Acute cholecystitis management at a tertiary care center: are we following current guidelines?

PURPOSE: After the Tokyo 2018 guidelines (TG2018) were published, evidence from the 2018 CHOCOLATE RCT supported early cholecystectomy for acute cholecystitis (AC), even in high-risk patients. This study aims to investigate AC management at our tertiary care center in the years following these publications. METHODS: A retrospective cohort study was performed on patients admitted from 2018 to 2023. AC severity was graded using TG2018 definitions. Comorbidities were summarized using Charlson Comorbidity Index (CCI) and frailty using the 5-item modified Frailty Index (5mFI). Compliance with TG2018 recommendations for management strategy was investigated. Outcomes were compared between patients who underwent surgery versus non-operative management (NOM). Subset analysis based on patients' age, frailty, and comorbidities was performed. RESULTS: Among 642 AC patients, 57% underwent cholecystectomy and 43% NOM (22% percutaneous cholecystostomy, 21% antibiotics only). NOM patients had greater length of stay (LOS), complications, deaths, readmissions, and discharge to nursing/rehab versus surgery patients. In 70% of patients managed non-operatively, TG2018 were not followed. Patients managed non-operatively despite TG2018 were more likely to undergo delayed cholecystectomy compared to those in whom guidelines were followed (17% vs. 4%). In subset analysis, healthy octogenarians were significantly less likely to be managed according to TG2018 (9.4%); patients undergoing surgery had a trend towards shorter LOS (3.1 vs. 4.8 days) than those managed non-operatively but no difference in other outcomes. CONCLUSION: Most patients undergoing NOM could potentially undergo cholecystectomy if guidelines are considered. A more objective approach to risk assessment may optimize patient selection and outcomes.

Desmoid Tumors in Familial Adenomatous Polyposis Patients: Favorable Outcomes with Multidisciplinary Management.

OBJECTIVE: In this study, we aimed to describe the clinical features, management, and outcomes of desmoid tumors (DTs) in familial adenomatous polyposis (FAP) patients at a high-volume sarcoma center. METHODS: Consecutive patients with FAP and DTs were identified from our institutional databases (1985-2021). Patient demographics, treatment, and outcomes were described. Categorical data were compared using Fisher's exact test, and Kaplan-Meier curves were used to estimate progression-free survival (PFS). RESULTS: Forty-five patients with 67 DTs were identified: 39 mesenteric or retroperitoneal (58.2%), 17 abdominal wall (25.4%), 4 extremity (6%), 4 breast (6%) and 3 back (4.4%). Severe DT symptoms were present in 12 patients (26.7%). Initial treatments per tumor were observation in 30 (44.8%) DTs, chemotherapy in 15 (22.4%) DTs, surgery in 10 (14.9%) DTs, and other systemic therapies in 10 (14.9%) DTs. The majority of DTs remained stable with observation or a single intervention (77.8%). Median PFS was 23.4 years (95% confidence interval 7.6-39.2). In the 12 severely symptomatic patients, four patients required more than two interventions for DT control. At a median follow-up of 6.0 years (range 0.7-35.8 years), 33 (73.3%) patients were alive with disease, 7 (15.6%) were alive without disease, and 5 (11.1%) died of other causes. No patients died of DT-related complications. CONCLUSIONS: The majority of DTs in FAP patients remained stable with observation or a single intervention. There were no DT-related deaths; however, 12 of 45 patients (26.7%) experienced significant tumor morbidity and required more interventions for disease control. Further studies on quality of life are required.

Selection of Patients With Rectal Cancer for Preoperative Chemoradiotherapy: Are T Category and Nodal Status All That Matters?

