Impact of neoadjuvant immunotherapy on postoperative complications after surgery for rectal cancer.

INTRODUCTION: Despite the increasing use of immunotherapy in treating various cancer types, there is still limited understanding of its impact on surgical complications. We used a national database to examine the difference in surgical outcomes for rectal cancer patients who received standard neoadjuvant chemoradiation plus neoadjuvant immunotherapy and patients who received neoadjuvant chemoradiation only. METHODS: This retrospective cohort study used the National Cancer Database (NCDB). We selected patients aged 18-90 with T1-3, N1-2, and M0 rectal cancer who underwent curative-intent surgery between 2010 and 2020. We performed a 1:1 propensity match to control for patient age, sex, Charlson-Deyo comorbidity index, surgical approach, and tumor site. Our primary outcome was difference in surgical outcomes (hospital length of stay, unplanned 30-day readmission, 30-day mortality) between the two groups. Secondary outcomes included days from diagnosis to surgery and pathologic outcomes. RESULTS: Our study included 26 229 patients, of which 126 received immunotherapy in addition to chemoradiation and 26 103 received only chemoradiation. In our matched population of 125 pairs of patients, patients who received immunotherapy and chemoradiation underwent surgery later compared to patients who only received chemoradiation (median 245 vs. 144 days, p < 0.001). There were no significant differences in median length of stay (5 vs. 5 days, p = 0.202), unplanned 30-day readmission (7 vs. 9, p = 0.617), and 30-day mortality (0 vs. 1, p = 1.000) between the two groups. CONCLUSION: Neoadjuvant immunotherapy for rectal cancer is not associated with adverse surgical outcomes. This work can help clinicians optimize treatment protocols and move closer toward strategies tailored to specific patient profiles.

Poor Acceptance of the Revised Classification of Premalignant Anal Lesions Following the LAST Standardized Project.

INTRODUCTION: The Lower Anogenital Squamous Terminology (LAST) Project recommended unified classification for HPV-associated squamous lesions of the lower anogenital tract, using a 2-tiered nomenclature in 2013. Adherence to the new nomenclature worldwide is unknown. This study aims to assess the trend of the use of the two-tiered High Squamous Intraepithelial Lesion and Low Squamous Intraepithelial Lesion (HSIL/LSIL) as opposed to the traditional three-tiered Anal Intraepithelial Neoplasia (AIN I/II/III) classification as suggested by the LAST Project. METHODS: A literature search on full-text English language studies of premalignant anal lesion was performed on PubMed from 2002-2022. The studies were categorized by continent, and the prevalence of HSIL/LSIL classification vs AIN I/II/III was calculated. RESULTS: 546 studies and 251 studies were identified using the AIN I/II/II and the HSIL/LSIL classification respectively. Global trend suggested a statistically significant downward trend in the use of the two-tiered nomenclature system in publications globally. Regional trend including North America, Europe, and other (Asia and Latin America) showed variance in adoption of the two-tiered nomenclature system. CONCLUSION: Despite multidisciplinary collaborative effort, adherence to the recommendations to use the two-tiered system for HPV-associated premalignant anal lesions continues to be suboptimal. Further efforts are needed to identify the cause of poor adherence to be able to create strategies that reinforces unification of terminology and integration of LAST the recommendations.

Hospital Quality Mediates Impact of Care Fragmentation Following Elective Colectomy.

BACKGROUND: Readmission at a non-index hospital, or care fragmentation (CF), has been previously linked to greater morbidity and resource utilization. However, a contemporary evaluation of the impact of CF on readmission outcomes following elective colectomy is lacking. We additionally sought to evaluate the role of hospital quality in mediating the effect of CF. METHODS: All records for adults undergoing elective colectomy were tabulated from the 2016 to 2020 Nationwide Readmissions Database. Patients readmitted non-electively within 30 days to a non-index center comprised the CF cohort (others: Non-CF). Hierarchical mixed-effects models were constructed to ascertain risk-adjusted rates of major adverse events (MAEs, a composite of in-hospital mortality and any complication) attributable to center-level effects. Hospitals with risk-adjusted MAE rates ≥50th percentile were considered Low-Quality Hospitals (LQHs) (others: High-Quality Hospitals [HQHs]). RESULTS: Of 68,185 patients readmitted non-electively within 30 days, 8968 (13.2%) were categorized as CF. On average, CF was older, of greater comorbidity burden, and more often underwent colectomy for cancer, relative to Non-CF. Following risk adjustment, CF remained independently associated with greater likelihood of MAE (adjusted odds ratio [AOR] 1.16, 95% Confidence Interval [CI] 1.05-1.27) and per-patient expenditures (ß+$2,280, CI +$1080-3490). Further, readmission to non-index LQH was linked with significantly increased odds of MAE, following initial care at HQH (AOR 1.43, CI 1.03-1.99) and LQH (AOR 1.72, CI 1.30-2.28; Reference: Non-CF). CONCLUSIONS: Care fragmentation was associated with greater morbidity and resource utilization at readmission following elective colectomy. Further, rehospitalization at non-index LQH conferred significantly inferior outcomes. Novel efforts are needed to improve continuity of care.

