Anal dysplasia and anal cancer screening practices among liver transplant centers in the United States: Results of an online survey.

BACKGROUND: Solid organ transplant recipients are at an increased risk for anogenital Human Papillomavirus (HPV)-related disease, including anal high-grade squamous intraepithelial lesions (HSIL) and anal squamous cell cancer (ASCC). Guidelines for ASCC screening in transplant recipients are limited. Our aim was to understand current practice of ASCC screening in adult liver transplant (LT) candidates and recipients at transplant centers across the United States. METHODS: We surveyed medical directors of 113 LT centers across the United States which had publicly available contact information. The survey evaluated center perceptions on cancer and HPV disease risk in transplant populations, ASCC screening, barriers and facilitators for ASCC screening and HPV vaccination practices. RESULTS: We received 26/113 (23%) responses, of which 24 were complete and included in the analysis. Eleven of 24 (46%) centers reported screening for ASCC and 3/24 (12.5%) centers reported having formal guidelines. Centers who perform ASCC screening were more likely to perform transplants in people living with HIV and were more aware of the burden of HPV disease in transplant populations. All respondents believed that additional data on the impact of screening on ASCC incidence would support screening decisions. Increased access to specialists for screening/high-resolution anoscopy was also perceived as a facilitator. Only 7/24 (29%) centers regularly evaluated HPV vaccination status of their patients. CONCLUSION: This national survey of LT centers reveals non-standardized ASCC screening practices, and identified data, educational and resource needs to improve prevention of ASCC in this population.

Decreasing Readmissions After Ileostomy Creation Through a Perioperative Quality Improvement Program.

BACKGROUND: Readmission after ileostomy creation in patients undergoing colorectal surgery creates a significant burden on health care cost and patient quality of care, with a 30-day readmission rate of 40%. OBJECTIVE: This study aimed to evaluate the implementation of our perioperative quality improvement program, Decreasing Readmissions After Ileostomy Creation. DESIGN: Perioperative interventions were administered to patients who underwent ileostomy creation. SETTINGS: A single tertiary care academic center. PATIENTS: Eighty patients participated in this program from February 2020 to January 2021. MAIN OUTCOME MEASURES: The primary outcomes measured were 30-day readmission rates and causes of readmission, which were compared to a historical national database. Descriptive statistics were used to evaluate the effectiveness of this quality improvement program. RESULTS: Eighty patients were enrolled in this prospective quality improvement program. The mean age was 52 (±15.06) years. The most common indication for patients undergoing creation of an ileostomy was colorectal cancer (40%; n = 32). The overall 30-day readmission rate was 8.75% (n = 7) throughout the study period, which was significantly lower than historical cohort data (20.10%; p = 0.01). Among the 7 readmitted patients, 3 (3.75%) were readmitted due to dehydration. The most significant associated risk factor for all-cause readmission was urgent/emergent operative status, which was associated with an increased risk of readmission ( p = 0.01). The 3 readmitted patients with dehydration had a mean Dehydration Readmission After Ileostomy Prediction risk score of 11.71 points, compared to 9.59 points in nondehydrated patients, who did not require readmission ( p = 0.38). LIMITATIONS: This study is limited by its small sample size (N = 80). CONCLUSIONS: The Decreasing Readmissions After Ileostomy Creation program has been successful in reducing both the all-cause readmission rate and readmission due to dehydration both within an academic tertiary care referral center and in comparison with historical readmission rates. See Video Abstract at http://links.lww.com/DCR/B894 . DISMINUCIN DE LA READMISIN DESPUS DE LA CREACIN DE UNA ILEOSTOMA MEDIANTE UN PROGRAMA DE MEJORA DE LA CALIDAD PERIOPERATORIA: ANTECEDENTES:La readmisión después de la creación de una ileostomía en pacientes de cirugía colorrectal crea una carga significativa sobre el costo de la atención médica y la calidad de la atención del paciente, con una tasa de readmisión a los 30 días que llega al 40%.OBJETIVO:Este estudio tiene como objetivo evaluar la implementación de nuestro programa de mejora de la calidad perioperatoria que disminuyen los reingresos después de la creación de ileostomía.DISEÑO:Se administraron intervenciones perioperatorias a pacientes que se sometieron a la creación de una ileostomía.AJUSTE:Se trataba de un único centro académico de atención terciaria.PACIENTES:Participaron 80 pacientes en este programa desde febrero de 2020 hasta enero de 2021.PRINCIPALES MEDIDAS DE RESULTADO:Los principales resultados medidos fueron las tasas de reingreso a los 30 días y las causas de reingreso, que se compararon con una base de datos histórica nacional. Se utilizaron estadísticas descriptivas para evaluar la eficacia de este programa de mejora de la calidad.RESULTADOS:Ochenta pacientes se inscribieron en este programa prospectivo de mejora de la calidad. La edad media fue de 52 (± 15,06) años. La indicación más común para los pacientes que se sometieron a la creación de una ileostomía fue el cáncer colorrectal (40%, n = 32). La tasa general de reingreso a los 30 días fue del 8,75% (n = 7) durante todo el período de estudio, lo que fue significativamente más bajo que los datos históricos de la cohorte (20,10%, p = 0,01). Entre los 7 pacientes readmitidos, tres (3,75%) fueron readmitidos por deshidratación. El factor de riesgo asociado más significativo para la readmisión por todas las causas fue el estado operatorio urgente / emergencia, que se asoció con un mayor riesgo de readmisión (p = 0,01). Los tres pacientes readmitidos con deshidratación tuvieron una puntuación de riesgo promedio de readmisión por deshidratación después de la predicción de ileostomía de 11,71 puntos, en comparación con los pacientes no deshidratados, que no requirieron readmisión (media, 9,59 puntos, p = 0,38).LIMITACIONES:Este estudio está limitado por su pequeño tamaño de muestra (n = 80).CONCLUSIONES:El programa de disminución de las readmisiones después de la creación de una ileostomía ha logrado reducir tanto la tasa de readmisión por todas las causas como la readmisión por deshidratación, tanto dentro de un centro académico de referencia de atención terciaria como en comparación con las tasas históricas de readmisión. Consulte Video Resumen en http://links.lww.com/DCR/B894 . (Traducción-Dr Yolanda Colorado ).

