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Background: The use of synoptic reporting has been shown to improve documentation of critical information and provide added value related to data access and extraction, data reliability, relevant detail, and completeness of information. Surgeon acceptance and adoption of synoptic reports has lagged behind other specialties., Objective: This study aimed to evaluate the process of implementing a synoptic operative report., Design: This study was a mixed-methods process evaluation including surveys and qualitative interviews., Settings: This study focused on colorectal surgery practices across the United States., Patients: Twenty-eight board-certified colorectal surgeons were included., Interventions: The synoptic operative report for rectal cancer was implemented., Main Outcome Measures: Acceptability, feasibility, and usability were measured by Likert-type survey questions and followed up with individual interviews to elicit experiences with implementation as well as motivations and barriers to use., Results: Among all study participants, 28 surgeons completed the electronic survey (76% response rate) and 21 (57%) completed the telephone interview. Mean usability was 4.14 (range, 1-5; SE, 0.15), mean feasibility was 3.90 (SE, 0.15), and acceptability was 3.98 (SE, 0.18). Participants indicated that substantial administrative and technical support were necessary but not always available for implementation, and many were frustrated by the need to change their workflow., Limitations: Most surgeon participants were male, white, had >12 years in practice, and used Epic electronic medical record systems. Therefore, they may not represent the perspectives of all US colon and rectal surgeons. In addition, as the synoptic operative report is implemented more broadly across the United States, it will be important to consider variations in the process by electronic medical record system., Conclusions: The synoptic operative report for rectal cancer was easy to implement and incorporate into workflow, in general, but surgeons remained concerned about additional burden without immediate and tangible value. Despite recognizing benefits, many participants indicated they only implemented the synoptic operative report because it was mandated by the National Accreditation Program for Rectal Cancer. See Video Abstract at http://links.lww.com/DCR/B735MOTIVACIONES Y BARRERAS HACIA LA IMPLEMENTACIÓN DE UN INFORME OPERATIVO SINÓPTICO DE CÁNCER RECTAL: UNA EVALUACIÓN DEL PROCESOANTECEDENTES:Se ha demostrado que el uso de informes sinópticos mejora la documentación de información crítica y proporciona un valor agregado relacionado con el acceso y extracción de datos, la confiabilidad de los datos, los detalles relevantes y la integridad de la información. La aceptación y adopción de informes sinópticos por parte de los cirujanos se ha quedado rezagada con respecto a otras especialidades.OBJETIVO:Evaluar el proceso de implementación de un informe operativo sinóptico.DISEÑO:Evaluación de procesos de métodos mixtos que incluyen encuestas y entrevistas cualitativas.AJUSTES:Prácticas de cirugía colorrectal en los Estados Unidos.PACIENTES:Veintiocho cirujanos colorrectales certificados por la junta.INTERVENCIONES:Implementación del informe operatorio sinóptico de cáncer de recto.PRINCIPALES MEDIDAS DE RESULTADO:Aceptabilidad, viabilidad y usabilidad medidas por preguntas de encuestas tipo Likert y seguidas con entrevistas individuales para obtener experiencias con la implementación, así como motivaciones y barreras para el uso.RESULTADOS:Entre todos los participantes del estudio, 28 cirujanos completaron la encuesta electrónica (tasa de respuesta del 76%) y 21 (57%) completaron la entrevista telefónica. La usabilidad media fue 4,14 (rango = 1-5, error estándar (EE) = 0,15), la factibilidad media fue 3,90 (EE = 0,15) y la aceptabilidad fue 3,98 (EE = 0,18). Los participantes indicaron que se necesitaba un apoyo administrativo y técnico sustancial, pero que no siempre estaba disponible para la implementación y muchos se sintieron frustrados por la necesidad de cambiar su flujo de trabajo.LIMITACIONES:La mayoría de los cirujanos participantes eran hombres, blancos, tenían >12 años en la práctica y usaban sistemas de registros médicos electrónicos de Epic. Por lo tanto, es posible que no representen las perspectivas de todos los cirujanos de colon y recto de EE. UU. Además, a medida que el informe operativo sinóptico se implemente de manera más amplia en los EE. UU., Será importante considerar las variaciones en el proceso por sistema EMR.CONCLUSIONES:El informe quirúrgico sinóptico para el cáncer de recto fue en general fácil de implementar e incorporar en el flujo de trabajo, pero los cirujanos seguían preocupados por la carga adicional sin valor inmediato y tangible. A pesar de reconocer los beneficios, muchos participantes indicaron que solo implementaron el informe operativo sinóptico porque era un mandato del Programa Nacional de Acreditación para el Cáncer de Recto. Consulte Video Resumen en http://links.lww.com/DCR/B735 (Traducción-Dr. Xavier Delgadillo)., (Copyright © 2022 The Author(s). Published by Wolters Kluwer Health, Inc. on behalf of the American Society of Colon and Rectal Surgeons.)

