The third-year surgical clerkship marks many students’ first exposure to surgery. However, what students expect they will engage in during their clerkship compared to their actual experience is largely unknown. We aimed to compare the expectations and realities of medical students’ experience during the surgery clerkship. A survey assessing how frequently students expected to perform certain fundamental tasks and skills was administered to all third-year medical students before their clerkship. A similar survey was administered at the conclusion of the clerkship exploring what activities students actually engaged in and if any barriers to engagement were encountered. 83 students responded to the pre-survey and 69 responded to the post-survey (response rates of 97

OBJECTIVE: In order to effectively create and implement an educational program to improve opioid prescribing practices, it is important to first consider the unique perspectives of residents on the frontlines of the opioid epidemic. We sought to better understand resident perspectives on opioid prescribing, current practices in pain management, and opioid education as a needs assessment for designing future educational interventions.DESIGN: This is a qualitative study using focus groups of surgical residents at 4 different institutions.SETTING: We conducted focus groups using a semistruc-tured interview guide in person or over video conferenc-ing. The residency programs selected for participation represent a broad geographic range and varying resi-dency sizes.PARTICIPANTS: We used purposeful sampling to recruit general surgery residents from the University of Utah, University of Wisconsin, Dartmouth-Hitchcock Medical Center, and the University of Alabama at Birmingham. All general surgery residents at these locations were eli-gible for inclusion. Participants were assigned to focus groups by residency site and their status as junior (PGY-2, PGY-3) or senior resident (PGY-4, PGY-5). RESULTS: We completed 8 focus groups with a total of 35 residents included. We identified 4 main themes. First, residents relied on clinical and nonclinical factors when making decisions about opioid prescribing. How-ever, hidden curricula based on unique institutional cul-tures and attending preferences heavily influenced residents' prescribing practices. Second, residents acknowledged that stigma and biases towards certain patient groups influenced opioid prescribing practices. Third, residents encountered barriers within their health systems to evidence-based opioid prescribing. Fourth, residents did not routinely receive formal edu-cation on pain management or opioid prescribing. Resi-dents recommended several interventions to improve the current state of opioid prescribing, including stan-dardized prescribing guidelines, improved patient educa-tion, and formal training during the first year of residency. CONCLUSIONS: Our study highlighted several areas of opioid prescribing that can be improved upon through educational interventions. These findings can be used to develop programs aimed at improving residents' opioid prescribing practices, both during and after training, and ultimately the safe care of surgical patients.ETHICS STATEMENT: This project was approved by the University of Utah Institutional Review Board, ID # 00118491. All participants provided written informed consent. (J Surg Ed 80:786-796.(c) 2023 Association of Program Directors in Surgery. Published by Elsevier Inc. All rights reserved.)

Background: Poor sleep leads to poor health outcomes. Phase I of our sleep quality improvement project showed severe sleep disturbance in the ward setting. We implemented a novel PostOp Pack to improve sleep quality.Methods: Patients underwent elective, general surgery procedures. Fitbit trackers measured total sleep time. Patients completed the inpatient Richards-Campbell Sleep Questionnaire, which combines 5 do-mains into a cumulative score (0-10 0). Patients completed the outpatient Pittsburgh Sleep Quality Index preoperatively and postoperatively. Patients received the PostOp Pack, which included physical items and a sleep-protective order set to reduce nighttime awakenings. Patients from phase I served as the historical control. The primary outcome was the percentage of patients with Richards-Campbell Sleep Questionnaire total sleep score >= 50. The secondary outcomes included the mean Richards-Campbell Sleep Questionnaire domain scores and Fitbit total sleep time.Results: A total of 49 patients were compared with 64 historical controls. The percentage of patients with a total sleep score >= 50 was significantly higher in patients receiving a PostOp Pack versus historical control (69% vs. 44%, difference 26%, 95% confidence interval 6.1-45%, P = .01). The mean Richards -Campbell Sleep Questionnaire Total Sleep Score was significantly higher in patients with a PostOp Pack (62 vs 49, mean difference 13, 95% confidence interval 6-21, P <= .01). The PostOp Pack Richards -Campbell Sleep Questionnaire domain scores were significantly higher in various areas: Sleep Latency (68 vs 49, P <= .01), Awakenings (56 vs 40, P = .01), Sleep Quality (61 vs 49, P = .02), and Noise Disturbance (70 vs 59, P = .04). Of all patients, 92% would use PostOp Pack again in a future hospitalization. No patients had a failure to rescue event with PostOp Pack. The mean total sleep time was significantly improved with PostOp Pack on night 1 (6.4 vs 4.7 hours, P = .03).Conclusion: The PostOp Pack improves inpatient sleep quality and is safe.(c) 2022 Elsevier Inc. All rights reserved.

