Squamous Cell Carcinoma of the Colon: Evaluation of Treatment Modalities and Survival.

BACKGROUND: Squamous cell carcinoma of the colon (CSCC) is a rare subtype of colon cancer. This study aimed to evaluate treatment strategies and overall survival. METHODS: Utilizing the Surveillance, Epidemiology and End Results Program (SEER) database from 2008-2019, patients 18 years of age with CSCC colon where identified. Treatment strategies and overall survival was summarized using Kaplan Meier analysis and the log-rank test. Adjusted cox proportion hazard ratios were calculated to evaluate the effect of confounding variables. RESULTS: After exclusions, 153 patients met inclusion criteria. The most common treatment modalities included surgery alone (52.1%), surgery and adjuvant chemotherapy (12.9%), and no treatment (26.4%). Kaplan Meier analysis revealed patients undergoing surgery and adjuvant chemotherapy had significant improvements in overall survival (log-rank p=0.002). Cox regression analysis revealed tumor grade (HR: 2.12 95% CI: 1.17-3.86) and receipt of chemotherapy (HR: 2.66 95% CI: 1.23-5.76) as the only factors associated with improvements in OS. CONCLUSIONS: Patients undergoing surgery in combination with chemotherapy had the best overall survival when compared to those that underwent surgery alone. Tumor grade and receipt of chemotherapy were independent associated with overall survival.

A Novel Approach to Analyze Disparities in Colorectal Cancer Screening and Mortality.

INTRODUCTION: Reducing disparities in colorectal cancer (CRC) screening rates and mortality remains a priority. Mitigation strategies to reduce these disparities have largely been unsuccessful. The primary aim is to determine variables in models of healthcare utilization and their association with CRC screening and mortality in North Carolina. METHODS: A cross-sectional analysis of publicly available data across North Carolina using variable reduction techniques with clustering to evaluate association of CRC screening rates and mortality was performed. RESULTS: Three million sixty-five thousand five hundred thirty-seven residents (32.1%) were aged 50 y or more. More than two-thirds (68.8%) were White, while 20.5% were Black. Approximately 61% aged 50 y or more underwent CRC screening (range: 44.0%-80.5%) and had a CRC mortality of 44.8 per 100,000 (range 22.8 to 76.6 per 100,000). Cluster analysis identified two factors, designated social economic education index (factor 1) and rural provider index (factor 2) for inclusion in the multivariate analysis. CRC screening rates were associated with factor 1, consisting of socioeconomic and education variables, and factor 2, comprised of the number of providers per 10,000 individuals aged 50 y or more and rurality. An increase in both factors 1 and 2 by one point would result in an increase in CRC screening rated by 6.8%. CRC mortality was associated with factor 2. An increase in one point in factor 1 results in a decrease in mortality risk by 10.9%. CONCLUSIONS: In North Carolina, using variable reduction with clustering, CRC screening rates were associated with the inter-relationship of the number of providers and rurality, while CRC mortality was associated with the inter-relationship of social, economic, and education variables.

An analysis of virtual reality in abdominal surgery-A scoping review.

BACKGROUND: The integration of virtual reality (VR) in surgery has gained prominence as VR applications have increased in popularity. METHODS: A scoping review was undertaken, gathering the most relevant sources, utilising a detailed literature search of medical and academic databases including EMBASE, PubMed, Cochrane, IEEE, Google Scholar, and the Google search engine. RESULTS: Of the 18 articles included, 7 focused on VR in colon surgery, 5 addressed VR in pancreas surgery, and the remaining 6 concentrated on VR in liver surgery. All the articles concluded that VR has a promising future in abdominal surgery by facilitating precision, visualisation, and surgeon training. CONCLUSIONS: Adopting VR technology in abdominal surgery has the potential to improve preoperative planning, decrease perioperative anxiety among patients, and facilitate the training of surgeons, residents, and medical students. Additional supporting studies are necessary before VR can be widely implemented in surgical care delivery.

Rectal cancer presentation during the COVID-19 pandemic: Are decreasing screening rates leading to an increase in acute presentations?

