Prophylactic defunctioning stomas improve clinical outcomes of anastomotic leak following rectal cancer resections: An analysis of the US Rectal Cancer Consortium.

PURPOSE: Anastomotic leak (AL) is a complication of low anterior resection (LAR) that results in substantial morbidity. There is immense interest in evaluating immediate postoperative and long-term oncologic outcomes in patients who undergo diverting loop ileostomies (DLI). The purpose of this study is to understand the relationship between fecal diversion, AL, and oncologic outcomes. METHODS: This is a retrospective multicenter cohort study using patient data obtained from the US Rectal Cancer Consortium database compiled from six academic institutions. The study population included patients with rectal adenocarcinoma undergoing LAR. The primary outcome was the incidence of AL among patients who did or did not receive DLI during LAR. Secondary outcomes included risk factors for AL, receipt of adjuvant therapy, 3-year overall survival, and 3-year recurrence. RESULTS: Of 815 patients, 38 (4.7%) suffered AL after LAR. Patients with AL were more likely to be male, have unintentional preoperative weight loss, and are less likely to undergo DLI. On multivariable analysis, DLI remained protective against AL (p < 0.001). Diverted patients were less likely to undergo future surgical procedures including additional ostomy creation, completion proctectomy, or pelvic washout for AL. Subgroup analysis of 456 patients with locally advanced disease showed that DLI was correlated with increased receipt of adjuvant therapy for patients with and without AL on univariate analysis (SHR:1.59; [95% CI 1.19-2.14]; p = 0.002), but significance was not met in multivariate models. CONCLUSION: Lack of DLI and preoperative weight loss was associated with anastomotic leak. Fecal diversion may improve the timely initiation of adjuvant oncologic therapy. The long-term outcomes following routine diverting stomas warrant further study.

Development of a Predictive Nomogram for Circumferential Resection Margin in Rectal Cancer Surgery.

INTRODUCTION: Circumferential resection margin (CRM) is a key quality metric and predictor of oncologic outcomes and overall survival following surgery for rectal cancer. We aimed to develop a nomogram to identify patients at risk for a positive CRM in the preoperative setting. METHODS: We performed a retrospective evaluation of the National Cancer Database from 2010 to 2014 for patients with clinical stage I-III rectal cancer who underwent total mesorectal excision. Patients were excluded for emergency operation, resection for cancer recurrence, palliative resection, transanal resection, and missing CRM status. The primary outcome was positive CRM. Secondary outcomes included overall survival. RESULTS: There were 28,790 patients included. 2245 (7.8%) had a positive CRM. Higher tumor grade, lack of neoadjuvant chemotherapy, mucinous/signet tumor histology, open approach, abdominoperineal resection, higher T stage, lymphovascular invasion, and perineural invasion were all significantly associated with positive CRM (P < 0.05) and were included in the nomogram. The C-statistic was 0.703, suggesting a good predictive model. CONCLUSIONS: Positive CRM is associated with specific patient demographics and tumor characteristics. These factors can be used along with preoperative MRI to predict CRM positivity in the preoperative period and plan accordingly.

Opioid Utilization in Outpatient Anorectal Surgery: An Opportunity for Improvement.

INTRODUCTION: The opioid epidemic has resulted in close examination of postsurgical prescribing patterns. Little is known about postoperative opioid use in outpatient anorectal procedures. This study evaluated patient opioid use and created prescribing recommendations for these procedures. METHODS: One hundred and four patients undergoing outpatient anorectal procedures from January to May 2018 were surveyed on opioid consumption, surgical experience, and pain satisfaction. Patients were grouped into three tiers based on opioid usage. Multivariable models were used to determine factors associated with poor pain control. RESULTS: Patient satisfaction with pain control was 85.6%. Twenty five percent of patients reported leftover medication and 9.6% of patients requested opioid refills. Opioid prescribing recommendations were generated for each tier using 50th percentile with interquartile ranges. On multivariable modeling, the high-tier group was associated with poorer pain control. CONCLUSIONS: We created opioid quantity prescribing guidelines for common outpatient anorectal procedures. A multimodal approach to pain control utilizing nonopioids may reduce healthcare utilization.

The correlation Between anal pap cytology and histologic outcomes in HIV-Positive males.

