Mediating Factors Between Race and Time to Treatment in Colorectal Cancer.

BACKGROUND: Previous disparities research has demonstrated that underrepresented racial minority patients have worse colorectal cancer outcomes and that they experience unnecessary delays in time to treatment. These delays may explain worse colorectal cancer outcomes for minority patients and serve as a marker of inequalities in our healthcare system. OBJECTIVE: This study aims to quantify the mechanisms that contribute to this disparity in treatment delay. DESIGN: This is a retrospective analysis of colorectal cancer patients who underwent elective resection from 2004 to 2017. A causal inference mediation analysis using the counterfactual framework was utilized to estimate the extent to which racial disparities among patient factors explain the racial disparities in time to treatment. Mediators included income, education, comorbidities, insurance, and hospital type. SETTINGS: This study was conducted at hospitals participating in the National Cancer Database. PATIENTS: Stage I-III colorectal cancer patients, ≥18 years old, who underwent elective resection from 2004 through 2017 were included. MAIN OUTCOMES MEASURES: The primary measures were indirect effects of mediators between race and delayed time to treatment. RESULTS: Of the 504,405 patients (370,051 colon and 134,354 rectal), 10%, 5%, and 4% were black, Hispanic, and other. In multivariable models, compared to white patients, these patients had 25%, 27%, and 17% greater odds of delayed treatment. Mediation analyses suggested that 43%, 20%, and 31% of the treatment delay among them could be removed if an intervention equalized income, education, comorbidities, insurance, and hospital type to that of white patients. Treatment at an academic hospital explained 15% to 32% of the racial disparity and was the most potent mediator. LIMITATIONS: This study was limited by its retrospective design and failure to capture all meaningful mediators. CONCLUSIONS: Black, Hispanic, and other colorectal cancer patients experience treatment delays when compared to white patients. Equalization of the mediators used in this study could reduce treatment delays by 20% to 43% depending on the racial/ethnic group. Future research should identify other causes of racial disparities in treatment delay and intervene accordingly. See Video Abstract at http://links.lww.com/DCR/B871 . FACTORES MEDIADORES ENTRE LA RAZA Y EL TIEMPO HASTA EL TRATAMIENTO EN EL CNCER COLORECTAL: ANTECEDENTES:Investigaciones anteriores sobre disparidades han demostrado que los pacientes de minorías raciales subrepresentados tienen peores resultados de cáncer colorrectal y que experimentan retrasos innecesarios en el tiempo de tratamiento. Estos retrasos pueden explicar los peores resultados del cáncer colorrectal para los pacientes de minorías y servir como un marcador de desigualdades en nuestro sistema de salud.OBJETIVO:Este estudio tiene como objetivo cuantificar los mecanismos que contribuyen a esta disparidad en el retraso del tratamiento.DISEÑO:Este es un análisis retrospectivo de pacientes con cáncer colorrectal que se sometieron a resección electiva entre 2004 y 2017. Se utilizó un análisis de mediación de inferencia causal utilizando el marco contra factual para estimar hasta qué punto las disparidades raciales entre los factores del paciente explican las disparidades raciales en el tiempo hasta el tratamiento. Los mediadores incluyeron ingresos económicos, educación, comorbilidades, seguro médico y tipo de hospital.AJUSTES:Este estudio se realizó en hospitales que participan en la Base de datos nacional del cáncer.PACIENTES:Se incluyeron pacientes con cáncer colorrectal en estadio I-III, ≥18 años, que se sometieron a resección electiva entre 2004 y 2017.PRINCIPALES RESULTADOS MEDIDAS:Las principales mediciones fueron el efecto indirecto de los mediadores entre la raza y el retraso en el tratamiento.RESULTADOS:De los 504,405 pacientes (370,051 de colon, 134,354 rectal), 10%, 5%, 4% eran negros, hispanos, y otros, respectivamente. En modelos multivariables, en comparación con los pacientes blancos, estos pacientes tenían un 25%, 27%, y 17% más de probabilidades de retrasar el tratamiento. Los análisis de medición sugirieron que el 43%, 20%, 31% del retraso del tratamiento entre, respectivamente, podría eliminarse si una intervención igualara los ingresos económicos, la educación, las comorbilidades, el seguro médico y el tipo de hospital a los de los pacientes blancos. El tratamiento en un hospital académico demostró entre el 15% y el 32% de la disparidad racial y fue el mediador más potente.LIMITACIONES:Este estudio estuvo limitado por su diseño retrospectivo; falla en capturar a todos los mediadores significativos.CONCLUSIONES:Los pacientes negros, hispanos y otros con cáncer colorrectal experimentan retrasos en el tratamiento en comparación con los pacientes blancos. La igualación de los mediadores utilizados en este estudio podría reducir los retrasos en el tratamiento en un 20-43%, según el grupo racial / étnico. Las investigaciones futuras deberían identificar otras causas de disparidades raciales en el retraso del tratamiento e intervenir sobre ellas. Consulte Video Resumen en http://links.lww.com/DCR/B871 . (Traducción-Dr. Yolanda Colorado ).

Laser Ablation of Pilonidal Sinus Disease: A Pilot Study.

