Publications by authors named "Scott R Steele"

305 Publications

Is Intestinal Diversion an Effective Treatment for Distal Crohn's Disease?

Inflamm Bowel Dis 2021 Jun 2. Epub 2021 Jun 2.

Division of Colon and Rectal Surgery, Cedars-Sinai Medical Center, Los Angeles, California, USA.

Background: Fecal diversion with an ileostomy is selectively used in cases of medically refractory Crohn's proctocolitis or advanced perianal disease. The aim of this study was to evaluate clinical improvement after fecal diversion in Crohn's disease (CD) and factors associated with clinical improvement.

Methods: A retrospective chart review of adult CD patients undergoing ileostomy formation for distal disease between 2000 and 2019 at 2 CD referral centers was conducted. The primary outcome was the rate of clinical improvement with diversion that allowed for successful restoration of intestinal continuity. Secondary outcomes included the rate of clinical and endoscopic improvement after fecal diversion, ileostomy morbidity, need for subsequent total proctocolectomy and end ileostomy, and factors associated with a clinical response to fecal diversion.

Results: A total of 132 patients with a median age of 36 years (interquartile range, 25-49) were included. Mean duration of disease was 16.2 years (10.4) years. Indication for surgery was medically refractory proctocolitis with perianal disease (n = 59; 45%), perianal disease alone (n = 24; 18%), colitis (n = 37; 28%), proctitis (n = 4; 3%), proctocolitis alone (n = 4; 3%), and ileitis with perianal disease (n = 4; 3%). Medications used before surgery included corticosteroids (n = 59; 45%), immunomodulators (n = 55; 42%) and biologics (n = 82; 62%). The clinical and endoscopic response to diversion was 43.2% (n = 57) and 23.9% (n = 16). At a median follow-up of 35.3 months (interquartile range, 10.6-74.5), 25 patients (19%) had improved and had ileostomy reversal, but 86 (65%) did not improve, with 50 (38%) undergoing total proctocolectomy for persistent symptoms. There were no significant predictors of clinical improvement.

Conclusions: The use of a "temporary" ileostomy is largely ineffective in achieving clinical response.
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http://dx.doi.org/10.1093/ibd/izab126DOI Listing
June 2021

Anal Squamous Cell Carcinoma in Ulcerative Colitis: Can Pouches Withstand Traditional Treatment Protocols?

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

Department of Colorectal Surgery, Digestive Disease Surgical Institute, Cleveland Clinic, Cleveland, Ohio General Surgery, Digestive Disease Surgical Institute, Cleveland Clinic, Cleveland, Ohio Department of Gastroenterology, Digestive Disease Surgical Institute, Cleveland Clinic, Cleveland, Ohio.

Background: Anal squamous cell carcinoma has rarely reported in ulcerative colitis.

Objective: Understand the prognosis of anal squamous cell carcinoma in the setting of ulcerative colitis.

Design: Retrospective review.

Setting: Referral center.

Patients: Adult patients with both ulcerative colitis (556.9/K51.9) and anal squamous cell carcinoma (154.3/C44.520) between January 1, 2000 to August 1, 2019.

Main Outcomes Measures: Treatment and survival of anal squamous cell carcinoma.

Results: Seventeen adult patients with ulcerative colitis and anal dysplasia and/or anal squamous cell carcinoma were included out of 13,499 ulcerative colitis patients treated; 6 had a diagnosis of anal squamous cell carcinoma, 8 had high grade squamous intraepithelial lesions, and 3 had low grade squamous intraepithelial lesions. There were 4 males (23%) and median age of 55 years (range, 32-69) years. At diagnosis, 6 had an ileal pouch anal anastomosis of which 5 had active pouchitis, 1 had an ileorectal anastomosis with active proctitis, 1 had a Hartman's stump with disuse proctitis, 5 had pancolitis, and 4 had left sided colitis. Of the 6 with anal squamous cell carcinoma, all received 5-FU and mitomycin C with external beam radiation therapy. Four patients had an ileal pouch anal anastomosis, all of whom required intestinal diversion or pouch excision due to treatment intolerance. At a median follow-up of 60 months, three patients experienced mortality: one at 0 months (treatment related myocardial infarction), one at 60 months (metastatic anal squamous cell carcinoma), and one at 129 months (malignant peripheral nerve sheath tumor); the remaining had no residual disease.

Limitations: Retrospective, small number of patients.

Conclusion: Anal squamous cell carcinoma in the setting of ulcerative colitis is extremely rare. In the setting of IPAA, diversion may be necessary to prevent radiation intolerance. Careful examination of the perianal region should be performed at the time of surveillance endoscopy. See Video Abstract at http://links.lww.com/DCR/B582.
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http://dx.doi.org/10.1097/DCR.0000000000002011DOI Listing
April 2021

Perfusion Assessment in Left-Sided/Low Anterior Resection (PILLAR III): A Randomized, Controlled, Parallel, Multicenter Study Assessing Perfusion Outcomes with PINPOINT Near-Infrared Fluorescence Imaging in Low Anterior Resection.

Dis Colon Rectum 2021 Apr 13. Epub 2021 Apr 13.

University of California, Irvine, Orange, CA Kaiser Permanente LAMC, Los Angeles, CA Washington University School of Medicine, St Louis, MO Houston Methodist Hospital, Houston, TX University of South Florida, Tampa, FL Suburban Surgical Associates, St Louis, MO University of Cincinnati Physicians, Cincinnati, OH University of Nevada School of Medicine Johns Hopkins University, Baltimore, MD MD Anderson Cancer Center - Baptist Medical Center, Jacksonville, FL University of California, San Francisco, San Francisco, CA Ochsner Clinic Foundation, New Orleans, LA NSLIJ/Hofstra North Shore School of Medicine At Lenox Hill Hospital, New York, NY Mount Sinai, New York, NY Medical College of South Carolina, Charleston, SC Baylor University Medical Center, Dallas, TX Cleveland Clinic Foundation, Cleveland, OH.

Background: Indocyanine green fluoroscopy has been shown to improve anastomotic leak rates in early phase trials.

Objective: We hypothesized that the use of fluoroscopy to ensure anastomotic perfusion may decrease anastomotic leak following low anterior resection.

Design: We performed a 1:1 randomized, controlled, parallel study. Recruitment of 450-1000 patients was planned over 2-years.

