TransCare Initiative: An Institutional Knowledge-to-Action Project for Surgery and Gender Equity Education.

BACKGROUND: The transgender/gender nonconforming (TGNC) population is growing exponentially, but surgeon education has not advanced accordingly. Our objective was to assess department-wide understanding, awareness, and comfort in treating TGNC patients and identify specific gaps in education and training needs. METHODS: A survey covering 4 domains (personal perceptions; prior healthcare training/experience; comfort providing care; barriers to access) regarding TGNC patients was distributed to surgery faculty and trainees at an urban referral center. The survey contained 24 5-point Likert scale and 6 multiple choice demographic items. There was a 4-week response window. Descriptive statistics assessed the relative frequency of responses. The main outcome measures were the gaps and variation in each domain. RESULTS: There was a 47.59% (89/187) response rate and split evenly between trainees and attendings. Over half (51.21%, n = 44) reported formal TGNC training, mainly in medical school (27.5%, n = 22). Most knew (72.41%, n = 63) and had experience caring for TGNC patients (74.71%, n = 65). There was disparity understanding general concepts, with disagreement on definitions (8.99%, n = 8) and gender choice (14%, n = 12). Most reported comfort with communication, and could initiate conversations on pronouns (75.6%, n = 65) and gender identity (71.7%, n = 65). Over 40% could not complete a comprehensive history and admitted discomfort performing physical exams. Despite this, 88.51% (n = 77) felt they could provide an adequate level of care. Most respondents recognized unique TGNC health risks (91.86%, n = 79) and access barriers (82.76%, n = 72), including providers' lack of TGNC cultural competency (82.76%, n = 72). CONCLUSION: Disparities existed across all domains needed for inclusive TGNC surgical care. Respondents were aware of unique health needs and barriers to access. Provider self-perceived experience did not match the knowledge and skill required to provide optimal care for TGNC patients.

Use of a Convex Pouching System in the Postoperative Period: A National Consensus.

Convex pouching systems have been available for ostomy patients for decades; however, controversy remains over the use of convexity in the postoperative period. A group of 10 nurses and physicians with expertise caring for patients with an ostomy completed a scoping review identifying research-based evidence and gaps in our knowledge of the safety and effectiveness related to the use of a convex pouching system following ostomy surgery. Results of this scoping review demonstrated the need for a structured consensus to define best practices when selecting a pouching system that provides a secure and reliable seal around the stoma, avoids undermining and leakage of effluent from the pouching system, and contributes to optimal health-related quality of life for patients following ostomy surgery. The expert panel reached consensus on 8 statements for the use of convex products immediately after surgery and throughout the first 6 months after stoma creation, as well as describing goals in choosing the best pouching system for the patient with an ostomy.

Survey Results on Use of a Convex Pouching System in the Postoperative Period.

PURPOSE: The purpose of this study was to validate time frames for postoperative care following stoma surgery and to determine participants' current practice with convex pouching systems during the postoperative period. DESIGN: A Cross-sectional survey. SUBJECTS AND SETTING: The sample comprised 332 ostomy care specialists practicing in the United States. Most (n = 220; 66%) had more than 10 years' experience caring for patients with ostomies, 82% (n = 272) were certified WOC or ostomy care nurses (CWOCN and COCN), and 7% (n = 23) were board-certified colorectal surgeons. METHODS: A 23-item online questionnaire was created for purposes of the study. Items in the questionnaire queried professional background and experience caring for patients with an ostomy. A single item was used to identify postoperative care periods following ostomy surgery. Additional items queried current practice patterns related to use of convex pouching systems and the timing of their use. Data were collected from January 18 to February 8, 2021. RESULTS: Most respondents (n = 270; 90%) agreed with the following postoperative periods after ostomy surgery: immediate postoperative period (days 0-8); postoperative period (days 9-30); and transition phase (days 31-180). Most respondents (n = 274; 95%) indicated they would use a convex pouching system when clinically appropriate during the first 30 days following ostomy surgery and 79% (n = 228) indicated using a convex pouching system regardless of when the surgery was performed. Less than 1% (n = 2) indicated never using convexity within the first 30 days following stoma surgery, and only 3% (n = 8) indicated avoidance of convexity pouching systems in the immediate postoperative period. CONCLUSIONS: Findings indicate that use of convexity during the postoperative period is prevalent to provide a secure seal and predictable wear time.

