MicroRNA signatures differentiate types, grades, and stages of breast invasive ductal carcinoma (IDC): miRNA-target interacting signaling pathways.

BACKGROUND: Invasive ductal carcinoma (IDC) is the most common form of breast cancer which accounts for 85% of all breast cancer diagnoses. Non-invasive and early stages have a better prognosis than late-stage invasive cancer that has spread to lymph nodes. The involvement of microRNAs (miRNAs) in the initiation and progression of breast cancer holds great promise for the development of molecular tools for early diagnosis and prognosis. Therefore, developing a cost effective, quick and robust early detection protocol using miRNAs for breast cancer diagnosis is an imminent need that could strengthen the health care system to tackle this disease around the world. METHODS: We have analyzed putative miRNAs signatures in 100 breast cancer samples using two independent high fidelity array systems. Unique and common miRNA signatures from both array systems were validated using stringent double-blind individual TaqMan assays and their expression pattern was confirmed with tissue microarrays and northern analysis. In silico analysis were carried out to find miRNA targets and were validated with q-PCR and immunoblotting. In addition, functional validation using antibody arrays was also carried out to confirm the oncotargets and their networking in different pathways. Similar profiling was carried out in Brca2/p53 double knock out mice models using rodent miRNA microarrays that revealed common signatures with human arrays which could be used for future in vivo functional validation. RESULTS: Expression profile revealed 85% downregulated and 15% upregulated microRNAs in the patient samples of IDC. Among them, 439 miRNAs were associated with breast cancer, out of which 107 miRNAs qualified to be potential biomarkers for the stratification of different types, grades and stages of IDC after stringent validation. Functional validation of their putative targets revealed extensive miRNA network in different oncogenic pathways thus contributing to epithelial-mesenchymal transition (EMT) and cellular plasticity. CONCLUSION: This study revealed potential biomarkers for the robust classification as well as rapid, cost effective and early detection of IDC of breast cancer. It not only confirmed the role of these miRNAs in cancer development but also revealed the oncogenic pathways involved in different progressive grades and stages thus suggesting a role in EMT and cellular plasticity during breast tumorigenesis per se and IDC in particular. Thus, our findings have provided newer insights into the miRNA signatures for the classification and early detection of IDC.

Conversion of Failed J-Pouch to Kock Pouch: Indications, Contraindications, and Outcomes.

BACKGROUND: The IPAA has been successful in restoring intestinal continuity and preserving continence in the majority of patients requiring a proctocolectomy. However, a subset of individuals experience significant complications that might result in pouch failure. The conversion of the J-pouch to a continent ileostomy pouch represents a significant surgical procedure. In this article, we discuss the indications and contraindications, present the technical principles applied for the conversion, and describe the outcomes of such conversion in the literature. OBJECTIVE: The main objective during the conversion of the J-pouch to a continent ileostomy is the creation of a sufficiently sized reservoir with a high-quality valve mechanism while preserving as much small bowel as possible. CONCLUSIONS: The conversion of the J-pouch to a continent ileostomy represents a significant surgical procedure. When performed in centers of expertise, it can be a good option for patients who otherwise will require an end ileostomy. Indications for conversion include most cases of J-pouch failure, with a few important exceptions. See video from symposium .

Colonic interposition in esophagectomy: an ACS-NSQIP study.

INTRODUCTION: For patients with cancer or injury of the esophagus, esophagectomy with reconstruction using the stomach (gastric pull-up, GPU) or colon (colonic interposition, CI) can restore function but is associated with high morbidity. We sought to describe the differences in outcomes between the two replacement organs using a national database. METHODS: From ACS-NSQIP, patients who underwent GPU or CI between 2006 and 2020 were identified. Univariate analyses were performed on length of stay, complications, reoperation, readmission, and mortality. Variables with P ≤ 0.2 were included in the multivariate regression. Primary outcomes were 30-day reoperation, readmission, and mortality. Data were assessed using Chi-squared tests and logistic regression. RESULTS: There were 12,545 GPU and 502 CI patients. GPU patients were older with higher BMI, and more likely to be male (80.3% versus 70.3%, P < 0.0001) and white (77.8% versus 69.1%, P < 0.0001). More GPU patients had independent functional status and underlying bleeding disorders, but fewer other preoperative comorbidities than CI patients. On univariate analysis, CI patients had longer hospital stays (13 versus 10 days, P < 0.0001); more reoperations (23.9% versus 14.5%, P < 0.0001); a lower rate of discharge to home (70.9% versus 82.1%, P < 0.0001); and a higher mortality rate (6.2% versus 2.9%, P < 0.0001). On multivariate analysis, CI was associated with increased risk of reoperation but not with readmission or mortality. Reoperation was associated with CI, smoking, chronic wound, hypertension, higher ASA class, contaminated or dirty wound class, and longer operative time. Readmission was associated with female gender, hypertension, and longer operative time. Mortality was associated with age, metastatic cancer, preoperative sepsis, preoperative renal failure, malignant esophageal disease, higher ASA class, incomplete closure, and longer operative time. CONCLUSION: Colonic interposition, although a more difficult option with traditionally worse outcomes, should still be considered for patients requiring esophagectomy if the stomach cannot be used to restore continuity, as differences in outcomes appear to be due to underlying frailty of patients rather than the procedure.

