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BACKGROUND: The significance of lymphovascular invasion (LVI) in esophageal adenocarcinoma (EAC) has not yet been described. Potential utility as an adjunct to current staging guidelines remains unknown. METHODS: The National Cancer Database was queried from 2006 to 2020. Univariate and multivariable models, Kaplan Meier method, and log-rank test were used. Subgroup analyses by pN stage were conducted. RESULTS: Of 9,689 patients, 23.2% had LVI. LVI was an independent prognostic factor (hazard ratio [HR] 1.401, 95% confidence interval [CI] 1.307-1.502, p < 0.0001) with reduction in median survival to 20.0 months (95% CI 18.9-21.4) from 39.7 months (95% CI 37.8-42.3, p < 0.0001). Multivariable survival analysis adjusted on pN and pT stage found that patients with LVI had decreased survival in a given pN stage (p < 0.001). pN0/LVI+ patients had a similar prognosis to the higher staged pN1/LVI- (28.6 months), although pN1/LVI- patients did slightly worse (p = 0.0135). Additionally, patients with pN1/LVI+ had equivalent survival compared with pN2/LVI- (p = 0.178) as did pN2/LVI+ patients compared with pN3/LVI- (p = 0.995). CONCLUSIONS: In these data, LVI is an independent negative prognostic factor in EAC. LVI was associated with a survival reduction similar to an upstaged nodal status irrespective of T stage. Patients with LVI may be better classified at a higher pN stage.
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Secondary amyloidosis (AA) is a disorder of protein conformation associated with inflammatory disorders. Detailed reports of patients diagnosed with AA and inflammatory bowel disease (IBD) are limited. This study reports the cases of eight patients, across three tertiary medical centers, diagnosed with both IBD and AA between 2000 and 2020. Seven patients had a diagnosis of Crohn disease (CD), while one had ulcerative colitis (UC). All patients were diagnosed with AA after being diagnosed with IBD (median: 15 years later). The small bowel (62.5%) and the colon (62.5%) were the most common IBD locations. 4 patients had undergone TNF-alpha inhibitor therapy and all CD patients required surgical treatment of their IBD. A history of fistula or abscess was identified in 5 patients. The most common initial site of AA was the kidney (75%). All 8 patients presented with some form of renal dysfunction and proteinuria (median: 1500 mg/24 h). Hypoalbuminemia was found in most patients. Six patients developed chronic kidney disease and 4 required dialysis. Anti TNF-alpha antibody therapy led to rapid improvement of renal function in one of four patients who received it. Three patients required a renal transplant. Four patients had died upon the latest follow-up (5-year survival: 75%). The presence of proteinuria, fistula, or abscess should serve as indicators for potentially increased AA risk in CD patients.
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INTRODUCTION: Physicians have gravitated toward larger group practice arrangements in recent years. However, consolidation trends in colorectal surgery have yet to be well described. Our objective was to assess current trends in practice consolidation within colorectal surgery and evaluate underlying demographic trends including age, gender, and geography. METHODS: We performed a retrospective cross-sectional study using the Center for Medicare Services National Downloadable File from 2015 to 2022. Colorectal surgeons were categorized by practice size and by region, gender, and age. RESULTS: From 2015 to 2022, the number of colorectal surgeons in the United States increased from 1369 to 1621 (+18.4%), while the practices with which they were affiliated remained relatively stable (693-721, +4.0%). The proportion of colorectal surgeons in groups of 1-2 members fell from 18.9% to 10.7%. Conversely, those in groups of 500+ members grew from 26.5% to 45.2% (linear trend P < 0.001). The midwest region demonstrated the highest degree of consolidation. Affiliations with group practices of 500+ members saw large increases from both female and male surgeons (+148.9% and +86.9%, respectively). New surgeons joining the field since 2015 overwhelmingly practice in larger groups (5.3% in groups of 1-2, 50.1% in groups of 500+). CONCLUSIONS: Colorectal surgeons are shifting toward larger practice affiliations. Although this change is happening across all demographic groups, it appears unevenly distributed across geography, gender, and age. New surgeons are preferentially joining large group practices.
