Timing of readmissions for complications following emergency colectomy: follow-up beyond post-operative day 30 matters.

BACKGROUND AND PURPOSE: Emergency colectomies are associated with a higher risk of complications compared to elective ones. A critical assessment of complications occurring beyond post-operative day 30 (POD30) is lacking. This study aimed to assess the readmission rate and factors associated with readmission 6-months following emergency colectomy. METHODS: A retrospective cohort study of adult patients who underwent emergency colectomy (2010-2018) was performed using the Nationwide Readmissions Database. The cohort was divided into two groups: (i) no readmission and (ii) emergency readmission(s) for complications related to colectomy (defined using ICD-9/10 codes). Readmissions were categorized as either "early" (POD0-30) or "late" (> POD30). Differences between groups were described and multivariable regression controlling for relevant covariates defined a priori were used to identify factors associated with timing of readmission and cost. RESULTS: Of 141,481 eligible cases, 13.22% (n = 18,699) were readmitted within 6-months of emergency colectomy for colectomy-related complications, 61.63% of which were "late" readmissions (> POD30). The most common reasons for "late" readmission were for bleeding, gastrointestinal, and infectious complications (20.80%, 25.30%, and 32.75%, respectively). On multiple logistic regression, female gender (OR 1.12; 95%CI 1.04-1.21), open procedures (OR 1.12, 95%CI 1.011-1.24), and sigmoidectomies (OR 1.51, 95%CI 1.39-1.65, relative to right hemicolectomies) were the strongest predictors of "late" readmission. On multiple linear regression, "late" readmissions were associated with a $1717.09 USD (95%CI $1717.05-$1717.12) increased cost compared to "early" readmissions. DISCUSSION: The majority of colectomy-related readmissions following emergency colectomy occur beyond POD30 and are associated with cases that are of overall higher morbidity, as well as open sigmoidectomies. Given the associated increased cost of care, mitigation of such readmissions by close follow-up prior to and beyond POD30 is advisable.

Extended versus limited mesenteric excision for operative Crohn's disease: 30-Day outcomes from the ACS-NSQIP database.

PURPOSE: Recent studies have suggested that extended mesenteric excision (ME) may reduce surgical reintervention in Crohn's Disease (CD), but there remains clinical concerns regarding potential peri-operative morbidity. This retrospective study compares 30-day perioperative morbidity between limited and extended ME in segmental colectomies for CD. METHODS: Using the American College of Surgeons National Surgical Quality Improvement (ACS-NSQIP) colectomy-specific database, all patients with CD undergoing segmental colectomy for non-malignant indications between 2014-2019 were included. A lymph node harvest of 12 or more nodes was used as a surrogate for extended ME. The primary outcome was NSQIP major morbidity. Secondary outcomes included abdominal complications and perioperative bleeding. RESULTS: Of 3,709 patients included from the ACS-NSQIP database, 3,087 underwent limited ME and 622 underwent extended ME. On univariate analysis, those with limited mesenteric excision were less likely to be anemic (46.1% vs 55.0%, p < 0.001) and have undergone an open surgery (44.7% vs 34.7%, p < 0.001). On univariate comparison of limited and extended ME, there was no significant difference in major morbidity. On multiple logistic regression, controlling for age, sex, BMI, smoking, preoperative sepsis, preoperative anemia, surgical approach, emergency surgery, stoma creation, bowel preparation, and immunosuppression, the extent of ME was not an independent predictor of NSQIP major morbidity (OR 1.1, 95% CI 0.84-1.44). Likewise, the extent of ME was not associated with an increase in abdominal complications (OR 0.95, 95% CI 0.76-1.19) or post-operative bleeding (OR 1.89, 95% CI 0.75-1.53). CONCLUSION: Extended ME for CD was not associated with an increase in 30-day perioperative major morbidity.

Is the Hartmann's procedure for diverticulitis obsolete? National trends in colectomy for diverticulitis in the emergency setting from 1993 to 2018.

