary outcome was overall days of opioid use. Secondary outcomes included pain and satisfaction scores over multiple time points and new persistent opioid use. The Visual Analog Scale, Functional Pain Scale, and EQ-5D-3L measured patient-reported pain and satisfaction. Univariate analysis compared outcomes overall and at individual time points. Two-way mixed ANOVA evaluated pain and satisfaction measures between groups and over time. RESULTS Thirty-two patients were randomized into each arm (64 total). The control group consumed significantly more opioids after discharge(median 121.3MME vs 23.5MME, P < 0.001). Significantly more control patients requested additional narcotics (P = 0.004), made unplanned calls (P = 0.009), and had unplanned clinic visits (P = 0.003). The control group had significantly more days on opioids (mean 14.4 vs 2.2, P < 0.001). Three control patients (9.4%) versus no experimental patients had new persistent opioid use. The mean global health, EQ5D-3L, Visual Analog Scale, and Functional Pain scores were comparable between groups over time. CONCLUSIONS An ERAS protocol in ambulatory anorectal surgery is feasible, and resulted in reduced opioid use, and healthcare utilization, with no difference in pain or patient satisfaction. This challenges the paradigm that extended opioids are needed for effective postoperative pain management.

BACKGROUND There is wide variation in gender distribution in colorectal surgery across different European countries. OBJECTIVE This study aimed to evaluate female representation, implicit bias, and members' perception on female participation and representation at the European Society of Coloproctology 2017 annual scientific meeting. DESIGN This was a retrospective mixed-methods cross-sectional observational study. SETTINGS The study was conducted using data from the 2017 European Society of Coloproctology annual scientific meeting program and attendees. MAIN OUTCOME MEASURES The primary outcome measure was the percentage of female speakers in the formal program and assessment for implicit bias. Secondary outcomes were the percentage of women attending the conference, the percentage of women serving on committees, and the results of the online survey. METHODS Female representation was retrospectively quantified by role, session type, and topic. Implicit bias was measured classifying the introductions of speakers by moderators as formal (using a professional title) or informal (using name only), then further stratified by gender. An online survey was disseminated and analyzed to investigate the members' perception as a benchmark analysis. RESULTS Disparities were found between sexes, with fewer women attending the conference (25%), serving as session chairs (8%), speakers (21%), and on committees (10%) compared with men. There were no differences across sexes regarding the formal or informal introduction. The survey among our members showed that significantly fewer women felt equally endorsed within the society compared with men (33% versus 63%; p < 0.001). LIMITATIONS The retrospective design with data available to be analyzed was limited by the sessions recorded (27/49) and survey respondents (28%). CONCLUSIONS Female representation within European Society of Coloproctology as chair, speaker, attendee, and committee member was much lower than male representation, both in absolute numbers and relative to membership. Greater awareness of this disparity and inclusiveness are aims of our society. The impact of these initiatives will be determined by reevaluating these metrics at the 2020 annual meeting. See Video Abstract at http://links.lww.com/DCR/B384. REPRESENTACIN Y POSICIN FEMENINA EN LA SOCIEDAD EUROPEA DE COLOPROCTOLOGA BASADA EN LOS HECHOS Y LAS OPINIONES DE SUS MIEMBROS ANTECEDENTES:Existe una amplia variabilidad en la distribucion de generos en la cirugia colorrectal en los diferentes paises de Europa.OBJETIVO:Evaluar la representacion femenina, el sesgo implicito y la percepcion de los miembros sobre la participacion y representacion femenina en el 12° Congreso cientifico anual de la Sociedad Europea de Coloproctologia.DESIGN:Este fue un estudio observacional retrospectivo de metodos mixtos transversales.AJUSTES:Los analisis se realizaron utilizando los datos del programa cintifico de la reunion y los datos de los presentes en el Congreso de la ESCP en 2017.MEDIDAS PRINCIPALES DE RESULTADOS:La principal medida en el resultado fue el porcentaje de disertantes femeninas en el programa definitivo y la evaluacion del sesgo implicito. Los resultados secundarios fueron el porcentaje de mujeres que asistieron a la conferencia, trabajaron en los comites y los resultados de la encuesta informatica.METODOS:La representacion femenina se cuantifico retrospectivamente segun el rol, tipo de sesion y temas. Se midio el sesgo implicito clasificando las introducciones de los disertantes por parte de los moderadores de manera formal (usando un titulo profesional) o informal (usando solamente el nombre), y luego fueron estratificadas por genero. Se difundio y analizo una encuesta informatica para investigar la percepcion de los miembros como analisis de referencia.RESULTADOS:Se encontraron disparidades de genero, con menos mujeres presentes en la conferencia (25%), obrando como presidentes de sesion (8%), como disertantes (21%) y como miembros de comites (10%) comparadas con los hombres. No hubo diferencia entre sexos con respecto a la introduccion formal o informal. La encuesta informatica entre los miembros mostro significativamente que menos mujeres se sentian respaldadas igualitariamente dentro de la sociedad comparadas con los hombres (33% frente a 63%, p

