Colon and Rectal Surgery : Journal of the American College of Surgeons (2024)

Table of Contents
A Machine Learning Model to Predict Response to Chemoradiation among Patients with Rectal Cancer An Analysis of Rectal Prolapse Repair Trends Using American College of Surgeons NSQIP Data from 2007 to 2021 An Assessment of Risk Factors for Financial Toxicity among Colorectal Cancer Patients in Massachusetts Cardamonin Inhibits the TNFa-Induced Epithelial-Mesenchymal Transition of Intestinal Epithelial Cells via Inhibition of NFkb/p38 Regulated STAT3 Signaling Comparison of Levatorplasty along with Altemeier Procedure Compared with Altemeier Alone on Fecal Incontinence and Recurrence Rate Comparison of Wafi Ileostomy with Brook Ileostomy in Stage III Rectal Cancer Surgery Defining Opportunities to Improve Perioperative Ostomy Care and Education Does Sequence of Colorectal Cancer Diagnosis Matter for Patients with Multiple Primary Cancers? A Surveillance, Epidemiology, and End Results Database Cohort Study Efficacy of Preoperative Chemoradiotherapy for Rectal Cancer Using Exosomal miRNA Elucidating a Key Mechanism of Perioperative and Postoperative Ileus: Microvascular Serum Leak-Activation of the Cyclooxygenase Pathway Causing Colonic Dysmotility Emergency Surgery for Colon and Rectal Cancer in the Michigan Surgical Quality Collaborative Emerging Population Perspectives: Exploring Colorectal Cancer in Adults under 50 Years of Age Endometriosis and Its Role in Pouch Patients: A Matched-Pair Analysis Endoscopic Transanal Vacuum-Assisted Rectal Drainage Therapy as Treatment for Low Pelvic Anastomotic Leak External Validation of a Prediction Model for Local Recurrence after Curative Rectal Cancer Surgery: A Large Multicenter Cohort Study in Japan Factors Mediating the Impact of Care Fragmentation on Outcomes in Rectal Cancer Frailty, Not Age, Predicts Postoperative Complication in Patients Undergoing Proctectomy for Inflammatory Bowel Disease Geriatric Assessment for Aging Patients Facing Colorectal Surgery: A Qualitative Study of Clinician Perspectives Hidden Disparity: Race Modifies the Impact of Insurance Provider on Screening Colonoscopy Completion Rate Impact of Lateral Pelvic Lymph Node Downstaging Post Neoadjuvant Therapy: Characteristics, Management, and Oncological Outcomes Impact of Preoperative Bowel Stimulation Before Loop Ileostomy Closure Impact of the 2014 Medicaid Expansion on Trends in Stage of Colon Cancer at Presentation Increased MLK4 Expression in Colorectal Cancer Is Associated with Worse Oncologic Outcomes Intraluminal Extracellular Matrix Hydrogel Reduces Leak Rate in a Rodent Model of Rectal Resection Investigation of Creeping Fat Associated Fibroblasts in Smooth Muscle Cell Hypertrophy in Crohn’s Disease Stricture Formation Language Discordant Colorectal Patients Demonstrated Decreased Postoperative Interaction with Medical System Long-Term Outcomes after Colectomy and Liver Transplantation for Inflammatory Bowel Disease with Primary Sclerosing Cholangitis Minimally Invasive Colectomy under Neuraxial Anesthesia in Frail Patients Nature, Nurture or Both? Genetic Risk, Healthy Lifestyle, and Severe Diverticulitis Objective Performance Indicators During Robotic Colorectal Surgery Can Be Used to Assess Trainee Progression Over a Decade with Transanal Minimally Invasive Surgery: Analyzing Short- and Long-Term Oncological Outcomes of 208 Patients with Rectal Lesion Pelvic MRI after Total Neoadjuvant Therapy for Rectal Cancer Poorly Predicts a Complete Clinical Response Perspectives of Patients with Ulcerative Colitis about Surgery Positive Lateral Lymph Node after Neoadjuvant Therapy in Locally Advanced Rectal Cancer: Characteristics, Management, and Oncological Outcomes Pouch Advancement Flap for Management of Pouch-Related Fistula Primary and Revisional Restorative Proctocolectomy with Ileal Pouch Anal Anastomosis: Quaternary Center Experience with over 500 Patients Recurrent Disease Prediction in Uncomplicated Diverticulitis Using a Polygenic Risk Score Shifting Paradigm: Outcomes with Neoadjuvant Chemotherapy for cT4 and cN2 Colon Cancer Simplifying Patient Education with Custom GPT: The Critical Role of Prompt Specificity Single-Cell Analyses Reveal Novel Immune and Nonimmune Features of Perianal Fistulizing Crohn’s Disease Stratifying Endoscopic Submucosal Dissection Risks: A Validated Perforation Risk Scoring Tool Take as Much as Possible: A Statewide Qualitative Exploration Understanding Positive Surgical Margins for Colorectal Cancer The Impact of RAS/BRAF Mutation on Tumor Regression Grade after Total Neoadjuvant Therapy in Rectal Cancer Patients The Natural History of Complicated Diverticulitis with Abscess Managed Nonoperatively at Index Admission: A Longitudinal Analysis of State Inpatient and Emergency Department Databases from the Healthcare Cost and Use Project The Readability, Actionability, and Quality of Hemorrhoid Online Education Materials: Are We Addressing Patient Concerns? The Relationship Between the Microbiome and Diverticular Disease: A Mendelian Randomization Study The Utility of Intraoperative Hologram Support in Transanal Approach for Lower Rectal Cancer Treatment of Colon Cancer Cells with Lipid Nanoparticles Delivered TNFSF14 (LIGHT) mRNA Induces Immunogenic Cell Death and Inhibits Metastatic Tumor Growth Understanding and Optimizing Surgical Recovery Through the Lens of Patients with Colorectal Disease: A Qualitative Study in an Enhanced Recovery after Surgery Setting Use of a Patient Engagement Technology Improves Adherence to a Colorectal Enhanced Recovery Program Why Are Young Patients with Colorectal Cancer Dying? Early-Onset Colorectal Cancer Tumors Have a More Permissive Tumor Immune Microenvironment Than Late-Onset Tumors ePosters A Study of the Effect of Arterial Calcification on Indocyanine Green Perfusion Time of Dissected Margins in Colorectal Surgery A Validated Integration of Tumor Deposits and Lymph Nodes to Improve Prognostication in Colon Cancer Analyses of Deoxyribonucleic Acid Derived from Circulating Nucleosomes in Patients with Colorectal Cancer by Silver Nanoscale Hexagonal Column Chips Anesthesia Adjuncts on Patients Undergoing Colectomy: An Analysis of NSQIP-Reported Outcomes Colorectal Cancer Resection Outcomes in Dialysis Patients: An American College of Surgeons NSQIP Study Colorectal Linitis Plastica: A Rare Neoplastic Condition with Common Histological Features Comparative Study of Cylindrical and Circular Ring Magnets in Colonic Anastomosis in Rats Comparing a Data-Driven Versus Clinician-Curated Approach in Developing Machine-Learning Models to Predict Colorectal Cancer Surgery Outcomes Conditional Survival of Patients with Appendiceal Neuroendocrine Neoplasms after Resection Differences in Objective Performance Indicators During Robotic Proctectomy: Early vs Advanced Cancer Patients Does Unilateral Gluteoplasty Alone Correct Anal Incontinence Post War Injuries to Anal Sphincter? Effects of Surgical Specialization and Surgeon Resection Volume on Cancer-Free and Overall Survival after Emergent Colon Cancer Resection Efficacy of Diltiazem and Lidocaine vs Nifedipine and Lidocaine in Acute Fissure in Ano: a Randomized Controlled Trial (NDRF Trial) Endorobotic Submucosal Dissection (ERSD) Versus Transanal Minimally Invasive Surgery (TAMIS): A Propensity Score-Matched Comparison Enhanced Recovery after Surgery (ERAS) for Colectomy in Ukraine: A Nationwide Practice Survey Evaluating the Effectiveness of Same-Day Discharge in Colectomy Patients: A Systematic Review and Meta-Analysis Genetic Sequencing in Non-Responders to Total Neoadjuvant Chemotherapy and Radiation with Locally Advanced Rectal Cancer Intracorporeal Anastomosis: A Nine-Year Review of Minimally Invasive Colorectal Surgery Outcomes Is Operating on Diverticulitis in the Elderly Patient Safe? Knowledge of Colorectal Cancer Symptoms and Risk Factors in Sri Lanka: A Cross-Sectional Study Long-Term Survival in Young-Onset Rectal Cancer: Does It Differ from Older Patients? Lymph Node Metastases in Appendiceal Neuroendocrine Neoplasms: An Analysis from the National Cancer Database Management of Rectal Prolapse in Octogenarians: Lesson Learned in 13 Years’ Experience from a High-Volume Center Management of Severe Immune Checkpoint Inhibitor Related Colitis Mastering the Precision of Colorectal Endoscopic Submucosal Dissection Preoperative Enteral Immunonutrition in Patients Undergoing Elective Colorectal Cancer Surgery May Improve Short-Term Postoperative Outcomes: A Systematic Review and Meta-Analysis Prevalence of Anxiety, Depression, and Stress in Colorectal Cancer Patients in Sri Lanka Recurrent Rectal Prolapse: Re-Recurrence Rate and Risk Factors Risk Factors for Withdrawal of Care after Colorectal Surgery Robotic vs Laparoscopic Surgery for Colon Cancer: Short-term Outcomes of a Randomized Trial Safety of Laparoscopic and Robotic Surgery for Elderly Patients with Colorectal Cancer: A Multicenter Retrospective Study Single Center Review of Patients with Rectal Cancer Undergoing Nonoperative Protocols Sociodemographic and Patient Characteristics Associated with Colon Cancer in Young Adults under Age 45 Years Socioeconomic and Clinicopathologic Disparities in Early Onset Colon Adenocarcinoma Surgical Management of Early-Onset Colorectal Cancer (EOCRC) with Liver Metastases Is Associated with Improved Survival Temporal Trends and Factors Associated with Declining Surgery in Patients with Resectable Colon Cancer The Impact of Operative Start Time on the Outcomes of Minimally Invasive Colectomy The Influence of Surgical Subspecialization on Outcomes in Emergency Colorectal Surgery: A Comprehensive Systematic Review and Meta-Analysis Time to Definitive Treatment in Care Coordination for Rectal Cancer Patients Use of Virtual Reality Simulator as a Tool to Understand Colorectal Anatomy and Medical Students’ Interest in Colorectal Surgery Using Artificial Intelligence-Enhanced White-Light Colonoscopy for Predicting Deeply Invasive Colorectal Cancer: A Diagnostic Accuracy Meta-Analysis Ventral Mesh Rectopexy (VMR) Variations in Technique and Care Process: A Multicenter Study Visceral Fat Area (VFA) Analysis Is a More Sensitive Metric than BMI for Determining Obesity Related Perioperative Outcomes in Colorectal Procedures

A Machine Learning Model to Predict Response to Chemoradiation among Patients with Rectal Cancer

Francesco Celotto, MD, Filippo Crimì, MD, Christian Salvatore, PhD, Isabella Castiglioni, PhD, Gaya Spolverato, MD, FACS

University of Padova, Padova, Italy; DeepTrace Technologies, Milan, Italy

Introduction: In the context of increasing use of rectum-sparing protocols for rectal cancer treatment, identifying patients with a pathological complete response (pCR) to preoperative chemoradiotherapy (pCRT) remains challenging. This study uses advanced MRI and a robust radiomic-based machine-learning approach to predict pCRT response in rectal cancer patients based on pretreatment staging MRI. We investigate the potential of radiomic features to capture disease heterogeneity and inform personalized therapeutic decisions for locally advanced rectal cancer.

Methods: Pretreatment staging MRI data from 102 subjects were collected and divided into training (n = 72) and validation (n = 30) cohorts. Histological diagnosis from definitive operation or follow-up determined 72.2% of the training cohort as “not responding” to pCRT and 27.8% as pCR. Various machine-learning models were trained and cross-validated using radiomic features to classify patients. The model was subsequently tested in an external validation cohort.

Results: Three machine-learning models were developed, achieving a best-performing model with a receiver operating characteristic area under the curve (ROC-AUC) of 73% and an accuracy of 69.9%. Sensitivity and positive predictive value (PPV) reached 78.2% and 79.8%, respectively. Testing on the validation cohort showed sensitivity of 80.8%, specificity of 75.0%, and accuracy of 80.0% (Figure 1).

Conclusion: This study demonstrates the potential of a radiomic-based machine-learning approach to predict treatment response in rectal cancer patients using staging MRI. The top-performing model shows promising discriminative capabilities, highlighting the importance of integrating advanced imaging and computational methodologies in personalized rectal cancer management.

An Analysis of Rectal Prolapse Repair Trends Using American College of Surgeons NSQIP Data from 2007 to 2021

Racquel Gaetani, MD, Michael Jonczyk, MD, Kristen Donohue, MD, FACS, Piyush Gupta, MD, Julia T Saraidaridis, MD, FACS

Lahey Hospital and Medical Center, Burlington, MA; Rutgers University, Atlantic Highlands, NJ; MedStar Georgetown University Hospital, Washington, DC

Introduction: With the advent of minimally invasive surgery (MIS) techniques, there has been an increase in the surgical options available for the repair of rectal prolapse. It is unclear how use of MIS approaches has affected the landscape of rectal prolapse repair.

Methods: This was a retrospective case series using American College of Surgeons NSQIP from 2007 to 2021. The primary outcome was trend in use of operative approaches (MIS, open, or perineal). Secondary outcomes included demographic differences in approach.

Results: A total of 15,423 patients underwent repair during this period. Of these, 92.0% were women and 53% were over the age of 70 years. Abdominal approach patients were younger (MIS 61.2 years, open 60.1 years) than perineal repair (75.2 years) (p < 0.01). They were also healthier with fewer comorbid conditions, including COPD, hypertension, congestive heart failure, and end-stage renal disease (p < 0.01). Operative time was significantly shorter for perineal repair (87.5 min vs 144.9 min open and 158.3 min MIS, p < 0.01). Over time, perineal repair remained the most common (55.9%), followed by MIS (24.2%) and open approaches (19.7%). MIS use increased from 8% in 2007 to 38.8% in 2021, while open and perineal repair declined (open: 32.9% to 13.0%, perineal: 59.1% to 48.3%, all p < 0.01). In the age group <70 years who underwent perineal repair (2602 patients), 46.7% of these patients were American Society of Anesthesiologists class I or II and 92% were functionally independent (Figure 1).

Conclusion: From 2007 to 2021, MIS repair of rectal prolapse has been increasingly used. However, perineal repair is still used for a significant number of repairs, even in patients who are young with good performance status.

An Assessment of Risk Factors for Financial Toxicity among Colorectal Cancer Patients in Massachusetts

Anastasia Bogdanovski, MD, Ashley L O’Donoghue, PhD, Jorge L Gomez-Mayorga, MD, Rafael R H Martin, MD, Iman Abedin, MBBS, Nishant Uppal, MD, Aaron Fleishman, MPH, Qing L Hu-Bianco, MD, MS, Kristen Crowell, MD, FACS, Benjamin C James, MD, FACS

Beth Israel Deaconess Medical Center, Boston, MA

Introduction: Colorectal cancer (CRC) patients face an elevated risk of financial distress, with a bankruptcy rate 3 times higher than the general population. Despite established connections between financial toxicity (FT) and adverse outcomes, risk factors contributing to financial burden in CRC patients have not been explored.

Methods: Massachusetts Cancer Registry data from 2010 to 2019, linked with national credit bureau financial data, were used to identify factors associated with FT in CRC patients (ICD C180-189, C199, C209). After excluding patients with prediagnosis bankruptcy, demographic variables, tumor stage, treatment status, and Area Deprivation Index (ADI) were analyzed. Using multivariate regression, the outcome credit score over time was assessed, reflecting a composite score of payment history, credit balances, use, and credit depth.

Results: A total of 7,227 CRC patients with median financial follow-up of 5.3 [interquartile range (IQR) 3.3, 7.3] years were included. Mean credit score was 716 points, 95% CI [703, 730], with significant variations in points: age <62 years (median) (-11), Black or Hispanic race (-78 and -62), unmarried (-28), ADI below median (-14), non-homeowner (-5), income below median of $52,000 (-18), and distant or regional disease (-10 and -7), all p < 0.001. Post-diagnosis, there was notable disparity among cancer and treatment type (Table 1). Colon cancer patients experienced the largest decline in credit score (-6 points, p = 0.002) compared with rectal and rectosigmoid cancer.

Table 1. - Change in Vantage Score After Diagnosis of Colorectal Cancer Based on Treatment Type

Treatment Frequency Coefficient (Credit score change post-diagnosis compared with reference) p Value
None 293 (4.1%) -28.40 <0.001
Chemotherapy Only 525 (7.3%) -14.23 <0.001
Radiation Only 12 (0.2%) -62.03 0.001
Chemotherapy and Radiation 212 (2.9%) -8.79 0.058
Surgery Only 3,345 (46.3%) Reference Reference
Surgery and Chemotherapy 1,883 (26.1%) 2.59 0.091
Surgery and Radiation 10 (0.1%) -15.92 0.263
Surgery, Chemotherapy, and Radiation 920 (12.7%) -2.46 0.306
Unknown 27 (0.4%) -25.11 0.070

Conclusion: CRC-related FT risk factors include younger age, unmarried status, disadvantaged areas, race, lower income, disease spread, and treatment status. This model helps identify at-risk CRC patients for FT, facilitating personalized treatment and surveillance strategies.

Cardamonin Inhibits the TNFa-Induced Epithelial-Mesenchymal Transition of Intestinal Epithelial Cells via Inhibition of NFkb/p38 Regulated STAT3 Signaling

Jana E DeJesus, MD, Xiaofu Wang, BS, Yanping Gu, MD, Jaclyn R Dempsey, MD, Geetha Radhakrishnan, MD, Ravi Radhakrishnan, MD, FACS

The University of Texas Medical Branch, Galveston, TX

Introduction: Approximately one-fifth of Crohn’s Disease patients will experience stricture, leading to bowel obstruction and chronic pain. There is no treatment for stricture except operation. Intestinal epithelial cell (IEC) barrier disruption is a fundamental step in Crohn’s, leading to epithelial-mesenchymal transition (EMT) into a pro-inflammatory phenotype that contributes to intestinal fibrosis. Cardamonin (CDN) is a natural compound that decreases activation of the pro-inflammatory STAT3 and NFκB pathways. However, the exact mechanism of action is unknown. We hypothesized that CDN attenuates EMT in IECs through NFkb/p38 regulated STAT3 signaling.

Methods: The immortalized rat intestinal epithelial cell line IEC-6 was pre-treated with either CDN or other specific inhibitors of NFkb (Bay117082), p38MAPK (SB203580), and STAT3 (Stattic and FLLL31) then treated with TNFa to induce EMT. Proteins including a-smooth muscle actin and phosphorylated p38 and STAT3 were isolated for Western Blot and DNA binding assays. NFkbp65 nuclear translocation was confirmed by immunofluorescence staining. DNA binding was evaluated with ELISA.

Results: TNFa increased the phosphorylation of p38 and STAT3 and DNA binding activity. Specific inhibition of NFkb and p38 reduced STAT3 activation. CDN reduced TNFa-induced levels of a-SMA (EMT marker) in IECs in a dose-dependent manner. Treatment with specific pathway inhibitors Bay117082, SB203580, Stattic, and FLLL31 yielded similar reductions in a-SMA. Notably, CDN dose-dependently inhibited TNFa-induced STAT3 phosphorylation and DNA binding without affecting NFkb nuclear translocation and p38 phosphorylation (Figure 1).

Conclusion: EMT in IECs may be regulated by NFkb/p38 regulated STAT3 signaling. CDN suppressed TNFa-induced STAT3 activity without affecting upstream factors NFkb and p38.

Comparison of Levatorplasty along with Altemeier Procedure Compared with Altemeier Alone on Fecal Incontinence and Recurrence Rate

Farzad Mokhtariesbuie, MD, Mina Alvandipour, MD

Johns Hopkins University, Baltimore, MD; Mazandaran University of Medical Science, Sari, Islamic Republic of Iran

Introduction: Despite the generally favorable efficacy of the Altemeier procedure for rectal prolapse, the recurrence rate remains significant. Our assessment emphasizes whether Levatorplasty, along with the Altemeier, can minimize the recurrence rate and reduce fecal incontinence.

Methods: Forty patients with rectal prolapse were candidates for the Altemeier procedure, randomly divided into 2 groups, to receive Altemeier or Altemeier along with Levatorplasty. Postoperative outcomes such as bowel movements, fecal continence through the Wexner scale questioner, and rectal prolapse recurrence were assessed in all patients at 6 months and 1 year after the operation.

Results: The male/female ratio and age were not different between groups. There were no mortality or major complications like dehiscence in any patients. Minor complication, such as anal stricture and bleeding, was not significantly different between groups. The Wexner score was significantly lower in patients with Levatorplasty along with the Altemeier procedure compared with Altemeier alone at 6 months (p < 0.05) and 1 year after operation (p < 0.05). The recurrence rate after 1 year was significantly lower in patients receiving Levatorplasty along with the Altemeier procedure compared with Altemeier alone (10% vs 25%, p < 0.05). The postoperative length of stay at the hospital was not different between the groups. The rate of constipation was reduced after operation in both groups, although it was not significant (Figure 1).

Conclusion: We demonstrate that Levatorplasty in conjunction with Altemeier, is associated with better bowel function and a decreased incontinence rate. Levatorplasty significantly reduced the recurrence rate and/or need for a second operation.

Comparison of Wafi Ileostomy with Brook Ileostomy in Stage III Rectal Cancer Surgery

Mahir Gachabayov, MD, Wafi Attaallah, MD, PhD, Ernesto Barzola, MD, PhD, Mirkhalig Javadov, MD, Alisina Bulut, MD, Orkhan Verdiyev, MD, Ryan F Bendl, DO, FACS, Roberto C Bergamaschi, MD, PhD, FACS, FRCS, FASCRS, FASCRS

Westchester Medical Center, Valhalla, NY; Marmara University School of Medicine, Istanbul, Turkey; University of Seville, Seville, Spain; Marmara University School of Medicine, Kartal, Turkey; Jacobi Medical Center, Albert Einstein College of Medicine, New York, NY

Introduction: The aim of this study was to compare Wafi ileostomy with Brooke ileostomy in terms of overall complication in patients with resectable stage III adenocarcinoma located in the distal rectum.

Methods: This was a prospective cohort study enrolling patients in 2 institutions. Wafi ileostomy was defined as insertion of a soft polyvinylchloride tube into the afferent limb of the terminal ileum with a flexible rubber drain passed behind the backwall of its efferent limb to occlude the lumen. Propensity score matching with a 1:1 ratio was employed to compare diagnosis-matched patients.

Results: During 5 years, 110 and 116 patients underwent total mesorectal excision (TME) with Wafi and Brooke ileostomy, respectively. A total of 99 Wafi vs 99 Brooke patients were included and were comparable in age, gender, and American Society of Anesthesiologists score. Ileostomy reversal was carried out at median postoperative day (POD) 14 (same hospital stay) vs median 150 days (readmission), p < 0.001. Recovery after reversal was uneventful except for 1 postoperative obstruction requiring reoperation after Brooke reversal. Incisional surgical site infection rate after reversal did not differ (p = 0.772). Rate of colorectal anastomotic leak identified at CT scan with rectal contrast was 11.1% vs 4.0% (p = 0.104). Rate of dehydration with/without kidney failure (1% vs 22.7%; p <;0.001), emergency room visit with/without readmission (1% vs 24.5%; p < 0.001) were significantly higher in Brooke patients.

Conclusion: Wafi ileostomy with its reversal within the same hospital stay was associated with fewer complications. The evidence regarding the impact that ileostomy technique and/or timing of reversal might have on colorectal anastomotic leak rate is inconclusive at this time.

Defining Opportunities to Improve Perioperative Ostomy Care and Education

Hannah Ficarino, MD, Burkely Smith, MD, MSPH, Jernell Simmons, BS, Ivan I Herbey, MD, Daniel Chu, MD, MSPH, FACS, Wendy Landier, PhD, CRNP, FAAN, Smita Bhatia, MD, MPH, Robert H Hollis IV, MD, MSPH, FACS

University of Alabama at Birmingham, Birmingham, AL

Introduction: Patients with a new ostomy must obtain, understand, and use ostomy care-related resources to manage their ostomy after discharge. Many patients experience issues with their new stoma. We sought to qualitatively identify opportunities to improve perioperative ostomy care and education.

Methods: Patients who underwent construction of a new ostomy, their caregivers, and providers were purposively recruited to complete semi-structured phone interviews. Interviews included questions about ostomy-related experiences, education, and resources in the preoperative, inpatient, and post-discharge phases of care. Interviews were transcribed and thematically coded using inductive content analysis with NVivo 12 Software.

Results: Overall, 53 interviews of 20 patients, 16 caregivers, and 17 providers were conducted. The median age of patients and caregivers was 60 years, 69% were non-Hispanic White, 79% were women, and 40% had limited health literacy. Themes representing barriers in the preoperative phase included ‘not knowing what to expect regarding an ostomy’, ‘patient difficulty understanding of their health condition’, and ‘overwhelming amount of information regarding an ostomy’. Inpatient phase themes included ‘not knowing the best ostomy supplies to use’, ‘challenges with ostomy appliance application’, and ‘lack of patient acceptance/maladjustment’. Post-discharge themes included ‘difficulty obtaining supplies’, ‘challenges caring for inflamed skin’, ‘variability in home healthcare’, ‘missing outpatient resources’, and ‘limited information on hydration and diet management’. Example quotes are shown in Table 1.

