(1) Background: Colorectal cancer (CRC) is the third most common cancer and the second leading cause of cancer-related mortality worldwide. Up to 50% of patients with CRC develop metastatic CRC (mCRC). Surgical and systemic therapy advances can now offer significant survival advantages. Understanding the evolving treatment options is essential for decreasing mCRC mortality. We aim to summarize current evidence and guidelines regarding the management of mCRC to provide utility when making a treatment plan for the heterogenous spectrum of mCRC. (2) Methods: A comprehensive literature search of PubMed and current guidelines written by major cancer and surgical societies were reviewed. The references of the included studies were screened to identify additional studies that were incorporated as appropriate. (3) Results: The standard of care for mCRC primarily consists of surgical resection and systemic therapy. Complete resection of liver, lung, and peritoneal metastases is associated with better disease control and survival. Systemic therapy now includes chemotherapy, targeted therapy, and immunotherapy options that can be tailored by molecular profiling. Differences between colon and rectal metastasis management exist between major guidelines. (4) Conclusions: With the advances in surgical and systemic therapy, as well as a better understanding of tumor biology and the importance of molecular profiling, more patients can anticipate prolonged survival. We provide a summary of available evidence for the management of mCRC, highlighting the similarities and presenting the difference in available literature. Ultimately, a multidisciplinary evaluation of patients with mCRC is crucial to selecting the appropriate pathway.

Background and Aims: Acute cellular rejection (ACR) is a frequent complication after liver transplantation. By reducing ischemia and graft damage, dynamic preservation techniques may diminish ACR. We performed a systematic review to assess the effect of currently tested organ perfusion (OP) approaches versus static cold storage (SCS) on post-transplant ACR-rates. Approach and Results: A systematic search of Medline, Embase, Cochrane Library, and Web of Science was conducted. Studies reporting ACR-rates between OP and SCS and comprising at least 10 liver transplants performed with either hypothermic oxygenated perfusion (HOPE), normothermic machine perfusion, or normothermic regional perfusion were included. Studies with mixed perfusion approaches were excluded. Eight studies were identified (226 patients in OP and 330 in SCS). Six studies were on HOPE, one on normothermic machine perfusion, and one on normothermic regional perfusion. At meta-analysis, OP was associated with a reduction in ACR compared with SCS [OR: 0.55 (95% CI, 0.33–0.91), p=0.02]. This effect remained significant when considering HOPE alone [OR: 0.54 (95% CI, 0.29–1), p=0.05], in a subgroup analysis of studies including only grafts from donation after cardiac death [OR: 0.43 (0.20–0.91) p=0.03], and in HOPE studies with only donation after cardiac death grafts [OR: 0.37 (0.14–1), p=0.05]. Conclusions: Dynamic OP techniques are associated with a reduction in ACR after liver transplantation compared with SCS. PROSPERO registration: CRD42022348356.

