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Unruh KR, Bastawrous AL, Kanneganti S, Kaplan JA, Moonka R, Rashidi L, Sillah A, Simianu VV. The Impact of Prolonged Operative Time Associated With Minimally Invasive Colorectal Surgery: A Report From the Surgical Care Outcomes Assessment Program. Dis Colon Rectum 2024; 67:302-312. [PMID: 37878484 DOI: 10.1097/dcr.0000000000002925] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/27/2023]
Abstract
BACKGROUND Increased operative time in colorectal surgery is associated with worse surgical outcomes. Laparoscopic and robotic operations have improved outcomes, despite longer operative times. Furthermore, the definition of "prolonged" operative time has not been consistently defined. OBJECTIVE The first objective was to define prolonged operative time across multiple colorectal operations and surgical approaches. The second was to describe the impact of prolonged operative time on length of stay and short-term outcomes. DESIGN A retrospective cohort study. SETTING Forty-two hospitals in the Surgical Care Outcomes Assessment Program from 2011 to 2019. PATIENTS There were a total of 23,098 adult patients (age 18 years or older) undergoing 6 common, elective colorectal operations: right colectomy, left/sigmoid colectomy, total colectomy, low anterior resection, IPAA, or abdominoperineal resection. MAIN OUTCOME MEASURES Prolonged operative time defined as the 75th quartile of operative times for each operation and approach. Outcomes were length of stay, discharge home, and complications. Adjusted models were used to account for factors that could impact operative time and outcomes across the strata of open and minimally invasive approaches. RESULTS Prolonged operative time was associated with longer median length of stay (7 vs 5 days open, 5 vs 4 days laparoscopic, 4 vs 3 days robotic) and more frequent complications (42% vs 28% open, 24% vs 17% laparoscopic, 27% vs 13% robotic) but similar discharge home (86% vs 87% open, 94% vs 94% laparoscopic, 93% vs 96% robotic). After adjustment, each additional hour of operative time above the median for a given operation was associated with 1.08 (1.06-1.09) relative risk of longer length of stay for open operations and 1.07 (1.06-1.09) relative risk for minimally invasive operations. LIMITATIONS Our study was limited by being retrospective, resulting in selection bias, possible confounders for prolonged operative time, and lack of statistical power for subgroup analyses. CONCLUSIONS Operative time has consistent overlap across surgical approaches. Prolonged operative time is associated with longer length of stay and higher probability of complications, but this negative effect is diminished with minimally invasive approaches. See Video Abstract . EL IMPACTO DEL TIEMPO OPERATORIO PROLONGADO ASOCIADO CON LA CIRUGA COLORRECTAL MNIMAMENTE INVASIVA UN INFORME DEL PROGRAMA DE EVALUACIN DE RESULTADOS DE ATENCIN QUIRRGICA ANTECEDENTES:El aumento del tiempo operatorio en la cirugía colorrectal se asocia con peores resultados quirúrgicos. Las operaciones laparoscópicas y robóticas han mejorado los resultados, a pesar de los tiempos operatorios más prolongados. Además, la definición de tiempo operatorio "prolongado" no se ha definido de manera consistente.OBJETIVO:Primero, definir el tiempo operatorio prolongado a través de múltiples operaciones colorrectales y enfoques quirúrgicos. En segundo lugar, describir el impacto del tiempo operatorio prolongado sobre la duración de la estancia y los resultados a corto plazo.DISEÑO:Estudio de cohorte retrospectivo.ESCENARIO:42 hospitales en el Programa de Evaluación de Resultados de Atención Quirúrgica de 2011-2019.PACIENTES:23 098 pacientes adultos (de 18 años de edad y mayores), que se sometieron a seis operaciones colorrectales electivas comunes: colectomía derecha, colectomía izquierda/sigmoidea, colectomía total, resección anterior baja, anastomosis ileoanal con bolsa o resección abdominoperineal.PRINCIPALES MEDIDAS DE RESULTADO:Tiempo operatorio prolongado definido como el cuartil 75 de tiempos operatorios para cada operación y abordaje. Los resultados fueron la duración de la estancia hospitalaria, el alta domiciliaria y las complicaciones. Se usaron modelos ajustados para tener en cuenta los factores que podrían afectar tanto el tiempo operatorio como los resultados en los estratos de abordajes abiertos y mínimamente invasivos.RESULTADOS:El tiempo operatorio prolongado se asoció con una estancia media más prolongada (7 vs. 5 días abiertos, 5 vs. 4 días laparoscópicos, 4 vs. 3 días robóticos), complicaciones más frecuentes (42 % vs. 28 % abiertos, 24 % vs. 17 % laparoscópica, 27% vs. 13% robótica), pero similar alta domiciliaria (86% vs. 87% abierta, 94% vs. 94% laparoscópica, 93% vs. 96% robótica). Después del ajuste, cada hora adicional de tiempo operatorio por encima de la mediana para una operación determinada se asoció con un riesgo relativo de 1,08 (1,06, 1,09) de estancia hospitalaria más larga para operaciones abiertas y un riesgo relativo de 1,07 (1,06, 1,09) para operaciones mínimamente invasivas.LIMITACIONES:Nuestro estudio estuvo limitado por ser retrospectivo, lo que resultó en un sesgo de selección, posibles factores de confusión por un tiempo operatorio prolongado y falta de poder estadístico para los análisis de subgrupos.CONCLUSIONES:El tiempo operatorio tiene una superposición constante entre los enfoques quirúrgicos. El tiempo operatorio prolongado se asocia con una estadía más prolongada y una mayor probabilidad de complicaciones, pero este efecto negativo disminuye con los enfoques mínimamente invasivos. ( Traducción-Dr. Mauricio Santamaria ).
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Affiliation(s)
- Kenley R Unruh
- Department of Surgery, Virginia Mason Franciscan Health, Seattle, Washington
| | - Amir L Bastawrous
- Swedish Cancer Institute, Swedish Medical Center, Seattle, Washington
| | - Shalini Kanneganti
- Franciscan Surgical Associates at St Joseph Hospital, Tacoma, Washington
| | - Jennifer A Kaplan
- Department of Surgery, Virginia Mason Franciscan Health, Seattle, Washington
| | - Ravi Moonka
- Department of Surgery, Virginia Mason Franciscan Health, Seattle, Washington
| | - Laila Rashidi
- MultiCare Colon and Rectal Surgery, Tacoma, Washington
| | - Arthur Sillah
- School of Public Health, University of Washington, Seattle, Washington
- Surgical Care Outcomes Assessment Program, Seattle, Washington
| | - Vlad V Simianu
- Department of Surgery, Virginia Mason Franciscan Health, Seattle, Washington
- Surgical Care Outcomes Assessment Program, Seattle, Washington
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Kim HC, Simianu VV. Contemporary management of anorectal fistula. Surg Open Sci 2024; 17:40-43. [PMID: 38268776 PMCID: PMC10806345 DOI: 10.1016/j.sopen.2023.12.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2023] [Accepted: 12/27/2023] [Indexed: 01/26/2024] Open
Abstract
Anorectal fistula is a common, chronic condition, and is primarily managed surgically. Herein, we provide a contemporary review of the relevant etiology and anatomy anorectal fistula, treatment recommendations that summarize relevant outcomes and alternative considerations, in particular when to refer to a fistula expert.
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Affiliation(s)
- Hyung Chan Kim
- Department of Surgery, Virginia Mason Franciscan Health, Seattle, WA, United States of America
| | - Vlad V. Simianu
- Department of Surgery, Virginia Mason Franciscan Health, Seattle, WA, United States of America
- Center for Digestive Health, Virginia Mason Franciscan Health, Seattle, WA, United States of America
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Stovall SL, Johnson MP, Evans ET, Kaplan JA, Law JK, Moonka R, Bahnson HT, Simianu VV. Understanding the Geographic Distribution of Diverticulitis Hospitalizations in Washington State. Am Surg 2023; 89:5720-5728. [PMID: 37144833 DOI: 10.1177/00031348231174002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/06/2023]
Abstract
BACKGROUND The incidence of diverticulitis in the United States is increasing, and hospitalization remains a surrogate for disease severity. State-level characterization of diverticulitis hospitalization is necessary to better understand the distribution of disease burden and target interventions. METHODS A retrospective cohort of diverticulitis hospitalizations from 2008 through 2019 was created using Washington State's Comprehensive Hospital Abstract Reporting System. Hospitalizations were stratified by acuity, presence of complicated diverticulitis, and surgical intervention using ICD diagnosis and procedure codes. Patterns of regionalization were characterized by hospital case burden and distance travelled by patients. RESULTS During the study period, 56,508 diverticulitis hospitalizations occurred across 100 hospitals. Most hospitalizations were emergent (77.2%). Of these, 17.5% were for complicated diverticulitis, and 6.6% required surgery. No single hospital received more than 5% (n = 235) of average annual hospitalizations. Surgeons operated in 26.5% of total hospitalizations (13.9% of emergent hospitalizations, and 69.2% of elective hospitalizations). Operations for complicated disease made up 40% of emergent surgery and 28.7% of elective surgery. Most patients traveled fewer than 20 miles for hospitalization, regardless of acuity (84% for emergent hospitalization and 77.5% for elective hospitalization). DISCUSSION Hospitalizations for diverticulitis are primarily emergent, nonoperative, and broadly distributed across Washington State. Hospitalization and surgery occur close to patients' homes, regardless of acuity. This decentralization needs to be considered if improvement initiatives and research in diverticulitis are to have meaningful, population-level impact.
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Affiliation(s)
- Stephanie L Stovall
- Department of General, Thoracic, and Vascular Surgery, Virginia Mason Franciscan Health, Seattle, WA, USA
| | - Meredith P Johnson
- Department of General, Thoracic, and Vascular Surgery, Virginia Mason Franciscan Health, Seattle, WA, USA
| | - Ethan T Evans
- Diabetes Clinical Research Program, Benaroya Research Institute, Seattle, WA, USA
| | - Jennifer A Kaplan
- Department of General, Thoracic, and Vascular Surgery, Virginia Mason Franciscan Health, Seattle, WA, USA
| | - Joanna K Law
- Department of Gastroenterology, Virginia Mason Franciscan Health, Seattle, WA, USA
| | - Ravi Moonka
- Department of General, Thoracic, and Vascular Surgery, Virginia Mason Franciscan Health, Seattle, WA, USA
| | - Henry T Bahnson
- Clinical Research Program, Benaroya Research Institute, Seattle, WA, USA
| | - Vlad V Simianu
- Department of General, Thoracic, and Vascular Surgery, Virginia Mason Franciscan Health, Seattle, WA, USA
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Stovall SL, Soriano CR, Kaplan JA, La Selva D, Lord J, Moonka R, Zisman TL, Simianu VV. Characterizing Regionalization of Inflammatory Bowel Disease Hospitalizations and Operations in Washington State. J Gastrointest Surg 2023; 27:2493-2505. [PMID: 37532905 DOI: 10.1007/s11605-023-05731-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/22/2023] [Accepted: 05/30/2023] [Indexed: 08/04/2023]
Abstract
BACKGROUND Hospitalizations for inflammatory bowel disease (IBD) are a major contributor of healthcare utilization. We assessed IBD hospitalizations and surgical operations in Washington State to characterize regionalization patterns. METHODS We identified a cohort of hospitalizations for Crohn's disease (CD) or ulcerative colitis (UC) from 2008 to 2019 using Washington State's Comprehensive Hospital Abstract Reporting System (CHARS). Hospitalizations were characterized by emergent or elective acuity and whether an operation or endoscopic procedure was performed. Facility volume and distance travelled by patients were used to determine regionalization. RESULTS There were 20,494 IBD-related hospitalizations at 95 hospitals: 13,585 (66.3%) with CD and 6,909 (33.7%) with UC. Emergencies accounted for 78.2% of all IBD-related hospitalizations and did not differ between CD (78.3%) and UC (77.9%) (p = 0.54). Surgery was performed during 10.3% and endoscopy during 30.6% of emergent hospitalizations. 72.0% of emergent hospitalizations occurred at 22 facilities, while 71.1% of elective hospitalizations were concentrated at 9 facilities. Operations were performed during 78.5% of elective hospitalizations, and five hospitals performed 69% of all elective surgery. Laparoscopic surgery increased in both emergent (17% to 52%, p < 0.001) and elective operations (18% to 42%, p < 0.001) from 2008 to 2019. CONCLUSIONS In Washington State, most IBD hospitalizations were emergent, which were decentralized and typically non-operative. By contrast, most elective admissions involved surgery and were centralized at a few high-volume centers. Further understanding the drivers behind IBD hospitalizations may help optimize emergent medical and elective surgical care at a state level.
