Bashar Safar

Background and Objectives: Little is known about the relationship between neoadjuvant chemotherapy (NAC) and perioperative morbidity for patients undergoing combined resection of rectal cancer and sLM. The purpose of this study is to determine the impact of NAC on 30‐day morbidity for patients who undergo combined resection of primary rectal cancer and sLM.Materials and Methods: A retrospective cohort study of patients undergoing combined resection of primary rectal cancer and sLM between 2016 and 2020 at participating NSQIP hospitals. Multivariate logistic regression models were used to assess the relationship between NAC and 30‐day morbidity rates.Results: Among 878 patients who underwent combined resection of primary rectal cancer and sLM, 672 (76.54%) received NAC. There were no significant differences in the rates of 30‐day overall morbidity between patients who received NAC and those who did not (37.65% vs. 37.68%, p = 0.95). On adjusted analysis, there was no association between receipt of NAC and rates of overall morbidity (adjusted OR = 1.10, 95% CI 0.78−1.56, p = 0.95).Conclusions: The receipt of NAC does not appear to be associated with increased perioperative morbidity in patients undergoing combined resection of primary rectal cancer and sLM.

Aim: The purpose of this study is to assess US operative trends and outcomes of ulcerative colitis (UC) patients undergoing total proctocolectomy with ileal pouch−anal anastomosis (TPC‐IPAA) or completion proctectomy with IPAA (CP‐IPAA). Methods: Adult UC patients who underwent TPC‐IPAA or CP‐IPAA were analysed retrospectively using the 2016–2020 American College of Surgeons National Surgical Quality Improvement Program database. Factors associated with 30‐day overall and serious morbidity were identified using multivariable logistic regression. Results: A total of 1696 patients were identified, with 958 patients (56.5%) undergoing TPC‐IPAA and 738 (43.5%) undergoing CP‐IPAA. A greater proportion of TPC‐IPAAs were performed each year (except in 2019) compared to CP‐IPAAs over the study period ( P trend P = 0.076) and serious morbidity (14.3% vs. 12.7%, P = 0.352) between TPC‐IPAA and CP‐IPAA patients. Robotic TPC‐IPAA had no differences in complications compared to laparoscopic and open approaches. Robotic CP‐IPAA had higher anastomotic leak rates and longer hospital length of stay compared to laparoscopic and open approaches. Obesity was associated with increased odds of overall and serious morbidity for patients who underwent TPC‐IPAA. Steroid/immunosuppressive therapy was associated with increased odds of overall and serious morbidity for patients who underwent CP‐IPAA. Conclusions: Obese patients should be informed of their increased morbidity risk and offered counselling on weight loss prior to surgery when feasible. Patients on steroid/immunosuppressive therapy within 30 days preoperatively should not undergo CP‐IPAA or should delay surgery until they can be safely off those medications.

BACKGROUND: The worsening opioid epidemic has led to an increased number of surgical patients with chronic preoperative opioid use. However, the impact of opioids on perioperative outcomes has yet to be fully elucidated. The purpose of this study was to assess the association between preoperative opioid dose and surgical outcomes among colectomy patients. METHODS: Adult colectomy patients in the IBM MarketScan database (2010–2017) were stratified based on preoperative opioid dose, calculated as the average opioid dose in morphine milligram equivalents (MME) in the 90 days prior to surgery: 0 MME, 1 to 49 MME, and 50 or more MME. The association between preoperative opioid dose and anastomotic leak, the primary outcome of interest, as well as other postoperative complications, was assessed using multivariable regression. RESULTS: Among 45,515 adult colectomy patients, 71.4% did not use opioids (0 MME), 27.4% had an opioid dose between 1 and 49 MME, and 1.2% had an opioid dose at or above 50 MME. Patients with preoperative opioid use exhibited a higher incidence of anastomotic leak (0 MME: 4.8%, 1–49 MME: 5.5%, ≥50 MME: 8.3%; p trend = 0.001). Multivariable analysis demonstrated a dose–response relationship between preoperative opioids and surgical outcomes, as the odds of anastomotic leak worsened with increasing opioid dose (1–49 MME: OR 1.19, 95% CI 1.08–1.31, p < 0.001; ≥50 MME: OR 1.64, 95% CI 1.20–2.24, p = 0.002). Similar dose–response relationships were seen after risk-adjustment for lung complications, pneumonia, delirium, and 30-day readmission (p < 0.05 for all). CONCLUSIONS: Providers should exercise caution when prescribing opioids preoperatively, as increasing doses of preoperative opioids were associated with worse surgical outcomes and higher 30-day readmission among adult colectomy patients.

Background: The prognostic implication of mutant KRAS (mKRAS) among patients with primary disease in the rectum remains unknown.Methods: From 2000 to 2018, patients undergoing hepatectomy for colorectal liver metastases at 10 collaborating international institutions with documented KRAS status were surveyed.Results: A total of 834 (65.8%) patients with primary colon cancer and 434 (34.2%) patients with primary rectal cancer were included. In patients with primary colon cancer, mKRAS served as a reliable prognostic biomarker of poor overall survival (OS) (hazard ratio [HR]: 1.58, 95% CI 1.28‐1.95) in the multivariable analysis. Although a trend towards significance was noted, mKRAS was not found to be an independent predictor of OS in patients with primary rectal tumors (HR 1.34, 95% CI 0.98‐1.80). For colon cancer, the specific codon impacted in mKRAS appears to reflect underlying disease biology and oncologic outcomes, with codon 13 being associated with particularly poor OS in patients with left‐sided tumors (codon 12, HR 1.56, 95% CI 1.22‐1.99; codon 13, HR 2.10 95% CI 1.43‐3.08;). Stratifying the rectal patient population by codon mutation did not confer prognostic significance following hepatectomy.Conclusions: While the left‐sided colonic disease is frequently grouped with rectal disease, our analysis suggests that there exist fundamental biologic differences that drive disparate outcomes. Although there was a trend toward significance of KRAS mutations for patients with primary rectal cancers, it failed to achieve statistical significance.

