Is the writing on the wall? The relationship between the number of disease-modifying anti-inflammatory bowel disease drugs used and the risk of surgical resection

BACKGROUND

Disease-modifying anti-inflammatory bowel disease drugs (DMAIDs) revolutionized the management of ulcerative colitis (UC). This study assessed the relationship between the number and timing of drugs used to treat UC and the risk of colectomy and postoperative complications.

METHODS

This was a retrospective review of adult patients with UC treated with disease-modifying drugs between 2005 and 2020 in the MarketScan database. Landmark and time-varying regression analyses were used to analyze risk of surgical resection. Multivariable Cox regression analysis was used to determine risk of postoperative complications, emergency room visits, and readmissions.

RESULTS

A total of 12,193 patients with UC and treated with disease-modifying drugs were identified. With a median follow-up time of 1.7 years, 23.8% used >1 drug, and 8.3% of patients required surgical resection. In landmark analyses, using 2 and ≥3 drugs before the landmark date was associated with higher incidence of surgery for each landmark than 1 drug. Multivariable Cox regression showed hazard ratio (95% CIs) of 4.22 (3.59-4.97), 11.7 (9.01-15.3), and 22.9 (15.0-34.9) for using 2, 3, and ≥4 drugs, respectively, compared with using 1 DMAID. That risk was constant overtime. The number of drugs used preoperatively was not associated with an increased postoperative risk of any complication, emergency room visits, or readmission.

CONCLUSION

The use of multiple disease-modifying drugs in UC is associated with an increased risk of surgical resection with each additional drug. This provides important prognostic data and highlights the importance of patient counseling with minimal concern regarding risk of postoperative morbidity for additional drugs.

Closed-incision negative-pressure wound therapy reduces superficial surgical site infections after open colon surgery: an NSQIP Colectomy Study

BACKGROUND

The use of closed-incision negative-pressure wound therapy (iNPWT) has increased in the last decade across surgical fields, including colectomy.

AIM

To compare postoperative outcomes associated with use of iNPWT following open colectomy from a large national database.

METHODS

A retrospective review of patients who underwent operations from 2015 to 2020 was performed using the National Surgical Quality Improvement Program (NSQIP) Targeted Colectomy Database. Intraoperative placement of iNPWT was identified in patients undergoing open abdominal operations with closure of all wound layers including skin. Propensity score matching was performed to define a control group who underwent closure of all wound layers without iNPWT. Patients were matched in a 1:4 (iNPWT vs control) ratio and postoperative rates of superficial, deep and organ-space surgical site infection (SSI), wound disruption, and readmission.

FINDINGS

A matched cohort of 1884 was selected. Patients with iNPWT had longer median operative time (170 (interquartile range: 129-232) vs 161 (114-226) min; P<0.05). Compared to patients without iNPWT, patients with iNPWT experienced a lower rate of 30-day superficial incisional SSI (3% vs 7%; P<0.05) and readmissions (10% vs 14%; P<0.05). iNPWT did not decrease risk of deep SSI, organ-space SSI, or wound disruption.

CONCLUSION

Although there is a slightly increased operative time, utilization of iNPWT in open colectomy is associated with lower odds of superficial SSI and 30-day readmission. This suggests that iNPWT should be routinely utilized in open colon surgery to improve patient outcomes.

Increasing Adoption of Laparoscopy in Urgent and Emergent Colectomies for Pediatric Ulcerative Colitis

INTRODUCTION

While minimally invasive surgery (MIS) approaches are commonly utilized in the elective surgical setting for pediatric ulcerative colitis (UC), their role in urgent and emergent disease is less clear. We aim to assess trends in the surgical approaches for pediatric UC patients requiring urgent and emergent colectomies and their associated outcomes.

METHODS

Retrospective review of 81 pediatric UC patients identified in National Surgical Quality Improvement Program Pediatric who underwent urgent or emergent colectomy (2012-2019). Trends in approach were assessed using linear regression. Patient characteristics and clinical outcomes were stratified by approach and compared using standard univariate statistics. Multivariable analysis was used to model the influence of covariates on postoperative length of stay.

