Informed Consent and Shared Decision Making in the Perioperative Environment.

Informed consent and shared decision making (SDM) are crucial portions of preoperative patient management. Informed consent is a standard for surgery from both a legal and ethical standpoint, involving disclosure of potential risks of a procedure and ensuring patient understanding of these risks. SDM is a process in which a clinician and patients decide between two or more treatment plans, taking into account the patient's goals and values. SDM is a particularly important aspect of patient-centered care when two or more treatment options exist or in situations where an indicated treatment may not align with the patient's long-term goals. This article details aspects of and issues surrounding informed consent and SDM.

Associations of Race, Ethnicity, and Social Determinants of Health With Colorectal Cancer Screening.

BACKGROUND: Racial and ethnic disparities in receipt of recommended colorectal cancer screening exist; however, the impact of social determinants of health on such disparities has not been recently studied in a national cohort. OBJECTIVE: This study aimed to determine whether social determinants of health attenuate racial disparities in receipt of colorectal cancer screening. DESIGN: This was a cross-sectional telephone survey of self-reported race and ethnicity and up-to-date colorectal cancer screening. Associations between race/ethnicity and colorectal cancer screening were tested before and after adjustment for demographics, behavioral factors, and social determinants of health. SETTING: This was a nationally representative telephone survey of US residents in 2018. PATIENTS: The patients included were US residents aged 50 to 75 years. MAIN OUTCOME MEASURES: The primary outcome was up-to-date colorectal cancer screening status, according to 2008 US Preventive Services Task Force recommendations. RESULTS: This study included 226,106 respondents aged 50 to 75 years. Before adjustment, all minority racial and ethnic groups demonstrated a significantly lower odds of screening than those of non-Hispanic white respondents. After adjustment for demographics, behavioral factors, and social determinants of health, compared to non-Hispanic white respondents, odds of screening were found to be increased among non-Hispanic black respondents (OR, 1.10; p = 0.02); lower but attenuated among Hispanic respondents (OR, 0.73; p < 0.001), non-Hispanic American Indian/Alaskan Native respondents (OR, 0.85; p = 0.048), and non-Hispanic respondents of other races (OR, 0.82; p = 0.01); and lower but not attenuated among non-Hispanic Asian respondents (OR, 0.68; p < 0.001). LIMITATIONS: Recall bias, participant bias, and residual confounding. CONCLUSIONS: Adjustment for social determinants of health reduced racial and ethnic disparities in colorectal cancer screening among all minority racial and ethnic groups except non-Hispanic Asian individuals; however, other unmeasured confounders likely exist. See Video Abstract at http://links.lww.com/DCR/B977 . ASOCIACIN DE RAZA, ETNICIDAD Y DETERMINANTES SOCIALES DE LA SALUD CON LA DETECCIN DEL CNCER COLORRECTAL: ANTECEDENTES: Existen disparidades raciales y étnicas en la recepción de las pruebas recomendadas de detección de cáncer colorrectal; sin embargo, el impacto de los determinantes sociales de la salud en dichas disparidades no se ha estudiado recientemente en una cohorte nacional.OBJETIVO: El objetivo de este estudio fue determinar si los determinantes sociales de la salud atenúan las disparidades raciales en la recepción de pruebas de detección del cáncer colorrectal.DISEÑO: Encuesta telefónica transversal de raza y etnia autoinformada y detección actualizada de cáncer colorrectal. Las asociaciones entre la raza/etnicidad y la detección del cáncer colorrectal se probaron antes y después del ajuste por demografía, factores conductuales y determinantes sociales de la salud.ESCENARIO: Esta fue una encuesta telefónica representativa a nivel nacional de los residentes de EE. UU. en 2018.PACIENTES: Los pacientes eran residentes de EE. UU. de 50 a 75 años.PRINCIPALES MEDIDAS DE RESULTADO: Estado actualizado de detección de cáncer colorrectal, según las recomendaciones del Grupo de Trabajo de Servicios Preventivos de EE. UU. de 2008.RESULTADOS: Este estudio incluyó a 226.106 encuestados de 50 a 75 años. Antes del ajuste, todos los grupos étnicos y raciales minoritarios demostraron probabilidades significativamente más bajas de detección en comparación con los encuestados blancos no hispanos. Después del ajuste por demografía, factores conductuales y determinantes sociales de la salud, en comparación con los encuestados blancos no hispanos, las probabilidades de detección aumentaron entre los encuestados negros no hispanos (OR 1,10, p = 0,02); más bajo pero atenuado entre los encuestados hispanos (OR 0,73, p < 0,001), los encuestados indios americanos/nativos de Alaska no hispanos (OR 0,85, p = 0,048) y los encuestados no hispanos de otras razas (OR 0,82, p = 0,01); y menor pero no atenuado entre los encuestados asiáticos no hispanos (OR 0,68, p < 0,001).LIMITACIONES: Sesgo de recuerdo y sesgo de participante, así como confusión residual.CONCLUSIONES: El ajuste para los determinantes sociales de la salud redujo las disparidades raciales y étnicas en la detección del cáncer colorrectal entre todos los grupos étnicos y raciales minoritarios, excepto las personas asiáticas no hispanas; sin embargo, es probable que existan otros factores de confusión no medidos. Consulte Video Resumen en http://links.lww.com/DCR/B977 . (Traducción-Dr. Felipe Bellolio ).

