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Chand M, Keller DS, Devoto L, McGurk M. Furthering Precision in Sentinel Node Navigational Surgery for Oral Cancer: a Novel Triple Targeting System. J Fluoresc 2018; 28:483-486. [DOI: 10.1007/s10895-018-2211-x] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2017] [Accepted: 01/18/2018] [Indexed: 11/27/2022]
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Althans AR, Brady JT, Times ML, Keller DS, Harvey AR, Kelly ME, Patel ND, Steele SR. Colorectal Cancer Safety Net: Is It Catching Patients Appropriately? Dis Colon Rectum 2018; 61:115-123. [PMID: 29219921 DOI: 10.1097/dcr.0000000000000944] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
BACKGROUND Disparities in access to colorectal cancer care are multifactorial and are affected by socioeconomic elements. Uninsured and Medicaid patients present with advanced stage disease and have worse outcomes compared with similar privately insured patients. Safety net hospitals are a major care provider to this vulnerable population. Few studies have evaluated outcomes for safety net hospitals compared with private institutions in colorectal cancer. OBJECTIVE The purpose of this study was to compare demographics, screening rates, presentation stage, and survival rates between a safety net hospital and a tertiary care center. DESIGN Comparative review of patients at 2 institutions in the same metropolitan area were conducted. SETTINGS The study included colorectal cancer care delivered either at 1 safety net hospital or 1 private tertiary care center in the same city from 2010 to 2016. PATIENTS A total of 350 patients with colorectal cancer from each hospital were evaluated. MAIN OUTCOME MEASURES Overall survival across hospital systems was measured. RESULTS The safety net hospital had significantly more uninsured and Medicaid patients (46% vs 13%; p < 0.001) and a significantly lower median household income than the tertiary care center ($39,299 vs $49,741; p < 0.0001). At initial presentation, a similar percentage of patients at each hospital presented with stage IV disease (26% vs 20%; p = 0.06). For those undergoing resection, final pathologic stage distribution was similar across groups (p = 0.10). After a comparable median follow-up period (26.6 mo for safety net hospital vs 29.2 mo for tertiary care center), log-rank test for overall survival favored the safety net hospital (p = 0.05); disease-free survival was similar between hospitals (p = 0.40). LIMITATIONS This was a retrospective review, reporting from medical charts. CONCLUSIONS Our results support the value of safety net hospitals for providing quality colorectal cancer care, with survival and recurrence outcomes equivalent or improved compared with a local tertiary care center. Because safety net hospitals can provide equivalent outcomes despite socioeconomic inequalities and financial constraints, emphasis should be focused on ensuring that adequate funding for these institutions continues. See Video Abstract at http://links.lww.com/DCR/A454.
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Affiliation(s)
- Alison R Althans
- Case Western Reserve University School of Medicine, Cleveland, Ohio
| | - Justin T Brady
- Department of Surgery, University Hospitals Cleveland Medical Center, Cleveland, Ohio
| | - Melissa L Times
- Division of Colorectal Surgery, Department of Surgery, MetroHealth Medical Center, Cleveland, Ohio
| | - Deborah S Keller
- Division of Colorectal Surgery, Department of Surgery, Baylor University Medical Center, Dallas, Texas
| | - Alexis R Harvey
- Case Western Reserve University School of Medicine, Cleveland, Ohio
| | - Molly E Kelly
- Case Western Reserve University School of Medicine, Cleveland, Ohio
| | - Nilam D Patel
- Case Western Reserve University School of Medicine, Cleveland, Ohio
| | - Scott R Steele
- Department of Colorectal Surgery, Digestive Disease and Surgery Institute, Cleveland Clinic Foundation, Case Western Reserve University School of Medicine, Cleveland, Ohio
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Keller DS, Berho M, Wexner SD, Chand M. Can surgical technology better guide oncological resections in colon cancer? Colorectal Dis 2018; 20:77-78. [PMID: 29166554 DOI: 10.1111/codi.13970] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/14/2017] [Accepted: 11/06/2017] [Indexed: 02/08/2023]
Affiliation(s)
- D S Keller
- Department of Surgery and Interventional Sciences, University College London Hospitals, NHS Trusts, GENIE Centre, University College London, London, UK
| | - M Berho
- Department of Pathology and Laboratory Medicine, Cleveland Clinic Florida, Weston, FL, USA
| | - S D Wexner
- Division of Colorectal Surgery, Department of Surgery, Cleveland Clinic Florida, Weston, FL, USA
| | - M Chand
- Department of Surgery and Interventional Sciences, University College London Hospitals, NHS Trusts, GENIE Centre, University College London, London, UK
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Joshi HM, Keller DS, Chand M. Utilization of Indocyanine green to demonstrate lymphatic mapping in colon cancer. J Surg Oncol 2017; 116:1005-1007. [PMID: 29082528 DOI: 10.1002/jso.24795] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2017] [Accepted: 07/13/2017] [Indexed: 01/06/2023]
Affiliation(s)
- Heman M Joshi
- Department of Surgery, University College London Hospital, London, United Kingdom
| | - Deborah S Keller
- Department of Surgery, University College London Hospital, London, United Kingdom.,Division of Colorectal Surgery, Department of Surgery, Baylor University Medical Center, Dallas, Texas
| | - Manish Chand
- Department of Surgery, University College London Hospital, London, United Kingdom
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Keller DS, Mercadel A, Ho J, Lichliter WE. Comparative Analysis of Physician Reimbursement for Open and Laparoscopic Colorectal Surgery: Is Reimbursement Aligned with Effort? J Am Coll Surg 2017. [DOI: 10.1016/j.jamcollsurg.2017.07.248] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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Keller DS, Qiu J, Senagore AJ. Predicting opportunities to increase utilization of laparoscopy for rectal cancer. Surg Endosc 2017; 32:1556-1563. [PMID: 28917020 DOI: 10.1007/s00464-017-5844-y] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2017] [Accepted: 08/22/2017] [Indexed: 02/06/2023]
Abstract
BACKGROUND Despite proven safety and efficacy, rates of laparoscopy for rectal cancer in the US are low. With reports of inferiority with laparoscopy compared to open surgery, and movements to develop accredited centers, investigating utilization and predictors of laparoscopy are warranted. Our goal was to evaluate current utilization and identify factors impacting use of laparoscopic surgery for rectal cancer. METHODS The Premier™ Hospital Database was reviewed for elective inpatient rectal cancer resections (1/1/2010-6/30/2015). Patients were identified by ICD-9-CM diagnosis codes, and then stratified into open or laparoscopic approaches by ICD-9-CM procedure codes or billing charge. Logistic multivariable regression identified variables predictive of laparoscopy. The Cochran-Armitage test assessed trend analysis. The main outcome measures were trends in utilization and factors independently associated with use of laparoscopy. RESULTS 3336 patients were included-43.8% laparoscopic (n = 1464) and 56.2% open (n = 1872). Use of laparoscopy increased from 37.6 to 55.3% during the study period (p < 0.0001). General surgeons performed the majority of all resections, but colorectal surgeons were more likely to approach rectal cancer laparoscopically (41.31 vs. 36.65%, OR 1.082, 95% CI [0.92, 1.27], p < 0.3363). Higher volume surgeons were more likely to use laparoscopy than low-volume surgeons (OR 3.72, 95% CI [2.64, 5.25], p < 0.0001). Younger patients (OR 1.49, 95% CI [1.03, 2.17], p = 0.036) with minor (OR 2.13, 95% CI [1.45, 3.12], p < 0.0001) or moderate illness severity (OR 1.582, 95% CI [1.08, 2.31], p < 0.0174) were more likely to receive a laparoscopic resection. Teaching hospitals (OR 0.842, 95% CI [0.710, 0.997], p = 0.0463) and hospitals in the Midwest (OR 0.69, 95% CI [0.54, 0.89], p = 0.0044) were less likely to use laparoscopy. Insurance status and hospital size did not impact use. CONCLUSIONS Laparoscopy for rectal cancer steadily increased over the years examined. Patient, provider, and regional variables exist, with hospital status, geographic location, and colorectal specialization impacting the likelihood. However, surgeon volume had the greatest influence. These results emphasize training and surgeon-specific outcomes to increase utilization and quality in appropriate cases.
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Affiliation(s)
- Deborah S Keller
- Division of Colon and Rectal Surgery, Department of Surgery, Baylor University Medical Center, 3500 Gaston Street, R-1013, Dallas, TX, 75246, USA.
| | - Jiejing Qiu
- Healthcare Economics and Outcomes Research, Medtronic, Mansfield, MA, USA
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Carmichael JC, Keller DS, Baldini G, Bordeianou L, Weiss E, Lee L, Boutros M, McClane J, Steele SR, Feldman LS. Clinical practice guideline for enhanced recovery after colon and rectal surgery from the American Society of Colon and Rectal Surgeons (ASCRS) and Society of American Gastrointestinal and Endoscopic Surgeons (SAGES). Surg Endosc 2017; 31:3412-3436. [DOI: 10.1007/s00464-017-5722-7] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2017] [Accepted: 07/10/2017] [Indexed: 12/16/2022]
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Althans AR, Brady JT, Keller DS, Stein SL, Steele SR, Times M. Are we catching women in the safety net? Colorectal cancer outcomes by gender at a safety net hospital. Am J Surg 2017; 214:715-720. [PMID: 28918849 DOI: 10.1016/j.amjsurg.2017.07.022] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2017] [Revised: 06/29/2017] [Accepted: 07/17/2017] [Indexed: 01/13/2023]
Abstract
BACKGROUND Our goal was to evaluate presentation and outcomes for colorectal cancer across gender in a safety net hospital (SNH). METHODS An institutional Tumor Registry was reviewed for colorectal cancer resections 12/2009-2/2016. Patients were stratified into male and female cohorts. The main outcome measures were stage at presentation and oncologic outcomes across gender. RESULTS 170 women (48.6%) and 180 men (51.4%) were evaluated; 129 (84.1%) females and 143 (79.4%) males underwent curative resection. There were no significant differences in prior colorectal cancer screening. On presentation, there were similar rates of stage IV disease across genders (p = 0.3). After median follow-up of 26.5 months (female) and 29.9 months (male), there were no significant differences in overall survival, survival by stage, or disease-free survival by gender (all p = 0.7). The local (1.4% females vs. 2.6% males, p = 0.7) and distant recurrence (16.6% females vs. 14.9% males, p = 0.7) were similar across gender. CONCLUSION With equal access to treatment, there were no significant differences in overall survival, survival by stage, or local or distant recurrence rates by gender. These findings stress the importance of the SNH system, and need for continued support.
