Partial Colectomy Research Articles

DOP51 Risk of kidney failure in patients with Inflammatory Bowel Disease undergoing colectomy: a nationwide cohort study

Abstract Background Inflammatory bowel disease (IBD) is frequently accompanied by kidney complications. Potential triggers or subpopulations at high-risk of kidney problems are not well elucidated. We hypothesized that surgical interventions, specifically colectomy, might in part explain this risk. Methods A nationwide Swedish cohort study comprising 82,052 individuals with biopsy-proven IBD diagnosed during 1965-2017, with follow-up until 2019. We investigated the association between incident colectomy (time-varying exposure) and future risk of kidney failure (diagnosis of end-stage kidney disease or death due to chronic kidney disease) using Cox proportional hazard models. We also examined the impact of partial vs. total colectomy and the presence of a stoma. Covariates included age, sex, education level, and selected comorbidities. Results Over a median follow-up of 14 years, 15,922 individuals underwent colectomy, and 952 kidney failure events occurred. Colectomy was associated with an increased relative risk of kidney failure (adjusted hazard ratio [aHR] 1.60; 95% CI 1.39-1.84). Compared to periods without colectomy, undergoing total colectomy (aHR 1.82; 95% CI 1.54-2.15) and colectomy with the presence of a stoma (aHR 2.40; 95% CI 1.75-3.28) showed higher risks versus partial colectomy or colectomy without a stoma, respectively. Subgroup analyses revealed higher kidney failure risk in patients with ulcerative colitis and those aged ≥40 years at IBD diagnosis. In absolute risks, at 30-year after colectomy, 8.9% of patients with IBD had kidney failure, with an absolute risk difference of 4.5% (95% CI 1.9-7.0%). Conclusion In people with IBD, rates of kidney failure are higher among those undergoing colectomy, particularly following total colectomy or colectomy with a stoma. This study identifies a high-risk population that may benefit from established protocols for kidney function monitoring/surveillance and referral to nephrologist care.

Resident dictation of operative notes: a reimbursement comparison and mixed-methods analysis

PurposeSurgical documentation is crucial to ensure quality patient care and accurate coding and billing. Operative dictation also serves as a valuable educational opportunity for surgical trainees. However, resident dictations may not fully capture procedural details and complexities, resulting in missed revenue opportunities. On July 1, 2021, our university-based surgery department implemented a policy requiring attendings to dictate all operative reports. The purpose of this mixed-method study was to investigate the financial impact of this policy and explore differences in resident and attending dictations.MethodsCore general surgery operations performed by the Department of Surgery between July 1, 2020 and June 30, 2022 were identified from billing data. The surgeon, current procedural terminology (CPT) and modifier codes, and relative value units (RVUs) for each case were acquired. Surgeons not present for the entire study period or cases requiring multiple surgeons were excluded. Descriptive statistics and Kolmogorov–Smirnov (KS) non-parametric tests compared pre- and post-policy RVU distributions on overall charges and 18 key general surgery operations. Targeted thematic analysis was performed on operative reports pre- and post-policy to explore resident and attending differences.ResultsA total of 42 attendings performed 16,233 cases, billing 28,560 CPT codes (50.3% pre- vs. 49.7% post-policy). There was a small but statistically significant increase in RVU distribution post-policy, mean 20.2 pre- vs. 20.3 RVUs post-, $4372 pre- vs. $4418 per case post-, KS = 0.02 (p = 0.009). Specifically, higher RVU distributions were seen among attending-dictated cases for melanoma (p = 0.009), minimally invasive ventral hernia repair (VHR, p = 0.008), parathyroidectomy (p < 0.001), anorectal incision and drainage (p = 0.003) and anorectal exam under anesthesia (p = 0.029). Higher RVU distributions were noted among resident-dictated, attending-edited cases for partial colectomy (p = 0.043), and open VHR (p = 0.004). No differences were noted among the remaining operations (p > 0.05). Three major themes were noted from focused sampling of 112 operative reports: billable items, clinical/surgical reasoning, and technical details. Differences in billable items and clinical and surgical reasoning were the most influential on modifying clinical implications of operative notes. Themes and differences were consistent regardless of surgeon or specialty.ConclusionAdopting an attending-only operative dictation policy yielded a small increase in billable RVUs, predominantly from select operations. Gaps in coding-directed language and depth of clinical reasoning were noted in resident dictations. These findings reveal an educational opportunity that concomitantly optimizes patient care, resident education, and procedural revenue.

