Publications by authors named "Kellie L Mathis"

123 Publications

Acute social isolation and postoperative surgical outcomes. Lessons learned from COVID-19 pandemic.

Minerva Surg 2022 Aug;77(4):348-353

Unit of Colon and Rectal Surgery, Department of Surgery, Mayo Clinic, Rochester, MN, USA -

Background: During COVID-19 pandemic, hospitals changed visitation policy to limit the infection spread. We aimed to evaluate the impact of evolving visitation policy on short-term surgical outcomes.

Methods: All adult patients who underwent colorectal surgery between January 1, 2020, and May 12, 2020, at our institution were included. Patients were divided into: before implementing the no visitor allowed policy (VA) or no visitor allowed policy (NVA) groups, based on the hospital admission date.. The primary outcomes were 30-day readmission rate and length of stay (LOS).

Results: A total of 439 patients were included. Of them, 128 (29.2%) patients had surgery during the NVA policy, and 311 (70.8%) patients underwent surgery during VA policy. Patients who had surgery during the NVA policy were more likely to have emergency surgery and a longer operation time. However, the other baseline characteristics, surgical approach, underlying disease, extent of resection, and the need for intraoperative blood transfusion were comparable between the two groups. There was no difference between both groups regarding the 30-day readmission rate (10.3% vs. 7.8% in the NVA group; P>0.05) and median LOS (4 days vs. 3 days in the NVA group; P>0.05).

Conclusions: Restricting inpatient visitors for patients undergoing colorectal surgery was not associated with increased postoperative complications and readmission rates. LOS was similar between the two groups. This strategy can be safely implemented in cases of crisis. Further studies are needed to confirm these findings.
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http://dx.doi.org/10.23736/S2724-5691.21.09243-1DOI Listing
August 2022

Surgical Management of Enterovesical Fistula in Crohn's Disease in the Biologic Era.

Inflamm Bowel Dis 2022 Jun 25. Epub 2022 Jun 25.

Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, MN, USA.

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http://dx.doi.org/10.1093/ibd/izac133DOI Listing
June 2022

Re-resection of Microscopically Positive Margins Found on Intra-Operative Frozen Section Analysis Does Not Result in a Survival Benefit in Patients Undergoing Surgery and Intraoperative Radiation Therapy for Locally Recurrent Rectal Cancer.

Dis Colon Rectum 2021 Dec 27. Epub 2021 Dec 27.

Division of Colon and Rectal Surgery, Mayo Clinic, Rochester, Minnesota.

Background: Intraoperative frozen section analysis provides real-time margin resection status which can guide intraoperative decisions made by the surgeon and radiation oncologist. For patients with locally recurrent rectal cancer undergoing surgery and intraoperative radiation therapy, intraoperative re-resection of positive margins to achieve negative margins is common practice.

Objective: To assess if re-resection of positive margins found on intraoperative frozen section analysis improves oncological outcomes.

Design: This is a retrospective cohort study.

Settings: This study was an analysis of a prospectively maintained multicenter database.

Patients: All patients who underwent surgical resection of locally recurrent rectal cancer with intraoperative radiation therapy between 2000 and 2015 were included and followed for 5 years. Three groups were compared: initial R0 resection (IR0), initial R1 converted to R0 after re-resection (IR1-R0) and initial R1 that remained R1 after re-resection (IR1-R1). Grossly positive margin resections (R2) were excluded.

Main Outcome Measures: The primary outcome measures were 5-year overall survival, recurrence-free survival, and local re-recurrence.

Results: A total of 267 patients were analyzed (initial R0 resection n=94, initial R1 converted to R0 after re-resection n=95, initial R1 that remained R1 after re-resection n=78). Overall survival was 4.4 years for initial R0 resection, 2.7 years for initial R1 converted to R0 after re-resection and 2.9 years for initial R1 that remained R1 after re-resection (p=0.01). Recurrence free survival was 3.0 years for initial R0 resection and 1.8 years for both initial R1 converted to R0 after re-resection and initial R1 that remained R1 after re-resection (p<=0.01). Overall survival did not differ for patients with R1 and re-resection R1 or R0 (p=0.62). Recurrence-free survival and freedom from local re-recurrence did not differ between groups.

Limitations: Heterogeneous patient population, restricted to those receiving intraoperative radiation therapy.

Conclusions: Re-resection of microscopically positive margins to obtain R0 status does not appear to provide a significant survival advantage or prevent local re-recurrence in patients undergoing surgery and intraoperative radiation therapy for locally recurrent rectal cancer. See Video Abstract at http://links.lww.com/DCR/B886.
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http://dx.doi.org/10.1097/DCR.0000000000002349DOI Listing
December 2021

Perianal Basal Cell Carcinoma: 35-Year Experience.

Dis Colon Rectum 2021 Dec 27. Epub 2021 Dec 27.

Division of Colon and Rectal Surgery, Mayo Clinic Rochester, Minneapolis.

Background: Basal cell carcinoma of the perianal region is a rare anorectal disease. This condition is not related to exposure to ultra-violet radiation. Due to the low prevalence and poor detection, there is a paucity of data relating to this condition in literature. Perianal basal cell carcinoma present different surgical challenges from other anatomic locations and may not share the same prevalence or natural history. Here, we describe the largest series to date on the surgical management of perianal basal cell carcinoma.

Objective: To present our 3- year experience in managing perianal basal cell carcinoma.

Design: This was a retrospective single center analysis.

Setting: The study was conducted at a large tertiary referral academic healthcare system.

Patients: All patients undergoing surgical management of pathology confirmed perianal basal cell carcinoma.

Interventions: All patients underwent surgical management of their disease.

Main Outcome Measures: The primary outcomes were disease recurrence, mortality, and wound complications.

Results: A total of 29 patients were identified with an average follow up of 5.5 years. 27.6% of patients had multiple basal cell carcinoma in other anatomic locations at index presentation. 93% of patients were adequately treated with local excision but 60% had wound dehiscence at time of first follow up visit. Ultimately there were no recurrences or disease related mortality during the follow-up period.

Limitations: Limitations to our study include its nonrandomized retrospective nature, single-institution experience, and small patient sample size.

Conclusions: Perianal basal cell carcinoma carries a high rate of synchronous presentation in other locations and should prompt a thorough evaluation. Perianal BCCs can and should be successfully treated with local excision despite the high rate of wound complications. See Video Abstract at http://links.lww.com/DCR/B883.
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http://dx.doi.org/10.1097/DCR.0000000000002234DOI Listing
December 2021

Intraoperative Fluid Management a Modifiable Risk Factor for Surgical Quality - Improving Standardized Practice.

Ann Surg 2022 05 21;275(5):891-896. Epub 2022 Jan 21.

Colon and Rectal Surgery, Department of Surgery, Mayo Clinic, Rochester, MN.

Objective: We aimed to determine a safe zone of intraoperative fluid management associated with the lowest postoperative complication rates without increased acute kidney injury (AKi) risk for elective colorectal surgery patients.

Background: To date, standard practice within institutions, let alone national expectations related to fluid administration, are limited. This fact has perpetuated a quality gap.