Severe Obesity Contributes to Worse Outcomes After Elective Colectomy for Chronic Diverticular Disease.

BACKGROUND: Both obesity and chronic diverticular disease (DD) are on the rise. Understanding surgical outcomes for patients with obesity undergoing colectomy for DD is imperative to improve care and minimize complications. Our objective was to investigate the impact of obesity on outcomes after elective colectomy specifically for chronic DD. METHODS: Using the American College of Surgeons National Surgical Quality Improvement Program database from 2012 to 2018, patients who underwent elective colectomy for chronic DD were grouped into four body mass index categories. Baseline characteristics, surgical approach and procedure, and 30-day morbidity and mortality were assessed. RESULTS: Of 24,559 patients, 21.7% were of normal weight, 35.8% were overweight, 35.9% were obese, and 6.6% were severely obese. Patients with severe obesity were younger, more functionally dependent, and had more comorbidities (all P [Formula: see text] 0.0001). Patients with severe obesity were more likely to have unplanned conversion to open surgery from laparoscopic and robotic approaches (AOR 2.15, 95% CI 1.24-3.70). Obesity class did not significantly affect the type of surgical procedure patients underwent (Hartmann's, colectomy with anastomosis and diversion, or colectomy with primary anastomosis). There were increased odds of any perioperative complications (AOR 1.43, 95% CI 1.19-1.71) and non-home discharge (AOR 2.39, 95% CI 1.59-3.57) in patients with severe obesity compared to normal weight patients. CONCLUSIONS: Obesity is associated with poorer outcomes in patients undergoing elective colectomy for chronic DD. Futures studies to examine the impact of preemptive weight loss to improve outcomes after elective colectomy for chronic sequelae of DD are needed.

Robotic Surgery for Complicated Diverticular Disease.

Diverticular disease is common, and increasing in prevalence worldwide. The treatment for acute and chronic diverticular disease has a huge clinical and economic burden. Surgery is standard for complicated diverticulitis, and there are several benefits to using robotic surgery in these cases. Complicated diverticular disease can result in fistula, fibrosis, and deranged anatomy, which present technical challenges to the surgeon. Understanding and anticipating these anatomical challenges is key to successful surgery. While fears of conversion in complicated cases may stop surgeons from using traditional laparoscopic surgery, robotic surgery is especially promising for enhancing dexterity, visualization, and facilitating completely minimally invasive surgery in these complicated cases. In this chapter, we review end-to-end technical strategies of robotic colorectal surgery for complicated diverticular disease, including cases with colovesicular, colovaginal, and colocutaneous fistulae.

Coping with access barriers to non-communicable disease medicines: qualitative patient interviews in eight counties in Kenya.

BACKGROUND: There is rich literature on barriers to medicines access for the treatment of non-communicable diseases (NCDs) in high-income countries. Less is known about low- and middle-income countries, in particular the differences in coping with medicines access barrier by household wealth and disease. The aim of this study was to compare the coping mechanisms of patients with the lack of availability and affordability of cardio-vascular diseases, diabetes and asthma medicines in Kenya. METHODS: This qualitative study was part of a larger mixed methods evaluation study conducted in eight counties of Kenya from 2016 to 2019. Forty-nine patient interviews at study end line explored their NCD journey, perceptions of availability, stockouts and affordability of NCD medicines, their enrollment in health insurance, and their relationship with the private chemists. Transcribed interviews were coded using Nvivo software. A two-step thematic approach was used, first conducting a priority coding which was followed by coding emerging and divergent themes. RESULTS: Overall, we found that patients across all disease types and wealth level faced frequent medicine stock-outs at health facilities. In the absence of NCD medicines at health facilities, patients coped by purchasing medicines from local chemists, switching health facilities, requesting a different prescription, admitting oneself to an inpatient facility, establishing connections with local staff to receive notifications of medicine stock, stocking up on medicines, utilizing social capital to retrieve medicines from larger cities and obtaining funds from a network of friends and family. Categorizing by disease revealed patterns in coping choices that were based on the course of the disease, severity of the symptoms and the direct and indirect costs incurred as a result of stockouts of NCD medicines. Categorizing by wealth highlight differences in households' capacity to cope with the unavailability and unaffordability of NCD medicines. CONCLUSIONS: The type of coping strategies to access barriers differ by NCD and wealth group. Although Kenya has made important strides to address NCD medicines access challenges, prioritizing enrollment of low wealth households in county health insurance programs and ensuring continuous availability of essential NCD medicines at public health facilities close to the patient homes could improve access.