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Affiliation(s)
- Alison R Althans
- Department of Surgery, Division of Colorectal Surgery, University Hospitals Case Medical Center, Cleveland, OH, USA
| | - Justin T Brady
- Department of Surgery, Division of Colorectal Surgery, University Hospitals Case Medical Center, Cleveland, OH, USA
| | - Deborah S Keller
- Department of Surgery, Division of Colorectal Surgery, Baylor University Medical Center, Dallas, TX, USA
| | - Sharon L Stein
- Department of Surgery, Division of Colorectal Surgery, University Hospitals Case Medical Center, Cleveland, OH, USA
| | - Scott R Steele
- Digestive Disease and Surgery Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Melissa Times
- Department of Surgery, Division of Colorectal Surgery, MetroHealth Medical Center, Cleveland, OH, USA.
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Abstract
BACKGROUND Laparoscopic colectomy has been shown to be safe, oncologically comparable, and clinically beneficial over open colectomy for colon cancer, but utilization remains low. Objectives To evaluate the cost of laparoscopic colectomy vs open colectomy for colon cancer. METHODS The authors conducted a retrospective claims data analysis using the 2012 and 2013 Truven Health Analytics MarketScan Commercial Claims and Encounter Database. The denominator population consisted of individuals who had commercial insurance coverage in all months of 2012 and >1 month in 2013 and pharmacy coverage throughout eligibility. The study population included individuals aged 18-64 years who were identified with colon cancer in 2013 and underwent an elective inpatient open colectomy or laparoscopic colectomy between January and November 2013. The cost and re-admission rate of open vs laparoscopic colectomy were compared after risk, adjusting for comorbidities, demographics, and geographic region. RESULTS During the study period, 1299 elective inpatient colon cancer colectomies were performed (open, n = 558; laparoscopic, n = 741). After risk adjustment, the laparoscopic vs open group was shown to have lower re-admission rates (6.61 and 10.93 per 100 cases, respectively, p = .0165), lower average re-admission costs ($1676 and $3151, respectively, p = .0309), and lower 30-day post-discharge healthcare utilization costs ($4842 and $7121, respectively, p = .0047). Average allowed cost for the combined inpatient and 30-day post-discharge period was lower for laparoscopic vs open colectomy cases ($36,395 and $44,226, respectively, p < .001). CONCLUSIONS The cost of laparoscopic colectomy was found to be statistically significantly less than that of open colectomy in patients undergoing elective surgery for colon cancer.
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Affiliation(s)
| | | | - Deborah S Keller
- b LLP LTD, Department of Surgery , Houston Methodist Hospital , Houston , TX , USA
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111
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Keller DS, Pedraza R, Tahilramani RN, Flores-Gonzalez JR, Ibarra S, Haas EM. Impact of long-acting local anesthesia on clinical and financial outcomes in laparoscopic colorectal surgery. Am J Surg 2017. [DOI: 10.1016/j.amjsurg.2015.10.035] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
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112
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Arends RHGP, Karsdal MA, Verburg KM, West CR, Bay-Jensen AC, Keller DS. Identification of serological biomarker profiles associated with total joint replacement in osteoarthritis patients. Osteoarthritis Cartilage 2017; 25:866-877. [PMID: 28115232 DOI: 10.1016/j.joca.2017.01.006] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/10/2016] [Revised: 12/15/2016] [Accepted: 01/12/2017] [Indexed: 02/02/2023]
Abstract
OBJECTIVE Establish a biomarker panel associated with all-cause total joint replacement (TJR) through identification of patients with osteoarthritis (OA) who do or do not progress to TJR and investigate effects of nonsteroidal anti-inflammatory drugs (NSAIDs). DESIGN Serum samples from patients enrolled in phase III trials of tanezumab who experienced TJR (n = 174) or matched patients who did not (n = 321) were analyzed for bone, cartilage, soft tissue, and inflammation markers. Classification and Regression Tree (CART) analysis was used to identify biomarker phenotypes associated with TJR. RESULTS At baseline, biomarker combinations for patients who did not use NSAIDs before starting tanezumab and used NSAIDs during tanezumab treatment <90 days ("nonNSAID"), identified 77% (95% confidence interval [CI]: 71-84%) of patients who experienced TJR and 77% (95% CI: 65-86%) who did not over a 6-month study period (on average). These biomarker combinations increased odds of identifying patients to remain free of a TJR by 3.3-fold. In patients who used NSAIDs continuously (during screening and ≥90 days during tanezumab treatment), 64% (95% CI: 54-73%) who had TJR and 75% (95% CI: 68-83%) who did not were identified by biomarker combinations different from nonNSAID patients, with an increase in odds of identifying patients to remain free of a TJR by two-fold. CONCLUSIONS Although validation on other cohorts is necessary, biomarkers may assist in identifying patients who will need TJR. The profiles suggest NSAID use increases importance of bone metabolism in TJR pathology.
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Affiliation(s)
- R H G P Arends
- Pfizer Inc, 445 Eastern Point Road, Groton, CT 06340, United States.
| | - M A Karsdal
- Nordic Bioscience, Herlev Hovedgade, DK-2730, Herlev, Denmark.
| | - K M Verburg
- Pfizer Inc, 445 Eastern Point Road, Groton, CT 06340, United States.
| | - C R West
- Pfizer Inc, 445 Eastern Point Road, Groton, CT 06340, United States.
| | - A C Bay-Jensen
- Nordic Bioscience, Herlev Hovedgade, DK-2730, Herlev, Denmark.
| | - D S Keller
- Pfizer Inc, 445 Eastern Point Road, Groton, CT 06340, United States.
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113
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Keller DS, Kroll D, Papaconstantinou HT, Ellis CN. Development and Validation of a Methodology to Reduce Mortality Using the Veterans Affairs Surgical Quality Improvement Program Risk Calculator. J Am Coll Surg 2017; 224:602-607. [DOI: 10.1016/j.jamcollsurg.2016.12.033] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2016] [Accepted: 12/19/2016] [Indexed: 10/20/2022]
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115
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Keller DS, Senagore AJ, Fitch K, Bochner A, Haas EM. A new perspective on the value of minimally invasive colorectal surgery-payer, provider, and patient benefits. Surg Endosc 2016; 31:2846-2853. [PMID: 27815745 DOI: 10.1007/s00464-016-5295-x] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2016] [Accepted: 10/14/2016] [Indexed: 12/15/2022]
Abstract
BACKGROUND The clinical benefits of minimally invasive surgery (MIS) are proven, but overall financial benefits are not fully explored. Our goal was to evaluate the financial benefits of MIS from the payer's perspective to demonstrate the value of minimally invasive colorectal surgery. METHODS A Truven MarketScan® claim-based analysis identified all 2013 elective, inpatient colectomies. Cases were stratified into open or MIS approaches based on ICD-9 procedure codes; then costs were assessed using a similar distribution across diagnosis related groups (DRGs). Care episodes were compared for average allowed costs, complication, and readmission rates after adjusting costs for demographics, comorbidities, and geographic region. RESULTS A total of 4615 colectomies were included-2054 (44.5 %) open and 2561 (55.5 %) MIS. Total allowed episode costs were significantly lower MIS than open ($37,540 vs. $45,284, p < 0.001). During the inpatient stay, open cases had significantly greater ICU utilization (3.9 % open vs. 2.0 % MIS, p < 0.001), higher overall complications (52.8 % open vs. 32.3 % MIS, p < 0.001), higher colorectal-specific complications (32.5 % open vs. 17.9 % MIS, p < 0.001), longer LOS (6.39 open vs. 4.44 days MIS, p < 0.001), and higher index admission costs ($39,585 open vs. $33,183 MIS, p < 0.001). Post-discharge, open cases had significantly higher readmission rates/100 cases (11.54 vs. 8.28; p = 0.0013), higher average readmission costs ($3055 vs. $2,514; p = 0.1858), and greater 30-day healthcare costs than MIS ($5699 vs. $4357; p = 0.0033). The net episode cost of care was $7744/patient greater for an open colectomy, even with similar DRG distribution. CONCLUSIONS In a commercially insured population, the risk-adjusted allowed costs for MIS colectomy episodes were significantly lower than open. The overall cost difference between MIS and open was almost $8000 per patient. This highlights an opportunity for health plans and employers to realize financial benefits by shifting from open to MIS for colectomy. With increasing bundled payment arrangements and accountable care sharing programs, the cost impact of shifting from open to MIS introduces an opportunity for cost savings.
