Downstaging after preoperative chemoradiation for locally advanced rectal cancer is associated with better survival than pathologic stage 0-1 disease treated with upfront surgery.

BACKGROUND AND OBJECTIVES: It is unknown how patients with locally advanced rectal cancer with significant response to preoperative radiotherapy/chemoradiotherapy fare relative to patients with true pathologic 0-1 disease undergoing upfront surgery. We aimed to determine whether survival is improved in locally advanced rectal cancer downstaged to pathologic stage 0-1 disease compared to true pathologic stage 0-1 tumors. METHODS: A retrospective review of the National Cancer Database between 2004 and 2016 was conducted. Three groups were identified: (1) clinical stage 2-3 disease downstaged to pathologic stage 0-1 disease after radiotherapy, (2) clinical stage 2-3 disease not downstaged after radiotherapy, and (3) true pathologic 0-1 tumors undergoing upfront surgery. The primary endpoint was overall survival and was compared using Kaplan-Meier and multivariate Cox regression analyses. RESULTS: The study population consisted of 59,884 patients. Of the 40,130 patients with locally advanced rectal cancer treated with preoperative radiation, 12,670 (31.5%) had significant downstaging (group 1), while 27,460 (68.4%) had no significant downstaging (group 2). A total of 19,754 had pathologic 0-1 disease treated with upfront resection (group 3). On Kaplan-Meier analysis, downstaged patients had significantly better overall survival compared to both non-downstaged and true pathologic stage 0-1 patients (median 156 vs. 99 and 136 months, respectively, p < 0.001). On multivariate analysis, downstaged patients had significantly better survival (HR 0.88, p < 0.001) compared to true pathologic 0-1 patients. CONCLUSIONS: Locally advanced rectal cancer downstaged after preoperative radiotherapy has significantly better survival compared to true pathologic stage 0-1 disease treated with upfront surgery. Response to chemoradiotherapy likely identifies a subset of patients with a particularly good prognosis.

Use of Game Theory to model patient engagement after surgery: a qualitative analysis.

BACKGROUND: Patient engagement is challenging to define and operationalize. Qualitative analysis allows us to explore patient perspectives on this topic and establish themes. A game theoretic signaling model also provides a framework through which to further explore engagement. METHODS: Over a 6-mo period, thirty-eight interviews were conducted within 6 wk of discharge in patients undergoing thyroid, parathyroid, or colorectal surgery. Interviews were transcribed, anonymized, and analyzed using the NVivo 11 platform. A signaling model was then developed depicting the doctor-patient interaction surrounding the patient's choice to reach out to their physician with postoperative concerns based upon the patient's perspective of the doctor's availability. This was defined as "engagement". We applied the model to the qualitative data to determine possible causations for a patient's engagement or lack thereof. A private hospital's and a safety net hospital's populations were contrasted. RESULTS: The private patient population was more likely to engage than their safety-net counterparts. Using our model in conjunction with patient data, we determined possible etiologies for this engagement to be due to the private patient's perceived probability of dealing with an available doctor and apparent signals from the doctor indicating so. For the safety-net population, decreased access to care caused them to be less willing to engage with a doctor perceived as possibly unavailable. CONCLUSIONS: A physician who understands these Game Theory concepts may be able to alter their interactions with their patients, tailoring responses and demeanor to fit the patient's circumstances and possible barriers to engagement.

Prognostic value of neoadjuvant treatment response in locally advanced rectal cancer.

