Precision cut intestinal slices, a novel model of acute food allergic reactions.

BACKGROUND: Food allergy affects up to 10% of the pediatric population. Despite ongoing efforts, treatment options remain limited. Novel models of food allergy are needed to study response patterns downstream of IgE-crosslinking and evaluate drugs modifying acute events. Here, we report a novel human ex vivo model that displays acute, allergen-specific, IgE-mediated smooth muscle contractions using precision cut intestinal slices (PCIS). METHODS: PCIS were generated using gut tissue samples from children who underwent clinically indicated surgery. Viability and metabolic activity were assessed from 0 to 24 h. Distribution of relevant cell subsets was confirmed using single nucleus RNA sequencing. PCIS were passively sensitized using plasma from peanut allergic donors or peanut-sensitized non-allergic donors, and exposed to various stimuli including serotonin, histamine, FcɛRI-crosslinker, and food allergens. Smooth muscle contractions and mediator release functioned as readouts. A novel program designed to measure contractions was developed to quantify responses. The ability to demonstrate the impact of antihistamines and immunomodulation from peanut oral immunotherapy (OIT) was assessed. RESULTS: PCIS viability was maintained for 24 h. Cellular distribution confirmed the presence of key cell subsets including mast cells. The video analysis tool reliably quantified responses to different stimulatory conditions. Smooth muscle contractions were allergen-specific and reflected the clinical phenotype of the plasma donor. Tryptase measurement confirmed IgE-dependent mast cell-derived mediator release. Antihistamines suppressed histamine-induced contraction and plasma from successful peanut OIT suppressed peanut-specific PCIS contraction. CONCLUSION: PCIS represent a novel human tissue-based model to study acute, IgE-mediated food allergy and pharmaceutical impacts on allergic responses in the gut.

External validation of the Codman score in colorectal surgery: a pragmatic tool to drive quality improvement.

AIM: The simple six-variable Codman score is a tool designed to reduce the complexity of contemporary risk-adjusted postoperative mortality rate predictions. We sought to externally validate the Codman score in colorectal surgery. METHODS: The American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) participant user file and colectomy targeted dataset of 2020 were merged. A Codman score (composed of six variables: age, American Society of Anesthesiologists score, emergency status, degree of sepsis, functional status and preoperative blood transfusion) was assigned to every patient. The primary outcome was in-hospital mortality and secondary outcome was morbidity at 30 days. Logistic regression analyses were performed using the Codman score and the ACS NSQIP mortality and morbidity algorithms as independent variables for the primary and secondary outcomes. The predictive performance of discrimination area under receiver operating curve (AUC) and calibration of the Codman score and these algorithms were compared. RESULTS: A total of 40 589 patients were included and a Codman score was generated for 40 557 (99.02%) patients. The median Codman score was 3 (interquartile range 1-4). To predict mortality, the Codman score had an AUC of 0.92 (95% CI 0.91-0.93) compared to the NSQIP mortality score 0.93 (95% CI 0.92-0.94). To predict morbidity, the Codman score had an AUC of 0.68 (95% CI 0.66-0.68) compared to the NSQIP morbidity score 0.72 (95% CI 0.71-0.73). When body mass index and surgical approach was added to the Codman score, the performance was no different to the NSQIP morbidity score. The calibration of observed versus expected predictions was almost perfect for both the morbidity and mortality NSQIP predictions, and only well fitted for Codman scores of less than 4 and greater than 7. CONCLUSION: We propose that the six-variable Codman score is an efficient and actionable method for generating validated risk-adjusted outcome predictions and comparative benchmarks to drive quality improvement in colorectal surgery.

Anal Adenocarcinoma: A Rare Entity in Need of Multidisciplinary Management.