Impact of a High-Resolution Anoscopy Clinic on Management of Anal Dysplasia in Women Living With HIV.

BACKGROUND: The rate of anal squamous cell cancer (aSCC) is increasing among women living with HIV. Treatment of precursor high grade squamous intraepithelial lesions (HSIL) may reduce the risk of progression to aSCC. The objective of this study was to examine effects of a dedicated high-resolution anoscopy (HRA) clinic on management of HSIL in women with HIV. METHODS: Women living with HIV who underwent anal dysplasia screening at a single institution between 2006 and 2020 were reviewed. Those who underwent screening before (Group A) and after (Group B) the implementation of an HRA program in 2017 were compared. The primary outcome of interest was the successful detection and treatment of HSIL. RESULTS: A total of 201 women living with HIV underwent anal dysplasia screening between 2006 and 2020. Seventy-seven patients were found to have abnormal anal cytology requiring further treatment: 43 (55.8%) in Group A and 34 (44.2%) patients in Group B. Of the patients with abnormal anal cytology, 76.7% of patients in Group A received further biopsy and treatment, whereas 79.4% of Group B patients underwent subsequent biopsy and treatment. In propensity score weighting logistic regression analysis, the Group B was 4.6 times as likely to diagnosis HSIL on biopsy compared to Group A (OR = 4.60, 95% CI: 1.15 to 18.38, P = .03). CONCLUSIONS: Anal dysplasia is common among women living with HIV. The establishment of a HRA program was associated with increased identification and treatment of HSIL among women living with HIV, which may prevent the progression to aSCC.

Influence of Binary Toxin Gene Detection and Decreased Susceptibility to Antibiotics among Clostridioides difficile Strains on Disease Severity: a Single-Center Study.

