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Hawkins AT, Penson DF, Geiger TM, Bonnet KR, Mutch MG, Maguire LH, Schlundt DG, Rothman RL. The Patient Perspective on Colectomy for Recurrent Diverticulitis: A Qualitative Study. Ann Surg 2024; 279:818-824. [PMID: 38318711 PMCID: PMC10997445 DOI: 10.1097/sla.0000000000006225] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2024]
Abstract
OBJECTIVE Understand the patient's decision-making process regarding colectomy for recurrent diverticulitis. BACKGROUND The decision to pursue elective colectomy for recurrent diverticulitis is highly preference-sensitive. Little is known about the patient's perspective in this decision-making process. METHODS We performed a qualitative study utilizing focus groups of patients with recurrent diverticulitis at 3 centers across the United States. Using an iterative inductive/deductive approach, we developed a conceptual framework to capture the major themes identified in the coded data. RESULTS From March 2019 to July 2020, 39 patients were enrolled across 3 sites and participated in 6 focus groups. After coding the transcripts using a hierarchical coding system, a conceptual framework was developed. Major themes identified included participants' beliefs about surgery, such as normative beliefs (eg, subjective, value placed on surgery), control beliefs (eg, self-efficacy, stage of change), and anticipated outcomes (eg, expectations, anticipated regret); the role of behavioral management strategies (eg, fiber, eliminate bad habits); emotional experiences (eg, depression, embarrassment); current symptoms (eg, severity, timing); and quality of life (eg, cognitive load, psychosocial factors). Three sets of moderating factors influencing patient choice were identified: clinical history (eg, source of diagnosis, multiple surgeries), clinical protocols (eg, pre-op and post-op education), and provider-specific factors (eg, specialty, choice of surgeon). CONCLUSIONS Patients view the decision to undergo colectomy through 3 major themes: their beliefs about surgery, their psychosocial context, and moderating factors that influence participant choice to undergo surgery. This knowledge is essential both for clinicians counseling patients who are considering colectomy and for researchers studying the process to optimize care for recurrent diverticulitis.
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Affiliation(s)
- Alexander T Hawkins
- Division of General Surgery, Section of Colon & Rectal Surgery, Vanderbilt University Medical Center, Nashville, TN
| | - David F Penson
- Department of Urology, Vanderbilt University Medical Center, Nashville, TN
- Geriatric Research Education and Clinical Center, Tennessee Valley Healthcare System, Nashville, TN
| | - Timothy M Geiger
- Division of General Surgery, Section of Colon & Rectal Surgery, Vanderbilt University Medical Center, Nashville, TN
| | | | - Matthew G Mutch
- Department of Surgery, Section of Colon and Rectal Surgery, Washington University School of Medicine, Saint Louis, MO
| | - Lilias H Maguire
- Colon and Rectal Surgery, University of Pennsylvania, Philadelphia, PA
| | | | - Russell L Rothman
- Center for Health Services Research, Vanderbilt University Medical Center, Nashville, TN
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Hite MA, McCutcheon T, Feng MP, Ford MM, Geiger TM, Hopkins MB, Muldoon RL, Irlmeier R, Fa A, Ye F, Hawkins AT. Opioid Utilization in Outpatient Anorectal Surgery: An Opportunity for Improvement. J Surg Res 2023; 291:105-115. [PMID: 37354704 DOI: 10.1016/j.jss.2023.05.021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2023] [Revised: 04/19/2023] [Accepted: 05/16/2023] [Indexed: 06/26/2023]
Abstract
INTRODUCTION The opioid epidemic has resulted in close examination of postsurgical prescribing patterns. Little is known about postoperative opioid use in outpatient anorectal procedures. This study evaluated patient opioid use and created prescribing recommendations for these procedures. METHODS One hundred and four patients undergoing outpatient anorectal procedures from January to May 2018 were surveyed on opioid consumption, surgical experience, and pain satisfaction. Patients were grouped into three tiers based on opioid usage. Multivariable models were used to determine factors associated with poor pain control. RESULTS Patient satisfaction with pain control was 85.6%. Twenty five percent of patients reported leftover medication and 9.6% of patients requested opioid refills. Opioid prescribing recommendations were generated for each tier using 50th percentile with interquartile ranges. On multivariable modeling, the high-tier group was associated with poorer pain control. CONCLUSIONS We created opioid quantity prescribing guidelines for common outpatient anorectal procedures. A multimodal approach to pain control utilizing nonopioids may reduce healthcare utilization.
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Affiliation(s)
- Melissa A Hite
- Section of Colon & Rectal Surgery, Department of Surgery, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Tonna McCutcheon
- Section of Colon & Rectal Surgery, Department of Surgery, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Michael P Feng
- Section of Colon & Rectal Surgery, Department of Surgery, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Molly M Ford
- Section of Colon & Rectal Surgery, Department of Surgery, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Timothy M Geiger
- Section of Colon & Rectal Surgery, Department of Surgery, Vanderbilt University Medical Center, Nashville, Tennessee
| | - M Benjamin Hopkins
- Section of Colon & Rectal Surgery, Department of Surgery, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Roberta L Muldoon
- Section of Colon & Rectal Surgery, Department of Surgery, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Rebecca Irlmeier
- Department of Biostatistics, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Andrea Fa
- Section of Colon & Rectal Surgery, Department of Surgery, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Fei Ye
- Department of Biostatistics, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Alexander T Hawkins
- Section of Colon & Rectal Surgery, Department of Surgery, Vanderbilt University Medical Center, Nashville, Tennessee.
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Hawkins AT, Ueland T, Aher C, Geiger TM, Spann MD, Horst SN, Schafer IV, Ye F, Fan R, Sharp KW. Shared Decision-Making in General Surgery: Prospective Comparison of Telemedicine vs In-Person Visits. J Am Coll Surg 2023; 236:762-771. [PMID: 36728391 DOI: 10.1097/xcs.0000000000000538] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
BACKGROUND The coronavirus disease 2019 (COVID-19) pandemic has accelerated a shift toward virtual telemedicine appointments with surgeons. While this form of healthcare delivery has potential benefits for both patients and surgeons, the quality of these interactions remains largely unstudied. We hypothesize that telemedicine visits are associated with lower quality of shared decision-making. STUDY DESIGN We performed a mixed-methods, prospective, observational cohort trial. All patients presenting for a first-time visit at general surgery clinics between May 2021 and June 2022 were included. Patients were categorized by type of visit: in-person vs telemedicine. The primary outcome was the level of shared decision-making as captured by top box scores of the CollaboRATE measure. Secondary outcomes included quality of shared decision-making as captured by the 9-item Shared Decision-Making Questionnaire and satisfaction with consultation survey. An adjusted analysis was performed accounting for potential confounders. A qualitative analysis of open-ended questions for both patients and practitioners was performed. RESULTS During a 13-month study period, 387 patients were enrolled, of which 301 (77.8%) underwent in-person visits and 86 (22.2%) underwent telemedicine visits. The groups were similar in age, sex, employment, education, and generic quality-of-life scores. In an adjusted analysis, a visit type of telemedicine was not associated with either the CollaboRATE top box score (odds ratio 1.27; 95% CI 0.74 to 2.20) or 9-item Shared Decision-Making Questionnaire (β -0.60; p = 0.76). Similarly, there was no difference in other outcomes. Themes from qualitative patient and surgeon responses included physical presence, time investment, appropriateness for visit purpose, technical difficulties, and communication quality. CONCLUSIONS In this large, prospective study, there does not appear to be a difference in quality of shared decision making in patients undergoing in-person vs telemedicine appointments.
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Affiliation(s)
- Alexander T Hawkins
- Section of Colon and Rectal Surgery (Hawkins, Ueland, Geiger, Schafer), Vanderbilt University Medical Center, Nashville, TN
| | - Thomas Ueland
- Section of Colon and Rectal Surgery (Hawkins, Ueland, Geiger, Schafer), Vanderbilt University Medical Center, Nashville, TN
| | - Chetan Aher
- From the Division of General Surgery (Aher, Spann, Sharp), Vanderbilt University Medical Center, Nashville, TN
| | - Timothy M Geiger
- Section of Colon and Rectal Surgery (Hawkins, Ueland, Geiger, Schafer), Vanderbilt University Medical Center, Nashville, TN
| | - Matthew D Spann
- From the Division of General Surgery (Aher, Spann, Sharp), Vanderbilt University Medical Center, Nashville, TN
| | - Sara N Horst
- Departments of Gastroenterology, Hepatology, and Nutrition (Horst), Vanderbilt University Medical Center, Nashville, TN
| | - Isabella V Schafer
- Section of Colon and Rectal Surgery (Hawkins, Ueland, Geiger, Schafer), Vanderbilt University Medical Center, Nashville, TN
| | - Fei Ye
- Biostatistics (Ye, Fan), Vanderbilt University Medical Center, Nashville, TN
| | - Run Fan
- Biostatistics (Ye, Fan), Vanderbilt University Medical Center, Nashville, TN
| | - Kenneth W Sharp
- From the Division of General Surgery (Aher, Spann, Sharp), Vanderbilt University Medical Center, Nashville, TN
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Harrison NJ, Lopez AA, Shroder MM, Bachmann JM, Burnell E, Hopkins MB, Geiger TM, Hawkins AT. Collection and Utilization of Patient-Reported Outcome Measures in a Colorectal Surgery Clinic. J Surg Res 2022; 280:515-525. [PMID: 36081311 DOI: 10.1016/j.jss.2022.07.042] [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] [Received: 02/28/2022] [Revised: 07/13/2022] [Accepted: 07/28/2022] [Indexed: 11/27/2022]
Abstract
INTRODUCTION The routine collection of patient-reported outcome measures (PROMs) promises to improve patient care. However, in colorectal surgery, PROMs are uncommonly collected outside of clinical research studies and rarely used in clinical care. We designed and implemented a quality improvement project with the goals of routinely collecting PROMs and increasing the frequency that PROMs are utilized by colorectal surgeons in clinical practice. METHODS This mixed-methods, quality improvement project was conducted in the colorectal surgery clinic of a tertiary academic medical center. Patients were administered up to five PROMs before each appointment. PROM completion rates were measured. Additionally, we performed two educational interventions to increase utilization of our electronic health record's PROM dashboard by colorectal surgeons. Utilization rates and attitudes toward the PROM dashboard were measured. RESULTS Overall, patients completed 3600 of 3977 (90.9%) administered PROMs during the study period. At baseline, colorectal surgeons reviewed 6.7% of completed PROMs. After two educational interventions, this increased to 39.3% (P = 0.004). Colorectal surgeons also felt that the PROM dashboard was easier to use. Barriers to greater PROM dashboard utilization included poor user interface/user experience and a perceived lack of knowledge, time, and relevance. CONCLUSIONS The collection of PROMs in colorectal surgery clinics is feasible and can result in high PROM completion rates. Educational interventions can improve the utilization of PROMs by colorectal surgeons in clinical practice. Our experience collecting PROMs through this quality improvement initiative can serve as a template for other colorectal surgery clinics interested in collecting and utilizing data from PROMs.
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Affiliation(s)
- Noah J Harrison
- Vanderbilt University School of Medicine, Nashville, Tennessee
| | - Andrea A Lopez
- Vanderbilt University School of Medicine, Nashville, Tennessee
| | - Megan M Shroder
- Division of General Surgery, Vanderbilt University Medical Center, Section of Colon & Rectal Surgery, Nashville, Tennessee
| | - Justin M Bachmann
- Medicine Service, Veterans Affairs Tennessee Valley Healthcare System; Assistant Professor, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Emily Burnell
- Vanderbilt University Medical Center, Population Health, Nashville, Tennessee
| | - Michael B Hopkins
- Division of General Surgery, Vanderbilt University Medical Center, Section of Colon & Rectal Surgery, Nashville, Tennessee
| | - Timothy M Geiger
- Division of General Surgery, Vanderbilt University Medical Center, Section of Colon & Rectal Surgery, Nashville, Tennessee
| | - Alexander T Hawkins
- Division of General Surgery, Vanderbilt University Medical Center, Section of Colon & Rectal Surgery, Nashville, Tennessee.
