Trends and benefits of prophylactic ureter catheters in the era of minimally invasive surgery.

BACKGROUND: The recent spike in ureter injury (UI) amidst the rise of minimally invasive surgery (MIS) has focused attention on the propriety of prophylactic ureter catheters (PUCs) for abdominopelvic operations. METHODS: A retrospective review of PUCs for rectal cancer resection following neoadjuvant therapy, combined with a comprehensive literature review. RESULTS: There were zero UI in the current study. Literature review revealed a nationwide spike in PUCs in the last 30 years, dependent on operation: 1) colorectal resection-increased from 1.1% to 4.4%, 2) sigmoid colectomy for diverticulitis-increased from 6.7% to 16.3%. This 2-4 fold increase parallels the rise of MIS: 15 of the 20 latest studies (75%) either combined open operations and MIS (4 studies) or focused solely on MIS (11 studies). Medial-to-lateral dissection identified as a UI risk factor. Only 20-30% of UI identified intraoperatively. CONCLUSIONS: Intraoperative UI is missed in 70-80% of cases. The prevention, identification, ease of ureter repair, and net decrease in operative time support the use of PUCs. Medial-to-lateral dissection is identified as a potential contributing factor to UI.

Rectal resection following neoadjuvant therapy in a Midwest community hospital setting: The case for standardization over centralization as the means to optimize rectal cancer outcomes in the United States.

BACKGROUND: Incomplete and flawed national databases reveal strikingly inferior outcomes for rectal cancer patients resected at "low" versus "high " volume hospitals, therefore, a study of outcomes of a "high" volume surgeon in a "low" volume Midwest community hospital setting examined this perception in comparison to contemporary studies. METHODS: Review of 109 consecutive patients who underwent open resection of rectal cancer following neoadjuvant therapy, 1999-2010. RESULTS: Despite the majority of tumors in the low rectum (54%), the rate of abdominoperineal resection was only 39% with R0 resection achieved in 94% and primary anastomosis in 61/109 patients (56%). Disease-free survival (DFS) 73%: stage 0 (complete response)- 100%, stage I- 88%, stage II- 68%, stage III- 50%, stage IV- 0% with recurrence rate of 11% (local recurrence (LR) - 3%, distant - 8%). CONCLUSION: Outcomes of rectal cancer resection by a "high" volume surgeon in a "low" volume Midwest community hospital setting were comparable to contemporary studies from tertiary care institutions. Geographic location and hospital capacity matter less than access to multispecialty expertise providing neoadjuvant therapy and following standard principles of oncologic resection, in efforts to optimize rectal cancer outcomes.

Outcomes of rectal resection following neoadjuvant therapy in the elderly: Can rectal cancer patients be too old for a neoadjuvant approach?

BACKGROUND: Neoadjuvant therapy has improved outcomes of resection for rectal carcinoma, however, there is limited data regarding its impact on elderly patients. METHODS: A retrospective review of 109 patients, 74 patients <70 years (Group 1) vs 35 elderly patients ≥ 70 years (Group 2), who underwent neoadjuvant therapy followed by open resection from 1999 to 2010. RESULTS: Neoadjuvant therapy was completed by 73/74 patients in Group 1 (99%) vs 30/35 patients in Group 2 (86%) (p = 0.013). R0 resection was accomplished in 94% (Group 1-96%, Group 2-91%). The overall recurrence rate was 12% for Group 1 vs 9% for Group 2. Kaplan-Meier analysis revealed a statistically significant difference in overall survival favoring Group 1 (p = 0.002). CONCLUSIONS: Neoadjuvant therapy was safely administered to completion in 86% of elderly patients with similar rates of R0 resection and recurrence versus a younger patient population and should not be denied on the basis of advanced age alone.

Defining payments associated with the treatment of colorectal cancer.

BACKGROUND: While bundled payments aim to reduce variations in health care spending across the continuum of care, data reporting on variations in payments for privately insured patients undergoing treatment for colon cancer (CC) are lacking. The current study sought to characterize variations in payments received for the treatment of CC using a cohort of commercially insured patients. METHODS: Patients who underwent a colectomy for CC were identified using the MarketScan Database for 2010-2014. Multivariable regression analysis was used to calculate and compare risk-adjusted payments between patients. RESULTS: A total of 18,337 patients were identified who met inclusion criteria. The median risk-adjusted payment for surgery was $26,408 (IQR: $19,193-$38,037) ranging from $19,762 (IQR: $15,595-$25,636) among patients in the lowest quartile of payments to $33,809 (IQR: $24,783-$48,254) for patients in the highest (+△71.1%). The median risk-adjusted payment for chemotherapy was $70,090 (IQR: $57,813-$83,216); compared with patients in the lowest quartile of payments, payments associated with chemotherapy were 40.4% higher among patients in the highest quartile of payments (Q1 versus Q4: $56,827 [IQR: 49,173-65,353] versus $79,801 [IQR: 67,270-90,999]). When stratified by treatment type, patients in the highest two quartiles of risk-adjusted payments accounted for a total of 58.5% of all payments, whereas patients in the lower two quartiles of risk-adjusted payments accounted for only 41.5% of all payments. A younger patient age, increasing patient comorbidity and undergoing an open operation were associated with higher overall payments. CONCLUSIONS: Wide variations in payments exist for the treatment for colon cancer. Episode-based bundle payments for surgery and chemotherapy may differentially impact reimbursement for CC.