Engagement and factors associated with annual anal human papillomavirus screening among sexual and gender minority individuals.

Objectives: Annual screening with a provider has been recommended for groups at highest risk for anal cancer. Anal self-sampling could help address screening barriers, yet no studies have examined annual engagement with this method. Methods: The Prevent Anal Cancer Self-Swab Study recruited sexual and gender minority individuals 25 years and over who have sex with men in Milwaukee, Wisconsin to participate in an anal cancer screening study. Participants were randomized to a home or clinic arm. Home-based participants were mailed an anal human papillomavirus self-sampling kit at baseline and 12 months, while clinic-based participants were asked to schedule and attend one of five participating clinics at baseline and 12 months. Using Poisson regression, we conducted an intention-to-treat analysis of 240 randomized participants who were invited to screen at both timepoints. Results: 58.8% of participants completed annual (median=370 days) anal screening. When stratified by HIV status, persons living with HIV had a higher proportion of home (71.1%) versus clinic (22.2%) annual screening ( p <0.001). Non-Hispanic Black participants had a higher proportion of home-based annual anal screening engagement (73.1%) compared to annual clinic screening engagement (31.6%) ( p =0.01). Overall, annual screening engagement was significantly higher among participants who had heard of anal cancer from an LGBTQ organization, reported "some" prior anal cancer knowledge, preferred an insertive anal sex position, and reported a prior cancer diagnosis. Annual screening engagement was significantly lower for participants reporting a medical condition. Conclusions: Annual screening engagement among those at disproportionate anal cancer risk was higher in the home arm.

The influence of home versus clinic anal human papillomavirus sampling on high-resolution anoscopy uptake in the Prevent Anal Cancer Self-Swab Study.

Background Anal cancer disproportionately affects sexual and gender minority individuals living with HIV. High-resolution anoscopy (HRA) is an in-clinic procedure to detect precancerous anal lesions and cancer, yet prospective data on factors associated with HRA attendance are lacking. We examined whether anal HPV sampling at home versus in a clinic impacts HRA uptake and assessed HRA acceptability. Methods Sexual and gender minority individuals were randomised to home-based self-sampling or clinical sampling. All were asked to attend in-clinic HRA 1year later. We regressed HRA attendance on study arm using multivariable Poisson regression and assessed HRA acceptability using χ 2 tests. Results A total of 62.8% of 196 participants who engaged in screening attended HRA. Although not significant (P =0.13), a higher proportion of participants who engaged in clinic-based screening attended HRA (68.5%) compared to home-based participants (57.9%). Overall, HRA uptake was higher among participants with anal cytology history (aRR 1.40, 95% CI 1.07-1.82), and lower among participants preferring a versatile anal sex position versus insertive (aRR 0.70, 95% CI 0.53-0.91), but did not differ by race or HIV serostatus. In the clinic arm, persons living with HIV had lower HRA attendance (42.9%) versus HIV-negative participants (73.3%) (P =0.02) and Black non-Hispanic participants had lower HRA attendance (41.7%) than White non-Hispanic participants (73.1%), (P =0.04). No differences in attendance by race or HIV status were observed in the home arm. Conclusions HRA uptake differed significantly by race and HIV status in the clinic arm but not the home arm.

Factors associated with decreased anal sphincter tone and the accuracy of forced anal examinations to detect individuals having receptive anal intercourse: An observational study.

