CASE SUMMARY: A healthy 52-year-old woman without any family history presents for a health maintenance appointment and opts for a fecal immunochemical test for colorectal cancer screening after reviewing her options. After a positive result, she is referred for colonoscopy. She is found to have 3 small (<10 mm) polyps that are completely resected via snare polypectomy and return as tubular adenomas on histologic examination. It is recommended that she return for repeat colonoscopy in 3 years, at which point she has a normal examination with excellent preparation by an experienced endoscopist and is given the option to return to her average-risk screening interval.

Background: We sought to identify patterns of care for patients with appendiceal cancer and identify clinical factors associated with patient selection for multimodality treatment, including cytoreductive surgery and perioperative intraperitoneal chemotherapy (CRS/PIC). Materials and methods: National Cancer Database (NCDB) data from 2004 to 2014 of all diagnoses of appendiceal cancers were examined. We examined treatment modalities, as well as demographic, tumor-specific, and survival data. A multivariate logistic regression analysis was performed to determine the patient cohort most likely to receive CRS/PIC. Kaplan-Meier was used to estimate survival for all treatment groups. Significance was evaluated at P <= 0.05. Results: We analyzed data on 18,055 patients. Nine thousand nine hundred ninety-two (55.3%) were treated with surgery only, 5848 (32.4%) received surgery and systemic chemotherapy, 1393 (7.71%) received CRS/PIC, 520 (2.88%) received chemotherapy alone, and 302 (1.67%) received neither surgery nor chemotherapy. Significant predictors of receiving CRS/PIC included male sex (OR 1.33, 95% CI: 1.11-1.59), white race (OR 2.00, 95% CI 1.40-2.86), non-Hispanic ethnicity (OR 1.92, 95% CI 1.21-3.05), private insurance (OR 1.52, 95% CI 1.26-1.84), and well-differentiated tumors (OR 4.25, CI: 3.39-5.32) (P < 0.05). Treatment with CRS/PIC was associated with a higher 5-year survival for mucinous malignancies, when compared to surgery alone (65.6% versus 62.4%, P < 0.01). Treatment with CRS/PIC was also associated with higher 5-year survival for well-differentiated malignancies, when compared to all other treatment modalities (74.9% versus 65.4%, P < 0.01). Conclusions: Patients were more likely to undergo CRS/PIC if they were male, white, privately insured, and with well-differentiated tumors. CRS/PIC was associated with improved survival in patients with mucinous and low-grade tumors. (C) 2019 Elsevier Inc. All rights reserved.

Diverticulitis in immunocompromised patients is of special clinical importance because these patients experience a higher rate of morbidity and mortality than the general population due to diverticulitis. Immunocompromised patients tend to present later than the general population and may have less impressive findings on physical exam and CT scan. They are more likely to fail non-operative management and have more complications after emergent surgery. Just like in immunocompetent patients, the decision to pursue elective colectomy after diverticulitis is individualized to the patient's risk of surgery, co-morbidities, effect on lifestyle, chronic symptoms, or severity of attacks.

Background: Benign anal diseases, including hemorrhoids, fissures, abscesses, fistulas, and anal condylomata, affect 10%-15% of our population. Most patients seen by nonsurgical providers experience delayed treatment. We examined at our institution whether an educational session on anorectal diseases would benefit trainees from medical and surgical specialties. Materials and Methods: The study took place at Oregon Health & Science University, a primary institutional practice with 130 resident participants. An exploratory study using a 10-point pretest and posttest regarding these diseases was designed and administered to medical subspecialties, including general surgery (GS), emergency medicine, internal medicine, and family medicine, obstetrics/gynecology, and pediatric residents. Intervention was a 50-min presentation highlighting anatomy, history and physical findings, and disease treatment. The posttest was repeated after 6 mo to evaluate retention and overall satisfaction, and differences were evaluated. Results: With the exception of GS, posttest scores improved. Internal medicine improved most significantly. GS residents scored better on the pretest than other specialties; their posttest scores, however, declined. The survey demonstrated residents with prior education scored better on the pretest. PGY-1 and PGY-2 residents improved most on their posttest. On 6-mo retest, 17.6% of residents responded and posttest performance was 72%. Conclusions: Nonsurgical residents have limited knowledge about benign anal diseases but demonstrate improvement after educational intervention. Surgery residents performed well, but demonstrate regression to the mean, common in test taking, but may also require a more advanced lecture. Formal institutional, regional, and national educational interventions are needed to improve the understanding of these diseases. (C) 2019 Elsevier Inc. All rights reserved.