Table 1. - Representative Quotes from Patients, Caregivers, and Providers for Select Identified Themes

Phase of care Reported Barrier Patient Example Quotation Caregiver Example Quotation Provider Example Quotation
Preoperative Not knowing what to expect regarding an ostomy “I really didn’t look up any ’cause I really didn’t know—it really didn’t talk about a whole lotta about the bag itself or anything until I was in the hospital and had the surgery...” “Personally, we didn’t know it was gonna be as major a deal as it was” “They don’t always make the connection that [it] is a fecal diversion... but it doesn’t always click that it’s a fecal diversion until it’s actually there”
Preoperative Overwhelming amount of new information regarding an ostomy “Yeah, there’s a lot of information out there, but you’re wading through too much junk.” “It was overwhelming, just all the information that was coming after surgery... That was overwhelming.” “If any patient already is healthcare illiterate or has a new diagnosis on top of having a new surgery, it could be overwhelming...”
Inpatient Not knowing the best supplies to use “⋯because it’s just knowin’ how to put it on and what worked best for you. What may work best for the person teaching you may not totally work for you at all.” “Just there’s so many different options about the paste and the paste rings, and this kinda bag and that kinda bag. It was overwhelming.” “I think, though, sometimes the issue we come onto is just trying to find the right bag to fit. There’s some people need a belt and other ones don’t.”
Inpatient Lack of patient acceptance or mal-adjustment “Didn’t have enough time to prep yourself mentally” “That my husband did not participate with that...just him not really participating” “There was one lady... who would just not look at the ostomy. She... came back with ostomy related complications.. she was not doing the ostomy care as predicted”
Inpatient Challenges with ostomy appliance application “Yeah, trying to keep your bags on. It was hard. It was frustrating. I stayed depressed.” “I guess the most difficult, I would say, would probably be makin’ sure to cut around the—to cut the circle to make sure it would fit on.” “Their dexterity is a little bit more limited, right after that they have surgery. I think with the medications and pain, it is a bit harder for them to figure out how to cut the circle and put on the bag appropriately.”
Post-discharge Difficulty obtaining supplies “I would just say maybe a little bit more prepared as far as just like the logistics of stuff afterwards, and maybe⋯ well, your home health company will have all these samples for you and these catalogs. You can order whatever. They had none of that.” “I had a difficult time finding my husband[‘s] ostomy bags” “⋯ there’s 30 different supplies you gotta keep up with, all of the stuff, the supplies, and one of the biggest things is ordering, and when to order, because we will have folks say, nobody told me I had to order my own stuff.”
Post-discharge Caring for inflamed skin “I took my first bag off after leaving the hospital and the skin come off with it. Then, they got inflamed and irritated. Then, that’s still what I’m dealin’ with today⋯.” “Cause he would be raw and really red around it... we learned just what we could use to kinda treat it and get it where it wasn’t so red.” “⋯It becomes unpouchable because the skin just gets so excoriated and the stoma can be retracted.”
Post-discharge Variability in home health care “Well, we did, but it was the biggest waste of time I ever heard. We let ‘em go ‘cause, as far as them helpin’ us with everything havin’ to do with bags, they never did that” “Well, the little girl from home health didn’t ever do nothin’ but talk to us. She never changed it. Just looked at it, but never took one off or none of that” “In my experience home health has been very individualized based on the home health nurse that comes out to help them.”
Post-discharge Hydration/diet management “Trying to figure out what you can eat, what you can’t eat, what’ll cause a blockage, what won’t cause the blockage” “The only problem that my wife’s havin’ right now is she’s havin’ a lotta ballooning from passing gas... She’s trying to learn what to not to eat to pass the gas, or to have the gas” “I think they learn pretty quickly that this thing is functioning all the time. They need to drink to keep up with it”

Conclusion: Patients, caregivers, and providers report perioperative barriers to obtaining, understanding, and using ostomy care related resources and education. These findings inform the development of health-literacy sensitive interventions to improve ostomy care and education.

Does Sequence of Colorectal Cancer Diagnosis Matter for Patients with Multiple Primary Cancers? A Surveillance, Epidemiology, and End Results Database Cohort Study

Anjelli Wignakumar, MBBS, BSc (Hons), Sameh H E Rizkalla, MBBCh, MD, FACS, Justin Dourado, MD, Victoria R Detrolio, BS, Brett Weiss, BS, Marylise Boutros, MD, FACS, Steven D Wexner, MD, PhD (Hon), FACS, FRCS (Eng,Ed), Hon FRCS (I,Gl), Hon FRCS (I,Gl)

Cleveland Clinic Florida, Weston, FL; Cleveland Clinic Florida, Plantation, FL; Cleveland Clinic Florida, Boca Raton, FL; Cleveland Clinic, Morristown, NJ

Introduction: In patients with multiple primary cancers, the impact of when colorectal cancer (CRC) develops within the series of cancers is unknown. This study aimed to assess the features and outcomes of CRC as an isolated primary compared with CRC that presents in a sequence of primary tumors.

Methods: This retrospective cohort included patients with stage I-IV colorectal adenocarcinoma from the Surveillance, Epidemiology, and End Results (SEER) Program database (2000-2020). Patients were classified into 3 groups; A: CRC as the only malignancy, B: CRC as the first of multiple primary malignancies, C: CRC as the second of multiple primary malignancies. The primary outcomes were overall survival (OS) and cancer specific survival (CSS).

Results: Of 592,062 patients, 424,919, 70,432 and 96,711 were in Groups A, B and C, respectively. Patients in Group A were younger, had a higher pretreatment carcinoembryonic antigen, and more frequent liver metastases. Group B had more men and left-sided CRC, and Group C had more right-sided CRC. Groups A and C had more T4 tumors and less surgical treatment. Group A most frequently underwent systemic adjuvant treatment for their disease. The longest OS and CSS was noted in Group B (50.4 and 51.3 months), followed by Group A (41.8 and 42.2 months) and then Group C (39.2 and 39.8 months respectively).

Conclusion: CRC presenting as the first of multiple primary malignancies often had less advanced disease, higher rate of operative treatment, and improved OS and CSS than CRC presenting as an isolated primary or second primary malignancy.

Efficacy of Preoperative Chemoradiotherapy for Rectal Cancer Using Exosomal miRNA

Yuma Wada, MD, PhD, Masaaki Nishi, MD, PhD, FACS, Takuya Tokunaga, MD, PhD, FACS, Chie Takasu, MD, PhD, FACS, Hideya Kashihara, MD, PhD, FACS, Toshiaki Yoshimoto, MD, PhD, Mitsuo Shimada, MD, PhD, FACS

Tokushima University, Department of Surgery, Tokushima, Japan

Introduction: We recently reported the blood-based transcriptomic biomarkers for identification of response to preoperative chemoradiotherapy (PCRT) followed by operation in patients with locally advanced rectal cancer (LARC). In this study, we sought to develop a liquid biopsy assay of exosomal miRNA for identifying response to PCRT in patients with LARC.

Methods: We analyzed 27 serum specimens from stage II-III patients diagnosed with LARC who underwent PCRT. We performed RT-qPCR followed by logistic regression analysis to develop an integrated transcriptomic panel and establish a risk-assessment model, combined exosomal miRNA with CEA level. The association between exo-miRNA expression and predicted response to PCRT (Grade 2.3 = Responder, Grade 1 = Non-responder) was examined using pretreatment blood samples.

Results: We used comprehensive expression profiling of a training cohort of PCRT-responder and non-responder serum specimens to identify an optimized transcriptomic panel of 5 exosomal miRNAs. We identified patients with response to PCRT (area under the curve [AUC] = 0.87, 95% CI = 0.68-0.97). Our risk model was more accurate for identification of response to PCRT than the panel (AUC = 0.90). Moreover, we applied our model to detect patients with pathological complete response, and showed it was dramatically superior to currently used pathological features (AUC = 0.92) (Figure 1).

Conclusion: Our risk assessment signature for predicting response to PCRT has a potential for clinical translation as a liquid biopsy assay in patients with LARC. Our findings highlight the potential clinical impact of our model for improved selection and management of patients with this malignancy.

Elucidating a Key Mechanism of Perioperative and Postoperative Ileus: Microvascular Serum Leak-Activation of the Cyclooxygenase Pathway Causing Colonic Dysmotility

Tiffany Cho*, Sima M Lilly, Anthony J Bauer, PhD

Liberty College of Osteopathic Medicine, Lynchburg, VA

*Excellence in Research Award recipient.

Introduction: Perioperative and postoperative ileus (POI) represent a significant clinical burden and a $1 billion annual healthcare expenditure. Previous studies have suggested that intestinal manipulation and the ensuing inflammatory milieu trigger a subsequent causal mechanism of ileus. We aimed to establish that microvascular leakage of serum activates a cyclo-oxygenase-mediated suppression in colonic motility as a key mechanism of ileus.

Methods: A “running the bowel” mouse model of POI was constructed, live colon imaged to assess vascular leak of intravenous injected 70 kDa FITC-dextran, and mid-colonic circular and longitudinal muscle contractility recorded in a 37°C Krebs-perfused chamber. Serum, COX-1/2 activation, and prostanoids were investigated using indomethacin (10 µM), selective COX-2 inhibitor valdecoxib (3 µM), and prostaglandin E2 (0.1 µM) (n = 4-5 each).

Results: Confocal microscopy demonstrated a profuse colonic transmural microvascular leak immediately and 24 hours after operation, but no leak in controls. Serum caused a dose-dependent decrease in circular muscle contractions (2.5% = 37.0 ± 9.98% and 5.0% = 7.2 ± 3.89% of control). Indomethacin and valdecoxib pretreatment slightly increased basal spontaneous activity. Furthermore, indomethacin significantly blocked the 2.5% serum-induced suppression of contractions (94.7 ± 23.05% of control) and valdecoxib paradoxically increased (5.2 ± 2.14%) contractions upon the addition of 2.5% serum. Serum suppressed longitudinal muscle contractile frequency, and additionally caused the development of a significant tonic contracture - both were significantly blocked with indomethacin. Prostaglandin E2 (0.1 µM) markedly suppressed circular muscle contractions (105.1 ± 21.46 to 27.3 ± 7.11 mg/min) and generated longitudinal muscle tone.

Conclusion: The results demonstrate that a key mechanism of perioperative- and postoperative-ileus is the activation of the cyclooxygenase/prostanoid pathway via the postoperative microvascular leakage of serum.

Emergency Surgery for Colon and Rectal Cancer in the Michigan Surgical Quality Collaborative

Evan Monge, BS, Ashley A Duby, MS, Nicholas Kunnath, MS, Michael F McGee, MD, FACS, Samantha K Hendren, MD, MPH, FACS, Calista Harbaugh, MD

University of Michigan, Ann Arbor, MI

Introduction: When patients present with obstructing or perforated colorectal cancer (CRC), surgeons must decide whether to emergently resect the involved intestine or perform fecal diversion alone. Little is known about current practice patterns for emergent CRC.

Methods: Using clinical registry data from 69 Michigan Surgical Quality Collaborative (MSQC) hospitals collected by trained nurse abstractors, we identified patients who underwent urgent or emergent operation for colon, rectosigmoid, or rectal cancer (2016-2023). The primary outcome was diversion (primary procedure code indicating stoma creation only) vs resection (intestinal resection with or without stoma). Descriptive and multivariable logistic regression analyses adjusting for patient characteristics were performed to compare patients who underwent diversion vs resection.

Results: There were 3,376 patients with 2,960 (87.7%) colon, 216 (6.4%) rectosigmoid, and 200 (5.9%) rectal cancer. Most were >65 years of age (65.6%) and White (79.4%), with approximately half women (50.9%). Most operations were performed in teaching hospitals (87.7%) with 200-499 beds (50.4%). More patients underwent resection (89.0%) than diversion (11.0%). Risk-adjusted rate of diversion was significantly lower among patients with colon vs rectosigmoid or rectal tumor (Figure 1). Adjusted odds of diversion were significantly higher among patients with disseminated cancer (adjusted odds ratio [aOR] 5.83 (4.34-7.84); p < 0.001), and lower among patients aged >65 years (0.36 (0.19-0.68); p = 0.002) and on dialysis (0.11 (0.03-0.46); p = 0.002).

Conclusion: While resection has the potential to cure, it may risk incomplete resection or postoperative complication that delays or obviate candidacy for chemotherapy. Future work will assess outcomes after emergent operation such as positive surgical margins, and opportunities for statewide quality improvement.

Emerging Population Perspectives: Exploring Colorectal Cancer in Adults under 50 Years of Age

Samantha Savitch, MD, Sarah Bradley, PhD, MPH, CPH, Maedeh Marzoughi, BS, Claire Ashmead-Meers, MSc, Crystal A Vitous, MA, MPH, Pasithorn A Suwanabol, MD, MS, FACS

University of Michigan, Ann Arbor, MI

Introduction: Colorectal cancer (CRC) diagnoses among adults aged <50 years have increased by an alarming 20% over the past 2 decades. Such patients often face unique barriers to diagnosis and may have different priorities and concerns compared with their older counterparts. In this study, we aimed to explore the perspectives of younger adults with CRC to optimize comprehensive cancer care for this emerging population.

Methods: Data for this study were derived from semi-structured qualitative interviews conducted with patients diagnosed with CRC under age 50 years (n = 35). Participants were recruited through convenience sampling across 3 academic institutions where they had received CRC treatment. Interview data were analyzed iteratively through steps informed by thematic analysis. Findings presented here are preliminary, as data collection and analysis are ongoing.

Results: Patient concerns were categorized into 4 distinct dimensions of health: (1) physical health (eg incontinence, loss of vitality, and expenses related to healthcare); (2) mental health (eg uncertainty surrounding survivorship, anxiety about timing of diagnosis, and long-term mental healthcare needs); (3) family planning (eg uncertainty about fertility after chemotherapy, and considerations about egg and sperm preservation); and (4) career (eg job security, challenges in pursuing advanced degrees, and reliance on employment-derived benefits) (Table 1).

Table 1. - Illustrative Quotes from Patient Interviews

Dimension of Health Illustrative Quote
Physical Health One of my biggest things is since my rectum is gone, I no longer have that feeling of sensation like in my cheeks; basically, the cheeks and the anus area is all dead. So, sitting too long for me; it could be a soft chair or hard chair, when I sit down for a half of an hour or maybe 15 minutes, it is like sitting down when you are 20 years old and getting up when you are 80 years old (47-year-old man)
My teeth are a wreck, and it’s all because of chemo. I just, I don’t want to get emotional, I just went to the dentist yesterday, and I just get so frustrated... All these things to pay. I should be happy to be alive. But I probably have $20,000 out of my pocket. And I get 50/50 dental coverage... I have so much money in my mouth, it’s not funny (48-year-old woman)
Mental Health [I have] a lot of survivor guilt. Like I had a friend die of colon cancer months after me. You know, I swear it’s all about early detection. And I even thanked my primary guy... because he could have blown me off and been like, ‘Ah, it’s just internal hemorrhoids. We’re not going to worry about it. You’re not 50 yet. Blah. Blah. Blah.’ If he hadn’t sent me then, who knows? Because my girlfriend who passed a couple of months after me, she didn’t go to the doctor (51-year-old woman)
After I had my daughter, like she is three months old, just had my CT scan and there is like two weeks’ time where I am thinking that I have cancer again. I picked up a notebook. I picked up a journal and I wrote, it is called like my ‘Dear [Daughter’s Name] notebook’. So, I try to write entries to my daughter. So, some of my first entries I wrote, ‘I might have cancer. I love you so much. I hope I can watch you grow up.’ I just add newspaper clippings and pictures because if I do pass away some day, [Daughter’s Name] can have this notebook that shows how much I love her. Because I do think that it could happen again. I always think that I am going to die. I think about death every day (34-year-old woman)
Family Planning I can’t have any more kids. So they asked me if I wanted to freeze some sperm and all of that, and I was like ‘Nah’ to them... I needed the money first of all, and then also it was that I didn’t want to have any more kids [because] I didn’t know if I was going to live or die, I didn’t know anything... I barely had any money. So like do I risk putting this money up to freeze something when I don’t even know if I am going to be here or not? (33-year-old man)
They said [chemotherapy] doesn’t have that big of an effect on fertility. But they always put that question mark at the end. And so, I would get really nervous, and I know I wanted to in some way have a family. And I would rather have just been safe, and so I was like ‘I will do the injections. I just want to save a few of my eggs just in case.’ (22-year-old woman)
Career It has been extremely tough. It has totally changed our lives. I went from being a provider for my family, making enough money to take care of my family, where my wife was staying home, to now not being able to work and her having to pick up little side jobs and stuff just to try to help make ends meet... We don’t make enough to be able to cover a lot of the things that is needed (48-year-old man)
I couldn’t do any lifting or anything. I worked in... a very physical job. So, I couldn’t. And then I had the port placed any my boss wanted to know if I could come back to work. And I liked talked to the nurse that was like, “I wouldn’t recommend it.” So, I didn’t. So, I just collected all my sick pay. And then I was separated from my employer (43-year-old man)
I do know that when I got diagnosed with cancer, that I was going to finish my degree. I was like, ‘Gosh darn it, if I only have one year left on this planet, I’m going to finish something’... I did a [degree program] for three more years, because I wanted to stay in the [Institution] benefits insurance. I probably would not have done that if I didn’t have this cancer looming over me... So, it definitely changed my career trajectory (38-year-old man)

Conclusion: Younger adults with CRC encounter unique challenges that may not receive adequate attention from cancer providers, particularly in addressing their psychosocial well-being. A comprehensive understanding of these unique challenges is essential for the development of tailored treatment programs that meet the needs of this growing population.

Endometriosis and Its Role in Pouch Patients: A Matched-Pair Analysis

Jessica Stockheim, MD, Mikhael Belkovsky, MD, Hermann P Kessler, MD, PhD, FACS

Cleveland Clinic, Department of Colorectal Surgery, Digestive Disease Institute, Cleveland, OH

Introduction: Clinical signs of endometriosis are heterogeneous, and symptoms are similar to those reported in patients with inflammatory bowel disease (IBD) and ileal pouch-anal anastomosis (IPAA) with pouchitis. This study aimed to assess the effects of endometriosis on pouch performance and outcomes.

Methods: Retrospectively, patients who underwent pouch creation between 1985 and 2022 and ICD-coded endometriosis were included. The study cohort was matched using the nearest propensity score matching method based on a 1:3 ratio with respect to IBD diagnosis, pouch type, age at pouch creation, BMI, and American Society of Anesthesiologists score.

Results: A total of 22 study patients were included, with 45.5% histopathological proof of endometriosis. Endometriosis patients underwent open procedures more often than those in the control group (77.3. % vs 59.1%). Completion proctectomy (54.5% vs 65.2%) and total proctocolectomy with J-pouch (36.4% vs 25.8%) were the most frequent procedures. Hysterectomy was performed in 50.0% of the study cohort, of those in 90.9% after the initial pouch creation. Operation-related postoperative complication rate was similar (31.8% vs 24.2%). The rate of pouch revision was equal in both cohorts (13.6% vs 12.1%). The time to stoma reversal was longer in the endometriosis group (111 days vs 106 days). Long-term postoperative complication of pouch failure (9.0% vs 12.1%), sporadic pouchitis (18.2% vs 1.5%) or fistula (9.0% vs 19.7%) varied (Table 1).

Table 1. - Overview of Medical History and Intraoperative Parameters

Variable Pouch + Endometriosis (study) (N = 22) Pouch
(control) (N = 66)
Proof of endometriosis: Clinically 12 (54.5%) -
Proof of endometriosis: Pathologically 10 (45.5%) -
Hysterectomy 11 (50.0%) 2 (3.1%)
Hysterectomy: after pouch creation 10 (90.9%) -
Hysterectomy: before pouch creation 1 (4.5%) 2 (3.1%)
Operation duration (min) 180 (123) 209 (80.7)
Intraoperative anastomosis level (cm) 1.54 (.24) 1.50 (0.33)
Intraoperative oophoropexy 6 (27.3%) 9 (13.6%)

Conclusion: Our study showed that pouch creation in patients with endometriosis is safe with no more complication and excellent long-term results.

Endoscopic Transanal Vacuum-Assisted Rectal Drainage Therapy as Treatment for Low Pelvic Anastomotic Leak

Andrea Fabiola Hernández Trejo, MD, Luis E Salgado Cruz, MD, Hugo Antonio Rangel Rios, MD, Alberto Felix Chapa Lobo, MD

Hospital San José and Centro Médico Zambrano Hellion TecSalud, Monterrey, Mexico; Hospital Angeles Valle Oriente, San Pedro Garza Garcia, Mexico; Hospital Angeles Valle Oriente, Monterrey, Mexico

Introduction: Anastomotic leak (AL) occurs in up to 30% of patients after low rectal anastomosis. It is associated with increased morbidity, deterioration in function and reduced cancer-free survival. There is no universally accepted treatment algorithm, which must be individualized according to patient’s general condition, size and location of anastomotic defect, and presence of diverting stoma. Endoscopic transanal vacuum-assisted rectal drainage (ETVARD) is a new method to treat colorectal AL. The objective of this study is to report on the effectiveness of ETVARD therapy for closure of AL.

Methods: We studied all patients with anastomotic leak treated with ETVARD therapy using a device made by the team, in a center specialized in the treatment of colorectal disease, from 2018 to 2023. Patients diagnosed with rectal cancer and inflammatory bowel disease (IBD) were included.

Results: A total of 10 patients with an average age of 50.7 years were included, 70% of whom were men, 8 patients with diagnosis of rectal cancer and 2 with IBD. A loop ileostomy was performed during the first intervention in all patients. The time between operation and first sponge was less than 3 weeks in 9/10 cases, with an average of 17 days. Salvage of the anastomosis was achieved in 90% of the cases, with a closure time of 25.6 days (12-60) and number of sponge replacements of 4 times (3-6) on average. Closure of stoma was achieved in all patients (Figure 1).

Conclusion: ETVARD therapy allows preservation of the anastomosis and control of sepsis, prevention of reintervention, as well as a high rate of ileostomy closure.

External Validation of a Prediction Model for Local Recurrence after Curative Rectal Cancer Surgery: A Large Multicenter Cohort Study in Japan

Yusuke Fujii, MD, Koya Hida, MD, PhD, Kazutaka Obama, MD, PhD, FACS, Ryosuke Okamura, MD, PhD, FACS, Nobuaki Hoshino, MD, PhD, MPH, Yoshiro Itatani, MD, PhD, FACS, Hiromitsu Kinoshita, MD, PhD, Hisatsugu Maekawa, MD, PhD

Department of Surgery, Kyoto University Hospital, Kyoto, Japan

Introduction: The early diagnosis of local recurrence after curative operation for rectal cancer is crucial. We previously developed a prediction model using data from 2 academic hospitals in Japan and Korea and demonstrated its usefulness. External validation is necessary to assess the generalizability of this prediction model on a broader scale.

Methods: We analyzed cohort data of 1500 consecutive patients who underwent elective resection for cStage II-III rectal cancer from 69 facilities nationwide in Japan between 2010 and 2011. We used the scoring system of our prediction model (tumor differentiation: 2, tumor depth, lymph node metastasis, surgical procedure, postoperative complication, tumor height, carcinoembryonic antigen level: 1) to calculate the total score for each case. We performed risk stratification and graphed the cumulative local recurrence rate for each group. We also conducted a model comparison between our model and the TNM stage classification.

Results: We excluded cases with pStage IV and non-R0 and analyzed 1398 cases. The 5-year local recurrence rate for the low-risk group (rating: 0-2), medium-risk group (3-5), and high-risk group (6-8) was 4.9%, 17.7%, and 36.7%, respectively. When comparing our model with TNM staging, the discrimination for 2-year local recurrence was useful for our model (c-index: 0.686 and 0.616, respectively), whereas there was a tendency for the similar discrimination for 5-year local recurrence (0.672 and 0.646, respectively) (Figure 1).

Conclusion: The local recurrence prediction model after curative operation for rectal cancer, which we had developed, was externally validated. Particularly, it was deemed advantageous over stage classification when predicting 2-year local recurrence.

Factors Mediating the Impact of Care Fragmentation on Outcomes in Rectal Cancer

Daniel A Metzger, MD, Julianna Brouwer, MPH, Dawn Chirko, Alessio Pigazzi, MD, FACS, Steven Chao, MD, FACS, Heather Yeo, MD, FACS

New York Presbyterian Weill Cornell Medical Center, New York, NY

Introduction: Treatment of rectal cancer requires a multidisciplinary approach; however, care fragmentation studies in this population have been limited. This study aimed to determine the demographic, clinical, and hospital variables that influence the impact of care fragmentation. We hypothesized that fragmented care has varied effects in different populations and care facilities.

Methods: Stage II-III rectal cancer patients treated with operation, chemotherapy, and radiation (2004-2020) were selected from the National Cancer Database and divided into fragmented and unified care groups. Propensity score matching was performed. Survival was compared using Kaplan-Meier and multivariate Cox models. Demographic, disease characteristic, and hospital type subgroups were analyzed to determine the differential impact of fragmentation.

Results: A total of 55,391 patients were included; 68% (37,620) received fragmented care and 32% (17,771) unified care. After matching, there was no significant difference in overall survival (hazard ratio [HR] 1.00, 95% CI 0.96-1.04; p > 0.9). Subgroup analyses showed a negative impact of fragmentation on survival in patients with Medicaid (adjusted hazard ratio [aHR] 1.16, 95% CI 1.05-1.28; p-0.003) and patients living >100 miles from the hospital (aHR 1.34, 95% CI 1.13-1.60; p < 0.001). Patients treated in academic hospitals had the longest median survival (127 months, Figure 1). Within academic hospitals, unified care was associated with improved survival compared with fragmented (aHR 0.93, 95% CI 0.89-0.98; p-0.005). Tumor grade, stage, and comorbidity did not appear to mediate the impact of fragmentation.

Conclusion: Care fragmentation in rectal cancer is common but its impact on survival varies by patient socioeconomic and hospital factors. Efforts to reduce disparity in care delivery should focus on groups most negatively impacted by fragmentation.

Frailty, Not Age, Predicts Postoperative Complication in Patients Undergoing Proctectomy for Inflammatory Bowel Disease

Olivia R Ziegler, MD, Alicia C Greene, DO, McKell Quattrone, MD, Michael J Deutsch, MD, FACS, Jeffrey S Scow, MD, FACS, Patricio B Lynn, MD, Audrey S Kulaylat, MD, MSc, FACS

Penn State Health Milton S. Hershey Medical Center, Hershey, PA

Introduction: In some surgical populations, frailty appears to be a greater risk for postoperative complication than age. We hypothesized that in patients with inflammatory bowel disease (IBD) undergoing proctectomy, frailty would be associated with postoperative complication, independent of age.

Methods: IBD patients undergoing proctectomy from 2006 to 2021 were identified in the NSQIP Participant Use File database. The modified 5-item frailty index was calculated for each patient, with frailty defined as scores of 2 or more. Complications included 30-day mortality, reoperation, or postoperative morbidity. Logistic regression was performed to test for association.

Results: A total of 7,012 patients were included, 5% (344) were frail. Modelling frailty alone, frailty was associated with increased risk of complication (1.7 odds ratio [OR], p < 0.001). Modelling age alone, age was not associated with increased complication (OR = 1.00, p = 0.298). Adjusting for age, frailty, sex, smoking, steroid use, and American Society of Anesthesiologists (ASA) score, neither age 65-79 years (OR = 0.98, p = 0.88) nor age over 80 years were associated with increased complication (OR = 1.03, p = 0.94) compared with age 18-64 years. Frailty continued to be associated with increased complication (OR = 1.49, p = 0.003), as did steroid use (OR = 1.27, p = 0.001) smoking (OR = 1.47, p < 0.001) and ASA over 2 (OR = 1.45, p < 0.001).

