Publications by authors named "Christy E Cauley"

37 Publications

Expected Versus Experienced Health-Related Quality of Life Among Patients Recovering From Cancer Surgery: A Prospective Cohort Study.

Ann Surg Open 2021 Jun 8;2(2):e060. Epub 2021 Apr 8.

Ariadne Labs, Brigham and Women's Hospital, Harvard. T.H. School of Public Health, Boston, MA.

Patient expectations of the impact of surgery on postoperative health-related quality of life (HRQL) may reflect the effectiveness of patient-provider communication. We sought to compare expected versus experienced HRQL among patients undergoing cancer surgery.

Methods: Adults undergoing cancer surgery were eligible for inclusion (2017-2019). Preoperatively, patients completed a smartphone-based survey assessing expectations for HRQL 1 week and 1, 3, and 6 months postoperatively based on the 8 short-form 36 (SF36) domains (physical functioning, physical role limitations, pain, general health, vitality, social functioning, emotional role limitations, and mental health). Experienced HRQL was then assessed through smartphone-based SF36 surveys 1, 3, and 6 months postoperatively. Correlations between 1- and 6-month trends in expected versus experienced HRQL were determined.

Results: Among 101 consenting patients, 74 completed preoperative expectations and SF36 surveys (73%). The mean age was 54 years (SD 14), 49 (66%) were female, and the most common operations were for breast (34%) and abdominal (31%) tumors. Patients expected HRQL to worsen 1 week after surgery and improve toward minimal disability over 6 months. There was poor correlation (≤±0.4) between 1- and 6-month trends in expected versus experienced HRQL in all SF36 domains except for moderate correlation in physical functioning (0.50, 95% confidence interval [0.22-0.78], < 0.001) and physical role limitations (0.41, 95% confidence interval [0.05-0.77], = 0.024). Patients expected better HRQL than they experienced.

Conclusions: Preoperative expectations of postoperative HRQL correlated poorly with lived experiences except in physical health domains. Surgeons should evaluate factors which inform expectations around physical and psychosocial health and use these data to enhance shared decision-making.
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http://dx.doi.org/10.1097/AS9.0000000000000060DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8221715PMC
June 2021

Zip Code-Related Income Disparities in Patients with Colorectal Cancer.

Am Surg 2021 Jun 8:31348211023435. Epub 2021 Jun 8.

Department of General and Gastrointestinal Surgery, 2348Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA.

Introduction: Screening and early detection reduce morbidity and mortality in colorectal cancer. Our aim is to study the effect of income disparities on the clinical characteristics of patients with colorectal cancer in Massachusetts.

Methods: Patients were extracted from a database containing all surgically treated colorectal cancers between 2004 and 2015 at a tertiary hospital in Massachusetts. We split patients into 2 groups: "above-median income" and "below-median income" according to the median income of Massachusetts ($74,167).

Results: The analysis included 817 patients. The above-median income group consisted of 528 patients (65%) and the below-median income group consisted of 289 patients (35%). The mean age of presentation was 64 ± 15 years for the above-median income group and 67 ± 15 years for the below-median income group ( = .04). Patients with below-median income were screened less often ( < .001) and presented more frequently with metastatic disease ( = .02). Patients with above-median income survived an estimated 15 months longer than those with below-median income ( < .001). The survival distribution was statistically significantly different between the groups for stage III disease ( = .004), but not stages I, II, or IV ( = 1, 1, and .2, respectively). For stage III disease, a lower proportion of below-median income patients received chemotherapy (61% vs. 79%, = .002) and a higher proportion underwent nonelective surgery (5% vs. 2%, = .007).

Conclusions: In Massachusetts, patients with colorectal cancer residing in lower income areas are screened less, received adjuvant chemotherapy less, and have worse outcomes, especially when analyzing those who present with stage III disease.
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http://dx.doi.org/10.1177/00031348211023435DOI Listing
June 2021

Is Microsatellite Status Associated With Prognosis in Stage II Colon Cancer With High-Risk Features?

Dis Colon Rectum 2021 May;64(5):545-554

Section of Colon and Rectal Surgery, Massachusetts General Hospital, Boston, Massachusetts.

Background: The influence of microsatellite instability on prognosis in high-risk stage II colon cancer is unknown.

Objective: This study aimed to investigate the relationship between microsatellite instability and overall survival in high-risk stage II colon cancer.

Design: This is a retrospective review of the National Cancer Database from 2010 to 2016.

Settings: This study included national cancer epidemiology data from the American College of Surgeons Commission on Cancer.

Patients: Included were 16,788 patients with stage II colon adenocarcinoma and known microsatellite status (1709 microsatellite unstable).

Main Outcome Measures: The primary outcome measured was overall survival.

Results: Microsatellite unstable cancers with high-risk features had significantly better overall survival than microsatellite stable cancers with high-risk features (5-year survival 80% vs 72%, p = 0.01), and had survival equivalent to microsatellite stable cancers with low-risk features (5-year survival, 80%). When stratified by specific high-risk features, patients with lymphovascular invasion, perineural invasion, or high-grade histology had overall survival similar to patients without these features, only in microsatellite unstable cancers. However, patients with high-risk features of T4 stage, positive margins, and <12 lymph nodes saw no survival benefit based on microsatellite status. This was confirmed on multivariable Cox regression modeling. A subgroup analysis of patients who did not receive chemotherapy similarly demonstrated that microsatellite unstable cancers with lymphovascular invasion, perineural invasion, or high-grade histology had overall survival similar to microsatellite unstable cancers without those features.

Limitations: The study is limited by the lack of specific clinical data and potential treatment bias.

Conclusions: In microsatellite unstable cancers, lymphovascular invasion, perineural invasion, and high-grade histology are not associated with worse overall survival, even when deferring adjuvant chemotherapy. These data support National Comprehensive Cancer Network recommendations to forego chemotherapy in stage II cancers with microsatellite instability and these features. In contrast, some high-risk features were associated with worse survival despite microsatellite unstable biology, and therapies to improve survival need to be explored. See Video Abstract at http://links.lww.com/DCR/B500. ¿EL ESTADO MICROSATÉLITE ESTÁ ASOCIADO CON EL PRONÓSTICO EN EL CÁNCER DE COLON EN ESTADIO II CON CARACTERÍSTICAS DE ALTO RIESGO: Se desconoce la influencia de la inestabilidad microsatélite en el pronóstico del cáncer de colon en estadio II de alto riesgo.Investigar la relación entre la inestabilidad microsatélite y la supervivencia general en el cáncer de colon en estadio II de alto riesgo.Revisión retrospectiva de la base de datos nacional del cáncer de 2010 a 2016.Este estudio incluyó datos nacionales de epidemiología del cáncer de la Comisión de Cáncer del Colegio Americano de Cirujanos.16,788 pacientes con adenocarcinoma de colon en estadio II y estado microsatélite conocido (1,709 microsatélite inestables).Supervivencia global.Los cánceres microsatélite inestables con características de alto riesgo tuvieron una supervivencia general significativamente mejor que los cánceres microsatélite estables con características de alto riesgo (supervivencia a 5 años 80% vs 72%, p = 0.01), y tuvieron una supervivencia equivalente a los cánceres microsatélite estables con características de bajo riesgo (supervivencia a 5 años 80%). Al estratificar por características específicas de alto riesgo, los pacientes con invasión linfovascular, invasión perineural o histología de alto grado tuvieron una supervivencia general similar a la de los pacientes sin estas características, solo en cánceres microsatélite inestables. Sin embargo, los pacientes con características de alto riesgo en estadio T4, márgenes positivos y <12 ganglios linfáticos no tuvieron ningún beneficio de supervivencia basado en el estado de microsatélites. Esto se confirmó en un modelo de regresión de Cox multivariable. Un análisis de subgrupos de pacientes que no recibieron quimioterapia demostró de manera similar que los cánceres microsatélite inestables con invasión linfovascular, invasión perineural o histología de alto grado tenían una supervivencia general similar a los cánceres microsatélite inestables sin esas características.El estudio está limitado por la falta de datos clínicos específicos y el posible sesgo de tratamiento.En los cánceres microsatélite inestables, la invasión linfovascular, la invasión perineural y la histología de alto grado no se asocian con una peor sobrevida general, incluso cuando se aplaza la quimioterapia adyuvante. Estos datos respaldan las recomendaciones de la National Comprehensive Cancer Network de omitir la quimioterapia en los cánceres en estadio II con inestabilidad microsatélite y estas características. Por el contrario, algunas características de alto riesgo se asociaron con una peor supervivencia a pesar de la biología microsatélite inestable, y es necesario considerar las terapias para mejorar la supervivencia.Consulte Video Resumen en http://links.lww.com/DCR/B500. (Traducción-Dr. Jorge Silva Velazco).
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http://dx.doi.org/10.1097/DCR.0000000000001914DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8097721PMC
May 2021

Redeployment of Health Care Workers in the COVID-19 Pandemic: A Qualitative Study of Health System Leaders' Strategies.

