Publications by authors named "Deborah Nagle"

46 Publications

Effectiveness of the Ileostomy Pathway in Reducing Readmissions for Dehydration: Does It Stand the Test of Time?

Dis Colon Rectum 2020 08;63(8):1151-1155

Department of Surgery, Elisabeth-TweeSteden Hospital, Tilburg, the Netherlands.

Background: The ileostomy pathway, introduced in 2011, has proved to be successful in eliminating hospital readmissions for high-output ileostomy or dehydration in the following period of 7 months in a single institution. However, it is unclear whether this short-term success, immediately after the initiation of the program, can be sustainable in the long term.

Objective: The aim of this study was to assess the efficacy and the durability of the ileostomy pathway in reducing readmissions for dehydration over a longer period of time.

Design: This was a retrospective review of the patients who entered into the ileostomy pathway, since its introduction on March 1, 2011, until January 31, 2015.

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

Patients: Patients undergoing colorectal surgery with the creation of a new end or loop ileostomy were included.

Intervention: The long-term sustainability of the ileostomy pathway was assessed.

Main Outcome Measures: The primary end point was readmission within 30 days after discharge for a high-output ileostomy or dehydration.

Results: A total of 393 patients (male n = 195, female n = 198, median age 52 (18-87) years) were included: 161 prepathway and 232 on-pathway. Overall 30-day postdischarge readmission rates decreased from 35.4% to 25.9% (p = 0.04). Readmissions due to high output and/or dehydration dropped from 15.5% to 3.9% (p < 0.001). Readmissions due to small-bowel obstructions dropped from 9.9% to 4.3%, (p = 0.03).

Limitations: The possible limitations of the study included a nonrandomized comparison of the patient groups and those patients who were possibly admitted to different institutions.

Conclusions: The present ileostomy pathway decreases readmissions for high-output ileostomy and dehydration in patients with new ileostomies and is durable in the long term. See Video Abstract at http://links.lww.com/DCR/B233. EFICACIA DE VÍA DE ILEOSTOMÍA PARA REDUCIR LOS REINGRESOS POR DESHIDRATACIÓN: ¿RESISTE LA PRUEBA DEL TIEMPO?: La vía de ileostomía, introducida en 2011, ha demostrado ser exitosa en la eliminación de reingresos hospitalarios por ileostomía de alto rendimiento o deshidratación, por un período de 7 meses, en una sola institución. Sin embargo, no se ha aclarado si el éxito es a corto plazo, inmediatamente después del inicio del programa, y de que pueda ser sostenible a largo plazo.El objetivo de este estudio fue evaluar la eficacia y la durabilidad de la vía de ileostomía, para disminuir los reingresos por deshidratación, durante un período de tiempo más largo.Esta fue una revisión retrospectiva de pacientes que ingresaron a la vía de ileostomía, desde su introducción el 1 de marzo de 2011 hasta el 31 de enero de 2015.Este estudio se realizó en un centro académico terciario.Se incluyeron pacientes sometidos a cirugía colorrectal con la creación de una nueva ileostomía de extremo o asa.Evaluar la sostenibilidad de la vía de ileostomía a largo plazo.El punto final primario fue el reingreso dentro de los 30 días posteriores al alta, por una ileostomía de alto gasto o deshidratación.Se incluyeron un total de 393 pacientes (hombres n = 195, mujeres n = 198, edad media 52 [18-87] años), 161 antes de la vía y 232 en la vía. En general, las tasas de reingreso después del alta a 30 días, disminuyeron de 35.4% a 25.9% (p = 0.04). Los reingresos por alto rendimiento y / o deshidratación, disminuyeron del 15.5% al 3.9% (p < 0.001). Los reingresos debidos a obstrucciones del intestino delgado, disminuyeron del 9.9% al 4.3% (p = 0.03).Las posibles limitaciones del estudio incluyeron una comparación no aleatoria de los grupos de pacientes, y de aquellos pacientes que posiblemente fueron admitidos en diferentes instituciones.La vía de ileostomía disminuye los reingresos por ileostomía de alto gasto y deshidratación, en nuevos pacientes con ileostomía, y es duradera a largo plazo. Consulte Video Resumen en http://links.lww.com/DCR/B233.
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http://dx.doi.org/10.1097/DCR.0000000000001627DOI Listing
August 2020

Minimally invasive colectomy is associated with reduced risk of anastomotic leak and other major perioperative complications and reduced hospital resource utilization as compared with open surgery: a retrospective population-based study of comparative effectiveness and trends of surgical approach.

Surg Endosc 2020 02 14;34(2):610-621. Epub 2019 May 14.

Digital Surgery, Global Medical Affairs, Johnson & Johnson, Cincinnati, OH, USA.

Background: We used a population-based database to: (1) compare clinical and economic outcomes between minimally invasive surgery (MIS) and open surgery (OS) for colectomy; and (2) evaluate contemporary trends in MIS rates.

Methods: Retrospective Premier Healthcare Database review of patients undergoing elective inpatient colectomy between January 1, 2010 and September 30, 2017 (first = index admission). Patients were classified into MIS (laparoscopic/robotic) or OS groups, and by left or right colectomy. Propensity score matching (1:1 ratio) of MIS and OS groups was used to address potential confounding from patient/hospital/provider characteristics. Study outcomes, measured during index admission, included major perioperative complications [anastomotic leak (AL), bleeding, infection, and a composite of infection/AL], operating room time (ORT), length of stay (LOS), and total hospital costs.

Results: Among 134,970 study-eligible patients, MIS rates increased from ~ 2% (2010) to 19-23% (2017), driven by a > tenfold increase in robotic surgery. The matched MIS and OS colectomy groups comprised 46,708 (left) and 44,560 (right) total patients. Risks of AL, bleeding, and infection were lower for MIS versus OS (all p < 0.001). In left: AL occurred in 7.9% of MIS versus 9.9% of OS; bleeding 7.8% versus 9.7%; infection 3.3% versus 5.8%; infection/AL 9.8% versus 13.3%. In right: AL 8.9% versus 11.1%; bleeding 9.8% versus 10.8%; infection 3.0% versus 5.1%; infection/AL 10.5% versus 10.4%. Although ORTs were longer with MIS (left: 240.8 vs. 216.2 min; right: 192.8 vs. 178.0 min), LOS was shorter (left: 5.4 vs. 7.1 days; right: 5.5 vs. 7.1 days), and total hospital costs were lower (left: $18,564 vs. $19,960; right: $17,375 vs. $19,417) versus OS (all p < 0.001).