Setting: Multicenter.

Patients: Patients undergoing resection defined as anastomosis within 10cm of anal verge.

Intervention: Patients underwent standard evaluation of tissue perfusion versus standard in conjunction with perfusion evaluation using indocyanine green fluoroscopy.

Main Outcome Measure: Primary outcome was anastomotic leak, with secondary outcomes of perfusion assessment and the rate of postoperative abscess requiring intervention.

Results: This study was concluded early due to decreasing accrual rates. A total of 25 centers recruited 347 patients, of which 178 were randomized to perfusion and 169 to standard. The groups had comparable tumor-specific and patient-specific demographics. Neoadjuvant chemoradiation was performed in 63.5% of perfusion and 65.7% of standard (p>0.05). Mean level of anastomosis was 5.2+3.1cm in perfusion compared to 5.2+3.3cm in standard (p>0.05). Sufficient visualization of perfusion was reported in 95.4% of patients in the perfusion group. Postoperative abscess requiring surgical management was reported in 5.7% of PFN and 4.2% of standard (p=0.75). Anastomotic leak was reported in 9.0% of perfusion compared to 9.6% of standard (p=0.37). On multivariate regression analysis, there was no difference in anastomotic leak rates between perfusion and standard (OR 0.845; 95% CI (0.375, 1.905); p=0.34).

Limitations: The pre-determined sample size to adequately reduce the risk of type II error was not achieved.

Conclusion: Successful visualization of perfusion can be achieved with ICG-F. However, no difference in anastomotic leak rates was observed between patients who underwent perfusion assessment versus standard surgical technique. In experienced hands, the addition of routine ICG-F to standard practice adds no evident clinical benefit. See Video Abstract at http://links.lww.com/DCR/B560 .
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http://dx.doi.org/10.1097/DCR.0000000000002007DOI Listing
April 2021

Defining the Economic Burden of Perioperative Venous Thromboembolism in Inflammatory Bowel Disease in the United States.

Dis Colon Rectum 2021 07;64(7):871-880

Department of Colon & Rectal Surgery, Cleveland Clinic, Cleveland, Ohio.

Background: Patients with IBD are at increased risk of venous thromboembolism.

Objective: This study aims to define the economic burden associated with inpatient venous thromboembolism after surgery for IBD that presently remains undefined.

Design: This study is a retrospective, cross-sectional analysis using the National Inpatient Sample from 2004 to 2014.

Setting: Participating hospitals across the United States were sampled.

Patients: The International Classification of Diseases, 9th Revision codes were used to identify patients with a primary diagnosis of IBD.

Interventions: Major abdominopelvic bowel surgery was performed.

Main Outcome Measures: The primary outcome measured was the occurrence of inpatient venous thromboembolism. Univariate and multivariable patient- and hospital-level logistic regression models were used to compare patient characteristics, hospital characteristics, and outcomes between venous thromboembolism and non-venous thromboembolism cohorts. Total average direct costs were then compared between cohorts, and the resulting difference was extrapolated to the national population.

Results: Of 26,080 patients included, inpatient venous thromboembolism was identified in 581 (2.2%). On multivariable analysis, diagnosis of ulcerative colitis, transfer status, length of preoperative hospitalization, and insurance status were independently associated with inpatient venous thromboembolism. Patients with venous thromboembolism were observed to be associated with an increased median length of stay (17.6 vs 6.7 days; p < 0.001) and higher inpatient mortality (5.0% vs 1.1%; OR 4.7, SE 3.2-7.0; p < 0.001). After adjusting for clinically relevant covariates, the additional cost associated with each inpatient venous thromboembolism was $31,551 (95% CI, $29,136-$33,965).

Limitations: Our study is limited by the administrative nature of the National Inpatient Sample database, which limits our ability to evaluate the impact of clinical covariates (eg, use of venous thromboembolism chemoprophylaxis, steroid use, and nutrition status).

Conclusion: Inpatient venous thromboembolism in abdominopelvic surgery for IBD is an infrequent, yet costly, morbid complication. Given the magnitude of patient morbidity and economic burden, venous thromboembolism prevention should be a national quality improvement and research priority. See Video Abstract at http://links.lww.com/DCR/B544.

Definicin Impacto Econmico De La Tromboembolia Venosa Perioperatoria En La Enfermedad Inflamatoria Intestinal En Los Estados Unidos: ANTECEDENTES:Pacientes con enfermedad inflamatoria intestinal (EII) tienen un mayor riesgo de tromboembolismo venoso (TEV).OBJETIVO:Definir el impacto económico de TEV hospitalaria después de la cirugía por EII, que en la actualidad permanece indefinida.DISEÑO:Un análisis transversal retrospectivo utilizando la Muestra Nacional de Pacientes Internos (NIS) de 2004 a 2014.ENTORNO CLINICO:Hospitales participantes muestreados en los Estados Unidos.PACIENTES:Se utilizaron los códigos de la 9ª edición de la Clasificación Internacional de Enfermedades (ICD-9) para identificar a los pacientes con diagnóstico primario de EII.INTERVENCIONES:Cirugía mayor abdominopélvica intestinal.PRINCIPALES MEDIDAS DE VALORACION:Incidencia de TEV en pacientes hospitalizados, utilizando modelos de regresión logística univariado y multivariable a nivel de pacientes y hospitales para comparar las características de los pacientes, las características del hospital y los resultados entre las cohortes de TEV y no TEV. Se compararon los costos directos promedio totales entre cohortes y la diferencia resultante extrapolando a la población nacional.RESULTADOS:De 26080 pacientes incluidos, se identificó TEV hospitalario en 581 (2,2%). En análisis multivariable, el diagnóstico de colitis ulcerosa, el estado de transferencia (entre centros hospitalarios), la duración de la hospitalización preoperatoria y el nivel de seguro medico se asociaron de forma independiente con la TEV hospitalaria. Se observó que los pacientes con TEV se asociaron con un aumento de la duración media de la estancia (17,6 versus a 6,7 días; p <0,001) y una mayor mortalidad hospitalaria (5,0% versus a 1,1%; OR 4,7, SE 3,2 -7,0; p <0,001). Después de ajustar las covariables clínicamente relevantes, el costo adicional asociado con cada TEV para pacientes hospitalizados fue de $ 31,551 USD (95% C.I. $ 29,136 - $ 33,965).LIMITACIONES:Estudio limitado por la naturaleza administrativa de la base de datos del NIS, que limita nuestra capacidad para evaluar el impacto de las covariables clínicas (por ejemplo, el uso de quimioprofilaxis de TEV, el uso de esteroides y el estado nutricional).CONCLUSIÓN:TEV hospitalaria en la cirugía abdominopélvica para la EII es una complicación mórbida infrecuente, pero costosa. Debido a la magnitud de la morbilidad el impacto económico, la prevención del TEV debería ser una prioridad de investigación y para mejoría de calidad a nivel nacional. Consulte Video Resumen en http://links.lww.com/DCR/B544.
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http://dx.doi.org/10.1097/DCR.0000000000001942DOI Listing
July 2021

Ileal pouch-anal anastomosis in the elderly: A systematic review and meta-analysis.