Background: Existing studies on the effects of biological medications on surgical complications among patients with ulcerative colitis have mixed results. Because biologicals may hinder response to infections and wound healing, preoperative exposure may increase postoperative complications., Objective: The purpose of this study was to evaluate associations between biological exposure within 6 months preceding colectomy or proctocolectomy and postoperative complications among patients with ulcerative colitis., Design: This was a retrospective cohort study with multivariate regression analysis after coarsened exact matching., Settings: A large commercial insurance claims database (2003-2016) was used., Patients: A total of 1794 patients with ulcerative colitis underwent total abdominal colectomy with end ileostomy, total proctocolectomy with end ileostomy, or total proctocolectomy with IPAA. Twenty-two percent were exposed to biologicals in the 6 months preceding surgery., Main Outcomes Measures: Healthcare use (length of stay, unplanned reoperation/procedure, emergency department visit, or readmission) and complications (infectious, hernia or wound disruption, thromboembolic, or cardiopulmonary) within 30 postoperative days were measured., Results: Exposure to biological medications was associated with shorter surgical hospitalization (7 vs 8 d; p <0.001) but otherwise was not associated with differences in healthcare use or postoperative complications., Patients: who underwent total proctocolectomy with IPAA had higher odds of infectious complications compared with those who underwent total abdominal colectomy with end ileostomy (adjusted OR = 2.2 (95% CI, 1.5-3.0); p < 0.001) but had lower odds of cardiopulmonary complications (adjusted OR = 0.4 (95% CI, 0.3-0.6); p < 0.001)., Limitations: Analysis of private insurance database claims data may not represent uninsured or government-insured patients and may be limited by coding accuracy. Matched cohorts differed in age and Charlson Comorbidity Index, which could be influential even after multivariate adjustments., Conclusions: Biological exposure among patients with ulcerative colitis is not associated with higher odds of postoperative complications or healthcare resource use. These data, in combination with clinical judgment and patient preferences, may aid in complex decision-making regarding operative timing, operation type, and perioperative medication management. See Video Abstract at http://links.lww.com/DCR/B370. EL USO DE MEDICAMENTOS BIOLÓGICOS NO AUMENTA LAS COMPLICACIONES POSTOPERATORIAS ENTRE PACIENTES CON COLITIS ULCERATIVA SOMETIDOS A UNA COLECTOMÍA: UN ANÁLISIS DE COHORTE RETROSPECTIVO DE PACIENTES CON SEGURO PRIVADO: Estudios existentes sobre los efectos de medicamentos biológicos, en complicaciones quirúrgicas, en pacientes con colitis ulcerativa, presentan resultados mixtos. Debido a que los productos biológicos pueden retrasar la respuesta a las infecciones y curación de heridas, su exposición preoperatoria pueden aumentar las complicaciones postoperatorias.Evaluar las asociaciones entre la exposición biológica dentro de los seis meses anteriores a la colectomía o proctocolectomía y las complicaciones postoperatorias entre los pacientes con colitis ulcerativa.Estudio de cohorte retrospectivo con análisis de regresión multivariante después de una coincidencia exacta aproximada.Una gran base de datos de reclamaciones de seguros comerciales (2003-2016).Un total de 1.794 pacientes con colitis ulcerativa, se sometieron a colectomía abdominal total con ileostomía terminal, proctocolectomía total con ileostomía terminal o proctocolectomía total con anastomosis anal y bolsa ileal. 22% estuvieron expuestos a productos biológicos, seis meses antes de la cirugía.Utilización de la atención médica (duración de la estadía, reoperación o procedimiento no planificado, visita al servicio de urgencias o reingreso) y complicaciones (infecciosas, hernias o dehiscencias de heridas, tromboembólicas o cardiopulmonares) dentro de los 30 días postoperatorios.La exposición a medicamentos biológicos se asoció con una hospitalización quirúrgica más corta (7 frente a 8 días, p <0,001), pero por lo demás, no se asoció con diferencias en la utilización de la atención médica o complicaciones postoperatorias. Los pacientes que se sometieron a proctocolectomía total con anastomosis anal y bolsa ileal, tuvieron mayores probabilidades de complicaciones infecciosas, en comparación con aquellos que se sometieron a colectomía abdominal total con ileostomía final (aOR 2.2, IC 95% [1.5-3.0], p <0.001) pero tuvieron menores probabilidades de complicaciones cardiopulmonares (aOR 0.4, IC 95% [0.3-0.6], p <0.001).El análisis de los datos de reclamaciones, de la base de datos de los seguros privados, puede no representar a pacientes no asegurados o asegurados por el gobierno, y puede estar limitado por la precisión de la codificación. Las cohortes emparejadas diferían en la edad y el índice de comorbilidad de Charlson, lo que podría influir incluso después de ajustes multivariados.La exposición biológica entre los pacientes con colitis ulcerativa, no se asocia con mayores probabilidades de complicaciones postoperatorias, o a la utilización de recursos sanitarios. Estos datos, en combinación con el juicio clínico y las preferencias del paciente, pueden ayudar en la toma de decisiones complejas con respecto al momento quirúrgico, el tipo de operación y el manejo de la medicación perioperatoria. Consulte Video Resumen en http://links.lww.com/DCR/B370. (Traducción-Dr Fidel Ruiz Healy).

