Surgical and medical outcomes in robotic compared to laparoscopic colectomy global prospective cohort from the American college of surgeons national surgical quality improvement program.

BACKGROUND: Evidence regarding the outcomes benefits of robotic approach, when compared to a laparoscopic approach, in colectomy remain limited. OBJECTIVE: This study aimed to analyze the value of robotic approach compared to laparoscopic approach in minimally invasive colectomy. DESIGN: Cohort study of the National Surgical Quality Improvement Program (NSQIP). SETTING: This study included data from the NSQIP from 1/2016 to 12/2021. PATIENT: Adult patients undergoing minimally invasive (laparoscopic or robotic) colorectal surgery. INTERVENTION: Robotic versus laparoscopic colectomy. OUTCOME MEASURES: Risk ratios for the incidence of medical and surgical morbidity and overall mortality. RESULTS: Compared to laparoscopic, robotic colectomy was associated with a significant decrease in postoperative morbidity [RR 0.84 (95%CI 0.72-0.96), P < 0.001], a significant reduction in postoperative mortality [RR 0.83 (95%CI 0.79-0.90), P 0.010)], and in post operative ileus [RR: 0.80 (95%CI 0.75-0.84), P < 0.001]. Yet, robotic approach was associated with a significant increase in total operative time despite a significant decrease in total length of stay. No benefit was observed regarding anastomotic leak. LIMITATIONS: Observational nature of the study cannot exclude residual bias. CONCLUSIONS: In this prospective cohort from the NSQIP, robotic colectomy was associated with a significant reduction in postoperative ileus, unplanned conversion to open surgery, morbidity, and overall mortality when compared to laparoscopic colectomy.

Causes of death in patients operated for colorectal cancer.

BACKGROUND: Colorectal cancer remains the third leading cause of cancer-related mortality in the United States. This study evaluates the causes of death in patients operated on for colorectal cancer and their determinants. METHODS: An Instructional Review Board-approved database containing patients who underwent surgical resection for colorectal cancer from 2004 to 2018 (last followed up in December 2020) in a tertiary care institution. Data on the underlying cause of death was extracted from the Registry of Vital Records and Statistics in Massachusetts. RESULTS: A total of 576 deaths were recorded in the database, of which 290 (50.35%) patients died of colorectal cancer. Deaths from colorectal cancer gradually decreased over time, whereas deaths from other cancers increased, and deaths from cardiovascular diseases remained stable. Patients who died from colorectal cancer were younger, died earlier in the disease course, had fewer comorbidities, higher rates of stage IV disease, rectal cancer, neoadjuvant therapy, extramural vascular invasion, perineural invasion, R0 resection, and preserved mismatch repair protein status. On multivariate analysis, age (adjusted odds ratio for 10-year increase = 0.79, 95% confidence interval 0.65-0.95), American Society of Anesthesiologists score (adjusted odds ratio = 0.64, confidence interval 0.42-0.98), stage IV disease (adjusted odds ratio = 3.02, confidence interval 1.59-5.9), neoadjuvant therapy (adjusted odds ratio = 7.91, confidence interval 2.64-28.13), extramural vascular invasion (adjusted odds ratio = 2.3, confidence interval 1.36-3.91) & time from diagnosis to death (adjusted odds ratio = 0.76, confidence interval 0.68-0.83) predicted death due to colorectal cancer versus other causes, whereas tumor location, perineural invasion, R0 resection, and mismatch repair protein status did not. CONCLUSION: There is a declining trend of deaths from colorectal cancer, presumably reflecting advances in colorectal cancer management strategies and better screening over time. However, younger patients disproportionately contribute to death due to colorectal cancer and need aggressive screening and management strategies.

Metformin Does not Affect Outcomes in Patients With Locally Advanced Rectal Cancer Treated With Neoadjuvant Therapy and Resection.

