Improving outcomes and cost-effectiveness of colorectal surgery

Endoscopic intermuscular dissection for locally advanced rectal cancer: A case report

BACKGROUND

Endoscopic submucosal dissection is considered curative for patients with early rectal cancer when level of submucosal invasion is < 1000 microns with favourable histopathological features. Recent data suggests even deeper submucosal invasion can potentially be curative if R0 resection can be achieved and when no high-risk histopathological features are seen in the resected specimen. To achieve R0 resection, deeper dissection is required.

CASE SUMMARY

A 66 year old New Zealand European male presented with 3 mo history of per rectal bleeding. He was referred for a colonoscopy test to investigate this further. This revealed a malignant appearing lesion in the rectum. Biopsies however showed high grade dysplasia only. Given endoscopic appearances suspicious for deep submucosal invasion, patient was consented for endoscopic intermuscular dissection (EID). The case was successfully performed, and the presence of muscularis propria was confirmed in the resected specimen. There were no complications and total procedure time was 124 min. Lesion was clear of radial margins however deep margins were positive confirming it was at least a pT2 cancer. Patient was recommended to have further treatment but could not have radical surgery due to comorbidities and instead was referred for long course chemoradiotherapy.

CONCLUSION

EID is a safe and feasible option for management of rectal cancer in highly selected patients.

Conditions associated with worse acceptance of a simplified accelerated recovery after surgery protocol in laparoscopic colorectal surgery

Background

Enhanced Recovery Surgical Programs were initially applied to colorectal procedures and used as multimodal approach to relieve the response to surgical stress. An important factor that negatively impacts the success of these programs is the poor tolerance of these patients to certain items in the adopted protocol, especially with regard to post-operative measures. The identification of these factors may help to increase the success rate of such programs, ensuring that benefits reach a greater number of patients and that resources are better allocated. Thus, the aims of this study were to assess the results of the implementation of a Simplified Accelerated Recovery Protocol (SARP) and to identify possible factors associated with failure to implement postoperative protocol measures in patients submitted to laparoscopic colorectal surgery.

Methods

161 patients were randomly divided into two groups. The SARP group (n = 84) was submitted to the accelerated recovery program and the CC group (n = 77), to conventional postoperative care. The SARP group was further divided into two subgroups: patients who tolerated the protocol (n = 51) and those who did not (n = 33), in order to analyze factors contributing to protocol nontolerance.

Results

The groups had similar sociodemographic and clinical characteristics. The SARP group had a shorter hospital stay, better elimination of flatus, was able to walk and to tolerate a diet sooner (p < 0.0001). Complications rates and readmissions to emergency room were similar between groups. Multivariate analysis revealed that prolonged operating time, stoma creation and rates of surgical complications were independently associated with poor adherence to SARP (p < 0.0001).

Conclusions

The use of our SARP resulted in improved recovery from laparoscopic colorectal surgery and proved to be safe for patients. Extensive surgeries, occurrence of complications, and the need for ostomy were variables associated with poor program adhesion.

Trial registration Trial Registry: RBR2b4fyr—Date of registration: 03 October 2017.

Development and Impact of an Institutional Enhanced Recovery Program on Opioid Use, Length of Stay, and Hospital Costs Within an Academic Medical Center: A Cohort Analysis of 7774 Patients

BACKGROUND

Enhanced Recovery (ER) is a change management framework in which a multidisciplinary team of stakeholders utilizes evidence-based medicine to protocolize all aspects of a surgical care to allow more rapid return of function. While service-specific reports of ER adoption are common, institutional-wide adoption is complex, and reports of institution-wide ER adoption are lacking in the United States. We hypothesized that ER principles were generalizable across an institution and could be implemented across a multitude of surgical disciplines with improvements in length of stay, opioid consumption, and cost of care.

METHODS

Following the establishment of a formal institutional ER program, ER was adopted in 9 distinct surgical subspecialties over 5 years at an academic medical center. We compared length of stay, opioid consumption, and total cost of care in all surgical subspecialties as a function of time using a segmented regression/interrupted time series statistical model.

