Association of National Accreditation Program for Rectal Cancer Accreditation with Outcomes after Rectal Cancer Surgery.

BACKGROUND: The National Accreditation Program for Rectal Cancer (NAPRC) defined a set of standards in 2017 centered on multidisciplinary program structure, evidence-based care processes, and internal audit to address widely variable rectal cancer practices and outcomes across U.S. hospitals. There have been no studies to-date testing the association between NAPRC accreditation and rectal cancer outcomes. STUDY DESIGN: This was a retrospective, observational study of Medicare beneficiaries aged 65-99 years with rectal cancer who underwent proctectomy from 2017-2020. The primary exposure was NAPRC accreditation and the primary outcomes included mortality (in-hospital, 30-day, 1-year) and 30-day complications, readmissions, and reoperations. Associations between NAPRC accreditation and each outcome were tested using multivariable logistic regression with risk-adjustment for patient and hospital characteristics. RESULTS: Among 1,985 hospitals, 65 were NAPRC accredited (3.3%). Accredited hospitals were more likely to be nonprofit and teaching with ≥ 250 beds. Among 20,202 patients, 2,078 patients (10%) underwent proctectomy at an accredited hospital. Patients at accredited hospitals were more likely to have an elective procedure with a minimally invasive approach and sphincter preservation. Risk-adjusted in-hospital mortality (1.1% vs. 1.3%; p=0.002), 30-day mortality (2.1% vs. 2.9%; p<0.001), 30-day complication (18.3% vs. 19.4%; p=0.01), and 1-year mortality rates (11.0% vs. 12.1%; p<0.001) were significantly lower at accredited compared to non-accredited hospitals. CONCLUSIONS: NAPRC accredited hospitals have lower risk-adjusted morbidity and mortality for major rectal cancer surgery. Although NAPRC standards address variability in practice, without directly addressing surgical safety, our findings suggest that NAPRC accredited hospitals may provide higher quality surgical care.

Uptake of Total Mesorectal Excision and Total Mesorectal Excision Grading for Rectal Cancer: A Statewide Study.

