Mental health disorders as a risk factor in young patients with rectal prolapse.

BACKGROUND: Rectal prolapse (RP) typically presents in the elderly, though it can present in younger patients lacking traditional risk factors. The current study compares medical and mental health history, presentation, and outcomes for young and older patients with RP. METHODS: This is a single-center retrospective review of patients who underwent abdominal repair of RP between 2005 and 2019. Individuals were dichotomized into two groups based on age greater or less than 40 years. RESULTS: Of 156 patients, 25 were < 40. Younger patients had higher rates of diagnosed mental health disorders (80% vs 41%, p < 0.001), more likely to take SSRIs (p = .02), SNRIs (p = .021), anxiolytics (p = 0.033), and antipsychotics (p < 0.001). Younger patients had lower preoperative incontinence but higher constipation. Both groups had low rates of recurrence (9.1% vs 11.6%, p = 0.73). CONCLUSIONS: Young patients with RP present with higher concomitant mental health diagnoses and represent unique risk factors characterized by chronic straining compared to pelvic floor laxity.

Impact of neoadjuvant chemotherapy for locally advanced colon cancer on postoperative complications.

PURPOSE: Although not considered standard therapy, neoadjuvant chemotherapy (NAC) is an encouraging alternative for selected patients with locally advanced colon cancer (LAC). The aim of this study was to compare 30-day postoperative outcomes between patients undergoing upfront surgery and those undergoing NAC for LAC. METHODS: Using the ACS-NSQIP data from 2016 to 2020, 11,498 patients with LAC were divided into those who underwent upfront colectomy (96.2%) and those who received NAC (3.8%). The primary outcome was a composite outcome encompassing 30-day major postoperative complications. Propensity score matched (PSM) analysis and multivariable logistic regression were performed. RESULTS: After PSM analysis, there was no statistically significant difference in the development of a major complication. NAC was not significantly associated with the primary outcome. Risk factors for postoperative complications were T4 stage, older age, male sex, black race, smoking, dependent status, severe COPD, hypoalbuminemia, and preoperative transfusion. Laparoscopic and robotic surgery was protective. CONCLUSION: NAC did not increase the odds of developing a major complication.

Immunohistochemical analysis of Tn antigen expression in colorectal adenocarcinoma and precursor lesions.

BACKGROUND: The Tn antigen (CD175) is an O-glycan expressed in various types of human adenocarcinomas, including colorectal cancer (CRC), though prior studies have relied heavily upon poorly characterized in-house generated antibodies and lectins. In this study, we explored Tn expression in CRC using ReBaGs6, a well-characterized recombinant murine antibody with high specificity for clustered Tn antigen. METHODS: Using well-defined monoclonal antibodies, expression patterns of Tn and sialylated Tn (STn) antigens were characterized by immunostaining in CRC, in matched peritumoral [transitional margin (TM)] mucosa, and in normal colonic mucosa distant from the tumor, as well as in adenomas. Vicia villosa agglutinin lectin was used to detect terminal GalNAc expression. Histo-scoring (H scoring) of staining was carried out, and pairwise comparisons of staining levels between tissue types were performed using paired samples Wilcoxon rank sum tests, with statistical significance set at 0.05. RESULTS: While minimal intracellular Tn staining was seen in normal mucosa, significantly higher expression was observed in both TM mucosa (p < 0.001) and adenocarcinoma (p < 0.001). This pattern was reflected to a lesser degree by STn expression in these tissue types. Interestingly, TM mucosa demonstrates a Tn expression level even higher than that of the adenocarcinoma itself (p = 0.019). Colorectal adenomas demonstrated greater Tn and STn expression relative to normal mucosa (p < 0.001 and p = 0.012, respectively). CONCLUSIONS: In summary, CRC is characterized by alterations in Tn/STn antigen expression in neoplastic epithelium as well as peritumoral benign mucosa. Tn/STn antigens are seldom expressed in normal mucosa. This suggests that TM mucosa, in addition to CRC itself, represents a source of glycoproteins rich in Tn that may offer future biomarker targets.

Dose-Intensified Infliximab Rescue Therapy for Severe Ulcerative Colitis Does Not Reduce Short-term Colectomy Rates or Increase Postoperative Complications.