Anal Squamous Intraepithelial Lesions and Anal Cancer Management in Low Resource Settings.

A low resource setting (LRS) is defined as a health care system which does not meet the criteria defined by the World Health Organization (WHO) or other national/international organizations in the following areas: infrastructure, materials, and human resources. 1 Patients encounter barriers which limit their access to care and services that are considered standard of care. While LRS is most commonly associated with developing countries, it is easy to overlook communities in developed countries which lack the financial resources to afford basic health care. This article describes the societal implications and barriers to care for both squamous intraepithelial lesions (SILs) and anal cancer in LRS, the existing screening/surveillance approaches, available treatment approaches to anal cancer, and it also discusses potential evidence-based approaches to bridge the gap for these disparities in anal cancer care.

Metformin use and the risk of anal intraepithelial neoplasia in type II diabetic patients.

AIM: Emerging evidence has suggested that metformin may be protective against the development of human-papillomavirus-related cancers. Anal intraepithelial neoplasia (AIN) is highly associated with human papillomavirus infection and a precancerous status of anal cancer. The aim of this study was to investigate the relationship between metformin usage and the development of AIN in a large national sample. METHODOLOGY: The IBM MarketScan dataset was used to design a nested case-control study from 2010 to 2017. Patients aged 18-65 years with type 2 diabetes mellitus (DM) were evaluated, and cases of AIN were identified. Four controls were randomly selected in the risk set of each case by using incidence density sampling. The association between metformin usage and AIN was assessed using multivariate logistic regression modelling. RESULTS: A total of 258 patients with type 2 DM were diagnosed with AIN during the study interval, and these were matched to 1032 control patients without a diagnosis of AIN. Patients who developed AIN had 38% lower odds of prior metformin use compared to those without a history of AIN (P < 0.01) and this finding remained robust after adjusting for age, sex, human immunodeficiency virus infection and DM complications (P = 0.02). Patients with AIN had 56% lower odds of long-term metformin use compared to control patients (P = 0.01). CONCLUSIONS: An AIN diagnosis in patients with DM is associated with 56% lower likelihood of prior metformin use. This relationship suggests that metformin could potentially play a protective role against AIN. Prospective studies in non-diabetic patients are warranted to examine these findings further.

