Association of High BMI With Morbidity and Mortality in Common Emergency General Surgery Procedures.

INTRODUCTION: Emergency general surgery (EGS) patients are at increased risk for postoperative morbidity and mortality. Obesity is a risk factor for poor outcomes in this population. Our study aimed to explore the association of body mass index (BMI) with postoperative outcomes in patients requiring common EGS procedures. METHODS: A retrospective review of the 2018-2020 National Surgical Quality Improvement Program database identified patients undergoing four common EGS procedures: large bowel resection, small bowel resection, cholecystectomy, and appendectomy. Patients were classified by BMI: normal weight (18.5-24.9 kg/m2), obesity classes I (30-34.9 kg/m2), II (35-39.9 kg/m2), III (40-49.9 kg/m2), and IV (≥50 kg/m2). Main outcomes of interest were major adverse event (MAE) and mortality. RESULTS: From 2018 to 2020, a total of 82,540 patients underwent one of four common EGS procedures. On unadjusted analysis, obesity class IV had higher mortality rates compared to classes I-III (6.2% vs 3.1%, P < 0.001). Patients in obesity classes I-III had lower odds of MAE and death relative to those of normal weight. Compared to other patients with obesity, those in obesity class IV were at increased risk of MAE (odds ratio 1.27; 95% confidence interval 1.13-1.44) and death (odds ratio 1.69; 95% confidence interval 1.34-2.13). CONCLUSIONS: Patients with varying degrees of obesity have different risk profiles following common EGS procedures. While patients in lower obesity classes had reduced odds of adverse outcomes, those with BMI ≥50 kg/m2 were particularly at greater risk for postoperative morbidity and mortality. This vulnerable population warrants further investigation and increased vigilance to ensure high-quality care.

The Association Between Sex and Survival for Anal Squamous Cell Carcinoma.

BACKGROUND: The incidence of anal squamous cell carcinoma (SCC) is rising, despite the introduction of a vaccine against human papillomavirus (HPV), the most common etiology of anal SCC. The rate of anal SCC is higher among women and sex-based survival differences may exist. We aimed to examine the association between sex and survival for stage I-IV anal SCC. MATERIALS AND METHODS: The National Cancer Database was used to identify patients with stage I-IV anal SCC from 2004-2016. Outcomes were assessed utilizing log rank tests, Kaplan-Meier statistics, and Cox proportional-hazard modeling. Subgroup analyses by disease stage and by HPV status were performed. Outcomes of interest were median, 1-, and 5-year survival by sex. RESULTS: There were 31,185 patients with stage I-IV anal SCC. 10,714 (34.3%) were male and 20,471 (65.6%) were female. 1- and 5- year survival was 90.2% (95% CI 89.8 - 90.7) and 67.7% (95% CI 66.9 - 68.5) for females compared to 85.8% (95% CI 85.1 - 86.5) and 55.9% (95% CI 54.7 - 57.0) for males. In subgroup analysis, females demonstrated improved unadjusted and adjusted survival for all stages of disease. Female sex was an independent predictor of improved survival (HR 0.68, 95% CI 0.65 - 0.71, P < 0.001). CONCLUSIONS: We demonstrate better overall survival for females compared to males for stage I-IV anal SCC. It is not clear why women have a survival advantage over men, though exposure to prominent risk factors may play a role. High-risk men may warrant routine screening for anal cancer.

Workplace absenteeism amongst patients undergoing open vs. robotic radical prostatectomy, hysterectomy, and partial colectomy.

BACKGROUND: There is controversy regarding the widespread uptake of robotic surgery across several surgical disciplines. While it has been shown to confer clinical benefits such as decreased blood loss and shorter hospital stays, some argue that the benefits of this technology do not outweigh its high cost. We performed a retrospective insurance-based analysis to investigate how undergoing robotic surgery, compared to open surgery, may impact the time in which an employed individual returns to work after undergoing major surgery. METHODS: We identified a cohort of US adults with employer-sponsored insurance using claims data from the MarketScan database who underwent either open or robotic radical prostatectomy, hysterectomy/myomectomy, and partial colectomy from 2012 to 2016. We performed multiple regression models incorporating propensity scores to assess the effect of robotic vs. open surgery on the number of absent days from work, adjusting for demographic characteristics and baseline absenteeism. RESULTS: In a cohort of 1157 individuals with employer-sponsored insurance, those undergoing open surgery, compared to robotic surgery, had 9.9 more absent workdays for radical prostatectomy (95%CI 5.0 to 14.7, p < 0.001), 25.3 for hysterectomy/myomectomy (95%CI 11.0-39.6, p < 0.001), and 29.8 for partial colectomy (95%CI 14.8-44.8, p < 0.001) CONCLUSION: For the three major procedures studied, robotic surgery was associated with fewer missed days from work compared to open surgery. This information helps payers, patients, and providers better understand some of the indirect benefits of robotic surgery relative to its cost.