BACKGROUND: For locally advanced rectal cancer, response to neoadjuvant radiation has been associated with improved outcomes but has not been well characterized in general practice. The goals of this study were to describe disease response rates after neoadjuvant treatment and to evaluate the association between disease response and survival. MATERIALS AND METHODS: Retrospective cohort study of patients aged 18-80 y with clinical stage II and III rectal adenocarcinoma in the National Cancer Database (2006-2012). All patients underwent radical resection after neoadjuvant treatment. Treatment responses were defined as follows: no tumor response; intermediate-T and/or N downstaging with residual disease; and complete-ypT0N0. Multivariable, multinomial regression was used to evaluate the association between neoadjuvant radiation use and disease response. Multivariable Cox regression was used to evaluate the association between disease response and overall risk of death. RESULTS: Among 12,024 patients, 12% had a complete and 30% an intermediate response. Neoadjuvant chemotherapy alone was less likely to achieve an intermediate (relative risk ratio: 0.70 [0.56-0.88]) or a complete response (relative risk ratio: 0.59 [0.41-0.84]) relative to neoadjuvant radiation. Tumor response was associated with improved 5-y overall survival (complete = 90.2%, intermediate = 82.0%, no response = 70.5%; log-rank, P < 0.001). Complete and intermediate pathologic responses were associated with decreases in risk of death (hazard ratio: 0.40 [0.34-0.48] and 0.63 [0.57-0.69], respectively) compared to no response. Primary tumor and nodal response were independently associated with decreased risk of death. CONCLUSIONS: Neoadjuvant radiation is associated with treatment response, and pathologic response is associated with improved survival. Pathologic response may be an early benchmark for the oncologic effectiveness of neoadjuvant treatment.

Patterns of Care for Colorectal Liver Metastasis Within an Integrated Health System: Secular Trends and Outcomes.

BACKGROUND: Utilization of evidence-based treatments for patients with colorectal liver metastasis (CRC-LM) outside high-volume centers is not well-characterized. We sought to describe trends in treatment and outcomes, and identify predictors of therapy within a nationwide integrated health system. METHODS: Observational cohort study of patients with CRC-LM treated within the Veterans Affairs (VA) health system (1998-2012). Secular trends and outcomes were compared on the basis of treatment type. Multivariate regression was used to identify predictors of no treatment (chemotherapy or surgery). RESULTS: Among 3270 patients, 57.3 % received treatment (chemotherapy and/or surgery) during the study period. The proportion receiving treatment doubled (38 % in 1998 vs. 68 % in 2012; trend test, p < 0.001), primarily driven by increased use of chemotherapy (26 vs. 57 %; trend test, p < 0.001). Among patients having surgery (16 %), the proportion having ablation (10 vs. 61.9 %; trend test, p < 0.001) and multimodality therapy (15 vs. 67 %; trend test, p < 0.001) increased significantly over time. Older patients [65-75 years: odds ratio (OR) 1.65, 95 % confidence interval (CI) 1.39-1.97; >75 years: OR 3.84, 95 % CI 3.13-4.69] and those with high comorbidity index (Charlson ≥3: OR 1.47, 95 % CI 1.16-1.85) were more likely to be untreated. Overall survival was significantly different based on treatment strategy (log-rank p < 0.001). CONCLUSIONS: The proportion of CRC-LM patients receiving treatment within the largest integrated health system in the US (VA health system) has increased substantially over time; however, one in three patients still does not receive any treatment. Future initiatives should focus on increasing treatment among older patients as well as on evaluating reasons leading to the no-treatment approach and increased use of ablation procedures.

Pushing the Limits of Local Excision for Rectal Cancer: Transanal Minimally Invasive Surgery (TAMIS) for Rectal Cancer Using the Port-in-Port Technique.

BACKGROUND: Radical rectal resection remains the standard of care for the operative treatment of rectal cancer. Local excision via transanal minimally invasive surgery (TAMIS) using disposable transanal access ports is an increasingly more common alternative for selected patients. Because of significant variation in perineal anatomy, currently available disposable transanal ports do not allow adequate access for every patient. This report demonstrates TAMIS for one such patient via a novel approach using a single-incision laparoscopic port inserted within a disposable transanal access port. METHODS: The patient is a 66-year-old man with a history of metastatic anterior uT3N0 rectal cancer 9 cm from the anal verge occupying 40% of the rectal circumference. The patient refused radical resection and opted for multimodality therapy with local excision. He underwent preoperative chemoradiation with good tumor response. The TAMIS procedure was attempted and aborted due to poor visualization and inadequate access/exposure using the commercially available Gelpoint Path transanal access system. The TAMIS procedure was reattempted and successfully completed via insertion of a laparoscopic single-incision port (GelPoint Mini) within the transanal access port itself (port-in-port technique) to overcome the deficiencies of the transanal access port. This report describes the port-in-port technique together with the stepwise approach to TAMIS. RESULTS: The TAMIS procedure was completed successfully without complications involving grossly negative margins. The patient's postoperative course was uncomplicated, and he was discharged on postoperative day 1. The final pathology showed a complete pathologic response. At this writing, the patient continues to do well 14 months after surgery. CONCLUSIONS: Currently available disposable transanal access ports may not allow adequate exposure for all patients undergoing TAMIS. This report describes a port-in-port technique that may allow improved exposure for patients with a difficult perineal anatomy.