BACKGROUND: Anal adenocarcinoma is a rare clinical entity for which the optimal management is not defined. OBJECTIVE: This study aimed to describe the multidisciplinary management and outcomes of patients with anal adenocarcinoma. DESIGN: This is a retrospective cohort study. SETTING: This study was conducted at a quaternary cancer center. PATIENTS: Men and women with anal adenocarcinoma treated between 1995 and 2016 were selected. INTERVENTIONS: Fifty-two patients were treated with either chemoradiotherapy or trimodality therapy including radiation therapy, chemotherapy, and surgical resection. MAIN OUTCOME MEASURES: Local failure, regional failure, and distant metastasis rates were estimated using the cumulative incidence method. The Kaplan-Meier method was used to estimate progression-free survival and overall survival. The multivariable Cox proportional hazards model was used to evaluate the clinical predictors of outcome. RESULTS: There was a higher 5-year rate of local failure in patients treated with chemoradiotherapy compared with trimodality therapy (53% vs 10%; p < 0.01). The 5-year incidence of distant metastases was 29% (trimodality therapy) versus 30% (chemoradiotherapy; p = 0.9); adjuvant chemotherapy did not reduce the incidence of distant metastases (p = 0.8). Five-year overall survival was 73% (trimodality therapy) versus 49.4% (chemoradiotherapy; p = 0.1). On multivariable analysis, factors associated with worse overall survival were treatment with chemoradiotherapy, cT3-4 category disease, and node-positive disease. LIMITATIONS: This study is limited by its small sample size and retrospective nature. CONCLUSIONS: Although treatment may continue to be tailored to individual patients, better outcomes with a trimodality therapy approach were observed. See Video Abstract at http://links.lww.com/DCR/B708.ADENOCARCINOMA ANAL: UNA ENTIDAD POCO FRECUENTE EN NECESIDAD DE UN MANEJO MULTIDISCIPLINARIO. ANTECEDENTES: El adenocarcinoma anal es una entidad clínica poco frecuente por lo que aún no se define el manejo óptimo. OBJETIVO: Describir el manejo multidisciplinario y los resultados de los pacientes con adenocarcinoma anal. DISEO: Estudio de cohorte retrospectivo. ENTORNO CLINICO: Centro de cáncer cuaternario. PACIENTES: Hombres y mujeres con adenocarcinoma anal tratados entre 1995 y 2016. INTERVENCIONES: Cincuenta y dos pacientes fueron tratados con quimiorradioterapia o terapia trimodal que incluyó: radioterapia, quimioterapia y resección quirúrgica. PRINCIPALES MEDIDAS DE VALORACION: Se estimaron las tasas de falla local, falla regional y metástasis a distancia mediante el método de incidencia acumulada. Se utilizó el método de Kaplan-Meier para estimar la supervivencia libre de progresión y la supervivencia global. Los riesgos proporcionales de multivariable Cox se utilizaron para evaluar los predictores clínicos de los resultados. RESULTADOS: Hubo una mayor tasa de falla local a cinco años en pacientes tratados con quimiorradioterapia en comparación con terapia trimodal (53% vs 10%; p < 0,01). La incidencia a cinco años de metástasis a distancia fue del 29% (terapia trimodal) versus 30% (quimiorradioterapia) (p = 0,9); la quimioterapia adyuvante no redujo la incidencia de metástasis a distancia (p = 0,8). La supervivencia global a cinco años fue del 73% (terapia trimodal) versus 49,4% (quimiorradioterapia); p = 0,1. En el análisis multivariable, los factores asociados con una peor supervivencia general fueron el tratamiento con quimiorradioterapia, enfermedad de categoría cT3-4 y enfermedad con ganglios positivos. LIMITACIONES: Este estudio está limitado por su pequeño tamaño de muestra y su naturaleza retrospectiva. CONCLUSIONES: Aunque el tratamiento puede seguir adaptándose a pacientes individuales, se observaron mejores resultados con un enfoque TTM. Conslute Video Resumen en http://links.lww.com/DCR/B708. (Traducción- Dr. Francisco M. Abarca-Rendon).

Post-operative outcomes in patients with locally advanced colon cancer: a comparison of operative approach.