BACKGROUND: Anal intraepithelial neoplasia is a precursor to anal carcinoma. The use of anal pap cytology has been accepted as a screening method for anal carcinoma, however sensitivity and specificity vary. MATERIALS AND METHODS: Retrospective cohort study involving 155 HIV-positive males with abnormal anal cytology and surgical resection. RESULTS: 155 patients met inclusion criteria. 31.6% were diagnosed with atypical cytology, 61.9% with low-grade cytology, and 6.4% with high-grade cytology. At surgery, 19.4% were diagnosed with condylomata, 34.8% with anal intraepithelial neoplasia 1, 17.4% with anal intraepithelial neoplasia 2, 27.1% with anal intraepithelial neoplasia 3 and 1.3% with anal carcinoma. There was a positive correlation between high-grade anal cytology and high-grade histology (r = 0.27; p = 0.0008). Comparison of risk factors showed no significant association. CONCLUSION: Anal cytology has a significant correlation with surgical histology. There were still instances of high-grade lesions being found after low-grade cytology. This highlights the necessity of patients with low-grade cytology undergoing anoscopic evaluation.

Is newer always better?: comparing cost and short-term outcomes between laparoscopic and robotic right hemicolectomy.

BACKGROUND: Enthusiasm is high for expansion of robotic assisted surgery into right hemicolectomy. But data on outcomes and cost is lacking. Our objective was to determine the association between surgical approach and cost for minimally invasive right hemicolectomy. We hypothesized that a robot approach would have increased costs (both economic and opportunity) while achieving similar short-term outcomes. METHODS: We performed a retrospective cohort analysis with a simulation of operating room utilization at a quaternary care, academic institution. We enrolled patients undergoing minimally invasive right hemicolectomy from November 2017 to August 2019. Patients were categorized by the intended approach- laparoscopic or robotic. The primary outcome was the technical variable direct cost. Secondary outcomes included total cost, supply cost, operating room utilization, operative time, conversion, length of stay and 30-day post-operative outcomes. RESULTS: 79 patients were included in the study. A robotic approach was used in 22% of the cohort. The groups differed significantly only in etiology of surgery. Robotic surgery was associated with a 1.5 times increase in the technical variable direct cost (p < 0.001), increased supply cost (2.6 times; p < 0.001) and increased total cost (1.3 times; p < 0.001). Significant differences were observed in median room time (Robotic: 285 min vs. Laparoscopic: 170 min; p < 0.001) and procedure time (Robotic: 203 min vs. Laparoscopic: 118 min; p < 0.001). There were no differences observed in post-operative outcomes including length of stay or readmission. In a simulation of OR utilization, 45 laparoscopic right hemicolectomies could be performed in an OR in a month compared to 31 robotic cases. CONCLUSIONS: Robotic right hemicolectomy was associated with increased costs with no improvement in post-operative outcomes. In a simulation of operating room efficiency, a robotic approach was associated with 14 fewer cases per month. Practitioners and administrators should be aware of the increased cost of a robotic approach.

Safety considerations with new treatment regimens for anal cancer.

Introduction: Anal cancer is a rare malignancy, but incidence rates are rising. Primary chemoradiation is the standard of care for early disease with surgery reserved for salvage. Despite success in terms of survival, patients suffer significant morbidity. Research is underway to advance the field and improve outcomes for these patients.Areas covered: This review aims to discuss the safety and efficacy of new approaches to treat anal cancer. A literature search was performed from January 1950 through November 2020 via PubMed and ClinicalTrials.gov databases to obtain data from ongoing or published studies examining new regimens for the treatment of anal cancers. Pertinent topics covered include miniature drug conjugates, epidermal growth factor receptor inhibitors, checkpoint inhibitor combinations, and novel immunomodulators.Expert opinion: Based on emerging clinical data, the treatment paradigm for anal cancer is likely to shift in the upcoming years. One of the largest areas of investigation is the field of immunotherapy, which may emerge as an integral component of anal cancer for all treatment settings.

Benchmarking patient satisfaction scores in a colorectal patient population.

BACKGROUND: Healthcare reimbursement is rapidly moving away from a fee-for-service model toward value-based purchasing. An integral component of this new focus on quality is patient-centered outcomes. One metric used to define patient satisfaction is the Press Ganey Patient Satisfaction Survey. Data are lacking to accurately benchmark these scores based on diagnosis. We sought to identify if different colorectal disease processes affected a patient's perception of their healthcare experience. METHODS: Adult colorectal patients seen between July 2015 and September 2016 in a tertiary hospital colorectal clinic were mailed a Press Ganey survey. Patients were stratified based on diagnosis: neoplasia, IBD, anorectal and benign colorectal disease. Survey scores were compared across the groups with adjustment for confounding variables. RESULTS: 312 patients responded and formed the cohort. The mean age was 61 (range 18-93) and 56% were women. The cohort breakdown was 38% neoplasia, 32% anorectal, 21% benign, and 9% IBD. In a multivariable model, there was a difference in PG scores by diagnosis; patients with neoplasia had higher Overall scores (ß 10.2; Std Error 4.0; p = 0.01), Care Provider scores (ß 8.5; Std Error 4.2; p = 0.04), Nurse Assistant scores (ß 15.0; Std Error 5.7; p = 0.01), and Personal Issues scores (ß 11.8; Std Error 5/0; p = 0.01). CONCLUSION: Press Ganey scores were found to vary significantly. Patients with a neoplasia diagnosis reported higher overall satisfaction, Care Provider, Nurse Assistant, and Personal Issues scores. Adjustment for disease condition is important when assessing patient satisfaction as an indicator of quality and as a metric for reimbursement. This study adds to increasing evidence about bias in these scores.