Nearly 23 million adults ages 50-75 are overdue for colorectal cancer (CRC) screening. In March 2020, the Centers for Medicare & Medicaid issued guidance that all non-urgent procedures be delayed due to the COVID-19 pandemic. Screening delays may have effects on the presentation of rectal cancer and the natural history of the disease. The aim of this study was to determine if procedural suspension due to the COVID-19 pandemic was associated with an increased proportion of acute presentations or more advanced stage at diagnosis for patients with rectal cancer. We conducted a single-center, retrospective review of adult patients with new or recurrent rectal adenocarcinoma from 2016-2021. We compared patients presenting before (pre-COVID) to those diagnosed after (COVID) March 1, 2020. Of 208 patients diagnosed with rectal cancer, 163 were diagnosed pre-COVID and 45 patients in the COVID group. Cohorts did not differ among age, sex, race, insurance status, marital status, rurality, or BMI. There was no difference in stage at presentation with the majority diagnosed with stage III disease (40.0% vs 33.3%, p = 0.26). Similar proportions of patients presented acutely (67.5% vs 64.4%, p = 0.71). Presenting symptoms were also similar between cohorts. On adjusted analysis, male sex, white race, and uninsured status were found to have significant impact acuity of presentation, while diagnosis before or after the onset of the pandemic remained non-significant (OR 1.25, 95% CI0.57-2.72; p = 0.59). While screening rates have decreased during the COVID pandemic, patients with rectal cancer did not appear to have an increased level of acuity or stage at presentation. These findings could result from the indolent nature of the disease and may change as the pandemic progresses.

Second Primary Cancer Among Patients With Papillary Thyroid Carcinoma Following the Chernobyl Disaster.

Importance: To our knowledge, there are no complete population-based studies of the risks of developing second malignant tumors after papillary thyroid carcinoma (PTC) in patients following the Chernobyl nuclear accident. Objective: To study the risk of second primary cancers in patients with PTC after the Chernobyl disaster. Design, Setting, and Participants: This was a retrospective cohort study conducted in the Republic of Belarus over a 31-year time frame evaluating patients with primary PTC and second malignant tumors. Personal data from the Belarussian Cancer Registry were used in the investigation, and only second primary cancers were included in the analysis. Patients were observed from January 1, 1990, to December 31, 2021, for the establishment of second primary malignant tumors. Main Outcomes and Measures: For analysis, synchronous and metachronous tumors were grouped into 1 group (second primary cancer group). If the patient had more than 2 cancers, they were observed until development of a second tumor and, subsequently, the development of a third tumor. The starting point for calculating the number of person-years was the date of thyroid cancer diagnosis. The end point for calculating the number of person-years was the date of diagnosis of the second primary malignant tumor, the date of death, the date of the last visit of the patient, or December 31, 2021 (the end the of study period). The incidence of a second primary malignant tumor with PTC was calculated for the study groups using standardized incidence ratios. Results: Of the 30 568 patients with a primary PTC included in this study, 2820 (9.2%) developed a second malignant tumor (2204 women and 616 men); the mean (SD) age of all patients at time of the primary cancer was 53.9 (12.6) years and at time of the secondary cancer was 61.5 (11.8) years. Overall, the standardized incidence ratio was statistically significant for all types of cancer (1.25; 95% CI, 1.21-1.30), including solid malignant tumors (1.20; 95% CI, 1.15-1.25) and all leukemias (1.61; 95% CI, 2.17-2.13). Cancers of the digestive system (466 cases [21.1%]), genital organs (376 cases [17.1%]), and breasts (603 cases [27.4%]) were the most prevalent second primary tumors in women following PTC. Second primary tumors of the gastrointestinal tract (146 cases [27.7%]), genitourinary system (139 cases [22.6%]), and urinary tract (139 cases [22.6%]) were the most prevalent in men. Urinary tract cancers (307 cases [10.9%]) and gastrointestinal tumors (612 cases [21.4%]) were the most prevalent second primary tumors overall. Conclusions and Relevance: This cohort study reports the increased incidence of solid secondary tumors in men and women over a 31-year time frame after the Chernobyl disaster. Moreover, there was a statistically significant increased risk of second tumors of the breast, colon, rectum, mesothelium, eye, adnexa, meninges, and adrenal glands as well as Kaposi sarcoma. These data might have an effect on the follow-up of this cohort of patients to detect secondary malignant tumors at an early stage.