INTRODUCTION: Surgeons may choose an open approach to locally advanced colon cancer (LACC) because of the elevated conversion rate (minimally invasive to open) in these patients (resulting in part from a judgment of the technical feasibility of a minimally invasive approach). Poorer outcomes have been suggested in those requiring conversion from a minimal access to an open approach; however, the influence of conversion has not been studied in LACC. We sought to compare perioperative outcomes in patients with T4aN2 colon cancer undergoing minimally invasive surgery (MIS), planned open (PO), and converted (CN) procedures to evaluate the influence of conversion in this subgroup. METHODS: A retrospective cohort study was conducted using the NSQIP database. Patients with T4aN2 colon cancer undergoing elective resection were included; rectal/unknown tumor location, and T4b disease were excluded (to ensure homogeneity in surgical management). Patients were divided into cohorts based on approach: PO, MIS, and CN. Summary statistics were compared between groups. Multivariable analysis was conducted for mortality and morbidity outcomes. RESULTS: 1286 cases were included (313 PO, 842 MIS, 131 CN); 10.2% underwent conversion. Those undergoing MIS had a shorter length of stay than those undergoing PO or CN (p < 0.0001). On univariable analysis, CN resulted in increased rates of any complication (p < 0.0001). CN also had a greater rate of anastomotic leak (p = 0.0046) and death (p = 0.05). On multivariable analysis, significant predictors of any complication included age, ASA class, M stage, and approach; however, CN did not increase the risk of complication compared with MIS, whereas PO nearly doubled the risk of complication (OR = 1.98, p = 0.0083). The only significant predictor of mortality on multivariable analysis was age (HR = 1.09, p = 0.0002)-approach was not associated with mortality. CONCLUSION: PO confers the greatest risk of suffering any complication. Surgical approach was not associated with death. Results of our study challenge the notion that conversion is associated with the worst perioperative outcomes and an MIS approach should be considered in patients with LACC.

Starting late does not increase the risk of post-operative complications in patients undergoing common general surgical procedures.

BACKGROUND: There is a paucity of evidence surrounding the issue of delays on the day of surgery with respect to both causes and consequences. We sought to determine whether patients whose operations started late were at increased risk of post-operative complications. METHODS: We conducted a retrospective cohort study of 1420 first-of-the-day common general surgical procedures, dividing these into "on-time start" (OTS) and "late-start" (LS) cases. Our primary outcomes were minor and major complication rate; our secondary objective was to identify factors predicting LS. Groups were compared using univariable and multivariable analysis. RESULTS: LS rate was 55.3%. On univariable analysis, LS had higher rates of major and minor complications (7.3% vs. 3.5%, p = 0.002; 3.8% vs. 1.6%, p = 0.011). On multivariable analysis, LS was not associated with increased odds of any complications. Minor complications were predicted by operative duration [OR = 1.005 (1.002-1.008)], female sex [OR = 1.78 (1.037-3.061)], and undergoing an ileostomy closure procedure [OR = 10.60 (2.791-40.246)], and were reduced in those undergoing surgery on Wednesdays [OR = 0.38 (0.166-0.876)]. Major complications were predicted by operative duration [OR = 1.007 (1.003-1.011)] and ASA class [OR = 6.73 (1.505-30.109)]. Multivariable analysis using LS as an outcome identified that anesthesia time [OR = 1.35 (1.031-1.403)], insulin-dependent diabetes [OR = 1.91 (1.128-3.246)], and dyspnea upon moderate exertion [OR = 2.52 (1.423-4.522)] were predictive of LS. CONCLUSIONS: Most cases in our study started late. While this has significant efficiency and economic costs, it is not associated with adverse patient outcomes. This topic remains incompletely described. Further research is needed to improve efficiency and patient experience by investigating the causes of operative delays.

Anastomotic leak after colorectal surgery: does timing affect failure to rescue?

BACKGROUND: Anastomotic leak (AL) is a common complication after colectomy with a relatively high failure to rescue rate (FTR), or death after major complications. There is emerging evidence to suggest an early AL may be associated with increased technical difficulty. Whether the timing of an AL is associated with higher FTR has not been established. METHODS: Patients who underwent a colectomy between 2012 and 2017 were identified from the American College of Surgeons National Quality Improvement Program (ACS NSQIP database). The primary outcome was FTR after AL. The predictor variable used was day of post-operative leak (POD) categorized into early (POD ≤ 3), intermediate (3 < POD ≤ 20) and late (20 < POD ≤ 30) AL. These POD groups were compared to generate hypotheses to explain any association observed between timing of AL and FTR. RESULTS: Of 135,539 identified patients, 4613 patients experienced an AL (3.4%) with an overall FTR of 6.4%. FTR differed by timing of AL: early AL was found to have a FTR of 28/195 (12.6%), with a FTR in intermediate AL of 152/2550 (5.6%) and 3/356 (0.8%) in late AL patients (p < 0.0001). When compared by timing of AL, patients differed by sex, pre-operative bowel preparation, de-functioning ostomy rates and re-operation rates (p < 0.05). Controlling for age, ASA, sex, emergency status, operative approach, indication, de-functioning ostomy, re-operation and concurrent procedure, an early AL was found to have a 2.3-fold increased risk of FTR (95% CI 1.38-3.84, p = 0.001), with a late AL having a 0.15-fold decreased risk (95% CI 0.04-0.49, p = 0.002), both compared to an intermediate AL. CONCLUSION: Early ALs, occurring within three days of surgery, may carry a significant risk of FTR. Given the findings identified here, this may support the use of early detection algorithms and interventions of AL to minimize the risk of FTR.

