Increasing Adoption of Laparoscopy in Urgent and Emergent Colectomies for Pediatric Ulcerative Colitis.

INTRODUCTION: While minimally invasive surgery (MIS) approaches are commonly utilized in the elective surgical setting for pediatric ulcerative colitis (UC), their role in urgent and emergent disease is less clear. We aim to assess trends in the surgical approaches for pediatric UC patients requiring urgent and emergent colectomies and their associated outcomes. METHODS: Retrospective review of 81 pediatric UC patients identified in National Surgical Quality Improvement Program Pediatric who underwent urgent or emergent colectomy (2012-2019). Trends in approach were assessed using linear regression. Patient characteristics and clinical outcomes were stratified by approach and compared using standard univariate statistics. Multivariable analysis was used to model the influence of covariates on postoperative length of stay. RESULTS: The proportion of MIS cases increased by 5.53% per year (P = 0.01) over the study interval. Sixty-three patients (77.8%) received MIS resections and 18 patients (22.2%) received open resections. Patients undergoing open colectomies were younger and had a higher proportion of preoperative conditions, most notably preoperative sepsis (27.8% versus 4.8%, P = 0.01), and higher American Society of Anesthesiologists [III-IV] classification (83.3% versus 58.8%, P = 0.004). Mean operative time was comparable (open, 173.6 versus MIS, 206.1 min). In the univariate analysis, open approach was associated with increased postoperative length of stay (13.1 versus 7.2 d, P = 0.002). However, after adjusting for confounders, there was no significant difference. CONCLUSIONS: There has been a steady increase in the adoption of laparoscopy in urgent and emergent colectomy for pediatric UC. Short-term outcomes between approaches appear comparable.

Neoadjuvant chemotherapy does not increase risk for anastomotic leak for simultaneous resection of primary colon cancer with synchronous liver metastasis: A NSQIP-colectomy analysis.

BACKGROUND AND OBJECTIVES: In patients with colon cancer with synchronous liver metastasis, treatment algorithms are complex and often require multidisciplinary evaluation. Neoadjuvant therapy is frequently utilized, but there is an unclear relationship with postoperative outcomes in patients with simultaneous resection. METHODS: This is a retrospective cohort study from the National Surgical Quality Improvement Program and Targeted Colectomy databases. All patients with stage IV colon cancer undergoing simultaneous colectomy with synchronous liver metastasis resection or ablation between 2015 and 2019 were identified and categorized into subgroups based on receipt of neoadjuvant chemotherapy. Multivariable logistic regression was utilized to assess for risk factors of anastomotic leaks and serious postoperative complications. RESULTS: We identified 1006 patients who underwent simultaneous colectomy and liver operations. Of those, 418 (41.6%) received neoadjuvant chemotherapy within 90 days of surgery, while 588 (58.4%) had simultaneous upfront surgery. On multivariable logistic regression, neoadjuvant therapy was not associated with postoperative anastomotic leaks (odds ratio [OR]: 1.30; p = 0.39) or serious complications (OR: 1.04; p = 0.82). CONCLUSION: Neoadjuvant therapy does not increase postoperative complications in simultaneous colon and liver resections. These results may alleviate concerns regarding postoperative morbidity in the decision-making process of administering neoadjuvant therapy.

Emergent Colon Resections: Does Surgeon Specialization Influence Outcomes?

