Gender Related Differences in Surgeon Compensation: Survey Results from the American Society of Colon and Rectal Surgeons.

OBJECTIVE: We sought to understand the effect of sex on compensation among colorectal surgeons and to determine which factors contribute to gender-based differences in compensation. SUMMARY OF BACKGROUND DATA: The sex-based wage gap in the medical profession is among the most pronounced wage gaps in the U.S. Data regarding the wage gap among colorectal surgeons and the underlying reasons for this disparity remain unclear. METHODS: The Healthcare Economics Committee of the American Society of Colon and Rectal Surgeons conducted a survey to evaluate surgeon demographics, compensation, and practice characteristics. To evaluate the effect of sex on compensation, we performed multivariable linear regression with backward selection. We used a two-sided P -value with a significance threshold <0.05. RESULTS: The mean difference in normalized total compensation between men and women was $46,250, and when salary was adjusted for FTEs, the difference was $57,000. Women were more likely to perform anorectal surgery, less likely to perform general surgery and less likely to hold positions in leadership. After adjustments, women reported significantly lower compensation (aOR, 0.88; 95% CI, 0.80-0.97). Time spent doing abdominal surgery (aOR, 1.13; 95% CI 1.03-1.23), professor status (aOR, 1.17; 95% CI, 1.03-1.32) and instructor status (aOR, 1.49; 95% 1.28-1.73) were independently associated with compensation. CONCLUSIONS: We found a 12% adjusted sex wage gap among colorectal surgeons. Gender-based differences in leadership positions and allocation of effort may contribute. Further research will be necessary to clarify sources of wage inequalities. Still, our results should prompt expedient actions to support closing the gap.

Current trends in nonoperative management for rectal adenocarcinoma: An unequal playing field?

BACKGROUND AND OBJECTIVES: Increasing evidence suggests patient-oriented benefits of nonoperative management (NOM) for rectal cancer. However, vigilant surveillance requires excellent access to care. We sought to examine patient, socioeconomic, and facility-level factors associated with NOM over time. METHODS: Using the National Cancer Database (2006-2017), we examined patients with Stage II-III rectal adenocarcinoma, who received neoadjuvant chemoradiation and received NOM versus surgery. Factors associated with NOM were assessed using multivariable logistic regression with backward stepwise selection. RESULTS: There were 59,196 surgical and 8520 NOM patients identified. NOM use increased from 12.9% to 15.9% between 2006 and 2017. Patients who were Black (adjusted odds ratio [aOR]: 1.36, 95% confidence interval [CI]: 1.26-1.47), treated at community cancer centers (aOR: 1.22, 95% CI: 1.12-1.30), without insurance (aOR: 1.87, 95% CI: 1.68-2.09), and with less education (aOR: 1.53, 95% CI: 1.42-1.65) exhibited higher odds of NOM. Patients treated at high-volume centers (aOR: 0.79, 95% CI: 0.74-0.84) and those who traveled >25.6 miles for care (aOR: 0.59, 95% CI: 0.55-0.64) had lower odds of NOM. CONCLUSIONS: Vulnerable groups who traditionally have difficulty accessing comprehensive cancer care were more likely to receive NOM, suggesting that healthcare disparities may be driving utilization. More research is needed to understand NOM decision-making in rectal cancer treatment.

Robotic left-stapled total intracorporeal bowel anastomosis versus stapled partial extracorporeal anastomosis: operative technical description and outcomes.

