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Weed CN, Bernier GV, Christante DH, Feldmann T, Flum DR, Kaplan JA, Moonka R, Thirlby RC, Simianu VV. Evaluating variation in enhanced recovery for colorectal surgery: a report from the Surgical Care Outcomes Assessment Program. Colorectal Dis 2022; 24:111-119. [PMID: 34610205 DOI: 10.1111/codi.15938] [Citation(s) in RCA: 2] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/15/2021] [Revised: 08/19/2021] [Accepted: 09/12/2021] [Indexed: 12/18/2022]
Abstract
AIM Robust data demonstrate that enhanced recovery protocols (ERPs) decrease length of stay, complications and cost. However, little is known about the reasons for variation in compliance with ERPs. The aim of this work was to confirm the efficacy of ERPs in a regional network, and to determine factors that are associated with ERP delivery in diverse hospital settings. METHOD A prospective cohort of patients was created by recording all elective colorectal operations at hospitals in the Surgical Care Outcomes Assessment Program (SCOAP). The delivery of 12 ERP components was tracked at all sites, and factors associated with ERP component delivery and affecting outcomes were reported. RESULTS From 2016 to 2019, 9274 elective colorectal operations were performed at 36 hospitals. Indications were 48% cancer, 23% diverticulitis and 8% inflammatory bowel disease. Minimally invasive surgery was used in 71%. The proportion of cases with six or more ERP components received increased from 23% in 2016 to 50% in 2019. An increase in components was associated with a shorter length of stay and fewer combined adverse events and reinterventions. Further, increasing numbers of ERP components provided an incremental benefit to patients even when delivered in a low-volume centre or by a low-volume surgeon, and regardless of patient presentation. CONCLUSION At SCOAP hospitals, the delivery of increasing numbers of ERP components was associated with improved perioperative outcomes and decreased complications after elective colorectal surgery. The variation in delivery of these evidence-based components in subsets of our cohort indicates an important opportunity for quality improvement initiatives.
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Affiliation(s)
- Christina N Weed
- Department of Surgery, Virginia Mason Medical Center, Seattle, Washington, USA
| | - Greta V Bernier
- Colon and Rectal Surgery Clinic, University of Washington Medicine - Valley Medical Center, Renton, Washington, USA
| | | | | | - David R Flum
- Department of Surgery, University of Washington, Seattle, Washington, USA
| | - Jennifer A Kaplan
- Department of Surgery, Virginia Mason Medical Center, Seattle, Washington, USA
| | - Ravi Moonka
- Department of Surgery, Virginia Mason Medical Center, Seattle, Washington, USA
| | - Richard C Thirlby
- Department of Surgery, Virginia Mason Medical Center, Seattle, Washington, USA.,Surgical Care Outcomes Assessment Program, Seattle, Washington, USA
| | - Vlad V Simianu
- Department of Surgery, Virginia Mason Medical Center, Seattle, Washington, USA.,Surgical Care Outcomes Assessment Program, Seattle, Washington, USA
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2
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Unruh KR, Bastawrous AL, Bernier GV, Flum DR, Kumar AS, Moonka R, Thirlby RC, Simianu VV. Evaluating the Regional Uptake of Minimally Invasive Colorectal Surgery: a Report from the Surgical Care Outcomes Assessment Program. J Gastrointest Surg 2021; 25:2387-2397. [PMID: 33206328 DOI: 10.1007/s11605-020-04875-1] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/04/2020] [Accepted: 11/10/2020] [Indexed: 01/31/2023]
Abstract
BACKGROUND Minimally invasive surgery (MIS) for colorectal disease has well-known benefits, but many patients undergo open operations. When choosing an MIS approach, robotic technology may have benefits over traditional laparoscopy and is increasingly used. However, the broad adoption of MIS, and specifically robotics, across colorectal operations has not been well described. Our primary hypothesis is that rates of MIS in colorectal surgery are increasing, with different contributions of robotics to abdominal and pelvic colorectal operations. METHODS Rates of MIS colorectal operations are described using a prospective cohort of elective colorectal operations at hospitals in the Surgical Care Outcomes Assessment Program (SCOAP) from 2011 to 2018. The main outcome was proportion of cases approached using open, laparoscopic, and robotic surgery. Factors associated with increased use of MIS approaches were described. RESULTS Across 21,423 elective colorectal operations, rates for MIS (laparoscopic or robotic surgery) increased from 44% in 2011 to 75% in 2018 (p < 0.001). Approaches for abdominal operations (n = 12,493) changed from 2 to 11% robotic, 43 to 63% laparoscopic, and 56 to 26% open (p < 0.001). Approaches for pelvic operations (n = 8930) changed from 3 to 33% robotic, 40 to 42% laparoscopic, and 57 to 24% open(p < 0.001). These trends were similar for high-(100 + operations/year) and low-volume hospitals and surgeons. CONCLUSIONS At SCOAP hospitals, the majority of elective colorectal operations is now performed minimally invasively. The increase in the MIS approach is primarily driven by laparoscopy in abdominal procedures and robotics in pelvic procedures.
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Affiliation(s)
- Kenley R Unruh
- Department of Surgery, Virginia Mason Medical Center, 1100 9th Ave, C6-GS, Seattle, WA, 98101, USA
| | | | - Greta V Bernier
- Colon and Rectal Surgery Clinic, University of Washington Medicine-Valley Medical Center, Renton, WA, USA
| | - David R Flum
- Department of Surgery, University of Washington, Seattle, WA, USA
| | - Anjali S Kumar
- Department of Medical Education and Clinical Sciences, Washington State University, Spokane, WA, USA
| | - Ravi Moonka
- Department of Surgery, Virginia Mason Medical Center, 1100 9th Ave, C6-GS, Seattle, WA, 98101, USA
| | - Richard C Thirlby
- Department of Surgery, Virginia Mason Medical Center, 1100 9th Ave, C6-GS, Seattle, WA, 98101, USA
| | - Vlad V Simianu
- Department of Surgery, Virginia Mason Medical Center, 1100 9th Ave, C6-GS, Seattle, WA, 98101, USA.
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3
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Abstract
Laparoscopic ileocecectomy is advocated as the ideal surgical approach for ileocecal Crohn's disease. Our experience suggests that equivalent outcomes are accomplished through a small right lower quadrant (RLQ) transverse incision in this patient population. We conducted a retrospective chart review of 39 patients undergoing ileocectomy for Crohn's disease using a RLQ transverse incision between 1991 and 2009. The mean operative time was 99 minutes with a mean length of hospital stay of 4.2 days and mean duration until return of bowel function of 2.9 days. There were no deaths or major complications. Long-term follow-up revealed four patients (13%) who required hospitalization for small bowel obstructions, one patient (3%) developed an incisional hernia, and no patients required an ileostomy. Ileocecectomy performed for Crohn's disease using a RLQ transverse incision yielded similar hospital lengths of stay and time to return of bowel function as those published for laparoscopic resection. This approach may result in shorter operative times when compared with the inexperienced surgeon performing a laparoscopic resection. Long-term follow-up revealed the risk for future RLQ ileostomy is low and the development of hernias or bowel obstruction is unlikely.
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Affiliation(s)
- Michael J. Campbell
- From the Department of General Surgery, Virginia Mason Medical Center, Seattle, Washington
| | - Nathaniel B. Paull
- From the Department of General Surgery, Virginia Mason Medical Center, Seattle, Washington
| | - Richard C. Thirlby
- From the Department of General Surgery, Virginia Mason Medical Center, Seattle, Washington
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4
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Unruh KR, Bastawrous AL, Bernier GV, Flum DR, Kumar AS, Moonka R, Thirlby RC, Simianu VV. Evaluating the Regional Uptake of Robotic Colorectal Surgery: A Report from the Surgical Care Outcomes Assessment Program Collaborative. J Am Coll Surg 2019. [DOI: 10.1016/j.jamcollsurg.2019.08.963] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
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5
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Kaplan SJ, Seabott HM, Cunningham EB, Helman JD, Calderon A, Thirlby RC, Schenarts KD. Resident Wellness and Social Support: Development and Cognitive Validation of a Resident Social Capital Assessment Tool. J Surg Educ 2018; 75:313-320. [PMID: 29500143 DOI: 10.1016/j.jsurg.2018.02.002] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/17/2017] [Revised: 12/23/2017] [Accepted: 02/01/2018] [Indexed: 06/08/2023]
Abstract
OBJECTIVE The purpose of this study is to develop and generate validity evidence for an instrument to measure social capital in residents. DESIGN Mixed-methods, phased approach utilizing a modified Delphi technique, focus groups, and cognitive interviews. SETTING Four residency training institutions in Washington state between February 2016 and March 2017. PARTICIPANTS General surgery, anesthesia, and internal medicine residents ranging from PGY-1 to PGY-6. RESULTS The initial resident-focused instrument underwent revision via Delphi process with 6 experts; 100% expert consensus was achieved after 4 cycles. Three focus groups were conducted with 19 total residents. Focus groups identified 6 of 11 instrument items with mean quality ratings ≤4.0 on a 1-5 scale. The composite instrument rating of the draft version was 4.1 ± 0.5. After refining the instrument, cognitive interviews with the final version were completed with 22 residents. All items in the final version had quality ratings >4.0; the composite instrument rating was 4.8 ± 0.1. CONCLUSIONS Social capital may be an important factor in resident wellness as residents rely upon each other and external social support to withstand fatigue, burnout, and other negative sequelae of rigorous training. This instrument for assessment of social capital in residents may provide an avenue for data collection and potentially, identification of residents at-risk for wellness degradation.
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Affiliation(s)
- Stephen J Kaplan
- Department of Surgery, Section of General, Thoracic, and Vascular Surgery, Virginia Mason Medical Center, Seattle, Washington.
| | - Heather M Seabott
- Department of Surgery, Section of General, Thoracic, and Vascular Surgery, Virginia Mason Medical Center, Seattle, Washington; Department of Graduate Medical Education, Virginia Mason Medical Center, Seattle, Washington
| | - Erika B Cunningham
- Department of Medicine, Virginia Mason Medical Center, Seattle, Washington
| | - James D Helman
- Department of Anesthesiology, Virginia Mason Medical Center, Seattle, Washington
| | - Alvin Calderon
- Department of Medicine, Virginia Mason Medical Center, Seattle, Washington
| | - Richard C Thirlby
- Department of Surgery, Section of General, Thoracic, and Vascular Surgery, Virginia Mason Medical Center, Seattle, Washington
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Davidson GH, Flum DR, Talan DA, Kessler LG, Lavallee DC, Bizzell BJ, Farjah F, Stewart SD, Krishnadasan A, Carney EE, Wolff EM, Comstock BA, Monsell SE, Heagerty PJ, Ehlers AP, DeUgarte DA, Kaji AH, Evans HL, Yu JT, Mandell KA, Doten IC, Clive KS, McGrane KM, Tudor BC, Foster CS, Saltzman DJ, Thirlby RC, Lange EO, Sabbatini AK, Moran GJ. Comparison of Outcomes of antibiotic Drugs and Appendectomy (CODA) trial: a protocol for the pragmatic randomised study of appendicitis treatment. BMJ Open 2017; 7:e016117. [PMID: 29146633 PMCID: PMC5695382 DOI: 10.1136/bmjopen-2017-016117] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/27/2022] Open
Abstract
INTRODUCTION Several European studies suggest that some patients with appendicitis can be treated safely with antibiotics. A portion of patients eventually undergo appendectomy within a year, with 10%-15% failing to respond in the initial period and a similar additional proportion with suspected recurrent episodes requiring appendectomy. Nearly all patients with appendicitis in the USA are still treated with surgery. A rigorous comparative effectiveness trial in the USA that is sufficiently large and pragmatic to incorporate usual variations in care and measures the patient experience is needed to determine whether antibiotics are as good as appendectomy. OBJECTIVES The Comparing Outcomes of Antibiotic Drugs and Appendectomy (CODA) trial for acute appendicitis aims to determine whether the antibiotic treatment strategy is non-inferior to appendectomy. METHODS/ANALYSIS CODA is a randomised, pragmatic non-inferiority trial that aims to recruit 1552 English-speaking and Spanish-speaking adults with imaging-confirmed appendicitis. Participants are randomised to appendectomy or 10 days of antibiotics (including an option for complete outpatient therapy). A total of 500 patients who decline randomisation but consent to follow-up will be included in a parallel observational cohort. The primary analytic outcome is quality of life (measured by the EuroQol five dimension index) at 4 weeks. Clinical adverse events, rate of eventual appendectomy, decisional regret, return to work/school, work productivity and healthcare utilisation will be compared. Planned exploratory analyses will identify subpopulations that may have a differential risk of eventual appendectomy in the antibiotic treatment arm. ETHICS AND DISSEMINATION This trial was approved by the University of Washington's Human Subjects Division. Results from this trial will be presented in international conferences and published in peer-reviewed journals. TRIAL REGISTRATION NUMBER NCT02800785.
