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Khoraminejad B, Sakowitz S, Gao Z, Chervu N, Curry J, Ali K, Bakhtiyar SS, Benharash P. Association of substance-use disorder with outcomes of major elective abdominal operations: A contemporary national analysis. Surg Open Sci 2024; 19:44-49. [PMID: 38585038 PMCID: PMC10995883 DOI: 10.1016/j.sopen.2024.03.006] [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] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2024] [Accepted: 03/15/2024] [Indexed: 04/09/2024] Open
Abstract
Background Affecting >20million people in the U.S., including 4 % of all hospitalized patients, substance use disorder (SUD) represents a growing public health crisis. Evaluating a national cohort, we aimed to characterize the association of concurrent SUD with perioperative outcomes and resource utilization following elective abdominal operations. Methods All adult hospitalizations entailing elective colectomy, gastrectomy, esophagectomy, hepatectomy, and pancreatectomy were tabulated from the 2016-2020 National Inpatient Sample. Patients with concurrent substance use disorder, comprising alcohol, opioid, marijuana, sedative, cocaine, inhalant, hallucinogen, or other psychoactive/stimulant use, were considered the SUD cohort (others: nSUD). Multivariable regression models were constructed to evaluate the independent association between SUD and key outcomes. Results Of ∼1,088,145 patients, 32,865 (3.0 %) comprised the SUD cohort. On average, SUD patients were younger, more commonly male, of lowest quartile income, and of Black race. SUD patients less frequently underwent colectomy, but more often pancreatectomy, relative to nSUD.Following risk adjustment and with nSUD as reference, SUD demonstrated similar likelihood of in-hospital mortality, but remained associated with increased odds of any perioperative complication (Adjusted Odds Ratio [AOR] 1.17, CI 1.09-1.25). Further, SUD was linked with incremental increases in adjusted length of stay (β + 0.90 days, CI +0.68-1.12) and costs (β + $3630, CI +2650-4610), as well as greater likelihood of non-home discharge (AOR 1.54, CI 1.40-1.70). Conclusions Concurrent substance use disorder was associated with increased complications, resource utilization, and non-home discharge following major elective abdominal operations. Novel interventions are warranted to address increased risk among this vulnerable population and address significant disparities in postoperative outcomes.
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Affiliation(s)
- Baran Khoraminejad
- CORELAB, Department of Surgery, University of California, Los Angeles, Los Angeles, CA, United States of America
- Boston University, Boston, MA, United States of America
| | - Sara Sakowitz
- CORELAB, Department of Surgery, University of California, Los Angeles, Los Angeles, CA, United States of America
| | - Zihan Gao
- CORELAB, Department of Surgery, University of California, Los Angeles, Los Angeles, CA, United States of America
| | - Nikhil Chervu
- CORELAB, Department of Surgery, University of California, Los Angeles, Los Angeles, CA, United States of America
- Department of Surgery, University of California, Los Angeles, Los Angeles, CA, United States of America
| | - Joanna Curry
- CORELAB, Department of Surgery, University of California, Los Angeles, Los Angeles, CA, United States of America
| | - Konmal Ali
- CORELAB, Department of Surgery, University of California, Los Angeles, Los Angeles, CA, United States of America
| | - Syed Shahyan Bakhtiyar
- CORELAB, Department of Surgery, University of California, Los Angeles, Los Angeles, CA, United States of America
- Department of Surgery, University of Colorado, Denver, Aurora, CO, United States of America
| | - Peyman Benharash
- CORELAB, Department of Surgery, University of California, Los Angeles, Los Angeles, CA, United States of America
- Department of Surgery, University of California, Los Angeles, Los Angeles, CA, United States of America
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Rafaqat W, Lagazzi E, McChesney S, Smith MC, UrRahman M, Lee H, DeWane MP, Khan A. To Resect or Not to Resect: A Nationwide Comparison of Management of Sigmoid Volvulus. J Surg Res 2024; 297:101-108. [PMID: 38484451 DOI: 10.1016/j.jss.2023.12.054] [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: 08/11/2023] [Revised: 10/29/2023] [Accepted: 12/24/2023] [Indexed: 04/19/2024]
Abstract
INTRODUCTION Despite the high recurrence rate of sigmoid volvulus, there is reluctance to perform a prophylactic colectomy in frail patients due to the operation's perceived risks. We used a nationally representative database to compare risk of recurrence in patients undergoing a prophylactic colectomy versus endoscopic detorsion alone. METHODS We performed a retrospective cohort study using the National Readmission Database (2016-2019) including patients aged ≥18 y who had an emergent admission for sigmoid volvulus and underwent endoscopic detorsion on the day of admission. We performed a 1:1 propensity matching adjusting for patient demographics, frailty score comprising of 109 components, and hospital characteristics. Our primary outcome was readmission due to colonic volvulus and secondary outcomes included mortality, complications, length of stay (LOS), and costs during index admission and readmission. We performed a subgroup analysis in patients with Hospital Frailty Score >5. RESULTS We included 2113 patients of which 1046 patients (49.5%) underwent a colectomy during the initial admission. In the matched population of 830 pairs, readmission due to colonic volvulus was significantly lower in patients undergoing endoscopy followed by colectomy than endoscopy alone. Patients undergoing a colectomy had higher gastric and renal complications, longer LOS, and higher costs but no difference in mortality. In the subgroup analysis of frail patients, readmission was significantly lower in patients with prophylactic colectomy with no significant difference in mortality in 439 matched patients. CONCLUSIONS Prophylactic colectomy was associated with lower readmission, a higher rate of complications, increased LOS, and higher costs compared to sigmoid decompression alone.
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Affiliation(s)
- Wardah Rafaqat
- Division of Trauma, Emergency General Surgery, and Surgical Critical care, Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Emanuele Lagazzi
- Division of Trauma, Emergency General Surgery, and Surgical Critical care, Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Shannon McChesney
- Section of Surgical Sciences, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Michael C Smith
- Section of Surgical Sciences, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Mujeeb UrRahman
- Department of Surgery, District Headquarters Hospital, Buner, Pakistan
| | - Hanjoo Lee
- Department of Surgery, Harbor-UCLA Medical Center, Torrance, California
| | - Michael P DeWane
- Division of Trauma, Emergency General Surgery, and Surgical Critical care, Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Aimal Khan
- Section of Surgical Sciences, Vanderbilt University Medical Center, Nashville, Tennessee.
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Yu HC, Pu TW, Kang JC, Chen CY, Hu JM, Su RY. Stercoral perforation of the cecum: A case report. World J Gastrointest Surg 2024; 16:1189-1194. [DOI: 10.4240/wjgs.v16.i4.1189] [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: 11/26/2023] [Revised: 01/11/2024] [Accepted: 03/18/2024] [Indexed: 04/22/2024] Open
Abstract
BACKGROUND With less than 90 reported cases to date, stercoral perforation of the colon is a rare occurrence. Stercoral ulceration is thought to occur due to ischemic pressure necrosis of the bowel wall, which is caused by the presence of a stercoraceous mass. To underscore this urgent surgical situation concerning clinical presentation, surgical treatment, and results, we present the case of a 66-year-old man with a stercoral perforation.
CASE SUMMARY A 66-year-old man with a history of hypertension, hyperlipidemia, and gout presented at the emergency department with lower abdominal pain and a low-grade fever lasting for a few hours. Abdominal computed tomography indicated a suspected bezoar (approximately 7.6 cm) in the dilated cecum, accompanied by pericolic fat stranding, mild proximal dilatation of the ileum, pneumoperitoneum, and minimal ascites. Intraoperatively, feculent peritonitis with isolated cecal perforation were observed. Consequently, a right hemicolectomy with peritoneal lavage was performed. A histopathological examination supported the intraoperative findings.
CONCLUSION In stercoral perforations, a diagnosis should be diligently pursued, especially in older adults, and prompt surgical intervention should be implemented.
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Affiliation(s)
- Hung-Chun Yu
- Department of Surgery, Taichung Armed Forces General Hospital, Taichung 411228, Taiwan
- Department of Surgery, Tri-Service General Hospital, National Defense Medical Center, Taipei 11490, Taiwan
| | - Ta-Wei Pu
- Division of Colon and Rectal Surgery, Department of Surgery, Tri-Service General Hospital Songshan Branch, National Defense Medical Center, Taipei 105, Taiwan
| | - Jung-Cheng Kang
- Division of Colon and Rectal Surgery, Department of Surgery, Taiwan Adventist Hospital, Taipei 105, Taiwan
| | - Chao-Yang Chen
- Division of Colon and Rectal Surgery, Department of Surgery, Tri-Service General Hospital Songshan Branch, National Defense Medical Center, Taipei 105, Taiwan
| | - Je-Ming Hu
- Division of Colon and Rectal Surgery, Department of Surgery, Tri-Service General Hospital, National Defense Medical Center, Taipei 114, Taiwan
| | - Ruei-Yu Su
- Department of Pathology, Tri-Service General Hospital, National Defense Medical Center, Taipei 105, Taiwan
- Department of Pathology and Laboratory Medicine, Taoyuan Armed Forces General Hospital, Taoyuan 325, Taiwan
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Xue X, Zeng H, Chen D, Zheng B, Liang B, Xu D, Lin S. Comparing the short-term clinical outcomes and therapeutic effects of different colectomies in patients with refractory slow-transit constipation in eastern countries: a network meta-analysis. Updates Surg 2024; 76:411-422. [PMID: 38329678 DOI: 10.1007/s13304-024-01762-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2023] [Accepted: 01/16/2024] [Indexed: 02/09/2024]
Abstract
Surgical treatment has been widely used in patients with refractory slow transit constipation (RSTC). The aim of this network meta-analysis (NMA) was to compare the effects of different colectomies on short-term postoperative complications and quality of life in patients with RSTC. Electronic literature searches were performed in the PubMed, Web of Science, EMBASE, WANFANG DATA, and Cochrane Central Register of controlled trials databases and were searched up to December 2022. Selected to compare the short-term clinical outcomes and quality of life of the treatment of RSTC. A random-effects Bayesian NMA was conducted to assess and rank the effectiveness of different surgical modalities. This study included a total of six non-randomized controlled trials involving 336 subjects. It was found that subtotal colectomy with cecorectal anastomosis (CRA) demonstrated superior effectiveness in several aspects, including reduced hospital stay (MD 0.06; 95% CI [0.02, 1.96]), shorter operative time (MD 4.75; 95% CI [0.28, 14.07]), lower constipation index (MD 0.61; 95% CI [0.04, 1.71]), improved quality of life (MD 4.42; 95% CI [0.48, 4.42]). Additionally, in terms of short-term clinical outcomes, subtotal colectomy with ileosigmoidal anastomosis (SC-ISA) procedure ranked the highest in reducing small bowel obstruction (OR 0.24; 95% CI [0.02, 0.49]), alleviating abdominal pain (OR 0.53; 95% CI [0.05, 1.14]), minimizing abdominal distension (OR 0.33; 95% CI [0.02, 0.65]), and reducing incision infection rates (OR 0.17; 95% CI [0.01, 0.33]). Furthermore, SC-ISA ranked as the best approach in terms of patient satisfaction (OR 0.66; 95% CI [0.02, 1.46]). Based on our research findings, we recommend that CRA be considered as the preferred treatment approach for patients diagnosed with RSTC.
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Affiliation(s)
- Xueyi Xue
- Department of Gastroenterology and Anorectal Surgery, Longyan First Affiliated Hospital of Fujian Medical University, No. 105 Jiuyi North Road, Longyan, 364000, Fujian, China
| | - Hao Zeng
- Department of Gastroenterology and Anorectal Surgery, Longyan First Affiliated Hospital of Fujian Medical University, No. 105 Jiuyi North Road, Longyan, 364000, Fujian, China
- Fujian Medical University, Fuzhou, China
| | - Dongbo Chen
- Department of Gastroenterology and Anorectal Surgery, Longyan First Affiliated Hospital of Fujian Medical University, No. 105 Jiuyi North Road, Longyan, 364000, Fujian, China
| | - Biaohui Zheng
- Department of Gastroenterology and Anorectal Surgery, Longyan First Affiliated Hospital of Fujian Medical University, No. 105 Jiuyi North Road, Longyan, 364000, Fujian, China
| | - Baofeng Liang
- Department of Gastroenterology and Anorectal Surgery, Longyan First Affiliated Hospital of Fujian Medical University, No. 105 Jiuyi North Road, Longyan, 364000, Fujian, China
- Department of Outpatient Services, Shanghang County Hospital, Longyan, Fujian, China
| | - Dongbo Xu
- Department of Gastroenterology and Anorectal Surgery, Longyan First Affiliated Hospital of Fujian Medical University, No. 105 Jiuyi North Road, Longyan, 364000, Fujian, China
| | - Shuangming Lin
- Department of Gastroenterology and Anorectal Surgery, Longyan First Affiliated Hospital of Fujian Medical University, No. 105 Jiuyi North Road, Longyan, 364000, Fujian, China.
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Ng AP, Chervu N, Porter G, Mallick S, Le N, Benharash P, Lee H. Cost variation of nonelective surgery for ulcerative colitis across the United States. J Gastrointest Surg 2024; 28:488-493. [PMID: 38583900 DOI: 10.1016/j.gassur.2024.01.036] [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: 12/13/2023] [Revised: 01/07/2024] [Accepted: 01/27/2024] [Indexed: 04/09/2024]
Abstract
BACKGROUND Although clinical outcomes of surgery for ulcerative colitis (UC) have improved in the modern biologic era, expenditures continue to increase. A contemporary cost analysis of UC operative care is lacking. The present study aimed to characterize risk factors and center-level variation in hospitalization costs after nonelective resection for UC. METHODS All adults with UC in the 2016-2020 Nationwide Readmissions Database undergoing nonelective colectomy or rectal resection were identified. Mixed-effects models were developed to evaluate patient and hospital factors associated with costs. Random effects were estimated and used to rank hospitals by increasing risk-adjusted center-level costs. High-cost hospitals (HCHs) in the top decile of expenditure were identified, and their association with select outcomes was subsequently assessed. RESULTS An estimated 10,280 patients met study criteria with median index hospitalization costs of $40,300 (IQR, $26,400-$65,000). Increased time to surgery was significantly associated with a +$2500 increment in costs per day. Compared with low-volume hospitals, medium- and high-volume centers demonstrated a -$5900 and -$8200 reduction in costs, respectively. Approximately 19.2% of variability in costs was attributable to interhospital differences rather than patient factors. Although mortality and readmission rates were similar, HCH status was significantly associated with increased complications (adjusted odds ratio [AOR], 1.39), length of stay (+10.1 days), and nonhome discharge (AOR, 1.78). CONCLUSION The present work identified significant hospital-level variation in the costs of nonelective operations for UC. Further efforts to optimize time to surgery and regionalize care to higher-volume centers may improve the value of UC surgical care in the United States.
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Affiliation(s)
- Ayesha P Ng
- Cardiovascular Outcomes Research Laboratories, David Geffen School of Medicine at UCLA, Los Angeles, California, United States
| | - Nikhil Chervu
- Cardiovascular Outcomes Research Laboratories, David Geffen School of Medicine at UCLA, Los Angeles, California, United States
| | - Giselle Porter
- Cardiovascular Outcomes Research Laboratories, David Geffen School of Medicine at UCLA, Los Angeles, California, United States
| | - Saad Mallick
- Cardiovascular Outcomes Research Laboratories, David Geffen School of Medicine at UCLA, Los Angeles, California, United States
| | - Nguyen Le
- Cardiovascular Outcomes Research Laboratories, David Geffen School of Medicine at UCLA, Los Angeles, California, United States
| | - Peyman Benharash
- Cardiovascular Outcomes Research Laboratories, David Geffen School of Medicine at UCLA, Los Angeles, California, United States; Division of Cardiac Surgery, Department of Surgery, David Geffen School of Medicine at UCLA, Los Angeles, California, United States
| | - Hanjoo Lee
- Division of Colon and Rectal Surgery, Department of Surgery, Harbor-UCLA Medical Center, Torrance, California, United States.
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Coeckelberghs E, Bislenghi G, Wolthuis A, Teunkens A, Dewinter G, Coppens S, Vanhaecht K, D'Hoore A. Quality indicators for ambulatory colectomy: literature search and expert consensus. Surg Endosc 2024; 38:1894-1901. [PMID: 38316661 PMCID: PMC10978605 DOI: 10.1007/s00464-023-10660-3] [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: 10/09/2023] [Accepted: 12/22/2023] [Indexed: 02/07/2024]
Abstract
BACKGROUND Care for patients undergoing elective colectomy has become increasingly standardized using Enhanced Recovery Programs (ERP). ERP, encorporating minimally invasive surgery (MIS), decreased postoperative morbidity and length of stay (LOS). However, disruptive changes are needed to safely introduce colectomy in an ambulatory or same-day discharge (SDD) setting. Few research groups showed the feasibility of ambulatory colectomy. So far, no minimum standards for the quality of care of this procedure have been defined. This study aims to identify quality indicators (QIs) that assess the quality of care for ambulatory colectomy. METHODS A literature search was performed to identify recommendations for ambulatory colectomy. Based on that search, a set of QIs was identified and categorized into seven domains: preparation of the patient (pre-admission), anesthesia, surgery, in-hospital monitoring, home monitoring, feasibility, and clinical outcomes. This list was presented to a panel of international experts (surgeons and anesthesiologists) in a 1 round Delphi to assess the relevance of the proposed indicators. RESULTS Based on the literature search (2010-2021), 3841 results were screened on title and abstract for relevant information. Nine papers were withheld to identify the first set of QIs (n = 155). After excluding duplicates and outdated QIs, this longlist was narrowed down to 88 indicators. Afterward, consensus was reached in a 1 round Delphi on a final list of 32 QIs, aiming to be a comprehensive set to evaluate the quality of ambulatory colectomy care. CONCLUSION We propose a list of 32 QI to guide and evaluate the implementation of ambulatory colectomy.