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Affiliation(s)
- Deborah S Keller
- Department of Surgery, Baylor University Medical Center, 3500 Gaston Street, R-1013, Dallas, TX, 75246, USA.
| | - Anthony J Senagore
- Department of Surgery, University of Texas Medical Branch at Galveston, Galveston, TX, USA
| | | | | | - Eric M Haas
- Minimally Invasive Colon and Rectal Surgery, University of Texas Medical Center at Houston, Houston, TX, USA
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Keller DS, Geisler DP, Ibarra SH, Flores-Gonzalez JR, Haas EM. Can Readmissions Be Predicted in Laparoscopic Colorectal Surgery? J Am Coll Surg 2016. [DOI: 10.1016/j.jamcollsurg.2016.08.447] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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117
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Keller DS, Cologne KG, Senagore AJ, Haas EM. Does one score fit all? Measuring risk in ulcerative colitis. Am J Surg 2016; 212:433-9. [DOI: 10.1016/j.amjsurg.2015.10.033] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2015] [Revised: 10/13/2015] [Accepted: 10/28/2015] [Indexed: 12/12/2022]
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Keller DS, Madhoun N, Ponte-Moreno OI, Ibarra S, Haas EM. Transversus abdominis plane blocks: pilot of feasibility and the learning curve. J Surg Res 2016; 204:101-8. [DOI: 10.1016/j.jss.2016.04.012] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2015] [Revised: 03/24/2016] [Accepted: 04/13/2016] [Indexed: 11/30/2022]
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Keller DS, Flores-Gonzalez JR, Ibarra S, Mahmood A, Haas EM. Is there value in alvimopan in minimally invasive colorectal surgery? Am J Surg 2016; 212:851-856. [PMID: 27262754 DOI: 10.1016/j.amjsurg.2016.02.016] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2015] [Revised: 02/15/2016] [Accepted: 02/27/2016] [Indexed: 12/01/2022]
Abstract
BACKGROUND Alvimopan's goal is to minimize postoperative ileus and optimize outcomes; however, evidence in laparoscopic surgery is lacking. Our goal was to evaluate the benefit of alvimopan in laparoscopic colorectal surgery with an enhanced recovery pathway (ERP). METHODS Laparoscopic colorectal cases were stratified into alvimopan and control cohorts, then case-matched for comparability. All followed an identical ERP. The main outcomes were length of stay, complications, readmissions, and costs in the alvimopan and control groups. RESULTS About 321 patients were analyzed in each cohort. Operative times were comparable (P = .08). Postoperatively, complication rates were similar (P = .29), with no difference in ileus (P = 1.00). The length of stay (3.69 vs 3.49 days; P = .16), readmission (2.8% vs 3.7%; P = .66) and reoperation rates (2.2% vs 1.6%; P = .77) were comparable for alvimopan and controls, respectively. Total costs were similar ($14,932.47 alvimopan vs $14,846.56 controls; P = .90), but the additional costs in the alvimopan group could translate to savings of $27,577 in the cohort. CONCLUSIONS Alvimopan added no benefit in patient outcomes in laparoscopic colorectal surgery with an ERP. These results could drive a change in current practice. Controlled studies are warranted to define the cost and/or benefit in clinical practice.
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Affiliation(s)
- Deborah S Keller
- Colorectal Surgical Associates, Houston, TX, USA; Department of Surgery, Houston Methodist Hospital, 7900 Fannin, Suite 2700, Houston, TX 77054, USA.
| | | | | | - Ali Mahmood
- Colorectal Surgical Associates, Houston, TX, USA; Department of Surgery, Houston Methodist Hospital, 7900 Fannin, Suite 2700, Houston, TX 77054, USA; Minimally Invasive Colon and Rectal Surgery, The University of Texas Medical School at Houston, Houston, TX, USA
| | - Eric M Haas
- Colorectal Surgical Associates, Houston, TX, USA; Department of Surgery, Houston Methodist Hospital, 7900 Fannin, Suite 2700, Houston, TX 77054, USA; Minimally Invasive Colon and Rectal Surgery, The University of Texas Medical School at Houston, Houston, TX, USA
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120
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Keller DS, Tahilramani RN, Flores-Gonzalez JR, Mahmood A, Haas EM. Transanal Minimally Invasive Surgery: Review of Indications and Outcomes from 75 Consecutive Patients. J Am Coll Surg 2016; 222:814-22. [PMID: 27016903 DOI: 10.1016/j.jamcollsurg.2016.02.003] [Citation(s) in RCA: 35] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2015] [Revised: 01/11/2016] [Accepted: 02/02/2016] [Indexed: 02/07/2023]
Abstract
BACKGROUND Transanal minimally invasive surgery (TAMIS) is an advanced local excision platform that helps overcome technical limitations and morbidity associated with other resection methods. Our goal was to review the indications and outcomes of TAMIS in a large series. STUDY DESIGN A review of a prospective database identified patients who underwent TAMIS from 2010 to 2014. Demographic, perioperative, short-term outcomes, and recurrence data were analyzed. RESULTS There were 75 patients with 76 lesions analyzed. Mean age was 64.0 years (SD 11.6 years) and mean BMI was 27.4 kg/m(2) (SD 4.7 kg/m(2)). Median American Society of Anesthesiologists (ASA) score was 2 (range 1 to 4). There were 59 benign (77.3%) and 17 malignant (22.7%) lesions: 6 pT0, 6 pT1, 4 pT2, and 1 pT3. Median lesion distance from the anal verge was 10 cm (range 6 to 16 cm). Mean operative time was 76.0 minutes (SD 36.1 minutes). Three patients had intraperitoneal entry; all were closed transanally, but 2 had temporary diverting ileostomies fashioned to ensure healing. Median length of stay was 1 day (range 0 to 6). One patient had a fragmented lesion (1.3%). Five patients had positive margins: 2 in palliative pT2 resections, and 3 in pT1, pT2, and gastrointestinal stromal tumor (GIST) patients. They were managed with radical resection (pT1 and pT2 lesions) and surveillance/medical oncology (GIST). Postoperatively, 3 patients had complications (bleeding, rectal stricture, and recto-vaginal fistula), and all were managed nonoperatively. After median follow-up of 39.5 months (range 10.5 to 65.3 months), 1 pT1 patient with negative margins developed a local recurrence and underwent salvage APR. CONCLUSIONS Transanal minimally invasive surgery is a viable option for excision of benign or early stage rectal masses, with mid-term oncologic outcomes comparable to those of radical resection. Further, TAMIS minimizes the morbidity and can allow more patients to benefit from the minimally invasive approach.
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Affiliation(s)
- Deborah S Keller
- Colorectal Surgical Associates LLP, LTD, Houston, TX; Department of Surgery, Houston Methodist Hospital, Houston, TX
| | - Reena N Tahilramani
- Colorectal Surgical Associates LLP, LTD, Houston, TX; Minimally Invasive Colon and Rectal Surgery, The University of Texas Medical School at Houston, Houston, TX
| | | | - Ali Mahmood
- Colorectal Surgical Associates LLP, LTD, Houston, TX; Minimally Invasive Colon and Rectal Surgery, The University of Texas Medical School at Houston, Houston, TX; Department of Surgery, Houston Methodist Hospital, Houston, TX
| | - Eric M Haas
- Colorectal Surgical Associates LLP, LTD, Houston, TX; Minimally Invasive Colon and Rectal Surgery, The University of Texas Medical School at Houston, Houston, TX; Department of Surgery, Houston Methodist Hospital, Houston, TX.
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Abstract
The treatment for rectal cancer and benign rectal lesions continues to progress in the arena of minimally invasive surgery. While surgical excision of the primary mass remains essential for eradication of disease, there has been a paradigm shift towards less invasive resection methods. Local excision is increasing in popularity for its low morbidity and excellent functional results in select patients. Transanal minimally invasive surgery (TAMIS) is a new technology developed to elevate the practice of local excision to state-of-the-art resection. The goal of this article is to evaluate the history, short-term outcomes, and evolution of the TAMIS technique for excision of benign and malignant rectal neoplasia.
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Affiliation(s)
- D S Keller
- Colorectal Surgical Associates, Houston, TX, USA
- Division of Colon and Rectal Surgery, Houston Methodist Hospital, Houston, TX, USA
| | - E M Haas
- Colorectal Surgical Associates, Houston, TX, USA.
- Division of Minimally Invasive Colorectal Surgery, Department of Surgery, University of Texas Medical School at Houston, 7900 Fannin, Suite 2700, Houston, TX, 77054, USA.
- Division of Colon and Rectal Surgery, Houston Methodist Hospital, Houston, TX, USA.
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Keller DS, Flores-Gonzalez JR, Ibarra S, Haas EM. Review of 500 single incision laparoscopic colorectal surgery cases - Lessons learned. World J Gastroenterol 2016; 22:659-667. [PMID: 26811615 PMCID: PMC4716067 DOI: 10.3748/wjg.v22.i2.659] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/02/2015] [Revised: 09/09/2015] [Accepted: 11/19/2015] [Indexed: 02/06/2023] Open
Abstract
Single incision laparoscopic surgery (SILS) is a minimally invasive platform with specific benefits over traditional multiport laparoscopic surgery. The safety and feasibility of SILS has been proven, and the applications continue to grow with experience. After 500 cases at a high-volume, single-institution, we were able to standardize instrumentation and operative steps, as well as develop adaptations in technique to help overcome technical and ergonomic challenges. These technical adaptations have allowed the successful application of SILS to technically difficult patient populations, such as pelvic cases, inflammatory bowel disease cases, and high body mass index patients. This review is a frame of reference for the application and wider integration of the single incision laparoscopic platform in colorectal surgery.
