Publications by authors named "Lieba R Savitt"

8 Publications

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Preliminary Report from the Pelvic Floor Disorders Consortium: Large Scale Data Collection through Quality Improvement Initiatives to Provide Data on Functional Outcomes Following Rectal Prolapse Repair.

Dis Colon Rectum 2021 Apr 26. Epub 2021 Apr 26.

Pelvic Floor Disorders Center, Section of Colon and Rectal Surgery, Massachusetts General Hospital, Boston, MA Department of Colorectal Surgery, Digestive Disease Institute, Cleveland Clinic, Cleveland, OH Department of Surgery, The University of Chicago Medicine, Chicago, IL Department of Surgery, Mount Sinai School of Medicine, New York, NY Pelvic Floor Disorders Center, Section of Colon and Rectal Surgery, Massachusetts General Hospital, Boston, MA Division of Colorectal Surgery, University of Massachusetts-Baystate, Springfield, MA Department of General Surgery, Division of Colorectal Surgery, Stanford University Medical Center, Stanford, CA Pelvic Floor Disorders Center, Section of Colon and Rectal Surgery, Massachusetts General Hospital, Boston, MA.

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

Objective: To report on preliminary data captured during a large-scale quality improvement initiative to measure and improve function in patients undergoing rectal prolapse repair.

Design: Retrospective analysis of prospectively collected surgical quality improvement data. Settings: This study was conducted at 14 tertiary centers specializing in pelvic floor disorders from 2017 to 2019.

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

Main Outcome Measures: Preoperative and three-month postoperative Wexner Incontinence Score and Altomare Obstructed Defecation Score.

Results: The cohort included 112 patients undergoing abdominal surgery 71 suture rectopexy /56% MIS, 41 ventral rectopexy/93% MIS). Those offered perineal approaches (N=68) were older (median age 75 vs 62, p<0.01) and had more comorbidities (ASA3-4: 51% vs. 24%, p<0.01), but also reported higher pre-intervention rates of fecal incontinence (Wexner 11.4 ± 6.4 vs. 8.6+/-5.8, p<0.01). Patients undergoing perineal procedures had similar incremental improvements in function after surgery as patients undergoing abdominal repair (change in Wexner -2.6 ± 6.4 vs. -3.1 ± 5.6, p= 0.6; change in Altomare -2.9 ± 4.6 vs. -2.7 ± 4.9, p=0.8). Similarly, posterior suture rectopexy and ventral mesh rectopexy patients had similar incremental improvements in overall scores; however, ventral mesh rectopexy patients had a higher decrease in the need to use pads after surgery.

Limitations: Retrospective data analysis and three-month follow up.

Conclusions: Functional outcomes improved in all patients undergoing prolapse surgery. Larger cohorts are necessary to show superiority amongst surgical procedures. Quality improvement methods may allow for systematic, yet practical acquisition of information and data analysis. We call for the creation of a robust database to benefit this patient population. See Video Abstract at http://links.lww.com/DCR/B581 .
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http://dx.doi.org/10.1097/DCR.0000000000001962DOI Listing
April 2021

Bowel Function After J-Pouch May Be More Complex Than Previously Appreciated: A Comprehensive Analysis to Highlight Existing Knowledge Gaps.

Dis Colon Rectum 2020 02;63(2):207-216

Section of Colon and Rectal Surgery, Massachusetts General Hospital, Boston, Massachusetts.

Background: Functional outcomes following J-pouch for ulcerative colitis have been studied, but lack standardization in which symptoms are reported. Furthermore, the selection of symptoms studied has not been patient centered.

Objective: This study aimed to utilize a validated bowel function survey to determine which symptoms are present after J-pouch creation, and whether patients display a functional profile similar to low anterior resection syndrome.

Design: This study is a retrospective analysis of a prospectively maintained single-center database.

Settings: This study was conducted at the colorectal surgery center of a tertiary care academic hospital PATIENTS:: Included were 159 patients with J-pouch, ≥6 months after ileostomy reversal.

