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.

Evaluation of Pelvic Anastomosis by Endoscopic and Contrast Studies Prior to Ileostomy Closure: Are Both Necessary? A Single Institution Review

Contrast enema is the gold standard technique for evaluating a pelvic anastomosis (PA) prior to ileostomy closure. With the increasing use of flexible endoscopic modalities, the need for contrast studies may be unnecessary. The objective of this study is to compare flexible endoscopy and contrast studies for anastomotic inspection prior to defunctioning stoma reversal. Patients with a protected PA undergoing ileostomy closure between July 2014 and June 2019 at our institution were retrospectively identified. Demographics and clinical outcomes in patients undergoing preoperative evaluation with endoscopic and/or contrast studies were analyzed. We identified 207 patients undergoing ileostomy closure. According to surgeon's preference, 91 patients underwent only flexible endoscopy (FE) and 100 patients underwent both endoscopic and contrast evaluation (FE + CE) prior to reversal. There was no significant difference in pelvic anastomotic leak (2.2% vs. 1%), anastomotic stricture (1.1% vs. 6%), pelvic abscess (2.2% vs. 3.0%), or postoperative anastomotic complications (4.4% vs. 9%) between groups FE and FE + CE (P > .05). Flexible endoscopy alone appears to be an acceptable technique for anastomotic evaluation prior to ileostomy closure. Further studies are needed to determine the effectiveness of different diagnostic modalities for pelvic anastomotic inspection.

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.

Pilot study of the safety and feasibility of immediate adjuvant chemotherapy (IAC) in nonmetastatic colonic adenocarcinoma (nmCC)

150

Background: The optimal timing of adjuvant chemotherapy (AC) in nmCC is poorly defined. Delays in AC result in decreased survivalbut fear of postoperative complications often causes long intervals between surgery and AC initiation. Given the transient immune suppression, inflammatory changes and increase in circulating tumor cells occurring in the perioperative period, effective cytotoxic treatments should be considered at this time to limit metastatic spread. The immediate adjuvant chemotherapy concept intends to capitalize on the therapeutic benefits that can be achieved in the perioperative period (intraoperative and early postoperative). We aim to demonstrate that IAC is safe and tolerable for patients with nmCC. Methods: Patients with nmCC microsatellite stable invasive adenocarcinomas were treated with intravenous Leucovorin 20mg/m2 followed by a single dose of 5-Flurouracil 400mg/m2 at the time of minimally invasive surgical resection. High risk stage II and stage III received the first dose of standard AC at 14 days after surgery. Serial measurements of blood-based biomarkers (circulating tumor cells, cell free DNA, and neutrophil lymphocyte ratio were measured. Quality of life (QOL) was measured using EORTC QLQ-C30. Results: Of the 20 patients recruited, 40% had final pathology of stage III, 40% stage II and 20% stage I. All patients received intra-operative chemotherapy with no associated morbidity. Median length of stay was 2 days (range of 2-4). Grade 1 complications were reported in 2 (10%) of patients. No grade 2 or higher adverse events were reported. There was no mortality. Early postoperative AC was administered to 65% of patients. The median time to AC was 14 days (range 14-36). Overall quality of life and health scores were similar before surgery and at 30-day postoperatively (p < 0.05). Conclusions: A protocol based on immediate adjuvant chemotherapy starting at the time of surgical resection was found to be safe and feasible in nmCC with no adverse effects on surgical morbidity or quality of life. Further prospective studies are needed to explore the oncologic benefit of this novel systemic treatment approach.

Body image mediates the impact of pain on depressive symptoms in patients with systemic lupus erythematosus

Objective

Systemic lupus erythematosus (SLE) is a multisystem autoimmune disease with treatment manifestations that can cause changes in appearance, including skin rashes, alopecia, vitiligo, and scars. SLE has been shown to adversely impact body image outcomes, and previous research has identified that greater disease activity is associated with worse body image outcomes which, in turn, are associated with greater depressive symptoms. For patients with SLE who also experience significant pain, poor body image outcomes may further compromise wellbeing and lead to greater depressive symptoms. The role of pain in body image has not been explored in SLE. Thus, the present study examined whether body image (specifically, body image-related quality of life) serves as a mediator of the relationship between pain and depressive symptoms among patients with SLE.

Methods

Multiple mediation analysis was used to examine the hypothesis that body image-related quality of life mediates the relationship between pain and depressive symptoms in a sample of patients with SLE ( N = 135) from an urban region in Los Angeles, California.

Results

The sample was predominately female (92.6%) with a mean disease duration of approximately 17 years. Approximately one-quarter of the sample had elevated depressive symptoms. Body image-related quality of life was a significant mediator in the relationship between pain and depressive symptoms. The model accounted for 51% of the total variance in depressive symptoms ( R2 = 0.51).

Conclusion

This cross-sectional study suggested that body image-related quality of life may mediate the effects of pain on depressive symptoms among patients with SLE.

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.