BACKGROUND: Dose-intensified rescue therapy with infliximab for hospitalized patients with ulcerative colitis has become increasingly popular in recent years. However, there is ongoing debate about both the efficacy of these regimens to reduce the rate of colectomy and the associated risks of increased infliximab exposure. OBJECTIVE: The purpose of this study was to compare the colectomy and postoperative complication rates in hospitalized patients with severe ulcerative colitis receiving standard infliximab induction therapy (3 doses of 5 mg/kg at weeks 0, 2, and 6) and dose-intensified regimens including a higher weight-based dosing or more rapid interval. DESIGN: This was a retrospective cohort study. SETTINGS: This study was conducted at an academic tertiary care hospital. PATIENTS: A total of 145 adult patients received inpatient rescue infliximab therapy for the treatment of ulcerative colitis between 2008 and 2020. MAIN OUTCOME MEASURES: The primary outcome was colectomy rate within 3 months of rescue therapy. Secondary outcomes include mid-term colectomy rates, as well as perioperative complications in patients receiving colectomy within 3 months of rescue infliximab initiation. RESULTS: The proportion of dose-intensified regimens increased over time. Unadjusted 3-month colectomy rates were 14% in patients who received standard rescue infliximab dosing, 16% in patients given a single dose-escalated dose, and 24% in patients given multiple inpatient dose-escalated doses. These rates were not statistically significantly different. Of the patients requiring colectomy within 3 months of infliximab rescue, those who received multiple inpatient doses of dose-escalated therapy had a higher percentage of colectomy during the initial hospitalization but a lower rate of perioperative complications. LIMITATIONS: This study was limited by the use of retrospective data and the limited power to account for the heterogeneity of disease. CONCLUSIONS: No significant difference was found in colectomy rates between patients receiving standard or dose-intensified regimens. However, dose-intensified regimens, including multiple inpatient doses given to patients with more severe disease, were not associated with a greater risk of perioperative complications. See Video Abstract at http://links.lww.com/DCR/B864 . LA TERAPIA DE RESCATE CON DOSIS INTENSIFICADA DE INFLIXIMAB EN COLITIS ULCEROSA GRAVE NO REDUCE LAS TASAS DE COLECTOMA A CORTO PLAZO NI AUMENTA LAS COMPLICACIONES POSOPERATORIAS: ANTECEDENTES:La terapia de rescate de dosis intensificada con infliximab para pacientes hospitalizados con colitis ulcerosa se ha vuelto cada vez más popular en los últimos años. Sin embargo, existe un debate en curso sobre la eficacia de estos regímenes para reducir la tasa de colectomía y los riesgos asociados a una mayor exposición al infliximab.OBJETIVO:El propósito de este estudio fue comparar las tasas de colectomía y complicaciones posoperatorias en pacientes hospitalizados con colitis ulcerosa grave que recibieron terapia estándar de inducción de infliximab (3 dosis de 5 mg/kg en las semanas 0, 2, 6) y regímenes de dosis intensificada que incluyen una dosificación más alta basada en el peso o intervalo más rápido.DISEÑO:Fue un estudio de cohorte retrospectivo.ENTORNO CLÍNICO:Este estudio se realizó en un hospital académico de tercer nivel.PACIENTES:Un total de 145 pacientes adultos que recibieron terapia de rescate con infliximab para el tratamiento de la colitis ulcerosa entre 2008 y 2020.PRINCIPALES MEDIDAS DE VALORACIÓN:El resultado principal fue la tasa de colectomía dentro de los 3 meses posteriores a la terapia de rescate. Los resultados secundarios incluyen tasas de colectomía a mediano plazo, así como las complicaciones perioperatorias en pacientes que reciben colectomía dentro de los 3 meses posteriores al inicio de infliximab de rescate.RESULTADOS:La proporción de regímenes de dosis intensificada aumentó con el tiempo. Las tasas de colectomía de 3 meses no ajustadas fueron del 14% en los pacientes que recibieron dosis estándar de infliximab de rescate, del 16% en los pacientes que recibieron una dosis única escalonada y del 24% en los pacientes que recibieron múltiples dosis hospitalarias escalonadas. Estas tasas no fueron estadísticamente significativas. De los pacientes que requirieron colectomía dentro de los 3 meses posteriores al rescate de infliximab, aquellos que recibieron terapia de múltiples dosis hospitalarias escalonadas tuvieron un mayor porcentaje de colectomía durante la hospitalización inicial pero una menor tasa de complicaciones perioperatorias.LIMITACIONES:Datos retrospectivos y poder limitado para explicar la heterogeneidad de la enfermedad.CONCLUSIONES:No se encontraron diferencias significativas en las tasas de colectomía entre los pacientes que recibieron regímenes estándar o de dosis intensificada. Sin embargo, los regímenes de dosis intensificadas, incluidas múltiples dosis hospitalarias administradas a pacientes con enfermedad más grave, no se asociaron con un mayor riesgo de complicaciones perioperatorias. Consulte Video Resumen en http://links.lww.com/DCR/B864 . (Traducción-Dr. Ingrid Melo ).