Clostridioides difficile infection (CDI) is the fifth leading cause of death from nonmalignant gastrointestinal disease in the United States. The contribution of resistance to C. difficile-active antibiotics to the outcomes of CDI is unclear. We evaluated the antimicrobial susceptibility of C. difficile isolates in a U.S. hospital and determined associations of clinical variables and binary toxin positivity with antibiotic resistance. C. difficile spores were cultured from fecal specimens of adult patients with CDI for genotyping and antimicrobial susceptibility assay (for clindamycin [CLI], fidaxomicin [FDX], metronidazole [MTZ], moxifloxacin [MXF], tigecycline [TGC], and vancomycin [VAN]). Electronic medical records were reviewed for clinical data extraction. Ninety-seven of 130 (75%) fecal samples grew toxigenic C. difficile in culture. Most of the isolates were tcdA+ tcdB+ cdtB- (80.4%), and 18.6% and 1% were tcdA+ tcdB+ cdtB+ and tcdA-tcdB+ cdtB+, respectively. Susceptibility to VAN, MTZ, FDX, TGC, MXF, and CLI was 96%, 94%, 100%, 100%, 8%, and 79%, respectively. Six isolates, all cdtB positive and belonging to the 027 ribotype, were resistant to VAN and/or MTZ. Higher MICs were found in isolates with a mutation in the VAN-related resistance gene vanR, but not vanS. In addition, cdtB+ isolates exhibited higher MICs of VAN, MTZ, TGC, CLI, and MXF compared to cdtB- strains. Patients with greater intestinal inflammation or severe disease were more likely to be infected with cdtB+ strains. Decreased susceptibility to antibiotics is not directly associated with either severe or recurrent CDI. However, antimicrobial susceptibility of C. difficile is decreased in strains positive for the binary toxin gene.

Preoperative REM sleep is associated with complication development after colorectal surgery.

BACKGROUND: While total sleep duration and rapid eye movement (REM) sleep duration have been associated with long-term mortality in non-surgical cohorts, the impact of preoperative sleep on postoperative outcomes has not been well studied. METHODS: In this secondary analysis of a prospective observational cohort study, patients who recorded at least 1 sleep episode using a consumer wearable device in the 7 days before elective colorectal surgery were included. 30-day postoperative outcomes among those who did and did not receive at least 6 h of total sleep, as well as those who did and did not receive at least 1 h of rapid eye movement (REM) sleep, were compared. RESULTS: 34 out of 95 (35.8%) patients averaged at least 6 h of sleep per night, while 44 out of 82 (53.7%) averaged 1 h or more of REM sleep. Patients who slept less than 6 h had similar postoperative outcomes compared to those who slept 6 h or more. Patients who averaged less than 1 h of REM sleep, compared to those who achieved 1 h or more of REM sleep, had significantly higher rates of complication development (29.0% vs. 9.1%, P = 0.02), and return to the OR (10.5% vs. 0%, P = 0.04). After adjustment for confounding factors, increased REM sleep duration remained significantly associated with decreased complication development (increase in REM sleep from 50 to 60 min: OR 0.72, P = 0.009; REM sleep ≥ 1 h: OR 0.22, P = 0.03). CONCLUSION: In this cohort of patients undergoing elective colorectal surgery, those who developed a complication within 30 days were less likely to average at least 1 h of REM sleep in the week before surgery than those who did not develop a complication. Preoperative REM sleep duration may represent a risk factor for surgical complications; however additional research is necessary to confirm this relationship.

Wearable technology and the association of perioperative activity level with 30-day readmission among patients undergoing major colorectal surgery.

BACKGROUND: The proliferation of wearable technology presents a novel opportunity for perioperative activity monitoring; however, the association between perioperative activity level and readmission remains underexplored. This study sought to determine whether physical activity data captured by wearable technology before and after colorectal surgery can be used to predict 30-day readmission. METHODS: In this prospective observational cohort study of adults undergoing elective major colorectal surgery (January 2018 to February 2019) at a single institution, participants wore an activity monitor 30 days before and after surgery. The primary outcome was return to baseline percentage, defined as step count on the day before discharge as a percentage of mean preoperative daily step count, among readmitted and non-readmitted patients. RESULTS: 94 patients had sufficient data available for analysis, of which 16 patients (17.0%) were readmitted within 30 days following discharge. Readmitted patients achieved a lower return to baseline percentage compared to patients who were not readmitted (median 15.1% vs. 31.8%; P = 0.004). On multivariable analysis adjusting for readmission risk and hospital length of stay, an absolute increase of 10% in return to baseline percentage was associated with a 40% decreased risk of 30-day readmission (odds ratio 0.60; P = 0.02). Analysis of the receiver operating characteristic curve identified 28.9% as an optimal return to baseline percent threshold for predicting readmission. CONCLUSIONS: Achieving a higher percentage of an individual's preoperative baseline activity level on the day prior to discharge after major colorectal surgery is associated with decreased risk of 30-day hospital readmission.