Main Outcome Measures: The primary outcomes were individual answers to the Memorial Sloan Kettering Cancer Center Bowel Function Instrument. The original Bowel Function Instrument validation cohort was used as an historical comparison (n = 127).

Results: The mean total Bowel Function Instrument score for the J-pouch cohort was 59.9 ± 9.7 compared with a reported average score of 63.7 ± 11.6 for patients with low anterior resection in the validation cohort (p < 0.001), indicating worse bowel function in patients with J-pouch. When evaluating the Bowel Function Instrument subscales, patients with J-pouch reported frequency subscale scores of 18.2 ± 3.8, diet scores of 12.2 ± 3.8, and urgency scores of 15.9 ± 3.7, compared with 21.7 ± 4.5 (p < 0.001), 14.1 ± 3.7 (p < 0.001), and 15.0 ± 3.9 (p = 0.04) for patients undergoing rectal resection. Furthermore, 90.4% of patients with J-pouch state that they are sometimes, rarely, or never able to wait 15 minutes to get to the toilet. In addition, 56.4% of patients report having another bowel movement within 15 minutes of the last bowel movement, sometimes, always, or most of the time, and 50.6% of patients say that they sometimes, rarely, or never feel like their bowels have been totally emptied after a bowel movement.

Limitations: This study is limited because it took place at a single center and the Bowel Function Instrument was only validated for patients undergoing rectal resection.

Conclusions: Patients that undergo J-pouch surgery exhibit a constellation of bowel function symptoms that is more complex than fecal incontinence and frequency alone, despite the focus on these functional outcomes in the literature. See Video Abstract at http://links.lww.com/DCR/B73. LA FUNCIÓN INTESTINAL DESPUÉS DE LA BOLSA EN J PUEDE SER MÁS COMPLEJA DE LO QUE SE APRECIABA ANTERIORMENTE: UN ANÁLISIS EXHAUSTIVO PARA RESALTAR LAS BRECHAS DE CONOCIMIENTO EXISTENTES: Se han estudiado los resultados funcionales después de la bolsa en J para la colitis ulcerosa, pero carecen de estandarización en la que se informen los síntomas. Además, la selección de los síntomas estudiados no se ha centrado en el paciente.Utilizar una encuesta validada de la función intestinal para determinar qué síntomas están presentes después de la bolsa en J y si los pacientes muestran un perfil funcional similar al síndrome de resección anterior baja.Análisis retrospectivo de una base de datos de un solo centro mantenida prospectivamente.Centro de cirugía colorrectal de un hospital académico de atención terciaria.159 pacientes con bolsa en J, ≥6 meses después de la reversión de ileostomía.Instrumento para la función intestinal del "Memorial Sloan Kettering Cancer Center"; cohorte de validación original de instrumentos de función intestinal utilizada como comparación histórica (n = 127).La puntuación media total del instrumento de función intestinal para la cohorte de bolsa J fue 59.9 ± 9.7 en comparación con un puntaje promedio reportado de 63.7 ± 11.6 para pacientes con resección anterior baja en la cohorte de validación (p < 0.001), lo que indica peor función intestinal en pacientes con bolsa en J. Al evaluar las subescalas del instrumento de función intestinal, los pacientes con bolsa en J informaron puntuaciones de subescala de frecuencia de 18.2 ± 3.8, puntuaciones de dieta de 12.2 ± 3.8 y puntuaciones de urgencia de 15.9 ± 3.7, en comparación con 21.7 ± 4.5 (p < 0.001), 14.1 ± 3.7 (p < 0.001) y 15.0 ± 3.9 (p = 0.04) respectivamente para pacientes con resección rectal. Además, el 90.4% de los pacientes con bolsa en J afirman que a veces, rara vez o nunca pueden esperar 15 minutos para llegar al baño. Además, el 56.4% de los pacientes reportan haber tenido otra evacuación intestinal dentro de los 15 minutos posteriores a la última evacuación intestinal, a veces, siempre o la mayor parte del tiempo, y el 50.6% de los pacientes dicen que a veces, rara vez o nunca sienten que sus intestinos han sido vaciados totalmente después de una evacuación intestinal.Estudio en un solo centro, instrumento de función intestinal validado solo para pacientes con resección rectalLos pacientes que se someten a una bolsa en J exhiben una constelación de síntomas de la función intestinal que es más compleja que la incontinencia fecal y la frecuencia sola, a pesar del enfoque en estos resultados funcionales en la literatura.Consulte Video Resumen en http://links.lww.com/DCR/B73. (Traducción-Dr. Gonzalo Federico Hagerman).
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http://dx.doi.org/10.1097/DCR.0000000000001543DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7071733PMC
February 2020