Barriers to Evidence-Based Colorectal Cancer Care in Ukraine.

BACKGROUND: The incidence of colorectal cancer (CRC) is increasing in many low- to middle-income countries, including Ukraine. Ukraine reports high mortality rates in CRC patients. To identify potential areas for targeted interventions to improve CRC care in Ukraine, we investigated Ukrainian clinician perspectives on evidence-based CRC treatment guidelines. METHODS: An explanatory sequential mixed-methods study design was used. A survey was administered to attendees of a regional surgical conference. Semi-structured interviews were subsequently performed with practicing clinicians in Ukraine. Interviews were coded to identify prominent themes. RESULTS: Quantitative: 105 clinicians completed the survey. 76% of respondents reported using guidelines in daily practice. Lack of English proficiency was cited by 28.6% of respondents as a barrier to guideline use. Improved knowledge and additional financial resources were reported as factors that would be helpful in providing evidence-based care. QUANTITATIVE: 15 clinicians were interviewed. Two major themes were identified: limitations in access to the medical literature resources (language barriers and financial barriers), and sense of clinician initiative and willingness to learn despite hardships. CONCLUSIONS: Clinicians in Ukraine have positive perspectives on utilization of evidence-based CRC treatment guidelines. However, they face major barriers in accessing resources needed to keep up-to-date on the current literature. Fortunately, there exists both willingness and initiative on the clinician level to pursue continuing education. Efforts should be made on the international society level to improve open-access and foreign language translation availability to support physicians in Ukraine and other low- to middle-income countries.

The Current Landscape of Staging and Treatment of Colorectal Cancer in a Region of Ukraine: a Mixed Methods Study.

BACKGROUND: In Ukraine, the 1-year mortality for colorectal cancer is much higher than that seen in high-income countries. We investigated practice patterns of colorectal cancer treatment in a region of Ukraine to account for high mortality rates. METHODS: An explanatory sequential mixed methods design was used. Data from patients who underwent surgery for colorectal cancer in Ivano-Frankivsk from 2011 to 2015 were collected via retrospective chart review, and descriptive statistics were calculated. Semi-structured interviews were performed with local practicing surgeons and oncologists until thematic saturation was reached. RESULTS: A total of 960 patients who underwent surgery were identified in the Ivano-Frankivsk region with colon (689) or rectal (271) cancer. 11.7% of patients underwent preoperative CT of the abdomen and pelvis, and only 1.7% underwent CT of the chest. 4.1% of patients underwent a complete preoperative colonoscopy, while 31.0% had incomplete colonoscopies. Postoperatively, 31.1% of patients with stage II colon cancer and 43.9% of patients with stage III colon cancer underwent adjuvant chemotherapy. For patients with stage II and III rectal cancers, 20.9% and 33.3% underwent chemotherapy, while 68.4% and 66.7% underwent radiation therapy, respectively. Fifteen physicians completed interviews. Two major themes emerged regarding physician perceptions on providing colorectal cancer care: lack of resources and systems level issues negatively impacting patient care. CONCLUSION: In this region in Ukraine, staging practices for colorectal malignancies are inconsistent and inadequate, and adjuvant treatments are varied. This is likely attributable to the lack of resources facing providers and the prohibitively high cost of care to patients.

Local versus Radical Excision of Early Distal Rectal Cancers: A National Cancer Database Analysis.

BACKGROUND: Local excision (LE) has been proposed as an alternative to radical resection for early distal rectal cancer, for which the optimal oncologic treatment remains unclear. OBJECTIVE: The goal of this study was to compare the overall survival of rectal cancer patients with early distal tumors who underwent LE versus abdominoperineal resection (APR) using a large contemporary database. METHODS: The National Cancer Database (2004-2013) was used to identify patients with early T-stage rectal adenocarcinoma who underwent LE or APR. Patients were split into groups based on T stage and type of surgery (LE vs. APR). The primary outcome measure was overall survival. An adjusted Cox proportional hazards model was used to evaluate the impact of treatment strategy on survival. RESULTS: Overall, there were 2084 patients with T1 tumors and 912 patients with T2 tumors. For patients with T1 disease, after adjusting for age, sex, income level, race, Charlson score, insurance payor, and tumor size, there was no significant difference in survival between the LE and APR groups (hazard ratio [HR] 0.89, 95% confidence interval [CI] 0.65-1.22; P = 0.49). For patients with T2 disease, after adjusting for age, Charlson score, and tumor size, there was no significant difference in survival between patients undergoing LE + chemoradiation therapy (CRT) and APR (HR 1.11, 95% CI 0.84-1.45; P = 0.47). CONCLUSIONS: Patients with early distal rectal adenocarcinoma who underwent LE had similar survival to patients who underwent APR. LE is an acceptable oncologic treatment strategy for patients with T1 rectal cancers, and LE with CRT is an acceptable oncologic treatment for patients with T2 distal rectal cancers.