Conclusions: Compared with OS, MIS was associated with significantly lower risk of major perioperative complications (including AL), lower LOS, and lower total hospital costs, despite longer OR times. MIS colectomy rates have increased over time; recent gains appear to be due to uptake of robotic surgery.
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http://dx.doi.org/10.1007/s00464-019-06805-yDOI Listing
February 2020

A dual-perspective analysis of the hospital and payer-borne burdens of selected in-hospital surgical complications in low anterior resection for colorectal cancer.

Hosp Pract (1995) 2019 Apr 1;47(2):80-87. Epub 2019 Feb 1.

a Epidemiology, Medical Devices , Johnson & Johnson , New Brunswick , NJ , USA.

Objectives: The economic burden of surgical complications is borne in distinctly different ways by hospitals and payers. This study quantified the incidence and economic burden - from both the hospital and payer perspective - of selected major colorectal surgery complications in patients undergoing low anterior resection (LAR) for colorectal cancer.

Methods: Retrospective, observational study of patient undergoing LAR for colorectal cancer between 1/1/2010 and 7/1/2015. Analyses were replicated in two large healthcare administrative databases: Premier (hospital discharge and billing data; hospital perspective) and Optum (insurance claims data; payer perspective). Multivariable analyses evaluated the association between infection (surgical site or bloodstream), anastomotic leak, and bleeding complications and the following outcomes: hospital length of stay (LOS), non-home discharge, 90-day all-cause readmission, index admission costs to the hospital, index admission payer expenditures, and index admission +90-day post-discharge payer expenditures.

Results: 9,738 eligible LAR patients were included (7,479 in Premier; 2,259 in Optum). Overall, the incidences of infection, anastomotic leak, and bleeding complications were 6.4%, 10.6%, and 10.9%, respectively, during the index hospitalization. Each complication was associated with statistically significant longer LOS, higher risk of non-home discharge, higher risk of 90-day readmission, greater costs to the hospital, and higher payer expenditures.

Conclusions: In-hospital infection, anastomotic leak, and bleeding were associated with a substantial economic burden, for both hospitals and payers, in patients undergoing LAR for colorectal cancer. This study provides information which may be used to quantify the potential economic value and impact of innovations in surgical care and delivery that reduce the incidence and burden of these complications.
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http://dx.doi.org/10.1080/21548331.2019.1568718DOI Listing
April 2019

Pelvic and Lower Gastrointestinal Tract Anatomical Characterization of the Average Male.

Surg Innov 2019 Apr 12;26(2):180-191. Epub 2018 Nov 12.

1 Virginia Tech-Wake Forest University Center for Injury Biomechanics, Winston-Salem, NC, USA.

Objective: Colorectal surgeons report difficulty in positioning surgical devices in males, particularly those with a narrower pelvis. The objectives of this study were to (1) characterize the anatomy of the pelvis and surrounding soft tissue from magnetic resonance and computed tomography scans from 10 average males (175 cm, 78 kg) and (2) develop a model representing the mean configuration to assess variability.

Methods: The anatomy was characterized from existing scans using segmentation and registration techniques. Size and shape variation in the pelvis and soft tissue morphology was characterized using the Generalized Procrustes Analysis to compute the mean configuration.

Results: There was considerable variability in volume of the psoas, connective tissue, and pelvis and in surface area of the mesorectum, pelvis, and connective tissue. Subject height was positively correlated with mesorectum surface area (P = .028, R = 0.47) and pelvis volume ( P = .041, R = 0.43). The anterior-posterior distance between the inferior pelvic floor muscle and pubic symphysis was positively correlated with subject height ( P = .043, r = 0.65). The angle between the superior mesorectum and sacral promontory was negatively correlated with subject height ( P = .042, r = -0.65). The pelvic inlet was positively correlated with subject weight ( P = .001, r = 0.89).

Conclusions: There was considerable variability in organ volume and surface area among average males with some correlations to subject height and weight. A physical trainer model created from these data helped surgeons trial and assess device prototypes in a controllable environment.
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http://dx.doi.org/10.1177/1553350618812317DOI Listing
April 2019

Initial Assessment of Mucosal Capture and Leak Pressure After Gastrointestinal Stapling in a Porcine Model.

Obes Surg 2018 11;28(11):3446-3453

Ethicon, Inc., 4545 Creek Rd, Cincinnati, OH, 45242, USA.

Background: Anastomotic leak is a leading cause of morbidity and mortality in gastrointestinal surgery. The serosal aspect of staple lines is commonly observed for integrity, but the mucosal surface and state of mucosa after firing is less often inspected. We sought to assess the degree of mucosal capture when using stapling devices and determine whether incomplete capture influences staple line integrity.

Methods: Porcine ileum was transected in vivo and staple lines were collected and rated for degree of mucosal capture on a 5-point scale from 1 (mucosa mainly captured on both sides) to 5 (majority of mucosa not captured). Mucosal capture was also assessed in ex vivo staple lines, and fluid leakage pressure and location of first leak was assessed. Stapling devices studied were Echelon Flex GST with 60-mm blue (GST60B) and green (GST60G) cartridges, and Medtronic EndoGIA Universal with Tri-Staple Technology™ with 60 mm medium (EGIA60AMT) reloads (purple).

Results: GST60B and GST60G staple lines produced significantly better mucosal capture scores than the EGIA60AMT staple lines (p < 0.001, in all tests). Compared to EGIA60AMT, leak pressures were 39% higher for GST60B (p < 0.001) and 23% higher for GST60G (p = 0.022). Initial staple line leak site was associated with incomplete mucosal capture 78% of the time.