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Affiliation(s)
- Stephanie L Stovall
- Department of Surgery, Virginia Mason Franciscan Health, 1100 9th Ave, C6-GS, Seattle, WA, 98101, USA
| | - Celine R Soriano
- Department of Surgery, Virginia Mason Franciscan Health, 1100 9th Ave, C6-GS, Seattle, WA, 98101, USA
| | - Jennifer A Kaplan
- Department of Surgery, Virginia Mason Franciscan Health, 1100 9th Ave, C6-GS, Seattle, WA, 98101, USA
| | - Danielle La Selva
- Center for Digestive Health, Virginia Mason Franciscan Health, Seattle, WA, USA
| | - James Lord
- Benaroya Research Institute, Seattle, WA, USA
- Department of Gastroenterology, Virginia Mason Franciscan Health, Seattle, WA, USA
| | - Ravi Moonka
- Department of Surgery, Virginia Mason Franciscan Health, 1100 9th Ave, C6-GS, Seattle, WA, 98101, USA
| | - Timothy L Zisman
- Department of Gastroenterology, Virginia Mason Franciscan Health, Seattle, WA, USA
| | - Vlad V Simianu
- Department of Surgery, Virginia Mason Franciscan Health, 1100 9th Ave, C6-GS, Seattle, WA, 98101, USA.
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Soriano CR, Evans E, Lin BS, Kaplan JA, Post AB, Bahnson HT, Simianu VV. Where are Colorectal Resections being Performed? Colon and Rectal Cancer Operations in Washington State are Decentralized. J Gastrointest Surg 2023; 27:2583-2585. [PMID: 37430095 DOI: 10.1007/s11605-023-05776-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/15/2023] [Accepted: 06/20/2023] [Indexed: 07/12/2023]
Affiliation(s)
- Celine R Soriano
- Department of Surgery, Virginia Mason Franciscan Health, Seattle, WA, USA
| | - Ethan Evans
- Benaroya Research Institute, Seattle, WA, USA
| | - Bruce S Lin
- Department of Hematology-Oncology, Virginia Mason Franciscan Health, Seattle, WA, USA
| | - Jennifer A Kaplan
- Department of Surgery, Virginia Mason Franciscan Health, Seattle, WA, USA
| | - Amber B Post
- Department of Radiation Oncology, Virginia Mason Franciscan Health, Seattle, WA, USA
| | | | - Vlad V Simianu
- Department of Surgery, Virginia Mason Franciscan Health, Seattle, WA, USA.
- Virginia Mason Medical Center, 1100 9th Ave, C6-GS, Seattle, WA, 98101, USA.
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Unruh K, Stovall S, Chang L, Deal S, Kaplan JA, Moonka R, Simianu VV. Implementation of a structured robotic colorectal curriculum for general surgery residents. J Robot Surg 2023; 17:2331-2338. [PMID: 37378796 DOI: 10.1007/s11701-023-01660-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2023] [Accepted: 06/21/2023] [Indexed: 06/29/2023]
Abstract
There is increasing demand for colorectal robotic training for general surgery residents. We implemented a robotic colorectal surgery curriculum expecting that it would increase resident exposure to the robotic platform and would increase the number of graduating general surgery residents obtaining a robotic equivalency certificate. The aim of this study is to describe the components of the curriculum and characterize the immediate impact of the implementation or residents. Our curriculum started in 2019 and consists of didactics, simulation, and clinical performance. Objectives are specified for both junior residents (post-graduate years [PGY]1-2) and senior residents (PGY3-5). The robotic colorectal surgical experience was characterized by comparing robotic to non-robotic operations, differences in robotic operations across post-graduate year, and percentage of graduates achieving an equivalency certificate. Robotic operations are tracked using case log annotation. From 2017 to 2021, 25 residents logged 681 major operations on the colorectal service (PGY1 mean = 7.6 ± 4.6, PGY4 mean = 29.7 ± 14.4, PGY5 mean = 29.8 ± 14.8). Robotic colorectal operations made up 24% of PGY1 (49% laparoscopic, 27% open), 35% of PGY4 (35% laparoscopic, 29% open), and 41% of PGY5 (44% laparoscopic, 15% open) major colorectal operations. Robotic bedside experience is primarily during PGY1 (PGY1 mean 2.0 ± 2.0 bedside operations vs 1.4 ± 1.6 and 0.2 ± 0.4 for PGY4 and 5, respectively). Most PGY4 and 5 robotic experience is on the console (PGY4 mean 9.1 ± 7.7 console operations, PGY5 mean 12.0 ± 4.8 console operations). Rates of robotic certification for graduating chief residents increased from 0% for E-2013 to 100% for E-2018. Our robotic colorectal curriculum for general surgery residents has facilitated earlier and increased robotic exposure for residents and increased robotic certification for our graduates.
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Affiliation(s)
- Kenley Unruh
- Department of Surgery, Virginia Mason Franciscan Health, Virginia Mason Medical Center, 1100 9Th Ave, Seattle, WA, 98101, USA.
| | - Stephanie Stovall
- Department of Surgery, Virginia Mason Franciscan Health, Virginia Mason Medical Center, 1100 9Th Ave, Seattle, WA, 98101, USA
| | - Lily Chang
- Department of Surgery, Virginia Mason Franciscan Health, Virginia Mason Medical Center, 1100 9Th Ave, Seattle, WA, 98101, USA
| | - Shanley Deal
- Department of Surgery, Virginia Mason Franciscan Health, Virginia Mason Medical Center, 1100 9Th Ave, Seattle, WA, 98101, USA
| | - Jennifer A Kaplan
- Department of Surgery, Virginia Mason Franciscan Health, Virginia Mason Medical Center, 1100 9Th Ave, Seattle, WA, 98101, USA
| | - Ravi Moonka
- Department of Surgery, Virginia Mason Franciscan Health, Virginia Mason Medical Center, 1100 9Th Ave, Seattle, WA, 98101, USA
| | - Vlad V Simianu
- Department of Surgery, Virginia Mason Franciscan Health, Virginia Mason Medical Center, 1100 9Th Ave, Seattle, WA, 98101, USA
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Stovall SL, Kaplan JA, Law JK, Flum DR, Simianu VV. Diverticulitis is a population health problem: Lessons and gaps in strategies to implement and improve contemporary care. World J Gastrointest Surg 2023; 15:1007-1019. [PMID: 37405108 PMCID: PMC10315108 DOI: 10.4240/wjgs.v15.i6.1007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/27/2023] [Revised: 04/10/2023] [Accepted: 04/24/2023] [Indexed: 06/15/2023] Open
Abstract
The disease burden of diverticulitis is high across inpatient and outpatient settings, and the prevalence of diverticulitis has increased. Historically, patients with acute diverticulitis were admitted routinely for intravenous antibiotics and many had urgent surgery with colostomy or elective surgery after only a few episodes. Several recent studies have challenged the standards of how acute and recurrent diverticulitis are managed, and many clinical practice guidelines (CPGs) have pivoted to recommend outpatient management and individualized decisions about surgery. Yet the rates of diverticulitis hospitalizations and operations are increasing in the United States, suggesting there is a disconnect from or delay in adoption of CPGs across the spectrum of diverticular disease. In this review, we propose approaching diverticulitis care from a population level to understand the gaps between contemporary studies and real-world practice and suggest strategies to implement and improve future care.
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Affiliation(s)
- Stephanie Lee Stovall
- Department of Surgery, Virginia Mason Franciscan Health, Seattle, WA 98101, United States
| | - Jennifer A Kaplan
- Department of Surgery, Virginia Mason Franciscan Health, Seattle, WA 98101, United States
| | - Joanna K Law
- Department of Gastroenterology, Virginia Mason Franciscan Health, Seattle, WA 98101, United States
| | - David R Flum
- Department of Surgery, University of Washington Medical, Seattle, WA 98195, United States
| | - Vlad V Simianu
- Department of Surgery, Virginia Mason Franciscan Health, Seattle, WA 98101, United States
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Kennecke HF, O'Callaghan CJ, Loree JM, Moloo H, Auer R, Jonker DJ, Raval M, Musselman R, Ma G, Caycedo-Marulanda A, Simianu VV, Patel S, Pitre LD, Helewa R, Gordon VL, Neumann K, Nimeiri H, Sherry M, Tu D, Brown CJ. Neoadjuvant Chemotherapy, Excision, and Observation for Early Rectal Cancer: The Phase II NEO Trial (CCTG CO.28) Primary End Point Results. J Clin Oncol 2023; 41:233-242. [PMID: 35981270 PMCID: PMC9839227 DOI: 10.1200/jco.22.00184] [Citation(s) in RCA: 10] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023] Open
Abstract
PURPOSE Organ-sparing therapy for early-stage I/IIA rectal cancer is intended to avoid functional disturbances or a permanent ostomy associated with total mesorectal excision (TME). The objective of this phase II trial was to determine the outcomes and organ-sparing rate of patients with early-stage rectal cancer treated with neoadjuvant chemotherapy followed by transanal excision surgery (TES). METHODS This phase II trial included patients with clinical T1-T3abN0 low- or mid-rectal adenocarcinoma eligible for endoscopic resection who were treated with 3 months of chemotherapy (modified folinic acid-fluorouracil-oxaliplatin 6 or capecitabine-oxaliplatin). Those with evidence of response proceeded to transanal endoscopic surgery 2-6 weeks later. The primary end point was protocol-specified organ preservation rate, defined as the proportion of patients with tumor downstaging to ypT0/T1N0/X and who avoided radical surgery. RESULTS Of 58 patients enrolled, all commenced chemotherapy and 56 proceeded to surgery. A total of 33/58 patients had tumor downstaging to ypT0/1N0/X on the surgery specimen, resulting in an intention-to-treat protocol-specified organ preservation rate of 57% (90% CI, 45 to 68). Of 23 remaining patients recommended for TME surgery on the basis of protocol requirements, 13 declined and elected to proceed directly to observation resulting in 79% (90% CI, 69 to 88) achieving organ preservation. The remaining 10/23 patients proceeded to recommended TME of whom seven had no histopathologic residual disease. The 1-year and 2-year locoregional relapse-free survival was, respectively, 98% (95% CI, 86 to 100) and 90% (95% CI, 58 to 98), and there were no distant recurrences or deaths. Minimal change in quality of life and rectal function scores was observed. CONCLUSION Three months of induction chemotherapy may successfully downstage a significant proportion of patients with early-stage rectal cancer, allowing well-tolerated organ-preserving surgery.