Differential Index-Hospitalization Cost Center Impact of Enhanced Recovery After Surgery Program Implementation.

BACKGROUND: Most hospitals in the United States are reimbursed for colectomy via a bundled payment based on the diagnosis-related group assigned. Enhanced recovery after surgery programs have been shown to improve the value of colorectal surgery, but little is known about the granular financial tradeoffs required at individual hospitals. OBJECTIVE: The purpose of this study is to analyze the index-hospitalization impact on specific cost centers associated with enhanced recovery after surgery implementation for diagnosis-related groups commonly assigned to patients undergoing colon resections. DESIGN: We performed a single-institution retrospective, nonrandomized, preintervention (2013-2014) and postintervention (2015-2017) analysis of hospital costs. SETTING: This study was conducted at an academic medical center. PATIENTS: A total of 1297 patients with diagnosis-related group 330 (colectomy with complications/comorbidities) and 331 (colectomy without complications/comorbidities) were selected. MAIN OUTCOME MEASURES: The primary outcome was total index-hospitalization cost. Secondary outcomes included specific cost center expenses. RESULTS: Total median cost for diagnosis-related group 330 in the pre-enhanced recovery after surgery group was $24,111 ($19,285-$28,658) compared to $21,896 ($17,477-$29,179) in the enhanced recovery after surgery group, p = 0.01. Total median cost for diagnosis-related group 331 in the pre-enhanced recovery after surgery group was $19,268 ($17,286-$21,858) compared to $18,444 ($15,506-$22,847) in the enhanced recovery after surgery group, p = 0.22. When assessing cost changes after enhanced recovery after surgery implementation for diagnosis-related group 330, operating room costs increased (p = 0.90), nursing costs decreased (p = 0.02), anesthesia costs increased (p = 0.20), and pharmacy costs increased (p = 0.08). For diagnosis-related group 331, operating room costs increased (p = 0.001), nursing costs decreased (p < 0.001), anesthesia costs increased (p = 0.03), and pharmacy costs increased (p = 0.001). LIMITATIONS: This is a single-center study with a pre- and postintervention design. CONCLUSIONS: The returns on investment at the hospital level for enhanced recovery after surgery implementations in colorectal surgery result largely from cost savings associated with decreased nursing expenses. These savings likely offset increased spending on operating room supplies, anesthesia, and medications. See Video Abstract at http://links.lww.com/DCR/B204. IMPACTO DE LA IMPLEMENTACIÓN DEL PROTOCOLO DE RECUPERACIÓN MEJORADA DESPUÉS DE CIRUGÍA EN EL COSTO DE LA HOSPITALIZACIÓN ÍNDICE EN CENTROS ESPECÍFICOS: La mayoría de los hospitales en los Estados Unidos son reembolsados por la colectomía a través de un paquete de pago basado en el grupo de diagnóstico asignado. Se ha demostrado que los programas de recuperación después de la cirugía mejoran el valor de la cirugía colorrectal, pero se sabe poco sobre las compensaciones financieras granulares que se requieren en los hospitales individuales.El objetivo de este estudio es analizar el impacto del índice de hospitalización en centros de costos específicos asociados con la implementación de RMDC para grupos relacionados con el diagnóstico comúnmente asignados a pacientes que se someten a resecciones de colon.Realizamos un análisis retrospectivo, no aleatorio, previo (2013-2014) y posterior a la intervención (2015-2017) de los costos hospitalarios de una sola institución.Centro médico académico.Un total de 1. 297 pacientes con diagnóstico relacionado con el grupo 330 (colectomía con complicaciones/comorbilidades) y 331 (colectomía sin complicaciones/comorbilidades).El resultado primario fue el índice total de costos de hospitalización. Los resultados secundarios incluyeron gastos específicos del centro de costos.El costo medio total para el grupo relacionado con el diagnóstico de 330 en el grupo de recuperación pre-mejorada después de la cirugía fue de $24,111 ($19,285- $28,658) en comparación con $21,896 ($17,477- $29,179) en el grupo de recuperación mejorada después de la cirugía, p = 0.01. El costo medio total para DRG 331 en el grupo de recuperación pre-mejorada después de la cirugía fue de $19,268 ($17,286- $21,858) en comparación con $18,444 ($15,506-$22,847) en el grupo de recuperación mejorada después de la cirugía, p = 0.22. Al evaluar los cambios en los costos después de una recuperación mejorada después de la implementación de la cirugía para el grupo 330 relacionado con el diagnóstico, los costos de la sala de operaciones aumentaron (p = 0.90), los costos de enfermería disminuyeron (p = 0.02) los costos de anestesia aumentaron (p = 0.20) y los costos de farmacia aumentaron (p = 0.08). Para el grupo 331 relacionado con el diagnóstico, los costos de la sala de operaciones aumentaron (p = 0.001), los costos de enfermería disminuyeron (p < 0.001) los costos de anestesia aumentaron (p = 0.03) y los costos de farmacia aumentaron (p = 0.001).Este es un estudio de un solo centro con un diseño previo y posterior a la intervención.El retorno de la inversión a nivel hospitalario para una recuperación mejorada después de la implementación de la cirugía en la cirugía colorrectal se debe en gran parte al ahorro de costos asociado con la disminución de los gastos de enfermería. Es probable que estos ahorros compensen el aumento de los gastos en suministros de quirófano, anestesia y medicamentos. Consulte Video Resumen en http://links.lww.com/DCR/B204. (Traducción-Dr. Gonzalo Hagerman).

