How have US colorectal cancer mortality trends changed in the past 20 years?

In the last two decades, colorectal cancer (CRC) mortality has been decreasing in the United States. However, the mortality trends for the different subtypes of CRC, including different sides of colon, rectosigmoid, and rectal cancer remain unclear. We analyzed the mortality trends of different subtypes of CRC based on Centers for Disease Control and Prevention's Wide-Ranging Online Data for Epidemiologic Research data from 1999 to 2020. We calculated age-adjusted mortality rates (AAMR) per 100,000 individuals and examined the trends over time by estimating the average annual percent change (AAPC) using the Joinpoint Regression Program. Our study shows that the overall CRC rates decreased significantly from 26.42 to 15.98 per 100,000 individuals, with an AAPC of -2.41. However, the AAMR of rectosigmoid cancer increased significantly from 0.82 to 1.08 per 100,000 individuals, with the AAPC of +1.10. Men and Black individuals had the highest AAMRs respectively (23.90 vs. 26.93 per 100,000 individuals). The overall AAMR of CRC decreased for those aged ≥50 years but increased significantly from 1.02 to 1.58 per 100,000 individuals for those aged 15-49 years, with an AAPC of +0.75. Rural populations had a higher AAMR than the urban populations (22.40 vs. 19.60 per 100,000 individuals). Although overall CRC mortality declined, rising trends in young-onset CRC and rectosigmoid cancer warrant attention. Disparities persist in terms of sex, race, and geographic region, and urbanization level, emphasizing the need for targeted public health measures.

The Decline of Small Practice in Colorectal Surgery: Practice Consolidation From 2015-2022.

INTRODUCTION: Physicians have gravitated toward larger group practice arrangements in recent years. However, consolidation trends in colorectal surgery have yet to be well described. Our objective was to assess current trends in practice consolidation within colorectal surgery and evaluate underlying demographic trends including age, gender, and geography. METHODS: We performed a retrospective cross-sectional study using the Center for Medicare Services National Downloadable File from 2015 to 2022. Colorectal surgeons were categorized by practice size and by region, gender, and age. RESULTS: From 2015 to 2022, the number of colorectal surgeons in the United States increased from 1369 to 1621 (+18.4%), while the practices with which they were affiliated remained relatively stable (693-721, +4.0%). The proportion of colorectal surgeons in groups of 1-2 members fell from 18.9% to 10.7%. Conversely, those in groups of 500+ members grew from 26.5% to 45.2% (linear trend P < 0.001). The midwest region demonstrated the highest degree of consolidation. Affiliations with group practices of 500+ members saw large increases from both female and male surgeons (+148.9% and +86.9%, respectively). New surgeons joining the field since 2015 overwhelmingly practice in larger groups (5.3% in groups of 1-2, 50.1% in groups of 500+). CONCLUSIONS: Colorectal surgeons are shifting toward larger practice affiliations. Although this change is happening across all demographic groups, it appears unevenly distributed across geography, gender, and age. New surgeons are preferentially joining large group practices.

Medicare Reimbursement in Colorectal Surgery: A Growing Problem.