Neoadjuvant treatment for rectal cancer-A value-based proposition.

Over the last decade, the use of neoadjuvant chemo-radiation has been an integral part of the care of patients with locally advanced rectal cancer. However, emerging data are beginning to challenge the current treatment paradigm of neoadjuvant chemo-radiation followed by radical resection and subsequent adjuvant chemotherapy. Going forward, the challenge will be to identify patients for whom radiation can be safely omitted and those for whom it can potentially provide added oncologic value. J. Surg. Oncol. 2016;114:304-310. © 2016 Wiley Periodicals, Inc.

Time Trends, Clinical Characteristics, and Risk Factors of Chronic Anal Fissure Among a National Cohort of Patients with Inflammatory Bowel Disease.

BACKGROUND: Chronic anal fissure (CAF) is a common problem that causes significant morbidity. Little is known about the risk factors of CAF among patients with inflammatory bowel disease (IBD). AIM: To study the clinical characteristics and prevalence of CAF among a cohort of IBD patients. METHODS: We performed a population-based study on IBD patients from the National Veterans Affairs administrative datasets from 1998 to 2011. IBD and AF were identified by ICD-9 diagnosis codes. RESULTS: We identified 60,376 patients with IBD between the ages of 18-90 years, 94% males, 59% diagnosed with ulcerative colitis (UC), and 88% were Caucasians. The overall prevalence of CAF was 4% for both males and females. African Americans (AA) were two times more likely to have CAF compared to Caucasians (8 vs. 4%; OR 2.0, 95% CI 1.6-20.2, p = 0.0001) or Hispanics (8 vs. 4.8%; OR 2.1, 95% CI 1.4-25.2, p = 0.0001). The prevalence of CAF significantly dropped with age from 7% at age group 20-50 to 1.5% at 60-90 (p = 0.0001). CD patients were two times more likely to have CAF than UC patients (6 vs. 3%; OR 1.9, 95% CI 1.5-18.2, p = 0.0001). The initial diagnosis of CAF occurred within 14 years after the initial diagnosis of IBD in 74.5% patients. CONCLUSIONS: CAF is more prevalent among IBD than what is reported in the general population and diagnosed after the diagnosis of IBD. CAF is more prevalent among patients with CD, younger patients, and AA. The current results lay the groundwork for further outcome studies relate to anal fissure such as utilization, hospitalization, and cost.

Infectious postoperative complications decrease long-term survival in patients undergoing curative surgery for colorectal cancer: a study of 12,075 patients.

