Publications by authors named "Fabian Grass"

84 Publications

Emergent and Urgent Surgery for Ulcerative Colitis in the United States in the Minimally Invasive and Biologic Era.

Dis Colon Rectum 2021 Dec 9. Epub 2021 Dec 9.

Division of Colon and Rectal Surgery, Department of Surgery, Mayo Clinic, Rochester, Minnesota Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota.

Background: While the overall adoption of minimally invasive surgery in the non-emergent management of ulcerative colitis is established, little is known about its utilization in emergency settings.

Objective: To assess rates of urgent and emergent surgery over time in the era of emerging biologic therapies and to highlight the current practice in the United States regarding the utilization of minimally invasive surgery for urgent and emergent indications for ulcerative colitis.

Design: This was a retrospective analysis.

Settings: American College of Surgeons National Quality Improvement Program database.

Patients: All adult patients who underwent emergent or urgent colectomy for ulcerative colitis were included.

Outcome Outcome Measures: Rates of emergency operations over time and utilization trends of minimally invasive surgery in urgent and emergent settings were assessed. Unadjusted and adjusted overall, surgical, and medical 30-day complication rates were compared between open and minimally invasive surgery.

Results: A total of 2,219 patients were identified. Of those, 1,515 patients (68.3%) underwent surgery in an urgent setting and 704 (31.7%) as an emergency. Emergent cases decreased over time (21% in 2006 to 8% in 2018; p<0.0001). However, the rate of urgent surgeries has not significantly changed (42% in 2011 to 46% in 2018, p-value 0.44). Minimally invasive surgery was offered to 70% of patients in the urgent group (1,058 / 1,515) and 22.6% of emergent indications (159/704). Overall, minimally invasive surgery was increasingly utilized over the study period in urgent (38% in 2011 to 71% in 2018; p<0.0001) and emergent (0% in 2005 to 42% in 2018; p<0.0001) groups. Compared to minimally invasive surgery, open surgery was associated with a higher risk of overall, surgical, septic complications, and prolonged hospitalization.

Limitations: This study was limited by its retrospective nature of the analysis.

Conclusion: Based on a nationwide analysis from the Unites States, minimally invasive surgery has been increasingly and safely implemented for emergent and urgent indications for ulcerative colitis While the sum of emergent and urgent cases remained the same over the study period, emergency cases decreased significantly over the study period, which may be related to improved medical treatment options and a collaborative, specialized team approach. See Video Abstract at http://links.lww.com/DCR/B847.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1097/DCR.0000000000002109DOI Listing
December 2021

Oral Antibiotics Bowel Preparation Without Mechanical Preparation For Minimally Invasive Colorectal Surgeries: Current Practice And Future Prospects.

Dis Colon Rectum 2021 Nov 24. Epub 2021 Nov 24.

Colon and Rectal Surgery, Mayo Clinic, Rochester, MN, USA Department of Visceral Surgery, Lausanne University Hospital CHUV, Rue du Bugnon 46, 1011 Lausanne, Switzerland.

Background: The efficacy of preoperative oral antibiotics alone compared to mechanical bowel preparation and oral antibiotics in minimally invasive surgery is still a matter of ongoing debate.

Objective: This study aimed to assess the trend of surgical site infection rates in parallel to the utilization of bowel preparation modality over time for minimally invasive surgery colorectal surgeries in the United States.

Design: Retrospective analysis.

Settings: The American College of Surgeons National Surgical Quality Improvement Program database.

Patients: Adult patients who underwent elective colorectal surgery and reported bowel preparation modality.

Main Outcome Measures: The trends and compare surgical site infection rates for mutually exclusive groups according to the underlying disease (colorectal cancer, inflammatory bowel disease, and diverticular disease) who underwent bowel preparation using oral antibiotics or combined mechanical bowel preparation and oral antibiotics. Patients who had rectal surgery were analyzed separately.

Results: A total of 30,939 patients were included. Of them, 12,417 (40%) had rectal resections. Over the seven-year study period, mechanical bowel preparation and oral antibiotics utilization has increased from 29.3% in 2012 to 64.0% in 2018; p<0.0001 at the expense of no preparation and mechanical bowel preparation alone. Similarly, oral antibiotics utilization has increased from 2.3% in 2012 to 5.5% in 2018; p<0.0001. For colon cancer patients, patients who had oral antibiotics alone had higher superficial surgical site infection rates compared to patients who had combined mechanical bowel preparation and oral antibiotics (1.9% vs. 1.1%; p=0.043). Superficial, deep and organ space surgical site infection rates were similar for all other comparative colon surgery groups (cancer, inflammatory bowel disease, and diverticular disease). Patients with rectal cancer who had oral antibiotics had higher rates of deep surgical site infection (0.9% vs. 0.1%; p=0.004). However, superficial, deep and organ space surgical site infection rates were similar for all other comparative rectal surgery groups.

Limitations: Retrospective nature of the analysis.

Conclusion: This study revealed widespread adoption of mechanical bowel preparation and oral antibiotics mechanical bowel preparation and oral antibiotics and increased adoption of oral antibiotics over the study period. Surgical site infection rates appear to be similar from a clinical relevance standpoint among most comparative groups, questioning systematic preoperative addition of mechanical bowel preparation to oral antibiotics alone in all patients for minimally invasive colorectal surgery. See Video Abstract at http://links.lww.com/DCR/B828 .
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1097/DCR.0000000000002096DOI Listing
November 2021

Economic considerations of a connected tracking device after colorectal surgery.

Br J Surg 2021 12;108(12):e407-e408

Department of Visceral Surgery, Lausanne University Hospital (CHUV), University of Lausanne (UNIL), Lausanne, Switzerland.

View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1093/bjs/znab377DOI Listing
December 2021

Challenges Related to Surgical Site Infection Prevention-Results after Standardized Bundle Implementation.

J Clin Med 2021 Sep 29;10(19). Epub 2021 Sep 29.

Department of Visceral Surgery, Lausanne University Hospital CHUV, 1011 Lausanne, Switzerland.

Aim: The aim of this study was to assess the implementation of an intraoperative standardized surgical site infection (SSI) prevention bundle.

Methods: The multimodal, evidence-based care bundle included nine intraoperative items (antibiotic type, timing, and re-dosing; disinfection; induction temperature control > 36.5°; glove change; intra-cavity lavage; wound protection; and closure strategy). The bundle was applied to all consecutive patients undergoing colonic resections. The primary outcome, SSI, was independently assessed by the National Infection Surveillance Committee for up to 30 postoperative days. A historical, institutional pre-implementation control group (2012-2017) with an identical methodology was used for comparison.

Findings: In total, 1516 patients were included, of which 1256 (82.8%) were in the control group and 260 (17.2%) were in the post-implementation group. After 2:1 propensity score matching, the groups were similar for all items ( > 0.05). Overall compliance with the care bundle was 77% (IQR 77-88). The lowest compliance rates were observed for temperature control (53% overall), intra-cavity lavage (64% overall), and wound protection and closure (68% and 63% in the SSI group, respectively). Surgical site infections were reported in 58 patients (22.2%) vs. 21.4% in the control group ( = 0.79). Infection rates were comparable throughout the Centers for Disease Control and Prevention (CDC) categories: superficial, 12 patients (4.5%) vs. 4.2%, = 0.82; deep incisional, 10 patients (3.7%) vs. 5.1%, = 0.34; organ space, 36 (14%) vs. 12.4%, = 0.48. After propensity score matching, rates remained comparable throughout all comparisons (all > 0.05).

Conclusions: The implementation of an intraoperative standardized care bundle had no impact on SSI rates. This may be explained by insufficient compliance with the individual measures.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.3390/jcm10194524DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8509330PMC
September 2021

Development and validation of a prediction score for safe outpatient colorectal resections.

Surgery 2021 Sep 6. Epub 2021 Sep 6.