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Cirugía Colorrectal , Humanos , Estudios Retrospectivos , Masculino , Femenino , Estudios Transversales , Estados Unidos , Cirugía Colorrectal/tendencias , Cirugía Colorrectal/estadística & datos numéricos , Anciano , Persona de Mediana Edad , Práctica de Grupo/estadística & datos numéricos , Práctica de Grupo/tendencias , Pautas de la Práctica en Medicina/estadística & datos numéricos , Pautas de la Práctica en Medicina/tendencias , Cirujanos/estadística & datos numéricos , Cirujanos/tendenciasRESUMEN
In the last two decades, colorectal cancer (CRC) mortality has been decreasing in the United States. However, the mortality trends for the different subtypes of CRC, including different sides of colon, rectosigmoid, and rectal cancer remain unclear. We analyzed the mortality trends of different subtypes of CRC based on Centers for Disease Control and Prevention's Wide-Ranging Online Data for Epidemiologic Research data from 1999 to 2020. We calculated age-adjusted mortality rates (AAMR) per 100,000 individuals and examined the trends over time by estimating the average annual percent change (AAPC) using the Joinpoint Regression Program. Our study shows that the overall CRC rates decreased significantly from 26.42 to 15.98 per 100,000 individuals, with an AAPC of -2.41. However, the AAMR of rectosigmoid cancer increased significantly from 0.82 to 1.08 per 100,000 individuals, with the AAPC of +1.10. Men and Black individuals had the highest AAMRs respectively (23.90 vs. 26.93 per 100,000 individuals). The overall AAMR of CRC decreased for those aged ≥50 years but increased significantly from 1.02 to 1.58 per 100,000 individuals for those aged 15-49 years, with an AAPC of +0.75. Rural populations had a higher AAMR than the urban populations (22.40 vs. 19.60 per 100,000 individuals). Although overall CRC mortality declined, rising trends in young-onset CRC and rectosigmoid cancer warrant attention. Disparities persist in terms of sex, race, and geographic region, and urbanization level, emphasizing the need for targeted public health measures.
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Neoplasias Colorrectales , Mortalidad , Humanos , Neoplasias Colorrectales/mortalidad , Neoplasias Colorrectales/epidemiología , Estados Unidos/epidemiología , Masculino , Persona de Mediana Edad , Femenino , Anciano , Adulto , Mortalidad/tendencias , Adulto Joven , Adolescente , Anciano de 80 o más AñosRESUMEN
BACKGROUND: Surgical site infections (SSIs) are one of the most common complications following diverting loop ileostomy (DLI) closures. This study assesses SSIs after DLI closure and the temporal trends in skin closure technique. METHODS: A retrospective review was conducted using the American College of Surgeons National Surgical Quality Improvement Program database for adult patients who underwent a DLI closure between 2012 and 2021 across a multistate health system. Skin closure technique was categorized as primary, primary â+ âdrain, or purse-string closure. The primary outcome was SSI at the former DLI site. RESULTS: A SSI was diagnosed in 5.7% of patients; 6.9% for primary closure, 5.7% for primary closure â+ âdrain, and 2.7% for purse-string closure (p â= â0.25). A diagnosis of Crohn's disease, diverticular disease, and increasing operative time were significant risk factors for SSIs. There was a positive trend in the use of purse-string closure over time (p â< â0.0001). CONCLUSIONS: This study identified a low SSI rate after DLI closure which did not vary significantly based on skin closure technique. Utilization of purse-string closure increased over time.