INTRODUCTION: There is emerging evidence that metformin may have a protective effect in patients with cancer. However, its current evidence in locally advanced rectal cancer (LARC) is inconclusive. We aim to assess the effect of metformin on long-term outcomes in patients with LARC who received neoadjuvant therapy and surgical resection. METHODS: A retrospective review of 324 patients with nonmetastatic LARC who received neoadjuvant therapy and major surgical resection from 2004 to 2018. There were 27 patients who received metformin before surgery and 297 patients who did not receive metformin. RESULTS: Metformin users were associated with a significantly higher age, BMI, ASA score, and 30-day readmissions (P < .05). There was no difference in overall survival (OS, P = .18) or disease-free survival (DFS, P = .33) between the two groups. On Cox regression, metformin intake did not predict OS (HR 0.85, 95% CI 0.4-1.77) when controlled for age (HR 1.04, 1.02-1.06), sex (HR 1.13, 0.69-1.85), BMI (HR 0.97, 0.92-1.02), ASA score (HR: 1.7, 1.06-2.73), TNT (HR 0.31, 0.1-0.92), pathological Stage III disease (HR 2.55, 1.51-4.32), extramural vascular invasion (EMVI) (HR 3.06, 1.7-5.5), and adjuvant therapy (HR 0.1, 0.04-0.27 for <25 months OS and HR 0.3, 0.15-0.59 for ≥25 months). Disease-free survival showed a similar trend with no significant effect of metformin (HR 0.77, 0.39-1.52) when controlled for age, sex, BMI, ASA, TNT, Stage III disease, EMVI, and adjuvant therapy. CONCLUSION: Metformin does not affect long-term survival in LARC treated with neoadjuvant therapy followed by surgical resection. Studies with larger sample sizes are needed to validate the findings further.

Trends and Determinants of Location of Death Due to Colorectal Cancer in the United States : A Nationwide Study.

BACKGROUND: Colorectal cancer (CRC) is the second leading cause of cancer-related mortality in the United States (US); however, there are limited data on location of death in patients who die from CRC. We examined the trends in location of death and determinants in patients dying from CRC in the US. METHODS: We utilized the Centers for Disease Control and Prevention Wide-Ranging Online Data for Epidemiologic Research database to extract nationwide data on underlying cause of death as CRC. A multinomial logistic regression was performed to assess associations between clinico-sociodemographic characteristics and location of death. RESULTS: There were 850,750 deaths due to CRC from 2003 to 2019. There was a gradual decrease in deaths in hospital, nursing home, or outpatient facility/emergency department over time and an increase in deaths at home and in hospice. Relative to White decedents, Black, Asian, and American Indian/Alaska Native decedents were less likely to die at home and in hospice compared with hospitals. Individuals with lower educational status also had a lower risk of dying at home or in hospice compared with in hospitals. CONCLUSIONS: The gradual shift in location of death of patients who die of CRC from institutionalized settings to home and hospice is a promising trend and reflects the prioritization of patient goals for end-of-life care by healthcare providers. However, there are existing sociodemographic disparities in access to deaths at home and in hospice, which emphasizes the need for policy interventions to reduce health inequity in end-of-life care for CRC.

Incidence of Secondary Cancers After Neoadjuvant Therapy for Locally Advanced Rectal Cancer.

INTRODUCTION: Whether neoadjuvant chemoradiation for locally advanced rectal cancer (LARC) induces secondary cancers is controversial. This retrospective cohort study describes the incidence of secondary cancers in LARC patients. METHODS: We compared 364 LARC patients who received conventional (50.4 Gy) or short course neoadjuvant radiation (25 Gy x 5 fractions) followed by resection to 142 patients with surgically resected rectal cancer who did not receive radiation at a single institution from 2004 to 2018. Secondary cancer was defined as any nonmetastatic noncolorectal malignancy diagnosed via biopsy or definitive imaging criteria at least 6 mo after completion of neoadjuvant therapy or after resection in the comparison group. RESULTS: Among the neoadjuvant radiation group (364 patients, 40% female, age 61 ± 13 y), 32 patients developed 34 (9.3%) secondary cancers. Three cases involved a pelvic organ. Among the comparison group (142 patients, 39% female, age 64 ± 15 y), 15 patients (10.6%) developed a secondary cancer. Five cases involved pelvic organs. Secondary cancer incidence did not differ between groups. Latency period to secondary cancer diagnosis was 6.7 ± 4.3 y. Patients who received radiation underwent longer median follow-up (6.8 versus 4.5 y, P < 0.01) and were significantly less likely to develop a pelvic organ cancer (odds ratio 0.18; 95% confidence interval, 0.04-0.83; P = 0.02). No genetic mutations or cancer syndromes were identified among patients with secondary cancers. CONCLUSIONS: Neoadjuvant chemoradiation is not associated with increased secondary cancer risk in LARC patients and may have a local protective effect on pelvic organs, especially prostate. Ongoing follow-up is critical to continue risk assessment.

