Racial, ethnic and socioeconomic disparities in diagnosis, treatment, and survival of patients with breast cancer.

BACKGROUND: The objective of this study was to determine the influence of race/ethnicity and socioeconomic status (SES) on breast cancer outcomes. METHODS: A retrospective analysis was performed of Non-Hispanic Black (NHB), Non-Hispanic White (NHW), and Hispanic patients with non-metastatic breast cancer in the SEER cancer registry between 2007 and 2016. RESULTS: A total of 382,975 patients were identified. On multivariate analysis, NHB (OR 1.18, 95%CI: 1.15-1.20) and Hispanic (OR 1.20, 95%CI: 1.17-1.22) patients were more likely to present with higher stage disease than NHW patients. There was an increased likelihood of not undergoing breast-reconstruction for NHB (OR 1.07, 95%CI: 1.03-1.11) and Hispanic patients (OR 1.60, 95%CI 1.54-1.66). NHB patients had increased hazard for all-cause mortality (HR: 1.13, 95%CI 1.10-1.16). All-cause mortality increased across SES categories (lower SES: HR 1.33, 95%CI 1.30-1.37, middle SES: HR 1.20, 95%CI 1.17-1.23). CONCLUSIONS: This population-based analysis confirms worse disease presentation, access to surgical therapy, and survival across racial, ethnic, and socioeconomic factors. These disparities were compounded across worsening SES and insurance coverage.

Racial disparities in colon cancer survival: A propensity score matched analysis in the United States.

BACKGROUND: Black patients are disproportionally impacted by colorectal cancer, both with respect to incidence and mortality. Studies accounting for patient- and community-level factors that contribute to such disparities are lacking. Our objective is to determine if Black compared to White race is associated with worse survival in colon cancer, while accounting for socioeconomic and clinical factors. METHODS: A retrospective analysis was performed of Black or White patients with nonmetastatic colon cancer in the Surveillance, Epidemiology, and End Results cancer registry between 2008 and 2016. Multivariable Cox regression analysis and propensity-score matching was performed. RESULTS: A total of 100,083 patients were identified, 15,155 Black patients and 84,928 White patients. Median follow-up was 38 months (interquartile range: 15-67). Black patients were more likely to lack health insurance and reside in counties with low household income, high unemployment, and lower high school completion rates. Black race was associated with poorer unadjusted 5-year cancer-specific survival (79.4% vs 82.4%, P < .001). After multivariable adjustment, Black race was associated with greater 5-year cancer-specific mortality (hazard ratio: 1.19, 95% confidence interval: 1.13-1.25, P < .001) and overall mortality (hazard ratio: 1.12, 95% confidence interval: 1.08-1.16, P < .001). Mortality was higher for Black patients across stages: stage I (hazard ratio: 1.08, 95% confidence interval: 1.08-1.09), stage II (hazard ratio: 1.06, 95% confidence interval: 1.06-1.07), stage III (1.03, 95% confidence interval: 1.03-1.04). Propensity-score matching identified 27,640 patients; Black race was associated with worse 5-year overall survival (67.5% vs 70.2%, P = .003) and cancer-specific survival (79.4% vs 82.3%, P < .001). CONCLUSIONS: This US population-based analysis confirms poorer overall survival and cancer-specific survival in Black patients undergoing surgery for nonmetastatic colon cancer despite accounting for trans-sectoral factors that have been implicated in structural racism.

Impact of BMI on Adverse Events After Laparoscopic and Open Surgery for Rectal Cancer.

PURPOSE: The impact of body mass index (BMI) on outcomes after open or laparoscopic surgery for rectal cancer remains unclear. The objective of this retrospective cohort study was to examine the interaction of body mass index and surgical modality (i.e., laparoscopy versus open) with respect to short-term clinical outcomes in patients with rectal cancer. METHODS: The ACS-NSQIP database (2012-2016) was reviewed for patients undergoing open or laparoscopic surgery for rectal cancer. The primary outcome was 30-day all-cause morbidity. Logistic regression and Cox proportional hazard models were used for analysis. RESULTS: A total of 16,145 patients were grouped into open (N = 6759, 42%) and laparoscopic (N  = 9386, 58%) cohorts. Patients with higher BMI (p < 0.001) and those undergoing open surgery (p < 0.001) were at increased risk of all-cause morbidity. There was no significant change in the odds ratio of experiencing all-cause morbidity between open and laparoscopic surgery with increasing BMI (p = 0.572). Median length of stay was significantly shorter in the laparoscopy group (4 days vs. 6 days; p < 0.001), at the cost of increased operative time (239 min vs. 210 min, p < 0.001). The difference in operative time between laparoscopy and open surgery did not increase with rising BMI (i.e., ∆37 min vs. ∆39 min at BMI 25 kg/m2 vs 50 kg/m2, respectively, p = 0.491). CONCLUSION: BMI may not be a strong modifier for surgical approach with respect to short-term clinical outcomes in patients with obesity and rectal cancer. Laparoscopic surgery was associated with improved short-term clinical outcomes, without much change in the absolute difference in operative time compared with open surgery, even at higher BMIs.

