Circumferential resection margin (CRM) is a key quality metric and predictor of oncologic outcomes and overall survival following surgery for rectal cancer. We aimed to develop a nomogram to identify ...patients at risk for a positive CRM in the preoperative setting.
We performed a retrospective evaluation of the National Cancer Database from 2010 to 2014 for patients with clinical stage I-III rectal cancer who underwent total mesorectal excision. Patients were excluded for emergency operation, resection for cancer recurrence, palliative resection, transanal resection, and missing CRM status. The primary outcome was positive CRM. Secondary outcomes included overall survival.
There were 28,790 patients included. 2245 (7.8%) had a positive CRM. Higher tumor grade, lack of neoadjuvant chemotherapy, mucinous/signet tumor histology, open approach, abdominoperineal resection, higher T stage, lymphovascular invasion, and perineural invasion were all significantly associated with positive CRM (P < 0.05) and were included in the nomogram. The C-statistic was 0.703, suggesting a good predictive model.
Positive CRM is associated with specific patient demographics and tumor characteristics. These factors can be used along with preoperative MRI to predict CRM positivity in the preoperative period and plan accordingly.
Resection of T4 colon cancer remains challenging compared to lower T stages. Data on the effect of neoadjuvant radiation to improve resectability and survival are lacking. The purpose of this study ...is to describe the use and outcomes of neoadjuvant radiation therapy in clinical T4 colon cancer.
Adults with clinical evidence of T4 locally advanced colon cancer were included from the National Cancer Database (2004–2014). Bivariate and multivariable analyses were used to examine the association between neoadjuvant radiation therapy and R0 resection rate, multivisceral resection, and overall survival.
Fifteen thousand two hundred and seven patients with clinical T4 disease who underwent resection were identified over the study period. One hundred ninety-five (1.3%) underwent neoadjuvant radiation therapy. Factors associated with the use of neoadjuvant radiation therapy included younger age, male sex, private insurance, lower Charlson Comorbidity Index score, and treatment at an academic research program. Neoadjuvant radiation therapy was associated with superior R0 resection rates (87.2% neoadjuvant radiation therapy vs 79.8% no neoadjuvant radiation therapy; P = .009). Five-year overall survival was increased in the neoadjuvant radiation therapy group (62.0% neoadjuvant radiation therapy vs 45.7% no neoadjuvant radiation therapy; P < .001). The benefit of neoadjuvant radiation therapy persisted in a Cox proportional hazards multivariable model containing a number of confounding variables, including comorbidity and postoperative chemotherapy (odds ratio 1.37; 95% confidence interval 1.05–1.77; P = .01). In a subgroup analysis of T4b patients, there was an even greater size effect in adjusted overall survival (odds ratio 1.71; 95% confidence interval 1.07–2.72; P = .02).
Although radiation is rarely used in locally advanced colon cancer, this National Cancer Database analysis suggests that the use of neoadjuvant radiation for clinical T4 disease may be associated with superior R0 resection rates and improved overall survival. Patients with clinical T4b disease may benefit the most from treatment. Neoadjuvant radiation therapy should be considered on a case-by-case basis in locally advanced colon cancer.
In randomized trial involving 171 adults with familial adenomatous polyposis, the incidence of disease progression was not significantly lower with combination therapy with eflornithine (an inhibitor ...of ornithine decarboxylase) and sulindac (an NSAID) than with either drug alone.
Racial discrepancies in treatment and outcomes of acute diverticulitis have been observed, yet underlying factors are poorly understood. We aimed to identify racial inequalities in health literacy ...among patients hospitalized with acute diverticulitis and characterize factors associated with more severe presentation.
We performed a retrospective cohort analysis of 947 Black or White patients admitted with acute diverticulitis at a quaternary referral center from January 2009 through September 2019. Health literacy was determined by the validated Brief Health Literacy Screening, and socioeconomic status was defined by the area deprivation index, a composite of multiple neighborhood socioeconomic deprivation measures. The primary outcome was severity of disease presentation represented by systemic inflammatory response syndrome criteria; secondary outcomes included intensive care unit admission, length of stay, and invasive interventions.