BACKGROUND: Historically, Hartmann's procedure (HP) has been the operation of choice for diverticulitis in the emergency setting. However, recent evidence has demonstrated the safety of primary anastomosis (PA) with or without diverting ileostomy. The purpose of this study was to evaluate the trends of, and factors associated with, HP compared to PA in emergency surgery for diverticulitis over 25 years. METHODS: Using the National Inpatient Sample database, we identified adult patients ≥ 18 years old who underwent emergency surgery for diverticulitis (HP or PA) between 1993 and 2018 using ICD-9 and ICD-10 codes. Patients with inflammatory bowel disease, gastrointestinal cancer or who underwent elective diverticulitis surgery were excluded. Trends in HP were analyzed using multivariable linear regression, and factors associated with HP were assessed with multiple logistic regression. RESULTS: Of 499,433 patients who underwent colectomy in the emergency setting for acute diverticulitis, 271,288 (54.3%) had a HP and 228,145 (45.7%) had a PA. Median age was 61 years (IQR: 50-73), 53% were women, and 70.5% were white. The proportion of HP slightly increased over the study period-HP comprised 52.6% of included cases in 1993-98 and 55.2% of cases in 2014-2018 (p = 0.017). Advanced age (reference = 18-44 years; 45-54 years: OR 1.16, 95% CI 1.10-1.22; 55-64 years: OR 1.26, 95% CI 1.20-1.33; 65-74 years: OR 1.33, 95% CI 1.25-1.42; ≥ 75 years: OR 1.51, 95% CI 1.41-1.62), complicated diverticulitis (OR 1.41, 95% CI 1.36-1.46), and severity of illness (reference = minor; moderate: OR 1.46, 95% CI 1.38-1.54; major/extreme: OR 3.43, 95% CI 3.25-3.63) were associated with increased odds of HP. CONCLUSIONS: Over a 26-year period, HP has remained the most performed procedure in the emergency setting for diverticulitis. Future work should focus on knowledge translation with a possible change in practice as more randomized controlled trials provide support for PA.

Incidence and Factors Associated With Mental Health Disorders in Patients With Rectal Cancer Post-Restorative Proctectomy.

BACKGROUND: Most patients with rectal cancer experience bowel symptoms post-restorative proctectomy. The incidence of mental health disorders post-restorative proctectomy and its association with bowel symptoms are unknown. OBJECTIVES: This study aimed 1) to describe the incidence of mental health disorders in patients who underwent restorative proctectomy for rectal cancer and 2) to study the association between incident mental health disorders and bowel dysfunction after surgery. DESIGN: This retrospective cohort study used the Clinical Practice Research Datalink and Hospital Episode Statistics databases. SETTINGS: The databases were based in the United Kingdom. PATIENTS: All adult patients who underwent restorative proctectomy for a rectal neoplasm between 1998 and 2018 were included. MAIN OUTCOME MEASURES: The primary outcome was an incident mental health disorder. The associations between bowel, sexual, and urinary dysfunctions and incident mental health disorders were studied using Cox proportional hazard regression models. RESULTS: In total, 2197 patients who underwent restorative proctectomy were identified. Of 1858 patients without preoperative bowel, sexual, or urinary dysfunction, 1455 had no preoperative mental health disorders. In this cohort, 466 patients (32.0%) developed incident mental health disorders following restorative proctectomy during 6333 person-years of follow-up. On multivariate Cox regression, female sex (adjusted HR 1.30; 95% CI, 1.06-1.56), metastatic disease (adjusted HR 1.57; 95% CI, 1.14-2.15), incident bowel dysfunction (adjusted HR 1.41, 95% CI, 1.13-1.77), and urinary dysfunction (adjusted HR 1.57; 95% CI, 1.16-2.14) were found to be associated with developing incident mental health disorders post-restorative proctectomy. LIMITATIONS: This study was limited by its observational study design and residual confounding. CONCLUSIONS: Incident mental health disorders after restorative proctectomy for rectal cancer are common. The presence of bowel and urinary functional impairment significantly increases the risk of poor psychological outcomes among rectal cancer survivors. CON LOS TRASTORNOS DE SALUD MENTAL EN PACIENTES CON CNCER DE RECTO POSTERIOR A PROCTECTOMA RESTAURADORA: ANTECEDENTES: La mayoría de los pacientes con cáncer de recto experimentan síntomas intestinales después de la proctectomía restauradora. Se desconoce la incidencia de trastornos de salud mental posteriores a la proctectomía restauradora y su asociación con síntomas intestinales.OBJETIVOS: Los objetivos de nuestro estudio son: a) describir la incidencia de trastornos de salud mental en pacientes sometidos a proctectomía restauradora por cáncer de recto; b) estudiar la asociación entre los trastornos de salud mental incidentes y la disfunción intestinal después de la cirugía.DISEÑO: Este fue un estudio de cohorte retrospectivo que utilizó las bases de datos Clinical Practice Research Datalink y Hospital Episode Statistics.ENTORNO CLÍNICO: Las bases de datos se basaron en el Reino Unido.PACIENTES: Se incluyeron todos los pacientes adultos que se sometieron a una proctectomía restauradora por una neoplasia rectal entre 1998 y 2018.PRINCIPALES MEDIDAS DE VALORACIÓN: El resultado primario fue un trastorno de salud mental incidente. Las asociaciones entre la disfunción intestinal, sexual y urinaria y los trastornos de salud mental incidentes se estudiaron utilizando modelos de regresión de riesgos proporcionales de Cox.RESULTADOS: En total, se identificaron 2.197 pacientes que se sometieron a proctectomía restauradora. De 1.858 pacientes sin disfunción intestinal, sexual o urinaria preoperatoria, 1.455 personas tampoco tenían trastornos de salud mental preoperatorios. En esta cohorte, 466 (32,0 %) pacientes desarrollaron trastornos de salud mental incidentes después de la PR durante 6333 años-persona de seguimiento. En la regresión multivariada de Cox, sexo femenino (HRa 1,30, IC 95% 1,06-1,56), enfermedad metastásica (HRa 1,57, IC 95% 1,14-2,15) e incidencia intestinal (HRa 1,41, IC del 95 %: 1,13 a 1,77) y la disfunción urinaria (aHR 1,57, IC del 95 %: 1,16 a 2,14) se asociaron con el desarrollo de trastornos de salud mental incidentes después de la proctectomía restauradora.LIMITACIONES: Este estudio estuvo limitado por el diseño del estudio observacional y la confusión residual.CONCLUSIÓN: Los trastornos de salud mental incidentes después de la proctectomía restauradora para el cáncer de recto son comunes. La presencia de deterioro funcional intestinal y urinario aumenta significativamente el riesgo de malos resultados psicológicos entre los sobrevivientes de cáncer de recto. (Traducción- Dr. Ingrid Melo ).

