Racial disparities in survival of early onset colon cancer (Age<50): A matched NCDB analysis.

BACKGROUND: Early-onset colon cancer (EOCC) has increasing incidence and disproportionately affects African-Americans. This analysis aims to compare EOCC survival among Black and White patients after matching relevant socio-demographic factors and stage. METHODS: The 2004-2017 NCDB database was queried for Black and White patients, age<50, who underwent colectomy for adenocarcinoma. A one-to-one match on race was performed based on sociodemographic factors and disease stage (I-IV). Five-year survival differences were analyzed with Cox proportional hazards models. RESULTS: 5322 Black-White matched pairs were analyzed. Compared to White patients, Black patients averaged more days to surgery (19 â€‹± â€‹68 vs 16 days â€‹± â€‹32, p â€‹< â€‹0.001) and to chemotherapy (63 â€‹± â€‹8 vs. 57 â€‹± â€‹39, p â€‹< â€‹0.001). Black stage III patients were 20% less likely to receive chemotherapy (OR 0.8, 95% CI 0.7-0.9, p â€‹= â€‹0.0006), and had a 17% increased rate of death (HR 1.17, 95% CI 1.0-1.3, p â€‹= â€‹0.01) after adjusting for sex, comorbidity score, tumor location and chemotherapy. CONCLUSIONS: Black patients with stage 3 EOCC are less likely to receive chemotherapy and have worse survival. Further evaluation is warranted to identify potential factors driving these observed.

Multicenter phase II trial of transanal total mesorectal excision for rectal cancer: preliminary results.

BACKGROUND: Transanal TME (taTME) combines abdominal and transanal dissection to facilitate sphincter preservation in patients with low rectal tumors. Few phase II/III trials report long-term oncologic and functional results. We report early results from a North American prospective multicenter phase II trial of taTME (NCT03144765). METHODS: 100 patients with stage I-III rectal adenocarcinoma located ≤ 10 cm from the anal verge (AV) were enrolled across 11 centers. Primary and secondary endpoints were TME quality, pathologic outcomes, 30-day and 90-day outcomes, and stoma closure rate. Univariable regression analysis was performed to assess risk factors for incomplete TME and anastomotic complications. RESULTS: Between September 2017 and April 2022, 70 males and 30 females with median age of 58 (IQR 49-62) years and BMI 27.8 (IQR 23.9-31.8) kg/m2 underwent 2-team taTME for tumors located a median 5.8 (IQR 4.5-7.0) cm from the AV. Neoadjuvant radiotherapy was completed in 69%. Intersphincteric resection was performed in 36% and all patients were diverted. Intraoperative complications occurred in 8% including 3 organ injuries, 2 abdominal and 1 transanal conversion. The 30-day and 90-day morbidity rates were 49% (Clavien-Dindo (CD) ≥ 3 in 28.6%) and 56% (CD ≥ 3 in 30.4% including 1 mortality), respectively. Anastomotic complications were reported in 18% including 10% diagnosed within 30 days. Higher anastomotic risk was noted among males (p = 0.05). At a median follow-up of 5 (IQR 3.1-7.4) months, 98% of stomas were closed. TME grade was complete or near complete in 90%, with positive margins in 2 cases (3%). Risk factors for incomplete TME were ASA ≥ 3 (p = 0.01), increased time between NRT and surgery (p = 0.03), and higher operative blood loss (p = 0.003). CONCLUSION: When performed at expert centers, 2-team taTME in patients with low rectal tumors is safe with low conversion rates and high stoma closure rate. Mid-term results will further evaluate oncologic and functional outcomes.

Cost associated with diverting ostomy after rectal cancer surgery: a transnational analysis.

BACKGROUND: Diverting ileostomy and colostomy after total mesorectal excision reduces the risk of complications related to anastomotic leakages but is associated with a reduction in health-related quality of life and long-term economic consequences that are unknown. Our objective was to estimate the lifetime costs of stoma placement after rectal cancer resection in the U.S., England, and Germany. METHODS: Input parameters were derived from quasi-systematic literature searches. Decision-analytic models with survival from colorectal cancer-adjusted life tables and country-specific stoma reversal proportions were created for the three countries to calculate lifetime costs. Main cost items were stoma maintenance costs and reimbursement for reversal procedures. Discounting was applied according to respective national guidelines. Sensitivity analysis was conducted to explore the impact of parameter uncertainty onto the results. RESULTS: The cohort starting ages and median survival were 63 and 11.5 years for the U.S., 69 years and 8.5 years for England, and 71 and 6.5 years for Germany. Lifetime discounted stoma-related costs were $26,311, £9512, and €10,021, respectively. All three models were most sensitive to the proportion of ostomy reversal, age at baseline, and discount rate applied. CONCLUSION: Conservative model-based projections suggest that stoma care leads to significant long-term costs. Efforts to reduce the number of patients who need to undergo a diverting ostomy could result in meaningful cost savings.

Discordance in Total Mesorectal Excision Specimen Grading in a Prospective Phase 2 Multicenter Rectal Cancer Trial: Are We Overestimating the Quality of Our Resections?