BACKGROUND: Pilonidal disease is classically treated with wide local excision, although a number of minimally invasive approaches are currently under investigation. We aimed to determine the safety and feasibility of laser ablation of pilonidal sinus disease. IMPACT OF INNOVATION: Laser ablation provides a minimally invasive means of obliterating pilonidal sinus tracts without a need for excessive tract dilation. Laser ablation can be performed more than once on the same patient if necessary. TECHNOLOGY MATERIALS AND METHODS: This technique uses the NeoV V1470 Diode Laser (neoLaser Ltd, Caesarea, Israel) with a 2-mm probe. We performed laser ablation in adults and pediatric patients. PRELIMINARY RESULTS: We performed 27 laser ablation procedures in 25 patients, with a median operative time of 30 minutes. Eighty percent of patients reported either no pain or mild pain at the 2-week postoperative visit. The median time to return to work or school was 3 days. Eighty-eight percent of patients reported being satisfied or very satisfied with the procedure at their most recent follow-up (median, 6 mo). Eighty-two percent of patients were healed at 6 months. CONCLUSIONS AND FUTURE DIRECTIONS: Laser ablation of pilonidal disease is safe and feasible. Patients experienced short recovery time and reported low levels of pain and high levels of satisfaction.

Factors contributing to the utilization of robotic colorectal surgery: a systematic review and meta-analysis.

BACKGROUND: Some studies have suggested disparities in access to robotic colorectal surgery, however, it is unclear which factors are most meaningful in the determination of approach relative to laparoscopic or open surgery. This study aimed to identify the most influential factors contributing to robotic colorectal surgery utilization. METHODS: We conducted a systematic review and random-effects meta-analysis of published studies that compared the utilization of robotic colorectal surgery versus laparoscopic or open surgery. Eligible studies were identified through PubMed, EMBASE, CINAHL, Cochrane CENTRAL, PsycINFO, and ProQuest Dissertations in September 2021. RESULTS: Twenty-nine studies were included in the analysis. Patients were less likely to undergo robotic versus laparoscopic surgery if they were female (OR = 0.91, 0.84-0.98), older (OR = 1.61, 1.38-1.88), had Medicare (OR = 0.84, 0.71-0.99), or had comorbidities (OR = 0.83, 0.77-0.91). Non-academic hospitals had lower odds of conducting robotic versus laparoscopic surgery (OR = 0.73, 0.62-0.86). Additional disparities were observed when comparing robotic with open surgery for patients who were Black (OR = 0.78, 0.71-0.86), had lower income (OR = 0.67, 0.62-0.74), had Medicaid (OR = 0.58, 0.43-0.80), or were uninsured (OR = 0.29, 0.21-0.39). CONCLUSION: When determining who undergoes robotic surgery, consideration of factors such as age and comorbid conditions may be clinically justified, while other factors seem less justifiable. Black patients and the underinsured were less likely to undergo robotic surgery. This study identifies nonclinical disparities in access to robotics that should be addressed to provide more equitable access to innovations in colorectal surgery.

Bowel stimulation before loop ileostomy closure to reduce postoperative ileus: a multicenter, single-blinded, randomized controlled trial.

INTRODUCTION: The objective of this study was to evaluate the impact of preoperative bowel stimulation on the development of postoperative ileus (POI) after loop ileostomy closure. METHODS: This was a multicenter, randomized controlled trial (NCT025596350) including adult (≥ 18 years old) patients who underwent elective loop ileostomy closure at 7 participating hospitals. Participants were randomly assigned (1:1) using a centralized computer-generated sequence with block randomization to either preoperative bowel stimulation or no stimulation (control group). Bowel stimulation consisted of 10 outpatient sessions within the 3 weeks prior to ileostomy closure and was performed by trained Enterostomal Therapy nurses. The primary outcome was POI, defined as an intolerance to oral food in the absence of clinical or radiological signs of obstruction, on or after postoperative day 3, that either (a) required nasogastric tube insertion; or (b) was associated with two of the following: nausea/vomiting, abdominal distension, or the absence of flatus. RESULTS: Between January 2017 and November 2020, 101 patients were randomized, and 5 patients never underwent ileostomy closure; thus, 96 patients (47 stimulated vs. 49 control) were analyzed according to a modified intention-to-treat protocol. Baseline characteristics were well balanced in both groups. The incidence of POI was lower among patients randomized to stimulation (6.4% vs. 24.5%, p = 0.034; unadjusted RR: 0.26, 95% CI 0.078-0.87). Stimulated patients also had earlier median time to first flatus (2.0 days (1.0-2.0) vs. 2.0 days (2.0-3.0), p = 0.025), were more likely to pass flatus on postoperative day 1 (46.8% vs. 22.4%, p = 0.022), and had a shorter median postoperative hospital stay (3.0 days (2.0-3.5) vs. 4.0 days (2.0-6.0), p = 0.003). CONCLUSIONS: Preoperative bowel stimulation via the efferent limb of the ileostomy reduced POI after elective loop ileostomy closure.

Keep Them on the Table: Outcomes Are Improved After Minimally Invasive Colectomy Despite Longer Operative Times in Patients With High-Risk Colon Cancer.