OBJECTIVE: We sought to characterize the effect of postoperative complications on long-term survival after colorectal cancer (CRC) resection. BACKGROUND: The impact of early morbidity on long-term survival after curative-intent CRC surgery remains controversial. METHODS: The Veterans Affairs Surgical Quality Improvement Program and Central Cancer Registry databases were linked to acquire perioperative and cancer-specific data for 12,075 patients undergoing resection for nonmetastatic CRC (1999-2009). Patients were categorized by presence of any complication within 30 days and by type of complication (noninfectious vs infectious). Univariate and multivariate survival analyses adjusted for patient, disease, and treatment factors were performed, excluding early deaths (<90 days). Subset analysis was performed to determine the specific impact of severe postoperative infections. RESULTS: The overall morbidity and infectious complication rates were 27.8% and 22.5%, respectively. Patients with noninfectious postoperative complications were older, had lower preoperative serum albumin, had worse functional status, and had higher American Society of Anesthesiologists scores than patients with infectious complications and without complications (all P < 0.001). The presence of any complication was independently associated with decreased long-term survival [hazard ratio, 1.24; 95% confidence interval (1.15-1.34)]. Multivariate analysis by complication type demonstrated increased risk only with infectious complications [hazard ratio, 1.31; 95% confidence interval (1.21-1.42)]. Subset analysis demonstrated this effect predominantly in patients with severe infections [hazard ratio, 1.41; 95% confidence interval (1.15-1.73)]. CONCLUSIONS: The presence of postoperative complications after CRC resection is associated with decreased long-term survival, independent of patient, disease, and treatment factors. The impact on long-term outcome is primarily driven by infectious complications, particularly severe postoperative infections.

Postoperative transitional care needs in the elderly: an outcome of recovery associated with worse long-term survival.

OBJECTIVE: To characterize transitional care needs (TCNs) after colorectal cancer (CRC) surgery and examine their association with age and impact on overall survival (OS). BACKGROUND: TCNs after cancer surgery represent additional burden for patients and are associated with higher short-term mortality. They are not well-characterized in CRC patients, particularly in the context of a growing elderly population, and their effect on long-term survival is unknown. METHODS: A retrospective cohort study of CRC patients (N = 486) having curative surgery at a tertiary referral center (2002-2011) was conducted. Outcomes included TCNs (home health or nonhome destination at discharge) and OS. Patients were compared on the basis of age: young (<65 years), old (65-74 years), and oldest (≥75 years). Multivariate logistic regression models were used to examine the association of age with TCNs, and OS was compared on the basis of TCNs and stage, using the Kaplan-Meier method. RESULTS: TCNs were required by 130 patients (27%). The oldest patients had highest TCNs (49%) compared with the other age groups (P < 0.01), with rehabilitation services as their primary TCNs (80%). After multivariate analysis, patients 75 years or older had significantly increased TCN risk (odds ratio, 4.7; 95% confidence interval, 2.6-8.5). TCN was associated with worse OS for patients with early- and advanced stage CRC (P < 0.001). CONCLUSIONS: TCNs after CRC surgery are common and significantly increased in patients 75 years or older, represent an outcome of postoperative recovery, and are associated with worse long-term survival. Preoperative identification of higher risk populations should be used for patient counseling, advanced preoperative planning, and to implement strategies targeted at minimizing TCNs.

Sphincter preservation rates after radical resection for rectal cancer in the United States veteran population: opportunity for improvement in early disease.

BACKGROUND: Sphincter preservation (SP) is an important goal of rectal cancer surgery. We hypothesized that SP rates among veteran patients have increased and are comparable to national rates, and that a subset of patients with early disease still undergo non-SP procedures. METHODS: Patients with nonmetastatic primary rectal adenocarcinoma who underwent curative-intent rectal resection were identified from the Veterans Affairs Central Cancer Registry (VACCR) database (1995-2010). SP trends over time were described and compared to the Surveillance, Epidemiology, and End-Results (SEER) population. Subset analysis was performed in patients with nonirradiated, pathologic stage 0-I rectal cancers, a population that may qualify for novel SP strategies. RESULTS: Of 5,145 study patients, 3,509 (68 %) underwent SP surgery. The VACCR SP rate increased from 59.9 % in 1995-1999 to 79.3 % in 2005-2010, when it exceeded that of SEER (76.9 %, p = 0.023). On multivariate analysis, recent time period was independently associated with higher likelihood of SP (odds ratio [OR] 2.64, p < 0.001). Preoperative radiotherapy (OR 0.51, p < 0.001) and higher pathologic stage (OR 0.37, stage III, p < 0.001) were negative predictors. In patients with nonirradiated pathologic stage 0-I cancers, SP rates also increased, but 25 % of these patients underwent non-SP procedures. Within this subset, patients with clinical stage 0 and I disease still had significant rates of abdominoperineal resection (7.7 and 17.0 %, respectively). CONCLUSIONS: SP rates among veterans have increased and surpass national rates. However, an unacceptable proportion of patients with stage 0-I rectal cancers still undergo non-SP procedures. Multimodal treatment with local excision may further improve SP rates in this subset of patients.

