Outcomes of Colectomy and Proctectomy According to Surgeon Training: General vs Colorectal Surgeons

BACKGROUND

Colectomies and proctectomies are commonly performed by both general surgeons (GS) and colorectal surgeons (CRS). The aim of our study was to examine the outcomes of elective colectomy, urgent colectomy, and elective proctectomy according to surgeon training.

STUDY DESIGN

Data were obtained from the Vizient database for adults who underwent elective colectomy, urgent colectomy, and elective proctectomy from 2020-2022. Operations performed in the setting of trauma and patients within the database's highest relative expected mortality risk group were excluded. Outcomes were compared according to surgeon's specialty: GS vs. CRS. The primary outcome was in-hospital mortality. The secondary outcome was in-hospital complication rate. Data were analyzed using multivariate logistic regression.

RESULTS

Of 149,516 elective colectomies, 75,711(50.6%) were performed by GS and 73,805(49.4%) by CRS. Compared to elective colectomies performed by CRS, elective colectomies performed by GS had higher rates of complications(4.9% vs. 3.9%, OR1.23, 95%CI 1.17-1.29,p<.01) and mortality(0.5% vs. 0.2%, OR2.06, 95%CI 1.72-2.47,p<.01). Of 71,718 urgent colectomies, 54,680(76.2%) were performed by GS, while 17,038(23.8%) were performed by CRS. Compared to urgent colectomies performed by CRS, urgent colectomies performed by GS were associated with higher rates of complications(12.1% vs. 10.4%, OR1.14, 95%CI 1.08-1.20,p<.01) and mortality (5.1% vs. 2.3%, OR2.08, 95%CI 1.93-2.23,p<.01). Of 43,749 elective proctectomies, 28,458(65.0%) were performed by CRS and 15,291(35.0%) by GS. Compared to proctectomies performed by CRS, those performed by GS were associated with higher rates of complications (5.3% vs. 4.4%, OR1.16, 95%CI 1.06-1.27,p<.01) and mortality(0.3% vs. 0.2%, OR1.49, 95%CI 1.02-2.20,p=.04).

CONCLUSIONS

In this nationwide study, colectomies and proctectomies performed by CRS were associated with improved outcomes compared to GS. Hospitals without a CRS on staff should consider prioritizing recruiting CRS specialists.

Validation of an endoscopic anastomotic grading score as an intraoperative method for assessing stapled rectal anastomoses

PURPOSE

Anastomotic leak is a dreaded complication of colorectal surgery. An endoscopic grading score of the perianastomotic mucosa has been previously developed at our institution (UCI) to assess colorectal anastomotic integrity. The objective of this study is to validate the UCI anastomotic score and determine its impact in anastomotic failure.

METHODS

As a follow-up study of the UCI grading score implementation during 2011 to 2014, patients undergoing stapled colorectal anastomoses after sigmoidectomy or proctectomy at a single institution from 2015 to 2018 were retrospectively reviewed. Patients were grouped into three tiers based on endoscopic appearance (grade 1, circumferentially normal mucosa; grade 2, ischemia/congestion < 30% of circumference; grade 3, ischemia/congestion > 30% of circumference).

RESULTS

On the basis of endoscopic mucosal evaluation, grade 1 anastomosis was observed in 299 patients (94%), grade 2 anastomosis in 14 patients (4.4%), and grade 3 anastomosis in 5 patients (1.6%). All grade 3 classifications were immediately and successfully revised intraoperatively with reclassification as a grade 1 anastomosis. The anastomotic leak rate of the follow-up study period from 2015 to 2018 was 6.4% which was lower compared to the anastomotic leak rate of 12.2% in the original study period from 2011 to 2014 (p = 0.07). Anastomotic leak rate for the entire patient series was 8.5%. A grade 2 anastomosis was associated with higher anastomotic leak rate compared to a grade 1 anastomosis (35.7% vs. 7.4%, p < 0.05). None of the five grade 3 anastomoses resulted in an anastomotic leak upon revision.

CONCLUSION

This study further validates the anastomotic grading score and suggests that its systematic implementation can result in a reduction in anastomotic leaks.

Intraoperative Anastomotic Evaluation Methods: Rigid Proctoscopy Versus Flexible Endoscopy

INTRODUCTION

Rigid proctosigmoidoscopy (RP) and flexible sigmoidoscopy (FS) are two modalities commonly used for intraoperative evaluation of colorectal anastomoses. This study seeks to determine whether there is an association between the endoscopic modality used to evaluate colorectal anastomoses and the rate of anastomotic leak (AL), organ space infection, and overall infectious complication.

METHODS

The 2012-2018 American College of Surgeons National Surgical Quality Improvement Program database was queried for patients undergoing colorectal anastomoses. Anastomotic evaluation method (RP versus FS) was identified by Current Procedural Terminologycoding and used for group classification. Outcomes measured included AL, organ space infections, and overall infection. Multivariable logistic regression analysis for predicting AL was performed.

RESULTS

We identified 7100 patients who underwent a colorectal anastomosis with intraoperative endoscopic evaluation. RP was utilized in 3397 (47.8%) and FS in 3703 (52.2%) patients. RP was used more commonly in diverticulitis (44.5% versus 36.2%, P < 0.01), while FS was used more frequently in malignancy (47.5% versus 36.7%, P < 0.01). Anastomotic evaluation with FS was associated with lower rates of organ space infection (3.8% versus 4.8%, P = 0.025) and AL (2.9% versus 3.8%, P = 0.028) compared to RP. On multivariate logistic regression modeling, anastomotic evaluation with RP was associated with a higher risk of AL (odds ratio 1.403, 95% CI 1.028-1.916, P = 0.033) compared to FS.

CONCLUSIONS

Compared to FS, rigid proctosigmoidoscopic evaluation of a colorectal anastomosis was associated with an increased rate of AL and organ space infection.

Risk factors for SARS-CoV-2 seropositivity in a health care worker population during the early pandemic

BACKGROUND

While others have reported severe acute respiratory syndrome-related coronavirus 2(SARS-CoV-2) seroprevalence studies in health care workers (HCWs), we leverage the use of a highly sensitive coronavirus antigen microarray to identify a group of seropositive health care workers who were missed by daily symptom screening that was instituted prior to any epidemiologically significant local outbreak. Given that most health care facilities rely on daily symptom screening as the primary method to identify SARS-CoV-2 among health care workers, here, we aim to determine how demographic, occupational, and clinical variables influence SARS-CoV-2 seropositivity among health care workers.

METHODS

We designed a cross-sectional survey of HCWs for SARS-CoV-2 seropositivity conducted from May 15th to June 30th 2020 at a 418-bed academic hospital in Orange County, California. From an eligible population of 5,349 HCWs, study participants were recruited in two ways: an open cohort, and a targeted cohort. The open cohort was open to anyone, whereas the targeted cohort that recruited HCWs previously screened for COVID-19 or work in high-risk units. A total of 1,557 HCWs completed the survey and provided specimens, including 1,044 in the open cohort and 513 in the targeted cohort. Demographic, occupational, and clinical variables were surveyed electronically. SARS-CoV-2 seropositivity was assessed using a coronavirus antigen microarray (CoVAM), which measures antibodies against eleven viral antigens to identify prior infection with 98% specificity and 93% sensitivity.

RESULTS

Among tested HCWs (n = 1,557), SARS-CoV-2 seropositivity was 10.8%, and risk factors included male gender (OR 1.48, 95% CI 1.05-2.06), exposure to COVID-19 outside of work (2.29, 1.14-4.29), working in food or environmental services (4.85, 1.51-14.85), and working in COVID-19 units (ICU: 2.28, 1.29-3.96; ward: 1.59, 1.01-2.48). Amongst 1,103 HCWs not previously screened, seropositivity was 8.0%, and additional risk factors included younger age (1.57, 1.00-2.45) and working in administration (2.69, 1.10-7.10).

CONCLUSION

SARS-CoV-2 seropositivity is significantly higher than reported case counts even among HCWs who are meticulously screened. Seropositive HCWs missed by screening were more likely to be younger, work outside direct patient care, or have exposure outside of work.

