Appendectomy Is Oncologically Equivalent to Right Hemicolectomy for Well-Differentiated T1 Appendiceal Adenocarcinoma.

BACKGROUND: Right hemicolectomy is recommended for appendiceal adenocarcinoma but may not be needed for early stage disease. OBJECTIVE: This study aimed to determine whether appendectomy offers adequate oncologic outcomes for T1 appendiceal adenocarcinoma from a national cohort of patients. DESIGN: Patients with T1 appendiceal adenocarcinoma (mucinous and nonmucinous histology) treated with either a right hemicolectomy or appendectomy between 2004 and 2016 were retrieved. Multivariate Cox regression analysis was used to identify predictors of overall survival. SETTING: The study was conducted using a national cancer database. PATIENTS: A total of 320 patients (median age, 62 y; 47% women) were identified: 69 (22%) underwent an appendectomy and 251 (78%) underwent a right hemicolectomy. MAIN OUTCOME MEASURE: Overall survival was measured. RESULTS: Nonmucinous adenocarcinoma was identified in 194 (61%), whereas 126 (39%) had mucinous adenocarcinoma. Of the overall cohort, 43% had well-differentiated histology, 39% had moderately differentiated disease, and 4% had poorly differentiated tumors. The rate of lymph node metastasis was lower in well-differentiated tumors (3%) compared with moderately (10%) or poorly differentiated tumors (25%). On univariate survival analysis, right hemicolectomy was associated with improved 1-, 3-, and 5-year overall survival in patients with moderately/poorly differentiated disease ( p < 0.001) but not for well-differentiated disease ( p = 1.000). After adjustment, right hemicolectomy was associated with overall survival improvement for moderately/poorly differentiated T1 adenocarcinoma (HR = 0.26 [95% CI, 0.08-0.82]; p = 0.02) but not for well-differentiated disease. LIMITATIONS: This study was limited by its retrospective nature. CONCLUSIONS: The current analysis from the National Cancer Database demonstrates that appendectomy is associated with equivalent survival to right hemicolectomy for well-differentiated T1 adenocarcinoma, whereas for moderately and poorly differentiated disease, right hemicolectomy is oncologically superior to appendectomy. See Video Abstract at http://links.lww.com/DCR/B689 . LA APENDICECTOMA ES ONCOLGICAMENTE EQUIVALENTE A LA HEMICOLECTOMA DERECHA PARA EL ADENOCARCINOMA APENDICULAR T BIEN DIFERENCIADO: ANTECEDENTES:La hemicolectomía derecha se recomienda para el adenocarcinoma apendicular, pero puede no ser necesaria para la enfermedad en estadio temprano.OBJETIVO:Este estudio tuvo como objetivo determinar si la apendicectomía ofrece resultados oncológicos adecuados para el adenocarcinoma apendicular T1 de una cohorte nacional de pacientes.DISEÑO:Se recuperaron pacientes con adenocarcinoma apendicular T1 (histología mucinoso y no mucinoso) tratados con hemicolectomía derecha o apendicectomía entre 2004-2016. Se utilizó un análisis de regresión de Cox multivariante para identificar los predictores de la supervivencia global.ENTORNO CLÍNICO:Base de datos nacional sobre cáncer.PACIENTES:Se identificaron un total de 320 pacientes (mediana de edad 62 años, 47% mujeres): 69 (22%) se sometieron a una apendicectomía y 251 (78%) se sometieron a una hemicolectomía derecha.PRINCIPAL MEDIDA DE RESULTADO:Sobrevida global.RESULTADOS:Se identificó adenocarcinoma no mucinoso en 194 (61%) mientras que 126 (39%) tenían adenocarcinoma mucinoso. De la cohorte general, el 43% tenía una histología bien diferenciada, el 39% tenía una enfermedad moderadamente diferenciada y el 4% tenía tumores poco diferenciados. La tasa de metástasis en los ganglios linfáticos fue menor en los tumores bien diferenciados (3%) en comparación con los tumores moderadamente (10%) o pobremente diferenciados (25%). En el análisis de sobrevida univariante, la hemicolectomía derecha se asoció con una mejor sobrevida general a 1, 3, y 5 años en pacientes con enfermedad moderada / pobremente diferenciada ( p < 0,001) pero no para la enfermedad bien diferenciada ( p = 1,000). Después del ajuste, la hemicolectomía derecha se asoció con una mejora de la sobrevida general para el adenocarcinoma T1 moderadamente / poco diferenciado (HR = 0,26, IC del 95%: 0,08-0,82, p = 0,02) pero no para la enfermedad bien diferenciada.LIMITACIONES:Este estudio estuvo limitado por su naturaleza retrospectiva.CONCLUSIONES:El análisis actual de la base de datos nacional de cáncer demuestra que la apendicectomía se asocia con una sobrevida similar a la hemicolectomía derecha para el adenocarcinoma T1 bien diferenciado, mientras que para la enfermedad moderada y pobremente diferenciada, la hemicolectomía derecha es oncológicamente superior a la apendicectomía. Consulte Video Resumen en http://links.lww.com/DCR/B689 . (Traducción-Dr. Yazmin Berrones-Medina ).