Conclusions: There are differences in degree of mucosal capture between commercial staplers, and the devices that produce better mucosal capture had significantly higher leak pressures. Further research is needed to determine the significance of these findings on staple line healing throughout the postoperative period.
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http://dx.doi.org/10.1007/s11695-018-3363-0DOI Listing
November 2018

The impact of surgeon choices on costs associated with uncomplicated minimally invasive colectomy: you are not as important as you think.

Gastroenterol Rep (Oxf) 2018 May 27;6(2):108-113. Epub 2017 Sep 27.

Division of Colon and Rectal Surgery, Department of Surgery, Beth Israel Deaconess Medical Center, Boston, MA, USA.

Background: There is increasing public discussion about the escalating cost of healthcare in America. There are no published data regarding the contribution of individual surgeons' choices on the cost of uncomplicated minimally invasive colectomy.

Methods: A review of a hospital cost-accounting database of the direct costs related to the index operation and post-operative care of all patients who underwent elective minimally invasive segmental colectomy over a 1-year period was performed.

Results: A total of 111 cases were enrolled in this study, 18 of which were performed robotically. The average direct cost after minimally invasive colectomy was $5536. The cost of robotic colectomy was 53% greater than laparoscopic ($7806 vs $5096,  < 0.001). There was no statistically significant difference in overall costs among laparoscopic cases performed by three surgeons ($5099 vs $5108 vs $5055,  = 0.987). Average operating room supply costs among the three surgeons were $1236, $1105 and $1030, respectively ( = 0.067), with a standard deviation of $328 (6.4% of overall cost).

Conclusions: No significant difference in overall costs between surgeons was demonstrated despite varied training, experience levels and operative techniques. Total costs are relatively institutionally fixed and minimally influenced by variations in individual surgeon preferences.
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http://dx.doi.org/10.1093/gastro/gox035DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5952919PMC
May 2018

Rectal Eversion Technique: A Method to Achieve Very Low Rectal Transection and Anastomosis With Particular Value in Laparoscopic Cases.

Dis Colon Rectum 2017 Dec;60(12):1329-1331

Colon and Rectal Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts.

Introduction: Transection of the rectum at the anorectal junction is required for proper resection in ulcerative colitis and restorative proctocolectomy. Achieving stapled transection at the pelvic floor is often challenging, particularly during laparoscopic proctectomy. Transanal mucosectomy and handsewn anastomosis are frequently used to achieve adequate resection. Rectal eversion provides an alternative for low anorectal transection and maintains the ability to perform stapled anastomosis.

Technique: The purpose of this article is to describe a technique for low anorectal transection. The work was conducted at tertiary care center by 2 colon and rectal surgeons on patients undergoing total proctocolectomy with creation of ileal pouch rectal anastomosis for ulcerative colitis. We measured the ability to achieve low stapled anastomosis.

Results: Very low transection was achieved, allowing for creation of IPAA without leaving significant rectal cuff. This study was limited because it is an early experience that was not performed in the setting of a scientific investigation. No sphincter or bowel functional data were obtained or evaluated.

Conclusions: Rectal eversion technique provides an alternative to mucosectomy when low pelvic transection is difficult to achieve. See Video at http://links.lww.com/DCR/A441.
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http://dx.doi.org/10.1097/DCR.0000000000000932DOI Listing
December 2017

Bioscaffold-mediated mucosal remodeling following short-segment colonic mucosal resection.

J Surg Res 2017 10 22;218:353-360. Epub 2017 Jul 22.

McGowan Institute for Regenerative Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania; Department of Bioengineering, University of Pittsburgh, Pittsburgh, Pennsylvania; Department of Surgery, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania. Electronic address:

Precancerous or cancerous lesions of the gastrointestinal tract often require surgical resection via endomucosal resection. Although excision of the colonic mucosa is an effective cancer treatment, removal of large lesions is associated with high morbidity and complications including bleeding, perforation, fistula formation, and/or stricture, contributing to high clinical and economic costs and negatively impacting patient quality of life. The present study investigates the use of a biologic scaffold derived from extracellular matrix (ECM) to promote restoration of the colonic mucosa following short segment mucosal resection. Six healthy dogs were assigned to ECM-treated (tubular ECM scaffold) and mucosectomy only control groups following transanal full circumferential mucosal resection (4 cm in length). The temporal remodeling response was monitored using colonoscopy and biopsy collection. Animals were sacrificed at 6 and 10 wk, and explants were stained with hematoxylin and eosin (H&E), Alcian blue, and proliferating cell nuclear antigen (PCNA) to determine the temporal remodeling response. Both control animals developed stricture and bowel obstruction with no signs of neomucosal coverage after resection. ECM-treated animals showed an early mononuclear cell infiltrate (2 weeks post-surgery) which progressed to columnar epithelium and complex crypt structures nearly indistinguishable from normal colonic architecture by 6 weeks after surgery. ECM scaffold treatment restored colonic mucosa with appropriately located PCNA+ cells and goblet cells. The study shows that ECM scaffolds may represent a viable clinical option to prevent complications associated with endomucosal resection of cancerous lesions in the colon.
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http://dx.doi.org/10.1016/j.jss.2017.06.066DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6214663PMC
October 2017

Practice changes for reducing UTIs in colon and rectal surgery patients.

Bull Am Coll Surg 2017 03;102(3):31-6

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March 2017

Erratum to: Primary vs. delayed perineal proctectomy-there is no free lunch.

Int J Colorectal Dis 2017 08;32(8):1213

Department of Surgery, Division of Colon and Rectal Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA.

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http://dx.doi.org/10.1007/s00384-017-2838-0DOI Listing
August 2017

Primary vs. delayed perineal proctectomy-there is no free lunch.

Int J Colorectal Dis 2017 Aug 6;32(8):1207-1212. Epub 2017 May 6.

Department of Surgery, Division of Colon and Rectal Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA.

Purpose: Perineal wound complications associated with anorectal excision are associated with prolonged wound healing and readmission. In order to avoid these problems, the surgeon may choose to leave the anorectum in situ. The purpose of this study is to compare complications and outcomes after primary vs. delayed anorectum removal.

Methods: A retrospective review of all patients undergoing proctectomy or proctocolectomy with permanent stoma between 2004 and 2014 in a single tertiary institution was conducted.

