Faculty Bibliography

Risk-adjusted institutional transfusion rates are not currently available on a national level. A surrogate means of benchmarking transfusion practices to use for internal quality improvement was studied. Blood utilization was prospectively studied among all colorectal surgery patients at the study institution (July 2010-November 2012), and these data were benchmarked with transfusion data from the National Surgical Quality Improvement Program (NSQIP) database by hospital type and size. Using NSQIP, the study institution's colorectal surgery transfusion rate was 16.3% (150/920 cases), which was slightly higher than the 14.3% national mean transfusion rate (12 191/85 507 cases; P = .08). When broken down by hospital type and size, the study hospital had a similar rate of blood transfusion compared with academic hospitals (P = .35) but a significantly higher rate than community hospitals, regardless of patient volume (P = .03). Benchmarking blood utilization compared with similar-type hospitals using NSQIP may be a surrogate method to assess adherence to evidence-based transfusion guidelines and identify areas for structured quality improvement initiatives.

IMPORTANCE/OBJECTIVE:High-resolution anoscopy (HRA) is becoming increasingly advocated as a method of screening for anal dysplasia in high-risk patients. OBJECTIVE:To describe, through HRA findings, the association between patient symptomatology and anal dysplasia among patients at high risk for anal dysplasia. DESIGN, SETTING, AND PARTICIPANTS/METHODS:Univariable and multivariable analyses were conducted of data from a prospectively maintained HRA database on all patients undergoing HRA with biopsy from November 1, 2011, to March 13, 2014, at a tertiary care HRA clinic. Data included demographics, medical history and comorbidities, HIV status and related measures (CD4 cell counts, HIV viral load, and use of highly active antiretroviral therapy), sexual orientation (when available), patient symptoms at initial presentation, physical examination findings, anal Papanicolaou (Pap) smear findings. MAIN OUTCOMES AND MEASURES/METHODS:High-resolution anoscopy diagnosis of high- vs low-grade dysplasia or no dysplasia. RESULTS:One hundred sixty-one HRA biopsy specimens (mean [SEM], 1.77 [0.11] biopsy specimens per patient) were obtained from 91 patients (mean [SEM] age, 45.7 [1.2] years; 61 men [67%]; 47 black patients [52%]; and 70 human immunodeficiency virus-positive patients [77%]). Twenty-seven patients (30%) had high-grade dysplasia, 26 had low-grade dysplasia (29%), and 38 had no dysplasia (42%). The majority of patients (63 [69%]) were asymptomatic (anal pain, 11 [12%]; bleeding, 14 [15%]; and pruritus, 10 [11%]). Forty-one patients (45%) presented with anal pain (odds ratio, 5.25; 95% CI, 1.44-21.82; P = .02), and patients with either high- or low-grade dysplasia were more likely to present with anal lesions on physical examination compared with patients without dysplasia (odds ratio, 4.34; 95% CI, 1.78-11.20; P = .002). Multivariable analysis suggested that anal pain was independently associated with high-grade dysplasia (odds ratio, 6.42; 95% CI, 1.18-43.3; P = .03). CONCLUSIONS AND RELEVANCE/CONCLUSIONS:Anal dysplasia is a silent disease that is frequently asymptomatic. However, patients with anal pain, anal lesions, and other high-risk factors are at increased risk of having high-grade anal dysplasia. These patients may benefit from routine screening with HRA.

BACKGROUND AND OBJECTIVES/OBJECTIVE:Guidelines on the management of colon cancer state that extensive colectomy should be "considered" for patients of young age (<50). This study aimed to compare the risk of metachronous cancer, overall recurrence and mortality between segmental and extended colon resections in patients under the age of 50 with sporadic CRC. METHODS:We performed a retrospective review of patients age <50 undergoing surgery for CRC from 1991 to 2009. Patients were divided into two groups based on extent of resection: segmental versus extended. The primary outcomes analyzed were metachronous tumors, disease recurrence, and overall survival. RESULTS:Two hundred seventy one patients underwent segmental resection and 30 underwent extended resection. 3.3% in the segmental resection group developed metachronous CRC versus 0% in the extended resection group (P = 0.61). There was no significant difference in the risk of recurrence or mortality for those who underwent a segmental resection compared to those with an extended resection. In a regression model, type of surgery was not an independent risk factor for recurrence or mortality. CONCLUSIONS:Extended colectomy for sporadic CRC in patients younger than 50 does not improve disease-free or overall survival. Further study to determine if segmental resection is appropriate oncologic treatment is warranted.

