Use of fluorescence imaging and indocyanine green during colorectal surgery: Results of an intercontinental Delphi survey.

BACKGROUND: Fluorescence imaging with indocyanine green is increasingly being used in colorectal surgery to assess anastomotic perfusion, and to detect sentinel lymph nodes. METHODS: In this 2-round, online, Delphi survey, 35 international experts were asked to vote on 69 statements pertaining to patient preparation and contraindications to fluorescence imaging during colorectal surgery, indications, technical aspects, potential advantages/disadvantages, and effectiveness versus limitations, and training and research. Methodological steps were adopted during survey design to minimize risk of bias. RESULTS: More than 70% consensus was reached on 60 of 69 statements, including moderate-strong consensus regarding fluorescence imaging's value assessing anastomotic perfusion and leak risk, but not on its value mapping sentinel nodes. Similarly, although consensus was reached regarding most technical aspects of its use assessing anastomoses, little consensus was achieved for lymph-node assessments. Evaluating anastomoses, experts agreed that the optimum total indocyanine green dose and timing are 5 to 10 mg and 30 to 60 seconds pre-evaluation, indocyanine green should be dosed milligram/kilogram, lines should be flushed with saline, and indocyanine green can be readministered if bright perfusion is not achieved, although how long surgeons should wait remains unknown. The only consensus achieved for lymph-node assessments was that 2 to 4 injection points are needed. Ninety-six percent and 100% consensus were reached that fluorescence imaging will increase in practice and research over the next decade, respectively. CONCLUSION: Although further research remains necessary, fluorescence imaging appears to have value assessing anastomotic perfusion, but its value for lymph-node mapping remains questionable.

The evolution of pelvic dissection for rectal cancer from blunt dissection to total mesorectal excision.

"Modern" rectal cancer treatment began in the 18th century. However, initial results of the pioneer surgeons were very poor. During the next several decades, significant progress was made towards the cure of rectal cancer. Improvements have included lowering mortality, reducing recurrence, and optimizing functional outcomes. This article reviews the individuals and their advancements in rectal cancer treatment. It describes the changes in the surgical approach for tumor resection, the study of the lymphatic spread of rectal cancer and the advances in sphincter preservation procedures from the era of blunt dissection until the paradigm changing revolution of total mesorectal excision.

Association Between Adjuvant Chemotherapy and Overall Survival in Patients With Rectal Cancer and Pathological Complete Response After Neoadjuvant Chemotherapy and Resection.

Importance: Although American guidelines recommend use of adjuvant chemotherapy in patients with locally advanced rectal cancer, individuals who achieve a pathological complete response (pCR) following neoadjuvant chemoradiotherapy are less likely to receive adjuvant treatment than incomplete responders. The association and resection of adjuvant chemotherapy with survival in patients with pCR is unclear. Objective: To determine whether patients with locally advanced rectal cancer who achieve pCR after neoadjuvant chemoradiation therapy and resection benefit from the administration of adjuvant chemotherapy. Design, Setting, and Participants: This retrospective propensity score-matched cohort study identified patients with locally advanced rectal cancer from the National Cancer Database from 2006 through 2012. We selected patients with nonmetastatic invasive rectal cancer who achieved pCR after neoadjuvant chemoradiation therapy and resection. Exposures: We matched patients who received adjuvant chemotherapy to patients who did not receive adjuvant treatment in a 1:1 ratio. We separately matched subgroups of patients with node-positive disease before treatment and node-negative disease before treatment to investigate for effect modification by pretreatment nodal status. Main Outcome and Measures: We compared overall survival between groups using Kaplan-Meier survival methods and Cox proportional hazards models. Results: We identified 2455 patients (mean age, 59.5 years; 59.8% men) with rectal cancer with pCR after neoadjuvant chemoradiation therapy and resection. We matched 667 patients with pCR who received adjuvant chemotherapy and at least 8 weeks of follow-up after surgery to patients with pCR who did not receive adjuvant treatment. Over a median follow-up of 3.1 years (interquartile range, 1.94-4.40 years), patients treated with adjuvant chemotherapy demonstrated better overall survival than those who did not receive adjuvant treatment (hazard ratio, 0.44; 95% CI, 0.28-0.70). When stratified by pretreatment nodal status, only those patients with pretreatment node-positive disease exhibited improved overall survival with administration of adjuvant chemotherapy (hazard ratio, 0.24; 95% CI, 0.10-0.58). Conclusions and Relevance: The administration of adjuvant chemotherapy in patients with rectal cancer with pCR is associated with improved overall survival, particularly in patients with pretreatment node-positive disease. Although this study suggests a beneficial effect of adjuvant treatment on survival in patients with pCR, these results are limited by the presence of potential unmeasured confounding in this nonrandomized study.

