Understanding Patients' Decisions to Obtain Unplanned, High-Resource Health Care After Colorectal Surgery

Readmissions and emergency department (ED) visits after colorectal surgery (CRS) are common, burdensome, and costly. Effective strategies to reduce these unplanned postdischarge health care visits require a nuanced understanding of how and why patients make the decision to seek care. We used a purposefully stratified sample of 18 interview participants from a prospective cohort of adult CRS patients. Thirteen (72%) participants had an unplanned postdischarge health care visit. Participant decision-making was classified by methodology (algorithmic, guided, or impulsive), preexisting rationale, and emotional response to perceived health care needs. Participants voiced clear mental algorithms about when to visit an ED. In addition, participants identified facilitators and barriers to optimal health care use. They also identified tangible targets for health care utilization reduction efforts, such as improved care coordination with streamlined discharge instructions and improved communication with the surgical team. Efforts should be directed at improving postdischarge communication and care coordination to reduce CRS patients' high-resource health care utilization.

Simulation for Colorectal Surgery

Introduction: Colorectal surgery is a highly specialized field in surgery that deals with the surgical intervention of disease processes of the colon, rectum, and anus. Gaining proficiency in this field requires training both inside and outside of the operating room. Simulation plays a key role in training surgeons in colorectal surgery. The goal of this study is to review the currently available simulators for training in the field of colorectal surgery. Methods: A review of the literature was conducted to identify simulators that are both physical such as benchtop, live animal, and cadaver, as wells as virtual reality (VR) simulators. Any reported validity evidence for these simulators were also presented. Results: There are several benchtop physical models made of silicone for training in basic colorectal tasks, such as hand-sewn and stapled anastomosis. To improve realism, explanted animal and cadaveric specimens were also used for training. To improve repeatability, objective assessment, both commercial and VR simulators also exist for training in both open and laparoscopic colorectal surgery and emerging areas such as endoscopic submucosal dissection. Conclusion: Simulation-based training in colorectal surgery is here to stay and is going to play a significant role in training, credentialing, and quality improvements.

Surgical Treatment for Crohn's Disease: A Role of Kono-S Anastomosis in the West

More than 80% of patients with Crohn's disease (CD) will require surgical intervention during their lifetime, with high rates of anastomotic recurrence and stenosis necessitating repeat surgery. Current data show that pharmacotherapy has not significantly improved the natural history of postoperative clinical and surgical recurrence of CD. In 2003, antimesenteric hand-sewn functional end-to-end (Kono-S) anastomosis was first performed in Japan. This technique has yielded very desirable outcomes in terms of reducing the incidence of anastomotic surgical recurrence. The most recent follow-up of these patients showed that very few had developed surgical recurrence. This new approach is superior to stapled functional end-to-end anastomosis because the stumps are sutured together to create a stabilizing structure (a "supporting column"), serving as a supportive backbone of the anastomosis to help prevent distortion of the anastomotic lumen due to disease recurrence and subsequent clinical symptoms. This technique requires careful mesenteric excision for optimal preservation of the blood supply and innervation. It also results in a very wide anastomotic lumen on the antimesenteric side. The Kono-S technique has shown efficacy in preventing surgical recurrence and the potential to become the new standard of care for intestinal CD.

Prophylaxis of Crohn's disease recurrence: A surgeon's perspective

Management of inflammatory bowel disease has evolved extensively in the last three decades. We have learnt a lot about the pathophysiology and natural history of the disease. New effective classes of drugs with the associated potential morbidity have been introduced. New surgical techniques have been popularized leading to a better understanding of the optimal timing of surgery. The result is a very complex subspecialty of gastroenterology and colorectal surgery called the "IBDologist." Only if we manage these complex patients in the context of a multi-disciplinary team will we be able to obtain outstanding outcomes, specifically with high and sustained remission rates for these patients.

The Landmark Series: Minimally Invasive (Laparoscopic and Robotic) Colorectal Cancer Surgery

Current high-quality evidence supports the routine use of the laparoscopic approach for patients with colon cancer. Laparoscopic colectomy is associated with earlier resumption of gastrointestinal function and shorter hospital stay, with no increased morbidity or mortality. Pathology and long-term oncologic outcomes are similar to those achieved with open surgery. The absolute benefits of laparoscopic resection for rectal cancer are still under evaluation. While its safety in terms of early postoperative clinical outcomes has been confirmed, two recent randomized controlled trial (RCTs) have questioned its routine use even in expert hands, since its non-inferiority has not been demonstrated when compared with the gold standard of open surgery. Furthermore, the impact of robotic technology is still unclear, since the only RCT available so far failed to demonstrate any benefits compared with standard laparoscopic rectal resection.

Diverting colostomy is an effective and reversible option for severe hemorrhagic radiation proctopathy

BACKGROUND

Severe chronic radiation proctopathy (CRP) is difficult to treat.

AIM

To evaluate the efficacy of colostomy and stoma reversal for CRP.