BACKGROUND Despite common beliefs, underuse of laparoscopic colorectal surgery remains an issue. A paradigm shift to increase laparoscopy and align payment with effort is needed, with pressures to improve value. OBJECTIVE The purpose of this study was to compare reimbursement across surgical approach and payer for common colorectal procedures and to propose a novel way to increase use in the United States. DATA SOURCES Centers for Medicare & Medicaid Services (Medicare) reimbursement and commercial claims data from 2012 to 2015 were used. STUDY SELECTION Reimbursement across payers was mapped for the 10 most common colorectal procedures using the open and laparoscopic approaches. MAIN OUTCOME MEASURES The reimbursement difference across approaches by payer and potential value proposition from a cost-shifting model increasing reimbursement with corresponding increases in laparoscopic use was measured. RESULTS For Medicare, reimbursement was lower laparoscopically than open for the majority. With commercial, laparoscopy was reimbursed less for 3 procedures. When laparoscopic reimbursement was higher, the amount was not substantial. Medicare payments were consistently lower than commercial, with corresponding lower reimbursement for laparoscopy. Increasing reimbursement by 10%, 20%, and 30% resulted in significant cost savings with laparoscopy. Savings were amplified with increasing use, with additional savings over baseline at all levels, except 30% reimbursement/10% increased use. LIMITATIONS The study was limited by the use of claims data, which could have coding errors and confounding in the case mix across approaches. CONCLUSIONS Reimbursement for laparoscopic colorectal surgery is comparatively lower than open. Reimbursement can be increased with significant overall cost savings, as the reimbursement/case is still less than total cost savings with laparoscopy compared with open cases. Incentivizing surgeons toward laparoscopy could drive use and improve outcomes, cost, and quality as we shift to value-based payment. See Video Abstract at http://links.lww.com/DCR/B290. CAMBIOS EN LOS PARADIGMAS DE REEMBOLSOS MEDICOS: UN MODELO PARA ALINEAR EL REEMBOLSO AL VALOR REAL DE LA CIRUGIA COLORRECTAL LAPAROSCOPICA EN LOS ESTADOS UNIDOS: A pesar de las creencias comunes, la subutilizacion de la cirugia colorrectal laparoscopica sigue siendo un problema. Se necesita un cambio en los paradigmas para aumentar y alinear el rembolso de la laparoscopia aplicando mucho esfuerzo para obtener una mejoria en su valor real.Comparar los reembolsos del abordaje quirurgico y los de la administracion para procedimientos colorrectales comunes y proponer una nueva forma de aumentar su uso en los Estados Unidos.Reembolsos en los Centros de Servicios de Medicare y Medicaid (Medicare) y los datos de reclamos comerciales encontrados de 2012-2015.El reembolso administrativo se mapeo para los diez procedimientos colorrectales mas comunes utilizando los enfoques abiertos y laparoscopicos.Diferencias de reembolso entre los enfoques por parte de la administracion y la propuesta de valor real de un modelo de cambio de costos que aumentan el reembolso con los aumentos correspondientes si se utiliza la laparoscopia.Para Medicare, el reembolso fue menor para una mayoria por via laparoscopica que abierta. Comercialmente, la laparoscopia se reembolso menos por 3 procedimientos. Cuando el reembolso laparoscopico fue mayor, la cantidad no fue sustancial. Los pagos de Medicare fueron consistentemente mas bajos que los pagos comerciales, con el correspondiente reembolso mas bajo por laparoscopia. El aumento del reembolso en un 10%, 20% y 30% resulto en ahorros de costos significativos con la laparoscopia. Los ahorros se amplificaron con el aumento de la utilizacion, con ahorros adicionales sobre la linea de base en todos los niveles, excepto el 30% de reembolso / 10% de mayor uso.Uso de datos de reclamos, que podrian tener errores de codificacion y confusion en la combinacion de casos entre enfoques.El reembolso por la cirugia colorrectal laparoscopica es comparativamente mas bajo que el abordaje abierto. El reembolso se puede aumentar con ahorros significativos en los costos generales, ya que el reembolso / caso es aun menor que el ahorro total en los costos de la laparoscopia en comparacion con los casos abiertos. Incentivar a los cirujanos hacia la laparoscopia podria impulsar la utilizacion y mejorar los resultados, el costo y la calidad a medida que se pasa al pago basado en el valor real. Consulte Video Resumen en http://links.lww.com/DCR/B290. (Traduccion-Dr Xavier Delgadillo).