Risk Factors for Postdischarge Venothromboembolism After Colorectal Resection.

BACKGROUND: Current guidelines recommend extended-duration thromboprophylaxis for all abdominal oncologic resections. However, other high-risk patients may benefit from extended thromboprophylaxis. OBJECTIVE: The purpose of this study was to identify risk factors for postdischarge venothromboembolism after colorectal procedures. DESIGN: This was a retrospective cohort study. DATA SOURCES: The New York Statewide Planning and Research Cooperative System database (2005-2013) was the data source for this study. STUDY SELECTION: Colon and rectal resections were evaluated. Cases with in-hospital mortality or length of stay ≥30 days were excluded. MAIN OUTCOME MEASURES: Postdischarge venothromboembolism was defined at 30-days after the procedure requiring representation to the emergency department or hospital admission with a new diagnosis of venothromboembolism using International Classification of Diseases, Ninth Revision, codes. Factors associated with postdischarge venothromboembolism were then evaluated using a hierarchical bivariate analysis. A hierarchical mixed-effects model was created using a manual stepwise approach assessing variables meeting p < 0.1 on bivariate analysis. RESULTS: Among 128,163 patients, postdischarge venothromboembolism occurred in 0.7% (n = 789) of the population. Multiple factors were associated with postdischarge venothromboembolism on bivariate analysis. On multivariable analysis, benign conditions requiring operative intervention remained at high risk, with ulcerative colitis imparting an 93% increased odds when compared with other resections (OR, 1.93 (95% CI: 1.30-2.86); p = 0.001). Advanced malignancies (stages III and IV) were associated with increased postdischarge venothromboembolism risk, whereas stage I and II malignancies were not. The only protective factor was a laparoscopic procedure (OR, 0.80 (95% CI: 0.67-0.95); p = 0.010). There was no significant difference in procedure type after controlling for primary diagnosis. LIMITATIONS: This was a retrospective analysis of administrative data with inherent limitations. Only patients who presented with postdischarge venothromboembolism to a hospital within New York State were captured. CONCLUSIONS: This study identifies risk factors for postdischarge venothromboembolism and suggests that ulcerative colitis increases risk for postdischarge venothromboembolism whereas Crohn's disease does not. Ulcerative colitis postdischarge venothromboembolism rates exceeded even those of malignancy, suggesting that a future study is necessary to determine the efficacy of extended duration thromboprophylaxis in high-risk benign conditions, such as ulcerative colitis.

High volume improves outcomes: The argument for centralization of rectal cancer surgery.

BACKGROUND: Centralization of care to "centers of excellence" in Europe has led to improved oncologic outcomes; however, little is known regarding the impact of nonmandated regionalization of rectal cancer care in the United States. METHODS: The Statewide Planning and Research Cooperative System (SPARCS) was queried for elective abdominoperineal and low anterior resections for rectal cancer from 2000 to 2011 in New York with the use of International Classification of Diseases, Ninth Revision codes. Surgeon volume and hospital volume were grouped into quartiles, and high-volume surgeons (≥ 10 resections/year) and hospitals (≥ 25 resections/year) were defined as the top quartile of annual caseload of rectal cancer resection and compared with the bottom 3 quartiles during analyses. Bivariate and multilevel regression analyses were performed to assess factors associated with restorative procedures, 30-day mortality, and temporal trends in these endpoints. RESULTS: Among 7,798 rectal cancer resections, the overall rate of no-restorative proctectomy and 30-day mortality decreased by 7.7% and 1.2%, respectively, from 2000 to 2011. In addition, there was a linear increase in the proportion of cases performed by both high-volume surgeons and high-volume hospitals and a decrease in the number of surgeons and hospitals performing rectal cancer surgery. High-volume surgeons at high-volume hospitals were associated independently with both less nonrestorative proctectomies (odds ratio 0.65, 95% confidence interval 0.48-0.89) and mortality (odds ratio 0.43, 95% confidence interval 0.21-0.87) rates. No patterns of significant improvement within the volume strata of the surgeon and hospitals were observed over time. CONCLUSION: This study suggests that the current trend toward regionalization of rectal cancer care to high-volume surgeons and high-volume centers has led to improved outcomes. These findings have implications regarding the policy of health care delivery in the United States, supporting referral to high-volume centers of excellence.