BACKGROUND: Total mesorectal excision is associated with decreased local recurrence and improved disease-free survival following rectal cancer resection. The extent to which total mesorectal excision has been adopted in the United States is unknown. OBJECTIVE: We sought to assess trends in total mesorectal excision performance and grading in Michigan hospitals. DESIGN: This is a retrospective cohort study from the Michigan Surgical Quality Collaborative. Trends in total mesorectal excision performance and grade assignment were analyzed by using χ tests and linear regression. SETTINGS: Participating hospitals (initially 14 hospitals, now 38) abstracted medical records data for rectal cancer cases from 2007 to 2016. PATIENTS: Patients who underwent rectal cancer resection were included. MAIN OUTCOME MEASURE: The main outcome measures were surgeon-documented total mesorectal excision performance and pathologist-reported total mesorectal excision grade. RESULTS: Of 510 rectal cancer cases, 367 (72.0%) had surgeon-reported total mesorectal excision performance and 78 (15.3%) had pathologist-reported total mesorectal excision grade. Between-hospital variability in total mesorectal excision performance ranged from 0% to 97% and total mesorectal excision grading ranged from 0% to 90%. Total mesorectal excision grading was associated with a higher likelihood of also having adequate lymph node assessment (88.5% versus 71.9%, p = 0.002). There has been a statistically significant trend toward an increase in total mesorectal excision grading in the original 14 hospitals (p = 0.001), but not in the complete cohort of all hospitals (p = 0.057). LIMITATIONS: This is a retrospective cohort design with sampled rectal cancer cases. In addition, there is insufficient granularity to capture all factors associated with total mesorectal excision performance or grade assignment. CONCLUSIONS: The rates of total mesorectal excision performance and grade assignment are widely variable throughout the state of Michigan. Overall, grade assignment remains very low. This suggests an opportunity for quality improvement projects to increase total mesorectal excision performance and grading, involving both the surgeons and pathologists for effective implementation. See Video Abstract at http://links.lww.com/DCR/B53. IMPLEMENTACIÓN DE LA ESCISIÓN MESORRECTAL TOTAL Y LA CLASIFICACIÓN POR ESCISIÓN MESORRECTAL TOTAL PARA EL CÁNCER RECTAL: UN ESTUDIO A NIVEL ESTATAL.: La escisión mesorrectal total se asocia con una menor recurrencia local y una mejor supervivencia libre de enfermedad después de la resección del cáncer rectal. Se desconoce hasta que punto se ha adoptado la escisión mesorrectal total en los Estados Unidos.Se intento evaluar las tendencias en el rendimiento y la clasificación de la escisión mesorrectal total en los hospitales de Michigan.Este es un estudio de cohorte retrospectivo de la "Michigan Surgical Quality Collaborative". Las tendencias en el rendimiento de la escisión mesorrectal total y la asignación de grado se analizaron mediante pruebas de chi-cuadrada y regresión lineal.Los hospitales participantes (inicialmente 14 hospitales, ahora 38) extrajeron datos de registros médicos de los casos de cáncer rectal desde 2007 hasta 2016.Pacientes que se sometieron a resección de cáncer rectal.Las principales medidas de resultado fueron el rendimiento de la escisión mesorrectal total documentado por el cirujano y el grado de escisión mesorrectal total informada por el patólogo.De 510 casos de cáncer rectal, 367 (72.0%) tenían un rendimiento de escisión mesorrectal total reportado por el cirujano y 78 (15.3%) tenían un grado de escisión mesorrectal total reportado por el patólogo. La variabilidad entre hospitales en el rendimiento de la escisión mesorrectal total varió del 0 al 97% y la clasificación de la escisión mesorrectal total varió del 0 al 90%. La clasificación de la escisión mesorrectal total se asoció con una mayor probabilidad de tener también una evaluación adecuada de los ganglios linfáticos (88.5% versus 71.9%, p = 0.002). Ha habido una tendencia estadísticamente significativa hacia un aumento en la clasificación de la escisión mesorrectal total en los 14 hospitales originales (p = 0.001), pero no en la cohorte completa de todos los hospitales (p = 0.057).Diseño de cohorte retrospectivo con casos de cáncer rectal muestreados. Además, no hay suficiente granularidad para capturar todos los factores asociados con el rendimiento de la escisión mesorrectal total o la asignación de grados.Las tasas de rendimiento de escisión mesorrectal total y asignación de grado son muy variables en todo el estado de Michigan. En general, la asignación de calificaciones sigue siendo muy baja. Esto sugiere una oportunidad para que los proyectos de mejora de la calidad aumenten el rendimiento y la clasificación de la escisión mesorrectal total, involucrando tanto a los cirujanos como a los patólogos para una implementación efectiva. Vea el resumen del video en http://links.lww.com/DCR/B53.

Completeness of operative reports for rectal cancer surgery.

INTRODUCTION: Synoptic operative reporting has been shown to improve completeness and consistency in surgical documentation. We sought to determine whether operative reports contain the key elements recommended by the National Accreditation Program for Rectal Cancer. METHODS: Rectal cancer operative reports from June-December 2018 were submitted from ten hospitals in Michigan. These reports were analyzed to identify key elements in the synoptic operative template and assessed for completeness. RESULTS: In total, 110 operative reports were reviewed. Thirty-one (28%) reports contained all 24 elements; all of these reports used a synoptic template. Overall, 62 (56%) reports used a synoptic template and 48 (44%) did not. Using a synoptic template significantly improved documentation, as these reports contained 92% of required elements, compared to 39% for narrative reports (p < 0.001). CONCLUSIONS/DISCUSSION: Narrative operative reports inconsistently document rectal cancer resection. This study provides evidence that synoptic reporting will improve quality of documentation for rectal cancer surgery.

Academic Hospitals Discharge Fewer Patients to Postacute Care Facilities After Colorectal Resection.