J Patient Saf 2021 06;17(4):256-263

From the Ariadne Labs, Brigham and Women's Hospital, Harvard T.H. Chan School of Public Health.

Objectives: This study aimed to determine the strategies used and critical considerations among an international sample of hospital leaders when mobilizing human resources in response to the clinical demands associated with the COVID-19 pandemic surge.

Methods: This was a cross-sectional, qualitative research study designed to investigate strategies used by health system leaders from around the world when mobilizing human resources in response to the global COVD-19 pandemic. Prospective interviewees were identified through nonprobability and purposive sampling methods from May to July 2020. The primary outcomes were the critical considerations, as perceived by health system leaders, when redeploying health care workers during the COVID-19 pandemic determined through thematic analysis of transcribed notes. Redeployment was defined as reassigning personnel to a different location or retraining personnel for a different task.

Results: Nine hospital leaders from 9 hospitals in 8 health systems located in 5 countries (United States, United Kingdom, New Zealand, Singapore, and South Korea) were interviewed. Six hospitals in 5 health systems experienced a surge of critically ill patients with COVID-19, and the remaining 3 hospitals anticipated, but did not experience, a similar surge. Seven of 8 hospitals redeployed their health care workforce, and 1 had a redeployment plan in place but did not need to use it. Thematic analysis of the interview notes identified 3 themes representing effective practices and lessons learned when preparing and executing workforce redeployment: process, leadership, and communication. Critical considerations within each theme were identified. Because of the various expertise of redeployed personnel, retraining had to be customized and a decentralized flexible strategy was implemented. There were 3 concerns regarding redeployed personnel. These included the fear of becoming infected, the concern over their skills and patient safety, and concerns regarding professional loss (such as loss of education opportunities in their chosen profession). Transparency via multiple different types of communications is important to prevent the development of doubt and rumors.

Conclusions: Redeployment strategies should critically consider the process of redeploying and supporting the health care workforce, decentralized leadership that encourages and supports local implementation of system-wide plans, and communication that is transparent, regular, consistent, and informed by data.
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http://dx.doi.org/10.1097/PTS.0000000000000847DOI Listing
June 2021

Delay to Intervention for Complicated Diverticulitis is Associated with Higher Inpatient Mortality.

J Gastrointest Surg 2021 Mar 16. Epub 2021 Mar 16.

Department of Surgery, Massachusetts General Hospital, 15 Parkman Street, WACC 460, Boston, MA, 02114, USA.

Background: Patients with diverticular disease complicated by abscess and/or perforation represent the most severely afflicted with the highest mortality and poorest outcomes. This study investigated patient and operative factors associated with poor outcomes from diverticulitis complicated by abscess or perforation.

Methods: We analyzed the National Inpatient Sample to identify inpatient discharges for colonic diverticulitis in the United States from 1/1988 to 9/2015. We identified patients with perforation and/or intestinal abscess based on ICD-9 codes. The primary outcome was inpatient mortality.

Results: During the study period, a total of 993,220 patients were discharged with diverticulitis from sampled U.S. hospitals. From this group, 10.7% had an abscess and 1.0% had a perforation associated with diverticular disease. Inpatient mortality of diverticulitis patients with a perforation was 5.4% compared to 1.5% in those without a perforation (p<0.001). Patients with a perforation who underwent surgery had an inpatient mortality of 6.3% vs. 3.0% mortality amongst patients with a perforation who did not undergo an operation (p<0.001). Patients with a perforation that underwent surgery had a 31% increased mortality risk for each day after admission that a procedure was delayed (OR 1.31, CI 1.05-1.78; p=0.03). Mortality risk was increased for patients with either abscess or perforation who underwent surgery if they were female, age ≥65, higher comorbidity, were admitted urgently, underwent peritoneal lavage, or had a post-procedural complication.

Conclusions: Patients with perforated diverticular disease had substantial associated inpatient mortality compared to those with uncomplicated diverticulitis. This increased risk may be associated with performance of peritoneal lavage or because of a delay to procedural intervention.
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http://dx.doi.org/10.1007/s11605-021-04972-9DOI Listing
March 2021

We Asked the Experts: The WHO Surgical Safety Checklist and the COVID-19 Pandemic: Recommendations for Content and Implementation Adaptations.

World J Surg 2021 05 26;45(5):1293-1296. Epub 2021 Feb 26.

Ariadne Labs, Harvard T.H. Chan School of Public Health, Brigham and Women's Hospital, University of Calgary, Boston, MA, 403-826-7913, USA.

Background: As surgical systems are forced to adapt and respond to new challenges, so should the patient safety tools within those systems. We sought to determine how the WHO SSC might best be adapted during the COVID-19 pandemic.

Methods: 18 Panelists from five continents and multiple clinical specialties participated in a three-round modified Delphi technique to identify potential recommendations, assess agreement with proposed recommendations and address items not meeting consensus.

Results: From an initial 29 recommendations identified in the first round, 12 were identified for inclusion in the second round. After discussion of recommendations without consensus for inclusion or exclusion, four additional recommendations were added for an eventual 16 recommendations. Nine of these recommendations were related to checklist content, while seven recommendations were related to implementation.

Conclusions: This multinational panel has identified 16 recommendations for sites looking to use the surgical safety checklist during the COVID-19 pandemic. These recommendations provide an example of how the SSC can adapt to meet urgent and emerging needs of surgical systems by targeting important processes and encouraging critical discussions.
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http://dx.doi.org/10.1007/s00268-021-06000-yDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7908955PMC
May 2021

Diverticular Disease Epidemiology: Rising Rates of Diverticular Disease Mortality Across Developing Nations.

Dis Colon Rectum 2021 01;64(1):81-90

Section of Colon and Rectal Surgery, Division of General and Gastrointestinal Surgery, Department of Surgery, Massachusetts General Hospital, Boston, Massachusetts.

Background: The incidence of diverticular disease is growing in the Western world. However, the global burden of disease is unknown in the developing world.

Objective: This study aimed to determine the global burden of diverticular disease as measured by disease-specific mortality while identifying indicators of rising disease rates.

Design: We undertook an ecological analysis based on data from the World Health Organization Mortality Database. Then, we analyzed global age-adjusted mortality rates from diverticular disease and compared them to national rates of overweight adults, health expenditures, and dietary composition.

Settings: National vital statistics data were collected.

Patients: Diverticular disease deaths from January 1, 1994 through December 31, 2016 were evaluated.

Main Outcome Measures: The primary outcome measured was the national age-adjusted mortality rate.

