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Hong JS, Shamim A, Atta H, Nonnecke EB, Merl S, Patwardhan S, Manell E, Gunes E, Jordache P, Chen B, Lu W, Shen B, Dionigi B, Kiran RP, Sykes M, Zorn E, Bevins CL, Weiner J. Application of enzyme-linked immunosorbent assay to detect antimicrobial peptides in human intestinal lumen. J Immunol Methods 2024; 525:113599. [PMID: 38081407 PMCID: PMC10956375 DOI: 10.1016/j.jim.2023.113599] [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: 09/13/2023] [Revised: 12/04/2023] [Accepted: 12/06/2023] [Indexed: 12/23/2023]
Abstract
Intestinal transplantation is the definitive treatment for intestinal failure. However, tissue rejection and graft-versus-host disease are relatively common complications, necessitating aggressive immunosuppression that can itself pose further complications. Tracking intraluminal markers in ileal effluent from standard ileostomies may present a noninvasive and sensitive way to detect developing pathology within the intestinal graft. This would be an improvement compared to current assessments, which are limited by poor sensitivity and specificity, contributing to under or over-immunosuppression, respectively, and by the need for invasive biopsies. Herein, we report an approach to reproducibly analyze ileal fluid obtained through stoma sampling for antimicrobial peptide/protein concentrations, reasoning that these molecules may provide an assessment of intestinal homeostasis and levels of intestinal inflammation over time. Concentrations of lysozyme (LYZ), myeloperoxidase (MPO), calprotectin (S100A8/A9) and β-defensin 2 (DEFB2) were assessed using adaptations of commercially available enzyme-linked immunosorbent assays (ELISAs). The concentration of α-defensin 5 (DEFA5) was assessed using a newly developed sandwich ELISA. Our data support that with proper preparation of ileal effluent specimens, precise and replicable determination of antimicrobial peptide/protein concentrations can be achieved for each of these target molecules via ELISA. This approach may prove to be reliable as a clinically useful assessment of intestinal homeostasis over time for patients with ileostomies.
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Affiliation(s)
- Julie S Hong
- Columbia Center of Translational Immunology, Department of Medicine, Columbia University, New York, NY, United States of America.
| | - Abrar Shamim
- Columbia Center of Translational Immunology, Department of Medicine, Columbia University, New York, NY, United States of America; College of Dental Medicine, Columbia University, New York, NY, United States of America
| | - Hussein Atta
- Columbia Center of Translational Immunology, Department of Medicine, Columbia University, New York, NY, United States of America
| | - Eric B Nonnecke
- Department of Microbiology and Immunology, University of California Davis School of Medicine, Davis, CA, United States of America
| | - Sarah Merl
- Department of Pathology and Cell Biology, Columbia University, New York, NY, United States of America
| | - Satyajit Patwardhan
- Columbia Center of Translational Immunology, Department of Medicine, Columbia University, New York, NY, United States of America
| | - Elin Manell
- Columbia Center of Translational Immunology, Department of Medicine, Columbia University, New York, NY, United States of America; Department of Clinical Sciences, Swedish University of Agricultural Sciences, Uppsala, Sweden
| | - Esad Gunes
- Columbia Center of Translational Immunology, Department of Medicine, Columbia University, New York, NY, United States of America
| | - Philip Jordache
- Columbia Center of Translational Immunology, Department of Medicine, Columbia University, New York, NY, United States of America
| | - Bryan Chen
- Columbia Center of Translational Immunology, Department of Medicine, Columbia University, New York, NY, United States of America
| | - Wuyuan Lu
- Department of Biochemistry and Molecular Biology, University of Maryland School of Medicine, Baltimore, MD, United States of America
| | - Bo Shen
- Department of Surgery, Columbia University/New York-Presbyterian Hospital, New York, NY, United States of America
| | - Beatrice Dionigi
- Department of Surgery, Columbia University/New York-Presbyterian Hospital, New York, NY, United States of America
| | - Ravi P Kiran
- Department of Surgery, Columbia University/New York-Presbyterian Hospital, New York, NY, United States of America
| | - Megan Sykes
- Columbia Center of Translational Immunology, Department of Medicine, Columbia University, New York, NY, United States of America; Department of Surgery, Columbia University/New York-Presbyterian Hospital, New York, NY, United States of America
| | - Emmanuel Zorn
- Columbia Center of Translational Immunology, Department of Medicine, Columbia University, New York, NY, United States of America
| | - Charles L Bevins
- Department of Microbiology and Immunology, University of California Davis School of Medicine, Davis, CA, United States of America
| | - Joshua Weiner
- Columbia Center of Translational Immunology, Department of Medicine, Columbia University, New York, NY, United States of America; Department of Surgery, Columbia University/New York-Presbyterian Hospital, New York, NY, United States of America
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Herman K, Kiran RP, Shen B. Insulated tip/needle-knife endoscopic stricturotomy is safe and effective for treatment of non-traversable anorectal strictures. Endosc Int Open 2024; 12:E231-E236. [PMID: 38362359 PMCID: PMC10869208 DOI: 10.1055/a-2230-7372] [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] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/22/2023] [Accepted: 10/24/2023] [Indexed: 02/17/2024] Open
Abstract
Background and study aims The treatment of anorectal strictures is particularly challenging and historically focused on surgical resection and/or diversion. There are a number of endoscopic options, but repeat interventions are common. The use of the needle knife stricturotomy technique as an alternative to surgery in the treatment of a variety of strictures has been described, but its use for the treatment of severe anorectal and anopouch strictures has not been studied. Patients and methods Our Inflammatory Bowel Disease department's records were queried to identify patients with endoscopic non-traversable anorectal/anopouch strictures. Consecutive patients that underwent insulated tip/needle-knife endoscopic stricturotomy treatment were included. Primary outcome was immediate traversability of the treated stricture by the endoscope. Other outcomes included need for reintervention, 30-day post-procedure events, and follow-up period events. Results All strictures were immediately successfully traversed following endoscopic stricturotomy treatment. The mean time to endoscopic reintervention was 5.3 months, with the majority of these patients undergoing repeat stricturotomy. Over a mean follow-up period of 12.8 months, two patients (8%) required surgical intervention (resection with coloanal anastomosis with a colostomy and complete proctectomy) for refractory stricture disease following initial endoscopic stricturotomy. Seven patients (29%) in our study have not required any further reintervention throughout the study period. There were no 30-day post-procedure adverse events and no adverse post-procedure events. Conclusions Endoscopic stricturotomy is safe and effective in treating severe anorectal/anopouch strictures.
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Affiliation(s)
- Koby Herman
- Colorectal Surgery, Columbia University Irving Medical Center, New York, United States
| | - Ravi P. Kiran
- Colorectal Surgery, Columbia University Irving Medical Center, New York, United States
| | - Bo Shen
- Center for Inflammatory Bowel Disease, Columbia University Irving Medical Center, New York, United States
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Herman K, Kiran RP, Shen B. Correction: Insulated tip/needle-knife endoscopic stricturotomy is safe and effective for treatment of non-traversable anorectal strictures. Endosc Int Open 2024; 12:3. [PMID: 38404543 PMCID: PMC10890906 DOI: 10.1055/a-2272-9459] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/27/2024] Open
Abstract
[This corrects the article DOI: 10.1055/a-2230-7372.].
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Affiliation(s)
- Koby Herman
- Colorectal Surgery, Columbia University Irving Medical Center, New York, United States
| | - Ravi P. Kiran
- Colorectal Surgery, Columbia University Irving Medical Center, New York, United States
| | - Bo Shen
- Center for Inflammatory Bowel Disease, Columbia University Irving Medical Center, New York, United States
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Ahmed Ali U, Kiran RP. Conversion of Failed J Pouch to Kock Pouch: Indications, Contraindications and Outcomes. Dis Colon Rectum 2024:00003453-990000000-00536. [PMID: 38276945 DOI: 10.1097/dcr.0000000000003182] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/27/2024]
Abstract
BACKGROUND The ileal pouch-anal anastomosis has been successful in restoring intestinal continuity and preserving continence in the majority of patients requiring a proctocolectomy. However, a subset of individuals experience significant complications that might result in pouch failure. The conversion of the J pouch to a continent ileostomy pouch represents a significant surgical procedure. In this article, we discuss the indications and contraindications, present the technical principles applied for the conversion, and describe the outcomes of such conversion in the literature. OBJECTIVE The main objective during the conversion of the J pouch to a continent ileostomy is the creation of a sufficiently sized reservoir with a high-quality valve mechanism while preserving as much small bowel as possible. CONCLUSIONS The conversion of the J pouch to a continent ileostomy represents a significant surgical procedure. When performed in centers of expertise, it can be a good option for patients who otherwise will require an end ileostomy. Indications for conversion include most cases of J pouch failure, with few important exceptions. See Video.
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Affiliation(s)
- Usama Ahmed Ali
- Division of Colorectal Surgery and Center for Inflammatory Bowel Disease, Columbia University Irving Medical Center-New York Presbyterian Hospital, New York, NY
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Bertucci Zoccali M, Moallem DH, Park H, Uhlemann AC, Church JM, Kiran RP. Role of Microbiome in the Outcomes Following Surgical Repair of Perianal Fistula: Prospective Cohort Study Design and Preliminary Results. World J Surg 2023; 47:3373-3379. [PMID: 37821648 DOI: 10.1007/s00268-023-07212-0] [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] [Accepted: 09/18/2023] [Indexed: 10/13/2023]
Abstract
BACKGROUND Anal fistulae are common, predominantly cryptoglandular, and almost invariably require surgical treatment. Recurrences are common for procedures other than fistulotomy regardless of technique and adequacy of repair. Growing evidence supports the pivotal role of specific intestinal bacteria in anastomotic failures after bowel resection. Anal crypts harbor colonic microbiota suggesting that similar mechanisms to anastomotic healing might prevail after anal fistula repair and hence influence healing. This study aims at assessing the potential role of the intestinal microbiome in the clinical outcomes after surgical repair of cryptoglandular anal fistula. METHODS This is a pilot prospective cohort study enrolling patients with anal fistula undergoing endoanal advancement flap. For microbiome analysis, stool samples are taken via rectal swab before the procedure; additionally, a portion of the fistula is collected intraoperatively after fistulectomy. Samples from groups with treatment failure are compared to samples from patients who healed after surgical repair. Alpha and beta diversities and differential abundance of microbial taxa are determined and compared between groups with DADA2 analytical pipeline. RESULTS Five patients have been enrolled to date (one female, four male). At median follow-up of 6 months (2-11), one patient experienced disease recurrence at 3 months. DNA from the 5 rectal swab and tissue samples was extracted, showing increased relative abundance of Enterococcus faecalis in samples from the patient who developed a recurrent fistula but not in those without recurrence. CONCLUSION These very preliminary data suggest that intestinal microbiome may represent a crucial determinant of the surgical outcomes after anal fistula surgery.
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Affiliation(s)
- Marco Bertucci Zoccali
- Division of Colorectal Surgery, Department of Surgery, New York Presbyterian/Columbia University Medical Center, New York, USA.
| | - Dalia H Moallem
- Division of Infectious Diseases, Department of Medicine, New York Presbyterian/Columbia University Medical Center, New York, NY, USA
| | - Heekuk Park
- Division of Infectious Diseases, Department of Medicine, New York Presbyterian/Columbia University Medical Center, New York, NY, USA
| | - Anne-Catrin Uhlemann
- Division of Infectious Diseases, Department of Medicine, New York Presbyterian/Columbia University Medical Center, New York, NY, USA
| | - James M Church
- Division of Colorectal Surgery, Department of Surgery, New York Presbyterian/Columbia University Medical Center, New York, USA
| | - Ravi P Kiran
- Division of Colorectal Surgery, Department of Surgery, New York Presbyterian/Columbia University Medical Center, New York, USA
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Reif de Paula T, Augestad KM, Kiran RP, Keller DS. Erratum to "Management of the positive pathologic circumferential resection margin in rectal cancer: A national cancer database (NCDB) study" [Eur J Surg Oncol 47 (2) (February 2021) 296-303]. Eur J Surg Oncol 2023; 49:106949. [PMID: 37620244 DOI: 10.1016/j.ejso.2023.06.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/26/2023]
Affiliation(s)
- Thais Reif de Paula
- Division of Colorectal Surgery, Department of Surgery, Columbia University Medical Center, New York, NY, USA
| | - Knut Magne Augestad
- Department of Digestive Surgery, Akershus University Hospital, University of Oslo, Lorenskog, Norway
| | - Ravi P Kiran
- Division of Colorectal Surgery, Department of Surgery, Columbia University Medical Center, New York, NY, USA
| | - Deborah S Keller
- Division of Colorectal Surgery, Department of Surgery, Columbia University Medical Center, New York, NY, USA.
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Moodley Y, van Wyk J, Ning Y, Wexner S, Gounden C, Naidoo V, Kader S, Neugut AI, Kiran RP. Self-adherence to post-colonoscopy consults in patients undergoing diagnostic colonoscopy: Findings from a cross-sectional, quantitative survey at a South African quaternary hospital. PLoS One 2023; 18:e0288752. [PMID: 37463177 DOI: 10.1371/journal.pone.0288752] [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] [Received: 01/13/2023] [Accepted: 07/04/2023] [Indexed: 07/20/2023] Open
Abstract
Post-colonoscopy consults empower patients to make informed decisions around their subsequent treatment, and non-compliance with these consults ("no-shows") hinders disease management. There is a paucity in the literature regarding self-adherence to post-colonoscopy consults in resource-limited settings such as South Africa. An understanding of self-adherence to post-colonoscopy consults in this setting is required to establish whether improved interventions are needed, and what specific elements of self-adherence should be addressed with these interventions. The objective of this hypothesis-generating, cross-sectional, quantitative survey was to conduct a baseline assessment of cognitive, motivational, social, and behavioural variables related to self-adherence to post-colonoscopy consults in patients who underwent diagnostic colonoscopy at a South African quaternary hospital. The Adherence Determinants Questionnaire (ADQ) was administered in 47 patients to establish a baseline assessment of elements related to self-adherence to post-colonoscopy consults, including interpersonal aspects of care, perceived utility, severity, susceptibility, subjective norms, intentions, and supports/barriers. ADQ scores were transformed to a percentage of the maximum score for each element (100.0%). The overall mean transformed ADQ score was 57.8%. The mean transformed scores for specific ADQ components were as follows: subjective norms (40.8%), perceived severity (55.4%), perceived utility (56.6%), intentions (59.4%), supports/barriers (59.9%), interpersonal aspects (62.2%), and perceived susceptibility (65.9%). There were no statistically significant differences in overall mean transformed ADQ scores and individual ADQ elements across categories of participant age (p-values ranging between 0.180 and 0.949 when compared between participants ≤40 years and >40 years old), gender (p-values ranging between 0.071 and 0.946 when compared between males and females), and race (p-values ranging between 0.119 and 0.774 when compared between Black Africans and non-Black Africans). Our findings suggest a general need for appropriate interventions to improve self-adherence to post-colonoscopy consults in our setting.
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Affiliation(s)
- Yoshan Moodley
- Gastrointestinal Cancer Research Group, Nelson R. Mandela School of Medicine, University of KwaZulu-Natal, Durban, South Africa
- Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
| | - Jacqueline van Wyk
- Department of Health Sciences Education, University of Cape Town, Cape Town, South Africa
- School of Clinical Medicine, Nelson R. Mandela School of Medicine, University of KwaZulu-Natal, Durban, South Africa
| | - Yuming Ning
- Department of Surgery, Columbia University, New York, NY, United States of America
| | - Steven Wexner
- Ellen Leifer Shulman and Steven Shulman Digestive Disease Center, Cleveland Clinic Florida, Weston, Florida, United States of America
| | - Cathrine Gounden
- Gastrointestinal Cancer Research Group, Nelson R. Mandela School of Medicine, University of KwaZulu-Natal, Durban, South Africa
| | - Vasudevan Naidoo
- Gastrointestinal Cancer Research Group, Nelson R. Mandela School of Medicine, University of KwaZulu-Natal, Durban, South Africa
| | - Shakeel Kader
- Gastrointestinal Cancer Research Group, Nelson R. Mandela School of Medicine, University of KwaZulu-Natal, Durban, South Africa
| | - Alfred I Neugut
- Department of Medicine and Herbert Irving Comprehensive Cancer Center, Columbia University, New York, NY, United States of America
| | - Ravi P Kiran
- Department of Surgery, Columbia University, New York, NY, United States of America
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Mundi PS, Dela Cruz FS, Grunn A, Diolaiti D, Mauguen A, Rainey AR, Guillan K, Siddiquee A, You D, Realubit R, Karan C, Ortiz MV, Douglass EF, Accordino M, Mistretta S, Brogan F, Bruce JN, Caescu CI, Carvajal RD, Crew KD, Decastro G, Heaney M, Henick BS, Hershman DL, Hou JY, Iwamoto FM, Jurcic JG, Kiran RP, Kluger MD, Kreisl T, Lamanna N, Lassman AB, Lim EA, Manji GA, McKhann GM, McKiernan JM, Neugut AI, Olive KP, Rosenblat T, Schwartz GK, Shu CA, Sisti MB, Tergas A, Vattakalam RM, Welch M, Wenske S, Wright JD, Hibshoosh H, Kalinsky K, Aburi M, Sims PA, Alvarez MJ, Kung AL, Califano A. A Transcriptome-Based Precision Oncology Platform for Patient-Therapy Alignment in a Diverse Set of Treatment-Resistant Malignancies. Cancer Discov 2023; 13:1386-1407. [PMID: 37061969 PMCID: PMC10239356 DOI: 10.1158/2159-8290.cd-22-1020] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [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: 09/12/2022] [Revised: 01/14/2023] [Accepted: 03/14/2023] [Indexed: 04/17/2023]
Abstract
Predicting in vivo response to antineoplastics remains an elusive challenge. We performed a first-of-kind evaluation of two transcriptome-based precision cancer medicine methodologies to predict tumor sensitivity to a comprehensive repertoire of clinically relevant oncology drugs, whose mechanism of action we experimentally assessed in cognate cell lines. We enrolled patients with histologically distinct, poor-prognosis malignancies who had progressed on multiple therapies, and developed low-passage, patient-derived xenograft models that were used to validate 35 patient-specific drug predictions. Both OncoTarget, which identifies high-affinity inhibitors of individual master regulator (MR) proteins, and OncoTreat, which identifies drugs that invert the transcriptional activity of hyperconnected MR modules, produced highly significant 30-day disease control rates (68% and 91%, respectively). Moreover, of 18 OncoTreat-predicted drugs, 15 induced the predicted MR-module activity inversion in vivo. Predicted drugs significantly outperformed antineoplastic drugs selected as unpredicted controls, suggesting these methods may substantively complement existing precision cancer medicine approaches, as also illustrated by a case study. SIGNIFICANCE Complementary precision cancer medicine paradigms are needed to broaden the clinical benefit realized through genetic profiling and immunotherapy. In this first-in-class application, we introduce two transcriptome-based tumor-agnostic systems biology tools to predict drug response in vivo. OncoTarget and OncoTreat are scalable for the design of basket and umbrella clinical trials. This article is highlighted in the In This Issue feature, p. 1275.