BACKGROUND: Relationships between high-volume surgeons and improved postoperative outcomes have been well documented. Colorectal procedures are often performed by general surgeons, particularly in emergent settings, and may form a large component of their practice. The influence of subspecialized training on outcomes after emergent colon surgery, however, is not well described. OBJECTIVE: The purpose of this study was to determine whether subspecialty training in colorectal surgery is associated with differences in postoperative outcomes after emergency colectomy. DESIGN: This was a retrospective cohort study. SETTINGS: Three tertiary care hospitals participating in the National Surgical Quality Improvement Project were included. PATIENTS: Patients undergoing emergent colon resections were identified at each institution and stratified by involvement of either a colorectal surgeon or a general or acute care surgeon. MAIN OUTCOME MEASURES: Propensity score matching was used to isolate the effect of surgeon specialty on the primary outcomes, including postoperative morbidity, mortality, length of stay, and the need for unplanned major reoperation, in comparable cohorts of patients. RESULTS: A total of 889 cases were identified, including 592 by colorectal and 297 by general/acute care surgeons. After propensity score matching, cases performed by colorectal surgeons were associated with significantly lower rates of 30-day mortality (6.7% vs 16.4%; p = 0.001), postoperative morbidity (45.0% vs 56.7%; p = 0.009), and unplanned major reoperation (9.7% vs 16.4%; p = 0.04). In addition, length of stay was ≈4.4 days longer among patients undergoing surgery by general/acute care surgeons (p < 0.001). LIMITATIONS: This study was limited by its retrospective design, with potential selection bias attributed to referral patterns. CONCLUSIONS: After controlling for underlying disease states and illness severity, emergent colon resections performed by colorectal surgeons were associated with significantly lower rates of postoperative morbidity and mortality when compared with noncolorectal surgeons. These findings may have implications for referral patterns for institutions. See Video Abstract at http://links.lww.com/DCR/A767.

Truven Health Analytics MarketScan Databases for Clinical Research in Colon and Rectal Surgery.

The MarketScan databases are a family of administrative claims databases that contain data on inpatient and outpatient claims, outpatient prescription claims, clinical utilization records, and healthcare expenditures. The three main databases available for use are each composed of a convenience sample for one of the following patient populations: (1) patients with employer-based health insurance from contributing employers, (2) Medicare beneficiaries who possess supplemental insurance paid by their employers, and (3) patients with Medicaid in one of eleven participating states. Eleven supplemental databases are available, which are utilized to overcome the limited clinical data available in the core MarketScan databases. There are several limitations to this database, primarily related to the fact that individuals or their family members within two of the core databases mandatorily possess some form of employer-based health insurance, which prevents the dataset from being nationally representative. Nonetheless, this database provides detailed and rigorously maintained claims data to identify healthcare utilization patterns among this cohort of patients.

Prognostic Significance of Tumor Deposits in Stage III Colon Cancer.

BACKGROUND: The American Joint Committee on Cancer includes extranodal tumor deposits in the tumor-node-metastasis classification of colon cancer. However, it is unclear how tumor deposits compare with lymph node metastases in prognostic significance. This study evaluated the survival impact of tumor deposits relative to lymph node metastases in stage III colon cancer. METHODS: The US National Cancer Database (2010-2012) was reviewed for resectable stage III adenocarcinoma of the colon, and stratified by presence of tumor deposits and lymph node metastases. Univariate and multivariate survival analyses were performed. RESULTS: Of 6424, 10.1% had both tumor deposits and lymph node metastases [5-year survival (5YS) 40.2%], 2.5% had tumor deposits alone (5YS 68.1%), and 87.4% had lymph node metastases alone (5YS 55.4%). Patients with lymph node metastases alone tended to have a greater number of lymph nodes retrieved (20.9 versus 18.8, p = 0.0126) and were more likely to receive adjuvant therapy (66.9 vs 58.0%, p = 0.003) than those with only tumor deposits. Patients with both had significantly worse survival at all T stages (p < 0.05, all). There was no significant difference in survival between tumor deposits alone and lymph node metastases alone at any T stage (p > 0.8, all). After controlling for patient, disease, and treatment characteristics, patients with tumor deposits alone [hazard ratio (HR) 0.56, p = 0.001] or only lymph node metastases (HR 0.64, p < 0.001) were associated with improved survival relative to patients with both. CONCLUSIONS: Concomitant presence of tumor deposits and lymph node invasion carries poor prognostic significance. Tumor deposits alone appear to have prognostic implications similar to lymph node invasion alone.

Increased Postoperative Morbidity Associated With Prolonged Laparoscopic Colorectal Resections Is Not Increased by Resident Involvement.