In the United States, colorectal cancer (CRC) screening and surveillance is recommended until age 75. However, rates of surgery for CRC are greatest in the elderly, questioning current guidelines. Tumor sidedness is an emerging prognostic marker that may help guide screening and treatment decisions, with specific benefit evaluating CRC anatomic distribution in the elderly. Our objective was to investigate the anatomical distribution of CRC in the elderly and factors associated with right-sidedness. The National Cancer Database (2004–2016) was used to identify elderly patients with CRC. Cases were stratified by tumor sidedness and elderly subgroups: 65–74, 75–84, and ≥ 85 years of age, and further categorized by primary site. Multivariate analysis identified factors associated with CRC right-sidedness. The outcomes were CRC sidedness in the elderly, the anatomic distribution by age group, and factors associated with right-sidedness. There were 508,219 colorectal cancer patients aged over 65 years identified, 54% of whom had a right-sided cancer. The right-sided incidence rates by age group were 49% (65–74 years), 58.2% (75–84 years), and 65.9% (≥ 85 years) (p 5 cm (OR 1.474; 95% CI 1.453–1.495; p

Background: Ileal pouch-anal anastomosis (IPAA) for ulcerative colitis (UC) can be performed as either 2- or 3-stage procedure. IPAA in the elderly has been reported as safe and feasible, but little work to date has assessed outcomes by procedure. The aim of our study was to assess use and short-term outcomes of 2- and 3-stage IPAA in older adults. Methods: The American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) Database was searched for ≥ 65-year-old patients who underwent IPAA for UC in 2- or 3-stage from 2012 to 2016. The primary endpoint was the rate and trends of the two approaches over time. Secondary endpoints included 30-day adverse events and complication-associated costs. Results: Overall, 123 patients were included: 77.5% (n = 83) 2-stage and 40 (32.5%) 3-stage IPAA. Mean age was 68.7 ± 3.9years, with 43 (34.9%) women. The use of the 3-stage IPAA increased over time (18.8% in 2012 vs. 33.3% in 2016), with decreasing use of 2-stage IPAA (81.3% vs. 66.7%, p < 0.001). The morbidity associated with the procedures decreased over time, overall (81.3% in 2012 and 51.5% in 2016, p < 0.001) and in each group individually. No differences were observed in postoperative complications across groups (45.8% 2-stage, 32.5% 3-stage). The overall mean costs of care when no postoperative complications occurred was $25,910, vs. $38,577 when any complication occurred (p < 0.001), but no differences were observed between groups. Conclusion: In a national analysis, there was a trend of increasing 3-stage vs. 2-stage IPAA for UC in older Americans. Complications and complication-associated costs were comparable across approaches, suggesting that the choice of procedure type should be based on the specific patient comorbidities and surgeon preferences.

