Rectal Cancer Survival for Residual Carcinoma In Situ Vs. Pathologic Complete Response After Neoadjuvant Therapy.

BACKGROUND: Pathologic complete response after neoadjuvant chemoradiotherapy for rectal cancer is associated with improved survival. It is unclear whether residual carcinoma in situ portends a similar outcome. OBJECTIVE: To compare survival of patients with locally advanced rectal cancer who received neoadjuvant therapy and achieved pathologic carcinoma in situ versus pathologic complete response. DESIGN: Retrospective cohort study. SETTING: National public database. PATIENTS: A total of 4,594 patients in the National Cancer Database from 2006 to 2016 with locally advanced rectal cancer who received neoadjuvant therapy, underwent surgery, and had node-negative, ypTis or ypT0 on final pathology were included. 4,321 (94.1%) had ypT0 and 273 (5.9%) had ypTis on final pathology. MAIN OUTCOME MEASURES: Overall survival. RESULTS: Median age was 60 years. 1,822 patients (39.7%) were female. 54.5% (n = 2,503) had stage II disease and 45.5% (n = 2,091) had stage III disease on initial staging. The ypTis group had decreased overall survival compared to the ypT0 group (HR 1.42, 95% CI 1.04-1.95, p = 0.028). Other factors associated with decreased overall survival were an older age at diagnosis, increasing Charlson-Deyo score, and poorly differentiated tumor grade. Variables associated with improved survival were female sex, private insurance, and receipt of both neoadjuvant and adjuvant chemotherapy. For the total cohort, there was no difference in survival between clinical stage 2 versus stage 3. LIMITATIONS: Standard therapy versus total neoadjuvant therapy were unable to be abstracted. Overall survival was defined as time from surgery to death from any cause or last contact, allowing for some erroneously misclassified deaths. CONCLUSIONS: ypTis is associated with worse overall survival than ypT0 for locally advanced rectal cancer patients who receive neoadjuvant chemoradiotherapy followed by surgery. For this cohort, clinical stage was not a significant predictor of survival. Prospective trials comparing survival for these pathologic outcomes are needed. See Video Abstract.

Bacteriophage therapy and current delivery strategies for orthopedic infections: A SCOPING review.

OBJECTIVES: Interest in phages as adjunctive therapy to treat difficult infections has grown in the last decade. However, phage dosing and delivery for orthopedic infections have not been systematically summarized. METHODS: Following PRISMA-ScR guidelines, we conducted a SCOPING review through September 1st, 2023, of MEDLINE, Embase, Web of Science Core Collection, and Cochrane Central. RESULTS: In total, 77 studies were included, of which 19 (24.7%) were in vitro studies, 17 (22.1%) were animal studies, and 41 (53.2%) were studies in humans. A total of 137 contemporary patients receiving phage therapy are described. CONCLUSIONS: Direct phage delivery remains the most studied form of phage therapy, notably in prosthetic joint infections, osteomyelitis, and diabetic foot ulcers. Available evidence describing phage therapy in humans suggests favorable outcomes for orthopedic infections, though this evidence is composed largely of low-level descriptive studies. Several phage delivery devices have been described, though a lack of comparative and in-human evidence limits their therapeutic application. Limitations to the use of phage therapy for orthopedic infections that need to be overcome include a lack of understanding related to optimal dosing and phage pharmacokinetics, bacterial heterogeneity in an infection episode, and phage therapy toxicity.

Assessing the Association Between Endoscopic Tattooing and Lymph Node Yield in Rectal Cancer.