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Hawkins AT, Rothman R, Geiger TM, Bonnet KR, Mutch MG, Regenbogen SE, Schlundt DG, Penson DF. Surgeons' Perspective of Decision Making in Recurrent Diverticulitis: A Qualitative Analysis. Ann Surg Open 2022; 3:e157. [PMID: 35528025 PMCID: PMC9074822 DOI: 10.1097/as9.0000000000000157] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2022] [Accepted: 04/04/2022] [Indexed: 11/26/2022] Open
Abstract
Objective This study employs qualitative methodology to assess surgeons' perspective on decision making in management of recurrent diverticulitis to improve patient-centered decision making. Summary Background Data The decision to pursue colectomy for patients with recurrent diverticulitis is nuanced. Strategies to enact broad acceptance of guidelines for surgery are hindered because of a knowledge gap in understanding surgeons' current attitudes and opinions. Methods We performed semi-structured interviews with board-certified North American general and colorectal surgeons who manage recurrent diverticulitis. We purposely sampled specialists by both surgeon and practice factors. An iterative inductive/deductive strategy was used to code and analyze the interviews and create a conceptual framework. Results 25 surgeons were enrolled over a nine-month period. There was diversity in surgeons' gender, age, experience, training, specialty (colorectal vs general surgery) and geography. Surgeons described the difficult process to determine who receives an operation. We identified seven major themes as well as twenty subthemes of the decision-making process. These were organized into a conceptual model. Across the spectrum of interviews, it was notable that there was a move over time from decisions based on counting episodes of diverticulitis to a focus on improving quality of life. Surgeons also felt that quality of life was more dependent on psychosocial factors than the degree of physiological dysfunction. [What about what surprised you/]. Conclusions Surgeons mostly have discarded older dogma in recommending colectomy for recurrent diverticulitis based on number and severity of episodes. Instead, decision making in recurrent diverticulitis is complex, involving multiple surgeon and patient factors and evolving over time. Surgeons struggle with this decision and education- or communication-based interventions that focus on shared decision making warrant development.
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Affiliation(s)
- Alexander T Hawkins
- Division of General Surgery, Section of Colon & Rectal Surgery, Vanderbilt University Medical Center, Nashville, TN
| | - Russell Rothman
- Center for Health Services Research, Vanderbilt University Medical Center, Nashville, TN
| | - Timothy M Geiger
- Division of General Surgery, Section of Colon & Rectal Surgery, Vanderbilt University Medical Center, Nashville, TN
| | | | - Matthew G Mutch
- Department of Surgery, Section of Colon and Rectal Surgery, Washington University School of Medicine, Saint Louis, Missouri
| | - Scott E Regenbogen
- Division of Colorectal Surgery, Department of Surgery, University of Michigan, Ann Arbor, Michigan
| | | | - David F Penson
- Department of Urology, Vanderbilt University Medical Center, Nashville, TN
- Geriatric Research Education and Clinical Center, Tennessee Valley Healthcare System, Nashville, TN
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Abstract
OBJECTIVE This study aims to characterize the extent of geographic variation in elective sigmoid resection for diverticulitis and to identify factors associated with observed variation. INTRODUCTION National guidelines for treatment of recurrent diverticulitis fail to offer strong recommendations for or against surgical intervention. We hypothesize that healthcare market factors will be significantly associated with geographic variation in colon resection for diverticulitis, a discretionary surgical intervention. METHODS We used Center for Medicare Services 100% inpatient Limited Data Set (LDS) files from January 2013 through September 2015 to calculate an observed to expected standardized colon resection ratio for each hospital referral region (HRR). We then analyzed patient, hospital-, and market-level factors associated with variation of colectomy. For each HRR, a Herfindahl-Hirschman index, a measure of market competition, was calculated. RESULTS A total of 19,557 Medicare patients underwent an elective colon resection for diverticulitis at 2462 hospitals over the study period. Standardized colon resection ratios ranged from 0 in the Tuscaloosa HRR to 3.7 in the Royal Oak, MI HRR. Few patient factors were associated with variation, but a number of hospital factors (size, area, profit status, and critical access designation) all were associated with variation. In an analysis of market factors, increased surgeon density, and decreased market competition were associated with higher predicted rates of colon resection. CONCLUSION We observed pronounced variation (excess of 3-fold) in standardized colon resection ratios for recurrent diverticulitis. Surgeon density and hospital level factors were strongly associated with this variation and may be the main drivers of colonic resection for diverticular disease. Further investigation and stronger national guidelines are needed to optimize patient selection for colectomy.
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Affiliation(s)
- Alexander T Hawkins
- Section of Colon & Rectal Surgery, Department of Surgery, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Lauren R Samuels
- Department of Biostatistics, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Russell L Rothman
- Center for Health Services Research, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Timothy M Geiger
- Section of Colon & Rectal Surgery, Department of Surgery, Vanderbilt University Medical Center, Nashville, Tennessee
| | - David F Penson
- Department of Urology, Vanderbilt University Medical Center, Nashville, Tennessee
- GRECC, Tennessee Valley Healthcare System, Nashville, Tennessee
| | - Matthew J Resnick
- Department of Urology, Vanderbilt University Medical Center, Nashville, Tennessee
- Embold Health, Nashville, Tennessee
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Hamdan S, Kripalani S, Geiger TM, Dennis BM, Ford MM, Zhao Z, Ye F, Hawkins AT. Far from black and white: Role of race, health literacy, and socioeconomic factors in the presentation of acute diverticulitis. Surgery 2021; 170:1637-1643. [PMID: 34183181 DOI: 10.1016/j.surg.2021.05.049] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2021] [Revised: 04/01/2021] [Accepted: 05/27/2021] [Indexed: 11/29/2022]
Abstract
BACKGROUND Racial discrepancies in treatment and outcomes of acute diverticulitis have been observed, yet underlying factors are poorly understood. We aimed to identify racial inequalities in health literacy among patients hospitalized with acute diverticulitis and characterize factors associated with more severe presentation. METHODS We performed retrospective cohort analysis of 947 Black or White patients admitted with acute diverticulitis at a quaternary referral center from January 2009 through September 2019. Health literacy was determined by the validated Brief Health Literacy Screening, and socioeconomic status was defined by area deprivation index, a composite of multiple neighborhood socioeconomic deprivation measures. The primary outcome was severity of disease presentation represented by systemic inflammatory response syndrome criteria; secondary outcomes included intensive care unit admission, length of stay, and invasive interventions. RESULTS Among all study participants, 121 (12.8%) self-identified as Black. Overall, 140 (14.8%) patients had inadequate health literacy, and 495 (52.3%) had area deprivation index greater than the national median. There was no association between race or area deprivation index and health literacy. A total of 340 (35.9%) patients met criteria for systemic inflammatory response syndrome, and 88 (9.3%) underwent an intervention; median length of stay was 3.5 days. Race, health literacy, and area deprivation index were not significantly associated with outcomes (P > .05). CONCLUSION Among patients with acute diverticulitis, no difference in severity of presentation by race, health literacy, or area deprivation index was observed. These findings suggest that differences in presentation of acute diverticulitis may not be driven by these social factors. Future studies should include considerations of clinical characteristics of acute diverticulitis, such as the role of access and underuse of healthcare resources.
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Affiliation(s)
- Saif Hamdan
- Vanderbilt University School of Medicine, Nashville, TN
| | - Sunil Kripalani
- Center for Clinical Quality and Implementation Research, Vanderbilt University Medical Center, Nashville, TN; Department of Medicine, Vanderbilt University Medical Center, Nashville, TN
| | - Timothy M Geiger
- Department of Surgery, Division of Colon & Rectal Surgery, Vanderbilt University Medical Center, Nashville, TN
| | - Bradley M Dennis
- Department of Surgery, Division of Trauma and Surgical Critical Care, Vanderbilt University Medical Center, Nashville, TN
| | - Molly M Ford
- Department of Surgery, Division of Colon & Rectal Surgery, Vanderbilt University Medical Center, Nashville, TN
| | - Zhiguo Zhao
- Department of Biostatistics, Vanderbilt University Medical Center, Nashville, TN
| | - Fei Ye
- Department of Biostatistics, Vanderbilt University Medical Center, Nashville, TN
| | - Alexander T Hawkins
- Department of Surgery, Division of Colon & Rectal Surgery, Vanderbilt University Medical Center, Nashville, TN.
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Arhin ND, Shen C, Bailey CE, Matsuoka LK, Hawkins AT, Holowatyj AN, Ciombor KK, Hopkins MB, Geiger TM, Kam AE, Roth MT, Lebeck Lee CM, Lapelusa M, Dasari A, Eng C. Surgical resection and survival outcomes in metastatic young adult colorectal cancer patients. Cancer Med 2021; 10:4269-4281. [PMID: 34132476 PMCID: PMC8267130 DOI: 10.1002/cam4.3940] [Citation(s) in RCA: 3] [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] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2021] [Revised: 04/09/2021] [Accepted: 04/12/2021] [Indexed: 12/17/2022] Open
Abstract
Background The incidence of colorectal cancer in adults younger than age 50 has increased with rates expected to continue to increase over the next decade. The objective of this study is to examine the survival benefit of surgical resection (primary and/or metastatic) versus palliative therapy in this patient population. Methods We identified 6708 young adults aged 18–45 years diagnosed with metastatic colorectal cancer (mCRC) from 2004 to 2015 from the SEER database. Overall survival (OS) was analyzed using Kaplan–Meier estimation, log rank test, and multivariate Cox proportional hazards model. Results Sixty‐three percent of patients in our study underwent primary tumor resection (PTR), with 40% undergoing PTR alone and 23% undergoing both resection of primary disease and metastasectomy. The median OS for patients who underwent both PTR and metastasectomy was 36 months, compared to 13 months for those who did not receive any surgical intervention. The multivariate analysis showed significant OS benefit of receiving both PTR and metastasectomy (HR 0.34, 95% CI: 0.31–0.37, p < 0.001) compared to palliative therapy. Undergoing PTR only and metastasectomy only were also associated with improved OS (HR 0.46, 95% CI: 0.43–0.49, p < 0.001 and HR 0.64, 95% CI: 0.55–0.76, p < 0.001, respectively). Conclusion This is the largest observational study to evaluate survival outcomes in young‐onset mCRC patients and the role of surgical intervention of the primary and/or metastatic site. Our study provides evidence of statistically significant increase in OS for young mCRC patients who undergo surgical intervention of the primary and/or metastatic site.
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Affiliation(s)
- Nina D Arhin
- Division of Hematology and Oncology, Department of Internal Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Chan Shen
- Department of Surgery, Department of Public Health Sciences, Penn State College of Medicine, Hershey, PA, USA
| | - Christina E Bailey
- Division of Surgical Oncology and Endocrine Surgery, Department of Surgery, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Lea K Matsuoka
- Division of Hepatobiliary Surgery and Liver Transplantation, Department of Surgery, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Alexander T Hawkins
- Section of Colon & Rectal Surgery, Department of Surgery, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Andreana N Holowatyj
- Department of Medicine, Vanderbilt University Medical Center/Vanderbilt-Ingram Cancer Center, Nashville, TN, USA
| | - Kristen K Ciombor
- Division of Hematology and Oncology, Department of Internal Medicine, Vanderbilt University Medical Center/Vanderbilt-Ingram Cancer Center, Nashville, TN, USA
| | - Michael B Hopkins
- Division of General Surgery, Colon and Rectal Surgery, Department of Surgery, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Timothy M Geiger
- Division of General Surgery, Colon and Rectal Surgery, Department of Surgery, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Audrey E Kam
- Division of Hematology, Oncology and Cell Therapy, Department of Internal Medicine, Rush University Medical Center, Chicago, IL, USA
| | - Marc T Roth
- Division of Hematology and Oncology, Department of Internal Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
| | | | - Michael Lapelusa
- Department of Internal Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Arvind Dasari
- Department of Gastrointestinal Medical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Cathy Eng
- Division of Hematology and Oncology, Department of Internal Medicine, Vanderbilt University Medical Center/Vanderbilt-Ingram Cancer Center, Nashville, TN, USA
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Cimino SK, Ciombor KK, Chakravarthy AB, Bailey CE, Hopkins MB, Geiger TM, Hawkins AT, Eng C. Safety considerations with new treatment regimens for anal cancer. Expert Opin Drug Saf 2021; 20:889-902. [PMID: 33900857 DOI: 10.1080/14740338.2021.1915281] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
Introduction: Anal cancer is a rare malignancy, but incidence rates are rising. Primary chemoradiation is the standard of care for early disease with surgery reserved for salvage. Despite success in terms of survival, patients suffer significant morbidity. Research is underway to advance the field and improve outcomes for these patients.Areas covered: This review aims to discuss the safety and efficacy of new approaches to treat anal cancer. A literature search was performed from January 1950 through November 2020 via PubMed and ClinicalTrials.gov databases to obtain data from ongoing or published studies examining new regimens for the treatment of anal cancers. Pertinent topics covered include miniature drug conjugates, epidermal growth factor receptor inhibitors, checkpoint inhibitor combinations, and novel immunomodulators.Expert opinion: Based on emerging clinical data, the treatment paradigm for anal cancer is likely to shift in the upcoming years. One of the largest areas of investigation is the field of immunotherapy, which may emerge as an integral component of anal cancer for all treatment settings.