BACKGROUND:The Accordion severity grading system is a novel system to score the severity of postoperative complications in a standardized fashion. This study aims to demonstrate the validity of the Accordion system in colorectal surgery by correlating severity grades with short-term outcomes after right colectomy for colon cancer. METHODS:This is a retrospective cohort review of patients who underwent right colectomy for cancer between January 1, 2002, and January 31, 2007, at a single tertiary care referral center. Complications were categorized according to the Accordion severity grading system: grades 1 (mild), 2 (moderate), 3-5 (severe), and 6 (death). Outcome measures were hospital stay, 30-d readmission rate and 1-y survival. Correlation between Accordion grades and outcome measures is reflected by Spearman rho (ρ). One-year survival was obtained per Kaplan-Meier method and compared by logrank test for trend. Significance was set at P ≤ 0.05. RESULTS:Overall, 235 patients underwent right colectomy for cancer of which 122 (51.9%) had complications. In total, 52 (43%) had an Accordion grade 1 complication; 44 (36%) grade 2; four (3%) grade 3; 11 (9%) grade 4; seven (6%) grade 5; and four (3%) grade 6. There was significant correlation between Accordion grades and hospital stay (ρ = 0.495, P < 0.001) and 30-d readmission rate (ρ = 0.335, P < 0.001). There was a significant downward trend in 1-y survival as complication severity by Accordion grade increased (P = 0.02). CONCLUSIONS:The Accordion grading system is a useful tool to estimate short-term outcomes after right colectomy for cancer. High-grade Accordion complications are associated with longer hospital stay and increased risk of readmission and mortality.

BACKGROUND:Preoperative radiation therapy with 5-fluorouracil chemotherapy is a standard of care for cT3-4 rectal cancer. Studies incorporating additional cytotoxic agents demonstrate increased morbidity with little benefit. We evaluate a template that: (1) includes the benefits of preoperative radiation therapy on local response/control; (2) provides preoperative multidrug chemotherapy; and (3) avoids the morbidity of concurrent radiation therapy and multidrug chemotherapy. METHODS AND MATERIALS/METHODS:Patients with cT3-4, any N, any M rectal cancer were eligible. Patients were confirmed to be candidates for pelvic surgery, provided response was sufficient. Preoperative treatment was 5 fractions radiation therapy (25 Gy to involved mesorectum, 20 Gy to elective nodes), followed by 4 cycles of FOLFOX [5-fluorouracil, oxaliplatin, leucovorin]. Extirpative surgery was performed 4 to 9 weeks after preoperative chemotherapy. Postoperative chemotherapy was at the discretion of the medical oncologist. The principal objectives were to achieve T stage downstaging (ypT < cT) and preoperative grade 3+ gastrointestinal morbidity equal to or better than that of historical controls. RESULTS:76 evaluable cases included 7 cT4 and 69 cT3; 59 (78%) cN+, and 7 cM1. Grade 3 preoperative GI morbidity occurred in 7 cases (9%) (no grade 4 or 5). Sphincter-preserving surgery was performed on 57 (75%) patients. At surgery, 53 patients (70%) had ypT0-2 residual disease, including 21 (28%) ypT0 and 19 (25%) ypT0N0 (complete response); 24 (32%) were ypN+. At 30 months, local control for all evaluable cases and freedom from disease for M0 evaluable cases were, respectively, 95% (95% confidence interval [CI]: 89%-100%) and 87% (95% CI: 76%-98%). Cases were subanalyzed by whether disease met requirements for the recently activated PROSPECT trial for intermediate-risk rectal cancer. Thirty-eight patients met PROSPECT eligibility and achieved 16 ypT0 (42%), 15 ypT0N0 (39%), and 33 ypT0-2 (87%). CONCLUSION/CONCLUSIONS:This regimen achieved response and morbidity rates that compare favorably with those of conventionally fractionated radiation therapy and concurrent chemotherapy.

PURPOSE/OBJECTIVE:Restorative proctocolectomy with ileal pouch-anal anastomosis (IPAA) is the preferred surgical treatment for patients with ulcerative colitis and familial adenomatous polyposis. As obesity is becoming more epidemic in surgical patients, the aim of this study was to investigate if obesity increases complication rates following IPAA. METHODS:This study was conducted as a retrospective review of patients undergoing IPAA between January 1990 and April 2011. Patients were categorized by body mass index (BMI): BMI < 30 (non-obese) and BMI ≥ 30 (obese). Preoperative patient demographics, operative variables, and postoperative complications were recorded through chart review. The primary outcome studied was cumulative complication rate. RESULTS:A total of 103 non-obese and 75 obese patients were identified who underwent IPAA. Obese patients had an increased rate of overall complications (80 % vs. 64%, p = 0.03), primarily accounted for by increased pouch-related complications (61% vs. 26%, p < 0.01). In particular, obese patients had more anastomotic/pouch strictures (27% vs. 6%, p < 0.01), inflammatory pouch complications (17 % vs. 4%, p < 0.01) and pouch fistulas (12% vs. 3%, p = 0.03). In a regression model, obesity remained a significant risk factor (odds ratio [OR] = 2.86, p = 0.01) for pouch-related complications. CONCLUSIONS:Obesity is associated with an increased risk of overall and pouch-related complications following IPAA. Obese patients should be counseled preoperatively about these risks accordingly.

Radiation damage to the rectum following radiotherapy for pelvic malignancies can range from acute dose-limiting side effects to major morbidity affecting health-related quality of life. No standard guidelines exist for diagnosis and management of radiation proctitis. This article reviews the definitions, staging, and clinical features of radiation proctitis, and summarizes the modalities available for the treatment of acute and chronic radiation proctitis. Because of the paucity of well-controlled, blinded, randomized studies, it is not possible to fully assess the comparative efficacy of the different approaches to management. However, the evidence and rationale for use of the different strategies are presented.