Drainage of anorectal abscesses in the operating room is associated with a decreased risk of abscess recurrence and fistula formation.

BACKGROUND: Timely incision and drainage (I&D) is first line management for anorectal abscesses. We aimed to define current practices in anorectal abscess management and identify factors associated with abscess recurrence and fistula formation. METHODS: Index episodes of anorectal abscesses treated with I&D in 2014-2018 at a multi-hospital healthcare system were included. Association with one-year abscess recurrence or fistula formation was evaluated using Cox proportional hazard regression. Fistulae were captured only among patients without fistulae at the index operation. RESULTS: A total of 458 patients met study criteria. One-year rate of abscess recurrence or fistula formation was 20.3%. When compared to bedside procedures, drainage in the operating room was associated with a reduced risk of either recurrence or fistula formation (aHR 0.20 [95%CI 0.114-0.367]). CONCLUSIONS: Improved exposure and patient comfort in the operating room may allow more complete drainage contributing to decreased rates of abscess recurrence or fistula formation.

Transanal excision with adjuvant therapy for pT1N0 rectal tumors with high-risk features offers equivalent survival to radical resection: A National Cancer Database analysis.

BACKGROUND: Current guidelines favor transabdominal radical resection (RR) over transanal local excision (TAX) followed by adjuvant therapy (TAXa) for pT1N0 rectal tumors with high-risk features. Comparison of oncologic outcomes between these approaches is limited, although the former is associated with increased postoperative morbidity. We hypothesize that such treatment strategies result in equivalent long-term survival. METHODS: A retrospective cohort study was conducted using the National Cancer Database (2010-2016) to identify patients with pT1N0 rectal adenocarcinoma with high-risk features who underwent TAX or RR for curative intent. The primary outcome was 5-year overall survival (OS), evaluated with log-rank and Cox-proportional hazards testing. RESULTS: A total of 1159 patients (age 67.4 ± 12.9 years; 56.6% male; 83.3% White) met study criteria, of which 1009 (87.1%) underwent RR and 150 (12.9%) underwent TAXa. Patients undergoing TAXa had shorter lengths of stay (RR = 6.5 days, TAXa = 2.7 days, p < 0.001). The 5-year OS was equivalent between groups. TAX without adjuvant therapy was associated with an increased risk of mortality (hazard ratio 1.81, 95% confidence interval 1.17-2.78, p = 0.01). CONCLUSIONS: This is the largest study to demonstrate equivalent 5-year OS between TAXa and RR for T1N0 rectal cancer with high-risk features. These findings may guide the development of prospective, randomized trials and influence changes in practice recommendations for early-stage rectal cancer.

The Role of Adjuvant Chemotherapy Following Right Hemicolectomy for Non-metastatic Mucinous and Nonmucinous Appendiceal Adenocarcinoma.

BACKGROUND: Appendiceal adenocarcinoma (AA) represents a heterogenous group of neoplasms with distinct histologic features. The role and efficacy of adjuvant chemotherapy (AC) in non-metastatic disease remain controversial. The aim of this study was to ascertain the role of AC in non-metastatic AA in a national cohort of patients. METHODS: The National Cancer Database (NCDB) was queried to identify patients diagnosed with stage I-III mucinous and nonmucinous AA who underwent right hemicolectomy between 2006 and 2016. Kaplan-Meier and Cox regression analyses were used to evaluate the impact of AC on overall survival (OS) stratified by each pathologic stage. RESULTS: A total of 1433 mucinous and 1954 nonmucinous AA were identified; 578 (40%) and 722 (40%) received AC respectively. In both AC groups, there was a higher proportion of T4 disease, lymph node metastasis, pathologic stage III, and poorly/undifferentiated grade (all P<0.05). On unadjusted analysis, there was no significant association between AC and OS for stage I-III mucinous AA. For nonmucinous AA, AC significantly improved OS only for stage II and III disease. On adjusted analysis, AC was independently associated with an improved OS for stage III nonmucinous AA (HR: 0.61, 95%CI 0.45-0.84, P=0.002), while for mucinous AA, AC was associated with worse outcomes for stage I/II disease (HR: 1.4, 95%CI 1.02-1.91, P=0.038) and had no significant association with OS for stage III disease. CONCLUSION: This current analysis of a national cohort of patients suggests a beneficial role for AC in stage III nonmucinous AA and demonstrates no identifiable benefit for stage I-III mucinous AA.