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Affiliation(s)
- Ellen Coeckelberghs
- Leuven Institute for Healthcare Policy, Department of Public Health and Primary Care, KU Leuven - University of Leuven, Leuven, Belgium.
| | - Gabriele Bislenghi
- Department of Abdominal Surgery, University Hospitals Leuven, Leuven, Belgium
| | - Albert Wolthuis
- Department of Abdominal Surgery, University Hospitals Leuven, Leuven, Belgium
| | - An Teunkens
- Department of Anaesthesiology, University Hospitals Leuven, Leuven, Belgium
| | - Geertrui Dewinter
- Department of Anaesthesiology, University Hospitals Leuven, Leuven, Belgium
| | - Steve Coppens
- Department of Anaesthesiology, University Hospitals Leuven, Leuven, Belgium
| | - Kris Vanhaecht
- Leuven Institute for Healthcare Policy, Department of Public Health and Primary Care, KU Leuven - University of Leuven, Leuven, Belgium
- Department of Quality Management, University Hospitals Leuven, Leuven, Belgium
| | - André D'Hoore
- Department of Abdominal Surgery, University Hospitals Leuven, Leuven, Belgium
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Perivoliotis K, Tzovaras G, Tepetes K, Baloyiannis I. Comparison of intracorporeal and extracorporeal anastomosis in laparoscopic right colectomy: an updated meta-analysis and trial sequential analysis. Updates Surg 2024; 76:375-396. [PMID: 38216794 DOI: 10.1007/s13304-023-01737-8] [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] [Subscribe] [Scholar Register] [Received: 04/18/2023] [Accepted: 12/19/2023] [Indexed: 01/14/2024]
Abstract
This meta-analysis was conducted to provide updated evidence regarding perioperative safety and efficacy, of IC and EC anastomosis in laparoscopic right colectomies. In this study, the Cochrane Handbook for Systematic Reviews of Interventions and the PRISMA guidelines were applied. The study protocol received a PROSPERO registration (CRD42020214596). A systematic literature search of the electronic scholar databases (Medline, Web of Science and Scopus) was performed. To reduce type I error, a trial sequential analysis (TSA) algorithm was introduced. The quality of evidence was evaluated based on the GRADE methodology. In total, 46 studies were included in this meta-analysis, Pooled comparisons and TSA confirmed that IC is superior in terms of incisional hernia (0.29; 95%CI: 0.19, 0.44), open conversion (0.45; 95%CI: 0.30, 0.67), reoperation (0.62; 95%CI: 0.46, 0.84]), LOS (- 0.76; 95%CI: - 1.03, - 0.49), blood loss (- 11.50; 95%CI: - 18.42, - 4.58), and cosmesis (- 1.71; 95%CI: - 2.01, - 1.42). Postoperative pain and return of bowel function were, also, shortened when the anastomosis was fashioned intracorporeally. The grading of most evidence ranged from 'low' to 'high'. Due to the discrepancy in the results of RCTs and non-RCTs, and the proportionally smaller sample size of the former, further randomized trials are required to increase the evidence of this comparison.
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Affiliation(s)
| | - George Tzovaras
- Department of Surgery, University Hospital of Larissa, Mezourlo, 41110, Larissa, Greece
| | - Konstantinos Tepetes
- Department of Surgery, University Hospital of Larissa, Mezourlo, 41110, Larissa, Greece
| | - Ioannis Baloyiannis
- Department of Surgery, University Hospital of Larissa, Mezourlo, 41110, Larissa, Greece
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de Almeida Leite RM, Araujo SEA, de Souza AV, Cauley C, Goldstone R, Francone T, Barchi LC, Callado GY, Fagundes L, Ribeiro U, Bossie H, Ricciardi R. Surgical and medical outcomes in robotic compared to laparoscopic colectomy global prospective cohort from the American college of surgeons national surgical quality improvement program. Surg Endosc 2024:10.1007/s00464-024-10717-x. [PMID: 38498211 DOI: 10.1007/s00464-024-10717-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2023] [Accepted: 01/28/2024] [Indexed: 03/20/2024]
Abstract
BACKGROUND Evidence regarding the outcomes benefits of robotic approach, when compared to a laparoscopic approach, in colectomy remain limited. OBJECTIVE This study aimed to analyze the value of robotic approach compared to laparoscopic approach in minimally invasive colectomy. DESIGN Cohort study of the National Surgical Quality Improvement Program (NSQIP). SETTING This study included data from the NSQIP from 1/2016 to 12/2021. PATIENT Adult patients undergoing minimally invasive (laparoscopic or robotic) colorectal surgery. INTERVENTION Robotic versus laparoscopic colectomy. OUTCOME MEASURES Risk ratios for the incidence of medical and surgical morbidity and overall mortality. RESULTS Compared to laparoscopic, robotic colectomy was associated with a significant decrease in postoperative morbidity [RR 0.84 (95%CI 0.72-0.96), P < 0.001], a significant reduction in postoperative mortality [RR 0.83 (95%CI 0.79-0.90), P 0.010)], and in post operative ileus [RR: 0.80 (95%CI 0.75-0.84), P < 0.001]. Yet, robotic approach was associated with a significant increase in total operative time despite a significant decrease in total length of stay. No benefit was observed regarding anastomotic leak. LIMITATIONS Observational nature of the study cannot exclude residual bias. CONCLUSIONS In this prospective cohort from the NSQIP, robotic colectomy was associated with a significant reduction in postoperative ileus, unplanned conversion to open surgery, morbidity, and overall mortality when compared to laparoscopic colectomy.
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Affiliation(s)
- Rodrigo Moisés de Almeida Leite
- Colon and Rectal Surgery Department, Massachussets General Hospital, 15 Parkman Street, WACC 460, Boston, MA, 02114, USA
- Colon & Rectal Surgery Resident, Albert Einstein Israelite Hospital, Sao Paulo, Brazil
| | - Sergio Eduardo Alonso Araujo
- Staff Colorectal Surgeon and Medical Director, Oncology Division, Albert Einstein Israelite Hospital, São Paulo, Brazil
| | | | - Christy Cauley
- Department of Surgery, Massachussets General Hospital, Boston, MA, 02214, USA
| | - Rob Goldstone
- Department of Surgery, Massachussets General Hospital, Boston, MA, 02214, USA
| | - Todd Francone
- Department of Surgery, Massachussets General Hospital, Boston, MA, 02214, USA
| | - Leandro Cardoso Barchi
- Gastrointestinal Surgery Division, University of Sao Paulo Medical School, São Paulo, Brazil
| | | | | | - Ulysses Ribeiro
- Gastrointestinal Surgery Division, University of Sao Paulo Medical School, São Paulo, Brazil
| | | | - Rocco Ricciardi
- Colon and Rectal Surgery Department, Massachussets General Hospital, 15 Parkman Street, WACC 460, Boston, MA, 02114, USA.
- Department of Surgery, Massachussets General Hospital, Boston, MA, 02214, USA.
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Pavlidis ET, Galanis IN, Pavlidis TE. Management of obstructed colorectal carcinoma in an emergency setting: An update. World J Gastrointest Oncol 2024; 16:598-613. [PMID: 38577464 PMCID: PMC10989363 DOI: 10.4251/wjgo.v16.i3.598] [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: 10/21/2023] [Revised: 12/06/2023] [Accepted: 01/16/2024] [Indexed: 03/12/2024] Open
Abstract
Colorectal carcinoma is common, particularly on the left side. In 20% of patients, obstruction and ileus may be the first clinical manifestations of a carcinoma that has advanced (stage II, III or even IV). Diagnosis is based on clinical presentation, plain abdominal radiogram, computed tomography (CT), CT colonography and positron emission tomography/CT. The best management strategy in terms of short-term operative or interventional and long-term oncological outcomes remains unknown. For the most common left-sided obstruction, the first choice should be either emergency surgery or endoscopic decompression by self-expendable metal stents or tubes. The operative plan should be either one-stage or two-stage resection. One-stage resection with on-table bowel decompression and irrigation can be accompanied or not accompanied by proximal defunctioning stoma (colostomy or ileostomy). Primary anastomosis is more convenient but has increased risks of anastomotic leakage and morbidity. Two-stage resection (Hartmann's procedure) is safer and the most widely used despite temporally affecting quality of life. Damage control surgery in high-risk frail patients is less frequently performed since it can be successfully substituted with endoscopic stenting or tubing. For the less common right-sided obstruction, one-stage surgical resection is more beneficial than endoscopic decompression. The role of minimally invasive surgery (laparoscopic or robotic) is a subject of debate. Emergency laparoscopic-assisted management is advantageous to some extent but requires much expertise due to inherent difficulties in dissecting the distended colon and the risk of rupture and subsequent septic complications. The decompressing stent as a bridge to elective surgery more substantially decreases the risks of morbidity and mortality than emergency surgery for decompression and has equivalent medium-term overall survival and disease-free survival rates. Its combination with neoadjuvant chemotherapy or radiation may have a positive effect on long-term oncological outcomes. Management plans are crucial and must be individualized to better fit each case.
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Affiliation(s)
- Efstathios T Pavlidis
- 2nd Propedeutic Department of Surgery, Hippokration General Hospital, School of Medicine, Aristotle University of Thessaloniki, Thessaloniki 54642, Greece
| | - Ioannis N Galanis
- 2nd Propedeutic Department of Surgery, Hippokration General Hospital, School of Medicine, Aristotle University of Thessaloniki, Thessaloniki 54642, Greece
| | - Theodoros E Pavlidis
- 2nd Propedeutic Department of Surgery, Hippokration General Hospital, School of Medicine, Aristotle University of Thessaloniki, Thessaloniki 54642, Greece
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Mankarious MM, Greene AC, Schaefer EW, Clarke K, Kulaylat AN, Jeganathan NA, Deutsch MJ, Kulaylat AS. Is the writing on the wall? The relationship between the number of disease-modifying anti-inflammatory bowel disease drugs used and the risk of surgical resection. J Gastrointest Surg 2024:S1091-255X(24)00367-6. [PMID: 38575464 DOI: 10.1016/j.gassur.2024.03.011] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/02/2024] [Revised: 02/27/2024] [Accepted: 03/09/2024] [Indexed: 04/06/2024]
Abstract
BACKGROUND Disease-modifying anti-inflammatory bowel disease drugs (DMAIDs) revolutionized the management of ulcerative colitis (UC). This study assessed the relationship between the number and timing of drugs used to treat UC and the risk of colectomy and postoperative complications. METHODS This was a retrospective review of adult patients with UC treated with disease-modifying drugs between 2005 and 2020 in the MarketScan database. Landmark and time-varying regression analyses were used to analyze risk of surgical resection. Multivariable Cox regression analysis was used to determine risk of postoperative complications, emergency room visits, and readmissions. RESULTS A total of 12,193 patients with UC and treated with disease-modifying drugs were identified. With a median follow-up time of 1.7 years, 23.8% used >1 drug, and 8.3% of patients required surgical resection. In landmark analyses, using 2 and ≥3 drugs before the landmark date was associated with higher incidence of surgery for each landmark than 1 drug. Multivariable Cox regression showed hazard ratio (95% CIs) of 4.22 (3.59-4.97), 11.7 (9.01-15.3), and 22.9 (15.0-34.9) for using 2, 3, and ≥4 drugs, respectively, compared with using 1 DMAID. That risk was constant overtime. The number of drugs used preoperatively was not associated with an increased postoperative risk of any complication, emergency room visits, or readmission. CONCLUSION The use of multiple disease-modifying drugs in UC is associated with an increased risk of surgical resection with each additional drug. This provides important prognostic data and highlights the importance of patient counseling with minimal concern regarding risk of postoperative morbidity for additional drugs.
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Affiliation(s)
- Marc M Mankarious
- Department of Surgery, Pennsylvania State University, College of Medicine, Hershey, Pennsylvania, United States
| | - Alicia C Greene
- Department of Surgery, Pennsylvania State University, College of Medicine, Hershey, Pennsylvania, United States
| | - Eric W Schaefer
- Department of Public Health Sciences, Penn State College of Medicine, Hershey, Pennsylvania, United States
| | - Kofi Clarke
- Division of Gastroenterology and Hepatology, Department of Medicine, Pennsylvania State University, Hershey, Pennsylvania, United States
| | - Afif N Kulaylat
- Department of Surgery, Pennsylvania State University, College of Medicine, Hershey, Pennsylvania, United States
| | - Nimalan A Jeganathan
- Division of Colon and Rectal Surgery, Department of Surgery, Pennsylvania State University, College of Medicine, Hershey, Pennsylvania, United States
| | - Michael J Deutsch
- Division of Colon and Rectal Surgery, Department of Surgery, Pennsylvania State University, College of Medicine, Hershey, Pennsylvania, United States
| | - Audrey S Kulaylat
- Division of Colon and Rectal Surgery, Department of Surgery, Pennsylvania State University, College of Medicine, Hershey, Pennsylvania, United States.
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11
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Simmonds A, Keller-Biehl L, Khader A, Timmerman W, Amendola M. Comparing Outcomes in Patients Undergoing Colectomy at Veteran Affairs Hospitals and Non-Veteran Affairs Hospitals: A Multiinstitutional Study. J Surg Res 2024; 295:449-456. [PMID: 38070259 DOI: 10.1016/j.jss.2023.11.034] [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: 04/14/2023] [Revised: 10/15/2023] [Accepted: 11/13/2023] [Indexed: 02/25/2024]
Abstract
INTRODUCTION The Veteran Affairs Surgical Quality Improvement Program (VASQIP) and National Surgical Quality Improvement Program (NSQIP) are large databases designed to measure surgical outcomes for their respective populations. We sought to compare surgical outcomes in patients undergoing colectomies at Veterans Affairs (VA) hospitals versus non-VA hospitals. METHODS After institutional review baord approval, records for 271,523 colectomies from NSQIP and 11,597 from VASQIP between the years 2015 and 2019 were compiled. Demographics, comorbidity, 30-d mortality, and other outcomes were examined using Chi-squared, analysis of variance, Mann Whitney U, and Fisher's Exact Test within SPSS version 26. RESULTS VASQIP patients were more likely to be male (94.3% versus 48.4%, P < 0.001) and older (median 63, 52-72 versus 67, 60-72 P < 0.001). Veterans were also more likely to have diabetes (25.3% versus 15.8%, P < 0.001), chronic obstructive pulmonary disease (15.4% versus 5.5%, P < 0.001), and congestive heart failure (17.0% versus 1.3%, P < 0.001). Veterans had slightly better 30-d mortality (2.4% versus 2.8%, P = 0.003), less organ space infections (2.8% versus 5.8%, P < 0.001), or postoperative sepsis (3.4% versus 5.3%). Non-VA patients were more likely to be having emergent surgery (13.4% versus 9.6%, P < 0.001) or undergo a laparoscopic approach (57.9% versus 50.2%, P < 0.001). Non-VA patients had shorter postoperative length of stay (5.99 d versus 7.32 d, P < 0.001) and were less likely to return to the operating room (5.3% versus 8.4%, P < 0.001) CONCLUSIONS: Despite increased comorbidity, VA hospitals and hospitals enrolled in NSQIP have managed to achieve markedly similar rates of 30-d mortality following colectomy. Further study is needed to better understand the differences between both the populations and surgical outcomes between VA hospitals and non-VA hospitals.
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Affiliation(s)
- Alexander Simmonds
- Virginia Commonwealth University School of Medicine, Richmond, Virginia; Department of Surgery, Central Virginia VA Health Care System, Richmond, Virginia.
| | - Lucas Keller-Biehl
- Virginia Commonwealth University School of Medicine, Richmond, Virginia; Department of Surgery, Central Virginia VA Health Care System, Richmond, Virginia
| | - Adam Khader
- Department of Surgery, Central Virginia VA Health Care System, Richmond, Virginia
| | - William Timmerman
- Department of Surgery, Central Virginia VA Health Care System, Richmond, Virginia
| | - Michael Amendola
- Virginia Commonwealth University School of Medicine, Richmond, Virginia; Department of Surgery, Central Virginia VA Health Care System, Richmond, Virginia
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12
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Piazza O Sed N, Noviello D, Filippi E, Conforti F, Furfaro F, Fraquelli M, Costantino A, Danese S, Vecchi M, Fiorino G, Allocca M, Caprioli F. Superior predictive value of transmural over endoscopic severity for colectomy risk in ulcerative colitis: a multicentre prospective cohort study. J Crohns Colitis 2024; 18:291-299. [PMID: 37632350 PMCID: PMC10896635 DOI: 10.1093/ecco-jcc/jjad152] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/07/2023] [Indexed: 08/28/2023]
Abstract
BACKGROUND AND AIMS Endoscopic activity is associated with an increased risk of surgery in patients with ulcerative colitis [UC]. Transmural activity, as defined by Milan Ultrasound Criteria [MUC] > 6.2, reliably detects endoscopic activity in patients with UC. The present study aimed to assess in UC patients whether transmural severity is a better predictor of colectomy as compared to endoscopy. METHODS Consecutive adult UC patients were recruited in two IBD Referral Centres and underwent colonoscopy and intestinal ultrasound in a blinded fashion. The need for colectomy was assessed at follow-up. Univariable and multivariable logistic and Cox regression analyses were performed. Receiver operating characteristic [ROC] analysis was used to compare MUC baseline values and Mayo Endoscopic Scores [MES] in predicting colectomy risk. RESULTS Overall, 141 patients were enrolled, and 13 underwent colectomy in the follow-up period. Both MES (hazard ratio [HR]: 3.15, 95% confidence interval [CI]: 1.18-8.37, p = 0.02) and MUC [HR: 1.48, 95% CI: 1.19-1.76, p < 0.001] were associated with colectomy risk, but only MUC was independently associated with this event on multivariable analysis [HR: 1.46, 95% CI: 1.06-2.02, p = 0.02]. MUC was the only independent variable associated with colectomy risk in patients with clinically active disease (odds ratio [OR]: 1.53 [1.03-2.27], p = 0.03). MUC demonstrated higher accuracy than MES (area under ROC curve [AUROC] 0.83, 95% CI: 0.75-0.92 vs 0.71, 95% CI: 0.62-0.80) and better performance for predicting colectomy [p = 0.02]. The optimal MUC score cut-off value for predicting colectomy, as assessed by the Youden index, was 7.7. CONCLUSIONS A superior predictive value was found for transmural vs endoscopic severity for colectomy risk in UC patients.
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Affiliation(s)
- Nicole Piazza O Sed
- Gastroenterology and Endoscopy Unit, Foundation IRCCS Ca' Granda, Ospedale Maggiore Policlinico, Milan, Italy
| | - Daniele Noviello
- Gastroenterology and Endoscopy Unit, Foundation IRCCS Ca' Granda, Ospedale Maggiore Policlinico, Milan, Italy
- Department of Pathophysiology and Transplantation, University of Milan, Milan, Italy
| | - Elisabetta Filippi
- Department of Pathophysiology and Transplantation, University of Milan, Milan, Italy
| | - Francesco Conforti
- Gastroenterology and Endoscopy Unit, Foundation IRCCS Ca' Granda, Ospedale Maggiore Policlinico, Milan, Italy
| | - Federica Furfaro
- Gastroenterology and Endoscopy, IRCCS Ospedale San Raffaele Milano, Milan, Italy
| | - Mirella Fraquelli
- Gastroenterology and Endoscopy Unit, Foundation IRCCS Ca' Granda, Ospedale Maggiore Policlinico, Milan, Italy
| | - Andrea Costantino
- Gastroenterology and Endoscopy Unit, Foundation IRCCS Ca' Granda, Ospedale Maggiore Policlinico, Milan, Italy
- Department of Pathophysiology and Transplantation, University of Milan, Milan, Italy
| | - Silvio Danese
- Gastroenterology and Endoscopy, IRCCS Ospedale San Raffaele Milano, Milan, Italy
- University Vita-Salute San Raffaele Milano, Milan, Italy
| | - Maurizio Vecchi
- Gastroenterology and Endoscopy Unit, Foundation IRCCS Ca' Granda, Ospedale Maggiore Policlinico, Milan, Italy
- Department of Pathophysiology and Transplantation, University of Milan, Milan, Italy
| | - Gionata Fiorino
- University Vita-Salute San Raffaele Milano, Milan, Italy
- IBD Unit, Gastroenterology and Digestive Endoscopy, San Camillo-Forlanini Hospital, Rome, Italy
| | - Mariangela Allocca
- Gastroenterology and Endoscopy, IRCCS Ospedale San Raffaele Milano, Milan, Italy
| | - Flavio Caprioli
- Gastroenterology and Endoscopy Unit, Foundation IRCCS Ca' Granda, Ospedale Maggiore Policlinico, Milan, Italy
- Department of Pathophysiology and Transplantation, University of Milan, Milan, Italy
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Choi MS, Yun SH, Lee SC, Shin JK, Park YA, Huh J, Cho YB, Kim HC, Lee WY. Learning curve for single-port robot-assisted colectomy. Ann Coloproctol 2024; 40:44-51. [PMID: 36535706 PMCID: PMC10915530 DOI: 10.3393/ac.2022.00745.0106] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/01/2022] [Revised: 11/05/2022] [Accepted: 11/06/2022] [Indexed: 12/24/2022] Open
Abstract
PURPOSE Since the introduction of robotic surgery, robots for colorectal cancer have replaced laparoscopic surgery, and a single-port robot (SPR) platform has been launched and is being used to treat patients. We analyzed the learning curve and initial complications of using an SPR platform in colorectal cancer surgery. METHODS We reviewed 39 patients who underwent SPR colectomy from April to October 2019. All surgeries were performed by the same surgeon using an SPR device. A learning curve was generated using the cumulative sum methodology to assess changes in total operation time, docking time, and surgeon console time. We grouped the patients into 3 groups according to the time period: the first 11 were phase 1, the next 11 were phase 2, and the last 17 were phase 3. RESULTS The mean age of the patients was 61.28±13.03 years, and they had a mean body mass index of 23.79±2.86 kg/m2. Among the patients, 23 (59.0%) were male, and 16 (41.0%) were female. The average operation time was 186.59±51.30 minutes, the average surgeon console time was 95.49±35.33 minutes, and the average docking time (time from skin incision to robot docking) was 14.87±10.38 minutes. The surgeon console time differed significantly among the different phases (P<0.001). Complications occurred in 8 patients: 2 ileus, 2 postoperation hemoglobin changes, 3 urinary retentions, and 1 complicated fluid collection. CONCLUSION In our experience, the learning curve for SPR colectomy was achieved after the 18th case.
