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Choi BH, Church J, Sonett J, Kiran RP. Colonic interposition in esophagectomy: an ACS-NSQIP study. Surg Endosc 2023; 37:9563-9571. [PMID: 37730851 DOI: 10.1007/s00464-023-10420-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2023] [Accepted: 08/29/2023] [Indexed: 09/22/2023]
Abstract
INTRODUCTION For patients with cancer or injury of the esophagus, esophagectomy with reconstruction using the stomach (gastric pull-up, GPU) or colon (colonic interposition, CI) can restore function but is associated with high morbidity. We sought to describe the differences in outcomes between the two replacement organs using a national database. METHODS From ACS-NSQIP, patients who underwent GPU or CI between 2006 and 2020 were identified. Univariate analyses were performed on length of stay, complications, reoperation, readmission, and mortality. Variables with P ≤ 0.2 were included in the multivariate regression. Primary outcomes were 30-day reoperation, readmission, and mortality. Data were assessed using Chi-squared tests and logistic regression. RESULTS There were 12,545 GPU and 502 CI patients. GPU patients were older with higher BMI, and more likely to be male (80.3% versus 70.3%, P < 0.0001) and white (77.8% versus 69.1%, P < 0.0001). More GPU patients had independent functional status and underlying bleeding disorders, but fewer other preoperative comorbidities than CI patients. On univariate analysis, CI patients had longer hospital stays (13 versus 10 days, P < 0.0001); more reoperations (23.9% versus 14.5%, P < 0.0001); a lower rate of discharge to home (70.9% versus 82.1%, P < 0.0001); and a higher mortality rate (6.2% versus 2.9%, P < 0.0001). On multivariate analysis, CI was associated with increased risk of reoperation but not with readmission or mortality. Reoperation was associated with CI, smoking, chronic wound, hypertension, higher ASA class, contaminated or dirty wound class, and longer operative time. Readmission was associated with female gender, hypertension, and longer operative time. Mortality was associated with age, metastatic cancer, preoperative sepsis, preoperative renal failure, malignant esophageal disease, higher ASA class, incomplete closure, and longer operative time. CONCLUSION Colonic interposition, although a more difficult option with traditionally worse outcomes, should still be considered for patients requiring esophagectomy if the stomach cannot be used to restore continuity, as differences in outcomes appear to be due to underlying frailty of patients rather than the procedure.
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Affiliation(s)
- Beatrix Hyemin Choi
- Colorectal Surgery, Columbia University Irving Medical Center/New York Presbyterian Hospital, 161 Ft. Washington Avenue, Floor 8, New York, NY, 10032, USA.
| | - James Church
- Colorectal Surgery, Columbia University Irving Medical Center/New York Presbyterian Hospital, 161 Ft. Washington Avenue, Floor 8, New York, NY, 10032, USA
| | - Joshua Sonett
- Thoracic Surgery, Columbia University Irving Medical Center/New York Presbyterian Hospital, 161 Ft. Washington Avenue, Floor 3, New York, NY, 10032, USA
| | - Ravi Pokala Kiran
- Colorectal Surgery, Columbia University Irving Medical Center/New York Presbyterian Hospital, 161 Ft. Washington Avenue, Floor 8, New York, NY, 10032, USA
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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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Bakes D, Kiran RP. Overview of Common Complications in Inflammatory Bowel Disease Surgery. Gastrointest Endosc Clin N Am 2022; 32:761-776. [PMID: 36202515 DOI: 10.1016/j.giec.2022.05.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
The complication rate after surgery in patients with inflammatory bowel disease is high owing to chronic inflammatory and suboptimal physiologic state, the effect of steroids and immunosuppressive medication, and the inherent complexity of the surgical procedures. Although some of the complications after surgery are similar for Crohn disease and ulcerative colitis, others are specific to the diagnosis. Complications are divided into early postoperative and late complications. Specific complications are related to more extensive surgery such as a proctocolectomy or reoperative procedures or with complex reconstructive procedures such as the ileoanal pouch and continent ileostomy.
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Affiliation(s)
- Debbie Bakes
- Division of Colorectal Surgery, Columbia University Medical Center, New York Presbyterian Hospital, 161 Fort Washington Avenue, 8th Floor, Herbert Irving Pavilion, New York, NY 10032, USA
| | - Ravi Pokala Kiran
- Division of Colorectal Surgery, Columbia University Medical Center, New York Presbyterian Hospital, 161 Fort Washington Avenue, 8th Floor, Herbert Irving Pavilion, New York, NY 10032, USA.
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Moodley Y, Moodley VM, Mashele SS, Kiran RP, Madiba TE. Geospatial distribution of severe paediatric intussusception in KwaZulu-Natal province, South Africa. Pan Afr Med J 2020; 36:320. [PMID: 33193974 PMCID: PMC7603819 DOI: 10.11604/pamj.2020.36.320.19814] [Citation(s) in RCA: 2] [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] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2019] [Accepted: 12/12/2019] [Indexed: 11/18/2022] Open
Abstract
Introduction intussusception in South African (SA) children is often severe. A proportion of cases require management at quaternary hospitals which are a scare resource in SA. A geospatial investigation of severe paediatric intussusception (SPI) in the KwaZulu-Natal (KZN) province of SA would assist with identifying regions which should be targeted for preventative interventions. This could reduce resource utilisation for this condition at quaternary hospitals. The objective of this study was to determine the geospatial distribution of SPI in KZN. Methods this was a retrospective analysis of data for patients with SPI who were admitted to a quaternary hospital in KZN over an 11-year period. Data related to patient demographics, duration of hospitalization, surgical intervention, inpatient mortality and residential postal code were extracted from the electronic hospital admissions system. Each residential postal code was linked to a corresponding KZN district municipality. Descriptive statistical methods were used to determine the distribution of various characteristics in the study sample. Semi-quantitative geospatial analysis was used to determine the distribution of patients with SPI in each KZN district municipality. Results the study sample consisted of 182 patients with SPI. Most patients were <1 year old (83.5%), male (51.1%) and black African (87.9%). All patients underwent surgical intervention. Inpatient mortality was 2.7%. The majority of patients in the study sample resided in the eThekwini and King Cetshwayo district municipalities (51.1% and 14.8%, respectively). Conclusion preventative interventions for SPI should be considered for rollout in the eThekwini and King Cetshwayo district municipalities of KZN, SA.
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Affiliation(s)
- Yoshan Moodley
- Faculty of Health and Environmental Sciences, Central University of Technology, Bloemfontein, South Africa
| | | | - Sitheni Samson Mashele
- Faculty of Health and Environmental Sciences, Central University of Technology, Bloemfontein, South Africa
| | - Ravi Pokala Kiran
- Columbia University Medical Center and Mailman School of Public Health, New York, 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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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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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, 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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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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12
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Van Dalen ASHM, Ali UA, Murray ACA, Kiran RP. Optimizing Patient Selection for Laparoscopic and Open Colorectal Cancer Resections: A National Surgical Quality Improvement Program–Matched Analysis. Am Surg 2019. [DOI: 10.1177/000313481908500230] [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] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
The aim of this study was to identify patients undergoing colorectal cancer (CRC) resection who might benefit specifically from either an open or laparoscopic approach. From the NSQIP database (2012–2013), patients who underwent laparoscopic colectomy (LC) or open colectomy (OC) for CRC were identified. The two groups were matched and compared in terms of any, medical, and surgical complications. A wide range of patient characteristics were collected and analyzed. Interaction analysis was performed in a multivariable regression model to identify risk factors that may make LC or OC more beneficial in certain subgroups of patients. Overall, OC (n = 6593) was associated with a significantly higher risk of any [odds ratio (OR) 2.03, 95% confidence interval (CI) 1.87–2.20], surgical (OR 1.98, 95% CI 1.82–2.16), and medical (OR 1.71, 95% CI 1.51–1.94) complications than LC (n = 6593). No subgroup of patients benefited from an open approach. Patients with obesity (BMI > 30) (P = 0.03) and older age (>65 years) (P = 0.01) benefited more than average from a laparoscopic approach. For obese patients, LC was associated with less overall complications (OC vs LC: OR 1.92 obese vs 1.21 nonobese patients). For elderly patients, LC was more preferable regarding the risk of medical complications (OC vs LC OR of 1.91 vs 1.34 for younger patients). No subgroup of CRC patients benefited specifically more from an open colorectal resection. This supports that the laparoscopic technique should be performed whenever feasible. For the obese and elderly patients, the benefits of the laparoscopic approach were more pronounced.
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Affiliation(s)
| | - Usama Ahmed Ali
- Department of Surgery, Amsterdam Gastroenterology and Metabolism, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
- Department of Surgery, University Medical Centre Utrecht, Utrecht, The Netherlands
| | - Alice C. A. Murray
- Department of Colorectal Surgery, Columbia University Medical Centre, New York, New York
| | - Ravi Pokala Kiran
- Department of Colorectal Surgery, Columbia University Medical Centre, New York, New York
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13
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van Dalen ASHM, Ali UA, Murray ACA, Kiran RP. Optimizing Patient Selection for Laparoscopic and Open Colorectal Cancer Resections: A National Surgical Quality Improvement Program-Matched Analysis. Am Surg 2019; 85:206-213. [PMID: 30819300] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/09/2023]
Abstract
The aim of this study was to identify patients undergoing colorectal cancer (CRC) resection who might benefit specifically from either an open or laparoscopic approach. From the NSQIP database (2012-2013), patients who underwent laparoscopic colectomy (LC) or open colectomy (OC) for CRC were identified. The two groups were matched and compared in terms of any, medical, and surgical complications. A wide range of patient characteristics were collected and analyzed. Interaction analysis was performed in a multivariable regression model to identify risk factors that may make LC or OC more beneficial in certain subgroups of patients. Overall, OC (n = 6593) was associated with a significantly higher risk of any [odds ratio (OR) 2.03, 95% confidence interval (CI) 1.87-2.20], surgical (OR 1.98, 95% CI 1.82-2.16), and medical (OR 1.71, 95% CI 1.51-1.94) complications than LC (n = 6593). No subgroup of patients benefited from an open approach. Patients with obesity (BMI > 30) (P = 0.03) and older age (>65 years) (P = 0.01) benefited more than average from a laparoscopic approach. For obese patients, LC was associated with less overall complications (OC vs LC: OR 1.92 obese vs 1.21 nonobese patients). For elderly patients, LC was more preferable regarding the risk of medical complications (OC vs LC OR of 1.91 vs 1.34 for younger patients). No subgroup of CRC patients benefited specifically more from an open colorectal resection. This supports that the laparoscopic technique should be performed whenever feasible. For the obese and elderly patients, the benefits of the laparoscopic approach were more pronounced.