Developing Opioid Prescription Guidelines After Anorectal Surgery: Do Patient-Reported Outcomes and Risk Factors Influence Consumption?

BACKGROUND: Opioids prescribed to address postoperative pain drive opioid-related deaths in the United States. Prescribing guidelines have been developed for many general surgical procedures, which have decreased opioid prescription and consumption. The literature on opioids after anorectal surgery is lacking. OBJECTIVE: We analyzed our data on opioid prescription and consumption to create opioid-prescribing guidelines for anorectal procedures. DESIGN: We designed a prospectively collected postoperative survey given to consecutive patients undergoing anorectal surgery by colorectal surgeons. SETTINGS: Patients had surgery at 2 academic, university-affiliated hospitals. PATIENTS: Patients undergoing anorectal surgery from May 3, 2018, to December 18, 2019, were included in the study. Patients were excluded if they were <18 years of age, had a concurrent abdominopelvic surgery, consumed opioids in the week before their operation, or were without follow-up at 3 months postoperatively. MAIN OUTCOME MEASURES: The primary outcome of this study was the number of opioid pills needed to fulfill consumption of 80% of patients. Secondary outcome measures were patient, operative, and postoperative factors associated with increasing pill consumption. RESULTS: Eighteen 5-mg oxycodone tablets were needed to fulfill the needs of 80% of patients. An overall median of 8 pills was consumed. Pill prescription was independently predictive of increased consumption. The only patient factor associated with increased consumption was race; no other patient or operative factors were predictive of consumption. LIMITATIONS: Limitations of this study include its partially retrospective nature, use of self-reported data, and lack of racial diversity among our cohort. CONCLUSIONS: Without any clinical factors predictive of increased consumption, prescription guidelines can be standardized to ≤18 5-mg oxycodone tablets across anorectal surgery patients. As prescription is correlated with consumption, further work is needed to determine whether lesser quantities of opioids prescribed offer similar postoperative pain relief for patients undergoing anorectal surgery. See Video Abstract at http://links.lww.com/DCR/B821 .DESARROLLO DE PAUTAS PARA LA PRESCRIPCIÓN DE OPIOIDES DESPUÉS DE CIRUGÍA ANORRECTAL: ¿INFLUYEN EN EL CONSUMO LOS RESULTADOS INFORMADOS POR EL PACIENTE Y LOS FACTORES DE RIESGO? ANTECEDENTES: Los opioides recetados para tratar el dolor posoperatorio provocan muertes relacionadas con los opioides en los Estados Unidos. Se han desarrollado pautas de prescripción para muchos procedimientos quirúrgicos generales y estas han conducido a una disminución de la prescripción y el consumo de opioides. Hay una carencia de literatura sobre el uso de opioides después de cirugía anorrectal. OBJETIVO: Analizamos nuestros datos sobre prescripción y consumo de opioides para crear pautas de prescripción de opioides para procedimientos anorrectales. DISEO: Diseñamos una encuesta postoperatoria recopilada prospectivamente que se administró a pacientes consecutivos sometidos a cirugía anorrectal por cirujanos colorrectales. AJUSTES: Los pacientes fueron operados en dos hospitales académicos afiliados a la universidad. PACIENTES: Se incluyeron en el estudio pacientes sometidos a cirugía anorrectal desde el 3/05/2018 hasta el 18/12/2019. Se excluyó a los pacientes que tenían menos de 18 años, a los que se sometieron a cirugía abdominopélvica concurrente, a los que consumieron opioides en la semana anterior a la operación, o si no tenían seguimiento a los 3 meses del postoperatorio. PRINCIPALES MEDIDAS DE DESENLACE: El desenlace principal de este estudio fue el número de píldoras de opioides necesarias para satisfacer el consumo del 80% de los pacientes. Las medidas de desenlace secundarias fueron los factores del paciente, operatorios y posoperatorios asociados con el aumento del consumo de píldoras. RESULTADOS: Fueron necesarios dieciocho comprimidos de oxicodona de 5 mg para cubrir las necesidades del 80% de los pacientes. Se consumió una mediana general de 8 píldoras. La prescripción de la píldora fue un predictor independiente de un mayor consumo. El único factor del paciente asociado con un mayor consumo fue la raza; ningún otro paciente o factores operativos fueron predictivos del consumo. LIMITACIONES: Las limitaciones de este estudio incluyen su naturaleza parcialmente retrospectiva, el uso de datos autoinformados y la falta de diversidad racial entre nuestra cohorte. CONCLUSIONES: Sin ningún factor clínico que prediga un aumento del consumo, las pautas de prescripción se pueden estandarizar a dieciocho o menos comprimidos de oxicodona de 5 mg en pacientes sometidos a cirugía anorrectal. Como la prescripción se correlaciona con el consumo, se necesita más trabajo para determinar si cantidades menores de opioides prescritos ofrecen un alivio del dolor posoperatorio similar para los pacientes sometidos a cirugía anorrectal. Consulte Video Resumen en http://links.lww.com/DCR/B821 . (Traducción-Juan Carlos Reyes ).

