Publications by authors named "Madhulika G Varma"

48 Publications

Consolidation mFOLFOX6 Chemotherapy After Chemoradiotherapy Improves Survival in Patients With Locally Advanced Rectal Cancer: Final Results of a Multicenter Phase II Trial.

Dis Colon Rectum 2018 Oct;61(10):1146-1155

Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York.

Background: Adding modified FOLFOX6 (folinic acid, fluorouracil, and oxaliplatin) after chemoradiotherapy and lengthening the chemoradiotherapy-to-surgery interval is associated with an increase in the proportion of rectal cancer patients with a pathological complete response.

Objective: The purpose of this study was to analyze disease-free and overall survival.

Design: This was a nonrandomized phase II trial.

Settings: The study was conducted at multiple institutions.

Patients: Four sequential study groups with stage II or III rectal cancer were included.

Intervention: All of the patients received 50 Gy of radiation with concurrent continuous infusion of fluorouracil for 5 weeks. Patients in each group received 0, 2, 4, or 6 cycles of modified FOLFOX6 after chemoradiation and before total mesorectal excision. Patients were recommended to receive adjuvant chemotherapy after surgery to complete a total of 8 cycles of modified FOLFOX6.

Main Outcome Measures: The trial was powered to detect differences in pathological complete response, which was reported previously. Disease-free and overall survival are the main outcomes for the current study.

Results: Of 259 patients, 211 had a complete follow-up. Median follow-up was 59 months (range, 9-125 mo). The mean number of total chemotherapy cycles differed among the 4 groups (p = 0.002), because one third of patients in the group assigned to no preoperative FOLFOX did not receive any adjuvant chemotherapy. Disease-free survival was significantly associated with study group, ypTNM stage, and pathological complete response (p = 0.004, <0.001, and 0.001). A secondary analysis including only patients who received ≥1 cycle of FOLFOX still showed differences in survival between study groups (p = 0.03).

Limitations: The trial was not randomized and was not powered to show differences in survival. Survival data were not available for 19% of the patients.

Conclusions: Adding modified FOLFOX6 after chemoradiotherapy and before total mesorectal excision increases compliance with systemic chemotherapy and disease-free survival in patients with locally advanced rectal cancer. Neoadjuvant consolidation chemotherapy may have benefits beyond increasing pathological complete response rates. See Video Abstract at http://links.lww.com/DCR/A739.
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http://dx.doi.org/10.1097/DCR.0000000000001207DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6130918PMC
October 2018

Does Extended PET Acquisition in PET/MRI Rectal Cancer Staging Improve Results?

AJR Am J Roentgenol 2018 10 14;211(4):896-900. Epub 2018 Aug 14.

1 Department of Radiology and Biomedical Imaging, University of California, San Francisco, 505 Parnassus Ave, San Francisco, CA 94143.

Objective: The purpose of this study was to determine if extended PET acquisition times in the pelvis during PET/MRI increase detection rates of potentially metastatic lymph nodes in patients with rectal cancer.

Materials And Methods: Our study was approved by the institutional review board of the University of California, San Francisco. Twenty-two patients with biopsy-proven rectal cancer underwent imaging via simultaneous 3-T time-of-flight PET/MRI, with seven undergoing two separate PET/MRI examinations, for a total of 29 studies. Each examination included both a whole-body PET/MRI and a dedicated pelvic PET/MRI with both 3- and 15-minute PET acquisitions for the pelvis. Three radiologists interpreted each examination with PET only, MRI only, then combined PET and MRI examinations, using all available images. Additionally, the 3- and 15-minute PET acquisitions of the pelvis were reviewed separately by a single radiologist.

Results: A total of 94 lymph nodes were identified as abnormal on PET, all with MRI anatomic correlates. Of these, 37 (39.4%) were seen only on the dedicated 15-minute acquisition. Fifty-seven (60.6%) nodes measured 5 mm or less, including 29 (30.9%) seen only on the 15-minute acquisition. Thirty-one (33.0%) nodes measured 5.1-10 mm, including eight (25.8%) seen only on the 15-minute acquisition. Of the 17 subjects imaged for initial staging, 11 (64.7%) were upstaged as a result of the increased PET acquisition time (10 from N1 to N2 and one from N0 to N1).

Conclusion: Longer PET acquisition times during PET/MRI for rectal cancer increases the number of FDG-avid lymph nodes detected without increasing scan time.
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http://dx.doi.org/10.2214/AJR.18.19620DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7000107PMC
October 2018

Vitamin D Levels in Patients with Colorectal Cancer Before and After Treatment Initiation.

J Gastrointest Cancer 2019 Dec;50(4):769-779

UCSF Helen Diller Family Comprehensive Cancer Center, University of California, San Francisco, CA, USA.

Purpose: We aimed to described 25-hydroxyvitamin D [25(OH)D] levels in newly diagnosed colorectal cancer (CRC) patients and to re-evaluate levels after chemotherapy.

Methods: Permanent residents of the San Francisco Bay Area with a new CRC diagnosis of any stage were recruited prior to any non-surgical therapy. Serum 25(OH)D levels were measured at time of diagnosis and 6-month follow-up. Supplement use was not restricted. The primary endpoint was the frequency of vitamin D deficiency in patients with newly diagnosed CRC of all stages. The Kruskal-Wallis and Spearman correlation tests were used to evaluate associations of patient characteristics with 25(OH)D levels.

Results: Median 25(OH)D level at baseline was 27.0 ng/mL (range 7.2, 59.0); 65% of patients had insufficient levels (25(OH)D < 30 ng/mL) (n = 94). Race, disease stage, multivitamin use, vitamin D supplementation, and county of residence were associated with baseline 25(OH)D levels (P < 0.05). The median change in 25(OH)D from baseline to 6 months was - 0.7 ng/mL [- 19.4, 51.7] for patients treated with chemotherapy (n = 58) and 1.6 ng/mL [- 6.4, 33.2] for patients who did not receive chemotherapy (n = 19) (P = 0.26). For patients who received vitamin D supplementation during chemotherapy, the median 25(OH)D change was 8.3 ng/mL [- 7.6, 51.7] versus - 1.6 [- 19.4, 24.3] for chemotherapy patients who did not take vitamin D supplements (P = 0.02).

