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Although a significant proportion of patients are readmitted to non-index hospitals after surgery, risk factors for non-index hospital readmission are not well defined. Using the California Office of State Health Planning and Development database from 2008 to 2012, patients readmitted to index versus non-index hospitals after colorectal surgery were directly compared. Risk factors for non-index hospital readmission were assessed through logistic regression. Among the 14,401 patients requiring readmission, 10,890 (75.6%) were readmitted to index hospitals, whereas 3,511 (24.4%) were readmitted to non-index hospitals. Patients readmitted to non-index hospitals were more likely to be men and have a greater Charlson comorbidity index, non-private insurance, longer initial length of stay, longer travel distance, and non-home discharge disposition. On multivariable logistic regression analysis, living ≥10 miles from the index hospital was strongly predictive of non-index hospital readmission (odds ratio, 1.8; 95% confidence interval, 1.63 to 2.00). Approximately 25% of readmissions after colorectal surgery will be to non-index hospitals. Risks factors include greater comorbidities, non-private health insurance, occurrence of an inpatient complication, longer length of stay, greater travel distance, and non-home discharge disposition. •Up to one fourth of readmissions after colorectal surgery will be to non-index hospitals.•Substantial variability in non-index hospital readmission rates exists.•Multiple factors are associated with non-index hospital readmission.•Greater travel distance is one of the strongest predictors.

IntroductionUnderstanding postoperative opioid use patterns among different populations is key to developing opioid stewardship programs.MethodsWe performed a retrospective cohort study on opioid prescribing, use, and pain after general surgery procedures for patients cared for by a transitional pain service at a veterans administration hospital. Discharge opioid prescription quantity, 90-day opioid prescription, and patient reported outcome pain measures were compared between chronic opioid users and non-opioid users (NOU). Additionally, 90-day total opioid use was evaluated for NOU.ResultsOf 257 patients, 34 (13%) were on chronic opioid therapy, over 50% had a mental health disorder, and 29% had a history and/or presence of a substance use disorder. NOU were prescribed a median (IQR) of 10 (7, 12) tablets at discharge, while chronic opioid users were prescribed 6 (0, 12) tablets (p<0.001). 90-day opioid prescription (not including baseline opioid prescription for chronic users) was 10 (7, 15) and 6 (0, 12) tablets, respectively (p=0.001). There were no differences in changes in pain intensity or pain interference scores during recovery between groups. Median 90-day opioid use post discharge for NOU was 4 (0, 10) pills.DiscussionNon-opioid and chronic opioid users required very few opioid pills following surgery, and patients on chronic opioid therapy quickly returned to their baseline opioid use after a small opioid prescription at discharge. There was no difference in pain recovery between groups. Opioid prescribing guidelines should include patients on chronic opioid therapy and could consider recommending a more conservative prescribing approach.

Leftover pills from postoperative opioid prescriptions place patients and members of their communities at risk for opioid misuse. We aimed to better understand patients’ post-discharge opioid consumption patterns to inform new methods of postoperative opioid prescribing. We assessed post-discharge opioid consumption of general surgery patients and assessed the adequacy of discharge opioid prescriptions. We then compared patient opioid consumption to a number of theoretical discharge prescriptions based on different opioid prescribing guidelines and a proposed discharge prescription based on the metric 24-h pre-discharge opioid consumption (PDOC). 62/99 patients (62.6%) returned an opioid log book. Median 24-h PDOC was 22.5 MME (IQR 5.0–45.0) and median discharge prescription size was 15 pills (IQR:10–20). Prescriptions were adequate for 83.7% of patients. The median number of pills used was 3 (IQR:0–11) and median time to opioid cessation was 3 days (IQR:0–5). Actual prescriptions were consistent with national opioid prescribing guidelines. Prescriptions based on the formula 2 × 24-h PDOC would have decreased the number of leftover pills by 7.5 per patient. Despite prescribing opioids consistent with national opioid prescribing guidelines, patients still receive too many pills. Improved opioid prescribing could be accomplished by use of the formula 2 × 24-h PDOC. •General surgery patients use very few opioids following hospital discharge.•Current prescribing guidelines recommend higher amounts of opioids than needed.•The metric 24-h pre-discharge opioid consumption could be used to help improve opioid stewardship.

Background Duodenal adenocarcinoma is a rare cancer usually studied as a group with periampullary or small bowel adenocarcinoma; therefore, its natural history is poorly understood. Methods Patients with duodenal adenocarcinoma were identified from a single-institution pancreaticoduodenectomy database. Patients with adenocarcinoma arising from the ampulla of Vater were excluded. Univariate and multivariate analyses were performed to identify clinicopathologic variables associated with survival and recurrence after resection. Results From 1984 to 2006, a total of 122 patients with duodenal adenocarcinoma underwent pancreaticoduodenectomy. Overall survival after resection was 48% at 5 years and 41% at 10 years. Five-year survival decreased as the number of lymph nodes involved by metastasis increased from 0 to 1–3 to ≥4 (68%, 58%, 17%, respectively, P  < 0.01) and as the lymph node ratio increased from 0 to >0–0.2 to >0.2–0.4 to >0.4 (68%, 57%, 14%, 14%, respectively, P  < 0.01). Lymph node metastasis was the only independent predictor of decreased survival in multivariate analysis. Recurrence after resection was predominantly distant (81%). Adjuvant chemoradiation did not decrease local recurrence or prolong overall survival; however, patients who received chemoradiation more commonly had nodal metastasis ( P  = 0.03). Conclusions The prognostic significance of both the absolute number and ratio of involved lymph nodes emphasizes the need for adequate lymphadenectomy to accurately stage duodenal adenocarcinoma. The mostly distant pattern of recurrence underscores the need for the development of effective systemic therapies.

