Geriatric Assessment in Colorectal Surgery: A Systematic Review.

INTRODUCTION: The prevalence of colorectal surgery among older adults is expected to rise due to the aging population. Geriatric conditions (e.g., frailty) are risk factors for poor surgical outcomes. The goal of this systematic review is to examine how current literature describes geriatric assessment interventions in colorectal surgery and associated outcomes. METHODS: Systematic searches of Ovid MEDLINE, Cochrane Library, CINAHL, Embase, and Web of Science were completed. Review was performed according to Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) guidelines and prospectively registered in PROSPERO, the international prospective register of systematic reviews in health and social care. All cohort studies and randomized trials of adult colorectal surgery patients where geriatric assessment was performed were included. Geriatric assessment with/without management interventions were identified and described. RESULTS: Seven-hundred ninety-three studies were identified. Duplicates (197) were removed. An additional 525 were excluded after title/abstract review. After full-text review, 20 studies met the criteria. Reference list review increased final total to 25 studies. All 25 studies were cohort studies. No randomized clinical trials were identified. Heterogeneous assessments were organized into geriatrics domains (mind, mobility, medications, matters most, and multi-complexity). Incomplete evaluations across geriatric domains were performed with few studies describing the use of assessments to impact management decisions. CONCLUSIONS: There are no randomized trials assessing the impact of geriatric assessment to tailor management strategies and improve outcomes in colorectal surgery. Few studies performed assessments to evaluate the geriatric domain matters most. These findings represent a gap in evidence for the efficacy of geriatric assessment and management strategies in colorectal surgical care.

Incidence of Secondary Cancers After Neoadjuvant Therapy for Locally Advanced Rectal Cancer.

INTRODUCTION: Whether neoadjuvant chemoradiation for locally advanced rectal cancer (LARC) induces secondary cancers is controversial. This retrospective cohort study describes the incidence of secondary cancers in LARC patients. METHODS: We compared 364 LARC patients who received conventional (50.4 Gy) or short course neoadjuvant radiation (25 Gy x 5 fractions) followed by resection to 142 patients with surgically resected rectal cancer who did not receive radiation at a single institution from 2004 to 2018. Secondary cancer was defined as any nonmetastatic noncolorectal malignancy diagnosed via biopsy or definitive imaging criteria at least 6 mo after completion of neoadjuvant therapy or after resection in the comparison group. RESULTS: Among the neoadjuvant radiation group (364 patients, 40% female, age 61 ± 13 y), 32 patients developed 34 (9.3%) secondary cancers. Three cases involved a pelvic organ. Among the comparison group (142 patients, 39% female, age 64 ± 15 y), 15 patients (10.6%) developed a secondary cancer. Five cases involved pelvic organs. Secondary cancer incidence did not differ between groups. Latency period to secondary cancer diagnosis was 6.7 ± 4.3 y. Patients who received radiation underwent longer median follow-up (6.8 versus 4.5 y, P < 0.01) and were significantly less likely to develop a pelvic organ cancer (odds ratio 0.18; 95% confidence interval, 0.04-0.83; P = 0.02). No genetic mutations or cancer syndromes were identified among patients with secondary cancers. CONCLUSIONS: Neoadjuvant chemoradiation is not associated with increased secondary cancer risk in LARC patients and may have a local protective effect on pelvic organs, especially prostate. Ongoing follow-up is critical to continue risk assessment.

Surgical and medical outcomes in robotic compared to laparoscopic colectomy global prospective cohort from the American college of surgeons national surgical quality improvement program.

BACKGROUND: Evidence regarding the outcomes benefits of robotic approach, when compared to a laparoscopic approach, in colectomy remain limited. OBJECTIVE: This study aimed to analyze the value of robotic approach compared to laparoscopic approach in minimally invasive colectomy. DESIGN: Cohort study of the National Surgical Quality Improvement Program (NSQIP). SETTING: This study included data from the NSQIP from 1/2016 to 12/2021. PATIENT: Adult patients undergoing minimally invasive (laparoscopic or robotic) colorectal surgery. INTERVENTION: Robotic versus laparoscopic colectomy. OUTCOME MEASURES: Risk ratios for the incidence of medical and surgical morbidity and overall mortality. RESULTS: Compared to laparoscopic, robotic colectomy was associated with a significant decrease in postoperative morbidity [RR 0.84 (95%CI 0.72-0.96), P < 0.001], a significant reduction in postoperative mortality [RR 0.83 (95%CI 0.79-0.90), P 0.010)], and in post operative ileus [RR: 0.80 (95%CI 0.75-0.84), P < 0.001]. Yet, robotic approach was associated with a significant increase in total operative time despite a significant decrease in total length of stay. No benefit was observed regarding anastomotic leak. LIMITATIONS: Observational nature of the study cannot exclude residual bias. CONCLUSIONS: In this prospective cohort from the NSQIP, robotic colectomy was associated with a significant reduction in postoperative ileus, unplanned conversion to open surgery, morbidity, and overall mortality when compared to laparoscopic colectomy.

Perceptions of Mobile Health Technology in Elective Surgery: A Qualitative Study of North American Surgeons.

