Background: We sought to identify hospital factors that are associated with utilization of minimally invasive surgery (MIS) for rectal cancer. Methods: This was a population-based study of ...individuals with rectal cancer who underwent low anterior resection or abdominal perineal resection between 2010 and 2019 in Ontario. Site of surgery, diagnosis and surgical procedure were identified using physician billing data, with MIS identified through surgical premium codes. The following factors were assessed for an association with utilization of MIS: geographic region, annual hospital volume, city size, cancer centre level, presence of fellowship and/or general surgery program, and presence/absence of a competing hospital within 20 km. Comparison of mean MIS rates was done using analysis of variance. Results: A total of 10 959 individuals with rectal cancer undergoing surgical resection were identified. Of these, complete surgical data were available in 7990, with 45% undergoing MIS. A total of 88 hospitals were identified. There was significant variation in MIS utilization among the 14 geographic regions (range 20%-81%, p < 0.01). There was no correlation between hospital volume and MIS rate (p = 0.47). Increasing city size was associated with the use of MIS (< 2 5K 34%, 25K-100K 33%, 100K-500K 50%, > 500K 57%, p = 0.04) as was the presence of a competing hospital within 20 km (58% v. 32%, p < 0.01). Neither the presence of a cancer centre (p = 0.17) or training program (p = 0.71) was associated with MIS. Conclusion: There is substantial regional variation in MIS utilization. Increasing hospital volume did not correlate with higher utilization rates, though larger city sizes did. Future inquiry is required to explore how these centres differ and how this relates to patient outcomes.
Objective
To evaluate and describe attitudes, quality of life (Qol), needs and preferences of patients with head and neck cancer after 3 years of follow‐up care.
Methods
This is an exploratory ...prospective study of recurrence‐free patients. Survey results were compared between 1‐, 2‐ and 3‐year post‐treatment and by disease characteristics.
Results
A total of 116 patients were included with 46% oropharyngeal cancer, 66% early stage disease and 41% having had surgery. After 3 years, most patients reported good to excellent health (88%), however expressed uncertainty regarding recurrence (66%), multiple needs (information on prognosis 91%, long‐term sequalae 72%) and wanted to continue with follow‐up (96%). Few changes were observed over time, with exceptions. Patients with more advanced disease, oral cancer or who had surgery experienced declining Qol (p < 0.050). Women experienced improvements in Qol domains (pain p = 0.028, speech p = 0.009) over time. Attitudes towards communication with oncologists demonstrated improved patient comfort (p = 0.044) over the 3 years; however, patients' beliefs about their prognosis did not (71% vs. 73% vs. 77% did not believe they were cured, p = 0.581).
Conclusion
Although patients' needs, preferences and attitudes towards follow‐up did not change drastically, important needs persist. This work supports identifying individual patient needs and the challenges in addressing prognostic expectations.
A finite element-based approach was created to generate fiber scale permeability and thermal conductivity tensors for unidirectional fiber-reinforced composites. This model used fiber radius, volume ...fraction, and symmetry angle in addition to an assigned temperature and pressure gradient as inputs. Results and comparisons are presented for both Newtonian and non-Newtonian fluids. Permeability and conductivity values generated by the model agreed strongly with experimental and numerical data obtained by other research. The model was also able to capture the dependence of these tensors on fiber structure and fluid properties. This was accomplished within the confines of a small computational domain.
Resection of lung metastases is considered standard treatment for patients with metastatic colorectal cancer. We describe surgical management, prognostic factors, and outcomes in routine clinical ...practice.
All cases of colorectal cancer lung metastases in Ontario, Canada, resected during 2002 to 2009 were identified using the Ontario Cancer Registry and linked electronic records. Pathology reports were reviewed to identify extent of disease.
The study population included 420 patients (60% male). Median age was 64 years. A solitary metastasis was present in 61% (256 of 420). Mean size of the largest metastasis was 2.4 cm. Lymph nodes were resected in 63% (263 of 420) of patients. The 5-year cancer-specific survival (CSS) and overall survival (OS) was 42% (95% confidence interval CI, 37% to 47%) and 40% (95% CI, 35% to 45%), respectively. On adjusted analyses, greater number (p < 0.001) and size (p = 0.001) of lesions and lymph node involvement (p < 0.001) were associated with inferior CSS and OS. Lymph node positivity was strongly associated with survival (adjusted CSS hazard ratio, 2.19 95% CI, 1.48 to 3.25; adjusted OS hazard ratio, 2.08 95% CI, 1.41 to 3.07). Unadjusted 5-year CSS/OS was 49%/47% for node-negative disease and 19%/19% for node-positive disease. The negative prognostic effect of size (>2 cm) and number (>1) of lesions was additive: 5-year CSS/OS ranged from 57%/55% (single lesion <2 cm) to 24%/20% (multiple lesions, largest lesion>2 cm).
