The SAGES MASTERS program presents: the top 10 seminal articles for laparoscopic left and sigmoid colectomy pathway for uncomplicated disease.

BACKGROUND: As one of the 8 Society of American Gastrointestinal and Endoscopic Surgeons (SAGES) Masters Program clinical pathways, the Colorectal Pathway aims to deliver educational content for the general surgeon organized along 3 levels of performance (competency, proficiency and mastery) each represented by an anchoring procedure. In this article, the SAGES Colorectal Task Force presents focused summaries of the top 10 seminal articles selected for laparoscopic left/sigmoid colectomy for uncomplicated disease. METHODS: Using a systematic literature search of Web of Science, the most cited articles on laparoscopic left and sigmoid colectomy were identified, reviewed, and ranked by members of the SAGES Colorectal Task Force. Additional articles not identified in the literature search were included if deemed impactful by expert consensus. The top 10 ranked articles were then summarized, including their findings, strengths and limitations with emphasis on relevance and impact in the field. RESULTS: The top 10 articles selected focus on variations in minimally invasive surgical techniques, video demonstrations, stratified approaches for benign and malignant disease as well as assessments of the learning curve. CONCLUSIONS: The selected top 10 seminal articles for laparoscopic left and sigmoid colectomy in uncomplicated disease are considered by the SAGES colorectal task force to be fundamental to the knowledge base of minimally invasive surgeons as they progress to mastery in these procedures.

Annual Structured Communication Skills Training for Surgery Residents.

INTRODUCTION: There is no formalized communication curriculum for surgical training. The aim of this study is to determine the benefit of annual communication skill-building workshops for surgical residents over several years. METHODS: The general surgery and the integrated cardiothoracic surgery residents in a tertiary care, urban academic center participated in a 2-hour communication skill-building workshop each year from July 2017 to June 2021. Each participant was administered an anonymous pre-session and post-session survey with a 5-point Likert scale to assess their self-reported preparedness and their evaluation of the workshop. Survey responses were divided into three groups based on their experience in this workshop; no experience (Experience 0), 1 y of experience (Experience 1), and two or more years of experience (Experience 2+). They were compared among groups. RESULTS: Seventy-one surgical residents participated in the workshop generating 124 survey results (Experience 0, 71 [57.3%], Experience 1, 41 [33.1%], and Experience 2+, 12 [9.7%]). Self-reported preparedness scores improved for the overall group as well as for each experience group. While scores decreased significantly in the following years, they improved after each workshop. Scores were significantly better with more experience (4, interquartile range [IQR] 3-4 in Experience 0, 4, IQR 3-5 in Experience 1, 4, IQR 4-5 in Experience 2+, P < 0.001 between Experience 0 and Experience 1, P = 0.041 between Experience 1 and Experience 2+). All residents reported an overwhelmingly positive review of the curriculum. CONCLUSIONS: Yearly 2-hour communication skills practice increased surgical residents' self-reported preparedness, and the repetition helped the improvement. Annual workshops are important for residents to be more prepared for serious illness communication.

Multiplexed single-cell analysis reveals prognostic and nonprognostic T cell types in human colorectal cancer.

Clinical outcomes in colorectal cancer (CRC) correlate with T cell infiltrates, but the specific contributions of heterogenous T cell types remain unclear. To investigate the diverse function of T cells in CRC, we profiled 37,931 T cells from tumors and adjacent normal colon of 16 patients with CRC with respect to transcriptome, TCR sequence, and cell surface markers. Our analysis identified phenotypically and functionally distinguishable effector T cell types. We employed single-cell gene signatures from these T cell subsets to query the TCGA database to assess their prognostic significance. We found 2 distinct cytotoxic T cell types. GZMK+KLRG1+ cytotoxic T cells were enriched in CRC patients with good outcomes. GNLY+CD103+ cytotoxic T cells with a dysfunctional phenotype were not associated with good outcomes, despite coexpression of CD39 and CD103, markers that denote tumor reactivity. We found 2 distinct Treg subtypes associated with opposite outcomes. While total Tregs were associated with good outcomes, CD38+ Tregs were associated with bad outcomes independently of stage and possessed a highly suppressive phenotype, suggesting that they inhibit antitumor immunity in CRC. These findings highlight the potential utility of these subpopulations in predicting outcomes and support the potential for novel therapies directed at CD38+ Tregs or CD8+CD103+ T cells.