BACKGROUND: Medicare reimbursement rates have decreased across various specialties but have not yet been studied in colorectal surgery. OBJECTIVE: This study aimed to analyze Medicare reimbursement trends in colorectal surgery. DESIGN: Observational study. SETTING: The Centers for Medicare and Medicaid Services' Physician Fee Schedule was evaluated for reimbursement data for the 20 most common colorectal surgery procedures from 2006 to 2020. MAIN OUTCOME MEASURES: Inflation-adjusted annual percentage change, compound annual growth rate, and total percentage change were the outcome measures. A subanalysis was performed comparing the changes in reimbursement between 2006 to 2016 and 2016 to 2020 because of legislative changes that went into effect in 2016. RESULTS: During the study period, the inflation-unadjusted mean Medicare reimbursement rate for the 20 most common colorectal surgery procedures increased by +15.6%. This rise was surpassed by the inflation rate of +31.3%. Consequently, the inflation-adjusted reimbursement rate decreased by -11%. The adjusted reimbursement rates decreased the most at -33.8% for a flexible colonoscopy with biopsy and increased the most at +45.3% for a diagnostic rigid proctosigmoidoscopy. Annual percentage change was -0.79%, and the compound annual growth rate was -0.98%. There was an accelerated decrease in annual reimbursement rates from 2016 to 2020 at -2.23% compared to 2006 to 2016 at -0.22% ( p = 0.03). The only procedure that had an increase in adjusted reimbursement rate from 2016 to 2020 was the injection of sclerosing solution for hemorrhoids. LIMITATIONS: Only Medicare reimbursement data were analyzed. CONCLUSIONS: Medicare reimbursements for colorectal surgery procedures are decreasing at an accelerating rate. Although this study is limited to Medicare data, it still presents a representation of overall reimbursement changes because Medicare policies have a ripple effect in the commercial insurance market. It is vital to understand the financial trends to be able to structure future patient care teams and to advocate for the sustainability of colorectal surgery practices in the United States. See Video Abstract at http://links.lww.com/DCR/C136 . REEMBOLSO DE MEDICARE EN CIRUGA COLORRECTAL UN PROBLEMA CRECIENTE: ANTECEDENTES: Las tasas de reembolso de Medicare han disminuido en varias especialidades, pero aún no han sido estudiado en cirugía colorrectal.OBJETIVO: Analizar las tendencias de reembolso de Medicare en cirugía colorrectal.DISEÑO: Estudio observacional.CONTEXTO: Se evaluó el programa de tarifas médicas de los Centros de Servicios de Medicare y Medicaid para obtener datos de reembolso de los 20 procedimientos más comunes en cirugía colorrectal entre los años 2006 y 2020.PRINCIPALES MEDIDAS DE RESULTADO: Variación porcentual anual ajustada por inflación, tasa de crecimiento anual compuesta y variación porcentual total. Se realizó un subanálisis comparando los cambios en el reembolso entre los años 2006 a 2016 y 2016 a 2020 debido a los cambios legislativos que entraron en vigencia en 2016.RESULTADOS: Durante el período de estudio, la tasa media de reembolso de Medicare sin ajuste por inflación para los 20 procedimientos más comunes en cirugía colorrectal aumentó en +15,6 %. Esta suba fue superada por la tasa de inflación del +31,3%. En consecuencia, la tasa de reembolso ajustada por inflación disminuyó un -11%. Lo máximo que disminuyeron las tasas ajustadas de reembolso fue a -33,8% para una colonoscopia flexible con biopsia y aumentaron más a +45,3% para una proctosigmoidoscopia rígida de diagnóstico. El cambio porcentual anual fue -0,79% y la tasa de crecimiento anual compuesto fue -0,98%. Hubo una disminución acelerada en las tasas de reembolso anual de 2016 a 2020 a -2,23 % en comparación con 2006 a 2016 a -0,22% ( p = 0,03). El único procedimiento que tuvo un aumento en la tasa de reembolso ajustada de 2016 a 2020 fue la inyección de solución esclerosante para las hemorroides.LIMITACIONES: Solo se analizaron los datos de reembolso de Medicare.CONCLUSIONES: Los reembolsos de Medicare por procedimientos en cirugía colorrectal están disminuyendo a un ritmo acelerado. Aunque este estudio se limita a los datos de Medicare, aún presenta una representación de los cambios generales en los reembolsos, ya que las pólizas de Medicare tienen un efecto dominó en el mercado de seguros comerciales. Es fundamental comprender las tendencias financieras para poder estructurar futuros equipos de atención de pacientes y abogar por la sostenibilidad de las prácticas de cirugía colorrectal en los Estados Unidos. Consulte Video Resumen video en https://links.lww.com/DCR/C136 . (Traducción-Dr. Osvaldo Gauto ).

Could meeting the standards of the National Accreditation Program for Rectal Cancer in the National Cancer Database improve patient outcomes?