INTRODUCTION: Preoperative endoscopic tattooing is an effective tool for intraoperative tumor localization in colon cancer. Endoscopic tattooing in rectal cancer may have unidentified benefits on lymph node yield, making it easier for pathologists to identify nodes during histopathologic assessment. There remains concern that tattoo ink may alter anatomical planes, increasing surgical difficulty. METHODS: Retrospective chart reviews from 2016 to 2021 of n = 170 patients presenting with rectal cancer were divided into two groups: with (n = 79) and without (n = 91) endoscopic tattoos. Demographics, operative details, tumor characteristics, prior chemoradiation, and pathologic details were collected. Primary outcome was total lymph node yield. Secondary outcomes were rates of adequate (> 12) nodes, margin status, and operative variables including operative time. RESULTS: No differences between pathologic stage, tumor height, high inferior mesenteric artery ligation, operative times, conversion rate, or surgical approach (open versus minimally invasive) were noted between groups. Receipt of neoadjuvant chemoradiation was less frequent in the endoscopic tattooing group (53.2% versus 76.9%, P ≤ 0.001). Total node number and rate of adequate lymph node yield were higher with endoscopic tattooing (20.5 ± 7.6 versus 16.8 ± 6.6 lymph nodes and 100.0% versus 83.5% adequate lymph node harvest, both P ≤ 0.001). Rates of positive circumferential and distal margins and complete total mesorectal excision were also similar. Regression analysis identified endoscopic tattooing (Incidence Risk Ratio 1.17, 95% confidence interval 1.04-1.31) and operative time more than 300 min (Incidence Risk Ratio 0.88, 95% confidence interval 0.77-0.99) had significant effects on lymph node harvest. Removal of patients with inadequate lymph node yield resulted in similar rates of total and positive lymph nodes. CONCLUSIONS: Endoscopic rectal tattooing is associated with increased lymph node yield (including after neoadjuvant chemoradiotherapy) without sacrificing oncologic or perioperative outcomes, although this effect is inconsistent when only considering patients with an adequate lymph node yield.

Optimizing Appropriate Disposal of Unused Postoperative Opioid: What Happens to Unused Medication?

BACKGROUND: Increase in opioid prescribing practices has occurred with concurrent increases in the levels of abuse, addiction, and diversion of opioid pain medication. With 82.5 opioid prescriptions prescribed for every 100 U.S. citizens, the need for more effective strategies aimed at improving opioid disposal exist. Our study sought to examine the planned rates of appropriate opioid disposal after introduction of an activated charcoal home drug disposal system (Deterra®) in combination with formalized opioid disposal education. METHODS: Participants were recruited from an academic, public safety-net hospital and grouped into 3 cohorts, no formalized opioid disposal education (No Education), written and verbal patient education on appropriate opioid disposal (Education), and Deterra® in addition to formalized opioid disposal education (Deterra). Outcomes included patients reporting unacceptable methods of opioid disposal, storage of unused opiates, and patient satisfaction with disposal instructions. RESULTS: Reported unacceptable opioid disposal decreased from 80.6% (n = 87) in the no education group to 20% (n = 10) in the education group to 6% (n = 3) in the Deterra group (P < .001). Education decreased long-term storage of opioid medication after completion of usage from 42% (n = 36) to 2% (n = 1), P < .001. Between the education and Deterra groups, more patients felt that the disposal instructions were clear (94% (n = 47) vs 73% (n = 36), P = .006) and more followed acceptable disposal instructions (80% (n = 39) vs 94% (n = 47) P < .001). CONCLUSION: Deterra® along with formal opioid disposal education increases patients reporting plans for compliance with appropriate opioid disposal.

Increased cost burden associated with robot-assisted rectopexy: do patient outcomes justify increased expenditure?