Phase IIa Clinical Biomarker Trial of Dietary Arginine Restriction and Aspirin in Colorectal Cancer Patients

After potentially curative treatment, colorectal cancer (CRC) patients remain at high risk for recurrence, second primary CRC, and high-risk adenomas. In combination with existing data, our previous findings provide a rationale for reducing tissue polyamines as tertiary prevention in non-metastatic CRC patients. The goal of this study was to demonstrate rectal tissue polyamine reduction in optimally treated stage I-III CRC patients after intervention with daily oral aspirin + dietary arginine restriction. A single-institution phase IIa clinical trial was conducted. Patients were treated with aspirin 325 mg/day and an individualized dietary regimen designed to reduce arginine intake by ≥30% over a 12-week study period. Dietary intake, endoscopy with rectal biopsies, and phlebotomy were performed pre- and post-intervention. The primary endpoint was to demonstrate ≥50% decrease in rectal tissue putrescine levels from baseline as a measure of polyamine reduction in the target tissue. Twenty eligible patients completed the study. After study intervention, mean dietary arginine intake decreased from 3.7 g/day ± 1.3 SD to 2.6 g/day ± 1.2 SD (29.7% decrease, p < 0.02 by Sign test). Mean plasma arginine levels decreased from 46.0 ng/mL ± 31.5 SD at baseline to 35 ng/mL ± 21.7 SD (p < 0.001). Rectal tissue putrescine levels were 0.90 nMol/mg-protein pre-intervention and 0.99 nMol/mg-protein post-intervention (p < 0.64, NS). No significant differences were observed for the other tissue polyamines investigated: spermidine (p < 0.13), spermine (p < 0.21), spermidine:spermine ratio (p < 0.71). Among CRC survivors, treatment with daily oral aspirin and an individualized dietary arginine restriction intervention resulted in lower calculated dietary arginine intake and plasma arginine levels but did not affect rectal tissue polyamine levels.

The Demographics and Alpha Omega Alpha Honor Medical Society Membership Status of Surgery’s Top Leadership

Purpose

Diversity and equity are priorities of many academic Departments of Surgery (DoS). Induction into Alpha Omega Alpha Honor Medical Society (AOA) denotes academic excellence and can potentially propel an academic career. Research has demonstrated that underrepresented in medicine (URM) students are less likely to be elected to AOA. In this study, we aim to examine the Chairs in American departments of surgery to examine their gender, racial, and ethnic background and AOA membership status.

Method

An anonymous survey was generated via REDCap and electronically sent to the Chair of Surgery at the top 75 DoS based on “Reputation” on Doximity Residency Navigator 2020-2021. Seven chairs with non-publicly accessible email addresses were excluded.

Results

Of the eligible chairs (N = 68), 38 (55.9%) completed the survey, of which 34 (89.5%) identified as men. AOA membership was reported in 65.8% (n = 25) respondents, with 8% (n = 2) self-identifying as women and 92% (n = 23) self-identifying as men. Of the men respondents, 74% (n = 25) reported AOA membership, while 50% of women (n = 2) reported AOA membership. Of the AOA chairs, 4% (n = 1) self-identified as Asian while 96% (n = 24) self-identified as White. The majority (57.9%, n = 22) of eligible chair respondents were White, men, and AOA members. Of the 25 AOA members, 18 (72.0%) felt their membership has positively impacted their career.

Conclusions

We found that the majority of American Surgical Chairs self-identify as white men. The number of men who were AOA was higher than women chairs.

Analysis of delay in adjuvant chemotherapy in locally advanced rectal cancer

BACKGROUND

Adjuvant chemotherapy (AC) after neoadjuvant chemoradiation and surgical resection has been the standard of care for locally advanced rectal cancer. However, there are no evidence-based guidelines regarding the optimal timing of AC for rectal cancer. The objective of this study was to evaluate the effect of AC timing on overall survival for rectal cancer.

METHODS

The National Cancer Database (NCDB) from 2004 to 2016 was queried for primary clinical stage II or III rectal cancer patients who had undergone neoadjuvant chemoradiation followed by surgery and AC. Patients were grouped based on AC initiation: early ≤ 4 weeks, intermediate 4-8 weeks, and delayed ≥ 8 weeks. The primary outcome was overall survival.

RESULTS

We identified 8722 patients, of which 905 (10.4%) received early AC, 4621 (53.0%) intermediate AC, and 3196 (36.6%) delayed AC. Pathological lymph-node metastasis (ypN +) was positive in 73% of early AC, 74% intermediate AC, and 63% delayed AC (p < 0.05). The 5-year survival probability was 71.1% (95% CI 68-74%) for early AC, 73.2% (95% CI 72-75%) intermediate AC, and 65.8% (95% CI 64-68%) delayed AC (p < 0.001). Using Cox proportional hazard modeling, patients undergoing delayed AC had an associated decreased survival compared to patients receiving early AC (HR 1.18; 95% CI 1.028-1.353, p = 0.018) or intermediate AC (HR 1.28; 95% CI 1.179-1.395, p < 0.01).

CONCLUSIONS

Delay in AC administration may be associated with decreased 5-year survival. Compared to early or intermediate AC, patients in the delayed AC group were observed to have increased risk of death, despite having lower proportions with ypN + disease. Patients with higher socioeconomic and education status were more likely to receive early chemotherapy.

Impact of microsatellite status in early-onset colonic cancer

BACKGROUND

The molecular profile of early-onset colonic cancer is undefined. This study evaluated clinicopathological features and oncological outcomes of young patients with colonic cancer according to microsatellite status.

METHODS

Anonymized data from an international collaboration were analysed. Criteria for inclusion were patients younger than 50 years diagnosed with stage I-III colonic cancer that was surgically resected. Clinicopathological features, microsatellite status, and disease-specific outcomes were evaluated.

RESULTS

A total of 650 patients fulfilled the criteria for inclusion. Microsatellite instability (MSI) was identified in 170 (26.2 per cent), whereas 480 had microsatellite-stable (MSS) tumours (relative risk of MSI 2.5 compared with older patients). MSI was associated with a family history of colorectal cancer and lesions in the proximal colon. The proportions with pathological node-positive disease (45.9 versus 45.6 per cent; P = 1.000) and tumour budding (20.3 versus 20.5 per cent; P = 1.000) were similar in the two groups. Patients with MSI tumours were more likely to have BRAF (22.5 versus 6.9 per cent; P < 0.001) and KRAS (40.0 versus 24.2 per cent; P = 0.006) mutations, and a hereditary cancer syndrome (30.0 versus 5.0 per cent; P < 0.001; relative risk 6). Five-year disease-free survival rates in the MSI group were 95.0, 92.0, and 80.0 per cent for patients with stage I, II, and III tumours, compared with 88.0, 88.0, and 65.0 per cent in the MSS group (P = 0.753, P = 0.487, and P = 0.105 respectively).

CONCLUSION

Patients with early-onset colonic cancer have a high risk of MSI and defined genetic conditions. Those with MSI tumours have more adverse pathology (budding, KRAS/BRAF mutations, and nodal metastases) than older patients with MSI cancers.

Conflict of Interest Disclosure Among the Highest Earning Physicians Receiving Compensation From Vascular Device Companies

OBJECTIVE

To characterize the association between payments made by vascular device companies to clinicians, and the conflict of interest (COI) declarations on relevant publications.

SUMMARY BACKGROUND DATA

Close association between medical device companies and clinicians is essential in the advancement of surgical technology. When evaluating the efficacy of novel equipment, identification of these relationships can minimize the risk of bias in relevant studies.

METHODS

Using the Open Payments Database (OPD), the 10 highest compensated clinicians from 10 vascular device companies were identified. In the population based bibliometric analysis, general payments, number of payments, h-index, and academic rank were identified. PubMed and Scopus were queried to identify author publications. Relevance to payment received and COI disclosures were identified for each article.

RESULTS

The physicians identified earned $33,442,266.74 with a median of $92,500 in 2017. The authors published an average of 6.46+/-9.08 articles in 2018. Relevant COI was identified in 74%. In 50.5% of the relevant publications was a COI declared. The median h index of authors was 18+/-23. Community based physicians had a higher rate of COI disclosure (65.6%) compared to academic physicians (47.6%) (P = .008). Low h-index authors had a higher rate of COI declaration (71.4%) compared to high h-index (43.6%) (P = .001).

