1
|
Muñoz JM, Levin PJ, Saur NM, Cox CK. Multidisciplinary Approach to Evaluation of Rectovaginal Fistulas. Am J Obstet Gynecol 2024:S0002-9378(24)00555-6. [PMID: 38703939 DOI: 10.1016/j.ajog.2024.04.029] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2023] [Revised: 04/25/2024] [Accepted: 04/25/2024] [Indexed: 05/06/2024]
Abstract
Thorough evaluation of a rectovaginal fistula (RVF) is essential to optimize surgical repair. The underlying cause should be addressed and treated, which can affect the timing as well as approach to repair. It is imperative to be well-prepared as the highest chance of successful closure occurs during the initial repair attempt. Our objective is to demonstrate how multidisciplinary colorectal surgery and urogynecology teams use specific methods during exam under anesthesia to evaluate a complex RVF and optimize surgical approach to repair. Anesthesia may be provided with monitored anesthesia care and posterior perineal block. This pain control allows for a wide range of techniques to evaluate the fistula, using anoscopy, fistula probe, hydrogen peroxide, and sigmoidoscopy. Additionally, the teams show how curettage and subsequent seton placement can encourage closure by secondary intention and decrease the risk of abscess formation, respectively.
Collapse
Affiliation(s)
- Jaclyn M Muñoz
- Division of Urogynecology and Pelvic Reconstructive Surgery, Department of Obstetrics and Gynecology, University of Pennsylvania, Philadelphia PA, USA.
| | - Pamela J Levin
- Division of Urogynecology and Pelvic Reconstructive Surgery, Department of Obstetrics and Gynecology, University of Pennsylvania, Philadelphia PA, USA
| | - Nicole M Saur
- Division of Urogynecology and Pelvic Reconstructive Surgery, Department of Obstetrics and Gynecology, University of Pennsylvania, Philadelphia PA, USA
| | - Caroline K Cox
- Division of Urogynecology and Pelvic Reconstructive Surgery, Department of Obstetrics and Gynecology, University of Wisconsin, Madison, WI, USA
| |
Collapse
|
2
|
Montroni I, Ugolini G, Saur NM, Rostoft S, Spinelli A, Van Leeuwen BL, De Liguori Carino N, Ghignone F, Jaklitsch MT, Kenig J, Garutti A, Zingaretti C, Foca F, Vertogen B, Nanni O, Wexner SD, Audisio RA. Predicting Functional Recovery and Quality of Life in Older Patients Undergoing Colorectal Cancer Surgery: Real-World Data From the International GOSAFE Study. J Clin Oncol 2023; 41:5247-5262. [PMID: 37390383 DOI: 10.1200/jco.22.02195] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2022] [Revised: 03/10/2023] [Accepted: 05/09/2023] [Indexed: 07/02/2023] Open
Abstract
PURPOSE The GOSAFE study evaluates risk factors for failing to achieve good quality of life (QoL) and functional recovery (FR) in older patients undergoing surgery for colon and rectal cancer. METHODS Patients age 70 years and older undergoing major elective colorectal surgery were prospectively enrolled. Frailty assessment was performed and outcomes, including QoL (EQ-5D-3L) recorded (3/6 months postoperatively). Postoperative FR was defined as a combination of Activity of Daily Living ≥5 + Timed Up & Go test <20 seconds + MiniCog >2. RESULTS Prospective complete data were available for 625/646 consecutive patients (96.9%; 435 colon and 190 rectal cancer), 52.6% men, and median age was 79.0 years (IQR, 74.6-82.9 years). Surgery was minimally invasive in 73% of patients (321/435 colon; 135/190 rectum). At 3-6 months, 68.9%-70.3% patients experienced equal/better QoL (72.8%-72.9% colon, 60.1%-63.9% rectal cancer). At logistic regression analysis, preoperative Flemish Triage Risk Screening Tool ≥2 (3-month odds ratio [OR], 1.68; 95% CI, 1.04 to 2.73; P = .034, 6-month OR, 1.71; 95% CI, 1.06 to 2.75; P = .027) and postoperative complications (3-month OR, 2.03; 95% CI, 1.20 to 3.42; P = .008, 6-month OR, 2.56; 95% CI, 1.15 to 5.68; P = .02) are associated with decreased QoL after colectomy. Eastern Collaborative Oncology Group performance status (ECOG PS) ≥2 is a strong predictor of postoperative QoL decline in the rectal cancer subgroup (OR, 3.81; 95% CI, 1.45 to 9.92; P = .006). FR was reported by 254/323 (78.6%) patients with colon and 94/133 (70.6%) with rectal cancer. Charlson Age Comorbidity Index ≥7 (OR, 2.59; 95% CI, 1.26 to 5.32; P = .009), ECOG ≥2 (OR, 3.12; 95% CI, 1.36 to 7.20; P = .007 colon; OR, 4.61; 95% CI, 1.45 to 14.63; P = .009 rectal surgery), severe complications (OR, 17.33; 95% CI, 7.30 to 40.8; P < .001), fTRST ≥2 (OR, 2.71; 95% CI, 1.40 to 5.25; P = .003), and palliative surgery (OR, 4.11; 95% CI, 1.29 to 13.07; P = .017) are risk factors for not achieving FR. CONCLUSION The majority of older patients experience good QoL and stay independent after colorectal cancer surgery. Predictors for failing to achieve these essential outcomes are now defined to guide patients' and families' preoperative counseling.
Collapse
Affiliation(s)
- Isacco Montroni
- U.O. Department of Surgery, Colorectal Surgery Unit Ospedale S. Maria delle Croci, Ravenna, AUSL Romagna, Italy
| | - Giampaolo Ugolini
- U.O. Department of Surgery, Colorectal Surgery Unit Ospedale S. Maria delle Croci, Ravenna, AUSL Romagna, Italy
| | - Nicole M Saur
- University of Pennsylvania, Perelman School of Medicine, Department of Surgery, Division of Colon and Rectal Surgery, Philadelphia, PA
| | - Siri Rostoft
- Oslo University Hospital and University of Oslo, Oslo, Norway
| | - Antonino Spinelli
- Division of Colon and Rectal Surgery, Humanitas Clinical and Research Center, Rozzano (MI), Italy
| | - Barbara L Van Leeuwen
- Department of Surgical Oncology, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands
| | | | - Federico Ghignone
- U.O. Department of Surgery, Colorectal Surgery Unit Ospedale S. Maria delle Croci, Ravenna, AUSL Romagna, Italy
| | - Michael T Jaklitsch
- Division of Surgery, Division of Aging, Brigham and Women's Hospital, Boston, MA
| | - Jakub Kenig
- Department of General, Oncologic and Geriatric Surgery Jagiellonian University Medical College, Krakov, Poland
| | - Anna Garutti
- U.O. Department of Surgery, Colorectal Surgery Unit Ospedale S. Maria delle Croci, Ravenna, AUSL Romagna, Italy
| | - Chiara Zingaretti
- IRCCS Istituto Romagnolo per lo Studio dei Tumori (IRST) "Dino Amadori," Meldola, Italy
| | - Flavia Foca
- IRCCS Istituto Romagnolo per lo Studio dei Tumori (IRST) "Dino Amadori," Meldola, Italy
| | - Bernadette Vertogen
- IRCCS Istituto Romagnolo per lo Studio dei Tumori (IRST) "Dino Amadori," Meldola, Italy
| | - Oriana Nanni
- IRCCS Istituto Romagnolo per lo Studio dei Tumori (IRST) "Dino Amadori," Meldola, Italy
| | - Steven D Wexner
- Cleveland Clinic Florida, Department of Colorectal Surgery, Weston, FL
| | - Riccardo A Audisio
- Department of Surgery, Institute of Clinical Sciences, Sahlgrenska University Hospital, Göteborg, Sweden
| |
Collapse
|
3
|
Nugent ST, Raj LK, Aarons CB, Saur NM, Kovach SJ, Fischer JP, Etzkorn JR, Shin TM, Giordano CN, Higgins HW, Walker JL, Miller CJ. Perianal and anal skin cancers treated with Mohs micrographic surgery and interdisciplinary care: Local recurrence rates and patient-reported outcomes. J Am Acad Dermatol 2023; 89:1283-1285. [PMID: 37579842 DOI: 10.1016/j.jaad.2023.07.1034] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2022] [Revised: 07/23/2023] [Accepted: 07/25/2023] [Indexed: 08/16/2023]
Affiliation(s)
- Shannon T Nugent
- Department of Internal Medicine, Pennsylvania Hospital, Philadelphia, PA
| | - Leela K Raj
- Department of Dermatology, Hospital of the University of Pennsylvania, Philadelphia, PA
| | - Cary B Aarons
- Division of Colon and Rectal Surgery, Department of Surgery, Hospital of the University of Pennsylvania, Philadelphia, PA
| | - Nicole M Saur
- Division of Colon and Rectal Surgery, Department of Surgery, Hospital of the University of Pennsylvania, Philadelphia, PA
| | - Stephen J Kovach
- Division of Plastic Surgery, Hospital of the University of Pennsylvania, Philadelphia, PA
| | - John P Fischer
- Division of Plastic Surgery, Hospital of the University of Pennsylvania, Philadelphia, PA
| | - Jeremy R Etzkorn
- Department of Dermatology, Hospital of the University of Pennsylvania, Philadelphia, PA
| | - Thuzar M Shin
- Department of Dermatology, Hospital of the University of Pennsylvania, Philadelphia, PA
| | - Cerrene N Giordano
- Department of Dermatology, Hospital of the University of Pennsylvania, Philadelphia, PA
| | - H William Higgins
- Department of Dermatology, Hospital of the University of Pennsylvania, Philadelphia, PA
| | - Joanna L Walker
- Department of Dermatology, Hospital of the University of Pennsylvania, Philadelphia, PA
| | - Christopher J Miller
- Department of Dermatology, Hospital of the University of Pennsylvania, Philadelphia, PA.