BACKGROUND: Robot-assisted surgical techniques have flourished over the years, with refinement in instrumentation and optics allowing for adaptation and increasing utilization across surgical fields. Transabdominal rectopexy with mesh for rectal prolapse may stand to benefit significantly from the use of a robotic platform. However, increased operative times and immediate associated costs of robotic surgery may provide a counterargument to widespread adoption. METHODS: To determine which approach to the treatment of rectal prolapse, laparoscopic or robotic, is more cost effective and provides better outcomes with fewer complications, a retrospective review was performed at a single tertiary care academic institution from May 2013 to December 2020. Twenty-two patients underwent transabdominal mesh rectopexy through a robot-assisted DaVinci platform (Intuitive Sunnyvale, CA), and thirty through a laparoscopic platform. Main outcome measures included operative, hospital, and total cost as defined by total charges billed. Secondary outcomes included rate of recurrence, intra-operative complications, median operative time, post-operative complications, average hospital length of stay, inpatient pain medication usage, and post-operative functional outcomes. RESULTS: Cost analysis for robot-assisted versus laparoscopic rectopexy demonstrated operating room costs of $46,118 ± $9329 for the robotic group, versus $33,090 ± $15,395 (p = 0.002) for the laparoscopic group. Inpatient hospital costs were $60,723 ± $20,170 vs. $40,798 ± $14,325 (p = 0.001), and total costs were $106,841 ± $25,513 vs. $73,888 ± $28,129 (p ≤ 0.001). When secondary outcomes were compared for the robotic versus laparoscopic groups, there were no differences in any of the aforementioned outcome variables except for operative time, which was 79 min longer in the robotic group (p ≤ 0.001). CONCLUSIONS: Robot-assisted mesh rectopexy demonstrated no clinical benefit over traditional laparoscopic mesh rectopexy, with significantly higher operative and hospital costs. A reduction in the acquisition and maintenance costs for robotic surgery is needed before large-scale adoption and implementation of the robotic platform for this procedure.

Prevalence of and Risk Factors for Incidental Colonic Diverticulosis.

INTRODUCTION: The true prevalence and pathogenesis of diverticulosis is poorly understood. Risk factors for diverticulosis are presently unclear, with most clinicians attributing its development to years of chronic constipation. Previous studies have been limited by their failure to include young, ethnically diverse patient populations. METHODS: Patients who presented to the emergency department of our hospital from January-September 2019 and underwent abdominal computerized tomography (CT) scan for the evaluation of appendicitis were included. CT's were reviewed for the presence of diverticulosis. Risk factors for diverticulosis were determined for two age groups: >40 and ≤ 40. RESULTS: A total of 359 patients were included in the study. The median age was 38.57.1% were male. 81.6% were Hispanic. 43.5% had colonic diverticulosis on CT. 198 patients (55.1%) were ≤ age 40. The rate of diverticulosis in this group was 35.3% (n = 70). Those with diverticulosis were not significantly older (median age 29 versus 27, P = 0.061) but had a higher median body mass index (BMI) (28.4 versus 25.3, P = 0.003) compared to those without diverticulosis. On multivariate analysis, no characteristics were associated with the presence of diverticulosis for this group. Over age 40, 53.4% of patients (n = 86) had diverticulosis. Patients with diverticulosis were more likely to be Hispanic (95.3% versus 73.3%, P ≤ 0.001), less likely to be Asian (2.4% versus 16.0%, P = 0.004), had a higher median BMI (28.7 versus 25.5, P ≤ 0.001), and were more likely to use alcohol (30.2% versus 14.7%, P = 0.024) than those without diverticulosis. On multivariate analysis, characteristics associated with the presence of diverticulosis were BMI >30 (odds ratio OR 2.22, 95% confidence interval CI 1.03-4.80), Hispanic ethnicity (OR 10.05, 95% CI 1.74-58.26), and alcohol use (OR 3.44, 95% CI 1.26-9.39). CONCLUSIONS: There was a higher rate of asymptomatic diverticulosis in the <40 cohort than previously reported in the literature. Obesity, alcohol use, and Hispanic ethnicity were associated with the presence of diverticulosis in patients > age 40, but no risk factors for diverticulosis were identified for patients ≤ age 40, suggesting that diverticular pathogenesis may differ by age. Constipation was not a risk factor for diverticulosis in either age group. The data regarding the prevalence of diverticulosis in Hispanic patients is lacking and should be the focus of future inquiry.

Endoscopy Reports for Rectosigmoid Tumors: Frequently Missing Key Information Needed for Surgical Planning.

