27.09 Defining Surgeon Volume Threshold for Improved Outcomes From Minimally Invasive Colectomy

Posted on January 18, 2018

M. A. Adam1, D. Becerra1, M. C. Turner1, C. R. Mantyh1, J. Migaly1  1Duke University Medical Center,Department Of Surgery,Durham, NC, USA

Introduction: The association between surgeon volume and improved outcomes for minimally invasive colectomy (MIC) has been established. However, a definition of a high-volume MIC surgeon remains unclear. We aimed to determine the number of MIC per surgeon per year that is associated with the lowest risk of postoperative complications. 

Methods: Adult patients undergoing MIC were identified from the HCUP-National Inpatient Sample (2008-2009). Multivariabe logistic regression with restricted cubic splines was utilized to examine the association between the number of annual MIC/surgeon and risk of complications.

Results: 6554 patients were identified; 51% had a diagnosis of colon cancer. Overall, 20% experienced a postoperative complication and 0.5% died in hospital. Median surgeon volume was 10 cases/year. After adjustment for case and procedure mix, the likelihood of experiencing a complication decreased with increasing surgeon volume up to 20 MIC cases/year (p<0.01) (Figure). The vast majority of patients (70%) underwent surgery by low-volume (<20 cases/year). Patients treated by low volume surgeons were more likely to experience conversion to open colectomy (0.8% vs. 0.3%), postoperative complications (21% vs. 17%), prolonged hospital length of stay (6 vs. 5 days), and higher inflation-adjusted hospital costs ($12669 vs. $11752), (all p<0.01). 

Conclusion:  This study identifies a surgeon volume threshold (>20 cases/year) that is associated with improved patient outcomes from minimally invasive colectomy. Identifying a threshold number of cases defining a high-volume MIC surgeon is important, as it has implications for quality improvement, criteria for referral and reimbursement, and surgical education.

 

27.08 Predictive Value of Leukocyte and Platelet-derived Ratios in Locally Advanced Rectal Adenocarcinoma

Posted on January 18, 2018

W. H. Ward1, A. C. Esposito2, N. Goel1, K. J. Ruth3, E. R. Sigurdson1, J. E. Meyer5, C. S. Denlinger4, J. M. Farma1  1Fox Chase Cancer Center,Department Of Surgical Oncology,Philadelphia, PA, USA 2Temple University,Lewis Katz School Of Medicine,Philadelpha, PA, USA 3Fox Chase Cancer Center,Biostatistics And Bioinformatics Facility,Philadelphia, PA, USA 4Fox Chase Cancer Center,Department Of Hematology/Oncology,Philadelphia, PA, USA 5Fox Chase Cancer Center,Department Of Radiation Oncology,Philadelphia, PA, USA

Introduction:
Although advances in the multidisciplinary treatment of locally advanced rectal cancer have improved survival, there is variability in response to therapy. In addition to tumor biology, host factors and immunologic capacity may play a role. Given the morbidity of therapy and risk of recurrence, there is much interest in preoperative identification of predictive biomarkers.  In colorectal cancer, recent data suggest the utility of the lymphocyte-to-monocyte ratio (LMR), neutrophil-to-lymphocyte ratio (NLR), and platelet-to-lymphocyte ratio (PLR) in predicting survival. The aim of our study was to examine these factors in our rectal cancer patients and determine whether any association exists between these ratios and overall survival.  

Methods:
Using data from a prospectively maintained database at our tertiary referral center, a query was completed for all patients with clinical stage II to III rectal adenocarcinoma who underwent comprehensive treatment from 2002-2016.  We included patients with full demographic, staging, treatment, and survival data who had a complete blood count collected prior to neoadjuvant chemoradiation (pre-CRT) and again prior to surgery (post-CRT).  LMR, NLR, and PLR were calculated for the pre-CRT and post-CRT time points.  Potential cutpoints associated with overall survival (OS) differences were determined using the maxstat R package, which identifies optimal cutpoints while controlling for repeat testing (p<0.05). Survival curves based on these cutpoints were compared using log-rank tests and were adjusted for age and stage using Cox regression.

