Publications by authors named "Brooke H Gurland"

9 Publications

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Preliminary Report From the Pelvic Floor Disorders Consortium: Large-Scale Data Collection Through Quality Improvement Initiatives to Provide Data on Functional Outcomes After Rectal Prolapse Repair.

Dis Colon Rectum 2021 Aug;64(8):986-994

Pelvic Floor Disorders Center, Section of Colon and Rectal Surgery, Massachusetts General Hospital, Boston, Massachusetts.

Background: The surgical management of rectal prolapse is constantly evolving, yet numerous clinical trials and meta-analyses studying operative approaches have failed to make meaningful conclusions.

Objective: The purpose of this study was to report on preliminary data captured during a large-scale quality improvement initiative to measure and improve function in patients undergoing rectal prolapse repair.

Design: This was a retrospective analysis of prospectively collected surgical quality improvement data.

Settings: This study was conducted at 14 tertiary centers specializing in pelvic floor disorders from 2017 to 2019.

Patients: A total of 181 consecutive patients undergoing external rectal prolapse repair were included.

Main Outcome Measures: Preoperative and 3-month postoperative Wexner incontinence score and Altomare obstructed defecation score were measured.

Results: The cohort included 112 patients undergoing abdominal surgery (71 suture rectopexy/56% minimally invasive, 41 ventral rectopexy/93% minimally invasive). Those offered perineal approaches (n = 68) were older (median age, 75 vs 62 y; p < 0.01) and had more comorbidities (ASA 3-4: 51% vs 24%; p < 0.01) but also reported higher preintervention rates of fecal incontinence (Wexner 11.4 ± 6.4 vs 8.6 ± 5.8; p < 0.01). Patients undergoing perineal procedures had similar incremental improvements in function after surgery as patients undergoing abdominal repair (change in Wexner, -2.6 ± 6.4 vs -3.1 ± 5.6, p = 0.6; change in Altomare, -2.9 ± 4.6 vs -2.7 ± 4.9, p = 0.8). Similarly, patients undergoing posterior suture rectopexy and ventral mesh rectopexy had similar incremental improvements in overall scores; however, patients undergoing ventral mesh rectopexy had a higher decrease in the need to use pads after surgery.

Limitations: The study was limited by its retrospective data analysis and 3-month follow-up.

Conclusions: Functional outcomes improved in all of the patients undergoing prolapse surgery. Larger cohorts are necessary to show superiority among surgical procedures. Quality improvement methods may allow for systematic yet practical acquisition of information and data analysis. We call for the creation of a robust database to benefit this patient population. See Video Abstract at http://links.lww.com/DCR/B581.