Background: Patients seeking second opinions are a challenge for the colorectal cancer provider because of complexity, failed therapeutic relationship with another provider, need for reassurance, and desire for exploration of treatment options., Objective: The purpose of this study was to describe the patient and treatment characteristics of patients seeking initial and second opinions in colorectal cancer care at a multidisciplinary colorectal cancer clinic., Design: This was a retrospective cohort study., Settings: A prospectively collected clinical registry of a multidisciplinary colorectal cancer clinic was included., Patients: The study included patients with colon or rectal cancer seen from 2012 to 2017., Main Outcome Measures: Data were analyzed for initial versus second opinion and demographic and clinical characteristics., Results: Of 1711 patients with colorectal cancer, 1008 (58.9%) sought an initial opinion and 700 (40.9%) sought a second opinion. As compared with initial-opinion patients, second-opinion patients were more likely to have stage IV disease (OR = 1.94 (95% CI, 1.47-2.58)), recurrent disease (OR = 1.67 (95% CI, 1.13-2.46)), and be ages 40 to 49 years (OR = 1.47 (95% CI, 1.02-2.12)). Initial- and second-opinion cohorts were similar in terms of sex, race, and proportion of colon versus rectal cancer. Among second-opinion patients, 246 (35%) transitioned their care to the multidisciplinary colorectal cancer clinic., Limitations: We were unable to capture the final treatment plan for those patients who did not transfer care to the multidisciplinary colorectal cancer clinic., Conclusions: Patients seeking a second opinion represent a unique subset of patients with colorectal cancer. In general, they are younger and more likely to have stage IV or recurrent disease than patients seeking an initial opinion. Although transfer of care to a multidisciplinary colorectal cancer clinic after second opinion is lower than for initial consultations, multidisciplinary colorectal cancer clinics provide an important role for patients with complex disease characteristics and treatment needs. See Video Abstract at http://links.lww.com/DCR/B192. CARACTERíSTICAS DE LOS PACIENTES QUE BUSCAN UNA SEGUNDA OPINIóN EN CLíNICAS MULTIDISCIPLINARIAS ESPECIALIZADAS EN CáNCER COLORECTAL: Los pacientes que buscan una segunda opinión son un desafío para el médico que trata el cáncer colorrectal debido a la complejidad de la situación, a la relación terapéutica fallida con otro especialista, a la necesidad de tranquilidad y el deseo de explorar otras opciones del tratamiento.El describir las características y el tratamiento de los pacientes que buscan opiniones iniciales y secundarias en la atención del cáncer colorrectal en una clínica especializada de manera multidisciplinaria en cáncer colorrectal.Este es un estudio de cohortes retrospectivo.Registro clínico de casos obtenidos prospectivamente en una clínica especializada de manera multidisciplinaria en cáncer colorrectal.Todos aquellos pacientes con cáncer de colon o recto examinados entre 2012-2017.Se analizaron los datos obtenidos en la opinión inicial y se compararon con la segunda opinión, se revisaron tanto sus características demográficas como clínicas.De 1711 pacientes con cáncer colorrectal, 1008 (58.9%) buscaron una opinión inicial, 700 (40.9%) buscaron una segunda opinión. En comparación con los pacientes de opinión inicial, los pacientes de segunda opinión presentaron más probabilidades de tener enfermedad en estadio IV (OR 1.94, IC 95% 1.47-2.58), enfermedad recurrente (OR 1.67, IC 95% 1.13-2.46) y tener edades entre 40 y 49 (O 1.47, IC 95% 1.02-2.12). Las cohortes iniciales y de segunda opinión fueron similares en términos de género, raza y proporción del cáncer de colon versus cáncer de recto. Entre los pacientes de segunda opinión, 246 (35%) transfirieron su tratamiento hacia una clínica multidisplinaria especializada en cáncer colorrectal.No se obtuvieron los planes del tratamiento final de aquellos pacientes que no transfirieron sus cuidados hacia una la clínica especializada en cáncer colorrectal.Los pacientes que buscan una segunda opinión representan un subconjunto único de personas con cáncer colorrectal. En general, son más jóvenes y tienen más probabilidades de tener enfermedad en estadio IV o recurrente, con relación a aquellos pacientes que buscan una opinión inicial. Aunque la transferencia de los cuidados hacia una clínica multidisciplinaria especializada en cáncer colorrectal después de una segunda opinión es menor que para las consultas iniciales. Las clínicas multidisciplinarias especializadas en cáncer colorrectal juegan un papel importante con los pacientes que tienen características complejas de enfermedad y necesidades particulares en el tratamiento. Consulte Video Resumen en http://links.lww.com/DCR/B192. (Traducción-Dr Xavier Delgadillo).