OBJECTIVES: To report the results of a rigorous quality control (QC) process in the grading of total mesorectal excision (TME) specimens during a multicenter prospective phase 2 trial of transanal TME. BACKGROUND: Grading of TME specimens is based on the macroscopic assessment of the mesorectum and standardized through synoptic pathology reporting. TME grade is a strong predictor of outcomes with incomplete (IC) TME associated with increased rates of local recurrence relative to complete or near complete (NC) TME. Although TME grade serves as an endpoint in most rectal cancer trials, in protocols incorporating centralized review of TME specimens for quality assurance, discordance in grading and the management thereof has not been previously described. METHODS: A phase 2 prospective transanal TME trial was conducted from 2017 to 2022 across 11 North American centers with TME quality as the primary study endpoint. QC measures included (1) training of site pathologists in TME protocols, (2) blinded grading of de-identified TME specimen photographs by central pathologists, and (3) reconciliation of major discordance before trial reporting. Cohen Kappa statistic was used to assess agreement in grading. RESULTS: Overall agreement in grading of 100 TME specimens between site and central reviewer was rated as fair, (κ = 0.35; 95% CI: 0.10-0.61; P < 0.0001). Concordance was noted in 54%, with minor and major discordance in 32% and 14% of cases, respectively. Upon reconciliation, 13/14 (93%) major discordances were resolved. Pre versus postreconciliation rates of complete or NC and IC TME are 77%/16% and 7% versus 69%/21% and 10%. Reconciliation resulted in a major upgrade (IC-NC; N = 1) or major downgrade (NC/C-IC, N = 4) in 5 cases overall (5%). CONCLUSIONS: A 14% rate of major discordance was observed in TME grading between the site and central reviewers. The resolution resulted in a major change in final TME grade in 5% of cases, which suggests that reported rates or TME completeness are likely overestimated in trials. QC through a central review of TME photographs and reconciliation of major discordances is strongly recommended.

Management of left-sided malignant colorectal obstructions with curative intent: a network meta-analysis.

BACKGROUND: Several management options exist for colonic decompression in the setting of malignant large bowel obstruction, including oncologic resection, surgical diversion, and SEMS as a bridge-to-surgery. Consensus has yet to be reached on optimal treatment pathways. The aim of the present study was to perform a network meta-analysis comparing short-term postoperative morbidity and long-term oncologic outcomes between oncologic resection, surgical diversion, and self-expanding metal stents (SEMS) in left-sided malignant colorectal obstruction with curative intent. METHODS: Medline, Embase, and CENTRAL were systematically searched. Articles were included if they compared two or more of the following in patients presenting with curative left-sided malignant colorectal obstruction: (1) emergent oncologic resection; (2) surgical diversion; and/or (3) SEMS. The primary outcome was overall 90-day postoperative morbidity. Pairwise meta-analyses were performed with inverse variance random effects. Random-effect Bayesian network meta-analysis was performed. RESULTS: From 1277 citations, 53 studies with 9493 patients undergoing urgent oncologic resection, 1273 patients undergoing surgical diversion, and 2548 patients undergoing SEMS were included. Network meta-analysis demonstrated a significant improvement in 90-day postoperative morbidity in patients undergoing SEMS compared to urgent oncologic resection (OR0.34, 95%CrI0.01-0.98). Insufficient RCT data pertaining to overall survival (OS) precluded network meta-analysis. Pairwise meta-analysis demonstrated decreased five-year OS for patients undergoing urgent oncologic resection compared to surgical diversion (OR0.44, 95%CI0.28-0.71, p < 0.01). CONCLUSIONS: Bridge-to-surgery interventions may offer short- and long-term benefits compared to urgent oncologic resection for malignant colorectal obstruction and should be increasingly considered in this patient population. Further prospective study comparing surgical diversion and SEMS is needed.

Assessing the Quality of Online Health Information and Trend Data for Colorectal Malignancies.

INTRODUCTION: Patients often refer to the internet to learn about different health conditions. This study aims to assess the landscape of online health information on malignant colorectal conditions, focusing on the popularity, quantity, and quality of internet resources pertaining to these conditions. This information can be used as a guide for surgeons to supplement patient information at the time of surgical evaluation and to help design optimal online health information. METHODS: The terms "colon cancer," "rectal cancer," "anal cancer," and "colorectal cancer" were searched using the Google search engine. The number of search results or "hits" obtained per search term was recorded and the first 50 websites for each search term were reviewed. Included websites did not have a password requirement, were in English, and were free. Quality assessments were performed using the DISCERN instrument, and mean DISCERN scores were compared using analysis of variance. The popularity of each search term was determined using Google Trends, which generates a relative search volume score. RESULTS: A total of 431 million hits were obtained for the term "colon cancer," 72.5 million for "rectal cancer," 244 million for "anal cancer," and 194 million for "colorectal cancer." Mean DISCERN scores for reviewed websites ranged between 39.7 and 40.6, and were thus within the "fair" category. There were no significant differences in mean DISCERN scores across search terms (P = 0.5). Colon cancer had the highest relative search volume score (61.8), followed by colorectal cancer (43.4/100), rectal cancer (42.5/100), and anal cancer (41.7/100). CONCLUSIONS: Although there is a large amount of online information on malignant colorectal conditions, the quality of the available information is inadequate. Clinician guidance to resources aimed at higher quality from guidance of the DISCERN tool may be of value for patient education.

