Nelya Melnitchouk

Impact of Procedural Specialty on Maternity Leave and Career Satisfaction Among Female Physicians

Objective: The aim of this study was to perform a large-scale, national survey of physician mothers to define the personal, professional, and financial impact of maternity leave and its relationship to career satisfaction for female physicians in procedural and nonprocedural fields. Summary of Background Data: Little is known about the impact of maternity leave on early career female physicians or how childbearing affects career satisfaction. Methods: A nationwide sample of physician mothers completed a 45-question anonymous, secure, online questionnaire regarding the impact of pregnancy and childbearing. Results: One thousand five hundred forty-one respondents were attending physicians during their most recent pregnancy and 393 (25.5%) practiced in a procedural field. Overall, 609 (52.9%) reported losing over

Transanal anorectal stricturoplasty using the Heineke–Mikulicz principle: a novel technique

10,000 in income during leave with no significant difference between procedural and nonprocedural fields. Maternity leave was included in only 28.9% of female physicians’ most recent contracts. Proceduralists were more likely to report negative impact on referrals by maternity leave [odds ratio (OR) 1.78, 95% confidence interval (95% CI) 1.28–2.47, P = 0.001], a requirement to complete missed shifts (OR 3.04, 95% CI 2.12–4.36, P < 0.001), and owing money to their practice (OR 2.71, 95% CI 1.34–5.50, P = 0.006). Proceduralists were also significantly more likely to report desire to have chosen a less demanding specialty (OR 2.33, 95% CI 1.80–3.02, P < 0.001). Conclusions: Female physicians lose significant income during maternity leave and report high rates of career dissatisfaction, particularly those in procedural specialties. Given these findings, improved family leave policies may help improve career satisfaction for female physicians.

National Surgical Quality Improvement Program analysis of unplanned reoperation in patients undergoing low anterior resection or abdominoperineal resection for rectal cancer

Current surgical options for the treatment of rectal stricture are either technically difficult or result in a high rate of recurrence. We describe the results of a simple and potentially effective technique of transanal stricturoplasty using the Heineke–Mikulicz principle.

Colorectal Cancer in Ukraine: Regional Disparities and National Trends in Incidence, Management, and Mortality

Background: The rate of unplanned reoperation for rectal cancer can provide information about surgical quality. We sought to determine factors associated with unplanned reoperation after low anterior resection and abdominoperineal resection for patients with rectal cancer and outcomes after these reoperations. Methods: The American College of Surgeons National Surgical Quality Improvement Program database was used to conduct this retrospective study. Patients who underwent elective low anterior resection and abdominoperineal resection for rectal cancer from 2012–2014 were identified. The primary outcomes were 30‐day reoperation rates and postoperative complications. Results: A total of 454 low anterior resection patients (5.9%) and 289 abdominoperineal resection patients (8.1%) required reoperation within 30 days of their index operation. The most common reasons for reoperation were infection, bleeding, and bowel obstruction. Multivariate analysis revealed that male sex (odds ratio: 1.5, P = .001), poor functional status (odds ratio: 2.2, P = .04), operative time (odds ratio: 1.001, P = .01), low preoperative albumin (odds ratio: 0.79, P = .04), and lack of ostomy (odds ratio, 0.66, P = .005) were independent risk factors for reoperation after low anterior resection. Smoking (odds ratio: 1.7, P = .001), chronic obstructive pulmonary disease (odds ratio: 1.8, P = .03), poor functional status (odds ratio: 2.1, P = .032), operative time (odds ratio: 1.003, P < .001), low preoperative albumin (odds ratio: 0.69, P = .007), and open approach (odds ratio: 1.5, P = .02) were independent risk factors for reoperation after abdominoperineal resection. Postoperative complication rates are high for those undergoing reoperation, often leading to non‐home discharge (P < .001) after reoperation. Conclusion: Reoperation after low anterior resection and abdominoperineal resection for rectal cancer is not uncommon. This study highlights the indications for reoperation, potentially modifiable preoperative risk factors for reoperation, and the morbidity associated with such operations.

