Background: Total neoadjuvant therapy (TNT) is an accepted approach for the management of locally advanced rectal cancer (LARC) and is associated with a decreased risk of development of metastatic disease compared to standard neoadjuvant therapy. However, questions remain regarding surgical outcomes and local control in patients who proceed to surgery, particularly when radiation is given first in the neoadjuvant sequence. We report on our institution's experience with patients who underwent short-course radiation therapy, consolidation chemotherapy, and surgery. Methods: We retrospectively reviewed surgical specimen outcomes, postoperative complications, and local/pelvic control in a large cohort of patients with LARC who underwent neoadjuvant therapy incorporating upfront short-course radiation therapy followed by consolidation chemotherapy. Results: In our cohort of 83 patients who proceeded to surgery, a complete/near-complete mesorectal specimen was achieved in 90 % of patients. This outcome was not associated with the time interval from completion of radiation to surgery. Postoperative complications were acceptably low. Local control at two years was 93.4 % for all patients- 97.6 % for those with low-risk disease and 90.4 % for high-risk disease. Conclusion: Upfront short-course radiation therapy and consolidation chemotherapy is an effective treatment course. Extended interval from completion of short-course radiation therapy did not impact surgical specimen quality.

Aim The purpose of this study is to assess US operative trends and outcomes of ulcerative colitis (UC) patients undergoing total proctocolectomy with ileal pouch-anal anastomosis (TPC-IPAA) or completion proctectomy with IPAA (CP-IPAA). Methods Adult UC patients who underwent TPC-IPAA or CP-IPAA were analysed retrospectively using the 2016-2020 American College of Surgeons National Surgical Quality Improvement Program database. Factors associated with 30-day overall and serious morbidity were identified using multivariable logistic regression. Results A total of 1696 patients were identified, with 958 patients (56.5%) undergoing TPC-IPAA and 738 (43.5%) undergoing CP-IPAA. A greater proportion of TPC-IPAAs were performed each year (except in 2019) compared to CP-IPAAs over the study period (P trend <0.001). Unadjusted analysis showed comparable rates of overall (20.8% vs. 24.4%, P = 0.076) and serious morbidity (14.3% vs. 12.7%, P = 0.352) between TPC-IPAA and CP-IPAA patients. Robotic TPC-IPAA had no differences in complications compared to laparoscopic and open approaches. Robotic CP-IPAA had higher anastomotic leak rates and longer hospital length of stay compared to laparoscopic and open approaches. Obesity was associated with increased odds of overall and serious morbidity for patients who underwent TPC-IPAA. Steroid/immunosuppressive therapy was associated with increased odds of overall and serious morbidity for patients who underwent CP-IPAA. Conclusions Obese patients should be informed of their increased morbidity risk and offered counselling on weight loss prior to surgery when feasible. Patients on steroid/immunosuppressive therapy within 30 days preoperatively should not undergo CP-IPAA or should delay surgery until they can be safely off those medications.

Background: The decriminalization of cannabis across the United States has led to an increased number of patients reporting cannabis use prior to surgery. However, it is unknown whether preoperative cannabis use disorder (CUD) increases the risk of postoperative complications among adult colectomy patients. Methods: Adult patients undergoing an elective colectomy were retrospectively analyzed from the National Inpatient Sample database (2004-2018). To control for potential confounders, patients with CUD, defined using ICD-9/10 codes, were propensity score matched to patients without CUD in a 1:1 ratio. The association between preoperative CUD and composite morbidity, the primary outcome of interest, was assessed. Subgroup analyses were performed after stratification by age (>= 50 years). Results: Among 432,018 adult colectomy patients, 816 (0.19%) reported preoperative CUD. The prevalence of CUD increased nearly three-fold during the study period from 0.8/1000 patients in 2004 to 2.0/1000 patients in 2018 (P-trend<0.001). After propensity score matching, patients with CUD exhibited similar rates of composite morbidity (140 of 816; 17.2%) as those without CUD (151 of 816; 18.5%) (p = 0.477). Patients with CUD also had similar anastomotic leak rates (CUD: 5.64% vs. No CUD: 6.25%; p = 0.601), hospital lengths of stay (CUD: 5 days, IQR 4-7 vs. No CUD: 5 days, IQR 4-7) (p = 0.415), and hospital charges as those without CUD. Similar findings were seen among patients aged >= 50 years in the subgroup analysis. Conclusions: Though the prevalence of CUD has increased drastically over the past 15 years, preoperative CUD was not associated with an increased risk of composite morbidity among adult patients undergoing an elective colectomy.