BACKGROUND: Although there is extensive literature on robotic total intracorporeal anastomosis (TICA) for right colon resection, left total ICA using the da Vinci Xi robotic platform has only been described in short case series previously. In this study, we report on the largest cohort of robotic left total ICA, provide a description of our institution's techniques, and compare outcomes to robotic left partial extracorporeal anastomosis (PECA). METHODS: Patients who underwent robotic left colectomy for any underlying pathology from July 1, 2016 through April 30, 2020 were identified by procedure code. A technical description is provided for two unique techniques performed at our institution. Outcomes included operative time, length of stay, supply cost, post-operative ileus, post-operative morbidity and mortality and need for complete mobilization of the splenic flexure. RESULTS: From a review of our institution's data, 83 robotic TICA cases were identified and 76 robotic PECA cases were identified. Common procedures included low anterior resection, sigmoidectomy, left hemicolectomy, and rectopexy with resection. TICA was associated with significantly shorter intraoperative time compared to PECA. CONCLUSIONS: Our series shows that TICA is a safe and feasible technique that does not increase the risk of adverse outcomes. Using either the anvil-forward or anvil-backward technique, we were able to reliably reproduce this method in a total of 83 patients undergoing left colon resection for either benign or malignant diseases.

Preoperative Serum Vedolizumab Levels Do Not Impact Postoperative Outcomes in Inflammatory Bowel Disease.

BACKGROUND: Vedolizumab has been proposed to lead to fewer postoperative complications because of its gut specificity. Studies, however, suggest an increased risk of surgical site infections, yet the data are conflicting. OBJECTIVE: This study aimed to assess the effect of vedolizumab drug levels on postoperative outcomes in patients undergoing major abdominal surgery for IBD. DESIGN: This was a retrospective study of a prospectively maintained database. SETTING: Patients were operated on by a single surgeon at an academic medical center. PATIENTS: A total of 72 patients with IBD undergoing major abdominal surgery were included. INTERVENTIONS: Patients were exposed preoperatively to vedolizumab. MAIN OUTCOME MEASURES: The primary outcome measured was the postoperative morbidity in patients who had IBD with detectable vs undetectable vedolizumab levels. RESULTS: A total of 72 patients were included in the study. Thirty-eight patients had detectable vedolizumab levels (>1.6 µg/mL), and 34 had undetectable vedolizumab levels. The overall rate of complications was 39%, and ileus was the most common complication. There were no significant differences in clinical variables between the detectable and undetectable vedolizumab level patient groups except for the time between the last dose and surgery (p < 0.01). There were 42 patients in the ulcerative colitis cohort; 48% had an undetectable vedolizumab level and 52% had a detectable vedolizumab level. There were no differences in any postoperative morbidity between ulcerative colitis groups. The Crohn's cohort had 27 patients; 48% had an undetectable vedolizumab levels and 52% had a detectable vedolizumab level. There was a significantly lower incidence of postoperative ileus in patients who had Crohn's disease with detectable vedolizumab levels compared with patients with an undetectable vedolizumab level (p < 0.04). LIMITATIONS: Limitations include a low overall patient population and a high rate of stoma formation. CONCLUSIONS: Serum vedolizumab levels do not influence postoperative morbidity in IBD. Vedolizumab may reduce the incidence of postoperative ileus in patients with Crohn's disease. See Video Abstract at http://links.lww.com/DCR/B574. LOS NIVELES DE VEDOLIZUMAB EN SUERO PREOPERATORIO, NO AFECTAN LOS RESULTADOS POSTOPERATORIOS EN LA ENFERMEDAD INFLAMATORIA INTESTINAL: ANTECEDENTES:Se ha propuesto que el vedolizumab presenta menos complicaciones postoperatorias debido a su especificidad intestinal. Sin embargo, estudios sugieren un mayor riesgo de infecciones en el sitio quirúrgico, aunque los datos son contradictorios.OBJETIVO:Evaluar el efecto en los niveles del fármaco vedolizumab, en resultados postoperatorios de pacientes sometidos a cirugía mayor abdominal, por enfermedad inflamatoria intestinal.DISEÑO:Estudio retrospectivo de una base de datos mantenida prospectivamente.ENTORNO CLÍNICO:Pacientes intervenidos por un solo cirujano en un centro médico académico.PACIENTES:Un total de 72 pacientes con enfermedad inflamatoria intestinal sometidos a cirugía mayor abdominal.INTERVENCIONES:Exposición preoperatoria a vedolizumab.PRINCIPALES MEDIDAS DE VALORACIÓN:Morbilidad postoperatoria en pacientes con enfermedad inflamatoria intestinal, con niveles detectables versus no detectables de vedolizumab.RESULTADOS:Se incluyó en el estudio a un total de 72 pacientes. Treinta y ocho pacientes tuvieron niveles detectables de vedolizumab (> 1,6 mcg / ml) y 34 con niveles no detectables de vedolizumab. La tasa global de complicaciones fue del 39% y el íleo fue la complicación más común. No hubo diferencias significativas en las variables clínicas entre los grupos de pacientes con niveles detectables y no detectables de vedolizumab, excepto por el intervalo de tiempo entre la última dosis y la cirugía (p <.01). La cohorte de colitis ulcerosa tuvo 42 pacientes, el 48% con un nivel no detectable de vedolizumab y el 52% un nivel detectable de vedolizumab. No hubo diferencias en ninguna morbilidad postoperatoria entre los grupos de colitis ulcerosa. La cohorte de Crohn tuvo 27 pacientes, 48% con niveles no detectables de vedolizumab y el 52% con niveles detectables de vedolizumab. Hubo una incidencia significativamente menor de íleo postoperatorio en pacientes de Crohn con niveles detectables de vedolizumab, comparados con los pacientes con un nivel no detectable de vedolizumab (p <0,04).LIMITACIONES:Las limitaciones incluyen una baja población general de pacientes y una alta tasa de formación de estomas.CONCLUSIONES:Los niveles séricos de vedolizumab no influyen en la morbilidad postoperatoria de la enfermedad inflamatoria intestinal. Vedolizumab puede reducir la incidencia de íleo postoperatorio en pacientes de Crohn. Consulte Video Resumen en http://links.lww.com/DCR/B574.

