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:Inflammatory bowel disease (IBD) may be associated with cognitive impairment. Cognitive decline is also linked to weaker anesthesia-induced alpha wave electroencephalographic (EEG) signals. We aimed to characterize the associations between cognition and EEG alpha power in patients with IBD. METHODS:In this prospective cohort study, patients with IBD and controls undergoing diagnostic or screening colonoscopies underwent preprocedural cognitive testing using the tablet-based brain health assessment (BHA), intraprocedural EEG monitoring, and follow-up testing. Primary outcomes were BHA scores and EEG alpha power. Secondary outcomes included within-participant changes in cognitive performance. RESULTS:We enrolled 40 patients with IBD and 42 control patients. Fifteen patients with IBD and 17 controls completed follow-up cognitive testing 6-18 months after endoscopy. Patients with IBD were younger (mean age 42 vs 56 years, P < 0.001), were more likely to screen positively for depression ( P = 0.004), and had fewer years of education (16.2 vs 17.3 years, P = 0.03). Fifteen patients with IBD had active endoscopic inflammation. Adjusting for demographics, education level, and depression, EEG alpha power did not differ between groups. Median BHA scores indicated moderate likelihood of cognitive impairment in both groups. However, controls demonstrated improved within-participant follow-up performance ( P < 0.01), whereas patients with IBD did not ( P = 0.16). DISCUSSION:Patients with IBD and controls demonstrate preprocedural cognitive impairment on BHA, but no differences in EEG alpha power. Lack of follow-up improvement in patients with IBD may suggest lower baseline cognitive function while highlighting the importance of further investigations on cognition in this population.

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

To evaluate the feasibility and diagnostic performance of 68Ga-CBP8 PET/MR enterography for noninvasive detection of bowel collagen deposition and differentiation of inflammatory from fibrotic or mixed strictures in Crohn’s disease. Patients with stricturing Crohn’s disease scheduled for bowel resection or endoscopic biopsy were prospectively enrolled. PET/MR enterography was performed after intravenous administration of 68Ga-collagen binding probe 8 (68Ga-CBP8). Focal radiotracer uptake was defined as activity exceeding local background and anatomically corresponding to an MR-identified bowel stricture. Surgical and biopsy specimens underwent blinded pathologic evaluation for fibrosis. Descriptive statistics, sensitivity and specificity were calculated to assess diagnostic performance. Differences in SUVmax and SUVmax stricture-to-uninvolved bowel ratio between fibrotic and non-fibrotic segments were evaluated using the Mann–Whitney U test, with p < 0.05 considered statistically significant. Five patients (4 M, 1 F; median age: 50; IQR: 11) with seven strictured bowel segments (median length: 24 mm; IQR: 14) were included. Five segments (71.4

BACKGROUND:With estimated global postoperative mortality rates at 1% to 4% leading to approximately 3 million to 12 million deaths per year, an urgent need exists for reliable measures of perioperative risk. Existing approaches suffer from poor performance, place a high burden on clinicians to gather data, or do not incorporate intraoperative data. Previous work demonstrated that intraoperative anesthetics induce prefrontal electroencephalogram (EEG) oscillations in the alpha band (8 to 12 Hz) that correlate with postoperative cognitive outcomes. METHODS:The authors analyzed a retrospective cohort of 1,081 patients undergoing surgery with general anesthesia at Massachusetts General Hospital (Boston, Massachusetts) with intraoperative EEG recordings. The association between EEG alpha power and adverse outcomes was characterized using statistical models that were fitted on propensity weighted data. The primary outcome was postoperative mortality, measured from date of surgery to date of death or last follow-up. Secondary outcomes included mortality within prespecified time windows (30 days, 90 days, 180 days, and 1 yr), hospital and postanesthesia care unit lengths of stay, discharge to long-term care, and 30-day hospital readmission. RESULTS:Alpha power was associated with mortality risk (hazard ratio, 0.92; 95% CI, 0.85 to 0.99; P = 0.039). Within specified time windows, alpha power was associated with 30-day mortality (odds ratio, 0.81; 95% CI, 0.66 to 0.95; P = 0.010), 90-day mortality (odds ratio, 0.68; 95% CI, 0.55 to 0.79; P < 0.001), 180-day mortality (odds ratio, 0.75; 95% CI, 0.66 to 0.83; P < 0.001), and 1-yr mortality (odds ratio, 0.85; 95% CI, 0.79 to 0.91; P < 0.001). Additionally, alpha power was associated with discharge to long-term care (odds ratio, 0.91; 95% CI, 0.86 to 0.96; P < 0.001). We did not find significant associations among alpha power and 30-day readmission and hospital or postanesthesia care unit lengths of stay. CONCLUSIONS:Intraoperative EEG alpha power is independently associated with postoperative mortality and adverse outcomes, suggesting it could represent a broad measure of postoperative physical resilience and provide clinicians with a low-burden, personalized measure of postoperative risk.