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Affiliation(s)
- Sarah K Cimino
- Department of Pharmacy, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Kristen K Ciombor
- Department of Medicine: Division of Hematology and Oncology, Vanderbilt University Medical Center, Nashville, TN, USA
| | - A Bapsi Chakravarthy
- Department of Radiation Oncology, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Christina E Bailey
- Department of Surgery: Division of Surgical Oncology and Endocrine Surgery, Vanderbilt University Medical Center, Nashville, TN, USA
| | - M Benjamin Hopkins
- Department of Surgery: Division of Colon and Rectal Surgery, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Timothy M Geiger
- Department of Surgery: Division of Colon and Rectal Surgery, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Alexander T Hawkins
- Department of Surgery: Division of Colon and Rectal Surgery, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Cathy Eng
- Department of Medicine: Division of Hematology and Oncology, Vanderbilt University Medical Center, Nashville, TN, USA
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Rakhit S, Geiger TM. Technical considerations for elective colectomy for diverticulitis. Seminars in Colon and Rectal Surgery 2021. [DOI: 10.1016/j.scrs.2020.100801] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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Kelly Wu W, Tombazzi CR, Howe CF, Kendall MA, Walton DB, Washington MK, Ford MM, Hopkins MB, Geiger TM, Hawkins AT, Muldoon RL. Idiopathic Myointimal Hyperplasia of the Mesenteric Veins: A Rare Imitator of Inflammatory Bowel Disease. Am Surg 2020:3134820973390. [PMID: 33342253 DOI: 10.1177/0003134820973390] [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] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Idiopathic myointimal hyperplasia of the mesenteric veins (IMHMV) is a rare cause of chronic colonic ischemia characterized by intimal smooth muscle proliferation and luminal narrowing of the small to medium sized mesenteric veins. It predominantly affects the rectosigmoid colon in otherwise healthy, middle-aged males. Definitive diagnosis and treatment are surgical; however, patients are frequently misdiagnosed, which often results in a protracted clinical course. We describe a case of IMHMV presenting as left hemicolitis in a 53-year-old male, as well as the endoscopic, histopathologic, and radiographic findings that established the diagnosis.
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Affiliation(s)
- W Kelly Wu
- Department of Surgery, 12328Vanderbilt University Medical Center, Nashville, TN, USA
| | - Claudio R Tombazzi
- Department of Medicine, 12328Vanderbilt University Medical Center, Nashville, TN, USA
| | - Catherine F Howe
- Department of Medicine, Division of Gastroenterology, 12328Vanderbilt University Medical Center, Nashville, TN, USA
| | - Melissa A Kendall
- Department of Surgery, 7831University of South Florida, Tampa, FL, USA
| | - Douglas B Walton
- Department of Pathology, 12328Vanderbilt University Medical Center, Nashville, TN, USA
| | - Mary K Washington
- Department of Pathology, 12328Vanderbilt University Medical Center, Nashville, TN, USA
| | - Molly M Ford
- Section of Colon and Rectal Surgery, Department of Surgery, 12328Vanderbilt University Medical Center, Nashville, TN, USA
| | - Michael B Hopkins
- Section of Colon and Rectal Surgery, Department of Surgery, 12328Vanderbilt University Medical Center, Nashville, TN, USA
| | - Timothy M Geiger
- Section of Colon and Rectal Surgery, Department of Surgery, 12328Vanderbilt University Medical Center, Nashville, TN, USA
| | - Alexander T Hawkins
- Section of Colon and Rectal Surgery, Department of Surgery, 12328Vanderbilt University Medical Center, Nashville, TN, USA
| | - Roberta L Muldoon
- Section of Colon and Rectal Surgery, Department of Surgery, 12328Vanderbilt University Medical Center, Nashville, TN, USA
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McEvoy MD, Wanderer JP, Shi Y, Ramanujan KS, Geiger TM, Shotwell MS, Shaw AD, Hawkins AT, Martin BJ, Mythen MG, Sandberg WS. The effect of adding goal-directed hemodynamic management for elective patients in an established enhanced recovery program for colorectal surgery: results of quasi-experimental pragmatic trial. Perioper Med (Lond) 2020; 9:35. [PMID: 33292514 PMCID: PMC7682072 DOI: 10.1186/s13741-020-00163-3] [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] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2020] [Accepted: 10/29/2020] [Indexed: 02/04/2023] Open
Abstract
Background Recent literature has demonstrated that hemodynamic instability in the intraoperative period places patients at risk of poor outcomes. Furthermore, recent studies have reported that stroke volume optimization and protocolized hemodynamic management may improve perioperative outcomes, especially surgical site infection (SSI), in certain high-risk populations. However, the optimal strategy for intraoperative management of all elective patients within an enhanced recovery program remains to be elucidated. Methods We performed a pre-post quasi-experimental study to assess the effect of adding goal-directed hemodynamic therapy to an enhanced recovery program (ERP) for colorectal surgery on SSI and other outcomes. Three groups were compared: “Pre-ERP,” defined as historical control (before enhanced recovery program); “ERP,” defined as enhanced recovery program using zero fluid balance; and “ERP+GDHT,” defined as enhanced recovery program plus goal-directed hemodynamic therapy. Outcomes were obtained through our National Surgical Quality Improvement Program participation. Results A total of 623 patients were included in the final analysis (Pre-ERP = 246, ERP = 140, and ERP + GDHT = 237). Demographics and baseline clinical characteristics were balanced between groups. We did not observe statistically significant differences in SSI or composite complication rates in unadjusted or adjusted analysis. There was no evidence of association between study group and 30-day readmission. American Society of Anesthesiologists status ≥ 3 and open surgical approach were significantly associated with increased risk of SSI, composite complication, and 30-day readmission (p < 0.05 for all) in all groups. Conclusions There was no evidence that addition of goal-directed hemodynamic therapy for all patients in an enhanced recovery program for colorectal surgery affects the risk of SSI, composite complications, or 30-day readmission. Further research is needed to investigate whether there is benefit of goal-directed hemodynamic therapy for select high-risk populations. Trial registration NCT03189550. Registered 16 June 2017–Retrospectively registered, https://www.clinicaltrials.gov/ct2/results?cond=&term=NCT03189550&cntry=&state=&city=&dist=
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Affiliation(s)
- Matthew D McEvoy
- Department of Anesthesiology, Vanderbilt University Medical Center, 1301 Medical Center Drive, TVC 4648, Nashville, TN, 37232, USA.
| | - Jonathan P Wanderer
- Department of Anesthesiology, Vanderbilt University Medical Center, 1301 Medical Center Drive, TVC 4648, Nashville, TN, 37232, USA
| | - Yaping Shi
- Department of Biostatistics, Vanderbilt University Medical Center, 1301 Medical Center Drive, TVC 4648, Nashville, TN, 37232, USA
| | - Krishnan S Ramanujan
- Department of Anesthesiology, Vanderbilt University Medical Center, 1301 Medical Center Drive, TVC 4648, Nashville, TN, 37232, USA
| | - Timothy M Geiger
- Department of Surgery, Vanderbilt University Medical Center, 1301 Medical Center Drive, TVC 4648, Nashville, TN, 37232, USA
| | - Matthew S Shotwell
- Department of Biostatistics, Vanderbilt University Medical Center, 1301 Medical Center Drive, TVC 4648, Nashville, TN, 37232, USA
| | - Andrew D Shaw
- Department of Anesthesiology & Pain Medicine, University of Alberta, Edmonton, Alberta, Canada
| | - Alexander T Hawkins
- Department of Surgery, Vanderbilt University Medical Center, 1301 Medical Center Drive, TVC 4648, Nashville, TN, 37232, USA
| | - Barbara J Martin
- Department of Quality, Safety & Risk Prevention, Vanderbilt University Medical Center, 1301 Medical Center Drive, TVC 4648, Nashville, TN, 37232, USA
| | - Michael G Mythen
- University College London Hospitals National Institute of Health Research Biomedical Research Centre, London, UK
| | - Warren S Sandberg
- Department of Anesthesiology, Vanderbilt University Medical Center, 1301 Medical Center Drive, TVC 4648, Nashville, TN, 37232, USA
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13
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Hawkins AT, Rothman RL, Geiger TM, Canedo J, Edwards-Hollingsworth K, LaNeve DC, Penson DF. Patient-Reported Outcome Measures in Colon and Rectal Surgery: A Systematic Review and Quality Assessment. Dis Colon Rectum 2020; 63:1156-1167. [PMID: 32692077 PMCID: PMC8029646 DOI: 10.1097/dcr.0000000000001717] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND There is growing interest in using patient-reported outcome measures to support value-based care in colorectal surgery. To draw valid conclusions regarding patient-reported outcomes data, measures with robust measurement properties are required. OBJECTIVE The purpose of this study was to assess the use and quality of patient-reported outcome measures in colorectal surgery. DATA SOURCES Three major databases were searched for studies using patient-reported outcome measures in the context of colorectal surgery. STUDY SELECTION Articles that used patient-reported outcome measures as outcome for colorectal surgical intervention in a comparative effectiveness analysis were included. Exclusion criteria included articles older than 11 years, non-English language, age <18 years, fewer than 40 patients, case reports, review articles, and studies without comparison. MAIN OUTCOME MEASURES This was a quality assessment using a previously reported checklist of psychometric properties. RESULTS From 2007 to 2018, 368 studies were deemed to meet inclusion criteria. These studies used 165 distinct patient-reported outcome measures. Thirty were used 5 or more times and were selected for quality assessment. Overall, the measures were generally high quality, with 21 (70%) scoring ≥14 on an 18-point scale. Notable weaknesses included management of missing data (14%) and description of literacy level (0%). LIMITATIONS The study was limited by its use of original articles for quality assessment. Measures were selected for quality analysis based on frequency of use rather than other factors, such as impact of the article or number of patients in the study. CONCLUSIONS Patient-reported outcome measures are widely used in colorectal research. There was a wide range of measures available, and many were used only once. The most frequently used measures are generally high quality, but a majority lack details on how to deal with missing data and information on literacy levels. As the use of patient-reported outcome measures to assess colorectal surgical intervention increases, researchers and practitioners need to become more knowledgeable about the measures available and their quality.
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Affiliation(s)
- Alexander T. Hawkins
- Vanderbilt University Medical Center, Department of General Surgery, Section of Colon & Rectal Surgery, Nashville, TN
| | - Russell L. Rothman
- Vanderbilt University Medical Center, Center for Health Services Research, Nashville, TN
| | - Timothy M. Geiger
- Vanderbilt University Medical Center, Department of General Surgery, Section of Colon & Rectal Surgery, Nashville, TN
| | - Juan Canedo
- Vanderbilt University Medical Center, Center for Health Services Research, Nashville, TN
| | - Kamren Edwards-Hollingsworth
- Vanderbilt University Medical Center, Department of General Surgery, Section of Colon & Rectal Surgery, Nashville, TN
| | - David C. LaNeve
- Vanderbilt University Medical Center, Department of General Surgery, Section of Colon & Rectal Surgery, Nashville, TN
| | - David F. Penson
- Vanderbilt University Medical Center, Department of Urologic Surgery, Nashville, TN
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14
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Kavalukas SL, Baucom RB, Geiger TM, Ford MM, Muldoon RL, Cavin NA, Killion BE, Hopkins MB, Rothman RL, Penson DF, Hawkins AT. Benchmarking patient satisfaction scores in a colorectal patient population. Surg Endosc 2020; 35:309-316. [PMID: 32040633 DOI: 10.1007/s00464-020-07401-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2018] [Accepted: 01/30/2020] [Indexed: 11/28/2022]
Abstract
BACKGROUND Healthcare reimbursement is rapidly moving away from a fee-for-service model toward value-based purchasing. An integral component of this new focus on quality is patient-centered outcomes. One metric used to define patient satisfaction is the Press Ganey Patient Satisfaction Survey. Data are lacking to accurately benchmark these scores based on diagnosis. We sought to identify if different colorectal disease processes affected a patient's perception of their healthcare experience. METHODS Adult colorectal patients seen between July 2015 and September 2016 in a tertiary hospital colorectal clinic were mailed a Press Ganey survey. Patients were stratified based on diagnosis: neoplasia, IBD, anorectal and benign colorectal disease. Survey scores were compared across the groups with adjustment for confounding variables. RESULTS 312 patients responded and formed the cohort. The mean age was 61 (range 18-93) and 56% were women. The cohort breakdown was 38% neoplasia, 32% anorectal, 21% benign, and 9% IBD. In a multivariable model, there was a difference in PG scores by diagnosis; patients with neoplasia had higher Overall scores (β 10.2; Std Error 4.0; p = 0.01), Care Provider scores (β 8.5; Std Error 4.2; p = 0.04), Nurse Assistant scores (β 15.0; Std Error 5.7; p = 0.01), and Personal Issues scores (β 11.8; Std Error 5/0; p = 0.01). CONCLUSION Press Ganey scores were found to vary significantly. Patients with a neoplasia diagnosis reported higher overall satisfaction, Care Provider, Nurse Assistant, and Personal Issues scores. Adjustment for disease condition is important when assessing patient satisfaction as an indicator of quality and as a metric for reimbursement. This study adds to increasing evidence about bias in these scores.