| |
Collapse
|
4
|
Kim A, Roberson JL, Maguire LH, Jian B, Saur NM. Eosinophilic Myenteric Ganglionitis Presenting as Sigmoid Volvulus: A Brief Report. Am Surg 2023; 89:5021-5023. [PMID: 37501639 DOI: 10.1177/00031348231191198] [Citation(s) in RCA: 0] [Impact Index Per Article: 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] [Indexed: 07/29/2023]
Abstract
Eosinophilic myenteric ganglionitis (EMG) is a rare pathologic finding within the Auerbach myenteric plexus characterized by eosinophilic infiltration on light microscopy. The plexus's ultimate obliteration results in chronic intestinal pseudo-obstruction (CIPO). EMG is almost exclusively seen in the pediatric population. The diagnosis of EMG is made through full-thickness rectal biopsy and EMG is not detectable through routine screening measures such as imaging or colonoscopy. The current treatment modality for this disorder is not standardized, and has often been treated with systemic steroids given its eosinophilic involvement. This case presents a 73-year-old male with chronic constipation presenting with new obstipation in the setting of recent orthopedic intervention requiring outpatient opioids. Admission radiographs were consistent with sigmoid volvulus. Following endoscopic detorsion, exploratory laparotomy revealed diffuse colonic dilation and distal ischemia requiring a Hartmann's procedure. Surgical pathology revealed EMG, increasing the complexity of subsequent surgical decision-making after his urgent operation.
Collapse
Affiliation(s)
- Alyson Kim
- Drexel University College of Medicine, Philadelphia, PA, USA
| | - Jeffrey L Roberson
- Department of Surgery, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | - Lillias H Maguire
- Division of Colon and Rectal Surgery, Department of Surgery, Hospital of the University of Pennsylvania, Philadelphia, PA, USA
- Corporal Michael J. Crescenz Memorial Veterans Affairs Medical Center, Philadelphia, PA, USA
| | - Bo Jian
- Department of Pathology and Laboratory Medicine, Hospital of the University of Pennsylvania, Philadelphia, PA, USA
| | - Nicole M Saur
- Division of Colon and Rectal Surgery, Department of Surgery, Hospital of the University of Pennsylvania, Philadelphia, PA, USA
| |
Collapse
|
5
|
Tong JKC, Mascuilli T, Wirtalla C, Aarons CB, Saur NM, Mahmoud NN, Karakousis GC, Kelz RR. Evaluating Changes in Surgical Outcomes for Patients With Inflammatory Bowel Disease Following Medicaid Expansion. Inflamm Bowel Dis 2023; 29:1579-1585. [PMID: 36573827 DOI: 10.1093/ibd/izac255] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/02/2022] [Indexed: 10/05/2023]
Abstract
BACKGROUND Little is known about the impact of Medicaid expansion on the surgical care of inflammatory bowel disease. We sought to determine whether Medicaid expansion is associated with improved postsurgical outcomes for patients with inflammatory bowel disease undergoing a colorectal resection. METHODS We performed a risk-adjusted difference-in-difference study examining postsurgical outcomes for patients ages 26 to 64 with Crohn's disease or ulcerative colitis undergoing a colorectal resection across 15 states that did and did not expand Medicaid before (2012-2013) and after (2016-2018) policy reform. Primary study outcomes included 30-day readmission and postoperative complication. RESULTS Study population included 11 394 patients with inflammatory bowel disease that underwent a colorectal resection. States that underwent Medicaid expansion were associated with a rise in Medicaid enrollment following policy reform (11.8% pre-Medicaid expansion vs 19.7% post-Medicaid expansion). Difference-in-difference analysis revealed a statistically significant lower odds of 30-day readmission in patients undergoing a colorectal resection in expansion states following policy reform relative to patients in nonexpansion states prior to reform (odds ratio, 0.56; 95% confidence interval, 0.36-0.86). No changes in odds of postoperative complication were noted across expansion and nonexpansion states. CONCLUSIONS Medicaid expansion is associated with a rise in Medicaid enrollment in expansion states following policy reform. There were greater improvements in postoperative outcomes associated with patients in expansion states following policy reform relative to patients in nonexpansion states prior to reform, which may have been related to improved perioperative care and medical management.
Collapse
Affiliation(s)
- Jason K C Tong
- University of Pennsylvania, Department of Surgery, Center for Surgery and Health Economics, Philadelphia, PA, USA
- National Clinicians Scholars Veterans Affairs Scholar, Philadelphia, PA, USA
| | - Tory Mascuilli
- University of Pennsylvania, Department of Surgery, Center for Surgery and Health Economics, Philadelphia, PA, USA
| | - Christopher Wirtalla
- University of Pennsylvania, Department of Surgery, Center for Surgery and Health Economics, Philadelphia, PA, USA
| | - Cary B Aarons
- University of Pennsylvania, Perelman School of Medicine, Philadelphia, PA, USA
- University of Pennsylvania, Department of Surgery, Division of Colon and Rectal Surgery, Philadelphia, PA, USA
| | - Nicole M Saur
- University of Pennsylvania, Perelman School of Medicine, Philadelphia, PA, USA
- University of Pennsylvania, Department of Surgery, Division of Colon and Rectal Surgery, Philadelphia, PA, USA
| | - Najjia N Mahmoud
- University of Pennsylvania, Perelman School of Medicine, Philadelphia, PA, USA
- University of Pennsylvania, Department of Surgery, Division of Colon and Rectal Surgery, Philadelphia, PA, USA
| | - Giorgos C Karakousis
- University of Pennsylvania, Department of Surgery, Center for Surgery and Health Economics, Philadelphia, PA, USA
- University of Pennsylvania, Perelman School of Medicine, Philadelphia, PA, USA
| | - Rachel R Kelz
- University of Pennsylvania, Department of Surgery, Center for Surgery and Health Economics, Philadelphia, PA, USA
- University of Pennsylvania, Perelman School of Medicine, Philadelphia, PA, USA
| |
Collapse
|
6
|
Sharon CE, Strohl C, Saur NM. Frailty Assessment and Prehabilitation as Part of a PeRioperative Evaluation and Planning (PREP) Program for Patients Undergoing Colorectal Surgery. Clin Colon Rectal Surg 2023; 36:184-191. [PMID: 37113278 PMCID: PMC10125297 DOI: 10.1055/s-0043-1761151] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/29/2023]
Abstract
Frailty assessment and prehabilitation can be incrementally implemented in a multidisciplinary, multiphase pathway to improve patient care. To start, modifications can be made to a surgeon's practice with existing resources while adapting standard pathways for frail patients. Frailty screening can identify patients in need of additional assessment and optimization. Personalized utilization of frailty data for optimization through prehabilitation can improve postoperative outcomes and identify patients who would benefit from adapted care. Additional utilization of the multidisciplinary team can lead to improved outcomes and a strong business case to add additional members of the team.