Methods: Elective colorectal surgeries between 2018 and 2020 were included. Unadjusted odds ratios (ORs) for postoperative ileus, prolonged LOS, and AKi were plotted against the rate of intraoperative RL infusion (mL/ kg/h) and total intraoperative volume. Binary logistic regression analysis, including fluid volumes as a confounder, was used to identify risk factors for postoperative complications.

Results: A total of 2900 patients were identified. Of them, 503 (17.3%) patients had ileus, 772 (26.6%) patients had prolonged LOS, and 240 (8.3%) patients had AKI. The intraoperative fluid resuscitation rate (mg/kg/h) was less impactful on postoperative ileus, LOS, and AKI than the total amount of intraoperative fluid. A total fluid administration range between 300 mL and 2.7 L was associated with the lowest complication rate. Total intraoperative RL ≥2.7 L was independently associated with a higher risk of ileus (adjusted OR 1.465; 95% confidence interval 1.154-1.858) and prolonged LOS (adjusted OR 1.300; 95% confidence interval 1.047-1.613), but not AKI. Intraoperative RL ≤300 mL was not associated with an increased risk of AKI.

Conclusion: Total intraoperative RL ≥2.7 L was independently associated with postoperative ileus and prolonged LOS in elective colorectal surgery patients. A new potential standard for intraoperative fluids will require anesthesia case planning (complexity and duration) to ensure total fluid volume meets this new opportunity to improve care.
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http://dx.doi.org/10.1097/SLA.0000000000005384DOI Listing
May 2022

Rectal cancer with synchronous inguinal lymph node metastasis without distant metastasis. A call for further oncological evaluation.

Eur J Surg Oncol 2022 May 20;48(5):1100-1103. Epub 2021 Dec 20.

Division of Colon and Rectal Surgery, Mayo Clinic, Rochester, MN, USA. Electronic address:

This study aimed to compare the survival of patients with isolated inguinal lymph node metastases from rectal cancer to patients with inguinal and additional synchronous distant metastases from rectal cancer who treated with curative intent. A retrospective review of all consecutive adult patients with rectal adenocarcinoma and inguinal lymph node involvement who underwent curative therapy at our institution from 2002 to 2020 was conducted. Patients were classified as having synchronous inguinal lymph node metastasis (SILNM), or synchronous inguinal lymph node and distant organ metastasis (SILNDOM). Patients in the SILNM group had a median overall survival of 75 months compared to 17.6 months in the SILNDOM group;p-value = 0.09. The recurrence-free survival for patients with SILNM was 19.6 months compared to 2.4 months in the SILNDOM group;p-value = 0.053. In conclusion, SILNM appears to represent a distinct subgroup of patients with metastatic rectal cancer. These patients warrant consideration of treatment with curative intent. Further studies are needed.
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http://dx.doi.org/10.1016/j.ejso.2021.12.018DOI Listing
May 2022

Risk of malignancy and outcomes of surgically resected presacral tailgut cysts: A current review of the Mayo Clinic experience.

Colorectal Dis 2022 04 6;24(4):422-427. Epub 2022 Jan 6.

Division of Colon and Rectal Surgery, Mayo Clinic, Jacksonville, Florida, USA.

Aim: The aim of this study was to describe the surgical management, outcomes and risk of malignancy of presacral tailgut cysts.

Method: A retrospective analysis of all patients who underwent resection of tailgut cyst at Mayo Clinic in Arizona, Florida and Minnesota between 2008 and 2020 was performed. Demographics, presentation, evaluation, surgical approach, postoperative complications, pathology and recurrence rates were reviewed.

Results: Seventy-three patients were identified (81% female) with a mean age of 45 years. Thirty-nine patients (53%) were symptomatic, most commonly with pelvic pain (26 patients). Digital rectal examination identified a palpable mass in 68%. Mean tumour size was 6 cm. Resection was primarily performed through a posterior approach (77%, n = 56), followed by a transabdominal approach (18%, n = 13) and a combined approach (5%, n = 4). Six patients underwent a minimally invasive resection (laparoscopic/robotic). Coccygectomy or distal sacrectomy was performed in 41 patients (56%). Complete resection was achieved in 94% of patients. Thirty-day morbidity occurred in 18% and was most commonly wound related; there was no mortality. Malignancy was identified in six patients (8%). For the 30 patients with follow-up greater than 1 year, the median follow-up was 39 months (range 1.0-11.1 years). Local recurrence was identified in three patients and distant metastatic disease in one patient.

Conclusion: The rate of malignancy in presacral tailgut cysts based on this current review was 8%. Overall recurrence was 5% at a median of 24 months.
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http://dx.doi.org/10.1111/codi.16030DOI Listing
April 2022

Emergent and Urgent Surgery for Ulcerative Colitis in the United States in the Minimally Invasive and Biologic Era.

Dis Colon Rectum 2022 Aug 5;65(8):1025-1033. Epub 2022 Jul 5.

Division of Colon and Rectal Surgery, Department of Surgery, Mayo Clinic, Rochester, Minnesota.

Background: Although the overall adoption of minimally invasive surgery in the nonemergent management of ulcerative colitis is established, little is known about its utilization in emergency settings.

Objective: The goal of this study was to assess rates of urgent and emergent surgery over time in the era of emerging biologic therapies and to highlight the current practice in the United States regarding the utilization of minimally invasive surgery for urgent and emergent indications for ulcerative colitis.

Design: This was a retrospective analysis study.

Settings: Data were collected from the American College of Surgeons National Quality Improvement Program database.

Patients: All adult patients who underwent emergent or urgent colectomy for ulcerative colitis were included.

Main Outcome Measures: Rates of emergency operations over time and utilization trends of minimally invasive surgery in urgent and emergent settings were assessed. Unadjusted and adjusted overall, surgical, and medical 30-day complication rates were compared between open and minimally invasive surgery.

Results: A total of 2219 patients were identified. Of those, 1515 patients (68.3%) underwent surgery in an urgent setting and 704 (31.7%) as an emergency. Emergent cases decreased over time (21% in 2006 to 8% in 2018; p < 0.0001). However, the rate of urgent surgeries has not significantly changed (42% in 2011 to 46% in 2018; p = 0.44). Minimally invasive surgery was offered to 70% of patients in the urgent group (1058/1515) and 22.6% of emergent indications (159/704). Overall, minimally invasive surgery was increasingly utilized over the study period in urgent (38% in 2011 to 71% in 2018; p < 0.0001) and emergent (0% in 2005 to 42% in 2018; p < 0.0001) groups. Compared to minimally invasive surgery, open surgery was associated with a higher risk of surgical, septic, and overall complications, and prolonged hospitalization.

Limitations: This study was limited by its retrospective nature of the analysis.

Conclusion: Based on a nationwide analysis from the United States, minimally invasive surgery has been increasingly and safely implemented for emergent and urgent indications for ulcerative colitis. Although the sum of emergent and urgent cases remained the same over the study period, emergency cases decreased significantly over the study period, which may be related to improved medical treatment options and a collaborative, specialized team approach. See Video Abstract at http://links.lww.com/DCR/B847 .