Background Inferior mesenteric artery ligation techniques for left colon and rectal resections include stapling, using an energy device, or suture ligation based on surgeon preference. To our knowledge, no studies have demonstrated superiority of one technique over the other. Methods This retrospective study utilized an institutional database for adult rectal cancer patients undergoing total mesorectal excision (2006–2021). The association between IMA ligation technique (stapled, energy, or suture ligation) and primary outcomes of intra- and 30-day post-operative bleeding complications necessitating transfusion were assessed. Primary and secondary outcomes were analyzed using ANOVA, Pearson's Chi-squared or Fisher's exact test when appropriate. Results Among the 769 rectal cancer patients included, 69 (8.97%) underwent stapled ligation, 281 (36.54%) underwent energy ligation, and 419 (54.59%) underwent suture ligation. Patients in the suture ligation group more frequently underwent open procedures (17.39% vs 19.22% vs 92.84%; p < 0.001) compared to the stapled and energy groups, respectively. There were no differences in intra- (5.80%, 3.20%, 7.16%; p = 0.082) or post-operative bleeding necessitating transfusion (7.25%, 7.47%, 5.73%; p = 0.634). However, there was significantly more bleeding post-operatively for patients in the energy cohort compared to the suture ligation cohort when receiving an open approach (14.81% vs 5.91%: p = 0.016). There were no differences in 30-day overall morbidity, readmission, reoperation, or length of stay between groups. Conclusions Energy and stapling of the IMA is as safe as traditional IMA suture ligation, with potential benefit of suture ligation over bipolar energy in decreasing post-operative bleeding when undergoing an open approach.

An estimated 25% of patients with colorectal cancer (CRC) present with distant metastases at the time of diagnosis, the most common site being the liver. Although prior studies have reported that a simultaneous approach to resections in these patients can lead to increased rates of complications, emerging literature shows that minimally invasive surgical (MIS) approaches can mitigate this additional morbidity. This is the first study utilizing a large national database to investigate colorectal and hepatic procedure-specific risks in robotic simultaneous resections for CRC and colorectal liver metastases (CRLM). Utilizing the ACS-NSQIP targeted colectomy, proctectomy, and hepatectomy files, 1,721 patients were identified who underwent simultaneous resections of CRC and CRLM from 2016 to 2021. Of these patients, 345 (20%) underwent resections by an MIS approach, defined as either laparoscopic (n = 266, 78%) or robotic (n = 79, 23%). Patients who underwent robotic resections had lower rates of ileus compared to those who had open surgeries. The robotic group had similar rates of 30-day anastomotic leak, bile leak, hepatic failure, and post-operative invasive hepatic procedures compared to both the open and laparoscopic groups. The rate of conversion to open (8% vs. 22%, p = 0.004) and median LOS (5 vs. 6 days, p = 0.022) was significantly lower for robotic compared to laparoscopic group. This study, which is the largest national cohort of simultaneous CRC and CRLM resections, supports the safety and potential benefits of a robotic approach in these patients.

Preoperative chemotherapy, or neoadjuvant therapy (NAC) can be used to improve resectability but can also have hepatotoxic effects on the future liver remnant. The purpose of this study was to investigate the impact of NAC on 30-day morbidity among patients undergoing a resection of primary colon cancer and synchronous liver metastases (sLM). This was a retrospective study using the National Surgical Quality Improvement Program database (2012–2020). The association between NAC and 30-day overall morbidity, the primary outcome, was assessed. Subgroup analyses for low and high-risk procedures were performed. Among 968 patients who underwent the combined resection, 571 (58.99