BACKGROUND: Readmission after ileostomy creation continues to be a major cause of morbidity with rates ranging from 15% to 30% due to dehydration and obstruction. Rural environments pose an added risk of readmission due to larger travel distances and lack of consistent home health services. OBJECTIVE: This study aimed to reduce ileostomy-related readmission rates in a rural academic medical center. DESIGN: This is a rapid cycle quality improvement study. SETTING: This single-center study was conducted in a rural academic medical center. PATIENTS: Colorectal surgery patients receiving a new ileostomy were included in this study. INTERVENTIONS: Improvement initiatives were identified through Plan-Do-Study-Act cycles (enhanced team continuity, standardized rehydration, nursing/staff education). MAIN OUTCOME MEASURES: Thirty-day readmission, average length of stay, and average time to readmission served as main outcome measures. RESULTS: Roughly equal rates of ileostomy were created in each time point, consistent with a tertiary care colorectal practice. The preimplementation readmission rate was 29%. Over the course of the entire quality improvement initiative, re-admission rates decreased by more than 50% (29% to 14%). PDSA cycle 1, which involved integrating a service-specific physician assistant to the team, allowed for greater continuity of care and had the most dramatic effect, decreasing rates by 27.5% (29% to 21%). Standardization of oral rehydration therapy and the implementation of a patient-directed intake/output sheet during PDSA cycle 2 resulted in further improvement in readmission rates (21% to 15%). Finally, implementation of nurse and physician assistant (PA)-driven patient education on fiber supplementation resulted in an additional yet nominal decrease in readmissions (15% to 14%). Latency to readmission also significantly increased throughout the study period. LIMITATIONS: This study was limited by its small sample size in a single-center study. CONCLUSION: Implementation of initiatives targeting enhanced team continuity, the standardization of rehydration therapies, and improved patient education decreased readmission rates in patients with new ileostomies. Rural centers, where outpatient resources are not as readily available or accessible, stand to benefit the most from these types of targeted interventions to decrease readmission rates. See Video Abstract at http://links.lww.com/DCR/B771. REDUCCIÓN EN LAS READMISIONES POR ILEOSTOMÍAS NE MEDIOS DE ATENCIÓN MÉDICA RURAL: INICIATIVA DE MEJORÍA EN LA CALIDAD ANTECEDENTES: La readmisión después de la creación de una ileostomía sigue siendo una de las principales causas de morbilidad con tasas que oscilan entre el 15% y el 30% debido a la deshidratación y la oclusión. Un entorno rurale presenta un riesgo adicional de readmisión debido a las mayores distancias de viaje y la falta de servicios de salud domiciliarios adecuados. OBJETIVO: Reducir las tasas de reingreso por ileostomía en un centro médico académico rural. DISEÑO: Estudio de mejoría de la calidad de ciclo rápido. AJUSTE: Estudio unicéntrico en una unidad de servicio médico académico rural. PACIENTES: Pacientes de cirugía colorrectal a quienes se les confeccionó una ileostomía. INTERVENCIONES: Iniciativas de mejoría identificadas a través de los ciclos Planificar-Hacer-Estudiar-Actuar (Continuidad del equipo mejorada, rehidratación estandarizada, educación de enfermería / personal). PRINCIPALES MEDIDAS DE RESULTADO: 30 días de readmisión, duración media de la estadía hospitalaria, tiempo medio de reingreso. RESULTADOS: Se crearon tasas aproximadamente iguales de ileostomías un momento dado de tiempo, subsecuentes en la práctica colorrectal de atención terciaria. La tasa de readmisión previa a la implementación del estudio fue del 29%. En el transcurso de toda la iniciativa de mejoría en la calidad, las tasas de readmisión disminuyeron en más del 50% (29% a 14%). El ciclo 1 de PDSA, que implicó la integración en el equipo de un asistente médico específico, lo que permitió una mayor continuidad en la atención y tuvo el mayor efecto disminuyendo las tasas en un 27,5% (29% a 21%). La estandarización de una terapia de rehidratación oral y la implementación de una hoja de ingresos / perdidas dirigida al paciente durante el ciclo 2 de PDSA resultó en una mejoría adicional en las tasas de readmisión (21% a 15%). Finalmente, la implementación de la educación del paciente impulsada por enfermeras y AF sobre el consumo suplementario de dietas con fibra dio como resultado una disminución adicional, aunque nominal, de las readmisiones (15% a 14%). La latencia hasta la readmisión también aumentó significativamente durante el período de estudio. LIMITACIONES: Estudio de un solo centro con un muestreo de pequeño tamaño. CONCLUSIONES: La implementación de iniciativas dirigidas a mejorar la continuidad en el equipo, la estandarización de las terapias de rehidratación y la mejoría en la información de los pacientes disminuyeron las tasas de readmisión en todos aquellas personas con nuevas ileostomías. Los centros rurales, donde los recursos para pacientes ambulatorios no están tan fácilmente disponibles o accesibles, son los que más beneficiaron de este tipo de intervenciones específicas para reducir las tasas de readmisión. Consulte Video Resumen en http://links.lww.com/DCR/B771. (Traducción—Dr. Xavier Delgadillo)