BACKGROUND:Obesity is associated with an increased risk of conversion to open surgery, which in turn is associated with worse postoperative outcomes. We hypothesize that, with its improved ergonomics and instrument dexterity, the robotic approach to right colectomy will be associated with a decreased risk of conversion to open compared with laparoscopic right colectomy (LRC). METHODS:Obese adults (body mass index [BMI], ≥30 kg/m2) undergoing elective LRC or robotic right colectomy (RRC) for colon adenocarcinoma (2015-2022) were identified from the American College of Surgeons National Surgical Quality Improvement Program and its colectomy-targeted participant user file. The primary outcome was conversion to open surgery. Secondary outcomes included operative time and the development of postoperative complications. RESULTS:A total of 11,026 patients (81.9%) underwent LRC, and 2430 (18.1%) underwent RRC. Patients undergoing RRC were younger (64.8 vs 65.8 years; P <.001), more likely to be White (77.9% vs 67.9%; P <.001), and more obese (BMI, 36.1 vs 35.5 kg/m2; P <.001). On multivariate analysis, RRC remained associated with decreased conversion to open surgery (odds ratio [OR], 0.55; P <.001) but increased operative time (b = 51.8 min; P <.001) and a higher incidence of postoperative kidney injury (OR, 2.10; P <.001). There were no differences in the rates of postoperative transfusion, surgical site infection, or anastomotic leak. CONCLUSION:In patients with obesity, RRC is associated with a nearly 50% reduction in conversion rate but increased operative time. Given the difficulties of converting to open in patients with obesity and worse postoperative outcomes associated with conversion, the robotic platform may be beneficial for patients with obesity who require a right colectomy.

OBJECTIVE:To validate the utility of recurrence prediction value (RPV) in identifying patients with UICC stage II colon cancer who would benefit from adjuvant chemotherapy (AC). SUMMARY BACKGROUND DATA:The benefits of AC in Stage II colon cancer remain insufficient. METHODS:We performed a multi-institutional international retrospective analysis of patients with Stage II colon cancer who had undergone surgery. RPV was developed based on the weighting of each high-risk factor. Data from multi-institutional databases in Japan, the United States, and Jordan were used (cohort 1). In addition, nationwide data were obtained from Denmark (Cohort 2). The primary endpoint was recurrence-free survival (RFS). RESULTS:According to the RPV, a low score was found in 750 (70.2%) patients and high scores in 318 (29.8%) patients in cohort 1. The corresponding numbers were 1031 (70.4%) and 433 (29.6%) patients in cohort 2, respectively. The five-year RFS rates were significantly higher in the group of patients who received AC than in the group who did not in the RPV high sub-group of cohort1 (76.2% vs. 55.6%, P <0.001) and in cohort2 (65.6% vs. 49.8%, P=0.001). Multivariate analyses revealed that AC was an independent prognostic factor for RFS only in the RPV high sub-group of both cohort 1 (hazard ratio (HR) 0.48; 95% confidence interval (CI) 0.29-0.81; P=0.005) and cohort2 (HR 0.69; 95% CI 0.48-0.99; P=0.043). CONCLUSIONS:This global study validates a readily available clinical data-based algorithm for predicting recurrence in Stage II colon cancer, identifying patients across diverse populations who benefit significantly from AC.

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.

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: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.

BACKGROUND:The Perioperative Optimization of Senior Health (POSH) clinic was established to address vulnerabilities and improve outcomes in frail older patients. This study describes the results of comprehensive perioperative optimization by the POSH interdisciplinary team (IDT) in patients who underwent colorectal surgery. METHODS:Frail patients planned for colorectal surgery and enrolled in the POSH clinic (10/2021-09/2023) were retrospectively identified. Descriptive statistics were used to summarize the findings of preoperative geriatric assessment and postoperative outcomes. Outcomes were compared with a contemporary propensity-matched cohort using chi-squared analysis and two-sample t-tests for categorical and continuous variables, respectively. RESULTS:Thirty-six patients with a median age of 80 years and a mean Charlson Comorbidity Index of 6.11 were planned for colorectal surgeries, most commonly colectomy (62.1%) and ostomy reversal (20.7%). Twenty-nine patients underwent surgical management after interdisciplinary optimization in the POSH clinic. The most common interventions recommended included advance care planning (86.2%), physical therapy (55.2%), and medication management (34.5%). Postoperatively, 75% of patients were discharged home, and there were no mortalities within 90 days. There were no significant differences in postoperative outcomes when compared to a contemporary propensity-matched cohort. The remaining seven patients enrolled in POSH did not undergo surgical management after surgery was deemed inconsistent with their goals of care, and three of these patients expired within 1 year of evaluation in POSH. CONCLUSIONS:The POSH model provides high-risk patients with individualized risk stratification, comprehensive interdisciplinary strategies for risk mitigation, and alignment of care with patient goals. When elective colorectal surgery was within their goals of care, frail older adults safely underwent operative intervention after careful perioperative optimization. Future studies should include a mixed-method exploration of the patient perspective and a randomized controlled trial to quantify the impact of the POSH clinic on short- and long-term postoperative outcomes.