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Affiliation(s)
- Hagen F. Kennecke
- Providence Cancer Institute and Earle A Chiles Research Institute, Portland, OR,Hagen F. Kennecke, MD, MHA, Providence Cancer Institute, 4805 NE Glisan St, Portland, OR 97213; Twitter: @HKENNECKE; e-mail:
| | | | | | - Hussein Moloo
- The Ottawa Hospital Research Institute, Ottawa, ON, Canada
| | - Rebecca Auer
- The Ottawa Hospital Research Institute, Ottawa, ON, Canada
| | | | - Manoj Raval
- Providence-St. Paul's Hospital, Vancouver, BC, Canada
| | | | - Grace Ma
- Health Sciences North, Sudbury, ON, Canada
| | | | | | - Sunil Patel
- Canadian Cancer Trials Group, Queen's University, Kingston, ON, Canada
| | | | | | | | | | | | - Max Sherry
- Canadian Cancer Trials Group, Queen's University, Kingston, ON, Canada
| | - Dongsheng Tu
- Canadian Cancer Trials Group, Queen's University, Kingston, ON, Canada
| | - Carl J. Brown
- Providence-St. Paul's Hospital, Vancouver, BC, Canada
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Booth AT, Allen S, Simianu VV, Jensen CC, Schermerhorn ML, George VV, Curran T. Selective type & screen for elective colectomy based on a transfusion risk score may generate substantial cost savings. Surg Endosc 2022; 36:8817-8824. [PMID: 35616730 DOI: 10.1007/s00464-022-09307-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2021] [Accepted: 04/25/2022] [Indexed: 01/06/2023]
Abstract
BACKGROUND Preoperative type and screen are currently recommended for all patients undergoing colectomy. We aimed to identify risk factors for transfusion and define a low-risk cohort of patients undergoing colectomy in whom type and screen may be safely avoided. METHODS We identified all patients undergoing elective colectomy in the National Surgical Quality Improvement Project-Targeted Colectomy files from 2012 to 2016. Patients transfused preoperatively and those undergoing other concurrent major abdominal procedures were excluded. We compared patients who received blood transfusion on the day of surgery to those who did not. Half of the cohort was randomly selected for development of a points-based model predicting blood transfusion on the day of surgery. This model was then validated using the remaining patients. RESULTS Of 61,964 patients undergoing colectomy, 3128 (5%) patients were transfused with 1290 (2.1%) occurring on the day of surgery. Preoperative anemia was the strongest predictor of blood transfusion on the day of surgery. Among patients with hematocrit > 35%, day of surgery transfusion risk was 0.8%; 99% of patients with hematocrit > 35% had a score 20 or less. Selective type and screen for patients with score ≤ 20 or hematocrit > 35% would avoid type and screen in 91% and 81% of patients, respectively. CONCLUSION Transfusion following elective colectomy is rare and can be accurately predicted by preoperative patient characteristics. Selective type and screen based on these parameters have the potential to prevent operative delays and lower cost.
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Affiliation(s)
- Alexander T Booth
- Department of Surgery, Medical University of South Carolina, 30 Courtenay Drive, Suite 249, MSC 295, Charleston, SC, 29425, USA
| | - Shelby Allen
- Department of Surgery, Medical University of South Carolina, 30 Courtenay Drive, Suite 249, MSC 295, Charleston, SC, 29425, USA
| | - Vlad V Simianu
- Department of Surgery, Virginia Mason Medical Center, Seattle, WA, USA
| | | | - Marc L Schermerhorn
- Department of Surgery, Beth Israel Deaconess Medical Center, Boston, MA, USA
| | - Virgilio V George
- Department of Surgery, Medical University of South Carolina, 30 Courtenay Drive, Suite 249, MSC 295, Charleston, SC, 29425, USA
| | - Thomas Curran
- Department of Surgery, Medical University of South Carolina, 30 Courtenay Drive, Suite 249, MSC 295, Charleston, SC, 29425, USA.
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Kennecke HF, Bahnson HT, Lin B, O'Rourke C, Kaplan J, Pham H, Suen A, Simianu VV. Patterns of Practice and Improvements in Survival Among Patients With Stage 2/3 Rectal Cancer Treated With Trimodality Therapy. JAMA Oncol 2022; 8:1466-1470. [PMID: 35980607 PMCID: PMC9389431 DOI: 10.1001/jamaoncol.2022.2831] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Question How has trimodality therapy and survival for patients with stage 2/3 rectal cancer changed in the US? Findings This cohort study of 32 467 patients in the National Cancer Database (2006-2016) found that the use of postoperative chemotherapy/radiation therapy decreased (28% vs 8%), while preoperative chemotherapy/radiation therapy and multiagent chemotherapy increased (24% vs 45%). A migration to lower pathologic stage occurred as well as a significant improvement in survival. Meaning Greater use of perioperative therapy for stage 2/3 rectal cancers was associated with significant survival improvement in the clinical setting. Importance This study quantifies the trends in trimodality therapy use and its association with pathologic stage and overall survival of patients with rectal cancer at the population level. Objective To describe changes between 2006 and 2016 in the sequence and use of chemotherapy/radiation therapy (C/RT), multiagent (MA) chemotherapy, and total neoadjuvant therapy (TNT) for patients with stage 2/3 rectal cancer and identify associations with pathologic stage and survival over time. Design, Setting, and Participants This retrospective cohort analysis included patient records from the National Cancer Database between 2006 and 2016. Of 110 372 patient records, 77 905 were excluded owing to not receiving trimodality therapy and other predefined exclusion criteria. The final analytic cohort comprised 32 467 patients records treated with trimodality therapy, with 24 297 considered in the survival analysis. Data analysis was performed between June 2020 and December 2021. Exposures Trimodality therapy was defined as including all of the following: definitive surgery; radiation therapy (RT), alone or in combination with chemotherapy; and neoadjuvant/adjuvant single-agent (SA) or multiagent (MA) chemotherapy independent of RT. Main Outcomes and Measures Using Cox multivariable survival analyses across demographics, surgery type, stage, year of diagnosis, and facility type, treatment groups were allocated as the following: group A: TNT (n = 8883 [27%]); group B: preoperative C/RT plus postoperative SA chemotherapy (n = 5967 [18%]); group C: preoperative C/RT plus postoperative MA chemotherapy (n = 12 926 [40%]); and group D: postoperative C/RT plus MA chemotherapy (n = 4689 [14%]). Results The final analytic cohort comprised 32 467 patients (mean [SD] age at diagnosis, 57.6 [11.6] years; 12 549 [38.7%] women and 19 918 [61.3%] men). Comparing 2016 with 2006, treatment shifted to fewer patients receiving postoperative C/RT (group D) (28% vs 8%; P < .001), and more preoperative C/RT and postoperative MA chemotherapy (group C) (24% vs 45%; P < .001) being used. While clinical stage 2 and 3 distribution remained unchanged, pathologic downstaging was observed to stages 0, 1, 2, and 3: 0.60%, 10%, 31%, and 57% vs 2.8%, 22%, 29%, and 45%, from 2006 to 2015, respectively (P < .001). More recent year of diagnosis was associated with an adjusted hazard ratio of 0.77 (95% CI, 0.67-0.87) for mortality within 36 months after diagnosis (2015 vs 2006). Conclusions and Relevance In this cohort study, the shift toward preoperative C/RT and lower pathologic stage was associated with improved overall survival in stage 2/3 rectal cancers.
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Affiliation(s)
| | | | - Bruce Lin
- Virginia Mason Hospital and Medical Center, Seattle, Washington
| | | | - Jennifer Kaplan
- Virginia Mason Hospital and Medical Center, Seattle, Washington
| | - Huong Pham
- Virginia Mason Hospital and Medical Center, Seattle, Washington
| | - Andrew Suen
- Virginia Mason Hospital and Medical Center, Seattle, Washington
| | - Vlad V Simianu
- Virginia Mason Hospital and Medical Center, Seattle, Washington
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11
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Cragle CE, Schlenker J, Moonka R, Wiebusch A, Simianu VV. Presentation and management of a case of rectal cancer complicated by perforation and necrotizing soft tissue infection. J Surg Case Rep 2022; 2022:rjac318. [PMID: 35919701 PMCID: PMC9341225 DOI: 10.1093/jscr/rjac318] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2022] [Accepted: 06/13/2022] [Indexed: 11/26/2022] Open
Abstract
A 68-year-old man presented with septic shock and severe perineal pain from a perforated low-rectal cancer causing a perineal necrotizing soft tissue infection. He underwent laparoscopic diverting colostomy and multiple surgical debridements resulting in extensive perineal and left leg wounds. A multidisciplinary rectal cancer team recommended against neoadjuvant chemoradiation or chemotherapy in his current state. He underwent up-front, urgent robotic-assisted abdominoperineal resection with immediate oblique rectus abdominus muscle flap closure. Final pathology demonstrated a T4N1b adenocarcinoma with negative resection margins. The patient subsequently underwent adjuvant chemotherapy. Now at over 18 months, he remains cancer free.
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Affiliation(s)
- Chad E Cragle
- General and Thoracic Surgery, Virginia Mason Medical Center , Seattle, WA 98101 , USA
| | - James Schlenker
- Plastic and Reconstructive Surgery, Virginia Mason Medical Center , Seattle, WA 98101 , USA
| | - Ravi Moonka
- Colon and Rectal Surgery, Virginia Mason Medical Center , Seattle, WA 98101 , USA
| | - Abigail Wiebusch
- General and Thoracic Surgery, Virginia Mason Medical Center , Seattle, WA 98101 , USA
| | - Vlad V Simianu
- Colon and Rectal Surgery, Virginia Mason Medical Center , Seattle, WA 98101 , USA
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12
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Simianu VV. Guiding patients through the muddy water of malignant colorectal polyp management. Am J Surg 2022; 224:657. [DOI: 10.1016/j.amjsurg.2022.02.036] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2022] [Accepted: 02/10/2022] [Indexed: 01/11/2023]
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13
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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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14
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Tung J, Lin B, Schlenker J, Simianu VV. A case report of the rarest anal cancer: Basal cell carcinoma. Ann Med Surg (Lond) 2022; 74:103291. [PMID: 35198166 PMCID: PMC8844807 DOI: 10.1016/j.amsu.2022.103291] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2021] [Revised: 01/09/2022] [Accepted: 01/23/2022] [Indexed: 12/03/2022] Open
Abstract
A 69-year-old male truck driver with history of chronic anal fissures and facial basal cell carcinoma developed rectal bleeding and pain, and was diagnosed with a 5cm basal cell cancer of the anus with sphincter invasion. His workup entailed physical exam, CT and MRI which confirmed external and internal sphincter invasion without evidence of distant metastatic disease. After review of chemoradiation and surgical options, the patient elected to proceed with robotic-assisted abdominoperineal resection with end colostomy with complex local-tissue reconstruction. He is now two years out and disease free. While radiation and surgery have both been described in the literature as viable treatments, surgical resection may be the best option for patients with large lesions with sphincter invasion, who travel from afar and have occupational restrictions. This case highlights the importance of a multidisciplinary approach in assessing the patient with a rare disease process, presenting all viable options for treatment, and electing the optimal treatment through shared decision making. Basal (BCC) cell carcinoma makes up less than 1% of anorectal neoplasms. Radiation, cryotherapy, Moh’s surgery, local excision, and abdominoperineal resection can be used for anal BCC. Due to it’s rarity, we recommend a multidisciplinary approach for this pathology. Details of a robotic abdominoperineal resection with complex perineal closure performed are discussed. The highlight of this report lies in honoring patient's wishes and what treatment best fits their lifestyle.