Comparable perioperative outcomes, long-term outcomes, and quality of life in a retrospective analysis of ulcerative colitis patients following 2-stage versus 3-stage proctocolectomy with ileal pouch-anal anastomosis.

Int J Colorectal Dis 2019 Mar 4;34(3):491-499. Epub 2019 Jan 4.

Division of General and Gastrointestinal Surgery, Department of Surgery, Massachusetts General Hospital, 55 Fruit St, GRB-425, Boston, MA, 02114, USA.

Purpose: Many surgeons assume 3-stage ileal pouch-anal anastomosis (IPAA) is safer than 2-stage IPAA in patients with active ulcerative colitis (UC), although recent data suggest outcomes are comparable. This study aimed to compare perioperative complications, late complications, and functional outcomes after 2- versus 3-stage IPAA in patients with active UC.

Methods: A retrospective review was conducted of patients who underwent 2- or 3-stage IPAA for active UC from 2000 to 2015 in a high-volume institution. Patients completed quality-of-life surveys 6 months following ileostomy reversal. Perioperative and late complications were recorded. Outcomes were compared with the Fisher exact test, and multivariable logistic regression was used to adjust for potential confounders.

Results: We identified 212 patients who underwent 2- or 3-stage IPAA for active UC, of whom 157 patients (74.1%) underwent 2-stage procedures and 55 (25.9%) underwent 3-stage procedures. More patients undergoing 2-stage procedures were taking immunomodulators preoperatively (46.3% vs. 23.1%, p = 0.01), but there was no difference in use of steroids (p = 0.09) or biologic agents (p = 0.85). Three-stage procedures were more likely to be urgent (78.6% vs. 30.2%, p < 0.001). There were no differences in perioperative complications (p = 0.50), anastomotic leak (p = 0.94), pouchitis (p = 0.45), pouch failure (p = 0.46), perceived quality of life (p = 0.68), number of bowel movements per day (p = 0.27), or sexual satisfaction (p = 0.21) between the 2- and 3-stage groups.

Conclusions: Patients undergoing 2-stage compared to 3-stage IPAA for active ulcerative colitis have comparable outcomes and quality of life following ileostomy reversal. Two-stage IPAA appears to be safe and appropriate, even in high-risk patients.
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http://dx.doi.org/10.1007/s00384-018-03221-xDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6450759PMC
March 2019

The Contributions of Internal Intussusception, Irritable Bowel Syndrome, and Pelvic Floor Dyssynergia to Obstructed Defecation Syndrome.

Dis Colon Rectum 2019 01;62(1):56-62

Colorectal Surgery Center, Department of General and Gastrointestinal Surgery, Massachusetts General Hospital, Boston, Massachusetts.

Background: Recently, there has been a trend toward surgical management of internal intussusception despite an unclear correlation with constipation symptoms.

Objective: This study characterizes constipation in patients with obstructed defecation syndrome and identifies whether internal intussusception or other diagnoses such as irritable bowel syndrome may be contributing to symptoms.

Design: Patients evaluated for obstructed defecation at a pelvic floor disorder center were studied from a prospectively maintained database. With the use of defecography, patients were classified by Oxford Rectal Prolapse Grade. Coexisting disorders such as enterocele, rectocele, and dyssynergia were also identified. The presence of irritable bowel syndrome was defined using Rome IV criteria, and constipation severity was quantified with the Varma constipation severity instrument.