RESULTS

The proportion of MIS cases increased by 5.53% per year (P = 0.01) over the study interval. Sixty-three patients (77.8%) received MIS resections and 18 patients (22.2%) received open resections. Patients undergoing open colectomies were younger and had a higher proportion of preoperative conditions, most notably preoperative sepsis (27.8% versus 4.8%, P = 0.01), and higher American Society of Anesthesiologists [III-IV] classification (83.3% versus 58.8%, P = 0.004). Mean operative time was comparable (open, 173.6 versus MIS, 206.1 min). In the univariate analysis, open approach was associated with increased postoperative length of stay (13.1 versus 7.2 d, P = 0.002). However, after adjusting for confounders, there was no significant difference.

CONCLUSIONS

There has been a steady increase in the adoption of laparoscopy in urgent and emergent colectomy for pediatric UC. Short-term outcomes between approaches appear comparable.

Survival outcomes of anal adenocarcinoma versus rectal adenocarcinoma: A retrospective cohort study

BACKGROUND

Anal adenocarcinoma (AA) is a rare malignancy with decreased survival compared to rectal adenocarcinoma (RA). However, AA continues to be treated with similar algorithms compared to rectal cancer with minimal data regarding the efficacy of these treatment algorithms.

METHODS

A retrospective chart review of patients with non-metastatic AA at a single tertiary-care institution from 1995 to 2020. This cohort was matched 2:1 to a group of RA patients for comparison. The primary outcome of interest was overall survival rates.

RESULTS

Sixteen patients with stages I-III AA were matched to a cohort of RA. There were no significant differences between the cohorts with regard to patient demographics, comorbidities, disease stage or histologic features. There were also no significant differences in treatment modalities between the two cohorts with a majority undergoing multimodal therapy with chemoradiation and surgery. All patients with AA demonstrated significantly worse survival than all patients with rectal adenocarcinoma (five-year survival 47.7% vs. 82.3%, respectively. p < 0.05). When looking at a sub-group of patients who underwent combination chemoradiation and surgery from each cohort, anal adenocarcinoma continued to exhibit lower overall survival (five-year survival 41.6% and 86.4%, respectively. p < 0.05). In a multi-variable model that adjusted for location, American Joint Committee on Cancer (AJCC) stage and treatment pathway, tumor location in the anal canal was an independent predictor of overall survival (Hazard ratio [HR] 2.7, p < 0.05).

CONCLUSION

AA has worse survival as compared to RA despite similar treatment. This study highlights the need to evaluate the current classification and treatment pathways to improve outcomes.

Changing disposition patterns in the era of COVID-19 after colon resections: A National Surgical Quality Improvement Program colectomy study

BACKGROUND

The COVID-19 pandemic severely impacted post-hospitalization care facilities in the United States and hindered their ability to accept new patients for various reasons. This study aimed to assess the impact of the pandemic on discharge disposition after colon surgery and associated postoperative outcomes.

METHODS

A retrospective cohort study was performed using the National Surgical Quality Improvement Participant Use File and targeted colectomy. Patients were divided into the following 2 cohorts: (1) pre-pandemic (2017-2019) and (2) pandemic (2020). The primary outcomes included discharge disposition-post-hospitalization facility versus home. The secondary outcomes were rates of 30-day readmissions and other postoperative outcomes. The multivariable analysis assessed for confounders and effect modification on discharge to home.

RESULTS

Discharge to posthospitalization facilities decreased by 30% in 2020 compared to 2017 to 2019 (7% vs 10%, P < .001). This occurred despite an increase in emergency cases (15% vs 13%, P < .001) and open surgical approach (32% vs 31%, P < .001) in 2020. Multivariable analysis revealed that patients in 2020 had 38% lower odds of going to post-hospitalization facilities (odds ratio 0.62, P < .001) after adjusting for surgical indications and underlying comorbidities. This decrease in patients going to a post-hospitalization facility was not associated with an increased length of stay or an increase in 30-day readmissions or postoperative complications.

CONCLUSION

During the pandemic, patients undergoing colonic resection were less likely to be discharged to a post-hospitalization facility. This shift was not associated with an increase in 30-day complications. This should prompt further research to assess the reproducibility of these associations, especially in a setting without a global pandemic.