Radical surgery for highly advanced gastric cancer with direct invasion to transverse colon, splenic serosa, and pancreas inducing pancreatic duct infection: A case report

Background: According to the GLOBOCAN 2020 results, gastric cancer is the fifth most commonly diagnosed cancer, and fourth most common cause of cancer death worldwide. An estimated 6-27% of patients with gastric cancer show invasion of the adjacent organs at diagnosis. In a previous study, curative resection was shown to significantly improve the prognosis of patients without peritoneal or liver metastases. Herein, we present a case of gastric cancer with invasion of the adjacent organs in a patient who underwent curative surgery. Case presentation: An 80-year-old woman presented with body weight loss and slight fever. Upper gastrointestinal endoscopy revealed Borrmann type 3 gastric cancer extending from the gastric fundus to the corpus. Contrast-enhanced computed tomography (eCT) revealed extensive invasion of the gastric cancer into the transverse colon and pancreas. The eCT also revealed gas in the pancreatic duct, indicating that the gastric lumen was connected to the pancreatic duct because of the tumor. We performed en-bloc tumor resection via total gastrectomy with D2 lymph node dissection, distal pancreatectomy, and partial colectomy. The patient was postoperatively diagnosed with T4b (SI: pancreatic, transverse colon, and splenic serosa), N0 Stage IIIA gastric cancer. The histological type was poorly differentiated adenocarcinoma. Adjuvant chemotherapy was initiated two months after surgery, but was continued for only two months because of severe adverse events. Two years after surgery, the patient remains well. Conclusion: Advanced gastric cancer with extensive invasion of the adjacent organs but no distant metastasis can be treated with en-bloc tumor resection.

Surgical outcomes and predictors of overall survival of stage I-III appendiceal adenocarcinoma: Retrospective cohort analysis of the national cancer database

BackgroundThis study aimed to determine predictors of overall survival (OS) after surgical treatment of stage I-III appendiceal adenocarcinoma and compare the outcomes of partial colectomy and hemicolectomy. MethodsA retrospective analysis of the U.S. National Cancer Database (NCDB) including patients who underwent surgery for stage I-III appendiceal adenocarcinoma between 2005 and 2019 was conducted. A propensity-score matched analysis was undertaken to compare the outcomes of partial and hemicolectomy and multivariate analysis was performed to determine predictive factors of OS. The main outcome was OS and its independent predictors. Results2607 patients (51.6 % male) with a mean age of 61.6 ± 13.9 years were included. 61.7 % of patients underwent hemicolectomy while 31.7 % underwent partial colectomy. After matching, partial colectomy, and hemicolectomy had similar OS (117.3 vs 117.2 months; p = 0.08), positive resection margins, short-term mortality, and 30-day readmission. The hemicolectomy group was associated with more examined lymph nodes and longer hospital stays. Older age (HR: 1.047, p < 0.0001), rural residence area (HR: 3.6, p = 0.025), higher Charlson score (HR: 1.6, p = 0.016), signet-ring cell carcinoma (HR: 2.37, p = 0.009), adjuvant systemic treatment (HR: 1.55, p = 0.015), positive surgical margins (HR: 1.83, p = 0.017), positive lymph nodes number (HR: 1.09, p < 0.0001), and examined lymph nodes number (HR: 0.962, p = 0.001) were independent predictors of OS. ConclusionsPartial colectomy and hemicolectomy had similar OS and clinical outcomes. Older age, rural residence, higher Charlson score, signet-ring pathology, adjuvant systemic treatment, positive surgical margins, positive lymph node number, and examined lymph node number were independent predictors of OS.

Giant retroperitoneal liposarcoma with spread to the upper third of the left thigh

Background. Large tumors, such as giant liposarcoma, are a challenge for modern medicine because of difficulty of treatment and possible impact on functions of the adjacent tissues and organs. The review of this clinical case may help develop new strategies and approaches to treatment of similar pathologies. Purpose. Review of the clinical case has a goal to educate medical specialists and students by helping to expand their understanding of rare oncologic diseases and to prove high effectiveness of surgery in locally advanced types of retroperitoneal liposarcomas using the clinical case as an example. Materials and methods. Female patient C., 56 years old, sought for medical help in the clinical unit of State Organization «Grigoriev Institute for Medical Radiology and Oncology of the National Academy of Medical Sciences of Ukraine» in June 2021. The following diagnosis was established: retroperitoneal liposarcoma with spread to the left thigh, St. II–ІІІ сТ3N0M0. An en-bloc surgery (removal of the retroperitoneal tumor with mobilization of the left ureter, intraabdominal removal of the thigh part of the tumor of the left thigh from beneath the inguinal ligament) was performed after the standard preoperative preparation. The surgery went without complications. The wound healed primarily. The follow-up period of the patient was 16 months. Clinical laboratory examination did not show any local recurrences and distant metastases. Results. For retroperitoneal sarcoma, the goal of surgery is to achieve the complete resection of the tumor (R0). Partial removal (R2) tumor should be strongly avoided, as this has been demonstrated to have higher recurrence risk and a detrimental effect on oncologic outcomes. The tumor involvement of organs and structures does necessitate concomitant resection. Resection of one or more adjacent organs is carried out in 58–87% of all cases of primary RPS. Most commonly, ipsilateral nephrectomy and partial colectomy are also performed. In cases of hypothetical necessity of removing all adjacent organs, an extended or compartmental approach to resection is recommended. The main idea is to resect not only evidently affected organs but also surfaces to obtain circumferential «soft tissue margins». This approach is controversial but data from some sarcoma care centers in Italy and France indicate its effectiveness. Conclusions. Treating RPS in specialized centers of oncosurgery with surgical planning based on CT and MRI data is of vital importance, especially using assessment by related surgical specialists. In large RPS, achieving a classic R0 resection level is a challenge, even in a compartmental approach, therefore division of resections into R2 and R0/R1 is reasonable. The choice of approach determines success of the surgery due to the narrowness of the surgical field.