Background: The National Accreditation Program for Rectal Cancer is a collaborative effort to improve the quality of rectal cancer care, including multidisciplinary assessment, treatment planning, and documentation using synoptic radiology, pathology, and operative reports., Objective: The purpose of this study was to examine the implementation and use of a synoptic operative report for rectal cancer., Design: This was a convergent mixed-methods implementation study of electronic medical record data, surveys, and qualitative interviews., Settings: The study was conducted at US medical centers., Participants: Colorectal surgeons were included., Intervention: After development, the synoptic operative report was iteratively revised and ultimately approved by the American Society of Colon and Rectal Surgeons Executive Council and the National Accreditation Program for Rectal Cancer and then implemented into participants' institutional electronic medical record systems., Main Outcome Measures: Change in fidelity to documentation of 19 critical items after implementation of synoptic reports and in-depth details and perspectives about the synoptic operative report were measured., Results: Thirty-seven surgeons from 14 institutions submitted preimplementation operative reports (n = 180); 32 of 37 surgeons submitted postimplementation reports (n = 118). The operation type, approach, and formation of a stoma were present in >70% of preimplementation reports; however, the location of the tumor, the type of reconstruction, and the distal margin were reported in <50%. Each item was present in ≥89% of postimplementation reports. Twenty eight of 37 participants completed the survey, and 21 of 37 participants completed qualitative interviews. Emergent themes included concerns for additional burden and time constraints using the synoptic report themselves, as well as errors or absent information in traditional narrative operative reports of other surgeons., Limitations: The study was limited by its sample size, cross-sectional nature, specialized centers, and inclusion of colorectal surgeons only., Conclusions: Although fidelity to the 19 items substantially increased after implementation of the synoptic report, reactions to the synoptic report varied among surgeons. Many indicated concerns that it would hinder workflow or add extra time burden. Others felt the synoptic report could indirectly improve rectal cancer quality of care and provide useful data for quality improvement and research. More work is needed to update and improve the synoptic operative report and streamline the workflow. See Video Abstract at http://links.lww.com/DCR/B100. IMPLEMENTACIÓN DE UN INFORME OPERATIVO SINÓPTICO PARA EL CÁNCER DE RECTO: UN ESTUDIO UTILIZANDO MÉTODOS MIXTOS: El Programa Nacional de Acreditación para el Cáncer Rectal es una iniciativa de colaboración para mejorar la calidad de la atención del cáncer rectal, utilizando evaluación multidisciplinaria, planificación del tratamiento y documentación mediante radiología sinóptica, patología e informes quirúrgicos.Examinar la implementación y el uso de un informe operativo sinóptico para el cáncer de recto.Estudio de implementación de métodos mixtos convergentes de datos de registros médicos electrónicos, encuestas y entrevistas cualitativas.Centros médicos de los Estados Unidos.Cirujanos colorrectales.Después de su formulación, el informe operativo sinóptico fue revisado de forma iterativa y finalmente aprobado por el Consejo Ejecutivo de la Sociedad Americana de Cirujanos de Colon y Rectal y el Programa Nacional de Acreditación para el Cáncer Rectal. Posteriormente, se implementó en los sistemas de registros médicos electrónicos institucionales de los participantes.Cambios en la precisión de documentación de 19 ítems críticos después de la implementación de informes sinópticos; Revisión de detalles y perspectivas en a profundidad sobre el informe operativo sinóptico.Treinta y siete cirujanos de 14 instituciones presentaron informes operativos previos a la implementación (n = 180); 32/37 cirujanos presentaron informes posteriores a la implementación (n = 118). El tipo de operación, el enfoque y la formación de un estoma estuvieron presentes en > 70% de los informes previos a la implementación; sin embargo, la ubicación del tumor, el tipo de reconstrucción y el margen distal se informaron en <50%. Cada ítem estuvo presente en > 89% de los informes posteriores a la implementación. 28/37 participantes completaron la encuesta y 21/37 participantes completaron entrevistas cualitativas. Los temas emergentes incluyeron preocupaciones por la carga adicional y las limitaciones de tiempo usando el informe sinóptico en sí, y errores o información ausente en los informes operativos narrativos tradicionales de otros cirujanos.Tamaño de la muestra, estudio transversal, centros especializados, cirujanos colorrectales solamente.Aunque la fidelidad a los 19 ítems aumentó sustancialmente después de la implementación del informe sinóptico, las reacciones al informe sinóptico variaron entre los cirujanos. Muchos indicaron preocupaciones de que obstaculizaría el flujo de trabajo o agregaría una carga de tiempo adicional. Otros consideraron que el informe sinóptico podría mejorar indirectamente la calidad de la atención del cáncer de recto y proporcionar datos útiles para la mejora de la calidad y la investigación. Se necesita más trabajo para actualizar y mejorar el informe operativo sinóptico y agilizar el flujo de trabajo. Consulte Video Resumen en http://links.lww.com/DCR/B100. (Traducción-Dr. Adrian E. Ortega).

