Colon and Rectal

BOSTON – The day of the week a patient is discharged from the hospital may have an impact the likelihood of readmission.

Patients discharged home from the hospital on a Thursday after colorectal cancer surgery are more likely to be readmitted within 30 days than those discharged on any other day of the week, investigators found.

Neil Osterweil/Frontline Medical News

In contrast, there were no significant day-dependent differences in readmission rates among patients discharged to a skilled nursing facility or acute rehabilitation program, although patients admitted to clinical facilities had higher overall readmission rates, reported Anna Gustin and coinvestigators at the Levine Cancer Institute at the Carolinas Medical Center in Charlotte, N.C.

“For a patient discharged on a Thursday, if you’re going to get an infection, it’s going to be probably during the weekend, when it’s difficult to contact your primary physician, and when other resources are not as readily available,” said Ms. Gustin, who conducts epidemiologic research at Levine Cancer Center and is also a pre-med student and Japanese major at Wake Forest University in Winston-Salem, N.C.

In a study presented in a poster session at the annual Society of Surgical Oncology Cancer Symposium, Ms. Gustin and her coauthors looked at factors influencing readmission rates among patients undergoing surgery for primary, nonmetastatic colorectal cancer resections.

They drew on the to evaluate outcomes for 93,04 SEER-(Surveillance, Epidemiology, and End Results) Medicare database seven patients aged 66 years and older treated for primary colorectal cancer from 1998 through 2009.

They looked at potential contributing factors such as patient demographics, socioeconomic status, length of stay, days of admission and discharge, and discharge setting (home or clinical facility).

They use multivariate logistic regression models to analyze readmission rates at 14 and 30 days after initial discharge.

Focusing on home discharges, they found that as the week progressed, there was a significant likelihood that a patient discharged home would be readmitted (P less then .001 by chi-square and Cochran-Armitage tests). As noted before, the highest rate of readmission was for patients discharged on Thursday, at 12.4%, compared with 10.1% for patients discharged on Sunday, the discharge day least likely to be associated with rehospitalization.

In multivariate analysis, factors significantly associated with risk for 30-day readmission included male vs. female (hazard ratio, 1.16), black vs. other race (HR, 1.22), length of stay 5, 6-7, or 8-10 vs. 12 or more days (HR, 0.48, 0.59, 0.77, respectively), Charlson comorbidity index score 0, 1 or 3 vs. 3 (HR, 0.59, 0.73, 0.82, respectively), and home discharge vs. other (HR, 0.66; all above comparisons significant as shown by 95% confidence intervals).

The authors concluded that although home discharge itself reduces the likelihood of readmission, “improvements in preparing patients for discharge to home are needed. Additional outpatient interventions could rescue patients from readmission.”

They also suggested reexamining staffing policies and weekend availability of resources for patients, and call for addressing disparities in readmissions based on race, sex, length of stay, and comorbidities.

The study was internally supported. The authors reported having no relevant disclosures.

BOSTON – The day of the week a patient is discharged from the hospital may have an impact the likelihood of readmission.

Patients discharged home from the hospital on a Thursday after colorectal cancer surgery are more likely to be readmitted within 30 days than those discharged on any other day of the week, investigators found.

Neil Osterweil/Frontline Medical News

In contrast, there were no significant day-dependent differences in readmission rates among patients discharged to a skilled nursing facility or acute rehabilitation program, although patients admitted to clinical facilities had higher overall readmission rates, reported Anna Gustin and coinvestigators at the Levine Cancer Institute at the Carolinas Medical Center in Charlotte, N.C.

“For a patient discharged on a Thursday, if you’re going to get an infection, it’s going to be probably during the weekend, when it’s difficult to contact your primary physician, and when other resources are not as readily available,” said Ms. Gustin, who conducts epidemiologic research at Levine Cancer Center and is also a pre-med student and Japanese major at Wake Forest University in Winston-Salem, N.C.

In a study presented in a poster session at the annual Society of Surgical Oncology Cancer Symposium, Ms. Gustin and her coauthors looked at factors influencing readmission rates among patients undergoing surgery for primary, nonmetastatic colorectal cancer resections.

They drew on the to evaluate outcomes for 93,04 SEER-(Surveillance, Epidemiology, and End Results) Medicare database seven patients aged 66 years and older treated for primary colorectal cancer from 1998 through 2009.

They looked at potential contributing factors such as patient demographics, socioeconomic status, length of stay, days of admission and discharge, and discharge setting (home or clinical facility).

They use multivariate logistic regression models to analyze readmission rates at 14 and 30 days after initial discharge.

Focusing on home discharges, they found that as the week progressed, there was a significant likelihood that a patient discharged home would be readmitted (P less then .001 by chi-square and Cochran-Armitage tests). As noted before, the highest rate of readmission was for patients discharged on Thursday, at 12.4%, compared with 10.1% for patients discharged on Sunday, the discharge day least likely to be associated with rehospitalization.

In multivariate analysis, factors significantly associated with risk for 30-day readmission included male vs. female (hazard ratio, 1.16), black vs. other race (HR, 1.22), length of stay 5, 6-7, or 8-10 vs. 12 or more days (HR, 0.48, 0.59, 0.77, respectively), Charlson comorbidity index score 0, 1 or 3 vs. 3 (HR, 0.59, 0.73, 0.82, respectively), and home discharge vs. other (HR, 0.66; all above comparisons significant as shown by 95% confidence intervals).

The authors concluded that although home discharge itself reduces the likelihood of readmission, “improvements in preparing patients for discharge to home are needed. Additional outpatient interventions could rescue patients from readmission.”

They also suggested reexamining staffing policies and weekend availability of resources for patients, and call for addressing disparities in readmissions based on race, sex, length of stay, and comorbidities.

The study was internally supported. The authors reported having no relevant disclosures.

BOSTON – The day of the week a patient is discharged from the hospital may have an impact the likelihood of readmission.

Patients discharged home from the hospital on a Thursday after colorectal cancer surgery are more likely to be readmitted within 30 days than those discharged on any other day of the week, investigators found.

Neil Osterweil/Frontline Medical News

In contrast, there were no significant day-dependent differences in readmission rates among patients discharged to a skilled nursing facility or acute rehabilitation program, although patients admitted to clinical facilities had higher overall readmission rates, reported Anna Gustin and coinvestigators at the Levine Cancer Institute at the Carolinas Medical Center in Charlotte, N.C.

“For a patient discharged on a Thursday, if you’re going to get an infection, it’s going to be probably during the weekend, when it’s difficult to contact your primary physician, and when other resources are not as readily available,” said Ms. Gustin, who conducts epidemiologic research at Levine Cancer Center and is also a pre-med student and Japanese major at Wake Forest University in Winston-Salem, N.C.

In a study presented in a poster session at the annual Society of Surgical Oncology Cancer Symposium, Ms. Gustin and her coauthors looked at factors influencing readmission rates among patients undergoing surgery for primary, nonmetastatic colorectal cancer resections.

They drew on the to evaluate outcomes for 93,04 SEER-(Surveillance, Epidemiology, and End Results) Medicare database seven patients aged 66 years and older treated for primary colorectal cancer from 1998 through 2009.

They looked at potential contributing factors such as patient demographics, socioeconomic status, length of stay, days of admission and discharge, and discharge setting (home or clinical facility).

They use multivariate logistic regression models to analyze readmission rates at 14 and 30 days after initial discharge.

Focusing on home discharges, they found that as the week progressed, there was a significant likelihood that a patient discharged home would be readmitted (P less then .001 by chi-square and Cochran-Armitage tests). As noted before, the highest rate of readmission was for patients discharged on Thursday, at 12.4%, compared with 10.1% for patients discharged on Sunday, the discharge day least likely to be associated with rehospitalization.

In multivariate analysis, factors significantly associated with risk for 30-day readmission included male vs. female (hazard ratio, 1.16), black vs. other race (HR, 1.22), length of stay 5, 6-7, or 8-10 vs. 12 or more days (HR, 0.48, 0.59, 0.77, respectively), Charlson comorbidity index score 0, 1 or 3 vs. 3 (HR, 0.59, 0.73, 0.82, respectively), and home discharge vs. other (HR, 0.66; all above comparisons significant as shown by 95% confidence intervals).

The authors concluded that although home discharge itself reduces the likelihood of readmission, “improvements in preparing patients for discharge to home are needed. Additional outpatient interventions could rescue patients from readmission.”

They also suggested reexamining staffing policies and weekend availability of resources for patients, and call for addressing disparities in readmissions based on race, sex, length of stay, and comorbidities.

The study was internally supported. The authors reported having no relevant disclosures.

BOSTON – Expanding access to health insurance for low- and moderate-income families has apparently improved colorectal cancer care in Massachusetts, and may do the same for other states that participate in Medicaid expansion under the Affordable Care Act.

That assertion comes from investigators at Massachusetts General Hospital in Boston. They found that following the introduction in 2006 of a universal health insurance law in the Bay State – the law that would serve as a model for the Affordable Care Act – the rate of elective colorectal resections increased while the rate of emergent resections decreased.

In contrast, in three states used as controls, the opposite occurred.

“This could be due to a variety of different factors, including earlier diagnosis, presenting with disease more amenable to surgical resection. It could also be due to increased referrals from primary care providers or GI doctors,” said Dr. Andrew P. Loehrer from the Massachusetts General Hospital Department of Surgery, at the annual Society of Surgical Oncology Cancer Symposium.

He acknowledged, however, that the administrative dataset he and his colleagues used in the study lacks information about clinical staging or use of neoadjuvant therapy, making it difficult to determine whether insured patients actually present at an earlier, more readily treatable disease stage.

Nonetheless, “from a cancer standpoint, my study provides early, hopeful evidence. In order to definitively say that this improves care, we need to have some more of the cancer-specific variables, but with this study, combined with some other work that we and other groups have done, we see that patients in Massachusetts are presenting with earlier stage disease, whether it’s acute disease or cancer, and they’re getting more appropriate care in a more timely fashion,” he said in an interview.

Role model

Dr. Loehrer noted that disparities in access to health care have been shown in previous studies to be associated with the likelihood of unfavorable outcomes for patients with colorectal cancer. For example, a 2008 study (Lancet Oncol. 2008 Mar;9:222-31) showed that uninsured patients with colorectal cancer had a twofold greater risk for presenting with advanced disease than privately insured patients. Additionally, a 2004 study (Br J Surg. 91:605-9) showed that patients who presented with colorectal cancer requiring emergent resection had significantly lower 5-year overall survival than patients who underwent elective resection.

Massachusetts implemented its pioneering health insurance reform law in 2006. The law increased eligibility for persons with incomes up to 150% of the Federal Poverty Level, created government-subsidized insurance for those with incomes from 150% to 300% of the poverty line, mandated that all Bay State residents have some form of health insurance, and allowed young adults up to the age of 26 to remain on their parents’ plans.

To see whether insurance reform could have a salutary effect on cancer care, the investigators drew on Agency for Health Research and Quality (AHRQ) State Inpatient Databases for Massachusetts and for Florida, New Jersey, and New York as control states. They used ICD-9 diagnosis codes to identify patients with colorectal cancer, including those who underwent resection.

To establish procedure rates, they used U.S. Census Bureau data to establish the population of denominators, which included all adults 18-54 years of age who were insured either through Medicaid, Commonwealth Care (in Massachusetts), or were listed as uninsured or self-pay. Medicare-insured patients were not included, as they were not directly affected by the reform law.