BACKGROUND: Although the accuracy of preoperative MRI staging has been established on follow-up histopathologic examination, the reproducibility of MRI staging has been evaluated in studies with expert radiologists reading a large sample of MRI images and therefore is not generalizable to the real-world setting. OBJECTIVE: The purpose of this study was to evaluate the interrater reliability of MRI for distance to the mesorectal fascia, T category, mesorectal lymph node status, and extramural depth of invasion for preoperative staging of primary rectal cancer. DESIGN: This was a prospective, cross-sectional survey. SETTINGS: The study was conducted in Ontario, Canada. PARTICIPANTS: Participants included GI radiologists. INTERVENTIONS: Participants read 5 preselected staging MRIs using a synoptic report and participated in an educational Webinar. MAIN OUTCOME MEASURES: Distance to the mesorectal fascia, T category, extramural depth of invasion, and mesorectal lymph node status for each MRI were abstracted. Data were analyzed in aggregate using percentage of agreement, Fleiss κ, and interclass correlation coefficients to assess interrater reliability. RESULTS: Reliability was highest for distance to the mesorectal fascia with an intraclass correlation of 0.58 (95% CI, 0.27-0.80). Kappa scores for T category, mesorectal lymph node status, and extramural depth of invasion were 0.38 (95% CI, 0.23-0.46), 0.41 (95% CI, 0.32-0.49), and 0.37 (95% CI, 0.16-0.82). There was no difference when radiologists were stratified by experience or volume. LIMITATIONS: Scores may have been affected by MRI selection, because they were chosen to demonstrate diagnostic challenges for the Webinar and did not reflect a representative sample. CONCLUSIONS: Interrater reliability was highest for distance to mesorectal fascia, and therefore, it may be a more reliable criterion than T category, extramural depth of invasion, or mesorectal lymph node status. Combined with the fact that an uninvolved mesorectal fascia is more consistent with the overall goal of rectal cancer surgery, it should be considered as an important MRI criterion for preoperative treatment decision making in the real-world setting. See Video Abstract at http://links.lww.com/DCR/A763.

Safe laparoscopic subtotal cholecystectomy in the face of severe inflammation in the cystohepatic triangle: a retrospective review and proposed management strategy for the difficult gallbladder

Background: Laparoscopic subtotal cholecystectomy (LSC) can be employed when extensive fibrosis or inflammation of the cystohepatic triangle prohibits safe dissection of the cystic duct and artery. The purpose of this study was to compare postoperative outcomes in patients with severe cholecystitis who underwent laparoscopic cholecystectomy (LC) or LSC. Methods: In this retrospective study, we compared the postoperative outcomes of patients with severe cholecystitis who underwent LC or LSC between July 2010 and July 2016 at St. Joseph's Health Centre, Toronto. We further stratified LSC cases on the basis of the extent of gallbladder (GB) dissection and GB remnant closure. Results: A total of 105 patients who underwent LC and 46 who underwent LSC were included in the study. There were 4 bile duct injuries in the LC group and 0 in the LSC group. Bile leaks (relative risk [RR] 3.4, 95% confidence interval [CI] 1.01­11.5) and subphrenic collections (RR 3.1, 95% CI 1.3­8.0) were more common in the LSC group. Overall postoperative morbidity did not differ significantly between the 2 groups. Postoperative endoscopic retrograde cholangiopancreatography (ERCP) (RR 3.2, 95% CI 1.1­9.5) and biliary stent insertion (RR 4.6, 95% CI 1.2­17.5) were more common in the LSC group. Bile leaks appeared to be more prominent with open GB remnants but all cases of leak were successfully managed with ERCP and biliary stenting. Conclusion: LSC may mitigate the risk of bile duct injury when dissection into the cystohepatic triangle is unsafe. There were more bile leaks in patients who underwent LSC; however, they were readily managed with endoscopic stents. Long-term biliary fistulae were not observed. LSC should be considered early as a means of completing difficult cholecystectomies safely without the need for cholecystostomy tube or conversion to laparotomy.