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Affiliation(s)
- Moon Suk Choi
- Department of Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Seong Hyeon Yun
- Department of Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Sung Chul Lee
- Department of Surgery, Dankook University Hospital, Cheonan, Korea
| | - Jung Kyong Shin
- Department of Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Yoon Ah Park
- Department of Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Jungwook Huh
- Department of Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Yong Beom Cho
- Department of Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Hee Cheol Kim
- Department of Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Woo Yong Lee
- Department of Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
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Bernklev L, Nilsen JA, Augestad KM, Holme Ø, Pilonis ND. Management of non-curative endoscopic resection of T1 colon cancer. Best Pract Res Clin Gastroenterol 2024; 68:101891. [PMID: 38522886 DOI: 10.1016/j.bpg.2024.101891] [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: 01/04/2024] [Accepted: 02/07/2024] [Indexed: 03/26/2024]
Abstract
Endoscopic resection techniques enable en-bloc resection of T1 colon cancers. A complete removal of T1 colon cancer can be considered curative when histologic examination of the specimens shows none of the high-risk factors for lymph nodes metastases. Criteria predicting lymph nodes metastases include deep submucosal invasion, poor differentiation, lymphovascular invasion, and high-grade tumor budding. In these cases, complete (R0), local endoscopic resection is considered sufficient as negligible risk of lymph nodes metastases does not outweigh morbidity and mortality associated with surgical resection. Challenges arise when endoscopic resection is incomplete (RX/R1) or high-risk histological features are present. The risk of lymph node metastasis in T1 CRC ranges from 1% to 36.4%, depending on histologic risk factors. Presence of any risk factor labels the patient "high risk," warranting oncologic surgery with mesocolic lymphadenectomy. However, even if 70%-80% of T1-CRC patients are classified as high-risk, more than 90% are without lymph node involvement after oncological surgery. Surgical overtreatment in T1 CRC is a challenge, requiring a balance between oncologic safety and minimizing morbidity/mortality. This narrative review explores the landscape of managing non-curative T1 colon cancer, focusing on the choice between advanced endoscopic resection techniques and surgical interventions. We discuss surveillance strategies and shared decision-making, emphasizing the importance of a multidisciplinary approach.
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Affiliation(s)
- Linn Bernklev
- Clinical Effectiveness Research Group, University of Oslo, Oslo, Norway; Department of Gastroenterology, Akershus University Hospital, Lørenskog, Norway.
| | - Jens Aksel Nilsen
- Clinical Effectiveness Research Group, University of Oslo, Oslo, Norway; Vestre Viken Hospital Trust, Bærum Hospital, Norway
| | - Knut Magne Augestad
- Department of Gastrointestinal Surgery, Akershus University Hospital, Lørenskog, Norway; Division of Surgery Campus Ahus, University of Oslo, Oslo, Norway
| | - Øyvind Holme
- Clinical Effectiveness Research Group, University of Oslo, Oslo, Norway; Department of Research, Sorlandet Hospital Trust, Kristiansand, Norway
| | - Nastazja Dagny Pilonis
- Clinical Effectiveness Research Group, University of Oslo, Oslo, Norway; Medical Center of Postgraduate Education, Warsaw, Poland; Department of Gastroenterological Oncology, Maria Sklodowska-Curie Memorial Cancer Center, Warsaw, Poland; Department of General, Endocrine and Transplant Surgery, Medical University of Gdansk, Gdansk, Poland
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15
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Sakowitz S, Bakhtiyar SS, Verma A, Ebrahimian S, Vadlakonda A, Mabeza RM, Lee H, Benharash P. Association of time to resection with survival in patients with colon cancer. Surg Endosc 2024; 38:614-623. [PMID: 38012438 DOI: 10.1007/s00464-023-10548-2] [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: 05/17/2023] [Accepted: 10/15/2023] [Indexed: 11/29/2023]
Abstract
PURPOSE Colon cancer (CC) remains a leading cause of cancer-related mortality worldwide, for which colectomy represents the standard of care. Yet, the impact of delayed resection on survival outcomes remains controversial. We assessed the association between time to surgery and 10-year survival in a national cohort of CC patients. METHODS This retrospective cohort study identified all adults who underwent colectomy for Stage I-III CC in the 2004-2020 National Cancer Database. Those who required neoadjuvant therapy or emergent resection < 7 days from diagnosis were excluded. Patients were classified into Early (< 25 days) and Delayed (≥ 25 days) cohorts after an adjusted analysis of the relationship between time to surgery and 10-year survival. Survival at 1-, 5-, and 10-years was assessed via Kaplan-Meier analyses and Cox proportional hazard modeling, adjusting for age, sex, race, income quartile, insurance coverage, Charlson-Deyo comorbidity index, disease stage, location of tumor, receipt of adjuvant chemotherapy, as well as hospital type, location, and case volume. RESULTS Of 165,991 patients, 84,665 (51%) were classified as Early and 81,326 (49%) Delayed. Following risk adjustment, Delayed resection was associated with similar 1-year [hazard ratio (HR) 1.01, 95% confidence interval (CI) 0.97-1.04, P = 0.72], but inferior 5- (HR 1.24, CI 1.22-1.26; P < 0.001) and 10-year survival (HR 1.22, CI 1.20-1.23; P < 0.001). Black race [adjusted odds ratio (AOR) 1.36, CI 1.31-1.41; P < 0.001], Medicaid insurance coverage (AOR 1.34, CI 1.26-1.42; P < 0.001), and care at high-volume hospitals (AOR 1.12, 95%CI 1.08-1.17; P < 0.001) were linked with greater likelihood of Delayed resection. CONCLUSIONS Patients with CC who underwent resection ≥ 25 days following diagnosis demonstrated similar 1-year, but inferior 5- and 10-year survival, compared to those who underwent surgery within 25 days. Socioeconomic factors, including race and Medicaid insurance, were linked with greater odds of delayed resection. Efforts to balance appropriate preoperative evaluation with expedited resection are needed to optimize patient outcomes.
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Affiliation(s)
- Sara Sakowitz
- Cardiovascular Outcomes Research Laboratories (CORELAB), University of California, Los Angeles, Los Angeles, CA, USA
| | - Syed Shahyan Bakhtiyar
- Cardiovascular Outcomes Research Laboratories (CORELAB), University of California, Los Angeles, Los Angeles, CA, USA
- Department of Surgery, University of Colorado, Aurora, CO, USA
| | - Arjun Verma
- Cardiovascular Outcomes Research Laboratories (CORELAB), University of California, Los Angeles, Los Angeles, CA, USA
| | - Shayan Ebrahimian
- Cardiovascular Outcomes Research Laboratories (CORELAB), University of California, Los Angeles, Los Angeles, CA, USA
| | - Amulya Vadlakonda
- Cardiovascular Outcomes Research Laboratories (CORELAB), University of California, Los Angeles, Los Angeles, CA, USA
| | - Russyan Mark Mabeza
- Cardiovascular Outcomes Research Laboratories (CORELAB), University of California, Los Angeles, Los Angeles, CA, USA
| | - Hanjoo Lee
- Cardiovascular Outcomes Research Laboratories (CORELAB), University of California, Los Angeles, Los Angeles, CA, USA
- Division of Colon & Rectal Surgery, Harbor-UCLA Medical Center, Torrance, CA, USA
| | - Peyman Benharash
- Cardiovascular Outcomes Research Laboratories (CORELAB), University of California, Los Angeles, Los Angeles, CA, USA.
- Department of Surgery, University of California, Los Angeles, CA, USA.
- UCLA Division of Cardiac Surgery, 64-249 Center for Health Sciences, Los Angeles, CA, 90095, USA.
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Abstract
Acute severe ulcerative colitis (ASUC) is one of life-threatening complications that occur in one-fifth of ulcerative colitis (UC) patients with significant morbidity and an estimated mortality rate up to 1%. There are no validated clinical scoring systems for ASUC. Intravenous corticosteroids remain the cornerstone for the management of ASUC patients However, one-third of patients are steroid refractory and require colectomy in the pre-biologic era or salvage therapy in the post-biologic era. The currently available predictors of non-response to steroids and salvages therapy are sub-optimal. Furthermore, there is a need for the development of clear outcome measures for ASUC patients. Although infliximab and cyclosporin are both effective as salvage therapy, they still carry a rate of treatment failure. Hence, there is an unmet need to explore alternative therapeutic options before colectomy particularly in prior infliximab-exposed patients. This may include the introduction of small molecules with rapid onset of action as a salvage or sequential therapy and the use of slow-onset other biological therapy after "bridging" with cyclosporine. In this article, we explore the current best evidence-based practice and detail the gaps in knowledge in the management of ASUC.
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Affiliation(s)
| | - Emma Whitehead
- IBD Unit, Hull University Teaching Hospitals, Hull, HU3 2JZ, UK
| | - Shaji Sebastian
- IBD Unit, Hull University Teaching Hospitals, Hull, HU3 2JZ, UK.
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Hope E, Kuronen-Stewart C, Wilson DC, Henderson P, Clark C. The Impact of Biologic Therapies on Rate of Colectomy in Paediatric-onset Ulcerative Colitis - A Population-Based Cohort Study. J Pediatr Surg 2024; 59:230-234. [PMID: 37981545 DOI: 10.1016/j.jpedsurg.2023.10.034] [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: 10/07/2023] [Accepted: 10/11/2023] [Indexed: 11/21/2023]
Abstract
AIM Biologic therapies have been associated with reduced rate of colectomy in ulcerative colitis (UC) in adults, but data are limited in paediatric-onset UC. Our aim was to define the rate of colectomy in paediatric-onset UC, including post-transition into adult care, and to evaluate the impact of biologic therapies on rate of colectomy. METHOD All prevalent patients diagnosed with paediatric-onset UC in South-East Scotland were identified from a prospectively accrued database at our regional tertiary centre. Patients exposed to biologics or surgery were identified and further data collected from health records. Kaplan-Meier analysis was used to calculate cumulative risk of colectomy over time. RESULTS 145 prevalent patients were identified between 2000 and 2021. Median follow-up was 7.9 years (IQR 4.1-13.1). 23 patients (16 %) underwent a colectomy. 50/145 (34 %) patients received biologic therapy, and 13/23 (57 %) patients who underwent colectomy received biologics. The cumulative risk of colectomy across the whole cohort at 1, 5, and 10 years was 3 %, 13 % and 16 %, respectively. Patients exposed to biologics had a higher colectomy rate at 5 and 10 years (22 % and 34 %). Patients in the pre-biologic era (2000-2008) had non-significantly reduced time from diagnosis to colectomy (2.4 vs 3.7 years, p = 0.204). CONCLUSION We have defined the 1-, 5-, and 10-year colectomy rate in a population-based cohort of Paediatric-onset UC patients. Patients who received biologic therapy had a significantly increased risk of colectomy. Increased severity of disease in these patients may account for the greater colectomy risk. LEVEL OF EVIDENCE Level 1.
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Affiliation(s)
- Emma Hope
- Department of Paediatric Surgery, Royal Hospital for Children and Young People, Edinburgh, 50 Little France Crescent, Edinburgh, EH16 4TJ, UK
| | - Cameron Kuronen-Stewart
- Department of Paediatric Surgery, Royal Hospital for Children and Young People, Edinburgh, 50 Little France Crescent, Edinburgh, EH16 4TJ, UK.
| | - David C Wilson
- Department of Paediatric Gastroenterology and Nutrition, Royal Hospital for Children and Young People, Edinburgh, 50 Little France Crescent, Edinburgh, EH16 4TJ, UK; Department of Child Life and Health, University of Edinburgh, 50 Little France Crescent, Edinburgh, EH16 4TJ, UK
| | - Paul Henderson
- Department of Paediatric Gastroenterology and Nutrition, Royal Hospital for Children and Young People, Edinburgh, 50 Little France Crescent, Edinburgh, EH16 4TJ, UK; Department of Child Life and Health, University of Edinburgh, 50 Little France Crescent, Edinburgh, EH16 4TJ, UK
| | - Claire Clark
- Department of Paediatric Surgery, Royal Hospital for Children and Young People, Edinburgh, 50 Little France Crescent, Edinburgh, EH16 4TJ, UK
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Cawich SO, Plummer JM, Griffith S, Naraynsingh V. Colorectal resections for malignancy: A pilot study comparing conventional vs freehand robot-assisted laparoscopic colectomy. World J Clin Cases 2024; 12:488-494. [PMID: 38322459 PMCID: PMC10841952 DOI: 10.12998/wjcc.v12.i3.488] [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: 09/26/2023] [Revised: 12/06/2023] [Accepted: 12/29/2023] [Indexed: 01/18/2024] Open
Abstract
BACKGROUND Laparoscopic colectomy is widely accepted as a safe operation for colorectal cancer, but we have experienced resistance to the introduction of the FreeHand® robotic camera holder to augment laparoscopic colorectal surgery. AIM To compare the initial results between conventional and FreeHand® robot-assisted laparoscopic colectomy in Trinidad and Tobago. METHODS This was a prospective study of outcomes from all laparoscopic colectomies performed for colorectal carcinoma from November 29, 2021 to May 30, 2022. The following data were recorded: Operating time, conversions, estimated blood loss, hospitalization, morbidity, surgical resection margins and number of nodes harvested. All data were entered into an excel database and the data were analyzed using SPSS ver 20.0. RESULTS There were 23 patients undergoing colectomies for malignant disease: 8 (35%) FreeHand®-assisted and 15 (65%) conventional laparoscopic colectomies. There were no conversions. Operating time was significantly lower in patients undergoing robot-assisted laparoscopic colectomy (95.13 ± 9.22 vs 105.67 ± 11.48 min; P = 0.045). Otherwise, there was no difference in estimated blood loss, nodal harvest, hospitalization, morbidity or mortality. CONCLUSION The FreeHand® robot for colectomies is safe, provides some advantages over conventional laparoscopy and does not compromise oncologic standards in the resource-poor Caribbean setting.
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Affiliation(s)
- Shamir O Cawich
- Department of Surgery, University of the West Indies, St Augustine, Trinidad and Tobago
| | - Joseph Martin Plummer
- Department of General Surgery and Consultant General and Colorectal Surgeon, Department of Surgery, University of the West Indies, Kingston, KIN7, Jamaica
| | - Sahle Griffith
- Department of Surgery, Queen Elizabeth Hospital, Bridgetown, Barbados
| | - Vijay Naraynsingh
- Department of Surgery, Port of Spain General Hospital, Port of Spain, Trinidad and Tobago
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Gachabayov M, Kajmolli A, Quintero L, Felsenreich DM, Popa DE, Ignjatovic D, Bergamaschi R. Inadvertent laparoscopic lavage of perforated colon cancer: a systematic review. Langenbecks Arch Surg 2024; 409:35. [PMID: 38197963 DOI: 10.1007/s00423-023-03224-5] [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: 08/26/2023] [Accepted: 12/31/2023] [Indexed: 01/11/2024]
Abstract
BACKGROUND Although laparoscopic lavage for perforated diverticulitis with peritonitis has been grabbing the headlines, it is known that the clinical presentation of peritonitis can also be caused by an underlying perforated carcinoma. The aim of this study was to determine the incidence of patients undergoing inadvertent laparoscopic lavage of perforated colon cancer as well as the delay in cancer diagnosis. METHODS The PubMed database was systematically searched to include all studies meeting inclusion criteria. Studies were screened through titles and abstracts with potentially eligible studies undergoing full-text screening. The primary endpoints of this meta-analysis were the rates of perforated colon cancer patients having undergone inadvertent laparoscopic lavage as well as the delay in cancer diagnosis. This was expressed in pooled rate % and 95% confidence intervals. RESULTS Eleven studies (three randomized, two prospective, six retrospective) totaling 642 patients met inclusion criteria. Eight studies reported how patients were screened for cancer and the number of patients who completed follow-up. The pooled cancer rate was 3.4% (0.9%, 5.8%) with low heterogeneity (Isquare2 = 34.02%) in eight studies. Cancer rates were 8.2% (0%, 3%) (Isquare2 = 58.2%) and 1.7% (0%, 4.5%) (Isquare2 = 0%) in prospective and retrospective studies, respectively. Randomized trials reported a cancer rate of 7.2% (3.1%, 11.2%) with low among-study heterogeneity (Isquare2 = 0%) and a median delay to diagnosis of 2 (1.5-5) months. CONCLUSIONS This systematic review found that 7% of patients undergoing laparoscopic lavage for peritonitis had perforated colon cancer with a delay to diagnosis of up to 5 months.
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Affiliation(s)
- Mahir Gachabayov
- Department of Surgery, Jacobi Medical Center, New York City Health Hospitals, Building 1, Suite 610, 1400 Pelham Parkway S, New York, NY, USA
- Department of Surgery, New York Medical College, Valhalla, NY, USA
| | - Agon Kajmolli
- Department of Surgery, Jacobi Medical Center, New York City Health Hospitals, Building 1, Suite 610, 1400 Pelham Parkway S, New York, NY, USA
- Department of Surgery, New York Medical College, Valhalla, NY, USA
| | - Luis Quintero
- Department of Surgery, Jacobi Medical Center, New York City Health Hospitals, Building 1, Suite 610, 1400 Pelham Parkway S, New York, NY, USA
- Department of Surgery, New York Medical College, Valhalla, NY, USA
| | - Daniel M Felsenreich
- Division of Visceral Surgery, Department of Surgery, Medical University of Vienna, Vienna, Austria
| | - Dorin E Popa
- Department of General Surgery, Linköping University Hospital, Linköping, Sweden
| | - Dejan Ignjatovic
- Department of Digestive Surgery, Akershus University Hospital, University of Oslo, Lorenskog, Norway
| | - Roberto Bergamaschi
- Department of Surgery, Jacobi Medical Center, New York City Health Hospitals, Building 1, Suite 610, 1400 Pelham Parkway S, New York, NY, USA.