Trends in the adoption of diverting loop ileostomy for acute complicated diverticulitis in the United States.

BACKGROUND: Acute complicated diverticulitis poses a substantial burden to individual patients and the health care system. A significant proportion of the cases necessitate emergency operations. The choice between Hartmann's procedure and primary anastomosis with diverting loop ileostomy remains controversial. METHODS: Using American College of Surgeons National Surgical Quality Improvement Program patient user file data from 2012 to 2020, patients undergoing Hartmann's procedure and primary anastomosis with diverting loop ileostomy for nonelective sigmoidectomy for complicated diverticulitis were identified. Major adverse events, 30-day mortality, perioperative complications, operative duration, reoperation, and 30-day readmissions were assessed. RESULTS: Of 16,921 cases, 6.3% underwent primary anastomosis with diverting loop ileostomy, showing a rising trend from 5.3% in 2012 to 8.4% in 2020. Primary anastomosis with diverting loop ileostomy patients, compared to Hartmann's procedure, had similar demographics and fewer severe comorbidities. Primary anastomosis with diverting loop ileostomy exhibited lower rates of major adverse events (24.6% vs 29.3%, P = .001). After risk adjustment, primary anastomosis with diverting loop ileostomy had similar risks of major adverse events and 30-day mortality compared to Hartmann's procedure. While having lower odds of respiratory (adjusted odds ratio 0.61, 95% confidence interval 0.45-0.83) and infectious (adjusted odds ratio 0.78, 95% confidence interval 0.66-0.93) complications, primary anastomosis with diverting loop ileostomy was associated with a 36-minute increment in operative duration and increased odds of 30-day readmission (adjusted odds ratio 1.30, 95% confidence interval 1.07-1.57) compared to Hartmann's procedure. CONCLUSION: Primary anastomosis with diverting loop ileostomy displayed comparable odds of major adverse events compared to Hartmann's procedure in acute complicated diverticulitis while mitigating infectious and respiratory complication risks. However, primary anastomosis with diverting loop ileostomy was associated with longer operative times and greater odds of 30-day readmission. Evolving guidelines and increasing primary anastomosis with diverting loop ileostomy use suggest a shift favoring primary anastomosis, especially in complicated diverticulitis. Future investigation of disparities in surgical approaches and patient outcomes is warranted to optimize acute diverticulitis care pathways.

Cost variation of nonelective surgery for ulcerative colitis across the United States.

BACKGROUND: Although clinical outcomes of surgery for ulcerative colitis (UC) have improved in the modern biologic era, expenditures continue to increase. A contemporary cost analysis of UC operative care is lacking. The present study aimed to characterize risk factors and center-level variation in hospitalization costs after nonelective resection for UC. METHODS: All adults with UC in the 2016-2020 Nationwide Readmissions Database undergoing nonelective colectomy or rectal resection were identified. Mixed-effects models were developed to evaluate patient and hospital factors associated with costs. Random effects were estimated and used to rank hospitals by increasing risk-adjusted center-level costs. High-cost hospitals (HCHs) in the top decile of expenditure were identified, and their association with select outcomes was subsequently assessed. RESULTS: An estimated 10,280 patients met study criteria with median index hospitalization costs of $40,300 (IQR, $26,400-$65,000). Increased time to surgery was significantly associated with a +$2500 increment in costs per day. Compared with low-volume hospitals, medium- and high-volume centers demonstrated a -$5900 and -$8200 reduction in costs, respectively. Approximately 19.2% of variability in costs was attributable to interhospital differences rather than patient factors. Although mortality and readmission rates were similar, HCH status was significantly associated with increased complications (adjusted odds ratio [AOR], 1.39), length of stay (+10.1 days), and nonhome discharge (AOR, 1.78). CONCLUSION: The present work identified significant hospital-level variation in the costs of nonelective operations for UC. Further efforts to optimize time to surgery and regionalize care to higher-volume centers may improve the value of UC surgical care in the United States.