Results:
A total of 146 patients were included.  Cutpoints were significantly associated with OS for pre-CRT ratios but not for post-CRT ratios.  Within the pre-treatment group, “low” (<2.86) LMR was associated with decreased OS (log-rank p=0.004, 5 year OS= 69% [95%CI 54%-80%]) compared to “high” (>2.86) LMR (5 year OS= 86% [95%CI 75%-93%]).  In the same group, “high” NLR (>4.47) was associated with decreased OS (log-rank p<0.001), and “high” PLR (>203.6) was associated with decreased OS (log-rank p<0.001).  With adjustment for age and final pathologic stage, the associations of NLR and PLR with OS retained their statistical significance (p=0.017 and p=0.005, respectively), and the association of LMR and OS had borderline statistical significance (p=0.075).

Conclusion:
If obtained prior to the start of neoadjuvant chemoradiation, LMR, NLR, and PLR values are accurate predictors of 5-year OS in patients with locally advanced rectal adenocarcinoma.  Following the administration of neoadjuvant therapy, these ratios lose their predictive ability.  Further confirmation of the value of these ratios in larger datasets will be important.
 

27.07 Post-Discharge Opioid Utilization after Colorectal Surgery is Modified by ERAS Pathways

Posted on January 18, 2018

K. E. Hudak1, L. E. Goss2, R. K. Burton3, P. K. Patel1, E. A. Dasinger2, G. D. Kennedy2, J. A. Cannon2, M. S. Morris2, J. S. Richman2, D. I. Chu2  1University Of Alabama at Birmingham,School Of Medicine,Birmingham, Alabama, USA 2University Of Alabama at Birmingham,Department Of Gastrointestinal Surgery,Birmingham, Alabama, USA 3University Of Alabama at Birmingham,School Of Public Health,Birmingham, Alabama, USA

Introduction:  The excess utilization of opioids after surgery is common and may contribute to the national opioid epidemic. Enhanced Recovery After Surgery (ERAS) pathways have been shown to decrease in-hospital opioid utilization, but their effect on post-discharge opioid utilization is unclear. We hypothesized that patients undergoing ERAS for colorectal surgery would have decreased opioid utilization on discharge and at one-year post-discharge.

Methods:  A single-institution ERAS database was used to identify all patients undergoing colorectal surgery in 2015. ERAS patients were then matched by sex, race, age, indication, and procedure with pre-ERAS patients from 2013-14 to create a comparison group. Patient/procedure-level characteristics were included. Excluded were patients who died within one year of surgery, long-term dependent opioid users, and opioid users above the 99th percentile of oral morphine equivalents (OME). Outcomes evaluated included OME at discharge, total OME within 1-year, OME per pill (OME/P) at discharge, opioid type, and pill counts. Variables with p<0.05 on bivariate comparisons were included in adjusted linear models.

Results: Of 395 patients included in this study, 89.6% were prescribed an opioid on discharge. Pre-ERAS (n=197) and ERAS (n=198) patients were similar by matched characteristics and smoking status, ASA class, hypertension and diabetes. Compared to pre-ERAS patients, ERAS patients had more minimally invasive surgeries (43.4% vs. 32.5%), more ostomies (38.9% vs. 25.9%) and had lower rates of baseline opioid use (15.2% vs. 29.4%) (p<0.03). More ERAS patients were discharged with no opioids compared to pre-ERAS patients (13.1% vs. 7.6%, p=0.07). Among those discharged with opioids, ERAS patients received an average of 403 OME and 60.6 pills vs. 343 OME and 46.9 pills for pre-ERAS (p<0.03 for all). However, the OME/P at discharge was significantly lower for ERAS (6.9 vs. 7.6, p<0.01), which remained after adjustment for covariate differences (7.0 vs 7.9, p=0.01). ERAS patients used more low-OME medications, such as tramadol (35.9% vs. 0%, p<0.001) and were prescribed fewer high-OME medications containing hydrocodone or oxycodone (37.9% vs. 72%, p<0.01). At one-year post-discharge, ERAS patients received fewer additional high-OME prescriptions (34.3% vs. 43.7%, p<0.01).