High Rate of Positive Circumferential Resection Margins Following Rectal Cancer Surgery: A Call to Action.

OBJECTIVES: To identify predictors of positive circumferential resection margin following rectal cancer resection in the United States. BACKGROUND: Positive circumferential resection margin is associated with a high rate of local recurrence and poor morbidity and mortality for rectal cancer patients. Prior study has shown poor compliance with national rectal cancer guidelines, but whether this finding is reflected in patient outcomes has yet to be shown. METHODS: Patients who underwent resection for stage I-III rectal cancer were identified from the 2010-2011 National Cancer Database. The primary outcome was a positive circumferential resection margin. The relationship between patient, hospital, tumor, and treatment-related characteristics was analyzed using bivariate and multivariate analysis. RESULTS: A positive circumferential resection margin was noted in 2859 (17.2%) of the 16,619 patients included. Facility location, clinical T and N stage, histologic type, tumor size, tumor grade, lymphovascular invasion, perineural invasion, type of operation, and operative approach were significant predictors of positive circumferential resection margin on multivariable analysis. Total proctectomy had nearly a 30% increased risk of positive margin compared with partial proctectomy (OR 1.293, 95%CI 1.185-1.411) and a laparoscopic approach had nearly 22% less risk of a positive circumferential resection margin compared with an open approach (OR 0.882, 95%CI 0.790-0.985). CONCLUSIONS: Despite advances in surgical technique and multimodality therapy, rates of positive circumferential resection margin remain high in the United States. Several tumor and treatment characteristics were identified as independent risk factors, and advances in rectal cancer care are necessary to approach the outcomes seen in other countries.

Visceral obesity, not elevated BMI, is strongly associated with incisional hernia after colorectal surgery.

BACKGROUND: High BMI is often used as a proxy for obesity and has been considered a risk factor for the development of an incisional hernia after abdominal surgery. However, BMI does not accurately reflect fat distribution. OBJECTIVE: The purpose of this work was to investigate the relationship among different obesity measurements and the risk of incisional hernia. DESIGN: This was a retrospective cohort study. SETTINGS: The study included a single academic institution in New York from 2003 to 2010. PATIENTS: The study consists of 193 patients who underwent colorectal cancer resection. MAIN OUTCOME MEASURES: Preoperative CT scans were used to measure visceral fat volume, subcutaneous fat volume, total fat volume, and waist circumference. A diagnosis of incisional hernia was made either through physical examination in medical chart documentation or CT scan. RESULTS: Forty-one patients (21.2%) developed an incisional hernia. The median time to hernia was 12.4 months. After adjusting for patient and surgical characteristics using Cox regression analysis, visceral obesity (HR 2.04, 95% CI 1.07-3.91) and history of an inguinal hernia (HR 2.40, 95% CI 1.09-5.25) were significant risk factors for incisional hernia. Laparoscopic resection using a transverse extraction site led to a >75% reduction in the risk of incisional hernia (HR 0.23, 95% CI 0.07-0.76). BMI > 30 kg/m was not significantly associated with incisional hernia development. LIMITATIONS: Limitations include the retrospective design without standardized follow-up to detect hernias and the small sample size attributed to inadequate or unavailable CT scans. CONCLUSIONS: Visceral obesity, history of inguinal hernia, and location of specimen extraction site are significantly associated with the development of an incisional hernia, whereas BMI is poorly associated with hernia development. These findings suggest that a lateral transverse location is the incision site of choice and that new strategies, such as prophylactic mesh placement, should be considered in viscerally obese patients.