Conclusion: Age alone is not associated with increased complication in patients with IBD undergoing proctectomy. Instead, a simple frailty score can be considered as an additional tool for risk stratification and incorporated into preoperative discussions.

Geriatric Assessment for Aging Patients Facing Colorectal Surgery: A Qualitative Study of Clinician Perspectives

Atziri G Rubio-Chavez, MD, Stefanie J Soelling, MD, Hiroko Kunitake, MD, FACS, Rocco Ricciardi, MD, FACS, Zara Cooper, MD, FACS, Christine Ritchie, MD, MSPH, Christy E Cauley, MD, FACS

Massachusetts General Hospital, Boston, MA; Brigham & Women’s Hospital, Boston, MA; Mongan Institute Center for Aging and Serious Illness, Massachusetts General Hospital, Boston, MA

Introduction: Aging patients face unique perioperative challenges. The aims of this study were to describe clinicians’ perceived challenges of older adults undergoing colorectal resection and examine barriers and facilitators of geriatric assessment use in colorectal surgery.

Methods: Purposive and snowball sampling methods were used to recruit clinicians treating older colorectal surgical patients across the US for focus groups. Rapid analysis was performed to identify themes using a hybrid inductive-deductive approach.

Results: Virtual focus groups (July-August 2023) were conducted (n = 4; surgeons, geriatricians, anesthesiologists, nurses, and advanced practice providers). Clinical experience varied (mean 8.7 years, SD 7.8). Several major themes emerged when discussing challenges unique to older adults: cognitive issues with instruction recall, mental health/isolation, physical function, nutrition/hydration, care coordination, identifying goals, living situation, and caregiver burden. New ostomy care needs, multimorbidity, and lack of social support added complexity to preparation and recovery. Most clinicians did not routinely conduct comprehensive geriatric assessments and lacked access to geriatric perioperative programs. Instead, the “eyeball test” for physical function typically occurred. Cognition, activities of daily living, and social support were informally assessed by a few. Communication among surgical team members regarding patient limitations in cognition, function, and social support is a major challenge. Delaying operation to optimize geriatric conditions was viewed as a risk. Shorter screenings (ie 10 minutes) were suggested to identify high-risk patients.

Conclusion: Clinicians identified unique perioperative challenges for older adults, in particular new ostomy formation and limited social support. Prioritizing screenings to identify high-risk patients is the first step toward improving the use of geriatric assessment in surgical clinics.

Hidden Disparity: Race Modifies the Impact of Insurance Provider on Screening Colonoscopy Completion Rate

Alexa Pohl, MD, PhD, Javier Cuevas, MS, Eric Bernier, MSN, RN, CPHQ, Uri Ladabaum, MD, MS, Arden M Morris, MD, MPH, FACS

Stanford University School of Medicine, Stanford, CA; Stanford Health Care, Redwood City, CA

Introduction: Colorectal cancer screening disparity has been documented within the domains of population health and primary care, but the pipeline from referral to colonoscopy completion has been largely ignored. In this study, we examined data from a large healthcare network and identified demographic groups at highest risk of attrition in the referral-to-colonoscopy pipeline.

Methods: We identified 6,242 completed screening colonoscopies from 8,159 referrals to general surgery, colorectal surgery, and gastroenterology. We included referrals from only the 3 most prevalent insurance types (private, Medicare/Medicare Advantage, and Medicaid) and the 4 most prevalent self-reported racial/ethnic identities (Non-Hispanic White, Black or African American, Hispanic, and Asian). We used logistic regression to test whether race and insurance predicted colonoscopy completion after referral.

Results: A total of 76% of screening colonoscopy referrals resulted in procedure completion. Patients who self-identified as Asian were more likely to undergo colonoscopy than patients who identified as White, Hispanic, or Black (p = 0.002, Figure 1A). Given covariance between race and insurance type, we disaggregated the data by race and found that insurance type predicted completion among patients identifying as White, Black and Asian, but not as Hispanic (Figure 1B). There was a significant interaction between race and insurance type.

Conclusion: Social determinants of health interact, and limiting equity analyses to 1 determinant may mask meaningful disparities. These data will be used to inform ongoing health equity/quality improvement operations, and we encourage other institutions to examine their practice patterns from a health equity perspective.

Impact of Lateral Pelvic Lymph Node Downstaging Post Neoadjuvant Therapy: Characteristics, Management, and Oncological Outcomes

Ibrahim Gomaa, MD, Sara A M Aboelmaaty, MD, Jyi Cheng Ng, MD, Richard Sassun, MD, Annaclara Sileo, MD, David W Larson, MD, FASCRS, FACS

Mayo Clinic, Rochester, MN

Introduction: Lateral lymph node (LLN) involvement and its impact on local recurrence (LR) in patients with locally advanced rectal cancer (LARC) remains a concern. This study aims to investigate preoperative LLN involvement and its impact on LR in LARC undergoing neoadjuvant therapy.

Methods: Adults with LARC underwent neoadjuvant therapy, either chemoradiation or total neoadjuvant therapy (TNT), followed by operation between 2012 and 2023; Division of Colon and Rectal Surgery at a higher volume center was included. Patients were divided into 2 groups based on LLN status, including patients with negative LLN on baseline MRI (cLLN-) (n = 310) compared with positive LLN on baseline MRI, which downstaged to negative on restaging (cLLN±) (N = 83). Stage IV disease, positive LLN on restaging, and lack of baseline MRI were excluded.

Results: The study included 393 patients with no significant differences between both groups regarding age, gender, BMI, involved mesorectal fascia, and clinical T stage. However, a significantly higher proportion of cLLN± patients received TNT as neoadjuvant (61.4%, 43.5%; p = 0.004) and LLN dissection (16.9%, 2.9%; p < 0.001) compared with cLLN- patients; however, all the dissected LLN were negative for metastasis. Kaplan-Meier curves demonstrated no significant difference between both groups with LR (1.3% vs 2.4%, p = 0.4), LLN recurrence (0.3% vs 0%, p = 0.61), and disease-free survival (DFS) (87.1% vs 92.8%, p = 0.12) for cLLN- and cLLN±, respectively (Figure 1).

Conclusion: Positive LLN at that downstage after neoadjuvant therapy on restaging imaging did not significantly impact oncological outcomes, including LR, LLN recurrence, and DFS, compared with patients with negative LLN on baseline MRI.

Impact of Preoperative Bowel Stimulation Before Loop Ileostomy Closure

Daniel Rivera Alonso, MD, Jana Dziakova, MD, Cristina Sánchez Del Pueblo, MD, Leyre Lopez, MD, Maria Del Campo Martin, MD, Eva García Romero, MD, María Rosario Caparrós, CNP, Maria A De Miguel Lopez, CNP, Jose M Muguerza, MD, Antonio J Torres, MD, PhD, FASMBS, FACS (Hon)

Hospital Clínico San Carlos, Madrid, Spain

Introduction: The objective of this study was to assess the impact of preoperative bowel stimulation before loop ileostomy closure on the development of postoperative ileus (POI).

Methods: This is a retrospective analysis that compares patients with and without preoperative stimulation of the efferent limb before ileostomy closure between the years 2019 and 2023 in a Spanish tertiary center. Stimulation consisted of infusing 500 mL of saline chloride solution mixed with a thickening agent into the distal limb of the ileostomy loop. This method was performed in 6 outpatient sessions within the 2 weeks before ileostomy reversal, under the supervision of a trained stoma nurse. The primary outcome was POI, and other secondary outcomes were related to morbidity, length of stay, and ileus predictors.

Results: A total of 104 patients were included (57 stimulated vs 47 control). Baseline characteristics were well balanced in both groups. The incidence of POI was lower among patients who underwent stimulation (10.5% vs 27.7%, p = 0.024). Despite no differences found in median time to first flatus (1.72 ± 1.49 days vs 2.06 ± 0.91 days, p = 0.183), the stimulated group were more likely to pass flatus on postoperative day 1 (45.5% vs 23.4%, p = 0.002). This group also had a shorter time to oral intake (1 vs 1.21 days), p = 0.008. No significant difference was found regarding nasogastric tube insertion, 30-day morbidity or length of stay (Table 1).

Table 1. - Results Between Groups

Variable Stimulation (n = 57) Control (n = 47) p Value
Postoperative ileus 6 (10.5%) 13 (27.7%) 0,024
Nasogastric tube insertion 4 (7%) 6 (12.8%) 0,322
Oral intake 1 (1.0 – 1.0) 1.21 (1.0 – 2.0) 0,008
Return of flatus, days 1.72 (±1.49) 2.06 (±0.91) 0,183
Return of stool, days 2.96 (±1.92) 3.12 (±1.22) 0,616
Flatus on day 1 25 (45.5%) 11 (23.4%) 0,002
30-day complications 9 (8.77%) 5 (10.6%) 0,444
Length of stay, days 5.70 (±4.02) 6.14 (±3.11) 0,535

Conclusion: Preoperative bowel stimulation of distal limb is a feasible therapy that might reduce POI after ileostomy closure.

Impact of the 2014 Medicaid Expansion on Trends in Stage of Colon Cancer at Presentation

Katherine Pavleszek, BS, Denise Danos, PhD, Grant Collins, BS, Gabrielle Prezkop, MD, Elyse Bevier-Rawls, MD, FACS, Lindsey Gade, MD, Mohammed S Rais, BS, Linzi Paul, MS, Valentine N Nfonsam, MD, FACS

Louisiana State University Health Sciences Center, New Orleans, LA

Introduction: Previous short-term studies showed that Medicaid expansion is associated with improved colorectal cancer screening rate and earlier disease stage at time of diagnosis. This study analyzes long-term trends in the proportion of primary invasive colon cancer diagnosed at early stages.

Methods: We performed a 10-year (2011-2020) analysis of the incidence of primary invasive colon cancer using the National Cancer Database (NCBD). States’ Medicaid expansion status was derived from the NCDB and classified as expansion (states that expanded in January 2014) and non-expansion. Trends were analyzed over 4 time periods, 1 pre-expansion period (2011-13), 2 post-expansion periods (2014-16, 2017-19) and COVID-19 (2020). The study included uninsured and Medicaid patients aged 40-64 years. The primary outcome was early stage at diagnosis.

Results: Before expansion, there was no significant difference in the proportion of newly diagnosed colon cancer cases presenting at an early stage between expansion and non-expansion states (odds ratio [OR] (95% CI): 1.07 (0.97, 1.17); p = 0.18). During 2014-2016 the odds of early stage at diagnosis were 27% greater in states that expanded Medicaid compared with non-expansion states (Figure 1). During 2017-2019, the odds were 32% greater in states that expanded Medicaid. There was no significant difference during 2020 (OR (95% CI): 1.16 (0.99, 1.37); p = 0.073).

Conclusion: There was a significant increase in the proportion of early-stage colon cancer diagnosis in Medicaid expansion states compared with non-expansion states. However, these improvements diminished during the COVID-19 pandemic. Additionally, the proportion of early diagnoses in the expansion group has been down-trending even before the pandemic.

Increased MLK4 Expression in Colorectal Cancer Is Associated with Worse Oncologic Outcomes

Hitesh Kapoor, MBBS, Anders Mellgren, MD, FACS, Piush Srivastava, PhD, Marhama Zafar, MBBS, Narjes Sweis, MD, Ajay Rana, PhD, Gerald Gantt, MD, FACS

University of Illinois Chicago, Chicago, IL

Introduction: While the biological relevance of MLK4 expression is not completely understood in colorectal cancer (CRC), MLK4 may have an adverse role in the progression of the disease. We sought to evaluate MLK4 expression in CRC and its possible association with oncologic outcomes.

Methods: We collected matched colorectal tissues from a prospectively maintained biorepository of patients who underwent standard-of-care operation at a tertiary medical center. Immunohistochemistry was performed to analyze MLK4 expression in normal and tumor samples. We examined MLK4 expression in CRC and compared it with the matched normal tissues of patients with CRC using immunohistochemistry staining. The difference in expression of MLK4 was quantified using a visual scoring system. In silico analysis of MLK4 mRNA expression was performed using the Cancer Genome Atlas database in a cohort of 640 patient samples.

Results: MLK4 was found to have increased expression in colon tumor compared with normal colon tissue (p value: 0.04). In silico analysis revealed that increased MLK4 mRNA expression was associated with progressive disease (Figure 1).

Conclusion: MLK4 is a novel kinase that has been associated with tumorigenesis in gastrointestinal malignancy. MLK4 has increased expression in CRC and is associated with worse oncologic outcomes. Further work is needed to elucidate its possible role in tumorigenesis or as a prognostic indicator of disease progression.

Intraluminal Extracellular Matrix Hydrogel Reduces Leak Rate in a Rodent Model of Rectal Resection

Vincent Anto, MD, Charles J Patterson, BS, Stephen Badylak, DVM, PhD, MD

University of Pittsburgh, Pittsburgh, PA

Introduction: Anastomotic leak is a challenging complication of rectal resection. Temporary diverting stomas are used to reduce leak morbidity but have inherent complications. A significant reduction in anastomotic leak could preclude the need for diversion. Urinary bladder matrix (UBM) is a form of acellular extracellular matrix that promotes constructive remodeling of tissues but has not been studied in colorectal anastomoses. We aimed to create a reproducible rodent model of a low rectal anastomosis to evaluate the efficacy of UBM products in reducing leak rate and discover mechanisms involved in anastomotic healing.

Methods: Rats underwent a standardized distal colonic resection and anastomosis. Rats were randomly assigned to control or UBM hydrogel after anastomotic creation. Blinded necropsy was performed on postoperative day 7 with a multi-modal assessment of anastomotic leak. A comprehensive histologic assessment evaluated the quality of healing. Further experiments compared UBM hydrogel to inert synthetic hydrogel to evaluate biological vs mechanical augmentation.

Results: Anastomotic leak occurred in 46% of control animals with a significantly lower leak rate of 8% in UBM hydrogel treated animals. Histologic evaluation demonstrated significant improvement in anastomoses treated with the hydrogel. Immunohistochemistry demonstrated a reduction in inflammatory infiltrate and an increased proportion of pro-remodeling M2 macrophage phenotype in hydrogel treated anastomoses. Improved anastomotic healing was seen in UBM hydrogel but not inert hydrogel.

Conclusion: This rodent model of low rectal anastomoses presents a dependable platform for surgical device testing. UBM hydrogel demonstrated a reduction in rectal anastomotic leak rate by promoting constructive remodeling of the tissue.

Investigation of Creeping Fat Associated Fibroblasts in Smooth Muscle Cell Hypertrophy in Crohn’s Disease Stricture Formation

Benjamin Pham, BA, Khristian E Bauer-Rowe, BS, Norah Liang, MD, Michelle Griffin, MD, PhD, Jason L Guo, PhD, Deshka Foster, MD, PhD, Jeffrey A Norton, MD, FACS, Jeong S Hyun, MD, Michael T Longaker, MD, MBA, FACS

Stanford University, Stanford, CA

Introduction: Intestinal stricture significantly causes morbidity in Crohn’s disease (CD) patients. While smooth muscle (SM) expansion is a major histological characteristic of strictures, its origins are poorly understood. To better understand this phenomenon, we characterized SM expansion using a novel surgical mouse model of CD and used spatial transcriptomics to analyze gene expression from human stricture samples.

Methods: We created anti-mesenteric colotomies in C57/B6 mice and closed the bowel transversely under mechanical tension to generate strictures with creeping fat (CF) and fibrosis. The stricture samples were quantified for SM expansion vs unwounded controls. We performed lineage-tracing using GFP expressing Myh11+ smooth muscle cells (SMCs) from Myh11-CreERT2; mTmG mice and ACTA2 (marker for SMCs and myofibroblasts). We used spatial transcriptomics and CellChat on three human pediatric strictures to spatially quantify gene expression and communication patterns.

Results: In our model, we found significant increases in SM thickness. Through lineage-tracing, we observed that SMCs expanded into the colotomy site adjacent to the CF. Our spatial transcriptomics data revealed that the interface between bowel and CF was enriched for SM and myofibroblast genes. We identified that Notch signaling, a potent stimulator of SMC growth, is enriched in CF.

Conclusion: These observations suggest our model can replicate SM expansion found in human CD strictures. Gene expression and cell signaling data indicate that SM expansion is influenced by the interface region. These data suggest CF may be a source of myofibroblasts that acquire SMC characteristics at the interface.

Language Discordant Colorectal Patients Demonstrated Decreased Postoperative Interaction with Medical System

Dawn Chirko, BS, Debra D’Angelo, MS, Eshani Pareek, MBS, Julie Hong, MD, Caroline Young, MS, Alexander L Zhao, BS, Shahenda Khedr, BA, Gala Cygiel, MD, Steven Y Chao, MD, FACS

Weill Cornell Medicine, New York, NY; New York Presbyterian Queens, Flushing, Queens, NY

Introduction: Limited studies describe colorectal surgery outcomes for patients receiving language concordant (LC) and language discordant (LD) care. We hypothesize that LD patients have worse operative outcomes than LC and English speaking (ES) patients.

Methods: A single-center retrospective cohort study analyzed colorectal resection (2015-2023), categorizing patients as ES or non-ES. Non-ES patients were further classified as LC or LD, based on the surgeon’s non-English language proficiency. Bivariate analyses were performed to compare clinical characteristics between groups. Multivariable regression analysis examined language concordance as a predictor of surgical outcomes, while controlling for confounders. All analyses were performed in R (version 4.1.1).

Results: A total of 1,161 patients were included (623 ES, 99 LC, 439 LD). Within bivariate analyses, LC and LD patients were more likely than ES patients to have colorectal cancer (p < 0.001), lower American Society of Anesthesiologists classification (p < 0.001), lower BMI (p < 0.001), higher rate of elective operation (p = 0.004), and a higher proportion of Asian patients (p < 0.001). On multivariable analysis, LD patients had shorter length of stay (incidence rate ratio [IRR] [95% CI], 0.85 [0.78, 0.92], p < 0.001), were less likely to call within 30 days (odds ratio [OR] [95% CI], 0.05 [0.01, 0.27], p = 0.001), and were more likely to be discharged home (OR [95%], 1.84 [1.14, 3.01], p = 0.013), compared with ES patients (Table 1).

Conclusion: Compared with ES and LC patients, LD patients demonstrated decreased interaction with the medical system after operation. Further research should ascertain whether this relates to better outcomes or hesitancy to initiate care due to language discordance.

Long-Term Outcomes after Colectomy and Liver Transplantation for Inflammatory Bowel Disease with Primary Sclerosing Cholangitis

Abraham J Matar, MD, Muneera R Kapadia, MD, FACS, Kinga S Olortegui, MD, MS, FACS, Randolph M Steinhagen, MD, FACS, Ira Leeds, MD, FACS, Wolfgang B Gaertner, MD, FACS, Alessandro Fichera, MD, FACS, William C Chapman Jr, MD, Virginia L Shaffer, MD, FACS, Jahnavi K Srinivasan, MD, FACS

University of Minnesota, Minneapolis, MN; University of North Carolina, Chapel Hill, NC; University of Chicago, Chicago, IL; Icahn School of Medicine at Mount Sinai, New York, NY; Yale University, New Haven, CT; Baylor University Medical Center, Dallas, TX; Washington University in St Louis, Saint Louis, MO; Emory University, Atlanta, GA

Introduction: The fraction of patients with primary sclerosing cholangitis and inflammatory bowel disease (PSC-IBD) that require both liver transplantation (LT) and total abdominal colectomy (TAC) is small, thereby limiting significant conclusions regarding long-term outcomes. The objective of this study was to investigate the long-term outcomes in this patient population.

Methods: Adult and pediatric patients from 9 centers from the US IBD Surgery Collaborative who underwent staged LT and TAC for PSC-IBD were included.

Results: Among 127 patients, 66 underwent TAC-before-LT, with a median time from TAC to LT of 7.9 years, while 61 underwent LT-before-TAC, with a median time from LT to TAC of 4.4 years. Median patient survival post TAC was significantly worse in those undergoing LT-before-TAC compared with TAC-before-LT (16.0 years vs 42.6 years, p = 0.007), while post LT survival was not impacted by the order of TAC and LT (21.6 years vs 22.0 years, p = 0.81) (Figure 1). Patients undergoing TAC for medically refractory disease had a higher incidence of PSC recurrence (rPSC) (p = 0.02) and biliary complication (0.09) compared with those undergoing TAC for oncologic indications. Definitive TAC reconstruction with either end ileostomy or ileal-pouch anal anastomosis (IPAA) did not impact post-LT or post-TAC outcomes.

Conclusion: Long term survival in PSC-IBD was contingent upon progression to LT and was not impacted by the need for TAC. PSC-IBD patients undergoing TAC for medically refractory disease had a higher incidence of rPSC and biliary complication. The use of IPAA was a viable alternative to end ileostomy.

Minimally Invasive Colectomy under Neuraxial Anesthesia in Frail Patients

Filippo Carannante, MD, PhD, Valentina Miacci, MD, Gianfranco Bianco, MD, Vincenzo Citriniti, MD, Renato Ricciardi, MD, Stefano Rizzo, MD, Gianluca Costa, MD, Marco Caricato, MD, FACS, Gabriella Teresa Capolupo, MD, FACS

UOC Chirurgia Colorettale, Fondazione Policlinico Campus Bio-Medico di Roma, Rome, Italy

Introduction: General anesthesia is the most widely used anesthesia technique for major abdominal operation, but it may have longer recovery time, high cost, and environmental impact. In addition, general anesthesia may be contraindicated in some frail patients. Our study aims to evaluate the feasibility and safety of performing colorectal surgery with minimally invasive techniques in frail patients under spinal anesthesia. Then we compared this group of patients with a retrospective one, performing a propensity score match analysis.

Methods: From June 2021 to June 2023, all frail patients undergoing colic resection operation with laparoscopic technique under spinal anesthesia at high-volume colorectal surgery Italian University Hospital were included.

Results: We enrolled 87 patients. In all patients, the operation was successfully completed under spinal anesthesia and laparoscopic technique. The average hospital stay was about 4 days (range 3-7). A total of 5 patients (6.9%) required ICU admission, but 30-day mortality was 0. Propensity score matching with a retrospective cohort showed a statistically significant reduction in ICU stay and length of stay (respectively p < 0.001 e p 0.03). The operative complication rate was also reduced, anastomotic leakage (p = 0.06) and pneumonia (p = 0.09) in particular, but with no statistical significance.

Conclusion: Our preliminary data show that performing major operation with minimally invasive technique under spinal anesthesia can be feasible and safe, if performed by experienced operators, and can be a viable alternative for the treatment of frail and/or high-risk patients.

Nature, Nurture or Both? Genetic Risk, Healthy Lifestyle, and Severe Diverticulitis

Thomas E Ueland, BS, Jonathan Mosley, MD, PhD, Jamie R Robinson, MD, PhD, Richard Peek, MD, Eric R Gamazon, PhD, Lillias H Maguire, MD, FACS, Christopher Neylan, MD, Rebecca Hoffman, MD, MSCE, FACS, Alexander T Hawkins, MD, MPH, FACS

Vanderbilt University School of Medicine, Nashville, TN; Hospital of the University of Pennsylvania, Philadelphia, PA; Geisinger Medical Center, Danville, PA

Introduction: Polygenic risk scores may improve stratification of diverticulitis severity, but the extent of value added to lifestyle contributions is unknown. This study aimed to optimize a polygenic risk score for severe diverticulitis and evaluate performance when including influential lifestyle factors.

Methods: A polygenic risk score to estimate individual genetic risk was optimized for severe diverticulitis (operative intervention or at least 2 inpatient admissions) in our institutional biobank. In an independent analysis cohort from the UK Biobank, a healthy lifestyle score was assigned based on guideline-consistent patterns in diet, exercise, smoking, alcohol intake, and BMI. A Cox proportional hazards model assessed effects of the individual polygenic risk and lifestyle scores on incident severe diverticulitis. Gene by environment interactions were tested with relative excess risk and attributable proportion due to interaction.

Results: Among 218,501 eligible UK Biobank patients at enrollment, 2,646 developed severe diverticulitis. At 15-year follow-up, the risk of severe diverticulitis was 2.17 times greater in the high vs low genetic risk group. Relative to a favorable lifestyle and low genetic risk, there were stepwise increases in hazard ratios (HRs) among patients with intermediate genetic and lifestyle risk (HR [95% CI] 1.97 [1.49-2.60]) as well as unfavorable lifestyle and high genetic risk (HR [95% CI] 3.81 [2.80-5.19]). No interactions were observed (Figure 1).

Conclusion: A polygenic risk score brought additional value to a lifestyle-only stratification approach for severe diverticulitis. Future personalized genomic profiles for disease severity may inform shared decision-making discussions about elective operative intervention.

Objective Performance Indicators During Robotic Colorectal Surgery Can Be Used to Assess Trainee Progression

Mishal Gillani, MD, Manali Rupji, MS, Terrah J Paul Olson, MD, FACS, Patrick S Sullivan, MD, FACS, Virginia L Shaffer, MD, FACS, Glen C Balch, MD, FACS, Mallory C Shields, PhD, Yuan Liu, PhD, Seth A Rosen, MD, FACS

Emory University School of Medicine, Atlanta, GA; Winship Cancer Institute, Emory University, Atlanta, GA; Intuitive Surgical, Norcross, GA

Introduction: It is imperative to benchmark surgical skill progression during training. Existing assessment tools are subjective and non-scalable. Objective performance indicators (OPIs), machine learning-enabled metrics derived from robotic systems data, offer objective data regarding surgeon movements and robotic arm kinematics. In this study, we identified OPIs during robotic proctectomy (RP) that significantly differed between the first 6 months (FSM) and second 6 months (SSM) of an academic year.

Methods: Endoscopic video synchronized to robotic system data was captured across 73 RPs. Using ratio of economy of motion, a calculated OPI, we assigned each surgical step to attending or trainee. OPIs were compared among 10 general surgery residents and 4 colorectal surgery fellows during FSM and SSM. Comparisons were made using t-test or sum-rank test as appropriate.

Results: Residents exhibited greater master clutch usage and energy activation duration during SSM. In contrast, fellows exhibited more master clutch use, shorter energy activation duration, greater dominant wrist articulation (roll, pitch, yaw), higher velocity, acceleration and jerk for dominant and non-dominant arms, higher 3rd arm and camera metrics (movement, path length, moving time, velocity, acceleration, jerk) and longer dominant arm path length during SSM (Table 1).