Low Anterior Resection Syndrome in a Reference North American Sample: Prevalence and Associated Factors.

BACKGROUND: Low anterior resection syndrome (LARS) is a well-described consequence of rectal cancer treatment. Studying the degree to which bowel dysfunction exists in the general population may help to better interpret to what extent LARS is related to disease and/or cancer treatment. Currently, North American LARS normative data are lacking. The aim of this study was to describe the prevalence of bowel dysfunction, as measured by the LARS score, and quality of life (QoL) in a reference North American sample. Quality of life was measured and associations between participant characteristics and LARS were identified. STUDY DESIGN: This was a single-institution cross-sectional study of asymptomatic adults who underwent screening and surveillance colonoscopies from 2018 to 2021 with no/benign endoscopic findings. Survey was conducted on select comorbidities, sociodemographic factors, LARS, and QoL. Outcomes were LARS and QoL. Multivariable linear regression accounting for a priori clinical factors associated with bowel dysfunction was performed. RESULTS: Of 1,004 subjects approached, 502 (50.0%) participated, and 135 (26.9%) participants had major/minor LARS. On multiple linear regression, female sex (ß = 2.15, 95% CI 0.30 to 4.00), younger age (ß = -0.10, 95% CI -0.18 to -0.03), White ethnicity (ß = 2.45, 95% CI 0.15 to 4.74), and the presence of at least one of the following factors: diabetes, depression, neurologic disorder, or cholecystectomy (ß = 3.54, 95% CI 1.57 to 5.51) were independently associated with a higher LARS score. Individuals with LARS had lower global QoL, functional subscales, and various symptom subscale scores. CONCLUSIONS: Our study identified the baseline prevalence of LARS in asymptomatic adults who have not undergone a low anterior resection. These normative data will allow for more accurate interpretation of ongoing studies on LARS in North American rectal cancer patients.

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.

Emergency colectomies in the NOAC era: a nationwide analysis demonstrating increased complications.