Objective and Design: Forced anal examinations are used to prosecute sexual and gender minorities (SGM) in at least seven countries under the presumption that decreased sphincter tone, estimated by a finger inserted into the anal canal, can detect persons practicing receptive anal intercourse. In a cross-sectional analysis of the baseline data from a longitudinal study, we aimed to determine factors associated with sphincter tone and the accuracy of sphincter tonality to detect persons engaging in receptive anal intercourse. Setting: Clinicians in Chicago, Houston, and Milwaukee, USA conducted digital anal rectal examinations (DARE) on 838 participants, 94.0% of whom were cisgendered males. Clinicians used the Digital Rectal Examination Scoring System to score sphincter resting tone (RT) and squeeze tone (ST). On a separate survey, individuals reported their preferred position for anal intercourse: i.e., either always/mostly insertive anal intercourse, always/mostly receptive anal intercourse, or both receptive and insertive anal intercourse. Multivariable regression assessed factors associated with decreased sphincter tone while area under the Receiver Operating Characteristic curves (AUC) estimated the accuracy of sphincter tonality to detect receptive anal intercourse. Results: 11.3% had decreased RT (95/838) and 6.3% had decreased ST (53/838). The accuracy of DARE to detect any receptive anal intercourse was little better than random guessing (AUC 0.53, 95% CI 0.51 to 0.55, and AUC 0.51, 95% CI 0.49 to 0.53, respectively. RT and ST decreased with age regardless of sexual behavior (p trend <0.01 for both). Compared to individuals having always/mostly insertive anal intercourse, individuals having always/mostly receptive anal intercourse was associated with decreased RT, but not ST, while those equally preferring both insertive and receptive anal intercourse were not associated with decreased RT or ST. Conclusions: Decreased sphincter tone is uncommon among SGM who prefer receptive anal intercourse. Given virtually no accuracy, a finger inserted into the anus has no utility to detect individuals practicing receptive anal intercourse and thus should not be used as such. Trial registration: NCT04090060. Summary Box: What is already known on this topic: To gather evidence for prosecution of sexual and gender minorities, forced anal exams are used in multiple countries. The examination includes inserting the index finger into the anal canal to detect decreased sphincter tone which is considered evidence of receptive anal intercourse. We found only two small studies (n= 58 and n=24) assessing factors associated with decreased sphincter tone and none assessing the accuracy of sphincter tone to detect sexual and gender minorities having receptive anal intercourse.What this study adds: Our study suggests that a finger inserted into the anal canal is not useful to detect a history of receptive anal intercourse. As such, the sexual practices of individuals cannot be known using a forced anal examination.

Lending a hand: The utility of hand-assisted laparoscopic surgery in diverticulitis with fistula.

BACKGROUND: Current guidelines recommend elective colectomy for the management of diverticulitis-associated fistulas. These cases present considerable operative challenges, and surgical approaches and fistula tract management vary widely. Hand-assisted laparoscopic surgery offers the benefits of minimally invasive surgery while maintaining the tactile advantages of open surgery. This study aims to evaluate outcomes of hand-assisted laparoscopic surgery colectomy for diverticulitis-associated fistulas, fistula tract, and urinary catheter management. METHODS: A retrospective review of patients with diverticulitis-associated fistula who underwent elective hand-assisted laparoscopic surgery colectomy between January 2, 2008, and September 8, 2022, was performed. Patients with Crohn disease or who underwent emergency surgery were excluded. RESULTS: Seventy patients were included; the mean patient age was 64.1 ± 14.8 years, and the mean body mass index was 30.9 ± 9.1 kg/m2. Colovesical fistulas were most common (n = 48; 68.6%), followed by colovaginal fistulas (n = 22; 31.4%). The median operative time was 186 minutes. Conversion to an open approach occurred in 4 cases (5.7%). The fistula tract remnant was left without intervention in 35 patients (50%), and omental coverage occurred in 23 cases (32.9%). The median duration of the urinary catheter was 3 days (range = 1-63). There were no postoperative urine leaks. Three patients (4.3%) were readmitted in ≤30 days. There were no 30-day mortalities. CONCLUSION: The challenges of colectomy for diverticulitis-associated fistulas can be mitigated using the hand-assisted laparoscopic surgery technique. We found a low conversion-to-open rate, falling below rates reported for laparoscopic colectomy. There were no cases of postoperative urine leak, suggesting that no intervention or omental coverage is a safe approach to fistula tract management.

Evaluation of the Rothman Index in Predicting Readmission after Colorectal Resection.

The Rothman Index (RI) is a real-time health indicator score that has been used to quantify readmission risk in several fields but has never been studied in gastrointestinal surgery. In this retrospective single-institution study, the association between RI scores and readmissions after unplanned colectomy or proctectomy was evaluated in 427 inpatients. Patient demographics and perioperative measures, including last RI, lowest RI, and increasing/decreasing RI score, were collected. In the selected cohort, 12.4% of patients were readmitted within 30 days of their initial discharge. Last RI, lowest RI, decreasing RI, and increasing RI scores remained significant after controlling for covariates in separate multivariate regression analyses. The last RI score at the time of discharge was found to be the most strongly associated with 30-day readmission risk following colorectal resection. These findings support the RI as a potential tool in the inpatient management of postoperative patients to identify those at high risk of readmission.

Going for Broke: The Impact of Cost of Living on Surgery Resident Stipend Value.