Will My Patient Survive an Anastomotic Leak? Predicting Failure to Rescue Using the Modified Frailty Index.

IMPORTANCE: Failure to rescue (FTR), or death after major complications, has emerged as a marker of hospital-level quality of care. OBJECTIVE: To evaluate the predictive performance of the ACS-NSQIP modified frailty index (mFI) in determining FTR following an anastomotic leak (AL) after a colectomy for colorectal cancer. DESIGN: Retrospective cohort study. SETTING: Multicenter interrogation of the 2012-2016 American College of Surgeons (ACS) colectomy procedure targeted National Surgical Quality Improvement Program (NSQIP) database. PATIENTS AND METHODS: A total of 50,944 patients who underwent colectomy for colorectal cancer. EXPOSURE: Frailty as measured by: (1) Age, ASA, and emergency status (model 1), (2) Age, ASA, emergency status, and mFI (model 2), (3) ACS-NSQIP mortality prediction (model 3). MAIN OUTCOME AND MEASURE: Primary outcome was FTR after AL. RESULTS: A total of 1755 patients experienced an AL (3.46%) with a FTR rate of 6.44%. The mean age was 65.6 years (95% CI 65.28-65.58 years), median ASA was 3 (IQR 2-3), 51 patients (2.92%) were partially or totally dependent, 366 (20.86%) were diabetic, 105 (5.98%) had a history of chronic obstructive pulmonary disease (COPD), 32 (1.82%) had a history of congestive heart disease (CHD), and 966 (55.04%) were on hypertensive treatment. The performance of model 1 (AUROC 0.77; 95% CI 0.72-0.81), model 2 (AUROC 0.77; 95% CI 0.73-0.82), and model 3 (AUROC 0.79; 95% CI 0.75-0.83) to predict FTR was not different (p = 0.44). CONCLUSIONS AND RELEVANCE: Age and ASA remain the most reliable predictors of failure to rescue anastomotic leak after colectomy for colorectal cancer. Addition of the modified frailty index, or all variables collected by NSQIP, did not significantly improve predictive performance.

Neoadjuvant therapy versus direct to surgery for T4 colon cancer: meta-analysis.

BACKGROUND: Despite persistently poor oncological outcomes, approaches to the management of T4 colonic cancer remain variable, with the role of neoadjuvant therapy unclear. The aim of this review was to compare oncological outcomes between direct-to-surgery and neoadjuvant therapy approaches to T4 colon cancer. METHODS: A librarian-led systematic search of MEDLINE, Embase, the Cochrane Library, Web of Science, and CINAHL up to 11 February 2020 was performed. Inclusion criteria were primary research articles comparing oncological outcomes between neoadjuvant therapies or direct to surgery for primary T4 colonic cancer. Based on PRISMA guidelines, screening and data abstraction were undertaken in duplicate. Quality assessment was carried out using Cochrane risk-of-bias tools. Random-effects models were used to pool effect estimates. This study compared pathological resection margins, postoperative morbidity, and oncological outcomes of cancer recurrence and overall survival. RESULTS: Four studies with a total of 43 063 patients met the inclusion criteria. Compared with direct to surgery, neoadjuvant therapy was associated with increased rates of margin-negative resection (odds ratio (OR) 2.60, 95 per cent c.i. 1.12 to 6.02; n = 15 487) and 5-year overall survival (pooled hazard ratio 1.42, 1.10 to 1.82, I2 = 0 per cent; n = 15 338). No difference was observed in rates of cancer recurrence (OR 0.42, 0.15 to 1.22; n = 131), 30-day minor (OR 1.12, 0.68 to 1.84; n = 15 488) or major (OR 0.62, 0.27 to 1.44; n = 15 488) morbidity, or rates of treatment-related adverse effects. CONCLUSION: Compared with direct to surgery, neoadjuvant therapy improves margin-negative resection rates and overall survival.

Minimally Invasive Surgical Approaches Are Safe and Appropriate in N2 Colorectal Cancer.