Frailer Patients Undergoing Robotic Colectomies for Colon Cancer Experience Increased Complication Rates Compared With Open or Laparoscopic Approaches.

BACKGROUND: Minimally invasive surgical techniques are routinely promoted as alternatives to open surgery because of improved outcomes. However, the impact of robotic surgery on certain subsets of the population, such as frail patients, is poorly understood. OBJECTIVE: The purpose of our study was to examine the association between frailty and minimally invasive surgical approaches with colon cancer surgery. DESIGN: This is a retrospective study of prospectively collected outcomes data. Thirty-day surgical outcomes were compared by frailty and surgical approach using doubly robust multivariable logistic regression with propensity score weighting, and testing for interaction effects between frailty and surgical approach. SETTING: Patients undergoing an open, laparoscopic, or robotic colectomy for primary colon cancer, 2012 to 2016, were identified from the American College of Surgeons National Surgical Quality Improvement Program database. PATIENTS: Patients undergoing a colectomy with an operative indication for primary colon cancer were selected. MAIN OUTCOME MEASURES: The primary outcomes measured were 30-day postoperative complications. RESULTS: After propensity score weighting of patients undergoing colectomy, 33.8% (n = 27,649) underwent an open approach versus 34.3% (n = 28,058) underwent laparoscopic surgery versus 31.9% (n = 26,096) underwent robotic surgery. Robotic (OR, 0.53; 95% CI, 0.42-0.69, p < 0.001) and laparoscopic (OR, 0.58; 95% CI, 0.52-0.66, p < 0.001) surgeries were independently associated with decreased rates of major complications. Frailer patients had increased complication rates (OR, 1.56; 95% CI, 1.07-2.25, p = 0.018). When considering the interaction effects between surgical approach and frailty, frailer patients undergoing robotic surgery were more likely to develop a major complication (combined adjusted OR, 3.15; 95% CI, 1.34-7.45, p = 0.009) compared with patients undergoing open surgery. LIMITATIONS: Use of the modified Frailty Index as an associative proxy for frailty was a limitation of this study. CONCLUSIONS: Although minimally invasive surgical approaches have decreased postoperative complications, this effect may be reversed in frail patients. These findings challenge the belief that robotic surgery provides a favorable alternative to open surgery in frail patients. See Video Abstract at http://links.lww.com/DCR/B163. LOS PACIENTES MÁS FRÁGILES SOMETIDOS A COLECTOMÍA ROBÓTICA POR CÁNCER DE COLON EXPERIMENTAN MAYORES TASAS DE COMPLICACIONES EN COMPARACIÓN CON ABORDAJES LAPAROSCÓPICO O ABIERTO: Las técnicas quirúrgicas mínimamente invasivas estan frecuentement promovidas como alternativas a la cirugía abierta debido a sus mejores resultados. Sin embargo, el impacto de la cirugía robótica en ciertos subgrupos de población, como el caso de los pacientes endebles, es poco conocido.El propósito de nuestro estudio fue examinar la asociación entre la fragilidad de los pacientes y el aborgaje quirúrgico mínimamente invasivo para la cirugía de cáncer de colon.Estudio retrospectivo de datos de resultados recolectados prospectivamente. Los resultados quirúrgicos a 30 días se compararon entre fragilidad y abordaje quirúrgico utilizando la regresión logística multivariable doblemente robusta con ponderación de puntaje de propensión y pruebas de efectos de interacción entre fragilidad y abordaje quirúrgico.Los pacientes identificados en la base de datos del Programa Nacional de Mejora de la Calidad Quirúrgica del Colegio Estadounidense de Cirujanos, que fueron sometidos a una colectomía abierta, laparoscópica o robótica por cáncer de colon primario, de 2012 a 2016.Todos aquellos pacientes seleccionados con indicación quirúrgica de cáncer primario de colon que fueron sometidos a una colectomía.Las complicaciones postoperatorias a 30 días.Luego de ponderar el puntaje de propensión de los pacientes colectomizados, el 33.8% (n = 27,649) fué sometido a laparotomía versus el 34.3% (n = 28,058) operados por laparoscopía versus el 31.9% (n = 26,096) operados con tecnica robótica. Las cirugías robóticas (OR 0.53, IC 95% 0.42-0.69, p < 0.001) y laparoscópicas (OR 0.58, IC 95% 0.52-0.66, p < 0.001) se asociaron de forma independiente con una disminución de las tasas de complicaciones mayores. Los pacientes más delicados tenían mayores tasas de complicaciones (OR 1.56, IC 95% 1.07-2.25, p = 0.018). Al considerar los efectos de interacción entre el abordaje quirúrgico y la fragilidad, los pacientes más débiles sometidos a cirugía robótica tenían más probabilidades de desarrollar una complicación mayor (OR ajustado combinado 3.15, IC 95% 1.34-7.45, p = 0.009) en comparación con los pacientes sometidos a cirugía abierta.El uso del índice de fragilidad modificado como apoderado asociativo de la fragilidad.Si bien los abordajes quirúrgicos mínimamente invasivos han disminuido las complicaciones postoperatorias, este efecto puede revertirse en pacientes lábiles. Estos hallazgos desafían la creencia de que la cirugía robótica proporciona una alternativa favorable a la cirugía abierta en pacientes frágiles. Consulte Video Resumen en http://links.lww.com/DCR/B163. (Traducción-Dr. Xavier Delgadillo).