Colorectal Dis 2021 Apr 7. Epub 2021 Apr 7.

Department of Colorectal Surgery, Digestive Disease Surgical Institute, Cleveland Clinic, Cleveland, OH, USA.

Aim: Despite good overall outcomes in most patients undergoing ileal pouch-anal anastomosis (IPAA), there is still hesitation about performing an IPAA in older patients due to the comorbidity burden and concern about incontinence. The aim of this work was to identify short- and long-term outcomes in older patinets undergoing IPAA to determine the perioperative safety and long-term functional success of IPAA in older patients.

Method: A literature search was performed for all publications on IPAA in adults aged ≥50 years that reported short- and long-term outcomes. Data extraction included demographics, 30-day outcomes, long-term functional outcomes and pouch failure. Data were further separated by age group (50-65 and ≥65 years). Outcomes were compared between age groups. Study quality and risk of bias was assessed using the Newcastle-Ottawa Scale.

Results: Of 1053 publications reviewed, 13 full papers were included in the analysis. The overall 30-day morbidity and mortality rates were 47.3% and 1.3%, respectively. Thirty-day postoperative rates of small bowel obstruction and pelvic sepsis were 7.6% and 9.9%, respectively. After a median follow-up time of 62 months, rates of pouchitis, incontinence and pouch failure were 13.9%, 17.5% and 7.5%, respectively. There was no statically significant difference in rates of short- or long-term functional outcomes based on age 50-65 versus ≥65 years.

Conclusion: Increasing age did not increase the rate of short- or long-term outcomes, including pouch failure. These data suggest that the decision for IPAA construction should not be based on age alone.
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http://dx.doi.org/10.1111/codi.15665DOI Listing
April 2021

Sergio Eduardo Alonso Araujo, MD, PhD, FASCRS.

Authors:
Scott R Steele

Clin Colon Rectal Surg 2021 May 29;34(3):127-128. Epub 2021 Mar 29.

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

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http://dx.doi.org/10.1055/s-0040-1718690DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8007237PMC
May 2021

Jason Hall, MD, FACS, MPH.

Authors:
Scott R Steele

Clin Colon Rectal Surg 2021 Mar 24;34(2):77-78. Epub 2021 Feb 24.

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

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http://dx.doi.org/10.1055/s-0040-1716696DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7904333PMC
March 2021

Sarah A. Vogler, MD, MBA, FACS, FASCRS.

Authors:
Scott R Steele

Clin Colon Rectal Surg 2021 Jan 30;34(1):1-2. Epub 2020 Oct 30.

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

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http://dx.doi.org/10.1055/s-0040-1714243DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7843942PMC
January 2021

Intraoperative Colonoscopy During Colorectal Surgery Does Not Increase Postoperative Complications: An Assessment From the ACS-NSQIP Procedure-targeted Cohort.

Surg Laparosc Endosc Percutan Tech 2021 Jan 12. Epub 2021 Jan 12.

Department of Colorectal Surgery, Digestive Disease and Surgery Institute, Cleveland Clinic, Cleveland, OH.

Intraoperative colonoscopy (IOC) is an adjunct in colorectal surgery to detect the location of the lesions and assessing anastomotic integrity. The authors aimed to evaluate the safety and feasibility and postoperative morbidity of IOC in left-sided colectomy patients for colorectal cancer. Patients undergoing elective left-sided colectomy without any proximal diversion for colorectal cancer between 2013 and 2016 were reviewed from the American College of Surgeons National Surgical Quality Improvement Program procedure-targeted database. Demographics, comorbidities, short-term outcomes, and postoperative morbidity of patients were evaluated. A total of 8811 patients were identified and IOC was performed for 1143 (12.97%) patients. There was no significant difference in postoperative complications between the IOC and non-IOC groups. Patients with IOC had shorter total hospital length of stay. The use of IOC does not adversely affect short-term outcomes after colorectal resections. Surgeons may utilize IOC liberally for left-sided colorectal resections.
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http://dx.doi.org/10.1097/SLE.0000000000000907DOI Listing
January 2021

Pushing the Envelope in Endoscopic Submucosal Dissection: Is It Feasible and Safe in Scarred Lesions?

Dis Colon Rectum 2021 Mar;64(3):343-348

Digestive Diseases and Surgery Institute, Cleveland Clinic, Cleveland, Ohio.

Background: Endoscopic submucosal dissection is an established advanced polypectomy technique to manage large colorectal polyps.

Objective: The purpose of this study was to evaluate patients who had endoscopic submucosal dissection in the setting of significant scarring attributed to a previous intervention to determine whether this is safe and feasible.

Design: The study used a prospectively maintained database.

Settings: A scarred lesion was defined as a nonlifting polyp with a history of previous attempted removal with endoscopic mucosal resection, snare, or biopsy where there was no suspicion of malignancy.

Patients: All consecutive patients in the previous 14 months were included.

Intervention: Endoscopic submucosal dissection was the study intervention.

Main Outcome Measures: Thirty-day morbidity and mortality, readmission, length of stay, and recurrence were measured.