Contexte: La cholécystectomie laparoscopique subtotale (CLS) peut être utilisée si une fibrose ou une inflammation étendue du triangle cystohépatique empêche l'ablation sécuritaire du canal et de l'artère cystiques. Cette étude avait pour but de comparer les résultats postopératoires chez des patients atteints de cholécystite grave ayant subi une cholécystectomie laparoscopique (CL) ou une CLS. Méthodes: Dans cette étude rétrospective, nous avons comparé les résultats postopératoires des patients atteints de cholécystite grave ayant subi une CL ou une CSL entre juillet 2010 et juillet 2016 au St. Joseph's Health Centre de Toronto. Nous avons ensuite stratifié les cas de CSL selon la proportion de la vésicule biliaire excisée et la suture du reliquat. Résultats: En tout, 105 patients ayant subi une CL et 46 une CLS ont été inclus dans l'étude. On a dénombré 4 lésions du canal cholédoque dans le groupe CL et 0 dans le groupe CLS. Les fuites biliaires (risque relatif [RR] 3,4, intervalle de confiance [IC] de 95 % 1,01­ 11,5) et les collections sous-diaphragmatiques (RR 3,1, IC de 95 % 1,3­8,0) ont été plus fréquentes dans le groupe CSL. Globalement, la morbidité postopératoire n'a pas été significativement différente entre les 2 groupes. La cholangiopancréatographie rétrograde endoscopique (CPRE) postopératoire (RR 3,2, IC de 95 % 1,1­9,5) et la pose d'une endoprothèse biliaire (RR 4,6, IC de 95 % 1,2­17,5) ont été plus fréquentes dans le groupe CLS. Les fuites biliaires ont semblé plus marquées en l'absence de suture des reliquats, mais tous les cas de fuite ont été traités avec succès par CPRE et endoprothèse biliaire. Conclusion: La CLS pourrait atténuer le risque de lésion du canal cholédoque lorsqu'il est contre-indiqué d'intervenir au niveau du triangle cystohépatique. On a observé plus de fuites biliaires chez les patients soumis à la CLS; par contre, ces fuites ont rapidement été corrigées à l'aide d'endoprothèses. Aucune fistule biliaire n'a été observée à long terme. La CLS devrait être envisagé sans tarder pour finaliser sécuritairement les cholécystectomies compliquées sans recourir au drain de cholécystostomie ou à conversion en laparotomie.

Current Delivery of Hyperthermic Intraperitoneal Chemotherapy with Cytoreductive Surgery (CS/HIPEC) and Perioperative Practices: An International Survey of High-Volume Surgeons.

BACKGROUND: Cytoreductive surgery and heated intraperitoneal chemotherapy (CS/HIPEC) is performed for selected indications at a limited number of specialized centers worldwide. Currently there is no standardized approach to the perioperative care process. We sought to capture current practices in the perioperative management of patients who undergo CS/HIPEC at high-volume centers. METHODS: Surgeon members of the American Society of Peritoneal Surface Malignancies working at high-volume CS/HIPEC centers (>10 cases/year) were invited to complete an online survey. The survey included questions relating to preoperative preparation of patients, intraoperative practices, and postoperative care. RESULTS: Ninety-seven surgeons from five continents completed the survey (response rate 55%). The majority (80%) practiced in academic environments. Most respondents (68%) indicated that a formal preoperative preparatory pathway for CS/HIPEC surgery existed at their centers, but few (26%) had used enhanced recovery protocols in this group of patients. Whereas the intraoperative technical practices of the CS/HIPEC procedure were relatively consistent across respondents, there was little agreement on pre- and postoperative care practices, including use of mechanical bowel preparation, nutritional supplementation, methods of perioperative analgesia, timing of physical therapy and ambulation, nasogastric tube and Foley removal, intravenous fluids, blood transfusion parameters, and postoperative use of deep-vein thrombosis prophylaxis and antibiotics. CONCLUSIONS: Perioperative care practices for CS/HIPEC are widely variable nationally and internationally. Standardization of such practices offers an opportunity to incorporate evidence-based interventions and may enhance patient outcomes and improve care standards across all centers that offer this procedure.

Predictors of Pathologic Complete Response Following Neoadjuvant Chemoradiotherapy for Rectal Cancer.