BACKGROUND: The use of Non-vitamin K antagonist oral anticoagulants (NOAC) has increased substantially since their introduction in 2010. The lack of readily available reversal agents poses a challenge in perioperative management. The aim of this study was to evaluate the impact of NOACs on the outcomes of emergency colectomies. METHODS: All adult patients on long-term anticoagulation who underwent emergency colectomies were identified from the Nationwide Inpatient Sample (NIS) database from 2002 to 2018. Long-term anticoagulation was defined using ICD-9/10 codes. Two cohorts were compared: anticoagulated patients in the pre-NOAC era (2002-2010) and anticoagulated patients in the NOAC era (2010-2018). Outcomes of interest were postoperative surgical complications, mortality and need for transfusion. RESULTS: Of 13,218 patients on long-term anticoagulation, 3,264 patients were treated in the pre-NOAC era and 9,954 in the NOAC era. Over the study period, there was a significant increase in the proportion of anticoagulated patients undergoing emergency colectomies (R2 = 0.91). On univariate analysis, anticoagulated patients in the NOAC era were medically more comorbid and had higher rates of postoperative surgical complications (73.3% vs 60.3%, p < 0.001) and mortality (8.2% vs. 6.7%, p = 0.006), but had lower rates of postoperative bleeding (3.5% vs. 4.4%, p = 0.002) and transfusions (38.1% vs. 45.4%, p < 0.001). On multivariable regression, after accounting for clinically significant covariates, anticoagulation in the NOAC era was associated with decreased rates of postoperative bleeding (OR 0.70, 95%CI 0.57-0.88) and transfusions (OR 0.71 95%CI 0.64-0.77) but remained an independent predictor of increased overall postoperative complications (OR 1.26, 95%CI 1.14-1.39). CONCLUSION: Prevalence of long-term anticoagulation in patients undergoing emergency colectomies is increasing. Although associated with lower rates of postoperative bleeding and transfusions, anticoagulation in the NOAC era is associated with higher rates of overall postoperative complications. Evidence-based guidelines for perioperative management of patients on NOACs in the emergency colorectal surgery setting are needed.

Bowel stimulation before loop ileostomy closure to reduce postoperative ileus: a multicenter, single-blinded, randomized controlled trial.

INTRODUCTION: The objective of this study was to evaluate the impact of preoperative bowel stimulation on the development of postoperative ileus (POI) after loop ileostomy closure. METHODS: This was a multicenter, randomized controlled trial (NCT025596350) including adult (≥ 18 years old) patients who underwent elective loop ileostomy closure at 7 participating hospitals. Participants were randomly assigned (1:1) using a centralized computer-generated sequence with block randomization to either preoperative bowel stimulation or no stimulation (control group). Bowel stimulation consisted of 10 outpatient sessions within the 3 weeks prior to ileostomy closure and was performed by trained Enterostomal Therapy nurses. The primary outcome was POI, defined as an intolerance to oral food in the absence of clinical or radiological signs of obstruction, on or after postoperative day 3, that either (a) required nasogastric tube insertion; or (b) was associated with two of the following: nausea/vomiting, abdominal distension, or the absence of flatus. RESULTS: Between January 2017 and November 2020, 101 patients were randomized, and 5 patients never underwent ileostomy closure; thus, 96 patients (47 stimulated vs. 49 control) were analyzed according to a modified intention-to-treat protocol. Baseline characteristics were well balanced in both groups. The incidence of POI was lower among patients randomized to stimulation (6.4% vs. 24.5%, p = 0.034; unadjusted RR: 0.26, 95% CI 0.078-0.87). Stimulated patients also had earlier median time to first flatus (2.0 days (1.0-2.0) vs. 2.0 days (2.0-3.0), p = 0.025), were more likely to pass flatus on postoperative day 1 (46.8% vs. 22.4%, p = 0.022), and had a shorter median postoperative hospital stay (3.0 days (2.0-3.5) vs. 4.0 days (2.0-6.0), p = 0.003). CONCLUSIONS: Preoperative bowel stimulation via the efferent limb of the ileostomy reduced POI after elective loop ileostomy closure.

Patient and surgeon preferences for early ileostomy closure following restorative proctectomy for rectal cancer: why aren't we doing it?