Reporte Preliminar Del Consorcio De Trastornos Del Piso Plvico Recoleccin De Datos A Gran Escala Mediante Iniciativas De Mejoramiento De La Calidad Para Proporcionar Informacin Sobre Los Resultados Funcionales: ANTECEDENTES:El tratamiento quirúrgico del prolapso rectal está evolucionando constantemente, sin embargo, numerosos estudios clínicos y metaanálisis que evalúan los tratamientos quirúrgicos no han logrado demostrar conclusiones significativas.OBJETIVO:Reportar datos preliminares obtenidos a gran escala durante una iniciativa de mejoramiento de la calidad para medir y mejorar la función en pacientes sometidos a reparación de prolapso rectal.DISEÑO:Análisis retrospectivo de datos recolectados prospectivamente de mejoramiento de la calidad quirúrgica.ENTORNO CLINICO:Este estudio se realizó en 14 centros terciarios especializados en trastornos del piso pélvico del 2017 al 2019.PACIENTES:Un total de 181 pacientes consecutivos sometidos a reparación de prolapso rectal externo.PRINCIPALES MEDIDAS DE VALORACION:Escala de incontinencia de Wexner y de defecación obstruida de Altomare preoperatoria y tres meses postoperatoria.RESULTADOS:El cohorte incluyó 112 pacientes sometidos a cirugía abdominal (71 rectopexia con sutura / 56% minimally invasive, 41 rectopexia ventral / 93% minimally invasive). Aquellos a los que se les realizaron abordajes perineales (n = 68) eran mayores (edad media de 75 vs. 62, p <0,01) y tenían mayorcomorbilidades (ASA 3-4: 51% vs. 24%, p <0,01), además reportaron una mayor tasa de incontinencia fecal previo a la intervención (Wexner 11,4 ± 6,4 vs. 8,6 +/- 5,8, p <0,01). Posterior a la cirugía, los pacientes sometidos a procedimientos perineales tuvieron mejoría progresiva en la función similar que los pacientes sometidos a reparación abdominal (cambio en Wexner -2,6 ± 6,4 vs. -3,1 ± 5,6, p = 0,6; cambio en Altomare -2,9 ± 4,6 vs. -2,7 ± 4,9, p = 0,8). De manera similar, los pacientes con rectopexia posterior con sutura y rectopexia ventral con malla tuvieron mejoría progresiva similares en las escalas generales; no obstante, pacientes con rectopexia ventral con malla tuvieron una mayor disminución en la necesidad de usar paños protectores después de la cirugía.LIMITACIONES:Análisis de datos retrospectivo y seguimiento de tres meses.CONCLUSIONES:Los resultados funcionales mejoraron en todos los pacientes sometidos a cirugía de prolapso. Se necesitan cohortes más grandes para demostrar superioridad entre los procedimientos quirúrgicos. Métodos de mejoramiento de la calidad pueden permitir la adquisición sistemática, pero práctica de información y análisis de datos. Hacemos un llamado para la creación de una base de datos sólida para beneficiar a esta población de pacientes. Consulte Video Resumen en http://links.lww.com/DCR/B581. (Traducción- Dr Francisco M. Abarca-Rendon).
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http://dx.doi.org/10.1097/DCR.0000000000001962DOI Listing
August 2021

Postoperative complications and recurrence rates after rectal prolapse surgery versus combined rectal prolapse and pelvic organ prolapse surgery.

Int Urogynecol J 2021 Apr 17. Epub 2021 Apr 17.

Department of Surgery, Division of Colorectal Surgery, Stanford University School of Medicine, Stanford, CA, USA.

Introduction And Hypothesis: Our primary objectives were to compare < 30-day postoperative complications and RP recurrence rates after RP-only surgery and combined surgery. Our secondary objectives were to determine preoperative predictors of < 30-day complications and RP recurrence.

Methods: A prospective IRB-approved cohort study was performed at a single tertiary care center from 2017 to 2020. Female patients with symptomatic RP underwent either RP-only surgery or combined surgery based on the discretion of the colorectal and FPMRS surgeons. Primary outcome measures were < 30-day complications separated into Clavien-Dindo (CD) classes and rectal prolapse on physical examination.

Results: Seventy women had RP-only surgery and 45 had combined surgery with a mean follow-up time of 208 days. Sixty-eight percent underwent abdominal RP repair, and 32% underwent perineal RP repair. Twenty percent had one or more complications, 14% in the RP-only group and 29% in the combined surgery group (p = 0.06). On multivariate analysis, combined surgery patients had a 30% increased risk of complications compared to RP-only surgery patients (RR = 1.3). Most of these complications were minor (14/17, 82.4%) and categorized as CD I or II, including urinary retention and UTI. Twelve percent of this cohort had RP recurrence, 11% in the RP-only group and 13% in the combined surgery group (p = 0.76). Preoperative risk factors for RP recurrence included a primary complaint of rectal bleeding (RR 5.5) and reporting stools consistent with Bristol Stool Scale of 1 (RR 2.1).

Conclusion: Patients undergoing combined RP + POP surgery had a higher risk of complications and equivalent RP recurrence rates compared to patients undergoing RP-only surgery.
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http://dx.doi.org/10.1007/s00192-021-04778-yDOI Listing
April 2021

Rectal Prolapse: Age-Related Differences in Clinical Presentation and What Bothers Women Most.