CONCLUSION

A high degree of inconsistency was found between self-declared COI and relevant articles published by the highest compensated physicians. We propose a policy of full disclosure and the addition of a link to each author's OPD page on all publications to increase access to potential COI.

Surgical Outcome in Laparoscopic Abdominal Surgical Operations with Clostridium Difficile Infection

Introduction: Postoperative Clostridium difficile infection (CDI) has associated morbidity, but it is unknown how it impacts different operations. We sought to determine the incidence and postoperative morbidity following abdominal surgery.

Method: The National Surgical Quality Improvement Program database (2015-2019) was utilized to evaluate adult (≥18 years-old) patients who developed CDI following laparoscopic abdominal operations. Univariate and multivariate analysis were performed to evaluate outcomes.

Results: A total of 973 338 patients were studied and the overall incidence of CDI was .3% within 30 days of operation. Colorectal surgery had the highest incidence of CDI (1601/167 949,1.0%) with significantly longer mean length of stay (LOS) (8.0 days± 9.0, P < .01) compared to other surgical procedures. CDI patients also had a longer mean length of stay (6.6± 8.0 vs 2.1 ± 3.6 days, P < .01) and increased mortality (1.8% vs .2%, AOR: 4.64, CI: 3.45-5.67, P < .01) compared to patients without CDI.

Conclusions: This national analysis demonstrates that CDI is a significant complication following abdominal surgery and is associated with increased LOS and mortality. Furthermore, laparoscopic colorectal surgery appears to have the greatest risk of CDI. Future research is needed to determine the exact cause in order to decrease the incidence of CDI by reconsidering the protocol of antibiotic use within the high-risk population.

Microsatellite instability in young patients with rectal cancer: molecular findings and treatment response

In this study of 400 patients with early-onset rectal cancer, 12.5 per cent demonstrated microsatellite instability (MSI). MSI was associated with a reduced likelihood of nodal positivity, an increased rate of pathological complete response, and improved disease-specific survival.

Infection prevention strategies are highly protective in COVID-19 units while main risks to healthcare professionals come from coworkers and the community

Background

Early evaluations of healthcare professional (HCP) COVID-19 risk occurred during insufficient personal protective equipment and disproportionate testing, contributing to perceptions of high patient-care related HCP risk. We evaluated HCP COVID-19 seropositivity after accounting for community factors and coworker outbreaks.

Methods

Prior to universal masking, we conducted a single-center retrospective cohort plus cross-sectional study. All HCP (1) seen by Occupational Health for COVID-like symptoms (regardless of test result) or assigned to (2) dedicated COVID-19 units, (3) units with a COVID-19 HCP outbreak, or (4) control units from 01/01/2020 to 04/15/2020 were offered serologic testing by an FDA-authorized assay plus a research assay against 67 respiratory viruses, including 11 SARS-CoV-2 antigens. Multivariable models assessed the association of demographics, job role, comorbidities, care of a COVID-19 patient, and geocoded socioeconomic status with positive serology.

Results

Of 654 participants, 87 (13.3%) were seropositive; among these 60.8% (N = 52) had never cared for a COVID-19 patient. Being male (OR 1.79, CI 1.05–3.04, p = 0.03), working in a unit with a HCP-outbreak unit (OR 2.21, CI 1.28–3.81, p < 0.01), living in a community with low owner-occupied housing (OR = 1.63, CI = 1.00–2.64, p = 0.05), and ethnically Latino (OR 2.10, CI 1.12–3.96, p = 0.02) were positively-associated with COVID-19 seropositivity, while working in dedicated COVID-19 units was negatively-associated (OR 0.53, CI = 0.30–0.94, p = 0.03). The research assay identified 25 additional seropositive individuals (78 [12%] vs. 53 [8%], p < 0.01).

Conclusions

Prior to universal masking, HCP COVID-19 risk was dominated by workplace and community exposures while working in a dedicated COVID-19 unit was protective, suggesting that infection prevention protocols prevent patient-to-HCP transmission.

Article summary

Prior to universal masking, HCP COVID-19 risk was dominated by workplace and community exposures while working in a dedicated COVID-19 unit was protective, suggesting that infection prevention protocols prevent patient-to-HCP transmission.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13756-021-01031-5.

Characteristics of Early-Onset vs Late-Onset Colorectal Cancer: A Review

Importance

The incidence of early-onset colorectal cancer (younger than 50 years) is rising globally, the reasons for which are unclear. It appears to represent a unique disease process with different clinical, pathological, and molecular characteristics compared with late-onset colorectal cancer. Data on oncological outcomes are limited, and sensitivity to conventional neoadjuvant and adjuvant therapy regimens appear to be unknown. The purpose of this review is to summarize the available literature on early-onset colorectal cancer.

Observations

Within the next decade, it is estimated that 1 in 10 colon cancers and 1 in 4 rectal cancers will be diagnosed in adults younger than 50 years. Potential risk factors include a Westernized diet, obesity, antibiotic usage, and alterations in the gut microbiome. Although genetic predisposition plays a role, most cases are sporadic. The full spectrum of germline and somatic sequence variations implicated remains unknown. Younger patients typically present with descending colonic or rectal cancer, advanced disease stage, and unfavorable histopathological features. Despite being more likely to receive neoadjuvant and adjuvant therapy, patients with early-onset disease demonstrate comparable oncological outcomes with their older counterparts.

Conclusions and Relevance

The clinicopathological features, underlying molecular profiles, and drivers of early-onset colorectal cancer differ from those of late-onset disease. Standardized, age-specific preventive, screening, diagnostic, and therapeutic strategies are required to optimize outcomes.

Prevention of Autoimmune Diabetes in NOD Mice by Dimethyl Fumarate

Oxidative stress plays critical roles in the pathogenesis of diabetes. This study tested the hypothesis that by protecting β-cells against oxidative stress and inflammation, an Nrf2 activator, dimethyl fumarate (DMF), may prevent or delay the onset of type 1 diabetes in non-obese diabetic (NOD) mice. Firstly, islet isolation was conducted to confirm the antioxidative effects of DMF oral administration on islet cells. Secondly, in a spontaneous diabetes model, DMF (25 mg/kg) was fed to mice once daily starting at the age of 8 weeks up to the age of 22 weeks. In a cyclophosphamide-induced accelerated diabetes model, DMF (25 mg/kg) was fed to mice twice daily for 2 weeks. In the islet isolation study, DMF administration improved the isolation yield, attenuated oxidative stress and enhanced GCLC and NQO1 expression in the islets. In the spontaneous model, DMF significantly reduced the onset of diabetes compared to the control group (25% vs. 54.2%). In the accelerated model, DMF reduced the onset of diabetes from 58.3% to 16.7%. The insulitis score in the islets of the DMF treatment group (1.6 ± 0.32) was significantly lower than in the control group (3.47 ± 0.21). The serum IL-1α, IL-1β, IL-2, IL-4, IL-5, IL-6, IL-9, IL-12p70, IFN-γ, TNF-α, MCP-1 and CXCL16 levels in the DMF-treated group were lower than in the control group. In conclusion, DMF may protect islet cells and reduce the incidence of autoimmune diabetes in NOD mice by attenuating insulitis and proinflammatory cytokine production.

Outcomes of Minimally Invasive Colectomy for Perforated Diverticulitis

BACKGROUND

We hypothesized that a laparoscopic approach to sigmoidectomy for perforated diverticulitis is associated with less morbidity and mortality.

METHODS

The NSQIP database was used to investigate adult patients who underwent emergent colectomy with end colostomy for perforated diverticulitis. A multivariate analysis using logistic regression was used to compare outcomes of patients by surgical approach.