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Affiliation(s)
- Sandra L Kavalukas
- Division of General Surgery, Colon and Rectal Surgery, Vanderbilt University Medical Center, 1161 21st Ave South, Room D5248 MCN, Nashville, TN, 37232, USA
| | - Rebeccah B Baucom
- Division of General Surgery, Colon and Rectal Surgery, Vanderbilt University Medical Center, 1161 21st Ave South, Room D5248 MCN, Nashville, TN, 37232, USA
| | - Timothy M Geiger
- Division of General Surgery, Colon and Rectal Surgery, Vanderbilt University Medical Center, 1161 21st Ave South, Room D5248 MCN, Nashville, TN, 37232, USA
| | - Molly M Ford
- Division of General Surgery, Colon and Rectal Surgery, Vanderbilt University Medical Center, 1161 21st Ave South, Room D5248 MCN, Nashville, TN, 37232, USA
| | - Roberta L Muldoon
- Division of General Surgery, Colon and Rectal Surgery, Vanderbilt University Medical Center, 1161 21st Ave South, Room D5248 MCN, Nashville, TN, 37232, USA
| | - Nicholas A Cavin
- Division of General Surgery, Colon and Rectal Surgery, Vanderbilt University Medical Center, 1161 21st Ave South, Room D5248 MCN, Nashville, TN, 37232, USA
| | - Benjamin E Killion
- Division of General Surgery, Colon and Rectal Surgery, Vanderbilt University Medical Center, 1161 21st Ave South, Room D5248 MCN, Nashville, TN, 37232, USA
| | - M Benjamin Hopkins
- Division of General Surgery, Colon and Rectal Surgery, Vanderbilt University Medical Center, 1161 21st Ave South, Room D5248 MCN, Nashville, TN, 37232, USA
| | - Russell L Rothman
- Center for Health Services Research, Vanderbilt University Medical Center, Nashville, TN, USA
| | - David F Penson
- Department of Urologic Surgery, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Alexander T Hawkins
- Division of General Surgery, Colon and Rectal Surgery, Vanderbilt University Medical Center, 1161 21st Ave South, Room D5248 MCN, Nashville, TN, 37232, USA.
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Wu CL, King AB, Geiger TM, Grant MC, Grocott MPW, Gupta R, Hah JM, Miller TE, Shaw AD, Gan TJ, Thacker JKM, Mythen MG, McEvoy MD. American Society for Enhanced Recovery and Perioperative Quality Initiative Joint Consensus Statement on Perioperative Opioid Minimization in Opioid-Naïve Patients. Anesth Analg 2020; 129:567-577. [PMID: 31082966 DOI: 10.1213/ane.0000000000004194] [Citation(s) in RCA: 77] [Impact Index Per Article: 19.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
Surgical care episodes place opioid-naïve patients at risk for transitioning to new persistent postoperative opioid use. With one of the central principles being the application of multimodal pain interventions to reduce the reliance on opioid-based medications, enhanced recovery pathways provide a framework that decreases perioperative opioid use. The fourth Perioperative Quality Initiative brought together a group of international experts representing anesthesiology, surgery, and nursing with the objective of providing consensus recommendations on this important topic. Fourth Perioperative Quality Initiative was a consensus-building conference designed around a modified Delphi process in which the group alternately convened for plenary discussion sessions in between small group discussions. The process included several iterative steps including a literature review of the topics, building consensus around the important questions related to the topic, and sequential steps of content building and refinement until agreement was achieved and a consensus document was produced. During the fourth Perioperative Quality Initiative conference and thereafter as a writing group, reference applicability to the topic was discussed in any area where there was disagreement. For this manuscript, the questions answered included (1) What are the potential strategies for preventing persistent postoperative opioid use? (2) Is opioid-free anesthesia and analgesia feasible and appropriate for routine operations? and (3) Is opioid-free (intraoperative) anesthesia associated with equivalent or superior outcomes compared to an opioid minimization in the perioperative period? We will discuss the relevant literature for each questions, emphasize what we do not know, and prioritize the areas for future research.
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Affiliation(s)
- Christopher L Wu
- From the Department of Anesthesiology, Hospital for Special Surgery, New York, New York.,Department of Anesthesiology, Weill Cornell Medicine, New York, New York.,The Armstrong Institute for Patient Safety and Quality, Johns Hopkins Medicine, Baltimore, Maryland
| | - Adam B King
- Department of Anesthesiology, Vanderbilt, Vanderbilt University School of Medicine and University Medical Center, Nashville, Tennessee
| | - Timothy M Geiger
- Department of Surgery, Vanderbilt, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Michael C Grant
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins School of Medicine, Baltimore, Maryland
| | - Michael P W Grocott
- Department of Anaesthesia, Perioperative Medicine and Critical Care, Southampton National Institute of Health Research Biomedical Research Centre, University Hospital Southampton National Health Service (NHS) Foundation Trust/University of Southampton, Southampton, United Kingdom
| | - Ruchir Gupta
- Department of Anesthesiology, Stony Brook School of Medicine, Stony Brook, New York
| | - Jennifer M Hah
- Division of Pain Medicine, Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University, Palo Alto, California
| | - Timothy E Miller
- Department of Anesthesiology, Duke University Medical Center, Durham, North Carolina
| | - Andrew D Shaw
- Department of Anesthesiology and Pain Medicine, University of Alberta, Edmonton, Alberta, Canada
| | - Tong J Gan
- Department of Anesthesiology, Stony Brook School of Medicine, Stony Brook, New York
| | - Julie K M Thacker
- Department of Surgery, Duke University School of Medicine, Durham, North Carolina
| | - Michael G Mythen
- University College London Hospitals National Institute of Health Research Biomedical Research Centre, London, United Kingdom
| | - Matthew D McEvoy
- Department of Anesthesiology, Vanderbilt, Vanderbilt University School of Medicine and University Medical Center, Nashville, Tennessee
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Raymond BL, Wanderer JP, Hawkins AT, Geiger TM, Ehrenfeld JM, Stokes JW, McEvoy MD. Use of the American College of Surgeons National Surgical Quality Improvement Program Surgical Risk Calculator During Preoperative Risk Discussion: The Patient Perspective. Anesth Analg 2019; 128:643-650. [PMID: 30169413 DOI: 10.1213/ane.0000000000003718] [Citation(s) in RCA: 23] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
BACKGROUND The American College of Surgeons (ACS) National Surgical Quality Improvement Program Surgical Risk Calculator (ACS Calculator) provides empirically derived, patient-specific risks for common adverse perioperative outcomes. The ACS Calculator is promoted as a tool to improve shared decision-making and informed consent for patients undergoing elective operations. However, to our knowledge, no data exist regarding the use of this tool in actual preoperative risk discussions with patients. Accordingly, we performed a survey to assess (1) whether patients find the tool easy to interpret, (2) how accurately patients can predict their surgical risks, and (3) the impact of risk disclosure on levels of anxiety and future motivations to decrease personal risk. METHODS Patients (N = 150) recruited from a preoperative clinic completed an initial survey where they estimated their hospital length of stay and personal perioperative risks of the 12 clinical complications analyzed by the ACS Calculator. Next, risk calculation was performed by entering participants' demographics into the ACS Calculator. Participants reviewed their individualized risk reports in detail and then completed a follow-up survey to evaluate their perceptions. RESULTS Nearly 90% of participants desire to review their ACS Calculator report before future surgical consents. High-risk patients were 3 times more likely to underestimate their risk of any complication, serious complication, and length of stay compared to low-risk patients (P < .001). After reviewing their calculated risks, 70% stated that they would consider participating in prehabilitation to decrease perioperative risk, and nearly 40% would delay their surgery to do so. Knowledge of personal ACS risk calculations had no effect on anxiety in 20% and decreased anxiety in 71% of participants. CONCLUSIONS The ACS Calculator may be of particular benefit to high-risk surgical populations by providing realistic expectations of outcomes and recovery. Use of this tool may also provide motivation for patients to participate in risk reduction strategies.
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Affiliation(s)
| | | | | | - Timothy M Geiger
- General Surgery, Vanderbilt University Medical Center, Nashville, Tennessee
| | | | - John W Stokes
- General Surgery, Vanderbilt University Medical Center, Nashville, Tennessee
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17
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Edwards DA, Hedrick TL, Jayaram J, Argoff C, Gulur P, Holubar SD, Gan TJ, Mythen MG, Miller TE, Shaw AD, Thacker JKM, McEvoy MD, Geiger TM, Gordon DB, Grant MC, Grocott M, Gupta R, Hah JM, Hurley RW, Kent ML, King AB, Oderda GM, Sun E, Wu CL. American Society for Enhanced Recovery and Perioperative Quality Initiative Joint Consensus Statement on Perioperative Management of Patients on Preoperative Opioid Therapy. Anesth Analg 2019; 129:553-566. [DOI: 10.1213/ane.0000000000004018] [Citation(s) in RCA: 45] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
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18
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Hopkins MB, Geiger TM, Bethurum AJ, Ford MM, Muldoon RL, Beck DE, Stewart TG, Hawkins AT. Comparing pathologic outcomes for robotic versus laparoscopic Surgery in rectal cancer resection: a propensity adjusted analysis of 7616 patients. Surg Endosc 2019; 34:2613-2622. [PMID: 31346754 DOI: 10.1007/s00464-019-07032-1] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2019] [Accepted: 07/19/2019] [Indexed: 02/06/2023]
Abstract
BACKGROUND Margin negative resection of rectal cancer with minimally invasive techniques remains technically challenging. Robotic surgery has potential advantages over traditional laparoscopy. We hypothesize that the difference in the rate of negative margin status will be < 6% between laparoscopic and robotic approach. METHODS The National Cancer Database (2010-2014) was queried for adults with locally advanced rectal cancer who underwent neoadjuvant chemoradiation and curative resection to conduct an observational retrospective cohort study of a prospectively maintained database. Patients were grouped by either robotic (ROB) or laparoscopic (LAP) approach in an intent-to-treat analysis. Primary outcome was negative margin status, defined as a composite of circumferential resection margin and distal margin. Secondary outcomes included length of stay (LOS), readmission, 90-day mortality, and overall survival. RESULTS 7616 patients with locally advanced rectal cancer who underwent minimally invasive resection were identified. 2472 (32%) underwent attempted robotic approach. The overall conversion rate was 13% and was increased in the laparoscopic group [LAP: 15% vs. ROB: 8%; OR 0.47; 95% CI (0.39, 0.57)]. Differences in margin negative resection rate were within the prespecified range of practical equivalence (LAP: 93% vs.: ROB 94%; 95% CI (0.69, 1.06); [Formula: see text] = 1). For secondary outcomes, there was no difference in 30-day readmission [LAP: 9% vs.: ROB 8%; 95% CI (0.84, 1.24)] and 90-day mortality [LAP: 1% vs.: ROB 1%; 95% CI (0.38, 1.24)]. While the median LOS was 5 days in both groups, the mean LOS was 0.6 (95% CI: 0.24, 0.89) days shorter in the robotic group. CONCLUSION This robust analysis supports either robotic or laparoscopic approach for resection of locally advanced rectal cancer from a margin perspective. Both have similar readmission and 5-year overall survival rates. Patients undergoing robotic surgery have a 0.6-day decrease in LOS and decreased conversion rate.