OBJECTIVE: The objective of this study was to provide a direct comparison of first-year general surgery resident stipends across states and major cities, using the Cost-of-Living Index (COLI) to determine stipend value. BACKGROUND: Financial challenges are among residents' top sources of stress, and this may be exacerbated in areas with high costs of living. A 2021 survey found that the mean first-year medical resident stipend increased by 0.6%, or $358, from 2020 to 2021, and only 33% of institutions used cost-of-living to determine annual resident stipend adjustments. METHODS: An American Medical Association database was used to identify accredited general surgery residency programs. The 2021-2022 stipend data for first-year general surgery positions were obtained, then data were grouped by state and major city and averaged. Major cities were defined as cities with >4 programs.A direct comparison of stipends was performed using the COLI. RESULTS: Stipend data were available for 337 of 346 general surgery programs. The national average first-year residency stipend was $60,064±$4233. The average COLI-adjusted stipend was $57,090±$5742, with a value loss of -$3493, or 5%.For major cities, the average stipend was $63,383±$4524, and the average COLI-adjusted stipend was $46,929±$8383, with an average value loss of -$16,454, or 26%. CONCLUSIONS: The financial burdens that residents face cannot be overlooked, and the cost of living has a meaningful impact on resident stipend value. The current Graduate Medical Education compensation structure limits federal and institutional capacity to adjust for the cost of living and creates an insulated market in which residents are under-compensated.

Home-based self-sampling vs clinician sampling for anal precancer screening: The Prevent Anal Cancer Self-Swab Study.

Sexual minority men are at increased risk for anal squamous cell carcinoma. Our objective was to compare screening engagement among individuals randomized to self-collect an anal canal specimen at home or to attend a clinic appointment. Specimen adequacy was then assessed for human papillomavirus (HPV) DNA genotyping. A randomized trial recruited cisgendered sexual minority men and transgender people in the community and assigned them to use a home-based self-collection swabbing kit or attend a clinic-based swabbing. Swabs were sent for HPV genotyping. The proportions of participants completing screening in each study arm and the adequacy of their specimens for HPV genotyping were assessed. Relative risks were estimated for factors associated with screening. A total of 240 individuals were randomized. Age (median, 46 years) and HIV status (27.1% living with HIV) did not differ by study arm. A total of 89.2% and 74.2% of home-arm and clinic-arm individuals returned the swab, respectively (P = .003), difference between groups, 15.0% (95% CI 5.4%-24.6%). Among black individuals, 96.2% and 63.2% in the home and clinic arms screened (P = .006). Among individuals with HIV, 89.5% and 51.9% in the home and clinic arms screened (P < .001). Self-collected swabs and clinician-collected swabs were comparable in adequacy for HPV genotyping (96.3% and 93.3%, respectively). People at highest risk for anal cancer may be more likely to screen if they are able to self-collect swabs at home rather than attend a clinic.

Digital Anal Rectal Examination Usage Among Individuals at Increased Risk for Anal Cancer.

OBJECTIVE: Multiple organizations recommend an annual digital anal rectal examination (DARE) for people at highest risk for anal cancer. The authors assessed DARE usage among sexual minority men and transgender women. METHODS: Community-recruited and asymptomatic individuals from a mid-sized US city were enrolled into the Prevent Anal Cancer Self-Swab Study, a longitudinal clinical trial of anal cancer screening. Self-reported data from the baseline survey were used to assess usage of DARE in the last year and during the lifetime. Adjusted odds ratios (aORs) and CIs for factors associated with each outcome were determined using multivariable logistic regression. RESULTS: Among 241 participants, median age was 46 years (interquartile range, 33-57 years), 27.0% were living with HIV, and 24.5% reported a previous diagnosis of anal warts. A total of 13.7% (95% CI = 9.4%-18.0%) of individuals reported a DARE in the previous year, whereas 53.9% (95% CI = 47.7%-60.2%) reported a DARE during the lifetime. The following were associated with a DARE in the previous year: increasing age (aOR = 1.04; 95% CI = 1.01-1.08 for each additional year), any previous anal cytology (aOR = 2.62; 95% CI = 1.19-5.80, compared with no previous test or no knowledge of a test), and preferred receptive position during anal sex (aOR = 4.93; 95% CI = 1.17-20.86 compared with insertive). CONCLUSIONS: Despite guidelines recommending an annual DARE, it was uncommonly reported. There is an urgent need to understand barriers to conducting DARE among individuals most vulnerable to anal cancer and their health care providers.

Predicting Neoadjuvant Treatment Response in Rectal Cancer Using Machine Learning: Evaluation of MRI-Based Radiomic and Clinical Models.

