Objective: The objective of this study was to determine whether perioperative continuation of code status limitations is associated with early postoperative mortality and to characterize postoperative code-status trajectories preceding early deaths. Summary Background Data: Decisions about perioperative management of do-not-resuscitate (DNR) orders are common, yet their relationship to early postoperative outcomes remains poorly understood. Methods: This was a retrospective cohort study conducted from March 2024 to June 2025 across 5 hospitals within a single academic health system. We included adults aged 18 years or older who presented for a procedure under anesthesia with a code status other than full code. The exposure was perioperative code status (reversal to full code vs. not full code). The primary outcome was all-cause mortality within 3 days of the procedure. The secondary outcome was use of invasive hemodynamic monitoring. Associations were estimated using multivariable logistic regression. Results: Among 2833 eligible patients, none were excluded. The median age was 79 years (IQR, 70–86), and 59% were women. Of 2833 patients, 2323 (82%) reversed to full code perioperatively, and 510 (18%) remained not full code. Forty-four patients (1.6%) died within 3 days. Three-day mortality occurred in 15 of 510 patients (2.9%) who remained not full code and in 29 of 2,323 patients (1.2%) who reversed to full code. After adjustment for age, sex, ASA physical status, operative stress score, and race, not full code status was associated with higher odds of 3-day mortality (adjusted odds ratio, 2.18; 95% CI, 1.14–4.16), corresponding to an adjusted absolute risk difference of 1.43% (95% CI, 0.06%–2.95%). Among patients who died within 3 days and remained hospitalized, 34 of 42 (81%) died after transition to comfort-focused care. Invasive hemodynamic monitoring was more common among patients who remained not full code (adjusted absolute risk difference, 3.74%; 95% CI, 0.91%–6.93%). Conclusions: Among adults presenting for a procedure with code-status limitations, continuation of a nonfull code status was associated with higher early postoperative mortality. This pattern reflects downstream clinical trajectories and treatment decisions rather than missed opportunities for perioperative rescue.

BACKGROUND:NRAS and BRAF mutations occur in approximately 5% and 12% of colorectal cancers, respectively, but their prognostic significance in Stage IV disease remains unclear. We hypothesized that NRAS and BRAF mutations confer worse survival and surgical outcomes, with effects modified by tumor location and microsatellite instability (MSI). METHODS:We conducted a retrospective cohort study using the National Cancer Database (2021-2023) of adults with clinical Stage IV colorectal cancer, stratified by NRAS and BRAF mutation status. A subset analysis included patients undergoing surgical resection. The primary outcome was two-year overall survival, with a secondary outcome of positive surgical margins. Cox proportional hazards and logistic regression were used for survival and surgical outcomes. RESULTS:Of 22,595 patients, 77.1% had no mutation, 15.3% BRAF, 6.2% NRAS, and 1.5% concurrent mutations. BRAF-mutant tumors were more often right-sided (51.2% vs. 26.0%, p<0.001) and MSI (28.8% vs. 4.6%, p<0.001), while NRAS-mutant tumors resembled those without mutations. On multivariable analysis, NRAS (HR=1.13, 95% CI 1.01-1.26, p=0.04), concurrent mutations (HR=1.29, 95% CI 1.05-1.60, p=0.02), and BRAF (HR=1.87, 95% CI 1.73-2.02, p<0.001) were associated with increased two-year mortality. MSI status modified this effect, with MSI/BRAF tumors associated with lower mortality (HR=0.54, p<0.001), while right-sided tumor location independently predicted increased mortality (HR=1.38, p<0.001). Only BRAF-mutant tumors were associated with an increased risk of positive surgical margins (OR=1.52, p<0.001). CONCLUSIONS:BRAF mutations confer worse survival and surgical outcomes than NRAS mutations. MSI modifies BRAF-associated risk, while right-sided location independently predicts survival. These findings refine risk stratification and surgical decision-making.