Variation in Competence of Graduating General Surgery Trainees

To examine the readiness of general surgery residents in their final year of training to perform 5 common surgical procedures based on their documented performance during training. Intraoperative performance ratings were analyzed using a Bayesian mixed effects approach, adjusting for rater, trainee, procedure, case complexity, and postgraduate year (PGY) as random effects as well as month in academic year and cumulative, procedure-specific performance per trainee as fixed effects. This model was then used to estimate each PGY 5 trainee's final probability of being able to independently perform each procedure. The actual, documented competency rates for individual trainees were then identified across each of the 5 most common general surgery procedures: appendectomy, cholecystectomy, ventral hernia repair, groin hernia repair, and partial colectomy. This study was conducted using data from members of the SIMPL collaborative. A total of 17,248 evaluations of 927 PGY5 general surgery residents were analyzed from 2015 to 2021. The percentage of residents who requested a SIMPL rating during their PGY5 year and achieved a ≥90% probability of being rated as independent, or "Practice-Ready," was 97.4% for appendectomy, 82.4% for cholecystectomy, 43.5% for ventral hernia repair, 24% for groin hernia repair, and 5.3% for partial colectomy. There is substantial variation in the demonstrated competency of general surgery residents to perform several common surgical procedures at the end of their training. This variation in readiness calls for careful study of how surgical residents can become more adequately prepared to enter independent practice.

Targeting BCMA in Plasmablastic Lymphoma: Two Cases of Therapeutic Response to Teclistamab

Plasmablastic lymphoma (PBL) is an aggressive subtype of B-cell Non-Hodgkin lymphoma (B-NHL) with poor outcomes. PBL occurs more commonly in HIV-positive or immunocompromised patients, but it can also occur in immunocompetent patients. Despite anthracycline-based induction therapy, PBL is associated with chemotherapy resistance and early disease relapse, yielding a median overall survival of 7 to 15 months (Castillo JJ, et al. Blood. 2015). The advent of novel therapies altered the therapeutic landscape for many common subtypes of B-NHL, but progress in PBL is lacking due to the rarity of this disease and the lack of effective therapeutic targets. While PBL does not express many common B-NHL markers (e.g. CD19 or CD20), it does highly express B-cell maturation antigen (BCMA). However, data regarding the efficacy of therapies targeting BCMA in PBL is limited. Herein, we report two cases of relapsed/refractory PBL treated with the BCMA-targeting bispecific antibody teclistamab. Patient 1 was a 33 year old male without significant comorbidities when he was diagnosed with Stage IIE PBL after presenting with a chest wall mass. He was treated with six cycles of dose-adjusted EPOCH-V, followed by radiation to the involved region and a BEAM autologous hematopoietic stem cell transplant. Post-transplant imaging showed him to be in a CR on day 30 PET, but he developed recurrent PBL on his day 100 PET exam with osseus lesions. He was then treated with daratumumab and ICE chemotherapy for four cycles, with an initial resolution of osseus lesions. However, he developed relapsed disease with perilymphatic lung nodules. His PBL was confirmed to express BCMA and he was started on teclistamab monotherapy. Following one cycle of weekly teclistamab (1.5mg/kg), his post-treatment PET imaging demonstrated a complete response. He then underwent a consolidative allogeneic hematopoietic stem cell transplant from a matched unrelated donor. As of this report, he remains in a complete response based on his 30 day PET restaging imaging after transplant and without clinical evidence of disease more than 90 days after transplant. Patient 2 was a 60 year old male with medical history of comorbid CAD, stage IV chronic kidney disease, chronic back pain requiring opioid treatment, and peripheral arterial disease when he was diagnosed with Stage IV PBL after he was found to have mass-like thickening of his descending colon on a CT scan. He underwent partial colectomy, with pathology revealing PBL and his post-operative staging PET/CT scan noting osseus, splenic, and hepatic lesions consistent with advanced stage disease. He was initially treated with DA-EPOCH for six cycles with intrathecal methotrexate, which yielded an initial complete response, though he relapsed four months after completing therapy. He was then treated with gemcitabine, oxaliplatin, and daratumumab but progressed after eight cycles on treatment with abdominal and perisplenic masses confirmed on biopsy to be PBL He was then initiated on teclistamab, which was continued weekly. His treatment course was complicated by a viral pneumonia from which he recovered with IVIG and supportive measures. Following 2 total cycles of therapy, his repeat PET/CT imaging was consistent with a complete response (Figure 1), and he remains on weekly teclistamab therapy with no evidence of disease to date. The encouraging responses noted in our two cases illustrate the therapeutic potential of targeting BCMA using teclistamab in PBL. In our cases, teclistamab was a well tolerated therapy, even in our patient with significant comorbidities. This report provides a foundation for future prospective, multicenter clinical trials to evaluate the efficacy and safety of teclistamab in the treatment of relapsed and refractory PBL.