Psychometric validation of the Arthritis Helplessness Index in systemic lupus erythematosus

Objective Helplessness is a relevant construct in systemic lupus erythematosus (SLE), an unpredictable chronic illness with no known cure characterized by relapsing and remitting features. However, no measure of helplessness has been validated in this population. The present study examined the structural validity, reliability, and convergent validity of the Arthritis Helplessness Index, a measure initially developed for rheumatoid arthritis populations, in a sample of patients with SLE. Methods Patients with SLE ( N = 136) receiving medical care at a private hospital completed the Arthritis Helplessness Index and other self-report measures. The structural validity of the Arthritis Helplessness Index was examined using confirmatory factor analysis. Internal consistency reliability was evaluated with Cronbach's coefficient alpha. Pearson product-moment correlations were used to examine convergent validity with measures of depression, anxiety and mastery. Results The five-item Arthritis Helplessness Index-Helplessness measure demonstrated a tenable factor structure (comparative fit index 0.98, root mean square error of approximation 0.06, standardized root mean residual 0.04). Internal consistency reliability was fair (α = 0.69). Convergent validity was evidenced by significant correlations with measures of depression, anxiety and mastery. Conclusion The five-item Arthritis Helplessness Index-Helplessness scale can confidently be used as a measure of helplessness in SLE.

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.

The mediational role of helplessness in psychological outcomes in systemic lupus erythematosus

Objective Systemic lupus erythematosus (SLE) is a chronic autoimmune disease that can result in disability and psychological distress. Although pain has been associated with depressive symptomatology and stress in SLE, a paucity of theoretical models have been used to explain the relationship between pain and psychological distress in this population. Thus, the present study examined helplessness as a mediator of the relationship between pain and psychological distress among patients with SLE. Methods Multiple mediation analysis was used to examine the hypothesis that learned helplessness mediates the relationship between pain and symptoms of anxiety, depression, and stress in a sample of patients with SLE ( N = 136) receiving medical care at Cedars Sinai Medical Center. Results The mean score on the Helplessness subscale was 14.5 ( SD = 5.4). Helplessness fully mediated the relationship between pain vitality and symptoms of anxiety (BCa 95% CI (-0.073, -0.015)), depression (BCa 95% CI (-0.502, -0.212)), and stress (BCa 95% CI (-0.063, -0.027)). Conclusion Participants reported a high level of perceived inability to control one's disease. Helplessness fully mediated the relationship between pain and measures of anxiety, depression, and perceived stress among patients with SLE.

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.

The psychometric properties of the Perceived Stress Scale-10 among patients with systemic lupus erythematosus

Objective Systemic lupus erythematosus (SLE) is a chronic, multisystem autoimmune disease characterized by periods of remission and recurrent flares, which have been associated with stress. Despite the significance of stress in this disease, the Perceived Stress Scale-10 has yet to be psychometrically evaluated in patients with SLE. Methods Exploratory factor analysis was used to examine the structural validity of the Perceived Stress Scale-10 among patients with SLE ( N = 138) receiving medical care at Cedars Sinai Medical Center. Cronbach's coefficient alpha was used to examine internal consistency reliability, and Pearson product-moment correlations were used to examine convergent validity with measures of anxiety, depression, helplessness, and disease activity. Results Exploratory factor analysis provided support for a two-factor structure (comparative fit index = .95; standardized root mean residual = .04; root mean square error of approximation = .08). Internal consistency reliability was good for both factors (α = .84 and .86). Convergent validity was evidenced via significant correlations with measures of anxiety, depression, and helplessness. There were no significant correlations with the measure of disease activity. Conclusion The Perceived Stress Scale-10 can be used to examine perceived stress among patients with SLE.

Body Mass Index Significantly Impacts Outcomes of Colorectal Surgery

There are limited data regarding the association between body mass index (BMI) and colorectal surgery outcomes. We sought to evaluate the effect of BMI on short-term surgical outcomes in colon and rectal surgery patients in the United States. The American College of Surgeons National Surgery Quality Improvement Project database was used to identify all patients who underwent colon or rectal resection from 2005 to 2013. Multivariate regression analysis was used to assess the independent effect of BMI on outcomes. A total of 206,360 patients underwent colorectal resection during the study period. Of these, 3.2 per cent of patients were underweight (BMI < 18.5), 23.8 per cent patients were normal weight (18.5 ≤, BMI < 25), 26.5 per cent were overweight (25 ≤, BMI < 30), 25.2 per cent were obese (30 ≤, BMI < 40), and 5.3 per cent were morbidly obese (BMI ≥ 40). Underweight patients had longer length of stay (confidence interval: 2.70–3.49, P < 0.001) and higher mortality (adjusted odds ratio: 1.45, P < 0.01) compared with patients with a normal BMI. Morbidly obese patients had the highest overall morbidity rate compared with normal BMI patients (adjusted odds ratio: 1.53, confidence interval: 1.42–1.64, P < 0.01). BMI is associated with outcomes in colon and rectal surgery patients. Underweight and morbidly obese patients have a significantly increased risk of postsurgical complications compared with those with normal BMI.