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Affiliation(s)
- Jivatesh Tung
- Section of Colon and Rectal Surgery, Department of Surgery, Virginia Mason Medical Center, Seattle, WA, USA
| | - Bruce Lin
- Section of Hematology-Oncology, Department of Medicine, Virginia Mason Medical Center, Seattle, WA, USA
| | - James Schlenker
- Section of Plastic Surgery, Department of Surgery, Virginia Mason Medical Center, Seattle, WA, USA
| | - Vlad V. Simianu
- Section of Colon and Rectal Surgery, Department of Surgery, Virginia Mason Medical Center, Seattle, WA, USA
- Corresponding author. Virginia Mason Medical Center, 1100 9th Ave, C6-GS, Seattle, WA, 98101.
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15
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Bhama AR, Zoccali MB, Chapman BC, Davids JS, Eisenstein S, Fish DR, Sherman KL, Simianu VV, Zaghiyan KN. Practice Variations in Chemodenervation for Anal Fissure Among American Society of Colon and Rectal Surgeons Members. Dis Colon Rectum 2021; 64:1167-1171. [PMID: 34192713 DOI: 10.1097/dcr.0000000000002194] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Affiliation(s)
- Anuradha R Bhama
- Department of Surgery, Rush University Medical Center, Chicago, Illinois
| | | | - Brandon C Chapman
- Department of Surgery, University of Colorado School of Medicine, Aurora, Colorado
| | - Jennifer S Davids
- Department of Surgery, University of Massachusetts, Wooster, Massachusetts
| | - Samuel Eisenstein
- Department of Surgery, UC San Diego Health System, La Jolla, California
| | - Daniel R Fish
- Department of Surgery, Baystate Medical Center; Springfield, Massachusetts
| | - Karen L Sherman
- Department of Surgery, Duke University Health System, Durham, North Carolina
| | - Vlad V Simianu
- Department of Surgery, Virginia Mason Medical Center, Seattle, Washington
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Soriano CR, Powell CR, Chiorean MV, Simianu VV. Role of hospitalization for inflammatory bowel disease in the post-biologic era. World J Clin Cases 2021; 9:7632-7642. [PMID: 34621815 PMCID: PMC8462259 DOI: 10.12998/wjcc.v9.i26.7632] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/19/2021] [Revised: 05/17/2021] [Accepted: 08/12/2021] [Indexed: 02/06/2023] Open
Abstract
Treatment for inflammatory bowel disease (IBD) often requires specialized care. While much of IBD care has shifted to the outpatient setting, hospitalizations remain a major site of healthcare utilization and a sizable proportion of patients with inflammatory bowel disease require hospitalization or surgery during their lifetime. In this review, we approach IBD care from the population-level with a specific focus on hospitalization for IBD, including the shifts from inpatient to outpatient care, the balance of emergency and elective hospitalizations, regionalization of specialty IBD care, and contribution of surgery and endoscopy to hospitalized care.
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Affiliation(s)
- Celine R Soriano
- Department of Surgery, Virginia Mason Franciscan Health, Seattle, WA 98101, United States
| | - Charleston R Powell
- Department of Internal Medicine, Madigan Army Medical Center, Tacoma, WA 98431, United States
| | - Michael V Chiorean
- Department of Gastroenterology, Swedish Medical Center, Seattle, WA 98109, United States
| | - Vlad V Simianu
- Department of Surgery, Virginia Mason Franciscan Health, Seattle, WA 98101, United States
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17
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Weed CN, Simianu VV. If Enhanced Recovery Is So Good for Our Patients, Should We Be Applying It to Every Case? J Am Coll Surg 2021; 232:185-186. [PMID: 33451448 DOI: 10.1016/j.jamcollsurg.2020.10.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2020] [Accepted: 10/26/2020] [Indexed: 11/24/2022]
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18
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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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19
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Soriano CR, Cheng RR, Corman JM, Moonka R, Simianu VV, Kaplan JA. Feasibility of injected indocyanine green for ureteral identification during robotic left-sided colorectal resections. Am J Surg 2021; 223:14-20. [PMID: 34353619 DOI: 10.1016/j.amjsurg.2021.07.012] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2021] [Revised: 06/01/2021] [Accepted: 07/16/2021] [Indexed: 12/29/2022]
Abstract
BACKGROUND Ureteral identification is essential to performing safe colorectal surgery. Injected immunofluorescence may aid with ureteral identification, but feasibility without ureteral catheterization is not well described. METHODS Case series of robotic colorectal resections where indocyanine green (ICG) injection with or without ureteral catheter placement was performed. Imaging protocol, time to ureteral identification, and factors impacting visualization are reported. RESULTS From 2019 to 2020, 83 patients underwent ureteral ICG injection, 20 with catheterization and 63 with injection only. Main indications were diverticulitis (52%) and cancer (36%). Median time to instill ICG was faster with injection alone than with catheter placement (4min vs 13.5min, p < 0.001). Median time [IQR] to right ureter (0.3 [0.01-1.2] min after robot docking) and left ureter (5.5 [3.1-8.8] min after beginning dissection) visualization was not different between injection alone and catheterization. CONCLUSION ICG injection alone is faster than with indwelling catheter placement and equally reliable at intraoperative ureteral identification.
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Affiliation(s)
- Celine R Soriano
- Department of Surgery, Virginia Mason Franciscan Health, Seattle, WA, USA.
| | - Ron Ron Cheng
- Department of Urology, Virginia Mason Franciscan Health, Seattle, WA, USA
| | - John M Corman
- Department of Urology, Virginia Mason Franciscan Health, Seattle, WA, USA
| | - Ravi Moonka
- Department of Surgery, Virginia Mason Franciscan Health, Seattle, WA, USA
| | - Vlad V Simianu
- Department of Surgery, Virginia Mason Franciscan Health, Seattle, WA, USA
| | - Jennifer A Kaplan
- Department of Surgery, Virginia Mason Franciscan Health, Seattle, WA, USA
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20
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Abstract
OBJECTIVE To assess the comparative risk of recurrence and ostomy after elective resection or medical therapy for uncomplicated diverticulitis, incorporating outpatient episodes of recurrence. BACKGROUND While surgeons historically recommended colon resection for uncomplicated diverticulitis to reduce the risk of recurrence or colostomy, no prior studies have quantified this risk when considering outpatient episodes of disease. It remains to be determined whether surgery actually decreases those risks. METHODS Retrospective cohort study employing an adjusted time-to-event analysis to assess the relationship of medical or surgical treatment with diverticulitis recurrence and/or receipt of an ostomy. Subjects were adults with ≥1 year continuous enrollment treated for ≥2 episodes of uncomplicated diverticulitis from a nationwide commercial claims dataset (2008-2014). RESULTS Of 12,073 patients (mean age 56 ± 14 yr, 59% women), 19% underwent elective surgery and 81% were treated by medical therapy on their second treatment encounter for uncomplicated diverticulitis. At 1 year, patients treated by elective surgery had lower rates of recurrence (6%) versus those treated by medical therapy (32%) [15% vs 61% at 5 years, adjusted hazard ratio 0.17 (95% confidence interval: 0.15-0.20)]. At 1 year, the rate of ostomy after both treatments was low [surgery (inclusive of stoma related to the elective colectomy), 4.0%; medical therapy, 1.6%]. CONCLUSIONS Elective resection for uncomplicated diverticulitis decreases the risk of recurrence, still 6% to 15% will recur within 5 years of surgery. The risk of ostomy is not lower after elective resection, and considering colostomies related to resection, ostomy prevention should not be considered an appropriate indication for elective surgery.
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21
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Simianu VV, Curran T, Gaertner WB, Sklow B, Kuntz KM, Kwaan MR, Madoff RD, Jensen CC. A Cost-Effectiveness Evaluation of Surgical Approaches to Proctectomy. J Gastrointest Surg 2021; 25:1512-1523. [PMID: 32394122 DOI: 10.1007/s11605-020-04615-5] [Citation(s) in RCA: 3] [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: 12/01/2019] [Accepted: 04/16/2020] [Indexed: 01/31/2023]
Abstract
BACKGROUND Robotic surgery is increasingly used for proctectomy, but the cost-effectiveness of this approach is uncertain. Robotic surgery is considered more expensive than open or laparoscopic approaches, but in certain situations has been demonstrated to be cost-effective. We examined the cost-effectiveness of open, laparoscopic, and robotic approaches to proctectomy from societal and healthcare system perspectives. METHODS We developed a decision-analytic model to evaluate one-year costs and outcomes of robotic, laparoscopic, and open proctectomy based on data from the available literature. The robustness of our results was tested with one-way and multi-way sensitivity analyses. RESULTS Open proctectomy had increased cost and lower quality of life (QOL) compared with laparoscopy and robotic approaches. In the societal perspective, robotic proctectomy costs $497/case more than laparoscopy, with minimal QOL improvements, resulting in an incremental cost-effectiveness ratio (ICER) of $751,056 per quality-adjusted life year (QALY). In the healthcare sector perspective, robotic proctectomy resulted in $983/case more and an ICER of $1,485,139/QALY. One-way sensitivity analyses demonstrated factors influencing cost-effectiveness primarily pertained to the operative cost and the postoperative length of stay (LOS). In a probabilistic sensitivity analysis, the cost-effective approach to proctectomy was laparoscopic in 42% of cases, robotic in 39%, and open in 19% at a willingness-to-pay (WTP) of $100,000/QALY. CONCLUSIONS Laparoscopic and robotic proctectomy cost less and have higher QALY than the open approach. Based on current data, laparoscopy is the most cost-effective approach. Robotic proctectomy can be cost-effective if modest differences in costs or postoperative LOS can be achieved.