Table 1. - Examples of Differences in Trainee OPIs During the First and Second Half of an Academic Year

OPI Trainee FSM SSM p Value
Master clutch [n] Resident 1 [0 - 6] 3 [0 - 9.5] 0.035
Energy activation duration [sec] Resident 1.15 [0.55 - 1.84] 1.48 [0.68 - 2.52] 0.008
Camera movements [n] Fellow 6 [2 - 17] 10 [4 - 26] <0.001
Camera velocity [m/sec] Fellow 0.05 [0.03 - 0.07] 0.06 [0.05 - 0.08] <0.001
3rd arm moving time [sec] Fellow 0 [0 - 10.63] 12.85 [0 - 61.62] <0.001
Dominant arm path length [m] Fellow 1.32 [0.44 - 3.10] 1.83 [0.64 - 5.48] 0.007
Dominant wrist roll [rad] Fellow 22.56 [7.28 - 52.07] 30.91 [11.22 - 88.48] 0.003
Non-dominant arm jerk [m/sec3] Fellow 13.26 [9.72 - 16.71] 16.10 [10.59 - 22.30] <0.001

All variables are presented as median with interquartile range.

OPI = objective performance indicator, FSM = first six months, SSM = second six months, n = numbers, sec = seconds, m = meters, rad = radians.

Conclusion: During RP, OPIs significantly differ for trainees during FSM and SSM of an academic year. This study is the first to demonstrate feasibility of using OPIs as an objective and scalable way to track trainee progression within robotic colorectal surgery. Further studies are needed to assess whether OPIs may be useful for benchmarking and guiding robotic curricula.

Over a Decade with Transanal Minimally Invasive Surgery: Analyzing Short- and Long-Term Oncological Outcomes of 208 Patients with Rectal Lesion

Kamil Erozkan, MD, FACS, David R Rosen, MD, FACS, Michael Klingler, MD, Attila Ulkucu, MD, Lukas Schabl, MD, Ali Alipouriani, MD, Hermann P Kessler, MD, PhD, FACS, Scott R Steele, MD, FACS, Emre Gorgun, MD, MBA, FASCRS, FACS

Cleveland Clinic, Cleveland, OH

Introduction: Transanal minimally invasive surgery (TAMIS) is frequently used to treat rectal lesions that are not amenable to conventional polypectomy or endoscopic resection. Few studies have reported long-term outcomes of TAMIS. This study aims to assess the long-term outcomes in patients who underwent TAMIS for rectal lesion.

Methods: Patients who underwent TAMIS for rectal neoplasm at a tertiary care center between June 2010 and August 2023 were retrospectively reviewed. The primary outcomes were long-term oncological outcomes, including local recurrence, distant metastasis, mortality, disease-free and overall survival rate. The secondary outcome was short-term oncological outcome.

Results: The current study included a total of 208 individuals, of whom 74 (35.6%) were women, with a median age of 64 (19.3) years. Malignant lesions were larger than benign lesions (3.2 cm vs 3.5 cm, p = 0.03). Short-term oncological outcomes were comparable in both groups (Table 1). The median follow-up duration was 37 months. During the follow-up period, local recurrence and metastasis occurred in 1 patient (0.8%) with benign disease, 16 months after TAMIS. Local recurrence occurred in 8 (%) patients with malignant disease at a median follow-up of 23.5 months. Distant metastasis was noted in 5 patients (5.9%) with malignant disease. The 3-year disease-free and overall survival rate for patients with malignant disease was 91% and 96.6% (p = 0.015), respectively (Table 1).

Table 1. - Short- and Long-term Oncological Outcomes

Short-term Oncological Outcomes Benign (n = 123) Malign (n = 85) p Value
Lesion size, cm (IQR) 3.2 (2.5) 3.5 (1.3) 0.031
Piecemeal resection, n (%) 21 (17.1%) 11 (12.9%) 0.19
Margin involvement, n (%) 11 (10.7%) 16 (21.3%) 0.05
Long-term Oncological Outcomes
Local recurrence, n (%) 1 (0.8%) 8 (9.4%) 0.003
Distant metastasis, n (%) 1 (0.8%) 5 (5.9%) 0.09
Disease related mortality, n (%) 0 (0%) 5 (5.9%) 0.006
3 year Disease-free survival rate, % 98.9% 91% 0.015
3 year Overall survival rate, % 100% 96.6% 0.001

Conclusion: TAMIS is an effective technique for rectal lesion, offering an acceptable short- and long-term oncological outcome for both benign and malignant lesions.

Pelvic MRI after Total Neoadjuvant Therapy for Rectal Cancer Poorly Predicts a Complete Clinical Response

Nicholas R Suss, MD, Ryan Johnson, MD, Kinga S Olortegui, MD, MS, FACS, Stan Liauw, MD, Ardaman Shergill, MD, Blase N Polite, MD, Benjamin D Shogan, MD, FACS

University of Chicago, Chicago, IL; University of Cincinnati, Cincinnati, OH

Introduction: Determining complete clinical response (cCR) after total neoadjuvant therapy (TNT) for rectal cancer remains challenging. Often, post-TNT endoscopic restaging demonstrates cCR while restaging MRI demonstrates persistent disease; nonetheless, these patients often pursue nonoperative management (NOM). We examined the outcomes between patients with negative vs persistent disease on their initial post-TNT MRI.

Methods: We analyzed stage II/III rectal cancer patients from an academic center (1/1/15-9/9/22). Patients underwent TNT, had cCR on restaging endoscopy, and entered NOM. Demographics, recurrence, endoscopic, and MRI results were abstracted. Published criteria to define endoscopic/MRI cCR was used.

Results: Of 66 patients receiving TNT, 30 (45.5%) were endoscopically negative on restaging, had a restaging MRI, and entered NOM. Mean time between TNT completion and restaging MRI was shorter vs restaging endoscopy (32.4 days vs 41.2; p = 0.04). While all patients showed endoscopic cCR, restaging MRI showed residual disease in 12 (40%) patients. No difference emerged between patients with negative or positive restaging MRI (Table 1). After a mean follow-up of 4.75 years (range = 1.85-8.94), 9 patients (30%) experienced recurrence. The mean time to recurrence from cCR determination was 1.4 years (range = 0.33-3.1). There was no difference in recurrence between patients with negative vs positive restaging MRI (33% vs 27.8%; p = 0.74). Eight patients had an initial positive restaging MRI but developed no recurrence; after a mean of 1.12 years (range = 0.21-2.52) from that initial MRI, all patients showed an MRI cCR.

Table 1. - Negative MRI vs Positive MRI Restaging Findings

Characteristic All Patients MRI Negative (n = 18, 60%) MRI Positive (n = 12, 40%) p Value
Stage, n (%) 0.19
II 9 (30%) 7 (38.9%) 2 (16.7%)
III 21 (70%) 11 (61.1%) 10 (83.3%)
Tumor volume, mean cm3 (SD) 21.4 (22.02) 20.8 (18.87) 22.2 (26.95) 0.87
Length of Follow-Up, mean years, (SD) 4.75 (1.59) 5.09 (1.73) 4.24 (1.27) 0.16
Location of tumor from anal verge on MRI, cm (SD) 4.50 (2.58) 4.49 (2.78) 4.53 (2.36) 0.97
Location of tumor from anal verge on endoscopy/DRE, cm (SD) 4.15 (3.27) 3.22 (2.76) 5.54 (3.59) 0.06
Recurrence, n (%) 9 (30%) 5 (27.8%) 4 (33.3%) 0.74
Alive, n (%) 28 (93.3%) 17 (94.4%) 11 (91.7%) 0.77

Conclusion: In patients with endoscopic cCR, patients with negative vs persistent disease on their initial post-TNT MRI have similar outcomes.

Perspectives of Patients with Ulcerative Colitis about Surgery

Alexis A Webber, MD, Alexis Graham-Stephenson, MD, Ariel Nehemiah, MD, Keren Ladin, PhD, MSc, Alysse G Wurcel, MD, MS, FIDSA, Julia T Saraidaridis, MD, FACS

Albany Medical Center, Albany, NY; Lahey Hospital and Medical Center, Somerville, MA; Perelman School of Medicine, Department of Surgery, Philadelphia, PA; Tufts Medical Center, Department of Medicine, Division of Geographic Medicine and Infectious Diseases, Boston, MA; Lahey Hospital and Medical Center, Burlington, MA

Introduction: With increasing medical and surgical options available for the treatment of ulcerative colitis (UC), it is unclear what patient preferences are for informational needs before operation. In particular, racially/ethnically minoritized patients struggle with additional barriers in shared decision-making before operation. The aim of this study was to evaluate the experience of UC patients who underwent operation to better understand gaps and opportunities in surgical counseling, focusing on a diverse patient population.

Methods: This was a multi-site, qualitative study using semi-structured interviews of patients with UC who had undergone operation. Recruitment was via a multilayered approach drawing from pre-existing irritable bowel disease patient registries and an online UC/ileal pouch-anal anastomosis support. Interviews focused on preoperative counseling, level of perioperative support, experiences of discrimination, and opportunities for improved care. Responses were analyzed, coded and categorized using deductive and inductive methods. Descriptive statistics were performed.

Results: There were 26 participants: 23% Black, 65% White, and 12% other. Many expressed perceived lack of choice regarding operation. Participants highlighted good rapport with surgeons, strong social support, and an early introduction of surgery as facilitators of comfort with their decision to undergo operation. Factors such as bad rapport with surgeons, lack of social support, fear of ostomy, and financial anxiety were identified as barriers to decision-making. Participants emphasized the importance of not minimizing complications to improve perioperative counseling.

Conclusion: Participants reported interest in increased counseling before deciding on surgery. Incorporation of patient decision aids could help support and standardize shared decision-making for UC and improve patient satisfaction.

Positive Lateral Lymph Node after Neoadjuvant Therapy in Locally Advanced Rectal Cancer: Characteristics, Management, and Oncological Outcomes

Ibrahim Gomaa, MD, Sara A M Aboelmaaty, MD, Richard Sassun, MD, Jyi Cheng Ng, MD, Annaclara Sileo, MD, David W Larson, MD, FASCRS, FACS

Mayo Clinic, Rochester, MN

Introduction: Lateral pelvic lymph node (LLN) metastasis has been reported to occur in 15% to 20% of patients with locally advanced rectal cancer (LARC). This study aims to compare the oncological outcomes of positive LLNs that remained positive on restaging MRI, whether they underwent lateral lymph node dissection (LLND) or not.

Methods: Adults with LARC undergoing neoadjuvant therapy followed by operation between 2012 and 2023, in the Division of Colon and Rectal Surgery at a higher-volume center was included. All patients whose pretherapy LLN remained positive on restaging imaging were included and divided into 2 groups based on LLND treatment. Of the 65 patients, 38 did not have LLND (LLN-D) (n = 38) compared with those who had LLND (LLN+D) (n = 27). Stage IV disease, negative LLN on restaging MRI, and lack of baseline MRI were excluded.

Results: The study included 65 patients with no significant difference between groups regarding age, gender, BMI, involved mesorectal fascia, clinical TN stage, and other clinical and pathological tumor characteristics. In the LLN+D group, 7 (25.9%) patients were LLN positive on pathology. After median follow-up of 39 (41) months, Kaplan-Meier curves demonstrated no significant difference between both groups LLN-D and LLN+D with a general local recurrence (LR) of (7.9% vs 18.5%, p = 0.18), LLN recurrence (2.6% vs 4.7%, p = 0.37), and disease-free survival (DFS) (68.4% vs 66.7%, p = 0.89) (Figure 1).

Conclusion: Positive lateral lymph node with or without dissection resulted in no significant improvement in oncological outcomes, including LR, DFS, and most surprisingly, in LLNR post neoadjuvant therapy.

Pouch Advancement Flap for Management of Pouch-Related Fistula

Giulia De Carlo, MD, Mikhael Belkovsky, MD, Arielle Kanters, MD, Jeremy Lipman, MD, MHPE, FACS, Tracy L Hull, MD, FACS, Stefan D Holubar, MD

Cleveland Clinic, Cleveland, OH; Cleveland Clinic, Shaker Heights, OH

Introduction: Pouch-related fistula is estimated to occur in 5-12% of patients with ileal-pouch-anal-anastomosis (IPAA). While cryptoglandular and Crohn’s-related fistula are commonly treated with endorectal advancement flap, the use of pouch advancement flap (PAF) has not been previously studied. We aim to report a series of patients who underwent PAF to treat pouch-perineal fistula (PPF) and pouch-vaginal fistula (PVF).

Methods: This retrospective study was conducted in a high-volume tertiary referral colorectal center. We included all patients with IPAA who underwent PAF between 2010 and 2023. Our primary endpoint was sustained fistula healing, defined as fistula healing (on physical exam and pouchoscopy) after PAF without the need for additional operation.

Results: A total of 30 patients met our inclusion criteria, 14 (46.7%) with PPF, 14 (46.7%) with PVF and 2 (6.6%) with both. Complex fistula, defined as fistula with multiple tracks, was diagnosed in 6 cases (20.0%). While an initial PAF healing was reached by 18 (60.0%) patients, only 12 (40.0%) achieved our primary endpoint. Comparing PPF and PVF, no difference was found for the primary endpoint (50.0% vs 35.7%, p = 0.70). Temporary fecal diversion was performed at or before PAF in 8 (26.7%). Comparing patients with and without fecal diversion, no difference was found for the primary endpoint (25.0% vs 45.0% p = 0.41) (Table 1).

Table 1. - Patient Population and Outcomes

Population and outcomes n = 30
Age in years, mean (IQR) 44.1 (35.6-56.3)
Women, n (%) 23 (76.7%)
BMI, mean (IQR) 26.4 (23.3-27.8)
Months from IPAA to fistula diagnosis, mean (IQR) 142 (84.4-252.9)
Biologic use at time of PAF, n (%) 10 (33.3%)
Overall fistula healing - with or without further surgery, n (%) 25 (83.3%)
Follow-up duration in months, mean (IQR) 23.3 (5.35-33.6)

Conclusion: Pouch advancement flap for pouch-related fistula has outcomes comparable to those prior descriptions of advancement flaps for non-pouch-related fistula. While selection bias may skew our results, fecal diversion is not associated with improved outcomes.

Primary and Revisional Restorative Proctocolectomy with Ileal Pouch Anal Anastomosis: Quaternary Center Experience with over 500 Patients

Mehmet Gulmez, MD, Pranav Hinduja, MBBS, Daniel J Wong, MD, Eren Esen, MD, Arman Erkan, MD, FACS, Michael J Grieco, MD, FACS, Andre Da Luz Moreira, MD, Feza Remzi, MD, FACS

Inflammatory Bowel Disease Center, Department of Surgery, NYU Langone Health, New York, NY

Introduction: Restorative proctocolectomy with ileal pouch-anal anastomosis (RP/IPAA) is a complex procedure that requires significant experience. Due to the scarcity of providers performing revisional IPAA and historical concerns about worse function, patient and providers may be reluctant to pursue revisional IPAA operation. As such, our aim is to report our experience within the last decade.

Methods: Patients undergoing primary and revisional IPAA at our inflammatory bowel disease (IBD) center between 2017 and 2023 were included. Operative, short- and long-term outcomes were compared.

Results: There were 510 patients (primary, n = 252; redo, n = 258). Patients were referred from 47 out of 50 states. Age, sex, BMI and American Society of Anesthesiologists score were comparable. Thirty-day morbidity (41% vs 45%, p = 1.04) and readmission (15.9% vs 22.2%, p = 0.06) were similar. Sixteen patients in the primary group underwent revisional IPAA and 10 patients in revisional group underwent secondary revisional operation. Twenty patients in primary group and 19 patients in revisional group were rediverted after closure of their ileostomy. Eight patients in the revisional group and 2 patients in the primary group had their pouches excised. Functioning pouch rate was significantly higher in primary group (92.4%) compared with the revisional group (83.9%) (p < 0.05). Overall functional and quality of life (QoL) outcomes were similar during median follow-up of 25 months.

Conclusion: Centralization of subspecialty care is known to improve outcomes and minimal yearly volumes for IPAA operation have recently been advocated for in society guidelines. Our data supports that complex revisional IPAA can safely be performed, in a specialized high-volume IPAA centers with equivalent long-term pouch survival and QoL.

Recurrent Disease Prediction in Uncomplicated Diverticulitis Using a Polygenic Risk Score

Dylan Carmichael, DO, MS, Diane Smelser, PhD, James T Dove, MS, Jeremy S Haley, MS, Wesley Hill, MS, Rebecca L Hoffman, MD, MSCE, FACS

Geisinger College of Health Sciences, Danville, PA

Introduction: The decision to operate on a patient with uncomplicated diverticulitis is non-standardized. Patients with a higher genetic risk have been shown to have a higher incidence of diverticulitis. The aim of this study was to determine if a polygenic risk score (PRS) could predict recurrence specifically in those with uncomplicated diverticulitis.

Methods: All patients whose whole genomes were sequenced within the Geisinger MyCode Community Health Initiative and whose diagnosis was uncomplicated diverticulitis were included. Recurrence was defined as diverticulitis >90 days after the initial encounter (censored for operative intervention). The PRS was calculated using prior genome wide association studies (GWAS) and a test data set of MyCode participants. Patients were placed into quartiles (4 = highest risk) based on their genetic risk. Univariate and multivariate analyses were performed.

Results: A total of 4,517 patients were included; 62.9% women. The mean age was 74.2 (±11.6) years. A total of 1,735 (38.4%) patients had at least 1 recurrence. There was a 1.5-fold increase in prevalence between the 4th and 1st quartiles for patients with 2 recurrences (3 total episodes), and a 1.2-fold increase if ≥3 recurrences. In patients <50 years of age, the difference was 1.6-fold compared with >50 years of age (1.1-fold; Figure 1). Patients in the 4th quartile were significantly more likely to have ≥3 recurrences (odds ratio [OR] 1.23, 95% CI 1.04-1.44).

Conclusion: Patients with uncomplicated diverticulitis in the highest PRS quartile demonstrated significantly higher recurrence rate, which was more pronounced in patients <50 years. The future of diverticulitis care may involve the incorporation of genetics into conversations regarding timing of operative intervention.

Shifting Paradigm: Outcomes with Neoadjuvant Chemotherapy for cT4 and cN2 Colon Cancer

Bennett W Hartley, MD, Vivi Chen, MD, Ernest Camp, MD, FACS, Cary Hsu, MD, FACS, Eric Silberfein, MD, FACS, Atif Iqbal, MD, FACS, Samir Awad, MD, FACS, Eugene A Choi, MD, FACS, Christy Y Chai, MD, FACS, Derek Erstad, MD

Baylor College of Medicine, Houston, TX

Introduction: Upfront surgical resection (USR) is the standard of care for resectable, non-metastatic colon cancer. However, for locally advanced (cT4) and high nodal burden (cN2) disease, we hypothesized that neoadjuvant chemotherapy (NAC) would associate with tumor downstaging, reduced positive margins, and improved overall survival (OS) compared with USR.

Methods: A retrospective cohort study using the National Cancer Database (NCDB) (2010-2020) was performed. Non-metastatic, mismatch repair stable colon cancer was included (n = 15,924); cT4 (8,299 USR, 2,095 NAC) and cN2 (6,205 USR, 1,369 NAC). All USR patients received adjuvant chemotherapy. Propensity scored matching and multivariate logistic regression were used to compare groups. OS measured with Kaplan-Meier method.

Results: For cT4 and cN2 colon cancer, compared with USR, NAC was associated with reduced margin positivity (cT4: 12.5% vs 20.5%, p < 0.0001; cN2: 7.8% vs 12.5%, p < 0.0001), increased rate of pathologic downstaging (cT4: 43.9% vs 8.4%, p < 0.0001; cN2: 70.9% vs 7%, p < 0.0001), and reduced positive lymph node ratio (cT4: 8.7% vs18.7%, p < 0.0001; cN2: 17.3% vs 39%, p < 0.0001) (Figure 1). After propensity matching, compared with USR, NAC was associated with improved OS for cN2 patients (p < 0.05). Factors associated with NAC use for cT4 disease included: age <65 years (OR 1.22), academic facility (OR 2.27) and low comorbidity (Charlson-Deyo score = 0) (OR 1.41). Factors associated with NAC use were similar for cN2 patients (Figure 1).

Conclusion: Among cT4 and cN2 colon cancer patients, NAC was associated with reduced margin positivity, tumor downstaging, and improved survival. Our findings suggest that NAC might be beneficial for locally advanced and high nodal burden colon cancer.

Simplifying Patient Education with Custom GPT: The Critical Role of Prompt Specificity

Abiha Abdullah, MBBS, Wendelyn Oslock, MD, Fatima Abdullah, MBBS, Areeba Ahmer, MBBS, Lauren Wood, MSPH, Nathan C English, MBChB, Michael Rubyan, PhD, Bayley Jones, MD, Robert H Hollis, MD, Daniel Chu, MD, FACS

University of Pittsburgh, Pittsburgh, PA; University of Alabama, Birmingham, AL; Aga Khan University, Karachi, Pakistan; University of Michigan, Ann Arbor, MI

Introduction: Health literacy is critical for patients’ ability to understand and act on health information. However, many education materials do not meet NIH-recommended 6th-grade reading levels. Recognizing the potential of ChatGPT to democratize complex medical information, we aimed to create a custom GPT to evaluate the impact of prompt wording on simplifying education materials.

Methods: Colorectal education materials from a tertiary health center were collected for 3 categories: preoperative, postoperative, and ostomy-specific education (n = 63). After training a custom ChatGPT on literature comprehensibility, 3 GPT-generated prompts were used to simplify existing educational materials. Prompt A included the specific metric of 6th-grade reading level, Prompt B emphasized explaining “without medical terms,” and Prompt C recommended “removing medical jargon.” Readability was quantified using 3 scores: Flesch Kincaid Reading-Ease (FKRE) which captures ease of reading, as well as Flesch Kincaid Grade-Level (FKGL) and SMOG which estimates grade level. Results were compared via paired t-tests.

Results: Overall, Prompt A improved readability compared with baseline with increase in FKRE (64 to 71.3), reduction in FKGL (6.7 to 5.8), and reduction in SMOG score (10.4 to 9.5) (all p < 0.001). Conversely, Prompts B and C both worsened readability with decreased FKRE to 50.8 and 49.8 from 64, increased FKGL to 8.5 and 8.7 from 6.7, and increased SMOG scores to 12.7 and 13 from 10.4 (all p < 0.001) respectively.

Conclusion: ChatGPT prompts with specific metrics have the greatest impact on generation of more readable educational materials regardless of custom-trained-GPT use, which is essential insight for development of health-literacy tools.

Single-Cell Analyses Reveal Novel Immune and Nonimmune Features of Perianal Fistulizing Crohn’s Disease

Khai Nguyen, BA, Siyan Cao, MD, PhD, Marco Colonna, MD

Washington University School of Medicine, Saint Louis, MO

Introduction: Perianal fistula occurs in ~30-40% of Crohn’s disease (CD) patients. Its management remains a major clinical challenge, and little is known about its etiology.

Methods: Patients with CD with perianal fistula (PCD; n = 12); CD without perianal involvement (NPCD; n = 10); or idiopathic perianal fistula (IPF; n = 21) were biopsied from the fistula tracts, external opening of the fistula, and rectal mucosa during examination under anesthesia or colonoscopy. Immune cells were analyzed using mass cytometry (CyTOF), while PCD and IPF fistula tracts were characterized using single-cell RNA-sequencing (scRNA-seq).

Results:CyTOF revealed a skewed mucosal immune landscape in PCD. In fistula tracts, PCD harbored increased memory T cells and Tregs and overexpression of TIGIT and CD226 relative to IPF. In the rectum, Th17 and IL17+CD8 + T cells were expanded in PCD. In PCD fistula tracts, fistula opening, and rectum, expression of T cell exhaustion markers CD39 and CD127 were altered, and CD172+TREM1+ colitogenic macrophages were substantially enriched. scRNA-seq identified additional differences between PCD and IPF fistula tracts. Stromal cell composition was altered in PCD, and myeloid cells exhibited increased expression of NLRP3 inflammasome and IFN stimulated genes. Type 1 and 2 interferon response pathways were upregulated in the stromal, myeloid and B lymphocyte compartments. IFNG+ Th17 cells were significantly increased in PCD.

Conclusion: Our single cell analyses of the fistula tracts and adjacent tissues revealed previously unknown immune and stromal cell features of PCD. Elevated IFN signaling may implicate usage of JAK-inhibitors to treat PCD.

Stratifying Endoscopic Submucosal Dissection Risks: A Validated Perforation Risk Scoring Tool

Attila Ulkucu, MD, Mariano Laporte, MD, Brogan Catalano, MHA, BSN, RN, Emre Gorgun, MD, FASCRS, FACS

Digestive Diseases and Surgery, Cleveland Clinic, Cleveland Clinic, OH; Digestive Diseases and Surgery, Cleveland Clinic, Westlake, OH

Introduction: Endoscopic submucosal dissection (ESD) provides a less invasive approach for colorectal lesion removal but carries perforation risk that can cause considerable morbidity. This study aims to build a predictive model to assess perforation to improve patient safety during ESD.

Methods: Patients who underwent ESD for colorectal lesion at a tertiary care center between March 2011 and November 2023 were reviewed from a prospectively maintained database. We stratified subjects into derivation and validation sets using 50-50 allocation. Perforation predictors through univariate analysis were evaluated for independence through multivariate analysis. Model efficacy was assessed using the receiver operating characteristic curve.

Results: The study involved 1051 patients (515 men, 536 women), with lesions mainly in the right colon (638), left colon (181), rectum (137), and transverse colon (98). Perforation occurred in 108 patients (10%), of whom only 8 (7%) were converted to operation. On univariate analysis, significant perforation predictors included the first 100 procedures (63.3% vs 36.7%, p < 0.001), lesion size >35 mm (59.2% vs 38.8%, p < 0.005), extended operative time (mean 169 vs 76.9 minutes, p < 0.001), lower lift degree (p < 0.005), and incomplete resection (18.4% vs 2.9%, p < 0.001). In multivariate analysis, fibrosis (odds ratio [OR]: 2.67, p = 0.01), the first 100 procedures (OR: 14.6, p < 0.001), and lesion size >35 mm (OR: 3.50, p < 0.001) emerged as significant independent preoperative predictors of perforation. ESD perforation risk score validation achieved adequate performance of 71% (accuracy 80.19%) (Figure 1, Table 1).

Table 1. - ESD Perforation Risk Assessment Score Sheet

Factor Score Present (Yes/No)
Fibrosis 1
First 100 Procedures 7
Lesion Size >35 mm 2
Total Score
Optimal Cut-off Point 3 N/A

Conclusion: This study introduces a validated ESD perforation risk model that provides clinicians with a reliable tool for patient risk assessment, counseling and potential planning.