BACKGROUND: Some patients with rectal cancer who receive neoadjuvant chemoradiotherapy (nCRT) achieve a pathologic complete response (pCR) and may be eligible for less radical surgery or non-operative management. The aim of this study was to identify variables that predict pCR after nCRT for rectal cancer and to examine the impact of pCR on postoperative complications. METHODS: A retrospective review was performed of the NCDB from 2006 to 2011. Patients with rectal cancer who received nCRT followed by radical resection were included in this study. Multivariable analysis of the association between clinicopathologic characteristics and pCR was performed, and propensity-adjusted analysis was used to identify differences in postoperative morbidity between pCR and non-pCR patients. RESULTS: A total of 23,747 patients were included in the study. Factors associated with pCR included lower tumor grade, lower clinical T and N stage, higher radiation dose, and delaying surgery by more than 6-8 weeks after the end of radiation, while lack of health insurance was linked with a lower likelihood of pCR. Complete response was not associated with an increased risk of major postoperative complications. CONCLUSIONS: Several clinical, pathologic, and treatment variables can help to predict which patients are most likely to have pCR after nCRT for rectal cancer. Awareness of these variables can be valuable in counseling patients regarding prognosis and treatment options.

Central, But Not Peripheral, Circulating Tumor Cells are Prognostic in Patients Undergoing Resection of Colorectal Cancer Liver Metastases.

BACKGROUND: Colorectal cancer liver metastases (CRLMs) are potentially curable with resection, but most patients recur and succumb to their disease. Clinical covariates do not account for all outcomes. Circulating tumor cells (CTCs) are prognostic in the primary and metastatic settings of breast, prostate and colorectal cancer (CRC), and evolving evidence supports their role in CRLMs. Our objective was to determine whether CTCs in peripheral (PV) and hepatic venous (HV) compartments are associated with disease-free survival (DFS) and overall survival (OS) post-CRLM resection. METHODS: CTCs were measured by CellSearch assay from intraoperative HV and PV samples from 63 patients who underwent CRLM resection from June 2007 to August 2012 at a single center. DFS and OS were primary endpoints. RESULTS: HV CTCs > 3 were associated with shorter DFS and OS, but not PV CTCs, although no significant difference was found between CTC measurements in the two compartments. By univariate analysis, CRC stage and site, CRLM recurrence, and hepatic capsule invasion were also associated with OS, but only HV CTCs and CRC site were significant by multivariate Cox. Only HV CTCs were associated with DFS by multivariate analysis. Cases with elevated HV CTCs had hepatic vein invasion and lymph node metastases, and were younger with larger tumors. CONCLUSIONS: Elevated HV CTCs are prognostic for DFS and OS following CRLM resection. Clinicopathologic features associated with HV CTCs are identifiable preoperatively and should be considered in CRLM surgical decision making. We found no evidence that PV CTCs are prognostic in this setting.

National disparities in minimally invasive surgery for rectal cancer.

BACKGROUND: Social and racial disparities have been identified as factors contributing to differences in access to care and oncologic outcomes in patients with colorectal cancer. The aim of this study was to investigate national disparities in minimally invasive surgery (MIS), both laparoscopic and robotic, across different racial, socioeconomic and geographic populations of patients with rectal cancer. METHODS: We utilized the American College of Surgeons National Cancer Database to identify patients with rectal cancer from 2004 to 2011 who had undergone definitive surgical procedures through either an open, laparoscopic or robotic approach. Inclusion criteria included only one malignancy and no adjuvant therapy. Multivariate analysis was performed to investigate differences in age, gender, race, income, education, insurance coverage, geographic setting and hospital type in relation to the surgical approach. RESULTS: A total of 8633 patients were identified. The initial surgical approach included 46.5% open (4016), 50.9% laparoscopic (4393) and 2.6% robotic (224). In evaluating type of insurance coverage, patients with private insurance were most likely to undergo laparoscopic surgery [OR (odds ratio) 1.637, 95% CI 1.178-2.275], although there was a less statistically significant association with robotic surgery (OR 2.167, 95% CI 0.663-7.087). Patients who had incomes greater than $46,000 and received treatment at an academic center were more likely to undergo MIS (either laparoscopic or robotic). Race, education and geographic setting were not statistically significant characteristics for surgical approach in patients with rectal cancer. CONCLUSIONS: Minimally invasive approaches for rectal cancer comprise approximately 53% of surgical procedures in patients not treated with adjuvant therapy. Robotics is associated with patients who have higher incomes and private insurance and undergo surgery in academic centers.