BACKGROUND: Radiomics is an approach to medical imaging that quantifies the features normally translated into visual display. While both radiomic and clinical markers have shown promise in predicting response to neoadjuvant chemoradiation therapy (nCRT) for rectal cancer, the interrelationship is not yet clear. METHODS: A retrospective, single-institution study of patients treated with nCRT for locally advanced rectal cancer was performed. Clinical and radiomic features were extracted from electronic medical record and pre-treatment magnetic resonance imaging, respectively. Machine learning models were created and assessed for complete response and positive treatment effect using the area under the receiver operating curves. RESULTS: Of 131 rectal cancer patients evaluated, 68 (51.9%) were identified to have a positive treatment effect and 35 (26.7%) had a complete response. On univariate analysis, clinical T-stage (OR 0.46, p = 0.02), lymphovascular/perineural invasion (OR 0.11, p = 0.03), and statin use (OR 2.45, p = 0.049) were associated with a complete response. Clinical T-stage (OR 0.37, p = 0.01), lymphovascular/perineural invasion (OR 0.16, p = 0.001), and abnormal carcinoembryonic antigen level (OR 0.28, p = 0.002) were significantly associated with a positive treatment effect. The clinical model was the strongest individual predictor of both positive treatment effect (AUC = 0.64) and complete response (AUC = 0.69). The predictive ability of a positive treatment effect increased by adding tumor and mesorectal radiomic features to the clinical model (AUC = 0.73). CONCLUSIONS: The use of a combined model with both clinical and radiomic features resulted in the strongest predictive capability. With the eventual goal of tailoring treatment to the individual, both clinical and radiologic markers offer insight into identifying patients likely to respond favorably to nCRT.

The influence of home versus clinic anal human papillomavirus sampling on high-resolution anoscopy uptake in the Prevent Anal Cancer Self-Swab Study.

Background: Anal cancer disproportionately affects men who have sex with men (MSM) living with HIV. High-resolution anoscopy (HRA) is an in-clinic procedure to detect precancerous anal lesions and cancer, yet prospective data on factors associated with HRA attendance are lacking. We examined whether anal HPV sampling at home versus in a clinic impacts HRA uptake and assessed HRA acceptability. Method: MSM and trans persons 25 years and older were randomized to home-based self-sampling or clinical sampling. All were asked to attend in-clinic HRA one year later. We regressed HRA attendance on study arm using multivariable Poisson regression and assessed HRA acceptability using χ 2 tests. Results: 62.8% of 196 participants who engaged in screening attended HRA. Although not significant ( p =0.13), a higher proportion of participants who engaged in clinic-based screening attended HRA (68.5%) compared to home-based participants (57.9%). Overall, HRA uptake was higher among participants with anal cytology history (aRR 1.44, 95% CI 1.11 - 1.87) and lower among participants preferring versatile anal sex position versus insertive (aRR 0.70, 95% CI 0.53 - 0.91), but did not differ by race or HIV serostatus. In the clinic arm, persons living with HIV had lower HRA attendance (42.9%) versus HIV-negative participants (73.3%) ( p =0.02) and Black non-Hispanic participants had lower HRA attendance (41.7%) than White non-Hispanic participants (73.1%), ( p =0.04); however, no differences in attendance by race or HIV status were observed in the home arm. Conclusions: HRA uptake differed significantly by race and HIV status in the clinic arm but not the home arm.

Successful infusional 5-fluorouracil administration in a patient with vasospastic angina.

A 48-year-old female with metastatic colon adenocarcinoma and history of pre-existing coronary vasospasm with ventricular tachycardia (VT) successfully tolerated de novo 5-fluorouracil (5-FU) chemotherapy infusions with prophylactic administration and optimization of anti-spasm medications. 5-FU has been reported to produce severe cardiotoxic side effects, including coronary vasospasm, ventricular arrhythmias, and sudden cardiac death, and is not typically reported in individuals with pre-existing coronary vasospasm.

Long term clinical outcomes and associated predictors of progression free survival in anal canal cancer.