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Affiliation(s)
- Giana H Davidson
- Department of Surgery, University of Washington, Seattle, Washington, USA
| | - David R Flum
- Department of Surgery, University of Washington, Seattle, Washington, USA
| | - David A Talan
- Department of Emergency Medicine, Olive-View UCLA Medical Center, Sylmar, California, USA
| | - Larry G Kessler
- Department of Health Services, University of Washington, Seattle, Washington, USA
| | | | - Bonnie J Bizzell
- The Comparative Effectiveness Research Translation Network, CODA Chair, Patient Advisory Group, Seattle, Washington, USA
| | - Farhood Farjah
- Department of Surgery, University of Washington, Seattle, Washington, USA
| | - Skye D Stewart
- Department of Surgery, University of Washington, Seattle, Washington, USA
| | - Anusha Krishnadasan
- Department of Emergency Medicine, Olive-View UCLA Medical Center, Sylmar, California, USA
| | - Erin E Carney
- Department of Surgery, University of Washington, Seattle, Washington, USA
| | - Erika M Wolff
- Department of Surgery, University of Washington, Seattle, Washington, USA
| | - Bryan A Comstock
- Department of Biostatistics, University of Washington, Seattle, Washington, USA
| | - Sarah E Monsell
- Department of Biostatistics, University of Washington, Seattle, Washington, USA
| | - Patrick J Heagerty
- Department of Biostatistics, University of Washington, Seattle, Washington, USA
| | - Annie P Ehlers
- Department of Surgery, University of Washington, Seattle, Washington, USA
| | - Daniel A DeUgarte
- Department of Surgery, Harbor-UCLA Medical Center, Torrance, Califorina, USA
| | - Amy H Kaji
- Department of Emergency Medicine, Harbor-UCLA Medical Center, Torrance, California, USA
| | - Heather L Evans
- Department of Surgery, Harborview Medical Center, Seattle, Washington, USA
| | - Julianna T Yu
- Department of Emergency, Virginia Mason Medical Center, Seattle, Washington, USA
| | - Katherine A Mandell
- Department of Surgery, Swedish Medical Center-First Hill, Seattle, Washington, USA
| | - Ian C Doten
- Department of Emergency Medicine, Swedish Medical Center-First Hill, Seattle, Washington, USA
| | - Kevin S Clive
- Department of Surgery, Madigan Army Medical Center, Fort Lewis, Washington, USA
| | - Karen M McGrane
- Department of Emergency Medicine, Madigan Army Medical Center, Fort Lewis, Washington, USA
| | - Brandon C Tudor
- Department of Emergency Medicine, Providence Regional Medical Center, Everett, Washington, USA
| | - Careen S Foster
- Department of Trauma and Acute Care Surgery, Providence Regional Medical Center, Everett, WA, USA
| | - Darin J Saltzman
- Department of Surgery, Olive-View UCLA Medical Center, Sylmar, California, USA
| | - Richard C Thirlby
- Department of Surgery, Virginia Mason Medical Center, Seattle, Washington, USA
| | - Erin O Lange
- Department of Surgery, University of Washington, Seattle, Washington, USA
| | - Amber K Sabbatini
- Department of Emergency Medicine, Harborview Medical Center, Seattle, Washington, USA
| | - Gregory J Moran
- Department of Emergency Medicine, Olive-View UCLA Medical Center, Sylmar, California, USA
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Simianu VV, Fichera A, Bastawrous AL, Davidson GH, Florence MG, Thirlby RC, Flum DR. Number of Diverticulitis Episodes Before Resection and Factors Associated With Earlier Interventions. JAMA Surg 2017; 151:604-10. [PMID: 26864286 DOI: 10.1001/jamasurg.2015.5478] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
IMPORTANCE Despite professional recommendations to delay elective colon resection for patients with uncomplicated diverticulitis, early surgery (after <3 preceding episodes) appears to be common. Several factors have been suggested to contribute to early surgery, including increasing numbers of younger patients, a lower threshold to operate laparoscopically, and growing recognition of "smoldering" (or nonrecovering) diverticulitis episodes. However, the relevance of these factors in early surgery has not been well tested, and most prior studies have focused on hospitalizations, missing outpatient events and making it difficult to assess guideline adherence in earlier interventions. OBJECTIVE To describe patterns of episodes of diverticulitis before surgery and factors associated with earlier interventions using inpatient, outpatient, and antibiotic prescription claims. DESIGN, SETTING, AND PARTICIPANTS This investigation was a nationwide retrospective cohort study from January 1, 2009, to December 31, 2012. The dates of the analysis were July 2014 to May 2015. Participants were immunocompetent adult patients (age range, 18-64 years) with incident, uncomplicated diverticulitis. EXPOSURE Elective colectomy for diverticulitis. MAIN OUTCOMES AND MEASURES Inpatient, outpatient, and antibiotic prescription claims for diverticulitis captured in the MarketScan (Truven Health Analytics) databases. RESULTS Of 87 461 immunocompetent patients having at least 1 claim for diverticulitis, 6.4% (n = 5604) underwent a resection. The final study cohort comprised 3054 nonimmunocompromised patients who underwent elective resection for uncomplicated diverticulitis, of whom 55.6% (n = 1699) were male. Before elective surgery, they had a mean (SD) of 1.0 (0.9) inpatient claims, 1.5 (1.5) outpatient claims, and 0.5 (1.2) antibiotic prescription claims related to diverticulitis. Resection occurred after fewer than 3 episodes in 94.9% (2897 of 3054) of patients if counting inpatient claims only, in 80.5% (2459 of 3054) if counting inpatient and outpatient claims only, and in 56.3% (1720 of 3054) if counting all types of claims. Based on all types of claims, patients having surgery after fewer than 3 episodes were of similar mean age compared with patients having delayed surgery (both 47.7 years, P = .91), were less likely to undergo laparoscopy (65.1% [1120 of 1720] vs 70.8% [944 of 1334], P = .001), and had more time between the last 2 episodes preceding surgery (157 vs 96 days, P < .001). Patients with health maintenance organization or capitated insurance plans had lower rates of early surgery (50.1% [247 of 493] vs 57.4% [1429 of 2490], P = .01) than those with other insurance plan types. CONCLUSIONS AND RELEVANCE After considering all types of diverticulitis claims, 56.3% (1720 of 3054) of elective resections for uncomplicated diverticulitis occurred after fewer than 3 episodes. Earlier surgery was not explained by younger age, laparoscopy, time between the last 2 episodes preceding surgery, or financial risk-bearing for patients. In delivering value-added surgical care, factors driving early, elective resection for diverticulitis need to be determined.
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Affiliation(s)
- Vlad V Simianu
- Department of Surgery, University of Washington, Seattle
| | | | | | - Giana H Davidson
- Department of Surgery, University of Washington, Seattle3Surgical Outcomes Research Center, University of Washington, Seattle
| | | | - Richard C Thirlby
- Department of Surgery, Virginia Mason Medical Center, Seattle, Washington
| | - David R Flum
- Department of Surgery, University of Washington, Seattle3Surgical Outcomes Research Center, University of Washington, Seattle
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8
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Gaskill CE, Kling CE, Varghese TK, Veenstra DL, Thirlby RC, Flum DR, Alfonso-Cristancho R. Financial benefit of a smoking cessation program prior to elective colorectal surgery. J Surg Res 2017; 215:183-189. [PMID: 28688645 DOI: 10.1016/j.jss.2017.03.067] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2017] [Revised: 03/07/2017] [Accepted: 03/30/2017] [Indexed: 11/28/2022]
Abstract
BACKGROUND Cigarette smoking increases the risk of postoperative complications nearly 2-fold. Preoperative smoking cessation programs may reduce complications as well as overall postoperative costs. We aim to create an economic evaluation framework to estimate the potential value of preoperative smoking cessation programs for patients undergoing elective colorectal surgery. METHODS A decision-analytic model from the payer perspective was developed to integrate the costs and incidence of 90-day postoperative complications and readmissions for a cohort of patients undergoing elective colorectal surgery after a smoking cessation program versus usual care. Complication, readmission, and cost data were derived from a cohort of 534 current smokers and recent quitters undergoing elective colorectal resections in Washington State's Surgical Care and Outcomes Assessment Program linked to Washington State's Comprehensive Hospital Abstract Reporting System. Smoking cessation program efficacy was obtained from the literature. Sensitivity analyses were performed to account for uncertainty. RESULTS For a cohort of patients, the base case estimates imply that the total direct medical costs for patients who underwent a preoperative smoking cessation program were on average $304 (95% CI: $40-$571) lower per patient than those under usual care during the first 90 days after surgery. The model was most sensitive to the odds of recent quitters developing complications or requiring readmission, and smoking program efficacy. CONCLUSIONS A preoperative smoking cessation program is predicted to be cost-saving over the global postoperative period if the cost of the intervention is below $304 per patient. This framework allows the value of smoking cessation programs of variable cost and effectiveness to be determined.
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Affiliation(s)
- Cameron E Gaskill
- Department of Surgery, University of Washington, Seattle, Washington; Surgical Outcomes Research Center, Department of Surgery, University of Washington, Seattle, Washington.
| | - Catherine E Kling
- Department of Surgery, University of Washington, Seattle, Washington; Department of Surgery, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Thomas K Varghese
- Department of Cardiothoracic Surgery, University of Utah, Salt Lake City, Utah
| | - David L Veenstra
- Department of Surgery, University of Washington, Seattle, Washington; Surgical Outcomes Research Center, Department of Surgery, University of Washington, Seattle, Washington
| | - Richard C Thirlby
- Department of Surgery, Virginia Mason Medical Center, Seattle, Washington
| | - David R Flum
- Department of Surgery, University of Washington, Seattle, Washington; Surgical Outcomes Research Center, Department of Surgery, University of Washington, Seattle, Washington
| | - Rafael Alfonso-Cristancho
- Department of Surgery, University of Washington, Seattle, Washington; Surgical Outcomes Research Center, Department of Surgery, University of Washington, Seattle, Washington
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Simianu VV, Basu A, Alfonso-Cristancho R, Thirlby RC, Flaxman AD, Flum DR. Assessing surgeon behavior change after anastomotic leak in colorectal surgery. J Surg Res 2016; 205:378-383. [PMID: 27664886 DOI: 10.1016/j.jss.2016.06.075] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2016] [Revised: 05/28/2016] [Accepted: 06/27/2016] [Indexed: 11/30/2022]
Abstract
BACKGROUND Recency effect suggests that people disproportionately value events from the immediate past when making decisions, but the extent of this impact on surgeons' decisions is unknown. This study evaluates for recency effect in surgeons by examining use of preventative leak testing before and after colorectal operations with anastomotic leaks. MATERIALS AND METHODS Prospective cohort of adult patients (≥18 y) undergoing elective colorectal operations at Washington State hospitals participating in the Surgical Care and Outcomes Assessment Program (2006-2013). The main outcome measure was surgeons' change in leak testing from 6 mo before to 6 mo after an anastomotic leak occurred. RESULTS Across 4854 elective colorectal operations performed by 282 surgeons at 44 hospitals, there was a leak rate of 2.6% (n = 124). The 40 leaks (32%) in which the anastomosis was not tested occurred across 25 surgeons. While the ability to detect an overall difference in use of leak testing was limited by small sample size, nine (36%) of 25 surgeons increased their leak testing by 5% points or more after leaks in cases where the anastomosis was not tested. Surgeons who increased their leak testing more frequently performed operations for diverticulitis (45% versus 33%), more frequently began their cases laparoscopically (65% versus 37%), and had longer mean operative times (195 ± 99 versus 148 ± 87 min), all P < 0.001. CONCLUSIONS Recency effect was demonstrated by only one-third of eligible surgeons. Understanding the extent to which clinical decisions may be influenced by recency effect may be important in crafting quality improvement initiatives that require clinician behavior change.