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14
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Murray AC, Markar S, Mackenzie H, Baser O, Wiggins T, Askari A, Hanna G, Faiz O, Mayer E, Bicknell C, Darzi A, Kiran RP. An observational study of the timing of surgery, use of laparoscopy and outcomes for acute cholecystitis in the USA and UK. Surg Endosc 2018; 32:3055-3063. [PMID: 29313126 DOI: 10.1007/s00464-017-6016-9] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [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: 10/01/2017] [Accepted: 12/19/2017] [Indexed: 12/21/2022]
Abstract
BACKGROUND Evidence supports early laparoscopic cholecystectomy for acute cholecystitis. Differences in treatment patterns between the USA and UK, associated outcomes and resource utilization are not well understood. METHODS In this retrospective, observational study using national administrative data, emergency patients admitted with acute cholecystitis were identified in England (Hospital Episode Statistics 1998-2012) and USA (National Inpatient Sample 1998-2011). Proportions of patients who underwent emergency cholecystectomy, utilization of laparoscopy and associated outcomes including length of stay (LOS) and complications were compared. The effect of delayed treatment on subsequent readmissions was evaluated for England. RESULTS Patients with a diagnosis of acute cholecystitis totaled 1,191,331 in the USA vs. 288 907 in England. Emergency cholecystectomy was performed in 628,395 (52.7% USA) and 45,299 (15.7% England) over the time period. Laparoscopy was more common in the USA (82.8 vs. 37.9%; p < 0.001). Pre-treatment (1 vs. 2 days; p < 0.001) and total ( 4 vs. 7 days; p < 0.001) LOS was lower in the USA. Overall incidence of bile duct injury was higher in England than the USA (0.83 vs. 0.43%; p < 0.001), but was no different following laparoscopic surgery (0.1%). In England, 40.5% of patients without an immediate cholecystectomy were subsequently readmitted with cholecystitis. An additional 14.5% were admitted for other biliary complications, amounting to 2.7 readmissions per patient in the year following primary admission. CONCLUSION This study highlights management practices for acute cholecystitis in the USA and England. Despite best evidence, index admission laparoscopic cholecystectomy is performed less in England, which significantly impacts subsequent healthcare utilization.
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Affiliation(s)
- A C Murray
- Division of Colorectal Surgery, New York Presbyterian Hospital/Columbia University Medical Center, Herbert Irving Pavilion, 161 Fort Washington Avenue, Floor: 8, New York, NY, 10032, USA.,Department of Surgery and Cancer, Imperial College London, London, UK
| | - S Markar
- Department of Surgery and Cancer, Imperial College London, London, UK
| | - H Mackenzie
- Department of Surgery and Cancer, Imperial College London, London, UK
| | - O Baser
- Department of Biostatistics, Mailman School of Public Health, Columbia University, New York, NY, USA
| | - T Wiggins
- Department of Surgery and Cancer, Imperial College London, London, UK
| | - A Askari
- Department of Surgery and Cancer, Imperial College London, London, UK
| | - G Hanna
- Department of Surgery and Cancer, Imperial College London, London, UK
| | - O Faiz
- Department of Surgery and Cancer, Imperial College London, London, UK
| | - E Mayer
- Department of Surgery and Cancer, Imperial College London, London, UK
| | - C Bicknell
- Department of Surgery and Cancer, Imperial College London, London, UK
| | - A Darzi
- Department of Surgery and Cancer, Imperial College London, London, UK
| | - R P Kiran
- Division of Colorectal Surgery, New York Presbyterian Hospital/Columbia University Medical Center, Herbert Irving Pavilion, 161 Fort Washington Avenue, Floor: 8, New York, NY, 10032, USA. .,Department of Biostatistics, Mailman School of Public Health, Columbia University, New York, NY, USA.
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15
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Al-Mazrou AM, Kiran RP, Lee-Kong S, Feingold D, Pappou EP. Robotic right hemicolectomy with intracorporeal anastomosis using V-Loc™ - a video vignette. Colorectal Dis 2017; 19:696. [PMID: 28544562 DOI: 10.1111/codi.13737] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [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: 03/17/2017] [Accepted: 04/12/2017] [Indexed: 02/08/2023]
Affiliation(s)
- A M Al-Mazrou
- Department of Colorectal Surgery, Columbia University Medical Center, New York, NY, USA
| | - R P Kiran
- Department of Colorectal Surgery, Columbia University Medical Center, New York, NY, USA
| | - S Lee-Kong
- Department of Colorectal Surgery, Columbia University Medical Center, New York, NY, USA
| | - D Feingold
- Department of Colorectal Surgery, Columbia University Medical Center, New York, NY, USA
| | - E P Pappou
- Department of Colorectal Surgery, Columbia University Medical Center, New York, NY, USA
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16
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Al-Mazrou AM, Kiran RP, Pappou EP, Feingold D, Lee-Kong S. Robotic ventral mesh rectopexy - a video vignette. Colorectal Dis 2017; 19:695. [PMID: 28520090 DOI: 10.1111/codi.13736] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/17/2017] [Accepted: 04/12/2017] [Indexed: 02/08/2023]
Affiliation(s)
- A M Al-Mazrou
- Division of Colorectal Surgery, New York Presbyterian Hospital, Columbia University, New York City, New York, USA
| | - R P Kiran
- Division of Colorectal Surgery, New York Presbyterian Hospital, Columbia University, New York City, New York, USA
| | - E P Pappou
- Division of Colorectal Surgery, New York Presbyterian Hospital, Columbia University, New York City, New York, USA
| | - D Feingold
- Division of Colorectal Surgery, New York Presbyterian Hospital, Columbia University, New York City, New York, USA
| | - S Lee-Kong
- Division of Colorectal Surgery, New York Presbyterian Hospital, Columbia University, New York City, New York, USA
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17
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Valizadeh N, Murray ACA, Suradkar K, Al-Mazrou A, Kiran RP. Impact of preoperative steroid or immunosuppressant use on short-term outcomes following colectomy in Crohn's disease patients. Tech Coloproctol 2017; 21:217-223. [PMID: 28205051 DOI: 10.1007/s10151-017-1591-2] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [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: 08/23/2016] [Accepted: 12/28/2016] [Indexed: 02/06/2023]
Abstract
BACKGROUND Evaluating the impact of steroid or immunosuppressants (SI) therapy prior to colectomy in Crohn's disease (CD) patients on postoperative septic and colectomy-specific outcomes using the American College of Surgeons (ACS)-National Surgical Quality Improvement Program (NSQIP)-targeted colectomy database. METHODS All CD patients undergoing colectomy were retrieved from the 2012-2013 NSQIP-targeted database. Thirty-day postoperative outcomes were compared for patients who were on steroids or immunosuppressants (SI) within the 30 days prior to colectomy to the others using univariable and multivariable analyses. RESULTS Of 2208 CD patients, 1387 (63%) were on SI. Patients in the SI group were younger, and a greater proportion underwent laparoscopic surgery (p < 0.05). SI use was associated with a higher rate of sepsis (7.6 vs. 5.2%), anastomotic leak (5.6 vs. 3.5%), and return to operating room (6.8 vs. 3.3%). On multivariable analysis, SI was associated with sepsis, septic shock, and anastomotic leak [odds ratio = 1.58, 95% confidence interval 1.09-2.27]. CONCLUSIONS These results suggest that SI use within 30 days of colectomy is associated with a higher rate of sepsis and septic shock and anastomotic leak in CD patients. Withholding SI prior to surgery, or the selective use of an ostomy to mitigate the consequences of a leak and hence sepsis need due consideration prior to surgery.
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Affiliation(s)
- N Valizadeh
- Department of Colorectal Surgery, Columbia University Medical Center, Presbyterian Hospital, New York, NY, 10032, USA
| | - A C A Murray
- Department of Colorectal Surgery, Columbia University Medical Center, Presbyterian Hospital, New York, NY, 10032, USA
| | - K Suradkar
- Department of Colorectal Surgery, Columbia University Medical Center, Presbyterian Hospital, New York, NY, 10032, USA
| | - A Al-Mazrou
- Department of Colorectal Surgery, Columbia University Medical Center, Presbyterian Hospital, New York, NY, 10032, USA
| | - R P Kiran
- Department of Colorectal Surgery, Columbia University Medical Center, Presbyterian Hospital, New York, NY, 10032, USA.
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18
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Ludvigsson JF, Lebwohl B, Ekbom A, Kiran RP, Green PHR, Höijer J, Stephansson O. Outcomes of Pregnancies for Women Undergoing Endoscopy While They Were Pregnant: A Nationwide Cohort Study. Gastroenterology 2017; 152:554-563.e9. [PMID: 27773807 DOI: 10.1053/j.gastro.2016.10.016] [Citation(s) in RCA: 40] [Impact Index Per Article: 5.7] [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: 08/24/2016] [Revised: 10/08/2016] [Accepted: 10/14/2016] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS Endoscopy is an integral part of the investigation and management of gastrointestinal disease. We aimed to examine outcomes of pregnancies for women who underwent endoscopy during their pregnancy. METHODS We performed a nationwide population-based cohort study, linking data from the Swedish Medical Birth Registry (for births from 1992 through 2011) with those from the Swedish Patient Registry. We identified 3052 pregnancies exposed to endoscopy (2025 upper endoscopies, 1109 lower endoscopies, and 58 endoscopic retrograde cholangiopancreatographies). Using Poisson regression, we calculated adjusted relative risks (ARRs) for adverse outcomes of pregnancy according to endoscopy status using 1,589,173 unexposed pregnancies as reference. To consider the effects of disease activity, we examined pregnancy outcomes (preterm birth, stillbirth, small for gestational age, or congenital malformations) in women who underwent endoscopy just before or after pregnancy. Secondary outcome measures included induction of labor, low birth weight (<2500 g), cesarean section, Apgar score <7 at 5 minutes, and neonatal death within 28 days. To consider intrafamilial factors, we compared pregnancies within the same mother. RESULTS Exposure to any endoscopy during pregnancy was associated with an increased risk of preterm birth (ARR, 1.54; 95% confidence interval [CI], 1.36-1.75) or small for gestational age (ARR, 1.30; 95% CI, 1.07-1.57) but not of congenital malformation (ARR, 1.00; 95% CI, 0.83-1.20) or stillbirth (ARR, 1.45; 95% CI, 0.87-2.40). None of the 15 stillbirths to women with endoscopy occurred <2 weeks after endoscopy. ARRs were independent of trimester. Compared to women with endoscopy <1 year before or after pregnancy, endoscopy during pregnancy was associated with preterm birth (ARR, 1.16) but not with small for gestational age (ARR, 1.19), stillbirth (ARR, 1.11), or congenital malformation (ARR, 0.90). Restricting the study population to women having an endoscopy during pregnancy or before/after, and only analyzing data from women without a diagnosis of inflammatory bowel disease, celiac disease, or liver disease, endoscopy during pregnancy was not linked to preterm birth (ARR, 1.03; 95% CI, 0.84-1.27). Comparing births within the same mother, for which only 1 birth had been exposed to endoscopy, we found no association between endoscopy and gestational age or birth weight. CONCLUSIONS In a nationwide population-based cohort study, we found endoscopy during pregnancy to be associated with increased risk of preterm birth or small for gestational age, but not of congenital malformation or stillbirth. However, these risks are small and likely due to intrafamilial factors or disease activity.