Division of Colon and Rectal Surgery, Mayo Clinic, Rochester, MN. Electronic address:

Background: Avoiding unnecessary inpatient stay may decrease hospital-acquired complications and costs while increasing patient satisfaction. This study aimed to develop and validate a score to identify patients eligible for safe same-day discharge after colorectal resections.

Methods: This bi-institutional retrospective cohort study included consecutive patients undergoing elective colon and rectal resections (2011-2018) for benign and malignant indications. Two multivariable logistic models were developed based on demographic and surgical risk factors to predict a combined endpoint (ileus, anastomotic leak, intra-abdominal abscess, and readmission). Development and validation datasets were randomly sampled from the entire cohort. Areas under the receiver operating characteristic curves (AUC) were evaluated, and Hosmer-Lemeshow goodness-of-fit tests were used to assess validation model fit.

Results: Of 5,389 patients, 1,182 (21.9%) experienced at least one complication of the combined endpoint. Male gender, open surgery, ASA ≥3, wound class ≥3, ileostomy, surgical duration >3 hours, and perioperative IV fluids >3 L all had significantly greater odds of the combined endpoint in the parsimonious multivariable model (all P < .05). The reduced model considering only the 4 variables with the highest OR (>1.5) contained open surgery, ASA ≥3, wound class ≥3, and surgical duration ≥3 hours as predictors (all P < .05, AUC of 0.65; 95% CI 0.63, 0.68). Both the parsimonious model and the reduced model demonstrated no lack of fit in the validation cohort.

Conclusion: The suggested score composed of preand intraoperative items may help physicians decide on patients' same-day discharge after colorectal resection.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.surg.2021.07.028DOI Listing
September 2021

Sarcopenia and major complications in patients undergoing oncologic colon surgery.

J Cachexia Sarcopenia Muscle 2021 Dec 22;12(6):1757-1763. Epub 2021 Aug 22.

Department of Visceral Surgery, Lausanne University Hospital CHUV, University of Lausanne (UNIL), Lausanne, Switzerland.

Background: Sarcopenia is a surrogate marker for malnutrition and frailty, which has been linked to higher complication rates and prolonged length of stay (LOS) after surgery. The study aim was to assess the correlation between computed tomography (CT)-based sarcopenia and short-term clinical outcomes after oncologic colon surgery.

Methods: This retrospective study included consecutive patients operated between May 2014 and December 2019. Three radiological indices of sarcopenia were measured at the level of the third lumbar vertebra on preoperative CT scans: skeletal muscle area (SMA), skeletal muscle index (SMI) (both markers of muscle quantity), and skeletal muscle radiation attenuation (SMRA) (marker of muscle quality). Patients with major complications (grade ≥ 3b according to the Clavien classification) were compared with those without. Statistical correlation between sarcopenia indices, LOS, and comprehensive complication index (CCI) was tested with the Pearson correlation coefficient.

Results: A total of 325 patients were included. Mean age was 67 years [standard deviation (SD) 14.3], mean body mass index was 26.0 kg/m (SD 5.3), and 193 (59%) were male. Fifty patients (15.4%) had major complications, while 275 (84.6%) did not. Patients with major complications had more open surgery (52 vs. 21%, P < 0.01), intraoperative blood loss (257 vs. 102 mL, P = 0.035), and intraoperative complications (22 vs. 9%, P = 0.012). Patients with major complications had significantly increased CCI scores (53 vs. 6, P < 0.01), reoperations (74 vs. 0%, P < 0.01), and LOS (33 vs. 7, P < 0.01). SMA and SMI were comparable between both groups (126.0 vs. 125.2 cm , P = 0.974, and 43.4 vs. 44.3 cm /m , P = 0.636, respectively), while SMRA was significantly lower in patients with major complications (33.6 vs. 37.3 HU, P = 0.018). A lower SMRA was correlated with prolonged LOS (r = -0.207, P < 0.01) and higher CCI (r = -0.144, P < 0.01), while the other sarcopenia indices had no influence on surgical outcomes.

Conclusions: Muscle quality (SMRA) as a specific sarcopenia marker was lower in patients with major complications and seems to prevail over muscle quantity (SMA and SMI) in the prediction of adverse outcomes after oncologic colon surgery.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1002/jcsm.12771DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8718051PMC
December 2021

Sexual dysfunction following surgery for rectal cancer: a single-institution experience.

Updates Surg 2021 Dec 8;73(6):2155-2159. Epub 2021 Jul 8.

Division of Colon and Rectal Surgery, Department of Surgery, Mayo Clinic, 200 First Street SW, RochesterRochester, MN, 55905, USA.

Although much focus is placed on oncological outcomes for rectal cancer, it is important to assess quality of life after surgery of which sexual function is an important component. This study set about to describe the prevalence of sexual dysfunction by resection type and gender among patients undergoing surgery for rectal cancer, usingretrospective analysis. All English-speaking living patients who underwent surgery for stage I-III rectal cancer with curative intent between 2012 and 2016 were identified from a prospectively maintained database at our institution. Eligible patients were invited to complete either the Female Sexual Function Index (FSFI) or the International Index of Erectile Function (IIEF). Primary outcomes were overall rates of sexual dysfunction, defined as more than one standard deviation below the mean of the normal population for each tool. A total of 147 patients responded, yielding a response rate of 38%. The overall sexual dysfunction rate was 70% at a median time from surgery of 38 months. Sixty-two men (62%) and 41 women (87%) reported overall scores that fell below one standard deviation of the population mean. There was no significant difference in sexual dysfunction for both male and female patients between low anterior resection, coloanal anastomosis, or abdominoperineal resection.. The present study revealed a high rate of sexual dysfunction after rectal cancer surgery, particularly in female patients. This study serves as a reminder to surgeons and their teams to openly discuss the impact of surgery on sexual function and ensure adequate consent and appropriate peri-operative management strategies. The retrospective nature of the analysis is the limitation of this study.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1007/s13304-021-01124-1DOI Listing
December 2021

Priorities, actions and risks in the COVID-19 pandemic: a flash SoMe survey among surgical oncologists.

Pleura Peritoneum 2021 Mar 25;6(1):7-12. Epub 2021 Jan 25.

Department of Visceral Surgery, Lausanne University Hospital CHUV, University of Lausanne (UNIL), Lausanne, Switzerland.

Objectives: Corona virus-induced disease 19 (COVID-19) pandemic has globally affected the surgical treatment of cancer patients and has challenged the ethical principles of surgical oncologists around the world. Not only treatment but also diagnosis and follow-up have been disrupted.

Methods: An online survey was sent through Twitter and by the surgical societies worldwide. The survey consisted of 29 closed-ended questions and was conducted over a period of 24 days beginning in March 26, 2020.

Results: Overall, 394 surgical oncologists from 41 different countries answered the questionnaire. The predominant guiding principle was "saving lives" 240 (62%), and the different aspects of lock-down found hence large support (mean 7.1-9.3 out of 10). Shut-down of elective surgery and modification of cancer care found a mean support of 7.0 ± 3.0 and 5.8 ± 3.1, respectively. Modification of cancer care longer than two weeks was considered unacceptable to 114 (29%) responders. Hundred and fifty six (40%) and 138 (36%) expect "return to normal" beyond six months for surgical practice and cancer care, respectively.

Conclusions: Surgical oncologists show strong and long-lasting support for lock-down measures aiming to save lives. The impact of the pandemic on surgical oncology is perceived controversially, but the majority was forced already now to accept what is inacceptable for many of their colleagues.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1515/pp-2020-0142DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8223800PMC
March 2021

[Surgery for colon cancer in 2021].

Rev Med Suisse 2021 Jun;17(743):1155-1158

Service de chirurgie viscérale, CHUV et Université de Lausanne, 1011 Lausanne.