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Affiliation(s)
- Prabhjot S. Mundi
- Department of Systems Biology, Columbia University Irving Medical Center, 1130 Saint Nicholas Ave, New York, NY USA 10032
- Herbert Irving Comprehensive Cancer Center, Columbia University Irving Medical Center, 1130 Saint Nicholas Ave, New York, NY USA 10032
| | - Filemon S. Dela Cruz
- Department of Pediatrics, Memorial Sloan Kettering Cancer Center, 1275 York Ave, New York, NY USA 10065
| | - Adina Grunn
- Department of Systems Biology, Columbia University Irving Medical Center, 1130 Saint Nicholas Ave, New York, NY USA 10032
| | - Daniel Diolaiti
- Department of Pediatrics, Memorial Sloan Kettering Cancer Center, 1275 York Ave, New York, NY USA 10065
| | - Audrey Mauguen
- Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, 1275 York Ave, New York, NY USA 10065
| | - Allison R. Rainey
- Department of Pediatrics, Memorial Sloan Kettering Cancer Center, 1275 York Ave, New York, NY USA 10065
| | - Kristina Guillan
- Department of Pediatrics, Memorial Sloan Kettering Cancer Center, 1275 York Ave, New York, NY USA 10065
| | - Armaan Siddiquee
- Department of Pediatrics, Memorial Sloan Kettering Cancer Center, 1275 York Ave, New York, NY USA 10065
| | - Daoqi You
- Department of Pediatrics, Memorial Sloan Kettering Cancer Center, 1275 York Ave, New York, NY USA 10065
| | - Ronald Realubit
- Department of Systems Biology, Columbia University Irving Medical Center, 1130 Saint Nicholas Ave, New York, NY USA 10032
| | - Charles Karan
- Department of Systems Biology, Columbia University Irving Medical Center, 1130 Saint Nicholas Ave, New York, NY USA 10032
- Herbert Irving Comprehensive Cancer Center, Columbia University Irving Medical Center, 1130 Saint Nicholas Ave, New York, NY USA 10032
| | - Michael V. Ortiz
- Department of Pediatrics, Memorial Sloan Kettering Cancer Center, 1275 York Ave, New York, NY USA 10065
| | - Eugene F. Douglass
- Department of Systems Biology, Columbia University Irving Medical Center, 1130 Saint Nicholas Ave, New York, NY USA 10032
| | - Melissa Accordino
- Herbert Irving Comprehensive Cancer Center, Columbia University Irving Medical Center, 1130 Saint Nicholas Ave, New York, NY USA 10032
- Department of Medicine, Columbia University Irving Medical Center, 630 W 168th Street, New York, NY USA 10032
| | - Suzanne Mistretta
- Herbert Irving Comprehensive Cancer Center, Columbia University Irving Medical Center, 1130 Saint Nicholas Ave, New York, NY USA 10032
| | - Frances Brogan
- Herbert Irving Comprehensive Cancer Center, Columbia University Irving Medical Center, 1130 Saint Nicholas Ave, New York, NY USA 10032
| | - Jeffrey N. Bruce
- Herbert Irving Comprehensive Cancer Center, Columbia University Irving Medical Center, 1130 Saint Nicholas Ave, New York, NY USA 10032
- Department of Neurological Surgery, Columbia University Irving Medical Center, 710 W 168th Street, New York, NY USA 10032
| | - Cristina I. Caescu
- Department of Systems Biology, Columbia University Irving Medical Center, 1130 Saint Nicholas Ave, New York, NY USA 10032
| | - Richard D. Carvajal
- Herbert Irving Comprehensive Cancer Center, Columbia University Irving Medical Center, 1130 Saint Nicholas Ave, New York, NY USA 10032
- Department of Medicine, Columbia University Irving Medical Center, 630 W 168th Street, New York, NY USA 10032
| | - Katherine D Crew
- Herbert Irving Comprehensive Cancer Center, Columbia University Irving Medical Center, 1130 Saint Nicholas Ave, New York, NY USA 10032
- Department of Medicine, Columbia University Irving Medical Center, 630 W 168th Street, New York, NY USA 10032
| | - Guarionex Decastro
- Herbert Irving Comprehensive Cancer Center, Columbia University Irving Medical Center, 1130 Saint Nicholas Ave, New York, NY USA 10032
- Department of Urology, Columbia University Irving Medical Center, 160 Fort Washington Ave, New York, NY USA 10032
| | - Mark Heaney
- Herbert Irving Comprehensive Cancer Center, Columbia University Irving Medical Center, 1130 Saint Nicholas Ave, New York, NY USA 10032
- Department of Medicine, Columbia University Irving Medical Center, 630 W 168th Street, New York, NY USA 10032
| | - Brian S Henick
- Herbert Irving Comprehensive Cancer Center, Columbia University Irving Medical Center, 1130 Saint Nicholas Ave, New York, NY USA 10032
- Department of Medicine, Columbia University Irving Medical Center, 630 W 168th Street, New York, NY USA 10032
| | - Dawn L Hershman
- Herbert Irving Comprehensive Cancer Center, Columbia University Irving Medical Center, 1130 Saint Nicholas Ave, New York, NY USA 10032
- Department of Medicine, Columbia University Irving Medical Center, 630 W 168th Street, New York, NY USA 10032
- Department of Epidemiology, Columbia University Mailman School of Public Health, 722 West 168th St. NY, NY 10032
| | - June Y. Hou
- Department of Obstetrics & Gynecology, Columbia University Irving Medical Center, 622 W 168th Street, New York, NY USA 10032
| | - Fabio M. Iwamoto
- Herbert Irving Comprehensive Cancer Center, Columbia University Irving Medical Center, 1130 Saint Nicholas Ave, New York, NY USA 10032
- Department of Neurology, Columbia University Irving Medical Center, 710 W 168th Street, New York, NY USA 10032
| | - Joseph G. Jurcic
- Herbert Irving Comprehensive Cancer Center, Columbia University Irving Medical Center, 1130 Saint Nicholas Ave, New York, NY USA 10032
- Department of Medicine, Columbia University Irving Medical Center, 630 W 168th Street, New York, NY USA 10032
| | - Ravi P. Kiran
- Herbert Irving Comprehensive Cancer Center, Columbia University Irving Medical Center, 1130 Saint Nicholas Ave, New York, NY USA 10032
- Department of Surgery, Columbia University Irving Medical Center, 622 W 168th Street, New York, NY USA 10032
| | - Michael D Kluger
- Herbert Irving Comprehensive Cancer Center, Columbia University Irving Medical Center, 1130 Saint Nicholas Ave, New York, NY USA 10032
- Department of Surgery, Columbia University Irving Medical Center, 622 W 168th Street, New York, NY USA 10032
| | - Teri Kreisl
- Novartis Five Cambridge, MA 02142, United States
| | - Nicole Lamanna
- Herbert Irving Comprehensive Cancer Center, Columbia University Irving Medical Center, 1130 Saint Nicholas Ave, New York, NY USA 10032
- Department of Medicine, Columbia University Irving Medical Center, 630 W 168th Street, New York, NY USA 10032
| | - Andrew B. Lassman
- Herbert Irving Comprehensive Cancer Center, Columbia University Irving Medical Center, 1130 Saint Nicholas Ave, New York, NY USA 10032
- Department of Neurology, Columbia University Irving Medical Center, 710 W 168th Street, New York, NY USA 10032
| | - Emerson A. Lim
- Herbert Irving Comprehensive Cancer Center, Columbia University Irving Medical Center, 1130 Saint Nicholas Ave, New York, NY USA 10032
- Department of Medicine, Columbia University Irving Medical Center, 630 W 168th Street, New York, NY USA 10032
| | - Gulam A. Manji
- Herbert Irving Comprehensive Cancer Center, Columbia University Irving Medical Center, 1130 Saint Nicholas Ave, New York, NY USA 10032
- Department of Medicine, Columbia University Irving Medical Center, 630 W 168th Street, New York, NY USA 10032
| | - Guy M McKhann
- Herbert Irving Comprehensive Cancer Center, Columbia University Irving Medical Center, 1130 Saint Nicholas Ave, New York, NY USA 10032
- Department of Neurological Surgery, Columbia University Irving Medical Center, 710 W 168th Street, New York, NY USA 10032
| | - James M. McKiernan
- Herbert Irving Comprehensive Cancer Center, Columbia University Irving Medical Center, 1130 Saint Nicholas Ave, New York, NY USA 10032
- Department of Urology, Columbia University Irving Medical Center, 160 Fort Washington Ave, New York, NY USA 10032
| | - Alfred I Neugut
- Herbert Irving Comprehensive Cancer Center, Columbia University Irving Medical Center, 1130 Saint Nicholas Ave, New York, NY USA 10032
- Department of Medicine, Columbia University Irving Medical Center, 630 W 168th Street, New York, NY USA 10032
- Department of Epidemiology, Columbia University Mailman School of Public Health, 722 West 168th St. NY, NY 10032
| | - Kenneth P. Olive
- Herbert Irving Comprehensive Cancer Center, Columbia University Irving Medical Center, 1130 Saint Nicholas Ave, New York, NY USA 10032
- Department of Medicine, Columbia University Irving Medical Center, 630 W 168th Street, New York, NY USA 10032
| | - Todd Rosenblat
- Herbert Irving Comprehensive Cancer Center, Columbia University Irving Medical Center, 1130 Saint Nicholas Ave, New York, NY USA 10032
- Department of Medicine, Columbia University Irving Medical Center, 630 W 168th Street, New York, NY USA 10032
| | - Gary K. Schwartz
- Herbert Irving Comprehensive Cancer Center, Columbia University Irving Medical Center, 1130 Saint Nicholas Ave, New York, NY USA 10032
- Department of Medicine, Columbia University Irving Medical Center, 630 W 168th Street, New York, NY USA 10032
| | - Catherine A Shu
- Herbert Irving Comprehensive Cancer Center, Columbia University Irving Medical Center, 1130 Saint Nicholas Ave, New York, NY USA 10032
- Department of Medicine, Columbia University Irving Medical Center, 630 W 168th Street, New York, NY USA 10032
| | - Michael B. Sisti
- Herbert Irving Comprehensive Cancer Center, Columbia University Irving Medical Center, 1130 Saint Nicholas Ave, New York, NY USA 10032
- Department of Neurological Surgery, Columbia University Irving Medical Center, 710 W 168th Street, New York, NY USA 10032
- Department of Otolaryngology Head and Neck Surgery, Columbia University Irving Medical Center, 710 W 168th Street, New York, NY USA 10032
- Department of Radiation Oncology, Columbia University Irving Medical Center, 161 Fort Washington Avenue, New York, NY 10032, United States
| | - Ana Tergas
- Department of Obstetrics & Gynecology, Columbia University Irving Medical Center, 622 W 168th Street, New York, NY USA 10032
| | - Reena M Vattakalam
- Herbert Irving Comprehensive Cancer Center, Columbia University Irving Medical Center, 1130 Saint Nicholas Ave, New York, NY USA 10032
- Department of Obstetrics & Gynecology, Columbia University Irving Medical Center, 622 W 168th Street, New York, NY USA 10032
| | - Mary Welch
- Herbert Irving Comprehensive Cancer Center, Columbia University Irving Medical Center, 1130 Saint Nicholas Ave, New York, NY USA 10032
- Department of Neurology, Columbia University Irving Medical Center, 710 W 168th Street, New York, NY USA 10032
| | - Sven Wenske
- Herbert Irving Comprehensive Cancer Center, Columbia University Irving Medical Center, 1130 Saint Nicholas Ave, New York, NY USA 10032
- Department of Urology, Columbia University Irving Medical Center, 160 Fort Washington Ave, New York, NY USA 10032
| | - Jason D. Wright
- Herbert Irving Comprehensive Cancer Center, Columbia University Irving Medical Center, 1130 Saint Nicholas Ave, New York, NY USA 10032
- Department of Obstetrics & Gynecology, Columbia University Irving Medical Center, 622 W 168th Street, New York, NY USA 10032
| | - Hanina Hibshoosh
- Herbert Irving Comprehensive Cancer Center, Columbia University Irving Medical Center, 1130 Saint Nicholas Ave, New York, NY USA 10032
- Department of Pathology and Cell Biology, Columbia University Irving Medical Center, 630 W 168th Street, New York, NY USA 10032
| | - Kevin Kalinsky
- Herbert Irving Comprehensive Cancer Center, Columbia University Irving Medical Center, 1130 Saint Nicholas Ave, New York, NY USA 10032
- Winship Cancer Institute of Emory University and Department of Hematology and Medical Oncology, Emory University School of Medicine, 1365-C Clifton Road NE, Atlanta, GA 30322, United States
| | - Mahalaxmi Aburi
- Department of Systems Biology, Columbia University Irving Medical Center, 1130 Saint Nicholas Ave, New York, NY USA 10032
| | - Peter A. Sims
- Department of Systems Biology, Columbia University Irving Medical Center, 1130 Saint Nicholas Ave, New York, NY USA 10032
- Department of Biochemistry & Molecular Biophysics, Columbia University Irving Medical Center, 701 W 168th Street, New York, NY USA 10032
| | - Mariano J. Alvarez
- Department of Systems Biology, Columbia University Irving Medical Center, 1130 Saint Nicholas Ave, New York, NY USA 10032
- DarwinHealth Inc. New York
| | - Andrew L. Kung
- Department of Pediatrics, Memorial Sloan Kettering Cancer Center, 1275 York Ave, New York, NY USA 10065
| | - Andrea Califano
- Department of Systems Biology, Columbia University Irving Medical Center, 1130 Saint Nicholas Ave, New York, NY USA 10032
- Herbert Irving Comprehensive Cancer Center, Columbia University Irving Medical Center, 1130 Saint Nicholas Ave, New York, NY USA 10032
- Department of Medicine, Columbia University Irving Medical Center, 630 W 168th Street, New York, NY USA 10032
- Department of Biochemistry & Molecular Biophysics, Columbia University Irving Medical Center, 701 W 168th Street, New York, NY USA 10032
- Department of Biomedical Informatics, Columbia University Irving Medical Center, 622 W 168th Street, New York, NY USA 10032
- J.P. Sulzberger Columbia Genome Center, Columbia University Irving Medical Center, 622 W 168th Street, New York, NY USA 10032
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9
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Moodley Y, Govender K, van Wyk J, Reddy S, Ning Y, Wexner S, Stopforth L, Bhadree S, Naidoo V, Kader S, Cheddie S, Neugut AI, Kiran RP. Predictors of treatment refusal in patients with colorectal cancer: A systematic review. Semin Oncol 2022; 49:456-464. [PMID: 36754712 PMCID: PMC10023422 DOI: 10.1053/j.seminoncol.2023.01.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [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: 01/13/2023] [Accepted: 01/14/2023] [Indexed: 01/30/2023]
Abstract
This systematic review was conducted to investigate predictors of treatment refusal in colorectal cancer (CRC) patients. An understanding of these predictors would inform statistical models for the identification of high-risk patients who might benefit from interventions that seek to improve treatment compliance. We performed a search of PubMed and Scopus to identify potentially relevant studies on predictors of treatment refusal in CRC patients that were published between January 1, 2000 and December 31, 2021. We screened manuscripts using predefined eligibility criteria. Information on study design, study location, patient characteristics, treatments, rates and predictors of treatment refusal, and the impact of treatment refusal on mortality or survival were collected from eligible studies. Study quality was assessed using the Newcastle-Ottawa score. The overall findings of the review process were summarized using descriptive statistics and a narrative synthesis. A total of 13 studies were included in this review. Ten studies reported on refusal of CRC surgery, refusal rate: 0.25%-3.26%; three studies reported on chemotherapy refusal (one of which reported on both surgery and chemotherapy refusal), refusal rate: 7.8%-41.5%; and one study reported on refusal of any cancer treatment, refusal rate: 8.7%. The bulk of the published literature confirmed the harmful association between treatment refusal and poor survival outcomes in CRC patients. Frequently cited predictors of treatment refusal included patient demographic characteristics (age, race, gender), clinical characteristics (disease stage, comorbidity), and factors that impact access to cancer care services (healthcare insurance, facility level). Potentially high rates of treatment refusal pose a challenge to CRC control. This review has identified several factors which must be considered when attempting to reduce treatment refusal in CRC patients. Furthermore, these factors should be tested as components of predictive risk models for this important outcome.