BACKGROUND: Although longer operative times are associated with increased postoperative morbidity, the influence of surgical residents on this association is unclear. OBJECTIVE: The purpose of this study was to evaluate whether morbidity associated with operative times in laparoscopic colorectal surgery is increased by resident training. DESIGN: This was a retrospective cohort study. SETTINGS: The study was conducted using a national database. PATIENTS: Laparoscopic ileocolectomies, partial colectomies, and low anterior resections were identified in the National Surgical Quality Improvement Project (2005-2012). This cohort was stratified by the presence of resident involvement (postgraduate clinical year ≤5) and then divided into tertiles of operative time (low, medium, and high), allowing comparisons of cases by duration with resident involvement with cases of similar length without resident involvement. MAIN OUTCOME MEASURES: Postoperative morbidity (infectious and noninfectious), length of hospital stay, and unplanned reoperations were the primary study outcomes. RESULTS: A total of 20,785 procedures were identified. In aggregate, prolonged operative time was associated with both infectious (OR = 1.49, p < 0.001 with residents; OR = 1.38, p < 0.001 without residents) and noninfectious complications (OR = 1.51, p < 0.001 with residents; OR = 1.48, p < 0.001 without residents) when compared with short cases without residents. Longer hospital stay was observed both within the highest (additional 1.2 days (p < 0.001) with residents; 1.1 days (p < 0.001) without residents) and middle (additional 0.4 days (p < 0.001) with residents; 0.4 days (p = 0.001) without residents) tertiles of operative time. Within the highest tertile of operative length, there was no statistically significant difference in complication rates between cases with and without resident participation. LIMITATIONS: The study was limited by its retrospective design and inability to define the complexity of case and extent of resident involvement. CONCLUSIONS: Although longer operative times confer increased postoperative morbidity, there was no significant difference in complication rates within the highest tertile between cases with and without resident participation. Resident involvement does not appear to add to the risk of morbidity associated with longer and more complicated surgeries. See Video Abstract at http://links.lww.com/DCR/A440.

Management of Large Cecal Polyps: When Can the Ileocecal Valve Be Spared?

BACKGROUND: Endoscopic mucosal resection comprises the first-line treatment for large cecal polyps. With up to 14% of unresectable colonic polyps harboring malignancy, the management of endoscopically unresectable cecal polyps remains an oncologic right hemicolectomy, which can be associated with substantial postoperative morbidity. OBJECTIVE: This study compares the outcomes of patients with cecal polyps who underwent either endoscopic mucosal resection, a cecectomy, or a right hemicolectomy. DATA SOURCES: Patients undergoing either endoscopic mucosal resection, partial cecectomy, or right hemicolectomy from 2008 to 2017 at a single tertiary care institution were selected. STUDY SELECTION: This was a retrospective cohort study. MAIN OUTCOME MEASURES: The primary outcomes measured were the rate of malignancy, complication rate, estimated blood loss, and hospital length of stay between surgical cohorts. RESULTS: One hundred twenty-nine patients with cecal polyps were identified, of which 52 were referred for surgery. Nineteen underwent partial cecectomy and 33 (27.3%) underwent right hemicolectomy. Two patients undergoing cecectomy required conversion to hemicolectomy because the resected specimen did not contain the polyp. The 2 surgical cohorts did not differ significantly regarding age, sex, or ASA classification. Procedural complication rates were higher among those undergoing hemicolectomy compared with those undergoing cecectomy (37.1% versus 5.9%, p = 0.02). Estimated blood loss (50 vs 10 mL, p = 0.02), operative duration (98 vs 76 minutes, p = 0.009), and length of stay (4 vs 2 days, p < 0.001) were higher in patients undergoing hemicolectomy than in those undergoing cecectomy. No invasive malignancies were identified on final pathology within the cecectomy cohort. LIMITATIONS: Single-institution data and retrospective design were limitations of this study. CONCLUSIONS: In tertiary centers, the majority of large cecal polyps are benign and can be addressed by using endoscopic mucosal resection. When involvement of the appendiceal orifice or ileocecal valve precludes endoscopic treatment, surgical resection is the standard of care. In the subset of cases not involving the ileocecal valve and without preoperative evidence of malignancy, partial cecectomy spares the ileocecal valve and can offer reduced postoperative morbidity compared with a formal right hemicolectomy. See Video Abstract at http://links.lww.com/DCR/A674.

Robotic versus standard laparoscopic elective colectomy: where are the benefits?