Settings: This study was conducted at a tertiary care university medical center (Massachusetts General Hospital).

Patients: The study included 317 consecutive patients with defecography imaging and a completed constipation severity instrument survey from May 2007 to July 2016.

Main Outcome Measures: The primary outcome measures were the Varma Constipation Severity Instrument overall score and obstructed defecation subscale score.

Results: Of 317 patients evaluated, 95 (30.0%) had no internal intussusception, 126 (39.7%) had intra-rectal intussusception, and 96 (30.3%) had intra-anal intussusception. There was no association between rising grade of internal intussusception and either overall constipation score or obstructed defecation subscale score. Irritable bowel syndrome was associated with an increase in overall constipation score and obstructed defecation subscale score (40.5 ± 13.6 vs 36.0 ± 15.1, p = 0.007, and 22.3 ± 5.8 vs 20.0 ± 6.6, p < 0.001). Multivariate regression found irritable bowel syndrome and dyssynergia to be associated with a significant increase in obstructed defecation subscale scores.

Limitations: The study was limited because it was an observational study from a single center.

Conclusions: Patients referred for surgical management of obstructive defecation syndrome should be screened and treated for irritable bowel syndrome and dyssynergia before considering surgical intervention. See Video Abstract at http://links.lww.com/DCR/A782.
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http://dx.doi.org/10.1097/DCR.0000000000001250DOI Listing
January 2019

A Quality-of-Life Comparison of Two Fecal Incontinence Phenotypes: Isolated Fecal Incontinence Versus Concurrent Fecal Incontinence With Constipation.

Dis Colon Rectum 2019 01;62(1):63-70

Department of Surgery, Massachusetts General Hospital, Boston, Massachusetts.

Background: Many patients with fecal incontinence report coexisting constipation. This subset of patients has not been well characterized or understood.

Objective: The purpose of this study was to report the frequency of fecal incontinence with concurrent constipation and to compare quality-of-life outcomes of patients with fecal incontinence with and without constipation.

Design: This was a prospective cohort study. Survey data, including Fecal Incontinence Severity Index, Constipation Severity Instrument, Fecal Incontinence Quality of Life survey (categorized as lifestyle, coping, depression, and embarrassment), Pelvic Organ Prolapse Inventory and Urinary Distress Inventory surveys, and anorectal physiology testing were obtained.

Settings: The study was conducted as a single-institution study from January 2007 to January 2017.

Patients: Study patients had fecal incontinence presented to a tertiary pelvic floor center.

Main Outcome Measures: Quality-of-life survey findings were measured.

Results: A total of 946 patients with fecal incontinence were identified, and 656 (69.3%) had coexisting constipation. Patients with fecal incontinence with constipation were less likely to report a history of pregnancy (89.2% vs 91.4%; p = 0.001) or complicated delivery, such as requiring instrumentation (9.1% vs 18.1%; p = 0.005), when compared with patients with isolated fecal incontinence. Patients with fecal incontinence with constipation had higher rates of coexisting pelvic organ prolapse (Pelvic Organ Prolapse Inventory: 18.4 vs 8.2; p < 0.01), higher rates of urinary incontinence (Urinary Distress Inventory: 30.2 vs 23.4; p = 0.01), and higher pressure findings on manometry; intussusception on defecography was common. Patients with fecal incontinence with concurrent constipation had less severe incontinence scores at presentation (21.0 vs 23.8; p < 0.001) and yet lower overall health satisfaction (28.9% vs 42.5%; p < 0.001). Quality-of-life scores declined as constipation severity increased for lifestyle, coping, depression, and embarrassment.

Limitations: This was a single-institution study, and surgeon preference could bias population and anorectal physiology testing.