Background: Enhanced Recovery After Surgery protocols have demonstrated decreased complication rates and length of stay. However, the influence of mental health on Enhanced Recovery After Surgery success is unknown. Method: A retrospective study of patient-reported outcomes for physical and mental health. We included patients who underwent elective minimally invasive colon resections, who completed the Patient-Reported Outcomes Measurement Information System 10 questionnaire preoperatively, and who had successful implementation of perioperative Enhanced Recovery After Surgery components. We evaluated the predictors of having successful expected Enhanced Recovery After Surgery outcomes using a multiple logistic regression, controlling for baseline patient characteristics, history of a mental health diagnosis, inpatient opiate use, and preoperative Patient-Reported Outcomes Measurement Information System 10 scores. Results: In total, 163 patients met inclusion criteria, with 23% failing Enhanced Recovery After Surgery, and 32% having a preoperative mental health diagnosis. The most common reason for failure of expected Enhanced Recovery After Surgery outcomes was length of stay (55.3%) followed by postoperative ileus (31.6%). Age, sex, the American Society of Anesthesiologists physical status classification, and preoperative Patient-Reported Outcomes Measurement Information System 10 scores were not significantly different between those who failed or succeeded, whereas length of stay was typically longer for those who failed Enhanced Recovery After Surgery (5.7 days failure vs 2.2 days success, P < .001). Patients with a previous mental health diagnosis, where depression and anxiety were most common, had significantly lower odds of successfully meeting expected Enhanced Recovery After Surgery outcomes (odds ratio of 0.23, 95% confidence interval: 0.09-0.55, P 1/4 .001). Conclusion: Patients with a mental health diagnosis have a lower likelihood of successfully meeting expected Enhanced Recovery After Surgery outcomes. The majority of these patients self-report normal mental and physical health preoperatively, indicating that even well-controlled mental health diagnoses have a negative impact on Enhanced Recovery After Surgery success.(c) 2022 Elsevier Inc. All rights reserved.

Background: Postoperative bowel function is a common concern for patients undergoing a sigmoidectomy. We have previously demonstrated that patients with symptomatic bowel function preoperatively have substantial improvement at long-term follow-up. However, the effect of the operative approach on patient-reported bowel function is largely unknown. We aimed to evaluate the differences in long-term patient-reported bowel function after robotic or laparoscopic sigmoid colectomies for benign and malignant disease. Materials and methods: A retrospective analysis of a prospectively collected institutional database from July 2015 to July 2020. Patients included underwent a sigmoid colectomy for benign or malignant disease and completed the Colorectal Functional Outcome (COREFO) questionnaire at preoperative presentation, postoperatively, and long-term follow-up. Differences between preoperative and postoperative scores, as well as differences between the robotic and laparoscopic cohorts, were compared using paired t-tests. Results: A total of 169 patients met inclusion criteria with a median age of 61 y, and 55% of the patients underwent robotic sigmoid colectomy, with the most common diagnosis being diverticular disease (62%). There was no significant difference between the presentation, short-term, or long-term follow-up total COREFO scores or subdomains based on the surgical technique. Patients that present asymptomatic remain asymptomatic, while those that are symptomatic demonstrate improvements for both the robotic and laparoscopic groups. Conclusions: Patient-reported long-term global bowel function does not appear to differ between patients who underwent elective robotic or laparoscopic sigmoid colectomy for benign or malignant disease. Patients that present asymptomatic remain asymptomatic, while those that are symptomatic demonstrate improvements, regardless of surgical technique. (c) 2022 Elsevier Inc. All rights reserved.