Collapse
Affiliation(s)
- Cimarron E. Sharon
- Department of Surgery, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Catherine Strohl
- Department of Geriatrics, University of Pennsylvania, Philadelphia, Pennsylvania
- Geriatric Surgery Program, Pennsylvania Hospital, Philadelphia, Pennsylvania
| | - Nicole M. Saur
- Department of Surgery, University of Pennsylvania, Philadelphia, Pennsylvania
- Geriatric Surgery Program, Pennsylvania Hospital, Philadelphia, Pennsylvania
- Division of Colon and Rectal Surgery, University of Pennsylvania, Philadelphia, Pennsylvania
| |
Collapse
|
7
|
Tong JKC, Mascuilli T, Wirtalla C, Aarons CB, Saur NM, Mahmoud NN, Kelz RR. Exploring ethnic differences in post-discharge patterns of surgical care for older adults admitted with diverticulitis. Colorectal Dis 2023; 25:1006-1013. [PMID: 36655392 PMCID: PMC10257996 DOI: 10.1111/codi.16484] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/15/2022] [Revised: 12/11/2022] [Accepted: 01/05/2023] [Indexed: 01/20/2023]
Abstract
AIM We aimed to evaluate ethnic differences in patterns of care following an index nonoperative admission for acute diverticulitis amongst a universally insured patient cohort. METHODS We identified nationwide Medicare beneficiaries aged 65.5 years or older hospitalized between 1 July 2015 and 1 November 2017 for nonoperative management of an index admission for diverticulitis. Patients were followed for 1 year to examine patterns of care. Primary categorical outcomes included receipt of an elective operation, emergency operation, nonoperative readmission or no further hospitalizations for diverticulitis. Multinomial regression was performed to determine the association between ethnicity and receipt of each primary outcome category whilst adjusting for potential confounders. We examined the use of percutaneous drainage during the index admission to better understand its association with subsequent care patterns. RESULTS Amongst 22 630 study patients, subsequent operative treatment was less common for Black, Hispanic, Asian and American Indian patients relative to White patients. Multinomial logistic regression noted that Black (relative risk 0.40; 95% CI 0.32-0.50) and Asian (relative risk 0.37; 95% CI 0.15-0.91) patients were associated with the lowest relative risk of undergoing an elective interval operation compared to White patients. Black patients were also associated with a 1.43 (95% CI 1.19-1.73) increased risk of requiring subsequent nonoperative readmissions for disease recurrence compared to White patients. The use of percutaneous drainage was higher amongst White patients relative to Black patients (6.9% vs. 4.0%, P value < 0.001). CONCLUSION We have identified ongoing inequities in the consumption of medical resources, with White patients being more likely to undergo elective colectomy and percutaneous drainage. Differences in care are not fully alleviated by equal access to insurance.
Collapse
Affiliation(s)
- Jason K C Tong
- Department of Surgery, Center for Surgery and Health Economics, University of Pennsylvania, Philadelphia, Pennsylvania, USA
- National Clinicians Scholars Veterans Affairs Fellow, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Tory Mascuilli
- Department of Surgery, Center for Surgery and Health Economics, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Christopher Wirtalla
- Department of Surgery, Center for Surgery and Health Economics, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Cary B Aarons
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
- Department of Surgery, Division of Colon and Rectal Surgery, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Nicole M Saur
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
- Department of Surgery, Division of Colon and Rectal Surgery, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Najjia N Mahmoud
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
- Department of Surgery, Division of Colon and Rectal Surgery, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Rachel R Kelz
- Department of Surgery, Center for Surgery and Health Economics, University of Pennsylvania, Philadelphia, Pennsylvania, USA
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| |
Collapse
|
8
|
Sharon CE, Song Y, Straker RJ, Kelly N, Shannon AB, Kelz RR, Mahmoud NN, Saur NM, Miura JT, Karakousis GC. Impact of the affordable care act's medicaid expansion on presentation stage and perioperative outcomes of colorectal cancer. J Surg Oncol 2022; 126:1471-1480. [PMID: 35984366 DOI: 10.1002/jso.27070] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [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: 05/05/2022] [Revised: 06/17/2022] [Accepted: 07/24/2022] [Indexed: 11/09/2022]
Abstract
BACKGROUND AND OBJECTIVES Medicaid expansion has improved healthcare coverage and preventive health service use. To what extent this has resulted in earlier stage colorectal cancer diagnoses and impacted perioperative outcomes is unclear. METHODS This was a retrospective difference-in-difference study using the National Cancer Database on adults (40-64) with Medicaid or no insurance, diagnosed with colorectal adenocarcinomas before (2010-2013) and after (2015-2018) expansion. The primary outcome was early-stage (American Joint Committee on Cancer Stage 0-1) diagnosis. The secondary outcomes were rate of local excision, emergency surgery, postoperative length of stay, rates of minimally invasive surgery, postoperative mortality, and overall survival (OS). RESULTS Medicaid expansion was associated with an increase in early-stage diagnoses for patients with colorectal cancers (odds ratio [OR]: 1.28, 95% confidence interval [CI]: 1.15-1.43), an increase in local excision (OR: 1.39, 95% CI: 1.13-1.69), and a decreased rate of emergent surgery (OR: 0.85, 95% CI: 0.75-0.97) and 90-day mortality (OR: 0.75, 95% CI: 0.59-0.97). Additionally, patients in expansion states postexpansion had an improved 5-year OS (hazard ratio: 0.88, 95% CI: 0.83-0.94). CONCLUSIONS Insurance coverage expansion may be particularly important for optimizing stage of diagnosis, subsequent survival, and perioperative outcomes for socioeconomically vulnerable patients.
Collapse
Affiliation(s)
- Cimarron E Sharon
- Department of Surgery, Hospital of The University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Yun Song
- Department of Surgery, Hospital of The University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Richard J Straker
- Department of Surgery, Hospital of The University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Nicholas Kelly
- Department of Surgery, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
| | - Adrienne B Shannon
- Department of Surgery, Hospital of The University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Rachel R Kelz
- Department of Surgery, Hospital of The University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Najjia N Mahmoud
- Department of Surgery, Hospital of The University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Nicole M Saur
- Department of Surgery, Hospital of The University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - John T Miura
- Department of Surgery, Hospital of The University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Giorgos C Karakousis
- Department of Surgery, Hospital of The University of Pennsylvania, Philadelphia, Pennsylvania, USA
| |
Collapse
|
9
|
Montroni I, Ugolini G, Saur NM, Rostoft S, Spinelli A, Van Leeuwen BL, De Liguori Carino N, Ghignone F, Jaklitsch MT, Somasundar P, Garutti A, Zingaretti C, Foca F, Vertogen B, Nanni O, Wexner SD, Audisio RA. Quality of Life in Older Adults After Major Cancer Surgery: The GOSAFE International Study. J Natl Cancer Inst 2022; 114:969-978. [PMID: 35394037 PMCID: PMC9275771 DOI: 10.1093/jnci/djac071] [Citation(s) in RCA: 16] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2021] [Revised: 01/11/2022] [Accepted: 03/23/2022] [Indexed: 11/28/2022] Open
Abstract
BACKGROUND Accurate quality of life (QoL) data and functional results after cancer surgery are lacking for older patients. The international, multicenter Geriatric Oncology Surgical Assessment and Functional rEcovery after Surgery (GOSAFE) Study compares QoL before and after surgery and identifies predictors of decline in QoL. METHODS GOSAFE prospectively collected data before and after major elective cancer surgery on older adults (≥70 years). Frailty assessment was performed and postoperative outcomes recorded (30, 90, and 180 days postoperatively) together with QoL data by means of the three-level version of the EuroQol five-dimensional questionnaire (EQ-5D-3L), including 2 components: an index (range = 0-1) generated by 5 domains (mobility, self-care, ability to perform the usual activities, pain or discomfort, anxiety or depression) and a visual analog scale. RESULTS Data from 26 centers were collected (February 2017-March 2019). Complete data were available for 942/1005 consecutive patients (94.0%): 492 male (52.2%), median age 78 years (range = 70-95 years), and primary tumor was colorectal in 67.8%. A total 61.2% of all surgeries were via a minimally invasive approach. The 30-, 90-, and 180-day mortality was 3.7%, 6.3%, and 9%, respectively. At 30 and 180 days, postoperative morbidity was 39.2% and 52.4%, respectively, and Clavien-Dindo III-IV complications were 13.5% and 18.7%, respectively. The mean EQ-5D-3L index was similar before vs 3 months but improved at 6 months (0.79 vs 0.82; P < .001). Domains showing improvement were pain and anxiety or depression. A Flemish Triage Risk Screening Tool score greater than or equal to 2 (odds ratio [OR] = 1.58, 95% confidence interval [CI] = 1.13 to 2.21, P = .007), palliative surgery (OR = 2.14, 95% CI = 1.01 to 4.52, P = .046), postoperative complications (OR = 1.95, 95% CI = 1.19 to 3.18, P = .007) correlated with worsening QoL. CONCLUSIONS GOSAFE shows that older adults' preoperative QoL is preserved 3 months after cancer surgery, independent of their age. Frailty screening tools, patient-reported outcomes, and goals-of-care discussions can guide decisions to pursue surgery and direct patients' expectations.
