Clinical practice guidelines for enhanced recovery after colon and rectal surgery from the American Society of Colon and Rectal Surgeons and the Society of American Gastrointestinal and Endoscopic Surgeons.

The American Society of Colon and Rectal Surgeons (ASCRS) and the Society of American Gastrointestinal and Endoscopic Surgeons (SAGES) are dedicated to ensuring high-quality innovative patient care for surgical patients by advancing the science, prevention, and management of disorders and diseases of the colon, rectum, and anus as well as minimally invasive surgery. The ASCRS and SAGES society members involved in the creation of these guidelines were chosen because they have demonstrated expertise in the specialty of colon and rectal surgery and enhanced recovery. This consensus document was created to lead international efforts in defining quality care for conditions related to the colon, rectum, and anus and develop clinical practice guidelines based on the best available evidence. While not proscriptive, these guidelines provide information on which decisions can be made and do not dictate a specific form of treatment. These guidelines are intended for the use of all practitioners, healthcare workers, and patients who desire information about the management of the conditions addressed by the topics covered in these guidelines. These guidelines should not be deemed inclusive of all proper methods of care nor exclusive of methods of care reasonably directed toward obtaining the same results. The ultimate judgment regarding the propriety of any specific procedure must be made by the physician in light of all the circumstances presented by the individual patient. This clinical practice guideline represents a collaborative effort between the American Society of Colon and Rectal Surgeons (ASCRS) and the Society of American Gastrointestinal and Endoscopic Surgeons (SAGES) and was approved by both societies.

The Association Between Sex and Survival for Anal Squamous Cell Carcinoma.

BACKGROUND: The incidence of anal squamous cell carcinoma (SCC) is rising, despite the introduction of a vaccine against human papillomavirus (HPV), the most common etiology of anal SCC. The rate of anal SCC is higher among women and sex-based survival differences may exist. We aimed to examine the association between sex and survival for stage I-IV anal SCC. MATERIALS AND METHODS: The National Cancer Database was used to identify patients with stage I-IV anal SCC from 2004-2016. Outcomes were assessed utilizing log rank tests, Kaplan-Meier statistics, and Cox proportional-hazard modeling. Subgroup analyses by disease stage and by HPV status were performed. Outcomes of interest were median, 1-, and 5-year survival by sex. RESULTS: There were 31,185 patients with stage I-IV anal SCC. 10,714 (34.3%) were male and 20,471 (65.6%) were female. 1- and 5- year survival was 90.2% (95% CI 89.8 - 90.7) and 67.7% (95% CI 66.9 - 68.5) for females compared to 85.8% (95% CI 85.1 - 86.5) and 55.9% (95% CI 54.7 - 57.0) for males. In subgroup analysis, females demonstrated improved unadjusted and adjusted survival for all stages of disease. Female sex was an independent predictor of improved survival (HR 0.68, 95% CI 0.65 - 0.71, P < 0.001). CONCLUSIONS: We demonstrate better overall survival for females compared to males for stage I-IV anal SCC. It is not clear why women have a survival advantage over men, though exposure to prominent risk factors may play a role. High-risk men may warrant routine screening for anal cancer.

The Distribution of Colorectal Surgeons in the United States.

BACKGROUND: Surgical resection is a mainstay of colorectal cancer treatment, and prior studies have shown improved outcomes in patients undergoing surgery for colorectal cancer by colorectal surgical specialists compared with nonspecialized surgeons. Here, we examine the geographic distribution of colorectal surgeons in the United States and its relationship with sociodemographic characteristics of the served population. METHODS: The Area Health Resource File from 2017 to 2018 was used to identify the number and location of colorectal surgeons practicing throughout the United States and sociodemographic characteristics at the county and hospital referral region (HRR) level. The main outcomes of interest were the density of colorectal surgeons per 100,000 population and associations with sociodemographic characteristics at the county and HRR level based on multivariable linear regression. RESULTS: In multivariable analysis, regions with higher proportion of nonwhite individuals and college-educated individuals had significantly more colorectal surgeons per 100,000 population, whereas regions with higher proportions of uninsured individuals had significantly fewer colorectal surgeons per 100,000 population at both the county and HRR levels. CONCLUSIONS: Geographic and sociodemographic variability exists in the distribution of colorectal surgeons in the United States. Such variability may be contributing to disparities in access to specialized colorectal care.