Results: During the study period, we identified 117 proctectomy patients; 69 (59%) patients had anorectum removed at index operation and 41% had the anorectum left in place. Patients with retained anorectum developed pelvic abscess significantly more frequently as compared to the other group (23 vs. 4%, p = 0.003). In patients with primary anorectum removal, 22 (32%) had perineal complications and 10 (15%) required reoperations. In patients with retained anorectum, 12 patients (25%) came back for delayed perineal proctectomy at a mean time of 277 days after the index operation; 7 of those (58%) developed postoperative wound complications. There was no difference in time to perineal wound healing between primary and delayed perineal proctectomy group (154 vs. 211 days, p = 0.319).

Conclusion: Surgery involving the distal rectum is associated with a significant number of infectious perineal complications. Although leaving the anorectum in place avoids a primary perineal wound, both approaches are associated with a significant number of complications including reoperation.
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http://dx.doi.org/10.1007/s00384-017-2790-zDOI Listing
August 2017

Massachusetts Healthcare Reform and Trends in Emergent Colon Resection.

Dis Colon Rectum 2016 Nov;59(11):1063-1072

1 Surgical Outcomes Analysis and Research, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts 2 Division of General Medicine and Primary Care, Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts 3 Division of Colon and Rectal Surgery, Department of Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts.

Background: Insurance impacts access to therapeutic options, yet little is known about how healthcare reform might change the pattern of surgical admissions.

Objective: We compared rates of emergent admissions and outcomes after colectomy before and after reform in Massachusetts with a nationwide control group.

Design: This study is a retrospective cohort analysis in a natural experiment. Prereform was defined as hospital discharge from 2002 through the second quarter of 2006 and postreform from the third quarter of 2006 through 2012. Categorical variables were compared by χ. Piecewise functions were used to test the effect of healthcare reform on the rate of emergent surgeries.

Settings: The study included acute care hospitals in the Massachusetts Healthcare Cost and Utilization Project State Inpatient Database (2002-2012) and the Nationwide Inpatient Sample (2002-2011).

Patients: Patients aged 18 to 64 years with public or no insurance who underwent inpatient colectomy (via International Classification of Diseases, Ninth Revision, Clinical Modification procedural code) were included and patients with Medicare were excluded.

Intervention: Massachusetts health care reform was the study intervention.

Main Outcome Measures: We measured the rate of emergent colectomy, complications, and mortality.

Results: The unadjusted rate of emergent colectomies was lower in Massachusetts after reform but did not change nationally over the same time period. For emergent surgeries in Massachusetts, a piecewise model with an inflection point (peak) in the third quarter of 2006, coinciding with implementation of healthcare reform in Massachusetts, had a lower mean squared error than a linear model. In comparison, the national rate of emergent surgeries demonstrated no change in pattern. Postreform, length of stay decreased by 1 day in Massachusetts; however, there were no significant improvements in other outcomes.

Limitations: The study was limited by its retrospective design and unadjusted analysis.

Conclusions: There was a unique and sustained decline in the rate of emergent colon resection among publically insured and uninsured patients after 2006 in Massachusetts, in contradistinction to the national pattern, suggesting improved access to care associated with health insurance expansion. The reasons for lack of improvement in outcomes are multifactorial.
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http://dx.doi.org/10.1097/DCR.0000000000000697DOI Listing
November 2016

Post operative stereotactic radiosurgery for positive or close margins after preoperative chemoradiation and surgery for rectal cancer.

J Gastrointest Oncol 2016 Jun;7(3):315-20

1 Department of Radiation Oncology, Istanbul University, Istanbul, Turkey ; 2 Radiation Oncology, 3 Department of Surgery, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, MA, USA.

Background: The incidence of positive margins after neoadjuvant chemoradiation and adequate surgery is very low. However, when patients do present with positive or close margins, they are at a risk of local failure and local therapy options are limited. We evaluated the role of stereotactic body radiotherapy (SBRT) in patients with positive or close margins after induction chemoradiation and total mesorectal excision.

Methods: This is a retrospective evaluation of patients treated with SBRT after induction chemoradiation and surgery for positive or close margins. Seven evaluable patients were included. Fiducial seeds were place at surgery. The Cyberknife(TM) system was used for planning and treatment. Patients were followed 1 month after treatment and 3-6 months thereafter. Descriptive statistics and Kaplan-Meir method was used to repot the findings.

Results: Seven patients (3 men and 4 women) were included in the study with a median follow-up of 23.5 months. The median initial radiation dose was 5,040 cGy (in 28 fractions) and the median SBRT dose was 2,500 cGy (in 5 fractions). The local control at 2 years was 100%. The overall survival at 1 and 2 years was 100% and 71% respectively. There was no Grade III or IV toxicity.

Conclusions: SBRT reirradiation is an effective and safe method to address positive or close margins after neoadjuvant chemoradiation and surgery for rectal cancer.
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http://dx.doi.org/10.21037/jgo.2015.11.03DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4880783PMC
June 2016

Readmission After Resections of the Colon and Rectum: Predictors of a Costly and Common Outcome.

Dis Colon Rectum 2015 Dec;58(12):1164-73

1 Surgical Outcomes Analysis & Research, Beth Israel Deaconess Medical Center, Boston, Massachusetts 2 Department of Surgery, Massachusetts General Hospital, Boston, Massachusetts 3 Department of Surgery, UMass Memorial Medical Center, Worcester, Massachusetts 4 Colon and Rectal Surgery, Beth Israel Deaconess Medical Center, Boston, Massachusetts 5 Division of Gastroenterology, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts 6 Division of Surgical Oncology, Beth Israel Deaconess Medical Center, Boston, Massachusetts.

Background: Readmission rates are a measure of surgical quality and an object of clinical and regulatory scrutiny. Despite increasing efforts to improve quality and contain cost, 6% to 25% of patients are readmitted after colorectal surgery.

Objective: The aim of this study is to define the predictors and costs of readmission following colorectal surgery.