Purpose There has been a noted reluctance to offer laparoscopic surgery to Crohn’s Disease patients due to the potential risks, and high rate, of converting the procedure to open. The purpose of this study was to compare clinical outcomes between Crohn’s Disease patients undergoing a planned open colectomy, to those undergoing a laparoscopic colectomy that was converted to open. Methods Crohn’s Disease patients undergoing an elective colectomy were identified using the ACS-NSQIP database (2012–2019). Patients were stratified based on operative approach: open, laparoscopic, and laparoscopic converted to open. Multivariable logistic regression was used to assess the impact of conversion to open on overall and serious postoperative morbidity. Results Among 8039 elective colectomies, 40.5% were performed open, 46.9% were completed laparoscopically, and 12.6% were converted to open. The conversion rate among all laparoscopic cases was 21.3%. On unadjusted analysis, conversion to open demonstrated similar rates of overall morbidity (P = 0.355) and serious morbidity (P = 0.724) compared to a planned open approach. On multivariable analysis, conversion to open was not associated with increased odds of overall morbidity (OR 1.12, 95% CI 0.94–1.30, P = 0.238) or serious morbidity (OR 1.20, 95% CI 0.98–1.46, P = 0.074), when compared to an open approach. Conclusion Among Crohn’s Disease patients, cases converted from laparoscopic to open exhibited similar outcomes as a planned open approach. Despite the limitations associated with this retrospective study, our findings suggest that laparoscopic surgery may be safely pursued among Crohn’s Disease patients, as the risks of conversion are potentially balanced by the benefits of laparoscopic surgery.

Background Robotic surgery is attractive for resection of low rectal cancer due to greater dexterity and visualization, but its benefit is poorly understood. We aimed to determine if operative approach impacts radial margin positivity (RMP) and postoperative outcomes among patients undergoing abdominoperineal resection (APR). Methods This was a retrospective cohort study of patients from the National Surgical Quality Improvement Program who underwent APR for low rectal cancer from 2016 to 2019. Patients were stratified by operative approach: robotic, laparoscopic, and open APR (R-APR, L-APR, and O-APR). Emergent cases were excluded. The primary outcome was RMP. 30-day postoperative outcomes were also evaluated, using logistic regression analysis. Results Among 1,807 patients, 452 (25.0%) underwent R-APR, 474 (26.2%) L-APR, and 881 (48.8%) O-APR. No differences regarding RMP (13.5% R-APR vs. 10.8% L-APR vs. 12.3% O-APR, p = 0.44), distal margin positivity, positive nodes, readmission, or operative time were observed between operative approaches. Adjusted analysis confirmed that operative approach did not predict RMP (p > 0.05 for all). Risk factors for RMP included American Society of Anesthesiologists (ASA) classification III (ASA I-II ref; OR 1.46, p = 0.039), pT3-4 stage (T0-2 ref, OR 4.02, p < 0.001), pN2 stage (OR 1.98, p = 0.004), disseminated cancer (OR 1.90, p = 0.002), and lack of preoperative radiation (OR 1.98, p < 0.01). Conclusions No difference in RMP was observed among R-APR, L-APR, and O-APR. Postoperatively, R-APR yielded greater benefit when compared to O-APR, but was comparable to that of L-APR. Minimally invasive surgery may be an appropriate option and worthy consideration for patients with distal rectal cancer requiring APR.

Aim: Depression is a prevalent disorder that is associated with adverse health outcomes, but an understanding of its effect in colorectal surgery remains limited. The purpose of this study was to examine the impact of history of depression among patients undergoing colectomy.Method: United States patients from Marketscan (2010–2017) who underwent colectomy were included and stratified by whether they had a history of depression within the past year, defined as (1) a diagnosis of depression during the index admission, (2) a diagnosis of depression during any inpatient or (3) outpatient admission within the year, and/or (4) a pharmacy claim for an antidepressant within the year. The primary outcomes were length of stay (LOS) and inpatient hospital charge. Secondary outcomes included in‐hospital mortality and postoperative complications. Logistic, negative binomial, and quantile regressions were performed.Results: Among 88 981 patients, 21 878 (24.6%) had a history of depression. Compared to those without, patients with a history of depression had significantly longer LOS (IRR = 1.06, 95% CI [1.05, 1.07]), increased inpatient charge (β = 467, 95% CI [167, 767]), and increased odds of in‐hospital mortality (OR = 1.37, 95% CI [1.08, 1.73]) after adjustment. History of depression was also independently associated with increased odds of respiratory complication, pneumonia, and delirium (all P < 0.05).Conclusion: History of depression was prevalent among individuals undergoing colectomy, and associated with greater mortality and inpatient charge, longer LOS, and higher odds of postoperative complication. These findings highlight the impact of depression in colorectal surgery patients and suggest that proper identification and treatment may reduce postoperative morbidity.