Background Frailty is associated with advancing age and may result in adverse postoperative outcomes. A suspected growing elderly population needing emergency colorectal surgery stimulated this study of the prevalence and impact of frailty. Methods Elderly patients (defined as aged at least 65 years by Medicare and the United States Census Bureau) who underwent emergency colorectal resection between 2012 and 2016 were identified from the American College of Surgeons National Surgical Quality Improvement Program population database. The five-item modified frailty index (mFI-5) score was calculated, and patients stratified into groups 0, 1 or 2 +. Main outcome measures were the prevalence of frailty, and its impact on 30-day postoperative morbidity, mortality, reoperation, duration of hospital stay (LOS), discharge destination and readmission. Results A total of 10 025 patients were identified with a median age 75 years, of whom 41·8 per cent were men. The majority (87·7 per cent) had an ASA fitness grade of III or greater and 3129 (31·2 per cent) were frail (mFI-5 group 2+). Major morbidity occurred in one-third of patients and the postoperative mortality rate was 15·9 per cent. Some 52·0 per cent of patients had a prolonged hospital stay and 11·0 per cent were readmitted. Although most patients (88·0 per cent) lived independently before surgery, only 45·4 per cent were discharged home directly. Frailty (mFI-5 2+) predicted mortality, overall and major morbidity, reoperation, prolonged LOS, discharge to an institution and readmission, but frailty was independent of sex. Conclusion Frailty is associated with morbidity, mortality and loss of independence in elderly patients needing emergency colorectal surgery.

Novel quality improvement(QI) methods are needed to optimize healthcare costs and value. Our goal was to determine if Statistical Process Control(SPC), an industrial QI tool, could transform length of stay(LOS) into a process measure, identify outliers, and their impact on surgical outcomes.SPC was performed on an institutional colorectal resection database 1/1/13-5/1/2018 to identify outliers and compare outcome variables across outliers and non-outliers. Control charts analyzed the process performance of LOS over time. Control limits were set at ± 1 standard deviation(SD) from the mean. Measures were stable within these limits.LOS was stable, with consistent annual rates and variation of outliers. Outliers had identifiable causes of variation that were significantly different from non-outliers(p 0.05). The variation resulted in more complications, readmissions, and reoperations in outliers(p 0.05).SPC can be applied to LOS, a stable process measure with decreasing variability over time, and easy outlier identification. Identifying outliers can facilitate targeted quality improvement.

The elderly constitute the majority of both colorectal cancer and surgical volume. Despite established safety and feasibility, laparoscopy may remain underutilized for colorectal cancer resections in the elderly. With proven benefits, increasing laparoscopy in elderly colorectal cancer patients could substantially improve outcomes. Our goal was to evaluate utilization and outcomes for laparoscopic colorectal cancer surgery in the elderly. A national inpatient database was reviewed for elective inpatient resections for colorectal cancer from 2010 to 2015. Patients were stratified into elderly (≥ 65 years) and non-elderly cohorts (

Background Reliable, easily accessible metrics of surgical quality are currently lacking. The HARM (HospitAl length of stay, Readmission and Mortality) score is a composite measure that has been validated across diverse surgical cohorts. The aim of this study was to validate the HARM score in a national population of patients undergoing abdominal surgery. Methods Data on all abdominal surgery in Norwegian hospitals from 2011 to 2017 were obtained from the Norwegian Patient Registry. Readmissions and 30‐day postoperative complications as well as deaths in and out of hospital were evaluated. The HARM scoring algorithm was tested after adjustment by establishing a newly proposed length of stay score. The correlation between the HARM score and complications, as well as the ability of aggregated HARM scores to discriminate between hospitals, were analysed. Risk adjustment models were developed for nationwide hospital comparisons. Results The data consisted of 407 113 primary operations on 295 999 patients in 85 hospitals. The HARM score was associated with complications and complication severity (Goodman–Kruskal γ value 0·59). Surgical specialty was the dominating variable for risk adjustment. Based on 1‐year data, the risk‐adjusted score classified 16 hospitals as low HARM score and 16 as high HARM score of the 53 hospitals that had at least 30 operations. Conclusion The HARM score correlates with major outcomes and is associated with the presence and severity of complications. After risk adjustment, the HARM score discriminated strongly between hospitals in a European population of abdominal surgery., The HARM score, calculated from length of stay, readmissions and postoperative mortality, was studied in a national gastrointestinal surgical population. It was found to be associated with complications and could differentiate between hospitals. benchmark in abdominal surgery