Factors Associated with Receipt of Oral Antibiotic Agents and Mechanical Bowel Preparation before Elective Colectomy.

Background: Pre-operative administration of combined oral antibiotic agents and mechanical bowel preparation has been demonstrated to improve post-operative outcomes after elective colectomy, however, many patients do not receive combined preparation. Patient and procedural determinants of combined preparation receipt remain understudied. Patients and Methods: All patients undergoing elective colectomy within the 2018 American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) Participant Use File and Targeted Colectomy datasets were included. Univariable and multivariable logistic regression analyses were performed to identify factors associated with receipt of combined preparation. Results: A total of 21,889 patients were included, of whom 13,848 (63.2%) received combined preparation pre-operatively. Patients who received combined preparation tended to be younger, male, of white race, and of non-Hispanic ethnicity (all p < 0.05). After multivariable adjustment, male gender, body mass index (BMI) 30-39 kg/m2, independent functional status, and laparoscopic and robotic surgical approaches were associated with receipt of combined preparation (all p < 0.05), whereas Asian race, hypertension, disseminated cancer, and inflammatory bowel disease were associated with omission of combined preparation (all p < 0.05). Conclusions: Patients with risk factors for infectious complications-including a poor functional status, comorbid conditions, and undergoing an open procedure-are less likely to receive combined preparation before elective colectomy. Similarly, female and Asian patients are less likely to receive combined preparation, emphasizing the need for equitable administration of combined preparation.

Incidence and Characterization of Rectal Complications From Fecal Management Systems.