Opioid Prescriptions After Hemorrhoidectomy.

BACKGROUND: Hemorrhoids cause more than 4 million ambulatory care visits in the United States annually, and hemorrhoidectomy is associated with significant postoperative pain. There are currently no evidence-based opioid-prescribing guidelines for hemorrhoidectomy patients. OBJECTIVE: The purpose of this study was to investigate patterns of opioid prescribing and to identify factors associated with opioid refill after hemorrhoidectomy. DESIGN: This was a retrospective database review. SETTINGS: The study was conducted using the Department of Defense Military Health System Data Repository (2006-2014). PATIENTS: Opioid-naïve patients aged 18 to 64 years enrolled in TRICARE insurance who underwent surgical hemorrhoidectomy were included in this study. MAIN OUTCOME MEASURES: We measured patterns of opioid prescriptions and predictors of a second opioid prescription within 2 weeks of the end date for the first prescription after hemorrhoidectomy. RESULTS: A total of 6294 patients were included; 5536 (88.0%) filled an initial opioid prescription with a median 5-day supply, and 1820 (32.9%) required an opioid refill. The modeled risk of refill based on initial prescription supply ranged from a high of 39.2% risk with an initial prescription of 1-day supply to an early nadir (26.1% risk of refill) with an initial 10-day supply. A variety of sociodemographic and clinical characteristics influenced the likelihood of opioid refill, including black race (OR = 0.75 (95% CI, 0.62-0.89)), history of substance abuse (OR = 3.26 (95% CI, 1.37-7.34)), and length of index opioid prescription (4-6 d, OR = 0.83 (95% CI, 0.72-0.96) or ≥7 d, OR = 0.67 (95% CI, 0.57-0.78) vs 1-3 d). LIMITATIONS: Variables assessed were limited because of the use of claims-based data. CONCLUSIONS: There is wide variability in the length of prescription opioid use after hemorrhoidectomy. Approximately one third of patients require a second prescription in the immediate postoperative period. The optimal duration appears to be between a 5- and 10-day supply. Clinicians may be able to more efficiently discharge patients with adequate analgesia while minimizing the potential for excess supply. See Video Abstract at http://links.lww.com/DCR/B112. PRESCRIPCIÓN DE MÉDICAMENTOS OPIOIDES DESPUÉS DE HEMORROIDECTOMÍA: Las afecciones hemorroidarias ocasionan anualmente más de cuatro millones de consultas ambulatorias en los Estados Unidos. La hemorroidectomía esta asociada con dolor postoperatorio muy significativo. Actualmente no existen pautas claras para la prescripción de medicamentos opioides después de hemorroidectomía, basada en la evidencia.Investigar los patrones de prescripción de medicamentos opioides e identificar los factores asociados con la acumulación de dichos opioides después de una hemorroidectomía.Revisión retrospectiva de una base de datos.Almacén de datos del Sistema de Salud militar del Departamento de Defensa de los Estados Unidos de América (2006-2014).Todos aquellos sometidos a hemorroidectomía quirúrgica, sin tratamiento opiode previo, comprendiodos entre 18-64 años y beneficiarios de seguro TRICARE.Patrones de prescripción de recetas de opioides, predictores de una segunda receta de opioides dentro las dos semanas posteriores a la fecha de finalización de la primera receta después de la hemorroidectomía.6.294 pacientes fueron incluidos en el estudio. 5.536 (88,0%) completaron una receta inicial de opioides con un suministro promedio de cinco días, y 1.820 (32,9%) pacientes requirieron reabastecerse de opioides. El riesgo modelado de reabastecimiento de opiodes basado en el suministro de la prescripción inicial, varió desde un alto riesgo (39.2%) con una prescripción inicial de suministro por día, hasta un acmé temprano (26.1% de riesgo de reabastecimiento) con un suministro inicial de 10 días. Una gran variedad de características socio-demográficas y clínicas influyeron en la probabilidad del reabastecimeinto de los opioides, incluida la raza negra (OR 0.75, intervalo de confianza (IC) del 95% (0.62, 0.89)), los antecedentes de abuso de substancias (OR 3.26, IC del 95% (1.37, 7.34)) y la duración del índice de la prescripción de opioides (4-6 días (OR 0.83, IC 95% (0.72, 0.96)), o 7 días o más (OR 0.67, IC 95% (0.57, 0,78)) comparados a 1-3 días.Las variables analizadas fueron limitadas debido al uso de datos basados en reclamos.Existe una gran variabilidad en la duración del uso de opioides recetados después de hemorroidectomía. Aproximadamente un tercio de los pacientes requieren una segunda prescripción en el postoperatorio inmediato. La duración óptima parece estar entre un suministro de cinco y 10 días. Los médicos pueden dar de alta de manera más eficiente a los pacientes con analgesia adecuada y minimizar el potencial de exceso de suministro. Consulte Video Resumen en http://links.lww.com/DCR/B112. (Traducción-Dr. Xavier Delgadillo).