Disparities in industry funding among Colorectal Surgeons: a cross-sectional study.

BACKGROUND: Health Industry and physician collaboration generates innovation. Colorectal Surgeon (CRS) selection to collaborate might not be random. We aim to identify CRS personal and professional characteristics that facilitate collaboration with the Industry. METHOD: Cross-sectional study of Industry payments to CRS (2014-2018) using Open Payments Database from Centers for Medicare & Medicaid Services. Multivariable regression compared variables predicting payment amount including gender, years in practice, leadership positions, H-index, Twitter presence and geographic location. RESULTS: Surgeons who were male received 3.1 times the amount in Industry payments as compared to females (p = 0.014). Chairs and Division Chiefs received 2.7 times the amount in payments as compared to those without these leadership positions (p = 0.003). Surgeons with an H-index ≥ 8 received 2.2 times the amount in payments as compared to those with H-index < 8 (p = 0.001). Surgeons in practice for 12-19 and 20-30 years received 3 times and 4.4 times the amount in payments as compared to surgeons in practice for 1-11 years (p = 0.036 and p = 0.017, respectively). Surgeons in the South received 3.2 times and 2 times the amount in payments as compared to surgeons in the Northeast (p < 0.0005) and in the Midwest (p = 0.006). Surgeons with Twitter accounts received 1.7 times the amount in payments as compared to surgeons without Twitter (p = 0.036). Among Twitter users, those with 321-17,200 followers received 4.7 times and 9.5 times the amount in payments as compared to those with 0-15 and 16-79 followers, respectively (p = 0.008 and p = 0.009). CONCLUSION: Industry payments are more commonly addressed to male, senior surgeons in leadership tracks with strong social media outreach. With the increasing gender and racial variety in the CRS field, it is expected that collaborations between industry and surgeons will become more diverse and inclusive.

Preventable Emergency Department Visits After Colorectal Surgery.

BACKGROUND: The emergency department plays a common and critical role in the treatment of postoperative patients. However, many quality improvement databases fail to record these interactions. As such, our understanding of the prevalence and etiology of postoperative emergency department visits in contemporary colorectal surgery is limited. Visits with potentially preventable etiologies represent a significant target for quality improvement, particularly in the current era of rapidly evolving postoperative and ambulatory care patterns. OBJECTIVE: We aimed to characterize postoperative emergency department visits and identify factors associated with these visits for potential intervention. DESIGN: This was a retrospective cohort study. SETTINGS: The study was conducted at an academic medical center. PATIENTS: Consecutive patients undergoing colectomy or proctectomy within the division of colorectal surgery at an academic medical center between 2014 and 2018 were included. MAIN OUTCOME MEASURES: Frequency and indication for emergency department visits, as well as clinical and sociodemographic factors associated with emergency department visits in the postoperative period, were included measures. RESULTS: From the 1763 individual operations, there were 207 emergency department visits from 199 patients (11%) within 30 days of discharge. Two thirds of emergency department visits led to readmission. Median (interquartile range) time to presentation was 8 days (4-16 d). Median time in the emergency department was 7.8 hours (6.0-10.1 h). One third of visits were identified as potentially preventable, most commonly for pain (17%) and stoma complications (excluding dehydration; 13%). A primary language other than English was associated with any postoperative emergency department visit risk ratio of 2.7 (95% CI, 1.3-5.3), as well as a preventable visit risk ratio of 3.6 (95% CI, 1.7-8.0). LIMITATIONS: This was a single-center study and a retrospective review. CONCLUSIONS: One third of emergency department visits after colorectal surgery are potentially preventable. Special attention should be directed toward those patients who do not speak English as a primary language. See Video Abstract at http://links.lww.com/DCR/B648. SE PUEDEN EVITAR LAS VISITAS AL SERVICIO DE URGENCIA DESPUS DE UNA CIRUGA COLORECTAL: ANTECEDENTES:Las unidades de emergencia tienen un rol fundamental en el periodo posterior a una cirugía. Sin embargo muchos de los registros en las bases de datos de estas secciones no son de buena calidad. Por esto analizar la prevalencia y etiología de las visitas postoperatorias en cirugía colorectal resulta ser bastante limitada. Para lograr una mejoría en la calidad es fundamental analizar las causas potencialmente evitables, especialmente al considerer la rapida evolucion de los parametros de medición actuales.OBJETIVO:Nuestro objetivo es caracterizar las visitas postoperatorias al servicio de urgencias e identificar los factores asociados potencialmente evitables.DISEÑO:Estudio de cohorte retrospectivo.AJUSTE:Centro médico académico, 2014-2018.PACIENTES:Pacientes consecutivos sometidos a colectomía o proctectomía dentro de la división de cirugía colorrectal en un centro médico académico entre 2014 y 2018.PRINCIPALES MEDIDAS DE RESULTADO:Frecuencia e indicación de las visitas al servicio de urgencias en el period postoperatorio: factores clínicos y sociodemográficos.RESULTADOS:De 1763 operaciones individuales, hubo 207 visitas al departamento de emergencias de 199 pacientes (11%) en los 30 días posteriores al alta. Dos tercios de las visitas al servicio de urgencias dieron lugar a readmisiones. La mediana [rango intercuartílico] de tiempo hasta la presentación fue de 8 [4-16] días. La mediana de tiempo en el servicio de urgencias fue de 7,8 [6-10,1] horas. Un tercio de las visitas se identificaron como potencialmente evitables, más comúnmente dolor (17%) y complicaciones del estoma (excluida la deshidratación) (13%). En los pacientes con poco manejo del inglés se asoció con una mayor frecuencia razón de visitas al departamento de emergencias posoperatorias [IC del 95%] 2,7 [1,3-5,3], así como opetancialmente evitables con un RR de 3,6 [1,7-8,0].LIMITACIONES:Estudio de un solo centro y revisión retrospectiva.CONCLUSIÓN:Al menos un tercio de las visitas al servicio de urgencias después de una cirugía colorrectal son potencialmente evitables. Se debe prestar especial atención a los pacientes que no hablan inglés como idioma materno. Consulte Video Resumen en http://links.lww.com/DCR/B648.