Open Versus Minimally Invasive Emergent Colectomy for Diverticulitis.

BACKGROUND: The role of minimally invasive surgery (MIS) in the acute management of diverticulitis remains controversial. Using a national cohort, we examined the relationship between operative approaches with acute clinical and financial outcomes. METHODS: Adults undergoing emergent colectomy for diverticulitis were tabulated from the 2015-2020 American College of Surgeons National Surgical Quality Improvement Program. Regression models were developed to analyze the association between open and MIS approaches with major adverse events (MAE), as well as secondary endpoints. A subgroup analysis was conducted to compare outcomes between open and MIS requiring conversion to open (CTO). RESULTS: Of 9194 patients, 1580 (17.3%) underwent MIS colectomy. The proportion of MIS resection increased from 15.1% in 2015 to 19.1% in 2020 (nptrend<.001). Compared to Open, MIS patients were younger, equally likely to be female, had a lower proportion of patients with ASA class ≥3, and a higher BMI. Preoperatively, MIS patients were less frequently diagnosed with sepsis. Following adjustment with open as reference, MIS approach had reduced odds of MAE (AOR .56), ostomy creation (AOR .12), shorter postoperative length of stay (LOS; ß -1.63), and a lower likelihood of nonhome discharge (AOR .45, all P < .001). Additionally, CTO was linked to decreased likelihood of MAE (AOR .78, P = .01), ostomy creation (AOR .02, P < .001), comparable LOS (ß -.46, P = .41), and reduced odds of nonhome discharge (AOR .58, P < .001), relative to open. DISCUSSION: Compared to planned open colectomy, MIS resection was associated with improved clinical and financial outcomes, even in cases of CTO. Our findings suggest that whenever possible, MIS should be attempted first in emergent colectomy for diverticulitis. Nevertheless, future prospective studies are likely needed to further elucidate specific patient and clinical factors.

Current Status of Contralateral Prophylactic Mastectomy: Investigating Structural Racial Disparity.

BACKGROUND: Contralateral prophylactic mastectomy (CPM) remains a personal decision, influenced by psychosocial factors including cosmesis and peace of mind. While utilization of CPM is disproportionately low among Black patients, the degree to which these disparities are driven by patient- vs hospital-level factors remains unknown. STUDY DESIGN: Patients undergoing mastectomy for non-metastatic ductal or lobular breast cancer were tabulated from the 2004-2020 National Cancer Database. The primary endpoint was receipt of CPM. Multivariable logistic regression models were constructed with interaction terms between Black-serving hospital (BSH) status and patient race to evaluate associations with CPM. Cox proportional hazard models were utilized to evaluate long-term survival. RESULTS: Of 597,845 women studied, 70,911 (11.9%) were Black. Following multivariable adjustment, Black race (Adjusted Odds Ratio [AOR] 0.65, 95% Confidence Interval [CI] 0.64 - 0.67) and treatment at BSH (AOR 0.84, CI 0.83 - 0.85) were independently linked to lower odds of CPM. Although predicted probability of CPM was universally lower at higher BSH, Black patients faced a steeper reduction compared to White patients. Furthermore, receipt of CPM was linked to improved survival (HR 0.84, CI 0.83 - 0.86), while Black race was associated with a greater hazard ratio of 10-year mortality (HR 1.14, CI 1.12 - 1.17). CONCLUSIONS: Hospitals serving a greater proportion of Black patients are less likely to utilize CPM, suggestive of disparities in access to CPM at the institutional level. Further research and education are needed to characterize surgeon-specific and institutional practices in patient counseling and shared decision-making that shape disparities in access to CPM.

To Resect or Not to Resect: A Nationwide Comparison of Management of Sigmoid Volvulus.