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Affiliation(s)
- Yoshan Moodley
- Gastrointestinal Cancer Research Group, Nelson R. Mandela School of Medicine, University of KwaZulu-Natal, Durban, South Africa; Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa.
| | - Kumeren Govender
- Nuffield Department of Medicine, John Radcliffe Hospital, University of Oxford, Oxford, United Kingdom
| | - Jacqueline van Wyk
- School of Clinical Medicine, Nelson R. Mandela School of Medicine, University of KwaZulu-Natal, Durban, South Africa; Department of Health Sciences Education, University of Cape Town, Cape Town, South Africa
| | - Seren Reddy
- Department of Electronic and Computer Engineering, Durban University of Technology, Durban, South Africa
| | - Yuming Ning
- Department of Surgery, Columbia University, New York, NY, USA
| | - Steven Wexner
- Ellen Leifer Shulman and Steven Shulman Digestive Disease Center, Cleveland Clinic Florida, Weston, FL, USA
| | - Laura Stopforth
- Gastrointestinal Cancer Research Group, Nelson R. Mandela School of Medicine, University of KwaZulu-Natal, Durban, South Africa
| | - Shona Bhadree
- Gastrointestinal Cancer Research Group, Nelson R. Mandela School of Medicine, University of KwaZulu-Natal, Durban, South Africa
| | - Vasudevan Naidoo
- Gastrointestinal Cancer Research Group, Nelson R. Mandela School of Medicine, University of KwaZulu-Natal, Durban, South Africa
| | - Shakeel Kader
- Gastrointestinal Cancer Research Group, Nelson R. Mandela School of Medicine, University of KwaZulu-Natal, Durban, South Africa
| | - Shalen Cheddie
- Gastrointestinal Cancer Research Group, Nelson R. Mandela School of Medicine, University of KwaZulu-Natal, Durban, South Africa
| | - Alfred I Neugut
- Department of Medicine and Herbert Irving Comprehensive Cancer Center, Columbia University, New York, NY, USA
| | - Ravi P Kiran
- Department of Surgery, Columbia University, New York, NY, USA
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10
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Fahy MR, Kelly ME, Aalbers AGJ, Abdul Aziz N, Abecasis N, Abraham-Nordling M, Akiyoshi T, Alberda W, Albert M, Andric M, Angeles MA, Angenete E, Antoniou A, Auer R, Austin KK, Aytac E, Aziz O, Bacalbasa N, Baker RP, Bali M, Baransi S, Baseckas G, Bebington B, Bedford M, Bednarski BK, Beets GL, Berg PL, Bergzoll C, Beynon J, Biondo S, Boyle K, Bordeianou L, Brecelj E, Bremers AB, Brunner M, Buchwald P, Bui A, Burgess A, Burger JWA, Burling D, Burns E, Campain N, Carvalhal S, Castro L, Caycedo-Marulanda A, Ceelan W, Chan KKL, Chang GJ, Chang M, Chew MH, Chok AY, Chong P, Clouston H, Codd M, Collins D, Colquhoun AJ, Constantinides J, Corr A, Coscia M, Cosimelli M, Cotsoglou C, Coyne PE, Croner RS, Damjanovich L, Daniels IR, Davies M, Delaney CP, de Wilt JHW, Denost Q, Deutsch C, Dietz D, Domingo S, Dozois EJ, Drozdov E, Duff M, Eglinton T, Enriquez-Navascues JM, Espín-Basany E, Evans MD, Eyjólfsdóttir B, Fearnhead NS, Ferron G, Flatmark K, Fleming FJ, Flor B, Folkesson J, Frizelle FA, Funder J, Gallego MA, Gargiulo M, García-Granero E, García-Sabrido JL, Gargiulo M, Gava VG, Gentilini L, George ML, George V, Georgiou P, Ghosh A, Ghouti L, Gil-Moreno A, Giner F, Ginther DN, Glyn T, Glynn R, Golda T, Griffiths B, Harris DA, Hagemans JAW, Hanchanale V, Harji DP, Helewa RM, Hellawell G, Heriot AG, Hochman D, Hohenberger W, Holm T, Hompes R, Hornung B, Hurton S, Hyun E, Ito M, Iversen LH, Jenkins JT, Jourand K, Kaffenberger S, Kandaswamy GV, Kapur S, Kanemitsu Y, Kazi M, Kelley SR, Keller DS, Ketelaers SHJ, Khan MS, Kiran RP, Kim H, Kim HJ, Koh CE, Kok NFM, Kokelaar R, Kontovounisios C, Kose F, Koutra M, Kristensen HØ, Kroon HM, Kumar S, Kusters M, Lago V, Lampe B, Lakkis Z, Larach JT, Larkin JO, Larsen SG, Larson DW, Law WL, Lee PJ, Limbert M, Loria A, Lydrup ML, Lyons A, Lynch AC, Maciel J, Manfredelli S, Mann C, Mantyh C, Mathis KL, Marques CFS, Martinez A, Martling A, Mehigan BJ, Meijerink WJHJ, Merchea A, Merkel S, Mehta AM, Mikalauskas S, McArthur DR, McCormick JJ, McCormick P, McDermott FD, McGrath JS, Malde S, Mirnezami A, Monson JRT, Navarro AS, Negoi I, Neto JWM, Ng JL, Nguyen B, Nielsen MB, Nieuwenhuijzen GAP, Nilsson PJ, Nordkamp S, Nugent T, Oliver A, O’Dwyer ST, O’Sullivan NJ, Paarnio K, Palmer G, Pappou E, Park J, Patsouras D, Peacock O, Pellino G, Peterson AC, Pinson J, Poggioli G, Proud D, Quinn M, Quyn A, Rajendran N, Radwan RW, Rajendran N, Rao C, Rasheed S, Rausa E, Regenbogen SE, Reims HM, Renehan A, Rintala J, Rocha R, Rochester M, Rohila J, Rothbarth J, Rottoli M, Roxburgh C, Rutten HJT, Safar B, Sagar PM, Sahai A, Saklani A, Sammour T, Sayyed R, Schizas AMP, Schwarzkopf E, Scripcariu D, Scripcariu V, Selvasekar C, Shaikh I, Simpson A, Skeie-Jensen T, Smart NJ, Smart P, Smith JJ, Solbakken AM, Solomon MJ, Sørensen MM, Sorrentino L, Steele SR, Steffens D, Stitzenberg K, Stocchi L, Stylianides NA, Swartling T, Spasojevic M, Sumrien H, Sutton PA, Swartking T, Takala H, Tan EJ, Taylor C, Tekin A, Tekkis PP, Teras J, Thaysen HV, Thurairaja R, Thorgersen EB, Toh EL, Tsarkov P, Tsukada Y, Tsukamoto S, Tuech JJ, Turner WH, Tuynman JB, Valente M, van Ramshorst GH, van Zoggel D, Vasquez-Jimenez W, Vather R, Verhoef C, Vierimaa M, Vizzielli G, Voogt ELK, Uehara K, Urrejola G, Wakeman C, Warrier SK, Wasmuth HH, Waters PS, Weber K, Weiser MR, Wheeler JMD, Wild J, Williams A, Wilson M, Wolthuis A, Yano H, Yip B, Yip J, Yoo RN, Zappa MA, Winter DC. Minimum standards of pelvic exenterative practice: PelvEx Collaborative guideline. Br J Surg 2022; 109:1251-1263. [PMID: 36170347 DOI: 10.1093/bjs/znac317] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2022] [Revised: 07/18/2022] [Accepted: 08/18/2022] [Indexed: 12/31/2022]
Abstract
This document outlines the important aspects of caring for patients who have been diagnosed with advanced pelvic cancer. It is primarily aimed at those who are establishing a service that adequately caters to this patient group. The relevant literature has been summarized and an attempt made to simplify the approach to management of these complex cases.
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11
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Ahmed Ali U, Kiran RP. Surgery for Crohn’s disease: upfront or last resort? Gastroenterol Rep (Oxf) 2022; 10:goac063. [PMID: 36381220 PMCID: PMC9645354 DOI: 10.1093/gastro/goac063] [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] [Received: 09/13/2022] [Accepted: 09/30/2022] [Indexed: 11/11/2022] Open
Abstract
Crohn’s disease (CD) can involve the entire gastrointestinal tract from the mouth to the anus and can lead to a constellation of symptoms. With the advancement of effective medical treatments for CD, a tendency has emerged to consider surgical treatment as a last resort. This potentially has the disadvantage of delaying surgery and if it fails might leave patients sicker, less well nourished, and with more severe complications. As with most non-malignant diseases, the choice of surgery vs medical treatment is a patient’s personal preference under the guidance of the treating physician, except in extreme situations where surgery might be the only option. In this article, we will discuss the available evidence regarding the optimal timing of surgery in CD, focusing on whether early surgery can bring benefits in terms of disease control, symptom relief, and quality of life.
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Affiliation(s)
- U Ahmed Ali
- Division of Colorectal Surgery, New York–Presbyterian/Columbia University Medical Center, New York, USA
| | - Ravi P Kiran
- Corresponding author. Division of Colorectal Surgery, New York–Presbyterian/Columbia University Medical Center, 177 Fort Washington Avenue, 7th Floor South Knuckle, New York, NY 10032, USA.
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12
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Kiran RP, Kochhar GS, Kariv R, Rex DK, Sugita A, Rubin DT, Navaneethan U, Hull TL, Ko HM, Liu X, Kachnic LA, Strong S, Iacucci M, Bemelman W, Fleshner P, Safyan RA, Kotze PG, D'Hoore A, Faiz O, Lo S, Ashburn JH, Spinelli A, Bernstein CN, Kane SV, Cross RK, Schairer J, McCormick JT, Farraye FA, Chang S, Scherl EJ, Schwartz DA, Bruining DH, Philpott J, Bentley-Hibbert S, Tarabar D, El-Hachem S, Sandborn WJ, Silverberg MS, Pardi DS, Church JM, Shen B. Management of pouch neoplasia: consensus guidelines from the International Ileal Pouch Consortium. Lancet Gastroenterol Hepatol 2022; 7:871-893. [PMID: 35798022 DOI: 10.1016/s2468-1253(22)00039-5] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/19/2021] [Revised: 01/18/2022] [Accepted: 01/27/2022] [Indexed: 02/07/2023]
Abstract
Surveillance pouchoscopy is recommended for patients with restorative proctocolectomy with ileal pouch-anal anastomosis in ulcerative colitis or familial adenomatous polyposis, with the surveillance interval depending on the risk of neoplasia. Neoplasia in patients with ileal pouches mainly have a glandular source and less often are of squamous cell origin. Various grades of neoplasia can occur in the prepouch ileum, pouch body, rectal cuff, anal transition zone, anus, or perianal skin. The main treatment modalities are endoscopic polypectomy, endoscopic ablation, endoscopic mucosal resection, endoscopic submucosal dissection, surgical local excision, surgical circumferential resection and re-anastomosis, and pouch excision. The choice of the treatment modality is determined by the grade, location, size, and features of neoplastic lesions, along with patients' risk of neoplasia and comorbidities, and local endoscopic and surgical expertise.
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Affiliation(s)
- Ravi P Kiran
- Division of Colorectal Surgery, Columbia University Irving Medical Center-New York Presbyterian Hospital, New York, NY, USA
| | - Gursimran S Kochhar
- Division of Gastroenterology, Hepatology, and Nutrition, Allegheny Health Network, Pittsburgh, PA, USA
| | - Revital Kariv
- Department of Gastroenterology, Tel Aviv Sourasky Medical Center and Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Douglas K Rex
- Indiana University School of Medicine, Indianapolis, IN, USA
| | - Akira Sugita
- Department of Clinical Research and Department of inflammatory Bowel Disease, Yokohama Municipal Citizens Hospital Yokohama, Japan
| | - David T Rubin
- University of Chicago Medicine Inflammatory Bowel Disease Center, Chicago, IL, USA
| | - Udayakumar Navaneethan
- IBD Center and IBD Interventional Unit, Center for Interventional Endoscopy, Orlando Health, Orlando, FL, USA
| | - Tracy L Hull
- Department of Colorectal Surgery, Cleveland Clinic, Cleveland, OH, USA
| | - Huaibin Mabel Ko
- Department of Pathology and Cell Biology, Columbia University Irving Medical Center-New York Presbyterian Hospital, New York, NY, USA
| | - Xiuli Liu
- Department of Pathology and Immunology, Washington University, St Louis, MO, USA
| | - Lisa A Kachnic
- Department of Radiation Oncology, Columbia University Irving Medical Center-New York Presbyterian Hospital, New York, NY, USA
| | - Scott Strong
- Department of Surgery, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Marietta Iacucci
- Institute of Immunology and Immunotherapy, NIHR Birmingham Biomedical Research Centre, University Hospitals NHS Foundation Trust, University of Birmingham, UK
| | - Willem Bemelman
- Department of Surgery, Academic Medical Center, Amsterdam, Netherlands
| | - Philip Fleshner
- Division of Colorectal Surgery, Cedars Sinai Medical Center, Los Angeles, CA, USA
| | - Rachael A Safyan
- Division of Hematology and Oncology, College of Physicians and Surgeons, Columbia University, New York, NY, USA
| | - Paulo G Kotze
- IBD Outpatients Clinic, Catholic University of Paraná, Curitiba, Brazil
| | - André D'Hoore
- Department of Abdominal Surgery, University Hospital Leuven, Belgium
| | - Omar Faiz
- Department of Surgery, St Mark's Hospital and Academic Institute, Harrow and Department of Surgery and Cancer, Imperial College London, London, UK
| | - Simon Lo
- Pancreatic and Biliary Disease Program, Digestive Diseases, Cedars Sinai Medical Center, Los Angeles, CA, USA
| | - Jean H Ashburn
- Department of Surgery, Wake Forest University Baptist Medical Center, Winston-Salem, NC, USA
| | - Antonino Spinelli
- Department of Biomedical Sciences, Humanitas University and IRCCS Humanitas Research Hospital, Division Colon and Rectal Surgery, Rozzano, Milan, Italy
| | - Charles N Bernstein
- University of Manitoba Inflammatory Bowel Disease Clinical and Research Centre, Winnipeg, MB, Canada
| | - Sunanda V Kane
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN, USA
| | - Raymond K Cross
- Inflammatory Bowel Disease Program, University of Maryland School of Medicine, MD, USA
| | - Jason Schairer
- Department of Gastroenterology, Henry Ford Health System, Detroit, MI, USA
| | - James T McCormick
- Division of Colon and Rectal Surgery, Allegheny Health Network, Pittsburgh, PA, USA
| | - Francis A Farraye
- Division of Gastroenterology and Hepatology, Mayo Clinic Florida, Jacksonville, FL, USA
| | - Shannon Chang
- Inflammatory Bowel Disease Center, NYU Langone Health, NYU Grossman School of Medicine, New York, NY, USA
| | - Ellen J Scherl
- Jill Roberts Center for IBD, Gastroenterology and Hepatology, Weill Cornell Medicine and NewYork Presbyterian Hospital, New York, NY, USA
| | - David A Schwartz
- Department of Gastroenterology, Vanderbilt University Medical Center, Nashville, TN, USA
| | - David H Bruining
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN, USA
| | - Jessica Philpott
- Department of Gastroenterology, Hepatology, and Nutrition, Cleveland Clinic, Cleveland, OH, USA
| | - Stuart Bentley-Hibbert
- Department of Radiology, Columbia University Irving Medical Center-New York Presbyterian Hospital, New York, NY, USA
| | - Dino Tarabar
- IBD Clinical Center, University Hospital Center Dr Dragiša Mišović, Belgrade, Serbia
| | - Sandra El-Hachem
- Division of Gastroenterology, Hepatology, and Nutrition, Allegheny Health Network, Pittsburgh, PA, USA
| | - William J Sandborn
- Department of Medicine, University of California San Diego, San Diego, CA, USA
| | - Mark S Silverberg
- Mount Sinai Hospital Inflammatory Bowel Disease Centre, Toronto, ON, Canada
| | - Darrell S Pardi
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN, USA
| | - James M Church
- Division of Colorectal Surgery, Columbia University Irving Medical Center-New York Presbyterian Hospital, New York, NY, USA
| | - Bo Shen
- Center for Interventional Inflammatory Bowel Disease, Columbia University Irving Medical Center-New York Presbyterian Hospital, New York, NY, USA.
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13
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Herman K, Nemeth S, Shen B, Church JM, Kiran RP. Laparoscopic ileal pouch-anal anastomosis reduces the risk of surgical site infections: An ACS-NSQIP study. Surgery in Practice and Science 2022. [DOI: 10.1016/j.sipas.2022.100114] [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: 10/16/2022] Open
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14
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Masuda K, Kornberg A, Miller J, Lin S, Suek N, Botella T, Secener KA, Bacarella AM, Cheng L, Ingham M, Rosario V, Al-Mazrou AM, Lee-Kong SA, Kiran RP, Stoeckius M, Smibert P, Del Portillo A, Oberstein PE, Sims PA, Yan KS, Han A. Multiplexed single-cell analysis reveals prognostic and nonprognostic T cell types in human colorectal cancer. JCI Insight 2022; 7:154646. [PMID: 35192548 PMCID: PMC9057629 DOI: 10.1172/jci.insight.154646] [Citation(s) in RCA: 17] [Impact Index Per Article: 8.5] [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: 09/01/2021] [Accepted: 02/16/2022] [Indexed: 01/21/2023] Open
Abstract
Clinical outcomes in colorectal cancer (CRC) correlate with T cell infiltrates, but the specific contributions of heterogenous T cell types remain unclear. To investigate the diverse function of T cells in CRC, we profiled 37,931 T cells from tumors and adjacent normal colon of 16 patients with CRC with respect to transcriptome, TCR sequence, and cell surface markers. Our analysis identified phenotypically and functionally distinguishable effector T cell types. We employed single-cell gene signatures from these T cell subsets to query the TCGA database to assess their prognostic significance. We found 2 distinct cytotoxic T cell types. GZMK+KLRG1+ cytotoxic T cells were enriched in CRC patients with good outcomes. GNLY+CD103+ cytotoxic T cells with a dysfunctional phenotype were not associated with good outcomes, despite coexpression of CD39 and CD103, markers that denote tumor reactivity. We found 2 distinct Treg subtypes associated with opposite outcomes. While total Tregs were associated with good outcomes, CD38+ Tregs were associated with bad outcomes independently of stage and possessed a highly suppressive phenotype, suggesting that they inhibit antitumor immunity in CRC. These findings highlight the potential utility of these subpopulations in predicting outcomes and support the potential for novel therapies directed at CD38+ Tregs or CD8+CD103+ T cells.
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Affiliation(s)
| | - Adam Kornberg
- Columbia Center for Translational Immunology,,Department of Microbiology & Immunology
| | - Jonathan Miller
- Department of Pediatrics,,Columbia Center for Human Development
| | - Sijie Lin
- Columbia Center for Translational Immunology
| | - Nathan Suek
- Columbia Center for Translational Immunology
| | | | | | | | | | - Matthew Ingham
- Department of Medicine, Division of Hematology & Oncology,,Herbert Irving Comprehensive Cancer Center, and
| | - Vilma Rosario
- Herbert Irving Comprehensive Cancer Center, and,Department of Surgery, Division of Colorectal Surgery, Columbia University, New York, New York, USA
| | - Ahmed M. Al-Mazrou
- Herbert Irving Comprehensive Cancer Center, and,Department of Surgery, Division of Colorectal Surgery, Columbia University, New York, New York, USA
| | - Steven A. Lee-Kong
- Herbert Irving Comprehensive Cancer Center, and,Department of Surgery, Division of Colorectal Surgery, Columbia University, New York, New York, USA
| | - Ravi P. Kiran
- Herbert Irving Comprehensive Cancer Center, and,Department of Surgery, Division of Colorectal Surgery, Columbia University, New York, New York, USA
| | | | | | | | - Paul E. Oberstein
- Department of Medicine, Division of Hematology & Oncology,,Herbert Irving Comprehensive Cancer Center, and
| | - Peter A. Sims
- Departments of Systems Biology and Biochemistry & Molecular Biophysics
| | - Kelley S. Yan
- Columbia Center for Human Development,,Department of Medicine, Division of Digestive & Liver Diseases, and,Department of Genetics & Development, Columbia University, New York, New York, USA
| | - Arnold Han
- Columbia Center for Translational Immunology,,Department of Microbiology & Immunology,,Herbert Irving Comprehensive Cancer Center, and,Department of Medicine, Division of Digestive & Liver Diseases, and
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15
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Syed A, Seoud T, Carleton NM, Thakkar S, Kiran RP, Shen B. Association Between Portal Vein Thrombosis and Pouchitis in Patients with Ulcerative Colitis. Dig Dis Sci 2022; 67:1303-1310. [PMID: 33948758 DOI: 10.1007/s10620-021-06969-5] [Citation(s) in RCA: 1] [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: 11/15/2020] [Accepted: 03/23/2021] [Indexed: 12/15/2022]
Abstract
BACKGROUND Pouchitis is the most common long-term complication in patients requiring colectomy ileal pouch-anal anastomosis with medically refractory ulcerative colitis or colitis-associated neoplasia. A previous small case series suggests associated between portal vein thrombosis (PVT) and ischemic pouchitis. AIM To evaluate the association between PVT and other demographic and clinical factors and pouchitis. METHODS We used Explorys Inc., a population-based database, to search medical records between 1999 and 2020 with SNOMED-CT code criteria for "construction of pouch" and "ileal pouchitis." Patients with pouchitis were compared to those with previous pouch construction without pouchitis. Factors associated with pouchitis identified with univariable analysis were introduced into a multivariable model. A post hoc analysis further stratified demographical findings of the association between PVT and pouchitis. RESULTS We identified 7900 patients with ileal pouchitis (7.5%) and 97,510 with pouch construction without pouchitis. In multivariate binary logistic regression, adjusted odds ratio (aOR) for the risk of pouchitis in patients with PVT was 10.78 (95% confidence interval [CI] 7.04-16.49, P < 0.001). Other significant factors associated with pouchitis included male gender (aOR 1.11, 95% CI 1.02-1.21, P = 0.018), deep vein thrombosis (aOR 1.46, 95% CI 1.23-1.72, P < 0.001), and the use of non-steroidal anti-inflammatory drugs (aOR 1.37, 95% CI 1.28-1.45, P < 0.001). Smoking was a protective factor (aOR 0.30, 95% CI 0.33-0.36, P < 0.001). Further sub-analysis showed a higher prevalence of younger patients with PVT and pouchitis. CONCLUSIONS We report PVT as an independent risk factor associated with pouchitis. Our findings support that PVT is a potentially manageable perioperative complication, and intervention may reduce the risk of pouchitis.