Factors Associated With General Surgery Residents' Operative Experience During the COVID-19 Pandemic.

Importance: The suspension of elective operations in March 2020 to prepare for the COVID-19 surge posed significant challenges to resident education. To mitigate the potential negative effects of COVID-19 on surgical education, it is important to quantify how the pandemic influenced resident operative volume. Objective: To examine the association of the pandemic with general surgical residents' operative experience by postgraduate year (PGY) and case type and to evaluate if certain institutional characteristics were associated with a greater decline in surgical volume. Design, Setting, and Participants: This retrospective review included residents' operative logs from 3 consecutive academic years (2017-2018, 2018-2019, and 2019-2020) from 16 general surgery programs. Data collected included total major cases, case type, and PGY. Faculty completed a survey about program demographics and COVID-19 response. Data on race were not collected. Operative volumes from March to June 2020 were compared with the same period during 2018 and 2019. Data were analyzed using Kruskal-Wallis test adjusted for within-program correlations. Main Outcome and Measures: Total major cases performed by each resident during the first 4 months of the pandemic. Results: A total of 1368 case logs were analyzed. There was a 33.5% reduction in total major cases performed in March to June 2020 compared with 2018 and 2019 (45.0 [95% CI, 36.1-53.9] vs 67.7 [95% CI, 62.0-72.2]; P < .001), which significantly affected every PGY. All case types were significantly reduced in 2020 except liver, pancreas, small intestine, and trauma cases. There was a 10.2% reduction in operative volume during the 2019-2020 academic year compared with the 2 previous years (192.3 [95% CI, 178.5-206.1] vs 213.8 [95% CI, 203.6-223.9]; P < .001). Level 1 trauma centers (49.5 vs 68.5; 27.7%) had a significantly lower reduction in case volume than non-level 1 trauma centers (33.9 vs 63.0; 46%) (P = .03). Conclusions and Relevance: In this study of operative logs of general surgery residents in 16 US programs from 2017 to 2020, the first 4 months of the COVID-19 pandemic was associated with a significant reduction in operative experience, which affected every PGY and most case types. Level 1 trauma centers were less affected than non-level 1 centers. If this trend continues, the effect on surgical training may be even more detrimental.

Novel Expression of GABAA Receptors on Resistance Arteries That Modulate Myogenic Tone.

The clinical administration of GABAergic medications leads to hypotension which has classically been attributed to the modulation of neuronal activity in the central and peripheral nervous systems. However, certain types of peripheral smooth muscle cells have been shown to express GABAA receptors, which modulate smooth muscle tone, by the activation of these chloride channels on smooth muscle cell plasma membranes. Limited prior studies demonstrate that non-human large-caliber capacitance blood vessels mounted on a wire myograph are responsive to GABAA ligands. We questioned whether GABAA receptors are expressed in human resistance arteries and whether they modulate myogenic tone. We demonstrate the novel expression of GABAA subunits on vascular smooth muscle from small-caliber human omental and mouse tail resistance arteries. We show that GABAA receptors modulate both plasma membrane potential and calcium responses in primary cultured cells from human resistance arteries. Lastly, we demonstrate functional physiologic modulation of myogenic tone via GABAA receptor activation in human and mouse arteries. Together, these studies demonstrate a previously unrecognized role for GABAA receptors in the modulation of myogenic tone in mouse and human resistance arteries.

Diagnostic Modalities in Gastrointestinal Bleeding.

A variety of diagnostic modalities is available to assist in the evaluation of patients presenting with acute gastrointestinal (GI) bleeding. This article reviews some older technologies like colonoscopy, nuclear scintigraphy, and conventional angiography and will also review the newest additions to the lower GI bleeding diagnostic toolbox, which are video capsule endoscopy and computed tomography (CT) angiography. The management algorithm used at a given institution depends on the available expertise and resources.

The Effect of Midyear Report Cards on Colonoscopy Quality Measures.