BACKGROUND: There is emerging evidence of the oncological safety of minimally invasive surgery in T4 colorectal cancer; however, such support is lacking in N2 disease. OBJECTIVE: This study aimed to compare oncological and perioperative outcomes of surgical resection for N2 colorectal cancer using an open versus minimally invasive approach. DESIGN: We conducted a retrospective cohort study using the National Surgical Quality Improvement Program's generic and targeted colectomy data sets. SETTINGS: Data about surgery for N2 colorectal cancer were obtained regarding North American hospitals participating in the American College of Surgeons National Surgical Quality Improvement Program. PATIENTS: All patients undergoing elective surgical resection for N2 colorectal cancer in participating hospitals between 2014 and 2018 were selected. INTERVENTIONS: Surgical resection of N2 colorectal cancer was performed. MAIN OUTCOME MEASURES: Our primary outcome was nodal yield. Secondary outcomes included perioperative complications and mortality. RESULTS: A total of 1837 patients underwent open and 3907 patients underwent minimally invasive surgery colectomies for N2 colorectal cancer (n = 5744). Median nodal yield was 20 (interquartile range, 15-27) in the open group and 21 (interquartile range, 16-28) in the minimally invasive group (p < 0.0001); however, nodal harvest between the 2 groups was not significantly different on multivariate analysis. Perioperative complications were higher on univariate analysis in the open surgery group, with respect to key outcomes including anastomotic leak and death (p < 0.001). LIMITATIONS: This study is limited by its retrospective design and by the fact that the staging data collected by the National Surgical Quality Improvement Program are pathological rather than clinical; however, prior studies found a 97% concordance between pathological and clinical N2 determination. CONCLUSIONS: Minimally invasive surgery approaches to colorectal cancer with N2 disease result in equivalent nodal harvests compared with open approaches. Our group supports the use of a minimally invasive approach in advanced nodal stage colorectal cancer in the appropriately selected patient. See Video Abstract at http://links.lww.com/DCR/B417. LOS ABORDAJES QUIRRGICOS MNIMAMENTE INVASIVOS SON SEGUROS Y APROPIADOS EN EL CNCER COLORRECTAL N: ANTECEDENTES:Existe evidencia emergente de la seguridad oncológica de la cirugía mínimamente invasiva en el cáncer colorrectal T4; sin embargo, semenjante apoyo falta en la enfermedad N2.OBJETIVO:comparar los resultados oncológicos y perioperatorios de la resección quirúrgica para el cáncer colorrectal N2 utilizando un abordaje abierto versus mínimamente invasivo.DISEÑO:Realizamos un estudio de cohorte retrospectivo utilizando los conjuntos de datos de colectomía genéricos y específicos del Programa Nacional de Mejoramiento de la Calidad Quirúrgica.AJUSTE:Hospitales de Norte America que participan en el Programa Nacional de Mejoramiento de la Calidad Quirúrgica del Colegio Americano de Cirujanos.PACIENTES:Todos los pacientes sometidos a resección quirúrgica electiva por cáncer colorrectal N2 en los hospitales participantes entre 2014 y 2018.INTERVENCIONES:Resección quirúrgica de cáncer colorrectal N2.PRINCIPALES MEDIDAS DE VOLORACION:Nuestro resultado principal fue el rendimiento nodal. Los resultados secundarios incluyeron complicaciones perioperatorias y mortalidad.RESULTADOS:1837 pacientes fueron sometidos a cirugía abierta y 3907 pacientes fueron sometidos a colectomías de cirugía mínimamente invasiva por cáncer colorrectal N2 (n = 5744). La mediana del rendimiento nodal fue 20 (IQR 15-27) en el grupo abierto y 21 (IQR 16-28) en el grupo mínimamente invasivo (p <0,0001); sin embargo, el rendimiento nodal entre los dos grupos no fue significativamente diferente en el análisis multivariado. Las complicaciones perioperatorias fueron mayores en el análisis univariado en el grupo de cirugía abierta, con respecto a los resultados clave, incluida la fuga anastomótica y la muerte (p <0,001).LIMITACIONES:Este estudio está limitado por su diseño retrospectivo y por el hecho de que los datos de estadificación recopilados por NSQIP son patológicos más que clínicos; sin embargo, estudios previos encontraron una concordancia del 97% entre la determinación patológica y clínica de N2.CONCLUSIONES:Los enfoques de cirugía mínimamente invasiva para el cáncer colorrectal con enfermedad N2 dan rendimientos nodales equivalentes a abordajes abiertos. Nuestro grupo apoya el uso de abordaje mínimamente invasivo en el cáncer colorrectal avanzado en estadio ganglionar en el paciente adecuadamente seleccionado. Consulte Video Resumenhttp://links.lww.com/DCR/B417.