Neoadjuvant chemotherapy does not increase risk for anastomotic leak for simultaneous resection of primary colon cancer with synchronous liver metastasis: A NSQIP-colectomy analysis

BACKGROUND AND OBJECTIVES

In patients with colon cancer with synchronous liver metastasis, treatment algorithms are complex and often require multidisciplinary evaluation. Neoadjuvant therapy is frequently utilized, but there is an unclear relationship with postoperative outcomes in patients with simultaneous resection.

METHODS

This is a retrospective cohort study from the National Surgical Quality Improvement Program and Targeted Colectomy databases. All patients with stage IV colon cancer undergoing simultaneous colectomy with synchronous liver metastasis resection or ablation between 2015 and 2019 were identified and categorized into subgroups based on receipt of neoadjuvant chemotherapy. Multivariable logistic regression was utilized to assess for risk factors of anastomotic leaks and serious postoperative complications.

RESULTS

We identified 1006 patients who underwent simultaneous colectomy and liver operations. Of those, 418 (41.6%) received neoadjuvant chemotherapy within 90 days of surgery, while 588 (58.4%) had simultaneous upfront surgery. On multivariable logistic regression, neoadjuvant therapy was not associated with postoperative anastomotic leaks (odds ratio [OR]: 1.30; p = 0.39) or serious complications (OR: 1.04; p = 0.82).

CONCLUSION

Neoadjuvant therapy does not increase postoperative complications in simultaneous colon and liver resections. These results may alleviate concerns regarding postoperative morbidity in the decision-making process of administering neoadjuvant therapy.

The Impact of Preoperative Anti-TNFα Therapy on Postoperative Outcomes Following Ileocolectomy in Crohn's Disease

BACKGROUND

Controversy remains regarding the impact of anti-TNFα agents on postoperative outcomes in Crohn's disease.

METHODS

Patients (≥ 18 years) with Crohn's disease (ICD-9, 555.0-555.2, 555.9) undergoing ileocolectomy between 2005 and 2013 were identified using the Truven MarketScan® database and stratified by receipt of anti-TNFα therapy. Multivariable logistic regression was performed to evaluate anti-TNFα use on emergency department (ED) visits, postoperative complications, and readmissions at 30 days, adjusting for potential confounders. Relationships between timing of anti-TNFα administration and outcomes were examined.

RESULTS

The sample contained 2364 patients with Crohn's disease undergoing ileocolectomy, with 28.5% (n = 674) who received biologic therapy. Median duration between anti-TNFα therapy and surgery was 33 days. Postoperative ED visits and readmission rates did not significantly differ among those receiving biologics and those that did not. Overall 30-day complication rates were higher among those receiving biologic therapy, namely related to wound and infectious complications. In multivariable analysis, anti-TNFα inhibitors were associated with increased odds of postoperative complications at 30 days (aggregate complications [OR 1.6], infectious complications [OR 1.5]). There was no significant association between timing of anti-TNFα administration and occurrence of postoperative outcomes.

CONCLUSION

Anti-TNFα therapy is independently associated with increased postoperative infectious complications following ileocolectomy in Crohn's disease. However, in patients receiving anti-TNFα therapy within 90 days of operative intervention, further delaying surgery may not attenuate risk of postoperative complications.

Correlation between Venous Thromboembolism Risk and Venous Congestion in Microvascular Reconstruction of the Lower Extremity

BACKGROUND

Risk for venous thromboembolism formation and the relationship to postoperative free flap venous congestion and flap failure have not been adequately evaluated in a trauma population. The authors aim to use the Caprini Risk Assessment Model to evaluate the association between venous thromboembolism risk and postoperative flap venous congestion following lower extremity free tissue transfer.

METHODS

A retrospective analysis was conducted of all patients who underwent lower extremity free flap reconstruction of traumatic defects at a single institution between 2007 and 2016. A Wilcoxon rank sum test was used for nonparametric analysis of aggregate Caprini Risk Assessment Model scores and flap outcomes. Flap venous congestion and failure rates as associated with the categorical variables underlying the Caprini Risk Assessment Model were further studied. Logistic regression was used to evaluate each of these outcomes and other flap-related covariates relative to the Caprini Risk Assessment Model categorical variables that had the greatest effect on our patient sample.