Background: The traditional treatment paradigm for patients with locally advanced rectal cancers has been neoadjuvant chemoradiation followed by curative intent surgery and adjuvant chemotherapy. This study aimed to assess surgery trends for locally advanced rectal cancers, factors associated with forgoing surgery, and overall survival outcomes.Methods: Adults with locally advanced rectal cancers were retrospectively analyzed using the National Cancer Database (2004-2019). Propensity score matching was performed. Factors associated with not undergoing surgery were identified using multivariable logistic regression. Kaplan-Meier and log-rank tests were used for 5-year overall survival analysis, stratified by stage and treatment type.Results: A total of 72,653 patients were identified, with 64,396 (88.64%) patients undergoing neoadjuvant + surgery +/- adjuvant therapy, 579 (0.80%) chemotherapy only, 916 (1.26%) radiation only, and 6,762 (9.31%) chemoradiation only. The proportion of patients who underwent surgery declined over the study period (95.61% in 2006 to 92.29% in 2019, P trend < .001), whereas the proportion of patients who refused surgery increased (1.45%-4.48%, P trend < .001). Factors associated with not undergoing surgery for locally advanced rectal cancers included older age, Black race (odds ratio 1.47, 95% CI 1.35 -1.60, P < .001), higher Charlson-Deyo score (score >3: 1.79, 1.58-2.04, P < .001), stage II cancer (1.22, 1.17-1.28, P < .001), lower median household income, and non-private insurance. Neoadjuvant + surgery +/- adjuvant therapy was associated with the best 5-year overall survival, regardless of stage, in unmatched and matched cohorts.Conclusion: Despite surgery remaining an integral component in the management of locally advanced rectal cancers, there is a concerning decline in guideline-concordant surgical care for rectal cancer in the United States, with evidence of persistent socioeconomic disparities. Providers should seek to understand patient perspectives/barriers and guide them toward surgery if appropriate candidates. Continued standardization, implementation, and evaluation of rectal cancer care through national accreditation programs are necessary to ensure that all patients receive optimal treatment. (c) 2023 Elsevier Inc. All rights reserved.

OBJECTIVE:The objective of this study was to evaluate the effect of geriatric surgical pathway (GSP) implementation on inpatient cost of care. BACKGROUND:Achieving high-value care for older patients is the goal of the American College of Surgeons Geriatric Verification Program (ACS-GSV). We have previously shown that implementation of our geriatric surgery pathway, which aligns with the ACS-GSV standards, resulted in a reduction in loss of independence and complications. METHODS:Patients ≥65 years who underwent an inpatient elective surgical procedure included in the American College of Surgeons National Quality Improvement Program (ACS NSQIP) registry from July 2016 through December 2017 were compared with those patients from February 2018 to December 2019 who were cared for on our GSP. An amalgamation of Clinformatics DataMart, the electronic health record, and the ACS NSQIP registry produced the analytical dataset. We compared mean total and direct costs of care for the entire cohort as well as through propensity matching of frail surgical patients to account for differences in clinical characteristics. RESULTS:The total mean cost of health care services during hospitalization was significantly lower in the cohort on our GSP ($23,361±$1110) as compared with the precohort ($25,452±$1723), P <0.001. On propensity-matched analysis, cost savings was more evident in our frail geriatric surgery patients. CONCLUSIONS:This study shows that high-value care can be achieved with the implementation of a GSP that aligns with the ACS-GSV program.

Hospital length of stay (LOS) has been used as a surgical quality metric. This study seeks to determine the safety and feasibility of right colectomy as a ≤24-h short-stay procedure for colon cancer patients. This was a retrospective cohort study using the ACS-NSQIP database and its Procedure Targeted Colectomy database (2012–2020). Adult patients with colon cancer who underwent right colectomies were identified. Patients were categorized into LOS ≤1 day (≤24-h short-stay), LOS 2–4 days, LOS 5–6 days, and LOS ≥7 days groups. Primary outcomes were 30-day overall and serious morbidity. Secondary outcomes were 30-day mortality, readmission, and anastomotic leak. The association between LOS and overall and serious morbidity was assessed using multivariable logistic regression. 19,401 adult patients were identified, with 371 patients (1.9