Rectal cancer treatment has evolved during the past 40 years with the use of a standardized surgical technique for tumour resection: total mesorectal excision. A dramatic reduction in local recurrence rates and improved survival outcomes have been achieved as consequences of a better understanding of the surgical oncology of rectal cancer, and the advent of adjuvant and neoadjuvant treatments to compliment surgery have paved the way for a multidisciplinary approach to disease management. Further improvements in imaging techniques and the ability to identify prognostic factors such as tumour regression, extramural venous invasion and threatened margins have introduced the concept of decision-making based on preoperative staging information. Modern treatment strategies are underpinned by accurate high-resolution imaging guiding both neoadjuvant therapy and precision surgery, followed by meticulous pathological scrutiny identifying the important prognostic factors for adjuvant chemotherapy. Included in these strategies are organ-sparing approaches and watch-and-wait strategies in selected patients. These pathways rely on the close working of interlinked disciplines within a multidisciplinary team. Such multidisciplinary forums are becoming standard in the treatment of rectal cancer across the UK, Europe and, more recently, the USA. This Review examines the essential components of modern-day management of rectal cancer through a multidisciplinary team approach, providing information that is essential for any practising colorectal surgeon to guide the best patient care. Rectal cancer treatment has evolved towards a multidisciplinary approach to disease management. This Review examines the essential components of rectal cancer management through a multidisciplinary team, with a focus on the effect of this approach and the elements used for staging and developing the treatment plan.

As one of the 12 clinical pathways of the Society of American Gastrointestinal and Endoscopic Surgeons (SAGES) Masters Program, the Colorectal Pathway intends to deliver didactic content organized along 3 levels of performance (competency, proficiency and mastery) each represented by an anchoring procedure (laparoscopic right colectomy, laparoscopic left/sigmoid colectomy, and intracorporeal anastomosis during minimally invasive (MIS) ileocecal or right colon resection). In this article, the SAGES Colorectal Task Force presents focused summaries of the top 10 seminal articles selected for laparoscopic right colectomy which surgeons should be familiar with.Using a systematic literature search of Web of Science, the most cited articles on laparoscopic right colectomy were identified, reviewed, and ranked by the SAGES Colorectal Task Force and invited subject experts. Additional articles not identified in the literature search were included if deemed impactful by expert consensus. The top 10 ranked articles were then summarized, with emphasis on relevance and impact in the field, findings, strengths and limitations, and conclusions.The top 10 seminal articles selected for the laparoscopic right colectomy anchoring procedure include articles on surgical techniques for benign and malignant disease, with anatomical and video illustrations, comparative outcomes of laparoscopic vs open colectomy, variations in technique with impact on clinical outcomes, and assessment of the learning curve.The top 10 seminal articles selected for laparoscopic right colectomy illustrate the diversity both in content and format of the educational curriculum of the SAGES Masters Program to support practicing surgeon progression to mastery within the Colorectal Pathway.

Background From clinical experience, many patients undergoing robotic assisted surgery (RAS) have a poor understanding of the technology. To ensure informed consent and appropriate expectations, a needs assessment for patient-centered education and outcome metrics in RAS is warranted. Our goal was to perform an assessment of patient understanding, comfort with robotic technology, and ability to obtain critical information from their surgeon when undergoing RAS. Methods Twenty patients planned for RAS by three surgeons were asked to complete a six-item Likert agreement scale survey prior to signing informed consent. The study coordinator administered surveys, while the surgeon left the room. Indicator statements were crafted to reduce bias and two-way evaluated for consistency. The surgeons were additionally asked their perception of each patient’s understanding and comfort with RAS. Frequency statistics and tendencies were analyzed. Results Surgeons strongly agreed all patients appropriately understood how RAS functioned and would ask more questions before signing consent, if needed. Patients were predominately not familiar with RAS and felt surgeons did not explain how RAS worked. There was wide variability on if patients understood how RAS worked for their treatment. Overall, patients were not completely comfortable with RAS for their care, did not understand the risks of RAS compared to other approaches, and did not feel their surgeon understood what they needed to know to make informed decisions. Conclusions This needs assessment demonstrated critical gaps in patient knowledge about RAS, surgeon communication skills, and the ability of surgeons to know what was important from the patient perspective. The development of RAS patient-centered education and outcome metrics could help address these gaps.