The effect of operative duration on the outcome of colon cancer procedures.

BACKGROUND: Prolonged operative duration has been associated with increased post-operative morbidity in numerous surgical subspecialties; however, data are limited in operations for colon cancer specifically and existing literature makes unwarranted methodological assumptions of linearity. We sought to assess the effects of extended operative duration on perioperative outcomes in those undergoing segmental colectomy for cancer using a methodologically sound approach. METHODS: We conducted a retrospective cohort study of patients undergoing segmental colectomy for cancer between 2014 and 2018, logged in the National Surgical Quality Improvement Program datasets. Our primary outcome was a composite of any complication within 30 days; secondary outcomes included length of stay and discharge disposition. Our main factor of interest was operative duration. RESULTS: We analyzed 26,380 segmental colectomy cases, the majority of which were approached laparoscopically (64.95%) and were right sided (62.93%). Median operative duration was 152 (95% CI 112-206) minutes. On multivariable regression, increased operative duration was linearly associated with any complication (OR = 1.003, 95% CI 1.003-1.003, p < 0.0001) in the overall cohort, as was length of stay (p < 0.0001). All subgroups except for the laparoscopic left colectomy group were linearly associated with operative duration. In the laparoscopic left colectomy group, an inflection point in the odds of any complication was found at 176 min (OR = 1.39, 95% CI 1.20-1.61, p < 0.0001). CONCLUSIONS: This study suggests that the risk of perioperative complications increases linearly with increasing operative duration, where each additional 30 min increases the odds of complication by 10%. In those undergoing laparoscopic left colectomy, the risk of complications sharply increases after ~ 3 h, suggesting that surgeons should aim to complete these procedures within 3 h where possible.

Surgical Morbidity of Full-Thickness Chest Wall Resection for Breast Cancer: A Retrospective Study of a National Database.

BACKGROUND: Full-thickness chest wall resection (FTCWR) is an underused modality for treating locally advanced primary or recurrent breast cancer invading the chest wall, for which little data exist regarding morbidity and mortality. We examined the postoperative complication rates in breast cancer patients undergoing FTCWR using a large multinational surgical outcomes database. METHODS: A retrospective cohort analysis was conducted using the American College of Surgeons National Surgical Quality Improvement Program database. All patients undergoing FTCWR for breast cancer between 2007 and 2016 were identified (n = 137). Primary outcome measures included 30-d postoperative morbidity, composite respiratory complications, and hospital length of stay (LOS). The secondary aim was to compare the postoperative morbidity of FTCWR to those of patients undergoing mastectomy. One-to-one coarsened exact matching was conducted between two groups, which were then compared with respect to morbidity, mortality, reoperations, readmissions, and LOS. RESULTS: The overall rate of postoperative morbidity was 11.7%. Two patients (1.5%) had respiratory complications requiring intubation. Median hospital LOS was 2 d. In the coarsened exact matching analysis, 122 patients were included in each of the two groups. Comparison of matched cohorts demonstrated an overall morbidity for the FTCWR group of 11.5% compared with 8.2% for the mastectomy group (8.2%) (P = 0.52). CONCLUSIONS: FTCWR for the local treatment of breast cancer can be performed with relatively low morbidity and respiratory complications. This is the largest study looking at postoperative complications for FTCWR in the treatment of breast cancer. Future studies are needed to determine the long-term outcomes of FTCWR in this patient population.

Adequacy of lymph node harvest following colectomy for obstructed and nonobstructed colon cancer.

BACKGROUND: Technical and clinical differences in resection of obstructed and non-obstructed colon cancers may result in differences in lymph node retrieval. The objective of this study is to compare the lymph node harvest following resection of obstructed and nonobstructed colon cancer patients. METHODS: A retrospective analysis utilizing the 2014-2018 NSQIP colectomy targeted data set was conducted. One-to-one coarsened exact matching (CEM) was utilized between patients undergoing resection for obstructed and non-obstructed colon cancer. The primary outcome was the adequacy of lymph node retrieval (LNR, ≥12 nodes). RESULTS: CEM resulted in 9412 patients. Patients with obstructed tumors were more likely to have inadequate LNR (13.3% vs 8.2%, p < .001) compared to those with nonobstructed tumors. Multivariate analysis demonstrated that patients with obstructing tumors had worse LNR compared to non-obstructed tumors (odds ratio [OR]: 0.74, 95% confidence interval [CI]: 0.62-0.87; p < .005). Increased age (OR: 0.99, 95% CI: 0.098-0.99), presence of preoperative sepsis (OR: 0.70, 95% CI: 0.055-0.90), left-sided and sigmoid tumors compared to right-sided (OR: 0.64, 95% CI: 0.51-0.81; OR: 0.69, 95% CI: 0.58-0.82, respectively), and open surgical resection compared to an minimally invasive surgical approach were associated with inadequate LNR (p < .05). CONCLUSION: This study demonstrated that resection for obstructing colon cancer compared to non-obstructed colon cancer is associated with increased odds of inadequate lymph node harvest.