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Affiliation(s)
- M Benjamin Hopkins
- Section of Colon & Rectal Surgery, Division of General Surgery, Vanderbilt University Medical Center, Vanderbilt University, 1161 21st Ave South, Room D5248 MCN, Nashville, TN, 37232, USA
| | - Timothy M Geiger
- Section of Colon & Rectal Surgery, Division of General Surgery, Vanderbilt University Medical Center, Vanderbilt University, 1161 21st Ave South, Room D5248 MCN, Nashville, TN, 37232, USA
| | - Alva J Bethurum
- Section of Colon & Rectal Surgery, Division of General Surgery, Vanderbilt University Medical Center, Vanderbilt University, 1161 21st Ave South, Room D5248 MCN, Nashville, TN, 37232, USA
| | - Molly M Ford
- Section of Colon & Rectal Surgery, Division of General Surgery, Vanderbilt University Medical Center, Vanderbilt University, 1161 21st Ave South, Room D5248 MCN, Nashville, TN, 37232, USA
| | - Roberta L Muldoon
- Section of Colon & Rectal Surgery, Division of General Surgery, Vanderbilt University Medical Center, Vanderbilt University, 1161 21st Ave South, Room D5248 MCN, Nashville, TN, 37232, USA
| | - David E Beck
- Section of Colon & Rectal Surgery, Division of General Surgery, Vanderbilt University Medical Center, Vanderbilt University, 1161 21st Ave South, Room D5248 MCN, Nashville, TN, 37232, USA
| | - Thomas G Stewart
- Department of Biostatistics, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Alexander T Hawkins
- Section of Colon & Rectal Surgery, Division of General Surgery, Vanderbilt University Medical Center, Vanderbilt University, 1161 21st Ave South, Room D5248 MCN, Nashville, TN, 37232, USA.
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19
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Maguire LH, Geiger TM, Hardiman KM, Regenbogen SE, Hopkins MB, Muldoon RL, Ford MM, Hawkins AT. Surgical management of primary colonic lymphoma: Big data for a rare problem. J Surg Oncol 2019; 120:431-437. [PMID: 31187517 DOI: 10.1002/jso.25582] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2019] [Accepted: 05/11/2019] [Indexed: 12/15/2022]
Abstract
BACKGROUND AND OBJECTIVES Primary colonic lymphoma (PCL) is rare, heterogeneous, and presents a therapeutic challenge for surgeons. Optimal treatment strategies are difficult to standardize, leading to variation in therapy. Our objective was to describe the patient characteristics, short-term outcomes, and five-year survival of patients undergoing nonpalliative surgery for PCL. METHODS We performed a retrospective cohort analysis in the National Cancer Database. Included patients underwent surgery for PCL between 2004 to 2014. Patients with metastases and palliative operations were excluded. Univariate predictors of overall survival were analyzed using multivariable Cox proportional hazard analysis. RESULTS We identified 2153 patients. Median patient age was 68. Diffuse large B-cell lymphoma accounted for 57% of tumors. 30- and 90-Day mortality were high (5.6% and 11.1%, respectively). Thirty-nine percent of patients received adjuvant chemotherapy. For patients surviving 90 days, 5-year survival was 71.8%. Chemotherapy improved survival (surgery+chemo, 75.4% vs surgery, 68.6%; P = .01). Adjuvant chemotherapy was associated with overall survival after controlling for age, comorbidity, and lymphoma subtype (HR 1.27; 95% CI, 1.07-1.51; P = .01). CONCLUSIONS Patients undergoing surgery for PCL have high rates of margin positivity and high short-term mortality. Chemotherapy improves survival, but <50% receive it. These data suggest the opportunity for improvement of care in patients with PCL.
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Affiliation(s)
- Lillias H Maguire
- Division of Colorectal Surgery, Department of Surgery, University of Michigan, Ann Arbor, Michigan
| | - Timothy M Geiger
- Section of Colon & Rectal Surgery, Department of Surgery, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Karin M Hardiman
- Division of Colorectal Surgery, Department of Surgery, University of Michigan, Ann Arbor, Michigan
| | - Scott E Regenbogen
- Division of Colorectal Surgery, Department of Surgery, University of Michigan, Ann Arbor, Michigan
| | - Michael Benjamin Hopkins
- Section of Colon & Rectal Surgery, Department of Surgery, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Roberta L Muldoon
- Section of Colon & Rectal Surgery, Department of Surgery, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Molly M Ford
- Section of Colon & Rectal Surgery, Department of Surgery, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Alexander T Hawkins
- Section of Colon & Rectal Surgery, Department of Surgery, Vanderbilt University Medical Center, Nashville, Tennessee
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McCutcheon T, Hawkins AT, Muldoon RL, Hopkins MB, Geiger TM, Ford MM. Correction to: Progression of anal intraepithelial neoplasia in HIV-positive individuals: predisposing factors. Tech Coloproctol 2019; 23:611. [PMID: 31168776 DOI: 10.1007/s10151-019-02012-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
Unfortunately, the "Informed consent" statement was incorrectly published in the original version. The complete correct reference should read as follows.
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Affiliation(s)
- T McCutcheon
- Department of General Surgery, Section of Colon and Rectal Surgery, Vanderbilt University Medical Center, 1161 21st Ave South, Room D5248 MCN, Nashville, TN, 37232, USA
| | - A T Hawkins
- Department of General Surgery, Section of Colon and Rectal Surgery, Vanderbilt University Medical Center, 1161 21st Ave South, Room D5248 MCN, Nashville, TN, 37232, USA.
| | - R L Muldoon
- Department of General Surgery, Section of Colon and Rectal Surgery, Vanderbilt University Medical Center, 1161 21st Ave South, Room D5248 MCN, Nashville, TN, 37232, USA
| | - M B Hopkins
- Department of General Surgery, Section of Colon and Rectal Surgery, Vanderbilt University Medical Center, 1161 21st Ave South, Room D5248 MCN, Nashville, TN, 37232, USA
| | - T M Geiger
- Department of General Surgery, Section of Colon and Rectal Surgery, Vanderbilt University Medical Center, 1161 21st Ave South, Room D5248 MCN, Nashville, TN, 37232, USA
| | - M M Ford
- Department of General Surgery, Section of Colon and Rectal Surgery, Vanderbilt University Medical Center, 1161 21st Ave South, Room D5248 MCN, Nashville, TN, 37232, USA
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Kavalukas SL, Hawkins AT, Baucom RB, Muldoon RL, Hopkins MB, Geiger TM, Ford MM. Patient Factors that Predict Completion Proctectomy in Crohn's Disease. Am Surg 2019; 85:431-433. [PMID: 31043206] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/09/2023]
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Kavalukas SL, Hawkins AT, Baucom RB, Muldoon RL, Hopkins MB, Geiger TM, Ford MM. Patient Factors that Predict Completion Proctectomy in Crohn's Disease. Am Surg 2019. [DOI: 10.1177/000313481908500436] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Affiliation(s)
- Sandra L. Kavalukas
- Division of General Surgery Section of Colon and Rectal Surgery Vanderbilt University Nashville, Tennessee
| | - Alexander T. Hawkins
- Division of General Surgery Section of Colon and Rectal Surgery Vanderbilt University Nashville, Tennessee
| | - Rebeccah B. Baucom
- Division of General Surgery Section of Colon and Rectal Surgery Vanderbilt University Nashville, Tennessee
| | - Roberta L. Muldoon
- Division of General Surgery Section of Colon and Rectal Surgery Vanderbilt University Nashville, Tennessee
| | - M. Benjamin Hopkins
- Division of General Surgery Section of Colon and Rectal Surgery Vanderbilt University Nashville, Tennessee
| | - Timothy M. Geiger
- Division of General Surgery Section of Colon and Rectal Surgery Vanderbilt University Nashville, Tennessee
| | - Molly M. Ford
- Division of General Surgery Section of Colon and Rectal Surgery Vanderbilt University Nashville, Tennessee
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Di Nizo DM, Hawkins AT, Stokes JW, Geiger TM, Wanderer JP, McEvoy MD. Gut Dysfunction as Etiology for Prolonged Length of Stay after an Enhanced Recovery Program Implementation. J Am Coll Surg 2018. [DOI: 10.1016/j.jamcollsurg.2018.08.289] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Ford MM, Kauffmann RM, Geiger TM, Hopkins MB, Muldoon RL, Hawkins AT. Resection for anal melanoma: Is there an optimal approach? Surgery 2018; 164:466-472. [PMID: 30041967 DOI: 10.1016/j.surg.2018.05.026] [Citation(s) in RCA: 9] [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] [Subscribe] [Scholar Register] [Received: 01/15/2018] [Revised: 03/30/2018] [Accepted: 05/05/2018] [Indexed: 01/13/2023]
Abstract
BACKGROUND Anal melanoma is a lethal disease, but its rarity makes understanding the behavior and effects of intervention challenging. Local resection and abdominal perineal resection are the proposed treatments for nonmetastatic disease. We hypothesize that there is no difference in overall survival between surgical therapies. METHODS The National Cancer Database (2004-2014) was queried for adults with a diagnosis of anal melanoma who underwent curative resection. Patients with metastatic disease were excluded. Patients were divided into 2 groups based on surgical approach (local resection versus abdominal perineal resection). Unadjusted and adjusted analyses were used to examine the association between surgical approach and R0 resection rate, short-term survival, and overall survival. RESULTS A total of 570 patients with anal melanoma who underwent resection were identified. The median age was 68 and 59% of patients were female. A total of 383 (67%) underwent local resection. Abdominal perineal resection was associated with higher rates of R0 resection rates (abdominal perineal resection 91% versus local resection 73%; P < .001). Overall 5-year survival for the entire cohort was 20%. There was no significant difference in 5-year overall survival (abdominal perineal resection 21% vs local resection 17%; P = .31). This persisted in a Cox proportional hazard multivariable model (odds ratio 0.84; 95% confidence interval 0.66-1.06; P = .15). Additionally, there was no improvement in overall survival for patients who underwent R0 resection (odds ratio 1.18; 95% confidence interval 0.90-1.56; P = .22). CONCLUSION Anal melanoma has a very poor prognosis, with only 1 of 5 patients alive at 5 years. Although local resection was associated with lower rates of R0 resection, there was no discernable difference in overall survival in both unadjusted and adjusted analysis.
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Affiliation(s)
- Molly M Ford
- Vanderbilt University, Division of General Surgery, Section of Colon & Rectal Surgery, Nashville, TN.
| | - Rondi M Kauffmann
- Vanderbilt University, Division of Surgical Oncology and Endocrine Surgery, Nashville, TN
| | - Timothy M Geiger
- Vanderbilt University, Division of General Surgery, Section of Colon & Rectal Surgery, Nashville, TN
| | - M Benjamin Hopkins
- Vanderbilt University, Division of General Surgery, Section of Colon & Rectal Surgery, Nashville, TN
| | - Roberta L Muldoon
- Vanderbilt University, Division of General Surgery, Section of Colon & Rectal Surgery, Nashville, TN
| | - Alexander T Hawkins
- Vanderbilt University, Division of General Surgery, Section of Colon & Rectal Surgery, Nashville, TN
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Hawkins AT, Sharp KW, Ford MM, Muldoon RL, Hopkins MB, Geiger TM. Management of colonoscopic perforations: A systematic review. Am J Surg 2018; 215:712-718. [DOI: 10.1016/j.amjsurg.2017.08.012] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2017] [Revised: 08/03/2017] [Accepted: 08/22/2017] [Indexed: 02/06/2023]
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Williams AD, Korolkova OY, Sakwe AM, Geiger TM, James SD, Muldoon RL, Herline AJ, Goodwin JS, Izban MG, Washington MK, Smoot DT, Ballard BR, Gazouli M, M'Koma AE. Correction: Human alpha defensin 5 is a candidate biomarker to delineate inflammatory bowel disease. PLoS One 2017; 12:e0189551. [PMID: 29211779 PMCID: PMC5718520 DOI: 10.1371/journal.pone.0189551] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Abstract
[This corrects the article DOI: 10.1371/journal.pone.0179710.].