Conclusion: Among patients with a new diagnosis of CRC, most patients were found to have 25(OH)D levels consistent with either deficiency or insufficiency. In the subset of patients who received chemotherapy and took a vitamin D supplement, serum 25(OH)D levels increased, suggesting that vitamin D repletion is a feasible intervention during chemotherapy.
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http://dx.doi.org/10.1007/s12029-018-0147-7DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6650370PMC
December 2019

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

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

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

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

Expert Commentary on Rectal Prolapse.

Dis Colon Rectum 2017 11;60(11):1135-1136

Section of Colorectal Surgery, University of California, San Francisco, California.

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http://dx.doi.org/10.1097/DCR.0000000000000954DOI Listing
November 2017

Characteristics Associated With Successful Fitting of a Vaginal Bowel Control System for Fecal Incontinence.

Female Pelvic Med Reconstr Surg 2016 Sep-Oct;22(5):359-63

From the *Department of Obstetrics and Gynecology, University of North Carolina, Chapel Hill, NC; †Section of Colorectal Surgery, University of California, San Francisco, San Francisco, CA; ‡Department of Obstetrics and Gynecology, Indiana University Health, Indianapolis, IN; §Grand Rapids Women's Health, Grand Rapids, MI; ∥Department of Obstetrics and Gynecology, University of Texas Medical Branch, League City, TX; and ¶Department of Obstetrics and Gynecology, University of Alabama at Birmingham, Birmingham, AL.

Objectives: We previously showed that management with a novel vaginal bowel control system was efficacious in women with moderate to severe fecal incontinence. The objective of this secondary analysis was to evaluate the clinical characteristics associated with device-fitting success.

Methods: This is a secondary analysis of an institutional review board-approved, multicenter, prospective, open-label clinical study of women aged 19 to 75 years with 4 or more episodes of fecal incontinence recorded on a 2-week baseline bowel diary. Those successfully fitted with the vaginal bowel control device entered a 1-month treatment period, and efficacy was assessed with a repeat bowel diary. Demographic data, medical and surgical history, and pelvic examination findings were compared across women with successful and unsuccessful completion of the fitting period. Multivariate logistic regression analysis was performed.

Results: Six clinical sites in the United States recruited from August 2012 through October 2013. Overall, 110 women underwent attempted fitting, of which 61 (55.5%) of 110 were successful and entered the treatment portion of the study. Multivariate logistic regression analysis revealed that previous prolapse surgery (P = 0.007) and shorter vaginal length (P = 0.041) were independently associated with unsuccessful fitting. Women who have not undergone previous prolapse surgery had 4.7 times the odds (95% confidence interval [CI], 1.53-14.53) of a successful fit. In addition, for every additional centimeter of vaginal length, women had 1.49 times the odds (95% CI, 1.02-2.17) of a successful fit.

Conclusions: Shorter vaginal length and previous prolapse surgery were associated with an increased risk of fitting failure. These findings may be used to inform patients regarding their expectation of successful fitting.
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http://dx.doi.org/10.1097/SPV.0000000000000290DOI Listing
December 2017

Successful implementation of an Enhanced Recovery After Surgery program shortens length of stay and improves postoperative pain, and bowel and bladder function after colorectal surgery.

BMC Anesthesiol 2016 08 3;16(1):55. Epub 2016 Aug 3.

Department of Anesthesia & Perioperative Medicine, University of California San Francisco, 505 Parnassus Ave. M917, San Francisco, CA, 94143-0624, USA.

Background: Despite international data indicating that Enhanced Recovery After Surgery (ERAS) programs, which combine evidence-based perioperative strategies, expedite recovery after surgery, few centers have successfully adopted this approach within the U.S. We describe the implementation and efficacy of an ERAS program for colorectal abdominal surgery in a tertiary teaching center in the U.S.

Methods: We used a multi-modal and continuously evolving approach to implement an ERAS program among all patients undergoing colorectal abdominal surgery at a single hospital at the University of California, San Francisco. 279 patients who participated in the Enhanced Recovery after Surgery program were compared to 245 previous patients who underwent surgery prior to implementation of the program. Primary end points were length of stay and readmission rates. Secondary end points included postoperative pain scores, opioid consumption, postoperative nausea and vomiting, length of urinary catheterization, and time to first solid meal.

Results: ERAS decreased both median total hospital length of stay (6.4 to 4.4 days) and post-procedure length of stay (6.0 to 4.1 days). 30-day all-cause readmission rates decreased from 21 to 9.4 %. Pain scores improved on postoperative day 0 (3.2 to 2.1) and day 1 (3.2 to 2.6) despite decreased opioid. Median time to first solid meal decreased from 4.7 to 2.7 days and duration of urinary catheterization decreased from 74 to 46 h. Similar improvements were observed in all other secondary end points.

Conclusions: These results confirm that a multidisciplinary, iterative, team-based approach is associated with a reduction in hospital stay and an acceleration in recovery without increasing readmission rates.
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http://dx.doi.org/10.1186/s12871-016-0223-0DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4973042PMC
August 2016

A Novel Decision Aid for Surgical Patients with Ulcerative Colitis: Results of a Pilot Study.

Dis Colon Rectum 2016 Jun;59(6):520-8

1 Philip R. Lee Institute for Health Policy Studies, University of California, San Francisco, California 2 Department of Surgery, University of California, San Francisco, California 3 The Dartmouth Institute for Health Policy & Clinical Practice, Lebanon, New Hampshire 4 Division of Gastroenterology, Department of Medicine, University of California, San Francisco, California 5 Section of Colorectal Surgery, Department of Surgery, University of California, San Francisco, California 6 Division of Geriatrics, Department of Medicine, University of California, San Francisco, California.

Background: Up to 30% of patients who have ulcerative colitis are faced with the complex decision between end ileostomy and IPAA. We developed a decision aid to encourage shared decision making between patients and surgeons.

Objective: The aim of this study is to determine whether a decision aid is effective and acceptable for surgical patients with ulcerative colitis and their treating surgeons.

Design: This was a prospective cohort study.

Settings: Patients and surgeons were enrolled from 3 colorectal surgery clinics.

Patients: Consecutive adult patients with ulcerative colitis who were candidates for IPAA and end ileostomy were selected.

Interventions: Patients used a multilingual decision aid before meeting with the surgeon.