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Affiliation(s)
- Jonas F Ludvigsson
- Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden; Department of Pediatrics, Örebro University Hospital, Sweden; Division of Epidemiology and Public Health, School of Medicine, University of Nottingham, City Hospital, Nottingham, UK.
| | - Benjamin Lebwohl
- Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden; Celiac Disease Center, Department of Medicine, Columbia University College of Physicians and Surgeons, New York, New York
| | - Anders Ekbom
- Clinical Epidemiology Unit, Department of Medicine Solna, Karolinska Institutet, Sweden
| | - Ravi Pokala Kiran
- Division of Colorectal Surgery New York Presbyterian/Columbia University Medical Center New York, New York
| | - Peter H R Green
- Celiac Disease Center, Department of Medicine, Columbia University College of Physicians and Surgeons, New York, New York
| | - Jonas Höijer
- Unit of Biostatistics, Institute of Environmental Medicine, Karolinska Institutet, Sweden
| | - Olof Stephansson
- Clinical Epidemiology Unit, Department of Medicine Solna, Karolinska Institutet, Sweden; School of Public Health, University of California, Berkeley, California
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19
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Abstract
For patients with ulcerative colitis requiring surgery, surgical options include a total proctocolectomy with an end ileostomy and ileal pouch-anal anastomosis or a continent reservoir, or instead, a subtotal colectomy with an ileorectal anastomosis. The ileal pouch-anal anastomosis is currently considered the gold standard procedure that is employed in the majority of patients. Despite strong data supporting the feasibility, durability and the maintenance of long term functional outcomes and quality of life, certain controversies pertaining to its relative role, method of creation and effects on related pelvic structures remain a matter of debate.
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Affiliation(s)
- Steven Lee-Kong
- a Division of Colorectal Surgery , Columbia University Medical Center/New York Presbyterian Hospital , New York , NY , USA
| | - Ravi Pokala Kiran
- a Division of Colorectal Surgery , Columbia University Medical Center/New York Presbyterian Hospital , New York , NY , USA
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20
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Wu XR, Kirat HT, Xhaja X, Hammel JP, Kiran RP, Church JM. The impact of mesenteric tension on pouch outcome and quality of life in patients undergoing restorative proctocolectomy. Colorectal Dis 2014; 16:986-94. [PMID: 25141985 DOI: 10.1111/codi.12748] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.6] [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: 03/20/2014] [Revised: 05/15/2014] [Accepted: 06/04/2014] [Indexed: 12/13/2022]
Abstract
AIM The study aimed to establish a method for the measurement of mesenteric tension after ileal pouch-anal anastomosis (IPAA) and to evaluate the impact of tension on clinical outcome and quality of life. METHODS All consecutive patients undergoing an open IPAA from July 2008 to October 2009 were prospectively enrolled. After the creation of the anastomosis, mesenteric tension was estimated by the surgeon in the operating room on a 10-point scale (1, least tension; 10, most tension). The association was analysed between mesenteric tension defined as low (1-2), medium (3-7) and high (8-10) and postoperative complications and quality of life (Cleveland Clinic Global Scale). RESULTS A mesenteric tension score was obtained in 134 patients (71 men, 53.0%). Median age was 38.5 (29.3-47.0) years. Fifty-six patients (41.8%) had a low, 59 (44.0%) a medium and 19 (14.2%) a high degree of mesenteric tension. Patients with a high mesenteric tension had a shorter anal transitional zone, a longer distance from the upper border of the symphysis pubis to the apex of the small bowel loop designated for the ileoanal anastomosis, a thinner abdominal wall at the stoma site and a longer distance from the pouch to the ileostomy. The proportion of patients with high mesenteric tension was less after stapled anastomosis. On long-term follow-up, patients with high mesenteric tension were more likely to suffer from anastomotic stricture and pouch failure. Pouch function was not influenced by mesenteric tension. CONCLUSION High mesenteric tension after IPAA is adversely associated with postoperative complications and pouch survival.
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Affiliation(s)
- X-R Wu
- Department of Colorectal Surgery, Cleveland Clinic Foundation, Cleveland, Ohio, USA
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21
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Elagili F, Stocchi L, Ozuner G, Kiran RP. Antibiotics alone instead of percutaneous drainage as initial treatment of large diverticular abscess. Tech Coloproctol 2014; 19:97-103. [PMID: 25417122 DOI: 10.1007/s10151-014-1250-9] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.2] [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: 04/12/2014] [Accepted: 10/25/2014] [Indexed: 01/29/2023]
Abstract
BACKGROUND There are limited data assessing the effectiveness of antibiotics as sole initial therapy in patients with large diverticular abscess. The aim of our study was to compare outcomes of selected patients treated with initial antibiotics alone versus percutaneous drainage. METHODS All patients with diverticular abscess ≥3 cm in diameter treated in our institution in 1994-2012 with percutaneous drainage or antibiotics alone followed by surgery were identified from an institutional diverticular disease database. Groups were compared based on patient and disease characteristics, treatment failures and postoperative outcomes. RESULTS Thirty-two patients were treated with antibiotics alone because of either technically impossible percutaneous drainage (n = 15) or surgeon preference (n = 17) while 114 underwent percutaneous drainage. Failure of initial treatment required urgent surgery in 8 patients with persistent symptoms during treatment with antibiotics alone (25 %) and in 21 patients (18 %) after initial percutaneous drainage (p = 0.21). Reasons for urgent surgery after percutaneous drainage were persistent symptoms (n = 16), technical failure of percutaneous drainage (n = 4) and small bowel injury (n = 1). Patients treated with antibiotics had a significantly smaller abscess diameter (5.9 vs. 7.1 cm, p = 0.001) and shorter interval from initial treatment to sigmoidectomy (mean 50 vs. 80 days, p = 0.02). The Charlson comorbidity index, initial treatment failure rates, postoperative mortality, overall morbidity, length of hospital stay during treatments, and overall and permanent stoma rates were comparable in the two groups. Postoperative complications following antibiotics alone were significantly less severe than after percutaneous drainage based on the Clavien-Dindo classification (p = 0.04). CONCLUSIONS Selected patients with diverticular abscess can be initially treated with antibiotics without adverse consequences on their outcomes.
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Affiliation(s)
- F Elagili
- Department of Colorectal Surgery, Digestive Disease Institute, Cleveland Clinic, 9500 Euclid Avenue, A-30, Cleveland, OH, 44195, USA,
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22
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Gohel TD, Burke CA, Lankaala P, Podugu A, Kiran RP, Thota PN, Lopez R, Sanaka MR. Polypectomy rate: a surrogate for adenoma detection rate varies by colon segment, gender, and endoscopist. Clin Gastroenterol Hepatol 2014; 12:1137-42. [PMID: 24315881 DOI: 10.1016/j.cgh.2013.11.023] [Citation(s) in RCA: 40] [Impact Index Per Article: 4.0] [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: 07/22/2013] [Revised: 10/29/2013] [Accepted: 11/15/2013] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS The adenoma detection rate (ADR) is an important measure of the quality of colonoscopy; it is associated with interval colorectal cancer and varies among sexes and locations. Recommended indicators of competence for colonoscopy include minimal ADRs >25% for average-risk men and >15% for women. These ADRs are rigorous, so polypectomy detection rate (PR) has been suggested as a surrogate. Colonoscopy is less effective in the proximal colon, where interval cancers are more likely to occur. We compared ADRs and PRs in different segments of colon and between sexes. METHODS We performed a cross-sectional review of findings from 2167 screening colonoscopies performed by 65 endoscopists on average-risk outpatients at the Cleveland Clinic, 2008-2009. We reviewed colonoscopy and pathology reports of randomly selected procedures (mean, 33 ± 16 procedures per endoscopist). We calculated PRs, ADRs, and correlation between PR and ADR for each colon segment and sex. RESULTS The mean overall PR was 42% ± 16.7%, and ADR was 25% ± 3.3%. The correlation between overall ADR and PR was strong (r = 0.80). PR of 40% in men and 30% in women correlated with the established minimum benchmark ADRs of 25% and 15% for men and women, respectively. PR was more strongly correlated with ADR in the proximal colon (r = 0.92) than the distal colon (r = 0.58). The correlation was stronger in men than in women, as well as in the entire colon (r = 0.88 vs 0.75), the proximal colon (r = 0.91 vs 0.87), and the distal colon (r = 0.75 vs 0.55). The advanced ADR was 4% and did not correlate with PR (r = 0.32). CONCLUSIONS On the basis of a review of findings from screening colonoscopies, overall PR correlates with ADR for the entire colon, but PR and ADR correlate most strongly for the proximal colon, where many adenomas can be missed and interval cancers develop. The correlation between PR and ADR is weaker for women than men and for distal colon. If PR is used as a surrogate for ADR, colon location and patient sex should be considered.
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Affiliation(s)
- Tushar D Gohel
- Department of Gastroenterology, Digestive Disease Institute, The Cleveland Clinic Foundation, Cleveland, Ohio
| | - Carol A Burke
- Department of Gastroenterology, Digestive Disease Institute, The Cleveland Clinic Foundation, Cleveland, Ohio
| | - Pavan Lankaala
- Department of Gastroenterology, Digestive Disease Institute, The Cleveland Clinic Foundation, Cleveland, Ohio
| | - Amareshwar Podugu
- Department of Gastroenterology, Digestive Disease Institute, The Cleveland Clinic Foundation, Cleveland, Ohio
| | - Ravi Pokala Kiran
- Department of Colorectal Surgery, Digestive Disease Institute, The Cleveland Clinic Foundation, Cleveland, Ohio
| | - Prashanthi N Thota
- Department of Gastroenterology, Digestive Disease Institute, The Cleveland Clinic Foundation, Cleveland, Ohio
| | - Rocio Lopez
- Department of Gastroenterology, Digestive Disease Institute, The Cleveland Clinic Foundation, Cleveland, Ohio
| | - Madhusudhan R Sanaka
- Department of Gastroenterology, Digestive Disease Institute, The Cleveland Clinic Foundation, Cleveland, Ohio.
