Importance Traditional postoperative outcomes may not fully reflect recovery after gastrointestinal (GI) cancer surgery. Days at home (DAH) is a patient-centered metric that integrates survival, complications, and health care use. Objective To characterize and identify an optimal postoperative observation window and validate DAH after elective GI cancer surgery. Design, Setting, and Participants This was a population-based retrospective cohort study from 2003 to 2021 in Ontario, Canada. Included were adults 18 years and older who underwent elective surgery for GI cancer. Patients were excluded if they were long-term care residents at baseline, underwent emergency surgery, or had another cancer diagnosis within a 2-year lookback. Study data were analyzed from April to November 2025. Exposures Covariates explored were age, sex, frailty, comorbidity burden, income quintile, cancer site, histology, metastatic disease, neoadjuvant therapy, procedure type, operative approach, and hospital volume. Main Outcomes and Measures The primary outcome was DAH, defined as days alive and out of health care institutions and assessed at 30, 90, 180, and 365 days. Death during the observation window resulted in a DAH = 0. DAH after surgery at 90 days (DAH-90) was established as an optimal window, based on the proportion of zeros and variability, while considering clinical pathways in GI cancer. Exploratory multivariable quantile regression examined patient, cancer, and treatment factors associated with DAH-90. Quantile plots evaluated these associations across the distribution of DAH-90. Validity was explored through associations with major morbidity (construct validity) and 1-year mortality (criterion validity). Results Among 91 270 operations in 89 378 participants (mean [SD] age, 67.3 [12.2] years; 51 343 male [56.2%]), median (IQR) DAH-90 was 82 (77-85) days. DAH-90 varied across cancer site, histology, and procedure. Median (IQR) DAH-90 was lowest for esophageal cancer (76 [63-80] days) and highest for small-bowel cancer (84 [80-86] days). In multivariable quantile regression, preoperative frailty was associated with 2.6 fewer DAH-90 (95% CI, 2.3-2.9 fewer days), whereas laparoscopic approach was associated with 3.0 more DAH-90 (95% CI, 2.9-3.1 more days). DAH-90 was lower among patients with major morbidity (median [IQR], 70 [41-79] days vs 83 [80-85] days; P < .001) and among patients who died within 1 year (median, 62 [0-80] days vs 83 [78-85] days; P < .001). Conclusions and Relevance Results of this study suggest that DAH-90 was found to be a valid and clinically meaningful outcome after GI cancer surgery. These findings support the use of DAH-90 in patient counseling, quality assessment, and future GI cancer surgery research.
IMPORTANCE For patients with slow-transit constipation (STC), total colectomy with ileorectal anastomosis (TC-IRA) remains the standard surgical treatment but is frequently complicated by diarrhea, fecal incontinence, and bowel obstruction. Subtotal colectomy with cecorectal anastomosis (SC-CRA) has emerged as a promising alternative; however, recurrence of constipation remains a critical concern. High-quality evidence comparing these 2 procedures is lacking. OBJECTIVE To compare the 1-year Wexner Constipation Score of patients with STC who underwent SC-CRA vs TC-IRA. DESIGN, SETTING, AND PARTICIPANTS This multicenter, open-label, noninferiority randomized clinical trial was conducted at 12 tertiary hospitals across 8 provinces in China from April 2022 to April 2025, with 12-month follow-up (final follow-up April 2026). Eligible participants were adults aged 18 years or older with Rome IV–defined functional constipation, fewer than 1 spontaneous bowel movement per week, and long-term laxative dependence, defined as the regular use of osmotic or stimulant laxatives, or prokinetic agents, at least 3 times weekly for 6 months or longer before enrollment. Of 272 adults assessed, 252 were randomized. These data were analyzed from March 2025 to March 2026. INTERVENTIONS Participants were randomly assigned in a 1:1 ratio to undergo either SC-CRA or TC-IRA. MAIN OUTCOMES AND MEASURES The primary outcome was the Wexner Constipation Score (WCS) at 12 months, with a prespecified noninferiority margin of 1.32 points. Secondary outcomes included fecal incontinence, morbidity, quality of life, and patient-reported satisfaction. RESULTS A total of 252 participants (mean age, 49.5 years; 221 female [87.7%] and 31 male [12.3%]) were randomized to undergo SC-CRA (n = 126) or TC-IRA (n = 126). At 12 months, adjusted mean (SD) WCS was 7.01 (3.31) in the SC-CRA group and 6.84 (3.68) in the TC-IRA group (adjusted mean difference, 0.17; 95% CI, –0.93 to 1.27), which fell within the prespecified noninferiority margin of 1.32 ( P = .02 for noninferiority). Early postoperative incontinence at 3 months was less frequent in the SC-CRA group than in the TC-IRA group (8.7% vs 21.4%; risk difference, –12.7%; 95% CI, –21.4% to –4.0%; P = .01). Perioperative morbidity did not differ significantly between groups (10.3% vs 12.7%; risk difference, –2.4%; 95% CI, –10.3% to 5.5%; P = .41), and quality-of-life scores at 12 months were comparable. However, patient-reported satisfaction at 12 months favored the TC-IRA group (97.5% vs 95.8%; P = .03). CONCLUSIONS AND RELEVANCE In this randomized clinical trial among patients with refractory STC, SC-CRA was noninferior to TC-IRA with respect to the WCS at 12 months, but patient-reported satisfaction at 1 year was higher in the TC-IRA group. Longer-term follow-up is needed. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT05352074 .
This quality improvement study evaluates the use of a genetic expression profile to determine whether patients with negative sentinel lymph node biopsy results and low risk per American Joint Committee on Cancer guidelines can be safely discharged postoperatively.