Main Outcome Measures: We measured changes in knowledge, treatment preference, and stage of decision making, as well as preparation for decision making, patient satisfaction, and surgeon satisfaction after using the decision aid.

Results: Twenty-five patients were enrolled; 5 had previously undergone subtotal colectomy. After using the decision aid, patients' knowledge scores improved by 39% (p < 0.006), 6 patients changed their treatment preference, and 8 reported increased certainty in treatment preference. The median for preparation for decision making was 75 of 100. Patient satisfaction with the decision aid (median score, 37/41) and surgeon satisfaction with the clinical encounter (median score, 38/45) were high. Patients who previously underwent subtotal colectomy had lower preparation for decision-making scores (median score, 58 vs 78 for surgery-naïve patients, p = 0.06), and did not report increased certainty in treatment preference after using the decision aid.

Limitations: The study included a small sample with no comparison group.

Conclusions: A novel decision aid for surgical patients with ulcerative colitis appears to be effective and acceptable in patients and surgeons from diverse clinical settings. Patients who have not yet initiated surgical treatment seem to benefit most. Future studies to validate the knowledge questionnaire and test the decision aid in a randomized fashion are warranted.
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http://dx.doi.org/10.1097/DCR.0000000000000572DOI Listing
June 2016

Impact of a Novel Vaginal Bowel Control System on Bowel Function.

Dis Colon Rectum 2016 Feb;59(2):127-31

1 Section of Colorectal Surgery, Department of Surgery, University of California, San Francisco, San Francisco, California 2 Division of Urogynecology and Reconstructive Surgery, University of North Carolina, Chapel Hill, North Carolina 3 Departments of Obstetrics and Gynecology and Urology, University of Texas Medical Branch, Galveston, Texas 4 Division of Urogynecology, Indiana University Health, Indianapolis, Indiana 5 Female Pelvic Medicine and Reconstructive Surgery, Indiana University Health System, Indiana University Health, Indianapolis, Indiana 6 Female Pelvic Medicine & Urogynecology Institute of Michigan, a division of Grand Rapids Women's Health, Grand Rapids, Michigan 7 Department of Obstetrics and Gynecology, University of Alabama at Birmingham, Birmingham, Alabama.

Background: Bowel dysfunction, including frequency, fecal urgency, stool consistency, and evacuation symptoms, contributes to fecal incontinence.

Objective: The purpose of this study was to examine the impact of a vaginal bowel control system on parameters of bowel function, including frequency, urgency, stool consistency, and evacuation.

Design: This was a secondary analysis of a multicenter, prospective clinical trial.

Settings: This study was conducted at 6 sites in the United States, including university hospitals and private practices in urogynecology and colorectal surgery.

Patients: A total of 56 evaluable female subjects aged 19 to 75 years with 4 or more fecal incontinence episodes on a 2-week bowel diary were included.

Interventions: The study intervention was composed of the vaginal bowel control system, consisting of a vaginal insert and pressure-regulated pump.

Main Outcome Measures: Subjects completed a 2-week baseline diary of bowel function before and after treatment completed at 1 month. Fecal urgency, consistency of stool (Bristol score), and completeness of evacuation were recorded for all bowel movements.

Results: Use of the insert was associated with an improvement in bowel function across all 4 categories. Two thirds (8/12) of subjects with a high frequency of daily stools (more than 2 per day) shifted to a normal or low frequency of stools. Analysis of Bristol stool scale scores demonstrated a significant reduction in the proportion of all bowel movements reported as liquid (Bristol 6 or 7), from 36% to 21% (p = 0.0001). On average, 54% of stools were associated with urgency at baseline compared with 26% at 1 month (p < 0.0001). Incomplete evacuations with all bowel movements were reduced from 39% to 26% of subjects at 1 month (p = 0.0034).

Limitations: The study follow-up period was 1 month (with an optional additional 2 months).

Conclusions: The vaginal bowel control system was associated with an improvement in bowel symptoms and function, including reduced bowel movement frequency, less fecal urgency, increased solid consistency, and improved evacuation in patients with significant fecal incontinence.
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http://dx.doi.org/10.1097/DCR.0000000000000517DOI Listing
February 2016

Impact of Surgery on Relationship Quality in Patients With Ulcerative Colitis and Their Partners.

Dis Colon Rectum 2015 Dec;58(12):1144-50

1 Philip R. Lee Institute for Health Policy Studies and Department of Surgery, University of California, San Francisco, San Francisco, California 2 Section of Colorectal Surgery, Department of Surgery, University of California, San Francisco, San Francisco, California.

Background: Although social support is important for quality of life in patients undergoing surgery for ulcerative colitis, the impact of surgery on patient relationships is not known.

Objective: We examined relationship parameters in patients with ulcerative colitis and their partners before and 6 months after surgery.

Design: This was a prospective cohort in which we performed an exploratory analysis.

Settings: Patients were enrolled from an academic medical center.

Patients: Surgical patients with ulcerative colitis and their partners were invited to participate.

Interventions: Patients underwent proctocolectomy in 1, 2, or 3 stages.

Main Outcome Measures: We measured quality of life and sexual function in patients, as well as relationship quality, empathy, and sexual satisfaction in patients and partners before and 6 months after surgery using validated questionnaires.

Results: The study sample consisted of 74 participants, including 37 patients (25 men and 12 women) and their opposite-sex partners. Quality of life improved significantly in male and female patients after surgery. Sexual function scores also improved after surgery in male and female patients; however, the changes reached statistical significance in male patients only. Sexual satisfaction scores improved significantly after surgery in female patients and their partners. There was little change in relationship quality or empathy after surgery, with the exception of slightly improved relationship quality reported by male partners. In general, patients and partners reported levels of relationship quality and empathy similar to normative populations.

Limitations: This study included a small, highly selected sample.

Conclusions: Male and female patients with ulcerative colitis have high-quality relationships that are not negatively affected by surgical treatment. Changes in sexual function do not necessarily coincide with changes in sexual satisfaction in this patient population. Future studies should evaluate the effect of high-quality relationships on surgical outcomes.
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http://dx.doi.org/10.1097/DCR.0000000000000494DOI Listing
December 2015

Differences in Symptom Severity and Quality of Life in Patients With Obstructive Defecation and Colonic Inertia.