Over the last decade, surgical management of colon cancer became more individualized due to new preoperative, surgical and oncological strategies. Recent high-level evidence demonstrated a favorable impact of these advanced concepts, which require proper planning and challenging surgical management form a technical standpoint, on cancer-specific survival. To tailor the best strategy, cases have to be discussed in multidisciplinary tumor boards with specialists in medical oncology, radiology, gastroenterology and pathology. In this review, these innovations are summarized within their scientific context, with focus on new strategies of preoperative bowel preparation, neoadjuvant chemotherapy and technical aspects, to illustrate the complexity of current colon cancer management.
View Article and Find Full Text PDF

Download full-text PDF

Source
June 2021

Completely intracorporeal anastomosis in robotic left colonic and rectal surgery: technique and 30-day outcomes.

Updates Surg 2021 Dec 15;73(6):2137-2143. Epub 2021 May 15.

Division of Colon and Rectal Surgery, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA.

As robotic surgery continues to disseminate into the field of colon and rectal surgery, there is a growing interest in the utilization of intracorporeal anastomosis to potentially improve surgical outcomes. The purpoe of this study was to compare feasibility, safety, and short-term outcomes of robotic sigmoid and low anterior resections performed with completely intracorporeal anastomosis (CICA) technique to the traditional extracorporeal assisted anastomosis (ECAA) technique. Consecutive series of patients who underwent elective robotic sigmoid or low anterior resections for benign or malignant disease utilizes either CICA or ECAA between August 2017 and November 2019. Surgical complications were assessed until 30 postoperative days and compared between the two groups. A total of 160 patients were identified; 73 (45.6%) in the CICA group and 87 (54.4%) in the ECAA group. Most of the procedures were performed for malignancy (76%). Estimated blood loss was lower in the CICA group (80.7 mL vs. 110.2 mL; p = 0.048), while operative times were longer (5.9 ± SD hours vs. 4.9 ± SD hours; p =  < 0.001). Overall conversion rate was 1.9%, with no conversions in the CICA group. Overall complications occurred in 54 patients (33.8%) with 13 (8.3%) representing major complications. There were no significant differences in 30 day outcomes between the two groups. This study demonstrates the feasibility and safety of robotic sigmoid and low anterior resections with CICA. Outcomes for robotic sigmoid and low anterior resections are encouraging regardless of anastomotic technique (CICA vs ECAA).
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1007/s13304-021-01061-zDOI Listing
December 2021

Minimally invasive ileal pouch-anal anastomosis for patients with obesity: a propensity score-matched analysis.

Langenbecks Arch Surg 2021 Nov 13;406(7):2419-2424. Epub 2021 May 13.

Division of Colon and Rectal Surgery, Department of Surgery, Mayo Clinic, 200 first St. Southwest, Rochester, MN, 55905, USA.

Background: Obesity is a risk factor for failure of pouch surgery completion. However, little is known about the impact of obesity on short-term outcomes after minimally invasive (MIS) ileal pouch-anal anastomosis (IPAA). This study aimed to assess short-term postoperative outcomes in patients undergoing MIS total proctocolectomy (TPC) with IPAA in patients with and without obesity.

Materials And Methods: All adult patients (≥ 18 years old) who underwent MIS IPAA as reported in the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) Participant User Files 2007 to 2018 were included. Patients were divided according to their body mass index (BMI) into two groups (BMI ≥ 30 kg/m vs. BMI < 30 kg/m). Baseline demographics, preoperative risk factors including comorbidities, American Society of Anesthesiologists Class, smoking, different preoperative laboratory parameters, and operation time were compared between the two groups. Propensity score matching (1:1) based on logistic regression with a caliber distance of 0.2 of the standard deviation of the logit of the propensity score was used to overcome biases due to different distributions of the covariates. Thirty-day postoperative complications including overall surgical and medical complications, surgical site infection (SSI), organ space infection, systemic sepsis, 30-day mortality, and length of stay were compared between both groups.

Results: Initially, a total of 2158 patients (402 (18.6%) obese and 1756 (81.4%) nonobese patients) were identified. After 1:1 matching, 402 patients remained in each group. Patients with obesity had a higher risk of postoperative organ/space infection (12.9%; vs. 6.5%; p-value 0.002) compared to nonobese patients. There was no difference between the groups regarding the risk of postoperative sepsis, septic shock, need for blood transfusion, wound disruption, superficial SSI, deep SSI, respiratory, renal, major adverse cardiovascular events (myocardial infarction, stroke, cardiac arrest requiring cardiopulmonary resuscitation), venous thromboembolism, 30-day mortality, and length of stay.

Conclusion: MIS IPAA can be safely performed in patients with obesity. However, patients with obesity have a 2-fold risk of organ space infection compared to patients without obesity. Loss of weight before MIS IPAA is recommended not only to allow for pouch creation but also to decrease organ space infections.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1007/s00423-021-02197-7DOI Listing
November 2021

The extent of colorectal resection and short-term outcomes in patients with ulcerative colitis.

Updates Surg 2021 Aug 30;73(4):1429-1434. Epub 2021 Mar 30.

Division of Colon and Rectal Surgery, Department of Surgery, Mayo Clinic, Rochester, MN, USA.

Objective: There is limited literature on the impact of the extent of resection on short-term outcomes in patients with ulcerative colitis (UC) in an elective setting. The aim of this study was to better understand the impact of approach and extent of resection on short-term outcomes for patients undergoing total proctocolectomy (TPC) and subtotal colectomy (STC) for UC.

Methods: Patients with UC who underwent elective TPC or STC were captured from the ACS-NSQIP® 2011-2018 database and divided into four cohorts: Open TPC (O-TPC), Laparoscopic TPC (L-STC), Open STC (O-STC), and Laparoscopic STC (L-STC). Baseline and perioperative variables were compared between the four groups alongside 30-day mortality and 30-day complication rates.

Results: Of 3387 patients, 368 (10.9%) underwent O-STC, 406 (12%) underwent O-TPC, 1958 (58%) underwent L-STC, and 655 (19%) underwent L-TPC. Overall rate of prolonged length of stay (LOS) was 27% and 9% needed a blood transfusion. There was no difference in the risk of complications between open TPC and open STC. Those who had open surgery had a higher risk of complications and prolonged LOS. Patients who had L-TPC had prolonged LOS compared to patients who had L-STC, but less compared to those who had O-STC.

Conclusion: Elective surgery for UC is associated with high rates of prolonged LOS and blood transfusion despite MIS approaches. Short-term outcomes and LOS are more impacted by the operative approach than the extent of resection. Despite this laparoscopic TPC has higher rates of prolonged LOS when compared to laparoscopic STC.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1007/s13304-021-01040-4DOI Listing
August 2021

Additional Value of Preoperative Albumin for Surgical Risk Stratification among Colorectal Cancer Patients.

Ann Nutr Metab 2020 15;76(6):422-430. Epub 2021 Mar 15.

Department of Visceral Surgery, Lausanne University Hospital CHUV, University of Lausanne, Lausanne, Switzerland,

Background: BMI ≤18.5 kg/m2 and preoperative weight loss may lead to inaccurate assessment of nutritional status, given the increasing prevalence of obesity. The aim of this study was to assess whether clinical evaluation of malnutrition based on these parameters is sufficient to predict complications after colorectal cancer surgery.

Materials And Methods: The American College of Surgeons-National Quality Improvement Program database was queried from 2005 to 2018. Patients undergoing elective colorectal cancer surgery were divided into 4 groups: (1) albumin <3.1 g/dL within 21 days of surgery, (2) European Society for Clinical Nutrition and Metabolism (ESPEN) 2 clinical parameters for malnutrition (≥10% loss of weight/6 months plus [BMI <20 kg/m2 if age <70 years OR BMI <22 kg/m2 if age ≥70 years]), (3) both aforementioned criteria, and (4) none of aforementioned criteria.