Incisional Hernias After Major Abdominal Operations: Analysis Within a Large Health Care System.

BACKGROUND: This will be the largest multi-institutional study looking at incidence of and duration to symptomatic hernia formation for major abdominal operations separated by malignant and benign disease process. METHODS: An IRB-approved retrospective study within the MedStar Hospital database was conducted, incorporating all isolated colectomy, hepatectomy, pancreatectomy, and gastrectomy procedures between the years 2002 and 2016. All patients were identified using ICD-9 and ICD-10 codes for relevant procedures, and then separated based on malignant or benign etiology. The rate of symptomatic incisional hernia rates was determined for each cohort based on subsequent hernia procedural codes identified. RESULTS: During this 15-year span, a total of 6448 major abdominal operations were performed at all 10 institutions, comprising 3835 colectomies, 1122 hepatectomies, 1165 pancreatectomies, and 326 gastrectomies. Total incidence of symptomatic incisional hernia occurrence requiring repair was 325 (5.0%). Separated by group, the overall incisional hernia repair rates for patients undergoing colectomy, hepatectomy, pancreatectomy, and gastrectomy are as follows, respectively: 6.4% (247), 2.5% (28), 3.6% (42), and 2.8% (9), P < 0.0001. The subsequent median duration to hernia repair was 498 d (interquartile range [IQR]: 312-924) for colectomy, 421 d (IQR: 340-518) for hepatectomy, 378 d (IQR: 284-527) for pancreatectomy, and 630 d (IQR: 419-1204) for gastrectomy (P = 0.03401). CONCLUSIONS: Symptomatic incisional hernia repair rates after major gastrointestinal and hepatobiliary surgery range from 2.1% to 6.4%. There was no significant increase in hernia rates in patients undergoing surgery for malignancy.

Treating Wisely: The Surgeon's Role in Antibiotic Stewardship.

: Antibiotic resistance continues to receive national attention as a leading public health threat. In 2015, President Barack Obama proposed a National Action Plan to Combat Antibiotic-Resistant Bacteria to curb the rise of "superbugs," bacteria resistant to antibiotics of last resort. Whereas many antibiotics are prescribed appropriately to treat infections, there continue to be a large number of inappropriately prescribed antibiotics. Although much of the national attention with regards to stewardship has focused on primary care providers, there is a significant opportunity for surgeons to embrace this national imperative and improve our practices. Local quality improvement efforts suggest that antibiotic misuse for surgical disease is common. Opportunities exist as part of day-to-day surgical care as well as through surgeons' interactions with nonsurgeon colleagues and policy experts. This article discusses the scope of the antibiotic misuse in surgery for surgical patients, and provides immediate practice improvements and also advocacy efforts surgeons can take to address the threat. We believe that surgical antibiotic prescribing patterns frequently do not adhere to evidence-based practices; surgeons are in a position to mitigate their ill effects; and antibiotic stewardship should be a part of every surgeons' practice.