They identified 18,598 patients admitted to Massachusetts hospitals for colorectal cancer from 2001 through 2011, and 147,482 admitted during the same period to hospitals in the control states.

The authors created Poisson difference-in-differences models which compare changes in the selected outcomes in Massachusetts with changes in the control states. The models were adjusted for age, sex, race, hospital type, and secular trends.

They found that admission rates for colorectal cancer increased over time in Massachusetts by 13.3 per 100,000 residents per quarter, compared with 8.3/100,000 in the control states, translating into an adjusted rate ratio (ARR) of 1.13. Resection rates for cancer, the primary study outcome, also grew by a significantly larger margin in Massachusetts, by 5.5/100,000, compared with 0.5/100,000 in control states, with an ARR of 1.37 (P less than .001 for both comparisons).

For the secondary outcome of changes in emergent and elective resections after admission, they found that emergent surgeries in Massachusetts declined by 2.7/100,000, but increased by 4.4/100,000 in the states without insurance reform. Similarly, elective resections after admission increased in the Bay State by 7.4/100,000, but decreased by 1.8/100,000 in control states.

Relative to controls, the adjusted probability that a patient with colorectal cancer in Massachusetts would have emergent surgery after admission declined by 6.1% (P = .014) and the probability that he or she would have elective resection increased by 7.8% (P = .005).

An analysis of the odds ratio of resection during admission, adjusted for age, race, presentation with metastatic disease, hospital type, and secular trends, showed that prior to reform uninsured patients in both Massachusetts and control states were significantly less likely than privately insured patients to have resections (odds ratio, 0.42 in Mass.; 0.45 in control states).

However, after the implementation of reform the gap between previously uninsured and privately insured in Massachusetts narrowed (OR, 0.63) but remained the same in control states (OR, 0.44).

Dr. Loehrer acknowledged in an interview that Massachusetts differs from other states in some regards, including in concentrations of health providers and in requirements for insurance coverage that were in place even before the 2006 reforms, but is optimistic that improvements in colorectal cancer care can occur in states that have embraced the Affordable Care Act.

“There are a lot of services that were available and we had high colonoscopy rates prior to all of this, but that said, the mechanism is exactly the same, there are still vulnerable populations, and at this point I think it’s hopeful and promising that we will see similar results in other states,” he said.

BOSTON – Expanding access to health insurance for low- and moderate-income families has apparently improved colorectal cancer care in Massachusetts, and may do the same for other states that participate in Medicaid expansion under the Affordable Care Act.

That assertion comes from investigators at Massachusetts General Hospital in Boston. They found that following the introduction in 2006 of a universal health insurance law in the Bay State – the law that would serve as a model for the Affordable Care Act – the rate of elective colorectal resections increased while the rate of emergent resections decreased.

In contrast, in three states used as controls, the opposite occurred.

“This could be due to a variety of different factors, including earlier diagnosis, presenting with disease more amenable to surgical resection. It could also be due to increased referrals from primary care providers or GI doctors,” said Dr. Andrew P. Loehrer from the Massachusetts General Hospital Department of Surgery, at the annual Society of Surgical Oncology Cancer Symposium.

He acknowledged, however, that the administrative dataset he and his colleagues used in the study lacks information about clinical staging or use of neoadjuvant therapy, making it difficult to determine whether insured patients actually present at an earlier, more readily treatable disease stage.

Nonetheless, “from a cancer standpoint, my study provides early, hopeful evidence. In order to definitively say that this improves care, we need to have some more of the cancer-specific variables, but with this study, combined with some other work that we and other groups have done, we see that patients in Massachusetts are presenting with earlier stage disease, whether it’s acute disease or cancer, and they’re getting more appropriate care in a more timely fashion,” he said in an interview.

Role model

Dr. Loehrer noted that disparities in access to health care have been shown in previous studies to be associated with the likelihood of unfavorable outcomes for patients with colorectal cancer. For example, a 2008 study (Lancet Oncol. 2008 Mar;9:222-31) showed that uninsured patients with colorectal cancer had a twofold greater risk for presenting with advanced disease than privately insured patients. Additionally, a 2004 study (Br J Surg. 91:605-9) showed that patients who presented with colorectal cancer requiring emergent resection had significantly lower 5-year overall survival than patients who underwent elective resection.

Massachusetts implemented its pioneering health insurance reform law in 2006. The law increased eligibility for persons with incomes up to 150% of the Federal Poverty Level, created government-subsidized insurance for those with incomes from 150% to 300% of the poverty line, mandated that all Bay State residents have some form of health insurance, and allowed young adults up to the age of 26 to remain on their parents’ plans.

To see whether insurance reform could have a salutary effect on cancer care, the investigators drew on Agency for Health Research and Quality (AHRQ) State Inpatient Databases for Massachusetts and for Florida, New Jersey, and New York as control states. They used ICD-9 diagnosis codes to identify patients with colorectal cancer, including those who underwent resection.

To establish procedure rates, they used U.S. Census Bureau data to establish the population of denominators, which included all adults 18-54 years of age who were insured either through Medicaid, Commonwealth Care (in Massachusetts), or were listed as uninsured or self-pay. Medicare-insured patients were not included, as they were not directly affected by the reform law.

They identified 18,598 patients admitted to Massachusetts hospitals for colorectal cancer from 2001 through 2011, and 147,482 admitted during the same period to hospitals in the control states.

The authors created Poisson difference-in-differences models which compare changes in the selected outcomes in Massachusetts with changes in the control states. The models were adjusted for age, sex, race, hospital type, and secular trends.

They found that admission rates for colorectal cancer increased over time in Massachusetts by 13.3 per 100,000 residents per quarter, compared with 8.3/100,000 in the control states, translating into an adjusted rate ratio (ARR) of 1.13. Resection rates for cancer, the primary study outcome, also grew by a significantly larger margin in Massachusetts, by 5.5/100,000, compared with 0.5/100,000 in control states, with an ARR of 1.37 (P less than .001 for both comparisons).

For the secondary outcome of changes in emergent and elective resections after admission, they found that emergent surgeries in Massachusetts declined by 2.7/100,000, but increased by 4.4/100,000 in the states without insurance reform. Similarly, elective resections after admission increased in the Bay State by 7.4/100,000, but decreased by 1.8/100,000 in control states.

Relative to controls, the adjusted probability that a patient with colorectal cancer in Massachusetts would have emergent surgery after admission declined by 6.1% (P = .014) and the probability that he or she would have elective resection increased by 7.8% (P = .005).

An analysis of the odds ratio of resection during admission, adjusted for age, race, presentation with metastatic disease, hospital type, and secular trends, showed that prior to reform uninsured patients in both Massachusetts and control states were significantly less likely than privately insured patients to have resections (odds ratio, 0.42 in Mass.; 0.45 in control states).

However, after the implementation of reform the gap between previously uninsured and privately insured in Massachusetts narrowed (OR, 0.63) but remained the same in control states (OR, 0.44).

Dr. Loehrer acknowledged in an interview that Massachusetts differs from other states in some regards, including in concentrations of health providers and in requirements for insurance coverage that were in place even before the 2006 reforms, but is optimistic that improvements in colorectal cancer care can occur in states that have embraced the Affordable Care Act.

“There are a lot of services that were available and we had high colonoscopy rates prior to all of this, but that said, the mechanism is exactly the same, there are still vulnerable populations, and at this point I think it’s hopeful and promising that we will see similar results in other states,” he said.

BOSTON – Expanding access to health insurance for low- and moderate-income families has apparently improved colorectal cancer care in Massachusetts, and may do the same for other states that participate in Medicaid expansion under the Affordable Care Act.

That assertion comes from investigators at Massachusetts General Hospital in Boston. They found that following the introduction in 2006 of a universal health insurance law in the Bay State – the law that would serve as a model for the Affordable Care Act – the rate of elective colorectal resections increased while the rate of emergent resections decreased.

In contrast, in three states used as controls, the opposite occurred.

“This could be due to a variety of different factors, including earlier diagnosis, presenting with disease more amenable to surgical resection. It could also be due to increased referrals from primary care providers or GI doctors,” said Dr. Andrew P. Loehrer from the Massachusetts General Hospital Department of Surgery, at the annual Society of Surgical Oncology Cancer Symposium.

He acknowledged, however, that the administrative dataset he and his colleagues used in the study lacks information about clinical staging or use of neoadjuvant therapy, making it difficult to determine whether insured patients actually present at an earlier, more readily treatable disease stage.

Nonetheless, “from a cancer standpoint, my study provides early, hopeful evidence. In order to definitively say that this improves care, we need to have some more of the cancer-specific variables, but with this study, combined with some other work that we and other groups have done, we see that patients in Massachusetts are presenting with earlier stage disease, whether it’s acute disease or cancer, and they’re getting more appropriate care in a more timely fashion,” he said in an interview.

Role model

Dr. Loehrer noted that disparities in access to health care have been shown in previous studies to be associated with the likelihood of unfavorable outcomes for patients with colorectal cancer. For example, a 2008 study (Lancet Oncol. 2008 Mar;9:222-31) showed that uninsured patients with colorectal cancer had a twofold greater risk for presenting with advanced disease than privately insured patients. Additionally, a 2004 study (Br J Surg. 91:605-9) showed that patients who presented with colorectal cancer requiring emergent resection had significantly lower 5-year overall survival than patients who underwent elective resection.

Massachusetts implemented its pioneering health insurance reform law in 2006. The law increased eligibility for persons with incomes up to 150% of the Federal Poverty Level, created government-subsidized insurance for those with incomes from 150% to 300% of the poverty line, mandated that all Bay State residents have some form of health insurance, and allowed young adults up to the age of 26 to remain on their parents’ plans.

To see whether insurance reform could have a salutary effect on cancer care, the investigators drew on Agency for Health Research and Quality (AHRQ) State Inpatient Databases for Massachusetts and for Florida, New Jersey, and New York as control states. They used ICD-9 diagnosis codes to identify patients with colorectal cancer, including those who underwent resection.

To establish procedure rates, they used U.S. Census Bureau data to establish the population of denominators, which included all adults 18-54 years of age who were insured either through Medicaid, Commonwealth Care (in Massachusetts), or were listed as uninsured or self-pay. Medicare-insured patients were not included, as they were not directly affected by the reform law.

They identified 18,598 patients admitted to Massachusetts hospitals for colorectal cancer from 2001 through 2011, and 147,482 admitted during the same period to hospitals in the control states.

The authors created Poisson difference-in-differences models which compare changes in the selected outcomes in Massachusetts with changes in the control states. The models were adjusted for age, sex, race, hospital type, and secular trends.

They found that admission rates for colorectal cancer increased over time in Massachusetts by 13.3 per 100,000 residents per quarter, compared with 8.3/100,000 in the control states, translating into an adjusted rate ratio (ARR) of 1.13. Resection rates for cancer, the primary study outcome, also grew by a significantly larger margin in Massachusetts, by 5.5/100,000, compared with 0.5/100,000 in control states, with an ARR of 1.37 (P less than .001 for both comparisons).

For the secondary outcome of changes in emergent and elective resections after admission, they found that emergent surgeries in Massachusetts declined by 2.7/100,000, but increased by 4.4/100,000 in the states without insurance reform. Similarly, elective resections after admission increased in the Bay State by 7.4/100,000, but decreased by 1.8/100,000 in control states.

