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Lo BD, Chen SY, Stem M, Papanikolaou A, Gabre-Kidan A, Safar B, Efron JE, Atallah C. Prevalence of cannabis use disorder and perioperative outcomes in adult colectomy patients: A propensity score-matched analysis. World J Surg 2024; 48:701-712. [PMID: 38342773 DOI: 10.1002/wjs.12085] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2023] [Accepted: 01/06/2024] [Indexed: 02/13/2024]
Abstract
BACKGROUND The decriminalization of cannabis across the United States has led to an increased number of patients reporting cannabis use prior to surgery. However, it is unknown whether preoperative cannabis use disorder (CUD) increases the risk of postoperative complications among adult colectomy patients. METHODS Adult patients undergoing an elective colectomy were retrospectively analyzed from the National Inpatient Sample database (2004-2018). To control for potential confounders, patients with CUD, defined using ICD-9/10 codes, were propensity score matched to patients without CUD in a 1:1 ratio. The association between preoperative CUD and composite morbidity, the primary outcome of interest, was assessed. Subgroup analyses were performed after stratification by age (≥50 years). RESULTS Among 432,018 adult colectomy patients, 816 (0.19%) reported preoperative CUD. The prevalence of CUD increased nearly three-fold during the study period from 0.8/1000 patients in 2004 to 2.0/1000 patients in 2018 (P-trend<0.001). After propensity score matching, patients with CUD exhibited similar rates of composite morbidity (140 of 816; 17.2%) as those without CUD (151 of 816; 18.5%) (p = 0.477). Patients with CUD also had similar anastomotic leak rates (CUD: 5.64% vs. No CUD: 6.25%; p = 0.601), hospital lengths of stay (CUD: 5 days, IQR 4-7 vs. No CUD: 5 days, IQR 4-7) (p = 0.415), and hospital charges as those without CUD. Similar findings were seen among patients aged ≥50 years in the subgroup analysis. CONCLUSIONS Though the prevalence of CUD has increased drastically over the past 15 years, preoperative CUD was not associated with an increased risk of composite morbidity among adult patients undergoing an elective colectomy.
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Affiliation(s)
- Brian D Lo
- Department of Anesthesia, Critical Care, and Pain Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Sophia Y Chen
- Colorectal Research Unit, Department of Surgery, The Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Miloslawa Stem
- Colorectal Research Unit, Department of Surgery, The Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Angelos Papanikolaou
- Colorectal Research Unit, Department of Surgery, The Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Alodia Gabre-Kidan
- Colorectal Research Unit, Department of Surgery, The Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Bashar Safar
- Division of Colon and Rectal Surgery, Department of Surgery, NYU Grossman School of Medicine, New York City, New York, USA
| | - Jonathan E Efron
- Colorectal Research Unit, Department of Surgery, The Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Chady Atallah
- Division of Colon and Rectal Surgery, Department of Surgery, NYU Grossman School of Medicine, New York City, New York, USA
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Chen SY, Radomski SN, Stem M, Done JZ, Caturegli G, Atallah C, Efron JE, Safar B. National trends and outcomes of total proctocolectomy and completion proctectomy ileal pouch-anal anastomosis procedures for ulcerative colitis. Colorectal Dis 2024; 26:497-507. [PMID: 38302723 DOI: 10.1111/codi.16891] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/08/2023] [Revised: 07/27/2023] [Accepted: 01/02/2024] [Indexed: 02/03/2024]
Abstract
AIM The purpose of this study is to assess US operative trends and outcomes of ulcerative colitis (UC) patients undergoing total proctocolectomy with ileal pouch-anal anastomosis (TPC-IPAA) or completion proctectomy with IPAA (CP-IPAA). METHODS Adult UC patients who underwent TPC-IPAA or CP-IPAA were analysed retrospectively using the 2016-2020 American College of Surgeons National Surgical Quality Improvement Program database. Factors associated with 30-day overall and serious morbidity were identified using multivariable logistic regression. RESULTS A total of 1696 patients were identified, with 958 patients (56.5%) undergoing TPC-IPAA and 738 (43.5%) undergoing CP-IPAA. A greater proportion of TPC-IPAAs were performed each year (except in 2019) compared to CP-IPAAs over the study period (P trend <0.001). Unadjusted analysis showed comparable rates of overall (20.8% vs. 24.4%, P = 0.076) and serious morbidity (14.3% vs. 12.7%, P = 0.352) between TPC-IPAA and CP-IPAA patients. Robotic TPC-IPAA had no differences in complications compared to laparoscopic and open approaches. Robotic CP-IPAA had higher anastomotic leak rates and longer hospital length of stay compared to laparoscopic and open approaches. Obesity was associated with increased odds of overall and serious morbidity for patients who underwent TPC-IPAA. Steroid/immunosuppressive therapy was associated with increased odds of overall and serious morbidity for patients who underwent CP-IPAA. CONCLUSIONS Obese patients should be informed of their increased morbidity risk and offered counselling on weight loss prior to surgery when feasible. Patients on steroid/immunosuppressive therapy within 30 days preoperatively should not undergo CP-IPAA or should delay surgery until they can be safely off those medications.
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Affiliation(s)
- Sophia Y Chen
- Colorectal Research Unit, Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Shannon N Radomski
- Colorectal Research Unit, Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Miloslawa Stem
- Colorectal Research Unit, Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Joy Z Done
- Colorectal Research Unit, Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Giorgio Caturegli
- Colorectal Research Unit, Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
- Department of Surgery, Yale University School of Medicine, New Haven, Connecticut, USA
| | - Chady Atallah
- Colorectal Research Unit, Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
- Department of Surgery, NYU Langone Health, New York City, New York, USA
| | - Jonathan E Efron
- Colorectal Research Unit, Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Bashar Safar
- Colorectal Research Unit, Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
- Department of Surgery, NYU Langone Health, New York City, New York, USA
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Radomski SN, Chen SY, Done JZ, Stem M, Safar B, Efron JE, Atallah C. Feasibility of robotic multivisceral resections in colorectal cancer patients: a NSQIP-based study. J Robot Surg 2023; 17:2929-2936. [PMID: 37837599 DOI: 10.1007/s11701-023-01725-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2023] [Accepted: 09/24/2023] [Indexed: 10/16/2023]
Abstract
Multivisceral robotic surgery may be an alternative to sequential procedures in select patients with colorectal cancer who are diagnosed with synchronous lesions or in those who require additional procedures at the time of resection. The aim of this study was to assess utilization of the robot for multivisceral resections and compare the surgical outcomes of this approach to laparoscopic resections. Adult colorectal surgery patients who underwent a colectomy or proctectomy and a concurrent abdominal surgery procedure in the American College of Surgeons NSQIP database (2016-2021) were included. The primary outcomes were 30-day postoperative overall and serious morbidity. Factors associated with morbidity were assessed using a multivariable logistic regression. Of the 3875 patients who underwent simultaneous multivisceral resections, 397 (10.3%) underwent a robotic approach and 962 (24.8%) a laparoscopic approach. Gynecological procedures (38%) comprised the largest proportion of concurrent procedures followed by hepatic resections (18%). On unadjusted analysis, rates of overall morbidity (25.4% vs. 30.0%) and serious morbidity (12.1% vs 12.0%) did not differ between the robotic and laparoscopic approach groups, respectively. The rate of conversion to open was lower for the robotic compared to laparoscopic approach (9.3% vs. 28.8%, p < 0.001), and length of stay was shorter (4 vs. 5, p < 0.001). On adjusted analysis, there was no significant difference in overall (OR 0.87, 95% CI 0.65-1.16, p = 0.34) or serious morbidity (OR 1.12, 95% CI 0.75-1.65, p = 0.59) between the two approaches even after concurrent procedure risk stratification. Robotic multivisceral resections can be performed with acceptable overall and serious morbidity in select patients with colorectal cancer. Rates of conversion and length of stay may be decreased with a robotic approach, and future research is needed to determine the optimal operative approach in this patient population.
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Affiliation(s)
- Shannon N Radomski
- Colorectal Research Unit, Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Sophia Y Chen
- Colorectal Research Unit, Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Joy Zhou Done
- Colorectal Research Unit, Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Miloslawa Stem
- Colorectal Research Unit, Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Bashar Safar
- Colorectal Research Unit, Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
- Divison of Colon and Rectal Surgery, Department of Surgery, NYU Langone Health, New York, NY, USA
| | - Jonathan E Efron
- Colorectal Research Unit, Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Chady Atallah
- Colorectal Research Unit, Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA.
- Divison of Colon and Rectal Surgery, Department of Surgery, NYU Langone Health, New York, NY, USA.
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Radomski SN, Chen SY, Stem M, Done JZ, Efron JE, Safar B, Atallah C. Simultaneous resection of colorectal cancer and synchronous colorectal liver metastases: A risk stratified analysis of the NSQIP database. J Surg Oncol 2023; 128:1095-1105. [PMID: 37448259 PMCID: PMC10592340 DOI: 10.1002/jso.27393] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2023] [Revised: 06/14/2023] [Accepted: 07/03/2023] [Indexed: 07/15/2023]
Abstract
BACKGROUND AND OBJECTIVES Over 25% of patients diagnosed with colorectal cancer (CRC) will develop colorectal liver metastases (CRLM). Controversy exists over the surgical management of these patients. This study aims to investigate the safety of a simultaneous surgical approach by stratifying patients based on procedure risk and operative approach. METHODS Using ACS-NSQIP (2016-2020), patients with CRC who underwent isolated colorectal, isolated hepatic, or simultaneous resections were identified. Colorectal and hepatic procedures were stratified by morbidity risk (high vs. low) and operative approach (open vs. minimally invasive). Thirty-day overall morbidity was compared between risk matched isolated and simultaneous resection groups. RESULTS A total of 65 417 patients were identified, with 1550 (2.4%) undergoing simultaneous resections. A total of 1207 (77.9%) underwent a low-risk colorectal and low-risk liver resection. On multivariate analysis, there was no significant difference in overall morbidity between patients who had a simultaneous open high-risk colorectal/low-risk hepatic procedure compared to patients who had an isolated open high-risk colorectal procedure (odds ratio: 1.19; 95% confidence interval: 0.94-1.50; p = 0.148). All other combinations of simultaneous procedures had statistically significant higher rates of morbidity than the isolated group. CONCLUSIONS Simultaneous resection of colorectal and synchronous CRLM is associated with an increased risk of morbidity in most circumstances in a risk stratified analysis, although rates of readmission and reoperation were not increased. Minimally invasive surgical approaches may significantly mitigate this morbidity.
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Affiliation(s)
- Shannon N. Radomski
- Colorectal Research Unit, Department of Surgery, The Johns Hopkins University School of Medicine, Baltimore, MD, United States
| | - Sophia Y. Chen
- Colorectal Research Unit, Department of Surgery, The Johns Hopkins University School of Medicine, Baltimore, MD, United States
| | - Miloslawa Stem
- Colorectal Research Unit, Department of Surgery, The Johns Hopkins University School of Medicine, Baltimore, MD, United States
| | - Joy Z. Done
- Colorectal Research Unit, Department of Surgery, The Johns Hopkins University School of Medicine, Baltimore, MD, United States
| | - Jonathan E. Efron
- Colorectal Research Unit, Department of Surgery, The Johns Hopkins University School of Medicine, Baltimore, MD, United States
| | - Bashar Safar
- Department of Surgery, New York University, New York, NY, United States
| | - Chady Atallah
- Department of Surgery, New York University, New York, NY, United States
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Chen SY, Radomski SN, Stem M, Papanikolaou A, Gabre-Kidan A, Gearhart SL, Efron JE, Atallah C. Factors associated with not undergoing surgery for locally advanced rectal cancers: An NCDB propensity-matched analysis. Surgery 2023; 174:1323-1333. [PMID: 37852832 DOI: 10.1016/j.surg.2023.09.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2023] [Revised: 08/01/2023] [Accepted: 09/05/2023] [Indexed: 10/20/2023]
Abstract
BACKGROUND The traditional treatment paradigm for patients with locally advanced rectal cancers has been neoadjuvant chemoradiation followed by curative intent surgery and adjuvant chemotherapy. This study aimed to assess surgery trends for locally advanced rectal cancers, factors associated with forgoing surgery, and overall survival outcomes. METHODS Adults with locally advanced rectal cancers were retrospectively analyzed using the National Cancer Database (2004-2019). Propensity score matching was performed. Factors associated with not undergoing surgery were identified using multivariable logistic regression. Kaplan-Meier and log-rank tests were used for 5-year overall survival analysis, stratified by stage and treatment type. RESULTS A total of 72,653 patients were identified, with 64,396 (88.64%) patients undergoing neoadjuvant + surgery ± adjuvant therapy, 579 (0.80%) chemotherapy only, 916 (1.26%) radiation only, and 6,762 (9.31%) chemoradiation only. The proportion of patients who underwent surgery declined over the study period (95.61% in 2006 to 92.29% in 2019, P trend < .001), whereas the proportion of patients who refused surgery increased (1.45%-4.48%, P trend < .001). Factors associated with not undergoing surgery for locally advanced rectal cancers included older age, Black race (odds ratio 1.47, 95% CI 1.35-1.60, P < .001), higher Charlson-Deyo score (score ≥3: 1.79, 1.58-2.04, P < .001), stage II cancer (1.22, 1.17-1.28, P < .001), lower median household income, and non-private insurance. Neoadjuvant + surgery ± adjuvant therapy was associated with the best 5-year overall survival, regardless of stage, in unmatched and matched cohorts. CONCLUSION Despite surgery remaining an integral component in the management of locally advanced rectal cancers, there is a concerning decline in guideline-concordant surgical care for rectal cancer in the United States, with evidence of persistent socioeconomic disparities. Providers should seek to understand patient perspectives/barriers and guide them toward surgery if appropriate candidates. Continued standardization, implementation, and evaluation of rectal cancer care through national accreditation programs are necessary to ensure that all patients receive optimal treatment.
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Affiliation(s)
- Sophia Y Chen
- Colorectal Research Unit, Department of Surgery, The Johns Hopkins University School of Medicine, Baltimore, MD
| | - Shannon N Radomski
- Colorectal Research Unit, Department of Surgery, The Johns Hopkins University School of Medicine, Baltimore, MD
| | - Miloslawa Stem
- Colorectal Research Unit, Department of Surgery, The Johns Hopkins University School of Medicine, Baltimore, MD
| | - Angelos Papanikolaou
- Colorectal Research Unit, Department of Surgery, The Johns Hopkins University School of Medicine, Baltimore, MD; Department of Surgery, NYU Langone Health, NYC, NY
| | - Alodia Gabre-Kidan
- Colorectal Research Unit, Department of Surgery, The Johns Hopkins University School of Medicine, Baltimore, MD
| | - Susan L Gearhart
- Colorectal Research Unit, Department of Surgery, The Johns Hopkins University School of Medicine, Baltimore, MD
| | - Jonathan E Efron
- Colorectal Research Unit, Department of Surgery, The Johns Hopkins University School of Medicine, Baltimore, MD
| | - Chady Atallah
- Colorectal Research Unit, Department of Surgery, The Johns Hopkins University School of Medicine, Baltimore, MD; Department of Surgery, NYU Langone Health, NYC, NY.
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Done JZ, Papanikolaou A, Stem M, Radomski SN, Chen SY, Atallah C, Efron JE, Safar B. Impact of preoperative chemotherapy on perioperative morbidity in combined resection of colon cancer and liver metastases. J Gastrointest Surg 2023; 27:2380-2387. [PMID: 37468732 DOI: 10.1007/s11605-023-05758-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/20/2023] [Accepted: 06/11/2023] [Indexed: 07/21/2023]
Abstract
BACKGROUND Preoperative chemotherapy, or neoadjuvant therapy (NAC) can be used to improve resectability but can also have hepatotoxic effects on the future liver remnant. The purpose of this study was to investigate the impact of NAC on 30-day morbidity among patients undergoing a resection of primary colon cancer and synchronous liver metastases (sLM). METHODS This was a retrospective study using the National Surgical Quality Improvement Program database (2012-2020). The association between NAC and 30-day overall morbidity, the primary outcome, was assessed. Subgroup analyses for low and high-risk procedures were performed. RESULTS Among 968 patients who underwent the combined resection, 571 (58.99%) received NAC. There was a lower rate of 30-day overall morbidity among patients who received NAC (34.50% vs. 41.56%, p = 0.026) and no difference in rates of postoperative liver failure, bile leak, need for invasive intervention for hepatic procedure, and anastomotic leak. On adjusted analyses, patients who received NAC had decreased odds of overall morbidity (OR 0.73, 95% CI 0.55-0.97, p = 0.031) compared to patients who did not receive NAC. On subgroup analyses, patients who received NAC prior to a low risk combined resection had lower rates of overall morbidity on both adjusted and unadjusted analyses. Among those undergoing high-risk combined resections, there was no difference in overall morbidity. DISCUSSION AND CONCLUSION Patients who are deemed to be candidates for preoperative chemotherapy can proceed with planned neoadjuvant chemotherapy prior to combined resection of primary colon cancer and sLM as preoperative neoadjuvant chemotherapy does not appear to be associated with increased postoperative morbidity.