Pushing the limits of local excision for rectal cancer: transanal minimally invasive surgery for an upper rectal/rectosigmoid lesion.

BACKGROUND: Transanal minimally invasive surgery (TAMIS) is an evolving technique for the local excision of early rectal cancers,1 particularly for mid-rectal lesions. The approach to upper rectal lesions is significantly more challenging and prone to complications. We demonstrate TAMIS for an upper rectal/rectosigmoid lesion, with transanal repair of an intraoperative rectal/rectosigmoid perforation. METHODS: The patient is an elderly male in whom colonoscopy demonstrated a large polypoid lesion of the upper rectum/rectosigmoid colon. On rigid proctoscopy, the lesion was 4 cm in size and occupied 40 % of the rectal circumference, with distal extent at 14 cm from the anal verge. Endoscopic ultrasound was consistent with TisN0 disease. Multiple attempts at endoscopic mucosal resection were unsuccessful and the patient refused radical resection. The patient underwent TAMIS with a disposable transanal access port, using our previously published stepwise technique.2 RESULTS: The patient successfully underwent TAMIS. Intraoperatively, a small full-thickness perforation was created proximal to the excision site and was primarily repaired. A stepwise approach to excision and repair is described. Postoperatively, the patient had low-grade fevers for which he was treated empirically with antibiotics. The fevers resolved without further intervention. Pathologic examination revealed a 3.5 cm villous adenoma with focal high-grade dysplasia, negative margins, and two negative lymph nodes. On outpatient follow-up, the patient was symptom-free and had no fevers, pain, bleeding, fecal incontinence, or genitourinary functional deficits. He is disease-free 10 months from his procedure. CONCLUSIONS: TAMIS of upper rectal lesions is technically challenging, but can be accomplished safely in well-selected patients.

Implementation of a regional virtual tumor board: a prospective study evaluating feasibility and provider acceptance.

BACKGROUND: Tumor board (TB) conferences facilitate multidisciplinary cancer care and are associated with overall improved outcomes. Because of shortages of the oncology workforce and limited access to TB conferences, multidisciplinary care is not available at every institution. This pilot study assessed the feasibility and acceptance of using telemedicine to implement a virtual TB (VTB) program within a regional healthcare network. MATERIALS AND METHODS: The VTB program was implemented through videoconference technology and electronic medical records between the Houston (TX) Veterans Affairs Medical Center (VAMC) (referral center) and the New Orleans (LA) VAMC (referring center). Feasibility was assessed as the proportion of completed VTB encounters, rate of technological failures/mishaps, and presentation duration. Validated surveys for confidence and satisfaction were administered to 36 TB participants to assess acceptance (1-5 point Likert scale). Secondary outcomes included preliminary data on VTB utilization and its effectiveness in providing access to quality cancer care within the region. RESULTS: Ninety TB case presentations occurred during the study period, of which 14 (15%) were VTB cases. Although one VTB encounter had a technical mishap during presentation, all scheduled encounters were completed (100% completion rate). Case presentations took longer for VTB than for regular TB cases (p=0.0004). However, VTB was highly accepted with mean scores for satisfaction and confidence of 4.6. Utilization rate of VTB was 75%, and its effectiveness was equivalent to that observed for non-VTB cases. CONCLUSIONS: Implementation of VTB is feasible and highly accepted by its participants. Future studies should focus on widespread implementation and validating the effectiveness of this model.

Treatment of bacteriobilia decreases wound infection rates after pancreaticoduodenectomy.