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Abstract
BACKGROUND Financial pressures have limited the ability of providers to use medication that may improve clinical outcomes and patient satisfaction. New interventions are often fraught with resistance from individual cost centers. A value realization tool (VRT) is essential for separate cost centers to communicate and comprehend the overall financial and clinical implications of post-surgical pain management medication interventions (PSMI). The goal was to describe development of a VRT. METHODS An evaluation of common in-patient PSMI approaches, impacts, and costs was performed. A multidisciplinary task force guided development of the VRT to ensure appropriate representation and relevance to clinical practice. The main outcome was an Excel-based tool that communicates the overall cost/benefit of PSMI for the post-operative patient encounter. RESULTS The VRT aggregated input data on costs, clinical impact, and nursing burden of PSMI assessment and monitoring into two high-level outcome reports: Overall Cost Impact and Nurse & Patient Impact. Costs included PSMI specific medication, equipment, professional placement, labor, overall/opioid-related adverse events, re-admissions, and length of stay. Nursing impact included level of practice interference, job satisfaction, and patient care metrics. Patient impact included pain scores, opioid use, PACU time, and satisfaction. Reference data was provided for individual institutions that may not collect all variables included in the VRT. CONCLUSIONS The VRT is a valuable way for administrators to assess PSMI cost/benefits and for individual cost centers to see the overall value of individual interventions. The user-friendly, decision-support tool allows the end-user to use built-in referenced or personalized outcome data, increasing relevance to their institutions. This broad picture could facilitate communication across cost centers and evidence-based decisions for appropriate use and impacts of PSMI.
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Affiliation(s)
| | - Amy Smalarz
- b b Strategic Market Insight , Acton , MA , USA
| | - Eric M Haas
- c c Colorectal Surgical Associates, LLP LTD, Division of Colon and Rectal Surgery, Houston Methodist Hospital, Houston, TX, USA, and Division of Minimally Invasive Colon and Rectal Surgery, Department of Surgery, The University of Texas Medical School , Houston , TX , USA
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Keller DS, Delaney CP, Hashemi L, Haas EM. A national evaluation of clinical and economic outcomes in open versus laparoscopic colorectal surgery. Surg Endosc 2015; 30:4220-8. [PMID: 26715021 DOI: 10.1007/s00464-015-4732-6] [Citation(s) in RCA: 61] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2015] [Accepted: 12/15/2015] [Indexed: 12/16/2022]
Abstract
BACKGROUND Surgical value is based on optimizing clinical and financial outcomes. The clinical benefits of laparoscopic surgery are well established; however, many patients are still not offered a laparoscopic procedure. Our objective was to compare the modern clinical and financial outcomes of laparoscopic and open colorectal surgery. METHODS The Premier Perspective database identified patients undergoing elective colorectal resections from January 1, 2013 to December 31, 2013. Cases were stratified by operative approach into laparoscopic and open cohorts. Groups were controlled on all demographics, diagnosis, procedural, hospital characteristics, surgeon volume, and surgeon specialty and then compared for clinical and financial outcomes. The main outcome measures were length of stay (LOS), complications, readmission rates, and cost by surgical approach. RESULTS A total of 6343 patients were matched and analyzed in each cohort. The most common diagnosis was diverticulitis (p = 0.0835) and the most common procedure a sigmoidectomy (p = 0.0962). The LOS was significantly shorter in laparoscopic compared to open (mean 5.78 vs. 7.80 days, p < 0.0001). The laparoscopic group had significantly lower readmission (5.82 vs. 7.68 %, p < 0.0001), complication (32.60 vs. 42.28 %, p < 0.0001), and mortality rates (0.52 vs. 1.28 %, p < 0.0001). The total cost was significantly lower in laparoscopic than in open (mean $17,269 vs. $20,552, p < 0.0001). By category, laparoscopy was significantly more cost-effective for pharmacy (p < 0.0001), room and board (p < 0.0001), recovery room (p = 0.0058), ICU (p < 0.0001), and laboratory and imaging services (both p < 0.0001). Surgical supplies (p < 0.0001), surgery (p < 0.0001), and anesthesia (p = 0.0053) were higher for the laparoscopic group. CONCLUSIONS Laparoscopy is more cost-effective and produces better patient outcomes than open colorectal surgery. Minimally invasive colorectal surgery is now the standard that should be offered to patients, providing value to both patient and provider.
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Affiliation(s)
- Deborah S Keller
- Colorectal Surgical Associates, 7900 Fannin, Suite 2700, Houston, TX, 77054, USA. .,Division of Colon and Rectal Surgery, Houston Methodist Hospital, Houston, TX, USA.
| | - Conor P Delaney
- University Hospitals-Case Medical Center, Cleveland, OH, USA
| | - Lobat Hashemi
- Healthcare Outcomes and Research, Covidien, Mansfield, MA, USA
| | - Eric M Haas
- Colorectal Surgical Associates, 7900 Fannin, Suite 2700, Houston, TX, 77054, USA.,Division of Colon and Rectal Surgery, Houston Methodist Hospital, Houston, TX, USA.,Department of Surgery, University of Texas Medical School at Houston, Houston, TX, USA
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Abstract
Single-incision laparoscopic surgery (SILS) was introduced to further the enhanced outcomes of multiport laparoscopy. Multiple studies have demonstrated the safety and feasibility of SILS for both benign and malignant colorectal disease. SILS provides the potential for improved cosmesis, postoperative outcomes, and patient quality of life. However, widespread use has been limited by technical demands and lack of an evidence and competency-based curriculum.
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Affiliation(s)
| | - Eric M Haas
- Colorectal Surgical Associates, Ltd, LLP, Houston, Texas ; Division of Minimally Invasive Colon and Rectal Surgery, Department of Surgery, The University of Texas Medical School at Houston, Houston, Texas ; Division of Colon and Rectal Surgery, Houston Methodist Hospital, Houston, Texas
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Madhoun N, Keller DS, Haas EM. Review of single incision laparoscopic surgery in colorectal surgery. World J Gastroenterol 2015; 21:10824-9. [PMID: 26478673 PMCID: PMC4600583 DOI: 10.3748/wjg.v21.i38.10824] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/09/2015] [Revised: 07/08/2015] [Accepted: 09/14/2015] [Indexed: 02/06/2023] Open
Abstract
As surgical techniques continue to move towards less invasive techniques, single incision laparoscopic surgery (SILS), a hybrid between traditional multiport laparoscopy and natural orifice transluminal endoscopic surgery, was introduced to further the enhanced outcomes of multiport laparoscopy. The safety and feasibility of SILS for both benign and malignant colorectal disease has been proven. SILS provides the potential for improved cosmesis, postoperative pain, recovery time, and quality of life at the drawback of higher technical skill required. In this article, we review the history, describe the available technology and techniques, and evaluate the benefits and limitations of SILS for colorectal surgery in the published literature.
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Keller DS, Langenfeld SJ, Lomelin DE, Oleynikov D, Haas EM. Effect of surgical approach on venous thromboembolism in inflammatory bowel disease patients. J Am Coll Surg 2015. [DOI: 10.1016/j.jamcollsurg.2015.08.053] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
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Keller DS, Tahilramani RN, Flores Gonzales JR, Sandhu JS, Haas EM. Transanal Minimally Invasive Surgery—Review of Indications and Outcomes in a Large Series. J Am Coll Surg 2015. [DOI: 10.1016/j.jamcollsurg.2015.07.076] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
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Keller DS, Ibarra S, Haas EM. Minimally invasive colorectal surgery: status and technical specifications. MINERVA CHIR 2015; 70:373-380. [PMID: 26149521] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/04/2023]
Abstract
Laparoscopy was the most significant technologic advance in colorectal surgery in the last quarter century. The safety, feasibility and oncologic equivalence have been proven, and undisputed clinical benefits have also been demonstrated over open approaches. Despite proven benefits, laparoscopic has not dominated the market, especially for colon and rectal cancer cases. Adaptations in laparoscopic technique were developed to increase use of minimally invasive surgery. Concurrently, there has been a paradigm shift toward less invasive technologies to further optimize patient outcomes. From these needs, hand assisted laparoscopic surgery (HALS), single incision laparoscopic surgery (SILS), and robotic assisted laparoscopic surgery (RALS) were applied to colorectal surgery. Each platform has unique costs and benefits, and similar outcomes when likened to each other in comparative studies. However, conventional laparoscopy, HALS, SILS, and RALS actually serve a complementary role as tools to increase the use of minimally invasive colorectal surgery. The goal of this paper is to review the history, current status, technical specifications, and evolution of the major minimally invasive platforms for colorectal surgery.
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Affiliation(s)
- D S Keller
- Minimally Invasive Surgery, The University of Texas, Medical School at Houston, Houston Methodist Hospital, Houston, TX, USA -
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Keller DS, Flores-Gonzalez JR, Sandhu J, Ibarra S, Madhoun N, Haas EM. SILS v SILS+1: a Case-Matched Comparison for Colorectal Surgery. J Gastrointest Surg 2015; 19:1875-9. [PMID: 26282851 DOI: 10.1007/s11605-015-2921-1] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/13/2015] [Accepted: 08/10/2015] [Indexed: 01/31/2023]
Abstract
BACKGROUND Single-incision laparoscopic surgery (SILS) is safe and feasible for benign and malignant colorectal diseases. SILS has comparable or improved outcomes compared to multiport laparoscopy but technical limitations when operating in the pelvis. To address these limitations, we developed an innovative SILS+1 approach using a single Pfannenstiel incision for pelvis access with one additional umbilical port. Our goal was to compare outcomes for SILS and SILS+1 in lower abdominal and pelvic colorectal surgery. METHODS Review of a prospectively maintained database identified patients who underwent an elective reduced port laparoscopic lower abdominal/pelvic colorectal procedure from 2009 to 2014. Cases were stratified by approach: SILS versus SILS+1 then matched 1:2 on age, gender, body mass index (BMI), comorbidity, and procedure. Demographic, perioperative, and postoperative outcome variables were evaluated. The main outcome measures were operative time, conversion rate, length of stay, complication, morbidity, and mortality rates. RESULTS One hundred thirty-two reduced port AR/LAR patients were evaluated-44 SILS and 88 SILS+1. The groups were similar in age, gender, BMI, and ASA class. The primary diagnosis in both cohorts was diverticulitis (90.9 % SILS, 87.5 % SILS+1), and main procedure performed an anterior rectosigmoidectomy (86.4 % SILS, 88.2 % SILS+1). Significantly more SILS+1 patients had previous abdominal surgery (p = 0.01). The operative time was significantly shorter in SILS+1 (mean 166.6 [SD 48.4] vs. 178.0 [SD 70.0], p = 0.03). The conversion rate to multiport or open surgery was also significantly lower with SILS+1 compared to SILS (1.1 vs. 11.4 %, p = 0.02). Postoperatively, the length of stay across the groups was similar. SILS trended towards higher complication and readmission rates (NS). There were no unplanned reoperations or mortality in either group. CONCLUSIONS SILS+1 facilitates pelvic and lower abdominal colorectal surgery, with shorter operative times and lower conversion rates. The additional port improved visualization and outcomes without any impact on length of stay, readmission, or complication rates.