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20
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Lee GW, Park SB. Congestive ischemic colitis successfully treated with anti-inflammatory therapy: A case report. World J Clin Cases 2024; 12:142-147. [PMID: 38292639 PMCID: PMC10824190 DOI: 10.12998/wjcc.v12.i1.142] [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: 08/28/2023] [Revised: 12/03/2023] [Accepted: 12/14/2023] [Indexed: 01/02/2024] Open
Abstract
BACKGROUND Congestive ischemic colitis is a rare subtype of ischemic colitis with an unknown pathophysiology. Excluding conservative management, such as fasting, no established treatment exists; therefore, surgical intervention should be considered in some cases if symptoms worsen. Current literature suggests that anti-inflammatory agents may effectively treat congestive ischemic colitis. CASE SUMMARY We present the case of a 68-year-old female patient who underwent laparoscopic left hemicolectomy for transverse colon cancer 3 years ago. Postoperatively, follow-up included an annual colonoscopy and abdominal computed tomography (CT) at a local clinic. However, progressive erythema and edema of the sigmoid colon were observed 1 year postoperatively. Upon admission to our hospital, she complained of abdominal pain and diarrhea. Abdominal CT showed thickening of the sigmoid colon walls, and colonoscopy revealed erythema, edema, and multiple ulcers with exudate in the sigmoid colon. CT angiography showed engorgement of the sigmoid vasa recta without any vascular abnormalities. The diagnosis was congestive ischemic colitis, and we treated the patient with anti-inflammatory agents. After 2 mo of glucocorticoid therapy (20 mg once daily) and 7 mo of 5-aminosalicylate therapy (1 g twice daily), the ulcers completely healed. She has not experienced any recurrence for 2 years. CONCLUSION Anti-inflammatory therapy, specifically glucocorticoids and 5-aminosalicylate, has demonstrated promising efficacy and introduces potential novel treatment options for congestive ischemic colitis.
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Affiliation(s)
- Geon Woo Lee
- Department of Internal Medicine, Pusan National University School of Medicine and Research Institute for Convergence of Biomedical Science and Technology, Pusan National University Yangsan Hospital, Yangsan 50612, South Korea
| | - Su Bum Park
- Department of Internal Medicine, Pusan National University School of Medicine and Research Institute for Convergence of Biomedical Science and Technology, Pusan National University Yangsan Hospital, Yangsan 50612, South Korea
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21
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Cheong C, Kim NW, Lee HS, Kang J. Intracorporeal versus extracorporeal anastomosis in minimally invasive right hemi colectomy: systematic review and meta-analysis of randomized controlled trials. Ann Surg Treat Res 2024; 106:1-10. [PMID: 38205092 PMCID: PMC10774696 DOI: 10.4174/astr.2024.106.1.1] [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] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2023] [Revised: 09/13/2023] [Accepted: 10/26/2023] [Indexed: 01/12/2024] Open
Abstract
Purpose Compared with extracorporeal anastomosis (ECA), intracorporeal anastomosis (ICA) is expected to provide some benefits, including a shorter operation time and less intraoperative bleeding. Nevertheless, the benefits of ICA have mainly been evaluated in nonrandomized studies. Owing to the recent update of randomized controlled trials (RCTs) for minimally invasive surgery (MIS) of right hemicolectomy (RHC), the need to measure the actual effect by synthesizing the outcomes of these studies has emerged. Methods We performed a comprehensive search of the PubMed, Embase, and Cochrane databases (from inception to January 30, 2023) for studies that applied ICA and ECA for RHC with MIS. We included 7 RCTs. The operation time, intraoperative blood loss, conversion rate, length of incision, and postoperative outcomes such as ileus, anastomosis leakage, length of hospitalization, and postoperative pain were compared between ICA and ECA. Results A total of 740 patients were included in the study. Among them, 377 and 373 underwent ICA and ECA, respectively. There were significant differences in age (P = 0.003) and incision type (P < 0.001) between ICA and ECA. ICA was associated with a significantly longer operation time (P = 0.033). Although the postoperative pain associated with ICA was significantly lower than that associated with ECA on postoperative day 2 (POD 2) (P = 0.003), it was not different on POD 3 between the groups. Other perioperative outcomes were similar between the 2 groups. Conclusion In this meta-analysis, ICA did not significantly improve short-term outcomes compared to ECA; other advantages to overcome ICA's longer operation time are not clear.
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Affiliation(s)
- Chinock Cheong
- Department of Surgery, Korea University Guro Hospital, Korea University College of Medicine, Seoul, Korea
| | - Na Won Kim
- Yonsei University Medical Library, Seoul, Korea
| | - Hye Sun Lee
- Biostatistics Collaboration Unit, Yonsei University College of Medicine, Seoul, Korea
| | - Jeonghyun Kang
- Department of Surgery, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
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22
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Shahait A, Pearl A, Saleh KJ. Outcomes of Colectomy in United States Veterans With Cirrhosis: Predicting Outcomes Using Nomogram. J Surg Res 2024; 293:570-577. [PMID: 37832308 DOI: 10.1016/j.jss.2023.09.055] [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: 05/26/2023] [Revised: 09/05/2023] [Accepted: 09/19/2023] [Indexed: 10/15/2023]
Abstract
INTRODUCTION With growing incidence of liver cirrhosis worldwide, there is more need for a risk assessment tool to aid in perioperative management of cirrhotic patients undergoing colorectal procedures. We aim to assess the association of open (OC) versus laparoscopic (LC) approach with colorectal procedures' outcomes and develop an easy-to-use nomogram to predict outcomes. METHODS We analyzed the Veterans Affairs Surgical Quality Improvement Program to identify all patients with cirrhosis and ascites who underwent colorectal procedures from 2008 to 2015. Model for End-stage Liver Disease score was calculated as well as five-items modified frailty index. The chi-square test was utilized to analyze categorical variables. Two-sided unpaired Student's t-test or Mann-Whitney U-test were used for numerical variables as appropriate. Multivariate logistic regression adjusting for demographics, comorbidities, and other preoperative factors was used to analyze postoperative outcomes. A predictive nomogram was constructed and internally validated. RESULTS A total of 731 patients were identified. Overall, complications occurred in 48.2% of patients, and 30-d mortality was 24.8%, with 57.5% were performed emergently. Malignant neoplasm was the most common indication (25.4%). LC was performed in 22.4%, with shorter operative time, less blood transfusions, shorter length of stay, and lower morbidity compared to OC. Overall, Model for End-stage Liver Disease score was an independent factor of mortality, while laparoscopic approach had a protective effect on morbidity. An easy-to-use nomogram was generated for morbidity and 30-d mortality with calculated area under cure of 74.5% and 77.9%, respectively, indicating reliability. CONCLUSIONS Although colectomy is a high-risk operation in cirrhotic veterans, LC may have favorable outcomes than OC in selected patients. An easy-to-use nomogram to predict morbidity and mortality for cirrhotic patients undergoing colectomy is proposed.
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Affiliation(s)
- Awni Shahait
- Departement of Surgery, Southern Illinois University School of Medicine, Carbondale, Illinois; Department of Surgery, John D Dingell Veterans Affairs Medical Center, Detroit, Michigan.
| | - Adam Pearl
- Department of Surgery, John D Dingell Veterans Affairs Medical Center, Detroit, Michigan
| | - Khaled J Saleh
- Department of Surgery, John D Dingell Veterans Affairs Medical Center, Detroit, Michigan
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23
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Ahuja V, Paredes LG, Leeds IL, Perkal MF, Tsutsumi A, Bhandarkar S, King JT. Racial disparities in complications following elective colon cancer resection: Impact of laparoscopic versus robotic approaches. Am J Surg 2024; 227:85-89. [PMID: 37806892 PMCID: PMC10842593 DOI: 10.1016/j.amjsurg.2023.09.038] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2023] [Revised: 09/05/2023] [Accepted: 09/27/2023] [Indexed: 10/10/2023]
Abstract
BACKGROUND We sought to examine differences in outcomes for Black and White patients undergoing robotic or laparoscopic colectomy to assess the potential impact of technological advancement. METHODS We queried the ACS-NSQIP database for elective robotic (RC) and laparoscopic (LC) colectomy for cancer from 2012 to 2020. Outcomes included 30-day mortality and complications. We analyzed the association between outcomes, operative approach, and race using multivariable logistic regression. RESULTS We identified 64,460 patients, 80.9% laparoscopic and 19.1% robotic. RC patients were most frequently younger, male, and White, with fewer comorbidities (P < 0.001). After adjustment, there was no difference in mortality by approach or race. Black patients who underwent LC had higher complications (OR 1.10, 95% CI 1.03-1.08, P = 0.005) than their White LC counterparts and RC patients. CONCLUSIONS Robotic colectomy was associated with lower rates of complications in minority patients. Further investigation is required to identify the causal pathway that leads to our finding.
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Affiliation(s)
- Vanita Ahuja
- VA Connecticut Healthcare System, US Department of Veterans Affairs, West Haven, CT, USA; Department of Surgery, Yale University School of Medicine, New Haven, CT, USA.
| | - Lucero G Paredes
- VA Connecticut Healthcare System, US Department of Veterans Affairs, West Haven, CT, USA; National Clinician Scholars Program, Yale School of Medicine, New Haven, CT, USA; Department of Surgery, Maine Medical Center, Portland, ME, USA
| | - Ira L Leeds
- VA Connecticut Healthcare System, US Department of Veterans Affairs, West Haven, CT, USA; Department of Surgery, Yale University School of Medicine, New Haven, CT, USA
| | - Melissa F Perkal
- VA Connecticut Healthcare System, US Department of Veterans Affairs, West Haven, CT, USA; Department of Surgery, Yale University School of Medicine, New Haven, CT, USA
| | - Ayaka Tsutsumi
- Department of Surgery, Yale University School of Medicine, New Haven, CT, USA
| | | | - Joseph T King
- VA Connecticut Healthcare System, US Department of Veterans Affairs, West Haven, CT, USA; Department of Neurosurgery, Yale School of Medicine, New Haven, CT, USA
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24
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Avellaneda N, Maroli A, Tottrup A, Buskens C, Kotze PG, Pellino G, Dige A, Haase AM, Haanappel A, Giorgi L, Carvello M, Maruyama BY, Christensen P, Spinelli A. Short and long-term outcomes of surgery for inflammatory (uncomplicated) ileocecal Crohn's disease: Multicentric retrospective analysis of 211 patients. Dig Liver Dis 2023:S1590-8658(23)01006-X. [PMID: 38044224 DOI: 10.1016/j.dld.2023.10.017] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/31/2023] [Revised: 10/11/2023] [Accepted: 10/19/2023] [Indexed: 12/05/2023]
Abstract
BACKGROUND Surgical management for patients with inflammatory ileocecal Crohn's disease (CD) could be a reasonable alternative to second-line medical treatment. AIM To assess short and long-term outcomes of patients operated on for inflammatory, ileocecal Crohn's disease. METHODS A retrospective analysis of patients intervened at four referral hospitals during 2012-2021 was performed. RESULTS 211 patients were included. 43% of patients underwent surgery more than 5 years after diagnosis, and 49% had been exposed to at least one biologic agent preoperatively. 89% were operated by laparoscopy, with 1.6% conversion rate. The median length of the resected bowel was 25 cm (7-92) and three patients (1.43%) received a stoma. Median follow-up was 36 (17-70) months. The endoscopic recurrence-free survival proportion at 24, 48, 72, 96, and 120 months was 56%, 52%, 45%, 38%, and 33%, respectively. The clinical recurrence-free survival proportion at 24, 48, 72, 96, and 120 months was 83%, 79%, 76%, 74%, and 74%, respectively. In multivariate analysis, previous biological treatment (HR=2.01; p = 0.001) was associated with a higher risk of overall recurrence. CONCLUSION Surgery in patients with primary inflammatory ileocecal CD is associated with good postoperative outcomes, low postoperative morbidity with reasonable recurrence rates.
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Affiliation(s)
- Nicolas Avellaneda
- Department of Surgery, Aarhus University Hospital, Denmark; General Surgery Department, CEMIC, Buenos Aires, Argentina.
| | - Annalisa Maroli
- Division of Colon and Rectal Surgery, IRCCS - Humanitas Research Hospital, Milano, Italy; Department of Biomedical science, Humanitas University, Milan, Italy
| | - Anders Tottrup
- Department of Surgery, Aarhus University Hospital, Denmark
| | - Christianne Buskens
- Colorectal Surgery Department, Amsterdam Medical Hospitals, Amsterdam, the Netherlands
| | - Paulo Gustavo Kotze
- Colorectal Surgery Unit, Pontifícia Universidade Católica do Paraná (PUCPR), Brazil
| | - Gianluca Pellino
- Department of Advanced Medical and Surgical Sciences, Università degli Studi della Campania "Luigi Vanvitelli", Naples, Italy; Colorectal Surgery, Vall d'Hebron University Hospital, Universitat Autonoma de Barcelona UAB, Barcelona, Spain
| | - Anders Dige
- Department of Hepatology and Gastroenterology, Aarhus University Hospital, Aarhus, Denmark
| | - Anne-Mette Haase
- Department of Hepatology and Gastroenterology, Aarhus University Hospital, Aarhus, Denmark
| | - Anouck Haanappel
- Colorectal Surgery Department, Amsterdam Medical Hospitals, Amsterdam, the Netherlands
| | - Lorenzo Giorgi
- Division of Colon and Rectal Surgery, IRCCS - Humanitas Research Hospital, Milano, Italy
| | - Michelle Carvello
- Division of Colon and Rectal Surgery, IRCCS - Humanitas Research Hospital, Milano, Italy; Department of Biomedical science, Humanitas University, Milan, Italy
| | | | | | - Antonino Spinelli
- Division of Colon and Rectal Surgery, IRCCS - Humanitas Research Hospital, Milano, Italy; Department of Biomedical science, Humanitas University, Milan, Italy
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25
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Bobrzyński Ł, Pach R, Szczepanik A, Kołodziejczyk P, Richter P, Sierzega M. What determines complications and prognosis among patients subject to multivisceral resections for locally advanced gastric cancer? Langenbecks Arch Surg 2023; 408:442. [PMID: 37987850 PMCID: PMC10663187 DOI: 10.1007/s00423-023-03187-7] [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: 04/25/2023] [Accepted: 11/16/2023] [Indexed: 11/22/2023]
Abstract
BACKGROUND Locally advanced gastric cancer (GC) extending to the surrounding tissues may require a multivisceral resection (MVR) to provide the best chance of cure. However, little is known about how the extent of organ resection affects the risks and benefits of surgery. METHODS An electronic database of patients treated between 1996 and 2020 in an academic surgical centre was reviewed. MVRs were defined as partial or total gastrectomy combined with splenectomy, distal pancreatectomy, or partial colectomy. RESULTS Suspected intraoperative tumour invasion of perigastric organs (cT4b) was found in 298 of 1476 patients with non-metastatic GC, and 218 were subject to MVRs, including the spleen (n = 126), pancreas (n = 51), and colon (n = 41). MVRs were associated with higher proportions of surgical and general complications, but not mortality. A nomogram was developed to predict the risk of major postoperative morbidity (Clavien-Dindo's grade ≥ 3a), and the highest odds ratio for major morbidity identified by logistic regression modelling was found for distal pancreatectomy (2.53, 95% CI 1.23-5.19, P = 0.012) and colectomy (2.29, 95% CI 1.04-5.09, P = 0.035). Margin-positive resections were identified by the Cox proportional hazards model as the most important risk factor for patients' survival (hazard ratio 1.47, 95% CI 1.10-1.97). The extent of organ resection did not affect prognosis, but a MVR was the only factor reducing the risk of margin positivity (OR 0.44, 95% CI 0.21-0.87). CONCLUSIONS The risk of multivisceral resections is associated with the organ being removed, but only MVRs increase the odds of complete tumour clearance for locally advanced gastric cancer.
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Affiliation(s)
- Łukasz Bobrzyński
- First Department of Surgery, Jagiellonian University Medical College, 2 Jakubowski Street, 30-688, Cracow, Poland
| | - Radosław Pach
- First Department of Surgery, Jagiellonian University Medical College, 2 Jakubowski Street, 30-688, Cracow, Poland
| | - Antoni Szczepanik
- First Department of Surgery, Jagiellonian University Medical College, 2 Jakubowski Street, 30-688, Cracow, Poland
| | - Piotr Kołodziejczyk
- First Department of Surgery, Jagiellonian University Medical College, 2 Jakubowski Street, 30-688, Cracow, Poland
| | - Piotr Richter
- First Department of Surgery, Jagiellonian University Medical College, 2 Jakubowski Street, 30-688, Cracow, Poland
| | - Marek Sierzega
- First Department of Surgery, Jagiellonian University Medical College, 2 Jakubowski Street, 30-688, Cracow, Poland.
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Rajack F, Medford S, Naab T. Clostridioides difficile infection leading to fulminant colitis with toxic megacolon. Autops Case Rep 2023; 13:e2023457. [PMID: 38034515 PMCID: PMC10687841 DOI: 10.4322/acr.2023.457] [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: 08/08/2023] [Accepted: 10/14/2023] [Indexed: 12/02/2023]
Abstract
Clostridioidesdifficile infection (CDI) is the culprit of millions of nosocomial infections in the United States. Programs that successfully decrease its incidence, therefore, render cost savings for the healthcare system. Toxic megacolon and perforation are two of the most significant complications with increased mortality rates. We report a 23-year-old nursing home resident hospitalized for fever, cough, and green sputum. After 3 days of antibiotic therapy, he developed abdominal distension, diarrhea, and vomiting and underwent a total colectomy. The colon was dilated to a maximum of 11 cm with markedly edematous mucosa and yellow pseudomembranes. Qualitative PCR of the stool detected Clostridioides difficile toxin B gene. While there is no consensus for the required interval between antibiotic treatment and CDI, this presentation 3 days after starting the antibiotic therapy is earlier than most proposed ranges.
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Affiliation(s)
- Fareed Rajack
- Howard University Hospital, Department of Pathology and Laboratory Medicine, Washington, D.C., United States of America
| | - Shawn Medford
- Howard University College of Medicine, Washington, D.C., United States of America
| | - Tammey Naab
- Howard University Hospital, Department of Pathology and Laboratory Medicine, Washington, D.C., United States of America
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27
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Sterk MFM, Crolla RMPH, Verseveld M, Dekker JWT, van der Schelling GP, Verhoef C, Olthof PB. Uptake of robot-assisted colon cancer surgery in the Netherlands. Surg Endosc 2023; 37:8196-8203. [PMID: 37644155 PMCID: PMC10615967 DOI: 10.1007/s00464-023-10383-5] [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: 06/02/2023] [Accepted: 08/06/2023] [Indexed: 08/31/2023]
Abstract
BACKGROUND The robot-assisted approach is now often used for rectal cancer surgery, but its use in colon cancer surgery is less well defined. This study aims to compare the outcomes of robotic-assisted colon cancer surgery to conventional laparoscopy in the Netherlands. METHODS Data on all patients who underwent surgery for colon cancer from 2018 to 2020 were collected from the Dutch Colorectal Audit. All complications, readmissions, and deaths within 90 days after surgery were recorded along with conversion rate, margin and harvested nodes. Groups were stratified according to the robot-assisted and laparoscopic approach. RESULTS In total, 18,886 patients were included in the analyses. The operative approach was open in 15.2%, laparoscopic in 78.9% and robot-assisted in 5.9%. The proportion of robot-assisted surgery increased from 4.7% in 2018 to 6.9% in 2020. There were no notable differences in outcomes between the robot-assisted and laparoscopic approach for Elective cT1-3M0 right, left, and sigmoid colectomy. Only conversion rate was consistently lower in the robotic group. (4.6% versus 8.8%, 4.6% versus 11.6%, and 1.6 versus 5.9%, respectively). CONCLUSIONS This nationwide study on surgery for colon cancer shows there is a gradual but slow adoption of robotic surgery for colon cancer up to 6.9% in 2020. When comparing the outcomes of right, left, and sigmoid colectomy, clinical outcomes were similar between the robotic and laparoscopic approach. However, conversion rate is consistently lower in the robotic procedures.