Ciruga De Urgencia Y Emergencia Para La Colitis Ulcerosa En Los Estados Unidos En La Era Mnimamente Invasiva Y De Terapia Biolgica: ANTECEDENTES:Si bien se ha establecido la adopción generalizada de la cirugía mínimamente invasiva en el tratamiento electivo de la colitis ulcerosa, se sabe poco sobre su utilización en situaciones de emergencia.OBJETIVO:Evaluar las tasas de cirugía de urgencia a lo largo del tiempo en la era de las terapias biológicas emergentes y destacar la práctica actual en los Estados Unidos con respecto a la utilización de la cirugía mínimamente invasiva para las indicaciones de urgencia y emergencia de la colitis ulcerosa.DISEÑO:Análisis retrospectivo.AJUSTES:Base de datos del Programa Nacional de Mejoramiento de la Calidad del Colegio Americano de Cirujanos.PACIENTES:Todos los pacientes adultos que se sometieron a colectomía de emergencia o urgencia por colitis ulcerosa.MEDIDAS DE RESULTADO:Se evaluaron las tasas de operaciones de emergencia a lo largo del tiempo y las tendencias de utilización de la cirugía mínimamente invasiva en entornos de urgencia y emergencia. Se compararon las tasas de complicaciones generales, quirúrgicas y médicas de 30 días no ajustadas y ajustadas entre la cirugía abierta y la mínimamente invasiva.RESULTADOS:Se identificaron un total de 2.219 pacientes. De ellos, 1.515 pacientes (68,3%) fueron intervenidos de urgencia y 704 (31,7%) de emergencia. Los casos emergentes disminuyeron con el tiempo (21% en 2006 a 8% en 2018; p <0,0001). Sin embargo, la tasa de cirugías urgentes no ha cambiado significativamente (42% en 2011 a 46% en 2018, p = 0,44). Se ofreció cirugía mínimamente invasiva al 70% de los pacientes del grupo urgente (1.058 / 1.515) y al 22,6% de las emergencias (159/704). En general, la cirugía mínimamente invasiva se utilizó cada vez más durante el período de estudio en grupos urgentes (38% en 2011 a 71% en 2018; p <0,0001) y emergentes (0% en 2005 a 42% en 2018; p <0,0001). En comparación con la cirugía mínimamente invasiva, la cirugía abierta se asoció con un mayor riesgo de complicaciones generales, quirúrgicas, sépticas y hospitalización prolongada.LIMITACIONES:Carácter retrospectivo del análisis.CONCLUSIÓNES:Basado en un análisis nacional de los Estados Unidos, la cirugía mínimamente invasiva se ha implementado de manera creciente y segura para las indicaciones emergentes y urgentes de la colitis ulcerosa. Si bien la suma de casos emergentes y urgentes permaneció igual durante el período de estudio, los casos de emergencia disminuyeron significativamente, lo que puede estar relacionado con mejores opciones de tratamiento médico y un enfoque de equipo colaborativo y especializado. Consulte Video Resumen en http://links.lww.com/DCR/B847 . (Traducción-Dr. Felipe Bellolio ).
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http://dx.doi.org/10.1097/DCR.0000000000002109DOI Listing
August 2022

Oral Antibiotics Bowel Preparation Without Mechanical Preparation For Minimally Invasive Colorectal Surgeries: Current Practice And Future Prospects.

Dis Colon Rectum 2021 Nov 24. Epub 2021 Nov 24.

Colon and Rectal Surgery, Mayo Clinic, Rochester, MN, USA Department of Visceral Surgery, Lausanne University Hospital CHUV, Rue du Bugnon 46, 1011 Lausanne, Switzerland.

Background: The efficacy of preoperative oral antibiotics alone compared to mechanical bowel preparation and oral antibiotics in minimally invasive surgery is still a matter of ongoing debate.

Objective: This study aimed to assess the trend of surgical site infection rates in parallel to the utilization of bowel preparation modality over time for minimally invasive surgery colorectal surgeries in the United States.

Design: Retrospective analysis.

Settings: The American College of Surgeons National Surgical Quality Improvement Program database.

Patients: Adult patients who underwent elective colorectal surgery and reported bowel preparation modality.

Main Outcome Measures: The trends and compare surgical site infection rates for mutually exclusive groups according to the underlying disease (colorectal cancer, inflammatory bowel disease, and diverticular disease) who underwent bowel preparation using oral antibiotics or combined mechanical bowel preparation and oral antibiotics. Patients who had rectal surgery were analyzed separately.

Results: A total of 30,939 patients were included. Of them, 12,417 (40%) had rectal resections. Over the seven-year study period, mechanical bowel preparation and oral antibiotics utilization has increased from 29.3% in 2012 to 64.0% in 2018; p<0.0001 at the expense of no preparation and mechanical bowel preparation alone. Similarly, oral antibiotics utilization has increased from 2.3% in 2012 to 5.5% in 2018; p<0.0001. For colon cancer patients, patients who had oral antibiotics alone had higher superficial surgical site infection rates compared to patients who had combined mechanical bowel preparation and oral antibiotics (1.9% vs. 1.1%; p=0.043). Superficial, deep and organ space surgical site infection rates were similar for all other comparative colon surgery groups (cancer, inflammatory bowel disease, and diverticular disease). Patients with rectal cancer who had oral antibiotics had higher rates of deep surgical site infection (0.9% vs. 0.1%; p=0.004). However, superficial, deep and organ space surgical site infection rates were similar for all other comparative rectal surgery groups.

Limitations: Retrospective nature of the analysis.

Conclusion: This study revealed widespread adoption of mechanical bowel preparation and oral antibiotics mechanical bowel preparation and oral antibiotics and increased adoption of oral antibiotics over the study period. Surgical site infection rates appear to be similar from a clinical relevance standpoint among most comparative groups, questioning systematic preoperative addition of mechanical bowel preparation to oral antibiotics alone in all patients for minimally invasive colorectal surgery. See Video Abstract at http://links.lww.com/DCR/B828 .
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http://dx.doi.org/10.1097/DCR.0000000000002096DOI Listing
November 2021

The Effect of Advanced Practice Providers on ACGME Colon and Rectal Surgery Resident Diagnostic Index Case Volumes.

J Surg Educ 2022 Mar-Apr;79(2):426-430. Epub 2021 Oct 23.

Mayo Clinic, Division of Colon and Rectal Surgery, Rochester, Minnesota.

Objective: Prior to 2015 residents in our Accreditation Council for Graduation Medical Education (ACGME) colon and rectal surgery training program were in charge of managing, with faculty oversight, the outpatient anorectal clinic at our institution. Starting in 2015 advanced practice providers (APPs) working in the division assumed management of the clinic. The effect of APPs on ACGME resident index diagnostic case volumes has not been explored. Herein we examine ACGME case log graduate statistics to determine if the inclusion of APPs into our anorectal clinic practice has negatively affected resident index diagnostic anorectal case volumes.

Design: ACGME year-end program reports were obtained for the years 2011 to 2019. Program anorectal diagnostic index volumes were recorded and compared to division volumes. Analysis of variance (ANOVA) and analysis of covariance (ANCOVA) tests were conducted to assess whether the number of cases per year (for each respective case type) prior to the introduction of APPs into the anorectal clinic (2011-2014) differed from the number of cases per year with the APP clinic in place (2015-2018). A p-value <0.05 was considered statistically significant.

Setting: Mayo Clinic, Rochester, Minnesota (quaternary referral center).

Participants: Colon and rectal surgery resident year-end ACGME reports (2011-2019).