Minimally Invasive Proctectomy for Rectal Cancer: A National Perspective on Short-term Outcomes and Morbidity.

BACKGROUND: Prior randomized trials showed comparable short-term outcomes between open and minimally invasive proctectomy (MIP) for rectal cancer. We hypothesize that short-term outcomes for MIP have improved as surgeons have become more experienced with this technique. METHODS: Rectal cancer patients who underwent elective abdominoperineal resection (APR) or low anterior resection (LAR) were included from the American College of Surgeons National Surgical Quality Improvement Program database (2016-2018). Patients were stratified based on intent-to-treat protocol: open (O-APR/LAR), laparoscopic (L-APR/LAR), robotic (R-APR/LAR), and hybrid (H-APR/LAR). Multivariable logistic regression analysis was used to assess the impact of operative approach on 30-day morbidity. RESULTS: A total of 4471 procedures were performed (43.41% APR and 36.59% LAR); O-APR 42.72%, L-APR 20.99%, R-APR 16.79%, and H-APR 19.51%; O-LAR 31.48%, L-LAR 26.34%, R-LAR 17.48%, and H-LAR 24.69%. Robotic APR and LAR were associated with shortest length of stay and significantly lower conversion rate. After adjusting for other factors, lap, robotic and hybrid APR and LAR were associated with decreased risk of overall morbidity when compared to open approach. R-APR and H-APR were associated with decreased risk of serious morbidity. No difference in the risk of serious morbidity was observed between the four LAR groups. CONCLUSION: Appropriate selection of patients for MIP can result in better short-term outcomes, and consideration for MIP surgery should be made.

Outcomes for Ulcerative Colitis With Delayed Emergency Colectomy Are Worse When Controlling for Preoperative Risk Factors.

BACKGROUND: Increasing evidence supports immediate colectomy in acute fulminant ulcerative colitis in comparison with ongoing medical management. Prior studies have been limited to inpatient-only administrative data sets or single-institution experiences. OBJECTIVE: The purpose of this study was to compare outcomes of early versus delayed emergency colectomy in patients admitted with ulcerative colitis flares while controlling for known preoperative risks and acuity. DESIGN: This is a cohort study of patients undergoing emergent total abdominal colectomies for ulcerative colitis compared by the timing of surgery. SETTING: Adult patients undergoing an emergent total abdominal colectomy for ulcerative colitis, 2005 to 2015, were identified in the American College of Surgeons National Surgical Quality Improvement Program database. PATIENTS: Patients undergoing total abdominal colectomy with an operative indication of ulcerative colitis admitted on a nonelective basis were selected. MAIN OUTCOME MEASURE: The primary outcomes measured were 30-day National Surgical Quality Improvement Program-reported mortality and postoperative complications, and early operation within 2 days of admission. RESULTS: We identified 573 total abdominal colectomies after propensity score matching. Median time to surgery was 1 hospital day in the early group versus 6 hospital days in the delayed group (p < 0.001). Early operation was associated with a lower mortality rate (4.9% versus 20.3% in matched groups, p < 0.001) and lower complication rate (64.5% versus 72.0%, p = 0.052). Multivariable logistic regression with propensity weighting of mortality on preoperative risk factors demonstrated that early surgery is associated with an 82% decrease in the odds of death compared with delayed surgery (p < 0.001). Regression of morbidity on preoperative risk factors demonstrated that early surgery is associated with a 35% decrease in the odds of a complication with delayed surgery (p = 0.034). LIMITATIONS: Quality improvement data were used for clinical research questions. CONCLUSIONS: Patients undergoing immediate surgical intervention for acute ulcerative colitis have decreased postoperative complications and mortality rates. Rapid and early transitioning from medical to surgical management may benefit those expected to require surgery on the same admission. See Video Abstract at http://links.lww.com/DCR/A800.