Multiquadrant surgery in the robotic era: a technical description and outcomes for da Vinci Xi robotic subtotal colectomy and total proctocolectomy.

BACKGROUND: Common colorectal procedures that require access to all quadrants of the abdomen are subtotal colectomy (STC) and total proctocolectomy (TPC). These are frequently performed with a surgical robot, but multiquadrant operations have unique challenges during robot-assisted surgery. METHODS: Patients who underwent robotic STC or TPC with the da Vinci Xi surgical robot at our institution from July 1, 2016 through June 30, 2019 were identified by diagnosis and procedure codes. A technical description is provided for the techniques utilized at our institution. Outcomes included operative times (OT), supply cost and length of stay. Associated morbidity and mortality was also analyzed. RESULTS: From a review of our institution's robotic surgery data, 37 cases were identified that utilized the described technique. Of these cases, 21 were robotic STC and 16 were TPC. Total mean OT was 276.86 min (SD ± 119.49). Mean OT was further analyzed by year, which demonstrated an overall decrease in OT from 350.91 min (SD ± 46.38) in 2016 to 221.43 min (SD ± 16.46) in 2018 (p = 0.008). A total of 21 cases were performed prior to 2018. Overall OT for STC was 222.81 min (SD ± 14.54) compared to overall TPC OT 347.81 min (SD ± 34.35). Median length of stay was 5 days [25th and 75th percentiles 4, 6, respectively]. There was no 30-day mortality and only one return to operating room for mesenteric bleeding. There was a low risk of mortality associated with this technique. CONCLUSIONS: The current study provides the largest cohort of patients assessed who have undergone multiquadrant robotic STC or TPC. The study provides a detailed description of the technique utilized at our institution. There was no associated 30-day mortality and a low risk of morbidity. The data suggest that the learning curve for improved operative time is between 15 and 20 cases.

General surgery training in the era of robotic surgery: a qualitative analysis of perceptions from resident and attending surgeons.