Is enhanced recovery enough for reducing 30-d readmissions after surgery?

BACKGROUND: Few enhanced recovery pathways (ERPs) include processes related to the hospital to home transfer. Little has been reported regarding readmissions in enhanced recovery programs. This study evaluates readmissions and identifies areas to optimize ERPs to prevent readmissions. METHODS: We conducted an observational, retrospective study at a single tertiary care center. Patients in an ERP for colorectal surgery were compared with a similar cohort who underwent surgery before protocol implementation. We evaluated 30-d readmission, compliance to enhanced recovery protocol, and diagnoses and patient care experiences related to transition of care. RESULTS: Readmission rates (17.6% versus 19.4%; P = 0.55) were similar. There was significant reduction in index hospitalization length of stay (5.3 versus 7.0 d; P < 0.001) and postoperative surgical site infection (7.3% versus 16.6%; P = 0.01). Although enhanced recovery was associated with reduced readmissions for surgical site infections (31% versus 50.7%, P = 0.02), there was a trend toward increased readmissions for small bowel obstruction-ileus (31% versus 19.1%, P = 0.13). ERPs did not impact perceptions of care transitions; however, those who were readmitted rated their transition lower than those that were not. CONCLUSIONS: Although ERPs did not reduce readmissions, the program was associated with reduced length of stay and surgical site infections. ERPs did not influence perceptions of the transition to home. Transition process measures aimed at reducing readmission and improving patient outcomes, including use of transition guides, remote vital sign and symptom monitoring, and early clinical follow-up have not traditionally been part of ERP protocols but should be considered.

Methods of Evaluation of Anorectal Causes of Obstructed Defecation.

Obstructed defecation is a complex disorder that results in impaired propagation of stool from the rectum. It is one of the major subtypes of functional constipation and can be secondary to either functional or anatomic etiologies. Patients with obstructed defecation typically present with symptoms of abdominal discomfort, a sensation of incomplete evacuation and rectal obstruction, passage of hard stools, the need for rectal or vaginal digitation, excessive straining, and reduced stool frequency. Evaluation of obstructed defecation is multimodal, starting with a thorough history and physical examination with focus on the abdominal, perineal, and rectal examination. Additional modalities to elicit the diagnosis of obstructed defecation include proctoscopy, colonic transit time studies, anorectal manometry, a rectal balloon expulsion test, defecography, electromyography, and ultrasound. The results from these studies should be taken in the context of each patient's clinical situation, as there is no single criterion standard for the diagnosis of obstructed defecation. Surgery is typically a last resort for these patients and the majority of patients will have good symptomatic management with diet and lifestyle changes. Patients who are found to have functional mechanisms behind their obstructed defecation also benefit from pelvic floor exercises and biofeedback therapy.

Trends in the Management of Non-emergent Surgery for Diverticular Disease and the Impact of Practice Parameters.

BACKGROUND: Due to the rise in diverticular disease, the ASCRS developed practice parameters to ensure high-quality patient care. Our study aims to evaluate the impact of the 2014 practice parameters on the treatment of non-emergent left-sided diverticular disease. METHODS: This is a retrospective cohort study using the ACS-National Surgical Quality Improvement Project (ACS-NSQIP). Elective sigmoid resections performed by year were evaluated and compared before and after practice parameters were published. RESULTS: Overall, 46,950 patients met inclusion criteria. There was a significant decrease in the number of non-emergent operations when evaluating before and after guideline implementation (P < .001). There was a significant decrease in the number of patients younger than 50 years of age operated electively for diverticular disease (25.8% vs. 23.9%, P = .005). Adoption of minimally invasive surgery continued to increase significantly throughout the study period. CONCLUSIONS: Publication of the 2014 ASCRS practice parameters is associated with a change in management of diverticular disease in the non-emergent setting.

Are IBD Patients Underscored when Determining Postoperative VTE Risk?