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Bhangu A, Kiran RP, Audisio R, Tekkis P. Survival outcome of operated and non-operated elderly patients with rectal cancer: A Surveillance, Epidemiology, and End Results analysis. Eur J Surg Oncol 2014; 40:1510-6. [PMID: 24704032 DOI: 10.1016/j.ejso.2014.02.239] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.9] [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: 12/17/2013] [Revised: 02/12/2014] [Accepted: 02/19/2014] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND With an ageing population, surgery is increasingly offered to elderly patients with rectal cancer, although outcomes for the oldest patients remain poorly defined. This study aimed to determine whether operative intervention improves outcome in elderly patients. METHOD Patients aged 18+ years diagnosed with rectal adenocarcinoma between 1998 and 2009 were identified from the Surveillance, Epidemiology, and End Results database. The primary endpoint was adjusted hazard ratios (HR) for 5-year cancer specific survival (CSS); the secondary endpoint was 5-year overall survival (OS). RESULTS With increasing age, patients were less likely to undergo surgery, receive a complete stage or receive neoadjuvant radiotherapy. CSS and OS increasingly diverged with age in patients undergoing surgery. Those aged 80+ had reduced CSS compared to those aged 70-79 years (stages I-III, respective adjusted HR 2.14, 1.58, 1.48, all p < 0.001). However, stage II patients aged 80+ treated with resection and neoadjuvant therapy had similar survival to those aged 70-79 years (adjusted HR 1.26, p = 0.149). For only patients aged 80+ years, those treated non-operatively had lower survival than those undergoing surgery, who in turn had the best survival when treated with neoadjuvant radiotherapy (adjusted HR 0.74, p = 0.001). CONCLUSION Contrary to common expectation, in patients aged over 80 with rectal cancer, surgery with or without other modalities was associated with better survival than non-operative treatment. Despite selection bias in this observational study, these findings support consideration of maximal therapy regardless of age in selected patients deemed to be fit, since this leads to outcomes equivalent to younger patients.
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Affiliation(s)
- A Bhangu
- Department of Colorectal Surgery, Royal Marsden Hospital, Fulham Road, London, UK; Division of Surgery, Imperial College, Chelsea and Westminster Campus, London, UK
| | - R P Kiran
- Division of Colorectal Surgery, New York Presbyterian Hospital, Columbia University Medical Center, New York, USA
| | - R Audisio
- Department of Surgery, University of Liverpool, Liverpool, UK
| | - P Tekkis
- Department of Colorectal Surgery, Royal Marsden Hospital, Fulham Road, London, UK; Division of Surgery, Imperial College, Chelsea and Westminster Campus, London, UK.
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Abstract
BACKGROUND The Surgical Care Improvement Project (SCIP) includes recommendations for mechanical and pharmacologic venous thromboembolism (VTE) prophylaxis after colorectal surgery. Compliance with these recommendations is publicly reported and included in current pay for performance plans. Presently, there is limited evidence to support compliance with these recommendations. AIM To determine the incidence of venous thromboembolic events in colorectal surgery patients who did or did not receive the recommended pharmacologic prophylaxis. METHODS We performed a retrospective analysis of prospectively accrued data from a single-center, tertiary care, colorectal surgery department. The main outcome measure was the occurrence of venous thromboembolic events and the need for blood transfusion after surgery. RESULTS Of 674 patients, 613(91%) received the recommended pharmacologic VTE prophylaxis and 61 (9%) did not. Diagnosis, patient variables, and type of surgery performed were similar in each group while operative time was increased in the compliant group (251 vs. 194 min, p < 0.05). In the compliant and noncompliant groups, the incidence of extremity deep venous thrombosis was 2.8 and 8.2% (p = 0.04), the incidence of pulmonary embolus 1.1 and 3.3% (p = 0.19), the incidence of portomesenteric venous thrombosis 2.6 and 4.9% (p = 0.38), and the incidence of any VTE 5.4 and 13.1% (p = 0.02), respectively. The use of perioperative red blood cell transfusions in the two groups was 9.1 and 14.8%, p = 0.17. In the subgroup analysis of open cases, there were no statistical differences in the occurrence of any type or combination of VTE. CONCLUSIONS Compliance with SCIP recommendations for pharmacologic VTE prophylaxis decreased the incidence of VTE after colorectal surgery with no increase in the use of perioperative transfusion. Colorectal surgeons who elect to skip these recommendations may jeopardize both the reputational score and financial reimbursement of their hospital and may put their patients at unnecessary risk for a preventable postoperative complication.
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Affiliation(s)
- H H Erem
- Department of Colorectal Surgery, Digestive Disease Institute, Cleveland Clinic, Cleveland, OH, USA,
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Peirce C, Burton M, Lavery I, Kiran RP, Walsh DJ, Dockery P, Coffey JC. Digital sculpting in surgery: a novel approach to depicting mesosigmoid mobilization. Tech Coloproctol 2014; 18:653-60. [PMID: 24500724 DOI: 10.1007/s10151-013-1116-6] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [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] [Received: 09/21/2013] [Accepted: 12/30/2013] [Indexed: 12/20/2022]
Abstract
BACKGROUND The aim of the present study was to develop a unique anatomic replica of the mesocolon using digital graphical software in order to provide an educational template for mesosigmoidectomy. METHODS The colon and mesocolon were fully mobilized from ileocecal to mesorectal levels in a cadaver. Both colon and mesocolon provided a template from which to generate a three dimensional replica in ZBrush. The model was deformed in ZBrush, to compare and contrast current and classic interpretations of mesosigmoidal topography. An animation was developed in which the replica was deformed to mimic operative mobilization. Contiguous shape changes were captured in two-and-a-half-dimensional (2.5D) screen snapshots. This was repeated for medial to lateral and lateral to medial mobilization of the mesosigmoid. RESULTS Topographic differences between classic and current appraisals of mesocolic anatomy were evident in 2.5D format. Using the model generated, contiguous shape changes during mesosigmoidal mobilization (i.e., between the left mesocolon, mobile/apposed mesosigmoid, and mesorectum) were replicated in animation format. By extracting and compiling 2.5D screen grabs a pictorial chronology of mobilization was developed. CONCLUSIONS Recent advances in mesocolic topography can be captured and rendered using advanced digital sculpting software with high-end graphics capabilities. This approach permits a depiction of contiguous changes in mesosigmoidal topography during mesosigmoidal mobilization. A compilation of images in either animation or screen grab format obviates the interpolation of shape changes required using standard educational approaches.
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Affiliation(s)
- C Peirce
- Department of Surgery, University Hospital Limerick, Limerick, Ireland,
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26
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Aytac E, Stocchi L, Ozdemir Y, Kiran RP. Factors affecting morbidity after conversion of laparoscopic colorectal resections. Br J Surg 2014; 100:1641-8. [PMID: 24264789 DOI: 10.1002/bjs.9283] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/26/2013] [Indexed: 12/13/2022]
Abstract
BACKGROUND The impact of conversion on postoperative outcomes of laparoscopic colorectal surgery remains controversial. The purpose of this study was to assess whether a conversion results in increased postoperative morbidity and mortality, and to evaluate whether any specific factors affect the outcomes of converted procedures. METHODS Outcomes of procedures requiring conversion among patients undergoing elective laparoscopic colorectal resection between 1992 and 2011 were compared with those for operations completed laparoscopically. Subset analyses were also performed to evaluate the selective impact of patient-, disease- and treatment-related factors and the timing of conversion during surgery on outcomes. Primary endpoints were postoperative mortality and morbidity. RESULTS Of 2483 patients undergoing laparoscopic colorectal resection, 270 (10.9 per cent) required conversion to open surgery. The 30-day postoperative mortality rate was comparable after laparoscopically completed and converted procedures (0.4 versus 0 per cent respectively; P = 0.610). Factors significantly associated with morbidity after conversion were smoking, cardiovascular co-morbidity, previous abdominal operations (particularly colectomy or hysterectomy) and adhesions. Overall morbidity was not affected by conversion (27.0 per cent at 30 days in both groups; P > 0.999). However, patients experiencing morbidity tended to have had earlier conversions: median (range) 40 (15-90) min into surgery versus 50 (15-240) min for those who did not develop morbidity (P = 0.006). The risk of reoperation for postoperative morbidity was higher following conversion because of complications (13 versus 2.9 per cent; P = 0.024). CONCLUSION Conversions of laparoscopic colorectal resection are not associated with increased overall morbidity, regardless of the timing of conversion.
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Affiliation(s)
- E Aytac
- Department of Colorectal Surgery, Digestive Disease Institute, Cleveland Clinic Foundation, 9500 Euclid Avenue,, Cleveland, Ohio, 44195, USA
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Gu J, Stocchi L, Remzi F, Kiran RP. Factors associated with postoperative morbidity, reoperation and readmission rates after laparoscopic total abdominal colectomy for ulcerative colitis. Colorectal Dis 2013; 15:1123-9. [PMID: 23627886 DOI: 10.1111/codi.12267] [Citation(s) in RCA: 18] [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: 09/20/2012] [Accepted: 12/21/2012] [Indexed: 01/20/2023]
Abstract
AIM The aim of this study was to evaluate factors affecting postoperative outcomes after laparoscopic total abdominal colectomy (TAC) with end ileostomy (EI) for ulcerative colitis (UC). METHOD Patients undergoing laparoscopic TAC/EI for severe UC/indeterminate colitis in our institution between 1998 and 2010 were retrospectively identified from a prospectively established database. Demographics, disease characteristics and perioperative outcomes were recorded. Associations between the 30-day postoperative outcome and patient-, disease- and treatment-related variables were assessed using univariate and multivariate logistic regression models. RESULTS Two hundred and four patients (105 men, median age 35.5 years) were identified. The conversion rate was 4.4%. Median blood loss and operation time were 100 ml and 185 min. Length of hospital stay was 5.8 ± 4.4 days. Overall postoperative morbidity, reoperation and readmission rates were 40, 7 and 17%, respectively Preoperative treatment with high steroid doses was significantly associated with postoperative morbidity on multivariate analysis (P = 0.011). Univariate analysis showed that lower preoperative body mass index (BMI), haemoglobin, serum albumin level and pancolitis were associated with reoperation, of which a lower BMI (P = 0.043) was also independently significant on multivariate analysis. No specific factor was significantly associated with readmission. CONCLUSION Preoperative clinical deterioration is associated with an adverse outcome after laparoscopic TAC for UC.