Results: Of 82,280 patients, 5,932 (7.2%) had hypoalbuminemia <3.1 g/dL, 764 (0.9%) fulfilled clinical ESPEN 2 parameters, and 338 (0.4%) met both criteria. After adjusting for baseline confounders, patients in the hypoalbuminemia group had a higher risk of overall complications (odds ratio [OR] 1.92, p < 0.05 vs. OR 1.18 in the ESPEN 2 group, p < 0.05), major complications (OR 1.98, p < 0.05 vs. OR 1.20, p < 0.05), surgical complications (OR 1.77, 95% p < 0.05 vs. OR 1.1, p > 0.05), medical complications (OR 1.73, p < 0.05 vs. OR 1.16, p > 0.05), surgical site infection (OR 1.32, p < 0.05 vs. OR 0.86, p > 0.05), and prolonged hospitalization (OR 1.79, p < 0.05 vs. OR 1.22, p < 0.05). Patients who met both criteria were at highest risk.

Conclusions: Preoperative measurement of serum albumin appears to be essential to identify patients at risk for complications after colorectal cancer surgery. Clinical evaluation through BMI and weight loss alone may underestimate surgery-associated risks in the USA.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1159/000514058DOI Listing
October 2021

Surgical Approach to Transverse Colon Cancer: Analysis of Current Practice and Oncological Outcomes Using the National Cancer Database.

Dis Colon Rectum 2021 03;64(3):284-292

Colon and Rectal Surgery, Mayo Clinic, Rochester, Minnesota.

Background: Surgical treatment for transverse colon cancer involves either extended colectomy or segmental resection, depending on the location of the tumor and surgeon perspective. However, the oncological safety of segmental resection has not yet been established in large cohort studies.

Objective: This study aims to compare segmental resection versus extended colectomy for transverse colon cancer in terms of oncological outcomes.

Design: This was a retrospective cohort study.

Settings: This study was conducted using a nationwide cohort.

Patients: A total of 66,062 patients who underwent colectomy with curative intent for transverse stage I to III adenocarcinoma were identified in the National Cancer Database (2004-2015).

Main Outcome Measures: Patients were divided in 2 groups based on the type of surgery received (extended versus segmental resection). The primary outcome was overall survival. Secondary outcomes were 30- and 90-day mortality, length of hospital stay, and readmission rate within 30 days of surgical discharge.

Results: Extended colectomy was performed in 44,417 (67.2%) patients, whereas 21,645 (32.8%) patients underwent segmental resection. Extended colectomy was associated with lower survival at multivariate analysis (HR, 1.07; 95% CI, 1.04-1.10; p < 0.001). The subgroup analysis showed that extended resection was independently associated with poorer survival in mid transverse colon cancers (HR, 1.08; 95% CI, 1.04-1.12; p < 0.001) and in stage III tumors (HR, 1.11; 95% CI, 1.04-1.18; p < 0.001). The number of at least 12 harvested lymph nodes was an independent predictor of improved survival in both overall and subgroup analyses.

Limitations: This study was limited by its retrospective design.

Conclusion: Extended colectomy was not associated with a survival advantage compared with segmental resection. On the contrary, extended colectomy was associated with slightly poorer survival in mid transverse cancers and locally advanced tumors. Segmental resection was found to be safe when appropriate margins and adequate lymph node harvest were achieved. See Video Abstract at http://links.lww.com/DCR/B454.

Abordaje Quirrgico Del Cncer De Colon Transverso Anlisis De La Prctica Actual Y Los Resultados Oncolgicos Utilizando La Base De Datos Nacional De Cncer: ANTECEDENTES:El tratamiento quirúrgico para el cáncer de colon transverso implica colectomía extendida o resección segmentaria, según la ubicación del tumor y la perspectiva del cirujano. Sin embargo, la seguridad oncológica de la resección segmentaria aún no se ha establecido en estudios de cohortes grandes.OBJETIVO:Este estudio tiene como objetivo comparar la resección segmentaria versus la colectomía extendida para el cáncer de colon transverso en términos de resultados oncológicos.DISEÑO:Este fue un estudio de cohorte retrospectivo.ESCENARIO:Este estudio se realizó utilizando una cohorte a nivel nacional.PACIENTES:Un total de 66,062 pacientes que se sometieron a colectomía con intención curativa por adenocarcinoma de colon transverso en estadio I-III fueron identificados en la Base de Datos Nacional del Cáncer (2004-2015).PRINCIPALES MEDIDAS DE RESULTADO:Los pacientes se dividieron en dos grupos según el tipo de cirugía recibida (resección extendida versus resección segmentaria). El resultado primario fue la supervivencia global. Los resultados secundarios fueron la mortalidad a los 30 y 90 días, la duración de la estancia hospitalaria y la tasa de reingreso dentro de los 30 días posteriores al alta quirúrgica.RESULTADOS:Se realizó colectomía extendida en 44,417 (67.2%) casos, mientras que 21,645 (32.8%) pacientes fueron sometidos a resección segmentaria. La colectomía extendida se asoció con una menor supervivencia en el análisis multivariado (HR 1.07 IC 95% 1.04-1.10; p <0.001). El análisis de subgrupos mostró que la resección extendida se asoció de forma independiente con una menor supervivencia en los cánceres de colon transverso medio (HR 1.08 IC 95% 1.04-1.12; p <0.001) y en tumores en estadio III (HR 1.11 IC 95% 1.04-1.18; p <0.001). Un número de al menos 12 ganglios linfáticos cosechados fue un predictor independiente de una mejor supervivencia en los análisis general y de subgrupos.LIMITACIONES:Este estudio estuvo limitado por su diseño retrospectivo.CONCLUSIÓN:La colectomía extendida no se asoció con una ventaja de supervivencia en comparación con la resección segmentaria. Por el contrario, la colectomía extendida se asoció con una supervivencia levemente menor en cánceres de colon transverso medio y tumores localmente avanzados. Se encontró que la resección segmentaria es segura cuando se logran los márgenes apropiados y la cosecha adecuada de ganglios linfáticos. Consulte Video Resumen en http://links.lww.com/DCR/B454.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1097/DCR.0000000000001887DOI Listing
March 2021

Surgical Resection for Crohn's and Cancer: A Comparison of Disease-Specific Risk Factors and Outcomes.

Dig Surg 2021 27;38(2):120-127. Epub 2021 Jan 27.

Department of Visceral Surgery, Lausanne University Hospital CHUV, University of Lausanne, Lausanne, Switzerland,

Background And Objectives: The goal of this study was to compare disease-specific risk factors and 30-day outcomes between patients with Crohn's disease (CD) and colon cancer (CC) undergoing right-sided surgical resection.

Methods: The American College of Surgeons-National Surgical Quality Improvement Program (ACS-NSQIP®) was interrogated to extract all patients ≥18 years undergoing elective right-sided resection for CD versus CC. Independent risk factors for surgical complications were identified through multivariable logistic regression for both groups. In a second step, surgical and medical 30-day morbidity was compared after risk adjustment.

Results: The cohort consisted of 17,516 patients, of which 2,899 (16.6%) underwent surgery for CD versus 14,617 (83.4%) for CC. Independent risk factors for surgical complications in patients with CD were male gender, African American race, ASA score (III or IV), active smoking, prolonged surgery, and preoperative anemia. Independent risk factors for surgical complications in the cancer group were age ≥70 years, male gender, ASA score (III or IV), respiratory and cardiovascular comorbidities, and preoperative hypoalbuminemia (<3.5 g/dL). After risk adjustment, surgical complications (OR 1.25, p = 0.002), sepsis (OR 1.64, p = 0.012), and unplanned readmissions (OR 1.39, p = 0.004) were more common in patients with CD. Thirty-day mortality was higher in cancer patients (1.1 vs. 0.1%, p < 0.0001).