Background: Reports of long term clinical outcomes for patients with squamous cell carcinoma (SCC) of the anal canal treated with chemotherapy and intensity modulated radiation therapy (IMRT) are limited. Pre-treatment hematologic variables associated with outcomes remain understudied. We sought to report the long-term clinical outcomes of a cohort of patients treated with definitive chemoradiation (CRT) utilizing helical tomotherapy (HT) IMRT at a single tertiary referral center. We further sought to examine for any correlations between pre-treatment hematologic parameters and progression free survival (PFS). Methods: Data from patients with SCC of the anal canal treated with definitive CRT using HT IMRT from 2005 to 2017 were collected. Pre-treatment patient characteristics examined for correlations with PFS included: hemoglobin (Hgb) level, age, diabetes mellitus (DM) status, smoking status, neutropenia, thrombocytopenia, leukopenia, neutrophil/lymphocyte ratio, neutrophil/WBC ratio, lymphocyte/WBC ratio, sex, transplant status, HIV status, Karnofsky performance score, T-stage, and N-stage. Pre-treatment Hgb levels were recorded within two weeks prior to starting CRT. Clinical outcomes, including PFS, were described using the Kaplan-Meier estimator. A multivariable (MVA) Cox model of PFS evaluated the impact of pre-treatment Hgb and diabetes while adjusting for T-stage and age. Results: The median patient age was 57 years old (range, 26-87) and there were 39 females (63.9%) with the remaining patients identifying as males. Median patient follow up was 5.8 years. The PFS was 83% at 5 years. The median pre-treatment Hgb was 13 g/dL. On multivariable analysis (MVA), Hgb ≤10 g/dL (HR: 11.891, 95% CI: 2.649-53.391, P=0.001) and a diagnosis of diabetes mellitus (HR: 4.524, 95% CI: 1.436-14.252, P=0.010) were both significantly associated with a worse PFS. These factors were independent of T-stage and age. Conclusions: Long-term clinical outcomes for patients with SCC of the anal canal treated with definitive CRT are presented. Pre-treatment hemoglobin of ≤10 g/dL and diabetes were both independently associated with worse PFS on MVA. This retrospective data supports further prospective study of the impact of hematologic markers and medical co-morbidities such as DM and their management on clinical outcomes for patients with SCC of the anal canal treated with curative-intent CRT.

Saddle block anesthetic technique for benign outpatient anorectal surgery.

BACKGROUND: Current American Society of Colorectal Surgery Clinical Practice Guidelines for Ambulatory Anorectal Surgery endorse use of monitored anesthesia care, general anesthesia, or spinal anesthesia based on physician and patient preference. Although several studies support the use of monitored anesthesia care over general anesthesia, the literature regarding spinal anesthesia is limited and heterogenous due to small sample sizes and disparate spinal anesthesia techniques. Saddle block anesthesia is a form of spinal anesthesia that localizes to the lowermost sacral spinal segments allowing for preservation of lower extremity motor function and faster recovery. We accrued one of the largest reported cohort of anorectal procedures using saddle block anesthesia, as such, we sought to evaluate our institutional 12-year experience. METHODS: Patients who underwent a benign anorectal procedure at our outpatient surgery center between July 2008-2020 were retrospectively reviewed. Demographics, surgical factors, perioperative times, and adverse events were collected from the electronic medical records. Saddle block anesthesia was generally performed in the preoperative area using a spinal needle (25-27 gauge) and a single injection technique of a 1:1 ratio local anesthetic mixed with 10% dextrose solution. Between 2.5-5 mg of hyperbaric anesthetic was injected intrathecally in the sitting position and the patient remained upright for 3-10 minutes. This technique of saddle block anesthesia provides analgesia for approximately 1-3 hours. RESULTS: In the study, 859 saddle block anesthesia patients were identified, with a mean age of 44.6 years and American Society of Anesthesia score of 1.9; 609 (70.9%) were male. Surgical indications included lesion removal (27.1%), anal fistula (25.8%), hemorrhoidectomy (24.7%), pilonidal disease (6.3%), anal fissure (5.8%), and a combination of prior (10.2%). Prone jackknife positioning was used in 91.6% of procedures. Saddle block anesthesia most often was performed with bupivacaine (48.9%) or ropivacaine (41.7%). The median procedural saddle block anesthesia time was 11 minutes, surgery time was 17 minutes, anesthesia time was 42 minutes, and recovery time was 91 minutes. Patients spent a median of 3 hours and 53 minutes in the facility. Adverse events included urinary retention (1.9%), conversion to general anesthesia (1.8%), spinal headache (1.5%), hemodynamic instability (0.9%), and injection site reaction (0.3%). CONCLUSION: Demonstrated using the largest known cohort of anorectal patients with saddle block anesthesia, saddle block anesthesia provides an effective method of analgesia to avoid general anesthesia with a low rate of adverse events.

Rationale and design of the Prevent Anal Cancer Self-Swab Study: a protocol for a randomised clinical trial of home-based self-collection of cells for anal cancer screening.