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Affiliation(s)
- J Gu
- Department of Colorectal Surgery, Digestive Disease Institute, Cleveland Clinic, Cleveland, Ohio, USA
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Turina M, Remzi FH, Dietz DW, Kiran RP, Seyidova-Khoshknabi D, Hammel JP, Vogel JD. Quantification of Risk for Early Unplanned Readmission after Rectal Resection: A Single-Center Study. J Am Coll Surg 2013; 217:200-8. [DOI: 10.1016/j.jamcollsurg.2013.05.016] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2013] [Revised: 05/17/2013] [Accepted: 05/17/2013] [Indexed: 10/26/2022]
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Warrier SK, Kalady MF, Kiran RP, Church JM. Results from an American Society of Colon and Rectal Surgeons survey on the management of young-onset colorectal cancer. Tech Coloproctol 2013; 18:265-72. [PMID: 23893218 DOI: 10.1007/s10151-013-1052-5] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/18/2013] [Accepted: 07/14/2013] [Indexed: 12/21/2022]
Abstract
BACKGROUND Young patients with colorectal cancer (CRC) present a diagnostic and clinical challenge. The aim of our study was to survey the approaches to preoperative evaluation and clinical management of young patients with CRC by colorectal surgeons in North America. METHODS A standard electronic survey was sent to the members of the American Society of Colon and Rectal Surgeons. The survey polled management decisions in various clinical scenarios for CRC patients less than 50 years old. Survey responses were collated and analyzed. RESULTS One hundred ninety surgeons responded and 140 completed the entire survey (response rate 10%). Eighty percent of surgeons would offer preoperative genetic testing if the patient's family met the Amsterdam criteria compared to only 67% if the criteria were not met. Of those offering preoperative tumor testing, 48% test microsatellite instability, 19% mismatch repair protein expression by immunohistochemistry, and 24% offer both. Decisions regarding the extent of the resection for cancer were dependent on family history: Most members (86%) would perform a segmental colectomy for CRC in a patient without family history. Eighty-four percent of respondents would offer a total abdominal colectomy if preoperative tests indicated Lynch syndrome. When questioned about MYH-associated polyposis, only 27% recognized the appropriate diagnosis. CONCLUSIONS Among the American Society of Colon and Rectal Surgeons, family history influences preoperative testing and surgical management decisions. A significant portion of surgeons do not offer preoperative genetic testing, despite implications on operative management, postoperative surveillance, and screening of family members.
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Affiliation(s)
- S K Warrier
- Department of Colorectal Surgery, Digestive Disease Institute, Cleveland Clinic, 9500 Euclid Ave, A30, Cleveland, OH, 44195, USA,
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Reshef A, Gurland B, Zutshi M, Kiran RP, Hull T. Colectomy with ileorectal anastomosis has a worse 30-day outcome when performed for colonic inertia than for a neoplastic indication. Colorectal Dis 2013; 15:481-6. [PMID: 23061597 DOI: 10.1111/codi.12058] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [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] [Received: 05/01/2012] [Accepted: 08/10/2012] [Indexed: 02/08/2023]
Abstract
AIM Whether bowel related dysfunction adversely affects postoperative recovery after total colectomy with ileorectal anastomosis (C + IRA) for colonic inertia (CI) has not been previously well evaluated. This study compared the early postoperative outcome of C + IRA for CI and for other noninflammatory indications. METHOD Patients undergoing elective C + IRA from 1999 to 2010 were identified from a prospectively maintained database. Since inflammation in the rectum or small bowel may influence the outcome, patients with inflammatory bowel disease were excluded. Patients undergoing surgery for CI (group A) were compared with patients having the operation for other benign noninflammatory diseases (group B). Demographics, American Society of Anesthesiologists (ASA) score, body mass index (BMI), surgical procedure and 30-day complications were assessed. RESULTS The study population consisted of 333 patients undergoing elective C + IRA (99 men, mean age 39 ± 16 years). The procedure was laparoscopic in 163 (49%) patients. Groups A (n = 131) and B (n = 202) had similar age and ASA score (39 ± 11 vs 39 ± 19 years, P = 0.4; 2.2 ± 0.5 vs 2.4 ± 0.7). Group A patients had lower BMI (25 ± 5 vs 28 ± 8 kg/m(2) , P = 0.002), more women (99 vs 51%, P < 0.001) and fewer laparoscopic procedures (43 vs 53%, P = 0.04). Compared with group B, group A had a greater incidence of postoperative ileus (32 vs 19%, P = 0.009), higher overall morbidity (36 vs 15%, P < 0.001) and increased length of stay (8.4 ± 6 vs 7.2 ± 5 days, P < 0.006). These differences persisted when subgroups of patients who underwent laparoscopic or open surgery were compared. CONCLUSION Although CI is considered a 'benign' condition, patients undergoing C + IRA for this indication have significant morbidity compared with patients having the operation for other noninflammatory benign conditions.
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Affiliation(s)
- A Reshef
- Department of Colorectal Surgery, Digestive Disease Institute, Cleveland Clinic, Cleveland, OH 44195, USA
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Reshef A, Stocchi L, Kiran RP, Flechner S, Budev M, Quintini C, Remzi FH. Case-matched comparison of perioperative outcomes after surgical treatment of sigmoid diverticulitis in solid organ transplant recipients versus immunocompetent patients. Colorectal Dis 2012; 14:1546-52. [PMID: 22564266 DOI: 10.1111/j.1463-1318.2012.03077.x] [Citation(s) in RCA: 42] [Impact Index Per Article: 3.5] [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: 01/07/2023]
Abstract
AIM To compare the perioperative outcomes following surgery for sigmoid diverticulitis in transplant recipients and immunocompetent patients. METHOD Solid organ transplant recipients operated on for sigmoid diverticulitis from 1995 to 2010 were case-matched to immunocompetent patients based on surgical procedure, American Society of Anesthesiologists classification, Hinchey score, elective vs urgent surgery, age ± 10 years and year of surgery ± 5 years. Demographics, clinical presentation and perioperative outcomes were assessed. RESULTS Of 5329 consecutive patients undergoing heart, lung, kidney and liver transplantation since 1995, 51 (0.6%) underwent surgery for diverticulitis between 1995 and 2010 with 14% mortality and 45% morbidity. Urgent surgery in 37/51 patients [Hartmann's procedure 28, sigmoidectomy with diverting ileostomy 8, loop ileostomy 1 (9 cases within 2 months after transplantation)] was associated with significantly increased postoperative mortality (19%vs 0%, P = 0.01), increased morbidity (51%vs 24%, P = 0.03) and longer mean hospital stay (19 vs 13 days, P = 0.1) when compared with immunocompetent patients. Four patients undergoing urgent surgery had suffered previous episodes of diverticulitis treated nonoperatively. Elective surgery was associated with no mortality in 14 transplant recipients (nine sigmoidectomy with diverting ileostomy, five sigmoidectomy without diversion) or in immunocompetent controls. Following elective procedures, transplant recipients had similar morbidity and increased hospital stay (29% and 9.6 vs 6.5 days, P = 0.2, respectively). Permanent stoma rates and postoperative morbidity after stoma takedown were comparable in the two groups. All living patients except one (kidney) retained their graft function. CONCLUSIONS Urgent surgery for sigmoid diverticulitis in transplant recipients is associated with worse postoperative outcomes when compared with immunocompetent patients, unlike elective surgery. Future studies will need to clarify the role of early surgery after the first diverticulitis episode.
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Affiliation(s)
- A Reshef
- Department of Colorectal Surgery, Digestive Disease Institute, Cleveland Clinic, Cleveland, Ohio 44195, USA
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El-Gazzaz G, Erem HH, Aytac E, Salcedo L, Stocchi L, Kiran RP. Risk of infection and hernia recurrence for patients undergoing ventral hernia repair with non-absorbable or biological mesh during open bowel procedures. Tech Coloproctol 2012. [PMID: 23179894 DOI: 10.1007/s10151-012-0928-0] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.5] [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: 12/22/2022]
Abstract
BACKGROUND Ventral hernia repair (VHR) with mesh performed concurrently with colorectal surgery is presumably associated with significant risks of infection and recurrence. The purpose of this study is to evaluate the outcomes of patients undergoing VHR with non-absorbable mesh (NAM) or biological mesh (BM) at the same time as open colorectal surgery. METHODS A retrospective review of short- and long-term outcomes for 25 patients undergoing repair of VHR with NAM or BM at the same time as an open colorectal procedure from 1991 to 2007 was performed. RESULTS The mean age of the patients was 50.8 ± 12.7 years. Fifteen patients (60 %) underwent VHR with NAM versus 10 (40 %) with BM at the time of colorectal surgery. Mean follow-up after surgery was 32.9 ± 38.2 months. Overall wound infection, mesh infection and hernia recurrence rates were 44, 36 and 36 %, respectively. There was no difference between the NAM and BM mesh repair groups in terms of operative indications (p = 0.23) and operations performed (p = 0.47). Both groups had similar gender, ASA score, age, BMI, operating time, hernia recurrence rate, wound infection and follow-up. CONCLUSIONS Although a proportion of patients who undergo concomitant use of mesh for VHR during colorectal resection has reasonable outcomes, there is a high associated risk of wound and mesh infection. Thus, a judicious decision regarding the use of mesh for hernia repair needs to be made on a case-by-case basis for patients undergoing open bowel surgery at the same time.
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Affiliation(s)
- G El-Gazzaz
- Department of Colorectal Surgery, Digestive Disease Institute, Cleveland Clinic Foundation, Cleveland, OH 44195, USA
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Ince M, Stocchi L, Khomvilai S, Kwon DS, Hammel JP, Kiran RP. Morbidity and mortality of the Hartmann procedure for diverticular disease over 18 years in a single institution. Colorectal Dis 2012; 14:e492-8. [PMID: 22356208 DOI: 10.1111/j.1463-1318.2012.03004.x] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.3] [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: 02/08/2023]
Abstract
AIM Hartmann's procedure for perforated diverticulitis is associated with substantial morbidity and mortality. This study analyses factors associated with morbidity/mortality and possible changes over time. METHOD Patients treated by urgent Hartmann's procedure for perforated diverticulitis between 1992 and 2010 were studied, and information was collected on age, sex, perioperative details, 30-day morbidity and mortality recorded in an institutional review board approved database supplemented by chart review. Patients were divided into four groups based on the year of surgery. Univariate and multivariate logistic regression analysis was performed to identify risk factors associated with morbidity and mortality. RESULTS In all, 199 patients (51% female, mean age 65 years, mean body mass index 28 kg/m(2)) were identified. The American Society of Anesthesiologists (ASA) score was 4 in 30% of patients and Hinchey Stage IV in 16%. The mean length of stay was 12.5 ± 10 days. Mortality was 15% and did not change significantly over time. Overall morbidity was 52% and significantly increased over time on univariate analysis (P = 0.007) but not on multivariate analysis (P = 0.11). Independent predictors of morbidity on multivariate analysis were Hinchey IV (P < 0.001) and hypoproteinaemia (P = 0.001). Independent predictors for mortality were ASA > 3 (P = 0.01), abnormal creatinine (P = 0.007), steroid use (P = 0.007), Hinchey IV (P = 0.032), low albumin (P < 0.001) and low body mass index (P = 0.001). CONCLUSION Mortality after Hartmann's procedure for perforated diverticulitis has not decreased during the last 18 years. Morbidity has actually increased over time although this is related to increased disease severity and comorbidity. Future efforts should focus on the identification of patient subgroups benefiting from earlier elective surgery and alternative surgical approaches when perforated diverticulitis does occur.