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Affiliation(s)
- Vlad V Simianu
- Department of Surgery, Virginia Mason Medical Center, Seattle, WA, USA.
| | - Thomas Curran
- Department of Surgery, Medical University of South Carolina, Charleston, SC, USA
| | - Wolfgang B Gaertner
- Division of Colon and Rectal Surgery, University of Minnesota, Minneapolis, MN, USA
| | - Bradford Sklow
- Division of Colon and Rectal Surgery, University of Minnesota, Minneapolis, MN, USA
| | - Karen M Kuntz
- Division of Health Policy and Management, University of Minnesota, Minneapolis, MN, USA
| | - Mary R Kwaan
- Department of Surgery, University of California Los Angeles, Los Angeles, CA, USA
| | - Robert D Madoff
- Division of Colon and Rectal Surgery, University of Minnesota, Minneapolis, MN, USA
| | - Christine C Jensen
- Division of Colon and Rectal Surgery, University of Minnesota, Minneapolis, MN, USA
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22
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Neufeld MY, Bauerle W, Eriksson E, Azar FK, Evans HL, Johnson M, Lawless RA, Lottenberg L, Sanchez SE, Simianu VV, Thomas CS, Drake FT. Where did the patients go? Changes in acute appendicitis presentation and severity of illness during the coronavirus disease 2019 pandemic: A retrospective cohort study. Surgery 2020; 169:808-815. [PMID: 33288212 PMCID: PMC7717883 DOI: 10.1016/j.surg.2020.10.035] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2020] [Revised: 10/16/2020] [Accepted: 10/28/2020] [Indexed: 01/02/2023]
Abstract
BACKGROUND The coronavirus disease 2019 pandemic restricted movement of individuals and altered provision of health care, abruptly transforming health care-use behaviors. It serves as a natural experiment to explore changes in presentations for surgical diseases including acute appendicitis. The objective was to determine if the pandemic was associated with changes in incidence of acute appendicitis compared to a historical control and to determine if there were associated changes in disease severity. METHODS The study is a retrospective, multicenter cohort study of adults (N = 956) presenting with appendicitis in nonpandemic versus pandemic time periods (December 1, 2019-March 10, 2020 versus March 11, 2020-May 16, 2020). Corresponding time periods in 2018 and 2019 composed the historical control. Primary outcome was mean biweekly counts of all appendicitis presentations, then stratified by complicated (n = 209) and uncomplicated (n = 747) disease. Trends in presentations were compared using difference-in-differences methodology. Changes in odds of presenting with complicated disease were assessed via clustered multivariable logistic regression. RESULTS There was a 29% decrease in mean biweekly appendicitis presentations from 5.4 to 3.8 (rate ratio = 0.71 [0.51, 0.98]) after the pandemic declaration, with a significant difference in differences compared with historical control (P = .003). Stratified by severity, the decrease was significant for uncomplicated appendicitis (rate ratio = 0.65 [95% confidence interval 0.47-0.91]) when compared with historical control (P = .03) but not for complicated appendicitis (rate ratio = 0.89 [95% confidence interval 0.52-1.52]); (P = .49). The odds of presenting with complicated disease did not change (adjusted odds ratio 1.36 [95% confidence interval 0.83-2.25]). CONCLUSION The pandemic was associated with decreased incidence of uncomplicated appendicitis without an accompanying increase in complicated disease. Changes in individual health care-use behaviors may underlie these differences, suggesting that some cases of uncomplicated appendicitis may resolve without progression to complicated disease.
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Affiliation(s)
- Miriam Y Neufeld
- Department of Surgery, Boston Medical Center/Boston University School of Medicine, MA.
| | - Wayne Bauerle
- Department of Surgery, Medical University of South Carolina, Charleston, SC
| | - Evert Eriksson
- Department of Surgery, Medical University of South Carolina, Charleston, SC
| | - Faris K Azar
- Department of Surgery, St Mary's Medical Center, West Palm Beach, FL; Department of Surgery, Florida Atlantic University, Boca Raton, FL
| | - Heather L Evans
- Department of Surgery, Medical University of South Carolina, Charleston, SC
| | - Meredith Johnson
- Department of Surgery, Virginia Mason Medical Center, Seattle, WA
| | | | - Lawrence Lottenberg
- Department of Surgery, St Mary's Medical Center, West Palm Beach, FL; Department of Surgery, Florida Atlantic University, Boca Raton, FL
| | - Sabrina E Sanchez
- Department of Surgery, Boston Medical Center/Boston University School of Medicine, MA
| | - Vlad V Simianu
- Department of Surgery, Virginia Mason Medical Center, Seattle, WA
| | | | - F Thurston Drake
- Department of Surgery, Boston Medical Center/Boston University School of Medicine, MA
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Kaplan JA, Simianu VV. Pelvic Floor Nonrelaxation: Approach to Evaluation and Treatment. Clin Colon Rectal Surg 2020; 34:49-55. [PMID: 33536849 DOI: 10.1055/s-0040-1714286] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
Dyssynergic defecation can be a complex, burdensome condition. A multidisciplinary approach to these patients is often indicated based on concomitant pathology or symptomatology across the pelvic organs. Escalating treatment options should be based on shared decision making and include medical and lifestyle optimization, pelvic floor physical therapy with biofeedback, Botox injection, sacral neuromodulation, rectal irrigation, and surgical diversion.
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Crown A, Simianu VV, Kennecke H, Lopez-Aguiar AG, Dillhoff M, Beal EW, Poultsides GA, Makris E, Idrees K, Smith PM, Nathan H, Beems M, Abbott D, Barrett J, Fields RC, Davidson J, Maithel SK, Rocha FG. Appendiceal Neuroendocrine Tumors: Does Colon Resection Improve Outcomes? J Gastrointest Surg 2020; 24:2121-2126. [PMID: 31749094 DOI: 10.1007/s11605-019-04431-6] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/04/2019] [Accepted: 10/16/2019] [Indexed: 01/31/2023]
Abstract
BACKGROUND Appendiceal neuroendocrine tumors (A-NETs) are rare neoplasms of the GI tract. They are typically managed according to tumor size; however, the impact of surgical strategy on the short- and long-term outcomes is unknown. METHODS All patients who underwent resection of A-NET at 8 institutions from 2000 to 2016 were analyzed retrospectively. Patient clinicopathologic features and outcomes were stratified according to resection type. RESULTS Of 61 patients identified with A-NET, mean age of presentation was 44.7 ± 16.0 years and patients were predominantly Caucasian (77%) and female (56%). Mean tumor size was 1.2 ± 1.3 cm with a median of 0.8 cm. Thirty-one patients (51%) underwent appendectomy and 30 (49%) underwent colonic resection. The appendectomy group had more T1 tumors (87% vs 42%, p < 0.01) than the colon resection group. Of patients in the colon resection group, 27% had positive lymph nodes and 3% had M1 disease. R0 resections were achieved in 90% of appendectomy patients and 97% of colon resection patients. Complications occurred with a higher frequency in the colon resection group (30%) compared with those in the appendectomy group (6%, p = 0.02). The colon resection group also had a longer length of stay, higher average blood loss, and longer average OR time. Median RFS and OS were similar between groups. CONCLUSION A-NET RFS and OS are equivalent regardless of surgical strategy. Formal colon resection is associated with increased length of stay, OR time, higher blood loss, and more complications. Further study is warranted to identify patients that are likely to benefit from more aggressive surgery.
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Affiliation(s)
- Angelena Crown
- Digestive Disease Institute, Virginia Mason Medical Center, Seattle, WA, USA
- Section of General, Thoracic and Vascular Surgery, Virginia Mason Medical Center, 1100 Ninth Av, Seattle, WA, 98101, USA
| | - Vlad V Simianu
- Digestive Disease Institute, Virginia Mason Medical Center, Seattle, WA, USA
- Section of General, Thoracic and Vascular Surgery, Virginia Mason Medical Center, 1100 Ninth Av, Seattle, WA, 98101, USA
| | - Hagen Kennecke
- Digestive Disease Institute, Virginia Mason Medical Center, Seattle, WA, USA
| | - Alexandra G Lopez-Aguiar
- Division of Surgical Oncology, Department of Surgery, Winship Cancer Institute, Emory University, Atlanta, GA, USA
| | - Mary Dillhoff
- Division of Surgical Oncology, The Ohio State University Comprehensive Cancer Center, Columbus, OH, USA
| | - Eliza W Beal
- Division of Surgical Oncology, The Ohio State University Comprehensive Cancer Center, Columbus, OH, USA
| | - George A Poultsides
- Department of Surgery, Stanford University Medical Center, Stanford, CA, USA
| | - Eleftherios Makris
- Department of Surgery, Stanford University Medical Center, Stanford, CA, USA
| | - Kamran Idrees
- Division of Surgical Oncology, Department of Surgery, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Paula Marincola Smith
- Division of Surgical Oncology, Department of Surgery, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Hari Nathan
- Division of Hepatopancreatobiliary and Advanced Gastrointestinal Surgery, Department of Surgery, University of Michigan, Ann Arbor, MI, USA
| | - Megan Beems
- Division of Hepatopancreatobiliary and Advanced Gastrointestinal Surgery, Department of Surgery, University of Michigan, Ann Arbor, MI, USA
| | - Daniel Abbott
- Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA
| | - James Barrett
- Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA
| | - Ryan C Fields
- Department of Surgery, Washington University School of Medicine, St. Louis, MO, USA
| | - Jesse Davidson
- Department of Surgery, Washington University School of Medicine, St. Louis, MO, USA
| | - Shishir K Maithel
- Division of Surgical Oncology, Department of Surgery, Winship Cancer Institute, Emory University, Atlanta, GA, USA
| | - Flavio G Rocha
- Digestive Disease Institute, Virginia Mason Medical Center, Seattle, WA, USA.
- Section of General, Thoracic and Vascular Surgery, Virginia Mason Medical Center, 1100 Ninth Av, Seattle, WA, 98101, USA.
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Wagner EM, Mupombwa T, Simianu VV, Dahlman M. Laparoscopic Management of 12cm Parasitic Fibroid on the Pelvic Brim. J Minim Invasive Gynecol 2019. [DOI: 10.1016/j.jmig.2019.09.552] [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: 11/29/2022]
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Simianu VV, Curran T, Gaertner W, Kwaan MR, Madoff R, Jensen CC. Cost-Effectiveness Evaluation of Surgical Approaches to Proctectomy. J Am Coll Surg 2019. [DOI: 10.1016/j.jamcollsurg.2019.08.864] [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: 11/25/2022]
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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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Crown A, Laskin R, Simianu VV, Rocha FG, Grumley J. Extreme Oncoplastic Breast Conserving Surgery: Can We Reduce Rates of Mastectomy and Chemotherapy Use? J Am Coll Surg 2019. [DOI: 10.1016/j.jamcollsurg.2019.08.922] [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: 11/28/2022]
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Simianu VV, Kumar AS. Surgical Care and Outcomes Assessment Program (SCOAP): A Nuanced, Flexible Platform for Colorectal Surgical Research. Clin Colon Rectal Surg 2019; 32:25-32. [PMID: 30647543 DOI: 10.1055/s-0038-1673351] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
Abstract
The Surgical Care and Outcomes Assessment Program (SCOAP) is a surgeon-led quality improvement (QI) initiative developed in Washington State to track and reduce variability in surgical care. It has developed into a collaboration of over two-thirds of the hospitals in the state, who share data and receive regular benchmarking reports. Data are abstracted at each site by trained abstractors. While there has some overlap with other national QI databases, the data captured by SCOAP has clinical nuances that make it pragmatic for studying surgical care. We review the unique properties of SCOAP and offer some examples of its novel applications.