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Affiliation(s)
- Joy Z Done
- Colorectal Research Unit, Department of Surgery, Johns Hopkins University, Baltimore, USA
| | - Angelos Papanikolaou
- Colorectal Research Unit, Department of Surgery, Johns Hopkins University, Baltimore, USA
| | - Miloslawa Stem
- Colorectal Research Unit, Department of Surgery, Johns Hopkins University, Baltimore, USA
| | - Shannon N Radomski
- Colorectal Research Unit, Department of Surgery, Johns Hopkins University, Baltimore, USA
| | - Sophia Y Chen
- Colorectal Research Unit, Department of Surgery, Johns Hopkins University, Baltimore, USA
| | - Chady Atallah
- Colorectal Research Unit, Department of Surgery, Johns Hopkins University, Baltimore, USA
| | - Jonathan E Efron
- Colorectal Research Unit, Department of Surgery, Johns Hopkins University, Baltimore, USA
| | - Bashar Safar
- Colorectal Research Unit, Department of Surgery, Johns Hopkins University, Baltimore, USA.
- Division of Colon and Rectal Surgery, Department of Surgery, New York University Grossman School of Medicine, NYU Langone Health, 530 First Ave, Suite 7V, New York, NY, 10016, USA.
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Radomski SN, Chen SY, Stem M, Done JZ, Atallah C, Safar B, Efron JE, Gabre-Kidan A. Procedure-specific risks of robotic simultaneous resection of colorectal cancer and synchronous liver metastases. J Robot Surg 2023; 17:2555-2558. [PMID: 37436675 PMCID: PMC10529917 DOI: 10.1007/s11701-023-01659-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2023] [Accepted: 06/21/2023] [Indexed: 07/13/2023]
Abstract
An estimated 25% of patients with colorectal cancer (CRC) present with distant metastases at the time of diagnosis, the most common site being the liver. Although prior studies have reported that a simultaneous approach to resections in these patients can lead to increased rates of complications, emerging literature shows that minimally invasive surgical (MIS) approaches can mitigate this additional morbidity. This is the first study utilizing a large national database to investigate colorectal and hepatic procedure-specific risks in robotic simultaneous resections for CRC and colorectal liver metastases (CRLM). Utilizing the ACS-NSQIP targeted colectomy, proctectomy, and hepatectomy files, 1,721 patients were identified who underwent simultaneous resections of CRC and CRLM from 2016 to 2021. Of these patients, 345 (20%) underwent resections by an MIS approach, defined as either laparoscopic (n = 266, 78%) or robotic (n = 79, 23%). Patients who underwent robotic resections had lower rates of ileus compared to those who had open surgeries. The robotic group had similar rates of 30-day anastomotic leak, bile leak, hepatic failure, and post-operative invasive hepatic procedures compared to both the open and laparoscopic groups. The rate of conversion to open (8% vs. 22%, p = 0.004) and median LOS (5 vs. 6 days, p = 0.022) was significantly lower for robotic compared to laparoscopic group. This study, which is the largest national cohort of simultaneous CRC and CRLM resections, supports the safety and potential benefits of a robotic approach in these patients.
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Affiliation(s)
- Shannon N Radomski
- Colorectal Research Unit, Ravitch Division of Colon and Rectal Surgery, Department of Surgery, The Johns Hopkins University School of Medicine, 600 N. Wolfe Street, Blalock 618, Baltimore, MD, 21287, USA
| | - Sophia Y Chen
- Colorectal Research Unit, Ravitch Division of Colon and Rectal Surgery, Department of Surgery, The Johns Hopkins University School of Medicine, 600 N. Wolfe Street, Blalock 618, Baltimore, MD, 21287, USA
| | - Miloslawa Stem
- Colorectal Research Unit, Ravitch Division of Colon and Rectal Surgery, Department of Surgery, The Johns Hopkins University School of Medicine, 600 N. Wolfe Street, Blalock 618, Baltimore, MD, 21287, USA
| | - Joy Zhou Done
- Colorectal Research Unit, Ravitch Division of Colon and Rectal Surgery, Department of Surgery, The Johns Hopkins University School of Medicine, 600 N. Wolfe Street, Blalock 618, Baltimore, MD, 21287, USA
| | - Chady Atallah
- Division of Colon and Rectal Surgery, Department of Surgery, NYU Langone Health, New York, NY, USA
| | - Bashar Safar
- Division of Colon and Rectal Surgery, Department of Surgery, NYU Langone Health, New York, NY, USA
| | - Jonathan E Efron
- Colorectal Research Unit, Ravitch Division of Colon and Rectal Surgery, Department of Surgery, The Johns Hopkins University School of Medicine, 600 N. Wolfe Street, Blalock 618, Baltimore, MD, 21287, USA
| | - Alodia Gabre-Kidan
- Colorectal Research Unit, Ravitch Division of Colon and Rectal Surgery, Department of Surgery, The Johns Hopkins University School of Medicine, 600 N. Wolfe Street, Blalock 618, Baltimore, MD, 21287, USA.
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Chen SY, Radomski SN, Stem M, Lo BD, Safar B, Efron JE, Atallah C. Safety and Feasibility of ≤24-h Short-Stay Right Colectomies for Primary Colon Cancer. World J Surg 2023; 47:2267-2278. [PMID: 37140607 PMCID: PMC10529467 DOI: 10.1007/s00268-023-07041-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/15/2023] [Indexed: 05/05/2023]
Abstract
BACKGROUND Hospital length of stay (LOS) has been used as a surgical quality metric. This study seeks to determine the safety and feasibility of right colectomy as a ≤24-h short-stay procedure for colon cancer patients. METHODS This was a retrospective cohort study using the ACS-NSQIP database and its Procedure Targeted Colectomy database (2012-2020). Adult patients with colon cancer who underwent right colectomies were identified. Patients were categorized into LOS ≤1 day (≤24-h short-stay), LOS 2-4 days, LOS 5-6 days, and LOS ≥7 days groups. Primary outcomes were 30-day overall and serious morbidity. Secondary outcomes were 30-day mortality, readmission, and anastomotic leak. The association between LOS and overall and serious morbidity was assessed using multivariable logistic regression. RESULTS 19,401 adult patients were identified, with 371 patients (1.9%) undergoing short-stay right colectomies. Patients undergoing short-stay surgery were generally younger with fewer comorbidities. Overall morbidity for the short-stay group was 6.5%, compared to 11.3%, 23.4%, and 42.0% for LOS 2-4 days, LOS 5-6 days, and LOS ≥7 days groups, respectively (p < 0.001). There were no differences in anastomotic leak, mortality, and readmission rates in the short-stay group compared to patients with LOS 2-4 days. Patients with LOS 2-4 days had increased odds of overall morbidity (OR 1.71, 95% CI 1.10-2.65, p = 0.016) compared to patients with short-stay but no differences in odds of serious morbidity (OR 1.20, 95% CI 0.61-2.36, p = 0.590). CONCLUSIONS ≤24-h short-stay right colectomy is safe and feasible for a highly-select group of colon cancer patients. Optimizing patients preoperatively and implementing targeted readmission prevention strategies may aid patient selection.
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Affiliation(s)
- Sophia Y Chen
- Colorectal Research Unit, Department of Surgery, The Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Shannon N Radomski
- Colorectal Research Unit, Department of Surgery, The Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Miloslawa Stem
- Colorectal Research Unit, Department of Surgery, The Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Brian D Lo
- Colorectal Research Unit, Department of Surgery, The Johns Hopkins University School of Medicine, Baltimore, MD, USA
- Department of Anesthesia, Critical Care, and Pain Medicine, Massachusetts General Hospital, Boston, MA, USA
| | - Bashar Safar
- Colorectal Research Unit, Department of Surgery, The Johns Hopkins University School of Medicine, Baltimore, MD, USA
- Department of Surgery, Division of Colon and Rectal Surgery, NYU Langone Health, 530 First Ave, Suite 7V, New York, NY, 10016, USA
| | - Jonathan E Efron
- Colorectal Research Unit, Department of Surgery, The Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Chady Atallah
- Colorectal Research Unit, Department of Surgery, The Johns Hopkins University School of Medicine, Baltimore, MD, USA.
- Department of Surgery, Division of Colon and Rectal Surgery, NYU Langone Health, 530 First Ave, Suite 7V, New York, NY, 10016, USA.
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Radomski SN, Chen SY, Stem M, Done JZ, Atallah C, Safar B, Efron JE, Gabre-Kidan A. Procedure-Specific Risks of Robotic Simultaneous Resection of Colorectal Cancer and Synchronous Liver Metastases. Res Sq 2023:rs.3.rs-2920026. [PMID: 37292634 PMCID: PMC10246223 DOI: 10.21203/rs.3.rs-2920026/v1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/10/2023]
Abstract
An estimated 25% of patients with colorectal cancer (CRC) present with distant metastases at the time of diagnosis, the most common site being the liver. Controversy exists regarding the safety of a simultaneous versus staged approach to resections in these patients, but reports have shown that minimally invasive surgery (MIS) approaches can mitigate morbidity. This is the first study utilizing a large national database to investigate colorectal and hepatic procedure-specific risks in robotic simultaneous resections for CRC and colorectal liver metastases (CRLM). Utilizing the ACS-NSQIP targeted colectomy, proctectomy, and hepatectomy files, 1,550 patients were identified who underwent simultaneous resections of CRC and CRLM from 2016-2020. Of these patients, 311 (20%) underwent resections by an MIS approach, defined as an either laparoscopic (n = 241, 78%) or robotic (n = 70, 23%). Patients who underwent robotic resections had lower rates of ileus compared to those who had an open surgery. The robotic group had similar rates of 30-day anastomotic leak, bile leak, hepatic failure, and post operative invasive hepatic procedures compared to both the open and laparoscopic groups. The rate of conversion to open was significantly lower for robotic compared to laparoscopic group (9% vs. 22%, p = 0.012). This report is the largest study to date of robotic simultaneous CRC and CRLM resections reported in the literature and supports the safety and potential benefits of this approach.
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Chen SY, Radomski SN, Stem M, Papanikolaou A, Gabre-Kidan A, Atallah C, Efron JE, Safar B. Colorectal Surgery Outcomes in the United States During the COVID-19 Pandemic. J Surg Res 2023; 287:95-106. [PMID: 36893610 PMCID: PMC9868386 DOI: 10.1016/j.jss.2022.12.041] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2022] [Revised: 12/02/2022] [Accepted: 12/25/2022] [Indexed: 01/24/2023]
Abstract
INTRODUCTION The purpose of this study was to assess colorectal surgery outcomes, discharge destination, and readmission in the United States during the COVID-19 pandemic. METHODS Adult colorectal surgery patients in the American College of Surgeons National Surgical Quality Improvement Program database (2019-2020) and its colectomy and proctectomy procedure-targeted files were included. The prepandemic time period was defined from April 1, 2019 to December 31, 2019. The pandemic time period was defined from April 1, 2020 to December 31, 2020 in quarterly intervals (Q2 April-June; Q3 July-September; Q4 October-December). Factors associated with morbidity and in-hospital mortality were assessed using multivariable logistic regression. RESULTS Among 62,393 patients, 34,810 patients (55.8%) underwent colorectal surgery prepandemic and 27,583 (44.2%) during the pandemic. Patients who had surgery during the pandemic had higher American Society of Anesthesiologists class and presented more frequently with dependent functional status. The proportion of emergent surgeries increased (12.7% prepandemic versus 15.2% pandemic, P < 0.001), with less laparoscopic cases (54.0% versus 51.0%, P < 0.001). Higher rates of morbidity with a greater proportion of discharges to home and lesser proportion of discharges to skilled care facilities were observed with no considerable differences in length of stay or worsening readmission rates. Multivariable analysis demonstrated increased odds of overall and serious morbidity and in-hospital mortality, during Q3 and/or Q4 of the 2020 pandemic. CONCLUSIONS Differences in hospital presentation, inpatient care, and discharge disposition of colorectal surgery patients were observed during the COVID-19 pandemic. Pandemic responses should emphasize balancing resource allocation, educating patients and providers on timely medical workup and management, and optimizing discharge coordination pathways.
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Affiliation(s)
- Sophia Y Chen
- Department of Surgery, The Johns Hopkins University School of Medicine, Colorectal Research Unit, Baltimore, Maryland
| | - Shannon N Radomski
- Department of Surgery, The Johns Hopkins University School of Medicine, Colorectal Research Unit, Baltimore, Maryland
| | - Miloslawa Stem
- Department of Surgery, The Johns Hopkins University School of Medicine, Colorectal Research Unit, Baltimore, Maryland
| | - Angelos Papanikolaou
- Department of Surgery, The Johns Hopkins University School of Medicine, Colorectal Research Unit, Baltimore, Maryland
| | - Alodia Gabre-Kidan
- Department of Surgery, The Johns Hopkins University School of Medicine, Colorectal Research Unit, Baltimore, Maryland
| | - Chady Atallah
- Department of Surgery, The Johns Hopkins University School of Medicine, Colorectal Research Unit, Baltimore, Maryland; Department of Surgery, NYU Langone Health, New York, New York
| | - Jonathan E Efron
- Department of Surgery, The Johns Hopkins University School of Medicine, Colorectal Research Unit, Baltimore, Maryland
| | - Bashar Safar
- Department of Surgery, The Johns Hopkins University School of Medicine, Colorectal Research Unit, Baltimore, Maryland; Department of Surgery, NYU Langone Health, New York, New York.
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Abstract
BACKGROUND The worsening opioid epidemic has led to an increased number of surgical patients with chronic preoperative opioid use. However, the impact of opioids on perioperative outcomes has yet to be fully elucidated. The purpose of this study was to assess the association between preoperative opioid dose and surgical outcomes among colectomy patients. METHODS Adult colectomy patients in the IBM MarketScan database (2010-2017) were stratified based on preoperative opioid dose, calculated as the average opioid dose in morphine milligram equivalents (MME) in the 90 days prior to surgery: 0 MME, 1 to 49 MME, and 50 or more MME. The association between preoperative opioid dose and anastomotic leak, the primary outcome of interest, as well as other postoperative complications, was assessed using multivariable regression. RESULTS Among 45,515 adult colectomy patients, 71.4% did not use opioids (0 MME), 27.4% had an opioid dose between 1 and 49 MME, and 1.2% had an opioid dose at or above 50 MME. Patients with preoperative opioid use exhibited a higher incidence of anastomotic leak (0 MME: 4.8%, 1-49 MME: 5.5%, ≥50 MME: 8.3%; p trend = 0.001). Multivariable analysis demonstrated a dose-response relationship between preoperative opioids and surgical outcomes, as the odds of anastomotic leak worsened with increasing opioid dose (1-49 MME: OR 1.19, 95% CI 1.08-1.31, p < 0.001; ≥50 MME: OR 1.64, 95% CI 1.20-2.24, p = 0.002). Similar dose-response relationships were seen after risk-adjustment for lung complications, pneumonia, delirium, and 30-day readmission (p < 0.05 for all). CONCLUSIONS Providers should exercise caution when prescribing opioids preoperatively, as increasing doses of preoperative opioids were associated with worse surgical outcomes and higher 30-day readmission among adult colectomy patients.
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Affiliation(s)
- Brian D Lo
- From the Colorectal Research Unit, Department of Surgery (Lo, Zhang, Stem, Taylor, Atallah, Efron, Safar), The Johns Hopkins University School of Medicine, Baltimore, MD
| | - George Q Zhang
- From the Colorectal Research Unit, Department of Surgery (Lo, Zhang, Stem, Taylor, Atallah, Efron, Safar), The Johns Hopkins University School of Medicine, Baltimore, MD
| | - Joseph K Canner
- Center for Surgical Trials and Outcomes Research, Department of Surgery (Canner), The Johns Hopkins University School of Medicine, Baltimore, MD
| | - Miloslawa Stem
- From the Colorectal Research Unit, Department of Surgery (Lo, Zhang, Stem, Taylor, Atallah, Efron, Safar), The Johns Hopkins University School of Medicine, Baltimore, MD
| | - James P Taylor
- From the Colorectal Research Unit, Department of Surgery (Lo, Zhang, Stem, Taylor, Atallah, Efron, Safar), The Johns Hopkins University School of Medicine, Baltimore, MD
| | - Chady Atallah
- From the Colorectal Research Unit, Department of Surgery (Lo, Zhang, Stem, Taylor, Atallah, Efron, Safar), The Johns Hopkins University School of Medicine, Baltimore, MD
| | - Jonathan E Efron
- From the Colorectal Research Unit, Department of Surgery (Lo, Zhang, Stem, Taylor, Atallah, Efron, Safar), The Johns Hopkins University School of Medicine, Baltimore, MD
| | - Bashar Safar
- From the Colorectal Research Unit, Department of Surgery (Lo, Zhang, Stem, Taylor, Atallah, Efron, Safar), The Johns Hopkins University School of Medicine, Baltimore, MD
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Sahyoun R, Lo BD, Zhang GQ, Stem M, Atallah C, Najjar PA, Efron JE, Safar B. Converting laparoscopic colectomies to open is associated with similar outcomes as a planned open approach among Crohn's disease patients. Int J Colorectal Dis 2022; 37:171-178. [PMID: 34611748 PMCID: PMC8492034 DOI: 10.1007/s00384-021-04020-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 08/19/2021] [Indexed: 02/04/2023]
Abstract
PURPOSE There has been a noted reluctance to offer laparoscopic surgery to Crohn's Disease patients due to the potential risks, and high rate, of converting the procedure to open. The purpose of this study was to compare clinical outcomes between Crohn's Disease patients undergoing a planned open colectomy, to those undergoing a laparoscopic colectomy that was converted to open. METHODS Crohn's Disease patients undergoing an elective colectomy were identified using the ACS-NSQIP database (2012-2019). Patients were stratified based on operative approach: open, laparoscopic, and laparoscopic converted to open. Multivariable logistic regression was used to assess the impact of conversion to open on overall and serious postoperative morbidity. RESULTS Among 8039 elective colectomies, 40.5% were performed open, 46.9% were completed laparoscopically, and 12.6% were converted to open. The conversion rate among all laparoscopic cases was 21.3%. On unadjusted analysis, conversion to open demonstrated similar rates of overall morbidity (P = 0.355) and serious morbidity (P = 0.724) compared to a planned open approach. On multivariable analysis, conversion to open was not associated with increased odds of overall morbidity (OR 1.12, 95% CI 0.94-1.30, P = 0.238) or serious morbidity (OR 1.20, 95% CI 0.98-1.46, P = 0.074), when compared to an open approach. CONCLUSION Among Crohn's Disease patients, cases converted from laparoscopic to open exhibited similar outcomes as a planned open approach. Despite the limitations associated with this retrospective study, our findings suggest that laparoscopic surgery may be safely pursued among Crohn's Disease patients, as the risks of conversion are potentially balanced by the benefits of laparoscopic surgery.