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Affiliation(s)
- Aslam Syed
- Division of Gastroenterology, Allegheny Health Network, Pittsburgh, PA, USA.,Department of Medicine, MetroHealth Medical Center, Case Western Reserve University, Cleveland, OH, USA
| | - Talal Seoud
- Division of Gastroenterology and Hepatology, Stony Brook University Hospital, Long Island, NY, USA
| | - Neil M Carleton
- Medical Scientist Training Program, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Shyam Thakkar
- Adjunct Faculty, Department of Biomedical Engineering, Carnegie Mellon University, Pittsburgh, PA, USA
| | - Ravi P Kiran
- Center for Inflammatory Bowel Disease, Columbia University Irving Medical Center/New York Presbyterian Hospital, Herbert Irving Pavilion-Rm 843, 161 Fort Washington Ave, New York, NY, 10032, USA
| | - Bo Shen
- Center for Inflammatory Bowel Disease, Columbia University Irving Medical Center/New York Presbyterian Hospital, Herbert Irving Pavilion-Rm 843, 161 Fort Washington Ave, New York, NY, 10032, USA.
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16
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Shen B, Kochhar GS, Rubin DT, Kane SV, Navaneethan U, Bernstein CN, Cross RK, Sugita A, Schairer J, Kiran RP, Fleshner P, McCormick JT, D'Hoore A, Shah SA, Farraye FA, Kariv R, Liu X, Rosh J, Chang S, Scherl E, Schwartz DA, Kotze PG, Bruining DH, Philpott J, Abraham B, Segal J, Sedano R, Kayal M, Bentley-Hibbert S, Tarabar D, El-Hachem S, Sehgal P, Picoraro JA, Vermeire S, Sandborn WJ, Silverberg MS, Pardi DS. Treatment of pouchitis, Crohn's disease, cuffitis, and other inflammatory disorders of the pouch: consensus guidelines from the International Ileal Pouch Consortium. Lancet Gastroenterol Hepatol 2022; 7:69-95. [PMID: 34774224 DOI: 10.1016/s2468-1253(21)00214-4] [Citation(s) in RCA: 28] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/23/2021] [Revised: 05/29/2021] [Accepted: 06/01/2021] [Indexed: 02/06/2023]
Abstract
Pouchitis, Crohn's disease of the pouch, cuffitis, polyps, and extraintestinal manifestations of inflammatory bowel disease are common inflammatory disorders of the ileal pouch. Acute pouchitis is treated with oral antibiotics and chronic pouchitis often requires anti-inflammatory therapy, including the use of biologics. Aetiological factors for secondary pouchitis should be evaluated and managed accordingly. Crohn's disease of the pouch is usually treated with biologics and its stricturing and fistulising complications can be treated with endoscopy or surgery. The underlying cause of cuffitis determines treatment strategies. Endoscopic polypectomy is recommended for large, symptomatic inflammatory polyps and polyps in the cuff. The management principles of extraintestinal manifestations of inflammatory bowel disease in patients with pouches are similar to those in patients without pouches.
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Affiliation(s)
- Bo Shen
- Center for Interventional Inflammatory Bowel Disease, Columbia University Irving Medical Center, NewYork Presbyterian Hospital, New York, NY, USA.
| | - Gursimran S Kochhar
- Division of Gastroenterology, Hepatology, and Nutrition, Allegheny Health Network, Pittsburgh, PA, USA
| | - David T Rubin
- University of Chicago Medicine Inflammatory Bowel Disease Center, Chicago, IL, USA
| | - Sunanda V Kane
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN, USA
| | - Udayakumar Navaneethan
- Center for IBD and Interventional IBD Unit, Digestive Health Institute, Orlando Health, Orlando, FL, USA
| | - Charles N Bernstein
- Inflammatory Bowel Disease Clinical and Research Centre, University of Manitoba, Winnipeg, MB, Canada
| | - Raymond K Cross
- Inflammatory Bowel Disease Program, University of Maryland School of Medicine, Maryland, MD, USA
| | - Akira Sugita
- Department of Clinical Research and Department of inflammatory Bowel Disease, Yokohama Municipal Citizens Hospital, Yokohama, Japan
| | - Jason Schairer
- Department of Gastroenterology, Henry Ford Health System, Detroit, MI, USA
| | - Ravi P Kiran
- Division of Colorectal Surgery, Columbia University Irving Medical Center, NewYork Presbyterian Hospital, New York, NY, USA
| | - Philip Fleshner
- Division of Colorectal Surgery, University of California-Cedars Sinai Medical Center, Los Angeles, CA, USA
| | - James T McCormick
- Division of Colon and Rectal Surgery, Allegheny Health Network, Pittsburgh, PA, USA
| | - André D'Hoore
- Department of Abdominal Surgery, University Hospital Leuven, Leuven, Belgium
| | - Samir A Shah
- Alpert Medical School of Brown University and Miriam Hospital, Gastroenterology Associates, Providence, RI, USA
| | - Francis A Farraye
- Division of Gastroenterology and Hepatology, Mayo Clinic Florida, Jacksonville, FL, USA
| | - Revital Kariv
- Department of Gastroenterology, Tel Aviv Sourasky Medical Center and Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Xiuli Liu
- Department of Pathology, Immunology, and Laboratory Medicine, University of Florida, Gainsville, FL, USA
| | - Joel Rosh
- Department of Pediatric Gastroenterology, Goryeb Children's Hospital/Atlantic Health, Morristown, NJ, USA
| | - Shannon Chang
- Division of Gastroenterology, New York University Langone Health, New York, NY, USA
| | - Ellen Scherl
- Jill Roberts Center for IBD, Division of Gastroenterology and Hepatology, Weill Cornell Medicine, NewYork Presbytarian Hospital, New York, NY, USA
| | - David A Schwartz
- Department of Gastroenterology, Vanderbilt University Medical Center, Nashville, TN, USA
| | | | - David H Bruining
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN, USA
| | - Jessica Philpott
- Department of Gastroenterology, Hepatology and Nutrition, Cleveland Clinic, Cleveland, OH, USA
| | - Bincy Abraham
- Houston Methodist and Weill Cornell Medical College, Houston, TX, USA
| | - Jonathan Segal
- Department of Gastroenterology and Hepatology, Hillingdon Hospital, Uxbridge, UK
| | - Rocio Sedano
- Department of Medicine, Division of Gastroenterology, Western University, London, ON, Canada
| | - Maia Kayal
- Department of Gastroenterology, Icahn School of Medicine at Mount Sinai Hospital, New York, NY, USA
| | - Stuart Bentley-Hibbert
- Department of Radiology, Columbia University Irving Medical Center, NewYork Presbyterian Hospital, New York, NY, USA
| | - Dino Tarabar
- IBD Clinical Center, University Hospital Center Dr Dragiša Mišović, Belgrade, Serbia
| | - Sandra El-Hachem
- Division of Gastroenterology, Hepatology, and Nutrition, Allegheny Health Network, Pittsburgh, PA, USA
| | - Priya Sehgal
- Division of Digestive and Liver Diseases, Columbia University Irving Medical Center, NewYork Presbyterian Hospital, New York, NY, USA
| | - Joseph A Picoraro
- Department of Pediatrics, Columbia University Irving Medical Center-Morgan Stanley Children's Hospital, New York, NY, USA
| | - Séverine Vermeire
- Department of Gastroenterology, University Hospitals Leuven, Leuven, Belgium
| | - William J Sandborn
- Department of Gastroenterology, University of California San Diego, San Diego, CA, USA
| | - Mark S Silverberg
- Inflammatory Bowel Disease Centre, Mount Sinai Hospital, Toronto, ON, Canada
| | - Darrell S Pardi
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN, USA
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Yan X, Goldsmith J, Mohan S, Turnbull ZA, Freundlich RE, Billings FT, Kiran RP, Li G, Kim M. Impact of Intraoperative Data on Risk Prediction for Mortality After Intra-Abdominal Surgery. Anesth Analg 2022; 134:102-113. [PMID: 34908548 PMCID: PMC8682663 DOI: 10.1213/ane.0000000000005694] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
BACKGROUND Risk prediction models for postoperative mortality after intra-abdominal surgery have typically been developed using preoperative variables. It is unclear if intraoperative data add significant value to these risk prediction models. METHODS With IRB approval, an institutional retrospective cohort of intra-abdominal surgery patients in the 2005 to 2015 American College of Surgeons National Surgical Quality Improvement Program was identified. Intraoperative data were obtained from the electronic health record. The primary outcome was 30-day mortality. We evaluated the performance of machine learning algorithms to predict 30-day mortality using: 1) baseline variables and 2) baseline + intraoperative variables. Algorithms evaluated were: 1) logistic regression with elastic net selection, 2) random forest (RF), 3) gradient boosting machine (GBM), 4) support vector machine (SVM), and 5) convolutional neural networks (CNNs). Model performance was evaluated using the area under the receiver operator characteristic curve (AUROC). The sample was randomly divided into a training/testing split with 80%/20% probabilities. Repeated 10-fold cross-validation identified the optimal model hyperparameters in the training dataset for each model, which were then applied to the entire training dataset to train the model. Trained models were applied to the test cohort to evaluate model performance. Statistical significance was evaluated using P < .05. RESULTS The training and testing cohorts contained 4322 and 1079 patients, respectively, with 62 (1.4%) and 15 (1.4%) experiencing 30-day mortality, respectively. When using only baseline variables to predict mortality, all algorithms except SVM (area under the receiver operator characteristic curve [AUROC], 0.83 [95% confidence interval {CI}, 0.69-0.97]) had AUROC >0.9: GBM (AUROC, 0.96 [0.94-1.0]), RF (AUROC, 0.96 [0.92-1.0]), CNN (AUROC, 0.96 [0.92-0.99]), and logistic regression (AUROC, 0.95 [0.91-0.99]). AUROC significantly increased with intraoperative variables with CNN (AUROC, 0.97 [0.96-0.99]; P = .047 versus baseline), but there was no improvement with GBM (AUROC, 0.97 [0.95-0.99]; P = .3 versus baseline), RF (AUROC, 0.96 [0.93-1.0]; P = .5 versus baseline), and logistic regression (AUROC, 0.94 [0.90-0.99]; P = .6 versus baseline). CONCLUSIONS Postoperative mortality is predicted with excellent discrimination in intra-abdominal surgery patients using only preoperative variables in various machine learning algorithms. The addition of intraoperative data to preoperative data also resulted in models with excellent discrimination, but model performance did not improve.
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Affiliation(s)
- Xinyu Yan
- Department of Biostatistics, Mailman School of Public Health, Columbia University, New York, NY
| | - Jeff Goldsmith
- Department of Biostatistics, Mailman School of Public Health, Columbia University, New York, NY
| | - Sumit Mohan
- Department of Medicine, Division of Nephrology, Columbia University Medical Center, New York, NY,Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, NY
| | | | - Robert E. Freundlich
- Department of Anesthesiology, Vanderbilt University Medical Center, Nashville, TN
| | - Frederic T. Billings
- Department of Anesthesiology, Vanderbilt University Medical Center, Nashville, TN
| | - Ravi P. Kiran
- Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, NY,Department of Surgery, Division of Colorectal Surgery, Columbia University Medical Center, New York, NY
| | - Guohua Li
- Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, NY,Department of Anesthesiology, Columbia University Medical Center, New York, NY
| | - Minjae Kim
- Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, NY,Department of Anesthesiology, Columbia University Medical Center, New York, NY,Correspondence: Minjae Kim, MD, MS, Assistant Professor, Department of Anesthesiology, Columbia University Medical Center, 622 West 168th Street, PH 5, Suite 505C, New York, NY 10032, Tel: 212.305.6494, Fax: 212.305.2182,
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18
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Church J, Shen B, Kiran RP. Ileoanal Pouch Syndrome? Or a New Normal? Dis Colon Rectum 2021; 64:e735. [PMID: 34538833 DOI: 10.1097/dcr.0000000000002277] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Affiliation(s)
- James Church
- Inflammatory Bowel Disease Center in the Division of Colorectal Surgery, Columbia University Medical Center/New York Presbyterian Hospital, New York, New York
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19
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Simon HL, de Paula TR, Profeta da Luz MM, Kiran RP, Keller DS. Predictors of Positive Circumferential Resection Margin in Rectal Cancer: A Current Audit of the National Cancer Database. Dis Colon Rectum 2021; 64:1096-1105. [PMID: 33951688 DOI: 10.1097/dcr.0000000000002115] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
BACKGROUND Positive circumferential resection margin is a predictor of local recurrence and worse survival in rectal cancer. National programs aimed to improve rectal cancer outcomes were first created in 2011 and continue to evolve. The impact on circumferential resection margin during this time frame has not been fully evaluated in the United States. OBJECTIVE The purpose of this study was to determine the incidence and predictors of positive circumferential resection margin after rectal cancer resection, across patient, provider, and tumor characteristics. DESIGN This was a retrospective cohort study. SETTINGS The study was conducted using the National Cancer Database, 2011-2016. PATIENTS Adults who underwent proctectomy for pathologic stage I to III rectal adenocarcinoma were included. MAIN OUTCOME MEASURES Rate and predictors of positive circumferential resection margin, defined as resection margin ≤1 mm, were measured. RESULTS Of 52,620 cases, circumferential resection margin status was reported in 90% (n = 47,331) and positive in 18.4% (n = 8719). Unadjusted analysis showed that patients with positive circumferential resection margin were more often men, had public insurance and shorter travel, underwent total proctectomy via open and robotic approaches, and were treated in Southern and Western regions at integrated cancer networks (all p < 0.001). Multivariate analysis noted that positive proximal and/or distal margin on resected specimen had the strongest association with positive circumferential resection margin (OR = 15.6 (95% CI, 13.6-18.1); p < 0.001). Perineural invasion, total proctectomy, robotic approach, neoadjuvant chemoradiation, integrated cancer network, advanced tumor size and grade, and Black race had increased risk of positive circumferential resection margin (all p < 0.050). Laparoscopic approach, surgery in North, South, and Midwest regions, greater hospital volume and travel distance, lower T-stage, and higher income were associated with decreased risk (all p < 0.028). LIMITATIONS This was a retrospective cohort study with limited variables available for analysis. CONCLUSIONS Despite creation of national initiatives, positive circumferential resection margin rate remains an alarming 18.4%. The persistently high rate with predictors of positive circumferential resection margin identified calls for additional education, targeted quality improvement assessments, and publicized auditing to improve rectal cancer care in the United States. See Video Abstract at http://links.lww.com/DCR/B584. PREDICTORES PARA UN MARGEN POSITIVO DE RESECCIN CIRCUNFERENCIAL EN EL CNCER DE RECTO UNA AUDITORA VIGENTE DE LA BASE DE DATOS NACIONAL DE CANCER ANTECEDENTES:El margen positivo de resección circunferencial es un predictor de recurrencia local y peor sobrevida en el cáncer de recto. Los programas nacionales destinados a mejorar los resultados del cáncer de recto se crearon por primera vez en 2011 y continúan evolucionando. La repercusión del margen de resección circunferencial durante este período de tiempo no se ha evaluado completamente en los Estados Unidos.OBJETIVO:Determinar la incidencia y los predictores para un margen positivo de resección circunferencial posterior a la resección del cáncer de recto, según las características del paciente, el proveedor y el tumor.DISEÑO:Estudio de cohorte retrospectivo.AMBITO:Base de datos nacional de cáncer, 2011-2016.PACIENTES:Adultos que se sometieron a proctectomía por adenocarcinoma de recto con un estadío por patología I-III.PRINCIPALES VARIABLES EVALUADAS:Tasa y predictores para un margen positivo de resección circunferencial, definido como margen de resección ≤ 1 mm.RESULTADOS:De 52,620 casos, la condición del margen de resección circunferencial se informó en el 90% (n = 47,331) y positivo en el 18.4% (n = 8,719). El análisis no ajustado mostró que los pacientes con margen positivo de resección circunferencial se presentó con mayor frecuencia en hombres, tenían un seguro social y viajes más cortos, se operaron de proctectomía total abierta y robótica, y fueron tratados en las regiones del sur y el oeste en redes integradas de cáncer (todos p <0,001). El análisis multivariado destacó que el margen proximal y / o distal positivo de la pieza resecada tenía la asociación más fuerte con el margen postivo de resección circunferencial (OR 15,6; IC del 95%: 13,6-18,1, p <0,001). La invasión perineural, la proctectomía total, el abordaje robótico, la quimioradioterapia neoadyuvante, la red de cáncer integrada, el tamaño y grado del tumor avanzado y la raza afroamericana tenían un mayor riesgo de un margen de una resección positiva circunferencial (todos p <0,050). El abordaje laparoscópico, la cirugía en las regiones Norte, Sur y Medio Oeste, un mayor volumen hospitalario y distancia de viaje, estadio T más bajo y mayores ingresos se asociaron con una disminución del riesgo (todos p <0,028).LIMITACIONES:Estudio de cohorte retrospectivo con variables limitadas disponibles para análisis.CONCLUSIONES:A pesar del establecimiento de iniciativas nacionales, la tasa de margen positivo de resección circunferencial continúa siendo alarmante, 18,4%. El índice continuamente elevado junto a los predictores de un margen positivo de resección circunferencial hace un llamado para una mayor educación, evaluaciones específicas de mejora de la calidad y difusión de las auditorías para mejorar la atención del cáncer de recto en los Estados Unidos. Vea el resumen de video en http://links.lww.com/DCR/B584. Consulte Video Resumen en http://links.lww.com/DCR/B584.