Design: This is a retrospective cohort study of patients undergoing elective and nonelective colectomy and/or proctectomy in the Healthcare Cost and Utilization Project Florida State Inpatient Database 2007 to 2011. Readmission is defined as inpatient admission within 30 days of discharge. Univariate analyses were performed of sex, age, Elixhauser score, race, insurance type, procedure, indication, readmission diagnosis, cost, and length of stay. Multivariate analysis was performed by logistic regression. Sensitivity analysis of nonemergent admissions was conducted.

Settings: This study was conducted in Florida acute-care hospitals.

Patients: Patients undergoing colectomy and proctectomy from 2007 to 2011 were included.

Intervention(s): There were no interventions.

Main Outcome Measure(s): The primary outcomes measured were readmission and the cost of readmission.

Results: A total of 93,913 patients underwent colectomy; 14.7% were readmitted within 30 days. From 2007 to 2011, readmission rates remained stable (14.6%-14.2%, trend p = 0.1585). After multivariate adjustment, patient factors associated with readmission included nonwhite race, age <65, and a diagnosis code other than neoplasm or diverticular disease (p < 0.0001). Patients with Medicare or Medicaid were more likely to be readmitted than those with private insurance (p < 0.0001). Patients with longer index admissions, those with stomas, and those undergoing all procedures other than sigmoid or transverse colectomy were more likely to be readmitted (p < 0.0001). High-volume hospitals had higher rates of readmission (p < 0.0001). The most common reason for readmission was infection (32.9%). Median cost of readmission care was $7030 (intraquartile range, $4220-$13,247). Fistulas caused the most costly readmissions ($15,174; intraquartile range, $6725-$26,660).

Limitations: Administrative data and retrospective design were limitations of this study.

Conclusions: Readmissions rates after colorectal surgery remain common and costly. Nonprivate insurance, IBD, and high hospital volume are significantly associated with readmission.
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http://dx.doi.org/10.1097/DCR.0000000000000433DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4638166PMC
December 2015

Evolving and Emerging Technologies in Colon and Rectal Surgery.

Clin Colon Rectal Surg 2015 Sep;28(3):129-30

Division of Colon and Rectal Surgery, Beth Israel Deaconess Medical Center, Boston, Massachusetts.

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http://dx.doi.org/10.1055/s-0035-1558643DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4593897PMC
September 2015

Real world dehiscence rates for patients undergoing abdominoperineal resection with or without myocutaneous flap closure in the national surgical quality improvement project.

Int J Colorectal Dis 2016 Jan 28;31(1):95-104. Epub 2015 Aug 28.

Division of Colon and Rectal Surgery, Department of Surgery, Beth Israel Deaconess Medical Center, 330 Brookline Avenue Stoneman 9, Boston, MA, 02215, USA.

Purpose: Perineal wound complications cause significant morbidity following abdominoperineal resection (APR). Myocutaneous flap closure may mitigate perineal wound complications though data is limited outside of specialized oncologic centers. We aim to compare rates of wound dehiscence in patients undergoing APR with and without flap closure.

Methods: All patients undergoing APR in the National Surgical Quality Improvement Program between 2005 and 2013 were included. Thirty-day rate of wound dehiscence and other perioperative outcomes were compared between the flap and non-flap cohorts. Subgroup analysis was performed for propensity score-matched cohorts and those receiving neoadjuvant radiation.

Results: Seven thousand two hundred and five patients underwent non-emergent APR [527 (7 %) flap vs. 6678 (93 %) non-flap]. Wound dehiscence occurred in 224 patients [38 (7 %) flap vs. 186 (3 %) non-flap] with 84/224 (38 %) of these reoperated. Reoperation was more common in flap patients [15 vs. 8 %; p = 0.001]. Overall morbidity was higher in flap closure [38 % flap vs. 31 % non-flap; p < 0.001]. Dehiscence was higher for flap closure in the propensity score-matched cohort [7 vs. 3 %; p < 0.001]. Flap closure was an independent predictor of dehiscence for both the overall and propensity score-matched groups. Dehiscence was not increased in patients who had neoadjuvant radiation [5.4 % flap vs. 2.6 % non-flap; p = 0.127].

Conclusions: This represents the largest study of flap vs. non-flap closure following APR and the first such study from a national database. Flap closure was independently associated with increased risk of wound dehiscence in both the overall and matched cohorts. This study highlights the challenge of wound complications following APR and provides real-world generalizable data.
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http://dx.doi.org/10.1007/s00384-015-2377-5DOI Listing
January 2016

Perioperative use of tamsulosin significantly decreases rates of urinary retention in men undergoing pelvic surgery.

Int J Colorectal Dis 2015 Sep 23;30(9):1223-8. Epub 2015 Jun 23.

Division of Colon and Rectal Surgery, Beth Israel Deaconess Medical Center, 330 Brookline Avenue, Stoneman 9, Boston, MA, 02215, USA,

Purpose: Urinary retention is a common complication of pelvic surgery, leading to urinary tract infection and prolonged hospital stays. Tamsulosin is an alpha blocker that works by relaxing bladder neck muscles. It is used to treat benign prostatic hypertrophy and retention. We aim to investigate the potential benefits of preemptive tamsulosin use on rates of urinary retention in men undergoing pelvic surgery.

Methods: This is a retrospective review of an institutional colorectal database. All men undergoing pelvic surgery between 2004 and 2013 were included. Patients given 0.4 mg of tamsulosin 3 days prior and after surgery at discretion of surgeon starting in 2007 were compared with patients receiving expectant postoperative management.

Results: One hundred eighty-five patients were included in the study (study group: N = 30; control group: N = 155). Study group patients were older (56.8 vs. 50.1 years). Overall urinary retention rate was 22% with significantly lower rates in the study group compared with control (6.7 vs. 25%; p = 0.029). Study group had higher rates of minimally invasive surgery (61 vs. 29.7%); however, this did not impact urinary retention rate (20.6 vs. 22.7% for minimally invasive surgery vs. open surgery; p = 0.85). Independent predictors of urinary retention included lack of preemptive tamsulosin (odds ratio (OR), 7.67; 95% confidence interval (CI), 1.4-41.7) and cancer location in the distal third of the rectum (OR, 18.8; 95% CI, 2.1-172.8).