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Affiliation(s)
- Rebecca Sahyoun
- grid.21107.350000 0001 2171 9311Department of Surgery, Colorectal Research Unit, Ravitch Division of Colorectal Surgery, Johns Hopkins University School of Medicine, 600 N. Wolfe Street, Blalock 618, MD 21287 Baltimore, USA
| | - Brian D. Lo
- grid.21107.350000 0001 2171 9311Department of Surgery, Colorectal Research Unit, Ravitch Division of Colorectal Surgery, Johns Hopkins University School of Medicine, 600 N. Wolfe Street, Blalock 618, MD 21287 Baltimore, USA
| | - George Q. Zhang
- grid.21107.350000 0001 2171 9311Department of Surgery, Colorectal Research Unit, Ravitch Division of Colorectal Surgery, Johns Hopkins University School of Medicine, 600 N. Wolfe Street, Blalock 618, MD 21287 Baltimore, USA
| | - Miloslawa Stem
- grid.21107.350000 0001 2171 9311Department of Surgery, Colorectal Research Unit, Ravitch Division of Colorectal Surgery, Johns Hopkins University School of Medicine, 600 N. Wolfe Street, Blalock 618, MD 21287 Baltimore, USA
| | - Chady Atallah
- grid.21107.350000 0001 2171 9311Department of Surgery, Colorectal Research Unit, Ravitch Division of Colorectal Surgery, Johns Hopkins University School of Medicine, 600 N. Wolfe Street, Blalock 618, MD 21287 Baltimore, USA
| | - Peter A. Najjar
- grid.21107.350000 0001 2171 9311Department of Surgery, Colorectal Research Unit, Ravitch Division of Colorectal Surgery, Johns Hopkins University School of Medicine, 600 N. Wolfe Street, Blalock 618, MD 21287 Baltimore, USA
| | - Jonathan E. Efron
- grid.21107.350000 0001 2171 9311Department of Surgery, Colorectal Research Unit, Ravitch Division of Colorectal Surgery, Johns Hopkins University School of Medicine, 600 N. Wolfe Street, Blalock 618, MD 21287 Baltimore, USA
| | - Bashar Safar
- grid.21107.350000 0001 2171 9311Department of Surgery, Colorectal Research Unit, Ravitch Division of Colorectal Surgery, Johns Hopkins University School of Medicine, 600 N. Wolfe Street, Blalock 618, MD 21287 Baltimore, USA
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Lo BD, Caturegli G, Stem M, Biju K, Safar B, Efron JE, Rajput A, Atallah C. The Impact of Surgical Delays on Short- and Long-Term Survival Among Colon Cancer Patients. Am Surg 2021; 87:1783-1792. [PMID: 34666557 DOI: 10.1177/00031348211047511] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
BACKGROUND The purpose of this study was to assess the impact of surgical delays on short- and long-term survival among colon cancer patients. METHODS Adult patients undergoing surgery for stage I, II, or III colon cancer were identified from the National Cancer Database (2010-2016). After categorization by wait times from diagnosis to surgery (<1 week, 1-3 weeks, 3-6 weeks, 6-9 weeks, 9-12 weeks, and >12 weeks), 30-day mortality, 90-day mortality, and 5-year overall survival were compared between patients both overall and after stratification by pathological disease stage. RESULTS Among 187 394 colon cancer patients, 24.2% waited <1 week, 30.5% waited 1-3 weeks, 29.0% waited 3-6 weeks, 9.7% waited 6-9 weeks, 3.3% waited 9-12 weeks, and 3.3% waited >12 weeks for surgery. Patients undergoing surgery 3-6 weeks after colon cancer diagnosis exhibited the best 30-day mortality (1.3%), 90-day mortality (2.3%), and 5-year overall survival (71.8%) (P < .001 for all). After risk-adjusting for confounders, all wait times beyond 6 weeks were associated with worse 5-year overall survival (6-9 weeks: HR 1.10, 95% CI 1.06-1.15; 9-12 weeks: HR 1.25, 95% CI 1.18-1.33; >12 weeks: HR 1.43, 95% CI 1.35-1.52; P < .001 for all). Subgroup analysis after stratification by disease stage demonstrated that patients with stage III colon cancer were able to wait up to 9 weeks before exhibiting worse 5-year overall survival, compared to 6 weeks for patients with stage I or II disease. CONCLUSIONS Colon cancer patients should undergo surgery 3-6 weeks after diagnosis, as all surgical delays beyond 6 weeks were associated with worse 30-day mortality, 90-day mortality, and 5-year overall survival.
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Affiliation(s)
- Brian D Lo
- Colorectal Research Unit, Department of Surgery, 1500The Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Giorgio Caturegli
- Colorectal Research Unit, Department of Surgery, 1500The Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Miloslawa Stem
- Colorectal Research Unit, Department of Surgery, 1500The Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Kevin Biju
- Colorectal Research Unit, Department of Surgery, 1500The Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Bashar Safar
- Colorectal Research Unit, Department of Surgery, 1500The Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Jonathan E Efron
- Colorectal Research Unit, Department of Surgery, 1500The Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Ashwani Rajput
- Colorectal Research Unit, Department of Surgery, 1500The Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Chady Atallah
- Colorectal Research Unit, Department of Surgery, 1500The Johns Hopkins University School of Medicine, Baltimore, MD, USA
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Zhang GQ, Canner JK, Prince EJ, Stem M, Taylor JP, Efron JE, Atallah C, Safar B. History of depression is associated with worsened postoperative outcomes following colectomy. Colorectal Dis 2021; 23:2559-2566. [PMID: 34166552 DOI: 10.1111/codi.15790] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/03/2021] [Revised: 04/21/2021] [Accepted: 06/10/2021] [Indexed: 02/08/2023]
Abstract
AIM Depression is a prevalent disorder that is associated with adverse health outcomes, but an understanding of its effect in colorectal surgery remains limited. The purpose of this study was to examine the impact of history of depression among patients undergoing colectomy. METHOD United States patients from Marketscan (2010-2017) who underwent colectomy were included and stratified by whether they had a history of depression within the past year, defined as (1) a diagnosis of depression during the index admission, (2) a diagnosis of depression during any inpatient or (3) outpatient admission within the year, and/or (4) a pharmacy claim for an antidepressant within the year. The primary outcomes were length of stay (LOS) and inpatient hospital charge. Secondary outcomes included in-hospital mortality and postoperative complications. Logistic, negative binomial, and quantile regressions were performed. RESULTS Among 88 981 patients, 21 878 (24.6%) had a history of depression. Compared to those without, patients with a history of depression had significantly longer LOS (IRR = 1.06, 95% CI [1.05, 1.07]), increased inpatient charge (β = 467, 95% CI [167, 767]), and increased odds of in-hospital mortality (OR = 1.37, 95% CI [1.08, 1.73]) after adjustment. History of depression was also independently associated with increased odds of respiratory complication, pneumonia, and delirium (all P < 0.05). CONCLUSION History of depression was prevalent among individuals undergoing colectomy, and associated with greater mortality and inpatient charge, longer LOS, and higher odds of postoperative complication. These findings highlight the impact of depression in colorectal surgery patients and suggest that proper identification and treatment may reduce postoperative morbidity.
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Affiliation(s)
- George Q Zhang
- Colorectal Research Unit, Ravitch Colorectal Division, Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA.,Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Joseph K Canner
- Department of Surgery, Johns Hopkins Surgery Center for Outcomes Research, The Johns Hopkins Hospital, Baltimore, MD, USA
| | - Elizabeth J Prince
- Department of Psychiatry and Behavioral Sciences, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Miloslawa Stem
- Colorectal Research Unit, Ravitch Colorectal Division, Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - James P Taylor
- Colorectal Research Unit, Ravitch Colorectal Division, Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Jonathan E Efron
- Colorectal Research Unit, Ravitch Colorectal Division, Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Chady Atallah
- Colorectal Research Unit, Ravitch Colorectal Division, Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Bashar Safar
- Colorectal Research Unit, Ravitch Colorectal Division, Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
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Zhang GQ, Sahyoun R, Stem M, Lo BD, Rajput A, Efron JE, Atallah C, Safar B. Operative Approach Does Not Impact Radial Margin Positivity in Distal Rectal Cancer. World J Surg 2021; 45:3686-3694. [PMID: 34495388 DOI: 10.1007/s00268-021-06278-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/25/2021] [Indexed: 11/24/2022]
Abstract
BACKGROUND Robotic surgery is attractive for resection of low rectal cancer due to greater dexterity and visualization, but its benefit is poorly understood. We aimed to determine if operative approach impacts radial margin positivity (RMP) and postoperative outcomes among patients undergoing abdominoperineal resection (APR). METHODS This was a retrospective cohort study of patients from the National Surgical Quality Improvement Program who underwent APR for low rectal cancer from 2016 to 2019. Patients were stratified by operative approach: robotic, laparoscopic, and open APR (R-APR, L-APR, and O-APR). Emergent cases were excluded. The primary outcome was RMP. 30-day postoperative outcomes were also evaluated, using logistic regression analysis. RESULTS Among 1,807 patients, 452 (25.0%) underwent R-APR, 474 (26.2%) L-APR, and 881 (48.8%) O-APR. No differences regarding RMP (13.5% R-APR vs. 10.8% L-APR vs. 12.3% O-APR, p = 0.44), distal margin positivity, positive nodes, readmission, or operative time were observed between operative approaches. Adjusted analysis confirmed that operative approach did not predict RMP (p > 0.05 for all). Risk factors for RMP included American Society of Anesthesiologists (ASA) classification III (ASA I-II ref; OR 1.46, p = 0.039), pT3-4 stage (T0-2 ref, OR 4.02, p < 0.001), pN2 stage (OR 1.98, p = 0.004), disseminated cancer (OR 1.90, p = 0.002), and lack of preoperative radiation (OR 1.98, p < 0.01). CONCLUSIONS No difference in RMP was observed among R-APR, L-APR, and O-APR. Postoperatively, R-APR yielded greater benefit when compared to O-APR, but was comparable to that of L-APR. Minimally invasive surgery may be an appropriate option and worthy consideration for patients with distal rectal cancer requiring APR.
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Affiliation(s)
- George Q Zhang
- Department of Surgery, Colorectal Research Unit, Ravitch Colorectal Division, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Rebecca Sahyoun
- Department of Surgery, Colorectal Research Unit, Ravitch Colorectal Division, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Miloslawa Stem
- Department of Surgery, Colorectal Research Unit, Ravitch Colorectal Division, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Brian D Lo
- Department of Surgery, Colorectal Research Unit, Ravitch Colorectal Division, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Ashwani Rajput
- Department of Surgery, Colorectal Research Unit, Ravitch Colorectal Division, Johns Hopkins University School of Medicine, Baltimore, MD, USA.,Division of Surgical Oncology, Johns Hopkins University School of Medicine, Baltimore, MD, USA.,Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Jonathan E Efron
- Department of Surgery, Colorectal Research Unit, Ravitch Colorectal Division, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Chady Atallah
- Department of Surgery, Colorectal Research Unit, Ravitch Colorectal Division, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Bashar Safar
- Department of Surgery, Colorectal Research Unit, Ravitch Colorectal Division, Johns Hopkins University School of Medicine, Baltimore, MD, USA.
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Aliu O, Lee AWP, Efron JE, Higgins RSD, Butler CE, Offodile AC. Assessment of Costs and Care Quality Associated With Major Surgical Procedures After Implementation of Maryland's Capitated Budget Model. JAMA Netw Open 2021; 4:e2126619. [PMID: 34559228 PMCID: PMC8463941 DOI: 10.1001/jamanetworkopen.2021.26619] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Abstract
IMPORTANCE In 2014, Maryland implemented the all-payer model, a distinct hospital funding policy that applied caps on annual hospital expenditures and mandated reductions in avoidable complications. Expansion of this model to other states is currently being considered; therefore, it is important to evaluate whether Maryland's all-payer model is achieving the desired goals among surgical patients, who are an at-risk population for most potentially preventable complications. OBJECTIVE To examine the association between the implementation of Maryland's all-payer model and the incidence of avoidable complications and resource use among adult surgical patients. DESIGN, SETTING, AND PARTICIPANTS This comparative effectiveness study used hospital discharge records from the Healthcare Cost and Utilization Project state inpatient databases to conduct a difference-in-differences analysis comparing the incidence of avoidable complications and the intensity of health resource use before and after implementation of the all-payer model in Maryland. The analytical sample included 2 983 411 adult patients who received coronary artery bypass grafting (CABG), carotid endarterectomy (CEA), spinal fusion, hip or knee arthroplasty, hysterectomy, or cesarean delivery between January 1, 2008, and December 31, 2016, at acute care hospitals in Maryland (intervention state) and New York, New Jersey, and Rhode Island (control states). Data analysis was conducted from July 2019 to July 2021. EXPOSURES All-payer model. MAIN OUTCOMES AND MEASURES Complications (infectious, cardiovascular, respiratory, kidney, coagulation, and wound) and health resource use (ie, hospital charges). RESULTS Of 2 983 411 total patients in the analytical sample, 525 262 patients were from Maryland and 2 458 149 were from control states. Across Maryland and the control states, there were statistically significant but not clinically relevant differences in the preintervention period with regard to patient age (mean [SD], 49.7 [19.0] years vs 48.9 [19.3] years, respectively; P < .001), sex (22.7% male vs 21.4% male; P < .001), and race (0.3% vs 0.4% American Indian, 2.8% vs 4.5% Asian or Pacific Islander, 25.9% vs 12.7% Black, 4.7% vs 11.9% Hispanic, and 63.5% vs 63.4% White; P < .001). After implementation of the all-payer model in Maryland, significantly lower rates of avoidable complications were found among patients who underwent CABG (-11.3%; 95% CI, -13.8% to -8.7%; P < .001), CEA (-1.6%; 95% CI, -2.9% to -0.3%; P = .02), hip arthroplasty (-0.8%; 95% CI, -1.0% to -0.5%; P < .001), knee arthroplasty (-0.4%; 95% CI, -0.7% to -0.1%; P = .01), and cesarean delivery (-1.0%; 95% CI, -1.3% to -0.7%; P < .001). In addition, there were significantly lower increases in index hospital costs in Maryland among patients who underwent CABG (-$6236; 95% CI, -$7320 to -$5151; P < .001), CEA (-$730; 95% CI, -$1367 to -$94; P = .03), spinal fusion (-$3253; 95% CI, -$3879 to -$2627; P < .001), hip arthroplasty (-$328; 95% CI, -$634 to -$21; P = .04), knee arthroplasty (-$415; 95% CI, -$643 to -$187; P < .001), cesarean delivery (-$300; 95% CI, -$380 to -$220; P < .001), and hysterectomy (-$745; 95% CI, -$974 to -$517; P < .001). Significant changes in patient mix consistent with a younger population (eg, a shift toward private/commercial insurance for orthopedic procedures, such as spinal fusion [4.3%; 95% CI, 3.4%-5.2%; P < .001] and knee arthroplasty [1.6%; 95% CI, 1.0%-2.3%; P < .001]) and a lower comorbidity burden across surgical procedures (eg, CABG: -0.7% [95% CI, -0.1% to -0.5%; P < .001]; hip arthroplasty: -3.0% [95% CI, -3.6% to -2.3%; P < .001]) were also observed. CONCLUSIONS AND RELEVANCE In this study, patients who underwent common surgical procedures had significantly fewer avoidable complications and lower hospital costs, as measured against the rate of increase throughout the study, after implementation of the all-payer model in Maryland. These findings may be associated with changes in the patient mix.
