Diverticulitis is a prevalent gastrointestinal disorder that is associated with significant morbidity and health care costs. Approximately 20% of patients with incident diverticulitis have at least 1 ...recurrence. Complications of diverticulitis, such as abdominal sepsis, are less likely to occur with subsequent events. Several risk factors, many of which are modifiable, have been identified including obesity, diet, and physical inactivity. Diet and lifestyle factors could affect risk of diverticulitis through their effects on the intestinal microbiome and inflammation. Preliminary studies have found that the composition and function of the gut microbiome differ between individuals with vs without diverticulitis. Genetic factors, as well as alterations in colonic neuromusculature, can also contribute to the development of diverticulitis. Less-aggressive and more-nuanced treatment strategies have been developed. Two multicenter, randomized trials of patients with uncomplicated diverticulitis found that antibiotics did not speed recovery or prevent subsequent complications. Elective surgical resection is no longer recommended solely based on number of recurrent events or young patient age and might not be necessary for some patients with diverticulitis complicated by abscess. Randomized trials of hemodynamically stable patients who require urgent surgery for acute, complicated diverticulitis that has not improved with antibiotics provide evidence to support primary anastomosis vs sigmoid colectomy with end colostomy. Despite these advances, more research is needed to increase our understanding of the pathogenesis of diverticulitis and to clarify treatment algorithms.
To develop recommendations for adjuvant therapy for patients with resected stage II colon cancer.
ASCO convened an Expert Panel to conduct a systematic review of relevant studies and develop ...recommendations for clinical practice.
Twenty-one observational studies and six randomized controlled trials met the systematic review inclusion criteria.
Adjuvant chemotherapy (ACT) is not routinely recommended for patients with stage II colon cancer who are not in a high-risk subgroup. Patients with T4 tumors are at higher risk of recurrence and should be offered ACT, whereas patients with other high-risk factors, including sampling of fewer than 12 lymph nodes in the surgical specimen, perineural or lymphovascular invasion, poorly or undifferentiated tumor grade, intestinal obstruction, tumor perforation, or grade BD3 tumor budding, may be offered ACT. The addition of oxaliplatin to fluoropyrimidine-based ACT is not routinely recommended, but may be offered as a result of shared decision making. Patients with mismatch repair deficiency/microsatellite instability tumors should not be routinely offered ACT; if the combination of mismatch repair deficiency/microsatellite instability and high-risk factors results in a decision to offer ACT, oxaliplatin-containing chemotherapy is recommended. Duration of oxaliplatin-containing chemotherapy is also addressed, with recommendations for 3 or 6 months of treatment with capecitabine and oxaliplatin or fluorouracil, leucovorin, and oxaliplatin, with decision making informed by key evidence of 5-year disease-free survival in each treatment subgroup and the rate of adverse events, including peripheral neuropathy.Additional information is available at www.asco.org/gastrointestinal-cancer-guidelines.
Highlights • Cultural barriers can reduce patient engagement in decision-making. • There is a need for more culturally appropriate shared decision-making resources. • This paper describes several ...strategies for interventions aimed at enhancing patient engagement across different cultural groups.
The COVID-19 pandemic has affected every aspect of medical care, including surgical treatment. It is critical to understand the association of government policies and infection burden with surgical ...access across the United States.
To describe the change in surgical procedure volume in the US after the government-suggested shutdown and subsequent peak surge in volume of patients with COVID-19.
This retrospective cohort study was conducted using administrative claims from a nationwide health care technology clearinghouse. Claims from pediatric and adult patients undergoing surgical procedures in 49 US states within the Change Healthcare network of health care institutions were used. Surgical procedure volume during the 2020 initial COVID-19-related shutdown and subsequent fall and winter infection surge were compared with volume in 2019. Data were analyzed from November 2020 through July 2021.
2020 policies to curtail elective surgical procedures and the incidence rate of patients with COVID-19.
Incidence rate ratios (IRRs) were estimated from a Poisson regression comparing total procedure counts during the initial shutdown (March 15 to May 2, 2020) and subsequent COVID-19 surge (October 22, 2020-January 31, 2021) with corresponding 2019 dates. Surgical procedures were analyzed by 11 major procedure categories, 25 subcategories, and 12 exemplar operative procedures along a spectrum of elective to emergency indications.
A total of 13 108 567 surgical procedures were identified from January 1, 2019, through January 30, 2021, based on 3498 Current Procedural Terminology (CPT) codes. This included 6 651 921 procedures in 2019 (3 516 569 procedures among women 52.9%; 613 192 procedures among children 9.2%; and 1 987 397 procedures among patients aged ≥65 years 29.9%) and 5 973 573 procedures in 2020 (3 156 240 procedures among women 52.8%; 482 637 procedures among children 8.1%; and 1 806 074 procedures among patients aged ≥65 years 30.2%). The total number of procedures during the initial shutdown period and its corresponding period in 2019 (ie, epidemiological weeks 12-18) decreased from 905 444 procedures in 2019 to 458 469 procedures in 2020, for an IRR of 0.52 (95% CI, 0.44 to 0.60; P < .001) with a decrease of 48.0%. There was a decrease in surgical procedure volume across all major categories compared with corresponding weeks in 2019. During the initial shutdown, otolaryngology (ENT) procedures (IRR, 0.30; 95% CI, 0.13 to 0.46; P < .001) and cataract procedures (IRR, 0.11; 95% CI, -0.11 to 0.32; P = .03) decreased the most among major categories. Organ transplants and cesarean deliveries did not differ from the 2019 baseline. After the initial shutdown, during the ensuing COVID-19 surge, surgical procedure volumes rebounded to 2019 levels (IRR, 0.97; 95% CI, 0.95 to 1.00; P = .10) except for ENT procedures (IRR, 0.70; 95% CI, 0.65 to 0.75; P < .001). There was a correlation between state volumes of patients with COVID-19 and surgical procedure volume during the initial shutdown (r = -0.00025; 95% CI, -0.0042 to -0.0009; P = .003), but there was no correlation during the COVID-19 surge (r = -0.00034; 95% CI, -0.0075 to 0.00007; P = .11).
