"I Wish There had been Resources": A Photo-Elicitation Study of Rectal Cancer Survivorship Care Needs

BACKGROUND

Rectal cancer survivors experience unique, prolonged posttherapy symptoms. Previous data indicate that providers are not skilled at identifying the most pertinent rectal cancer survivorship issues. Consequently, survivorship care is incomplete with the majority of rectal cancer survivors reporting at least one unmet posttherapy need.

METHODS

This photo-elicitation study combines participant-submitted photographs and minimally structured qualitative interviews to explore one's lived experiences. Twenty rectal cancer survivors from a single tertiary canter provided photographs representative of their life after rectal cancer therapy. The iterative steps informed by inductive thematic analysis were used to analyze the transcribed interviews.

RESULTS

Rectal cancer survivors had several recommendations to improve their survivorship care, which fell into three major themes: (1) informational needs (e.g., more details about posttherapy side effects); (2) continued multidisciplinary follow up care (e.g., dietary support); and (3) suggestions for support services (e.g., subsidized bowel altering medications and ostomy supplies).

CONCLUSIONS

Rectal cancer survivors desired more detailed and individualized information, access to longitudinal multidisciplinary follow-up care, and resources to ease the burdens of daily life. These needs may be met through the restructuring of rectal cancer survivorship care to include disease surveillance, symptom management, and support services. As screening and therapy continues to improve, providers must continue to screen and to provide services that address the physical and psychosocial needs of rectal cancer survivors.

What We Talk About When We Talk About Coping: A Qualitative Study of Surgery Residents' Coping following Complications and Deaths

OBJECTIVE

To explore how surgery residents cope with unwanted patient outcomes including post-operative complications and death.

SUMMARY BACKGROUND DATA

Surgery residents face a variety of work-related stressors that require them to engage coping strategies. Post-operative complications and deaths are a common source of such stressors. While few studies examine the response to these events and their impacts on subsequent decision-making, there has been little scholarly work exploring coping strategies among surgery residents specifically.

METHODS

This study investigated the ways in which general surgery residents cope with unwanted patient outcomes, including complications and deaths. Mid-level and senior residents (n=28) from 14 academic, community, and hybrid training programs across the United States participated in exploratory semi-structured interviews conducted by an experienced anthropologist. Interview transcripts were analyzed iteratively, informed by thematic analysis.

RESULTS

When discussing how they cope with complications and deaths, residents described both internal and external strategies. Internal strategies included a sense of inevitability, compartmentalization of emotions or experiences, thoughts of forgiveness, and beliefs surrounding resilience. External strategies included support from colleagues and mentors, commitment to change, and personal practices or rituals, such as exercise or psychotherapy.

CONCLUSIONS

In this novel qualitative study, general surgery residents described the coping strategies that they organically employed following post-operative complications and deaths. In order to improve resident well-being, it is critical to first understand the natural coping processes. Such efforts will facilitate structuring future support systems to aid residents during these difficult periods.

"Their Whole Lives Are Going To Change": A Photo-Elicitation Study of Rectal Cancer Survivorship

BACKGROUND

Rectal cancer survivors experience persistent symptoms, which may lead to unmet needs.

OBJECTIVE

This study aimed to explore the rectal cancer survivor experience and identify the impacts of treatment using photo-elicitation.

DESIGN

This was a novel study in which patients were instructed to take photographs that showed aspects of life that have been challenging to deal with since undergoing treatment. Participants underwent subsequent qualitative interviews using the photographs as prompts.

SETTING

The study was conducted in a cancer center in a tertiary medical center.

PATIENTS

Twenty patients were included who underwent curative-intent rectal cancer treatment.

MAIN OUTCOME MEASURES

Interviews were designed to explore the lived experiences of patients with rectal cancer after treatment.

RESULTS

Three major themes with regard to life after rectal cancer and its treatments emerged: physical symptoms, lifestyle changes, and changes over time. Physical symptoms encompassed GI issues, ostomy difficulties, and genitourinary symptoms. Lifestyle changes included those relating to diet, social life, and hobbies as well as major life changes and finances. Finally, patients spoke of improvement during the time of symptoms and impact on daily life.