Patient Factors Affecting Inpatient Mortality Following Colorectal Cancer Resection.

BACKGROUND: Our objective is to identify factors for inpatient death in patients undergoing resection for colorectal cancer (CRC). STUDY DESIGN: Unmatched 1:3 case-control study of surgically resected CRC at a tertiary care institution between 2004 and 2018. Variables for multivariate analysis were selected using tetrachoric correlation followed by a least absolute shrinkage and selection operator (LASSO) penalized regression model. RESULTS: A total of 140 patients were included (N = 35 patients who died inpatient, N = 105 patients who did not die). Patients who died were older, had higher Charlson Comorbidity Index (CCI), higher rates of preoperative anemia, hypoalbuminemia, emergency surgeries, blood transfusion, postoperative vasopressor requirement, anastomotic leak, and postoperative ICU admission than patients who underwent surgical resection without inpatient mortality. Anemia (aOR = 8.62, 1.44-91.58), emergency admission (aOR = 5.71, 1.46-24.36), and ICU admission (aOR 45.51, 8.31-448.4) significantly predicted inpatient mortality when controlled for CCI and hypoalbuminemia. CONCLUSIONS: Surprisingly, it appears that pre-existing anemia and perioperative factors are more important in predicting inpatient mortality of patients undergoing CRC surgery than baseline comorbidity or nutritional status.

The SAGES MASTERS program presents: the top 10 seminal articles for laparoscopic left and sigmoid colectomy pathway for uncomplicated disease.

BACKGROUND: As one of the 8 Society of American Gastrointestinal and Endoscopic Surgeons (SAGES) Masters Program clinical pathways, the Colorectal Pathway aims to deliver educational content for the general surgeon organized along 3 levels of performance (competency, proficiency and mastery) each represented by an anchoring procedure. In this article, the SAGES Colorectal Task Force presents focused summaries of the top 10 seminal articles selected for laparoscopic left/sigmoid colectomy for uncomplicated disease. METHODS: Using a systematic literature search of Web of Science, the most cited articles on laparoscopic left and sigmoid colectomy were identified, reviewed, and ranked by members of the SAGES Colorectal Task Force. Additional articles not identified in the literature search were included if deemed impactful by expert consensus. The top 10 ranked articles were then summarized, including their findings, strengths and limitations with emphasis on relevance and impact in the field. RESULTS: The top 10 articles selected focus on variations in minimally invasive surgical techniques, video demonstrations, stratified approaches for benign and malignant disease as well as assessments of the learning curve. CONCLUSIONS: The selected top 10 seminal articles for laparoscopic left and sigmoid colectomy in uncomplicated disease are considered by the SAGES colorectal task force to be fundamental to the knowledge base of minimally invasive surgeons as they progress to mastery in these procedures.

Association of age with outcomes in locally advanced rectal cancer treated with neoadjuvant therapy followed by surgery.

INTRODUCTION: We aimed to assess the association of age with outcomes in patients with Locally Advanced Rectal Cancer (LARC) who received neoadjuvant therapy followed by major surgery. METHODS: Retrospective review of 328 patients with LARC, N = 99 < 70 years (younger) versus N = 229 ≥ 70 years (elderly) from 2004 to 2018. RESULTS: Elderly patients had a higher American Society of Anesthesiologists (ASA) score, Charlson Comorbidity Index (CCI), length of stay and 30-day readmissions (p < 0.05). They also had worse overall survival (OS) & disease-free survival (DFS) (p < 0.001), but similar disease-specific survival (DSS) compared to younger group. Age was not associated with hazard of death (HR 1.01, 0.98-1.03). Rather, CCI (HR 1.29, 1.01-1.5), extramural vascular invasion (HR 4.98, 2.84-8.74), and adjuvant therapy (0.37, 0.21-0.64) were significantly associated with the hazard of death; when controlled for stage, tumor distance from anal verge, and neoadjuvant completion. CONCLUSION: Comorbidities and lower rates of adjuvant therapy, and not chronologic age, are associated with poor OS of elderly patients with LARC treated with neoadjuvant therapy and major surgery.