OBJECTIVES: To explore the surgeon-perceived added value of mobile health technologies (mHealth), and determine facilitators of and barriers to implementing mHealth. BACKGROUND: Despite the growing popularity of mHealth and evidence of meaningful use of patient-generated health data in surgery, implementation remains limited. METHODS: This was an exploratory qualitative study following the Consolidated Criteria for Reporting Qualitative Research. Purposive sampling was used to identify surgeons across the United States and Canada. The Consolidated Framework for Implementation Research informed development of a semistructured interview guide. Video-based interviews were conducted (September-November 2020) and interview transcripts were thematically analyzed. RESULTS: Thirty surgeons from 8 specialties and 6 North American regions were interviewed. Surgeons identified opportunities to integrate mHealth data pre- operatively (eg, expectation-setting, decision-making) and during recovery (eg, remote monitoring, earlier detection of adverse events) among higher risk patients. Perceived advantages of mHealth data compared with surgical and patient-reported outcomes included easier data collection, higher interpretability and objectivity of mHealth data, and the potential to develop more patientcentered and functional measures of health. Surgeons identified a variety of implementation facilitators and barriers around surgeon- and patient buy-in, integration with electronic medical records, regulatory/reimbursement concerns, and personnel responsible for mHealth data. Surgeons described similar considerations regarding perceptions of mHealth among patients, including the potential to address or worsen existing disparities in surgical care. CONCLUSIONS: These findings have the potential to inform the effective and equitable implementation of mHealth for the purposes of supporting patients and surgical care teams throughout the delivery of surgical care.

Smartphone-based Assessment of Preoperative Decision Conflict and Postoperative Physical Activity Among Patients Undergoing Cancer Surgery: A Prospective Cohort Study.

OBJECTIVE: To determine the prevalence of clinically significant decision conflict (CSDC) among patients undergoing cancer surgery and associations with postoperative physical activity, as measured through smartphone accelerometer data. BACKGROUND: Patients with cancer face challenging treatment decisions, which may lead to CSDC. CSDC negatively affects patient-provider relationships, psychosocial functioning, and health-related quality of life; however, physical manifestations of CSDC remain poorly characterized. METHODS: Adult smartphone-owners undergoing surgery for breast, skin-soft-tissue, head-and-neck, or abdominal cancer (July 2017-2019) were approached. Patients downloaded the Beiwe application that delivered the Decision Conflict Scale (DCS) preoperatively and collected smartphone accelerometer data continuously from enrollment through 6 months postop-eratively. Restricted-cubic-spline regression, adjusting for a priori potential confounders (age, type of surgery, support status, and postoperative complications) was used to determine trends in postoperative daily physical activity among patients with and without CSDC (DCS score >25/100). RESULTS: Among 99 patients who downloaded the application, 85 completed the DCS (86% participation rate). Twenty-three (27%) reported CSDC. These patients were younger (mean age 48.3 years [standard deviation 14.2]-vs-55.0 [13.3], P = 0.047) and more frequently lived alone (22%-vs-6%, P = 0.042). There were no differences in preoperative physical activity (115.4 minutes [95%CI 90.9, 139.9]-vs-110.8 [95%CI 95.7, 126.0], P = 0.753). Adjusted postoperative physical activity was lower among patients reporting CSDC at 30 days (difference 33.1 minutes [95%CI 5.93,60.2], P = 0.017), 60 days 35.5 [95%CI 8.50, 62.5], P = 0.010 and 90 days 31.8 [95%CI 5.44, 58.1], P = 0.018 postoperatively. CONCLUSIONS: CSDC was prevalent among patients who underwent cancer surgery and associated with lower postoperatively daily physical activity. These data highlight the importance of addressing modifiable decisional needs of patients through enhanced shared decision-making.

Molecular Basis of Extramural Vascular Invasion (EMVI) in Colorectal Carcinoma.

BACKGROUND: Extramural vascular invasion (EMVI) is a known poor prognostic factor in colorectal carcinoma; however, its molecular basis has not been defined. This study aimed to assess the expression of molecular markers in EMVI positive colorectal carcinoma to understand their tumor microenvironment. METHODS: Immunohistochemistry was performed on tissue microarrays of surgically resected colorectal cancer specimens for immunological markers, and BRAFV600E mutation (and on the tissue blocks for mismatch repair proteins). Automated quantification was used for CD8, LAG3, FOXP3, PU1, and CD163, and manual quantification was used for PDL1, HLA I markers (beta-2 microglobulin, HC10), and HLA II. The Wilcoxon rank-sum test was used to compare EMVI positive and negative tumors. A logistic regression model was fitted to assess the predictive effect of biomarkers on EMVI. RESULTS: There were 340 EMVI positive and 678 EMVI negative chemo naïve tumors. PDL1 was barely expressed on tumor cells (median 0) in the entire cohort. We found a significantly lower expression of CD8, LAG3, FOXP3, PU1 cells, PDL1 positive macrophages, and beta-2 microglobulin on tumor cells in the EMVI positive subset (p ≤ 0.001). There was no association of BRAFV600E or deficient mismatch repair proteins (dMMR) with EMVI. PU1 (OR 0.8, 0.7-0.9) and low PDL1 (OR 1.6, 1.1-2.3) independently predicted EMVI on multivariate logistic regression among all biomarkers examined. CONCLUSION: There is a generalized blunting of immune response in EMVI positive colorectal carcinoma, which may contribute to a worse prognosis. Tumor-associated macrophages seem to play the most significant role in determining EMVI.

Impact of Bundled Payment Care Improvement Initiative on Health Care Expenditure in Major Bowel Procedures.