Background: Many colorectal cancer patients receive complex surgical care remotely. We hypothesized that their readmission rates would be adversely affected after accounting for differences in travel distance from primary/index hospital and correlate with mortality. Materials and methods: We identified 48,481 colorectal cancer patients in the Surveillance, Epidemiology and End Results (SEER)-Medicare database. Travel distance was calculated, using Google Maps, and SAS. Multivariate negative binomial regression was used to identify factors associated with readmission rates. Overall survival was analyzed, using KaplaneMeier and Cox proportional hazard. Results and conclusions: Thirty-day readmissions occurred in 14.9% of the cohort, 27.5% of which were to a nonindex hospital. In the colon and rectal cancer cohorts, readmissions were 14.5% and 16.5%, respectively. Rectal cancer patients had an increase in readmission by 13% (incidence rate ratios [IRR] 1.13; 95% confidence interval [CI] 1.05-1.21). Factors associated with readmission were male gender, advanced disease, length of stay (LOS), discharge disposition, hospital volume, Charlson score, and poverty level (P < 0.05). Greater distance traveled increased the likelihood of readmission but did not affect mortality. Travel distance influences readmission rates but not mortality. Discharge readiness to decrease readmissions is essential for colorectal cancer patients discharged from index hospitals. (C) 2018 Elsevier Inc. All rights reserved.

BACKGROUND: The Fundamentals of Endoscopic Surgery examination is required for all general surgery residents. The test modules are not available for practice before the examination; however, similar modules are commercially available. OBJECTIVE: This study aims to determine which modules are most valuable for resident training and preparation for the examination by evaluating which correlates best with experience level. DESIGN: This was a single-institution study. SETTING: A virtual reality endoscopy simulator was utilized. PARTICIPANTS: General surgery residents and faculty endoscopists performed endoscopy simulator modules (Endobasket 2, Endobubble 1 and 2, Mucosal Evaluation 2, and Basic Navigation) designed to prepare residents for the Fundamentals of Endoscopic Surgery examination. Residents were assigned into junior and senior groups based on the completion of a dedicated endoscopy rotation. MAIN OUTCOME MEASURES: The primary outcomes measured were the mean time to completion, mean number of balloons popped, and mean number of wall hits for the 3 groups. RESULTS: A total of 21 junior residents, 11 senior residents, and 3 faculty participated. There were significant differences among groups in the mean time to completion for the Endobasket, Endobubble, and Mucosal Evaluation modules. The modules that correlated best with experience level were Endobubble 2 and Mucosal Evaluation 2. For Endobubble 2, juniors were slower than seniors, who were in turn slower than faculty (junior 118.8 ± 20.55 seconds, senior 100.3 ± 11.78 seconds, faculty 87.67 ± 2.848 seconds; p < 0.01). Juniors popped fewer balloons than seniors, who popped fewer balloons than faculty (junior 9.441 ± 3.838, senior 15.62 ± 4.133, faculty 28.78 ± 1.712; p < 0.001). For Mucosal Evaluation 2, juniors were slower than seniors, who were in turn slower than faculty (junior 468.8 ± 123.5 seconds, senior 368.6 ± 63.42 seconds, faculty 233.1 ± 70.45 seconds; p < 0.01). LIMITATIONS: Study residents have not completed the Fundamentals of Endoscopic Surgery examinations, so correlation with examination performance is not yet possible. CONCLUSIONS: Performance on Endobasket, Endobubble, and Mucosal Evaluation correlated well with experience level, providing benchmarks for each level to attain in preparation for the Fundamentals of Endoscopic Surgery examination. See Video Abstract at http://links.lww.com/DCR/A823.

Gastrointestinal stromal tumors (GISTs) are rare in occurrence, but comprise the most common mesenchymal tumors of the gastrointestinal tract and affect between 15 and 20 individuals per million per year. Due to recent advancements in molecular classification of these tumors, medical therapy has provided improved outcomes to a historically surgically managed disease. This review article briefly discusses the molecular characteristics, medical and surgical therapies, and future of GIST management.