Results: ANOVAs revealed a marginally significant (p = 0.007) downtrend for hemorrhoid diagnostic codes, and a significant uptrend (p = 0.000) for fistula cases. Controlling for overall division volume, ANCOVA only reveled significance for fistula cases (p = 0.004) with the involvement of APPs.

Conclusions: At our institution we found the inclusion of APPs into our anorectal clinic practice did not negatively affect colon and rectal surgery resident ACGME index diagnostic anorectal case volumes. Inclusion of APPs into a multidisciplinary practice can promote resident education by allowing trainees to pursue other educational opportunities without hindering ACGME index case volumes.
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http://dx.doi.org/10.1016/j.jsurg.2021.10.002DOI Listing
March 2022

Virtual interviews - Utilizing technological affordances as a predictor of applicant confidence.

Am J Surg 2021 Dec 16;222(6):1085-1092. Epub 2021 Oct 16.

Mayo Clinic, Division of Colon and Rectal Surgery, Rochester, MN, USA.

Purpose: In the midst of a pandemic, residency interviews transitioned to a virtual format for the first time. Little is known about the effect this will have on the match process. The study aim is to evaluate resident application processes and perceived outcomes.

Methods: An electronic survey was distributed to 142 colon and rectal surgery residency applicants (95% of total).

Results: A total of 77 applicants responded to the survey (54% response rate). Applicants reported high levels of satisfaction with virtual interviews but less comfort. Utilizing the mute button and using notes in a different way from face-to-face interviews were significantly associated with applicant confidence that they ranked the right program highest. A majority of applicants (73%) would recommend virtual interviews next year even if COVID-19 is not a factor.

Conclusion: While applicants appear generally satisfied with virtual interviews, they also reported less comfort. Applicant confidence was predicted by utilizing the unique technological affordances offered by the virtual platform.
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http://dx.doi.org/10.1016/j.amjsurg.2021.10.003DOI Listing
December 2021

Development and validation of a prediction score for safe outpatient colorectal resections.

Surgery 2022 02 6;171(2):336-341. Epub 2021 Sep 6.

Division of Colon and Rectal Surgery, Mayo Clinic, Rochester, MN. Electronic address:

Background: Avoiding unnecessary inpatient stay may decrease hospital-acquired complications and costs while increasing patient satisfaction. This study aimed to develop and validate a score to identify patients eligible for safe same-day discharge after colorectal resections.

Methods: This bi-institutional retrospective cohort study included consecutive patients undergoing elective colon and rectal resections (2011-2018) for benign and malignant indications. Two multivariable logistic models were developed based on demographic and surgical risk factors to predict a combined endpoint (ileus, anastomotic leak, intra-abdominal abscess, and readmission). Development and validation datasets were randomly sampled from the entire cohort. Areas under the receiver operating characteristic curves (AUC) were evaluated, and Hosmer-Lemeshow goodness-of-fit tests were used to assess validation model fit.

Results: Of 5,389 patients, 1,182 (21.9%) experienced at least one complication of the combined endpoint. Male gender, open surgery, ASA ≥3, wound class ≥3, ileostomy, surgical duration >3 hours, and perioperative IV fluids >3 L all had significantly greater odds of the combined endpoint in the parsimonious multivariable model (all P < .05). The reduced model considering only the 4 variables with the highest OR (>1.5) contained open surgery, ASA ≥3, wound class ≥3, and surgical duration ≥3 hours as predictors (all P < .05, AUC of 0.65; 95% CI 0.63, 0.68). Both the parsimonious model and the reduced model demonstrated no lack of fit in the validation cohort.

Conclusion: The suggested score composed of preand intraoperative items may help physicians decide on patients' same-day discharge after colorectal resection.
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http://dx.doi.org/10.1016/j.surg.2021.07.028DOI Listing
February 2022

Intracorporeal versus extracorporeal anastomosis for robotic ileocolic resection in Crohn's disease.

J Robot Surg 2022 Jun 27;16(3):601-609. Epub 2021 Jul 27.

Division of Colon and Rectal Surgery, Department of Surgery, Mayo Clinic, 200 First Street Southwest, Rochester, MN, 55905, USA.

To date, there is no cohort in the literature focusing on the impact of the type of anastomosis in robotic ileocolonic resections for Crohn's Disease (CD). We aimed to compare short-term postoperative outcomes of robotic ileocolic resection for CD between patients who had intracorporeal (ICA) or extracorporeal anastomosis (ECA). We retrospectively included all consecutive robotic ileocolonic resections for CD at our institution between 2014 and 2020. We compared baseline, perioperative characteristics, and postoperative outcomes between ICA and ECA. The analysis included 89 patients: 71% underwent ICA and 29% ECA. Groups were similar in age, sex, body mass index, smoking, CD duration, Montreal classification, surgical history, and previous CD medical treatments. Return to bowel function was achieved sooner in the ICA group (ICA 1.6 ± 0.7 day, ECA 2.1 ± 0.8 days; p = 0.026) despite longer operative time (ICA 235 ± 79 min, ECA 172 ± 51 min; p < 0.001), but no statistical difference was found regarding ileus rate and length of stay. Overall, 30-day postoperative complication rate was 23.6% (ICA 22.2%, ECA 26.9%; p = 0.635). There were no abdominal septic complications, anastomotic leaks, or severe postoperative complications. In conclusion, robotic ileocolic resection for CD shows acceptable 30 days outcomes for both ICA and ECA. ICA was associated with a faster return to bowel function without impact on the length of stay or 30-day complications. Further studies are needed to confirm the benefits of ICA in the setting of ileocolic resections for CD.
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http://dx.doi.org/10.1007/s11701-021-01283-8DOI Listing
June 2022

Sexual dysfunction following surgery for rectal cancer: a single-institution experience.

Updates Surg 2021 Dec 8;73(6):2155-2159. Epub 2021 Jul 8.

Division of Colon and Rectal Surgery, Department of Surgery, Mayo Clinic, 200 First Street SW, RochesterRochester, MN, 55905, USA.

Although much focus is placed on oncological outcomes for rectal cancer, it is important to assess quality of life after surgery of which sexual function is an important component. This study set about to describe the prevalence of sexual dysfunction by resection type and gender among patients undergoing surgery for rectal cancer, usingretrospective analysis. All English-speaking living patients who underwent surgery for stage I-III rectal cancer with curative intent between 2012 and 2016 were identified from a prospectively maintained database at our institution. Eligible patients were invited to complete either the Female Sexual Function Index (FSFI) or the International Index of Erectile Function (IIEF). Primary outcomes were overall rates of sexual dysfunction, defined as more than one standard deviation below the mean of the normal population for each tool. A total of 147 patients responded, yielding a response rate of 38%. The overall sexual dysfunction rate was 70% at a median time from surgery of 38 months. Sixty-two men (62%) and 41 women (87%) reported overall scores that fell below one standard deviation of the population mean. There was no significant difference in sexual dysfunction for both male and female patients between low anterior resection, coloanal anastomosis, or abdominoperineal resection.. The present study revealed a high rate of sexual dysfunction after rectal cancer surgery, particularly in female patients. This study serves as a reminder to surgeons and their teams to openly discuss the impact of surgery on sexual function and ensure adequate consent and appropriate peri-operative management strategies. The retrospective nature of the analysis is the limitation of this study.
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http://dx.doi.org/10.1007/s13304-021-01124-1DOI Listing
December 2021

Patient selection for elective colectomy for sigmoid diverticulitis.