Background: Minimally invasive approaches have been shown to reduce surgical site complications without compromising oncologic outcomes., Objective: The primary aim of this study is to evaluate the rates of successful oncologic resection and postoperative outcomes among laparoscopic, open, and robotic approaches to rectal cancer resection., Design: This is a multicenter, quasiexperimental cohort study using propensity score weighting., Settings: Interventions were performed in hospitals participating in the American College of Surgeons National Surgical Quality Improvement Program., Patients: Adult patients who underwent rectal cancer resection in 2016 were included., Main Outcome Measures: The primary outcome was a composite variable indicating successful oncologic resection, defined as negative distal and radial margins with at least 12 lymph nodes evaluated., Results: Among 1028 rectal cancer resections, 206 (20%) were approached laparoscopically, 192 (18.7%) were approached robotically, and 630 (61.3%) were open. After propensity score weighting, there were no significant sociodemographic or preoperative clinical differences among subcohorts. Compared to the laparoscopic approach, open and robotic approaches were associated with a decreased likelihood of successful oncologic resection (ORadj = 0.64; 95% CI, 0.43-0.94 and ORadj = 0.60; 95% CI, 0.37-0.97), and the open approach was associated with an increased likelihood of surgical site complications (ORadj = 2.53; 95% CI, 1.61-3.959). Compared to the laparoscopic approach, the open approach was associated with longer length of stay (6.8 vs 8.6 days, p = 0.002)., Limitations: This was an observational cohort study using a preexisting clinical data set. Despite adjusted propensity score methodology, unmeasured confounding may contribute to our findings., Conclusions: Resections that were approached laparoscopically were more likely to achieve oncologic success. Minimally invasive approaches did not lengthen operative times and provided benefits of reduced surgical site complications and decreased postoperative length of stay. Further studies are needed to clarify clinical outcomes and factors that influence the choice of approach. See Video Abstract at http://links.lww.com/DCR/B70. RESULTADOS ONCOLÓGICOS Y PERIOPERATORIOS DE LOS ABORDAJES LAPAROSCÓPICOS, ABIERTOS Y ROBÓTICOS PARA LA RESECCIÓN DEL CÁNCER RECTAL: UN ESTUDIO DE COHORTE MULTICÉNTRICO Y PONDERADO DEL PUNTAJE DE PROPENSIÓN: Se ha demostrado que los enfoques mínimamente invasivos reducen las complicaciones del sitio quirúrgico sin comprometer los resultados oncológicos.El objetivo principal de este estudio es evaluar las tasas de resección oncológica exitosa y los resultados postoperatorios entre los abordajes laparoscópico, abierto y robótico para la resección del cáncer rectal.Este es un estudio de cohorte cuasi-experimental multicéntrico que utiliza la ponderación de puntaje de propensión.Las intervenciones se realizaron en hospitales que participan en el Programa Nacional de Mejora de la Calidad Quirúrgica del Colegio Americano de Cirujanos.Se incluyeron pacientes adultos que se sometieron a resección de cáncer rectal en 2016.El resultado primario fue una variable compuesta que indicaba una resección oncológica exitosa, definida como márgenes negativos distales y radiales con al menos 12 ganglios linfáticos evaluados.Entre 1,028 resecciones de cáncer rectal, 206 (20%) fueron abordadas por vía laparoscópica, 192 (18.7%) robóticamente y 630 (61.3%) abiertas. Después de ponderar el puntaje de propensión, no hubo diferencias sociodemográficas o clínicas preoperatorias significativas entre las subcohortes. En comparación con el abordaje laparoscópico, los abordajes abiertos y robóticos se asociaron con una menor probabilidad de resección oncológica exitosa (ORadj = 0.64; IC 95%, 0.43-0.94 y ORadj = 0.60; IC 95%, 0.37-0.97), y el abordaje abierto se asoció con una mayor probabilidad de complicaciones del sitio quirúrgico (ORadj = 2.53; IC 95%, 1.61-3.959). En comparación con el abordaje laparoscópico, el abordaje abierto se asoció con una estadía más prolongada (6.8 frente a 8.6 días, p = 0.002).Este fue un estudio de cohorte observacional que utilizó un conjunto de datos clínicos preexistentes. A pesar de la metodología de puntuación de propensión ajustada, la confusión no medida puede contribuir a nuestros hallazgos.Las resecciones que se abordaron por vía laparoscópica tuvieron más probabilidades de lograr el éxito oncológico. Los enfoques mínimamente invasivos no alargaron los tiempos quirúrgicos y proporcionaron beneficios de la reducción de las complicaciones del sitio quirúrgico y la disminución de la duración de la estadía postoperatoria. Se necesitan más estudios para aclarar los resultados clínicos y los factores que influyen en la elección del enfoque. Vea video resumen en http://links.lww.com/DCR/B70.

Background: Sex-based treatment disparities occur in many diseases. Women undergo fewer procedural interventions, and their care is less consistent with guideline-based therapy. There is limited research exploring sex-based differences in ulcerative colitis treatment. We hypothesized that women are less likely to be treated with strategies consistent with long-term disease remission, including surgery and maintenance medications., Objective: The aim of this study was to determine if patient sex is associated with choice of treatment strategy for ulcerative colitis., Design: This is a retrospective cohort analysis., Setting: Data were gathered from a large commercial insurance claims database from 2007 to 2015., Patients: We identified a cohort of 38,851 patients newly diagnosed with ulcerative colitis, aged 12 to 64 years with at least 1 year of follow-up., Main Outcome Measures: The primary outcomes measured were the differences between male and female patients in 1) rates and types of index ulcerative colitis operations, 2) rates and types of ulcerative colitis medication prescriptions, and 3) rates of opioid prescriptions., Results: Men were more likely to undergo surgical treatment for ulcerative colitis (2.94% vs 1.97%, p < 0.001, OR 1.51, p < 0.001). The type of index operation performed did not vary by sex. Men were more likely to undergo treatment with maintenance medications, including biologic (12.4% vs 10.2%, p < 0.001, OR 1.22, p < 0.001), immunomodulatory (16.3% vs 14.9%, p < 0.001, OR 1.08, p = 0.006), and 5-aminosalicylate medications (67.0% vs 63.2%, p < 0.001, OR 1.18, p < 0.001). Women were more likely to undergo treatment with rescue therapies and symptomatic control with corticosteroids (55.5% vs 54.0%, p = 0.002, OR 1.07, p = 0.002) and opioids (50.2% vs 45.9%, p < 0.001, OR 1.17, p < 0.001)., Limitations: Claims data lack clinical characteristics acting as confounders., Conclusions: Men with ulcerative colitis were more likely to undergo treatment consistent with long-term remission or cure, including maintenance medications and definitive surgery. Women were more likely to undergo treatment consistent with short-term symptom management. Further studies to explore underlying mechanisms of sex-related differences in ulcerative colitis treatment strategies and disease trajectories are warranted. See Video Abstract at http://links.lww.com/DCR/A943.