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Affiliation(s)
- Hillary L Simon
- Division of Colorectal Surgery, Department of Surgery, Columbia University Medical Center, New York, New York
| | - Thais Reif de Paula
- Division of Colorectal Surgery, Department of Surgery, Columbia University Medical Center, New York, New York
| | - Magda M Profeta da Luz
- Division of Colorectal Surgery, Department of Surgery, Columbia University Medical Center, New York, New York
| | - Ravi P Kiran
- Division of Colorectal Surgery, Department of Surgery, Columbia University Medical Center, New York, New York
- Herbert Irving Comprehensive Cancer Center, Columbia University Medical Center, New York, New York
| | - Deborah S Keller
- Division of Colorectal Surgery, Department of Surgery, Columbia University Medical Center, New York, New York
- Herbert Irving Comprehensive Cancer Center, Columbia University Medical Center, New York, New York
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20
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Shen B, Kochhar GS, Kariv R, Liu X, Navaneethan U, Rubin DT, Cross RK, Sugita A, D'Hoore A, Schairer J, Farraye FA, Kiran RP, Fleshner P, Rosh J, Shah SA, Chang S, Scherl E, Pardi DS, Schwartz DA, Kotze PG, Bruining DH, Kane SV, Philpott J, Abraham B, Segal J, Sedano R, Kayal M, Bentley-Hibbert S, Tarabar D, El-Hachem S, Sehgal P, McCormick JT, Picoraro JA, Silverberg MS, Bernstein CN, Sandborn WJ, Vermeire S. Diagnosis and classification of ileal pouch disorders: consensus guidelines from the International Ileal Pouch Consortium. Lancet Gastroenterol Hepatol 2021; 6:826-849. [PMID: 34416186 DOI: 10.1016/s2468-1253(21)00101-1] [Citation(s) in RCA: 61] [Impact Index Per Article: 20.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/25/2021] [Revised: 03/12/2021] [Accepted: 03/15/2021] [Indexed: 12/12/2022]
Abstract
Restorative proctocolectomy with ileal pouch-anal anastomosis is an option for most patients with ulcerative colitis or familial adenomatous polyposis who require colectomy. Although the construction of an ileal pouch substantially improves patients' health-related quality of life, the surgery is, directly or indirectly, associated with various structural, inflammatory, and functional adverse sequelae. Furthermore, the surgical procedure does not completely abolish the risk for neoplasia. Patients with ileal pouches often present with extraintestinal, systemic inflammatory conditions. The International Ileal Pouch Consortium was established to create this consensus document on the diagnosis and classification of ileal pouch disorders using available evidence and the panellists' expertise. In a given individual, the condition of the pouch can change over time. Therefore, close monitoring of the activity and progression of the disease is essential to make accurate modifications in the diagnosis and classification in a timely manner.
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Affiliation(s)
- Bo Shen
- Center for Interventional Inflammatory Bowel Disease, Columbia University Irving Medical Center-New-York Presbyterian Hospital, NY, USA.
| | - Gursimran S Kochhar
- Division of Gastroenterology, Hepatology, and Nutrition, Allegheny Health Network, Pittsburgh, PA, USA
| | - Revital Kariv
- Department of Gastroenterology, Tel Aviv Sourasky Medical Center and Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Xiuli Liu
- Department of Pathology and Immunology, Washington University, MO, USA
| | - Udayakumar Navaneethan
- IBD Center and IBD Interventional Unit, Center for Interventional Endoscopy, Orlando Health, Orlando, FL, USA
| | - David T Rubin
- Inflammatory Bowel Disease Center, University of Chicago Medicine, Chicago, IL, USA
| | - Raymond K Cross
- Inflammatory Bowel Disease Program, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Akira Sugita
- Department of Clinical Research and Department of Inflammatory Bowel Disease, Yokohama Municipal Citizens Hospital Yokohama, Japan
| | - André D'Hoore
- Department of Abdominal Surgery, University Hospital Leuven, Belgium
| | - Jason Schairer
- Department of Gastroenterology, Henry Ford Health System, Detroit, MI, USA
| | - Francis A Farraye
- Division of Gastroenterology and Hepatology, Mayo Clinic Florida, Jacksonville, FL, USA
| | - Ravi P Kiran
- Division of Colorectal Surgery, Columbia University Irving Medical Center-New-York Presbyterian Hospital, NY, USA
| | - Philip Fleshner
- Division of Colorectal Surgery, University of California-Cedars Sinai Medical Center, Los Angeles, CA, USA
| | - Joel Rosh
- Department of Pediatric Gastroenterology, Goryeb Children's Hospital-Atlantic Health, Morristown, NJ, USA
| | - Samir A Shah
- Alpert Medical School of Brown University and Miriam Hospital, Gastroenterology Associates, Providence, RI, USA
| | - Shannon Chang
- Division of Gastroenterology, New York University Langone Health, New York, NY, USA
| | - Ellen Scherl
- New York Presbyterian Hospital, Jill Roberts Center for IBD, Weill Cornell Medicine, Gastroenterology and Hepatology, New York, NY, USA
| | - Darrell S Pardi
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN, USA
| | - David A Schwartz
- Department of Gastroenterology, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Paulo G Kotze
- IBD Outpatients Clinic, Catholic University of Paraná, Curitiba, Brazil
| | - David H Bruining
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN, USA
| | - Sunanda V Kane
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN, USA
| | - Jessica Philpott
- Department of Gastroenterology, Hepatology, and Nutrition, Cleveland Clinic, Cleveland, OH, USA
| | - Bincy Abraham
- Houston Methodist and Weill Cornell Medical College, Houston, TX, USA
| | - Jonathan Segal
- Department of Gastroenterology and Hepatology, Hillingdon Hospital, Uxbridge, UK
| | - Rocio Sedano
- Department of Medicine, Division of Gastroenterology, Western University, London, ON, Canada
| | - Maia Kayal
- Department of Gastroenterology, Icahn School of Medicine at Mount Sinai Hospital, New York, NY, USA
| | - Stuart Bentley-Hibbert
- Department of Radiology, Columbia University Irving Medical Center-New-York Presbyterian Hospital, NY, USA
| | - Dino Tarabar
- IBD Clinical Center, University Hospital Center Dr Dragiša Mišović, Belgrade, Serbia
| | - Sandra El-Hachem
- Division of Gastroenterology, Hepatology, and Nutrition, Allegheny Health Network, Pittsburgh, PA, USA
| | - Priya Sehgal
- Division of Digestive and Liver Diseases, Columbia University Irving Medical Center-New-York Presbyterian Hospital, NY, USA
| | - James T McCormick
- Division of Colon and Rectal Surgery, Allegheny Health Network, Pittsburgh, PA, USA
| | - Joseph A Picoraro
- Department of Pediatrics, Columbia University Irving Medical Center-Morgan Stanley Children's Hospital, New York, NY, USA
| | - Mark S Silverberg
- Mount Sinai Hospital Inflammatory Bowel Disease Centre, Toronto, ON, Canada
| | - Charles N Bernstein
- Inflammatory Bowel Disease Clinical and Research Centre, University of Manitoba, Winnipeg, MB, Canada
| | - William J Sandborn
- Department of Gastroenterology, University of California San Diego, San Diego, CA, USA
| | - Séverine Vermeire
- Department of Gastroenterology, University hospitals Leuven, Leuven, Belgium
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21
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Kim M, Li G, Mohan S, Turnbull ZA, Kiran RP, Li G. Intraoperative Data Enhance the Detection of High-Risk Acute Kidney Injury Patients When Added to a Baseline Prediction Model. Anesth Analg 2021; 132:430-441. [PMID: 32769380 DOI: 10.1213/ane.0000000000005057] [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] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND Aspects of intraoperative management (eg, hypotension) are associated with acute kidney injury (AKI) in noncardiac surgery patients. However, it is unclear if and how the addition of intraoperative data affects a baseline risk prediction model for postoperative AKI. METHODS With institutional review board (IRB) approval, an institutional cohort (2005-2015) of inpatient intra-abdominal surgery patients without preoperative AKI was identified. Data from the American College of Surgeons National Surgical Quality Improvement Program (preoperative and procedure data), Anesthesia Information Management System (intraoperative data), and electronic health record (postoperative laboratory data) were linked. The sample was split into derivation/validation (70%/30%) cohorts. AKI was defined as an increase in serum creatinine ≥0.3 mg/dL within 48 hours or >50% within 7 days of surgery. Forward logistic regression fit a baseline model incorporating preoperative variables and surgical procedure. Forward logistic regression fit a second model incorporating the previously selected baseline variables, as well as additional intraoperative variables. Intraoperative variables reflected the following aspects of intraoperative management: anesthetics, beta-blockers, blood pressure, diuretics, fluids, operative time, opioids, and vasopressors. The baseline and intraoperative models were evaluated based on statistical significance and discriminative ability (c-statistic). The risk threshold equalizing sensitivity and specificity in the intraoperative model was identified. RESULTS Of 2691 patients in the derivation cohort, 234 (8.7%) developed AKI. The baseline model had c-statistic 0.77 (95% confidence interval [CI], 0.74-0.80). The additional variables added to the intraoperative model were significantly associated with AKI (P < .0001) and the intraoperative model had c-statistic 0.81 (95% CI, 0.78-0.83). Sensitivity and specificity were equalized at a risk threshold of 9.0% in the intraoperative model. At this threshold, the baseline model had sensitivity and specificity of 71% (95% CI, 65-76) and 69% (95% CI, 67-70), respectively, and the intraoperative model had sensitivity and specificity of 74% (95% CI, 69-80) and 74% (95% CI, 73-76), respectively. The high-risk group had an AKI risk of 18% (95% CI, 15-20) in the baseline model and 22% (95% CI, 19-25) in the intraoperative model. CONCLUSIONS Intraoperative data, when added to a baseline risk prediction model for postoperative AKI in intra-abdominal surgery patients, improves the performance of the model.
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Affiliation(s)
- Minjae Kim
- From the Department of Anesthesiology, Columbia University Medical Center, New York, New York.,Department of Epidemiology
| | - Gen Li
- Department of Biostatistics, Mailman School of Public Health, Columbia University, New York, New York
| | - Sumit Mohan
- Department of Epidemiology.,Division of Nephrology, Department of Medicine, Columbia University Medical Center, New York, New York
| | - Zachary A Turnbull
- Department of Anesthesiology, Weill Cornell Medicine, New York, New York
| | - Ravi P Kiran
- Department of Epidemiology.,Division of Colorectal Surgery, Department of Surgery, Columbia University Medical Center, New York, New York
| | - Guohua Li
- From the Department of Anesthesiology, Columbia University Medical Center, New York, New York.,Department of Epidemiology
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22
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Campos Lobato LFD, Ferreira PCA, Wick EC, Kiran RP, Remzi FH, Kalady MF, Vogel JD. Risk factors for prolonged length of stay after colorectal surgery. Journal of Coloproctology 2021. [DOI: 10.1016/j.jcol.2013.02.001] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
Abstract
Objective Colorectal surgeons often struggle to explain to administrators/payers reasons for prolonged length of stay (LOS). This study aim was to identify factors associated with increased LOS after colorectal surgery.
Design The study population included patients from the 2007 American-College-of-Sur- geons-National-Surgical-Quality-Improvement-Program (ACS-NSQIP) database undergoing ileocolic resection, segmental colectomy, or anterior resection. The study population was divided into normal (below 75th percentile) and prolonged LOS (above the 75th percentile). A multivariate analysis was performed using prolonged LOS as dependent variable and ACS- NSQIP variables as predictive variables. P-value < 0.01 was considered significant.
Results 12,269 patients with a median LOS of 6 (inter-quartile range 4-9) days were includ- ed. There were 2,617 (21.3%) patients with prolonged LOS (median 15 days, inter-quartile range 13-22). 1,308 (50%) were female, and the median age was 69 (inter-quartile range 57-79) years. Risk factors for prolonged LOS were male gender, congestive heart failure, weight loss, Crohn's disease, preoperative albumin < 3.5 g/dL and hematocrit < 47%, base- line sepsis, ASA class ≥ 3, open surgery, surgical time ≥ 190 min, postoperative pneumonia, failure to wean from mechanical ventilation, deep venous thrombosis, urinary-tract in- fection, systemic sepsis, surgical site infection and reoperation within 30-days from the primary surgery.
Conclusion Multiple factors are associated with increased LOS after colorectal surgery. Our results are useful for surgeons to explain prolonged LOS to administrators/payers who are critical of this metric.
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Affiliation(s)
- Luiz Felipe de Campos Lobato
- Division of Coloproctology, Universidade de Brasília, Brasília, DF, Brazil
- Instituto de Coloproctologia de Brasília, Brasília, DF, Brazil
| | | | - Elizabeth C. Wick
- Department of Surgery, Johns Hopkins University, Baltimore, MD, United States of America
| | - Ravi P. Kiran
- Department of Colorectal Surgery, Digestive Disease Institute, Cleveland Clinic, Cleveland, OH, United States of America
| | - Feza H. Remzi
- Department of Colorectal Surgery, Digestive Disease Institute, Cleveland Clinic, Cleveland, OH, United States of America
| | - Matthew F. Kalady
- Department of Colorectal Surgery, Digestive Disease Institute, Cleveland Clinic, Cleveland, OH, United States of America
| | - Jon D. Vogel
- Department of Colorectal Surgery, Digestive Disease Institute, Cleveland Clinic, Cleveland, OH, United States of America
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Reif de Paula T, Augestad KM, Kiran RP, Keller DS. Management of the positive pathologic circumferential resection margin in rectal cancer: A national cancer database (NCDB) study. Eur J Surg Oncol 2021; 47:296-303. [PMID: 32800594 DOI: 10.1016/j.ejso.2020.07.033] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [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: 03/04/2020] [Revised: 06/11/2020] [Accepted: 07/23/2020] [Indexed: 12/21/2022]
Abstract
BACKGROUND The circumferential resection margin (CRM) is a primary predictor of local recurrence and survival in rectal cancer, and an important consideration in guiding treatment. CRM is usually predicted preoperatively, so optimal management of an unexpected pathologic positive CRM involvement is debatable. We aimed to investigate the postoperative management of T3N0 rectal cancers with a positive pathologic CRM, and the impact of each strategy on survival. METHODS The NCDB was reviewed for pathological T3N0 rectal cancer cases from 2010 to 2015, that received neoadjuvant chemotherapy, had surgical resection with pathological clear margins, but a positive pathologic CRM(disease≤2 mm from radial margin). The main outcomes were the incidence, treatment modalities used, and impact of each modality on survival. Univariate analysis evaluated the demographic and provider characteristics across treatment groups. Kaplan-Meier and Cox regression analysis assessed survival and factors associated with overall survival (OS). RESULTS Of 1607 cases with a positive CRM, 65% (1045) received no adjuvant treatment and 35% (n = 562) received adjuvant chemotherapy (AC). After matching, the 1-, 3-, and 5-year OS rates were 98.5%, 88.6% and 76.6% for AC and 96.9%, 84.6% and 68.4% for with no treatment (p = .027). Factors independently associated with improved OS were treatment at an academic/research facility (p = .009), minimally invasive approach (p = .005), well and moderately differentiated tumor (p < .001), absence of perineural invasion (p = .015) and AC administration (p = .047). CONCLUSION In T3N0 rectal cancers resected with local clear margins but a positive pathologic CRM, AC improved OS. However, only a third received this option. Further study is needed to investigate the disparities in AC use in these patients with unexpected pathologic results.
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Affiliation(s)
- Thais Reif de Paula
- Division of Colorectal Surgery, Department of Surgery, Columbia University Medical Center, New York, NY, USA.
| | - Knut Magne Augestad
- Department of Digestive Surgery, Akershus University Hospital, University of Oslo, Lorenskog, Norway.
| | - Ravi P Kiran
- Division of Colorectal Surgery, Department of Surgery, Columbia University Medical Center, New York, NY, USA.
| | - Deborah S Keller
- Division of Colorectal Surgery, Department of Surgery, Columbia University Medical Center, New York, NY, USA.
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Lan N, Zhi M, Chen Y, Wu X, Lan P, Kiran RP, Shen B. Experience of Hospital Admission and Surgery During the COVID-19 Pandemic: a Survey of IBD Patients. J Gastrointest Surg 2021; 25:282-286. [PMID: 32885361 PMCID: PMC7471558 DOI: 10.1007/s11605-020-04758-5] [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] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/27/2020] [Accepted: 07/19/2020] [Indexed: 01/31/2023]
Abstract
BACKGROUND The aim of this study was to evaluate the experience of surgery in IBD patients during the COVID pandemic. METHODS A survey was distributed among patients undergoing IBD-related surgeries from January 2020 to March 2020 via an online platform. The response was submitted anonymously. RESULTS A total of 78 patients responded to the survey. COVID-19 testing was conducted in 60 (76.9%) patients, and they were all tested negative. Emergent surgery was performed in 12 (15.4%) patients and postponed surgery in 18 (23.1%) patients. The surgical indications were mainly bowel obstruction (N = 21, 26.9%) and perianal abscess (N = 18, 23.1%). Postoperative complications were noted in 5.1% of cases, but no re-operation was required. Due to the ongoing COVID pandemic, 58 (74.4%) patients reported various levels of concern and anxiety for surgery. CONCLUSIONS Common surgical indications were for bowel obstruction and perianal abscess. Surgery can be postponed, but disease progression should be monitored closely and surgically intervened as needed. Most patients expressed anxiety resulting from the pandemic. The overall experience was satisfactory.