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Affiliation(s)
- Vlad V Simianu
- Department of Surgery, University of Washington, Seattle, Washington.
| | - Anirban Basu
- Department of Health Services, University of Washington, Seattle, Washington
| | - Rafael Alfonso-Cristancho
- Department of Surgery, Surgical Outcomes Research Center, University of Washington, Seattle, Washington
| | - Richard C Thirlby
- Department of Surgery, Virginia Mason Medical Center, Seattle, Washington
| | - Abraham D Flaxman
- Department of Global Health, Institute for Health Metrics and Evaluation, University of Washington, Seattle, Washington
| | - David R Flum
- Department of Surgery, University of Washington, Seattle, Washington; Department of Surgery, Surgical Outcomes Research Center, University of Washington, Seattle, Washington.
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10
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Drake FT, Mottey NE, Castelli AA, Florence MG, Johnson MG, Steele SR, Thirlby RC, Flum DR. Time-of-day and appendicitis: Impact on management and outcomes. Surgery 2016; 161:405-414. [PMID: 27592212 DOI: 10.1016/j.surg.2016.06.052] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2016] [Revised: 06/13/2016] [Accepted: 06/23/2016] [Indexed: 12/25/2022]
Abstract
BACKGROUND Observational research has shown that delayed presentation is associated with perforation in appendicitis. Many factors that affect the ability to present for evaluation are influenced by time of day (eg, child care, work, transportation, and office hours of primary care settings). Our objective was to evaluate for an association between care processes or clinical outcomes and presentation time of day. METHODS The study evaluated a prospective cohort of 7,548 adults undergoing appendectomy at 56 hospitals across Washington State. Relative to presentation time, patient characteristics, time to operation, imaging use, negative appendectomy, and perforation were compared using univariate and multivariate methodologies. RESULTS Overall, 63% of patients presented between noon and midnight. More men presented in the morning; however, race, insurance status, comorbid conditions, and white blood cell count did not differ by presentation time. Daytime presenters (6 am to 6 pm) were less likely to undergo imaging (94% vs 98%, P < .05) and had a nearly 50% decrease in median preoperative time (6.0 h vs 8.7 h, P < .001). Perforation significantly differed by time-of-day. Patients who presented during the workday (9 am to 3 pm) had a 30% increase in odds of perforation compared with patients presenting in the early morning/late night (adjusted odds ratio 1.29, 95% confidence interval, 1.05-1.59). Negative appendectomy did not vary by time-of-day. CONCLUSION Most patients with appendicitis presented in the afternoon/evening. Socioeconomic characteristics did not vary with time-of-presentation. Patients who presented during the workday more often had perforated appendicitis compared with those who presented early morning or late night. Processes of care differed (both time-to-operation and imaging use). Time-of-day is associated with patient outcomes, process of care, and decisions to present for evaluation; this association has implications for the planning of the surgical workforce and efforts directed at quality improvement.
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Affiliation(s)
- Frederick Thurston Drake
- Department of Surgery, Division of Endocrine Surgery, University of California, San Francisco Medical Center, San Francisco, CA; Department of Surgery, University of Washington Medical Center, Seattle, WA; Department of Surgery, Virginia Mason Medical Center, Seattle, WA; Surgical Outcomes Research Center (SORCE), Department of Surgery, University of Washington, Seattle, WA.
| | - Neli E Mottey
- Department of Surgery, University of Washington Medical Center, Seattle, WA; Department of Surgery, Virginia Mason Medical Center, Seattle, WA
| | - Anthony A Castelli
- Department of Surgery, University of Washington Medical Center, Seattle, WA; Department of Surgery, Virginia Mason Medical Center, Seattle, WA
| | | | | | - Scott R Steele
- Department of Surgery, Case Western Reserve University, Cleveland, OH
| | | | - David R Flum
- Department of Surgery, University of Washington Medical Center, Seattle, WA; Department of Surgery, Virginia Mason Medical Center, Seattle, WA; Surgical Outcomes Research Center (SORCE), Department of Surgery, University of Washington, Seattle, WA
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- Surgical Care and Outcomes Assessment Program (SCOAP) and the Comparative Effectiveness Research Translation Network (CERTAIN)
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11
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Ehlers AP, Simianu VV, Bastawrous AL, Billingham RP, Davidson GH, Fichera A, Florence MG, Menon R, Thirlby RC, Flum DR, Farjah F. Alvimopan Use, Outcomes, and Costs: A Report from the Surgical Care and Outcomes Assessment Program Comparative Effectiveness Research Translation Network Collaborative. J Am Coll Surg 2016; 222:870-7. [PMID: 27113517 DOI: 10.1016/j.jamcollsurg.2016.01.051] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2015] [Revised: 01/22/2016] [Accepted: 01/22/2016] [Indexed: 11/29/2022]
Abstract
BACKGROUND Randomized trials have found that alvimopan hastens return of bowel function and reduces length of stay (LOS) by 1 day among patients undergoing colorectal surgery. However, its effectiveness in routine clinical practice and its impact on hospital costs remain uncertain. STUDY DESIGN We performed a retrospective cohort study of patients undergoing elective colorectal surgery in Washington state (2009 to 2013) using data from a clinical registry (Surgical Care and Outcomes Assessment Program) linked to a statewide hospital discharge database (Comprehensive Hospital Abstract Reporting System). We used generalized estimating equations to evaluate the relationship between alvimopan and outcomes, and adjusted for patient, operative, and management characteristics. Hospital charges were converted to costs using hospital-specific charge to cost ratios, and were adjusted for inflation to 2013 US dollars. RESULTS Among 14,781 patients undergoing elective colorectal surgery at 51 hospitals, 1,615 (11%) received alvimopan. Patients who received alvimopan had a LOS that was 1.8 days shorter (p < 0.01) and costs that were $2,017 lower (p < 0.01) compared with those who did not receive alvimopan. After adjustment, LOS was 0.9 days shorter (p < 0.01), and hospital costs were $636 lower (p = 0.02) among those receiving alvimopan compared with those who did not. CONCLUSIONS When used in routine clinical practice, alvimopan was associated with a shorter LOS and limited but significant hospital cost savings. Both efficacy and effectiveness data support the use of alvimopan in routine clinical practice, and its use could be measured as a marker of higher quality care.
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Affiliation(s)
| | - Anne P Ehlers
- Department of Surgery, University of Washington, Seattle, WA.
| | - Vlad V Simianu
- Department of Surgery, University of Washington, Seattle, WA
| | | | | | | | | | | | - Raman Menon
- Department of Surgery, Swedish Medical Center, Seattle, WA
| | | | - David R Flum
- Department of Surgery, University of Washington, Seattle, WA
| | - Farhood Farjah
- Department of Surgery, University of Washington, Seattle, WA
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Nelson DW, Simianu VV, Bastawrous AL, Billingham RP, Fichera A, Florence MG, Johnson EK, Johnson MG, Thirlby RC, Flum DR, Steele SR. Thromboembolic Complications and Prophylaxis Patterns in Colorectal Surgery. JAMA Surg 2015; 150:712-20. [PMID: 26060977 DOI: 10.1001/jamasurg.2015.1057] [Citation(s) in RCA: 66] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
IMPORTANCE Venous thromboembolism (VTE) is an important complication of colorectal surgery, but its incidence is unclear in the era of VTE prophylaxis. OBJECTIVE To describe the incidence of and risk factors associated with thromboembolic complications and contemporary VTE prophylaxis patterns following colorectal surgery. DESIGN, SETTING, AND PARTICIPANTS Prospective data from the Washington State Surgical Care and Outcomes Assessment Program (SCOAP) linked to a statewide hospital discharge database. At 52 Washington State SCOAP hospitals, participants included consecutive patients undergoing colorectal surgery between January 1, 2006, and December 31, 2011. MAIN OUTCOMES AND MEASURES Venous thromboembolism complications in-hospital and up to 90 days after surgery. RESULTS Among 16,120 patients (mean age, 61.4 years; 54.5% female), the use of perioperative and in-hospital VTE chemoprophylaxis increased significantly from 31.6% to 86.4% and from 59.6% to 91.4%, respectively, by 2011 (P < .001 for trend for both). Overall, 10.6% (1399 of 13,230) were discharged on a chemoprophylaxis regimen. The incidence of VTE was 2.2% (360 of 16,120). Patients undergoing abdominal operations had higher rates of 90-day VTE compared with patients having pelvic operations (2.5% [246 of 9702] vs 1.8% [114 of 6413], P = .001). Those having an operation for cancer had a similar incidence of 90-day VTE compared with those having an operation for nonmalignant processes (2.1% [128 of 6213] vs 2.3% [232 of 9902], P = .24). On adjusted analysis, older age, nonelective surgery, history of VTE, and operations for inflammatory disease were associated with increased risk of 90-day VTE (P < .05 for all). There was no significant decrease in VTE over time. CONCLUSIONS AND RELEVANCE Venous thromboembolism rates are low and largely unchanged despite increases in perioperative and postoperative prophylaxis. These data should be considered in developing future guidelines.
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Affiliation(s)
| | - Daniel W Nelson
- Madigan Army Medical Center, Department of Surgery, Fort Lewis, Washington
| | - Vlad V Simianu
- University of Washington, Department of Surgery, Seattle
| | | | | | | | | | - Eric K Johnson
- Madigan Army Medical Center, Department of Surgery, Fort Lewis, Washington
| | - Morris G Johnson
- Skagit Valley Medical Center, Department of Surgery, Mount Vernon, Washington
| | - Richard C Thirlby
- Virginia Mason Medical Center, Department of Surgery, Seattle, Washington
| | - David R Flum
- University of Washington, Department of Surgery, Seattle
| | - Scott R Steele
- Madigan Army Medical Center, Department of Surgery, Fort Lewis, Washington
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13
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Minami CA, Sheils CR, Bilimoria KY, Johnson JK, Berger ER, Berian JR, Englesbe MJ, Guillamondegui OD, Hines LH, Cofer JB, Flum DR, Thirlby RC, Kazaure HS, Wren SM, O'Leary KJ, Thurk JL, Kennedy GD, Tevis SE, Yang AD. Process improvement in surgery. Curr Probl Surg 2015; 53:62-96. [PMID: 26806271 DOI: 10.1067/j.cpsurg.2015.11.001] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2015] [Accepted: 11/10/2015] [Indexed: 11/22/2022]
Affiliation(s)
- Christina A Minami
- Department of Surgery, Surgical Outcomes and Quality Improvement Center (SOQIC), Feinberg School of Medicine, Northwestern University, Chicago, IL; Center for Healthcare Studies in the Institute for Public Health and Medicine, Feinberg School of Medicine, Northwestern University, Chicago, IL
| | - Catherine R Sheils
- Department of Surgery, Surgical Outcomes and Quality Improvement Center (SOQIC), Feinberg School of Medicine, Northwestern University, Chicago, IL; University of Rochester School of Medicine, University of Rochester, Rochester, NY
| | - Karl Y Bilimoria
- Department of Surgery, Surgical Outcomes and Quality Improvement Center (SOQIC), Feinberg School of Medicine, Northwestern University, Chicago, IL; Center for Healthcare Studies in the Institute for Public Health and Medicine, Feinberg School of Medicine, Northwestern University, Chicago, IL.