Racial Disparities in Surgery: A Cross-Specialty Matched Comparison Between Black and White Patients.

Objective: To determine if Black race is associated with worse short-term postoperative morbidity and mortality when compared to White race in a contemporary, cross-specialty-matched cohort. Background: Growing evidence suggests poorer outcomes for Black patients undergoing surgery. Methods: A retrospective analysis was conducted comprising of all patients undergoing surgery in the National Surgical Quality Improvement Program dataset between 2012 and 2018. One-to-one coarsened exact matching was conducted between Black and White patients. Primary outcome was rate of 30-day morbidity and mortality. Results: After 1:1 matching, 615,118 patients were identified. Black race was associated with increased rate of all-cause morbidity (odds ratio [OR] = 1.10, 95% confidence interval [CI] 1.08-1.13, P < 0.001) and mortality (OR = 1.15, 95% CI 1.01-1.31, P = 0.039). Black race was associated with increased risk of re-intubation (OR = 1.33, 95% CI 1.21-1.48, P < 0.001), pulmonary embolism (OR = 1.55, 95% CI 1.40-1.71, P < 0.001), failure to wean from ventilator for >48 hours (OR = 1.14, 95% CI 1.02-1.29, P < 0.001), progressive renal insufficiency (OR = 1.63, 95% CI 1.43-1.86, P < 0.001), acute renal failure (OR = 1.39, 95% CI 1.16-1.66, P < 0.001), cardiac arrest (OR = 1.47, 95% CI 1.24-1.76 P < 0.001), bleeding requiring transfusion (OR = 1.39, 95% CI 1.34-1.43, P < 0.001), DVT/thrombophlebitis (OR = 1.24, 95% CI 1.14-1.35, P < 0.001), and sepsis/septic shock (OR = 1.09, 95% CI 1.03-1.15, P < 0.001). Black patients were also more likely to have a readmission (OR = 1.12, 95% CI 1.10-1.16, P < 0.001), discharge to a rehabilitation center (OR = 1.73, 95% CI 1.66-1.80, P < 0.001) or facility other than home (OR = 1.20, 95% CI 1.16-1.23, P < 0.001). Conclusion and Relevance: This contemporary matched analysis demonstrates an association with increased morbidity, mortality, and readmissions for Black patients across surgical procedures and specialties.

The impact of surgical modality on self-reported body image, quality of life and survivorship after anterior resection for colorectal cancer ­ a mixed methods study

Background: There is growing enthusiasm for robotic and transanal surgery as an alternative to open or laparoscopic surgery for colorectal cancer (CRC). We examined the impact of surgical modality on body image and quality of life (QOL) in patients receiving anterior resection for CRC. Methods: We used a mixed-methods approach, consisting of a chart review and semistructured interviews with CRC patients, at least 8 months after surgery. We assessed cosmetic outcomes and QOL using validated questionnaires. Results: Thirty patients were stratified into open (n = 8), laparoscopic (n = 12) and robotic (n = 10) groups. Mean body image scores were significantly higher (i.e., poorer body image) in patients receiving open surgery (mean difference [MD] +5.7 with laparoscopy, p < 0.001). Open surgery was more detrimental to physical function, including strenuous activities, prolonged ambulation and self-care (MD ­11.6 with laparoscopy, p = 0.039). Patients receiving laparoscopic surgery reported superior role (MD +27.6 with open surgery, p = 0.002) and social function (MD +13.7 with open surgery, p = 0.042), including the ability to enjoy hobbies, family life and social activities. Surgical modality did not impact emotional and cognitive function or symptoms including genitourinary function, pain and defecation. Conclusion: The negative impact of open surgery on body image and physical function warrants further educational interventions for patients. The protective effect of laparoscopy on role and function may be associated with "tumour factors" that are unaccounted for in the European Organization for Research and Treatment of Cancer questionnaires. Open surgery is detrimental to body image and physical function in patients receiving anterior resection for CRC. Prospective randomized studies are required to validate these findings.