BACKGROUND: The use of the surgical robot has increased annually since its introduction, especially in general surgery. Despite the tremendous increase in utilization, there are currently no validated curricula to train residents in robotic surgery, and the effects of robotic surgery on general surgery residency training are not well defined. In this study, we aim to explore the perceptions of resident and attending surgeons toward robotic surgery education in general surgery residency training. METHODS: We performed a qualitative thematic analysis of in-person, one-on-one, semi-structured interviews with general surgery residents and attending surgeons at a large academic health system. Convenient and purposeful sampling was performed in order to ensure diverse demographics, experiences, and opinions were represented. Data were analyzed continuously, and interviews were conducted until thematic saturation was reached, which occurred after 20 residents and seven attendings. RESULTS: All interviewees agreed that dual consoles are necessary to maximize the teaching potential of the robotic platform, and the importance of simulation and simulators in robotic surgery education is paramount. However, further work to ensure proper access to simulation resources for residents is necessary. While most recognize that bedside-assist skills are essential, most think its educational value plateaus quickly. Lastly, residents believe that earlier exposure to robotic surgery is necessary and that almost every case has a portion that is level-appropriate for residents to perform on the robot. CONCLUSIONS: As robotic surgery transitions from novelty to ubiquity, the importance of effective general surgery robotic surgery training during residency is paramount. Through in-depth interviews, this study provides examples of effective educational tools and techniques, highlights the importance of simulation, and explores opinions regarding the role of the resident in robotic surgery education. We hope the insights gained from this study can be used to develop and/or refine robotic surgery curricula.

Challenges in Clinical Trial Implementation: Results from a Survey of the National Accreditation Program of Breast Centers (NAPBC).

BACKGROUND: Although the results of clinical trials often guide best practices, changing clinical practice based on clinical trial results can be challenging. The objective of this study was to examine provider-reported barriers to adopting best clinical practices according to clinical trial data. METHODS: A cross-sectional survey was conducted of providers from the National Accreditation Program for Breast Centers about barriers that prevent the incorporation of trial findings. Descriptive analyses and multivariable analyses were performed to determine provider characteristics that were significantly associated with reported barriers. RESULTS: Overall, 383 institutions participated (63.5% response rate), with a total of 1226 physicians responding to the survey (80% response rate). Providers identified national guidelines and meetings as the most compelling way to receive practice-changing information. They reported the following internal barriers to trial implementation: patient preference (45%), strongly held beliefs by partners/colleagues (37%), and insufficient time to discuss new practices (30%). External barriers preventing trial implementation included a lack of agreement from multidisciplinary tumor boards (32%), fear of reimbursement loss (23%), and resistance from clinical staff (20%). Reported barriers differed by provider specialty, with plastic surgeons and radiation oncologists reporting that strongly held beliefs by partners/colleagues and disagreement from multidisciplinary tumor boards were the most significant factors preventing clinical trial implementation. CONCLUSIONS: Physician beliefs and patient preferences are the most frequently reported barriers to clinical trial implementation. Tactics to better educate providers about how to explain new clinical trial data to their patients and colleagues are needed.

Is There a Role for Ileal Pouch Anal Anastomosis in Crohn's Disease?

Traditionally, surgical interventions for colonic Crohn's disease (CD) have been limited to total abdominal colectomy and ileorectal anastomosis, or total proctocolectomy with end ileostomy if there is rectal involvement. However, improved understandings of the biology of CD, as well as the development of biologic therapies, have enabled more limited resections. Here, we review the indications for, and limitations of, specific procedures aiming to preserve intestinal continuity in colonic CD.

Gastrointestinal Malignancy: Genetic Implications to Clinical Applications.