Prospective Evaluation of a Tiered Opioid Prescribing Guideline for Inpatient Colorectal Operations.

OBJECTIVE: This study sought to prospectively validate an institutional prescribing guideline based on previously defined opioid consumption patterns following inpatient colorectal operations. BACKGROUND: In light of the opioid epidemic, reducing excess prescription quantities is key while still tailoring to patient needs. METHODS: This is a cohort study of elective colorectal operations (colectomies, proctectomies, and ostomy reversals) at a single tertiary care medical center. Opioid prescribing and consumption patterns [quantified as Equianalgesic 5 mg Oxycodone Pills (EOP)] were compared before and after adoption of a tiered opioid prescribing guideline. Tiers were divided based on opioid consumption in the 24 hours before discharge: Tier 1 (0 EOP), Tier 2 (0.1-3 EOP), and Tier 3 (>3 EOP). Our guideline recommended maximum prescriptions of 0 EOP for Tier 1, 12 EOP for Tier 2, and 30 EOP for Tier 3. Results: The study included 100 patients before and 101 after guideline adoption. Demographic and operative characteristics were similar between cohorts. Guideline adherence was 85%. Overall, there was a 41%reduction in mean prescription quantity and 53% reduction in excess pills per prescription. No change in opioid consumption or refill rates was observed. CONCLUSIONS: Adoption of a tiered opioid prescribing guideline significantly reduced opioid prescription quantity with no change in consumption or refill rates. Standardization of discharge prescriptions based on patient consumption in the 24 hours before discharge may be an important step toward minimizing excess prescribing.

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 satisfaction of asynchronous TeleHealth care compared to in-person visits following colorectal surgical resection.

BACKGROUND: The feasibility of remote visits following abdominal colorectal surgery has not been studied in relation to efficacy, patient satisfaction, and surgeon satisfaction. This study aims to assess reliability and satisfaction with a web-based questionnaire for post-operative visits following abdominal colorectal surgery. METHODS: This was a prospective single-arm cohort study at single-tertiary care center during admission for abdominal colorectal surgery. Using a web-based patient portal, patients completed a questionnaire 48 h prior to their scheduled in-person follow-up visits and submitted photographs of their incisions. Surgeons reviewed patient-entered data and responded within 24 h. Following the subsequent in-person visit, surgeons completed questionnaires to compare the accuracy of the web-based vs. in-person evaluations. Lastly, patients and surgeons completed separate satisfaction surveys after the in-person visits. RESULTS: A total of 33 patients were enrolled, of which 30 (90.9%) successfully completed the web questionnaire. Providers reported the online questionnaire to be concordant with the in-person visit in 90% of cases. Of the patients who completed the study, only half found the survey alone to be acceptable for follow-up. Patients spent significantly less time completing the online questionnaire (≤ 10 min) than in-person visits, including travel time (75 min, IQR 50-100). Only 12 patients (40%) uploaded photographs of their incisions. During in-person visits, management changes were employed in four patients (13.3%), of which 3 required treatment of superficial surgical site infections (10%). CONCLUSION: This asynchronous web-based visit format was acceptable to colorectal surgeons but was only embraced by half of patients, despite considerable time savings. While patients preferred in-person visits, there may be opportunities to expand TeleHealth acceptance that focus on patient selection and education. CLINICALTRIALS: gov: NCT05084131.

S184: preoperative sarcopenia is associated with worse short-term outcomes following transanal total mesorectal excision (TaTME) for rectal cancer.

INTRODUCTION: Malnutrition and deconditioning impact postoperative morbidity and mortality. Computed tomography (CT) body composition variables are used as markers of nutritional status and sarcopenia. The objective of this study is to evaluate the impact of sarcopenia, using CT variables, on postoperative outcomes following transanal total mesorectal excision (TaTME) for rectal cancer. METHODS: This was an institutional retrospective cohort analysis of consecutive rectal cancer patients who underwent TaTME between April 2014 and May 2020. Psoas muscle index (PMI) was calculated from diagnostic CT scans. Based on previous studies, patients in the lowest PMI tertile by gender were considered sarcopenic. Fisher's exact and Mann-Whitney U test were used to compare categorical and continuous variables, respectively. Readmission rates and postoperative complications were compared between groups. Backward stepwise logistic regression was used to determine the association between sarcopenia and 30-day postoperative complications. RESULTS: 85 patients were analyzed, of which 63% were male, with a median age of 59 (IQR: 51-65), and median BMI of 28 (IQR: 24-32). Of the entire cohort, 34% (n = 29) were sarcopenic (median PMI 5.39 IQR: 4.49-6.71). No significant difference in baseline characteristics between sarcopenic and nonsarcopenic patients were observed. 55% of sarcopenic patients experienced a complication within 30 days compared to 24% of nonsarcopenic patients (p = 0.01). 41% of sarcopenic patients required hospital readmission within 30 days compared to 17% of their nonsarcopenic counterparts (p = 0.014). Sarcopenic patients also experienced significantly higher rates of post-operative small bowel obstruction (10% vs. 0%, p = 0.04). Multivariable analyses identified that sarcopenic patients have a fourfold increase in odds of experiencing a 30-day postoperative complication (OR: 4.44, 95%CI: 1.6-12.4, p < 0.05) after adjusting for gender. CONCLUSION: Preoperative sarcopenia is associated with increased 30-day postoperative complications following TaTME for rectal cancer. Postoperative complications can have serious oncologic implications by delaying adjuvant chemotherapy. Therefore, preoperative recognition of sarcopenia prior to undergoing TaTME for rectal cancer may provide an opportunity for early intervention with prehabilitation programs.