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Affiliation(s)
| | | | | | | | | | - Eric M Haas
- Colorectal Surgical Associates, Houston, TX, USA. .,Houston Methodist Hospital, Houston, TX, USA. .,Minimally Invasive Colorectal Surgery, University of Texas Medical School, Houston, TX, USA.
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Keller DS, Ibarra S, Flores-Gonzalez JR, Ponte OM, Madhoun N, Pickron TB, Haas EM. Outcomes for single-incision laparoscopic colectomy surgery in obese patients: a case-matched study. Surg Endosc 2015; 30:739-744. [PMID: 26092004 DOI: 10.1007/s00464-015-4268-9] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2015] [Accepted: 05/01/2015] [Indexed: 01/12/2023]
Abstract
BACKGROUND Single-incision laparoscopic surgery (SILS) is safe and feasible for benign and malignant colorectal diseases. SILS offers several patient-related benefits over multiport laparoscopy. However, its use in obese patients has been limited from concerns of technical difficulty, oncologic compromise, and higher complication and conversion rates. Our objective was to evaluate the feasibility and efficacy of SILS for colectomy in obese patients. METHODS Review of a prospective database identified patients undergoing elective colectomy using SILS from 2009 to 2014. They were stratified into obese (BMI ≥ 30 kg/m(2)) and non-obese cohorts (BMI < 30 kg/m(2)) and then matched on patient characteristics, diagnosis, and operative procedure. Demographic and perioperative outcome data were evaluated. The primary outcome measures were operative time, length of stay (LOS), and conversion, complication, and readmission rates for each cohort. RESULTS A total of 160 patients were evaluated-80 in each cohort. Patients were well matched in demographics, diagnosis, and procedure variables. The obese cohort had significantly higher BMI (p < 0.001) and ASA scores (p = 0.035). Operative time (176.9 ± 64.0 vs. 144.4 ± 47.2 min, p < 0.001) and estimated blood loss (89.0 ± 139.5 vs. 51.6 ± 38.0 ml, p < 0.001) were significantly higher in the obese. There were no significant differences in conversion rates (p = 0.682), final incision length (p = 0.088), LOS (p = 0.332), postoperative complications (p = 0.430), or readmissions (p = 1.000) in the obese versus non-obese. Further, in malignant cases, lymph nodes harvested (p = 0.757) and negative distal margins (p = 1.000) were comparable across cohorts. CONCLUSIONS Single-incision laparoscopic colectomy in obese patients had significantly longer operative times, but comparable conversion rates, oncologic outcomes, lengths of stay, complication, and readmission rates as the non-obese cohorts. In the obese, where higher morbidity rates are typically associated with surgical outcomes, SILS may be the ideal platform to optimize outcomes in colorectal surgery. With additional operative time, the obese can realize the same clinical and quality benefits of minimally invasive surgery as the non-obese.
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Affiliation(s)
| | | | | | | | | | - T Bartley Pickron
- Colorectal Surgical Associates, Houston, TX, USA.,Division of Minimally Invasive Colon and Rectal Surgery, Department of Surgery, University of Texas Medical School at Houston, 7900 Fannin, Suite 2700, Houston, TX, 77030, USA
| | - Eric M Haas
- Colorectal Surgical Associates, Houston, TX, USA.,Division of Minimally Invasive Colon and Rectal Surgery, Department of Surgery, University of Texas Medical School at Houston, 7900 Fannin, Suite 2700, Houston, TX, 77030, USA
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Keller DS, Aboseif SR, Lesser T, Abbass MA, Tsay AT, Abbas MA. Algorithm-based multidisciplinary treatment approach for rectourethral fistula. Int J Colorectal Dis 2015; 30:631-8. [PMID: 25808012 DOI: 10.1007/s00384-015-2183-0] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 03/03/2015] [Indexed: 02/04/2023]
Abstract
PURPOSE The purpose of this study is to report the outcomes of an algorithm-based multidisciplinary treatment approach to rectourethral fistula. METHODS This study is a retrospective review of a prospectively collected database at a tertiary center of all consecutive patients treated between 2003 and 2013. RESULTS Thirty males (mean age 63 years) were reviewed. Prostate cancer treatment was the most common fistula etiology (97%). Urinary drainage consisted of urethral catheter in all patients and suprapubic catheter in 14 (47%). The rate of fecal diversion was 67%. During a mean follow-up of 72 months, healing rate was 90% and recurrence rate 0%. Spontaneous healing was achieved in 14 patients (47%): 8 (27%) without fecal diversion and 6 (20%) following fecal diversion. Thirteen patients (43%) required definitive intervention. The majority of operated patients underwent transanal or transperineal flap (endorectal, dartos, or gracilis) successfully. Only 2 patients (7%) required an abdominal approach (positive oncologic margins or non-functioning bladder). Fifteen out of the 20 patients (75%) who underwent fecal diversion had stoma closure with an overall permanent stoma rate of 17%. Long-term urinary incontinence was noted in 11 patients (37%). Six patients (20%) required permanent urinary diversion or drainage catheters. CONCLUSIONS Algorithm-based treatment approach for rectourethral fistula is useful in the management of this rare condition. Selective fecal diversion is possible, and majority of patients who require definitive intervention can be treated with a transanal or transperineal approach. The rate of permanent stoma is low, but long-term urinary dysfunction is frequent.
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Cologne KG, Keller DS, Liwanag L, Devaraj B, Senagore AJ. Use of the American College of Surgeons NSQIP Surgical Risk Calculator for Laparoscopic Colectomy: How Good Is It and How Can We Improve It? J Am Coll Surg 2015; 220:281-6. [DOI: 10.1016/j.jamcollsurg.2014.12.007] [Citation(s) in RCA: 62] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2014] [Revised: 12/08/2014] [Accepted: 12/08/2014] [Indexed: 02/04/2023]
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Crawshaw BP, Augestad KM, Keller DS, Nobel T, Swendseid B, Champagne BJ, Stein SL, Delaney CP, Reynolds HL. Multivisceral resection for advanced rectal cancer: outcomes and experience at a single institution. Am J Surg 2014; 209:526-31. [PMID: 25577290 DOI: 10.1016/j.amjsurg.2014.10.014] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2014] [Revised: 10/10/2014] [Accepted: 10/13/2014] [Indexed: 02/07/2023]
Abstract
BACKGROUND Multivisceral resection is often required in the treatment of locally advanced rectal cancers. Such resections are relatively rare and oncologic outcomes, especially when sphincter preservation is performed, are not fully demonstrated. METHODS A retrospective review was conducted of patients who underwent multivisceral resection for locally advanced rectal cancer with and without sphincter preservation. RESULTS Sixty-one patients underwent multivisceral resection for rectal cancer from 2005 to 2013 with a median follow-up of 27.8 months. Five-year overall and disease-free survival were 49.2% and 45.3%, respectively. Thirty-four patients (55.7%) had sphincter-sparing operations with primary coloanal anastomosis and temporary stoma. There was no significant difference in overall or disease-free survival, or recurrence with sphincter preservation compared with those with permanent stoma. CONCLUSIONS Multivisceral resection for locally advanced rectal cancer has acceptable oncologic and clinical outcomes. Sphincter preservation and subsequent reestablishment of gastrointestinal continuity does not impact oncologic outcomes and should be considered in many patients.