Medical Prophylaxis of Post-Surgical Crohn’s Disease Recurrence: Towards Timely Anti-TNF Therapy

Purpose The incidence of colorectal cancer (CRC) is increasing worldwide, and the greatest increase is in low- to middle-income countries, such as Ukraine. Better knowledge of epidemiology of CRC in Ukraine is needed to understand how best to decrease the burden of disease. Methods The National Cancer Registry of Ukraine (NCRU) was queried for CRC incidence, mortality, stage, and treatment in Ukraine and assessed for regional variation from 1999 to 2015. Joinpoint analysis was used to analyze the trends. Results The incidence of colon cancer increased from 10.6 to 13.3 occurrences per 100,000, which provided an average annual percent change (AAPC) of 1.48 (95% CI, 1.3 to 1.7; P < .05). The incidence of rectal and anal cancers also increased from 9.9 to 11.5 occurrences per 100,000, which provided an AAPC of 1.0 (95% CI, 0.8 to 1.3; P < .05). Mortality remained the same (AAPC, 0.1; 95% CI, −0.3 to 0.2; P = .4). The proportion of patients who received cancer-specific treatment increased from 54.6% to 68.5% for colon cancer and from 61% to 74.4% for rectal and anal cancers. Overall, 34.5% of patients with colon cancer and 27.5% of patients with rectal cancer died within a year of diagnosis in 2015. Great regional variations in 1-year mortality and treatment received were identified. Conclusion The incidence of CRC in Ukraine is increasing. Despite stable mortality rates, many do not receive cancer-specific treatment, and a large proportion of patients die within a year of diagnosis. These findings illustrate the need to promote establishment of a screening program and to improve access to cancer-specific therapy in Ukraine.

PTH-288 Trends in colon and rectal cancer epidemiology in ukraine: incidence, mortality and surgical management in comparison to a us hospital

Crohn’s disease typically affects the terminal ileum and proximal colon; approximately 50% of patients will require bowel resection due to penetrating disease or stricture within 10 years of disease diagnosis [1]. Intestinal resection for these patients is not curative with up to 90% of patients demonstrating endoscopic evidence of recurrence 1 year postoperatively [1]. Risk factors for Crohn’s disease recurrence after surgical therapy include cigarette smoking, younger age, penetrating disease, shorter duration of disease prior to resection, prior surgical resections, and ileocolic disease [2]. Antibiotics, thiopurines, and steroids all have variable efficacy in reducing postoperative recurrence. In 2009, Regueiro et al. [3] provided the first evidence that infliximab administered as a postoperative prophylactic therapy could reduce endoscopic, clinical, and histologic Crohn’s disease recurrence published as a proof-of-concept randomized trial. Although only 24 patients were included in this study, 9.1% of patients receiving infliximab within 4 weeks of surgery compared to 84.6% of patients receiving placebo had endoscopic recurrence at 1 year postoperatively. Subsequent trials have shown that the administration of anti-tumor necrosis factor (anti-TNF) agents several weeks postoperatively effectively reduces Crohn’s recurrence and anti-TNF agents are often superior to thiopurines [4, 5]. In 2017, the American Gastroenterological Association (AGA) published its guidelines on the management of Crohn’s disease after surgery [2] recommending anti-TNF therapy and/or thiopurines within 8 weeks of surgery as first-line pharmacological prophylaxis for disease recurrence. To date, there have been no studies assessing the percentage of high-risk Crohn’s patients actually receiving timely postoperative anti-TNF therapy and evaluating and analyzing the factors associated with delayed administration. In this issue of Digestive Diseases and Sciences, CohenMekelburg et al. [6] set out to determine the percentage of high-risk Crohn’s disease patients receiving postoperative prophylactic anti-TNF agents as well as the risk factors associated with delays in initiation of such medications. The authors hypothesized that specific patient factors, prior anti-TNF therapy, and the type of treatment center would impact the timing of postoperative prophylactic biologic therapy. To validate this hypothesis, a retrospective cohort study was carried out in 84 patients who were deemed by two independent reviewers at high risk for disease recurrence and were likely to benefit from postoperative biologic therapy. The authors found that 69% of patients had greater than a 4-week delay and 56% of patients had greater than an 8-week delay in starting postoperative biologic prophylaxis. Moreover, the authors found that patients with public insurance were more likely to have delays in initiating biologic therapy, whereas patients receiving preoperative biologic therapy or who received care at an inflammatory bowel disease (IBD) center were more likely to have timely therapy. Two specific methodological strengths of the study are the assessment of high risk of recurrence Crohn’s patients by two independent reviewers and a sensitivity analysis including immunomodulators and biologics. This is the first study to highlight the significant percentage of high-risk Crohn’s disease patients that have delayed postoperative biologic therapy. It is important to note, however, that the AGA Crohn’s disease postsurgical management guidelines were not published until 2017, after the current investigation’s completion (2016). Therefore, although the results of the Regueiro study examining the efficacy of postoperative biologic prophylaxis were published in 2009, the impetus to start biologics postoperatively may have been provider-specific as there were no formal published guidelines available prior to 2017. Therefore, an updated analysis * Nelya Melnitchouk nmelnitchouk@bwh.harvard.edu

PTU-240 Comparison of outcomes of abdominal and colorectal surgery in patients with left ventricular assist devices versus heart transplants

