Faculty Bibliography

Age is the strongest risk factor for colorectal cancer. Although there is updated guidance for the age at which to start screening, there is little guidance for individuals or their medical teams on how to decide when to stop. Current recommendations from the US Preventive Services Task Force and other societies focus primarily on age. For patients older than 85 years, guidelines discourage screening because the harms largely outweigh benefits. Although at a population level, the overall benefit of screening in older individuals decreases, one must individualize the recommendation based on comorbidities, functional status, screening history, and gender-not solely base it on age. Patient and caregiver preferences must also be thoroughly explored. Current models struggle with incorporating other colorectal cancer risk factors such as family history, previous adenomas, and modality of previous screening into recommendations and simulations, but are likely to improve with machine learning and whole electronic health record prediction-based approaches.

BACKGROUND:Colorectal cancer (CRC) screening reduces all-cause and CRC-related mortality. New research demonstrates that the faecal haemoglobin concentration (f-Hb) may indicate the presence of other serious diseases not related to CRC. We investigated the association between f-Hb, measured by a faecal immunochemical test (FIT), and both all-cause mortality and cause of death in a population-wide cohort of screening participants. METHODS:Between 2014 and 2018, 1,262,165 participants submitted a FIT for the Danish CRC screening programme. We followed these participants, using the Danish CRC Screening Database and several other national registers on health and population, until December 31, 2018. We stratified participants by f-Hb and compared them using a Cox proportional hazards regression on all-cause mortality and cause of death reported as adjusted hazard ratios (aHRs). We adjusted for several covariates, including comorbidity, socioeconomic factors, demography and prescription medication. RESULTS:We observed 21,847 deaths in the study period. Our multivariate analyses indicated an association relationship between increasing f-Hb and the risk of dying in the study period. This risk increased steadily from aHR 1.38 (95% CI: 1.32, 1.44) in those with a f-Hb of 7.1-11.9 μg Hb/g faeces to 2.20 (95% CI: 2.10, 2.30) in those with a f-Hb ≥60.0 μg Hb/g faeces, when compared to those with a f-Hb ≤7.0 μg Hb/g faeces. The pattern remained when excluding CRC from the analysis. Similar patterns were observed between incrementally increasing f-Hb and the risk of dying from respiratory disease, cardiovascular disease and cancers other than CRC. Furthermore, we observed an increased risk of dying from CRC with increasing f-Hb. CONCLUSIONS:Our findings support the hypothesis that f-Hb may indicate an elevated risk of having chronic conditions if causes for the bleeding have not been identified. The mechanisms still need to be established, but f-Hb may be a potential biomarker for several non-CRC diseases.

BACKGROUND:Current guidelines consider endoscopic resection appropriate treatment for malignant colon polyps with negative margins, low-grade histology, and no lymphovascular invasion. While increasing literature demonstrates a worse prognosis for advanced stage right- versus left-sided colon cancers after curative treatment, there is paucity of data regarding prognostic effect of location in patients undergoing endoscopic resection of T1 polyps. We hypothesized the more aggressive biologic behavior observed in advanced right-sided cancers would be similarly represented in malignant polyps, and this location would be associated with lower overall survival. METHODS:The National Cancer Database was queried for adults with T1NxMx tumors who underwent endoscopic polypectomy (2004-2017). Patients with positive margins or without follow-up information were excluded. RESULTS:A total of 2,337 patients met inclusion criteria; 22% had right-sided polyps. Endoscopically excised proximal tumors were more common in elderly, and those with public insurance and more comorbidities (all P < .01). Among patients with complete pathologic data, there were no statistical differences between right- and left-sided polyps with 1 cm median size, >92% without lymphovascular invasion, and 100% without tumor deposits. Univariate analysis showed 73% vs 86% 5-year overall survival for right versus left polyps (P < .01). After adjustment for available confounders, right-sided location remained significantly associated with worse overall survival (hazard ratio 1.49, 95% confidence interval 1.21-1.83). CONCLUSION/CONCLUSIONS:In this national cohort of patients with endoscopically excised malignant polyps, we identified right colon location as an independent prognostic factor associated with increased risk of mortality. Our data suggest polyp location should be taken into consideration when making clinical decisions regarding treatment and/or surveillance.