Dis Colon Rectum 2021 May;64(5):609-616

1 Stanford Pelvic Health Center, Stanford School of Medicine, Stanford, California 2 Stanford School of Medicine, Stanford, California 3 Stanford-Surgery Policy Improvement Research and Education (S-SPIRE) Center, Department of Surgery, Stanford School of Medicine, Stanford, California.

Background: Rectal prolapse has a diverse symptom profile that affects patients of all ages.

Objective: We sought to identify bothersome symptoms and clinical presentation that motivated patients who have rectal prolapse to seek care, characterize differences in symptom severity with age, and determine factors associated with bothersome symptoms.

Design: This study is a retrospective analysis of a prospectively maintained registry.

Settings: This study was conducted at a tertiary referral academic center.

Patients: Included were 129 consecutive women with full-thickness rectal prolapse.

Main Outcome Measures: The main outcomes measured were primary bothersome symptoms, 5-item Cleveland Clinic/Wexner Fecal Incontinence questionnaire, and the 5-item Obstructed Defecation Syndrome questionnaire. Patients were categorized by age <65 vs age ≥65 years.

Results: Cleveland Clinic/Wexner Fecal Incontinence score >9 was more common in older patients (87% vs 60%, p = 0.002). Obstructed Defecation Syndrome score >8 was more common in younger patients (57% vs 28%, p < 0.001). Older patients were more likely than younger patients to report bothersome symptoms of pain (38% vs 19%, p = 0.021) and bleeding (12% vs 2%, p = 0.046). Mucus discharge was reported by most patients (older, 72% vs younger, 66%, p = 0.54) but was bothersome for only 18%, regardless of age. Older patients had more severe prolapse expression than younger patients (at rest, 33% vs 11%; during activity, 26% vs 19%; only with defecation, 40% vs 64%, p = 0.006). Older patients were more likely to seek care within 6 months of prolapse onset (29% vs 11%, p = 0.056). On multivariable regression, increasing age, narcotic use, and nonprotracting prolapse at rest were associated with reporting pain as a primary concern.

Limitations: This was a single-center study with a small sample size.

Conclusions: Rectal prolapse-related bothersome symptoms and health care utilization differ by age. Although rectal pain is often not commonly associated with prolapse, it bothers many women and motivates older women to undergo evaluation. Patient-reported functional questionnaires may not reflect patients' primary concerns regarding specific symptoms and could benefit from supplementation with questionnaires to elicit individualized symptom priorities. See Video Abstract at http://links.lww.com/DCR/B492.

Prolapso De Recto: INFLUENCIA DE LA EDAD EN DIFERENCIAS VINCULADAS CON LA PRESENTACIÓN CLÍNICA Y LOS SÍNTOMAS MAS DESAGRADABLES: El prolapso de recto tiene una gran variedad de síntomas que afectan a pacientes con edades diferentes.Identificar los síntomas mas molestos y la presentación clínica que motivaron a los pacientes con un prolapso de recto a consultar por atención médica, caracterizar las diferencias de gravedad de los síntomas con relación a la edad y determinar los factores asociados con los síntomas mas molestos.Análisis retrospectivo de un registro prospectivo.Centro académico de referencia terciaria.Consecutivamente 129 mujeres que presentaban un prolapso rectal completo.Síntomas y molestias primarias, cuestionario de incontinencia fecal de la Cleveland Clinic / Wexner de 5 ítems, cuestionario de síndrome de defecación obstruida de 5 ítems. Los pacientes fueron categorizados en < 65 años versus ≥ 65 años.El puntaje de incontinencia fecal de la Cleveland Clinic / Wexner > 9 fue más común en pacientes mayores (87% vs 60%, p = 0.002). La puntuación del síndrome de defecación obstructiva > 8 fue más común en pacientes más jóvenes (57% vs 28%, p <0,001). Los pacientes mayores fueron más propensos que los pacientes jóvenes a informar síntomas y molestias de dolor (38% vs 19%, p = 0.021) y sangrado (12% vs 2%, p = 0.046). La mayoría de los pacientes informaron secresión de moco (mayores, 72% frente a más jóvenes, 66%, p = 0,54), pero sólo el 18% tuvo molestias, independientemente de la edad. Los pacientes mayores tenían una exteriorización de prolapso más grave que los pacientes jóvenes (en reposo, 33% frente a 11%; durante la actividad, 26% frente a 19%; solo con defecación, 40% frente a 64%, p = 0,006). Los pacientes mayores tenían más probabilidades de buscar atención médica dentro de los 6 meses posteriores al inicio del prolapso (29% frente a 11%, p = 0.056). Tras la regresión multivariable, el aumento de la edad, el uso de narcóticos y el prolapso no prolongado en reposo se asociaron con la notificación de dolor como queja principal.Centro único; tamaño de muestra pequeño.Los síntomas y molestias relacionadas con el prolapso rectal y la solicitud de atención médica difieren según la edad. Aunque el dolor rectal a menudo no se asocia comúnmente con el prolapso, incomoda a muchas pacientes y motiva a las mujeres mayores a someterse a un examen médico. Los cuestionarios funcionales con las respuestas de las pacientes pueden no reflejar las preocupaciones principales de éstos con respecto a los síntomas específicos y podrían requerir cuestionarios complementarios para así obtener prioridades individualizadas con relación a los síntomas identificados. Consulte Video Resumen en http://links.lww.com/DCR/B492. (Traducción-Dr. Xavier Delgadillo).
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http://dx.doi.org/10.1097/DCR.0000000000001843DOI Listing
May 2021