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Ileostomía , Infección de la Herida Quirúrgica , Adulto , Humanos , Ileostomía/efectos adversos , Infección de la Herida Quirúrgica/epidemiología , Infección de la Herida Quirúrgica/etiología , Técnicas de Sutura , Técnicas de Cierre de Heridas , Estudios Retrospectivos , Factores de RiesgoRESUMEN
BACKGROUND: There is currently no consensus on surgical management of splenic flexure adenocarcinoma (SFA). METHODS: Patients undergoing surgical resection for SFA between 1993 and 2015 were identified. Postoperative outcomes were compared between patients who underwent segmental (SR) vs. anatomical resection (AR). RESULTS: One-hundred and thirteen patients underwent SR and 89 underwent AR. More patients in the SR group had open resections, but there were otherwise no differences in demographics or surgical characteristics between the two groups. There were no differences in overall (p = 0.29) or recurrence-free(p = 0.37) survival. On multivariable analysis, increased age (HR 1.04, 1.01-1.07, p = 0.005), higher American Society of Anesthesiology classification (HR 3.1, 1.7-5.71, p < 0.001), and higher tumor stage (HR 8.84, 3.76-20.82, p < 0.001) were predictive of mortality. CONCLUSIONS: Short and long-term outcomes after SR and AR for SFA are not different, making SR a viable option for SFA surgical management.
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Adenocarcinoma , Colon Transverso , Neoplasias del Colon , Laparoscopía , Humanos , Colon Transverso/cirugía , Resultado del Tratamiento , Estudios Retrospectivos , Colectomía , Adenocarcinoma/cirugía , Adenocarcinoma/patologíaRESUMEN
AIM: The National Accreditation Program for Rectal Cancer (NAPRC) was developed to improve rectal cancer patient outcomes in the United States. The NAPRC consists of a set of process and outcome measures that hospitals must meet in order to be accredited. We aimed to assess the potential of the NAPRC by determining whether achievement of the process measures correlates with improved survival. METHODS: The National Cancer Database was used to identify patients undergoing curative proctectomy for non-metastatic rectal cancer from 2010 to 2014. NAPRC process measures identified in the National Cancer Database included clinical staging completion, treatment starting <60 days from diagnosis, carcinoembryonic antigen level measured prior to treatment, tumour regression grading and margin assessment. RESULTS: There were 48 669 patients identified with a mean age of 62 ± 12.9 years and 61.3% of patients were men. The process measure completed most often was assessment of proximal and distal margins (98.4%) and the measure completed least often was the serum carcinoembryonic antigen level prior to treatment (63.8%). All six process measures were completed in 23.6% of patients. After controlling for age, gender, comorbidities, annual facility resection volume, race and pathological stage, completion of all process measures was associated with a statistically significant mortality decrease (Cox hazard ratio 0.88, 95% CI 0.81-0.94, P < 0.001). CONCLUSION: Participating institutions provided complete datasets for all six process measures in less than a quarter of patients. Compliance with all process measures was associated with a significant mortality reduction. Improved adoption of NAPRC process measures could therefore result in improved survival rates for rectal cancer in the United States.