Effect of Plastic Bag Extraction in Minimally Invasive Appendectomy.

BACKGROUND: Evidence regarding the effects of plastic bag use for appendix removal during minimally invasive appendectomy remains scarce and conflicting. OBJECTIVE: This study aimed to analyze the effects of plastic bag use during minimally invasive appendectomy on preoperative infection risk, morbidity and mortality. DESIGN: This retrospective analysis of the prospective National Surgical Quality Improvement Program (NSQIP) cohort program. SETTING: This study included data from the NSQIP database between the years of 2016 and 2019. PATIENT: Adult patients undergoing minimally invasive (laparoscopic or robotic) without unplanned conversion to open surgery. INTERVENTION: Use of plastic bag for specimen removal during appendectomy. MAIN OUTCOME MEASURES: Risk ratios for the incidence of superficial surgical site infection, intra-abdominal abscess, overall medical morbidity, and overall mortality. RESULTS: There were 43 783 cases of minimally invasive appendectomy in the NSQIP database between the years of 2016 and 2019. Among those who reported information regarding use of plastic bag, 28 589 (91.87%) reported use of plastic bag for specimen removal. Use of plastic bag was associated with a significant decrease in superficial surgical site infection (RR .39 (95% CI: .31-.49), P < .001), and in the risk of postoperative intra-abdominal abscess (RR: 0.66 (.57-.77), P < .001)). We also observed a robust reduction in overall medical-related morbidity and overall mortality, even after adjusting for multiple confounders. LIMITATIONS: Observational nature of the study cannot exclude residual bias. Also, there was a significant rate of missing values for plastic bag use, which may bias results. CONCLUSIONS: In this global prospective cohort using NSQIP database, use of plastic bag for appendix removal during minimally invasive appendectomy was associated with a significant improvement in surgical related outcomes and reduction in morbidity and overall mortality.

Healthcare Resource Utilization After Surgical Treatment of Cancer: Value of Minimally Invasive Surgery.

BACKGROUND: As the US healthcare system moves towards value-based care, hospitals have increased efforts to improve quality and reduce unnecessary resource use. Surgery is one of the most resource-intensive areas of healthcare and we aim to compare health resource utilization between open and minimally invasive cancer procedures. METHODS: We retrospectively analyzed cancer patients who underwent colon resection, rectal resection, lobectomy, or radical nephrectomy within the Premier hospital database between 2014 and 2019. Study outcomes included length of stay (LOS), discharge status, reoperation, and 30-day readmission. The open surgical approach was compared to minimally invasive approach (MIS), with subgroup analysis of laparoscopic/video-assisted thoracoscopic surgery (LAP/VATS) and robotic (RS) approaches, using inverse probability of treatment weighting. RESULTS: MIS patients had shorter LOS compared to open approach: - 1.87 days for lobectomy, - 1.34 days for colon resection, - 0.47 days for rectal resection, and - 1.21 days for radical nephrectomy (all p < .001). All MIS procedures except for rectal resection are associated with higher discharge to home rates and lower reoperation and readmission rates. Within MIS, robotic approach was further associated with shorter LOS than LAP/VATS: - 0.13 days for lobectomy, - 0.28 days for colon resection, - 0.67 days for rectal resection, and - 0.33 days for radical nephrectomy (all p < .05) and with equivalent readmission rates. CONCLUSION: Our data demonstrate a significant shorter LOS, higher discharge to home rate, and lower rates of reoperation and readmission for MIS as compared to open procedures in patients with lung, kidney, and colorectal cancer. Patients who underwent robotic procedures had further reductions in LOS compare to laparoscopic/video-assisted thoracoscopic approach, while the reductions in LOS did not lead to increased rates of readmission.

Delayed Operative Management in Complicated Acute Appendicitis-Is Avoiding Extended Resection Worth the Wait ? Results from a Global Cohort Study.