Dis Colon Rectum 2015 Oct;58(10):994-8

1 Department of Surgery, University of California, San Francisco, San Francisco, California 2 Philip R. Lee Institute for Health Policy Studies, University of California, San Francisco, San Francisco, California 3 Section of Colorectal Surgery, Department of Surgery, University of California, San Francisco, San Francisco, California.

Background: Little is known about how obstructive defecation and colonic inertia symptoms contribute to constipation-related quality of life.

Objective: We sought to characterize the differences in quality of life in patients with severe obstructive defecation and colonic inertia symptoms.

Design: This study was a cross-sectional analysis of a prospective database.

Setting: Patients were enrolled at a single tertiary referral center.

Patients: We included consecutive adults with severe symptoms of obstructive defecation (n = 115) or colonic inertia (n = 90) as measured by the Constipation Severity Instrument.

Main Outcome Measures: The primary outcomes measured were the Pelvic Floor Distress Inventory, Constipation-Related Quality of Life instrument, Pelvic Floor Impact Questionnaire, and 12-item Short Form Health Survey.

Results: Although physical examination and anorectal physiology testing were similar between groups, patients with severe obstructive defecation symptoms reported worse pain, distress, and constipation-specific quality of life than patients with severe colonic inertia symptoms (all p < 0.001). Specifically, patients with severe obstructive defecation symptoms showed greater quality-of-life impairment related to eating, bathroom habits, and social functioning (all p ≤ 0.01). Furthermore, patients with severe obstructive defecation symptoms had inferior global quality of life on the 12-item Short Form Health Survey physical component score (p = 0.03) and mental component score (p = 0.06).

Limitations: The use of patient self-report instruments resulted in a proportion of patients with incomplete data.

Conclusion: Quality of life was impaired in both groups of patients; however, patients with severe obstructive defecation symptoms were affected to a significantly greater extent. The fact that there were no differences in objective findings on physical examination or anorectal physiology studies highlights the importance of assessing quality of life during the evaluation and treatment of constipated patients.
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http://dx.doi.org/10.1097/DCR.0000000000000439DOI Listing
October 2015

The American Society of Colon and Rectal Surgeons' Clinical Practice Guideline for the Treatment of Fecal Incontinence.

Dis Colon Rectum 2015 Jul;58(7):623-36

Prepared by the Clinical Practice Guidelines Committee of the American Society of Colon and Rectal Surgeons.

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http://dx.doi.org/10.1097/DCR.0000000000000397DOI Listing
July 2015

Effect of adding mFOLFOX6 after neoadjuvant chemoradiation in locally advanced rectal cancer: a multicentre, phase 2 trial.

Lancet Oncol 2015 Aug 14;16(8):957-66. Epub 2015 Jul 14.

Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA.

Background: Patients with locally advanced rectal cancer who achieve a pathological complete response to neoadjuvant chemoradiation have an improved prognosis. The need for surgery in these patients has been questioned, but the proportion of patients achieving a pathological complete response is small. We aimed to assess whether adding cycles of mFOLFOX6 between chemoradiation and surgery increased the proportion of patients achieving a pathological complete response.

Methods: We did a phase 2, non-randomised trial consisting of four sequential study groups of patients with stage II-III locally advanced rectal cancer at 17 institutions in the USA and Canada. All patients received chemoradiation (fluorouracil 225 mg/m(2) per day by continuous infusion throughout radiotherapy, and 45·0 Gy in 25 fractions, 5 days per week for 5 weeks, followed by a minimum boost of 5·4 Gy). Patients in group 1 had total mesorectal excision 6-8 weeks after chemoradiation. Patients in groups 2-4 received two, four, or six cycles of mFOLFOX6, respectively, between chemoradiation and total mesorectal excision. Each cycle of mFOLFOX6 consisted of racemic leucovorin 200 mg/m(2) or 400 mg/m(2), according to the discretion of the treating investigator, oxaliplatin 85 mg/m(2) in a 2-h infusion, bolus fluorouracil 400 mg/m(2) on day 1, and a 46-h infusion of fluorouracil 2400 mg/m(2). The primary endpoint was the proportion of patients who achieved a pathological complete response, analysed by intention to treat. This trial is registered with ClinicalTrials.gov, number NCT00335816.

Findings: Between March 24, 2004, and Nov 16, 2012, 292 patients were registered, 259 of whom (60 in group 1, 67 in group 2, 67 in group 3, and 65 in group 4) met criteria for analysis. 11 (18%, 95% CI 10-30) of 60 patients in group 1, 17 (25%, 16-37) of 67 in group 2, 20 (30%, 19-42) of 67 in group 3, and 25 (38%, 27-51) of 65 in group 4 achieved a pathological complete response (p=0·0036). Study group was independently associated with pathological complete response (group 4 compared with group 1 odds ratio 3·49, 95% CI 1·39-8·75; p=0·011). In group 2, two (3%) of 67 patients had grade 3 adverse events associated with the neoadjuvant administration of mFOLFOX6 and one (1%) had a grade 4 adverse event; in group 3, 12 (18%) of 67 patients had grade 3 adverse events; in group 4, 18 (28%) of 65 patients had grade 3 adverse events and five (8%) had grade 4 adverse events. The most common grade 3 or higher adverse events associated with the neoadjuvant administration of mFOLFOX6 across groups 2-4 were neutropenia (five in group 3 and six in group 4) and lymphopenia (three in group 3 and four in group 4). Across all study groups, 25 grade 3 or worse surgery-related complications occurred (ten in group 1, five in group 2, three in group 3, and seven in group 4); the most common were pelvic abscesses (seven patients) and anastomotic leaks (seven patients).

Interpretation: Delivery of mFOLFOX6 after chemoradiation and before total mesorectal excision has the potential to increase the proportion of patients eligible for less invasive treatment strategies; this strategy is being tested in phase 3 clinical trials.

Funding: National Institutes of Health National Cancer Institute.
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http://dx.doi.org/10.1016/S1470-2045(15)00004-2DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4670237PMC
August 2015

Impact of Patient Age on Procedure Type for Ulcerative Colitis: A National Study.

Dis Colon Rectum 2015 Aug;58(8):769-74

1 Philip R. Lee Institute for Health Policy Studies and Department of Surgery, University of California, San Francisco, San Francisco, California 2 Department of Epidemiology and Biostatistics, University of California, San Francisco, San Francisco, California 3 Section of Colorectal Surgery, Department of Surgery, University of California, San Francisco, San Francisco, California.

