Racial and Ethnic Disparities in Operative Experience Among General Surgery Residents: A Multi-Institutional Study from the US ROPE Consortium.

OBJECTIVE: To determine the relationship between race/ethnicity and case volume among graduating surgical residents. BACKGROUND: Racial/ethnic minority individuals face barriers to entry and advancement in surgery; however, no large-scale investigations of the operative experience of racial/ethnic minority residents have been performed. METHODS: A multi-institutional retrospective analysis of the Accreditation Council for Graduate Medical Education case logs of categorical general surgery residents at 20 programs in the US Resident OPerative Experience Consortium database was performed. All residents graduating between 2010 and 2020 were included. The total, surgeon chief, surgeon junior, and teaching assistant case volumes were compared between racial/ethnic groups. RESULTS: The cohort included 1343 residents. There were 211 (15.7%) Asian, 65 (4.8%) Black, 73 (5.4%) Hispanic, 71 (5.3%) "Other" (Native American or Multiple Race), and 923 (68.7%) White residents. On adjusted analysis, Black residents performed 76 fewer total cases (95% CI, -109 to -43, P <0.001) and 69 fewer surgeon junior cases (-98 to -40, P <0.001) than White residents. Comparing adjusted total case volume by graduation year, both Black residents and White residents performed more cases over time; however, there was no difference in the rates of annual increase (10 versus 12 cases per year increase, respectively, P =0.769). Thus, differences in total case volume persisted over the study period. CONCLUSIONS: In this multi-institutional study, Black residents graduated with lower case volume than non-minority residents throughout the previous decade. Reduced operative learning opportunities may negatively impact professional advancement. Systemic interventions are needed to promote equitable operative experience and positive culture change.

A multi-institutional study from the US ROPE consortium examining factors associated with endocrine surgery exposure for general surgery residents.

BACKGROUND: Prior analyses of general surgery resident case logs have indicated a decline in the number of endocrine procedures performed during residency. This study aimed to identify factors contributing to the endocrine operative experience of general surgery residents and compare those who matched in endocrine surgery fellowship with those who did not. METHODS: We analyzed the case log data of graduates from 18 general surgery residency programs in the US Resident Operative Experience Consortium over an 11-year period. RESULTS: Of the 1,240 residents we included, 17 (1%) matched into endocrine surgery fellowships. Those who matched treated more total endocrine cases, including more thyroid, parathyroid, and adrenal cases, than those who did not (81 vs 37, respectively, P < .01). Program-level factors associated with increased endocrine volume included endocrine-specific rotations (+10, confidence interval 8-12, P < .01), endocrine-trained faculty (+8, confidence interval 7-10, P < .01), and program co-location with otolaryngology residency (+5, confidence interval 2 -8, P < .01) or endocrine surgery fellowship (+4, confidence interval 2-6, P < .01). Factors associated with decreased endocrine volume included bottom 50th percentile in National Institute of Health funding (-10, confidence interval -12 to -8, P < .01) and endocrine-focused otolaryngologists (-3, confidence interval -4 to -1, P < .01). CONCLUSION: Several characteristics are associated with a robust endocrine experience and pursuit of an endocrine surgery fellowship. Modifiable factors include optimizing the recruitment of dedicated endocrine surgeons and the inclusion of endocrine surgery rotations in general surgery residency.

A Growing Divide? Social Determinants of the Use of Nonoperative Management of Rectal Cancer and Its Impact on Survival.