Results: The average age-adjusted mortality rate for diverticular disease was 0.51 ± 0.31/100,000 with a range of 0.11 to 1.75/100,000. During the study period, we noted that 57% of nations had increasing diverticular disease mortality rates, whereas only 7% had decreasing rates. More developed nations (40%) than developing nations (24%) were categorized as having high diverticular disease mortality burden over the time period of the study, and developed nations had higher percentages of overweight adults (58.9 ± 3.1%) than developing nations (50.6 ± 6.7%; p < 0.0001). However, developing nations revealed more rapid increases in diverticular disease mortality (0.027 ± 0.024/100,000 per year) than developed nations (0.005 ± 0.025/100,000 per year; p = 0.001), as well as faster expanding proportions of overweight adults (0.76 ± 0.12% per year) than in already developed nations (0.53 ± 0.10% per year; p<0.0001).

Limitations: Ecological studies cannot define cause and effect.

Conclusions: There is considerable variability in diverticular disease mortality across the globe. Developing nations were characterized by rapid increases in diverticular disease mortality and expanding percentages of overweight adults. Public health interventions in developing nations are needed to alter mortality rates from diverticular disease. See Video Abstract at http://links.lww.com/DCR/B397. EPIDEMIOLOGÍA DE LA ENFERMEDAD DIVERTICULAR: TASAS CRECIENTES DE MORTALIDAD POR ENFERMEDAD DIVERTICULAR EN LOS PAÍSES EN DESARROLLO: La incidencia de la enfermedad diverticular está creciendo en el mundo occidental. Sin embargo, la carga mundial de la enfermedad es desconocida en el mundo en desarrollo.Determinar la carga global de la enfermedad diverticular medida por la mortalidad específica de la enfermedad mientras se identifican los indicadores de aumento de las tasas de enfermedad.Realizamos un análisis ecológico basado en datos de la Base de datos de mortalidad de la Organización Mundial de la Salud. Luego, analizamos las tasas globales de mortalidad ajustadas por edad por enfermedad diverticular y las comparamos con las tasas nacionales de adultos con sobrepeso, gastos de salud y composición dietética.Datos nacionales de estadísticas vitales.Muertes por enfermedades diverticulares desde el 1 de enero de 1994 hasta el 31 de diciembre de 2016.Tasa nacional de mortalidad ajustada por edad.La tasa promedio de mortalidad ajustada por edad para la enfermedad diverticular fue de 0,51 ± 0,31 / 100,000 con un rango de 0,11 a 1,75 / 100,000. Durante el período de estudio, notamos que el 57% de las naciones tenían tasas crecientes de mortalidad por enfermedades diverticulares, mientras que solo el 7% tenían tasas decrecientes. Las naciones más desarrolladas (40%) que las naciones en desarrollo (24%) se clasificaron como que tienen una alta carga de mortalidad por enfermedad diverticular durante el período de tiempo del estudio, y las naciones desarrolladas tuvieron porcentajes más altos de adultos con sobrepeso (58.9 ± 3.1%) que las naciones en desarrollo (50,6 ± 6,7%) (p <0,0001). Sin embargo, las naciones en desarrollo revelaron aumentos más rápidos en la mortalidad por enfermedades diverticulares (0.027 ± 0.024 / 100,000 por año) que las naciones desarrolladas (0.005 ± 0.025 / 100,000 por año) (p = 0.001), así como proporciones de adultos con sobrepeso en expansión más rápida (0.76 ± 0.12% por año) que en las naciones ya desarrolladas (0.53 ± 0.10% por año) (p <0.0001).Los estudios ecológicos no pueden definir causa y efecto.Existe una considerable variabilidad en la mortalidad por enfermedad diverticular en todo el mundo. Los países en desarrollo se caracterizaron por un rápido aumento en la mortalidad por enfermedades diverticulares y porcentajes crecientes de adultos con sobrepeso. Se necesitan intervenciones de salud pública en los países en desarrollo para alterar las tasas de mortalidad por enfermedad diverticular. Consulte Video Resumen en http://links.lww.com/DCR/B397.
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http://dx.doi.org/10.1097/DCR.0000000000001804DOI Listing
January 2021

Infiltrating Tumor Border Configuration is a Poor Prognostic Factor in Stage II and III Colon Adenocarcinoma.

Ann Surg Oncol 2021 Jun 26;28(6):3408-3414. Epub 2020 Oct 26.

Division of General and Gastrointestinal Surgery, Department of General and Gastrointestinal Surgery, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA.

Introduction: Tumor border configuration (TBC) is a prognostic factor in colorectal adenocarcinoma; however, the significance of TBC is not well-documented in colon adenocarcinoma alone.

Objective: Our aim was to study the effect of TBC on overall and disease-free survival in stage II and III colon adenocarcinoma.

Methods: We included patients with stage II and III colon adenocarcinoma who were surgically treated at a tertiary medical center between 2004 and 2015, to ensure long-term follow-up. Patients were stratified into four groups based on stage and TBC. A Cox regression was used to model the relationship of groups while accounting for relevant confounders.

Results: The cohort consisted of 700 patients (371 stage II and 329 stage III). Infiltrating TBC was statistically significantly associated with stage (p < 0.001) and extramural vascular invasion (p < 0.001), but not histologic grade (p = 0.7). Compared with pushing TBC, infiltrating TBC increased the hazard of death by a factor of 1.8 [95% confidence interval (CI) 1.4-2.4; p < 0.001] and 1.7 (95% CI 1.3-2.2; p < 0.001). The hazard of death in patients with stage II disease (infiltrating TBC) or stage III disease (pushing TBC) was not significantly different (adjusted hazard ratio 1.1, 95% CI 0.7-1.7; p = 0.8).

Conclusion: Infiltrating TBC is a high-risk feature in patients with stage II and III colon adenocarcinoma. Stage II disease patients with infiltrating TBC and who are node-negative should be considered for adjuvant chemotherapy.
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http://dx.doi.org/10.1245/s10434-020-09281-0DOI Listing
June 2021

Octogenarians present with a less aggressive phenotype of colon adenocarcinoma.

Surgery 2020 12 9;168(6):1138-1143. Epub 2020 Oct 9.

Department of Surgery, Massachusetts General Hospital, Boston, MA.

Background: Octogenarians constitute a growing percentage of patients diagnosed with colon malignancies. This study aims to determine if the clinical and pathologic presentation of octogenarians with colon cancer differs from that of patients diagnosed at a younger age.

Methods: Data were collected retrospectively for all patients diagnosed with colon cancer who underwent resection at a single institution between January 1, 2004 and December 31, 2017; patients with rectal cancer were excluded. Patients were categorized by age at diagnosis: either 50 to 79 years of age or ≥80 years of age; those <50 years of age were excluded because of the greater risk of a hereditary etiology. The primary outcome was the correlation between patient age and pathologic features of the tumor, including tumor size, lymph node metastases, perineural invasion, and extramural venous invasion.

Results: Of 1,301 patients, 329 (25%) were ≥80. Female patients predominated the octogenarian cohort (61% vs 39%; P < .001). Octogenarians presented with larger tumors when compared to patients age 50 to 79 (5.2 cm vs 4.5 cm; P < .001). More patients ≥80 had tumors which were >8 cm (17.3% vs 8.9%; P < .001). Tumors in younger patients were more often detected on screening colonoscopy (23.1% vs 7.3%; P < .001). Regardless of tumor size, octogenarians were less likely to have positive lymph nodes than younger patients (P = .02). In addition, octogenarians were less likely to exhibit extramural venous invasion compared to younger patients across all tumor sizes (P < .001). Younger patients had greater median overall survival (6.4 years vs 4.4 years; P < .001), yet 3-year disease-free survival was comparable between age groups (P = .12).

Conclusion: Octogenarians with colon cancer present with larger tumors but appear to have less aggressive disease, as reflected in a lower pathologic stage, less extramural venous invasion, and less lymph node metastases, than younger patients with similar size tumors. Three-year disease-free survival is comparable between octogenarians and patients aged 50 to 79.
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http://dx.doi.org/10.1016/j.surg.2020.08.025DOI Listing
December 2020

Ten-year survival after pathologic complete response in rectal adenocarcinoma.