Several landmark studies revealed short-course preoperative radiotherapy (SC-RT, 25 Gy in 5 fractions) followed by chemotherapy to be non-inferior to conventionally fractionated long-course chemoradiation therapy (CF-CRT). The current attitude towards these treatment modalities among US practicing radiation oncologists (ROs) is unknown. We surveyed US ROs via an anonymous online institutional review board-approved survey. Questions pertained to management preferences, knowledge of landmark randomized trials and hypothetical approach within the frame of an alternative reimbursement system. We received 220 responses. Fifty-eight percent of respondents (n=128) support SC-RT. Approximately 81% of respondents were familiar with the results of the randomized Trans-Tasman Radiation Group Trial 0104 and 51% with results of the randomized Polish Colorectal Study Group. There was no association between the knowledge of these studies and support for SC-RT (p-value = 0.726). The majority of respondents (72%) prefer to manage their patients with CF-CRT. The reasons cited for this preference were to achieve higher pathological complete response rate, to decrease toxicity and to achieve a better rate of sphincter preservation. If patient insisted on receiving SC-RT, 92% would feel comfortable. In a hypothetical situation where reimbursement would not be based on the number of fractions, 72% of respondents would still continue to prefer CF-CRT. Most ROs who would preferentially use SC-RT if insurance reimbursed at the same rate as CF-CRT also indicated they supported SC-RT compared to those who did not support SC-RT (85.2% vs 14.8%, p-value < 0.001). Despite several randomized trials showing SC-RT to be comparable to CF-CRT, 42% of US radiation oncologists do not support SC-RT and 72% prefer to manage their localized rectal cancer patients with CF-CRT. This does not appear to be influenced by the US radiation oncology reimbursement system.Abstract TU_6_2947; Table 1Reasons stated by survey respondents (n=220) leading to preferred utilization of CF-CRT over SC-RT.Stated Reasons for choosing CF-CRT over SC-RTn (%)*Better overall survival14 (8.9%)Better local control30 (19.0%)Higher pCR rate64 (40.5%)Better sphincter preservation64 (40.5%)Fewer acute toxicities29 (18.4%)Fewer long-term toxicities62 (39.2%)*Percentages do not add up to 100% as multiple reasons could be selected by respondents. Open table in a new tab

Tabled 1REVIEWER RATINGCoverage of relevant topics★★★★★Improvement over previously available media★★★★Style of presentation and formatting★★★★★Quality of figures★★★★Overall★★★★★Stars:★: poor; ★★: adequate; ★★★: fair; ★★★★: good; ★★★★★: excellent. Open table in a new tab Schein’s Common Sense Emergency Abdominal Surgery is a godsend for anyone who evaluates patients with abdominal pain. Imagine a wise-cracking surgical chief resident or supremely confident surgical attending explaining what to ask the patient, what to examine, which diagnoses are most important to consider, and how urgently the operation needs to be done. More importantly, she explains why she chose the imaging tests or treatment options and how to safely perform the operation.For each emergency, the author walks the reader through the diagnostic workup, treatment choices, and technical details every acute care surgeon needs to know. The book covers preoperative evaluation, each major surgical emergency, and postoperative care. Key concepts are bolded. Diagrams are clear and colorful. Cartoons are somewhat funny, depending on how stressed the reader is. Despite having multiple international authors (experts in their field), the chapters have a fairly uniform, gently sarcastic style. Finally, we have a readable textbook that helps the author to learn sound surgical judgment.This book is ideal for surgical residents, young acute care/emergency general surgeons, surgical hospitalists, and physicians that evaluate patients with abdominal pain. Emergency medicine and gastroenterology providers will learn what diagnostic workup their surgical colleagues will want, as they collaborate in caring for a decompensating patient.Bottom Line. There are many surgical textbooks, yet, this paperback is the first one that my residents keep begging to borrow. I wish I had read this as a resident. I heartily recommend this for anyone who needs to evaluate patients with abdominal pain. Stars: ★: poor; ★★: adequate; ★★★: fair; ★★★★: good; ★★★★★: excellent. Schein’s Common Sense Emergency Abdominal Surgery is a godsend for anyone who evaluates patients with abdominal pain. Imagine a wise-cracking surgical chief resident or supremely confident surgical attending explaining what to ask the patient, what to examine, which diagnoses are most important to consider, and how urgently the operation needs to be done. More importantly, she explains why she chose the imaging tests or treatment options and how to safely perform the operation. For each emergency, the author walks the reader through the diagnostic workup, treatment choices, and technical details every acute care surgeon needs to know. The book covers preoperative evaluation, each major surgical emergency, and postoperative care. Key concepts are bolded. Diagrams are clear and colorful. Cartoons are somewhat funny, depending on how stressed the reader is. Despite having multiple international authors (experts in their field), the chapters have a fairly uniform, gently sarcastic style. Finally, we have a readable textbook that helps the author to learn sound surgical judgment. This book is ideal for surgical residents, young acute care/emergency general surgeons, surgical hospitalists, and physicians that evaluate patients with abdominal pain. Emergency medicine and gastroenterology providers will learn what diagnostic workup their surgical colleagues will want, as they collaborate in caring for a decompensating patient. Bottom Line. There are many surgical textbooks, yet, this paperback is the first one that my residents keep begging to borrow. I wish I had read this as a resident. I heartily recommend this for anyone who needs to evaluate patients with abdominal pain.