Cytoreductive Surgery and HIPEC in an Enhanced Recovery After Surgery Program: A Feasibility Study.

BACKGROUND: Cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC) have historically been associated with high morbidity given the physiologic insult of an extensive operation. Enhanced Recovery after Surgery (ERAS) pathways have been successful in improving postoperative outcomes for many procedures but have not been well studied in these cases. We examined the feasibility and effect of ERAS pathway implementation for patients undergoing CRS/HIPEC. MATERIALS AND METHODS: Patients with peritoneal carcinomatosis who underwent CRS/HIPEC between October 2015 to September 2018 were identified. Patient characteristics, disease pathology, and perioperative outcome data were obtained. Primary outcomes were hospital length of stay (LOS), 30-d readmissions, renal dysfunction, and complications. RESULTS: Of the 31 patients who were included, 11 (35.5%) patients underwent CRS/HIPEC prior to the implementation of the ERAS pathway, and 20 (64.5%) patients underwent CRS/HIPEC according to the ERAS guidelines. There were no significant differences in the baseline clinical or pathologic characteristics between groups. There was a significant decrease in LOS with ERAS pathway management from 9 d to 6 d (P = 0.002). No patients from either cohort experienced acute kidney injury. There was no significant difference in 30-d readmission rates or complications. CONCLUSIONS: In this feasibility study, ERAS pathway utilization significantly decreased postoperative LOS for patients undergoing CRS/HIPEC, without evidence of increased complications or readmissions. ERAS programs should be considered for integration into future CRS/HIPEC protocols.

Treatment of stage I-III rectal cancer: Who is refusing surgery?

BACKGROUND AND OBJECTIVES: Surgical resection is a cornerstone in the management of patients with rectal cancer. Patients may refuse surgical treatment for several reasons although the rate of refusal is currently unknown. METHODS: The National Cancer Database was utilized to identify patients with stage I-III rectal cancer. Patients who refused surgical resection were compared to patients who underwent curative resection. RESULTS: A total of 509 (2.6%) patients with stage I and 2082 (3.5%) patients with stage II/III rectal cancer refused surgery. In multivariable analysis for stage I disease, older age, Black race, and Medicaid/no insurance were independent predictors of surgery refusal. Patients were less likely to refuse surgery if they had a higher income or lived further distances from the treatment facility. In multivariable analysis for stage II/III disease, older age, Black race, insurance other than private, and rural county were independent predictors of surgery refusal. Patients were less likely to refuse surgery if they had higher Charlson comorbidity scores, lived further distances from the treatment facility, or underwent chemoradiation. There was a significant decrease in survival for patients refusing surgery compared to patients undergoing recommended surgery. CONCLUSIONS: A small proportion of patients refuse surgery for rectal cancer, and this treatment decision significantly affects survival.

Sociodemographic predictors of surgery refusal in patients with stage I-III colon cancer.

BACKGROUND AND OBJECTIVES: Over 104 000 cases of colon cancer are estimated to be diagnosed in 2020. Surgical resection is a critical part of colon cancer treatment and adequate resection impacts prognosis. However, some patients refuse potentially curative surgery. We aimed to identify the rate and predictors of surgery refusal among patients with colon cancer. METHODS: The National Cancer Database (2004-2015) was queried for patients diagnosed with stage I-III colonic adenocarcinoma. Sociodemographic factors, clinical features, and treatment facility characteristics were collected. Patients who underwent surgery with curative intent were compared to those who refused surgery. Multivariable analysis was used to identify factors associated with surgery refusal. Adjusted survival analysis was performed on propensity-matched cohorts. RESULTS: A total of 151 020 patients were included and 1071 (0.71%) refused surgery. In multivariable analysis older age, Black race, higher Charlson comorbidity score, Medicaid, Medicare, or lack of insurance were predictive of refusing surgery. After propensity matching, there was a significant difference in 5-year survival for patients who refused surgery vs those who underwent surgery (P < .001). CONCLUSIONS: There are racial and socioeconomic disparities in the refusal of surgery for colon cancer. Further studies are needed to better understand the drivers behind differences in refusing curative surgery for colon cancer.