BACKGROUND: Fecal management systems have become ubiquitous in hospitalized patients with fecal incontinence or severe diarrhea, especially in the setting of perianal wounds. Although fecal management system use has been shown to be safe and effective in initial series, case reports of rectal ulceration and severe bleeding have been reported, with a relative paucity of clinical safety data in the literature. OBJECTIVE: The purpose of this study was to determine the rate of rectal complications attributable to fecal management systems, as well as to characterize possible risk factors and appropriate management strategies for such complications. DESIGN: This was a retrospective cohort study. SETTINGS: The study was conducted at a large academic medical center. PATIENTS: All medical and surgical patients who underwent fecal management system placement from December 2014 to March 2017 were included. MAIN OUTCOME MEASURES: We measured any rectal complication associated with fecal management system use, defined as any rectal injury identified after fecal management system use confirmed by lower endoscopy. RESULTS: A total of 629 patients were captured, with a median duration of fecal management system use of 4 days. Overall, 8 patients (1.3%) experienced a rectal injury associated with fecal management system use. All of the patients who experienced a rectal complication had severe underlying comorbidities, including 2 patients on dialysis, 1 patient with cirrhosis, and 3 patients with a recent history of emergent cardiac surgery. In 3 patients the bleeding resolved spontaneously, whereas the remaining 5 patients required intervention: transanal suture ligation (n = 2), endoscopic clip placement (n = 1), rectal packing (n = 1), and proctectomy in 1 patient with a history of pelvic radiotherapy. LIMITATIONS: The study was limited by its retrospective design and single institution. CONCLUSIONS: This is the largest study to date evaluating rectal complications from fecal management system use. Although rectal injury rates are low, they can lead to serious morbidity. Advanced age, severe comorbidities, pelvic radiotherapy, and anticoagulation status or coagulopathy are important factors to consider before fecal management system placement. See Video Abstract at http://links.lww.com/DCR/B698. INCIDENCIA Y CARACTERIZACIN DE LAS COMPLICACIONES RECTALES DE LOS SISTEMAS DE MANEJO FECAL: ANTECEDENTES:Los sistemas de manejo fecal se han vuelto omnipresentes en pacientes hospitalizados con incontinencia fecal o diarrea severa, especialmente en el contexto de heridas perianales. Aunque se ha demostrado que el uso del sistema de tratamiento fecal es seguro y eficaz en la serie inicial, se han notificado casos de ulceración rectal y hemorragia grave, con una relativa escasez de datos de seguridad clínica en la literatura.OBJETIVO:Determinar la tasa de complicaciones rectales atribuibles a los sistemas de manejo fecal. Caracterizar los posibles factores de riesgo y las estrategias de manejo adecuadas para tales complicaciones.DISEÑO:Estudio de cohorte retrospectivo.ENTORNO CLINICO:Centro médico académico de mayor volumen.PACIENTES:Todos los pacientes médicos y quirúrgicos que se sometieron a la colocación del sistema de manejo fecal desde diciembre de 2014 hasta marzo de 2017.PRINCIPALES MEDIDAS DE VALORACION:Cualquier complicación rectal asociada con el uso del sistema de manejo fecal, definida como cualquier lesión rectal identificada después del uso del sistema de manejo fecal confirmada por endoscopia baja.RESULTADOS:Se identificaron un total de 629 pacientes, con una duración media del uso del sistema de manejo fecal de 4,0 días. En general, 8 (1,3%) pacientes desarrollaron una lesión rectal asociada con el uso del sistema de manejo fecal. Todos los pacientes que mostraron una complicación rectal tenían comorbilidades subyacentes graves, incluidos dos pacientes en diálisis, un paciente con cirrosis y tres pacientes con antecedentes recientes de cirugía cardíaca emergente. En tres pacientes el sangrado se resolvió espontáneamente, mientras que los cinco pacientes restantes requirieron intervención: ligadura de sutura transanal (2), colocación de clip endoscópico (1), taponamiento rectal (1) y proctectomía en un paciente con antecedentes de radioterapia pélvica.LIMITACIONES:Diseño retrospectivo, institución única.CONCLUSIONES:Este es el estudio más grande hasta la fecha que evalúa las complicaciones rectales del uso del sistema de manejo fecal. Si bien las tasas de lesión rectal son bajas, pueden provocar una morbilidad grave. La edad avanzada, las comorbilidades graves, la radioterapia pélvica y el estado de anticoagulación o coagulopatía son factores importantes a considerar antes de la colocación del sistema de manejo fecal. Consulte Video Resumen en http://links.lww.com/DCR/B698.

A history of Clostridioides difficile infection portends infection recurrence and worse outcomes after stoma reversal.