Relative to controls, the adjusted probability that a patient with colorectal cancer in Massachusetts would have emergent surgery after admission declined by 6.1% (P = .014) and the probability that he or she would have elective resection increased by 7.8% (P = .005).

An analysis of the odds ratio of resection during admission, adjusted for age, race, presentation with metastatic disease, hospital type, and secular trends, showed that prior to reform uninsured patients in both Massachusetts and control states were significantly less likely than privately insured patients to have resections (odds ratio, 0.42 in Mass.; 0.45 in control states).

However, after the implementation of reform the gap between previously uninsured and privately insured in Massachusetts narrowed (OR, 0.63) but remained the same in control states (OR, 0.44).

Dr. Loehrer acknowledged in an interview that Massachusetts differs from other states in some regards, including in concentrations of health providers and in requirements for insurance coverage that were in place even before the 2006 reforms, but is optimistic that improvements in colorectal cancer care can occur in states that have embraced the Affordable Care Act.

“There are a lot of services that were available and we had high colonoscopy rates prior to all of this, but that said, the mechanism is exactly the same, there are still vulnerable populations, and at this point I think it’s hopeful and promising that we will see similar results in other states,” he said.

JACKSONVILLE, FLA. – Over the past 30 years, transanal endoscopic microsurgery (TEM) has emerged as a technique for localized rectal cancer, but the need for expensive specialized equipment put it beyond the reach of most hospitals.

Now, early results with transanal minimally invasive surgery (TAMIS) may open the door to an option that achieves the benefits of TEM while using commonly available and less expensive equipment, according to a study presented at the Association for Academic Surgery/Society of University Surgeons Academic Surgical Congress.

Dr. John Costello, general surgery resident at Georgetown University, Washington, presented a poster summarizing the findings of a systematic literature review of TEM and TAMIS studies. The experience with TAMIS is more limited since Dr. Sam Atallah of Sebring, Fla., first introduced it in 2010. The review included the only head-to-head study of the technical aspects of TAMIS and TEM to date.

“Overall the results are very similar between the two approaches,” Dr. Costello said. “In many ways there are, at least anecdotally, some benefits potentially toward the TAMIS technique aside from cost: The perioperative morbidity may be a little lower and, particularly, there seemed to be fewer early problems with continence after surgery.”

The review found similar outcomes between the two approaches: low recurrence rates for small tumors (up to 3 cm) of 4% for TAMIS and 5% for TEM, although the study found that the recurrence rate for TEM increased with larger tumors. Surgery-related deaths with TAMIS ranged from 7.4% to19% and TEM from 6% to 31% across the studies reviewed.

The challenge with the systematic review was that the population of patients who had TAMIS was fewer than 500.

Dr. Costello elucidated the reasons that rectal cancer surgery has proved so challenging to surgeons over the years. The choice of operation was either limited to transabdominal or transanal excision, but the transanal approach had limitations anatomically and was found to be oncologically inferior for early stage cancer. Even with the evolution of the TEM approach, its adoption has been slow.

Either TEM or TAMIS would be a good option for patients too frail for the radical resection that low anterior resection or abdominal perineal resection demand, and would offer an option for palliation for advanced disease, Dr. Costello said. “You could locally resect patients in a way that they go home the same day or at most stay one day in the hospital,” he said.

“The challenge with TEM is that, although the oncologic outcomes are quite good with early-stage disease, the adoption has been very poor over 3 decades mainly because it requires specialized equipment with a very large upfront cost that is limited to use in the rectum,” Dr. Costello said. He estimated the initial capital investment cost for TEM equipment at up to $60,000 on average.

The TAMIS approach, on the other hand, carries a per-procedure equipment cost of about $500 over traditional laparoscopic surgery, he said. It can utilize the single-incision laparoscopic port (SILS) for the transanal approach. TAMIS sacrifices the three-dimensional view of TEM for two-dimensional, but it does provide 360-degree visualization. The surgeon must also be facile with the laparoscopic technique. “In the past that was a big challenge, but now all trainees are very familiar with laparoscopic surgery,” Dr. Costello said.

While the paucity of data on the TAMIS approach makes it difficult to make a strong case for the procedure, the path forward is clear, Dr. Costello said.

“We feel, as do a number of authors of the most papers, that the time truly is now for an actual prospective randomized trial to compare these techniques head-to-head, because colorectal surgeons now have the skill set to be facile at both,” Dr. Costello said.

The investigators had no financial relationships to disclose.

JACKSONVILLE, FLA. – Over the past 30 years, transanal endoscopic microsurgery (TEM) has emerged as a technique for localized rectal cancer, but the need for expensive specialized equipment put it beyond the reach of most hospitals.

Now, early results with transanal minimally invasive surgery (TAMIS) may open the door to an option that achieves the benefits of TEM while using commonly available and less expensive equipment, according to a study presented at the Association for Academic Surgery/Society of University Surgeons Academic Surgical Congress.

Dr. John Costello, general surgery resident at Georgetown University, Washington, presented a poster summarizing the findings of a systematic literature review of TEM and TAMIS studies. The experience with TAMIS is more limited since Dr. Sam Atallah of Sebring, Fla., first introduced it in 2010. The review included the only head-to-head study of the technical aspects of TAMIS and TEM to date.

“Overall the results are very similar between the two approaches,” Dr. Costello said. “In many ways there are, at least anecdotally, some benefits potentially toward the TAMIS technique aside from cost: The perioperative morbidity may be a little lower and, particularly, there seemed to be fewer early problems with continence after surgery.”

The review found similar outcomes between the two approaches: low recurrence rates for small tumors (up to 3 cm) of 4% for TAMIS and 5% for TEM, although the study found that the recurrence rate for TEM increased with larger tumors. Surgery-related deaths with TAMIS ranged from 7.4% to19% and TEM from 6% to 31% across the studies reviewed.

The challenge with the systematic review was that the population of patients who had TAMIS was fewer than 500.

Dr. Costello elucidated the reasons that rectal cancer surgery has proved so challenging to surgeons over the years. The choice of operation was either limited to transabdominal or transanal excision, but the transanal approach had limitations anatomically and was found to be oncologically inferior for early stage cancer. Even with the evolution of the TEM approach, its adoption has been slow.

Either TEM or TAMIS would be a good option for patients too frail for the radical resection that low anterior resection or abdominal perineal resection demand, and would offer an option for palliation for advanced disease, Dr. Costello said. “You could locally resect patients in a way that they go home the same day or at most stay one day in the hospital,” he said.

“The challenge with TEM is that, although the oncologic outcomes are quite good with early-stage disease, the adoption has been very poor over 3 decades mainly because it requires specialized equipment with a very large upfront cost that is limited to use in the rectum,” Dr. Costello said. He estimated the initial capital investment cost for TEM equipment at up to $60,000 on average.

The TAMIS approach, on the other hand, carries a per-procedure equipment cost of about $500 over traditional laparoscopic surgery, he said. It can utilize the single-incision laparoscopic port (SILS) for the transanal approach. TAMIS sacrifices the three-dimensional view of TEM for two-dimensional, but it does provide 360-degree visualization. The surgeon must also be facile with the laparoscopic technique. “In the past that was a big challenge, but now all trainees are very familiar with laparoscopic surgery,” Dr. Costello said.

While the paucity of data on the TAMIS approach makes it difficult to make a strong case for the procedure, the path forward is clear, Dr. Costello said.

“We feel, as do a number of authors of the most papers, that the time truly is now for an actual prospective randomized trial to compare these techniques head-to-head, because colorectal surgeons now have the skill set to be facile at both,” Dr. Costello said.

The investigators had no financial relationships to disclose.

JACKSONVILLE, FLA. – Over the past 30 years, transanal endoscopic microsurgery (TEM) has emerged as a technique for localized rectal cancer, but the need for expensive specialized equipment put it beyond the reach of most hospitals.

Now, early results with transanal minimally invasive surgery (TAMIS) may open the door to an option that achieves the benefits of TEM while using commonly available and less expensive equipment, according to a study presented at the Association for Academic Surgery/Society of University Surgeons Academic Surgical Congress.

Dr. John Costello, general surgery resident at Georgetown University, Washington, presented a poster summarizing the findings of a systematic literature review of TEM and TAMIS studies. The experience with TAMIS is more limited since Dr. Sam Atallah of Sebring, Fla., first introduced it in 2010. The review included the only head-to-head study of the technical aspects of TAMIS and TEM to date.

“Overall the results are very similar between the two approaches,” Dr. Costello said. “In many ways there are, at least anecdotally, some benefits potentially toward the TAMIS technique aside from cost: The perioperative morbidity may be a little lower and, particularly, there seemed to be fewer early problems with continence after surgery.”

The review found similar outcomes between the two approaches: low recurrence rates for small tumors (up to 3 cm) of 4% for TAMIS and 5% for TEM, although the study found that the recurrence rate for TEM increased with larger tumors. Surgery-related deaths with TAMIS ranged from 7.4% to19% and TEM from 6% to 31% across the studies reviewed.

The challenge with the systematic review was that the population of patients who had TAMIS was fewer than 500.

Dr. Costello elucidated the reasons that rectal cancer surgery has proved so challenging to surgeons over the years. The choice of operation was either limited to transabdominal or transanal excision, but the transanal approach had limitations anatomically and was found to be oncologically inferior for early stage cancer. Even with the evolution of the TEM approach, its adoption has been slow.

Either TEM or TAMIS would be a good option for patients too frail for the radical resection that low anterior resection or abdominal perineal resection demand, and would offer an option for palliation for advanced disease, Dr. Costello said. “You could locally resect patients in a way that they go home the same day or at most stay one day in the hospital,” he said.

“The challenge with TEM is that, although the oncologic outcomes are quite good with early-stage disease, the adoption has been very poor over 3 decades mainly because it requires specialized equipment with a very large upfront cost that is limited to use in the rectum,” Dr. Costello said. He estimated the initial capital investment cost for TEM equipment at up to $60,000 on average.

The TAMIS approach, on the other hand, carries a per-procedure equipment cost of about $500 over traditional laparoscopic surgery, he said. It can utilize the single-incision laparoscopic port (SILS) for the transanal approach. TAMIS sacrifices the three-dimensional view of TEM for two-dimensional, but it does provide 360-degree visualization. The surgeon must also be facile with the laparoscopic technique. “In the past that was a big challenge, but now all trainees are very familiar with laparoscopic surgery,” Dr. Costello said.

While the paucity of data on the TAMIS approach makes it difficult to make a strong case for the procedure, the path forward is clear, Dr. Costello said.

“We feel, as do a number of authors of the most papers, that the time truly is now for an actual prospective randomized trial to compare these techniques head-to-head, because colorectal surgeons now have the skill set to be facile at both,” Dr. Costello said.

The investigators had no financial relationships to disclose.

JACKSONVILLE, FLA. – Robotic-assisted colectomy took longer than the laparoscopic operation but didn’t result in better surgical outcomes in a large NSQIP data–based study.

As health care moves away from fee-for-service to a value-based model, the longer operative times and comparative outcomes to laparoscopic colectomy suggest that the use of robotic technologies in straightforward colon resections may not be justified at this time, investigators at Duke University concluded.

“This is the largest analysis to date of robotic-assisted vs. laparoscopic colectomy,” Dr. Brian Ezekian, general surgery resident at Duke, reported at the Association for Academic Surgery/Society of University Surgeons Academic Surgical Congress. “While the robotic approach is still in its infancy, the technology is associated with increased operative times without improved clinical outcomes, so our study suggests that the routine use of robotic surgery for colectomy may not be financially justifiable at this time.”