Surgical resection improves overall survival of patients with small bowel leiomyosarcoma.

PURPOSE: Small bowel leiomyosarcoma (SB LMS) is a rare disease with few studies characterizing its outcomes. This study aims to evaluate surgical outcomes for patients with SB LMS. METHODS: The National Cancer Database was queried from 2004 to 2016 to identify patients with SB LMS who underwent surgical resection. The primary outcome was overall survival. RESULTS: A total of 288 patients with SB LMS who had undergone surgical resection were identified. The median age was 63, and the majority of patients were female (56%), White (82%), and had a Charlson comorbidity score of zero (76%). Eighty-one percent of patients had negative margins following surgical resection. Fourteen percent of patients had metastatic disease at the time of diagnosis. Nineteen percent of patients received chemotherapy and 3% of patients received radiation. One-year overall survival was 77% (95% CI: 72-82%) and 5-year overall survival was 43% (95% CI: 36-49%). Higher grade (HR: 1.98, 95% CI: 1.10-3.55, p = 0.02) and metastatic disease at diagnosis (HR: 2.57, 95% CI: 1.45-4.55, p = 0.001) were independently associated with higher risk of death. CONCLUSION: SB LMS is a rare disease entity, with treatment centering on complete surgical resection. Our results demonstrate that overall survival is higher than previously thought. Timely diagnosis to allow for complete surgical resection is key, and investigation into the possible role of chemotherapy or radiation therapy is needed.

Colon Neuroendocrine Tumors: A New Lymph Node Staging Classification.

BACKGROUND: The American Joint Commission on Cancer, the European Neuroendocrine Tumor Society, and the North American Neuroendocrine Tumor Society all classify colon neuroendocrine tumor (NET) nodal metastasis as N0 or N1. This binary classification does not allow for further prognostication by the total number of positive lymph nodes. This study aimed to evaluate whether the total number of positive lymph nodes affects the overall survival for patients with colon NET. METHODS: The National Cancer Database was used to identify patients with colon NET. Nearest-neighborhood grouping was performed to classify patients by survival to create a new nodal staging system. The Surveillance, Epidemiology, and End Results database was used to validate the new nodal staging classification. RESULTS: Colon NETs were identified in 2472 patients. Distinct 5-year survival rates were estimated for the patients with N0 (no positive lymph nodes; 69.8%; 95% confidence interval [CI], 66.7-72.7%), N1a (1 positive lymph node; 63.9%; 95% CI, 59.6-68.0%), N1b (2-9 positive lymph nodes; 38.9%; 95% CI, 35.4-42.3%), and N2 (≥ 10 positive lymph nodes; 15.7%; 95% CI, 11.9-20.0%; p < 0.001) nodal classifications. The validation population showed distinct 5-year survival rates with the new nodal staging. In multivariable Cox regression, the new nodal stage was a significant independent predictor of overall survival. CONCLUSIONS: The number of positive locoregional lymph nodes in colon NETs is an independent prognostic factor. For patients with colon NETs, N0, N1a, N1b, and N2 classifications for nodal metastasis more accurately predict survival than current staging systems.

Survival in Patients with High-Grade Colorectal Neuroendocrine Carcinomas: The Role of Surgery and Chemotherapy.