INTRODUCTION: Squamous cell carcinoma of the anus is a common cancer among sexual minority men, especially HIV-positive sexual minority men; however, there is no evidenced-based national screening protocol for detection of anal precancers. Our objective is to determine compliance with annual anal canal self-sampling or clinician-sampling for human papillomavirus (HPV) DNA. METHODS AND ANALYSIS: This is a prospective, randomised, two-arm clinical study to evaluate compliance with annual home-based versus clinic-based HPV DNA screening of anal canal exfoliated cells. The setting is primary care community-based clinics. Recruitment is ongoing for 400 HIV-positive and HIV-negative sexual minority men and transgender persons, aged >25 years, English or Spanish speaking, no current use of anticoagulants other than nonsteroidal anti-inflammatory drugs and no prior diagnosis of anal cancer. Participants are randomised to either receive a swab in the mail for home-based collection of an anal canal specimen at 0 and 12 months (arm 1) or attend a clinic for clinician collection of an anal canal specimen at 0 and 12 months (arm 2). Persons will receive clinic-based Digital Anal Rectal Examinations and high-resolution anoscopy-directed biopsy to assess precancerous lesions, stratified by study arm. Anal exfoliated cells collected in the study are assessed for high-risk HPV persistence and host/viral methylation. The primary analysis will use the intention-to-treat principle to compare the proportion of those who comply with 0-month and 12-month sampling in the home-based and clinic-based arms. The a priori hypothesis is that a majority of persons will comply with annual screening with increased compliance among persons in the home-based arm versus clinic-based arm. ETHICS AND DISSEMINATION: The study has been approved by the Medical College of Wisconsin Human Protections Committee. Results will be disseminated to communities where recruitment occurred and through peer-reviewed literature and conferences. TRIAL REGISTRATION NUMBER: NCT03489707.

Impact of Auricular Neurostimulation in Patients Undergoing Colorectal Surgery with an Enhanced Recovery Protocol: A Pilot Randomized, Controlled Trial.

BACKGROUND: Narcotics are the cornerstone of postoperative pain control, but the opioid epidemic and the negative physiological and psychological effects of narcotics implore physicians to utilize nonpharmacological methods of pain control. OBJECTIVE: This pilot study investigated a novel neurostimulation device for postoperative analgesia. We hypothesized that active neurostimulation would decrease postoperative narcotic requirements. DESIGN: This was a placebo-controlled, double-blinded trial. SETTINGS: This trial was conducted at an academic medical center and a Veterans Affairs hospital. PATIENTS: This trial included adult patients who underwent elective bowel resection between December 2016 and April 2018. INTERVENTIONS: Patients were randomly assigned to receive an active or inactive (sham) device, which was applied to the right ear before surgery and continued for 5 days. MAIN OUTCOME MEASURES: The primary outcome was total opioid consumption. The secondary outcomes included pain, nausea, anxiety, return of bowel function, complications, 30-day readmissions, and opioid consumption at 2 weeks and 30 days. RESULTS: A total of 57 patients participated and 5 withdrew; 52 patients were included in the analysis. Twenty-eight patients received an active device and 24 received an inactive device. There was no difference in total narcotic consumption between active and inactive devices (90.79 ± 54.93 vs 90.30 ± 43.03 oral morphine equivalents/day). Subgroup analyses demonstrated a benefit for patients after open surgery (p = 0.0278). When patients were stratified by decade, those aged 60 to 70 and >70 years derived a benefit from active devices in comparison with those aged 30 to 40, 40 to 50, and 50 to 60 years old (p = 0.01092). No serious adverse events were related to this study. LIMITATIONS: This study was limited by the small sample sizes. CONCLUSIONS: No difference in opioid use was found with auricular neurostimulation. However, this pilot study suggests that older patients and those with larger abdominal incisions may benefit from auricular neurostimulation. Further investigation in these high-risk patients is warranted. See Video Abstract at http://links.lww.com/DCR/B452.ClinicalTrials.gov identifier: NCT02892513. IMPACTO DE LA NEUROESTIMULACIN AURICULAR EN PACIENTES SOMETIDOS A CIRUGA COLORRECTAL CON UN PROTOCOLO DE RECUPERACIN MEJORADA UN ENSAYO PILOTO ALEATORIZADO Y CONTROLADO: ANTECEDENTES:Los narcóticos son la piedra angular del control del dolor postoperatorio, pero la epidemia de opioides y los efectos fisiológicos y psicológicos negativos de los narcóticos incentivan a los médicos a que utilicen métodos no farmacológicos de control del dolor.OBJETIVO:Este estudio piloto investigó un nuevo dispositivo de neuroestimulación para analgesia postoperatoria. Hipotetizamos que la neuroestimulación activa disminuiría los requerimientos narcóticos postoperatorios.DISEÑO:Este fue un ensayo doble ciego controlado con placebo.ESCENARIO:Esto se llevó a cabo en un centro médico académico y en un hospital de Asuntos de Veteranos (Veterans Affairs hospital).PACIENTES:Este ensayo incluyó pacientes adultos que se sometieron a resección intestinal electiva entre diciembre de 2016 y abril de 2018.INTERVENCIONES:Los pacientes fueron asignados al azar para recibir un dispositivo activo o inactivo (falso), que se aplicó al oído derecho antes de la cirugía y se mantuvo durante 5 días.PRINCIPALES MEDIDAS DE RESULTADO:El resultado primario fue el consumo total de opioides; los resultados secundarios incluyeron dolor, náusea, ansiedad, retorno de la función intestinal, complicaciones, reingresos a 30 días y consumo de opioides a 2 semanas y a 30 días.RESULTADOS:Participaron un total de 57 pacientes y 5 se retiraron; Se incluyeron 52 pacientes en el análisis. Veintiocho pacientes recibieron un dispositivo activo y 24 recibieron un dispositivo inactivo. No hubo diferencias en el consumo total de narcóticos entre los dispositivos activos e inactivos (90.79 ± 54.93 vs 90.30 ± 43.03 equivalentes de morfina oral [OME] / día). Los análisis de subgrupos demostraron un beneficio para los pacientes después de cirugía abierta (p = 0.0278). Cuando los pacientes se estratificaron por década, aquellos de 60-70 y > 70 años obtuvieron un beneficio de los dispositivos activos en comparación con los de 30-40, 40-50 y 50-60 años (p = 0.01092). No hubo eventos adversos graves relacionados con este estudio.LIMITACIONES:Este estudio estuvo limitado por los pequeños tamaños de muestra.CONCLUSIONES:No se encontró diferencia en el uso de opioides con la neuroestimulación auricular. Sin embargo, este estudio piloto sugiere que los pacientes mayores y aquellos con incisiones abdominales más grandes pueden beneficiarse de la neuroestimulación auricular. Está justificada la investigación adicional en estos pacientes de alto riesgo. Consulte Video Resumen en http://links.lww.com/DCR/B452. (Traducción-Dr. Jorge Silva Velazco).