RESULTS

We found a total of 2937 adult patients who underwent emergent colectomy for perforated diverticulitis during 2012-2017. The rate of minimally invasive surgery (MIS) was 11.4% with 38.6% conversion rate to open. The 30-day mortality and morbidity rates were 8.8% and 65.8%, respectively. Following adjustment using a multivariate analysis, the open approach was associated with higher morbidity (67.2% vs 56.8%, AOR: 1.70, P < .01) and mean hospitalization length of patients (13 days vs 10 days, P < .01) compared to the MIS approach. Respiratory complications of ventilator dependency (14.3% vs 6%, AOR: 2.95, P < .01) and unplanned intubation (7.4% vs 2.4%, AOR: 2.14, P = .03) were significantly higher in the open approach. However, patients who underwent the open approach were older (age >70; 33.5% vs 24%, P < .01) with more comorbid conditions such as COPD (10.8% vs 7.2%, P = .04) and CHF (9% vs 3.1%, P < .0).

CONCLUSION

The MIS approach to emergent partial colectomy for perforated diverticulitis is associated with decreased morbidity and hospitalization length of patients. Utilization of the MIS approach for partial colectomy for perforated diverticulitis is 11.4% with a conversion rate of 38.6%. Efforts should be directed toward increasing the utilization of laparoscopic approaches for the surgical treatment of perforated diverticulitis.

Short-term outcomes of laparoscopic approach to colonic obstruction for colon cancer

BACKGROUND

We speculated that a laparoscopic approach to emergent/urgent partial colectomy for colonic obstruction would be associated with less morbidity and shorter length of stay with similar mortality to open colectomy. We compared the outcomes of laparoscopic and open approaches to emergent/urgent partial colectomy for colonic obstruction from colonic cancer using data from the National Surgical Quality Improvement Program (NSQIP) database for the period of 2012-2017.

METHODS

Multivariate analysis compared NSQIP data points following laparoscopic, laparoscopic converted to open, and open colectomy for emergent/urgent colectomy for colonic obstruction from colon cancer from 2012 to 2017.

RESULTS

A total of 1293 patients who underwent emergent colectomy for colon obstruction from colon cancer during 2012-2017 were identified within the NSQIP database. Laparoscopic approach was used for colonic obstruction in 19.3% of operations with a conversion rate of 28.5%. A laparoscopic approach to obstructing colonic cancers was associated with lower morbidity (50% vs. 61.8%, AOR: 0.67, P = 0.01) and shorter hospitalization length (10 days vs. 13 days, mean difference: 3 days, P < 0.01) compared with an open approach. However, the mean operation duration was longer in laparoscopic operations than open operations (159 min vs. 137 min, P < 0.01).

CONCLUSION

A laparoscopic approach to malignant colonic obstruction is associated with decreased morbidity. This suggests that efforts should be directed towards increasing the utilization of laparoscopic approaches for the surgical treatment of colonic obstruction.

Predictive Factors of Acute Respiratory Failure in Esophagectomy for Esophageal Malignancy

Acute respiratory failure (ARespF) is a common complication after esophagectomy that contributes to higher morbidity and mortality. Using the Nationwide Inpatient Sample database, we sought to identify predictors of ARespF in 6352 patients who underwent esophagectomy for malignancy between 2006 and 2008. Multivariate regression analyses were performed to identify preoperative factors (patient characteristics, comorbidities, procedural type, tumor's location, hospital teaching status, and payer type) predictive of ARespF in esophagectomy. The overall rate of ARespF was 27.08 per cent. For comorbidities, independent risk factors for higher rate of ARF included weight loss (adjusted odds ratio [AOR], 3.63; 95% confidence interval [CI], 3.02 to 4.37), pulmonary hypertension (AOR, 2.38; 95% CI, 1.85 to 3.45), congestive heart failure (AOR, 2.35; 95% CI, 1.77 to 3.13), liver disease (AOR, 1.95; 95% CI, 1.22 to 3.12), chronic lung disease (AOR, 1.40; 95% CI, 1.17 to 1.66), and anemia (AOR, 1.26; 95% CI, 1.04 to 1.51). Cervical location of malignancy (AOR, 2.32; 95% CI, 1.51 to 3.56), total esophagectomy (AOR, 1.64; 95% CI, 1.41 to 1.90), and non-teaching hospital (AOR, 1.45; 95% CI, 1.20 to 1.75) were independent risk factors for ARespF. There was no effect of age, gender, race, hypertension, diabetes, renal failure, obesity, smoking, peripheral vascular disorder, or payer type on ARespF. We identified multiple preoperative risk factors that have an impact on development of ARespF after esophagectomy. Surgeons can use these factors to inform patients of potential risks and should consider these factors during surgical-decision making.

Laparoscopic Sleeve Gastrectomy or Laparoscopic Gastric Bypass for Patients with Metabolic Syndrome: An MBSAQIP Analysis

In patients undergoing bariatric surgery, the presence of metabolic syndrome (MetS) contributes to perioperative morbidity. We aimed to evaluate the utilization and outcome of severely obese patients with MetS who underwent laparoscopic sleeve gastrectomy (LSG) versus laparoscopic Roux-en-Y gastric bypass (LRYGB). Using the 2015 and 2016 Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program database, data were obtained for patients with MetS undergoing LSG or LRYGB. There were 29,588 MetS patients (LSG: 58.7% vs LRYGB: 41.3%). There was no significant difference in 30-day mortality (0.1% for LSG vs 0.2% for LRYGB, adjusted odds ratio (AOR) 0.58, confidence interval (CI) 0.32–1.05, P = 0.07) or length of stay between groups (2 ± 2 for LSG vs 2.2 ± 2 days for LRYGB, P = 0.40). Compared with LRYGB, LSG was associated with significantly shorter operative time (78 ± 39 vs 122 ± 54 minutes, P < 0.01), lower overall morbidity (2.3% vs 4.4%, AOR 0.53, CI 0.46–0.60, P < 0.01), lower serious morbidity (1.5% vs 2.3%, AOR 0.64, CI 0.53–0.76, P < 0.01), lower 30-day reoperation (1.2% vs 2.3%, AOR 0.52, CI 0.43–0.63, P < 0.01), and lower 30-day readmission (4.2% vs 6.6%, AOR 0.62, CI 0.55–0.69, P < 0.01). In conclusion, LSG is the predominant operation being performed for severely obese patients with MetS, and its popularity may in part be related to its improved perioperative safety profile.

Colorectal Surgery in Kidney Transplant Recipients: A Decade of Trends and Outcomes in the United States

There is paucity of data evaluating the trends and outcomes of colorectal surgery (CRS) in kidney transplant recipients (KTRs). Using the Nationwide Inpatient Sample 2001 to 2010, a retrospective review of CRS performed in KTRs was performed. Trends, demographics, indications, and outcomes were examined for elective and emergent cases and compared with the general population (GP) on multivariate logistic regression. A total of 2616 KTRs underwent CRS, 50 per cent of which were done emergently. KTRs developed colon and rectal cancer at a younger age and had significantly higher incidence of comorbidities compared with the GP. Diverticular disease was the most common indication for surgery (48%) followed by cancer (30.6%). Compared with the GP, KTRs had higher rates of mortality (6.29 vs 3.64%), wound complications (8.02 vs 5.37%), and acute renal failure (ARF) (17.14 vs 7.10%) (all P < 0.05). No difference was seen in the incidence of anastomotic leak. On multivariate analysis, KTRs had higher associated odds of ARF (odds ratio, 2.02; P < 0.001), whereas the odds of mortality, wound, and anastomotic complications were similar to the GP. Emergency surgery in KTRs was associated with worse outcomes compared with the elective setting. KTRs undergoing CRS have unique characteristics that are different than the GP. They are at an increased risk of complications, especially acute renal failure.

Morbidity of Diverting Ileostomy for Rectal Cancer: Analysis of the American College of Surgeons National Surgical Quality Improvement Program

There is controversy regarding the potential benefits of diverting ileostomy after low anterior resection (LAR). This study aims to examine the morbidity associated with diverting ileostomy in rectal cancer. A retrospective review of LAR cases was performed using the American College of Surgeons National Surgical Quality Improvement Program (2005 to 2011). Patients who underwent LAR with and without diversion were selected. Demographics, intraoperative events, and postoperative complications were reviewed. Among the 6337 cases sampled, 991 (16%) received a diverting ileostomy. Patients who were diverted were younger (60 vs 63 years), predominantly male (64 vs 53%), and more likely to have received pre-operative radiation (39 vs 12%). There was no significant difference in steroid use, weight loss, or intraoperative transfusion. Postoperatively, there was no significant difference in length of stay, rate of septic complications, wound infections, and mortality. The rate of reoperation was lower in the diverted group (4.5 vs 6.9%). Diversion was associated with a higher risk-adjusted rate of acute renal failure (OR 2.4; 95% CI (1.2, 4.6); P < 0.05). The use of diverting ileostomy reduces the rate of reoperation but is associated with an increased risk of acute renal insufficiency. These findings emphasize the need for refinement of patient selection and close follow-up to limit morbidity.