INTRODUCTION: Nonoperative management (NOM) of locally advanced rectal cancer was described as early as 2004. Initial national data demonstrated increase in utilization of NOM from 1998 to 2010, but newer national utilization data are not available. METHODS: We performed a retrospective cohort study using the National Cancer Database to assess utilization and 5-y overall survival (OS) of NOM of locally advanced rectal cancer. All patients had American Joint Committee on Cancer stage 2 or 3 rectal cancer, were over 40 y old, received both chemotherapy and radiation therapy, and were not being treated with palliative intent. RESULTS: 74,780 patients were analyzed. 64,540 (86.2%) underwent a definitive resection, 10,330 (13.8%) had NOM. Utilization of NOM steadily increased from 11.3% in 2010 to 18.6% in 2018. Multivariate regression identified the highest predictors of utilization of NOM to be uninsured status, government insurance, Black race, and treatment at a community cancer center. Multivariate regression identified NOM as the highest hazard for mortality (hazard ratio = 2.286, confidence interval 2.209-2.366). After propensity score matching, the mean estimated 5-y OS was 52.0% for those managed operatively compared to 39.8% for those managed nonoperatively. CONCLUSIONS: From 2004 to 2018, the utilization of NOM of locally advanced rectal cancer significantly increased. However, there was a significant discrepancy in OS in comparison to surgical resection for these patients. Further study is needed to determine the long-term oncologic safety of NOM.

Lymph node retrieval colon cancer: Are we making the grade?

BACKGROUND: Adequate lymph node (LN) excision is imperative for pathologic staging and determination of adjuvant treatment. METHODS: he 2004-2017 National Cancer Database (NCDB) was queried for curative colon cancer resections. Tumors were categorized by location: left, right, and transverse colon cancers. Adequate (12-20 LNs) vs. inadequate (<12 LNs) lymphadenectomy was examined and sub-analysis of <12 LNs, 12-20 LNs or >20 LNs. Primary outcome was predictors of inadequate lymph node retrieval. RESULTS: Of 101,551 patients, 11.2% (11,439) had inadequate lymphadenectomy. The inadequate lymphadenectomy rate steadily decreased. On multivariable analysis, inadequate LN retrieval was associated with transverse (OR 1.49, CI [1.30-1.71]) and left colon cancers (OR 2.66, CI [2.42-2.93], whereas income >$63,333 had decreased likelihood of inadequate LN retrieval (OR 0.68, CI[0.56-0.82]. CONCLUSION: We are making the grade as NCDB data demonstrates a steady decrease in inadequate lymphadenectomy (2004-2017). There remain socioeconomic risk factors for inadequate lymphadenectomy that need to be addressed.

The Presence of Implicit Gender Bias in Colon and Rectal Surgery Residency Letters of Recommendation.