INTRODUCTION: Despite the high recurrence rate of sigmoid volvulus, there is reluctance to perform a prophylactic colectomy in frail patients due to the operation's perceived risks. We used a nationally representative database to compare risk of recurrence in patients undergoing a prophylactic colectomy versus endoscopic detorsion alone. METHODS: We performed a retrospective cohort study using the National Readmission Database (2016-2019) including patients aged ≥18 y who had an emergent admission for sigmoid volvulus and underwent endoscopic detorsion on the day of admission. We performed a 1:1 propensity matching adjusting for patient demographics, frailty score comprising of 109 components, and hospital characteristics. Our primary outcome was readmission due to colonic volvulus and secondary outcomes included mortality, complications, length of stay (LOS), and costs during index admission and readmission. We performed a subgroup analysis in patients with Hospital Frailty Score >5. RESULTS: We included 2113 patients of which 1046 patients (49.5%) underwent a colectomy during the initial admission. In the matched population of 830 pairs, readmission due to colonic volvulus was significantly lower in patients undergoing endoscopy followed by colectomy than endoscopy alone. Patients undergoing a colectomy had higher gastric and renal complications, longer LOS, and higher costs but no difference in mortality. In the subgroup analysis of frail patients, readmission was significantly lower in patients with prophylactic colectomy with no significant difference in mortality in 439 matched patients. CONCLUSIONS: Prophylactic colectomy was associated with lower readmission, a higher rate of complications, increased LOS, and higher costs compared to sigmoid decompression alone.

Colorectal cancer genetic referral: Are we doing enough?

Purpose: Guidelines are published for referral to genetic counseling and multigene panel genetic testing for colorectal cancer. We hypothesize that these guidelines are not recognized in practice, resulting in the underreferral of patients to genetic counseling. We aimed to investigate the clinical impact of these guidelines. Methods: This was a retrospective cohort study conducted using a single academic-institution colorectal cancer patient registry. The registry included all patients ≥18 years old with a pathologic diagnosis of colon cancer, rectal cancer, or polyposis from January 2018 to January 2020 with complete chart data to determine inclusion into the genetic referral cohort. Results: Out of 225 colon cancer patients, 92 met criteria for referral to genetic testing, but only 56 patients obtained referral and 39 completed testing. For rectal cancer, 29 out of 127 patients met criteria for referral, but only 11 obtained referral and 8 completed testing. Actionable variants, defined as pathogenic or likely pathogenic, were identified in 18 colon cancer and 5 rectal cancer patients. Age made a significant difference in the referral rate for colon cancer (P = 0.02) but not rectal cancer (P > 0.05). Conclusion: Our study demonstrates poor adherence to guideline-based genetic testing. These data emphasize the need for more consistent referral to genetic testing for diagnosis of underlying inherited cancer syndromes.

National analysis of racial disparities in emergent surgery for colorectal cancer.

Background: Racial disparities in access to preoperative evaluation for colorectal cancer remain unclear. Emergent admission may indicate lack of access to timely care. The present work aimed to evaluate the association of admission type with race among patients undergoing colorectal cancer surgery. Methods: All adults undergoing resection for colorectal cancer in 2011-2020 National Inpatient Sample were identified. Multivariable regression models were developed to examine the association of admission type with race. Primary outcome was major adverse events (MAE), including mortality and complications. Secondary outcomes included costs and length of stay (LOS). Interaction terms between year, admission type, and race were used to analyze trends. Results: Of 722,736 patients, 67.6 % had Elective and 32.4 % Emergent admission. Black (AOR 1.38 [95 % CI 1.33-1.44]), Hispanic (1.45 [1.38-1.53]), and Asian/Pacific Islander or Native American (1.25 [1.18-1.32]) race were associated with significantly increased odds of Emergent operation relative to White. Over the study period, non-White patients consistently comprised over 5 % greater proportion of the Emergent cohort compared to Elective. Furthermore, Emergent admission was associated with 3-fold increase in mortality and complications, 5-day increment in LOS, and $10,100 increase in costs. MAE rates among Emergent patients remained greater than Elective with a widening gap over time. Non-White patients experienced significantly increased MAE regardless of admission type. Conclusion: Non-White race was associated with increased odds of emergent colorectal cancer resection. Given the persistent disparity over the past decade, systematic approaches to alleviate racial inequities in colorectal cancer screening and improve access to timely surgical treatment are warranted.

Early discharge following colectomy for colon cancer: A national perspective.

