Rectal cancer: Maximizing local control and minimizing toxicity.

Adoption of multimodality treatment approach for rectal cancer has resulted in significant improvements in oncologic outcomes. The roles of chemotherapy, radiation, and surgery in rectal cancer treatment are continuously evolving with the goal of achieving the best possible oncologic and functional outcome while minimizing treatment toxicity. The aim of this review is to summarize the most recent trials focusing on organ-sparing treatment strategies and the optimal selection of patients for neoadjuvant radiation therapy.

Clinical staging accuracy and the use of neoadjuvant chemoradiotherapy for cT3N0 rectal cancer: Propensity score matched National Cancer Database analysis.

BACKGROUND: While neoadjuvant chemoradiation therapy (nCRT) is accepted as standard of care for locally advanced rectal cancer, the approach to treatment of patients with clinically staged T3N0 disease has been increasingly debated. This study examines the accuracy of clinical staging for cT3N0 rectal cancer as recorded in the National Cancer Data Base and evaluates the role of nCRT in treating these patients. METHODS: Total of 15,843 patients with clinically staged T3N0M0 rectal cancer who either received nCRT or proceeded to surgery-first met inclusion criteria. Propensity score matching was employed to balance the groups. RESULTS: 23% of cT3N0 patients undergoing surgery-first were found to have pathologically positive nodes. Another 16% turned out to have < stage II disease on surgical pathology. Survival curves for matched nCRT and surgery-first groups demonstrated a survival advantage for cT3N0 patients treated with nCRT. CONCLUSIONS: Poor clinical staging accuracy can result in both undertreatment and overtreatment of cT3N0 rectal cancer.

Parenteral Nutrition Instead of Early Reoperation in the Management of Early Postoperative Small Bowel Obstruction.

BACKGROUND: In majority of patients, early postoperative small bowel obstruction (EPSBO) resolves with nasogastric decompression and bowel rest alone, while in some patients, symptoms persist without urgent indications for surgery. The purpose of this study was the evaluation of home parenteral nutrition (HPN) instead of elective surgery as an initial approach to persistent EPSBO. METHODS: Patients developing EPSBO prescribed HPN without reoperation within 6 weeks after index intestinal surgery were identified from an institutional HPN registry and retrospectively compared with patients undergoing reoperation for EPSBO within the same time period. RESULTS: Thirty-four patients for the HPN group and 27 patients in elective reoperative (REOP) group met the inclusion criteria. In the HPN group, mean interval between surgery and PN initiation was 11 days. HPN duration ranged from 17 to 244 days with a median of 60 days. Thirty-one patients (91%) successfully recovered bowel function and resumed enteral nutrition without reoperation, while 3 patients required reoperation > 6 weeks after index surgery due to HPN failure. In the REOP group, mean interval between index surgery and reoperation was 17 days. At reoperation, 12 patients required bowel resection, 5 having incidental enterotomies, and 3 required new stoma creation. Postoperatively, 2 patients developed enterocutaneous fistulas, 1 experienced an anastomotic leak, and another had fascial dehiscence. CONCLUSION: HPN is a safe alternative to elective surgery in clinically stable patients with persistent EPSBO. This approach avoids hazardous reoperation during the recovery phase when adhesions are at their worst.

Time Attributable to Obesity in Surgery: A Multi-specialty Report on Day-of-Surgery Resource Utilization from 189,264 Cases.

BACKGROUND: Obesity presents a unique challenge in caring for surgical patients and has been shown to adversely affect outcomes for several operative procedures. However, quantitative data on surgical resource utilization attributable to obesity are scarce. The aim of this study was to quantify day-of-surgery resource utilization by degree of obesity. METHODS: Patients undergoing one of 14 common surgical procedures at our multicenter institution between 2008 and 2017 were identified from our operating room management databank. Multiple-variable regression analysis (MVRA) was performed to quantify the independent effect of body mass index (BMI) category on day-of-surgery resource utilization variables including procedure time, non-operative OR time, PACU time, number of unique staff and number of supplies used. Trends in mean BMI were examined for each procedure studied. RESULTS: MVRA of the 189,264 cases in the database revealed consistently significant (p < 0.05) stepwise increase in procedure time by BMI category for all procedures studied. Non-operative OR time was also significantly prolonged, though to a lesser degree. There was no significant impact on number of unique staff, supplies utilized or PACU time by BMI category. Procedures most impacted by BMI category in terms of resource utilization were ventral hernia repair, laminectomy and hysterectomy. CONCLUSION: Our study quantified day-of-surgery resource utilization for 14 major surgical procedures by BMI category. The need for additional resources to accommodate patients in higher BMI groups was consistent across all procedures studied and was primarily reflected by lengthened operative times.

Thrombelastographic pattern recognition in renal disease and trauma.

BACKGROUND: Thrombelastography (TEG) is a viscoelastic hemostatic assay. We have observed that end-stage renal disease (ESRD) and trauma-induced coagulopathy (TIC) produce distinctive TEG tracings. We hypothesized that rigorously definable TEG patterns could discriminate between healthy controls and patients with ESRD and TIC. METHODS: TEG was performed on blood from ESRD patients (n = 54) and blood from trauma patients requiring a massive blood transfusion (n = 16). Plots of independent TEG parameters were analyzed for patterns coupled to disease state, compared with controls. Decision trees for taxonomic classification were then built using the "R-Project" statistical software. RESULTS: Minimally overlapping clusters of TEG results were observed for the three patient groups when coordinate pairs of maximum amplitude (MA) and TEG-activated clotting time (ACT) were plotted on orthogonal axes. Based on these groupings, a taxonomical classification tree was constructed using MA and TEG ACT. Branch points were set at an ACT of 103 s, and these branches subdivided for MA at 60.8 mm for the high ACT branch and 72.6 mm for the low ACT branch, providing a correct classification rate of 93.4%. CONCLUSIONS: ESRD and TIC demonstrate distinct TEG patterns. The coagulopathy of ESRD is typified by a prolonged enzymatic phase of clot formation, with normal-to-elevated final clot strength. Conversely, TIC is typified by prolonged clot formation and weakened clot strength. Our taxonomic categorization constitutes a rigorous system for the algorithmic interpretation of TEG based on cluster analysis. This will form the basis for clinical decision support software for viscoelastic hemostatic assays.