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Finances as a Social Determinant of Health in Surgery

Introduction Cost in healthcare is a complex, multifaceted topic that affects every stakeholder differently. Understanding the financial implications of surgical care as a social determinant of health (SDH) has become an increasingly crucial aspect of this field of study. Patients undergoing surgery and perioperative care face rising costs of healthcare that impact their lives well beyond the acute recovery phase. The World Health Organization's (WHO) Commission…

The Conserved Transcriptional Response to Adversity: Prepared for Social Determinants of Health in Surgery

Acknowledgements Preparation of this chapter was supported by NIH grants R01-AG073053, R01-CA261752, UG3-CA260317, U19-AG051426, and P30-AG017265, and the Breast Cancer Research Foundation. Introduction Beginning in 2007, a series of RNA profiling studies found that human beings who were exposed to adverse social conditions for extended periods of time showed a recurrent pattern of alterations in immune cell gene expression. , This pattern was characterized by increased…

Allostatic Load—Measurement Issues in Cancer Patients and Other Populations

Introduction An emerging hypothesis about disparities in cancer risk and outcomes among disparity populations is that psychological and social stressors impact biological processes that play a role in the initiation and progression of disease. Allostatic load is an indicator of biological dysregulation in response to psychological and social stress that is used to measure the impact of these stressors on biological functioning. AL is an index…

Internalizing Social Determinants of Health: The Ecosocial and Weathering Theories

An Introduction to Social Epidemiology Healthy People 2030 emphasizes the need to focus on the social determinants of health (SDH), specifically with the goal to “create social, physical, and economic environments that promote attaining the full potential for health and well-being for all.” Social determinants of health refer to the nonmedical conditions and environments where people live, work, and play that ultimately impacts their health outcomes.…

Social Determinants of Health in Surgery Overview

Introduction Health outcomes are mediated by the intersection of socioeconomic and environmental factors with healthcare. Although life expectancy and disease outcomes have improved over time, it is important to note these improvements have not been equal across all populations, with significant disparities observed across race, ethnicity, and socioeconomic status. , The World Health Organization defines social determinants of health as the “conditions in which people are…

Evidence-Based Decision Making in Colon and Rectal Surgery

Evidence-based surgical practice is rapidly becoming synonymous with “quality” care. The topics of evidence-based care in colorectal surgery are immense and diverse, and many have been covered in other chapters of this textbook. In the following pages, we attempt to highlight areas of interest in colorectal surgery, not previously covered, that involve evidence-based care of the colorectal surgery patient. Enhanced Recovery Pathways During the past decade,…

Reoperative Pelvic Surgery

Mastering the challenges of reoperative pelvic surgery requires preparation, a thorough understanding of pelvic anatomy, the ability to think several steps ahead, considerable experience, and no small measure of courage on the part of the surgeon. This chapter covers the anatomy of the reoperative pelvis, common pitfalls encountered during reoperative pelvic surgery, the preoperative preparation of the patient, useful technical tips, and finally a discussion of…

Reducing the Risk of Infection in the Elective and Emergent Colectomy Patient

Colorectal surgery is associated with a greater risk for infections than most other surgical specialties and is considered an outlier for surgical site infections (SSIs). In addition to SSI, as with other types of surgical operations, patients undergoing colectomy are at risk for respiratory, urinary tract, and line-related infections, as well as the development of Clostridium difficile . Perioperative measures can reduce the occurrence of these…

Ostomy Construction and Management: Personalizing the Stoma for the Patient

More than a million patients in North America live with some type of intestinal stoma. These stomas are typically constructed as one of the last components of a long and challenging surgical procedure. Stomal construction is important because their function will have significant impact on the ostomate's life. Stomal creation is a technical exercise that if done correctly will result in good function and minimal complications…

Prevention, Diagnosis, and Management of Anastomotic Leak

Incidence and Consequences of Anastomotic Leak Anastomotic leak is perhaps the most physiologically significant and psychologically devastating complication that commonly occurs following operations for colon or rectal disease. The reported incidence of anastomotic leak following colorectal surgery has varied from 1% to 30%, largely based on the criteria for diagnosis and the length of follow-up; the highest leak rate is seen with anastomoses involving the distal…

