Limited literature exists regarding surgeon perceptions and practice patterns for low anterior resection syndrome (LARS). In this study, we sought to understand how colon and rectal surgery faculty perceive and manage LARS. We invited colon and rectal surgery faculty (CRS faculty) members from all programs that offer an Accreditation Council for Graduate Medical Education (ACGME)-accredited colon and rectal surgery residency (n = 378) to participate in an electronic survey. Descriptive statistical analyses and ordered logistic regression were performed. The survey achieved a response rate of 30.1

Background Irrespective of baseline diabetes status, preoperative hemoglobin A1c (A1C) influences perioperative care in patients undergoing metabolic and bariatric surgery (MBS). Accordingly, the American Society of Metabolic and Bariatric Surgery (ASMBS) endorses that patients undergoing MBS should receive a preoperative A1C test. We aimed to assess the proportion of MBS patients who received a preoperative A1C test and determine whether baseline diabetes status influences receipt of a test. Methods We queried the 2017 to 2022 MBSAQIP database for patients undergoing open, laparoscopic, or robotic Roux-en-Y gastric bypass (RYGB) or sleeve gastrectomy. Using descriptive methods, we compared the clinical and demographic characteristics of patients who received a preoperative A1C test with patients who did not. We performed logistic regression analysis using diabetes status as a predictor variable and receipt of a test as the outcome, covarying for sociodemographic and clinical factors. Results We identified 996,217 patients who underwent RYGB or sleeve gastrectomy between 2017 to 2022. The average age of the cohort was 43.8 years (SD = 11.9) and 81.0% were female. Overall, 45.7% received a preoperative A1C test. The proportion who was tested increased over the six-year study period, from 35.5% in 2017 to 56.0% in 2022. Compared to those who were not tested, patients who were tested were more likely to have several cardiopulmonary comorbidities, including COPD (1.4% vs 1.2%, p < 0.001), PE (1.4% vs 1.2%, p < 0.001), sleep apnea (39.3 vs. 36.4%, p < 0.001), HTN (47.1% vs 44.0%, p < 0.001), and MI (1.2% vs. 1.0%, p < 0.001), though the differences in proportions were small and may not be clinically significant. Compared to patients who did not have diabetes or had diabetes controlled by diet alone, patients with non-insulin dependent diabetes had 77% increased odds of receiving a A1C test (adjusted OR (aOR) 1.77, p < 0.001); insulin dependent patients had 113% increased odds (aOR 2.13, p < 0.001). Conclusion Despite society recommendations endorsing measurement of preoperative A1C prior to MBS, less than half of patients undergoing MBS between 2017 and 2022 received a preoperative A1C test. Additionally, there were differential patterns in testing based on diabetes status. Preoperative glycemic evaluation is an area for continued quality improvement.

BackgroundUse of online crowdfunding to mitigate health-related cost burden is common in the US, but its usage among candidates for metabolic and bariatric surgery (MBS) is unknown. We aimed to identify GoFundMe campaigns fundraising for MBS and characterize sources of financial strain. We also aimed to determine factors associated with successful crowdfunding.MethodsWe searched GoFundMe for campaigns fundraising for MBS. Data items were extracted by two investigators with disagreements resolved by a third. We assessed associations between these data items and category of money raised using ordered logistic regression.ResultsWe identified 539 campaigns, of which 33.6% were raising funds for sleeve gastrectomy, 24.1% for Roux-en-Y gastric bypass, and 2.0% for biliopancreatic diversion with duodenal switch. Most campaigns were created by the patient (73.1%) who had health insurance (53.4%) and at least one obesity-associated disease (56.8%). Over half (53.6%) sought funds for a direct medical expense and 35.1% sought funds for a non-medical expense, which included lost wages (15.6%), food (10.8%), transportation (10.2%), childcare (7.1%), and/or housing (5.8%). The median requested was $8000 (IQR 10,440) and the median raised was $860 (IQR 3173). The majority (63.1%) of campaigns earned less than 25% of their requested amount. Campaigns that shared mental health-related disease (aOR 0.55, 95% CI 0.32-0.95) and non-surgical attempts to lose weight (aOR 0.59, 95% CI 0.37-0.94) had lower odds of raising a higher category of money compared to campaigns not disclosing these details.ConclusionsPatients pursuing MBS in the US use online crowdfunding to subsidize both medical and non-medical expenses, but the majority of campaigns are unsuccessful. Our study highlights unmet financial need among MBS candidates.