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Affiliation(s)
- Oluseyi Aliu
- Department of Plastic Surgery, Johns Hopkins University, Baltimore, Maryland
| | | | - Jonathan E. Efron
- Department of Surgery, Johns Hopkins University, Baltimore, Maryland
| | | | - Charles E. Butler
- Department of Plastic Surgery, University of Texas MD Anderson Cancer Center, Houston
| | - Anaeze C. Offodile
- Department of Plastic Surgery, University of Texas MD Anderson Cancer Center, Houston
- Department of Health Services Research, University of Texas MD Anderson Cancer Center, Houston
- Baker Institute for Public Policy, Rice University, Houston, Texas
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Oduyale OK, Eltahir AA, Stem M, Prince E, Zhang GQ, Safar B, Efron JE, Atallah C. What Does a Diagnosis of Depression Mean for Patients Undergoing Colorectal Surgery? J Surg Res 2021; 260:454-461. [PMID: 33272593 PMCID: PMC7959253 DOI: 10.1016/j.jss.2020.11.006] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2020] [Revised: 09/23/2020] [Accepted: 11/01/2020] [Indexed: 12/13/2022]
Abstract
BACKGROUND Depression has been linked to increased morbidity and mortality in patients after surgery. The purpose of this study is to investigate the impact of documented depression diagnosis on in-hospital postoperative outcomes of patients undergoing colorectal surgery. MATERIALS AND METHODS Patients from the National Inpatient Sample (2002-2017) who underwent proctectomies and colectomies were included. The outcomes measured included total hospital charge, length of stay, delirium, wound infection, urinary tract infection (UTI), pneumonia, deep vein thrombosis, pulmonary embolism, mortality, paralytic ileus, leak, and discharge trends. Multivariable logistic and Poisson regression analyses were performed. RESULTS Of the 4,212,125 patients, depression diagnosis was present in 6.72% of patients who underwent colectomy and 6.54% of patients who underwent proctectomy. Regardless of procedure type, patients with depression had higher total hospital charges and greater rates of delirium, wound infection, UTI, leak, and nonroutine discharge, with no difference in length of stay. On adjusted analysis, patients with a depression diagnosis who underwent colectomies had increased risk of delirium (odds ratio (OR) 2.11, 95% confidence interval (CI) 1.93-2.32), wound infection (OR 1.08, 95% CI 1.03-1.12), UTI (OR 1.15, 95% CI 1.10-1.20), paralytic ileus (OR 1.06, 95% CI 1.03-1.09), and leak (OR 1.37, 95% CI 1.30-1.43). Patients who underwent proctectomy showed similar results, with the addition of significantly increased total hospital charges among the depression group. Depression diagnosis was independently associated with lower risk of in-hospital mortality (colectomy OR 0.58, 95% CI 0.53-0.62; proctectomy OR 0.72, 95% CI 0.55-0.94). CONCLUSIONS Patients with a diagnosis of depression suffer worse in-hospital outcomes but experience lower risk of in-hospital mortality after undergoing colorectal surgery. Further studies are needed to validate and fully understand the driving factors behind this.
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Affiliation(s)
- Oluseye K Oduyale
- Colorectal Research Unit, Ravitch Colorectal Division, Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Ahmed A Eltahir
- Colorectal Research Unit, Ravitch Colorectal Division, Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Miloslawa Stem
- Colorectal Research Unit, Ravitch Colorectal Division, Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Elizabeth Prince
- Department of Psychiatry and Behavioral Sciences, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - George Q Zhang
- Colorectal Research Unit, Ravitch Colorectal Division, Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Bashar Safar
- Colorectal Research Unit, Ravitch Colorectal Division, Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Jonathan E Efron
- Colorectal Research Unit, Ravitch Colorectal Division, Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Chady Atallah
- Colorectal Research Unit, Ravitch Colorectal Division, Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland.
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18
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Biju K, Zhang GQ, Stem M, Sahyoun R, Safar B, Atallah C, Efron JE, Rajput A. Impact of Treatment Coordination on Overall Survival in Rectal Cancer. Clin Colorectal Cancer 2021; 20:187-196. [PMID: 33618972 DOI: 10.1016/j.clcc.2021.01.002] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2020] [Revised: 01/15/2021] [Accepted: 01/17/2021] [Indexed: 10/22/2022]
Abstract
BACKGROUND Rectal cancer treatment is often multimodal, comprising of surgery, chemotherapy, and radiotherapy. However, the impact of coordination between these modalities is currently unknown. We aimed to assess whether delivery of nonsurgical therapy within same facility as surgery impacts survival in patients with rectal cancer. METHODS A patient cohort with rectal cancer stages II to IV who received multimodal treatment between 2004 and 2016 from National Cancer Database was retrospectively analyzed. Patients were categorized into three groups: (A) surgery + chemotherapy + radiotherapy at same facility (surgery + 2); (B) surgery + chemotherapy or radiotherapy at same facility (surgery + 1); or (C) only surgery at reporting facility (chemotherapy + radiotherapy elsewhere; surgery + 0). The primary outcome was 5-year overall survival (OS), analyzed using Kaplan-Meier curves, log-rank tests, and Cox proportional-hazards models. RESULTS A total of 44,716 patients (16,985 [37.98%] surgery + 2, 12,317 [27.54%] surgery + 1, and 15,414 [34.47%] surgery + 0) were included. In univariate analysis, we observed that surgery+2 patients had significantly greater 5-year OS compared to surgery + 1 or surgery + 0 patients (5-year OS: 63.46% vs 62.50% vs 61.41%, respectively; P= .002). We observed similar results in multivariable Cox proportional-hazards analysis, with surgery + 0 group demonstrating increased hazard of mortality when compared to surgery + 2 group (HR: 1.09; P< .001). These results held true after stratification by stage for stage II (HR 1.10; P= .022) and stage III (HR 1.12; P< .001) but not for stage IV (P= .474). CONCLUSION Greater degree of care coordination within the same facility is associated with greater OS in patients with stage II to III rectal cancer. This finding illustrates the importance of interdisciplinary collaboration in multimodal rectal cancer therapy.
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Affiliation(s)
- Kevin Biju
- Colorectal Research Unit, Department of Surgery, The Johns Hopkins University School of Medicine, Baltimore, MD
| | - George Q Zhang
- Colorectal Research Unit, Department of Surgery, The Johns Hopkins University School of Medicine, Baltimore, MD
| | - Miloslawa Stem
- Colorectal Research Unit, Department of Surgery, The Johns Hopkins University School of Medicine, Baltimore, MD
| | - Rebecca Sahyoun
- Colorectal Research Unit, Department of Surgery, The Johns Hopkins University School of Medicine, Baltimore, MD
| | - Bashar Safar
- Colorectal Research Unit, Department of Surgery, The Johns Hopkins University School of Medicine, Baltimore, MD
| | - Chady Atallah
- Colorectal Research Unit, Department of Surgery, The Johns Hopkins University School of Medicine, Baltimore, MD
| | - Jonathan E Efron
- Colorectal Research Unit, Department of Surgery, The Johns Hopkins University School of Medicine, Baltimore, MD
| | - Ashwani Rajput
- Colorectal Research Unit, Department of Surgery, The Johns Hopkins University School of Medicine, Baltimore, MD.
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19
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Atallah C, Taylor JP, Lo BD, Stem M, Brocke T, Efron JE, Safar B. Local excision for T1 rectal tumours: are we getting better? Colorectal Dis 2020; 22:2038-2048. [PMID: 32886836 DOI: 10.1111/codi.15344] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/18/2020] [Accepted: 08/17/2020] [Indexed: 12/13/2022]
Abstract
AIM The objective was to assess the effect of three different surgical treatments for T1 rectal tumours, radical resection (RR), open local excision (open LE) and laparoscopic local excision (laparoscopic LE), on overall survival (OS). METHODS Adults from the National Cancer Database (2008-2016) with a diagnosis of T1 rectal cancer were stratified by treatment type (LE vs RR). We assumed that laparoscopic LE equates to transanal minimally invasive surgery (TAMIS) or transanal endoscopic microsurgery. The primary outcome was 5-year OS. Subgroup analyses of the LE group stratified by time period [2008-2010 (before TAMIS) vs 2011-2016 (after TAMIS)] and approach (laparoscopic vs open) were performed. RESULTS Among 10 053 patients, 6623 (65.88%) underwent LE (74.33% laparoscopic LE vs 25.67% open LE) and 3430 (34.12%) RR. The use of LE increased from 52.69% in 2008 to 69.47% in 2016, whereas RR decreased (P < 0.001). In unadjusted analysis, there was no significant difference in 5-year OS between the LE and RR groups (P = 0.639) and between the two LE time periods (P = 0.509), which was consistent with the adjusted analysis (LE vs RR, hazard ratio 1.05, 95% CI 0.92-1.20, P = 0.468; 2008-2010 LE vs 2011-2016 LE, hazard ratio 1.09, 95% CI 0.92-1.29, P = 0.321). Laparoscopic LE was associated with improved OS in the unadjusted analysis only (P = 0.006), compared to the open LE group (hazard ratio 0.94, 95% CI 0.78-1.12, P = 0.495). CONCLUSIONS This study supports the use of a LE approach for T1 rectal tumours as a strategy to reduce surgical morbidity without compromising survival.
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Affiliation(s)
- C Atallah
- Colorectal Research Unit, Ravitch Colorectal Division, Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - J P Taylor
- Colorectal Research Unit, Ravitch Colorectal Division, Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - B D Lo
- Colorectal Research Unit, Ravitch Colorectal Division, Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - M Stem
- Colorectal Research Unit, Ravitch Colorectal Division, Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - T Brocke
- Colorectal Research Unit, Ravitch Colorectal Division, Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - J E Efron
- Colorectal Research Unit, Ravitch Colorectal Division, Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - B Safar
- Colorectal Research Unit, Ravitch Colorectal Division, Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
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20
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Courtney A, Howell AM, Daulatzai N, Savva N, Warren O, Mills S, Rasheed S, Milind G, Tekkis N, Gardiner M, Dai T, Safar B, Efron JE, Darzi A, Tekkis P, Kontovounisios C. CRC COVID: Colorectal cancer services during COVID-19 pandemic. Study protocol for service evaluation. Int J Surg Protoc 2020; 23:15-19. [PMID: 32835148 PMCID: PMC7417919 DOI: 10.1016/j.isjp.2020.07.005] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2020] [Revised: 07/27/2020] [Accepted: 07/30/2020] [Indexed: 11/04/2022] Open
Abstract
COVID-19 disrupted healthcare provision worldwide. This is a four-phase multi-centre service evaluation of colorectal cancer services. Conducted through a research collaborative in the UK, Ireland and the USA. The aim is to evaluate the impact of the COVID-19 pandemic on service provision.
Introduction COVID-19 has had an impact on the provision of colorectal cancer care. The aim of the CRC COVID study is to describe the changes in colorectal cancer services in the UK and USA in response to the pandemic and to understand the long-term impact. Methods and analysis This study comprises 4 phases. Phase 1 is a survey of colorectal units that aims to evaluate adherences and deviations from the best practice guidelines during the COVID-19 pandemic. Phase 2 is a monthly prospective data collection of service provision that aims to determine the impact of the service modifications on the long-term cancer specific outcomes compared to the national standards. Phase 3 aims to predict costs attributable to the modifications of the CRC services and additional resources required to treat patients whose treatment has been affected by the pandemic. Phase 4 aims to compare the impact of COVID-19 on the NHS and USA model of healthcare in terms of service provision and cost, and to propose a standardised model of delivering colorectal cancer services for future outbreaks. Ethics and dissemination This study is a service evaluation and does not require HRA Approval or Ethical Approval in the UK. Local service evaluation registration is required for each participating centre. In the USA, Ethical Approval was granted by the Research and Development Committee. The results of this study will be disseminated to stakeholders, submitted for peer review publications, conference presentations and circulated via social media. Registration details Nil.
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Affiliation(s)
- Alona Courtney
- Imperial College London, Department of Surgery and Cancer, Chelsea & Westminster Campus, 369 Fulham Rd, Chelsea, London SW10 9NH, United Kingdom.,Chelsea & Westminster Hospital, 369 Fulham Rd, Chelsea, London SW10 9NH, United Kingdom
| | - Ann-Marie Howell
- Chelsea & Westminster Hospital, 369 Fulham Rd, Chelsea, London SW10 9NH, United Kingdom
| | - Najib Daulatzai
- Chelsea & Westminster Hospital, 369 Fulham Rd, Chelsea, London SW10 9NH, United Kingdom
| | - Nicos Savva
- London Business School, Regent's Park, London NW1 4SA, United Kingdom
| | - Oliver Warren
- Chelsea & Westminster Hospital, 369 Fulham Rd, Chelsea, London SW10 9NH, United Kingdom
| | - Sarah Mills
- Chelsea & Westminster Hospital, 369 Fulham Rd, Chelsea, London SW10 9NH, United Kingdom
| | - Shahnawaz Rasheed
- Royal Marsden Hospital, 203 Fulham Rd, Chelsea, London SW3 6JJ, United Kingdom
| | - Goel Milind
- London Business School, Regent's Park, London NW1 4SA, United Kingdom
| | - Nicholas Tekkis
- University of Cambridge School of Clinical Medicine, Hills Road, Cambridge CB2 0SP, United Kingdom
| | - Matthew Gardiner
- Kennedy Institute of Rheumatology, University of Oxford, Roosevelt Drive, Headington, Oxford OX3 7FY, United Kingdom
| | - Tinglong Dai
- Johns Hopkins University Carey Business School, The Charm'tastic Mile, 100 International Drive, Baltimore, MD 21202, United States
| | - Bashar Safar
- Johns Hopkins Hospital, 1800 Orleans St, Baltimore, MD 21287, United States
| | - Jonathan E Efron
- Johns Hopkins Hospital, 1800 Orleans St, Baltimore, MD 21287, United States
| | - Ara Darzi
- Imperial College London, Department of Surgery and Cancer, Queen Elizabeth the Queen Mother Wing (QEQM), St Mary's Campus, Praed St, Paddington, London W2 1NY, United Kingdom
| | - Paris Tekkis
- Imperial College London, Department of Surgery and Cancer, Chelsea & Westminster Campus, 369 Fulham Rd, Chelsea, London SW10 9NH, United Kingdom.,Royal Marsden Hospital, 203 Fulham Rd, Chelsea, London SW3 6JJ, United Kingdom
| | - Christos Kontovounisios
- Imperial College London, Department of Surgery and Cancer, Chelsea & Westminster Campus, 369 Fulham Rd, Chelsea, London SW10 9NH, United Kingdom.,Chelsea & Westminster Hospital, 369 Fulham Rd, Chelsea, London SW10 9NH, United Kingdom.,Royal Marsden Hospital, 203 Fulham Rd, Chelsea, London SW3 6JJ, United Kingdom
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21
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Lo BD, Zhang GQ, Stem M, Sahyoun R, Efron JE, Safar B, Atallah C. Do specific operative approaches and insurance status impact timely access to colorectal cancer care? Surg Endosc 2020; 35:3774-3786. [PMID: 32813058 DOI: 10.1007/s00464-020-07870-4] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2020] [Accepted: 08/05/2020] [Indexed: 12/14/2022]
Abstract
INTRODUCTION The increased use of minimally invasive surgery in the management of colorectal cancer has led to a renewed focus on how certain factors, such as insurance status, impact the equitable distribution of both laparoscopic and robotic surgery. Our goal was to analyze surgical wait times between robotic, laparoscopic, and open approaches, and to determine whether insurance status impacts timely access to treatment. METHODS After IRB approval, adult patients from the National Cancer Database with a diagnosis of colorectal cancer were identified (2010-2016). Patients who underwent radiation therapy, neoadjuvant chemotherapy, had wait times of 0 days from diagnosis to surgery, or had metastatic disease were excluded. Primary outcomes were days from cancer diagnosis to surgery and days from surgery to adjuvant chemotherapy. Multivariable Poisson regression analysis was performed. RESULTS Among 324,784 patients, 5.9% underwent robotic, 47.5% laparoscopic, and 46.7% open surgery. Patients undergoing robotic surgery incurred the longest wait times from diagnosis to surgery (29.5 days [robotic] vs. 21.7 [laparoscopic] vs. 17.2 [open], p < 0.001), but the shortest wait times from surgery to adjuvant chemotherapy (48.9 days [robotic] vs. 49.9 [laparoscopic] vs. 54.8 [open], p < 0.001). On adjusted analysis, robotic surgery was associated with a 1.46 × longer wait time to surgery (IRR 1.462, 95% CI 1.458-1.467, p < 0.001), but decreased wait time to adjuvant chemotherapy (IRR 0.909, 95% CI 0.905-0.913, p < 0.001) compared to an open approach. Private insurance was associated with decreased wait times to surgery (IRR 0.966, 95% CI 0.962-0.969, p < 0.001) and adjuvant chemotherapy (IRR 0.862, 95% CI 0.858-0.865, p < 0.001) compared to Medicaid. CONCLUSION Though patients undergoing robotic surgery experienced delays from diagnosis to surgery, they tended to initiate adjuvant chemotherapy sooner compared to those undergoing open or laparoscopic approaches. Private insurance was independently associated not only with access to robotic surgery, but also shorter wait times during all stages of treatment.