Conclusion: ERAS modifies post-discharge opioid utilization for patients undergoing colorectal surgery. On discharge, more patients undergoing ERAS required no opioids and at one year, ERAS patients required less opioid prescriptions. While ERAS patients discharged with opioids did receive more OMEs overall, these OMEs were distributed over more pills and ERAS patients actually received more low-potency (low OME) pills, accounting for a lower OME/P ratio. These findings suggest a potential role for ERAS in reducing post-discharge opioids utilization and an additional need to standardize post-discharge prescriptions patterns.

 

27.06 Colon Cancer Stages I-III: Why Roam When You Can Resect Near Home?

Posted on January 18, 2018

O. K. Jawitz1, M. Turner1, M. Adam1, C. Mantyh1, J. Migaly1  1Duke University Medical Center,Department Of Surgery,Durham, NC, USA

Introduction:
Cancer resections performed at high-volume colorectal surgery centers are associated with improved post-operative outcomes including fewer complications such as anastomotic leak and increased survival. It is not known if patients who do not live in proximity to high-volume centers benefit from choosing to travel to these institutions as opposed to receiving their care at local, low-volume centers. 

Methods:
The 2006-2014 National Cancer Database (NCDB) was queried for patients with pathologic stage I-III colon adenocarcinoma who underwent cancer treatment at a single center. Travel distances to treatment centers were calculated. Matching the first and fourth quartiles of travel distance with first and fourth quartiles of institution surgical volume established short distance/low-volume (local) and long distance/high-volume (travel) cohorts. The primary outcome of interest was overall survival compared between the local and travel cohorts. Secondary outcomes included incidence of positive resection margins, adequate lymph node harvesting, length of stay, readmission rates, 30-day and 90-day mortality, and use of adjuvant chemotherapy.

Results:
A total of 33,339 patients met inclusion criteria, including 18,163 patients that traveled ≤2.6 miles to centers that performed ≤ 34 resections per year (local) and 15,176 patients that traveled ≥ 21.8 miles to centers that performed ≥ 83 resections annually (travel). In unadjusted analysis, patients in the travel cohort had lower rates of positive resection margins (3.3% vs. 5.0%, p<0.001), more frequently had adequate lymph node harvests (88.9% vs. 79.2%, p<0.001), and had lower 30-day (2.4% vs. 4.0%, p<0.001) and 90-day mortality (4.0% vs. 6.6%, p<0.001). On multivariable logistic regression analysis adjusting for patient demographic, tumor, and facility characteristics, traveling longer distances to high-volume centers remained an independent predictor of improved overall survival (hazard ratio 0.84, p<0.001) and secondary outcomes of adequate lymph node harvesting (OR 0.48, p<0.001), negative resection margins (OR 0.65, p<0.001), lower readmission rates (OR 0.84, p<0.001), 30-day mortality (OR 0.75, p<0.001), and 90-day mortality (OR 0.74, p<0.001). 

Conclusion:
For patients with stage I-III colon cancer who do not live in proximity to high-volume colorectal surgery centers, traveling to these institutions as opposed to receiving treatment at local low-volume centers conveys a postoperative survival advantage. Additionally, rates of adequate oncologic resections and readmission are superior to those who seek care locally. Patients with stage I-III colon cancer should be encouraged to undergo surgical resection at high-volume centers, even if this involves traveling outside of their local region. 
 

27.05 Fecal Microbiota Transplant Protocol Implementation: A Community-Based University Hospital Experience

Posted on January 18, 2018

R. Duarte-Chavez2, T. R. Wojda1,3, B. Geme1, G. Fioravanti2, S. P. Stawicki3  1St. Luke’s University Health Network,Division Of Gastroenterology,Bethlehem, PA, USA 2St. Luke’s University Health Network,Department Of Internal Medicine,Bethlehem, PA, USA 3St. Luke’s University Health Network,Department Of Surgery,Bethlehem, PA, USA

Introduction: Clostridium difficile (CD) is a serious and increasingly prevalent healthcare associated infection. The pathogenesis of CD infection (CDI) includes the acquisition of CD with a disruption of the native gut flora. Antibiotics are a major risk although other contributors have been identified. Management combines discontinuation of the offending agent, initiation of CD-specific antibiotic(s), probiotic use, fecal microbial transplantation (FMT), and surgery as the “last resort” option. The aim of this study is to review short-term clinical results following the implementation of FMT protocol at our community-based University hospital.