Results: Ninety-one patients had endoscopic submucosal dissection over a 14-month period with a median polyp size of 31.5 mm (range, 20-45 mm). Eleven patients (12%) were confirmed as having significant scar. There were significantly more previous endoscopic mucosal resections in the scarred group (scarred: 63.6% vs nonscarred: 2.5%; p < 0.001). Significantly more of the scarred patients had their endoscopic submucosal dissection in the operating room versus the endoscopy suite (scarred: 82.0% vs nonscarred: 17.5%; p < 0.001). The 30-day morbidity rate was 18.7%. There were no mortalities. There was no difference in 30-day morbidity between scarred and nonscarred lesions (scarred: 9% vs nonscarred: 20%; p = 0.4). There were more day-case procedures in the nonscarred group (nonscarred: 93.7% vs scarred: 36.4%; p < 0.001). There was no malignancy on final pathology in the scarred group. There was no difference in readmission rate between the scarred and nonscarred lesions. The overall follow-up colonoscopy rate was 53%, and there were no polyp recurrences identified.

Limitations: The study was limited by its small sample size, single institute, surgeon experience, and short follow-up.

Conclusions: Not only is endoscopic submucosal dissection in patients who have scarred lesions technically feasible and safe, it avoids a bowel resection in the majority of patients who have exhausted other advanced endoscopy techniques. See Video Abstract at http://links.lww.com/DCR/B427.

Empujar El Sobre En La Diseccin Endoscpica Submucosa Es Factible Y Seguro En Lesiones Cicatrizadas: ANTECEDENTES:La disección endoscópica submucosa es una técnica de polipectomía avanzada establecida para tratar pólipos colorrectales grandes.OBJETIVO:Evaluar a pacientes que se sometieron a disección submucosa endoscópica en el contexto de cicatrices significativas debido a una intervención previa para determinar si esto es seguro y factible.DISEÑO:Base de datos mantenida prospectivamente.AJUSTE:Una lesión cicatrizada se definió como un pólipo que no se levanta con antecedentes de intento de extirpación previa con resección endoscópica de la mucosa, lazo o biopsia, donde no había sospecha de malignidad.PACIENTES:Todos los pacientes consecutivos en los últimos 14 meses.INTERVENCIÓN:Disección submucosa endoscópica.MEDIDAS DE RESULTADOS PRINCIPALES:Morbilidad y mortalidad a 30 días, reingreso, duración de la estadía, recurrencia.RESULTADOS:Noventa y un pacientes tuvieron disección submucosa endoscópica durante un período de 14 meses con tamaño de pólipo mediana de 31,5 mm (rango, 20 - 45 mm). Se confirmó que once pacientes (12%) tenían una cicatriz significativa. Hubo significativamente más resecciones de mucosa endoscópica previas en el grupo con cicatrices (con cicatrices: 63,6% vs. sin cicatrices: 2,5%, p <0,001). Significativamente más de los pacientes con cicatrices tuvieron su disección submucosa endoscópica en el quirófano en comparación con la sala de endoscopia (con cicatrices: 82% vs. sin cicatrices: 17.5%, p <0.001). La tasa de morbilidad a 30 días fue del 18,7%. No hubo muertes. No hubo diferencia en la morbilidad a 30 días entre las lesiones cicatrizadas y no cicatrizadas (cicatrizadas: 9% frente a no cicatrizadas: 20%, p = 0,4). Hubo más procedimientos ambulatorios en el grupo sin cicatrices (sin cicatrices: 93,7% frente a cicatrices: 36,36%, p <0,001). No hubo malignidad en la patología final en el grupo con cicatrices. No hubo diferencia en la tasa de reingreso entre las lesiones cicatrizadas y no cicatrizadas. La tasa general de colonoscopia de seguimiento fue del 53% y no se identificaron recurrencias de pólipos.LIMITACIONES:Tamaño de muestra pequeño, experiencia de un solo instituto y cirujanos y seguimiento corto.CONCLUSIÓN:La disección endoscópica submucosa en pacientes con lesiones cicatrizadas no solo es técnicamente factible y segura, sino que evita una resección intestinal en la mayoría de los pacientes que han agotado otras técnicas endoscópicas avanzadas. Consulte Video Resumen en http://links.lww.com/DCR/B427.
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http://dx.doi.org/10.1097/DCR.0000000000001870DOI Listing
March 2021

Evaluation of Factors Associated With Successful Matriculation to Colon and Rectal Surgery Fellowship.

Dis Colon Rectum 2021 02;64(2):234-240

National Cancer Institute, National Institutes of Health, Bethesda, Maryland.

Background: As an increasing number of general surgery residents apply for fellowship positions, it is important to identify factors associated with successful matriculation. For applicants to colon and rectal surgery, there are currently no objective data available to distinguish which applicant attributes lead to successful matriculation.

Objective: The purpose of this study was to identify objective factors that differentiate colon and rectal surgery fellowship applicants who successfully matriculate with those who apply but do not matriculate.

Design: This was a retrospective analysis of colon and rectal surgery applicant characteristics.

Settings: Deidentified applicant data provided by the Association of American Medical Colleges from 2015 to 2017 were included.

Main Outcome Measures: Applicant demographics, medical school and residency factors, number of program applications, number of publications, and journal impact factors were analyzed to determine associations with successful matriculation.

Results: Most applicants (n = 371) and subsequent matriculants (n = 248) were white (61%, 62%), male (65%, 63%), US citizens (80%, 88%) who graduated from US allopathic medical schools (66%, 75%). Statistically significant associations included graduation from US allopathic medical schools (p < 0.0001), US citizenship (p < 0.0001), and number of program applications (p = 0.0004). Other factors analyzed included American Osteopathic Association membership (p = 0.57), university-based residency (p = 0.51), and residency association with a colon and rectal surgery training program (p = 0.89). Number of publications and journal impact factors were not statistically different between cohorts (p = 0.067, p = 0.150).

Limitations: American Board of Surgery In-Training Examination scores, rank list, and subjective characteristics, such as strength of interview and letters of recommendation, were not available using our data source.

Conclusions: Successful matriculation to a colon and rectal surgery fellowship program was found to be associated with US citizenship, graduation from a US allopathic medical school, and greater number of program applications. The remaining objective metrics analyzed were not associated with successful matriculation. Subjective and objective factors that were unable to be measured by this study are likely to play a determining role. See Video Abstract at http://links.lww.com/DCR/B415.