Background and ObjectivesOver 25% of patients diagnosed with colorectal cancer (CRC) will develop colorectal liver metastases (CRLM). Controversy exists over the surgical management of these patients. This study aims to investigate the safety of a simultaneous surgical approach by stratifying patients based on procedure risk and operative approach. MethodsUsing ACS-NSQIP (2016-2020), patients with CRC who underwent isolated colorectal, isolated hepatic, or simultaneous resections were identified. Colorectal and hepatic procedures were stratified by morbidity risk (high vs. low) and operative approach (open vs. minimally invasive). Thirty-day overall morbidity was compared between risk matched isolated and simultaneous resection groups. ResultsA total of 65 417 patients were identified, with 1550 (2.4%) undergoing simultaneous resections. A total of 1207 (77.9%) underwent a low-risk colorectal and low-risk liver resection. On multivariate analysis, there was no significant difference in overall morbidity between patients who had a simultaneous open high-risk colorectal/low-risk hepatic procedure compared to patients who had an isolated open high-risk colorectal procedure (odds ratio: 1.19; 95% confidence interval: 0.94-1.50; p = 0.148). All other combinations of simultaneous procedures had statistically significant higher rates of morbidity than the isolated group. ConclusionsSimultaneous resection of colorectal and synchronous CRLM is associated with an increased risk of morbidity in most circumstances in a risk stratified analysis, although rates of readmission and reoperation were not increased. Minimally invasive surgical approaches may significantly mitigate this morbidity.

Introduction: The purpose of this study was to assess colorectal surgery outcomes, discharge destination, and readmission in the United States during the COVID-19 pandemic.Methods: Adult colorectal surgery patients in the American College of Surgeons National Surgical Quality Improvement Program database (2019-2020) and its colectomy and proc-tectomy procedure-targeted files were included. The prepandemic time period was defined from April 1, 2019 to December 31, 2019. The pandemic time period was defined from April 1, 2020 to December 31, 2020 in quarterly intervals (Q2 April-June; Q3 July-September; Q4 October-December). Factors associated with morbidity and in-hospital mortality were assessed using multivariable logistic regression.Results: Among 62,393 patients, 34,810 patients (55.8%) underwent colorectal surgery pre -pandemic and 27,583 (44.2%) during the pandemic. Patients who had surgery during the pandemic had higher American Society of Anesthesiologists class and presented more frequently with dependent functional status. The proportion of emergent surgeries increased (12.7% prepandemic versus 15.2% pandemic, P < 0.001), with less laparoscopic cases (54.0% versus 51.0%, P < 0.001). Higher rates of morbidity with a greater proportion of discharges to home and lesser proportion of discharges to skilled care facilities were observed with no considerable differences in length of stay or worsening readmission rates. Multivariable analysis demonstrated increased odds of overall and serious morbidity and in-hospital mortality, during Q3 and/or Q4 of the 2020 pandemic.Conclusions: Differences in hospital presentation, inpatient care, and discharge disposition of colorectal surgery patients were observed during the COVID-19 pandemic. Pandemic responses should emphasize balancing resource allocation, educating patients and pro-viders on timely medical workup and management, and optimizing discharge coordination pathways.(c) 2023 Published by Elsevier Inc.

Multivisceral robotic surgery may be an alternative to sequential procedures in select patients with colorectal cancer who are diagnosed with synchronous lesions or in those who require additional procedures at the time of resection. The aim of this study was to assess utilization of the robot for multivisceral resections and compare the surgical outcomes of this approach to laparoscopic resections. Adult colorectal surgery patients who underwent a colectomy or proctectomy and a concurrent abdominal surgery procedure in the American College of Surgeons NSQIP database (2016–2021) were included. The primary outcomes were 30-day postoperative overall and serious morbidity. Factors associated with morbidity were assessed using a multivariable logistic regression. Of the 3875 patients who underwent simultaneous multivisceral resections, 397 (10.3