Methods: Following IRB / Infection Control Committee approvals, FMT protocol was implemented for patients with CDI. Prospective tracking of FMT procedures (Jul 1, 2015-Feb 1, 2017) was conducted using REDCap™ data capture system. Indications for FMT included: (a) ≥ 3 CDI recurrences; (b) ≥2 hospital admissions with severe CDI; or (c) first episode of complicated CDI (CCDI). Risk factors for CDI and treatment failure were assessed. Patients were followed for ≥3 months to assess cure/failure, relapse and side effects. Frozen 250 mL FMT samples were acquired from OpenBiome (Somerville, MA). After 4 hrs of thawing, the liquid suspension was applied colonoscopically, from terminal ileum to mid-transverse colon. Recorded data included disease severity (Hines VA CDI Severity Score, HVCSS), concomitant medications, number of FMT treatments, non-FMT therapies, cure rates, and mortality.

Results: Thirty-five patients (mean age 58.5 yrs, 69% female) received FMT, with primary cure in 30 (86%) cases. Within this sub-group, 2/30 (6.7%) patients recurred and were subsequently cured with long-term oral vancomycin (OV). Among 5/35 (14%) primary FMT failures, 3 (60%) were cured with long-term OV and 2 (40%) required colectomy. For the 7 patients who either failed FMT or recurred, long-term OV was curative in all but 2 cases (Fig 1). For patients with severe CDI (HVCSS ≥3), primary / secondary cure rates were 6/10 (60%) and 8/10 (80%), respectively. Patients with CCDI (n=4) had higher HVCSS (4 vs 3) and mortality of 25%. Characteristics of patients who failed initial FMT included older age (70 vs 57 yrs), female sex (80% vs 67%), severe CDI (80% vs. 13%), as well as opioid use during the initial infection (60% vs 37%) and at the time of FMT (60% vs 27%). Most commonly reported side effect of FMT was loose stools.

Conclusion: This study supports the efficacy and safety of FMT in the setting of CDI, with primary (86%) and secondary (71%) non-surgical cure rates being consistent with previous reports. The potential role of opioid use as a modulator of CDI warrants further study.

27.04 A Preoperative Prediction Model for Risk of Multiple Admissions after Colon Cancer Surgery

Posted on January 18, 2018

J. H. Fieber1, C. E. Sharoky1, K. Collier1, R. L. Hoffman1, C. Wirtalla1, E. C. Paulson1, G. C. Karakousis1, R. R. Kelz1  1University Of Pennsylvania,Department Of Surgery,Philadelphia, PA, USA

Introduction: Colon cancer treatment commonly has a profound impact on patients’ and caregivers’ ability to maintain their involvement in the work force, potentially leading to loss of insurance and income. The use of medical services, including multiple hospital admissions [MuAdmin], contributes to time lost at work. We developed a simplified model to predict preoperative risk of MuAdmin amongst patients undergoing colon resection to help patients prepare for treatment and to guide improvement efforts.

Methods: Patients ≥18 years-old with colon cancer that underwent elective surgical resection without postoperative complications identified in discharge claims from California and New York (2008-2011) were included. The primary outcome factor, MuAdmin, was defined as the 90th percentile for admissions following resection. Logistic regression models were developed to identify factors predictive of MuAdmin. A weighted point system was developed using beta-coefficients (β) (p<0.05). A point value of 1 was assigned to β<0.5, 2 was assigned to 0.5≤β<1, and 3 was assigned to β≥1.   A random sample of 75% of the data was used for model development leaving a 25% sample for validation.