BACKGROUND: Discharge to a nonhome destination (ie, skilled nursing facility, subacute rehabilitation, or long-term care facility) after surgery is associated with increased mortality and higher costs and is less desirable to patients than discharge to home. OBJECTIVE: We sought to identify modifiable hospital-level factors that may reduce rates of nonhome discharge after colorectal resection. DESIGN: This was a retrospective cohort study of patients undergoing colorectal resection in the Michigan Surgical Quality Collaborative (July 2012 to June 2015). Patient- and hospital-level characteristics were tested for association with nonhome discharge patterns. SETTINGS: Patients were identified using prospectively collected data from the Michigan Surgical Quality Collaborative, a statewide collaborative encompassing 63 community, academic, and tertiary hospitals. PATIENTS: Patients undergoing colon and rectal resections were included. MAIN OUTCOME MEASURE: The main outcome measure was hospital use patterns of nonhome discharge. RESULTS: Of the 9603 patients identified, 1104 (11.5%) were discharged to a nonhome destination. After adjustments for patient factors associated with nonhome discharge, we identified variability in hospital use patterns for nonhome discharge. Designation as a low utilizer hospital was associated with affiliation with a medical school (p = 0.020) and high outpatient volume (p = 0.028). After adjustments for all hospital factors, only academic affiliation maintained a statistically significant relationship (OR = 4.94; p = 0.045). LIMITATIONS: This study had a retrospective cohort design with short-term follow-up of sampled cases. Additionally, by performing our analysis on the hospital level, there is a decreased sample size. CONCLUSIONS: This population-based study shows that there is significant variation in hospital practices for nonhome discharge. Specifically, hospitals affiliated with a medical school are less likely to discharge patients to a facility, even after adjustment for patient and procedural risk factors. This study raises the concern that there may be overuse of subacute facility discharge in certain hospitals, and additional study is warranted. See Video Abstract at http://links.lww.com/DCR/A837.

The American Society of Colon and Rectal Surgeons Assessment Tool for Performance of Laparoscopic Colectomy.

BACKGROUND: The lack of consensus for performance assessment of laparoscopic colorectal resection is a major impediment to quality improvement. OBJECTIVE: The purpose of this study was to develop and assess the validity of an evaluation tool for laparoscopic colectomy that is feasible for wide implementation. DESIGN: During the pilot phase, a small group of experts modified previous assessment tools by watching videos for laparoscopic right colectomy with the following categories of experience: novice (less than 20 cases), intermediate (50-100 cases), and expert (more than 500 cases). After achieving sufficient reliability (κ > 0.8), a user-friendly tool was validated among a large group of blinded, trained experts. SETTING: The study was conducted through the American Society of Colon and Rectal Surgeons Operative Competency Evaluation Committee. PATIENTS: Raters were from the Operative Competency Evaluation Committee of the American Society of Colon and Rectal Surgeons. MAIN OUTCOME MEASURES: Assessment tool reliability and internal consistency were measured. RESULTS: From October 2014 through February 2015, 4 groups of 5 raters blinded to surgeon skill level evaluated 6 different laparoscopic right colectomy videos (novice = 2, intermediate = 2, expert = 2). The overall Cronbach α was 0.98 (>0.9 = excellent internal consistency). The intraclass correlation for the overall assessment was 0.93 (range, 0.77-0.93) and was >0.74 (excellent) for each step. The average scores (scale, 1-5) for experts were significantly better than those in the intermediate category, with a mean (SD) of 4.51 (0.56) versus 2.94 (0.56; p = 0.003). Videos in the intermediate group scored more favorably than beginner videos for each individual step and overall performance (mean (SD) = 3.00 (0.32) vs 1.78 (0.42); p = 0.006). LIMITATIONS: The study was limited by rater bias to technique and style. CONCLUSIONS: The unique and robust methodology in this trial produced an assessment tool that was feasible for raters to use when assessing videotaped laparoscopic right hemicolectomies. The potential applications for this new tool are widespread, including both training and evaluation of competence at the attending level. See Video Abstract at http://links.lww.com/DCR/A369, http://links.lww.com/DCR/A370, http://links.lww.com/DCR/A371.

Risk factors for readmission after elective colectomy: postoperative complications are more important than patient and operative factors.

BACKGROUND: Colon resections are associated with substantial risk for morbidity and readmissions, and these have become markers for quality of care. OBJECTIVE: The purpose of this study was to determine risk factors for readmissions after elective colectomies to improve patient care and better understand the complex issues associated with readmissions. DESIGN: This was an analysis of the prospective, statewide, multicenter Michigan Surgical Quality Collaborative database. SETTINGS: The analysis was conducted at academic and community medical centers in the state of Michigan. PATIENTS: Elective laparoscopic and open ileocolic and segmental colectomies from 2008 through 2010 were included. MAIN OUTCOME MEASURES: Univariate analysis and a multivariate logistic regression model were used to determine influence of patient characteristics, operative factors, and postoperative complications on the incidence of 30-day postoperative readmission. RESULTS: The readmission rate among 4013 cases was 7.3% (N = 293). On the basis of multivariate logistic regression, the top 3 significant risk factors associated with readmission were stroke (OR, 10.0 [95% CI, 2.70-37.0]; p = 0.001), venous thromboembolism (OR, 6.5 [95% CI, 3.7-11.3]; p < 0.0001), and organ-space surgical site infection (OR, 5.6 [95% CI, 3.4-9.4]; p < 0.0001). Important factors that contributed to readmission risk but were not found to be independent predictors of readmission included diabetes mellitus, preoperative steroids, smoking, cardiac comorbidities, age >80 years, anastomotic leaks, fascial dehiscence, sepsis, pneumonia, unplanned intubation, and length of stay. LIMITATIONS: The Michigan Surgical Quality Collaborative is a large database, and true causal relations are difficult to determine; reason for readmission is not recorded in the database. CONCLUSIONS: Postoperative complications account for the majority of risk factors behind readmissions after elective colectomy, whereas preoperative risk factors have less direct influence. Current strategies addressing readmission rates should focus on reducing preventable complications.