Loop ileostomy (LI) is commonly employed during colorectal surgeries to reduce the consequences of anastomotic leak. Unfortunately, LI is associated with a 10–30

INTRODUCTION:Hemorrhoid disease is very common problem in the Medicare population. Prior work has shown significant variation in county-level practices of hemorrhoidectomy; however, regional variation of rubber band ligation (RBL) has yet to be assessed. This is important as many different practitioners from different specialties can perform this procedure repeatedly in an office-based setting. We aim to evaluate the variation of RBL and hemorrhoidectomy over a 7-y period. METHODS:Using Medicare part B claims data, we identified all beneficiaries >65 y seen for hemorrhoid disease between 2006 and 2013. Current Procedural Terminology (CPT) codes were used to identify all events for hemorrhoidectomy (46083, 46250, 46255, 46257, 46260, and 46261) or RBL (46221) by hospital referral region (HRR). We determined HRR-level rates of hemorrhoidectomy and RBL per 1000 beneficiaries adjusted for age, sex, and race. We calculated annual coefficients of variation (SD × 100/mean) for hemorrhoidectomy and RBL. RESULTS:1.2 to 1.3 million fee-for-service Medicare beneficiaries were seen annually for evaluation of hemorrhoid disease. Mean-adjusted annual rates for hemorrhoidectomy by HRRs varied from 4.34 to 63.03 per 1000 beneficiaries. Mean-adjusted rates of RBL by HRRs varied from 7.06 to 163 per 1000 beneficiaries. Annual procedural coefficients of variation over the study period were 41-48 (high) for hemorrhoidectomy and 69-74 (very high) for RBL. CONCLUSIONS:While continued high variation exists for hemorrhoidectomy, there is very high variation for RBL between HRRs in treating hemorrhoid disease among Medicare beneficiaries. There are substantial Medicare expenditures in this high-volume population that are likely unwarranted.

Aim The aim of this work was to evaluate physicians' perceptions of ostomates' quality of life (QoL) and comfort of care among an international sample of physicians caring for ostomates. Method This was a cross-sectional survey study. We conducted a survey of primary care physicians (PCP), gastroenterologists (GI), and general surgeons (GS) from three continents using the SERMO online physician platform. We piloted the survey for content, clarity and domain development using a pilot sample of physicians from each speciality before use. We summarized responses to questions related to physician comfort of ostomate care with descriptive statistics. We conducted multiple logistic regression with the primary outcome of physician perception of ostomate QoL. Results A total of 617 physicians (PCP 264, GI 176, GS 177) completed the survey representing North America, Europe and Australia similarly. The average age was 46 years and 21% were women. Ninety per cent of physicians care for an ostomate at least once per month. Eighty eight per cent had access to enterostomal nurses. Eighty two per cent of physicians believed that ostomates have decreased QoL. Forty seven per cent believed that ostomates have decreased overall health. Almost half of respondents answered incorrectly to a 'bogus question' citing fake clinical evidence supporting a negative impact of ostomies on social relationships. Increased physician comfort in ostomy care (OR 1.30, p = 0.04) and US-based physicians (OR 1.75, p = 0.01) were associated with increased odds of answering that ostomates have no decreased QoL. Conclusion Among a diverse international sample, most physicians believe that ostomates have decreased QoL but not overall health. Physician implicit bias, physician comfort and geographical variability account for these findings. Targeted efforts to increase physician comfort in ostomate care and establish universal best practices is needed.

