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Background There is increasing demand for colorectal robotic training for general surgery residents. We implemented a robotic colorectal surgery curriculum expecting that it would increase resident exposure to the robotic platform and would increase the number of graduating general surgery residents obtaining a robotic equivalency certificate. Methods Our curriculum started in 2019 and consists of didactics, simulation, and clinical performance. Objectives are specified for both junior residents (post-graduate years [PGY]1-2) and senior residents (PGY3-5). The robotic colorectal surgical experience was characterized by comparing robotic to non-robotic operations, differences in robotic operations across post-graduate year, and percentage of graduates achieving an equivalency certificate. Robotic operations are tracked using case log annotation. Results From 2017-2021, 25 residents logged 681 major operations on the colorectal service (PGY1 mean = 7.6 ± 4.6, PGY4 mean = 29.7 ± 14.4, PGY5 mean = 29.8 ± 14.8). Robotic colorectal operations made up 24% of PGY1 (49% laparoscopic, 27% open), 35% of PGY4 (35% laparoscopic, 29% open) and 41% of PGY5 (44% laparoscopic, 15% open) major colorectal operations. Robotic bedside experience is primarily during PGY1 (PGY1 mean 2.0 ± 2.0 bedside operations vs 1.4 ± 1.6 and 0.2 ± 0.4 for PGY4 and 5, respectively). Most PGY4 and 5 robotic experience is on the console (PGY4 mean 9.1 ± 7.7 console operations, PGY5 mean 12.0 ± 4.8 console operations). Rates of robotic certification for graduating chief residents increased from 0% for E-2013 to 100% for E-2018. Conclusions Our study was limited by being retrospective and its limited ability to compare robotic experience between resident cohorts. Regardless, our robotic colorectal curriculum for general surgery residents has facilitated earlier and increased robotic experience for residents and increased robotic certification for our graduates.

Treatment for inflammatory bowel disease (IBD) often requires specialized care. While much of IBD care has shifted to the outpatient setting, hospitalizations remain a major site of healthcare utilization and a sizable proportion of patients with inflammatory bowel disease require hospitalization or surgery during their lifetime. In this review, we approach IBD care from the population-level with a specific focus on hospitalization for IBD, including the shifts from inpatient to outpatient care, the balance of emergency and elective hospitalizations, regionalization of specialty IBD care, and contribution of surgery and endoscopy to hospitalized care.

Background Rectal prolapse, with or without concurrent vaginal prolapse, is a debilitating condition. Despite debate regarding the optimal surgical approach, operative repair remains the mainstay of treatment. Our objective was to describe trends of rectal prolapse repair in Washington State. Methods A retrospective cohort of patients undergoing rectal prolapse repair was created from the Washington State Comprehensive Hospital Abstract Reporting System. Age- and sex-adjusted rates of rectal prolapse repair (RPR) alone and concurrent rectal and vaginal prolapse repair (CRVR), trends over time, and factors associated with variation in rates are described. Results There were 2755 hospitalizations in which patients underwent RPR, with 33.3% undergoing CRVR. Seventy-five percent of all repairs were in patients older than 50. Rates for rectal prolapse repair went from 3.72/100,000 people in 2008 to 3.25/100,000 people in 2019 (p = 0.003) and did not increase in patients ages 65–79 (p = 0.09) or older than 80 (p = 0.945). Perineal repairs accounted for 31% of repairs and declined after 2014. Minimally-invasive abdominal repairs doubled from 32.5% in 2008 to 65.4% in 2019 (p

Thin films of a chlorophyll-like compound methyl-pheophorbide a (Pheo) were prepared from a solution by both spin-coating and drop-casting methods. Despite the fundamental similarity of these two techniques, different self-assembly conditions of Pheo molecules determined the difference in the films morphology. Smoother films without detectable crystallinity were obtained by the spin-coating method, while the drop-cast films featured ordering of molecules and formation of clusters with a size of ~ 1 µm and more. As a result, the films have different photoelectrical properties and, hence, the conditions governing the aggregate growth should be controlled precisely. The Pheo films in any form are good photoconductors: photons from the red and near-infrared domain are the main contributors in the photoinduced current.

Operating on obese patients can increase case complexity and result in worse outcomes. We described the incremental impact of BMI on morbidity and outcomes of colorectal operations and whether laparoscopic and robotic(MIS) approaches mitigate this morbidity differently.A retrospective cohort of patients undergoing elective colorectal operations in SCOAP was created to examine the association of increasing BMI on surgical outcomes. Additionally, multivariable logistic regression models were constructed.From 2011 to 2019, 22,863 elective colorectal operations (mean age 62, 55% female) were performed at 42 hospitals. Patients had BMI≥30 in 7576(33%) and BMI≥40 in 1180(5%) of operations. After risk adjustment, BMI≥40 was associated with increased conversions(OR1.57,95%CI1.26-1.96), increased combined adverse events(CAE)(OR1.32,95%CI1.15-1.52), and death(OR2.24, 95%CI1.41-3.55)(all p 0.01). MIS approaches were each associated with lower CAE(lap OR0.49,95%CI0.46-0.53; robot OR0.42,95%CI0.37-0.47), and death(lap OR0.24,95%CI0.18-0.33; robot OR0.18,95%CI0.10-0.35)(all p 0.01).Severe obesity is associated with increased conversion rates and worse short-term outcomes after colorectal surgery, though this trend is partially mitigated with a minimally invasive approach. These findings support the broad application of MIS for colorectal operations in obese patients.