| | - Julie K Johnson
- Department of Surgery, Surgical Outcomes and Quality Improvement Center (SOQIC), Feinberg School of Medicine, Northwestern University, Chicago, IL; Center for Healthcare Studies in the Institute for Public Health and Medicine, Feinberg School of Medicine, Northwestern University, Chicago, IL
| | - Elizabeth R Berger
- Department of Surgery, Surgical Outcomes and Quality Improvement Center (SOQIC), Feinberg School of Medicine, Northwestern University, Chicago, IL; Department of Surgery, Loyola University Medical Center, Maywood, IL
| | - Julia R Berian
- Department of Surgery, Surgical Outcomes and Quality Improvement Center (SOQIC), Feinberg School of Medicine, Northwestern University, Chicago, IL; Department of Surgery, University of Chicago Medical Center, Chicago, IL
| | - Michael J Englesbe
- Department of Surgery, University of Michigan Health Systems, Ann Arbor, MI
| | | | - Leonard H Hines
- Department of Surgery, University of Tennessee College of Medicine, Knoxville, TN
| | - Joseph B Cofer
- Department of Surgery, University of Tennessee College of Medicine, Chattanooga, TN
| | - David R Flum
- Department of Surgery, University of Washington School of Medicine, Seattle, WA
| | | | - Hadiza S Kazaure
- Department of Surgery, Stanford University School of Medicine, Palo Alto, CA
| | - Sherry M Wren
- Department of Surgery, Stanford University School of Medicine, Palo Alto, CA
| | - Kevin J O'Leary
- Division of Hospital Medicine, Feinberg School of Medicine, Northwestern University, Chicago, IL
| | - Jessica L Thurk
- Feinberg School of Medicine, Northwestern University, Chicago, IL
| | - Gregory D Kennedy
- Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, WI
| | - Sarah E Tevis
- Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, WI
| | - Anthony D Yang
- Department of Surgery, Surgical Outcomes and Quality Improvement Center (SOQIC), Feinberg School of Medicine, Northwestern University, Chicago, IL; Center for Healthcare Studies in the Institute for Public Health and Medicine, Feinberg School of Medicine, Northwestern University, Chicago, IL
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Pugel AE, Simianu VV, Bastawrous AL, Billingham RP, Fichera A, Florence MG, Menon R, Thirlby RC, Farjah F, Flum DR. Alvimopan Use, Outcomes, and Costs: A Report from the Surgical Care Outcomes and Assessment Program Comparative Effectiveness Research Translation Network Collaborative. J Am Coll Surg 2015. [DOI: 10.1016/j.jamcollsurg.2015.07.052] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
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15
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Lord JD, Shows DM, Chen J, Thirlby RC. Human Blood and Mucosal Regulatory T Cells Express Activation Markers and Inhibitory Receptors in Inflammatory Bowel Disease. PLoS One 2015; 10:e0136485. [PMID: 26305224 PMCID: PMC4548948 DOI: 10.1371/journal.pone.0136485] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2015] [Accepted: 08/04/2015] [Indexed: 12/31/2022] Open
Abstract
Background FOXP3+ regulatory T cells (Tregs) are critical for preventing intestinal inflammation. However, FOXP3+ T cells are paradoxically increased in the intestines of patients with the inflammatory bowel disease (IBD) ulcerative colitis (UC) or Crohn’s disease (CD). We determined whether these FOXP3+ cells in IBD patients share or lack the phenotype of such cells from patients without IBD. Methods We quantified and characterized FOXP3+ Treg populations, as well as FOXP3- CD4+ T cells, in the lamina propria lymphocytes (LPL) of intestine surgically resected from patients with and without IBD, and in the blood of controls or Crohn’s patients with or without disease activity. Results In all samples, a similar fraction of FOXP3+ cells expressed the “natural” Treg (nTreg) marker Helios, suggesting that, in IBD, these cells are not entirely “induced” Tregs (iTregs) derived from activated effector T cells. Helios+ and Helios- FOXP3+ T cells demonstrated similar expression of maturation markers, activation markers, and inhibitory molecules between IBD patients and controls, while FOXP3- cells paradoxically expressed more of the inhibitory receptors CD39, CTLA4, and PD-1 in inflamed mucosa. Greater expression of activation markers was also seen in both Helios+ and Helios- Tregs, relative to FOXP3- cells, in both IBD patients and controls, indicating that Tregs are effectively activated by antigen in IBD. Conclusions Extensive immunophenotyping revealed that Helios+ and Helios- mucosal Tregs exist at a similar frequency, and have a similar expression of inhibitory molecules and activation markers in patients with IBD as in healthy controls.
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Affiliation(s)
- James D. Lord
- Translational Research Program at the Benaroya Research Institute at Virginia Mason, Seattle Washington, United States of America
- * E-mail:
| | - Donna M. Shows
- Translational Research Program at the Benaroya Research Institute at Virginia Mason, Seattle Washington, United States of America
| | - Janice Chen
- Translational Research Program at the Benaroya Research Institute at Virginia Mason, Seattle Washington, United States of America
| | - Richard C. Thirlby
- Department of Surgery, Virginia Mason Medical Center, Seattle, Washington, United States of America
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16
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Lord J, Chen J, Thirlby RC, Sherwood AM, Carlson CS. T-cell receptor sequencing reveals the clonal diversity and overlap of colonic effector and FOXP3+ T cells in ulcerative colitis. Inflamm Bowel Dis 2015; 21:19-30. [PMID: 25437819 PMCID: PMC4526221 DOI: 10.1097/mib.0000000000000242] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND FOXP3 regulatory T cell prevent inflammation but are paradoxically increased in ulcerative colitis (UC). Local T-cell activation has been hypothesized to account for increased FOXP3 expression in colon lamina propria (LP) T cells. METHODS To see if human FOXP3 LP T cells are an activated fraction of otherwise FOXP3 effector T cells and explore their clonal diversity in health and disease, we deep sequenced clonally unique T-cell receptor hypervariable regions of FOXP3 and FOXP3CD4 T-cell subpopulations from inflamed versus noninflamed colon LP or mesenteric lymph nodes of patients with or without UC. RESULTS The clonal diversity of each LP T-cell population was not different between patients with versus without UC. Repertoire overlap was only seen between a minority of FOXP3 and FOXP3 cells, including recently activated CD38 cells and Th17-like CD161 effector T cells, but this repertoire overlap was not different between patients with versus without UC and was no larger than the overlap between Helios and Helios FOXP3 cells. CONCLUSIONS Thus, at steady state, only a minority of FOXP3, and particularly Helios, T cells share a T-cell receptor sequence with FOXP3 effector populations in the colon LP, even in UC, revealing distinct clonal origins for LP regulatory T cell and effector T cells in humans.
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Affiliation(s)
- James Lord
- Translational Research Program at the Benaroya Research Institute at Virginia Mason, 1201 Ninth Avenue, Seattle WA 98101,Corresponding Author: James Lord, MD, PhD, Benaroya Research Institute, Address: 1201 9th Ave., Seattle, WA 98101, Phone: 206-287-1088; Fax: 206-342-6581;
| | - Janice Chen
- Translational Research Program at the Benaroya Research Institute at Virginia Mason, 1201 Ninth Avenue, Seattle WA 98101
| | - Richard C. Thirlby
- Department of Surgery, Virginia Mason Medical Center 1100 Ninth Avenue, Seattle WA 98101
| | - Anna M. Sherwood
- Adaptive Biotechnologies, 1551 Eastlake Ave E, Suite 200, Seattle WA 98102
| | - Christopher S. Carlson
- Adaptive Biotechnologies, 1551 Eastlake Ave E, Suite 200, Seattle WA 98102,Fred Hutchinson Cancer Research Center, 1100 Fairview Ave N, Seattle, WA 98109
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Drake FT, Mottey NE, Farrokhi ET, Florence MG, Johnson MG, Mock C, Steele SR, Thirlby RC, Flum DR. Time to appendectomy and risk of perforation in acute appendicitis. JAMA Surg 2014; 149:837-44. [PMID: 24990687 DOI: 10.1001/jamasurg.2014.77] [Citation(s) in RCA: 115] [Impact Index Per Article: 11.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
IMPORTANCE In the traditional model of acute appendicitis, time is the major driver of disease progression; luminal obstruction leads inexorably to perforation without timely intervention. This perceived association has long guided clinical behavior related to the timing of appendectomy. OBJECTIVE To evaluate whether there is an association between time and perforation after patients present to the hospital. DESIGN, SETTING, AND PARTICIPANTS Using data from the Washington State Surgical Care and Outcomes Assessment Program (SCOAP), we evaluated patterns of perforation among patients (≥18 years) who underwent appendectomy from January 1, 2010, to December 31, 2011. Patients were treated at 52 diverse hospitals including urban tertiary centers, a university hospital, small community and rural hospitals, and hospitals within multi-institutional organizations. MAIN OUTCOMES AND MEASURES The main outcome of interest was perforation as diagnosed on final pathology reports. The main predictor of interest was elapsed time as measured between presentation to the hospital and operating room (OR) start time. The relationship between in-hospital time and perforation was adjusted for potential confounding using multivariate logistic regression. Additional predictors of interest included sex, age, number of comorbid conditions, race and/or ethnicity, insurance status, and hospital characteristics such as community type and appendectomy volume. RESULTS A total of 9048 adults underwent appendectomy (15.8% perforated). Mean time from presentation to OR was the same (8.6 hours) for patients with perforated and nonperforated appendicitis. In multivariate analysis, increasing time to OR was not a predictor of perforation, either as a continuous variable (odds ratio = 1.0 [95% CI, 0.99-1.01]) or when considered as a categorical variable (patients ordered by elapsed time and divided into deciles). Factors associated with perforation were male sex, increasing age, 3 or more comorbid conditions, and lack of insurance. CONCLUSIONS AND RELEVANCE There was no association between perforation and in-hospital time prior to surgery among adults treated with appendectomy. These findings may reflect selection of those at higher risk of perforation for earlier intervention or the effect of antibiotics begun at diagnosis but they are also consistent with the hypothesis that perforation is most often a prehospital occurrence and/or not strictly a time-dependent phenomenon. These findings may also guide decisions regarding personnel and resource allocation when considering timing of nonelective appendectomy.
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Affiliation(s)
- Frederick Thurston Drake
- Department of Surgery, University of Washington Medical Center, Seattle2University of Washington Surgical Outcomes Research Center, Seattle3Department of Global Health, University of Washington, Seattle
| | - Neli E Mottey
- Department of Surgery, University of Washington Medical Center, Seattle2University of Washington Surgical Outcomes Research Center, Seattle
| | - Ellen T Farrokhi
- University of Washington Surgical Outcomes Research Center, Seattle4Providence Regional Medical Center, Everett, Washington
| | | | | | - Charles Mock
- Department of Surgery, University of Washington Medical Center, Seattle3Department of Global Health, University of Washington, Seattle
| | - Scott R Steele
- Department of Surgery, Madigan Army Medical Center, Ft Lewis, Tacoma, Washington
| | - Richard C Thirlby
- Department of Surgery, Virginia Mason Medical Center, Seattle, Washington
| | - David R Flum
- Department of Surgery, University of Washington Medical Center, Seattle2University of Washington Surgical Outcomes Research Center, Seattle
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18
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Drake FT, Mottey NE, Castelli AA, Florence MG, Johnson MG, Steele SR, Thirlby RC, Flum DR. Day vs night: time-of-day is associated with clinical management and outcomes in appendicitis. J Am Coll Surg 2014. [DOI: 10.1016/j.jamcollsurg.2014.07.634] [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: 11/26/2022]
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19
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Courcoulas AP, Christian NJ, Belle SH, Berk PD, Flum DR, Garcia L, Horlick M, Kalarchian MA, King WC, Mitchell JE, Patterson EJ, Pender JR, Pomp A, Pories WJ, Thirlby RC, Yanovski SZ, Wolfe BM. Weight change and health outcomes at 3 years after bariatric surgery among individuals with severe obesity. JAMA 2013; 310:2416-25. [PMID: 24189773 PMCID: PMC3955952 DOI: 10.1001/jama.2013.280928] [Citation(s) in RCA: 321] [Impact Index Per Article: 29.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
IMPORTANCE Severe obesity (body mass index [BMI] ≥35) is associated with a broad range of health risks. Bariatric surgery induces weight loss and short-term health improvements, but little is known about long-term outcomes of these operations. OBJECTIVE To report 3-year change in weight and select health parameters after common bariatric surgical procedures. DESIGN AND SETTING The Longitudinal Assessment of Bariatric Surgery (LABS) Consortium is a multicenter observational cohort study at 10 US hospitals in 6 geographically diverse clinical centers. PARTICIPANTS AND EXPOSURE: Adults undergoing first-time bariatric surgical procedures as part of routine clinical care by participating surgeons were recruited between 2006 and 2009 and followed up until September 2012. Participants completed research assessments prior to surgery and 6 months, 12 months, and then annually after surgery. MAIN OUTCOMES AND MEASURES Three years after Roux-en-Y gastric bypass (RYGB) or laparoscopic adjustable gastric banding (LAGB), we assessed percent weight change from baseline and the percentage of participants with diabetes achieving hemoglobin A1c levels less than 6.5% or fasting plasma glucose values less than 126 mg/dL without pharmacologic therapy. Dyslipidemia and hypertension resolution at 3 years was also assessed. RESULTS At baseline, participants (N = 2458) were 18 to 78 years old, 79% were women, median BMI was 45.9 (IQR, 41.7-51.5), and median weight was 129 kg (IQR, 115-147). For their first bariatric surgical procedure, 1738 participants underwent RYGB, 610 LAGB, and 110 other procedures. At baseline, 774 (33%) had diabetes, 1252 (63%) dyslipidemia, and 1601 (68%) hypertension. Three years after surgery, median actual weight loss for RYGB participants was 41 kg (IQR, 31-52), corresponding to a percentage of baseline weight lost of 31.5% (IQR, 24.6%-38.4%). For LAGB participants, actual weight loss was 20 kg (IQR, 10-29), corresponding to 15.9% (IQR, 7.9%-23.0%). The majority of weight loss was evident 1 year after surgery for both procedures. Five distinct weight change trajectory groups were identified for each procedure. Among participants who had diabetes at baseline, 216 RYGB participants (67.5%) and 28 LAGB participants (28.6%) experienced partial remission at 3 years. The incidence of diabetes was 0.9% after RYGB and 3.2% after LAGB. Dyslipidemia resolved in 237 RYGB participants (61.9%) and 39 LAGB participants (27.1%); remission of hypertension occurred in 269 RYGB participants (38.2%) and 43 LAGB participants (17.4%). CONCLUSIONS AND RELEVANCE Among participants with severe obesity, there was substantial weight loss 3 years after bariatric surgery, with the majority experiencing maximum weight change during the first year. However, there was variability in the amount and trajectories of weight loss and in diabetes, blood pressure, and lipid outcomes. TRIAL REGISTRATION clinicaltrials.gov Identifier: NCT00465829.