Background Decision-making under uncertainty may be influenced by an individual’s personality. The primary aim was to explore associations between surgeon personality traits and colorectal anastomotic decision-making. Methods Colorectal surgeons worldwide participated in a two-part online survey. Part 1 evaluated surgeon characteristics using the Big Five Inventory to measure personality (five domains: agreeableness; conscientiousness; extraversion; emotional stability; openness) in response to scenarios presented in Part 2 involving anastomotic decisions (i.e. rejoining the bowel with/without temporary stomas, or permanent diversion with end colostomy). Anastomotic decisions were compared using repeated-measure ANOVA. Mean scores of traits domains were compared with normative data using two-tailed t tests. Results In total, 186 surgeons participated, with 127 surgeons completing both parts of the survey (68.3 per cent). One hundred and thirty-one surgeons were male (70.4 per cent) and 144 were based in Europe (77.4 per cent). Forty-one per cent (77 surgeons) had begun independent practice within the last 5 years. Surgeon personality differed from the general population, with statistically significantly higher levels of emotional stability (3.25 versus 2.97 respectively), lower levels of agreeableness (3.03 versus 3.74), extraversion (2.81 versus 3.38) and openness (3.19 versus 3.67), and similar levels of conscientiousness (3.42 versus 3.40 (all P Conclusion Colorectal surgeons have different personality traits from the general population. Certain traits seem to be associated with anastomotic decision-making but only in specific scenarios. Further exploration of the association of personality, risk-taking, and decision-making in surgery is necessary.

Despite advances in rectal cancer surgery, anastomotic leakage (AL) remains a common complication with a significant impact on patient recovery, health care costs, and oncologic outcomes. The spectrum of clinical severity associated with AL is broad, and treatment options are diverse with highly variable practices across the colorectal community. To be effective, the treatment must match not only the patient's current status but also the type of leak, the surgeon's skill, and the resources available. In this chapter, we will review the current and emergent treatment modalities for AL after rectal cancer surgery.

AIM Stage II colon cancers are a heterogeneous category, with controversy over use of adjuvant chemotherapy (AC). Patients with high-risk features may benefit from AC to improve overall survival (OS). Current guidelines do not routinely recommend AC in low-risk cases, but the actual use and benefit on OS in this cohort have not been fully examined on a national scale. We aimed to evaluate the use and impact of AC on OS in low-risk Stage II colon cancer. METHODS The national cancer database was reviewed for Stage II colon cancers undergoing curative resection (2010-2015). Cases with preoperative radio-chemotherapy or high-risk features were excluded. Cases were stratified into 'AC' and 'no AC' cohorts, and then propensity score matched. Kaplan-Meier and Cox regression analysed OS. The main outcome measures were the incidence and impact of AC on OS in low-risk Stage II colon cancer. RESULTS Of 39 926 patients evaluated, 8.2% (n = 3275) received AC. Matching resulted in 3275 cases per cohort. AC significantly improved 1-, 3- and 5-year OS versus no AC (P = 0.0017). The 5-year absolute risk reduction was 2.6%, relative risk reduction 12%, with a number needed to treat of 38. In the Cox model, AC remained significantly associated with increased OS (hazard ratio 0.816; 95% CI 0.713-0.934; P