BACKGROUND: Patients with inflammatory bowel disease (IBD) have an increased risk of venous thromboembolism (VTE) following colorectal surgery and there is currently no consensus on post-surgical VTE prevention or specific VTE risk assessment tools. We sought to evaluate VTE risk after colorectal surgery and determine if known risk factors used in risk assessment tools adequate correlate with VTE risk in IBD patients. METHODS: Retrospective cohort study using the National Surgical Quality Improvement Project (NSQIP) Participant User File from 2010 to 2018. RESULTS: A total of 27,679 patients were included; 19,015 (68.7%) had Crohn's disease (CD) and 8664 (31.3%) ulcerative colitis (UC). Of these, 16,749 (60.5%) underwent abdominopelvic procedures, 10,178 (36.8%) complex pelvic procedures, and 752 (2.7%) small bowel operations. The overall VTE rate was 2.3%. The VTE rate in patients with CD and UC was 1.8% and 3.6% (p < 0.001) respectively. Overall median time to VTE was 9 days after surgery. VTE rate was highest in patients who underwent complex pelvic procedures (3.6%; 361/10,178). A risk score was calculated using 16/40 available variables from the Caprini VTE Risk Assessment tool; risk score ranged from 3 to 12 points. Most patients that developed a VTE had a score between 3 and 5 points (75.6%), and only 24.5% had a score of 6 or higher. Patients with higher risk scores did not have a higher VTE incidence. CONCLUSION: Post-surgical VTE rates are high in IBD patients. Over half of the events occurred following discharge and in patients with an apparent low-risk score. Additional studies are warranted to define a recommended postoperative VTE prophylaxis regimen for patients with IBD.

Magnetic resonance imaging accuracy in staging early and locally advanced rectal cancer.

INTRODUCTION: Magnetic Resonance Imaging (MRI) is the standard pretreatment staging in patients with rectal cancer. Accurate tumor staging is paramount to determining the appropriate treatment course for patients diagnosed with rectal cancer. The current study aims to re-evaluate the accuracy of pre-operative MRI in staging of both early and locally advanced rectal cancer following completion of neoadjuvant therapy (NAT) compared to the pathologic stage. METHODS: A retrospective review of patients treated for rectal cancer between 2015 and 2020 at a single academic institution. All patients underwent rectal cancer protocol MRIs before surgical resection. Analysis was carried out in two groups: early rectal cancer: T1/2 N0 tumors with upfront surgical resection (N = 40); and locally advanced disease: T3 or greater or N+ disease receiving NAT, with restaging MRI following NAT (n = 63). RESULTS: 103 patients were included in analysis. MRI accuracy in early tumors was 35% ICC = 0.52 (95% CI 0.25-0.71) T stage and 66% ICC = 0 (95% CI -0.24, 0.29) for 29 patients with nodal data for N stage. There was 28% understaging of T2 tumors and 34% understaging of N0 stage by MRI. Post NAT MRI had 44% accuracy ICC = 0.57 (95% CI -0.15-0.20) T stage and 60% accuracy ICC = 0.32 (95% CI 0.08-0.52) N stage. Tumor invasion was overstaged on MRI: 40% T2, 29% T3, 90% T4. Nodal inaccuracy was due to overstaging, 61% N1, 90% N2. CONCLUSIONS: In locally advanced rectal cancer MRI overstaged tumors, this could be due to the continued effect of NAT from MRI to resection. This overstaging is of little clinical significance as it doesn't alter the treatment plan, except in cases of complete clinical response. In early rectal cancer, MRI had limited accuracy compared to pathology, understaging a quarter of patients who would benefit from NAT before surgery. Other adjunct imaging modalities should be considered to improve accuracy in staging early rectal cancer and consideration of complete response and enrollment in watch and wait protocols.

Geographic Reach of Surgery Residency Applicants During In-Person and Virtual Interviews.