Introduction Patients undergoing colorectal surgery with fecal ostomy experience biopsychosocial challenges during recovery. We aimed (1) to describe clinician's perceived challenges with biopsychosocial recovery after ostomy surgery and (2) to examine current solutions to address patient psychosocial challenges while recovering. Methods We conducted qualitative focus groups evaluating clinician perspectives using a semistructured interview guide. Colorectal surgeons, gastrointestinal psychologists, colorectal surgery nurse practitioners, and ostomy nurses were included. Results Five interview sessions were performed including focus groups and individual interviews. Clinicians were 73% female, all White, and with varied experience (2-40 y in practice). All participants reported ostomy-related emotional distress occurs after surgery and impacts patient recovery and adaptation. Participants reported distress was mitigated when the ostomy relieved functional symptoms and in patients with time to cope with needing an ostomy due to chronic diseases. Patients with permanent ostomies were felt to adapt faster. Emotional distress increased dependence on caregivers, prolonged hospital stays, and delayed adaptation to daily life. Ostomy nurses reported they spent significant time addressing patient distress in clinical encounters. Participants reported a lack of training, time, and resources to help manage patients’ emotional distress. Conclusions Clinicians treating colorectal surgery patients with ostomy frequently note clinically significant emotional distress. This distress hinders patients’ ability to adapt to life with an ostomy. An ostomy specific distress management intervention is needed to improve biopsychosocial outcomes during surgical recovery and adaptation.

BACKGROUND:Unplanned readmission within 30 days following colorectal surgery occurs in up to 20% of older patients (≥65 years), representing a significant clinical and economic burden. Designing effective interventions to reduce readmission depends on whether risk factors are modifiable or actionable. This study identified and categorized the drivers of readmission, with a specific focus on actionable factors. METHODS:We analyzed data from 49,021 elective colectomy and proctectomy cases aged ≥65 years and discharged home in the National Surgical Quality Improvement Program from 2016 to 2020 using univariate and multivariable logistic regression. We categorized factors associated with readmission in 4 groups: (1) comorbidities, (2) preoperative clinical characteristics and geriatric vulnerabilities, (3) surgical stressors, and (4) postoperative complications before discharge. We restricted our analytic cohort to patients aged ≥65 years who were initially discharged to their home. The primary outcome was a composite of unplanned readmission or 30-day mortality. RESULTS:Unplanned readmission occurred in 4,569 (9.3%) of this sample; an additional 76 patients (0.2%) died within 30 days without a prior readmission, yielding a composite adverse outcome of 4,645 (9.5%). Among comorbidities, chronic heart failure (strongest predictor) (odds ratio, 1.96; 95% confidence interval, 1.49-2.53), insulin-dependent diabetes (odds ratio, 1.52; 95% confidence interval, 1.35-1.7), and chronic obstructive pulmonary disease (odds ratio, 1.38; 95% confidence interval, 1.23-1.55) were most strongly associated with readmission. Geriatric vulnerabilities included total functional dependence (strongest predictor) (odds ratio, 2.81; 95% confidence interval, 1.24-6.35) and preoperative hypoalbuminemia (<3.0 g/dL; odds ratio, 1.75; 95% confidence interval, 1.47-2.08). Surgical stressors-ostomy creation (odds ratio, 1.83; 95% confidence interval, 1.69-1.99), prolonged operations (>240 minutes; odds ratio, 1.87; 95% confidence interval, 1.71-2.05)-and complications (ileus: odds ratio, 5.56; 95% confidence interval, 5.16-5.98; and acute renal failure: odds ratio, 6.09; 95% confidence interval, 2.82-13.16) also increased risk. DISCUSSION:Readmissions in older adults reflect the interplay of medical, geriatric, and surgical risks, some of which are modifiable or actionable. A holistic approach that integrates perioperative optimization (eg, malnutrition), proactive comorbidity control (eg, diuretic and insulin management), and tailored postdischarge monitoring and support may mitigate readmission rates.

BACKGROUND:Patients undergoing fecal ostomy surgery often struggle to adapt to life, particularly when the surgery is performed for colorectal cancer. Maladaptation to life with an ostomy is associated with psychosocial challenges that affect daily quality of life (QoL). The aim of this systematic review was to identify interventions that address the self-care education and psychosocial needs of patients with colorectal cancer living with an ostomy and to examine their efficacy and effectiveness. METHODS:A systematic search was conducted in Ovid MEDLINE, American Psychological Association PsycInfo, Cochrane Clinical Trials, Cumulative Index to Nursing and Allied Health Literature, Embase, and Web of Science on September 10, 2025. Randomized controlled trials, prospective cohort studies, case studies, and retrospective studies of tested interventions used before or after ostomy surgery with a specific focus on patients with colorectal cancer were included. Patient-reported outcomes, including QoL, were summarized. RESULTS:A total of 14 of the 21 included studies reported a positive outcome in QoL for the intervention group. The remaining studies reported mixed results or did not use validated QoL measures. Several studies used additional resources, such as trained nurses. No study reported harm associated with the intervention. CONCLUSION:Interventions designed to improve QoL in patients with colorectal cancer after ostomy surgery showed promising improvements in patient-centered outcomes; however, these interventions are resource-intensive. Most studies reported improved QoL or no harm. Future work is needed to understand the scalability of these interventions to better support this patient population.