Evaluating patients undergoing colorectal surgery to estimate and minimize morbidity and mortality.

This review discusses the preoperative evaluation of patients preparing for elective colorectal resection, touching on several specific categories of morbidity, including cardiac, pulmonary, hepatic, renal, and surgical site complications. For each of these, the evidence for practices that optimize patient function and minimize risk is reviewed. Finally, authors discuss how to counsel high-risk surgical patients, including those for whom elective surgery is not recommended.

Get screened: a pragmatic randomized controlled trial to increase mammography and colorectal cancer screening in a large, safety net practice.

BACKGROUND: Most randomized controlled trials of interventions designed to promote cancer screening, particularly those targeting poor and minority patients, enroll selected patients. Relatively little is known about the benefits of these interventions among unselected patients. METHODS/DESIGN: "Get Screened" is an American Cancer Society-sponsored randomized controlled trial designed to promote mammography and colorectal cancer screening in a primary care practice serving low-income patients. Eligible patients who are past due for mammography or colorectal cancer screening are entered into a tracking registry and randomly assigned to early or delayed intervention. This 6-month intervention is multimodal, involving patient prompts, clinician prompts, and outreach. At the time of the patient visit, eligible patients receive a low-literacy patient education tool. At the same time, clinicians receive a prompt to remind them to order the test and, when appropriate, a tool designed to simplify colorectal cancer screening decision-making. Patient outreach consists of personalized letters, automated telephone reminders, assistance with scheduling, and linkage of uninsured patients to the local National Breast and Cervical Cancer Early Detection program. Interventions are repeated for patients who fail to respond to early interventions. We will compare rates of screening between randomized groups, as well as planned secondary analyses of minority patients and uninsured patients. Data from the pilot phase show that this multimodal intervention triples rates of cancer screening (adjusted odds ratio 3.63; 95% CI 2.35 - 5.61). DISCUSSION: This study protocol is designed to assess a multimodal approach to promotion of breast and colorectal cancer screening among underserved patients. We hypothesize that a multimodal approach will significantly improve cancer screening rates.The trial was registered at Clinical Trials.gov NCT00818857.

Complications and sexual function after vaginectomy for anorectal tumors.

PURPOSE: The objective of this study was to determine complication rates and functional outcomes of females who underwent vaginectomy during anorectal tumor resection and to determine whether flap reconstruction of the vagina improves sexual function. METHODS: A retrospective review was performed of all females who underwent multivisceral resections involving the vagina for anorectal tumors at two academic hospitals from 1985 to 2004. Living patients were contacted, and a 25-question telephone questionnaire was administered. RESULTS: Fifty-four patients were identified. Nineteen patients had flap reconstruction of the vagina and 35 had primary repair. Eighty-three percent of patients experienced surgical complications, including perineal wound complications in 33 percent (14/42) of those with perineal incisions and vaginal complications in 41 percent (22/54) of the cohort. There was a nonsignificant decrease in perineal wound complications when flap reconstruction was performed (22 vs. 42 percent). Twenty-three patients completed the questionnaire (96 percent of those eligible). Six patients were able to have sexual intercourse after surgery and nine were not. Reasons for inability to have sexual intercourse were: inadequate vaginal capacity (n = 4), pain (n = 2), and chronic wound or fistula (n = 3). No living patients who had flap reconstruction were able to have sexual intercourse. Only 20 percent of patients remembered a preoperative discussion of possible sexual effects of surgery; however, overall quality of life was preserved. CONCLUSIONS: Anorectal tumor resections involving the vagina are associated with a high rate of complications, including inability to have intercourse after surgery, even with flap reconstruction. Females should be counseled regarding potential loss of sexual function.