RESULTS

There were 7774 patients among 9 distinct surgical populations including 2155 patients in the pre-ER cohort and 5619 patients in the post-ER cohort. The introduction of an ER protocol was associated with several significant changes: a reduction in length of stay in 5 of 9 specialties; reduction in opioid consumption in 8 specialties; no change or reduction in maximum patient-reported pain scores; and reduction or no change in hospital costs in all specialties. The ER program was associated with an aggregate increase in profit over the study period.

CONCLUSIONS

Institution-wide efforts to adopt ER can generate significant improvements in patient care, opioid consumption, hospital capacity, and profitability within a large academic medical center.

Preoperative C-reactive protein-to-albumin ratio predicts anastomotic leak in elderly patients after curative colorectal surgery

BACKGROUND

Anastomotic leak (AL), as one of the most devastating complications, is the leading cause of mortality in colorectal cancer (CRC) patients after resection. This study was aimed to investigate potential risk factors for AL in elderly surgical CRC patients.

METHODS

A total of 1068 elderly subjects who underwent elective curative colorectal surgery from 2012 to 2018 were retrospectively evaluated and enrolled into this study population. The predictive value of C-reactive protein-to-albumin ratio (CAR) for AL in surgical CRC patients was evaluated by receiver operating characteristic (ROC) curve analysis. Potential risk factors for AL were assessed by the univariate and multivariate logistic regression analyses.

RESULTS

Of all the 1068 enrolled patients, 81 patients have developed AL with an incidence of 7.6% (81/1068). Preoperative CAR was an effective predictor for AL with an area under the curve (AUC) of 0.758, 95% CI of 0.700-0.817, a cut-off value of 2.44, a sensitivity of 61.09% and a specificity of 80.25%, respectively (P< 0.001). Duration of operation (OR: 2.05, 95% CI: 1.21-3.44, P= 0.013) and preoperative CAR (OR: 1.94, 95% CI: 1.21-3.11, P= 0.007) were two independent risk factors for AL by the multivariate logistic regression analysis.

CONCLUSIONS

Our study indicate that preoperative CAR level and duration of operation were two independent predictors for AL among elderly surgical CRC patients.

Feasibility of ambulatory surgery for anal fistula with LIFT procedure

Background

Ambulatory surgery maintains the advantages of a more rapid return to work and overall reduced hospital costs. The specific impact of ambulatory surgery for anal fistula using the LIFT procedure (ligation of the intersphincteric fistula tract) is presented.

Methods

A total of 218 consecutive patients with anal fistula who underwent ambulatory LIFT surgery were retrospectively compared with 386 cases managed as in-patients. Patient demographics, comorbidities, postoperative morbidity and pain as well as readmission rates within 30 days and satisfaction ratings were compared between the two groups.

Results

When compared with patients undergoing in-patient surgery, those in the ambulatory group were younger with a better level of education (P < 0.05). Ambulatory cases returned to work after shorter postoperative periods (P < 0.01) but experienced more frequent postoperative external hemorrhoidal thrombosis and more reported postoperative pain (P < 0.05). There were no differences in the overall rate of complications or readmissions between the two groups. Ambulatory patients reported higher satisfaction ratings than in-patients (P < 0.05).

Conclusions

The LIFT procedure for anal fistula can be safely performed in the ambulatory setting resulting in an acceptable level of satisfaction and a more rapid return to work when compared with in-patient fistula management.

Hospital cost associated with anemia in elective colorectal surgery: a historical cohort study

PURPOSE

Anemia is highly prevalent in the colorectal surgery population, affecting 30-70% of patients. Anemia is associated with significant morbidity and mortality; however, there is a lack of evidence on how much anemia impacts healthcare costs. This study aims to determine the hospital cost of index surgical admission, postoperative length of stay, and transfusion rate associated with preoperative anemia in elective major colorectal surgery.

METHODS

This historical cohort study included 851 adult inpatients having elective colorectal surgery at a tertiary care academic health sciences network between April 2010 and February 2016. Anemia was defined as hematocrit ≤ 39%. The primary outcome was total hospital costs standardized to 2016 CAD. Secondary outcomes were postoperative length of stay and transfusion. Multivariable regression analyses and propensity score methods were used to measure adjusted associations between anemia and outcomes.