AIM: The National Accreditation Program for Rectal Cancer (NAPRC) was developed to improve rectal cancer patient outcomes in the United States. The NAPRC consists of a set of process and outcome measures that hospitals must meet in order to be accredited. We aimed to assess the potential of the NAPRC by determining whether achievement of the process measures correlates with improved survival. METHODS: The National Cancer Database was used to identify patients undergoing curative proctectomy for non-metastatic rectal cancer from 2010 to 2014. NAPRC process measures identified in the National Cancer Database included clinical staging completion, treatment starting <60 days from diagnosis, carcinoembryonic antigen level measured prior to treatment, tumour regression grading and margin assessment. RESULTS: There were 48 669 patients identified with a mean age of 62 ± 12.9 years and 61.3% of patients were men. The process measure completed most often was assessment of proximal and distal margins (98.4%) and the measure completed least often was the serum carcinoembryonic antigen level prior to treatment (63.8%). All six process measures were completed in 23.6% of patients. After controlling for age, gender, comorbidities, annual facility resection volume, race and pathological stage, completion of all process measures was associated with a statistically significant mortality decrease (Cox hazard ratio 0.88, 95% CI 0.81-0.94, P < 0.001). CONCLUSION: Participating institutions provided complete datasets for all six process measures in less than a quarter of patients. Compliance with all process measures was associated with a significant mortality reduction. Improved adoption of NAPRC process measures could therefore result in improved survival rates for rectal cancer in the United States.

Transanal Minimally Invasive Surgery: A Useful Technique That Continues to Evolve.

Colorectal cancer remains the 3rd most common cancer diagnosed among men and women in the United States. With improved screening, premalignant rectal lesions and rectal cancers are being detected at earlier stages. In addition, the use of neoadjuvant chemo- and radiotherapy has led to downstaging of larger lesions. There is growing interest among colorectal surgeons in local excision with organ preservation for patients with rectal cancer. There are multiple platforms for local excision of rectal cancers, including transanal excision (TAE), transanal endoscopic microsurgery (TEM) and transanal minimally invasive surgery (TAMIS). TAMIS was developed as an affordable platform that uses conventional laparoscopic equipment familiar to many colorectal surgeons. TAMIS allows for full-thickness benign or malignant lesion excision in any quadrant without the need for patient repositioning. The literature has shown that, for appropriately selected patients, TAMIS provides superior excision quality compared to TAE. Furthermore, TAMIS has oncologic outcomes equivalent to TEM at a fraction of the cost. Recently, robotic TAMIS has been introduced, which takes advantage of the articulating instruments of the robotic platform without the need for a skilled assistant. This article will cover multiple technical aspects for TAMIS including patient selection and preparation, technical tips for successful excision and defect closure, and recent advances, including robotic TAMIS.

Radiomic Features of Primary Rectal Cancers on Baseline T2 -Weighted MRI Are Associated With Pathologic Complete Response to Neoadjuvant Chemoradiation: A Multisite Study.

BACKGROUND: Twenty-five percent of rectal adenocarcinoma patients achieve pathologic complete response (pCR) to neoadjuvant chemoradiation and could avoid proctectomy. However, pretreatment clinical or imaging markers are lacking in predicting response to chemoradiation. Radiomic texture features from MRI have recently been associated with therapeutic response in other cancers. PURPOSE: To construct a radiomics texture model based on pretreatment MRI for identifying patients who will achieve pCR to neoadjuvant chemoradiation in rectal cancer, including validation across multiple scanners and sites. STUDY TYPE: Retrospective. SUBJECTS: In all, 104 rectal cancer patients staged with MRI prior to long-course chemoradiation followed by proctectomy; curated from three institutions. FIELD STRENGTH/SEQUENCE: 1.5T-3.0T, axial higher resolution T2 -weighted turbo spin echo sequence. ASSESSMENT: Pathologic response was graded on postsurgical specimens. In total, 764 radiomic features were extracted from single-slice sections of rectal tumors on processed pretreatment T2 -weighted MRI. STATISTICAL TESTS: Three feature selection schemes were compared for identifying radiomic texture descriptors associated with pCR via a discovery cohort (one site, N = 60, cross-validation). The top-selected radiomic texture features were used to train and validate a random forest classifier model for pretreatment identification of pCR (two external sites, N = 44). Model performance was evaluated via area under the curve (AUC), accuracy, sensitivity, and specificity. RESULTS: Laws kernel responses and gradient organization features were most associated with pCR (P ≤ 0.01); as well as being commonly identified across all feature selection schemes. The radiomics model yielded a discovery AUC of 0.699 ± 0.076 and a hold-out validation AUC of 0.712 with 70.5% accuracy (70.0% sensitivity, 70.6% specificity) in identifying pCR. Radiomic texture features were resilient to variations in magnetic field strength as well as being consistent between two different expert annotations. Univariate analysis revealed no significant associations of baseline clinicopathologic or MRI findings with pCR (P = 0.07-0.96). DATA CONCLUSION: Radiomic texture features from pretreatment MRIs may enable early identification of potential pCR to neoadjuvant chemoradiation, as well as generalize across sites. LEVEL OF EVIDENCE: 3 TECHNICAL EFFICACY STAGE: 2.