BACKGROUND: Colorectal neuroendocrine tumors are a rare malignancy, yet their incidence appears to be increasing. The optimal treatment for the high-grade subset of these tumors remains unclear. We aimed to examine the relationship between different treatment modalities and outcomes for patients with high-grade neuroendocrine carcinomas (HGNECs) of the colon and rectum. METHODS: The National Cancer Database (2004-2015) was used to identify patients diagnosed with colorectal HGNECs. The primary outcome was overall survival. A Cox Proportional hazard model was used to identify risk factors for survival. RESULTS: Overall, 1208 patients had HGNECs; 452 (37.4%) patients had primary tumors of the rectum, and 756 (62.5%) patients had primary tumors of the colon. A total of 564 (46.7%) patients presented with stage IV disease. The median survival was 9.0 months [95% confidence interval (CI) 8.2-9.8]. In multivariable analysis, surgical resection [hazard ratio (HR) 0.54, 95% CI 0.44-0.66; p < 0.001], chemotherapy (HR 0.74, 95% CI 0.69-0.79; p < 0.001), and rectum as the primary site of tumor (HR 0.62, 95% CI 0.51-0.76; p < 0.001) were associated with better overall survival, while older age (HR 1.01, 95% CI 1.00-1.01; p = 0.02) and the presence of metastatic disease (HR 3.34, 95% CI 2.69-4.15; p < 0.001) were associated with worse survival. CONCLUSIONS: Patients with colorectal HGNECs selected for chemotherapy and surgical resection of the primary tumor demonstrated better overall survival than those managed without resection. Patients who were able to undergo systemic chemotherapy may benefit from potentially curative resection of the primary tumor.

Effect of Medicaid Expansion on Colorectal Cancer Screening Rates.

BACKGROUND: Colorectal cancer screening decreases incidence and improves survival. Minorities and low-income patients have lower screening rates. The Affordable Care Act increased insurance coverage for low-income Americans by funding Medicaid expansion. Not all states expanded Medicaid. The effect of Medicaid expansion on colorectal cancer screening is unknown. OBJECTIVE: This study aimed to evaluate if Medicaid expansion improved colorectal cancer screening for minorities and low-income patients. DESIGN: We used the Behavior Risk Factor Surveillance System, a nationally representative health-related telephone survey, to compare colorectal cancer screening rates from 2012 to 2016 based on Medicaid expansion status. A difference-in-difference analysis was used to compare the trends. SETTINGS: All states were included in this survey. PATIENTS: Respondents aged 50 to 64 from the early expansion, 2014 expansion, and nonexpansion states were selected. INTERVENTIONS: Medicaid expansion was funded by the Affordable Care Act. MAIN OUTCOME MEASURES: The primary outcome measured was the screening rate based on US Preventive Services Task Force guidelines. RESULTS: Overall screening in expansion states increased (early, +4.5%, p < 0.001; 2014, +1.3%, p = 0.17) compared with nonexpansion states. Screening among low-income respondents increased in early expansion states (+5.7%; p = 0.003), whereas there was no change in 2014 expansion states compared with nonexpansion states (2014, -0.3%, p = 0.89). For blacks, there was a significant increase in early expansion states, but no change in 2014 expansion states (early, +8.1%, p = 0.045; 2014, -1.5%, p = 0.64). There was no significant change for Hispanic respondents in early or 2014 expansion states compared with nonexpansion states (early, +6.5%, p = 0.11; 2014, +1.2%, p = 0.77). LIMITATIONS: Survey data are subject to response and recall bias. Factors other than Medicaid expansion may have influenced the screening rate. CONCLUSIONS: The colorectal cancer screening rate has increased in all settings, but expansion accelerated the increases in early expansion states and among low-income and black respondents; however, there was no similar increase for Hispanic respondents. It will be important to continue to monitor the effects of Medicaid expansion on colorectal cancer care, especially the incidence by stage and mortality. See Video Abstract at http://links.lww.com/DCR/A792.

Anatomic Distribution of Colorectal Adenocarcinoma in Young Patients.

BACKGROUND: The incidence of colorectal cancer has increased in the younger population. Studies show an increased prevalence of left-sided tumors in younger patients; however, exact anatomic distribution is not known. OBJECTIVE: We sought to determine the anatomic distribution of colorectal cancer in young patients and to calculate the proportion of tumors that would be within reach of a flexible sigmoidoscopy. DESIGN: The National Cancer Database (2004-2015) was used to identify patients with colorectal cancer. SETTINGS: This was a multicenter study using national data. PATIENTS: The study included 117,686 patients under the age of 50 years diagnosed with colorectal cancer and 1,331,048 patients over the age of 50 years diagnosed with colorectal cancer. MAIN OUTCOME MEASURES: The primary outcome was the proportion of left-sided tumors in patients under the age of 50 years. RESULTS: A total of 74.4% of patients under age 50 years and 56.1% of patients over age 50 years had left-sided colorectal cancer. LIMITATIONS: The study is a retrospective review and does not exclude young patients who developed colorectal cancer with familial syndromes with a colorectal cancer disposition. CONCLUSIONS: A total of 74.4% of colorectal cancers diagnosed before age 50 years are left sided. In light of recent changes to screening recommendations, distribution of disease in young patients is important to both provider and patient education and decision-making. See Video Abstract at http://links.lww.com/DCR/A966.