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Affiliation(s)
- Nan Lan
- Department of Internal Medicine, Canton Medical Education Foundation, Canton, OH USA
| | - Min Zhi
- grid.12981.330000 0001 2360 039XDepartment of Gastroenterology, The Sixth Affiliated Hospital, Sun Yat-sen University, Guangzhou, Guangdong China
| | - Yan Chen
- grid.412465.0Department of Gastroenterology, The Second Affiliated Hospital Zhejiang University School of Medicine, Hangzhou, Zhejiang China
| | - Xianrui Wu
- grid.12981.330000 0001 2360 039XDepartment of Colorectal Surgery, The Sixth Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
| | - Ping Lan
- grid.12981.330000 0001 2360 039XDepartment of Colorectal Surgery, The Sixth Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
| | - Ravi P. Kiran
- grid.21729.3f0000000419368729Division of Colorectal Surgery, Columbia University Irving Medical Center/NewYork Presbyterian Hospital, New York, NY USA
| | - Bo Shen
- grid.21729.3f0000000419368729Center for Inflammatory Bowel Disease, Columbia University Irving Medical Center/NewYork Presbyterian Hospital, New York, NY USA
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Keller DS, Reif de Paula T, Kiran RP, Nemeth SK. Evaluating the association of the new National Surgical Quality Improvement Program modified 5-factor frailty index with outcomes in elective colorectal surgery. Colorectal Dis 2020; 22:1396-1405. [PMID: 32291861 DOI: 10.1111/codi.15066] [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: 12/17/2019] [Accepted: 02/03/2020] [Indexed: 02/08/2023]
Abstract
BACKGROUND The 5-factor modified frailty index (mFI-5) is a new, NSQIP-based, predictive tool for mortality and postoperative complications. The mFI-5's predictive ability has been validated within the large-scale NSQIP database but applicability in institutional databases has not been investigated. We sought to assess the association between the mFI-5 and morbidity/mortality at the institutional level. METHODS A divisional database was queried for 2017 elective colorectal resections and an mFI-5 calculated. The main outcome measure was the association and predictive value of the mFI-5 with major morbidity/mortality and minor complications. Univariable analyses were performed via the Cochran-Armitage Test and Cramer's V. Logistic regression evaluated the relationship between the mFI-5 and morbidity/mortality while accounting for demographics and pre-operative risk factors. Receiver operating characteristic (ROC) curves were plotted to visualize the predictive strength for outcomes. RESULTS Four hundred and twelve patients were analyzed. 8.7% had major morbidity/mortality and 31.6% minor complications. The mFI-5 categorized patients into 0 (n = 335), 1 (n = 58), and 2+ (n = 19) groups. Univariable analysis showed a higher mFI-5 was associated significantly with major morbidity/mortality (P = 0.004), but not minor (P = 0.281). Multivariable logistic regression showed a strong association between an mFI-5 score of 2+ with major complications (Major: OR = 4.616, CI [1.442-14.776], P = 0.010). ROC curves showed the mFI-5 was poor for predicting outcomes and performed better when other risk factors were added to the model. CONCLUSION The mFI-5 tool has an independent association with major morbidity/mortality in an institutional dataset for elective colorectal surgery, but is not predictive. Its predictive ability is enhanced when other patient-specific risk factors are incorporated.
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Affiliation(s)
- D S Keller
- Division of Colorectal Surgery, Department of Surgery, Columbia University Medical Center, New York, New York, USA
| | - T Reif de Paula
- Division of Colorectal Surgery, Department of Surgery, Columbia University Medical Center, New York, New York, USA
| | - R P Kiran
- Division of Colorectal Surgery, Department of Surgery, Columbia University Medical Center, New York, New York, USA
| | - S K Nemeth
- Department of Surgery, Columbia HeartSource, Center for Innovation and Outcomes Research, Columbia University Medical Center, New York, New York, USA
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Faye AS, Oh A, Kumble LD, Kiran RP, Wen T, Lawlor G, Lichtiger S, Abreu MT, Hur C. Fertility Impact of Initial Operation Type for Female Ulcerative Colitis Patients. Inflamm Bowel Dis 2020; 26:1368-1376. [PMID: 31880776 PMCID: PMC7534416 DOI: 10.1093/ibd/izz307] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [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: 09/17/2019] [Indexed: 02/07/2023]
Abstract
BACKGROUND Ileal pouch-anal anastomosis (IPAA) is the mainstay of surgical treatment for patients with ulcerative colitis (UC) but is associated with an increased risk of infertility. We developed a simulation model examining the impact of initial surgical procedure on quality-adjusted life-years (QALYs) and fertility end points. METHODS A patient-level state transition model was used to analyze outcomes by surgical approach strategy for females of childbearing age. Initial surgical options included IPAA, rectal-sparing colectomy with end ileostomy (RCEI), and ileorectal anastomosis (IRA). The primary outcome examined was QALYs, whereas secondary outcomes included UC and fertility-associated end points. RESULTS IPAA resulted in higher QALYs for patients aged 20-30 years, as compared with RCEI. For patients aged 35 years, RCEI resulted in higher QALYs (7.54 RCEI vs 7.53 IPAA) and was associated with a 28% higher rate of childbirth, a 14-month decrease in time to childbirth, and a 77% reduction in in vitro fertilization utilization. When accounting for the decreased infertility risk associated with laparoscopic IPAA, IPAA resulted in higher QALYs (7.57) even for patients aged 35 years. CONCLUSIONS Despite an increased risk of infertility, our model results suggest that IPAA may be the optimal surgical strategy for female UC patients aged 20-30 years who desire children. For patients aged 35 years, RCEI should additionally be considered, as QALYs for RCEI and IPAA were similar. These quantitative data can be used by patients and providers to help develop an individualized approach to surgical management choice.
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Affiliation(s)
- Adam S Faye
- Division of Digestive and Liver Diseases, Department of Medicine, New York, New York, USA
| | - Aaron Oh
- Division of Digestive and Liver Diseases, Department of Medicine, New York, New York, USA
| | - Lindsay D Kumble
- Division of Digestive and Liver Diseases, Department of Medicine, New York, New York, USA
| | - Ravi P Kiran
- Department of Colorectal Surgery, New York, New York, USA
| | - Timothy Wen
- Department of Obstetrics and Gynecology, New York Presbyterian Columbia University Medical Center, New York, New York, USA
| | - Garrett Lawlor
- Division of Digestive and Liver Diseases, Department of Medicine, New York, New York, USA
| | - Simon Lichtiger
- Division of Digestive and Liver Diseases, Department of Medicine, New York, New York, USA
| | - Maria T Abreu
- Division of Gastroenterology, Department of Medicine, University of Miami, Miami, Florida, USA
| | - Chin Hur
- Division of Digestive and Liver Diseases, Department of Medicine, New York, New York, USA
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de Paula TR, Nemeth S, Kiran RP, Keller DS. Predictors of complications from stoma closure in elective colorectal surgery: an assessment from the American College of Surgeons National Surgical Quality Improvement Program (ACSNSQIP). Tech Coloproctol 2020; 24:1169-1177. [PMID: 32696174 PMCID: PMC7373840 DOI: 10.1007/s10151-020-02307-5] [Citation(s) in RCA: 4] [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] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/19/2020] [Accepted: 07/13/2020] [Indexed: 01/08/2023]
Abstract
BACKGROUND There is significant morbidity after diverting ileostomy closure, so identifying predictors of complications could be of great benefit. The aim of our study was to evaluate the incidence and risk factors for postoperative morbidity after elective ileostomy closure. METHODS The ACS-NSQIP dataset was evaluated for elective ileostomy closures from 1/1/2015 to 12/31/2016. Demographic characteristics, operative, and postoperative outcomes were evaluated. The primary outcome was 30-day major morbidity (Clavien class III and greater). Secondary outcomes were rates and predictors of major morbidity, superficial site infection (SSI), reoperation, and readmission from multivariate logistic regression modeling. RESULTS We retrospectively evaluated 1885 patients. The median operative time was 65 (IQR 50-90) minutes and median length of stay was 3 (IQR 2-5) days. Major morbidity was recorded in 6.7%, including mortality (1.0%), deep/organ space SSI (2.6%), dehiscence (0.8%), reintubation (0.5%), sepsis (1.7%), septic shock (0.8%), and reoperation (3.7%). Readmission was recorded in 9.7% and 6.2% had SSI. Multivariate logistic regression showed male sex (OR 1.584; 95% CI 1.068-2.347; p = 0.022) and longer operative time (OR 1.004; 95% CI 1.001-1.007; p = 0.009) were among those variables associated with increased odds of major morbidity. Dyspnea (OR 2.431; 95% CI 1.139-5.094; p = 0.021) and longer operative time (OR 1.003; 95% CI 1.001-1.007; p = 0.034) were among the independent risk factors for SSI. Male sex (OR 2.246; 95% CI 1.297-3.892; p = 0.004, chronic obstructive pulmonary disease (OR 2.959; 95% CI 1.153-7.591; p = 0.024), and longer operative time (OR 1.005; 95% CI 1.001-1.009; p = 0.011) were associated with increased odds of reoperation. Chronic obstructive pulmonary disease (OR 2.578; 95% CI 1.338-4.968; p = 0.005), wound infection (OR 2.680; 95% CI 1.043-6.890; p = 0.041), and inflammatory bowel disease (OR 2.565; 95% CI 1.203-5.463; p = 0.015) were associated with increased odds of readmission. CONCLUSIONS Elective stoma closure has significant risk of morbidity. Patients with longer operative times were at increased risk for major morbidity, overall SSI, and reoperation. From the analysis, factors specifically associated with major morbidity, overall infectious complications, readmissions, and reoperations were identified. This information can be used to prospectively prepare for these high-risk patients, potentially improving postoperative outcomes.
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Affiliation(s)
- T R de Paula
- Division of Colorectal Surgery, Department of Surgery, Columbia University Medical Center, New York, NY, USA
| | - S Nemeth
- Columbia HeartSource, Department of Surgery, Center for Innovation and Outcomes Research, Columbia University Medical Center, New York, NY, USA
| | - R P Kiran
- Division of Colorectal Surgery, Department of Surgery, Columbia University Medical Center, New York, NY, USA
| | - D S Keller
- Division of Colorectal Surgery, Department of Surgery, Columbia University Medical Center, New York, NY, USA. .,Division of Colon and Rectal Surgery, Department of Surgery, Herbert Irving Comprehensive Cancer Center, NewYork-Presbyterian, Columbia University Medical Center, Herbert Irving Pavilion, 161 Fort Washington Avenue, 8th Floor, New York, NY, 10032, USA.
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Chen Y, Yu Q, Farraye FA, Kochhar GS, Bernstein CN, Navaneethan U, Wu K, Zhong J, Schwartz DA, Wu H, Zheng JJ, Iacucci M, Kiran RP, Shen B. Patterns of endoscopy during COVID-19 pandemic: a global survey of interventional inflammatory bowel disease practice. Intest Res 2020; 19:332-340. [PMID: 32475088 PMCID: PMC8322031 DOI: 10.5217/ir.2020.00037] [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] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/25/2020] [Accepted: 05/13/2020] [Indexed: 01/05/2023] Open
Abstract
Background/Aims Performance of diagnostic or therapeutic endoscopic procedures in inflammatory bowel disease (IBD) patients can be challenging during a viral pandemic; the main concerns being the safety and protection of patients and health care providers (HCP). The aim of this study is to identify endoscopic practice patterns and outcomes of IBD and coronavirus disease 19 (COVID-19) with a worldwide survey of HCP. Methods The 20-item survey questionnaire was sent to physician members of the American Society for Gastrointestinal Endoscopy Special Interest Group in Interventional IBD, Chinese IBD Society Endoscopy Interest Group, and the China Crohn’s and Colitis Foundation. Results A total of 141 respondents submitted valid responses. Nighty-five respondents (67.9%) reported that at least 25% of their scheduled emergent endoscopic procedures were canceled or postponed during the pandemic. Fifty-six respondents (40.0%) have performed emergent endoscopy during the pandemic. A few respondents (9/140, 6.4%) estimated that more than 25% of their patients had worsened disease due to delayed or canceled emergent endoscopy procedures. More than 80% of respondents believed that personal protective equipment (PPE) for the endoscopy team, room sterilization, and pre-procedure screening of patients for COVID-19 were necessary. Out of 140 respondents, 16 (11.4%) reported that several of their patients had COVID-19. Eight clinicians (5.7%) reported that they or their endoscopy colleagues developed work-related COVID-19. Conclusions Cancellation of elective and emergent endoscopy in IBD care during the pandemic was common. Few respondents reported that their patients’ disease conditions worsened due to the cancellation of the endoscopy procedure. Most respondents voiced the need for proper PPE during the procedure regardless of patients’ COVID-19 status and screening the patients for COVID-19.
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Affiliation(s)
- Yan Chen
- Center for Infllammatory Bowel Diseases, Department of Gastroenterology, The 2nd Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, China
| | - Qiao Yu
- Center for Infllammatory Bowel Diseases, Department of Gastroenterology, The 2nd Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, China
| | - Francis A Farraye
- Department Gastroenterology and Hepatology, Mayo Clinic Florida, Jacksonville, FL, USA
| | - Gursimran S Kochhar
- Department of Gastroenterology, Allegheny General Hospital, Pittsburgh, PA, USA
| | - Charles N Bernstein
- Section of Gastroenterology, University of Manitoba IBD Clinical and Research Center, Winnepeg, MB, Canada
| | | | - Kaicun Wu
- Department of Gastroenterology, Xijin Hospital, The Fourth Military Medical University, Xi'an, China
| | - Jie Zhong
- Department of Gastroenterology, Ruijin Hospital of Shanghai Jiaotong University, Shanghai, China
| | - David A Schwartz
- Department of Gastroenterology, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Hao Wu
- Department of Gastroenterology, Zhongshan Hospital of Fudan University, Shanghai, China
| | | | - Marietta Iacucci
- Institute of Translational Medicine, Institute of immunology and immunotherapy and NIHR Biomedical Research Centre, University of Birmingham and University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Ravi P Kiran
- Division of Colorectal Surgery, Columbia University Irving Medical Center, New York-Presbyterian Hospital, New York, NY, USA
| | - Bo Shen
- Center for Inflammatory Bowel Disease, Columbia University Irving Medical Center, New York-Presbyterian Hospital, New York, NY, USA
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Chen Y, Hu S, Wu H, Farraye FA, Bernstein CN, Zheng JJ, Kiran RP, Shen B. Patterns of care for inflammatory bowel disease in China during the COVID-19 pandemic. Lancet Gastroenterol Hepatol 2020; 5:632-634. [PMID: 32411921 PMCID: PMC7220174 DOI: 10.1016/s2468-1253(20)30131-x] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/23/2020] [Revised: 04/26/2020] [Accepted: 04/27/2020] [Indexed: 12/26/2022]
Affiliation(s)
- Yan Chen
- Center of Inflammatory Bowel Disease, Department of Gastroenterology, the Second Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, China
| | - Shurong Hu
- Center of Inflammatory Bowel Disease, Department of Gastroenterology, the Second Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, China
| | - Hao Wu
- Department of Gastroenterology, Zhongshan Hospital of Fudan University, Shanghai, China
| | - Francis A Farraye
- Department of Gastroenterology and Hepatology, Mayo Clinic Florida, Jacksonville, FL, USA
| | - Charles N Bernstein
- University of Manitoba IBD Clinical and Research Centre, Section of Gastroenterology, Winnipeg, MB, Canada
| | | | - Ravi P Kiran
- Division of Colorectal Surgery, Columbia University Irving Medical Center/New York-Presbyterian Hospital, New York, NY 10032, USA
| | - Bo Shen
- Center for Inflammatory Bowel Disease, Columbia University Irving Medical Center/New York-Presbyterian Hospital, New York, NY 10032, USA.
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Reif de Paula T, Simon H, Shah M, Lee-Kong S, Kiely JM, Kiran RP, Keller DS. Analysis of the impact of EEA stapler size on risk of anastomotic complications in colorectal anastomosis: does size matter? Tech Coloproctol 2020; 24:283-290. [PMID: 32036461 DOI: 10.1007/s10151-020-02155-3] [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: 10/14/2019] [Accepted: 01/29/2020] [Indexed: 01/19/2023]
Abstract
BACKGROUND Colorectal anastomotic complications are dreaded and dramatically affect outcomes. Causes are multifactorial, with the size of the end-to-end anastomosis (EEA) stapler a modifiable factor and potential target for risk reduction. Our goal was to examine the impact of the EEA stapler size on the risk of anastomotic complications in left-sided colorectal resections. METHODS A prospective divisional database was reviewed for consecutive elective left-sided resections with a colorectal anastomosis using an EEA stapler from January 2013 May 2018 inclusive. Patients were stratified into 25-29 mm or 30-33 mm cohorts. Patient and disease demographics, operative variables, and postoperative outcomes were evaluated. The main outcome measures were the rate and factors associated with anastomotic complications. RESULTS Four hundred seventy-three cases were evaluated, 185 ( 39.1%) were in the 25-29 mm group and 288 (60.9%) in the 30-33 mm group. Patients were comparable in demographics and operative variables. More males were anastomosed with the 30-33 mm than with the 25-29 mm stapler (57.6% vs 28.6%, p < 0.01). Significantly more patients developed an anastomotic stricture with the 25-29 mm than with the 30-33 mm staplers (7.1% vs. 2.1%; p = 0.007). There was no significant difference in leak rates or reoperation/interventions between groups. On logistic regression, neither gender, operative indication nor approach were associated with anastomotic leak, readmission, or reoperation/intervention. Stapler size remained significantly associated with stricture (p = 0.032). CONCLUSIONS The 25-29 mm EEA staplers were associated with an increased rate of anastomotic stricture compared to 30-33 mm staplers in left-sided colorectal anastomoses. As stapler size is a simple process measure that is easily modifyable, this is a potential target for improving anastomotic complication rates. Further controlled trials may help assess the impact of stapler size on improving patient and quality outcomes.
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Affiliation(s)
- T Reif de Paula
- Division of Colorectal Surgery, Division of Colon and Rectal Surgery, Department of Surgery NewYork-Presbyterian, Columbia University Medical Center, 161 Fort Washington Avenue, 8th Floor, Herbert Irving PavilionNew York, NY, 10032, USA
| | - H Simon
- Division of Colorectal Surgery, Division of Colon and Rectal Surgery, Department of Surgery NewYork-Presbyterian, Columbia University Medical Center, 161 Fort Washington Avenue, 8th Floor, Herbert Irving PavilionNew York, NY, 10032, USA
| | - M Shah
- Department of Surgery, Columbia University Medical Center, New York, NY, USA
| | - S Lee-Kong
- Division of Colorectal Surgery, Division of Colon and Rectal Surgery, Department of Surgery NewYork-Presbyterian, Columbia University Medical Center, 161 Fort Washington Avenue, 8th Floor, Herbert Irving PavilionNew York, NY, 10032, USA
| | - J M Kiely
- Division of Colorectal Surgery, Division of Colon and Rectal Surgery, Department of Surgery NewYork-Presbyterian, Columbia University Medical Center, 161 Fort Washington Avenue, 8th Floor, Herbert Irving PavilionNew York, NY, 10032, USA
| | - R P Kiran
- Division of Colorectal Surgery, Division of Colon and Rectal Surgery, Department of Surgery NewYork-Presbyterian, Columbia University Medical Center, 161 Fort Washington Avenue, 8th Floor, Herbert Irving PavilionNew York, NY, 10032, USA
| | - D S Keller
- Division of Colorectal Surgery, Division of Colon and Rectal Surgery, Department of Surgery NewYork-Presbyterian, Columbia University Medical Center, 161 Fort Washington Avenue, 8th Floor, Herbert Irving PavilionNew York, NY, 10032, USA.