Role of Age as a Predictor of Major Complications After Elective Surgery for Ulcerative Colitis.

The incidence of ulcerative colitis (UC) in the elderly population is increasing. The aim of this study was to assess the degree to which age and other factors increase the risk of developing major complications in patients undergoing elective surgery for UC. Using the ACS-NSQIP database from 2016 to 2020, patients undergoing elective surgery for UC were divided into four categories: younger than 30, 30-49, 50-69, and 70 or older. A composite outcome was created including major complications and multivariable analysis was performed to identify factors associated with composite major complications. 5946 patients diagnosed with ulcerative colitis who underwent elective surgery were included in the analysis. 14.1% of all patients developed a major complication. For patients with UC, factors associated with the development of a major complication were age 50-69 (OR 1.31, P = .034), male sex (OR 1.38, P < .001), Black race (OR 1.47, P = .049), dependent status (OR 2.06, P = .028), hypoalbuminemia (OR 1.92, P < .001), preoperative steroid treatment (OR 1.27, P = .038), preoperative transfusion (OR 1.91, P < .001), open surgical approach (OR 1.44, P = .002), and partial colectomy (OR 1.51, P = .007). Specifically in patients aged 70 or older, hypoalbuminemia (OR 3.20, P < .001) and preoperative transfusion (OR 2.78, P = .019) were associated with a major complication. Age is a risk factor for the development of a major complication in UC patients undergoing elective surgery. However, it is not the only risk factor nor is it the one that increases the risk the most.

Decreasing rates of colectomy for benign neoplasms: A nationwide analysis.

Despite advances in endoscopic techniques for management of benign colonic neoplasms, a rise in rates of surgical treatment has been reported. We used a nationally representative cohort to characterize temporal trends, patient characteristics, and outcomes associated with colectomy for colonic neoplasms. All patients undergoing elective partial colectomy for benign or malignant colonic neoplasms were identified using the 2012-2019 National Inpatient Sample. Those presenting with inflammatory bowel disease, or experiencing intestinal perforation were excluded. Patients with benign neoplasms were classified as the Benign cohort (others: Malignant). Trends, characteristics, and outcomes were assessed between groups. Of 569,280 colectomy procedures included for analysis, 153,435 (27.0%) were performed for benign lesions. The proportion of Benign operations decreased from 28.6% in 2012 to 23.7% in 2019 (P for trend<0.001). While overall national incidence of colectomy for benign neoplasms decreased from 2012 to 2019 (IRD -1.19, 95%CI -1.20- -1.19), Black patients demonstrated an incremental increase (IRD +0.04, 95%CI +0.02-0.06). On average, Benign was younger (66 [57-72] vs 68 years [58-77], P<0.001), and demonstrated a lower Elixhauser comorbidity index (2 [1-3] vs 3 [2-4], P<0.001), relative to Malignancy. Following adjustment, Benign demonstrated lower odds of in-hospital mortality (AOR 0.61, 95%CI 0.50-0.74; P<0.001), stoma creation (AOR 0.46, 95%CI 0.43-0.50; P<0.001), and infectious complications (AOR 0.68, 95%CI 0.63-0.73; P<0.001). The present national study identifies a decrease in colectomy for benign polyps from 2012-2019. Future investigations should identify patients who would most benefit from surgical resection and address persistent inequities in access to screening and treatment for colonic neoplasms.

Metachronous colorectal cancer risk according to Lynch syndrome pathogenic variant after extensive versus partial colectomy in the Netherlands: a retrospective cohort study