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Affiliation(s)
- Benjamin P Crawshaw
- Department of Colorectal Surgery, University Hospitals Case Medical Center, 11100 Euclid Avenue, Cleveland, OH 44106, USA.
| | - Knut M Augestad
- Department of Colorectal Surgery, University Hospitals Case Medical Center, 11100 Euclid Avenue, Cleveland, OH 44106, USA
| | - Deborah S Keller
- Department of Colorectal Surgery, University Hospitals Case Medical Center, 11100 Euclid Avenue, Cleveland, OH 44106, USA
| | - Tamar Nobel
- Department of Colorectal Surgery, University Hospitals Case Medical Center, 11100 Euclid Avenue, Cleveland, OH 44106, USA
| | - Brian Swendseid
- Department of Colorectal Surgery, University Hospitals Case Medical Center, 11100 Euclid Avenue, Cleveland, OH 44106, USA
| | - Bradley J Champagne
- Department of Colorectal Surgery, University Hospitals Case Medical Center, 11100 Euclid Avenue, Cleveland, OH 44106, USA
| | - Sharon L Stein
- Department of Colorectal Surgery, University Hospitals Case Medical Center, 11100 Euclid Avenue, Cleveland, OH 44106, USA
| | - Conor P Delaney
- Department of Colorectal Surgery, University Hospitals Case Medical Center, 11100 Euclid Avenue, Cleveland, OH 44106, USA
| | - Harry L Reynolds
- Department of Colorectal Surgery, University Hospitals Case Medical Center, 11100 Euclid Avenue, Cleveland, OH 44106, USA
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Keller DS, Swendseid B, Khan S, Delaney CP. Readmissions after ileostomy closure: cause to revisit a standardized enhanced recovery pathway? Am J Surg 2014; 208:650-5. [DOI: 10.1016/j.amjsurg.2014.05.003] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2013] [Revised: 12/15/2013] [Accepted: 05/09/2014] [Indexed: 12/20/2022]
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Keller DS, Ermlich BO, Delaney CP. Demonstrating the benefits of transversus abdominis plane blocks on patient outcomes in laparoscopic colorectal surgery: review of 200 consecutive cases. J Am Coll Surg 2014; 219:1143-8. [PMID: 25442068 DOI: 10.1016/j.jamcollsurg.2014.08.011] [Citation(s) in RCA: 38] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2014] [Revised: 08/01/2014] [Accepted: 08/29/2014] [Indexed: 11/28/2022]
Abstract
BACKGROUND Quality improvement in colorectal surgery (CRS) requires implementation of tools to improve patient and financial outcomes, and assessment of results. Our objective was to evaluate the durability of transversus abdominis plane (TAP) blocks and a standardized enhanced recovery protocol (ERP) on a large series of laparoscopic colorectal resections. STUDY DESIGN Two hundred consecutive laparoscopic CRS patients received TAP blocks under laparoscopic guidance at the end of their operation. All were managed with a standardized ERP. Demographic, perioperative, and postoperative outcomes variables were analyzed. The main outcomes measures were length of stay (LOS), readmission, reoperation, morbidity, and mortality rates. RESULTS Of 200 cases, 194 were elective and 6 emergent. The main diagnosis was colorectal cancer (45%). The mean patient age was 61.2 years, mean body mass index was 29.2 kg/m(2), and the majority (63%) were American Society of Anesthesiologists (ASA) class III. The main procedure performed was a segmental colectomy (64%). Mean operative time was 181 minutes. Nine cases (4.5%) were converted to open. The median LOS was 2 days (range 1 to 8 days). Twenty-one percent were discharged by postoperative day (POD) 1, 41% by POD 2, and 77% by POD 3. By POD 7, 99% were discharged. Twelve percent (n = 24) had complications, and 6.5% (n = 13) were readmitted. There were 3 unplanned reoperations and no mortalities. Comparing the first and second groups of 100 consecutive patients further tested the consistency of the TAP block benefit. With comparable demographics, there were no significant differences in readmission, complication, or reoperation rates over the entire series. CONCLUSIONS Adding TAP blocks to an ERP facilitated shorter LOS with low readmission and reoperation rates when compared to previously published series. The effect appears durable and consistent in a large case series. Transversus abdominis plane blocks may be an efficient, cost-effective method for improving laparoscopic CRS results.
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Affiliation(s)
- Deborah S Keller
- Division of Colorectal Surgery, University Hospitals-Case Medical Center, Cleveland, OH
| | - Bridget O Ermlich
- Department of Surgery, University Hospitals-Case Medical Center, Cleveland, OH
| | - Conor P Delaney
- Division of Colorectal Surgery, University Hospitals-Case Medical Center, Cleveland, OH.
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Keller DS, Swendseid B, Khorgami Z, Champagne BJ, Reynolds HL, Stein SL, Delaney CP. Predicting the unpredictable: comparing readmitted versus non-readmitted colorectal surgery patients. Am J Surg 2013; 207:346-51; discussion 350-1. [PMID: 24439160 DOI: 10.1016/j.amjsurg.2013.09.008] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2013] [Revised: 08/27/2013] [Accepted: 09/01/2013] [Indexed: 12/18/2022]
Abstract
BACKGROUND To evaluate readmissions to determine predictors and patterns of readmission. METHODS Prospective database review identified readmitted and non-readmitted patients after colorectal surgery. Variables for the index and readmission episode were examined. RESULTS A total of 212 readmissions and 3,292 nonreadmissions were analyzed. The majority was elective. Readmitted patients were older (P = .003), had more comorbidities (P < .0001), longer operative times (P < .0001), length of stay (P < .0001), and higher costs (P = .002). At the time of discharge, more readmitted patients required temporary nursing (P < .0001). Independent readmission predictors were higher American Society of Anesthesiologists score, previous abdominal operation, intensive care unit stay, and dysmotility/constipation surgery. At the time of readmission, 29.2% required reoperation. More than half had an open procedure initially (55.2%). After initial open procedures, reoperative time (P = .05) and LOS were longer (P = .028), and more patients required temporary nursing care at the time of discharge (P = .046). Readmissions caused an additional mean hospital cost of $12,670.89. CONCLUSIONS Readmitted patients have distinct demographic and outcomes variables. As most were elective cases, stratifying patients preoperatively may enable perioperative planning for this higher risk group.
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Affiliation(s)
- Deborah S Keller
- Division of Colorectal Surgery, Department of Surgery, University Hospitals Case Medical Center, Cleveland, OH, USA
| | - Brian Swendseid
- School of Medicine, Case Western Reserve University, Cleveland, OH, USA
| | - Zhamak Khorgami
- Division of Colorectal Surgery, Department of Surgery, University Hospitals Case Medical Center, Cleveland, OH, USA
| | - Bradley J Champagne
- Division of Colorectal Surgery, Department of Surgery, University Hospitals Case Medical Center, Cleveland, OH, USA
| | - Harry L Reynolds
- Division of Colorectal Surgery, Department of Surgery, University Hospitals Case Medical Center, Cleveland, OH, USA
| | - Sharon L Stein
- Division of Colorectal Surgery, Department of Surgery, University Hospitals Case Medical Center, Cleveland, OH, USA
| | - Conor P Delaney
- Division of Colorectal Surgery, Department of Surgery, University Hospitals Case Medical Center, Cleveland, OH, USA.
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Keller DS, Paspulati R, Kjellmo A, Rokseth KM, Bankwitz B, Wibe A, Delaney CP. MRI-defined height of rectal tumours. Br J Surg 2013; 101:127-32. [DOI: 10.1002/bjs.9355] [Citation(s) in RCA: 36] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/25/2013] [Indexed: 12/28/2022]
Abstract
Abstract
Background
There is no standard for reporting rectal cancer distances from the distal resection margin in the literature. The objective was to demonstrate the importance of rectal cancer measurement from a standardized point.
Methods
Review of databases at two international institutions identified 50 patients with rectal adenocarcinoma within 15 cm of the anal verge (AV), who had preoperative magnetic resonance imaging (MRI) and underwent surgery with curative intent. Expert radiologists reviewed the magnetic resonance images for anatomical distances from the anorectal ring (ARR) to the AV, from the ARR to the dentate line (DL), and from the DL to the AV. Anatomical measurements were compared with preoperative measurements to assess reporting inconsistencies.
Results
Fifty patients with rectal adenocarcinoma were included in the study. The mean(s.d.) anatomical distance was 1·66(0·61) cm from the ARR to the DL, 3·78(0·61) cm from the ARR to the AV (maximum 5·5 cm) and 2·11(0·10) cm from the DL to the AV. The mean radiological distance from the distal tumour was 2·90(1·60) (median 3·2, range 0–7·5) cm to the ARR, 4·36(3·20) (median 4·2, range −0·5 to 12·8) cm to the DL and 6·13(3·39) (median 6·0, range 0–14·1) cm to the AV. There was a significant difference in the distal tumour margin between measurements made by the expert radiologists and reported preoperative measurements (P < 0·001). Significant differences were also found between the expert radiologists' MRI and rigid proctoscopic measurements (P = 0·025).
Conclusion
There was up to 5·5 cm variation, depending on which landmark was chosen for reporting the distal margin of rectal cancer. This has potential implications for surgical planning, interpreting radiological images and comparative studies.