The study sampled the American College of Surgeons’ National Surgical Quality Improvement Program (NSQIP) database for patients who had either a robotic or laparoscopic colectomy from 2012 to 2013. Among the 15,976 patients included, 498 of them (3.1%) had robotic colectomy, Dr. Ezekian said.

“The major finding of our study was that robotic-assisted colectomy was associated with roughly 30-minute longer operative times, whereas the short-term clinical outcomes were comparable between the two groups,” Dr. Ezekian said. “This held true for a subset analysis of patients undergoing segmental colectomy only.”

The analysis found no significant difference between the two approaches in rates of wound complications, urinary tract infections, cardiopulmonary or thromboembolic complications, kidney failure or insufficiency, anastomotic leaks, transfusions, unplanned readmissions, or 30-day death.

The key difference was in the operative times associated with each approach. The median time for robotic-assisted colectomy was 196 minutes vs. 166 minutes for the laparoscopic approach. The study found a similar gap for segmental resections only: 190 minutes for the robotic-assisted approach vs. 153 minutes for the laparoscopic approach.

Dr. Ezekian acknowledged that this observation might merely reflect an early experience with this novel technology. “A future direction for this research is to see if operative times for robotic-assisted surgery decrease over time once there are more years in the NSQIP database or in single-institution studies,” he said.

The authors had no financial relationships to disclose.

JACKSONVILLE, FLA. – Robotic-assisted colectomy took longer than the laparoscopic operation but didn’t result in better surgical outcomes in a large NSQIP data–based study.

As health care moves away from fee-for-service to a value-based model, the longer operative times and comparative outcomes to laparoscopic colectomy suggest that the use of robotic technologies in straightforward colon resections may not be justified at this time, investigators at Duke University concluded.

“This is the largest analysis to date of robotic-assisted vs. laparoscopic colectomy,” Dr. Brian Ezekian, general surgery resident at Duke, reported at the Association for Academic Surgery/Society of University Surgeons Academic Surgical Congress. “While the robotic approach is still in its infancy, the technology is associated with increased operative times without improved clinical outcomes, so our study suggests that the routine use of robotic surgery for colectomy may not be financially justifiable at this time.”

The study sampled the American College of Surgeons’ National Surgical Quality Improvement Program (NSQIP) database for patients who had either a robotic or laparoscopic colectomy from 2012 to 2013. Among the 15,976 patients included, 498 of them (3.1%) had robotic colectomy, Dr. Ezekian said.

“The major finding of our study was that robotic-assisted colectomy was associated with roughly 30-minute longer operative times, whereas the short-term clinical outcomes were comparable between the two groups,” Dr. Ezekian said. “This held true for a subset analysis of patients undergoing segmental colectomy only.”

The analysis found no significant difference between the two approaches in rates of wound complications, urinary tract infections, cardiopulmonary or thromboembolic complications, kidney failure or insufficiency, anastomotic leaks, transfusions, unplanned readmissions, or 30-day death.

The key difference was in the operative times associated with each approach. The median time for robotic-assisted colectomy was 196 minutes vs. 166 minutes for the laparoscopic approach. The study found a similar gap for segmental resections only: 190 minutes for the robotic-assisted approach vs. 153 minutes for the laparoscopic approach.

Dr. Ezekian acknowledged that this observation might merely reflect an early experience with this novel technology. “A future direction for this research is to see if operative times for robotic-assisted surgery decrease over time once there are more years in the NSQIP database or in single-institution studies,” he said.

The authors had no financial relationships to disclose.

JACKSONVILLE, FLA. – Robotic-assisted colectomy took longer than the laparoscopic operation but didn’t result in better surgical outcomes in a large NSQIP data–based study.

As health care moves away from fee-for-service to a value-based model, the longer operative times and comparative outcomes to laparoscopic colectomy suggest that the use of robotic technologies in straightforward colon resections may not be justified at this time, investigators at Duke University concluded.

“This is the largest analysis to date of robotic-assisted vs. laparoscopic colectomy,” Dr. Brian Ezekian, general surgery resident at Duke, reported at the Association for Academic Surgery/Society of University Surgeons Academic Surgical Congress. “While the robotic approach is still in its infancy, the technology is associated with increased operative times without improved clinical outcomes, so our study suggests that the routine use of robotic surgery for colectomy may not be financially justifiable at this time.”

The study sampled the American College of Surgeons’ National Surgical Quality Improvement Program (NSQIP) database for patients who had either a robotic or laparoscopic colectomy from 2012 to 2013. Among the 15,976 patients included, 498 of them (3.1%) had robotic colectomy, Dr. Ezekian said.

“The major finding of our study was that robotic-assisted colectomy was associated with roughly 30-minute longer operative times, whereas the short-term clinical outcomes were comparable between the two groups,” Dr. Ezekian said. “This held true for a subset analysis of patients undergoing segmental colectomy only.”

The analysis found no significant difference between the two approaches in rates of wound complications, urinary tract infections, cardiopulmonary or thromboembolic complications, kidney failure or insufficiency, anastomotic leaks, transfusions, unplanned readmissions, or 30-day death.

The key difference was in the operative times associated with each approach. The median time for robotic-assisted colectomy was 196 minutes vs. 166 minutes for the laparoscopic approach. The study found a similar gap for segmental resections only: 190 minutes for the robotic-assisted approach vs. 153 minutes for the laparoscopic approach.

Dr. Ezekian acknowledged that this observation might merely reflect an early experience with this novel technology. “A future direction for this research is to see if operative times for robotic-assisted surgery decrease over time once there are more years in the NSQIP database or in single-institution studies,” he said.

The authors had no financial relationships to disclose.

A significant number of elective colon resections for uncomplicated diverticulitis are done in individuals who have experienced fewer than three episodes.

Researchers analyzed nationwide data from 87,461 immunocompetent patients with at least one claim for diverticulitis, of whom 5,604 (6.4%) underwent a resection.

©selvanegra/Thinkstock.com

According to a paper published online Feb. 10 in JAMA Surgery, 94.9% of resections, in a final cohort of 3,054 patients, occurred in individuals with fewer than three episodes of diverticulitis, if only inpatient claims were counted (doi:10.1001/jamasurg.2015.5478).

If both inpatient and outpatient claims for diverticulitis were counted, 80.5% of patients who underwent resection had experienced fewer than three episodes, and if all types of claims (including antibiotic prescription claims for diverticulitis) were counted, that figure dropped to 56.3%.

Individuals who underwent early resection were slightly more likely to be male (risk ratio [RR], 1.07; 95% confidence interval [CI], 1.02-1.13; P = .004) but were of a similar age to those who underwent resection after three or more episodes of diverticulitis.

The mean time between the last two episodes of diverticulitis was longer in individuals who underwent early surgery compared to those who delayed surgery (157 days vs. 96 days; P less than .001).

Patients residing in the South were also significantly more likely to undergo early surgery than were those residing in an other regions, with 60.5% of policy holders there undergoing early surgery compared to 50.7% in the West.

Insurance status also influenced the likelihood of early surgery, as patients with HMO or capitated insurance plans were less likely to undergo early surgery than were patients with other plan types.

In the last decade, professional guidelines have moved toward recommending elective surgery for diverticulitis after three or more episodes, but at the same time, the incidence of elective resection has more than doubled, reported Dr. Vlad V. Simianu of the University of Washington, Seattle, and coauthors.

This study covered a period of data in which guidelines on elective resection have remained in a relatively steady state, offering an opportunity to assess guideline adherence.

“Within this context, the suspected drivers of early elective surgery (younger age, laparoscopy, more frequent episodes, and personal financial risk) were not found to be associated with earlier operations for diverticulitis,” the authors wrote.

The analysis found laparoscopy was not associated with early surgery, which the authors said challenged the hypothesis that the threshold for early surgical resection might be lowered by the availability of laparoscopy.

The lack of an age difference between those undergoing early resection also challenged the notion that younger patients may experience more severe diverticulitis and suffer a greater impact on their quality of life and that this may drive physicians to operate earlier.

The authors noted that patient factors such as quality of life and anxiety about future episodes of diverticulitis, and surgeon-related factors such as training, local practice, and referral patterns were not tested, and that these may account for some of decisions about early surgery.

The National Institute of Diabetes and Digestive and Kidney Diseases and the University of Washington supported the study. No conflicts of interest were declared.

A significant number of elective colon resections for uncomplicated diverticulitis are done in individuals who have experienced fewer than three episodes.

Researchers analyzed nationwide data from 87,461 immunocompetent patients with at least one claim for diverticulitis, of whom 5,604 (6.4%) underwent a resection.

©selvanegra/Thinkstock.com

According to a paper published online Feb. 10 in JAMA Surgery, 94.9% of resections, in a final cohort of 3,054 patients, occurred in individuals with fewer than three episodes of diverticulitis, if only inpatient claims were counted (doi:10.1001/jamasurg.2015.5478).

If both inpatient and outpatient claims for diverticulitis were counted, 80.5% of patients who underwent resection had experienced fewer than three episodes, and if all types of claims (including antibiotic prescription claims for diverticulitis) were counted, that figure dropped to 56.3%.

Individuals who underwent early resection were slightly more likely to be male (risk ratio [RR], 1.07; 95% confidence interval [CI], 1.02-1.13; P = .004) but were of a similar age to those who underwent resection after three or more episodes of diverticulitis.

The mean time between the last two episodes of diverticulitis was longer in individuals who underwent early surgery compared to those who delayed surgery (157 days vs. 96 days; P less than .001).

Patients residing in the South were also significantly more likely to undergo early surgery than were those residing in an other regions, with 60.5% of policy holders there undergoing early surgery compared to 50.7% in the West.

Insurance status also influenced the likelihood of early surgery, as patients with HMO or capitated insurance plans were less likely to undergo early surgery than were patients with other plan types.

In the last decade, professional guidelines have moved toward recommending elective surgery for diverticulitis after three or more episodes, but at the same time, the incidence of elective resection has more than doubled, reported Dr. Vlad V. Simianu of the University of Washington, Seattle, and coauthors.

This study covered a period of data in which guidelines on elective resection have remained in a relatively steady state, offering an opportunity to assess guideline adherence.

“Within this context, the suspected drivers of early elective surgery (younger age, laparoscopy, more frequent episodes, and personal financial risk) were not found to be associated with earlier operations for diverticulitis,” the authors wrote.

The analysis found laparoscopy was not associated with early surgery, which the authors said challenged the hypothesis that the threshold for early surgical resection might be lowered by the availability of laparoscopy.

The lack of an age difference between those undergoing early resection also challenged the notion that younger patients may experience more severe diverticulitis and suffer a greater impact on their quality of life and that this may drive physicians to operate earlier.

The authors noted that patient factors such as quality of life and anxiety about future episodes of diverticulitis, and surgeon-related factors such as training, local practice, and referral patterns were not tested, and that these may account for some of decisions about early surgery.

The National Institute of Diabetes and Digestive and Kidney Diseases and the University of Washington supported the study. No conflicts of interest were declared.

A significant number of elective colon resections for uncomplicated diverticulitis are done in individuals who have experienced fewer than three episodes.

Researchers analyzed nationwide data from 87,461 immunocompetent patients with at least one claim for diverticulitis, of whom 5,604 (6.4%) underwent a resection.