Results: A total of 14,805 patients underwent colon surgery with 27.3% requiring at least 1 admission. MuAdmin, defined as ≥2 admissions following resection, impacted 9.7% of patients.  The statistically significant predictors of MuAdmin were Elixhauser comorbidity index ≥3 (β=0.30), metastasis (β=0.96), payer system (Medicare β=0.25, Medicaid β=0.58), and the number of prior admissions in the year before resection (1: β=0.43, 2: β=0.54, 3: β=1.45). Scores ranged from 0-8. Scores ≤1 had <7% risk of MuAdmin, scores between 2-5 had at 10-21% risk of MuAdmin and scores ≥6 had a >30% risk of MuAdmin. Our prediction model accurately stratified patients by the likelihood of MuAdmin. [Table 1: Observed and Predicted Rates of MuAdmin following Colon Cancer Resection by Risk Score]

Conclusion: Following discharge after resection of colon cancer, almost a third of patients are admitted at least once and nearly 10% require 2 or more admissions in the year following surgery.  A simple, preoperative clinical model can predict the likelihood of multiple admissions in patients anticipating resection.  This information can assist patients and caregivers in managing time off from work to minimize the threat of unemployment and financial hardship.

27.03 Colorectal Surgical Site Infection Prevention Kits Prior to Elective Colectomy Improves Outcomes

Posted on January 18, 2018

S. E. Deery1, S. T. McWalters2, S. R. Reilly3, H. N. Milch1, D. W. Rattner1, E. A. Mort3,4, D. C. Hooper5, M. G. Del Carmen1,6, L. G. Bordeianou1  1Massachusetts General Hospital,Colorectal Center,Boston, MA, USA 2Massachusetts General Hospital,Edward P. Lawrence Center For Quality And Safety,Boston, MASSACHUSETTS, USA 3Massachusetts General Hospital,Department Of Patient Safety And Quality,Boston, MASSACHUSETTS, USA 4Massachusetts General Hospital,Department Of General Internal Medicine,Boston, MASSACHUSETTS, USA 5Massachusetts General Hospital,Division Of Infectious Diseases,Boston, MASSACHUSETTS, USA 6Massachusetts General Hospital,Department Of Obstetrics And Gynecology,Boston, MASSACHUSETTS, USA

Introduction:
Patient compliance with preoperative mechanical and antibiotic bowel preparation, skin washes, carbohydrate loading, and avoidance of fasting are key components of successful colorectal ERAS and surgical site infection (SSI)-reduction programs. In July 2016, we began a quality improvement project distributing a free SSI Prevention KIT (SSIPK) containing patient instructions (Figure), mechanical and oral bowel preparation, chlorhexidine washes, and carbohydrate drink to all patients scheduled for elective colectomy, with the goal of improving patient compliance and rates of SSI.

Methods:
This was a prospective data audit of our first 221 SSIPK+ patients, who were compared to historical controls (SSIPK-) of 1,760 patients undergoing elective colectomy (1/1/13–3/31/17). A 1:1 propensity score system accounted for nonrandom treatment assignment with the Chi square test to compare matched patients’ compliance and complications.

Results:
SSIPK+ (N=219) and SSIPK- (N=219) matched patients were statistically identical on demographics, comorbidities, BMI, surgical indication, surgeon, and procedure. SSIPK+ patients had higher compliance with mechanical (95% vs. 71%, P < 0.001) and oral antibiotic (94% vs. 27%, P < 0.001) bowel preparation. This translated into lower overall SSI rates (5.9% vs. 11.4%, P = .04). SSIPK+ patients also had lower rates of anastomotic leak (2.7% vs. 6.8%, P = 0.04), prolonged postoperative ileus (5.9% vs. 14.2%, P < .01), and unplanned intubation (0% vs. 2.3%, P = .02). Furthermore, SSIPK+ patients had shorter mean hospital length of stay (3.1 vs. 5.4 days, P < .01) and had fewer unplanned readmissions (5.9% vs. 14.6%, P < .001). There were no differences in rates of postoperative pneumonia, urinary tract infection, Clostridium difficile colitis, sepsis, or death. 

Conclusion:
Provision of a free-of-charge SSIPK improves patient compliance with preoperative instructions, which is associated with significantly lower rates of surgical site infections, lower rates of prolonged postoperative ileus, and shorter hospital stays with fewer readmissions. Widespread utilization of such a kit could therefore lead to significantly improved outcomes and lower costs.
 

