Megan C. Turner

Insurance Status, Not Race, is Associated With Use of Minimally Invasive Surgical Approach for Rectal Cancer.

Objective: To determine the impact of race and insurance on use of minimally invasive (MIS) compared with open techniques for rectal cancer in the United States. Background: Race and socioeconomic status have been implicated in disparities of rectal cancer treatment. Methods: Adults undergoing MIS (laparoscopic or robotic) or open rectal resections for stage I to III rectal adenocarcinoma were included from the National Cancer Database (2010–2012). Multivariate analyses were employed to examine the adjusted association of race and insurance with use of MIS versus open surgery. Results: Among 23,274 patients, 39% underwent MIS and 61% open surgery. Overall, 86% were white, 8% black, and 3% Asian. Factors associated with use of open versus MIS were black race, Medicare/Medicaid insurance, and lack of insurance. However, after adjustment for patient demographic, clinical, and treatment characteristics, black race was not associated with use of MIS versus open surgery [odds ratio [OR] 0.90, P = 0.07). Compared with privately insured patients, uninsured patients (OR 0.52, P < 0.01) and those with Medicare/Medicaid (OR 0.79, P < 0.01) were less likely to receive minimally invasive resections. Lack of insurance was significantly associated with less use of MIS in black (OR 0.59, P = 0.02) or white patients (OR 0.51, P < 0.01). However, among uninsured patients, black race was not associated with lower use of MIS (OR 0.96, P = 0.59). Conclusions: Insurance status, not race, is associated with utilization of minimally invasive techniques for oncologic rectal resections. Due to the short-term benefits and cost-effectiveness of minimally invasive techniques, hospitals may need to improve access to these techniques, especially for uninsured patients.

Can binimetinib, encorafenib and masitinib be more efficacious than currently available mutation-based targeted therapies for melanoma treatment?

ABSTRACT Introduction: Historically, there were few effective and durable treatments for metastatic melanoma. Recently, mutation based targeted therapies have revolutionized treatment and outcomes for patients with metastatic melanoma. Specifically, inhibitors aimed at BRAF, NRAS, and C-KIT mutations are now commonly used in treatment for patients harboring the specific mutations. Areas covered: A brief review of current BRAF, NRAS, and C-KIT inhibitors provides background for a thorough review of newly developed agents namely binimetinib, a MEK inhibitor, encorafenib a BRAF inhibitor, and masitinib which inhibits C-KIT. Expert opinion: While the 3 novel agents reviewed here have potential for use in melanoma, optimal utilization will occur once a more personalized approach incorporating genomic, proteomic, and immunologic data guides therapeutic decisions.

Association Between Neoadjuvant Chemoradiation and Survival for Patients With Locally Advanced Rectal Cancer

To examine the overall survival differences for the following neoadjuvant therapy modalities – no therapy, chemotherapy alone, radiation alone and chemoradiation – in a large cohort of patients with locally advanced rectal cancer.

Practice Guidelines and Future Directions of Bowel Preparation: Science and History

Preoperative bowel preparation has been a principle of colorectal surgery as a mechanism to prevent postoperative complications. The use of combined enteral antibiotics, mechanical preparation, and parenteral antibiotic prophylaxis has been trialed in various methods over the years. Combination of all three therapies leads to improved postoperative outcomes compared to streamlined preparations in elective colorectal surgery. Advances in the understanding of the human microbiome have prompted interest in the impact of bacterial communities on tissue healing and human immune response. Further directions of study include optimization of antibiotic timing and comprehensive characterization of colonic bacterial communities. The current practices of preoperative bowel preparation vary considerably, and surgeon adherence to best practice guidelines remains challenging.

SS21. Foam Sclerotherapy for Low-Flow Vascular Malformations Is Safe and Effective in Children

woman who previously had an IVC filter placement followed by a resection of a benign leiomyoma as well as a right salpingo-oophorectomy in 2015. A follow-up computed tomography scan showed propagation of IVC thrombus. The thrombus was suspected to be an intracaval extension of tumor and, therefore, she was taken for an exploration of the IVC from confluence to juxtahepatic cava, a complex retrieval of the IVC filter, and a resection of intracaval mass by a venotomy of the common iliac vein and juxtahepatic cava.