Among all study participants, 121 (12.8%) self-identified as Black. Overall, 140 (14.8%) patients had inadequate health literacy, and 495 (52.3%) had area deprivation index greater than the national median. There was no association between race or area deprivation index and health literacy. A total of 340 (35.9%) patients met criteria for systemic inflammatory response syndrome, and 88 (9.3%) underwent an intervention; median length of stay was 3.5 days. Race, health literacy, and area deprivation index were not significantly associated with outcomes (P > .05).
Among patients with acute diverticulitis, no difference in severity of presentation by race, health literacy, or area deprivation index was observed. These findings suggest that differences in presentation of acute diverticulitis may not be driven by these social factors. Future studies should include considerations of clinical characteristics of acute diverticulitis, such as the role of access and underuse of healthcare resources.
Anal intraepithelial neoplasia is a precursor to anal carcinoma. The use of anal pap cytology has been accepted as a screening method for anal carcinoma, however sensitivity and specificity vary.
...Retrospective cohort study involving 155 HIV-positive males with abnormal anal cytology and surgical resection.
155 patients met inclusion criteria. 31.6% were diagnosed with atypical cytology, 61.9% with low-grade cytology, and 6.4% with high-grade cytology. At surgery, 19.4% were diagnosed with condylomata, 34.8% with anal intraepithelial neoplasia 1, 17.4% with anal intraepithelial neoplasia 2, 27.1% with anal intraepithelial neoplasia 3 and 1.3% with anal carcinoma. There was a positive correlation between high-grade anal cytology and high-grade histology (r = 0.27; p = 0.0008). Comparison of risk factors showed no significant association.
Anal cytology has a significant correlation with surgical histology. There were still instances of high-grade lesions being found after low-grade cytology. This highlights the necessity of patients with low-grade cytology undergoing anoscopic evaluation.
•Anal cytology has a significant correlation with surgical histology.•No risk factors other than anal cytology predict more advanced surgical histology.•There were instances of high-grade lesions found after low-grade anal cytology.•Patients with low-grade anal cytology should be referred for anoscopic evaluation.
Background
Enthusiasm is high for expansion of robotic assisted surgery into right hemicolectomy. But data on outcomes and cost is lacking. Our objective was to determine the association between ...surgical approach and cost for minimally invasive right hemicolectomy. We hypothesized that a robot approach would have increased costs (both economic and opportunity) while achieving similar short-term outcomes.
Methods
We performed a retrospective cohort analysis with a simulation of operating room utilization at a quaternary care, academic institution. We enrolled patients undergoing minimally invasive right hemicolectomy from November 2017 to August 2019. Patients were categorized by the intended approach- laparoscopic or robotic. The primary outcome was the technical variable direct cost. Secondary outcomes included total cost, supply cost, operating room utilization, operative time, conversion, length of stay and 30-day post-operative outcomes.
Results
79 patients were included in the study. A robotic approach was used in 22% of the cohort. The groups differed significantly only in etiology of surgery. Robotic surgery was associated with a 1.5 times increase in the technical variable direct cost (
p
< 0.001), increased supply cost (2.6 times;
p
< 0.001) and increased total cost (1.3 times;
p
< 0.001). Significant differences were observed in median room time (Robotic: 285 min vs. Laparoscopic: 170 min;
p
< 0.001) and procedure time (Robotic: 203 min vs. Laparoscopic: 118 min;
p
< 0.001). There were no differences observed in post-operative outcomes including length of stay or readmission. In a simulation of OR utilization, 45 laparoscopic right hemicolectomies could be performed in an OR in a month compared to 31 robotic cases.
Conclusions
Robotic right hemicolectomy was associated with increased costs with no improvement in post-operative outcomes. In a simulation of operating room efficiency, a robotic approach was associated with 14 fewer cases per month. Practitioners and administrators should be aware of the increased cost of a robotic approach.