Contexte: On observe un intérêt croissant pour la chirurgie transanale robotique comme solution de rechange à la chirurgie ouverte ou laparoscopique dans les cas de cancer colorectal (CCR). Nous avons analysé l'impact de la modalité chirurgicale sur l'image corporelle et la qualité de vie (QdV) chez les patients ayant subi une résection antérieure pour CCR. Méthodes: Nous avons utilisé une approche à méthodologie mixte, composée d'une revue des dossiers et d'entrevues semi-structurées avec des patients atteints de CCR, au moins 8 mois après la chirurgie. Nous avons évalué les résultats cosmétiques et la QdV au moyen de questionnaires validés. Résultats: Trente patients ont été stratifiés en 3 groupes : chirurgie ouverte (n = 8), laparoscopique (n = 12) et robotique (n = 10). Les scores moyens pour l'image corporelle ont été significativement plus élevés (c.-à-d., image corporelle plus négative) chez les patients ayant subi une chirurgie ouverte (différence moyenne [DM] +5,7 avec la laparoscopie, p < 0,001). La chirurgie ouverte a été plus nuisible au fonctionnement physique, y compris aux activités exigeantes, à la déambulation prolongée et à l'autosoin (DM ­11,6 avec la laparoscopie, p = 0,039). Les patients soumis à une chirurgie laparoscopique ont fait état d'un rôle (DM +27,6 avec la chirurgie ouverte, p = 0,002) et d'un fonctionnement social meilleurs (DM +13,7 avec la chirurgie ouverte, p = 0,042), y compris la capacité d'apprécier les loisirs et les activités familiales et sociales. La modalité chirurgicale n'a pas exercé d'impact sur le fonctionnement émotionnel et cognitif ou sur les symptômes, y compris la fonction urogénitale, la douleur et la défécation. Conclusion: L'impact négatif de la chirurgie ouverte sur l'image corporelle et le fonctionnement physique justifie que l'on renseigne plus adéquatement nos patients. L'effet protecteur de la laparoscopie aux plans du rôle et du fonctionnement serait associé à des « facteurs tumoraux ¼ qui n'entrent pas en ligne de compte dans les questionnaires de l'Organisation européenne pour la recherche et le traitement du cancer. La chirurgie ouverte nuit à l'image corporelle et au fonctionnement physique chez les patients qui subissent une résection antérieure pour CCR. Des études prospectives randomisées sont nécessaires pour valider ces résultats.

Emergency laparoscopic and open repair of incarcerated ventral hernias: a multi-institutional comparative analysis with coarsened exact matching.

BACKGROUND: The safety of emergent laparoscopic repair of incarcerated ventral hernias is not well established. The objective of this study was to determine if emergent laparoscopic repair of incarcerated ventral hernias is comparable to open repair with respect to short-term clinical outcomes. METHODS: Patients undergoing emergency repair of an incarcerated ventral hernia with associated obstruction and/or gangrene were identified using the ACS-NSQIP 2012-2016 dataset. One-to-one coarsened exact matching (CEM) was conducted between patients undergoing laparoscopic and open repair. Matched cohorts were compared with respect to morbidity, mortality, readmission, reoperation, missed enterotomies, and length of stay. Missed enterotomy was defined as any re-operative procedure within 30 days that required resection of large or small bowel segments, based on CPT codes. Multivariate analysis was conducted to determine adjusted predictors of morbidity. RESULTS: A total of 1642 patients were identified after CEM. Laparoscopic compared to open repair was associated with a lower rate of 30-day wound-morbidity (OR 0.35, 95% CI 0.22-0.57, p < 0.001). Laparoscopic repair was not associated with lower 30-day non-wound morbidity (OR 0.73, 95% CI 0.51-1.06, p = 0.094). Laparoscopic repair was associated with shorter LOS (3.6 days vs. 4.3 days, p = 0.014). A higher rate of missed enterotomies was observed in the laparoscopic cohort (0.7% vs. 0.0%, p = 0.031). There were no group differences with respect to 30-day readmission, reoperation, or mortality. CONCLUSIONS: Emergency laparoscopic repair of incarcerated ventral hernias is associated with lower rates of wound-morbidity and shorter hospital stays compared to open repair. However, laparoscopic repair is associated with a higher rate of missed enterotomies; a rate which is low and comparable to elective non-incarcerated ventral hernia repairs.

Effect of time to operation on outcomes in adults who underwent emergency general surgery procedure.