BACKGROUND: Robotic approaches for colorectal surgery have been growing in popularity as experience with the new technology develops, but are frequently associated with longer operative time. It is unclear whether prolonged operative duration in robotic cases translates to increased morbidity. This study aims to compare the outcomes of non-emergent laparoscopic and robotic colon resections. METHODS: Patients undergoing non-emergent laparoscopic (LC) or robotic (RC) colon resections were identified in National Surgical Quality Improvement Project (2013-2015). Patients were matched 1:1 between cohorts using propensity score matching. To account for the prolonged operative time associated with robotic cases, operative times were stratified into approach-specific (LC or RC) tertiles (low, medium, and high) as covariates in the matching algorithm. RESULTS: RC increased significantly over time and had lower conversion rates (6.0% among RC versus 11.5% among LC, P < 0.001). RC cases were longer (226 min versus 178 min, P < 0.001). Unadjusted complication rates were higher in the LC cohort (17.5% versus 15.2%, P < 0.001). After propensity score matching, RC was not associated with a significant difference in postoperative morbidity (15.2% among RC versus 15.9% among LC, P = 0.434). The robotic approach was associated with a one-half day shorter length of stay (4.6 d versus 5.2 d, P < 0.001), but similar 30-day readmission rates (8.9% versus 8.3%, P = 0.368). CONCLUSIONS: After controlling for operative duration and patient covariates, RC was associated with similar rates of postoperative morbidity, but decreased conversion rates and shorter length of stay. Further studies examining costs are needed to evaluate whether these benefits offset the increased costs associated with robotic approaches.

Trends and Attributable Costs of Anorectal Involvement in Pediatric Crohn's Disease.

BACKGROUND: Pediatric Crohn's disease (CD) with anorectal involvement has not been well characterized. We sought to describe trends in the prevalence of pediatric CD with anorectal involvement and its influence on health-care utilization. MATERIALS AND METHODS: Patients (<21 y of age) with an International Classification of Diseases, Ninth Revision diagnosis of CD (555.X) were identified in the Kid's Inpatient Database (2003, 2006, 2009, 2012) and stratified by anorectal involvement based on the International Classification of Diseases, Ninth Revision diagnosis and procedural codes. Patient characteristics and resource utilization (length of stay [LOS] and costs) were compared between CD patients with and without anorectal involvement using univariate and multivariable analyses. Propensity score matching was used to estimate attributable LOS and costs. RESULTS: There were 26,029 patients with CD identified in the study interval. Of these, 1706 (6.6%) had anorectal involvement. Those with anorectal disease were younger (age 16 versus 17 y old), more likely to be male (59.4% versus 49.9%) and black or Hispanic (24.7% versus 18.2%), and were more commonly treated in urban teaching hospitals compared with rural or nonteaching hospitals (83.2% versus 70.9%) (P < 0.001 for all). The proportion of patients with anorectal involvement increased over time (odds ratio 1.03, 95% confidence interval 1.02-1.05). After propensity score matching, attributable LOS and costs were 0.5 d and approximately $1600, respectively. CONCLUSIONS: There has been an increase in the proportion of pediatric CD hospitalizations with anorectal manifestations. This pattern of disease is associated with longer hospitalization and higher costs compared with CD alone. Further research is required to understand the underlying etiology of these observed trends.

Robotic versus laparoscopic colectomy for stage I-III colon cancer: oncologic and long-term survival outcomes.