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Affiliation(s)
- Brian D Lo
- Colorectal Research Unit, Ravitch Division of Colon and Rectal Surgery, Department of Surgery, The Johns Hopkins University School of Medicine, 600 N. Wolfe St., Blalock 618, Baltimore, MD, 21205, USA
| | - George Q Zhang
- Colorectal Research Unit, Ravitch Division of Colon and Rectal Surgery, Department of Surgery, The Johns Hopkins University School of Medicine, 600 N. Wolfe St., Blalock 618, Baltimore, MD, 21205, USA
| | - Miloslawa Stem
- Colorectal Research Unit, Ravitch Division of Colon and Rectal Surgery, Department of Surgery, The Johns Hopkins University School of Medicine, 600 N. Wolfe St., Blalock 618, Baltimore, MD, 21205, USA
| | - Rebecca Sahyoun
- Colorectal Research Unit, Ravitch Division of Colon and Rectal Surgery, Department of Surgery, The Johns Hopkins University School of Medicine, 600 N. Wolfe St., Blalock 618, Baltimore, MD, 21205, USA
| | - Jonathan E Efron
- Colorectal Research Unit, Ravitch Division of Colon and Rectal Surgery, Department of Surgery, The Johns Hopkins University School of Medicine, 600 N. Wolfe St., Blalock 618, Baltimore, MD, 21205, USA
| | - Bashar Safar
- Colorectal Research Unit, Ravitch Division of Colon and Rectal Surgery, Department of Surgery, The Johns Hopkins University School of Medicine, 600 N. Wolfe St., Blalock 618, Baltimore, MD, 21205, USA
| | - Chady Atallah
- Colorectal Research Unit, Ravitch Division of Colon and Rectal Surgery, Department of Surgery, The Johns Hopkins University School of Medicine, 600 N. Wolfe St., Blalock 618, Baltimore, MD, 21205, USA.
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22
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Atallah C, Oduyale O, Stem M, Eltahir A, Almaazmi HH, Efron JE, Safar B. Are academic hospitals better at treating metastatic colorectal cancer? Surgery 2020; 169:248-256. [PMID: 32680747 DOI: 10.1016/j.surg.2020.05.023] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2020] [Revised: 05/03/2020] [Accepted: 05/05/2020] [Indexed: 01/05/2023]
Abstract
BACKGROUND There is a strong association between hospital volume and surgical outcomes in resectable colorectal cancer. The purpose of our study was to investigate the association between hospital facility type and survival of patients with metastatic colorectal cancer. METHODS Adults from the National Cancer Database (2010-2015) with a primary diagnosis of colorectal metastases were included and stratified by facility type: community cancer program, comprehensive community cancer program, and academic/research program. The primary outcome was 5-year overall survival, analyzed using Kaplan-Meier survival curves, log-rank test, and the Cox proportional hazards regression model. RESULTS Among the 52,958 included patients, 13.72% were treated at a community cancer program, 49.89% at a comprehensive community cancer program, and 36.29% at an academic/research program. A significant increase in the proportion of patients being treated in an academic/research program has been observed from 2010 to 2015. An academic/research program tended to use more chemotherapy with colorectal radical resection and liver or lung resection and immunotherapy with chemotherapy. In adjusted analysis, the academic/research program had decreased risk of mortality in comparison to the community cancer program and the comprehensive community cancer program (hazard ratio 0.90, 95% confidence interval 0.86-0.94; 0.87, 0.85-0.90; each P < .001; respectively). Similar results were seen after stratifying by metastatic site and treatment type. CONCLUSION The prognosis and overall survival of patients with metastatic disease is better in an academic/research program compared with a community cancer program or a comprehensive community cancer program, with this difference persisting across sites of metastatic disease and treatment types. Further studies are required to validate these results and investigate disparities in the management of metastatic colorectal cancer.
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Affiliation(s)
- Chady Atallah
- Colorectal Research Unit, Ravitch Colorectal Division, Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD.
| | - Oluseye Oduyale
- Colorectal Research Unit, Ravitch Colorectal Division, Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Miloslawa Stem
- Colorectal Research Unit, Ravitch Colorectal Division, Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Ahmed Eltahir
- Colorectal Research Unit, Ravitch Colorectal Division, Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Hamda H Almaazmi
- Colorectal Research Unit, Ravitch Colorectal Division, Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD; Department of Surgery, George Washington University School of Medicine and Health Sciences, Washington, DC
| | - Jonathan E Efron
- Colorectal Research Unit, Ravitch Colorectal Division, Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Bashar Safar
- Colorectal Research Unit, Ravitch Colorectal Division, Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD
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23
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Truta B, Leeds IL, Canner JK, Efron JE, Fang SH, Althumari A, Safar B. Early Discontinuation of Infliximab in Pregnant Women With Inflammatory Bowel Disease. Inflamm Bowel Dis 2020; 26:1110-1117. [PMID: 31670762 DOI: 10.1093/ibd/izz250] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/10/2019] [Indexed: 02/07/2023]
Abstract
OBJECTIVES Early discontinuation of infliximab (IFX) in pregnant women with inflammatory bowel disease (IBD) decreases the intrauterine fetal exposure to the drug but may increase the risk of disease flaring leading to poor pregnancy outcomes. In this study, we assessed the impact of early IFX discontinuation on mother's disease activity and on their at-risk babies. METHODS In a retrospective study of the Truven Health Analytics MarketScan database from 2011 to 2015, we compared IBD patients who discontinued IFX more than 90 days ("early IFX") with those who discontinue IFX 90 days or less ("late IFX) before delivery. We evaluated the risk of flaring, defined by new steroid prescriptions, visits to emergency room and/or hospital admissions, the pregnancy outcomes, and the at-risk babies. RESULTS After IFX discontinuation, the early IFX group (68 deliveries) required significantly more steroid prescriptions than the late IFX group (318 deliveries) to control disease activity (P < 001). There were more preterm babies in the early IFX group (P < 049), but no difference within the 2 groups was noticed in the rate of intrauterine growth retardation, small for gestation, and stillborn babies. Similarly, there was no increase in acute respiratory infections, development delays, and congenital malformations in babies of the mothers from the late IFX vs early IFX groups. CONCLUSIONS Steroid-free remission IBD mothers are at risk for disease flares and preterm babies when IFX is discontinued early in pregnancy. Continuation of IFX seems to be safe at least for the first year of life.
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Affiliation(s)
- Brindusa Truta
- Division of Gastroenterology and Hepatology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Ira L Leeds
- Division of Gastroenterology and Hepatology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA.,Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Joseph K Canner
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Jonathan E Efron
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Sandy H Fang
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Azah Althumari
- Division of Gastroenterology and Hepatology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Bashar Safar
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
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24
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Zhang GQ, Taylor JP, Stem M, Almaazmi H, Efron JE, Atallah C, Safar B. Aggressive Multimodal Treatment and Metastatic Colorectal Cancer Survival. J Am Coll Surg 2020; 230:689-698. [PMID: 32014570 DOI: 10.1016/j.jamcollsurg.2019.12.024] [Citation(s) in RCA: 26] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2019] [Accepted: 12/16/2019] [Indexed: 01/16/2023]
Abstract
BACKGROUND We aimed to assess patient and demographic factors, treatment trends, and survival outcomes of patients with colorectal cancer with metastasis to the liver, lung, or both sites. Differences remain among national guidelines about the optimal management strategy. METHODS Adults from the National Cancer Database (2010 to 2015) with a primary diagnosis of colorectal liver, lung, or liver and lung metastases were included and stratified by metastasis site. The primary end point was 5-year overall survival, analyzed using Kaplan-Meier survival curves, log-rank test, and the Cox proportional hazards model. RESULTS Among 82,609 included patients, 70.42% had liver, 8.74% had lung, and 20.85% had simultaneous liver and lung metastases. Treatment with chemotherapy alone was used the most (21.11%), followed by chemotherapy with colorectal radical resection (CRRR) (19.4%), no treatment (14.35%), CRRR alone (9.03%), and chemotherapy with CRRR and liver/lung resection (8.22%). Patients with lung metastasis had significantly better 5-year overall survival rates than the other 2 metastatic groups (15.99%, 16.70%, and 5.51%; p < 0.001), even after stratifying by treatment type and adjusting for other factors. Chemotherapy with CRRR and liver/lung resection was associated with the greatest reduction in mortality risk for all sites in both unadjusted (35.15%, 44.52%, and 20.10%; p < 0.001) and adjusted analyses (hazard ratio 0.42; 95% CI, 0.38 to 0.47; p < 0.001; hazard ratio 0.31; 95% CI, 0.18 to 0.53; p < 0.001; and hazard ratio 0.79; 95% CI, 0.62 to 1.01; p = 0.064 for trend), and forgoing treatment or CRRR alone offered the worst overall survival. CONCLUSIONS Patients with metastasis to lung had increased overall survival compared with other sites of metastases, regardless of treatment modality. Combined resection of primary tumor, metastasectomy, and chemotherapy appears to offer the greatest chance of survival.
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Affiliation(s)
- George Q Zhang
- Colorectal Research Unit, Ravitch Colon and Rectal Surgery, Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD
| | - James P Taylor
- Colorectal Research Unit, Ravitch Colon and Rectal Surgery, Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Miloslawa Stem
- Colorectal Research Unit, Ravitch Colon and Rectal Surgery, Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Hamda Almaazmi
- Colorectal Research Unit, Ravitch Colon and Rectal Surgery, Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Jonathan E Efron
- Colorectal Research Unit, Ravitch Colon and Rectal Surgery, Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Chady Atallah
- Colorectal Research Unit, Ravitch Colon and Rectal Surgery, Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Bashar Safar
- Colorectal Research Unit, Ravitch Colon and Rectal Surgery, Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD.
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25
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Almaazmi H, Stem M, Lo BD, Taylor JP, Fang SH, Safar B, Efron JE, Atallah C. The Impact of Imatinib on Survival and Treatment Trends for Small Bowel and Colorectal Gastrointestinal Stromal Tumors. J Gastrointest Surg 2020; 24:98-108. [PMID: 31388887 DOI: 10.1007/s11605-019-04344-4] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/07/2019] [Accepted: 07/24/2019] [Indexed: 01/31/2023]
Abstract
BACKGROUND The aim of this study is to assess treatment trends and overall survival (OS) in small bowel (SB) and colorectal (CR) gastrointestinal stromal tumors (GIST) with respect to the introduction of imatinib in 2008. METHODS Patients diagnosed with SB and CR GIST were identified from the National Cancer Database (2004-2015). The primary outcome was 5- and 10-year OS. Patients were stratified by tumor site, time period (before and after imatinib), and treatment type. OS was analyzed using Kaplan-Meier survival curves, log-rank test, and Cox proportional hazards models. RESULTS A total of 8441 cases were included (SB 81.66%; CR 18.34%). Radical resection was the most common treatment (SB 42.33%; CR 38.69%). The addition of chemotherapy to radical resection for SB GIST increased between the two time periods (31.76 to 40.43%; p < 0.001), and was associated with improved unadjusted and adjusted OS (2009-2015: adjusted HR [AHR] 0.73, 95% CI 0.59-0.89, p = 0.002). Patients with SB GIST had better 5- and 10-year OS compared with CR (SB 69.83% and 47.68%; CR 61.33% and 45.39%; p < 0.001), even after stratifying by treatment type and tumor size and adjusting for other factors (SB 5-year AHR 1.35, 95% CI 1.19-1.53; 10-year AHR 1.23, 95% CI 1.09-1.38; each p < 0.001). CONCLUSION CR GIST are associated with lower OS than SB GIST. Radical resection is the most common treatment type for both sites. Chemotherapy with radical resection offers better OS in SB GIST, but not in CR GIST. Further studies are needed to assess the biology of CR GIST to explain the worse OS.
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Affiliation(s)
- Hamda Almaazmi
- Colorectal Research Unit, Ravitch Colorectal Division, Department of Surgery, The Johns Hopkins University School of Medicine, 600 N. Wolfe Street, Blalock 618, Baltimore, MD, 21205, USA
| | - Miloslawa Stem
- Colorectal Research Unit, Ravitch Colorectal Division, Department of Surgery, The Johns Hopkins University School of Medicine, 600 N. Wolfe Street, Blalock 618, Baltimore, MD, 21205, USA
| | - Brian D Lo
- Colorectal Research Unit, Ravitch Colorectal Division, Department of Surgery, The Johns Hopkins University School of Medicine, 600 N. Wolfe Street, Blalock 618, Baltimore, MD, 21205, USA
| | - James P Taylor
- Colorectal Research Unit, Ravitch Colorectal Division, Department of Surgery, The Johns Hopkins University School of Medicine, 600 N. Wolfe Street, Blalock 618, Baltimore, MD, 21205, USA
| | - Sandy H Fang
- Colorectal Research Unit, Ravitch Colorectal Division, Department of Surgery, The Johns Hopkins University School of Medicine, 600 N. Wolfe Street, Blalock 618, Baltimore, MD, 21205, USA
| | - Bashar Safar
- Colorectal Research Unit, Ravitch Colorectal Division, Department of Surgery, The Johns Hopkins University School of Medicine, 600 N. Wolfe Street, Blalock 618, Baltimore, MD, 21205, USA
| | - Jonathan E Efron
- Colorectal Research Unit, Ravitch Colorectal Division, Department of Surgery, The Johns Hopkins University School of Medicine, 600 N. Wolfe Street, Blalock 618, Baltimore, MD, 21205, USA
| | - Chady Atallah
- Colorectal Research Unit, Ravitch Colorectal Division, Department of Surgery, The Johns Hopkins University School of Medicine, 600 N. Wolfe Street, Blalock 618, Baltimore, MD, 21205, USA.
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26
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Chen SY, Leeds IL, Cerullo M, Jones JL, Buchwald UK, Efron JE, Gearhart SL, Safar B, Fang SH. Anal Cancer Screening Attitudes and Practices in Maryland Healthcare Providers: Implications for National Trends. J Surg Oncol 2019. [DOI: 10.31487/j.jso.2019.03.07] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
Background: Anal cancer incidence is increasing in the US. Though formally established national anal cancer screening guidelines are nonexistent, many providers advocate screening to avoid late disease presentation. This study assesses the knowledge, attitudes, and practices of anal cancer screening among providers to identify the degree of variation and barriers to screening.
Methods: Healthcare providers from two academic medical centers and a statewide community primary care group were surveyed using a questionnaire adapted from the National Survey of Primary Care Physicians’ Recommendations and Practice for Cancer Screening. Descriptive statistics were performed to explore providers’ responses and Fisher’s exact test to explore variation.
Results: 86 providers completed the questionnaire (response rate 24.2%): 81.4% physicians, 18.6% advanced practitioners. 48.2% of respondents perform anal cancer screening. 5.8% correctly identified all high-risk patient factors. “HIV+ patient” was identified most frequently as high-risk (93.5%), “organ transplant recipient” (42.9%) least frequently. Anal pap test was the most recommended first-line screening test (76.6%) followed by digital anorectal exam (19.2%), HPV test (8.5%), and high-resolution anoscopy (HRA) (6.4%). Clinical evidence (72.3%) and national guidelines (70.2%) were most influential in guiding providers’ screening recommendations. Lack of qualified screening providers (34.1%), lack of patient follow-up after positive test results (22.7%), and patient non-compliance to initial screening (15.9%) were identified as “usual” barriers.
Conclusions: Anal cancer screening attitudes and practices vary among providers. Development of national practice guidelines that define a multidisciplinary team approach from primary care anal cancer screening to specialist referral for HRA may reduce screening variability.
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Almaazmi H, Taylor JP, Stem M, Yu D, Lo BD, Safar B, Efron JE. Anal Squamous Cell Carcinoma: Radiation Therapy Alone Must Be Avoided. J Surg Res 2019; 247:530-540. [PMID: 31648811 DOI: 10.1016/j.jss.2019.09.049] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2019] [Revised: 08/07/2019] [Accepted: 09/20/2019] [Indexed: 02/01/2023]
Abstract
BACKGROUND Anal squamous cell carcinoma (ASCC) is the most common histological subtype of anal cancer. Rates have been observed to increase in recent years. Combined chemoradiotherapy (CCRT) is currently the gold standard of treatment. The aim of this study is to assess ASCC prevalence, treatment trends, and overall survival (OS) in the United States. METHODS Patients diagnosed with stage I-IV ASCC were identified from the National Cancer Database from 2004 to 2015. The primary outcome was 5-year OS, which was analyzed using Kaplan-Meier survival curves, log-rank test, and Cox proportional hazards models. RESULTS 34,613 cases were included (stage I: 21.45%; II: 41.00%; III: 31.62%; IV: 5.94%), with an increasing trend in prevalence. CCRT was the most used treatment. Multimodal treatment, combining surgery with CCRT, offered the best OS rates for stage I, II, and IV cancers (I: 84.87%; II: 75.12%; IV: 33.08%), comparable with survival of stage III patients treated with CCRT (III: 61.14%). Radiation alone had the worse OS rates, and on adjusted analysis, radiation treatment alone had the greatest risk of mortality (I: hazard ratio, 2.01; 95% confidence interval, 1.14-3.54; P = 0.016; II: 2.05, 1.44-2.93, P < 0.001; IV: 1.99, 0.99-4.02, P = 0.054). CONCLUSIONS ASCC has increased in prevalence, notably in stage III and IV disease. Although CCRT is the most commonly used treatment type for all stages of ASCC, multimodal treatment offers better OS in stages I, II, and IV. Treatment with radiation alone offers the worst OS no matter the stage and should no longer be used as a solitary treatment modality.