Role of Microbiome in the Outcomes Following Surgical Repair of Perianal Fistula: Prospective Cohort Study Design and Preliminary Results.

BACKGROUND: Anal fistulae are common, predominantly cryptoglandular, and almost invariably require surgical treatment. Recurrences are common for procedures other than fistulotomy regardless of technique and adequacy of repair. Growing evidence supports the pivotal role of specific intestinal bacteria in anastomotic failures after bowel resection. Anal crypts harbor colonic microbiota suggesting that similar mechanisms to anastomotic healing might prevail after anal fistula repair and hence influence healing. This study aims at assessing the potential role of the intestinal microbiome in the clinical outcomes after surgical repair of cryptoglandular anal fistula. METHODS: This is a pilot prospective cohort study enrolling patients with anal fistula undergoing endoanal advancement flap. For microbiome analysis, stool samples are taken via rectal swab before the procedure; additionally, a portion of the fistula is collected intraoperatively after fistulectomy. Samples from groups with treatment failure are compared to samples from patients who healed after surgical repair. Alpha and beta diversities and differential abundance of microbial taxa are determined and compared between groups with DADA2 analytical pipeline. RESULTS: Five patients have been enrolled to date (one female, four male). At median follow-up of 6 months (2-11), one patient experienced disease recurrence at 3 months. DNA from the 5 rectal swab and tissue samples was extracted, showing increased relative abundance of Enterococcus faecalis in samples from the patient who developed a recurrent fistula but not in those without recurrence. CONCLUSION: These very preliminary data suggest that intestinal microbiome may represent a crucial determinant of the surgical outcomes after anal fistula surgery.

Feasibility and Safety of Ambulatory Surgery as the Next Management Paradigm in Colorectal Resection Surgery.

BACKGROUND: Current clinical dogma favors universal inpatient admission after colorectal resection particularly in the presence of an anastomosis. OBJECTIVE: We evaluate the feasibility and safety of ambulatory surgery in carefully selected patients undergoing colorectal resection/anastomosis. METHODS: Between October 2020 and October 2021, all patients undergoing colorectal resection/anastomosis meeting specific criteria {no major comorbidity [American Society of Anesthesiologist (ASA) <4], not on therapeutic anticoagulation, compliant patient/family} were counseled preoperatively for ambulatory surgery (discharge <24 h postsurgery). Complicated surgery (ileoanal pouch, enterocutaneous fistula repair, reoperative pelvic surgery, multiple resections) and/or ostomy creation (loop/end ileostomy, Hartmann's, abdominoperineal resection) were exclusions. Discharge was at 6 to 8 hours postoperatively if all predetermined factors (no ostomy teaching needed, ambulating comfortably, tolerating diet, stable vitals, and blood-work) were met and patients were willing, or was postponed to the next day at patient request. All discharged patients received phone checks the next day with the option also given for voluntary readmission if inpatient care was preferred by patient. Patients discharged <24 hours postop (AmbC) were compared to those staying on as inpatients admitted (InpC) and also to a comparable historical (October 2019-October 2020) group when ambulatory surgery was not offered (HistC). RESULTS: Of 184 abdominal colorectal surgery patients, 97 had complicated colorectal resection and/or ostomy. Of the remaining 87, 29 (33.3%) were discharged <24 hours postoperatively [7 (24%) patients at 8 h]. Of these 29 AmbC patients, 4 were readmitted <30 days (ileus: 1, rectal bleeding: 2, nausea/vomiting: 1), 1 readmission was on first postdischarge day, none were voluntary post phone-check. AmbC and InpC (n=58) had similar age, sex, race, body mass index, and comorbidity. InpC had greater estimated blood loss (109 vs 34 mL, P <0.001) while length of stay was expectedly significantly longer (109 vs 17 hours, P <0.001). There was no mortality in either group. AmbC and InpC had similar readmission, reoperation, anastomotic leak, ileus, and surgical site infection. Mean length of stay for HistC was 83 hours. AmbC and HistC had similar age, sex, race, body mass index, and ASA class. Complications including readmission, reoperation, anastomotic leak, ileus, and surgical site infection were also similar for AmbC and HistC. CONCLUSIONS: With careful patient selection, preoperative education, perioperative management, and postoperative follow-up, ambulatory surgery is feasible in up to a third of patients undergoing colorectal resection/anastomosis and can be performed with comparable safety to the time-honored practice of routine inpatient hospitalization. Refinements in inclusion/exclusion criteria and postoperative outpatient follow-up will allow a paradigm shift in how such patients are managed, which has huge implications for patient experience, care-giver workload and health care finances.

Construction of and Conversion to Continent Ileostomy: A Systematic Review.