Alterations in the DNA sequences of genes, or mutations, have traditionally been viewed as the primary factors driving tumor progression, however, epigenetic evidence would suggest that some heritable traits are mediated by changes in DNA expression that are not dependent upon alterations in the primary DNA sequence. Advances in the genetic understanding of cancer have, in some instances, allowed for more precise administration of anti-neoplastic therapy. Targeted therapies, the aim of which are to target specific cellular proteins or processes used by the cancer cells, have been advocated to avoid the adverse side effects attributable to a lack of cell specificity associated with traditional chemotherapy. Here we aim to describe the current state of understanding regarding the genetic related causes of cancers, the targeted therapies aimed at killing them and the inter-relationship between these two.

Advances in Biomarkers: Going Beyond the Carcinoembryonic Antigen.

Using biologically available markers to guide treatment decisions in colorectal cancer care is becoming increasingly common, though our understanding of these biomarkers is in its infancy. In this article, we will discuss how this area is rapidly changing, review important biomarkers being used currently, and explain how the results influence clinical decision-making. We will also briefly discuss the possibility of a liquid biopsy and explore several exciting and new options.

Ghrelin decreases motor deficits after traumatic brain injury.

BACKGROUND: Pharmacologic therapy for traumatic brain injury (TBI) has remained relatively unchanged for decades. Ghrelin, an endogenously produced peptide, has been shown to prevent apoptosis and blood-brain barrier dysfunction after TBI. We hypothesize that ghrelin treatment will prevent neuronal degeneration and improve motor coordination after TBI. MATERIALS AND METHODS: A weight drop model created severe TBI in three groups of BALB/c mice: Sham, TBI, and TBI + ghrelin (20 µg intraperitoneal ghrelin). Brain tissue was examined by hematoxylin and eosin and Fluoro-Jade B (FJB) staining to evaluate histologic signs of injury, cortical volume loss, and neuronal degeneration. Additionally, motor coordination was assessed. RESULTS: Ghrelin treatment prevented volume loss after TBI (19.4 ± 9.8 mm(3)versus 71.4 ± 31.4 mm(3); P < 0.05). Similarly, although TBI increased FJB-positive neuronal degeneration, ghrelin treatment decreased FJB staining in TBI resulting in immunohistologic patterns similar to sham. Compared with sham, TBI animals had a significant increase in foot faults at d 1, 3, and 7 (2.75 ± 0.42; 2.67 ± 0.94; 3.33 ± 0.69 versus 0.0 ± 0.0; 0.17 ± 0.19; 0.0 ± 0.0; P < 0.001). TBI + ghrelin animals had significantly decreased foot faults compared with TBI at d 1, 3, and 7 (0.42 ± 0.63; 0.5 ± 0.43; 1.33 ± 0.58; P versus TBI <0.001; P versus sham = NS). CONCLUSIONS: Ghrelin treatment prevented post-TBI cortical volume loss and neurodegeneration. Furthermore, ghrelin improved post-TBI motor deficits. The mechanisms of these effects are unclear; however, a combination of the anti-apoptotic and inflammatory modulatory effects of ghrelin may play a role. Further studies delineating the mechanism of these observed effects are warranted.

Differences in the Receipt of Regional Anesthesia Based on Race and Ethnicity in Colorectal Surgery.

BACKGROUND: Health equity in pain management during the perioperative period continues to be a topic of interest. The authors evaluated the association of race and ethnicity with regional anesthesia in patients who underwent colorectal surgery and characterized trends in regional anesthesia. METHODS: Using the American College of Surgeons National Surgical Quality Improvement Program database from 2015 to 2020, the research team identified patients who underwent open or laparoscopic colorectal surgery. Associations between race and ethnicity and use of regional anesthesia were estimated using logistic regression models. RESULTS: The final sample size was 292,797, of which 15.6% (n = 45,784) received regional anesthesia. The unadjusted rates of regional anesthesia for race and ethnicity were 15.7% white, 15.1% Black, 12.8% Asian, 29.6% American Indian or Alaska Native, 16.3% Native Hawaiian or Pacific Islander, and 12.4% Hispanic. Black (odds ratio [OR] 0.93, 95% confidence interval [CI] 0.90-0.96, p < 0.001) and Asian (OR 0.76, 95% CI 0.71-0.80, p < 0.001) patients had lower odds of regional anesthesia compared to white patients. Hispanic patients had lower odds of regional anesthesia compared to non-Hispanic patients (OR 0.72, 95% CI 0.68-0.75, p < 0.001). There was a significant annual increase in regional anesthesia from 2015 to 2020 for all racial and ethnic cohorts (p < 0.05). CONCLUSION: There was an annual increase in the use of regional anesthesia, yet Black and Asian patients (compared to whites) and Hispanics (compared to non-Hispanics) were less likely to receive regional anesthesia for colorectal surgery. These differences suggest that there are racial and ethnic differences in regional anesthesia use for colorectal surgery.