Extensive colectomy (subtotal or total colectomy) is often advised for carriers of Lynch syndrome with colorectal cancer. However, the risk of metachronous colorectal cancer might differ by Lynch syndrome variant, meaning that partial colectomy, which has better functional outcomes, might be adequate for some patients with low-risk variants. We aimed to assess the risk of metachronous colorectal cancer after partial colectomy and extensive colectomy in carriers of Lynch syndrome with different pathogenic variants. For this retrospective cohort study, carriers of Lynch syndrome with colorectal cancer in the Netherlands were identified by linkage of the Dutch Foundation for the Detection of Hereditary Tumors (StOET) database and the Dutch Nationwide Network and Registry of Histopathology and Cytopathology (PALGA) database. Data on demographics, Lynch syndrome variants, colorectal cancers, surgery types, mortality, and surveillance colonoscopies were extracted. Data on colorectal cancer and surveillance colonoscopies were updated until Feb 28, 2022. Data on survival status was updated until Feb 7, 2022. MLH1, MSH2, and EPCAM were classified as high-risk variants and MSH6 and PMS2 as low-risk variants. Patients for whom the type of surgery was unknown were excluded. Cox regression time-to-event analyses were done to assess the risk of metachronous colorectal cancer in four subgroups based on pathogenic variant (high-risk vs low-risk variants) and the extent of surgery (extensive colectomy vs partial colectomy). Sex, age at the time of primary colorectal cancer, primary colorectal cancer stage, performance of surveillance colonoscopies, adherence to the surveillance guidelines, and time period of primary colorectal cancer diagnosis were added to the model as possible confounders. Metachronous colorectal cancer was defined as colorectal cancer diagnosed more than 6 months after the primary colorectal cancer. Patients were censored at time of death or assembly of the database. Of 1908 carriers of Lynch syndrome registered in StOET, 532 with a history of colorectal cancer were identified after linkage with PALGA. Five carriers were excluded because of an unknown surgery type, leaving 527 in our sample (mean age at primary colorectal cancer 48·7 years [SD 12·1]; 274 [52%] male and 253 [48%] female). 121 (23%) patients developed metachronous colorectal cancer (median time from primary colorectal cancer to metachronous colorectal cancer 11·0 years [IQR 2·1-17·8]). Metachronous colorectal cancer occurred in 12 (12%) of 97 patients with high-risk variants and extensive colectomy, in 85 (32%) of 267 patients with high-risk variants and partial colectomy, in zero (0%) of 11 patients with low-risk variants and extensive colectomy, and in 24 (16%) of 152 patients with low-risk variants and partial colectomy. Partial colectomy was associated with a higher risk of metachronous colorectal cancer than extensive colectomy in the high-risk variant group (hazard ratio 1·97, 95% CI 1·04-3·73; p=0·039). The risk of metachronous colorectal cancer did not differ between carriers of low-risk variants who had partial colectomy and those of high-risk variants who had extensive colectomy (1·14, 0·55-2·36; p=0·72). The risk of metachronous colorectal cancer after partial colectomy in carriers of low-risk variants is similar to the risk after extensive colectomy in carriers of high-risk variants. This finding suggests that partial colectomy followed by endoscopic surveillance is an appropriate management approach to treat colorectal cancer in carriers of low-risk Lynch syndrome variants. None.

FRI663 A Rare Case Of Igf-2 Induced Hypoglycemia Associated With Metastatic Colon Cancer

Abstract Disclosure: A. Alshaakh Mohd Mari: None. A. Varshney: None. A. Sidhu: None. M. Matos: None. M. Kinaan: None. Introduction: The diagnosis of hypoglycemia in patients without diabetes is uncommon and nonislet cell tumor hypoglycemia (NICTH) represent a minority of these cases. The most common mechanism is related to IGF-2 production from tumor cells. Case description: A 66-year-old man with a history of stage IV colon cancer presented to the hospital due to breathlessness while receiving chemotherapy (Bevacizumab plus FOLFOX4). He had partial colectomy and chemotherapy 3 years earlier but was recently found to have metastatic disease to the liver. A CT abdomen during hospitalization showed a 15 cm hepatic mass occupying the entire right hepatic lobe. Endocrinology was consulted due to persistent postprandial and fasting hypoglycemia despite dextrose infusion. He had no history of diabetes and denied taking any diabetes medications. Plasma blood glucose (BG) was noted to be 74 mg/dl (74-106) while on dextrose. An 8AM cortisol was checked to exclude adrenal insufficiency and was 8.08 mcg/dL (4.30-22.40). A 72 hour fast was done but discontinued at 8 hours when plasma BG dropped to 48 and patient became symptomatic. At the time C-peptide and Insulin levels were low &amp;lt;0.05 ng/mL (0.48-5.05) and &amp;lt;1.0 mU/L (3.0-25) respectively, with normal Beta-hydroxybutyrate (BHB) 1.1 mg/dL (0.2-2.8). At the end of the fast 1 mg of glucagon was administered and his BG increased to 112 mg/dl in 2 hrs. IGF-1 levels were undetectable &amp;lt;15 ng/mL and IGF-2 levels were found to be 175 ng/mL. The IGF2:IG1 ratio was at 11 confirming IGF-2 mediated NICTH. Dexamethasone 10 mg daily was started, and BG were maintained &amp;gt; 70mg/dl without dextrose infusion. Discussion: In approximately 50% of NICTH, the tumor is identified prior to the onset of hypoglycemia, but up to 50% of these patients may be asymptomatic despite hypoglycemia. Our patient had a known hepatic lesion and was minimally symptomatic despite very low BG. The mechanism for NICTH can include insulin secretion from the tumor, replacement of hepatic tissue and increased glucose utilization by the tumor, or most commonly, IGF-2 secretion. In the case of IGF-2 mediated hypoglycemia insulin, proinsulin, C-peptide, and β-hydroxybutyrate levels are low. An elevated IGF-2:IGF-1 ratio (&amp;gt;10) confirms the diagnosis. The primary treatment is through surgical removal or debulking of the tumor. Neoadjuvant therapies such as radiation and chemotherapy may reduce occurrences of hypoglycemia, but only temporarily. Glucocorticoids may be used when the underlying malignancy cannot be treated. Presentation: Friday, June 16, 2023

Whole Foods Introduction Associated With Symptomatic Anastomotic Ulceration in Children With Short Bowel Syndrome.