Does the Length of the Prolapsed Rectum Impact Outcome of Surgical Repair?

Dis Colon Rectum 2021 May;64(5):601-608

1 Digestive Disease & Surgery Institute, Cleveland Clinic, Cleveland, Ohio 2 Alleghany Health, Erie, Pennsylvania 3 Stanford Digestive Health Center, Palo Alto, California.

Background: There are many surgical options for the treatment of rectal prolapse with varying recurrence rates reported. The association between rectal prolapse length and recurrence risk has not been explored previously.

Objective: The purpose of this study was to determine whether length of prolapse predicts a risk of recurrence.

Design: Consecutive patients from a prospectively collected institutional review board-approved data registry were evaluated.

Settings: The study was conducted at the Cleveland Clinic Department of Colorectal Surgery.

Patients: All patients from 2010 to 2018 who underwent surgical intervention for rectal prolapse were included.

Intervention: Perineal repair with Delorme procedure and Altemeier, as well as abdominal repair with ventral rectopexy, resection rectopexy, and posterior rectopexy, was included.

Main Outcome Measures: Prolapse length, recurrence, type of surgery, and primary or secondary procedure were measured.

Results: In total, 280 patients had prolapse surgery over 8 years, mean age was 59 years (SD = 18 y), and 92.4% were female. Seventy percent had a prolapse length documented as <5 cm, and 30% had prolapse length documented as >5 cm. The mean prolapse length was 4.8 cm (SD = 2.9 cm). The overall rate of recurrent prolapse was 18%. There were 51 patients who had a recurrent prolapse after their first prolapse surgery. Factors significant for recurrence on univariate analysis were a perineal approach (p = 0.03), previous Delorme procedure (p < 0.001), and prolapse length >5 cm (p = 0.04). On multivariate analysis there was significantly increased recurrence with length of prolapse >5 cm (OR = 2.2 (95% CI, 1.1-4.4); p = 0.02) and having a previous Delorme procedure (OR = 4.0 (95% CI, 1.6-10.1); p = 0.004). For each 1-cm increase in prolapse, the odds of recurrence increased by a factor of 2.2.

Limitations: This was a retrospective study of a heterogenous patient cohort.