BACKGROUND: Total neoadjuvant therapy in the treatment of stage II and III rectal cancer involves the administration of either induction or consolidation chemotherapy with chemoradiation before surgery. Total neoadjuvant therapy is associated with an increased complete response rate, which is defined as the proportion of patients who either had a pathological complete response after surgery or sustained a clinical complete response for at least 1 year under surveillance. OBJECTIVE: To identify the predictors of complete response to total neoadjuvant therapy and compare different diagnostic tools in predicting complete response. DESIGN: Retrospective cohort study. SETTINGS: A single tertiary care center. PATIENTS: Patients with stage II and III rectal cancer who were diagnosed between January 2015 and December 2021. INTERVENTION: Total neoadjuvant therapy. MAIN OUTCOME MEASURES: Complete response rate, predictors of complete response, sensitivity and specificity of sigmoidoscopy, and MRI in predicting complete response. RESULTS: One hundred nineteen patients (mean age 56 [±11.3] years, 47 [39.5%] women, 100 [84%] stage III rectal cancer) were included. The median tumor size was 5.1 (4–6.5) cm, and 63 (52.9%) were low rectal tumors. Twenty-one patients (17.6%) had extramural vascular invasion and 62 (52.1%) had elevated CEA at baseline. One hundred eight patients (90.8%) received consolidation chemotherapy. After total neoadjuvant therapy, 88 of 119 patients (73.9%) underwent surgery, of whom 20 (22.7%) had pathological complete response. Thirty-one patients (26.1%) underwent watch-and-wait, of whom 24 (77.4%) had sustained clinical complete response. Overall, the complete response rate was 37%. Low rectal tumors (OR 1.5 [95% CI, 1.03–2.4], p = 0.04) and absence of extramural vascular invasion (OR 2.2 [95% CI, 1.1–5.6], p = 0.01) were predictors of complete response. In predicting complete response, sigmoidoscopy was more sensitive (76.0% vs 62.5%) and specific (72.5% vs 69.2%) than MRI. The specificity further increased when 2 techniques were combined (82.5%). LIMITATIONS: Retrospective study. CONCLUSIONS: The complete response rate after total neoadjuvant therapy was 37%. Low rectal tumors and the absence of extramural vascular invasion were predictors of complete response. Sigmoidoscopy was better in predicting incomplete response, whereas combination (MRI and sigmoidoscopy) was better in predicting complete response. See Video ¿QUÉ PREDICE LA RESPUESTA COMPLETA A LA TERAPIA NEOADYUVANTE TOTAL EN EL CÁNCER DE RECTO LOCALMENTE AVANZADO?: ANTECEDENTES: La terapia neoadyuvante total en el tratamiento del cáncer de recto en estadios II-III implica la administración de quimioterapia de inducción o de consolidación con quimio radiación antes de la cirugía. La terapia neoadyuvante total se asocia con una mayor tasa de respuesta completa, que se define como la proporción de pacientes que tuvieron una respuesta patológica completa después de la cirugía o una respuesta clínica completa sostenida al menos durante un año bajo vigilancia. OBJETIVO: Identificar los predictores de respuesta completa a la terapia neoadyuvante total y comparar diferentes herramientas de diagnóstico para predecir la respuesta completa. DISEÑO: Estudio de cohorte retrospectivo. LUGARES: Un único centro de atención terciaria. PACIENTES: Pacientes con cáncer de recto en estadio II-III diagnosticados entre enero de 2015 y diciembre de 2021. INTERVENCIÓN(S): Terapia neoadyuvante total. PRINCIPALES MEDIDAS DE RESULTADO: Tasa de respuesta completa, predictores de respuesta completa, sensibilidad y especificidad de la sigmoidoscopia y la resonancia magnética para predecir la respuesta completa. RESULTADOS: Se incluyeron 119 pacientes [edad media 56 (±11,3) años, 47 (39,5%) mujeres, 100 (84%) cáncer de recto en estadio III]. La mediana del tamaño tumoral fue de 5,1 (4-6,5) cm, 63 (52,9%) fueron tumores rectales bajos. Veintiún (17,6%) pacientes tenían invasión vascular extramural (EMVI), 62 (52,1%) tenían CEA elevado al inicio del estudio. Ciento ocho (90,8%) pacientes recibieron quimioterapia de consolidación. Después de la TNT, 88 (73,9%) de 119 pacientes fueron intervenidos quirúrgicamente, de los cuales 20 (22,7%) tuvieron respuesta patológica completa. Treinta y un (26,1%) pacientes fueron sometidos a observación y espera, de los cuales 24 (77,4%) tuvieron una respuesta clínica completa sostenida. La tasa de respuesta completa general fue del 37%. Los tumores rectales bajos [OR 1,5 (IC 95% 1,03-2,4), p = 0,04] y la ausencia de EMVI [OR 2,2 (IC 95% 1,1-5,6), p = 0,01] fueron predictores de respuesta completa. Para predecir la respuesta completa, la sigmoidoscopia fue más sensible (76,0 % frente a 62,5 %) y específica (72,5 % frente a 69,2 %) que la resonancia magnética. La especificidad aumentó aún más cuando se combinaron dos técnicas (82,5%). LIMITACIONES: Estudio retrospectivo. CONCLUSIONES: La tasa de respuesta completa después de la terapia neoadyuvante total fue del 37%. Los tumores rectales bajos y la ausencia de EMVI fueron predictores de respuesta completa. La sigmoidoscopia fue mejor para predecir la respuesta incompleta, mientras que la combinación (MRI y sigmoidoscopia) fue mejor para predecir la respuesta completa. (Traducción—Dr Osvaldo Gauto)