OBJECTIVE: Medical students often feel underprepared entering surgical residency. We have previously reported the results of a sub-intern needs assessment (SINA) which informed the creation of a standardized sub-internship curriculum. We aimed to determine if implementation of this curriculum into students' sched-uled rotations would improve student confidence in their abilities related to the AAMC Core Entrustable Pro-fessional Activities for Entering Residency (CEPAERs).DESIGN: We surveyed 4th year medical students during their surgery sub-internship. Sub-interns participated in a weekly series of 2-hour didactic sessions. We utilized interactive lectures and case scenarios addressing the pertinent topics identified in our previous needs assess-ment. The surveys were administered before and after the rotation and linked using unique identifiers. The sur-veys assessed confidence in each of the CEPAERs as well as the top 25 topics prioritized by our needs assessment. Self-reported confidence in each of the topics was mea-sured using Likert scales (CEPAER scale 1-5, SINA scale 1-6). Pre-and post-curriculum confidence on a variety of topics were compared using paired t-tests.SETTING: Geisel School of Medicine at Dartmouth/Dart-mouth-Hitchcock Medical Center, a tertiary-care aca-demic medical center. PARTICIPANTS: Fourth year medical students participat-ing in their general surgery sub-internship.RESULTS: Twelve medical students participated in gen-eral and thoracic surgery sub-internships over the course of the study period. Ten (83%) participated in the didac-tic curriculum and they all completed both the pre-and postsurvey. 100% of the respondents agreed that the cur-riculum provided a useful supplement to their clinical experience. With respect to the CEPAERs, students reported improved confidence in 77% of the areas, with statistically significant increases occurring in the follow-ing areas: ability to prioritize a differential diagnosis (average Likert rating improved from 3.7 to 4.1, p = 0.04), comfort entering and discussing orders (2.9-3.8, p = 0.007), and overall preparedness to be a surgical intern (3.2-3.8, p = 0.02). Students also reported improvement in confidence in 92% of the basic intern responsibility topics, with statistically significant increases in maintenance fluid calculations (Likert rating 3.5-4.5, p = 0.001), repleting electrolytes (3.8-4.6, p = 0.01), interpretation of chest and abdominal x-rays (4-5, p = 0.02; 3.6-4.5, p=0.004, respectively), manage-ment of oliguria (3.2-3.8, p = 0.02), and time manage-ment/organization skills (4.5-5.4, p = 0.04). CONCLUSIONS: Implementation of a standardized sub -intern curriculum improved student confidence in 33 of the 38 basic intern responsibilities, core Entrustable Pro-fessional Activities, and overall preparedness to be a sur-gical intern. While limited by a single institution design, we believe these results offer a new avenue for educat-ing and preparing medical students for residency within their existing sub-internships.( J Surg Ed 79:1402-1412. (c) 2022 Association of Program Directors in Surgery. Published by Elsevier Inc. All rights reserved.) ABBREVIATIONS: CEPAERs, AAMC Core Entrustable Professional Activities for Entering Residency SINA, Sub -Intern Needs Assessment ACGME Core Competency Practice-Based Learning and Improvement

Background Many patients with inflammatory bowel disease (IBD) are referred to surgeons when medical treatments are ineffective, signifying poor disease control. We aimed to assess the association of IBD diagnosis with physical and mental health upon presentation to a colorectal surgeon. Methods We included all new patients presenting to colorectal surgery clinic over 1.5 years. During registration, patients completed the PROMIS Global-10, a validated outcome measure assessing physical and mental health. We grouped patients by diagnosis: IBD, anorectal, benign colorectal, and malignancy. Details on IBD patients were obtained via chart review. We evaluated the interaction between PROMIS scores and diagnosis through ANOVA analysis and post hoc Tukey-Kramer pairwise comparison. We estimated the strength of association of age, sex, and visit diagnosis with poor physical and mental health (PROMIS: -1 SD) through logistic regression. Results Eight hundred ninety-seven patients were included. The cohort was as follows: IBD (99) (Crohn = 73; ulcerative colitis = 26), anorectal (378), benign colorectal (224), and malignancy (196). The mean age of patients was 56 (+/- 17) years. Fifty-seven percent were female. The IBD group was youngest (P < 0.001). IBD had significantly lower PROMIS scores on pairwise comparison; anorectal had the highest scores. Controlling for age and sex, the IBD group had 4.1x odds of poor physical health (95% confidence interval 2.46-6.76) and 2.9x odds of poor mental health (95% confidence interval 1.66-5.00). Conclusions Patients with IBD, specifically Crohn disease, have worse physical and mental health on presentation to a colorectal surgeon compared to patients presenting with other colorectal diagnoses. These patients considering surgery might benefit from added support during the perioperative period. Lay Summary Our study found that patients with inflammatory bowel disease are in worse overall mental and physical health at presentation to a colorectal surgeon than patients with other colorectal diagnoses. Patients with Crohn in particular need more support during the perioperative period.