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Affiliation(s)
- Vlad V Simianu
- Colorectal Surgery Program, Virginia Mason Medical Center, Seattle, Washington
| | - Anjali S Kumar
- Elson S. Floyd College of Medicine, Washington State University, Everett, Spokane, Tri-Cities, and Vancouver, Washington
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Simianu VV, Gaertner WB, Kuntz K, Kwaan MR, Lowry AC, Madoff RD, Jensen CC. Cost-Effectiveness Evaluation of Laparoscopic vs Robotic Minimally Invasive Colectomy. J Am Coll Surg 2018. [DOI: 10.1016/j.jamcollsurg.2018.07.301] [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: 11/25/2022]
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Simianu VV, Shamitoff A, Hippe DS, Godwin BD, Shriki JE, Drake FT, O'Malley RB, Maximin S, Bastawrous S, Moshiri M, Lee JH, Cuevas C, Dighe M, Flum D, Bhargava P. The Reliability of a Standardized Reporting System for the Diagnosis of Appendicitis. Curr Probl Diagn Radiol 2017; 46:267-274. [PMID: 27743632 PMCID: PMC5821469 DOI: 10.1067/j.cpradiol.2016.07.006] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
PURPOSE Computed tomography (CT) is a fast and ubiquitous tool to evaluate intra-abdominal organs and diagnose appendicitis. However, traditional CT reporting does not necessarily capture the degree of uncertainty and indeterminate findings are still common. The purpose of this study was to evaluate the reproducibility of a standardized CT reporting system for appendicitis across a large population and the system's impact on radiologists' certainty in diagnosing appendicitis. METHODS Using a previously described standardized reporting system, eight radiologists retrospectively evaluated CT scans, blinded to all clinical information, in a stratified random sample of 237 patients from a larger cohort of patients imaged for possible appendicitis (2010-2014). Receiver operating characteristic (ROC) curves and the area under the ROC curve (AUC) were used to evaluate the diagnostic performance of readers for identifying appendicitis. Two-thirds of these scans were randomly selected to be independently read by a second reader, using the original CT reports to balance the number of positive, negative and indeterminate exams across all readers. Inter-reader agreement was evaluated. RESULTS There were 113 patients with appendicitis (mean age 38, 67% male). Using the standardized report, radiologists were highly accurate at identifying appendicitis (AUC=0.968, 95%CI confidence interval: 0.95, 0.99. Inter-reader agreement was >80% for most objective findings, and certainty in diagnosing appendicitis was high and reproducible (AUC=0.955 and AUC=0.936 for the first and second readers, respectively). CONCLUSIONS Using a standardized reporting system resulted in high reproducibility of objective CT findings for appendicitis and achieved high diagnostic accuracy in an at-risk population. Predictive tools based on this reporting system may further improve communication about certainty in diagnosis and guide patient management, especially when CT findings are indeterminate.
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Affiliation(s)
- Vlad V Simianu
- Department of Surgery, University of Washington, Seattle, WA
| | - Anna Shamitoff
- Department of Surgery, University of Washington, Seattle, WA
| | - Daniel S Hippe
- Department of Radiology, University of Washington, Seattle WA
| | | | - Jabi E Shriki
- Department of Radiology, University of Washington, Seattle WA
| | | | - Ryan B O'Malley
- Department of Radiology, University of Washington, Seattle WA
| | - Suresh Maximin
- Department of Radiology, University of Washington, Seattle WA
| | | | - Mariam Moshiri
- Department of Radiology, University of Washington, Seattle WA
| | - Jean H Lee
- Department of Radiology, University of Washington, Seattle WA
| | - Carlos Cuevas
- Department of Radiology, University of Washington, Seattle WA
| | - Manjiri Dighe
- Department of Radiology, University of Washington, Seattle WA
| | - David Flum
- Department of Surgery, University of Washington, Seattle, WA
| | - Puneet Bhargava
- Department of Radiology, University of Washington, Seattle WA.
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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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Sanger PC, Simianu VV, Gaskill CE, Armstrong CAL, Hartzler AL, Lordon RJ, Lober WB, Evans HL. Diagnosing Surgical Site Infection Using Wound Photography: A Scenario-Based Study. J Am Coll Surg 2017; 224:8-15.e1. [PMID: 27746223 PMCID: PMC5183503 DOI: 10.1016/j.jamcollsurg.2016.10.027] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2016] [Accepted: 10/03/2016] [Indexed: 11/29/2022]
Abstract
BACKGROUND Postoperative surgical site infections (SSI) are common and costly. Most occur post discharge, and can result in potentially preventable readmission or unnecessary urgent evaluation. Mobile health approaches incorporating patient-generated wound photos are being implemented in an attempt to optimize triage and management. We assessed how adding wound photos to existing data sources modifies provider decision making. STUDY DESIGN We used a web-based simulation survey using a convenience sample of providers with expertise in surgical infections. Participants viewed a range of scenarios, including surgical history, physical exam, and description of wound appearance. All participants reported SSI diagnosis, diagnostic confidence, and management recommendations (main outcomes) first without, and then with, accompanying wound photos. At each step, participants ranked the most important features contributing to their decision. RESULTS Eighty-three participants completed a median of 5 scenarios (interquartile range 4 to 7). Most participants were physicians in academic surgical specialties (n = 70 [84%]). The addition of photos improved overall diagnostic accuracy from 67% to 76% (p < 0.001), and increased specificity from 77% to 92% (p < 0.001), but did not significantly increase sensitivity (55% to 65%; p = 0.16). Photos increased mean confidence in diagnosis from 5.9 of 10 to 7.4 of 10 (p < 0.001). Overtreatment recommendations decreased from 48% to 16% (p < 0.001), and undertreatment did not change (28% to 23%; p = 0.20) with the addition of photos. CONCLUSIONS The addition of wound photos to existing data as available via chart review and telephone consultation with patients significantly improved diagnostic accuracy and confidence, and prevented proposed overtreatment in scenarios without SSI. Post-discharge mobile health technologies have the potential to facilitate patient-centered care, decrease costs, and improve clinical outcomes.
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Affiliation(s)
- Patrick C Sanger
- Department of Biomedical Informatics and Medical Education, University of Washington, Seattle, WA.
| | - Vlad V Simianu
- Department of Surgery, University of Washington, Seattle, WA
| | | | | | - Andrea L Hartzler
- Group Health Research Institute, Group Health Cooperative, Seattle, WA
| | - Ross J Lordon
- Department of Biomedical Informatics and Medical Education, University of Washington, Seattle, WA
| | - William B Lober
- Department of Biomedical Informatics and Medical Education, University of Washington, Seattle, WA; Department of Biobehavioral Nursing and Health Systems, University of Washington, Seattle, WA
| | - Heather L Evans
- Department of Surgery, University of Washington, Seattle, WA
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Gaskill CE, Simianu VV, Carnell J, Hippe DS, Bhargava P, Flum DR, Davidson GH. Use of Computed Tomography to Determine Perforation in Patients With Acute Appendicitis. Curr Probl Diagn Radiol 2016; 47:6-9. [PMID: 28162864 DOI: 10.1067/j.cpradiol.2016.12.002] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2016] [Revised: 11/30/2016] [Accepted: 12/03/2016] [Indexed: 12/22/2022]
Abstract
PURPOSE Urgent appendectomy has long been the standard of care for acute appendicitis. Six randomized trials have demonstrated that antibiotics can safely treat appendicitis, but approximately 1 in 4 of these patients eventually requires appendectomy. Overall treatment success may be limited by complex disease including perforation. Patients׳ success on antibiotic therapy may depend on preoperative identification of complex disease on imaging. However, the effectiveness of computed tomography (CT) in differentiating complex disease including perforated from nonperforated appendicitis remains to be determined. The purpose of this study was to assess the preoperative diagnostic accuracy of CT in determining appendiceal perforation in patients operated for acute appendicitis. METHODS We performed a retrospective review of pathology and radiology reports from consecutive patients who presented to the emergency department with suspicion for acute appendicitis between January 2012 and May 2015. CT scans were re-reviewed by abdominal imaging fellowship-trained radiologists using standardized criteria, and the radiologists were blinded to pathology and surgical findings. Radiologists specifically noted presence or absence of periappendiceal gas, abscess, appendicolith, fat stranding, and bowel wall thickening. The overall radiologic impression as well as these specific imaging findings was compared to results of pathology and operative reports. Pathology reports were considered the standard for diagnostic accuracy. RESULTS Eighty-nine patients (65% male, average age of 34 years) presenting with right lower quadrant pain underwent CT imaging and prompt appendectomy. Final pathology reported perforation in 48% (n = 43) of cases. Radiologic diagnosis of perforation was reported in 9% (n = 8), correctly identifying perforation in 37.5% (n = 3), and incorrectly reporting perforation in 62.5% of nonperforated cases per pathology. Radiology missed 93% (n = 40) of perforations postoperatively diagnosed by pathology. There was no secondary finding (fat stranding, diameter >13mm, abscess, cecal wall thickening, periappendiceal gas, simple fluid collection, appendicolith, and phlegmon) with a clinically reliable sensitivity or specificity to predict perforated appendicitis. Surgeon׳s report of perforation was consistent with the pathology report of perforation in only 28% of cases. CONCLUSIONS The usefulness of a CT for determining perforation in acute appendicitis is limited, and methods to improve precision in identifying patients with complicated appendicitis should be explored as this may help for improving risk prediction for failure of treatment with antibiotic therapy and help guide patients and providers in shared decision-making for treatment options.
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Affiliation(s)
- Cameron E Gaskill
- Department of Surgery, University of Washington, Seattle, WA; Surgical Outcomes Research Center, University of Washington, Seattle, WA.
| | - Vlad V Simianu
- Department of Surgery, University of Washington, Seattle, WA; Surgical Outcomes Research Center, University of Washington, Seattle, WA
| | | | - Daniel S Hippe
- Department of Radiology, University of Washington, Seattle, WA
| | - Puneet Bhargava
- Department of Radiology, University of Washington, Seattle, WA
| | - David R Flum
- Department of Surgery, University of Washington, Seattle, WA; Surgical Outcomes Research Center, University of Washington, Seattle, WA
| | - Giana H Davidson
- Department of Surgery, University of Washington, Seattle, WA; Surgical Outcomes Research Center, University of Washington, Seattle, WA
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Simianu VV, Grounds MA, Joslyn SL, LeClerc JE, Ehlers AP, Agrawal N, Alfonso-Cristancho R, Flaxman AD, Flum DR. Understanding clinical and non-clinical decisions under uncertainty: a scenario-based survey. BMC Med Inform Decis Mak 2016; 16:153. [PMID: 27905926 PMCID: PMC5131551 DOI: 10.1186/s12911-016-0391-3] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [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] [Subscribe] [Scholar Register] [Received: 05/08/2016] [Accepted: 11/22/2016] [Indexed: 11/17/2022] Open
Abstract
BACKGROUND Prospect theory suggests that when faced with an uncertain outcome, people display loss aversion by preferring to risk a greater loss rather than incurring certain, lesser cost. Providing probability information improves decision making towards the economically optimal choice in these situations. Clinicians frequently make decisions when the outcome is uncertain, and loss aversion may influence choices. This study explores the extent to which prospect theory, loss aversion, and probability information in a non-clinical domain explains clinical decision making under uncertainty. METHODS Four hundred sixty two participants (n = 117 non-medical undergraduates, n = 113 medical students, n = 117 resident trainees, and n = 115 medical/surgical faculty) completed a three-part online task. First, participants completed an iced-road salting task using temperature forecasts with or without explicit probability information. Second, participants chose between less or more risk-averse ("defensive medicine") decisions in standardized scenarios. Last, participants chose between recommending therapy with certain outcomes or risking additional years gained or lost. RESULTS In the road salting task, the mean expected value for decisions made by clinicians was better than for non-clinicians(-$1,022 vs -$1,061; <0.001). Probability information improved decision making for all participants, but non-clinicians improved more (mean improvement of $64 versus $33; p = 0.027). Mean defensive decisions decreased across training level (medical students 2.1 ± 0.9, residents 1.6 ± 0.8, faculty1.6 ± 1.1; p-trend < 0.001) and prospect-theory-concordant decisions increased (25.4%, 33.9%, and 40.7%;p-trend = 0.016). There was no relationship identified between road salting choices with defensive medicine and prospect-theory-concordant decisions. CONCLUSIONS All participants made more economically-rational decisions when provided explicit probability information in a non-clinical domain. However, choices in the non-clinical domain were not related to prospect-theory concordant decision making and risk aversion tendencies in the clinical domain. Recognizing this discordance may be important when applying prospect theory to interventions aimed at improving clinical care.