BACKGROUND: Early ileostomy closure (EIC), ≤ 2 weeks from creation, is a relatively new practice. Multiple studies have demonstrated that this approach is safe, feasible, and cost-effective. Despite the demonstrated benefits, this is neither routine practice, nor has it been studied, in North America. This study aimed to assess patient and surgeon perspectives about EIC. METHODS: A mixed-methods, cross-sectional study of patients and surgeons was performed. Rectal cancer survivors from a single institution who underwent restorative proctectomy with diverting loop ileostomy and subsequent closure within the last 5 years were contacted. North American surgeons with high rectal cancer volumes (> 20 cases/year) were included. Surveys (patients) and semi-structured interviews (surgeons) were conducted. Analysis employed descriptive statistics and thematic analysis, respectively. RESULTS: Forty-eight patients were surveyed (mean age 65.1 ± 11.8 years; 54.2% male). Stoma closure occurred after a median of 7.7 months (IQR 4.8-10.9) and 50.0% (24) found it "difficult" or "very difficult" to live with their stoma. Patients considered improvement in quality of life and quicker return to normal function the most important advantages of EIC, whereas the idea of two operations in two weeks being too taxing on the body was deemed the biggest disadvantage. Most patients (35, 72.9%) would have opted for EIC. Surgeon interviews (15) revealed 4 overarching themes: (1) there are many benefits to EIC; (2) specific patient characteristics would make EIC an appropriate option; (3) many barriers to implementing EIC exist; and (4) many logistical hurdles need to be addressed for successful implementation. Most surgeons (12, 80.0%) would "definitely want to participate" in a North American randomized-controlled trial (RCT) on EIC for rectal cancer patients. CONCLUSIONS: Implementing EIC poses many logistical challenges. Both patients and surgeons are interested in further exploring EIC and believe it warrants a North American RCT to motivate a change in practice.

Efficacy and safety of extended duration to perioperative thromboprophylaxis with low molecular weight heparin on disease-free survival after surgical resection of colorectal cancer (PERIOP-01): multicentre, open label, randomised controlled trial.

OBJECTIVE: To determine the efficacy and safety of extended duration perioperative thromboprophylaxis by low molecular weight heparin when assessing disease-free survival in patients undergoing resection for colorectal cancer. DESIGN: Multicentre, open label, randomised controlled trial. SETTINGS: 12 hospitals in Quebec and Ontario, Canada, between 25 October 2011 and 31 December 2020. PARTICIPANTS: 614 adults (age ≥18 years) were eligible with pathologically confirmed invasive adenocarcinoma of the colon or rectum, no evidence of metastatic disease, a haemoglobin concentration of ≥8 g/dL, and were scheduled to undergo surgical resection. INTERVENTIONS: Random assignment to extended duration thromboprophylaxis using daily subcutaneous tinzaparin at 4500 IU, beginning at decision to operate and continuing for 56 days postoperatively, compared with in-patient postoperative thromboprophylaxis only. MAIN OUTCOME MEASURES: Primary outcome was disease-free survival at three years, defined as survival without locoregional recurrence, distant metastases, second primary (same cancer), second primary (other cancer), or death. Secondary outcomes included venous thromboembolism, postoperative major bleeding complications, and five year overall survival. Analyses were done in the intention-to-treat population. RESULTS: The trial stopped recruitment prematurely after the interim analysis for futility. The primary outcome occurred in 235 (77%) of 307 patients in the extended duration group and in 243 (79%) of 307 patients in the in-hospital thromboprophylaxis group (hazard ratio 1.1, 95% confidence interval 0.90 to 1.33; P=0.4). Postoperative venous thromboembolism occurred in five patients (2%) in the extended duration group and in four patients (1%) in the in-hospital thromboprophylaxis group (P=0.8). Major surgery related bleeding in the first postoperative week was reported in one person (<1%) in the extended duration and in six people (2%) in the in-hospital thromboprophylaxis group (P=0.1). No difference was noted for overall survival at five years in 272 (89%) patients in the extended duration group and 280 (91%) patients in the in-hospital thromboprophylaxis group (hazard ratio 1.12; 95% confidence interval 0.72 to 1.76; P=0.1). CONCLUSIONS: Extended duration to perioperative anticoagulation with tinzaparin did not improve disease-free survival or overall survival in patients with colorectal cancer undergoing surgical resection compared with in-patient postoperative thromboprophylaxis alone. The incidences of venous thromboembolism and postoperative major bleeding were low and similar between groups. TRIAL REGISTRATION: ClinicalTrials.gov NCT01455831.

MORPHEUS Phase II-III Study: A Pre-Planned Interim Safety Analysis and Preliminary Results.