PURPOSE:The purpose of his study was to report on a cohort of patients managed with nonoperative management (NOM) with a watch-and-wait strategy after achieving complete response (CR) to sequential short-course radiation therapy (SCRT) and consolidation chemotherapy.METHODS:This was a retrospective study of patients treated SCRT and chemotherapy who achieved a CR and were managed with NOM. Bowel function was assessed with European Organisation for Research and Treatment of Cancer (EORTC) Quality of Life Questionnaire Core 30, EORTC Quality of Life Questionnaire-Colorectal Cancer 29, and the low anterior resection syndrome (LARS) questionnaires. Endpoints included overall survival (OS), freedom from local failure (FFLF), freedom from distant metastasis, and disease-free survival (DFS).RESULTS:Twenty-six patients met inclusion criteria. Seven (26.9%) patients developed local failure at a median of 6.8 months following CR, of which 5 were successfully salvaged. Median FFLF was not reached, with 6-month, 1-, and 2-year FFLF rates of 100.0%, 82.3%, and 71.3%. Median OS was not reached, with 6-month, 1-, and 2-year OS rates of 100%. Median DFS was not reached, with 6-month, 1-, and 2-year DFS rates of 100%, 95.0%, and 89.4%. Questionnaire response rate was 83.3%. Median LARS score was 27. Major, minor, and no LARS occurred in 3 (20%), 6 (40%), and 6 (40%) patients, respectively. There were no differences in questionnaire scores between patients who had the majority of their anal sphincter complex irradiated and those who did not.CONCLUSION:NOM with a watch-and-wait strategy is safe and feasible in patients with locally advanced rectal cancer who achieve CR after sequential SCRT and chemotherapy, with evidence for good anorectal function.

BACKGROUND:The worsening opioid epidemic has led to an increased number of surgical patients with chronic preoperative opioid use. However, the impact of opioids on perioperative outcomes has yet to be fully elucidated. The purpose of this study was to assess the association between preoperative opioid dose and surgical outcomes among colectomy patients.METHODS:Adult colectomy patients in the IBM MarketScan database (2010-2017) were stratified based on preoperative opioid dose, calculated as the average opioid dose in morphine milligram equivalents (MME) in the 90 days prior to surgery: 0 MME, 1 to 49 MME, and 50 or more MME. The association between preoperative opioid dose and anastomotic leak, the primary outcome of interest, as well as other postoperative complications, was assessed using multivariable regression.RESULTS:Among 45,515 adult colectomy patients, 71.4% did not use opioids (0 MME), 27.4% had an opioid dose between 1 and 49 MME, and 1.2% had an opioid dose at or above 50 MME. Patients with preoperative opioid use exhibited a higher incidence of anastomotic leak (0 MME: 4.8%, 1-49 MME: 5.5%, ≥50 MME: 8.3%; p trend = 0.001). Multivariable analysis demonstrated a dose-response relationship between preoperative opioids and surgical outcomes, as the odds of anastomotic leak worsened with increasing opioid dose (1-49 MME: OR 1.19, 95% CI 1.08-1.31, p < 0.001; ≥50 MME: OR 1.64, 95% CI 1.20-2.24, p = 0.002). Similar dose-response relationships were seen after risk-adjustment for lung complications, pneumonia, delirium, and 30-day readmission (p < 0.05 for all).CONCLUSIONS:Providers should exercise caution when prescribing opioids preoperatively, as increasing doses of preoperative opioids were associated with worse surgical outcomes and higher 30-day readmission among adult colectomy patients.