BACKGROUND: Although early discharge after colectomy has garnered significant interest, contemporary, large-scale analyses are lacking. OBJECTIVE: The present study utilized a national cohort of patients undergoing colectomy to examine costs and readmissions following early discharge. METHODS: All adults undergoing elective colectomy for primary colon cancer were identified in the 2016-2019 Nationwide Readmissions Database. Patients with perioperative complications or prolonged length of stay (>8 days) were excluded to enhance cohort homogeneity. Patients discharged by postoperative day 3 were classified as Early, and others as Routine. Entropy balancing and multivariable regression were used to assess the risk-adjusted association of early discharge with costs and non-elective readmissions. Importantly, we compared 90-day stroke rates to examine whether our results were influenced by preferential early discharge of healthier patients. RESULTS: Of an estimated 153,996 patients, 45.5% comprised the Early cohort. Compared to Routine, the Early cohort was younger and more commonly male. Patients in the Early group more commonly underwent left-sided colectomy and laparoscopic operations. Following multivariable adjustment, expedited discharge was associated with a $4,500 reduction in costs as well as lower 30-day (adjusted odds ratio [AOR] 0.74, p<0.001) and 90-day non-elective readmissions (AOR 0.74, p<0.001). However, among those readmitted within 90 days, Early patients were more commonly readmitted for gastrointestinal conditions (45.8 vs 36.4%, p<0.001). Importantly, both cohorts had comparable 90-day stroke rates (2.2 vs 2.1%, p = 0.80). CONCLUSIONS: The present work represents the largest analysis of early discharge following colectomy for cancer and supports its relative safety and cost-effectiveness.

Suction thrombectomy of distal medium vessel occlusion using microcatheter during mechanical thrombectomy for acute ischemic stroke: A case series.

While mechanical thrombectomy is known to be effective for distal medium vessel occlusion (DMVO) as well as large vessel occlusion, tortuous DMVO are predisposed to vessel injury during stent retriever thrombectomy. Furthermore, getting access to the thrombus may be difficult during suction thrombectomy using a dedicated suction catheter. Most studies describe DMVO treatment using stent retrievers and dedicated suction catheters, but there are limited studies reporting DMVO treated with suction thrombectomy using a microcatheter. Herein, we describe three cases of DMVO treated with suction thrombectomy that was performed using a microcatheter and subsequently showed good results. Therefore, suction thrombectomy using a microcatheter is a viable alternative treatment for tortuous DMVO.

Engaging primary care physicians is critical in the screening and diagnosis of colorectal cancer at safety-net hospital systems.

Background: Primary care physicians (PCP) play a key role in offering colorectal cancer (CRC) screenings, particularly amongst underserved populations. Given potential delays in or omission of CRC screening in the absence of a PCP, we aimed to determine stage of CRC at diagnosis in an underserved population. Methods: A retrospective chart review was conducted at two Los Angeles County safety-net hospitals. Inclusion criteria were a CRC diagnosis between 2018 and 2021 and age between 50 and 75 years at diagnosis time. The primary outcome was the cancer stage at diagnosis. Results: A total of 373 patients were included, of those, 52.5 % had a PCP. Compared to others, PCP was similar in age, racial composition, and primary spoken language (Table 1). Of patients with a PCP, 52.0% were diagnosed by screening. After screening, the most common indication for colonoscopy were blood per rectum (24.9 %) and imaging findings (18.0 %). Patients with a PCP had a significantly lower rate of late stage CRC than those without a PCP (42.4 % vs. 68.0 %, p < 0.001). After adjustment, having a PCP was associated with significantly reduced odds of late stage CRC (Adjusted Odds Ratio 0.83, 95 % Confidence Interval [0.68-1.04]). Having a PCP was not associated with any adjusted increase in number of adenomas or tumor size. Conclusions: Patients with a PCP, irrespective of undergoing screening, were diagnosed at earlier CRC stages. This underlines the crucial role of PCPs in CRC and diagnosis, reinforcing the need for their active involvement in these processes.

Association of time to resection with survival in patients with colon cancer.