BACKGROUND: The Bundled Payments for Care Improvement initiative links payments for Medicare beneficiaries during an episode of care (90 days from index surgery). OBJECTIVE: This study aimed to determine whether major bowel participating Bundled Payments for Care Improvement organizations experience greater cost savings for colectomy while maintaining satisfactory quality outcomes compared to nonparticipating organizations. DESIGN: This is an Analysis of all Bundled Payments for Care Improvement participating hospitals for major bowel procedures (major bowel group) and propensity score-matched against Bundled Payments for Care Improvement organizations that do not include major bowel procedures (nonmajor bowel group) and those that do not participate in any Bundled Payments for Care Improvement program (non-Bundled Payments for Care Improvement group). SETTING: Programs accepting Medicare and Medicaid in the United States. PATIENTS: Patients included were major bowel cases in the Medicare Standard Analytic file within Medicare Severity Diagnosis-Related Groups 329-331 at participating facilities between January 1, 2011, and June 30, 2016. MAIN OUTCOME MEASURES: Main outcome measures included average total care expenditure and quality of care (length of stay, morbidity, and mortality) from 3 days preoperatively to 90 days postoperatively. RESULTS: We abstracted 7609 major bowel episodes from 23 major bowel group facilities, 21,872 episodes from nonmajor bowel-matched hospitals, and 19,383 episodes from non-Bundled Payments for Care Improvement-matched hospitals. From the baseline (January 2011 to June 2012) to final period (July 2015 to June 2016), we noted a $2955 average reduction in care expenditures. The largest decrease in average total episode expenditure occurred within the major bowel group (14% reduction) compared to the other groups (6% reduction for nonmajor bowel and 5% reduction for non-Bundled Payments for Care Improvement). Utilizing a generalized estimating equation to adjust for patient demographics, comorbidities, and hospital characteristics, the average total episode expenditure for the major bowel group decreased by $4885 (95% CI $4838-$4932; p < 0.001) compared to $2050 (95% CI $2038-$2061) for the non-Bundled Payments for Care Improvement group. All groups had similar reductions in length of stay, 30-day and 90-day complication rates, and readmission rates. LIMITATIONS: Analyses were limited by the retrospective nature of the study. CONCLUSIONS: Bundled Payments for Care Improvement participation for major bowel procedures resulted in a greater decrease in average total cost per episode of care than in nonparticipating hospitals without compromise in quality of care. See Video Abstract at http://links.lww.com/DCR/B837.IMPACTO DE LA INICIATIVA BUNDLED PAYMENT AGRUPADOS PARA LA MEJORA DE LA ATENCIÓN DEL GASTO SANITARIO EN LOS PROCEDIMIENTOS INTESTINALES MAYORESANTECEDENTES:La iniciativa de Bundled Payment para la mejora de la atención vincula los pagos para los beneficiarios de Medicare durante un episodio de atención (90 días desde la cirugía índice).OBJETIVO:Determinar si las principales organizaciones de Bundled Payment para el mejoramiento de la atención relacionados a los procedimientos intestinales experimentan mayores ahorros en los costos para una colectomía manteniendo resultados satisfactorios de calidad en comparación con las organizaciones no participantes.DISEÑO:Análisis de todos los hospitales participantes del programa Bundled Payment para la mejora de la atención para procedimientos intestinales mayores (grupo que incluyen procedimientos intestinales mayores) y puntaje de propensión comparado con las organizaciones que no incluyen dichos procedimientos (grupo que no incluye procedimientos intestinales mayores) y aquellos que no participan en ningún programa de Bundled Payment para la mejora de la atención (grupo no BPCI).MARCO:Programas que aceptan Medicare y Medicaid en los Estados Unidos.PACIENTES:Casos intestinales mayores en el archivo analítico estándar de Medicare dentro de los grupos relacionados con el diagnóstico 329-331 en los centros participantes entre el 1/1/2011-30/6/2016.PRINCIPALES MEDIDAS DE RESULTADO:Gasto total promedio y calidad de la atención (duración de la estadía, morbilidad, mortalidad) desde los 3 días preoperatorio hasta los 90 días postoperatorio.RESULTADOS:Hemos extraído 7609 episodios intestinales mayores de 23 instalaciones del grupo que incluyen procedimientos intestinales mayores, 21.872 episodios de hospitales del grupo que no incluyen procedimientos intestinales mayores y 19.383 episodios de hospitales del grupo no BPCI. Desde la línea de base (1/2011 - 6/2012) hasta el período final (7/2015 - 6/2016), notamos una reducción promedio de $2955 en los gastos de atención. La mayor disminución en el gasto promedio total por episodios ocurrió dentro del grupo que incluyen intestinales mayores (14% de reducción) en comparación con los otros grupos (6% de reducción para el grupo que no incluyen procedimientos intestinales mayores, 5% de reducción para el no BPCI). Utilizando una ecuación de estimación generalizada para ajustar los datos demográficos del paciente, las comorbilidades y las características del hospital, el gasto total promedio por episodio para el grupo que incluyen procedimientos intestinales mayores disminuyó en $ 4885 (IC del 95%: $4838-4932; p <0,001) en comparación con $2050 (IC del 95%: $2038-2061) para el grupo que no pertenece al programa BPCI. Todos los grupos tuvieron reducciones similares en la duración de la estancia, tasas de complicaciones de 30/90 días y de readmisión.LIMITACIONES:Análisis limitados por la naturaleza retrospectiva del estudio.CONCLUSIONES:La participación de Bundled Payment para la mejora de la atención en aquellos procedimientos intestinales mayores resultó en una disminución mayor en el costo total promedio por episodio de atención que en los hospitales no participantes, sin comprometer la calidad de la atención. Consulte Video Resumen en http://links.lww.com/DCR/B837. (Traducción-Dr Osvaldo Gauto).

Tumour genotypes account for survival differences in right- and left-sided colon cancers.