BACKGROUND: Continent ileostomy was first introduced by Nils Kock in 1969 as Kock pouch (K-pouch). Its most characteristic feature, the nipple valve that offers continence' was a later addition. Even though today's continent ileostomy is sidelined by ileal pouch-anal anastomosis as the gold standard of restorative procedures for colectomy patients, it remains an excellent option for select patients, offering an alternative to end-ileostomy or a poorly functioning ileoanal pouch. OBJECTIVE: The study aimed to summarize principles and techniques behind K-pouch construction, both de novo and as "J to K" conversion, as well as examine surgical outcomes following the procedure in the modern era regardless of indication. DATA SOURCES: Data sources included PubMed and the Cochrane Library up to July 2021. STUDY SELECTION: The study selection materials included articles reviewing continent ileostomy procedures and outcomes between 2000-2021. Case reports and series <15 were excluded. RESULTS: Fifteen articles were selected for review, describing 958 patients with a K-pouch, 510 patients who had undergone a Barnett continent intestinal reservoir, and 40 who had undergone construction of a T-pouch. CONCLUSION: Continent ileostomies carried out in specialized centers by experienced surgeons can be a great option for patients who would otherwise be confined by an end ileostomy. High pouch survival rates with higher quality-of-life scores than end ileostomy and comparable with IPAA make continent ileostomy a great option, even if we consider the less than ideal reoperation and complication rates. However, it is of paramount importance that patients are carefully selected, thoroughly educated, highly motivated, and engaged in their care. Specifically, for patients with Crohn's disease, further research is needed to help elucidate factors that affect pouch survival and candidacy for K-pouch creation. Finally, continuous surgical technique modifications and refinements can allow even more patients to be considered suitable for the procedure.

Association Between Portal Vein Thrombosis and Pouchitis in Patients with Ulcerative Colitis.

BACKGROUND: Pouchitis is the most common long-term complication in patients requiring colectomy ileal pouch-anal anastomosis with medically refractory ulcerative colitis or colitis-associated neoplasia. A previous small case series suggests associated between portal vein thrombosis (PVT) and ischemic pouchitis. AIM: To evaluate the association between PVT and other demographic and clinical factors and pouchitis. METHODS: We used Explorys Inc., a population-based database, to search medical records between 1999 and 2020 with SNOMED-CT code criteria for "construction of pouch" and "ileal pouchitis." Patients with pouchitis were compared to those with previous pouch construction without pouchitis. Factors associated with pouchitis identified with univariable analysis were introduced into a multivariable model. A post hoc analysis further stratified demographical findings of the association between PVT and pouchitis. RESULTS: We identified 7900 patients with ileal pouchitis (7.5%) and 97,510 with pouch construction without pouchitis. In multivariate binary logistic regression, adjusted odds ratio (aOR) for the risk of pouchitis in patients with PVT was 10.78 (95% confidence interval [CI] 7.04-16.49, P < 0.001). Other significant factors associated with pouchitis included male gender (aOR 1.11, 95% CI 1.02-1.21, P = 0.018), deep vein thrombosis (aOR 1.46, 95% CI 1.23-1.72, P < 0.001), and the use of non-steroidal anti-inflammatory drugs (aOR 1.37, 95% CI 1.28-1.45, P < 0.001). Smoking was a protective factor (aOR 0.30, 95% CI 0.33-0.36, P < 0.001). Further sub-analysis showed a higher prevalence of younger patients with PVT and pouchitis. CONCLUSIONS: We report PVT as an independent risk factor associated with pouchitis. Our findings support that PVT is a potentially manageable perioperative complication, and intervention may reduce the risk of pouchitis.

Impact of Intraoperative Data on Risk Prediction for Mortality After Intra-Abdominal Surgery.