BACKGROUND: Patients who undergo an emergency procedure have an increase in postoperative morbidity and mortality. Emergency procedures constitute 14.2% of all general surgery procedures and account for 53.5% of deaths. Among this population, time to surgery from arrival to the emergency department (ED) has not been evaluated as an independent risk factor for morbidity and mortality. MATERIAL AND METHODS: Patients who underwent an emergency general surgery procedure from 2013 to 2015 were identified using a local American College of Surgeons National Surgical Quality Improvement Project (ACS-NSQIP) database. Outcomes of interest included 30-d mortality, all morbidity, and severe morbidity. Multivariate analyses were conducted using a logistic regression model using clinically relevant covariates to determine predictors of the outcome measures. RESULTS: A total of 974 patients were included in the final analysis. The prolonged median time from ED presentation to OR was predictive of all morbidity (14.3 h versus 13.3 h, P = 0.009) and severe morbidity (13.3 h versus 14.4 h, P = 0.063) on univariate analysis. Time from ED presentation to OR was not predictive of mortality (13.5 h versus 13.6 h, P = 0.474). Multivariate analysis demonstrated an adjusted increased odd of morbidity of 2.3 (95% CI: 1.01-5.24) for priority level A cases within the fourth quartile compared to that of the first quartile of time (P = 0.048). CONCLUSIONS: This study corroborates with known data that morbidity and mortality increases in patients who are older, have multiple comorbidities, and higher ASA class. Furthermore, the time from ED arrival to the OR is associated with an overall increase in morbidity.

The effect of a simultaneous versus a staged resection of metastatic colorectal cancer on time to adjuvant chemotherapy.

BACKGROUND AND OBJECTIVES: Patients with colorectal cancer with synchronous liver metastases may undergo a staged or a simultaneous resection. This study aimed to determine whether the time to adjuvant chemotherapy was delayed in patients undergoing a simultaneous resection. METHODS: A retrospective cohort study was conducted between 2005 and 2016. The primary outcome was time to adjuvant chemotherapy. A multivariate linear regression was conducted to ascertain the adjusted effect of a simultaneous versus a staged approach on time to adjuvant chemotherapy. RESULTS: A total of 155 patients were included. A total of 127 patients underwent a staged resection, whereas 28 patients underwent a simultaneous resection. Age, sex, and American Society of Anesthesiologists class as well tumor, node, metastasis stage, tumor location, and number and size of metastases were not significantly different between the groups. The median time to adjuvant chemotherapy was 70 and 63 days for the staged and simultaneous groups, respectively (P = .27). Multivariate analysis did not demonstrate an increased propensity for prolonged time to chemotherapy after simultaneous resection (rate ratio: 0.97, 95% CI: 0.71-1.32, P = .84). There were no significant differences in the length of stay, complications, overall survival, and disease-free survival between the groups (P > .05). CONCLUSIONS: This study demonstrated that simultaneous resection does not result in significant delay of adjuvant chemotherapy compared with a staged approach.

Concurrent risk-reduction surgery in patients with increased lifetime risk for breast and ovarian cancer: an analysis of the National Surgical Quality Improvement Program (NSQIP) database.

BACKGROUND: Patients with genetic susceptibility to breast and ovarian cancer are eligible for risk-reduction surgery. Surgical morbidity of risk-reduction mastectomy (RRM) with concurrent bilateral salpingo-oophorectomy (BSO) is unknown. Outcomes in these patients were compared to patients undergoing RRM without BSO using a large multi-institutional database. METHODS: A retrospective cohort analysis was conducted using the American College of Surgeon's National Surgical Quality Improvement Program (NSQIP) 2007-2016 datasets, comparing postoperative morbidity between patients undergoing RRM with patients undergoing RRM with concurrent BSO. Patients with genetic susceptibility to breast/ovarian cancer undergoing risk-reduction surgery were identified. The primary outcome was 30-day postoperative major morbidity. Secondary outcomes included surgical site infections, reoperations, readmissions, length of stay, and venous thromboembolic events. A multivariate analysis was performed to determine predictors of postoperative morbidity and the adjusted effect of concurrent BSO on morbidity. RESULTS: Of the 5470 patients undergoing RRM, 149 (2.7%) underwent concurrent BSO. The overall rate of major morbidity and postoperative infections was 4.5% and 4.6%, respectively. There was no significant difference in the rate of postoperative major morbidity (4.5% vs 4.7%, p = 0.91) or any of the secondary outcomes between patients undergoing RRM without BSO vs. those undergoing RRM with concurrent BSO. Multivariable analysis showed Body Mass Index (OR 1.05; p < 0.001) and smoking (OR 1.78; p = 0.003) to be the only predictors associated with major morbidity. Neither immediate breast reconstruction (OR 1.02; p = 0.93) nor concurrent BSO (OR 0.94; p = 0.89) were associated with increased postoperative major morbidity. CONCLUSION: This study demonstrated that RRM with concurrent BSO was not associated with significant additional morbidity when compared to RRM without BSO. Therefore, this joint approach may be considered for select patients at risk for both breast and ovarian cancer.