Oncologic Outcomes After Transanal Total Mesorectal Excision for Rectal Cancer.

BACKGROUND: Recent series have raised concerns about the oncologic outcomes of transanal total mesorectal excision for mid and low rectal cancer. There is a paucity of large data sets from the United States to contribute to the ongoing international discourse. OBJECTIVE: This study aimed to investigate the rate of local recurrence and other oncologic outcomes in patients undergoing transanal total mesorectal excision for rectal adenocarcinoma. DESIGN: This study is a retrospective review of patients undergoing transanal total mesorectal excision for primary rectal cancer from January 2014 to December 2019. SETTINGS: This study was conducted at a single academic tertiary care medical center in the United States. PATIENTS: Consecutive patients aged ≥18 years undergoing surgical resection for primary rectal cancer were selected. INTERVENTION: The transanal total mesorectal excision procedures were performed utilizing a 2-team approach. MAIN OUTCOME MEASURES: Primary outcomes were pathologic quality, local and distant recurrence, treatment-related complications, and overall- and cancer-specific survival. RESULTS: Seventy-nine consecutive patients were included. The median age was 58 years (interquartile range, 50-64), and median BMI was 28 kg/m2 (interquartile range, 24.6-32.4). The mesorectum was complete in 69 patients (87.3%), nearly complete in 9 (11.4%), and incomplete in 1 (1.3%). There was circumferential resection margin involvement (<1 mm) in 4 patients (5.1%), and no patients had a positive distal margin (<1 mm) or intraoperative rectal perforation. Composite optimal pathology was achieved in 94.9% of specimens. Median follow-up was 29 months (range, 6-68). There were no local recurrences. Distant metastases were found in 10 (13.5%) patients and diagnosed after a median of 14 months (range, 0.6-53). Disease-free survival was 91.2% at 2 years, and overall survival was 94.7% at 2 years. LIMITATIONS: Retrospective design, a single center, and relatively short follow-up period were limitations of this study. CONCLUSION: The oncologic outcomes of this cohort support the use of transanal total mesorectal excision in the surgical management of mid to low rectal cancer at centers with appropriate expertise. See Video Abstract at http://links.lww.com/DCR/B723. RESULTADOS ONCOLGICOS DESPUS DE LA EXCISIN TOTAL DEL MESORRECTO POR VA TRANSANAL EN CASOS DE CNCER RECTAL: ANTECEDENTES:Estudios recientes han suscitado preocupación sobre los resultados oncológicos de la excisión total del mesorecto por vía transanal en casos de cáncer de recto medio y bajo. Existe una gran escasez de conjuntos de datos en los Estados Unidos, para contribuir en el actual discurso internacional sobre el tema.OBJETIVO:Investigar la tasa de recurrencia local y otros resultados oncológicos en pacientes sometidos a una excisión total del mesorrecto por vía transanal por adenocarcinomas de recto.DISEÑO:Revisión retrospectiva de pacientes sometidos a excisión total del mesorecto por vía transanal en casos de cáncer de recto primario desde enero de 2014 hasta diciembre de 2019.AJUSTE:Centro médico Universitario de atención terciaria único en los Estados Unidos.PACIENTES:Aquellos pacientes consecutivos de ≥ 18 años de edad, sometidos a resección quirúrgica por cáncer de recto primario.INTERVENCIÓN:Los procedimientos de excisión total del mesorecto por vía transanal se realizaron utilizando un enfoque de dos equipos.PRINCIPALES MEDIDAS DE RESULTADO:Los resultados primarios fueron la calidad anatomo-patológica de las piezas, la recidiva local y a distancia, las complicaciones relacionadas con el tratamiento y la sobrevida global específica para el cáncer.RESULTADOS:Se incluyeron 79 pacientes consecutivos. La mediana de edades fue de 58 años (IQR, 50-64) y la mediana del índice de masa corporal fue de 28 kg / m (IQR, 24,6-32,4). El mesorrecto se encontraba completo en 69 pacientes (87,3%), casi completo en 9 (11,4%) e incompleto en 1 (1,3%). Hubo afectación de CRM (<1 mm) en 4 pacientes (5,1%) y ningún paciente tuvo un margen distal positivo (<1 mm) o perforación rectal intraoperatoria. La histopatología óptima compuesta se logró en el 94,9% de las muestras. La mediana de seguimiento fue de 29 meses (rango 6-68). No se presentaron recurrencias locales. Se encontraron metástasis a distancia en 10 (13,5%) pacientes y se diagnosticaron después de una mediana de 14 meses (rango 0,6-53). La sobrevida libre de enfermedad fue del 91,2% a los 2 años y la sobrevida global fue del 94,7% a los 2 años.LIMITACIONES:Diseño retrospectivo, unicéntrico y período de seguimiento relativamente corto.CONCLUSIÓN:Los resultados oncológicos de este estudio de cohortes, apoyan la realización de excisión total del mesorecto por vía transanal para el tratamiento quirúrgico del cáncer de recto medio y bajo, en centros con la experiencia adecuada. Consulte Video Resumen en http://links.lww.com/DCR/B723. (Traducción-Dr. Xavier Delgadillo).