Many women eligible for breast conservation therapy (BCT) elect unilateral mastectomy (UM) with or without contralateral prophylactic mastectomy (CPM) and cite a desire for “peace of mind.” This study aimed to characterize how peace of mind is defined and measured and how it relates to surgical choice. Nine databases were searched for relevant articles through 8 October 2023, and data were extracted from articles meeting the inclusion criteria. The inclusion criteria were met by 20 studies. Most were prospective cohort studies (65

Introduction: Low anterior resection syndrome (LARS) can be a debilitating condition that develops after undergoing sphincter-preserving surgery for rectal cancer. Chemotherapy-induced peripheral neuropathy is a common side effect of platinum-based chemotherapy agents used as systemic therapy for rectal cancer treatment. The purpose of this study was to determine the potential relationship between CIPN and LARS. Methods: This was a retrospective review of patients who underwent a low anterior resection for rectal cancer and received systemic therapy contacted at least six months from the most recent surgery. Eligible patients were called and completed the relevant surveys over the phone or email. Results: There was a total of 42 patients who completed the surveys with 33 (79%) having major LARS. Presence of a diverting ileostomy was the only significantly differentcharacteristic in those with major LARS versus those without. CIPN was independently associated with LARS (p = 0.046) on linear regression when controlling for neoadjuvant chemoradiation, diverting ileostomy and tumor distance from the anal verge. Conclusions: Developing severe CIPN is associated with developing LARS. Further studies evaluating the etiology behind this relationship should be conducted.

BACKGROUND:Failure to rescue after elective surgery is associated with increased healthcare costs. These costs are poorly understood and have not been reported for colorectal surgery. This study aimed to assess the incremental costs of failure to rescue after elective colorectal surgery. METHODS:This was a retrospective study of adult patients identified in the National Inpatient Sample from 2016 to 2019 who underwent an elective colectomy or proctectomy. Patients were stratified into 4 groups: uneventful recovery, successfully rescued, failure to rescue, and died without rescue attempts. "Rescue" was defined as admissions with ≥1 procedure code ≥1 day after the initial procedure. The primary outcome was total admission costs. RESULTS:Of 451,490 admissions for elective colorectal resection, 94.6% had an uneventful recovery, 4.8% were successfully rescued, 0.4% were failure to rescue, and 0.3% died without rescue attempts. The median total hospital cost for the uneventful recovery cohort was $16,751 (IQR, $12,611-$23,116), for the successfully rescued cohort was $42,295 (IQR, $27,959-$67,077), for the failure-to-rescue cohort was $53,182 (IQR, $30,852-$95,615), and for the died without attempted rescue cohort was $29,296 (IQR, $19,812-$45,919). When comparing cost quantiles by regression analysis, failure-to-rescue patients had significantly higher costs than the successfully rescued patients for the last 3 quantiles (fifth quantile [90th percentile], $163,963 vs $106,521; P < .001). CONCLUSION:Across a nationally representative cohort, the median total hospital costs for patients who failed to be rescued were $10,887 more than for those who were successfully rescued. These findings emphasize the importance of shared decision making and medical futility and highlight opportunities for resource optimization after postoperative complications.

Low Anterior Resection Syndrome (LARS) is a syndrome of lifestyle-limiting defecatory dysfunction diagnosed after the treatment of rectal cancer that can afflict 41% of patients one year after surgery. Currently, the treatment of LARS is reactionary to the development of symptoms, and post-treatment pelvic floor physical therapy (PFPT) is one form of treatment utilized to mitigate the symptoms of LARS and improve patient quality of life. Prehabilitation is the physical and/or lifestyle preparation that improves recovery following surgery. For rectal cancer patients, general prehabilitation while undergoing neoadjuvant chemoradiotherapy is safe and feasible. However, no studies have examined whether pelvic floor physical therapy prehabilitation, which we term “PrePFPT,” could mitigate the development of LARS. In this commentary, we argue that PrePFPT should become an active area of research in rectal cancer to improve functional and quality of life outcomes. We highlight two proposed international trials, which will evaluate pre- and postoperative PFPT as a strategy to reduce the incidence of LARS. We conclude with our own proposed PrePFPT study design.