BACKGROUND: Although mortality following pancreaticoduodenectomy is decreasing, postoperative morbidity remains high. It was hypothesized that culture-directed treatment of bacteriobilia would decrease the incidence of infectious complications following pancreaticoduodenectomy. METHODS: In a retrospective study of 197 pancreaticoduodenectomy patients, those in the control group (n = 128, 2005-2009) were given perioperative prophylactic antibiotics, whereas those in the treatment group (n = 69, 2009-2011) were continued on antibiotics until intraoperative bile culture results became available. Patients with bacteriobilia received 10 days of antibiotic treatment, which was otherwise discontinued in patients without bacteriobilia. Various complication rates were compared using Fisher's exact test for categorical variables, Wilcoxon rank sum test for ordinal variables, and a two-sample t-test for continuous variables. RESULTS: Demographics, comorbidities, baseline clinical characteristics, and intraoperative and postoperative variables were similar between the two groups. There were higher incidences of elevated creatinine (19% versus 4%; P = 0.004) and preoperative hyperglycaemia (18% versus 7%; P = 0.053) in the control group. Fewer patients in the control group underwent preoperative biliary stenting (48% versus 67%; P = 0.017) and intraperitoneal drains were placed at the time of resection more frequently in the control group (85% versus 38%; P < 0.001). Bacteriobilia was found in 59% of patients. Treatment of bacteriobilia was associated with a decrease in the rate of postoperative wound infections (12% in the control group versus 3% in the treatment group; P = 0.036) and overall complication severity score (1 in the control group versus 0 in the treatment group; P = 0.027). CONCLUSIONS: Prolonged antibiotic therapy for bacteriobilia may decrease postoperative wound infection rates after pancreaticoduodenectomy. A randomized prospective trial is warranted to provide evidence to further support this practice.

Clinical outcomes of oncologic gastrointestinal resections in patients with cirrhosis.

BACKGROUND: Cirrhosis is a risk factor for postoperative morbidity and mortality after general surgical procedures. However, the impact of cirrhosis on outcomes of surgical resection for gastrointestinal (GI) malignancies has not been described. The authors' objective was to characterize early postoperative and transitional outcomes in cirrhotic patients undergoing GI cancer surgery. METHODS: Query of the National Inpatient Sample Database (2005-2008) identified 106,729 patients who underwent resection for GI malignancy; 1479 (1.4%) had cirrhosis. The association of cirrhosis with postoperative outcomes was examined. The primary outcome measure was in-hospital mortality. Secondary outcomes included length-of-stay (LOS) and discharge to long-term care facility (LTCF). RESULTS: Cirrhotic patients had higher risk of in-hospital mortality (8.9% vs 2.8%, P < .001), longer LOS (11.5 ± 0.26 vs 10.0 ± 0.03 days, P < .001), and higher rate of discharge to LTCF (19.0% vs 15.7%, P < .001). Mortality was highest in patients with moderate to severe liver dysfunction (21.5% vs 6.5%, P < .001). On multivariate analysis, cirrhosis was an independent predictor of in-hospital mortality (odds ratio [OR], 3.0; 95% confidence interval [CI] 2.5-3.7) and nonhome discharge (OR, 1.7; 95% CI, 1.4-2.0). In cirrhotic patients, moderate to severe liver dysfunction was the only independent predictor of in-hospital mortality (OR, 4.03; 95% CI, 2.7-5.9), but did not predict discharge disposition. CONCLUSIONS: Resection of GI malignancy in cirrhotics is associated with poor early postoperative and transitional outcomes, with severity of liver disease being the primary determinant of postoperative mortality. These data suggest that GI cancer operations can be performed safely in well-selected cirrhotic patients with mild liver dysfunction.

A stepwise approach to transanal endoscopic microsurgery for rectal cancer using a single-incision laparoscopic port.