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Affiliation(s)
- M Ince
- Department of Colorectal Surgery, Cleveland Clinic Foundation, Cleveland, Ohio, USA
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Navaneethan U, Venkatesh PGK, Lashner BA, Shen B, Kiran RP. The impact of ulcerative colitis on the long-term outcome of patients with primary sclerosing cholangitis. Aliment Pharmacol Ther 2012; 35:1045-53. [PMID: 22428605 DOI: 10.1111/j.1365-2036.2012.05063.x] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.1] [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] [Received: 01/09/2012] [Revised: 02/02/2012] [Accepted: 02/26/2012] [Indexed: 12/18/2022]
Abstract
BACKGROUND The impact of ulcerative colitis (UC) on the outcome of primary sclerosing cholangitis (PSC) outcome remains unclear. AIM To investigate whether the presence of UC is associated with a worse clinical of associated PSC. METHODS A total of 222 patients with PSC (167 with UC and 55 without UC) seen and followed at a single centre from 1985 to 2011 were included. Clinical and demographic variables were obtained and patients were followed until the date of their last clinic visit. RESULTS The median age at presentation of PSC with associated UC was 38 vs. 47 years without UC (P < 0.001). At presentation, median serum bilirubin (2.1 vs. 4.5, P < 0.001) and the Mayo PSC Risk Score (0.95 vs. 1.69, P < 0.001) were lower in those with UC vs. those without UC. A total of 55 of 167 (32.9%) patients with PSC-UC developed colon neoplasia in contrast to 1 of the 55 (1.8%) patients with PSC. (P < 0.001) On proportional hazards analysis, UC (hazard ratio (HR) = 0.90 [95% confidence interval (CI): 0.60-1.34, P = 0.60] was not associated with death or orthotopic liver transplantation (OLT), when adjusting for gender, Mayo risk score and year of PSC diagnosis; whereas the revised Mayo risk score [HR = 5.08, 95% CI: (2.62-9.86), P < 0.001] was associated with a greater risk of OLT or death. CONCLUSIONS Primary sclerosing cholangitis often is recognised at an early stage in patients with concurrent ulcerative colitis; ulcerative colitis has no impact on long-term prognosis in terms of liver-related outcomes when adjusted for the severity of liver disease.
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Affiliation(s)
- U Navaneethan
- Department of Gastroenterology, The Cleveland Clinic, Cleveland, OH, USA
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Navaneethan U, Choudhary M, Venkatesh PGK, Lashner BA, Remzi FH, Shen B, Kiran RP. The effects of liver transplantation on the clinical course of colitis in ulcerative colitis patients with primary sclerosing cholangitis. Aliment Pharmacol Ther 2012; 35:1054-63. [PMID: 22428731 DOI: 10.1111/j.1365-2036.2012.05067.x] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.1] [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] [Received: 01/01/2012] [Revised: 02/04/2012] [Accepted: 02/28/2012] [Indexed: 02/06/2023]
Abstract
BACKGROUND The course of ulcerative colitis (UC) following orthotopic liver transplantation (OLT) for primary sclerosing cholangitis (PSC) is unclear. AIM To investigate the clinical course of UC, before and after OLT for PSC. METHODS From a historical cohort of 86 patients with PSC-UC who underwent OLT, 77 patients who were followed up at our institution both before and after OLT from 1985 to 2011 were included. RESULTS Ulcerative colitis was diagnosed in 77 (97.5%) patients before OLT. Nineteen of 77 (24.7%) patients underwent colectomy before OLT. In the other 58 patients, the course of UC after OLT when compared to the last 5 years before OLT was quiescent in 48 patients (82.8%) while 9/58 (15.5%) of patients underwent colectomy post-OLT. There was a total of 97 colitis flares over a total of 621 years of follow-up from PSC/UC diagnosis to OLT (0.156 flares per patient year) whereas post-OLT, there were 31 flares over a total of 511 years of post-OLT follow-up (0.061 flares per patient year) (P < 0.001). On univariable analysis, the number of UC flares [Odds ratio (OR) 1.52; 95% Confidence interval (1.02-2.27), P = 0.04] and dysplasia [OR 47.00; 95% CI (6.48-340.66), P < 0.001] increased the risk of colectomy following OLT; the use of corticosteroids [OR 0.07; 95% CI (0.01-0.63), P = 0.008] and 5-aminosalicylate [OR 0.18; 95% CI (0.04-0.83), P = 0.04] was protective. CONCLUSIONS Ulcerative colitis in the presence of primary sclerosing cholangitis remains quiescent, and may improve in most patients after orthotopic liver transplantation.
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Affiliation(s)
- U Navaneethan
- Department of Gastroenterology, Digestive disease Institute, The Cleveland Clinic, Cleveland, OH, USA
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Abstract
AIM The aim of this study was to characterize formally the mesocolic anatomy during and following total mesocolic excision. Total mesocolic excision may improve survival in patients with colon cancer. Although this requires a detailed knowledge of normal and variant mesocolic anatomy, the latter is poorly characterized. No studies have prospectively characterized the anatomy of the entire mesocolon. METHOD Total mesocolic excision was performed in 109 patients undergoing total abdominal colectomy. The mesocolon was maintained intact thereby permitting a precise anatomical characterization from ileocaecal to mesorectal levels. Two- and three-dimensional schematic reconstructions were generated to illustrate in situ conformation. RESULTS Several previously undocumented findings emerged, including: (i) the mesocolon was continuous from ileocaecal to rectosigmoid level; (ii) a mesenteric confluence occurred at the ileocaecal and rectosigmoid junction as well as at the hepatic and splenic flexures; (iii) each flexure (and ileocaecal junction) was a complex of peritoneal and omental attachments to the colon centred on a mesenteric confluence; (iv) the proximal rectum originated at the confluence of the mesorectum and mesosigmoid; and (v) a plane occupied by Toldt's fascia separated the entire apposed mesocolon from the retroperitoneum. CONCLUSION When the mesocolon is fully mobilized during a total mesocolic excision of the colon, several anatomical findings that have not been previously documented emerge. These findings provide a rationalization of the surgical, embryological and anatomical approaches to the mesocolon. This has implications for all related sciences.
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Affiliation(s)
- K Culligan
- Department of Surgery, University of Limerick, Limerick, Ireland
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Abstract
AIM Whether reoperation in the postoperative period adversely affects oncologic outcomes for colorectal cancer patients undergoing resection has not been well characterized. The aim of this study was to determine whether long-term oncological outcomes are affected for patients who undergo repeat surgery in the early postoperative period. METHOD From a prospective colorectal cancer database, patients who underwent resection for colorectal cancer between 1982 and 2008 and were reoperated within 30 days after surgery (group A) were matched for age (±5 years), gender, year of surgery (±2 years), American Society of Anesthesiology score, tumor site (colon or rectum), cancer stage and differentiation with patients who did not undergo reoperation (group B). The two groups were compared for overall survival (OS), disease-free survival (DFS) and local recurrence (LR). RESULTS In total, 89 reoperated patients (45 rectal, 44 colon cancer) were matched to an equal number of non-reoperated patients. Anterior resection (39.2%) and right hemicolectomy (19.1%) were predominant primary operations. Indications for reoperation were anastomotic leak/abscess (n=40, 45%), massive bleeding (n=15, 16.9%), bowel obstruction (n=11, 12.4%), wound complications (n=9, 10.1%) and other indications (n=14, 15.6%). Group A had significantly greater overall morbidity (100% vs 27%, P=0.001) and required more blood transfusions (20.2% vs 7.9%, P=0.045). Adjuvant therapy use, on the other hand, was more common in group B (23.6% vs 12.3%, P=0.1). The 5-year OS and DFS were lower in the reoperated group (OS 55.3% vs 66.4%, P=0.02; DFS 50.8% vs 60.8%, P=0.06, respectively). Five-year LR was slightly lower in the reoperated group (2.9% vs 6.3%, P=0.34). CONCLUSIONS Compared with non-reoperated patients matched for patient, tumour and operative characteristics, patients reoperated in the early postoperative period have worse long-term oncological outcomes. Adoption of strategies to reduce the risk of reoperation may be associated with the additional advantage of improved oncological outcomes in addition to the short-term advantages.
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Affiliation(s)
- W Khoury
- Department of Colorectal Surgery, Cleveland Clinic Foundation, Cleveland, Ohio 44195, USA
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Abstract
AIM Gender-related differences in preoperative characteristics and early and long-term outcome for patients undergoing ileal pouch anal anastomosis (IPAA) have not previously been well studied. METHOD All male and female patients undergoing IPAA at a single centre between 1983 and 2008 were compared for perioperative variables and long-term outcome. Statistical tests were used as appropriate. A multivariate analysis was performed to evaluate the effects of gender on pouch failure. RESULTS Female patients (n=1495) were younger than male patients (n=1912) (P<0.001). Surgery type and pouch configuration were similar, although male gender was associated with a higher use of ileostomy (P<0.001) and a higher incidence of 30-day anastomotic separation (P=0.001). During a median follow up of 9.9 (female) and 9.3 (male) years, female patients were more likely to develop bowel obstruction (20.8 vs 16.7%, P=0.02) and pouch-related fistula (10.9 vs 7.6%, P=0.001). Women had a higher number of daily bowel movements than men (P=0.001), and more frequently had urgency (P=0.001), daily seepage (P=0.01) and pad use (P<0.001). A higher percentage of female patients reported dietary (P<0.001) and work (P=0.022) restrictions and lower mental component of the Short-Form 36 quality of life score (P=0.018). On multivariate analysis of perioperative variables, female gender was associated with pouch failure (P=0.05). CONCLUSION The gender of the patient seems to be associated with specific differences in preoperative variables and postoperative outcomes for patients undergoing IPAA.
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Affiliation(s)
- M Rottoli
- Colorectal Surgery, Cleveland Clinic Foundation, Cleveland, OH 44195, USA
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Ince M, Kirat HT, Geisler DP, Remzi FH, Kiran RP. The negative effects of surgery persist beyond the early postoperative period after laparoscopic colorectal resection. Tech Coloproctol 2011; 15:173-7. [PMID: 21431387 DOI: 10.1007/s10151-011-0677-5] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [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] [Received: 11/12/2010] [Accepted: 02/01/2011] [Indexed: 02/04/2023]
Abstract
PURPOSE The recovery benefits of laparoscopy are traditionally believed to minimize the initial negative impact of surgery on early postoperative quality of life (QOL). We evaluate whether laparoscopic colectomy leads to recovery of QOL early after surgery and evaluate factors associated with the change in QOL. METHODS Preoperative and early postoperative QOL data (SF-36) were prospectively accrued for patients undergoing laparoscopic colorectal resection (LCR) (2002-2009). Changes in postoperative QOL from preoperative values and effects of patient, disease, operation and postoperative outcomes on these changes were evaluated. RESULTS One hundred and sixty-six patients (female = 86) underwent LCR for cancer (n = 79), Crohn's disease (n = 24), diverticulitis (n = 38), and ulcerative colitis (n = 25) with complete SF-36 scores. Median age was 56.9 (range: 15-91) years, mean body mass index 27.4 ± 6.2 kg/m(2) with American Society of Anesthesiologists (ASA) class being II in 94 patients. Median operative time was 152.5 (range: 50-358) min; mean length of stay (LOS) 4.5 ± 3.3 days. At 4 weeks, the postoperative SF-36 physical component scale (PCS) continued to be lower than the preoperative PCS (41.8 ± 8.8 vs. 47.1 ± 9.4, P < 0.001), while the postoperative SF-36 mental component scale (MCS) was similar to the preoperative MCS (45.6 ± 10.2 vs. 46.1 ± 11.9, P = 0.17). Gender, age, operation, LOS, surgeon, ASA, BMI, complications, and readmission were not associated with a change in QOL from preoperative values. Cancer as an indication for surgery was associated with less improvement of MCS and PCS (P = 0.024 and 0.004, respectively). CONCLUSIONS Although patients who undergo LCR may have clinical evidence of healing at 4 weeks after surgery, QOL does not return to the preoperative level. This finding may help develop evidence-based recommendations pertaining to timing of return to full activity.