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Affiliation(s)
- The Writing Group for CERTAIN-CHOICES
- Department of Surgery, University of Washington, Seattle, WA USA
- Department of Psychology, University of Washington, Seattle, WA USA
- Foster School of Business, University of Washington, Seattle, WA USA
- Surgical Outcomes Research Center (SORCE), University of Washington Medical Center, Box 354808, 1107 NE 45th St., Suite 502, Seattle, WA 98105 USA
- Institute for Health Metrics and Evaluation, University of Washington, Seattle, WA USA
| | - Vlad V. Simianu
- Department of Surgery, University of Washington, Seattle, WA USA
- Surgical Outcomes Research Center (SORCE), University of Washington Medical Center, Box 354808, 1107 NE 45th St., Suite 502, Seattle, WA 98105 USA
| | | | - Susan L. Joslyn
- Department of Psychology, University of Washington, Seattle, WA USA
| | - Jared E. LeClerc
- Department of Psychology, University of Washington, Seattle, WA USA
| | - Anne P. Ehlers
- Department of Surgery, University of Washington, Seattle, WA USA
| | - Nidhi Agrawal
- Foster School of Business, University of Washington, Seattle, WA USA
| | - Rafael Alfonso-Cristancho
- Surgical Outcomes Research Center (SORCE), University of Washington Medical Center, Box 354808, 1107 NE 45th St., Suite 502, Seattle, WA 98105 USA
| | - Abraham D. Flaxman
- Institute for Health Metrics and Evaluation, University of Washington, Seattle, WA USA
| | - David R. Flum
- Department of Surgery, University of Washington, Seattle, WA USA
- Surgical Outcomes Research Center (SORCE), University of Washington Medical Center, Box 354808, 1107 NE 45th St., Suite 502, Seattle, WA 98105 USA
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Ehlers AP, Drake FT, Kotagal M, Simianu VV, Agrawal N, Joslyn S, Flum DR. Factors Influencing Delayed Hospital Presentation in Patients with Appendicitis. J Am Coll Surg 2016. [DOI: 10.1016/j.jamcollsurg.2016.06.223] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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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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Simianu VV, Morris AM, Varghese TK, Porter MP, Henderson JA, Buchwald DS, Flum DR, Javid SH. Evaluating disparities in inpatient surgical cancer care among American Indian/Alaska Native patients. Am J Surg 2016; 212:297-304. [PMID: 26846176 PMCID: PMC4939142 DOI: 10.1016/j.amjsurg.2015.10.030] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2015] [Revised: 09/14/2015] [Accepted: 10/07/2015] [Indexed: 12/25/2022]
Abstract
BACKGROUND American Indian/Alaska Native (AI/AN) patients with cancer have the lowest survival rates of all racial and ethnic groups, possibly because they are less likely to receive "best practice" surgical care than patients of other races. METHODS Prospective cohort study comparing adherence with generic and cancer-specific guidelines on processes of surgical care between AI/AN and non-Hispanic white (NHW) patients in Washington State (2010 to 2014) was conducted. RESULTS A total of 156 AI/AN and 6,030 NHW patients underwent operations for 10 different cancers, and had similar mean adherence to generic surgical guidelines (91.5% vs 91.9%, P = .57). AI/AN patients with breast cancer less frequently received preoperative diagnostic core needle biopsy (81% vs 94%, P = .004). AI/AN patients also less frequently received care adherent to prostate cancer-specific guidelines (74% vs 92%, P = .001). CONCLUSION Although AI/ANs undergoing cancer operations in Washington receive similar overall best practice surgical cancer care to NHW patients, there remain important, modifiable disparities that may contribute to their lower survival.
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Affiliation(s)
- Vlad V Simianu
- Surgical Outcomes Research Center, Department of Surgery, University of Washington, UW Medical Center, Box 354808, 1107 NE 45th Street, Suite 502, Seattle, WA 98105, USA
| | - Arden M Morris
- Department of Surgery, University of Michigan, Ann Arbor, MI, USA
| | - Thomas K Varghese
- Surgical Outcomes Research Center, Department of Surgery, University of Washington, UW Medical Center, Box 354808, 1107 NE 45th Street, Suite 502, Seattle, WA 98105, USA
| | - Michael P Porter
- Department of Urology, University of Washington, Seattle, WA, USA
| | | | - Dedra S Buchwald
- Department of Epidemiology, University of Washington, Seattle, WA, USA
| | - David R Flum
- Surgical Outcomes Research Center, Department of Surgery, University of Washington, UW Medical Center, Box 354808, 1107 NE 45th Street, Suite 502, Seattle, WA 98105, USA
| | - Sara H Javid
- Surgical Outcomes Research Center, Department of Surgery, University of Washington, UW Medical Center, Box 354808, 1107 NE 45th Street, Suite 502, Seattle, WA 98105, USA.
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Simianu VV, Varghese TK, Flanagan MR, Flum DR, Shankaran V, Oelschlager BK, Mulligan MS, Wood DE, Pellegrini CA, Farjah F. Positron emission tomography for initial staging of esophageal cancer among medicare beneficiaries. J Gastrointest Oncol 2016; 7:395-402. [PMID: 27284472 DOI: 10.21037/jgo.2015.10.03] [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] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
BACKGROUND The role of positron emission tomography (PET) in the initial staging of esophageal cancer is to detect occult metastases, but its ability to do so has not been evaluated at the population-level. In 2001, Medicare approved reimbursement of PET for esophageal cancer staging. We hypothesized rapid adoption of PET after 2001 and a coincident increase in the prevalence of stage IV disease. METHODS A retrospective cohort study [1997-2009] was conducted of 12,870 Medicare beneficiaries with esophageal cancer using the Surveillance, Epidemiology, and End-Results (SEER)-Medicare database. RESULTS PET use increased from <3% before 2001 to 44% in 2009 (post-PET era) (P trend <0.001). Over the same period, the prevalence of stage IV disease also increased (20% in 1997 and 28% in 2009, P trend <0.001). After adjusting for changing patient characteristics over time, the rate of increase in stage IV disease in the post-PET era [relative risk (RR) =1.06; 95% confidence interval (CI), 1.00-1.13] was no different than the rate of increase in the pre-PET era (RR =1.02; 95% CI, 1.02-1.04). Over the entire study period, the prevalence of unrecorded stage decreased by more than half (43% to 18%, adjusted P trend <0.001) with coincident increases in stage 0-III (37% to 53%, adjusted P trend <0.001) as well as stage IV disease. CONCLUSIONS The increasing frequency of PET use and stage IV disease over time is more likely explained by improved documentation rather than PET's ability to detect occult metastases. The absence of compelling population-level impact compliments previous studies, revealing an opportunity to increase value through selective use of PET.
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Affiliation(s)
- Vlad V Simianu
- 1 Division of General Surgery, Department of Surgery, 2 Surgical Outcomes Research Center (SORCE), 3 Division of Cardiothoracic Surgery, Department of Surgery, 4 Division of Oncology, Department of Medicine, University of Washington, Seattle, WA, USA
| | - Thomas K Varghese
- 1 Division of General Surgery, Department of Surgery, 2 Surgical Outcomes Research Center (SORCE), 3 Division of Cardiothoracic Surgery, Department of Surgery, 4 Division of Oncology, Department of Medicine, University of Washington, Seattle, WA, USA
| | - Meghan R Flanagan
- 1 Division of General Surgery, Department of Surgery, 2 Surgical Outcomes Research Center (SORCE), 3 Division of Cardiothoracic Surgery, Department of Surgery, 4 Division of Oncology, Department of Medicine, University of Washington, Seattle, WA, USA
| | - David R Flum
- 1 Division of General Surgery, Department of Surgery, 2 Surgical Outcomes Research Center (SORCE), 3 Division of Cardiothoracic Surgery, Department of Surgery, 4 Division of Oncology, Department of Medicine, University of Washington, Seattle, WA, USA
| | - Veena Shankaran
- 1 Division of General Surgery, Department of Surgery, 2 Surgical Outcomes Research Center (SORCE), 3 Division of Cardiothoracic Surgery, Department of Surgery, 4 Division of Oncology, Department of Medicine, University of Washington, Seattle, WA, USA
| | - Brant K Oelschlager
- 1 Division of General Surgery, Department of Surgery, 2 Surgical Outcomes Research Center (SORCE), 3 Division of Cardiothoracic Surgery, Department of Surgery, 4 Division of Oncology, Department of Medicine, University of Washington, Seattle, WA, USA
| | - Michael S Mulligan
- 1 Division of General Surgery, Department of Surgery, 2 Surgical Outcomes Research Center (SORCE), 3 Division of Cardiothoracic Surgery, Department of Surgery, 4 Division of Oncology, Department of Medicine, University of Washington, Seattle, WA, USA
| | - Douglas E Wood
- 1 Division of General Surgery, Department of Surgery, 2 Surgical Outcomes Research Center (SORCE), 3 Division of Cardiothoracic Surgery, Department of Surgery, 4 Division of Oncology, Department of Medicine, University of Washington, Seattle, WA, USA
| | - Carlos A Pellegrini
- 1 Division of General Surgery, Department of Surgery, 2 Surgical Outcomes Research Center (SORCE), 3 Division of Cardiothoracic Surgery, Department of Surgery, 4 Division of Oncology, Department of Medicine, University of Washington, Seattle, WA, USA
| | - Farhood Farjah
- 1 Division of General Surgery, Department of Surgery, 2 Surgical Outcomes Research Center (SORCE), 3 Division of Cardiothoracic Surgery, Department of Surgery, 4 Division of Oncology, Department of Medicine, University of Washington, Seattle, WA, USA
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Simianu VV, Sham JG, Wright AS, Stewart SD, Alloosh M, Sturek M, Cummings DE, Flum DR. A Large Animal Survival Model to Evaluate Bariatric Surgery Mechanisms. Surg Sci 2016; 6:337-345. [PMID: 27213116 PMCID: PMC4871691 DOI: 10.4236/ss.2015.68050] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Background The impact of Roux-en-Y gastric bypass (RYGB) on type 2 diabetes mellitus is thought to result from upper and/or lower gut hormone alterations. Evidence supporting these mechanisms is incomplete, in part because of limitations in relevant bariatric-surgery animal models, specifically the lack of naturally insulin-resistant large animals. With overfeeding, Ossabaw swine develop a robust metabolic syndrome, and may be suitable for studying post-surgical physiology. Whether bariatric surgery is feasible in these animals with acceptable survival is unknown. Methods Thirty-two Ossabaws were fed a high-fat, high-cholesterol diet to induce obesity and insulin resistance. These animals were assigned to RYGB (n = 8), RYGB with vagotomy (RYGB-V, n = 5), gastrojejunostomy (GJ, n = 10), GJ with duodenal exclusion (GJD, n = 7), or sham operation (n = 2) and were euthanized 60 days post-operatively. Post-operative changes in weight and food intake are reported. Results Survival to scheduled necropsy among surgical groups was 77%, living an average of 57 days post-operatively. Cardiac arrest under anesthesia occurred in 4 pigs. Greatest weight loss (18.0% ± 6%) and food intake decrease (57.0% ± 20%) occurred following RYGB while animals undergoing RYGB-V showed only 6.6% ± 3% weight loss despite 50.8% ± 25% food intake decrease. GJ (12.7% ± 4%) and GJD (1.2% ± 1%) pigs gained weight, but less than sham controls (13.4% ± 10%). Conclusions A survival model of metabolic surgical procedures is feasible, leads to significant weight loss, and provides the opportunity to evaluate new interventions and subtle variations in surgical technique (e.g. vagus nerve sparing) that may provide new mechanistic insights.