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Affiliation(s)
| | | | - Mareille Verseveld
- Department of Surgery, Franciscus Gasthuis & Vlietland, Rotterdam, The Netherlands
| | | | | | - Cornelis Verhoef
- Department of Surgery, Erasmus MC Cancer Institute, Dr. Molewaterplein 40, 3015GD, Rotterdam, The Netherlands
| | - Pim B Olthof
- Department of Surgery, Amphia Hospital, Breda, The Netherlands.
- Department of Surgery, Erasmus MC Cancer Institute, Dr. Molewaterplein 40, 3015GD, Rotterdam, The Netherlands.
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28
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Soliman SS, Rolandelli RH, Chang GC, Nemecz AK, Nemeth ZH. How the COVID-19 pandemic affected the severity and clinical presentation of diverticulitis. Intest Res 2023; 21:493-499. [PMID: 37915181 PMCID: PMC10626013 DOI: 10.5217/ir.2022.00042] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/01/2022] [Revised: 08/11/2022] [Accepted: 09/01/2022] [Indexed: 11/03/2023] Open
Abstract
BACKGROUND/AIMS Single-institution studies showed that patients presented with more severe diverticulitis and underwent more emergency operations during the coronavirus disease 2019 (COVID-19) pandemic. Therefore, we studied this trend using nationwide data from the American College of Surgeons National Surgical Quality Improvement Program database. METHODS Patients (n = 23,383) who underwent a colectomy for diverticulitis in 2018 (control year) and 2020 (pandemic year) were selected. We compared these groups for differences in disease severity, comorbidities, perioperative factors, and complications. RESULTS During the pandemic, colonic operations for diverticulitis decreased by 13.14%, but the rates of emergency operations (17.31% vs. 20.04%, P< 0.001) and cases with a known abscess/perforation (50.11% vs. 54.55%, P< 0.001) increased. Likewise, the prevalence of comorbidities, such as congestive heart failure, acute renal failure, systemic inflammatory response syndrome, and septic shock, were higher during the pandemic (P< 0.05). During this same period, significantly more patients were classified under American Society of Anesthesiologists classes 3, 4, and 5, suggesting their preoperative health states were more severe and life-threatening. Correspondingly, the average operation time was longer (P< 0.001) and complications, such as organ space surgical site infection, wound disruption, pneumonia, acute renal failure, septic shock, and myocardial infarction, increased (P< 0.05) during the pandemic. CONCLUSIONS During the pandemic, surgical volume decreased, but the clinical presentation of diverticulitis became more severe. Due to resource reallocation and possibly patient fear of seeking medical attention, diverticulitis was likely underdiagnosed, and cases that would have been elective became emergent. This underscores the importance of monitoring patients at risk for diverticulitis and intervening when criteria for surgery are met.
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Affiliation(s)
- Sara S. Soliman
- Department of Surgery, Morristown Medical Center, Morristown, NJ, USA
| | | | - Grace C. Chang
- Department of Surgery, Morristown Medical Center, Morristown, NJ, USA
| | - Amanda K. Nemecz
- Department of Surgery, Morristown Medical Center, Morristown, NJ, USA
| | - Zoltan H. Nemeth
- Department of Surgery, Morristown Medical Center, Morristown, NJ, USA
- Department of Anesthesiology, Columbia University, New York, NY, USA
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29
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Pervaiz SS, D'Adamo C, Mavanur A, Wolf JH. A retrospective comparison of 90-day outcomes, length of stay, and readmissions between robotic-assisted and laparoscopic colectomy. J Robot Surg 2023; 17:2205-2209. [PMID: 37277593 DOI: 10.1007/s11701-023-01642-7] [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: 02/12/2023] [Accepted: 05/28/2023] [Indexed: 06/07/2023]
Abstract
Investigations generally assess 30 days of perioperative outcomes with robotic-assisted and laparoscopic colectomy. Outcomes beyond 30 days serve as a quality metric of surgical services and an assessment of 90 days of outcomes may have greater clinical utility. The purpose of this study was to assess 90 days of outcomes, length of stay (LOS), and readmissions among patients who underwent a robotic-assisted versus laparoscopic colectomy using a national database. Patients undergoing either robotic-assisted or laparoscopic colectomy were identified using Current Procedural Terminology (CPT) codes within PearlDiver, a national, inpatient records database from 2010 to 2019. Outcomes were defined using the National Surgical Quality Improvement Program (NSQIP) risk calculator and identified using International Classification of Disease (ICD) diagnosis codes. Categorical variables were compared using chi-square tests, and continuous variables were compared using paired t tests. Covariate-adjusted regression models were also constructed to evaluate these associations while accounting for potential confounders. A total of 82,495 patients were assessed in this study. At 90 days, patients of the laparoscopic colectomy cohort experienced a higher rate of complications than patients who underwent robotic-assisted colectomy (9.5 vs. 6.6%, p < 0.001). There were no significant differences in LOS (6 vs. 6.5 days, p = 0.08) and readmissions (6.1 vs. 6.7%, p = 0.851) at 90 days. Patients undergoing robotic-assisted colectomy have a lower risk for morbidity at 90 days. Neither approach is superior for LOS nor 90 days of readmissions. Both techniques are effective minimally invasive procedures, yet patients may gain a greater risk benefit from robotic colectomy.
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Affiliation(s)
- Sahir S Pervaiz
- Department of Surgery, Hospital of the University of Pennsylvania, Philadelphia, PA, USA
| | - Christopher D'Adamo
- Department of Family and Community Medicine, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Arun Mavanur
- Department of Surgery, Sinai Hospital, Baltimore, MD, USA
- Department of Surgery, Georgetown University, Washington, DC, USA
- Department of Surgery, Johns Hopkins University, Baltimore, MD, USA
| | - Joshua H Wolf
- Department of Surgery, Sinai Hospital, Baltimore, MD, USA.
- Department of Surgery, Georgetown University, Washington, DC, USA.
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Le Cosquer G, Capirchio L, Rivière P, Denis MA, Poullenot F, Remue C, Zerbib F, Leonard D, Célérier B, Kartheuser A, Laharie D, Dewit O. Time trend in surgical indications and outcomes in ulcerative colitis-A two decades in-depth retrospective analysis. Dig Liver Dis 2023; 55:1338-1344. [PMID: 37029063 DOI: 10.1016/j.dld.2023.03.003] [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: 12/21/2022] [Revised: 02/20/2023] [Accepted: 03/10/2023] [Indexed: 04/09/2023]
Abstract
BACKGROUND Recent data regarding the impact of biologics and new surgical techniques on the indications and outcomes of colectomy for ulcerative colitis (UC) are limited. AIMS The present study aimed at determining the trend of colectomy in UC by comparing colectomy indications and outcomes between 2000 and 2010 and 2011-2020. METHODS This observational retrospective study was conducted in two tertiary hospitals, including consecutive patients who underwent colectomy between 2000 and 2020. All data concerning UC history, treatment and surgeries were collected. RESULTS Among the 286 patients included, 87 underwent colectomy in 2001-2010 and 199 in 2011-2020. Patients' characteristics were similar between groups, except for prior biologic exposure (50.6 % vs. 74.9%; p<0.001). The indications of colectomy significantly decreased for refractory UC (50.6 % vs. 37.7%; p = 0.042), but were similar for acute severe UC (36.8 % vs. 42.2%; p = 0.390) and (pre)neoplastic lesions (12.6 % vs. 20.1%; p = 0.130). A widespread use of laparoscopy (47.7 % vs. 81.4%; p<0.001) was associated with fewer early complications (12.6 % vs. 5.5%; p = 0.038). CONCLUSION Over the last two decades, the proportion of surgery for refractory UC significantly decreased compared to other surgical indications while surgical outcomes improved despite larger exposure to biologics.
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Affiliation(s)
- Guillaume Le Cosquer
- Department of Gastroenterology, CHU de Bordeaux, Centre Médico-chirurgical Magellan, Hôpital Haut-Lévêque; Université de Bordeaux, INSERM CIC 1401, Bordeaux, France
| | - Lena Capirchio
- Department of Hepato-gastroenterology, Cliniques Universitaires Saint-Luc, Brussels, Belgium
| | - Pauline Rivière
- Department of Gastroenterology, CHU de Bordeaux, Centre Médico-chirurgical Magellan, Hôpital Haut-Lévêque; Université de Bordeaux, INSERM CIC 1401, Bordeaux, France
| | - Marie Armelle Denis
- Department of Hepato-gastroenterology, Cliniques Universitaires Saint-Luc, Brussels, Belgium
| | - Florian Poullenot
- Department of Gastroenterology, CHU de Bordeaux, Centre Médico-chirurgical Magellan, Hôpital Haut-Lévêque; Université de Bordeaux, INSERM CIC 1401, Bordeaux, France
| | - Christophe Remue
- Colorectal Surgery Unit, Cliniques Universitaires Saint-Luc, Brussels, Belgium
| | - Frank Zerbib
- Department of Gastroenterology, CHU de Bordeaux, Centre Médico-chirurgical Magellan, Hôpital Haut-Lévêque; Université de Bordeaux, INSERM CIC 1401, Bordeaux, France
| | - Daniel Leonard
- Colorectal Surgery Unit, Cliniques Universitaires Saint-Luc, Brussels, Belgium
| | - Bertrand Célérier
- Department of Digestive and Endocrine Surgery, CHU de Bordeaux, Hôpital Haut-Lévêque, Pessac, France
| | - Alex Kartheuser
- Colorectal Surgery Unit, Cliniques Universitaires Saint-Luc, Brussels, Belgium
| | - David Laharie
- Department of Gastroenterology, CHU de Bordeaux, Centre Médico-chirurgical Magellan, Hôpital Haut-Lévêque; Université de Bordeaux, INSERM CIC 1401, Bordeaux, France
| | - Olivier Dewit
- Department of Hepato-gastroenterology, Cliniques Universitaires Saint-Luc, Brussels, Belgium.
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Rentea RM, Renaud E, Ricca R, Derderian C, Englum B, Kawaguchi A, Gonzalez K, Speck KE, Villalona G, Kulaylat A, Wakeman D, Yousef Y, Rialon K, Somme S, Lucas D, Levene T, Chang H, Baerg J, Acker S, Fisher J, Kelley-Quon LI, Baird R, Beres AL. Surgical Management of Ulcerative Colitis in Children and Adolescents: A Systematic Review from the APSA Outcomes and Evidence-Based Practice Committee. J Pediatr Surg 2023; 58:1861-1872. [PMID: 36941170 DOI: 10.1016/j.jpedsurg.2023.02.042] [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: 12/30/2022] [Revised: 02/06/2023] [Accepted: 02/15/2023] [Indexed: 02/25/2023]
Abstract
INTRODUCTION The incidence of ulcerative colitis (UC) is increasing. Roughly 20% of all patients with UC are diagnosed in childhood, and children typically present with more severe disease. Approximately 40% will undergo total colectomy within ten years of diagnosis. The objective of this study is to assess the available evidence regarding the surgical management of pediatric UC as determined by the consensus agreement of the American Pediatric Surgical Association Outcomes and Evidence-Based Practice Committee (APSA OEBP). METHODS Through an iterative process, the membership of the APSA OEBP developed five a priori questions focused on surgical decision-making for children with UC. Questions focused on surgical timing, reconstruction, use of minimally invasive techniques, need for diversion, and risks to fertility and sexual function. A systematic review was conducted, and articles were selected for review following Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Risk of Bias was assessed using Methodological Index for Non-Randomized Studies (MINORS) criteria. The Oxford Levels of Evidence and Grades of Recommendation were utilized. RESULTS A total of 69 studies were included for analysis. Most manuscripts contain level 3 or 4 evidence from single-center retrospective reports, leading to a grade D recommendation. MINORS assessment revealed a high risk of bias in most studies. J-pouch reconstruction may result in fewer daily stools than straight ileoanal anastomosis. There are no differences in complications based on the type of reconstruction. The timing of surgery should be individualized to patients and does not affect complications. Immunosuppressants do not appear to increase surgical site infection rates. Laparoscopic approaches result in longer operative times but shorter lengths of stay and fewer small bowel obstructions. Overall, complications are not different using an open or minimally invasive approach. CONCLUSIONS There is currently low-level evidence related to certain aspects of surgical management for UC, including timing, reconstruction type, use of minimally invasive techniques, need for diversion, and risks to fertility and sexual function. Multicenter, prospective studies are recommended to better answer these questions and ensure the best evidence-based care for our patients. LEVEL OF EVIDENCE Level of evidence III. STUDY TYPE Systematic review.
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Affiliation(s)
- Rebecca M Rentea
- Children's Mercy-Kansas City, University of Missouri- Kansas City, Department of Pediatric Surgery, Kansas City, MO, USA
| | - Elizabeth Renaud
- Division of Pediatric Surgery, Hasbro Children's Hospital, Alpert Medical School at Brown University, Providence, RI, USA
| | - Robert Ricca
- Division of Pediatric Surgery, Prisma Health Upstate, University of South Carolina School of Medicine, Greenville, SC, USA
| | - Christopher Derderian
- Division of Pediatric Surgery, Children's Hospital Colorado, University of Colorado, Denver, CO, USA
| | - Brian Englum
- Division of Pediatric Surgery, University of Maryland, Baltimore, MD, USA
| | - Akemi Kawaguchi
- Department of Pediatric Surgery. Children's Memorial Hermann Hospital, UTHealth, Houston, TX, USA
| | - Katherine Gonzalez
- Division of Pediatric Surgery, St. Luke's Children's Hospital, Boise, ID, USA
| | - K Elizabeth Speck
- Division of Pediatric Surgery, C.S Mott Children's Hospital, University of Michigan, Ann Arbor, MI, USA
| | | | - Afif Kulaylat
- Division of Pediatric Surgery, Penn State Hershey, Hershey, PA, USA
| | - Derek Wakeman
- Division of Pediatric Surgery, University of Rochester, Rochester, NY, USA
| | - Yasmine Yousef
- Division of Pediatric Surgery, Montreal Children's Hospital, McGill University, Montreal, QC, Canada
| | - Kristy Rialon
- Division of Pediatric Surgery, Texas Children's Hospital, Baylor College of Medicine, Houston, TX, USA
| | - Sig Somme
- Division of Pediatric Surgery, Children's Hospital Colorado, University of Colorado, Denver, CO, USA
| | - Donald Lucas
- Division of Pediatric Surgery, Naval Medical Center, San Diego, CA, USA
| | - Tamar Levene
- Division of Pediatric Surgery, Joe DiMaggio Children's Hospital, Hollywood, FL, USA
| | - Henry Chang
- Division of Pediatric Surgery, Hopkins ALL Children's Hospital, St. Petersburg, FL, USA
| | - Joanne Baerg
- Division of Pediatric Surgery, Presbyterian Health Services, Albuquerque, NM, USA
| | - Shannon Acker
- Division of Pediatric Surgery, Children's Hospital Colorado, University of Colorado, Denver, CO, USA
| | - Jeremy Fisher
- University Surgical Associates, UT College of Medicine, Chattanooga, TN, USA
| | - Lorraine I Kelley-Quon
- Division of Pediatric Surgery, Children's Hospital Los Angeles, University of Southern California, Los Angeles, CA, USA
| | - Robert Baird
- Division of Pediatric Surgery, BC Women's and Children's Hospital, University of British Columbia, Vancouver, BC, Canada
| | - Alana L Beres
- St. Christopher's Hospital for Children, Drexel University School of Medicine, Division of Pediatric Surgery, Philadelphia, PA, USA.
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Wan FT, Chin SE, Gwee R, Chong Y, Au-Yong A, Matthews A, Zaw MWW, Lie SA, Loh L, Koh D, Ladlad J, Khoo N, Aw D, Chong CXZ, Ho LML, Ng JL, Sivarajah SS, Tan WJ, Foo FJ, Koh FH. Pre-operative erector spinae plane block should be considered a viable option for laparoscopic colectomies. Surg Endosc 2023; 37:7128-7135. [PMID: 37322360 DOI: 10.1007/s00464-023-10171-1] [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: 01/18/2023] [Accepted: 05/08/2023] [Indexed: 06/17/2023]
Abstract
BACKGROUND The Erector Spinae Plane (ESP) block is a recent development in the field of regional anaesthesia and has been increasingly explored for abdominal surgeries to reduce opioid use and improve pain control. Colorectal cancer is the commonest cancer in multi-ethnic Singapore and requires surgery for curative treatment. ESP is a promising alternative in colorectal surgeries, but few studies have evaluated its efficacy in such surgeries. Therefore, this study aims to evaluate the use of ESP blocks in laparoscopic colorectal surgeries to establish its safety and efficacy in this field. METHODS A prospective two-armed interventional cohort study comparing T8-T10 ESP blocks with conventional multimodal intravenous analgesia for laparoscopic colectomies was conducted in a single institution in Singapore. The decision for doing an ESP block versus conventional multimodal intravenous analgesia was made by a consensus between the attending surgeon and anesthesiologist. Outcomes measured were total intra-operative opioid consumption, post-operative pain control and patient outcome. Post-operative pain control was measured by pain score, analgesia use, and amount of opioids consumed. Patient outcome was determined by presence of ileus. RESULTS A total of 146 patients were included, of which 30 patients received an ESP block. Overall, the ESP group had a significantly lower median opioid usage both intra-operatively and post-operatively (p = 0.031). Fewer patients required patient-controlled analgesia and rescue analgesia post-operatively for pain control (p < 0.001) amongst the ESP group. Pain scores were similar and post-operative ileus was absent in both groups. Multivariate analysis found that the ESP block had an independent effect on reducing intra-opioid consumption (p = 0.014). Multivariate analysis of post-operative opioid use and pain scores did not yield statistically significant results. CONCLUSIONS The ESP block was an effective alternative regional anaesthesia for colorectal surgery that reduced intra-operative and post-operative opioid use while attaining satisfactory pain control.