Body Mass Index Significantly Impacts Outcomes of Colorectal Surgery

There are limited data regarding the association between body mass index (BMI) and colorectal surgery outcomes. We sought to evaluate the effect of BMI on short-term surgical outcomes in colon and rectal surgery patients in the United States. The American College of Surgeons National Surgery Quality Improvement Project database was used to identify all patients who underwent colon or rectal resection from 2005 to 2013. Multivariate regression analysis was used to assess the independent effect of BMI on outcomes. A total of 206,360 patients underwent colorectal resection during the study period. Of these, 3.2 per cent of patients were underweight (BMI < 18.5), 23.8 per cent patients were normal weight (18.5 ≤ BMI < 25), 26.5 per cent were overweight (25 ≤ BMI < 30), 25.2 per cent were obese (30 ≤ BMI < 40), and 5.3 per cent were morbidly obese (BMI ≥ 40). Underweight patients had longer length of stay (confidence interval: 2.70-3.49, P < 0.001) and higher mortality (adjusted odds ratio: 1.45, P < 0.01) compared with patients with a normal BMI. Morbidly obese patients had the highest overall morbidity rate compared with normal BMI patients (adjusted odds ratio: 1.53, confidence interval: 1.42-1.64, P < 0.01). BMI is associated with outcomes in colon and rectal surgery patients. Underweight and morbidly obese patients have a significantly increased risk of postsurgical complications compared with those with normal BMI.

Colorectal Surgery in Patients with HIV and AIDS: Trends and Outcomes over a 10-Year Period in the USA

BACKGROUND

HIV has become a chronic disease, which may render this population more prone to developing the colorectal pathologies that typically affect older Americans.

METHODS

A retrospective review of the Nationwide Inpatient Sample was performed to identify patients who underwent colon and rectal surgery from 2001 to 2010. Multivariate analysis was used to evaluate outcomes among the general population, patients with HIV, and patients with AIDS.

RESULTS

Hospital admissions for colon and rectal procedures of patients with HIV/AIDS grew at a faster rate than all-cause admissions of patients with HIV/AIDS, with mean yearly increases of 17.8 and 2.1 %, respectively (p < 0.05). Patients with HIV/AIDS undergoing colon and rectal operations for cancer, polyps, diverticular disease, and Clostridium difficile were younger than the general population (51 vs. 65 years; p < 0.01). AIDS was independently associated with increased odds of mortality (OR 2.11; 95 % CI 1.24, 3.61), wound complications (OR 1.53; 95 % CI 1.09, 2.17), and pneumonia (OR 2.02; 95 % CI 1.33, 3.08). Risk-adjusted outcomes of colorectal surgery in patients with HIV did not differ significantly from the general population.

CONCLUSION

Postoperative outcomes in patients with HIV are similar to the general population, while patients with AIDS have a higher risk of mortality and certain complications.

Outcomes of conversion of laparoscopic colorectal surgery to open surgery

Objectives:

There is limited data regarding the outcomes of patients who undergo conversion to open surgery during a laparoscopic operation in colorectal resection. We sought to identify the outcomes of such patients.

Methods:

The NIS (National Inpatient Sample) database was used to identify patients who had conversion from laparoscopic to open colorectal surgery during the 2009 to 2012 period. Multivariate regression analysis was performed to identify risk-adjusted outcomes of conversion to open surgery.

Results:

We sampled 776 007 patients who underwent colorectal resection. 337 732 (43.5%) of the patients had laparoscopic resection. Of these, 48 265 procedures (14.3%) were converted to open surgery. The mortality of converted patients was increased, when compared with successfully completed laparoscopic operations, but was still lower than that of open procedures (0.6% vs. 1.4% vs. 3.9%, respectively; adjusted odds ratio [AOR], 1.61 and 0.58, respectively; P < .01). The most common laparoscopic colorectal procedure was right colectomy (41.2%). The lowest rate of conversion is seen with right colectomy while proctectomy had the highest rate of conversion (31.2% vs. 12.9%, AOR, 2.81, P < .01). Postsurgical complications including intra-abdominal abscess (AOR, 2.64), prolonged ileus (AOR, 1.50), and wound infection (AOR, 2.38) were higher in procedures requiring conversion (P < .01).

Conclusions:

Conversion of laparoscopic to open colorectal resection occurs in 14.3% of cases. Compared with patients who had laparoscopic operations, patients who had conversion to open surgery had a higher mortality, higher overall morbidity, longer length of hospitalization, and increased hospital charges. The lowest conversion rate was in right colectomy and the highest was in proctectomy procedures. Wound infection in converted procedures is higher than in laparoscopic and open procedures.

Colorectal Cancer Resections in the Aging US Population: A Trend Toward Decreasing Rates and Improved Outcomes

IMPORTANCE

The incidence of colorectal cancer in elderly patients is likely to increase, but there is a lack of large nationwide data regarding the mortality and morbidity of colorectal cancer resections in the aging population.

OBJECTIVE

To examine the surgical trends and outcomes of colorectal cancer treatment in the elderly.

DESIGN, SETTING, AND PARTICIPANTS

A review of operative outcomes for colorectal cancer in the United States was conducted in a Nationwide Inpatient Sample from January 1, 2001, through December 31, 2010. Patients were stratified within age groups of 45 to 64, 65 to 69, 70 to 74, 75 to 79, 80 to 84, and 85 years and older. Postoperative complications and yearly trends were analyzed. A multivariate logistic regression was used to compare in-hospital mortality and morbidity between individual groups of patients 65 years and older and those aged 45 to 64 years while controlling for sex, comorbidities, procedure type, diagnosis, and hospital status.