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Affiliation(s)
- Anita P Courcoulas
- Department of Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
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Belle SH, Berk PD, Chapman WH, Christian NJ, Courcoulas AP, Dakin GF, Flum DR, Horlick M, King WC, McCloskey CA, Mitchell JE, Patterson EJ, Pender JR, Steffen KJ, Thirlby RC, Wolfe BM, Yanovski SZ. Baseline characteristics of participants in the Longitudinal Assessment of Bariatric Surgery-2 (LABS-2) study. Surg Obes Relat Dis 2013; 9:926-35. [PMID: 23602493 DOI: 10.1016/j.soard.2013.01.023] [Citation(s) in RCA: 91] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2013] [Revised: 01/28/2013] [Accepted: 01/29/2013] [Indexed: 12/28/2022]
Affiliation(s)
- Steven H Belle
- University of Pittsburgh Graduate School of Public Health, Pittsburgh, Pennsylvania.
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21
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Campbell MJ, Paull NB, Thirlby RC. Transverse incisions for resection of ileocolic Crohn's disease. Am Surg 2013; 79:279-283. [PMID: 23461954] [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: 06/01/2023]
Abstract
Laparoscopic ileocecectomy is advocated as the ideal surgical approach for ileocecal Crohn's disease. Our experience suggests that equivalent outcomes are accomplished through a small right lower quadrant (RLQ) transverse incision in this patient population. We conducted a retrospective chart review of 39 patients undergoing ileocectomy for Crohn's disease using a RLQ transverse incision between 1991 and 2009. The mean operative time was 99 minutes with a mean length of hospital stay of 4.2 days and mean duration until return of bowel function of 2.9 days. There were no deaths or major complications. Long-term follow-up revealed four patients (13%) who required hospitalization for small bowel obstructions, one patient (3%) developed an incisional hernia, and no patients required an ileostomy. Ileocecectomy performed for Crohn's disease using a RLQ transverse incision yielded similar hospital lengths of stay and time to return of bowel function as those published for laparoscopic resection. This approach may result in shorter operative times when compared with the inexperienced surgeon performing a laparoscopic resection. Long-term follow-up revealed the risk for future RLQ ileostomy is low and the development of hernias or bowel obstruction is unlikely.
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Affiliation(s)
- Michael J Campbell
- Department of General Surgery, Virginia Mason Medical Center, Seattle, Washington 98101, USA
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Seabott H, Smith RK, Alseidi A, Thirlby RC. The surgical residency interview: a candidate-centered, working approach. J Surg Educ 2012; 69:802-806. [PMID: 23111050 DOI: 10.1016/j.jsurg.2012.06.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/13/2012] [Revised: 05/23/2012] [Accepted: 06/07/2012] [Indexed: 06/01/2023]
Abstract
PURPOSE The interview process is a pivotal, differentiating component of the residency match. Our bias is toward a working interview, producing better fulfillment of the needs of both parties, and a more informed match selection for the candidates and program. METHODS We describe a "candidate-centered" approach for integrating applicant interviews into our daily work schedule. Applicants are informed upon accepting the interview of the working interview model. Our program offers 33 interview days over a 12-week period. A maximum of 5 applicants are hosted per day. Applicants are assigned to 1 of our general, thoracic, vascular, or plastic surgery teams. The interview day begins with the applicant changing into scrubs, attending a morning conference, and taking part in a program overview by a Chief Resident. Applicants join their host team where 4-8 hours are spent observing the operative team, on rounds and sharing lunch. The faculty and senior residents are responsible for interviewing and evaluating applicants though the Electronic Residency Application Service. RESULTS A total of 13 surgeons are involved in the interview process resulting in broad-based evaluations. Each surgeon interviewed between 3 and 12 applicants. Faculty rate this interview approach highly because it allows them to maintain a rigorous operative schedule while interacting with applicants. Current residents are engaged in welcoming applicants to view the program. Faculty and residents believe cooperating in a real world manner aids their assessment of the applicant. Applicants routinely provide positive feedback, relaying this approach is informative, transparent, and should be the "standard." Applicants believe they are presented a realistic view of the program. Ultimately, this candidate-centered process may be attributable to our resident cohort who exhibit high satisfaction, excellent resident morale, and very low dropout rate. CONCLUSIONS We present a candidate-centered, working interview approach used in the selection of general surgery residents. While it may require more resources than the traditional approach, it harbors advantages for the applicant and the program.
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Affiliation(s)
- Heather Seabott
- Department of Graduate Medical Education, Virginia Mason Medical Center, Seattle, WA, USA
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23
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Thirlby RC. Is my patient wet or dry? Should my patient be wet or dry?: A first step in answering these queries: Comment on "Effect of the volume of fluids administered on intraoperative oliguria in laparoscopic bariatric surgery". ACTA ACUST UNITED AC 2012; 147:234-5. [PMID: 22430903 DOI: 10.1001/archsurg.2011.1413] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Affiliation(s)
- Richard C Thirlby
- Section of General, Thoracic, and Vascular Surgery, Virginia Mason Medical Center, 1100 Ninth Ave, PO Box 900, C6-GSUR, Seattle, WA 98111, USA.
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Dawson K, Wiebusch A, Thirlby RC. Preoperative tattooing and improved lymph node retrieval rates from colectomy specimens in patients with colorectal cancers. ACTA ACUST UNITED AC 2010; 145:826-30. [PMID: 20855751 DOI: 10.1001/archsurg.2010.180] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
HYPOTHESIS India ink tattooing at the time of colonoscopy increases the yield of lymph nodes found in pathological analysis of colectomy specimens. DESIGN Retrospective study. SETTING Virginia Mason Medical Center, Seattle, Washington. PATIENTS Two hundred nine patients with colorectal cancers underwent surgical resections between April 5, 2006, and June 25, 2009, at one institution. MAIN OUTCOME MEASURES A retrospective review of a prospectively collected database was performed, with review of pathology reports for all cases. Adequate lymph node analysis was defined as evaluation of at least 12 lymph nodes. RESULTS Of 209 patients undergoing resections, 174 had colonic neoplasms, and 35 had rectal neoplasms. Sixty-two of 174 patients with colon cancer had India ink tattooing at the time of colonoscopy. The mean (range) numbers of lymph nodes examined in tattooed and nontattooed specimens were 23 (7-77) and 19 (2-74), respectively (P = .03). At least 12 lymph nodes were analyzed for 87.1% of the tattooed specimens compared with 72.3% of the nontattooed specimens (P = .02). Eight of 35 patients with rectal cancer had India ink tattooing at the time of colonoscopy. Fifty-four percent of patients with rectal cancer had undergone neoadjuvant chemoradiotherapy. The median numbers of lymph nodes examined in tattooed and nontattooed specimens were 19 and 16, respectively. CONCLUSIONS Tattooing of colonic lesions at the time of preoperative colonoscopy seems to increase the quality of lymph node analysis. We advocate routine tattooing of all suspicious neoplasms at the time of colonoscopy.
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Affiliation(s)
- Katie Dawson
- Department of General, Thoracic and Vascular Surgery, Virginia Mason Medical Center, 1100 Ninth Ave., Seattle, WA 98101, USA
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Speicher JE, Thirlby RC, Burggraaf J, Kelly C, Levasseur S. Results of completion gastrectomies in 44 patients with postsurgical gastric atony. J Gastrointest Surg 2009; 13:874-80. [PMID: 19224297 DOI: 10.1007/s11605-009-0821-y] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/06/2008] [Accepted: 01/28/2009] [Indexed: 01/31/2023]
Abstract
INTRODUCTION Postsurgical gastric atony occurs infrequently after gastric surgery. However, the symptoms are disabling and refractory to medical management. The only effective treatment is completion gastrectomy. A few studies have examined in detail the long-term results of this radical procedure. METHODS From 1988 through 2007, 44 patients (84% female, 16% male) underwent near-total or total completion gastrectomies for refractory postsurgical gastric atony. The average age was 52 (range 32-72). Gastric atony was documented using radionuclide solid food emptying studies. Charts were reviewed retrospectively to identify preoperative symptoms and long-term postoperative function, and the patients were contacted by phone to evaluate their current level of function. RESULTS Of the original 44 patients, 66% (n = 29) were evaluated postoperatively at a mean of 5.6 + 4.5 years (range 0.5-15.0 years). Fourteen patients (32%) had died, and seven (16%) were lost to follow-up. Most common presenting symptoms were abdominal pain (98%), vomiting (98%), nausea (77%), diet limitation (75%), heartburn (64%), and weight loss (59%, average = 19% of BW). Postoperative complications occurred in 36% (n = 16), most commonly bowel obstruction (11%), anastomotic stricture (9%), and anastomotic leak (7%), and there was one perioperative death. At last follow-up, there were significant improvements in abdominal pain (97% to 59%, p < 0.001), vomiting (97% to 31%, p < 0.001), nausea (86% to 45%, p < 0.001), and diet limited to liquids or nothing at all (57% to 7%, p < 0.001). Some symptoms were more common postoperatively, including early satiety (24% to 89%, p < 0.001), and postprandial fullness (10% to 72%, p < 0.001). Average BMI at the time of surgery and at last follow-up were 23 and 21, respectively. Osteoporosis was diagnosed pre- and postoperatively in 17% and 67% of patients, respectively (p < 0.001). Seventy-eight percent of patients stated that they were in better health after surgery, while 17% were neutral, and 6% stated that they were worse off. Mean satisfaction with surgery was 4.7 (1-5 Likert scale). CONCLUSION Completion gastrectomies in this patient population resulted in significant improvements in abdominal pain, vomiting, nausea, and severe diet limitations. Most patients, however, have significant ongoing gastrointestinal complaints, and the incidence of osteoporosis is high. Patient satisfaction is high; about 78% of patients believed their health status is improved. We believe these data support the selective use of completion gastrectomies in patients with severe postsurgical gastroparesis.
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Affiliation(s)
- James E Speicher
- Department of General, Thoracic, and Vascular Surgery, Virginia Mason Medical Center, 1100 Ninth Ave, C6-GSUR, Seattle, WA 98111, USA
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Abstract
Based on current literature review, most patients with suspected or possible appendicitis should undergo cross-sectional imaging. CT scanning is preferred in most patients; US is recommended in children or pregnant women. MRI is usually indicated in women or children with nondiagnostic US. Thin young men with classic history, laboratory studies, and examination are best managed with standard appendectomy without imaging. Most other patients should undergo cross-sectional imaging (i.e., CT scan).
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Affiliation(s)
- Joshua D Hawkins
- Virginia Mason Medical Center, C6-GSUR, 1100 Ninth Avenue, P.O. Box 900, Seattle, WA 98111, USA
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Affiliation(s)
- Richard C Thirlby
- Section of General, Thoracic, and Vascular Surgery, Virginia Mason Medical Center, Seattle, WA 98111-0900, USA.