BACKGROUND: For high-risk patients, traditional surgical dogma advises open operations, with short operative times, to "get them off the table" instead of longer minimally invasive surgery approaches. OBJECTIVE: The aim of this study was to compare postoperative outcomes in patients with high-risk colon cancer undergoing elective longer minimally invasive surgery operations compared with shorter open operations. DESIGN: Retrospective comparative cohort study. SETTINGS: Interventions were performed in hospitals participating in the national surgical database. PATIENTS: The National Surgical Quality Improvement Program database was used to identify patients with colon cancer with ASA class 3 to 4 undergoing right and sigmoid colectomy between 2012 and 2017. MAIN OUTCOME MEASURES: Thirty-day postoperative outcomes were compared between short open and long minimally invasive groups. RESULTS: A total of 3775 patients were identified as having undergone long minimally invasive right colectomy and short open right colectomy (33% open, 67% minimally invasive surgery), and 1042 patients were identified as having undergone long minimally invasive sigmoid colectomy and short open sigmoid colectomy (36% open, 64% minimally invasive). Patients undergoing long minimally invasive right colectomy had significantly lower rates of overall morbidity, severe adverse events, mortality, superficial surgical site infections, and wound disruptions, as well as discharge to a higher level of care and shorter length of stay ( p < 0.05). Patients undergoing long minimally invasive sigmoid colectomy had decreased rates of overall morbidity, severe adverse events, and length of stay, as well as discharge to a higher level of care compared with the patients undergoing short open sigmoid colectomy ( p < 0.05). LIMITATIONS: This study was limited by the retrospective nature and standardized outcome measures. CONCLUSIONS: In high-risk patients undergoing colectomy for colon cancer, outcomes were worse with shorter open compared with longer minimally invasive surgery operations. Focus should shift from getting patients "off the table" faster to longer, but safer, minimally invasive surgery in high-risk patients. See Video Abstract at http://links.lww.com/DCR/B642 . MANTNGALOS SOBRE LA MESA HAY MEJORES RESULTADOS DESPUS DE COLECTOMA MNIMAMENTE INVASIVA A PESAR DE TIEMPOS QUIRRGICOS MS PROLONGADOS EN PACIENTES CON CNCER DE COLON DE ALTO RIESGO: ANTECEDENTES:Para los pacientes de alto riesgo, el dogma quirúrgico tradicional aconseja operaciones abiertas, con tiempos quirúrgicos cortos, con el fin de "sacarlos de la mesa" en lugar de enfoques quirúrgicos mínimamente invasivos más prolongados.OBJETIVO:El objetivo de este estudio fue comparar los resultados posoperatorios en pacientes electivos de cáncer de colon de alto riesgo sometidos a operaciones de cirugía mínimamente invasiva más prolongadas en comparación con operaciones abiertas más cortas.DISEÑO:Los resultados posoperatorios de pacientes con cáncer de colon con clase 3-4 de la Sociedad Americana de Anestesiología sometidos a colectomía derecha o sigmoidea se compararon en un análisis multivariado. Se comparó el grupo de colectomía derecha abierta corta (tiempo operatorio <116 minutos) y colectomía derecha mínimamente invasiva larga (tiempo operatorio> 132 minutos). También se compararon la colectomía sigmoidea abierta corta (tiempo operatorio <127 minutos) y la colectomía sigmoidea mínimamente invasiva larga (tiempo operatorio> 161 minutos).ESCENARIO:Las intervenciones se realizaron en hospitales participantes en la base de datos quirúrgica nacional.PACIENTES:La base de datos del Programa Nacional de Mejoramiento de la Calidad Quirúrgica se utilizó para identificar a los pacientes con cáncer de colon con clase 3-4 de la Sociedad Americana de Anestesiología sometidos a colectomía derecha y sigmoidea entre 2012-2017.PRINCIPALES MEDIDAS DE RESULTADO:Se compararon los resultados posoperatorios a los treinta días entre el grupo de procedimientos abiertos cortos y el de mínimamente invasivos largos.RESULTADOS:Se identificó un total de 3.775 pacientes sometidos a colectomía derecha mínimamente invasiva larga y colectomía derecha abierta corta (33% abierta, 67% cirugía mínimamente invasiva) y se identificaron 1042 pacientes sometidos a colectomía sigmoidea mínimamente invasiva larga y colectomía sigmoidea abierta corta (36% abierta, 64% mínimamente invasiva). Los pacientes con colectomía derecha larga mínimamente invasiva tuvieron significativamente menor morbilidad general, eventos adversos graves, mortalidad, infecciones superficiales del sitio quirúrgico, dehiscencia de herida, alta a un nivel más alto de atención y estadía más corta ( p <0.05). Los pacientes con colectomía sigmoidea mínimamente invasiva prolongada tuvieron menor morbilidad general, eventos adversos graves, duración de la estadía y alta a un nivel más alto de atención en comparación con los pacientes con colectomía sigmoidea abierta corta ( p <0.05).LIMITACIONES:Este estudio estuvo limitado por la naturaleza retrospectiva y las medidas de resultado estandarizadas.CONCLUSIONES:En los pacientes de alto riesgo sometidos a colectomía por cáncer de colon, los resultados fueron peores con operaciones abiertas más cortas en comparación con operaciones mínimamente invasivas más largas. El enfoque debe pasar de hacer que los pacientes "salgan rápido de la mesa quirúrgica" a una cirugía mínimamente invasiva más prolongada pero más segura, en pacientes de alto riesgo. Consulte Video Resumen en http://links.lww.com/DCR/B642 . (Traducción-Dr. Jorge Silva Velazco ).