Conclusions: The greater the length of prolapsed rectum, the greater the risk of recurrence. The length of prolapse should be considered when planning the most appropriate surgical repair to modify the recurrence risk. See Video Abstract at http://links.lww.com/DCR/B463. EL TAMAÑO DEL RECTO PROLAPSADO AFECTA EL RESULTADO DE LA REPARACIÓN QUIRÚRGICA?: Existen muchas opciones quirúrgicas para el tratamiento del prolapso de recto con diferentes tasas de recurrencia publicadas. La asociación entre el tamaño del prolapso rectal y el riesgo de recurrencia no se han explorado previamente.Determinar si el largo en el tamaño del prolapso predice un riesgo de recidiva.Se evaluaron pacientes consecutivos de un registro de datos aprobado por el IRB recopilado prospectivamente.Departamento de cirugía colorrectal de la Clínica Cleveland, en Ohio.Todos aquellos pacientes que entre 2010 y 2018 se sometieron a una intervención quirúrgica por prolapso completo de recto.La reparación perineal incluyó los procedimientos de Altemeier y Delorme. Las reparaciones abdominales incluidas fueron la rectopexia ventral, la rectopexia con resección y la rectopexia posterior.Tamaño del prolapso, recurrencia, tipo de intervención quirúrgica y tipo de procedimiento (primario o secundario).En total, 280 pacientes se sometieron a cirugía de prolapso rectal durante 8 años, la edad media fue de 59 años (DE 18) donde el 92,4% eran mujeres. El 70% tenían un tamaño de prolapso documentado como < 5 cm y 30% tenían un tamaño de prolapso documentada como > 5 cm. La longitud media del prolapso fue de 4,8 cm (DE 2,9).La tasa general de recidiva del prolapso fue de 18%. Hubo 51 pacientes que presentaron recidiva del prolapso después de una primera cirugía. Los factores significativos para la recidiva en el análisis univariado fueron el abordaje perineal (p = 0.03), un procedimiento de Delorme previo (p <0.001) y el tamaño del prolapso > 5 cm (p = 0.04). En el análisis multivariado, hubo un aumento significativo de la recidiva en aquellos prolapsos de > 5 cm (OR 2,2; IC del 95%: 1,09-4,4; p = 0,02) con un procedimiento de Delorme previo (OR 4; IC del 95%: 1,6 a 10,1; p = 0,004). Por cada centímetro de tamaño del prolapso, las probabilidades de recidiva aumentaron en un factor de 2,2.Estudio retrospectivo de una cohorte de pacientes heterogénea.Cuanto mayor es el tamaño del recto prolapsado, mayor es el riesgo de recidiva. Se debe evaluar muy cuidadosamente el tamaño de los prolapsos para escoger la corrección quirúrgica más apropiada y así disminuir el riesgo de recidivas.Consulte Video Resumen en http://links.lww.com/DCR/B463. (Traducción-Dr Xavier Delgadillo).
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http://dx.doi.org/10.1097/DCR.0000000000001856DOI Listing
May 2021

Resection Rectopexy Is Still an Acceptable Operation for Rectal Prolapse.

Am Surg 2018 Sep;84(9):1470-1475

The aim of this study was to compare resection rectopexy (RR) with ventral mesh rectopexy (VMR). This institutional review board-approved retrospective study compared patients with rectal prolapse, who underwent RR or VMR from 2009 to 2016. The primary end point was the comparison of complications and prolapse recurrence rates. Seventy-nine RR and 108 VMR patients qualified. Using propensity score matching, the two groups were not significantly different ( = 0.818). There were no differences regarding gender (female 103 72; = 0.4) and age (59.3 53.9; = 0.054). Patients in the VMR group had a greater body mass index (25.5 22.9; = 0.001) and poorer physical status (American Society of Anesthesiologists 3 57.4% 41.8%; = 0.04). The VMR group had more: robotic approaches (69.4% 8.9%; < 0.001), concomitant urogynecological procedures (63 19; < 0.001), and longer operative time (269 206 minutes; < 0.001) but a reduced length of stay (2 5 days; < 0.001). The median follow-up (16 26 months; = 0.125) and the median time of recurrence (14 38 months; = 0.163) were similar. No differences were observed for complications or recurrence (10.2% 10.1%; = 0.43). We failed to identify superiority based on surgical technique.
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September 2018

Consensus Statement of Definitions for Anorectal Physiology Testing and Pelvic Floor Terminology (Revised).