PURPOSE: Colon cancer (CC) remains a leading cause of cancer-related mortality worldwide, for which colectomy represents the standard of care. Yet, the impact of delayed resection on survival outcomes remains controversial. We assessed the association between time to surgery and 10-year survival in a national cohort of CC patients. METHODS: This retrospective cohort study identified all adults who underwent colectomy for Stage I-III CC in the 2004-2020 National Cancer Database. Those who required neoadjuvant therapy or emergent resection < 7 days from diagnosis were excluded. Patients were classified into Early (< 25 days) and Delayed (≥ 25 days) cohorts after an adjusted analysis of the relationship between time to surgery and 10-year survival. Survival at 1-, 5-, and 10-years was assessed via Kaplan-Meier analyses and Cox proportional hazard modeling, adjusting for age, sex, race, income quartile, insurance coverage, Charlson-Deyo comorbidity index, disease stage, location of tumor, receipt of adjuvant chemotherapy, as well as hospital type, location, and case volume. RESULTS: Of 165,991 patients, 84,665 (51%) were classified as Early and 81,326 (49%) Delayed. Following risk adjustment, Delayed resection was associated with similar 1-year [hazard ratio (HR) 1.01, 95% confidence interval (CI) 0.97-1.04, P = 0.72], but inferior 5- (HR 1.24, CI 1.22-1.26; P < 0.001) and 10-year survival (HR 1.22, CI 1.20-1.23; P < 0.001). Black race [adjusted odds ratio (AOR) 1.36, CI 1.31-1.41; P < 0.001], Medicaid insurance coverage (AOR 1.34, CI 1.26-1.42; P < 0.001), and care at high-volume hospitals (AOR 1.12, 95%CI 1.08-1.17; P < 0.001) were linked with greater likelihood of Delayed resection. CONCLUSIONS: Patients with CC who underwent resection ≥ 25 days following diagnosis demonstrated similar 1-year, but inferior 5- and 10-year survival, compared to those who underwent surgery within 25 days. Socioeconomic factors, including race and Medicaid insurance, were linked with greater odds of delayed resection. Efforts to balance appropriate preoperative evaluation with expedited resection are needed to optimize patient outcomes.

Acceptability and Feasibility of Text Message Interface to Assess Parents' Real-time PICU Experiences.

INTRODUCTION: Parents of children in the pediatric intensive care unit (PICU) experience substantial stress; a parent's perception of their child's illness severity, more than objective measures, predicts psychological outcomes. No tools exist to assess parents' real-time experiences. This pilot study evaluated the feasibility and acceptability of a text-based tool to measure parental experience. METHODS: Inclusion criteria included PICU stay >48 h, physician approval, smartphone access, and English-speaking caregiver. Eligible parents received a text-based baseline survey and surveys every other day while hospitalized regarding their mood/experiences and optional open-ended questions regarding stressors. They received post-discharge follow-up surveys at 1 week and 1, 3, and 6 months. Follow-up surveys assessed mood and symptoms of depression, anxiety, and post-traumatic stress. Interviews and surveys about the interface were conducted 1 week and 3 months following discharge. Feasibility was assessed by descriptive statistics (eg, response rates), and acceptability was assessed by descriptive statistics (survey results) and thematic analyses of interviews. RESULTS: Of 20 enrolled participants, the first 5 were excluded due to technical issues. Of the 15 included, results demonstrated feasibility and acceptability. Most participants (86%) completed all surveys during the PICU stay and continued to complete surveys at a high rate: 79%-94% 3 months post-discharge. All participants agreed that the system was easy to use and were satisfied with the system at discharge, and 91% remained satisfied 3 months post-discharge. Additionally, 76% reported comfort, and 69% reported benefit. From the interviews, participants lauded the system's convenience and applicability of content. Some proposed changes to improve ergonomics. Many suggested this interface could help teams better support families. CONCLUSIONS: A text-based interface for measuring experience in the PICU is feasible and acceptable to parents. Further research can explore how this could identify parents most at risk of adverse psychological sequelae and lead to earlier supportive interventions.

Impact of robotic total mesorectal excision upon pathology metrics in overweight males with low rectal cancer: a pooled analysis of 836 cases.