INTRODUCTION: Endoscopy reports by gastroenterologists describing rectosigmoid tumors often are missing crucial data for surgical planning, leading to high rates of repeat exams before surgical decision-making. We hypothesize that there will be significant deficiencies in the endoscopic reporting of rectosigmoid lesions leading to high rates of repeat endoscopic examination at our institution. METHODS: Retrospective review from January 2016 to November 2019 included 188 patients with rectosigmoid lesions referred for surgery with an outside endoscopy report. Three criteria were abstracted from these reports or included pictures: (1) distance from the tumor to an anatomical landmark (anal verge, dentate line, sphincter), (2) Tattoo placement (if performed) and location, and (3) tumor relationship to the valves of Houston. Reports were classified exemplary, nearly adequate, or inadequate if 3, 2, and ≤ 1 of these criteria were met, respectively. RESULTS: Distance was reported in 38.8% (n = 73) of reports, with the anal verge being the most commonly reported anatomical landmark (32.4%, n = 61 reports). Tattoo was placed in 34.6% (n = 65), though only 21.8% (n = 41) described the location of the tattoo relative to the tumor. Relationship to the valves of Houston was seen in 29.2% (n = 55) of reports. Only 5.3% (n = 10) of outside endoscopy reports were graded as exemplary, 20.2% (n = 38) nearly adequate, and the remaining 74.5% (n = 140) inadequate. A total of 87.5% (n = 165) of patients required repeat endoscopy with a significantly higher proportion from the inadequate group. CONCLUSIONS: Many referring endoscopy reports contain inadequate information for the surgical planning of rectosigmoid tumor resection. Efforts to improve documentation (particularly about distance and location within the rectum) must be undertaken.

New Frontiers in Management of Early and Advanced Rectal Cancer.

It is important to understand advances in treatment options for rectal cancer. We attempt to highlight advances in rectal cancer treatment in the form of a systematic review. Early-stage rectal cancer focuses on minimally invasive endoluminal surgery, with importance placed on patient selection as the driving factor for improved outcomes. To achieve a complete pathologic response, various neoadjuvant chemoradiation regimens have been employed. Short-course radiation therapy, total neoadjuvant chemotherapy, and others provide unique advantages with select patient populations best suited for each. With a clinical complete response, a "watch and wait" non-operative surveillance has been introduced with preliminary equivalency to radical resection. Various modalities for total mesorectal excision, such as robotic or transanal, have advantages and can be utilized in select patient populations. Tumors demonstrating solid organ or peritoneal spread, traditionally defined as unresectable lesions conveying a terminal diagnosis, have recently undergone advances in hepatic and pulmonary metastasectomy. Hepatic and pulmonary metastasectomy has demonstrated clear advantages in 5-year survival over standard chemotherapy. With the peritoneal spread of colorectal cancer, HIPEC with cytoreductive therapy has emerged as the preferred treatment. Understanding the various therapeutic interventions will pave the way for improved patient outcomes.

"Unresectable" polyp management utilizing advanced endoscopic techniques results in high rate of colon preservation.

PURPOSE: "Endoscopically unresectable" benign polyps identified during screening colonoscopy are often referred for segmental colectomy. Application of advanced endoscopic techniques can increase endoscopic polyp resection, sparing patients the morbidity of colectomy. This retrospective case-control study aimed to evaluate the success of colon preserving resection of "endoscopically unresectable" benign polyps using advanced endoscopic techniques including endoscopic mucosal resection, endoscopic submucosal dissection, endoluminal surgical intervention, full-thickness laparo-endoscopic excision, and combined endo-laparoscopic resection. METHODS: A prospectively maintained institutional database identified 95 patients referred for "endoscopically unresectable" benign polyps from 2015 to 2018. Cases were compared to 190 propensity score matched controls from the same database undergoing elective laparoscopic colectomy for other reasons. Primary outcome was rate of complete endoscopic polyp removal. Secondary outcomes included length of stay, unplanned 30-day readmission and reoperation, 30-day mortality, and post-procedural complications. RESULTS: Advanced endoscopic techniques achieved complete polyp removal without colectomy in 66 patients (70%). Failure was most commonly associated with previously attempted endoscopic resection and occult malignancy. Compared with matched colectomy controls, endoscopic polyp resection resulted in significantly shorter hospital length of stay (1.13 ± 2.41 vs 3.89 ± 4.57 days; p < 0.001), lower unplanned 30-day readmission (1.1% vs 7.7%; p < 0.05), and fewer postoperative complications (4.2% vs 33.9%; p < 0.001). Unplanned 30-day reoperation (2.1% vs 4.4%; p = 0.34) and 30-day mortality (0% vs 0.6%; p = 0.75) trended lower. CONCLUSIONS: Endoscopic resection of complex polyps can be highly successful, and it is associated with favorable outcomes and decreased morbidity when compared with segmental colon resection. Attempting colon preservation using these techniques is warranted.