Anastomotic ulceration (AU) is a rare but life-threatening complication of pediatric short bowel syndrome (SBS). AUs may be challenging to detect and refractory to treatment. This study aimed to identify features associated with symptomatic bleeding AUs in children with SBS and factors that may impact resolution of bleeding. The relationship between dietary changes and symptomatic anastomotic hemorrhage was also explored. We conducted a retrospective chart review of 381 patients cared for in the Intestinal Rehabilitation Program at our center from 2013 to 2022. Patients with symptomatic AUs were identified based on at least 1 endoscopic procedure showing AUs and evidence of clinically significant gastrointestinal bleeding. We collected patient demographics, clinical characteristics, dietary history, radiologic imaging, and histopathology. We used descriptive statistics to identify patterns of presentation. AUs were identified in 22 patients who were followed for a median duration of 2.9 years after anastomotic ulcer identification. AUs uniformly evolved years after the initial anastomosis (median 3.2 years). Characteristics included bowel stricture (4/22), small bowel-colon anastomosis (19/22), partial colectomy (17/22), and an increase in whole foods fraction (12/18). Bleeding resolved with operative intervention in the majority with anastomotic stricture (3/4). Recurrent bleeding was common in those without stricture (13/18). In a subset of patients without stricture, whole food reduction was associated with improvement or resolution of bleeding (5/6). We observed a higher proportion of patients with AUs who responded to surgical intervention in the subset of children with definitive anastomotic strictures versus those without, suggesting that careful characterization of intestinal anatomy may be critical to predicting response to therapy. We also observed that bleeding from AU typically first manifested within 1 year of a shift from elemental or hydrolyzed enteral formula to a whole food-based diet (including commercial blenderized feeds), which may indicate that components of the enteral diet play a role in the pathogenesis of AU. Further studies are needed to validate these hypotheses.

The topographical distribution of lymph node metastases in colon cancer resections

In accordance with international guidelines all lymph nodes in colon cancer specimens must be examined to obtain accurate staging. This study aimed to determine the topographical location of lymph node metastases and evaluate if a more limited sampling approach could be an alternative. Partial colectomies received at the Department of Pathology, Zealand University Hospital during a six-month period were included. At the macroscopic examination, each specimen was divided into three different segments: a segment containing the index tumor and the tumor-feeding artery, an oral and an anal segment. The number of lymph nodes and lymph node metastases were registered separately for each segment. Resections from 93 patients were included. Of 2466 lymph nodes, 1839 (74.6 %) were located in the tumor segment, 308 (12.5 %) in the oral, and 319 (12.9 %) in the anal segment, respectively. In 133 (5,4 %) lymph nodes a metastasis was present. Of these 129 (97.0 %) were located in the tumor segment, one (0.8 %) in the oral segment, and three (2.3 %) in the anal segment. No patients had metastasis in the oral or anal segments without metastases also being present in the tumor segment leading to consideration of the need for lymph node harvest of the complete specimen upon initial examination. As such, the segment containing the index tumor and tumor-feeding artery could be regarded as a sentinel segment indicating a potential need for lymph node dissection in the oral and anal segments.

Evaluating Educational Outcomes Using Patient Outcomes of New Surgeons Performing Partial Colectomy Compared to Cholecystectomy.

Despite ongoing efforts to improve surgical education, surgical residents face gaps in their training. However, it is unknown if differences in the training of surgeons are reflected in the patient outcomes of those surgeons once they enter practice. This study aimed to compare the patient outcomes among new surgeons performing partial colectomy-a common procedure for which training is limited-and cholecystectomy-a common procedure for which training is robust. The authors retrospectively analyzed all adult Medicare claims data for patients undergoing inpatient partial colectomy and inpatient cholecystectomy between 2007 and 2018. Generalized additive mixed models were used to investigate the associations between surgeon years in practice and risk-adjusted rates of 30-day serious complications and death for patients undergoing partial colectomy and cholecystectomy. A total of 14,449 surgeons at 4,011 hospitals performed 340,114 partial colectomy and 355,923 cholecystectomy inpatient operations during the study period. Patients undergoing a partial colectomy by a surgeon in their 1st vs 15th year of practice had higher rates of serious complications (5.22% [95% CI, 4.85%-5.60%] vs 4.37% [95% CI, 4.22%-4.52%]; P < .01) and death (3.05% [95% CI, 2.92%-3.17%] vs 2.83% [95% CI, 2.75%-2.91%]; P < .01). Patients undergoing a cholecystectomy by a surgeon in their 1st vs 15th year of practice had similar rates of 30-day serious complications (4.11% vs 3.89%; P = .11) and death (1.71% vs 1.70%; P = .93). Patients undergoing partial colectomy faced a higher risk of serious complications and death when the operation was performed by a new surgeon compared to an experienced surgeon. Conversely, patient outcomes following cholecystectomy were similar for new and experienced surgeons. More attention to partial colectomy during residency training may benefit patients.