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

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

Current Evidence for Minimally Invasive Surgery During the COVID-19 Pandemic and Risk Mitigation Strategies: A Narrative Review.

OBJECTIVE: Our objective was to review the literature surrounding the risks of viral transmission during laparoscopic surgery and propose mitigation measures to address these risks. SUMMARY BACKGROUND DATA: The SARS-CoV-2 pandemic has caused surgeons the world over to re-evaluate their approach to surgical procedures given concerns over the risk of aerosolization of viral particles and exposure of operating room staff to infection. International society guidelines advise against the use of laparoscopy; however, the evidence on this topic is scant and recommendations are based on the perceived most cautious course of action. METHODS: We conducted a narrative review of the existing literature surrounding the risks of viral transmission during laparoscopic surgery and balance these risks against the benefits of minimally invasive approaches. We also propose mitigation measures to address these risks that we have adopted in our institution. RESULTS AND CONCLUSION: While it is currently assumed that open surgery minimizes operating room staff exposure to the virus, our findings reveal that this may not be the case. A well-informed, evidence-based opinion is critical when making decisions regarding which operative approach to pursue, for the safety and well-being of the patient, the operating room staff, and the healthcare system at large. Minimally invasive surgical approaches offer significant advantages with respect to both patient care, and the mitigation of the risk of viral transmission during surgery, provided the appropriate equipment and expertise are present.

Association of high ligation versus low ligation of the inferior mesenteric artery on anastomotic leak, postoperative complications, and mortality after minimally invasive surgery for distal sigmoid and rectal cancer.

BACKGROUND: In the treatment of distal sigmoid and rectal cancer, the appropriate level for the ligation of the inferior mesenteric artery (IMA) remains unresolved. High ligation divides the IMA proximally at its origin, and low ligation ligates the IMA distal to the origin of left colic artery. We assessed the association of level of ligation in scheduled minimally invasive resection of sigmoid and rectal cancers on anastomotic leak, postoperative complications, and death within 30 days. METHODS: We identified all patients with primary sigmoid and rectal cancer treated with scheduled minimally invasive resection and primary anastomosis between January 2002 and June 2018 using linked institutional and National Surgical Quality Improvement Program databases. We assessed the association of level of ligation with each outcome by fitting individual univariable and multivariable logistic regression models, adjusting for surgical approach, tumor location, neoadjuvant chemoradiotherapy, and Charlson comorbidity index. RESULTS: We included 158 patients treated with high ligation and 123 patients treated with low ligation. Overall, 12 patients had an anastomotic leak requiring intervention within 30 days: 5 in the high ligation group (3.2%, 95% CI 1.4-7.2%) and 7 in the low ligation group (5.7%, 95% CI 2.8-11.3%). There was no association between the level of ligation and anastomotic leak (unadjusted OR 1.85, 95% CI 0.58-6.38; adjusted OR 0.63, 95% CI 0.16-2.55). Similarly, there was no association between the level of ligation and reoperation for anastomotic leak (OR 1.29, 95% CI 0.15-10.9), major complications (Clavien-Dindo III-V; OR 2.22, 95% CI 0.90-5.77), minor complications (Clavien-Dindo I-II; OR 1.51, 95% CI 0.88-2.60), and all complications (OR 1.58, 95% CI 0.94-2.67). No deaths occurred in either group. CONCLUSIONS: There was no association of level of ligation of the IMA with anastomotic leak, postoperative complications as a composite, or death. The choice of high or low ligation of the IMA should be made based on technical factors such as length for the creation of a tension-free anastomosis.

Technical Performance as a Predictor of Clinical Outcomes in Laparoscopic Gastric Cancer Surgery.