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Affiliation(s)
- M Ince
- A30 Department of Colorectal Surgery, Cleveland Clinic Foundation, 9500 Euclid Avenue, Cleveland, OH 44195, USA
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Abstract
PURPOSE Pouchitis is the most common complication of IPAA. Identifying factors predictive of pouchitis may improve outcomes by modifying contributing factors and enhancing patient selection. The most objective means for confirming pouchitis is by histology because the clinical and endoscopic diagnoses rely on more subjective assessments. The importance of histological pouchitis in the absence of clinical or endoscopic findings is unknown. METHODS Prospectively collected data on patients with IPAA and pouch surveillance were evaluated. Patients who developed pouchitis, defined as symptoms of pouchitis confirmed by endoscopic biopsy (group B) were compared with those without any episode of clinical, endoscopic, or histological pouchitis (group A) for pre- and intraoperative factors and outcomes. Asymptomatic patients with histological pouchitis on surveillance biopsies (group C) were further compared with group A. Patients with Crohn's disease were excluded. RESULT Of the 673 patients with pouch biopsies, 422 (62.7%) were in group A, 161 (23.9%) in group B, and 90 (13.4%) in group C. Mean follow-up was 9.8 (±5.1), 12.4 (±5.4), and 13. (±4.7) years. Of the 43 preoperative factors evaluated, those associated with group B included leukocytosis (P < .001), rheumatologic extraintestinal disease (P < .001), disease proximal to splenic flexure (P = .001), pulmonary comorbidity (P = .004), prior steroid use (P = .006), and age at operation and diagnosis (P = .018 and .021). Of the 10 intraoperative factors evaluated, pouchitis was associated with S-pouch reconstruction (P < .001), transfusion (P < .001), and 2-stage instead of 3-stage operation (P = .05), all surrogates for operative complexity. On multivariate analysis, pulmonary comorbidity (OR 3.38, 95% CI 1.62-7.07), disease proximal to splenic flexure (OR 2.37, 95% CI 1.18-4.77), extraintestinal disease manifestations (OR 1.6, 95% CI 1.01-2.54), and S-pouch reconstruction (OR 1.59, 95% CI 0.99 - 2.54) were associated with pouchitis. Patients in group B had worse outcomes, including more strictures (P = .015), bowel obstructions (P = .019), fistulas (P = .18), and lower quality of life (P < .001). Group C patients had the same outcomes as those in group A and the finding was not predicted by the above-mentioned parameters. CONCLUSION Patients with symptomatic, biopsy-confirmed pouchitis have worse long-term outcomes than those without pouchitis. This complication is associated with specific pre- and intraoperative factors. Histological pouchitis incidentally found on surveillance biopsy in asymptomatic patients is of no clinical relevance and does not influence outcome. Identification of these preoperative factors associated with the subsequent development of pouchitis will strengthen patient counseling and may facilitate risk stratification.
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Affiliation(s)
- Jeremy M Lipman
- Department of Colorectal Surgery, Cleveland Clinic Foundation, Cleveland, OH, USA
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Kiran RP, El-Gazzaz G, Remzi FH, Church JM, Lavery IC, Hammel J, Fazio VW. Influence of age at ileoanal pouch creation on long-term changes in functional outcomes. Colorectal Dis 2011; 13:184-90. [PMID: 19906054 DOI: 10.1111/j.1463-1318.2009.02127.x] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.3] [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: 12/12/2022]
Abstract
AIM We reviewed the functional results and quality of life (QOL) of patients who had had an ileoanal pouch (IPAA) for at least 15 years. METHOD Retrospective analysis was undertaken of data accrued prospectively into a pouch database since 1983. Patients who had retained an IPAA for at least 15 years were identified. Trends in IPAA function and QOL of the patients were determined over a time-period of 15 years after formation of the IPAA. Data were compared for patients who were < 35, 35-55 and > 55 years of age when the IPAA was formed. RESULTS Three hundred and ninety-six of a total of 3276 patients in the database (53% men, median age 36 years and median follow-up 17.1 years) underwent IPAA with at least 15 years of follow-up. The final pathology was ulcerative colitis in 78%; 66.4% of patients had a restorative proctocolectomy, 91.4% underwent temporary diversion, 59% had a J-pouch configuration and 63.1% a stapled anastomosis. The frequency of bowel movements remained the same over the follow-up period. There was an increase in the incidence of incontinence and urgency after 15 years with no significant change in dietary, social, work and sexual restrictions during follow-up. Patients in all three age groups experienced deterioration in pouch function at 15 years of follow up compared with the function at 5 years. The QOL of the patients remained high and stable. CONCLUSION There is a deterioration of pouch function after 15 years, irrespective of the age of the patient when the IPAA was formed. Despite this, QOL appears to be high for all patients who retain their pouch.
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Affiliation(s)
- R P Kiran
- Department of Colorectal Surgery, Cleveland Clinic Foundation, Cleveland, Ohio, USA.
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42
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Melton GB, Kiran RP, Fazio VW, He J, Shen B, Goldblum JR, Achkar JP, Lavery IC, Remzi FH. Do preoperative factors predict subsequent diagnosis of Crohn's disease after ileal pouch-anal anastomosis for ulcerative or indeterminate colitis? Colorectal Dis 2010; 12:1026-32. [PMID: 19624520 DOI: 10.1111/j.1463-1318.2009.02014.x] [Citation(s) in RCA: 33] [Impact Index Per Article: 2.4] [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: 12/13/2022]
Abstract
AIM The aim of this study was to determine preoperative clinical factors associated with subsequent diagnosis revision to Crohn's disease (CD) following total proctocolectomy with ileal pouch-anal anastomosis (IPAA) for ulcerative colitis (UC) or indeterminate colitis (IC) patients. METHOD Presumed UC and IC patients undergoing IPAA from a large single-institution prospective database with change of diagnosis to CD were identified and compared with patients without diagnosis change. RESULTS A total of 2814 patients (47% male, median age 37 years) with presumed UC (85%) or IC (15%) underwent primary IPAA. At a median follow up of 9.6 years, 184 (7%) had the diagnosis revised to CD from histopathological examination of the colectomy specimen immediately in 97 (53%) or at a median interval of 36 months in 87 (47%). CD and UC/IC patients had had a similar operative technique, length of stay and 30-day morbidity. The postoperative CD diagnosis was associated with a preoperative diagnosis of IC (P < 0.0001) and perianal fistula (P = 0.002). Patients with a delayed diagnosis of CD were associated with a 3-stage procedure (P < 0.0001, OR = 2.8) (95% CI = 1.8-4.4), colonic stricture (P = 0.04, OR = 2.9 [95% CI = 1.1-7.4]), perianal fistula (P = 0.02, OR = 2.9 [95% CI = 1.2-7.2]), oral ulceration (P = 0.009, OR = 3.8 [95% CI = 1.2-9.6]) and younger age (P < 0.0001, OR = 0.048 [95% CI = 0.011-0.19]). CONCLUSION A few patients having IPAA for presumed UC/IC were subsequently diagnosed to have CD which was associated with perianal fistula and the diagnosis of postoperative preoperative IC. The delayed diagnosis of CD was associated with a three-stage procedure, colorectal stricture, anal fissure, mouth ulceration and younger age.
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Affiliation(s)
- G B Melton
- Digestive Disease Institute, Department of Colorectal Surgery, Cleveland Clinic Foundation, Cleveland, Ohio 44195, USA
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43
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Abstract
Complex perianal disease may be extremely debilitating for the patient with significant impingement on quality of life. The accurate identification of anatomical areas of involvement and subsequent appropriate management is crucial to achieving a successful outcome when treating anorectal sepsis and anal fistulae. Magnetic resonance imaging (MRI) has become a powerful tool in the evaluation of anal anatomy. In patients with complex disease MRI is an important adjunct in delineating disease location and extent, its relationship to sphincter muscles, and in planning management. MRI also plays an important role in evaluating the response to medical and surgical therapies.
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Affiliation(s)
- Myles Joyce
- Department of Colorectal Surgery, Cleveland Clinic Foundation, Cleveland, OH 44195, USA
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Ozturk E, Kiran RP, Remzi F, Geisler D, Fazio V. Hand-assisted laparoscopic surgery may be a useful tool for surgeons early in the learning curve performing total abdominal colectomy. Colorectal Dis 2010; 12:199-205. [PMID: 19183331 DOI: 10.1111/j.1463-1318.2009.01777.x] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.4] [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: 02/08/2023]
Abstract
OBJECTIVE We evaluated outcomes after hand-assisted (HALC) and straight laparoscopic (LC) techniques for the initial laparoscopic total abdominal colectomy (TAC) procedures performed by surgeons starting their laparoscopic careers. METHOD The first eight HALC cases of two surgeons performing TAC by this technique (Group A) were compared with the first (Group B) and last eight (Group C) TAC cases of three surgeons performing LC. Groups A and B were compared with a matched group of open total colectomy cases (Group D) and to the eight cases performed by an experienced surgeon (Group E). Demographics, intra-operative and postoperative outcomes including operation time, morbidity, conversion and readmission rates and length of hospital stay (LOS) were compared using Wilcoxon or Chi-squared tests. RESULTS Demographics of the patients were similar. Groups A, B C and E had similar operating time (P = 0.10) which was significantly longer than Group D (P < 0.0001). Morbidity (P = 0.75) and readmission rates were similar (P = 0.89). Conversion rate was significantly higher for Group B (Group B: 41.7%vs Group A: 0%, P = 0.008), in the early period. LOS was comparable between minimally invasive groups but significantly shorter than open surgery group (P = 0.0005). For Groups A and C, operating time (P = 0.55), conversion rate (P = 0.11), morbidity (P = 0.83) and LOS (P = 0.12) were similar. CONCLUSIONS Hand-assisted laparoscopic colectomy may be associated with a significantly shorter learning curve for TAC as results are better than early LC and comparable with LC performed by experienced laparoscopic surgeons. It may be a better option for surgeons early in their laparoscopic career.