Perioperative pleiotropic statin effects in general surgery.

BACKGROUND: Evidence suggests that statins may decrease inflammation, airway hyperreactivity, and hypercoagulability while improving revascularization mediated by cholesterol-independent pathways. This study evaluated whether the preoperative use of statins is associated with decreased postoperative major noncardiac complications in noncardiac procedures. STUDY DESIGN: This was a single-institution study of noncardiac operations performed from 2005 to 2010. The use of statins was identified from electronic medical records and merged with local National Surgical Quality Improvement Program data. Preoperative statin exposure was defined as statin use before operation, as documented by admission medication reconciliation and outpatient or pharmacy records. The primary end point was major noncardiac complications, and secondary end points included respiratory, infectious (sepsis and organ space infection) and complications of venous thromboembolism (VTE). Multivariable logistic regression was performed for each end point while we controlled for clinical covariates meeting P < .10 on bivariate analysis. RESULTS: Preoperative statin use was present in 10.5% (n = 814) of 7,777 total cases. Procedure type included general operation (n = 2,605, 33.5%), breast/endocrine (n = 739, 9.5%), colorectal (n = 1,533, 19.7%), hepatobiliary/pancreatic (n = 397, 5.1%), orthopedic (n = 205, 2.6%), skin/ear-nose- throat (145, 1.9%), thoracic (n = 53, 0.7%), upper gastrointestinal (n = 651, 8.4%), and vascular cases (1,449, 18.6%). On multivariable analysis, the use of statins was associated with decreased major, noncardiac complications (odds ratio [OR] 0.62, 95% confidence interval [95% CI] 0.49-0.92, P < .001), respiratory complications (OR 0.63, 95% CI 0.50-0.79, P = .017), VTE (OR 0.41, 95% CI 0.18-0.98, P = .044), and infectious complications (OR 0.65, 95% CI 0.45-0.94, P = .023). CONCLUSION: The preoperative use of statins is independently associated with decreased risk of major complications. This effect is likely driven by reduction in respiratory, VTE, and infectious complication rates. These results warrant future clinical trials to assess the perioperative benefit of statin use in noncardiac procedures.

Risk score for unplanned vascular readmissions.

OBJECTIVE: Vascular surgery patients have high readmission rates, and identification of high-risk groups that may be amenable to targeted interventions is an important strategy for readmission prevention. This study aimed to determine predictors of unplanned readmission and develop a risk score for predicting readmissions after vascular surgery. METHODS: The National Surgical Quality Improvement Program database for 2011 was queried for major vascular surgical procedures. The primary end point was unplanned 30-day readmissions. The data were randomly split into two-thirds for development and one-third for validation. Multivariable logistic regression was used to create and validate a point score system to predict unplanned readmissions. RESULTS: Overall, 24,929 patients were included, with 2507 readmissions (10.1%). A point-based scoring system was developed with the use of factors predictive for readmission, including procedure type; discharge destination; race; non-elective presentation; pulmonary, renal, and cardiac comorbidities; diabetes; steroid use; hypoalbuminemia; anemia; venothromboembolism before discharge; graft failure before discharge; and bleeding disorder. The point score stratified patients into 3 groups: low risk (0-3 points) with a readmission rate of 5.4%, moderate risk (4-7 points) with a readmission rate of 8.6%, and high risk (≥ 8 points) with a readmission rate of 16.4%. The model had a C-statistic = 0.67. CONCLUSIONS: Through the use of patient, operative, and predischarge events, this novel vascular surgery-specific readmission score accurately identified patients at high risk for 30-day unplanned readmission. This model could help direct discharge and home health care resources to patients at high risk, ultimately reducing readmissions and improving efficiency.

Defining high risk: cost-effectiveness of extended-duration thromboprophylaxis following major oncologic abdominal surgery.