Authors:
Kellie L Mathis

Surgery 2021 12 2;170(6):1855. Epub 2021 Jul 2.

Mayo Clinic, Rochester, MN. Electronic address:

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http://dx.doi.org/10.1016/j.surg.2021.06.011DOI Listing
December 2021

Posterior-First Two-Stage Approach to En Bloc Resection of Locally Recurrent Rectal Cancer Involving the Pelvic Sidewall.

Dis Colon Rectum 2021 08;64(8):e465-e470

Division of Colon and Rectal Surgery, Department of Surgery, Mayo Clinic, Rochester, Minnesota.

Introduction: Using standard anterior-only or anterior then posterior approaches can make an R0 resection difficult to achieve in patients with pelvic sidewall recurrences because of confined working spaces and poor visibility.

Technique: Given the limitations of standard approaches, we have used a novel posterior-first then anterior 2-stage approach allowing us to widely expose and secure deep margins and control vessels under direct visualization.

Results: We present a technical note describing this approach in patients with recurrent rectal cancer involving the pelvic sidewall with extrapelvic extension.

Conclusion: The posterior-first approach may assist in achieving a higher number of R0 resections in patients with locally recurrent rectal cancer involving the pelvic sidewall.
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http://dx.doi.org/10.1097/DCR.0000000000002091DOI Listing
August 2021

Minimally invasive ileal pouch-anal anastomosis for patients with obesity: a propensity score-matched analysis.

Langenbecks Arch Surg 2021 Nov 13;406(7):2419-2424. Epub 2021 May 13.

Division of Colon and Rectal Surgery, Department of Surgery, Mayo Clinic, 200 first St. Southwest, Rochester, MN, 55905, USA.

Background: Obesity is a risk factor for failure of pouch surgery completion. However, little is known about the impact of obesity on short-term outcomes after minimally invasive (MIS) ileal pouch-anal anastomosis (IPAA). This study aimed to assess short-term postoperative outcomes in patients undergoing MIS total proctocolectomy (TPC) with IPAA in patients with and without obesity.

Materials And Methods: All adult patients (≥ 18 years old) who underwent MIS IPAA as reported in the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) Participant User Files 2007 to 2018 were included. Patients were divided according to their body mass index (BMI) into two groups (BMI ≥ 30 kg/m vs. BMI < 30 kg/m). Baseline demographics, preoperative risk factors including comorbidities, American Society of Anesthesiologists Class, smoking, different preoperative laboratory parameters, and operation time were compared between the two groups. Propensity score matching (1:1) based on logistic regression with a caliber distance of 0.2 of the standard deviation of the logit of the propensity score was used to overcome biases due to different distributions of the covariates. Thirty-day postoperative complications including overall surgical and medical complications, surgical site infection (SSI), organ space infection, systemic sepsis, 30-day mortality, and length of stay were compared between both groups.

Results: Initially, a total of 2158 patients (402 (18.6%) obese and 1756 (81.4%) nonobese patients) were identified. After 1:1 matching, 402 patients remained in each group. Patients with obesity had a higher risk of postoperative organ/space infection (12.9%; vs. 6.5%; p-value 0.002) compared to nonobese patients. There was no difference between the groups regarding the risk of postoperative sepsis, septic shock, need for blood transfusion, wound disruption, superficial SSI, deep SSI, respiratory, renal, major adverse cardiovascular events (myocardial infarction, stroke, cardiac arrest requiring cardiopulmonary resuscitation), venous thromboembolism, 30-day mortality, and length of stay.

Conclusion: MIS IPAA can be safely performed in patients with obesity. However, patients with obesity have a 2-fold risk of organ space infection compared to patients without obesity. Loss of weight before MIS IPAA is recommended not only to allow for pouch creation but also to decrease organ space infections.
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http://dx.doi.org/10.1007/s00423-021-02197-7DOI Listing
November 2021

Program Director Opinions of Virtual Interviews: Whatever Makes my Partners Happy.

J Surg Educ 2021 Nov-Dec;78(6):e12-e18. Epub 2021 May 9.

Mayo Clinic, Division Colon and Rectal Surgery, Rochester, Minnesota.

Objective: To assess the processes and outcomes of 2021 colon and rectal surgery match season: one of the first National Resident Matching Program (NRMP) match to conduct uniformly virtual interviews for all programs and candidates due to the Covid-19 pandemic. Since this if the first-year interviews were held entirely virtual for a (NRMP) match season, we sought to determine: (1) How did program directors (PDs) in this year's fellowship conduct their virtual interviews? (2) Were any of these conduct decisions associated with the PD satisfaction with the resulting match? (3) What is the PDs opinion of how interviews should occur next year if COVID-19 is not a factor?

Design And Setting: The authors sent an anonymous survey to the PDs of all programs participating in the 2021 colon and rectal surgery residency match directly following match day 2020.

Participants: Forty-one colon and rectal residency PDs (70% response rate) responded to the survey (78% Male) representing a range of experience (M = 7.61, SD = 5.66, years as PD at current institution), and program type (77.5% Academic, 7.5% Independent Academic Medical Center, 15% Nonacademic).

Results: While programs utilized several different platforms, conducted various forms of training for their faculty, and provided applicants with different types of information, interview day(s) across the specialty are reported to have proceeded smoothly. PDs as a whole were very satisfied with their match results this year (M = 4.65, SD = .66), and this satisfaction was not impacted by virtual interview decisions or processes. However, only 55% of PDs agree or strongly agree that next year's interviews should be virtual regardless of COVID-19, a judgement solely influenced by the opinion of other program faculty on virtual interviews, regardless of satisfaction with match or comfort with technology.

Conclusion: While PDs report high satisfaction with virtual interview processes and outcomes, there is less agreement that colon and rectal surgery residency interviews should move to a solely virtual platform.
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http://dx.doi.org/10.1016/j.jsurg.2021.04.008DOI Listing
December 2021

Patient colon and rectal operative outcomes when treated with immune checkpoint inhibitors.

Eur J Surg Oncol 2021 09 2;47(9):2436-2440. Epub 2021 Apr 2.

Colon and Rectal Surgery, Department of Surgery, Mayo Clinic, Rochester, MN, USA. Electronic address:

There is limited data about the safety of colorectal surgery after immune checkpoint inhibitors (ICI). We aimed to share our experience about postoperative outcomes of colorectal surgery for patients treated with ICI. Overall, 31 patients were identified, 22 (71%) underwent elective and nine (29%) underwent emergent/urgent surgery. The 30-day Clavien Dindo class ≥ III complication rates were 27.3% (n = 6) for elective and 55.5% (n = 5) for emergent/urgent cases. Four patients underwent emergency surgery for immune-related colonic perforation and developed postoperative septic shock; two died. Considering patients' comorbidities, cancer stage, and surgical complexity, elective colorectal surgery after ICI seems relatively safe. However, emergent/urgent colorectal surgery was associated with high postoperative morbidity. Indeed, colonic perforation in the setting of ICI treatment has a significant risk of postoperative mortality. Therefore, for patients on ICI with any acute abdominal symptoms, surgical consult should be involved, and colon perforation should be ruled out.
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http://dx.doi.org/10.1016/j.ejso.2021.03.257DOI Listing
September 2021

Colectomy in the Setting of Cytomegalovirus Infection: Non-Restorative Initially.