J Surg Oncol 2021 Jan 6;123(1):293-298. Epub 2020 Oct 6.

Department of Surgery, Massachusetts General Hospital, Boston, Massachusetts, USA.

Background: Multimodal treatment is the standard of care for rectal adenocarcinoma, with a subset of patients achieving a pathologic complete response (pCR). While pCR is associated with improved overall survival (OS), long-term data on patients with pCR is limited.

Methods: This is a single institution retrospective cohort study of all patients with clinical stages II/III rectal adenocarcinoma who underwent neoadjuvant chemoradiation therapy and operative resection (January 1, 2004-December 31, 2017). PCR was defined as no tumor identified in the rectum or associated lymph nodes by final pathology.

Results: Of 370 patients in this cohort, 50 had a pCR (13.5%). For pCR patients, 5-year disease-free survival (DFS) was 92%, 5-year OS was 95%. Twenty-six patients had surgery > 10 years before the study end date, of which 20 had an OS > 10 years (77%) with median OS 12.1 years and 95% alive to date (19/20). Of the 50 pCR patients, there was a single recurrence in the lung at 44.3 months after proctectomy which was surgically resected.

Conclusion: For patients with rectal adenocarcinoma that undergo neoadjuvant chemoradiation and surgical resection, pCR is associated with excellent long-term DFS and OS. Many patients live greater than 10 years with no evidence of disease recurrence.
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http://dx.doi.org/10.1002/jso.26247DOI Listing
January 2021

Adjuvant Chemotherapy Benefits on Patients with Extramural Vascular Invasion in Stages II and III Colon Cancer.

J Gastrointest Surg 2020 Oct 2. Epub 2020 Oct 2.

Department of General and Gastrointestinal Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA.

Introduction: Extramural vascular invasion (EMVI) is a poor prognostic factor in colon cancer. However, the benefit of adjuvant chemotherapy in patients with EMVI is not well defined. The objective of this study is to determine if there is a survival benefit for using adjuvant chemotherapy in patients with EMVI-positive colon cancers.

Methods: We performed a retrospective review of all patients with stages II and III colon adenocarcinoma who underwent surgical resection between 2004 and 2015. Cox regression was used to determine the effect of chemotherapy on EMVI-positive patients while adjusting for the extent of invasion, regional lymph node metastasis, histologic grade, age, site of tumor, and ASA score.

Results: A total of 750 patients were included in this study. Extramural vascular invasion was present in 93 out of 387 stage II patients (24%) and 187 out of 363 stage III patients (52%). The Cox regression model showed that in patients with EMVI, those who did not receive adjuvant chemotherapy had a 1.6-fold (1.1-2.3) increase in the hazard of death compared with those who received chemotherapy.

Conclusions: Patients who were EMVI-negative fared better than those who were EMVI-positive. In patients who were EMVI-positive, adjuvant chemotherapy improved overall survival.
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http://dx.doi.org/10.1007/s11605-020-04810-4DOI Listing
October 2020

Smartphone-Based Assessment of Preoperative Decision Conflict and Postoperative Physical Activity Among Patients Undergoing Cancer Surgery: A Prospective Cohort Study.

Ann Surg 2020 Sep 15. Epub 2020 Sep 15.

Ariadne Labs, Brigham and Women's Hospital, Harvard. T.H. School of Public Health, Boston, MA.

Objective: To determine the prevalence of clinically significant decision conflict (CSDC) among patients undergoing cancer surgery and associations with postoperative physical activity, as measured through smartphone accelerometer data.

Background: Patients with cancer face challenging treatment decisions, which may lead to CSDC. CSDC negatively affects patient-provider relationships, psychosocial functioning, and health-related quality of life; however, physical manifestations of CSDC remain poorly characterized.

Methods: Adult smartphone-owners undergoing surgery for breast, skin-soft-tissue, head-and-neck, or abdominal cancer (July 2017-2019) were approached. Patients downloaded the Beiwe application that delivered the Decision Conflict Scale (DCS) preoperatively and collected smartphone accelerometer data continuously from enrollment through 6 months postoperatively. Restricted-cubic-spline regression, adjusting for a priori potential confounders (age, type of surgery, support status, and postoperative complications) was used to determine trends in postoperative daily physical activity among patients with and without CSDC (DCS score≥25/100).

Results: Among 99 patients who downloaded the application, 85 completed the DCS (86% participation rate). Twenty-three (27%) reported CSDC. These patients were younger (mean age 48.3 [standard deviation 14.2]-vs.-55.0 [13.3],p = 0.047) and more frequently lived alone (22%-vs.-6%,p = 0.042). There were no differences in preoperative physical activity (115.4 minutes [95%CI 90.9,139.9]-vs.-110.8 [95% 95.7,126.0],p = 0.753). Adjusted postoperative physical activity was lower among patients reporting CSDC at 30 days (difference 33.1 minutes [95%CI 5.93,60.2],p = 0.017), 60 days (35.5[95%CI 8.50,62.5],p = 0.010) and 90 days (31.8[95%CI 5.44,58.1],p = 0.018) postoperatively.

Conclusions: CSDC was prevalent among patients who underwent cancer surgery and associated with lower postoperatively daily physical activity. These data highlight the importance of addressing modifiable decisional needs of patients through enhanced shared decision-making.
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http://dx.doi.org/10.1097/SLA.0000000000004487DOI Listing
September 2020

Increasing Incidence of Left-Sided Colorectal Cancer in the Young: Age Is Not the Only Factor.

J Gastrointest Surg 2020 10 10;24(10):2416-2422. Epub 2020 Jun 10.

Department of Colorectal Surgery, Cleveland Clinic Foundation, Cleveland Clinic, 9500 Euclid Avenue, Cleveland, OH, 44195, USA.

Background: Recent single-institution studies have shown that colorectal cancer (CRC) in patients < 50 is predominantly left-sided. The aims of this study were to 1 compare the incidence of left-sided CRC in patients under and over 50, 2 investigate this trend over time, and 3 examine whether racial differences exist in the anatomical distribution of CRC.

Methods: We used the Nationwide Inpatient Sample to identify all patients with colon or rectal cancer who underwent a resection from 2000 to 2014. Logistic regression models were used to determine the odds of a patient having a left-sided CRC based on age and race.

Results: A total of 1,547,589 patients underwent resection, with a mean age of 68.6. Overall, 65.1% of patients < 50 had a left-sided CRC compared with 47.2% of patients ≥ 50 (OR = 2.1; 95% CI 2.0, 2.1). The difference was greater as patients became older with 39.9% of patients > 70 having a left-sided CRC (< 50 vs ≥ 70; OR = 2.8; 95% CI 2.7, 2.9). The incidence of CRC in those under 50 increased over the study period due to an increase in left-sided tumors. The distribution of CRC varied with race, with African-Americans having a lower odds for left-sided CRC (OR = 0.89; 95% CI 0.87, 0.91) and Asians/Pacific Islanders having a higher odds (OR = 1.8; 95% CI 1.7, 1.9).

Conclusion: In the < 50 age group, the incidence of CRC is increasing, with majority of these tumors left-sided. Tumor location varies with both age and race.
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http://dx.doi.org/10.1007/s11605-020-04663-xDOI Listing
October 2020

Sessile Serrated Polyposis: Not an Inherited Syndrome?

Dis Colon Rectum 2020 02;63(2):183-189

Department of Colorectal Surgery, Cleveland Clinic, Cleveland, Ohio.

Background: Researchers are searching in vain for a coherent genetic explanation for serrated polyposis. We hypothesize that there is no consistent monogenetic inheritance.

Objective: The purpose of this study was to describe the serrated polyposis phenotype, assessing features of mendelian inheritance, and to compare these features with patients with a solitary sessile serrated lesion.

Design: This was a retrospective review of a prospectively maintained database comparing patients with serrated polyposis versus solitary sessile serrated lesions.

Settings: The study was conducted at a single-institution tertiary referral center.