RESULTS

One hundred twelve patients underwent lower extremity free flap reconstruction. One hundred eight free flaps were analyzed. Eight patients were excluded. The majority of patients were male (75.9 percent) and required reconstruction because of acute trauma (68.1 percent versus 31.9 percent for chronic wounds). There was no statistically significant association found between age, body mass index, or timing of trauma versus venous congestion, flap failure, or other flap-related covariates.

CONCLUSION

In patients with significantly elevated Caprini Risk Assessment Model scores, there was no significant association between venous thromboembolism risk and flap failure following free tissue reconstruction of lower extremities.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Risk, III.

Development and Validation of a Prediction Model for Mortality and Adverse Outcomes Among Patients With Peripheral Eosinopenia on Admission for Clostridium difficile Infection

Importance

Recent evidence from an animal model suggests that peripheral loss of eosinophils in Clostridium difficile infection (CDI) is associated with severe disease. The ability to identify high-risk patients with CDI as early as the time of admission could improve outcomes by guiding management decisions.

Objective

To construct a model using clinical indices readily available at the time of hospital admission, including peripheral eosinophil counts, to predict inpatient mortality in patients with CDI.

Design, Setting, and Participants

In a cohort study, a total of 2065 patients admitted for CDI through the emergency department of 2 tertiary referral centers from January 1, 2005, to December 31, 2015, formed a training and a validation cohort. The sample was stratified by admission eosinophil count (0.0 cells/μL or >0.0 cells/μL), and multivariable logistic regression was used to construct a predictive model for inpatient mortality as well as other disease-related outcomes.

Main Outcomes and Measures

Inpatient mortality was the primary outcome. Secondary outcomes included the need for a monitored care setting, need for vasopressors, and rates of inpatient colectomy.

Results

Of the 2065 patients in the study, 1092 (52.9%) were women and patients had a mean (SD) age of 63.4 (18.4) years. Those with an undetectable eosinophil count at admission had increased in-hospital mortality in both the training (odds ratio [OR], 2.01; 95% CI, 1.08-3.73; P = .03) and validation (OR, 2.26; 95% CI, 1.33-3.83; P = .002) cohorts in both univariable and multivariable analysis. Undetectable eosinophil counts were also associated with indicators of severe sepsis, such as admission to monitored care settings (OR, 1.40; 95% CI, 1.06-1.86), the need for vasopressors (OR, 2.08; 95% CI, 1.32-3.28), and emergency total colectomy (OR, 2.56; 95% CI, 1.12-5.87). Other significant predictors of mortality at admission included increasing comorbidity burden (for each 1-unit increase: OR, 1.13; 95% CI, 1.05-1.22) and lower systolic blood pressures (for each 1-mm Hg increase: OR, 0.99; 95% CI, 0.98-1.00). In a subgroup analysis of patients presenting without initial tachycardia or hypotension, only patients with undetectable admission eosinophil counts, but not those with an elevated white blood cell count, had significantly increased odds of inpatient mortality (OR, 5.76; 95% CI, 1.99-16.64).

Conclusions and Relevance

This study describes a simple, widely available, inexpensive model predicting CDI severity and mortality to identify at-risk patients at the time of admission.

Truven Health Analytics MarketScan Databases for Clinical Research in Colon and Rectal Surgery

The MarketScan databases are a family of administrative claims databases that contain data on inpatient and outpatient claims, outpatient prescription claims, clinical utilization records, and healthcare expenditures. The three main databases available for use are each composed of a convenience sample for one of the following patient populations: (1) patients with employer-based health insurance from contributing employers, (2) Medicare beneficiaries who possess supplemental insurance paid by their employers, and (3) patients with Medicaid in one of eleven participating states. Eleven supplemental databases are available, which are utilized to overcome the limited clinical data available in the core MarketScan databases. There are several limitations to this database, primarily related to the fact that individuals or their family members within two of the core databases mandatorily possess some form of employer-based health insurance, which prevents the dataset from being nationally representative. Nonetheless, this database provides detailed and rigorously maintained claims data to identify healthcare utilization patterns among this cohort of patients.

