Publications by authors named "Sarah A Vogler"

13 Publications

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

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

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

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

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

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

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

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

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

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

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

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

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

Pelvic Floor Disorders.

Sarah A Vogler

Clin Colon Rectal Surg 2021 Jan 4;34(1):3-4. Epub 2020 Nov 4.

Department of Colorectal Surgery, Cleveland Clinic, Ohio.

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January 2021

System-Wide Improvement for Transitions After Ileostomy Surgery: Can Intensive Monitoring of Protocol Compliance Decrease Readmissions? A Randomized Trial.

Dis Colon Rectum 2019 03;62(3):363-370

Division of Colon and Rectal Surgery, Department of Surgery, University of Minnesota, Minneapolis, Minnesota.

Background: Hospital readmission is common after ileostomy formation and frequently associated with dehydration.

Objective: This study was conducted to evaluate a previously published intervention to prevent dehydration and readmission.

Design: This is a randomized controlled trial.

Setting: This study was conducted in 3 hospitals within a single health care system.

Patients: Patients undergoing elective or nonelective ileostomy as part of their operative procedure were selected.

Intervention: Surgeons, advanced practice providers, inpatient and outpatient nurses, and wound ostomy continence nurses participated in a robust ileostomy education and monitoring program (Education Program for Prevention of Ileostomy Complications) based on the published intervention. After informed consent, patients were randomly assigned to a postoperative compliance surveillance and prompting strategy that was directed toward the care team, versus usual care.

Outcome Measures: Unplanned hospital readmission within 30 days of discharge, readmission for dehydration, acute renal failure, estimated direct costs, and patient satisfaction were the primary outcomes measured.

Results: One hundred patients with an ileostomy were randomly assigned. The most common indications were rectal cancer (n = 26) and ulcerative colitis (n = 21), and 12 were emergency procedures. Although intervention patients had better postdischarge phone follow-up (90% vs 72%; p = 0.025) and were more likely to receive outpatient intravenous fluids (25% vs 6%; p = 0.008), they had similar overall hospital readmissions (20.4% vs 19.6%; p = 1.0), readmissions for dehydration (8.2% vs 5.9%; p = 0.71), and acute renal failure events (10.2% vs 3.9%; p = 0.26). Multivariable analysis found that weekend discharges to home were significantly associated with readmission (OR, 4.5 (95% CI, 1.2-16.9); p = 0.03). Direct costs and patient satisfaction were similar.

Limitations: This study was limited by the heterogeneous patient population and by the potential effect of the intervention on providers taking care of patients randomly assigned to usual care.

Conclusions: A surveillance strategy to ensure compliance with an ileostomy education program tracked patients more closely and was cost neutral, but did not result in decreased hospital readmissions compared with usual care. See Video Abstract at
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March 2019

Rectal Prolapse.

Sarah A Vogler

Dis Colon Rectum 2017 11;60(11):1132-1135

Division of Colon and Rectal Surgery, University of Minnesota, Minneapolis, Minnesota.

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November 2017

The importance of extended postoperative venous thromboembolism prophylaxis in IBD: a National Surgical Quality Improvement Program analysis.

Dis Colon Rectum 2014 Apr;57(4):482-9

1Department of Surgery, University of Utah, Salt Lake City, Utah 2Department of Pediatrics, University of Utah, Salt Lake City, Utah.

Background: The National Comprehensive Cancer Network recommends that patients who have colorectal cancer receive up to 4 weeks of postoperative out-of-hospital venous thromboembolism prophylaxis. Patients with IBD are at high risk for venous thromboembolism, but there are no recommendations for routine postdischarge prophylaxis.

Objective: The purpose of this study was to compare the postoperative venous thromboembolism rate in IBD patients versus patients who have colorectal cancer to determine if IBD patients warrant postdischarge thromboembolism prophylaxis.

Design: This study is a retrospective review of IBD patients and patients who had colorectal cancer who underwent major abdominal and pelvic surgery.

Patients: Data were collected from the American College of Surgeons National Surgical Quality Improvement Program (2005-2010).

Main Outcome Measures: The primary outcome was 30-day postoperative venous thromboembolism in IBD patients and patients who had colorectal cancer. Risk factors for venous thromboembolism were analyzed with the use of univariate testing and stepwise logistic regression.

Results: A total of 45,964 patients were identified with IBD (8888) and colorectal cancer (37,076). The 30-day postoperative rate of venous thromboembolism in IBD patients was significantly higher than in patients who had colorectal cancer (2.7% vs 2.1%, p < 0.001). In a model with 15 significant covariates, the OR for venous thromboembolism was 1.26 (95% CI, 1.021-1.56; p = 0.03) for the IBD patients in comparison with the patients who have colorectal cancer.