BACKGROUND: We explored image-guided adaptive endorectal brachytherapy patients electing non-operative management for rectal cancer. We present the first pre-planned interim analysis. METHODS: In this open-label phase II-III randomized study, patients with operable cT2-3ab N0 M0 rectal cancer received 45 Gy in 25 fractions of pelvic external beam radiotherapy (EBRT) with 5-FU/Capecitabine. They were randomized 1:1 to receive either an EBRT boost of 9 Gy in 5 fractions (Arm A) or three weekly adaptive brachytherapy (IGAEBT) boosts totaling 30 Gy (Arm B). Patient characteristics and toxicity are presented using descriptive analyses; TME-free survival between arms with the intention to treat the population is explored using the Kaplan-Meier method. RESULTS: A total of 40 patients were in this analysis. Baseline characteristics were balanced; acute toxicities were similar. Complete clinical response (cCR) was 50% (n = 10/20) in Arm A and 90% in Arm B (n = 18/20). Median follow-up was 1.3 years; 2-year TME-free survival was 38.6% (95% CI: 16.5-60.6%) in the EBRT arm and 76.6% (95% CI: 56.1-97.1%) in the IGAEBT arm. CONCLUSIONS: Radiation intensification with IGAEBT is feasible. This interim analysis suggests an improvement in TME-free survival when comparing IGAEBT with EBRT, pending confirmation upon completion of this trial.

Oral Antibiotic Bowel Preparation Prior to Urgent Colectomy Reduces Odds of Organ Space Surgical Site Infections: a NSQIP Propensity-Score Matched Study.

BACKGROUND: Preoperative administration of oral antibiotic bowel preparation (OABP) alone has been shown to reduce infectious outcomes in patients undergoing elective colectomy. However, it remains unclear if these benefits extend to the emergency setting. This is a retrospective, propensity-score matched study comparing 30-day perioperative morbidity between those who received OABP alone versus no preparation prior to urgent colectomy. METHODS: Using the American College of Surgeons National Surgical Quality Improvement Program database, adults undergoing urgent colectomy from 2012 to 2019 were included. Those who were clinically obstructed or who received mechanical bowel preparation were excluded. Outcomes of interest included: surgical site infection (SSI), leak, ileus, and major morbidity. RESULTS: Of 24,559 patients meeting inclusion criteria, 878 (3.6%) received OABP prior to urgent colectomy. Prior to matching, those receiving no preparation were more likely to have higher ASA class, diabetes, hypertension, preoperative sepsis, open procedures, and a dirty wound classification. After matching, 1756 patients, remained with 878 in each arm. Preoperative characteristics were balanced on univariate analysis. Postoperatively, patients receiving OABP experienced decreased organ space SSI (11.2% vs. 15.5%, p = 0.009) and ileus (30.3% vs. 35.3%, p = 0.029), with no difference in leak rates (3.3% vs 3.3%, p = 1.000) or NSQIP major morbidity (47.4% vs. 49.9%, p = 0.316). On multivariate logistic regression, including propensity score, the reduction in organ space SSI associated with OABP persisted (OR 0.684, 95% CI 0.516-0.903). CONCLUSION: OABP prior to select urgent colectomies was associated with fewer organ space SSIs and may be considered when feasible.

The impact of delaying colonoscopies during the COVID-19 pandemic on colorectal cancer detection and prevention.

PURPOSE: The COVID-19 pandemic resulted in a partial to total shutdown of endoscopy in many healthcare centers. This study aims to quantify the impact of the reduction in colonoscopies on colorectal cancer (CRC) detection and screening. METHODS: After institutional ethics board approval, the endoscopy database at an academic tertiary-care center in Montreal, Canada, was searched for all colonoscopies performed from during the first wave locally (March-June 2020), and during the ramp up period where endoscopy service resumed (July to August 2020). We compared these periods to the same periods in 2019, the pre-pandemic periods. The indications, CRC and adenoma detection rates, as well as the prioritization of urgent procedures were compared. RESULTS: In the first wave, only 462 colonoscopies were performed, compared to 2515 in the same period in 2019, an 82% reduction. The ramp up period saw 843 colonoscopies performed compared to 1328 in 2019, a 35% reduction. Urgent and inpatient colonoscopies numbers increased (324 (24.8%) vs. 220 (5.7%)) while surveillance and high-risk screening colonoscopies fell (376 (28.8%) vs 1869 (48.6%)). Emergency access to colonoscopy was preserved with a median time to endoscopy of < 1 day (IQR 0,1) in both pandemic periods. During the pandemic periods, there was an absolute reduction in CRC diagnosis of 28, despite the CRC detection per colonoscopy rate increasing slightly in the first wave from 1.7% (44) to 3.9% (18), and in the ramp up period from 2.5% (33) to 3.6% (31). The rate of adenoma detection per colonoscopy did not increase significantly between the pre- and pandemic periods, resulting in reduction in adenoma removal in 723 patients. DISCUSSION: The restriction of access to colonoscopy resulted in a significant reduction in screening and surveillance of high-risk patients, adenomas removed, and CRCs diagnosed. Clinicians and patients will face the oncologic ramifications this the coming years.