BACKGROUND:With the advent of enhanced recovery after surgery pathways, older adults who undergo major elective surgery return home early in the postoperative period and rely more on care-partner support. Little has been done to assess current challenges that older patient/care-partner dyads experience after major elective surgery and to identify intervention targets to improve transitions home after surgery. METHODS:This multimethods study recruited 15 dyads of major elective surgery patients aged 65+ years from 3 surgical specialties and their care-partners (30 participants total). Demographic, quality of life, and caregiver burden surveys were completed. Each participant underwent a 1-on-1 interview exploring challenges, resources received, and communication experiences. Survey data were analyzed using descriptive statistics. Interview data were analyzed deductively, mapping themes onto the 5Ms of the Geriatrics framework. RESULTS:We enrolled 6 thoracic, 5 colorectal, and 4 orthopedic patients, along with their care-partners (n = 30). Most participants were female (67%) and educated (ie, college degree +, 57%). Zarit Burden Interview surveys suggested mild-moderate burden (9.3; standard deviation, 10.38) with thoracic care-partners reporting higher burden (14.33; standard deviation, 13.98). World Health Organization quality-of-life scores were also lower among thoracic surgery dyads. The range of when the interview occurred in relation to the surgery date was 1-5 months. Qualitative analysis revealed the need for emotional support, improved anticipatory guidance about expected recovery, and assistance with activities of daily living/independent activities of daily living and medication management. CONCLUSION:Older surgical patients and their care-partners identified specific targets to improve transitions out of the hospital during surgical recovery, including enhanced communication, education, and emotional/physical support. Surgical teams, researchers, and health care system leaders can use these findings to improve care quality and support care-partners assisting older adults.

AIM:The incidence of colorectal cancer in adults <50 years old is rising, yet data to guide preoperative counselling of younger patients are limited. We hypothesized that younger adults have lower rates of anastomotic leak after anterior resection than that of older adults. METHODS:Adults undergoing elective anterior resection for nonmetastatic colorectal cancer were identified from the American College of Surgeons National Surgical Quality Improvement Program (2012-2023) and stratified by age (<50 vs ≥50 years). Multivariable analyses evaluated associations between age and postoperative outcomes, including anastomotic leak, reoperation, and respiratory and renal complications. RESULTS:Of 42,633 patients, 7213 (16.9%) were <50 years. Younger patients had lower rates of diabetes (7.0 vs. 19.3%, p < 0.001) but were more often obese (17.7 vs. 14.5%, p < 0.001) and diagnosed with rectal cancer (46.2 vs. 39.8%, p < 0.001). On univariate analysis, younger patients had similar leak rates compared with older patients (3.4 vs. 3.5%, p = 0.70) but fewer respiratory (0.7 vs. 2.2%, p < 0.001) and renal (0.9 vs. 2.3%, p < 0.001) complications. On multivariable analysis, younger age was not associated with risk of leak (OR = 1.05, p = 0.54) or reoperation (OR = 0.92, p = 0.21) but was protective against respiratory (OR = 0.40, p < 0.001) and renal (OR = 0.48, p < 0.001) complications. Protective factors against leak included faecal diversion (OR = 0.87, p = 0.03), female sex (OR = 0.61, p < 0.001), laparoscopic approach (OR = 0.75, p < 0.001), preoperative antibiotics (OR = 0.63, p < 0.001) and nonsmoking status (OR = 0.69, p < 0.001). CONCLUSION:Younger colorectal cancer patients had fewer comorbidities and medical complications but similar anastomotic leak and reoperation rates compared to older adults, highlighting the importance of preoperative counselling to guide patient expectations.