Syphilitic proctitis presenting as locally advanced rectal cancer: A case report.

INTRODUCTION: Syphilis is an infectious disease that is uncommonly encountered in surgical patients. We present a case of severe syphilitic proctitis leading to large bowel obstruction with imaging findings mimicking locally advanced rectal cancer. PRESENTATION OF CASE: A 38-year-old man who had sex with men presented to the emergency department with a 2 week history of obstipation. The patient's medical history was significant for poorly controlled HIV. Imaging demonstrated a large mass in the rectum and the patient was admitted to the colorectal surgery service for management of presumed rectal cancer. Sigmoidoscopy demonstrated a rectal stricture and biopsies showed severe proctitis without evidence for malignancy. Given the patient's history and discordant clinical findings an infectious workup was pursued. The patient tested positive for syphilis and was diagnosed with syphilitic proctitis. He underwent treatment with penicillin and although he experienced a Jarisch-Herxheimer reaction, his bowel obstruction completely resolved. Final pathology on the rectal biopsies demonstrated positive Warthin-Starry and spirochete immunohistochemical stain. DISCUSSION: This case illustrates key aspects in the care of a patient with syphilitic proctitis mimicking an obstructing rectal cancer, including the need for high clinical suspicion, thorough evaluation including sexual and sexually transmitted disease history, multidisciplinary communication, and management of the Jarisch-Herxheimer reaction. CONCLUSION: Severe proctitis leading to large bowel obstruction is a possible presentation of syphilis, and a high degree of clinical suspicion is necessary to be able to accurately identify the cause. An increased awareness of the Jarisch-Herxheimer reaction following treatment of syphilis is critical to provide appropriate care in this patient population.

Association of Rural Residence and Receipt of Guideline-Concordant Care for Locoregional Colon Cancer.

BACKGROUND: Incidence and mortality rates of colon cancer (CC) are higher in rural populations. This study aimed to determine whether rural residence is associated with differences in guideline-concordant care for patients with locoregional CC. METHODS: Patients with stages I-III CC from 2006 to 2016 were identified in the National Cancer Database. Guideline-concordant care (GCC) was defined as resection with negative margins, adequate nodal harvest, and receipt of adjuvant chemotherapy for patients with high-risk stage II or III disease. Multivariable logistic regression (MVR) was performed to evaluate the association between rural residence and the odds of receiving GCC. Effect modification was evaluated using a two-way interaction for rurality by insurance status. RESULTS: Of 320,719 identified patients, 6191 (2%) were rural. The rural patients had lower income and lower educational status than the urban patients and were more often Medicare-insured (p < 0.001). The rural patients traveled farther (44.5 vs. 7.5 miles; p < 0.001), although time to surgery was similar (8 vs. 9 days). The two cohorts had similar resection rates (98.8% vs. 98.0%), margin positivity (5.4% vs. 4.8%), adequate lymphadenectomy (80.9% vs. 83.0%), adjuvant chemotherapy (stage III: 69.2% vs. 68.7%), and receipt of GCC (66.5% vs. 68.3%). In the MVR, the odds of receiving GCC did not differ between the rural and urban patients (odds ratio, 0.99; 95% confidence interval, 0.94-1.05%). Insurance status did not differentially influence the receipt of GCC by the rural versus the urban patients (interaction: p = 0.83). CONCLUSIONS: Rural and urban patients with locoregional CC are equally likely to receive GCC, suggesting that differences in cancer care delivery may not explain rural-urban disparities.

Robotic colorectal surgery: quality assessment of patient information available on the internet using webscraping.