Background: Historically, older patients with ulcerative colitis were not considered candidates for ileal pouch-anal anastomosis. However, more recent evidence suggests that this procedure can be performed in older patients with acceptable surgical and functional results.

Objective: The purpose of this work was to determine whether older age is independently associated with surgical procedure type among patients with ulcerative colitis in a large national database.

Design: This was a cross-sectional analysis of ulcerative colitis patients undergoing end ileostomy or IPAA, grouped by age.

Settings: This study was conducted in a university teaching hospital.

Patients: Patients with ulcerative colitis who underwent total proctocolectomy or completion proctectomy with either IPAA or end ileostomy from 2005 to 2012 in the American College of Surgeons National Surgery Quality Improvement Program database were included in this study.

Main Outcome Measures: The primary outcome was procedure type (end ileostomy or IPAA). Patient factors associated with procedure type, including age and trends over time, were examined using multivariate logistic regression.

Results: Among 3635 patients with ulcerative colitis, 28.2% underwent end ileostomy and 71.8% underwent IPAA. Older patients were more likely to undergo end ileostomy than patients ≤50 years of age after adjustment for sex, smoking, BMI, frailty trait count, and ASA class (p < 0.001). The odds of end ileostomy decreased by 12% per year between 2005 and 2012 in patients aged 61 to 70 years compared with patients ≤50 years of age (adjusted OR, 0.88 per year; p = 0.021).

Limitations: We were unable to analyze other potentially important determinants of procedure type, such as surgeon, patient preference, and anal sphincter integrity.

Conclusions: Age remains strongly associated with procedure type. The use of end ileostomy, however, is decreasing over time in patients 61 to 70 years of age as evidence accumulates that IPAA is an acceptable option for older patients with ulcerative colitis (see Video, Supplemental Digital Content 1, http://links.lww.com/DCR/A191).
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http://dx.doi.org/10.1097/DCR.0000000000000398DOI Listing
August 2015

Outcomes after ileoanal pouch surgery in frail and older adults.

J Surg Res 2015 Oct 8;198(2):327-33. Epub 2015 Apr 8.

Department of Surgery, University of California, San Francisco, San Francisco, California; Philip R. Lee Institute for Health Policy Studies, University of California, San Francisco, San Francisco, California; Division of Geriatrics, Department of Medicine, University of California, San Francisco, San Francisco, California.

Background: Evidence from single-center studies suggests that ileal pouch-anal anastomosis (IPAA) can be safely performed in selected older patients with ulcerative colitis. The impact of age and frailty on surgical outcomes and hospital length of stay after IPAA has not been examined.

Methods: We identified all patients with ulcerative colitis who underwent total proctocolectomy or completion proctectomy with IPAA in the National Surgery Quality Improvement Program database from 2005-2012. We examined the associations of age and frailty trait count with length of hospital stay and surgical complications using multivariate regression.

Results: IPAA was performed in 2493 patients with ulcerative colitis. Thirty-day mortality was 0.2% (n = 6). The majority of patients had no serious postoperative complications (age ≤50 y: 79.5%, age 51-60 y: 80.4%, and age >60 y: 79.1%). After multivariate risk adjustment, patients aged >60 y had a similar mean number of complications as patients aged ≤50 y (0.31 versus 0.35, P = 0.47) and a 0.8-d longer mean length of hospital stay (7.4 versus 8.2 d, P = 0.035). Compared to patients with zero frailty traits, a frailty trait count ≥1 was associated with a similar mean number of complications (0.31 versus 0.34, P = 0.36) and length of hospital stay (7.4 versus 7.7 d, P = 0.25).

Conclusions: In this analysis of patients undergoing IPAA at National Surgery Quality Improvement Program hospitals, surgical complications were not substantially increased in older patients or those with frailty traits. Older age was associated with a small increase in hospital length of stay. These findings suggest that IPAA is safe in selected older adults with ulcerative colitis.
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http://dx.doi.org/10.1016/j.jss.2015.04.014DOI Listing
October 2015

A vaginal bowel-control system for the treatment of fecal incontinence.

Obstet Gynecol 2015 Mar;125(3):540-547

Departments of Obstetrics and Gynecology, University of Alabama at Birmingham, Birmingham, Alabama; the University of North Carolina, Chapel Hill, North Carolina; the University of Texas Medical Branch, Galveston, Texas; Indiana University Health, Bloomington, Indianapolis, Indiana; Department of Colorectal Surgery, Grand Rapids Women's Health, Grand Rapids, Michigan; and the University of California, San Francisco, San Francisco, California.

Objective: To evaluate the effectiveness and safety of a vaginal bowel-control device and pump system for fecal incontinence treatment.

Methods: Women with a minimum of four fecal incontinence episodes over 2 weeks were fit with the intravaginal device. Treatment success, defined as a 50% or greater reduction of incontinent episodes, was assessed at 1 month. Participants were invited into an optional extended-wear period of another 2 months. Secondary outcomes included symptom improvement measured by the Fecal Incontinence Quality of Life, Modified Manchester Health Questionnaire, and Patient Global Impression of Improvement. Adverse events were collected. Intention-to-treat analysis included participants who were successfully fit entering treatment. Per protocol, analysis included participants with a valid 1-month treatment diary.

Results: Sixty-one of 110 (55.5%) participants from six clinical sites were successfully fit and entered treatment. At 1 month, intention-to-treat success was 78.7% (48/61, P<.001); per protocol success, 85.7% (48/56, P<.001) and 85.7% (48/56) considered bowel symptoms "very much better" or "much better." There was significant improvement in all Fecal Incontinence Quality of Life (P<.001) and Modified Manchester (P≤.007) subscales. Success rate at 3 months was 86.4% (38/44; 95% confidence interval 73-95%). There were no serious adverse events; the most common study-wide device-related adverse event was pelvic cramping or discomfort (25/110 participants [22.7%]), the majority of events (16/25 [64%]) occurring during the fitting period.

Conclusion: In women successfully fit with a vaginal bowel-control device for nonsurgical treatment for fecal incontinence, there was significant improvement in fecal incontinence by objective and subjective measures.

Clinical Trial Registration: ClinicalTrials.gov, www.clinicaltrials.gov, NCT01655498.