BACKGROUND: Radical rectal resection with total mesorectal excision is the current standard of care for the operative treatment of rectal cancer. Local excision is an acceptable alternative in selected patients with early disease (T(is)0-T(1)) and low-risk features, in whom radical resection may be associated with unacceptably high morbidity. With recent data demonstrating favorable results in well-selected patients, the role of local excision for rectal cancer is expanding.1 (,) 2 Transanal endoscopic microsurgery (TEM), which requires the use of an operating anoscope, has been used for the local excision of mid-upper rectal tumors. We describe an alternative approach to TEM for rectal cancer. METHODS: We present a stepwise technique for TEM using a single-incision laparoscopic (SILS) port. The patient is a 64 year-old male with a right anterolateral rectal polyp 7 cm from the anal verge, which on snare polypectomy demonstrated in-situ carcinoma with positive margins. Endoscopic ultrasound demonstrated uT(1) disease with no lymphadenopathy. He opted for local excision and underwent TEM. Our stepwise approach includes: (1) delineation of excision margins, (2) full thickness incision of the rectal wall, (3) circumferential dissection, and full thickness excision, and (4) suture repair. RESULTS: The procedure was performed without intraoperative or postoperative complications. Final pathology revealed in-situ carcinoma with widely negative margins. At 1- and 3-week follow-up visits, the patient was pain free with normal bowel activity and no rectal bleeding or genitourinary dysfunction. DISCUSSION: TEM using a SILS port is an effective technique for the local excision of mid-upper rectal cancer in well-selected patients.

Hand-assisted laparoscopy leads to efficient colorectal cancer surgery.

BACKGROUND: Laparoscopic-assisted (LA) colorectal resections have improved short-term outcomes compared with open resections. Lack of tactile feedback, though, has led to lengthy operations and high conversion rates with attendant adverse effects on patients. Hand-assisted laparoscopy (HAL), in contrast, provides tactile feedback while still being minimally invasive. We hypothesize that HAL compared with LA for colorectal cancer resections will be associated with lower conversion rates and decreased operative times, without compromising the advantages of laparoscopy. MATERIALS AND METHODS: We performed a retrospective case-matched study of patients undergoing LA or HAL colorectal cancer resections from 2002 to 2010, using a prospectively maintained colorectal cancer database at a Veterans Affairs Medical Center. Short-term outcomes analyzed (using the Wilcoxon signed rank and McNemar's tests) included operative and perioperative variables and surrogate markers of adequacy of oncologic care. RESULTS: Forty-seven LA patients were matched 1:1 by age and resection with 47 HAL patients. Patients in the HAL group had significantly lower blood loss (100 versus 150 cc, P = 0.04), operative times (206 versus 252 min, P = 0.002), and conversion rates (6% versus 38%, P < 0.0005). They also spent fewer days in the intensive care unit (0 versus 1, P = 0.004) and had quicker return of flatus (3 versus 4 d, P = 0.03). HAL resulted in more lymph nodes resected (21 versus 15, P = 0.03) and a more adequate lymph node harvest (98% versus 77%, P = 0.01). CONCLUSIONS: HAL is associated with improved operative efficiency, conversion rates, and lymphadenectomy as compared with LA colorectal cancer resections. HAL should be considered in the management of colorectal cancer patients.

Racial and ethnic disparities in outcomes with radiation therapy for rectal adenocarcinoma.

BACKGROUND: Race/ethnicity may modify cancer outcomes and manifest as survival disparities for patients with rectal cancer. Our objective was to determine whether disparate rectal cancer outcomes result from variable efficacy of radiation therapy for major racial/ethnic groups. METHODS: The Los Angeles County Cancer Surveillance Program (CSP) identified patients with rectal adenocarcinoma between the years 1988 and 2006. Patients who underwent curative-intent surgery were grouped by race/ethnicity and by receipt (yes vs. no) and timing (neoadjuvant vs. adjuvant) of radiation therapy. The impact of receipt and timing of radiation therapy on overall survival was then assessed. RESULTS: Of 4,961 patients in CSP, 2,229 (45%) received radiation therapy. Overall, there was no difference in survival among patients according to receipt of radiation therapy. We then examined the radiation cohort, wherein 919 (41%) and 1,310 (59%) patients received neoadjuvant or adjuvant radiation, respectively. Overall, patients who received neoadjuvant compared to adjuvant radiation had improved survival (median survival (MS), 9.4 vs. 6.8 years, respectively; p < 0.001). Among those patients who received neoadjuvant radiation, whites, Hispanics, and Asians had significantly longer survival than blacks (MS, 10.4, 10.4, and 10.4 vs. 4.4 years, respectively; p = 0.003). On multivariate analysis, race/ethnicity was an independent predictor of survival (p = 0.001). CONCLUSIONS: To our knowledge, this is the first study examining the efficacy of radiation therapy for racial/ethnic groups with rectal cancer. Disparate outcomes were observed for the administration of radiation therapy for select racial/ethnic groups. The reasons for these disparities in outcomes should be investigated to better optimize radiation therapy for patients with rectal cancer.