BACKGROUND: The optimal management of complicated acute appendicitis remains undefined. According to current guidelines, a trial of non-operative management with delayed appendectomy may be associated with better outcomes for patients, including a reduced rate of extended resection appendectomy. METHODS: We conducted an analysis of the American College of Surgeons National Surgical Quality Improvement program to analyze the outcomes of hemodynamically stable patients presenting with complicated (abscess, perforation, or both) appendicitis submitted to early (less than 24 h) or delayed (24 h or more) operative management. RESULTS: Delayed operative management was associated with a significant reduction of the rate of extended resection appendectomy (RR: 2.15, 95% CI: 1.59 - 2.81, p < 0.001). Delayed operative management was associated with a non-significant trend towards reduced mortality (RR: 2.17; 95% CI: 0.98-2.85, p = 0.05). Delayed operative management was also associated with a significant decrease in total operative time and a significant reduction in the rate of postoperative abscess. There was no association between delayed intervention and medical related morbidity (RR: 1.01; 95% CI 0.91-1.11, p 0.811). However, delayed operative management was associated with a significant increase in total length of stay (coefficient 1.10; 95% CI: 1.02 to 1.18, p < 0.001). CONCLUSION: Delayed operative management may be associated with a reduction in the need of extended resection appendectomy, shorter operative time, and a trend towards reduced mortality. On the other hand, it may also be associated with an increased length of in-hospital stay and short-term morbidity.

Association of age with treatment at high-volume hospitals and distance traveled for care, in patients with rectal cancer who seek curative resection.

BACKGROUND: The association between volume and outcomes has led to recommendations that patients undergo surgery at high-volume centers. We aimed to determine if older patients with rectal cancer are undergoing operations at high-volume centers. METHODS: We identified patients ≥50 years old who underwent rectal cancer resection using the NCDB (2004-2015). Tertiles were used to categorize facility volume and distance traveled. RESULTS: Higher facility volume was associated with improved outcomes. Patients >75 years old were less likely than patients 50-59 years old to be treated at high-volume centers. Traveling >16.8 miles was associated with treatment at high-volume facilities, however patients >75 years old were less likely to travel >16.8 miles. CONCLUSIONS: Higher facility volume is associated with improved outcomes after rectal cancer resection. However, older patients are less likely to be treated at high-volume facilities. Older patients travel shorter distances for care, suggesting that care integration across networks must be optimized.

The Use of Single-Agent Versus Multiple-Agent Concurrent Chemoradiotherapy in the Treatment of Locally Advanced Rectal Cancer.

PURPOSE: The use of concurrent chemoradiotherapy is frequently recommended in the treatment of locally advanced rectal cancer; however, the ideal chemotherapy regimen remains unknown, and there is variability in chemotherapy agents used among different institutions. We sought to examine differences in overall survival between patients receiving single versus multiple-agent concurrent chemoradiotherapy. METHODS: The National Cancer Database was used to identify 31,025 patients with rectal cancer who received concurrent chemoradiotherapy between 01/2006 and 12/2016. We compared patients who received single-agent chemotherapy with those who received multiple-agent concurrent chemoradiotherapy. The primary outcome of interest was overall survival. The groups were compared using univariate analysis and Cox proportional hazard models to adjust for potential confounding factors. RESULTS: 18,544 patients received single-agent and 12,481 patients received multiple-agent chemotherapy. The former were older with more comorbidities as evidenced by their higher Charlson-Deyo Scores. Those receiving multiple-agent chemotherapy were more likely to have clinical stage III disease (52.9% vs 43.3%, p < 0.001) and less likely to have well-differentiated cancer (6.9% vs 7.7%, p < 0.001). The rates of negative resection margin were identical (p = 0.225) between the two groups. On multivariable analysis after adjusting for comorbidities, radiation dose, and resection margins, single-agent chemotherapy was associated with worse overall survival (HR 1.09, 95% CI 1.057-1.124, p < 0.001). CONCLUSION: Multiple-agent chemoradiotherapy is associated with improved overall survival in locally advanced rectal cancer; however, chemotherapy regimen does not affect resection margins. The modest overall survival benefit with multiple-agent chemotherapy must be balanced with the potential associated toxicity.

Impact of Bundled Payment Care Improvement Initiative on Health Care Expenditure in Major Bowel Procedures.