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Marshall GT, Thirlby RC, Bredfeldt JE, Hampson NB. Treatment of gastrointestinal radiation injury with hyperbaric oxygen. Undersea Hyperb Med 2007; 34:35-42. [PMID: 17393937] [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: 05/14/2023]
Abstract
BACKGROUND Chronic radiation enteritis develops in 5-20% of patients following abdominal and pelvic radiation. Current treatments are largely ineffective. OBJECTIVE To assess the effectiveness of hyperbaric oxygen therapy (HBO2) as a treatment for chronic radiation enteritis and evaluate the relative effectiveness in treatment of the proximal and distal gastrointestinal tract. DESIGN Case series of 65 consecutive patients with chronic radiation enteritis treated between July 1991 and June 2003 with HBO2. SETTING A tertiary referral academic medical center. PATIENTS 65 patients (37 male, 28 female; mean age 65 years) were treated with HBO2 for radiation damage to the alimentary tract. INTERVENTIONS Patients were treated with an initial series of 30 daily treatments, each administering 90 minutes of 100% oxygen at 2.36 atmospheres absolute pressure. Thirty-two patients with partial symptom response or endoscopic evidence of healing received an additional 6 to 30 treatments. RESULTS The primary indication for HBO2 was bleeding (n = 54) with 16 patients requiring transfusions. Additional indications were pain, diarrhea, weight loss, fistulas and obstruction. Follow-up ranged from 1 to 60 months (mean = 23 months). The main outcome measures were effects on bleeding, pain, diarrhea, weight loss, fistulas and obstruction. Endoscopic documentation of healing was used when available. The response rate was 68%, with a complete and partial response rate of 43 and 25%, respectively. The response rate for rectal disease was 65% and for proximal sites was 73%. The response rate for bleeding was 70% and for other symptoms was 58%. CONCLUSION This series represents the largest clinical series reported using HBO2 for treatment of radiation injury to the GI tract. The findings suggest that HBO2 results in healing or clinically significant improvement in two thirds of patients with chronic radiation enteritis.
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Affiliation(s)
- G T Marshall
- Section of General Surgery, Virginia Mason Medical Center Seattle, Washington, USA
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Liu SS, Richman JM, Thirlby RC, Wu CL. Efficacy of Continuous Wound Catheters Delivering Local Anesthetic for Postoperative Analgesia: A Quantitative and Qualitative Systematic Review of Randomized Controlled Trials. J Am Coll Surg 2006; 203:914-32. [PMID: 17116561 DOI: 10.1016/j.jamcollsurg.2006.08.007] [Citation(s) in RCA: 305] [Impact Index Per Article: 16.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2006] [Revised: 07/28/2006] [Accepted: 08/02/2006] [Indexed: 10/24/2022]
Affiliation(s)
- Spencer S Liu
- Department of Anesthesiology, Hospital for Special Surgery and the Weill College of Medicine of Cornell University, New York, NY 10021, USA.
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Affiliation(s)
- Clancy J Clark
- Department of General Surgery, Virginia Mason Medical Center, Seattle, Washington, USA
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Clark CJ, Thirlby RC, Picozzi V, Schembre DB, Cummings FP, Lin E. In Brief. Curr Probl Surg 2006. [DOI: 10.1067/j.cpsurg.2006.06.004] [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: 11/22/2022]
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Thirlby RC, Bahiraei F, Randall J, Drewnoski A. Effect of Roux-en-Y gastric bypass on satiety and food likes: the role of genetics. J Gastrointest Surg 2006; 10:270-7. [PMID: 16455461 DOI: 10.1016/j.gassur.2005.06.012] [Citation(s) in RCA: 45] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/01/2004] [Accepted: 06/15/2005] [Indexed: 01/31/2023]
Abstract
Among factors influencing the outcome of bariatric surgery may be genetics and familial risk. The purpose of this study was to assess the etiology of obesity and its impact on hunger, satiety, and food likes in obese patients undergoing Roux-en-Y gastric bypass (RYGB). This study was based on 76 patients undergoing RYGB procedures performed by a single surgeon. A previously described 100-point obesity risk index (ORI) was used to assess familial obesity risk. Hunger and satiety were assessed using a standardized Visual Analog Scale "Snickers" test, and food preferences for regular vs. low-fat potato chips were measured preoperatively and postoperatively. Patients were stratified preoperatively into high ORI (n = 34) and low ORI (n = 42) groups. Before operation, high-ORI patients preferred high-fat (regular) potato chips to low-fat (baked) potato chips, whereas the low-ORI patients liked both food types equivalently (P < 0.05). After operation (n = 43), both groups showed lower preferences for high-fat potato chips (P < 0.05 for high-ORI group). As anticipated, hunger was dramatically suppressed after RYGB. However, there was more satiety in the high-ORI group (P < 0.05, ANOVA). Most patients undergoing bariatric surgery had a strong familial or genetic component to their disease. RYGB in high-ORI patients was associated with a significant decline in preference of fatty food and a significantly prolonged drop in hunger ratings after a fast and after a standard 282 kcal meal. The success of bariatric surgery may be influenced by the etiology of obesity.
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Affiliation(s)
- Richard C Thirlby
- Department of Surgery, Virginia Mason Medical Center, 1100 Ninth Avenue, PO Box 900, Seattle, WA 98101-0900, USA.
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Cohen Z, Senagore AJ, Dayton MT, Koruda MJ, Beck DE, Wolff BG, Fleshner PR, Thirlby RC, Ludwig KA, Larach SW, Weiss EG, Bauer JJ, Holmdahl L. Prevention of postoperative abdominal adhesions by a novel, glycerol/sodium hyaluronate/carboxymethylcellulose-based bioresorbable membrane: a prospective, randomized, evaluator-blinded multicenter study. Dis Colon Rectum 2005; 48:1130-9. [PMID: 15868230 DOI: 10.1007/s10350-004-0954-8] [Citation(s) in RCA: 80] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
INTRODUCTION Postoperative abdominal adhesions are associated with significant morbidity and mortality, placing a substantial burden on healthcare systems worldwide. Development of a bioresorbable membrane containing up to 23 percent glycerol and chemically modified sodium hyaluronate/carboxymethylcellulose offers ease of handling and has been shown to provide significant postoperative adhesion prevention in animals. This study was designed to assess the safety of glycerol hyaluronate/carboxymethylcellulose and to evaluate its efficacy in reducing the incidence, extent, and severity of postoperative adhesion development in surgical patients. METHODS Twelve centers enrolled 120 patients with ulcerative colitis or familial polyposis who were scheduled for a restorative proctocolectomy and ileal pouch-anal anastomosis with diverting loop ileostomy. Before surgical closure, patients were randomized to no anti-adhesion treatment (control) or treatment with glycerol hyaluronate/carboxymethylcellulose membrane under the midline incision. At ileostomy closure, laparoscopy was used to evaluate the incidence, extent, and severity of adhesion formation to the midline incision. RESULTS Data were analyzed using the intent-to-treat population. Treatment with glycerol hyaluronate/carboxymethylcellulose resulted in 19 of 58 patients (33 percent) with no adhesions compared with 6 of 60 adhesion-free patients (10 percent) in the no treatment control group (P = 0.002). The mean extent of postoperative adhesions to the midline incision was significantly lower among patients treated with glycerol hyaluronate/carboxymethylcellulose compared with patients in the control group (P < 0.001). The severity of postoperative adhesions to the midline incision was significantly less with glycerol hyaluronate/carboxymethylcellulose than with control (P < 0.001). Adverse events were similar between treatment and no treatment control groups with the exception of abscess and incisional wound complications were more frequently observed with glycerol hyaluronate/carboxymethylcellulose. CONCLUSIONS Glycerol hyaluronate/carboxymethylcellulose was shown to effectively reduce adhesions to the midline incision and adhesions between the omentum and small bowel after abdominal surgery. Safety profiles for the treatment and no treatment control groups were similar with the exception of more infection complications associated with glycerol hyaluronate/carboxymethylcellulose use. Animal models did not predict these complications.
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Affiliation(s)
- Zane Cohen
- Department of Surgery, Mount Sinai Hospital, University of Toronto, Toronto, Canada
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Abstract
OBJECTIVE To review the potential and proven benefits and complications of epidural anesthesia/analgesia. SUMMARY BACKGROUND DATA Advances in analgesia/anesthesia have improved patient satisfaction and perioperative outcomes. Epidural anesthesia/analgesia is one of these advances that is gaining rapid acceptance due to a perceived reduction in morbidity and overall patient satisfaction. METHODS A MEDLINE search was conducted for all pertinent articles on epidural anesthesia/analgesia. RESULTS Retrospective, prospective, and meta-analysis studies have demonstrated an improvement in surgical outcome through beneficial effects on perioperative pulmonary function, blunting the surgical stress response and improved analgesia. In particular, significant reduction in perioperative cardiac morbidity ( approximately 30%), pulmonary infections ( approximately 40%), pulmonary embolism ( approximately 50%), ileus ( approximately 2 days), acute renal failure ( approximately 30%), and blood loss ( approximately 30%) were noted in our review of the literature. Potential complications related to epidural anesthesia/analgesia range from transient paresthesias (<10%) to potentially devastating epidural hematomas (0.0006%). CONCLUSIONS Epidural anesthesia/analgesia has been demonstrated to improve postoperative outcome and attenuate the physiologic response to surgery.
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Affiliation(s)
- Robert J Moraca
- Department of Surgery, Virginia Mason Medical Center, Seattle, Washington 98101, USA
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36
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Abstract
BACKGROUND The influence of genetics on obesity is well established. Adoption studies and twin studies suggest that about 80% of the obesity risk is genetic. We designed a tool to predict outcomes of treatments in patients with sporadic or familial obesity. METHODS Two factors best correlate with multifactorial genetic risk: 1) familial history and 2) age of onset. 147 morbidly obese adults self- or physician-referred for possible surgery for morbid obesity (age 17-66 y, BMI 35-82) were studied. Six elements were selected to measure the genetic influence on patients' weight: 3 personal weight milestones (weight at age 10, 20 and 30), and 3 family history factors (parents' weight, siblings' weight and second degree relatives' weight. These 6 elements of personal and family history information were collected prospectively on 35 obese patients and a feasible scoring system devised, with 0 points signifying no genetic component and 100 points suggesting the maximal possible genetic risk for obesity. Prospective data were then collected on 147 consecutive patients seen in consultation for possible bariatric surgery, to provide this "obesity risk index" (ORI). RESULTS The final scoring system for the ORI assigned 50 possible points for personal weight milestones and 50 possible points for family history factors. At age 10, patients receive 10 or 20 points for being 2 or 3 SD above the mean BMI for age, respectively. At age 20, 10 or 20 points are received for BMI > 30 or 40, respectively. At age 30, 5 or 10 points are received for BMI > 35 or 50, respectively. 0 to 28 points are awarded for parental obesity, with 7 or 14 points for each parent with BMI > 30 or 40, respectively. The mean BMI of all siblings was calculated, with 6 or 12 points received for mean BMI greater than 30 or 40, respectively. Two points are awarded for each second degree relative with BMI > 35, to a maximum of 10 points. The mean (+/- SEM) score for our first 114 patients was 32 +/- 2 (range 0 to 87). The median score was 28.13% of patients had scores < 10; conversely, 13% scored points on all 6 elements. CONCLUSION An ORI has been devised to quantify the genetic contribution to an individual's weight. Using this scoring system, we found that about 85% of patients who are candidates for bariatric surgery have elements in their history to suggest a genetic risk for morbid obesity. About 15% have extremely strong genetic ORIs.
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Affiliation(s)
- Richard C Thirlby
- Virginia Mason Medical Center, 1100 Ninth Avenue, C6-SUR, P.O. Box 900, Seattle, WA 98111-0900, USA.
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Abstract
The optimal treatment of patients with small bowel obstruction should be predicated upon answering the following diagnostic questions in each patient: 1) does the patient have mechanical bowel obstruction or an ileus?, 2) could the patient have colonic obstruction or a cause of obstruction other than adhesions (eg, hernia, cancer, Crohn's disease)?, 3) is the obstruction partial or complete?, and 4) is strangulation present, and hence immediate operation necessary, or is a period of observation appropriate? The most efficient way to answer these questions in many patients is by performing a careful history and physical examination, laboratory tests, and CT scanning. Surgical intervention should occur within 48 hours of admission in the vast majority of patients with complete small bowel obstruction due to adhesions. The chance for durable endoscopic treatment of any patient with SBO, in our opinion, is remote.
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Affiliation(s)
- Joshua M. Cooper
- Department of Surgery, Virginia Mason Medical Center, 1100 Ninth Avenue, C6-SUR,Seattle, Washington 98101, USA.