AIM: We sought to identify genetic differences between right- and left-sided colon cancers and using these differences explain lower survival in right-sided cancers. METHOD: A retrospective review of patients diagnosed with colon cancer was performed using The Cancer Genome Atlas, a cancer genetics registry with patient and tumour data from 20 North American institutions. The primary outcome was 5-year overall survival. Predictors for survival were identified using directed acyclic graphs and Cox proportional hazards models. RESULTS: A total of 206 right- and 214 left-sided colon cancer patients with 84 recorded deaths were identified. The frequency of mutated alleles differed significantly in 12 of 25 genes between right- and left-sided tumours. Right-sided tumours had worse survival with a hazard ratio of 1.71 (95% confidence interval 1.10-2.64, P = 0.017). The total effect of the genetic loci on survival showed five genes had a sizeable effect on survival: DNAH5, MUC16, NEB, SMAD4, and USH2A. Lasso-penalized Cox regression selected 13 variables for the highest-performing model, which included cancer stage, positive resection margin, and mutated alleles at nine genes: MUC16, USH2A, SMAD4, SYNE1, FLG, NEB, TTN, OBSCN, and DNAH5. Post-selection inference demonstrated that mutations in MUC16 (P = 0.01) and DNAH5 (P = 0.02) were particularly predictive of 5-year overall survival. CONCLUSIONS: Our study showed that genetic mutations may explain survival differences between tumour sites. Further studies on larger patient populations may identify other genes, which could form the foundation for more precise prognostication and treatment decisions beyond current rudimentary TNM staging.

Infiltrating Tumor Border Configuration is a Poor Prognostic Factor in Stage II and III Colon Adenocarcinoma.

INTRODUCTION: Tumor border configuration (TBC) is a prognostic factor in colorectal adenocarcinoma; however, the significance of TBC is not well-documented in colon adenocarcinoma alone. OBJECTIVE: Our aim was to study the effect of TBC on overall and disease-free survival in stage II and III colon adenocarcinoma. METHODS: We included patients with stage II and III colon adenocarcinoma who were surgically treated at a tertiary medical center between 2004 and 2015, to ensure long-term follow-up. Patients were stratified into four groups based on stage and TBC. A Cox regression was used to model the relationship of groups while accounting for relevant confounders. RESULTS: The cohort consisted of 700 patients (371 stage II and 329 stage III). Infiltrating TBC was statistically significantly associated with stage (p < 0.001) and extramural vascular invasion (p < 0.001), but not histologic grade (p = 0.7). Compared with pushing TBC, infiltrating TBC increased the hazard of death by a factor of 1.8 [95% confidence interval (CI) 1.4-2.4; p < 0.001] and 1.7 (95% CI 1.3-2.2; p < 0.001). The hazard of death in patients with stage II disease (infiltrating TBC) or stage III disease (pushing TBC) was not significantly different (adjusted hazard ratio 1.1, 95% CI 0.7-1.7; p = 0.8). CONCLUSION: Infiltrating TBC is a high-risk feature in patients with stage II and III colon adenocarcinoma. Stage II disease patients with infiltrating TBC and who are node-negative should be considered for adjuvant chemotherapy.

Improving staging of rectal cancer in the pelvis: the role of PET/MRI.

PURPOSE: The role of positron emission tomography/magnetic resonance (PET/MR) in evaluating the local extent of rectal cancer remains uncertain. This study aimed to investigate the possible role of PET/MR versus magnetic resonance (MR) in clinically staging rectal cancer. METHODS: This retrospective two-center cohort study of 62 patients with untreated rectal cancer investigated the possible role of baseline staging PET/MR versus stand-alone MR in determination of clinical stage. Two readers reviewed T and N stage, mesorectal fascia involvement, tumor length, distance from the anal verge, sphincter involvement, and extramural vascular invasion (EMVI). Sigmoidoscopy, digital rectal examination, and follow-up imaging, along with surgery when available, served as the reference standard. RESULTS: PET/MR outperformed MR in evaluating tumor size (42.5 ± 21.03 mm per the reference standard, 54 ± 20.45 mm by stand-alone MR, and 44 ± 20 mm by PET/MR, P = 0.004), and in identifying N status (correct by MR in 36/62 patients [58%] and by PET/MR in 49/62 cases [79%]; P = 0.02) and external sphincter infiltration (correct by MR in 6/10 and by PET/MR in 9/10; P = 0.003). No statistically significant differences were observed in relation to any other features. CONCLUSION: PET/MR provides a more precise assessment of the local extent of rectal cancers in evaluating cancer length, N status, and external sphincter involvement. PET/MR offers the opportunity to improve clinical decision-making, especially when evaluating low rectal tumors with possible external sphincter involvement.

Is Microsatellite Status Associated With Prognosis in Stage II Colon Cancer With High-Risk Features?