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Affiliation(s)
- D S Keller
- Division of Colorectal Surgery, Department of Surgery, University Hospitals Case Medical Center, Case Western Reserve University, Cleveland, Ohio, USA
| | - R Paspulati
- Department of Radiology, University Hospitals Case Medical Center, Case Western Reserve University, Cleveland, Ohio, USA
| | - A Kjellmo
- Department of Radiology, St Olav's Hospital, Trondheim University Hospital, Trondheim, Norway
| | - K M Rokseth
- Department of Radiology, St Olav's Hospital, Trondheim University Hospital, Trondheim, Norway
| | - B Bankwitz
- Department of Statistics, Case Western Reserve University, Cleveland, Ohio, USA
| | - A Wibe
- Department of Surgery, Institute of Cancer Research and Molecular Medicine, Norwegian University of Science and Technology, St Olav's Hospital, Trondheim University Hospital, Trondheim, Norway
| | - C P Delaney
- Division of Colorectal Surgery, Department of Surgery, University Hospitals Case Medical Center, Case Western Reserve University, Cleveland, Ohio, USA
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Keller DS, Thomay AA, Gaughan J, Olszanski A, Wu H, Berger AC, Farma JM. Outcomes in patients with mucosal melanomas. J Surg Oncol 2013; 108:516-20. [DOI: 10.1002/jso.23445] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2013] [Accepted: 09/03/2013] [Indexed: 12/25/2022]
Affiliation(s)
- Deborah S. Keller
- Department of Surgery; Temple University School of Medicine; Philadelphia Pennsylvania
| | - Alan A. Thomay
- Department of Surgical Oncology; Fox Chase Cancer Center; Philadelphia Pennsylvania
| | - John Gaughan
- Biostatistics Consulting Center; Temple University School of Medicine; Philadelphia Pennsylvania
| | - Anthony Olszanski
- Department of Medical Oncology; Fox Chase Cancer Center; Philadelphia Pennsylvania
| | - Hong Wu
- Department of Surgical Pathology; Fox Chase Cancer Center; Philadelphia Pennsylvania
| | - Adam C. Berger
- Department of Surgery; Thomas Jefferson University Hospital; Philadelphia Pennsylvania
| | - Jeffrey M. Farma
- Department of Surgical Oncology; Fox Chase Cancer Center; Philadelphia Pennsylvania
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Keller DS, Hashemi L, Lu M, Delaney CP. Short-term outcomes for robotic colorectal surgery by provider volume. J Am Coll Surg 2013; 217:1063-9.e1. [PMID: 24041555 DOI: 10.1016/j.jamcollsurg.2013.07.390] [Citation(s) in RCA: 42] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2013] [Revised: 06/30/2013] [Accepted: 07/03/2013] [Indexed: 11/26/2022]
Abstract
BACKGROUND There has been a rapid increase in robotic colorectal surgery. Benefits of this technology are unclear and being investigated. However, differences in outcomes between centers have not been evaluated. Our aim was to evaluate outcomes for robotic colorectal procedures by surgeon and hospital volume. STUDY DESIGN A national inpatient database was reviewed for robotic colorectal resections performed during an 18-month period. Hospitals and surgeons were stratified into high, average, and low case volumes based on a normal distribution scale. High, average, and low volume was defined as ≤ 10, 11 to 20, and >20, respectively, for hospitals, and ≤ 5, 6 to 15, and >15, respectively, for surgeons. Short-term outcomes and hospital cost were evaluated. RESULTS There were 1,428 robotic colorectal cases across 123 hospitals and 411 surgeons evaluated. Only 13% (n = 16) of hospitals and 4.4% (n = 18) of surgeons performed a high volume of robotic colorectal cases. Lower volume was associated with significantly more overall complications (p < 0.001; p < 0.001), longer length of stay (p = 0.005; p < 0.001), and higher cost (p < 0.001; p < 0.001) at the hospital and surgeon level, respectively. High-volume hospitals and surgeons had significantly lower rates of postoperative bleeding (p < 0.001; p < 0.001) and ileus (p = 0.003; p = 0.0014). CONCLUSIONS Lower-volume providers, who are performing the majority of procedures, are generating more complications, longer hospital lengths of stay, and higher costs of care. These results have a negative impact on quality outcomes measures for those facilities. Although surgeons and hospitals continue to selectively explore robotics, this should be limited to high volume and interested surgeons and hospitals to offer high-quality outcomes to patients.
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Affiliation(s)
- Deborah S Keller
- Division of Colorectal Surgery, Department of Surgery, University Hospitals Case Medical Center, Cleveland, OH
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141
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Keller DS, Champagne BJ, Stein SL, Ermlich BO, Delaney CP. Pilot study evaluating the efficacy of AlloMEM™ for prevention of intraperitoneal adhesions and peritoneal regeneration after loop ileostomy. Surg Endosc 2013; 27:3891-6. [PMID: 23670746 DOI: 10.1007/s00464-013-3004-6] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2013] [Accepted: 04/26/2013] [Indexed: 10/26/2022]
Abstract
OBJECTIVE This study was designed to evaluate the feasibility of AlloMEM™, a novel lyophililzed human peritoneal membrane, at peritoneal reconstitution, and decreasing adhesion formation after temporary loop ileostomy. METHODS In a pilot study, ten patients had AlloMEM™ used during elective formation of a temporary diverting loop ileostomy for benign or malignant colorectal disease. A blinded investigator and the operating surgeon analyzed the change in adhesion formation and peritoneal remodelling using ileostomy mobilization time and a 5-point adhesion scale grading intra-abdominally and at the subcutaneous and fascial levels. RESULTS The mean body mass index was 31 [standard deviation (SD) 5.6], and 40 % of patients had previous abdominal surgery. Ileostomies were reversed after a mean 14 weeks (SD 6.0). The mean ileostomy mobilization time was 27.2 min (SD 12.0). From baseline to ileostomy reversal, there were significant increases in adhesions at the subcutaneous (p = 0.0002) and fascial levels (p = 0.0024). The increased subcutaneous adhesions were associated with improved peritoneal remodeling. There was no significant increase in adhesions from baseline to ileostomy reversal at the intra-abdominal points (p = 0.9393) or around the ileostomy site (p = 0.6128). The median hospital length of stay was 2.6 days (range, 2-3). A single adverse event related to product packaging led to redesign of the packaging process. CONCLUSIONS Use of AlloMEM™ in ileostomy closures suggested improvement in adhesions around the fascia and promotion of peritoneal remodeling. AlloMEM™ was safe, feasible, and easy to use in this pilot study. Comparative research is needed to assess the outcomes with this novel product.
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Affiliation(s)
- Deborah S Keller
- Division of Colorectal Surgery, Department of Surgery, Institute for Surgery and Innovation, University Hospitals Case Medical Center, Case Western Reserve University, 11100 Euclid Avenue, 7 Lakeside, Cleveland, OH, 44106-5047, USA,
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142
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Keller DS, Parkman HP, Boucek DO, Sankineni A, Meilahn JE, Gaughan JP, Harbison S. Surgical outcomes after gastric electric stimulator placement for refractory gastroparesis. J Gastrointest Surg 2013; 17:620-6. [PMID: 23358845 DOI: 10.1007/s11605-013-2147-z] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/12/2012] [Accepted: 01/09/2013] [Indexed: 01/31/2023]
Abstract
BACKGROUND Gastric electric stimulation (GES) is used for refractory gastroparesis symptoms. Although symptomatic improvement has been reported with GES, few studies describe the need for additional surgery after placement. Our goal was to evaluate the outcomes of a large series of GES at a single institution. METHODS A retrospective review was performed for patients undergoing Enterra GES (Medtronic, Inc.) placement for refractory gastroparesis from October 2000 to October 2011. The main outcome measures were the need/indications for additional procedures and symptom improvement. RESULTS A total of 266 patients had a GES implanted; 233 had complete records and were included in the analysis. Fifty-eight percent (n = 135) required an additional procedure after GES placement. Nutrition access (45 patients requiring 77 procedures) and subcutaneous pocket issues (n = 21) were the most common indications for subsequent procedures. Twelve percent (n = 29) had the GES explanted, mainly for continued gastroparetic symptoms (n = 11), mechanical issues (n = 9), or infection (n = 4). Ninety patients had subsequent hospitalizations, mainly for gastroparetic flares. Mortality during the follow-up period was 2.1 %. BMI was predictive of additional surgical procedure: when overweight, the risk of pocket revision increased 4.45 times (OR = 4.452). Of 74 most recent patients with prospective long-term outcome data, 70 % reported improved symptoms of pain, bloating, and nausea. CONCLUSIONS Although most patients reported symptomatic improvement after GES implantation, there is often a need for additional surgical procedures as well as associated complications after GES placement. Additional procedures were most frequent for surgical nutrition and subcutaneous pocket issues; pocket revisions were more frequent in obese patients. From our results, we amended our practice to add a jejunostomy tube in malnourished patients and suture the stimulator to the subcutaneous pocket fascia. Further studies will determine if these changes reduce the rate of complications and additional procedures after GES placement.
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Affiliation(s)
- Deborah S Keller
- Department of Surgery, Temple University School of Medicine, Philadelphia, PA 19140, USA
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143
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Keller DS, Delaney CP. The Role of Enhanced Recovery Pathways in the Setting of Minimally Invasive Colorectal Surgery. Seminars in Colon and Rectal Surgery 2013. [DOI: 10.1053/j.scrs.2012.10.004] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/24/2023]
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144
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Lawrence JK, Keller DS, Samia H, Ermlich B, Brady KM, Nobel T, Stein SL, Delaney CP. Discharge within 24 to 72 hours of colorectal surgery is associated with low readmission rates when using Enhanced Recovery Pathways. J Am Coll Surg 2013; 216:390-4. [PMID: 23352608 DOI: 10.1016/j.jamcollsurg.2012.12.014] [Citation(s) in RCA: 72] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2012] [Revised: 12/03/2012] [Accepted: 12/11/2012] [Indexed: 12/31/2022]
Abstract
BACKGROUND Enhanced Recovery Pathways (ERPs) have demonstrated reduced hospital length of stay and improved outcomes after colorectal surgery. Concerns exist about increases in readmission rates. Laparoscopic colorectal surgery with an ERP can permit earlier discharge without compromising safety or increasing readmission rates. STUDY DESIGN A review of a prospective database was performed for major elective colorectal procedures by a single surgeon. All patients followed a standardized ERP and discharge criteria. Patients were categorized by approach and day of discharge (DoD) of ≤ 1, ≤ 2, ≤ 3, ≤ 7, and >7 days. Main outcomes measures were length of stay and 30-day readmission rates in each group. RESULTS Eight hundred and six cases (609 laparoscopic, 197 open) were identified during a 64-month period. Mean age was similar for the laparoscopic (59.1 years) and open (58.3 years) groups. Mean overall DoD was at 5 days (± 4.8 days); by approach, the mean laparoscopic DoD was at 3.9 days and open DoD was at 8.4 days. Twenty-nine percent were discharged within 48 hours (38% laparoscopic and 8% open) and 50% were discharged within 72 hours (62% laparoscopic and 19% open). Only 8.9% of all patients (n = 72) were readmitted (7.2% laparoscopic, 14.2% open). The cumulative readmission rate for laparoscopic patients in early DoD groups postoperative days 1, 2, and 3 were 0.2%, 1.6%, and 3.4%, respectively. CONCLUSIONS Combining laparoscopy with an ERP optimizes patient care in colorectal surgery. The combination permits early discharge; 38% were discharged within 2 days and 62% within 3 days of surgery, with low readmission rates. These results support that early DoD is possible without compromising patient safety or increasing readmission rates. This might be a marker for low readmission rate, and suggests that readmission rate alone might not be an adequate marker of quality.