Racial and Ethnic Variation Associated With Human Papillomavirus Genotype in Anal Dysplasia.

BACKGROUND: Human Papillomavirus (HPV) is known to cause dysplasia and cancer. In cervical disease, there are documented differences in prevalence of HPV genotypes among racial/ethnic groups. Little is known about prevalence of HPV genotypes in anal dysplasia. This study aimed to evaluate association between HPV genotypes and race/ethnicity in a racially heterogenous population with anal dysplasia. METHODS: This was a single-institution retrospective review of patients treated for anal dysplasia between 2008 and 2019. HPV genotype, obtained via anal swab testing, was recorded as HPV 16, HPV 18, or other non-16/18 high-risk (HR) HPV genotypes. Univariate and multivariate logistic regression analyses were used to evaluate the association between patient factors and HPV genotype. RESULTS: Of 517 patients meeting inclusion criteria, 46.8% identified as White, 37.1% as Black, 13.2% as Hispanic, and 2.9% as other/unknown. Race/ethnicity (P = 0.016) and sex (P < 0.001) were significantly associated with differences in prevalence of HPV genotypes. Black (odds ratio 1.56, 95% confidence interval 1.00-2.44) and male (odds ratio 2.35, 95% confidence interval 1.42-3.92) patients were significantly more likely to have non-16/18 HR HPV genotypes. CONCLUSIONS: In a racially and socioeconomically diverse cohort of patients with anal dysplasia, Black race and male sex were associated with increased likelihood of infection with a non-16/18 HR HPV genotype. Many of these genotypes are not covered by currently available vaccines. Further study is warranted to evaluate anal HPV genotypes in a larger cohort, as this may have important implications in HPV vaccination and anal dysplasia screening efforts.

Laparoscopic Versus Robotic Proctectomy Outcomes: An ACS-NSQIP Analysis.