IF09. Image-Based Three-Dimensional Fusion Computed Tomography Decreases Radiation Exposure, Fluoroscopy Time, and Procedure Time During Endovascular Aortic Aneurysm Repair

had widely patent SMAs at last follow-up. Mean total seal zone length was 41.4 mm. There was a single secondary intervention for asymptomatic SMA stenosis requiring stent placement 1 year after F-EVAR. There were no Type IA endoleaks and no endoleaks related to SMA fenestrations. Five patients of the entire cohort (4.7%) required SMA stenting at the index procedure. Three of these patients had prior EVAR (n 1⁄42) or open repair (n 1⁄4 1), One patient had a pre-existing critical SMA stenosis and underwent planned SMA stenting, and in one patient, the graft was deployed imprecisely and low, and the SMA was successfully stented from a brachial approach. Conclusions: The unstented SMA in association with F-EVAR remains widely patent in the presence of fenestrations or struts and is not associated with endoleaks. The need for adjunctive SMA stenting may be related to prior aortic intervention and case complexity. Follow-up DUS and CTA surveillance confirms that SMA patency remains in the normal or <70% stenosis range after F-EVAR regardless of whether it is encompassed by a large fenestration or crossing struts.

Jejunal arterial access for retrograde mesenteric stenting

&NA; Endovascular approaches have replaced open surgical revascularization in most patients with mesenteric ischemia; however, flush ostial occlusions may not be amenable to traditional antegrade access. Retrograde mesenteric stenting has been previously described, but this technique requires a formal laparotomy and dissection of the proximal superior mesenteric artery. We present here a modification of this technique that requires only a “mini‐laparotomy” and no open vascular repair of the superior mesenteric artery as well as a review of our initial institutional experience with this procedure. Our approach differs from previously described work by minimizing mesenteric dissection, avoiding the need for repair of an arteriotomy, and limiting the size of the laparotomy incision in this population of profoundly comorbid patients.

Reply to Hasty Conclusions

Thank you for furthering the discussion on appropriateness of preoperative bowel preparation for elective colorectal surgery. The manuscript describes several important concepts in the evolution of preoperative preparation including oral antibiotics (OA), mechanical bowel preparation (MBP), and intravenous antibiotics (IVA). The authors address the change in preparation of formulas over time, comment on the use of National Surgical Quality Improvement Program (NSQIP) to generate guidelines, and cite recent meta-analyses. This article is protected by copyright. All rights reserved.

The appropriateness of 30-day mortality as a quality metric in colorectal cancer surgery

BACKGROUND Our study compares 30-day vs. 90-day mortality following colorectal cancer surgery (CRS), and examines hospital performance ranking based on this assessment. METHODS Mortality rates were compared between 30 vs. 90 days following CRS for patients with stage I-III colorectal cancers from the National Cancer Database (2004-2012). Risk-adjusted hierarchical regression models evaluated hospital performance based on mortality. Hospitals were ranked into top (10%), middle (80%), and lowest (10%) performance groups. RESULTS Among 185,464 patients, 90-day mortality was nearly double the 30-day mortality (4.4% vs. 2.5%). Following risk adjustment 176 hospitals changed performance ranking: 39% in the top 30-day mortality group changed ranking to the middle group; 37% of hospitals in the lowest 30-day group changed ranking to the middle 90-day group. CONCLUSIONS Evaluation of hospital performance based on 30-day mortality is associated with misclassification for 15% of hospitals. Ninety-day mortality may be a better quality metric in oncologic CRS.

Development of Multiple Visceral Artery Pseudoaneurysms Following Pancreatic Injury from Penetrating Trauma

Visceral artery pseudoaneurysm is a rare, life-threatening pathology, which can lead to life threatening intrabdominal hemorrhage if left untreated. Diagnosis is often difficult due to vague symptomology. Herein, we present a case of a patient presenting with multiple delayed visceral arterial pseudoaneurysms due to a pancreatic leak following an exploratory laparotomy for several abdominal gunshot wounds. Open intervention was considered prohibitively high risk, given the patient’s hostile abdomen and loss of normal tissue planes secondary to inflammation. Due to the complexity of the anatomy involved in these pseudoaneurysms, this was managed successfully with a combination of coil embolization and stent-graft placement.