BACKGROUND: Selection for colorectal surgery residency relies on letters of recommendation for assessment of candidates' strengths and weaknesses. It is unclear whether this process incorporates implicit gender bias. OBJECTIVE: This study aimed to assess the presence of gender bias in letters of recommendation for colorectal surgery residency. DESIGN: Mixed methods assessment of the characteristics described within the blinded letters of the 2019 application cycle to a single academic residency. SETTINGS: Academic medical center. PATIENTS: Blinded letters from the 2019 colorectal surgery residency application cycle. INTERVENTIONS: Characteristics of the letters were qualitatively and quantitatively analyzed. MAIN OUTCOME MEASURES: Association of gender with the presence of descriptors within the letters. RESULTS: A total of 111 applicants, 409 letter writers, and 658 letters were analyzed. Forty-three percent of applicants were female. Female and male applicants had an equal mean number of positive (5.4 vs 5.8; p = 0.10) and negative (0.5 vs 0.4; p = 0.07) attributes represented. Female applicants were more likely to be described as having poor academic skills (6.0 vs 3.4%; p = 0.04) and possessing negative leadership qualities (5.2% vs 1.4%; p < 0.01) than male applicants. Male applicants were more likely to be described as kind (36.6% vs 28.3%; p = 0.03), curious (16.4% vs 9.2%; p = 0.01), possessing positive academic skills (33.7% vs 20.0%; p < 0.01), and possessing positive teaching skills (23.5% vs 17.0%; p = 0.04). LIMITATIONS: This study analyzed a single year of applications to an academic center and may not be generalizable. CONCLUSIONS: There are differences in the qualities used to describe female versus male applicants in colorectal surgery residency application letters of recommendation. Female applicants were more often described in negative academic terms and possessing negative leadership qualities. Males were more likely to be described as kind, curious, academically impressive, and possessing good teaching skills. The field may benefit from educational initiatives to reduce implicit gender bias in letters of recommendation. See Video Abstract at http://links.lww.com/DCR/C191 . LA PRESENCIA DE SESGO DE GNERO IMPLCITO EN LAS CARTAS DE RECOMENDACIN DE RESIDENCIA EN CIRUGA DE COLON Y RECTO: ANTECEDENTES:La selección para la residencia en cirugía colorrectal se basa en cartas de recomendación para la evaluación subjetiva de las fortalezas y debilidades de los candidatos. No está claro si este proceso incorpora un sesgo de género implícito.OBJETIVO:Evaluar la presencia de sesgo de género en las cartas de recomendación para la residencia en cirugía colorrectal.DISEÑO:Evaluación de métodos mixtos de las características descritas dentro de las cartas selladas del ciclo de solicitud de 2019 a una sola residencia académica.ENTORNO CLÍNICO:Centro médico académico.PACIENTES:Cartas selladas del ciclo de solicitud de residencia en cirugía colorrectal de 2019.INTERVENCIONES:Las características de las cartas se determinaron utilizando medidas cualitativas y cuantitativas.PRINCIPALES MEDIDAS DE VALORACIÓN:Asociación del género con la presencia de descriptores dentro de las cartas.RESULTADOS:Hubo 111 solicitantes, 409 escritores de cartas y se analizaron 658 cartas. El 43% de los solicitantes eran mujeres. Los solicitantes masculinos y femeninos tenían el mismo promedio de atributos positivos (5,4 frente a 5,8; p = 0,10) y negativos (0,5 frente a 0,4; p = 0,07) representados. Las solicitantes femeninas tenían más probabilidades de ser descritas como con deficientes habilidades académicas (6,0 frente a 3,4%, p = 0,04) y poseían cualidades de liderazgo negativas (5,2% frente a 1,4%; p < 0,01) en comparacion con los solicitantes masculinos. Los solicitantes masculinos tenían más probabilidades de ser descritos como amables (36,6 % frente a 28,3%; p = 0,03), curiosos (16,4% frente a 9,2%; p = 0,01), que poseían habilidades académicas positivas (33,7 % frente a 20,0%; p < 0,01), y habilidades docentes positivas (23,5% vs 17,0%; p = 0,04).LIMITACIONES:Este estudio analizó un solo año de solicitudes a un centro académico y puede no ser generalizable.CONCLUSIÓN:Existen diferencias en las cualidades utilizadas para describir a los solicitantes femeninos versus masculinos en las cartas de recomendación de solicitud de residencia en cirugía colorrectal. Las candidatas femeninas se describieron con mayor frecuencia en términos académicos negativos y poseían cualidades de liderazgo negativas. Los hombres eran más propensos a ser descritos como amables, curiosos, académicamente impresionantes y con buenas habilidades docentes. El campo puede beneficiarse de iniciativas educativas para reducir el sesgo de género implícito en las cartas de recomendación. Consulte Video Resumen en http://links.lww.com/DCR/C191 . (Traducción-Dr. Ingrid Melo ).

Disparities in the Operative Experience Between Female and Male General Surgery Residents: A Multi-institutional Study From the US ROPE Consortium.

OBJECTIVE: To examine differences in resident operative experience between male and female general surgery residents. BACKGROUND: Despite increasing female representation in surgery, sex and gender disparities in residency experience continue to exist. The operative volume of male and female general surgery residents has not been compared on a multi-institutional level. METHODS: Demographic characteristics and case logs were obtained for categorical general surgery graduates between 2010 and 2020 from the US Resident OPerative Experience Consortium database. Univariable, multivariable, and linear regression analyses were performed to compare differences in operative experience between male and female residents. RESULTS: There were 1343 graduates from 20 Accreditation Council for Graduate Medical Education-accredited programs, and 476 (35%) were females. There were no differences in age, race/ethnicity, or proportion pursuing fellowship between groups. Female graduates were less likely to be high-volume residents (27% vs 36%, P < 0.01). On univariable analysis, female graduates performed fewer total cases than male graduates (1140 vs 1177, P < 0.01), largely due to a diminished surgeon junior experience (829 vs 863, P < 0.01). On adjusted multivariable analysis, female sex was negatively associated with being a high-volume resident (OR = 0.74, 95% CI: 0.56 to 0.98, P = 0.03). Over the 11-year study period, the annual total number of cases increased significantly for both groups, but female graduates (+16 cases/year) outpaced male graduates (+13 cases/year, P = 0.02). CONCLUSIONS: Female general surgery graduates performed significantly fewer cases than male graduates. Reassuringly, this gap in operative experience may be narrowing. Further interventions are warranted to promote equitable training opportunities that support and engage female residents.