Key gaps in pathologic reporting for appendiceal mucinous neoplasms: time for universal synoptic reporting?

INTRODUCTION: The prognosis of appendiceal mucinous neoplasms (AMN) is directly related to their histopathology. Existing classification schemes encompass tumors with widely divergent clinical behaviors within a single diagnosis, making it difficult for clinicians to interpret pathology reports to counsel patients on optimal management. We sought to examine pathology reports generated for AMN for inclusion of essential histologic features. METHODS: Pathology reports of appendectomy specimens with a diagnosis of AMN (2002-2015) at our center ("internal") and from referring institutions ("external") were retrospectively reviewed for inclusion of the following 5 essential items: layer of invasion, mucin dissection (low grade neoplasms only), perforation, margins, and serosal implants. RESULTS: Sixty-nine patients were included, 54 with external reports available. Benign/low grade tumors comprised 29.0% and 27.8% of internal and external reports, respectively. Thirty-seven internal reports (53.6%) were signed out by specialist gastrointestinal pathologists. External reports were 66.7% complete for layer of invasion, 26.7% for mucin dissection, 64.8% for perforation, 68.5% for margins, 53.7% for serosal implants, and 18.5% for all items. Internal reports were 75.4% complete for layer of invasion, 40.0% for mucin dissection, 40.6% for perforation, 82.6% for margins, 69.6% for serosal implants, and 17.4% for all items. Eight external (14.8%) and 24 internal (34.8%) reports were synoptic. Synoptic reports were more likely to be complete for all key items both external and internal. CONCLUSION: Most pathology reports are incomplete for essential features needed for management and discussion of AMN with patients. Synoptic reports improve completeness of reporting for these tumors.

Development and implementation of a synoptic MRI report for preoperative staging of rectal cancer on a population-based level.

BACKGROUND: Colorectal cancer physician champions across the province of Ontario, Canada, reported significant concern about appropriate selection of patients for preoperative chemoradiotherapy because of perceived variation in the completeness and consistency of MRI reports. OBJECTIVE: The purpose of this work was to develop, pilot test, and implement a synoptic MRI report for preoperative staging of rectal cancer. DESIGN: This was an integrated knowledge translation project. SETTINGS: This study was conducted in Ontario, Canada. PATIENTS: Surgeons, radiologists, radiation oncologists, medical oncologists, and pathologists treating patients with rectal cancer were included in this study. INTERVENTIONS: A multifaceted knowledge translation strategy was used to develop, pilot test, and implement a synoptic MRI report. This strategy included physician champions, audit and feedback, assessment of barriers, and tailoring to the local context. A radiology webinar was conducted to pilot test the synoptic MRI report. MAIN OUTCOME MEASURES: Seventy-three (66%) of 111 Ontario radiologists participated in the radiology webinar and evaluated the synoptic MRI report. RESULTS: A total of 78% and 90% radiologists expressed that the synoptic MRI report was easy to use and included all of the appropriate items; 82% noted that the synoptic MRI report improved the overall quality of their information, and 83% indicated they would consider using this report in their clinical practice. An MRI report audit after implementation of the synoptic MRI report showed a 39% improvement in the completeness of MRI reports and a 37% uptake of the synoptic MRI report format across the province. LIMITATIONS: Radiologists evaluating the synoptic MRI report and participating in the radiology webinar may not be representative of gastroenterologic radiologists in other geographic jurisdictions. The evaluation of completeness and uptake of the synoptic MRI reports is limited because of unmeasured differences that may occur before and after the MRI. CONCLUSIONS: A synoptic MRI report for preoperative staging of rectal cancer was successfully developed and pilot tested in the province of Ontario, Canada.