Level Of Evidence: : II.
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http://dx.doi.org/10.1097/AOG.0000000000000639DOI Listing
March 2015

Perineal flap reconstruction following oncologic anorectal extirpation: an outcomes assessment.

Plast Reconstr Surg 2015 Jan;135(1):176e-184e

San Francisco, Calif. From the Divisions of Plastic and Reconstructive Surgery and Colorectal Surgery, University of California, San Francisco.

Background: The poorly healing perineal wound is a significant complication of abdominoperineal resection. The authors examined criteria for immediate flap coverage of the perineum and long-term cross-sectional surgical outcomes.

Methods: Patients who underwent abdominoperineal resection or pelvic exenteration for anorectal cancer were retrospectively analyzed. Demographic characteristics, premorbid and oncologic data, surgical treatment, reconstruction method, and recovery were recorded. Outcomes of successful wound healing, surgical complications necessitating intervention (admission or return to the operating room), and progression to chronic wounds were assessed.

Results: The authors identified 214 patients who underwent this procedure from 1995 to 2013. Forty-seven patients received pedicled flaps and had higher rates of recurrence and reoperation, active smoking, Crohn disease, human immunodeficiency virus, and anal cancers, and had higher American Joint Committee on Cancer tumor stages. Thirty-day complication rates were equivalent in the two groups. There were no complete flap losses or reconstructive failures. Perineal wound complication rates were marginally but not significantly higher in the flap group (55 percent versus 41 percent; p = 0.088). Infectious complications, readmissions for antibiotics, and operative revision were more frequent in the flap cohort. A larger proportion of the primary closure cohort developed chronic draining perineal wounds (23.3 versus 8.5 percent; p = 0.025).

Conclusions: Immediate flap coverage of the perineum was less likely to progress to a chronic draining wound, but had higher local infectious complication rates. The authors attribute this to increased comorbidity in the selected patient population, reflecting the surgical decision making in approaching these high-risk closures and ascertainment bias in diagnosis of infectious complications with multidisciplinary examination.

Clinical Question/level Of Evidence: Risk, III.
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http://dx.doi.org/10.1097/PRS.0000000000000837DOI Listing
January 2015

Outcomes Analysis of Biologic Mesh Use for Abdominal Wall Reconstruction in Clean-Contaminated and Contaminated Ventral Hernia Repair.

Ann Plast Surg 2015 Aug;75(2):201-4

From the Divisions of *Plastic and Reconstructive Surgery, and †Colorectal Surgery, University of California, San Francisco, San Francisco, CA.

Background: Repair of grade 3 and grade 4 ventral hernias is a distinct challenge, given the potential for infection, and the comorbid nature of the patient population. This study evaluates our institutional outcomes when performing single-stage repair of these hernias, with biologic mesh for abdominal wall reinforcement.

Methods: A prospectively maintained database was reviewed for all patients undergoing repair of grade 3 (potentially contaminated) or grade 4 (infected) hernias, as classified by the Ventral Hernia Working Group. All those patients undergoing repair with component separation techniques and biologic mesh reinforcement were included. Patient demographics, comorbidities, and postoperative complications were analyzed. Univariate analysis was performed to define factors predictive of hernia recurrence and wound complications.

Results: A total of 41 patients underwent single-stage repair of grade 3 and grade 4 hernias during a 4-year period. The overall postoperative wound infection rate was 15%, and hernia recurrence rate was 12%. Almost all recurrences were seen in grade 4 hernia repairs, and in those patients undergoing bridging repair of the hernia. One patient required removal of the biologic mesh. Those factors predicting hernia recurrence were smoking (P = 0.023), increasing body mass index (P = 0.012), increasing defect size (P = 0.010), and bridging repair (P = 0.042). No mesh was removed due to perioperative infection. Mean follow-up time for this patient population was 25 months.

Conclusions: Single-stage repair of grade 3 hernias performed with component separation and biologic mesh reinforcement is effective and offers a low recurrence rate. Furthermore, the use of biologic mesh allows for avoidance of mesh explantation in instances of wound breakdown or infection. Bridging repairs are associated with a high recurrence rate, as is single-stage repair of grade 4 hernias.
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http://dx.doi.org/10.1097/SAP.0000000000000030DOI Listing
August 2015

Outcomes after rectal cancer surgery in elderly nursing home residents.

Dis Colon Rectum 2012 Dec;55(12):1229-35

Phillip R Lee Institute of Health Policy Studies, University of California, San Francisco, California 94118, USA.

Background: As the population ages, an increasing number of elderly persons will undergo surgery for rectal cancer. The use of sphincter-sparing surgery in frail older adults is controversial.

Objective: The aim of this study was to examine mortality and bowel function after proctectomy in nursing home residents.

Design: This is a retrospective cohort study.

Setting: This investigation was conducted in nursing homes in the United States contracted with the Center for Medicare and Medicaid Services.

Patients: Nursing home residents age 65 and older undergoing proctectomy for rectal cancer (2000-2005) were included.

Main Outcome Measures: The primary outcomes measured were fecal incontinence and the 1-year mortality rate.

Results: Operative mortality was 18% after proctectomy with permanent colostomy and 13% after sphincter-sparing proctectomy (adjusted relative risk, 1.25 (95% CI 0.90-1.73), p = 0.188). One-year mortality was high: 40% after sphincter-sparing proctectomy and 51% after proctectomy with permanent colostomy (adjusted hazard ratio 1.32 (95% CI 1.09-1.60), p = 0.004). After sphincter-sparing proctectomy, 37% of residents were incontinent of feces. Residents with the poorest functional status (Minimum Data Set-Activities of Daily Living quartile 4) were significantly more likely to be incontinent of feces than residents with the best functional status (Minimum Data Set-Activities of Daily Living quartile 1) (76% vs 13%, adjusted relative risk 3.28 (95% CI 1.74- 6.18), p= 0.0002). Fecal incontinence was also associated with dementia (adjusted relative risk 1.55 (95% CI 1.15-2.09), p = 0.004) and renal failure (adjusted relative risk 1.93 (95% CI 1.10-3.38), p = 0.022).

Limitations: Measures of fecal incontinence in nursing home registries are not as well studied as those commonly used in clinical practice.