Take as Much as Possible: A Statewide Qualitative Exploration Understanding Positive Surgical Margins for Colorectal Cancer

Sarah Bradley, PhD, Andrew Millis, MD, Sara L Schaefer, MD, Brendan M Rosamond, BS, Mary Byrnes, PhD, MUP, Michael F McGee, MD, FACS, Samantha K Hendren, MD, MPH, FACS, Calista Harbaugh, MD

University of Michigan, Ann Arbor, MI; University of Houston, Fulshear, TX

Introduction: Positive surgical margins, indicating incomplete cancer resection, occur in 5-10% of colorectal cancer (CRC) resections, and rate significantly varies between hospitals. Little is known about what leads to positive margins, and thus opportunities to prevent them.

Methods: Convenience sampling was used to recruit 29 general and colorectal surgeons who perform CRC operations at participating Michigan Surgical Quality Collaborative (MSQC) hospitals. Semi-structured qualitative interviews explored pre-, intra-, and postoperative domains associated with positive margins. Interviews were recorded, transcribed, and analyzed iteratively using descriptive content analysis.

Results: Participants represented diverse practice settings, subspecialty training, and years of experience. First, they described opportunities to prevent positive margins through preoperative recognition of at-risk patients in multidisciplinary case review, consideration of neoadjuvant treatment, and anticipatory involvement of multi-specialty surgeons for multivisceral resection. Second, participants described intraoperative findings that suggested increased risk of positive margins (eg tumor perforation, desmoplastic reaction) and steps they might take to elucidate (eg frozen margins) or address positive margins (eg clips to guide radiation). When a positive margin was unavoidable, surgeons’ ethos varied on when to “take as much as possible” vs perform fecal diversion alone. Third, they described how pathologic margins were determined, and potential for conflict with clinical definitions. Lastly, participants described the implications of positive margins for both patients and surgeons (Figure 1).

Conclusion: Positive margins in CRC operation result from complex processes spanning pre- to postoperative care. Leveraging a multi-hospital collaborative allowed for broad insight across diverse settings and highlighted opportunities for quality improvement through standardization and education.

The Impact of RAS/BRAF Mutation on Tumor Regression Grade after Total Neoadjuvant Therapy in Rectal Cancer Patients

Sara A M Aboelmaaty, MD, Ibrahim Gomaa, MD, Jyi Cheng Ng, MD, Richard Sassun, MD, Annaclara Sileo, MD, David W Larson, MD, FASCRS, FACS

Mayo Clinic, Rochester, MN

Introduction: The impact of RAS/BRAF mutation on tumor regression grade (TRG) after total neoadjuvant therapy (TNT) in patients with rectal cancer is unclear. The aim of this study is to assess complete response rate after TNT in RAS/BRAF mutant rectal cancer.

Methods: Adults with rectal cancer undergoing TNT followed by curative operation between 2016 and 2023 in the Division of Colon and Rectal Surgery at a higher volume center were included. Patients were divided into 2 groups based on mutation status, including patients with mutant RAS/BRAF (RAS+) (n = 89) compared with wild type RAS/BRAF (RAS-) (n = 101). Patients with concurrent mutations were excluded.

Results: The study included 190 patients with no significant difference between groups regarding age, gender, BMI, staging, and other tumor characteristics. Out of the RAS+ group, only 5 (5.6%) were BRAF mutated. There was no significant difference in MRI TRG between groups. However, a significantly higher proportion of RAS- patients were high responders in pathology TRG (pTRG) (41.6%, 25.8%; p = 0.022). There was no significant difference in pathological complete response (pCR) rate between the groups (15.8%, 6.7%; p = 0.050). Regarding follow up, distant metastasis was significantly higher in the RAS+ group (17.8% vs 31.5%, p = 0.029), Table 1.

Table 1. - Tumor Regression Grades

Variable RAS-
(n = 101)
RAS+
(n = 89)
p Value
MRI Tumor regression grade (%) Complete response 4 (4.3) 6 (7.4) 0.81
Near complete response 19 (20.4) 14 (17.3)
Partial, poor, and response 70 (75.3) 61 (75.3)
Pathology complete response (%) Yes 16 (15.8) 6 (6.7) 0.050
High response (%) (Score 0 and 1) 42 (41.6) 23 (25.8) 0.022
Pathology TRG (%) Complete response (Score 0) 16 (15.8) 6 (6.7) 0.10
Near complete response (Score 1) 26 (25.7) 17 (19.1)
Minimal response (Score 2) 43 (42.6) 46 (51.7)
Poor/No response (Score 3) 16 (15.8) 20 (22.5)

Conclusion: RAS/BRAF mutations have an adverse effect on pathology TRG after TNT in patients with rectal cancer. Moreover, these mutations have a negative impact on distant metastasis and disease-free survival.

The Natural History of Complicated Diverticulitis with Abscess Managed Nonoperatively at Index Admission: A Longitudinal Analysis of State Inpatient and Emergency Department Databases from the Healthcare Cost and Use Project

Rachel Kalbfell, BS, Catherine Zivanov, MD, Jessica M Felton, MD, Rebecca Hoffman, MD, FACS, Matthew L Silviera, MD, MS, Kerri A Ohman, MD, FACS

Washington University in St Louis School of Medicine, St Louis, MO; LifeBridge Health, Owungs Mills, MD; Geisinger Health System, Danville, PA

Introduction: In 2020, clinical practice guidelines for the management of complicated diverticulitis shifted from recommending interval elective colectomy to consideration of elective resection. However, population-level evidence for long-term outcomes after nonoperative management of complicated diverticulitis is limited.

Methods: A retrospective longitudinal analysis of the State Inpatient and Emergency Department Databases from the Healthcare Cost and Use Project was performed to identify index presentations of acute diverticulitis complicated by abscess from 2005 to 2015 that were managed nonoperatively. Outcomes of interest included time to colectomy and recurrent episodes. Multivariate logistic regression was used to compare patients managed nonoperatively for 1 year from index admission with those who underwent operation within 1 year of index admission.

Results: Of 38,420 patients, 24,214 (63.1%) were managed nonoperatively within 1 year of their index presentation, and 14,206 (36.9%) underwent operative intervention within 1 year. Of the nonoperative group, 7.1% of patients underwent operation by year 3 and 10.4% by year 5 (Table 1). For those managed nonoperatively year 1, there was a 10.2% recurrence rate, and 88.8% had no admissions. Patients with Medicaid (hazard ratio [HR] 0.73, CI 0.65-0.80), self-pay (HR 0.53, CI 0.47-0.59), and no charge (HR 0.56, CI 0.45-0.69) were less likely to undergo operation than those with Medicare, while patients with private insurance were more likely. Non-White patients were less likely to undergo operation than White patients.

Table 1. - Kaplan-Meier Estimates of the Below Events for Patients Managed Non-Operatively in the First Year

Event 6 Months 1 Year 3 Years 5 Years
Procedure - - 7.1% (6.7% - 7.5%) 10.4% (10.0% - 10.9%)
Recurrence 6.0% (5.7% - 6.3%) 10.1% (9.7% - 10.5%) 21.8% (21.2% - 22.4%) 27.6% (27.0% - 28.3%)
Readmission 4.4% (4.1% - 4.6%) 7.2% (6.9% - 7.5%) 16.7% (16.2% - 17.2%) 21.4% (20.8% - 22.0%)
ED Visit 1.8% (1.6% -2.0%) 3.5% (3.3% - 3.7%) 8.1% (7.7% - 8.5%) 11.2% (10.7% - 11.7%)
Death - - 1.5% (1.3% - 1.7%) 2.7% (2.4% - 2.9%)

Conclusion: Among patients with acute diverticulitis with abscess who are successfully managed nonoperatively during their index admission, a majority can be safely managed nonoperatively without elective operation.

The Readability, Actionability, and Quality of Hemorrhoid Online Education Materials: Are We Addressing Patient Concerns?

Isabel Eng, BA, Formosa C Chen, MD, FACS, Marcia M Russell, MD, FACS, Daniela Salinas, MPH, Tara A Russell, MD, PhD, MPH

University of California, Los Angeles, Los Angeles, CA; Olive View-UCLA Medical Center, Sylmar, CA

Introduction: Hemorrhoids represent a commonly treated surgical condition in the US. While many adults seek education online about hemorrhoids, online resource quality is poorly defined. We assessed quality of hemorrhoid websites in English and Spanish with respect to readability, actionability, and provision of critical guidance.

Methods: We selected the top 30 results for hemorrhoids, symptoms, and treatment in English and Spanish on 3 search engines (Bing, Google, Yahoo). Using the SMOG (English) and SOL (Spanish) readability indices, we reported median education levels required for comprehension relative to the average US reading level (eighth grade). We evaluated websites using a quality checklist assessing 3 categories (formatting, actionability, critical guidance) and developed heat maps to visualize relationships between readability, quality, and search position.

Results: After removing duplicates, 95 English and 43 Spanish websites remained. Median education levels required for website comprehension were first-year university (SMOG = 13.0, interquartile range [IQR] 12.4-14.1) and tenth grade (SOL = 10.6, IQR = 9.15-20.8). A total of 43.2% of English and 48.4% of Spanish websites met at least 1 criterion in each checklist category. 71.2% of English and 51.6% of Spanish websites detailed circumstances to see a provider; 49.5% of English and 23.7% of Spanish websites identified rectal bleeding as potential sign of malignancy (Figure 1).

Conclusion: Most English and Spanish hemorrhoid websites failed to provide high-quality patient education, as they exceeded the average US reading level and lacked actionable recommendations and critical guidance. Online resources are essential for patients of all health literacy levels; improvement is critical to reduce disparity in health literacy and hemorrhoid outcomes.

The Relationship Between the Microbiome and Diverticular Disease: A Mendelian Randomization Study

Christopher Neylan*, MD, John DePaolo, MD, Michael Levin, Jeffrey Roberson, MD, Scott M Damrauer, MD, FACS, Lillias H Maguire, MD, FACS

Hospital of the University of Pennsylvania, Philadelphia, PA

*Excellence in Research Award recipient.

Introduction: Diverticular disease is clinically associated with alterations in the gut microbiome, but whether this relationship is causal or correlative is unclear. Mendelian randomization (MR) is a statistical technique that can elucidate causality by using genetic variants as instrumental variables. In this project, we use MR to analyze the relationship between gut microbiome composition and diverticular disease.

Methods: Publicly available genome-wide association study summary statistics were obtained for human gut microbiome composition (n = 18,340) and for diverticular disease (n = 724,000). Univariable 2-sample MR and bidirectional MR were performed to assess the causal effect of microbiome composition on the presence of diverticular disease.

Results: Genetically proxied increased Oxalobacter (odds ratio [OR] 0.88, [95% CI 0.80 - 0.97]) and Ruminococcus (OR 0.68, [95% CI 0.56 - 0.82]) abundance in the gut microbiome was associated with decreased genetic liability to diverticular disease. A significant effect was not seen in the reverse direction. Downstream analysis of the single nucleotide polymorphism (SNP) that comprised the Ruminococcus instrumental variable implicated the FUT2 gene pathway. FUT2 controls secretion of fucosylated mucus glycans that may contribute to healthy gastrointestinal mucosa.

Conclusion: MR analysis suggests a causal, protective relationship between increased abundance of Oxalobacter and Ruminococcus and the occurrence of diverticular disease. Downstream analysis implicates the FUT2 gene, which provides a plausible link between microbiome alteration and mucosal integrity and suggests a mechanism through which microbiome changes may lead to diverticular disease.

The Utility of Intraoperative Hologram Support in Transanal Approach for Lower Rectal Cancer

Toshiaki Yoshimoto, MD, PhD, Takuya Tokunaga, MD, PhD, FACS, Masato Yoshikawa, MD, Yuma Wada, MD, PhD, Hideya Kashihara, MD, PhD, FACS, Chie Takasu, MD, PhD, FACS, Masaaki Nishi, MD, PhD, FACS, Toshihiro Nakao, MD, PhD, FACS, Kozo Yoshikawa, MD, FACS, Mitsuo Shimada, MD, PhD, FACS

Tokushima University, Tokushima, Japan

Introduction: The utility of transanal approach for lower rectal cancer has been reported, however, specific anatomical understanding is required. The present study examined the utility of holograms with mixed reality as an intraoperative support tool for assessing the complex pelvic anatomy.

Methods: Polygon (stereolithography) files of patients’ pelvic organs were created and exported from the SYNAPSE VINCENT imaging system and uploaded into the Holoeyes MD virtual reality software. We conducted preoperative simulations using HoloLens wearable goggles. During operation, holograms were referenced through HoloLens to confirm anatomy multifariously over the sterile surgical field. A survey on the utility of holograms was conducted among 12 gastrointestinal surgeons.

Results: Transanal lateral lymph node dissection with vascular involvement: Preoperative CT revealed lymph nodes infiltrating the internal pudendal artery. The use of holograms during operation allowed real-time visualization of the spatial relationship between blood vessels and lymph nodes, enabling a safe and precise resection. Resection of pelvic recurrent tumor: In cases of pelvic recurrence post rectal resection, a perineal incision was reopened, and transanal tumor resection was performed laparoscopically. The reference to holograms during operation provided clear visualization of the recurrent tumor’s location, facilitating its precise and secure dissection. In the survey, 75% of surgeons responded that holograms accurately reflected the actual anatomy. Additionally, 92% of surgeons stated that the use of holograms during operation, compared with preoperative preparation, enhanced their anatomical understanding (Figure 1).

Conclusion: In transanal approach for lower rectal cancer, holograms prove beneficial for enhancing spatial awareness.

Treatment of Colon Cancer Cells with Lipid Nanoparticles Delivered TNFSF14 (LIGHT) mRNA Induces Immunogenic Cell Death and Inhibits Metastatic Tumor Growth

Guilin Qiao, PhD

University of California San Francisco, San Francisco, CA

Introduction: Boosting TNFSF14 (LIGHT) expression in the tumor microenvironment has been shown to increase anti-tumor immune response and patient LIGHT expression in resected colorectal liver metastases appeared to improve survival. For this immunotherapy to be viable in patients, a delivery system is essential. Our study explores lipid nanoparticles (LPN) to deliver LIGHT mRNA into tumors and evaluate its potential to induce immunogenic cell death (ICD).

Methods: Murine (CT26, MC38), human (HT-29), and patient-derived (CRC633) metastatic colon cancer cells were transfected with LPN-LIGHT mRNA. LIGHT expression and apoptosis-related molecule levels were assessed. In vivo, LIGHT mRNA transfected colon tumor cells were inoculated into syngeneic mice, which were then challenged 7 days later with the same tumor cells.

Results: After LPN transfection, over 95% of colon cancer cells expressed LIGHT in vitro. LIGHT mRNA transfection significantly boosted apoptosis in all treated human patient-derived and murine colon cancer cells and led to more than 75% of colon cancer cells expressing calreticulin, a hallmarker of ICD, on the cell surface (Figure 1A-D). In vivo, a significantly lower rate of metastatic tumor development was observed in challenged mice that had LNP-induced LIGHT-expressing primary tumors compared with controls (Figure 1E).

Conclusion: Lipid nanoparticle transfection of LIGHT mRNA triggers ICD in murine and human colon cancer cells and inhibits patient-derived metastatic colon tumor growth in vivo. These results underscore the potential of LIGHT mRNA transfection as a promising therapeutic approach for inducing antitumor immune responses in colon cancer cells, both in vitro and in living organisms.

Understanding and Optimizing Surgical Recovery Through the Lens of Patients with Colorectal Disease: A Qualitative Study in an Enhanced Recovery after Surgery Setting

Yaxin Li, MSc, Leah Gramlich, MD, Gregg Nelson, MD, PhD, Chelsia Gillis, PhD, RD

McGill University, Montreal, QC, Canada; University of Alberta, Edmonton, AB, Canada; Cumming School of Medicine, University of Calgary, Calgary, AB, Canada

Introduction: As perioperative care shifts to a more patient-centered model, understanding needs and experiences of patients is vital. Aligning evidence-based care with patient priorities encourages adherence to recovery-oriented interventions. We aimed to explore patient-defined recovery and elements that modify the recovery process for patients with colorectal disease under enhanced recovery after surgery (ERAS) care.

Methods: A qualitative study was conducted at an ERAS-participating hospital in Alberta, Canada, between April 2018 and June 2019. A co-design focus group set the research direction, and semi-structured interviews were conducted postoperatively in hospital or within 3 months postdischarge. A purposive sampling strategy was used to capture participants of different ages and colorectal conditions. Transcripts were transcribed verbatim and analyzed through manifest and latent summative content analysis.

Results: Twenty patients were enrolled [mean age of 62 (SD:13) years; 45% had cancer; n = 17 interview, n = 2 focus group and interview, n = 1 focus group only]. Recovery was defined by patients as the return to normal routines and the process of recovery started preoperatively. Our patient-oriented recovery model comprised 4 themes (Figure 1). First, Phases of recovery: recovery was described as multidimensional (physical was the top priority) with distinct phases as early, late/long-term, and the endpoint. Second, Recovery facilitators: recovery was supported through positive mindsets, conscious recovery, and taking an active role. Third, Recovery barriers: recovery was hindered by negative mindsets and treatment side-effects. Finally, Recovery catalysts: communication, autonomy, and expectations facilitated active or passive recovery.

Conclusion: Our proposed recovery model could be used to enhance patient-centered surgical care.

Use of a Patient Engagement Technology Improves Adherence to a Colorectal Enhanced Recovery Program

Alizeh Abbas, MD, Marshall C McLeod, PhD, Wendelyn Oslock, MD, Bayley Jones, MD, Nathan C English, MBChB, Alfonsus Adrian Harsono, MD, Robert H Hollis, MD, MSPH, FACS, Daniel Chu, MD, FACS

University of Alabama at Birmingham, Birmingham, AL

Introduction: The impact of patient engagement technology (PET) use on colorectal enhanced recovery program (ERP) adherence remains largely unexplored. Therefore, the aim of this study was to evaluate the association between PET use and ERP adherence.

Methods: A retrospective cohort study using single-institution American College of Surgeons NSQIP data for patients enrolled in a PET and undergoing elective colorectal surgery between 2018 and 2023 was conducted. PET use was defined as completion of at least 1 survey. The primary outcome was overall high ERP adherence (>70%). The secondary outcome was adherence to individual ERP components. Multivariable regression modelling was performed to calculate odds ratio (OR) in SAS. Significance was assessed at p < 0.05.

Results: Of 587 patients, 28.4% achieved >70% ERP adherence. Overall, most patients were White (73%), women (60%), had private insurance (54%), had high literacy (79%), and had used a PET (64%). Compared with low-ERP adherence group (<70%), high-ERP adherence patients had more often completed at least 1 PET survey (71% vs 62%, p < 0.05). On adjusted analysis, PET users had higher odds of high ERP adherence in comparison with PET non-users (odds ratio [OR]: 1.62, 95% CI: 1.04-2.57, p = 0.036). PET use was associated with higher odds of adherence to preoperative pain block use (OR: 2.10, 95% CI: 1.25-3.53, p = 0.005) compared with non-use.

Conclusion: Use of PET improves overall high adherence (>70%) to the components of colorectal ERPs with particular attention to preoperative pain block use. Enhancing PET access and use are potential areas of future intervention to improve ERP adherence and patient outcomes.

Why Are Young Patients with Colorectal Cancer Dying? Early-Onset Colorectal Cancer Tumors Have a More Permissive Tumor Immune Microenvironment Than Late-Onset Tumors

Letizia Todeschini, MD, Guilin Qiao, PhD, Tommaso Pollini, MD, Marco Zampese, MD, Paul Wong, BS, Ajay V Maker, MD, FACS

University of California, San Francisco, San Francisco, CA

Introduction: Disturbingly, colorectal cancer (CRC) has become the leading cause of cancer-related death in men under 50 years of age. Early-onset CRC (EOCRC) presents with more aggressive features and advanced stages compared with late‐onset CRC (LOCRC). Despite extensive research on their clinicopathological and genetic profiles, explanation for outcomes remain unknown. We hypothesize that EOCRC have a different tumor immune microenvironment (TIME) than LOCRC.

Methods: RNA transcripts were identified from 506 resected primary CRC (56 EOCRC, 450 LOCRC). Enrichment scores of different immune cell types, reflecting relative abundance within the tumor, were calculated with the “xCell” R package. Components of the TIME were extracted and compared with Wilcoxon rank-sum test.

Results: Enrichment scores for M1-polarized macrophages (p < 0.001), plasmacytoid and activated myeloid dendritic cells (p < 0.001), naïve CD8 + T cells (p = 0.002), CD4+ helper T cells Th1 and Th2 (p < 0.001), and NK T cells (p < 0.001) were significantly lower in EOCRC compared with LOCRC (Table 1). Further, the M1 (pro-inflammatory) to M2 (pro-tumoral) macrophage ratio was significantly lower in the EOCRC group than in the LOCRC group (p < 0.001, Table 1). The disparity in immune cell composition persisted and remained significant across TNM sages and after adjusting for DNA mismatch-repair/microsatellite-stability status and correlated with decreased anti-tumor immunity.

Table 1. - xCell Deconvolution Results in Early-Onset CRC and Late-Onset CRC Samples

Feature Median enrichment scores in EOCRC Median enrichment scores in LOCRC p Value Adjusted p Value
NK T cells 8.96 × 10-3 2.83 × 10-2 <0.001 <0.001
Naive CD8 + T cells 1.98 × 10-20 2.36 × 10-18 0.002 <0.001
CD4+ helper T cells Th2 1.62 × 10-2 9.41 × 10-2 <0.001 <0.001
CD4+ helper T cells Th1 7.95 × 10-19 8.42 × 10-3 <0.001 <0.001
Plasmacytoid dendritic cells 2.18 × 10-5 5.61 × 10-3 <0.001 <0.001
Activated myeloid dendritic cells 2.34 × 10-2 6.06 × 10-2 <0.001 <0.001
M1 macrophages 5.60 × 10-3 1.21 × 10-2 <0.001 <0.001
M1-macrophages to M2-macrophages ratio 3.85 37.99 <0.001 <0.001

Conclusion: The TIME of early-onset CRC void of cytotoxic and anti-tumor pro-inflammatory cells. This unbiased analysis provides provocative explanation for the recently encountered spurt of young patients with aggressive-phenotype CRC. Our study suggests that the TIME composition may explain the biological aggressiveness of EOCRC. Further investigation is warranted to determine cell dynamics and therapeutical implications.

ePosters

A Study of the Effect of Arterial Calcification on Indocyanine Green Perfusion Time of Dissected Margins in Colorectal Surgery

Jun Kiuchi, MD, PhD, FACS, Yoshaiki Kuriu, MD, PhD, Tomohiro Arita, MD, PhD, Hiroki Shimizu, MD, PhD, Kenji Nanishi, MD, PhD, Hiroshi Arakawa, MD, Yudai Nakabayashi, MD, Ryo Ishida, MD, Rie Shibata, MD, Eigo Otsuji, MD, PhD

Kyoto Prefectural University of Medicine, Kyoto, Japan

Introduction: In colorectal surgery with anastomosis, evaluation of blood flow at the anastomosis using indocyanine green (ICG) is widely used. However, the ICG perfusion time varies greatly among individuals, and it is often difficult to determine the necessity of additional bowel resection. In this study, we focused on atherosclerosis as the cause of such individual differences and analyzed its effect on ICG perfusion time.

Methods: Among the cases in which colorectal resection with anastomosis was performed for colorectal cancer in our hospital, 216 cases in which the root of the inferior mesenteric artery was dissected were retrospectively analyzed. The percentage of calcification in the volume of the abdominal aorta (Ao calcification rate) was calculated as an indicator of atherosclerosis.

Results: 1) ICG perfusion time was strongly correlated with Ao calcification rate. 2) There were 9 cases in which the bowel resection line was changed after ICG perfusion evaluation, and the Ao calcification rate was significantly higher in the resection line-changed cases than in the non-changed cases. 3) High Ao calcification rate was significantly associated with male, older age, history of ischemic disease, hyperlipidemia, and hypertension. In addition, male, older age, and hypertension were independent risk factors for high Ao calcification rate. 4) High Ao calcification rate was an independent risk factor for change in resection line.

Conclusion: The degree of calcification of the abdominal aorta is significantly associated with ICG perfusion time and is an independent risk factor for change of bowel resection line.

A Validated Integration of Tumor Deposits and Lymph Nodes to Improve Prognostication in Colon Cancer

Richard Sassun, MD, Annaclara Sileo, MD, Jyi Cheng Ng, MD, Ibrahim Gomaa, MD, Sara A M Aboelmaaty, MD, Nicholas P Mckenna, MD, David W Larson, MD, FASCRS, FACS

Mayo Clinic, Rochester, MN

Introduction: Tumor deposits (TDs) have known prognostic value in colon cancer, but the current AJCC staging only accounts for TDs if there are no positive lymph nodes (LN+). This study aimed to refine AJCC staging, combining TD and LNs to improve prognostication.

Methods: A “real LN+ (RLN+)” count was derived using a formula based on two criteria: if TD = 0, current AJCC N staging applies; if TD = 1 and LN+ = 0, then RLN+ = 4 because the N1c group has a disease-free survival (DFS) and an overall survival (OS) more similar to the N2a group rather than N1b according to the literature. The developed formula was as follows: RLN+ = TD + LN+ + 3 * √(TDLN+).

RLN+ was then used to derive refined N and TNM stages according to AJCC staging. To assess the efficiency of the refined N stages, Kaplan-Meier and ROC curves analyses were performed using the refined N/TNM stages and current AJCC N/TNM stages for 3-year DFS and OS. External validation was performed on National Cancer Database (NCDB).

Results: 788 non-metastatic CC patients (2010-2022) in a multi-institutional database were recruited. ROC curve areas were greater in the refined stages (3-year DFS, 0.64 AJCC TNM versus 0.66 refined TNM; 3-year OS, 0.63 AJCC TNM versus 0.66 refined TNM). Kaplan-Meier curves revealed significant overlap among AJCC N stages, whereas in the refined N stages, such overlap was absent. NCDB validation was successful, yielding similar results.

Conclusion: The refined N stages provided superior DFS and OS stratification compared to current AJCC staging suggesting its implementation for better prognostication of CC.