A New Bibliometric Index: The Top 100 Most Disruptive and Developmental Publications in Colorectal Surgery Journals.

BACKGROUND: A new bibliometric index called the disruption score was recently proposed to identify innovative and paradigm-changing publications. OBJECTIVE: The goal was to apply the disruption score to the colorectal surgery literature to provide the community with a repository of important research articles. DESIGN: This study is a bibliometric analysis. SETTINGS: The 100 most disruptive and developmental publications in Diseases of the Colon & Rectum, Colorectal Disease, International Journal of Colorectal Disease, and Techniques in Coloproctology were identified from a validated data set of disruption scores and linked with the iCite National Institutes of Health tool to obtain citation counts. MAIN OUTCOME MEASURES: The primary outcomes measured were the disruption score and citation count. RESULTS: We identified 12,127 articles published in Diseases of the Colon & Rectum (n = 8109), International Journal of Colorectal Disease (n = 1912), Colorectal Disease (n = 1751), and Techniques in Coloproctology (n = 355) between 1954 and 2014. Diseases of the Colon & Rectum had the most articles in the top 100 most disruptive and developmental lists. The disruptive articles were in the top 1% of the disruption score distribution in PubMed and were cited between 1 and 671 times. Being highly cited was weakly correlated with high disruption scores (r = 0.09). Developmental articles had disruption scores that were more strongly correlated with citation count (r = 0.18). LIMITATIONS: This study is subject to the limitations of bibliometric indices, which change over time. DISCUSSION: The disruption score identified insightful and paradigm-changing studies in colorectal surgery. These studies include a wide range of topics and consistently identified editorials and case reports/case series as important research. This bibliometric analysis provides colorectal surgeons with a unique archive of research that can often be overlooked but that may have scholarly significance. See Video Abstract at http://links.lww.com/DCR/B639.UN NUEVO INDICE BIBLIOMÉTRICO: LAS 100 MAS IMPORTANTES PUBLICACIONES EN INNOVACIONES DESESTABILIZADORAS Y DE DESARROLLO EN LAS REVISTAS DE CIRUGÍA COLORRECTALANTECEDENTES:Un nuevo índice bibliométrico llamado innovación desestabilizadora y de desarrollo ha sido propuesto para identificar publicaciones de vanguardia y que pueden romper paradigmas.OBJETIVO:La meta fué aplicar el índice de desestabilización a la literature en cirugía colorectal para aportar a la comunidad con un acervo importante de artículos de investigación.DISEÑO:Un análisis bibliométrico.PARAMETROS:Las 100 publicaciones mas desestabilizadores y de desarrollo en las revistas: Diseases of the Colon and Rectum, Colorectal Disease, International Journal of Colorectal Disease, y Techniques in Coloproctology se recuperaron de una base de datos validada con puntuaciones de desestabilización y se ligaron con la herramienta iCite NIH para obtener la cuantificación de citas.PRINCIPAL MEDIDA DE RESULTADO:El índice desestabilizador y la cuantificación de citas.RESULTADOS:Se identificaron 12,127 articulos publicados en Diseases of the Colon and Rectum (n = 8,109), International Journal of Colorectal Disease (n = 1,912), Colorectal Disease (n = 1,751), y Techniques in Coloproctology (n = 355) de 1954-2014. Diseases of the Colon and Rectum representó la mayoría de las publicaciones dentro de la lista de los 100 mas desestabilizadores y de desarrollo. Esta literatura desestabilizadora se encuentra en el principal 1% de la distribución de la puntuacón desestabilizadora en PubMed y se citaron de 1 a 671 veces. El ser citado con frecuencia se relacionó vagamente con las puntuaciones de desastibilización (r = 0.09). Los artículos de desarrollo tuvieron puntuaciones de desestabilización que estuvieron muy correlacionados con la cuantificación de las citas (r = 0.18).LIMITACIONES:Las sujetas a las limitaciones de los índices bibliométricos, que se modifican en el tiempo.DISCUSION:La putuación de desestabilicación identificó trabajos perspicaces, pragmáticos y modificadores de paradigmas en cirugía colorrectal. Es de interés identificar que se incluyeron una gran variedad de temas y en forma consistente editoriales, reportes de casos y series de casos que representaron una investigación importante. Este análisis bibliométrico aporta a los cirujanos colorrectales de un acervo de investigación único que puede con frecuencia pasarse por alto, y sin embargo tener una gran importancia académica. Consulte Video Resumen en http://links.lww.com/DCR/B639. (Traducción- Dr. Miguel Esquivel-Herrera).