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Affiliation(s)
- Hamda Almaazmi
- Department of Surgery, Colorectal Research Unit, Ravitch Colorectal Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - James P Taylor
- Department of Surgery, Colorectal Research Unit, Ravitch Colorectal Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Miloslawa Stem
- Department of Surgery, Colorectal Research Unit, Ravitch Colorectal Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - David Yu
- Department of Surgery, Queen's University School of Medicine, Kingston, Ontario, Canada
| | - Brian D Lo
- Department of Surgery, Colorectal Research Unit, Ravitch Colorectal Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Bashar Safar
- Department of Surgery, Colorectal Research Unit, Ravitch Colorectal Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Jonathan E Efron
- Department of Surgery, Colorectal Research Unit, Ravitch Colorectal Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland.
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Chen SY, Stem M, Gearhart SL, Safar B, Fang SH, Azad NS, Murphy AG, Narang AK, Wolfgang CL, Efron JE. Readmission Adversely Affects Survival in Surgical Rectal Cancer Patients. World J Surg 2019; 43:2506-2517. [PMID: 31222644 DOI: 10.1007/s00268-019-05053-4] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
BACKGROUND Readmission has received attention as a potential healthcare quality metric. No studies have investigated the relationship between readmission and survival in patients undergoing rectal cancer surgery. The aims of this study were to identify factors associated with 30-day readmission after rectal cancer surgery and to determine the impact of readmission on overall survival (OS). METHODS Patients who underwent surgical treatment for rectal/rectosigmoid adenocarcinoma stages I-IV were identified using the National Cancer Database (2004-2014). Multivariable logistic regression was used to identify factors for readmission. 2:1 nearest neighbor caliper matching without replacement was used to ensure similarity of patients being compared. Survival analyses were performed using Kaplan-Meier method along with log-rank test and Cox proportional hazards model. RESULTS Of 110,167 patients, 7045 (6.39%) were readmitted. Factors associated with readmission included higher Charlson comorbidity score, non-private or no insurance, procedure type, hospitals in the Northeast, South, and Midwest regions, and prolonged length of stay. Within the matched cohort (13,756 non-readmitted and 6878 readmitted), readmitted patients had worse 5- and 10-year OS regardless of cancer stage (p < 0.001) and procedure type. Five- and 10-year OS were 58.98% and 41.01% for readmitted patients, 64.96% and 43.50% for non-readmitted patients. Readmitted patients had shorter OS by 13.14 months and increased risk of mortality (HR 1.20, 95% CI 1.15-1.25, p < 0.001). CONCLUSIONS Thirty-day readmission after rectal cancer surgery is associated with decreased OS. Efforts to reduce readmissions should be considered to advance cancer care and enhance the potential for improved patient survival.
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Affiliation(s)
- Sophia Y Chen
- Department of Surgery, The Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Miloslawa Stem
- Department of Surgery, The Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Susan L Gearhart
- Department of Surgery, The Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Bashar Safar
- Department of Surgery, The Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Sandy H Fang
- Department of Surgery, The Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Nilofer S Azad
- Department of Oncology, The Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Adrian G Murphy
- Department of Oncology, The Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Amol K Narang
- Department of Radiation Oncology & Molecular Sciences, The Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Christopher L Wolfgang
- Department of Surgery, The Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Jonathan E Efron
- Department of Surgery, The Johns Hopkins University School of Medicine, Baltimore, MD, USA.
- Mark M. Ravitch Professor of Surgery, The Johns Hopkins University School of Medicine, 733 North Broadway, Suite G-45, Baltimore, MD, 21205, USA.
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Meyers PM, Leeds IL, Enumah ZO, Burkhart RA, He J, Haut ER, Efron JE, Johnston FM. Missed psychosocial risk factors during routine preoperative evaluations are associated with increased complications after elective cancer surgery. Surgery 2019; 166:177-183. [DOI: 10.1016/j.surg.2019.04.015] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2019] [Revised: 04/08/2019] [Accepted: 04/20/2019] [Indexed: 01/03/2023]
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Leeds IL, Meyers PM, Enumah ZO, He J, Burkhart RA, Haut ER, Efron JE, Johnston FM. Psychosocial Risks are Independently Associated with Cancer Surgery Outcomes in Medically Comorbid Patients. Ann Surg Oncol 2019; 26:936-944. [DOI: 10.1245/s10434-018-07136-3] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2018] [Indexed: 11/18/2022]
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Chen SY, Stem M, Gearhart SL, Safar B, Fang SH, Efron JE. Functional dependence versus frailty in gastrointestinal surgery: Are they comparable in predicting short-term outcomes? Surgery 2018; 164:1316-1324. [DOI: 10.1016/j.surg.2018.06.007] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2018] [Revised: 06/06/2018] [Accepted: 06/06/2018] [Indexed: 12/21/2022]
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Leeds IL, Rosenblum AJ, Wise PE, Watkins AC, Goldblatt MI, Haut ER, Efron JE, Johnston FM. Eye of the beholder: Risk calculators and barriers to adoption in surgical trainees. Surgery 2018; 164:1117-1123. [PMID: 30149939 PMCID: PMC8383120 DOI: 10.1016/j.surg.2018.07.002] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2018] [Revised: 06/30/2018] [Accepted: 07/02/2018] [Indexed: 01/03/2023]
Abstract
BACKGROUND Accurate risk assessment before surgery is complex and hampered by behavioral factors. Underutilized risk-based decision-support tools may counteract these barriers. The purpose of this study was to identify perceptions of and barriers to the use of surgical risk-assessment tools and assess the importance of data framing as a barrier to adoption in surgical trainees. METHODS We distributed a survey and risk assessment activity to surgical trainees at four training institutions. The primary outcomes of this study were descriptive risk assessment practices currently performed by residents, identifiable influences and obstacles to adoption, and the variability of preference sets when comparing modified System Usability Scores of a current risk calculator to a purpose-built calculator revision. Risk calculator comparison responses were compared with simple and multivariable regression to identify predictors for preferentiality. RESULTS We collected responses from 124 surgical residents (39% response rate). Participants endorsed familiarity with direct verbal communication (100%), sketch diagrams (87%), and brochures (59%). The most contemporary risk communication frameworks, such as best-worst case scenario framing (38%), case-specific risk calculators (43%), and all-procedure calculators (52%) were the least familiar. Usage favored traditional models of communication with only 26% of residents regularly using a strategy other than direct verbal discussion or anatomic sketch diagrams. Barriers limiting routine use included lack of electronic and clinical workflow integration. The mean modified System Usability Scores domain scores were widely dispersed for all domains, and no domain demonstrated one calculator's superiority over another. CONCLUSION Risk assessment tools are underutilized by trainees. Of importance, preference sets of clinicians appear to be unpredictable and may benefit more from a customizable, bespoke approach.
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Affiliation(s)
- Ira L Leeds
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Andrew J Rosenblum
- Johns Hopkins University Bloomberg School of Public Health, Baltimore, MD
| | - Paul E Wise
- Department of Surgery, Washington University School of Medicine in St. Louis, MO
| | | | | | - Elliott R Haut
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD; Johns Hopkins University Bloomberg School of Public Health, Baltimore, MD
| | - Jonathan E Efron
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Fabian M Johnston
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD.
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Choi Y, Huntley JH, Efron JE, Sato K, Marohn MR, Pollack CE. Survivorship care for early-stage colorectal cancer: a national survey of general surgeons and colorectal surgeons. Colorectal Dis 2018; 20:996-1003. [PMID: 29956455 DOI: 10.1111/codi.14321] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/02/2018] [Accepted: 05/21/2018] [Indexed: 12/24/2022]
Abstract
AIM Few data are available on the optimal long-term care of early-stage colorectal cancer survivors, termed survivorship care. We aimed to investigate current practice in the management of patients following treatment for early-stage colorectal cancer. METHOD We performed an internet survey of members of the American Society for Colon and Rectal Surgeons about several aspects of long-term care, including allocation of clinician responsibility, challenges with transitions to primary care physicians (PCPs), long-term care plan provision and recommended surgical follow-up duration. RESULTS Overall, 251 surgeons responded. Surgeons reported taking primary responsibility for managing adverse surgical effects (93.2%) and surveillance testing (imaging and laboratories 68.6%, endoscopy 82.4%). Barriers to PCP handoffs included patient preference for surgical follow-up (endorsed by 76.6%) and inadequate communication with PCPs (endorsed by 36.9%). Approximately one-third of surgeons routinely provide survivorship care plans to PCPs; surgeons who received formal survivorship training were more likely to do so compared to those without such training (OR 3.29, 95% CI 1.57, 6.92). Although only 20.4% of surgeons follow their patients beyond 5 years, individuals in practice longer were more likely to continue long-term follow-up than those with ≤ 10 years of experience. CONCLUSIONS This is the largest survey of surgeons regarding long-term management for early-stage colorectal cancer and highlights the potential for improved coordination with PCPs and increased implementation of survivorship care plans.
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Affiliation(s)
- Y Choi
- Department of Medicine, Johns Hopkins School of Medicine, Lutherville, MD, USA
| | - J H Huntley
- Department of Medicine, Johns Hopkins School of Medicine, Lutherville, MD, USA
| | - J E Efron
- Department of Surgery, Johns Hopkins School of Medicine, Lutherville, MD, USA
| | - K Sato
- Department of Surgery, Johns Hopkins School of Medicine, Lutherville, MD, USA
| | - M R Marohn
- Department of Surgery, Johns Hopkins School of Medicine, Lutherville, MD, USA
| | - C E Pollack
- Department of Medicine, Johns Hopkins School of Medicine, Lutherville, MD, USA
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Calotta NA, Coon D, Bos TJ, Ostrander BT, Scott AV, Grant MC, Efron JE, Sacks JM. Early ambulation after colorectal oncologic resection with perineal reconstruction is safe and effective. Am J Surg 2018; 218:125-130. [PMID: 30471809 DOI: 10.1016/j.amjsurg.2018.10.005] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2018] [Revised: 09/18/2018] [Accepted: 10/06/2018] [Indexed: 02/07/2023]
Abstract
BACKGROUND Post-operative bedrest is common following perineal reconstruction despite little supporting data. We sought to determine the safety of early ambulation following colorectal oncologic resection and flap-based perineal reconstruction. METHODS A retrospective cohort study was conducted with two cohorts: standard bedrest (BC) and early ambulation (EAC). Ambulation capacity was objectively assessed. Regression analysis was performed to determine the effects of ambulation timing on 60-day reoperations or readmissions and other surgical outcomes. RESULTS There were 57 participants. Those in the EAC were significantly more ambulatory on post-operative days one through three (p < 0.0001). There was no significant difference in 60-day reoperations (25% BC versus 9% EAC, p = 0.14) or readmissions (33% BC versus 15% EAC, p = 0.12). Early ambulation significantly reduced minor complication rates (38% BC versus 9% EAC, p = 0.02). CONCLUSIONS Early ambulation following perineal reconstruction is safe and may potentially decrease wound complications. SUMMARY AND KEYWORDS Institution of early ambulation protocols is rapidly becoming the standard of care for many oncological surgery patients. In cases requiring perineal reconstruction with vascularized flaps, however, there is no data to uproot the historical practice of mandatory bedrest. Our study demonstrates that the benefits of early ambulation are attainable in these patients without compromising reconstructive outcomes.
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Affiliation(s)
- Nicholas A Calotta
- Department of Plastic and Reconstructive Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Devin Coon
- Department of Plastic and Reconstructive Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Tobias J Bos
- Department of Plastic and Reconstructive Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA; Department of Surgery, Leiden University Medical Center, Leiden, the Netherlands
| | - Benjamin T Ostrander
- Department of Plastic and Reconstructive Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Andrew V Scott
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Michael C Grant
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Jonathan E Efron
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Justin M Sacks
- Department of Plastic and Reconstructive Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA.
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Leeds IL, Rosenblum AJ, Wise PE, Watkins AC, Goldblatt MI, Haut ER, Efron JE, Johnston FM. Variations in Data Visualization and Barriers to Adoption of Risk-Assessment Tools for Young Surgeons. J Am Coll Surg 2018. [DOI: 10.1016/j.jamcollsurg.2018.07.512] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
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Chen SY, Stem M, Cerullo M, Gearhart SL, Safar B, Fang SH, Weiss MJ, He J, Efron JE. The Effect of Frailty Index on Early Outcomes after Combined Colorectal and Liver Resections. J Gastrointest Surg 2018; 22:640-649. [PMID: 29209981 DOI: 10.1007/s11605-017-3641-5] [Citation(s) in RCA: 27] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/16/2017] [Accepted: 11/13/2017] [Indexed: 01/31/2023]
Abstract
BACKGROUND Although previous studies have examined frailty as a potential predictor of adverse surgical outcomes, little is reported on its application. We sought to assess the impact of the 5-item modified frailty index (mFI) on morbidity in patients undergoing combined colorectal and liver resections. METHODS Adult patients who underwent combined colorectal and liver resections were identified using the ACS-NSQIP database (2005-2015). The 5-item mFI consists of history of chronic obstructive pulmonary disease, congestive heart failure, hypertension, diabetes, and partial/total dependence. Patients were stratified into three groups: mFI 0, 1, or ≥ 2. The impact of the mFI on primary outcomes (30-day overall and serious morbidity) was assessed using multivariable logistic regression. Subgroup analyses by age and hepatectomy type was also performed. RESULTS A total of 1928 patients were identified: 55.1% with mFI = 0, 33.2% with mFI = 1, and 11.7% with mFI ≥ 2. 75.9% of patients underwent wedge resection/segmentectomy (84.6% colon, 15.4% rectum), and 24.1% underwent hemihepatectomy (88.8% colon, 11.2% rectum). On unadjusted analysis, patients with mFI ≥ 2 had significantly greater rates of overall and serious morbidity, regardless of age and hepatectomy type. These findings were consistent with the multivariable analysis, where patients with mFI ≥ 2 had increased odds of overall morbidity (OR 1.41, 95% CI 1.02-1.96, p = 0.037) and were more than twice likely to experience serious morbidity (OR 2.12, 95% CI 1.47-3.04, p < 0.001). CONCLUSIONS The 5-item mFI is significantly associated with 30-day morbidity in patients undergoing combined colorectal and liver resections. It is a tool that can guide surgeons preoperatively in assessing morbidity risk in patients undergoing concomitant resections.
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Affiliation(s)
- Sophia Y Chen
- Department of Surgery, The Johns Hopkins University School of Medicine, 600 N. Wolfe Street, Blalock 618, Baltimore, MD, 21287, USA
| | - Miloslawa Stem
- Department of Surgery, The Johns Hopkins University School of Medicine, 600 N. Wolfe Street, Blalock 618, Baltimore, MD, 21287, USA
| | - Marcelo Cerullo
- Department of Surgery, The Johns Hopkins University School of Medicine, 600 N. Wolfe Street, Blalock 618, Baltimore, MD, 21287, USA
| | - Susan L Gearhart
- Department of Surgery, The Johns Hopkins University School of Medicine, 600 N. Wolfe Street, Blalock 618, Baltimore, MD, 21287, USA
| | - Bashar Safar
- Department of Surgery, The Johns Hopkins University School of Medicine, 600 N. Wolfe Street, Blalock 618, Baltimore, MD, 21287, USA
| | - Sandy H Fang
- Department of Surgery, The Johns Hopkins University School of Medicine, 600 N. Wolfe Street, Blalock 618, Baltimore, MD, 21287, USA
| | - Matthew J Weiss
- Department of Surgery, The Johns Hopkins University School of Medicine, 600 N. Wolfe Street, Blalock 618, Baltimore, MD, 21287, USA
| | - Jin He
- Department of Surgery, The Johns Hopkins University School of Medicine, 600 N. Wolfe Street, Blalock 618, Baltimore, MD, 21287, USA
| | - Jonathan E Efron
- Department of Surgery, The Johns Hopkins University School of Medicine, 600 N. Wolfe Street, Blalock 618, Baltimore, MD, 21287, USA.
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Farrow NE, Aboagye JK, Lau BD, Najjar P, Orgill DP, Popoola VO, Kraus PS, Hobson DB, Shaffer DL, Safar B, Gearhart S, Efron JE, Streiff MB, Haut ER. The role of extended/outpatient venous thromboembolism prophylaxis after abdominal surgery for cancer or inflammatory bowel disease. Journal of Patient Safety and Risk Management 2018. [DOI: 10.1177/1356262217753427] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Abstract
Background Current guidelines recommend in-hospital venous thromboembolism prophylaxis for many patients and extended/outpatient prophylaxis in high-risk patients undergoing abdomino-pelvic surgery for cancer. Despite these guidelines, extended venous thromboembolism prophylaxis is not used uniformly at all institutions. This study aimed to evaluate the impact of postdischarge prophylaxis practices at two academic medical centers on the rate of postdischarge venous thromboembolism. Methods We retrospectively analyzed data from the Brigham and Women’s Hospital and the Johns Hopkins Hospital’s American College of Surgeons, National Surgical Quality Improvement Program registries from 1 August 2014 to 30 June 2015. Brigham and Women’s Hospital patients received four weeks supply of extended/outpatient venous thromboembolism prophylaxis, while Johns Hopkins Hospital patients did not. We determined the proportion of patients in each cohort that developed venous thromboembolism within 30 days of surgery. Results Four hundred and eighty-nine patients underwent abdominal surgery for cancer and inflammatory bowel disease; 181 (37.0%) patients from Brigham and Women’s Hospital and 308 (63.0%) patients from Johns Hopkins Hospital. Fourteen patients developed postoperative venous thromboembolism. Seven patients developed in-hospital venous thromboembolism and seven developed venous thromboembolism postdischarge. All postdischarge venous thromboembolism occurred in the Johns Hopkins group, and this difference was statistically significant (p = 0.0498). There was no difference in postdischarge bleeding rates between the groups. Conclusions Extended prophylaxis likely prevents postdischarge venous thromboembolism after major abdominal surgery without an increased risk of bleeding.