Psychosocial frailty is under-screened for and under-treated in patients undergoing surgery, even though patients with psychosocial frailty are at increased risk for postoperative complications. Numerous approaches exist to identifying psychosocial frailty in the preoperative period, ranging from neighborhood-level indices to patientlevel, patient-reported data. Presurgical optimization of psychosocial frailty has returned mixed results, focusing primarily on psychological well-being with limited attention paid to addressing a patient's social risk profile. Mediators and moderators of psychosocial frailty in surgical outcomes must be further elucidated before investigators can appropriately trial psychosocial optimization programs that benefit patients. In recent years, new policies and system-level changes have incentivized screening for psychosocial frailty, and additional reimbursement strategies should be formulated to address frailty in the preoperative period in a feasible, sustainable, and cost-effective manner.

Artificial Intelligence (AI) touches innumerable aspects of our lives today. It plays our music, turns on our lights, answers our weather questions, and even helps navigate our cars safely down the road - to name but a few capabilities. Review of the literature shows that AI applications are rapidly infiltrating most aspects of healthcare. For the microcosm of colorectal surgery, AI can assist in specimen acquisition, pathologic and radiologic diagnosis, selection of treatment modality, pre/postoperative risk stratification, and more globally in surgeon education, grantsmanship, and claims assessment. However, with such power comes the risk of its abuse, and subsequent harm to patients (and providers). Understanding a brief history of AI and the hierarchy of the predominant forms with which we interact, allow us to better understand the nature of these risks and how we can apply ethical frameworks to better understand and mitigate/prevent them. Finally, considering President Biden's October 2023 executive order, we can evaluate how US policy addresses these concerns.

The modern rectal cancer treatment paradigm offers additional opportunities for organ preservation, most notably via total neoadjuvant therapy (TNT) and consideration for a watch-and-wait (WW) surveillance-only approach. A major barrier to widespread implementation of a WW approach to rectal cancer is the potential discordance between a clinical complete response (cCR) and a pathologic complete response (pCR). In the pre-TNT era, the identification of predictors of pCR after neoadjuvant therapy had been previously studied. However, the last meta-analysis to assess the summative evidence on this important treatment decision point predates the acceptance and dissemination of TNT strategies. The purpose of this systematic review was to assess preoperative predictors of pCR after TNT to guide the ideal selection criteria for WW in the current era. An exhaustive literature review was performed and the electronic databases Embase, Ovid, MEDLINE, PubMed, and Cochrane were comprehensively searched up to 27 June 2023. Search terms and their combinations included “rectal neoplasms”, “total neoadjuvant therapy”, and “pathologic complete response”. Only studies in English were included. Randomized clinical trials or prospective/retrospective cohort studies of patients with clinical stage 2 or 3 rectal adenocarcinoma who underwent at least 8 weeks of neoadjuvant chemotherapy in addition to chemoradiotherapy with pCR as a measured study outcome were included. In this systematic review, nine studies were reviewed for characteristics positively or negatively associated with pCR or tumor response after TNT. The results were qualitatively grouped into four categories: (1) biochemical factors; (2) clinical factors; (3) patient demographics; and (4) treatment sequence for TNT. The heterogeneity of studies precluded meta-analysis. The level of evidence was low to very low. There is minimal data to support any clinicopathologic factors that either have a negative or positive relationship to pCR and tumor response after TNT. Additional data from long-term trials using TNT is critical to better inform those considering WW approaches following a cCR.

IRB approval was obtained for this single center retrospective review of patients who had elective colorectal resections during ERAS implementation from January 2016 to December 2016 versus years later from January 2019 to December 2019. Data was collected for internal quality improvement analysis and maintained in a secure database known as Research Electronic Data Capture (REDCap, Boston University, CTSI 1UL1TR001430).2 We collected data including age, sex, American Society of Anesthesiologists (ASA) status, diagnosis, indications for surgery, procedure, operative approach, and operative times. The primary outcomes were length of stay, readmission rates, and ERAS teaching. Data was analyzed using SAS software version 9.4 (SAS Institute, Cary, NC). A chi-squared test or Fisher’s exact test was used to evaluate ERAS teaching. All tests were 2-sided, and a p value less than or equal to 0.05 was considered statistically significant.