BACKGROUND: The influence of microsatellite instability on prognosis in high-risk stage II colon cancer is unknown. OBJECTIVE: This study aimed to investigate the relationship between microsatellite instability and overall survival in high-risk stage II colon cancer. DESIGN: This is a retrospective review of the National Cancer Database from 2010 to 2016. SETTINGS: This study included national cancer epidemiology data from the American College of Surgeons Commission on Cancer. PATIENTS: Included were 16,788 patients with stage II colon adenocarcinoma and known microsatellite status (1709 microsatellite unstable). MAIN OUTCOME MEASURES: The primary outcome measured was overall survival. RESULTS: Microsatellite unstable cancers with high-risk features had significantly better overall survival than microsatellite stable cancers with high-risk features (5-year survival 80% vs 72%, p = 0.01), and had survival equivalent to microsatellite stable cancers with low-risk features (5-year survival, 80%). When stratified by specific high-risk features, patients with lymphovascular invasion, perineural invasion, or high-grade histology had overall survival similar to patients without these features, only in microsatellite unstable cancers. However, patients with high-risk features of T4 stage, positive margins, and <12 lymph nodes saw no survival benefit based on microsatellite status. This was confirmed on multivariable Cox regression modeling. A subgroup analysis of patients who did not receive chemotherapy similarly demonstrated that microsatellite unstable cancers with lymphovascular invasion, perineural invasion, or high-grade histology had overall survival similar to microsatellite unstable cancers without those features. LIMITATIONS: The study is limited by the lack of specific clinical data and potential treatment bias. CONCLUSIONS: In microsatellite unstable cancers, lymphovascular invasion, perineural invasion, and high-grade histology are not associated with worse overall survival, even when deferring adjuvant chemotherapy. These data support National Comprehensive Cancer Network recommendations to forego chemotherapy in stage II cancers with microsatellite instability and these features. In contrast, some high-risk features were associated with worse survival despite microsatellite unstable biology, and therapies to improve survival need to be explored. See Video Abstract at http://links.lww.com/DCR/B500. ¿EL ESTADO MICROSATÉLITE ESTÁ ASOCIADO CON EL PRONÓSTICO EN EL CÁNCER DE COLON EN ESTADIO II CON CARACTERÍSTICAS DE ALTO RIESGO: Se desconoce la influencia de la inestabilidad microsatélite en el pronóstico del cáncer de colon en estadio II de alto riesgo.Investigar la relación entre la inestabilidad microsatélite y la supervivencia general en el cáncer de colon en estadio II de alto riesgo.Revisión retrospectiva de la base de datos nacional del cáncer de 2010 a 2016.Este estudio incluyó datos nacionales de epidemiología del cáncer de la Comisión de Cáncer del Colegio Americano de Cirujanos.16,788 pacientes con adenocarcinoma de colon en estadio II y estado microsatélite conocido (1,709 microsatélite inestables).Supervivencia global.Los cánceres microsatélite inestables con características de alto riesgo tuvieron una supervivencia general significativamente mejor que los cánceres microsatélite estables con características de alto riesgo (supervivencia a 5 años 80% vs 72%, p = 0.01), y tuvieron una supervivencia equivalente a los cánceres microsatélite estables con características de bajo riesgo (supervivencia a 5 años 80%). Al estratificar por características específicas de alto riesgo, los pacientes con invasión linfovascular, invasión perineural o histología de alto grado tuvieron una supervivencia general similar a la de los pacientes sin estas características, solo en cánceres microsatélite inestables. Sin embargo, los pacientes con características de alto riesgo en estadio T4, márgenes positivos y <12 ganglios linfáticos no tuvieron ningún beneficio de supervivencia basado en el estado de microsatélites. Esto se confirmó en un modelo de regresión de Cox multivariable. Un análisis de subgrupos de pacientes que no recibieron quimioterapia demostró de manera similar que los cánceres microsatélite inestables con invasión linfovascular, invasión perineural o histología de alto grado tenían una supervivencia general similar a los cánceres microsatélite inestables sin esas características.El estudio está limitado por la falta de datos clínicos específicos y el posible sesgo de tratamiento.En los cánceres microsatélite inestables, la invasión linfovascular, la invasión perineural y la histología de alto grado no se asocian con una peor sobrevida general, incluso cuando se aplaza la quimioterapia adyuvante. Estos datos respaldan las recomendaciones de la National Comprehensive Cancer Network de omitir la quimioterapia en los cánceres en estadio II con inestabilidad microsatélite y estas características. Por el contrario, algunas características de alto riesgo se asociaron con una peor supervivencia a pesar de la biología microsatélite inestable, y es necesario considerar las terapias para mejorar la supervivencia.Consulte Video Resumen en http://links.lww.com/DCR/B500. (Traducción-Dr. Jorge Silva Velazco).

Diverticular Disease Epidemiology: Rising Rates of Diverticular Disease Mortality Across Developing Nations.