BACKGROUND: While short-term data suggest that robotic resections are safe for oncologic operations, long-term outcomes remain uncertain. This study evaluates the impact of robotic and laparoscopic approaches on oncologic and survival outcomes in partial and total colectomies for colon cancer. METHODS: The US National Cancer Database (2010-2012) was reviewed for patients with stage I-III adenocarcinoma of the colon, who underwent robotic and laparoscopic partial or total colectomies. Lymph node retrieval, surgical margins, and survival were compared between surgical approaches with linear and logistic regressions. Propensity score matching was then used to create comparable laparoscopic and robotic cohorts and compare survivor functions. RESULTS: Of 15,112 patients, 5.1% underwent robotic approaches (n = 765, conversion rate 10.6%), and 94.9% laparoscopic (n = 14,347, conversion rate 15.1%). Robotic approach was associated with Hispanic race (p = 0.009), private insurance (p = 0.001), and earlier stage (p = 0.028). There was no difference in number of lymph nodes retrieved (p = 0.6200) or negative surgical margins (p = 0.6700). In multivariate analysis, robotic approaches were associated with an improved hazard of mortality (HR 0.79, p = 0.027). Linear regression found no difference in lymph node retrieval (- 0.39, p = 0.285). Logistic regression found no difference in rates of positive margins (OR 1.09, p = 0.649). After propensity score matching, robotic approaches were associated with improved survival in stage II (5YS 66.9% vs. 56.8%, p = 0.0189) and III disease (5YS 78.6% vs. 64.9%, p = 0.0241). CONCLUSION: Robotic approaches to partial and total colectomies for stage I-III colon cancer offer comparable oncologic outcomes as laparoscopic approaches. Relative to laparoscopic approaches, robotic approaches appear to offer improved long-term survival.

Adjuvant Chemotherapy Improves Overall Survival of Rectal Cancer Patients Treated with Neoadjuvant Chemoradiotherapy Regardless of Pathologic Nodal Status.

BACKGROUND: After neoadjuvant chemoradiotherapy for rectal cancer, the interpretation of surgical pathology poses difficulties in deciding the need for adjuvant chemotherapy (AC). The aim of this study was to determine whether there is a survival benefit to providing AC in patients with node-negative disease on surgical pathology. METHODS: Patients with clinical stage II and III rectal adenocarcinoma who received neoadjuvant chemoradiation and definitive surgical resection from 2006 to 2012 were identified in the National Cancer Data Base. Patients were stratified by both receipt of AC and nodal status on surgical pathology. Propensity score matching was used to form two cohorts (AC vs. no AC) with otherwise balanced characteristics. Overall survival was compared by Kaplan-Meier analysis, and multivariable survival analysis was performed by a Weibull model. RESULTS: After propensity score matching, 4172 patients who received adjuvant therapy (2645 node negative and 1527 node positive) and 4172 patients who did not receive adjuvant therapy (3063 node negative and 1109 node positive) were identified. Among patients with either node-negative or node-positive disease, the use of AC was associated with a significant improvement in overall survival. These results were also observed after using a multivariable survival model to control for clinical stage as well as patient- and facility-related characteristics. CONCLUSIONS: In both patients with node-negative and node-positive disease on surgical pathology, the use of AC is associated with a survival benefit. In the absence of contraindications, AC should continue to be routinely recommended to patients after neoadjuvant chemoradiotherapy for locally advanced rectal cancers.

Squamous Cancers of the Rectum Demonstrate Poorer Survival and Increased Need for Salvage Surgery Compared With Squamous Cancers of the Anus.

BACKGROUND: Squamous cell cancers of the anus are rare GI malignancies for which neoadjuvant chemoradiation is the first-line treatment for nonmetastatic disease. Squamous cancers of the rectum are far less common, and it is unclear to what degree chemoradiotherapy improves their outcomes. OBJECTIVE: The purpose of this study was to compare stage-specific survival for anal and rectal squamous cancers stratified by treatment approach. DESIGN: This was a retrospective cohort study. SETTINGS: The study was conducted at Commission on Cancer designated hospitals. PATIENTS: Patients (2006-2012) identified in the National Cancer Database with pretreatment clinical stage I to III cancers who underwent chemoradiotherapy, with and without subsequent salvage surgical resection (low anterior resection or abdominoperineal resection), ≥12 weeks after chemoradiotherapy were included in the study. MAIN OUTCOME MEASURES: Overall survival and the need for salvage surgery were measured. RESULTS: Anal cancers (n = 11,224) typically presented with stage II (45.7%) or III (36.3%) disease, whereas rectal cancer stages (n = 1049) were more evenly distributed (p < 0.001). More patients with rectal cancer underwent low anterior or abdominoperineal resections 12 weeks or later after chemoradiotherapy versus those undergoing abdominoperineal resection for anal cancer (3.8% versus 1.2%; p < 0.001). Stage I and II rectal cancer was associated with poorer survival compared with anal cancer (stage I, p = 0.017; stage II, p < 0.001); survival was similar for stage III disease. Salvage surgery for anal cancer was associated with worse survival for stage I to III cancers; salvage surgery did not significantly affect survival for rectal cancer. LIMITATIONS: This was a retrospective study without cancer-specific survival measures. CONCLUSIONS: Squamous rectal cancers are associated with significantly worse survival than squamous cancers of the anus for clinical stage I and II disease. Despite both cancers exhibiting squamous histology, rectal cancers may be less radiosensitive than anal cancers, as suggested by the greater incidence of salvage surgery that does not appear to significantly improve overall survival. See Video Abstract at http://links.lww.com/DCR/A422.