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Affiliation(s)
- Norma E Farrow
- Department of Surgery, The Johns Hopkins University School of Medicine, Johns Hopkins University, Baltimore, USA
| | - Jonathan K Aboagye
- Department of Surgery, The Johns Hopkins University School of Medicine, Johns Hopkins University, Baltimore, USA
| | - Brandyn D Lau
- Department of Radiology and Radiological Science, Johns Hopkins School of Medicine, Baltimore, MD
- Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD
- Division of Health Sciences Informatics, The Johns Hopkins University School of Medicine, Johns Hopkins University, Baltimore, USA
- The Armstrong Institute for Patient Safety, Johns Hopkins Medicine, Johns Hopkins University, Baltimore, USA
| | - Peter Najjar
- Department of Surgery, Brigham and Women’s Hospital, Boston, USA
| | - Dennis P Orgill
- Department of Surgery, Brigham and Women’s Hospital, Boston, USA
| | - Victor O Popoola
- Department of Surgery, The Johns Hopkins University School of Medicine, Johns Hopkins University, Baltimore, USA
| | - Peggy S Kraus
- Department of Surgery, The Johns Hopkins University School of Medicine, Johns Hopkins University, Baltimore, USA
| | - Deborah B Hobson
- Department of Surgery, The Johns Hopkins University School of Medicine, Johns Hopkins University, Baltimore, USA
| | - Dauryne L Shaffer
- Department of Surgery, The Johns Hopkins University School of Medicine, Johns Hopkins University, Baltimore, USA
| | - Bashar Safar
- Department of Surgery, The Johns Hopkins University School of Medicine, Johns Hopkins University, Baltimore, USA
| | - Susan Gearhart
- Department of Surgery, The Johns Hopkins University School of Medicine, Johns Hopkins University, Baltimore, USA
| | - Jonathan E Efron
- Department of Surgery, The Johns Hopkins University School of Medicine, Johns Hopkins University, Baltimore, USA
| | - Michael B Streiff
- The Armstrong Institute for Patient Safety, Johns Hopkins Medicine, Johns Hopkins University, Baltimore, USA
- Department of Medicine, Johns Hopkins University, Johns Hopkins University School of Medicine, Johns Hopkins University, Baltimore, USA
| | - Elliott R Haut
- Department of Surgery, The Johns Hopkins University School of Medicine, Johns Hopkins University, Baltimore, USA
- Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD
- Division of Health Sciences Informatics, The Johns Hopkins University School of Medicine, Johns Hopkins University, Baltimore, USA
- The Armstrong Institute for Patient Safety, Johns Hopkins Medicine, Johns Hopkins University, Baltimore, USA
- Department of Anesthesiology & Critical Care Medicine, Johns Hopkins University, The Johns Hopkins University School of Medicine, Johns Hopkins University, Baltimore, USA
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Eluri S, Parian AM, Limketkai BN, Ha CY, Brant SR, Dudley-Brown S, Efron JE, Fang SG, Gearhart SL, Marohn MR, Meltzer SJ, Bashar S, Truta B, Montgomery EA, Lazarev MG. Nearly a Third of High-Grade Dysplasia and Colorectal Cancer Is Undetected in Patients with Inflammatory Bowel Disease. Dig Dis Sci 2017. [PMID: 28631086 PMCID: PMC6435268 DOI: 10.1007/s10620-017-4652-5] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
BACKGROUND It is unclear whether intensive surveillance protocols have resulted in a decreased incidence of colorectal cancer (CRC) in inflammatory bowel disease (IBD). AIMS To determine the prevalence and characteristics of IBD associated high-grade dysplasia (HGD) or CRC that was undetected on prior colonoscopy. METHODS This is a single-center, retrospective study from 1994 to 2013. All participants had a confirmed IBD diagnosis and underwent a colectomy with either HGD or CRC found in the colectomy specimen.The undetected group had no HGD or CRC on prior colonoscopies. The detected group had HGD or CRC identified on previous biopsies. RESULTS Of 70 participants, with ulcerative colitis (UC) (n = 47), Crohn's disease (CD) (n = 21), and indeterminate colitis (n = 2), 29% (n = 20) had undetected HGD/CRC at colectomy (15 HGD and 5 CRC). In the undetected group, 75% had prior LGD, 15% had indefinite dysplasia, and 10% had no dysplasia (HGD was found in colonic strictures). Patients in the undetected group were more likely to have pancolitis (55 vs. 20%) and multifocal dysplasia (35 vs. 8%). The undetected group was less likely to have CRC at colectomy (25 vs. 62%). There was a trend toward right-sided HGD/CRC at colectomy (40 vs. 20%; p = 0.08). In addition, 84% of the lesions found in the rectum at colectomy were not seen on prior colonoscopy in the undetected group. CONCLUSIONS The prevalence of previously undetected HGD/CRC in IBD found at colectomy was 29%. The high proportion of undetected rectal and right-sided HGD/CRC suggests that these areas may need greater attention during surveillance.
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Affiliation(s)
- Swathi Eluri
- Division of Gastroenterology and Hepatology, School of Medicine, University of North Carolina at Chapel Hill, 4119B Bioinformatics Building, 130 Mason Farm Road, Chapel Hill, NC, 27599-7080, USA.
- Johns Hopkins University School of Medicine, 600 N. Wolfe Street, Baltimore, MD, 21287, USA.
| | - Alyssa M Parian
- Division of Gastroenterology and Hepatology, School of Medicine, University of North Carolina at Chapel Hill, 4119B Bioinformatics Building, 130 Mason Farm Road, Chapel Hill, NC, 27599-7080, USA
| | - Berkeley N Limketkai
- Stanford University School of Medicine, Stanford, CA, USA
- Digestive Health Liver Clinic, 900 Blake Wilbur Dr, MC 5355, Palo Alto, CA, 94304, USA
| | - Christina Y Ha
- David Geffen School of Medicine, University of California Los Angeles, Los Angeles, CA, USA
- Ronald Reagan UCLA Medical Center, 757 Westwood Plaza, Los Angeles, CA, 90095, USA
| | - Steven R Brant
- Division of Gastroenterology and Hepatology, School of Medicine, University of North Carolina at Chapel Hill, 4119B Bioinformatics Building, 130 Mason Farm Road, Chapel Hill, NC, 27599-7080, USA
| | - Sharon Dudley-Brown
- Division of Gastroenterology and Hepatology, School of Medicine, University of North Carolina at Chapel Hill, 4119B Bioinformatics Building, 130 Mason Farm Road, Chapel Hill, NC, 27599-7080, USA
| | - Jonathan E Efron
- Division of Gastroenterology and Hepatology, School of Medicine, University of North Carolina at Chapel Hill, 4119B Bioinformatics Building, 130 Mason Farm Road, Chapel Hill, NC, 27599-7080, USA
| | - Sandy G Fang
- Division of Gastroenterology and Hepatology, School of Medicine, University of North Carolina at Chapel Hill, 4119B Bioinformatics Building, 130 Mason Farm Road, Chapel Hill, NC, 27599-7080, USA
| | - Susan L Gearhart
- Division of Gastroenterology and Hepatology, School of Medicine, University of North Carolina at Chapel Hill, 4119B Bioinformatics Building, 130 Mason Farm Road, Chapel Hill, NC, 27599-7080, USA
| | - Michael R Marohn
- Division of Gastroenterology and Hepatology, School of Medicine, University of North Carolina at Chapel Hill, 4119B Bioinformatics Building, 130 Mason Farm Road, Chapel Hill, NC, 27599-7080, USA
| | - Stephen J Meltzer
- Division of Gastroenterology and Hepatology, School of Medicine, University of North Carolina at Chapel Hill, 4119B Bioinformatics Building, 130 Mason Farm Road, Chapel Hill, NC, 27599-7080, USA
| | - Safar Bashar
- Division of Gastroenterology and Hepatology, School of Medicine, University of North Carolina at Chapel Hill, 4119B Bioinformatics Building, 130 Mason Farm Road, Chapel Hill, NC, 27599-7080, USA
| | - Brindusa Truta
- Division of Gastroenterology and Hepatology, School of Medicine, University of North Carolina at Chapel Hill, 4119B Bioinformatics Building, 130 Mason Farm Road, Chapel Hill, NC, 27599-7080, USA
| | - Elizabeth A Montgomery
- Division of Gastroenterology and Hepatology, School of Medicine, University of North Carolina at Chapel Hill, 4119B Bioinformatics Building, 130 Mason Farm Road, Chapel Hill, NC, 27599-7080, USA
| | - Mark G Lazarev
- Division of Gastroenterology and Hepatology, School of Medicine, University of North Carolina at Chapel Hill, 4119B Bioinformatics Building, 130 Mason Farm Road, Chapel Hill, NC, 27599-7080, USA
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Leeds IL, Truta B, Parian AM, Chen SY, Efron JE, Gearhart SL, Safar B, Fang SH. Early Surgical Intervention for Acute Ulcerative Colitis Is Associated with Improved Postoperative Outcomes. J Gastrointest Surg 2017; 21:1675-1682. [PMID: 28819916 PMCID: PMC6201293 DOI: 10.1007/s11605-017-3538-3] [Citation(s) in RCA: 31] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/20/2017] [Accepted: 08/07/2017] [Indexed: 01/31/2023]
Abstract
BACKGROUND Timing of surgical intervention for acute ulcerative colitis has not been fully examined during the modern immunotherapy era. Although early surgical intervention is recommended, historical consensus for "early" ranges widely. The purpose of this study was to evaluate outcomes according to timing of urgent surgery for acute ulcerative colitis. METHODS All non-elective total colectomies in ulcerative colitis patients were identified in the National Inpatient Sample from 2002 to 2014. Procedures, comorbidities, diagnoses, and in-hospital outcomes were collected using International Classification of Disease, 9th Revision codes. An operation was defined as early if within 24 hours of admission. Results were compared between the early versus delayed surgery groups. RESULTS We found 69,936 patients that were admitted with ulcerative colitis, and 2650 patients that underwent non-elective total colectomy (3.8%). Early intervention was performed in 20.4% of patients who went to surgery. More early operations were performed laparoscopically (28.1% versus 23.3%, p = 0.021) and on more comorbid patients (Charlson Index, p = 0.008). Median total hospitalization costs were $20,948 with an early operation versus $33,666 with a delayed operation (p < 0.001). Delayed operation was an independent risk for a complication (OR = 1.46, p = 0.001). Increased hospitalization costs in the delayed surgery group were statistically significantly higher with a reported complication (OR = 3.00, p < 0.001) and lengths of stay (OR = 1.26, p < 0.001). CONCLUSION Delayed operations for acute ulcerative colitis are associated with increased postoperative complications, increased lengths of stay, and increased hospital costs. Further prospective studies could demonstrate that this association leads to improved outcomes with immediate surgical intervention for medically refractory ulcerative colitis.
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Affiliation(s)
- Ira L Leeds
- Department of Surgery, Johns Hopkins University School of Medicine, 600 North Wolfe Street, Blalock 618, Baltimore, MD, 21287, USA
| | - Brindusa Truta
- Department of Medicine, Division of Gastroenterology and Hepatology, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Alyssa M Parian
- Department of Medicine, Division of Gastroenterology and Hepatology, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Sophia Y Chen
- Department of Surgery, Johns Hopkins University School of Medicine, 600 North Wolfe Street, Blalock 618, Baltimore, MD, 21287, USA
| | - Jonathan E Efron
- Department of Surgery, Johns Hopkins University School of Medicine, 600 North Wolfe Street, Blalock 618, Baltimore, MD, 21287, USA
| | - Susan L Gearhart
- Department of Surgery, Johns Hopkins University School of Medicine, 600 North Wolfe Street, Blalock 618, Baltimore, MD, 21287, USA
| | - Bashar Safar
- Department of Surgery, Johns Hopkins University School of Medicine, 600 North Wolfe Street, Blalock 618, Baltimore, MD, 21287, USA
| | - Sandy H Fang
- Department of Surgery, Johns Hopkins University School of Medicine, 600 North Wolfe Street, Blalock 618, Baltimore, MD, 21287, USA.
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Kates M, Chappidi MR, Brant A, Milbar N, Sopko NA, Meyer C, Terezakis SA, Herman JM, Efron JE, Safar B, Tran PT, Ahuja N, Pierorazio PM, Bivalacqua TJ. High dose-rate Intra-Operative Radiation Therapy During High Risk Genitourinary Surgery: Initial Observations and a Proposal for its Study in Bladder Cancer. Bladder Cancer 2017; 3:191-199. [PMID: 28824947 PMCID: PMC5545919 DOI: 10.3233/blc-170104] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
BACKGROUND High dose-rate Intra-Operative Radiation Therapy (HD-IORT) is used to provide effective local control for patients with high-risk locally advanced or recurrent tumors. However, the utility of HD-IORT for patients with bladder cancer has not been studied. OBJECTIVE To characterize our institutional experience with HD-IORT in patients with cancer requiring genitourinary surgery, in an effort to identify patients with bladder cancer that may benefit from HD-IORT. METHODS We performed a retrospective review of all patients who have undergone HD-IORT during genitourinary surgery at our institution. Patients were stratified by surgical margin status, and primary outcomes assessed were overall survival, recurrence free survival and 90-day complications. Patients undergoing cystectomy and HD-IORT with sarcomatoid urothelial cancer were compared to a similar cohort undergoing cystectomy alone. A sample case of one such patient is discussed in detail. RESULTS 84 patients at our institution have undergone HD-IORT with genitourinary surgery. Positive surgical margin status was the greatest predictor of both OS (HR = 3.42) and RFS (HR = 2.61). The overall 90-day complication rate was 61%, with wound infections (43%) and GI complications (21%) being most common. 4 of these patients had sarcomatoid urothelial histology, and all are still alive with >2 yrs follow up. This compares to a 52% 1 yr survival in our sarcomatoid urothelial cohort (25 pts) that did not undergo HD-IORT. CONCLUSIONS Our institutional experience with HD-IORT has been promising, particularly among patients with locally advanced disease and sarcomatoid histology. We are currently enrolling patients in a multi-institutional registry to assess the utility of HD-IORT in high risk bladder cancer.
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Affiliation(s)
- Max Kates
- The James Buchanan Brady Urological Institute and Department of Urology, The Johns Hopkins School of Medicine, Baltimore, MD, USA
| | - Meera R Chappidi
- The James Buchanan Brady Urological Institute and Department of Urology, The Johns Hopkins School of Medicine, Baltimore, MD, USA
| | - Aaron Brant
- The James Buchanan Brady Urological Institute and Department of Urology, The Johns Hopkins School of Medicine, Baltimore, MD, USA
| | - Niv Milbar
- The James Buchanan Brady Urological Institute and Department of Urology, The Johns Hopkins School of Medicine, Baltimore, MD, USA
| | - Nikolai A Sopko
- The James Buchanan Brady Urological Institute and Department of Urology, The Johns Hopkins School of Medicine, Baltimore, MD, USA
| | - Christian Meyer
- The James Buchanan Brady Urological Institute and Department of Urology, The Johns Hopkins School of Medicine, Baltimore, MD, USA
| | - Stephanie A Terezakis
- The James Buchanan Brady Urological Institute and Department of Urology, The Johns Hopkins School of Medicine, Baltimore, MD, USA
| | - Joseph M Herman
- The James Buchanan Brady Urological Institute and Department of Urology, The Johns Hopkins School of Medicine, Baltimore, MD, USA
| | - Jonathan E Efron
- The James Buchanan Brady Urological Institute and Department of Urology, The Johns Hopkins School of Medicine, Baltimore, MD, USA
| | - Bashar Safar
- The James Buchanan Brady Urological Institute and Department of Urology, The Johns Hopkins School of Medicine, Baltimore, MD, USA
| | - Phuoc T Tran
- The James Buchanan Brady Urological Institute and Department of Urology, The Johns Hopkins School of Medicine, Baltimore, MD, USA
| | - Nita Ahuja
- The James Buchanan Brady Urological Institute and Department of Urology, The Johns Hopkins School of Medicine, Baltimore, MD, USA
| | - Phillip M Pierorazio
- The James Buchanan Brady Urological Institute and Department of Urology, The Johns Hopkins School of Medicine, Baltimore, MD, USA
| | - Trinity J Bivalacqua
- The James Buchanan Brady Urological Institute and Department of Urology, The Johns Hopkins School of Medicine, Baltimore, MD, USA
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Fabrizio AC, Grant MC, Siddiqui Z, Alimi Y, Gearhart SL, Wu C, Efron JE, Wick EC. Is enhanced recovery enough for reducing 30-d readmissions after surgery? J Surg Res 2017; 217:45-53. [PMID: 28602223 DOI: 10.1016/j.jss.2017.04.007] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2016] [Revised: 03/21/2017] [Accepted: 04/11/2017] [Indexed: 12/20/2022]
Abstract
BACKGROUND Few enhanced recovery pathways (ERPs) include processes related to the hospital to home transfer. Little has been reported regarding readmissions in enhanced recovery programs. This study evaluates readmissions and identifies areas to optimize ERPs to prevent readmissions. METHODS We conducted an observational, retrospective study at a single tertiary care center. Patients in an ERP for colorectal surgery were compared with a similar cohort who underwent surgery before protocol implementation. We evaluated 30-d readmission, compliance to enhanced recovery protocol, and diagnoses and patient care experiences related to transition of care. RESULTS Readmission rates (17.6% versus 19.4%; P = 0.55) were similar. There was significant reduction in index hospitalization length of stay (5.3 versus 7.0 d; P < 0.001) and postoperative surgical site infection (7.3% versus 16.6%; P = 0.01). Although enhanced recovery was associated with reduced readmissions for surgical site infections (31% versus 50.7%, P = 0.02), there was a trend toward increased readmissions for small bowel obstruction-ileus (31% versus 19.1%, P = 0.13). ERPs did not impact perceptions of care transitions; however, those who were readmitted rated their transition lower than those that were not. CONCLUSIONS Although ERPs did not reduce readmissions, the program was associated with reduced length of stay and surgical site infections. ERPs did not influence perceptions of the transition to home. Transition process measures aimed at reducing readmission and improving patient outcomes, including use of transition guides, remote vital sign and symptom monitoring, and early clinical follow-up have not traditionally been part of ERP protocols but should be considered.