BACKGROUND: The incidence of diverticular disease is growing in the Western world. However, the global burden of disease is unknown in the developing world. OBJECTIVE: This study aimed to determine the global burden of diverticular disease as measured by disease-specific mortality while identifying indicators of rising disease rates. DESIGN: We undertook an ecological analysis based on data from the World Health Organization Mortality Database. Then, we analyzed global age-adjusted mortality rates from diverticular disease and compared them to national rates of overweight adults, health expenditures, and dietary composition. SETTINGS: National vital statistics data were collected. PATIENTS: Diverticular disease deaths from January 1, 1994 through December 31, 2016 were evaluated. MAIN OUTCOME MEASURES: The primary outcome measured was the national age-adjusted mortality rate. RESULTS: The average age-adjusted mortality rate for diverticular disease was 0.51 ± 0.31/100,000 with a range of 0.11 to 1.75/100,000. During the study period, we noted that 57% of nations had increasing diverticular disease mortality rates, whereas only 7% had decreasing rates. More developed nations (40%) than developing nations (24%) were categorized as having high diverticular disease mortality burden over the time period of the study, and developed nations had higher percentages of overweight adults (58.9 ± 3.1%) than developing nations (50.6 ± 6.7%; p < 0.0001). However, developing nations revealed more rapid increases in diverticular disease mortality (0.027 ± 0.024/100,000 per year) than developed nations (0.005 ± 0.025/100,000 per year; p = 0.001), as well as faster expanding proportions of overweight adults (0.76 ± 0.12% per year) than in already developed nations (0.53 ± 0.10% per year; p<0.0001). LIMITATIONS: Ecological studies cannot define cause and effect. CONCLUSIONS: There is considerable variability in diverticular disease mortality across the globe. Developing nations were characterized by rapid increases in diverticular disease mortality and expanding percentages of overweight adults. Public health interventions in developing nations are needed to alter mortality rates from diverticular disease. See Video Abstract at http://links.lww.com/DCR/B397. EPIDEMIOLOGÍA DE LA ENFERMEDAD DIVERTICULAR: TASAS CRECIENTES DE MORTALIDAD POR ENFERMEDAD DIVERTICULAR EN LOS PAÍSES EN DESARROLLO: La incidencia de la enfermedad diverticular está creciendo en el mundo occidental. Sin embargo, la carga mundial de la enfermedad es desconocida en el mundo en desarrollo.Determinar la carga global de la enfermedad diverticular medida por la mortalidad específica de la enfermedad mientras se identifican los indicadores de aumento de las tasas de enfermedad.Realizamos un análisis ecológico basado en datos de la Base de datos de mortalidad de la Organización Mundial de la Salud. Luego, analizamos las tasas globales de mortalidad ajustadas por edad por enfermedad diverticular y las comparamos con las tasas nacionales de adultos con sobrepeso, gastos de salud y composición dietética.Datos nacionales de estadísticas vitales.Muertes por enfermedades diverticulares desde el 1 de enero de 1994 hasta el 31 de diciembre de 2016.Tasa nacional de mortalidad ajustada por edad.La tasa promedio de mortalidad ajustada por edad para la enfermedad diverticular fue de 0,51 ± 0,31 / 100,000 con un rango de 0,11 a 1,75 / 100,000. Durante el período de estudio, notamos que el 57% de las naciones tenían tasas crecientes de mortalidad por enfermedades diverticulares, mientras que solo el 7% tenían tasas decrecientes. Las naciones más desarrolladas (40%) que las naciones en desarrollo (24%) se clasificaron como que tienen una alta carga de mortalidad por enfermedad diverticular durante el período de tiempo del estudio, y las naciones desarrolladas tuvieron porcentajes más altos de adultos con sobrepeso (58.9 ± 3.1%) que las naciones en desarrollo (50,6 ± 6,7%) (p <0,0001). Sin embargo, las naciones en desarrollo revelaron aumentos más rápidos en la mortalidad por enfermedades diverticulares (0.027 ± 0.024 / 100,000 por año) que las naciones desarrolladas (0.005 ± 0.025 / 100,000 por año) (p = 0.001), así como proporciones de adultos con sobrepeso en expansión más rápida (0.76 ± 0.12% por año) que en las naciones ya desarrolladas (0.53 ± 0.10% por año) (p <0.0001).Los estudios ecológicos no pueden definir causa y efecto.Existe una considerable variabilidad en la mortalidad por enfermedad diverticular en todo el mundo. Los países en desarrollo se caracterizaron por un rápido aumento en la mortalidad por enfermedades diverticulares y porcentajes crecientes de adultos con sobrepeso. Se necesitan intervenciones de salud pública en los países en desarrollo para alterar las tasas de mortalidad por enfermedad diverticular. Consulte Video Resumen en http://links.lww.com/DCR/B397.

Ten-year survival after pathologic complete response in rectal adenocarcinoma.

BACKGROUND: Multimodal treatment is the standard of care for rectal adenocarcinoma, with a subset of patients achieving a pathologic complete response (pCR). While pCR is associated with improved overall survival (OS), long-term data on patients with pCR is limited. METHODS: This is a single institution retrospective cohort study of all patients with clinical stages II/III rectal adenocarcinoma who underwent neoadjuvant chemoradiation therapy and operative resection (January 1, 2004-December 31, 2017). PCR was defined as no tumor identified in the rectum or associated lymph nodes by final pathology. RESULTS: Of 370 patients in this cohort, 50 had a pCR (13.5%). For pCR patients, 5-year disease-free survival (DFS) was 92%, 5-year OS was 95%. Twenty-six patients had surgery > 10 years before the study end date, of which 20 had an OS > 10 years (77%) with median OS 12.1 years and 95% alive to date (19/20). Of the 50 pCR patients, there was a single recurrence in the lung at 44.3 months after proctectomy which was surgically resected. CONCLUSION: For patients with rectal adenocarcinoma that undergo neoadjuvant chemoradiation and surgical resection, pCR is associated with excellent long-term DFS and OS. Many patients live greater than 10 years with no evidence of disease recurrence.

The growing trend for no primary surgery in colorectal cancer.

AIM: In colorectal cancer (CRC), surgery of the primary site is commonly curative. Our aim was to determine estimates of 'no surgery' for primary CRC while identifying common reasons for no surgery. METHOD: We identified all patients with a diagnosis of colorectal adenocarcinoma from the National Cancer Database between January 2004 and December 2016. Then, we identified patients who did not undergo surgery on the primary tumour and their demographic, tumour and institutional characteristics. Kaplan-Meier and logistic regression analyses were used to evaluate specific factors associated with overall survival as related to no surgery and recommendations against operative management. RESULTS: A total of 1,208,878 patients with CRC were identified, 14.5% of whom had no surgery of the primary cancer. No surgery was more common in rectal cancer than in colon cancer. Despite a steady incidence of CRC diagnoses, the likelihood of no surgery grew by 170% over the study period. Metastatic disease was noted in 53.7% of the no surgery cohort. Nine per cent of the no surgery patient cohort received a recommendation against surgery despite the absence of metastatic disease, 7.5% refused surgery and only 2% underwent palliative surgery. On multivariable analysis, patients who were not recommended to have surgery were more likely to be older, uninsured, comorbid and receive care at a single hospital. The no surgery patients had significantly lower overall survival. CONCLUSION: A substantial proportion of patients with CRC do not have surgery. Interventions aimed at expanding access and promoting second opinions at other cancer hospitals might reduce the growing rate of no surgery in CRC.

We Asked the Experts: The WHO Surgical Safety Checklist and the COVID-19 Pandemic: Recommendations for Content and Implementation Adaptations.