Discharge Prescribing Protocol Decreases Opioids in Circulation and Does Not Increase Refills After Colorectal Surgery.

BACKGROUND: Up to 10% of patients develop new, persistent opioid use after surgery. We aimed to assess our prescribing practices and patient utilization of opioids after colorectal surgery. OBJECTIVE: This study aimed to implement an opioid-prescribing protocol that will minimize the number of postoperative opioids to decrease community circulation and persistent use by patients. DESIGN: This was a single-institution, prospective study based on questionnaires of postoperative patients in 2019 and 2020 to determine opioid prescribing and usage patterns. Based on these preliminary results, a protocol was implemented in which patients were discharged with 5 or 15 oxycodone 5 mg equivalents based on opioid usage in the 24 hours before discharge. Patients were surveyed after protocol implementation. SETTINGS: Our institution is a large referral center for surgical treatment of colorectal disease. PATIENTS: Adults who underwent inpatient abdominal colorectal procedures. MAIN OUTCOME MEASURES: End points included the number of opioids prescribed, number of prescribed opioids taken, and refill rate. Nonparametric testing was used. RESULTS: Of 77 eligible patients, 61 were opioid naive. Preprotocol, opioid-naive patients (n = 29) were prescribed a median of 30 (interquartile range [IQR], 30-45) tablets but took only 10 (IQR, 0-10; p < 0.0001). Eighty-three percent took 20 or fewer tablets. After protocol implementation, opioid-naive patients (n = 32) were prescribed fewer tablets (median 15; IQR, 7-15; p < 0.0001) but took a similar number of tablets as the preprotocol group (median 10; IQR, 0-10; p = 0.21). The refill rate remained similar (13.8% vs 18.8%; p = 0.60). Protocol adherence was 90.6%. LIMITATIONS: This study is limited by sample size, cohort heterogeneity, and generalizability. CONCLUSIONS: Patients took significantly fewer opioids than were prescribed. Our protocol limited overprescribing and resulted in fewer opioids in the community without opportunity costs such as increased refills. Long-term studies are needed to assess the effects of persistent opioid use after surgery. See Video Abstract at http://links.lww.com/DCR/C93 .

