Management of non-curative endoscopic resection of T1 colon cancer.

Endoscopic resection techniques enable en-bloc resection of T1 colon cancers. A complete removal of T1 colon cancer can be considered curative when histologic examination of the specimens shows none of the high-risk factors for lymph nodes metastases. Criteria predicting lymph nodes metastases include deep submucosal invasion, poor differentiation, lymphovascular invasion, and high-grade tumor budding. In these cases, complete (R0), local endoscopic resection is considered sufficient as negligible risk of lymph nodes metastases does not outweigh morbidity and mortality associated with surgical resection. Challenges arise when endoscopic resection is incomplete (RX/R1) or high-risk histological features are present. The risk of lymph node metastasis in T1 CRC ranges from 1% to 36.4%, depending on histologic risk factors. Presence of any risk factor labels the patient "high risk," warranting oncologic surgery with mesocolic lymphadenectomy. However, even if 70%-80% of T1-CRC patients are classified as high-risk, more than 90% are without lymph node involvement after oncological surgery. Surgical overtreatment in T1 CRC is a challenge, requiring a balance between oncologic safety and minimizing morbidity/mortality. This narrative review explores the landscape of managing non-curative T1 colon cancer, focusing on the choice between advanced endoscopic resection techniques and surgical interventions. We discuss surveillance strategies and shared decision-making, emphasizing the importance of a multidisciplinary approach.

Hospital variations in failure to rescue after abdominal surgery: a nationwide, retrospective observational study.

OBJECTIVES: This study aims to determine hospital variation and intensive care unit characteristics associated with failure to rescue after abdominal surgery in Norway. DESIGN: A nationwide retrospective observational study. SETTING: All 52 hospitals in Norway performing elective and acute abdominal surgery. PARTICIPANTS: All 598 736 patients undergoing emergency and elective abdominal surgery from 2011 to 2021. PRIMARY OUTCOME MEASURE: Primary outcome was failure to rescue within 30 days (FTR30), defined as in-hospital or out-of-hospital death within 30 days of a surgical patient who developed at least one complication within 30 days of the surgery (FTR30). Other outcome variables were surgical complications and hospital FTR30 variation. Statistical analysis was conducted separately for general surgery and abdominal surgery. RESULTS: The 30-day postoperative complication rate was 30.7 (183 560 of 598 736 surgeries). Of general surgical complications (n=25 775), circulatory collapse (n=6127, 23%), cardiac arrhythmia (n=5646, 21%) and surgical infections (n=4334, 16 %) were most common and 1507 (5.8 %) patients were reoperated within 30 days. One thousand seven hundred and forty patients had FTR30 (6.7 %). The severity of complications was strongly associated with FTR30. In multivariate analysis of general surgery, adjusted for patient characteristics, only the year of surgery was associated with FTR30, with an estimated linear trend of -0.31 percentage units per year (95% CI (-0.48 to -0.15)). The driving distance from local hospitals to the nearest referral intensive care unit was not associated with FTR30. Over the last decade, FTR30 rates have varied significantly among similar hospitals. CONCLUSIONS: Hospital factors cannot explain Norwegian hospitals' significant FTR variance when adjusting for patient characteristics. The national FTR30 measure has dropped around 30% without a corresponding fall in surgical complications. No association was seen between rural hospital location and FTR30. Policy-makers must address microsystem issues causing high FTR30 in hospitals.

Role of preoperative in-hospital delay on appendiceal perforation while awaiting appendicectomy (PERFECT): a Nordic, pragmatic, open-label, multicentre, non-inferiority, randomised controlled trial.