Evolving surgical treatment decisions for male breast cancer: an analysis of the National Surgical Quality Improvement Program (NSQIP) database.

BACKGROUND: Male breast cancer (MBC) is a rare malignancy, and gender-specific treatment outcomes are currently lacking. The use of a large, multi-national surgical-outcomes database may provide a better understanding of treatment patterns and postoperative morbidity in men who undergo oncological breast surgery. METHODS: A retrospective cohort analysis was conducted between 2007 and 2016 using the American College of Surgeons National Surgical Quality Improvement Program database (NSQIP), examining MBC treatment patterns and postoperative complication rates. All men undergoing surgery for the treatment of invasive or in situ carcinoma of the breast were identified. Clinical characteristics, demographics, and surgical treatment options most frequently used for this population were described. In addition, the 30-day postoperative complication rates in the surgical treatment of male breast cancer were evaluated. RESULTS: A total of 1773 MBC patients with a median age of 65 years (IQR 56-74 years) were included in this analysis. Mean body mass index (BMI) was 29.1 (IQR 25.4-33.8). In this study population, 177 (10.0%) had a diagnosis of in situ breast cancer, while the remaining 1596 (90.0%) had invasive disease. While most men underwent mastectomy, 282 (15.9%) had breast-conserving surgery. There were 74 (4.2%) patients who underwent immediate breast reconstruction. In addition, 118 (6.7%) patients elected to have a contralateral prophylactic mastectomy. Overall, the rate of morbidity was 4.6%, comprising mostly of wound complications (3.2%). CONCLUSION: Analysis of this large, prospective multi-institutional cohort revealed that complication rates are low and comparable to reported rates in the female breast cancer population. What is also significant about this analysis is that the cohort demonstrated the importance of cosmetic considerations in MBC patients, as some men decide to undergo breast-conserving surgery or immediate breast reconstruction. Contralateral prophylactic mastectomy in the treatment of MBC is also performed.

Considering the cost of a simultaneous versus staged approach to resection of colorectal cancer with synchronous liver metastases in a publicly funded healthcare model.

BACKGROUND: Simultaneous resection for colorectal cancer with synchronous liver metastases is an established alternative to a staged approach. This study aimed to compare these approaches with regards to economic parameters and short-term outcomes. METHODS: A retrospective cohort analysis was conducted between 2005 and 2016. The primary outcome was cost per episode of care. Secondary measures included 30-day clinical outcomes. A multivariate analysis was performed to determine the adjusted effect of a simultaneous surgical approach on total cost of care. RESULTS: Fifty-three cases were identified; 27 in the staged approach, and 26 in the simultaneous group. Age (P = 0.49), sex (P = 0.20), BMI (P = 0.74), and ASA class (P = 0.44) were comparable between groups. Total cost ($20297 vs $27522), OR ($6830 vs $10376), PACU ($675 vs $1182), ward ($7586 vs $11603) and pharmacy costs ($728 vs $1075) were significantly less for the simultaneous group (P < 0.05). The adjusted rate ratio for total cost of care in the staged group compared to simultaneous group was 1.51 (95%CI: 1.16-1.97, P < 0.05). The groups had comparable Clavien-Dindo scores (P = 0.89), 30-day readmissions (P = 0.44), morbidity (P = 0.50) and mortality (P = 1.00). CONCLUSIONS: Our study demonstrates that a simultaneous approach is associated with a significantly lower total cost while maintaining comparable short-term outcomes.

Diagnostic utility of staging abdominal computerized tomography and repeat endoscopy in detecting localization errors at initial endoscopy in colorectal cancer.