Treatment Strategies and Survival Trends for Anorectal Melanoma: Is it Time for a Change?

BACKGROUND: Immunotherapy advances for the treatment of cutaneous melanoma question its efficacy in treating anorectal mucosal melanoma (ARMM). We aimed to identify the prevalence, current management, and overall survival (OS) for ARMM. METHODS: Review of patients with ARMM from 2004 to 2015 National Cancer Database. Factors associated with immunotherapy were identified using multivariable logistic regression. The primary outcome was 2- and 5-year OS. Subgroup analysis by treatment type was performed. RESULTS: A total of 1331 patients were identified with a significant increase in prevalence (2004: 6.99%, 2015: 10.53%). ARMM patients were older, white, on Medicare, and from the South. The most common treatment was surgery (48.77%), followed by surgery + radiation (11.75%), surgery + immunotherapy (8.68%), and surgery + chemotherapy (8.68%). 16.93% of patients received immunotherapy, with utilization increasing (7.24%: 2004, 21.27%: 2015, p < 0.001). Patients who received immunotherapy had a significantly better 2-year OS (42.47% vs. 49.21%, p < 0.001), and other therapies did not reveal a significant difference. Adjusted analysis showed no difference in 2- and 5-year OS based on therapy type. CONCLUSION: The prevalence of ARMM has increased. The use of immunotherapy has increased substantially. Some survival benefit with the administration of immunotherapy may exist that has yet to be revealed. A more aggressive treatment paradigm is warranted.

Readmission Adversely Affects Survival in Surgical Rectal Cancer Patients.

BACKGROUND: Readmission has received attention as a potential healthcare quality metric. No studies have investigated the relationship between readmission and survival in patients undergoing rectal cancer surgery. The aims of this study were to identify factors associated with 30-day readmission after rectal cancer surgery and to determine the impact of readmission on overall survival (OS). METHODS: Patients who underwent surgical treatment for rectal/rectosigmoid adenocarcinoma stages I-IV were identified using the National Cancer Database (2004-2014). Multivariable logistic regression was used to identify factors for readmission. 2:1 nearest neighbor caliper matching without replacement was used to ensure similarity of patients being compared. Survival analyses were performed using Kaplan-Meier method along with log-rank test and Cox proportional hazards model. RESULTS: Of 110,167 patients, 7045 (6.39%) were readmitted. Factors associated with readmission included higher Charlson comorbidity score, non-private or no insurance, procedure type, hospitals in the Northeast, South, and Midwest regions, and prolonged length of stay. Within the matched cohort (13,756 non-readmitted and 6878 readmitted), readmitted patients had worse 5- and 10-year OS regardless of cancer stage (p < 0.001) and procedure type. Five- and 10-year OS were 58.98% and 41.01% for readmitted patients, 64.96% and 43.50% for non-readmitted patients. Readmitted patients had shorter OS by 13.14 months and increased risk of mortality (HR 1.20, 95% CI 1.15-1.25, p < 0.001). CONCLUSIONS: Thirty-day readmission after rectal cancer surgery is associated with decreased OS. Efforts to reduce readmissions should be considered to advance cancer care and enhance the potential for improved patient survival.

Predicting the Risk of Readmission From Dehydration After Ileostomy Formation: The Dehydration Readmission After Ileostomy Prediction Score.