Morphological and Genetic Variation Among Populations of the Fiddler Crab Minuca burgersi (Holthuis, 1967) (Crustacea: Brachyura: Ocypodidae) from Shores of the Caribbean Basin and Western South Atlantic Ocean.

For this study, in addition to museum vouchers, 1437 specimens of Minuca burgersi (Holthuis, 1967) were collected from crab colonies at 105 locations in the western Atlantic Ocean to examine diversity in a species with a large geographic range. Both allometric and geometric morphometry were coupled with the molecular analysis of DNA to give a broader perspective of intraspecific variability in this species. A total of 1153 specimens from the Caribbean Sea and the Atlantic coast of South America demonstrated that M. burgersi from both regions are very similar in their pattern of growth. The average carapace width (CW) for Caribbean is larger than the average for South American males and females. However, size distribution based on CW is unimodal in Caribbean and bimodal in South American populations. The carapace length-width ratio is about 0.68 in females and 0.66 in males. South American males express asymmetric elongation of the cheliped in smaller CW intervals than Caribbean males. In a sample of 259 females, carapace shape is distinct between South American and Caribbean populations. Caribbean populations have less swelling in the branchial regions than South American populations. The swelling correlates primarily with geographic region and to a lesser degree with substrate and salinity. Molecular data from the 16S rDNA and cytochrome c oxidase subunit I (COI) reveal three clades within Minuca burgersi. Two clades are distributed in the Caribbean and the third in eastern South America. The timing of divergence between Caribbean and South American clades is coincident with an increased rate of water and sediment outflow from the Amazon as inferred from the geologic record. Current patterns and associated gene flow within the Caribbean were subsequently influenced by the closing of the Isthmus of Panama. We speculate that various populations may employ different larval dispersion mechanisms resulting in genetic heterogeneity. Consequently, there is considerable biological divergence among populations of M. burgersi in the Caribbean and South America.

Improving understanding of type 2 diabetes remission: research recommendations from Diabetes UK's 2019 remission workshop.

AIM: To describe the process and outputs of a workshop convened to identify key priorities for future research in the area of remission of type 2 diabetes, and provide recommendations to researchers and research funders on how best to address them. With the ultimate aim of enabling the remission of type 2 diabetes to become a possibility for more people. METHODS: A 1-day research workshop was conducted, bringing together 31 researchers, people living with diabetes, healthcare professionals and members of staff from Diabetes UK to identify and prioritize recommendations for future research into remission of type 2 diabetes. RESULTS: Workshop attendees identified 10 key themes for further research. Four of these themes were prioritized for further focus: (i) understanding how to personalize lifestyle approaches based on biology, patient choice and subtypes; (ii) understanding the biology of remission; (iii) understanding the most effective approaches to implementation of lifestyle interventions; and (iv) understanding the best approaches to combining therapies (gut hormones, other drugs, lifestyle approaches and bariatric surgery). CONCLUSIONS: This paper outlines recommendations to address the current gaps in knowledge related to remission of type 2 diabetes.

The effects of ketamine on typical and atypical depressive symptoms.

OBJECTIVE: Ketamine's effects on different dimensions of depressive symptomatology, including typical/melancholic and atypical depression, remain largely unknown. This study examined the effects of a single intravenous dose of ketamine on general depressive symptoms (measured using the Montgomery-Asberg Depression Rating Scale (MADRS), typical/melancholic symptoms (measured using the MADRS5), and atypical symptoms (measured using the Scale for Atypical Symptoms (SAS)). METHODS: Data from 68 participants with treatment-resistant major depressive disorder (MDD) or bipolar depression were pooled from three separate, double-blind, placebo-controlled, crossover studies investigating ketamine's efficacy in depression. MDD participants were unmedicated; bipolar participants received therapeutic-dose lithium or valproate. Clinical symptoms were collected preinfusion and up to 14 days postinfusion. Effect sizes were calculated for days 1 and 3 postinfusion. The primary measures of interest for this exploratory analysis were total MADRS, MADRS5, and SAS scores. Individual symptoms were also analyzed in an exploratory manner. RESULTS: Scores improved significantly at Day 1 postinfusion (MADRS: Cohen's d = 0.64; MADRS5: Cohen's d = 0.61; SAS: Cohen's d = 0.41) and continued to be significantly improved over placebo at Day 3 (MADRS: Cohen's d = 0.49; MADRS5: Cohen's d = 0.43; SAS: Cohen's d = 0.39). Effect sizes were greater for typical/melancholic than atypical symptoms at Day 1 postinfusion. CONCLUSION: Ketamine appears to effectively treat both the typical/melancholic and atypical symptoms of depression, but may have early preferential effects for the former.