Prevalence of male and female sexual dysfunction is high following surgery for rectal cancer.

OBJECTIVE: To measure sexual function and quality of life (QOL) after rectal cancer treatment. SUMMARY BACKGROUND DATA: Previous studies on sexual function after rectal cancer treatment have focused on males and have not used validated instruments. METHODS: Patients undergoing curative rectal cancer surgery from 1980 to 2003 were administered a questionnaire, including the Female Sexual Function Index (FSFI) or International Index of Erectile Function (IIEF), and the EORTC QLQ-C30/CR-38. Multiple logistic regression was used to test associations of clinical factors with outcomes. RESULTS: Eighty-one women (81.0%) and 99 men (80.5%) returned the questionnaire; 32% of women and 50% of men are sexually active, compared with 61% and 91% preoperatively (P < 0.04); 29% of women and 45% of men reported that "surgery made their sexual lives worse." Mean (SD) FSFI and IIEF scores were 17.5 (11.9) and 29.3 (22.8). Specific sexual problems in women were libido 41%, arousal 29%, lubrication 56%, orgasm 35%, and dyspareunia 46%, and in men libido 47%, impotence 32%, partial impotence 52%, orgasm 41%, and ejaculation 43%. Both genders reported a negative body image. Patients seldom remembered discussing sexual risks preoperatively and seldom were treated for dysfunction. Current age (P < 0.001), surgical procedure (P = 0.003), and preoperative sexual activity (P = 0.001) were independently associated with current sexual activity. Gender (male, P = 0.014), surgical procedure (P = 0.005), and radiation therapy (P = 0.0001) were independently associated with the outcome "surgery made sexual life worse." Global QOL scores were high. CONCLUSIONS: Sexual problems after surgery for rectal cancer are common, multifactorial, inadequately discussed, and untreated. Therefore, sexual dysfunction should be discussed with rectal cancer patients, and efforts to prevent and treat it should be increased.

Interferon-beta gene therapy improves survival in an immunocompetent mouse model of carcinomatosis.

BACKGROUND: Interferon-beta (IFNbeta) has multiple antitumor effects; however, its use has been limited by its short half-life in vivo. This limitation may be overcome by IFNbeta gene therapy. We evaluated adenovirus-IFNbeta therapy in an immunocompetent mouse model of carcinomatosis. METHODS: Mice that were treated intraperitoneally 5 days after tumor (mouse ovarian teratoma) inoculation with an adenoviral vector that contains the mouse IFNbeta gene (Ad-IFNbeta), control adenoviral vector or saline solution. Mice were monitored for multiple outcome measures and toxicity. To determine the mechanism of antitumor effect, flow cytometry of ascites fluid was performed to differentiate immune cell populations. Nitric oxide in ascites fluid was measured with an electrochemical microsensor. RESULTS: Tumor burden was decreased and survival was prolonged (P<.001) in the Ad-IFNbeta group after a single treatment of 3.3 x 10(8) plaque-forming units, with acceptable toxicity. By flow cytometry, an increase in the proportion of natural killer cells (from less than 2% of the gated population to more than 8%; P=.024) and an increase in macrophages were seen in the treated animals. Although there was a trend toward increased levels of nitric oxide in Ad-IFNbeta treatment groups, it was not statistically significant. CONCLUSION: IFNbeta gene therapy results in decreased tumor burden and improved survival in an aggressive, immunocompetent mouse model of carcinomatosis. This therapy warrants further evaluation as a treatment for disseminated peritoneal cancer.

Anatomic and functional characteristics of the rat ileal pouch.

BACKGROUND: The definitive operation for chronic ulcerative colitis (UC) and familial adenomatous polyposis is total proctocolectomy with ileal pouch-anal anastomosis (IPAA). Mild inflammation (pouchitis) is omnipresent in pouches and becomes severe in 50% of UC patients with IPAA. The etiology of pouchitis is likely due to combined genetic, microbial, and immunologic factors. Epithelial cell exposure to surgical trauma and/or to changes in intestinal bacterial composition may account for the inflammatory infiltrate. Progress in understanding pouchitis is restricted by the lack of suitable animal models. METHODS: An ileal pouch-rectal anastomosis [IPRA] in rats was developed to reproduce a model of human IPAA and clinical, gross and histologic criteria were determined. RESULTS: Many shared features with human ileal pouch were observed. CONCLUSION: IPRA is an important in vivo model to study mechanisms of repair, defense and immunity that may contribute to pouchitis.