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Affiliation(s)
- Fang-Ting Wan
- Lee Kong Chian School of Medicine, 11 Mandalay Road, Singapore, 308232, Singapore
| | - Shuen-Ern Chin
- Lee Kong Chian School of Medicine, 11 Mandalay Road, Singapore, 308232, Singapore
| | - Ryan Gwee
- Lee Kong Chian School of Medicine, 11 Mandalay Road, Singapore, 308232, Singapore
| | - Yvette Chong
- Colorectal Service, Department of General Surgery, Sengkang General Hospital, 110 Sengkang East Way, Singapore, 544886, Singapore
| | - Angie Au-Yong
- Department of Anaesthesiology, SingHealth, Singapore, Singapore
| | - Abey Matthews
- Department of Anaesthesiology, SingHealth, Singapore, Singapore
| | - Ma-Wai-Wai Zaw
- Department of Anaesthesiology, SingHealth, Singapore, Singapore
| | - Sui-An Lie
- Department of Anaesthesiology, SingHealth, Singapore, Singapore
| | - Leonard Loh
- Department of Anaesthesiology, SingHealth, Singapore, Singapore
| | - Daphne Koh
- Department of Anaesthesiology, SingHealth, Singapore, Singapore
| | - Jasmine Ladlad
- Colorectal Service, Department of General Surgery, Sengkang General Hospital, 110 Sengkang East Way, Singapore, 544886, Singapore
| | - Nathanelle Khoo
- Colorectal Service, Department of General Surgery, Sengkang General Hospital, 110 Sengkang East Way, Singapore, 544886, Singapore
| | - Darius Aw
- Colorectal Service, Department of General Surgery, Sengkang General Hospital, 110 Sengkang East Way, Singapore, 544886, Singapore
| | - Cheryl X Z Chong
- Colorectal Service, Department of General Surgery, Sengkang General Hospital, 110 Sengkang East Way, Singapore, 544886, Singapore
| | - Leonard M L Ho
- Colorectal Service, Department of General Surgery, Sengkang General Hospital, 110 Sengkang East Way, Singapore, 544886, Singapore
| | - Jia-Lin Ng
- Colorectal Service, Department of General Surgery, Sengkang General Hospital, 110 Sengkang East Way, Singapore, 544886, Singapore
| | - Sharmini S Sivarajah
- Colorectal Service, Department of General Surgery, Sengkang General Hospital, 110 Sengkang East Way, Singapore, 544886, Singapore
| | - Winson J Tan
- Colorectal Service, Department of General Surgery, Sengkang General Hospital, 110 Sengkang East Way, Singapore, 544886, Singapore
| | - Fung-Joon Foo
- Colorectal Service, Department of General Surgery, Sengkang General Hospital, 110 Sengkang East Way, Singapore, 544886, Singapore
| | - Frederick H Koh
- Colorectal Service, Department of General Surgery, Sengkang General Hospital, 110 Sengkang East Way, Singapore, 544886, Singapore.
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Ahuja V, Paredes LG, Leeds IL, Perkal MF, King JT. Clinical outcomes of elective robotic vs laparoscopic surgery for colon cancer utilizing a large national database. Surg Endosc 2023; 37:7199-7205. [PMID: 37365394 DOI: 10.1007/s00464-023-10215-6] [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] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2023] [Accepted: 06/11/2023] [Indexed: 06/28/2023]
Abstract
BACKGROUND Prior studies have shown comparable outcomes between laparoscopic and robotic approaches across a range of surgeries; however, these have been limited in size. This study investigates differences in outcomes following robotic (RC) vs laparoscopic (LC) colectomy across several years utilizing a large national database. METHODS We analyzed data from ACS NSQIP for patients who underwent elective minimally invasive colectomies for colon cancer from 2012 to 2020. Inverse probability weighting with regression adjustment (IPWRA) incorporating demographics, operative factors, and comorbidities was used. Outcomes included mortality, complications, return to the operating room (OR), post-operative length of stay (LOS), operative time, readmission, and anastomotic leak. Secondary analysis was performed to further assess anastomotic leak rate following right and left colectomies. RESULTS We identified 83,841 patients who underwent elective minimally invasive colectomies: 14,122 (16.8%) RC and 69,719 (83.2%) LC. Patients who underwent RC were younger, more likely to be male, non-Hispanic White, with higher body mass index (BMI) and fewer comorbidities (for all, P < 0.05). After adjustment, there were no differences between RC and LC for 30-day mortality (0.8% vs 0.9% respectively, P = 0.457) or overall complications (16.9% vs 17.2%, P = 0.432). RC was associated with higher return to OR (5.1% vs 3.6%, P < 0.001), lower LOS (4.9 vs 5.1 days, P < 0.001), longer operative time (247 vs 184 min, P < 0.001), and higher rates of readmission (8.8% vs 7.2%, P < 0.001). Anastomotic leak rates were comparable for right-sided RC vs LC (2.1% vs 2.2%, P = 0.713), higher for left-sided LC (2.7%, P < 0.001), and highest for left-sided RC (3.4%, P < 0.001). CONCLUSIONS Robotic approach for elective colon cancer resection has similar outcomes to its laparoscopic counterpart. There were no differences in mortality or overall complications, however anastomotic leaks were highest after left RC. Further investigation is imperative to better understand the potential impact of technological advancement such as robotic surgery on patient outcomes.
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Affiliation(s)
- Vanita Ahuja
- Department of Surgery, Yale University School of Medicine, New Haven, CT, USA
- VA Connecticut Healthcare System, US Department of Veterans Affairs, West Haven, CT, USA
| | - Lucero G Paredes
- VA Connecticut Healthcare System, US Department of Veterans Affairs, West Haven, CT, USA.
- National Clinician Scholars Program, Yale University School of Medicine, New Haven, CT, 06510-8088, USA.
- Department of Surgery, Maine Medical Center, Portland, ME, USA.
| | - Ira L Leeds
- Department of Surgery, Yale University School of Medicine, New Haven, CT, USA
- VA Connecticut Healthcare System, US Department of Veterans Affairs, West Haven, CT, USA
| | - Melissa F Perkal
- Department of Surgery, Yale University School of Medicine, New Haven, CT, USA
- VA Connecticut Healthcare System, US Department of Veterans Affairs, West Haven, CT, USA
| | - Joseph T King
- VA Connecticut Healthcare System, US Department of Veterans Affairs, West Haven, CT, USA
- Department of Neurosurgery, Yale School of Medicine, New Haven, CT, USA
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Devadas K, Giri S, Varghese J, George A. CRAB score for prediction of colectomy within 2 years following admission for acute severe ulcerative colitis. Saudi J Gastroenterol 2023; 29:295-299. [PMID: 37040219 PMCID: PMC10644996 DOI: 10.4103/sjg.sjg_521_22] [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: 11/28/2022] [Revised: 02/17/2023] [Accepted: 03/12/2023] [Indexed: 04/12/2023] Open
Abstract
Background The Oxford and Swedish indexes were developed to predict in-hospital colectomy in acute severe ulcerative colitis (ASUC), but not long-term prediction, and all these indexes were based on Western data. Our study aimed to analyze the predictors of colectomy within 3 years of ASUC in an Indian cohort and derive a simple predictive score. Methods A prospective observational study was conducted in a tertiary health care center in South India over a period of 5 years. All patients admitted with ASUC were followed up for a period of 24 months after the index admission, to look for progression to colectomy. Results A total of 81 (47 male) patients were included in the derivation cohort. Fifteen (18.5%) patients required colectomy during a follow-up period of 24 months. On regression analysis, C-reactive protein (CRP) and serum albumin were independent predictors of 24-month colectomy. The CRAB (CRP + AlBumin) score was obtained by multiplying coefficient of beta to albumin and CRP (CRAB score = CRP x 0.2 - Albumin x 0.26). The CRAB score demonstrated an AUROC of 0.923 and a score of >0.4 with a sensitivity of 82% and specificity of 92% for the prediction of 2-year colectomy following ASUC. The score was validated in a validation cohort of 31 patients, and at >0.4, the score had a sensitivity of 83% and a specificity of 96% in predicting colectomy. Conclusion CRAB score is a simple prognostic score that can predict 2-year colectomy in ASUC patients with high sensitivity and specificity.
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Affiliation(s)
- Krishnadas Devadas
- Department of Medical Gastroenterology, Medical College Trivandrum, Kerala, India
| | - Suprabhat Giri
- Department of Gastroenterology, Nizam’s Institute of Medical Sciences, Hyderabad, Telangana, India
| | - Jijo Varghese
- Medical Gastroenterology Medical College Trivandrum, Trivandrum, India
| | - Antony George
- Medical Gastroenterology Medical College Trivandrum, Trivandrum, India
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Abdelnaby A, Alcabes A. Can Colorectal Surgery Be Performed as an Outpatient Surgery? Adv Surg 2023; 57:279-285. [PMID: 37536859 DOI: 10.1016/j.yasu.2023.04.008] [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: 08/05/2023]
Abstract
The potential to discharge patients safely within the same day after colorectal surgery has developed over time with concurrent advances in concepts of enhanced recovery pathways, along with minimally invasive techniques available to surgeons. The advent of planned same-day discharges after elective colectomy is made possible by research establishing improved length of stay with minimal morbidity in patients undergoing minimally invasive surgery and especially minimally invasive surgery in the setting of an enhanced recovery after surgery (ERAS) protocol. In tracing the timeline of research and development of knowledge in this setting, the safety of outpatient colorectal surgery can be established.
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Affiliation(s)
- Abier Abdelnaby
- Colon and Rectal Surgical Services, Montefiore Medical Center, Bronx, NY, USA; Department of Surgery, The University Hospital for Albert Einstein College of Medicine, 1825 Eastchester Road, Bronx, NY 10461, USA.
| | - Analena Alcabes
- Department of Surgery, The University Hospital for Albert Einstein College of Medicine, 1825 Eastchester Road, Bronx, NY 10461, USA; Montefiore Medical Center, Bronx, NY, USA
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Thompson HM, Williams H, Omer DM, Yuval JB, Verheij FS, Fiasconaro M, Widmar M, Wei IH, Pappou EP, Smith JJ, Nash GM, Weiser MR, Paty PB, Shahrokni A, Garcia-Aguilar J. Comparison of short-term outcomes and survival between minimally invasive colectomy and open colectomy in patients 80 years of age and older. J Robot Surg 2023; 17:1857-1865. [PMID: 37022559 PMCID: PMC10527224 DOI: 10.1007/s11701-023-01575-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2023] [Accepted: 03/12/2023] [Indexed: 04/07/2023]
Abstract
We investigated the short- and long-term outcomes of patients 80 years of age and older with colon cancer who underwent robotic colectomy versus laparoscopic colectomy. Data for patients treated at a comprehensive cancer center between January 2006 and November 2018 were collected retrospectively. Outcomes from minimally invasive laparoscopic or robotic colectomy were compared. Survival was analyzed by the Kaplan-Meier method with significance evaluated by the log-rank test. The laparoscopic (n = 104) and the robotic (n = 75) colectomy groups did not differ across baseline characteristics. Patients who underwent a robotic colectomy had a shorter median length of hospital stay (5 versus 6 days; p < 0.001) and underwent fewer conversions to open surgery (3% versus 17%; p = 0.002) compared to the laparoscopic cohort. The groups did not differ in postoperative complication rates, overall survival or disease-free survival. Elderly patients undergoing robotic colectomy for colon cancer have a shorter hospital stay and lower rates of conversion without compromise to oncologic outcomes.
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Affiliation(s)
- Hannah M Thompson
- Colorectal Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Hannah Williams
- Colorectal Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Dana M Omer
- Colorectal Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Jonathan B Yuval
- Colorectal Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Floris S Verheij
- Colorectal Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Megan Fiasconaro
- Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Maria Widmar
- Colorectal Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Iris H Wei
- Colorectal Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Emmanouil P Pappou
- Colorectal Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - J Joshua Smith
- Colorectal Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Garrett M Nash
- Colorectal Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Martin R Weiser
- Colorectal Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Philip B Paty
- Colorectal Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Armin Shahrokni
- Department of Medicine, Geriatrics Service, Jersey Shore Medical Center, Neptune Township, NJ, USA
| | - Julio Garcia-Aguilar
- Colorectal Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA.
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Alexandre AF, Kimura T, Feng Q, Han W, Shortridge E, Schwartz J, Wexner SD. Effectiveness and Cost of Stenting in Ureteral Injury in Colorectal Surgeries in the US: 2015 - 2019. JSLS 2023; 27:e2023.00023. [PMID: 37829173 PMCID: PMC10566578 DOI: 10.4293/jsls.2023.00023] [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: 10/14/2023] Open
Abstract
Background Intraoperative ureteral injury (IUI) during colorectal surgery can have devastating consequences. This study aimed to assess the clinical and economic impact of pre-operative ureteral stenting in colorectal surgeries. Methods A retrospective cohort study was conducted using United States hospital data (October 2015 - December 2019). IUI incidence was examined across selected inpatient surgery types (elective colectomy, enterectomy, proctectomy, enterostomy, other colorectal procedures; emergency colectomy). Stenting effectiveness was evaluated as the difference in IUI and intraoperative detection rates between propensity score-matched groups. The additional hospital cost for stenting was also estimated considering the savings from IUIs that were potentially avoidable or detected by stenting. Results In total, 283,549 colorectal surgeries were analyzed. Across surgery types, stent use and IUI incidence ranged from 1.47% - 8.86% and from 0.91% - 2.90%, respectively. Stents were used in 6.75% of elective colectomy cases, where they were associated with an absolute reduction of 1.14 percentage points (95% CI: -1.85 to -1.03) in IUI rate and a 21.6 percentage point reduction in the intraoperative detection rate. Additional hospital costs for stenting ranged from $1,464 - $4,436 across surgery types. Additional results varied by case but were consistent with the colectomy example. Conclusions While effective in limited settings, the IUI reduction attributed to stenting and ability to shift IUI detection to the intraoperative setting could not offset the hospital cost of stent placement during colectomy (and colorectal surgery, in general). There thus remains an ongoing need in colorectal surgery for a universal, cost-effective solution to prevent IUI.
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Affiliation(s)
- Ana Filipa Alexandre
- Health Economics Outcomes Research, Astellas Pharma Europe B.V., Leiden, The Netherlands. (Dr. Alexandre was Astellas employee at time of study)
| | - Tomomi Kimura
- Global Development, Astellas Pharma US, Inc., Northbrook, IL. (Drs. Kimura, Feng, Han, Shortridge, Schwartz)
| | - Qi Feng
- Global Development, Astellas Pharma US, Inc., Northbrook, IL. (Drs. Kimura, Feng, Han, Shortridge, Schwartz)
| | - Wei Han
- Global Development, Astellas Pharma US, Inc., Northbrook, IL. (Drs. Kimura, Feng, Han, Shortridge, Schwartz)
| | - Emily Shortridge
- Global Development, Astellas Pharma US, Inc., Northbrook, IL. (Drs. Kimura, Feng, Han, Shortridge, Schwartz)
| | - Jason Schwartz
- Global Development, Astellas Pharma US, Inc., Northbrook, IL. (Drs. Kimura, Feng, Han, Shortridge, Schwartz)
| | - Steven D Wexner
- Colorectal Surgery, Cleveland Clinic Florida, Weston, FL. (Dr. Wexner)
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Waser A, Balaphas A, Uhe I, Toso C, Buchs NC, Ris F, Meyer J. Incidence of diverticulitis recurrence after sigmoid colectomy: a retrospective cohort study from a tertiary center and systematic review. Int J Colorectal Dis 2023; 38:157. [PMID: 37261498 PMCID: PMC10235134 DOI: 10.1007/s00384-023-04454-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 05/25/2023] [Indexed: 06/02/2023]
Abstract
INTRODUCTION Our aim was to determine the incidence of diverticulitis recurrence after sigmoid colectomy for diverticular disease. METHODS Consecutive patients who benefited from sigmoid colectomy for diverticular disease from January 2007 to June 2021 were identified based on operative codes. Recurrent episodes were identified based on hospitalization codes and reviewed. Survival analysis was performed and was reported using a Kaplan-Meier curve. Follow-up was censored for last hospital visit and diverticulitis recurrence. The systematic review of the literature was performed according to the PRISMA statement. Medline, Embase, CENTRAL, and Web of Science were searched for studies reporting on the incidence of diverticulitis after sigmoid colectomy. The review was registered into PROSPERO (CRD42021237003, 25/06/2021). RESULTS One thousand three-hundred and fifty-six patients benefited from sigmoid colectomy. Four hundred and three were excluded, leaving 953 patients for inclusion. The mean age at time of sigmoid colectomy was 64.0 + / - 14.7 years. Four hundred and fifty-eight patients (48.1%) were males. Six hundred and twenty-two sigmoid colectomies (65.3%) were performed in the elective setting and 331 (34.7%) as emergency surgery. The mean duration of follow-up was 4.8 + / - 4.1 years. During this period, 10 patients (1.1%) developed reccurent diverticulitis. Nine of these episodes were classified as Hinchey 1a, and one as Hinchey 1b. The incidence of diverticulitis recurrence (95% CI) was as follows: at 1 year: 0.37% (0.12-1.13%), at 5 years: 1.07% (0.50-2.28%), at 10 years: 2.14% (1.07-4.25%) and at 15 years: 2.14% (1.07-4.25%). Risk factors for recurrence could not be assessed by logistic regression due to the low number of incidental cases. The systematic review of the literature identified 15 observational studies reporting on the incidence of diverticulitis recurrence after sigmoid colectomy, which ranged from 0 to 15% for a follow-up period ranging between 2 months and over 10 years. CONCLUSION The incidence of diverticulitis recurrence after sigmoid colectomy is of 2.14% at 15 years, and is mostly composed of Hinchey 1a episodes. The incidences reported in the literature are heterogeneous.
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Affiliation(s)
- Alexia Waser
- Medical School, University of Geneva, Geneva, Switzerland
| | - Alexandre Balaphas
- Medical School, University of Geneva, Geneva, Switzerland
- Division of Digestive Surgery, University Hospitals of Geneva, Geneva, Switzerland
| | - Isabelle Uhe
- Medical School, University of Geneva, Geneva, Switzerland
- Division of Digestive Surgery, University Hospitals of Geneva, Geneva, Switzerland
| | - Christian Toso
- Medical School, University of Geneva, Geneva, Switzerland
- Division of Digestive Surgery, University Hospitals of Geneva, Geneva, Switzerland
| | - Nicolas C Buchs
- Medical School, University of Geneva, Geneva, Switzerland
- Division of Digestive Surgery, University Hospitals of Geneva, Geneva, Switzerland
| | - Frédéric Ris
- Medical School, University of Geneva, Geneva, Switzerland
- Division of Digestive Surgery, University Hospitals of Geneva, Geneva, Switzerland
| | - Jeremy Meyer
- Medical School, University of Geneva, Geneva, Switzerland.
- Division of Digestive Surgery, University Hospitals of Geneva, Geneva, Switzerland.