Analyses of Deoxyribonucleic Acid Derived from Circulating Nucleosomes in Patients with Colorectal Cancer by Silver Nanoscale Hexagonal Column Chips

Tatsuya Kinjo, MD, PhD, FACS, Yoshihiro Miyagi, MD, Mitsuhisa Takatsuki, MD, PhD, FACS

University of the Ryukyus, Okinawa, Japan

Introduction: The number of colorectal cancer cases annually is approximately 1,900,000 worldwide. There is a lack of simple early detection methods for this disease. We report the usefulness of a simple and rapid cancer screening method using autofluorescence imaging with silver nanoscale hexagonal column chips (NHCs) that detects circulating nucleosomes bound to cell-free DNA. Silver NHCs can be used in a sensitive liquid biopsy, although the combined constituents of the NHCs have not been identified. We extracted DNA combined with the surface of NHCs by physical fracturing using a bead beater homogenizer and generated polymerase chain reaction (PCR) products for high-throughput sequencing of multiple amplicons through next-generation sequencing (NGS).

Methods: Twenty-four patients underwent surgery for colorectal cancer or benign disease. An examiner blinded to the sample details measured the area of autofluorescence at two different wavelengths to detect cancer using NHCs. DNA samples were extracted from the physically lysed surface products using the NHCs. Next-generation sequencing was performed using the MiFish method on a MiSeq platform.

Results: Based on the NHCs, the sensitivity and specificity of diagnostic cancer were 17/22 = 0.78 and 2/3 = 0.89, respectively. We obtained dsDNA from five patients with colorectal cancer and detected variants of Cadherin 13 related to epithelial-mesenchymal transition in Stage I mucinous adenocarcinoma and thyroid hormone receptor beta, known as a tumor suppressor in Stage IV.

Conclusion: Nanoscale hexagonal column chips may be useful for liquid biopsies in cancer screening to characterize tumors in patients with colorectal cancer.

Anesthesia Adjuncts on Patients Undergoing Colectomy: An Analysis of NSQIP-Reported Outcomes

Fauzi Feris Jassir, MD, Justin Dourado, MD, Jessica V Baran, MS, Avraham Belizon, MD, FACS

Florida Atlantic University, Boca Raton, FL; Florida Atlantic University, Greenacres, FL

Introduction: The addition of regional and spinal anesthesia techniques has been linked to reduced pain and improved outcomes in many areas of general surgery. This study aims to evaluate its effectiveness in patients undergoing colectomy.

Methods: Utilizing the National Surgical Quality Improvement Program database, we evaluated patients who underwent colectomy at Boca Raton Regional Hospital from 2020 to 2023. Patients either received general anesthesia alone, or the addition of spinal or regional (adjunctive) anesthesia. Outcomes assessed were related to hospital stay and discharge disposition.

Results: A total of 273 patients were evaluated with 103 (37.7%) males. Most cases were elective with 60% being performed minimally invasively. The use of adjunctive anesthesia was not associated with differences in surgical site infections, 30-day mortality, or acute kidney injury. Patients who received adjunctive anesthesia were more likely to have a shorter length of stay (3 v. 7 days, p < 0.01), be discharged home (p = 0.06), and have a functional status on discharge defined as independent (p = 0.018). Additionally, a lack of adjunctive anesthesia was associated with higher rates of blood transfusion (p = 0.005) and postoperative pneumonia (p = 0.028).

Conclusion: Performing adjunctive anesthesia (regional and spinal anesthesia) in patients undergoing colectomies is associated with shorter length of stay, higher functional status on discharge, and lower morbidity.

Colorectal Cancer Resection Outcomes in Dialysis Patients: An American College of Surgeons NSQIP Study

Nicholas Bartschat, MD, Jeremy Chang, MD, Kristina L Guyton, MD, Jennifer Hrabe, MD, FACS, Irena Gribovskaja-Rupp, MD, FACS, Imran Hassan, MBBS, FACS

University of Iowa, Iowa City, IA

Introduction: Dialysis dependence is associated with higher incidence of postoperative complications in general surgery patients, though data is conflicting regarding complications after colorectal resections for malignancy. Utilizing the American College of Surgeons (ACS) National Surgical Quality Improvement Program (NSQIP) database, we assessed outcomes in dialysis patients undergoing elective colorectal cancer resections and compared these to patients not on dialysis. We hypothesized that dialysis patients would have higher rates of 30-day morbidity and mortality following colorectal cancer resection.

Methods: Patients who underwent elective colectomy or proctectomy for malignancy from 2015-2021 were selected. Demographics and outcomes data were abstracted. Primary endpoint was 30-day mortality rate. Multivariable logistic regression was conducted to identify independent risk factors. Major and minor complication rates were assessed as determined by Clavien-Dindo classification.

Results: We identified 111,246 patients, of which 475 (0.4%) were dialysis-dependent preoperatively. Dialysis patients had more frequent minor (13.5% vs 9.9%, P < 0.01) and major (9.3% vs 4.5%, P < 0.001) complications compared to non-dialysis patients, as well as longer length of stay (median 6 vs 4 days, P < 0.001) and higher readmission rate (15.8% vs 10%, P < 0.001).

30-day mortality rate was increased in the dialysis group (3.2% vs 0.6%, P < 0.001). Preoperative dialysis dependence was an independent risk factor for mortality in multivariate analysis accounting for demographic and comorbidity confounders.

Subgroup analysis amongst dialysis patients revealed heightened combined mortality risk with preoperative history of COPD (P < 0.01).

Conclusion: Our findings reveal heightened perioperative risk for dialysis patients undergoing elective colorectal cancer resections, particularly in those with other comorbidities.

Colorectal Linitis Plastica: A Rare Neoplastic Condition with Common Histological Features

Thanh Nguyen, MD, Mahir Gachabayov, MD, Katherine Lam, MD, Salma Khan, MBBS, James Clarke, MD, Ryan F Bendl, DO

Westchester Medical Center, Valhalla, NY

Introduction: Colorectal linitis plastica (CRLP) is an extremely rare (accounting for 1/1000 cases of colon cancer) but aggressive malignancy. CRLP can be either primary or metastatic spread from the stomach or breast. The aim of this systematic review was to evaluate the clinical presentation, diagnosis, treatment, and outcomes in patients with CRLP.

Methods: The Pubmed, Medline, and EMBASE databases were systematically searched by two independent researchers for reports published between 1980 and 2020.

Results: Sixty-nine published cases were included. CRLP was primary in 55 and secondary in 14 patients. Mean age was 50 ± 18 years. Male to female ratio was 57:43. Most common presenting symptom was abdominal pain (43%), diarrhea (29%), hematochezia (19%), and constipation (17%). Time from the onset of symptoms to diagnosis varied from 3 days to 6 years. The diagnosis was made at surgery in 50%, colonoscopy with biopsy in 33%, and autopsy in 27%. CRLP histology showed signet cell carcinoma in most patients. The location of CRLP was colon in 55%, rectum in 19%, and anus in 3%. For some patients, the disease involved both the colon and the rectum. Breast cancer was the primary tumor in 7 out of 14 patients, gastric cancer in 6, and ovarian cancer in 1 patient. One-year overall survival was 23%, despite surgery and chemoradiation in all patients.

Conclusion: CRLP is infrequently diagnosed at colonoscopy, and despite R0 resection followed by a chemoradiation, is currently associated with a 77% mortality at 1 year.

Comparative Study of Cylindrical and Circular Ring Magnets in Colonic Anastomosis in Rats

Miaomiao Zhang, PhD, Lei Wang, PhD, Shuqin Xu, PhD, Yi Lyu, MD, PhD, Xiaopeng Yan, MD, PhD

Department of Hepatobiliary Surgery, The First Affiliated Hospital of Xi’an Jiaotong University, Xi’an, China; School of Future Technology, Xi’an Jiaotong University, Xi’an, China

Introduction: The study of magnetic compression anastomosis (MCA) has covered the whole digestive tract and has the advantages of simplicity and reliability. However, there is no report on whether the design diversity of magnetic anastomosis device structure affects the anastomosis effect. This study aimed to investigate the difference of colonic side-to-side anastomosis effect between cylindrical and circular ring magnets.

Methods: Thirty SD rats were randomly divided into cylindrical group, circular ring group, and cylindrical - circular ring group, with 10 rats in each group. Side-to-side colonic anastomosis was completed by transanal magnets implantation without incision of the colon. Operation time, perioperative complications and magnets discharge time were recorded. The experimental animals were euthanized 4 weeks after operation, and the anastomotic specimens were obtained. The burst pressure and diameter of the anastomosis were measured respectively, and the formation of the anastomosis was observed by naked eye. The histological difference of each group was observed by light microscope.

Results: The colonic side-to-side anastomosis was completed in all 30 rats. There were no postoperative complications of bleeding and intestinal obstruction. There were no significant differences in operation time, magnet discharge time, anastomotic bursting pressure and anastomotic diameter among the three groups (P > 0.05). The gross specimens of the three groups showed good anastomotic healing, and histological observation indicated good mucosal continuity without significant differences on healing.

Conclusion: The results show that there is no significant difference in the establishment of rat colonic side-to-side anastomosis between cylindrical and circular ring magnets.

Comparing a Data-Driven Versus Clinician-Curated Approach in Developing Machine-Learning Models to Predict Colorectal Cancer Surgery Outcomes

Karoline B Bräuner, MD, PhD, Maliha Mashkoor, MSc, Viviane Lin, MD, Andreas W Rosen, MD, Mikail Gögenur, MD, Tobias F Justesen, MD, Andi Tsouchnika, MSc, Ismail Gogenur, MD, DMSc

Zealand University Hospital, Køge, Denmark; Zealand University Hospital, København S, Denmark

Introduction: Many studies of predictive modelling exist, and data driven approaches have become more accessible. However, results from data driven models may be difficult to interpret, impacting trust from clinicians and implementation in the clinic. We compared the performance of prediction models using a solely data-driven versus a combined data- and clinician-driven (parsimonious) approach wherein multiple data points were combined into clinical phenotypes to reduce complexity and increase interpretability.

Methods: Data from four Danish observational health databases were harmonized into the Observational Medical Outcomes Partnership Common Data Model and used to predict outcomes after colorectal cancer surgery. We trained models for predicting 90-day, 365-day, and 5-year mortality and major surgical complications, using only preoperatively available covariates. Predictive performance was assessed for discrimination and calibration, using area under the receiver operating characteristic (AUROC) and calibration-in-the-large (CIL).

Results: Using parsimonious models, covariate count for mortality outcomes decreased from 347, 421, and 562 to 127, 105, and 85, and complications from 547 to 106. Both data-driven and parsimonious mortality models had good discrimination with AUROC of 0.817 - 0.871 for the data-driven versus 0.839 - 0.875 for the parsimonious models with CIL of 0.99 - 1.01. The AUROC predicting postoperative complications was 0.744 in the data-driven versus 0.779 in the parsimonious model with similar CIL of 0.99.

Conclusion: Using a parsimonious approach for training prediction models did not significantly decrease performance for predicting outcomes after colorectal cancer surgery in three of the four models and resulted in a greatly reduced number of covariates.

Conditional Survival of Patients with Appendiceal Neuroendocrine Neoplasms after Resection

Lauren Weaver, MD, Alexander M Troester, MD, Sarah Mott, MS, Lindsay L Welton, MD, Shreya Gupta, MD, Wolfgang B Gaertner, MD, FACS, Imran Hassan, MD, FACS, Paolo Goffredo, MD

University of Minnesota, Minneapolis, MN; University of Iowa Health Care, Iowa City, IA; University of Minnesota, Minneapolis, OH; University of Iowa Hospitals and Clinics, Cedar Rapids, IA

Introduction: Conditional overall survival (COS), the probability of surviving after a specific time interval, offers valuable and dynamic insight into patient prognosis. Currently, data on COS of appendiceal neuroendocrine neoplasms are scarce. This study aimed to investigate COS using the National Cancer Database.

Methods: Adults with an appendiceal neuroendocrine neoplasm who underwent colectomy were identified from 2010-2017. Tumor histologies, including neuroendocrine tumor grade 1(NET G1), NET G2-G3, neuroendocrine carcinoma (NEC), mixed neuroendocrine non-neuroendocrine neoplasm (MiNEN), and goblet cell carcinoma (GCC), were recorded. Kaplan-Meier methods plotted 5-year survival and 2-year COS. Cox regression models estimated the effect of patient and tumor characteristics.

Results: Of 3,541 patients (90% <70 years old, 43% male, 88% White), 40% had NET G1, 4% NET G2-G3, 10% NEC, 12% MiNEN, and 30% GCC. Overall 5-year survival by tumor histology was 95% NET G1, 95% NET G2-G3, 91% NEC, 82% MiNEN and 92% GCC. After 2-years, 3,092 patients survived. For 2-year COS, patients with NET, NEC, and GCC demonstrated a ≥95% survival at 5-years, while MiNEN had lower survival at 86%. In multivariable analysis, mortality after 2-years was associated with age ≥70, MiNEN and GCC histology, visceral peritoneal invasion, nodal involvement, and increasing tumor size ≥1 cm.

Conclusion: In this national cohort, patients with appendiceal neuroendocrine neoplasms had high OS, and even higher 2-year COS. While neuroendocrine staging is based on size and nodal involvement, tumor invasion may also identify patients with worse prognosis, potentially needing closer follow-up. MiNEN and GCC demonstrated worse COS, likely reflecting more aggressive tumor biology.

Differences in Objective Performance Indicators During Robotic Proctectomy: Early vs Advanced Cancer Patients

Mishal Gillani, MD, Manali Rupji, MS, Virginia L Shaffer, MD, FACS, Patrick S Sullivan, MD, FACS, Glen C Balch, MD, FACS, Mallory C Shields, PhD, Terrah J Paul Olson, MD, FACS, Yuan Liu, PhD, Seth A Rosen, MD, FACS

Emory University School of Medicine, Atlanta, GA; Winship Cancer Institute, Emory University, Atlanta, GA; Intuitive Surgical, Norcross, GA; Rollins School of Public Health, Emory University, Atlanta, GA

Introduction: Surgery for patients with advanced rectosigmoid cancer is generally perceived to be more complex, but the absence of objective intra-operative data hinders a thorough understanding of differences in techniques required during such procedures. Objective performance indicators (OPIs), machine-learning-enabled metrics, provide objective data regarding surgeon movements and robotic arm kinematics. In this study, we identified differences in OPIs during robotic proctectomy (RP) between patients with early and advanced rectosigmoid cancer.

Methods: Endoscopic videos synchronized to robotic systems data were annotated to delineate individual surgical steps during 41 RPs. Eleven patients had early-stage lesions, while 30 patients had more advanced cancers. OPIs during mesenteric dissection, rectal mobilization and pelvic dissection (PD) steps were analyzed.

Results: Patients with advanced cancer had the following OPI differences: across all steps, greater dominant arm path length, velocity, acceleration and jerk, more dominant wrist roll and pitch; during mesenteric dissection, greater camera velocity, acceleration and jerk, higher dominant and non-dominant arm acceleration; during rectal mobilization, more dominant wrist roll, greater dominant arm velocity, acceleration and jerk; during posterior PD, greater dominant arm velocity, acceleration and jerk; during anterior PD, greater dominant arm acceleration; during right PD, longer dominant arm path length, velocity and acceleration; during left PD, lesser non-dominant wrist roll, greater dominant arm velocity, acceleration and jerk.

Conclusion: This is the first study to identify step-specific OPIs that differ during RP in patients with varying stages of rectosigmoid cancer. While our work demonstrates feasibility, further studies involving larger patient samples are needed.

Does Unilateral Gluteoplasty Alone Correct Anal Incontinence Post War Injuries to Anal Sphincter?

Waheeb Al-Kubati, MBBS

Sana’a University, Sana’a, Yemen

Introduction: Irreversible traumatic war injuries to the anal sphincter lead to fecal incontinence “requiring a stoma”, which has a significant negative impact on a patient’s well-being. This study evaluates the outcomes and durability of unilateral gluteoplasty with/ without adjuvant surgical techniques, to manage end-stage fecal incontinence.

Methods: Prospectively, from November 2009 and January 2024, 56 male patients, with traumatic fecal incontinence, were managed by unilateral gluteoplasty. We add anal column plication, smooth muscle-plasty, and pectinoplasty to restore neo-anal cushions, improve resting anal pressure and reduce soiling. All patients scored preoperatively, 3, and 6 months postoperatively.

Results: All patients were male with a mean age of 22 years. 50% of patients had already undergone emergency operations and colostomy post penetrating war injuries with complete anal sphincter destruction and fecal incontinence. 78.6% were significantly improved post unilateral gluteoplasty, allowing for colostomy closure. Their estimated manometric studies and functional scores improved significantly. Others remained incontinent due to sensory incontinence despite excellent voluntary sphincter tone. Resting anal pressure improved dramatically post anal column plication, smooth muscle-plasty, and pectinoplasty.

Conclusion: Components of normal anal continence include sensory, reservoir components, and motor squeeze. Therefore, no perfect replacement for a normal anal sphincter. Gluteoplasty, a skeletal muscle wrap, alone is sufficient to restore the squeeze component. But, it’s not enough to maintain normal resting anal pressure. Patients with sensory incontinence are unlikely to benefit from it. The presence of a sensory reservoir and a skin-lined anal canal (pectin) also, appear to be important in addressing fecal incontinence.

Effects of Surgical Specialization and Surgeon Resection Volume on Cancer-Free and Overall Survival after Emergent Colon Cancer Resection

Jenny Engdahl, MD

Faculty of Medicine, Lund University, Helsingborg, Sweden

Introduction: The effect of surgical specialization on long-term survival of patients undergoing emergent colon cancer resections is largely unknown.

Methods: A retrospective ten-year analysis of all patients who underwent emergent colon cancer resections at a secondary care hospital was performed. The most senior surgeon performing the procedures was classified as colorectal surgeon (CS) or non-colorectal surgeon (NCS). NCS were further divided into acute care surgeons (ACS) or general surgeons (GS). Overall survival (OS) and cancer-free survival (CFS) were compared in patients operated by surgeons with different specializations.

Results: In total 235 emergent procedures were performed, 99 (42%) and 136 (58%) were performed by CS and NCS, respectively. Cumulative OS was similar in patients operated by CS and NCS. Cox regression analysis adjusted for clinically relevant confounders confirmed similar OS and CFS in patients operated by CS and NCS (HR 0.95 (0.67-1.36), p = 0.794 and HR 0.94 (0.63-1.41), p = 0.774). OS and CFS were similar in patients operated by ACS and CS (HR 1.10 (0.75-1.62), p = 0.629 and HR 1.24 (0.80-1.92), p = 0.343), but was significantly shorter in patients operated by GS (HR 1.78 (1.05-3.00), p = 0.031) and (HR 1.83 (1.02-3.26), p = 0.041).

Conclusion: The long-term outcome after emergent colon cancer resections was similar in patients operated by CS and NCS, and the subgroup of ACS, indicating equivalent surgical quality. The less advantageous survival in patients operated by GS may be explained by less exposure to colorectal and emergent surgery, regular rotations for GS at colorectal and acute care units may improve outcome.

Efficacy of Diltiazem and Lidocaine vs Nifedipine and Lidocaine in Acute Fissure in Ano: a Randomized Controlled Trial (NDRF Trial)

Pankaj Kumar, MBBS, MS, FACS, Prakash K Sasmal, MBBS, MS, FACS, Aitha Saikrishna, Tushar S Mishra, MBBS, MS, FACS, Pradeep K Singh, MBBS, MS, FACS

All India Institute of Medical Sciences, Bhubaneswar, Odisha, India

Introduction: The NDRF trial aimed to compare the efficacy and side effects of local application of Diltiazem vs Nifedipine in management of acute anal fissure.

Methods: One hundred forty-four patients with acute anal fissure were randomized to receive either a combination of Diltiazem (2% w/w) + Lidocaine (2% w/w) or Lidocaine (1.5% w/w) + Nifedipine (0.3% w/w). Patients were instructed to apply the drugs at perianal area using the supplied accurate rectal applicator, twice daily for four weeks. All patients also received a combination of Polyethylene Glycol 3350 & Ispaghula Powder at a dose of 10 gm (2 TSF), once daily. They were followed-up at one week and one month for the assessment of the side effects, bleeding, pain and healing of the fissure.

Results: Fissure healing rates were 93% in the Nifedipine arm and 100% in the Diltiazem arm among those who completed the study, with a non-significant p-value of 0.11. Two participants in the Nifedipine group discontinued treatment due to dizziness, while the Diltiazem group showed no signs of side effects. There were no notable differences between the two groups regarding the occurrence of pain and bleeding in patients at both one week and one-month follow-up.

Conclusion: Both drug combinations are equally effective in managing Acute Fissure in Ano, with a high success rate and minimal side effects. All patients with Fissure in Ano should be offered a trial of the combination of a topical calcium channel blocker and lidocaine, along with a stool softener.

Endorobotic Submucosal Dissection (ERSD) Versus Transanal Minimally Invasive Surgery (TAMIS): A Propensity Score-Matched Comparison

Kamil Erozkan, MD, FACS, Metincan Erkaya, MD, Attila Ulkucu, MD, Lukas Schabl, MD, Ali Alipouriani, MD, David R Rosen, MD, FACS, Josh Sommovilla, MD, Emre Gorgun, MD, MBA, FASCRS, FACS

Cleveland Clinic, Cleveland, OH

Introduction: Minimally invasive transanal excision techniques enhance dissection precision while maintaining minimally invasive treatment compared to traditional transanal excision. Transanal minimally invasive surgery (TAMIS) is a prevalent approach that provides full-thickness resection. Endorobotic submucosal dissection (ESRD) offers the opportunity for submucosal dissection with the assistance of a robotic surgical system. This study aimed to compare these two techniques’ short-term surgical and oncological outcomes.

Methods: Patients who underwent ERSD or TAMIS from June 2010 to August 2023 were retrospectively reviewed. Groups were then matched using propensity scores according to significant differences in univariate analysis. Primary outcomes focused on the en-bloc resection rate and margin involvement.

Results: The study reviewed 248 TAMIS and 41 ERSD patients. After univariate analysis, the lesion size and the distance from the anal verge were used for propensity score-matching, and 34 patients from each procedure were matched. Margin involvement and en-bloc resection rates were similar between ERSD and TAMIS. ERSD had a lower estimated blood loos than TAMIS (p < 0.01), and the median length of stay was shorter for ERSD (p < 0.01). No differences were found between ERSD and TAMIS regarding specimen surface, complication, surgery due to complication, readmission, additional intervention, and mortality rates.

Conclusion: ERSD may be a viable alternative to TAMIS with favorable short-term outcomes. Further studies are warranted to investigate long-term functional and oncological outcomes between these two approaches.

Enhanced Recovery after Surgery (ERAS) for Colectomy in Ukraine: A Nationwide Practice Survey

Inesa Huivaniuk, MD, Marta Antoniv, MD, Taras Ivanykovych, Anastasiia Prystaia, MD, Ali Dzhemiliev, MD, Anastasiia Liakh, Slava Kopetskyi, MD, Ronald Bleday, MD, FACS, Nelya Melnitchouk, MD, FACS, Julie Hallet, MD, MSc, FRCSC, FSSO, FACS

National Cancer Intitute, Kyiv, Ukraine; Brigham & Women’s Hospital, Boston, MA; Danylo Halytsky Lviv National Medical University, Lviv, Ukraine; Feofaniya Clinical Hospital, Kyiv, Ukraine; Sunnybrook Health Sciences Centre, Toronto, ON, Canada

Introduction: In Ukraine, the adoption and adherence to ERAS (Enhanced Recovery After Surgery) protocols remains unclear. We examined practice intentions regarding ERAS for patients undergoing colectomy across Ukraine.

Methods: We conducted a self-administered web-based survey of surgeons, anesthesiologists, and hospital administrators involved in perioperative colectomy care in Ukraine. We developed a questionnaire through item generation and reduction, followed by reliability and validity testing. We compared responses across hospital size using the Chi-Square test.

Results: Among 285 respondents were 112 surgeons, 135 anesthesiologists, and 38 administrators. Use of and compliance with standardized ERAS protocols for colectomy was reported by 12%. Mechanical bowel preparation was used by 49% of surgeons, while 19% combined it with oral antibiotics. For intraoperative care: 34% of anesthesiologists did not focus on normothermia, 46% omitted active warming, and 64% did not routinely measure patient temperature. Preoperative antibiotic prophylaxis within 60 minutes of incision was reported by 37%, with 33% indicating variability in administration. Postoperative antibiotic administration varied, with 36% surgeons reporting continuing for 4 to 7 days after surgery and 8% extending beyond 7 days. Solid diet was resumed once intestinal motility normalized as per 63% of surgeons. Ambulation was reported to occur within 24 hours by 37% of surgeons. Reported use of components of ERAS protocols did not differ by hospital size (p > 0.05).

Conclusion: Inconsistency in ERAS protocol adoption highlights the need for nationwide standardization of perioperative care, which can go through guidelines implementation and monitoring, and will need to be tailored to the Ukrainian context.

Evaluating the Effectiveness of Same-Day Discharge in Colectomy Patients: A Systematic Review and Meta-Analysis

Joao P Goncalves Kasakewitch, MD, Ana C D Rasador, MD, Carlos André B D Silveira, MD, Diego L Lima, MD, Abier A Abdelnaby, MD, FACS

Beth Israel Deaconess Medical Center, Boston, MA; Bahiana School of Medicine and Public Health, Salvador, Brazil; Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY

Introduction: Our systematic review and meta-analysis aims to assess the viability of same-day discharge (SDD) in colectomy patients, with the goal of minimize hospital stays, costs, analgesia use, and complications.

Methods: Cochrane, Embase, MEDLINE, PubMed, and Web of Science were searched for studies on adults undergoing minimally invasive colectomies with SDD, focusing on outcomes like reoperation, readmission, complications, and mortality.

Results: From 1,067 records, 8 were included, comprising 3 comparative and 5 single-arm studies with a total of 21,526 patients. Our meta-analysis revealed that SDD colectomy patients experienced significantly lower postoperative complication rates (9.2%) compared to those with a LOS greater than 24 hours (27.9%; RR 0.34; 95% CI: 0.25, 0.46; P < 0.001), with no significant differences in readmissions, reoperations, and mortality rates between the two groups. In a pooled analysis including both comparative and single-arm studies, the overall event rates per 100 patients were 11.6 for postoperative complications (10.2%; 95% CI: 6.03, 21.17; I2 = 95%), 7.5 for readmissions (7%; 95% CI: 6.21, 9.05; I2 = 35%), 1.7 for reoperations (1.4%; 95% CI: 0.9, 3.23; I2 = 42%), 10.4 for 30-day ED visits (11.1%; 95% CI: 5.77, 17.88; I2 = 80%), 0.83 for mortality (0.7%; 95% CI: 0.29, 2.34; I2 = 0%), and 16.3 for SDD failure (17.3%; 95% CI: 7.48, 31.87; I2 = 88%).