©selvanegra/Thinkstock.com

According to a paper published online Feb. 10 in JAMA Surgery, 94.9% of resections, in a final cohort of 3,054 patients, occurred in individuals with fewer than three episodes of diverticulitis, if only inpatient claims were counted (doi:10.1001/jamasurg.2015.5478).

If both inpatient and outpatient claims for diverticulitis were counted, 80.5% of patients who underwent resection had experienced fewer than three episodes, and if all types of claims (including antibiotic prescription claims for diverticulitis) were counted, that figure dropped to 56.3%.

Individuals who underwent early resection were slightly more likely to be male (risk ratio [RR], 1.07; 95% confidence interval [CI], 1.02-1.13; P = .004) but were of a similar age to those who underwent resection after three or more episodes of diverticulitis.

The mean time between the last two episodes of diverticulitis was longer in individuals who underwent early surgery compared to those who delayed surgery (157 days vs. 96 days; P less than .001).

Patients residing in the South were also significantly more likely to undergo early surgery than were those residing in an other regions, with 60.5% of policy holders there undergoing early surgery compared to 50.7% in the West.

Insurance status also influenced the likelihood of early surgery, as patients with HMO or capitated insurance plans were less likely to undergo early surgery than were patients with other plan types.

In the last decade, professional guidelines have moved toward recommending elective surgery for diverticulitis after three or more episodes, but at the same time, the incidence of elective resection has more than doubled, reported Dr. Vlad V. Simianu of the University of Washington, Seattle, and coauthors.

This study covered a period of data in which guidelines on elective resection have remained in a relatively steady state, offering an opportunity to assess guideline adherence.

“Within this context, the suspected drivers of early elective surgery (younger age, laparoscopy, more frequent episodes, and personal financial risk) were not found to be associated with earlier operations for diverticulitis,” the authors wrote.

The analysis found laparoscopy was not associated with early surgery, which the authors said challenged the hypothesis that the threshold for early surgical resection might be lowered by the availability of laparoscopy.

The lack of an age difference between those undergoing early resection also challenged the notion that younger patients may experience more severe diverticulitis and suffer a greater impact on their quality of life and that this may drive physicians to operate earlier.

The authors noted that patient factors such as quality of life and anxiety about future episodes of diverticulitis, and surgeon-related factors such as training, local practice, and referral patterns were not tested, and that these may account for some of decisions about early surgery.

The National Institute of Diabetes and Digestive and Kidney Diseases and the University of Washington supported the study. No conflicts of interest were declared.

JACKSONVILLE, FLA. – An enhanced recovery protocol after colorectal surgery nearly eliminated differences in hospital stays between black and white patients, according to a study based on data from the University of Alabama at Birmingham.

Dr. Tyler S. Wahl, a resident at UAB reported on the institution’s experience with the Enhanced Recovery After Surgery (ERAS) pathway at the Association of Academic Surgery/Society of University Surgeons Academic Surgical Congress. “ERAS has been shown to reduce length of stay, cost, and perioperative complications without compromising readmission or mortality rates,” Dr. Wahl said. Dr. Daniel Chu was senior author.

Surgical literature has increasingly demonstrated disparities among black patients undergoing major surgery: longer lengths of stay, more readmissions, increased postoperative mortality and lower survival rates after colorectal cancer resections, Dr. Wahl said. The UAB investigators set out to determine whether the ERAS pathway would reduce disparities in length of stay among black and white patients when compared to the traditional pathway.

Before UAB started using ERAS for colorectal patients, the average length of stay for patients undergoing colorectal surgery was 6.7 days with significant differences between black and white patients: 8 days vs. 6.1 days, respectively. However, after implementation of the ERAS pathway in January 2015, average length of stay declined to 4.7 days overall. Black patients had dramatic reductions in length of stay, compared with white patients, with stays of 3.9 days vs. 5 days, respectively.

“Not only were patients leaving much earlier, but their length of stay was also shorter than predicted using the American College of Surgeons Risk Calculator,” Dr. Wahl said.

The UAB study was a retrospective, matched cohort analysis of 258 patients – 129 patients from pre-ERAS years were compared with 129 ERAS patients from January to October 2015.

Study subjects were similar in many patient- and procedure-specific factors; however, differences in operative approach, indication, ostomy formation, and operative time did not change the predicted length of stay among races, Dr. Wahl said.

Dr. Wahl said the racial makeup of the study differs from most ERAS literature in colorectal patients. “The overall percentage of the African American population was 30% within our study, as most ERAS literature has 10% or less,” he added.

“Further work needs to be pursued to find what’s driving these dramatic results among the black population,” he said.

Dr. Wahl and coauthors had no disclosures.

JACKSONVILLE, FLA. – An enhanced recovery protocol after colorectal surgery nearly eliminated differences in hospital stays between black and white patients, according to a study based on data from the University of Alabama at Birmingham.

Dr. Tyler S. Wahl, a resident at UAB reported on the institution’s experience with the Enhanced Recovery After Surgery (ERAS) pathway at the Association of Academic Surgery/Society of University Surgeons Academic Surgical Congress. “ERAS has been shown to reduce length of stay, cost, and perioperative complications without compromising readmission or mortality rates,” Dr. Wahl said. Dr. Daniel Chu was senior author.

Surgical literature has increasingly demonstrated disparities among black patients undergoing major surgery: longer lengths of stay, more readmissions, increased postoperative mortality and lower survival rates after colorectal cancer resections, Dr. Wahl said. The UAB investigators set out to determine whether the ERAS pathway would reduce disparities in length of stay among black and white patients when compared to the traditional pathway.

Before UAB started using ERAS for colorectal patients, the average length of stay for patients undergoing colorectal surgery was 6.7 days with significant differences between black and white patients: 8 days vs. 6.1 days, respectively. However, after implementation of the ERAS pathway in January 2015, average length of stay declined to 4.7 days overall. Black patients had dramatic reductions in length of stay, compared with white patients, with stays of 3.9 days vs. 5 days, respectively.

“Not only were patients leaving much earlier, but their length of stay was also shorter than predicted using the American College of Surgeons Risk Calculator,” Dr. Wahl said.

The UAB study was a retrospective, matched cohort analysis of 258 patients – 129 patients from pre-ERAS years were compared with 129 ERAS patients from January to October 2015.

Study subjects were similar in many patient- and procedure-specific factors; however, differences in operative approach, indication, ostomy formation, and operative time did not change the predicted length of stay among races, Dr. Wahl said.

Dr. Wahl said the racial makeup of the study differs from most ERAS literature in colorectal patients. “The overall percentage of the African American population was 30% within our study, as most ERAS literature has 10% or less,” he added.

“Further work needs to be pursued to find what’s driving these dramatic results among the black population,” he said.

Dr. Wahl and coauthors had no disclosures.

JACKSONVILLE, FLA. – An enhanced recovery protocol after colorectal surgery nearly eliminated differences in hospital stays between black and white patients, according to a study based on data from the University of Alabama at Birmingham.

Dr. Tyler S. Wahl, a resident at UAB reported on the institution’s experience with the Enhanced Recovery After Surgery (ERAS) pathway at the Association of Academic Surgery/Society of University Surgeons Academic Surgical Congress. “ERAS has been shown to reduce length of stay, cost, and perioperative complications without compromising readmission or mortality rates,” Dr. Wahl said. Dr. Daniel Chu was senior author.

Surgical literature has increasingly demonstrated disparities among black patients undergoing major surgery: longer lengths of stay, more readmissions, increased postoperative mortality and lower survival rates after colorectal cancer resections, Dr. Wahl said. The UAB investigators set out to determine whether the ERAS pathway would reduce disparities in length of stay among black and white patients when compared to the traditional pathway.

Before UAB started using ERAS for colorectal patients, the average length of stay for patients undergoing colorectal surgery was 6.7 days with significant differences between black and white patients: 8 days vs. 6.1 days, respectively. However, after implementation of the ERAS pathway in January 2015, average length of stay declined to 4.7 days overall. Black patients had dramatic reductions in length of stay, compared with white patients, with stays of 3.9 days vs. 5 days, respectively.

“Not only were patients leaving much earlier, but their length of stay was also shorter than predicted using the American College of Surgeons Risk Calculator,” Dr. Wahl said.

The UAB study was a retrospective, matched cohort analysis of 258 patients – 129 patients from pre-ERAS years were compared with 129 ERAS patients from January to October 2015.

Study subjects were similar in many patient- and procedure-specific factors; however, differences in operative approach, indication, ostomy formation, and operative time did not change the predicted length of stay among races, Dr. Wahl said.

Dr. Wahl said the racial makeup of the study differs from most ERAS literature in colorectal patients. “The overall percentage of the African American population was 30% within our study, as most ERAS literature has 10% or less,” he added.

“Further work needs to be pursued to find what’s driving these dramatic results among the black population,” he said.

Dr. Wahl and coauthors had no disclosures.

Post-surgical pain scores may be an overlooked quality indicator among hospitals, according to new research linking patient-reported pain scores with institutional pain management practices and also surgical outcomes.

A retrospective cohort study of patient-reported pain scores after colorectal resections at 52 Michigan hospitals, published in Annals of Surgery (2016 Jan 7; epub ahead of print; doi: 10.1097/SLA.0000000000001541), found that patients treated at the best-performing hospitals for postoperative pain scores were more likely to have received patient-controlled analgesia, compared with those in the worst-performing ones (56.5% vs. 22.8%; P less than .001).

For their research, Dr. Scott E. Regenbogen of the University of Michigan, Ann Arbor, and his colleagues looked at patient-reported pain scores on the first morning post-surgery for 7,221 colorectal operations between 2012 and 2014. The participating hospitals were part of a statewide collaborative that collects data on surgery patients with the aim of improving quality.

Dr. Regenbogen and his colleagues found that patients in the quartile of hospitals with the best pain scores stayed fewer days (6.5 vs. 7.9, P less than .007) and had fewer post-surgical complications (20.3% vs. 26.4%; P less than .001), compared with those in the worst-performing quartile of hospitals.

In addition, Dr. Regenbogen and his colleagues found postoperative emergency department visits, readmissions, and pulmonary complications to be significantly lower in the quartile of hospitals with the best pain scores. The fewer pulmonary complications seen linked with better pain control “could be an indicator of better pulmonary toilet or lesser respiratory depression,” they noted.

DiverDave/Wikicommons Creative Commons License

The correlation between surgical outcomes and pain scores, the investigators wrote, suggests “consistency in the overall quality performance across both clinical and patient-reported outcomes for colectomy.”

Mean self-rated pain scores, in which patients characterize the intensity of their pain on a scale of 0 to 10, ranged from 4 to 6 across the hospitals in the study, with 5.1 (standard deviation 2.44) reported for the cohort as a whole. The type of surgery also affected pain scores, with minimally invasive procedures associated with lower scores, compared with open or converted procedures. The type of anesthesia used (local or epidural) also significantly affected scores.

Hospitals with better pain scores tended to be somewhat larger than those with poor scores, and performed more colorectal resections per year, the investigators found.

The researchers noted that while a previous meta-analysis showed that patient-controlled analgesia post-surgery provided superior pain control, compared with intermittent treatment (Cochrane Database Syst Rev. 2006 Oct 18;18:CD003348), the hospitals in this study varied widely in their approaches, with 89% of the poorly performing quartile of hospitals using intermittent parenteral narcotics, compared with 66% in the best-performing quartile.

Dr. Regenbogen and his colleagues noted in their analysis that it was possible that the association between pain control and clinical outcomes such as readmissions and complications was driven by case or patient complexity differences among institutions. The 52 hospitals in the study varied in size and type, with community and academic hospitals as well as rural and urban institutions represented.