Limitations: This study was limited by the retrospective design and the limitations of the data included in the database.

Conclusions: Patients with IBD had a significantly increased risk for postoperative venous thromboembolism in comparison with patients who had colorectal cancer. Therefore, postdischarge venous thromboembolism prophylaxis recommendations for IBD patients should mirror that for patients who have colorectal cancer. This would suggest a change in clinical practice to extend out-of-hospital prophylaxis for 4 weeks in postoperative IBD patients.
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April 2014

Sacrocolpopexy with rectopexy for pelvic floor prolapse improves bowel function and quality of life.

Dis Colon Rectum 2013 Dec;56(12):1415-22

1Department of Surgery, Hiroshima University, Hiroshima, Japan 2Department of Surgery, University of Utah, Salt Lake City, Utah 3Department of Gynecology, Abbott Northwestern Hospital, Minneapolis, Minnesota 4Division of Colon and Rectal Surgery, University of Minnesota, Minneapolis, Minnesota.

Background: Sacrocolpopexy with rectopexy is advocated for combined rectal and vaginal prolapse, but limited outcome data have been reported.

Objective: The purpose of this study was to evaluate the indications and outcomes of sacrocolpopexy and rectopexy by comparing pre- and postoperative function and quality of life.

Design: A retrospective review of prospectively collected data was performed of all patients undergoing sacrocolpopexy and rectopexy at our institution from 2004 to 2011.

Interventions And Outcome Measures: Preoperatively, all patients underwent physiology testing and completed 4 validated questionnaires assessing bowel symptom severity and associated quality of life. Patients completed the same questionnaires in 2012.

Results: A total of 110 women (median age, 55 years; range, 28-88) underwent a sacrocolpopexy and rectopexy, 33 with concomitant hysterectomy. All patients had rectal prolapse (n = 96) or rectal intussusception (n = 14), and each also had either enterocele (n = 86) or vaginal prolapse (n = 48). Rectal prolapse with enterocele was the most common presentation (n = 75). Previous surgery included rectal prolapse repair (21%) and hysterectomy (57%). Complications included presacral bleeding (n = 2), ureteral injury (n = 2), wound infection (n = 8), and pulmonary embolism (n = 2). There were no mortalities. Fifty-two patients completed the follow-up questionnaires, with a median follow-up of 29 (range, 4-90) months, and preoperative surveys were available in 30 of these patients. Preoperatively, 93% reported constipation; 82% reported resolution or improvement postoperatively. Constipation severity, measured with the Patient Assessment of Constipation Symptom Questionnaire, demonstrated improvement (1.86-1.17; p < 0.001). Fecal incontinence severity scores (Fecal Incontinence Severity Index) improved (39-24; p < 0.01), and 82% of incontinent patients reported cure or improvement. Quality-of-life scores also improved significantly. No patient developed recurrent rectal prolapse.

Limitations: This was a retrospective review, and the response rate to questionnaires was limited.

Conclusions: Sacrocolpopexy and rectopexy for combined middle and posterior compartment prolapse is a safe procedure, with low risk for recurrence, and improves bowel function and quality of life in most patients.
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December 2013

Readmission after colorectal surgery is related to preoperative clinical conditions and major complications.

Dis Colon Rectum 2013 Sep;56(9):1087-92

Division of Colon and Rectal Surgery, University of Minnesota, Minneapolis, MN 55455, USA.

Background: Hospital readmission is increasingly perceived as a marker of quality and is poorly investigated in patients receiving colorectal surgery.

Objective: The objective of this study was to describe patterns and etiology of readmission, to determine the rate of readmission, and to identify risk factors for readmission after colorectal surgery.

Design: This study is a retrospective medical chart review. Significant (p < 0.1) preoperative and perioperative factors associated with readmission on univariate analysis were examined in a multivariable model.

Setting: The investigation was conducted in a tertiary care hospital.

Patients: Patients included adults undergoing major colorectal operations by colorectal surgeons at the University of Minnesota in 2008-2009.

Main Outcome Measures: The primary outcome measure was hospital readmission at 60 days.

Results: The study included 220 patients. Common surgical indications were inflammatory bowel disease (21%), colorectal cancer (39%), and diverticular disease (13%), and 11% were emergencies. Readmissions at 60 days occurred in 25% (n = 54), mostly because of major complications (57%), nonspecific nausea, vomiting and/or pain (18%), dehydration (11%), and wound infections (11%). Predictors of readmission in multivariable analysis were major complications (OR, 13.0), female sex (OR, 5.9), prednisone use (OR, 4.3), BMI ≥30 (OR, 2.6), and preoperative weight loss (OR, 3.4). Age and comorbidity (Charlson score) were not predictors.