PURPOSE Organ-sparing therapy for early-stage I/IIA rectal cancer is intended to avoid functional disturbances or a permanent ostomy associated with total mesorectal excision (TME). The objective of this phase II trial was to determine the outcomes and organ-sparing rate of patients with early-stage rectal cancer treated with neoadjuvant chemotherapy followed by transanal excision surgery (TES). METHODS This phase II trial included patients with clinical T1-T3abN0 low- or mid-rectal adenocarcinoma eligible for endoscopic resection who were treated with 3 months of chemotherapy (modified folinic acid–fluorouracil-oxaliplatin 6 or capecitabine-oxaliplatin). Those with evidence of response proceeded to transanal endoscopic surgery 2-6 weeks later. The primary end point was protocol-specified organ preservation rate, defined as the proportion of patients with tumor downstaging to ypT0/T1N0/X and who avoided radical surgery. RESULTS Of 58 patients enrolled, all commenced chemotherapy and 56 proceeded to surgery. A total of 33/58 patients had tumor downstaging to ypT0/1N0/X on the surgery specimen, resulting in an intention-to-treat protocol-specified organ preservation rate of 57% (90% CI, 45 to 68). Of 23 remaining patients recommended for TME surgery on the basis of protocol requirements, 13 declined and elected to proceed directly to observation resulting in 79% (90% CI, 69 to 88) achieving organ preservation. The remaining 10/23 patients proceeded to recommended TME of whom seven had no histopathologic residual disease. The 1-year and 2-year locoregional relapse-free survival was, respectively, 98% (95% CI, 86 to 100) and 90% (95% CI, 58 to 98), and there were no distant recurrences or deaths. Minimal change in quality of life and rectal function scores was observed. CONCLUSION Three months of induction chemotherapy may successfully downstage a significant proportion of patients with early-stage rectal cancer, allowing well-tolerated organ-preserving surgery.

A 68-year-old man presented with septic shock and severe perineal pain from a perforated low-rectal cancer causing a perineal necrotizing soft tissue infection. He underwent laparoscopic diverting colostomy and multiple surgical debridements resulting in extensive perineal and left leg wounds. A multidisciplinary rectal cancer team recommended against neoadjuvant chemoradiation or chemotherapy in his current state. He underwent up-front, urgent robotic-assisted abdominoperineal resection with immediate oblique rectus abdominus muscle flap closure. Final pathology demonstrated a T4N1b adenocarcinoma with negative resection margins. The patient subsequently underwent adjuvant chemotherapy. Now at over 18 months, he remains cancer free.

Background The coronavirus disease 2019 pandemic restricted movement of individuals and altered provision of health care, abruptly transforming health care-use behaviors. It serves as a natural experiment to explore changes in presentations for surgical diseases including acute appendicitis. The objective was to determine if the pandemic was associated with changes in incidence of acute appendicitis compared to a historical control and to determine if there were associated changes in disease severity. Methods The study is a retrospective, multicenter cohort study of adults (N = 956) presenting with appendicitis in nonpandemic versus pandemic time periods (December 1, 2019–March 10, 2020 versus March 11, 2020–May 16, 2020). Corresponding time periods in 2018 and 2019 composed the historical control. Primary outcome was mean biweekly counts of all appendicitis presentations, then stratified by complicated (n = 209) and uncomplicated (n = 747) disease. Trends in presentations were compared using difference-in-differences methodology. Changes in odds of presenting with complicated disease were assessed via clustered multivariable logistic regression. Results There was a 29% decrease in mean biweekly appendicitis presentations from 5.4 to 3.8 (rate ratio = 0.71 [0.51, 0.98]) after the pandemic declaration, with a significant difference in differences compared with historical control (P = .003). Stratified by severity, the decrease was significant for uncomplicated appendicitis (rate ratio = 0.65 [95% confidence interval 0.47–0.91]) when compared with historical control (P = .03) but not for complicated appendicitis (rate ratio = 0.89 [95% confidence interval 0.52–1.52]); (P = .49). The odds of presenting with complicated disease did not change (adjusted odds ratio 1.36 [95% confidence interval 0.83–2.25]). Conclusion The pandemic was associated with decreased incidence of uncomplicated appendicitis without an accompanying increase in complicated disease. Changes in individual health care–use behaviors may underlie these differences, suggesting that some cases of uncomplicated appendicitis may resolve without progression to complicated disease.

Background The incidence of diverticulitis in the United States is increasing, and hospitalization remains a surrogate for disease severity. State-level characterization of diverticulitis hospitalization is necessary to better understand the distribution of disease burden and target interventions. Methods A retrospective cohort of diverticulitis hospitalizations from 2008 through 2019 was created using Washington State’s Comprehensive Hospital Abstract Reporting System. Hospitalizations were stratified by acuity, presence of complicated diverticulitis, and surgical intervention using ICD diagnosis and procedure codes. Patterns of regionalization were characterized by hospital case burden and distance travelled by patients. Results During the study period, 56,508 diverticulitis hospitalizations occurred across 100 hospitals. Most hospitalizations were emergent (77.2%). Of these, 17.5% were for complicated diverticulitis, and 6.6% required surgery. No single hospital received more than 5% (n = 235) of average annual hospitalizations. Surgeons operated in 26.5% of total hospitalizations (13.9% of emergent hospitalizations, and 69.2% of elective hospitalizations). Operations for complicated disease made up 40% of emergent surgery and 28.7% of elective surgery. Most patients traveled fewer than 20 miles for hospitalization, regardless of acuity (84% for emergent hospitalization and 77.5% for elective hospitalization). Discussion Hospitalizations for diverticulitis are primarily emergent, nonoperative, and broadly distributed across Washington State. Hospitalization and surgery occur close to patients’ homes, regardless of acuity. This decentralization needs to be considered if improvement initiatives and research in diverticulitis are to have meaningful, population-level impact .