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Affiliation(s)
- Anne C Fabrizio
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Michael C Grant
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Zishan Siddiqui
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Yewande Alimi
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Susan L Gearhart
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Christopher Wu
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Jonathan E Efron
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Elizabeth C Wick
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland.
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Abstract
It is evident that the use of laparoscopy in the management of rectal cancer has gained popularity in the last few years. It is still, however, not widely accepted as the standard of care. Multiple randomized trials have shown that short-term outcomes and perioperative morbidity and mortality of laparoscopic proctectomy are equivalent to open surgery. However, data regarding long-term oncologic outcomes are still scarce, with only a few randomized trials reporting similar outcomes in both laparoscopic and open group. A more recent trial failed to replicate those results in patients with locally advanced rectal cancer. In this article, we will look at the most recent evidence regarding the use of laparoscopy for patients with rectal cancer. We will also briefly discuss the different approaches and new minimally invasive techniques used in this field, and we will talk about the challenges facing the widespread adoption of laparoscopic surgery in the management of rectal cancer.
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Affiliation(s)
- Chady Atallah
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Jonathan E Efron
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
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Althumairi AA, Canner JK, Gearhart SL, Safar B, Sacks J, Efron JE. Predictors of Perineal Wound Complications and Prolonged Time to Perineal Wound Healing After Abdominoperineal Resection. World J Surg 2017; 40:1755-62. [PMID: 26908238 DOI: 10.1007/s00268-016-3450-0] [Citation(s) in RCA: 45] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
BACKGROUND Perineal wound following abdominoperineal resection (APR) is associated with high complication rate and delayed healing. We aim to evaluate the risk factors for delayed wound healing and wound complications following APR. METHODS A retrospective review of patients who underwent APR was performed. Non-delayed wound healing occurred within 6 weeks. Major complications included infection, necrosis, and dehiscence that required surgical interventions. Minor complications included drainage and superficial dehiscence that were treated conservatively. Patients were compared for type of wound closure (primary vs. flap reconstruction). Effect of patients' demographic and clinical variables on time to healing, and on major and minor wound complications was examined. RESULTS 215 patients were identified, of which 175 (81 %) had primary closure and 40 (19 %) had flap reconstruction. Overall, major wound complications occurred in 14 (7 %) of patients and minor wound complications occurred in 48 (22 %). Mean time to wound healing was 6.3 weeks in the primary closure group and 9.3 weeks in the flap reconstruction group (p = 0.02). Delayed wound healing occurred in 44 (25 %) of the primary closure group and in 25 (62 %) of the flap reconstruction group (p < 0.001). Delayed wound healing was associated with smoking (p = 0.005), hypoalbuminemia (p = 0.05), neoadjuvant chemotherapy (p = 0.02), and flap reconstruction (p = 0.03). Hypoalbuminemia was associated with major wound complications (p = 0.002), while neoadjuvant chemotherapy was associated with minor wound complications (p = 0.01). CONCLUSIONS Wound complications and delayed healing are related to patients' nutritional status, smoking, and neoadjuvant chemotherapy. Patients with these risk factors are at risk of delayed wound healing even if they underwent flap reconstruction.
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Affiliation(s)
- Azah A Althumairi
- Department of Surgery, Johns Hopkins University School of Medicine, 600 N. Wolfe Street, Baltimore, MD, 21287, USA
| | - Joseph K Canner
- Center for Surgical Trials and Outcomes Research, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Susan L Gearhart
- Department of Surgery, Johns Hopkins University School of Medicine, 600 N. Wolfe Street, Baltimore, MD, 21287, USA
| | - Bashar Safar
- Department of Surgery, Johns Hopkins University School of Medicine, 600 N. Wolfe Street, Baltimore, MD, 21287, USA
| | - Justin Sacks
- Department of Plastic and Reconstructive Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Jonathan E Efron
- Department of Surgery, Johns Hopkins University School of Medicine, 600 N. Wolfe Street, Baltimore, MD, 21287, USA.
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Addae JK, Gani F, Fang SY, Wick EC, Althumairi AA, Efron JE, Canner JK, Euhus DM, Schneider EB. A comparison of trends in operative approach and postoperative outcomes for colorectal cancer surgery. J Surg Res 2017; 208:111-120. [DOI: 10.1016/j.jss.2016.09.019] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2016] [Revised: 08/27/2016] [Accepted: 09/12/2016] [Indexed: 12/18/2022]
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Gani F, Hundt J, Daniel M, Efron JE, Makary MA, Pawlik TM. Variations in hospitals costs for surgical procedures: inefficient care or sick patients? Am J Surg 2017; 213:1-9. [DOI: 10.1016/j.amjsurg.2016.05.007] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2016] [Revised: 04/26/2016] [Accepted: 05/01/2016] [Indexed: 01/10/2023]
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Leeds IL, Alturki H, Canner JK, Schneider EB, Efron JE, Wick EC, Gearhart SL, Safar B, Fang SH. Outcomes of abdominoperineal resection for management of anal cancer in HIV-positive patients: a national case review. World J Surg Oncol 2016; 14:208. [PMID: 27495294 PMCID: PMC4974747 DOI: 10.1186/s12957-016-0970-x] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2016] [Accepted: 08/02/2016] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND The incidence of anal cancer in human immunodeficiency virus (HIV)-positive individuals is increasing, and how co-infection affects outcomes is not fully understood. This study sought to describe the current outcome disparities between anal cancer patients with and without HIV undergoing abdominoperineal resection (APR). METHODS A retrospective review of all US patients diagnosed with anal squamous cell carcinoma, undergoing an APR, was performed. Cases were identified using a weighted derivative of the Healthcare Utilization Project's National Inpatient Sample (2000-2011). Patients greater than 60 years old were excluded after finding a skewed population distribution between those with and without HIV infection. Multivariable logistic regression and generalized linear modeling analysis examined factors associated with postoperative outcomes and cost. Perioperative complications, in-hospital mortality, length of hospital stay, and hospital costs were compared for those undergoing APR with and without HIV infection. RESULTS A total of 1725 patients diagnosed with anal squamous cell cancer undergoing APR were identified, of whom 308 (17.9 %) were HIV-positive. HIV-positive patients were younger than HIV-negative patients undergoing APR for anal cancer (median age 47 years old versus 51 years old, p < 0.001) and were more likely to be male (95.1 versus 30.6 %, p < 0.001). Postoperative hemorrhage was more frequent in the HIV-positive group (5.1 versus 1.5 %, p = 0.05). Mortality was low in both groups (0 % in HIV-positive versus 1.49 % in HIV-negative, p = 0.355), and length of stay (LOS) (10+ days; 75th percentile of patient data) was similar (36.9 % with HIV versus 29.8 % without HIV, p = 0.262). Greater hospitalization costs were associated with patients who experienced a complication. However, there was no difference in hospitalization costs seen between HIV-positive and HIV-negative patients (p = 0.66). CONCLUSIONS HIV status is not associated with worse postoperative recovery after APR for anal cancer as measured by length of stay or hospitalization cost. Further study may support APRs to be used more aggressively in HIV-positive patients with anal cancer.
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Affiliation(s)
- Ira L Leeds
- Department of Surgery, The Johns Hopkins Hospital, 600 North Wolfe Street, Blalock 618, Baltimore, MD, 21287, USA.
| | - Hasan Alturki
- Johns Hopkins Surgery Center for Outcomes Research, Department of Surgery, The Johns Hopkins Hospital, Baltimore, MD, USA
| | - Joseph K Canner
- Johns Hopkins Surgery Center for Outcomes Research, Department of Surgery, The Johns Hopkins Hospital, Baltimore, MD, USA
| | - Eric B Schneider
- Johns Hopkins Surgery Center for Outcomes Research, Department of Surgery, The Johns Hopkins Hospital, Baltimore, MD, USA
| | - Jonathan E Efron
- Department of Surgery, The Johns Hopkins Hospital, 600 North Wolfe Street, Blalock 618, Baltimore, MD, 21287, USA
| | - Elizabeth C Wick
- Department of Surgery, The Johns Hopkins Hospital, 600 North Wolfe Street, Blalock 618, Baltimore, MD, 21287, USA
| | - Susan L Gearhart
- Department of Surgery, The Johns Hopkins Hospital, 600 North Wolfe Street, Blalock 618, Baltimore, MD, 21287, USA
| | - Bashar Safar
- Department of Surgery, The Johns Hopkins Hospital, 600 North Wolfe Street, Blalock 618, Baltimore, MD, 21287, USA
| | - Sandy H Fang
- Department of Surgery, The Johns Hopkins Hospital, 600 North Wolfe Street, Blalock 618, Baltimore, MD, 21287, USA
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Althumairi AA, Canner JK, Ahuja N, Sacks JM, Safar B, Efron JE. Time to Chemotherapy After Abdominoperineal Resection: Comparison Between Primary Closure and Perineal Flap Reconstruction. World J Surg 2016; 40:225-30. [PMID: 26336877 DOI: 10.1007/s00268-015-3224-0] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
BACKGROUND Wound complications are frequent flowing abdominoperineal resection (APR); this can lengthen the time to chemotherapy. Flap reconstruction is being used in an attempt to improve wound healing. OBJECTIVES To assess the effect of flap reconstruction after APR on time to perineal wound healing and administration of adjuvant chemotherapy in patients with rectal adenocarcinoma. METHODS A retrospective review of patients who underwent APR for rectal adenocarcinoma between 2002 and 2012 was performed. Patients were divided into two groups based on type of perineal wound closure (primary vs. flap). Patients were compared for time to perineal wound healing, and time to adjuvant chemotherapy. RESULTS 115 patients were identified; of whom 67 received adjuvant chemotherapy. 56 (84%) patients underwent primary closure while 11 (16%) underwent flap reconstruction. There was no difference in time to perineal wound healing (6.8 vs. 6.3 weeks, p = 0.40) and time to receive adjuvant chemotherapy (9.3 vs. 10.7 weeks, p = 0.79) between the primary closure and flap reconstruction groups, respectively. 25 (45%) of the primary closure group had a delay in receiving adjuvant chemotherapy versus 6 (55%) of the flap reconstruction group (p = 0.55). Delay in receiving adjuvant chemotherapy because of perineal wound complications occurred in 18 (32%) patients with primary closure versus 3 (28%) patients with flap reconstruction (p = 0.14). CONCLUSIONS Flap reconstruction does not reduce the length of time to initiating chemotherapy; there was no difference in length of healing between the two groups. Therefore, flap reconstruction should be selectively used based on the size of the perineal defect.
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Affiliation(s)
- Azah A Althumairi
- Department of Surgery, Johns Hopkins University School of Medicine, 600 N. Wolfe Street, Blalock 618, Baltimore, MD, 21287, USA
| | - Joseph K Canner
- Center for Surgical Trials and Outcomes Research, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Nita Ahuja
- Department of Surgery, Johns Hopkins University School of Medicine, 600 N. Wolfe Street, Blalock 618, Baltimore, MD, 21287, USA
| | - Justin M Sacks
- Department of Plastic and Reconstructive Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Bashar Safar
- Department of Surgery, Johns Hopkins University School of Medicine, 600 N. Wolfe Street, Blalock 618, Baltimore, MD, 21287, USA
| | - Jonathan E Efron
- Department of Surgery, Johns Hopkins University School of Medicine, 600 N. Wolfe Street, Blalock 618, Baltimore, MD, 21287, USA.
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Althumairi AA, Canner JK, Gearhart SL, Safar B, Fang SH, Wick EC, Efron JE. Risk factors for wound complications after abdominoperineal excision: analysis of the ACS NSQIP database. Colorectal Dis 2016; 18:O260-6. [PMID: 27178168 DOI: 10.1111/codi.13384] [Citation(s) in RCA: 39] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/27/2015] [Accepted: 03/24/2016] [Indexed: 02/08/2023]
Abstract
AIM The perineal wound following abdominoperineal excision (APR) is associated with a high complication rate. We aimed to evaluate the risk factors for wound complications and examine the effect of flap reconstruction on wound healing. METHOD The American College of Surgeons National Surgical Quality Improvement Program (NSQIP) database was searched for patients who underwent APR for rectal adenocarcinoma. They were divided into two groups: primary closure of the perineal wound and flap reconstruction. A logistic regression analysis was performed to identify the risk factors for deep surgical site infection (SSI) and wound dehiscence. RESULTS A total of 8449 (94%) patients from the database underwent primary closure and 550 (6%) underwent flap reconstruction. Patients who underwent flap reconstruction had a longer operation time, a higher incidence of deep SSI, wound dehiscence, more blood transfusion requirement and a higher rate of return to the operating room (all P < 0.001). Risk factors for deep SSI were African American race (OR 1.5, P = 0.02), American Society of Anesthesiologists (ASA) classification ≥ 4 (OR 3.2, P < 0.001), body mass index (BMI) ≥ 35 kg/m(2) (OR 1.7, P = 0.006), weight loss (OR 2, P < 0.001) and closure with a flap (OR 1.9, P < 0.001). Risk factors for wound dehiscence included ASA classification ≥ 4 (OR 2.2, P = 0.003), history of smoking (OR 2.2, P < 0.001), history of chronic obstructive pulmonary disease (OR 1.7, P = 0.03), BMI ≥ 35 kg/m(2) (OR 1.9, P = 0.001) and closure with a flap (OR 2.9, P < 0.001). CONCLUSION Perineal wound complications are related to a patient's race, ASA classification, smoking, obesity and weight loss. Compared with primary closure, closure with a flap was associated with higher odds of wound infection and dehiscence and was not protective of wound complications in the presence of other risk factors. Therefore optimizing the patient's medical condition will lead to a better outcome irrespective of the technique used for perineal wound closure.
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Affiliation(s)
- A A Althumairi
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - J K Canner
- Center for Surgical Trials and Outcomes Research, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - S L Gearhart
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - B Safar
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - S H Fang
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - E C Wick
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - J E Efron
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
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Abstract
Genitourinary structures are at risk of injury during colorectal surgery. The incidence of injury is low; however, the risk is higher in cases involving severe inflammatory or infectious processes, locally advanced or recurrent cancer, previous radiation, and reoperation. Consideration of the anatomical relationship between the genitourinary system, and the colon and rectum is crucial to avoid injuries. Intraoperative diagnostic techniques such as intravenous pyelogram (IVP), fluoroscopic cystogram, or retrograde urethrogram can aid in identifying suspected injuries. Early recognition and repair of injuries decrease the morbidity of an injury. Repair of injuries depends on the location and extent of the injury. Simple injuries may be repaired primarily, while complex injuries may require more advanced repairs such as a flap reconstruction.
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Affiliation(s)
- Azah A. Althumairi
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Jonathan E. Efron
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
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50
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Gani F, Makary MA, Wick EC, Efron JE, Fang SH, Safar B, Hundt J, Pawlik TM. Bundled Payments for Surgical Colectomy Among Medicare Enrollees. JAMA Surg 2016; 151:e160202. [DOI: 10.1001/jamasurg.2016.0202] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Affiliation(s)
- Faiz Gani
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Martin A. Makary
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Elizabeth C. Wick
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Jonathan E. Efron
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Sandy H. Fang
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Bashar Safar
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - John Hundt
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Timothy M. Pawlik
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
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