Use of medical chaperones by colon and rectal surgeons in outpatient practice.

BACKGROUND: The purpose of this study is to determine the frequency and motivations for medical chaperone use during anorectal exams by colon and rectal surgeons in the outpatient setting. STUDY DESIGN: This cross-sectional study examined factors impacting chaperone use via an anonymous online survey distributed via the American Society of Colon and Rectal Surgeons email list. Routine chaperone use was defined as ≥ 90%. RESULTS: Of 1,380 emailed board-certified colon and rectal surgeons, 402 (29.1%) completed the survey in November 2019. Median years in practice was 14, and 72.3% were male. Overall, 65.2% reported routine use of chaperones during anorectal exams. Over half (56.3%) felt chaperones should be mandatory and were more likely to report routine use than those who did not (85.7 vs. 39.1%; p < 0.001). Only 23.7% reported that their institutions had formal chaperone policies. The most common reason for use was medicolegal (91.8%), and the most common barrier was chaperone availability (56.7%). When chaperones were used, 42% did not document use in the medical record. On multivariable analysis, increased odds of routine chaperone use were independently associated with: being ≤ 10 years in practice, routine chaperone use during fellowship, and chaperones being routinely available. CONCLUSION: Half of surgeons felt that chaperones should be mandatory, suggesting lack of consensus among the cohort. Despite expressing legal concerns, one-third did not use chaperones and nearly half who used chaperones did not document their use. Efforts to improve chaperone availability, documentation of chaperone use, and knowledge of policies are necessary.

Development of a Practice Guideline for Discharge Opioid Prescribing After Major Colorectal Surgery.