MAIN OUTCOMES AND MEASURES

In-hospital mortality and morbidity.

RESULTS

Among the estimated 1,043,108 patients with colorectal cancer sampled, 63.8% of the operations were performed on those 65 years and older and 22.6% on patients 80 years and older. Patients 80 years and older were 1.7 times more likely to undergo urgent admission than those younger than 65 years. Patients younger than 65 years accounted for 46.0% of the laparoscopies performed in the elective setting compared with 14.1% for patients 80 years and older. Mortality during the 10 years decreased by a mean of 6.6%, with the most considerable decrease observed in the population 85 years and older (9.1%). Patients 80 years and older had an associated $9492 higher hospital charge and an increased 2½-day length of stay vs patients younger than 65 years. Compared with patients aged 45 to 64 years, higher risk-adjusted in-hospital mortality was observed in patients with advancing age: 65 to 69 years (odds ratio, 1.32; 95% CI, 1.18-1.49), 70 to 74 years (2.02; 1.82-2.24), 75 to 79 years (2.51; 2.28-2.76), 80 to 84 years (3.15; 2.86-3.46), and 85 years and older (4.72; 4.30-5.18) (P < .01). Compared with patients aged 45 to 64 years, higher risk-adjusted morbidity was noted in those with advancing age: 65 to 69 years (odds ratio, 1.25; 95% CI, 1.21-1.29), 70 to 74 years (1.40; 1.36-1.45), 75 to 79 years (1.54; 1.49-1.58), 80 to 84 years (1.68; 1.63-1.74), and 85 years and older (1.96; 1.89-2.03) (P < .01).

CONCLUSIONS AND RELEVANCE

Most operations for colorectal cancer are performed on the aging population, with an overall decrease in the number of cases performed. Despite the overall improved mortality seen during the past 10 years, the risk-adjusted mortality and morbidity of the elderly continue to be substantially higher than that for the younger population.

Early Outcome of Treatment of Chronic Mesenteric Ischemia

There are limited data regarding long-term outcomes of chronic mesenteric ischemia (CMI) of the intestine. We sought to identify treatment outcomes of CMI. The NIS database was used to identify patients admitted for the diagnosis of CMI between 2002 and 2012. Multivariate analysis using logistic regression was performed to quantify outcomes of CMI. A total of 160,889 patients were admitted for chronic vascular insufficiency of intestine; of which 7,906 patients underwent surgical/endovascular treatment for CMI. Among patients who underwent surgery 62 per cent had endovascular treatment and 38 per cent had open vascular treatment. Need of open surgery (adjusted odds ratio (AOR): 5.13, P < 0.01) and age ≥70 years (AOR: 3.41, P < 0.01) had strong associations with mortality of patients. Open vascular treatment has higher mortality (AOR: 5.07, P < 0.01) and morbidity (AOR: 2.14, P < 0.01). However, endovascular treatment had higher risk of postoperative wound hematoma (AOR: 2.81, P < 0.01). Most patients admitted for CMI are treated with endovascular treatment. Endovascular treatment has the advantage of lower mortality and morbidity. Need to open surgery and age ≥70 years have strong associations with mortality of patients.

Predictive Factors of Ventilator Dependency after Colon and Rectal Surgery

There is limited data analyzing ventilator dependency by operative diagnoses and types of the procedures performed in colorectal surgery. We sought to identify predictive factors of ventilator dependency in colorectal surgery and investigate complication rates across various colorectal procedures. The National Surgical Quality Improvement Program database was used to examine the clinical data of patients with ventilator dependency for more than 48 hours after colorectal resection during 2005-2013. Multivariate regression analysis was performed to identify predictors of ventilator dependency. A total of 219,716 patients who underwent colorectal resection were identified. The rate of ventilator dependency was 3.9 per cent. The rate varied significantly based on patient diagnosis; with the highest rate seen in patients with acute mesenteric ischemia (25.9%). The highest risk of ventilator dependency according to the patients indication of surgery, type of the procedure, and preoperative factors exist in lower gastrointestinal bleeding [adjusted odds ratio (AOR): 77.44, P < 0.01], total colectomy (AOR: 1.58, P = 0.04), and American Society of Anesthesiologists classification of three or greater (AOR: 2.52, P < 0.01). Also, serum albumin level (AOR: 0.67, P < 0.01) seems to be associated with ventilator dependency. The overall rate of ventilator dependency is 3.9 per cent in colorectal surgery. However, depending on the indication for surgery, rates can be as high as 25.9 per cent. American Society of Anesthesiologist score can predict the risk of postoperative ventilator dependency in patients undergoing colorectal surgery. Serum albumin level is reversely associated with postoperative ventilator dependency.