Evaluacin De Factores Vinculados En La Inmatriculacin Exitosa Para Becas De Ciruga Colorrectal: ANTECEDENTES:A medida que un número cada vez mayor de residentes de Cirugía General solicitan una beca, es importante identificar los factores vinculados con una inmatriculación exitosa. Para los candidatos a una beca en Cirugía Colorrectal, hoy en día no existen datos objetivos disponibles para distinguir qué atributos del solicitante conducen a una inmatriculación exitosa.OBJETIVO:Identificar objetivamente los factores que diferencian un candidato a una beca en Cirugía Colorrectal que se inmatricula con éxito de aquel que aplica pero no llega a inmatricularse.DISEÑO:Análisis retrospectivo de las características de los solicitantes de beca para Cirugía Colorrecatl.AJUSTES:Datos de los solicitantes no identificados, proporcionados por la Asociación de Colegios Médicos Estadounidenses de 2015 a 2017.PRINCIPALES MEDIDAS DE RESULTADO:Se analizaron los factores demográficos del solicitante, las facultades de medicina y los factores de la residencia, el número de solicitudes de programas, el número y el factor de impacto de las publicaciones realizadas para determinar la asociación con una inmatriculación exitosa.RESULTADOS:La mayoría de los solicitantes (n = 371) que posteriormente fueron inmatriculados exitosamente (n = 248) eran blancos (61%, 62%, respectivamente), hombres (65%, 63%), ciudadanos estadounidenses (80%, 88%) que se graduaron de Facultades de medicina alopática en los EE. UU. (66%, 75%). Las asociaciones estadísticamente significativas incluyeron la graduación de las escuelas de medicina alopática de los EE. UU. (P <0,0001), la ciudadanía de los EE. UU. (P <0,0001) y el número de solicitudes de programas (p = 0,0004). Otros factores analizados incluyeron: membresía AOA (p = 0,57), la residencia universitaria (p = 0,51) y asociación de la residencia con un programa de formación en Cirugía Colorrectal (p = 0,89). El número de publicaciones y los factores de impacto de las revistas no fueron estadísticamente diferentes entre las cohortes (p = 0,067, p = 0,15, respectivamente).LIMITACIONES:El Score ABSITE, la posición en lista de clasificación y las características subjetivas como el de una buena entrevista y las cartas de recomendación no se encontraban disponibles en la fuente de datos.CONCLUSIONES:Se encontró que la inmatriculación exitosa a un programa de becas de Cirugía Colorreectal estaba asociada con la ciudadanía estadounidense, la graduación en una Facultad de medicina alopática en los EE. UU, y al mayor número de solicitudes de programas. El analisis de las medidas objetivas restantes no se asociaron con una inmatriculación exitosa. Es probable que los factores subjetivos y objetivos que no pudieron ser medidos por este estudio jueguen un papel determinante. Consulte Video Resumen en http://links.lww.com/DCR/B415. (Traducción-Dr Xavier Delgadillo).
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http://dx.doi.org/10.1097/DCR.0000000000001849DOI Listing
February 2021

Surgical intervention for mechanical large bowel obstruction at a tertiary hospital: Which patients receive a stoma and how often are they reversed?

Am J Surg 2021 03 18;221(3):594-597. Epub 2020 Nov 18.

Department of Colorectal Surgery, Digestive Disease and Surgery Institute, Cleveland Clinic, Cleveland, OH, USA. Electronic address:

Background: The surgical management of large bowel obstruction (LBO) is heterogeneous and influenced by multiple variables. The aim of this study was to analyze and compare the surgical interventions and outcomes of patients necessitating surgery for LBO.

Methods: Patients with LBO between 2000 and 2017 were included. Main outcomes measures are intraoperative findings, operative management, post-operative outcomes and stoma closure rates.

Results: 133 patients were included with predominately left-sided obstruction (82%). The most common etiology was colorectal cancer (44%) followed by extrinsic malignant compression (29%). The most common operation performed was fecal diversion without resection (46%). This group had significantly more stage 4 carcinoma, carcinomatosis and had the lowest stoma closure rate (16%). Eighty-six percent of the operated patients underwent fecal diversion, of these, 27% had stoma reversal at 6 months. Patients that had a resection and anastomosis with diverting loop ileostomy were most likely to undergo stoma reversal (p = 0.005) and had the lowest number of patients with stage-IV carcinoma.

Conclusions: In this single institution analysis, the management of LBO entails high operative and stoma rates, with less than 30% of patient undergoing stoma closure. Resection, anastomosis and DLI had the highest chance of stoma reversal.
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http://dx.doi.org/10.1016/j.amjsurg.2020.11.029DOI Listing
March 2021

Prevention and Treatment of Stricturing Crohn's Disease - Perspectives and Challenges.

Expert Rev Gastroenterol Hepatol 2021 Apr 28;15(4):401-411. Epub 2020 Dec 28.

Department of Gastroenterology, Hepatology & Nutrition, Digestive Diseases and Surgery Institute, Cleveland Clinic Foundation, Cleveland, Ohio, USA.

: Fibrostenosis is a hallmark of Crohn's disease (CD), remains a challenge in today's clinical management of inflammatory bowel disease patients and represents a key event in the disease course necessitating improved preventative strategies and a multidisciplinary approach to diagnosis and management. With the advent of anti-fibrotic therapies and well-defined clinical endpoints for stricturing CD, there is promise to impact the natural history of disease.: This review summarizes current evidence in the natural history of stricturing Crohn's disease, discusses management approaches as well as future perspectives on intestinal fibrosis.: Currently, there are no specific therapies to prevent progression to fibrosis or to treat it after it becomes clinically apparent. In addition to the international effort by the Stenosis Therapy and Anti-Fibrotic Research (STAR) consortium to standardize definitions and propose endpoints in the management of stricturing CD, further research to improve our understanding of mechanisms of intestinal fibrosis will help pave the way for the development of future anti-fibrotic therapies.
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http://dx.doi.org/10.1080/17474124.2021.1854732DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8026566PMC
April 2021

Clinical staging accuracy and the use of neoadjuvant chemoradiotherapy for cT3N0 rectal cancer: Propensity score matched National Cancer Database analysis.

Am J Surg 2021 03 17;221(3):561-565. Epub 2020 Nov 17.

Digestive Disease & Surgery Institute, Cleveland Clinic, United States.

Background: While neoadjuvant chemoradiation therapy (nCRT) is accepted as standard of care for locally advanced rectal cancer, the approach to treatment of patients with clinically staged T3N0 disease has been increasingly debated. This study examines the accuracy of clinical staging for cT3N0 rectal cancer as recorded in the National Cancer Data Base and evaluates the role of nCRT in treating these patients.