Dimethyl Fumarate Alleviates Dextran Sulfate Sodium-Induced Colitis, through the Activation of Nrf2-Mediated Antioxidant and Anti-inflammatory Pathways

Oxidative stress and chronic inflammation play critical roles in the pathogenesis of ulcerative colitis (UC) and inflammatory bowel diseases (IBD). A previous study has demonstrated that dimethyl fumarate (DMF) protects mice from dextran sulfate sodium (DSS)-induced colitis via its potential antioxidant capacity, and by inhibiting the activation of the NOD-, LRR- and pyrin domain-containing protein 3 (NLRP3) inflammasome. This study aims to clarify the nuclear factor erythroid 2-related factor 2/antioxidant responsive element (Nrf2/ARE) pathway pharmacological activation and anti-inflammatory effect by DMF, through focusing on other crucial antioxidant enzymes and inflammatory mediator, including glutamate-cysteine ligase catalytic subunit (GCLC), glutathione peroxidase (GPX) and cyclooxygenase-2 (COX-2), in a DSS-induced colitis mouse model. The oral administration of DMF attenuated the shortening of colons and alleviated colonic inflammation. Furthermore, the expression of key antioxidant enzymes, including GCLC and GPX, in the colonic tissue were significantly increased by DMF administration. In addition, protein expression of the inflammatory mediator, COX-2, was reduced by DMF administration. Our results suggest that DMF alleviates DSS-induced colonic inflammatory damage, likely via up-regulating GCLC and GPX and down-regulating COX-2 protein expression in colonic tissue.

High and low estimated glomerular filtration rates are associated with adverse outcomes in patients undergoing surgery for gastrointestinal malignancies

BACKGROUND

Abnormally high estimated glomerular filtration rates (eGFRs) are associated with endothelial dysfunction and frailty. Previous studies have shown that low eGFR is associated with increased morbidity, but few reports address high eGFR. The purpose of this study is to evaluate the association of high eGFR with surgical outcomes in patients undergoing surgery for gastrointestinal malignancies.

METHODS

We identified patients who underwent elective surgery for gastrointestinal malignancies from 2005 to 2015 in the American College of Surgeons National Surgical Quality Improvement Program database. We evaluated associations of eGFR with surgical outcomes by Cox or logistic models with restricted cubic spline functions, adjusting for case mix variables (i.e. age, gender, race and diabetes).

RESULTS

The median eGFR is 83 (interquartile range 67-96) mL/min/1.73 m2. Thirty-day mortality was 1.9% (2555/136 896). There is a U-shaped relationship between eGFR and 30-day mortality. The adjusted hazard ratios (95% confidence intervals) for eGFRs of 30, 60, 105 and 120 mL/min/1.73 m2 (versus 90 mL/min/1.73 m2) are 1.73 (1.52-1.97), 1.00 (0.89-1.11), 1.42 (1.31-1.55) and 2.20 (1.79-2.70), respectively. Similar associations are shown for other surgical outcomes, including return to the operating room and postoperative pneumonia. Subgroup analyses show that eGFRs both higher and lower than the respective medians are consistently associated with a higher risk of adverse outcomes across age, gender and race.

CONCLUSIONS

High and low eGFRs are associated with more adverse surgical outcomes in patients undergoing surgery for gastrointestinal malignancies. The eGFR associated with the lowest postoperative risk is approximately at the median eGFR of a given population.

Improved survival with adjuvant chemotherapy in locally advanced rectal cancer patients treated with preoperative chemoradiation regardless of pathologic response

OBJECTIVE

The aim of this study is to examine the effect of postoperative chemotherapy on survival in patients with stage II or III rectal adenocarcinoma who undergo neoadjuvant chemoradiation (CRT) and surgical resection.

METHODS

A retrospective review of the National Cancer Database (NCDB) from 2006 to 2013 was performed. Cases were analyzed based on pathologic complete response (pCR) status and use of adjuvant therapy. The Kaplan-Meier method was used to estimate overall survival probabilities.

RESULTS

23,045 cases were identified, of which 5832 (25.31%) achieved pCR. In the pCR group, 1513 (25.9%) received adjuvant chemotherapy, and in the non-pCR group, 5966 (34.7%) received adjuvant therapy. In the pCR group, five-year survival probability was 87% (95% CI 84%-89%) with adjuvant therapy and 81% (95% CI 79%-82%) without adjuvant therapy. In the non-pCR group, five-year survival probability was 78% (95% CI 76%-79%) with adjuvant therapy and 70% (95% CI 69%-71%) without adjuvant therapy. In the non-pCR and node-negative subgroup (ypN-), five-year survival probability was 86% (95% CI 84%-88%) with adjuvant therapy and 76% (95% CI 74%-77%) without adjuvant therapy. In the non-pCR and node-positive subgroup (ypN+), five-year survival probability was 67% (95% CI 65%-70%) with adjuvant therapy and 60% (95% CI 58%-63%) without adjuvant therapy.

CONCLUSIONS

Adjuvant chemotherapy in stage II or III rectal adenocarcinoma is associated with increased five-year survival probability regardless of pCR status. We observed similar survival outcomes among non-pCR ypN- treated with adjuvant chemotherapy compared with patients achieving pCR treated with adjuvant chemotherapy.

Association of Compensation From the Surgical and Medical Device Industry to Physicians and Self-declared Conflict of Interest

Importance

Surgical and medical device manufacturers have a cooperative relationship with clinicians. When evaluating published works, one should assess the integrity and academic credentials of the authors, who serve as putative experts. A relationship with a relevant manufacturer may increase the potential risk for bias in relevant studies.

Objective

To characterize the association of industrial payments by device manufacturers, self-declared conflict of interest (COI), and relevance of publications among physicians receiving the highest compensation.

Design, Setting, and Participants

This population-based bibliometric analysis identified 10 surgical and medical device manufacturing companies and the 10 physicians receiving the highest compensation from each company using the 2015 Open Payments Database (OPD) general payments data. For each of the 100 physicians, the total amount of general payments, number of payments, institution type, and academic rank were recorded. Royalty or license payments were excluded. A search of PubMed identified articles published by each physician from January 1 through December 31, 2016, and their associated COI declaration. Scopus was used to identify bibliometric data reported as the h index (number of papers by a researcher with at least h citations each).

Main Outcomes and Measures

Discrepancy between self-declared COI and industry payments.

Results

The 100 physicians included in the sample population (88% men) were paid a total of $12 446 969, with a median payment of $95 993. Fifty physicians (50.0%) were faculty at academic institutions. The mean (SD) h index was 18 (18; range, 0-75) for the authors. In 2016, 412 articles were published by these physicians, with a mean (SD) of 4 (6) publications (range, 0-25) and median of 1 (36 physicians had no publications). Of these articles, 225 (54.6%) were relevant to the general payments received by the authors. Only in 84 of the 225 relevant publications (37.3%) was the potential COI declared by the authors.

Conclusions and Relevance

A high level of inconsistency was found between self-declared COI and the OPD among the physicians receiving the highest industry payments. Therefore, a policy of full disclosure for all publications, regardless of relevance, is proposed. No statistically significant association was demonstrated between academic rank or productivity and industrial payments.