J Gastrointest Surg 2021 10 9;25(10):2684-2685. Epub 2021 Apr 9.

Division of Colon and Rectal Surgery, Mayo Clinic, Rochester, MN, USA.

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http://dx.doi.org/10.1007/s11605-021-05008-yDOI Listing
October 2021

Coping with errors in the operating room: Intraoperative strategies, postoperative strategies, and sex differences.

Surgery 2021 08 30;170(2):440-445. Epub 2021 Mar 30.

Division Colon and Rectal Surgery, Mayo Clinic, Rochester, MN.

Background: Prior work has identified intraoperative and postoperative coping strategies among surgeons and has demonstrated surgical errors to have a significant impact on patient outcomes and physicians. Little research has considered which coping strategies are most common among surgeons and if there exist coping strategy differences among sex or training level.

Methods: An electronic survey was distributed to surgical faculty and trainees at 3 institutions. Variables included coping techniques after making an error in the operating room. Participants were asked to report the effectiveness of their overall coping strategy.

Results: A total of 168 participants (56% male, 45% faculty) experienced an operative error and answered questions regarding coping strategies. The only coping strategy significantly associated with positive ratings of coping effectiveness was, upon error, taking a step back and taking time to think and act (r = 0.17; P = .024). There were differences between men and women in both intra and postoperative coping strategies. Men (mean = 3.69/5, standard error = .09) viewed their overall coping strategy as more effective than women (mean = 3.38/5, standard error = .09), t(158.86) = 2.47; P = .015.

Conclusion: Although both male and female surgeons reported making errors in the operating room, differences exist in the strategies surgeons use to cope with these mistakes, and strategies differ in their ratings of effectiveness.
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http://dx.doi.org/10.1016/j.surg.2021.02.035DOI Listing
August 2021

The extent of colorectal resection and short-term outcomes in patients with ulcerative colitis.

Updates Surg 2021 Aug 30;73(4):1429-1434. Epub 2021 Mar 30.

Division of Colon and Rectal Surgery, Department of Surgery, Mayo Clinic, Rochester, MN, USA.

Objective: There is limited literature on the impact of the extent of resection on short-term outcomes in patients with ulcerative colitis (UC) in an elective setting. The aim of this study was to better understand the impact of approach and extent of resection on short-term outcomes for patients undergoing total proctocolectomy (TPC) and subtotal colectomy (STC) for UC.

Methods: Patients with UC who underwent elective TPC or STC were captured from the ACS-NSQIP® 2011-2018 database and divided into four cohorts: Open TPC (O-TPC), Laparoscopic TPC (L-STC), Open STC (O-STC), and Laparoscopic STC (L-STC). Baseline and perioperative variables were compared between the four groups alongside 30-day mortality and 30-day complication rates.

Results: Of 3387 patients, 368 (10.9%) underwent O-STC, 406 (12%) underwent O-TPC, 1958 (58%) underwent L-STC, and 655 (19%) underwent L-TPC. Overall rate of prolonged length of stay (LOS) was 27% and 9% needed a blood transfusion. There was no difference in the risk of complications between open TPC and open STC. Those who had open surgery had a higher risk of complications and prolonged LOS. Patients who had L-TPC had prolonged LOS compared to patients who had L-STC, but less compared to those who had O-STC.

Conclusion: Elective surgery for UC is associated with high rates of prolonged LOS and blood transfusion despite MIS approaches. Short-term outcomes and LOS are more impacted by the operative approach than the extent of resection. Despite this laparoscopic TPC has higher rates of prolonged LOS when compared to laparoscopic STC.
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http://dx.doi.org/10.1007/s13304-021-01040-4DOI Listing
August 2021

Expert Commentary on Adult Intussusception.

Authors:
Kellie L Mathis

Dis Colon Rectum 2021 06;64(6):648-649

Mayo Clinic, Rochester, Minnesota.

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http://dx.doi.org/10.1097/DCR.0000000000002043DOI Listing
June 2021

Additional Value of Preoperative Albumin for Surgical Risk Stratification among Colorectal Cancer Patients.

Ann Nutr Metab 2020 15;76(6):422-430. Epub 2021 Mar 15.

Department of Visceral Surgery, Lausanne University Hospital CHUV, University of Lausanne, Lausanne, Switzerland,

Background: BMI ≤18.5 kg/m2 and preoperative weight loss may lead to inaccurate assessment of nutritional status, given the increasing prevalence of obesity. The aim of this study was to assess whether clinical evaluation of malnutrition based on these parameters is sufficient to predict complications after colorectal cancer surgery.

Materials And Methods: The American College of Surgeons-National Quality Improvement Program database was queried from 2005 to 2018. Patients undergoing elective colorectal cancer surgery were divided into 4 groups: (1) albumin <3.1 g/dL within 21 days of surgery, (2) European Society for Clinical Nutrition and Metabolism (ESPEN) 2 clinical parameters for malnutrition (≥10% loss of weight/6 months plus [BMI <20 kg/m2 if age <70 years OR BMI <22 kg/m2 if age ≥70 years]), (3) both aforementioned criteria, and (4) none of aforementioned criteria.

Results: Of 82,280 patients, 5,932 (7.2%) had hypoalbuminemia <3.1 g/dL, 764 (0.9%) fulfilled clinical ESPEN 2 parameters, and 338 (0.4%) met both criteria. After adjusting for baseline confounders, patients in the hypoalbuminemia group had a higher risk of overall complications (odds ratio [OR] 1.92, p < 0.05 vs. OR 1.18 in the ESPEN 2 group, p < 0.05), major complications (OR 1.98, p < 0.05 vs. OR 1.20, p < 0.05), surgical complications (OR 1.77, 95% p < 0.05 vs. OR 1.1, p > 0.05), medical complications (OR 1.73, p < 0.05 vs. OR 1.16, p > 0.05), surgical site infection (OR 1.32, p < 0.05 vs. OR 0.86, p > 0.05), and prolonged hospitalization (OR 1.79, p < 0.05 vs. OR 1.22, p < 0.05). Patients who met both criteria were at highest risk.

Conclusions: Preoperative measurement of serum albumin appears to be essential to identify patients at risk for complications after colorectal cancer surgery. Clinical evaluation through BMI and weight loss alone may underestimate surgery-associated risks in the USA.
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http://dx.doi.org/10.1159/000514058DOI Listing
October 2021

Surgical Approach to Transverse Colon Cancer: Analysis of Current Practice and Oncological Outcomes Using the National Cancer Database.

Dis Colon Rectum 2021 03;64(3):284-292

Colon and Rectal Surgery, Mayo Clinic, Rochester, Minnesota.

Background: Surgical treatment for transverse colon cancer involves either extended colectomy or segmental resection, depending on the location of the tumor and surgeon perspective. However, the oncological safety of segmental resection has not yet been established in large cohort studies.

Objective: This study aims to compare segmental resection versus extended colectomy for transverse colon cancer in terms of oncological outcomes.

Design: This was a retrospective cohort study.