Methods: Total of 15,843 patients with clinically staged T3N0M0 rectal cancer who either received nCRT or proceeded to surgery-first met inclusion criteria. Propensity score matching was employed to balance the groups.

Results: 23% of cT3N0 patients undergoing surgery-first were found to have pathologically positive nodes. Another 16% turned out to have < stage II disease on surgical pathology. Survival curves for matched nCRT and surgery-first groups demonstrated a survival advantage for cT3N0 patients treated with nCRT.

Conclusions: Poor clinical staging accuracy can result in both undertreatment and overtreatment of cT3N0 rectal cancer.
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http://dx.doi.org/10.1016/j.amjsurg.2020.11.030DOI Listing
March 2021

Serious Gastrointestinal Complications After Cardiac Surgery and Associated Mortality.

Ann Thorac Surg 2020 Nov 18. Epub 2020 Nov 18.

Department of Thoracic and Cardiovascular Surgery, Cleveland Clinic, Cleveland, Ohio.

Background: Severe gastrointestinal (GI) complications (GICs) after cardiac surgery are associated with poor outcomes. Herein, we characterize the severe forms of GICs and associated risk factors of mortality.

Methods: We retrospectively analyzed the clinically significant postoperative GICs after cardiac surgical procedures performed at our institution from January 2010 to April 2017. Multivariable analysis was used to identify predictors for in-hospital mortality.

Results: Of 29,909 cardiac surgical procedures, GICs occurred in 1037 patients (3.5% incidence), with overall in-hospital mortality of 14% compared with 1.6% in those without GICs. GICs were encountered in older patients with multiple comorbidities who underwent complex prolonged procedures. The most lethal GICs were mesenteric ischemia (n = 104), hepatopancreatobiliary (HPB) dysfunction (n = 139), and GI bleeding (n = 259), with mortality rates of 45%, 27%, and 17%, respectively. In the mesenteric ischemia subset, coronary artery disease (odds ratio [OR], 4.57; P = .002], coronary bypass grafting (OR, 6.50; P = .005), reoperation for bleeding/tamponade (OR, 12.07; P = .01), and vasopressin use (OR, 11.27; P < .001) were predictors of in-hospital mortality. In the HPB complications subset, hepatic complications occurred in 101 patients (73%), pancreatitis in 38 (27%), and biliary disease in 31 (22%). GI bleeding occurred in 20 patients (31%) with HPB dysfunction. In the GI bleeding subset, HPB disease (OR, 10.99; P < .001) and bivalirudin therapy (OR, 12.84; P = .01) were predictors for in-hospital mortality.

Conclusions: Although relatively uncommon, severe forms of GICs are associated with high mortality. Early recognition and aggressive treatment are mandatory to improve outcomes.
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http://dx.doi.org/10.1016/j.athoracsur.2020.09.034DOI Listing
November 2020

The Authors Reply.

Dis Colon Rectum 2020 09;63(9):e512-e513

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http://dx.doi.org/10.1097/DCR.0000000000001737DOI Listing
September 2020

Tsuyoshi Konishi, MD, PhD.

Authors:
Scott R Steele

Clin Colon Rectal Surg 2020 Nov 2;33(6):325-326. Epub 2020 Nov 2.

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

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http://dx.doi.org/10.1055/s-0040-1714233DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7653861PMC
November 2020

Venkatesh Munikrishnan, MRCS(Ed), FRCS(Ed), CCT(UK), Manish Chand, MBBS, BSc, FRCS, FASCRS, MBA, PhD.

Authors:
Scott R Steele

Clin Colon Rectal Surg 2020 Sep 21;33(5):243-244. Epub 2020 Sep 21.

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

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http://dx.doi.org/10.1055/s-0040-1715122DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7505696PMC
September 2020

The "One" Behind the Algorithm.

Authors:
Scott R Steele

Ann Surg 2021 03;273(3):e103-e104

Rupert B. Turnbull MD Endowed Chair in Colorectal Surgery, Department of Colorectal Surgery, Cleveland Clinic, Cleveland, OH.

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http://dx.doi.org/10.1097/SLA.0000000000004304DOI Listing
March 2021

A Paradigm Shift in Physician Reimbursement: A Model to Align Reimbursement to Value in Laparoscopic Colorectal Surgery in the United States.

Dis Colon Rectum 2020 10;63(10):1446-1454

Department of Colorectal Surgery, Digestive Disease and Surgical Institute, Cleveland Clinic Foundation, Cleveland, Ohio.

Background: Despite common beliefs, underuse of laparoscopic colorectal surgery remains an issue. A paradigm shift to increase laparoscopy and align payment with effort is needed, with pressures to improve value.

Objective: The purpose of this study was to compare reimbursement across surgical approach and payer for common colorectal procedures and to propose a novel way to increase use in the United States.

Data Sources: Centers for Medicare & Medicaid Services (Medicare) reimbursement and commercial claims data from 2012 to 2015 were used.

Study Selection: Reimbursement across payers was mapped for the 10 most common colorectal procedures using the open and laparoscopic approaches.

Main Outcome Measures: The reimbursement difference across approaches by payer and potential value proposition from a cost-shifting model increasing reimbursement with corresponding increases in laparoscopic use was measured.

Results: For Medicare, reimbursement was lower laparoscopically than open for the majority. With commercial, laparoscopy was reimbursed less for 3 procedures. When laparoscopic reimbursement was higher, the amount was not substantial. Medicare payments were consistently lower than commercial, with corresponding lower reimbursement for laparoscopy. Increasing reimbursement by 10%, 20%, and 30% resulted in significant cost savings with laparoscopy. Savings were amplified with increasing use, with additional savings over baseline at all levels, except 30% reimbursement/10% increased use.

Limitations: The study was limited by the use of claims data, which could have coding errors and confounding in the case mix across approaches.