However, they wrote, it is more likely that “both pain scores and clinical outcomes reflect … global features of the quality of care in hospitals’ surgical performance. Thus, hospitals with the most streamlined, high-quality perioperative care pathways experience the best pain scores, as well as improved clinical outcomes.”

The findings, they concluded, “reveal systematic clinical care variation that could be reduced to improve patients’ experience of pain after colorectal resections.”

The researchers noted as a limitation of the study its reliance on patient-reported pain measures, and that it did not include data on patients’ pain history, opioid use prior to admission, or the administration of pre-emptive analgesia before surgery. The study was funded by the Michigan Surgical Quality Collaborative, which receives support from Blue Cross Blue Shield. None of the study authors declared conflicts of interest.

Post-surgical pain scores may be an overlooked quality indicator among hospitals, according to new research linking patient-reported pain scores with institutional pain management practices and also surgical outcomes.

A retrospective cohort study of patient-reported pain scores after colorectal resections at 52 Michigan hospitals, published in Annals of Surgery (2016 Jan 7; epub ahead of print; doi: 10.1097/SLA.0000000000001541), found that patients treated at the best-performing hospitals for postoperative pain scores were more likely to have received patient-controlled analgesia, compared with those in the worst-performing ones (56.5% vs. 22.8%; P less than .001).

For their research, Dr. Scott E. Regenbogen of the University of Michigan, Ann Arbor, and his colleagues looked at patient-reported pain scores on the first morning post-surgery for 7,221 colorectal operations between 2012 and 2014. The participating hospitals were part of a statewide collaborative that collects data on surgery patients with the aim of improving quality.

Dr. Regenbogen and his colleagues found that patients in the quartile of hospitals with the best pain scores stayed fewer days (6.5 vs. 7.9, P less than .007) and had fewer post-surgical complications (20.3% vs. 26.4%; P less than .001), compared with those in the worst-performing quartile of hospitals.

In addition, Dr. Regenbogen and his colleagues found postoperative emergency department visits, readmissions, and pulmonary complications to be significantly lower in the quartile of hospitals with the best pain scores. The fewer pulmonary complications seen linked with better pain control “could be an indicator of better pulmonary toilet or lesser respiratory depression,” they noted.

DiverDave/Wikicommons Creative Commons License

The correlation between surgical outcomes and pain scores, the investigators wrote, suggests “consistency in the overall quality performance across both clinical and patient-reported outcomes for colectomy.”

Mean self-rated pain scores, in which patients characterize the intensity of their pain on a scale of 0 to 10, ranged from 4 to 6 across the hospitals in the study, with 5.1 (standard deviation 2.44) reported for the cohort as a whole. The type of surgery also affected pain scores, with minimally invasive procedures associated with lower scores, compared with open or converted procedures. The type of anesthesia used (local or epidural) also significantly affected scores.

Hospitals with better pain scores tended to be somewhat larger than those with poor scores, and performed more colorectal resections per year, the investigators found.

The researchers noted that while a previous meta-analysis showed that patient-controlled analgesia post-surgery provided superior pain control, compared with intermittent treatment (Cochrane Database Syst Rev. 2006 Oct 18;18:CD003348), the hospitals in this study varied widely in their approaches, with 89% of the poorly performing quartile of hospitals using intermittent parenteral narcotics, compared with 66% in the best-performing quartile.

Dr. Regenbogen and his colleagues noted in their analysis that it was possible that the association between pain control and clinical outcomes such as readmissions and complications was driven by case or patient complexity differences among institutions. The 52 hospitals in the study varied in size and type, with community and academic hospitals as well as rural and urban institutions represented.

However, they wrote, it is more likely that “both pain scores and clinical outcomes reflect … global features of the quality of care in hospitals’ surgical performance. Thus, hospitals with the most streamlined, high-quality perioperative care pathways experience the best pain scores, as well as improved clinical outcomes.”

The findings, they concluded, “reveal systematic clinical care variation that could be reduced to improve patients’ experience of pain after colorectal resections.”

The researchers noted as a limitation of the study its reliance on patient-reported pain measures, and that it did not include data on patients’ pain history, opioid use prior to admission, or the administration of pre-emptive analgesia before surgery. The study was funded by the Michigan Surgical Quality Collaborative, which receives support from Blue Cross Blue Shield. None of the study authors declared conflicts of interest.

Post-surgical pain scores may be an overlooked quality indicator among hospitals, according to new research linking patient-reported pain scores with institutional pain management practices and also surgical outcomes.

A retrospective cohort study of patient-reported pain scores after colorectal resections at 52 Michigan hospitals, published in Annals of Surgery (2016 Jan 7; epub ahead of print; doi: 10.1097/SLA.0000000000001541), found that patients treated at the best-performing hospitals for postoperative pain scores were more likely to have received patient-controlled analgesia, compared with those in the worst-performing ones (56.5% vs. 22.8%; P less than .001).

For their research, Dr. Scott E. Regenbogen of the University of Michigan, Ann Arbor, and his colleagues looked at patient-reported pain scores on the first morning post-surgery for 7,221 colorectal operations between 2012 and 2014. The participating hospitals were part of a statewide collaborative that collects data on surgery patients with the aim of improving quality.

Dr. Regenbogen and his colleagues found that patients in the quartile of hospitals with the best pain scores stayed fewer days (6.5 vs. 7.9, P less than .007) and had fewer post-surgical complications (20.3% vs. 26.4%; P less than .001), compared with those in the worst-performing quartile of hospitals.

In addition, Dr. Regenbogen and his colleagues found postoperative emergency department visits, readmissions, and pulmonary complications to be significantly lower in the quartile of hospitals with the best pain scores. The fewer pulmonary complications seen linked with better pain control “could be an indicator of better pulmonary toilet or lesser respiratory depression,” they noted.

DiverDave/Wikicommons Creative Commons License

The correlation between surgical outcomes and pain scores, the investigators wrote, suggests “consistency in the overall quality performance across both clinical and patient-reported outcomes for colectomy.”

Mean self-rated pain scores, in which patients characterize the intensity of their pain on a scale of 0 to 10, ranged from 4 to 6 across the hospitals in the study, with 5.1 (standard deviation 2.44) reported for the cohort as a whole. The type of surgery also affected pain scores, with minimally invasive procedures associated with lower scores, compared with open or converted procedures. The type of anesthesia used (local or epidural) also significantly affected scores.

Hospitals with better pain scores tended to be somewhat larger than those with poor scores, and performed more colorectal resections per year, the investigators found.

The researchers noted that while a previous meta-analysis showed that patient-controlled analgesia post-surgery provided superior pain control, compared with intermittent treatment (Cochrane Database Syst Rev. 2006 Oct 18;18:CD003348), the hospitals in this study varied widely in their approaches, with 89% of the poorly performing quartile of hospitals using intermittent parenteral narcotics, compared with 66% in the best-performing quartile.

Dr. Regenbogen and his colleagues noted in their analysis that it was possible that the association between pain control and clinical outcomes such as readmissions and complications was driven by case or patient complexity differences among institutions. The 52 hospitals in the study varied in size and type, with community and academic hospitals as well as rural and urban institutions represented.

However, they wrote, it is more likely that “both pain scores and clinical outcomes reflect … global features of the quality of care in hospitals’ surgical performance. Thus, hospitals with the most streamlined, high-quality perioperative care pathways experience the best pain scores, as well as improved clinical outcomes.”

The findings, they concluded, “reveal systematic clinical care variation that could be reduced to improve patients’ experience of pain after colorectal resections.”

The researchers noted as a limitation of the study its reliance on patient-reported pain measures, and that it did not include data on patients’ pain history, opioid use prior to admission, or the administration of pre-emptive analgesia before surgery. The study was funded by the Michigan Surgical Quality Collaborative, which receives support from Blue Cross Blue Shield. None of the study authors declared conflicts of interest.

Older age, female sex, preoperative chronic steroid use, azotemia, respiratory insufficiency, and coagulopathy all predicted death within a month of colectomy in patients with toxic colitis in the National Surgical Quality Improvement Project database.

The study is the largest to evaluate patients undergoing colectomy for toxic colitis, according to lead investigator Dr. Anand Dayama of the University of California, Davis, and his associates.

Dmitrii Kotin/©Thinkstock

“In a case such as multiorgan failure with toxic colitis, the decision whether ... to operate can be an immensely difficult one,” Dr. Dayama and his colleagues wrote. “This study can help in making informed decisions in order to avoid the medicolegal ramifications of either performing an unnecessary procedure or withholding a lifesaving one,” they wrote in the American Journal of Surgery.

Surgical salvage remains the preferred treatment for patients with medically refractory toxic colitis. To assess outcomes in these patients, the researchers queried the National Surgical Quality Improvement Project database for relevant International Classification of Diseases, Ninth Revision codes between 2005 and 2012 (Am J Surg. 2015 Nov;210[5]:852-8).

The results underscored the severity of toxic colitis, they said. Of 189 patients, more than 26% died within 30 days after surgery, one in five developed postsurgical sepsis, about 17% had cardiovascular complications, 15% had wound complications, and 13% had renal complications. Furthermore, patients who were 70-80 years old had 3.5 times greater odds of dying, compared with younger patients (95% confidence interval, 1.0-12.8), and the increased likelihood of death rose by 22.2 when patients were older than 80 years (95% CI, 5.7-86.4).

Other baseline predictors of 30-day mortality included female sex (odds ratio, 4.1), blood urea nitrogen levels above 40 mg/dL (OR, 4.1), an international normalized ratio exceeding 2 (OR, 7.7), preoperative respiratory insufficiency (OR, 2.73), and a history of chronic steroid use (OR, 3.9), the researchers said. In addition, patients who died within 30 days after surgery were more likely than survivors to have undergone prolonged mechanical ventilation (56% vs. 27%), to have returned to the operating room (18% vs. 14%), to have acute renal failure (28% vs. 6%), or to have suffered a cardiac arrest that required cardiopulmonary resuscitation (18% vs. 7%). Survivors averaged about 2 fewer days in the hospital, compared with patients who died after surgery.

“The high morbidity and mortality of toxic colitis requires early and intensive medical management with IV [intravenous] steroids, antibiotics, decompressive maneuvers, and other resuscitative measures to treat the underlying cause,” they emphasized. “If there is no sign of improvement within 7 days or if there are any signs of deterioration, urgent surgical intervention should be considered.”

The link between female sex and mortality might reflect hormonal changes associated with menopause, but the study did not assess hormonal status or use of hormone therapy, the investigators noted. The association between chronic steroid use and postoperative death “is highly relevant” because long-term steroids are so often used in inflammatory bowel disease, they added. Clinical guidelines (Am J Gastroenterol. 2012 Feb;107:179-94) recommend that patients with acute severe ulcerative colitis proceed to second-line therapy or surgery if they do not respond to 3 days of intravenous steroids, because unnecessary delays can increase the risk of postoperative complications, they added.

The researchers reported no funding sources and had no disclosures.

Older age, female sex, preoperative chronic steroid use, azotemia, respiratory insufficiency, and coagulopathy all predicted death within a month of colectomy in patients with toxic colitis in the National Surgical Quality Improvement Project database.

The study is the largest to evaluate patients undergoing colectomy for toxic colitis, according to lead investigator Dr. Anand Dayama of the University of California, Davis, and his associates.