Collapse
Affiliation(s)
- Isacco Montroni
- Colorectal surgery Unit, Ospedale “per gli Infermi”, AUSL Romagna, Faenza, Italy
| | - Giampaolo Ugolini
- Colorectal surgery Unit, Ospedale “per gli Infermi”, AUSL Romagna, Faenza, Italy
| | - Nicole M Saur
- Perelman School of Medicine, Department of Surgery, Division of Colon and Rectal Surgery, University of Pennsylvania, Philadelphia, PA, USA
| | - Siri Rostoft
- Department of Geriatric Medicine, Oslo University Hospital and Institute of Clinical Medicine, University of Oslo, Oslo, Norway
| | - Antonino Spinelli
- Department of Biomedical Sciences, Humanitas University, Milan, Italy
- IRCCS Humanitas Research Hospital, Rozzano, Milan, Italy
| | - Barbara L Van Leeuwen
- Department of Surgical Oncology, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands
| | | | - Federico Ghignone
- Colorectal surgery Unit, Ospedale “per gli Infermi”, AUSL Romagna, Faenza, Italy
| | - Michael T Jaklitsch
- Division of Thoracic Surgery and Division of Aging, Brigham and Women’s Hospital, Boston, MA, USA
| | - Ponnandai Somasundar
- Department of Surgery, Roger Williams Medical Center, Boston University, Providence, RI, USA
| | - Anna Garutti
- Colorectal surgery Unit, Ospedale “per gli Infermi”, AUSL Romagna, Faenza, Italy
| | - Chiara Zingaretti
- Unit of Biostatistics and Clinical Trials, IRCCS Istituto Romagnolo per lo Studio dei Tumori (IRST) “Dino Amadori”, Meldola, Italy
| | - Flavia Foca
- Unit of Biostatistics and Clinical Trials, IRCCS Istituto Romagnolo per lo Studio dei Tumori (IRST) “Dino Amadori”, Meldola, Italy
| | - Bernadette Vertogen
- Unit of Biostatistics and Clinical Trials, IRCCS Istituto Romagnolo per lo Studio dei Tumori (IRST) “Dino Amadori”, Meldola, Italy
| | - Oriana Nanni
- Unit of Biostatistics and Clinical Trials, IRCCS Istituto Romagnolo per lo Studio dei Tumori (IRST) “Dino Amadori”, Meldola, Italy
| | - Steven D Wexner
- Department of Colorectal Surgery, Cleveland Clinic Florida, Weston, FL, USA
| | - Riccardo A Audisio
- Department of Surgery, Institute of Clinical Sciences, Sahlgrenska University Hospital, Göteborg, Sweden
| |
Collapse
|
10
|
Saur NM, Davis BR, Montroni I, Shahrokni A, Rostoft S, Russell MM, Mohile SG, Suwanabol PA, Lightner AL, Poylin V, Paquette IM, Feingold DL. The American Society of Colon and Rectal Surgeons Clinical Practice Guidelines for the Perioperative Evaluation and Management of Frailty Among Older Adults Undergoing Colorectal Surgery. Dis Colon Rectum 2022; 65:473-488. [PMID: 35001046 DOI: 10.1097/dcr.0000000000002410] [Citation(s) in RCA: 14] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Affiliation(s)
- Nicole M Saur
- Department of Surgery, Division of Colon and Rectal Surgery, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Bradley R Davis
- Department of Surgery, Carolinas Medical Center, Charlotte, North Carolina
| | - Isacco Montroni
- Department of Surgery, Ospedale per gli Infermi, Faenza, Italy
| | - Armin Shahrokni
- Department of Medicine/Geriatrics, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Siri Rostoft
- Department of Geriatric Medicine, Oslo University Hospital, Oslo, Norway
- Institute of Clinical Medicine, University of Oslo, Oslo, Norway
| | - Marcia M Russell
- Department of Surgery, David Geffen School of Medicine at University of California, Los Angeles, Los Angeles, California
- Department of Surgery, VA Greater Los Angeles Healthcare System, Los Angeles, California
| | - Supriya G Mohile
- James P. Wilmot Cancer Institute, Division of Hematology/Oncology, Department of Medicine, University of Rochester School of Medicine and Dentistry, Rochester, New York
| | - Pasithorn A Suwanabol
- Department of Surgery, University of Michigan, Ann Arbor, Michigan
- Center for Healthcare Outcomes and Policy, University of Michigan, Ann Arbor, Michigan
| | - Amy L Lightner
- Department of Colorectal Surgery, Digestive Disease and Surgery Institute, Cleveland Clinic Foundation, Cleveland, Ohio
| | - Vitaliy Poylin
- Division of Gastrointestinal and Oncologic Surgery, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Ian M Paquette
- Division of Colon and Rectal Surgery, University of Cincinnati, Cincinnati, Ohio
| | - Daniel L Feingold
- Section of Colorectal Surgery, Rutgers University, New Brunswick, New Jersey
| |
Collapse
|
11
|
Soegaard Ballester JM, Goodsell KE, Ermer JP, Karakousis GC, Miura JT, Saur NM, Mahmoud NN, Brooks A, Tchou JC, Gabriel PE, Shulman LN, Wachtel H. New Operative Reporting Standards: Where We Stand Now and Opportunities for Innovation. Ann Surg Oncol 2022; 29:1797-1804. [PMID: 34523005 DOI: 10.1245/s10434-021-10766-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2021] [Accepted: 08/15/2021] [Indexed: 11/18/2022]
Abstract
BACKGROUND The American College of Surgeons Commission on Cancer's (CoC) new operative standards for breast cancer, melanoma, and colon cancer surgeries will require that surgeons provide synoptic documentation of essential oncologic elements within operative reports. Prior to designing and implementing an electronic tool to support synoptic reporting, we evaluated current documentation practices at our institution to understand baseline concordance with these standards. METHODS Applicable procedures performed between 1 January 2018 and 31 December 2018 were included. Two independent reviewers evaluated sequential operative notes, up to a total of 100 notes, for documentation of required elements. Complete concordance (CC) was defined as explicit documentation of all required CoC elements. Mean percentage CC and surgeon-specific CC were calculated for each procedure. Interrater reliability was assessed via Cohen's kappa statistic. RESULTS For sentinel lymph node biopsy, mean CC was 66% (n = 100), with surgeon-specific CC ranging from 6 to 100%, and for axillary dissection, mean CC was 12% (n = 89) and surgeon-specific CC ranged from 0 to 47%. The single surgeon performing melanoma wide local excision had a mean CC of 98% (n = 100). For colon resections, mean CC was 69% (n = 96) and surgeon-specific CC ranged from 39 to 94%. Kappa scores were 0.77, 0.78, -0.15, and 0.78, respectively. CONCLUSIONS We identified heterogeneity in current documentation practices. In our cohort, rates of baseline concordance varied across surgeons and procedures. Currently, documentation elements are interspersed within the operative report, posing challenges to chart abstraction with resulting imperfect interrater reliability. This presents an exciting opportunity to innovate and improve compliance by introducing an electronic synoptic documentation tool.