BACKGROUND: All-cause readmission rates in patients undergoing ileostomy formation are as high as 20% to 30%. Dehydration is a leading cause. No predictive model for dehydration readmission has been described. OBJECTIVE: The purpose of this study was to develop and validate the Dehydration Readmission After Ileostomy Prediction scoring system to predict the risk of readmission for dehydration after ileostomy formation. DESIGN: Patients who underwent ileostomy formation were identified using the American College of Surgeons National Surgical Quality Improvement Program data set (2012-2015). Predictors for dehydration were identified using multivariable logistic regression analysis and translated into a point scoring system based on corresponding ß-coefficients using 2012-2014 data (derivation). Model discrimination was assessed with receiver operating characteristic curves using 2015 data (validation). SETTINGS: This study used the American College of Surgeons National Surgical Quality Improvement Program. PATIENTS: A total of 8064 (derivation) and 3467 patients (validation) were included from the American College of Surgeons National Surgical Quality Improvement Program. MAIN OUTCOME MEASURES: Dehydration readmission within 30 days of operation was measured. RESULTS: A total of 8064 patients were in the derivation sample, with 2.9% (20.1% overall) readmitted for dehydration. Twenty-five variables were queried, and 7 predictors were identified with points assigned: ASA class III (4 points), female sex (5 points), IPAA (4 points), age ≥65 years (5 points), shortened length of stay (5 points), ASA class I to II with IBD (7 points), and hypertension (9 points). A 39-point, 5-tier risk category scoring system was developed. The model performed well in derivation (area under curve = 0.71) and validation samples (area under curve = 0.74) and passed the Hosmer-Lemeshow goodness-of-fit test. LIMITATIONS: Limitations of this study pertained to those of the American College of Surgeons National Surgical Quality Improvement Program, including a lack of generalizability, lack of ileostomy-specific variables, and inability to capture multiple readmission International Classification of Diseases, 9/10 edition, codes. CONCLUSIONS: The Dehydration Readmission After Ileostomy Prediction score is a validated scoring system that identifies patients at risk for dehydration readmission after ileostomy formation. It is a specific approach to optimize patient factors, implement interventions, and prevent readmissions. See Video Abstract at http://links.lww.com/DCR/A746.

Routine Pouchoscopy Prior to Ileostomy Takedown May Not Be Necessary in Patients with Chronic Ulcerative Colitis.

BACKGROUND: Creation of a J pouch is the gold standard surgical intervention in the treatment of chronic ulcerative colitis (UC). Pouchoscopy prior to ileostomy takedown is commonly performed. We describe the frequency, indication, and findings on pouchoscopy, and determine if pouchoscopy affects rates of complications after takedown. METHODS: All UC or indeterminate inflammatory bowel disease patients with a J pouch were retrospectively evaluated from January 1994 to December 2014. Cases were defined as having routine (asymptomatic) pouchoscopy after pouch creation but before ileostomy takedown. Controls were defined as having no pouchoscopy or pouchoscopy on the same day as that of takedown. RESULTS: The study included 178 patients (81.5% cases, 18.5% controls). Fifty two percent of pouchoscopies were reported as normal. Common abnormal endoscopy findings included stricture (35%), pouchitis (7%), and cuffitis (0.7%). Length of stay during takedown hospitalization was shorter for cases than controls (3 vs. 5 days; p = 0.001), but neither short- nor long-term complications were statistically different between cases and controls. Abnormalities on pouchoscopy were not predictive for short-term complications (p = 0.73) or long-term complications (p = 0.55). Routine pouchoscopy did not delay takedown surgery in any of the included patients. CONCLUSIONS: Routine pouchoscopy may not be necessary prior to ileostomy takedown; its greatest utility is in patients with suspected pouch complications.

Prognostic and Predictive Clinicopathologic Factors of Squamous Anal Canal Cancer in HIV-Positive and HIV-Negative Patients: Does HAART Influence Outcomes?