INTRODUCTION: Since 2011, our institution has distributed annual reports, in June, to providers with personalized data regarding adenoma detection rate (ADR), colonoscope withdrawal time (CW), and cecal intubation (CI) rate, using standardized reporting systems. We examined the impact of distribution of individualized reports at the midpoint of each year on colonoscopy outcomes in the latter half of each year. METHODS: Providers with endoscopy privileges, performing ≥20 colonoscopies/year, at our center throughout a five-year period (2011-2015) were included. The three metrics recorded and reported were ADR, CW, and CI using standard benchmark rates. The mean values of each metric from January through June (1st half) and July through December (2nd half) were calculated. Curve estimation test was used to determine the significance of ADR in the respective time period. RESULTS: Fifteen providers were eligible for the study. Collective ADR in the 1st half of all years was 26.9% and in the second half of all years was 28.1% (p = 0.476). CW for all years was more than 9 minutes while CI was above 90% for all providers. There was no significant increase in the CI and CW during the 5-year study period. Overall, ADR increased from 26.43% (2011) to 33.47% (2015) (p = 0.137). When examining ADR during each of the 12 months following the June report cards, there was no month-to-month trend observed (p = 0.893). CONCLUSION: Endoscopists at our institutions met/exceeded the quality metrics in the first half of each year from the beginning of the study. Routine reporting may maintain, but not improve, outcomes. Long-term studies to determine if periodic feedback to endoscopists improves the quality of endoscopy as per national standards for detection of early colorectal cancers are required.

Elevation of Serum CEA in Patients with Squamous Cell Carcinoma of the Anus.

The proportion of anal cancer cases that produce elevated carcinoembryonic antigen (CEA) levels is not well described in the medical literature. In this study, we used electronic health record data from a single urban cancer center to identify patients from 2004-2018 with anal cancer who have also had a pre-initial treatment CEA measurement. We identified 40 patients who met our eligibility criteria. Of those, 11 (27.5%) had an elevated pretreatment CEA. Elevated CEA was not associated with any of the clinical or demographic covariates; however, three out of five patients with a recurrence had an elevated CEA.

Alvimopan Significantly Reduces Length of Stay and Costs Following Colorectal Resection and Ostomy Reversal Even Within an Enhanced Recovery Protocol.

BACKGROUND: Alvimopan accelerates GI recovery after colorectal resection. Data on real-world cost-effectiveness have been mixed. OBJECTIVE: This study aimed to evaluate if adding alvimopan to an enhanced recovery pathway reduces length of stay. DESIGN: Patients undergoing colorectal resection or ostomy reversal for the year before and after the introduction of alvimopan were evaluated. SETTING: This study was conducted at a single academic medical center. PATIENTS: Patients undergoing elective colorectal resection (488) or ostomy reversal (148) were included. MAIN OUTCOME MEASURES: The primary outcomes measured were length of stay and prolonged length of stay defined as >75th percentile for each procedure. RESULTS: Two hundred eighty-six patients (45%) received alvimopan. Alvimopan and no-alvimopan groups had similar demographics, comorbidities, operative indication, and case mix. In the alvimopan group, more of the colorectal resections were laparoscopic (87% vs 79%, p = 0.015). Length of stay was reduced with alvimopan (6.2 vs 4.9 days, p = 0.003), and this effect persisted when controlling for procedure type, approach, and ASA class (decreased length of stay by 1.0 day, p = 0.014). The alvimopan group had lower risk of prolonged length of stay (14.7% vs 23.1%, p = 0.007) and ileus (10.8% vs 16.2%, p = 0.05). On multivariable analysis, no alvimopan use (OR, 1.8; 95% CI, 1.2-2.7), ASA ≥3 (OR, 2.0; 95% CI, 1.3-3.1), and history of cardiac surgery (OR, 2.8; 95% CI, 1.2-6.5) were significant predictors of prolonged length of stay. Alvimopan use was associated with a lower risk of infectious complications other than surgical site infection (2.8% vs 6.7%, p = 0.025), and did not increase risk of any adverse outcomes. The addition of alvimopan to the protocol resulted in cost savings of $708.39 per patient. LIMITATIONS: Data collected from a single center limit external validity. CONCLUSIONS: The introduction of alvimopan to a postoperative protocol following elective colorectal resection or ostomy reversal significantly reduces length of stay and is associated with cost savings even within an enhanced recovery protocol. See Video Abstract at http://links.lww.com/DCR/A911.

Colorectal sarcoma: more than a gastrointestinal stromal tumor.