Vagal nerve stimulation protects cardiac injury by attenuating mitochondrial dysfunction in a murine burn injury model.

Mitochondria play a central role in the integration and execution of a wide variety of apoptotic signals. In the present study, we examined the deleterious effects of burn injury on heart tissue. We explored the effects of vagal nerve stimulation (VNS) on cardiac injury in a murine burn injury model, with a focus on the protective effect of VNS on mitochondrial dysfunction in heart tissue. Mice were subjected to a 30% total body surface area, full-thickness steam burn followed by right cervical VNS for 10 min. and compared to burn alone. A separate group of mice were treated with the M3-muscarinic acetylcholine receptor (M3-AchR) antagonist 4-DAMP or phosphatidylinositol 3 Kinase (PI3K) inhibitor LY294002 prior to burn and VNS. Heart tissue samples were collected at 6 and 24 hrs after injury to measure changes in apoptotic signalling pathways. Burn injury caused significant cardiac pathological changes, cardiomyocyte apoptosis, mitochondrial swelling and decrease in myocardial ATP content at 6 and 24 hrs after injury. These changes were significantly attenuated by VNS. VNS inhibited release of pro-apoptotic protein cytochrome C and apoptosis-inducing factor from mitochondria to cytosol by increasing the expression of Bcl-2, and the phosphorylation level of Bad (pBad(136)) and Akt (pAkt(308)). These protective changes were blocked by 4-DAMP or LY294002. We demonstrated that VNS protected against burn injury-induced cardiac injury by attenuating mitochondria dysfunction, likely through the M3-AchR and the PI3K/Akt signalling pathways.

Autologous Fat Grafting: an Emerging Treatment Option for Complex Anal Fistulas.

BACKGROUND: Autologous fat grafting (AFG) has shown promise in the treatment of complex wounds, with trials reporting good healing rates and safety profile. We aim to investigate the role of AFG in managing complex anorectal fistulas. METHODS: This was a retrospective review of a prospectively maintained IRB-approved database. We examined the rates of symptom improvement, clinical closure of fistula tracts, recurrence, complications, and worsening fecal incontinence. Perianal disease activity index (PDAI) was obtained for patients undergoing combination of AFG and fistula plug treatment. RESULTS: In total, 52 unique patients underwent 81 procedures, of which Crohn's was present in 34 (65.4%) patients. The majority of patients previously underwent more common treatments such as endorectal advancement flap or ligation of intersphincteric fistula tract. Fat-harvesting sites and processing technique were selected by the plastic surgeons based on availability of trunk fat deposits. When analyzing patients by their last procedure, 41 (80.4%) experienced symptom improvement, and 29 (64.4%) experienced clinical closure of all fistula tracts. Recurrence rate was 40.4%, and complication rate was 15.4% (7 postoperative abscesses requiring I&D and 1 bleeding episode ligated at bedside). The abdomen was the most common site of lipoaspirate harvest at 63%, but extremities were occasionally used. There were no statistically significant differences in outcomes when comparing single graft treatment to multiple treatments, Crohn's and non-Crohn's, different methods of fat preparation, and diversion. CONCLUSION: AFG is a versatile procedure that can be done in conjunction with other therapies and does not interfere with future treatments if recurrence occurs. It is a promising and affordable method to safely address complex fistulas.