BACKGROUND: Better alignment of opioid prescription quantities with patient need could help reduce excessive prescribing. OBJECTIVE: The study sought to develop an institutional prescribing guideline based on defined opioid consumption patterns after inpatient colorectal operations. DESIGN: This was a retrospective cohort study. SETTINGS: The study was conducted at a single tertiary care center. PATIENTS: Patients who underwent elective major colorectal procedures between July 2018 and January 2019 were included. MAIN OUTCOME MEASURES: The study measured prescription and consumption quantities measured as equianalgesic oxycodone 5-mg pills. RESULTS: Patients were categorized into 3 groups based on consumption in the 24-hour period before discharge: tier 1 consumed 0 equianalgesic oxycodone 5-mg pills (n = 53), tier 2 consumed 0.1 to 3.0 equianalgesic oxycodone 5-mg pills (n = 25), and tier 3 consumed >3.0 equianalgesic oxycodone 5-mg pills (n = 22). Average prescription quantity was 17.5 ± 10.5 equianalgesic oxycodone 5-mg pills (range, 0-78). Patients consumed a mean of 6.7 ± 10.9 equianalgesic oxycodone 5-mg pills after discharge and had 10.8 ± 10.2 equianalgesic oxycodone 5-mg pill excess, whereas 51% of patients consumed no pills. Opioid consumption was significantly different between each tier (p < 0.001). A prescribing guideline was developed to satisfy the majority of patients: 0 equianalgesic oxycodone 5-mg pills if tier 1, 12 pills if tier 2, and 30 pills if tier 3. Tiered guideline adoption could reduce prescribed pills by 45% and excess pills per prescription by 73%. Patient history of IBD was independently associated with increased odds of exceeding the guideline (adjusted OR = 7.2 (95% CI, 1.6-32.6)). LIMITATIONS: The study was limited by its single-center, retrospective design and that outpatient opioid consumption was self-reported. CONCLUSIONS: Following hospital discharge after major colorectal surgery, more than half of patients consumed no opioid pills, and 62% of prescribed opioids were in excess. Outpatient opioid consumption was highly associated with inpatient opioid use in the 24 hours before discharge. Prospective validation of this prescribing guideline is needed, but adoption could reduce excessive prescribing. See Video Abstract at http://links.lww.com/DCR/B575. DESARROLLO DE UNA GUA PRCTICA PARA LA PRESCRIPCIN DE OPIOIDES AL EGRESO DESPUS DE UNA CIRUGA COLORRECTAL MAYOR: ANTECEDENTES:Una mejor alineación de las cantidades de prescripción de opioides con las necesidades del paciente podría ayudar a reducir la prescripción excesiva.OBJETIVO:El estudio buscó desarrollar una guía institucional de prescripción basada en patrones definidos de consumo de opioides luego de cirugías colorrectales hospitalarias.DISEÑO:Estudio de cohorte retrospectivo.ENTORNO CLÍNICO:El estudio se llevó a cabo en un solo centro de atención terciaria.PACIENTES:Pacientes que se sometieron a procedimientos colorrectales mayores electivos entre julio de 2018 y enero de 2019.PRINCIPALES MEDIDAS DE RESULTADO:El estudio midió las cantidades de prescripción y consumo medidas como píldoras de 5 mg de oxicodona equianalgésica (EOP).RESULTADOS:Los pacientes se clasificaron en tres grupos según el consumo en el período de 24 horas antes del egreso: el nivel 1 consumió 0 EOP (n = 53), el nivel 2 consumió 0,1-3 EOP (n = 25) y el nivel 3 consumió más de 3 EOP (n = 22). La cantidad promedio de prescripción fue 17,5 (± 10,5) EOP (rango: 0-78). Los pacientes consumieron una media de 6,7 (± 10,9) EOP posterior al egreso y tuvieron un exceso de 10,8 (± 10,2) EOP, mientras que el 51% de los pacientes no consumieron píldoras. El consumo de opioides fue significativamente diferente entre cada nivel (p <0,001). Se desarrolló una guía de prescripción para satisfacer a la mayoría de los pacientes: 0 EOP del nivel 1, 12 EOP del nivel 2 y 30 EOP del nivel 3. La adquisición de una guía escalonada podría reducir las píldoras recetadas en un 45% y el exceso de píldoras por receta en un 73%. El historial del paciente de enfermedad inflamatoria intestinal se asoció de forma independiente con un aumento de las probabilidades de superar la guía (ORa 7,2; IC del 95%: 1,6-32,6).LIMITACIONES:El estudio estuvo limitado por su diseño retrospectivo de un solo centro y por el consumo de opioides del paciente ambulatorio el cual fue autoinformado.CONCLUSIONES:Tras el egreso hospitalario de una cirugía colorrectal mayor, más de la mitad de los pacientes no consumieron pastillas opioides y el 62% de los opioides prescritos estaban en exceso. El consumo de opioides como paciente ambulatorio estuvo altamente asociado con el uso de opioides como paciente hospitalizado en las 24 horas previas al egreso. Se necesita una validación prospectiva de esta guía de prescripción, pero la adopción podría reducir la prescripción excesiva. Consulte Video Resumen en http://links.lww.com/DCR/B575.

Total Transperineal Laparoscopic Proctectomy for the Treatment of Crohn's Proctitis.

INTRODUCTION: Completion proctectomy is traditionally performed using a combination of abdominal and perineal approaches. Access to and exposure of the pelvis through the abdominal cavity can be limited in patients with prior surgery or inflammatory conditions. We describe a novel technique for a total transperineal approach for proctectomy for Crohn's proctitis, avoiding technical challenges, risks, and recovery associated with abdominal surgery. TECHNIQUE: We utilized the skills and expertise acquired from our experience with transanal total mesorectal excision to perform a total transperineal laparoscopic proctectomy in a male patient with medically refractory proctitis. He previously underwent an anterior resection, drainage of a chronic presacral abscess, omental pedicle flap transposition to the pelvis, and end colostomy for severe Crohn's colitis. The total transperineal laparoscopic proctectomy approach avoids the need for abdominal access, including the risks associated with abdominal entry, adhesiolysis, pelvic access and visualization, and wound-related issues. Following an initial intersphincteric perineal dissection, the GelPOINT Path minimal access platform is utilized to perform a total transperineal proctectomy. RESULTS: The patient recovered uneventfully and was discharged to home 2 days after surgery. At 1-month postoperative follow-up, the patient is recovering well with complete healing of the perineal wound. CONCLUSION: We demonstrate the feasibility, safety, and technical steps of a minimally invasive completion proctectomy for fistulizing Crohn's proctitis by using a total transperineal approach. This approach allowed us to utilize direct, inline, high-definition visualization to access and safely operate in the distal aspects of a narrow, scarred, and fibrotic pelvis while avoiding the need for any abdominal access. Advanced experience with redo pelvic and minimally invasive transanal surgery is critical. See Video at http://links.lww.com/DCR/B664.

Defining Anastomotic Leaks After Colorectal Surgery: Results of a National Survey.