BACKGROUND:Circumferential resection margin (CRM) positivity predicts recurrence after abdominoperineal resection (APR) for rectal cancer, yet preoperative risk factors remain poorly defined. METHODS:Using the American College of Surgeons National Surgical Quality Improvement Program's proctectomy database (2016-2023), we analyzed adults undergoing elective APR for non-metastatic rectal cancer, stratified by CRM status. Univariate and multivariable analyses identified preoperative predictors of CRM positivity. RESULTS:Of 5497 patients, 10.6% had CRM+, with rates rising from 8.1% to 13.6% over the study period (p < 0.001). Independent predictors of CRM + included male sex (OR = 1.56, p < 0.001), open approach (OR = 1.47, p < 0.001), clinical T4 (OR = 2.58, p = 0.003) and N2 disease (OR = 2.74, p < 0.001), multivisceral resection (OR = 1.50, p = 0.021), and hypoalbuminemia (OR = 1.75, p < 0.001). Preoperative radiation within 90 days was protective (OR = 0.47, p < 0.001). CONCLUSION:These preoperative risk factors for CRM + after APR can guide risk stratification, patient counseling, and consideration of intraoperative frozen sections in high-risk cases.

Total proctocolectomy (TPC) with end ileostomy is performed for inflammatory bowel disease (IBD) or diffuse polyposis/malignancy, but evidence regarding robotic versus laparoscopic TPC remains limited. We hypothesized that robotic TPC is associated with lower conversion rates. We queried the National Surgical Quality Improvement Program’s proctectomy database (2016–2023) for adult patients undergoing elective TPC for IBD or polyposis/malignancy. Cases were categorized by intended approach (robotic versus laparoscopic). Conversion to open surgery served as the primary endpoint, with operative time, postoperative organ space infections, and renal complications as secondary outcomes. Among 2,035 patients, 1,505 (74

BACKGROUND:Education and support for ostomy are instrumental in surgical recovery and adaptation. This study aimed to evaluate (i) the challenges faced by fecal ostomy patients with colorectal cancer and (ii) the resources necessary for recovery. METHODS:This study recruited patients 21 to 90 days after scheduled fecal ostomy surgery for locally advanced or metastatic colorectal cancer from a single tertiary academic center. This study conducted 1:1 semistructured interviews until thematic saturation using hybrid deductive-inductive coding. RESULTS:This study interviewed 20 patients (80% male; mean age of 59.7 years). Several major themes emerged, including challenges in (i) practical ostomy management, (ii) emotional distress, (iii) adaptation to daily life, and (iv) provider relationships. The participants faced ostomy care challenges owing to peristomal skin issues, leaks, and difficulty ordering supplies. Many participants noted significant distress or anxiety related to embarrassment caused by leaks, odors, or noise. This distress led participants to fear going out in public, embarrassment from the ostomy, and anxiety about their daily activities (eg, returning to work and relationships). When adapting to life with an ostomy, several participants noted that anxiety affected their ability to care for the ostomy and resume their daily activities, leading to social isolation. Patients reported challenges with provider relationships and a lack of anticipatory guidance from the surgical team preoperatively, including insufficient education on practical management, ordering of ostomy supplies, ensuring adequate hydration, and maintaining proper nutrition. CONCLUSION:Patients with colorectal cancer who require fecal ostomy face several challenges related to ostomy. Interventions that address practical management, navigating distress, adaptation, and provider education are needed to provide tailored education and support.