Does umbilical contamination correlate with colorectal surgery patient outcomes?

PURPOSE: Most preoperative assessment tools to evaluate risk for postoperative complications require multiple data points to be collected and can be logistically burdensome. This study evaluated if umbilical contamination, a simple bedside assessment, correlated with surgical outcomes. METHODS: A 6-point score to measure umbilical contamination was developed and applied prospectively to patients undergoing colorectal surgery at an academic medical center. RESULTS: There were 200 patients enrolled (mean age 58.1 ± 14.8; 56% female). The mean BMI was 28.6 ± 7.4. Indications for surgery included colon cancer (24%), rectal cancer (18%), diverticulitis (13.5%), and Crohn's disease (12.5%). Umbilical contamination scores were 0 (23%, cleanest), 1 (26%), 2 (21%), 3 (24%), 4 (6%), and 5 (0%, dirtiest). Umbilical contamination did not correlate with preoperative functional status (p > 0.2). Umbilical contamination correlated with increased length of stay (rho = 0.19, p = 0.007) and postoperative complications (OR 1.3, 1.02-1.7, p = 0.04), but not readmission (p = 0.3) or discharge disposition (p > 0.2). CONCLUSION: Sterile preparation of the abdomen is an important component of proper surgical technique and umbilical contamination correlates with increased postoperative complications.

Evaluating the Accuracy of Hemorrhoids: Comparison Among Specialties and Symptoms.

BACKGROUND: A large proportion of patients with anorectal complaints are referred to colorectal surgeons with the label of hemorrhoids. OBJECTIVE: The purpose of this study was to review presenting symptoms and frequency of accurate diagnosis, as well as to analyze determinants of misdiagnosis to guide educational endeavors. DESIGN: This was a retrospective study. SETTINGS: The study was conducted at a tertiary care academic center. PATIENTS: The charts of patients referred to a colorectal clinic with the diagnosis of hemorrhoids from January 1, 2012, to January 1, 2017, were reviewed. MAIN OUTCOME MEASURES: The accuracy of the referring provider's diagnosis of hemorrhoids was measured. RESULTS: Review of charts identified 476 patients with the referral diagnosis of hemorrhoids. The most common presenting symptoms were bleeding (63%; n = 302), pain (48%; n = 228), and protrusion (39%; n = 185). Anal examination (ie, external inspection and/or digital internal examination) was documented in only 48%. The hemorrhoid diagnostic accuracy was 65% (n = 311). Among patients with incorrect hemorrhoid diagnoses (35%; n = 169), actual diagnosis was anal fissure (34%), skin tag (27%), and hypertrophied papilla (6%). One rectal and 2 anal carcinomas were found (0.63%). Compared with general practitioners, gastroenterologists had 86% higher odds of correct diagnosis (OR = 1.86 (95% CI, 1.10-3.10); p = 0.02), whereas the gynecologists had 68% lower odds of correct diagnosis at the time of referral (OR = 0.32 (95% CI, 0.10-0.80); p = 0.02). On multivariable analysis, referring specialty was not predictive of accurate diagnosis. Patients presenting with protrusion had 73% higher odds of accurate diagnosis (OR = 1.7 (95% CI, 1.1-2.7); p = 0.02), whereas patients presenting with pain (OR = 1.6 (95% CI, 1.1-2.5); p = 0.03) or pruritus (OR = 2.5 (95% CI, 1.2-5.0); p = 0.008) were more likely to be misdiagnosed. LIMITATIONS: This is a retrospective study. Not all of the charts contained all data points. The number of patients may limit the power of the study to detect some differences. CONCLUSIONS: A variety of anorectal complaints are diagnosed as hemorrhoids by providers who have initial contact with the patients. Educational programs directed toward improving physician knowledge can potentially improve diagnostic accuracy and earlier initiation of appropriate care. Presenting symptoms other than protrusion lead to higher rate of misdiagnosis by a referring physician. See Video Abstract at http://links.lww.com/DCR/A847.