Background: Without prophylactic surgery, patients with familial adenomatous polyposis are at high risk for colorectal cancer development. Various surgical options for prophylaxis are available. Patient decision-making for preventative treatments is often influenced by the preferences of healthcare providers., Objective: We determined surgeon preferences for the surgical options available to patients with familial adenomatous polyposis., Design: We obtained preference estimates for postoperative health states from colorectal surgeons who had treated ≥10 patients with familial adenomatous polyposis., Settings: Assessments were made at an annual meeting of the American Society of Colon and Rectal Surgeons., Main Outcome Measures: Utilities were measured through the time trade-off method. We determined utilities for 3 procedures used for prophylaxis, including total proctocolectomy with permanent ileostomy, colectomy with ileorectal anastomosis, and total proctocolectomy with IPAA. We also assessed utilities for 2 short-term health states: 90 days with a temporary ileostomy and 2 years with a poorly functioning ileoanal pouch., Results: Twenty-seven surgeons who had cared for >1700 patients with familial adenomatous polyposis participated in this study. The highest utility scores were provided for colectomy with ileorectal anastomosis (0.98). Lower utility scores were provided for total proctocolectomy with permanent ileostomy (0.87) and IPAA (0.89). The number of patients with familial adenomatous polyposis who were treated by participating surgeons did not influence these estimates; however, more-experienced surgeons gave lower utility scores for a poorly functioning ileoanal pouch than less-experienced surgeons (0.15, 0.50, and 0.25 for high-, medium-, and low-volume surgeons; p = 0.02)., Limitations: This study was limited by the sample size., Conclusions: For patients with familial adenomatous polyposis and relative rectal sparing, surgeon preferences are greatest for colectomy with ileorectal anastomosis. Utility estimates provided by this study are important for understanding surgical decision-making and suggest a role for ileorectal anastomosis in appropriately selected patients. See Video Abstract at http://links.lww.com/DCR/A656.

Background: Multidisciplinary care is critical for the successful treatment of stage III colorectal cancer, yet receipt of adjuvant chemotherapy remains unacceptably low. Peer support, or exposure to others treated for colorectal cancer, has been proposed as a means to improve patient acceptance of cancer care., Objective: The purpose of our study was to evaluate the effect of peer support on the attitudes of patients with colorectal cancer toward chemotherapy and their adherence to it., Design: We conducted a population-based survey of patients with sage III colorectal cancer and compared demographics and adjuvant chemotherapy adherence after patient-reported exposure to peer support., Settings: Patients were identified by using Surveillance, Epidemiology, and End Results Program cancer registries and were recruited 3 to 12 months after cancer resection., Patients: All patients with stage III colorectal cancer who underwent colorectal resection between 2011 and 2013 and were located in the Detroit and Georgia regions were included., Main Outcome Measures: The main outcome measure was adjuvant chemotherapy adherence. Exposure to peer support was an intermediate outcome., Results: Among 1301 patient respondents (68% response rate), 48% reported exposure to peer support. Exposure to peer support was associated with younger age, higher income, and having a spouse or domestic partner. Exposure to peer support was significantly associated with receipt of adjuvant chemotherapy (OR, 2.94; 95% CI, 1.89-4.55). Those exposed to peer support reported positive effects on attitudes toward chemotherapy., Limitations: This study has limitations inherent to survey research including the potential lack of generalizability and responses that are subject to recall bias. Additionally, the survey results do not allow for determination of the temporal relationship between peer support exposure and receipt of chemotherapy., Conclusion: Our study demonstrates that exposure to peer support is associated with higher adjuvant chemotherapy adherence. These data suggest that facilitated peer support programs could positively influence patient expectations and coping with diagnosis and treatment, thereby affecting the uptake of postoperative chemotherapy. See Video Abstract at http://links.lww.com/DCR/A587.

Background: There is excellent evidence that surgical safety checklists contribute to decreased morbidity and mortality., Objective: The purpose of this study was to develop a surgical checklist composed of the key phases of care for patients with rectal cancer., Design: A consensus-oriented decision-making model involving iterative input from subject matter experts under the auspices of The American Society of Colon and Rectal Surgeons was designed., Settings: The study was conducted through meetings and discussion to consensus., Patients: Patient data were extracted from an initial literature review., Main Outcome Measures: The checklist was measured by its ability to improve care in complex rectal surgery cases by reducing the possibility of omission through the division of treatment into 3 distinct phases., Results: The process generated a 25-item checklist covering the spectrum of care for patients with rectal cancer who were undergoing surgery., Limitations: The study was limited by its lack of prospective validation., Conclusions: The American Society of Colon and Rectal Surgeons rectal cancer surgery checklist is composed of the essential elements of preoperative, intraoperative, and postoperative care that must be addressed during the surgical treatment of patients with rectal cancer.