A Surgical Clostridium-Associated Risk of Death Score Predicts Mortality After Colectomy for Clostridium difficile.

BACKGROUND: A Clostridium difficile-associated risk of death score was recently developed and validated by using a national cohort of both nonsurgical and surgical patients admitted with C difficile infection. However, risk scores specifically derived from surgical cohorts and designed for patients with C difficile infection are currently unavailable. OBJECTIVE: The aim of this study was to develop a risk of death score for patients with C difficile infection who are being considered for total abdominal colectomy because of the failure of medical therapy. DESIGN: This is a retrospective cohort study. SETTINGS: This study was conducted with the use of a national database. PATIENTS: All patients undergoing total colectomy for C difficile infection were identified in the National Surgical Quality Improvement Program database from 2005 to 2014. MAIN OUTCOME MEASURES: Variables similar to the original scoring system were used in multivariable analyses to determine the risk of 30-day mortality for patients, and a model was constructed to estimate the predicted probability of mortality after surgery. RESULTS: Of 532 patients who underwent surgery, 32.7% experienced 30-day postoperative mortality. Patient covariates associated with significantly increased mortality included age greater than 80 years (OR 5.5, p = 0.003), need for preoperative mechanical ventilation (OR 3.1, p < 0.001), chronic steroid use (OR 2.9, p < 0.001), underlying cardiopulmonary disease (OR 2.0, p = 0.001), and acute renal failure (OR=1.7, p = 0.03). These and other comorbidities, including hepatic disease, a cancer diagnosis, and both insulin- and noninsulin-dependent diabetes mellitus, were used to construct a model to estimate the predicted probability of mortality, which ranged from 8.0% to 96.1% based on individual comorbidity profiles. These estimates differed substantially when compared with those obtained using the National Surgical Quality Improvement Program risk calculator, which estimated the risk of mortality among surgical patients as being consistently lower. LIMITATIONS: This study was limited by its retrospective design. CONCLUSIONS: Our surgical scoring system allows preoperative risk stratification for patients being evaluated for colectomy for C difficile infection, potentially helping to avoid futile surgery. See Video Abstract at http://links.lww.com/DCR/A434.

Palliative therapy for stage IV rectal adenocarcinoma: how frequently is it used?

BACKGROUND: Palliative care is associated with decreased cost and improved quality of life, although its use in stage IV rectal cancer is understudied. MATERIALS AND METHODS: Stage IV rectal cancer patients (2004-2011) who did not undergo surgery with curative intent were identified within the National Cancer Database. Patients receiving palliative therapy were stratified by the type of intervention, as were patients undergoing chemotherapy that was not designated as palliative. Logistic regression was used to identify factors associated with the receipt of palliative therapy. RESULTS: A total of 11,245 patients were analyzed, of which 2314 (20.6%) received palliative therapy. Use of palliative therapy as a category of treatments did not change significantly from 2004-2012 (19.4%-23.0%; P = 0.14), but the use of palliative chemotherapy nearly doubled (4.7%-8.7%; P < 0.001). Factors associated with the use of palliative therapy included age >60 y and increasing chronic comorbidities; these subgroups also had lower odds of receiving chemotherapy that was not designated as palliative. Differences in gender and race were not associated with variations in the receipt of palliative therapy. CONCLUSIONS: For stage IV rectal cancers managed without curative intent, use of palliative therapies remains consistently low, with a preference for sicker patients.