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Affiliation(s)
- Vlad V Simianu
- Departments of Surgery, University of Washington, Seattle, USA
| | - Jonathan G Sham
- Departments of Surgery, University of Washington, Seattle, USA
| | - Andrew S Wright
- Departments of Surgery, University of Washington, Seattle, USA
| | - Skye D Stewart
- Departments of Surgery, University of Washington, Seattle, USA
| | - Mouhamad Alloosh
- Department of Cellular and Integrative Physiology, Indiana University School of Medicine, Indianapolis, USA
| | - Michael Sturek
- Department of Cellular and Integrative Physiology, Indiana University School of Medicine, Indianapolis, USA
| | | | - David R Flum
- Departments of Surgery, University of Washington, Seattle, USA ; Departments of Health Services, University of Washington, Seattle, USA
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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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Steele SR, Simianu VV, Flum DR. Misclassification of Acceptable Venous Thromboembolism Prophylaxis Leading to Flawed Inferences and Recommendations Regarding Prevention Efforts--Reply. JAMA Surg 2015; 151:198-9. [PMID: 26501764 DOI: 10.1001/jamasurg.2015.3428] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [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)
- Scott R Steele
- Department of Colon and Rectal Surgery, University Hospitals Case Medical Center, Cleveland, Ohio
| | - Vlad V Simianu
- Department of Surgery, University of Washington, Seattle
| | - David R Flum
- Department of Surgery, University of Washington, Seattle
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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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Bommareddi SR, Simianu VV, Mann LV, Mann GN. High-quality results of cytoreductive surgery and heated intraperitoneal chemotherapy perfusion for carcinomatosis at a low volume institution. J Surg Oncol 2015; 112:219-24. [PMID: 26274508 DOI: 10.1002/jso.23985] [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] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2015] [Accepted: 07/10/2015] [Indexed: 11/11/2022]
Abstract
BACKGROUND AND OBJECTIVES Maximal cytoreductive surgery (CS) with heated intraperitoneal chemotherapy perfusion (HIPEC) for peritoneal carcinomatosis can improve oncologic outcomes, but is associated with significant morbidity. Whether low-volume experience with CS/HIPEC results in acceptable outcomes is unknown. METHODS A retrospective review of all patients undergoing CS/HIPEC by a single surgeon. Experience was divided into first versus second 50 cases, and patient characteristics, operative details, and outcomes were compared. RESULTS Ninety patients underwent 100 CS/HIPEC procedures (mean age 57 years, 68% female). -Compared to the initial experience, the second 50 cases included more high grade tumors (68 vs. 52%) and greater disease burden (PCI 14.2 vs. 12.4). Operative times remained unchanged and mean blood loss decreased (978 vs. 684 ml). Hospital stay (mean 18.1 vs. 12.6 days), major complications (24 vs. 16%), and perioperative mortality (8 vs. 2%) declined. Overall median survival was 18 months and was longer with low grade tumors (26 vs. 16 months, P = 0.03). CONCLUSIONS Patients experienced reduced EBL, fewer major complications, and shorter hospital stay, despite having higher disease burden and higher grade tumors. This suggests that even low-volume experience with CS/HIPEC can lead to a trend in reduction of adverse perioperative events with acceptable oncologic outcomes.
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Affiliation(s)
- Swaroop R Bommareddi
- Department of Surgery, Division of Surgical Oncology, University of Washington School of Medicine, Seattle, Washington
| | - Vlad V Simianu
- Department of Surgery, Division of Surgical Oncology, University of Washington School of Medicine, Seattle, Washington
| | - Lisa V Mann
- Department of Surgery, Division of Surgical Oncology, University of Washington School of Medicine, Seattle, Washington
| | - Gary N Mann
- Department of Surgery, Division of Surgical Oncology, University of Washington School of Medicine, Seattle, Washington
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Pugel AE, Simianu VV, Flum DR, Patchen Dellinger E. Use of the surgical safety checklist to improve communication and reduce complications. J Infect Public Health 2015; 8:219-25. [PMID: 25731674 PMCID: PMC4417373 DOI: 10.1016/j.jiph.2015.01.001] [Citation(s) in RCA: 65] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2014] [Accepted: 01/22/2015] [Indexed: 12/15/2022] Open
Abstract
Existing evidence suggests that communication failures are common in the operating room, and that they lead to increased complications, including infections. Use of a surgical safety checklist may prevent communication failures and reduce complications. Initial data from the World Health Organization Surgical Safety Checklist (WHO SSC) demonstrated significant reductions in both morbidity and mortality with checklist implementation. A growing body of literature points out that while the physical act of "checking the box" may not necessarily prevent all adverse events, the checklist is a scaffold on which attitudes toward teamwork and communication can be encouraged and improved. Recent evidence reinforces the fact the compliance with the checklist is critical for the effects on patient safety to be realized.
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Affiliation(s)
- Anne E Pugel
- Department of Surgery, University of Washington, PO Box 356410, Seattle, WA 98195, USA; Surgical Outcomes Research Center, University of Washington, 1107 NE 45th Street, Suite 502, Seattle, WA 98195, USA
| | - Vlad V Simianu
- Department of Surgery, University of Washington, PO Box 356410, Seattle, WA 98195, USA; Surgical Outcomes Research Center, University of Washington, 1107 NE 45th Street, Suite 502, Seattle, WA 98195, USA
| | - David R Flum
- Department of Surgery, University of Washington, PO Box 356410, Seattle, WA 98195, USA; Surgical Outcomes Research Center, University of Washington, 1107 NE 45th Street, Suite 502, Seattle, WA 98195, USA
| | - E Patchen Dellinger
- Department of Surgery, University of Washington, PO Box 356410, Seattle, WA 98195, USA.
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Simianu VV, Flum DR. Rethinking elective colectomy for diverticulitis: A strategic approach to population health. World J Gastroenterol 2014; 20:16609-16614. [PMID: 25469029 PMCID: PMC4248204 DOI: 10.3748/wjg.v20.i44.16609] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/28/2014] [Revised: 08/15/2014] [Accepted: 09/19/2014] [Indexed: 02/06/2023] Open
Abstract
Diverticulitis is one of the leading indications for elective colon resection. Surgeons are trained to offer elective operations after a few episodes of diverticulitis in order to prevent future recurrences and potential emergency. However, most emergency surgery happens during the initial presentation. After recovery from an episode, much of the subsequent management of diverticulitis occurs in the outpatient setting, rendering inpatient “episode counting” a poor measure of the severity or burden of disease. Evidence also suggests that the risk of recurrence of diverticulitis is small and similar with or without an operation. Accordingly, contemporary evaluations of the epidemiologic patterns of treatments for diverticulitis have failed to demonstrate that the substantial rise in elective surgery over the last few decades has been successful at preventing emergency surgery at a population level. Multiple professional societies are calling to “individualize” decisions for elective colectomy and there is an international focus on “appropriate” indications for surgery. The rethinking of elective colectomy should come from a patient-centered approach that considers the risks of recurrence, quality of life, patient wishes and experiences about surgical and medical treatment options as well as operative morbidity and risks.
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Affiliation(s)
- André M Ilbawi
- University of Washington School of Medicine, Seattle, WA
| | - Vlad V Simianu
- University of Washington School of Medicine, Seattle, WA
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Ilbawi AM, Simianu VV, Millie M, Soriano P. Wide local excision of perianal mucinous adenocarcinoma. J Clin Oncol 2014; 3:483-5. [PMID: 24590647 DOI: 10.1016/j.ijscr.2012.05.017] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2012] [Accepted: 05/23/2012] [Indexed: 11/17/2022] Open
Affiliation(s)
- André M Ilbawi
- University of Washington School of Medicine, Seattle, WA
| | - Vlad V Simianu
- University of Washington School of Medicine, Seattle, WA
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50
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Sham JG, Simianu VV, Wright AS, Stewart SD, Alloosh M, Sturek M, Cummings DE, Flum DR. Evaluating the mechanisms of improved glucose homeostasis after bariatric surgery in Ossabaw miniature swine. J Diabetes Res 2014; 2014:526972. [PMID: 25215301 PMCID: PMC4158302 DOI: 10.1155/2014/526972] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/06/2014] [Revised: 07/29/2014] [Accepted: 08/07/2014] [Indexed: 12/26/2022] Open
Abstract
BACKGROUND Roux-en-Y gastric bypass (RYGB) is the most common bariatric operation; however, the mechanism underlying the profound weight-independent effects on glucose homeostasis remains unclear. Large animal models of naturally occurring insulin resistance (IR), which have been lacking, would provide opportunities to elucidate such mechanisms. Ossabaw miniature swine naturally exhibit many features that may be useful in evaluating the anti diabetic effects of bariatric surgery. METHODS Glucose homeostasis was studied in 53 Ossabaw swine. Thirty-two received an obesogenic diet and were randomized to RYGB, gastrojejunostomy (GJ), gastrojejunostomy with duodenal exclusion (GJD), or Sham operations. Intravenous glucose tolerance tests and standardized meal tolerance tests were performed prior to, 1, 2, and 8 weeks after surgery and at a single time-point for regular diet control pigs. RESULTS High-calorie-fed Ossabaws weighed more and had greater IR than regular diet controls, though only 70% developed IR. All operations caused weight-loss-independent improvement in IR, though only in pigs with high baseline IR. Only RYGB induced weight loss and decreased IR in the majority of pigs, as well as increasing AUCinsulin/AUCglucose. CONCLUSIONS Similar to humans, Ossabaw swine exhibit both obesity-dependent and obesity-independent IR. RYGB promoted weight loss, IR improvement, and increased AUCinsulin/AUCglucose, compared to the smaller changes following GJ and GJD, suggesting a combination of upper and lower gut mechanisms in improving glucose homeostasis.
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Affiliation(s)
- Jonathan G. Sham
- Department of Surgery, University of Washington, Seattle, WA 98195, USA
- *Jonathan G. Sham:
| | - Vlad V. Simianu
- Department of Surgery, University of Washington, Seattle, WA 98195, USA
| | - Andrew S. Wright
- Department of Surgery, University of Washington, Seattle, WA 98195, USA
| | - Skye D. Stewart
- Department of Surgery, University of Washington, Seattle, WA 98195, USA
| | - Mouhamad Alloosh
- Department of Cellular and Integrative Physiology, Indiana University School of Medicine, Indianapolis, IN 46202, USA
| | - Michael Sturek
- Department of Cellular and Integrative Physiology, Indiana University School of Medicine, Indianapolis, IN 46202, USA
| | - David E. Cummings
- Department of Medicine, University of Washington, Seattle, WA 98195, USA
| | - David R. Flum
- Department of Surgery, University of Washington, Seattle, WA 98195, USA
- Department of Health Services, University of Washington, Seattle, WA 98195, USA
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