Full-Thickness Laparoendoscopic Excision for Management of Complex Colon Polyps.

BACKGROUND: Benign colon polyps are increasingly being detected because of improved colonoscopic screening and early detection of masses on the adenoma-to-carcinoma pathway. Full-thickness laparoendoscopic excision is a colon-preserving technique for endoscopically unresectable polyps consisting of endoscopically guided nonanatomic wedge colectomy. OBJECTIVE: This study aimed to evaluate the safety and success of full-thickness laparoendoscopic excision compared to segmental colectomy for complex polyps not amenable to endoscopic resection. DESIGN: This is a retrospective case-control study. SETTINGS: This study was conducted at a tertiary academic center. PATIENTS: A prospectively maintained institutional database identified 22 patients with benign complex polyps managed with full-thickness laparoendoscopic excision from 2015 to 2020. These patients were compared with 22 propensity score-matched controls from the same database that underwent laparoscopic segmental colectomy. MAIN OUTCOME MEASURES: Primary outcome was inpatient length of stay. Secondary outcomes included operative details and postoperative morbidities. RESULTS: Full-thickness laparoendoscopic excision was successful in all patients. Patients had a median age of 64 years (41-85), and 82% were men. Final pathology revealed complete excision of benign lesions in 20 of 22 patients and adenocarcinoma in 2 of 22. For the adenocarcinomas, 1 patient underwent subsequent elective colectomy without complications, and 1 patient declined surgery. Propensity score matching was successful for age, sex, BMI, ASA score, colon location, and prior abdominal surgery. Compared with controls, cases had significantly shorter operative time (89.5 minutes (46-290) vs 122 minutes (85-200), p = 0.009), length of stay (1 day (0-17) vs 3 days (1-8), p < 0.001), and reduced blood loss (5 mL (2-15) vs 25 mL (10-150), p < 0.001). Thirty-day morbidity (9.1% vs 27.3%, p = 0.240) was not significantly different. An unplanned 30-day reoperation was performed in 1 patient for suspected small-bowel obstruction. There was 1 mortality due to decompensated cirrhosis in the treatment group. LIMITATIONS: This study was limited by its single-institution retrospective design. CONCLUSIONS: Full-thickness laparoendoscopic excision is safe and successful compared with corresponding segmental colectomy for complex polyps. Favorable postoperative outcomes, including decreased operative time, length of stay, and blood loss, make it a useful approach for managing complex polyps throughout the colon.

Reduction of Opioid Overprescribing and Use Following Standardized Educational Intervention: A Survey of Patient Experiences Following Anorectal Procedures.