Is the writing on the wall? The relationship between the number of disease-modifying anti-inflammatory bowel disease drugs used and the risk of surgical resection.

BACKGROUND: Disease-modifying anti-inflammatory bowel disease drugs (DMAIDs) revolutionized the management of ulcerative colitis (UC). This study assessed the relationship between the number and timing of drugs used to treat UC and the risk of colectomy and postoperative complications. METHODS: This was a retrospective review of adult patients with UC treated with disease-modifying drugs between 2005 and 2020 in the MarketScan database. Landmark and time-varying regression analyses were used to analyze risk of surgical resection. Multivariable Cox regression analysis was used to determine risk of postoperative complications, emergency room visits, and readmissions. RESULTS: A total of 12,193 patients with UC and treated with disease-modifying drugs were identified. With a median follow-up time of 1.7 years, 23.8% used >1 drug, and 8.3% of patients required surgical resection. In landmark analyses, using 2 and ≥3 drugs before the landmark date was associated with higher incidence of surgery for each landmark than 1 drug. Multivariable Cox regression showed hazard ratio (95% CIs) of 4.22 (3.59-4.97), 11.7 (9.01-15.3), and 22.9 (15.0-34.9) for using 2, 3, and ≥4 drugs, respectively, compared with using 1 DMAID. That risk was constant overtime. The number of drugs used preoperatively was not associated with an increased postoperative risk of any complication, emergency room visits, or readmission. CONCLUSION: The use of multiple disease-modifying drugs in UC is associated with an increased risk of surgical resection with each additional drug. This provides important prognostic data and highlights the importance of patient counseling with minimal concern regarding risk of postoperative morbidity for additional drugs.

Survival outcomes of anal adenocarcinoma versus rectal adenocarcinoma: A retrospective cohort study.

BACKGROUND: Anal adenocarcinoma (AA) is a rare malignancy with decreased survival compared to rectal adenocarcinoma (RA). However, AA continues to be treated with similar algorithms compared to rectal cancer with minimal data regarding the efficacy of these treatment algorithms. METHODS: A retrospective chart review of patients with non-metastatic AA at a single tertiary-care institution from 1995 to 2020. This cohort was matched 2:1 to a group of RA patients for comparison. The primary outcome of interest was overall survival rates. RESULTS: Sixteen patients with stages I-III AA were matched to a cohort of RA. There were no significant differences between the cohorts with regard to patient demographics, comorbidities, disease stage or histologic features. There were also no significant differences in treatment modalities between the two cohorts with a majority undergoing multimodal therapy with chemoradiation and surgery. All patients with AA demonstrated significantly worse survival than all patients with rectal adenocarcinoma (five-year survival 47.7% vs. 82.3%, respectively. p < 0.05). When looking at a sub-group of patients who underwent combination chemoradiation and surgery from each cohort, anal adenocarcinoma continued to exhibit lower overall survival (five-year survival 41.6% and 86.4%, respectively. p < 0.05). In a multi-variable model that adjusted for location, American Joint Committee on Cancer (AJCC) stage and treatment pathway, tumor location in the anal canal was an independent predictor of overall survival (Hazard ratio [HR] 2.7, p < 0.05). CONCLUSION: AA has worse survival as compared to RA despite similar treatment. This study highlights the need to evaluate the current classification and treatment pathways to improve outcomes.

Changing disposition patterns in the era of COVID-19 after colon resections: A National Surgical Quality Improvement Program colectomy study.