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Proctectomía , Neoplasias del Recto , Masculino , Humanos , Estados Unidos , Persona de Mediana Edad , Anciano , Femenino , Antígeno Carcinoembrionario , Neoplasias del Recto/cirugía , Neoplasias del Recto/patología , Evaluación de Resultado en la Atención de Salud , Acreditación , Estudios Retrospectivos , Estadificación de Neoplasias , Resultado del TratamientoRESUMEN
BACKGROUND: Medicare reimbursement rates have decreased across various specialties but have not yet been studied in colorectal surgery. OBJECTIVE: This study aimed to analyze Medicare reimbursement trends in colorectal surgery. DESIGN: Observational study. SETTING: The Centers for Medicare and Medicaid Services' Physician Fee Schedule was evaluated for reimbursement data for the 20 most common colorectal surgery procedures from 2006 to 2020. MAIN OUTCOME MEASURES: Inflation-adjusted annual percentage change, compound annual growth rate, and total percentage change were the outcome measures. A subanalysis was performed comparing the changes in reimbursement between 2006 to 2016 and 2016 to 2020 because of legislative changes that went into effect in 2016. RESULTS: During the study period, the inflation-unadjusted mean Medicare reimbursement rate for the 20 most common colorectal surgery procedures increased by +15.6%. This rise was surpassed by the inflation rate of +31.3%. Consequently, the inflation-adjusted reimbursement rate decreased by -11%. The adjusted reimbursement rates decreased the most at -33.8% for a flexible colonoscopy with biopsy and increased the most at +45.3% for a diagnostic rigid proctosigmoidoscopy. Annual percentage change was -0.79%, and the compound annual growth rate was -0.98%. There was an accelerated decrease in annual reimbursement rates from 2016 to 2020 at -2.23% compared to 2006 to 2016 at -0.22% ( p = 0.03). The only procedure that had an increase in adjusted reimbursement rate from 2016 to 2020 was the injection of sclerosing solution for hemorrhoids. LIMITATIONS: Only Medicare reimbursement data were analyzed. CONCLUSIONS: Medicare reimbursements for colorectal surgery procedures are decreasing at an accelerating rate. Although this study is limited to Medicare data, it still presents a representation of overall reimbursement changes because Medicare policies have a ripple effect in the commercial insurance market. It is vital to understand the financial trends to be able to structure future patient care teams and to advocate for the sustainability of colorectal surgery practices in the United States. See Video Abstract at http://links.lww.com/DCR/C136 . REEMBOLSO DE MEDICARE EN CIRUGA COLORRECTAL UN PROBLEMA CRECIENTE: ANTECEDENTES: Las tasas de reembolso de Medicare han disminuido en varias especialidades, pero aún no han sido estudiado en cirugía colorrectal.OBJETIVO: Analizar las tendencias de reembolso de Medicare en cirugía colorrectal.DISEÑO: Estudio observacional.CONTEXTO: Se evaluó el programa de tarifas médicas de los Centros de Servicios de Medicare y Medicaid para obtener datos de reembolso de los 20 procedimientos más comunes en cirugía colorrectal entre los años 2006 y 2020.PRINCIPALES MEDIDAS DE RESULTADO: Variación porcentual anual ajustada por inflación, tasa de crecimiento anual compuesta y variación porcentual total. Se realizó un subanálisis comparando los cambios en el reembolso entre los años 2006 a 2016 y 2016 a 2020 debido a los cambios legislativos que entraron en vigencia en 2016.RESULTADOS: Durante el período de estudio, la tasa media de reembolso de Medicare sin ajuste por inflación para los 20 procedimientos más comunes en cirugía colorrectal aumentó en +15,6 %. Esta suba fue superada por la tasa de inflación del +31,3%. En consecuencia, la tasa de reembolso ajustada por inflación disminuyó un -11%. Lo máximo que disminuyeron las tasas ajustadas de reembolso fue a -33,8% para una colonoscopia flexible con biopsia y aumentaron más a +45,3% para una proctosigmoidoscopia rígida de diagnóstico. El cambio porcentual anual fue -0,79% y la tasa de crecimiento anual compuesto fue -0,98%. Hubo una disminución acelerada en las tasas de reembolso anual de 2016 a 2020 a -2,23 % en comparación con 2006 a 2016 a -0,22% ( p = 0,03). El único procedimiento que tuvo un aumento en la tasa de reembolso ajustada de 2016 a 2020 fue la inyección de solución esclerosante para las hemorroides.LIMITACIONES: Solo se analizaron los datos de reembolso de Medicare.CONCLUSIONES: Los reembolsos de Medicare por procedimientos en cirugía colorrectal están disminuyendo a un ritmo acelerado. Aunque este estudio se limita a los datos de Medicare, aún presenta una representación de los cambios generales en los reembolsos, ya que las pólizas de Medicare tienen un efecto dominó en el mercado de seguros comerciales. Es fundamental comprender las tendencias financieras para poder estructurar futuros equipos de atención de pacientes y abogar por la sostenibilidad de las prácticas de cirugía colorrectal en los Estados Unidos. Consulte Video Resumen video en https://links.lww.com/DCR/C136 . (Traducción-Dr. Osvaldo Gauto ).