Laparoscopic Sleeve Gastrectomy or Laparoscopic Gastric Bypass for Patients with Metabolic Syndrome: An MBSAQIP Analysis

In patients undergoing bariatric surgery, the presence of metabolic syndrome (MetS) contributes to perioperative morbidity. We aimed to evaluate the utilization and outcome of severely obese patients with MetS who underwent laparoscopic sleeve gastrectomy (LSG) versus laparoscopic Roux-en-Y gastric bypass (LRYGB). Using the 2015 and 2016 Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program database, data were obtained for patients with MetS undergoing LSG or LRYGB. There were 29,588 MetS patients (LSG: 58.7% vs LRYGB: 41.3%). There was no significant difference in 30-day mortality (0.1% for LSG vs 0.2% for LRYGB, adjusted odds ratio (AOR) 0.58, confidence interval (CI) 0.32-1.05, P = 0.07) or length of stay between groups (2 ± 2 for LSG vs 2.2 ± 2 days for LRYGB, P = 0.40). Compared with LRYGB, LSG was associated with significantly shorter operative time (78 ± 39 vs 122 ± 54 minutes, P < 0.01), lower overall morbidity (2.3% vs 4.4%, AOR 0.53, CI 0.46-0.60, P < 0.01), lower serious morbidity (1.5% vs 2.3%, AOR 0.64, CI 0.53-0.76, P < 0.01), lower 30-day reoperation (1.2% vs 2.3%, AOR 0.52, CI 0.43-0.63, P < 0.01), and lower 30-day readmission (4.2% vs 6.6%, AOR 0.62, CI 0.55-0.69, P < 0.01). In conclusion, LSG is the predominant operation being performed for severely obese patients with MetS, and its popularity may in part be related to its improved perioperative safety profile.

Laparoscopic loop ileostomy reversal with intracorporeal anastomosis is associated with shorter length of stay without increased direct cost

BACKGROUND

Laparoscopic ileostomy closure with intracorporeal anastomosis offers potential advantages over open reversal with extracorporeal anastomosis, including earlier return of bowel function and reduced postoperative pain. In this study, we aim to compare the outcome and cost of laparoscopic ileostomy reversal (utilizing either intracorporeal or extracorporeal anastomosis) with open ileostomy reversal.

METHODS

A retrospective review of sequential patients undergoing elective loop ileostomy reversal between 2013 and 2016 at a single, high-volume institution was performed. Patients were stratified on the basis of operative approach: open reversal, laparoscopic-assisted reversal with extracorporeal anastomosis (LE), and laparoscopic reversal with intracorporeal anastomosis (LI). Linear and logistic regressions were utilized to perform multivariate analysis and determine risk-adjusted outcomes.

RESULTS

Of 132 sequential cases of loop ileostomy reversal, 50 (38%) underwent open, 49 (37%) underwent LE, and 33 (22%) underwent LI. Demographic data and preoperative comorbidities were similar between the three cohorts. Median length of stay was significantly shorter for LI (52.1 h, p < 0.05) compared to open (69.0 h) and LE (69.6 h). After risk-adjusted analysis, length of stay was significant shorter in LI compared to LE (GM 0.78, 95% CI 0.64-0.93, p < 0.01) and open reversal (GM 0.78, 95% CI 0.66-0.93, p < 0.01). Risk-adjusted 30-day morbidity rates were similar for LI compared to LE (OR 0.43, 95% CI 0.081-2.33, p = 0.33) and open reversal (OR 0.53, 95% CI 0.09-3.125, p = 0.48). Median in-hospital direct cost was similar for LI ($6575.00), LE ($6722.50), and open reversal ($6181.00).

CONCLUSION

Laparoscopic ileostomy reversal with intracorporeal anastomosis was associated with shorter length of stay without increased overall direct cost. The technique of laparoscopic ileostomy reversal warrants continued study in a randomized clinical trial.

Ileocolic Resection for Crohn's Disease: A Minimally Invasive Approach Claims Its Place

Ileocolic resection is the most common operation performed for Crohn's disease patients with terminal ileum involvement. We sought to evaluate the outcomes in Crohn's disease patients who underwent open ileocolic resection (OIC) and laparoscopic ileocolic resection (LIC) by using the ACS-NSQIP database from 2006 to 2015. Of 5670 patients, 48.3 per cent (2737) patients had OIC and 51.7 per cent (2933) had LIC. The number of LIC increased from 40 per cent in 2006 to 60.7 per cent in 2015. Moreover, the annual number of LIC surgeries has exceeded the number of OIC surgeries since 2013. Patients in the LIC group had shorter hospital length of stay compared with OIC group (6 ± 5 days vs 8.6 ± 8 days, P < 0.01). The LIC procedure also had shorter operation time compared with OIC (148 ± 58 vs 153 ± 76 minutes, P = 0.01). Overall morbidity (15.8% vs 25.3%, AOR: 0.54, confidence interval (CI): 0.46–0.62, P < 0.01), serious morbidity (10.9% vs 18%, AOR: 0.55, CI: 0.46–0.65, P < 0.01), and SSI (9.9% vs 15.5%, AOR: 0.59, CI: 0.49–0.70, P < 0.01) rates were lower in the LIC group than the OIC group. We demonstrated that in Crohn's disease patients, LIC has improved outcomes for ileocolic resection compared with OIC and has been chosen as the preferential treatment approach for most patients.

Ileocolic Resection for Crohn's Disease: A Minimally Invasive Approach Claims Its Place

Ileocolic resection is the most common operation performed for Crohn's disease patients with terminal ileum involvement. We sought to evaluate the outcomes in Crohn's disease patients who underwent open ileocolic resection (OIC) and laparoscopic ileocolic resection (LIC) by using the ACS-NSQIP database from 2006 to 2015. Of 5670 patients, 48.3 per cent (2737) patients had OIC and 51.7 per cent (2933) had LIC. The number of LIC increased from 40 per cent in 2006 to 60.7 per cent in 2015. Moreover, the annual number of LIC surgeries has exceeded the number of OIC surgeries since 2013. Patients in the LIC group had shorter hospital length of stay compared with OIC group (6 ± 5 days vs 8.6 ± 8 days, P < 0.01). The LIC procedure also had shorter operation time compared with OIC (148 ± 58 vs 153 ± 76 minutes, P = 0.01). Overall morbidity (15.8% vs 25.3%, AOR: 0.54, confidence interval (CI): 0.46-0.62, P < 0.01), serious morbidity (10.9% vs 18%, AOR: 0.55, CI: 0.46-0.65, P < 0.01), and SSI (9.9% vs 15.5%, AOR: 0.59, CI: 0.49-0.70, P < 0.01) rates were lower in the LIC group than the OIC group. We demonstrated that in Crohn's disease patients, LIC has improved outcomes for ileocolic resection compared with OIC and has been chosen as the preferential treatment approach for most patients.

Robotic versus laparoscopic sleeve gastrectomy: a MBSAQIP analysis

BACKGROUND

Laparoscopic sleeve gastrectomy has become the procedure of choice for the treatment of morbid obesity. Robotic sleeve gastrectomy is an alternative surgical option, but its utilization has been low. The aim of this study was to evaluate the contemporary outcomes of robotic sleeve gastrectomy (RSG) versus laparoscopic sleeve gastrectomy (LSG) using a national database from accredited bariatric centers.

STUDY DESIGN

Using the 2015 Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP) database, clinical data for patients who underwent RSG or LSG were examined. Emergent and revisional cases were excluded. A multivariate logistic regression model was utilized to compare the outcomes between RSG and LSG.

RESULTS

A total of 75,079 patients underwent sleeve gastrectomy with 70,298 (93.6%) LSG and 4781 (6.4%) RSG. Preoperative sleep apnea and hypoalbumenia were significantly higher in the RSG group (P < 0.01). Mean length of stay was similar between RSG and LSG (1.8 ± 2.0 vs. 1.7 ± 2.0 days, P = 0.17). Operative time was longer in the RSG group (102 ± 43 vs. 74 ± 36 min, P < 0.01). There was no significant difference in 30-day mortality between the RSG versus LSG group (0.02% vs. 0.01%, AOR 0.85; 95% CI 0.11-6.46, P = 0.88). However, RSG was associated with higher serious morbidity (1.1% vs. 0.8%, AOR 1.40; 95% CI 1.05-1.86, P < 0.01), higher leak rate (1.5% vs. 0.5%, AOR 3.14; 95% CI 2.65-4.42, P < 0.01), and higher surgical site infection rate (0.7% vs. 0.4%, AOR 1.55; 95% CI 1.08-2.23, P = 0.01).