A Model for a Formal Mentorship Program in Surgical Residency.

BACKGROUND: Mentorship is a key component in preventing burnout and attrition in surgical training, yet many residencies lack a formal program, one method used to establish successful mentor relationships. We aimed to measure the difference in resident perceptions and experience after the implementation of a mentorship program. METHODS: An anonymous survey was distributed to all general surgery residents at a single academic institution before and after implementation of a year-long mentorship program that involved assigned mentors, two social events, and recommended mentorship meetings. Responses were recorded on a five-point Likert scale. RESULTS: Half of respondents (n = 17, 53%) attended at least one event, and 66% (n = 21) had at least one mentor meeting. The proportion of residents who identified a faculty mentor increased from 59% to 75%. Residents with two or more mentor meetings (n = 12, 38%) were more likely to report faculty were interested in mentoring and cared about their development (3.5 versus 4.6, 3.6 versus 4.6, P < 0.001). They were more likely to identify faculty approachable for resident performance (3.8 versus 4.6, P < 0.02) and outside of work concerns (3.2 versus 4.3, P < 0.01) and were more likely to be satisfied with the amount of mentorship received (2.8 versus 4.0 P < 0.001). CONCLUSIONS: Implementation of a formal mentorship program resulted in an improvement in resident perception of faculty involvement and support. Meeting with a mentor resulted in a significant improvement in resident perception. Implementation of a mentorship program can improve resident experience, and few interactions are needed to affect the change.

Evaluation of Healthcare Use and Clinical Outcomes of Alvimopan in Patients Undergoing Bowel Resection: A Propensity Score-Matched Analysis.

BACKGROUND: Postoperative ileus is a significant complication after bowel resection surgeries. Alvimopan is the only US Food and Drug Administration-approved therapy for accelerating the return of bowel function after large- and small-bowel resection. OBJECTIVE: The purpose of this study was to estimate the healthcare use and in-hospital morbidities associated with on-label use of alvimopan in patients undergoing bowel resection surgeries. DESIGN: A retrospective observational propensity-matched cohort study was conducted using a large hospital administrative database. SETTING: The study included inpatient postsurgical patients. PATIENTS: Patients aged ≥18 years undergoing a primary large or small segmental bowel resection with discharge dates between January 2010 and December 2014 were included. INTERVENTIONS: Patients receiving 2 to 15 doses of alvimopan were defined as the treatment cohort, and those without any alvimopan use were included as control subjects. MAIN OUTCOME MEASURES: The primary outcome was postoperative length of stay. Secondary outcomes included postoperative in-hospital morbidities, inpatient mortality, intensive care unit length of stay, discharge disposition, and 30-day readmission. RESULTS: Each propensity-score matched cohort included 18,559 patients. The mean (±SD) postoperative length of stay was 4.62 ± 2.45 days in alvimopan-treated patients compared with 5.24 ± 3.35 days in control subjects (p < 0.001). Alvimopan-treated patients had lower rates of postoperative GI complication (12.15% vs 16.50%; p < 0.001). The rates of urinary tract infections; other postoperative infections; and cardiovascular, pulmonary, thromboembolic, and cerebrovascular events were also lower compared with the control subjects. LIMITATIONS: The study was limited by its inability to generalize to the US population, because the database included a convenience sample of hospital discharges. The identification of patients undergoing bowel resection and their clinical conditions relied on the accuracy and completeness of International Classification of Diseases, Ninth Revision, Clinical Modification diagnosis and procedure coding. There may be a confounding effect by the use of enhanced recovery pathways associated with the use of alvimopan. CONCLUSIONS: The use of alvimopan was associated with a reduction of 0.62 days in postsurgery length of stay and lower rates of postoperative GI complications, infections, and other in-hospital morbidities. See Video Abstract at http://links.lww.com/DCR/A703.

Colorectal Cancer Safety Net: Is It Catching Patients Appropriately?