RESULTS

Before surgery, 381/851 (45%) patients were anemic. The mean (standard deviation [SD]) cost of index admission for an elective colorectal surgery was 20,040 (23,219) CAD. Anemia was associated with an adjusted 14% relative increase in costs (95% confidence interval [CI], 6 to 23; P < 0.001). The total hospitalization cost attributable to anemia was 3,027 CAD (95% CI, 2,670 to 3,388). Hospital costs and length of stay were highly associated; anemia was associated with an 18% increase in length of stay (95% CI, 7 to 30; P < 0.001) and increased transfusion rates (risk ratio, 4.7; 95% CI, 2.71 to 8.33; P < 0.001).

CONCLUSION

Over 2,600 CAD per index surgical admission is attributable to preoperative anemia. Preoperative interventions with per patient cost of less than 2,600 CAD could be cost effective at the hospital level.

TRIAL REGISTRATION

www.clinicaltrials.gov (NCT03476707); registered 26 March, 2018.

Evaluating the direct economic burden of health care-associated infections among patients with colorectal cancer surgery in China

BACKGROUND

Little is known about the direct economic burden associated with health care-associated infection (HAI) in patients undergoing colorectal cancer surgery in China. This study aims to fill this knowledge gap.

METHODS

This study was a prospective monitoring case-control study. The direct economic burden was presented as the median of the 1:1 pair differences of various hospitalization fees and hospital length of stay. Wilcoxon signed-rank tests were used to explore the differences in the direct economic burden.

RESULTS

Out of 448 patients, 38 had acquired HAIs, with the infection incidence being 8.93%. The total direct economic burden of HAIs was $1,589.30 (P <.05). Among various infection sites, deep surgical site infection had the highest direct economic burden of $8,654.44, followed by multisite infections ($5,946.52). When it comes to various hospitalization costs, the cost for Western medicine ($846.13) constituted the highest proportion of economic burden followed by treatment cost ($145.73) and bed charge ($126.75). On average, the length of hospital stay in the infection group was 6 days longer than that in the control group (P <.05).

CONCLUSIONS

HAI was associated with considerable economic burden for patients who underwent colorectal cancer surgery in China. The study highlights the necessity of taking effective measures to decrease incidence of HAIs to reduce economic burden.

Effects of parecoxib on postoperative pain and opioid-related symptoms following gynecologic surgery

Objective

To examine the analgesic and opioid-sparing effects of parecoxib following major gynecologic surgery.

Methods

This is a large subset analysis of patients from a multicenter, randomized, double-blind, placebo-controlled study of parecoxib/valdecoxib (PAR/VAL) for postoperative pain. Pain severity, pain interference with function, opioid use, occurrence of opioid-related symptoms, and Patient/Physician Global Evaluation of Study Medication were compared between placebo and PAR/VAL treatment groups in the days following surgery.

Results

Pain scores were reduced in the PAR/VAL group (n=98), relative to placebo (n=97), on Day 2 (−21%, P<0.001) and Day 3 (−23%, P=0.004). Pain interference with function scores were also significantly lower in the PAR/VAL group, compared with placebo, on Day 2 (−29%, P<0.001) and Day 3 (−28%, P=0.013). Consumption of supplemental morphine was significantly lower in the PAR/VAL group relative to placebo at 24 hours (−37%, P=0.010) and trended lower at 48 (−28%) and 72 hours (−26%). Patients in the PAR/VAL group also had a reduced risk of experiencing specific opioid-related symptoms, including “inability to concentrate” (relative risk =0.53) and “nausea” (relative risk =0.60) on Day 2. Both Patient and Physician Global Evaluation of Study Medication scores were better in the PAR/VAL group than in the placebo group.

Conclusion

The current study adds support for the use of parecoxib in patients following major gynecologic surgery.

Do hospital factors impact readmissions and mortality after colorectal resections at minority-serving hospitals?

BACKGROUND

Minority-serving hospitals have greater readmission rates after operative procedures including colectomy; however, little is known about the contribution of hospital factors to readmission risk and mortality in this setting. This study evaluated the impact of hospital factors on readmissions and inpatient mortality after colorectal resections at minority-serving hospitals in the context of patient- and procedure-related factors.

METHODS

More than 168,000 patients who underwent colorectal resections in 374 California hospitals (2004-2011) were analyzed using the State Inpatient Database and American Hospital Association Hospital Survey data. Sequential logistic regression analyses were performed to determine the associations between minority-serving hospital status and 30-day, 90-day, and repeated readmissions.