Shaw, Robert D. MD; Read, Jackson BS; Eid, Mark MD; Wilson, Matthew Z. MD, FACS; Ivatury, Srinivas J. MD, MHA, FACS, FASCRS Author Information

OBJECTIVE:To assess the current barriers in robotic surgery training for general surgery residents. DESIGN:Multi-institutional web-based survey. SETTING:9 academic medical centers with a general surgery residency. PARTICIPANTS:General surgery residents of at least PGY-3 training level. RESULTS:163 general surgery residents were contacted with 80 responses (49.1%). The most common responders were PGY-3s (38.8%) followed by PGY-5s (27.5%). The Northeast represented 42.5% of responses. Colorectal cases were the most common robotic case residents were involved in (51.3%). Residents' typical roles were assisting at the bedside (31.3%) and splitting time between assisting at the bedside and operating at the surgeon console (31.3%). 43% report to be either extremely or somewhat dissatisfied with their robotic surgery experience. 62.5% report they do not intend to integrate robotic surgery into their future practice. 93.8% of residents have a standardized robotic curriculum. 47.5% report using the simulator only during required didactic time with 52.5% having the robotic simulator conveniently located. The majority of residents report that the presence of dual consoles and first-assists in robotic cases enhance their robotic training (93% - 62%, respectively). 72.5% felt like they had more autonomy during laparoscopic cases and 96.8% of residents felt that an attendings' lack of experience impacted their time operating at the surgeon console. CONCLUSIONS:General surgery residents report lack of effective OR teaching, real clinical experience, and simulated experience as main barriers in their robotic surgery training. Dual consoles and first-assistants are favorably looked upon. Lack of attending experience and comfort were universally negatively associated with resident participation. For residents interested in robotic surgery, advocating for more robust investment in dual consoles, first-assistants, and faculty development would likely improve their robotic surgery training experience. However, residency programs should consider whether robotic surgery should be a core competency of an already time restricted training paradigm.

AIM:We aimed to evaluate long-term changes in patient-reported bowel function from presentation of anal canal squamous cell carcinoma (SCC) successfully treated with the modified Nigro protocol using a patient-reported outcome measure for bowel function. METHOD:This is a retrospective study of prospectively collected patient-reported outcomes for bowel function. We included patients that were successfully treated with the modified Nigro protocol for anal SCC and had completed the Colorectal Functional Outcomes (COREFO) questionnaire at presentation, following the modified Nigro treatment (post-Nigro), and at subsequent surveillance visits (medium and long term). We compared the differences in mean domain and total COREFO scores using a paired t test for each paired time point. RESULTS:Twenty-seven patients met inclusion criteria. Time from completion of the modified Nigro was post-Nigro at 3-6 months, medium-length follow-up at 8-12 months and long-term follow-up at 12-18 months. There was significant improvement in the stool-related aspects domain (pain, bleeding and anal skin irritation) from presentation to our short- and medium-length follow-up (42.5 to 23.7, P = 0.01). There was worsening in the frequency domain in the medium term (7.23 to 14.5, P = 0.02). There were no differences in any other domain or time point. CONCLUSION:Global bowel function does not appear to change following successful treatment of anal canal SCC with the modified Nigro protocol in the long term. There are some improvements in stool-related aspects and worsening in bowel movement frequency at medium-length follow-up. These findings should help surgeons counsel patients with regard to bowel function expectations for those with anal canal SCC in the long term.

Case Summary: A 59-year-old previously healthy, asymptomatic man initially presented for his first screening colonoscopy. At this time, a friable, partially obstructing tumor was encountered in his proximal rectum. Final workup demonstrated a mrT2N1M0 upper rectal cancer. The patient went on to successfully complete total neoadjuvant chemoradiation therapy and was taken to the operating room for an uncomplicated robotic-assisted low anterior resection with primary anastomosis. His final pathology revealed an ypT2N1M0 rectal cancer, and he was subsequently followed in surveillance per National Comprehensive Cancer Network guidelines. At long-term follow-up visits he continued to report significant depressive symptoms and functional impairment. Despite aggressive medical management with fiber supplementation and antidiarrheal medications, the patient continued to struggle with bowel movement frequency and urgency. He reported having 4 to 6 clustered bowel movements during the day and 1 to 2 stools at night that significantly limited his ability to perform normal day-to-day activities.