Early Outcome of Treatment of Chronic Mesenteric Ischemia

There are limited data regarding long-term outcomes of chronic mesenteric ischemia (CMI) of the intestine. We sought to identify treatment outcomes of CMI. The NIS database was used to identify patients admitted for the diagnosis of CMI between 2002 and 2012. Multivariate analysis using logistic regression was performed to quantify outcomes of CMI. A total of 160,889 patients were admitted for chronic vascular insufficiency of intestine; of which 7,906 patients underwent surgical/endovascular treatment for CMI. Among patients who underwent surgery 62 per cent had endovascular treatment and 38 per cent had open vascular treatment. Need of open surgery (adjusted odds ratio (AOR): 5.13, P < 0.01) and age ≥70 years (AOR: 3.41, P < 0.01) had strong associations with mortality of patients. Open vascular treatment has higher mortality (AOR: 5.07, P < 0.01) and morbidity (AOR: 2.14, P < 0.01). However, endovascular treatment had higher risk of postoperative wound hematoma (AOR: 2.81, P < 0.01). Most patients admitted for CMI are treated with endovascular treatment. Endovascular treatment has the advantage of lower mortality and morbidity. Need to open surgery and age ≥70 years have strong associations with mortality of patients.

Predictive Factors of Ventilator Dependency after Colon and Rectal Surgery

There is limited data analyzing ventilator dependency by operative diagnoses and types of the procedures performed in colorectal surgery. We sought to identify predictive factors of ventilator dependency in colorectal surgery and investigate complication rates across various colorectal procedures. The National Surgical Quality Improvement Program database was used to examine the clinical data of patients with ventilator dependency for more than 48 hours after colorectal resection during 2005–2013. Multivariate regression analysis was performed to identify predictors of ventilator dependency. A total of 219,716 patients who underwent colorectal resection were identified. The rate of ventilator dependency was 3.9 per cent. The rate varied significantly based on patient diagnosis; with the highest rate seen in patients with acute mesenteric ischemia (25.9%). The highest risk of ventilator dependency according to the patients indication of surgery, type of the procedure, and preoperative factors exist in lower gastrointestinal bleeding [adjusted odds ratio (AOR): 77.44, P < 0.01], total colectomy (AOR: 1.58, P = 0.04), and American Society of Anesthesiologists classification of three or greater (AOR: 2.52, P < 0.01). Also, serum albumin level (AOR: 0.67, P < 0.01) seems to be associated with ventilator dependency. The overall rate of ventilator dependency is 3.9 per cent in colorectal surgery. However, depending on the indication for surgery, rates can be as high as 25.9 per cent. American Society of Anesthesiologist score can predict the risk of postoperative ventilator dependency in patients undergoing colorectal surgery. Serum albumin level is reversely associated with postoperative ventilator dependency.

Outcomes of Bowel Resection in Patients with Crohn's Disease

There is limited data regarding outcomes of bowel resection in patients with Crohn's disease. We sought to investigate complications of such patients after bowel resection. The Nationwide Inpatient Sample databases were used to examine the clinical data of Crohn's patients who underwent bowel resection during 2002 to 2012. Multivariate regression analysis was performed to investigate outcomes of such patients. We sampled a total of 443,950 patients admitted with the diagnosis of Crohn's disease. Of these, 20.5 per cent had bowel resection. Among patients who had bowel resection, 51 per cent had small bowel Crohn's disease, 19.4 per cent had large bowel Crohn's disease, and 29.6 per cent had both large and small bowel Crohn's disease. Patients with large bowel disease had higher mortality risk compared with small bowel disease [1.8% vs 1%, adjusted odds ratio (AOR): 2.42, P < 0.01]. Risks of postoperative renal failure (AOR: 1.56, P < 0.01) and respiratory failure (AOR: 1.77, P < 0.01) were higher in colonic disease compared with small bowel disease but postoperative enteric fistula was significantly higher in patients with small bowel Crohn's disease (AOR: 1.90, P < 0.01). Of the patients admitted with the diagnosis of Crohn's disease, 20.5 per cent underwent bowel resection during 2002 to 2012. Although colonic disease has a higher mortality risk, small bowel disease has a higher risk of postoperative fistula.

Outcomes of Bowel Resection in Patients with Crohn's Disease

There is limited data regarding outcomes of bowel resection in patients with Crohn's disease. We sought to investigate complications of such patients after bowel resection. The Nationwide Inpatient Sample databases were used to examine the clinical data of Crohn's patients who underwent bowel resection during 2002 to 2012. Multivariate regression analysis was performed to investigate outcomes of such patients. We sampled a total of 443,950 patients admitted with the diagnosis of Crohn's disease. Of these, 20.5 per cent had bowel resection. Among patients who had bowel resection, 51 per cent had small bowel Crohn's disease, 19.4 per cent had large bowel Crohn's disease, and 29.6 per cent had both large and small bowel Crohn's disease. Patients with large bowel disease had higher mortality risk compared with small bowel disease [1.8% vs 1%, adjusted odds ratio (AOR): 2.42, P < 0.01]. Risks of postoperative renal failure (AOR: 1.56, P < 0.01) and respiratory failure (AOR: 1.77, P < 0.01) were higher in colonic disease compared with small bowel disease but postoperative enteric fistula was significantly higher in patients with small bowel Crohn's disease (AOR: 1.90, P < 0.01). Of the patients admitted with the diagnosis of Crohn's disease, 20.5 per cent underwent bowel resection during 2002 to 2012. Although colonic disease has a higher mortality risk, small bowel disease has a higher risk of postoperative fistula.