Physical Well-Being and Route of Benign Hysterectomy

OBJECTIVES

We sought to determine if there is an association between preoperative risk factors as defined by the American Society of Anesthesiologists (ASA) physical status score and the route of hysterectomy for benign indications.

METHODS

In this retrospective cohort study, the American College of Surgeons National Surgical Quality Improvement Project database was used to determine the route of hysterectomy, using Current Procedural Terminology codes, and associated ASA class. The analysis included abdominal, vaginal, total laparoscopic, and laparoscopic assisted vaginal routes of hysterectomy. Routes of hysterectomy were also grouped as either abdominal or minimally invasive for analysis. Multinomial logistic regression was used to model route of hysterectomy as a function of patient covariates, including ASA class, age, race and ethnicity, and body mass index.

RESULTS

The analysis included 117,919 patients from the National Surgical Quality Improvement Project database. Patients with ASA classification of III or IV to V had significantly decreased odds of undergoing a minimally invasive approach for hysterectomy (odds ratio [OR], 0.81 [95% confidence interval (CI)], 0.77-0.85; and OR, 0.42 [95% CI, 0.37-0.48], respectively). Secondary outcome analysis revealed that a body mass index of more than 30 kg/m² was associated with significantly lower odds of undergoing a minimally invasive hysterectomy (OR, 0.87; 95% CI, 0.85-0.89). With respect to race/ethnicity, all non-White groups had decreased odds of undergoing a hysterectomy via a minimally invasive approach. Age 75 years or older was correlated with an increased likelihood of minimally invasive hysterectomy (OR, 1.18; 95% CI, 1.10-1.26).

CONCLUSIONS

Patients with increased preoperative risk as defined by a high ASA classification are less likely to undergo a hysterectomy using a minimally invasive route for benign indications.

Prognostic Significance of Tumor Deposits in Stage III Colon Cancer

BACKGROUND

The American Joint Committee on Cancer includes extranodal tumor deposits in the tumor-node-metastasis classification of colon cancer. However, it is unclear how tumor deposits compare with lymph node metastases in prognostic significance. This study evaluated the survival impact of tumor deposits relative to lymph node metastases in stage III colon cancer.

METHODS

The US National Cancer Database (2010-2012) was reviewed for resectable stage III adenocarcinoma of the colon, and stratified by presence of tumor deposits and lymph node metastases. Univariate and multivariate survival analyses were performed.

RESULTS

Of 6424, 10.1% had both tumor deposits and lymph node metastases [5-year survival (5YS) 40.2%], 2.5% had tumor deposits alone (5YS 68.1%), and 87.4% had lymph node metastases alone (5YS 55.4%). Patients with lymph node metastases alone tended to have a greater number of lymph nodes retrieved (20.9 versus 18.8, p = 0.0126) and were more likely to receive adjuvant therapy (66.9 vs 58.0%, p = 0.003) than those with only tumor deposits. Patients with both had significantly worse survival at all T stages (p < 0.05, all). There was no significant difference in survival between tumor deposits alone and lymph node metastases alone at any T stage (p > 0.8, all). After controlling for patient, disease, and treatment characteristics, patients with tumor deposits alone [hazard ratio (HR) 0.56, p = 0.001] or only lymph node metastases (HR 0.64, p < 0.001) were associated with improved survival relative to patients with both.

CONCLUSIONS

Concomitant presence of tumor deposits and lymph node invasion carries poor prognostic significance. Tumor deposits alone appear to have prognostic implications similar to lymph node invasion alone.

Association of Preoperative Anti-Tumor Necrosis Factor Therapy With Adverse Postoperative Outcomes in Patients Undergoing Abdominal Surgery for Ulcerative Colitis

Importance

Despite the increasing use of anti-tumor necrosis factor (TNF) therapy in ulcerative colitis, its effects on postoperative outcomes remain unclear, with many patients requiring surgical intervention despite optimal medical management.