Conclusions: Preemptive perioperative use of tamsulosin may significantly decrease the incidence of urinary retention in men undergoing pelvic surgery. This may play a role in avoidance of urinary retention, particularly in patients with distal rectal cancer.
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http://dx.doi.org/10.1007/s00384-015-2294-7DOI Listing
September 2015

Case report of a traumatic rectal neuroma.

Gastroenterol Rep (Oxf) 2016 Nov 19;4(4):331-333. Epub 2015 Jun 19.

Department of Surgery, Division of Colorectal Surgery, Beth Israel Deaconess Medical Center, Boston, MA, USA.

Traumatic neuroma is a well-recognized complication of lower extremity amputation, yet has also been noted to occur elsewhere. We report a clinical case and English-language literature review of traumatic rectal neuroma, a well-known pathologic entity not previously reported in this anatomic location.
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http://dx.doi.org/10.1093/gastro/gov023DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5193054PMC
November 2016

Stereotactic body radiotherapy (SBRT) reirradiation for pelvic recurrence from colorectal cancer.

J Surg Oncol 2015 Mar 2;111(4):478-82. Epub 2015 Feb 2.

Department of Radiation Oncology, University of Istanbul, Istanbul, Turkey.

Background And Objectives: When surgery is not adequate or feasible, stereotactic body radiotherapy (SBRT) reirradiation has been used for recurrent cancers. We report the outcomes of a series of patients with pelvic recurrences from colorectal cancer reirradiated with SBRT.

Methods: The Cyberknife(TM) Robotic Stereotactic Radiosurgery system with fiducial based real time tracking was used. Patients were followed with imaging of the pelvis.

Results: Four women and 14 men with 22 lesions were included. The mean dose was 25 Gy in median of five fractions. The mean prescription isodose was 77%, with a median maximum dose of 32.87 Gy. There were two local failures, with a crude local control rate of 89%. The median overall survival was 43 months. One patient had small bowel perforation and required surgery (Grade IV), two patients had symptomatic neuropathy (1 Grade III) and one patient developed hydronephrosis from ureteric fibrosis requiring a stent (Grade III).

Conclusions: Local recurrence in the pelvis after modern combined modality treatment for colorectal cancer is rare. However it presents a therapeutic dilemma when it occurs; often symptomatic and eventually life threatening. SBRT can be a useful non-surgical modality to control pelvic recurrences after prior radiation for colorectal cancer.
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http://dx.doi.org/10.1002/jso.23858DOI Listing
March 2015

Treatment of fecal incontinence: state of the science summary for the National Institute of Diabetes and Digestive and Kidney Diseases workshop.

Am J Gastroenterol 2015 Jan 21;110(1):138-46; quiz 147. Epub 2014 Oct 21.

National Institutes of Diabetes, Digestive and Kidney Diseases, National Institute of Health, Bethesda, Maryland, USA.

This is the second of a two-part summary of a National Institutes of Health conference on fecal incontinence (FI) that summarizes current treatments and identifies research priorities. Conservative medical management consisting of patient education, fiber supplements or antidiarrheals, behavioral techniques such as scheduled toileting, and pelvic floor exercises restores continence in up to 25% of patients. Biofeedback, often recommended as first-line treatment after conservative management fails, produces satisfaction with treatment in up to 76% and continence in 55%; however, outcomes depend on the skill of the therapist, and some trials are less favorable. Electrical stimulation of the anal mucosa is ineffective, but continuous electrical pulsing of sacral nerves produces a ≥50% reduction in FI frequency in a median 73% of patients. Tibial nerve electrical stimulation with needle electrodes is promising but remains unproven. Sphincteroplasty produces short-term clinical improvement in a median 67%, but 5-year outcomes are poor. Injecting an inert bulking agent around the anal canal led to ≥50% reductions of FI in up to 53% of patients. Colostomy is used as a last resort because of adverse effects on quality of life. Several new devices are under investigation but not yet approved. FI researchers identify the following priorities for future research: (1) trials comparing the effectiveness, safety, and cost of current therapies; (2) studies addressing barriers to consulting for care; and (3) translational research on regenerative medicine. Unmet patient needs include FI in special populations (e.g., neurological disorders and nursing home residents) and improvements in behavioral treatments.
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http://dx.doi.org/10.1038/ajg.2014.303DOI Listing
January 2015

Gabapentin significantly decreases posthemorrhoidectomy pain: a prospective study.

Int J Colorectal Dis 2014 Dec 1;29(12):1565-9. Epub 2014 Oct 1.

Colon and Rectal Surgery, Beth Israel Deaconess Medical Center, 330 Brookline Avenue, Stoneman 9, Boston, MA, 02215, USA,

Purpose: Surgery for hemorrhoidectomy remains a painful procedure despite advances in pain management. Gabapentin is widely used for control of acute and chronic pain. Our aim was to evaluate the effect of gabapentin on posthemorrhoidectomy pain and opioid use.

Methods: A prospective, open-label study. Patients requiring hemorrhoid surgery were recruited to be in control (standard of care) or treatment group (standard of care plus daily gabapentin).

Results: Twenty-one treatment and 18 control patients were recruited. One patient from study group and two patients from control group were excluded due to failure to follow up. Pain levels for gabapentin group were significantly lower on postoperative days 1, 7, and 14 compared to the standard treatment group (3.68 vs. 6.82 p < 0.01, 2.68 vs. 5 p = 0.02 and 0.75 vs. 3.64 p < 0.001 respectively). There was a trend toward less opioids taken in gabapentin group for postoperative days 1, 7, and 14 (4.69 vs. 6.36; 2.13 vs. 2.73, and 0.125 vs. 0.9) but it did not reach statistical significance. The average hemorrhoidal grade and number of hemorrhoidal complexes removed was slightly higher in gabapentin group. Five control group patients experienced postoperative complications versus two gabapentin group patients. No gabapentin related complications were seen in the treatment group. The average cost of gabapentin course was $5.34 per patient.