BACKGROUND: Clostridioides difficile infection is reported to occur after 2.2% of colorectal operations and is associated with longer length of hospital stay, greater overall healthcare cost, and significant morbidity and mortality. The incidence of Clostridioides difficile infection is greatest after elective stoma reversal. The purpose of this study was to evaluate the effect of prior Clostridioides difficile infection on patients undergoing stoma reversal. We hypothesized that patients with a history of Clostridioides difficile infection who underwent stoma reversal will be at an increased risk of postoperative Clostridioides difficile infection compared with patients without a history of Clostridioides difficile infection. METHODS: This was an observational cohort study of patients undergoing elective stoma reversal surgery by colorectal surgeons at a single academic institution during a 10-year period. A prospectively maintained institutional database was queried to identify 454 patients who underwent stoma reversal surgery between January 1, 2007 and December 31, 2017. The primary outcomes were Clostridioides difficile infection after stoma reversal and time to Clostridioides difficile infection after bowel refunctionalization. Secondary outcomes included postoperative complications, length of hospital stay, discharge destination, and 30-day readmission rate. Univariate and multivariable logistic regression analyses were conducted to identify factors associated with Clostridioides difficile infection after stoma reversal. RESULTS: A total of 445 patients were identified who underwent elective stoma reversal, 42 of whom had a history of Clostridioides difficile infection before the stoma reversal. There were no significant differences in patient age, number of days diverted, or use of perioperative antibiotics between patients with and without a history of Clostridioides difficile infection. The incidence of postreversal Clostridioides difficile infection was 23.4% in patients with a history of Clostridioides difficile infection compared with 9.6% in patients with no Clostridioides difficile infection history (P = .004); however, time to Clostridioides difficile infection after reversal did not differ. History of Clostridioides difficile infection was also associated with greater risk of postoperative complications (26.2% vs 9.4%, P < .01), increased length of stay (3 vs 5 days postoperatively, P < .01), increased likelihood of discharge to a skilled-care facility (11.9% vs 6.2%, P < .01), and readmission (13.7 vs 31.0%, P < .01) within 30 days. In a multivariable logistic regression model, history of Clostridioides difficile infection, increased length of hospital stay, and discharge to a skilled facility were associated with increased risk of Clostridioides difficile infection after reversal, while proton pump inhibitors use was associated with decreased risk of Clostridioides difficile infection. CONCLUSION: Patients with a prior history of Clostridioides difficile infection who underwent stoma reversal exhibited higher rates of postoperative Clostridioides difficile infection and were at greater risk of postoperative complications, discharge to a skilled facility, and 30-day readmission. Furthermore, research into interventions aimed at improving outcomes in this unique, high-risk population is needed.

Preoperative opioid use is associated with increased risk of postoperative complications within a colorectal-enhanced recovery protocol.

BACKGROUND: As the opioid epidemic escalates, preoperative opioid use has become increasingly common. Recent studies associated preoperative opioid use with postoperative morbidity. However, limited study of its impact on patients within enhanced recovery protocols (ERP) exists. We assessed the impact of preoperative opioid use on postoperative complications among colorectal surgery patients within an ERP, hypothesizing that opioid-exposed patients would be at increased risk of complications. METHODS: Elective colorectal cases from August 2013 to June 2017 were reviewed in a retrospective cohort study comparing preoperative opioid-exposed patients to opioid-naïve patients. Postoperative complications were defined as a composite of complications captured by the American College of Surgeons National Surgical Quality Improvement Program. Logistic regression identified risk factors for postoperative complications. RESULTS: 707 patients were identified, including 232 (32.8%) opioid-exposed patients. Opioid-exposed patients were younger (57.9 vs 61.9 years; p < 0.01) and more likely to smoke (27.6 vs 17.1%; p < 0.01). Laparoscopic procedures were less common among opioid-exposed patients (44.8 vs 58.1%; p < 0.01). Median morphine equivalents received were higher in opioid-exposed patients (65.0 vs 20.1 mg; p < 0.01), but compliance to ERP elements was otherwise equivalent. Postoperative complications were higher among opioid-exposed patients (28.5 vs 15.0%; p < 0.01), as was median length of stay (4.0 vs 3.0 days; p < 0.01). Logistic regression identified multiple patient- and procedure-related factors independently associated with postoperative complications, including preoperative opioid use (p = 0.001). CONCLUSION: Preoperative opioid use is associated with increased risk of postoperative complications in elective colorectal surgery patients within an ERP. These results highlight the negative impact of opioid use, suggesting an opportunity to further reduce the risk of surgical complications through ERP expansion to include preoperative mitigation strategies for opioid-exposed patients.

Wearable Technology in the Perioperative Period: Predicting Risk of Postoperative Complications in Patients Undergoing Elective Colorectal Surgery.