Patient decision aids for cancer treatment: are there any alternatives?

BACKGROUND: Although patient decision aids (pDAs) are effective, widespread use of pDAs for cancer treatment has not been achieved. The objectives of this study were to perform a systematic review to identify alternate types of decision support interventions (DSIs) for cancer treatment and a meta-analysis to compare the effectiveness of these DSIs to pDAs. METHODS: The inclusion criteria for the study were: 1) all published studies using a randomized, controlled trial design, and 2) DSIs involving treatment decision-making for breast, prostate, colorectal, and/or lung cancer. For this analysis, DSIs were classified as pDAs if: 1) one reported outcome measure mapped onto the International Patient Decision Aids Standards Collaboration effectiveness criterion, and 2) the DSI was evaluated relative to standard consultation. Random effects models were used to compare the effectiveness of pDAs relative to other identified DSIs for reported outcomes. RESULTS: A total of 71 studies were reviewed, and 24 met the inclusion criteria. Overall, there were no significant differences in knowledge, satisfaction, anxiety, or decisional conflict scores between pDAs and other DSIs. CONCLUSIONS: This study showed that the effectiveness of other DSIs, including question prompt lists and audiorecording of the consultation, is similar to pDAs. This is important because it may be that these less complex DSIs may be all that is necessary to achieve similar outcomes as pDAs for cancer treatment.

Do MRI reports contain adequate preoperative staging information for end users to make appropriate treatment decisions for rectal cancer?

PURPOSE: This study was designed to elicit end-user opinions regarding the importance and diagnostic accuracy of MRI for T-category, threatened or involved circumferential margin (CRMi), and lymph node involvement (LNi) for preoperative staging of rectal cancer and to determine completeness of MRI reports for these elements on a population based level. METHODS: The first part of this study was a mailed survey of surgeons, radiation oncologists, and medical oncologists to elicit their opinions regarding the importance and diagnostic accuracy of T-category, CRMi, and LNi on MRI. The second part of the study was an audit of MRI reports issued for pre-operative staging of rectal cancer to assess the completeness of these reports for T-category, CRMi, and LNi. RESULTS: Although T-category, CRMi, and LNi were considered essential by 97, 94, and 77 % of respondents, respectively, the MRI report audit showed that only 40 % of MRI reports captured all of these elements. The majority of end users reported moderate diagnostic accuracy on MRI for T-category and CRMi and low diagnostic accuracy for LNi (52.3, 43, and 48.5 % respectively). Multivariate analysis showed that specialty was the only independent predictor of correct reporting of the diagnostic accuracy for each of the MRI elements. CONCLUSIONS: While end users consider T-category, CRMi and LNi essential for preoperative staging of rectal cancer, less than 40 % of MRI reports captured all of these elements. Therefore, strategies to improve communication between radiologists and end users are critical to improve the overall quality of care for rectal cancer patients.

Diagnostic accuracy of MRI for assessment of T category, lymph node metastases, and circumferential resection margin involvement in patients with rectal cancer: a systematic review and meta-analysis.