Surgical Residents' Perspective on Informed Consent-How Does It Compare With Attending Surgeons?

BACKGROUND: The informed consent discussion (ICD) is a compulsory element of clinical practice. Surgical residents are often tasked with obtaining informed consent, but formal instruction is not included in standard curricula. This study aims to examine attitudes of surgeons and residents concerning ICD. MATERIALS AND METHODS: A survey regarding ICD was administered to residents and attending surgeons at an academic medical center with an Accreditation Council for Graduate Medical Education-accredited general surgery residency. RESULTS: In total, 44 of 64 (68.75%) residents and 37 of 50 (72%) attending surgeons participated. Most residents felt comfortable consenting for elective (93%) and emergent (82%) cases, but attending surgeons were less comfortable with resident-led ICD (51% elective, 73% emergent). Resident comfort increased with postgraduate year (PGY) (PGY1 = 39%, PGY5 = 85%). A majority of participants (80% attending surgeons, 73% residents) believed resident ICD skills should be formally evaluated, and most residents in PGY1 (61%) requested formal instruction. High percentages of residents (86%) and attendings (100%) believed that ICD skills were best learned from direct observation of attending surgeons. CONCLUSIONS: Resident comfort with ICD increases as residents advance through training. Residents acknowledge the importance of their participation in this process, and in particular, junior residents believe formal instruction is important. Attending surgeons are not universally comfortable with resident-led ICDs, particularly for elective surgeries. Efforts for improving ICD education including direct observation between attending surgeons and residents and formal evaluation may benefit the residency curriculum.

I want to go home: should we abandon open surgery for treatment of rectal prolapse? Consideration of discharge destination following surgery for rectal prolapse.

AIM: Despite the financial and value-based implications associated with higher levels of care at discharge, few studies have evaluated modifiable treatment factors that may optimize postacute care. The aim of this work was to assess the association between operative approach and disposition to a higher level of care and other outcomes following surgery for rectal prolapse. METHOD: Using a retrospective cohort study design, the database of the National Surgical Quality Improvement Program was used to identify patients with rectal prolapse who underwent perineal repair or open or laparoscopic rectopexy with or without resection between 2012 and 2017. Discharge destination and 30-day postoperative outcomes were compared using propensity score mathcing and weighting. Nomograms generated using multivariable regression calculated the risk of requiring higher levels of care upon discharge and morbidity. RESULTS: Propensity-score analysis included 3000 patients [1500 in the perineal group, 580 in the open abdominal group and 920 in the minimally invasive (MIS) group]. Patients who received open abdominal surgery were more likely to require elevation of care at destination compared with those who received perineal surgery (OR 1.65, 95% CI 1.22-1.24) and MIS abdominal surgery (OR 1.80, 95% CI 1.18-2.76). Similar effects were seen for overall morbidity. Increased age, higher American Society of Anesthesiologists class, congestive heart failure, dependent functional status and open surgery were independent predictors of discharge to higher level of care (c-statistic = 0.79). CONCLUSION: Open surgery compared with MIS and perineal surgery was associated with higher levels of discharge disposition following rectal prolapse surgery. Future research should continue to identify modifiable treatment factors that reduce poor postoperative outcomes among patients with rectal prolapse.

Special Situations in the Management of Diverticular Disease.

Diverticular disease affects a large percentage of the US population, affecting over 30% among those older than 45 years old. It is responsible for ∼300,000 hospitalizations per year in the United States and can lead to serious complications such as hemorrhage, obstruction, abscess, fistulae, or bowel perforation. 2 It is an extremely common reason for emergency room and outpatient visits and evaluations by general and colorectal surgeons. In the US, patients usually present with sigmoid diverticulitis in the setting of a normal immune system so surgeons will follow well-established practice guidelines for treatment. However, there may be special circumstances in which the management of diverticulitis is not as straightforward. In this article, we will address patients who present with multifocal disease, giant colonic diverticulum, right-sided diverticulitis, and diverticulitis in the setting of immunosuppression and hopefully provide guidance for treatment in these special circumstances.

Early feeding in colorectal surgery patients: safe and cost effective.

PURPOSE: Enhanced recovery after surgery (ERAS) pathways has demonstrated improved outcomes in colorectal surgery. An important component of ERAS is early oral intake. The aim of this study is to determine the impact of early oral intake in patients following colorectal surgery. METHODS: A retrospective analysis of patients who underwent colectomy and proctectomy at an academic institution from January 2015 to November 2018 was performed. Postoperative outcomes were compared between patients who had postoperative day 0 (POD 0) oral intake and those who did not. RESULTS: A total of 436 ERAS patients had oral intake timing documented. The majority of patients were women (241, 55.3%) and white (313, 71.8%). The mean age was 57 ± 15.09. Patients who had early intake were found to have lower 30-day overall morbidity and length of stay (p < 0.05), and no difference in serious adverse events. Additionally, hospital costs were lower in the POD 0 feeding group for all patients (p < 0.05). CONCLUSION: We have demonstrated that early oral feeding in an established ERAS pathway is associated with improved clinical outcomes as well as decreased total hospital costs. Early postoperative feeding is safe in colorectal patients and should be prioritized to decrease complications and healthcare costs.