BACKGROUND: The implementation of protocolized care pathways has resulted in major improvements in surgical outcomes. Additional gains will require focused efforts to alter preexisting risk. Prehabilitation programs provide a promising avenue for risk reduction. OBJECTIVE: This study used wearable technology to monitor activity levels before colorectal surgery to evaluate the impact of preoperative activity on postoperative outcomes. DESIGN: This was a prospective nonrandomized observational study. SETTINGS: The study was conducted at a large academic medical center. PATIENTS: Patients undergoing elective colorectal surgery from January 2018 to February 1, 2019, were included. MAIN OUTCOME MEASURES: Patients were trained in the usage of wearable activity-tracking devices and instructed to wear the device for 30 days before surgery. Patients were stratified as active (≥5000 steps per day) and inactive (<5000 steps per day) based on preoperative step counts. Univariate analyses compared postoperative outcomes. Multivariable regression models analyzed the impact of preoperative activity on postoperative complications, adjusting for each patient's baseline risk as calculated using the American College of Surgeons National Surgical Quality Improvement Program Surgical Risk Calculator. Models were rerun without the addition of activity and the predictive ability of the models compared. RESULTS: Ninety-nine patients were included, with 40 (40.4%) classified as active. Active patients experienced fewer overall complications (11/40 (27.5%) vs 33/59 (55.9%); p = 0.005) and serious complications (2/40 (5%) vs 12/59 (20.3%); p = 0.032). Increased preoperative activity was associated with a decreased risk of any postoperative complication (OR = 0.386; p = 0.0440) on multivariable analysis. The predictive ability of the models for complications and serious complications was improved with the addition of physical activity. LIMITATIONS: The study was limited by its small sample size and single institution. CONCLUSIONS: There is significant room for improvement in baseline preoperative activity levels of patients undergoing colorectal surgery, and poor activity is associated with increased postoperative complications. These data will serve as the basis for an interventional trial investigating whether wearable devices help improve surgical outcomes through a monitored preoperative exercise program. See Video Abstract at http://links.lww.com/DCR/B145. TECNOLOGÍA PORTÁTIL EN EL PERÍODO PERIOPERATORIO: PREDICCIÓN DEL RIESGO DE COMPLICACIONES POSTOPERATORIAS EN PACIENTES SOMETIDOS A CIRUGÍA COLORRECTAL ELECTIVA: La implementación de vías de atención protocolizadas ha dado lugar a importantes mejoras en los resultados quirúrgicos. Para obtener más beneficios será necesario realizar esfuerzos concentrados para modificar el riesgo preexistente. Los programas de rehabilitación proporcionan una vía prometedora para la reducción del riesgo.Este estudio utilizó tecnología portátil para monitorear los niveles de actividad antes de la cirugía colorrectal para evaluar el impacto de la actividad preoperatoria en los resultados postoperatorios.Estudio observacional prospectivo no aleatorizado.Gran centro médico académico.Pacientes sometidos a cirugía colorrectal electiva desde enero de 2018 hasta el 1 de febrero de 2019.Los pacientes fueron entrenados en el uso de dispositivos portátiles para el seguimiento de la actividad y se les indicó usar el dispositivo durante 30 días antes de la cirugía. Los pacientes fueron estratificados como activos (> 5000 pasos / día) e inactivos (<5000 pasos / día) en base a los recuentos de pasos preoperatorios. Los análisis univariados compararon los resultados postoperatorios. Los modelos de regresión multivariable analizaron el impacto de la actividad preoperatoria en las complicaciones postoperatorias, ajustando el riesgo de referencia de cada paciente según lo calculado utilizando la Calculadora de riesgo quirúrgico del Programa Nacional de Mejora de la Calidad Quirúrgica del Colegio Americano de Cirujanos. Los modelos se volvieron a ejecutar sin agregar actividad, y se comparó la capacidad de predicción de los modelos.Noventa y nueve pacientes fueron incluidos con 40 (40.4%) clasificados como activos. Los pacientes activos experimentaron menos complicaciones generales [11/40 (27,5%) frente a 33/59 (55,9%); p = 0,005] y complicaciones graves [2/40 (5%) frente a 12/59 (20,3%); p = 0,032]. El aumento de la actividad preoperatoria se asoció con una disminución del riesgo de cualquier complicación postoperatoria (OR 0.386, p = 0.0440) en el análisis multivariable. La capacidad predictiva de los modelos para complicaciones y complicaciones graves mejoró con la adición de actividad física.Tamaño de muestra pequeño, una sola institución.Existe un margen significativo para mejorar los niveles basales de actividad preoperatoria de los pacientes de cirugía colorrectal, y la escasa actividad se asocia con mayores complicaciones postoperatorias. Estos datos servirán de base para un ensayo intervencionista que investigue si los dispositivos portátiles ayudan a mejorar los resultados quirúrgicos a través de un programa de ejercicio preoperatorio monitoreado. Consulte Video Resumen en http://links.lww.com/DCR/B145.