Dmitrii Kotin/©Thinkstock

“In a case such as multiorgan failure with toxic colitis, the decision whether ... to operate can be an immensely difficult one,” Dr. Dayama and his colleagues wrote. “This study can help in making informed decisions in order to avoid the medicolegal ramifications of either performing an unnecessary procedure or withholding a lifesaving one,” they wrote in the American Journal of Surgery.

Surgical salvage remains the preferred treatment for patients with medically refractory toxic colitis. To assess outcomes in these patients, the researchers queried the National Surgical Quality Improvement Project database for relevant International Classification of Diseases, Ninth Revision codes between 2005 and 2012 (Am J Surg. 2015 Nov;210[5]:852-8).

The results underscored the severity of toxic colitis, they said. Of 189 patients, more than 26% died within 30 days after surgery, one in five developed postsurgical sepsis, about 17% had cardiovascular complications, 15% had wound complications, and 13% had renal complications. Furthermore, patients who were 70-80 years old had 3.5 times greater odds of dying, compared with younger patients (95% confidence interval, 1.0-12.8), and the increased likelihood of death rose by 22.2 when patients were older than 80 years (95% CI, 5.7-86.4).

Other baseline predictors of 30-day mortality included female sex (odds ratio, 4.1), blood urea nitrogen levels above 40 mg/dL (OR, 4.1), an international normalized ratio exceeding 2 (OR, 7.7), preoperative respiratory insufficiency (OR, 2.73), and a history of chronic steroid use (OR, 3.9), the researchers said. In addition, patients who died within 30 days after surgery were more likely than survivors to have undergone prolonged mechanical ventilation (56% vs. 27%), to have returned to the operating room (18% vs. 14%), to have acute renal failure (28% vs. 6%), or to have suffered a cardiac arrest that required cardiopulmonary resuscitation (18% vs. 7%). Survivors averaged about 2 fewer days in the hospital, compared with patients who died after surgery.

“The high morbidity and mortality of toxic colitis requires early and intensive medical management with IV [intravenous] steroids, antibiotics, decompressive maneuvers, and other resuscitative measures to treat the underlying cause,” they emphasized. “If there is no sign of improvement within 7 days or if there are any signs of deterioration, urgent surgical intervention should be considered.”

The link between female sex and mortality might reflect hormonal changes associated with menopause, but the study did not assess hormonal status or use of hormone therapy, the investigators noted. The association between chronic steroid use and postoperative death “is highly relevant” because long-term steroids are so often used in inflammatory bowel disease, they added. Clinical guidelines (Am J Gastroenterol. 2012 Feb;107:179-94) recommend that patients with acute severe ulcerative colitis proceed to second-line therapy or surgery if they do not respond to 3 days of intravenous steroids, because unnecessary delays can increase the risk of postoperative complications, they added.

The researchers reported no funding sources and had no disclosures.

Older age, female sex, preoperative chronic steroid use, azotemia, respiratory insufficiency, and coagulopathy all predicted death within a month of colectomy in patients with toxic colitis in the National Surgical Quality Improvement Project database.

The study is the largest to evaluate patients undergoing colectomy for toxic colitis, according to lead investigator Dr. Anand Dayama of the University of California, Davis, and his associates.

Dmitrii Kotin/©Thinkstock

“In a case such as multiorgan failure with toxic colitis, the decision whether ... to operate can be an immensely difficult one,” Dr. Dayama and his colleagues wrote. “This study can help in making informed decisions in order to avoid the medicolegal ramifications of either performing an unnecessary procedure or withholding a lifesaving one,” they wrote in the American Journal of Surgery.

Surgical salvage remains the preferred treatment for patients with medically refractory toxic colitis. To assess outcomes in these patients, the researchers queried the National Surgical Quality Improvement Project database for relevant International Classification of Diseases, Ninth Revision codes between 2005 and 2012 (Am J Surg. 2015 Nov;210[5]:852-8).

The results underscored the severity of toxic colitis, they said. Of 189 patients, more than 26% died within 30 days after surgery, one in five developed postsurgical sepsis, about 17% had cardiovascular complications, 15% had wound complications, and 13% had renal complications. Furthermore, patients who were 70-80 years old had 3.5 times greater odds of dying, compared with younger patients (95% confidence interval, 1.0-12.8), and the increased likelihood of death rose by 22.2 when patients were older than 80 years (95% CI, 5.7-86.4).

Other baseline predictors of 30-day mortality included female sex (odds ratio, 4.1), blood urea nitrogen levels above 40 mg/dL (OR, 4.1), an international normalized ratio exceeding 2 (OR, 7.7), preoperative respiratory insufficiency (OR, 2.73), and a history of chronic steroid use (OR, 3.9), the researchers said. In addition, patients who died within 30 days after surgery were more likely than survivors to have undergone prolonged mechanical ventilation (56% vs. 27%), to have returned to the operating room (18% vs. 14%), to have acute renal failure (28% vs. 6%), or to have suffered a cardiac arrest that required cardiopulmonary resuscitation (18% vs. 7%). Survivors averaged about 2 fewer days in the hospital, compared with patients who died after surgery.

“The high morbidity and mortality of toxic colitis requires early and intensive medical management with IV [intravenous] steroids, antibiotics, decompressive maneuvers, and other resuscitative measures to treat the underlying cause,” they emphasized. “If there is no sign of improvement within 7 days or if there are any signs of deterioration, urgent surgical intervention should be considered.”

The link between female sex and mortality might reflect hormonal changes associated with menopause, but the study did not assess hormonal status or use of hormone therapy, the investigators noted. The association between chronic steroid use and postoperative death “is highly relevant” because long-term steroids are so often used in inflammatory bowel disease, they added. Clinical guidelines (Am J Gastroenterol. 2012 Feb;107:179-94) recommend that patients with acute severe ulcerative colitis proceed to second-line therapy or surgery if they do not respond to 3 days of intravenous steroids, because unnecessary delays can increase the risk of postoperative complications, they added.

The researchers reported no funding sources and had no disclosures.

CHICAGO – Watchful waiting with careful surveillance may become an option for the majority of locally advanced rectal cancer patients who have a complete clinical response to neoadjuvant therapy, according to a review of 442 rectal cancer patients at Memorial Sloan Kettering Cancer Center in New York.

Seventy-three of those patients had a complete clinical response to neoadjuvant therapy and opted for watchful waiting instead of surgery after weighing the risks and benefits – including about a 25% chance of local recurrence – with their doctors.

At 4 years’ follow-up, 54 (74%) remained cancer free. Nineteen patients had local tumor recurrence, generally within 13 months. Two of those patients had successful local excisions, and the remaining 17 had salvage total mesorectal excisions (TME).

There were no statistically significant differences in 4-year disease-specific and overall survival among the 73 patients and 72 other patients who opted for TME after neoadjuvant chemotherapy and were found to have had pathologic complete responses.

“In our cohort, watch and wait was safe. It’s an effective treatment strategy achieving a high rate of rectal preservation in tumors that respond to neoadjuvant therapy. I don’t think the rectum needs to come out in everybody,” said investigator Dr. J. Joshua Smith, a surgical oncologist at Sloan Kettering.

Several studies have reported similar results similar to the Sloan Kettering study, but other investigations have been retrospective, so optimal patient selection, assessment of response, surveillance protocols, and other matters remain uncertain. Sloan Kettering and about 20 other cancer centers in United States – all members of the Rectal Cancer Consortium – recently launched a randomized clinical trial to get a better handle on those issues.

Locally advanced rectal cancer patients will be randomized to either chemoradiation for 5.5 weeks followed by folinic acid, fluorouracil, and oxaliplatin (FOLFOX) or capecitabine and oxaliplatin (CapeOX) over about 16 weeks, or FOLFOX/CapeOX first and chemoradiation second. Those who have a significant clinical response will then undergo watchful waiting; those who do not will have TME.

About 50 patients have enrolled in the phase II trial so far; the investigators are looking for more than 200.

“I think ‘prime time for watchful waiting’ is around the corner, but not yet here. It must be preceded by a prospective trial.” Meanwhile, “how we define complete clinical response is important” when considering watchful waiting, Dr. Smith said at the annual clinical congress of the American College of Surgeons..

At Sloan Kettering, where watchful waiting has become more popular in recent years, complete clinical response means no tumor or lymph nodes on imaging, and, on digital rectal exam (DRE) and proctoscopy, normal flat mucosa, smooth induration, no mass, no nodules, no ulcerations, and no luminal narrowing; a pale scar and telangiectasias are okay.

In the first year, surveillance includes DRE and endoscopy every 3 months and imaging every 6 months. In the second year, DRE and endoscopy come every 4 months, and imaging again every 6 months. From years 3 to 5, DRE and endoscopy are done every 6 months, and imaging every 6-12 months. After 5 years, surveillance is by yearly DRE and endoscopy.

When discussing the option with patients, they need to know – besides the risk of recurrence – that watchful waiting is currently not standard medical management; surveillance must be frequent; they are at risk for a more extensive salvage TME than they might have had otherwise; and the approach might compromise the chance of a cure, Dr. Smith said.

Dr. Smith said he has no relevant disclosures.

[email protected]

CHICAGO – Watchful waiting with careful surveillance may become an option for the majority of locally advanced rectal cancer patients who have a complete clinical response to neoadjuvant therapy, according to a review of 442 rectal cancer patients at Memorial Sloan Kettering Cancer Center in New York.

Seventy-three of those patients had a complete clinical response to neoadjuvant therapy and opted for watchful waiting instead of surgery after weighing the risks and benefits – including about a 25% chance of local recurrence – with their doctors.

At 4 years’ follow-up, 54 (74%) remained cancer free. Nineteen patients had local tumor recurrence, generally within 13 months. Two of those patients had successful local excisions, and the remaining 17 had salvage total mesorectal excisions (TME).

There were no statistically significant differences in 4-year disease-specific and overall survival among the 73 patients and 72 other patients who opted for TME after neoadjuvant chemotherapy and were found to have had pathologic complete responses.

“In our cohort, watch and wait was safe. It’s an effective treatment strategy achieving a high rate of rectal preservation in tumors that respond to neoadjuvant therapy. I don’t think the rectum needs to come out in everybody,” said investigator Dr. J. Joshua Smith, a surgical oncologist at Sloan Kettering.

Several studies have reported similar results similar to the Sloan Kettering study, but other investigations have been retrospective, so optimal patient selection, assessment of response, surveillance protocols, and other matters remain uncertain. Sloan Kettering and about 20 other cancer centers in United States – all members of the Rectal Cancer Consortium – recently launched a randomized clinical trial to get a better handle on those issues.

Locally advanced rectal cancer patients will be randomized to either chemoradiation for 5.5 weeks followed by folinic acid, fluorouracil, and oxaliplatin (FOLFOX) or capecitabine and oxaliplatin (CapeOX) over about 16 weeks, or FOLFOX/CapeOX first and chemoradiation second. Those who have a significant clinical response will then undergo watchful waiting; those who do not will have TME.

About 50 patients have enrolled in the phase II trial so far; the investigators are looking for more than 200.

“I think ‘prime time for watchful waiting’ is around the corner, but not yet here. It must be preceded by a prospective trial.” Meanwhile, “how we define complete clinical response is important” when considering watchful waiting, Dr. Smith said at the annual clinical congress of the American College of Surgeons..