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Affiliation(s)
- D Sheldon
- Virginia Mason Medical Center, Seattle, WA, USA
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39
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Abstract
BACKGROUND After esophagectomy, the stomach is the most commonly utilized reconstructive conduit. There remains debate among surgeons regarding the requirements for pyloroplasty/pyloromyotomy following reconstruction. We present a series of patients having undergone near total esophagectomy and reconstruction with gastric tube without gastric emptying procedure to analyze critically these patients' ability to reestablish a subjectively acceptable and nutritionally adequate eating pattern without significant side effects of early satiety, dumping, or diarrhea. METHODS Between 1991 and 1998, 48 patients underwent esophagectomy utilizing this technique and were available for long-term follow-up and nutritional assessment. Patient weights were recorded at 2 weeks, 6 months, and 1 year and a telephone interview conducted at a mean of 36 months postoperatively for the evaluation of eating patterns and symptoms. A subgroup of these patients (32 of 48) completed a 3-day dietary record that was assessed by a certified nutritionist. This patient group included 10 patients (21%) who had received perioperative chemoradiotherapy. RESULTS Dietary intake was characterized as normal or minimally limited in 41 patients (85%). Those who had received perioperative chemoradiotherapy needed no significant increased time to return to a normal dietary baseline (6.1 versus 5.9 months). Mean weight loss prior to surgery was 3 kg. Weight loss continued for the first 6 months (mean 10 kg); however, 63% were able to gain weight from 6 months to 1 year following surgery (mean 3 kg). Most patients were overweight prior to operation (mean 115% of ideal body weight) and achieved a new postoperative baseline (mean 104% of ideal body weight) at 1 year. Patients demonstrated a mean daily caloric intake of 2,179 kilocalories per day, which was 98% of recommended according to their ideal body weight. Postoperative symptoms of short-term nausea (19%), occasional dysphagia with certain foods (38%), mild increased stool frequency (15%), and occasional regurgitation (25%) were noted. CONCLUSIONS Near-total esophagectomy with verticalized gastric tube without a gastric emptying procedure is well tolerated and allows a return to subjectively acceptable and nutritionally appropriate dietary eating pattern without significant associated side effects.
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Affiliation(s)
- D J Ludwig
- Section of General, Thoracic, and Vascular Surgery, Virginia Mason Medical Center, 1100 9th Avenue, C6-GSUR, Seattle, WA 98111, USA
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Thirlby RC, Sobrino MA, Randall JB. The long-term benefit of surgery on health-related quality of life in patients with inflammatory bowel disease. Arch Surg 2001; 136:521-7. [PMID: 11343542 DOI: 10.1001/archsurg.136.5.521] [Citation(s) in RCA: 51] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
HYPOTHESES Health-related quality of life (HRQL) has been shown to improve dramatically shortly after surgery in patients with inflammatory bowel disease (IBD). Our hypotheses were that (1) improved HRQL would be maintained long term in patients after surgery for ulcerative colitis and (2) the improved HRQL in patients with Crohn disease would decline with long-term follow-up. DESIGN Consecutive series of patients undergoing surgery for IBD between June 1994 and January 2000 prospectively investigated as a cohort outcomes study. PATIENTS Data were obtained in 139 patients. The diagnoses were Crohn disease (n = 56) and ulcerative colitis (n = 83). INTERVENTION Patients with Crohn disease underwent resections with or without stricturoplasties; all but 5 patients with ulcerative colitis underwent ileal pouch-anal anastomoses. MAIN OUTCOME MEASURE Health status was measured using the Health Status Questionnaire (HSQ) preoperatively and then every 3 months postoperatively. RESULTS Preoperative HSQ scores were very low in all 8 scales of the HSQ. Postoperatively, HRQL measures improved significantly (P<.05) both in patients with Crohn disease and ulcerative colitis, with scores equal to or better than published scores in the general population. In patients with Crohn disease, the scores improved significantly after surgical resection and steadily increased despite disease recurrence and reoperations. The HRQL at last follow-up was equivalent to the general population. The improvements were statistically significant in patients followed up for more than 1 year in 7 of 8 scales of the HSQ. CONCLUSIONS These results confirm that HRQL is poor in patients with IBD referred for possible operation. Surgical resection resulted in significant improvement in HRQL. More important, the results were durable. With follow-up up to 6 years, the HRQL in this cohort was equal to or better than norms for the general population both in patients with ulcerative colitis and with Crohn disease. We believe these data justify aggressive surgical intervention in many patients with IBD and support the prospective study of HRQL by surgeons treating patients with chronic diseases.
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Affiliation(s)
- R C Thirlby
- Section of General, Thoracic, and Vascular Surgery, Virginia Mason Medical Center, 1100 Ninth Ave, PO Box 900 (C6-GSUR), Seattle, WA 98111, USA.
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Abstract
Total colectomy, mucosal proctectomy, and ileal J pouch-anal anastomosis (IPAA) has become the procedure of choice for patients with ulcerative colitis and familial adenomatous polyposis. The purpose of this study was to determine the short- and long-term outcomes of patients undergoing IPAA by a single surgeon, correlating intraoperative technical aspects with outcomes, and to characterize better the clinical syndrome of pouchitis. A retrospective review was performed of 114 consecutive patients who underwent IPAA by a single surgeon between December 1987 and August 1996. Clinical follow-up and operative notes were reviewed, and patient questionnaires were obtained for all patients. The mean follow-up was 3 years (range 0.5-8.0 years). The average age of the patients was 39 years (range 16-72 years). There were 64 males and 50 females. Indications for operation were ulcerative colitis (n = 101) and familial polyposis coli (n = 13). Long-term morbidity occurred in 41% of patients (small bowel obstruction 10%, anastomotic stricture 9%). Pouch excision was required in only three patients. Stool frequency (mean +/- SE) was 6.1 +/- 0.2 and did not change with duration of follow-up. Only 7% of patients reported fecal soilage. The incidence of pouchitis was 59% (n = 67), with 4.2 +/- 0.3 episodes of pouchitis per patient. Using multivariate analysis, the factors significantly associated with the incidence of pouchitis were gender (p = 0.008) and duration of follow-up (p = 0. 02). A total of 37 of 50 women (74%) but only 30 of 64 men (47%) developed pouchitis. The incidence of pouchitis increased with the duration of follow-up. The incidences of pouchitis in patients followed for 6 months, 1 year, and 3 years were 25%, 37%, and 50%, respectively. Of patients followed more than 6 years, the incidence of pouchitis was 94% (15/16). There was not a significant correlation between anastomotic tension or the extent of arterial dissection of the ileal mesentery required to achieve IPAA and the incidence of pouchitis. The best antibiotics for pouchitis were metronidazole (54% of patients) and ciprofloxacin (37%). Eleven patients have required nearly continuous antibiotics. Patient satisfaction with the outcome is high, with a mean satisfaction of 8. 4 (0, dissatisfied; 10, extremely satisfied). This review demonstrates a high incidence of pouchitis in patients after IPAA, which is due to the more liberal definition of the syndrome and the complete follow-up achieved in this report compared to previous series. This study also is unique in identifying the significantly higher incidence of pouchitis in women, although the overall satisfaction with the clinical outcome in patients undergoing IPAA remains high.
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Affiliation(s)
- E J Simchuk
- Section of General, Thoracic, and Vascular Surgery, Virginia Mason Medical Center, Seattle, WA 98111, USA
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Sheldon DG, Sawchuk LL, Kozarek RA, Thirlby RC. Twenty cases of peristomal pyoderma gangrenosum: diagnostic implications and management. Arch Surg 2000; 135:564-8; discussion 568-9. [PMID: 10807281 DOI: 10.1001/archsurg.135.5.564] [Citation(s) in RCA: 103] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
HYPOTHESIS Our experience with peristomal ulcers suggested that peristomal pyoderma gangrenosum (PPG) is an infrequent and usually unrecognized complication of inflammatory bowel disease. We hypothesized that a review of our experience with PPG would clarify the essentials of its diagnosis, evaluation, and treatment. DESIGN A case series of 20 consecutive patients with PPG complicating inflammatory bowel disease were treated at our institution between 1986 and 1999. There were 15 women and 5 men. At the time of development of peristomal pyoderma, 10 of 20 patients had a diagnosis of Crohn disease (CD), while 9 had a diagnosis of ulcerative colitis (UC). One patient was diagnosed as having CD only after first developing PPG. MAIN OUTCOME MEASURE Healing of PPG. INTERVENTIONS All patients had failed local enterostomal care prior to referral. Debridements and/or stomal revisions were uniformly unsuccessful. Biopsies, when performed, did not provide clinically important information. Treatment was directed toward inflammatory bowel disease, with variable clinical responses to corticosteroids, metronidazole, cyclosporine, sulfasalazine, and infliximab. RESULTS Ultimately, 13 patients had a diagnosis of CD. Of these patients, 12 (92%) of 13 developed PPG coincident with recurrent disease. Two patients had a remote history of proctocolectomy for UC and subsequent evaluation revealed CD. One patient developed PPG adjacent to a urinary Kock pouch after cystectomy; ultimately, a diagnosis of CD was made. No patients were lost to follow-up, but in 1 case of UC, no evaluation for latent CD was carried out. The final diagnosis was CD disease in 13 (65%) of 20 and UC in 7 (35%) of 20 patients. All PPG ulcers healed completely, within an average of 11.4 months (median, 8 months; range, 1-41 months). Ulcer resolution was achieved with medical therapy alone in 14 (70%) of 20 cases. Resection of active gastrointestinal CD resulted in healing in 5 (83%) of 6 cases. One case healed 2 months after conservative therapy only. CONCLUSIONS This review of the largest reported series of PPG suggests the following: (1) PPG complicating inflammatory bowel disease is uncommon and often misdiagnosed by clinicians; (2) local wound care measures have little role in the healing of PPG; (3) PPG usually heralds active CD; (4) in patients with prior history of UC, PPG indicates CD until proven otherwise; (5) prolonged medical therapy (11 months), usually with immunosupression, is required for healing of PPG; and (6) if feasible, surgical resection of all active CD leads to the healing of PPG ulcers.
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Affiliation(s)
- D G Sheldon
- Section of General Thoracic, and Vascular Surgery, Virginia Mason Medical Center, Seattle, Wash 98111, USA
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Thirlby RC, Land JC, Fenster LF, Lonborg R. Effect of surgery on health-related quality of life in patients with inflammatory bowel disease: a prospective study. Arch Surg 1998; 133:826-32. [PMID: 9711955 DOI: 10.1001/archsurg.133.8.826] [Citation(s) in RCA: 73] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
BACKGROUND Health-related quality of life (HRQL) has increasingly become a factor in management decisions in patients with chronic diseases. OBJECTIVE To measure the effect of surgical resection on quality of life in patients with inflammatory bowel disease (IBD). DESIGN A consecutive series of patients undergoing surgery for IBD between June 1994 and December 1997 were prospectively investigated as a cohort outcomes study. PATIENTS Data were obtained in 63 patients. The primary diagnoses were Crohn's disease (n = 36) and ulcerative colitis (n = 27). INTERVENTION Patients with Crohn's disease underwent resection with or without stricturoplasty for intractable disease; all but 3 patients with ulcerative colitis underwent ileoanal anastomoses with ileoanal reservoir. MAIN OUTCOME MEASURE Health status was measured using the Health Status Questionnaire preoperatively and every 3 months postoperatively. RESULTS Preoperative measures of HRQL of the patients were low, with values well below the general population in all 8 scales of the Health Status Questionnaire. Postoperatively, HRQL measures improved significantly (P < .05) in both patients with Crohn's disease and those with ulcerative colitis, with scores equal to the general population in most scales. For example, average raw scores for general health in previously studied patient groups were 59 in patients with asthma, 55 in those with diabetes mellitus, 74 in the general population, and 54 and 73 preoperatively and postoperatively, respectively, in the present study. CONCLUSIONS The results of this study confirm that HRQL scores are low in many patients with IBD referred for operation and HRQL scores improve postoperatively to levels comparable to those of the general population. We believe these data justify early surgical intervention in many patients with symptomatic IBD.
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Affiliation(s)
- R C Thirlby
- Section of General, Thoracic, and Vascular Surgery, Virginia Mason Medical Center, Seattle, Wash 98111, USA.