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Sahakyan AM, Aleksanyan A, Batikyan H, Petrosyan H, Yesayan S, Sahakyan MA. Recurrence After Colectomy for Locally Advanced Colon Cancer: Experience from a Developing Country. Indian J Surg Oncol 2023; 14:339-344. [PMID: 37324317 PMCID: PMC10267088 DOI: 10.1007/s13193-022-01672-x] [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] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2022] [Accepted: 10/19/2022] [Indexed: 11/05/2022] Open
Abstract
Risk factors for disease recurrence following curative resection for locally advanced colon cancer (LACC) remain unclear as conflicting results have been reported in the literature. The aim of this study was to examine these factors in the setting of developing country's health care system affected by limited accessibility to the multimodal cancer treatment. Patients who had undergone curative colon resection for LACC between 2004 and 2018 were included. Data were obtained from a prospectively maintained database. Factors associated with disease recurrence, types of recurrence and recurrence-free survival were studied. A total of 118 patients with LACC were operated within the study period. Median follow-up was 36 (2-147) months. Adjuvant therapy was used in 41 (34.7%) patients and 62 (52.5%) were diagnosed with recurrence. In the multivariable analysis, disease recurrence was associated with tumor and nodal stages, as well as with the lymph node yield. Local recurrence, distant metastases, and peritoneal carcinomatosis were observed in 8 (6.8%), 30 (25.4%), and 24 (20.3%) patients, respectively. Early recurrence was diagnosed in 27 (22.9%) cases with peritoneal carcinomatosis being its most common type. Preoperative serum CA 19-9 levels, tumor, and nodal stages were linked to recurrence-free survival in the univariable analysis. Only tumor stage remained such in the multivariable model. Our findings suggest that lymph node yield, tumor, and nodal stages are associated with recurrence following curative resection for LACC. Supplementary Information The online version contains supplementary material available at 10.1007/s13193-022-01672-x.
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Affiliation(s)
- Artur M. Sahakyan
- Department of Surgery N1, Yerevan State Medical University After M. Heratsi, Yerevan, Armenia
- Department of General and Abdominal Surgery, ArtMed MRC, Yerevan, Armenia
| | - Andranik Aleksanyan
- Department of Surgery N1, Yerevan State Medical University After M. Heratsi, Yerevan, Armenia
- Clinic of Surgery, Mikaelyan Institute of Surgery, Yerevan, Armenia
| | - Hovhannes Batikyan
- Department of Surgery N1, Yerevan State Medical University After M. Heratsi, Yerevan, Armenia
| | - Hmayak Petrosyan
- Department of General and Abdominal Surgery, ArtMed MRC, Yerevan, Armenia
| | | | - Mushegh A. Sahakyan
- Department of Surgery N1, Yerevan State Medical University After M. Heratsi, Yerevan, Armenia
- The Intervention Center, Oslo University Hospital Rikshospitalet, Sognsvannsveien 20, 0424 Oslo, Norway
- Department of Research & Development, Division of Emergencies and Critical Care, Oslo University Hospital, Oslo, Norway
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Patel PV, Kao E, Stekol E, Heyman MB, Vu L, Verstraete SG. Evaluating the Relationship Between Nutrition and Post- colectomy Pouchitis in Pediatric Patients with Ulcerative Colitis. Dig Dis Sci 2023; 68:2188-2195. [PMID: 36807017 PMCID: PMC11017704 DOI: 10.1007/s10620-023-07872-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/19/2022] [Accepted: 02/10/2023] [Indexed: 02/23/2023]
Abstract
BACKGROUND Pouchitis is the most frequent complication following restorative proctocolectomy and ileal pouch anal anastomosis (RP-IPAA) in patients with Ulcerative colitis (UC). Pediatric data on nutritional status during RP-IPAA and in patients with pouchitis are limited. AIMS We aimed to delineate nutritional changes in children undergoing 2-stage and 3-stage surgeries and to evaluate the association between nutrition and the development of recurrent or chronic pouchitis. METHODS This single-center retrospective study involved 46 children with UC who underwent a RP-IPAA. Data were collected at each surgical stage and for up to 2-year post-ileostomy takedown. We used Wilcoxon matched-pairs signed-rank test to evaluate the differences in nutritional markers across surgical stages and logistic regression to identify the factors associated with recurrent or chronic pouchitis. RESULTS Twenty patients (43.5%) developed recurrent or chronic pouchitis. Children who underwent a 3-stage procedure had improvements in albumin, hematocrit, and body mass index (BMI)-for-age Z-scores (p < 0.01) between the first two stages. A positive trend in BMI-for-age Z-scores (p = 0.08) was identified in children with 2-stage procedures. All patients showed sustained nutritional improvement during the follow-up period. Among patients who underwent 3-stage surgeries, BMI worsened by 0.8 standard deviations (SDs) (p = 0.24) between the initial stages in those who developed recurrent or chronic pouchitis and improved by 1.1 SDs (p = 0.04) in those who did not. CONCLUSIONS Early improvement in BMI-for-age Z-scores following the initial stage was associated with lower rates of recurrent or chronic pouchitis. Larger prospective studies are needed to validate these findings.
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Affiliation(s)
- Perseus V Patel
- Department of Pediatrics, University of California San Francisco Benioff Children's Hospital, 550 16th Street, 4th Floor, Box 0136, San Francisco, CA, 94158, USA.
| | - Emily Kao
- Department of Surgery, University of California San Francisco, San Francisco, CA, USA
| | - Emily Stekol
- Department of Pediatrics, University of California San Francisco Benioff Children's Hospital, 550 16th Street, 4th Floor, Box 0136, San Francisco, CA, 94158, USA
| | - Melvin B Heyman
- Department of Pediatrics, University of California San Francisco Benioff Children's Hospital, 550 16th Street, 4th Floor, Box 0136, San Francisco, CA, 94158, USA
| | - Lan Vu
- Department of Surgery, University of California San Francisco, San Francisco, CA, USA
| | - Sofia G Verstraete
- Department of Pediatrics, University of California San Francisco Benioff Children's Hospital, 550 16th Street, 4th Floor, Box 0136, San Francisco, CA, 94158, USA
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Mundhra S, Thomas D, Jain S, Sahu P, Vuyyuru S, Kumar P, Kante B, Panwar R, Sahni P, Chaudhry R, Das P, Makharia G, Kedia S, Ahuja V. Low prevalence of Clostridioides difficile infection in acute severe ulcerative colitis: A retrospective cohort study from northern India. Indian J Gastroenterol 2023; 42:411-417. [PMID: 37171781 DOI: 10.1007/s12664-022-01336-2] [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: 08/09/2022] [Accepted: 12/25/2022] [Indexed: 05/13/2023]
Abstract
BACKGROUND The incidence of Clostridioides difficile infection (CDI) is high in ulcerative colitis and is associated with disease flares and adverse outcomes. However, the data on the dynamics of CDI in patients with acute severe ulcerative colitis (ASUC) is rather scarce. We evaluated the prevalence of CDI in patients with ASUC. METHODS This retrospective analysis of a prospectively maintained cohort admitted to the All India Institute of Medical Sciences, India, from May 2016 to December 2021, included patients with ASUC (as per Truelove and Witts criteria) who were tested for CDI. CDI testing was performed using enzyme-linked immunoassay for toxins A and B. Risk factors for developing CDI were analyzed along with short-term outcomes of ASUC. Steroid failure was defined as the need for medical rescue therapy or colectomy. RESULTS Total 153 patients with ASUC were included (mean age 34.92 ± 12.24 years; males 56.2%; disease duration 36 (IQR: 16-55.5) months, pancolitis 67.3%). Ninety-eight (63.4%), 72 (47%) and 10 (6.5%) patients, respectively, had received steroids, azathioprine and biologics in the past. Forty patients (26.14%) had a prior history of ASUC. Among risk factors for CDI, 14% of the patients had prior admission within 30 days, 22.2% had a recent history of antibiotics and 3.9% had long-term non-steroidal anti-inflammatory drug intake. Only one sample was positive for Clostridioides difficile toxin assay. Tissue Cytomegalovirus DNA-PCR positivity was noted in 57 patients (37.3%). Fifty-seven patients (37.3%) had steroid failure, 35 required medical rescue therapy and 30 (19.6%) required colectomy (eight after medical rescue therapy failure). CONCLUSION Despite antecedent risk factors for CDI, the overall prevalence of CDI in ASUC was low and the outcomes were determined by underlying disease severity.
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Affiliation(s)
- Sandeep Mundhra
- Department of Gastroenterology and Human Nutrition, All India Institute of Medical Sciences, New Delhi, 110 029, India
| | - David Thomas
- Department of Gastroenterology and Human Nutrition, All India Institute of Medical Sciences, New Delhi, 110 029, India
| | - Saransh Jain
- Department of Gastroenterology and Human Nutrition, All India Institute of Medical Sciences, New Delhi, 110 029, India
| | - Pabitra Sahu
- Department of Gastroenterology and Human Nutrition, All India Institute of Medical Sciences, New Delhi, 110 029, India
| | - Sudheer Vuyyuru
- Department of Gastroenterology and Human Nutrition, All India Institute of Medical Sciences, New Delhi, 110 029, India
| | - Peeyush Kumar
- Department of Gastroenterology and Human Nutrition, All India Institute of Medical Sciences, New Delhi, 110 029, India
| | - Bhaskar Kante
- Department of Gastroenterology and Human Nutrition, All India Institute of Medical Sciences, New Delhi, 110 029, India
| | - Rajesh Panwar
- Department of GI Surgery, All India Institute of Medical Sciences, New Delhi, 110 029, India
| | - Peush Sahni
- Department of GI Surgery, All India Institute of Medical Sciences, New Delhi, 110 029, India
| | - Rama Chaudhry
- Department of Microbiology, All India Institute of Medical Sciences, New Delhi, 110 029, India
| | - Prasenjit Das
- Department of Pathology, All India Institute of Medical Sciences, New Delhi, 110 029, India
| | - Govind Makharia
- Department of Gastroenterology and Human Nutrition, All India Institute of Medical Sciences, New Delhi, 110 029, India
| | - Saurabh Kedia
- Department of Gastroenterology and Human Nutrition, All India Institute of Medical Sciences, New Delhi, 110 029, India
| | - Vineet Ahuja
- Department of Gastroenterology and Human Nutrition, All India Institute of Medical Sciences, New Delhi, 110 029, India.
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Zhang T, Sun Y, Mao W. Meta‑analysis of randomized controlled trials comparing intracorporeal versus extracorporeal anastomosis in minimally invasive right hemi colectomy: upgrading the level of evidence. Int J Colorectal Dis 2023; 38:147. [PMID: 37248431 DOI: 10.1007/s00384-023-04445-2] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 05/24/2023] [Indexed: 05/31/2023]
Abstract
BACKGROUND Minimally invasive right hemicolectomy has been increasingly used for the treatment of right hemicolectomy disease, and both intracorporeal anastomosis (ICA) and extracorporeal anastomosis (ECA) are available to restore intestinal continuity. However, the advantages and disadvantages of these two anastomoses are highly controversial. The present meta-analysis evaluated the effectiveness of ICA versus ECA in minimally invasive right colectomy to improve the grade of evidence. METHODS We searched the PubMed, Embase, Cochrane Library, and Web of Science databases for randomized controlled trials (RCTs) comparing intracorporeal versus extracorporeal anastomosis in laparoscopic or robotic right hemicolectomy published from database inception to February 2023. Two researchers performed the literature review, data extraction, bias assessment, and meta-analysis of the data using Review Manager 5.4 software. RESULTS Seven RCTs with a total of 750 patients were included in the meta-analysis. The results showed a lower incidence of postoperative paralytic ileus (RR 0.62, 95% CI 0.39 ~ 0.99, p = 0.04) and shorter incision length (MD - 1.38; 95% CI: - 1.98 ~ - 0.78, p < 0.00001), but longer operative time (MD 10.69; 95% CI: 2.76 ~ 18.63, p = 0.008). The remaining events including bleeding (RR 0.49, 95% CI: 0.12 ~ 2.04, p = 0.33), anastomotic leak (RR 0.62, 95% CI: 0.39 ~ 0.99, p = 0.85), surgical site infection (RR 0.15, 95% CI: 0.22 ~ 1.25, p = 0.15), overall perioperative morbidity (RR 0.86, 95% CI: 0.58 ~ 1.26, p = 0.44), number of harvested lymph nodes (MD 0.75; 95% CI: - 0.15 ~ 1.65, p = 0.10), and length of hospital stay (MD - 0.27; 95% CI: - 0.91 ~ 0.38, p = 0.42) were not statistically significant. CONCLUSIONS Compared to ECA, ICA in minimally invasive right hemicolectomy reduced the risk of postoperative paralytic ileus and shortened the length of the incision but prolonged the operative time.
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Affiliation(s)
- Tuo Zhang
- Department of General Surgery, Qingdao Municipal Hospital, Qingdao Clinical Medical College, Nanjing Medical University, Qingdao, 266071, Shandong, China
| | - Yigong Sun
- Department of General Surgery, Qingdao Municipal Hospital of Qingdao University, Qingdao, 266071, Shandong, China
| | - Weizheng Mao
- Department of General Surgery, Qingdao Municipal Hospital, Qingdao Clinical Medical College, Nanjing Medical University, Qingdao, 266071, Shandong, China.
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Curfman KR, Jones IF, Conner JR, Neighorn CC, Wilson RK, Rashidi L. Robotic colorectal surgery in the emergent diverticulitis setting: is it safe? A review of large national database. Int J Colorectal Dis 2023; 38:142. [PMID: 37225935 DOI: 10.1007/s00384-023-04436-3] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 05/09/2023] [Indexed: 05/26/2023]
Abstract
BACKGROUND As robotic colorectal surgery continues to advance in conjunction with improved recovery protocols, we began implementing robotic surgery (RS) as an option for emergent diverticulitis surgery. Our hospital system utilizes the Da Vinci Xi system, and staff are required to undergo training, making emergent colorectal surgery a feasible option. However, it is essential to determine the safety with reproducibility of our experiences. METHODS A de-identified retrospective review was performed of Intuitive's national database which obtained data from 262 facilities from January 2018 through December 2021. This identified over 22,000 emergent colorectal surgeries. Of those, over 2500 were performed for diverticulitis in which 126 were RS, 446 laparoscopic surgery (LS), and 1952 open surgery (OS). Clinical outcome metrics including conversion rates, anastomotic leaks, intensive care unit (ICU) admissions, length of stay, mortality, and readmissions were obtained. The cohort was defined by patients who were seen in the emergency department (ED) with diverticulitis and proceeded to have a sigmoid colectomy within 24 h of ED arrival. RESULTS RS was associated with increased operating time (RS 262, LS 207, OS 182 min), but data has shown many benefits of emergent RS compared to OS. We identified significant decreases in ICU admission rates (OS 19.0%, RS 9.5%, p = 0.01) and anastomotic leak rates (OS 4.4%, RS 0.8%, p = 0.04), with borderline improvement in overall length of stay (OS 9.9, RS 8.9 days, p = 0.05). When compared with LS, RS showed many comparable results. However, RS witnessed a statistically significant improvement in anastomotic leak rates (LS 4.5%, RS 0.8%, p = 0.04). Importantly, there was a striking difference in conversion rates to OS. LS converted over 28.7% of cases to OS, whereas RS only converted 7.9%, p = 0.000005. CONCLUSION Given these findings, RS is another MIS tool that could be a safe and feasible option for the acute management of emergent diverticulitis.
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Affiliation(s)
| | - Ian F Jones
- Madigan Army Medical Center, Tacoma, WA, 98431, USA
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Yapa AKDS, Humes DJ, Crooks CJ, Lewis-Lloyd CA. Venous thromboembolism following colectomy for diverticular disease: an English population-based cohort study. Langenbecks Arch Surg 2023; 408:203. [PMID: 37212868 PMCID: PMC10203000 DOI: 10.1007/s00423-023-02920-6] [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: 10/25/2022] [Accepted: 04/29/2023] [Indexed: 05/23/2023]
Abstract
AIM This study reports venous thromboembolism (VTE) rates following colectomy for diverticular disease to explore the magnitude of postoperative VTE risk in this population and identify high risk subgroups of interest. METHOD English national cohort study of colectomy patients between 2000 and 2019 using linked primary (Clinical Practice Research Datalink) and secondary (Hospital Episode Statistics) care data. Stratified by admission type, absolute incidence rates (IR) per 1000 person-years and adjusted incidence rate ratios (aIRR) were calculated for 30- and 90-day post-colectomy VTE. RESULTS Of 24,394 patients who underwent colectomy for diverticular disease, over half (57.39%) were emergency procedures with the highest VTE rate seen in patients ≥70-years-old (IR 142.27 per 1000 person-years, 95%CI 118.32-171.08) at 30 days post colectomy. Emergency resections (IR 135.18 per 1000 person-years, 95%CI 115.72-157.91) had double the risk (aIRR 2.07, 95%CI 1.47-2.90) of developing a VTE at 30 days following colectomy compared to elective resections (IR 51.14 per 1000 person-years, 95%CI 38.30-68.27). Minimally invasive surgery (MIS) was shown to be associated with a 64% reduction in VTE risk (aIRR 0.36 95%CI 0.20-0.65) compared to open colectomies at 30 days post-op. At 90 days following emergency resections, VTE risks remained raised compared to elective colectomies. CONCLUSION Following emergency colectomy for diverticular disease, the VTE risk is approximately double compared to elective resections at 30 days while MIS was found to be associated with a reduced risk of VTE. This suggests advancements in postoperative VTE prevention in diverticular disease patients should focus on those undergoing emergency colectomies.
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Affiliation(s)
- Anjali K D S Yapa
- Gastrointestinal Surgery, National Institute for Health Research (NIHR) Nottingham Biomedical Research Centre (BRC), Nottingham University Hospitals NHS Trust and the University of Nottingham, School of Medicine, Queen's Medical Centre, Nottingham, UK.
| | - David J Humes
- Gastrointestinal Surgery, National Institute for Health Research (NIHR) Nottingham Biomedical Research Centre (BRC), Nottingham University Hospitals NHS Trust and the University of Nottingham, School of Medicine, Queen's Medical Centre, Nottingham, UK
| | - Colin J Crooks
- Gastrointestinal & Liver Theme, National Institute for Health Research (NIHR) Nottingham Biomedical Research Centre (BRC), Nottingham University Hospitals NHS Trust and the University of Nottingham, School of Medicine, Queen's Medical Centre, Nottingham, UK
| | - Christopher A Lewis-Lloyd
- Gastrointestinal Surgery, National Institute for Health Research (NIHR) Nottingham Biomedical Research Centre (BRC), Nottingham University Hospitals NHS Trust and the University of Nottingham, School of Medicine, Queen's Medical Centre, Nottingham, UK
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Kaarto P, Westfall KM, Brockhaus K, Paulus AL, Albright J, Ramm C, Cleary RK. Alvimopan is associated with favorable outcomes in open and minimally invasive colorectal surgery: a regional database analysis. Surg Endosc 2023:10.1007/s00464-023-10098-7. [PMID: 37130983 DOI: 10.1007/s00464-023-10098-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2022] [Accepted: 04/20/2023] [Indexed: 05/04/2023]
Abstract
BACKGROUND Alvimopan is a µ-opioid receptor antagonist associated with shorter time to gastrointestinal recovery in patients having open colorectal surgery. Data demonstrating the benefit of perioperative alvimopan for the minimally invasive surgical approach are inconsistent. The aim of this study is to determine colorectal surgery groups that benefit from perioperative alvimopan. METHODS This is a retrospective cohort analysis of colorectal surgery patients who had, and patients who did not have, perioperative alvimopan in the Michigan Surgical Quality Collaborative regional risk-adjusted database from 2018 through 2021. Main outcome measures were postoperative length of hospital stay, time to return of bowel function, and postoperative ileus. RESULTS There were 10,010 patients (30.3% open, 40.5% laparoscopic, 12.7% hand-assist laparoscopic, 43.5% robotic) who met inclusion criteria-4919 received alvimopan in the perioperative period and 5091 did not. When compared to those not receiving alvimopan, unadjusted outcomes showed that the alvimopan group had significantly shorter postoperative length of stay (4.75 days vs 5.5 days, p < 0.001), shorter time to return of bowel function (1.61 days vs 2.01 days, p < 0.001) and less postoperative ileus (5.45% vs 7.94%, p < 0.001). After adjustment, regression models confirmed that alvimopan was associated with an 9.6% reduction in hospital length of stay (p < 0.001), a 14.9% shorter time to return of bowel function (p < 0.001), and a 42.1% reduction in postoperative ileus (p < 0.001). Subgroup analysis showed significant benefit of alvimopan for all three outcomes in patients having the minimally invasive approach. CONCLUSIONS Alvimopan is associated with shorter hospital length of stay, shorter time to return of bowel function, and decreased postoperative ileus when administered to patients undergoing colorectal surgery. Benefit is not limited to the open approach and includes minimally invasive laparoscopic and robotic colorectal procedures.