Patients: Patients with serrated polyposis meeting World Health Organization criteria type I (≥5 serrated polyps proximal to the sigmoid, ≥2 of which are ≥10 mm in diameter) and isolated sessile serrated lesions were included MAIN OUTCOME MEASURES:: Disease phenotype was the main outcome measured.

Results: A total of 46 serrated polyposis patients were identified. Median age of first sessile serrated lesion was 66 years (interquartile range, 42-70 y). A total of 60.3% were current or past smokers (mean = 38.6 packs per year). Serrated polyposis patients had a higher number of all types of polyps (26.3 vs 4.4) and a higher rate of high-grade dysplasia (19.6% vs 3.7%) compared with patients with a solitary sessile serrated lesion. A total of 36.2% of patients had personal history of noncolorectal cancers, including skin, prostate, breast, thyroid, and renal cell cancers and leukemia. In addition, 32.6% had a family history of colorectal cancer in first- or second-degree relatives; these cancers were not young age of onset. Breast and prostate cancers were also common (family history of any cancer, 83.0%). Ten patients underwent genetic testing: 4 had negative panels, 1 had a pathogenic variant in MSH2, 1 an IVS7 deletion in PTEN, 2 negative APC sequencing (1 negative MYH), and 1 a pathogenic variant in Chek2.

Limitations: RNF4 was not sequenced. Genetic analysis was performed on a subset of patients.

Conclusions: The rate of associated cancers suggests an underlying genetic predisposition to disordered growth, but serrated polyposis does not have typical features of dominant inheritance. The association with smoking suggests that familial/environmental factors play a role. See Video Abstract at http://links.lww.com/DCR/B84. POLIPOSIS SERRADA SÉSIL: ¿NO ES UN SÍNDROME HEREDITARIO?: Los investigadores están buscando en vano una explicación genética coherente para la póliposis serrados. Suponemos que no existe una herencia monogenética consistente.1) Describir el fenotipo de póliposis serrada, evaluando las características de la herencia mendeliana, 2) comparar estas características con pacientes con una lesión serrada sésil solitaria.Revisión retrospectiva de una base de datos mantenida prospectivamente que compara pacientes con póliposis serrada versus lesiones serradas sésiles solitarias.Institución única, centro de referencia terciario.Pacientes con póliposis serrada que cumplen con los Criterios de la Organización Mundial de la Salud Tipo I (≥ 5 pólipos serrados proximales al sigmoideo, ≥2 de los cuales tienen ≥10 mm de diámetro) y lesiones serradas sésiles aisladas.Fenotipo de la enfermedad.Se identificaron un total de 46 pacientes con póliposis serrada. La edad mediana de la primera lesión serrada sésil fue de 66 años (RIC: 42-70 años). El 60.3% eran fumadores actuales o pasados (medio 38.6 paquetes / año). Los pacientes con póliposis serrada tuvieron un mayor número de todos los tipos de pólipos (26.3 versus 4.4) y una mayor tasa de displasia de alto grado (19.6% versus 3.7%) en comparación con los pacientes con una lesión serrada sésil solitaria. El 36.2% de los pacientes tenían antecedentes personales de cánceres no colorectales, incluyendo los cánceres de piel, próstata, mama, tiroides, células renales y leucemia. El 32.6% tenía antecedentes familiares de cáncer colorectal en familiares de primer o segundo grado; estos cánceres no eran de inicio de edad temprana. El cáncer de mama y próstata también fue frecuente (antecedentes familiares de cualquier tipo de cáncer: 83.0%). 10 pacientes se sometieron a pruebas genéticas: 4 tenían paneles negativos, 1 tenía una variante patogénica en MSH2, 1 una eliminación IVS7 en PTEN, 2 secuenciación APC negativa (1 MYH negativa) y 1 variante patogénica en Chek2.RNF4 no fue secuenciado. El análisis genético se realizó en un subconjunto de pacientes.La tasa de cánceres asociados sugiere una predisposición genética subyacente al crecimiento desordenado, pero la póliposis serrada no tiene características típicas de herencia dominante. La asociación con el tabaquismo sugiere que los factores familiares / ambientales juegan un papel. Consulte Video Resumen en http://links.lww.com/DCR/B84. (Traducción-Dr. Yesenia Rojas-Khalil).
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February 2020

DNR, DNI, and DNO?

J Palliat Med 2020 06 12;23(6):829-831. Epub 2019 Nov 12.

Department of Surgery, Massachusetts General Hospital, Boston, Massachusetts, USA.

The addition of a do-not-operate (DNO) section to current medical orders for life-sustaining treatment (MOLST) and physician orders for life-sustaining treatment (POLST) medical order forms would more completely document patients' wishes for invasive interventions at the end of life. We propose a modification of the MOLST and POLST forms, in addition to hospital and electronic medical records, to include a DNO section, in addition to preexisting do-not-resuscitate (DNR) and do-not-intubate (DNI) orders, with the goal of reducing suffering from nonbeneficial surgical interventions in patients with severe illness at the end of life.
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http://dx.doi.org/10.1089/jpm.2019.0486DOI Listing
June 2020

The Effect of Surgical Training and Operative Approach on Outcomes in Acute Diverticulitis: Should Guidelines Be Revised?

Dis Colon Rectum 2019 01;62(1):71-78

Colorectal Surgery Center, Department of Surgery, Massachusetts General Hospital, Boston, Massachusetts.

Background: Current guidelines accept partial colectomy and primary anastomosis with proximal diversion for select patients with perforated diverticulitis based on low-quality evidence.

Objective: This study aimed to compare the effect of operative approach and surgeon training on outcomes following urgent/emergent colectomy for diverticulitis.

Design: This is a statewide retrospective cohort study.

Setting: Data were obtained from the New York State all-payer sample from 2000 to 2014.

Patients: All patients who underwent an urgent/emergent sigmoid colectomy for diverticulitis with creation of an end colostomy or primary anastomosis with proximal diversion were included. We excluded all patients age <18 years, with IBD, colorectal cancer, ischemic colitis, or elective operations.

Main Outcome Measures: The main outcomes measured were postoperative in-hospital mortality and complications, RESULTS:: A total of 10,780 patients underwent urgent/emergent colectomy for diverticulitis: 10,600 (98.3%) received a Hartmann procedure and 180 (1.7%) received primary anastomosis with proximal diversion. Colorectal surgeons performed 6.0% of all operations. Utilization of primary anastomosis with proximal diversion was greater among colorectal surgeons but remained low overall (4.2% vs 1.5%; p < 0.001). Postoperative mortality was 2-fold greater when noncolorectal surgeons performed primary anastomosis vs Hartmann procedure (15% vs 7.4%; p < 0.001) and 1.4 times greater among noncolorectal surgeons than among colorectal surgeons (7.5% vs 5.3%; p = 0.04). On multivariable logistic regression (adjusting for patient demographics/characteristics, year, hospital academic status, and surgeon training) primary anastomosis with proximal diversion remained associated with increased mortality (OR, 2.7; 95% CI,1.7-4.4; p < 0.001), complications (OR, 1.8; 95% CI, 1.3-2.5; p < 0.001), and reoperation (OR, 3.4; 95% CI, 1.8-6.3; p < 0.001), whereas colorectal board certification was associated with decreased mortality (OR, 0.66; 95% CI, 0.46-0.95; p = 0.03).

Limitations: Selection bias secondary to retrospective nature and absence of disease severity were limitations of this study.

Conclusions: Despite current recommendations for primary anastomosis with proximal diversion for perforated diverticulitis, this operation in New York State was associated with increased postoperative morbidity and mortality when performed by general surgeons. Given that the majority of urgent/emergent colectomies for diverticulitis are not performed by colorectal surgeons, guidelines for operative management of perforated diverticulitis should be reevaluated. See Video Abstract at http://links.lww.com/DCR/A772.
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January 2019

A Quality-of-Life Comparison of Two Fecal Incontinence Phenotypes: Isolated Fecal Incontinence Versus Concurrent Fecal Incontinence With Constipation.