BACKGROUND: Appendicectomy remains the standard treatment for appendicitis. No international consensus exists on the surgical urgency for acute uncomplicated appendicitis, and recommendations vary from surgery without delay to surgery within 24 h. Longer in-hospital delay has been thought to increase the risk of perforation and further morbidity. Therefore, we aimed to compare the rate of appendiceal perforation in patients undergoing appendicectomy scheduled to two different urgencies (<8 h vs <24 h). METHODS: In this pragmatic, open-label, multicentre, non-inferiority, parallel, randomised controlled trial in two hospitals in Finland and one in Norway, patients (aged ≥18 years) with presumed uncomplicated acute appendicitis were randomly assigned (1:1) to an appendicectomy scheduled within 8 h or within 24 h to determine whether longer in-hospital delay (time between randomisation and surgical incision) is not inferior to shorter delay. Patients were excluded in cases of pregnancy, suspicion of perforated appendicitis (C-reactive protein level of ≥100 mg/L, fever >38·5°C, signs of complicated appendicitis on imaging studies, or clinical generalised peritonitis), or other reasons requiring prompt surgery. The recruiters were on-duty surgeons who decided to proceed with the appendicectomy. The randomisation sequence was generated using block randomisation with randomly varying block sizes and stratified by hospital districts; neither physicians nor patients were masked to group assignment. The primary outcome was perforated appendicitis diagnosed during surgery analysed in all patients who received an appendicectomy by intention to treat. The absolute difference in rates of perforated appendicitis was compared between the groups. Complications and other safety outcomes were analysed in all patients who received an appendicectomy. A margin of 5 percentage points was used to establish non-inferiority. This trial was registered at ClinicalTrials.gov (NCT04378868) and is closed to accrual. FINDINGS: Between May 18, 2020, and Dec 31, 2022, 2095 patients were assessed for eligibility, of whom 1822 were randomly assigned to appendicectomy scheduled within 8 h (n=914) or 24 h (n=908). After randomisation, 19 (1%) of 1822 patients were excluded due to protocol violation. 1803 patients were included in the intention-to-treat analyses, 985 (55%) of whom were male and 818 (45%) female. Appendiceal perforation rate was similar between groups (77 [8%] of 907 patients assigned to the <8 h group and 81 [9%] of 896 patients assigned to the <24 h group; absolute risk difference 0·6% [95% CI -2·1 to 3·2], p=0·68; risk ratio 1·065, 95% CI 0·790 to 1·435). No significant difference was found between the complication rates within 30 days (66 [7%] of 907 patients in the <8 h group vs 56 [6%] of 896 patients in the <24 h group; difference -1·0% [-3·3 to 1·3]; p=0·39), and no deaths occurred during this follow-up period. INTERPRETATION: In patients with presumed uncomplicated acute appendicitis, scheduling appendicectomy within 24 h does not increase the risk of appendiceal perforation compared with scheduling appendicectomy within 8 h. The results can be used to allocate operating room resources, for example postponing night-time appendicectomy to daytime. FUNDING: The Finnish Medical Foundation, Mary and Georg Ehrnrooth's Foundation, Biomedicum Helsinki Foundation, and the Finnish Government.

Use and safety of peripherally inserted central catheters and midline catheters in palliative care cancer patients: a retrospective review.

PURPOSE: Some cancer patients in palliative care require intravenous administration of symptom relieving drugs. Peripherally inserted central catheters (PICCs) and midline catheters (MCs) provide easy and accessible intravenous access. However, limited evidence supports the use of these devices in palliative care. The aim was to assess the use, safety, and efficacy of PICC and MC in this patient population. METHODS: A retrospective study of all palliative care cancer patients who received PICC or MC at the Department of Palliative Medicine at Akershus University Hospital between 2020 and 2022. RESULTS: A total of 374 patients were included; 239 patients received a PICC and 135 an MC with a total catheterization duration of 11,698 days. The catheters remained in place until death in 91% of patients, with a median catheter dwell time of 21 days for PICCs and 2 days for MCs. The complication rate was 3.3 per 1000 catheter days, with minor bleeding and accidental dislocation as the most common. The catheters were utilized primarily for opioids and other symptom directed treatments, and 89% of patients received a patient or nurse-controlled analgesia pump. Patients with PICC or MC discharged to home or nursing homes spent 81% of their time out of hospital. CONCLUSION: PICC and MC provide safe parenteral access for palliative care cancer patients where intravenous symptom treatment is indicated. Their use can facilitate intravenous symptom treatment beyond the confines of a hospital and supplement the traditional practice relying on subcutaneous administration.

Abdominal surgical trajectories associated with failure to rescue. A nationwide analysis.