BACKGROUND: Readmission after ileostomy creation in patients undergoing colorectal surgery creates a significant burden on health care cost and patient quality of care, with a 30-day readmission rate of 40%. OBJECTIVE: This study aimed to evaluate the implementation of our perioperative quality improvement program, Decreasing Readmissions After Ileostomy Creation. DESIGN: Perioperative interventions were administered to patients who underwent ileostomy creation. SETTINGS: A single tertiary care academic center. PATIENTS: Eighty patients participated in this program from February 2020 to January 2021. MAIN OUTCOME MEASURES: The primary outcomes measured were 30-day readmission rates and causes of readmission, which were compared to a historical national database. Descriptive statistics were used to evaluate the effectiveness of this quality improvement program. RESULTS: Eighty patients were enrolled in this prospective quality improvement program. The mean age was 52 (±15.06) years. The most common indication for patients undergoing creation of an ileostomy was colorectal cancer (40%; n = 32). The overall 30-day readmission rate was 8.75% (n = 7) throughout the study period, which was significantly lower than historical cohort data (20.10%; p = 0.01). Among the 7 readmitted patients, 3 (3.75%) were readmitted due to dehydration. The most significant associated risk factor for all-cause readmission was urgent/emergent operative status, which was associated with an increased risk of readmission (p = 0.01). The 3 readmitted patients with dehydration had a mean Dehydration Readmission After Ileostomy Prediction risk score of 11.71 points, compared to 9.59 points in nondehydrated patients, who did not require readmission (p = 0.38). LIMITATIONS: This study is limited by its small sample size (N = 80). CONCLUSIONS: The Decreasing Readmissions After Ileostomy Creation program has been successful in reducing both the all-cause readmission rate and readmission due to dehydration both within an academic tertiary care referral center and in comparison with historical readmission rates. See Video Abstract at http://links.lww.com/DCR/B894. DISMINUCIÓN DE LA READMISIÓN DESPUÉS DE LA CREACIÓN DE UNA ILEOSTOMÍA MEDIANTE UN PROGRAMA DE MEJORA DE LA CALIDAD PERIOPERATORIA ANTECEDENTES: La readmisión después de la creación de una ileostomía en pacientes de cirugía colorrectal crea una carga significativa sobre el costo de la atención médica y la calidad de la atención del paciente, con una tasa de readmisión a los 30 días que llega al 40%. OBJETIVO: Este estudio tiene como objetivo evaluar la implementación de nuestro programa de mejora de la calidad perioperatoria que disminuyen los reingresos después de la creación de ileostomía. DISEÑO: Se administraron intervenciones perioperatorias a pacientes que se sometieron a la creación de una ileostomía. AJUSTE: Se trataba de un único centro académico de atención terciaria. PACIENTES: Participaron 80 pacientes en este programa desde febrero de 2020 hasta enero de 2021. PRINCIPALES MEDIDAS DE RESULTADO: Los principales resultados medidos fueron las tasas de reingreso a los 30 días y las causas de reingreso, que se compararon con una base de datos histórica nacional. Se utilizaron estadísticas descriptivas para evaluar la eficacia de este programa de mejora de la calidad. RESULTADOS: Ochenta pacientes se inscribieron en este programa prospectivo de mejora de la calidad. La edad media fue de 52 (± 15,06) años. La indicación más común para los pacientes que se sometieron a la creación de una ileostomía fue el cáncer colorrectal (40%, n = 32). La tasa general de reingreso a los 30 días fue del 8,75% (n = 7) durante todo el período de estudio, lo que fue significativamente más bajo que los datos históricos de la cohorte (20,10%, p = 0,01). Entre los 7 pacientes readmitidos, tres (3,75%) fueron readmitidos por deshidratación. El factor de riesgo asociado más significativo para la readmisión por todas las causas fue el estado operatorio urgente / emergencia, que se asoció con un mayor riesgo de readmisión (p = 0,01). Los tres pacientes readmitidos con deshidratación tuvieron una puntuación de riesgo promedio de readmisión por deshidratación después de la predicción de ileostomía de 11,71 puntos, en comparación con los pacientes no deshidratados, que no requirieron readmisión (media, 9,59 puntos, p = 0,38). LIMITACIONES: Este estudio está limitado por su pequeño tamaño de muestra (n = 80). CONCLUSIONES: El programa de disminución de las readmisiones después de la creación de una ileostomía ha logrado reducir tanto la tasa de readmisión por todas las causas como la readmisión por deshidratación, tanto dentro de un centro académico de referencia de atención terciaria como en comparación con las tasas históricas de readmisión. Consulte Video Resumen en http://links.lww.com/DCR/B894. (Traducción—Dr Yolanda Colorado)

Background and Aims:Adalimumab (ADA) transport across the placenta increases with gestational age advances. We evaluated child-mother health outcomes related to the timing of the last ADA dose before delivery. Methods:Using IBM MarketScan data, we collected records for all children exposed to ADA during intrauterine life. We compared milestone achievements, congenital malformations, and respiratory infections rates in children from mothers of 2 groups: (1) a late ADA group, which continued therapy until 90 days or fewer before delivery; and (2) an early ADA group, which discontinued therapy more than 90 days before delivery. We also assessed the risk of flaring for mothers in the early group. Results:There were no significant differences in growth (P = .48), developmental delays (P = .25), or congenital malformations (P = .61) in the 427 children of the late group vs 70 children of early ADA group. Continuing ADA late in pregnancy did not increase the respiratory infection rate (P = .38). No differences occurred between groups in cesarean and premature delivery, intrauterine growth retardation, and stillbirths. ADA discontinuation was the only predictor of flaring in the third trimester of pregnancy (odds ratio = 6.04, 95% confidence interval 2.66-13.7). In the late group, mothers' risk of flaring decreased (16/447 vs 13/73, P < .001). Mothers with active disease were more likely to deliver prematurely vs mothers with quiet disease (6/29 vs 31/491, P = .003). Conclusion:Continuation of ADA in pregnancy close to delivery is of low risk for children. Early discontinuation, however, increases the risk of flaring in mothers and the likelihood of premature deliveries.