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Hawkins AT, Ford MM, Benjamin Hopkins M, Muldoon RL, Wanderer JP, Parikh AA, Geiger TM. Barriers to laparoscopic colon resection for cancer: a national analysis. Surg Endosc 2017; 32:1035-1042. [DOI: 10.1007/s00464-017-5782-8] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2017] [Accepted: 07/28/2017] [Indexed: 12/17/2022]
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Baucom RB, Poulose BK, Geiger TM. Commentary on "Perioperative hypothermia: turning up the heat on the conversation". Transl Gastroenterol Hepatol 2017; 1:17. [PMID: 28138584 DOI: 10.21037/tgh.2016.03.14] [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: 01/16/2016] [Accepted: 01/22/2016] [Indexed: 11/06/2022] Open
Affiliation(s)
- Rebeccah B Baucom
- Division of General Surgery, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Benjamin K Poulose
- Division of General Surgery, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Timothy M Geiger
- Division of General Surgery, Vanderbilt University Medical Center, Nashville, TN, USA
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Williams AD, Korolkova OY, Sakwe AM, Geiger TM, James SD, Muldoon RL, Herline AJ, Goodwin JS, Izban MG, Washington MK, Smoot DT, Ballard BR, Gazouli M, M'Koma AE. Human alpha defensin 5 is a candidate biomarker to delineate inflammatory bowel disease. PLoS One 2017; 12:e0179710. [PMID: 28817680 PMCID: PMC5560519 DOI: 10.1371/journal.pone.0179710] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2017] [Accepted: 06/03/2017] [Indexed: 02/06/2023] Open
Abstract
Inability to distinguish Crohn's colitis from ulcerative colitis leads to the diagnosis of indeterminate colitis. This greatly effects medical and surgical care of the patient because treatments for the two diseases vary. Approximately 30 percent of inflammatory bowel disease patients cannot be accurately diagnosed, increasing their risk of inappropriate treatment. We sought to determine whether transcriptomic patterns could be used to develop diagnostic biomarker(s) to delineate inflammatory bowel disease more accurately. Four patients groups were assessed via whole-transcriptome microarray, qPCR, Western blot, and immunohistochemistry for differential expression of Human α-Defensin-5. In addition, immunohistochemistry for Paneth cells and Lysozyme, a Paneth cell marker, was also performed. Aberrant expression of Human α-Defensin-5 levels using transcript, Western blot, and immunohistochemistry staining levels was significantly upregulated in Crohn's colitis, p< 0.0001. Among patients with indeterminate colitis, Human α-Defensin-5 is a reliable differentiator with a positive predictive value of 96 percent. We also observed abundant ectopic crypt Paneth cells in all colectomy tissue samples of Crohn's colitis patients. In a retrospective study, we show that Human α-Defensin-5 could be used in indeterminate colitis patients to determine if they have either ulcerative colitis (low levels of Human α-Defensin-5) or Crohn's colitis (high levels of Human α-Defensin-5). Twenty of 67 patients (30 percent) who underwent restorative proctocolectomy for definitive ulcerative colitis were clinically changed to de novo Crohn's disease. These patients were profiled by Human α-Defensin-5 immunohistochemistry. All patients tested strongly positive. In addition, we observed by both hematoxylin and eosin and Lysozyme staining, a large number of ectopic Paneth cells in the colonic crypt of Crohn's colitis patient samples. Our experiments are the first to show that Human α-Defensin-5 is a potential candidate biomarker to molecularly differentiate Crohn's colitis from ulcerative colitis, to our knowledge. These data give us both a potential diagnostic marker in Human α-Defensin-5 and insight to develop future mechanistic studies to better understand crypt biology in Crohn's colitis.
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Affiliation(s)
- Amanda D. Williams
- Department of Microbiology and Immunology, Meharry Medical College School of Medicine, Nashville, Tennessee, United States of America
- Department of Biology, Lipscomb University, Nashville, Tennessee, United States of America
| | - Olga Y. Korolkova
- Department of Biochemistry and Cancer Biology, Meharry Medical College School of Medicine, Nashville, Tennessee, United States of America
| | - Amos M. Sakwe
- School of Graduate Studies and Research, Meharry Medical College School of Medicine, Nashville, Tennessee, United States of America
| | - Timothy M. Geiger
- Department of Surgery, Vanderbilt University School of Medicine, Nashville, Tennessee, United States of America
- Vanderbilt-Ingram Cancer Center, Vanderbilt University School of Medicine, Nashville, Tennessee, United States of America
| | - Samuel D. James
- Department of Pathology, Meharry Medical College School of Medicine, Nashville General Hospital, Nashville, Tennessee, United States of America
- Department of Pathology, Microbiology, and Immunology Tennessee Valley Health Systems VA Medical Center, Vanderbilt University Medical Center, Nashville, Tennessee, United States of America
| | - Roberta L. Muldoon
- Department of Surgery, Vanderbilt University School of Medicine, Nashville, Tennessee, United States of America
- Vanderbilt-Ingram Cancer Center, Vanderbilt University School of Medicine, Nashville, Tennessee, United States of America
| | - Alan J. Herline
- Department of Surgery, Augusta University Medical Center, Augusta, Georgia, United States of America
| | - J. Shawn Goodwin
- Department of Biochemistry and Cancer Biology, Meharry Medical College School of Medicine, Nashville, Tennessee, United States of America
| | - Michael G. Izban
- Department of Pathology, Meharry Medical College School of Medicine, Nashville General Hospital, Nashville, Tennessee, United States of America
| | - Mary K. Washington
- Vanderbilt-Ingram Cancer Center, Vanderbilt University School of Medicine, Nashville, Tennessee, United States of America
- Department of Pathology, Vanderbilt University School of Medicine, Nashville, Tennessee, United States of America
| | - Duane T. Smoot
- Department of Medicine, Meharry Medical College School of Medicine, Nashville, Tennessee, United States of America
| | - Billy R. Ballard
- Department of Pathology, Meharry Medical College School of Medicine, Nashville General Hospital, Nashville, Tennessee, United States of America
| | - Maria Gazouli
- Department of Basic Medical Sciences, Laboratory of Biology, Medical School, National and Kapodistrian University of Athens, Athens, Greece
| | - Amosy E. M'Koma
- Department of Biochemistry and Cancer Biology, Meharry Medical College School of Medicine, Nashville, Tennessee, United States of America
- Department of Surgery, Vanderbilt University School of Medicine, Nashville, Tennessee, United States of America
- Vanderbilt-Ingram Cancer Center, Vanderbilt University School of Medicine, Nashville, Tennessee, United States of America
- * E-mail:
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McEvoy MD, Wanderer JP, King AB, Geiger TM, Tiwari V, Terekhov M, Ehrenfeld JM, Furman WR, Lee LA, Sandberg WS. A perioperative consult service results in reduction in cost and length of stay for colorectal surgical patients: evidence from a healthcare redesign project. Perioper Med (Lond) 2016; 5:3. [PMID: 26855773 PMCID: PMC4743367 DOI: 10.1186/s13741-016-0028-1] [Citation(s) in RCA: 32] [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] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2015] [Accepted: 01/29/2016] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND A major restructuring of perioperative care delivery is required to reduce cost while improving patient outcomes. In a test implementation of this notion, we developed and implemented a perioperative consult service (PCS) for colorectal surgery patients. METHODS A 6-month planning process was undertaken to engage key stakeholders from surgery, nursing, and anesthesia in a healthcare redesign project that resulted in the creation of a PCS to implement a coordinated clinical pathway. After Institutional Review Board (IRB) approval, data were collected for all elective colorectal procedures for three phases: phase 0 (pre-implementation; 1/2014-6/2014), phase 1 (7/2014-10/2014), and phase 2 (11/2014-10/2015). Length of stay (primary endpoint; LOS), total hospital cost, use of clinical pathway components, markers of functional recovery, and readmission and reoperation rates were analyzed. Outcomes and patient characteristics among phases were compared by two-tailed t tests and Wilcoxon rank-sum tests. Categorical variables were analyzed by chi-square and Fisher's exact tests. RESULTS We studied 544 patients (phase 0 = 179; phase 1 = 124; phase 2 = 241), with 365 consecutive patients being cared for in the redesigned care structure. Median LOS was reduced and sustained after implementation (phase 0, 4.24 days; phase 1, 3.32 days; phase 2, 3.32 days, P < 0.01 phase 0 v. phases 1 and 2), and mean LOS was reduced in phase 2 (phase 0, 5.26 days; phase 1, 4.93 days; phase 2, 4.36 days, P < 0.01 phase 0 v. phase 2). Total hospital cost was reduced by 17 % (P = 0.05, median). Application of clinical pathway components was higher in phases 1 and 2 compared to phase 0 (P < 0.01 for all components except anti-emetics); measures of functional recovery improved with successive phases. Reoperation and 30-day readmission rates were no different in phase 1 or phase 2 compared to phase 0 (P > 0.15). CONCLUSIONS Restructuring of perioperative care delivery through the launch of a PCS-reduced LOS and total cost in a significant and sustainable fashion for colorectal surgery patients. Based on the success of this care redesign project, hospital administration is funding expansion to additional services.
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Affiliation(s)
- Matthew D. McEvoy
- />Department of Anesthesiology, Vanderbilt University School of Medicine, Vanderbilt University Hospital, Nashville, TN 37232 USA
| | - Jonathan P. Wanderer
- />Department of Anesthesiology, Vanderbilt University School of Medicine, Vanderbilt University Hospital, Nashville, TN 37232 USA
- />Department of Biomedical Informatics, Vanderbilt University School of Medicine, Vanderbilt University Hospital, Nashville, TN 37232 USA
| | - Adam B. King
- />Department of Anesthesiology, Vanderbilt University School of Medicine, Vanderbilt University Hospital, Nashville, TN 37232 USA
| | - Timothy M. Geiger
- />Division of Colon and Rectal Surgery, Vanderbilt University School of Medicine, 1161 21st Ave South, D5248, Nashville, TN 37232-2543 USA
| | - Vikram Tiwari
- />Department of Anesthesiology, Vanderbilt University School of Medicine, Vanderbilt University Hospital, Nashville, TN 37232 USA
- />Department of Biomedical Informatics, Vanderbilt University School of Medicine, Vanderbilt University Hospital, Nashville, TN 37232 USA
| | - Maxim Terekhov
- />Department of Anesthesiology, Vanderbilt University School of Medicine, Vanderbilt University Hospital, Nashville, TN 37232 USA
| | - Jesse M. Ehrenfeld
- />Department of Anesthesiology, Vanderbilt University School of Medicine, Vanderbilt University Hospital, Nashville, TN 37232 USA
- />Department of Biomedical Informatics, Vanderbilt University School of Medicine, Vanderbilt University Hospital, Nashville, TN 37232 USA
- />Department of Surgery, Vanderbilt University School of Medicine, Vanderbilt University Hospital, Nashville, TN 37232 USA
- />Department of Health Policy, Vanderbilt University School of Medicine, Vanderbilt University Hospital, Nashville, TN 37232 USA
| | - William R. Furman
- />Department of Anesthesiology, Vanderbilt University School of Medicine, Vanderbilt University Hospital, Nashville, TN 37232 USA
- />Department of Surgery, Vanderbilt University School of Medicine, Vanderbilt University Hospital, Nashville, TN 37232 USA
| | - Lorri A. Lee
- />Department of Anesthesiology, Vanderbilt University School of Medicine, Vanderbilt University Hospital, Nashville, TN 37232 USA
- />Division of Neuroanesthesiology, Vanderbilt University School of Medicine, Vanderbilt University Hospital, Nashville, TN 37232 USA
| | - Warren S. Sandberg
- />Department of Anesthesiology, Vanderbilt University School of Medicine, Vanderbilt University Hospital, Nashville, TN 37232 USA
- />Department of Biomedical Informatics, Vanderbilt University School of Medicine, Vanderbilt University Hospital, Nashville, TN 37232 USA
- />Department of Surgery, Vanderbilt University School of Medicine, Vanderbilt University Hospital, Nashville, TN 37232 USA
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31
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Baucom RB, Phillips SE, Ehrenfeld JM, Muldoon RL, Poulose BK, Herline AJ, Wise PE, Geiger TM. Association of Perioperative Hypothermia During Colectomy With Surgical Site Infection. JAMA Surg 2015; 150:570-5. [DOI: 10.1001/jamasurg.2015.77] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Affiliation(s)
- Rebeccah B. Baucom
- Division of General Surgery, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Sharon E. Phillips
- Division of General Surgery, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Jesse M. Ehrenfeld
- Division of Anesthesiology, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Roberta L. Muldoon
- Division of General Surgery, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Benjamin K. Poulose
- Division of General Surgery, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Alan J. Herline
- Division of General Surgery, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Paul E. Wise
- Section of Colon and Rectal Surgery, Washington University School of Medicine, St Louis, Missouri
| | - Timothy M. Geiger
- Division of General Surgery, Vanderbilt University Medical Center, Nashville, Tennessee
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Baucom RB, Poulose BK, Herline AJ, Muldoon RL, Cone MM, Geiger TM. Smoking as dominant risk factor for anastomotic leak after left colon resection. Am J Surg 2015; 210:1-5. [PMID: 25910885 DOI: 10.1016/j.amjsurg.2014.10.033] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2014] [Revised: 09/30/2014] [Accepted: 10/03/2014] [Indexed: 01/25/2023]
Abstract
BACKGROUND Some risk factors for anastomotic leak have been identified, but the effect of smoking is unknown. METHODS This study aimed to evaluate the effect of smoking on clinical leak after left-sided anastomoses. Adult patients who underwent elective left colectomy between January 1, 2008 and December 31, 2012 were included. Those with stomas and inflammatory bowel diseases were excluded. Primary outcome was anastomotic leak requiring percutaneous drainage or operative intervention within 30 days. RESULTS There were 246 patients included; 56% were female. Most had a diagnosis of diverticular disease (53%) or cancer (37%). Anastomotic leak rate was 6.5% (n = 16). The rate in smokers was 17% versus 5% in nonsmokers (P = .01). Smokers had over 4 times greater chance of leak (odds ratio 4.2, 95% confidence interval 1.3 to 13.5, P = .02). CONCLUSION Smoking is a risk factor for leak after left colectomy. Consideration should be given to delaying elective left colectomy until smoking cessation is achieved.