Conclusions: Patients with Crohn's disease were more prone to surgical complications and postoperative sepsis compared to the cancer group undergoing the same procedure. Careful evaluation and correction of disease-specific modifiable risk factors of patients with CD and CC, respectively, are important.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1159/000511909DOI Listing
October 2021

Cost drivers of locally advanced rectal cancer treatment-An analysis of a leading healthcare insurer.

J Surg Oncol 2021 Mar 26;123(4):1023-1029. Epub 2021 Jan 26.

Division of Colon and Rectal Surgery, Mayo Clinic, Rochester, Minnesota, USA.

Background: To evaluate the economic burden of locally advanced rectal cancer (LARC) treatment from a society perspective through analysis of health insurance-derived data of commercially insured and Medicare Advantage (MA) patients.

Methods: Retrospective cost analysis of patients undergoing rectal resection within a multimodal (neoadjuvant chemoradiation + adjuvant chemotherapy) treatment strategy between January 1, 2010 and October 31, 2018, using the claims OptumLabs Data Warehouse database.

Results: In total, 1738 (935 commercial and 803 MA) patients were included. Overall treatment costs totaled $230,881,746 (on average $183 653 ± 82 384 per commercially insured and $73 681 ± 32 917 per MA patient). Cost distribution according to category (commercially insured patients) was: 29.92% related to outpatient care (follow-up visits/diagnostics), radiotherapy: 21.83%, index resection: 20.62%, chemotherapy: 17.44%, surgical inpatient: 6.32%, medical inpatient: 3.28%, emergency room: 0.58%. Relative cost distribution of the index resection itself differed marginally between the three approaches and was 21.49% for open, 19.30% for laparoscopic, and 20.93% for robotic surgery. Relative cost distributions of neoadjuvant, adjuvant, and outpatient treatments remained unchanged, independently of the surgical approach. This representation was similar in MA patients.

Conclusion: Index-surgery related costs were outweighed by costs related to oncological and outpatient workup/follow-up treatments independently of both surgical approach and insurance type.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1002/jso.26390DOI Listing
March 2021

Trends and consequences of surgical conversion in the United States.

Surg Endosc 2022 Jan 6;36(1):82-90. Epub 2021 Jan 6.

Division of Colon and Rectal Surgery, Department of Surgery, Mayo Clinic, 200 first St. Southwest, Rochester, MN, 55905, USA.

Background: The aim of this study was to identify national utilization trends of robotic surgery for elective colectomy, conversion rates over time, and the specific impact of conversion on postoperative morbidity. Conversion to open represents a hard endpoint for minimally invasive surgery (MIS) and is associated with worse outcomes when compared to MIS or even traditional open procedures.

Methods: All adult patients who underwent either laparoscopic or robotic elective colectomy from 2013 to 2018 as reported in the American College of Surgeons Quality Improvement Program (ACS-NSQIP) database were included. National trends of both robotic utilization and conversion rates were analyzed, overall and according to underlying disease (benign disease, inflammatory bowel disease (IBD), cancer), or the presence of obesity (body mass index (BMI) ≥ 30 kg/m). Demographic and surgical risk factors for surgical conversion to open were identified through multivariable regression analysis. Further assessed were overall and specific postoperative 30-day complications, which were risk adjusted and compared between converted patients and the remaining cohort.

Results: Of 66,652 included procedures, 5353 (8.0%) were converted to open. Conversion rates were 8.5% for laparoscopic and 4.9% for robotic surgery (p < 0.0001). A decline in conversion rates over the 6-year inclusion period was observed overall and for patients with obesity. This trend paralleled an increased utilization of the robotic platform. Several surrogates for advanced disease stages for cancer, diverticulitis, and IBD and prolonged surgical duration were identified as independent risk factors for unplanned conversion, while robotic approach was an independent protective factor (OR 0.44, p < 0.0001). Patients who had unplanned conversion were more likely to experience postoperative complications (OR 2.36; 95% CI [2.21-2.51]), length of hospital stay ≥ 6 days (OR 2.86; 95% CI [2.67-3.05], and 30-day mortality (OR 2.28; 95% CI [1.72-3.02]).

Conclusion: This nationwide study identified a decreasing trend in conversion rates over the 6-year inclusion period, both overall and in patients with obesity, paralleling increased utilization of the robotic platform. Unplanned conversion to open was associated with a higher risk of postoperative complications.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1007/s00464-020-08240-wDOI Listing
January 2022

How skilled are skilled facilities? Post-discharge complications after colorectal cancer surgery in the U.S.

Am J Surg 2021 07 14;222(1):20-26. Epub 2020 Dec 14.

Division of Colon and Rectal Surgery, Department of Surgery, Mayo Clinic, Rochester, MN, USA. Electronic address:

Background: Characteristics and indications for discharging patients to home or a specific facility type have been studied; however, critical evaluation of these facilities through analysis of post-discharge complications and readmission rates is mandatory. The aim of this study was to compare complications occurring after discharge to home, skilled, and unskilled care facilities to identify potential pitfalls.

Methods: All adult (≥18 years) patients who underwent surgery for colon or rectal cancer from 2012 to 2017 as reported in the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database were included. Patients were categorized according to the discharge destination into: home, skilled care (rehabilitation center, separate acute care, skilled facility), and unskilled care (multilevel senior community, facility which is home, unskilled facility). Demographics, surgical risk factors and predischarge complications were compared between the three groups. Primary endpoints were overall, major, surgical, and medical complications occurring post-discharge, within 30 days of surgery. Further assessed were specific complications, readmission, length of stay, and 30-day mortality.

Results: A total of 108,617 patients were identified. Of them, 100,478 (92%) discharged to home, 7313 (7%) to skilled, and 826 (1%) to unskilled care. Of patients discharged to skilled care, 1928 (26%) discharged to rehabilitation centers, 368 (5%) to separate acute care, and 5017 (69%) to skilled facilities. Adjusted overall, major, surgical, and medical post-discharge complications were highest among patients discharged to skilled care destinations. Subgroup analysis revealed separate acute care (inter-hospital transfer) to be associated with the highest morbidity. Main reasons for readmission were primarily related to surgical site infection and intestinal obstruction among the three main destinations, whereas readmissions for systemic sepsis and medical complications were more frequent in patients admitted to skilled care.

Conclusion: This study identified higher rates of post-discharge complications associated with skilled care destinations, despite risk adjustment. This over-morbidity is potentially related to prevailing medical complications and inter-hospital transfers. Further studies are needed to better understand those findings and to improve quality of post-acute care and related outcomes.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.amjsurg.2020.12.012DOI Listing
July 2021

Does IBD Portend Worse Outcomes in Patients with Rectal Cancer? A Case-Matched Analysis.

Dis Colon Rectum 2020 09;63(9):1265-1275

Department of Colorectal Surgery, Cleveland Clinic, Cleveland, Ohio.

Background: Patients with IBD are at increased risk for developing colorectal cancer. However, overall survival and disease-free survival for rectal cancer alone in patients with IBD has not been reported.

Objective: This study aimed to determine overall survival and disease-free survival for patients with rectal cancer in IBD versus non-IBD cohorts.

Design: This is a retrospective cohort study.

Setting: This study was conducted at an IBD referral center.

Patients: All consecutive adult patients with IBD diagnosed with rectal cancer and at least 1 year of postsurgery follow-up were included and matched in a 1:2 fashion (age, sex, preoperative stage) with patients with rectal cancer who did not have IBD.

Main Outcomes Measures: Five-year overall survival and disease-free survival, 30-day postoperative complication, readmission, reoperation, and mortality rates were measured.

Methods: Survival rates were calculated using Kaplan-Meier estimates. The association of risk factors and long-term outcomes was assessed using Cox proportion hazard models.