Background: Ostomy surgery is common and has traditionally been associated with high rates of morbidity and mortality, suggesting an important target for quality improvement., Objective: The purpose of this work was to evaluate the variation in outcomes after ostomy creation surgery within Michigan to identify targets for quality improvement., Design: This was a retrospective cohort study., Settings: The study took place within the 34-hospital Michigan Surgical Quality Collaborative., Patients: Patients included were those undergoing ostomy creation surgery between 2006 and 2011., Main Outcome Measures: We evaluated hospital morbidity and mortality rates after risk adjustment (age, comorbidities, emergency vs elective, and procedure type)., Results: A total of 4250 patients underwent ostomy creation surgery; 3866 procedures (91.0%) were open and 384 (9.0%) were laparoscopic. Unadjusted morbidity and mortality rates were 43.9% and 10.7%. Unadjusted morbidity rates for specific procedures ranged from 32.7% for ostomy-creation-only procedures to 47.8% for Hartmann procedures. Risk-adjusted morbidity rates varied significantly between hospitals, ranging from 31.2% (95% CI, 18.4-43.9) to 60.8% (95% CI, 48.9-72.6). There were 5 statistically significant high-outlier hospitals and 3 statistically significant low-outlier hospitals for risk-adjusted morbidity. The pattern of complication types was similar between high- and low-outlier hospitals. Case volume, operative duration, and use of laparoscopic surgery did not explain the variation in morbidity rates across hospitals., Limitations: This work was limited by its retrospective study design, by unmeasured variation in case severity, and by our inability to differentiate between colostomies and ileostomies because of the use of Current Procedural Terminology codes., Conclusions: Morbidity and mortality rates for modern ostomy surgery are high. Although this type of surgery has received little attention in healthcare policy, these data reveal that it is both common and uncommonly morbid. Variation in hospital performance provides an opportunity to identify quality improvement practices that could be disseminated among hospitals.

Background: Process and outcome measures for quality assessment of colorectal surgical care are poorly defined., Objective: The aim of this study was to develop candidate end points for use in surgeon-specific registries designed for case reporting and quality improvement program development., Design: The study design was based on modified Delphi-based development of consensus quality end points., Setting: This study was undertaken by the American Society of Colon and Rectal Surgeons Executive Council, Quality Committee, and by the ColoRectal Education System Template Committee, American Board of Colon and Rectal Surgery., Patients: No patients were included in this study., Interventions: Six areas of colorectal surgery were defined by members of the American Society of Colon and Rectal Surgeons' Executive Council and the American Board of Colon and Rectal Surgery to cover areas of importance for colorectal surgeons. These included colectomy, rectal cancer, hemorrhoidectomy, anal fistula and abscess, colonoscopy, and rectal prolapse. Relevant American Society of Colon and Rectal Surgeons' committee members through a series of 4 panel discussions identified important demographic, process, and outcome measures in each of these 6 areas that might be suitable for the American College of Surgeons case log. Panel size was sequentially expanded from 8 members to 28 members to include all active committee members. Panelists contributed additional process and outcome measures for inclusion during each discussion. Modified Delphi methodology was used to generate consensus, and, after each panel discussion, members rated the relative importance of each end point from 1 (least important) to 4 (most important)., Main Outcome Measures: The mean rating for each process and outcome measure after each round was recorded with the use of standardized definitions for relevant variables., Results: Eighty-nine process and outcome measures were compiled and rated. Mean scores following the final round ranged from a low of 1.3 (anal fistula/abscess, preoperative imaging) to a high of 4.0 (colectomy-anastomotic leak)., Limitations: The limitations of this study involved the use of consensus, small study size, and the fact that no end points were excluded., Conclusions: With the use of modified Delphi methodology, a consensus-derived ranked list of 89 process and outcome measures was developed in 6 key areas of colorectal surgery. These data provide a framework for development of guideline standards for case-reporting program development initiatives for colon and rectal surgery.

Background: Physician values regarding the benefit of continued medical therapy vs colectomy for moderate ulcerative colitis have not been defined. If physicians perceive these states differently than patients, their therapeutic recommendations may not align with patient values., Objective: This study aimed to compare physician and patient willingness to trade life years with moderately active ulcerative colitis vs undergoing colectomy., Design: This survey of physicians' and patients' utility values used standardized scenarios for moderately active ulcerative colitis and colectomy., Setting: The investigation was conducted at a tertiary academic medical center., Methods: Gastroenterologists, colorectal surgeons, and patients with ulcerative colitis who were either living with moderate disease or were postcolectomy completed the survey., Main Outcome Measures: Utility values were measured by the use of the time trade-off method., Results: We surveyed 17 physicians, 150 postcolectomy patients, and 69 patients with moderate ulcerative colitis. Utility values for ulcerative colitis and colectomy states were (0.87, 0.95), (0.86, 0.92), and (0.91, 0.91). On average, physicians and postcolectomy patients assessed the utility of life with ulcerative colitis more poorly than the postcolectomy state. Patients with moderately active ulcerative colitis who had not undergone colectomy viewed both health states equally., Limitations: This study was limited by the physician subject sample size., Conclusions: Patients living with moderate ulcerative colitis value the pre- and postcolectomy states differently than physicians and postcolectomy patients. Recognizing the differences between their own and patients' values may help physicians to better counsel patients preoperatively. In addition, exposure to postcolectomy patients may help those with moderate disease who are weighing the comparative benefits of colectomy.