PURPOSE: Extended-duration thromboprophylaxis (EDTPPX) is the practice of prescribing antithrombotic therapy for 21 days after discharge, commonly used in surgical patients who are at high risk for venothromboembolism (VTE). While guidelines recommend EDTPPX, criteria are vague due to a paucity of data. The criteria can be further informed by cost-effectiveness thresholds. This study sought to determine the VTE incidence threshold for the cost-effectiveness of EDTPPX compared to inpatient prophylaxis. METHODS: A decision tree was used to compare EDTPPX for 21 days after discharge to 7 days of inpatient prophylaxis with base case assumptions based on an abdominal oncologic resection without complications in an otherwise healthy individual. Willingness to pay was set at $50,000/quality-adjusted life year (QALY). Sensitivity analyses were performed to assess uncertainty within the model, with particular interest in the threshold for cost-effectiveness based on VTE incidence. RESULTS: EDTPPX was the dominant strategy when VTE probability exceeds 2.39 %. Given a willingness to pay threshold of $50,000/QALY, EDTPPX was the preferred strategy when VTE incidence exceeded 1.22 and 0.88 % when using brand name or generic medication costs, respectively. CONCLUSIONS: EDTPPX should be recommended whenever VTE incidence exceeds 2.39 %. When post-discharge estimated VTE risk is 0.88-2.39 %, patient preferences about self-injections and medication costs should be considered.

Laparotomy for small-bowel obstruction: first choice or last resort for adhesiolysis? A laparoscopic approach for small-bowel obstruction reduces 30-day complications.

INTRODUCTION: Small-bowel obstruction (SBO) requiring adhesiolysis is a frequent and costly problem in the United States with limited evidence regarding the most effective and safest surgical management. This study examines whether patients treated with laparoscopy for SBO have better 30-day surgical outcomes than their counterparts undergoing open procedures. METHODS: Patients with a diagnosis of adhesive SBO were selected from the ACS National Surgical Quality Improvement Program database from 2005 to 2010. Cases were classified as either laparoscopic or open adhesiolysis groups using Common Procedural Terminology codes. Chi square and Student's t test were used to compare patient and surgical characteristics with 30-day outcomes, including major complications, incisional complications, and mortality. Factors with p < 0.1 were included in the multivariable logistic regression for each outcome. A propensity score analysis for probability of being a laparoscopic case was used to address residual selection bias. A two-sided p value <0.05 was considered significant. RESULTS: Of the 9,619 SBO included in the analysis, 14.9 % adhesiolysis procedures were performed laparoscopically. Patients undergoing laparoscopic procedures had shorter mean operative times (77.2 vs. 94.2 min, p < 0.0001) and decreased postoperative length of stay (4.7 vs. 9.9 days, p < 0.0001). After controlling for comorbidities and surgical factors, patients having laparoscopic adhesiolysis were less likely to develop major complications [odds ratio (OR) = 0.7, 95 % confidence interval (CI) 0.58-0.85, p < 0.0001] and incisional complications (OR = 0.22, 95 % CI 0.15-0.33, p < 0.0001). The 30-day mortality was 1.3 % in the laparoscopic group versus 4.7 % in the open group (OR = 0.55, 95 % CI 0.33-0.85, p = 0.024). CONCLUSIONS: Laparoscopic adhesiolysis requires a specific skill set and may not be appropriate in all patients. Notwithstanding this, the laparoscopic approach demonstrates a benefit in 30-day morbidity and mortality even after controlling for preoperative patient characteristics. Given these findings in more than 9,000 patients and consistent rates of SBO requiring surgical intervention in the United States, increasing the use of laparoscopy could be a feasible way of to decrease costs and improving outcomes in this population.

Risk factors associated with 30-day postoperative readmissions in major gastrointestinal resections.