Dis Colon Rectum 2019 01;62(1):63-70

Department of Surgery, Massachusetts General Hospital, Boston, Massachusetts.

Background: Many patients with fecal incontinence report coexisting constipation. This subset of patients has not been well characterized or understood.

Objective: The purpose of this study was to report the frequency of fecal incontinence with concurrent constipation and to compare quality-of-life outcomes of patients with fecal incontinence with and without constipation.

Design: This was a prospective cohort study. Survey data, including Fecal Incontinence Severity Index, Constipation Severity Instrument, Fecal Incontinence Quality of Life survey (categorized as lifestyle, coping, depression, and embarrassment), Pelvic Organ Prolapse Inventory and Urinary Distress Inventory surveys, and anorectal physiology testing were obtained.

Settings: The study was conducted as a single-institution study from January 2007 to January 2017.

Patients: Study patients had fecal incontinence presented to a tertiary pelvic floor center.

Main Outcome Measures: Quality-of-life survey findings were measured.

Results: A total of 946 patients with fecal incontinence were identified, and 656 (69.3%) had coexisting constipation. Patients with fecal incontinence with constipation were less likely to report a history of pregnancy (89.2% vs 91.4%; p = 0.001) or complicated delivery, such as requiring instrumentation (9.1% vs 18.1%; p = 0.005), when compared with patients with isolated fecal incontinence. Patients with fecal incontinence with constipation had higher rates of coexisting pelvic organ prolapse (Pelvic Organ Prolapse Inventory: 18.4 vs 8.2; p < 0.01), higher rates of urinary incontinence (Urinary Distress Inventory: 30.2 vs 23.4; p = 0.01), and higher pressure findings on manometry; intussusception on defecography was common. Patients with fecal incontinence with concurrent constipation had less severe incontinence scores at presentation (21.0 vs 23.8; p < 0.001) and yet lower overall health satisfaction (28.9% vs 42.5%; p < 0.001). Quality-of-life scores declined as constipation severity increased for lifestyle, coping, depression, and embarrassment.

Limitations: This was a single-institution study, and surgeon preference could bias population and anorectal physiology testing.

Conclusions: Patients with fecal incontinence with concurrent constipation represent a different disease phenotype and have different clinical and anorectal physiology test findings and worse overall quality of life. Treatment of these patients requires careful consideration of prolapse pathology with coordinated treatment of coexisting disorders. See Video Abstract at http://links.lww.com/DCR/A783.
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http://dx.doi.org/10.1097/DCR.0000000000001242DOI Listing
January 2019

Nature versus nurture: the impact of nativity and site of treatment on survival for gastric cancer.

Gastric Cancer 2019 05 22;22(3):446-455. Epub 2018 Aug 22.

Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA.

Background: The prognosis of gastric cancer patients is better in Asia than in the West. Genetic, environmental, and treatment factors have all been implicated. We sought to explore the extent to which the place of birth and the place of treatment influences survival outcomes in Korean and US patients with localized gastric cancer.

Methods: Patients with localized gastric adenocarcinoma undergoing potentially curative gastrectomy from 1989 to 2010 were identified from the SEER registry and two single institution databases from the US and Korea. Patients were categorized into three groups: Koreans born/treated in Korea (KK), Koreans born in Korea/treated in the US (KUS), and White Americans born/treated in the US (W), and disease-specific survival rates compared.

Results: We identified 16,622 patients: 3,984 (24.0%) KK, 1,046 (6.3%) KUS, and 11,592 (69.7%) W patients. KK patients had longer unadjusted median (not reached) and 5-year disease-specific survival (81.6%) rates than KUS (87 months, 55.9%) and W (35 months, 39.2%; p < 0.001 for all comparisons) patients. This finding persisted on subset analyses of patients with stage IA tumors, without cardia/GEJ tumors, with > 15 examined lymph nodes, and treated at a US center of excellence. On multivariable analysis, KUS (HR 2.80, p < 0.001) and W (HR 5.79, p < 0.001) patients had an increased risk of mortality compared to KK patients.

Conclusions: Both the place of birth and the place of treatment significantly contribute to the improved prognosis of patients with gastric cancer in Korea relative to those in the US, implicating both nature and nurture in this phenomenon.
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http://dx.doi.org/10.1007/s10120-018-0869-zDOI Listing
May 2019

Case 23-2018: A 36-Year-Old Man with Episodes of Confusion and Hypoglycemia.

N Engl J Med 2018 Jul;379(4):376-385

From the Departments of Medicine (D.J.W., D.G.F.), Emergency Medicine (W.M.-K.), Radiology (L.X.), Surgery (C.E.C.), and Pathology (K.J.P.), Massachusetts General Hospital, and the Departments of Medicine (D.J.W., D.G.F.), Emergency Medicine (W.M.-K.), Radiology (L.X.), Surgery (C.E.C.), and Pathology (K.J.P.), Harvard Medical School - both in Boston.

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http://dx.doi.org/10.1056/NEJMcpc1802828DOI Listing
July 2018

Prospective Creation and Validation of the PREVENTT (Prediction and Enaction of Prevention Treatments Trigger) Scale for Surgical Site Infections (SSIs) in Patients With Diverticulitis.

Ann Surg 2019 12;270(6):1124-1130

Department of Surgery, North Shore Medical Center, Salem, MA.

Objective: Create and validate diverticulitis surgical site infection prediction scale.

Background: Surgical site infections cause significant morbidity after colorectal surgery. An infection prediction scale could target infection prevention bundles to high-risk patients.

Methods: Prospectively collected National Surgical Quality Improvement Program and electronic medical record data obtained on diverticulitis colectomy patients across a Healthcare Network-wide Colorectal Surgery Collaborative (5 hospitals). Patients with and without surgical site infections were compared. Predictive variables were identified using logistic regression model; model estimates obtained through 1000 bootstrap replications for scale validation.

Results: A total of 1737 colectomies were performed (2010-2016): mean age 59.9 years (SD 12.7), 56.4% female; 93.4% Caucasian; smokers 16.3%, diabetics 7.7%, steroid use 6.0%. Two hundred thirty-one (13.3%) were presented to operating room emergently and 138 (7.9%) with abscess at time of disease admission. Two hundred ninety-six patients underwent Hartman procedures, and 113 (6.5%) received diverted primary anastomosis. Average length of stay was 6.9 days (standard deviation 7.01), 30-day mortality was 1.5%, anastomotic leak rate was 3.1%. Twenty-one percent of patients (n = 366) developed a surgical site infection. Several predictors for infection were identified: obesity (body mass index >30), advanced age (>70 years), diabetes mellitus, preoperative abscess, open surgery, emergent operations, and prolonged operations (>3 h). Creation of protected anastomosis in emergent settings was associated with increased infection rates. Presence of more than 5 risk factors was associated with infection rates of 45.8% (c = 0.69).

Conclusions: Patients with diverticulitis have high surgical site infection rates due to nonmodifiable risk factors. Our Prediction and Enaction of Prevention Treatments Trigger scale can risk stratify patients for targeting surgical site infection prevention bundles and outcomes risk adjustments.
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December 2019

Use of Primary Anastomosis With Diverting Ileostomy in Patients With Acute Diverticulitis Requiring Urgent Operative Intervention.

Dis Colon Rectum 2018 May;61(5):586-592

Department of Surgery, Massachusetts General Hospital, Boston, Massachusetts.

Background: Previous studies suggest that urgent colectomy and primary anastomosis with diversion is safe for perforated diverticulitis. Current guidelines support this approach.

Objective: The purpose of this study was to describe the use of urgent or emergent primary anastomosis with diversion in diverticulitis before the 2014 American Society of Colon and Rectal Surgeons guidelines and compare national outcomes of primary anastomosis with diversion to the Hartmann procedure.

Design: This was a national retrospective cohort study.