BACKGROUND: Risk prediction models for postoperative mortality after intra-abdominal surgery have typically been developed using preoperative variables. It is unclear if intraoperative data add significant value to these risk prediction models. METHODS: With IRB approval, an institutional retrospective cohort of intra-abdominal surgery patients in the 2005 to 2015 American College of Surgeons National Surgical Quality Improvement Program was identified. Intraoperative data were obtained from the electronic health record. The primary outcome was 30-day mortality. We evaluated the performance of machine learning algorithms to predict 30-day mortality using: 1) baseline variables and 2) baseline + intraoperative variables. Algorithms evaluated were: 1) logistic regression with elastic net selection, 2) random forest (RF), 3) gradient boosting machine (GBM), 4) support vector machine (SVM), and 5) convolutional neural networks (CNNs). Model performance was evaluated using the area under the receiver operator characteristic curve (AUROC). The sample was randomly divided into a training/testing split with 80%/20% probabilities. Repeated 10-fold cross-validation identified the optimal model hyperparameters in the training dataset for each model, which were then applied to the entire training dataset to train the model. Trained models were applied to the test cohort to evaluate model performance. Statistical significance was evaluated using P < .05. RESULTS: The training and testing cohorts contained 4322 and 1079 patients, respectively, with 62 (1.4%) and 15 (1.4%) experiencing 30-day mortality, respectively. When using only baseline variables to predict mortality, all algorithms except SVM (area under the receiver operator characteristic curve [AUROC], 0.83 [95% confidence interval {CI}, 0.69-0.97]) had AUROC >0.9: GBM (AUROC, 0.96 [0.94-1.0]), RF (AUROC, 0.96 [0.92-1.0]), CNN (AUROC, 0.96 [0.92-0.99]), and logistic regression (AUROC, 0.95 [0.91-0.99]). AUROC significantly increased with intraoperative variables with CNN (AUROC, 0.97 [0.96-0.99]; P = .047 versus baseline), but there was no improvement with GBM (AUROC, 0.97 [0.95-0.99]; P = .3 versus baseline), RF (AUROC, 0.96 [0.93-1.0]; P = .5 versus baseline), and logistic regression (AUROC, 0.94 [0.90-0.99]; P = .6 versus baseline). CONCLUSIONS: Postoperative mortality is predicted with excellent discrimination in intra-abdominal surgery patients using only preoperative variables in various machine learning algorithms. The addition of intraoperative data to preoperative data also resulted in models with excellent discrimination, but model performance did not improve.

Predictors of Positive Circumferential Resection Margin in Rectal Cancer: A Current Audit of the National Cancer Database.

BACKGROUND: Positive circumferential resection margin is a predictor of local recurrence and worse survival in rectal cancer. National programs aimed to improve rectal cancer outcomes were first created in 2011 and continue to evolve. The impact on circumferential resection margin during this time frame has not been fully evaluated in the United States. OBJECTIVE: The purpose of this study was to determine the incidence and predictors of positive circumferential resection margin after rectal cancer resection, across patient, provider, and tumor characteristics. DESIGN: This was a retrospective cohort study. SETTINGS: The study was conducted using the National Cancer Database, 2011-2016. PATIENTS: Adults who underwent proctectomy for pathologic stage I to III rectal adenocarcinoma were included. MAIN OUTCOME MEASURES: Rate and predictors of positive circumferential resection margin, defined as resection margin ≤1 mm, were measured. RESULTS: Of 52,620 cases, circumferential resection margin status was reported in 90% (n = 47,331) and positive in 18.4% (n = 8719). Unadjusted analysis showed that patients with positive circumferential resection margin were more often men, had public insurance and shorter travel, underwent total proctectomy via open and robotic approaches, and were treated in Southern and Western regions at integrated cancer networks (all p < 0.001). Multivariate analysis noted that positive proximal and/or distal margin on resected specimen had the strongest association with positive circumferential resection margin (OR = 15.6 (95% CI, 13.6-18.1); p < 0.001). Perineural invasion, total proctectomy, robotic approach, neoadjuvant chemoradiation, integrated cancer network, advanced tumor size and grade, and Black race had increased risk of positive circumferential resection margin (all p < 0.050). Laparoscopic approach, surgery in North, South, and Midwest regions, greater hospital volume and travel distance, lower T-stage, and higher income were associated with decreased risk (all p < 0.028). LIMITATIONS: This was a retrospective cohort study with limited variables available for analysis. CONCLUSIONS: Despite creation of national initiatives, positive circumferential resection margin rate remains an alarming 18.4%. The persistently high rate with predictors of positive circumferential resection margin identified calls for additional education, targeted quality improvement assessments, and publicized auditing to improve rectal cancer care in the United States. See Video Abstract at http://links.lww.com/DCR/B584. PREDICTORES PARA UN MARGEN POSITIVO DE RESECCIN CIRCUNFERENCIAL EN EL CNCER DE RECTO UNA AUDITORA VIGENTE DE LA BASE DE DATOS NACIONAL DE CANCER: ANTECEDENTES:El margen positivo de resección circunferencial es un predictor de recurrencia local y peor sobrevida en el cáncer de recto. Los programas nacionales destinados a mejorar los resultados del cáncer de recto se crearon por primera vez en 2011 y continúan evolucionando. La repercusión del margen de resección circunferencial durante este período de tiempo no se ha evaluado completamente en los Estados Unidos.OBJETIVO:Determinar la incidencia y los predictores para un margen positivo de resección circunferencial posterior a la resección del cáncer de recto, según las características del paciente, el proveedor y el tumor.DISEÑO:Estudio de cohorte retrospectivo.AMBITO:Base de datos nacional de cáncer, 2011-2016.PACIENTES:Adultos que se sometieron a proctectomía por adenocarcinoma de recto con un estadío por patología I-III.PRINCIPALES VARIABLES EVALUADAS:Tasa y predictores para un margen positivo de resección circunferencial, definido como margen de resección ≤ 1 mm.RESULTADOS:De 52,620 casos, la condición del margen de resección circunferencial se informó en el 90% (n = 47,331) y positivo en el 18.4% (n = 8,719). El análisis no ajustado mostró que los pacientes con margen positivo de resección circunferencial se presentó con mayor frecuencia en hombres, tenían un seguro social y viajes más cortos, se operaron de proctectomía total abierta y robótica, y fueron tratados en las regiones del sur y el oeste en redes integradas de cáncer (todos p <0,001). El análisis multivariado destacó que el margen proximal y / o distal positivo de la pieza resecada tenía la asociación más fuerte con el margen postivo de resección circunferencial (OR 15,6; IC del 95%: 13,6-18,1, p <0,001). La invasión perineural, la proctectomía total, el abordaje robótico, la quimioradioterapia neoadyuvante, la red de cáncer integrada, el tamaño y grado del tumor avanzado y la raza afroamericana tenían un mayor riesgo de un margen de una resección positiva circunferencial (todos p <0,050). El abordaje laparoscópico, la cirugía en las regiones Norte, Sur y Medio Oeste, un mayor volumen hospitalario y distancia de viaje, estadio T más bajo y mayores ingresos se asociaron con una disminución del riesgo (todos p <0,028).LIMITACIONES:Estudio de cohorte retrospectivo con variables limitadas disponibles para análisis.CONCLUSIONES:A pesar del establecimiento de iniciativas nacionales, la tasa de margen positivo de resección circunferencial continúa siendo alarmante, 18,4%. El índice continuamente elevado junto a los predictores de un margen positivo de resección circunferencial hace un llamado para una mayor educación, evaluaciones específicas de mejora de la calidad y difusión de las auditorías para mejorar la atención del cáncer de recto en los Estados Unidos. Vea el resumen de video en http://links.lww.com/DCR/B584. Consulte Video Resumen en http://links.lww.com/DCR/B584.