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Affiliation(s)
- Patricia Kaarto
- Department of Pharmacy, St Joseph Mercy Hospital, Ann Arbor, MI, USA
| | | | - Kara Brockhaus
- Department of Pharmacy, St Joseph Mercy Hospital, Ann Arbor, MI, USA
| | - Amanda L Paulus
- Michigan State University School of Medicine, East Lansing, USA
| | - Jeremy Albright
- Biostatistics and Epidemiology Methods Consulting, BEMC, LLC, Ypsilanti, MI, USA
| | - Carole Ramm
- St Joseph Mercy Hospital, Ann Arbor, MI, USA
| | - Robert K Cleary
- Department of Surgery, St Joseph Mercy Hospital, Ann Arbor, MI, USA.
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Núñez L, Mesonero F, Rodríguez de Santiago E, Die J, Albillos A, López-Sanromán A. High incidence of surgery and initiation of medical therapies after colectomy for ulcerative colitis or inflammatory bowel disease unclassified. Gastroenterol Hepatol 2023; 46:369-375. [PMID: 36115628 DOI: 10.1016/j.gastrohep.2022.08.010] [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] [Subscribe] [Scholar Register] [Received: 06/30/2022] [Revised: 08/07/2022] [Accepted: 08/27/2022] [Indexed: 05/09/2023]
Abstract
BACKGROUND AND AIMS Despite novel medical therapies, colectomy has a role in the management of patients with ulcerative colitis (UC) and inflammatory bowel disease unclassified (IBDU). This study aimed to determine the incidence of unplanned surgery and initiation of immunomodulatory or biologic therapy (IMBT) after colectomy in patients with UC or IBDU, and identify associated factors. METHODS Data of patients with preoperative diagnosis of UC or IBDU who underwent colectomy and were followed up at a single tertiary centre was retrospectively collected. The primary outcome was the risk of unplanned surgery and initiation of IMBT during follow-up after colectomy. Secondary outcomes were development of Crohn's disease-like (CDL) complications and failure of reconstructive techniques. RESULTS 68 patients were included. After a median follow-up of 9.9 years, 32.4% of patients underwent unplanned surgery and IMBT was started in 38.2%. Unplanned surgery-free survival was 85% (95% confidence interval [CI] 73.8-91.6%) at 1 year, 76% (95% CI 63.2-84.9%) at 5 years and 69.1% (95% CI 55-79.6%) at 10 years. IMBT-free survival was 96.9% (95% CI 88.2-99.2%) at 1 year, 77.6% (95% CI 64.5-86.3%) at 5 years and 63.3% (95% CI 48.8-74.7%) at 10 years. 29.4% of patients met criteria for CDL complications. CDL complications were significantly associated to IMBT (hazard ratio 4.5, 95% CI 2-10.1). CONCLUSION In a retrospective study, we found a high incidence of unplanned surgery and IMBT therapy initiation after colectomy among patients with UC or IBDU. These results further question the historical concept of surgery as a "definitive" treatment.
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Affiliation(s)
- Laura Núñez
- Department of Gastroenterology and Hepatology, Hospital Universitario Ramón y Cajal, Universidad de Alcalá, IRYCIS, Madrid, Spain.
| | - Francisco Mesonero
- Department of Gastroenterology and Hepatology, Hospital Universitario Ramón y Cajal, Universidad de Alcalá, IRYCIS, Madrid, Spain
| | - Enrique Rodríguez de Santiago
- Department of Gastroenterology and Hepatology, Hospital Universitario Ramón y Cajal, Universidad de Alcalá, IRYCIS, Madrid, Spain
| | - Javier Die
- Colorectal Surgery Division, Department of General Surgery and Digestive Diseases, Hospital Universitario Ramón y Cajal, Universidad de Alcalá, IRYCIS, Madrid, Spain
| | - Agustín Albillos
- Department of Gastroenterology and Hepatology, Hospital Universitario Ramón y Cajal, Universidad de Alcalá, IRYCIS, Madrid, Spain
| | - Antonio López-Sanromán
- Department of Gastroenterology and Hepatology, Hospital Universitario Ramón y Cajal, Universidad de Alcalá, IRYCIS, Madrid, Spain
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Nagpal R, Ulaganathan H, Khan K, Egan B. Boon or Bane? Anti-Tumor Necrosis Factor Therapy Complicated by Listeria monocytogenes Meningitis Culminating in Colectomy for Ulcerative Colitis. J Med Cases 2023; 14:155-161. [PMID: 37303967 PMCID: PMC10251708 DOI: 10.14740/jmc4041] [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] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2023] [Accepted: 04/26/2023] [Indexed: 06/13/2023] Open
Abstract
Anti-tumor necrosis factor (TNF) biologics have revolutionized the management of inflammatory bowel diseases (IBDs) by promoting mucosal healing and delaying surgical intervention in ulcerative colitis (UC). However, biologics can potentiate the risk of opportunistic infections alongside the use of other immunomodulators in IBD. As recommended by the European Crohn's and Colitis Organisation (ECCO), anti-TNF-α therapy should be suspended in the setting of a potentially life-threatening infection. The objective of this case report was to highlight how the practice of appropriately discontinuing immunosuppression can exacerbate underlying colitis. We need to maintain a high index of suspicion for complications of anti-TNF therapy, so that we can intervene early and prevent potential adverse sequelae. In this report, a 62-year-old female presented to the emergency department with non-specific symptoms including fever, diarrhea and confusion on a background of known UC. She had been commenced on infliximab (INFLECTRA®) 4 weeks earlier. Inflammatory markers were elevated, and Listeria monocytogenes was identified on both blood cultures and cerebrospinal fluid (CSF) polymerase chain reaction (PCR). The patient improved clinically and completed a 21-day course of amoxicillin advised by microbiology. After a multidisciplinary discussion, the team planned to switch her from infliximab to vedolizumab (ENTYVIO®). Unfortunately, the patient re-presented to hospital with acute severe UC. Left-sided colonoscopy demonstrated modified Mayo endoscopic score 3 colitis. She has had recurrent hospital admissions over the past 2 years for acute flares of UC, ultimately culminating in colectomy. To our knowledge, our case-based review is unique in unpacking the dilemma of holding immunosuppression at the risk of IBD worsening.
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Affiliation(s)
- Ria Nagpal
- Department of Gastroenterology, Mayo University Hospital, Castlebar, County Mayo, Ireland
| | - Hemnaath Ulaganathan
- Department of Gastroenterology, Mayo University Hospital, Castlebar, County Mayo, Ireland
| | - Khushal Khan
- Department of Gastroenterology, Mayo University Hospital, Castlebar, County Mayo, Ireland
| | - Brian Egan
- Department of Gastroenterology, Mayo University Hospital, Castlebar, County Mayo, Ireland
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Subhaharan D, Ramaswamy PK, Willmann L, Moattar H, Bhullar M, Ishaq N, Dorrington A, Shukla D, McIvor C, Edwards J, Mohsen W. Older adults with acute severe ulcerative colitis have similar steroid non-response and colectomy rates as younger adults. World J Gastroenterol 2023; 29:2469-2478. [PMID: 37179589 PMCID: PMC10167901 DOI: 10.3748/wjg.v29.i16.2469] [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] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/15/2022] [Revised: 02/11/2023] [Accepted: 03/24/2023] [Indexed: 04/24/2023] Open
Abstract
BACKGROUND There is paucity of data on outcomes of acute severe ulcerative colitis (ASUC) in older adults (≥ 60 years of age). AIM To assess steroid non-response rates during the index admission for ASUC in older adults. Secondary outcomes were response to medical rescue therapy and colectomy rates; at index admission, 3 and 12 mo. METHODS This retrospective multicentre cohort study included ASUC admissions who received intravenous steroids between January 2013 and July 2020 at two tertiary hospitals. Electronic medical records were reviewed to collect clinical, biochemical, and endoscopic data. A modified Poisson regression model was used for analysis. RESULTS Of 226 ASUC episodes, 45 (19.9%) occurred in patients ≥ 60 years of age. Steroid non-response rates were comparable in older adults and patients < 60 years of age [19 (42.2%) vs 85 (47%), P = 0.618, crude risk ratio (RR) = 0.89 [95% confidence interval (CI): 0.61-1.30], adjusted RR = 0.99 (0.44-2.21). Rates of response to medical rescue therapy in older adults was comparable to the younger cohort [76.5% vs 85.7%, P = 0.46, crude RR = 0.89 (0.67-1.17)]. Index admission colectomy [13.3% vs 10.5%, P = 0.598, crude RR = 1.27 (0.53-2.99), adjusted RR = 1.43 (0.34-6.06)], colectomy at 3 mo [20% vs 16.6%, P = 0.66, crude RR = 1.18 (0.61-2.3), adjusted RR = 1.31 (0.32-0.53)] and colectomy at 12 mo [20% vs 23.2%, P = 0.682, crude RR = 0.85 (0.45-1.57), adjusted RR = 1.21 (0.29-4.97)], were similar between the two groups. CONCLUSION In older adults with ASUC, the steroid non-response rate, response to medical rescue therapy, and colectomy rate at index admission, 3 and 12 mo is similar to patients less than 60 years of age.
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Affiliation(s)
- Deloshaan Subhaharan
- Department of Digestive Diseases, Gold Coast University Hospital, Gold Coast 4215, Queensland, Australia
| | | | - Laura Willmann
- Department of Digestive Diseases, Gold Coast University Hospital, Gold Coast 4215, Queensland, Australia
| | - Hadi Moattar
- Department of Digestive Diseases, Gold Coast University Hospital, Gold Coast 4215, Queensland, Australia
| | - Maneesha Bhullar
- Department of Digestive Diseases, Gold Coast University Hospital, Gold Coast 4215, Queensland, Australia
| | - Naveed Ishaq
- Department of Digestive Diseases, Gold Coast University Hospital, Gold Coast 4215, Queensland, Australia
| | - Alexander Dorrington
- Department of Digestive Diseases, Gold Coast University Hospital, Gold Coast 4215, Queensland, Australia
| | - Dheeraj Shukla
- Department of Digestive Diseases, Gold Coast University Hospital, Gold Coast 4215, Queensland, Australia
| | - Carolyn McIvor
- Department of Gastroenterology, Logan Hospital, Logan 4131, Queensland, Australia
| | - John Edwards
- Department of Digestive Diseases, Gold Coast University Hospital, Gold Coast 4215, Queensland, Australia
| | - Waled Mohsen
- Department of Digestive Diseases, Gold Coast University Hospital, Gold Coast 4215, Queensland, Australia
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McKechnie T, Khamar J, Lee Y, Tessier L, Passos E, Doumouras A, Hong D, Eskicioglu C. Total Abdominal Colectomy Versus Diverting Loop Ileostomy and Antegrade Colonic Lavage for Fulminant Clostridioides Colitis: Analysis of the National Inpatient Sample 2016-2019. J Gastrointest Surg 2023:10.1007/s11605-023-05682-0. [PMID: 37081220 DOI: 10.1007/s11605-023-05682-0] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/23/2023] [Accepted: 04/10/2023] [Indexed: 04/22/2023]
Abstract
BACKGROUND When surgery is indicated for fulminant Clostridioides difficile infection (CDI), total abdominal colectomy (TAC) is the most common approach. Diverting loop ileostomy (DLI) with antegrade colonic lavage has been introduced as a colon-sparing surgical approach. Prior analyses of National Inpatient Sample (NIS) data suggested equivalent postoperative outcomes between groups but did not evaluate healthcare resource utilization. As such, we aimed to analyze a more recent NIS cohort to compare these two approaches in terms of both postoperative outcomes and healthcare resource utilization. METHODS A retrospective analysis of the NIS from 2016 to 2019 was conducted. The primary outcome was postoperative in-hospital morbidity. Secondary outcomes included postoperative in-hospital mortality, system-specific postoperative complications, total admission cost, and length of stay (LOS). Univariable and multivariable regressions were utilized to compare the two operative approaches. RESULTS In total, 886 patients underwent TAC and 409 patients underwent DLI with antegrade colonic lavage. Adjusted analyses demonstrated no difference between groups in postoperative in-hospital morbidity (aOR 0.96, 95%CI 0.64-1.44, p = 0.851) or in-hospital mortality (aOR 1.15, 95%CI 0.81-1.64, p = 0.436). Patients undergoing TAC experienced significantly decreased total admission cost (MD $79,715.34, 95%CI 133,841-25,588, p = 0.004) and shorter postoperative LOS (MD 4.06 days, 95%CI 6.96-1.15, p = 0.006). CONCLUSIONS There are minimal differences between TAC and DLI with antegrade colonic lavage for fulminant CDI in terms of postoperative morbidity and mortality. Healthcare resource utilization, however, is significantly improved when patients undergo TAC as evidenced by clinically important decreases in total admission cost and postoperative LOS.
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Affiliation(s)
- Tyler McKechnie
- Division of General Surgery, Department of Surgery, McMaster University, Hamilton, ON, L8N 4A6, Canada
| | - Jigish Khamar
- Michael G. DeGroote School of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Yung Lee
- Division of General Surgery, Department of Surgery, McMaster University, Hamilton, ON, L8N 4A6, Canada
- Harvard T.H. Chan School of Public Health, Harvard University, Boston, MA, USA
| | - Léa Tessier
- Michael G. DeGroote School of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Edward Passos
- Division of General Surgery, Department of Surgery, McMaster University, Hamilton, ON, L8N 4A6, Canada
- Michael G. DeGroote School of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Aristithes Doumouras
- Division of General Surgery, Department of Surgery, McMaster University, Hamilton, ON, L8N 4A6, Canada
- Michael G. DeGroote School of Medicine, McMaster University, Hamilton, Ontario, Canada
- Division of General Surgery, Department of Surgery, St. Joseph's Healthcare, Hamilton, Ontario, Canada
| | - Dennis Hong
- Division of General Surgery, Department of Surgery, McMaster University, Hamilton, ON, L8N 4A6, Canada
- Michael G. DeGroote School of Medicine, McMaster University, Hamilton, Ontario, Canada
- Division of General Surgery, Department of Surgery, St. Joseph's Healthcare, Hamilton, Ontario, Canada
| | - Cagla Eskicioglu
- Division of General Surgery, Department of Surgery, McMaster University, Hamilton, ON, L8N 4A6, Canada.
- Michael G. DeGroote School of Medicine, McMaster University, Hamilton, Ontario, Canada.
- Division of General Surgery, Department of Surgery, St. Joseph's Healthcare, Hamilton, Ontario, Canada.
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50
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Min J, An KY, Park H, Cho W, Jung HJ, Chu SH, Cho M, Yang SY, Jeon JY, Kim NK. Postoperative inpatient exercise facilitates recovery after laparoscopic surgery in colorectal cancer patients: a randomized controlled trial. BMC Gastroenterol 2023; 23:127. [PMID: 37069526 PMCID: PMC10111844 DOI: 10.1186/s12876-023-02755-x] [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] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/18/2022] [Accepted: 04/02/2023] [Indexed: 04/19/2023] Open
Abstract
BACKGROUND Early mobilization is an integral part of an enhanced recovery program after colorectal cancer surgery. The safety and efficacy of postoperative inpatient exercise are not well known. The primary objective was to determine the efficacy of a postoperative exercise program on postsurgical recovery of stage I-III colorectal cancer patients. METHODS We randomly allocated participants to postoperative exercise or usual care (1:1 ratio). The postoperative exercise intervention consisted of 15 min of supervised exercise two times per day for the duration of their hospital stay. The primary outcome was the length of stay (LOS) at the tertiary care center. Secondary outcomes included patient-perceived readiness for hospital discharge, anthropometrics (e.g., muscle mass), and physical function (e.g., balance, strength). RESULTS A total of 52 (83%) participants (mean [SD] age, 56.6 [8.9] years; 23 [44%] male) completed the trial. The median LOS was 6.0 days (interquartile range; IQR 5-7 days) in the exercise group and 6.5 days (IQR 6-7 days) in the usual-care group (P = 0.021). The exercise group met the targeted LOS 64% of the time, while 36% of the usual care group met the targeted LOS (colon cancer, 5 days; rectal cancer, 7 days). Participants in the exercise group felt greater readiness for discharge from the hospital than those in the usual care group (Adjusted group difference = 14.4; 95% CI, 6.2 to 22.6; P < 0.01). We observed a small but statistically significant increase in muscle mass in the exercise group compared to usual care (Adjusted group difference = 0.63 kg; 95% CI, 0.16 to 1.1; P = 0.03). CONCLUSION Postsurgical inpatient exercise may promote faster recovery and discharge after curative-intent colorectal cancer surgery. TRIAL REGISTRATION The study was registered at WHO International Clinical Trials Registry Platform (ICTRP; URL http://apps.who.int/trialsearch ); Trial number: KCT0003920 .
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Affiliation(s)
- Jihee Min
- National Cancer Survivorship Center, National Cancer Control Institute, National Cancer Center, Goyang-si, Republic of Korea
- Department of Sport Industry Studies, Exercise Medicine and Rehabilitation Laboratory, Yonsei University, Seoul, Republic of Korea
| | - Ki-Yong An
- Faculty of Kinesiology, Sport, and Recreation, University of Alberta, Edmonton, Alberta, Canada
| | - Hyuna Park
- National Cancer Survivorship Center, National Cancer Control Institute, National Cancer Center, Goyang-si, Republic of Korea
| | - Wonhee Cho
- National Cancer Survivorship Center, National Cancer Control Institute, National Cancer Center, Goyang-si, Republic of Korea
| | - Hye Jeong Jung
- Department of Nursing, Mo-Im Kim Nursing Research Institute, Yonsei University, Seoul, Republic of Korea
| | - Sang Hui Chu
- Department of Nursing, Mo-Im Kim Nursing Research Institute, Yonsei University, Seoul, Republic of Korea
| | - Minsoo Cho
- Department of Surgery, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Seung Yoon Yang
- Department of Surgery, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Justin Y Jeon
- National Cancer Survivorship Center, National Cancer Control Institute, National Cancer Center, Goyang-si, Republic of Korea.
- Exercise Medicine Center for Diabetes and Cancer Patients, Yonsei University, Seoul, Republic of Korea.
- Cancer Prevention Center, Yonsei Cancer Center, Shinchon Severance Hospital, Seoul, Republic of Korea.
- Department of Sports Industry Studies, Yonsei University, Seoul, South Korea.
| | - Nam Kyu Kim
- Department of Surgery, Yonsei University College of Medicine, Seoul, Republic of Korea.
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