Settings: The study was conducted with a national all-payer US sample from 1998 to 2011.

Patients: Patients included those admitted and treated with urgent or emergent colectomy for diverticulitis. Exclusion criteria were age <18 years, concurrent diagnosis of colorectal cancer or IBD, no fecal diversion performed, and operations >24 hours after admission.

Main Outcome Measures: In-hospital mortality was measured.

Results: A total of 124,198 patients underwent emergent or urgent colectomy for acute diverticulitis; 67,721 underwent concurrent fecal diversion, including 65,084 (96.1%) who underwent end colostomy and 2637 (3.9%) who underwent anastomosis with ileostomy. The rate of primary anastomosis with diverting ileostomy increased from 30 to 60 diverting ileostomy cases per 1000 operative diverticulitis cases in 1998 versus 2011 (incidence rate ratio = 2.04 (95% CI, 1.70-2.50). However, overall use remained low, with >90% of patients undergoing end colostomy. Complication rates were higher (32.1% vs 23.3%; p < 0.001) and in-hospital mortality rates were higher (16.0% vs 6.4%; p < 0.001) for primary anastomosis with diversion patients compared with end colostomy. These findings were consistent on multivariable logistic regression. Other factors that contributed to in-hospital mortality included increasing age, increasing comorbid disease burden, and socioeconomic status.

Limitations: Billing data can be inaccurate or biased because of nonmedically trained professional data entry. Selection bias could have affected the results of this retrospective study.

Conclusions: The use of primary anastomosis with proximal diversion for urgent colectomy in diverticulitis increased over our study period; however, overall use remained low. Poor national outcomes after primary anastomosis with proximal diversion might affect compliance with new guidelines. See Video Abstract at http://links.lww.com/DCR/A600.
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May 2018

Training Surgeons and Anesthesiologists to Facilitate End-of-Life Conversations With Patients and Families: A Systematic Review of Existing Educational Models.

J Surg Educ 2018 May - Jun;75(3):702-721. Epub 2017 Sep 20.

Center for Surgery and Public Health, Brigham and Women's Hospital, Boston, Massachusetts; Department of Surgery, Brigham and Women's Hospital, Boston, Massachusetts. Electronic address:

Objective: Despite caring for patients near the end-of-life (EOL), surgeons and anesthesiologists report low confidence in their ability to facilitate EOL conversations. This discrepancy exists despite competency requirements and professional medical society recommendations. The objective of this systematic review is to identify articles describing EOL communication training available to surgeons and anesthesiologists, and to assess their methodological rigor to inform future curricular design and evaluation.

Methods: This PRISMA-concordant systematic review identified English-language articles from PubMed, EMBASE, and manual review. Eligible articles included viewpoint pieces, and observational, qualitative, or case studies that featured an educational intervention for surgeons or anesthesiologists on EOL communication skills. Data on the study objective, setting, design, participants, intervention, and results were extracted and analyzed. The Newcastle-Ottawa Scale was used to assess methodological quality.

Results: Database and manual search returned 2710 articles. A total of 2268 studies were screened by title and abstract, 46 reviewed in full-text, and 16 included in the final analysis. Fifteen studies were conducted exclusively in academic hospitals. Two studies included attending surgeons as participants; all others featured residents, fellows, or a mix thereof. Fifteen studies used simulated role-playing to teach and assess EOL communication skills. Measured outcomes included knowledge, attitudes, confidence, self-rated or observer-rated communication skills, and curriculum feedback; significance of results varied widely. Most studies lacked adequate methodological quality and appropriate control groups to be confident about the significance and applicability of their results.

Conclusions: There are few quality studies evaluating EOL communication training for surgeons and anesthesiologists. These programs frequently use role-playing to teach and assess EOL communication skills. More studies are needed to evaluate the effect of these interventions on patient outcomes. However, evaluating the effectiveness of these initiatives poses methodological challenges.
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http://dx.doi.org/10.1016/j.jsurg.2017.08.006DOI Listing
September 2019

Predictors of In-hospital Postoperative Opioid Overdose After Major Elective Operations: A Nationally Representative Cohort Study.

Ann Surg 2017 04;265(4):702-708

*Massachusetts General Hospital, Department of Surgery, Boston, MA†Department of Surgery and Perioperative Care, Dell Medical School, University of Texas at Austin, Austin, TX‡Massachusetts General Hospital, Department Of Anesthesia, Critical Care and Pain Medicine, Boston, MA§Department of Anesthesia, Toronto General Hospital and University of Toronto, Toronto, Ontario, Canada.

Objective: The aim of this study was to describe national trends and outcomes of in-hospital postoperative opioid overdose (OD) and identify predictors of postoperative OD.

Summary Of Background Data: In 2000, the Joint Commission recommended making pain the 5th vital sign, increasing the focus on postoperative pain control. However, the benefits of pain management must be weighed against the potentially lethal risk of opioid OD.

Methods: This is a retrospective multi-institutional cohort study of patients undergoing 1 of 6 major elective inpatient operation from 2002 to 2011 using the Nationwide Inpatient Sample, an approximately 20% representative sample of all United States hospital admissions. Patients with postoperative OD were identified using ICD-9 codes for poisoning from opioids or adverse effects from opioids. Multivariate logistic regression was used to identify independent predictors.

Results: Among 11,317,958 patients, 9458 (0.1%) had a postoperative OD; this frequency doubled over the study period from 0.6 to 1.1 overdoses per 1000 cases. Patients with postoperative OD died more frequently during their hospitalization (1.7% vs 0.4%, P < 0.001). Substance abuse history was the strongest predictor of OD (odds ratio = 14.8; 95% confidence interval: 12.7-17.2). Gender, age, income, geographic location, operation type, and certain comorbid diseases also predicted OD (P < 0.05). Hospital variables, including teaching status, size, and urban/rural location, did not predict postoperative OD.

Conclusions: Postoperative OD is a rare, but potentially lethal complication, with increasing incidence. Postoperative monitoring and treatment safety interventions should be thoughtfully employed to target high-risk patients and avoid this potentially fatal complication.
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http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6153445PMC
April 2017

Cytologic characteristics of circulating epithelioid cells in pancreatic disease.

Cancer Cytopathol 2017 May 3;125(5):332-340. Epub 2017 Mar 3.

Department of Pathology, Massachusetts General Hospital, Boston, Massachusetts.

Background: Circulating epithelioid cells (CECs), also known as circulating tumor, circulating cancer, circulating epithelial, or circulating nonhematologic cells, are a prognostic factor in various malignancies that can be isolated via various protocols. In the current study, the authors analyzed the cytomorphologic characteristics of CECs isolated by size in a cohort of patients with benign and malignant pancreatic diseases to determine whether cytomorphological features could predict CEC origin.

Methods: Blood samples were collected from 9 healthy controls and 171 patients with pancreatic disease who were presenting for surgical evaluation before treatment. Blood was processed with the ScreenCell size-based filtration device. Evaluable CECs were analyzed in a blinded fashion for cytomorphologic characteristics, including cellularity; nucleoli; nuclear size, irregularity, variability, and hyperchromasia; and nuclear-to-cytoplasmic ratio. Statistical differences between variables were analyzed via the Fisher exact test.

Results: No CECs were identified among the 9 normal healthy controls. Of the 115 patients with CECs (positive or suspicious for), 25 had nonmalignant disease and 90 had malignancy. There were no significant differences in any of the cytologic criteria noted between groups divided by benign versus malignant, neoplastic versus nonneoplastic, or pancreatic ductal adenocarcinoma versus neuroendocrine tumor.

Conclusions: CECs were observed in patients with malignant and nonmalignant pancreatic disease, but not in healthy controls. There were no morphologic differences observed between cells from different pancreatic diseases, suggesting that numerous conditions may be associated with CECs in the circulation and that care must be taken not to overinterpret cells identified by cytomorphology as indicative of circulating tumor cells of pancreatic cancer. Additional studies are required to determine the origin and clinical significance of these cells. Cancer Cytopathol 2017;125:332-340. © 2017 American Cancer Society.
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http://dx.doi.org/10.1002/cncy.21841DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5432380PMC
May 2017

Survival, Healthcare Utilization, and End-of-life Care Among Older Adults With Malignancy-associated Bowel Obstruction: Comparative Study of Surgery, Venting Gastrostomy, or Medical Management.

