Deborah S. Keller M.D.

Joshi, H. M., D. S. Keller and M. Chand (2017). “Utilization of indocyanine green to demonstrate lymphatic mapping in colon cancer.” J Surg Oncol: 2017 Oct [Epub ahead of print].

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The principles of oncologic resection for colon cancer are based on excising the primary tumor with its blood supply and associated lymph node basin. While resection of the tumor and its named vessel are relatively consistent, the extent of the mesenteric lymphadenectomy can be variable, which affects the quality of the specimen and nodal yield, and potentially the survival outcomes for the patient through under-staging. According to The Royal College of Pathologists and The College of American Pathologists, an adequate colonic oncological resection requires a minimum of 12 nodes to be removed but there is accumulating evidence this is still a substandard lymph node yield.[7] Proponents of complete mesocolic excision (CME) argue that performing more radical surgery with a larger mesenteric specimen results in a greater number of lymph nodes and potentially improved survival outcomes.[8] However, there is no current consensus for a CME approach, and there are concerns for increased morbidity after extended lymph node dissection.[9] In addition, while studies have shown value, the role of the sentinel lymph node biopsy is still undefined in colon cancer staging.[10]

Keller, D. S., T. Ishizawa, R. Cohen and M. Chand (2017). “Indocyanine green fluorescence imaging in colorectal surgery: Overview, applications, and future directions.” Lancet Gastroenterol Hepatol 2(10): 757-766.

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Indocyanine green fluorescence imaging is a surgical tool with increasing applications in colorectal surgery. This tool has received acceptance in various surgical disciplines as a potential method to enhance surgical field visualisation, improve lymph node retrieval, and decrease the incidence of anastomotic leaks. In colorectal surgery specifically, small studies have shown that intraoperative fluorescence imaging is a safe and feasible method to assess anastomotic perfusion, and its use might affect the incidence of anastomotic leaks. Controlled trials are ongoing to validate these conclusions. The number of new indications for indocyanine green continues to increase, including innovative options for detecting and guiding management of colorectal metastasis to the liver. These advances could offer great value for surgeons and patients, by improving the accuracy and outcomes of oncological resections.

Althans, A. R., J. T. Brady, D. S. Keller, S. L. Stein, S. R. Steele and M. Times (2017). “Are we catching women in the safety net? Colorectal cancer outcomes by gender at a safety net hospital.” Am J Surg 214(4): 715-720.

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BACKGROUND: Our goal was to evaluate presentation and outcomes for colorectal cancer across gender in a safety net hospital (SNH). METHODS: An institutional Tumor Registry was reviewed for colorectal cancer resections 12/2009-2/2016. Patients were stratified into male and female cohorts. The main outcome measures were stage at presentation and oncologic outcomes across gender. RESULTS: 170 women (48.6%) and 180 men (51.4%) were evaluated; 129 (84.1%) females and 143 (79.4%) males underwent curative resection. There were no significant differences in prior colorectal cancer screening. On presentation, there were similar rates of stage IV disease across genders (p = 0.3). After median follow-up of 26.5 months (female) and 29.9 months (male), there were no significant differences in overall survival, survival by stage, or disease-free survival by gender (all p = 0.7). The local (1.4% females vs. 2.6% males, p = 0.7) and distant recurrence (16.6% females vs. 14.9% males, p = 0.7) were similar across gender. CONCLUSION: With equal access to treatment, there were no significant differences in overall survival, survival by stage, or local or distant recurrence rates by gender. These findings stress the importance of the SNH system, and need for continued support.

Keller, D. S., J. Qiu and A. J. Senagore (2017). “Predicting opportunities to increase utilization of laparoscopy for rectal cancer.” Surg Endosc: 2017 Sep [Epub ahead of print].

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BACKGROUND: Despite proven safety and efficacy, rates of laparoscopy for rectal cancer in the US are low. With reports of inferiority with laparoscopy compared to open surgery, and movements to develop accredited centers, investigating utilization and predictors of laparoscopy are warranted. Our goal was to evaluate current utilization and identify factors impacting use of laparoscopic surgery for rectal cancer. METHODS: The Premier Hospital Database was reviewed for elective inpatient rectal cancer resections (1/1/2010-6/30/2015). Patients were identified by ICD-9-CM diagnosis codes, and then stratified into open or laparoscopic approaches by ICD-9-CM procedure codes or billing charge. Logistic multivariable regression identified variables predictive of laparoscopy. The Cochran-Armitage test assessed trend analysis. The main outcome measures were trends in utilization and factors independently associated with use of laparoscopy. RESULTS: 3336 patients were included-43.8% laparoscopic (n = 1464) and 56.2% open (n = 1872). Use of laparoscopy increased from 37.6 to 55.3% during the study period (p < 0.0001). General surgeons performed the majority of all resections, but colorectal surgeons were more likely to approach rectal cancer laparoscopically (41.31 vs. 36.65%, OR 1.082, 95% CI [0.92, 1.27], p < 0.3363). Higher volume surgeons were more likely to use laparoscopy than low-volume surgeons (OR 3.72, 95% CI [2.64, 5.25], p < 0.0001). Younger patients (OR 1.49, 95% CI [1.03, 2.17], p = 0.036) with minor (OR 2.13, 95% CI [1.45, 3.12], p < 0.0001) or moderate illness severity (OR 1.582, 95% CI [1.08, 2.31], p < 0.0174) were more likely to receive a laparoscopic resection. Teaching hospitals (OR 0.842, 95% CI [0.710, 0.997], p = 0.0463) and hospitals in the Midwest (OR 0.69, 95% CI [0.54, 0.89], p = 0.0044) were less likely to use laparoscopy. Insurance status and hospital size did not impact use. CONCLUSIONS: Laparoscopy for rectal cancer steadily increased over the years examined. Patient, provider, and regional variables exist, with hospital status, geographic location, and colorectal specialization impacting the likelihood. However, surgeon volume had the greatest influence. These results emphasize training and surgeon-specific outcomes to increase utilization and quality in appropriate cases.

Keller, D. S., I. Tantchou, J. R. Flores-Gonzalez and D. P. Geisler (2017). “Predicting delayed discharge in a multimodal enhanced recovery pathway.” Am J Surg 214(4): 604-609.

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BACKGROUND: Despite advances with Enhanced Recovery Pathways(ERP), some patients have unexpected prolonged lengths of stay(LOS). Our goal was to identify the patient and procedural variables associated with delayed discharge despite an established ERP. METHODS: A divisional database was reviewed for minimally invasive colorectal resections with a multimodal ERP(8/1/13-7/31/15). Patients were stratified into ERP success or failure based on length of stay >/=5 days. Logistic regression modeling identified variables predictive of ERP failure. RESULTS: 274 patients were included- 229 successes and 45 failures. Groups were similar in demographics. Failures had higher rates of preoperative anxiety(p = 0.0352), chronic pain(p = 0.0040), prior abdominal surgery(p = 0.0313), and chemoradiation(p = 0.0301). Intraoperatively, failures had higher conversion rates(13.3% vs. 1.7%, p = 0.0002), transfusions(p = 0.0032), and longer operative times(219.8 vs. 183.5min,p = 0.0099). Total costs for failures were higher than successes($22,127 vs. $13,030,p = 0.0182). Variables independently associated with failure were anxiety(OR 2.28, p = 0.0389), chronic pain(OR 10.03, p = 0.0045), and intraoperative conversion(OR 8.02, p = 0.0043). CONCLUSIONS: Identifiable factors are associated with delayed discharge in colorectal surgery. By prospectively preparing for patient factors and changing practice to address procedural factors and ERP adherence, postoperative outcomes could be improved.