Depression is a prevalent disorder that is associated with adverse health outcomes, but an understanding of its effect in colorectal surgery remains limited. The purpose of this study was to examine the impact of history of depression among patients undergoing colectomy. United States patients from Marketscan (2010–2017) who underwent colectomy were included and stratified by whether they had a history of depression within the past year, defined as (1) a diagnosis of depression during the index admission, (2) a diagnosis of depression during any inpatient or (3) outpatient admission within the year, and/or (4) a pharmacy claim for an antidepressant within the year. The primary outcomes were length of stay (LOS) and inpatient hospital charge. Secondary outcomes included in-hospital mortality and postoperative complications. Logistic, negative binomial, and quantile regressions were performed. Among 88 981 patients, 21 878 (24.6%) had a history of depression. Compared to those without, patients with a history of depression had significantly longer LOS (IRR = 1.06, 95% CI [1.05, 1.07]), increased inpatient charge (β = 467, 95% CI [167, 767]), and increased odds of in-hospital mortality (OR = 1.37, 95% CI [1.08, 1.73]) after adjustment. History of depression was also independently associated with increased odds of respiratory complication, pneumonia, and delirium (all P  < 0.05). History of depression was prevalent among individuals undergoing colectomy, and associated with greater mortality and inpatient charge, longer LOS, and higher odds of postoperative complication. These findings highlight the impact of depression in colorectal surgery patients and suggest that proper identification and treatment may reduce postoperative morbidity.

Key Points Question Did the rates of avoidable complications and hospital costs among surgical patients change after the implementation of Maryland’s all-payer model, which caps hospital expenditures and mandates reductions in avoidable complications? Findings In this comparative effectiveness study of 525 262 Maryland patients who received surgery before and after implementation of Maryland’s all-payer model, lower complication rates were observed for coronary artery bypass grafting (11% decrease), carotid endarterectomy (2% decrease), hip arthroplasty (1% decrease), knee arthroplasty (<1% decrease), and cesarean delivery (1% decrease). Smaller estimated changes in hospital costs vs other states were also observed, with increases reduced by $6236 for coronary artery bypass grafting, $730 for carotid endarterectomy, $328 for hip arthroplasty, $415 for knee arthroplasty, $300 for cesarean delivery, and $745 for hysterectomy. Meaning This study found that after implementation of the all-payer model in Maryland, the rates of avoidable complications decreased, and a slower increase in hospital costs occurred across an array of surgical procedures.

Background: There is a strong association between hospital volume and surgical outcomes in resectable colorectal cancer. The purpose of our study was to investigate the association between hospital facility type and survival of patients with metastatic colorectal cancer. Methods: Adults from the National Cancer Database (2010-2015) with a primary diagnosis of colorectal metastases were included and stratified by facility type: community cancer program, comprehensive community cancer program, and academic/research program. The primary outcome was 5-year overall survival, analyzed using Kaplan-Meier survival curves, log-rank test, and the Cox proportional hazards regression model. Results: Among the 52,958 included patients, 13.72% were treated at a community cancer program, 49.89% at a comprehensive community cancer program, and 36.29% at an academic/research program. A significant increase in the proportion of patients being treated in an academic/research program has been observed from 2010 to 2015. An academic/research program tended to use more chemotherapy with colorectal radical resection and liver or lung resection and immunotherapy with chemotherapy. In adjusted analysis, the academic/research program had decreased risk of mortality in comparison to the community cancer program and the comprehensive community cancer program (hazard ratio 0.90, 95% confidence interval 0.86-0.94; 0.87, 0.85-0.90; each P < .001; respectively). Similar results were seen after stratifying by metastatic site and treatment type. Conclusion: The prognosis and overall survival of patients with metastatic disease is better in an academic/research program compared with a community cancer program or a comprehensive community cancer program, with this difference persisting across sites of metastatic disease and treatment types. Further studies are required to validate these results and investigate disparities in the management of metastatic colorectal cancer. (C) 2020 Elsevier Inc. All rights reserved.