Postoperative mortality and need for transitional care following liver resection for metastatic disease in elderly patients: a population-level analysis of 4026 patients.

OBJECTIVES: The goal of this study was to characterize the association of age with postoperative mortality and need for transitional care following hepatectomy for liver metastases. METHODS: A retrospective cohort study using the Nationwide Inpatient Sample (2005-2008) was performed. Patients undergoing hepatectomy for liver metastases were categorized by age as: Young (aged <65 years); Old (aged 65-74 years), and Oldest (aged ≥75 years). Multivariate logistic regression analyses were performed to identify predictors of in-hospital mortality and need for transitional care (non-home discharge). RESULTS: A total of 4026 patients were identified; 36.6% (n = 1475) were elderly (aged ≥65 years). Rates of in-hospital mortality and non-home discharge increased with advancing age group [1.3% vs. 2.2% vs. 3.3% (P = 0.005) and 2.1% vs. 6.1% vs. 18.3% (P < 0.001), respectively]. Independent predictors of in-hospital mortality were age within the Oldest category [odds ratio (OR) 2.21, 95% confidence interval (CI) 1.19-4.12] and a Deyo Comorbidity Index score of ≥3 (OR 6.95, 95% CI 3.55-13.60). Independent predictors for need for transitional care were age within the Old group (OR 2.44, 95% CI 1.66-3.58), age within the Oldest group (OR 8.48, 95% CI 5.87-12.24), a Deyo score of 1 (OR 2.00, 95% CI 1.40-2.85), a Deyo score of 2 (OR 4.70, 95% CI 2.93-7.56), a Deyo score of ≥3 (OR 6.41, 95% CI 3.67-11.20), and female gender (OR 1.56, 95% CI 1.15-2.11). CONCLUSIONS: Although increasing age was associated with higher risk for in-hospital mortality, the absolute risk was low and within accepted ranges, and comorbidity was the primary driver of mortality. Conversely, need for transitional care was significantly more common in elderly patients. Therefore, liver resection for metastases is safe in well-selected elderly patients, although consideration should be made for potential transitional care needs.

Predictors of lymph node metastases in patients with malignant adenomatous polyps of the colon.

BACKGROUND: We sought to describe predictors of lymph node positivity in patients with malignant colon polyps to identify low risk patients who may potentially avoid radical surgery. DESIGN: The National Cancer Database (2010-2015) was queried for all patients with malignant colonic polyps who underwent formal colonic resection. Univariate and multivariate methods were used to determine independent predictors of lymph node metastasis. RESULTS: 14,663 patients were identified. Lymph node disease was present in 9% of patients. High-grade disease, LVI, PNI, younger age, and left sided location were univariate predictors of lymph node disease. High-grade disease (OR 1.84), left sided location (OR 1.31), LVI (OR 5.79), and PNI (OR 1.70) were independent predictors, while elderly age (OR 0.64) was protective (all p-values <0.001). Elderly patients with low grade disease of the right/transverse colon without LVI/PNI had a 4.4% risk of lymph node disease. High grade, left-sided tumors with LVI, non-elderly age, had a 30% risk. CONCLUSION: Non-elderly age, left-sided location, LVI, PNI and high-grade histology are independent predictors of lymph node metastasis in malignant colonic polyps.