Objective: To investigate the predictors of postoperative mortality in coronavirus disease 2019 (COVID-19)–positive patients. Background: COVID-19–positive patients have more postoperative complications. Studies investigating the risk factors for postoperative mortality in COVID-19–positive patients are limited. Methods: COVID-19–positive patients who underwent surgeries/procedures in Cleveland Clinic between January 2020 and March 2021 were identified retrospectively. The primary outcome was postoperative/procedural 30-day mortality. Secondary outcomes were length of stay, intensive care unit admission, and 30-day readmission. Results: A total of 2543 patients who underwent 3027 surgeries/procedures were included. Total 48.5% of the patients were male. The mean age was 57.8 (18.3) years. A total of 71.2% had at least 1 comorbidity. Total 78.7% of the cases were elective. The median operative time was 94 (47.0–162) minutes and mean length of stay was 6.43 (13.4) days. Postoperative/procedural mortality rate was 4.01%. Increased age [odds ratio (OR): 1.66, 95% CI, 1.4–1.98; P<0.001], being a current smoker [2.76, (1.3–5.82); P=0.008], presence of comorbidity [3.22, (1.03–10.03); P=0.043], emergency [6.35, (3.39–11.89); P<0.001] and urgent versus [1.78, (1.12–2.84); P=0.015] elective surgery, admission through the emergency department [15.97, (2.00–127.31); P=0.009], or inpatient service [32.28, (7.75–134.46); P<0.001] versus outpatients were associated with mortality in the multivariable analysis. Among all specialties, thoracic surgery [3.76, (1.66–8.53); P=0.002] had the highest association with mortality. Total 17.5% of the patients required intensive care unit admission with increased body mass index being a predictor [1.03, (1.01–1.05); P=0.005]. Conclusions: COVID-19–positive patients have higher risk of postintervention mortality. Risk factors should be carefully evaluated before intervention. Further studies are needed to understand the impact of pandemic on long-term surgical/procedural outcomes.

Up to 15% of colorectal polyps are amenable for conventional polypectomy. Advanced endoscopic resection techniques are introduced for the treatment of those polyps. They provide higher en bloc resection rates compared with conventional techniques, while helping patients to avoid the complications of surgery. Note that 20 mm is considered as the largest size of a polyp that can be resected by polypectomy or endoscopic mucosal resection (EMR) in an en bloc fashion. Endoscopic submucosal dissection (ESD) is recommended for polyps larger than 20 mm. Intramucosal carcinomas and carcinomas with limited submucosal invasion can also be resected with ESD. EMR is snare resection of a polyp following submucosal injection and elevation. ESD involves several steps such as marking, submucosal injection, incision, and dissection. Bleeding and perforation are the most common complications following advanced endoscopic procedures, which can be treated with coagulation and endoscopic clipping. En bloc resection rates range from 44.5 to 63% for EMR and from 87.9 to 96% for ESD. Recurrence rates following EMR and ESD are 7.4 to 17% and 0.9 to 2%, respectively. ESD is considered enough for the treatment of invasive carcinomas in the presence of submucosal invasion less than 1000 μm, absence of lymphovascular invasion, well–moderate histological differentiation, low-grade tumor budding, and negative resection margins.

Early liver transplant (ELT) is the practice of liver transplant for those with severe alcohol-associated hepatitis or acute on chronic alcohol-associated liver disease, without requiring any minimum pre-transplant abstinence period. It is an increasingly adopted practice for alcohol-associated liver disease (ALD) capable of providing excellent outcomes, but there are concerns regarding equity in access to ELT. Our objectives were 1) to quantify the association between social determinants of health (SDoH) and progression from referral to listing, and 2) to identify geographic disparities in referrals for ELT. We included 501 ELT candidates and a comparison population of 165 SLT candidates referred from 2017 until 2023. Multivariable regression quantified the association between individual- and neighborhood-level SDoH and progression from referral to listing, adjusting for sociodemographic characteristics and MELD. Negative binomial regression quantified the association between neighborhood-level SDoH and the number of ELT referrals within 150Nmi of our institution, adjusting for relevant geographic confounders. ELT candidates with Medicaid insurance were less likely to progress from referral to evaluation than candidates with private insurance (RR 0.69, 95% CI 0.56-0.85). ELT candidates from census tracts with a high social vulnerability index (SVI) were less likely to progress from evaluation to listing than candidates from low SVI census tracts in Modified Poisson Regression (RR 0.64, 95% CI 0.46-0.88), but not in Cox regression (HR 0.67, 95% CI 0.41-1.09). These findings were not significant among SLT candidates. High SVI census tracts were less likely to have individuals referred for ALD compared to tracts with low SVI (IRR 0.53, 95% CI 0.42-0.66). Both individual- and neighborhood-level SDoH are important factors that ultimately influence who is eligible for transplant. Export