CONCLUSIONS

Robotic sleeve gastrectomy has longer operative time and is associated with higher postoperative morbidity including leak and surgical site infections. Laparoscopy should continue to be the surgical approach of choice for sleeve gastrectomy.

Risk Factors for Gastrointestinal Leak after Bariatric Surgery: MBASQIP Analysis

BACKGROUND

Gastrointestinal leak remains one of the most dreaded complications in bariatric surgery. We aimed to evaluate risk factors and the impact of common perioperative interventions on the development of leak in patients who underwent laparoscopic bariatric surgery.

STUDY DESIGN

Using the 2015 database of accredited centers, data were analyzed for patients who underwent laparoscopic sleeve gastrectomy or Roux-en-Y gastric bypass (LRYGB). Emergent, revisional, and converted cases were excluded. Multivariate logistic regression was used to analyze risk factors for leak, including provocative testing of anastomosis, surgical drain placement, and use of postoperative swallow study.

RESULTS

Data from 133,478 patients who underwent laparoscopic sleeve gastrectomy (n = 92,495 [69.3%]) and LRYGB (n = 40,983 [30.7%]) were analyzed. Overall leak rate was 0.7% (938 of 133,478). Factors associated with increased risk for leak were oxygen dependency (adjusted odds ratio [AOR] 1.97), hypoalbuminemia (AOR 1.66), sleep apnea (AOR 1.52), hypertension (AOR 1.36), and diabetes (AOR 1.18). Compared with LRYGB, laparoscopic sleeve gastrectomy was associated with a lower risk of leak (AOR 0.52; 95% CI 0.44 to 0.61; p < 0.01). Intraoperative provocative test was performed in 81.9% of cases and the leak rate was higher in patients with vs without a provocative test (0.8% vs 0.4%, respectively; p < 0.01). A surgical drain was placed in 24.5% of cases and the leak rate was higher in patients with vs without a surgical drain placed (1.6% vs 0.4%, respectively; p < 0.01). A swallow study was performed in 41% of cases and the leak rate was similar between patients with vs without swallow study (0.7% vs 0.7%; p = 0.50).

CONCLUSIONS

The overall rate of gastrointestinal leak in bariatric surgery is low. Certain preoperative factors, procedural type (LRYGB), and interventions (intraoperative provocative test and surgical drain placement) were associated with a higher risk for leaks.

Respiratory complications after colonic procedures in chronic obstructive pulmonary disease: does laparoscopy offer a benefit?

BACKGROUND

Patients with severe chronic obstructive pulmonary disease (COPD) are at a higher risk for postoperative respiratory complications. Despite the benefits of a minimally invasive approach, laparoscopic pneumoperitoneum can substantially reduce functional residual capacity and raise alveolar dead space, potentially increasing the risk of respiratory failure which may be poorly tolerated by COPD patients. This raises controversy as to whether open techniques should be preferentially employed in this population.

METHODS

The American College of Surgeons National Surgical Quality Improvement Program (NSQIP) database from 2011 to 2014 was used to examine the clinical data from patients with COPD who electively underwent laparoscopic and open colectomy. Patients defined as having COPD demonstrated either functional disability, chronic use of bronchodilators, prior COPD-related hospitalization, or reduced forced expiratory reserve volumes on lung testing (FEV1 <75%). Demographic data and preoperative characteristics were compared. Linear and logistic regressions were utilized to perform multivariate analysis and determine risk-adjusted outcomes.

RESULTS

Of the 4397 patients with COPD, 53.8% underwent laparoscopic colectomy (LC) while 46.2% underwent open colectomy (OC). The LC and OC groups were similar with respect to demographic data and preoperative comorbidities. Equivalent frequencies of exertional dyspnea (LC 35.4 vs OC 37.7%, P = 0.11) were noted. After multivariate risk adjustment, OC demonstrated an increased rate of overall respiratory complications including pneumonia, reintubation, and prolonged ventilator dependency when compared to LC (OR 1.60, 95% CI 1.30-1.98, P < 0.01). OC was associated with longer length of stay (10 ± 8 vs. 6.7 ± 7 days, P < 0.01) and higher readmission (OR 1.36, 95% CI 1.09-1.68, P < 0.01) compared to LC.

CONCLUSION

Despite the potential risks of laparoscopic pneumoperitoneum in the susceptible COPD population, a minimally invasive approach was associated with lower risk of postoperative respiratory complications, shorter length of stay, and decrease in postoperative morbidity.

Massive Submucosal Ganglia in Colonic Inertia

CONTEXT

- Colonic inertia is a debilitating form of primary chronic constipation with unknown etiology and diagnostic criteria, often requiring pancolectomy. We have occasionally observed massively enlarged submucosal ganglia containing at least 20 perikarya, in addition to previously described giant ganglia with greater than 8 perikarya, in cases of colonic inertia. These massively enlarged ganglia have yet to be formally recognized.

OBJECTIVE

- To determine whether such "massive submucosal ganglia," defined as ganglia harboring at least 20 perikarya, characterize colonic inertia.

DESIGN

- We retrospectively reviewed specimens from colectomies of patients with colonic inertia and compared the prevalence of massive submucosal ganglia occurring in this setting to the prevalence of massive submucosal ganglia occurring in a set of control specimens from patients lacking chronic constipation.

RESULTS

- Seven of 8 specimens affected by colonic inertia harbored 1 to 4 massive ganglia, for a total of 11 massive ganglia. One specimen lacked massive ganglia but had limited sampling and nearly massive ganglia. Massive ganglia occupied both superficial and deep submucosal plexus. The patient with 4 massive ganglia also had 1 mitotically active giant ganglion. Only 1 massive ganglion occupied the entire set of 10 specimens from patients lacking chronic constipation.

CONCLUSIONS

- We performed the first, albeit distinctly small, study of massive submucosal ganglia and showed that massive ganglia may be linked to colonic inertia. Further, larger studies are necessary to determine whether massive ganglia are pathogenetic or secondary phenomena, and whether massive ganglia or mitotically active ganglia distinguish colonic inertia from other types of chronic constipation.

The Growing Utilization of Laparoscopy in Emergent Colonic Disease

Emergent colonic disease has traditionally been managed with open procedures. Evaluation of recent trends suggests a shift toward minimally invasive techniques in this disease setting. The American College of Surgeons National Surgical Quality Improvement Program (NSQIP) targeted colectomy database from 2012 to 2014 was used to examine clinical data from patients who emergently underwent open colectomy (OC) and laparoscopic colectomy (LC). Multivariate regression was utilized to analyze preoperative characteristics and determine risk-adjusted outcomes with intent-to-treat and as-treated approach. Of 10,018 patients with emergent colonic operation, 90 per cent (9023) underwent OC whereas 10 per cent (995) underwent LC. Laparoscopic utilization increased annually, with LC composing 10.9 per cent of emergent colonic operations in 2014 compared with 9.3 per cent in 2012. Compared with LC, patients treated with OC had higher rates of overall morbidity (odds ratio 2.01, 95% confidence interval 1.74-2.34, P < 0.01) and 30-day mortality (odds ratio 1.79, 95% confidence interval 1.30-2.46, P < 0.01). Subset analysis of emergent patients without preoperative septic shock revealed consistent benefits with laparoscopy in overall morbidity, 30-day mortality, ileus, and surgical site infection. In select patients with hemodynamic stability, emergent LC appears to be a safe and beneficial operation. This study reflects the growing preference and utilization of minimally invasive techniques in emergent colonic operations.