BACKGROUND: Magnetic resonance imaging (MRI) is increasingly being used for rectal cancer staging. The purpose of this study was to determine the accuracy of phased array MRI for T category (T1-2 vs. T3-4), lymph node metastases, and circumferential resection margin (CRM) involvement in primary rectal cancer. METHODS: Medline, Embase, and Cochrane databases were searched using combinations of keywords relating to rectal cancer and MRI. Reference lists of included articles were also searched by hand. Inclusion criteria were: (1) original article published January 2000-March 2011, (2) use of phased array coil MRI, (3) histopathology used as reference standard, and (4) raw data available to create 2×2 contingency tables. Patients who underwent preoperative long-course radiotherapy or chemoradiotherapy were excluded. Two reviewers independently extracted data. Sensitivity, specificity, and diagnostic odds ratio were estimated for each outcome using hierarchical summary receiver-operating characteristics and bivariate random effects modeling. RESULTS: Twenty-one studies were included in the analysis. There was notable heterogeneity among studies. MRI specificity was significantly higher for CRM involvement [94%, 95% confidence interval (CI) 88-97] than for T category (75%, 95% CI 68-80) and lymph nodes (71%, 95% CI 59-81). There was no significant difference in sensitivity between the three elements as a result of wide overlapping CIs. Diagnostic odds ratio was significantly higher for CRM (56.1, 95% CI 15.3-205.8) than for lymph nodes (8.3, 95% CI 4.6-14.7) but did not differ significantly from T category (20.4, 95% CI 11.1-37.3). CONCLUSIONS: MRI has good accuracy for both CRM and T category and should be considered for preoperative rectal cancer staging. In contrast, lymph node assessment is poor on MRI.

Preventive health practices and behavioral risk factors in women surviving traumatic brain injury.

Traumatic brain injury (TBI) affects millions globally and is considered a universal public health concern. Our study addresses a considerable knowledge gap about the health of female survivors of TBI. Using a retrospective cohort study design, we examined behavioral risk factors, access to health screenings, and primary care services among women with a history of moderate to severe TBI. We compared findings with a general female population. Female survivors (n = 75) appeared to have comparable use of primary care services with the general population. Significantly more women reported poor mental health postinjury; reported alcohol consumption was also greater.

Factors associated with mortality and reoperation in 377 children with total anomalous pulmonary venous connection.

BACKGROUND: We sought to determine era-specific changes in the incidence of mortality and reoperation in children with total anomalous pulmonary venous connection. METHODS AND RESULTS: We reviewed the records of 377 children presenting from 1946 to 2005 with total anomalous pulmonary venous connection. Multivariable parametric regression models determined the incidence and risk factors for death and reoperation after repair. Pulmonary venous connection was supracardiac in 44%, infracardiac in 26%, cardiac in 21%, and mixed in 9%. Pulmonary venous obstruction was present in 48% at presentation, most frequently with infracardiac connection type (P<0.001). In total, 327 patients were repaired (median age, 1.7 months). Overall survival from repair was 65+/-6% at 14 years, with a current survival of 97%. Significant (P<0.01) incremental risk factors for postrepair death were cardiac connection type, earlier operation year, younger age at repair, use of epinephrine postoperatively, and postoperative pulmonary venous obstruction. More recent operation year was associated with younger age at repair (P<0.001), decreased use of deep hypothermic circulatory arrest (P<0.001), and use of specific drugs postoperatively (P<0.001). Risk-adjusted estimated 1-year survival for a patient repaired at birth with unfavorable morphology in 2005 is 37% (95% CI, 8 to 80) compared with 96% (95% CI, 91 to 99) for a patient with favorable morphology repaired at 1 year of age. Freedom from reoperation was 82+/-6% at 11 years after repair, with increased risk associated with mixed connection type (P=0.04) and postoperative pulmonary venous obstruction (P<0.001). CONCLUSIONS: Mortality after total anomalous pulmonary venous connection repair has decreased but remains highest in young patients and in those with cardiac connection type or pulmonary venous obstruction. Unfavorable anatomic characteristics remain important determinants of postrepair survival despite improved perioperative care.

Age-related rates of colorectal cancer and the factors associated with overall survival.