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Affiliation(s)
- Rebeccah B Baucom
- Division of General Surgery, Vanderbilt University Medical Center, D-5203 Medical Center North, 1161 Medical Center Drive, Nashville, TN 37232, USA.
| | - Benjamin K Poulose
- Division of General Surgery, Vanderbilt University Medical Center, D-5203 Medical Center North, 1161 Medical Center Drive, Nashville, TN 37232, USA
| | - Alan J Herline
- Division of General Surgery, Vanderbilt University Medical Center, D-5203 Medical Center North, 1161 Medical Center Drive, Nashville, TN 37232, USA
| | - Roberta L Muldoon
- Division of General Surgery, Vanderbilt University Medical Center, D-5203 Medical Center North, 1161 Medical Center Drive, Nashville, TN 37232, USA
| | - Molly M Cone
- Division of General Surgery, Vanderbilt University Medical Center, D-5203 Medical Center North, 1161 Medical Center Drive, Nashville, TN 37232, USA
| | - Timothy M Geiger
- Division of General Surgery, Vanderbilt University Medical Center, D-5203 Medical Center North, 1161 Medical Center Drive, Nashville, TN 37232, USA
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33
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Kauffmann RM, Grayson BL, Mosse CA, Geiger TM. Perineal Lymphoma: A Diagnostic Dilemma. Am Surg 2014. [DOI: 10.1177/000313481408001110] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Rondi M. Kauffmann
- Division of General Surgery Colorectal Surgery Vanderbilt University Medical Center Nashville, Tennessee
| | - Britney L. Grayson
- Division of General Surgery Colorectal Surgery Vanderbilt University Medical Center Nashville, Tennessee
| | - Claudio A. Mosse
- Department of Pathology, Microbiology and Immunology Vanderbilt University Medical Center Nashville, Tennessee
- Pathology and Laboratory Medicine Service Tennessee Valley Healthcare Service VA Hospital Nashville, Tennessee
| | - Timothy M. Geiger
- Division of General Surgery Colorectal Surgery Vanderbilt University Medical Center Nashville, Tennessee
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Kauffmann RM, Grayson BL, Mosse CA, Geiger TM. Perineal lymphoma: a diagnostic dilemma. Am Surg 2014; 80:E302-E303. [PMID: 25347485] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/04/2023]
Affiliation(s)
- Rondi M Kauffmann
- Division of General Surgery, Colorectal Surgery, Vanderbilt University Medical Center, Nashville, Tennessee, USA
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Abstract
It is well recognized that obesity contributes to multiple co-morbidities, and it would seem intuitive that obese patients experience an increase in post-operative complications after colorectal surgery. Overall, the data examining postoperative morbidity and mortality in the obese colorectal patient is inconsistent. Studies have shown a trend for obese patients have a higher post-operative risk of pulmonary embolism, atelectasis, cardiac complications, and thromboembolic disease. However, even with multiple large trials concluding this, there are also many studies showing no difference. The literature has shown that using laparoscopic techniques is safe and feasible, but there is a higher rate of conversion to open, and longer operative times. In addition, obese patients might have a higher leak rate for distal anastomosis as compared with normal weight patients. These patients also have a higher post-operative rate of stomal complications and fascial dehiscense. In reviewing the literature, at best, the complication rate in obese patients is the same as non-obese patients after colorectal surgery, but there are significant trends that suggest a negative effect of obesity after colorectal surgery.
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Affiliation(s)
- Timothy M Geiger
- Colon and Rectal Surgery, Department of Surgery, Vanderbilt University Medical Center, Nashville, Tennessee
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36
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Geiger TM, Horst S, Muldoon R, Wise PE, Enrenfeld J, Poulose B, Herline AJ. Perioperative core body temperatures effect on outcome after colorectal resections. Am Surg 2012; 78:607-612. [PMID: 22546136] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/31/2023]
Abstract
The World Health Organization has set a standard of maintaining a core body temperature above 36°C in the perioperative period. The purpose of this study was to examine the relationship between both intraoperative temperature (IOT) and immediate postop core body temperature as it relates to postop complications. A retrospective analysis of a prospective database of patients who underwent an elective segmental colectomy without a stoma, for 3 diagnoses was performed. Six postoperative outcomes were examined: length of stay (LOS), placement of a nasogastric tube, return to the operating room, placement of an interventional drain, diagnosed leak, and surgical site infection (SSI). Statistics were calculated using a two-sample Wilcoxon rank-sum (Mann-Whitney) test. Seventy-nine patients met the inclusion criteria and there were no preoperative differences between the groups (those with a postop complication vs without). LOS > 9 days (36.64°C vs 35.98°C; P = 0.011) and clinical leak (37.06°C vs 35.99°C; P = 0.005) both had a statistically higher average IOT than those who did not. Patients with SSI trended to a higher IOT (36.44°C vs 35.99°C; P = 0.062). When the last IOT recorded was compared with the six outcomes, again length of stay and leak both were statistically significant (P = 0.018, P = 0.012) showing a higher temperature related to a higher complication rate. No other complications were related to IOT, nor did postop temperature relate to complication. In our data, relatively lower IOTs were protective for LOS and clinical leaks, with a trend of lower SSI rates. Further research is needed to fully endorse or refute the absolute recommendations for core body temperature.
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Affiliation(s)
- Timothy M Geiger
- Department of Colon and Rectal Surgery, Vanderbilt University, Nashville, Tennessee 37232, USA.
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37
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Geiger TM, Horst S, Muldoon R, Wise PE, Enrenfeld J, Poulose B, Herline AJ. Perioperative Core Body Temperatures Effect on Outcome after Colorectal Resections. Am Surg 2012. [DOI: 10.1177/000313481207800545] [Citation(s) in RCA: 7] [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: 11/16/2022]
Abstract
The World Health Organization has set a standard of maintaining a core body temperature above 36°C in the perioperative period. The purpose of this study was to examine the relationship between both intraoperative temperature (IOT) and immediate postop core body temperature as it relates to postop complications. A retrospective analysis of a prospective database of patients who underwent an elective segmental colectomy without a stoma, for 3 diagnoses was performed. Six postoperative outcomes were examined: length of stay (LOS), placement of a nasogastric tube, return to the operating room, placement of an interventional drain, diagnosed leak, and surgical site infection (SSI). Statistics were calculated using a two-sample Wilcoxon rank-sum (Mann-Whitney) test. Seventy-nine patients met the inclusion criteria and there were no preoperative differences between the groups (those with a postop complication vs without). LOS > 9 days (36.64°C vs 35.98°C; P = 0.011) and clinical leak (37.06°C vs 35.99°C; P = 0.005) both had a statistically higher average IOT than those who did not. Patients with SSI trended to a higher IOT (36.44°C vs 35.99°C; P = 0.062). When the last IOT recorded was compared with the six outcomes, again length of stay and leak both were statistically significant ( P = 0.018, P = 0.012) showing a higher temperature related to a higher complication rate. No other complications were related to IOT, nor did postop temperature relate to complication. In our data, relatively lower IOTs were protective for LOS and clinical leaks, with a trend of lower SSI rates. Further research is needed to fully endorse or refute the absolute recommendations for core body temperature.
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Affiliation(s)
- Timothy M. Geiger
- Departments of Colon and Rectal Surgery, Vanderbilt University, Nashville, Tennessee
| | - Sara Horst
- Gastroenterology, Vanderbilt University, Nashville, Tennessee
| | - Roberta Muldoon
- Departments of Colon and Rectal Surgery, Vanderbilt University, Nashville, Tennessee
| | - Paul E. Wise
- Departments of Colon and Rectal Surgery, Vanderbilt University, Nashville, Tennessee
| | | | - Ben Poulose
- General Surgery, Vanderbilt University, Nashville, Tennessee
| | - Alan J. Herline
- Departments of Colon and Rectal Surgery, Vanderbilt University, Nashville, Tennessee
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Abstract
Screening reduces the burden of disease from colorectal cancer through early detection of cancerous lesions and removal of precancerous polyps. The ideal colorectal cancer screening modality should be cost-effective, increase life-years gained, permit long intervals between tests with high patient compliance and low risk to the patient. Although no single colorectal cancer screening method is perfect, several options exist. Government agencies and medical societies have published screening recommendations with differing guidelines; yet, despite the lack of a consistent standard, it is clear that colorectal cancer screening is cost-effective. In this review, the authors address several options for screening, identify risks and benefits, and present methods to risk stratify patients. A thorough discussion with the patient about potential benefits and harms is critical before initiating any screening regimen.
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Affiliation(s)
- Timothy M Geiger
- Department of Colon and Rectal Surgery, Lahey Clinic, Burlington, Massachusetts
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Geiger TM, Roberts PL, Read TE, Marcello PW, Schoetz DJ, Ricciardi R. Has the Use of Anti-Adhesion Barriers Affected the National Rate of Bowel Obstruction?. Am Surg 2011. [DOI: 10.1177/000313481107700636] [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] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
In this study, we analyzed temporal trends in anti-adhesion barrier application and admission rates for small bowel obstruction. We used data from the Nationwide Inpatient Sample and identified patients with ICD-9 codes for “application or administration of anti-adhesion barrier substances” from October 2002 through December 2007. Next, we identified cases of bowel obstruction coded from January 1997 through December 2007. We then used Kendall correlation analyses and the Joinpoint regression program to evaluate changes in trends. From October 1, 2002 through December 31, 2007, a total of 28,014 patients had an anti-adhesion barrier substance applied. During the study period, application of anti-adhesion barriers increased from 0.7 applications per 100,000 to 2.6 applications per 100,000 population (Joinpoint and Kendall; P < 0.002). Since 1997 there has been a steady rise in hospitalizations for bowel obstruction, increasing from 18.3 cases per 100,000 to 19.8 cases per 100,000 population (Joinpoint and Kendall; P < 0.002). In conclusion, the application of anti-adhesion barriers has increased significantly since 2002, yet bowel obstructions continue to be a major health problem.
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Affiliation(s)
- Timothy M. Geiger
- Department of Colorectal Surgery, Lahey Clinic, Burlington, Massachusetts
| | | | - Thomas E. Read
- Department of Colorectal Surgery, Lahey Clinic, Burlington, Massachusetts
| | - Peter W. Marcello
- Department of Colorectal Surgery, Lahey Clinic, Burlington, Massachusetts
| | - David J. Schoetz
- Department of Colorectal Surgery, Lahey Clinic, Burlington, Massachusetts
| | - Rocco Ricciardi
- Department of Colorectal Surgery, Lahey Clinic, Burlington, Massachusetts
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Geiger TM, Roberts PL, Read TE, Marcello PW, Schoetz DJ, Ricciardi R. Has the use of anti-adhesion barriers affected the national rate of bowel obstruction? Am Surg 2011; 77:773-777. [PMID: 21679649] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/30/2023]
Abstract
In this study, we analyzed temporal trends in anti-adhesion barrier application and admission rates for small bowel obstruction. We used data from the Nationwide Inpatient Sample and identified patients with ICD-9 codes for "application or administration of anti-adhesion barrier substances" from October 2002 through December 2007. Next, we identified cases of bowel obstruction coded from January 1997 through December 2007. We then used Kendall correlation analyses and the Joinpoint regression program to evaluate changes in trends. From October 1, 2002 through December 31, 2007, a total of 28,014 patients had an anti-adhesion barrier substance applied. During the study period, application of anti-adhesion barriers increased from 0.7 applications per 100,000 to 2.6 applications per 100,000 population (Joinpoint and Kendall; P < 0.002). Since 1997 there has been a steady rise in hospitalizations for bowel obstruction, increasing from 18.3 cases per 100,000 to 19.8 cases per 100,000 population (Joinpoint and Kendall; P < 0.002). In conclusion, the application of anti-adhesion barriers has increased significantly since 2002, yet bowel obstructions continue to be a major health problem.