Gender Differences in Surgeon Burnout and Barriers to Career Satisfaction: A Qualitative Exploration.

BACKGROUND: Physician burnout is a highly prevalent issue in the surgical community. Burnout is associated with poor career satisfaction; female gender, and younger age place surgeons at higher risk for burnout. Here, we examined drivers behind burnout and career dissatisfaction in female and junior surgical faculty, with specific attention paid to gender-based differences. MATERIALS AND METHODS: Participants included full-time surgery faculty members at a single academic surgery center. Both male and female faculty members were included, at ranks ranging from instructor to associate professor. Semistructured interviews were conducted by a faculty member at the institution until thematic saturation was reached. Field notes were compiled from each interview, and these data were coded thematically. RESULTS: Fourteen female faculty and nine male faculty members were interviewed. For both female and male faculty, lack of control with work life was a significant theme contributing to burnout. Positive factors contributing to career satisfaction for both genders included enjoyment of patient care and teaching, teamwork and collegiality, and leadership support. For female faculty, the major theme of gender bias in the workplace as a risk factor for burnout was prominent. Male faculty struggled more than their female counterparts with guilt over complications and second victim syndrome. CONCLUSIONS: Gender differences driving career dissatisfaction and burnout exist between female and male surgical faculty. Acknowledging these differences when designing efforts to address physician wellness and decrease burnout is critical.

Racial and Socioeconomic Disparities After Surgical Resection for Rectal Cancer.

BACKGROUND: There are various racial, socioeconomic, and tumor-specific factors that can impact rectal cancer outcomes. The current systematic review and meta-analysis evaluate the effect socioeconomic and racial variables on overall survival of rectal cancer patients after surgical resection. METHODS: A literature search was performed via electronic databases according to Systematic Reviews and Meta-Analyses and Meta-analysis Of Observational Studies in Epidemiology guidelines. All studies were evaluated by three authors and validated for data extraction. Predictive variables and survival profiles (1-, 5-, and 10-y survival and overall survival) reported by the studies were recorded for the systematic review. Hazard ratios, odds ratios, and 95% confidence intervals were extracted for meta-analysis. Forest plots were used to interpret the results. The primary outcome was the effect size of the predictive variables on overall survival after surgical resection. RESULTS: Of the 265 articles collected, 22 met inclusion criteria. Sixteen studies were used for the systematic review, and 17 studies were considered for meta-analysis. Overall, 662,053 subjects with rectal cancer were studied (439,766 with race reported), of which 344,193 (78.3%) were White and 60,283 (13.7%) were Black. The median survival was 56.8% for White patients and 47.9% for Black patients. Meta-analysis revealed that race, socioeconomic variables (education level, income level, and insurance status), and facility characteristics (type and volume) were significantly associated with overall survival in rectal cancer. CONCLUSIONS: Racial and socioeconomic disparities are present in outcomes for rectal cancer patients undergoing surgical resection. It is important to consider these disparities in the management of patients with rectal cancer to minimize any consequent disparities in surgical outcomes.

The Distribution of Colorectal Surgeons in the United States.

BACKGROUND: Surgical resection is a mainstay of colorectal cancer treatment, and prior studies have shown improved outcomes in patients undergoing surgery for colorectal cancer by colorectal surgical specialists compared with nonspecialized surgeons. Here, we examine the geographic distribution of colorectal surgeons in the United States and its relationship with sociodemographic characteristics of the served population. METHODS: The Area Health Resource File from 2017 to 2018 was used to identify the number and location of colorectal surgeons practicing throughout the United States and sociodemographic characteristics at the county and hospital referral region (HRR) level. The main outcomes of interest were the density of colorectal surgeons per 100,000 population and associations with sociodemographic characteristics at the county and HRR level based on multivariable linear regression. RESULTS: In multivariable analysis, regions with higher proportion of nonwhite individuals and college-educated individuals had significantly more colorectal surgeons per 100,000 population, whereas regions with higher proportions of uninsured individuals had significantly fewer colorectal surgeons per 100,000 population at both the county and HRR levels. CONCLUSIONS: Geographic and sociodemographic variability exists in the distribution of colorectal surgeons in the United States. Such variability may be contributing to disparities in access to specialized colorectal care.