LIMITATIONS

There may be bias because of the homogeneity of our study population, which may not represent the experiences of younger patients, those of lower socioeconomic status, or those who chose not to participate. Our sample was also overrepresented by patients with a complete pathologic response after neoadjuvant chemotherapy and excluded individuals with recurrence. Finally, single interviews with each individual at different points from their treatment may have resulted in recall bias.

CONCLUSIONS

This photo-elicitation study provided rectal cancer survivors with a unique opportunity to share how rectal cancer treatment has impacted their lives beyond traditional metrics such as postoperative complications and long-term survival. In addition to improving preoperative counseling and expectation setting, future efforts should focus on postoperative symptom surveillance and appropriate referral when needed. See Video Abstract at http://links.lww.com/DCR/C7.

SUS VIDAS ENTERAS VAN A CAMBIAR UN ESTUDIO DE OBTENCIN DE IMGENES SOBRE LA SUPERVIVENCIA AL CNCER DE RECTO

ANTECEDENTES:Los sobrevivientes de cáncer de recto experimentan síntomas persistentes, lo que puede dar lugar a necesidades no satisfechas.OBJETIVO:Explorar la experiencia de los sobrevivientes de cáncer de recto e identificar los impactos del tratamiento mediante el uso de fotoestimulación.DISEÑO:En este nuevo estudio, se instruyó a los pacientes para que tomaran fotografías que mostraran aspectos de la vida que han sido difíciles de manejar desde que se sometieron al tratamiento. Los participantes se sometieron posteriormente a entrevistas cualitativas utilizando las fotografías como estimuladores.ESCENARIO:Centro oncológico en un centro médico terciario.PARTICIPANTES:Veinte pacientes que se sometieron a tratamiento de cáncer de recto con intención curativa.PRINCIPALES MEDIDAS DE RESULTADO:Las entrevistas se diseñaron para explorar las experiencias vividas por los pacientes con cáncer de recto después del tratamiento.RESULTADOS:Surgieron tres temas principales con respecto a la vida después del cáncer de recto y sus tratamientos: síntomas físicos; cambios en el estilo de vida; y cambios en el tiempo. Los síntomas físicos abarcaron problemas gastrointestinales, dificultades de las ostomías y síntomas genitourinarios. Los cambios en el estilo de vida incluyeron aquellos relacionados con la dieta, la vida social y los pasatiempos, así como cambios importantes en la vida y las finanzas. Por último, los pacientes hablaron de una mejoría con el tiempo de los síntomas y el impacto en la vida diaria.LIMITACIONES:Puede haber sesgo debido a la homogeneidad de nuestra población de estudio, que puede no representar las experiencias de los pacientes más jóvenes, los de nivel socioeconómico más bajo o los que optaron por no participar. Nuestra muestra también estuvo sobrerrepresentada por pacientes con una respuesta patológica completa después de la quimioterapia neoadyuvante y excluyó a los individuos con recurrencia. Finalmente, las entrevistas individuales con cada paciente en diferentes puntos de su tratamiento pueden dar lugar a que los participantes experimenten un sesgo de recuerdo.CONCLUSIONES:Este estudio de obtención de fotografías brinda a los sobrevivientes de cáncer de recto una oportunidad única de compartir cómo el tratamiento del cáncer de recto ha impactado sus vidas más allá de las métricas tradicionales, como las complicaciones posoperatorias y la supervivencia a largo plazo. Además de mejorar el asesoramiento preoperatorio y el establecimiento de expectativas, los esfuerzos futuros deben centrarse en la vigilancia de los síntomas posoperatorios y la derivación adecuada cuando sea necesario. Consulte Video Resumen en http://links.lww.com/DCR/C7.

The Best Gift You Could Give a Resident: A Qualitative Study of Well-Being Resources and Use Following Unwanted Outcomes

In recent years, there has been increasing focus on the well-being of resident physicians. Considering the persistent problem of burnout and attrition particularly among surgical trainees, this is a well-warranted and laudable area of focus. However, despite the widespread adoption of resources available to residents through individual institutions, there is little understanding of how and why these resources are engaged or not during particularly vulnerable moments, such as following an unwanted patient event including postoperative complications and deaths.

Methods

This qualitative study explored access to and usage of resources to promote well-being following an unwanted patient outcome through semi-structured interviews of 28 general surgery residents from 14 residency programs across the United States, including community, academic, and hybrid programs. A qualitative descriptive approach was used to analyze transcripts.