Collapse
Affiliation(s)
| | - Kristin E Goodsell
- University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | - Jae P Ermer
- Department of Surgery, University of Pennsylvania, Philadelphia, PA, 19104, USA
| | - Giorgos C Karakousis
- Department of Surgery, University of Pennsylvania, Philadelphia, PA, 19104, USA
- University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | - John T Miura
- Department of Surgery, University of Pennsylvania, Philadelphia, PA, 19104, USA
- University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | - Nicole M Saur
- Department of Surgery, University of Pennsylvania, Philadelphia, PA, 19104, USA
- University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | - Najjia N Mahmoud
- Department of Surgery, University of Pennsylvania, Philadelphia, PA, 19104, USA
- University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | - Ari Brooks
- Department of Surgery, University of Pennsylvania, Philadelphia, PA, 19104, USA
- University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | - Julia C Tchou
- Department of Surgery, University of Pennsylvania, Philadelphia, PA, 19104, USA
- University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | - Peter E Gabriel
- University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
- Department of Radiation Oncology, University of Pennsylvania, Philadelphia, PA, USA
- Abramson Cancer Center, University of Pennsylvania, Philadelphia, PA, USA
| | - Lawrence N Shulman
- University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
- Abramson Cancer Center, University of Pennsylvania, Philadelphia, PA, USA
| | - Heather Wachtel
- Department of Surgery, University of Pennsylvania, Philadelphia, PA, 19104, USA.
- University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA.
| |
Collapse
|
12
|
Tong JKC, Mavroudis CL, Wirtalla C, Saur NM, Aarons CB, Mahmoud NN, Kelz RR. Investigating the Impact of the Affordable Care Act on Patients with Inflammatory Bowel Disease Undergoing Colorectal Surgery. J Am Coll Surg 2021. [DOI: 10.1016/j.jamcollsurg.2021.07.097] [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: 11/27/2022]
|
13
|
Soegaard Ballester JM, Goodsell KE, Ermer JP, Karakousis GC, Miura JT, Saur NM, Mahmoud NN, Brooks A, Tchou JC, Gabriel PE, Shulman LN, Wachtel H. ASO Visual Abstract: New Operative Reporting Standards: Where We Stand Now and Opportunities for Innovation. Ann Surg Oncol 2021. [PMID: 34642847 DOI: 10.1245/s10434-021-10842-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Affiliation(s)
| | - Kristin E Goodsell
- University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | - Jae P Ermer
- Department of Surgery, Hospital of the University of Pennsylvania, Philadelphia, PA, USA
| | - Giorgos C Karakousis
- Department of Surgery, Hospital of the University of Pennsylvania, Philadelphia, PA, USA.,University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | - John T Miura
- Department of Surgery, Hospital of the University of Pennsylvania, Philadelphia, PA, USA.,University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | - Nicole M Saur
- Department of Surgery, Hospital of the University of Pennsylvania, Philadelphia, PA, USA.,University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | - Najjia N Mahmoud
- Department of Surgery, Hospital of the University of Pennsylvania, Philadelphia, PA, USA.,University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | - Ari Brooks
- Department of Surgery, Hospital of the University of Pennsylvania, Philadelphia, PA, USA.,University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | - Julia C Tchou
- Department of Surgery, Hospital of the University of Pennsylvania, Philadelphia, PA, USA.,University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | - Peter E Gabriel
- University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA.,Department of Radiation Oncology, University of Pennsylvania, Philadelphia, PA, USA.,Abramson Cancer Center, University of Pennsylvania, Philadelphia, PA, USA
| | - Lawrence N Shulman
- University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA.,Abramson Cancer Center, University of Pennsylvania, Philadelphia, PA, USA
| | - Heather Wachtel
- Department of Surgery, Hospital of the University of Pennsylvania, Philadelphia, PA, USA. .,University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA.
| |
Collapse
|
14
|
Montroni I, Saur NM, Shahrokni A, Suwanabol PA, Chesney TR. Surgical Considerations for Older Adults With Cancer: A Multidimensional, Multiphase Pathway to Improve Care. J Clin Oncol 2021; 39:2090-2101. [PMID: 34043436 PMCID: PMC10476754 DOI: 10.1200/jco.21.00143] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2021] [Revised: 03/20/2021] [Accepted: 04/07/2021] [Indexed: 01/19/2023] Open
Affiliation(s)
- Isacco Montroni
- Colon and Rectal Surgery, Ospedale “per gli Infermi”, AUSL Romagna, Faenza, Italy
| | - Nicole M. Saur
- Division of Colon and Rectal Surgery, Department of Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Armin Shahrokni
- Geriatrics Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Pasithorn A. Suwanabol
- Department of Surgery, Center for Healthcare Outcomes and Policy, University of Michigan, Ann Arbor, MI
| | - Tyler R. Chesney
- Department of Surgery, St Michael's Hospital, Toronto, Ontario, Canada
- Division of General Surgery, Department of Surgery, University of Toronto, Toronto, Ontario, Canada
- Li Ka Shing Knowledge Institute, St Michael's Hospital, Toronto, Ontario, Canada
| |
Collapse
|
15
|
Brooks ES, Tong J, Mavroudis CW, Wirtalla C, Karakousis GC, Saur NM, Aarons CB, Mahmoud NN, Kelz RR. The effects of the Affordable Care Act on access and outcomes of colon surgery. Am J Surg 2021; 222:613-618. [PMID: 33487402 DOI: 10.1016/j.amjsurg.2021.01.019] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [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: 09/14/2020] [Revised: 01/03/2021] [Accepted: 01/11/2021] [Indexed: 12/12/2022]
Abstract
BACKGROUND Insurance status has been strongly associated with both access to and outcomes of colon resection (CRS). Under the Affordable Care Act (ACA), individual states opted to participate in Medicaid expansion (ME) and adopt essential health benefits (EHB). METHODS We performed a quasi-experimental difference-in-differences (DID) analysis of 2012-2017 state-level inpatient claims with risk adjustment. We examined frequency of emergent presentation and in-hospital death. Subset analyses were performed by insurance type. RESULTS Among the 73,961 CRS patients, 49.6% were in a state with both ME and EHB, 34.7% presented emergently, and 2.0% died. Adoption of ME and EHB was associated with a significant, 24%, reduction in the likelihood of in-hospital mortality, and no significant change in emergent presentation for CRS. CONCLUSIONS The ACA's ME was strongly associated with a decrease in mortality following colon resection among Medicaid beneficiaries. These findings support the adoption of healthcare policies that improve access to insurance.
Collapse
Affiliation(s)
- Ezra S Brooks
- University of Pennsylvania, Perelman School of Medicine, Philadelphia, PA, USA.
| | - Jason Tong
- University of Pennsylvania, Center for Surgery and Health Economics, Department of Surgery, Philadelphia, PA, USA
| | - Catherine W Mavroudis
- University of Pennsylvania, Center for Surgery and Health Economics, Department of Surgery, Philadelphia, PA, USA
| | - Christopher Wirtalla
- University of Pennsylvania, Center for Surgery and Health Economics, Department of Surgery, Philadelphia, PA, USA
| | - Giorgos C Karakousis
- University of Pennsylvania, Center for Surgery and Health Economics, Department of Surgery, Philadelphia, PA, USA
| | - Nicole M Saur
- University of Pennsylvania, Department of Surgery, Philadelphia, PA, USA
| | - Cary B Aarons
- University of Pennsylvania, Department of Surgery, Philadelphia, PA, USA
| | - Najjia N Mahmoud
- University of Pennsylvania, Center for Surgery and Health Economics, Department of Surgery, Philadelphia, PA, USA
| | - Rachel R Kelz
- University of Pennsylvania, Center for Surgery and Health Economics, Department of Surgery, Philadelphia, PA, USA
| |
Collapse
|
16
|
Abstract
PURPOSE OF REVIEW The goal of this manuscript is to present new and thought-provoking information related to the surgical care of older patients. We focused on four main areas including communication, surgical pathways, the care of emergency surgery patients, and functional recovery and quality of life. We sought to answer how these areas have evolved, affecting the care of older patients. RECENT FINDINGS Older patients with cancer present particular challenges in relation to communication, goals, surgical treatment, and post-surgical outcomes. Communication should be clear early and during the treatment course. A multidisciplinary, multimodality, multi-phase pathway can be utilized to improve the postoperative outcomes of older patients with cancer. Functional recovery and quality of life can and should be measured in this population. Communication is complicated in cancer patients, which is made more complex with advancing age. Communication is the cornerstone of the treatment of older patients. Future research should focus on interventions to improve communication and measure quality of life and functional recovery metrics.