Settings: This study was conducted using a nationwide cohort.

Patients: A total of 66,062 patients who underwent colectomy with curative intent for transverse stage I to III adenocarcinoma were identified in the National Cancer Database (2004-2015).

Main Outcome Measures: Patients were divided in 2 groups based on the type of surgery received (extended versus segmental resection). The primary outcome was overall survival. Secondary outcomes were 30- and 90-day mortality, length of hospital stay, and readmission rate within 30 days of surgical discharge.

Results: Extended colectomy was performed in 44,417 (67.2%) patients, whereas 21,645 (32.8%) patients underwent segmental resection. Extended colectomy was associated with lower survival at multivariate analysis (HR, 1.07; 95% CI, 1.04-1.10; p < 0.001). The subgroup analysis showed that extended resection was independently associated with poorer survival in mid transverse colon cancers (HR, 1.08; 95% CI, 1.04-1.12; p < 0.001) and in stage III tumors (HR, 1.11; 95% CI, 1.04-1.18; p < 0.001). The number of at least 12 harvested lymph nodes was an independent predictor of improved survival in both overall and subgroup analyses.

Limitations: This study was limited by its retrospective design.

Conclusion: Extended colectomy was not associated with a survival advantage compared with segmental resection. On the contrary, extended colectomy was associated with slightly poorer survival in mid transverse cancers and locally advanced tumors. Segmental resection was found to be safe when appropriate margins and adequate lymph node harvest were achieved. See Video Abstract at http://links.lww.com/DCR/B454.

Abordaje Quirrgico Del Cncer De Colon Transverso Anlisis De La Prctica Actual Y Los Resultados Oncolgicos Utilizando La Base De Datos Nacional De Cncer: ANTECEDENTES:El tratamiento quirúrgico para el cáncer de colon transverso implica colectomía extendida o resección segmentaria, según la ubicación del tumor y la perspectiva del cirujano. Sin embargo, la seguridad oncológica de la resección segmentaria aún no se ha establecido en estudios de cohortes grandes.OBJETIVO:Este estudio tiene como objetivo comparar la resección segmentaria versus la colectomía extendida para el cáncer de colon transverso en términos de resultados oncológicos.DISEÑO:Este fue un estudio de cohorte retrospectivo.ESCENARIO:Este estudio se realizó utilizando una cohorte a nivel nacional.PACIENTES:Un total de 66,062 pacientes que se sometieron a colectomía con intención curativa por adenocarcinoma de colon transverso en estadio I-III fueron identificados en la Base de Datos Nacional del Cáncer (2004-2015).PRINCIPALES MEDIDAS DE RESULTADO:Los pacientes se dividieron en dos grupos según el tipo de cirugía recibida (resección extendida versus resección segmentaria). El resultado primario fue la supervivencia global. Los resultados secundarios fueron la mortalidad a los 30 y 90 días, la duración de la estancia hospitalaria y la tasa de reingreso dentro de los 30 días posteriores al alta quirúrgica.RESULTADOS:Se realizó colectomía extendida en 44,417 (67.2%) casos, mientras que 21,645 (32.8%) pacientes fueron sometidos a resección segmentaria. La colectomía extendida se asoció con una menor supervivencia en el análisis multivariado (HR 1.07 IC 95% 1.04-1.10; p <0.001). El análisis de subgrupos mostró que la resección extendida se asoció de forma independiente con una menor supervivencia en los cánceres de colon transverso medio (HR 1.08 IC 95% 1.04-1.12; p <0.001) y en tumores en estadio III (HR 1.11 IC 95% 1.04-1.18; p <0.001). Un número de al menos 12 ganglios linfáticos cosechados fue un predictor independiente de una mejor supervivencia en los análisis general y de subgrupos.LIMITACIONES:Este estudio estuvo limitado por su diseño retrospectivo.CONCLUSIÓN:La colectomía extendida no se asoció con una ventaja de supervivencia en comparación con la resección segmentaria. Por el contrario, la colectomía extendida se asoció con una supervivencia levemente menor en cánceres de colon transverso medio y tumores localmente avanzados. Se encontró que la resección segmentaria es segura cuando se logran los márgenes apropiados y la cosecha adecuada de ganglios linfáticos. Consulte Video Resumen en http://links.lww.com/DCR/B454.
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http://dx.doi.org/10.1097/DCR.0000000000001887DOI Listing
March 2021

Synchronous resection of colorectal cancer primary and liver metastases: an outcomes analysis.

HPB (Oxford) 2021 08 18;23(8):1277-1284. Epub 2021 Jan 18.

Division of Hepatobiliary and Pancreatic Surgery, Mayo Clinic, Rochester, MN, USA.

Background: Concurrent resection of the primary cancer and synchronous colorectal cancer liver metastases (CRCLM) was evaluated for differences in outcomes following stratification of both the liver and colorectal resection.

Methods: Consecutive cases of synchronous resection of both the CRC primary and CRCLM were reviewed retrospectively at a single, high-volume institution over a 17-year period (2000-2017).

Results: 273 patients underwent simultaneous resection of CRCLM. The distribution of the primary lesion was similar between the colon (52.4%) and rectum (47.6%), while 46.9% of patients had bilobar liver disease. Major liver/major colorectal resection (n = 24) were significantly more likely to experience colorectal specific morbidity (OR 3.98, 95% CI 1.56-10.15, p = 0.004), liver specific morbidity (OR 7.4, 95% CI 2.22-24.71, p = 0.001), total morbidity (OR 2.91, 95% CI 1.18-7.18, p = 0.020) and 90-day mortality (OR 5.50, 95% CI 1.27-23.81, p = 0.023). Failure to receive adjuvant chemotherapy secondary to postoperative morbidity was associated with significantly worsened survival (HR for death 5.91, 95% CI 1.59-22.01, p = 0.008).

Conclusions: Postoperative morbidity precluding the administration of adjuvant chemotherapy is associated with an increase in mortality. Combining a major liver with major colorectal resection is associated with a significant increase in major morbidity and 90-day mortality, and should be avoided.
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http://dx.doi.org/10.1016/j.hpb.2021.01.002DOI Listing
August 2021

Surgical Resection for Crohn's and Cancer: A Comparison of Disease-Specific Risk Factors and Outcomes.

Dig Surg 2021 27;38(2):120-127. Epub 2021 Jan 27.

Department of Visceral Surgery, Lausanne University Hospital CHUV, University of Lausanne, Lausanne, Switzerland,

Background And Objectives: The goal of this study was to compare disease-specific risk factors and 30-day outcomes between patients with Crohn's disease (CD) and colon cancer (CC) undergoing right-sided surgical resection.

Methods: The American College of Surgeons-National Surgical Quality Improvement Program (ACS-NSQIP®) was interrogated to extract all patients ≥18 years undergoing elective right-sided resection for CD versus CC. Independent risk factors for surgical complications were identified through multivariable logistic regression for both groups. In a second step, surgical and medical 30-day morbidity was compared after risk adjustment.