Intraoperative Data Enhance the Detection of High-Risk Acute Kidney Injury Patients When Added to a Baseline Prediction Model.

BACKGROUND: Aspects of intraoperative management (eg, hypotension) are associated with acute kidney injury (AKI) in noncardiac surgery patients. However, it is unclear if and how the addition of intraoperative data affects a baseline risk prediction model for postoperative AKI. METHODS: With institutional review board (IRB) approval, an institutional cohort (2005-2015) of inpatient intra-abdominal surgery patients without preoperative AKI was identified. Data from the American College of Surgeons National Surgical Quality Improvement Program (preoperative and procedure data), Anesthesia Information Management System (intraoperative data), and electronic health record (postoperative laboratory data) were linked. The sample was split into derivation/validation (70%/30%) cohorts. AKI was defined as an increase in serum creatinine ≥0.3 mg/dL within 48 hours or >50% within 7 days of surgery. Forward logistic regression fit a baseline model incorporating preoperative variables and surgical procedure. Forward logistic regression fit a second model incorporating the previously selected baseline variables, as well as additional intraoperative variables. Intraoperative variables reflected the following aspects of intraoperative management: anesthetics, beta-blockers, blood pressure, diuretics, fluids, operative time, opioids, and vasopressors. The baseline and intraoperative models were evaluated based on statistical significance and discriminative ability (c-statistic). The risk threshold equalizing sensitivity and specificity in the intraoperative model was identified. RESULTS: Of 2691 patients in the derivation cohort, 234 (8.7%) developed AKI. The baseline model had c-statistic 0.77 (95% confidence interval [CI], 0.74-0.80). The additional variables added to the intraoperative model were significantly associated with AKI (P < .0001) and the intraoperative model had c-statistic 0.81 (95% CI, 0.78-0.83). Sensitivity and specificity were equalized at a risk threshold of 9.0% in the intraoperative model. At this threshold, the baseline model had sensitivity and specificity of 71% (95% CI, 65-76) and 69% (95% CI, 67-70), respectively, and the intraoperative model had sensitivity and specificity of 74% (95% CI, 69-80) and 74% (95% CI, 73-76), respectively. The high-risk group had an AKI risk of 18% (95% CI, 15-20) in the baseline model and 22% (95% CI, 19-25) in the intraoperative model. CONCLUSIONS: Intraoperative data, when added to a baseline risk prediction model for postoperative AKI in intra-abdominal surgery patients, improves the performance of the model.

Radiomics of MRI for pretreatment prediction of pathologic complete response, tumor regression grade, and neoadjuvant rectal score in patients with locally advanced rectal cancer undergoing neoadjuvant chemoradiation: an international multicenter study.