The primary goal of this study is to assess current patient information available on the internet concerning robotic colorectal surgery. Acquiring this information will aid in patients understanding of robotic colorectal surgery. Data was acquired through a web-scraping algorithm. The algorithm used two Python packages: Beautiful Soup and Selenium. The long-chain keywords incorporated into Google, Bing and Yahoo search engines were 'Da Vinci Colon-Rectal Surgery', 'Colorectal Robotic Surgery' and 'Robotic Bowel Surgery'. 207 websites resulted, were sorted and evaluated according to the ensuring quality information for patients (EQIP) score. Of the 207 websites visited, 49 belonged to the subgroup of hospital websites (23.6%), 46 to medical centers (22.2%), 45 to practitioners (21.7%), 42 to health care systems (20,2%), 11 to news services (5.3%), 7 to web portals (3.3%), 5 to industry (2.4%), and 2 to patient groups (0.9%). Only 52 of the 207 websites received a high rating. The quality of available information on the internet concerning robotic colorectal surgery is low. The majority of information was inaccurate. Medical facilities involved in robotic colorectal surgery, robotic bowel surgery and related robotic procedures should develop websites with credible information to guide patient decisions.

Association of distance traveled on receipt of surgery in patients with locally advanced rectal cancer.

PURPOSE: Studies have shown patients residing in rural settings have worse cancer-related outcomes than those in urban settings. Specifically, rural patients with colorectal cancer have lower rates of screening and longer time to treatment. However, physical distance traveled has not been as well studied. This study sought to determine disparities in receipt of surgery in patients by distance traveled for care. METHODS: A retrospective cohort study of patients with AJCC stage II/III rectal adenocarcinoma was identified within the National Cancer Database (2004-2017). Primary outcome was correlation of distance traveled to receipt of surgery. Multi-variable logistic regression was used to adjust for confounding factors. RESULTS: 65,234 patients were included in the analysis. 94.6% resided in urban-metro areas while 2.2% resided in rural areas. Patients were predominantly non-Hispanic White (NHW) (75.2%) with an overall median age at diagnosis of 61 (IQR 52-71). Overall, 82.6% of patients received surgery. NHW patients were more likely to receive surgery than non-Hispanic Black patients (OR 0.67; 95% CI 0.61-0.73, p < 0.001), as were patients who were privately insured (OR 1.90, 95% CI 1.67-2.15, p < 0.001) or had Medicare (OR 1.68, 95% CI 1.47-1.92, p < 0.001) compared to uninsured patients. Patients traveling distances in the 4th quartile (median 47.9 miles) were more likely to receive surgery than those traveling the shortest distances (1st quartile: median 2.5 miles) (OR 1.37, 95% CI 1.24-1.50, p < 0.001). CONCLUSION: Patients traveling farther distances were more likely to receive surgery than those traveling shorter distances. Shorter distance traveled does not appear to be associated with higher rates of surgical resection in patients with stage II/III rectal cancer.

Developing and validating a multivariable prediction model for predicting the cost of colon surgery.

Hospitals are burdened with predicting, calculating, and managing various cost-affecting parameters regarding patients and their treatments. Accuracy in cost prediction is further affected when a patient suffers from other health issues that hinder the traditional prognosis. This can lead to an unavoidable deficit in the final revenue of medical centers. This study aims to determine whether machine learning (ML) algorithms can predict cost factors based on patients undergoing colon surgery. For the forecasting, multiple predictors will be taken into the model to provide a tool that can be helpful for hospitals to manage their costs, ultimately leading to operating more cost-efficiently. This proof of principle will lay the groundwork for an efficient ML-based prediction tool based on multicenter data from a range of international centers in the subsequent phases of the study. With a mean absolute percentage error result of 18%-25.6%, our model's prediction showed decent results in forecasting the costs regarding various diagnosed factors and surgical approaches. There is an urgent need for further studies on predicting cost factors, especially for cases with anastomotic leakage, to minimize unnecessary hospital costs.

Emergency Surgery for Diverticulitis: Relationship of Outcomes to Patient Age and Surgical Procedure.