The Role of Biomarkers in Surgery for Ulcerative Colitis: A Review.

Ulcerative colitis (UC) is an inflammatory condition that generally affects the rectum and extends proximally into the colon in a continuous, distal-to-proximal pattern. Surgical resection (total proctocolectomy) is the only cure for UC and is often necessary in managing complicated or refractory disease. However, recent advances in biologically targeted therapies have resulted in improved disease control, and surgery is required in only a fraction of cases. This ever-increasing array of options for medical management has added complexity to surgical decision-making. In some circumstances, the added time required to ensure failure of medical therapy can delay colectomy in patients who will ultimately need it. Indeed, many patients with severe disease undergo trials of multiple medical therapies prior to considering surgery. In severe cases of UC, continued medical management has been associated with a delay to surgical intervention and higher rates of morbidity and mortality. Biomarkers represent a burgeoning field of research, particularly in inflammatory bowel disease and cancer. This review seeks to highlight the different possible settings for surgery in UC and the role various biomarkers might play in each.

Outcomes for a Large Cohort of Patients with Rectal Neuroendocrine Tumors: an Analysis of the National Cancer Database.

BACKGROUND: Rectal neuroendocrine tumors comprise 20% of neuroendocrine tumors in the alimentary tract, but there is controversy surrounding the optimal management of this disease. The purpose of this study is to better define treatment for patients with rectal neuroendocrine tumors. METHODS: Using the National Cancer Database, we analyzed patients with rectal neuroendocrine tumors between 2004 and 2015. Patients with metastatic disease and missing treatment data were excluded. We examined overall survival stratified by tumor size, treatment type, and presence of positive lymph nodes using Kaplan-Meier analysis with log-rank test. Cox proportional hazard regression model was performed to identify factors associated with overall survival. RESULTS: In total, 17,448 patients with rectal neuroendocrine tumors were identified; 16,531 of these patients met inclusion criteria. The majority of patients had tumors ≤ 10 mm (9216 patients, 79.8%), and approximately 90% underwent local excision. The probability of 5-year overall survival was significantly higher for patients with smaller tumors (≤ 10 mm: 94.1% 11-20 mm: 85.7%, > 20 mm: 71.8%; p < 0.001) and those with no positive lymph nodes (91.4% versus 53.3%, p < 0.001). The probability of 5-year overall survival differed based on treatment modality (local excision: 93.6%, radical resection: 79.1%, observation alone: 77.1%; p < 0.001). On multivariable Cox regression, when compared to local excision, radical resection was not associated with a difference in overall survival but observation alone was associated with significantly worse OS (HR = 2.750, p < 0.001). CONCLUSIONS: There is a significant difference in overall survival between patients who underwent local excision versus observation alone. Excision of the tumor should be offered to all patients with rectal neuroendocrine tumors who are appropriate surgical candidates, regardless of the tumor size.

International Socioeconomic Predictors of Colon and Rectal Cancer Mortality: Is Colorectal Cancer a First World Problem?

PURPOSE: Colorectal cancer (CRC) is a leading cause of international morbidity and is the second highest cause of cancer-related mortality in the world. The purpose of this study was to investigate the relationship between international health care spending on CRC mortality over time. METHODS: This is a retrospective study using a publicly available data from the WHO Global Health Observatory database. General estimating equations were used to analyze the relationship between total health care expenditure per capita (THEpc) and CRC mortality at the country level. The primary predictors of interest were quartiles of THEpc. Other exposure variables included gross domestic product per capita (GDPpc), smoking (% of adult population smoking), physician density (per 10,000), and time. RESULTS: Mortality decreased significantly from 2000 to 2016 (coefficient [95% CI], -2.2 [-3.3 to -1.1]; P < .001). THEpc, GDPpc, time, and percentage of adult population smoking were significant predictors of CRC mortality. Patients in the top two quartiles of THEpc had 3% higher rates of CRC mortality compared with countries in Q1 THEpc (Q3: 3.4 [1.9-4.8], P < .001; Q4: 3.2 [1.4-5.0], P = .001). Similar trends were seen in GDPpc (Q4: 3.2 [1.4-5.0], P = .001; Q3: 3.4 [1.9-4.8], P < .001; Q2: 1.7 [0.7-2.6], P < .001; Q1: reference). CONCLUSION: Overall, mortality decreased significantly over the study period. Countries with higher health expenditures and higher gross domestic products experienced higher rates of CRC mortality. Further research will be necessary to determine the cause for this, but we postulate that it may be a result of more robust diagnostic and follow-up methods in countries with more resources.