Background Virtual interviews for surgery residency may improve interview opportunities for applicants from underrepresented in medicine (UIM) and lower socioeconomic backgrounds. Objective To compare the geographic reach of surgical residency applicants during in-person versus virtual interviews. Methods This study compared applicants for the 2019 (in-person) and 2020 (virtual interviews) application cycle for surgery residency. Geographic reach (GR) was defined as the distance between applicants' current location and the program. Federal Financial Institutions Examination Council's website supplied socioeconomic data using applicants' geographic locations. Applicant demographics, United States Medical Licensing Examination (USMLE) scores, and geographic distance to program were collected. Multivariable analyses examined GR with interaction terms between interview type, UIM status, and socioeconomic status, while controlling for USMLE scores. Results A total of 667 (2019) and 698 (2020) National Resident Matching Program applications were reviewed. Overall, there was no difference in GR for applicants during in-person and virtual interviews in multivariable testing. UIM status had no association with GR for in-person interviews, but virtual interviews were associated with an increased GR for UIM applicants compared to non-UIM applicants (235.17; 95% CI 28.87-441.47; P=.02). For in-person interviews, applicants living in communities with poverty levels ≥7% had less GR vs those in communities with levels <7% (-332.45; 95% CI -492.10, -172.79; P<.001), an effect not observed during virtual interviews. Conclusions There was no difference in overall GR, or the proportion of UIM applicants or those from higher poverty level communities, but virtual survey interviews during the COVID-19 pandemic were associated with increased GR for UIM and from lower socioeconomic backgrounds applicants.

Outcomes Following Recent and Distant Neoadjuvant Radiation in Rectal Cancer: An Institutional Retrospective Review and Analysis of NSQIP.

BACKGROUND: Neoadjuvant chemoradiotherapy (nCRT) is the standard of care in locally advanced rectal cancer (LARC). However, radiation therapy is thought to increase operative difficulty due to induction of fibrosis. Total neoadjuvant therapy (TNT) protocols increase the time between completion of radiation and surgical resection which may lead to increased operative difficulty and complications. METHODS: A single institution retrospective review of patients ≥18 years with LARC undergoing nCRT from 2015 to 2022. Patients were dichotomized in 2 cohorts: <90 days from radiation to surgery (recent radiation), and ≥90 days from radiation to surgery (distant radiation). Institutional data was compared to National Surgical Quality Improvement Program (NSQIP) rectal cancer data from 2016 to 2020. Outcomes included intraoperative complications, 30-day morbidity, and oncologic outcomes. RESULTS: One hundred forty-six institutional patients included, 120 had recent radiation, 26 had distant radiation. Thirty-day morbidity and intraoperative complications did not differ. There was greater radial margin positivity (7% vs. 24%), fewer lymph nodes harvested (17 ± 5 vs. 15 ± 6), and a lower rate of complete mesorectal dissection (88% vs. 65%,) in distant radiation patients 3059 patients were included in NSQIP analysis, 2029 completed radiation <90 days before surgery and 1030 without radiation 90 days before surgery. Patients without radiation 90 days preoperatively had more radial margin positivity (9.2% vs. 4.6%), organ space infection (8.6% vs. 6.4%), and pneumonia (2.2% vs. 0.9%). CONCLUSION: The present study suggests that increased time between radiation and surgery results in more challenging dissection with less complete mesorectal dissection and increased radial margin positivity without increasing technical complications.

Perioperative use of NSAIDs and the risk of short-term endoscopic recurrence in Crohn's disease patients: A retrospective cohort study.

BACKGROUND: More evidence is needed on the use of NSAID based postoperative pain regimens for Crohn's disease (CD) and its association with recurrence. Our goal is to assess the impact of perioperative use of NSAIDs on endoscopic disease recurrence in patients with CD. METHODS: A retrospective cohort study was conducted. The primary outcome measured was endoscopic disease recurrence within 24 months of surgery, defined as a Rutgeerts score ≥ i2. RESULTS: We identified 107 patients with CD that underwent index ileocolectomy with primary anastomosis between January 2009 and July 2019. Endoscopic disease recurrence was identified in 28 (26.2%) and clinical recurrence in 18 (16.8%) patients. Exposure to NSAIDs did not increase 24-month endoscopic recurrence risk (22.2% vs. 38.5% patients, p = 0.12). CONCLUSION: In patients with CD undergoing elective ileocolic resection and primary ileocolic anastomosis, NSAID use in the perioperative period did not impact endoscopic or clinical disease recurrence rate.

Impact of National Accreditation Program for Rectal Cancer guidelines on surgical margin status.