Risk Factors of Postoperative Myocardial Infarction after Colorectal Surgeries

There are limited data regarding the specific risk factors of postoperative myocardial infarction (MI) in patients undergoing colorectal resectional surgery. We sought to identify risk factors of acute MI after colorectal resection operations. The National Inpatient Sample database was used to identify patients who had postoperative MI after colorectal resection operations between 2002 and 2010. Statistical analysis was performed to identify factors predictive of postoperative MI. We sampled a total of 2,513,124 patients undergoing colorectal resection, of whom 38,317 (1.5%) sustained a postoperative MI. Patients with postoperative MI had associated 28.5 per cent in-hospital mortality. Risk factors identified include ( P < 0.01): history of congestive heart failure (odds ratio [OR], 8.18), chronic renal failure (OR, 3.86), age 70 years or older (OR, 3.68), peripheral vascular disorders (OR, 2.93), fluid and electrolyte disorders (OR, 2.69), emergency admission (OR, 2.56), preoperative weight loss (OR, 2.49), cardiac valvular disease (OR, 2.46), chronic lung disease (OR, 1.75), deficiency anemia (OR, 1.22), colorectal cancer (OR, 1.77), and hypertension (OR, 1.14). Postoperative MI occurs in less than 2 per cent of colorectal resections. However, patients sustaining postoperative MI are over six times more likely to die. Congestive heart failure and chronic renal failure are the strongest predictors of postoperative MI.

Risk factors of postoperative myocardial infarction after colorectal surgeries

There are limited data regarding the specific risk factors of postoperative myocardial infarction (MI) in patients undergoing colorectal resectional surgery. We sought to identify risk factors of acute MI after colorectal resection operations. The National Inpatient Sample database was used to identify patients who had postoperative MI after colorectal resection operations between 2002 and 2010. Statistical analysis was performed to identify factors predictive of postoperative MI. We sampled a total of 2,513,124 patients undergoing colorectal resection, of whom 38,317 (1.5%) sustained a postoperative MI. Patients with postoperative MI had associated 28.5 per cent in-hospital mortality. Risk factors identified include (P < 0.01): history of congestive heart failure (odds ratio [OR], 8.18), chronic renal failure (OR, 3.86), age 70 years or older (OR, 3.68), peripheral vascular disorders (OR, 2.93), fluid and electrolyte disorders (OR, 2.69), emergency admission (OR, 2.56), preoperative weight loss (OR, 2.49), cardiac valvular disease (OR, 2.46), chronic lung disease (OR, 1.75), deficiency anemia (OR, 1.22), colorectal cancer (OR, 1.77), and hypertension (OR, 1.14). Postoperative MI occurs in less than 2 per cent of colorectal resections. However, patients sustaining postoperative MI are over six times more likely to die. Congestive heart failure and chronic renal failure are the strongest predictors of postoperative MI.

Preoperative Leukocytosis in Colorectal Cancer Patients

BACKGROUND

Preoperative asymptomatic leukocytosis has been reported as a factor that affects morbidity of surgical patients. We sought to identify the relationship between asymptomatic preoperative leukocytosis and postoperative complications in elective colorectal cancer surgery.

STUDY DESIGN

The NSQIP database was used to examine the clinical data of patients who had preoperative leukocytosis (white blood cell count more than 11,000/μL) and colorectal cancer resection from 2005 to 2013. Patients with preoperative sepsis, recent steroid use, disseminated cancer, renal failure, pneumonia, and emergently admitted patients were excluded from the study. Multivariate regression analysis was performed to identify outcomes of preoperative leukocytosis.

RESULTS

We evaluated a total of 59,805 patients with a diagnosis of colorectal cancer who underwent colorectal resection. The rate of preoperative asymptomatic leukocytosis was 5.6%. Asymptomatic leukocytosis was associated with preoperative serum albumin level (adjusted odds ratio [AOR] 0.58, p < 0.01) and blood urea nitrogen/creatinine ratio (AOR 1.01, p < 0.01). Preoperative asymptomatic leukocytosis had significant associations with increased mortality (AOR 1.76, p < 0.01) and morbidity of patients (AOR 1.26, p < 0.01). Postsurgical complications that had the strongest associations with asymptomatic leukocytosis were cardiac arrest (AOR 1.78, p = 0.03) and unplanned intubation (AOR 1.61, p < 0.01). Also, infectious complications were significantly higher in patients with leukocytosis (AOR 1.18, p = 0.01).

CONCLUSIONS

Preoperative asymptomatic leukocytosis has a prevalence of 5.6% in colorectal cancer resections and carries a significant increased risk of mortality and morbidity. Asymptomatic leukocytosis is associated with preoperative dehydration and malnutrition. Further studies are indicated to validate and explain these findings.