BACKGROUND: As surgical systems are forced to adapt and respond to new challenges, so should the patient safety tools within those systems. We sought to determine how the WHO SSC might best be adapted during the COVID-19 pandemic. METHODS: 18 Panelists from five continents and multiple clinical specialties participated in a three-round modified Delphi technique to identify potential recommendations, assess agreement with proposed recommendations and address items not meeting consensus. RESULTS: From an initial 29 recommendations identified in the first round, 12 were identified for inclusion in the second round. After discussion of recommendations without consensus for inclusion or exclusion, four additional recommendations were added for an eventual 16 recommendations. Nine of these recommendations were related to checklist content, while seven recommendations were related to implementation. CONCLUSIONS: This multinational panel has identified 16 recommendations for sites looking to use the surgical safety checklist during the COVID-19 pandemic. These recommendations provide an example of how the SSC can adapt to meet urgent and emerging needs of surgical systems by targeting important processes and encouraging critical discussions.

Special Considerations of Anastomotic Leak in Patients with Rectal Cancer.

Anastomotic leak in patients with rectal cancer has the potential to cause worse oncologic outcomes in addition to major morbidity and mortality risk of this dreaded complication. Anatomic location of the rectal cancer determines the ability to perform a restorative operation and the height of the anastomosis in relation to the anal canal. Clinical staging dictates the need for neoadjuvant treatment (such as chemotherapy and radiation) which may also contribute to anastomotic leak risk. In addition to oncologic outcomes, anastomotic leak can impact bowel function, the need for permanent stoma, and long-term quality of life. This study will discuss special considerations for anastomotic leak prevention and clinical implications of this complication in patients with rectal cancer.

Sessile Serrated Polyposis: Not an Inherited Syndrome?

BACKGROUND: Researchers are searching in vain for a coherent genetic explanation for serrated polyposis. We hypothesize that there is no consistent monogenetic inheritance. OBJECTIVE: The purpose of this study was to describe the serrated polyposis phenotype, assessing features of mendelian inheritance, and to compare these features with patients with a solitary sessile serrated lesion. DESIGN: This was a retrospective review of a prospectively maintained database comparing patients with serrated polyposis versus solitary sessile serrated lesions. SETTINGS: The study was conducted at a single-institution tertiary referral center. PATIENTS: Patients with serrated polyposis meeting World Health Organization criteria type I (≥5 serrated polyps proximal to the sigmoid, ≥2 of which are ≥10 mm in diameter) and isolated sessile serrated lesions were included MAIN OUTCOME MEASURES:: Disease phenotype was the main outcome measured. RESULTS: A total of 46 serrated polyposis patients were identified. Median age of first sessile serrated lesion was 66 years (interquartile range, 42-70 y). A total of 60.3% were current or past smokers (mean = 38.6 packs per year). Serrated polyposis patients had a higher number of all types of polyps (26.3 vs 4.4) and a higher rate of high-grade dysplasia (19.6% vs 3.7%) compared with patients with a solitary sessile serrated lesion. A total of 36.2% of patients had personal history of noncolorectal cancers, including skin, prostate, breast, thyroid, and renal cell cancers and leukemia. In addition, 32.6% had a family history of colorectal cancer in first- or second-degree relatives; these cancers were not young age of onset. Breast and prostate cancers were also common (family history of any cancer, 83.0%). Ten patients underwent genetic testing: 4 had negative panels, 1 had a pathogenic variant in MSH2, 1 an IVS7 deletion in PTEN, 2 negative APC sequencing (1 negative MYH), and 1 a pathogenic variant in Chek2. LIMITATIONS: RNF4 was not sequenced. Genetic analysis was performed on a subset of patients. CONCLUSIONS: The rate of associated cancers suggests an underlying genetic predisposition to disordered growth, but serrated polyposis does not have typical features of dominant inheritance. The association with smoking suggests that familial/environmental factors play a role. See Video Abstract at http://links.lww.com/DCR/B84. POLIPOSIS SERRADA SÉSIL: ¿NO ES UN SÍNDROME HEREDITARIO?: Los investigadores están buscando en vano una explicación genética coherente para la póliposis serrados. Suponemos que no existe una herencia monogenética consistente.1) Describir el fenotipo de póliposis serrada, evaluando las características de la herencia mendeliana, 2) comparar estas características con pacientes con una lesión serrada sésil solitaria.Revisión retrospectiva de una base de datos mantenida prospectivamente que compara pacientes con póliposis serrada versus lesiones serradas sésiles solitarias.Institución única, centro de referencia terciario.Pacientes con póliposis serrada que cumplen con los Criterios de la Organización Mundial de la Salud Tipo I (≥ 5 pólipos serrados proximales al sigmoideo, ≥2 de los cuales tienen ≥10 mm de diámetro) y lesiones serradas sésiles aisladas.Fenotipo de la enfermedad.Se identificaron un total de 46 pacientes con póliposis serrada. La edad mediana de la primera lesión serrada sésil fue de 66 años (RIC: 42-70 años). El 60.3% eran fumadores actuales o pasados (medio 38.6 paquetes / año). Los pacientes con póliposis serrada tuvieron un mayor número de todos los tipos de pólipos (26.3 versus 4.4) y una mayor tasa de displasia de alto grado (19.6% versus 3.7%) en comparación con los pacientes con una lesión serrada sésil solitaria. El 36.2% de los pacientes tenían antecedentes personales de cánceres no colorectales, incluyendo los cánceres de piel, próstata, mama, tiroides, células renales y leucemia. El 32.6% tenía antecedentes familiares de cáncer colorectal en familiares de primer o segundo grado; estos cánceres no eran de inicio de edad temprana. El cáncer de mama y próstata también fue frecuente (antecedentes familiares de cualquier tipo de cáncer: 83.0%). 10 pacientes se sometieron a pruebas genéticas: 4 tenían paneles negativos, 1 tenía una variante patogénica en MSH2, 1 una eliminación IVS7 en PTEN, 2 secuenciación APC negativa (1 MYH negativa) y 1 variante patogénica en Chek2.RNF4 no fue secuenciado. El análisis genético se realizó en un subconjunto de pacientes.La tasa de cánceres asociados sugiere una predisposición genética subyacente al crecimiento desordenado, pero la póliposis serrada no tiene características típicas de herencia dominante. La asociación con el tabaquismo sugiere que los factores familiares / ambientales juegan un papel. Consulte Video Resumen en http://links.lww.com/DCR/B84. (Traducción-Dr. Yesenia Rojas-Khalil).