Conclusions: Daily use of gabapentin in perioperative period significantly decreased reported levels of postoperative pain. This effective, inexpensive addition improves pain after hemorrhoid surgery. Randomized placebo-controlled studies would better define the usefulness of this medication for posthemorrhoidectomy pain.
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http://dx.doi.org/10.1007/s00384-014-2018-4DOI Listing
December 2014

A fatal case of diffuse enteritis after colectomy for ulcerative colitis: a case report and review of the literature.

Am J Gastroenterol 2014 Jul;109(7):1086-9

Department of Medicine and Division of Gastroenterology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA.

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http://dx.doi.org/10.1038/ajg.2014.118DOI Listing
July 2014

Changing approaches to rectal prolapse repair in the elderly.

Gastroenterol Rep (Oxf) 2013 Nov 11;1(3):198-202. Epub 2013 Oct 11.

Colon and Rectal Surgery, Beth Israel Deaconess Medical Center, Boston, MA, USA and Department of Surgery, Beth Israel Deaconess Medical Center, Boston, MA USA.

Aim: The abdominal approach to rectal prolapse is associated with lower rates of recurrence but a higher chance of complications and has been traditionally reserved for younger patients. However, longer life expectancy and wider use of laparoscopic techniques necessitates another look at the abdominal approach in older patients.

Methods: This was a retrospective review of data from patients undergoing abdominal repair of rectal prolapse between 2005 and 2011.

Results: Forty-six abdominal repairs (laparoscopic or open suture rectopexy, sigmoidectomy and rectopexy and low anterior resection) were performed during the study period. Twenty-nine repairs (63%) were performed in patients under the age of 70 (average age 51) and 17 (37%) in patients older than 70 (average age 76; range 71-89). Most of the cases performed during the initial 3 years of the study were via laparotomy. However, in the last 4 years, the laparoscopic approach was used in 83% of younger patients and 69% of older patients. Average length of stay was 2.6 days for younger and 3.8 days for older patients. Both groups had similar rates of re-admission: 20% vs 23%. The rate of wound infection was higher in the younger patients (5% vs nil). However, rates of urinary tract infection, two instances (10%) vs four (30%), urinary retention, one instance (5%) vs two (15.4%), ileus, one instance (5%) vs two (15.4%) were higher in the older group.

Conclusion: Wider use of laparoscopy has precipitated a change in the approach to rectal prolapse in older patients. Although associated with a slightly higher rate of post-operative complications, the abdominal approach to rectal prolapse is feasible, safe and effective in patients older than 70 years.
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http://dx.doi.org/10.1093/gastro/got025DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3937996PMC
November 2013

Laparoscopic colectomy decreases the time to administration of chemotherapy compared with open colectomy.

Ann Surg Oncol 2014 Oct 14;21(11):3587-91. Epub 2014 Apr 14.

Colon & Rectal Surgery, Beth Israel Deaconess Medical Center, Boston, MA, USA,

Background: Minimally invasive colon surgery (MIS) has been shown to minimize pain and decrease overall recovery time. No studies have shown a clear oncologic benefit. Some literature suggests that the time to administration of chemotherapy can be important to improve outcomes for advanced colon cancer. The goal of this study is to evaluate the effect of minimally invasive surgery on the timing of chemotherapy administration.

Methods: This was a retrospective review of all patients undergoing surgery for colon cancer at a tertiary institution between 2004 and 2013.

Results: A total of 668 partial colectomies for cancer were performed; 241 were stage III and above and deemed appropriate for chemotherapy. Eighty-five patients did not receive chemotherapy (patient's wishes, age/comorbidities or lost to follow-up). Of the 156 patients who received chemotherapy, 57 underwent MIS and 99 had open colectomy. Average time to chemotherapy after MIS colectomy was 42.9 versus 60.3 days for open surgery (p < 0.001). In the open group, 52 (53 %) people had postoperative complications and readmissions versus 24 (39 %) in the MIS group. Postoperative complications increased the time to chemotherapy for all patients. However, among patients with complications, patients in the MIS group were still able to start chemotherapy earlier (p < 0.05) than open colectomy patients. Multivariate analysis revealed the MIS approach as the only factor lowering time between surgery and chemotherapy.

Conclusions: Laparoscopic colectomy decreases the time interval from surgery to the start of chemotherapy compared with open colectomy. Postoperative complications increase the time to chemotherapy for both open and MIS surgery.
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http://dx.doi.org/10.1245/s10434-014-3703-9DOI Listing
October 2014

Reducing urinary tract infections in colon and rectal surgery.

Dis Colon Rectum 2014 Jan;57(1):91-7

Division of Colon and Rectal Surgery, Beth Israel Deaconess Medical Center, Boston, Massachusetts.

Background: Urinary tract infection is associated with increased morbidity, mortality, and healthcare costs. Colon and rectal surgery has been shown to be an independent risk factor for urinary tract infection. Decreased length of the indwelling urinary catheter may play a role in decreasing the rate of urinary tract infection.

Objective: The aim of this study was to investigate the effect of standardized indwelling urinary catheter management on urinary tract infection.

Design: This was a prospective cohort study.

Settings: This study was conducted in an urban academic tertiary care center.

Patients: All of the patients were undergoing colon or rectal resection from 2010 to 2012 at a single National Surgical Quality Improvement Program participating institution.

Interventions: Intervention 1 (group 1) included implementation of a daily electronic order prompt requiring justification for an indwelling urinary catheter for >24 hours. Intervention 2 (group 2) included intervention 1 plus sterile intraoperative placement of a urinary catheter after the antiseptic preparation and draping of the patient.

Main Outcome Measures: The primary outcome measured was urinary tract infection rate.

Results: A total of 811 patients were identified (control = 215; group 1 = 476; group 2 = 120). Patient demographics and comorbidities were similar among the groups. No differences existed in the proportion of proctectomy among the groups. Urinary tract infection rate decreased significantly with the implementation of each intervention (control, 6.9%; group 1, 2.7%; group 2, 0.8%; p = 0.004). The lone urinary tract infection in group 2 involved ureteral reconstruction and stent placement at the time of surgery.

Limitations: This study was limited by its small sample size and single institution design.