OBJECTIVE: To investigate whether pretreatment MRI-based radiomics of locally advanced rectal cancer (LARC) and/or the surrounding mesorectal compartment (MC) can predict pathologic complete response (pCR), neoadjuvant rectal (NAR) score, and tumor regression grade (TRG). METHODS: One hundred thirty-two consecutive patients with LARC who underwent neoadjuvant chemoradiation and total mesorectal excision (TME) were retrospectively collected from 2 centers in the USA and Italy. The primary tumor and surrounding MC were segmented on the best available T2-weighted sequence (axial, coronal, or sagittal). Three thousand one hundred ninety radiomic features were extracted using a python package. The most salient radiomic features as well as MRI parameter and clinical-based features were selected using recursive feature elimination. A logistic regression classifier was built to distinguish between any 2 binned categories in the considered endpoints: pCR, NAR, and TRG. Repeated k-fold validation was performed and AUCs calculated. RESULTS: There were 24, 87, and 21 T4, T3, and T2 LARCs, respectively (median age 63 years, 32 to 86). For NAR and TRG, the best classification performance was obtained using both the tumor and MC segmentations. The AUCs for classifying NAR 0 versus 2, pCR, and TRG 0/1 versus 2/3 were 0.66 (95% CI, 0.60-0.71), 0.80 (95% CI, 0.74-0.85), and 0.80 (95% CI, 0.77-0.82), respectively. CONCLUSION: Radiomics of pretreatment MRIs can predict pCR, TRG, and NAR score in patients with LARC undergoing neoadjuvant treatment and TME with moderate accuracy despite extremely heterogenous image data. Both the tumor and MC contain important prognostic information. KEY POINTS: • Machine learning of rectal cancer on images from the pretreatment MRI can predict important patient outcomes with moderate accuracy. • The tumor and the tissue around it both contain important prognostic information.

Video-based coaching in surgical education: a systematic review and meta-analysis.

BACKGROUND: In the era of competency-based surgical education, VBC has gained increased attention and may enhance the efficacy of surgical education. The objective of this systematic review was to summarize the existing evidence of video-based coaching (VBC) and compare VBC to traditional master-apprentice-based surgical education. METHODS: We performed a systematic review and meta-analysis of randomized controlled trials (RCT) assessing VBC according to the PRISMA and Cochrane guidelines. The MEDLINE, EMBASE, and COCHRANE and Researchgate databases were searched for eligible manuscripts. Standard mean difference (SMD) of performance scoring scales was used to assess the effect of VBC versus traditional training without VBC (control). RESULTS: Of 627 studies identified, 24 RCTs were eligible and evaluated. The studies included 778 surgical trainees (n = 386 VBC vs. n = 392 control). 13 performance scoring scales were used to assess technical competence; OSATS-GRS was the most common (n = 15). VBC was provided preoperative (n = 11), intraoperative (n = 1), postoperative (n = 10), and perioperative (n = 2). The majority of studies were unstructured, where identified coaching frameworks were PRACTICE (n = 1), GROW (n = 2) and Wisconsin Coaching Framework (n = 1). There was an effect on performance scoring scales in favor of VBC coaching (SMD 0.87, p < 0.001). In subgroup analyses, the residents had a larger relative effect (SMD 1.13; 0.61-1.65, p < 0.001) of VBC compared to medical students (SMD 0.43, 0.06-0.81, p < 0.001). The greatest source of potential bias was absence of blinding of the participants and personnel (n = 20). CONCLUSION: Video-based coaching increases technical performance of medical students and surgical residents. There exist significant study and intervention heterogeneity that warrants further exploration, showing the need to structure and standardize video-based coaching tools.

Elevation of Serum CEA in Patients with Squamous Cell Carcinoma of the Anus.

The proportion of anal cancer cases that produce elevated carcinoembryonic antigen (CEA) levels is not well described in the medical literature. In this study, we used electronic health record data from a single urban cancer center to identify patients from 2004-2018 with anal cancer who have also had a pre-initial treatment CEA measurement. We identified 40 patients who met our eligibility criteria. Of those, 11 (27.5%) had an elevated pretreatment CEA. Elevated CEA was not associated with any of the clinical or demographic covariates; however, three out of five patients with a recurrence had an elevated CEA.

Alvimopan Significantly Reduces Length of Stay and Costs Following Colorectal Resection and Ostomy Reversal Even Within an Enhanced Recovery Protocol.

BACKGROUND: Alvimopan accelerates GI recovery after colorectal resection. Data on real-world cost-effectiveness have been mixed. OBJECTIVE: This study aimed to evaluate if adding alvimopan to an enhanced recovery pathway reduces length of stay. DESIGN: Patients undergoing colorectal resection or ostomy reversal for the year before and after the introduction of alvimopan were evaluated. SETTING: This study was conducted at a single academic medical center. PATIENTS: Patients undergoing elective colorectal resection (488) or ostomy reversal (148) were included. MAIN OUTCOME MEASURES: The primary outcomes measured were length of stay and prolonged length of stay defined as >75th percentile for each procedure. RESULTS: Two hundred eighty-six patients (45%) received alvimopan. Alvimopan and no-alvimopan groups had similar demographics, comorbidities, operative indication, and case mix. In the alvimopan group, more of the colorectal resections were laparoscopic (87% vs 79%, p = 0.015). Length of stay was reduced with alvimopan (6.2 vs 4.9 days, p = 0.003), and this effect persisted when controlling for procedure type, approach, and ASA class (decreased length of stay by 1.0 day, p = 0.014). The alvimopan group had lower risk of prolonged length of stay (14.7% vs 23.1%, p = 0.007) and ileus (10.8% vs 16.2%, p = 0.05). On multivariable analysis, no alvimopan use (OR, 1.8; 95% CI, 1.2-2.7), ASA ≥3 (OR, 2.0; 95% CI, 1.3-3.1), and history of cardiac surgery (OR, 2.8; 95% CI, 1.2-6.5) were significant predictors of prolonged length of stay. Alvimopan use was associated with a lower risk of infectious complications other than surgical site infection (2.8% vs 6.7%, p = 0.025), and did not increase risk of any adverse outcomes. The addition of alvimopan to the protocol resulted in cost savings of $708.39 per patient. LIMITATIONS: Data collected from a single center limit external validity. CONCLUSIONS: The introduction of alvimopan to a postoperative protocol following elective colorectal resection or ostomy reversal significantly reduces length of stay and is associated with cost savings even within an enhanced recovery protocol. See Video Abstract at http://links.lww.com/DCR/A911.