OBJECTIVE: The purpose of this study was to evaluate the relationship between technical performance and patient outcomes in laparoscopic gastric cancer surgery. BACKGROUND: Laparoscopic gastrectomy for cancer is an advanced procedure with high rate of postoperative morbidity and mortality. Many variables including patient, disease, and perioperative management factors have been shown to impact postoperative outcomes; however, the role of surgical performance is insufficiently investigated. METHODS: A retrospective review was performed for all patients who had undergone laparoscopic gastrectomy for cancer at 3 teaching institutions between 2009 and 2015. Patients with available, unedited video-recording of their procedure were included in the study. Video files were rated for technical performance, using Objective Structured Assessments of Technical Skills (OSATS) and Generic Error Rating Tool instruments. The main outcome variable was major short-term complications. The effect of technical performance on patient outcomes was assessed using logistic regression analysis with backward selection strategy. RESULTS: Sixty-one patients with available video recordings were included in the study. The overall complication rate was 29.5%. The mean Charlson comorbidity index, type of procedure, and the global OSATS score were included in the final predictive model. Lower performance score (OSATS ≤29) remained an independent predictor for major short-term outcomes (odds ratio 6.49), while adjusting for comorbidities and type of procedure. CONCLUSIONS: Intraoperative technical performance predicts major short-term outcomes in laparoscopic gastrectomy for cancer. Ongoing assessment and enhancement of surgical skills using modern, evidence-based strategies might improve short-term patient outcomes. Future work should focus on developing and studying the effectiveness of such interventions in laparoscopic gastric cancer surgery.

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

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

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

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

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

Operative Strategies for Perforated Diverticulitis: A Systematic Review and Meta-analysis.

BACKGROUND: The traditional approach for perforated diverticulitis, the Hartmann procedure, has considerable morbidity and the challenge of stoma reversal. Alternative procedures, including primary resection and anastomosis and laparoscopic lavage, have been proposed but remain controversial. OBJECTIVE: The purpose of this study was to compare operative strategies for perforated diverticulitis. DATA SOURCES: MEDLINE, Embase, Cochrane Library, and the grey literature were searched from inception to October 2017. STUDY SELECTION: We included randomized clinical trials evaluating operative strategies for perforated diverticulitis. INTERVENTIONS: Hartmann procedure, primary resection and anastomosis, and laparoscopic lavage were included. MAIN OUTCOME MEASURES: Data were independently extracted by 2 investigators. Risk of bias was evaluated using the Cochrane risk-of-bias tool. Pooled risk ratios for major complications, reoperation, and mortality were determined using random-effects models. RESULTS: Six trials including 626 patients with perforated diverticulitis were identified. Laparoscopic lavage and sigmoidectomy had comparable rates of early reoperation and postoperative mortality; major complications (Clavien-Dindo >IIIa) were more frequent after laparoscopic lavage (RR = 1.68 (95% CI, 1.10-2.56); 3 trials, 305 patients). Comparing approaches for sigmoidectomy, primary resection and anastomosis had similar rates of major complications (RR = 0.88 (95% CI, 0.49-1.55); 3 trials, 255 patients) and postoperative mortality (RR = 0.58 (95% CI, 0.20-1.70); 3 trials, 254 patients) compared with the Hartmann procedure. However, patients who underwent primary resection and anastomosis were more likely to be stoma free at 12 months compared with the Hartmann procedure (RR = 1.40 (95% CI, 1.18-1.67); 4 trials, 283 patients) and to experience fewer major complications related to the stoma reversal procedure (RR = 0.26 (95% CI, 0.07-0.89); 4 trials, 186 patients). LIMITATIONS: There were no limitations to this study. CONCLUSIONS: Laparoscopic lavage is associated with increased risk of major complications versus primary resection for Hinchey III diverticulitis. The lower rate of stoma reversal and higher rate of complications after the Hartmann procedure suggest primary resection and anastomosis as the optimal management of perforated diverticulitis.

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

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

Comparison of two novel staging systems with the TNM system in predicting stage III colon cancer survival.

BACKGROUND AND OBJECTIVES: Adaptations of the TNM staging system that incorporate the Lymph Node Ratio (LNR) have been proposed for stage III colon cancer. This study compared the concordance of two novel staging systems and the TNM system with observed survival outcomes in stage III patients. METHODS: A review of patients who underwent surgery for stage III colon cancer between January 2002 and April 2015 at a tertiary care centre was performed. The Kaplan-Meier method was used to estimate the 5-year overall (OS) and disease free survival (DFS) rates, and the concordance probability was calculated to evaluate the discriminatory power of the staging systems. RESULTS: Two hundred and sixty-one patients were identified. For TNM stages IIIA, IIIB, and IIIC, 5-year OS was 83.4%, 67.6%, and 38.3%, respectively (P < 0.001). All three staging systems were independently predictive of OS and DFS (P < 0.001). However, the novel staging system by Sugimoto et al18 was the most favourable prognostic tool, with a concordance of 0.646 for DFS and 0.659 for OS. CONCLUSIONS: The novel staging system by Sugimoto et al18 was superior to the TNM system. Incorporating LNR into staging models for node positive colon cancers may improve survival information available to patients and potentially aid treatment decisions.