OBJECTIVE: The ability to detect and treat complications of surgery early is essential for optimal patient outcomes. The failure-to-rescue (FTR) rate is defined as the death rate among patients who develop at least one complication after the surgical procedure and may be used to monitor a hospital's quality of surgical care. The aim of this observational study was to explore FTR in Norway and to see if we could identify surgical trajectories associated with high FTR. METHOD: Data on all abdominal surgeries in Norwegian hospitals from 2011 to 2017 were obtained from the Norwegian Patient Registry and linked with the National Population Register. Surgical and other postoperative complication rates and FTR within 30 days (deaths occurring in and out of the hospital) were assessed. We identified surgical trajectories (type of procedures-type of complication-dead/alive at 30 days after operation) associated with the highest volume of deaths (high volume of FTR [FTR-V]) and highest risk of death after a postoperative complication. RESULTS: Of the total 626 052 primary abdominal procedures, 224 871 (35.8%) had at least one complication, which includes 83 037 patients. The most common postoperative complications were sepsis (N = 14 331) and respiratory failure (N = 7970). The high-volume trajectories (FTR-V) were endoscopic retrograde cholangiopancreatography-sepsis-death (N = 294, 13.8%); open colon resections-sepsis-death (N = 279, 28.1%) and procedures with stoma formation-sepsis-death (N = 272, 27%). Similarly, patients operated with embolectomy of the visceral arteries and experiencing postoperative sepsis were associated with an extremely high risk of 30-day FTR of 81.5%. In general, an FTR patient had a higher mean age, an increased rate of emergency surgery and more comorbidity. Hospital size was not associated with FTR. CONCLUSION: At a national level, there exist high-volume and high-risk surgical trajectories associated with FTR. These trajectories represent major targets for quality improvement initiatives.

Educational value of surgical telementoring.

Educating surgeons is a time-consuming process. In addition to theoretical knowledge, the practical tasks of surgical procedures must be mastered. Translation of such knowledge from mentor to mentee may be efficiently done by surgical telementoring (ST). This is a review on surgical telementoring. Recent technological advances have made this tool in surgical education more available and applicable but future applications of ST have to be wisely guided by high-quality trials.

Management of the positive pathologic circumferential resection margin in rectal cancer: A national cancer database (NCDB) study.

BACKGROUND: 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. METHODS: 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). RESULTS: 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). CONCLUSION: 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.

Fracture and embolization of an implantable venous access device in patient with atrial septal defect.

Totally implantable venous access devices (TIVADs) are frequently used for the administration of chemotherapy or parenteral nutrition and have proved to be safe and improve patient quality of life during treatment. Catheter-related infections are the most common complication, whereas catheter fracture and embolization is rarely seen. We present a case of a 61-year-old cancer patient in which the TIVAD fractured and embolized to the patient's left knee 18 months after its initial placement. An endovascular procedure with intraoperative imaging revealed that the catheter had embolized to the popliteal artery and was successfully removed, the only explanation being the presence of an atrial septal defect. A bubble echocardiogram was unsuccessful in confirming the diagnosis. The catheter fracture could be related to an intravascular procedure that was performed 18 months prior to remove fibrin sheaths as a cause of port malfunction, or it could be a case of pinch-off syndrome.

Video-based coaching in surgical education: a systematic review and meta-analysis.

BACKGROUND: In the era of competency-based surgical education, VBC has gained increased attention and may enhance the efficacy of surgical education. The objective of this systematic review was to summarize the existing evidence of video-based coaching (VBC) and compare VBC to traditional master-apprentice-based surgical education. METHODS: We performed a systematic review and meta-analysis of randomized controlled trials (RCT) assessing VBC according to the PRISMA and Cochrane guidelines. The MEDLINE, EMBASE, and COCHRANE and Researchgate databases were searched for eligible manuscripts. Standard mean difference (SMD) of performance scoring scales was used to assess the effect of VBC versus traditional training without VBC (control). RESULTS: Of 627 studies identified, 24 RCTs were eligible and evaluated. The studies included 778 surgical trainees (n = 386 VBC vs. n = 392 control). 13 performance scoring scales were used to assess technical competence; OSATS-GRS was the most common (n = 15). VBC was provided preoperative (n = 11), intraoperative (n = 1), postoperative (n = 10), and perioperative (n = 2). The majority of studies were unstructured, where identified coaching frameworks were PRACTICE (n = 1), GROW (n = 2) and Wisconsin Coaching Framework (n = 1). There was an effect on performance scoring scales in favor of VBC coaching (SMD 0.87, p < 0.001). In subgroup analyses, the residents had a larger relative effect (SMD 1.13; 0.61-1.65, p < 0.001) of VBC compared to medical students (SMD 0.43, 0.06-0.81, p < 0.001). The greatest source of potential bias was absence of blinding of the participants and personnel (n = 20). CONCLUSION: Video-based coaching increases technical performance of medical students and surgical residents. There exist significant study and intervention heterogeneity that warrants further exploration, showing the need to structure and standardize video-based coaching tools.