RESULTS

Thirty-day, 90-day, and repeated readmission rates were 11.2%, 16.9%, and 2.9%, respectively. Odds for 30-day, 90-day, and repeated readmissions after colorectal resections were 19%, 20%, and 38% more likely at minority-serving hospitals versus non-minority-serving hospitals, respectively (P < .01), after controlling for age, sex, comorbidities, year, and procedure type. Patient factors accounted for up to 65% of the observed increase in odds for readmission at minority-serving hospitals while hospital-level factors contributed roughly 40%. Inpatient mortality was significantly greater at minority-serving hospitals versus non-minority-serving hospitals (4.9% vs 3.8%; P < .001). Risk factors significantly associated with readmissions and inpatient mortality included Medicaid/Medicare primary insurance, emergent operation, and ostomy creation. Low procedure volume was significantly associated with increased odds for inpatient mortality.

CONCLUSION

Patient-level factors seemed to dominate the increased readmission risk after colorectal resections at minority-serving hospitals while hospital factors were less contributory. These findings need to be further validated to shape quality improvement interventions to decrease readmissions.

Understanding the Value of Both Laparoscopic and Robotic Approaches Compared to the Open Approach in Colorectal Surgery

INTRO

Although the use of laparoscopy has significantly increased in colorectal procedures, robotic surgery may enable additional cases to be performed using a minimally invasive approach. We separately evaluated the value of laparoscopic and robotic colorectal procedures compared to the open approach.

METHODS

Patients undergoing nonemergent colorectal operations from 2010 to 2013 with National Surgical Quality Improvement Project data were identified. Robotic and laparoscopic procedures were separately matched (1:1) to open cases. Outcomes included 30-day composite morbidity, length of stay, operative time, and inpatient costs. Frequently used intraoperative disposable items were categorized, and significant cost contributors were identified by surgical approach. Statistical differences were determined with Chi-square and Wilcoxon signed-rank tests.

RESULTS

Both laparoscopic (n = 67) and robotic (n = 45) approaches were associated with decreased composite morbidity compared to matched open cases (lap vs. open: 22.4% vs. 49.2%, P < .01; robotic vs. open: 6.7% vs. 33.3%, P < .01). Median length of stay was significantly shorter for both laparoscopic and robotic compared to open surgery (lap vs. open: 5 vs. 7 days, P < .01; robotic vs. open: 5 vs. 7 days, P < .01). Median hospital costs were similar between laparoscopic and open surgery ($13,319 vs. $14,039; P = .80) and robotic and open surgery ($13,778 vs. $13,629; P = .48).

CONCLUSION

These findings illustrate the value for both laparoscopic and robotic approaches to colorectal surgery compared to the open approach in terms of short-term outcomes and inpatient costs. Advanced intraoperative disposable items such as cutting staplers and energy devices are important targets for additional cost containment.

Markers of Perioperative Bowel Complications in Colorectal Surgery Patients

Colorectal cancer is a clinical condition whose treatment often involves intestinal resection. Such treatment frequently results in two major gastrointestinal complications after surgery: anastomotic leakage and prolonged ileus. Anastomotic leakage is a serious complication which, more often than not, is diagnosed late; to date, C-reactive protein is the only available diagnostic marker. A monocentric, prospective, open case-control study was performed in patients (n = 117) undergoing colorectal surgery. Intestinal fatty acid binding protein (i-FABP), citrulline, D-lactate, exhaled hydrogen, Escherichia coli genomic DNA, and ischemia modified albumin (IMA) were determined preoperatively, postoperatively, and on the following four consecutive days. Bacterial DNA was not detected in any sample, and i-FABP and D-lactate lacked any distinct potential to detect postoperative bowel complications. Exhaled breath hydrogen content showed unacceptably low sensitivity. However, citrulline turned out to be a specific marker for prolonged ileus on postoperative days 3-4. Using a cut-off value of 20 μmol/L, a sensitivity and specificity of ~75% was achieved on postoperative day 4. IMA was found to be an efficient predictor of anastomosis leak by calculating the difference between preoperative and postoperative values. This test had 100% sensitivity and 80% specificity and 100% negative and 20% positive predictive value.