Results: A total of 107 study patients with IBD who had rectal cancer were matched to 215 control patients; preoperative stages were as follows: 31% with stage I, 19% with stage II, 40% with stage III, and 10% with stage IV. Differences were observed (IBD vs non-IBD) in neoadjuvant chemotherapy (33.6% vs 52.6%, p = 0.001) and preoperative radiotherapy (35.5% vs 53.5%, p = 0.003). Postoperative complication rates were similar. On surgical pathology, patients with IBD had more lymphovascular invasion (12.9% vs 5.6%, p = 0.04) and positive circumferential resection margins (5.4% vs 0.9%, p = 0.03). On multivariable analysis, the diagnosis of IBD did not significantly impact long-term mortality (HR, 0.91; 95% CI, 0.53-1.57; p = 0.73) or disease-free survival (HR, 1.36; 95% CI, 0.84-2.21; p = 0.22).

Limitations: This study was limited by its retrospective design and the use of single-center data.

Conclusions: Patients have rectal cancer with IBD and without IBD have similar long-term and disease-free survival, despite lower rates of neoadjuvant treatment and higher margin positivity in patients with IBD. See Video Abstract at http://links.lww.com/DCR/B271. ¿LA ENFERMEDAD INFLAMATORIA INTESTINAL ACARREA PEORES RESULTADOS EN PACIENTES CON CÁNCER RECTAL? UN ANÁLISIS DE CASOS-COINCIDENTES: Los pacientes con enfermedad inflamatoria intestinal (EII) tienen un mayor riesgo de desarrollar cáncer colorrectal. Sin embargo, no se ha informado la supervivencia general y la supervivencia libre de enfermedad para el cáncer rectal solo en pacientes con EII.Determinar la supervivencia general y la supervivencia libre de enfermedad para pacientes con cáncer rectal en cohortes con EII versus sin EII.Estudio de cohorte retrospectivo.Centro de referencia para enfermedad inflamatoria intestinal.todos los pacientes adultos con EII diagnosticados con cáncer rectal, consecutives, y al menos un año de seguimiento postoperatorio se incluyeron y se emparejaron de manera 1: 2 (edad, sexo, etapa preoperatoria) con pacientes con cáncer rectal sin EII.Se midieron la supervivencia general a cinco años y la supervivencia libre de enfermedad, complicaciones postoperatorias a los 30 días, reingreso, reoperación y tasas de mortalidad.Las tasas de supervivencia se calcularon utilizando estimaciones de Kaplan-Meier. La asociación de factores de riesgo y resultados a largo plazo se evaluó mediante modelos de riesgo de proporción de Cox.Un total de 107 pacientes con EII y cáncer rectal se compararon con 215 pacientes de control; las etapas preoperatorias fueron las siguientes: 31% de Etapa I, 19% de Etapa II, 40% de Etapa III y 10% de Etapa IV. Se observaron diferencias (EII versus no EII) en quimioterapia neoadyuvante (33.6% frente a 52.6%, p = 0.001) y radioterapia preoperatoria (35.5% frente a 53.5%, p = 0.003). Las tasas de complicaciones postoperatorias fueron similares. En la patología quirúrgica, los pacientes con EII tuvieron más invasión linfovascular (12.9% frente a 5.6%, p = 0.04) y márgenes de resección circunferencial positivos (5.4% frente a 0.9%, p = 0.03). En el análisis multivariable, el diagnóstico de EII no tuvo un impacto significativo en la mortalidad a largo plazo (HR 0.91; IC del 95%: 0.53-1.57, p = 0.73) o la supervivencia libre de enfermedad (HR 1.36; IC del 95%: 0.84-2.21, p = 0.22)Diseño retrospectivo, centro único de datos.Los pacientes con EII y sin EII con cáncer rectal tienen una supervivencia similar a largo plazo y libre de enfermedad, a pesar de las tasas más bajas de tratamiento sneoadyuvante y un mayor margen positivo en pacientes con EII. Consulte Video Resumen en http://links.lww.com/DCR/B271.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1097/DCR.0000000000001666DOI Listing
September 2020

Challenges of Modeling Outcomes for Surgical Infections: A Word of Caution.

Surg Infect (Larchmt) 2021 Jun 20;22(5):523-531. Epub 2020 Oct 20.

Division of Colon and Rectal Surgery, Mayo Clinic, Rochester, Minnesota, USA.

We developed a novel analytic tool for colorectal deep organ/space surgical site infections (C-OSI) prediction utilizing both institutional and extra-institutional American College of Surgeons-National Surgical Quality Improvement Program (ACS-NSQIP) data. Elective colorectal resections (2006-2014) were included. The primary end point was C-OSI rate. A Bayesian-Probit regression model with multiple imputation (BPMI) via Dirichlet process handled missing data. The baseline model for comparison was a multivariable logistic regression model (generalized linear model; GLM) with indicator parameters for missing data and stepwise variable selection. Out-of-sample performance was evaluated with receiver operating characteristic (ROC) analysis of 10-fold cross-validated samples. Among 2,376 resections, C-OSI rate was 4.6% (n = 108). The BPMI model identified (n = 57; 56% sensitivity) of these patients, when set at a threshold leading to 80% specificity (approximately a 20% false alarm rate). The BPMI model produced an area under the curve (AUC) = 0.78 via 10-fold cross- validation demonstrating high predictive accuracy. In contrast, the traditional GLM approach produced an AUC = 0.71 and a corresponding sensitivity of 0.47 at 80% specificity, both of which were statstically significant differences. In addition, when the model was built utilizing extra-institutional data via inclusion of all (non-Mayo Clinic) patients in ACS-NSQIP, C-OSI prediction was less accurate with AUC = 0.74 and sensitivity of 0.47 (i.e., a 19% relative performance decrease) when applied to patients at our institution. Although the statistical methodology associated with the BPMI model provides advantages over conventional handling of missing data, the tool should be built with data specific to the individual institution to optimize performance.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1089/sur.2020.208DOI Listing
June 2021

Correlation of postoperative fluid balance and weight and their impact on outcomes.

Langenbecks Arch Surg 2020 Dec 13;405(8):1191-1200. Epub 2020 Oct 13.

Department of Visceral Surgery, Lausanne University Hospital CHUV, Rue du Bugnon 46, CH - 1011, Lausanne, Switzerland.

Introduction: Normovolemia after major surgery is critical to avoid complications. The aim of the present study was to analyze correlation between fluid balance, weight gain, and postoperative outcomes.

Methods: All consecutive patients undergoing elective or emergency major abdominal surgery needing intermediate care unit (IMC) admission from September 2017 to January 2018 were included. Postoperative fluid balances and daily weight changes were calculated for postoperative days (PODs) 0-3. Risk factors for postoperative complications (30-day Clavien) and prolonged length of IMC and hospital stay were identified through uni- and multinominal logistic regression.

Results: One hundred eleven patients were included, of which 55% stayed in IMC beyond POD 1. Overall, 67% experienced any complication, while 30% presented a major complication (Clavien ≥ III). For the entire cohort, median cumulative fluid balance at the end of PODs 0-1-2-3 was 1850 (IQR 1020-2540) mL, 2890 (IQR 1610-4000) mL, 3890 (IQR 2570-5380) mL, and 4000 (IQR 1890-5760) mL respectively, and median weight gain was 2.2 (IQR 0.3-4.3) kg, 3 (1.5-4.7) kg, and 3.9 (2.5-5.4) kg, respectively. Fluid balance and weight course showed no significant correlation (r = 0.214, p = 0.19). Extent of surgery, analyzed through Δ albumin and duration of surgery, significantly correlated with POD 2 fluid balances (p = 0.04, p = 0.006, respectively), as did POD 3 weight gain (p = 0.042). Prolonged IMC stay of ≥ 3 days was related to weight gain ≥ 3 kg at POD 2 (OR 2.8, 95% CI 1.01-8.9, p = 0.049).