Tailored Treatment of Colorectal Cancer: Surgical, Molecular, and Genetic Considerations.

Colorectal cancer (CRC) is a complex cancer disease, and approximately 40% of the surgically cured patients will experience cancer recurrence within 5 years. During recent years, research has shown that CRC treatment should be tailored to the individual patient due to the wide variety of risk factors, genetic factors, and surgical complexity. In this review, we provide an overview of the considerations that are needed to provide an individualized, patient-tailored treatment. We emphasize the need to assess the predictors of CRC, and we summarize the latest research on CRC genetics and immunotherapy. Finally, we provide a summary of the significant variations in the colon and rectal anatomy that is important to consider in an individualized surgical approach. For the individual patient with CRC, a tailored treatment approach is needed in the preoperative, operative, and postoperative phase.

Analysis of free text in electronic health records for identification of cancer patient trajectories.

With an aging patient population and increasing complexity in patient disease trajectories, physicians are often met with complex patient histories from which clinical decisions must be made. Due to the increasing rate of adverse events and hospitals facing financial penalties for readmission, there has never been a greater need to enforce evidence-led medical decision-making using available health care data. In the present work, we studied a cohort of 7,741 patients, of whom 4,080 were diagnosed with cancer, surgically treated at a University Hospital in the years 2004-2012. We have developed a methodology that allows disease trajectories of the cancer patients to be estimated from free text in electronic health records (EHRs). By using these disease trajectories, we predict 80% of patient events ahead in time. By control of confounders from 8326 quantified events, we identified 557 events that constitute high subsequent risks (risk > 20%), including six events for cancer and seven events for metastasis. We believe that the presented methodology and findings could be used to improve clinical decision support and personalize trajectories, thereby decreasing adverse events and optimizing cancer treatment.

Predicting colorectal surgical complications using heterogeneous clinical data and kernel methods.

OBJECTIVE: In this work, we have developed a learning system capable of exploiting information conveyed by longitudinal Electronic Health Records (EHRs) for the prediction of a common postoperative complication, Anastomosis Leakage (AL), in a data-driven way and by fusing temporal population data from different and heterogeneous sources in the EHRs. MATERIAL AND METHODS: We used linear and non-linear kernel methods individually for each data source, and leveraging the powerful multiple kernels for their effective combination. To validate the system, we used data from the EHR of the gastrointestinal department at a university hospital. RESULTS: We first investigated the early prediction performance from each data source separately, by computing Area Under the Curve values for processed free text (0.83), blood tests (0.74), and vital signs (0.65), respectively. When exploiting the heterogeneous data sources combined using the composite kernel framework, the prediction capabilities increased considerably (0.92). Finally, posterior probabilities were evaluated for risk assessment of patients as an aid for clinicians to raise alertness at an early stage, in order to act promptly for avoiding AL complications. DISCUSSION: Machine-learning statistical model from EHR data can be useful to predict surgical complications. The combination of EHR extracted free text, blood samples values, and patient vital signs, improves the model performance. These results can be used as a framework for preoperative clinical decision support.

Support Vector Feature Selection for Early Detection of Anastomosis Leakage From Bag-of-Words in Electronic Health Records.