Cytoreductive Surgery and HIPEC in an Enhanced Recovery After Surgery Program: A Feasibility Study.

BACKGROUND: Cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC) have historically been associated with high morbidity given the physiologic insult of an extensive operation. Enhanced Recovery after Surgery (ERAS) pathways have been successful in improving postoperative outcomes for many procedures but have not been well studied in these cases. We examined the feasibility and effect of ERAS pathway implementation for patients undergoing CRS/HIPEC. MATERIALS AND METHODS: Patients with peritoneal carcinomatosis who underwent CRS/HIPEC between October 2015 to September 2018 were identified. Patient characteristics, disease pathology, and perioperative outcome data were obtained. Primary outcomes were hospital length of stay (LOS), 30-d readmissions, renal dysfunction, and complications. RESULTS: Of the 31 patients who were included, 11 (35.5%) patients underwent CRS/HIPEC prior to the implementation of the ERAS pathway, and 20 (64.5%) patients underwent CRS/HIPEC according to the ERAS guidelines. There were no significant differences in the baseline clinical or pathologic characteristics between groups. There was a significant decrease in LOS with ERAS pathway management from 9 d to 6 d (P = 0.002). No patients from either cohort experienced acute kidney injury. There was no significant difference in 30-d readmission rates or complications. CONCLUSIONS: In this feasibility study, ERAS pathway utilization significantly decreased postoperative LOS for patients undergoing CRS/HIPEC, without evidence of increased complications or readmissions. ERAS programs should be considered for integration into future CRS/HIPEC protocols.

Treatment of stage I-III rectal cancer: Who is refusing surgery?

BACKGROUND AND OBJECTIVES: Surgical resection is a cornerstone in the management of patients with rectal cancer. Patients may refuse surgical treatment for several reasons although the rate of refusal is currently unknown. METHODS: The National Cancer Database was utilized to identify patients with stage I-III rectal cancer. Patients who refused surgical resection were compared to patients who underwent curative resection. RESULTS: A total of 509 (2.6%) patients with stage I and 2082 (3.5%) patients with stage II/III rectal cancer refused surgery. In multivariable analysis for stage I disease, older age, Black race, and Medicaid/no insurance were independent predictors of surgery refusal. Patients were less likely to refuse surgery if they had a higher income or lived further distances from the treatment facility. In multivariable analysis for stage II/III disease, older age, Black race, insurance other than private, and rural county were independent predictors of surgery refusal. Patients were less likely to refuse surgery if they had higher Charlson comorbidity scores, lived further distances from the treatment facility, or underwent chemoradiation. There was a significant decrease in survival for patients refusing surgery compared to patients undergoing recommended surgery. CONCLUSIONS: A small proportion of patients refuse surgery for rectal cancer, and this treatment decision significantly affects survival.

Sociodemographic predictors of surgery refusal in patients with stage I-III colon cancer.

BACKGROUND AND OBJECTIVES: Over 104 000 cases of colon cancer are estimated to be diagnosed in 2020. Surgical resection is a critical part of colon cancer treatment and adequate resection impacts prognosis. However, some patients refuse potentially curative surgery. We aimed to identify the rate and predictors of surgery refusal among patients with colon cancer. METHODS: The National Cancer Database (2004-2015) was queried for patients diagnosed with stage I-III colonic adenocarcinoma. Sociodemographic factors, clinical features, and treatment facility characteristics were collected. Patients who underwent surgery with curative intent were compared to those who refused surgery. Multivariable analysis was used to identify factors associated with surgery refusal. Adjusted survival analysis was performed on propensity-matched cohorts. RESULTS: A total of 151 020 patients were included and 1071 (0.71%) refused surgery. In multivariable analysis older age, Black race, higher Charlson comorbidity score, Medicaid, Medicare, or lack of insurance were predictive of refusing surgery. After propensity matching, there was a significant difference in 5-year survival for patients who refused surgery vs those who underwent surgery (P < .001). CONCLUSIONS: There are racial and socioeconomic disparities in the refusal of surgery for colon cancer. Further studies are needed to better understand the drivers behind differences in refusing curative surgery for colon cancer.

Surgical resection improves overall survival of patients with small bowel leiomyosarcoma.