Dis Colon Rectum 2018 Apr;61(4):421-427

Prepared on behalf of the Pelvic Floor Disorders Committee and the Clinical Practice Guidelines Committee of The American Society of Colon and Rectal Surgeons.

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http://dx.doi.org/10.1097/DCR.0000000000001070DOI Listing
April 2018

Surgical complications impact patient perception of hospital care.

J Am Coll Surg 2013 Nov 10;217(5):843-9. Epub 2013 Sep 10.

Department of Colorectal Surgery, Digestive Disease Institute, Cleveland Clinic, Cleveland, OH. Electronic address:

Background: Public reporting of the Hospital Consumer Assessment of Healthcare Providers and Systems survey is designed to produce data on patients' perceptions of the quality of hospital care. The aim of this study was to assess the impact of complications on patient responses to Hospital Consumer Assessment of Healthcare Providers and Systems "top-box" (most favorable) scores.

Study Design: All patients who underwent a colorectal procedure from October 2009 to June 2012 at a single center were included. Patient complications were categorized as major, minor, or no complications and "surgical technique" or "medical." Chi-square and Wilcoxon rank sum tests were used to compare binary and ordinal top-box scores, respectively.

Results: One thousand four hundred and nine surveys were collected for 1,233 patients (mean age 53 ± 15.7 years; 701 [52.2%] females) who underwent 955 (67.8%) major abdominal, 114 (8.1%) anorectal, and 340 (24.1%) stoma-related operations. There were 195 (13.8%) major and 396 (28.1%) minor complications. There were 159 (11.3%) technique complications and 411 (29.2%) medical complications. Patients without any complications were more likely to recommend the hospital than those with complications (p = 0.023) irrespective of type of complication (minor vs major; p = 0.72 or technique vs medical; p = 0.5). Responsiveness of hospital staff was also reported as higher for patients without complications (p = 0.0003) and the type of complication did not influence this assessment (minor vs major; p = 0.71 and technique vs medical; p = 0.95).

Conclusions: The occurrence of any complication after colorectal surgery adversely impacts patients' self-reported perceptions of hospital care as measured by Hospital Consumer Assessment of Healthcare Providers and Systems. An instrument that more accurately reflects patients' assessment of quality in the context of variations in patient, disease, and surgical factors is required.
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http://dx.doi.org/10.1016/j.jamcollsurg.2013.06.015DOI Listing
November 2013

Ventral rectopexy for rectal prolapse and obstructed defecation.

Clin Colon Rectal Surg 2012 Mar;25(1):34-6

Department of Colorectal Surgery, Digestive Disease Institute, Cleveland Clinic Foundation, Cleveland, Ohio.

Ventral rectopexy has gained popularity in Europe to treat full-thickness rectal external and internal prolapse. This procedure has been shown to achieve acceptable anatomic results with low recurrence rates, few complications, and improvements of both constipation and fecal incontinence. The authors review the principles, techniques, and outcomes of ventral rectopexy.
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http://dx.doi.org/10.1055/s-0032-1301757DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3348728PMC
March 2012

Laparoscopic surgery for inflammatory bowel disease: results of the past decade.

Inflamm Bowel Dis 2002 Jan;8(1):46-54

Department of Colorectal Surgery, Cleveland Clinic Florida, Weston 33331, USA.

Laparoscopic colectomy is one of the most difficult laparoscopic procedures. Surgeons attempting to perform laparoscopic surgery for inflammatory bowel disease (IBD) must have significant experience with IBD and advanced laparoscopic skills. Surgical management for IBD may be treated with a range of laparoscopic procedures that vary in complexity. After 10 years of experience, studies comparing laparoscopy versus laparotomy are favoring laparoscopy when evaluating reduction in postoperative ileus, pain, and length of hospitalization, disability, and cosmesis. The indications and contraindications for laparoscopic surgery for IBD are evolving as surgical expertise and equipment improve.
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http://dx.doi.org/10.1097/00054725-200201000-00007DOI Listing
January 2002
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