A retrospective review and multi-specialty, evidence-based guideline for the management of necrotising otitis externa.

BACKGROUND: Necrotising otitis externa is a progressive infection of the external auditory canal which extends to affect the temporal bone and adjacent structures. Progression of the disease process can result in serious sequelae, including cranial nerve palsies and death. There is currently no formal published treatment guideline. OBJECTIVE: This study aimed to integrate current evidence and data from our own retrospective case series in order to develop a guideline to optimise necrotising otitis externa patient management. METHODS: A retrospective review of necrotising otitis externa cases within NHS Lothian, Scotland, between 2013 and 2018, was performed, along with a PubMed review. RESULTS: Prevalent presenting signs, symptoms and patient demographic data were established. Furthermore, features of cases associated with adverse outcomes were defined. A key feature of the guideline is defining at-risk patients with initial intensive treatment. Investigations and outcomes are assessed and treatment adjusted appropriately. CONCLUSION: This multi-departmental approach has facilitated the development of a succinct, systematic guideline for the management of necrotising otitis externa. Initial patient outcomes appear promising.

Comparing pathologic outcomes for robotic versus laparoscopic Surgery in rectal cancer resection: a propensity adjusted analysis of 7616 patients.

BACKGROUND: Margin negative resection of rectal cancer with minimally invasive techniques remains technically challenging. Robotic surgery has potential advantages over traditional laparoscopy. We hypothesize that the difference in the rate of negative margin status will be < 6% between laparoscopic and robotic approach. METHODS: The National Cancer Database (2010-2014) was queried for adults with locally advanced rectal cancer who underwent neoadjuvant chemoradiation and curative resection to conduct an observational retrospective cohort study of a prospectively maintained database. Patients were grouped by either robotic (ROB) or laparoscopic (LAP) approach in an intent-to-treat analysis. Primary outcome was negative margin status, defined as a composite of circumferential resection margin and distal margin. Secondary outcomes included length of stay (LOS), readmission, 90-day mortality, and overall survival. RESULTS: 7616 patients with locally advanced rectal cancer who underwent minimally invasive resection were identified. 2472 (32%) underwent attempted robotic approach. The overall conversion rate was 13% and was increased in the laparoscopic group [LAP: 15% vs. ROB: 8%; OR 0.47; 95% CI (0.39, 0.57)]. Differences in margin negative resection rate were within the prespecified range of practical equivalence (LAP: 93% vs.: ROB 94%; 95% CI (0.69, 1.06); [Formula: see text] = 1). For secondary outcomes, there was no difference in 30-day readmission [LAP: 9% vs.: ROB 8%; 95% CI (0.84, 1.24)] and 90-day mortality [LAP: 1% vs.: ROB 1%; 95% CI (0.38, 1.24)]. While the median LOS was 5 days in both groups, the mean LOS was 0.6 (95% CI: 0.24, 0.89) days shorter in the robotic group. CONCLUSION: This robust analysis supports either robotic or laparoscopic approach for resection of locally advanced rectal cancer from a margin perspective. Both have similar readmission and 5-year overall survival rates. Patients undergoing robotic surgery have a 0.6-day decrease in LOS and decreased conversion rate.

Correction to: Progression of anal intraepithelial neoplasia in HIV-positive individuals: predisposing factors.

Unfortunately, the "Informed consent" statement was incorrectly published in the original version. The complete correct reference should read as follows.

Assessing Hereditary Colorectal Cancer Referral Patterns to a Tertiary Care Center: A Novel Approach Using Geographic Information System Mapping.