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Cirugía Colorrectal , Procedimientos Quirúrgicos del Sistema Digestivo , Anciano , Humanos , Estados Unidos , Estudios Retrospectivos , Medicare , Evaluación de Resultado en la Atención de SaludAsunto(s)
Abdomen/cirugía , Prolapso de Órgano Pélvico/cirugía , Prolapso Rectal/cirugía , Prolapso Uterino/cirugía , Anciano , Incontinencia Fecal/diagnóstico , Incontinencia Fecal/etiología , Femenino , Humanos , Laparoscopía/instrumentación , Prolapso de Órgano Pélvico/patología , Prolapso Rectal/patología , Procedimientos Quirúrgicos Robotizados/métodos , Mallas Quirúrgicas/efectos adversos , Técnicas de Sutura , Resultado del Tratamiento , Prolapso Uterino/patologíaRESUMEN
BACKGROUND: General surgery residents may be underprepared for practice, due in part to declining operative autonomy during training. The factors that influence entrustment of autonomy in the operating room are unclear. OBJECTIVE: To identify and compare the factors that residents and faculty consider influential in entrustment of operative autonomy. METHODS: An anonymous survey of 29-item Likert-type scale (1-7, 1 = strongly disagree, 7 = strongly agree), 9 multiple-choice, and 4 open-ended questions was sent to 70 faculty and 45 residents in a large ACGME-approved general surgery residency program comprised of university, county, and VA hospitals in 2018. RESULTS: Sixty (86%) faculty and 38 (84%) residents responded. Faculty were more likely to identify resident-specific factors such as better resident reputation and higher skill level as important in fostering entrustment. Residents were more likely to identify environmental factors such as a focus on efficiency and a litigious malpractice environment as impeding entrustment. Both groups agreed that work hour restrictions do not decrease autonomy and entrustment does not increase risk to patients. More residents considered low faculty confidence level as a barrier to operative autonomy, while more faculty considered lower resident clinical skill as a barrier. Improvement in resident preparation for cases was cited as an important intervention that could enhance entrustment. CONCLUSIONS: Differences in perspectives exist between general surgery residents and faculty regarding entrustment of autonomy. Residents cite environmental and attending-related factors, while faculty cite resident-specific factors as most influential. Residents and faculty both agree that entrustment is integral to surgical training.
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Cirugía General , Internado y Residencia , Cirujanos , Competencia Clínica , Docentes Médicos , Cirugía General/educación , Humanos , Percepción , Autonomía ProfesionalRESUMEN
Colorectal cancer remains the 3rd most common cancer diagnosed among men and women in the United States. With improved screening, premalignant rectal lesions and rectal cancers are being detected at earlier stages. In addition, the use of neoadjuvant chemo- and radiotherapy has led to downstaging of larger lesions. There is growing interest among colorectal surgeons in local excision with organ preservation for patients with rectal cancer. There are multiple platforms for local excision of rectal cancers, including transanal excision (TAE), transanal endoscopic microsurgery (TEM) and transanal minimally invasive surgery (TAMIS). TAMIS was developed as an affordable platform that uses conventional laparoscopic equipment familiar to many colorectal surgeons. TAMIS allows for full-thickness benign or malignant lesion excision in any quadrant without the need for patient repositioning. The literature has shown that, for appropriately selected patients, TAMIS provides superior excision quality compared to TAE. Furthermore, TAMIS has oncologic outcomes equivalent to TEM at a fraction of the cost. Recently, robotic TAMIS has been introduced, which takes advantage of the articulating instruments of the robotic platform without the need for a skilled assistant. This article will cover multiple technical aspects for TAMIS including patient selection and preparation, technical tips for successful excision and defect closure, and recent advances, including robotic TAMIS.