A national analysis of operative treatment of adult patients with Hirschsprung's disease.

PURPOSE: Hirschsprung's disease is primarily a disease of infancy, but in rare cases, adults with this condition require surgery. The aim of this study is to identify the types of operations and postoperative outcomes in adults with Hirschsprung's disease on a national level. METHODS: The National Surgical Quality Improvement Program database was used to perform a retrospective review of all adult patients diagnosed with Hirschsprung's disease. Patients were divided into two groups depending on the type of operation: restoration of bowel continuity or diversion of fecal stream; clinicopathologic data and 30-day outcomes were compared between the two groups. RESULTS: A total of 32 patients were analyzed. Fourteen patients (43.8%) underwent diversion and 18 (56.2%) underwent restorative procedures. The median age was 49.5 years old for the diversion group and 23.5 years old for the reconstructive group (p = 0.001). The restorative surgery group was more likely to have an ASA 1-2 while the diversion group had a higher frequency of ASA 3-5 (p = 0.011). The median length of stay for the diversion surgery was 9.5 days and 5 days for the restoration group (p = 0.045). Complications occurred in 57% of patients in the diversion group and in 22% of patients in the restoration group (p = 0.049). There were otherwise no statistically significant differences in intraoperative data and postoperative complications. CONCLUSION: This is the first study using a national database to evaluate the surgical treatment of Hirschsprung's disease in adult patients. Complications are common and were more frequent in the older, sicker diversion group, with restoration of continuity being better tolerated in the younger, healthier patient population.

Sexual Dysfunction and Intimacy for Ostomates.

Sex and intimacy presents special challenges for the ostomate. Since some colorectal surgery patients will require either temporary or permanent stomas, intimacy and sexuality is a common issue for ostomates. In addition to the stoma, nerve damage, radiotherapy, and chemotherapy are often used in conjunction with stoma creation for cancer patients, thereby adding physiological dysfunction to the personal psychological impact of the stoma, leading to sexual dysfunction. The purpose of this paper is to describe the prevalence, etiology, and the most common types of sexual dysfunction in men and women after colorectal surgery and particularly those patients with stomas. In addition, treatment strategies for sexual dysfunction will also be described.

Are our publications failing the inspection?: a review of the publications in rectal cancer surgery between 2002 and 2012.

BACKGROUND: Quality of publications is considered a subjective measurement, and more weight is placed on prospective studies, especially randomized clinical trials and meta-analyses. OBJECTIVE: This study describes the type of publications and evaluates the quality of randomized clinical trials and review articles using an objective measurement. DATA SOURCES: Medline (PubMed) is the data source for this work. STUDY SELECTION: We used the terms "rectal neoplasms/surgery" and the filters "10 years," "humans," and "English." MAIN OUTCOME MEASURES: We measured compliance with checklist items. Randomized clinical trials were reviewed using the Consolidates Standards of Reporting Trials statement; systematic reviews/meta-analyses were reviewed using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement. RESULTS: A total of 3603 articles were identified: 20.8% were case report/series, 20.5% were retrospective cohorts, 14.0% were reviews or meta-analyses, 16.4% were prospective cohorts, 14.0% were other types of articles (comments, letters, or editorials), 5.5% were clinical trials (phase I/II), 4.2% were randomized clinical trials, and 4.4% were cross-sectional studies. We reviewed 108 randomized clinical trials; the maximum score possible was 74.0, the average score was 44.6 (range, 20.0-64.0), 4 (3.7%) were graded as "excellent," 21 (19.4%) were "good," 44 (40.7%) were "deficient," and 39 (36.1%) were graded as "fail." The predictors of higher scores for randomized clinical trials were year of publication after 2007 (p = 0.00), higher impact factor (p = 0.03), and declared funding (p = 0.01). Twenty-nine meta-analyses were reviewed; the average score was 19.64 (range, 12.0-25.0); 5 articles (17.2%) were graded as "excellent," 12 (41.4%) were "good," 10 (34.5%) were "deficient," and 2 (6.9%) were "fail." LIMITATIONS: Only 1 electronic database was used, so we lacked a validated score. In addition, the search terms did not include "colorectal." CONCLUSIONS: A total of 20.8% of the articles published were case reports and 25.0% of the articles were prospective or clinical trials. Although randomized clinical trials and systematic reviews provide the highest level of evidence, publications with missing data limit replication of the study and affect the generalizability of results to other populations. To improve the quality of our publications, authors, reviewers, and journal editors should consider the endorsement of standardize checklists.

Respiratory Musculature Evaluated by Computed Tomography in the Setting of Prolonged Mechanical Ventilation.