Conclusions: Reimbursement for laparoscopic colorectal surgery is comparatively lower than open. Reimbursement can be increased with significant overall cost savings, as the reimbursement/case is still less than total cost savings with laparoscopy compared with open cases. Incentivizing surgeons toward laparoscopy could drive use and improve outcomes, cost, and quality as we shift to value-based payment. See Video Abstract at http://links.lww.com/DCR/B290. CAMBIOS EN LOS PARADIGMAS DE REEMBOLSOS MÉDICOS: UN MODELO PARA ALINEAR EL REEMBOLSO AL VALOR REAL DE LA CIRUGÍA COLORRECTAL LAPAROSCÓPICA EN LOS ESTADOS UNIDOS: A pesar de las creencias comunes, la subutilización de la cirugía colorrectal laparoscópica sigue siendo un problema. Se necesita un cambio en los paradigmas para aumentar y alinear el rembolso de la laparoscopia aplicando mucho esfuerzo para obtener una mejoría en su valor real.Comparar los reembolsos del abordaje quirúrgico y los de la administración para procedimientos colorrectales comunes y proponer una nueva forma de aumentar su uso en los Estados Unidos.Reembolsos en los Centros de Servicios de Medicare y Medicaid (Medicare) y los datos de reclamos comerciales encontrados de 2012-2015.El reembolso administrativo se mapeó para los diez procedimientos colorrectales más comunes utilizando los enfoques abiertos y laparoscópicos.Diferencias de reembolso entre los enfoques por parte de la administración y la propuesta de valor real de un modelo de cambio de costos que aumentan el reembolso con los aumentos correspondientes si se utiliza la laparoscopía.Para Medicare, el reembolso fue menor para una mayoría por vía laparoscópica que abierta. Comercialmente, la laparoscopia se reembolsó menos por 3 procedimientos. Cuando el reembolso laparoscópico fue mayor, la cantidad no fue sustancial. Los pagos de Medicare fueron consistentemente más bajos que los pagos comerciales, con el correspondiente reembolso más bajo por laparoscopia. El aumento del reembolso en un 10%, 20% y 30% resultó en ahorros de costos significativos con la laparoscopía. Los ahorros se amplificaron con el aumento de la utilización, con ahorros adicionales sobre la línea de base en todos los niveles, excepto el 30% de reembolso / 10% de mayor uso.Uso de datos de reclamos, que podrían tener errores de codificación y confusión en la combinación de casos entre enfoques.El reembolso por la cirugía colorrectal laparoscópica es comparativamente más bajo que el abordaje abierto. El reembolso se puede aumentar con ahorros significativos en los costos generales, ya que el reembolso / caso es aún menor que el ahorro total en los costos de la laparoscopia en comparación con los casos abiertos. Incentivar a los cirujanos hacia la laparoscopía podría impulsar la utilización y mejorar los resultados, el costo y la calidad a medida que se pasa al pago basado en el valor real. Consulte Video Resumen en http://links.lww.com/DCR/B290. (Traducción-Dr Xavier Delgadillo).
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http://dx.doi.org/10.1097/DCR.0000000000001738DOI Listing
October 2020

Association Between Surgeon Technical Skills and Patient Outcomes.

JAMA Surg 2020 Oct;155(10):960-968

Surgical Outcomes and Quality Improvement Center, Feinberg School of Medicine, Department of Surgery, Northwestern University, Chicago, Illinois.

Importance: Postoperative complications remain common after surgery, but little is known about the extent of variation in operative technical skill and whether variation is associated with patient outcomes.

Objectives: To examine the (1) variation in technical skill scores of practicing surgeons, (2) association between technical skills and patient outcomes, and (3) amount of variation in patient outcomes explained by a surgeon's technical skill.

Design, Setting, And Participants: In this quality improvement study, 17 practicing surgeons submitted a video of a laparoscopic right hemicolectomy that was then rated by at least 10 blinded peer surgeons and 2 expert raters. The association between surgeon technical skill scores and risk-adjusted outcomes was examined using data from the American College of Surgeons National Surgical Quality Improvement Program. The association between technical skill scores and outcomes was examined for colorectal procedures and noncolorectal procedures (ie, assessed on whether technical skills demonstrated during colectomy were associated with patient outcomes across other cases). In addition, the proportion of patient outcomes explained by technical skill scores was examined using robust regression techniques. The study was conducted from September 23, 2016, to February 10, 2018; data analysis was performed from November 2018 to January 2019.

Exposures: Colorectal and noncolorectal procedures.

Main Outcomes And Measures: Any complication, mortality, unplanned hospital readmission, unplanned reoperation related to principal procedure, surgical site infection, and death or serious morbidity.

Results: Of the 17 surgeons included in the study, 13 were men (76%). The participants had a range from 1 to 28 years in surgical practice (median, 11 years). Based on 10 or more reviewers per video and with a maximum quality score of 5, overall technical skill scores ranged from 2.8 to 4.6. From 2014 to 2016, study participants performed a total of 3063 procedures (1120 colectomies). Higher technical skill scores were significantly associated with lower rates of any complication (15.5% vs 20.6%, P = .03; Spearman rank-order correlation coefficient r = -0.54, P = .03), unplanned reoperation (4.7% vs 7.2%, P = .02; r = -0.60, P = .01), and a composite measure of death or serious morbidity (15.9% vs 21.4%, P = .02; r = -0.60, P = .01) following colectomy. Similar associations were found between colectomy technical skill scores and patient outcomes for all types of procedures performed by a surgeon. Overall, technical skill scores appeared to account for 25.8% of the variation in postcolectomy complication rates and 27.5% of the variation when including noncolectomy complication rates.

Conclusions And Relevance: The findings of this study suggest that there is wide variation in technical skill among practicing surgeons, accounting for more than 25% of the variation in patient outcomes. Higher colectomy technical skill scores appear to be associated with lower complication rates for colectomy and for all other procedures performed by a surgeon. Efforts to improve surgeon technical skills may result in better patient outcomes.
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http://dx.doi.org/10.1001/jamasurg.2020.3007DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7439214PMC
October 2020

Development of a Risk Score and Nomogram to Predict Individual Benefit Attained from the Addition of Adjuvant Chemotherapy in the Treatment of Stage II Colon Cancer.

J Gastrointest Surg 2021 01 3;25(1):220-232. Epub 2020 Aug 3.

Division of Surgical Oncology, John Wayne Cancer Institute at Providence Saint John's Health Center, Santa Monica, CA, USA.

Background: Current guidelines recommend considering adjuvant chemotherapy (AC) for stage II colon cancer (CC) with poor prognostic clinicopathologic and molecular features. However, the relative impact of individual or constellations of high-risk features remains undefined. We developed an individualized point-of-care tool to predict survival benefit attained from the addition of AC.