BACKGROUND: The robotic platform is increasingly used in colorectal surgery. Recent upgrades in the robotic platform and introduction of proctectomy-specific reports from the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) warrant updated evaluation of minimally invasive proctectomy outcomes. The aim of this study was to compare outcomes in robotic versus laparoscopic proctectomy using ACS-NSQIP data. MATERIALS AND METHODS: The ACS-NSQIP data set was used to identify adult patients undergoing elective robotic and laparoscopic proctectomy in 2016 and 2017. Demographics, preoperative and intraoperative data, and postoperative outcomes were collected. Propensity-weighted analysis was used to estimate the effect of robotic versus laparoscopic surgery on outcomes. RESULTS: Of 3845 patients meeting inclusion criteria, 2681 (70%) underwent a laparoscopic approach and 1164 (30%) underwent a robotic approach. Patients undergoing a robotic procedure were more likely to be older, have higher American Society of Anesthesiologists scores, low rectal tumors, and have undergone chemotherapy or radiation before surgery. After propensity adjustment, a robotic approach was associated with a decrease in conversion to open operation (estimated mean difference, -6.7%; P < 0.01), length of stay (-0.6 d; P = 0.01), occurrence of postoperative ileus (-3.7%; P = 0.01), and an increase in operative time (20.3 min; P < 0.01). CONCLUSIONS: Using data from a national cohort, we found that compared with laparoscopy, robotic proctectomy is associated with decreased conversion to open operation, longer operation time, decreased length of stay, and decreased postoperative ileus. Our study identified several advantages to a robotic approach; however, further work is needed to assess cost-effectiveness in conjunction with clinical outcomes.

Retroileal anastomosis in hand-assisted laparoscopic left colectomy: experience at a single institution.

BACKGROUND: Left hemicolectomy and complicated sigmoid colectomy require an anastomosis between the transverse colon and rectum. Generous mobilization will typically allow the colon to reach to the rectum. However, despite full mobilization of the splenic flexure and extensive work on the mesentery, there are cases in which reach to the pelvis is still an issue. Retroileal routing of the colon is one technique for overcoming such a reach problem and achieving a tension-free anastomosis. Performing retroileal routing using laparoscopic techniques has been reported rarely, and to date, there are no data on this technique when performed in a hand-assisted laparoscopic fashion. This study aimed to describe the feasibility of doing a retroileal routing using a hand-assisted laparoscopic technique. METHODS: This was a retrospective chart review of patients who underwent a colon or rectal resection, either open or laparoscopic, with a pelvic anastomosis, by a single colorectal surgeon at an academic institution between 2008 and 2015 with a focus on the immediate and long-term postoperative complications, estimated blood loss, and operating room time for patients having an operation that included retroileal routing for construction of a colorectal anastomosis. RESULTS: A total of 340 patients fit inclusion criteria and of these, 13 underwent hand-assisted laparoscopic procedures with retroileal routing of the proximal colon to the colorectal anastomosis. Postoperative morbidity included intubation for CO2 retention in one patient and a RLL effusion in another patient; there were no anastomotic leaks. Long-term morbidities included two ventral hernias at 2 years postoperatively. Mean operating room time was 208 min. There were no 30- or 90-day mortalities. CONCLUSIONS: Hand-assisted laparoscopic retroileal routing is a feasible and safe technique in accomplishing a tension-free colorectal anastomosis when proximal colon length makes standard routing of the colon to the rectum an issue.

Initial Experience With Staging Rectal Adenocarcinoma Using 7T Magnetic Resonance Imaging.

BACKGROUND: Magnetic resonance imaging (MRI) has become the preferred method for local staging of rectal cancer. Current MRI technology, operating at 1.5-3 T, results in incorrectly reported tumor depth and therefore inaccurate staging in one-third of individuals. Inaccurate staging can result in suboptimal treatment in patients with rectal cancer and can submit them to unnecessary treatments. The Medical College of Wisconsin Center for Imaging Research houses one of approximately twenty experimental 7 T MRIs worldwide capable of imaging the human pelvis. We present our initial experience with this novel imaging technique for the human rectum. METHODS: This was a prospective observational trial conducted at a single institution. Patients diagnosed with rectal cancer and who underwent low anterior resection or abdominoperineal resection between July 2015 and July 2017 were included. Excised rectal specimens were suspended in a saline-filled container and imaged by MRI at 7T. Tumor depth and lymph node status were determined by a single radiologist who was blinded to the pathologic results. These MRI interpretations were then compared with the pathologic stage. RESULTS: Seven of the 10 patients received neoadjuvant chemoradiation. When using the T1-weighted volumetric interpolated breath-hold examination-flex fat-suppressed sequences, radiologic and pathologic interpretation was identical regarding tumor depth in 7 of 10 patients (70%). Nodal status was correctly interpreted by 7T MRI in 8 of 10 patients (80%). Lymph nodes as small as 2 mm were able to be correctly characterized as harboring malignancy. CONCLUSIONS: We have demonstrated that 7T MRI of the rectum ex vivo has a strong correlation with histologic results. With its superior signal-to-noise ratio and spatial resolution, 7T MRI holds promise in more accurately staging rectal cancer and may be useful in correctly categorizing response to neoadjuvant therapy.