27.02 Induction Chemotherapy versus Standard Treatment for Locally Advanced Rectal Cancer

Posted on January 18, 2018

C. Nganzeu1, J. J. Blank1, F. Ali1, W. Hall2, C. Peterson1, K. Ludwig1, T. Ridolfi1  2Medical College Of Wisconsin,Department Of Radiology,Milwaukee, WI, USA 1Medical College Of Wisconsin,Department Of Colorectal Surgery,Milwaukee, WI, USA

Introduction:
The standard treatment of stage II or III rectal adenocarcinoma is chemoradiation therapy (CRT) followed by surgical resection and adjuvant systemic chemotherapy. Recently there has been increased interest in the use of induction chemotherapy (IC), an approach that provides some or all systemic chemotherapy and CRT in the preoperative setting. Potential benefits of this treatment paradigm include tumor downstaging, early treatment of micrometastases, increased rate of sphincter preservation, decreased time with a diverting stoma, and patient compliance. However, little is known about this treatment strategy on a national level. The aims of this study were to define the frequency of IC use and evaluate treatment outcomes compared to standard CRT using the National Cancer Database.

Methods:
The National Cancer Database was queried for patients diagnosed with stage II or III rectal adenocarcinoma having received radiation, chemotherapy and surgical resection between 2004 and 2014. We compared patients with IC to patients having received standard combined CRT. Linear regression was performed to predict percent patients receiving IC by year. Propensity score matching was applied in a 1:10 fashion. A logistic model was fitted to obtain propensity scores. A greedy matching algorithm was then applied for predictor selection. Outcomes including downstaging, readmission, positive margins, and survival were evaluated.

Results:
A total of 33,480 patients met inclusion criteria. 96.4% of patients underwent standard CRT while 3.6% underwent IC. Of all patients diagnosed with stage II and III rectal cancer, only 2.8% received IC in 2004; this number rose to 4.4% in 2014. Propensity score matching yielded 10,531 patients receiving standard CRT and 1,073 patients who received IC for the analysis. The IC group had more tumor downstaging than standard CRT on surgical pathology (54% vs. 48.8%, p=0.006, respectively). This group also had significantly fewer 30-day readmissions after surgery (4.5% vs. 6.4%, p=0.021, respectively). There were no differences observed in 30-day or 90-day mortality (0.5% vs. 0.5%, p= 0.247 and 0.8% vs. 1.1%, P= 0.755, respectively), rate of positive margins (4.8% vs. 5.6%, p=0.398, respectively), or survival (p=0.587) between the two groups.

Conclusion:

The use of induction chemotherapy for patients with stage II and III rectal cancer increased significantly from 2004-2014. Induction chemotherapy was associated with improved downstaging before surgery and improved 30-day readmission rates after surgery without changing overall survival when compared to standard chemoradiation therapy.

 

27.01 Impact of Mental Health Diagnoses and Treatment on Outcomes after Colorectal Cancer Surgery

Posted on January 18, 2018

C. G. Ratcliff1,4,5, N. N. Massarweh2,5, S. Sansgiry5,6, L. Dindo1,5, H. Yu5,6, D. H. Berger2,5,7, J. A. Cully1,5  1Baylor College Of Medicine,Department Of Psychiatry & Behavioral Sciences,Houston, TX, USA 2Baylor College Of Medicine,Department Of Surgery,Houston, TX, USA 4Sam Houston State University,Department Of Psychology,Hunstville, TX, USA 5Michael E. DeBakey Veterans Affairs Medical Center,Houston, TX, USA 6Baylor College Of Medicine,Department Of Medicine,Houston, TX, USA 7Baylor St. Luke’s Medical Center,Houston, TX, USA

Introduction:  Data regarding the impact of mental health (MH) diagnosis and treatment on postoperative outcomes are evolving.  Presently, little is known about the prevalence and effect of MH treatment on outcomes following surgery for colorectal cancer (CRC).

Methods:  We identified 58,961 Veterans who underwent CRC surgery from 2000-2014 using Veteran Affairs (VA) Surgical Quality Improvement Program (VASQIP) linked to the VA Corporate Data Warehouse to identify MH diagnoses and services. Multivariable logistic regression adjusting for clinical and demographic factors was used to evaluate the association between MH diagnosis (defined as depression, anxiety, PTSD, bipolar, psychotic, personality, cognitive, and substance use disorders) that were documented 30d prior to surgery and the occurrence of 1+ postoperative complication (POCOMP), 90d readmission (90dReadm), and length of stay (LOS). The impact of MH treatment (defined as psychiatric medication and psychotherapy [meds+therapy], psychiatric medication alone [meds alone], psychotherapy alone [therapy alone], or no treatment) within the 30d prior to surgery was also examined.