BACKGROUND: Diaphragm atrophy has been observed in subjects who undergo invasive mechanical ventilation. We propose a new method to assess for respiratory muscle (RM) changes in subjects who undergo invasive mechanical ventilation by assessing for changes in respiratory muscles through computed tomography (CT). METHODS: A retrospective case series study was conducted on subjects who underwent invasive mechanical ventilation and received at least 2 chest CT scans during admission. Exclusion criteria included history of chronic mechanical ventilation dependence and neuromuscular disease. Respiratory muscle cross-sectional area (CSA) was measured at the T6 vertebrae. RESULTS: Fourteen subjects were included: mean (± SD) age, BMI, and admission APACHE II scores were 54.0 y (± 14.9), 32.6 kg/m2 (± 10.9), and 23.5 (± 6.0), respectively. Ten (71%) subjects were male. Mean length of time between CT chest scans was 7.5 d (± 3.3). Mean duration of invasive mechanical ventilation was 4.5 d (± 3.4). The percentage change in TM CSA among those who underwent invasive mechanical ventilation was 10.5% (± 6.1). CONCLUSIONS: We demonstrated that serial analysis of respiratory muscle CSA through CT chest scans can be a method to assess for respiratory muscle atrophy in subjects undergoing mechanical ventilation. Future prospective studies involving larger populations are needed to better understand how this method can be used to predict outcomes in mechanically ventilated patients.

Colonic Epithelial Circadian Disruption Worsens Dextran Sulfate Sodium-Induced Colitis.

BACKGROUND: Disruption of central circadian rhythms likely mediated by changes in microbiota and a decrease in gut-derived metabolites like short chain fatty acids (SCFAs) negatively impacts colonic barrier homeostasis. We aimed to explore the effects of isolated peripheral colonic circadian disruption on the colonic barrier in a mouse model of colitis and explore the mechanisms, including intestinal microbiota community structure and function. METHODS: Colon epithelial cell circadian rhythms were conditionally genetically disrupted in mice: TS4Cre-BMAL1lox (cBMAL1KO) with TS4Cre as control animals. Colitis was induced through 5 days of 2% dextran sulfate sodium (DSS). Disease activity index and intestinal barrier were assessed, as were fecal microbiota and metabolites. RESULTS: Colitis symptoms were worse in mice with peripheral circadian disruption (cBMAL1KO). Specifically, the disease activity index and intestinal permeability were significantly higher in circadian-disrupted mice compared with control animals (TS4Cre) (P < .05). The worsening of colitis appears to be mediated, in part, through JAK (Janus kinase)-mediated STAT3 (signal transducer and activator of transcription 3), which was significantly elevated in circadian-disrupted (cBMAL1KO) mice treated with DSS (P < .05). Circadian-disrupted (cBMAL1KO) mice also had decreased SCFA metabolite concentrations and decreased relative abundances of SCFA-producing bacteria in their stool when compared with control animals (TS4Cre). CONCLUSIONS: Disruption of intestinal circadian rhythms in colonic epithelial cells promoted more severe colitis, increased inflammatory mediators (STAT3 [signal transducer and activator of transcription 3]), and decreased gut microbiota-derived SCFAs compared with DSS alone. Further investigation elucidating the molecular mechanisms behind these findings could provide novel circadian directed targets and strategies in the treatment of inflammatory bowel disease.

Disruption of peripheral circadian rhythms of the colon epithelium results in worse colitis and increased intestinal permeability in mice when given dextran sulfate sodium. This may be mediated through alterations in microbiota, butyrate levels, and STAT3.

Tumor scatter after neoadjuvant therapy for rectal cancer: are we dealing with an invisible margin?

BACKGROUND: After the impressive response of rectal cancers to neoadjuvant therapy, it seems reasonable to ask: can we can excise the small ulcer locally or avoid a radical resection if there is no gross residual tumor? Does gross response reflect what happens to tumor cells microscopically after radiation? OBJECTIVE: The aim of this study was to identify microscopic tumor cell response to radiation. DESIGN: This study is a retrospective review of a prospectively collected database. SETTING: This investigation was conducted at a single tertiary medical center. PATIENTS: Patients were selected who had elective radical resection for rectal cancer after preoperative chemotherapy and radiation performed by 2 colorectal surgeons between 2006 and 2011. MAIN OUTCOME MEASURES: The primary outcome measured was tumor presence after radiation therapy RESULTS: Of the 75 patients, 20 patients were complete responders and 55 had residual cancer. Of these patients, 28 had no tumor cells seen outside the gross ulcer, and 27 (49.1%) had tumor outside the visible ulcer or microscopic tumor present with no overlying ulcer. Of these tumors, 81.5% were skewed away from the ulcer center. The mean distance of distal scatter was 1.0 cm from the visible ulcer edge to a maximum of 3 cm; 3 patients had tumor cells more than 2 cm distal to the visible ulcer edge. Tumor scatter outside the ulcer was not associated with poor prognostic factors, such as nodal and distant disease, perineural invasion, or mucin; however, it was associated with lymphovascular invasion (χ2 = 4.12, p = 0.038) LIMITATIONS: There was limited access to clinical information gathered outside our institution. CONCLUSIONS: Our study suggests that 1) after radiation, the gross ulcer cannot be used to determine the sole area of potential residual tumor, 2) cancer cells may be found up to 3 cm distally from the gross ulcer, so the traditional 2-cm margin may not be adequate, and 3) local excision of the ulcer or no excision after apparent complete response appears to be insufficient treatment for rectal cancer.