Results

Residents described 3 main types of institutional resources available to them to promote well-being, including counseling services, support from program leadership, and wellness committees. Residents also described important barriers to use for each of these resources, which limited their access and value of these resources. Finally, residents shared their recommendations for future initiatives, including additional protected time off during weekdays and regular usage of structured debrief sessions following adverse patient outcomes.

Conclusions

While institutional resources are commonly available to surgery residents, there remain important limitations and barriers to use, which may limit their effectiveness in supporting resident well-being in times of need. These barriers should be addressed at the program level to improve services and accessibility for residents.

"You Remember Those Days"-A Qualitative Study of Resident Surgeon Responses to Complications and Deaths

OBJECTIVE

Postoperative complications and deaths are unavoidable aspects of a surgical career, but little is known about the impacts of these unwanted outcomes on resident surgeons. The goal of this study was to characterize the impact of complications and deaths on surgery residents in order to facilitate development of improved support systems.

DESIGN

This qualitative study was designed to explore resident surgeons' experiences with unwanted outcomes, including postoperative complications and death. Semi-structured interviews explored a range of topics related to personal experiences with unwanted outcomes. Analyses of interview transcripts were performed iteratively and informed by thematic analysis.

SETTING

An anthropologist at the University of Michigan conducted interviews with general surgery residents from academic, community, and hybrid training programs across the country.

PARTICIPANTS

Twenty-eight mid-level and senior residents (PGY3 and above) were recruited for participation from 14 different training programs across the United States.

RESULTS

Resident surgeons described an initial period of emotional response, characterized by feelings of sadness, frustration, or grief. Simultaneously or soon afterward, interviewees described a period of intellectual response aimed at understanding how and why an outcome occurred, with the expressed goal of learning from it. Many residents described impacts to their personal lives. Several factors that influenced the duration and intensity of these responses were identified, including a sense of ownership, which was a powerful driver for improvement.

CONCLUSIONS

This qualitative study provides a nuanced description of resident surgeons' responses to unwanted outcomes. While emotional responses were characterized by strong feelings, such as sadness and grief, intellectual responses were focused on learning from the events. These data may help inform the development of structured support systems by residency programs.

STRUCTURED ABSTRACT

Facing post-operative complications and deaths is an unavoidable aspect of surgical training, but the impacts on surgery residents has not been well characterized. Through semi-structured interviews with general surgery residents from programs across the United States, this qualitative study explored the ways that residents respond to unwanted outcomes. Residents described an initial period of emotional response, characterized by strong feelings, often of sadness or grief. There was a subsequent or concomitant period of intellectual response, in which residents examined how and why this outcome occurred, with the goal of learning from it. A feeling of ownership was strengthened by involvement in patient care and length of rotation. In light of this detailed description of resident experiences, residency programs can foster the development of improved support for trainees as they navigate these profoundly impactful events.

Patient, Surgeon, or Hospital: Explaining Variation in Outcomes after Colectomy

BACKGROUND

Complication rates after colectomy remain high. Previous work has failed to establish the relative contribution of patient comorbidities, surgeon performance, and hospital systems in the development of complications after elective colectomy.

STUDY DESIGN

We identified all patients undergoing elective colectomy between 2012 and 2018 at hospitals participating in the Michigan Surgical Quality Collaborative. The primary outcome was development of a postoperative complication. We used risk- and reliability-adjusted generalized linear mixed models to estimate the degree to which variance in patient-, surgeon-, and hospital-level factors contribute to complications.

RESULTS

A total of 15,755 patients were included in the study. The mean hospital-level complication rate was 15.8% (range, 8.7% to 30.2%). The proportion of variance attributable to the patient level was 35.0%, 2.4% was attributable to the surgeon level, and 1.8% was attributable to the hospital level. The predicted probability of complication for the least comorbid patient was 1.5% (CI 0.7-3.1%) at the highest performing hospital with the highest performing surgeon, and 6.6% (CI 3.2-12.2%) at the lowest performing hospital with the lowest performing surgeon. By contrast, the most comorbid patient in the cohort had a 66.3% (CI 39.5-85.6%) or 89.4% (CI 73.7-96.2%) risk of complication.