Surgical Principles of Rectal Cancer.

This article reviews the oncological principles of rectal cancer surgery, beginning with an overview of the pertinent rectal and pelvic anatomy, followed by a discussion of the historical evolution in surgical management. Evidence supporting current practices with respect to proximal, distal, and circumferential margins are reviewed. Finally, operative approaches to restorative proctectomies and abdominoperineal resections are highlighted.

Early discharge after colorectal cancer resection: trends and impact on patient outcomes.

BACKGROUND: Implementation of early discharge in colorectal surgery has been effective in improving patient satisfaction and reducing healthcare costs. Readmission rates following early discharge among colorectal cancer patients are believed to be low, however, remain understudied. The objectives of this study were: (i) to describe trends in early post-operative discharge and the associated hospitalization costs; (ii) to explore patient outcomes and resource utilization following early discharge; and (ii) to identify predictors of readmission following early discharge. METHODS: This was a retrospective cohort study using the Nationwide Readmissions Database. Adult patients admitted with a primary colorectal neoplasm who underwent colectomy or proctectomy between 2010 and 2017 were identified using ICD-9/10 codes. The exposure of interest was early post-operative discharge defined as ≤ 3 days from surgery. Main outcome measures were 30-day readmissions, post-operative complication rates, LOS and cost. RESULTS: In total, 342,242 patients were identified, and of those, 51,977 patients (15.2%) had early discharges. During the study period, the proportion of early discharges significantly increased (R2 = 0.94), from 9.9 to 23.4%, while readmission rates in this group remained unchanged (mean 7.3% ± 0.5). Complications that required bounceback readmission (within 7 days) after early discharge, rather than during index admission, were an independent predictor of longer overall LOS (ß = 0.044, p < 0.001) and higher hospitalization costs (ß = 0.031, p < 0.001). On multiple logistic regression, factors independently associated with bounceback readmission following early discharge were: male gender (OR = 1.47, 95%CI 1.33-1.63); open surgery (OR = 1.37, 95%CI 1.23-1.52); presence of stoma (OR = 1.51, 95%CI 1.22-1.87); transfer to facility or discharge with home health service (OR = 1.53, 95%CI 1.34-1.75); and Medicare/Medicaid insurance (OR = 1.34, 95%CI 1.14-1.57), among others. CONCLUSION: Early post-operative discharge of colorectal cancer patients is increasing despite a lack of improvement in readmission rates and an overall increase in hospitalization costs. Premature discharge of select patients may result in readmissions due to critical complications related to surgery resulting in increased resource utilization.

Impact of the Covid-19 pandemic on rates of emergency department utilization and hospital admission due to general surgery conditions.

BACKGROUND: Recent literature reports a decrease in healthcare-seeking behaviours by adults during the Covid-19 pandemic. Given that emergency general surgery (GS) conditions are often associated with high morbidity and mortality if left untreated, the objective of this study was to describe and quantify the impact of the Covid-19 pandemic on rates of emergency department (ED) utilization and hospital admission due to GS conditions. METHODS: This cohort study involved the analysis of an institutional database and retrospective chart review. We identified adult patients presenting to the ED in a network of three teaching hospitals in Montreal, Canada during the first wave of the Covid-19 pandemic (March13-May13, 2020) and a control pre-pandemic period (March13-May13, 2019). Patients with GS conditions were included in the analysis. ED utilization rates, admission rates and 30-day outcomes were compared between the two periods using multivariate regression analysis. RESULTS: During the pandemic period, 258 patients presented to ED with a GS diagnosis compared to 351 patients pre-pandemically (adjusted rate ratio (aRR) 0.75; p < 0.001). Rate of hospital admission during the pandemic was also significantly lower (aRR = 0.77, p < 0.001). Patients had a significantly shorter ED stay during the pandemic (adjusted mean difference 5.0 h; p < 0.001). Rates of operative management during the pandemic were preserved compared to the pre-pandemic period. There were no differences in 30-day complications (adjusted odds ratio (aOR) 1.46; p = 0.07), ED revisits (aOR 1.10; p = 0.66) and (re)admissions (aOR 1.42; p = 0.22) between the two periods. CONCLUSION: There was a decrease in rates of ED utilization and hospital admissions due to GS conditions during the first wave of the Covid -19 pandemic; however, rates of operative management, complications and healthcare reutilization were unchanged. Although our findings are not generalizable to patients who did not seek healthcare, it was possible to successfully uphold institutional standards of care once patients presented to the ED.