The Growing Utilization of Laparoscopy in Emergent Colonic Disease

Emergent colonic disease has traditionally been managed with open procedures. Evaluation of recent trends suggests a shift toward minimally invasive techniques in this disease setting. The American College of Surgeons National Surgical Quality Improvement Program (NSQIP) targeted colectomy database from 2012 to 2014 was used to examine clinical data from patients who emergently underwent open colectomy (OC) and laparoscopic colectomy (LC). Multivariate regression was utilized to analyze preoperative characteristics and determine risk-adjusted outcomes with intent-to-treat and as-treated approach. Of 10,018 patients with emergent colonic operation, 90 per cent (9023) underwent OC whereas 10 per cent (995) underwent LC. Laparoscopic utilization increased annually, with LC composing 10.9 per cent of emergent colonic operations in 2014 compared with 9.3 per cent in 2012. Compared with LC, patients treated with OC had higher rates of overall morbidity (odds ratio 2.01, 95% confidence interval 1.74–2.34, P < 0.01) and 30-day mortality (odds ratio 1.79, 95% confidence interval 1.30–2.46, P < 0.01). Subset analysis of emergent patients without preoperative septic shock revealed consistent benefits with laparoscopy in overall morbidity, 30-day mortality, ileus, and surgical site infection. In select patients with hemodynamic stability, emergent LC appears to be a safe and beneficial operation. This study reflects the growing preference and utilization of minimally invasive techniques in emergent colonic operations.

Robotic ventral mesh rectopexy for rectal prolapse: a single-institution experience

BACKGROUND

Robotic ventral mesh rectopexy (RVMR) is an appealing approach for the treatment of rectal prolapse and other conditions. The aim of this study was to evaluate the outcomes of RVMR for rectal prolapse.

METHODS

We performed a retrospective chart review for patients who underwent RVMR for rectal prolapse at our institution between July 2012 and May 2016. Any patient who underwent RVMR during this time frame was included in our analysis. Any cases involving colorectal resection or other rectopexy techniques were excluded.

RESULTS

Of the 24 patients who underwent RVMR, 95.8% of patients were female. Median age was 67.5 years old (IQR 51.5-73.3), and 79.2% of patients were American Society of Anesthesiologists class III or IV. Median operative time was 191 min (IQR 164.3-242.5), and median length of stay was 3 days (IQR 2-3). There were no conversions, RVMR-related complications or mortality. Patients were followed for a median of 3.8 (IQR 1.2-15.9) months. Full-thickness recurrence occurred in 3 (12.4%) patients. Rates of fecal incontinence improved after surgery (62.5 vs. 41.5%, respectively) as did constipation (45.8 vs. 33.3%, respectively). No patients reported worsening symptoms postoperatively. Only one (4.2%) patient reported de novo constipation postoperatively.

CONCLUSIONS

RVMR is a feasible, safe and effective option for the treatment of rectal prolapse, with low short-term morbidity and mortality. Multicenter and long-term studies are needed to better assess the benefits of this procedure.

Randomized Clinical Trial of Epidural Compared with Conventional Analgesia after Minimally Invasive Colorectal Surgery

BACKGROUND

The effectiveness of thoracic epidural analgesia (EA) vs conventional IV analgesia (IA) after minimally invasive surgery is still unproven. We designed a randomized controlled trial comparing EA with IA after minimally invasive colorectal surgery.

STUDY DESIGN

A total of 87 patients who underwent minimally invasive colorectal procedures at a single institution between 2011 and 2014 were enrolled. Eight patients were excluded and 38 were randomized to EA and 41 to IA. Pain was assessed with the Visual Analogue Scale and quality of life with the Overall Benefit of Analgesia Score daily until discharge.

RESULTS

Mean age was 57 ± 14 years, 43% of patients were female, and mean BMI was 28.6 ± 6 kg/m². The 2 groups were similar in demographic characteristics and distribution of diagnoses and procedures. Epidural analgesia had a higher incidence of hypotensive systolic blood pressure (<90 mmHg) episodes (9 vs 2; p < 0.05) and a trend toward longer Foley catheter duration (3 ± 2 days vs 2 ± 4 days; p > 0.05). Epidural and IA had equivalent mean lengths of stay (4 ± 3 days vs 4 ± 3 days), daily Visual Analogue Scale scores (2.4 ± 2.0 vs 3.0 ± 2.0), and Overall Benefit of Analgesia Scores (3.2 ± 2.0 vs 3.2 ± 2.0), and similar time to start oral diet (2.8 ± 2 days vs 2.2 ± 1 days). Epidural analgesia patients used a higher total dose of narcotics (147.5 ± 192.0 mg vs 98.1 ± 112.0 mg; p > 0.05). Epidural and IV analgesia had equivalent total hospital charges ($144,991 ± $67,636 vs $141,339 ± $75,579; p > 0.05).

CONCLUSIONS

This study indicates that EA has no added clinical benefit in patients undergoing minimally invasive colorectal surgery. A trend toward higher total narcotics use and complications with EA was demonstrated.

Risk of Postoperative Venous Thromboembolism Among Pregnant Women

Venous thromboembolism (VTE) is a critical complication after surgery. Although pregnancy is a known risk factor of VTE, available data on the risk of postoperative VTE are scarce. Using the American College of Surgeons National Surgical Quality Improvement Program database between 2006 and 2012, we matched 2,582 pregnant women to 103,640 nonpregnant women based on age, race, body mass index, and modified Rogers score. Pregnant women, compared with matched nonpregnant women, experienced higher incidence of VTE (0.5% vs 0.3%; odds ratio 1.93, 95% confidence interval 1.1 to 3.37, p = 0.02). Pregnant women also showed higher risk of pneumonia, ventilator dependence ≥48 hours, bleeding, and sepsis than did the counterparts. In conclusion, pregnancy was associated with higher risk of VTE after surgery as well as other postoperative complications. The absolute risk difference was small, and careful evaluation against the potential risk and benefit should be given when surgical treatment is considered among pregnant women.

Association of pre-operative estimated GFR on post-operative pulmonary complications in laparoscopic surgeries

Despite a large body of evidence showing the pandemic of chronic kidney disease, the impact of pre-operative kidney function on the risk of post-operative pulmonary complications (PPCs) is not well known. We used multivariable logistic regression analyses with 3-level hierarchical adjustments to identify the association of pre-operative estimated glomerular filtration rate (eGFR) with PPCs in laparoscopic surgeries. Among 452,213 patients between 2005 and 2013 in the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) Database, a total of 3,727 patients (0.9%) experienced PPCs. We found a gradient association between lower eGFR and higher likelihood of PPCs in the unadjusted model. In the case-mix adjusted model, a reverse-J-shaped association was observed; a small albeit significant association with the highest eGFR category emerged. Further adjustment slightly attenuated these associations, but the PPCs risk in the eGFR groups of <30, 30-60, and ≥120 mL/min/1.73 m2 remained significant: odds ratios (95% confidence intervals) of 1.82 (1.54-2.16), 1.38 (1.24-1.54), and 1.28 (1.07-1.53), respectively (reference: 90-120 mL/min/1.73 m2). Our findings propose a need for careful pre-operative evaluation of cardiovascular and pulmonary functions and post-operative fluid management among patients with not only lower but also very high eGFR.

The Role of Fluorescent Angiography in Anastomotic Leaks

Anastomotic leaks following colorectal anastomosis has substantial implications including increased morbidity, longer hospitalization, and reduced overall survival. The etiology of leaks includes patient factors, technical factors, and anastomotic perfusion. An intact anastomotic blood supply is especially crucial in the physiology of anastomotic healing. To date, no established intraoperative methods have been developed that reliably and reproducibly identify and prevent leak occurrence. Recently, fluorescent angiography (FA) with indocyanine green (ICG) has emerged as an innovative modality for intraoperative perfusion assessment. ICG-FA can be performed before or after intestinal resection or, alternatively, after creation of the anastomosis. Angiographic assessment with near-infrared camera filters allows determination of perfusion adequacy, guiding additional intestinal resection and anastomotic revision. Early clinical experiences with ICG-FA demonstrated safety and feasibility. Large, multi-center prospective trials, such as the Perfusion Assessment in Laparoscopic Left-Sided/Anterior Resection Study (PILLAR II), demonstrated ease of use with remarkably low anastomotic leak rates after ICG-FA-guided intraoperative revision. Current randomized control trials featuring utilization in ICG-FA in low anterior resection are currently underway and will further clarify the role of ICG-FA in leak identification and prevention. Apart from colorectal surgery, FA has also been successfully employed in other surgical disciplines such as plastic surgery, vascular surgery, foregut surgery, urology, and gynecology.