BACKGROUND: The Bundled Payments for Care Improvement initiative links payments for Medicare beneficiaries during an episode of care (90 days from index surgery). OBJECTIVE: This study aimed to determine whether major bowel participating Bundled Payments for Care Improvement organizations experience greater cost savings for colectomy while maintaining satisfactory quality outcomes compared to nonparticipating organizations. DESIGN: This is an Analysis of all Bundled Payments for Care Improvement participating hospitals for major bowel procedures (major bowel group) and propensity score-matched against Bundled Payments for Care Improvement organizations that do not include major bowel procedures (nonmajor bowel group) and those that do not participate in any Bundled Payments for Care Improvement program (non-Bundled Payments for Care Improvement group). SETTING: Programs accepting Medicare and Medicaid in the United States. PATIENTS: Patients included were major bowel cases in the Medicare Standard Analytic file within Medicare Severity Diagnosis-Related Groups 329-331 at participating facilities between January 1, 2011, and June 30, 2016. MAIN OUTCOME MEASURES: Main outcome measures included average total care expenditure and quality of care (length of stay, morbidity, and mortality) from 3 days preoperatively to 90 days postoperatively. RESULTS: We abstracted 7609 major bowel episodes from 23 major bowel group facilities, 21,872 episodes from nonmajor bowel-matched hospitals, and 19,383 episodes from non-Bundled Payments for Care Improvement-matched hospitals. From the baseline (January 2011 to June 2012) to final period (July 2015 to June 2016), we noted a $2955 average reduction in care expenditures. The largest decrease in average total episode expenditure occurred within the major bowel group (14% reduction) compared to the other groups (6% reduction for nonmajor bowel and 5% reduction for non-Bundled Payments for Care Improvement). Utilizing a generalized estimating equation to adjust for patient demographics, comorbidities, and hospital characteristics, the average total episode expenditure for the major bowel group decreased by $4885 (95% CI $4838-$4932; p < 0.001) compared to $2050 (95% CI $2038-$2061) for the non-Bundled Payments for Care Improvement group. All groups had similar reductions in length of stay, 30-day and 90-day complication rates, and readmission rates. LIMITATIONS: Analyses were limited by the retrospective nature of the study. CONCLUSIONS: Bundled Payments for Care Improvement participation for major bowel procedures resulted in a greater decrease in average total cost per episode of care than in nonparticipating hospitals without compromise in quality of care. See Video Abstract at http://links.lww.com/DCR/B837.IMPACTO DE LA INICIATIVA BUNDLED PAYMENT AGRUPADOS PARA LA MEJORA DE LA ATENCIÓN DEL GASTO SANITARIO EN LOS PROCEDIMIENTOS INTESTINALES MAYORESANTECEDENTES:La iniciativa de Bundled Payment para la mejora de la atención vincula los pagos para los beneficiarios de Medicare durante un episodio de atención (90 días desde la cirugía índice).OBJETIVO:Determinar si las principales organizaciones de Bundled Payment para el mejoramiento de la atención relacionados a los procedimientos intestinales experimentan mayores ahorros en los costos para una colectomía manteniendo resultados satisfactorios de calidad en comparación con las organizaciones no participantes.DISEÑO:Análisis de todos los hospitales participantes del programa Bundled Payment para la mejora de la atención para procedimientos intestinales mayores (grupo que incluyen procedimientos intestinales mayores) y puntaje de propensión comparado con las organizaciones que no incluyen dichos procedimientos (grupo que no incluye procedimientos intestinales mayores) y aquellos que no participan en ningún programa de Bundled Payment para la mejora de la atención (grupo no BPCI).MARCO:Programas que aceptan Medicare y Medicaid en los Estados Unidos.PACIENTES:Casos intestinales mayores en el archivo analítico estándar de Medicare dentro de los grupos relacionados con el diagnóstico 329-331 en los centros participantes entre el 1/1/2011-30/6/2016.PRINCIPALES MEDIDAS DE RESULTADO:Gasto total promedio y calidad de la atención (duración de la estadía, morbilidad, mortalidad) desde los 3 días preoperatorio hasta los 90 días postoperatorio.RESULTADOS:Hemos extraído 7609 episodios intestinales mayores de 23 instalaciones del grupo que incluyen procedimientos intestinales mayores, 21.872 episodios de hospitales del grupo que no incluyen procedimientos intestinales mayores y 19.383 episodios de hospitales del grupo no BPCI. Desde la línea de base (1/2011 - 6/2012) hasta el período final (7/2015 - 6/2016), notamos una reducción promedio de $2955 en los gastos de atención. La mayor disminución en el gasto promedio total por episodios ocurrió dentro del grupo que incluyen intestinales mayores (14% de reducción) en comparación con los otros grupos (6% de reducción para el grupo que no incluyen procedimientos intestinales mayores, 5% de reducción para el no BPCI). Utilizando una ecuación de estimación generalizada para ajustar los datos demográficos del paciente, las comorbilidades y las características del hospital, el gasto total promedio por episodio para el grupo que incluyen procedimientos intestinales mayores disminuyó en $ 4885 (IC del 95%: $4838-4932; p <0,001) en comparación con $2050 (IC del 95%: $2038-2061) para el grupo que no pertenece al programa BPCI. Todos los grupos tuvieron reducciones similares en la duración de la estancia, tasas de complicaciones de 30/90 días y de readmisión.LIMITACIONES:Análisis limitados por la naturaleza retrospectiva del estudio.CONCLUSIONES:La participación de Bundled Payment para la mejora de la atención en aquellos procedimientos intestinales mayores resultó en una disminución mayor en el costo total promedio por episodio de atención que en los hospitales no participantes, sin comprometer la calidad de la atención. Consulte Video Resumen en http://links.lww.com/DCR/B837. (Traducción-Dr Osvaldo Gauto).