Conclusion: SDD is a feasible, safe option for patients with minimal comorbidities and complications undergoing minimally invasive colectomies, associated with low readmission and reoperation rates, and potentially fewer postoperative complications compared to extended hospital stays.

Genetic Sequencing in Non-Responders to Total Neoadjuvant Chemotherapy and Radiation with Locally Advanced Rectal Cancer

Mariam T Khan, MD, Grant Backer, Sierra Silverwood, James W Ogilvie, MD, FACS

Corewell Health West, Grand Rapids, MI; Michigan State University College of Human Medicine, Grand Rapids, MI

Introduction: A minority of patients will not show treatment response to total neoadjuvant therapy (TNT) for locally advanced rectal cancer (LARC). We conducted a pilot study looking for genetic patterns to identify patients who will not respond to TNT or will show complete response.

Methods: This was a retrospective study of patients with LARC undergoing TNT from 2015-2021. Non-responders had pathologic staging that was the same as or worse than pre-TNT clinical staging. Patients with complete pathologic response on final pathology served as a comparison cohort. Specimens were submitted for proprietary genomic sequencing of 648 known cancer mutations (Tempus ®; Chicago, IL); both biopsy and surgical specimens were submitted for non-responders to account for genomic alterations to tumor induced following chemotherapy.

Results: Sixteen patients met study criteria, with seven non-responders. In each group, six patients had banked tissue available from which specimens were submitted for testing. Mean age at diagnosis was 54.1 years. The majority of patients were male (69%) and Caucasian (n = 81%). There were 32 distinct mutations identified in the complete responder group and 21 in the non-responder group. TP53 was the most frequently identified mutation, followed by APC, KRAS, and LRP1B.

Conclusion: There is wide heterogeneity in identified mutations in patients who have excellent response to TNT and those who do poorly. Future research may consider applying targeted therapies to patients with no treatment response using data on mutations identified postoperatively.

Intracorporeal Anastomosis: A Nine-Year Review of Minimally Invasive Colorectal Surgery Outcomes

David Moros, MD, Manuel E Moros, MD, Hender Hernández, MD, Óscar Villamizar, MD, Ramón Durán, MD, Deivis López, MD

Clínica Gastroquirúrgica, Cúcuta, Colombia; Clínica Santa Ana S.A., Cúcuta, Colombia

Introduction: Restoration of intestinal continuity and creation of anastomoses are challenges in colorectal surgery. Currently, there are two minimally invasive techniques for ileocolonic and colorectal anastomosis: intracorporeal and extracorporeal.

Methods: Retrospective review of medical records of patients operated on between 01/2015 and 07/2023 in Cúcuta, Colombia, all performed by the same surgical team. We collected demographic information, preoperative characteristics, intraoperative details, and postoperative outcomes.

Results: Over nine years, 140 laparoscopic colorectal surgeries with intracorporeal anastomosis were performed. Mean age was 65 (SD: ±14) years, 71 (51%) were women, 112 (80%) had a BMI > 25, and 118 (85%) were classified as ASA II. In total, there were 99 (71%) right colectomies, 18 (13%) stoma closures, 10 (7%) left colectomies, 6 (4%) intestinal derivation, 4 (3%) subtotal colectomies, and 3 (2%) transverse colectomies. Median operative time was 120 (IQR:70-180) minutes with no conversion to extracorporeal anastomosis. 111 (79%) patients had malignant pathology and 29 (21%) had benign pathology. Regarding complications, 33 (24%) patients experienced prolonged postoperative ileus, 12 (9%) required reoperation, of which 7 (5%) were for anastomotic leakage, and 8 (6%) had surgical site infections. Median time to initiation of oral intake was 1 (IQR: 1-3) day, with a median hospital stay of 5 (IQR: 3-13) days. The 30-day postoperative mortality was 7 (5%) patients, with non-surgical causes in 6 (86%).

Conclusion: Intracorporeal colonic anastomosis is a feasible and safe option. The favorable results in terms of surgical site infection, length of hospital stay, and recovery of intestinal function confirm its benefits.

Is Operating on Diverticulitis in the Elderly Patient Safe?

Analena Alcabes, MD, Danny H Heo, BA, Suraj Chetty, BA, Thais Reif De Paula, MD, John H Marks, MD, FACS, FASCRS

Lankenau Medical Center Division of Colon and Rectal Surgery Mainline Health, Wynnewood, PA

Introduction: Morbidity and mortality rates following major colorectal resections are higher in elderly patients. This has led surgeons to hesitate to offer management surgery for the elderly. We hypothesize that elective surgery in the elderly for diverticulitis will prove to be safe in comparison to a younger patient population.

Methods: A prospective database was reviewed for adult patients undergoing elective resection for diverticulitis from 1996 to 2023. Patients were stratified in 2 groups, ≥70 years old and <70 years old. Patients’ demographics, intraoperative and postoperative outcomes were compared. The main outcome measures were intraoperative complications and postoperative morbidity and mortality.

Results: There were 753 patients included (age ≥ 70 n = 160, age < 70 n = 593).There was no significant difference in transfusion requirement, intraoperative complications, or conversion to open surgery. There was no difference in the rate of stoma formation between groups, 1.1% in the younger cohort, 1.8% in the elderly. Patients 70 and over had significantly longer mean length of stay (7.18 days versus 4.64 days; P < 0.001), and lower rate discharge to home (85.6% vs 99.2%, P < 0.001), higher postoperative morbidity rate (21% vs 8.2%; p < 0.001) and significantly higher 30-day mortality rate (1.8% vs 0.1%, P = 0.04315).

Conclusion: Elderly patients can undergo elective minimally invasive diverticulitis resection with low morbidity and mortality, the expectation of discharge to home, and without need for a stoma. While not surprisingly, outcomes are better in a younger patient population, the results in the elderly subcategory support offering elective surgery when indicated, for older patients.

Knowledge of Colorectal Cancer Symptoms and Risk Factors in Sri Lanka: A Cross-Sectional Study

Dakshitha Wickramasinghe, MBBS, MD, FRCS, Thamisha Nugaliyadda, MBBS, Nandadea Samarasekera, MBBS, FRCS

University of Colombo, Colombo, Sri Lanka

Introduction: There is no screening program for colorectal cancer (CRC) in Sri Lanka. Presentation to a doctor therefore depends on awareness of CRC symptoms and risk factors. This study aims to identify the knowledge of the above in the Sri Lankan population.

Methods: A descriptive cross-sectional study was conducted between May 2022 and May 2023 at the National Hospital of Sri Lanka. Simple random sampling was performed from adults (>18 years) visiting the hospital, excluding patients. A culturally adapted version of the Bowel Cancer Awareness Measure questionnaire was used.

Results: Five hundred patients were recruited (53.8% male). The median age was 45.51 (SD 13.19) years. 77.3% of the participants were married. 80.6% had AL or higher level of education. Only 15.5% of participants correctly identified all CRC symptoms. The mean number of symptoms identified were 5.6. Vomiting (5.1%), dyspepsia (2.0%) and dysuria (0.4%) were also believed to be symptoms of CRC. Only 6% of participants correctly identified all associated risk factors. Consumption of excessive alcohol was the most recognized risk factor (63%) of participants. 282 (55.7%) failed to recall any CRC risk factors. The median self-reported delay to seeking medical advice was 2 days (IQR 1-7). 9.5%, however, stated a delay of more than 2 weeks. Despite the limitations in knowledge, 40.7% of participants reported they felt confident in recognizing CRC symptoms. Female sex was highly correlated with the knowledge.

Conclusion: The knowledge on CRC symptoms and risk factors among Sri Lankans is poor. Females were more knowledgeable.

Long-Term Survival in Young-Onset Rectal Cancer: Does It Differ from Older Patients?

Jyi Cheng Ng, MD, Richard Sassun, Annaclara Sileo, Ibrahim Gomaa, Sara A M Aboelmaaty, David W Larson, MD, FASCRS, FACS, Kellie L Mathis, MD, FACS

Mayo Clinic Rochester, Rochester, MN; Rome, Italy; Avigliano, Italy; Rochester, MN; Oronoco, MN

Introduction: Despite the rising incidence in young-onset rectal cancer (yRC), current evidence on long-term outcomes in yRC are conflicting. This study aimed to investigate the 5-year overall survival (5Y-OS) and disease-free survival (5Y-DFS) in yRC patients.

Methods: Rectal cancer patients who underwent curative surgical resection between 2010-2020 were identified from a prospectively maintained multiinstitutional database and categorized into yRC (<50-year-old) and normal-onset (nRC) (≥50-year-old). Demographics, oncological, and pathological features were analyzed. Survival analyses were conducted using Kaplan-Meier curves, log-rank test, and Cox regression.

Results: 1395 patients (yRC = 378; nRC = 1017) were analyzed. yRC patients presented at a more advanced stage, were more likely to be treated with neoadjuvant and adjuvant therapy but has similar downstaging rates when compared to nRC. Despite a more advanced presentation and more aggressive treatment, 5Y-OS and 5Y-DFS of yRC were similar to nRC (5Y-OS:85.7% vs 85.6%, p = 0.991; 5Y-DFS:83.1% vs 83.8%, p = 0.601). After adjusting for age and stage, yRC showed significantly higher risk of poor 5Y-OS (HR = 2.08 95%CI = 1.24-3.47, p = 0.005), but no difference in 5Y-DFS (p = 0.924). On multivariate analysis, stage IV, age, recurrence, and yRC were independent predictors of poor 5Y-OS, whereas stage III, stage IV were risk factors for poor 5Y-DFS. Stage IV was the most significant predictor of poor 5Y-OS (HR = 4.79; 95% CI [1.13-20.27], p = 0.033) and 5Y-DFS (HR = 21.16; 95% CI [2.93-152.76], p = 0.002). Adjuvant chemotherapy and pathological downstaging were protective factors for 5Y-OS and 5Y-DFS.

Conclusion: yRC patients exhibited poorer 5Y-OS compared to nRC when adjusted for age and stage, highlighting complexities in disease progression and treatment response.

Lymph Node Metastases in Appendiceal Neuroendocrine Neoplasms: An Analysis from the National Cancer Database

Alexander M Troester, MD, Lauren Weaver, MD, Sarah Mott, MS, Lindsay L Welton, MD, Niccolo Allievi, MD, Imran Hassan, MBBS, FACS, Wolfgang B Gaertner, MD, FACS, Paolo Goffredo, MD

University of Minnesota, Minneapolis, MN; University of Iowa, Iowa City, IA; Papa Giovanni XXIII Hospital, Paderno Dugnano, Italy; University of Iowa, Cedar Rapids, IA

Introduction: Current NCCN guidelines recommend segmental colectomy for appendiceal neuroendocrine neoplasms >2.0 cm given their propensity for nodal involvement, as opposed to appendectomy alone. However, the biologic behavior of neuroendocrine tumors is also determined by several factors besides size, including histology, lymphovascular invasion (LVI), and grade. We hypothesized that additional tumor characteristics would enhance prediction of LN metastases, supporting clinician decision-making regarding the optimal extent of surgical resection.

Methods: The National Cancer Database (2010-2017) was queried for adults with stage I-III appendiceal neuroendocrine neoplasms who underwent right colectomy. Five histologic subgroups including neuroendocrine tumor grade 1(NET G1), NET G2-G3, neuroendocrine carcinoma (NEC), mixed neuroendocrine-non-neuroendocrine neoplasms (MiNEN), and goblet cell carcinoid (GCC) were independently analyzed.

Results: Of 3,541 patients (median age 51 years, 43% male, 88% White), 16% had positive LN. Overall, 40% had NET G1, 4% NET G2-G3, 10% NEC, 12% MiNEN, and 30% GCC. On multivariable analysis, factors associated with LN metastases included increasing depth of invasion, LVI, and increasing size, while GCC and MiNEN were not. Five-year overall survival (OS) was 92%; 95% NET G1, 95% NET G2-G3, 91% NEC, 82% MiNEN, and 92% GCC. Age >70, increasing Charlson-Deyo score, MiNEN histology, involved LN, and T4 tumors were independently associated with worse OS (p < 0.05).

Conclusion: In this national cohort, 1 in 6 patients with neuroendocrine neoplasms had positive LN, which was associated with increasing depth of invasion, LVI, and size >1 cm. These findings suggest additional factors, rather than size alone, should be considered when determining the extent of surgical resection.

Management of Rectal Prolapse in Octogenarians: Lesson Learned in 13 Years’ Experience from a High-Volume Center

Giulia De Carlo, MD, Mikhael Belkovsky, MD, Tracy L Hull, MD, FACS, Anna Spivak, DO

Cleveland Clinic, Cleveland, OH

Introduction: Rectal prolapse is a debilitating and embarrassing condition that increases with age. When treating elderly patients with rectal prolapse, surgeons often choose to perform perineal approaches as they are considered safer. We aimed to compare morbidity and mortality of abdominal and perineal approaches in a large octogenarian population.

Methods: We conducted a retrospective IRB approved review of all patients eighty or more years old who underwent rectal prolapse surgery from 2010 to 2023 at the Cleveland Clinic. Patients were grouped according to the approach chosen to treat the prolapse (perineal or abdominal).

Results: Of the164 patients included, abdominal approaches were performed in 58 (35.3%) and perineal approaches in 106 (64.6%). Comparing the two approaches, no differences were observed in female sex (96.6% vs 93.4%. p = 0.49), mean BMI (22.7 vs 23.8 kg/m2, p = 0.14), history of prior rectal prolapse surgery (32.8% vs 26.4%, p = 0.39) and general anesthesia use (98.3% vs 96.2%, p = 0.66). Patients undergoing abdominal procedures had a significantly longer length of stay (4.41 vs 3.82 days, p = 0.016). No differences were found in complication or in recurrence rates among groups (mean follow-up of 6.8 months, IQR 1.2-7.1).

Conclusion: When treating rectal prolapse, abdominal approaches appear to be as safe as perineal ones, even among octogenarians. Selection bias may skew our results, but we recommend consideration of abdominal approaches whenever possible and limiting perineal approaches to patients too frail for general anesthesia or with a complex history of prior abdominal surgeries.

Management of Severe Immune Checkpoint Inhibitor Related Colitis

Imran Khan, MD, Mikhael Belkovsky, MD, Faris S Almadi, MD, Jessica Stockheim, MD, Attila Ulkucu, MD, Arielle Kanters, MD, David Liska, MD, FACS, Jonathan B Mitchem, MD, FACS, Stefan D Holubar, MD, Michael A Valente, DO, FACS

Department of Colorectal Surgery, Digestive Disease Institute, Cleveland Clinic, Cleveland Clinic, OH

Introduction: The use of immune checkpoint inhibitors (ICI) in oncology has been rising. ICI related colitis is the most common gastrointestinal adverse event, and severe disease may require hospitalization and surgery. This study aimed to describe the surgical management of patients with severe ICI colitis and to compare them with hospitalized patients managed medically.

Methods: We retrospectively analyzed all patients who were hospitalized for ICI colitis between 2011 and 2023. Patients were grouped into surgical and medical management. Descriptive analysis comparing groups was performed using “R” 3.2.1.

Results: A total of 30 patients were included, 19 patients were medically managed and 11 underwent surgical intervention. No difference was observed when comparing age, sex, smoking history, ICI type, and presence of other ICI-related side effects. Comparing clinical presentation, the medically managed group had more diarrhea and bloody stools, while patients undergoing surgery experienced pain, guarding and/or fever. When comparing radiological and endoscopic findings, patients in the non-operative management group had colonic inflammation, while patients in surgical group had perforation, megacolon, and/or obstruction. Among patients undergoing surgery, 9 were open and 2 were laparoscopic. Primary anastomosis was performed in 3 patients, ileostomy in 5 and colostomy in 2. Postoperatively, 4 (36.3%) had complications Clavien-Dindo (CD) grade II and 1 (9.1%) had grade III. The mortality rate among operated patients was 2 (18.2%).

Conclusion: ICI related colitis requiring hospitalization is a severe condition. A significant proportion of these patients require surgery, which has high morbidity and mortality.

Mastering the Precision of Colorectal Endoscopic Submucosal Dissection

Attila Ulkucu, MD, Mikhael Belkovsky, MD, Kamil Erozkan, MD, FACS, Imran Khan, MD, Brogan Catalano, MHA, BSN, RN, Emre Gorgun, MD, FASCRS, FACS

Digestive Diseases and Surgery, Cleveland Clinic, Cleveland, OH

Introduction: This study investigates the learning curve for mastering Endoscopic Submucosal Dissection (ESD), a skill-intensive and time-consuming technique, in colorectal procedures.

Methods: Between 2011 and 2021, we studied the learning curve of ESD by comparing en-bloc resection rates, intraoperative complications, and conversion to surgery rates across the first and last consecutive 50 procedures. We used local polynomial regression to model learning curves, dividing the sample into groups of 100 to identify inflection points.

Results: A surgeon performed 400 colorectal ESDs on patients averaging 64 years old with a BMI of 30 kg/m². The ascending colon was the most common lesion site (20%). Following the initial 100 patients, en-bloc resection rates slightly decreased, while surgery conversions and complications marginally increased. The second group of 100 patients had a higher prevalence of complex Kudo class lesions (p = 0.006), with no significant change in other lesion types (p < 0.05), while en-bloc resection rates improved from 64% to 87% (p < 0.001). In the first and last 50 patients, en-bloc resection rates increased from 48% to 90% and conversion to laparoscopy decreased from 22% to 4%. Intraoperative complications decreased from 8% to 2% between. The study reported a consistent ESD success rate of 93% and a 96% uncomplicated rate. Enhanced skill resulted in reduced hospital stays (p = 0.007).

Conclusion: The learning curve for ESD is multifaceted, with a plateau in conversion rates after 100 procedures. While en-bloc resection rates and intraoperative complications improve steadily, gaining experience reveals a second learning curve for managing challenging and complex lesions.

Preoperative Enteral Immunonutrition in Patients Undergoing Elective Colorectal Cancer Surgery May Improve Short-Term Postoperative Outcomes: A Systematic Review and Meta-Analysis

Tyler McKechnie, MD, MSc, Tania Kazi, BHSc, Victoria Shi, MA, Niv Sne, MD, FRCSC, Aristithes Doumouras, MD, MPH, FRCSC, Dennis Hong, MD, FACS, Cagla Eskicioglu, MD, MSc, FACS

McMaster University, Hamilton, ON, Canada

Introduction: Various studies have begun exploring the role of immunonutrition in preoperative care, demonstrating both safety and efficacy. We designed the present systematic review and meta-analysis with the aim of comparing enteral immunonutrition to conventional preoperative nutrition prior to elective colorectal cancer surgery.

Methods: MEDLINE, Embase, and CENTRAL were searched up to March 2023. Articles were included if they evaluated patients undergoing elective colorectal surgery and compared preoperative enteral immunonutrition to conventional preoperative nutrition protocols. The outcomes of interest included surgical site infection (SSI), anastomotic leak, and length of stay (LOS). Inverse variance random effects meta-analyses were performed. Risk of bias was assessed with Cochrane tools. Certainty of evidence was assessed with GRADE.

Results: After reviewing 2,508 relevant citations, seven observational studies met inclusion criteria. Overall, 483 patients (mean age: 65.8 ± 10.2, 42.7% female) received enteral immunonutrition and 977 patients (mean age: 63.3 ± 8.4, 51.6% female) received conventional preoperative nutrition. Across five studies, there was a 34% relative risk reduction in SSI in the immunonutrition group (10.9% vs. 15.0%, 95% confidence intervals (CIs) 0.41-1.05, p = 0.08, I2 = 9%). Across six studies, there was a 43% relative risk reduction in anastomotic leak in the immunonutrition group (2.0% vs. 2.6%, 95%CI 0.27-1.20, p = 0.14, I2 = 0%). Across five studies, LOS was 0.42 days shorter in the immunonutrition group (95%CI -0.03-0.87, p = 0.07, I2 = 33%). GRADE certainty of evidence was very low for all outcomes.

Conclusion: The impact of enteral immunonutrition prior to colorectal surgery remains unclear. Point estimates suggest important benefits; however, the wide corresponding 95% CIs create significant uncertainty.

Prevalence of Anxiety, Depression, and Stress in Colorectal Cancer Patients in Sri Lanka

Dakshitha Wickramasinghe, MBBS, MD, FRCS, Thamisha Nugaliyadda, MBBS, Chathuri Suraweera, MBBS, MD, Sanjeewa Seneviratne, MBBS, MD, FRCS, Nandadea Samarasekera, MBBS, MD, FRCS

University of Colombo, Colombo, Sri Lanka

Introduction: Colorectal cancer (CRC) is the fourth commonest cancer in Sri Lanka. The psychological burden of CRC has not been previously studied.

Methods: A cross-sectional study was conducted at the National Hospital of Sri Lanka, and the National Cancer Institute, from 2021 January to 2022 December. Data on sociodemographic, tumour, and treatment were collected. Sinhala and Tamil versions of DASS-21 and Becks Depression Inventory (BDI) were used to assess the Depressio, Anxiety, and Stress.

Results: The median age of the participants was 59.1 (SD 11.1) years. Of the 100 participants, the majority were male (51.9%) and married (82.4%). The commonest tumour biology was T3 (n = 48), N0 (n = 55), and M0 (n = 75). Thirty-four, 39, and 34 participants had moderate-severe distress in Depression, Anxiety, and Stress, using DASS-21. Forty-one had a score of 16 or higher, qualifying for a diagnosis of depression using the BDI.

There were statistically significant correlations between Beck’s score and all three subscales of DASS, and between the three subscales of DASS. A backward logistic regression model for significant disability from CRC diagnosis in any of the scales was statistically significant. Part-time employment and retirement, and presence of metastasis increased the risk.

Conclusion: CRC patients in Sri Lanka experience significant psychological distress. Metastatic diseasee and financial constraints were identified to adversely affect these.

Recurrent Rectal Prolapse: Re-Recurrence Rate and Risk Factors

Giulia De Carlo, MD, Mikhael Belkovsky, MD, Tracy L Hull, MD, FACS, Anna Spivak, DO

Cleveland Clinic, Cleveland, OH

Introduction: Surgery for rectal prolapse has a high rate of recurrence, around 20 to 30%. Those cases typically require recurrent rectal prolapse (RRP) surgery. There are no guidelines to support surgical decision-making for RRP surgery. We aim to evaluate the re-recurrence rate and to identify re-recurrence risk factors.

Methods: We conducted a multicentric IRB approved retrospective study in two high-volume tertiary referral centers from 2010 to 2023. To mitigate selection bias, we included patients who underwent RRP surgery to treat the first recurrence. We excluded patients who underwent RRP surgery to treat a second recurrence or over. Univariate and multivariate analyses were performed to select independent re-recurrence risk factors.

Results: Of 129 patients who met the inclusion criteria, 48 (37%) underwent a perineal approach and 81 (63%) underwent an abdominal approach. The overall re-recurrence rate was 26.4% (34 cases). On univariate analysis, factors associated with re-recurrence were: age, baseline constipation, shorter time since previous prolapse surgery, perineal approach at previous prolapse surgery, and perineal approach at RRP surgery. On multivariate analysis, perineal approach at RRP surgery was the only risk factor independently associated with re-recurrence (OR 4.63, CI 1.52, 15.5, p = 0.009). Performing subgroup analysis of patients who underwent abdominal approaches, no differences in re-recurrence rate were found comparing open vs minimally invasive procedures (p = 0.188).

Conclusion: Our study identified the perineal approach at RRP surgery as a significant risk factor for re-recurrence. We recommend that surgeons should consider an abdominal approach to treat RRP to minimize rectal prolapse re-recurrence.

Risk Factors for Withdrawal of Care after Colorectal Surgery

Rebecca Tang, MD, Grace C Lee, MD, Rocco Ricciardi, MD, FACS

Massachusetts General Hospital, Boston, MA

Introduction: Risk factors for mortality after colorectal surgery have been described and used to guide surgical decision-making and counseling. Although postoperative mortality captures the most severe complications and failure to rescue, examining patterns of withdrawal of care provides a more nuanced and patient-facing understanding of these complicated postoperative courses. This study therefore seeks to identify risk factors for postoperative withdrawal of care after colorectal surgery.

Methods: Patients who underwent colorectal surgery in the American College of Surgeons (ACS) National Surgical Quality Improvement Program (NSQIP) from January 2021 through December 2021 were identified for analysis. Patients who underwent anorectal surgery were excluded. Risk factors for postoperative withdrawal of care were identified using multivariable logistic regression.

Results: 63,789 patients were identified who underwent colorectal surgery. Of these, 2,060 (3.2%) patients withdrew care postoperatively. Significant risk factors for postoperative withdrawal of care included age 65 years or greater (AOR 2.30, p < 0.001), functional status (AOR 2.17, p < 0.001), metastatic cancer (AOR 4.02, p < 0.001), urgent or emergent surgery (AOR 1.78, p < 0.001), postoperative reintubation (AOR 2.16, p < 0.001), new ventilator dependence (AOR 1.50, p = 0.002), postoperative renal failure (AOR 2.79, p < 0.001), and postoperative sepsis (AOR 2.04, p = 0.005) or septic shock (AOR 4.27, p < 0.001). Preoperative NSQIP morbidity and mortality scores, preoperative WBC, and postoperative reoperation were not predictive of withdrawal of care.

Conclusion: Increased age, decreased functional status, operative acuity, and major postoperative complications including respiratory failure, renal failure, and sepsis are significantly associated with withdrawal of care after colorectal surgery.

Robotic vs Laparoscopic Surgery for Colon Cancer: Short-term Outcomes of a Randomized Trial

Marco Milone, MD, PhD, FACS, FEBS, MIS, MIS

University of Naples Federico II, Naples, Italy

Introduction: No strong results certifying the superiority of robotic surgery have been produced so far in current literature. The implementation of robotic surgery for the treatment of colonic cancer should be based on confirmation of superior perioperative outcomes.

Methods: An interim analysis of an interventional multicenter randomized trial has been designed to compare short-term outcomes of patients who underwent laparoscopic versus robotic right or left colectomy for cancer from January 2017 to December 2019.

Results: A total of 323 patients were analyzed, whereof 142 received laparoscopic surgery and 181 robotic assisted surgery. 109 complications occurred in the short-term period, without differences between the two groups (p = 0,503), neither in intraoperative nor post-operative complications. Grade III complications have been found to be higher in the laparoscopic group (p = 0,045). Oncological radicality was similar in both groups. Functional recovery after surgery was better in the robotic group (p = 0,037) with a lower time to mobilization (p = 0,023). In the subgroup of right colectomy numbers of Grade III complications and lymph nodes retrieved were better for those undergoing robotic surgery (p = 0,008 and p = 0,009). Functional recovery was better for those undergoing robotic surgery in the subgroup of left colonic cancer (p = 0,009).