Collapse
Affiliation(s)
- Nicole M Saur
- Department of Surgery, University of Pennsylvania, 800 Walnut Street 20th floor, Philadelphia, PA, 19107, USA.
| | - Isacco Montroni
- Department of General Surgery, Ospedale per gli Infermi, Viale Stradone 9, 48018, Faenza, RA, Italy
| | - Riccardo A Audisio
- Department of Surgery, Institute of Clinical Sciences, Sahlgrenska University Hospital, Blå Stråket 5, 413 45, Göteborg, Sweden
| |
Collapse
|
17
|
Tong JK, Brooks ES, Lancaster CW, Wirtalla C, Aarons CB, Saur NM, Mahmoud NN, Karakousis GC, Kelz RR. The Impact of the Affordable Care Act on Surgeon Selection among Colorectal Surgery Patients. J Am Coll Surg 2020. [DOI: 10.1016/j.jamcollsurg.2020.07.747] [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]
|
18
|
Affiliation(s)
- Nicole M Saur
- Department of Surgery, University of Pennsylvania, Philadelphia
| | - Isacco Montroni
- Department of General Surgery, Ospedale per gli Infermi, Faenza, Italy
| |
Collapse
|
19
|
Concors SJ, Vining CM, Saur NM, Roses RE, Paulson EC. Combined Proctectomy and Hepatectomy for Metastatic Rectal Cancer Should be Undertaken with Caution: Results of a National Cohort Study. Ann Surg Oncol 2019; 26:3972-3979. [PMID: 31201596 DOI: 10.1245/s10434-019-07497-3] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2018] [Indexed: 12/24/2022]
Abstract
BACKGROUND Simultaneous proctectomy and hepatic resection for stage IV rectal cancer remains controversial due to concerns for increased morbidity and mortality. While small series have described simultaneous rectal and hepatic resection, surgical outcomes in a large national cohort have not been described. METHODS Overall, 9012 patients with stage IV rectal adenocarcinoma with hepatic metastases were identified in the National Cancer Data Base (2010-2015). Associations between treatment selection, tumor and patient characteristics, 30- and 90-day mortality, and factors predictive of survival after surgery were examined. Logistic regression analyses were used to evaluate associations between tumor/patient characteristics, and selection of combined proctectomy and hepatectomy (C-PH). Kaplan-Meier analysis was used to identify median survival stratified by age and other patient-specific factors. RESULTS Among patients included for analysis, 1331 (14.8%) underwent C-PH. Factors associated with lower rates of C-PH included increasing age, Black/Hispanic race, increased Charlson comorbidity score, Medicare/Medicaid/uninsured status, and treatment at a community cancer program. Thirty- and 90-day mortality increased with age (Chi square 11.4, p < 0.005; and Chi square 23.9, p < 0.001, respectively). On multivariate analysis, poorer survival after C-PH was associated with age > 70 years (hazard ratio [HR] 1.8, 95% confidence interval [CI] 1.0-2.5, p < 0.001), perineural invasion (HR 1.5, 95% CI 1.2-1.9, p < 0.001), kras mutation (HR 1.5, 95% CI 1.1-2.1, p = 0.006), positive circumferential margin (HR 1.3, 95% CI 1.0-1.7, p = 0.03), and omission of postoperative chemotherapy (HR 1.4, 95% CI 1.1-1.7, p = 0.002). CONCLUSIONS C-PH should be utilized with caution in frail, high-risk patients. Such patients may be better served by staged surgical management or nonsurgical therapy.
Collapse
Affiliation(s)
- Seth J Concors
- Department of Surgery, Hospital of the University of Pennsylvania, Philadelphia, PA, USA. .,Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA.
| | - Charles M Vining
- Department of Surgery, Hospital of the University of Pennsylvania, Philadelphia, PA, USA.,Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Nicole M Saur
- Department of Surgery, Hospital of the University of Pennsylvania, Philadelphia, PA, USA.,Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Robert E Roses
- Department of Surgery, Hospital of the University of Pennsylvania, Philadelphia, PA, USA.,Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Emily Carter Paulson
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA.,Department of Surgery, Corporal Michael J. Crescenz VA Medical Center, Philadelphia, PA, USA
| |
Collapse
|
20
|
Montroni I, Ugolini G, Spinelli A, Ercolani G, Jacklitsh MT, Rostoft S, Somasundar PS, Van Leeuwen B, de Liguori Carino N, Saur NM, Ferrari G, Ghignone F, Sermonesi G, Di Candido FR, Foca F, Zingaretti C, Vertogen B, Audisio R. Outcomes that matter to patients: The Geriatric Oncology Surgical Assessment and Functional rEcovery after Surgery (GOSAFE) study—Analysis of 471 patients. J Clin Oncol 2019. [DOI: 10.1200/jco.2019.37.15_suppl.11511] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
11511 Background: Older cancer patients value functional outcomes as much as survival but surgical studies lack functional recovery (FR) data. The international, multicenter GOSAFE study (ClinicalTrials.gov NCT03299270) aims to evaluate patients’ quality of life (QoL)and FR after cancer surgery and to assess predictors of FR. Methods: GOSAFE prospectively collects functional and clinical data before and after major elective cancer surgery on senior adults (≥70 years). Surgical outcomes are recorded (30 days, 90 days, and 180 dayspost-operatively) with QoL(EQ-5D-3L) and FR (Activities of Daily Living (ADL) + Timed Up and Go (TUG) + MiniCog), 28centers are prospectively enrolling patients; accrual ends February 2019. Results: 643 patients underwent major cancer surgery with curative(94%) or palliative (6%) intent (February 2017-September 2018). Median age was 78(range 70-94); 51.6% males, ASA III-IV 52%. Patients dependent (ADL < 5) were 8%. Frailty was detected by G8 > 14 in 32% and fTRST≥2 in 36% of patients. 639 (99%) lived at home, 32% lived alone, and 88% were able to go out. Major comorbidities (CCI > 6) were detected in 36% and 22% had cognitive impairment according to MiniCog (5% self-reported). 26% had > 3 kg weight loss, 30% were hospitalized in the last 90 days, 45% had ≥3 medications (6% none). For 471 patients, a 90-day comprehensive evaluation was available. Postoperative morbidity was 42% (30 day) and 63.3% (90 day), but Clavien-Dindo III-IV complications were only 11.2% and 17.6%. 90-day mortality was 7.4% (5% 30-day). QoL improved 90 days after surgery (mean EQ-5D index from 0.76 to 0.80). Patients with EQ-5D VAS score > 60 raised from 73.9% at baseline to 82.8% at 90 days. 29% had complete FR (ADL score > 4, MiniCog > 2, TUG < 20). Decreased functional capacity was seen in 23.4% of patients alive at 90-days. Conclusions: GOSAFE is the largest prospective study on older cancer patients undergoing major surgery. Interim analysis reports decreased functional capacity in a quarter of patients. The study will allow clinicians to associate clinical outcomes with individual factors of the preoperative assessment and create a user-friendly tool to predict outcomes that matter to patients.