Limitations: This was a retrospective study at a single institution, with a small sample size.

Conclusions: Predictors of readmission were major complications and immediate preoperative condition of the patients. Comorbidity profiling does not capture readmission risk. Because most readmissions relate to complications, further efforts to prevent these will improve readmission rates.
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September 2013

Decompressive laparotomy for abdominal compartment syndrome in children: before it is too late.

J Pediatr Surg 2010 Jun;45(6):1324-9

Department of Surgery, University of Utah, Salt Lake City, UT 84113, USA.

Purpose: Abdominal compartment syndrome (ACS) in children is an infrequently reported, rapidly progressive, and often lethal condition underappreciated in the pediatric population. This underrecognition can result in a critical delay in diagnosis causing increased morbidity and mortality. This study examines the clinical course of patients treated for ACS at our institution.

Methods: A review of children requiring an emergency laparotomy (n = 264) identified 26 patients with a diagnosis of ACS. ACS was defined as sustained intraabdominal hypertension (bladder pressure >12 mm Hg) that was associated with new onset organ dysfunction or failure.

Results: Patients ranged in age from 3 months to 17 years old and were cared for in the pediatric intensive care unit (PICU). Twenty-seven percent (n = 7) were transferred from referring hospitals, 50% (n = 13) were admitted directly from the emergency department, and 23% (n = 6) were inpatients before being transferred to PICU. Admission diagnoses included infectious enterocolitis (n = 12), postsurgical procedure (n = 10), and others (n = 4). Patients progressed to ACS rapidly, with most requiring decompressive laparotomy within 8 hours of PICU admission (range, <1-96 hours). Preoperatively, all patients had maximum ventilatory support and oliguria, 85% (n = 22) required vasopressors/inotropes, and 31% (n = 8) required hemodialysis. Mean bladder pressure was 25 mm Hg (range, 12-44 mm Hg). In 42% (n = 11), cardiac arrest preceeded decompressive laparotomy. All patients showed evidence of tissue ischemia before decompressive laparotomy with an average preoperative lactate of 8 (range, 1.2-20). Decompressive laparotomy was done at the bedside in the PICU in 13 patients and in the operating room in 14 patients. Abdominal wounds were managed with open vacuum pack or silastic silo dressings. Physiologic data including fluid resuscitation, oxygen index, mean airway pressure, vasopressor score, and urine output were recorded at 6-hour intervals beginning 12 hours before decompressive laparotomy and extending 12 hours after operation. The data demonstrate improvement of all physiologic parameters after decompressive laparotomy except for urine output, which continued to be minimal 12 hours post intervention. Mortality was 58% (n = 15) overall. The only significant factor related to increased mortality was bladder pressure (P = .046; odds ratio, 1.258). Cardiac arrest before decompressive laparotomy, need for hemodialysis, and transfer from referring hospital also trended toward increased mortality but did not reach significance.

Conclusion: Abdominal compartment syndrome in children carries a high mortality and may be a consequence of common childhood diseases such as enterocolitis. The diagnosis of ACS and the potential need for emergent decompressive laparotomy may be infrequently discussed in the pediatric literature. Increased awareness of ACS may promote earlier diagnosis, treatment, and possibly improve outcomes.
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June 2010

Closed gastroschisis: total parenteral nutrition-free survival with aggressive attempts at bowel preservation and intestinal adaptation.

J Pediatr Surg 2008 Jun;43(6):1006-10

Department of Surgery, University of Utah, Salt Lake City, UT 84132, USA.

Background: In infants with gastroschisis antenatal closure of the umbilical defect results in a proximal atresia with ischemia and/or volvulus of the extracorporeal midgut. It has been described as "closed gastroschisis" or "vanishing midgut."

Methods: A 10-year review of 219 gastroschisis patients identified 10 infants with this rare complication.

Results: In these 10 infants, the extracorporeal midgut was invariably matted and fibrosed. In 3 cases, the midgut had completely "vanished." In the remaining 7 cases, the remnant midgut was surgically reduced into the abdominal cavity with care not to compromise the diminutive vascular pedicle. Abdominal exploration was performed several weeks later to reestablish bowel continuity; 4 required an ostomy and 2 underwent a serial transverse enteroplasty. Mean residual length of salvaged small bowel was 79 cm with retention of the distal half of the colon. Eight infants survived the initial hospitalization, with a mean length of stay of 121 days and mean hospital charge of $287,094. Six of the 7 long-term survivors have been completely weaned off total parenteral nutrition.

Conclusion: A nihilistic attitude toward infants with closed gastroschisis may not be uniformly supported because in the majority of these infants' long-term independence from total parenteral nutrition was achieved.
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June 2008