Background: Early discharge after colectomy has been shown to be feasible in studies from specialty centers, but we hypothesized that benefits of early discharge might be offset by higher risk of readmission in the surgical community as a whole. Minimizing readmissions is a national health policy priority., Objective: This study aimed to determine whether hospitals discharging patients early had increased readmission rates., Design: Patients undergoing colectomy surgery for cancer were studied using national Medicare data (MEDPAR database). Multiple logistic regression was performed to determine whether hospitals with a pattern of early discharge (median length of stay ≤ 5 d after surgery) had increased readmission rates. Results were adjusted for patient comorbidity, emergency operation, laparoscopic surgery, demographic factors, and complications. A separate analysis at the patient level was conducted to determine risk factors for readmission., Settings: Early discharge rates at US acute care hospitals were investigated., Patients: Patients 65 and older undergoing colectomy surgery for cancer (2003-2008, n = 477,461) were included., Main Outcome Measure: The main outcome measure was 30-day, all hospital readmission rates., Results: Hospitals with a pattern of early discharge (median length of stay ≤ 5 d) were not found to have a higher risk-adjusted readmission rate than hospitals with the usual median length of stay (16.3% vs 15.7%, P = .077). However, changing the cutoff for "early discharge" to ≤ 4 days revealed an increased risk for readmission among "very early discharge" hospitals (risk-adjusted readmission rate 21.3% vs 15.7%, P < .001). At the patient level, independent risk factors for readmission included older age, male sex, black race, lower socioeconomic status, urgent/emergent surgery, comorbidities, complications, open (vs laparoscopic) surgery, and longer length of stay for the index hospitalization., Limitations: Limitations of this study included the limitations of the administrative data and elderly population., Conclusions: Hospitals with a pattern of early discharge (median length of stay ≤ 5 d after surgery) do not have a higher risk-adjusted readmission rate than other hospitals. These results support the safety of early discharge programs in the Medicare population.

Background: Mechanical bowel preparation before colectomy is controversial for several reasons, including a theoretically increased risk of Clostridium difficile infection., Objective: The primary aim of this study was to compare the incidence of C difficile infection among patients who underwent mechanical bowel preparation and those who did not. A secondary objective was to assess the association between C difficile infection and the use of oral antibiotics., Design: This was an observational cohort study., Setting: The Michigan Surgical Quality Collaborative Colectomy Project (n = 24 hospitals) participates in the American College of Surgeons-National Surgical Quality Improvement Program with additional targeted data specific to patients undergoing colectomies., Patients: Included were adult patients (21 years and older) admitted to participating hospitals for elective colectomy between August 2007 and June 2009., Main Outcome Measure: The main outcome measure was laboratory detection of a positive C difficile toxin assay or stool culture., Results: Two thousand two hundred sixty-three patients underwent colectomy and fulfilled inclusion criteria. Fifty-four patients developed a C difficile infection, for a hospital median rate of 2.8% (range, 0-14.7%). Use of mechanical bowel preparation was not associated with an increased incidence of C difficile infection (P = .95). Among 1685 patients that received mechanical bowel preparation, 684 (41%) received oral antibiotics. The proportion of patients in whom C difficile infection was diagnosed after the use of preoperative oral antibiotics was smaller than the proportion of patients with C difficile infection who did not receive oral antibiotics (1.6% vs 2.9%, P = .09)., Limitations: The potential exists for underestimation of C difficile infection because of the study's strict data collection criteria and risk of undetected infection after postoperative day 30., Conclusions: In contrast to previous single-center data, this multicenter study showed that the preoperative use of mechanical bowel preparation was not associated with increased risk of C difficile infection after colectomy. Moreover, the addition of oral antibiotics with mechanical bowel preparation did not confer any additional risk of infection.

Purpose: Appropriate use of adjuvant chemotherapy is a widely recognized quality measure of colorectal cancer care. The objective of this study was to test the hypothesis that surgical complications are associated with omission of chemotherapy for colorectal cancer., Methods: We used the 1998 to 2005 Surveillance, Epidemiology and End Results-Medicare database to study adjuvant chemotherapy use among patients with stage III colorectal cancer who underwent surgical resection. Chemotherapy use was compared between patients with and without complications. Univariate analyses and multiple logistic regression were used to test the association between complications and chemotherapy omission, while adjusting for demographics, comorbidity, and other factors. Associations between complications and time to chemotherapy were also studied., Results: We identified 17,108 eligible patients with stage III colorectal cancer (median age, 75 y; 24% rectal/rectosigmoid). Using a parsimonious list of complication codes, 18% of patients had ≥ 1 complication. Thirteen percent of patients had medical complications and 3.8% of patients had complications requiring reoperation or another procedure. Adjuvant chemotherapy was omitted among 46% of patients with complications, compared with 31% of patients with no complications (P < .0001). Having a complication was independently associated with omission of chemotherapy in multivariable analysis (adjusted OR, 1.76; 95% CI 1.59-1.95). Other factors significantly associated with chemotherapy omission were age, race, marital status, urgent/emergent admission, and type of operation. Risk ratios increase with multiple complications (P < .0001). Complications were also associated with an increased risk of chemotherapy delay (P < .0001)., Conclusions: Surgical complications are independently associated with omission of chemotherapy for stage III colorectal cancer and with a delay in adjuvant chemotherapy. These data suggest that complications of colorectal surgery may affect both short- and long-term cancer outcomes. Thus, the implementation of quality improvement measures that effectively reduce perioperative complications may also provide a long-term cancer survival benefit.

We report a patient who presented with rectal rupture and transanal evisceration, a rare entity with only 52 cases previously described in the world literature. Our case is the first to implicate sheer stress on the anterior rectum caused by postoperative adhesions as the major etiologic contributing feature. Moreover, this case is the third reported with chronic constipation without rectal prolapse as an additional preexisting contributory condition. A summary of the medical literature including etiology, treatment, and outcomes is presented.