The free text in electronic health records (EHRs) conveys a huge amount of clinical information about health state and patient history. Despite a rapidly growing literature on the use of machine learning techniques for extracting this information, little effort has been invested toward feature selection and the features' corresponding medical interpretation. In this study, we focus on the task of early detection of anastomosis leakage (AL), a severe complication after elective surgery for colorectal cancer (CRC) surgery, using free text extracted from EHRs. We use a bag-of-words model to investigate the potential for feature selection strategies. The purpose is earlier detection of AL and prediction of AL with data generated in the EHR before the actual complication occur. Due to the high dimensionality of the data, we derive feature selection strategies using the robust support vector machine linear maximum margin classifier, by investigating: 1) a simple statistical criterion (leave-one-out-based test); 2) an intensive-computation statistical criterion (Bootstrap resampling); and 3) an advanced statistical criterion (kernel entropy). Results reveal a discriminatory power for early detection of complications after CRC (sensitivity 100%; specificity 72%). These results can be used to develop prediction models, based on EHR data, that can support surgeons and patients in the preoperative decision making phase.

Data-driven Temporal Prediction of Surgical Site Infection.

Analysis of data from Electronic Health Records (EHR) presents unique challenges, in particular regarding nonuniform temporal resolution of longitudinal variables. A considerable amount of patient information is available in the EHR - including blood tests that are performed routinely during inpatient follow-up. These data are useful for the design of advanced machine learning-based methods and prediction models. Using a matched cohort of patients undergoing gastrointestinal surgery (101 cases and 904 controls), we built a prediction model for post-operative surgical site infections (SSIs) using Gaussian process (GP) regression, time warping and imputation methods to manage the sparsity of the data source, and support vector machines for classification. For most blood tests, wider confidence intervals after imputation were obtained in patients with SSI. Predictive performance with individual blood tests was maintained or improved by joint model prediction, and non-linear classifiers performed consistently better than linear models.

Data-driven approach for assessing utility of medical tests using electronic medical records.

OBJECTIVE: To precisely define the utility of tests in a clinical pathway through data-driven analysis of the electronic medical record (EMR). MATERIALS AND METHODS: The information content was defined in terms of the entropy of the expected value of the test related to a given outcome. A kernel density classifier was used to estimate the necessary distributions. To validate the method, we used data from the EMR of the gastrointestinal department at a university hospital. Blood tests from patients undergoing surgery for gastrointestinal surgery were analyzed with respect to second surgery within 30 days of the index surgery. RESULTS: The information content is clearly reflected in the patient pathway for certain combinations of tests and outcomes. C-reactive protein tests coupled to anastomosis leakage, a severe complication show a clear pattern of information gain through the patient trajectory, where the greatest gain from the test is 3-4 days post index surgery. DISCUSSION: We have defined the information content in a data-driven and information theoretic way such that the utility of a test can be precisely defined. The results reflect clinical knowledge. In the case we used the tests carry little negative impact. The general approach can be expanded to cases that carry a substantial negative impact, such as in certain radiological techniques.

Implementation of an electronic surgical referral service. Collaboration, consensus and cost of the surgeon - general practitioner Delphi approach.

BACKGROUND: Poor coordination between levels of care plays a central role in determining the quality and cost of health care. To improve patient coordination, systematic structures, guidelines, and processes for creating, transferring, and recognizing information are needed to facilitate referral routines. METHODS: Prospective observational survey of implementation of electronic medical record (EMR)-supported guidelines for surgical treatment. RESULTS: One university clinic, two local hospitals, 31 municipalities, and three EMR vendors participated in the implementation project. Surgical referral guidelines were developed using the Delphi method; 22 surgeons and seven general practitioners (GPs) needed 109 hours to reach consensus. Based on consensus guidelines, an electronic referral service supported by a clinical decision support system, fully integrated into the GPs' EMR, was developed. Fifty-five information technology personnel and 563 hours were needed (total cost 67,000 £) to implement a guideline supported system in the EMR for 139 GPs. Economical analyses from a hospital and societal perspective, showed that 504 (range 401-670) and 37 (range 29-49) referred patients, respectively, were needed to provide a cost-effective service. CONCLUSION: A considerable amount of resources were needed to reach consensus on the surgical referral guidelines. A structured approach by the Delphi method and close collaboration between IT personnel, surgeons and primary care physicians were needed to reach consensus.