Epidural analgesia in the era of enhanced recovery: time to rethink its use?

BACKGROUND: Previous assessments of the impact of epidural analgesia (EA) on outcomes after colorectal surgery were related to the period before widespread implementation of the enhanced recovery after surgery (ERAS) protocols. This study evaluates the impact of EA on postoperative recovery after colectomy using recent multicenter data. METHODS: Patients who underwent elective colectomy from the American College of Surgeons (ACS) National Surgical Quality Improvement Program (NSQIP) data (2014-2015) were identified. Demographics, comorbidities, diagnosis, procedure type and approach, and postoperative complications associated with EA were assessed. Impact of EA on postoperative ileus, length of stay (LOS), and prolonged LOS (defined as LOS > 75 percentile) was evaluated for all, open, and laparoscopic cases using univariable and multivariable analyses. RESULTS: Of 9045 elective colectomy procedures, 3081 (34.1%) received EA. Epidural analgesia was associated with greater rates of postoperative ileus (15.9% vs. 10.8%, p < 0.0001), superficial (5.5% vs. 4%, p = 0.001) and deep (1.8% vs. 0.6%, p < 0.0001) wound infections, pulmonary embolism (0.8% vs. 0.4%, p = 0.004), deep vein thrombosis (1.3% vs. 0.7%, p = 0.01), sepsis/septic shock (4.6% vs. 3.1%, p < 0.0001), unplanned reintubation (1.5% vs. 0.8%, p = 0.003), cardiac complications (1.2% vs. 0.7%, p = 0.03), and transfusion (9.1% vs. 5.9%, p < 0.0001). Postoperative length of stay (LOS) [mean (SD), days: 6.7(6.2) vs. 5(4.5) days, p < 0.0001] was greater for EA. On multivariable analysis, EA had no impact on postoperative ileus for all and laparoscopic cases. However, EA increased the likelihood for ileus (OR 1.34, 95% CI 1.02-1.78) after open colectomy alone. Similarly, EA did not influence prolonged LOS for all and laparoscopic cases but was independently associated with prolonged LOS after open colectomy (OR 1.4, 95% CI 1.1-1.8). CONCLUSION: Epidural analgesia was not associated with improved recovery after elective colectomy in the era of ERAS.

Latent class analysis stratifies mortality risk in patients developing acute kidney injury after high-risk intraabdominal general surgery: a historical cohort study.

PURPOSE: Risk stratification for postoperative acute kidney injury (AKI) evaluates a patient's risk for developing this complication using preoperative characteristics. Nevertheless, it is unclear if these characteristics are also associated with mortality in patients who actually develop this complication, so we aimed to determine these associations. METHODS: The 2011-15 American College of Surgeons National Surgical Quality Improvement Program was used to obtain a historical, observational cohort of high-risk intraabdominal general surgery patients with AKI, which was defined as an increase in serum creatinine > 177 µmol·L-1 (2 mg·dL-1) above the preoperative value and/or the need for dialysis. Latent class analysis, a model-based clustering technique, classified patients based on preoperative comorbidities and risk factors. The associations between the latent classes and the time course of AKI development and mortality after AKI were assessed with the Kruskall-Wallis test and Cox models. RESULTS: A seven-class model was fit on 3,939 observations (derivation cohort). Two patterns for the time course of AKI diagnosis emerged: an "early" group (median [interquartile range] day of diagnosis 3 [1-10]) and a "late" group (day 9 [3-16]). Three patterns of survival after AKI diagnosis were identified (groups A-C). Compared with the group with the lowest mortality risk (group A), the hazard ratios (95% confidence intervals) for 30-day mortality were 1.79 [1.55 to 2.08] for group B and 3.55 [3.06 to 4.13] for group C. These differences in relative hazard were similar after adjusting for the postoperative day of AKI diagnosis and surgical procedure category. CONCLUSIONS: Among patients with AKI after high-risk general surgery, the preoperative comorbid state is associated with the time course of and survival after AKI. This knowledge can stratify mortality risk in patients who develop postoperative AKI.