Impact of Enhanced Recovery Pathways and early urinary catheter removal on post-operative urinary retention.

BACKGROUND: Post-operative urinary retention (POUR) is a common complication after colorectal surgery. Enhanced recovery pathways (ERP) typically include early catheter removal but may place patients at risk for POUR. METHODS: This is a retrospective cohort analysis of patients undergoing colorectal surgery at a single institution between April 2014 and November 2017. Patients were stratified into non-ERP and ERP cohorts and post-operative outcomes were compared. RESULTS: Of 284 patients studied, ERP was applied to 161 (57%) while the remaining 123 (43%) recovered under standard care. Median duration of indwelling Foleys was 1 day for ERP and 2 days for non-ERP patients (p < 0.001). ERP patients experienced higher rates of straight catheterization (22% vs 12%,p = 0.036), Foley reinsertion (14% vs 7%,p = 0.07), and initiation of alpha antagonists (12% vs 5%,p = 0.04). Significant independent predictors of POUR were age (OR 1.03, p = 0.002), male gender (OR 2.79, p = 0.001), surgery duration (OR 1.27, p = 0.027), and ERP (OR 1.96, p = 0.025). CONCLUSION: ERP following colorectal surgery that include routine early Foley catheter removal on post-operative day one is associated with increased rates of POUR; however, this did not lead to increased rates of catheter-associated urinary tract infections during the index admission in the population studied.

Obesity Does Not Impact Perioperative or Postoperative Outcomes in Patients with Inflammatory Bowel Disease.

BACKGROUND: While the prevalence of obesity in IBD patients is rapidly increasing, it is unclear if obesity impacts surgical outcomes in this population. We aim to investigate the effects of BMI on perioperative and postoperative outcomes in IBD patients by stratifying patients into BMI groups and comparing outcomes between these groups. METHODS: This is a retrospective cohort study where IBD patients who underwent intestinal surgeries between the years of 2000 to 2014 were identified. The patients were divided into groups based on BMI: underweight (BMI <18.5), normal weight (BMI 18.5-24.9), overweight (BMI 25-29.9), and obese (BMI ≥30). Preoperative patient demographics, operative variables, and postoperative complications were collected and compared between BMI groups. RESULTS: A total of 391 surgeries were reviewed (34 underweight, 187 normal weight, 105 overweight, and 65 obese) from 325 patients. No differences were observed in preoperative patient demographics, type of IBD, preoperative steroid or biologic mediator use, or mean laboratory values. No differences were observed in percent operative procedures with anastomosis, surgeries converted to open, estimated blood loss, intraoperative complications, and median operative time. Thirty-day postoperative complication rates including total complications, wound infection, or anastomotic leak were similar between groups. There was a statistically significant increased postoperative bleeding risk (p = 0.029) in underweight patients. The relative percent for increased postoperative bleeding risk between BMI groups was as follows: 2.9% in underweight, zero in normal weight, 2.9% in overweight, and zero in obese. CONCLUSION: Obesity does not appear to impact intraoperative variables nor does obesity appear to worsen postoperative complication rates in IBD patients.