CONCLUSIONS

This study demonstrated that variance from measured factors at the patient level contributed more than 8-fold more to the development of complications after colectomy compared with variance at the surgeon and hospital level, highlighting the impact of patient comorbidities on postoperative outcomes. These results underscore the importance of initiatives that optimize patient foundational health to improve surgical care.

It's not fine: A photo-elicitation study of rectal cancer survivors' emotions and coping strategies

BACKGROUND

Comprehensive cancer care includes supporting the psychological health of survivors who are at high risk of distress. However, little is known about the emotional experiences of rectal cancer survivors specifically. We sought to explore psychological well-being and coping strategies utilized by rectal cancer survivors.

METHODS

Twenty rectal cancer survivors shared photographs of their post-treatment experiences. In follow-up interviews, participants discussed photographs' meanings and emotional experiences during their cancer journey. Transcribed interviews were analyzed using iterative steps of inductive thematic analysis.

RESULTS

Emotions ranged from sadness to anxiety and fear of cancer recurrence. Coping mechanisms were grouped into 3 categories: (1) seeking support and information; (2) focus on attitudes and perspectives; and (3) distancing strategies.

CONCLUSION

Our results highlight the persistent psychological impact of rectal cancer and need for additional support for survivors. Providers may help temper patients' fear of recurrence by explicitly discussing prognosis and risk of recurrence. Although multidisciplinary survivorship clinics are ideal, all cancer care providers and primary care physicians should feel empowered to screen for psychological distress and refer patients to appropriate resources when needed.

High-risk surgery among older adults: Not-quite shared decision-making

BACKGROUND

Shared decision-making is critical to optimal patient-centered care. For elective operations, when there is sufficient time for deliberate discussion, little is known about how surgeons navigate decision-making and how surgeons align care with patient preferences. In this context, we sought to explore surgeons' approaches to decision-making for adults ≥65 years at high-risk of postoperative complications or death.

METHODS

We conducted semistructured in-depth interviews with 46 practicing surgeons across Michigan. Transcripts were iteratively analyzed through steps informed by inductive thematic analysis.

RESULTS

Four major themes emerged characterizing how surgeons approach high-risk surgical decision-making for older adults: (1) risk assessment was defined as the process used by surgeons to identify and analyze factors that may negatively impact outcome; (2) expectations and goals described the process of surgeons engaging with patients and families to discuss potential outcomes and desired objectives; (3) external and internal motivating factors outlined extrinsic dynamics (eg, quality metrics, referrals) and intrinsic drivers (eg, surgeons' personal experiences) that influenced high-risk decision-making; and (4) decision-making approaches and challenges encompassed the roles of patients and surgeons and obstacles to engaging in a true shared decision-making process.

CONCLUSION

Although shared decision-making is strongly recommended, we found that surgeons who perform high-risk operations among older adults predominantly focused on assessing risk and setting expectations with patients and families rather than inviting them to actively participate in the decision-making process. Surgeons also reported influences on decision-making from quality metrics, referrals, and personal experiences. Patient involvement, however, was seldom discussed suggesting that surgeons may not be engaging in true shared decision-making when benefits should be weighed against a high likelihood of harm.

Potentiation of serotonin signaling protects against intestinal ischemia and reperfusion injury in mice

BACKGROUND

Knock-out of serotonin re-uptake transporters (SERT) or use of selective serotonin re-uptake inhibitors (SSRIs) potentiates enteric serotonin (5-HT) signaling and stimulates enterocyte proliferation. We hypothesized that increased serotonin signaling would mitigate epithelial injury from intestinal ischemia and reperfusion (I/R).

METHODS

Mice lacking SERT (SERTKO mice) and wild-type littermates (WTLM) were subjected to intestinal ischemia by superior mesenteric artery (SMA) occlusion. At intervals post-laparotomy with or without ischemia, ileum was harvested and prepared for staining. A WTLM subgroup treated with SSRI after SMA occlusion followed by reperfusion was also sacrificed and analyzed. Mucosal injury was scored, percentage of injured villi calculated, and enterocyte proliferation measured. Lastly, staining for enterocytes, enteroendocrine cells, and goblet cells, villus epithelial cellular make-up was investigated at baseline and 14 days after injury. Measurements were compared between groups using t test and chi-squared test.

KEY RESULTS

Mucosal injury after I/R was significantly decreased in SERTKO and SSRI-treated mice compared to WTLM at all intervals except baseline. Enterocyte proliferation was greater in SERTKO and SSRI-treated mice without alteration in cellular composition along villi (P > 0.05).