Objective

To assess the association of preoperative use of anti-TNF agents with adverse postoperative outcomes.

Design, Setting, and Participants

This analysis used insurance claims data from a large national database to identify patients 18 years or older with ulcerative colitis. These insured patients had inpatient and/or outpatient claims between January 1, 2005, and December 31, 2013, with Current Procedural Terminology codes for a subtotal colectomy or total abdominal colectomy, a total proctocolectomy with end ileostomy, or a combined total proctocolectomy and ileal pouch-anal anastomosis. Only data regarding the first or index surgical admission within the time frame were abstracted. Use of anti-TNF agents, corticosteroids, and immunomodulators within 90 days of surgery was identified using Healthcare Common Procedure Coding System codes. Inclusion in the study required the patient to have an International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) diagnosis code for ulcerative colitis. Exclusion occurred if the patient had a secondary ICD-9-CM diagnosis code for Crohn disease or if the patient was not continuously enrolled in an insurance plan for at least 180 days before and after the index surgery. Data were collected and analyzed from February 1, 2015, to June 2, 2016.

Main Outcomes and Measures

Outcomes included 90-day complications, emergency department visits, and readmissions. Multivariable logistic regression was used to model covariates, including anti-TNF agent use, on the occurrence of outcomes.

Results

Of the 2476 patients identified, 1379 (55.7%) were men, and the mean (SD) age was 42.1 (12.9) years. Among these, 950 (38.4%) underwent subtotal colectomy or total abdominal colectomy, 354 (14.3%) underwent total proctocolectomy with end ileostomy, and 1172 (47.3%) received ileal pouch-anal anastomoses. In univariate analyses, increased postoperative complications were observed among patients in the ileal pouch cohort who received anti-TNF agents preoperatively vs those who did not (137 [45.2%] vs 327 [37.6%]; P = .02) but not among those in the colectomy or proctocolectomy cohorts. An increase in complications was also observed on multivariable analyses among patients in the ileal pouch cohort (odds ratio, 1.38; 95% CI, 1.05-1.82).

Conclusions and Relevance

Unlike preoperative anti-TNF agent use among patients who underwent colectomy or total proctocolectomy and experienced no significant increase in postoperative complications, anti-TNF agent use within 90 days of surgery among patients who underwent ileal pouch-anal anastomosis was associated with higher 90-day postoperative complication rates.

Utilization and trends in palliative therapy for stage IV pancreatic adenocarcinoma patients: a U.S. population-based study

BACKGROUND

Pancreatic adenocarcinoma is an aggressive malignancy, with most patients diagnosed with advanced or metastatic disease. Palliative therapies comprise an important, but underutilized, aspect of care. This aim of this study was to characterize the trends, factors, and outcomes associated with utilization of palliative therapies.

METHODS

Patients with stage IV pancreatic adenocarcinoma from the 2003-2011 U.S. National Cancer Database were identified and stratified by receipt of palliative therapy. Linear regression, multivariable logistic regression, and survival analyses using multivariate proportional hazards models were performed.

RESULTS

Sixty-eight thousand and seventy-five patients with stage IV disease were identified, of which only 11,449 (16.8%) underwent designated palliative therapy. The majority received systemic chemotherapy (37.2%), followed by surgery (19.0%), pain management alone (15.3%), radiation (8.1%), referral alone (11.7%), or a combination thereof (8.7%). Utilization of palliative therapies increased from 12.9% in 2003 to 19.2% in 2011 (P<0.001). Patients were less likely to undergo palliation when older than 60 (OR 0.89, P<0.001), or of black or Hispanic race (OR 0.83, P<0.001; OR 0.80, P<0.001, respectively, vs. Caucasians). Presence of comorbidities increased the use of palliative therapy (OR 1.16 per comorbidity, P<0.001). Survival was improved in those receiving palliative systemic chemotherapy (HR 0.55, P<0.001) and palliative surgery (HR 0.94, P<0.001), although this may be due to selection bias.

CONCLUSIONS

Despite the continued dismal prognosis of pancreatic cancer, palliation of symptoms remains underutilized in this country, particularly in non-Caucasian, older patients. Increased awareness of palliative options may help increase its utilization.