BACKGROUND: The COVID-19 pandemic severely impacted post-hospitalization care facilities in the United States and hindered their ability to accept new patients for various reasons. This study aimed to assess the impact of the pandemic on discharge disposition after colon surgery and associated postoperative outcomes. METHODS: A retrospective cohort study was performed using the National Surgical Quality Improvement Participant Use File and targeted colectomy. Patients were divided into the following 2 cohorts: (1) pre-pandemic (2017-2019) and (2) pandemic (2020). The primary outcomes included discharge disposition-post-hospitalization facility versus home. The secondary outcomes were rates of 30-day readmissions and other postoperative outcomes. The multivariable analysis assessed for confounders and effect modification on discharge to home. RESULTS: Discharge to posthospitalization facilities decreased by 30% in 2020 compared to 2017 to 2019 (7% vs 10%, P < .001). This occurred despite an increase in emergency cases (15% vs 13%, P < .001) and open surgical approach (32% vs 31%, P < .001) in 2020. Multivariable analysis revealed that patients in 2020 had 38% lower odds of going to post-hospitalization facilities (odds ratio 0.62, P < .001) after adjusting for surgical indications and underlying comorbidities. This decrease in patients going to a post-hospitalization facility was not associated with an increased length of stay or an increase in 30-day readmissions or postoperative complications. CONCLUSION: During the pandemic, patients undergoing colonic resection were less likely to be discharged to a post-hospitalization facility. This shift was not associated with an increase in 30-day complications. This should prompt further research to assess the reproducibility of these associations, especially in a setting without a global pandemic.

The Impact of Preoperative Anti-TNFα Therapy on Postoperative Outcomes Following Ileocolectomy in Crohn's Disease.

BACKGROUND: Controversy remains regarding the impact of anti-TNFα agents on postoperative outcomes in Crohn's disease. METHODS: Patients (≥ 18 years) with Crohn's disease (ICD-9, 555.0-555.2, 555.9) undergoing ileocolectomy between 2005 and 2013 were identified using the Truven MarketScan® database and stratified by receipt of anti-TNFα therapy. Multivariable logistic regression was performed to evaluate anti-TNFα use on emergency department (ED) visits, postoperative complications, and readmissions at 30 days, adjusting for potential confounders. Relationships between timing of anti-TNFα administration and outcomes were examined. RESULTS: The sample contained 2364 patients with Crohn's disease undergoing ileocolectomy, with 28.5% (n = 674) who received biologic therapy. Median duration between anti-TNFα therapy and surgery was 33 days. Postoperative ED visits and readmission rates did not significantly differ among those receiving biologics and those that did not. Overall 30-day complication rates were higher among those receiving biologic therapy, namely related to wound and infectious complications. In multivariable analysis, anti-TNFα inhibitors were associated with increased odds of postoperative complications at 30 days (aggregate complications [OR 1.6], infectious complications [OR 1.5]). There was no significant association between timing of anti-TNFα administration and occurrence of postoperative outcomes. CONCLUSION: Anti-TNFα therapy is independently associated with increased postoperative infectious complications following ileocolectomy in Crohn's disease. However, in patients receiving anti-TNFα therapy within 90 days of operative intervention, further delaying surgery may not attenuate risk of postoperative complications.

Correlation between Venous Thromboembolism Risk and Venous Congestion in Microvascular Reconstruction of the Lower Extremity.

BACKGROUND: Risk for venous thromboembolism formation and the relationship to postoperative free flap venous congestion and flap failure have not been adequately evaluated in a trauma population. The authors aim to use the Caprini Risk Assessment Model to evaluate the association between venous thromboembolism risk and postoperative flap venous congestion following lower extremity free tissue transfer. METHODS: A retrospective analysis was conducted of all patients who underwent lower extremity free flap reconstruction of traumatic defects at a single institution between 2007 and 2016. A Wilcoxon rank sum test was used for nonparametric analysis of aggregate Caprini Risk Assessment Model scores and flap outcomes. Flap venous congestion and failure rates as associated with the categorical variables underlying the Caprini Risk Assessment Model were further studied. Logistic regression was used to evaluate each of these outcomes and other flap-related covariates relative to the Caprini Risk Assessment Model categorical variables that had the greatest effect on our patient sample. RESULTS: One hundred twelve patients underwent lower extremity free flap reconstruction. One hundred eight free flaps were analyzed. Eight patients were excluded. The majority of patients were male (75.9 percent) and required reconstruction because of acute trauma (68.1 percent versus 31.9 percent for chronic wounds). There was no statistically significant association found between age, body mass index, or timing of trauma versus venous congestion, flap failure, or other flap-related covariates. CONCLUSION: In patients with significantly elevated Caprini Risk Assessment Model scores, there was no significant association between venous thromboembolism risk and flap failure following free tissue reconstruction of lower extremities. CLINICAL QUESTION/LEVEL OF EVIDENCE: Risk, III.