OBJECTIVES: To compare outcomes in emergent surgical treatment of acute diverticulitis in the older population. DESIGN: Retrospective multi-institute database cohort analysis. SETTINGS AND PARTICIPANTS: American College of Surgeons National Surgical Quality Improvement Project (ACS NSQIP) and NSQIP Colectomy Targeted Database. METHODS: The American College of Surgeons National Surgical Quality Improvement Project Colectomy Targeted Database was merged with the main participate use file to identify adult patients undergoing emergent Hartmann procedure or primary anastomosis with diverting loop ileostomy for acute diverticulitis. Patients were subdivided into age cohorts (<65 years, 65-79 years, ≥80 years) and primary postoperative outcomes including mortality, morbidity, and readmission were compared using multivariate regression. RESULTS: A total of 6091 patients were identified. On multivariate analysis, 30-day mortality was higher in patients undergoing a Hartmann procedure aged 65-79 years [odds ratio (OR) 2.39, P < .001] and ≥80 years (OR 6.28, P < .001) compared to patients aged <65 years. In patients undergoing a primary anastomosis with diverting loop ileostomy, 30-day morbidity was lower only in the cohort aged ≥80 years (OR 2.63, P = .04). Readmission rates were similar across age groups within each procedure cohort. Comparing the 2 procedures, readmission rates in patients aged 65-79 years who underwent a Hartmann procedure were lower than those that underwent a primary anastomosis with diverting loop ileostomy (OR 2.43, P = .001). In patients aged ≥80 years, readmission rates were lower in patients who underwent a primary anastomosis with diverting loop ileostomy (OR 0.12, P = .04). Thirty-day mortality was also lower in patients aged ≥80 years if they underwent a primary anastomosis with diverting loop ileostomy (OR 0.15, P = .03) but similar for patients aged 65-79 years (OR 0.81, P = .70). CONCLUSION AND IMPLICATIONS: In patients undergoing a Hartmann procedure emergently for diverticulitis, mortality is higher in older patients. Patients aged ≥ 80 years had increased mortality if they underwent a Hartmann procedure compared to a primary anastomosis with diverting ileostomy; however, readmission rates vary with procedure performed. Careful consideration of age should be taken into account when operating emergently for diverticulitis.

Insurance Status in Rectal Cancer is Associated With Age at Diagnosis and May be Associated With Overall Survival.

BACKGROUND: There are approximately 44 180 new cases of rectal cancer diagnosed annually. While surgical resection remains the standard of care for definitive treatment, neoadjuvant chemoradiation therapy (NCRT) has significantly reduced recurrence rates postoperatively. NCRT is indicated for T3/T4 tumors, and relative indications include patients with T1/T2 lesions with clinically positive nodes. While this remains the standard of care, all patients may not receive equal treatment for their rectal cancer depending on various healthcare disparities. We aimed to discover how insurance status affected rectal cancer patients' time of diagnosis to treatment, age of diagnosis, and overall vitality. METHODS: A single-center retrospective chart and cancer registry review was performed for all patients diagnosed with rectal cancer of any stage between 2011 and 2018. A total of 94 rectal cancer patients were included in the analysis. Age, race, sex, insurance status, vitality, and grade were assessed. Time in days of diagnosis to the time of first treatment (neoadjuvant chemotherapy or radiation) was measured. Continuous variables were reported as means and SDs or medians and interquartile ranges and were analyzed with the unpaired t-test or Mann-Whitney U-test. Categorical variables were reported as frequencies and percentages and were analyzed with Fisher's exact test. Statistical significance was determined with a P < .05. All analyses were conducted using SAS version 9.4 (SAS Institute, Cary, NC, USA). RESULTS: Total race breakdown was as follows: white (61%), African-American (30%), and other (3%). There was no statistically significant difference in diagnosis time to first treatment in the uninsured versus insured groups (P = .9). There was a statistically significant difference in the age of diagnosis with insured mean age of 60.9 years and uninsured mean age of 52.4 years (P = .0080). There was no statistically significant difference in survival between the 2 groups (P = .54). For those who went onto have surgery, there was no difference in the median number of lymph nodes harvested between the 2 groups (P = .73). CONCLUSION: Insurance status did not affect timing to treatment or survival. Uninsured patients had a younger age of diagnosis by approximately 8 years on average. Uninsured patients received the same quality surgeries as uninsured patients in regard to lymph node harvests.