Methods: The National Cancer Database was queried for all patients with resected stage II CC from 2004 to 2015. A prognostic risk score and nomogram were constructed using twelve clinicopathologic and molecular prognostic factors associated with outcomes for CC. Overall survival (OS) was compared between surgery alone and AC groups. The nomogram was validated for discrimination and calibration using bootstrap-adjusted Harrell's concordance index (C-index). For population-level estimation, OS was compared based on quartiles.

Results: Of 132,666 patients with stage II CC, 16.8% received AC. The calibration curve of the constructed nomogram showed a good agreement between predicted and observed median and 3-, 5-, and 10-year survival (bootstrap-adjusted C-index 0.699, CI: 0.698-0.703). Population-level risk score analysis (median [Q1, Q3]; 4.9 [4.6, 5.5]) demonstrated that patients with scores > 3.34 had significantly decreased risk of death with the addition of AC (all p < 0.001). No survival advantage was associated with AC among patients with low risk scores (risk score < 3.34: HR: 0.94, 95% CI: 0.80-1.11, p = 0.47).

Discussion: A composite weighted risk score is critical to individualizing AC in select high-risk patients. Our nomogram provides individualized prognostication and estimation of benefit attained from AC. This may better inform treatment decisions and aid future trial design.
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http://dx.doi.org/10.1007/s11605-020-04757-6DOI Listing
January 2021

Outcomes after Early versus Delayed Urinary Bladder Catheter Removal after Proctectomy for Benign and Malignant Disease in 2,429 Patients: An Observational Cohort Study.

Surg Infect (Larchmt) 2021 Apr 23;22(3):310-317. Epub 2020 Jul 23.

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

There currently is no standard practice for optimal urinary catheter removal after rectal resection (proctectomy). Delayed removal may increase urinary tract infection risk, an important hospital quality metric. This study aimed to assess the effect of catheter duration on urinary tract infection rate. We hypothesized that early removal would be associated with fewer infections. We performed a retrospective review of patients who underwent proctectomy from January 2007 to December 2017 with urinary catheter placement in our colorectal surgery department. The main outcome measures were urinary tract infection, post-operative urinary retention, and length of stay. Patients were divided into early (post-operative day one or two) and late (day three or later) removal groups. A series of 2,429 patients were included; 1,176 in the early and 1,253 in the late group. The early group had a shorter median length of stay (5.26 versus 7 days). The urinary tract infection (n = 77) multivariable logistic regression model showed no association between timing of removal and infection; however, females had more infections (odds ratio [OR] 2.70, 95% confidence interval [CI] 1.65-4.41). The post-operative urinary retention model (n = 280) showed no association between the timing of removal and retention; however, patients who underwent pre-operative radiation (OR 1.55; 95% CI 1.15-2.09) or total proctocolectomy (OR 1.74; 95% CI 1.21-2.49) or were male (OR 1.35; 95% CI 1.02-1.78) were more likely to have retention. When analyzed by specific removal day, each one-day delay in removal increased the odds of infection by 21% (OR 1.21; 95% CI 1.09-1.35] and decreased the odds of retention by 12% (OR 0.88; 95% CI 0.80-0.97] with a cross-over at 9 days. Patients who experienced retention were not more likely to have infection. Early urinary catheter removal after proctectomy was associated with a lower urinary tract infection rate and a shorter hospital stay.
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http://dx.doi.org/10.1089/sur.2020.159DOI Listing
April 2021

Enhanced Recovery Pathway Benefits Patients Undergoing Nonelective Colorectal Surgery.

Ann Surg 2021 04;273(4):772-777

Department of Colorectal Surgery, Digestive Disease & Surgery Institute, Cleveland Clinic, Cleveland, OH.

Objective: The aim of our study was to determine if an enhanced recovery pathway (ERP) can successfully be applied in nonelective colorectal surgery.

Background: ERPs have been shown to reduce hospital length of stay (LOS), complications, and costs after elective colorectal surgery. Yet, little data exist regarding the benefits of ERPs in patients undergoing nonelective colorectal surgery. We hypothesized that ERP implementation in a nonelective colorectal surgery population is associated with decreased postoperative LOS.

Methods: A prospectively-maintained database was used to identify consecutive patients undergoing colorectal surgery after emergency room (ER) or hospital transfer admissions over a period from 2 years before until 1 year after implementation of a comprehensive ERP. The primary endpoint was LOS. Secondary endpoints included total LOS [TLOS = postoperative LOS + LOS of readmission(s)], readmission rates, complication rates, 30-day mortality, and hospital costs. Univariate and multivariate analyses were performed to assess the relationship between ERP implementation and LOS.

Results: We identified 269 pre-ERP and 135 ERP patients fulfilling the inclusion criteria. Admit source (ER 43.4% vs transfers 56.7%), Charlson comorbidity index, American Society of Anesthesiologists (ASA) status, diagnosis (inflammatory bowel disease 45.8%, malignancy 19.6%, benign intestinal obstructions 10.4%, diverticulitis 9.4%, others 10.4%), and blood loss were comparable (P > 0.05) between the cohorts. Pre-ERP patients had a higher number of previous abdominal surgeries, whereas post-ERP patients had more laparoscopy and more compliance with ERP elements. ERP patients had a shorter postoperative LOS [6 (4, 10) vs 7 (5, 12) days; P = 0.0007]. Hospital costs were 13.4% lower (P = 0.004). Postoperative 30-day morbidity, mortality, and readmissions were comparable, although reoperation rate was higher in the ERP group. On multivariate analysis, ERP implementation and laparoscopy were the only modifiable variables independently associated with shorter LOS, whereas longer operative times and higher ASA classification were associated with longer LOS.

Conclusions: Patients undergoing nonelective colorectal surgery after ER or hospital transfer admission benefit from the use of an ERP, demonstrating decreased LOS and costs without an increase in complications.
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http://dx.doi.org/10.1097/SLA.0000000000003438DOI Listing
April 2021

James W. Fleshman, MD, FACS, FASCRS.

Authors:
Scott R Steele

Clin Colon Rectal Surg 2020 Jul 3;33(4):187-188. Epub 2020 Jun 3.

Department of Colorectal Surgery, Cleveland Clinic, Case Western Reserve University, Cleveland, Ohio.

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http://dx.doi.org/10.1055/s-0040-1709440DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7329370PMC
July 2020