Adjuvant and Neoadjuvant Therapy for Colorectal Cancer: Molecular-Based Therapy

Colorectal cancer (CRC) is the third most common cancer and the fourth most common cancer cause of death worldwide. The incidence of CRC is low at ages younger than 50 years but increases significantly with age. Although the T (tumor size), N (presence of malignant lymph nodes), and M (presence of distant metastases) classification of disease at diagnosis provides a strong prognostic assessment to help direct…

Rare Colorectal Malignancies

Rare tumors of the colon and rectum account for 5% of all colorectal malignancy and can be broadly separated into four categories: epithelial ( Fig. 175.1 ), lymphoid, mesenchymal, or other ( Table 175.1 ). In this chapter we will describe the presentation, diagnosis, and treatment of these different tumor types. Open full size image FIGURE 175.1 The patient is a 25-year-old man who presented with…

Retrorectal Tumors

Retrorectal tumors comprise an uncommon group of lesions, originating from one or more of the three germ cell layers that occupy the retrorectal or presacral space. The reported incidence of less than 1% likely represents an underestimate, given the indolent nature of these tumors with often vague and nonspecific symptoms. Tumors are often heterogeneous and are more often congenital than acquired. Given the complexity of pelvic…

Neoplasms of the Anus: High-Grade Squamous Intraepithelial Lesions and Cancer

The perianal region includes the (1) anal canal, (2) perianus, and (3) perianal skin. This chapter will review the definition and anatomy of the anal canal and perianus and discuss the diagnosis and management of neoplasms that occur in these regions. Malignancies of the anal canal and perianus are uncommon and account for 2% of all lower gastrointestinal tract cancers. The most common malignancies include squamous…

Management of Metastatic Colorectal Cancer to the Liver

Colorectal cancer is the third most common cancer diagnosed in both males and females in the United States. As of January 2016 there are an estimated 1.4 million men and women living with a diagnosis of colorectal cancer, with an expected 134,490 new diagnoses and 49,190 deaths that same year. Of the projected new cases diagnosed in 2016, approximately 50% to 60% of those patients will…

Recurrent and Metastatic Colorectal Cancer

There are approximately 40,000 new diagnoses of rectal cancer in the United States each year. Developments such as total mesorectal excision (TME) and neoadjuvant chemoradiotherapy (NACXRT) as well as international guidelines have improved the prognosis of primary rectal cancer. But despite these advances, local recurrence after surgery remains a significant issue. Historically, local recurrence and metastatic disease signified an incurable condition, but there has increasingly been…

Minimally Invasive Approaches to Colon Cancer

Laparoscopic colectomy was first described more than three decades ago, following the success of laparoscopic approaches to biliary surgery and appendicitis in the 1980s. Jacobs et al. described their first 20 laparoscopic colectomies for benign and malignant conditions. The paper was fairly modern, with operative times (170 minutes for sigmoid and 155 minutes for right colectomy) and lengths of stay (3 to 5 days for right, 3…

Abdominoperineal Resection for Rectal Cancer

Abdominoperineal resection (APR) is the operation of choice for low-lying rectal cancers, as well as for many recurrent rectal cancers, and as salvage therapy for anal cancers. In very select circumstances, APR may also be appropriate for benign disease, such as in patients with severe refractory anorectal Crohn disease. Finally, APR may be used in both benign and malignant disease in patients whose underlying disease would…

Operations for Rectal Cancer: Low Anterior Resection—Open, Laparoscopic or Robotic, taTME, Coloanal Anastomosis

The management of rectal cancer has evolved over the past century. Since the first description of radical abdominoperineal resection (APR) by Miles in 1908, surgery for rectal cancer has moved toward less aggressive approaches to reduce morbidity and mortality while making sphincter preservation a priority. APR involves both abdominal and perineal dissection to remove the anorectal complex en bloc with the rectum followed by creation of…

Transanal Approaches to Early Rectal Cancer: Transanal Endoscopic Microsurgery and Conventional Transanal Excision

Widespread introduction of screening programs has resulted in a significant increase in the early detection of rectal cancers. In addition, staging tools and treatment modalities for rectal cancer have greatly improved. As a consequence, there is an increasing interest in multimodal organ-preserving strategies in patients with early rectal cancer (ERC), including the use of local excision (LE) and chemoradiation therapy (CRT). Until the 1990s, conventional transanal…