Ann Surg 2018 04;267(4):692-699

Center for Surgery and Public Health, Brigham and Women's Hospital, Boston, MA.

Objective: To compare survival, readmissions, and end-of-life care after palliative procedures compared with medical management for malignancy-associated bowel obstruction (MBO).

Background: MBO is a late complication of intra-abdominal malignancy for which surgeons are frequently consulted. Decisions about palliative treatments, which include medical management, surgery, or venting gastrostomy tube (VGT), are hampered by the paucity of outcomes data relevant to patients approaching the end of life.

Methods: Retrospective study using 2001 to 2012 Surveillance, Epidemiology, and End Results-Medicare data of patients 65 years or older with stage IV ovarian or pancreatic cancer who were hospitalized for MBO. Multivariate competing-risks regression models were used to compare the following outcomes: survival, readmission for MBO, hospice enrollment, intensive care unit (ICU) care in the last days of life, and location of death in an acute care hospital.

Results: Median survival after MBO admission was 76 days (interquartile range 26-319 days). Survival was shorter after VGT [38 days (interquartile range 23-69)] than medical management [72 days (23-312)] or surgery [128 days (42-483)]. As compared to medical management, patients treated with VGT had fewer readmissions [subdistribution hazard ratio 0.41 (0.29-0.58)], increased hospice enrollment [1.65 (1.42-1.91)], and less ICU care [0.69 (0.52-0.93)] and in-hospital death [0.47 (0.36-0.63)]. Surgery was associated with fewer readmissions [0.69 (0.59-0.80)], decreased hospice enrollment [0.84 (0.76-0.92)], and higher likelihood of ICU care [1.38 (1.17-1.64)].

Conclusions: VGT is associated with fewer readmissions and lower intensity healthcare utilization at the end of life than do medical management or surgery. Given the limited survival, regardless of management, hospitalization with MBO carries prognostic significance and presents a critical opportunity to identify patients' priorities for end-of-life care.
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http://dx.doi.org/10.1097/SLA.0000000000002164DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7509894PMC
April 2018

Truth in Reporting: How Data Capture Methods Obfuscate Actual Surgical Site Infection Rates within a Health Care Network System.

Dis Colon Rectum 2017 Jan;60(1):96-106

1 Division of General and GI Surgery, Massachusetts General Hospital, Boston, Massachusetts 2 Codman Center, Massachusetts General Hospital, Boston, Massachusetts 3 Department of Quality, Safety, and Value, Partners Healthcare, Boston, Massachusetts 4 Department of Surgery, Newton Wellesley Hospital, Newton, Massachusetts 5 Department of Surgery, North Shore Medical Center, Salem, Massachusetts 6 Department of Surgery, Brigham and Women's Hospital, Boston, Massachusetts 7 Department of Surgery, Faulkner Hospital, Boston, Massachusetts.

Background: Two systems measure surgical site infection rates following colorectal surgeries: the American College of Surgeons National Surgical Quality Improvement Program and the Centers for Disease Control and Prevention National Healthcare Safety Network. The Centers for Medicare & Medicaid Services pay-for-performance initiatives use National Healthcare Safety Network data for hospital comparisons.

Objective: This study aimed to compare database concordance.

Design: This is a multi-institution cohort study of systemwide Colorectal Surgery Collaborative. The National Surgical Quality Improvement Program requires rigorous, standardized data capture techniques; National Healthcare Safety Network allows 5 data capture techniques. Standardized surgical site infection rates were compared between databases. The Cohen κ-coefficient was calculated.

Setting: This study was conducted at Boston-area hospitals.

Patients: National Healthcare Safety Network or National Surgical Quality Improvement Program patients undergoing colorectal surgery were included.

Main Outcome Measures: Standardized surgical site infection rates were the primary outcomes of interest.

Results: Thirty-day surgical site infection rates of 3547 (National Surgical Quality Improvement Program) vs 5179 (National Healthcare Safety Network) colorectal procedures (2012-2014). Discrepancies appeared: National Surgical Quality Improvement Program database of hospital 1 (N = 1480 patients) routinely found surgical site infection rates of approximately 10%, routinely deemed rate "exemplary" or "as expected" (100%). National Healthcare Safety Network data from the same hospital and time period (N = 1881) revealed a similar overall surgical site infection rate (10%), but standardized rates were deemed "worse than national average" 80% of the time. Overall, hospitals using less rigorous capture methods had improved surgical site infection rates for National Healthcare Safety Network compared with standardized National Surgical Quality Improvement Program reports. The correlation coefficient between standardized infection rates was 0.03 (p = 0.88). During 25 site-time period observations, National Surgical Quality Improvement Program and National Healthcare Safety Network data matched for 52% of observations (13/25). κ = 0.10 (95% CI, -0.1366 to 0.3402; p = 0.403), indicating poor agreement.

Limitations: This study investigated hospitals located in the Northeastern United States only.

Conclusions: Variation in Centers for Medicare & Medicaid Services-mandated National Healthcare Safety Network infection surveillance methodology leads to unreliable results, which is apparent when these results are compared with standardized data. High-quality data would improve care quality and compare outcomes among institutions.
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http://dx.doi.org/10.1097/DCR.0000000000000715DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5214798PMC
January 2017

Surgeons' Perspectives on Avoiding Nonbeneficial Treatments in Seriously Ill Older Patients with Surgical Emergencies: A Qualitative Study.

J Palliat Med 2016 05 22;19(5):529-37. Epub 2016 Apr 22.

1 Ariadne Labs , Boston, Massachusetts.

Background: Clinical decisions for seriously ill older patients with surgical emergencies are highly complex. Measuring the benefits of burdensome treatments in this context is fraught with uncertainty. Little is known about how surgeons formulate treatment decisions to avoid nonbeneficial surgery, or engage in preoperative conversations about end-of-life (EOL) care.

Objective: We sought to describe how surgeons approach such discussions, and to identify modifiable factors to reduce nonbeneficial surgery near the EOL.

Design: Purposive and snowball sampling were used to recruit a national sample of emergency general surgeons. Semistructured interviews were conducted between February and May 2014.

Measurements: Three independent coders performed qualitative coding using NVivo software (NVivo version 10.0, QSR International). Content analysis was used to identify factors important to surgical decision making and EOL communication.

Results: Twenty-four surgeons were interviewed. Participants felt responsible for conducting EOL conversations with seriously ill older patients and their families before surgery to prevent nonbeneficial treatments. However, wide differences in prognostic estimates among surgeons, inadequate data about postoperative quality of life (QOL), patients and surrogates who were unprepared for EOL conversations, variation in perceptions about the role of palliative care, and time constraints are contributors to surgeons providing nonbeneficial operations. Surgeons reported performing operations they knew would not benefit the patient to give the family time to come to terms with the patient's demise.

Conclusions: Emergency general surgeons feel responsible for having preoperative discussions about EOL care with seriously ill older patients to avoid nonbenefical surgery. However, surgeons identified multiple factors that undermine adequate communication and lead to nonbeneficial surgery.
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http://dx.doi.org/10.1089/jpm.2015.0450DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4860675PMC
May 2016

Using a Palliative Care Framework for Seriously Ill Surgical Patients: The Example of Malignant Bowel Obstruction.

JAMA Surg 2016 08;151(8):695-6

Center for Surgery and Public Health, Brigham and Women's Hospital, Boston, Massachusetts5Department of Surgery, Brigham and Women's Hospital, Boston, Massachusetts.

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http://dx.doi.org/10.1001/jamasurg.2016.0057DOI Listing
August 2016