The role of adjuvant chemotherapy in stage II and III mucinous colon cancer.

INTRODUCTION: Mucinous adenocarcinoma is a subtype of colonic adenocarcinoma associated with worse survival compared to nonmucinous adenocarcinoma. Prior studies on the effect of chemotherapy on survival in mucinous adenocarcinoma have shown mixed results. The aim of this study is to evaluate the effect of chemotherapy on the survival of patients with stage II and III mucinous adenocarcinoma. METHODS: The National Cancer Database was used to identify patients diagnosed with stage II or III nonmucinous adenocarcinoma or mucinous adenocarcinoma between 2004 and 2016. The primary outcome was overall survival. RESULTS: Fourteen thousand and three hundred patients with stage II mucinous colon adenocarcinoma and 16 741 patients with stage III mucinous colon adenocarcinoma were identified. There was no significant difference in survival between nonmucinous adenocarcinoma and mucinous adenocarcinoma patients in adjusted analysis for stage II disease (HR:1.00, 95%CI:0.98-1.02, P = .99), but there was a significant difference for stage III disease (HR:1.05, 95%CI:1.03-1.07, P < .001). In propensity-matched cohorts of patients with mucinous adenocarcinoma, chemotherapy was significantly associated with survival in stage II (HR:0.79, 95%CI:0.69-0.90, P < .001) and stage III disease (HR:0.56, 95%CI:0.52-0.60, P < .001). CONCLUSIONS: Patients with stage II or stage III mucinous adenocarcinoma of the colon who are given adjuvant chemotherapy have significantly improved survival compared to patients not given chemotherapy.

Early versus late salvage abdominoperineal resection for anal squamous cell carcinoma: Is there a difference in survival?

BACKGROUND/OBJECTIVES: The first-line treatment for anal squamous cell carcinoma is Nigro protocol chemoradiotherapy. Some patients will fail curative intent chemoradiotherapy and have persistent disease while others may have an initial response followed by disease recurrence. The goal of this study is to investigate survival in anal squamous cell carcinoma patients who fail first-line treatment. METHODS: The National Cancer Database (2004-2013) was used to identify patients with anal squamous cell carcinoma. The primary outcome was overall survival. RESULTS: There were 256 patients in the early salvage group who underwent abdominoperineal resection (APR) within 6 months of completing chemoradiotherapy and 181 patients in the late salvage group who had APR 6 months or more after completion of chemoradiotherapy. Both groups of patients had similar tumor size (45 vs 50 mm; P = 0.07) and rate of positive margins (21.5% vs 15.6%;P = 0.13). There was no significant difference in overall survival between early and late salvage APR (hazard ratio [HR]: 0.81; 95% confidence interval [CI]: 0.50-1.32; P = 0.40). CONCLUSIONS: The overall survival of anal squamous cell carcinoma patients undergoing early vs late salvage APR after failure of chemoradiotherapy is similar. As a result, patients with persistent disease should be offered surgery just as readily as those with recurrent disease.

Treatment patterns and outcomes in goblet cell carcinoid tumors of the appendix.