Anastomotic Troubleshooting.

Anastomotic leak remains a critical and feared complication in colorectal surgery. The development of a leak can be catastrophic for a patient, resulting in overall increased morbidity and mortality. To help mitigate this risk, there are several ways to assess and potentially validate the integrity of a new anastomosis to give the patient the best chance of avoiding this postoperative complication. A majority of anastomoses will appear intact with no obvious sign of anastomotic dehiscence on gross examination. However, each anastomosis should be interrogated before the conclusion of an operation. The most common method to assess for an anastomotic leak is the air leak test (ALT). The ALT is a safe intraoperative method utilized to test the integrity of left-sided colon and rectal anastomoses and most importantly allows the ability to repair a failed test before concluding the operation. Additional troubleshooting is sometimes needed due to technical difficulties with the circular stapler. Problems, such as incomplete doughnuts and stapler misfiring, do occur and each surgeon should be prepared to address them.

The growing trend for no primary surgery in colorectal cancer.

AIM: In colorectal cancer (CRC), surgery of the primary site is commonly curative. Our aim was to determine estimates of 'no surgery' for primary CRC while identifying common reasons for no surgery. METHOD: We identified all patients with a diagnosis of colorectal adenocarcinoma from the National Cancer Database between January 2004 and December 2016. Then, we identified patients who did not undergo surgery on the primary tumour and their demographic, tumour and institutional characteristics. Kaplan-Meier and logistic regression analyses were used to evaluate specific factors associated with overall survival as related to no surgery and recommendations against operative management. RESULTS: A total of 1,208,878 patients with CRC were identified, 14.5% of whom had no surgery of the primary cancer. No surgery was more common in rectal cancer than in colon cancer. Despite a steady incidence of CRC diagnoses, the likelihood of no surgery grew by 170% over the study period. Metastatic disease was noted in 53.7% of the no surgery cohort. Nine per cent of the no surgery patient cohort received a recommendation against surgery despite the absence of metastatic disease, 7.5% refused surgery and only 2% underwent palliative surgery. On multivariable analysis, patients who were not recommended to have surgery were more likely to be older, uninsured, comorbid and receive care at a single hospital. The no surgery patients had significantly lower overall survival. CONCLUSION: A substantial proportion of patients with CRC do not have surgery. Interventions aimed at expanding access and promoting second opinions at other cancer hospitals might reduce the growing rate of no surgery in CRC.

Is Microsatellite Status Associated With Prognosis in Stage II Colon Cancer With High-Risk Features?