Prospective Creation and Validation of the PREVENTT (Prediction and Enaction of Prevention Treatments Trigger) Scale for Surgical Site Infections (SSIs) in Patients With Diverticulitis.

OBJECTIVE: Create and validate diverticulitis surgical site infection prediction scale. BACKGROUND: Surgical site infections cause significant morbidity after colorectal surgery. An infection prediction scale could target infection prevention bundles to high-risk patients. METHODS: Prospectively collected National Surgical Quality Improvement Program and electronic medical record data obtained on diverticulitis colectomy patients across a Healthcare Network-wide Colorectal Surgery Collaborative (5 hospitals). Patients with and without surgical site infections were compared. Predictive variables were identified using logistic regression model; model estimates obtained through 1000 bootstrap replications for scale validation. RESULTS: A total of 1737 colectomies were performed (2010-2016): mean age 59.9 years (SD 12.7), 56.4% female; 93.4% Caucasian; smokers 16.3%, diabetics 7.7%, steroid use 6.0%. Two hundred thirty-one (13.3%) were presented to operating room emergently and 138 (7.9%) with abscess at time of disease admission. Two hundred ninety-six patients underwent Hartman procedures, and 113 (6.5%) received diverted primary anastomosis. Average length of stay was 6.9 days (standard deviation 7.01), 30-day mortality was 1.5%, anastomotic leak rate was 3.1%. Twenty-one percent of patients (n = 366) developed a surgical site infection. Several predictors for infection were identified: obesity (body mass index >30), advanced age (>70 years), diabetes mellitus, preoperative abscess, open surgery, emergent operations, and prolonged operations (>3 h). Creation of protected anastomosis in emergent settings was associated with increased infection rates. Presence of more than 5 risk factors was associated with infection rates of 45.8% (c = 0.69). CONCLUSIONS: Patients with diverticulitis have high surgical site infection rates due to nonmodifiable risk factors. Our Prediction and Enaction of Prevention Treatments Trigger scale can risk stratify patients for targeting surgical site infection prevention bundles and outcomes risk adjustments.

The Effect of Surgical Training and Operative Approach on Outcomes in Acute Diverticulitis: Should Guidelines Be Revised?

BACKGROUND: Current guidelines accept partial colectomy and primary anastomosis with proximal diversion for select patients with perforated diverticulitis based on low-quality evidence. OBJECTIVE: This study aimed to compare the effect of operative approach and surgeon training on outcomes following urgent/emergent colectomy for diverticulitis. DESIGN: This is a statewide retrospective cohort study. SETTING: Data were obtained from the New York State all-payer sample from 2000 to 2014. PATIENTS: All patients who underwent an urgent/emergent sigmoid colectomy for diverticulitis with creation of an end colostomy or primary anastomosis with proximal diversion were included. We excluded all patients age <18 years, with IBD, colorectal cancer, ischemic colitis, or elective operations. MAIN OUTCOME MEASURES: The main outcomes measured were postoperative in-hospital mortality and complications, RESULTS:: A total of 10,780 patients underwent urgent/emergent colectomy for diverticulitis: 10,600 (98.3%) received a Hartmann procedure and 180 (1.7%) received primary anastomosis with proximal diversion. Colorectal surgeons performed 6.0% of all operations. Utilization of primary anastomosis with proximal diversion was greater among colorectal surgeons but remained low overall (4.2% vs 1.5%; p < 0.001). Postoperative mortality was 2-fold greater when noncolorectal surgeons performed primary anastomosis vs Hartmann procedure (15% vs 7.4%; p < 0.001) and 1.4 times greater among noncolorectal surgeons than among colorectal surgeons (7.5% vs 5.3%; p = 0.04). On multivariable logistic regression (adjusting for patient demographics/characteristics, year, hospital academic status, and surgeon training) primary anastomosis with proximal diversion remained associated with increased mortality (OR, 2.7; 95% CI,1.7-4.4; p < 0.001), complications (OR, 1.8; 95% CI, 1.3-2.5; p < 0.001), and reoperation (OR, 3.4; 95% CI, 1.8-6.3; p < 0.001), whereas colorectal board certification was associated with decreased mortality (OR, 0.66; 95% CI, 0.46-0.95; p = 0.03). LIMITATIONS: Selection bias secondary to retrospective nature and absence of disease severity were limitations of this study. CONCLUSIONS: Despite current recommendations for primary anastomosis with proximal diversion for perforated diverticulitis, this operation in New York State was associated with increased postoperative morbidity and mortality when performed by general surgeons. Given that the majority of urgent/emergent colectomies for diverticulitis are not performed by colorectal surgeons, guidelines for operative management of perforated diverticulitis should be reevaluated. See Video Abstract at http://links.lww.com/DCR/A772.