BACKGROUND: The purpose of this study was to identify differences in both demographic and pathologic factors associated with the age-related rates of colorectal cancer (CRC) and overall survival (OS). METHODS: The National Cancer Data Base (NCDB), 2004-2013, was queried for patients with CRC. Patients were stratified by age (≤50 vs. ≥60 years). Multivariable analysis was performed to identify factors associated with OS. RESULTS: A total of 670,030 patients were included; 488,121 with colon, and 181,909 with rectal or rectosigmoid cancer. For colon cancer, patients ≤50 years had higher proportions of pathologic stage III and IV disease than patients ≥60 (III: 33.7% vs. 28.6%, IV: 25.5% vs. 14.3%, respectively; P≤0.001). Similar differences were found for patients with rectal cancer (III: 35.8% vs. 28.6%, IV: 16.5% vs. 11.6%, respectively for age ≤50 and ≥60 years; P≤0.001). More aggressive pathologic factors were identified in the ≤50 cohort and were associated with worse OS, including higher tumor grade, lymphovascular invasion (LVI), perineural invasion (PNI), and elevated serum carcinoembryonic antigen (CEA). Disparities associated with OS were also identified for both colon and rectal cancer. For patients ≤50 with CRC, African-American and Hispanic race, lower income and lower education were associated with increased risk of mortality compared to the ≥60 cohort. CONCLUSIONS: There are clear differences in biological factors and in racial and socioeconomic disparities of patients with early onset CRC. Earlier screening should be seriously considered in patients under 50 years who are African-American and Hispanic, as these populations present with more aggressive and advanced disease.

Disparities in the Age-Related Rates of Colorectal Cancer in the United States.

The incidence of colorectal cancer (CRC) among Americans under the age of 50 years is increasing. The purpose of this study was to identify racial and socioeconomic disparities associated with this trend. The National Cancer Data Base was used to identify patients with CRC from 1998 to 2011. Patients were stratified by age (<50 versus >60 years), with ages 50 to 60 years omitted from the analysis to minimize overlapping trends between the two age groups. Relative frequencies (RFs) by year were plotted against demographic variables. Changes in RF over time and intervals from diagnosis to treatment (including surgery and chemotherapy) were compared. A total of 1,213,192 patients were studied; 885,510 patients with colon cancer and 327,682 with rectal or rectosigmoid cancer. Patients <50 years had higher RF for stage III/IV CRC compared with >60 years, with the highest rate of increase in stage III colon cancer (0.198% per year). Patients <50 years had higher RF for CRC if they were African-American or Hispanic. Hispanic patients <50 years had the highest rates of increase for both colon (RF = 0.300% per year) and rectal cancer (RF = 0.248% per year). Compared with race, other variables including education and income were not found to have as strong an association on age-related rates of CRC. No clinically significant differences were observed for time from diagnosis to treatment in either age group. Important racial disparities are associated with differences in age-related CRC rates, warranting further investigation to develop improved strategies for the earlier detection of CRC in these populations.

Lymphovascular and perineural invasion are associated with poor prognostic features and outcomes in colorectal cancer: A retrospective cohort study.

BACKGROUND: Lymphovascular and perineural invasion (LVI and PNI) are associated with poor outcomes in several cancers. We sought to identify clinical variables associated with LVI and PNI in colorectal cancer (CRC) and to determine their impact on survival. METHODS: A retrospective review was performed of the National Cancer Data Base (NCDB), 2004-2011. Patients with CRC and a documented LVI or PNI status were included. Multivariate analysis was conducted to examine the associations between clinical variables and LVI/PNI, PNI and survival, and LVI/PNI and lymph node (LN) status in patients with T1 and T2 tumors. RESULTS: In total, 158,777 patients were included. LVI status was documented for 139,026 patients, 26.3% of whom were positive. PNI status was documented in 142,034 patients, 11.1% of whom were positive. The multivariable model identified a number of pathologic and clinical characteristics associated with the presence of LVI and PNI, including a number of features of advanced CRC. PNI was independently associated with reduced survival (HR 3.55, 95%CI 1.78-7.09). In T1 or T2 tumors, LVI and PNI were significantly associated with LN involvement. CONCLUSIONS: LVI and PNI are associated with advanced CRC. PNI is an independent poor prognostic marker for survival in CRC. LVI and PNI are associated with LN involvement in T1 and T2 tumors. Documentation of LVI and PNI status on biopsy specimens may help in prognostication and decision-making in the management of these early tumors.