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Keller DS, Qiu J, Kiran RP. A National study on the adoption of laparoscopic colorectal surgery in the elderly population: current state and value proposition. Tech Coloproctol 2019; 23:965-972. [PMID: 31598786 DOI: 10.1007/s10151-019-02082-y] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/21/2019] [Accepted: 09/07/2019] [Indexed: 12/19/2022]
Abstract
BACKGROUND The economic and clinical benefits of laparoscopic colorectal surgery are proven, yet may be underutilized in appropriate cases, especially in the elderly. Since the elderly constitute the greatest colorectal surgical volume, our goal was to identify trends in utilization and impact of laparoscopy in this cohort. METHODS A national review of elective inpatient colorectal resections from the Premier Inpatient Database between 2010 and 2015 was performed. Patients were included if elderly (≥ 65 years), then grouped into open or laparoscopic procedures. The main outcome measures were trends in utilization by approach and total costs for the episode of care, length of stay (LOS), readmission, and complications by approach in the elderly. Multivariable regression models controlled for differences across platforms, adjusting for patient demographic, comorbidities and hospital characteristics. RESULTS In 70,655 elderly patients evaluated, laparoscopic adoption remained lower than open throughout the study period. Rates increased until 2013, then declined, with increasing rates of open surgery. Laparoscopy was associated with significantly lower mean total costs ($4012 less/case), complications and readmissions (36% and 33% less, respectively), and shorter LOS (2.6 less days) than open cases (all p < 0.0001). When complications occurred, they were less severe and the readmission episodes were less costly with laparoscopy than open colorectal surgery. CONCLUSION The adoption of laparoscopy in the elderly has lagged behind open surgery and even declined in recent years despite being associated with improved clinical outcomes and reduced cost. With this tremendous value proposition to increase use of laparoscopic surgery in the elderly, further work needs to evaluate root causes of the disparity.
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Affiliation(s)
- D S Keller
- Division of Colon and Rectal Surgery, Department of Surgery, NewYork-Presbyterian, Columbia University Medical Center, Herbert Irving Pavilion, 161 Fort Washington Avenue, 8th Floor, New York, NY, 10032, USA.
| | - J Qiu
- Minimally Invasive Therapies Group, Medtronic, Inc., Boulder, CO, USA
| | - R P Kiran
- Division of Colorectal Surgery, Department of Surgery, Columbia University Medical Center, New York, NY, USA
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Keller DS, Reif de Paula T, Kiely JM, Kiran RP. Adoption of Laparoscopic Surgery for Colorectal Cancer in the Elderly: Current State and Value Proposition. J Am Coll Surg 2019. [DOI: 10.1016/j.jamcollsurg.2019.08.862] [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: 10/25/2022]
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Keller DS, Reif de Paula T, Kiran RP. Ready for the National Accreditation Programs for Rectal Cancer? Auditing rectal cancer outcomes in the United States. Colorectal Dis 2019; 21:1213-1215. [PMID: 31206230 DOI: 10.1111/codi.14729] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/23/2019] [Accepted: 05/28/2019] [Indexed: 12/13/2022]
Affiliation(s)
- D S Keller
- Division of Colorectal Surgery, Department of Surgery, Columbia University Medical Center, New York, New York, USA
| | - T Reif de Paula
- Division of Colorectal Surgery, Department of Surgery, Columbia University Medical Center, New York, New York, USA
| | - R P Kiran
- Division of Colorectal Surgery, Department of Surgery, Columbia University Medical Center, New York, New York, USA
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de Paula TR, Nemeth SK, Kiran RP, Keller DS. Evaluating the Association of the New ACS-NSQIP Modified 5-Factor Frailty Index and Outcomes in Elective Colorectal Surgery. J Am Coll Surg 2019. [DOI: 10.1016/j.jamcollsurg.2019.08.148] [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: 11/28/2022]
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de Paula TR, Keller DS, Gorroochurn P, Kiran RP. Does Adjuvant Chemotherapy Improve Survival in T3N0 Rectal Cancer? An Evaluation of Use and Outcomes from the National Cancer Database. J Am Coll Surg 2019. [DOI: 10.1016/j.jamcollsurg.2019.08.141] [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: 10/25/2022]
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Keller DS, Reif de Paula T, Kiely JM, Kiran RP. Predictors of High Use and Variability in Opioid Utilization after Laparoscopic Colorectal Surgery. J Am Coll Surg 2019. [DOI: 10.1016/j.jamcollsurg.2019.08.867] [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: 10/25/2022]
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Keller DS, Reif de Paula T, Yu G, Zhang H, Al-Mazrou A, Kiran RP. Statistical Process Control (SPC) to drive improvement in length of stay after colorectal surgery. Am J Surg 2019; 219:1006-1011. [PMID: 31537326 DOI: 10.1016/j.amjsurg.2019.08.029] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [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: 08/04/2019] [Revised: 08/19/2019] [Accepted: 08/28/2019] [Indexed: 10/26/2022]
Abstract
BACKGROUND Novel quality improvement(QI) methods are needed to optimize healthcare costs and value. Our goal was to determine if Statistical Process Control(SPC), an industrial QI tool, could transform length of stay(LOS) into a process measure, identify outliers, and their impact on surgical outcomes. METHODS SPC was performed on an institutional colorectal resection database 1/1/13-5/1/2018 to identify outliers and compare outcome variables across outliers and non-outliers. Control charts analyzed the process performance of LOS over time. Control limits were set at ± 1 standard deviation(SD) from the mean. Measures were stable within these limits. RESULTS LOS was stable, with consistent annual rates and variation of outliers. Outliers had identifiable causes of variation that were significantly different from non-outliers(p < 0.05). The variation resulted in more complications, readmissions, and reoperations in outliers(p < 0.05). CONCLUSIONS SPC can be applied to LOS, a stable process measure with decreasing variability over time, and easy outlier identification. Identifying outliers can facilitate targeted quality improvement.
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Affiliation(s)
- Deborah S Keller
- Division of Colorectal Surgery, Columbia University Medical Center, New York, NY, USA.
| | - Thais Reif de Paula
- Division of Colorectal Surgery, Columbia University Medical Center, New York, NY, USA.
| | - Guanying Yu
- Division of Colorectal Surgery, Columbia University Medical Center, New York, NY, USA.
| | - Haiqing Zhang
- Division of Colorectal Surgery, Columbia University Medical Center, New York, NY, USA.
| | - Ahmed Al-Mazrou
- Division of Colorectal Surgery, Columbia University Medical Center, New York, NY, USA.
| | - Ravi P Kiran
- Division of Colorectal Surgery, Columbia University Medical Center, New York, NY, USA.
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Affiliation(s)
- K Gash
- Division of Colorectal Surgery, New York Presbyterian Hospital/Columbia University Medical Center, New York, New York, USA.,Department of Colorectal Surgery, North Bristol NHS Trust, Bristol, UK
| | - R P Kiran
- Mailman School of Public Health, Center for Innovations and Outcomes Research, Columbia University, New York, New York, USA
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Hyde LZ, Baser O, Mehendale S, Guo D, Shah M, Kiran RP. Impact of surgical approach on short-term oncological outcomes and recovery following low anterior resection for rectal cancer. Colorectal Dis 2019; 21:932-942. [PMID: 31062521 DOI: 10.1111/codi.14677] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [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: 12/10/2018] [Accepted: 04/08/2019] [Indexed: 12/11/2022]
Abstract
AIM The aim was to evaluate the influence of operative approach for low anterior resection (LAR) on oncological and postoperative outcomes. Minimally invasive surgical approaches are increasingly used for the treatment of rectal cancer with mixed outcomes. METHOD We compared patients undergoing LAR in the National Cancer Database between 2010 and 2015 by surgical approach. Multivariable regression was used to identify risk factors associated with conversion rate, prolonged length of stay (LOS) and 30-day unplanned readmission. RESULTS During the study period, 41 282 patients underwent LAR: 6035 robotic-assisted (RLAR) (14.6%), 13 826 laparoscopic (LLAR) (33.5%) and 21 421 open (OLAR) (51.9%). In propensity score matched analysis, RLAR compared to LLAR was associated with shorter LOS (6.3 vs 6.8 days, P < 0.0001), lower risk of prolonged LOS (22.1% vs 25.6%, P < 0.0001) and lower rate of conversion to open (7.5% vs 14.95%, P < 0.0001). Compared to OLAR, RLAR had shorter LOS (6.3 vs 7.8 days, P < 0.0001) and less prolonged LOS (14.1% vs. 20.9%, P < 0.0001). In multivariable analysis, for conversion to open, the laparoscopic approach was one of the risk factors; for prolonged LOS, conversion to open and non-robotic approaches (i.e. LLAR and OLAR) were risk factors; and for unplanned 30-day readmission, conversions and prolonged LOS were risk factors. CONCLUSIONS For patients with rectal cancer, RLAR shows recovery benefits over both open and laparoscopic LAR with reduced conversion to open compared with LLAR and less prolonged LOS compared with LLAR and OLAR. RLAR is associated with short-term oncological outcomes comparable to OLAR, supporting its use in minimally invasive surgery for rectal cancer.
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Affiliation(s)
- L Z Hyde
- Division of Colorectal Surgery, Columbia University Medical Center/New York Presbyterian Hospital, New York City, New York, USA
| | - O Baser
- Center for Innovation and Outcomes Research, Columbia University Medical Center, New York City, New York, USA
| | - S Mehendale
- Clinical Affairs, Intuitive Surgical, Sunnyvale, California, USA
| | - D Guo
- Clinical Affairs, Intuitive Surgical, Sunnyvale, California, USA
| | - M Shah
- Clinical Affairs, Intuitive Surgical, Sunnyvale, California, USA
| | - R P Kiran
- Division of Colorectal Surgery, Columbia University Medical Center/New York Presbyterian Hospital, New York City, New York, USA.,Center for Innovation and Outcomes Research, Columbia University Medical Center, New York City, New York, USA
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Raab GT, O'Neil DS, Kiran RP, Feingold DL, Lee-Kong SA, Horowitz DP, Neugut AI. Elevation of Serum CEA in Patients with Squamous Cell Carcinoma of the Anus. Cancer Invest 2019; 37:288-292. [PMID: 31319725 DOI: 10.1080/07357907.2019.1636388] [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] [Indexed: 10/26/2022]
Abstract
The proportion of anal cancer cases that produce elevated carcinoembryonic antigen (CEA) levels is not well described in the medical literature. In this study, we used electronic health record data from a single urban cancer center to identify patients from 2004-2018 with anal cancer who have also had a pre-initial treatment CEA measurement. We identified 40 patients who met our eligibility criteria. Of those, 11 (27.5%) had an elevated pretreatment CEA. Elevated CEA was not associated with any of the clinical or demographic covariates; however, three out of five patients with a recurrence had an elevated CEA.
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Affiliation(s)
- Gabriel T Raab
- Department of Epidemiology, Mailman School of Public Health, Columbia University , New York , New York , USA
| | - Daniel S O'Neil
- Department of Medicine, College of Physicians and Surgeons, Columbia University , New York , New York , USA
| | - Ravi P Kiran
- Department of Epidemiology, Mailman School of Public Health, Columbia University , New York , New York , USA.,Herbert Irving Comprehensive Cancer Center, College of Physicians and Surgeons, Columbia University , New York , New York , USA.,Department of Surgery, College of Physicians and Surgeons, Columbia University , New York , New York , USA
| | - Daniel L Feingold
- Herbert Irving Comprehensive Cancer Center, College of Physicians and Surgeons, Columbia University , New York , New York , USA.,Department of Surgery, College of Physicians and Surgeons, Columbia University , New York , New York , USA
| | - Steven A Lee-Kong
- Herbert Irving Comprehensive Cancer Center, College of Physicians and Surgeons, Columbia University , New York , New York , USA.,Department of Surgery, College of Physicians and Surgeons, Columbia University , New York , New York , USA
| | - David P Horowitz
- Herbert Irving Comprehensive Cancer Center, College of Physicians and Surgeons, Columbia University , New York , New York , USA.,Department of Radiation Oncology, Columbia University College of Physicians and Surgeons , New York , New York , USA
| | - Alfred I Neugut
- Department of Epidemiology, Mailman School of Public Health, Columbia University , New York , New York , USA.,Department of Medicine, College of Physicians and Surgeons, Columbia University , New York , New York , USA.,Herbert Irving Comprehensive Cancer Center, College of Physicians and Surgeons, Columbia University , New York , New York , USA
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Abstract
Crohn's disease is a chronic, inflammatory bowel condition that can affect the entire digestive tract and in many cases lead to enteric fistula formation. The management of enteric fistulas can be challenging and often requires a multidisciplinary approach.
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Affiliation(s)
| | - Ravi P Kiran
- Columbia University Medical Center and Mailman School of Public Health, New York Presbyterian Hospital-Columbia, New York, New York
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Raab GT, Lin A, Hillyer GC, Keller D, O'Neil DS, Accordino MK, Buono DL, Hur C, Kiran RP, Wright JD, Hershman DL, Neugut AI. Use of Bevacizumab for Elderly Patients With Stage IV Colon Cancer: Analysis of SEER-Medicare Data. Clin Colorectal Cancer 2019; 18:e294-e299. [PMID: 31266707 DOI: 10.1016/j.clcc.2019.05.008] [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] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2019] [Revised: 05/28/2019] [Accepted: 05/30/2019] [Indexed: 12/21/2022]
Abstract
BACKGROUND Bevacizumab is used for the treatment of metastatic colon cancer in conjunction with first-line chemotherapy. In this study, we examined receipt of first-line bevacizumab and predictors of its use among older patients with stage IV colon cancer. MATERIALS AND METHODS We used data from the Surveillance, Epidemiology, and End Results-Medicare dataset to identify patients with stage IV colon cancer diagnosed from 2005 to 2013 who received FOLFOX (5-fluorouracil/leucovorin/oxaliplatin) or FOLFIRI (5-fluorouracil/leucovorin/irinotecan) as first-line therapy. We used multivariable regression analysis to determine demographic and clinical factors associated with use of concomitant bevacizumab. RESULTS We identified 3785 patients with stage IV colon cancer who met our eligibility criteria. Of these, 2352 (62.1%) received bevacizumab. Bevacizumab use has decreased over time from 68.2% in 2005 to 57.6% in 2013 (odds ratio [OR], 0.94; 95% confidence interval [CI], 0.91-0.97). Patients were less likely to receive bevacizumab if they were older (compared with 65-69 years, ≥ 80 years: OR, 0.64; 95% CI, 0.52-0.80), or had multiple comorbidities (compared with comorbidity score of 0, score of 1: OR, 0.73; 95% CI, 0.60-0.89). CONCLUSION Over one-half of elderly patients received bevacizumab as part of their first-line therapy for stage IV colon cancer. Bevacizumab use has been slowly decreasing since 2005. Newer anti-epidermal growth factor receptor treatments have not been supplanting bevacizumab, as first-line biologic use in general has also decreased during this time period.
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Affiliation(s)
- Gabriel T Raab
- Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, NY
| | - Aijing Lin
- Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, NY
| | - Grace Clarke Hillyer
- Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, NY; Herbert Irving Comprehensive Cancer Center, Vagelos College of Physicians and Surgeons, Columbia University, New York, NY
| | - Deborah Keller
- Department of Surgery, Vagelos College of Physicians and Surgeons, Columbia University, New York, NY
| | - Daniel S O'Neil
- Department of Medicine, Vagelos College of Physicians and Surgeons, Columbia University, New York, NY
| | - Melissa Kate Accordino
- Herbert Irving Comprehensive Cancer Center, Vagelos College of Physicians and Surgeons, Columbia University, New York, NY; Department of Medicine, Vagelos College of Physicians and Surgeons, Columbia University, New York, NY
| | - Donna L Buono
- Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, NY
| | - Chin Hur
- Herbert Irving Comprehensive Cancer Center, Vagelos College of Physicians and Surgeons, Columbia University, New York, NY; Department of Medicine, Vagelos College of Physicians and Surgeons, Columbia University, New York, NY
| | - Ravi P Kiran
- Herbert Irving Comprehensive Cancer Center, Vagelos College of Physicians and Surgeons, Columbia University, New York, NY; Department of Surgery, Vagelos College of Physicians and Surgeons, Columbia University, New York, NY
| | - Jason D Wright
- Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, NY; Herbert Irving Comprehensive Cancer Center, Vagelos College of Physicians and Surgeons, Columbia University, New York, NY; Department of Obstetrics and Gynecology, Vagelos College of Physicians and Surgeons, Columbia University, New York, NY
| | - Dawn L Hershman
- Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, NY; Herbert Irving Comprehensive Cancer Center, Vagelos College of Physicians and Surgeons, Columbia University, New York, NY; Department of Medicine, Vagelos College of Physicians and Surgeons, Columbia University, New York, NY
| | - Alfred I Neugut
- Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, NY; Herbert Irving Comprehensive Cancer Center, Vagelos College of Physicians and Surgeons, Columbia University, New York, NY; Department of Medicine, Vagelos College of Physicians and Surgeons, Columbia University, New York, NY.
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Al-Mazrou AM, Haiqing Z, Guanying Y, Kiran RP. Sustained positive impact of ACS-NSQIP program on outcomes after colorectal surgery over the last decade. Am J Surg 2019; 219:197-205. [PMID: 31128841 DOI: 10.1016/j.amjsurg.2019.05.001] [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] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2019] [Revised: 04/28/2019] [Accepted: 05/07/2019] [Indexed: 12/16/2022]
Abstract
BACKGROUND We evaluate trends in outcomes after colorectal resection over the decade of the introduction of ACS-NSQIP as well as of targeted-colectomy information. STUDY DESIGN From 2007 to 2016, patients undergoing non-emergent colorectal procedures were included. Demographics, operative complexity (American Society of Anesthesiologists and wound classes); complications, early (<5 days) discharge and mortality were plotted over years. Outcomes after introduction of colectomy-targeted datasets (2013-2016) were compared to those prior (2007-2012). Multivariable analyses were performed to evaluate the impact of colectomy-targeted data on outcomes. RESULTS Of 310,632 included procedures, 131,122(42.2%) and 179,510(57.8%) were performed before and after the introduction of colectomy-targeted variables respectively. Most complications including surgical site and urinary tract infections, sepsis, septic shock, venous thromboembolism, respiratory complications, reoperation and mortality reduced over time with increased early discharge. On multivariable analysis, introduction of colectomy-targeted data was associated with lower surgical site (OR = 0.78,95%CI = [0.77-0.80]); systemic (OR = 0.94,95%CI = [0.91-0.98]) and urinary tract (OR = 0.70,95%CI = [0.67-0.74]) infections; reoperation (OR = 0.88,95%CI = [0.85-0.91]) and early discharge (OR = 1.60,95%CI = [1.57-1.63]). CONCLUSION Over its first decade of introduction, ACS-NSQIP has been associated with improved outcomes after colorectal surgery. The introduction of colectomy-targeted data has further improved outcomes.