Post-Operative Infection Prediction and Risk Factor Analysis in Colorectal Surgery Using Data Mining Techniques: A Pilot Study.

Background: Post-operative infections have many negative consequences for patients' health and the healthcare system. Among other things, they increase the recovery time and the risk of re-admission. Also, infection results in penalties for hospitals and decreases the quality performance measures. Surgeons can take preventive actions if they can identify high-risk patients. The purpose of this study was to develop a model to help predict those patients at risk for post-operative infection. Methods: A retrospective analysis was conducted on patients with colorectal post-operative infections. Univariable analysis was used to identify the features associated with post-operative infection. Then, a support vector classification-based method was employed to select the right features and build prediction models. Decision tree, support vector machine (SVM), logistic regression, naïve Bayes, neural network, and random forest algorithms were implemented and compared to determine the performance algorithm that best predicted high-risk patients. Results: From 2016 to the first quarter of 2017, 208 patients who underwent colorectal resection were analyzed. The factors with a statistically significant association (p < 0.05) with post-operative infections were elective surgery, origin status, steroid or immunosuppressant use, >10% loss of body weight in the prior six months, serum creatinine concentration, length of stay, unplanned return to the operating room, administration of steroids or immunosuppressants for inflammatory bowel disease, use of a mechanical bowel preparation, various Current Procedural Terminology (CPT) codes, and discharge destination. However, accurate prediction models can be developed with seven factors: age, serum sodium concentration, blood urea nitrogen, hematocrit, platelet count, surgical procedure time, and length of stay. Logistic regression and SVM were stable models for predicting infections. Conclusion: The models developed using the pre-operative features along with the full list of features helped us interpret the results and determine the significant factors contributing to infections. These factors present opportunities for proper interventions to mitigate infection risks and their consequences.

Operative time and length of stay is similar between robotic assisted and laparoscopic colon and rectal resections.

Robotic-assisted surgery is increasingly being utilized for colorectal surgery. Data are scarce and contradictory when outcomes are compared between robotic and laparoscopic surgery. All patients undergoing minimally invasive colorectal surgery were compared from 2011 to 2016. Outcomes between the two groups were statistically analyzed. p < 0.05 was considered statistically significant. 185 patients underwent laparoscopic resection and 70 underwent robotic resection. Demographics, ASA score, and BMI were similar between the two groups (p > 0.05). There was no statistical difference in median length of stay between laparoscopic and robotic colon (both 4 days; p = 0.5) and rectal (6 vs 4.5 days; p = 0.2) resections. Median operative times were also similar between the two approaches for colon (150.5 vs 169.5 min, p = 0.2) and rectal (197.0 vs 231.5 min, p = 0.9) resections. There was also no difference in operative time between the two approaches for right (median = 137 vs 130.5 min; p = 0.9) and left (median = 162.0 vs 170.5 min; p = 0.6) colectomies. Robotic surgery results in similar operative times and length of stay as laparoscopic surgery for patients undergoing colon and rectal resections.

Presenting Stage in Colon Cancer Is Associated with Insurance Status.

Colorectal cancer continues to be the third most common cause of cancer death in the United States. Access to health care is also a nationwide problem. The purpose of the current study is to see if insurance status is associated with stage of colon cancer at presentation. The tumor registry was queried for all patients with colon cancer from 2009 to 2014. Demographics, including insurance status was statistically analyzed to determine if an association existed between insurance status and stage of colon cancer at the time of presentation. There were 434 patients identified that underwent colonic resection during the study period; 224 were female and 210 were male. Of the 434 patients, 388 were insured and 46 were uninsured. When insurance status was compared with stage at diagnosis there was a statistically significant difference between the two groups. For patients that were uninsured, 13.01 per cent presented with stage I disease, 15.22 per cent with stage II disease, 34.78 per cent with stage III disease, and 36.96 with stage IV disease. For insured patients, 24.03 per cent present with stage I disease, 26.10 with stage II disease, 23.26 per cent with stage III disease, and 29.61 per cent with stage IV disease (P = 0.047). Access to health care continues to be a large problem and results in patients without insurance presenting with a high stage of disease.