CONCLUSIONS AND INFERENCES

Potentiation of 5-HT signaling is associated with mucosal protection from intestinal I/R injury without alterations in villus cell distribution, possibly via increased rates of enterocyte renewal.

Localization of muscarinic acetylcholine receptor 2 to the intestinal crypt stem cell compartment

The data presented in this article are related to the research article entitled “Distribution of muscarinic acetylcholine receptor subtypes in the murine small intestine” (E.D. Muise, N. Gandotra, J.J. Tackett, M.C. Bamdad, R.A. Cowles, 2016) [1]. We recently demonstrated that neuronal serotonin stimulates intestinal crypt cell division, and induces villus growth and crypt depth (E.R. Gross, M.D. Gershon, K.G. Margolis, Z.V. Gertsberg, Z. Li, R.A. Cowles, 2012; M.D. Gershon, 2013) [2], [3]. Scopolamine, a nonspecific muscarinic receptor antagonist, inhibited serotonin-induced intestinal mucosal growth [2]. Here we provide data regarding the localization of muscarinic acetylcholine receptor 2 to the intestinal crypt stem cell compartment.

Distribution of muscarinic acetylcholine receptor subtypes in the murine small intestine

AIMS

Serotonin stimulates enterocyte turnover in the small intestine and studies suggest this is mediated by neuronal signaling via a cholinergic pathway. Distribution of the five known muscarinic receptor subtypes (mAChRs) in the small intestine has not been fully studied, and their role in intestinal growth is unknown. We hypothesized that mAChRs have distinct anatomic distributions within the bowel, and that mAChRs present within intestinal crypts mediate the effects of acetylcholine on the small intestinal mucosa.

MAIN METHODS

Small intestine from male C57BL/6 mice ages 2, 4, 6, and 8weeks were harvested. RNA was isolated and cDNA synthesized for PCR-amplification of subtype specific mAChRs. Ileum was fixed with Nakane, embedded in epon, and immunofluorescence microscopy performed using polyclonal antibodies specific to each mAChR1-5.

KEY FINDINGS

All five mAChR subtypes were present in the mouse duodenum, jejunum, and ileum at all ages by RT-PCR. Immunofluorescence microscopy suggested the presence of mAChR1-5 in association with mature enterocytes along the villus and within the myenteric plexus. Only mAChR2 clearly localized to the crypt stem cell compartment, specifically co-localizing with Paneth cells at crypt bases.

SIGNIFICANCE

Muscarinic receptors are widely distributed along the entire alimentary tract. mAChR2 appears to localize to the crypt stem cell compartment, suggesting it is a plausible regulator of stem cell activity. The location of mAChR2 to the crypt makes it a potential therapeutic target for treatment of intestinal disease such as short bowel syndrome. The exact cellular location and action of each mAChR requires further study.

Enhanced serotonin signaling stimulates ordered intestinal mucosal growth

BACKGROUND

Significant quantities of serotonin (5-hydroxytryptamine; 5-HT) are found in the intestine, and studies have demonstrated that 5-HT can stimulate enterocyte cell division, suggesting regulatory roles in mucosal homeostasis and intestinal adaptation. We hypothesized that excess enteric 5-HT signaling enhances mucosal growth without changing intestinal villous cellular makeup.

METHODS

Mice lacking the serotonin reuptake transporter (SERT) and wild-type littermates (WTLM) were euthanized and their ileum analyzed. Villus height (VH), crypt depth (CD), and enterocyte height (EH) were measured. Enterocyte cell division was measured using Ki-67 immunofluorescence to calculate crypt proliferation index (CPI). Cellular distribution along villi was investigated by immunofluorescent staining for enterocytes, enteroendocrine cells, and goblet cells. Group measurements were compared using t-test and chi-squared test.

RESULTS

SERT knock-out (SERTKO) mice had significantly taller villi, deeper crypts, and taller enterocytes compared with WTLM (P < 0.0001). Similarly, enterocyte proliferation was greater in SERTKO compared with WTLM (P < 0.01). For SERTKO, mean values were: VH, 255.6 μm; CD, 66.7 μm; EH, 21.2 μm; and CPI, 52.8%. For WTLM, corresponding values were: VH, 207.8 μm; CD, 56.1 μm; EH, 19.5 μm; and CPI, 31.9%. The cellular composition along villi was not significantly different between genotypes (P > 0.05).