BACKGROUND: Disparities in access to colorectal cancer care are multifactorial and are affected by socioeconomic elements. Uninsured and Medicaid patients present with advanced stage disease and have worse outcomes compared with similar privately insured patients. Safety net hospitals are a major care provider to this vulnerable population. Few studies have evaluated outcomes for safety net hospitals compared with private institutions in colorectal cancer. OBJECTIVE: The purpose of this study was to compare demographics, screening rates, presentation stage, and survival rates between a safety net hospital and a tertiary care center. DESIGN: Comparative review of patients at 2 institutions in the same metropolitan area were conducted. SETTINGS: The study included colorectal cancer care delivered either at 1 safety net hospital or 1 private tertiary care center in the same city from 2010 to 2016. PATIENTS: A total of 350 patients with colorectal cancer from each hospital were evaluated. MAIN OUTCOME MEASURES: Overall survival across hospital systems was measured. RESULTS: The safety net hospital had significantly more uninsured and Medicaid patients (46% vs 13%; p < 0.001) and a significantly lower median household income than the tertiary care center ($39,299 vs $49,741; p < 0.0001). At initial presentation, a similar percentage of patients at each hospital presented with stage IV disease (26% vs 20%; p = 0.06). For those undergoing resection, final pathologic stage distribution was similar across groups (p = 0.10). After a comparable median follow-up period (26.6 mo for safety net hospital vs 29.2 mo for tertiary care center), log-rank test for overall survival favored the safety net hospital (p = 0.05); disease-free survival was similar between hospitals (p = 0.40). LIMITATIONS: This was a retrospective review, reporting from medical charts. CONCLUSIONS: Our results support the value of safety net hospitals for providing quality colorectal cancer care, with survival and recurrence outcomes equivalent or improved compared with a local tertiary care center. Because safety net hospitals can provide equivalent outcomes despite socioeconomic inequalities and financial constraints, emphasis should be focused on ensuring that adequate funding for these institutions continues. See Video Abstract at http://links.lww.com/DCR/A454.

Application of a simple, affordable quality metric tool to colorectal, upper gastrointestinal, hernia, and hepatobiliary surgery patients: the HARM score.

BACKGROUND: Quality is the major driver for both clinical and financial assessment. There remains a need for simple, affordable, quality metric tools to evaluate patient outcomes, which led us to develop the HospitAl length of stay, Readmission and Mortality (HARM) score. We hypothesized that the HARM score would be a reliable tool to assess patient outcomes across various surgical specialties. METHODS: From 2011 to 2015, we identified colorectal, hepatobiliary, upper gastrointestinal, and hernia surgery admissions using the Vizient Clinical Database. Individual and hospital HARM scores were calculated from length of stay, 30-day readmission, and mortality rates. We evaluated the correlation of HARM scores with complication rates using the Clavien-Dindo classification. RESULTS: We identified 525,083 surgical patients: 206,981 colorectal, 164,691 hepatobiliary, 97,157 hernia, and 56,254 upper gastrointestinal. Overall, 53.8% of patients were admitted electively with a mean HARM score of 2.24; 46.2% were admitted emergently with a mean HARM score of 1.45 (p < 0.0001). All HARM components correlated with patient complications on logistic regression (p < 0.0001). The mean length of stay increased from 3.2 ± 1.8 days for a HARM score < 2 to 15.1 ± 12.2 days for a HARM score > 4 (p < 0.001). In elective admissions, for HARM categories of < 2, 2-< 3, 3-4, and > 4, complication rates were 9.3, 23.2, 38.8, and 71.6%, respectively. There was a similar trend for increasing HARM score in emergent admissions as well. For all surgical procedure categories, increasing HARM score, with and without risk adjustment, correlated with increasing severity of complications by Clavien-Dindo classification. CONCLUSIONS: The HARM score is an easy-to-use quality metric that correlates with increasing complication rates and complication severity across multiple surgical disciplines when evaluated on a large administrative database. This inexpensive tool could be adopted across multiple institutions to compare the quality of surgical care.

The American Society of Colon and Rectal Surgeons Assessment Tool for Performance of Laparoscopic Colectomy.