Objectives and settingThe aim of this study was to create a hashtag #SoMe4Surgery on the social network application Twitter, and to examine the natural history of the resulting online community.Design and outcome measuresA prospective, four-stage framework was proposed and used: (1) inception phase (connection): users were actively invited to participate; (2) dissemination phase (contagion): several tweetchats were designed, scheduled and run; (3) adherence phase (feedback): Twitonomy and NodeXL summaries were regularly posted on Twitter; and (4) impact phase (outcomes): abstracts and manuscripts, and related projects on Twitter. Tweets, influencers and interactions were analysed, and a brief survey was shared with participants to assess demographics and motivations of social media use.ParticipantsUsers engaging with the #SoMe4Surgery hashtag.ResultsUsers of the hashtag came from a wide variety of specialties and geographical locations, as well as varying in age and stage of training. The inception of #SoMe4Surgery was followed by an increase in the follower count and impressions of users. A total of 675 tweeters posted 11 855 tweets with 30 122 retweets between 28 July and 27 December inclusive. There were new contributors and activity throughout the period. There were many more retweeters than accounts posting original content. Over a 10-day period ending on 31 December 2018, the number of followers of the 10 most influential accounts was higher than the number of followers of the 10 most engaging accounts (p=0.002). The mean (SD) number of tweetchat participants was 121 (64), who posted 719 (365) tweets and had a potential reach of 3 825 155 (1 887 205) accounts. Spin-off projects included surveys from low and medium-income countries, subspecialised hashtags, presentations and one publication.ConclusionsThe creation of a cohesive online surgical community may allow a flattened hierarchy, with increased engagement between surgeons, other healthcare professionals, researchers and patients.

Background Bevacizumab is used for the treatment of metastatic colon cancer in conjunction with first-line chemotherapy. In this study, we examined receipt of first-line bevacizumab and predictors of its use among older patients with stage IV colon cancer. Materials and Methods We used data from the Surveillance, Epidemiology, and End Results-Medicare dataset to identify patients with stage IV colon cancer diagnosed from 2005 to 2013 who received FOLFOX (5-fluorouracil/leucovorin/oxaliplatin) or FOLFIRI (5-fluorouracil/leucovorin/irinotecan) as first-line therapy. We used multivariable regression analysis to determine demographic and clinical factors associated with use of concomitant bevacizumab. Results We identified 3785 patients with stage IV colon cancer who met our eligibility criteria. Of these, 2352 (62.1%) received bevacizumab. Bevacizumab use has decreased over time from 68.2% in 2005 to 57.6% in 2013 (odds ratio [OR], 0.94; 95% confidence interval [CI], 0.91-0.97). Patients were less likely to receive bevacizumab if they were older (compared with 65-69 years, ≥ 80 years: OR, 0.64; 95% CI, 0.52-0.80), or had multiple comorbidities (compared with comorbidity score of 0, score of 1: OR, 0.73; 95% CI, 0.60-0.89). Conclusion Over one-half of elderly patients received bevacizumab as part of their first-line therapy for stage IV colon cancer. Bevacizumab use has been slowly decreasing since 2005. Newer anti-epidermal growth factor receptor treatments have not been supplanting bevacizumab, as first-line biologic use in general has also decreased during this time period.

The benefits of enhanced recovery program (ERP) implementation include patient engagement, improved patient outcomes and satisfaction, better team relationships, lower per episode costs of care, lower public consumption of narcotic prescription pills, and the promise of greater access to quality surgical care. Despite these positive attributes, vast numbers of surgical patients are not treated on ERPs, and many of those considered “on pathway” are unlikely to be exposed to a majority of recommended ERP elements. To explain the gap between ERP knowledge and action, this manuscript reviewed formal implementation strategies, proposed a novel change adoption model and focused on common barriers (and corollary solutions) that are encountered during the journey to a fully implemented and successful ERP. Given the nature of this review, IRB approval was not required/obtained. The information reviewed indicates that implementation of best practice is both a science and an art. What many surgeons have learned is that the “soft” skills of emotional intelligence, leadership, team dynamics, culture, buy-in, motivation, and sustainability are central to a successful ERP implementation. To lead teams toward achievement of pervasive and sustained adherence to best practices, surgeons need to learn new strategies, techniques, and skills.