INTRODUCTION:Little is known about the association between age and fecal ostomy surgery trends over time. We aim to 1) determine the rate of fecal ostomy operations over time and 2) compare rates of colostomy formation between patients older and younger than 65 y. MATERIALS AND METHODS:Retrospective multi-institutional cohort study of patients ≥18 y who underwent colorectal resection between 2003 and 2014 using the Nationwide Inpatient Sample database. Patients were identified using International Classification of Diseases, 9th edition Procedural Codes. A difference-in-difference analysis was performed to evaluate the differences in colostomy formation between age groups. RESULTS:Out of 819,441 adult patients who underwent major colorectal resection, 136,840 (16.6%) required ostomy formation. Median age was 63 y (interquartile range 51-74), 50% were female. Overall, 82,606 (10.0%) patients underwent a colostomy formation and 54,234 (6.6%) an ileostomy formation. Rates of colostomy formation decreased (13.2%-7.1% in <65 and 14.0%-7.2% in ≥65). Incidence of ileostomy formation increased for both age groups (6.1%-9.9% in <65 and 3.8%-6.3% in ≥65). The difference-in-difference analysis showed that the decline in colostomy formation was less pronounced among the older adult cohort (odds ratio 0.49, 95% confidence interval 0.47-0.50) than those <65 (odds ratio 0.42, 95% confidence interval 0.41-0.44). CONCLUSIONS:Incidence of colostomy formation decreased in both groups over the study period. In contrast, the decline in colostomy formation was slower among older adults. This highlights a significant change in surgical trends across the United States with increasing rates of ileostomy use. Appropriate resource allocation and support are vital to the recovery of this growing surgical patient population.

Objective:. Postdischarge transitions from the hospital to home in older (≥65 years) colorectal surgery patients have a high risk of medication errors, complications, and worsening of existing conditions. Up to 14% are readmitted within 30 days, costing ~$180 million annually. The anticipated 50% increase in colorectal cancer surgeries in older adults by 2040 necessitates an improvement in care transitions and outcomes. Methods:. We conducted semi-structured qualitative interviews with 10 surgeons from 8 US health systems to inform the design of a multicomponent care transition model. We selected participants through stratified purposive sampling based on experience with older surgical patients and/or leadership roles. Consolidated Criteria for Reporting Qualitative Studies guidelines were followed, and a detailed line-by-line editing and organizing style was used to analyze transcripts. Results:. The interviews identified challenges in care transitions and potential solutions, and 4 themes emerged: (1) Discharge planning should start before surgery and incorporate preoperative geriatrics evaluation and planning; (2) Coordinated communication and collaboration among multidisciplinary care teams are necessary but often lacking; (3) Educating older surgical patients and their care partners and involving them in care decisions is needed for successful management of care responsibilities after discharge; and (4) The complex and fragmented healthcare system creates care challenges postdischarge. Conclusions:. Discharge planning that begins preoperatively, integrates geriatrics domains, ensures timely and coordinated interdisciplinary communication postdischarge, and emphasizes patient and family education is essential to improve care transitions in older colorectal surgery patients. A multilevel care transition model incorporating these elements may enhance outcomes and reduce readmissions.

BACKGROUND:Evidence on the benefits of robotic vs laparoscopic approaches to abdominoperineal resection for rectal cancer is conflicting. This study aimed to determine whether the robotic approach offers a lower risk of conversion to open surgery and positive radial margins than the laparoscopic approach. METHODS:Patients who underwent elective abdominoperineal resection for rectal cancer in the 2016-2022 American College of Surgeons National Surgical Quality Improvement Program proctectomy database were stratified by the laparoscopic vs robotic approach. The primary outcomes were rates of conversion to open surgery and positive radial margins. The secondary outcomes included 30-day readmission and indication. Multivariable regressions were performed to assess outcome associations. RESULTS:Of 3925 patients, 1973 (50.3%) underwent laparoscopic resection, and 1952 (49.7%) underwent robotic abdominoperineal resection. The proportion of robotic cases increased significantly from 2016 to 2022, surpassing laparoscopic surgery (P <.001). Compared with patients who underwent laparoscopic resection, those who underwent robotic resection had a higher body mass index (≥35 kg/m²; 12.1% vs 15.2%, respectively; P <.001) and more frequent flap reconstruction (7.0% vs 11.1%, respectively; P <.001). On univariate analysis, compared with the laparoscopic approach, the robotic approach was associated with fewer conversions to open surgery (12.0% vs 3.6%, respectively; P <.001) but no difference in rates of positive radial margins (9.3% vs 10.1%, respectively; P =.41). Multivariate analysis demonstrated that the robotic approach was associated with decreased conversion rates (odds ratio [OR], 0.24; P <.001) without compromising radial margins (OR, 1.10; P =.46) but increased 30-day readmissions (OR, 1.23; P =.03), most commonly for wound or organ space infections (OR, 1.44; P =.02). CONCLUSION:Robotic abdominoperineal resection is associated with reduced risk of conversion to open surgery without compromising the circumferential resection margin. However, it is associated with increased readmission, particularly for wound and organ space infections.