Conclusions: The implementation of 2 low-cost practice interventions was associated with a statistically significant decrease in urinary tract infection in patients undergoing colorectal surgery at an academic tertiary care center.
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http://dx.doi.org/10.1097/DCR.0000000000000019DOI Listing
January 2014

Surgical therapies for fecal incontinence.

Curr Opin Gastroenterol 2014 Jan;30(1):69-74

Beth Israel Deaconess Medical Center, Division of Colorectal Surgery, Boston, Massachusetts, USA.

Purpose Of Review: Fecal incontinence is a significant source of morbidity and decreased quality of life (QOL) for many. Until recent years, few therapies beyond medical management were available for patients. Surgical treatment of fecal incontinence has evolved from colostomy and direct repair of muscle defects to interventional techniques such as nerve stimulation and bulking agents. We review the most recent surgical options for the treatment of fecal incontinence within the context of established therapies.

Recent Findings: Overlapping sphincteroplasty is an established therapy that improves continence and QOL, although results deteriorate over time. Implanted artificial bowel sphincter has a 100% complication rate and 80% are explanted over time. Sacral nerve stimulation has minimal risk and more durable long-term improvement in continence. Less invasive versions of nerve stimulation are being researched. Injectable biomaterials have shown some promise, although durability of results is not clear. Novel therapies, including muscle cell transfer and pelvic slings are currently being investigated.

Summary: Surgical therapies for fecal incontinence continue to evolve and show promise in improving QOL with a lower risk profile. Effective valuation of these therapies is currently limited by heterogeneous studies, short duration of follow up, and inconsistent outcome measures.
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http://dx.doi.org/10.1097/MOG.0000000000000029DOI Listing
January 2014

Timing is everything-colectomy performed on Monday decreases length of stay.

Am J Surg 2013 Sep 28;206(3):340-5. Epub 2013 May 28.

Department of Surgery, Beth Israel Deaconess Medical Center, Boston, MA, USA.

Background: Perioperative care of patients undergoing colon resection requires a multidisciplinary approach by the operating surgeon, residents, and nurses. Operations performed on Monday take full advantage of hospital resources throughout the week to meet expected discharge by Friday. In a current health care environment of diminishing means, improving the timing of surgery in relation to expected length of stay may play an important role in preserving health care resources.

Methods: A retrospective review of a prospectively collected colorectal surgical database identified all patients who underwent segmental colon resection at a single tertiary care referral center from 2004 to 2010. Length of stay for patients undergoing elective open and minimally invasive segmental colectomy was compared for Monday versus Tuesday through the weekend. Patient and surgeon demographics were recorded as well as postoperative outcomes and complications.

Results: A total of 868 segmental colectomies were performed during the study period. Length of stay was significantly decreased by .73 days (P < .01) for all segmental colectomies performed on Monday compared with those performed Tuesday through Sunday. There was also a significant decrease in length of stay looking independently at right (.96 days, P < .01) and left or sigmoid colectomies (.56 days, P < .01). There was no significant difference in patient or surgeon demographics to account for this difference.

Conclusions: Segmental colectomies have a significantly decreased length in stay when performed on Monday compared with the rest of the week. The decrease is independent of surgeon, comorbidities, and complications. This difference may be the result of patients' taking full advantage of hospital resources and ancillary support. Cost-effective measures may be evaluated and directed at adjustment of resources available throughout the week to reduce length of stay.
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http://dx.doi.org/10.1016/j.amjsurg.2012.11.014DOI Listing
September 2013

Ileostomy pathway virtually eliminates readmissions for dehydration in new ostomates.

Dis Colon Rectum 2012 Dec;55(12):1266-72

Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA.

Background: New ileostomates face significant physical and psychological adaptations. Despite advanced resources, such as wound, ostomy, and continence nurses, we observed a high readmission rate for dehydration among patients with new ileostomies.

Objective: Our goal was to create a pathway to reduce readmission and facilitate patient education and well-being.

Design: The 'Ileostomy Pathway' was established by a collaborative group at Beth Israel Deaconess Medical Center. A standardized set of patient education tools was developed to be used throughout the perioperative process. Patient's education started with the preoperative visit. All patients were directly engaged in ostomy management and trained in a stepwise progression. Patients were discharged from the hospital with flow sheets, supplies for recording intake/output, and visiting nurse services. Prospectively collected data from the first 7 months was compared with a retrospective database of the previous 4 years.

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

Patients: Patients with a new permanent or temporary ileostomy were included.

Interventions: A new ileostomy pathway was created.

Main Outcome Measures: The primary outcome measured was readmission rates.

Results: One hundred sixty-one patients were assigned to prepathway implementation and 42 were assigned to postpathway implementation. One hundred three of 203 (50.7%) patients were men, and 58 of 203 (28.6%) patients had permanent ostomies. Overall readmission rate was 35.4% and 21.4% for the prepathway and postpathway groups. The readmission rate for dehydration was 15.5% (25/161) for prepathway patients, but dropped to 0% in the study group. The average length of stay after creation of the new ostomy was 7.5 days and 6.6 days for prepathway and postpathway groups.

Limitations: This study was limited by its small sample size and the lack of randomization.

Conclusions: A simple, educational program for new ileostomy patients that includes preoperative teaching, standardized teaching materials, in-hospital engagement, observed management, and postdischarge tracking of intake and output is very effective in decreasing hospital readmission. The average length of stay remained stable, despite the addition of this teaching program to our perioperative/inpatient care.
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http://dx.doi.org/10.1097/DCR.0b013e31827080c1DOI Listing
December 2012

Radiation proctitis: current strategies in management.

Gastroenterol Res Pract 2011 17;2011:917941. Epub 2011 Nov 17.

Division of Colon and Rectal Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School Boston, 330 Brookline Avenue, Stoneman 9, Boston, MA 02215, USA.

Radiation proctitis is a known complication following radiation therapy for pelvic malignancy. The majority of cases are treated nonsurgically, and an understanding of the available modalities is crucial in the management of these patients. In this paper, we focus on the current treatments of radiation proctitis.
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http://dx.doi.org/10.1155/2011/917941DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3226317PMC
August 2012