PURPOSE: Small bowel leiomyosarcoma (SB LMS) is a rare disease with few studies characterizing its outcomes. This study aims to evaluate surgical outcomes for patients with SB LMS. METHODS: The National Cancer Database was queried from 2004 to 2016 to identify patients with SB LMS who underwent surgical resection. The primary outcome was overall survival. RESULTS: A total of 288 patients with SB LMS who had undergone surgical resection were identified. The median age was 63, and the majority of patients were female (56%), White (82%), and had a Charlson comorbidity score of zero (76%). Eighty-one percent of patients had negative margins following surgical resection. Fourteen percent of patients had metastatic disease at the time of diagnosis. Nineteen percent of patients received chemotherapy and 3% of patients received radiation. One-year overall survival was 77% (95% CI: 72-82%) and 5-year overall survival was 43% (95% CI: 36-49%). Higher grade (HR: 1.98, 95% CI: 1.10-3.55, p = 0.02) and metastatic disease at diagnosis (HR: 2.57, 95% CI: 1.45-4.55, p = 0.001) were independently associated with higher risk of death. CONCLUSION: SB LMS is a rare disease entity, with treatment centering on complete surgical resection. Our results demonstrate that overall survival is higher than previously thought. Timely diagnosis to allow for complete surgical resection is key, and investigation into the possible role of chemotherapy or radiation therapy is needed.

Implementation of liposomal bupivacaine transversus abdominis plane blocks into the colorectal enhanced recovery after surgery protocol: a natural experiment.

BACKGROUND: Enhanced recovery after surgery (ERAS) programs are now standard of care for colorectal surgery. Efforts have been aimed at decreasing postoperative opioid consumption. The goal of this study is to evaluate the effect of liposomal bupivacaine transversus abdominis plane (TAP) blocks on opioid use and its downstream effect on rates of ileus and hospital length of stay (LOS). METHODS: We performed a retrospective pre- and postintervention time-trend analysis (2016-2018) of ERAS patients undergoing laparoscopic colorectal surgery at two academic medical centers within the same hospital system. The intervention was liposomal bupivacaine TAP blocks versus standard local infiltration with bupivacaine with a primary outcome of total morphine milligram equivalents (MME) administered within 72 h of surgery. Secondary outcomes included hospital LOS and rate of postoperative ileus. RESULTS: There were 556 patients included at the control hospital, and 384 patients were included at the treatment hospital. Patients at both hospitals were similar with regard to age, body mass index, comorbidities, and surgical indication. In an adjusted time-trend analysis, the treatment hospital was associated with a significant decrease in MME administered (- 15.9 mg, p = 0.04) and hospital LOS (- 0.8 days, p < 0.001). There was no significant decrease in the rate of ileus at the treatment hospital (- 6.9%, p = 0.08). CONCLUSIONS: In a time-trend analysis, the addition of liposomal bupivacaine TAP blocks into the ERAS protocol resulted in significantly reduced opioid use and shorter hospital LOS for patients undergoing surgery at the treatment hospital. Liposomal bupivacaine TAP blocks should be considered for inclusion in the standard ERAS protocol.

Association of surgical approach and prolonged opioid prescriptions in patients undergoing major pelvic cancer procedures.

BACKGROUND: The rise in deaths attributed to opioid drugs has become a major public health problem in the United States and in the world. Minimally invasive surgery (MIS) is associated with a faster postoperative recovery and our aim was to investigate if the use of MIS was associated with lower odds of prolonged opioid prescriptions after major procedures. METHODS: Retrospective study using the IBM Watson Health Marketscan® Commerical Claims and Encounters Database investigating opioid-naïve cancer patients aged 18-64 who underwent open versus MIS radical prostatectomy (RP), partial colectomy (PC) or hysterectomy (HYS) from 2012 to 2017. Propensity weighted logistic regression analyses were used to estimate the independent effect of surgical approach on prolonged opioid prescriptions, defined as prescriptions within 91-180 days of surgery. RESULTS: Overall, 6838 patients underwent RP (MIS 85.5%), 4480 patients underwent PC (MIS 61.6%) and 1620 patients underwent HYS (MIS 41.8%). Approximately 70-80% of all patients had perioperative opioid prescriptions. In the weighted model, patients undergoing MIS were significantly less likely to have prolonged opioid prescriptions in all three surgery types (Odds Ratio [OR] 0.737, 95% Confidence Interval [CI] 0.595-0.914, p = 0.006; OR 0.728, 95% CI 0.600-0.882, p = 0.001; OR 0.655, 95% CI 0.466-0.920, p = 0.015, respectively). CONCLUSION: The use of the MIS was associated with lower odds of prolonged opioid prescription in all procedures examined. While additional studies such as clinical trials are needed for further confirmation, our findings need to be considered for patient counseling as postoperative differences between approaches do exist.

Colon Neuroendocrine Tumors: A New Lymph Node Staging Classification.