BACKGROUND: The American College of Surgeons established the National Accreditation Program for Rectal Cancer (NAPRC) to standardize rectal cancer care. We sought to assess the impact of NAPRC guidelines at a tertiary care center on surgical margin status. MATERIALS AND METHODS: The Institutional NSQIP database was queried for patients with rectal adenocarcinoma undergoing surgery for curative intent two years prior to and following implementation of NAPRC guidelines. Primary outcome was surgical margin status before (pre-NAPRC) versus after (post-NAPRC) implementation of NAPRC guidelines. RESULTS: Surgical pathology in five (5%) pre-NAPRC and seven (8%) post-NAPRC patients had positive radial margins (p = 0.59); distal margins were positive in three (3%) post-NAPRC and six (7%) post-NAPRC patients (p = 0.37). Local recurrence was observed in seven (6%) pre-NAPRC patients, there were no recurrences to date in post-NAPRC patients (p = 0.15). Metastasis was observed in 18 (17%) pre-NAPRC patients and four (4%) post-NAPRC patients (p = 0.55). CONCLUSION: NAPRC implementation was not associated with a change in surgical margin status for rectal cancer at our institution. However, the NAPRC guidelines formalize evidence-based rectal cancer care and we anticipate that improvements will be greatest in low-volume hospitals which may not utilize multidisciplinary collaboration.

Evaluation of Racial/Ethnic Disparities in the Surgical Management of Inflammatory Bowel Disease.

BACKGROUND: Disparities in managing inflammatory bowel disease (IBD) are multifactorial and occur at all stages of treatment, including surgical management. We aim to evaluate postoperative morbidity after abdominopelvic surgery among different racial/ethnic groups after surgical management of CD and UC and account for preoperative characteristics that may impact outcomes. METHODS: Patients were identified using the National Surgical Quality Improvement Project (NSQIP) file and merged with the targeted proctectomy (2016-2019) and colectomy file (2012-2019). All patients undergoing elective surgical management for ICD9/10 codes for CD and UC were included. The primary outcome was composite postoperative morbidity (CPM), a metric that identifies postoperative morbidity with available variables. Multivariable logistic regression modeling was performed to test the association between race/ethnicity and other risk factors with CPM. Postoperative outcomes were evaluated using propensity score modeling with 1:1 matching without replacement as a secondary analysis. RESULTS: In both CD and UC, CPM was highest for Black patients with 27.5% (326) and 26.1% (81), respectively. Followed by Hispanic patients with a CPM of 21.1% (73) after surgery for CD (p < 0.001) and 21.2% (31) for Asian patients after resection for UC (p = 0.005). After regression modeling, we found increased odds of CPM for Black patients after surgery for UC (OR 1.48, p = 0.013) and CD (OR 1.17, p < 0.001). Following propensity score matching (PSM), stoma creation rates were higher in Asian (10.4%, p = 0.010) and Hispanic patients (11.9%, p = 0.030) undergoing surgery for CD. CONCLUSIONS: Black patients are at increased risk of morbidity after surgery for both UC and CD. Increased morbidity in an already vulnerable population warrants targeted interventions, specifically focusing on faster access to specialized care, preoperative optimization, and culturally competent discussions on the benefits of MIS approaches are warranted in order to improve postoperative outcomes.

Recurrence and Survival of Neuroendocrine Neoplasms of the Rectum: Single-Center Experience.

BACKGROUND: In 2010, the World Health Organization proposed that rectal neuroendocrine neoplasms (NENs) be considered malignant. We hypothesized that patients with small, low-grade, locally excised tumors have a low risk of recurrence and death. METHODS: Retrospective review of institutional database 2006-2017 including consecutive adults with newly diagnosed rectum NENs. Outcome measures included risk of recurrence and 5-year overall survival. RESULTS: A total of 122 patients were diagnosed with rectal NENs. Most patients were asymptomatic and diagnosed during screening colonoscopy (80, 66.1%), had small tumors (median 0.6 cm, IQR 0.5-1) with intact muscularis propria on EUS (62/65, 95.4%), and were low grade (2017 WHO grades 1-2, n = 116, 95.1%). Lymph node and distant metastasis were found in 4 (3.3%) and 4 (3.3%) of patients, respectively. Patients were treated with local excision in 93.4% of cases with polypectomy (52, 42.6%), endoscopic mucosal resection (48, 39.3%), and transanal excision (14, 11.5%). Three patients (2.5%) required abdominoperineal resection or low anterior resection, and five patients (4.1%) received adjuvant chemotherapy. Of 87 patients surveilled, 4 (4.6%) recurred at a median time of 1 year (IQR 0.6-8). Death from neuroendocrine neoplasms occurred in 5 (4.1%) patients, all with lymph node (1/4) or metastatic disease (4/5) on presentation. Median time to death from NEN was 0.8 years (0.7-2.4). Overall 5-year survival for patients with localized disease was 98.2% (95% CI 93-99.5, Fig. 1). CONCLUSION: Patients with small, low grade rectal NENs treated with local excision have excellent oncologic outcomes.