Results: Within the cohort, 9,029 (15%) had a MH diagnosis (depression = 2,738 [30%], anxiety = 942 [10%], PTSD = 1,762 [20%], bipolar = 505 [6%], psychotic = 679 [8%], cognitive = 239 [3%], personality = 105 [1%], substance use = 4,579 [51%]). Among Veterans with a MH diagnosis, 136 (2%) received meds+therapy, 4,157 (46%) meds alone, 308 (3%) therapy alone, and 4,428 (49%) no treatment during the 30d before surgery.

POCOMP occurred in 30% and 90dReadm in 23% of Veterans. Median LOS was 8d (IQR 6). MH diagnosis was associated with greater odds of POCOMP (OR: 1.10, CI: 1.05-1.16), 90dReadm (OR: 1.10, CI: 1.04-1.16), and longer LOS (OR: 1.42, CI: 1.09-1.86) compared to no MH diagnosis.

Veterans with a MH diagnosis who received no preoperative MH treatment (OR: 1.08, CI: 1.00-1.15) or meds alone (OR: 1.15, CI: 1.07-1.24) had greater odds of POCOMP relative to Veterans without MH diagnosis. Similarly, Veterans with a MH diagnosis who received no preoperative MH treatment (OR: 1.13, CI: 1.04-1.21) or meds alone (OR: 1.15, CI: 1.07-1.24) had greater odds of 90dReadm relative to Veterans without MH diagnosis. Finally, Veterans with a MH diagnosis who received meds alone had longer LOS relative to Veterans without MH diagnosis (OR: 1.96, CI: 1.35-2.85). Odds of POCOMP, 90dReadm, and longer LOS for Veterans with a MH diagnosis who received meds+therapy or therapy alone did not statistically differ from Veterans without MH diagnoses.

Conclusion: MH diagnoses are associated with postoperative complications and readmissions among Veterans who undergo CRC surgery. Provision of preoperative psychotherapy, alone or in combination with psychiatric medication, may help mitigate the adverse effect of psychiatric conditions. Since few Veterans receive adequate preoperative MH treatment, screening for these psychiatric risk factors may be warranted.

23.10 Ablation of Cystathionine-Gamma-Lyase Promotes Colitis-Associated Carcinogenesis

Posted on January 18, 2018

K. Thanki1, M. Nicholls1, M. Maskey1, C. Phillips1, P. Johnson1, J. R. Zatarain1, K. Modis1, S. Qiu3, I. V. Pinchuk2, M. R. Hellmich1, C. Chao1  1University Of Texas Medical Branch,Surgery,Galveston, TX, USA 2University Of Texas Medical Branch,Internal Medicine,Galveston, TX, USA 3University Of Texas Medical Branch,Pathology,Galveston, TX, USA

Introduction: Hydrogen sulfide (H2S) is an important gasotransmitter that is anti-inflammatory at physiological levels. H2S is produced, in large part, by two enzymes in the reverse transsulfuration pathway: cystathionine-γ-lyase (CSE) and cystathionine-β-synthase (CBS). In mouse models of acute colitis, the activities of CSE and CBS are upregulated. Pharmacological inhibition or gene knockout (KO) of CSE worsens inflammation and delays tissue repair.  However the role of CSE in chronic inflammatory conditions, such as ulcerative colitis (UC) and UC-associated carcinogenesis (UCAC) is unknown.

Methods: C57BL/6 CSE knockout (CSE KO) mice and wild-type (WT) controls (N = 148) were given a single injection of the mutagen azoxymethane (AOM) and then randomized to receive either 1, 2 or 3 cycles of the colitis-inducer dextran sodium sulfate (DSS). Each cycle of colitis was induced by administration of 2% DSS in drinking water for a period of seven days followed by 14 days of regular drinking water. Tissues (colon, liver, and lymph nodes) were harvested at 21, 42, 63 and 80 days post AOM injection. Total tumor burden and inflammation were quantified by gross and histological examination using an established scoring system measuring inflammatory infiltrate, mucosal structure (crypt height, epithelial cell loss) and ulceration. CSE mRNA and protein levels from human normal mucosal and UC specimens were determined using qPCR and western blotting, respectively.