PURPOSE: Preventable readmissions represent a major burden on the health care system and risk stratification of patients can help direct costly resources. This study examines patient characteristics, surgical factors, and postoperative complications associated with 30-day postoperative readmissions in gastrointestinal (GI) resections. METHODS: Inpatients undergoing major GI surgery were selected from the 2011 American College of Surgeons (ACS) National Surgical Quality Improvement Program (NSQIP) database. Resections were classified into foregut, small bowel, colorectal, liver, and pancreatic using Current Procedural Terminology (CPT) codes. Postoperative complications were divided into pre- and post-discharge groups using time to complication and discharge. Univariate analysis compared patient and surgical characteristics and pre-discharge complications with 30-day unplanned readmission rates. Factors with a p value <0.1 were included in multivariate logistic regression. A p value <0.05 was considered statistically significant. RESULTS: For 42,609 patients undergoing GI resection, the overall 30-day unplanned readmission rate was 12.3 % ranging from 11.8 % for colorectal resections to 16.3 % for pancreatic resections. Major predictors of 30-day readmissions included pre-discharge major complications (odds ratio [OR] = 1.28, 95 % confidence interval [CI] 1.18-1.39, p < 0.0001), chronic steroid use (OR = 1.67, 95 % CI 1.50-1.86, p < 0.0001), operative time ≥4 h (OR = 1.45, 95 % CI 1.35-1.56, p < 0.0001) and discharge to a facility other than home (OR = 1.37, 95 % CI 1.23-1.50, p < 0.0001). CONCLUSIONS: Unplanned 30-day readmissions represent a major clinical and financial concern, but some may be foreseeable and potentially modifiable. This model provides insight into factors that could inform resource utilization and postoperative care to help prevent readmissions in select GI surgical patients.

Anastomotic leak or organ space surgical site infection: What are we missing in our quality improvement programs?

BACKGROUND: Expert panels of colorectal surgeons consistently rank anastomotic leak as among the most important quality metrics for colectomies. Nonetheless, most administrative and clinical databases do not collect data on anastomotic leaks and rely on reported organ space surgical site infections (OSI) as a proxy for identifying anastomotic leaks. This study questions the validity of using OSI as a surrogate for anastomotic leak. METHODS: The Upstate New York Surgical Quality Initiative (UNYSQI) is a collaboration of 12 hospitals that prospectively collects colectomy-specific metrics, including anastomotic leak, in addition to standard National Surgical Quality Improvement Program (NSQIP) data, including OSIs. Cases with an organ space infection and/or anastomotic leak were selected from the 2010-2011 UNYSQI database. Patient characteristics and outcomes were compared for cases with organ space infections and anastomotic leaks. RESULTS: Overall, 3% of colectomies had a reported organ space infection and 4% had an anastomotic leak. Among cases having anastomotic leaks, only 25% were also coded as having an organ space infection, leaving 75% of anastomotic leaks not captured by the NSQIP database (κ = 0.272; P ≤ .001). CONCLUSION: Organ space infection is a poor surrogate for anastomotic leak, resulting in grossly underestimated leak rates and seemingly represents different postoperative courses. Procedure-specific quality measures for colorectal surgery should include data collection on anastomotic leaks to provide accurate data for use in improving patient care.

Resident involvement is associated with worse outcomes after major lower extremity amputation.

BACKGROUND: Despite the recent major changes in vascular and general surgery training, there has been a paucity of literature examining the effect of these changes on training and surgical outcomes. Amputations represent a common cross-section in core competencies for general surgery and vascular surgery trainees. This study evaluates the effect of trainee participation on outcomes after above-knee and below-knee amputations. METHODS: The American College of Surgeons-National Surgical Quality Improvement Program (NSQIP) database (2005 to 2010) was queried using Current Procedural Terminology codes (American Medical Association, Chicago, Ill) for below-knee amputation (27880, 27882) and above knee-amputation (27590, 27592). Resident involvement was defined using the NSQIP variable and was narrowed to postgraduate year 1 to 5. Variables associated with resident involvement were identified, and mortality, morbidity, intraoperative transfusion, and operative time (75th percentile vs the bottom three quartiles) were evaluated as distinct categoric end points in logistic regression. Included in the model were variables with a P value <.1 on χ(2) or independent t-test, as appropriate. Significance was defined at P < .05. RESULTS: Residents were involved in 6587 of 11,038 amputations (62%). After adjustment for preoperative and intraoperative factors on logistic regression, there was a significant increase in major morbidity (odds ratio [OR], 1.27; 95% confidence interval [CI], 1.14-1.42; P < .001), intraoperative transfusion (OR, 1.78; 95% CI, 1.50-2.11; P < .001), and operative time (OR, 1.64 95% CI, 1.46-1.84; P < .001) in resident cases. CONCLUSIONS: Resident involvement was associated with increased odds of major morbidity after amputation and also with increased operative time and risk for intraoperative transfusions.