BACKGROUND: Anastomotic leaks are a dreaded complication after colorectal surgery. Although anastomotic leak is often used as a metric to compare patient outcomes, a standard definition does not exist. MATERIALS AND METHODS: A web-based survey was developed and distributed to US surgeons. Respondents were queried on the definition of anastomotic leaks using a 5-point Likert scale to rate different scenarios related to colorectal surgery. RESULTS: Of potential 2209 respondents, 649 (29%) responded to the survey. The majority of respondents was men (76%) and practiced colon and rectal surgery as their primary specialty (89%). Contrast extravasation at the anastomosis, regardless of timing related to the surgery, is the clinical scenario with greatest consensus (>85%). 50% of surgeons do not believe that an abscess near the anastomosis in an asymptomatic patient defines a leak. CONCLUSIONS: These results highlight the pressing need for standardization of the anastomotic leak definition given the implications on outcomes measurement, research trials, and health care reimbursement.

Transanal Minimally Invasive Surgery: An Effective Approach for Patients Who Require Redo Pelvic Surgery for Anastomotic Failure.

BACKGROUND: Anastomotic leaks cause significant patient morbidity that may require redo pelvic surgery. Transanal minimally invasive surgery facilitates direct access to the pelvis with increased visualization and maneuverability for technically difficult redo surgery. OBJECTIVE: This study aimed to assess the feasibility and outcomes of transanal minimally invasive surgery in redo proctectomy for anastomotic complications. DESIGN: This was a retrospective cohort study. SETTINGS: This study was conducted at a single tertiary-care institution. PATIENTS: Consecutive patients undergoing transanal minimally invasive redo proctectomy were included. INTERVENTIONS: Transanal minimally invasive redo proctectomy was performed. MAIN OUTCOME MEASURES: The primary end point was intraoperative feasibility. The secondary end points were safety, perioperative morbidity, and symptom resolution. RESULTS: Seven patients underwent redo proctectomy via transanal minimally invasive surgery for anastomotic defect (n = 6) or stricture (n = 1). Median time from initial to redo operation was 27 months (range, 13-67). Redo proctectomy included redo low anterior resection with coloanal anastomosis and diverting loop ileostomy (n = 4), completion proctectomy with end colostomy (n = 2), and pouch resection with end ileostomy (n = 1). Six patients had an open abdominal approach. There were no conversions for the anal approach. Median operative time was 6.4 hours (range, 4.0-7.1). All 4 planned redo coloanal anastomoses were successfully created. Hospital length of stay was a median of 8 days (interquartile range, 6-9). Intraoperative complications included 2 patients with carbon dioxide emboli, which resolved with supportive care; there was no adjacent organ injury. Three patients were readmitted within 30 days. There were no postoperative anastomotic leaks, and all 4 patients with diverted ileostomies underwent reversal at a median of 4 months (interquartile range, 4-6). All symptoms prompting redo surgery remain resolved at a median follow-up of 20 months. LIMITATIONS: This study was limited by its small sample size and its single-institution focus. CONCLUSION: For those with expertise in transanal surgery, transanal minimally invasive surgery is a safe and effective option for patients with anastomotic failure requiring redo proctectomy because it provides direct access to and visualization of the pelvis.

Twitter Use Among Departments of Surgery With General Surgery Residency Programs.

OBJECTIVE: To examine patterns of Twitter use by surgery departments with residency programs and understand relevant motivations and concerns. The primary outcome was to quantify account prevalence and activity. The secondary outcomes were to identify reasons for use and perceived benefits and concerns. DESIGN SETTING, AND PARTICIPANTS: A cross-sectional study was performed on Twitter accounts of departments of surgery with Accreditation Council of Graduate Medical Education accredited general surgery residencies. An anonymous survey was distributed to all programs with accounts. Data acquisition was completed in August 2019 and analysis was completed in February 2020. RESULTS: Among the 319 departments of surgery, only 80 (25%) had department of surgery Twitter accounts. Mean account age was 3.5 years (range: 0-9.8), with the highest account creation in 2017 (n = 23, 29%). Median total tweets per account was 314 (range 3-21,893), and median number of followers was 454 (range 18-22,353). Having a Twitter account was associated with program type: 66/123 (54%) university-based, 1/9 (11%) military, 13/124 (11%) community/university-affiliated, and 0/63 (0%) community (p < 0.01). Survey response rate was 40% (n = 32). Only 59% had formal posting guidelines. Daily logins (78%) and daily tweeting (53%) were common. The most frequent perceived benefits were "highlighting new research and major events" (97%), "increasing visibility within the academic community" (91%), and "improving resident engagement" (75%). The most common concerns were "professionalism" (72%), "privacy" (63%), and "time commitment" (53%). CONCLUSIONS: Though only a quarter of departments of general surgery had Twitter accounts, they were felt to be key for improving academic reach. Formal posting guidelines existed for 59% of survey respondents, although concerns about privacy and content were common. An underutilized tool for surgery departments to promote academic achievements, Twitter use represents a potential opportunity to engage the surgical community more broadly.

Opioid Consumption Patterns After Anorectal Operations: Development of an Institutional Prescribing Guideline.