Conclusions: Sphincter-sparing proctectomy in nursing home residents is frequently associated with postoperative fecal incontinence and should be considered only for continent patients with good functional status.
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http://dx.doi.org/10.1097/DCR.0b013e318267bfe3DOI Listing
December 2012

Fecal incontinence decreases sexual quality of life, but does not prevent sexual activity in women.

Dis Colon Rectum 2012 Oct;55(10):1059-65

Department of Surgery, University of California, San Francisco-East Bay, Oakland, California, USA.

Background: The impact of anal incontinence on women's sexual function is poorly understood.

Objective: The aim of this study was to investigate the relationship between anal incontinence and sexual activity and functioning in women.

Design: This is a cross-sectional study.

Settings: This investigation was conducted in a community-based integrated health care delivery system.

Patients: Included were 2269 ethnically diverse women aged 40 to 80 years.

Main Outcome Measures: Self-administered questionnaires assessed accidental leakage of gas (flatal incontinence) and fluid/mucus/stool (fecal incontinence) in the past 3 months. Additional questionnaires assessed sexual activity, desire and satisfaction, as well as specific sexual problems (difficulty with arousal, lubrication, orgasm, or pain). Multivariable logistic regression models compared sexual function in women with 1) isolated flatal incontinence, 2) fecal incontinence (with or without flatal incontinence), and 3) no fecal/flatal incontinence, controlling for potential confounders.

Results: Twenty-four percent of women reported fecal incontinence and 43% reported isolated flatal incontinence in the previous 3 months. The majority were sexually active (62% of women without fecal/flatal incontinence, 66% with isolated flatal incontinence, and 60% with fecal incontinence; p = 0.06). In comparison with women without fecal/flatal incontinence, women with fecal incontinence were more likely to report low sexual desire (OR: 1.41 (CI: 1.10-1.82)), low sexual satisfaction (OR: 1.56 (CI: 1.14-2.12)), and limitation of sexual activity by physical health (OR: 1.65 (CI: 1.19-2.28)) after adjustment for confounders. Among sexually active women, women with fecal incontinence were more likely than women without fecal/flatal incontinence to report difficulties with lubrication (OR: 2.66 (CI: 1.76-4.00)), pain (OR: 2.44 (CI: 1.52-3.91)), and orgasm (OR: 1.68 (CI: 1.12-2.51)). Women with isolated flatal incontinence reported sexual functioning similar to women without fecal/flatal incontinence.

Limitations: The cross-sectional design prevented evaluation of causality.

Conclusions: Although most women with fecal incontinence are at high risk for several aspects of sexual dysfunction, the presence of fecal incontinence does not prevent women from engaging in sexual activity. This indicates that sexual function is important to women with anal incontinence and should be prioritized during therapeutic management.
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http://dx.doi.org/10.1097/DCR.0b013e318265795dDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3720983PMC
October 2012

A randomized controlled trial of anorectal biofeedback for constipation.

Int J Colorectal Dis 2012 Apr 9;27(4):459-66. Epub 2011 Dec 9.

Department of Psychology, Ryerson University, 350 Victoria Street, Toronto, ON, M5B 2K3, Canada.

Purpose: The purposes of this study were: (1) to examine the efficacy of anorectal biofeedback (AB) for constipation compared to a biofeedback control (BC) treatment and (2) to examine the extent to which self-reported childhood sexual/physical abuse predicted biofeedback outcome.

Methods: Twenty-one patients with pelvic floor dyssynergia were randomized to either (1) an AB arm, where patients learned to isolate the anal sphincter using an electromyography probe, or (2) a BC arm that controlled for the nonspecific effects of biofeedback, where patients learned to relax trapezius or temporalis muscles with EMG feedback. Both treatments were delivered by registered nurses for six sessions. Prior to randomization and post-treatment, patients completed the validated Constipation Severity Instrument and two measures of quality of life (QOL), the Irritable Bowel Syndrome-QOL, and the SF-36. Generalized estimating equations examined the within-group and between-group differences over time.

Results: Pre- and post-treatment data were obtained for six AB and nine BC patients. AB patients' overall constipation severity scores decreased by 35.5% (vs. 15.3%), and their obstructive defecation symptom scores decreased by 37.9% (vs. 19.7%) compared to BC. A similar pattern was shown on the IBS-QOL. On the SF-36 Mental Health Composite (MCS), AB scores improved 28.0% compared to BC scores, which worsened 12.7%. Those without (vs. with) a childhood sexual/physical abuse history showed improvement on the MCS post-biofeedback.

Conclusions: While our sample was statistically underpowered, AB produced clinical improvements in constipation severity and QOL.
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http://dx.doi.org/10.1007/s00384-011-1355-9DOI Listing
April 2012

Chromosomal copy number alterations are associated with tumor response to chemoradiation in locally advanced rectal cancer.

Genes Chromosomes Cancer 2011 Sep 16;50(9):689-99. Epub 2011 May 16.

Department of Surgery, City of Hope, 1500 E. Duarte Road, Duarte, CA 91010, USA.

Rectal cancer response to chemoradiation (CRT) varies from no response to a pathologic complete response (pCR). Identifying predictive biomarkers of response would therefore be useful. We assessed whether chromosomal copy number alterations (CNAs) can assist in predicting pCR. Pretreatment tumor biopsies and paired normal surgical tissues from the proximal resection margin were collected from 95 rectal cancer patients treated with preoperative CRT and total mesorectal excision in a prospective Phase II study. Tumor and control DNA were extracted, and oligonucleotide array-based comparative genomic hybridization (aCGH) was used to identify CNAs, which were correlated with pCR. Ingenuity pathway analysis (IPA) was then used to identify functionally relevant genes in aberrant regions. Finally, a predictive model for pCR was built using support vector machine (SVM), and leave-one-out cross validation assessed the accuracy of aCGH. Chromosomal regions most commonly affected by gains were 20q11.21-q13.33, 13q11.32-23, 7p22.3-p22.2, and 8q23.3-q24.3, and losses were present at 18q11.32-q23, 17p13.3-q11.1, 10q23.1, and 4q32.1-q32.3. The 25 (26%) patients who achieved a pCR had significantly fewer high copy gains overall than non-pCR patients (P = 0.01). Loss of chromosomal region 15q11.1-q26.3 was significantly associated with non-pCR (P < 0.00002; Q-bound < 0.0391), while loss of 12p13.31 was significantly associated with pCR (P < 0.0003; Q-bound < 0.097). IPA identified eight genes in the imbalanced chromosomal regions that associated with tumor response. SVM identified 58 probes that predict pCR with 76% sensitivity, 97% specificity, and positive and negative predictive values of 91% and 92%. Our data indicate that chromosomal CNAs can help identify rectal cancer patients more likely to develop a pCR to CRT.
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http://dx.doi.org/10.1002/gcc.20891DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3134546PMC
September 2011

Sew or staple: does it make a difference?