ANTECEDENTES: Hasta el 10% de los pacientes desarrollan un nuevo uso persistente de opioides después de la cirugía. Nuestro objetivo fue evaluar nuestras prácticas de prescripción y la utilización de opioides por parte de los pacientes después de la cirugía colorrectal. OBJETIVO: Nuestro objetivo es implementar un protocolo de prescripción de opioides que minimice la cantidad de opioides posoperatorios para disminuir la circulación en la comunidad y el uso persistente por parte de los pacientes. DISEÑO: Estudio prospectivo, de una sola institución, basado en cuestionarios de pacientes postoperatorios en 2019 y 2020 para determinar los patrones de prescripción y uso de opioides. Con base en estos resultados preliminares, se implementó un protocolo en el que los pacientes eran dados de alta con 5 o 15 equivalentes de oxicodona de 5 mg según el uso de opioides en las 24 horas previas al alta. Los pacientes fueron encuestados después de la implementación del protocolo. AJUSTES: Nuestra institución es un gran centro de referencia para el tratamiento quirúrgico de la enfermedad colorrectal. PACIENTES: Adultos que se sometieron a procedimientos colorrectales abdominales con hospitalización. PRINCIPALES MEDIDAS DE RESULTADO: Los criterios de valoración incluyeron el número de opioides recetados, el número de opioides recetados tomados y la tasa de reabastecimiento. Se utilizaron pruebas no paramétricas. RESULTADOS: De 77 pacientes elegibles, 61 no habian recibido opioides. A los pacientes sin tratamiento previo con opioides antes del protocolo (n = 29) se les prescribió una mediana de 30 (rango intercuartilico [RIC] 30­45) comprimidos, pero solo tomaron 10 (RIC 0.10, p < 0,0001). El ochenta y tres por ciento tomo ≤20 comprimidos. Despues de la implementacion del protocolo, a los pacientes sin tratamiento previo con opioides (n = 32) se les prescribieron menos comprimidos (15; RIC 7.15, p < 0,0001), pero tomaron un numero similar antes de la intervención (10; RIC 0­10, p = 0,21). La tasa de reabastecimiento se mantuvo similar (13,8% frente a 18,8%, p = 0,60). La adherencia al protocolo fue del 90,6%. LIMITACIONES: Este estudio está limitado por el tamaño de la muestra, la heterogeneidad de la cohorte y la generalización. CONCLUSIONES: Los pacientes tomaron significativamente menos opioides de los prescritos. Nuestro protocolo limitó la prescripción excesiva y dio como resultados menos opioides en la comunidad sin costos de oportunidad, como el aumento de reabastecimiento. Se necesitan estudios a largo plazo para evaluar los efectos sobre el uso persistente de opioides después de la cirugía. Consulte Video Resumen en http://links.lww.com/DCR/C93 . (Traducción­Dr. Francisco M. Abarca-Rendon).

Standardized Letter of Recommendation: Can Everyone Be Awesome?

OBJECTIVE: Standardized letters of recommendation (SLOR) are hypothesized to decrease bias and provide consistent domains for evaluation. However, their ability to differentiate among applicants is unknown. The utilization and functionality of SLOR and the impact of SLOR domain rating on matching for colon and rectal surgery (CRS) residency applicants have yet to be assessed. DESIGN: Descriptive statistics and bivariate analysis were employed. Applicants were categorized into 3 groups; Top-tier(TT): applicants rated 100% Excellent/Very Good; Mid-Tier(MT) applicants rated 80-99% Excellent/Very Good; and Non-Top Tier(NTT) applicants rated <80% Excellent/Very Good. SETTING: University of Hospitals Cleveland Medical Center. PARTICIPANTS: SLORs submitted to a single colorectal surgery residency in 2019 were analyzed RESULTS: A total of 101 applicants were included, 54 (53.5%) of the applicants were male. 75 (74.2%) applicants who applied to our residency matched into a CRS residency, compared to the national rate of 66%. Of the 101 applicants with SLOR, 54 (53.5%) were categorized as TT, 26 (25.7%) as MT, and 21(20.8%) as NTT. The univariable analysis demonstrated a statistically significant difference in research experience (p=0.029) and match status (p=0.01) between applicant tiers. There were no statistically significant differences between applicant-tier and demographics, foreign medical graduates (FMG), H-indices, ABSITE scores, type of residency, preliminary year, completing an unaccredited CRS, and applicants with an additional degree. On multivariable analysis age (OR=0.65; CI=0.48-0.87) and FMG applicants (OR=0.05; CI=0.01-0.44) were inversely associated with successfully matching. Compared to TT applicants, MT (OR=0.07; CI=0.01-0.57) and NTT (OR=0.04; CI=0.01-0.34) applicants were inversely associated with a successful match. Individuals who completed research prior to residency but after medical school was associated with successfully matching (p=0.009). CONCLUSIONS: The presence of MT and NTT ratings is associated with failure to match and may represent an area of concern for CRS programs rather than a tool to discern differences between candidates.

Impact of the first COVID-19 surge on the outcomes of diverticulitis.