At Sloan Kettering, where watchful waiting has become more popular in recent years, complete clinical response means no tumor or lymph nodes on imaging, and, on digital rectal exam (DRE) and proctoscopy, normal flat mucosa, smooth induration, no mass, no nodules, no ulcerations, and no luminal narrowing; a pale scar and telangiectasias are okay.

In the first year, surveillance includes DRE and endoscopy every 3 months and imaging every 6 months. In the second year, DRE and endoscopy come every 4 months, and imaging again every 6 months. From years 3 to 5, DRE and endoscopy are done every 6 months, and imaging every 6-12 months. After 5 years, surveillance is by yearly DRE and endoscopy.

When discussing the option with patients, they need to know – besides the risk of recurrence – that watchful waiting is currently not standard medical management; surveillance must be frequent; they are at risk for a more extensive salvage TME than they might have had otherwise; and the approach might compromise the chance of a cure, Dr. Smith said.

Dr. Smith said he has no relevant disclosures.

[email protected]

CHICAGO – Watchful waiting with careful surveillance may become an option for the majority of locally advanced rectal cancer patients who have a complete clinical response to neoadjuvant therapy, according to a review of 442 rectal cancer patients at Memorial Sloan Kettering Cancer Center in New York.

Seventy-three of those patients had a complete clinical response to neoadjuvant therapy and opted for watchful waiting instead of surgery after weighing the risks and benefits – including about a 25% chance of local recurrence – with their doctors.

At 4 years’ follow-up, 54 (74%) remained cancer free. Nineteen patients had local tumor recurrence, generally within 13 months. Two of those patients had successful local excisions, and the remaining 17 had salvage total mesorectal excisions (TME).

There were no statistically significant differences in 4-year disease-specific and overall survival among the 73 patients and 72 other patients who opted for TME after neoadjuvant chemotherapy and were found to have had pathologic complete responses.

“In our cohort, watch and wait was safe. It’s an effective treatment strategy achieving a high rate of rectal preservation in tumors that respond to neoadjuvant therapy. I don’t think the rectum needs to come out in everybody,” said investigator Dr. J. Joshua Smith, a surgical oncologist at Sloan Kettering.

Several studies have reported similar results similar to the Sloan Kettering study, but other investigations have been retrospective, so optimal patient selection, assessment of response, surveillance protocols, and other matters remain uncertain. Sloan Kettering and about 20 other cancer centers in United States – all members of the Rectal Cancer Consortium – recently launched a randomized clinical trial to get a better handle on those issues.

Locally advanced rectal cancer patients will be randomized to either chemoradiation for 5.5 weeks followed by folinic acid, fluorouracil, and oxaliplatin (FOLFOX) or capecitabine and oxaliplatin (CapeOX) over about 16 weeks, or FOLFOX/CapeOX first and chemoradiation second. Those who have a significant clinical response will then undergo watchful waiting; those who do not will have TME.

About 50 patients have enrolled in the phase II trial so far; the investigators are looking for more than 200.

“I think ‘prime time for watchful waiting’ is around the corner, but not yet here. It must be preceded by a prospective trial.” Meanwhile, “how we define complete clinical response is important” when considering watchful waiting, Dr. Smith said at the annual clinical congress of the American College of Surgeons..

At Sloan Kettering, where watchful waiting has become more popular in recent years, complete clinical response means no tumor or lymph nodes on imaging, and, on digital rectal exam (DRE) and proctoscopy, normal flat mucosa, smooth induration, no mass, no nodules, no ulcerations, and no luminal narrowing; a pale scar and telangiectasias are okay.

In the first year, surveillance includes DRE and endoscopy every 3 months and imaging every 6 months. In the second year, DRE and endoscopy come every 4 months, and imaging again every 6 months. From years 3 to 5, DRE and endoscopy are done every 6 months, and imaging every 6-12 months. After 5 years, surveillance is by yearly DRE and endoscopy.

When discussing the option with patients, they need to know – besides the risk of recurrence – that watchful waiting is currently not standard medical management; surveillance must be frequent; they are at risk for a more extensive salvage TME than they might have had otherwise; and the approach might compromise the chance of a cure, Dr. Smith said.

Dr. Smith said he has no relevant disclosures.

[email protected]

CHICAGO – Access to equal care decreases but does not eliminate the survival disparities between black and white patients with rectal cancer, according to investigators from the University of Cincinnati, Ohio.

After rigorous propensity score matching of thousands of black and white patients for patient, disease, and treatment characteristics, median survival was 109.6 months among white patients and 85.8 months among black patients (J Am Coll Surg. 2015 Nov [doi: 10.1016/j.jamcollsurg.2015.07.056]).

“Blacks have worse outcomes, but we don’t have a clear explanation,” explained investigator and surgery resident Dr. Meghan Nolan. For now, the findings suggest that it might be a good idea to start screening black patients before age 50 years, perhaps even as early as age 40 years.

“We are urging people to screen at a lower age in black patients,” Dr. Nolan said at the annual clinical congress of the American College of Surgeons.

Racial disparities in rectal cancer are well known. The investigators wanted to see if they simply are because of unequal access to care, so they analyzed 178,414 white and 18,385 black patients in the National Cancer Data Base from 1998 to 2006.

Mean 5-year survival for blacks was 50.7%, compared with 56.2% for whites, and black patients were more likely to present with stage IV disease. Such findings aren’t new, the investigators noted.

To account for the difference in late-stage presentation, the investigators limited their analysis to patients with stage I-III rectal cancer. But even then, 5-year survival was 66.7% among whites and 58.7% among blacks.

That might have had something to do with the fact 85% of white patients, but only 78% of black patients, had surgery for those potentially curable lower-stage tumors. Among those who didn’t undergo surgery, patient refusal was slightly more common among black patients than white patients, which suggests that “cultural factors may be playing a role” in the surgery disparity, Dr. Nolan said.

The investigators controlled for the different surgery rates by limiting their analysis to stage I-III patients who had appropriate operations. The survival gap narrowed but did not disappear: 65.8% of white patients were alive at 5 years, compared with 61% of black patients. Blacks were also more likely to have positive margins on pathology. “I’m not sure why. That was a surprise,” Dr. Nolan said.

The propensity score matching led the team to conclude that there’s more at work than differences in access to care. A total of 7,569 pairs of black and white patients were matched for age at diagnosis, gender, insurance coverage, income, education, facility type, tumor stage, Charlson-Deyo score, surgical management, margin status, and other potential confounders.

Every matched patient completed their recommended therapy, and there was no statistical difference between matched black and white patients who received appropriate, stage-specific chemoradiation. Still, the survival differences persisted.

Dr. Nolan had no relevant disclosures.

[email protected]

CHICAGO – Access to equal care decreases but does not eliminate the survival disparities between black and white patients with rectal cancer, according to investigators from the University of Cincinnati, Ohio.

After rigorous propensity score matching of thousands of black and white patients for patient, disease, and treatment characteristics, median survival was 109.6 months among white patients and 85.8 months among black patients (J Am Coll Surg. 2015 Nov [doi: 10.1016/j.jamcollsurg.2015.07.056]).

“Blacks have worse outcomes, but we don’t have a clear explanation,” explained investigator and surgery resident Dr. Meghan Nolan. For now, the findings suggest that it might be a good idea to start screening black patients before age 50 years, perhaps even as early as age 40 years.

“We are urging people to screen at a lower age in black patients,” Dr. Nolan said at the annual clinical congress of the American College of Surgeons.

Racial disparities in rectal cancer are well known. The investigators wanted to see if they simply are because of unequal access to care, so they analyzed 178,414 white and 18,385 black patients in the National Cancer Data Base from 1998 to 2006.

Mean 5-year survival for blacks was 50.7%, compared with 56.2% for whites, and black patients were more likely to present with stage IV disease. Such findings aren’t new, the investigators noted.

To account for the difference in late-stage presentation, the investigators limited their analysis to patients with stage I-III rectal cancer. But even then, 5-year survival was 66.7% among whites and 58.7% among blacks.

That might have had something to do with the fact 85% of white patients, but only 78% of black patients, had surgery for those potentially curable lower-stage tumors. Among those who didn’t undergo surgery, patient refusal was slightly more common among black patients than white patients, which suggests that “cultural factors may be playing a role” in the surgery disparity, Dr. Nolan said.

The investigators controlled for the different surgery rates by limiting their analysis to stage I-III patients who had appropriate operations. The survival gap narrowed but did not disappear: 65.8% of white patients were alive at 5 years, compared with 61% of black patients. Blacks were also more likely to have positive margins on pathology. “I’m not sure why. That was a surprise,” Dr. Nolan said.

The propensity score matching led the team to conclude that there’s more at work than differences in access to care. A total of 7,569 pairs of black and white patients were matched for age at diagnosis, gender, insurance coverage, income, education, facility type, tumor stage, Charlson-Deyo score, surgical management, margin status, and other potential confounders.

Every matched patient completed their recommended therapy, and there was no statistical difference between matched black and white patients who received appropriate, stage-specific chemoradiation. Still, the survival differences persisted.

Dr. Nolan had no relevant disclosures.

[email protected]

CHICAGO – Access to equal care decreases but does not eliminate the survival disparities between black and white patients with rectal cancer, according to investigators from the University of Cincinnati, Ohio.

After rigorous propensity score matching of thousands of black and white patients for patient, disease, and treatment characteristics, median survival was 109.6 months among white patients and 85.8 months among black patients (J Am Coll Surg. 2015 Nov [doi: 10.1016/j.jamcollsurg.2015.07.056]).

“Blacks have worse outcomes, but we don’t have a clear explanation,” explained investigator and surgery resident Dr. Meghan Nolan. For now, the findings suggest that it might be a good idea to start screening black patients before age 50 years, perhaps even as early as age 40 years.

“We are urging people to screen at a lower age in black patients,” Dr. Nolan said at the annual clinical congress of the American College of Surgeons.

Racial disparities in rectal cancer are well known. The investigators wanted to see if they simply are because of unequal access to care, so they analyzed 178,414 white and 18,385 black patients in the National Cancer Data Base from 1998 to 2006.

Mean 5-year survival for blacks was 50.7%, compared with 56.2% for whites, and black patients were more likely to present with stage IV disease. Such findings aren’t new, the investigators noted.

To account for the difference in late-stage presentation, the investigators limited their analysis to patients with stage I-III rectal cancer. But even then, 5-year survival was 66.7% among whites and 58.7% among blacks.

That might have had something to do with the fact 85% of white patients, but only 78% of black patients, had surgery for those potentially curable lower-stage tumors. Among those who didn’t undergo surgery, patient refusal was slightly more common among black patients than white patients, which suggests that “cultural factors may be playing a role” in the surgery disparity, Dr. Nolan said.

The investigators controlled for the different surgery rates by limiting their analysis to stage I-III patients who had appropriate operations. The survival gap narrowed but did not disappear: 65.8% of white patients were alive at 5 years, compared with 61% of black patients. Blacks were also more likely to have positive margins on pathology. “I’m not sure why. That was a surprise,” Dr. Nolan said.

The propensity score matching led the team to conclude that there’s more at work than differences in access to care. A total of 7,569 pairs of black and white patients were matched for age at diagnosis, gender, insurance coverage, income, education, facility type, tumor stage, Charlson-Deyo score, surgical management, margin status, and other potential confounders.

Every matched patient completed their recommended therapy, and there was no statistical difference between matched black and white patients who received appropriate, stage-specific chemoradiation. Still, the survival differences persisted.

Dr. Nolan had no relevant disclosures.

[email protected]