Outcomes associated with resident involvement in partial colectomy.

BACKGROUND: Surgical cases that include trainees are associated with worse outcomes in comparison with those that include attending surgeons alone. OBJECTIVE: This study aimed to identify whether resident involvement in partial colectomy was associated with worse outcomes when evaluated by surgical approach and resident experience. DESIGN: This is a retrospective study using the National Surgical Quality Improvement Program database. SETTINGS: This study evaluates cases included in the National Surgical Quality Improvement Program database. PATIENTS: All patients were included who underwent partial colectomy including both open and laparoscopic approaches. INTERVENTIONS: Residents were involved. MAIN OUTCOME MEASURES: The primary outcome measures were the association of resident involvement and major complication events, minor complication events, unplanned return to operating room, and operative time. RESULTS: Cases with residents were associated with major complications (OR 1.18, CI 1.09-1.27, p < 0.001) on multivariate analysis. However, after including operative time in the model only open cases involving fifth year residents were still associated with major complications (OR 1.13, p = 0.037). Resident involvement was associated with increased likelihood of minor complications (OR 1.3, p < 0.001) and an increased risk of unplanned return to the operating room (OR 1.20, p < 0.001). Operative time was longer for cases with residents on average by 33.7 minutes and 27 minutes for open and laparoscopic cases. LIMITATIONS: This study was limited by its retrospective design and lack of data on teachings status, case complexity, and intraoperative evaluation of technique. CONCLUSIONS: Resident involvement in partial colectomies is associated with an increased major complications, minor complications, likelihood of return to the operating room, and operative time.

Recognizing risk: bowel resection in the chronic renal failure population.

BACKGROUND: There is a paucity of quality data on the effects of chronic kidney disease in abdominal surgery. The aim of this study was to define the risk and outcome predictors of bowel resection in stage 5 chronic kidney disease using a large national clinical database. METHODS: The American College of Surgeons National Surgical Quality Improvement Program database was queried from years 2005-2010 for major bowel resection in dialysis-dependent patients. Patient demographics, preoperative risk factors, and intraoperative variables were evaluated. Primary endpoints were mortality and morbidity after 30 days. Predictors of outcome were assessed by multivariate regression. RESULTS: The study included 1,685 patients with chronic kidney disease undergoing bowel resection. Overall mortality and morbidity were 27.5 and 58.3 %, respectively. Acute presentation was the strongest predictor of mortality (OR 2.39, CI 1.54-3.72, p < 0.001). Other predictors of mortality included hypoalbuminemia (OR 2.12, CI 1.39-3.24, p < 0.001), pulmonary comorbidity (OR 2.25, CI 1.67-3.03, p < 0.001), and cardiac comorbidity (OR 1.54, CI 1.16-2.05, p = 0.003). CONCLUSION: This study demonstrates that bowel resection in patients with chronic kidney disease confers a high mortality risk. Preoperative optimization of comorbid conditions may reduce mortality after bowel resection in dialysis-dependent patients. In addition, laparoscopy was associated with a reduction in postoperative morbidity suggesting that it should be used preferentially.

Tobacco smoking and postoperative outcomes after colorectal surgery.