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

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

Cost of open and laparoscopic distal gastrectomy: surgeon perceptions versus the reality of hospital spending.

BACKGROUND: Rising health care costs have led to increasing focus on cost containment and accountability from health care providers. We sought to explore surgeon awareness of supply costs for open and laparoscopic distal gastrectomy. METHODS: Surveys were sent in 2015 to surgeons at 8 academic hospitals in Toronto who performed distal gastrectomy for gastric adenocarcinoma. Respondents were asked to estimate the total cost, type and number of disposable equipment pieces required to perform open and laparoscopic distal gastrectomy. We determined the accuracy of estimates through comparisons with procedural invoices for distal gastrectomy performed between Jan. 1, 2011, and Dec. 31, 2015. All values are in 2015 Canadian dollars. RESULTS: Of the 53 surveys sent out, 12 were completed (response rate 23%). Surgeon estimates of total supply costs ranged from $500 to $3000 and from $1500 to $5000 for open and laparoscopic cases, respectively. Estimated supply costs for requested equipment ranged from $464 to $2055 for open cases and from $1870 to $2960 for laparoscopic cases. Invoices for actual equipment yielded a mean of $821 (standard deviation $543) (range $89-$2613) for open cases and $2678 (standard deviation $958) (range $835-$4102) for laparoscopic cases. Estimates of total cost were within 25% of the median invoice total in 1 response (9%) for open cases and 3 (27%) of those for laparoscopic cases. CONCLUSION: Respondents failed to accurately estimate equipment costs. The variation in true total costs and estimates of supply costs represents an opportunity for intraoperative cost minimization, efficient equipment selection and value-based purchasing arrangements.

CONTEXTE: En raison de l'augmentation des coûts des soins de santé on attend des professionnels qu'ils mettent davantage l'accent sur les restrictions budgétaires et l'imputabilité. Nous avons voulu vérifier à quel point les chirurgiens sont conscients du coût des fournitures utilisés dans les cas de gastrectomie distale ouverte et laparoscopique. MÉTHODES: Des questionnaires ont été envoyés en 2015 aux chirurgiens de 8 hôpitaux universitaires de Toronto qui pratiquent la gastrectomie distale pour l'adénocarcinome de l'estomac. On demandait aux participants d'estimé le coût total, le type et le nombre de fournitures jetables requises pour une gastrectomie distale ouverte et laparoscopique. Nous avons déterminé l'exactitude des estimations en comparant les factures pour les interventions de gastrectomie distale effectuées entre le 1er janvier 2011 et le 31 décembre 2015. Toutes les valeurs sont présentées en dollars canadiens. RÉSULTATS: Parmi les 53 questionnaires envoyés, 12 sont revenus complétés (taux de réponse 23 %). Les estimations des chirurgiens pour le coût total des fournitures allaient de 500 $ à 3000 $ et de 1500 $ à 5000 $ pour les interventions ouvertes et laparoscopiques, respectivement. Le coût estimé des fournitures pour l'équipement nécessaire variait de 464 $ à 2055 $ pour les interventions ouvertes et de 1870 $ à 2960 $ pour les interventions laparoscopiques. Les factures soumises pour les équipements réellement utilisés ont été en moyenne de 821 $ (écart-type 543 $) (éventail 89 $-2613 $) pour les interventions ouvertes et de 2678 $ (écart-type 958 $) (éventail 835 $-4102 $) pour les interventions laparoscopiques. Les estimations des coûts totaux se situaient à plus ou moins 25 % du montant total médian des factures dans 1 réponse (9 %) pour les interventions ouvertes et dans 3 réponses (27 %) pour les interventions laparoscopiques. CONCLUSION: Les participants n'ont pas été en mesure d'estimer avec exactitude le coût des fournitures. Cet écart entre les coûts totaux réels et estimés représente une occasion de réduire les coûts peropératoires, de sélectionner les équipements de façon efficiente et de conclure des contrats d'achat en fonction de la valeur.