Conclusions: Patients with fecal incontinence with concurrent constipation represent a different disease phenotype and have different clinical and anorectal physiology test findings and worse overall quality of life. Treatment of these patients requires careful consideration of prolapse pathology with coordinated treatment of coexisting disorders. See Video Abstract at http://links.lww.com/DCR/A783.
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http://dx.doi.org/10.1097/DCR.0000000000001242DOI Listing
January 2019

What Is the Risk of Anal Carcinoma in Patients With Anal Intraepithelial Neoplasia III?

Dis Colon Rectum 2018 12;61(12):1350-1356

Section of Colon and Rectal Surgery, Division of General and Gastrointestinal Surgery, Department of Surgery, Massachusetts General Hospital, Boston, Massachusetts.

Background: The risk of anal carcinoma after previous diagnosis of anal intraepithelial neoplasia III is unclear.

Objective: The purpose of this study was to estimate the risk of anal carcinoma in patients with anal intraepithelial neoplasia III and to identify predictors for subsequent malignancy.

Design: This was a retrospective review using the Surveillance, Epidemiology, and End Results registry (1973-2014).

Setting: The study was composed of population-based cancer registries from the United States.

Patients: Patients who were diagnosed with anal intraepithelial neoplasia III were included.

Main Outcome Measures: The primary outcome was rate of subsequent anal squamous cell carcinoma. Predictors for anal cancer were identified using logistic regression and Cox proportional hazard models.

Results: A total of 2074 patients with anal intraepithelial neoplasia III were identified and followed for a median time of 4.0 years (interquartile range, 1.8-6.7 y). Of the cohort, 171 patients (8.2%) subsequently developed anal cancer. Median time from anal intraepithelial neoplasia III diagnosis to anal cancer diagnosis was 2.7 years (interquartile range, 1.1-4.5 y). Fifty-two patients (30.4%) who developed anal carcinoma were staged T2 or higher. Ablative therapies for initial anal intraepithelial neoplasia III were associated with a reduction in the risk of anal cancer (OR = 0.3 (95% CI, 0.1-0.7); p = 0.004). Time-to-event analysis revealed that the 5-year incidence of anal carcinoma after anal intraepithelial neoplasia III was 9.5% or ≈1.9% per year.

Limitations: The registry did not record HIV status, surveillance schedule, use of high-resolution anoscopy, or provider specialty.

Conclusions: In the largest published cohort of patients with anal intraepithelial neoplasia III, ≈10% of patients were projected to develop anal cancer within 5 years. Nearly one third of anal cancers were diagnosed at stage T2 or higher despite a previous diagnosis of anal intraepithelial neoplasia III. Ablative procedures were associated with a decreased risk of cancer. This study highlights the considerable rate of malignancy in patients with anal intraepithelial neoplasia III and the need for effective therapies and surveillance. See Video Abstract at http://links.lww.com/DCR/A764.
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http://dx.doi.org/10.1097/DCR.0000000000001219DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6219933PMC
December 2018

Impact of Rising Grades of Internal Rectal Intussusception on Fecal Continence and Symptoms of Constipation.

Dis Colon Rectum 2016 Jan;59(1):54-61

1 Colorectal Surgery Program, Department of Surgery, Center for Pelvic Floor Disorders, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts 2 Division of Female Pelvic Medicine and Reconstructive Surgery, Department of Obstetrics and Gynecology Service, Pelvic Floor Disorders Center, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts.

Background: A theory of rectal intussusception has been advanced that intrarectal intussusception, intra-anal intussusception, and external rectal prolapse are points on a continuum and are a cause of fecal incontinence and constipation.

Objective: This study evaluates the association among rectal intussusception, constipation, fecal incontinence, and anorectal manometry.

Design: Patients undergoing defecography were studied from a prospectively maintained database and classified according to the Oxford Rectal Prolapse Grade as normal or having intra-rectal, intra-anal, or external intussusception. Patient symptoms were assessed using the Constipation Severity Index and the Fecal Incontinence Severity Index. Quality-of-life surveys were also used. Patients also underwent anorectal manometry.