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Affiliation(s)
- Ahmed M Al-Mazrou
- Division of Colorectal Surgery, NewYork-Presbyterian Hospital, Columbia University Medical Center, Herbert Irving Pavilion, 161 Fort Washington Avenue, Floor 8, New York, NY, 10032, United States
| | - Zhang Haiqing
- Division of Colorectal Surgery, NewYork-Presbyterian Hospital, Columbia University Medical Center, Herbert Irving Pavilion, 161 Fort Washington Avenue, Floor 8, New York, NY, 10032, United States
| | - Yu Guanying
- Division of Colorectal Surgery, NewYork-Presbyterian Hospital, Columbia University Medical Center, Herbert Irving Pavilion, 161 Fort Washington Avenue, Floor 8, New York, NY, 10032, United States
| | - Ravi P Kiran
- Division of Colorectal Surgery, NewYork-Presbyterian Hospital, Columbia University Medical Center, Herbert Irving Pavilion, 161 Fort Washington Avenue, Floor 8, New York, NY, 10032, United States.
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Kim M, Kiran RP, Li G. Acute kidney injury after hepatectomy can be reasonably predicted after surgery. J Hepatobiliary Pancreat Sci 2019; 26:144-153. [PMID: 30793845 DOI: 10.1002/jhbp.615] [Citation(s) in RCA: 10] [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] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND Hepatectomy presents unique challenges potentially heightening acute kidney injury (AKI) risk, but the full spectrum of risk factors has not been identified. METHODS Data for hepatectomy patients in the 2016 American College of Surgeons National Surgical Quality Improvement Program (n = 3,814) was randomly split into derivation (70%) and validation (30%) cohorts. AKI was defined as an increase in serum creatinine ≥0.3 mg/dl or ≥1.5-fold above the preoperative value within 30 days of surgery. Multivariable logistic regression assessed preoperative and intraoperative risk factors for AKI. RESULTS Of 2,692 patients (derivation cohort), 432 (16%) developed AKI. Risk factors were the following: age (years; adjusted odds ratio [aOR] 1.016 [95% confidence interval 1.006-1.026], female sex (aOR 0.65 [0.51-0.82]), body mass index (kg/m2 ; aOR 1.043 [1.024-1.062]), diabetes (aOR 1.71 [1.31-2.24]), hypertension (aOR 1.66 [1.30-2.13]), hematocrit (%; aOR 0.944 [0.924-0.966]), operative time (min; aOR 1.004 [1.003-1.004]), planned open procedure (aOR 2.00 [1.47-2.73]), and Pringle maneuver (aOR 1.36 [1.07-1.72]). The areas under the curve of the receiver operating characteristic curves were 0.74 (95% CI 0.71-0.76) and 0.71 (95% CI 0.67-0.75) in the derivation and validation cohorts, respectively. CONCLUSIONS Postoperative AKI affects one in six hepatectomy patients; preoperative and intraoperative factors can predict the risk of postoperative AKI.
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Affiliation(s)
- Minjae Kim
- Department of Anesthesiology, Columbia University Medical Center, 622 West 168th Street, PH 5, Suite 505C, New York, NY 10032, USA.,Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, NY, USA
| | - Ravi P Kiran
- Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, NY, USA.,Department of Surgery, Columbia University Medical Center, New York, NY, USA
| | - Guohua Li
- Department of Anesthesiology, Columbia University Medical Center, 622 West 168th Street, PH 5, Suite 505C, New York, NY 10032, USA.,Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, NY, USA
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Neugut AI, Lin A, Raab GT, Hillyer GC, Keller D, O'Neil DS, Accordino MK, Kiran RP, Wright J, Hershman DL. FOLFOX and FOLFIRI Use in Stage IV Colon Cancer: Analysis of SEER-Medicare Data. Clin Colorectal Cancer 2019; 18:133-140. [PMID: 30878317 DOI: 10.1016/j.clcc.2019.01.005] [Citation(s) in RCA: 32] [Impact Index Per Article: 6.4] [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: 12/27/2018] [Revised: 01/23/2019] [Accepted: 01/25/2019] [Indexed: 12/11/2022]
Abstract
BACKGROUND Shortly after the year 2000, randomized trials demonstrated that patients with metastatic colon cancer treated with infusional 5-fluorouracil (5-FU)/leucovorin with either oxaliplatin (FOLFOX) or irinotecan (FOLFIRI) had a comparable progression-free survival benefit, superior to patients who received 5-FU/leucovorin alone. Factors associated with the initial receipt of the FOLFOX or FOLFIRI regimen are unknown. Our goal was to investigate the patterns and predictors of use for first-line FOLFOX and FOLFIRI. PATIENTS AND METHODS We used the Surveillance, Epidemiology, and End Results (SEER)-Medicare linked data set to identify patients with newly diagnosed stage IV colon cancer between the years 2005 and 2013 who received either first-line FOLFOX or FOLFIRI. We used logistic regression to assess demographic and clinical predictors for FOLFOX versus FOLFIRI. Survival was compared by Kaplan-Meier models. RESULTS Overall, 3000 patients (79.3%) received FOLFOX and 785 (20.7%) FOLFIRI. FOLFOX was associated with later year of diagnosis (odds ratio [OR] = 0.66, 95% confidence interval [CI], 0.54 to 0.82 for 2011-2013 vs. 2005-2007), being female (OR = 0.82; 95% CI 0.69 to 0.98), and living in the southern region of the United States. FOLFIRI was associated with having a higher comorbidity index (OR = 1.33; 95% CI, 1.07 to 1.67 for >1 comorbidity score vs. 0). There was no survival difference observed between the two treatments. CONCLUSION The majority of SEER-Medicare patients received FOLFOX and not FOLFIRI as a first-line treatment for stage IV colon cancer. Several demographic and clinical factors were associated with the use of each specific regimen. No survival difference was detected for the 2 groups.
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Affiliation(s)
- Alfred I Neugut
- Herbert Irving Comprehensive Cancer Center, Vagelos College of Physicians and Surgeons, Columbia University, New York, NY; Department of Medicine, Vagelos College of Physicians and Surgeons, Columbia University, New York, NY; Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, NY.
| | - Aijing Lin
- Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, NY
| | - Gabriel T Raab
- Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, NY
| | - Grace Clarke Hillyer
- Herbert Irving Comprehensive Cancer Center, Vagelos College of Physicians and Surgeons, Columbia University, New York, NY; Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, NY
| | - Deborah Keller
- Department of Surgery, Vagelos College of Physicians and Surgeons, Columbia University, New York, NY
| | - Daniel S O'Neil
- Department of Medicine, Vagelos College of Physicians and Surgeons, Columbia University, New York, NY
| | - Melissa Kate Accordino
- Herbert Irving Comprehensive Cancer Center, Vagelos College of Physicians and Surgeons, Columbia University, New York, NY; Department of Medicine, Vagelos College of Physicians and Surgeons, Columbia University, New York, NY
| | - Ravi P Kiran
- Herbert Irving Comprehensive Cancer Center, Vagelos College of Physicians and Surgeons, Columbia University, New York, NY; Department of Surgery, Vagelos College of Physicians and Surgeons, Columbia University, New York, NY
| | - Jason Wright
- Herbert Irving Comprehensive Cancer Center, Vagelos College of Physicians and Surgeons, Columbia University, New York, NY; Department of Obstetrics and Gynecology, Vagelos College of Physicians and Surgeons, Columbia University, New York, NY; Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, NY
| | - Dawn L Hershman
- Herbert Irving Comprehensive Cancer Center, Vagelos College of Physicians and Surgeons, Columbia University, New York, NY; Department of Medicine, Vagelos College of Physicians and Surgeons, Columbia University, New York, NY; Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, NY
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Toledano S, Sackey J, Willcutts K, Parrott JS, Tomesko J, Al-Mazrou AM, Kiran RP, Brody RA. Exploring the Differences Between Early and Traditional Diet Advancement in Postoperative Feeding Outcomes in Patients With an Ileostomy or Colostomy. Nutr Clin Pract 2019; 34:631-638. [PMID: 30690780 DOI: 10.1002/ncp.10245] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [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: 11/06/2022] Open
Abstract
BACKGROUND We assessed the differences in postoperative feeding outcomes when comparing early and traditional diet advancement in patients who had an ostomy creation. METHODS At a U.S. tertiary care hospital, data from patients who underwent an ileostomy or colostomy creation from June 1, 2013, to April 30, 2017 were extracted from an institutional database. Patients who received early diet advancement (postoperative days 0 and 1) were compared with traditional diet advancement (postoperative day 2 and later) for demographics, preoperative risk factors, and operative features. The postoperative feeding outcomes included time to first flatus and ostomy output. Mann-Whitney U tests determined bivariate differences in postoperative feeding outcomes between groups. Poisson regression was used to adjust for unequal baseline characteristics. RESULTS Data from 255 patients were included; 204 (80.0%) received early diet advancement, and 51 (20.0%) had traditional diet advancement. Time to first flatus and time to first ostomy output were significantly shorter in the early compared with traditional diet advancement group (median difference of 1 day for both flatus and ostomy output, P < 0.001). Adjusting for baseline group differences (American Society for Anesthesiology Physical Status Classification System, surgical approach, resection and ostomy type) maintained the significant findings for both time to first flatus (β = 1.32, P = 0.01) and time to first ostomy output (β = 1.41, P < 0.001). CONCLUSIONS Early diet advancement is associated with earlier return of flatus and first ostomy output compared with traditional diet advancement after the creation of an ileostomy or colostomy.
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Affiliation(s)
- Sabrina Toledano
- Department of Nutritional Sciences, School of Health Professions, Rutgers University, Camden, New Jersey, USA
| | - Joachim Sackey
- Department of Nutritional Sciences, School of Health Professions, Rutgers University, Camden, New Jersey, USA
| | - Kate Willcutts
- University of Virginia Health System, Charlottesville, Virginia, USA
| | - J Scott Parrott
- Department of Interdisciplinary Studies, Rutgers University, Camden, New Jersey, USA
| | - Jennifer Tomesko
- Department of Nutritional Sciences, School of Health Professions, Rutgers University, Camden, New Jersey, USA
| | - Ahmed M Al-Mazrou
- NewYork-Presbyterian Hospital Columbia University Medical Center, New York, New York, USA
| | - Ravi P Kiran
- NewYork-Presbyterian Hospital Columbia University Medical Center, New York, New York, USA
| | - Rebecca A Brody
- Department of Nutritional Sciences, School of Health Professions, Rutgers University, Camden, New Jersey, USA
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48
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Al-Mazrou AM, Baser O, Kiran RP. Alvimopan, Regardless of Ileus Risk, Significantly Impacts Ileus, Length of Stay, and Readmission After Intestinal Surgery. J Gastrointest Surg 2018; 22:2104-2116. [PMID: 29987738 DOI: 10.1007/s11605-018-3846-2] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/14/2018] [Accepted: 06/13/2018] [Indexed: 01/31/2023]
Abstract
BACKGROUND Previous analyses evaluating alvimopan included patients at varying risk for ileus after intestinal resection, which may have precluded its widespread adoption. We assess the early and delayed effects of alvimopan in patients stratified by risk for ileus after intestinal and colon resection. METHODS From the Premier Perspective database, patients with elective small and large bowel resections from 2012 to 2014 were identified. Multivariable analysis identified 14 perioperative risk factors for postoperative ileus. Within low- (0-4 factors), intermediate- (5 factors), and high-risk (6-12 factors) ileus categories, alvimopan and no-alvimopan patients were propensity-score matched for demographics, morbidities, diagnosis, surgery and approach, postoperative complications, surgeon specialty, and hospital features. In-hospital postoperative ileus, length of stay, discharge destination, and ileus-related readmission were compared. RESULTS Of 52,948 patients, 15,719 (29.7%) received alvimopan. Risk for ileus in low- (18,784), intermediate- (14,370), and high-risk (19,794) categories was 8.9, 13, and 22% (p ≤ .0001) respectively. After matching, alvimopan was associated with significantly reduced in-hospital postoperative ileus in all (low, 6%; intermediate, 9.4%; and high risk, 16.2%) categories. Hospital stay and 30-, 60-, and 90-day postdischarge ileus were also significantly lower with alvimopan. For low-risk patients, alvimopan increased discharge to home, while 90-day emergency readmission was reduced. CONCLUSIONS Alvimopan, regardless of ileus risk, improves ileus, hospital stay, and ileus-related readmission after intestinal resection and these effects are sustained over the long term. Since fewer than a third of patients currently receive alvimopan, its routine adoption with small and large intestinal resection will significantly impact patients and health systems.
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Affiliation(s)
- Ahmed M Al-Mazrou
- Division of Colorectal Surgery, NewYork-Presbyterian Hospital/Columbia University Medical Center, Herbert Irving Pavilion, 161 Fort Washington Avenue, Floor 8, New York, NY, 10032, USA
| | - Onur Baser
- Center for Innovation and Outcomes Research, Department of Surgery, NewYork-Presbyterian Hospital/Columbia University Medical Center, New York, NY, USA
| | - Ravi P Kiran
- Division of Colorectal Surgery, NewYork-Presbyterian Hospital/Columbia University Medical Center, Herbert Irving Pavilion, 161 Fort Washington Avenue, Floor 8, New York, NY, 10032, USA.
- Center for Innovation and Outcomes Research, Department of Surgery, NewYork-Presbyterian Hospital/Columbia University Medical Center, New York, NY, USA.
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Hyde LZ, Al-Mazrou AM, Kuritzkes BA, Suradkar K, Valizadeh N, Kiran RP. Readmissions after colorectal surgery: not all are equal. Int J Colorectal Dis 2018; 33:1667-1674. [PMID: 30167778 DOI: 10.1007/s00384-018-3150-3] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [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] [Accepted: 08/20/2018] [Indexed: 02/04/2023]
Abstract
PURPOSE This study aims to assess factors associated with preventable readmissions after colorectal resection. METHODS All readmissions following colorectal resection from May 2013 to May 2016 at an academic medical center were reviewed. Readmissions that could be prevented were identified. Factors associated with preventable readmission were assessed using logistic regression. RESULTS Of 686 patients discharged during the study period, there were 75 patients (11%) with unplanned readmission. Twenty-nine readmissions (39%) were preventable-these readmissions were due to dehydration or acute kidney injury, pain, ostomy complications, and gastrointestinal bleeding. On regression analysis, the strongest preoperative risk factors associated with preventable readmission were urgent or emergent operation (OR 4.0, 95% CI 1.6-9.9), recent myocardial infarction (OR 2.9, 95% CI 1.0-9.0), total or subtotal colectomy (OR 2.8, 95% CI 1.1-7.3), and American Society of Anesthesiologist score ≥ 3 (OR 2.2, 95% CI 1.0-4.7). Intraoperative risk factors associated with preventable readmission included intraoperative stapler complication (OR 24.2, 95% CI 1.5-397). Postoperative risk factors associated with preventable readmission included postoperative arrhythmia (OR 5.6, 95% CI 2.0-16.1), and postoperative anemia (OR 2.6, 95% CI 1.2-5.7). On multivariable analysis while controlling for procedure type, urgent or emergent operation (OR 2.9, 95% CI 1.1-8.2), intraoperative stapler complication (OR 37.5, 95% CI 2.3-627.8), and postoperative arrhythmia (OR 4, 95% CI 1.3-12.8) remained statistically significant. CONCLUSION Approximately 40% of readmissions following colorectal surgery are potentially preventable. Since specific patients and factors that are associated with preventable readmission can be identified, resources should be targeted to factors associated with preventable readmissions.
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Affiliation(s)
- Laura Z Hyde
- Division of Colorectal Surgery, Columbia University Medical Center/New York Presbyterian Hospital, New York, NY, USA.,Department of Surgery, University of California San Francisco-East Bay, Oakland, CA, USA
| | - Ahmed M Al-Mazrou
- Division of Colorectal Surgery, Columbia University Medical Center/New York Presbyterian Hospital, New York, NY, USA
| | - Ben A Kuritzkes
- Division of Colorectal Surgery, Columbia University Medical Center/New York Presbyterian Hospital, New York, NY, USA
| | - Kunal Suradkar
- Division of Colorectal Surgery, Columbia University Medical Center/New York Presbyterian Hospital, New York, NY, USA
| | - Neda Valizadeh
- Division of Colorectal Surgery, Columbia University Medical Center/New York Presbyterian Hospital, New York, NY, USA
| | - Ravi P Kiran
- Division of Colorectal Surgery, Columbia University Medical Center/New York Presbyterian Hospital, New York, NY, USA.
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50
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Hyde LZ, Valizadeh N, Al-Mazrou AM, Kiran RP. ACS-NSQIP risk calculator predicts cohort but not individual risk of complication following colorectal resection. Am J Surg 2018; 218:131-135. [PMID: 30522696 DOI: 10.1016/j.amjsurg.2018.11.017] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [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: 10/01/2018] [Revised: 10/27/2018] [Accepted: 11/14/2018] [Indexed: 12/22/2022]
Abstract
OBJECTIVE Compare the ACS-NSQIP risk calculator with institutional risk for colorectal surgery. METHODS Actual and predicted outcomes were compared for both cohort and individuals. RESULTS For the cohort, the risk calculator was accurate for 7/8 outcomes; there were more serious complications than predicted (19.4 vs 14.7%, p < 0.05). Risk calculator Brier scores and null Brier scores were comparable. PATIENTS with better outcomes than predicted were current smokers (OR 4.3 95% CI 1.2-15.4), ASA ≥ 3 (OR 10.4, 95% CI 2.8-39.2), underwent total/subtotal colectomy (OR 3.5, 95% CI 1.1-12.2) or operated by Surgeon 2 (OR 2.9, 95% CI 1.4-11.6). Patients with serious complications who had low predicted risk had low ASA (OR 10.5, 95% CI 1.3-82.6), and underwent operation by Surgeon 2 (OR 11.8, 95% CI 2.5, 55.2). LIMITATIONS Single center study, sample size may bias subgroup analyses. CONCLUSIONS The ACS NSQIP calculator did not predict outcome better than sample risk.
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Affiliation(s)
- Laura Z Hyde
- Division of Colorectal Surgery, Columbia University Medical Center/New York Presbyterian Hospital, USA; Department of Surgery, University of California San Francisco East Bay, USA
| | - Neda Valizadeh
- Division of Colorectal Surgery, Columbia University Medical Center/New York Presbyterian Hospital, USA
| | - Ahmed M Al-Mazrou
- Division of Colorectal Surgery, Columbia University Medical Center/New York Presbyterian Hospital, USA
| | - Ravi P Kiran
- Division of Colorectal Surgery, Columbia University Medical Center/New York Presbyterian Hospital, USA.
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