CONCLUSIONS

Enhancing 5-HT signaling in mice increases VH, CD, EH, and crypt cell proliferation in the intestinal mucosa. 5-HT-associated growth did not alter the cellular composition of the villi. Serotonin may represent an important physiologic regulator of intestinal growth and adaptation and holds promise as a target for therapies aimed at enhancing intestinal recovery after injury or mucosal surface area loss.

Accurate assessment of bowel length: the method of measurement matters

PURPOSE

Small intestinal length has prognostic significance for patients with short bowel syndrome, and accurate measurement of Roux-en-Y limbs is considered important. The flexible elasticity of bowel makes its measurement highly subjective, yet a recommended method for intestinal measurement allowing accurate comparisons between surgeons remains undefined. Measurement of intestinal length has been described, but no comparison of the fidelity of measurement technique has been made. We hypothesized that silk suture and umbilical tape would yield the most consistent measurements.

METHODS

This institutional review board-approved prospective trial enrolled 12 volunteer surgeons and two Institutional Animal Care and Use Committee-donated rabbits. Participants were asked to measure short, medium, and long segments of small intestine in a euthanized rabbit using common operating room tools: 18-in silk suture, 75-cm umbilical tape, 15-cm straight ruler, laparoscopic Dorsey bowel graspers. Data were analyzed by analysis of variance repeated measures model.

RESULTS

Over short segments, intestinal measurements by grasper were significantly shorter than those by tape (P = 0.002) and ruler (P = 0.039). Over medium lengths of bowel, measurements by grasper were significantly shorter than those by suture (P = 0.032) and tape (P = 0.046), and measurements by ruler also were significantly shorter than those by suture (P = 0.008). Over the long intestinal segment, measurements by ruler resulted in the greatest variability, and comparison of variance across all possible pairs of groups found significant difference by method of measurement (P = 0.049). There was a significant difference in measurements taken along the mesenteric border compared with those taken along the antimesenteric border (P = 0.001).

CONCLUSIONS

Measurement technique along short segments matters less; however, rigid tools underestimate length, and smaller variances in measurement by silk suture and umbilical tape suggest that these methods are more reliable across longer distances.

Enhanced serotonin signaling increases intestinal neuroplasticity

BACKGROUND

The intestinal mucosa recovers from injury by accelerating enterocyte proliferation resulting in villus growth. A similar phenomenon is seen after massive bowel resection. Serotonin (5-HT) has been implicated as an important regulator of mucosal homeostasis by promoting growth in the epithelium. The impact of 5-HT on other components of growing villi is not known. We hypothesized that 5-HT-stimulated growth in the intestinal epithelium would be associated with growth in other components of the villus such as enteric neural axonal processes.

MATERIALS AND METHODS

Enteric serotonergic signaling is inactivated by the serotonin reuptake transporter, or SERT, molecule. Enhanced serotonin signaling was achieved via SERT knockout (SERTKO) and administration of selective serotonin reuptake inhibitors (SSRI) to wild-type mice (WT-SSRI). 5-HT synthesis inhibition was achieved with administration of 4-chloro-L-phenylalanine (PCPA). Intestinal segments from age-matched WT, SERTKO, WT-SSRI, and corresponding PCPA-treated animals were assessed via villus height, crypt depth, and crypt proliferation. Gap 43, a marker of neuroplasticity, was assessed via immunofluorescence and Western blot.

RESULTS

SERTKO and WT-SSRI mice had taller villi, deeper crypts, and increased enterocyte proliferation compared with WT mice. Gap 43 expression via immunofluorescence was significantly increased in SERTKO and WT-SSRI samples, as well as in Western blot analysis. PCPA-treated SERTKO and WT-SSRI animals demonstrated reversal of 5-HT-induced growth and Gap 43 expression.

CONCLUSIONS

Enhanced 5-HT signaling results in intestinal mucosal growth in both the epithelial cell compartment and the enteric nervous system. Furthermore, 5-HT synthesis inhibition resulted in reversal of effects, suggesting that 5-HT is a critically important regulator of intestinal mucosal growth and neuronal plasticity.