Introduction: During the first surge of the COVID-19 pandemic, healthcare utilization changed. We sought to examine the impact of the first COVID-19 surge on the outcomes of patients whose elective surgeries for diverticulitis were postponed and those who underwent urgent surgery during the surge. Materials and methods: This was a retrospective study from a single tertiary center in the Northeast of the US. Patients whose elective surgeries were delayed, or who underwent urgent surgery for diverticulitis during the first COVID-19 surge (3/16/2020 to 8/1/2020) were included. A cohort from 2019 was used for comparison. Variables were compared between groups including: procedure, death, length of stay, disposition, stoma rate, technique for surgery, and leak rate. Results: Forty-five patients were included in the COVID-19 group and 44 patients in the 2019 group. Twenty-seven patients had elective surgeries delayed during the COVID-19 surge. Ten (37%) required more urgent surgery, 80% with complicated disease. Six (22%) were admitted to the hospital and 13 (48%) required additional antibiotics. Eight (30%) patients postponed their surgeries indefinitely and 7 (26%) had surgery once permitted. There were no observed differences between the two groups in the rate of complicated disease, leaks, technique for surgery or stoma rate. Conclusions: During the first COVID-19 surge, over 1/3 of patients whose elective diverticulitis surgeries were postponed required urgent surgery, a majority of whom had complicated disease. There were no apparent differences in outcomes when compared to a pre-pandemic cohort, highlighting the importance of a triage system with the ability to escalate surgery in a timely manner.

A multi-institutional study from the US ROPE Consortium examining factors associated with directly entering practice upon residency graduation.

BACKGROUND: There is concern regarding the competency of today's general surgery graduates as a large proportion defer independent practice in favor of additional fellowship training. Little is known about the graduates who directly enter general surgery practice and if their operative experiences during residency differ from graduates who pursue fellowship. METHODS: Nineteen Accreditation Council for Graduate Medical Education-accredited general surgery programs from the US Resident OPerative Experience Consortium were included. Demographics, career choice, and case logs from graduates between 2010 to 2020 were analyzed. RESULTS: There were 1,264 general surgery residents who graduated over the 11-year period. A total of 248 (19.6%) went directly into practice and 1,016 (80.4%) pursued fellowship. Graduates directly entering practice were more likely to be a high-volume resident (43.1% vs 30.5%, P < .01) and graduate from a high-volume program (49.2% vs 33.0%, P < .01). Direct-to-practice graduates performed 53 more cases compared with fellowship-bound graduates (1,203 vs 1,150, P < .01). On multivariable analysis, entering directly into practice was positively associated with total surgeon chief case volume (odds ratio = 1.47, 95% confidence interval 1.18-1.84, P < .01) and graduating from a US medical school (odds ratio = 2.54, 95% confidence interval 1.45-4.44, P < .01) while negatively associated with completing a dedicated research experience (odds ratio = 0.31, 95% confidence interval 0.22-0.45, P < .01). CONCLUSION: This is the first multi-institutional study exploring resident operative experience and career choice. These data suggest residents who desire immediate practice can tailor their experience with less research time and increased operative volume. These data may be helpful for programs when designing their experience for residents with different career goals.

Management of Early-Stage Rectal Cancer.

CASE SUMMARY: A 59-year-old man underwent screening colonoscopy that identified a 2-cm rectal polyp in the posterior midline, 7 cm from the anal verge. Biopsy revealed a tubular adenoma with high-grade dysplasia. The patient underwent a robotic-assisted transanal minimally invasive surgery with full-thickness excision (Fig. 1). Final pathology confirmed a well-differentiated adenocarcinoma extending into the submucosa (sm2). There was no lymphovascular or perineural invasion, and the radial margin was 5 mm.

Travel Time to a High Volume Center Negatively Impacts Timing of Care in Rectal Cancer.