BACKGROUND: The American Joint Commission on Cancer, the European Neuroendocrine Tumor Society, and the North American Neuroendocrine Tumor Society all classify colon neuroendocrine tumor (NET) nodal metastasis as N0 or N1. This binary classification does not allow for further prognostication by the total number of positive lymph nodes. This study aimed to evaluate whether the total number of positive lymph nodes affects the overall survival for patients with colon NET. METHODS: The National Cancer Database was used to identify patients with colon NET. Nearest-neighborhood grouping was performed to classify patients by survival to create a new nodal staging system. The Surveillance, Epidemiology, and End Results database was used to validate the new nodal staging classification. RESULTS: Colon NETs were identified in 2472 patients. Distinct 5-year survival rates were estimated for the patients with N0 (no positive lymph nodes; 69.8%; 95% confidence interval [CI], 66.7-72.7%), N1a (1 positive lymph node; 63.9%; 95% CI, 59.6-68.0%), N1b (2-9 positive lymph nodes; 38.9%; 95% CI, 35.4-42.3%), and N2 (≥ 10 positive lymph nodes; 15.7%; 95% CI, 11.9-20.0%; p < 0.001) nodal classifications. The validation population showed distinct 5-year survival rates with the new nodal staging. In multivariable Cox regression, the new nodal stage was a significant independent predictor of overall survival. CONCLUSIONS: The number of positive locoregional lymph nodes in colon NETs is an independent prognostic factor. For patients with colon NETs, N0, N1a, N1b, and N2 classifications for nodal metastasis more accurately predict survival than current staging systems.

Survival in Patients with High-Grade Colorectal Neuroendocrine Carcinomas: The Role of Surgery and Chemotherapy.

BACKGROUND: Colorectal neuroendocrine tumors are a rare malignancy, yet their incidence appears to be increasing. The optimal treatment for the high-grade subset of these tumors remains unclear. We aimed to examine the relationship between different treatment modalities and outcomes for patients with high-grade neuroendocrine carcinomas (HGNECs) of the colon and rectum. METHODS: The National Cancer Database (2004-2015) was used to identify patients diagnosed with colorectal HGNECs. The primary outcome was overall survival. A Cox Proportional hazard model was used to identify risk factors for survival. RESULTS: Overall, 1208 patients had HGNECs; 452 (37.4%) patients had primary tumors of the rectum, and 756 (62.5%) patients had primary tumors of the colon. A total of 564 (46.7%) patients presented with stage IV disease. The median survival was 9.0 months [95% confidence interval (CI) 8.2-9.8]. In multivariable analysis, surgical resection [hazard ratio (HR) 0.54, 95% CI 0.44-0.66; p < 0.001], chemotherapy (HR 0.74, 95% CI 0.69-0.79; p < 0.001), and rectum as the primary site of tumor (HR 0.62, 95% CI 0.51-0.76; p < 0.001) were associated with better overall survival, while older age (HR 1.01, 95% CI 1.00-1.01; p = 0.02) and the presence of metastatic disease (HR 3.34, 95% CI 2.69-4.15; p < 0.001) were associated with worse survival. CONCLUSIONS: Patients with colorectal HGNECs selected for chemotherapy and surgical resection of the primary tumor demonstrated better overall survival than those managed without resection. Patients who were able to undergo systemic chemotherapy may benefit from potentially curative resection of the primary tumor.

Local Excision Versus Radical Resection for 1- to 2-cm Neuroendocrine Tumors of the Rectum: A National Cancer Database Analysis.

BACKGROUND: The optimal surgical management for 1- to 2-cm, nonmetastatic rectal neuroendocrine tumors remains unknown. OBJECTIVE: We sought to determine overall survival and operative outcomes in patients who underwent local excision versus radical resection of rectal neuroendocrine tumors. DESIGN: The National Cancer Database (2004-2013) was queried to identify patients with nonmetastatic rectal neuroendocrine tumors who underwent local excision or radical resection. SETTING: The study included national data. PATIENTS: There were 274 patients in the local excision group and 47 patients in the radical resection group. MAIN OUTCOME MEASURES: The primary outcome was overall survival. Secondary outcomes included 30-day mortality, hospital length of stay, and procedural outcomes. RESULTS: There were no differences in demographics between the 2 groups. Patients who underwent radical resection had slightly larger tumors with higher stage and grade. Patients undergoing local excision had higher rates of positive margins (8.23% vs 0%; p = 0.04). There were no deaths within 30 days in either group, but patients who had radical resection had longer median hospital length of stay (0 vs 3 d; p < 0.01). After adjusting with a Cox proportional hazards model, no difference was seen in survival between the 2 patient groups (HR = 2.39 (95% CI, 0.85-6.70); p = 0.10). LIMITATIONS: There are several limitations, which include that this work is a retrospective review; the data set does not include variables such as depth of tumor invasion, which may influence surgical treatment or local recurrence rates; and patients were not randomly assigned to treatment groups. CONCLUSIONS: There is no survival benefit to radical resection of 1- to 2-cm, nonmetastatic rectal neuroendocrine tumors. This suggests that local excision may be a feasible and less morbid option for intermediate-sized rectal neuroendocrine tumors. See Video Abstract at http://links.lww.com/DCR/A744.