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Laparoscopía , Neoplasias del Recto , Robótica , Cirugía Endoscópica Transanal , Femenino , Humanos , Masculino , Procedimientos Quirúrgicos Mínimamente Invasivos , Neoplasias del Recto/cirugía , RectoRESUMEN
BACKGROUND: The aim of this study was to determine whether patients undergoing thyroidectomy and parathyroidectomy have similar postoperative pain if managed with an opioid-sparing regimen versus an opioid-containing regimen. We hypothesized that an opioid-sparing regimen would provide equivalent analgesia. METHODS: We performed a prospective, randomized trial (clinicaltrials.govNCT03640247) comparing non-narcotic and narcotic postoperative pain regimens after discharge. Patients ≥18 y undergoing thyroidectomy or parathyroidectomy were eligible for inclusion. Patients were excluded if they were taking a narcotic. Patients in the nonnarcotic arm of the study received acetaminophen, alternating with ibuprofen, and patients in the narcotic arm received the same medications plus a narcotic. RESULTS: Of 126 patients, 64 patients were in the nonnarcotic group and 62 were in the narcotic group. The mean age was 54 ± 14 y, and 108 (86%) patients were female. Median pain scores were similar on postoperative day #0 (narcotic group 7 versus nonnarcotic group 7.5), postoperative day #1 (narcotic group 6 versus nonnarcotic group 6), postoperative day #2 (narcotic group 5 versus nonnarcotic group 5), postoperative day #3 (narcotic group 4 versus nonnarcotic group 4), postoperative day #4 (narcotic group 3 versus nonnarcotic 3) and postoperative day #5 (narcotic group 2.5 versus nonnarcotic group 2, all P > .1). A total of 31 (50%) patients in the narcotic group did not take a narcotic. A total of 8 (12.5%) patients in the nonnarcotic group and of 31 (50%) patients in the narcotic group took a median total of 2 narcotic tablets. CONCLUSION: An opioid-sparing pain medication regimen provides effective analgesia for most patients after thyroidectomy and parathyroidectomy.
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Analgésicos no Narcóticos/administración & dosificación , Analgésicos Opioides/administración & dosificación , Dolor Postoperatorio/tratamiento farmacológico , Paratiroidectomía/efectos adversos , Tiroidectomía/efectos adversos , Adulto , Anciano , Analgésicos Opioides/efectos adversos , Prescripciones de Medicamentos/estadística & datos numéricos , Quimioterapia Combinada/métodos , Quimioterapia Combinada/estadística & datos numéricos , Femenino , Humanos , Tiempo de Internación/estadística & datos numéricos , Masculino , Persona de Mediana Edad , Epidemia de Opioides/prevención & control , Trastornos Relacionados con Opioides/epidemiología , Trastornos Relacionados con Opioides/etiología , Trastornos Relacionados con Opioides/prevención & control , Manejo del Dolor/métodos , Manejo del Dolor/estadística & datos numéricos , Dimensión del Dolor/estadística & datos numéricos , Dolor Postoperatorio/diagnóstico , Dolor Postoperatorio/epidemiología , Dolor Postoperatorio/etiología , Alta del Paciente/estadística & datos numéricos , Readmisión del Paciente/estadística & datos numéricos , Estudios Prospectivos , Resultado del TratamientoRESUMEN
(1) Background: The relatively poor expert restaging accuracy of MRI in rectal cancer after neoadjuvant chemoradiation may be due to the difficulties in visual assessment of residual tumor on post-treatment MRI. In order to capture underlying tissue alterations and morphologic changes in rectal structures occurring due to the treatment, we hypothesized that radiomics texture and shape descriptors of the rectal environment (e.g., wall, lumen) on post-chemoradiation T2-weighted (T2w) MRI may be associated with tumor regression after neoadjuvant chemoradiation therapy (nCRT). (2) Methods: A total of 94 rectal cancer patients were retrospectively identified from three collaborating institutions, for whom a 1.5 or 3T T2w MRI was available after nCRT and prior to surgical resection. The rectal wall and the lumen were annotated by an expert radiologist on all MRIs, based on which 191 texture descriptors and 198 shape descriptors were extracted for each patient. (3) Results: Top-ranked features associated with pathologic tumor-stage regression were identified via cross-validation on a discovery set (n = 52, 1 institution) and evaluated via discriminant analysis in hold-out validation (n = 42, 2 