Colectomy for fulminant Clostridium difficile colitis: predictors of mortality.

The purpose of this study was to define clinical and radiographic variables associated with postoperative mortality after urgent colectomy for fulminant Clostridium difficile colitis. Data were obtained regarding patients undergoing colectomy for fulminant C. difficile colitis at two institutions (1997-2005). Univariate analysis of factors predicting 30-day mortality was performed using chi2 and Student's t tests. Multivariable logistic regression was done to include all variables whose P value was < 0.20. Clinical variables analyzed included: age, gender, recent operation, comorbidities, preoperative multisystem organ failure, vasopressors, symptom duration, time to surgery, serum albumin, change in serum albumin, serum creatinine, white blood cell count, and extent of colectomy. Computed tomography variables included: ascites, megacolon, and extent of colitis. Thirty-five patients (mean age 70 years, 46% male) underwent urgent colectomy for C. difficile colitis. The 30-day mortality rate was 45.7 per cent (16/35). The only clinical variable associated with mortality was preoperative multisystem organ failure (nonsurvivors 9/16 vs survivors: 4/19; P = 0.037). None of the three patients undergoing partial colectomy survived, although the difference in survival versus those undergoing subtotal colectomy was not significant. Patients with fulminant C. difficile colitis undergoing colectomy have a high mortality rate. Preoperative presence of multisystem organ failure was independently predictive of mortality.

Efficacy of manual dissection of lymph nodes in colon cancer resections.

The adequacy of lymph node dissection of colonic resection specimens influences the clinical and pathologic staging, leading to important postsurgical treatment decisions. Although manual lymph node dissection is the current standard at most institutions, recent statistical studies indicate that all lymph nodes, including those measuring 1-2 mm, should be recovered to be assured of lymph node negative status. Thus, we tested the efficacy of gross dissection by submitting the entire residual mesenteric fat. We analyzed 15 randomly chosen colonic resections (2 pT1, 1 pT2, 11 pT3, 1 pT4). After standard gross dissection of lymph nodes and submission of colonic material for diagnosis, the entire remaining mesenteric material was dehydrated over several days by serial washing in alcohol and acetone. All of the mesenteric tissue was submitted for histology. The average number of nodes found by original gross inspection was 20.8, while the average number of additional nodes found after clearing was 68.6. In all, 83% of the additional nodes were 2.0 mm or less in size. There were seven pN0 cases; one was upstaged by additional findings that may have been artifactual. There were four pN1 cases; three were upstaged to pN2 after submission of the mesenteric material. All four pN2 tumors had additional metastases identified. In all, 75% of all positive nodes were under 2.0 mm in size. In this limited sample, standard gross dissection proved sufficient for most pN0 tumors to remain node negative. However, our findings within the pN1 group show that examination of all of the mesenteric material may be necessary to be assured of correct pN status.

Rectal ulceration as a result of prostatic brachytherapy: a new clinical problem: report of three cases.

INTRODUCTION: Prostate cancer is the most common cancer of males in the United States. One treatment modality for localized prostate cancer is brachytherapy, the implantation of radioactive seeds directly into the prostate. Although this is an effective treatment option, significant complications can result. More commonly these complications involve the genitourinary tract, but radiation proctitis is a well-recognized, less common complication. A specific complication of brachytherapy, the development of a rectal ulcer is not well recognized. The clinical course of this complication and results of treatment options are unknown. METHODS: Three cases of rectal ulceration as a consequence of prostatic brachyradiotherapy are presented, and the presumed course of disease and treatment options is discussed. RESULTS: Two patients were initially treated with local advancement flaps that both failed. These patients developed rectourethral fistulas. One patient was treated with diverting colostomy and suprapubic urinary diversion. The second underwent proctectomy and coloanal anastomosis. This also failed after multiple attempts to treat perianastomotic fistulas. The third patient was treated endoscopically for bleeding and has had no further interventions. CONCLUSION: In the small percentage of patients who develop rectal ulcerations from prostatic brachyradiotherapy, local medical or surgical treatments will often result in failure. They also may contribute to the eventual development of rectourethral fistulas, the likely natural progression of this disease. These fistulas should be treated with both urinary and fecal diversion. Earlier stages of ulceration may be treated with rectal resection and reconstruction, but selection criteria for these procedures have yet to be determined.