BACKGROUND: Closer scrutiny of prescription patterns following surgery could contribute to the national effort to combat the opioid epidemic. OBJECTIVE: This study aimed to define opioid consumption patterns following anorectal operations for development of an institutional prescribing guideline. DESIGN: This was a retrospective cohort study. SETTING: The study was conducted at a single tertiary care center. PATIENTS: Patients undergoing outpatient anorectal surgery between July 2018 and January 2019 were included. MAIN OUTCOME MEASURES: The study measured prescription and consumption quantities measured as equianalgesic oxycodone 5-mg pills. RESULTS: There were 174 operations categorized into 4 operation categories: 72 hemorrhoid excisions, 55 fistulas-in-ano operations, 8 anal condyloma fulgurations, and 39 miscellaneous operations (14 sphincterotomies, 16 anal biopsies/skin tag excisions, and 9 transanal rectal lesion excisions). Prescription quantity was varied (range, 3-80 equianalgesic oxycodone 5-mg pills). Overall, 39% of patients consumed no pills, 18% consumed all, and 5% required refills. Of total pills prescribed, 63% of were unconsumed. Consumption was significantly different by operation category (average 13.6 equianalgesic oxycodone 5-mg pills after hemorrhoidectomies, 6.3 after fistula-in-ano operations, 5.8 after condyloma fulguration, and 2.9 after miscellaneous operations; p < 0.001). Home opioid requirements would be met for 80% of patients using the following guideline: 27 equianalgesic oxycodone 5-mg pills after hemorrhoidectomies, 13 after fistula-in-ano operations, 20 after anal condyloma fulguration, and 4 after miscellaneous operations. Guideline adoption would result in a 41% reduction in excess pills per prescription. LIMITATIONS: The study was limited by its retrospective, single-center design and because opioid consumption was self-reported. CONCLUSIONS: Opioid prescribing patterns and consumption are widely variable after anorectal operations and appear to be highly dependent on the operation category. It is noteworthy that 63% of opioids prescribed after anorectal operations were unused by the patient and may pose a significant public health risk. Based on the usage patterns observed in this study, prospective studies should be performed to optimize opioid prescribing. See Video Abstract at http://links.lww.com/DCR/B374. PATRONES DE CONSUMO DE OPIOIDES DESPUÉS DE OPERACIONES ANORRECTALES: DESARROLLO DE UNA GUÍA PARA PRESCRIPCIÓN INSTITUCIONAL: Una revisión enfocada de los patrones de prescripción después de la cirugía podría contribuir al esfuerzo nacional para combatir la epidemia de opioides.Este estudio tuvo como objetivo definir los patrones de consumo de opioides después de las operaciones anorrectales para el desarrollo de una guía para prescripción institucional.Estudio de cohorte retrospectivo.El estudio se realizó en un solo centro de atención de tercer nivel.pacientes de cirugía anorrectal ambulatoria entre julio de 2018 y enero de 2019.El estudio valoro el numero de recetas medicas y consumo de píldoras equianalgésicas de oxicodona de 5 mg.174 operaciones se clasificaron en cuatro categorías: 72 extirpaciones de hemorroides, 55 operaciones de fistula anal, 8 fulguraciones de condilomas anales y 39 operaciones misceláneas (14 esfinterotomías, 16 biopsias anales / extirpaciones de lesiones de piel y 9 escisiones de lesiones rectales por vía transanal). La cantidad de medicamentos recetados fue variada (rango: 3-80 pastillas de oxicodona equianalgésica de 5 mg). En general, el 39% de los pacientes no consumió píldoras, el 18% consumió todo y el 5% requirió equianalgesica adicional. Del total de píldoras recetadas, el 63% no se consumió. El consumo fue significativamente diferente según la categoría de la operación (promedio de 13,6 píldoras de oxicodona equianalgésica de 5 mg después de las hemorroidectomías, 6,3 después de las operaciones de fístula en el ano, 5,8 después de la fulguración del condiloma y 2,9 después de las operaciones misceláneas, p <0,001). Los requisitos de opioides en el hogar se cumplirían para el 80% de los pacientes con las siguientes pautas: 27 píldoras de oxicodona equianalgésicas de 5 mg después de las hemorroidectomías, 13 después de las operaciones de fístula anal, 20 después de la fulguración del condiloma anal y 4 después de operaciones misceláneas. La adopción de la guía daría como resultado una reducción del 41% en el exceso de píldoras por receta.El estudio estuvo limitado por su diseño retrospectivo de un solo centro y el consumo de opioides fue autoinformado.Los patrones de prescripción de opioides y el consumo son variables después de las operaciones anorrectales y parecen ser altamente dependientes de la categoría de la operación. En particular, el 63% de los opioides recetados después de las operaciones anorrectales no fueron utilizados por el paciente y pueden representar un riesgo significativo para la salud pública. Según los patrones de uso observados en este estudio, se deben realizar estudios prospectivos para optimizar la prescripción de opioides. Consulte Video Resumen en http://links.lww.com/DCR/B374.