BACKGROUND: A pilot study conducted at our institution showed that a significant amount of prescribed postoperative opioids is left unused with the potential for diversion and misuse. OBJECTIVE: This study aimed to evaluate the impact of provider- and patient-targeted educational interventions on postoperative opioid prescription and use following anorectal procedures. DESIGN: Patients were enrolled on July 2019 through March 2020 after implementing educational interventions (study) and were compared with the pilot study group (control) enrolled on August 2018 through May 2019. A telephone survey was conducted 1 week postoperatively. SETTINGS: This study was conducted at a 600-bed, safety-net hospital in southern California. PATIENTS: Adult patients undergoing ambulatory anorectal procedures were included. Patients who had undergone an examination under anesthesia, had been incarcerated, and had used opioids preoperatively were excluded. INTERVENTIONS: Educational interventions were developed based on the pilot study results. Providers received education on recommended opioid prescription quantities and a multimodal pain regimen. Standardized patient education infographics were distributed to patients pre- and postoperatively. MAIN OUTCOME MEASURES: The primary outcomes measured were total opioid prescribed, total opioid consumed, pain control satisfaction levels, and the need for additional opioid prescription. RESULTS: A total of 104 of 122 (85%) patients enrolled responded to the survey and were compared with the 112 patients included in the control group. Despite similar demographics, the study cohort was prescribed fewer milligram morphine equivalents (78.8 ± 11.3 vs 294.0 ± 33.1, p < 0.001), consumed fewer milligram morphine equivalents (23.0 ± 28.0 vs 57.1 ± 45.8, p < 0.001), and had a higher rate of nonopioid medication use (72% vs 10%, p < 0.001). The 2 groups had similar pain control satisfaction levels (4.1 ± 1.3 vs 3.9 ± 1.1 out of 5, p = 0.12) and an additional opioid prescription requirement (5% vs 4%, p = 1.0). LIMITATIONS: This study was limited by its single-center experience with specific patient population characteristics. CONCLUSION: Educational interventions emphasizing evidence-based recommended opioid prescription quantities and regimented multimodal pain regimens are effective in decreasing excessive opioid prescribing and use without compromising satisfactory pain control in patients undergoing ambulatory anorectal procedures. See Video Abstract at http://links.lww.com/DCR/B529. REDUCCIN DE LA SOBREPRESCRIPCIN Y EL USO DE OPIOIDES DESPUS DE UNA INTERVENCIN EDUCATIVA ESTANDARIZADA UNA ENCUESTA DE LAS EXPERIENCIAS EN PACIENTES POSTOPERADOS DE PROCEDIMIENTOS ANORRECTALES: ANTECEDENTES:Un estudio piloto realizado en nuestra institución mostró que una cantidad significativa de opioides posoperatorios recetados no se usa, con potencial de desvío y uso indebido.OBJETIVO:Evaluar el impacto de las intervenciones educativas dirigidas al paciente y al proveedor sobre la prescripción y el uso de opioides posoperatorios después de procedimientos anorrectales.DISEÑO:Los pacientes se incluyeron entre julio de 2019 y marzo de 2020 después de implementar intervenciones educativas (estudio) y se compararon con el grupo de estudio piloto (control) inscrito entre agosto de 2018 y mayo de 2019. Se realizó una encuesta telefónica una semana después de la cirugía.ENTORNO CLÍNICO:Hospital de 600 camas en el sur de California.PACIENTES:Pacientes adultos sometidos a procedimientos anorrectales ambulatorios. Los criterios de exclusión fueron pacientes que recibieron un examen bajo anestesia, pacientes encarcelados y uso preoperatorio de opioides.INTERVENCIONES:Se desarrollaron intervenciones educativas basadas en los resultados del estudio piloto. Los proveedores recibieron educación sobre las cantidades recomendadas de opioides recetados y un régimen multimodal para el dolor. Se distribuyeron infografías estandarizadas de educación para el paciente antes y después de la operación.PRINCIPALES MEDIDAS DE RESULTADO:Opioide total prescrito, opioide total consumido, niveles de satisfacción del control del dolor y necesidad de prescripción adicional de opioides.RESULTADOS:Un total de 104 de 122 (85%) pacientes inscritos respondieron a la encuesta y se compararon con los 112 pacientes incluidos en el grupo de control. A pesar de una demografía similar, a la cohorte del estudio se le prescribió menos miligramos de equivalente de morfina (MME) (78,8 ± 11,3 frente a 294,0 ± 33,1, p <0,001), consumió menos MME (23,0 ± 28,0 frente a 57,1 ± 45,8, p <0,001) y presentaron una mayor tasa de uso de medicamentos no opioides (72% vs 10%, p <0,001). Los dos grupos tenían niveles similares de satisfacción del control del dolor (4,1 ± 1,3 frente a 3,9 ± 1,1 de 5, p = 0,12) y la necesidad de prescripción de opioides adicionales (5% frente a 4%, p = 1,0).LIMITACIONES:Experiencia en un solo centro con características específicas de la población de pacientes.CONCLUSIÓN:Las intervenciones educativas que enfatizan las cantidades recomendadas de prescripción de opioides basadas en la evidencia y los regímenes de dolor multimodales reglamentados son efectivas para disminuir la prescripción y el uso excesivos de opioides sin comprometer el control satisfactorio del dolor en pacientes sometidos a procedimientos anorrectales ambulatorios. Video Resumen en http://links.lww.com/DCR/B529.