BACKGROUND: The lack of consensus for performance assessment of laparoscopic colorectal resection is a major impediment to quality improvement. OBJECTIVE: The purpose of this study was to develop and assess the validity of an evaluation tool for laparoscopic colectomy that is feasible for wide implementation. DESIGN: During the pilot phase, a small group of experts modified previous assessment tools by watching videos for laparoscopic right colectomy with the following categories of experience: novice (less than 20 cases), intermediate (50-100 cases), and expert (more than 500 cases). After achieving sufficient reliability (κ > 0.8), a user-friendly tool was validated among a large group of blinded, trained experts. SETTING: The study was conducted through the American Society of Colon and Rectal Surgeons Operative Competency Evaluation Committee. PATIENTS: Raters were from the Operative Competency Evaluation Committee of the American Society of Colon and Rectal Surgeons. MAIN OUTCOME MEASURES: Assessment tool reliability and internal consistency were measured. RESULTS: From October 2014 through February 2015, 4 groups of 5 raters blinded to surgeon skill level evaluated 6 different laparoscopic right colectomy videos (novice = 2, intermediate = 2, expert = 2). The overall Cronbach α was 0.98 (>0.9 = excellent internal consistency). The intraclass correlation for the overall assessment was 0.93 (range, 0.77-0.93) and was >0.74 (excellent) for each step. The average scores (scale, 1-5) for experts were significantly better than those in the intermediate category, with a mean (SD) of 4.51 (0.56) versus 2.94 (0.56; p = 0.003). Videos in the intermediate group scored more favorably than beginner videos for each individual step and overall performance (mean (SD) = 3.00 (0.32) vs 1.78 (0.42); p = 0.006). LIMITATIONS: The study was limited by rater bias to technique and style. CONCLUSIONS: The unique and robust methodology in this trial produced an assessment tool that was feasible for raters to use when assessing videotaped laparoscopic right hemicolectomies. The potential applications for this new tool are widespread, including both training and evaluation of competence at the attending level. See Video Abstract at http://links.lww.com/DCR/A369, http://links.lww.com/DCR/A370, http://links.lww.com/DCR/A371.

Using Modified Frailty Index to Predict Safe Discharge Within 48 Hours of Ileostomy Closure.

BACKGROUND: Enhanced recovery pathways allow for safe discharge and optimal outcomes within 48 hours after ileostomy closure. Unfortunately, some patients undergoing ileostomy closure have prolonged hospital stays. We have shown previously that the Modified Frailty Index can help predict patients who will fail early discharge after laparoscopic colorectal surgery. OBJECTIVE: The purpose of this study was to use the Modified Frailty Index to identify patients who were safe for early discharge after ileostomy closure. DESIGN: This was a retrospective review. SETTINGS: The study was conducted at a tertiary referral center. PATIENTS: Patients who underwent ileostomy closure (2006-2015) were stratified into early (≤48 hours) and late discharge groups. MAIN OUTCOME MEASURES: The Modified Frailty Index, morbidity, and readmission rates were measured. RESULTS: A total of 272 patients undergoing ileostomy closure were evaluated. Overall length of stay was 3.64 days (±3.23 days), with 114 patients (42%) discharged within 48 hours. Sex, age, and ASA scores were similar between early and later discharge groups (p > 0.2). Univariate logistic regression demonstrated that a Modified Frailty Index score of 0 was associated with early discharge (p = 0.03), whereas a Modified Frailty Index score ≤1 and ≤2 were not. There was no significant association between the Modified Frailty Index and complication or readmission rates. Postoperative complications occurred in 39 patients (14.3%), and 1 patient died secondary to an anastomotic leak. Fifteen patients (5.5%) were readmitted within 30 days. Readmission rate within 30 days was 3.2%, with a Modified Frailty Index score of 0, 6.1% for a Modified Frailty Index score of <1, and 5.9% for a Modified Frailty Index score of <2, for which there was not an association based on univariate logistic regression (Modified Frailty Index = 0, p = 0.13; <1, p = 0.55; <2, p = 0.53). LIMITATIONS: The study was limited by nature of being a retrospective review. CONCLUSIONS: Patients undergoing ileostomy closure with a Modified Frailty Index score of 0 are associated with higher rates of discharge within 48 hours of ileostomy closure surgery than those with a higher Modified Frailty Index, without higher readmission rates. This information can be helpful to better manage patient and resource use expectations for the duration of inpatient recovery.

Laparoscopic colectomy in the obese, morbidly obese, and super morbidly obese: when does weight matter?