Surgical management of rectal prolapse: The role of robotic surgery

The robotic technique as a safe approach in treatment of rectal prolapse has been widely reported during the last decade. Although there is limited clinical data regarding the benefits of robotic surgery, the safety of robotic surgery in rectal prolapse treatment has been cited by several authors. Also, the robotic approach helps overcome some of the laparoscopic approach challenges with purported advantages including improved visualization, more precise dissection, easier suturing, accurate identification of anatomic structures and fewer conversions to open surgery which can facilitate the conduct of technically challenging cases. These advantages can make robotic surgery ideally suited for minimally invasive ventral rectopexy. Currently, with greater surgeon experience in robotic surgery, the length of the procedure and the recurrence rate with the robotic approach are decreasing and short term outcomes for robotic rectal prolapse seem on par with laparoscopic and open techniques in recent studies. However, the high cost of robotic procedures is still an important issue. The benefits of a robotic approach must be weighed against the higher cost. More research is needed to better understand if the increased cost is justified by an improvement in outcomes. Also, published articles comparing long term outcomes of the robotic approach with other approaches are very limited at this time and further clinical trials are indicated to affirm the role of robotic surgery in the treatment of rectal prolapse.

Even modest hypoalbuminemia affects outcomes of colorectal surgery patients

BACKGROUND

A small decrease in the serum albumin from the normal level is a common condition in preoperative laboratory tests of colorectal surgery patients; however, there is limited data examining these patients. We sought to identify outcomes of such patients.

METHODS

The National Surgical Quality Improvement Program database was used to evaluate all patients who had modest levels of hypoalbuminemia (3 ≤ serum albumin < 3.5 g/dL) before colorectal resection from 2005 to 2012. Multivariate analysis using logistic regression was performed to quantify complications associated with modest hypoalbuminemia.

RESULTS

A total of 108,898 patients undergoing colorectal resection were identified, of which 16,962 (15.6%) had modest levels of preoperative hypoalbuminemia. Postsurgical complications significantly associated (P < .05) with modest hypoalbuminemia were as follows: hospitalization more than 30 days (adjusted odds ratio [AOR], 1.77), deep vein thrombosis (AOR, 1.64), unplanned intubation (AOR, 1.42), ventilator dependency for more than 48 hours (AOR, 1.30), and wound disruption (AOR, 1.22).

CONCLUSIONS

Modest hypoalbuminemia is a common preoperative condition in patients undergoing colorectal resection. Our analysis demonstrates that modest hypoalbuminemia has associations with increased postoperative complications, especially pulmonary complications.

Repair of complex parastomal hernias

Development of parastomal hernias (PH) is very common after stoma formation and carries a risk of subsequent bowel incarceration, obstruction and strangulation. The management of PH remains a challenge for the colorectal surgeon, and there are currently no standardized guidelines for the treatment of PH. Even more difficult is the management of complex parastomal hernias (CPH). We conducted a review of the literature to identify recent developments in the treatment of CPH, including analysis of the use of synthetic and biologic mesh prostheses, method of mesh placement and surgical approach.

Nationwide analysis of outcomes of bowel preparation in colon surgery

BACKGROUND

There are limited data comparing the outcomes of preoperative oral antibiotic bowel preparation (OBP) and mechanical bowel preparation (MBP) in colorectal surgery. We sought to identify the relationship between preoperative bowel preparations (BP) and postoperative complications in colon cancer surgery.

STUDY DESIGN

The NSQIP database was used to examine the clinical data of colon cancer patients undergoing scheduled colon resection during 2012 to 2013. Multivariate regression analysis was performed to identify correlations between BP and postoperative complications.

RESULTS

We evaluated a total of 5,021 patients who underwent elective colon resection. Of these, 44.8% had only MBP, 2.3% had only OBP, 27.6% had both MBP and OBP, and 25.3% of patients did not have any type of BP. In multivariate analysis of data, MBP and OBP were not associated with decreased risk of postoperative complications in right side (adjusted odds ratio [AOR] 0.80, 0.30, p = 0.08, 0.10, respectively) or left side colon resections (AOR 1.02, 0.68, p = 0.81, 0.24, respectively). However, the combination of MBP and OBP before left side colon resections resulted in a significantly decreased risk of overall morbidity (AOR 0.63, p < 0.01), superficial surgical site infection (AOR 0.31, p < 0.01), anastomosis leakage (AOR 0.44, p < 0.01), and intra-abdominal infections (AOR 0.44, p < 0.01).

CONCLUSIONS

Our analysis revealed that solitary mechanical bowel preparation and solitary oral bowel preparation had no significant effects on major postoperative complications after colon cancer resection. However, a combination of mechanical and oral antibiotic preparations showed a significant decrease in postoperative morbidity.

Risk factors of postoperative upper gastrointestinal bleeding following colorectal resections

There is limited data regarding the risk factors of postoperative upper GI bleeding (UGIB) in patients undergoing colorectal resection. We sought to identify risk factors of UGIB after colorectal resection. The NIS database was used to evaluate all patients who had colorectal resection complicated by UGIB between 2002 and 2010. Multivariate analysis using logistic regression was performed to quantify the association of preoperative variables with postoperative UGIB. We sampled a total of 2,514,228 patients undergoing colorectal resection, of which, 12,925 (0.5%) suffered a postoperative UGIB. The mortality of patients who had UGIB was significantly greater than patients without UGIB (14.9 vs. 4.7%; OR, 3.57; CI, 3.40-3.75; P < 0.01). Patients suffering from UGIB had an associated 14.9% inhospital mortality. History of chronic peptic ulcer disease (6.75; CI, 5.75-7.91; P < 0.01) and emergency admission (OR, 4.27; CI, 4.09-4.45; P < 0.01) are associated with UGIB. Duodenal ulcer as the source of bleeding is a mortality predictors of patients (OR, 1.71; CI, 1.49-1.97; P < 0.01). Postoperative UGIB occurs in less than 1 % of colorectal resections. However, patients suffering from postoperative UGIB are over three times more likely to die. Chronic peptic ulcer disease and emergency admission are respectively the strongest predictors of postoperative UGIB.