Collapse
Affiliation(s)
- Isacco Montroni
- Colorectal Surgery Unit, Ospedale per gli Infermi di Faenza, AUSL Romagna, Faenza, Italy
| | - Giampaolo Ugolini
- Colorectal Surgery Unit, Ospedale per gli Infermi di Faenza, AUSL Romagna, Faenza, Italy
| | - Antonino Spinelli
- Division of Colon and Rectal Surgery, Humanitas Clinical and Research Center, Department of Biomedical Sciences, Humanitas University, Rozzano, Milan, Italy
| | - Giorgio Ercolani
- U.O. Chirurgia Generale e Terapie Oncologiche Avanzate Ospedale "GB.Morgagni-L.Pierantoni", AUSL Romagna, Forli, Italy
| | | | | | | | - Barbara Van Leeuwen
- Department of Surgical Oncology, University Medical Center Groningen, University of Groningen, Groningen, Netherlands
| | - Nicola de Liguori Carino
- HPB Unit, Manchester Royal Infirmary, Central Manchester University Hospitals, Manchester, United Kingdom
| | - Nicole M. Saur
- University of Pennsylvania Perelman School of Medicine, Pennsylvania Hospital, Philadelphia, PA
| | | | - Federico Ghignone
- Colorectal Surgery, General Surgery, Ospedale per gli Infermi, Faenza, Italy
| | - Giacomo Sermonesi
- Colorectal Surgery General Surgery Ospedale per gli Infermi, Faenza, Italy
| | | | - Flavia Foca
- IRCCS-IRST (Istituto Scientifico Romagnolo per lo Studio e la Cura dei Tumori), Meldola, Italy
| | - Chiara Zingaretti
- Unità di Biostatistica e Sperimentazioni Cliniche, IRCCS/IRST Meldola, Ravenna, Italy
| | - Bernadette Vertogen
- Istituto Scientifico Romagnolo per lo Studio e la Cura dei Tumori IRCCS, Meldola, Italy
| | - Riccardo Audisio
- University of Gothenburg - Institute of Clinical Sciences, Gothenburg, Sweden
| | | |
Collapse
|
21
|
Birkett RT, Chamely E, Concors SJ, Bleier JI, Aarons CB, Shanmugan S, Saur NM, Paulson EC. Overuse and Limited Benefit of Chemotherapy for Stage II Colon Cancer in Young Patients. Clin Colorectal Cancer 2019; 18:292-300. [PMID: 31447135 DOI: 10.1016/j.clcc.2019.04.002] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [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: 11/30/2018] [Revised: 02/24/2019] [Accepted: 04/02/2019] [Indexed: 12/19/2022]
Abstract
BACKGROUND Few studies have confirmed a benefit for adjuvant chemotherapy (aCTX) in stage II colon cancer. We used the National Cancer Database to explore the use and efficacy of aCTX in patients with both normal-risk (NR) and high-risk (HR) young stage II colon cancer. PATIENTS AND METHODS We identified patients with stage II colon cancer who underwent colectomy between 2010 and 2015. HR patients included at least: lymphovascular or perineural invasion, < 12 lymph nodes, poor/un-differentiation, T4, or positive margins. Rates of aCTX by age and risk were calculated, and adjusted factors associated with aCTX were identified. Overall survival was estimated using the Kaplan-Meier method and Cox multivariable analyses for patients < 50 years. RESULTS Among the 81,066 stage II patients who underwent colectomy, 6093 (7.5%) were < 50 years old. Of these, 2669 patients were HR. Thirty percent of NR and almost 60% of HR patients < 50 years received aCTX, compared with 8% and 23% of patients > 50 years (P < .001). In NR patients < 50 years, 35.3% with microsatellite-stable tumors and 18% with microsatellite unstable tumors received aCTX (P < .001), whereas 63.6% and 43.2%, respectively, of HR patients did (P < .001). The most significant multivariable predictors of aCTX were risk status and age. On univariate analysis, there was no survival benefit associated with aCTX in patients < 50 years. Multivariate analysis failed to demonstrate a survival benefit for aCTX for either group (HR, 0.97; P = .84; NR, 0.1.03; P = .90). CONCLUSION Young patients with HR and NR colon cancer received aCXT more frequently than older patients with no demonstrable survival benefit. This bears further evaluation to avoid the real risks of over-treatment in this increasing population.
Collapse
Affiliation(s)
- Richard T Birkett
- Division of Colon and Rectal Surgery, Department of Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA.
| | - Elias Chamely
- Division of Colon and Rectal Surgery, Department of Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Seth J Concors
- Division of Colon and Rectal Surgery, Department of Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Joshua I Bleier
- Division of Colon and Rectal Surgery, Department of Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Cary B Aarons
- Division of Colon and Rectal Surgery, Department of Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Skandan Shanmugan
- Division of Colon and Rectal Surgery, Department of Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Nicole M Saur
- Division of Colon and Rectal Surgery, Department of Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Emily Carter Paulson
- Division of Colon and Rectal Surgery, Department of Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| |
Collapse
|
22
|
Abstract
Anastomotic leak is associated with increased morbidity and mortality after colorectal surgery. Although surgical techniques have improved over time, anastomotic leak is still a reality in colorectal surgery with rates ranging from as low as 1% for low-risk anastomoses, such as enteroenteric or ileocolic, to 19% for high-risk coloanal anastomoses. There are many varied risk factors for anastomotic leak. However, many of the risk factors have not been definitively proven in high-quality studies. Presumably, risk factors are cumulative and every effort should be made to optimize modifiable risk factors in the perioperative period. Treatment of anastomotic leak should start with the determination of patient stability followed by resuscitation and diagnostic imaging or operative exploration. Operative findings will dictate surgical approach with the goal of controlling sepsis and stabilizing the patient. If nonoperative treatment is undertaken, close patient monitoring is necessary to ensure control of sepsis and that intervention is undertaken if the clinical picture changes. Early intervention at each stage is key to decreasing the morbidity of anastomotic leak.
Collapse
Affiliation(s)
- Nicole M Saur
- Division of Colon and Rectal Surgery, Department of Surgery, Perelman School of Medicine University of Pennsylvania, Philadelphia, Pennsylvania
| | - E Carter Paulson
- Division of Colon and Rectal Surgery, Department of Surgery, Perelman School of Medicine University of Pennsylvania, Philadelphia, Pennsylvania.,Department of General Surgery, Corporal Michael J. Crescenze VA Medical Center, Philadelphia, Pennsylvania
| |
Collapse
|
23
|
Birkett RT, O'Donnell MAJT, Epstein AJ, Saur NM, Bleier JI, Paulson EC. Elective colon resection without curative intent in stage IV colon cancer. Surg Oncol 2019; 28:110-115. [DOI: 10.1016/j.suronc.2018.11.010] [Citation(s) in RCA: 9] [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: 10/04/2018] [Revised: 10/25/2018] [Accepted: 11/10/2018] [Indexed: 12/20/2022]
|
24
|
Montroni I, Ugolini G, Saur NM, Spinelli A, Rostoft S, Millan M, Wolthuis A, Daniels IR, Hompes R, Penna M, Fürst A, Papamichael D, Desai AM, Cascinu S, Gèrard JP, Myint AS, Lemmens VE, Berho M, Lawler M, De Liguori Carino N, Potenti F, Nanni O, Altini M, Beets G, Rutten H, Winchester D, Wexner SD, Audisio RA. Personalized management of elderly patients with rectal cancer: Expert recommendations of the European Society of Surgical Oncology, European Society of Coloproctology, International Society of Geriatric Oncology, and American College of Surgeons Commission on Cancer. Eur J Surg Oncol 2018; 44:1685-1702. [DOI: 10.1016/j.ejso.2018.08.003] [Citation(s) in RCA: 57] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2018] [Revised: 07/22/2018] [Accepted: 08/03/2018] [Indexed: 12/23/2022] Open
|
25
|
Wale A, Wexner SD, Saur NM, Massarotti H, Laurberg S, Kennedy E, Rockall A, Sebag-Montefiore D, Brown G. Session 1: The evolution and development of the multidisciplinary team approach: USA, European and UK experiences - what can we do better? Colorectal Dis 2018; 20 Suppl 1:17-27. [PMID: 29878684 DOI: 10.1111/codi.14073] [Citation(s) in RCA: 0] [Impact Index Per Article: 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] [Indexed: 02/08/2023]
Abstract
The process of determining the best treatments that should be offered to patients with newly diagnosed colon and rectal cancer remains highly variable around the world. The aim of this expert review was to agree the key elements of good quality preoperative treatment decision making.
Collapse
Affiliation(s)
- A Wale
- Royal Marsden NHS Foundation Trust, London, UK
| | - S D Wexner
- Digestive Disease Center, Cleveland Clinic, Weston, Florida, USA.,Department of Colorectal Surgery, Cleveland Clinic, Weston, Florida, USA
| | - N M Saur
- Division of Colon and Rectal Surgery, Pennsylvania Hospital, Philadelphia, Pennsylvania, USA
| | - H Massarotti
- Department of Colorectal Surgery, Cleveland Clinic, Weston, Florida, USA
| | - S Laurberg
- Aarhus University Hospital, Aarhus, Denmark
| | - E Kennedy
- General Surgery and Health Policy, Management and Evaluation, University of Toronto, Toronto, ON, Canada
| | - A Rockall
- Royal Marsden NHS Foundation Trust, London, UK
| | | | - G Brown
- Royal Marsden NHS Foundation Trust, London, UK.,Imperial College London, London, UK
| |
Collapse
|
26
|
Saur NM, Montroni I, Ghignone F, Ugolini G, Audisio RA. Attitudes of Surgeons toward Elderly Cancer Patients: A Survey from the SIOG Surgical Task Force. Visc Med 2017; 33:262-266. [PMID: 29034254 DOI: 10.1159/000477641] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022] Open
Abstract
Cancer care in elderly patients is complex. A recent survey showed that among mostly academic surgeons, practice patterns varied in the care of elderly patients. The authors suggested three areas of intervention in improving care of this population: frailty assessment, nutritional assessment, and assessment of quality of life.