Conclusion: Fluid balance and weight course showed only modest correlation. POD 2 weight may represent an easy and pragmatic tool to optimize fluid management and help to prevent fluid-related postoperative complications.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1007/s00423-020-02004-9DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7686193PMC
December 2020

Reply to: Comments on "Survival impact of adjuvant chemotherapy in patients with stage IIA colon cancer: Analysis of the National Cancer Database".

Int J Cancer 2021 02 7;148(4):1028-1029. Epub 2020 Sep 7.

Colon and Rectal Surgery, Mayo Clinic, Rochester, Minnesota, USA.

View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1002/ijc.33256DOI Listing
February 2021

Predicting primary postoperative pulmonary complications in patients undergoing minimally invasive surgery for colorectal cancer.

Updates Surg 2020 Dec 1;72(4):977-983. Epub 2020 Oct 1.

Division of Colon and Rectal Surgery, Department of Surgery, Mayo Clinic, 200 First St. Southwest, Rochester, MN, 55905, USA.

Objective: To determine the risk factors for developing primary postoperative pulmonary complications (PPC) in patients undergoing minimally invasive colorectal surgery (MIS) for the treatment of cancer and to identify the potential indicators for more extensive preoperative evaluation.

Materials And Methods: The ACS-NSQIP database was interrogated to capture patients who had elective colon or rectal cancer and underwent MIS between 2012 and 2017. Patients who had primary PPC including pneumonia, unplanned intubation and/or failure to wean from mechanical ventilation for > 48 h were compared to patients without PPC. Significant risk factors for PPC were retained to build a predictive risk model through logistic regression analysis. The model was then internally validated using 2018 data.

Results: Of 50,150 patients identified, 637 (1.3%) had PPC. The final risk prediction model included six variables: history of chronic obstructive pulmonary disease, age, smoking status, functional health status, pre-operative congestive heart failure, and American Society of Anesthesiology class ≥ 3. The model achieved good calibration (Hosmer-Lemeshow goodness-of-fit test, p = 0.614) and discrimination (c statistics = 0.757). Internal validation achieved similar discrimination (c statistics = 0.798).

Conclusion: Primary postoperative pulmonary complications affected 1.3% of patients undergoing MIS for colon or rectal cancer. The novel predictive risk score showed good discrimination and may help to identify patients who may benefit from perioperative optimization.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1007/s13304-020-00892-6DOI Listing
December 2020

Response to the Comment on "Robotic Surgery for Rectal Cancer Provides Advantageous Outcomes Over Laparoscopic Approach".

Ann Surg 2021 12;274(6):e740

Division of Colon and Rectal Surgery, Mayo Clinic, Rochester, MN 55905.

View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1097/SLA.0000000000004163DOI Listing
December 2021

Anaesthesia in a Toxic Environment: Pressurised Intraperitoneal Aerosol Chemotherapy: A Retrospective Analysis.

Turk J Anaesthesiol Reanim 2020 Aug 26;48(4):273-279. Epub 2019 Dec 26.

Department of Anaesthesiology, Lausanne University Hospital (CHUV), Lausanne, Switzerland.

Objective: Pressurised intraperitoneal aerosol chemotherapy (PIPAC) is a new type of intraperitoneal chemotherapy for peritoneal carcinosis via minimally invasive surgery. This technique's specificity is the remote application of the therapy because of the potential risk of exposure to toxic products. The present paper summarises the important aspects of PIPAC and analyses the anaesthetic outcomes.

Methods: This retrospective study included all patients undergoing PIPAC treatment between January 2015 and February 2018. Data on protocol adherence and perioperative anaesthetic complications and postoperative nausea and vomiting (PONV) and pain levels (visual analogue scale 0-10) from recovery room to 72 h were analysed.

Results: The overall analysis included 193 PIPAC procedures on 87 patients. Protocol adherence was high as regards the use of propofol (100%), rocuronium (98%), antiemetic prophylaxis (99%) and lidocaine intravenous (i.v.) (87%). No accidental exposure to chemotherapy occurred during the study period. Of the 87 patients, 6.3% suffered delayed recovery, 58% due to hypothermia and 42% due to excessive sedation or curarisation. In the recovery room, 16% of patients suffered moderate to severe pain, requiring >8 mg of morphine i.v., with average doses of 13.7 mg. Median postoperative pain scores were 1 and 3 at 12 h and 0 and 0 at 72 h at rest and mobilisation, respectively. PONV was observed in <10% of patients during the first 12 h, but in 40% at 72 h.

Conclusion: A dedicated anaesthetic protocol and intraoperative safety checklist facilitates safe, well-tolerated anaesthesia for PIPAC treatments.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.5152/TJAR.2019.15493DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7434348PMC
August 2020

Short term oncological outcomes of completely intracorporeal anastomosis after left sided robotic resections for colorectal cancer.

Br J Surg 2020 10 26;107(11):e498-e499. Epub 2020 Aug 26.

Division of Colon and Rectal Surgery, Mayo Clinic, Rochester, MN, USA.

View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1002/bjs.11955DOI Listing
October 2020

Colectomy for patients with super obesity: current practice and surgical morbidity in the United States.

Surg Obes Relat Dis 2020 Nov 29;16(11):1764-1769. Epub 2020 Jun 29.

Division of Colon and Rectal Surgery, Department of Surgery, Mayo Clinic, Rochester, Minnesota. Electronic address:

Background: While minimally invasive surgery contributed to improved outcomes in bariatric surgery, less is known about current utilization trends and outcomes related to surgical technique for colorectal resections in super-obese patients (body mass index ≥50 kg/m).

Objective: The aim of this study was to compare surgical modalities and short-term outcomes of patients with super obesity who underwent elective colectomy in the United States.

Setting: A retrospective review was performed of patients with super obesity who underwent elective colectomy between 2012 to 2018 using the American College of Surgeons National Quality Improvement Program data pool.

Methods: Patients were categorized into an open, laparoscopic, or robotic group. Baseline characteristics and perioperative outcomes including 30-day complications and length of stay were compared between the 3 groups. Furthermore, utilization trends of surgical modalities were assessed.

Results: Of 1199 patients, 338 (28.2%) had open, 735 (61.3%) laparoscopic, and 126 (10.5%) robotic colectomy during the study period, primarily for colon cancer (50.8%). Patients in the open group tended to have more baseline co-morbidities. Laparoscopic approach showed better risk-adjusted outcomes compared with open for postoperative ileus (adjusted odds ratio [aOR]: .6, 95% confidence interval [CI; .383-.965]), overall medical complications (aOR: .4, 95%CI [.3-.8]), and length of stay (OR .6, 95% CI [.394-.968]). Trend utilization showed increasing utilization of the robotic platform over the study period, which was associated with less unplanned conversion to open (aOR .417, 95%CI [.199-.872]).

Conclusion: Laparoscopic colectomy provides advantageous outcomes over open surgery for colectomy in super-obese patients. The robotic platform has been increasingly used over time, and potential benefits need to be further studied.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.soard.2020.06.033DOI Listing
November 2020

Trends of complications and innovative techniques' utilization for colectomies in the United States.

Updates Surg 2021 Feb 9;73(1):101-110. Epub 2020 Aug 9.

Division of Colon and Rectal Surgery, Department of Surgery, Mayo Clinic, 200 first St. Southwest, Rochester, MN, 55905, USA.