LigaSure™ haemorrhoidectomy and the risk of postoperative bleeding.

AIM: LigaSure™ is an electro-surgical device that has increasingly been utilized in haemorrhoid surgery. However, recent literature has highlighted a possible increased risk of delayed postoperative bleeding following LigaSure haemorrhoidectomy (LH). We aim to evaluate the rates of postoperative bleeding following LigaSure compared to Ferguson (closed) haemorrhoidectomy (FH). METHODS: A retrospective cohort study was undertaken at our single academic safety-net county hospital from August 2016 through July 2019 evaluating patients who received FH or LH. Patient demographics, surgical data, postoperative emergency department visit for pain or bleeding within 30 days and resulting transfusion requirement, and rates of readmission and interventions within 30 days were collected. RESULTS: Sixty-one FH and 66 LH patients were identified. The groups had no difference in demographics. The LH group and FH group had similar rates of postoperative emergency department visits (29% vs. 23%, P = 0.454), as well as visits for bleeding (20% vs. 11%, P = 0.204). The average operating time was also significantly shorter with LH (14.5 min vs. 24.9 min, P ≤ 0.001). On multivariate analysis, male sex (OR 7.28, 95% CI 1.88-28.25) and haemorrhoid grade ≤2 (OR 4.64, 95% CI 1.31-16.49) were significantly associated with postoperative bleeding on multivariate analysis. Use of LH was not independently associated with postoperative bleeding risk (OR 1.89, 95% CI 0.70-5.11). CONCLUSIONS: LH and FH have similar risks for postoperative bleeding and other complications. Male sex and haemorrhoid Grades 1 or 2 may be associated with increased postoperative bleeding risk. Excisional haemorrhoidectomy should be undertaken with caution for male patients with lower internal haemorrhoid grades.

Prevalence of mesothelin expression in peritoneal disease from colorectal and appendiceal cancers.

BACKGROUND: Mesothelin is a cell surface glycoprotein overexpressed in 28%-58% of colorectal cancer (CRC). We hypothesized that CRC mesothelin expression contributes to peritoneal spread and that it is selectively overexpressed in those with peritoneal metastasis versus distant metastasis. METHODS: This case-controlled study involved mesothelin immunohistochemistry staining of tumor specimens from patients with metastatic CRC/appendiceal cancers between 2017 and 2019. Staining reactivity was graded from trace to 4+ (low ≤1+; high >1+). Staining patterns were characterized on global (focal/patchy/diffuse) and cellular (apical/cytoplasmic) levels. Immunostaining of normal mesothelial cells served as internal control. RESULTS: Thirty-one patients were identified: 11 peritoneal (study) and 20 distant metastasis (control). The control group did not include appendiceal cancers. The study group had greater proportion of high staining reactivity (55% vs. 5%; odds ratio [OR] = 20.4, 95% confidence interval [CI] 1.96-211.8). The study group had more diffuse (36% vs. 0%; OR = 22.2, 95% CI 1.1-465.3) and cytoplasmic staining patterns (73% vs. 28%; OR = 6.9, 95% CI 1.3-37.2). CONCLUSION: Mesothelin expression is higher in CRC/appendiceal cancers with peritoneal metastasis than those with distant metastasis. Immunohistochemistry staining patterns suggestive of propensity towards peritoneal metastasis include diffuse and cytoplasmic staining. Mesothelin may be a potential target for novel treatments of CRC/appendiceal carcinoma with peritoneal involvement.

Patient and Physician Attitudes Toward Telemedicine in Cancer Clinics Following the COVID-19 Pandemic.