Surgical Management of Complex Enteric Fistulas in Crohn's Disease.

Crohn's disease is a chronic, inflammatory bowel condition that can affect the entire digestive tract and in many cases lead to enteric fistula formation. The management of enteric fistulas can be challenging and often requires a multidisciplinary approach.

Outcomes of Pregnancies for Women Undergoing Endoscopy While They Were Pregnant: A Nationwide Cohort Study.

BACKGROUND & AIMS: Endoscopy is an integral part of the investigation and management of gastrointestinal disease. We aimed to examine outcomes of pregnancies for women who underwent endoscopy during their pregnancy. METHODS: We performed a nationwide population-based cohort study, linking data from the Swedish Medical Birth Registry (for births from 1992 through 2011) with those from the Swedish Patient Registry. We identified 3052 pregnancies exposed to endoscopy (2025 upper endoscopies, 1109 lower endoscopies, and 58 endoscopic retrograde cholangiopancreatographies). Using Poisson regression, we calculated adjusted relative risks (ARRs) for adverse outcomes of pregnancy according to endoscopy status using 1,589,173 unexposed pregnancies as reference. To consider the effects of disease activity, we examined pregnancy outcomes (preterm birth, stillbirth, small for gestational age, or congenital malformations) in women who underwent endoscopy just before or after pregnancy. Secondary outcome measures included induction of labor, low birth weight (<2500 g), cesarean section, Apgar score <7 at 5 minutes, and neonatal death within 28 days. To consider intrafamilial factors, we compared pregnancies within the same mother. RESULTS: Exposure to any endoscopy during pregnancy was associated with an increased risk of preterm birth (ARR, 1.54; 95% confidence interval [CI], 1.36-1.75) or small for gestational age (ARR, 1.30; 95% CI, 1.07-1.57) but not of congenital malformation (ARR, 1.00; 95% CI, 0.83-1.20) or stillbirth (ARR, 1.45; 95% CI, 0.87-2.40). None of the 15 stillbirths to women with endoscopy occurred <2 weeks after endoscopy. ARRs were independent of trimester. Compared to women with endoscopy <1 year before or after pregnancy, endoscopy during pregnancy was associated with preterm birth (ARR, 1.16) but not with small for gestational age (ARR, 1.19), stillbirth (ARR, 1.11), or congenital malformation (ARR, 0.90). Restricting the study population to women having an endoscopy during pregnancy or before/after, and only analyzing data from women without a diagnosis of inflammatory bowel disease, celiac disease, or liver disease, endoscopy during pregnancy was not linked to preterm birth (ARR, 1.03; 95% CI, 0.84-1.27). Comparing births within the same mother, for which only 1 birth had been exposed to endoscopy, we found no association between endoscopy and gestational age or birth weight. CONCLUSIONS: In a nationwide population-based cohort study, we found endoscopy during pregnancy to be associated with increased risk of preterm birth or small for gestational age, but not of congenital malformation or stillbirth. However, these risks are small and likely due to intrafamilial factors or disease activity.

Correction to: Anal canal squamous cell cancer: are surgical alternatives to chemoradiation just as effective?

One of the author's middle name of this article was incorrectly published as "Emmanouil E. Pappou." This is now presented correctly in this article as "Emmanouil P. Pappou."

Anal canal squamous cell cancer: are surgical alternatives to chemoradiation just as effective?

PURPOSE: The purpose of this paper is to study long-term oncologic outcomes after different treatment strategies for anal canal cancer (SCAC). METHODS: Patients with SCAC (2004-2013) were identified from Surveillance, Epidemiology, and End Results (SEER) database. Patients undergoing radiation (RT) were compared to those undergoing local excision (LE), abdominoperineal resection (APR), and abdominoperineal resection after radiation (RT + APR). Overall survival (OS) and cancer-specific survival (CSS) data were evaluated using Kaplan-Meier and Cox regression. RESULTS: Two thousand seven hundred and seventy-two (83.8%) patients underwent RT, 382 (11.6%) LE, 77 (2.3%) APR, 76 (2.3%) RT + APR. Median age for the four groups was 60, 57, 64, and 56 years and 32, 49.7, 53.2, and 39.5% were male, respectively, while median tumor size was 4.4, 2.6, 5.3, and 5.5 cm, respectively. Five-year OS of RT, LE, APR, and RT + APR groups was 63.7, 79.6, 25.8, and 41.8% while CSS was 79.6, 92.5, 75.6, and 58.8%, respectively, (p < 0.001). Adjusted hazard ratios for OS for LE, APR, and RT + APR with RT as reference were 1.007 (0.702-1.444), 2.311 (1.367-3.906), and 2.072 (1.016-4.228), respectively. CONCLUSION: These data suggest that APR does not provide better outcomes in treatment of SCAC. Chemoradiation remains the gold standard treatment for majority of patients. Local excision is associated with favorable outcomes in some circumstances.