BACKGROUND: The influence of microsatellite instability on prognosis in high-risk stage II colon cancer is unknown. OBJECTIVE: This study aimed to investigate the relationship between microsatellite instability and overall survival in high-risk stage II colon cancer. DESIGN: This is a retrospective review of the National Cancer Database from 2010 to 2016. SETTINGS: This study included national cancer epidemiology data from the American College of Surgeons Commission on Cancer. PATIENTS: Included were 16,788 patients with stage II colon adenocarcinoma and known microsatellite status (1709 microsatellite unstable). MAIN OUTCOME MEASURES: The primary outcome measured was overall survival. RESULTS: Microsatellite unstable cancers with high-risk features had significantly better overall survival than microsatellite stable cancers with high-risk features (5-year survival 80% vs 72%, p = 0.01), and had survival equivalent to microsatellite stable cancers with low-risk features (5-year survival, 80%). When stratified by specific high-risk features, patients with lymphovascular invasion, perineural invasion, or high-grade histology had overall survival similar to patients without these features, only in microsatellite unstable cancers. However, patients with high-risk features of T4 stage, positive margins, and <12 lymph nodes saw no survival benefit based on microsatellite status. This was confirmed on multivariable Cox regression modeling. A subgroup analysis of patients who did not receive chemotherapy similarly demonstrated that microsatellite unstable cancers with lymphovascular invasion, perineural invasion, or high-grade histology had overall survival similar to microsatellite unstable cancers without those features. LIMITATIONS: The study is limited by the lack of specific clinical data and potential treatment bias. CONCLUSIONS: In microsatellite unstable cancers, lymphovascular invasion, perineural invasion, and high-grade histology are not associated with worse overall survival, even when deferring adjuvant chemotherapy. These data support National Comprehensive Cancer Network recommendations to forego chemotherapy in stage II cancers with microsatellite instability and these features. In contrast, some high-risk features were associated with worse survival despite microsatellite unstable biology, and therapies to improve survival need to be explored. See Video Abstract at http://links.lww.com/DCR/B500. ¿EL ESTADO MICROSATÉLITE ESTÁ ASOCIADO CON EL PRONÓSTICO EN EL CÁNCER DE COLON EN ESTADIO II CON CARACTERÍSTICAS DE ALTO RIESGO: Se desconoce la influencia de la inestabilidad microsatélite en el pronóstico del cáncer de colon en estadio II de alto riesgo.Investigar la relación entre la inestabilidad microsatélite y la supervivencia general en el cáncer de colon en estadio II de alto riesgo.Revisión retrospectiva de la base de datos nacional del cáncer de 2010 a 2016.Este estudio incluyó datos nacionales de epidemiología del cáncer de la Comisión de Cáncer del Colegio Americano de Cirujanos.16,788 pacientes con adenocarcinoma de colon en estadio II y estado microsatélite conocido (1,709 microsatélite inestables).Supervivencia global.Los cánceres microsatélite inestables con características de alto riesgo tuvieron una supervivencia general significativamente mejor que los cánceres microsatélite estables con características de alto riesgo (supervivencia a 5 años 80% vs 72%, p = 0.01), y tuvieron una supervivencia equivalente a los cánceres microsatélite estables con características de bajo riesgo (supervivencia a 5 años 80%). Al estratificar por características específicas de alto riesgo, los pacientes con invasión linfovascular, invasión perineural o histología de alto grado tuvieron una supervivencia general similar a la de los pacientes sin estas características, solo en cánceres microsatélite inestables. Sin embargo, los pacientes con características de alto riesgo en estadio T4, márgenes positivos y <12 ganglios linfáticos no tuvieron ningún beneficio de supervivencia basado en el estado de microsatélites. Esto se confirmó en un modelo de regresión de Cox multivariable. Un análisis de subgrupos de pacientes que no recibieron quimioterapia demostró de manera similar que los cánceres microsatélite inestables con invasión linfovascular, invasión perineural o histología de alto grado tenían una supervivencia general similar a los cánceres microsatélite inestables sin esas características.El estudio está limitado por la falta de datos clínicos específicos y el posible sesgo de tratamiento.En los cánceres microsatélite inestables, la invasión linfovascular, la invasión perineural y la histología de alto grado no se asocian con una peor sobrevida general, incluso cuando se aplaza la quimioterapia adyuvante. Estos datos respaldan las recomendaciones de la National Comprehensive Cancer Network de omitir la quimioterapia en los cánceres en estadio II con inestabilidad microsatélite y estas características. Por el contrario, algunas características de alto riesgo se asociaron con una peor supervivencia a pesar de la biología microsatélite inestable, y es necesario considerar las terapias para mejorar la supervivencia.Consulte Video Resumen en http://links.lww.com/DCR/B500. (Traducción-Dr. Jorge Silva Velazco).