BACKGROUND: Goblet cell carcinoid (GCC) tumors of the appendix are a rare malignancy. We aim to examine the overall survival per stage and the relationship between different treatment modalities and outcomes for patients with GCC tumors of the appendix. METHODS: We identified patients with GCC tumors of the appendix from the National Cancer Database. The main outcome was overall patient survival and cox proportional hazard models were used to ascertain predictors of survival. RESULTS: There were 2552 patients identified. The median age of diagnosis was 57 (interquartile range: 49-65) and 52.3% of patients were female. The 5-year survival for Stage I disease was 91.1% (95% confidence interval [CI]: 82.2%-95.7%), for Stage II disease was 90.5% (95% CI: 85.8%-93.7%), for Stage III disease was 57.0% (95% CI: 45.0%-67.3%), and for Stage IV disease was 18.9% (95% CI: 9.3%-31.0%). In a Cox proportional hazard model, older age (hazard ratio [HR]: 1.1; 95% CI: 1.03-1.12; P < .001), lymph node metastasis (HR: 6.9; 95% CI: 2.76-17.01; P < .001), and positive surgical margins (HR: 2.9; 95% CI:1.13-7.26; P = .003) were associated with worse overall survival for Stages I to III disease while only older age (HR: 1.03; 95% CI: 1.002-1.06; P = .04) was associated with worse overall survival for Stage IV disease. CONCLUSIONS: Patients with GCC tumors of the appendix who have the nonmetastatic disease have a high 5-year survival. We have identified several prognostic factors for GCC.

Does race impact survival for patients with anal squamous cell carcinoma?

BACKGROUND/OBJECTIVES: Racial disparities are known to impact cancer outcomes. The aim of this study was to assess current racial disparities in outcomes of anal squamous cell carcinoma (SCC). METHODS: The National Cancer Database was used to identify patients with anal SCC. The primary outcome was 5-year overall survival. RESULTS: There were 32 255 (88.1%) White patients and 4342 (11.9%) Black patients identified with anal SCC. Compared to White patients, Black patients were more likely to be younger, have lower median income, and be insured with Medicaid (all P < .001). The 5-year overall survival of Black and White patients for stage I disease was 71.2% and 80.6% (P < .001), for stage II disease, was 64.6% and 69.3% (P = .001), for stage III disease was 50.9% and 58.1% (P < .001), and for stage IV disease was 22.1% and 21.9% (P = .20). In a cox regression analysis, Black race was associated with significantly worse survival in stage I (HR: 1.37, 95% CI: 1.07-1.76, P = .01), stage II (HR: 1.30, 95% CI: 1.14-1.48, P < .001), and stage III disease (HR: 1.31, 95% CI: 1.16-1.47, P < .001) but not for stage IV disease (HR: 1.09, 95% CI: 0.89-1.35, P = .41). CONCLUSIONS: Black race is correlated with worse survival in patients diagnosed with anal SCC. This disparity in survival is likely multifactorial and requires further study.

New lymph node staging for rectal neuroendocrine tumors.

BACKGROUND AND OBJECTIVES: Current guidelines of the American Joint Commission on Cancer (AJCC) for rectal neuroendocrine tumors (NETs) classify tumor nodal status as N0/N1. This staging does not take into consideration the number of positive lymph nodes. The goal of this study is to determine how the number of positive lymph nodes affects the prognosis for patients with rectal NETs. METHODS: The National Cancer Database was used to identify patients with rectal NETs who underwent rectal resection. Nearest-neighborhood grouping was used to classify patients by survival to create a new nodal staging system. RESULTS: There were 687 patients with rectal NETs. There were distinct 5-year survival estimates for patients with N0 [81.8% (95%CI:77.1%-85.6%)], N1 (1-4 positive lymph nodes) [57.8% (95% confidence interval (CI: 51.2%-63.9%)] and N2 (≥5 positive lymph nodes) [32.6% (95%CI:25.1%-40.3%)] patients, P < 0.0001. Distinct 5-year survival estimates using the new nodal staging system was apparent for patients in the external validation set. After adjusting for predictors of survival in multivariable analysis, the new nodal stage remained an independent predictor of overall survival. CONCLUSIONS: The number of positive locoregional lymph nodes is an independent prognostic factor in rectal NETs. The next AJCC edition should consider classifying patients with rectal NETs as N0, N1, and N2 to provide better estimates of survival for patients.

Risk of appendiceal cancer in patients undergoing appendectomy for appendicitis in the era of increasing nonoperative management.