OBJECTIVE: The aim of this study was to delineate the impact of smoking on postoperative outcomes after colorectal resection for malignant and benign processes. BACKGROUND: Studies to date have implicated smoking as a risk factor for increased postoperative complications. However, there is a paucity of data on the effects of smoking after colorectal surgery and in particular for malignant compared with benign processes. METHODS: The American College of Surgeon's National Surgical Quality Improvement Program (2005-2010) database was queried for patients undergoing elective major colorectal resection for colorectal cancer, diverticular disease, or inflammatory bowel disease. Risk-adjusted 30-day outcomes were assessed and compared between patient cohorts identified as never-smokers, ex-smokers, and current smokers. Primary outcomes of incisional infections, infectious and major complications, and mortality were evaluated using regression modeling adjusting for patient characteristics and comorbidities. RESULTS: A total of 47,574 patients were identified, of which 26,333 had surgery for colorectal cancer, 14,019 for diverticular disease, and 7222 for inflammatory bowel disease. More than 60% of patients had never smoked, 20.4% were current smokers, and 19.2% were ex-smokers. After adjustment, current smokers were at a significantly increased risk of postoperative morbidity [odds ratio (OR), 1.3; 95% confidence interval (CI), 1.21-1.40] and mortality (OR, 1.5; 95% CI, 1.11-1.94) after colorectal surgery. This finding persisted across malignant and benign diagnoses and also demonstrated a significant dose-dependent effect when stratifying by pack-years of smoking. CONCLUSIONS: Smoking increases the risk of complications after all types of major colorectal surgery, with the greatest risk apparent for current smokers. A concerted effort should be made toward promoting smoking cessation in all patients scheduled for elective colorectal surgery.

Visceral obesity and colorectal cancer: are we missing the boat with BMI?

INTRODUCTION: Compared to subcutaneous fat, visceral fat is more metabolically active, leading to chronic inflammation and tumorigenesis. The aim of this study is to describe the effect of visceral obesity on colorectal cancer outcomes using computed tomography (CT) imaging to measure visceral fat. MATERIALS AND METHODS: We conducted a retrospective chart review of patients who underwent surgical resection for colorectal cancer. Visceral fat volume was measured by preoperative CT scans. Final analysis was performed by stratifying patients based on oncologic stage. RESULTS: Two hundred nineteen patients met the inclusion criteria, 111 viscerally obese and 108 nonobese. Body mass index (BMI) weakly correlated with visceral fat volume measurements (R (2) = 0.304). Whereas obese patients had no difference in survival when categorizing obesity by BMI, categorizing based on visceral fat volume resulted in significant differences in stage II and stage III patients. In stage II cancer, viscerally obese patients had a nearly threefold decrease in disease-free survival (hazard ratio (HR) = 2.72; 95 % confidence interval (CI) = 1.21, 6.10). In stage III cancer, viscerally obese patients had a longer time to recurrence (HR = 0.39; 95 % CI = 0.16, 0.99). CONCLUSION: This study shows that viscerally obese patients with stage II colorectal cancer are at higher risk for poor outcomes and should be increasingly considered for adjuvant chemotherapy.

The association between breast cancer prognostic indicators and serum 25-OH vitamin D levels.

BACKGROUND: Studies show that women with low vitamin D levels have an increased risk of breast cancer (BC) incidence and mortality, but there is a lack of research examining vitamin D levels and prognostic variables in BC patients. The aim of this study is to examine 25-OH vitamin D levels between BC cases and controls and by prognostic indicators among BC cases. METHODS: 25-OH vitamin D levels were collected from 194 women who underwent BC surgery and 194 cancer-free (CF) controls at the University of Rochester between January 2009 and October 2010. Mean 25-OH vitamin D levels and odds ratios (OR) were calculated by case/control status for the overall cohort and by prognostic indicators (invasiveness, ER status, triple-negative status, Oncotype DX score, molecular phenotype) for BC cases. RESULTS: BC cases had significantly lower 25-OH vitamin D levels than CF controls (BC: 32.7 ng/mL vs. CF: 37.4 ng/mL; P = .02). In case-series analyses, women with suboptimal 25-OH vitamin D concentrations (<32 ng/mL) had significantly higher odds of having ER- (OR = 2.59, 95% confidence interval [95% CI] = 1.08-6.23) and triple-negative cancer (OR = 3.15, 95% CI = 1.05-9.49) than those with optimal 25-OH D concentrations. Women with basal-like phenotype had lower 25-OH vitamin D levels than women luminal A phenotype (basal-like: 24.2 ng/mL vs. luminal A: 32.8 ng/mL; P = 0.04). CONCLUSIONS: BC patients with a more aggressive molecular phenotype (basal-like) and worse prognostic indicators (ER- and triple-negative) had lower mean 25-OH vitamin D levels. Further research is needed to elucidate the biological relationship between vitamin D and BC progression.