Settings: The study was conducted at a tertiary care university medical center (Massachusetts General Hospital).

Patients: The study included 147 consecutive patients undergoing evaluation for evacuatory dysfunction and involved defecography, symptoms questionnaires, and anorectal physiology testing from January 2011 to December 2013.

Main Outcome Measures: Symptom severity and quality-of-life scores were measured, as well as anal manometry results.

Results: Increasing Oxford grade was associated with an increase in severity of fecal incontinence (median score: normal = 23.9, intrarectal = 21.0, intra-anal = 30.0, external prolapse = 35.3; β = 4.71; p = 0.009), which persisted in a multivariable model including age (β = 2.13; p = 0.03), and decreased sphincter pressures (median mean resting pressure: normal = 75.4, intra-rectal = 69.7, intra-anal = 64.3, external prolapse = 48.3; β = -8.57; p = 0.003), which did not persist in a multivariable model. Constipation severity did not increase with rising intussusception (mean score: normal = 37.4, intrarectal = 35.0, intra-anal = 41.4, external prolapse = 32.9; p = 0.79), and balloon expulsion improved rather than worsened (normal = 47.1%, intrarectal = 60.5%, intra-anal = 82.9%, external prolapse = 93.1%; p < 0.001).

Limitations: The study was limited because it was an observational study from a single center.

Conclusions: Increasing grades of rectal intussusception are associated with increasing fecal incontinence but not constipation.
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http://dx.doi.org/10.1097/DCR.0000000000000510DOI Listing
January 2016

Sigmoidectomy syndrome? Patients' perspectives on the functional outcomes following surgery for diverticulitis.

Dis Colon Rectum 2012 Jan;55(1):10-7

Colon and Rectal Surgery Program, Division of Gastrointestinal Surgery, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts 02114, USA.

Background: Bowel function following surgery for diverticulitis has not previously been systematically described.

Objective: This study aimed to document the frequency, severity, and predictors of suboptimal bowel function in patients who have undergone sigmoid colectomy for diverticulitis.

Design: This study is a retrospective analysis.

Setting: This study was conducted at a large, academic medical center.

Patients: Three hundred twenty-five patients who underwent laparoscopic or open sigmoid colectomy with restoration of intestinal continuity for diverticulitis were included in the study population. Of these, 249 patients (76.6%) returned a 70-question survey incorporating the Fecal Incontinence Severity Index, the Fecal Incontinence Quality of Life Scale, and the Memorial Bowel Function Instrument.

Main Outcome Measures: Survey responders and nonresponders were compared with the use of χ and t tests. Responders with suboptimal bowel function (fecal incontinence, urgency and/or incomplete emptying) were then compared with those with good outcomes by the use of logistic regression analysis to determine the predictors of poor function.

Results: Of the responders, 24.8% reported clinically relevant fecal incontinence (Fecal Incontinence Severity Index ≥ 24), 19.6% reported fecal urgency (Memorial Bowel Function Instrument Urgency Subscale ≥ 4), and 20.8% reported incomplete emptying (Memorial Bowel Function Instrument Emptying Subscale ≥ 4). On logistic regression analysis, fecal incontinence was predicted by female sex (OR = 2.3, p = 0.008) and the presence of a preoperative abscess (OR = 1.4, p < 0.05). Fecal urgency was associated with female sex (OR = 1.3, p < 0.05) and a diverting ileostomy (OR = 2.1, p < 0.001). Incomplete emptying was associated with female sex (OR = 1.4, p < 0.05) and postoperative sepsis (OR = 1.9, p < 0.05).

Limitations: This study was limited by the fact that we did not use a nondiverticulitis control group and we had limited preoperative data on the history of bowel impairment symptoms.

Conclusion: One-fifth of patients reported fecal urgency, fecal incontinence, or incomplete emptying after surgery for diverticulitis. Despite the limitations of our study, these results are concerning and should be investigated further prospectively.
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http://dx.doi.org/10.1097/DCR.0b013e31823907a9DOI Listing
January 2012