METHODS

To assess the efficacy of colostomy in CRP, patients with severe hemorrhagic CRP who underwent colostomy or conservative treatment were enrolled. Patients with tumor recurrence, rectal-vaginal fistula or other types of rectal fistulas, or who were lost to follow-up were excluded. Rectal bleeding, hemoglobin (Hb), endoscopic features, endo-ultrasound, rectal manometry, and magnetic resonance imaging findings were recorded. Quality of life before stoma and after closure reversal was scored with questionnaires. Anorectal functions were assessed using the CRP symptom scale, which contains the following items: Watery stool, urgency, perianal pain, tenesmus, rectal bleeding, and fecal/gas incontinence.

RESULTS

A total of 738 continual CRP patients were screened. After exclusion, 14 patients in the colostomy group and 25 in the conservative group were included in the final analysis. Preoperative Hb was only 63 g/L ± 17.8 g/L in the colostomy group compared to 88.2 g/L ± 19.3 g/L (P < 0.001) in the conservative group. All 14 patients in the former group achieved complete remission of bleeding, and the colostomy was successfully reversed in 13 of 14 (93%), excepting one very old patient. The median duration of stoma was 16 (range: 9-53) mo. The Hb level increased gradually from 75 g/L at 3 mo, 99 g/L at 6 mo, and 107 g/L at 9 mo to 111 g/L at 1 year and 117 g/L at 2 years after the stoma, but no bleeding cessation or significant increase in Hb levels was observed in the conservative group. Endoscopic telangiectasia and bleeding were greatly improved. Endo-ultrasound showed decreased vascularity, and magnetic resonance imaging revealed an increasing presarcal space and thickened rectal wall. Anorectal functions and quality of life were significantly improved after stoma reversal, when compared to those before stoma creation.

CONCLUSION

Diverting colostomy is a very effective method in the remission of refractory hemorrhagic CRP. Stoma can be reversed, and anorectal functions can be recovered after reversal.

Chronic Antibiotic Dependent Pouchitis Is Associated With Older Age at the Time of Ileal Pouch Anal Anastomosis (J-pouch) Surgery

BACKGROUND

Risk factors for the development of chronic antibiotic dependent pouchitis (CADP) are not well understood.

METHODS

Using multivariable logistic regression, we compared clinical factors between 194 patients with acute antibiotic responsive pouchitis or CADP.

RESULTS

Individuals with CADP were significantly older (40.9 vs 30.8 years, P < 0.001) and demonstrated a longer disease duration before IPAA (10.3 vs 7.0 years, P = 0.004). Age ≥55 years at the time of IPAA was significantly associated with CADP (adjusted odds ratio = 4.35, 95% confidence interval = 1.01-18.7).

CONCLUSIONS

Although older age should not represent a barrier to IPAA, further studies evaluating etiologies of this association are warranted.

Untangling Neolithic and Bronze Age mitochondrial lineages in South Asia

Two key moments shaped the extant South Asian gene pool within the last 10 thousand years (ka): the Neolithic period, with the advent of agriculture and the rise of the Harappan/Indus Valley Civilisation; and Late Bronze Age events that witnessed the abrupt fall of the Harappan Civilisation and the arrival of Indo-European speakers. This study focuses on the phylogeographic patterns of mitochondrial haplogroups H2 and H13 in the Indian Subcontinent and incorporates evidence from recently released ancient genomes from Central and South Asia. It found signals of Neolithic arrivals from Iran and later movements in the Bronze Age from Central Asia that derived ultimately from the Steppe. This study shows how a detailed mtDNA phylogeographic approach, combining both modern and ancient variation, can provide evidence of population movements, even in a scenario of strong male bias such as in the case of the Bronze Age Steppe dispersals.

Challenges in IBD Research: Preclinical Human IBD Mechanisms

Preclinical human IBD mechanisms is part of five focus areas of the Challenges in IBD research document, which also include environmental triggers, novel technologies, precision medicine and pragmatic clinical research. The Challenges in IBD research document provides a comprehensive overview of current gaps in inflammatory bowel diseases (IBD) research and delivers actionable approaches to address them. It is the result of a multidisciplinary input from scientists, clinicians, patients, and funders, and represents a valuable resource for patient centric research prioritization. In particular, the preclinical human IBD mechanisms manuscript is focused on highlighting the main research gaps in the pathophysiological understanding of human IBD. These research gap areas include: 1) triggers of immune responses; 2) intestinal epithelial homeostasis and wound repair; 3) age-specific pathophysiology; 4) disease complications; 5) heterogeneous response to treatments; and 6) determination of disease location. As an approach to address these research gaps, the prioritization of reverse translation studies is proposed in which clinical observations are the foundation for experimental IBD research in the lab, and for the identification of new therapeutic targets and biomarkers. The use of human samples in validating basic research findings and development of precision medicine solutions is also proposed. This prioritization aims to put emphasis on relevant biochemical pathways and humanized in vitro and in vivo models that extrapolate meaningfully to human IBD, to eventually yield first-in-class and effective therapies.

Guidelines for Perioperative Care in Elective Colorectal Surgery: Enhanced Recovery After Surgery (ERAS®) Society Recommendations: 2018

BACKGROUND

This is the fourth updated Enhanced Recovery After Surgery (ERAS®) Society guideline presenting a consensus for optimal perioperative care in colorectal surgery and providing graded recommendations for each ERAS item within the ERAS® protocol.