Local excision versus radical resection in patients with rectal neuroendocrine tumours: a propensity score match analysis.

BACKGROUND: The rectum is a common site for neuroendocrine tumours of the gastrointestinal tract. Diagnosis of these tumours has been increasing in recent years, highlighting the need to better define treatment options for patients with rectal neuroendocrine tumours (rNETs). METHODS: We performed a retrospective analysis using the National Cancer Database (2004-2014) to compare overall survival (OS) between local excision (LE) and radical resection (RR). To minimize bias, we performed three propensity score-matched comparisons stratified by tumour size: <10 mm, 10-20 mm, >20 mm. We compared OS by Kaplan-Meier analysis. We also examined margin status and postoperative outcomes for each comparison. RESULTS: A total of 12 996 patients underwent surgical treatment for rNET. There was no significant difference in probability of 10-year OS between LE and RR for patients with tumours <10 mm (88.6% versus 83.8%, P = 0.631, respectively) and tumours 10-20 mm (69.5% versus 69.3%, P = 0.226, respectively). In patients with tumours >20 mm, probability of 10-year OS was significantly longer in the LE group (76.5% versus 37.0%, P < 0.001). For all tumour sizes <10 mm and >20 mm, RR had significantly higher rates of 30-day readmission and negative margins. In subset analysis, there was no difference in OS for patients with positive margins after LE versus negative margins after RR for all tumour size groups. CONCLUSIONS: Our findings suggest that LE is a reasonable treatment option in patients with rNETs, especially for patients with high perioperative risk. Limitations to this study include its retrospective nature and inability to analyse surgeon decision-making.

Predicting Overall Survival in Patients with Metastatic Rectal Cancer: a Machine Learning Approach.

BACKGROUND: A significant proportion of patients with rectal cancer will present with synchronous metastasis at the time of diagnosis. Overall survival (OS) for these patients are highly variable and previous attempts to build predictive models often have low predictive power, with concordance indexes (c-index) less than 0.70. METHODS: Using the National Cancer Database (2010-2014), we identified patients with synchronous metastatic rectal cancer. The data was split into a training dataset (diagnosis years 2010-2012), which was used to build the machine learning model, and a testing dataset (diagnosis years 2013-2014), which was used to externally validate the model. A nomogram predicting 3-year OS was created using Cox proportional hazard regression with lasso penalization. Predictors were selected based on clinical significance and availability in NCDB. Performance of the machine learning model was assessed by c-index. RESULTS: A total of 4098 and 3107 patients were used to construct and validate the nomogram, respectively. Internally validated c-indexes at 1, 2, and 3 years were 0.816 (95% CI 0.813-0.818), 0.789 (95% CI 0.786-0.790), and 0.778 (95% CI 0.775-0.780), respectively. External validated c-indexes at 1, 2, and 3 years were 0.811, 0.779, and 0.778, respectively. CONCLUSIONS: There is wide variability in the OS for patients with metastatic rectal cancer, making accurate predictions difficult. However, using machine learning techniques, more accurate models can be built. This will aid patients and clinicians in setting expectations and making clinical decisions in this group of challenging patients.