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Affiliation(s)
- Justin K Lawrence
- Division of Colorectal Surgery, University Hospitals Case Medical Center, Cleveland, OH 44106-5047, USA
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145
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Galanter M, Keller DS, Dermatis H, Egelko S. The impact of managed care on substance abuse treatment: a problem in need of solution. A report of the American Society of Addiction Medicine. Recent Dev Alcohol 2002; 15:419-36. [PMID: 11449756] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 02/20/2023]
Affiliation(s)
- M Galanter
- New York University School of Medicine, Department of Psychiatry, Division of Alcoholism and Drug Abuse, New York, New York 10016, USA
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146
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Galanter M, Keller DS, Dermatis H, Egelko S. The impact of managed care on substance abuse treatment: a report of the American Society of Addiction Medicine. J Addict Dis 2001; 19:13-34. [PMID: 11076117 DOI: 10.1300/j069v19n03_02] [Citation(s) in RCA: 44] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
This report examines the impact of managed care (MC) and related developments on substance abuse treatment, and evaluates how it has been associated with a decline in the availability of proper treatment for many addicted patients. A trend toward carve-out and for-profit MC organizations is associated with lower financial incentives for intensive treatment than in earlier staff-model and not-for-profit MC organizations. The value of substance abuse insurance coverage has declined by 75% between 1988 and 1998 for employees of mid-to large-size companies, compared with only an 11.5% decline for general health insurance. The shift towards MC has also been associated with a drastic reduction in frequency and duration of inpatient hospitalization, and there is no clear evidence that this reduction has been offset by a corresponding increase in outpatient support. In a survey of physicians treating addiction, the majority felt that MC had a negative impact on detoxification and rehabilitation, and on their ethical practice of addiction medicine.
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147
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Morgenstern J, Morgan TJ, McCrady BS, Keller DS, Carroll KM. Manual-guided cognitive-behavioral therapy training: a promising method for disseminating empirically supported substance abuse treatments to the practice community. Psychol Addict Behav 2001; 15:83-8. [PMID: 11419234] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/20/2023]
Abstract
A gap exists between empirically supported substance abuse treatments and those used in community settings. This study examined the feasibility of training substance abuse counselors to deliver cognitive-behavioral treatment (CBT) using treatment manuals. Participants were 29 counselors. Counselors were randomly assigned to receive CBT training or to a control group. Counselor attitudes were assessed pre- and posttraining. In addition, CBT therapy sessions were videotaped and rated for adherence and skillfulness. CBT counselors reported high levels of satisfaction with the training, intention to use CBT interventions, and confidence in their ability to do so. Ratings indicated that 90% of counselors were judged as having attained at least adequate levels of CBT skillfulness. Findings demonstrate the feasibility of using psychotherapy technology tools as a means of disseminating science-based treatments to the substance abuse practice community.
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Affiliation(s)
- J Morgenstern
- Mount Sinai School of Medicine, Department of Psychiatry, Box 1230, One Gustave L. Levy Place, New York, New York 10029, USA.
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Marley SE, Illyes EF, Keller DS, Meinert TR, Logan NB, Hendrickx MO, Conder GA. Efficacy of topically administered doramectin against eyeworms, lungworms, and gastrointestinal nematodes of cattle. Am J Vet Res 1999; 60:665-8. [PMID: 10376888] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/12/2023]
Abstract
OBJECTIVE To evaluate efficacy of topically administered doramectin against eyeworms, lungworms, and gastrointestinal nematodes of cattle. ANIMALS 400 cattle (20 cattle in each of 20 trials). PROCEDURE Trials were conducted in North America; natural and experimentally induced infections were used. In each trial, cattle were allocated randomly to control (placebo [saline [0.9% NaCl] solution at 1 ml/10 kg of body weight] or untreated; n = 10) or doramectin-treated (500 microg/kg of body weight; 10) groups. Treatments were applied in a single passage along the midline of the back, from the withers to the tailhead. Cattle were euthanatized > or =14 days after treatment, and worm burdens were determined by use of standard techniques. RESULTS Efficacy of doramectin was > or =95.3% against adults of Thelazia gulosa, T skrjabini, Dictyocaulus viviparus, Haemonchus contortus, H placei, Ostertagia lyrata, O ostertagi, Trichostrongylus axei, Bunostomum phlebotomum, Capillaria spp, Cooperia oncophora, C pectinata, C punctata, C spatulata, C surnabada, Nematodirus spathiger, Strongyloides papillosus, T colubriformis, Oesophagostomum radiatum, and Trichuris spp. Efficacy was 95.1% against fourth-stage larvae of D viviparus, H placei, O lyrata, O ostertagi, T axei, C oncophora, C punctata, C spatulata, C surnabada, N helvetianus, T colubriformis, O radiatum, and Trichuris spp. In addition, efficacy against inhibited fourth-stage larvae of O ostertagi and Ostertagia spp was > or =98.1%. CONCLUSIONS AND CLINICAL RELEVANCE A single topical application of doramectin pour-on was efficacious against a broad range of nematode species in cattle.
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Affiliation(s)
- S E Marley
- Pfizer Central Research, Groton, CT 06340, USA
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Stromberg BE, Woodward BW, Courtney CH, Kunkle WE, Johnson EG, Zimmerman GL, Zimmerman LA, Marley SE, Keller DS, Conder GA. Persistent efficacy of doramectin injectable against artificially induced infections with Cooperia punctata and Dictyocaulus viviparus in cattle. Vet Parasitol 1999; 83:49-54. [PMID: 10392767 DOI: 10.1016/s0304-4017(99)00034-5] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
Three studies were conducted to evaluate the persistent efficacy of doramectin injectable solution against experimental challenges with infective larvae of Cooperia punctata and Dictyocaulus viviparus. In each study, four groups of ten randomly-assigned calves, negative for trichostrongyle-type eggs on fecal examination, were treated subcutaneously in the midline of the neck with saline (1 ml/50 kg) on Day 0 or doramectin (200 microg/kg = 1 ml/50 kg) on Day 0, 7, or 14. Two additional calves from the same pool of animals were randomly assigned as larval-viability monitors and received no treatment. On Days 14-28, approximately 1000 and 50 infective larvae of Cooperia spp. and D. viviparus, respectively, were administered daily by gavage to each animal in Groups T1-T4. On Day 28, the two larval-viability monitor calves were inoculated in a similar manner with a single dose of approximately 30000 and 2000 larvae of Cooperia spp. and D. viviparus, respectively. Equal numbers of calves from each treatment group were killed on Days 42-45, as well as the two viability monitor animals to enumerate worm numbers. A 2% or 5% aliquot of small intestinal contents and washings were examined for worm quantification and identification, while 100% of the lung recoveries were quantified and identified. For each study and across the three studies, geometric mean worm recoveries for each treatment group were calculated from the natural log transformed data (worm count + 1) and were used to estimate percentage reduction. In the three studies, doramectin injectable solution was 97.5% efficacious against lungworms for up to 28 days and was 99.8% efficacious in reducing infection resulting from challenge with infective larvae of C. punctata for at least 28 days post-treatment.
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Affiliation(s)
- B E Stromberg
- Department of Veterinary Pathobiology, College of Veterinary Medicine, University of Minnesota, St. Paul 55108, USA.
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Rooney KA, Illyes EF, Sunderland SJ, Sarasola P, Hendrickx MO, Keller DS, Meinert TR, Logan NB, Weatherley AJ, Conder GA. Efficacy of a pour-on formulation of doramectin against lice, mites, and grubs of cattle. Am J Vet Res 1999; 60:402-4. [PMID: 10211679] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/12/2023]
Abstract
OBJECTIVE To determine effectiveness of a pour-on formulation of doramectin against Damalinia bovis, Haematopinus eurysternus, Linognathus vituli, Solenopotes capillatus, Chorioptes bovis, Sarcoptes scabiei, Hypoderma bovis, and Hypoderma lineatum. ANIMALS Cattle of various ages with naturally acquired or artificial infestations with 1 or more species of lice, mites, or grubs. PROCEDURE In 10 louse and 6 mite studies, cattle were treated with doramectin (500 microg/kg, topically) on day 0, and parasite counts were performed approximately weekly from days 0 to 35. In 6 grub studies, cattle expected to harbor Hypoderma spp were treated before emergence of warbles. After warbles began to emerge, they were counted every 2 weeks, and grubs were collected and identified by species. RESULTS Burdens of D bovis, H eurystemus, L vituli, and S capillatus on doramectin-treated cattle were 0 by 28 days after treatment. Burdens of C bovis and S scabiei decreased to 0 in naturally infested cattle and approximately 0 in artificially infested cattle by day 14 to 15. In grub studies, 107 of 136 control cattle had warbles, whereas 2 of 136 doramectin-treated cattle had 1 warble each, which represented a cure rate of 98.5%. CONCLUSION AND CLINICAL RELEVANCE One topical application of doramectin was highly efficacious against common species of lice, mites, and grubs known to affect performance, health, and appearance of cattle.
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Affiliation(s)
- K A Rooney
- Pfizer Central Research, Groton, CT 06340, USA
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