BACKGROUND: Colonoscopy has a reported localization error rate as high as 21% in detecting colorectal neoplasms. Preoperative repeat endoscopy has been shown to be protective against localization errors. There is a paucity of literature assessing the utility of staging computerized tomography (CT) and repeat endoscopy as diagnostic tools for detecting localization errors following initial endoscopy. The objective of this study is to determine the diagnostic characteristics of staging CT and repeat endoscopy in correcting localization errors at initial endoscopy. METHODS: A retrospective cohort study was conducted at a large tertiary academic center between January 2006 and August 2014. All patients undergoing surgical resection for CRC were identified. Group comparisons were conducted between (1) patients that underwent only staging CT (staging CT group), and (2) patients that underwent staging CT and repeat endoscopy (repeat endoscopy group). The primary outcome was localization error correction rate for errors at initial endoscopy. RESULTS: 594 patients were identified, 196 (33.0%) in the repeat endoscopy group, and 398 (77.0%) patients in the staging CT group. Error rates for each modality were as follows: initial endoscopy 8.8% (95% CI 6.5-11.0), staging CT 9.3% (95% CI 6.5-11.0), and repeat endoscopy 2.6% (95% CI 0.3-4.7); p < 0.01. Repeat endoscopy was superior to staging CT in correcting localization errors for left-sided / rectal lesions (81.2% vs. 33.3%; p < 0.01), right-sided lesions (80.0% vs. 54.5%; p = 0.21), and overall lesions (80.8% vs. 42.3%; p < 0.01). Repeat endoscopy compared to staging CT demonstrated relative risk reduction of 66.7% (95% CI 22-86%), absolute risk reduction of 38.5% (95% CI 14.2-62.8%), and odds ratio of 0.18 (95% CI 0.05-0.61) for correcting errors at initial endoscopy. CONCLUSIONS: Repeat endoscopy in colorectal cancer is superior to staging CT as a diagnostic tool for correcting localization-based errors at initial endoscopy.

Robotic simultaneous resection of rectal cancer and liver metastases.

Surgical resection is the only potential cure for colorectal cancer with synchronous liver metastases (SLM). Simultaneous resection of colorectal cancer and SLM using robotic-assistance has been rarely reported. We demonstrate that robotic-assisted simultaneous resection of colorectal cancer and SLMs is feasible, safe, and has potential to demonstrate good oncologic outcomes.

The safety and feasibility of early discharge following ileostomy reversal: a National Surgical Quality Improvement Program analysis.

BACKGROUND: This study aimed to compare 30-day clinical outcomes following routine ileostomy reversal between patients that underwent early discharge (<24 h) and standard discharge (postoperative day [POD] 2 or 3). METHODS: A retrospective cohort analysis was conducted between 2005 and 2014 using the American College of Surgeons National Surgical Quality Improvement Program data set. All patients undergoing ileostomy reversal who were discharged on POD 0 or 1 (early discharge group [EDG]) versus POD 2 or 3 (standard discharge group [SDG]) were identified. The primary outcome was the 30-day adverse event rate. The secondary outcome was the 30-day readmission rate. A multivariate analysis was performed to determine the adjusted effect of early discharge as well as the predictors of adverse events and readmissions. RESULTS: The study population consisted of 355 and 5805 patients in the EDG and SDG, respectively. There were 19 (5.4%) 30-day adverse events in the EDG and 341 (5.8%) in the SDG. The EDG had 17 (4.8%) 30-day readmissions and the SDG had 294 (5.1%). The adjusted odds ratio for 30-day adverse events in the EDG was 0.95 (P = 0.83), and for 30-day readmissions, it was 1.01 (P = 0.96). Higher BMI, longer operative time, ASA ≥3, chronic steroid use along with a history of bleeding disorder were significant predictors for adverse events and readmissions. CONCLUSIONS: Select patients discharged within 24 h of ileostomy reversal did not have a significantly higher rate of adverse events or readmissions compared to patients discharged on POD 2 or 3 following uncomplicated surgery. Predictors of adverse events and readmissions can guide the selection of patients suitable for early discharge.

A comparison of endoscopic localization error rate between operating surgeons and referring endoscopists in colorectal cancer.

BACKGROUND: Colonoscopy for colorectal cancer (CRC) has a localization error rate as high as 21 %. Such errors can have substantial clinical consequences, particularly in laparoscopic surgery. The primary objective of this study was to compare accuracy of tumor localization at initial endoscopy performed by either the operating surgeon or non-operating referring endoscopist. METHODS: All patients who underwent surgical resection for CRC at a large tertiary academic hospital between January 2006 and August 2014 were identified. The exposure of interest was the initial endoscopist: (1) surgeon who also performed the definitive operation (operating surgeon group); and (2) referring gastroenterologist or general surgeon (referring endoscopist group). The outcome measure was localization error, defined as a difference in at least one anatomic segment between initial endoscopy and final operative location. Multivariate logistic regression was used to explore the association between localization error rate and the initial endoscopist. RESULTS: A total of 557 patients were included in the study; 81 patients in the operating surgeon cohort and 476 patients in the referring endoscopist cohort. Initial diagnostic colonoscopy performed by the operating surgeon compared to referring endoscopist demonstrated statistically significant lower intraoperative localization error rate (1.2 vs. 9.0 %, P = 0.016); shorter mean time from endoscopy to surgery (52.3 vs. 76.4 days, P = 0.015); higher tattoo localization rate (32.1 vs. 21.0 %, P = 0.027); and lower preoperative repeat endoscopy rate (8.6 vs. 40.8 %, P < 0.001). Initial endoscopy performed by the operating surgeon was protective against localization error on both univariate analysis, OR 7.94 (95 % CI 1.08-58.52; P = 0.016), and multivariate analysis, OR 7.97 (95 % CI 1.07-59.38; P = 0.043). CONCLUSIONS: This study demonstrates that diagnostic colonoscopies performed by an operating surgeon are independently associated with a lower localization error rate. Further research exploring the factors influencing localization accuracy and why operating surgeons have lower error rates relative to non-operating endoscopists is necessary to understand differences in care.