Primary colorectal sarcomas have been defined as a rare and diverse group of mesenchymal cancers distinct from gastrointestinal stromal tumors (GISTs). Primary colorectal sarcomas have been recognized as a distinct entity from GISTs due to the dramatically worse prognosis these sarcomas carry. Also, primary colorectal sarcomas when compared to the more common colorectal adenocarcinoma, demonstrate more aggressive biology, present at a younger age and carry worse outcomes. At this time, surgery remains the mainstay of treatment and adjuvant chemotherapy has an unclear role in treatment of primary colorectal sarcoma. This paper attempts to review the available data regarding primary colorectal sarcomas.

Management of iatrogenic perforation during colonoscopy in ulcerative colitis patients: a survey of gastroenterologists and colorectal surgeons.

PURPOSE: Patients with ulcerative colitis, a high-risk group for the development of colon cancer, undergo colonoscopy more frequently than the general population. This increase in endoscopic evaluation also exposes these patients to an increased risk of complications, including iatrogenic perforation. Our survey study aims to determine factors that affect the management choices for iatrogenic perforations for ulcerative colitis patients in remission and identify areas of consensus among general gastroenterologists, inflammatory bowel disease specialists, and colorectal surgeons. METHODS: An anonymous, cross-sectional survey was performed using an online platform. A matrix questionnaire posed five clinical scenarios with six management options for an iatrogenic perforation in ulcerative colitis patients with varying disease distribution, disease activity, and maintenance regimens. RESULTS: One hundred thirty-eight general gastroenterologists, 35 inflammatory bowel disease specialists, and 174 colorectal surgeons responded to the survey; 47, 41, and 23%, respectively, answered they did not feel comfortable managing perforations in ulcerative colitis patients in remission. We found the greatest concordance among gastroenterologists and colorectal surgeons in cases of perforation in ulcerative colitis with a history of dysplasia; the majority of respondents chose staged total proctocolectomy with ileal pouch anal anastomosis. We found discordance in decision making for ulcerative colitis in remission without dysplasia, with perforation occurring in colitis involved and uninvolved areas. CONCLUSION: Our survey revealed that a significant fraction of gastroenterologists and colorectal surgeons are uncomfortable managing iatrogenic colonic perforations in ulcerative colitis patients. We have identified knowledge and practice gaps in defining the optimal management of iatrogenic perforations in ulcerative colitis patients.

Correction to: Anal canal squamous cell cancer: are surgical alternatives to chemoradiation just as effective?

One of the author's middle name of this article was incorrectly published as "Emmanouil E. Pappou." This is now presented correctly in this article as "Emmanouil P. Pappou."

Use of an ACE inhibitor or angiotensin receptor blocker is a major risk factor for dehydration requiring readmission in the setting of a new ileostomy.

PURPOSE: Diverting ileostomies help prevent major complications related to anastomoses after colorectal resection but can cause metabolic derangement and hypovolemia, leading to readmission. This paper aims to determine whether angiotensin-converting enzyme inhibitor (ACEi) or angiotensin receptor blocker (ARB) use increased the risk of readmission, or readmission specifically for dehydration after new ileostomy creation. METHODS: Retrospective analysis of patients undergoing diverting ileostomy at a tertiary-care hospital, 2009-2015. Primary outcome was 60-day readmission for dehydration; secondary outcomes included 60-day readmission for any cause, or for infection obstruction. RESULTS: Ninety-nine patients underwent diverting ileostomy creation, 59% with a primary diagnosis of colorectal cancer. The 60-day readmission rate was 36% (n = 36). Of readmitted patients, 39% (n = 14) were admitted for dehydration. Other readmission reasons were infection (33%) and obstruction (3%). The majority (64%, n = 9) of patients readmitted for dehydration were taking either an ACEi or an ARB. Compared to patients not readmitted for dehydration, those who were readmitted for dehydration were more likely to be on an ACEi or an ARB (11/85, 13% vs. 9/14, 64%). After controlling for covariates, ACEi or ARB use was significantly associated with risk of readmission (p < 0.0001, odds ratio = 13.56, 95% confidence interval 3.54-51.92,). No other diuretic agent was statistically associated with readmission for dehydration. CONCLUSIONS: ACEi and ARB use is a significant risk factor for readmission for dehydration following diverting ileostomy creation. Consideration should be given to withholding these medications after ileostomy creation to reduce this risk.