BACKGROUND AND OBJECTIVES: Management practices for acute appendicitis are changing. In cases of nonoperative treatment, the risk of missed or delayed diagnosis of malignancy should be considered. We aimed to identify predictors associated with appendiceal cancer diagnosis after appendectomy for acute appendicitis. MATERIALS AND METHODS: This retrospective cohort study was performed using the National Surgical Quality Improvement Program (NSQIP) appendectomy-targeted data set from 2016 to 2017. A total of 21 069 patients with imaging-confirmed or imaging indeterminate appendicitis who underwent appendectomy were included. Logistic regression was used to identify predictors of cancer diagnosis. RESULTS: Increasing age had an increasing monotonic relationship with the odds of pathologic cancer diagnosis after appendectomy (age 50-59 odds ratio [OR], 2.08, 95% confidence interval [CI], 1.28-3.39, P = .003; age 60-69 OR, 2.89, 95% CI, 1.72-4.83, P < .001; age 70-79 OR, 3.85, 95% CI, 2.08-7.12, P < .001; age >80 OR, 5.32, 95% CI, 2.38-11.9, P < .001). Other significant predictors included obesity, morbid obesity, normal preoperative white blood cell count, and imaging indeterminate for appendicitis. CONCLUSIONS: When counseling patients regarding operative vs nonoperative treatment options for management of acute appendicitis, the rising risk of a delayed or missed cancer diagnosis with increasing age must be discussed.

Omental flaps in patients undergoing abdominoperineal resection for rectal cancer.

BACKGROUND: Following abdominoperineal resection (APR) for rectal cancer, perineal wound complications are common. Omental flap creation may allow for decreased morbidity. The aim of this study was to assess wound complications in rectal cancer patients undergoing APR with and without the addition of an omental flap. METHODS: The National Surgical Quality Improvement Program Proctectomy targeted database from 2016 to 2017 was used to identify all patients undergoing APR for rectal cancer. The primary outcomes were wound complications such as superficial site infection, deep wound infection, organ space infection, and wound dehiscence. RESULTS: There were 3063 patients identified. One hundred seventy-three (5.6%) patients underwent APR with an omental flap repair while 2890 (94.4%) patients underwent APR without an omental flap repair. Patients in both groups were similar with regard to age, gender, body mass index, American Society of Anesthesia class, and neoadjuvant cancer treatment (all p > 0.05). Patients who underwent an omental flap repair were significantly more likely to have a postoperative organ space infection (10.4% vs. 6.5%, p = 0.04). There was no significant difference in rates of superficial site infection, deep wound infection, wound dehiscence, or reoperation between the two patient groups. In multivariable analysis, omental flap creation was independently associated with organ space infection (OR 1.72, 95%CI 1.02-2.90, p = 0.04). CONCLUSIONS: This is the largest study to evaluate omental flap use in rectal cancer patients undergoing APR. Omental flaps are independently associated with organ space infection.

Contemporary Surgical Management and Outcomes for Anal Melanoma: A National Cancer Database Analysis.

BACKGROUND: Anal melanoma is a rare disease with a poor prognosis. Limited data are available regarding oncologic outcomes during the last decade and surgical practice patterns. This study aimed to investigate survival and operative oncologic outcomes for patients with anal melanoma. METHODS: The National Cancer Database (2004-2013) was used to identify patients with nonmetastatic anal melanoma who underwent surgical treatment. The primary outcome was overall survival. RESULTS: The study enrolled 439 patients in the local excision group and 214 patients in the abdominoperineal resection (APR) group. The patients in the APR group were older (70 vs 65 years; p < 0.001) and had larger tumors (40 vs 25 mm; p < 0.001). After resection, the APR patients were more likely to have positive lymph nodes (65.7% vs 12.5%; p < 0.001) and less likely to have positive margins (10% vs 29.8%; p < 0.001). Overall survival did not differ significantly between the APR and local excision patients (hazard ratio [HR], 0.82; 95% confidence interval [CI], 0.67-1.01; p = 0.06). The patients undergoing local excision showed was a significant survival advantage for those with negative margins (HR, 0.70, 95% CI, 0.53-0.93; p = 0.009). Among the patients undergoing APR, a significant survival advantage was observed for those with negative nodes (HR, 0.50; 95% CI, 0.35-0.69; p = 0.002) and negative margins (HR, 0.34; 95% CI, 0.15-0.77; p < 0.001). CONCLUSIONS: The overall survival of anal melanoma patients is similar after local excision and APR. Patients with positive margins, positive lymph nodes, or both have a significantly decreased overall survival.