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Affiliation(s)
- Timothy M Geiger
- Department of Colorectal Surgery, Lahey Clinic, Burlington, Massachusetts, USA
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Geiger TM, MacKay G, Ricciardi R. Outcomes of Fast-Track Pathways for Open and Laparoscopic Surgery. Seminars in Colon and Rectal Surgery 2010. [DOI: 10.1053/j.scrs.2010.05.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
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Geiger TM, Miedema BW, Tsereteli Z, Sporn E, Thaler K. Stent placement for benign colonic stenosis: case report, review of the literature, and animal pilot data. Int J Colorectal Dis 2008; 23:1007-12. [PMID: 18594837 DOI: 10.1007/s00384-008-0518-9] [Citation(s) in RCA: 30] [Impact Index Per Article: 1.9] [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] [Accepted: 06/05/2008] [Indexed: 02/04/2023]
Abstract
BACKGROUND Permanent metal stent placement for malignant intestinal obstruction has been proven to be efficient. Temporary stents for benign conditions of the colon and rectum are less studied. This is a case study, review of the literature, and observation from an animal model on placement of stents in the colorectum for benign disease. MATERIALS AND METHODS A 55-year-old man presented with recurrent obstructions from a benign stricture of the distal sigmoid colon. After failed balloon dilations, a polyester coated stent was placed. The purpose of the stent was to improve symptoms and avoid surgery. The stent was expelled after 5 days. We conducted a literature review of stents placed for benign colorectal strictures and an animal study to evaluate stent migration. RESULTS In the literature, there were 53 reports of uncovered metal stents, four covered metal stents, and six polyester stents. Patency rates were 71%, and migration rate was 43%. Migration occurred earlier with polyester stents (mean=8 days) versus covered (32 days) or uncovered metal stents (112 days). Severe complications were seen in 23% of patients. Four 45-kg pigs underwent rectosigmoid transection with a 21-mm anastomosis and endoscopic placement of a Polyflex stent. Two stents were secured with suture. Stents without fixation were expelled within 24 h of surgery. Stents with fixation were expelled between postoperative days 2 and 14. CONCLUSION Stents for the treatment of benign colorectal strictures are safe, with comparable patency rates between stent types. Metal stents can cause severe complications. In a pig model, covered polyester stents tend to migrate early even with fixation. Further investigation needs to focus on new stent designs and/or better fixation.
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Affiliation(s)
- Timothy M Geiger
- Division of General Surgery, University of Missouri-Columbia, Columbia, MO 65212, USA
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Tsereteli Z, Sporn E, Geiger TM, Cleveland D, Frazier S, Rawlings A, Bachman SL, Miedema BW, Thaler K. Placement of a covered polyester stent prevents complications from a colorectal anastomotic leak and supports healing: randomized controlled trial in a large animal model. Surgery 2008; 144:786-92. [PMID: 19081022 DOI: 10.1016/j.surg.2008.05.018] [Citation(s) in RCA: 22] [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] [Subscribe] [Scholar Register] [Received: 12/06/2007] [Accepted: 05/29/2008] [Indexed: 02/07/2023]
Abstract
BACKGROUND Anastomotic leaks after colorectal operation continue to be a significant cause of morbidity. A covered endoluminal stent could seal a leak and eliminate the need for diversion. The aim of this study was to test the efficacy of a temporary covered stent to prevent leak related complications. METHODS Sixteen adult pigs (80-120 lbs) underwent open transection of the rectosigmoid followed by anastomosis with a circular stapler. Eight animals (study group) underwent endoscopic placement of a 21-mm covered polyester stent. Eight control group animals were left without stents. In all animals, a 2-cm leak was created along the anterior portion of the anastomosis. The animals were killed after 2 weeks and evaluated for abdominal infection, fistulae, and adhesions. The anastomosis was excised and the following parameters were assessed by a pathologist blinded to treatment: mucosal interruption (mm), inflammatory response, collagen type I and III, granulation, and fibrosis (grade 0-4). RESULTS Stents were spontaneously expelled between postoperative days 6 and 9. At necropsy, none of the animals in the study group had leak related complications, whereas in the control group, 5 (63%) developed intraabdominal infection (4 abscesses, 1 fistula) at the anastomosis (P = .002). Dense adhesions to the anastomosis were found in 7 (88%) control animals. On histology, anastomotic sites in the study group had significantly less mucosal interruption and granulation. Two pigs in the study group died on postoperative day 7, one due to evisceration and one from bladder necrosis. The mortality result is not different from controls (P = .47), both events seem to be unrelated to stent placement. CONCLUSION Temporary placement of a covered polyester stent across a colorectal anastomosis prevents leak-related complications and supports the healing of anastomotic leaks.
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Affiliation(s)
- Zurab Tsereteli
- Department of General Surgery, University of Missouri, Columbia, MO 65212, USA
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Geiger TM, Awad ZT, Burgard M, Singh A, Davis W, Thaler K, Miedema BW. Prognostic indicators of quality of life after cholecystectomy for biliary dyskinesia. Am Surg 2008; 74:400-404. [PMID: 18481495] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/26/2023]
Abstract
Approximately 30 per cent of patients who undergo cholecystectomy for biliary dyskinesia will continue to have symptoms after surgery. Quality of life has not been evaluated but may be decreased in these patients. The purpose of this study was to measure quality of life after laparoscopic cholecystectomy in these patients to better define optimal treatment of biliary dyskinesia. All patients with biliary dyskinesia (defined as the absence of gallstones, and a gallbladder ejection fraction of <35%) who underwent cholecystectomy at our institution from January 31, 2000 to January 31, 2005 were identified. Preoperative data including ultrasound, biochemical data, and pathology were retrieved by chart review. Postoperative assessment included the Gastrointestinal Quality of Life Index and a symptom survey. The postoperative quality of life was compared with historic standards. The quality of life was also compared with preoperative variables to determine if any variables predicted outcome. A total of 66 patients were identified as fitting the inclusion criteria. Forty-three patients were reached by phone and 30 agreed to participate. Patients were noted to have good recall as to preoperative symptoms when the retrospective survey of symptoms was compared with the medical record. The mean +/- SD postoperative quality of life in the study population was 113 +/- 20. This is higher than in historic patients with gallbladder disease before (84 +/- 19) and after (102 +/- 13) cholecystectomy. Quality of life in the study group was lower than the healthy control (125 +/- 13). Patients having both postprandial nausea and vomiting before surgery had a lower quality of life (P < 0.029) after surgery as compared with those without these preoperative symptoms. When adjusted for nausea and vomiting, the quality of life in study patients (119 +/- 14) was similar to normal controls. No other symptom, laboratory, pathologic, or sonographic data were predictive of a lower quality of life. Cholecystectomy is beneficial for most patients with biliary dyskinesia. Nausea and vomiting were negative predictors of quality of life after cholecystectomy. These patients with nausea and vomiting may have a global gastrointestinal motility disorder and are less likely to benefit from cholecystectomy.
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Affiliation(s)
- Timothy M Geiger
- Department of General Surgery, University of Missouri-Columbia,Columbia, Missouri 65212, USA
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Geiger TM, Awad ZT, Burgard M, Singh A, Davis W, Thaler K, Miedema BW. Prognostic Indicators of Quality of Life after Cholecystectomy for Biliary Dyskinesia. Am Surg 2008. [DOI: 10.1177/000313480807400507] [Citation(s) in RCA: 9] [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: 11/15/2022]
Abstract
Approximately 30 per cent of patients who undergo cholecystectomy for biliary dyskinesia will continue to have symptoms after surgery. Quality of life has not been evaluated but may be decreased in these patients. The purpose of this study was to measure quality of life after laparoscopic cholecystectomy in these patients to better define optimal treatment of biliary dyskinesia. All patients with biliary dyskinesia (defined as the absence of gallstones, and a gallbladder ejection fraction of <35%) who underwent cholecystectomy at our institution from January 31, 2000 to January 31, 2005 were identified. Preoperative data including ultrasound, biochemical data, and pathology were retrieved by chart review. Postoperative assessment included the Gastrointestinal Quality of Life Index and a symptom survey. The postoperative quality of life was compared with historic standards. The quality of life was also compared with preoperative variables to determine if any variables predicted outcome. A total of 66 patients were identified as fitting the inclusion criteria. Forty-three patients were reached by phone and 30 agreed to participate. Patients were noted to have good recall as to preoperative symptoms when the retrospective survey of symptoms was compared with the medical record. The mean ± SD postoperative quality of life in the study population was 113 ± 20. This is higher than in historic patients with gallbladder disease before (84 ± 19) and after (102 ± 13) cholecystectomy. Quality of life in the study group was lower than the healthy control (125 ± 13). Patients having both postprandial nausea and vomiting before surgery had a lower quality of life ( P < 0.029) after surgery as compared with those without these preoperative symptoms. When adjusted for nausea and vomiting, the quality of life in study patients (119 ± 14) was similar to normal controls. No other symptom, laboratory, pathologic, or sonographic data were predictive of a lower quality of life. Cholecystectomy is beneficial for most patients with biliary dyskinesia. Nausea and vomiting were negative predictors of quality of life after cholecystectomy. These patients with nausea and vomiting may have a global gastrointestinal motility disorder and are less likely to benefit from cholecystectomy.
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Affiliation(s)
- Timothy M. Geiger
- From the Department of General Surgery, University of Missouri-Columbia, Columbia, Missouri; the
| | - Ziad T. Awad
- Department of Surgery, University of Florida-Shands Jacksonville, Jacksonville, Florida
| | - Michael Burgard
- From the Department of General Surgery, University of Missouri-Columbia, Columbia, Missouri; the
| | - Amolak Singh
- From the Department of General Surgery, University of Missouri-Columbia, Columbia, Missouri; the
| | - Wade Davis
- Department of Health Management and Informatics, University of Missouri-Columbia, Columbia, Missouri
- Department of Statistics, University of Missouri-Columbia, Columbia, Missouri
| | - Klaus Thaler
- From the Department of General Surgery, University of Missouri-Columbia, Columbia, Missouri; the
| | - Brent W. Miedema
- From the Department of General Surgery, University of Missouri-Columbia, Columbia, Missouri; the
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Geiger TM, Miedema BW, Geana MV, Thaler K, Rangnekar NJ, Cameron GT. Improving rates for screening colonoscopy: Analysis of the health information national trends survey (HINTS I) data. Surg Endosc 2007; 22:527-33. [DOI: 10.1007/s00464-007-9673-2] [Citation(s) in RCA: 32] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2007] [Revised: 07/08/2007] [Accepted: 08/07/2007] [Indexed: 01/10/2023]
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Geiger TM, Tebb ZD, Sato E, Miedema BW, Awad ZT. Laparoscopic resection of colon cancer and synchronous liver metastasis. J Laparoendosc Adv Surg Tech A 2006; 16:51-3. [PMID: 16494549 DOI: 10.1089/lap.2006.16.51] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
The recommended surgical approach to synchronous colorectal metastasis has not been clarified. Simultaneous open liver and colon resection for synchronous colorectal carcinoma has been shown beneficial when compared to staged resections. A review of the literature has shown the benefits of both laparoscopic colon resection for colorectal cancer and laparoscopic left lateral segmentectomy in liver disease. We present the case of a 60-year-old male with sigmoid colon carcinoma and a synchronous solitary liver metastasis localized to the left lateral segment. Using laparoscopic techniques, we were able to achieve simultaneous resection of the sigmoid colon and left lateral liver segment.
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Affiliation(s)
- Timothy M Geiger
- Department of Surgery, University of Missouri-Columbia, McHaney Hall 4th Floor, 1 Hospital Drive, Columbia, MO 65212. USA.
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Mitchell GA, Abdullahad CM, Ruiz JA, Huseby RM, Alvarez DE, Geiger TM, Black FM, Heller ZH. Fluorogenic substrate assays for factors VIII and IX: introduction of a new solid phase fluorescent detection method. Thromb Res 1981; 21:573-84. [PMID: 6791298 DOI: 10.1016/0049-3848(81)90258-9] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
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