Anal canal squamous cell cancer: are surgical alternatives to chemoradiation just as effective?

PURPOSE: The purpose of this paper is to study long-term oncologic outcomes after different treatment strategies for anal canal cancer (SCAC). METHODS: Patients with SCAC (2004-2013) were identified from Surveillance, Epidemiology, and End Results (SEER) database. Patients undergoing radiation (RT) were compared to those undergoing local excision (LE), abdominoperineal resection (APR), and abdominoperineal resection after radiation (RT + APR). Overall survival (OS) and cancer-specific survival (CSS) data were evaluated using Kaplan-Meier and Cox regression. RESULTS: Two thousand seven hundred and seventy-two (83.8%) patients underwent RT, 382 (11.6%) LE, 77 (2.3%) APR, 76 (2.3%) RT + APR. Median age for the four groups was 60, 57, 64, and 56 years and 32, 49.7, 53.2, and 39.5% were male, respectively, while median tumor size was 4.4, 2.6, 5.3, and 5.5 cm, respectively. Five-year OS of RT, LE, APR, and RT + APR groups was 63.7, 79.6, 25.8, and 41.8% while CSS was 79.6, 92.5, 75.6, and 58.8%, respectively, (p < 0.001). Adjusted hazard ratios for OS for LE, APR, and RT + APR with RT as reference were 1.007 (0.702-1.444), 2.311 (1.367-3.906), and 2.072 (1.016-4.228), respectively. CONCLUSION: These data suggest that APR does not provide better outcomes in treatment of SCAC. Chemoradiation remains the gold standard treatment for majority of patients. Local excision is associated with favorable outcomes in some circumstances.

Ongoing challenges and controversies in ulcerative colitis surgery.

For patients with ulcerative colitis requiring surgery, surgical options include a total proctocolectomy with an end ileostomy and ileal pouch-anal anastomosis or a continent reservoir, or instead, a subtotal colectomy with an ileorectal anastomosis. The ileal pouch-anal anastomosis is currently considered the gold standard procedure that is employed in the majority of patients. Despite strong data supporting the feasibility, durability and the maintenance of long term functional outcomes and quality of life, certain controversies pertaining to its relative role, method of creation and effects on related pelvic structures remain a matter of debate.

Surgical Management of Complicated Colon Cancer.

The management of complicated colon cancer (locally invasive, obstructed, or perforated cancers) can pose diagnostic and therapeutic challenges to surgical management. Adherence to traditional surgical oncologic principles must often be balanced with the patients' clinical presentation and other parameters. While the goal of an R0 (no residual microscopic disease) resection must always be kept in mind, situations sometimes arise which can make this difficult to achieve. Recognition of complicated disease and availability of varied therapeutic modalities is important to ensure favorable patient outcomes. This review will discuss the surgical management of complicated colon cancer, with special focus on locally advanced disease.

Obesity, regardless of comorbidity, influences outcomes after colorectal surgery-time to rethink the pay-for-performance metrics?

An elevated body mass index (BMI) is associated with increased morbidity and mortality after colorectal surgery. While coexistent comorbid conditions are captured in some determinations of case-severity, BMI itself is not factored into pay for performance (P4P) initiatives. From the National Surgical Quality Improvement Program database 2006-2011, obese (BMI ≥30 kg/m(2)) and nonobese (BMI <30 kg/m(2)) patients with and without comorbidity undergoing colorectal resection were identified. Pre- and intraoperative factors as well as postoperative outcomes were compared. Of 130,415 patients, 31.3 % were obese. 80.4 % of obese and 72.9 % of nonobese patients had comorbid conditions. Among obese patients, overall rates of surgical site infection (SSI), wound dehiscence, and various medical complications were significantly higher for those with comorbidity compared to those without (p < 0.001 for all). Obese patients with comorbidity overall had greater risk of renal failure and urinary tract infection than nonobese patients. Regardless of comorbidity, obese patients more commonly had pulmonary embolism, failure to wean from the ventilator, overall SSI, and wound dehiscence. Comorbid factors associated with obesity influence outcomes; however, obesity itself in their absence is associated with worse outcomes. This supports inclusion of obesity as an independent determinant of case-severity, quality, and reimbursement after colorectal surgery.