Collapse
Affiliation(s)
- Nicole M Saur
- Division of Colon and Rectal Surgery, Department of Surgery, University of Pennsylvania, Perelman School of Medicine, Philadelphia, PA, USA
| | - Isacco Montroni
- Colorectal Surgery, General Surgery, AUSL Romagna, Ospedale per gli Infermi - Faenza, Faenza, Italy
| | - Federico Ghignone
- Department of Medical and Surgical Sciences (DIMEC), University of Bologna, Bologna, Italy
| | - Giampaolo Ugolini
- Colorectal Surgery, General Surgery, AUSL Romagna, Ospedale per gli Infermi - Faenza, Faenza, Italy.,Department of Medical and Surgical Sciences (DIMEC), University of Bologna, Bologna, Italy
| | - Riccardo A Audisio
- Department of Surgery, University of Liverpool, St Helens Teaching Hospital, St Helens, UK
| |
Collapse
|
27
|
|
28
|
Saur NM, Wexner SD. An update on minimally invasive techniques in colorectal surgery for neoplasia. MINERVA CHIR 2016; 71:377-381. [PMID: 27654935] [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: 06/06/2023]
Abstract
Minimally invasive colorectal surgery continues to evolve. As more is learned about the techniques and surgical and oncologic outcomes, practice and technique are modified. It also becomes clear that new technologies do not always provide improved outcomes, especially in novice hands. Therefore, it remains imperative that clinicians understand the benefits and limitations of each minimally-invasive technique. The goal remains to decrease the impact of surgery and provide an optimal recovery while remaining diligent to provide optimal functional and oncologic outcomes.
Collapse
Affiliation(s)
- Nicole M Saur
- Department of Colorectal Surgery, University of Pennsylvania, Philadelphia, PA, USA -
| | | |
Collapse
|
29
|
Saur NM, Wexner SD. Minimally invasive techniques to decrease the impact of colorectal surgery for neoplasia. MINERVA CHIR 2015; 70:257-272. [PMID: 25897590] [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
Minimally invasive colorectal surgery has evolved over the past few decades. Techniques currently in practice to decrease the impact of colorectal surgery for neoplasia include laparoscopy and its derivations, robotic surgery, transanal endoscopic surgery (TES), transanal total mesorectal excision (taTME), natural orifice specimen extraction (NOSE), needlescopic surgery, and advanced endoscopy. Many of the new techniques are variations of standard laparoscopy that aim to decrease the size of the incisions (needlescopic surgery), decrease the number of incisions (single-incision laparoscopic surgery, SILS), or eliminate the need for a specimen extraction incision (taTME). Each variation must be evaluated for safety and efficacy, especially in oncologic outcome. It is imperative that clinicians understand the role and limitation of each minimally-invasive technique. The goal moving forward should be to develop and sustain technology that is safe, effective, and offers superior clinical outcomes when compared to the current gold standards.
Collapse
Affiliation(s)
- N M Saur
- Department of Colorectal Surgery, Cleveland Clinic Florida, Weston, FL, USA -
| | | |
Collapse
|
30
|
Saur NM, England MR, Menzie W, Melanson AM, Trieu MQ, Berlin J, Hurley J, Krystyniak K, Kongable GL, Nasraway SA. Accuracy of a novel noninvasive transdermal continuous glucose monitor in critically ill patients. J Diabetes Sci Technol 2014; 8:945-50. [PMID: 24876448 PMCID: PMC4455366 DOI: 10.1177/1932296814536138] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
Stress hyperglycemia and hypoglycemia are associated with increased morbidity and mortality in the critically ill. Intermittent, random blood glucose (BG) measurements can miss episodes of hyper- and hypoglycemia. The purpose of this study was to determine the accuracy of the Symphony® continuous glucose monitor (CGM) in critically ill cardiac surgery patients. Fifteen adult cardiac surgery patients were evaluated immediately postoperatively in the intensive care unit. Prelude® SkinPrep prepared the skin and a sensor was applied to 2 test sites on each subject to monitor interstitial fluid glucose. Reference BG was sampled at 30- to 60-minute intervals. The skin at the test sites was inspected for adverse effects. Accuracy of the retrospectively analyzed CGM data relative to reference BG values was determined using continuous glucose-error grid analysis (CG-EGA) and mean absolute relative difference (MARD). Using 570 Symphony CGM glucose readings paired with reference BG measurements, CG-EGA showed that 99.6% of the readings were within zones A and B. BG measurements ranged from 73 to 251 mg/dL. The MARD was 12.3%. No adverse device effects were reported. The Symphony CGM system is able to safely, continuously, and noninvasively monitor glucose in the transdermal interstitial fluid of cardiac surgery intensive care unit patients with accuracy similar to that reported with other CGM systems. Future versions of the system will need real-time data analysis, fast warm-up, and less frequent calibrations to be used in the clinical setting.
Collapse
Affiliation(s)
- Nicole M Saur
- Departments of Surgery/Anesthesiology, Tufts Medical Center and Tufts University School of Medicine, Boston, MA, USA
| | - Michael R England
- Departments of Surgery/Anesthesiology, Tufts Medical Center and Tufts University School of Medicine, Boston, MA, USA
| | | | - Ann Marie Melanson
- Departments of Surgery/Anesthesiology, Tufts Medical Center and Tufts University School of Medicine, Boston, MA, USA
| | | | | | | | | | | | - Stanley A Nasraway
- Departments of Surgery/Anesthesiology, Tufts Medical Center and Tufts University School of Medicine, Boston, MA, USA
| |
Collapse
|
31
|
Saur NM, Kongable GL, Holewinski S, O'Brien K, Nasraway SA. Software-guided insulin dosing: tight glycemic control and decreased glycemic derangements in critically ill patients. Mayo Clin Proc 2013; 88:920-9. [PMID: 24001484 DOI: 10.1016/j.mayocp.2013.07.003] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/03/2013] [Revised: 07/01/2013] [Accepted: 07/08/2013] [Indexed: 01/27/2023]
Abstract
OBJECTIVE To determine whether glycemic derangements are more effectively controlled using software-guided insulin dosing compared with paper-based protocols. PATIENTS AND METHODS We prospectively evaluated consecutive critically ill patients treated in a tertiary hospital surgical intensive care unit (ICU) between January 1 and June 30, 2008, and between January 1 and September 30, 2009. Paper-based protocol insulin dosing was evaluated as a baseline during the first period, followed by software-guided insulin dosing in the second period. We compared glycemic metrics related to hyperglycemia, hypoglycemia, and glycemic variability during the 2 periods. RESULTS We treated 110 patients by the paper-based protocol and 87 by the software-guided protocol during the before and after periods, respectively. The mean ICU admission blood glucose (BG) level was higher in patients receiving software-guided intensive insulin than for those receiving paper-based intensive insulin (181 vs 156 mg/dL; P=.003, mean of the per-patient mean). Patients treated with software-guided intensive insulin had lower mean BG levels (117 vs 135 mg/dL; P=.0008), sustained greater time in the desired BG target range (95-135 mg/dL; 68% vs 52%; P=.0001), had less frequent hypoglycemia (percentage of time BG level was <70 mg/dL: 0.51% vs 1.44%; P=.04), and showed decreased glycemic variability (BG level per-patient standard deviation from the mean: ±29 vs ±42 mg/dL; P=.01). CONCLUSION Surgical ICU patients whose intensive insulin infusions were managed using the software-guided program achieved tighter glycemic control and fewer glycemic derangements than those managed with the paper-based insulin dosing regimen.
Collapse
|