BACKGROUND: Patients and their family members with hereditary colorectal cancer require longitudinal follow-up that is best achieved through a dedicated program with a registry. However, referrals for these conditions remain poor. Geographic information systems technology is a novel method to evaluate geographic variation in multiple realms but is being used more in health care. OBJECTIVE: The purpose of this study was to evaluate referral patterns with geographic information systems technology to better target efforts for improving overall referrals. We hypothesized that marked variation would exist as to the geospatial locations of referrals and that gastroenterologists would be the dominant referral source. DESIGN: This was a retrospective cross-sectional study. SETTINGS: The study was conducted at Vanderbilt University Medical Center. PATIENTS: The hereditary colorectal cancer registry was queried from June 2007 to August 2016 for demographics, distance to center, genetic mutations, and the specialty of the referring providers. Geospatial data on both patient and referring specialist were collected. MAIN OUTCOME MEASURES: We analyzed patient and referral data with geographic information systems technology to look for gaps and patterns. RESULTS: A total of 676 patients were entered into the registry during this period. Fifty-six percent were women, and the median age was 50 years (interquartile range, 42-60 y). The median distance from the center was 60 miles (interquartile range, 22-120 miles), and 31% carried an identified germline mutation. Gastroenterology represented the overall largest source of referrals and, when broken down by syndrome, they represented the top referral specialty for familial adenomatous polyposis. Surgeons were the largest referral source for Lynch syndrome. LIMITATIONS: The study was limited by covariates in the database. CONCLUSIONS: Our hereditary colorectal cancer registry serves a large geographic area, with the largest group of referrals coming from gastroenterologists. Performing this analysis with geographic information systems technology mapping allowed us to identify clustering of patients and providers throughout the region as well as gaps. This information will help to target outreach and distribution of educational materials for providers and their patients to increase registry enrollment. See Video Abstract at http://links.lww.com/DCR/A950.

Can smartphone vibration provide a valid alternative to tuning forks for use on the ENT ward round?

BACKGROUND: All patients undergoing tympanomastoid surgery should be assessed post-operatively for a 'dead ear'; however, tuning forks are frequently inaccessible. OBJECTIVE: To demonstrate that smartphone-based vibration applications provide equivalent accuracy to tuning forks when performing Weber's test. METHODS: Data were collected on lay participants with no underlying hearing loss. Earplugs were used to simulate conductive hearing loss. Both the right and left ears were tested with the iBrateMe vibration application on an iPhone and using a 512 Hz tuning fork. RESULTS: Occluding the left ear, the tuning fork lateralised to the left in 18 out of 20 cases. In 20 out of 20 cases, sound lateralised to the left with the iPhone (chi-square test, p = 0.147). Occluding the right ear, the tuning fork lateralised to the right in 19 out of 20 cases. In 19 out of 20 cases, sound lateralised to the right with the iPhone (chi-square test, p > 0.999). CONCLUSION: Smartphone-based vibration applications represent a viable, more accessible alternative to tuning forks when assessing for conductive hearing loss. They can therefore be utilised on the ward round, in patients following tympanomastoid surgery, for example.

Progression of anal intraepithelial neoplasia in HIV-positive individuals: predisposing factors.

BACKGROUND: The aim of the present study was to evaluate patient factors that affect the progression of anal dysplasia in human immunodeficiency virus (HIV)-positive individuals. METHODS: A retrospective cohort study of HIV-positive adults with human papilloma virus related anal lesions was performed from 2012 to 2017. All patients underwent surgical excision or biopsy and fulguration of lesions in the operating room without using high resolution anoscopy. Patients with initial presentation of squamous cell carcinoma were excluded. The study was designed to investigate progression between the first available histology and either the follow up histology or a negative examination. Patient files were reviewed and data was collected. A bivariate analysis of continuous and categorical variables was performed. RESULTS: One hundred and sixty-one patients met the inclusion criteria. Ninety-seven percent were male. Mean age was 41 years. Thirty-five percent were African American and 47% were Caucasian. After a median follow-up interval of 331 days (IQR 120-615 days) 14 (9%) of patients had progression of disease. Visible lesions on initial presentation, as opposed to lesions found  in patients undergoing examination under anesthesia because of HSIL on anal pap smear, was associated with progression (p = 0.0.2). A lower initial CD4 count (p = 0.01) and initial surgical pathology of anal condylomata (p = 0.01) were also associated with progression. High-risk serotype was associated with no change or regression (p = 0.01). CONCLUSIONS: In our large cohort of HIV-positive patients treated without high resolution anoscopy the rate of progression was low.  Most notably, visible lesions at initial presentation and CD4 count when lower were associated with progression. Initial surgical pathology of anal condylomata was associated with progression, while high-risk serotypes correlated with regression or stability. Identification of risk factors has important implications concerning postoperative surveillance and counseling of HIV-positive patients with anal condylomata/ anal dysplasia.