Conclusion: Robotic surgery is able to provide few severe complications and better post-operative recovery after colonic resections. The advantage of robotic platform has been maximized in right colonic resections.

Safety of Laparoscopic and Robotic Surgery for Elderly Patients with Colorectal Cancer: A Multicenter Retrospective Study

Takehito Yamamoto, MD, PhD, Koya Hida, MD, PhD, Hiroki Hashida, MD, PhD, FACS, Ryo Matsusue, MD, PhD, Ryo Takahashi, MD, PhD, Hiroaki Terajima, MD, PhD, Kazutaka Obama, MD, PhD, FACS

Department of Gastroenterological Surgery and Oncology, Medical Research Institute Kitano Hospital, Osaka, Japan; Department of Surgery, Graduate School of Medicine, Kyoto University, Kyoto, Japan; Department of Surgery, Kobe City Medical Center General Hospital, Hyogo, Japan; Department of Gastrointestinal Surgery, Tenri Yorozu Hospital, Tenri City, Nara, Japan; Department of Surgery, Kyoto Katsura Hospital, Kyoto, Japan

Introduction: Minimally-invasive surgery for colorectal cancer has been globally spreading. However, the safety for elderly patients has not been thoroughly examined.

Methods: Colorectal cancer patients who underwent laparoscopic or robotic surgery in 19 institutions in Japan between 2018 and 2023 were enrolled. Focusing on patients ≥80 years, the risk factors for postoperative complications were investigated. The severity of complications was evaluated by the Comprehensive Complication Index (CCI) as continuous variables ranging from 0 to 100.

Results: A total of 7303 patients were enrolled. In the group ≥80 years (n = 1665, 22.8%), postoperative complications (Clavien-Dindo ≥grade II) occurred in 210 patients (12.6%). Univariate analysis revealed that super-elderly (≥90 years), male, elevated ASA score, rectal cancer, robotic surgery, longer operation time, and increased blood loss were significantly correlated with the occurrence of complications. Multivariate logistic regression analysis revealed that age ≥90 years (odds ratio [OR]: 1.92, 95% confidence interval [CI]: 1.18-3.14, P = 0.009), rectal cancer (OR: 1.71, 95% CI: 1.22-2.39, P = 0.002), operation time ≥300 minutes (OR: 1.48, 95% CI: 1.05-2.07, P = 0.025), and blood loss ≥100 ml (OR: 2.00, 95% CI: 1.37-2.93, P < 0.001) independently affected the occurrence of complications. The CCI increased proportionally with the number of risk factors (0 factor: 8.7, 1 factor: 12.2, 2 factors: 20.9, 3 factors: 20.9, 4 factors: 39.8; median).

Conclusion: For elderly colorectal cancer patients aged 80 and above, surgeons should effectively shorten operation time and control blood loss. Furthermore, super-elderly patients require greater attention due to their high risk of complications.

Single Center Review of Patients with Rectal Cancer Undergoing Nonoperative Protocols

Alexander M Zorrilla, MD, Julian A Sanchez, MD, FACS, Marie S Dessureault, MD, FACS, Hope Hahl, ARNP, Heather W Chastain, PA, Amalia Stefanou, MD, FACS

University of South Florida, Tampa, FL; Moffitt Cancer Center, Tampa, FL

Introduction: Total neoadjuvant treatment (TNT) is becoming standard of care in rectal cancer treatment with patients increasingly having a complete clinical response (cCR) and avoiding surgery.

Methods: A retrospective review of a single NCI designated institutional ongoing database was performed for patients being followed with a cCR after receiving TNT.

Results: Between 2019 - 2023, 50 patients have achieved a cCR and elected to pursue nonoperative surveillance. The average age at diagnosis was 60.5 years, and 58% were male. Patients were followed for a mean of 10.4 months. All tumors were adenocarcinoma and mismatch-repair proficient. Tumor locations were separated into three groups and dependent on distance from anal verge. 20% of patients had high rectal tumors (>10 cm), 34% had middle rectal tumors (5-10 cm), and 46% of patients had low rectal tumors (0-5 cm). 34 patients received complete TNT treatment, with most deficiencies due to dose reduced chemotherapy. 52% of patients received consolidative chemotherapy and 44% received induction chemotherapy, and the remaining 2 patients had short course radiation. 4 patients developed distant metastasis without local recurrence (two lung, one liver, and one both lung and liver). Of the 50 patients followed, 12% had local biopsy proven local regrowth of rectal tumor requiring surgery. The mean time for regrowth diagnosis was 11.5 months.

Conclusion: Nonoperative surveillance for patients achieving a cCR after TNT may be an appropriate pathway for those attempting to avoid morbidity associated with rectal cancer surgical intervention.

Sociodemographic and Patient Characteristics Associated with Colon Cancer in Young Adults under Age 45 Years

Kelley Chan, MD, Bryan Palis, MA, Joseph Cotler, PhD, Xuan Zhu, MPH, Anani Hoegnifioh, MS, Clifford Y Ko, MD, FACS

American College of Surgeons, Chicago, IL

Introduction: Although colon cancer incidence and mortality have declined for older adults, both have increased for young adults under the age of 45 years. The objective of this study was to evaluate sociodemographic and patient characteristics associated with colon cancer in young adults compared to older adults.

Methods: This retrospective, observational study identified young adults (18-44 years) and older adults (45 years and older) diagnosed with colon cancer in 2015-2021 from the National Cancer Database. Prevalence by race and ethnicity was compared to 2021 US Census Bureau demographic data. Multivariable logistic regression adjusted for sociodemographic, patient, and tumor variables, predicted odds for colon cancer in young adults compared to older adults.

Results: Of 318,951 patients with colon cancer, 16,974 (5.6%) were young adults and 301,977 (94.4%) were older adults. Compared to the total US population, a higher proportion of young adults with colon cancer were non-Hispanic Black (16.9% vs 12.1%). After adjustment, colon cancer in young adults, was associated with obesity (OR 1.88, 95% CI 1.77-1.99), family history of gastrointestinal malignancy (OR 2.35, 95% CI 2.02-2.73), inflammatory bowel disease (OR 3.50, 95% CI 3.19-3.84), and symptoms such as abdominal pain (OR 1.63, 95% CI 1.51-1.77) or rectal bleeding (OR 1.19, 95% CI 1.09-1.29), compared to older adults.

Conclusion: Efforts to support the development of risk assessments utilizing sociodemographic and patient characteristics to identify adults under age 45 years with above-average risk of colon cancer may reduce the incidence and mortality of colon cancer in young adults.

Socioeconomic and Clinicopathologic Disparities in Early Onset Colon Adenocarcinoma

Subhadeep Paul, MD, Madison H Thrower, BS, Terry C Lairmore, MD, FACS

Ochsner LSU Shreveport Health, Shreveport, LA

Introduction: Annual incidence rates of early-onset colon adenocarcinoma (EOCA) have increased over the last decade. There is a lack of literature identifying risk factors for EOCA. The objective of our population-based analysis included identifying the socioeconomic and clinicopathologic disparities associated with EOCA.

Methods: After obtaining IRB approval, we queried the SEER database for all adult patients diagnosed with colon adenocarcinoma from 2010-2019. Clinicopathologic data was correlated to factors associated with age at diagnosis. Logistic regression utilizing stepwise selection was performed and univariate/multivariate linear regression models were generated. Overall survival (OS) using Kaplan-Meier analysis and log-rank test were performed. All statistical tests were performed through SPSS.

Results: Overall, 8127 patients (5.21%) were diagnosed with EOCA in the SEER database. Among that population, patients were diagnosed with comparatively more advanced disease stage (stage IV, n = 2435, 30%, p < 0.01). Significantly higher rates of Hispanic, Asian and Black patients were noted compared to Non-Hispanic White patients (47.3% vs 33.6%, p < 0.01). Primary disease site was in the sigmoid and descending colon (61.4%, p < 0.01). EOCA cohort was associated with lower median family income (69.6%, p < 0.01), rural cancer care (10.5%, p < 0.01), and uninsured status (22.4%, p < 0.01). Through KM analysis, EOCA cohort had decreased OS (33 months, log-rank p < 0.01).

Conclusion: Significant socioeconomic and clinicopathologic disparities exist regarding EOCA. Our analysis identified that minority races, lower income families and patients from rural counties had disproportionally higher representation in EOCA cohort. Identifying socioeconomic disparities can lead to more targeted screening programs based on demographics and improve treatment outcomes.

Surgical Management of Early-Onset Colorectal Cancer (EOCRC) with Liver Metastases Is Associated with Improved Survival

Faris S Almadi, MD, Jacob G Mansell, BS, Mikhael Belkovsky, MD, Federico N Aucejo, MD, Alok Khorana, MD, Smitha Krishnamurthi, MD, Josh Sommovilla, MD, Michael A Valente, DO, FACS, Scott R Steele, MD, FACS, David Liska, MD, FACS

Department of Colorectal Surgery, Digestive Disease Institute, Cleveland Clinic, Cleveland, OH; Department of Liver Transplantation, Digestive Disease Institute, Cleveland Clinic, Cleveland, OH; Department of Hematology and Medical Oncology, Taussig Cancer Center, Cleveland Clinic, Cleveland, OH; Department of Hematology and Medical Oncology, Taussig Cancer Institute, Cleveland Clinic, Cleveland, OH

Introduction: The prevalence of early-onset colorectal cancer (EOCRC) is rising and disproportionally associated with synchronous liver metastases. EOCRC patients undergo intensive medical and surgical interventions, likely due to physiological reserve and treatment goals. However, studies have questioned whether such treatments result in better oncologic outcomes. We hypothesize that EOCRC patients with isolated liver metastases receiving multi-agent chemotherapy and resection of primary and metastatic tumors have improved overall survival (OS) compared to treatment with non-curative-intent.

Methods: CRC patients diagnosed under age 50 with isolated synchronous liver metastases treated at a single institution from 2010-2020 were included. Patients were grouped based on treatment modalities: chemotherapy alone (Group 1), chemotherapy and primary tumor resection (Group 2), and chemotherapy with primary and metastatic tumor resection (Group 3). Survival analysis was performed by Kaplan-Meier Curves.

Results: Fifty-seven patients were included with a mean follow-up of 2.97 years: 5 in Group 1, 14 in Group 2, and 38 in Group 3. No significant differences were found in sex, primary tumor location, chemotherapy, ASA, Charlson Comorbidity Index, number, size, or location of metastases. Bevacizumab use varied significantly between groups (p < 0.001). EOCRC patients treated with chemotherapy and resection of primary and metastatic tumors had significantly improved 5-year OS rate at 72.4% compared to patients treated with surgery of the primary or chemotherapy alone.

Conclusion: Selection of EOCRC patients with isolated liver metastases for intensive curative-intent medical and surgical therapies is associated with long-term survival. Evaluation by multidisciplinary teams is crucial for optimal treatment and outcomes.

Temporal Trends and Factors Associated with Declining Surgery in Patients with Resectable Colon Cancer

Totadri Dhimal, MD, Bailey Hilty, MD, Anthony Loria, MD, Paula Cupertino, PhD, Fergal Fleming, MD, FACS

University of Rochester, Rochester, NY

Introduction: Colorectal cancer is the third leading cause of cancer mortality in the US and oncologic resection is the foundation of potential cure. Despite this, a small group patients decline potentially curative surgery. We sought to characterize trends in declining surgery and identify factors associated with declining surgery.

Methods: We identified patients with analytic stage I-III, including unknown stage, colonic adenocarcinoma captured by the National Cancer Database between 2012-2021. Sociodemographic, clinical, and treatment-related factors were collected and analyzed using a multivariable logistic regression to identify factors associated with declining surgery.

Results: Overall 446,159 patients (115,944 analytic stage I, 115,381 stage II, 157,144 stage III, 17,690 unknown analytic stage) were included and 3,029 declined surgery. Over the study, the rates of declining surgery per 100,000 patients with potentially resectable colon cancer rose. In a multivariable analysis, older age, biological females, Black race, lower income, and insurance status were associated with declining surgery whereas higher stage tumors were associated with undergoing surgery.

Conclusion: Rates of declining surgery for colon cancer are rising over the last decade and importantly, disaggregation of the data demonstrates racial and socioeconomic disparities in declining surgery. Given the lack of other curative therapy, understanding motivations for forgoing surgery is imperative for combatting disparities through targeted interventions and meaningful risk-benefit discussions. Additionally, further study of the clinical course for patients who decline surgery is essential to appropriately counsel patients regarding risks, particularly the unique risk of requiring emergent surgery for perforation or obstruction.

The Impact of Operative Start Time on the Outcomes of Minimally Invasive Colectomy

Marco Bertucci Zoccali, MD, FACS, Osama Jabi, MD, Hyemin B Choi, MD, Dilara Khoshknabi, MD, James M Church, MD, FACS, Pokala R Kiran, MD, FACS

Columbia University Irving Medical Center, New York, NY

Introduction: Minimally invasive surgery has significantly transformed the field of colorectal surgery. Due to various factors, there are instances where conversion to open surgery is necessary to safely complete the procedure. While it seems intuitive that a later start time might adversely affect outcomes, few reports address this concern. This study investigates the relationship between surgical start time and outcomes.

Methods: From a prospective institutional outcomes database, patients who underwent minimally invasive elective colectomy for any indication between 2012 and 2023 were included. The cohort was divided into a morning and an afternoon group based on whether the start time was before or after 12 pm. Demographics, comorbidity, intraoperative variables, and postoperative outcomes were retrieved. Univariate association between operative start time and outcomes was assessed.

Results: Of 1945 colectomies, 956 (49%) occurred in the morning and 989 (51%) in the afternoon. The afternoon group had older patients, more females, and higher rates of smoking and cardiac comorbidities. Notably, this group experienced higher conversion rate to open surgery (14.1% vs 8.4%, p = 0.001), longer operative time (median 3.1 vs 2.8, p = 0.001), and increased surgical site infections (3.2% vs 1.7%, p = 0.02), with extended hospital stay. However, rates of intraoperative complications, anastomotic leak, ileus, readmissions, and reoperations were comparable between groups.

Conclusion: Our findings suggest a significant correlation between surgical start times and outcomes for abdominal colorectal procedures. While surgeon- and operating room environment-related factors may play a role, further studies are warranted to identify potentially modifiable factors explaining the observed findings.

The Influence of Surgical Subspecialization on Outcomes in Emergency Colorectal Surgery: A Comprehensive Systematic Review and Meta-Analysis

Bruna Oliveira Trindade, Rafael R H Martin, MD, Patricia Marcolin, MD, Ivonne S Zuniga Jimenez, MD, Mariana P Silva, Fernando Lambreton Hinojosa, MD

Universidade Federal de Ciências da Saúde de Porto Alegre, Porto Alegre, Brazil; Beth Israel Deaconess Medical Center, Boston, MA; Universidade Federal da Fronteira Sul, Passo Fundo, Brazil; Universidad Nacional Autónoma de Nicaragua, Managua, Nicaragua; Escola Bahiana de Medicina e Saúde Pública, Lauro De Freitas, Brazil; University of Texas Medical Branch, Galveston, TX

Introduction: Major abdominal surgery conducted in an emergency setting is recognized to carry a significant risk of mortality. However, the influence of surgical subspecialization on outcomes in emergency colorectal surgery remains a subject of discussion, with conflicting reports. Prior studies have suggested that the surgeon’s specialization may play a role in predicting patient outcomes in these cases.

Methods: A comprehensive search of PubMed, Embase, and Cochrane databases was conducted to identify studies comparing emergency colorectal surgery outcomes between colorectal surgeons and non-colorectal surgeons. The primary outcomes were (1) 30 days mortality; (2) stoma formation; (3) reoperation; and (4) anastomotic dehiscence. Heterogeneity was examined with I2 statistics. Odds ratios (ORs) and their 95% confidence intervals (CIs) were computed with the use of a random-effects model.

Results: From a total of 1.915 studies, we included 26 cohorts with 92.786 patients, of whom 37.826 (40.8%) underwent surgery with a colorectal surgeon. The 30-day mortality rate (OR 1.44; 95% CI 1.26-1.66; p < 0.0001), reoperation rate (OR 1.41; 95% CI 1.05-1.90; p = 0.02) had statistically significant higher in patients treated by non-colorectal surgeon. Similarly, anastomotic dehiscence was more frequent in the non-colorectal surgeon group (OR 1.57; 95% CI 1.19-2.09; p = 0.002). Stoma formation rate (OR 1.32; 95% CI 0.99-1.77; p = 0.06) did not show a statistically significant difference between the groups.

Conclusion: This comprehensive systematic review and meta-analysis provides further evidence that colorectal surgeons yield improved outcomes for patients undergoing emergency colorectal surgery.

Time to Definitive Treatment in Care Coordination for Rectal Cancer Patients

Alexis L Woods, MD, Axenya Kachen, MPH, Rebeka Dejenie, BS, Ankit Sarin, MD, MHA, Sean Flynn, MD, Robert J Kucejko, MD, Erik R Noren, MD, Miquell Miller, MD, MSc

University of California, Davis, Sacramento, CA; University of Nevada, Reno, Reno, NV

Introduction: Timely coordination of rectal cancer treatment is essential, and the standard of care is within 60 days. Identifying patients with delays to definitive treatment and characterizing barriers to care is imperative for targeted interventions.

Methods: A retrospective review of rectal cancer patients at our tertiary cancer center from 2013-2023 was performed. Patients were stratified by time from biopsy date to initiation of definitive treatment (neoadjuvant chemoradiation or surgery) ≤60 days and >60 days. Chi-square analysis and multivariable logistic regression were done to analyze the time to definitive treatment and patient sociodemographic data.

Results: There were 355 rectal cancer patients during the study period, and 50.4% (179/355) had initiation of definitive treatment within 60 days. On univariate analysis, factors significantly associated with definitive treatment >60 days were sex (p = 0.049), age (p = 0.002), insurance (p = 0.002), and distance from hospital (p = 0.016). On multivariable analysis, factors more likely to have a delay in treatment >60 days were female sex (OR 1.60 [95% CI 1.01-2.55], p = 0.05), having Medicaid (OR 1.76 [95% CI 1.00, 3.12], p = 0.05) or Medicare insurance (OR 2.34 [95% CI 1.97, 4.62], p = 0.01), and living >100 miles from the hospital (OR 2.53 [95% CI 1.08-6.11], p = 0.03). Race, ethnicity, and social deprivation index were not significantly associated with delays to treatment.

Conclusion: In this retrospective study, 50% of rectal cancer patients referred to our tertiary cancer center are initiating definitive treatment after 60 days. Female sex, Medicare/Medicaid insurance, and living >100 miles from the hospital are significantly associated with delays to definitive treatment. Further research and targeted interventions are needed to improve timely coordination of care.

Use of Virtual Reality Simulator as a Tool to Understand Colorectal Anatomy and Medical Students’ Interest in Colorectal Surgery

Narjes Sweis, MD, Marhama Zafar, Gerald Gantt, MD, FACS, Amelia M Bartholomew, MD, FACS, Alejandra Perez-Tamayo, MD, Mohamad A Abdulhai, Anders Mellgren, MD, FACS, Vivek Chaudhry, MBBS, FACS

University of Illinois, Chicago, IL; Chicago, IL; Medford, MA

Introduction: Pelvic anatomy education is being revolutionized by virtual reality (VR), moving beyond traditional methods like lectures and cadaver dissections. VR offers medical students an immersive learning experience with 3D visualizations and interactive simulations tailored to individual patients, allowing them to view anatomical structures from any angle. Our study investigates how VR’s 3D visualization affects medical students’ understanding of pelvic anatomy and their interest in colorectal surgery and surgical careers.

Methods: At an urban academic center, 24 M1-M3 students were recruited. They engaged with VR pelvic models, based on CT and MRI scans from rectal cancer patients scheduled for surgery, using a 3D headset. We assessed changes in their perceived anatomy comprehension, confidence in participating in pelvic surgery, and interest in a career in colorectal surgery through pre- and post-activity surveys on a Likert scale.

Results: The study showed improvements in students’ perceived understanding of pelvic anatomy, with mean scores rising from 2.76 to 4.75. Confidence in pelvic surgery participation increased, with scores going from 2.57 to 3.88. Interest in colorectal surgery careers also grew, from 1.57 to 3.63. Using the Wilcoxon signed-rank test, 7 out of 8 post-activity scores significantly improved, each with a p-value of <0.001.

Conclusion: Integrating VR into medical education enhances the students’ perceived pelvic anatomy understanding and sparks interest in colorectal surgery, proving to be a valuable teaching tool. This innovation provides increased interest in surgical careers with a specific increased interest in colorectal surgery.

Using Artificial Intelligence-Enhanced White-Light Colonoscopy for Predicting Deeply Invasive Colorectal Cancer: A Diagnostic Accuracy Meta-Analysis

Muhammed Elhadi, MBBCh, MSc, Eric M Haas, MD, FACS, FASCRS

Houston Methodist Hospital, Houston, TX

Introduction: Colorectal cancer (CRC) presents significant health challenges, with late detection of invasive stages being a major barrier to effective treatment. While white-light colonoscopy is standard, its accuracy in identifying advanced cancer stages is limited. Artificial Intelligence (AI) integration into diagnostic processes shows promise, necessitating comparing its performance with that of traditional expert methods. This study evaluates the accuracy of AI-enhanced white-light colonoscopy in detecting CRC invasiveness compared to conventional diagnostics by endoscopic experts.

Methods: A systematic review was conducted in May 2023, sourcing studies from databases such as PubMed, EMBASE, and Cochrane Library. The review focused on studies comparing the predictive performance of AI with white-light colonoscopy against the judgment of at least three endoscopic experts. Statistical analysis was performed using R software, with the mada package pooling various diagnostic metrics.

Results: From 5 studies with 528 patients (220 with invasive CRC), AI showed a sensitivity of 78.6% (95% CI: 67.3-86.8%, I2 = 64.3%), specificity of 89.9% (95% CI: 82.1-94.5%, I2 = 68.9%), a false-positive rate of 10.1% (95% CI: 5.5-17.9%), and a diagnostic odds ratio of 32.72 (95% CI: 13.54-79.06). Positive and negative Likelihood Ratios were 7.78 (95% CI: 4.23-14.29) and 0.24 (95% CI: 0.15-0.38), indicating superior efficacy in excluding CRC’s invasiveness.

Conclusion: AI-enhanced colonoscopy improves CRC invasiveness prediction over traditional methods. This technology could play a pivotal role in early surgical intervention and the management of CRC. However, the moderate sensitivity and result heterogeneity underscore the need for further AI algorithm research and improvements for broader clinical adoption.

Ventral Mesh Rectopexy (VMR) Variations in Technique and Care Process: A Multicenter Study

Ellen Coeckelberghs, PhD, Mohamed Abasbassi, MD, Albert M Wolthuis, MD, FACS, Gabriele Bislenghi, MD, PhD, Kris Vanhaecht, PhD, Deborah Seys, PhD, Andre J L D’Hoore, MD, FACS, (Hon)

KU Leuven, Leuven, Belgium; AZ Ostend, Oostende, Belgium; University Hospitals Leuven, Leuven, Belgium

Introduction: Ventral Mesh Rectopexy (VMR) was first described in 2004 to improve surgical outcomes in patients with rectal prolapse. This study explores the variation in diagnostic work-up, perioperative management and surgical technique of VMR. The study aims to 1) benchmark key performance indicators 2) explore intra- and inter-hospital variation in care.

Methods: This observational, cross-sectional multicenter study was performed in 14 Flemish hospitals. Twenty consecutive patients undergoing VMR per hospital were included. Hospital-level quality of care was assessed using disease-specific process and outcome indicators that were predefined by the collaborative. Clinical and radiological data were collected, using a structured audit tool. Descriptive analyses were performed.

Results: A total of 280 female patients were included. Mean age was 62 ± 14 years. Eighteen percent of all patients had a total rectal prolapse, the most common indication was internal rectal prolapse and rectocele (40%). Sixty percent of the procedures were performed laparoscopically and 40% robotically. Considerable intra- and inter-hospital variation was observed. 15% of patients had mechanical bowel preparation. Only 3% of the procedures were performed as SDD, 47% of the patients remained 1 day and 50% ≥2 days. In one hospital 35% of procedures were performed in day-care. Only 2 patients experienced postop morbidity and 3 patients needed readmission within 30 days after surgery.

Conclusion: There is significant variance in the perioperative management and surgical technique of VMR within Flanders. This could reflect ongoing controversies related to diagnostics, surgical technique and perioperative management. This explorative data underscores the need to further standardize VMR.

Visceral Fat Area (VFA) Analysis Is a More Sensitive Metric than BMI for Determining Obesity Related Perioperative Outcomes in Colorectal Procedures

Ian A Orantes-Orellana, MS, BS, Charles M Bowen, MS, BS, Anthony P D’Andrea, MD, MPH, Pamela Daher, MD, FACS, Gautam Edhayan, MD, Peter Young, MD, Uma R Phatak, MD, FACS

University of Texas Medical Branch, Galveston, TX

Introduction: Obesity plays a striking role in many human diseases, contributing to morbidity and mortality. While body mass index (BMI) remains valid for objectively indexing obesity, it neglects to account for frailty, frame size, and muscle mass, which may confound BMI accuracy. Therefore, other metrics are necessary to quantify body habitus accurately, such as visceral fat area (VFA) measurements obtained from pre-operative CT scans. This study aimed to assess the usefulness of VFA compared to BMI as a predictor of surgical outcomes for colectomies.

Methods: A single-center retrospective review of 328 patients consented for elective colectomy performed between 1/1/2014 and 12/31/2021. Obesity was determined using two body habitus metrics: Body Mass Index (>30 kg/m2) and Visceral Fat Area (>130 cm2).

Results: Results include 129 (39.3%) obese patients under the BMI classification and 217 (66.2%) obese patients using the VFA classification. Regardless of metric, obese patients had more estimated blood loss and longer operation times compared to non-obese patients. Patients classified as obese using VFA had a significantly higher incidence of cardiovascular complications (4.15% vs. 0.0%; P = 0.03) and overall postoperative complications (29% vs. 18.9%, p = 0.047) compared to their non-obese counterparts with no significant difference seen using BMI.

Conclusion: Compared to BMI, the VFA metric is just as sensitive to intraoperative complications associated with obesity, such as estimated blood loss and length of operation. Furthermore, VFA may shed light on possible postoperative cardiac and overall complications in patients undergoing a colectomy, but further studies are needed.

© 2024 by the American College of Surgeons. Published by Wolters Kluwer Health, Inc. All rights reserved.
Colon and Rectal Surgery : Journal of the American College of Surgeons (2024)
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