BACKGROUND:Falls are the leading cause of fatal injury, and the most common cause of nonfatal trauma, among older adults. However, patient perspectives on preferences for obtaining fall education are not well reported.OBJECTIVE:To identify components of successful fall prevention education.DESIGN:Prospective qualitative study.SETTING:Tertiary care center; institutional.PARTICIPANTS:Adults aged 65 years or older with a history of falls who received services from inpatient trauma or outpatient geriatric services.INTERVENTIONS:One-hour face-to-face semistructured interview.MAIN OUTCOME MEASURE:Semistructured interviews sought to determine participants' history of fall education and perceived strengths and weaknesses of various formats of fall education.RESULTS:Nearly all participants (9/10) indicated they had not received fall prevention education of any kind. Many participants (6/10) reported that, despite not receiving any formal education about falls, they had either given or received information about falls from other older adults in their communities. Participants indicated that framing fall education as a part of healthy aging would be more desirable and mentioned involving participants' families as part of the education. The majority of participants (7/10) suggested fall education be delivered through in-person discussion with providers, and most (9/10) indicated this would provide a personalized approach with opportunity for questions. Participants specified fall education should consist of both environmental modifications (5/10) and awareness of one's surroundings (4/10).CONCLUSIONS:Despite histories of falls, nearly all participants reported they had not received formal fall education. However, many indicated they received fall information informally through their communities. Participants agreed successful fall prevention education would be delivered in an empowering way by a trusted member of the care team.

OBJECTIVES: Surgery residents have few opportunities to work closely with attending surgeons or conduct research during clinical time. We hypothesized that a mentorship elective with a required research project would benefit residents' career development, including their personal connections with faculty mentors, and would help them build their academic portfolio. DESIGN: We created a mentorship elective designed as a one-on-one apprenticeship. Completion of a scholarly project was a core component of the elective. Residents, faculty, and the most senior resident ('non-mentee') on the same service as the elective resident were interviewed after the completion of their rotation. SETTING: University-based surgery residency at Boston Medical Center, Boston, MA. PARTICIPANTS: All 5 residents in postgraduate year 4 (PGY-4) participated in the mentorship elective during the 2019 to 2020 academic year. Residents identified their faculty mentor. All mentees (5/5), most mentors (4/5), and all non-mentees (4/4) were interviewed. RESULTS: All mentees reported interacting with their mentor daily, performing clinical duties or discussing their research project. For mentees, the top factor when selecting their mentor was the mentor's clinical expertise, and the most valuable aspect of the rotation was developing a relationship with their mentor. All mentors responded that their mentee gained an understanding of running an academic surgical practice and developed research skills. Four of 5 mentees completed critical portions of their scholarly project during the elective with one publishing in a peer-reviewed journal, 2 having their work accepted to a national conference, and one creating vascular surgery educational videos. All stated the elective was valuable. CONCLUSIONS: A structured apprenticeship rotation allowed for closer relationships with attending surgeons and increased the scholarly achievement of PGY-4 surgery residents. We provide an example of how to incorporate a successful elective rotation into the surgery curriculum that strengthens resident career development and research productivity. (C) 2020 Association of Program Directors in Surgery. Published by Elsevier Inc. All rights reserved.

Schultz, Kurt S. BS; Phatak, Uma R. MD, MS; Hall, Jason F. MD, FACS; Favuzza, Joanne DO Author Information

BACKGROUND:Falls are the leading cause of fatal injury, and most common cause of non-fatal trauma, among older adults. We sought to elicit older patient's perspectives on fall risks for the general population as well as contributions to any personal falls to identify opportunities to improve fall education.METHODS:Ten patients with a history of falls from inpatient trauma and outpatient geriatric services were interviewed. Transcripts were analyzed independently by five individuals using triangulation and constant comparison (NVivo11, QSR International) to compare fall risks to fall causes.RESULTS:All patients reported that either they (9/10 participants) or someone they knew (8/10) had fallen. Despite this, only two personally worried about falling. Patient perceptions of fall risks fell into seven major themes: physiologic decline (8/10); underestimating limitations (7/10); environmental hazards (7/10), lack of awareness/rushing (4/10), misuse/lack of walking aids (3/10); positional transitions (2/10), and improper footwear (1/10). In contrast, the most commonly reported causes of personal falls were lack of awareness/rushing (7/10), environmental hazards (3/10), misuse/lack of walking aids (2/10), improper footwear (2/10), physiologic decline (2/10), underestimating limitations (1/10) and positional transitions (1/10). In general tended to attribute their own falls to their surroundings and were less likely to attribute physical or psychological limitations.CONCLUSION:Despite participants identifying falls as a serious problem, they were unlikely to worry about falling themselves. Participants were able to identify common fall risks. However, when speaking about personal experience, they were more likely to blame environmental hazards or rushing, and minimized the role of physiologic decline and personal limitations.