Background Mutational landscape is prognostic in colorectal cancer (CRC). Rat sarcoma (RAS) oncogenes, such as KRAS and NRAS, with driver mutations, portend poor survival outcomes, whereas pathologic mutations in HRAS are extremely rare, and their prognostic value remains uncertain. Methods This retrospective study analyzed the Oncology Research Information Exchange Network (ORIEN) alliance tumor RNA‐Seq data in Stages II and III CRC to investigate the association between RAS gene expression and survival outcomes. Results High transcript levels of HRAS were associated with superior overall survival (OS). The high HRAS‐associated OS benefit was most pronounced in patients with right‐sided primary expressing low KRAS transcript levels in the absence of pathologic KRAS mutations. Conclusions Contrary to the notion that RAS family genes are proto‐oncogenic, this study demonstrates that high HRAS transcript levels are associated with superior OS in Stages II and III CRC. The potential of HRAS as a prognostic biomarker should be explored further.

Purpose Colorectal cancer (CRC) incidence and mortality are increasing among young adults (YAs) aged 18–39. This study compared quality of life (QOL) between YA and older adult CRC survivors in the ColoCare Study. Methods Participants were grouped by age (years) as follows: 18–39 (YA), 40–49, 50–64, and 65 + . Functional QOL (physical, social, role, emotional, cognitive) and global QOL were assessed with the EORTC-QLQ-C30 at enrollment, 3, 6, and 12 months. Average scores were compared between groups over time using longitudinal mixed-effect modeling. Proportions with clinically meaningful QOL impairment were calculated using age-relevant thresholds and compared between groups over time using logistic regression with mixed effects. Results Participants ( N  = 1590) were n  = 81 YAs, n  = 196 aged 40–49, n  = 627 aged 50–64, and n  = 686 aged 65 + . Average physical function was better among YAs than participants aged 50–64 ( p  = 0.010) and 65 + ( p  < 0.001), and average social function was worse among YAs than aged 65 + ( p  = 0.046). Relative to YAs, all age groups were less likely to report clinically meaningful social dysfunction (aged 40–49 OR = 0.13, 95%CI = 0.06–0.29; aged 50–64 OR = 0.10, 95%CI = 0.05–0.21; aged 65 + OR = 0.07, 95%CI = 0.04–0.15) and role dysfunction (aged 40–49 OR = 0.36, 95%CI = 0.18–0.75; aged 50–64 OR = 0.41, 95%CI = 0.22–0.78; aged 65 + OR = 0.32, 95%CI = 0.17–0.61). Participants aged 40–49 were also less likely to report physical dysfunction (OR = 0.42, 95%CI = 0.19–0.93). Conclusion YA CRC survivors reported better physical and worse social function compared to older CRC survivors, and YA CRC survivors were more likely to report clinically meaningful social, role, and physical disfunction. Future work should further investigate QOL using age-relevant benchmarks to inform best practices for CRC survivorship care. Trial registration NCT02328677, registered December 2014.

Background High tumor budding and elevated systemic inflammation are adverse prognostic indicators in colorectal cancer. Its underlying mechanisms remain poorly understood. It is unclear whether systemic inflammation, angiogenesis, and cell‐to‐cell adhesion influence tumor budding. Methods We investigated n = 132 stage I–III colorectal cancer patients recruited at Huntsman Cancer Institute enrolled in the ColoCare Study. Tumor budding was evaluated using an evidence‐based scoring system, and patient sera were analyzed for nine circulating biomarkers using the Meso Scale Discovery platform. We examined associations between biomarkers and tumor budding using multivariable linear regression models adjusted for age, sex, neoadjuvant treatment, stage, and non‐steroidal anti‐inflammatory drug use. Results The study population was predominantly non‐Hispanic White (95%), with a mean age of 61 years; 56% were male. Most tumors were stage III (47%), located in the colon (64%), and exhibited low‐grade tumor budding (58%). Soluble intercellular adhesion molecule 1 was inversely associated with tumor budding overall (M1: β = −0.57, p = 0.03), among females (M1: β = −0.81, p‐value = 0.03) and later‐onset (≥ 50 years) colorectal cancer (M1: β = −0.71, p‐value = 0.008). C‐reactive protein was positively associated with tumor budding in males (M1: β = 0.23, p = 0.001), while interleukin‐8 (M1: β = 0.96, p‐value = 0.01) and soluble vascular adhesion molecule 1 (M2: β = 1.48, p‐value = 0.04) were positively associated with tumor budding in early‐onset patients. However, these associations did not remain statistically significant after correction for multiple testing. Conclusion Overall, our findings do not provide evidence of a significant association between biomarkers of systemic inflammation, angiogenesis, and cell‐to‐cell adhesion with tumor budding count. We observed patterns for some biomarkers, yet none remained statistically significant after correction for multiple testing. These findings provide preliminary insights for future studies. Trial Registration: ClinicalTrials.gov: NCT02328677. This study identified patterns between biomarkers of systemic inflammation, angiogenesis, and cell‐to‐cell adhesion with tumor budding in colorectal cancer, suggesting differences by age of disease onset and sex. These findings contribute to our understanding of the underlying mechanism of tumor budding and may provide guidance for future studies investigating the biological mechanisms of tumor budding that may be relevant for prognostic assessments and therapeutic interventions in colorectal cancer.