Segmental resection of splenic flexure colon cancers provides an adequate lymph node harvest and is a safe operative approach - an analysis of the ACS-NSQIP database.

INTRODUCTION: Fewer than 10% of colon cancers are found at the splenic flexure. A standard surgical approach to these cancers has not been defined. The goal of this study was to compare lymph node harvest and post-operative morbidity between segmental resection and formal left hemicolectomy for splenic flexure colon cancers. METHOD: Patients diagnosed with a splenic flexure cancer were identified from the 2012-2018 ACS-NSQIP colectomy-targeted database. Patients were categorized based on type of surgical resection - left hemicolectomy with colorectal anastomosis or segmental colectomy with colocolonic anastomosis. Demographic, clinicopathologic, and post-operative outcomes were compared between groups. Factors independently associated with lymph node harvest, operative time, and post-operative morbidity were investigated by linear and binomial logistic regression models. RESULTS: A total of 3,049 patients underwent colectomy for a splenic flexure cancer. Of these, 83.6% had a segmental colectomy and 73% were performed by a minimally invasive approach. T- and N-stage did not differ between segmental and left hemicolectomy groups (p = 0.703 and p = 0.429, respectively). Inadequate nodal harvest (< 12 nodes) was infrequent and similar between the two procedures (7.4% vs. 9.1%, p = 0.13). Operative time was significantly shorter for segmental colectomy (213 ± 83.5 min vs. 193 ± 84.1 min, p < 0.0001) and major morbidity was similar between the two surgical techniques (8.4% vs. 8.9%, p = 0.75). After accounting for demographic, clinicopathologic, and operative factors, binomial logistic regression showed that type of procedure was not significantly associated with LN harvest (OR 0.80, 95%CI 0.54-1.17) or major morbidity (OR 1.17, 95%CI 0.36-3.81). However, on linear regression, segmental splenic flexure resection was associated with shorter operative time (estimate 20.29, 95%CI 12.61-27.97, p < 0.0001). CONCLUSION: Splenic flexure resection for colon cancer is associated with an adequate lymph node harvest. Compared to a formal left hemicolectomy, a segmental resection also has a shorter operative time with equivalent post-operative morbidity.

Observational versus antibiotic therapy for acute uncomplicated diverticulitis: A non-inferiority meta-analysis based on a Delphi consensus.

BACKGROUND: The purpose of this study was to determine if observational therapy is noninferior to antibiotics for acute uncomplicated diverticulitis according to clinically relevant margins. METHODS: MEDLINE, EMBASE, and Cochrane were systematically searched by 2 independent reviewers to identify comparative studies of observational therapy versus antibiotics for acute uncomplicated diverticulitis. Non-inferiority margins (ΔNI) for each outcome were based on Delphi consensus including 50 patients and 55 physicians: persistent diverticulitis (ΔNI = 4.0%), progression to complicated diverticulitis (ΔNI = 3.0%), and time to recovery (ΔNI = 5 days). Risk differences and mean differences were pooled using random-effects meta-analysis. One-sided 90% confidence intervals and Z-tests were used to determine non-inferiority. A sensitivity analysis was performed, excluding patients post hoc determined to have complicated diverticulitis. RESULTS: Nine studies (3 randomized controlled trials, 6 observational studies) met inclusion criteria: observational therapy (n = 2,011) versus antibiotics (n = 1,144). Observational therapy was noninferior to antibiotics regarding the risk of persistent diverticulitis (pooled risk differences: -0.39%, 90% CI -3.22 to 2.44%, ΔNI: 4.0%, PNI < 0.001; I2 = 66%) and progression to complicated diverticulitis (pooled risk differences: -0.030%, 90% CI -0.99 to 0.92%, ΔNI: 3.0%, PNI < 0.001; I2 = 0%). On sensitivity analysis, observational therapy remained noninferior for both outcomes. When stratified by study design, observational therapy also remained noninferior for both outcomes among randomized controlled trials only. Only 1 study reported on time to recovery as a continuous outcome, with no statistical difference between antibiotics and observational therapy. CONCLUSION: According to clinically relevant ΔNIs, observational therapy was noninferior to antibiotics for the treatment of acute uncomplicated diverticulitis with regard to persistent diverticulitis and progression to complicated diverticulitis.