BACKGROUND: Regionalization of rectal cancer surgery may lead to worse disease free survival owing to longer travel time to reach a high volume center yet no study has evaluated this relationship at a single high volume center volume center. MATERIALS AND METHODS: This was a retrospective review of rectal cancer patients undergoing surgery from 2009 to 2019 at a single high volume center. Patients were divided into two groups based on travel time. The primary outcome was disease-free survival (DFS). Additional outcomes included treatment within 60 d of diagnosis, completeness of preoperative staging, and evaluation by a colorectal surgeon prior to initiation of treatment. RESULTS: A lower proportion of patients with long travel time began definitive treatment within 60 d of diagnosis (74.0% versus 84.0%, P= 0.01) or were seen by the treating colorectal surgeon before beginning definitive treatment (74.8% versus 85.4%, P < 0.01). On multivariable logistic regression analysis, patients with long travel time were significantly less likely to begin definitive treatment within 60 d of diagnosis (OR = 0.54; 95% CI = 0.31-0.93) or to be evaluated by a colorectal surgeon prior to initiating treatment (OR = 0.45; 95% CI = 0.25-0.80). There were no significant differences in DFS based on travel time. CONCLUSIONS: Although patients with long travel times may be vulnerable to delayed, lower quality rectal cancer care, there is no difference in DFS when definitive surgery is performed at a high volume canter. Ongoing research is needed to identify explanations for delays in treatment to ensure all patients receive the highest quality care.

Delaying definitive resection in early stage (I/II) colon cancer appears safe up to 6 weeks.

BACKGROUND: The objective of this study was to determine if there is an impact of surgical delay on 5-year overall survival (OS) from early stage colon cancer, and if so, to define how long surgery can safely be postponed. METHODS: Using the NCDB, we compared early (14-30 days) and delayed surgery (31-90 days) in patients with Stage I/II colon cancer. Outcomes included OS at five years and odds of death. RESULTS: Delayed resection conferred a decreased 5-year OS of 73.0% (95% CI, 72.6-73.4), compared to early resection 78.3% (95% CI, 77.9-78.8). When time to surgery was divided into one-week intervals, there was no difference in the odds of death with delay up to 35-41 days (6 weeks), but odds of death increased by 9% per week thereafter. CONCLUSIONS: These data support that definitive resection for early stage colon cancer may be safely delayed up to 6 weeks.

Colonic Stents as a Bridge to Surgery Compared with Immediate Resection in Patients with Malignant Large Bowel Obstruction in a NY State Database.

BACKGROUND: There is controversy surrounding the efficacy and safety of colonic stents as a bridge to surgery compared with immediate resection in patients presenting with an acute malignant large bowel obstruction. METHODS: Retrospective longitudinal cohort study using the NYS SPARCS Database. Patients with acute malignant large bowel obstruction who either had stent followed by elective surgery within 3 weeks (bridge to surgery) or underwent immediate resection between October 2009 and June 2016 in the state of New York were included. The primary outcome was rate of stoma creation at index resection. Secondary outcomes were 90-day readmission, reoperation, procedural complications, and discharge disposition. RESULTS: A total of 3059 patients were included, n = 2917 (95.4%) underwent an immediate resection and n = 142 (4.6%) underwent bridge to surgery. We analyzed 139 patients in propensity score-matched groups. Patients in the bridge to surgery group were less likely than those in the immediate resection group to get a stoma at the time of surgery (OR 0.33, 95% CI 0.18-0.60). They were also less likely to be discharged to a rehabilitation facility or require a home health aide upon discharge (OR 0.36, 95% CI 0.22-0.61). There were no differences in rates of 90-day readmission, reoperation, or procedural complications between groups. DISCUSSION: Colonic stenting as a bridge to surgery leads to less stoma creation, a significant quality of life advantage, compared with immediate resection. Patients should be counseled regarding these potential benefits when the technology is available.

Fragmented Care in the Treatment of Rectal Cancer and Time to Definitive Therapy.