Tabled 1REVIEWER RATINGCoverage of relevant topics★★★★★Improvement over previously available media★★★★Style of presentation and formatting★★★★★Quality of figures★★★★Overall★★★★★Stars:★: poor; ★★: adequate; ★★★: fair; ★★★★: good; ★★★★★: excellent. Open table in a new tab Schein’s Common Sense Emergency Abdominal Surgery is a godsend for anyone who evaluates patients with abdominal pain. Imagine a wise-cracking surgical chief resident or supremely confident surgical attending explaining what to ask the patient, what to examine, which diagnoses are most important to consider, and how urgently the operation needs to be done. More importantly, she explains why she chose the imaging tests or treatment options and how to safely perform the operation.For each emergency, the author walks the reader through the diagnostic workup, treatment choices, and technical details every acute care surgeon needs to know. The book covers preoperative evaluation, each major surgical emergency, and postoperative care. Key concepts are bolded. Diagrams are clear and colorful. Cartoons are somewhat funny, depending on how stressed the reader is. Despite having multiple international authors (experts in their field), the chapters have a fairly uniform, gently sarcastic style. Finally, we have a readable textbook that helps the author to learn sound surgical judgment.This book is ideal for surgical residents, young acute care/emergency general surgeons, surgical hospitalists, and physicians that evaluate patients with abdominal pain. Emergency medicine and gastroenterology providers will learn what diagnostic workup their surgical colleagues will want, as they collaborate in caring for a decompensating patient.Bottom Line. There are many surgical textbooks, yet, this paperback is the first one that my residents keep begging to borrow. I wish I had read this as a resident. I heartily recommend this for anyone who needs to evaluate patients with abdominal pain. Stars: ★: poor; ★★: adequate; ★★★: fair; ★★★★: good; ★★★★★: excellent. Schein’s Common Sense Emergency Abdominal Surgery is a godsend for anyone who evaluates patients with abdominal pain. Imagine a wise-cracking surgical chief resident or supremely confident surgical attending explaining what to ask the patient, what to examine, which diagnoses are most important to consider, and how urgently the operation needs to be done. More importantly, she explains why she chose the imaging tests or treatment options and how to safely perform the operation. For each emergency, the author walks the reader through the diagnostic workup, treatment choices, and technical details every acute care surgeon needs to know. The book covers preoperative evaluation, each major surgical emergency, and postoperative care. Key concepts are bolded. Diagrams are clear and colorful. Cartoons are somewhat funny, depending on how stressed the reader is. Despite having multiple international authors (experts in their field), the chapters have a fairly uniform, gently sarcastic style. Finally, we have a readable textbook that helps the author to learn sound surgical judgment. This book is ideal for surgical residents, young acute care/emergency general surgeons, surgical hospitalists, and physicians that evaluate patients with abdominal pain. Emergency medicine and gastroenterology providers will learn what diagnostic workup their surgical colleagues will want, as they collaborate in caring for a decompensating patient. Bottom Line. There are many surgical textbooks, yet, this paperback is the first one that my residents keep begging to borrow. I wish I had read this as a resident. I heartily recommend this for anyone who needs to evaluate patients with abdominal pain.

BACKGROUND: Anal cancer remains common among human immunodeficiency virus (HIV) patients. Chemoradiation has had mixed results. We evaluated outcome differences by HIV status.METHODS: We retrospectively analyzed 14 HIV+ and 72 HIV- anal cancer patients (2000 to 2013). Outcomes included chemoradiation tolerance, recurrence, and survival.RESULTS: HIV+ patients were more often male (100% vs 38%, P < .001) but diagnosed at similar stages (P = .49). They were less likely to receive traditional chemotherapy (36% vs 86%, P < .001). Recurrence (P = .55) and survival time (P = .48) were similar across groups. HIV+ patients had similar colostomy-free survival (P = .053). Receipt of 5-fluorouracil/mitomycin C (MMC) chemotherapy predicted recurrence-free and overall survival (Hazard ratios .278, .32). HIV status did not worsen recurrence (P = .71) or survival (P = .57).CONCLUSIONS: HIV+ patients received more non-MMC-based chemoradiation but had equivalent colostomy-free, recurrence, and overall survival. Use of 5-fluorouracil/MMC chemotherapy increased after 2008. (C) 2016 Elsevier Inc. All rights reserved.