Results: The cohort consisted of 17,516 patients, of which 2,899 (16.6%) underwent surgery for CD versus 14,617 (83.4%) for CC. Independent risk factors for surgical complications in patients with CD were male gender, African American race, ASA score (III or IV), active smoking, prolonged surgery, and preoperative anemia. Independent risk factors for surgical complications in the cancer group were age ≥70 years, male gender, ASA score (III or IV), respiratory and cardiovascular comorbidities, and preoperative hypoalbuminemia (<3.5 g/dL). After risk adjustment, surgical complications (OR 1.25, p = 0.002), sepsis (OR 1.64, p = 0.012), and unplanned readmissions (OR 1.39, p = 0.004) were more common in patients with CD. Thirty-day mortality was higher in cancer patients (1.1 vs. 0.1%, p < 0.0001).

Conclusions: Patients with Crohn's disease were more prone to surgical complications and postoperative sepsis compared to the cancer group undergoing the same procedure. Careful evaluation and correction of disease-specific modifiable risk factors of patients with CD and CC, respectively, are important.
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http://dx.doi.org/10.1159/000511909DOI Listing
October 2021

Cost drivers of locally advanced rectal cancer treatment-An analysis of a leading healthcare insurer.

J Surg Oncol 2021 Mar 26;123(4):1023-1029. Epub 2021 Jan 26.

Division of Colon and Rectal Surgery, Mayo Clinic, Rochester, Minnesota, USA.

Background: To evaluate the economic burden of locally advanced rectal cancer (LARC) treatment from a society perspective through analysis of health insurance-derived data of commercially insured and Medicare Advantage (MA) patients.

Methods: Retrospective cost analysis of patients undergoing rectal resection within a multimodal (neoadjuvant chemoradiation + adjuvant chemotherapy) treatment strategy between January 1, 2010 and October 31, 2018, using the claims OptumLabs Data Warehouse database.

Results: In total, 1738 (935 commercial and 803 MA) patients were included. Overall treatment costs totaled $230,881,746 (on average $183 653 ± 82 384 per commercially insured and $73 681 ± 32 917 per MA patient). Cost distribution according to category (commercially insured patients) was: 29.92% related to outpatient care (follow-up visits/diagnostics), radiotherapy: 21.83%, index resection: 20.62%, chemotherapy: 17.44%, surgical inpatient: 6.32%, medical inpatient: 3.28%, emergency room: 0.58%. Relative cost distribution of the index resection itself differed marginally between the three approaches and was 21.49% for open, 19.30% for laparoscopic, and 20.93% for robotic surgery. Relative cost distributions of neoadjuvant, adjuvant, and outpatient treatments remained unchanged, independently of the surgical approach. This representation was similar in MA patients.

Conclusion: Index-surgery related costs were outweighed by costs related to oncological and outpatient workup/follow-up treatments independently of both surgical approach and insurance type.
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http://dx.doi.org/10.1002/jso.26390DOI Listing
March 2021

Trends and consequences of surgical conversion in the United States.

Surg Endosc 2022 01 6;36(1):82-90. Epub 2021 Jan 6.

Division of Colon and Rectal Surgery, Department of Surgery, Mayo Clinic, 200 first St. Southwest, Rochester, MN, 55905, USA.

Background: The aim of this study was to identify national utilization trends of robotic surgery for elective colectomy, conversion rates over time, and the specific impact of conversion on postoperative morbidity. Conversion to open represents a hard endpoint for minimally invasive surgery (MIS) and is associated with worse outcomes when compared to MIS or even traditional open procedures.

Methods: All adult patients who underwent either laparoscopic or robotic elective colectomy from 2013 to 2018 as reported in the American College of Surgeons Quality Improvement Program (ACS-NSQIP) database were included. National trends of both robotic utilization and conversion rates were analyzed, overall and according to underlying disease (benign disease, inflammatory bowel disease (IBD), cancer), or the presence of obesity (body mass index (BMI) ≥ 30 kg/m). Demographic and surgical risk factors for surgical conversion to open were identified through multivariable regression analysis. Further assessed were overall and specific postoperative 30-day complications, which were risk adjusted and compared between converted patients and the remaining cohort.

Results: Of 66,652 included procedures, 5353 (8.0%) were converted to open. Conversion rates were 8.5% for laparoscopic and 4.9% for robotic surgery (p < 0.0001). A decline in conversion rates over the 6-year inclusion period was observed overall and for patients with obesity. This trend paralleled an increased utilization of the robotic platform. Several surrogates for advanced disease stages for cancer, diverticulitis, and IBD and prolonged surgical duration were identified as independent risk factors for unplanned conversion, while robotic approach was an independent protective factor (OR 0.44, p < 0.0001). Patients who had unplanned conversion were more likely to experience postoperative complications (OR 2.36; 95% CI [2.21-2.51]), length of hospital stay ≥ 6 days (OR 2.86; 95% CI [2.67-3.05], and 30-day mortality (OR 2.28; 95% CI [1.72-3.02]).

Conclusion: This nationwide study identified a decreasing trend in conversion rates over the 6-year inclusion period, both overall and in patients with obesity, paralleling increased utilization of the robotic platform. Unplanned conversion to open was associated with a higher risk of postoperative complications.
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http://dx.doi.org/10.1007/s00464-020-08240-wDOI Listing
January 2022

How skilled are skilled facilities? Post-discharge complications after colorectal cancer surgery in the U.S.

Am J Surg 2021 07 14;222(1):20-26. Epub 2020 Dec 14.

Division of Colon and Rectal Surgery, Department of Surgery, Mayo Clinic, Rochester, MN, USA. Electronic address:

Background: Characteristics and indications for discharging patients to home or a specific facility type have been studied; however, critical evaluation of these facilities through analysis of post-discharge complications and readmission rates is mandatory. The aim of this study was to compare complications occurring after discharge to home, skilled, and unskilled care facilities to identify potential pitfalls.

Methods: All adult (≥18 years) patients who underwent surgery for colon or rectal cancer from 2012 to 2017 as reported in the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database were included. Patients were categorized according to the discharge destination into: home, skilled care (rehabilitation center, separate acute care, skilled facility), and unskilled care (multilevel senior community, facility which is home, unskilled facility). Demographics, surgical risk factors and predischarge complications were compared between the three groups. Primary endpoints were overall, major, surgical, and medical complications occurring post-discharge, within 30 days of surgery. Further assessed were specific complications, readmission, length of stay, and 30-day mortality.

Results: A total of 108,617 patients were identified. Of them, 100,478 (92%) discharged to home, 7313 (7%) to skilled, and 826 (1%) to unskilled care. Of patients discharged to skilled care, 1928 (26%) discharged to rehabilitation centers, 368 (5%) to separate acute care, and 5017 (69%) to skilled facilities. Adjusted overall, major, surgical, and medical post-discharge complications were highest among patients discharged to skilled care destinations. Subgroup analysis revealed separate acute care (inter-hospital transfer) to be associated with the highest morbidity. Main reasons for readmission were primarily related to surgical site infection and intestinal obstruction among the three main destinations, whereas readmissions for systemic sepsis and medical complications were more frequent in patients admitted to skilled care.

Conclusion: This study identified higher rates of post-discharge complications associated with skilled care destinations, despite risk adjustment. This over-morbidity is potentially related to prevailing medical complications and inter-hospital transfers. Further studies are needed to better understand those findings and to improve quality of post-acute care and related outcomes.
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http://dx.doi.org/10.1016/j.amjsurg.2020.12.012DOI Listing
July 2021
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