Surgical outcomes of hyperthermic intraperitoneal chemotherapy: analysis of the american college of surgeons national surgical quality improvement program

IMPORTANCE

Hyperthermic intraperitoneal chemotherapy (HIPEC) and cytoreductive surgery have been shown to benefit selected patients with peritoneal carcinomatosis. However, these procedures are associated with high morbidity and mortality. Available data investigating the outcomes of HIPEC are mostly limited to single-center studies. To date, there have been few large-scale studies investigating the postoperative outcomes of HIPEC.

OBJECTIVE

To determine the associated 30-day morbidity and mortality of cytoreductive surgery-HIPEC in the treatment of metastatic and primary peritoneal cancer in American College of Surgeons National Surgical Quality Improvement Program centers.

DESIGN, SETTING, AND PARTICIPANTS

A retrospective review of HIPEC cases performed for primary and metastatic peritoneal cancer diagnoses was conducted. The cytoreductive surgical procedures were sampled, and disease processes were identified. Patient demographics, intraoperative occurrences, and postoperative complications were reviewed from the American College of Surgeons National Surgical Quality Improvement Program from 2005-2011.

MAIN OUTCOMES AND MEASURES

Thirty-day mortality and morbidity.

RESULTS

Of the cancers identified among the 694 sampled cases, 14% of patients had appendiceal cancer, 11% had primary peritoneal cancer, and 8% had colorectal cancer. The American Society of Anesthesiologists classification was 3 for 70% of patients. The average operative time was 7.6 hours, with 15% of patients requiring intraoperative transfusions. Postoperative bleeding (17%), septic shock (16%), pulmonary complications (15%), and organ-space infections (9%) were the most prevalent postoperative complications. The average length of stay was 13 days, with a 30-day readmission rate of 11%. The rate of reoperation was 10%, with an overall mortality rate of 2%.

CONCLUSIONS AND RELEVANCE

American College of Surgeons National Surgical Quality Improvement Program hospitals performing HIPEC have acceptable rates of morbidity and mortality.

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.

Factors Predictive of Venous Thromboembolism in Bariatric Surgery

Venous thromboembolism (VTE) is a significant cause of morbidity and mortality in bariatric surgery. The aim of this study was to evaluate the effect of patient characteristics, payer type, comorbidities, and surgical techniques on development of VTE in bariatric surgery. Using the National Inpatient Sample (NIS) database from 2006 to 2008, clinical data of 304,515 morbidly obese patients who underwent bariatric surgery were examined. Multiple regression analysis was performed to identify factors predictive of VTE. The overall rate of in-hospital VTE was 0.17 per cent, with the highest rate of VTE observed in open gastric bypass (0.45%). The VTE rate was significantly lower in laparoscopic compared with open gastric bypass (0.13% vs 0.45%, respectively, P < 0.01) and in nongastric bypass compared with gastric bypass procedures (0.06% vs 0.21%, respectively, P < 0.01). Alcohol abuse [odds ratio (OR): 8.7], open operation (OR: 2.5), gastric bypass procedures (OR: 2.4), renal failure (OR: 2.3), congestive heart failure (OR: 2.0), male gender (OR: 1.5), and chronic lung disease (OR: 1.4) were associated with a higher rate of VTE. This study identified several significant risk factors for development of VTE in bariatric surgery. To minimize the risk of VTE, surgeons may consider these factors in selection of appropriate prophylaxis and bariatric surgical options.

Factors predictive of venous thromboembolism in bariatric surgery

Venous thromboembolism (VTE) is a significant cause of morbidity and mortality in bariatric surgery. The aim of this study was to evaluate the effect of patient characteristics, payer type, comorbidities, and surgical techniques on development of VTE in bariatric surgery. Using the National Inpatient Sample (NIS) database from 2006 to 2008, clinical data of 304,515 morbidly obese patients who underwent bariatric surgery were examined. Multiple regression analysis was performed to identify factors predictive of VTE. The overall rate of in-hospital VTE was 0.17 per cent, with the highest rate of VTE observed in open gastric bypass (0.45%). The VTE rate was significantly lower in laparoscopic compared with open gastric bypass (0.13% vs 0.45%, respectively, P < 0.01) and in nongastric bypass compared with gastric bypass procedures (0.06% vs 0.21%, respectively, P < 0.01). Alcohol abuse [odds ratio (OR): 8.7], open operation (OR: 2.5), gastric bypass procedures (OR: 2.4), renal failure (OR: 2.3), congestive heart failure (OR: 2.0), male gender (OR: 1.5), and chronic lung disease (OR: 1.4) were associated with a higher rate of VTE. This study identified several significant risk factors for development of VTE in bariatric surgery. To minimize the risk of VTE, surgeons may consider these factors in selection of appropriate prophylaxis and bariatric surgical options.