A national cancer database analysis of the clinicopathologic characteristics and outcomes of appendiceal malignant mesenchymal tumors

The present study aimed to assess the characteristics and outcomes of appendiceal malignant mesenchymal tumors. This was a retrospective case-series study of patients with appendiceal malignant mesenchymal tumors in the national cancer database (2005–2019). The main outcomes were overall survival (OS) and short-term mortality. 53 patients (40 GISTs and 13 sarcomas) were included. 92.6% of GIST patients had stage I disease and 76.9% of GISTs were ≤2 cm. Most appendiceal GISTs were treated with appendectomy or partial colectomy whereas half of patients with appendiceal sarcoma underwent hemicolectomy or subtotal colectomy. Only one short-term mortality was recorded in the sarcoma group. One-third of patients with sarcoma had positive surgical margins versus 5.1% of patients with GISTs. GIST patients had longer median OS (117.1 vs 54.8 months) than sarcoma patients.

Having Outpatient Major Elective (HOME) Robotic Colon Resection Protocol: A Safe Approach to Ambulatory Colon Resection.

Within the past decade, colorectal surgery length of stay (LOS) has decreased from an average of 5-6 days to 2-3 days. However, elective colon resections have yet to become a common procedure with the potential for same-day discharge. During the COVID pandemic, hospital capacity was exceptionally strained and colon resections were delayed due to the lack of inpatient beds available. We sought to create a protocolized ERAS (enhanced recovery after surgery) pathway that would allow for safe and feasible ambulatory colon resections as well as decreasing overall hospital inpatient burden. Between November 2020 and March 2022, 15 patients were offered same-day discharges under the HOME protocol. Of the 15 patients, 11 patients agreed to be discharged home the day of surgery and followed prospectively for 30 days. All procedures were performed robotically. Patients were selected based on level of preoperative health (ASA class 1 and 2), low-risk for loss to follow-up, ability for close family supervision for 3 days postoperatively, and type of procedure (partial colectomy). Close follow-up was achieved with daily telephonic or televideo visits for 3 days post-operatively, as well as a 2-week outpatient clinic follow-up. A total of 11 patient underwent same-day surgery utilizing the protocol, 5 females and 6 males, between the ages of 34 and 62. All patients were ASA class 2. Indications for colon resection were cecal volvulus (1), recurrent sigmmoid diverticulitis (9), and Crohn's disease (1). Primary outcome was readmission rates within the 30-days. There were no readmissions or complications during the perioperative 30-day period. There was one emergency department return for pain who was not admitted. Average operative time was 132.1 minutes. Using a novel enhanced recovery protocol, we demonstrated the feasibility and safety of ambulatory partial colectomy in a highly select small subset of patients.

Which is the appropriate surgical procedure for appendiceal adenocarcinoma: appendectomy, partial colectomy or right hemicolectomy?

The purpose of this study was to explore the appropriate surgical procedure and clinical decision for appendiceal adenocarcinoma. A total of 1,984 appendiceal adenocarcinoma patients from 2004 to 2015 were retrospectively identified from the Surveillance, Epidemiology, and End Results (SEER) database. All patients were divided into three groups based on the extent of surgical resection: appendectomy (N = 335), partial colectomy (N = 390) and right hemicolectomy (N = 1,259). The clinicopathological features and survival outcomes of three groups were compared, and independent prognostic factors were assessed. The 5-year OS rates of patients who underwent appendectomy, partial colectomy and right hemicolectomy were 58.3%, 65.5% and 69.1%, respectively (right hemicolectomy vs appendectomy, P < 0.001; right hemicolectomy vs partial colectomy, P = 0.285; partial colectomy vs appendectomy, P = 0.045). The 5-year CSS rates of patients who underwent appendectomy, partial colectomy and right hemicolectomy were 73.2%, 77.0% and 78.7%, respectively (right hemicolectomy vs appendectomy, P = 0.046; right hemicolectomy vs partial colectomy, P = 0.545; partial colectomy vs appendectomy, P = 0.246). The subgroup analysis based on the pathological TNM stage indicated that there was no survival difference amongst three surgical procedures for stage I patients (5-year CSS rate: 90.8%, 93.9% and 98.1%, respectively). The prognosis of patients who underwent an appendectomy was poorer than that of those who underwent partial colectomy (5-year OS rate: 53.5% vs 67.1%, P = 0.005; 5-year CSS rate: 65.2% vs 78.7%, P = 0.003) or right hemicolectomy (5-year OS rate: 74.2% vs 53.23%, P < 0.001; 5-year CSS rate: 65.2% vs 82.5%, P < 0.001) for stage II disease. Right hemicolectomy did not show a survival advantage over partial colectomy for stage II (5-year CSS, P = 0.255) and stage III (5-year CSS, P = 0.846) appendiceal adenocarcinoma. Right hemicolectomy may not always be necessary for appendiceal adenocarcinoma patients. An appendectomy could be sufficient for therapeutic effect of stage I patients, but limited for stage II patients. Right hemicolectomy was not superior to partial colectomy for advanced stage patients, suggesting omission of standard hemicolectomy might be feasible. However, adequate lymphadenectomy should be strongly recommended.