This study found that the initial shutdown period in March through April 2020, was associated with a decrease in surgical procedure volume to nearly half of baseline rates. After the reopening, the rate of surgical procedures rebounded to 2019 levels, and this trend was maintained throughout the peak burden of patients with COVID-19 in fall and winter; these findings suggest that after initial adaptation, health systems appeared to be able to self-regulate and function at prepandemic capacity.
Diverticulitis of the sigmoid colon is an increasingly common disease. Patterns of care and management guidelines have significantly evolved in recent years.
To review and classify the primary data ...published since 2000 that are guiding decision making, technical considerations, and the outcomes of surgery for sigmoid diverticulitis.
We searched the National Guideline Clearinghouse, PubMed, and Cochrane databases for studies pertaining to the diagnosis and management of chronic and recurrent diverticulitis from January 1, 2000, to March 31, 2013. We supplemented this automated search with references drawn from included studies and PubMed. We rated the level of evidence according to American College of Cardiology/American Heart Association guidelines.
We identified 68 studies meeting inclusion criteria for final review. The studies were almost exclusively observational and had limited certainty of treatment effect. We found that complicated recurrence after recovery from an uncomplicated episode of diverticulitis is rare (<5%) and that age at onset younger than 50 years and 2 or more recurrences do not increase the risk of complications. Chronic symptoms may persist even after resection in 5% to 22% of patients. Prophylactic surgery is generally not recommended for average-risk patients with diverticulitis, irrespective of the number of episodes of acute, noncomplicated disease. Decisions to proceed with colon resection should be based instead on the patient-reported frequency and severity of diverticulitis symptoms.
The prior standard for proceeding with elective colectomy following 2 episodes of diverticulitis is no longer accepted. Decisions to proceed with colectomy should be made based on consideration of the risks of recurrent diverticulitis, the morbidity of surgery, ongoing symptoms, the complexity of disease, and operative risk. Laparoscopic surgery is preferred to open approaches. Recent evidence suggests that existing guidelines should be updated.
Palliative care has the potential to improve care for patients and families undergoing high-risk surgery.
To characterize the use of perioperative palliative care and its association with ...family-reported end-of-life experiences of patients who died within 90 days of a high-risk surgical operation.
This secondary analysis of administrative data from a retrospective cross-sectional patient cohort was conducted in the Department of Veterans Affairs (VA) Healthcare System. Patients who underwent any of 227 high-risk operations between January 1, 2012, and December 31, 2015, were included.
Palliative-care consultation within 30 days before or 90 days after surgery.
The outcomes were family-reported ratings of overall care, communication, and support in the patient's last month of life. The VA surveyed all families of inpatient decedents using the Bereaved Family Survey, a valid and reliable tool that measures patient and family-centered end-of-life outcomes.
A total of 95 204 patients underwent high-risk operations in 129 inpatient VA Medical Centers. Most patients were 65 years or older (69 278 72.8%), and the most common procedures were cardiothoracic (31 157 32.7%) or vascular (23 517 24.7%). The 90-day mortality rate was 6.0% (5740 patients) and varied by surgical subspecialty (ranging from 278 of 7226 3.8% in urologic surgery to 875 of 6223 patients 14.1% in neurosurgery). A multivariate mixed model revealed that families of decedents who received palliative care were 47% more likely to rate overall care in the last month of life as excellent than those who did not (odds ratio OR, 1.47 95% CI, 1.14-1.88; P = .007), after adjusting for patient's characteristics, surgical subspecialty of the high-risk operation, and survey nonresponse. Similarly, families of decedents who received palliative care were more likely to rate end-of-life communication (OR, 1.43 95% CI, 1.09-1.87; P = .004) and support (OR, 1.31 95% CI, 1.01-1.71; P = .05) components of medical care as excellent. Of the entire cohort, 3374 patients (3.75%) had a palliative care consultation, and 770 patients (0.8%) received it before surgery. Of all decedents, 1632 (29.9%) had a palliative care consultation, with 319 (5.6%) receiving it before surgery.
Receipt of a palliative consultation was associated with better ratings of overall end-of-life care, communication, and support, as reported by families of patients who died within 90 days of high-risk surgery. Yet only one-third of decedents was exposed to palliative care. Expanding integration of perioperative palliative care may benefit patients undergoing high-risk operations and their families.
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