BACKGROUND: The incidence of squamous cell carcinoma (SCC) of the anal canal has been rising over the past decades, especially in patients infected with human immunodeficiency virus (HIV). Despite the advent of potent multidrug regimens to treat HIV-termed highly active antiretroviral therapy (HAART), anal SCC rates have not declined, and the impact of HAART on anal SCC remains controversial. AIM: The purpose of this study was to define outcomes of anal SCC treatment in HIV-positive and HIV-negative patients. METHODS AND MATERIALS: A retrospective single-institution analysis was performed on all patients with anal SCC treated at the Johns Hopkins Hospital between 1991 and 2010. The primary outcomes measured were 5-year overall survival (5-year OS), median survival, and relapse rates. RESULTS: Our search identified 93 patients with anal SCC. Patients had a mean age of 54 years; 37.6% were male, and 21.5% were HIV-positive. Median follow-up was 28 months. Relapse occurred in 16.1% of patients. Median time to relapse was 20 months. Relapse rates were slightly higher with HIV-positive versus negative patients (30.0 vs. 12.3%) but did not reach statistical significance (p = 0.06). Among HIV-positive patients, those who relapsed were more likely to be on HAART than those who did not relapse (83.3 vs. 14.3%, p = 0.007). 5-year OS was 58.9% for the total group of patients with no significant difference between those who relapsed versus those who did not (76.2 vs. 54.5%, p = 0.20). No survival difference was seen between HIV-positive and negative patients. Survival was associated with AJCC stage in all patients. CONCLUSION: In our small series, HIV infection was not associated with a significantly higher relapse rate or worse 5-year OS among patients with anal SCC. HAART was associated with a higher rate of relapse in HIV-positive patients. AJCC staging predicted survival in both relapsed and non-relapsed patients regardless of HIV status.

A comparison of trends in operative approach and postoperative outcomes for colorectal cancer surgery.

BACKGROUND: Data-assessing trends and perioperative outcomes relative to surgical approach for colorectal cancer (CRC) surgery are lacking. We report national trends of CRC surgery and compare postoperative outcomes by surgical approach. METHODS: A total of 261,886 patients undergoing surgery for CRC were identified using the Nationwide Inpatient Sample from 2009 to 2012. Trends in surgical approach were assessed using the Cochrane-Armitage test of trends. Multivariable logistic and linear regression analyses were performed to compare length of stay (LOS), postoperative complications, and cost by surgical approach. RESULTS: At the time of surgery, 57.5% underwent an open procedure, whereas 42.4% underwent either a laparoscopic (39.9%) or robotic (2.5%) colorectal surgery. The use of minimally invasive surgery increased over time (2009 versus 2012: 37.3% versus 46.8%; P < 0.001). Postoperative morbidity was 15.9% and was higher after open surgery (open versus laparoscopic versus robotic: 18.4% versus 12.4% versus 13.3%; P < 0.001). Patients who underwent a minimally invasive surgery had shorter LOS (laparoscopic: OR, 0.55, 95% CI, 0.52-0.58; robotic: OR, 0.58; 95% CI, 0.49-0.69; both P < 0.001). Robotic surgery was consistently associated with the highest mean costs followed by laparoscopic and open surgery (P < 0.001). CONCLUSIONS: Patients undergoing minimally invasive colorectal surgery had a lower postoperative morbidity and shorter LOS compared with patients undergoing open colorectal surgery.

Postoperative complications following intraoperative radiotherapy in abdominopelvic malignancy: A single institution analysis of 113 consecutive patients.

BACKGROUND: Intraoperative radiotherapy (IORT) has advantages over external beam radiation therapy (EBRT). Few studies have described side effects associated with its addition. We evaluated our institution's experience with abdominopelvic IORT to assess safety by postoperative complication rates. METHODS: Prospectively collected IRB-approved database of all patients receiving abdominopelvic IORT (via high dose rate brachytherapy) at Johns Hopkins Hospital between November 2006 and May 2014 was reviewed. Patients were discussed in multidisciplinary conferences. Those selected for IORT were patients for whom curative intent resection was planned for which IORT could improve margin-negative resection and optimize locoregional control. Perioperative complications were classified via Clavien-Dindo scale for postoperative surgical complications. RESULTS: A total of 113 patients were evaluated. Most common diagnosis was sarcoma (50/113, 44%) followed by colorectal cancer (45/113, 40%), most of which were recurrent (84%). There were no perioperative deaths. A total of 57% of patients experienced a complication Grade II or higher: 24% (27/113) Grade II; 27% (30/113) Grade III; 7% (8/113) Grade IV. Wound complications were most common (38%), then gastrointestinal (25%). No radiotherapy variables were significantly associated with complications on uni/multi-variate analysis. CONCLUSIONS: Our institution's experience with IORT demonstrated historically expected postoperative complication rates. IORT is safe, with acceptable perioperative morbidity.