Variation in the volume-outcome relationship after rectal cancer surgery in the United States: Retrospective study with implications for regionalization.

BACKGROUND: Previous studies have demonstrated improved outcomes for patients with rectal cancer treated at higher-volume hospitals. However, little is known whether heterogeneity in this effect exists. The objective was to test whether the effect of increased annual rectal cancer resection volume on outcomes is consistent across all hospitals treating rectal cancer. METHODS: Adult stage I to III patients who underwent surgical resection for rectal adenocarcinoma from 2004 to 2016 were identified in the National Cancer Database. RESULTS: We included 120,522 patients treated at 763 hospitals in this retrospective cohort study. Higher volume was linearly and incrementally related to outcomes in unadjusted analyses. In adjusted models, for an average patient at the average hospital, the effect of increasing the annual caseload of rectal cancer resections by 20 resections per year was associated with 8%, (hazard ratio = 0.92, 95% confidence interval = 0.87, 0.97), 18% (odds ratio = 0.82, 95% confidence interval = 0.70, 0.98), and 16% (odds ratio = 0.84, 95% confidence interval = 0.73, 0.95) relative reductions in 5-year overall survival, 30-, and 90-day mortality, respectively, and with a 19% (odds ratio = 1.19, 95% confidence interval = 1.04, 1.36) relative increase in the rate of neoadjuvant chemoradiation. These effects varied by individual hospitals such that 39% of hospitals do not see any benefit in 5-year overall survival associated with higher volumes. Increased volume was associated with lower positive circumferential resection margin rates at 19% of the hospitals. CONCLUSION: This study confirms that higher-volume hospitals have improved outcomes after rectal cancer surgery. However, there exists significant variation in these effects induced by individual within-hospital effects. Regionalization policies may need to be flexible in identifying the hospitals that would achieve enhanced benefits from treating a larger volume of patients.

Social determinants of health Z-codes and postoperative outcomes after colorectal surgery: A national population-based study.

BACKGROUND: We sought to evaluate the impact of social determinants of health (SDOH) on postoperative outcomes following colorectal surgery. METHODS: This retrospective cohort study used PearlDiver-Mariner, an all-payer insurance claims database. Patients who underwent colectomy or proctectomy between 2010 and 2020 were included. SDOH were identified using International Classification of Diseases diagnosis codes. Outcomes were compared using multivariable regression models. RESULTS: The 30-day postoperative complication rate among 333,387 patients (mean age, 59 years; 58% female) was 27%. Approximately 5% of patients reported at least one SDOH at baseline. SDOH were not associated with length of stay but were associated with higher odds of 30-day postoperative complications (OR:1.16, 95% CI:1.12-1.20), including urinary tract infection (OR:1.27, 95% CI:1.20-1.35) anastomotic leak (OR:1.22, 95% CI:1.16-1.28), pneumonia (OR:1.19, 95% CI:1.11-1.27), deep vein thrombosis (OR:1.13, 95% CI:1.02-1.23), sepsis (OR:1.12, 95% CI:1.07-1.18), disruption of wound (OR:1.12, 95% CI:1.03-1.21), and acute kidney injury (OR:1.04, 95% CI:0.99-1.10). CONCLUSIONS: SDOH Z-codes were associated with worse postoperative complications following colorectal surgery and may help target high-risk patients.

Refining colorectal cancer classification and clinical stratification through a single-cell atlas.

BACKGROUND: Colorectal cancer (CRC) consensus molecular subtypes (CMS) have different immunological, stromal cell, and clinicopathological characteristics. Single-cell characterization of CMS subtype tumor microenvironments is required to elucidate mechanisms of tumor and stroma cell contributions to pathogenesis which may advance subtype-specific therapeutic development. We interrogate racially diverse human CRC samples and analyze multiple independent external cohorts for a total of 487,829 single cells enabling high-resolution depiction of the cellular diversity and heterogeneity within the tumor and microenvironmental cells. RESULTS: Tumor cells recapitulate individual CMS subgroups yet exhibit significant intratumoral CMS heterogeneity. Both CMS1 microsatellite instability (MSI-H) CRCs and microsatellite stable (MSS) CRC demonstrate similar pathway activations at the tumor epithelial level. However, CD8+ cytotoxic T cell phenotype infiltration in MSI-H CRCs may explain why these tumors respond to immune checkpoint inhibitors. Cellular transcriptomic profiles in CRC exist in a tumor immune stromal continuum in contrast to discrete subtypes proposed by studies utilizing bulk transcriptomics. We note a dichotomy in tumor microenvironments across CMS subgroups exists by which patients with high cancer-associated fibroblasts (CAFs) and C1Q+TAM content exhibit poor outcomes, providing a higher level of personalization and precision than would distinct subtypes. Additionally, we discover CAF subtypes known to be associated with immunotherapy resistance. CONCLUSIONS: Distinct CAFs and C1Q+ TAMs are sufficient to explain CMS predictive ability and a simpler signature based on these cellular phenotypes could stratify CRC patient prognosis with greater precision. Therapeutically targeting specific CAF subtypes and C1Q + TAMs may promote immunotherapy responses in CRC patients.