institutions). The best performing features for distinguishing low (ypT0-2) and high (ypT3-4) pathologic tumor stages after nCRT comprised directional gradient texture expression and morphologic shape differences in the entire rectal wall and lumen. Not only were these radiomic features found to be resilient to variations in magnetic field strength and expert segmentations, a quadratic discriminant model combining them yielded consistent performance across multiple institutions (hold-out AUC of 0.73). (4) Conclusions: Radiomic texture and shape descriptors of the rectal wall from post-treatment T2w MRIs may be associated with low and high pathologic tumor stage after neoadjuvant chemoradiation therapy and generalized across variations between scanners and institutions.
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Purpose Minimally invasive rectal cancer (RC) resection has become common, despite recent high-profile trials failing to show non-inferiority to open proctectomy. We hypothesized that at a high-volume center, laparoscopic resection may have superior outcomes compared to those seen in ALaCaRT and ACOSOG Z6051. Methods Retrospective review of patients undergoing laparoscopic proctectomy from 2007 to 2015 for RC was performed at a high-volume center. Primary outcome was successful resection defined by negative circumferential resection margin (CRM) and distal margin (DM), and complete total mesorectal excision (TME). Results A total of 89 patients were included. Of 33 patients with TME grading, 31 (93.9%) had complete/near complete TME, and 29 (87.9%) had a "successful resection" compared with 81.7% in ACOSOG and 82% in ALaCART trials using same criteria. CRM was ≥1 mm in 87 (97.8%) of patients. Mean DM was 3.8 cm; 97.8% of patients had negative DM. Conclusion High-volume centers can achieve similar high quality RC outcomes to those demonstrated in recent trials. Institutional outcomes should determine optimal surgical technique.
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BACKGROUND: Twenty-five percent of rectal adenocarcinoma patients achieve pathologic complete response (pCR) to neoadjuvant chemoradiation and could avoid proctectomy. However, pretreatment clinical or imaging markers are lacking in predicting response to chemoradiation. Radiomic texture features from MRI have recently been associated with therapeutic response in other cancers. PURPOSE: To construct a radiomics texture model based on pretreatment MRI for identifying patients who will achieve pCR to neoadjuvant chemoradiation in rectal cancer, including validation across multiple scanners and sites. STUDY TYPE: Retrospective. SUBJECTS: In all, 104 rectal cancer patients staged with MRI prior to long-course chemoradiation followed by proctectomy; curated from three institutions. FIELD STRENGTH/SEQUENCE: 1.5T-3.0T, axial higher resolution T2 -weighted turbo spin echo sequence. ASSESSMENT: Pathologic response was graded on postsurgical specimens. In total, 764 radiomic features were extracted from single-slice sections of rectal tumors on processed pretreatment T2 -weighted MRI. STATISTICAL TESTS: Three feature selection schemes were compared for identifying radiomic texture descriptors associated with pCR via a discovery cohort (one site, N = 60, cross-validation). The top-selected radiomic texture features were used to train and validate a random forest classifier model for pretreatment identification of pCR (two external sites, N = 44). Model performance was evaluated via area under the curve (AUC), accuracy, sensitivity, and specificity. RESULTS: Laws kernel responses and gradient organization features were most associated with pCR (P ≤ 0.01); as well as being commonly identified across all feature selection schemes. The radiomics model yielded a discovery AUC of 0.699 ± 0.076 and a hold-out validation AUC of 0.712 with 70.5% accuracy (70.0% sensitivity, 70.6% specificity) in identifying pCR. Radiomic texture features were resilient to variations in magnetic field strength as well as being consistent between two different expert annotations. Univariate analysis revealed no significant associations of baseline clinicopathologic or MRI findings with pCR (P = 0.07-0.96). DATA CONCLUSION: Radiomic texture features from pretreatment MRIs may enable early identification of potential pCR to neoadjuvant chemoradiation, as well as generalize across sites. LEVEL OF EVIDENCE: 3 TECHNICAL EFFICACY STAGE: 2.