Nearly a Third of High-Grade Dysplasia and Colorectal Cancer Is Undetected in Patients with Inflammatory Bowel Disease.

BACKGROUND: It is unclear whether intensive surveillance protocols have resulted in a decreased incidence of colorectal cancer (CRC) in inflammatory bowel disease (IBD). AIMS: To determine the prevalence and characteristics of IBD associated high-grade dysplasia (HGD) or CRC that was undetected on prior colonoscopy. METHODS: This is a single-center, retrospective study from 1994 to 2013. All participants had a confirmed IBD diagnosis and underwent a colectomy with either HGD or CRC found in the colectomy specimen.The undetected group had no HGD or CRC on prior colonoscopies. The detected group had HGD or CRC identified on previous biopsies. RESULTS: Of 70 participants, with ulcerative colitis (UC) (n = 47), Crohn's disease (CD) (n = 21), and indeterminate colitis (n = 2), 29% (n = 20) had undetected HGD/CRC at colectomy (15 HGD and 5 CRC). In the undetected group, 75% had prior LGD, 15% had indefinite dysplasia, and 10% had no dysplasia (HGD was found in colonic strictures). Patients in the undetected group were more likely to have pancolitis (55 vs. 20%) and multifocal dysplasia (35 vs. 8%). The undetected group was less likely to have CRC at colectomy (25 vs. 62%). There was a trend toward right-sided HGD/CRC at colectomy (40 vs. 20%; p = 0.08). In addition, 84% of the lesions found in the rectum at colectomy were not seen on prior colonoscopy in the undetected group. CONCLUSIONS: The prevalence of previously undetected HGD/CRC in IBD found at colectomy was 29%. The high proportion of undetected rectal and right-sided HGD/CRC suggests that these areas may need greater attention during surveillance.

Outcomes of abdominoperineal resection for management of anal cancer in HIV-positive patients: a national case review.

BACKGROUND: The incidence of anal cancer in human immunodeficiency virus (HIV)-positive individuals is increasing, and how co-infection affects outcomes is not fully understood. This study sought to describe the current outcome disparities between anal cancer patients with and without HIV undergoing abdominoperineal resection (APR). METHODS: A retrospective review of all US patients diagnosed with anal squamous cell carcinoma, undergoing an APR, was performed. Cases were identified using a weighted derivative of the Healthcare Utilization Project's National Inpatient Sample (2000-2011). Patients greater than 60 years old were excluded after finding a skewed population distribution between those with and without HIV infection. Multivariable logistic regression and generalized linear modeling analysis examined factors associated with postoperative outcomes and cost. Perioperative complications, in-hospital mortality, length of hospital stay, and hospital costs were compared for those undergoing APR with and without HIV infection. RESULTS: A total of 1725 patients diagnosed with anal squamous cell cancer undergoing APR were identified, of whom 308 (17.9 %) were HIV-positive. HIV-positive patients were younger than HIV-negative patients undergoing APR for anal cancer (median age 47 years old versus 51 years old, p < 0.001) and were more likely to be male (95.1 versus 30.6 %, p < 0.001). Postoperative hemorrhage was more frequent in the HIV-positive group (5.1 versus 1.5 %, p = 0.05). Mortality was low in both groups (0 % in HIV-positive versus 1.49 % in HIV-negative, p = 0.355), and length of stay (LOS) (10+ days; 75th percentile of patient data) was similar (36.9 % with HIV versus 29.8 % without HIV, p = 0.262). Greater hospitalization costs were associated with patients who experienced a complication. However, there was no difference in hospitalization costs seen between HIV-positive and HIV-negative patients (p = 0.66). CONCLUSIONS: HIV status is not associated with worse postoperative recovery after APR for anal cancer as measured by length of stay or hospitalization cost. Further study may support APRs to be used more aggressively in HIV-positive patients with anal cancer.