Introduction To describe the trends in colon and rectal cancer incidence, management and mortality in Ukraine. To compare the distribution of operations for colon and rectal cancer in the major referral hospital in Ukraine and a United States tertiary care centre. Method This is a population based study of colorectal cancer incidence, mortality and management in Ukraine over 14 years (1999–2012). The National Cancer Registry of Ukraine was queried for incidence, overall and 1 year mortality, stage at presentation and management. The distribution of operative interventions for colorectal cancer performed at the National Cancer Institute in Ukraine a 560-bed, major referral centre for oncologic surgery as compared to the Brigham and Women’s Hospital, 779-bed tertiary care centre in the US will be reported here. Results Over the last 14 years we noted an increase in incidence and mortality in colon and rectal cancer. Crude incidence rate increased from 17.7 cases per 100, 000 to 24.3 for colon cancer and 11.3 to 12.8 for rectal cancer. The distribution of stages at presentation remained constant: 52.6% presented with stage I and II, 21.6% with stage III and 19.5% with stage IV disease for colon cancer and 63.2% with stage I and II, 15.1% with stage III and 15.1 with stage IV for rectal cancer. Despite the majority of patients presenting with early stage disease, 40.6% of colon cancer patients and 33.8% of rectal cancer patients died within a year of diagnosis. This number improved with the increased use of combined therapy in management of colorectalcancer. (Figure1). A wide variety and number of cases were performed at the National Cancer Institute in Ukraine with similar distribution to Brigham and Women’s Hospital in 2013. 260 operations for colon and rectal cancer were performed at the National Cancer Institute and 268 at the Brigham and Women’s Hospital. Of them, 31% vs. 28% were hemicolectomies, 52% vs. 53% were anterior and low anterior resections, 12% vs. 13% were abdominoperineal resections respectively. Conclusion Despite some improvement in colorectal cancer care and 1 year mortality in Ukraine the prognosis is still poor. It is perplexing that even though the large number of patients are diagnosed with early disease the outcomes are still poor. Since the incidence of colorectal cancer in increasing more studies are needed to establish the feasibility of colon cancer screening, to confirm the accurate reporting of stage distribution and to characterise barriers to obtain adequate care for colorectal cancer in Ukraine. Disclosure of interest None Declared.

Barriers to Breastfeeding for US Physicians Who Are Mothers

Introduction As survival of patients with left ventricular assist devices (LVADs) and cardiac transplantation improves, surgeons must increasingly decide whether and when to operate on them. Method We conducted a retrospective review of abdominal and colorectal operations performed on patients with heart transplants or LVADs at a tertiary care hospital in Boston, MA between 2003–2013. Data were collected on comorbidities, anticoagulation and immunosuppression status, intra-and post-operative complications, need for blood product transfusion, type of surgery performed, 24-hr and thirty day mortality, and time post-transplant or LVAD insertion. Statistical testing for significance was done using the two-sided Fisher’s exact test. Results Over the 11-year period, 13 patients with LVADs and 32 patients with heart transplants underwent a total of 67 colorectal (22%) and other abdominal (78%) operations. The median time between LVAD insertion or heart transplant and abdominal surgery was 175 days and 765 days respectively. There was a tendency towards a higher proportion of elective (vs emergency) cases in heart transplant (74%) vs LVAD patients (53%) (p = 0.13). LVAD patients were more likely to be anticoagulated, and had an 18% incidence of postoperative bleeding, with a significantly greater proportion of patients requiring blood transfusion within the first postoperative week (47%) compared to transplant patients (8%) (p = 0.001). Venous thromboembolic (VTE) events were also significantly more common in the LVAD group (21%) vs transplant group (0%) (p = 0.01). Subgroup analysis revealed the incidence of VTE was significantly decreased in the LVAD group bridged for surgery (p = 0.0008). Despite all transplant patients being on immunosuppression medication, and 46% on steroids, there was no statistically significant difference in surgical site infections between the transplant (6%) and LVAD (12%) groups (p = 0.59). Mortality within 24 h tended to be higher in the LVAD group (13%) vs transplant group (0%), with borderline significance (p = 0.06). 30-day mortality was significantly higher in the LVAD group (21%) vs transplant group (0%) (p = 0.01). Conclusion Surgical outcomes were better in patients who had undergone heart transplantation compared to those with LVADs, especially with respect to the need for postoperative transfusion, the incidence of VTE, and 24-hr and 30-day mortality. The observed tendency to perform fewer elective cases in LVAD patients compared to transplant patients may be a reflection of clinical intuition of this finding. Surgeons should assess these higher-risk patients on a case-by-case basis. Surgeons should also bridge anticoagulation for LVAD patients whenever possible to reduce the risk of VTE. Disclosure of interest None Declared.