Propensity-Matched Analysis of Sigmoidectomies for Diverticular Disease.

BACKGROUND AND OBJECTIVES: The role for the robotic-assisted approach as a minimally invasive alternative to open colorectal surgery is in the evaluation phase. While the benefits of minimally invasive colorectal surgery when compared to the open approach have been clearly demonstrated, the adoption of laparoscopy has been limited. The purpose of this study was to evaluate clinical outcomes, hospital and payer characteristics of patients undergoing robotic-assisted, laparoscopic, and open elective sigmoidectomy for diverticular disease in the United States. METHODS: This is a retrospective propensity score-matched analysis. The Premier Healthcare Database was queried for patients with diverticular disease. Patients with diverticular disease who underwent robotic-assisted, laparoscopic, and open sigmoidectomy for diverticular disease from January 2013 through September 2015 were included. Propensity-score matching (1:1) facilitated comparison of robotic-assisted versus open approach and robotic-assisted versus laparoscopic approach. Peri-operative outcomes were assessed for both comparisons. RESULTS: There were several outcomes advantages for the robotic-assisted approach when compared to laparoscopic and open sigmoidectomy for diverticular disease that included significantly fewer conversions to open (P = .0002), shorter hospital length of stay, fewer postoperative complications-ileus, wound complications, and acute renal failure-and more patients discharged directly to home. CONCLUSIONS: The robotic-assisted minimally invasive approach to elective sigmoidectomy for diverticular disease results in favorable intra-operative and postoperative outcomes when compared to laparoscopic and open approaches.

Robotic-assisted ileocolic resection for Crohn's disease: outcomes from an early national experience.

Crohn's disease is an incurable inflammatory disorder that can affect the entire gastrointestinal tract. While medical management is considered first-line treatment, approximately 70-90% of patients with Crohn's disease will require at least one surgical intervention during the course of their lifetimes. Traditionally, abdominal surgery for Crohn's disease has been performed via an open approach with an increasing adoption of minimally invasive techniques. The aim of this study was to evaluate and compare postoperative outcomes from an initial national experience with robotic-assisted ileocolic resection for Crohn's disease. Patients who underwent elective ileocolic resection for Crohn's disease by robotic-assisted or open approaches from 2011 to Q3 2015 were identified using ICD-9 codes from the Premier Healthcare Database. Propensity-score matching (1:1) was performed using age, gender, race, Charlson index score, and year of surgery to form comparable cohorts in order to compare the robotic-assisted and open groups. 3641 patients underwent elective ileocolic resection for Crohn's disease during the study period (1910 [52.5%] open and 109 [3%] robotic-assisted). Post-matched comparison of cohorts (n = 108 per cohort) showed that robotic-assisted cases were longer by a mean of 60 min (p < 0.0001), had shorter length of hospital stay by a median of 2 days (p < 0.001) and a lower 30-day complication rate (24% vs. 38%; p = 0.039). This national database assessment of patients undergoing elective ileocolic resection for Crohn's disease demonstrated that a robotic-assisted approach was associated with longer operative times, shorter length of hospital stay and lower 30-day complication rates compared to open approach.

High-Risk Stage II Colon Cancer: Not All Risks Are Created Equal.

INTRODUCTION: Adjuvant chemotherapy is recommended in patients with stage II colon cancer with high-risk features (HRF). However, there is no quantification of the amount of risk conferred by each HRF or the overall survival (OS) benefit gained by chemotherapy based on the risk factor. OBJECTIVE: To assess survival benefits associated with adjuvant chemotherapy among stage II colon cancer patients having one or more HRF [T4 tumors, less than 12 lymph nodes examined (< 12LN), positive margins, high-grade tumor, perineural invasion (PNI), and lymphovascular invasion (LVI)]. METHODS: Patients diagnosed with stage II colon cancer between 2010 and 2013 were identified from California Cancer Registry. Propensity score weighted all-cause mortality hazard ratios (HR) were calculated for combinations of HRF. RESULTS: A total of 5160 stage II colon cancer patients were identified, of which 2398 had at least one HRF and 510 of 2398 (21%) received adjuvant chemotherapy. Compared with patients with a single HRF, presence of any 2 or ≥ 3 HRF showed increasingly poorer survival [HR 1.42, 95% confidence interval (CI) 1.16-1.73 and HR 2.50, 95% CI 1.96-3.20, respectively]. Chemotherapy was associated with improved overall survival only among patients with T4 as the single HRF (HR 0.51, 95% CI 0.34-0.78) or combinations involving T4 as T4/< 12 LN (HR 0.31, 95% CI 0.11-0.90), T4/high grade (HR 0.26, 95% CI 0.11-0.61), and T4/LVI (HR 0.16, 95% CI 0.04-0.61). CONCLUSIONS: Not all high-risk features have similar adverse effects on OS. T4 tumors and their combination with other HRF achieve the most survival benefit with adjuvant therapy. Type and number of high-risk features should be taken into consideration when recommending adjuvant chemotherapy in stage II colon cancer.