Background: Patients who undergo surgery for diverticulitis have high rates of postoperative surgical site infections (SSI). The Prediction and Enaction of Prevention Treatment Trigger (PREVENTT) Scale (Ann Surg) is used to identify patients at a high risk for SSI. Objectives: We hypothesized that patients with PREVENTT score ≥ 4 who receive antibiotics may have a lower SSI rate when compared to their predicted PREVENTT score rates. Design: Pilot study using prospectively collected institutional NSQIP data. Setting: Five hospitals including two academic ones that are part of a Colorectal Surgery Collaborative. Patients and Methods: Patients who underwent colectomy for diverticulitis between January 2016 and March 2020 were included in the study. Those with PREVENTT score ≥ 4 were considered for a 4-day course of postoperative antibiotics. Main Outcome Measure: The incidence of SSI in patients with PREVENTT score ≥ 4. Sample Size: A total of 572 patients underwent surgery for diverticulitis. Results: In all, 87 patients had PREVENTT score ≥ 4, and 34 of them (39.1%) were administered a 4-day course of postoperative antibiotics, with some surgeons also prescribing antibiotics to 70 of the remaining 485 patients (14.4%), who had lower PREVENTT scores. Patients who received antibiotics had overall more baseline comorbidities, including functional dependence (1.9% vs. 0, P = 0.003), ascites (0.96% vs. 0, P = 0.034), and renal failure (1.9% vs. 0.2%, P = 0.029). In addition, they were selected via PREVENTT to have had higher rates of open surgery, intra-operative abscesses, and longer surgeries ( P < 0.05). Only 4 of the 87 patients with PREVENTT ≥ 4 (4.6%) developed SSI. This rate was significantly lower than the predicted rate of PREVENTT score (4.6% vs. 35%, P < 0.001). Conclusion: The administration of preemptive postoperative antibiotics for 4 days after surgery significantly reduced the number of SSIs. Further research is needed to confidently argue in favor of a prolonged course of antibiotics; however, our results are encouraging and can help power future studies appropriately. Limitations: No randomization and lack of long-term follow-up data. Conflict of Interest: None to report.