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Abstract
BACKGROUND Recent studies have suggested that critical pathways and standard order sets decrease hospital length of stay and improve quality of care. A recently conducted prospective, randomized study at our institution found that patients undergoing elective colon resections had earlier return of bowel function if perioperative epidural anesthesia and analgesia were provided. All patients in the study were also placed on a standardized perioperative regimen. We hypothesized that the standardized perioperative protocol used in this study contributed to early return of bowel function and hospital discharge compared with similar patients managed off protocol. STUDY DESIGN To test this hypothesis, we performed a case-controlled study comparing the hospital courses of 36 study patients to 36 control patients undergoing colorectal surgery by the same surgeons during the same calendar year. The distribution of types of operations and anesthetic techniques was similar in both groups. RESULTS As dictated by the protocol, all study patients had their nasogastric tubes removed, were started on a low fat liquid diet, and ambulated in the first postoperative day. Nasogastric tubes were removed in control patients and study patients 2.2 +/- 0.9 (mean value +/- SD) and 1.0 +/- 0.0 days postoperatively, respectively. Control patients were started on an oral diet, usually clear liquids, an average of 2.9 +/- 1.1 days postoperatively, a specific liquid diet was started 1.0 day postoperatively in study patients (p < 0.001). Return of bowel function, as determined by bowel tones, flatus, and bowel movements, occurred approximately 1 day earlier in study patients. Study patients were discharged 1 day sooner than control patients. CONCLUSIONS Our results suggest that the return of bowel function and the length of stay of patients undergoing colon surgery are improved if patients are entered into a standardized protocol that eliminates variation in intraoperative and postoperative anesthesia and postoperative surgical care. We believe these results can be reproduced in routine clinical surgery by having a clearly outlined protocol for perioperative care similar to that used in this study.
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Affiliation(s)
- B G Bradshaw
- Department of Anesthesia, Virginia Mason Medical Center, Seattle, WA 98111, USA
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Abstract
BACKGROUND Bile duct calculi (BDC) can be cleared or treated with modern endoscopic techniques in most patients. However, large stones, bile duct strictures, or unusual anatomy may make endoscopic clearance difficult. The purpose of the present study was to determine the efficacy of extracorporeal shock-wave lithotripsy (ESWL) in treating patients with complicated BDC. METHODS Between 1989 and January 1995, 16 patients with BDC were treated at our institution with ESWL using a Dornier HM-3 lithotropter. The average age of patients was 62 years (range 32 to 88). Endoscopic retrograde cholangiopancreatography (ERCP) with sphincterotomy and attempted stone extraction (100%), nasobiliary drainage (83%), and biliary stents (6%) were used prior to ESWL. Eleven patients (61 %) had solitary stones, ranging in diameter from 0.5 to 2.6 cm, whereas 7 patients had multiple stones, ranging in diameter from 0.5 to 5.0 cm. The indications for ESWL were stone impaction (56%), stone size (38%), and bile duct stricture (6%). RESULTS The 16 patients received 27 ESWL treatments (mean = 2101 shock at 21 kV); with 4 patients (22%) requiring multiple treatments. Stone fragmentation was achieved in 94% of patients. All patients had ERCP performed post-ESWL, and only 2 (13%) patients required immediate operations. At discharge, 94% of patients were stone-free. Minor complications (eg, pain, hematuria) were common. With an average follow-up of 3 years, only 1 patient (6%) has required retreatment for BDC. Hepatic transplantation was required in an additional patient. CONCLUSIONS In this cohort of patients with both major medical comorbidities and/or technical contraindications to standard methods of endoscopic and surgical clearance of BDC, we found that ESWL facilitated stone clearance in 94% of patients with minimal morbidity and no mortality. In our opinion, ESWL should be used more frequently in the treatment of these complex patients.
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Affiliation(s)
- D M White
- Virginia Mason Medical Center, Seattle, Washington 98111, USA
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Abstract
Because transpapillary stents have been successfully placed to treat the ductal disruptions associated with pseudocysts, pancreatic ascites and pleural effusions, and pancreaticoenteric fistulas, we reviewed our experience with endoscopically placed prostheses in patients who had persistent pancreaticocutaneous fistulas but an otherwise intact duct. Nine patients who underwent endoscopic transpapillary stent placement for ongoing pancreaticocutaneous fistulas at our institution were retrospectively reviewed. Fistulas were present for a mean (+/-SEM) of 35 +/- 11 days and averaged 225 +/- 55 ml of output daily. Etiology of the fistulas included percutaneous pseudocyst drainage in four patients, pancreatic necrosis in two, complications of pancreatic surgery in two, and perforation of the duct of Santorini at the time of minor sphincterotomy in one. All patients had an otherwise intact duct at the time of endoscopic retrograde cholangiopancreatography. Six patients had transpapillary stents placed that did not bridge the area of leakage and three had prostheses placed across the ductal disruption. Eight of nine fistulas were successfully closed by means of this technique including five within 48 hours. There was one instance of stent migration and one patient developed prosthesis occlusion and an infected pseudocyst, which was treated with stent exchange. Stents were retrieved 10 to 14 days after fistula closure and no patient has had a recurrence at a median follow-up of 3 years. Transpapillary stents appear to effect closure of pancreaticocutaneous fistulas that fail to respond to conventional therapy.
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Affiliation(s)
- R A Kozarek
- Sections of Gastroenterology and General Surgery, Virginia Mason Medical Center, Seattle, Wash, USA
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Thirlby RC, Kelly R. Pectin and methyl cellulose do not affect intestinal function in patients after ileal pouch-anal anastomosis. Am J Gastroenterol 1997; 92:99-102. [PMID: 8995946] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
OBJECTIVES Although ileal pouch-anal anastomosis is the procedure of choice for most patients with ulcerative colitis or familial adenomatous polyposis, most patients have problems with stool frequency and/or consistency. Although most clinicians recommend fiber supplementation for these patients, we could find no studies that prove the efficacy of this practice. The first purpose of this study was to document the effect of fiber supplementation on intestinal function in patients after ileal pouch-anal anastomosis. Because pectin, a soluble fiber supplement, has been reported to slow gastric and intestinal transit, we also hypothesized that pectin would be a superior fiber supplement in these patients. The second purpose, therefore, was to determine whether the effects of pectin on intestinal transit would result in decreased stool frequency in patients with an ileal pouch. METHODS Thirteen patients who had undergone ileal pouch-anal anastomosis for ulcerative colitis were entered into a 9-wk crossover study. The protocol consisted of three 2-wk study periods, each of which was preceded by a 1-wk washout period. During the three study periods patients supplemented their diets, in random order, with Citrucel, 1 tablespoon twice daily; pectin, 1 tablespoon twice daily; or no supplement. Patients maintained detailed dietary and bowel function diaries. RESULTS The effects (mean +/- SE) of Citrucel and pectin supplementation are summarized in Table 1. There was no significant effect of either supplement on stool frequency, pouch function, bloating, or stool consistency. In addition, there were no differences in continence. CONCLUSIONS We found no evidence to support the common practice of fiber supplementation in patients with an ileal pouch. Furthermore, this study did not find that stool frequency decreased during supplementation with pectin. We conclude that there is little role for fiber supplementation in patients with an ileal pouch.
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Affiliation(s)
- R C Thirlby
- Department of Surgery, Virginia Mason Medical Center, Seattle, Washington, USA
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Thirlby RC, Quigley TM, Anderson RP. The shift toward a managed care environment in a multispecialty group practice model. Looking for reciprocal benefits. Arch Surg 1996; 131:1027-31. [PMID: 8857897 DOI: 10.1001/archsurg.1996.01430220021004] [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] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
Managed care is notably affecting the practice of surgery in the United States. Four principal elements are subject to change: (1) patient care patterns, (2) ethics, (3) education and research, and (4) surgeon compensation. The Virginia Mason Clinic, a multispecialty group practice, is adapting to the demands of managed and capitated care. With the patient as the primary focus of effort, the goal is to create optimum value in health care. The principles of Continuous Quality Improvement are used to increase value in health care by ensuring appropriate treatment with optimum outcome at reasonable cost. Practice patterns are shifting to provide value to patients and payers. Ethical conflicts threaten but have been avoided. Surgical education remains unaffected, but future funding is problematic. The emphasis in surgical research has shifted toward outcome-based studies. The conflict between work effort and resource conservation as determinants of physician compensation is less for surgical than for medical practitioners. Although the principal benefactors of the shift toward managed care have been the payers, patients have gained modestly through efficiencies in the health care process and more stable insurance premiums. The satisfaction level of the surgeons in our multispecialty group practice remains high. Surgical research is thriving, volumes and case mix remain excellent, and changes in practice pattern have enabled us to increase efficiency without compromising patient care.
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Affiliation(s)
- R C Thirlby
- Virginia Mason Medical Center, Department of Surgery, Seattle, Wash., USA
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Abstract
OBJECTIVE To review the results of laparoscopic cholecystectomy (LC) in patients with acute cholecystitis with attention to cost and clinical outcome. DESIGN Retrospective study. SETTING Large private metropolitan teaching hospital. PATIENTS Four hundred forty-six patients had LCs at our institution between January 1993 and February 1995. Acute cholecystitis, confirmed by clinical, laboratory, operative, and histopathological findings, was present in 60 patients. MAIN OUTCOME MEASURES The medical history, laboratory findings, gallbladder ultrasounds, timing of operation from the onset of symptoms, conversion rates to open procedures, operative times, intraoperative findings, complications, postoperative length of stay, cost of operative procedures and hospitalizations, and convalescence times were collected. RESULTS Laparoscopic cholecystectomy was attempted in 16 patients within 72 hours of the onset of symptoms of acute cholecystitis (group 1), in 19 patients with symptoms between 4 and 7 days (group 2), and in 25 patients with symptoms lasting more than 7 days (group 3). The only factor (eg, preoperative laboratory and ultrasound findings) that affected the outcome of the operation was duration of symptoms prior to operation. Patients who had LC done within 72 hours of the onset of symptoms had lower rates of conversion to open procedures, less difficult operations, shorter operative times, less costly procedures, and a shorter convalescence than those with symptoms for longer than 72 hours prior to operation. The conversion rates in patients operated within and after 72 hours were 12% and 30%, respectively. There were no bile duct injuries and no mortalities. CONCLUSIONS Laparoscopic cholecystectomy can be performed safely in most patients with acute cholelithiasis. However, we found that the duration of symptoms prior to LC affected the outcome; the conversion rates, hospital costs, and convalescence times increased in operated-on patients with symptoms for more than 72 hours. In our opinion, interval cholecystectomy may be a superior option in this latter group of patients.
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Affiliation(s)
- K P Koo
- Department of Surgery, Virginia Mason Medical Center, Seattle, Wash., USA
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Enayati PG, Traverso LW, Galagan K, Thirlby RC, Larson J, Hauptman EM, Kozarek RA. The meaning of equivocal pancreatic cytology in patients thought to have pancreatic cancer. Am J Surg 1996; 171:525-8. [PMID: 8651401 DOI: 10.1016/s0002-9610(96)00020-7] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
INTRODUCTION Fine needle aspirations (FNAs) and endoscopic retrograde cholangiopancreatography (ERCP)-guided brushings (BRUSH) are useful tools in the differentiation between malignant and benign disease of the pancreas. Once the decision to obtain a cytologic confirmation of one's clinical suspicion is made, the interpretation of the findings, especially an equivocal or negative cytology finding, can be unclear. This study seeks to evaluate the utility of cytologic studies in the evaluation of a patient with suspected pancreatic malignancy. METHODS A retrospective review of 224 cytologic reports, including 174 FNAs and 50 BRUSHs, from all pancreatic FNAs and BRUSHs performed between January 1989 and June 1995, was performed. Subsequent confirmation of the cytologic diagnosis was made either by histologic or strict clinical criteria. RESULTS Forty-three percent of the cytologic reports were read as malignant, all others reported as suspicious, atypical, or negative. All cytology studies read as malignant and all FNAs reported as suspicious were histologically or clinically confirmed to be malignant. Of those reported as atypical or negative, 55% and 49% were confirmed to be malignant. Both FNA and BRUSH were 100% specific, 75% sensitive, and 80% accurate. CONCLUSIONS We conclude that a cytological diagnosis of malignant or suspicious is reliable and useful for further therapy planning in the patient suspected to have a pancreatic malignancy. The reason for the cytologic tests was a strong clinical suspicion, therefore, a high incidence of cancer was found in the patients with atypical or negative readings. A diagnosis of atypical or negative is equivocal and requires further diagnostic maneuvers, frequently including surgery, to make the definitive diagnosis.
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Affiliation(s)
- P G Enayati
- Department of General Surgery, Virginia Mason Medical Center, Seattle, Washington 98111, USA
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