Inflamm Bowel Dis 2011 Apr 4;17(4):1046-7. Epub 2010 Nov 4.

Section of Colorectal Surgery, University of California, San Francisco, California, USA.

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http://dx.doi.org/10.1002/ibd.21496DOI Listing
April 2011

Gender-specific differences in pelvic organ function after proctectomy for inflammatory bowel disease.

Dis Colon Rectum 2011 Jan;54(1):66-76

Department of Surgery, University of California, San Francisco, San Francisco, California, USA.

Background: Significant concern exists regarding the effect of proctectomy on sexual function in patients with IBD. Little is known about gender-specific differences.

Objective: This study aimed to examine sexual function and quality of life in men and women with IBD before and after proctectomy.

Design: This is a prospective cohort study.

Setting: The study was conducted at a colorectal surgery center.

Patients: The patients included in this study have IBD and underwent proctectomy or proctocolectomy.

Intervention: The treatment provided was proctectomy or proctocolectomy.

Main Outcome Measures: Validated questionnaires were used to assess sexual function, quality of life, bowel habits, and urinary symptoms, and were completed before and 6 months after surgery.

Results: Sixty-six participants (41 men and 25 women) were evaluated at baseline and 6 months after proctocolectomy or completion proctectomy. A total of 48 IPAAs (31 men and 17 women) and 18 end ileostomies (10 men and 8 women) were created. Men reported improved scores on the International Index of Erectile Function (P = .003), a modified Sexual Function Questionnaire (P = .001), Inflammatory Bowel Disease Quality of Life (P < .001), and SF-36 (Mental Component Summary, P = .003; Physical Component Summary, P = .001) after surgery. Women had improvement in the desire subscale of the Female Sexual Function Index (P = .03), Inflammatory Bowel Disease Quality of Life scores (P = .04), and SF-36 (Mental Component Summary, P = .02; Physical Component Summary, P = .02). There was no gender difference in the magnitude of change in scores before and after surgery for any of the measures.

Limitations: Small sample size and sexually inactivity in 50% of cohort may have had an impact on our findings.

Conclusions: Both men and women reported improvements in general and IBD-specific quality of life after surgery, but only men demonstrated several areas of improved sexual function. Women reported improved sexual desire but no other sexual function improvement. The postsurgical gender difference in sexual function, despite similar improvements in quality of life, may be accounted for by unexamined aspects of female sexual function.
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http://dx.doi.org/10.1007/DCR.0b013e3181fd48d2DOI Listing
January 2011

Age differences in patients evaluated for constipation: constipation characteristics, symptoms, and bowel and dietary habits.

J Wound Ostomy Continence Nurs 2010 Nov-Dec;37(6):667-76

Department of Nursing and Health Science, California State University, East Bay, CA, USA.

Purpose: The purpose of this study was to determine the influence of age on various characteristics of constipation. We also sought to determine if age, comorbid conditions, and specific clinical characteristics such as use of pain medications were associated with an increase in the frequency of constipation-associated symptoms.

Subjects And Setting: The sample comprised 518 patients 18 years or older with a primary diagnosis of constipation. Subjects were drawn from the clinical database of all patients (n = 1228) referred from primary care or gastroenterology practices to the University of California, San Francisco Center for Pelvic Physiology between March 2003 and October 2007.

Design: Cross-sectional study.

Instruments: Patients completed 2 questionnaires. The clinical questionnaire obtained information on demographic characteristics and previous medical history. A second, investigator-developed questionnaire provided data about characteristics of constipation, symptoms of constipation, as well as various bowel and dietary habits.

Results: : Both younger and middle-aged patients were more than twice as likely as older patients to have infrequent bowel movements and abdominal bloating and to use position changes to facilitate bowel evacuations. In addition, younger patients were nearly 3 times as likely to report abdominal pain as older patients. Patients with constipation who present at a younger age report a higher frequency of certain characteristics, symptoms, and bowel habits.

Conclusions: Screening of younger patients for this common problem is warranted.
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http://dx.doi.org/10.1097/WON.0b013e3181f91082DOI Listing
March 2011

Validation of the risk index category as a predictor of surgical site infection in elective colorectal surgery.

Dis Colon Rectum 2010 May;53(5):721-7

Department of Surgery, City of Hope National Medical Center, Duarte, California, USA.

Purpose: The risk index category is a tool to predict and compare surgical site infection rates among surgeons and hospitals. However, the accuracy of the index in colorectal surgery has been questioned because the index was validated in a patient population with lower surgical site infection rates than recently reported in the literature. This study aims to validate the risk index category as a predictor of surgical site infection in a cohort of patients who underwent colorectal operations and were prospectively surveyed for surgical site infection.

Methods: Demographics, preoperative characteristics, and surgical data were obtained from 491 consecutive patients undergoing elective colorectal resections at a colorectal unit from April 2006 to July 2008. Surgical site infections were prospectively collected and stratified according to the Centers for Disease Control and Prevention criteria. Association of variables with surgical site infection was determined by univariate and multivariate analyses.

Results: A total of 95 (19.3%) patients developed surgical site infections. The rate of infection increased in each index category, from 13% for category 0 to 27% for category 3. Risk factors for surgical site infection in univariate analysis were as follows: high American Society of Anesthesiologists' scores, obesity, open surgery, and high index categories. Risk index category > or =2 (OR, 2.3; CI, 1.4-3.9; P < .01) was the only independent risk factor associated with infection in multivariate analysis.

Conclusion: The risk index category is a strong predictor for the development of surgical site infection in colorectal surgery patients when infections are prospectively collected and should be used to stratify patients when reporting infection rates in elective colorectal surgery.
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http://dx.doi.org/10.1007/DCR.0b013e3181cc573bDOI Listing
May 2010