Long-term survival of patients with resected colorectal cancer lung metastases in routine practice is comparable to outcomes reported in institutional case series. Lymph node positivity is strongly associated with reduced survival. Combining size and number of metastatic lesions in advance of the operation may facilitate treatment decision making.
•What is currently known about this topic?Patients with organic chronic constipation and fecal incontinence (CCFI) have improved Quality of Life (QoL) following appendicostomy or cecostomy creation ...and antegrade colonic enema (ACE) therapy.•What new information is contained in this article?Patients with functional CCFI have improved QoL following cecostomy creation and ACE therapy, and the QoL improvements are comparable to patients with refractory CCFI due to an organic cause.
We compared patient- and family-reported overall and stool-related quality of life (QoL) before and after an antegrade continence enema (ACE) procedure (cecostomy tube insertion) for refractory chronic constipation or fecal incontinence (CCFI). We hypothesized that patients with functional diagnoses experience similar improvements in QoL compared to those with organic diagnoses.
This is a cross-sectional study of patients undergoing cecostomy tube insertion for CCFI at a tertiary pediatric hospital from 2012 to 2019. Patients and/or primary caregivers completed validated stooling and overall QoL surveys based on three time points: before surgery, three months after surgery, and at the time of survey / date of last follow-up. Repeated measures analyses compared scores over time between subjects and within the diagnostic groups.
The response rate was 65% (22/34 patients, 12 organic and 10 functional diagnoses). Mean age was 8.3 years and 32% of the participants were female. Organic diagnoses were: spina bifida (6), anorectal malformation (5), and Hirschsprung Disease (1). There was substantial improvement in stool-related and overall QoL at three months post-ACE procedure (both p<0.001) for all patients; both scores continued to improve significantly until the date of last follow-up (median 4.1 years, IQR 2.3–5.6, p<0.001). There was no statistically significant difference in scores between patients with organic and functional diagnoses.
Caregivers perceive a significant, sustainable improvement in stooling habits and QoL following ACE therapy. The improvement is comparable between patients with a functional diagnosis and those with an underlying organic reason for their CCFI.
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Preeclampsia is uncommon prior to 24 weeks gestation and has been associated with partial and complete hydatidiform moles. We present an unusual case in which a patient was diagnosed with ...preeclampsia at 17 weeks gestation. Ultrasound findings were consistent with a partial hydatidiform mole. Within 24 hours of the onset of symptoms, the patient developed severe hemolysis, elevated liver enzymes, and low platelet count syndrome, with a platelet count of 20 x 10 (9) cells/L. Termination of pregnancy was performed with rapid resolution of signs, symptoms, and laboratory abnormalities. Triploid 69,XXY was confirmed at karyotype analysis. This case demonstrates the acuteness in which life-threatening maternal conditions can arise with this uncommon complication of pregnancy, and the importance of correct identification of the characteristic ultrasonographic findings associated with a partial hydatidiform mole.
Background: Individuals with locally advanced rectal cancer require multimodality treatment, including radiation, chemotherapy and surgery. Lack of recommended and timely treatment may lead to worse ...outcomes. We sought to determine the association between receipt of recommended and timely treatment and survival. Methods: This population-based study included individuals with stage 2 and 3 rectal cancer in Ontario, Canada, between 2010 and 2019. Patients were identified using the provincial cancer registry. Using linked administrative databases, we captured patient, provider and treatment details. Provincial guidelines were used to determine the receipt of recommended and timely treatment, including 1) initiating radiation within 28 days of completion of staging, 2) receiving surgery within 12 weeks of radiation completion, and 3) receiving adjuvant chemotherapy within 16 weeks of surgery completion. Multivariable logistic regression was conducted to assess for factors associated with receipt of recommended and timely care. Cox proportional hazard models were used to explore associations between receipt of such care and survival. Results: A total of 6688 individuals were identified (37% females, mean age of 65 ± 13 years); 2626 (38%) received recommended treatment, while 1356 (20%) received recommended and timely treatment. The following factors were found to be associated with recommended and timely treatment on adjusted analyses: younger age group, treatment at a regional cancer centre, increasing surgeon volume and few comorbidities (p < 0.05). After adjusting for age, sex, comorbidities, socioeconomic status, surgeon volume, and hospital type, we found inferior survival in those who did not receive recommended and timely treatment (hazard ratio 1.54, 95% confidence interval 1.26-1.87). Conclusion: Receipt of timely and recommended care is associated with improved survival. We identified that care provided by highvolume surgeons and at regional cancer centres was associated with increased odds of receipt of timely, recommended treatment.