Benefit of Surgical Resection of the Primary Tumor in Patients Undergoing Chemotherapy for Stage IV Colorectal Cancer with Unresected Metastasis.

PURPOSE: Resection of the primary tumor in patients with unresected metastatic colorectal cancer is controversial, and often performed only for palliation of symptoms. Our goal was to determine if resection of the primary tumor in this patient population is associated with improved survival. METHODS: This is a retrospective cohort study of the National Cancer Data Base from 2004 to 2012. The study population included all patients with synchronous metastatic colorectal adenocarcinoma who were treated with systemic chemotherapy. The study groups were patients who underwent definitive surgery for the primary tumor and those who did not. Patients were excluded if they had surgical intervention on the sites of metastasis or pathology other than adenocarcinoma. Primary outcome was overall survival. RESULTS: Of the 65,543 patients with unresected stage IV colorectal adenocarcinoma undergoing chemotherapy, 55% underwent surgical resection of the primary site. Patients who underwent surgical resection of the primary tumor had improved median survival compared to patients treated with chemotherapy alone (22 vs 13 months, p < .0001). The surgical survival benefit was present for patients who were treated with either multi-agent or single-agent chemotherapy (23 vs 14 months, p < 0.001; 19 vs 9 months, p < 0.001). Surgical resection of the primary tumor was also associated with improved survival when using multivariate analysis with propensity score matching (OR = 0.863; 95% CI [0.805-.924]; HR = 0.914; 95% CI [0.888-0.942]). CONCLUSIONS: Our results show that in patients with synchronous unresected stage IV colorectal adenocarcinoma undergoing single- or multi-agent chemotherapy, after adjusting for confounding variables, definitive resection of the primary site was associated with improved overall survival. Large randomized controlled trials are needed to determine if there is a causal relationship between surgery and increased overall survival in this patient population.

Laparoscopic Roux-en-Y gastric bypass: results and learning curve of a high-volume academic program.

HYPOTHESIS: Laparoscopic Roux-en-Y gastric bypass is a complex procedure performed on a high-risk patient population. Good results can be attained with experience and volume. DESIGN: Retrospective study. SETTING: Tertiary care academic hospital. PATIENTS: Seven hundred fifty consecutive morbidly obese patients undergoing surgery from March 1998 to April 2004. INTERVENTIONS: All patients underwent laparoscopic Roux-en-Y gastric bypass. MAIN OUTCOME MEASURES: Perioperative deaths and complications. RESULTS: The patient population was 85% women and had a mean body mass index of 47 kg/m2 (range, 32-86 kg/m2). The overall complication rate was 15% and the mortality was 0.3%. For the first 100 cases, the overall complication rate was 26% with a mortality of 1%. This complication rate decreased to approximately 13% and was stable for the next 650 patients. The incidence of major complications has also decreased since the first 100 cases. Leak decreased from 3% to 1.1%. Small-bowel obstruction decreased from 5% to 1.1%. Overall mean operating time was 138 minutes (range, 65-310 minutes). It decreased from 212 minutes for the first 100 cases to 132 minutes for the next 650 and 105 minutes (range, 65-200 minutes) for the last 100 cases. CONCLUSIONS: Laparoscopic Roux-en-Y gastric bypass is a technically difficult operation. This review of a large series in a high-volume program demonstrated that the morbidity and mortality could be reduced by 50% with experience. The results are similar to those reported from other major centers. In addition, as reported elsewhere, the learning curve for this procedure may be 100 cases.