Endoscopic and surgical treatment outcomes of colitis-associated advanced colorectal neoplasia: a multicenter cohort study.

Inflammatory bowel disease (IBD) patients are at increased risk of advanced neoplasia (high-grade dysplasia or colorectal cancer). The authors aimed to (1) assess synchronous and metachronous neoplasia following (sub)total or proctocolectomy, partial colectomy or endoscopic resection for advanced neoplasia in IBD, and (2) identify factors associated with treatment choice. In this retrospective multicenter cohort study, the authors used the Dutch nationwide pathology databank (PALGA) to identify patients diagnosed with IBD and colonic advanced neoplasia (AN) between 1991 and 2020 in seven hospitals in the Netherlands. Logistic and Fine & Gray's subdistribution hazard models were used to assess adjusted subdistribution hazard ratios for metachronous neoplasia and associations with treatment choice. The authors included 189 patients (high-grade dysplasia n =81; colorectal cancer n =108). Patients were treated with proctocolectomy ( n =33), (sub)total colectomy ( n =45), partial colectomy ( n =56) and endoscopic resection ( n =38). Partial colectomy was more frequently performed in patients with limited disease and older age, with similar patient characteristics between Crohn's disease and ulcerative colitis. Synchronous neoplasia was found in 43 patients (25.0%; (sub)total or proctocolectomy n =22, partial colectomy n =8, endoscopic resection n =13). The authors found a metachronous neoplasia rate of 6.1, 11.5 and 13.7 per 100 patient-years after (sub)total colectomy, partial colectomy and endoscopic resection, respectively. Endoscopic resection, but not partial colectomy, was associated with an increased metachronous neoplasia risk (adjusted subdistribution hazard ratios 4.16, 95% CI 1.64-10.54, P <0.01) compared with (sub)total colectomy. After confounder adjustment, partial colectomy yielded a similar metachronous neoplasia risk compared to (sub)total colectomy. High metachronous neoplasia rates after endoscopic resection underline the importance of strict subsequent endoscopic surveillance.

A case of anaplastic carcinoma of the pancreas with intrasplenic huge mass formation

Abstract Anaplastic carcinoma of the pancreas (ACP) is an aggressive pancreatic tumor that grows rapidly, and its clinical characteristics are poorly defined because of its rarity. Thus, preoperative diagnosis is difficult and most definitive diagnoses are generally made by surgery, highlighting the importance of collecting more cases of ACP. We report a case of a 79-year-old woman with ACP that was difficult to diagnose preoperatively. Abdominal enhanced computed tomography revealed a large and expansive tumor in the spleen containing multilocular cystic and solid components. The first preoperative diagnosis was splenic angiosarcoma, and the tumor could be resected by distal pancreatectomy, total gastrectomy and partial transverse colectomy. ACP was first diagnosed based on postoperative histopathological findings. ACP that spreads to the spleen and forms an intrasplenic mass is rare. However, ACP should be included in the differential diagnosis of such patients, and further research of ACP is essential for a favorable prognosis.

Human Immunodeficiency Virus and Hepatitis C Virus-related Disparities in Undergoing Emergency General Surgical Procedures in the United States, 2016-2019.

To determine whether people living with human immunodeficiency virus (PLWHIV) and people living with hepatitis C virus (PLWHCV) experience inequities in receipt of emergency general surgery (EGS) care. PLWHIV and PLWHCV face discrimination in many domains; it is unknown whether this extends to the receipt of EGS care. Using data from the 2016 to 2019 National Inpatient Sample, we examined 507,458 nonelective admissions of adults with indications for one of the 7 highest-burden EGS procedures (partial colectomy, small-bowel resection, cholecystectomy, operative management of peptic ulcer disease, lysis of peritoneal adhesions, appendectomy, or laparotomy). Using logistic regression, we evaluated the association between HIV/HCV status and the likelihood of undergoing one of these procedures, adjusting for demographic factors, comorbidities, and hospital characteristics. We also stratified analyses for the 7 procedures separately. After adjustment for covariates, PLWHIV had lower odds of undergoing an indicated EGS procedure [adjusted odds ratio (aOR): 0.81; 95% CI: 0.73-0.89], as did PLWHCV (aOR: 0.66; 95% CI: 0.63-0.70). PLWHIV had reduced odds of undergoing cholecystectomy (aOR: 0.68; 95% CI: 0.58-0.80). PLWHCV had lower odds of undergoing cholecystectomy (aOR: 0.57; 95% CI: 0.53-0.62) or appendectomy (aOR: 0.76; 95% CI: 0.59-0.98). PLWHIV and PLWHCV are less likely than otherwise similar patients to undergo EGS procedures. Further efforts are warranted to ensure equitable access to EGS care for PLWHIV and PLWHCV.