PURPOSE: COVID-19 has infected more than 94 million people worldwide and caused more than 2 million deaths. Patients with cancer are at significantly increased risk compared with the general population. Telemedicine represents a common strategy to prevent viral spread. We sought to evaluate patient with cancer and physician perceptions of telemedicine during the COVID-19 pandemic. METHODS: A 16-question survey was e-mailed to 1,843 active e-mails of patients presenting to one of the six cancer clinics at a comprehensive cancer care center from January 1, 2020, to June 1, 2020. A six-question survey was e-mailed to attending physicians of those clinics. Specialties included Medical Oncology, Hematology-Oncology, Surgical Oncology, Urological Oncology, and Gynecologic Oncology. RESULTS: Three hundred seventy-four patients (20.3%) and 14 physicians (66.7%) responded. Most (68.2%) currently prefer in-person visits, and 80.4% prefer in-person visits following pandemic resolution. More than half (52.2%) of patients preferring virtual visits do so because of convenience. Most (63.1%) patients with cancer are comfortable with a complete physical examination. Surgical patients are more likely to prefer a complete examination (P = .0476). Physicians prefer in-person visits (64.2%) and believe that virtual visits maybe or probably do not provide comparable care (64.2%). 71.4% believe that virtual visits help prevent the spread of infectious disease. CONCLUSION: Given preferences for in-person visits, cancer care teams should be prepared to continue providing in-person visits for many of their patients. The discrepancy between patient and provider concern for spread of infectious disease represents an area where patients may benefit from increased education. Providers should feel comfortable performing physical examinations at their own discretion.

COVID-19 Impact on Colorectal Daily Practice-How Long Will It Take to Catch Up?

BACKGROUND: All elective surgeries have been postponed at our institution starting 3/16/20 due to the COVID-19 pandemic. We assessed changes in hospital resource utilization and estimated the future backlog of cases in the colorectal surgery division of a large safety-net hospital. METHODS: Patients undergoing colorectal procedures from 3/16/20 to 4/23/20 (COVID) were compared with those from January through June 2018 (historical). Resource utilization rates were calculated by weekly case volumes and hospital stay in each group. A future catch up timeframe and new wait times from scheduling to surgery dates were calculated. RESULTS: The COVID and historical groups included 13 and 239 patients, respectively. The COVID group showed a 74% relative decrease in weekly surgical case rates (9.2 to 2.4 patients per week). Both groups had similar lengths of stay. The COVID group had a longer average ICU stay (1.4 ± 2.5 days vs. 0.4 ± 1.2 days, P = 0.016) and a 132% increase in ICU resource utilization. Overall, the COVID group had a 48% relative decrease in hospital resource utilization, owing to reduced volume but higher acuity. If the surgery numbers returns to pre-COVID volumes, the calculated "catch up" times range from 4.6 weeks to 9.2 weeks. Wait times for new cases may increase by 70% compared with pre-COVID levels. CONCLUSION: Cancelling elective colorectal surgeries results in a decrease in overall but increase in ICU-specific resource utilization. Though necessary, cancellations result in an increasing backlog of cases that poses significant future logistical and clinical challenges in an already overburdened safety-net hospital. Effective triage systems will be critical to prioritize this backlog.

Successful treatment of a high-risk nonseminomatous germ cell tumor using etoposide, methotrexate, actinomycin D, cyclophosphamide, and vincristine: A case report.

BACKGROUND: Choriocarcinoma is an infrequent entity and the most aggressive subtype of germ-cell tumors. Because of early metastatic spread and rapid disease progression, choriocarcinoma patients display poor prognosis. Although etoposide, methotrexate, actinomycin D, cyclophosphamide, and vincristine (EMA-CO) regimen is widely used to treat gestational trophoblastic tumors in females, its role in treating male choriocarcinoma is seldom reported. CASE SUMMARY: A 32-year-old man was diagnosed with burned-out primary germ cell tumors (GCT) with retroperitoneum, liver and lung metastases. Biopsy of the liver revealed pure choriocarcinoma. The patient received bleomycin, etoposide, and cisplatin chemotherapy. After two cycles of treatment, response evaluation revealed the mixed response. EMA-CO regimen was used in the second-line therapy. After eight cycles, the patient showed a potentially resectable state and thus, all residual masses were surgically removed. The patient was completely cured, and 10 years later, he is leading a healthy life without complications. CONCLUSION: This paper is the first case of high-risk nonseminomatous GCT in a male patient to be successfully treated with the EMA-CO regimen. The EMA-CO regimen can be used actively in patients with high-risk nonseminomatous GCT.