PURPOSE: Previous studies have demonstrated that obese patients (BMI >30) undergoing laparoscopic colectomy have longer operative times and increased complications when compared to non-obese cohorts. However, there is little data that specifically evaluates the outcomes of obese patients based on the degree of their obesity. The aim of this study was to evaluate the impact of increasing severity of obesity on patients undergoing laparoscopic colectomy. METHODS: A retrospective review was performed of all patients undergoing laparoscopic colectomy between 1996 and 2013. Patients were classified according to their BMI as obese (BMI 30.0-39.9), morbidly obese (BMI 40.0-49.9), and super obese (BMI >50). Main outcome measures included conversion rate, operative time, estimated blood loss, post-operative complications, and length of stay. RESULTS: There were 923 patients who met inclusion criteria. Overall, 604 (65.4%), 257 (27.9%), and 62 (6.7%) were classified as obese (O), morbidly obese (MO), and super obese (SO), respectively. Clinicopathologic characteristics were similar among the three groups. The SO group had significantly higher conversion rates (17.7 vs. 7 vs. 4.8%; P = 0.031), longer average hospital stays (7.1 days vs. 4.9 vs. 3.4; P = 0.001), higher morbidity (40.3 vs. 16.3 vs. 12.4%; P = 0.001), and longer operative times (206 min vs. 184 vs. 163; P = 0.04) compared to the MO and O groups, respectively. The anastomotic leak rate in the SO (4.8%; P = 0.027) and MO males (4.1%; P = 0.033) was significantly higher than MO females (2.2%) and all obese patients (1.8%). CONCLUSION: Increasing severity of obesity is associated with worse perioperative outcomes following laparoscopic colectomy.

Alvimopan in the setting of colorectal resection with an ostomy: To use or not to use?

BACKGROUND: Postoperative ileus (POI) is a major cause of morbidity, increased length of stay (LOS) and hospital cost after colorectal surgery. Alvimopan is a µ-opioid antagonist used to accelerate upper and lower gastrointestinal function after bowel resection. We hypothesized that alvimopan would reduce LOS in patients undergoing colorectal resection with stoma, a situation that has not been evaluated. METHODS: A retrospective review (2010-2015) identified 58 patients who underwent colorectal resection for benign or malignant disease with stoma creation and received alvimopan. They were case-matched to 58 non-alvimopan patients based on age, BMI, baseline comorbidities, stoma type created and surgical approach. We compared overall LOS, incidence of POI and other postoperative complications. RESULTS: There were equal numbers of laparoscopic (N = 18) and open resections (N = 40) in the alvimopan group and non-alvimopan group. There were also equal numbers of patients with an ileostomy (N = 37) or colostomy (N = 21) in each group. Overall, 41 patients underwent resection for malignant disease in the alvimopan group compared to 37 in the non-alvimopan group. There was a significant reduction in median LOS overall (alvimopan 5 (4-7) versus control 6 (4.75-9.25) days, P = 0.03). While the 6-day median LOS was similar for patients undergoing ileostomy creation (P = 0.25), alvimopan patients had a 3-day decreased median LOS that approached statistical significance (P = 0.06). The overall 30-day complication rate was higher in the control group (41.4 vs. 51.7%, P = 0.26), but the readmission rate within 30 days was higher in the alvimopan group (19 vs. 13.8%, P = 0.45). Neither of these differences reached statistically significance. CONCLUSION: The use of alvimopan in patients undergoing colorectal resection with stoma is associated with a significantly shorter LOS, but the increased readmission rate warrants further study. Based on these data, alvimopan should be evaluated in a controlled setting for patients undergoing colorectal resection with colostomy creation.

The Trump Effect: With No Peer Review, How Do We Know What to Really Believe on Social Media?

Social media is a source of news and information for an increasing portion of the general public and physicians. The recent political election was a vivid example of how social media can be used for the rapid spread of "fake news" and that posts on social media are not subject to fact-checking or editorial review. The medical field is susceptible to propagation of misinformation, with poor differentiation between authenticated and erroneous information. Due to the presence of social "bubbles," surgeons may not be aware of the misinformation that patients are reading, and thus, it may be difficult to counteract the false information that is seen by the general public. Medical professionals may also be prone to unrecognized spread of misinformation and must be diligent to ensure the information they share is accurate.