The aim of this pooled analysis was to evaluate the impact of robotic total mesorectal excision (TME) on pathology metrics in Male Overweight patients with Low rectal cancer (MOL). This was a multicenter retrospective pooled analysis of data. Two groups were defined: MOL (Male, Overweight, Low rectal cancer) and non-MOL. Overweight was defined as BMI ≥ 25 kg/m2. Low rectal cancer was defined as cancer within 6 cm from the anal verge. The primary endpoints of this study were histopathological metrics, namely circumferential resection margin (CRM) (mm), CRM involvement rate (%), and the quality of TME. Circumferential resection margin (CRM) was involved if < 1 mm. 836 (106 MOL and 730 non-MOL) patients that underwent robotic TME by six surgeons over 3 years were compared. No significant differences in demographics and perioperative variables were found, except for operating time, distal margin, and number of lymph nodes harvested. CRM involvement rate did not significantly differ (7.5% vs. 5.5%, p = 0.395). Mean CRM was statistically significantly narrower in MOL patients (6.6 vs. 7.7 mm, p = 0.04). Quality of TME did not differ. Distance of tumor from the anal verge was the only independent predictor of CRM involvement. Robotic TME may provide optimal pathology metrics in overweight males with low rectal cancer. Although CRM was a few millimeters narrower in MOL, the values were within the range of uninvolved margins making the difference statistically significant, but not clinically. Being MOL was not a risk factor for involvement of circumferential resection margin.

Care fragmentation is associated with increased mortality after ileostomy creation.

BACKGROUND: Ileostomy is the mainstay treatment option for various gastrointestinal conditions. Given the increased risk of post-discharge complications and high readmission rates that can be further aggravated by receiving care at different facilities (care fragmentation), further examination is necessary. We thus used a national cohort to explore the associations of care fragmentation among ileostomy patients experiencing adverse outcomes and increased hospitalization expenditures. METHODS: All adult hospitalizations for ileostomy were tabulated from the 2016 to 2020 Nationwide Readmissions Database. Those readmitted within 90 days after discharge were included for analysis. Patients treated at a different facility than the original location where the index ileostomy was performed were categorized into the care-fragmented cohort. Multivariable regressions were developed to characterize the association of the care-fragmented cohort with postoperative outcomes, readmissions, and expenditures. RESULTS: Of 52,254 patients with ileostomy creation hospitalizations with 90-day nonelective readmission, 9,045 (17.3%) experienced care fragmentation. Following risk adjustment, those experiencing care fragmentation faced increased odds of mortality (adjusted odds ratio 1.81, 95% confidence interval 1.54-2.12), cardiac (adjusted odds ratio 1.63, 95% confidence interval 1.42-1.85), respiratory (adjusted odds ratio 1.71, 95% confidence interval 1.53-1.91), infectious (adjusted odds ratio 1.33, 95% confidence interval 1.23-1.43), and thromboembolic (adjusted odds ratio 1.28, 95% confidence interval 1.13-1.45) complications. Furthermore, patients experiencing care fragmentation were more likely to have increased hospitalization costs ($1,700, 95% confidence interval 0.8-2.5). CONCLUSION: Care fragmentation in ileostomy patients demonstrated an increased risk for mortality, postoperative complications, and increased hospitalization expenses. To mitigate risks for adverse outcomes, future studies should evaluate the impacts of inter-hospital communication with the goal of improving care continuity and optimizing healthcare delivery for care-fragmented populations.

Risk factor analyses of contrast leakage and contrast-induced encephalopathy following coil embolization for unruptured intracranial aneurysm.

BACKGROUND: Contrast-induced encephalopathy (CIE) following endovascular interventions is a rare but serious complication. This study aimed to investigate the risk factors of contrast leakage (CL) and CIE in patients who underwent coil embolization of unruptured intracranial aneurysms (UIAs). METHODS: Patients with UIAs who underwent coil embolization at a single tertiary institute between January 2019 and January 2022 were enrolled retrospectively. CL was defined as cortical or subcortical contrast enhancement with effacement of the cortical sulci. CIE was defined as the new onset of neurological deficits associated with CL. Following the procedure, all patients underwent CT scans, and MRI scans were performed on those with symptoms. Patient and procedural risk factors were investigated. RESULTS: In total, 459 patients were analyzed. The median procedure time and contrast dose were 69 min and 96 mL, respectively. CL was evident in 35 patients. In the multivariate analysis, hypertension, large aneurysm, longer procedure time, and greater contrast dose were associated with CL. CIE was diagnosed in 19 patients, and the risk factors included large aneurysm, longer procedure time, and greater contrast dose. The procedure time was predictive of both CL (P<0.001) and CIE (P=0.01). The optimal cut-off value for procedure time was 81.5 min. All CIE patients recovered completely within 8-96 hours. CONCLUSIONS: A large aneurysm and prolonged procedure time may increase the patient's risk of CL and CIE due to increased contrast exposure. Patients who underwent a procedure that exceeded 1.5 hours necessitate post-procedure evaluation and monitoring.