Introduction: Biloma is an extrahepatic bile collection secondary to iatrogenic or traumatic biliary tree disruption. It is a rare complication of laparoscopy cholecystectomy with an incidence rate of approximately 2.5%. Without proper management, biloma can become infected and cause life-threatening complications such as peritonitis, biliary fistula, bilhemia and hemobilia. Here we described a case of complicated biloma after laparoscopic cholecystectomy. Case Description/Methods: The patient was a 24-year-old female with a past medical history of hypertension, obesity, and recent laparoscopic cholecystectomy complicated by hepatic subcapsular biloma. It was managed by biliary stent placement via endoscopic retrograde cholangiopancreatography (ERCP) and percutaneous drainage during the previous hospitalization. However, 6 days later, she presented with fever, chills, nausea, and right upper quadrant pain. Vital signs were fever 102.3 F and tachycardia 110 to 120 per min. The CT abdomen revealed decreased size in perihepatic fluid collection with air bubbles (14 x 11 x 18 cm; Figure). It also showed a common bile duct stent in place and a percutaneous drainage catheter tip in the inferior aspect of the collection. Lab results showed leukocytosis to 10.3, normal AST/ALT, total/direct bilirubin 2.1/12 mg/dL, and GGT 152 U/L. Broad-spectrum antibiotics were given in ED. The surgery team performed a laparoscopic lavage and discovered that the drain was not connected with the biloma. Two new drains were placed during the operation. She was discharged with PO antibiotics, and an outpatient follow-up was scheduled for drain removal.
Discussion(s): The management of biloma depends on the severity of the disease. Endoscopic therapy, such as a transpapillary biliary stent placement, can decrease the transpapillary pressure gradient, thus allowing preferential transpapillary bile flow rather than accumulation at the leaking site. However, given that stent placement does not reabsorb formed collection, patients failing ERCP should undergo percutaneous drainage or bile duct repair.Iatrogenic biloma can be detected by post-operational physical exams and image studies. Laparoscopic lavage with drainage should be considered in unresolved or infected biloma due to the high risk of peritonitis

Introduction: Nearly a quarter of older adults with inflammatory bowel disease (IBD) require surgery. Patients with IBD are at risk for complications postoperatively and this risk is increased in older adults. However, little is known about the risk factors leading to these complications.We assessed risk factors associated with adverse postoperative outcomes among older adults who underwent IBD-related surgery, as well as evaluated trends in emergency vs. elective surgery in this population.
Method(s): Using the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database, we identified adults >=60 years of age who underwent an IBD-related intestinal resection from 2005-2019. Our primary outcome included a 30-day composite of mortality, readmission, reoperation, and/or what we identified as serious complications listed in NSQIP.
Result(s): In total, 9,640 intestinal resections were performed among older adults with IBD from 2005-2019, with 48.3% having undergone resection for Crohn's disease (CD), and 51.7% for ulcerative colitis (UC). Nearly 37% experienced an adverse outcome, with the most common complication being infection (20.21%). From 2005 to 2015, there was no decrease in the number of emergent cases among older adults. On univariate analysis, higher rates of adverse postoperative outcomes were seen with increasing age (p< 0.001), with nearly 50% of those >=80 years of age having an adverse outcome. Patients who underwent an emergency surgery had a higher likelihood of postoperative complications (66.86%; p< 0.001). On multivariable analysis, albumin <=3 (aOR 1.99; 95%CI 1.69-2.33), the presence of two or more comorbidities (aOR, 1.50; 95%CI 1.27-1.76), totally dependent functional status as compared to those partially dependent or independent (aOR, 7.28; 95%CI 3.14-21.2), and emergency surgery (aOR, 1.70; 95% CI 1.36-2.11) significantly increased the odds of an adverse outcome. (Figure)
Conclusion(s): Overall 37% of older adults with IBD experienced an adverse outcome as a result of IBD-related surgery. Limited functional health status, low preoperative serum albumin levels, and those undergoing emergent surgery were associated with a significantly higher risk. This is particularly important as the number of older adults with IBD is increasing, with a persisting number of emergency cases over time. Given the high rate of surgery in this population, future research should focus on preoperative rehabilitation, nutritional optimization, and timely surgery to improve outcomes. (Table Presented)

Diverticular disorders are frequently encountered in the primary care setting. Diverticular bleeding is the most common cause of lower gastrointestinal bleeding. Low risk patients with uncomplicated diverticulitis can be managed in the outpatient setting, in some cases without the need for antibiotics. In patients with diverticulosis and persistent abdominal pain, chronic smoldering diverticulitis, segmental colitis associated with diverticulosis (SCAD), symptomatic uncomplicated diverticular disease (SUDD), and visceral hypersensitivity should all be considered. To avoid these complications, patients should be encouraged to lead an active lifestyle, consume a healthy diet, and avoid tobacco, alcohol, and certain medications. Contrary to conventional teaching, seeds and nuts do not need to be avoided.