BACKGROUND: The National Accreditation Program for Rectal Cancer (NAPRC) emphasizes a multidisciplinary approach for treating rectal cancer and has developed performance measures to ensure that patients receive standardized care. We hypothesized that rectal cancer patients receiving care at multiple centers would be less likely to receive timely and appropriate care. STUDY DESIGN: A single institution retrospective review of a prospectively maintained database was performed. All patients undergoing proctectomy and ≤1 other treatment modality (eg radiation and/or chemotherapy) for Stage II/III rectal adenocarcinoma were included. Unified care was defined as receiving all modalities of care at our institution, and fragmented care was defined as having at least 1 treatment modality at another institution. RESULTS: From 2009 to 2019, 415 patients met inclusion criteria, with 197 (47.5%) receiving fragmented care and 218 (52.5%) receiving unified care. The unified cohort patients were more likely to see a colorectal surgeon before starting treatment (89.0% vs 78.7%, p < 0.01) and start definitive treatment within 60 days of diagnosis (89.0% vs 79.7%, p = 0.01). On adjusted analysis, unified care patients were 2.78 times more likely to see a surgeon before starting treatment (95% CI 1.47-5.24) and 2.63 times more likely to start treatment within 60 days (95% CI 1.35-5.13). There was no difference in 90-day mortality or 5-year disease-free survival. CONCLUSIONS: This retrospective cohort study suggests patients with rectal cancer receiving fragmented care are at an increased risk of delays in care without any impact on disease-free survival. These findings need to be considered within the context of ongoing regionalization of rectal cancer care to ensure all patients receive optimal care, irrespective of whether care is delivered across multiple institutions.

Barriers to Regionalized Surgical Care: Public Perspective Survey and Geospatial Analysis.

OBJECTIVE: To describe public willingness to participate in regionalized surgical care for cancer. SUMMARY OF BACKGROUND DATA: Improved outcomes at high-volume centers following complex surgery have driven a push to regionalize surgical care. Patient attitudes toward regionalization are not well described. METHODS: As part of the Cornell National Social Survey, a cross-sectional telephone survey was performed. Participants were asked about their willingness to seek regionalized care in a hypothetical scenario requiring surgery. Their responses were compared with demographic characteristics. A geospatial analysis of hospital proximity was performed, as well as a qualitative analysis of barriers to regionalization. RESULTS: Cooperation rate was 48.1% with 1000 total respondents. They were an average of 50 years old (range 18 to 100 years) and 48.9% female. About 49.6% were unwilling to travel 5 hours or more to seek regionalized care for improved survival. Age >70 years [odds ratio (OR) 0.34, 95% confidence interval (95% CI) 0.19-0.60] and perceived distance to a center >30 minutes (OR 0.60, 95% CI 0.41-0.86) were associated with decreased willingness to seek regionalized care, while high income (OR 2.09, 95% CI 1.39-3.16) was associated with increased willingness. Proximity to a major center was not associated with willingness to travel (OR 0.92, 95% CI 0.67-1.22). Major perceived barriers to regionalization were transportation, life disruption, social support, socioeconomic resources, poor health, and remoteness. CONCLUSION: Americans are divided on whether the potential for improved survival with regionalization is worth the additional travel effort. Older age and lower income are associated with reduced willingness to seek regionalized care. Multiple barriers to regionalization exist, including a lack of knowledge of the location major centers.

Coping strategies among colorectal cancer patients undergoing surgery and the role of the surgeon in mitigating distress: A qualitative study.

BACKGROUND: Distress is common among cancer patients and leads to worse postoperative outcomes. Surgeons are often the first physicians to have in-depth conversations with patients about a new colorectal cancer diagnosis; therefore, it is important that these surgeons understand how patients cope with the distress of a diagnosis and how they can help patients manage this distress. METHODS: Patients with colorectal cancer were recruited from an outpatient surgery clinic. Purposive sampling was used to recruit patients if they were either planning to undergo surgery or had undergone surgery within six months. In-depth, open-ended, individual qualitative interviews were performed. Grounded theory was used to develop themes regarding patients' coping strategies and beliefs regarding the role of the surgeon in helping them cope. RESULTS: Patients described their own internal coping strategies using problem-focused, emotion-focused, and meaning-focused techniques. Patients also reported the importance of their social support network for coping. Patients believed surgeons and their teams should help patients manage the emotional components of their cancer diagnosis and surgical experience, especially if patients were experiencing high levels of distress or had inadequate coping skills. They did not believe surgeons themselves should be primarily responsible for helping them cope. CONCLUSION: In order for surgeons to guide diagnosis and initial management of distress in colorectal cancer patients undergoing surgery, they should screen patients for distress, identify and strengthen patients' own coping strategies, facilitate a strong social support network, and provide patients with the option to obtain further support from the surgeon's office.