Discrepancy between gastroenterologists' and general surgeons' perspectives on repeat endoscopy in colorectal cancer.

BACKGROUND: A myriad of localization options are available to endoscopists for colorectal cancer (CRC); however, little is known about the use of such techniques and their relation to repeat endoscopy before CRC surgery. We examined the localization practices of gastroenterologists and compared their perceptions toward repeat endoscopy to those of general surgeons. METHODS: We distributed a survey to practising gastroenterologists through a provincial repository. Univariate analysis was performed using the χ² test. RESULTS: Gastroenterologists (n = 69) reported using anatomical landmarks (91.3%), tattooing (82.6%) and image capture (73.9%) for tumour localization. The majority said they would tattoo lesions that could not be removed by colonoscopy (91.3%), high-risk polyps (95.7%) and large lesions (84.1%). They were equally likely to tattoo lesions planned for laparoscopic (91.3%) or open (88.4%) resection. Rectal lesions were less likely to be tattooed (20.3%) than left-sided (89.9%) or right-sided (85.5%) lesions. Only 1.4% agreed that repeat endoscopy is the standard of care, whereas 38.9% (n = 68) of general surgeons agreed (p < 0.001). General surgeons were more likely to agree that an incomplete initial colonoscopy was an indication for repeat endoscopy (p = 0.040). Further, 56% of general surgeons indicated that the findings of repeat endoscopy often lead to changes in the operative plan. CONCLUSION: Discrepancies exist between gastroenterologists and general surgeons with regards to perceptions toward repeat endoscopy and its indications. This is especially significant given that repeat endoscopy often leads to change in surgical management. Further research is needed to formulate practice recommendations that guide the use of repeat endoscopy, tattoo localization and quality reporting.

CONTEXTE: De nombreuses options de repérage s'offrent aux endoscopistes dans les cas de cancer colorectal; on en sait cependant peu sur l'utilisation de ces techniques et leur lien avec les endoscopies répétées avant les interventions chirurgicales de traitement de ce cancer. Nous avons étudié les pratiques de repérage employées par des gastroentérologues et comparé leurs perceptions des endoscopies répétées à celles des chirurgiens généralistes. MÉTHODES: Nous avons réalisé un sondage auprès de gastroentérologues en exercice figurant dans un répertoire provincial. Une analyse unidimensionnelle a été effectuée à l'aide du test χ². RÉSULTATS: Les gastroentérologues (n = 69) ont dit recourir à des repères anatomiques (91,3 %), au tatouage (82,6 %) et à des images (73,9 %) pour repérer les tumeurs. La majorité a dit tatouer les lésions ne pouvant être éliminées par coloscopie (91,3 %), les polypes à haut risque (95,7 %) et les lésions de grande taille (84,1 %). Ils étaient tout aussi susceptibles de tatouer les lésions devant être éliminées par résection laparoscopique (91,3 %) ou effractive (88,4 %). Ils étaient cependant moins susceptibles de tatouer les lésions rectales (20,3 %) que les lésions du côté gauche (89,9 %) ou du côté droit (85,5 %). Seul 1,4 % des gastroentérologues était d'avis que l'endoscopie répétée constitue une norme en matière de soins, contrairement à 38,9 % des chirurgiens généralistes (n = 68; p < 0,001). Les chirurgiens généralistes étaient plus nombreux à penser qu'une coloscopie initiale incomplète était susceptible d'être associée à des endoscopies répétées (p = 0,040). En outre, 56 % d'entre eux ont indiqué que les résultats d'endoscopies répétées menaient souvent à des changements sur le plan chirurgical. CONCLUSION: Il existe des divergences entre les perceptions des gastroentérologues et des chirurgiens généralistes quant aux endoscopies répétées et à leur indication. Ces divergences sont particulièrement pertinentes, étant donné que les endoscopies répétées entraînent souvent des changements aux interventions chirurgicales qui sont pratiquées ultérieurement. Des recherches approfondies seront nécessaires pour formuler des recommandations liées aux pratiques et orienter le recours aux endoscopies répétées et au repérage des lésions par tatouage ainsi que la production de rapports sur la qualité.