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Affiliation(s)
- E Ozturk
- Department of Colorectal Surgery, Cleveland Clinic Foundation, Ohio, USA
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Lian L, Kalady M, Geisler D, Kiran RP. Laparoscopic colectomy is safe and leads to a significantly shorter hospital stay for octogenarians. Surg Endosc 2010; 24:2039-43. [DOI: 10.1007/s00464-010-0900-x] [Citation(s) in RCA: 36] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2009] [Accepted: 01/06/2010] [Indexed: 12/13/2022]
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Abstract
BACKGROUND The aim of this study was to determine the fate of the rectum, functional results and quality of life after ileorectal anastomosis (IRA) in ulcerative colitis. METHODS Patients with ulcerative colitis and indeterminate colitis who underwent IRA from 1971 to 2006 were evaluated retrospectively. Twenty-two patients with an IRA were matched by age, sex and follow-up duration with 66 patients with an ileal pouch-anal anastomosis (IPAA) and compared for functional outcomes and quality of life. RESULTS Eighty-six patients with an IRA were included. Median follow-up was 9 (range 1-36) years. Rectal dysplasia and cancer rates were 17 and 8 per cent respectively. The rectum was resected in 46 patients (53 per cent) because of refractory proctitis in 24, rectal dysplasia in 15 and rectal cancer in seven. The cumulative probability of having a functioning IRA at 10 and 20 years was 74 and 46 per cent respectively. Patients with an IRA had fewer bowel movements (P = 0.020) and less night-time seepage (P = 0.020) but increased urgency (P < 0.001) compared with patients with an IPAA, whereas quality of life was similar. CONCLUSION In selected patients with ulcerative colitis IRA gives an acceptable quality of life and functional outcome that are comparable to those in patients with an IPAA. Owing to the risk of cancer, surveillance of the rectum is mandatory.
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Affiliation(s)
- A da Luz Moreira
- Department of Colorectal Surgery, Digestive Disease Institute, Cleveland Clinic, Ohio, USA
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El-Gazzaz G, Kiran RP, Lavery I. Wound complications in rectal cancer patients undergoing primary closure of the perineal wound after abdominoperineal resection. Dis Colon Rectum 2009; 52:1962-6. [PMID: 19934916 DOI: 10.1007/dcr.0b013e3181b71ef9] [Citation(s) in RCA: 90] [Impact Index Per Article: 6.0] [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: 02/08/2023]
Abstract
PURPOSE Perineal wound complications have a significant impact on postoperative morbidity after excision of the rectum and anus. The aim of this study is to evaluate factors affecting perineal wound complications after primary closure of the wound following abdominoperineal resection. METHODS Data were reviewed from all patients who underwent abdominoperineal resection for rectal carcinoma between 1982 and 2007. Data pertaining to demographics, tumor characteristics, and use of preoperative neoadjuvant therapy were retrieved. Complications studied included delayed wound healing, wound infection, dehiscence, abscess or sinus, reoperation, and perineal hernias. Patients who developed perineal wound complications (Group A) were compared with the remaining patients (Group B) to evaluate factors associated with the development of perineal wound complications. RESULTS Six hundred ninety-six patients (59% male) met the inclusion criteria. The mean age was 63 years (standard deviation, 13), and the mean body mass index was 28.9 kg/m2 (standard deviation, 7.8). Two hundred seventy-three patients (39.2%) received neoadjuvant chemoradiation. The overall rate of wound complications was 16.2%, and reoperation was required in 5.2% of patients. Group A and Group B patients were similar with respect to age (P = 0.1), gender (P = 0.7), grade (P = 0.4), and stage of disease (P = 0.5). A greater proportion of Group A patients had associated comorbidity (P = 0.001), obesity (0.04), neoadjuvant chemoradiation (0.02), and intraoperative bleeding (0.04). In multivariate analysis, comorbidity was the only independent factor associated with the development of perineal complications (odds ratio, 1.8 (1.09-2.96)). CONCLUSIONS Most patients have perineal wound healing without complications after abdominoperineal resection. In multivariate analysis, comorbidity was the only significant factor that predicted perineal wound complications.
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Affiliation(s)
- Galal El-Gazzaz
- Department of Colorectal Surgery, Cleveland Clinic Foundation, Cleveland, Ohio 44195, USA
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El-Gazzaz GS, Kiran RP, Remzi FH, Hull TL, Geisler DP. Outcomes for case-matched laparoscopically assisted versus open restorative proctocolectomy. Br J Surg 2009; 96:522-6. [PMID: 19358179 DOI: 10.1002/bjs.6578] [Citation(s) in RCA: 72] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
BACKGROUND The aim of this study was to compare safety, early and late outcomes, quality of life and functional results of laparoscopically assisted versus open ileal pouch-anal anastomosis (IPAA). METHODS Patients who had laparoscopically assisted IPAA between 1992 and 2007 were identified from a database and retrospectively matched for age, sex, body mass index (BMI) and operation date to patients who had open IPAA at a ratio of 1:2. Intraoperative, postoperative and long-term functional outcomes were compared. Quality of life was determined by the Cleveland Global Quality of Life scale at 1 and 5 years. RESULTS A total of 119 patients (59 men, 60 women; mean(s.d) age 35.5(14.2) years, BMI 24.7(5.0) kg/m(2)) had laparoscopically assisted IPAA, with conversion in nine patients (7.6 per cent); these were compared with 238 patients who had open IPAA. The 30-day and long-term results were similar, as well as quality of life at 1 and 5 years, except that patients in the laparoscopic group had shorter median time to stoma action (2 versus 3 days; P = 0.001) and marginally shorter hospital stay. Median operating times were longer in the laparoscopic group (272 versus 163 min; P = 0.040). CONCLUSION Laparoscopically assisted IPAA had similar outcomes to open IPAA, but with some short-term advantages.
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Affiliation(s)
- G S El-Gazzaz
- Department of Colorectal Surgery, A30, Cleveland Clinic Foundation, 9500 Euclid Avenue, Cleveland, Ohio 44195, USA
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Remzi FH, El Gazzaz G, Kiran RP, Kirat HT, Fazio VW. Outcomes following Turnbull–Cutait abdominoperineal pull-through compared with coloanal anastomosis. Br J Surg 2009; 96:424-9. [DOI: 10.1002/bjs.6458] [Citation(s) in RCA: 74] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Abstract
Background
The Turnbull–Cutait abdominoperineal pull-through procedure (T-C) is used as a last resort to avoid permanent diversion in patients with complex anorectal conditions. The aim was to evaluate short- and long-term outcomes after T-C.
Methods
Patients undergoing T-C from 1996 to 2007 were reviewed retrospectively in terms of demographics, diagnosis, indications and postoperative complications. Patients were contacted to obtain functional outcomes using a standardized questionnaire. Functional outcomes were compared with those in a matched group of patients undergoing handsewn coloanal anastomosis (CAA) for rectal cancer.
Results
Sixty-seven patients (40 men) underwent T-C. Postoperative complications included stricture in 11 patients (16 per cent), fistula in five (7 per cent), prolapse of the colon in five (7 per cent) and leak in two (3 per cent). Mean follow-up was 5·6 (s.d. 3·2) years. The operation failed in 17 patients (25 per cent). Among 44 patients (66 per cent) who completed questionnaires, faecal (P = 0·121) and urinary (P = 0·073) incontinence, and sexual function (P = 0·063) were comparable to those in patients who had CAA.
Conclusion
T-C is an option for patients with complex anorectal conditions that might otherwise require permanent diversion. Functional outcomes are comparable to those of CAA.
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Affiliation(s)
- F H Remzi
- A30 Department of Colorectal Surgery, Cleveland Clinic Foundation, Euclid Avenue, Cleveland, Ohio 44195, USA
| | - G El Gazzaz
- A30 Department of Colorectal Surgery, Cleveland Clinic Foundation, Euclid Avenue, Cleveland, Ohio 44195, USA
| | - R P Kiran
- A30 Department of Colorectal Surgery, Cleveland Clinic Foundation, Euclid Avenue, Cleveland, Ohio 44195, USA
| | - H T Kirat
- A30 Department of Colorectal Surgery, Cleveland Clinic Foundation, Euclid Avenue, Cleveland, Ohio 44195, USA
| | - V W Fazio
- A30 Department of Colorectal Surgery, Cleveland Clinic Foundation, Euclid Avenue, Cleveland, Ohio 44195, USA
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Kiran RP, Remzi FH, Fazio VW, Lavery IC, Church JM, Strong SA, Hull TL. Complications and functional results after ileoanal pouch formation in obese patients. J Gastrointest Surg 2008; 12:668-74. [PMID: 18228111 DOI: 10.1007/s11605-008-0465-3] [Citation(s) in RCA: 49] [Impact Index Per Article: 3.1] [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] [Received: 05/22/2007] [Accepted: 01/06/2008] [Indexed: 01/31/2023]
Abstract
OBJECTIVE Ileoanal pouch formation (IPAA) can be technically challenging in obese patients, and there is little data evaluating results after the procedure in these patients. We compare outcomes for patients with a body mass index (BMI) > or =30 undergoing IPAA when compared with those for patients with BMI <30. METHODS Retrospective analysis of prospectively accrued data for patients with BMI > or =30 undergoing IPAA. Patient and disease-related characteristics, complications, long-term function, and quality of life (QOL) using the Cleveland Global Quality of Life scale (CGQL) were determined for this group of patients (group B) and compared with those for patients with BMI <30 (group A). Kruskal-Wallis and Wilcoxon rank sum tests were used to compare quantitative or ordinal data and chi-square or Fisher's exact tests for categorical variables. Long-term mortality and complication rates were estimated using the Kaplan-Meier method with group comparisons performed using log rank tests. RESULTS There were 345 patients (median BMI 32.7) in group B and 1,671 patients in group A. When the cumulative risk of complications over 15 years was compared, group B patients had a significantly higher chance of getting a complication (94.9% vs 88%, p = 0.006). The rates of pelvic sepsis (6.7% vs 5.3%, p = 0.3), pouchitis (58.1 vs 54.4%, p = 0.9), pouch failure (6% vs 4.5%, p = 0.9), and hemorrhage (5.6% vs 4.8%, p = 0.7) were similar for group B and group A. Group B patients, however, had a significantly higher risk of the development of wound infection (18.8% vs 8.1%, p < 0.001) and anastomotic separation (10.4% vs 5.4%, p < 0.001), whereas group A patients had a higher rate of development of obstruction over time (26.7% vs 22.3%, p = 0.02). Long-term outcome including QOL and function after 15 years was comparable between groups. CONCLUSIONS Although technically demanding, IPAA can be undertaken in obese patients with acceptable morbidity. Good long-term functional results and QOL that is comparable to nonobese patients may be anticipated.
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Affiliation(s)
- R P Kiran
- Department of Colorectal Surgery, Cleveland Clinic Foundation, Desk A30, 9500 Euclid Avenue, Cleveland, OH 44122, USA.
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