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Terapia Neoadyuvante , Neoplasias del Recto , Quimioradioterapia , Humanos , Imagen por Resonancia Magnética , Neoplasias del Recto/diagnóstico por imagen , Neoplasias del Recto/terapia , Estudios RetrospectivosRESUMEN
PURPOSE: Most preoperative assessment tools to evaluate risk for postoperative complications require multiple data points to be collected and can be logistically burdensome. This study evaluated if umbilical contamination, a simple bedside assessment, correlated with surgical outcomes. METHODS: A 6-point score to measure umbilical contamination was developed and applied prospectively to patients undergoing colorectal surgery at an academic medical center. RESULTS: There were 200 patients enrolled (mean age 58.1 ± 14.8; 56% female). The mean BMI was 28.6 ± 7.4. Indications for surgery included colon cancer (24%), rectal cancer (18%), diverticulitis (13.5%), and Crohn's disease (12.5%). Umbilical contamination scores were 0 (23%, cleanest), 1 (26%), 2 (21%), 3 (24%), 4 (6%), and 5 (0%, dirtiest). Umbilical contamination did not correlate with preoperative functional status (p > 0.2). Umbilical contamination correlated with increased length of stay (rho = 0.19, p = 0.007) and postoperative complications (OR 1.3, 1.02-1.7, p = 0.04), but not readmission (p = 0.3) or discharge disposition (p > 0.2). CONCLUSION: Sterile preparation of the abdomen is an important component of proper surgical technique and umbilical contamination correlates with increased postoperative complications.
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Cirugía Colorrectal , Ombligo/cirugía , Femenino , Humanos , Masculino , Persona de Mediana Edad , Complicaciones Posoperatorias/etiología , Resultado del TratamientoRESUMEN
BACKGROUND: As our nation's population ages, operating on older and sicker patients occurs more frequently. Robotic operations have been thought to bridge the gap between a laparoscopic and an open approach, especially in more complex cases like proctectomy. METHODS: Our objective was to evaluate the use and outcomes of robotic proctectomy compared to open and laparoscopic approaches for rectal cancer in the elderly. A retrospective cross-sectional cohort study utilizing the Nationwide Inpatient Sample (NIS; 2006-2013) was performed. All cases were restricted to age 70 years old or greater. RESULTS: We identified 6740 admissions for rectal cancer including: 5879 open, 666 laparoscopic, and 195 robotic procedures. The median age was 77 years old. The incidence of a robotic proctectomy increased by 39%, while the open approach declined by 6% over the time period studied. Median (interquartile range) length of stay was shorter for robotic procedures at 4.3 (3-7) days, compared to laparoscopic 5.8 (4-8) and open at 6.7 (5-10) days (pâ¯<â¯0.01), while median total hospital charges were greater in the robotic group compared to laparoscopic and open cases ($64,743 vs. $55,813 vs. $50,355, respectively, pâ¯<â¯0.01). There was no significant difference in the risk of total complications between the different approaches following multivariate analysis. CONCLUSION: Robotic proctectomy was associated with a shorter LOS, and this may act as a surrogate marker for an overall improvement in adverse events. These results demonstrate that a robotic approach is a safe and feasible option, and should not be discounted solely based on age or comorbidities.