Despite an increasing trend towards utilization of minimally invasive approaches (MIS), results regarding their safety profile are contradictory. All patients who underwent elective colectomy for any underlying disease with an identifiable operative approach available from the targeted colectomy files of the ACS-NSQIP PUFs 2013 to 2018 were included. The trend of utilization and complication rates of the different operative approaches (open, laparoscopic, robotic) were assessed during the inclusion period. Furthermore, overall, surgical, and medical complications were compared between the three approaches. The study cohort included 78,987 patients. Of them, 12,335 (15.6%) patients underwent open, 57,874 (73.3%) laparoscopic, and 8,778 (11.1%) robotic surgery. There was an increasing trend towards the utilization of robotic surgery (2.5% increase per year) at the expense of the other approaches. With the increasing trend toward the utilization of the robotic approach, a decreasing trend in overall and surgical complications and length of stay was observed. After adjusting for the baseline confounders, robotic surgery was associated with shorter length of stay, lower rate of overall (OR 0.397; p < 0.05 compared to open and OR: 0.763; p < 0.05 compared to laparoscopy) and surgical complications (OR: 0.464; p < 0.05 compared to open and OR: 0.734; p < 0.05 compared to laparoscopy). This study revealed an increasing trend toward the utilization of MIS for elective colectomy in the US. Robotic surgery was associated with a decreasing trend in overall and surgical morbidity and length of stay.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1007/s13304-020-00862-yDOI Listing
February 2021

Readmissions Within 48 Hours of Discharge: Reasons, Risk Factors, and Potential Improvements.

Dis Colon Rectum 2020 08;63(8):1142-1150

Division of Colon and Rectal Surgery, Mayo Clinic, Rochester, Minnesota.

Background: Hospital readmission rate is an important quality metric and has been recognized as a key measure of hospital value-based purchasing programs.

Objective: This study aimed to assess the risk factors for hospital readmission with a focus on potentially preventable early readmissions within 48 hours of discharge.

Design: This is a retrospective cohort study.

Settings: This study was conducted at a tertiary academic facility with a standardized enhanced recovery pathway.

Patients: Consecutive patients undergoing elective major colorectal resections between 2011 and 2016 were included.

Main Outcome Measures: Univariable and multivariable risk factors for overall and early (<48 hours) readmissions were identified. Specific surgical and medical reasons for readmission were compared between early and late readmissions.

Results: In total, 526 of 4204 patients (12.5%) were readmitted within 30 days of discharge. Independent risk factors were ASA score (≥3; OR, 1.5; 95% CI, 1.1-2), excess perioperative weight gain (OR, 1.7; 95% CI, 1.3-2.3), ileostomy (OR, 1.4; 95% CI, 1-2), and transfusion (OR, 2; 95% CI, 1.4-3), or reoperation (OR, 11.4; 95% CI, 7.4-17.5) during the index stay. No potentially preventable risk factor for early readmission (128 patients, 24.3% of all readmissions, 3% of total cohort) was identified, and index hospital stay of ≤3 days was not associated with increased readmission (OR, 0.9; 95% CI, 0.7-1.2). Although ileus and small-bowel obstruction (early: 43.8% vs late: 15.5%, p < 0.001) were leading causes for early readmissions, deep infections (3.9% vs 16.3%, p < 0.001) and acute kidney injury (0% vs 5%, p = 0.006) were mainly observed during readmissions after 48 hours.

Limitations: Risk of underreporting due to loss of follow-up and the potential co-occurrence of complications were limitations of this study.

Conclusions: Early hospital readmission was mainly due to ileus or bowel obstruction, whereas late readmissions were related to deep infections and acute kidney injury. A suspicious attitude toward potential ileus-related symptoms before discharge and dedicated education for ostomy patients are important. A short index hospital stay was not associated with increased readmission rates. See Video Abstract at http://links.lww.com/DCR/B237. REINGRESOS DENTRO DE LAS 48 HORAS POSTERIORES AL ALTA: RAZONES, FACTORES DE RIESGO Y POSIBLES MEJORAS: La tasa de reingreso hospitalario es una métrica de calidad importante y ha sido reconocida como una medida clave de los programas hospitalarios de compras basadas en el valor.Evaluar los factores de riesgo para el reingreso hospitalario con énfasis en reingresos tempranos potencialmente prevenibles dentro de las 48 horas posteriores al alta.Estudio de cohorte retrospectivo.Institución académica terciaria con programa de recuperación mejorada estandarizado.Pacientes consecutivos sometidos a resecciones colorrectales mayores electivas entre 2011 y 2016.Se identificaron factores de riesgo uni y multivariables para reingresos totales y tempranos (<48 horas). Se compararon razones médicas y quirúrgicas específicas para el reingreso entre reingresos tempranos y tardíos.En total, 526/4204 pacientes (12,5%) fueron readmitidos dentro de los 30 días posteriores al alta. Los factores de riesgo independientes fueron puntuación ASA (≥3, OR 1.5; IC 95% 1.1-2), aumento de peso perioperatorio excesivo (OR 1.7; IC 95% 1.3-2.3), ileostomía (OR 1.4, IC 95%: 1-2) y transfusión (OR 2, IC 95% 1.4-3) o reoperación (OR 11.4; IC 95% 7.4-17.5) durante la estadía índice. No se identificó ningún factor de riesgo potencialmente prevenible para el reingreso temprano (128 pacientes, 24.3% de todos los reingresos, 3% de la cohorte total), y la estadía hospitalaria índice de ≤ 3 días no se asoció con un aumento en el reingreso (OR 0.9; IC 95% 0.7-1.2) Mientras que el íleo / obstrucción del intestino delgado (temprano: 43.8% vs. tardío: 15.5%, p < 0.001) fueron las principales causas de reingresos tempranos, infecciones profundas (3.9% vs 16.3%, p < 0.001) y lesión renal aguda (0 vs 5%, p = 0.006) se observaron principalmente durante los reingresos después de 48 horas.Riesgo de subregistro debido a la pérdida en el seguimiento, posible co-ocurrencia de complicaciones.El reingreso hospitalario temprano se debió principalmente a íleo u obstrucción intestinal, mientras que los reingresos tardíos se relacionaron con infecciones profundas y lesión renal aguda. Es importante tener una actitud suspicaz hacia los posibles síntomas relacionados con el íleo antes del alta y una educación específica para los pacientes con ostomía. La estadía hospitalaria índice corta no se asoció con mayores tasas de reingreso. Consulte Video Resumen en http://links.lww.com/DCR/B237.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1097/DCR.0000000000001652DOI Listing
August 2020

Survival impact of adjuvant chemotherapy in patients with stage IIA colon cancer: Analysis of the National Cancer Database.

Int J Cancer 2021 01 8;148(1):161-169. Epub 2020 Aug 8.

Colon and Rectal Surgery, Mayo Clinic, Rochester, Minnesota, USA.

Utility of adjuvant chemotherapy for stage II cancer remains a matter of debate. Clinical guidelines suggest adjuvant chemotherapy for stage II tumors with high-risk features, in particular T4 tumors. However, limited consensus exists regarding the importance of other high-risk features (lymphovascular or perineural invasion, microsatellite instability). Our study aimed to investigate the impact of adjuvant chemotherapy for stage IIA (T3N0) colon cancer patients. Patients who underwent colectomy for stage IIA colon adenocarcinoma (2010-2015) were identified in the National Cancer Database (NCDB) and divided in two groups based on receipt of adjuvant chemotherapy vs observation. Inverse probability of treatment weighting (IPTW)-adjusted Kaplan-Meier and Cox proportional hazards regression analyses were performed to compare overall survival between the two groups. Subgroup analysis of patients with specific high-risk features LVI, PNI and MSI was performed. Among 46 688 surgical patients with stage IIA colon adenocarcinoma 5937 (12.7%) received adjuvant chemotherapy, while 40 751 (87.3%) were observed. Five-year IPTW-adjusted survival was higher in the adjuvant chemotherapy group (79.7% [95% CI 79.1, 80.2]) compared to the observation group (70.3% [95% CI 69.7, 70.9]). Patients with high-risk pathological features showed an estimated 5-year survival benefit of 11.3% (78.2% [95% CI 77.4, 79.1] vs 66.9% [95% CI 65.9, 67.8]) when treated with adjuvant chemotherapy. This NCDB analysis revealed a survival benefit for patients with stage IIA colon adenocarcinoma and high-risk features that were treated with adjuvant chemotherapy.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1002/ijc.33203DOI Listing
January 2021
-->