METHODS

A wide database search on English literature publications was performed. Studies on each item within the protocol were selected with particular attention paid to meta-analyses, randomised controlled trials and large prospective cohorts and examined, reviewed and graded according to Grading of Recommendations, Assessment, Development and Evaluation (GRADE) system.

RESULTS

All recommendations on ERAS® protocol items are based on best available evidence; good-quality trials; meta-analyses of good-quality trials; or large cohort studies. The level of evidence for the use of each item is presented accordingly.

CONCLUSIONS

The evidence base and recommendation for items within the multimodal perioperative care pathway are presented by the ERAS® Society in this comprehensive consensus review.

Disparities in Emergent Colectomy for Colorectal Cancer Contribute to Inequalities in Postoperative Morbidity and Mortality in The US Health Care System

BACKGROUND AND AIMS

Colorectal cancer is the third most common cancer among both men and women in the United States. We aimed to determine racial and socioeconomic disparities in emergent colectomy rates for colorectal cancer in the US Health Care system.

MATERIAL AND METHODS

We performed a retrospective analysis of the National Inpatient Sample including adult patients (⩾18 years) diagnosed with colorectal cancer, and who underwent colorectal resection while admitted between 2008 and 2015. Multivariable logistic and linear regression were used to assess the association between emergent admissions, compared to elective admissions, and postoperative outcomes.

RESULTS

A total of 141,641 hospitalizations were included: 93,775 (66%) were elective admissions and 47,866 (34%) were emergent admissions. Black patients were more likely to undergo emergent colectomy, compared to white patients (42% vs 32%, p < 0.0001). Medicaid and Medicare patients were also more likely to have an emergent colectomy, compared to private insurance (47% and 36% vs 25%, respectively, p < 0.0001), as were patients with low household income, compared to highest (38% vs 31%, p < 0.0001). Emergent procedures were less likely to be laparoscopic (19% vs 38%, p < 0.0001). Patients undergoing emergent colectomy were significantly more likely to have postoperative venous thromboembolism, wound complications, infection, bleeding, cardiac failure, renal failure, respiratory failure, shock, and inpatient mortality.

CONCLUSION

There are significant racial and socioeconomic disparities in emergent colectomy rates for colorectal cancer. Efforts to reduce this disparity in colorectal cancer surgery patients should be prioritized to improve outcomes.

Cervical-length measurement in mid-gestation to predict spontaneous preterm birth in asymptomatic triplet pregnancy

OBJECTIVE

To assess the predictive value of sonographic cervical-length (CL) measurement in mid-gestation for spontaneous preterm birth (PTB) in asymptomatic triplet pregnancy.

METHODS

This was a retrospective study of asymptomatic triplet pregnancies followed at five Italian tertiary referral centers, between 2002 and 2015. CL was measured transvaginally between 18 and 24 weeks' gestation. Pregnancies with medically indicated PTB were excluded. Demographic and pregnancy characteristics of pregnancies complicated by PTB were analyzed and the distributions of CL measurements in these patients were calculated. Logistic regression analysis was performed to assess the association between CL and PTB, adjusted for confounders. Performance of CL measurement in prediction of PTB < 28, < 30 and < 32 weeks of gestation was assessed.

RESULTS

A total of 120 triplet pregnancies were included in the final analysis. Median CL was 35 (interquartile range (IQR), 29-40) mm measured at a median gestational age of 20 + 2 (IQR, 20 + 0 to 23 + 4) weeks. Overall, 23 (19.2%), 17 (14.2%) and eight (6.7%) patients had a CL < 25, < 20 and < 15 mm, respectively. Spontaneous PTB < 32 weeks occurred in 41 (34.2%) cases, < 30 weeks in 23 (19.2%) and < 28 weeks in 12 (10%) cases. CL < 15 mm was significantly more frequent in the group of patients who delivered < 28 (P = 0.03) and < 30 (P = 0.01) weeks' gestation, compared with those who delivered after 28 and after 30 weeks, respectively, while CL < 20 mm was more common in triplet pregnancies with delivery < 32 weeks compared with those delivered ≥ 32 weeks (P = 0.03). Logistic regression analysis was possible only for PTB < 32 weeks due to the small number of cases that delivered < 30 and < 28 weeks. After adjustment for confounders, CL was not significantly associated with PTB < 32 weeks (adjusted odds ratio, 0.97; 95% CI, 0.94-1.01). CL measurement had an area under the receiver-operating characteristics curve of 0.41 (95% CI, 0.20-0.62), 0.41 (95% CI, 0.26-0.56) and 0.42 (95% CI, 0.31-0.54) for the prediction of spontaneous PTB < 28, < 30 and < 32 weeks, respectively.

CONCLUSION

CL assessed in mid-gestation is a poor predictor of PTB < 28, < 30 and < 32 weeks' gestation in asymptomatic triplet pregnancy. Copyright © 2017 ISUOG. Published by John Wiley & Sons Ltd.