Background: Patients with cirrhosis have significant postoperative risks following major abdominal surgery. Historic literature and prediction tools do not reflect current practices, experiences and ...outcomes. We sought to describe postoperative outcomes in patients with cirrhosis after elective colorectal surgery. Methods: This retrospective cohort study included individuals in Ontario (population 14 million) with a diagnosis of cirrhosis. Individuals who underwent elective major colorectal surgery between 2009 and 2017 were included. Baseline characteristics, cirrhosis-specific characteristics, and outcomes were identified using linked administrative databases. Univariable and multivariable analysis was completed. Results: During the study period, 1439 patients were identified (41% female, mean age 65 yr). The Model for End-Stage Liver Disease-Na (MELDNa) score was available in 42% of individuals, with a median of 8 (interquartile range 7-11). The most common cirrhosis etiologies were nonalcoholic fatty liver disease (58%) and alcoholrelated (24%). Indications for surgery included colorectal cancer (70%), followed by diverticulitis (11%) and inflammatory bowel disease (10%). The 3 most common procedures performed were colon resection with primary anastomosis (66%), rectal resection with primary anastomosis (17%), and abdominal perineal resection (6%). The 90-day mortality was 7%. The average total length of hospital stay was 11 days. Assessed 90-day complications included readmission to hospital after discharge (23%), emergency department visit (37%), unplanned intensive care unit admission (6%) and hepatic decompensation (6%). Ninety-day mortality based on MELD-Na score included 5% in those with a score < 9; 15% in those with a score of 10-19; and 36% with a score > 20. Conclusion: This work confirms that the surgical risks are lower than once believed in patients with cirrhosis undergoing colorectal surgery in the elective setting. This evidence will guide management of patients in this high-risk group.
Background: Individuals with cirrhosis who develop colorectal cancer (CRC) are an understudied group, and there is a suspicion that this group has high treatment-related complications and poor ...survival. The objective of this study was to assess practice patterns and outcomes of those with cirrhosis and colorectal cancer treated within a universal health care system. Methods: This is a retrospective population-based cohort study of individuals with cirrhosis who underwent surgery for CRC between 2009 and 2017 in Ontario, Canada (population 14.6 million), using linked administrative databases. Patients with cirrhosis and CRC were identified using previously validated algorithms. Descriptive statistics were used to describe baseline characteristics, type of surgical procedure, usage of pre- and postoperative chemotherapy/radiation therapy, postsurgical hepatic decompensation, short-term complications and overall survival. Results: A total of 842 individuals were identified (83% colon cancer, 17% rectal cancer). The most common cirrhosis etiologies were nonalcoholic fatty liver disease (52%) and alcohol-associated (29%). The median Model for Endstage Liver Disease (MELD-Na) score was 9 (interquartile range 7-11). Overall 90-day mortality was 12% (6.8% in those with MELD < 10 and 22% in those with MELD > 10). Ninety-day readmission (27%) and emergency department visits (40%) were common, while 90-day hepatic decompensation was less so (9%). In those with locally advanced rectal cancer (stage II/III), 62% (n = 55 of 89) received neoadjuvant radiation and 38% (n = 34 of 89) received adjuvant chemotherapy. In those with stage III colon cancer, 43% received adjuvant chemotherapy (n = 90 of 213). Five-year overall survival was 52% for colon cancer and 56% for rectal cancer. Stage-specific 5-year survival was as follows: stage I 66%, stage II 55%, stage III 50%, stage IV 11%. Conclusion: This population-based study reported practice patterns and short/long-term outcomes of those with cirrhosis and CRC. Complications were common, and survival was poor.
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