BACKGROUND:Risk factors for mortality after elective colorectal surgery are used to guide surgical decision-making and counseling. Initiation of comfort care reflects a more patient-oriented outcome of complicated postoperative pathways and decision-making. OBJECTIVE:This study aims to identify factors associated with initiation of comfort care after elective colectomy for colon cancer. DESIGN:Retrospective analysis of prospectively collected quality improvement data. SETTINGS:Adults undergoing elective colectomies for colon adenocarcinoma were queried from the American College of Surgeons National Surgical Quality Improvement Program and its colectomy-targeted participant use files (2021-2022). PATIENTS:Adults undergoing elective colectomies for colon adenocarcinoma. MAIN OUTCOME MEASURES:Factors associated with initiation of comfort care were identified using univariate analysis and multivariable logistic regression. Mediation analysis was performed. RESULTS:Of 33,167 patients, 311 (0.9%) initiated comfort care. On multivariable analysis, risk factors for initiation of comfort care included older age (adjusted OR 1.68, p = 0.026), dependent functional status (adjusted OR 2.93, p < 0.001), ASA classification of III or higher (adjusted OR 4.14, p < 0.001), open approach (adjusted OR 2.19, p < 0.001), and postoperative complications including delirium (adjusted OR 1.84, p = 0.036), pneumonia (adjusted OR 3.28, p < 0.001), reintubation (adjusted OR 6.24, p < 0.001), renal failure requiring dialysis (adjusted OR 2.27, p = 0.043), septic shock (adjusted OR 6.06, p < 0.001), anastomotic leak (adjusted OR 3.86, p < 0.001), and reoperation (adjusted OR 1.80, p = 0.041). 41.9% of the variance in initiation of comfort care was explained by preoperative factors, 6.5% by operative factors, and 51.6% by postoperative factors. LIMITATIONS:The retrospective design limits the granularity of analysis and inferences of causal pathways. CONCLUSIONS:More than half of patients who died within 30 days of elective colectomy for colon cancer initiated comfort care. Most of the variance in initiation of comfort care was explained by factors unknown during preoperative decision-making. Goals of care should be revisited when major postoperative complications occur. Patients and families should also be counseled that their goals of care may change as the postoperative course evolves. See Video Abstract . FACTORES ASOCIADOS CON EL INICIO DE CUIDADOS PALIATIVOS TRAS UNA COLECTOMA ELECTIVA POR CNCER DE COLON:ANTECEDENTES:Los factores de riesgo de mortalidad tras una cirugía colorrectal electiva se utilizan para orientar la toma de decisiones quirúrgicas y el asesoramiento. El inicio de los cuidados paliativos refleja un resultado más orientado al paciente en los casos de complicaciones postoperatorias y en la toma de decisiones.OBJETIVO:El objetivo de este estudio es identificar los factores asociados con el inicio de cuidados paliativos tras una colectomía electiva por cáncer de colon.DISEÑO:Análisis retrospectivo de datos de mejora de la calidad recopilados prospectivamente.ENTORNO:Se consultó al Programa Nacional de Mejora de la Calidad Quirúrgica del Colegio Americano de Cirujanos y a sus archivos de uso de participantes específicos de colectomía (2021-2022) sobre adultos sometidos a colectomías electivas por adenocarcinoma de colon.PACIENTES:Adultos sometidos a colectomías electivas por adenocarcinoma de colon.PRINCIPALES MEDIDAS DE RESULTADO:Se identificaron los factores asociados con el inicio de cuidados paliativos mediante análisis univariante y regresión logística multivariante. Se realizó un análisis de mediación.RESULTADOS:De 33 167 pacientes, 311 (0,9 %) iniciaron cuidados paliativos. En el análisis multivariable, los factores de riesgo para el inicio de cuidados paliativos incluyeron la edad avanzada (AOR 1,68, p = 0,026), el estado funcional dependiente (AOR 2,93, p < 0,001), la puntuación ASA ≥3 (AOR 4,14, p < 0,001), el abordaje abierto (AOR 2,19, p < 0,001) y complicaciones postoperatorias, como delirio (OR 1,84, p = 0,036), neumonía (OR 3,28, p < 0,001), reintubación (OR 6,24, p < 0,001), insuficiencia renal que requirió diálisis (OR 2,27, p = 0,043), shock séptico (AOR 6,06, p < 0,001), fuga anastomótica (AOR 3,86, p < 0,001) y reintervención (AOR 1,80, p = 0,041). El 41,9 % de la varianza en el inicio de los cuidados paliativos se explicó por factores preoperatorios, el 6,5 % por factores operatorios y el 51,6 % por factores postoperatorios.LIMITACIONES:El diseño retrospectivo limita la granularidad del análisis y las inferencias sobre las vías causales.CONCLUSIONES:Más de la mitad de los pacientes que fallecieron en los 30 días posteriores a una colectomía electiva por cáncer de colon iniciaron cuidados paliativos. La mayor parte de la varianza en el inicio de los cuidados paliativos se explicó por factores desconocidos durante la toma de decisiones preoperatoria. Los objetivos de los cuidados deben revisarse cuando se producen complicaciones postoperatorias graves. También se debe informar a los pacientes y a sus familias de que los objetivos de los cuidados pueden cambiar a medida que evoluciona el postoperatorio. (AI-generated translation ).

AIM:Splenic flexure mobilization (SFM) is a technique hypothesized to decrease the risk of anastomotic leak by reducing anastomotic tension. Despite biological plausibility, prior studies have not demonstrated a consistent benefit. We evaluated the association between SFM and anastomotic leak rates in a large national cohort. METHODS:This was a retrospective cohort study of the American College of Surgeons National Surgical Quality Improvement Program's colectomy-targeted database (2012-2022). Adult patients undergoing elective minimally invasive or open sigmoid colectomy without diversion for diverticular disease were included and stratified by intraoperative SFM. The primary outcome was anastomotic leak. Secondary outcomes included conversion to open approach, operating time and postoperative transfusion, acute kidney injury (AKI) and ileus. RESULTS:Of 16,963 patients meeting inclusion criteria, 54.2% (N = 9186) underwent SFM. Demographics were similar between groups, but mobilization was more likely performed with a laparoscopic approach (60.6% vs. 49.4%, p < 0.001). In univariate analysis, SFM was associated with fewer anastomotic leaks (1.7 vs. 2.2%, p = 0.028) but increased conversion to open (7.3 vs. 6.0%, p < 0.001), operating time (218 vs. 193 min, p < 0.001) and postoperative ileus (6.5 vs. 5.4%, p < 0.001). On multivariable regression, SFM was associated with a lower risk of anastomotic leak (OR = 0.79, p = 0.04) but increased operating time (28.5 min, p < 0.001), conversion to open (OR = 1.75, p < 0.001), postoperative ileus (OR = 1.21, p = 0.01), transfusion (OR = 1.22, p = 0.04) and AKI (OR = 1.41, p = 0.04). CONCLUSION:SFM is associated with a lower risk of anastomotic leak in patients undergoing sigmoid colectomy for diverticular disease, supporting its selective use when carefully weighed against the potential tradeoffs.