The opioid epidemic has resulted in close examination of postsurgical prescribing patterns. Little is known about postoperative opioid use in outpatient anorectal procedures. This study evaluated ...patient opioid use and created prescribing recommendations for these procedures.
One hundred and four patients undergoing outpatient anorectal procedures from January to May 2018 were surveyed on opioid consumption, surgical experience, and pain satisfaction. Patients were grouped into three tiers based on opioid usage. Multivariable models were used to determine factors associated with poor pain control.
Patient satisfaction with pain control was 85.6%. Twenty five percent of patients reported leftover medication and 9.6% of patients requested opioid refills. Opioid prescribing recommendations were generated for each tier using 50th percentile with interquartile ranges. On multivariable modeling, the high-tier group was associated with poorer pain control.
We created opioid quantity prescribing guidelines for common outpatient anorectal procedures. A multimodal approach to pain control utilizing nonopioids may reduce healthcare utilization.
Background
Margin negative resection of rectal cancer with minimally invasive techniques remains technically challenging. Robotic surgery has potential advantages over traditional laparoscopy. We ...hypothesize that the difference in the rate of negative margin status will be < 6% between laparoscopic and robotic approach.
Methods
The National Cancer Database (2010–2014) was queried for adults with locally advanced rectal cancer who underwent neoadjuvant chemoradiation and curative resection to conduct an observational retrospective cohort study of a prospectively maintained database. Patients were grouped by either robotic (ROB) or laparoscopic (LAP) approach in an intent-to-treat analysis. Primary outcome was negative margin status, defined as a composite of circumferential resection margin and distal margin. Secondary outcomes included length of stay (LOS), readmission, 90-day mortality, and overall survival.
Results
7616 patients with locally advanced rectal cancer who underwent minimally invasive resection were identified. 2472 (32%) underwent attempted robotic approach. The overall conversion rate was 13% and was increased in the laparoscopic group LAP: 15% vs. ROB: 8%; OR 0.47; 95% CI (0.39, 0.57). Differences in margin negative resection rate were within the prespecified range of practical equivalence (LAP: 93% vs.: ROB 94%; 95% CI (0.69, 1.06);
p
δ
= 1). For secondary outcomes, there was no difference in 30-day readmission LAP: 9% vs.: ROB 8%; 95% CI (0.84, 1.24) and 90-day mortality LAP: 1% vs.: ROB 1%; 95% CI (0.38, 1.24). While the median LOS was 5 days in both groups, the mean LOS was 0.6 (95% CI: 0.24, 0.89) days shorter in the robotic group.
Conclusion
This robust analysis supports either robotic or laparoscopic approach for resection of locally advanced rectal cancer from a margin perspective. Both have similar readmission and 5-year overall survival rates. Patients undergoing robotic surgery have a 0.6-day decrease in LOS and decreased conversion rate.
Perforation during colonoscopy is a rare but well recognized complication with significant morbidity and mortality. We aim to systematically review the currently available literature concerning care ...and outcomes of colonic perforation. An algorithm is created to guide the practitioner in management of this challenging clinical scenario.
A systematic review of the literature based on PRISMA-P guidelines was performed. We evaluate 31 articles focusing on findings over the past 10 years.
Colonoscopic perforation is a rare event and published management techniques are marked by their heterogeneity. Reliable conclusions are limited by the nature of the data available – mainly single institution, retrospective studies. Consensus conclusions include a higher rate of perforation from therapeutic colonoscopy when compared to diagnostic colonoscopy and the sigmoid as the most common site of perforation. Mortality appears driven by pre-existing conditions. Treatment must be tailored according to the patient's comorbidities and clinical status as well as the specific conditions during the colonoscopy that led to the perforation.
•Colonoscopic perforation is a rare event and published management techniques are marked by their heterogeneity.•Reliable conclusions are limited by the nature of the data available – single institution, retrospective studies.•Consensus conclusions include a higher rate of perforation from therapeutic colonoscopy and the sigmoid as the most common site of perforation.•Mortality appears driven by pre-existing conditions.•Treatment must be tailored according to patient's comorbidities and clinical status.
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