Results: Colonic mucosa from UC patients (n=10) exhibited a 2.9-fold decrease in CSE mRNA (qPCR, p<0.05) and protein expression when compared to normal mucosa (n=8). CSE KO mice demonstrate comparable inflammation to WT mice in response to repeated DSS treatment. KO mice demonstrate accelerated UCAC and disease progression as reflected by increased number and area of tumors (i.e., tumor burden) at 21 days (Fig 1A,B). At all other later time points, there were no significant differences in tumor burden. The AOM treatment alone did not cause carcinogenesis in either WT or CSE KO mice.

Conclusion: Our data shows that the colon mucosa from UC patients expresses significantly less CSE, an important producer of H2S. In a mouse model of UCAC, we show that absence of CSE does not protect colon mucosa from inflammation but does accelerate the time to colitis-associated tumor formation, and increases total tumor burden. Theses data suggest that CSE does not impact the inflammatory response but is important in normal mucosal restitution after injury, protecting the colon from UCAC. 

 

20.09 Induction Chemotherapy versus Standard Treatment for Locally Advanced Rectal Cancer

Posted on January 18, 2018

C. Nganzeu1, J. J. Blank1, F. Ali1, W. Hall2, C. Peterson1, K. Ludwig1, T. Ridolfi1  2Medical College Of Wisconsin,Department Of Radiology,Milwaukee, WI, USA 1Medical College Of Wisconsin,Department Of Colorectal Surgery,Milwaukee, WI, USA

Introduction:
The standard treatment of stage II or III rectal adenocarcinoma is chemoradiation therapy (CRT) followed by surgical resection and adjuvant systemic chemotherapy. Recently there has been increased interest in the use of induction chemotherapy (IC), an approach that provides some or all systemic chemotherapy and CRT in the preoperative setting. Potential benefits of this treatment paradigm include tumor downstaging, early treatment of micrometastases, increased rate of sphincter preservation, decreased time with a diverting stoma, and patient compliance. However, little is known about this treatment strategy on a national level. The aims of this study were to define the frequency of IC use and evaluate treatment outcomes compared to standard CRT using the National Cancer Database.

Methods:
The National Cancer Database was queried for patients diagnosed with stage II or III rectal adenocarcinoma having received radiation, chemotherapy and surgical resection between 2004 and 2014. We compared patients with IC to patients having received standard combined CRT. Linear regression was performed to predict percent patients receiving IC by year. Propensity score matching was applied in a 1:10 fashion. A logistic model was fitted to obtain propensity scores. A greedy matching algorithm was then applied for predictor selection. Outcomes including downstaging, readmission, positive margins, and survival were evaluated.

Results:
A total of 33,480 patients met inclusion criteria. 96.4% of patients underwent standard CRT while 3.6% underwent IC. Of all patients diagnosed with stage II and III rectal cancer, only 2.8% received IC in 2004; this number rose to 4.4% in 2014. Propensity score matching yielded 10,531 patients receiving standard CRT and 1,073 patients who received IC for the analysis. The IC group had more tumor downstaging than standard CRT on surgical pathology (54% vs. 48.8%, p=0.006, respectively). This group also had significantly fewer 30-day readmissions after surgery (4.5% vs. 6.4%, p=0.021, respectively). There were no differences observed in 30-day or 90-day mortality (0.5% vs. 0.5%, p= 0.247 and 0.8% vs. 1.1%, P= 0.755, respectively), rate of positive margins (4.8% vs. 5.6%, p=0.398, respectively), or survival (p=0.587) between the two groups.

Conclusion:

The use of induction chemotherapy for patients with stage II and III rectal cancer increased significantly from 2004-2014. Induction chemotherapy was associated with improved downstaging before surgery and improved 30-day readmission rates after surgery without changing overall survival when compared to standard chemoradiation therapy.

 

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