Understand challenges faced by older adults who undergo elective major surgery. Preparation for and recovery from elective major surgery is often described from clinician perspectives, limiting insights into older patients’ experiences. We conducted a qualitative study with adults age 65+ years, 30-90 days post colectomy, using interviews and surveys at a Northeastern U.S. tertiary surgical clinic. Guided by a modified Framework method, we arranged data into domains, themes and subthemes. We categorized patient-identified challenges using the Geriatric 5 Ms framework as deductive themes. Then, we identified additional themes and subthemes inductively. From November 2022 to August 2023, twenty patients completed the study. Themes of personal patient challenges included: the mind (i.e., coping with uncertainty, anxiety/frustration, and underappreciated cognitive challenges), mobility (i.e., physical limitations and challenges completing activities of daily living), medications (i.e., understanding medication frequency and side effects), multi-complexity (i.e., surgical recovery in the context of multi-morbidity), and what matters most (i.e., matters related to self, care-partners, and recovery expectations). Themes of process characteristics included challenges discussing the decision for surgery, understanding expectations for surgical recovery, and obtaining anticipatory guidance. Patients with fecal ostomy described heightened emotional challenges and social support needs. Modifiable challenges older adult patients perceive after elective major surgery often stemmed from perioperative anxiety, uncertainty, inadequate communication and insufficient social support. These findings can guide clinicians in optimizing surgical care and inform future research developing interventions aimed at addressing emotional stressors and enhancing communication between patients and surgical teams.

Interval to surgery following short course radiotherapy (SCRT) for rectal cancer is not standardized. This study investigated pathologic outcomes and survival with varying intervals to surgery. Using the National Cancer Database, adults who received SCRT from 2005 to 2020 were grouped by additional neoadjuvant chemotherapy. Outcomes were analyzed for early (within 1 week) and delayed (over 4 weeks) intervals. Of 1154 patients, 671 received neoadjuvant SCRT and chemotherapy (Group 1: median interval 29 days, 50

OBJECTIVE:We sought to assess the patient-perceived acceptability of mobile health technology when applied in perioperative care. Although numerous use cases demonstrate the value of mHealth, there is limited knowledge about patient perceptions of such technology, which may explain lack of broader implementation. METHODS:We conducted a descriptive qualitative study of patients at a single, large academic health system. Purposive sampling identified patients within 30-90 days after major operations (≥10% composite morbidity) across 8 specialties. Semistructured interviews were conducted and resulting transcripts were analyzed deductively by theme of acceptability, as measured by the 7 constructs of Sekhon's Acceptability Framework for Healthcare Interventions. RESULTS:Thirty patients were interviewed prior to achieving thematic saturation. Patients had a positive Affective Attitude regarding using mHealth in perioperative processes and demonstrated significant Intervention Coherence, most commonly requesting centralized instructions, simplified communication channels, and easier sharing of media. Areas of Perceived Effectiveness of mHealth included preoperative expectation management via patient- and disease-specific education as well as point-of-care preoperative instructions. Postoperatively, patients believed mHealth tracking of their physical recovery would be motivational. Few patients expressed concerns about the Ethicality of data collection, especially if limited to a prespecified time around surgery. Most interviewees expressed high Self-Efficacy when engaging mobile technology but did consider accessibility concerns regarding disadvantaged populations. CONCLUSION:Patients recovering from major operations perceived mHealth to be acceptable and effective for improving perioperative care. These findings have the potential to inform the effective implementation of mHealth to optimize patient.