Preoperative bleeding requiring transfusion: An under-reported indication for hemorrhoidectomy.

BACKGROUND: Though hemorrhoids commonly cause minor gastrointestinal bleeding, major hemorrhage requiring blood transfusion is believed to be rare. We sought to identify the prevalence and risk factors for preoperative transfusion in surgical hemorrhoidectomy patients. METHODS: Patients undergoing surgical hemorrhoidectomy at a single institution (2012-2017) were evaluated for preoperative bleeding requiring transfusion. Bivariate analysis compared patients requiring transfusion to those who did not, and multivariable analysis evaluated for independent risk factors for transfusion. RESULTS: Out of 520 patients, 7.3% experienced hemorrhoidal bleeding requiring transfusion, and 80.6% reported bleeding. On multivariable analysis, the use of either an anticoagulant or non-aspirin antiplatelet agent was associated with transfusion (OR 3.08, p = 0.03). Patients requiring transfusion had extensive preoperative workups, including colonoscopy (94.7%), flexible sigmoidoscopy (7.89%), upper endoscopy (50%) and capsule endoscopy (26.3%). CONCLUSIONS: Bleeding requiring transfusion is an under-reported complication of hemorrhoids. Increased recognition could lead to expeditious surgical treatment and less costly diagnostic workup.

An Unintended Consequence of a New Opioid Legislation.

BACKGROUND: The Controlled Substance Act was enacted in efforts to reduce the abuse and misuse of opioid pain relievers. However, the effects of this regulation on the prescribing patterns of providers has yet to be realized. OBJECTIVE: We sought to identify the changes in opioid-prescribing patterns of an elective colorectal surgical practice as a result of this legislative change. DESIGN: This is a retrospective study of patients undergoing elective colorectal surgery. Patients were intentionally grouped into group A (January 1, 2012 to October 5, 2014) and group B (October 6, 2014 to December 31, 2016) to capture the period surrounding the new legislation. SETTINGS: We evaluated patients undergoing elective colorectal surgery at a single academic center over a 5-year period. PATIENTS: There were 443 patients undergoing elective colorectal surgery between 2012 and 2016. MAIN OUTCOME MEASURES: The primary outcome was total milligram morphine equivalent of pain medication prescribed at discharge. Secondary outcomes included total number of pills prescribed, total milligram morphine equivalent of pain medication at subsequent prescriptions, and numeric postoperative pain scores. RESULTS: Patients in group B were found to have a greater mean total milligram morphine equivalent prescribed at discharge (719 (SD 593) vs 660 (SD 548), p = 0.03), mean total quantity of pills prescribed at discharge (98 (SD 106) vs 87 (SD 63), p = 0.05), and mean total quantity of pills prescribed as subsequent prescriptions (77 (SD 117) vs 68 (SD 83), p = 0.05) compared with group A. On multivariable analysis, group B was a significant predictor of greater total milligram morphine equivalents prescribed at discharge compared with group A (p = 0.01). LIMITATIONS: This study is limited by analysis from a single institution. CONCLUSIONS: Efforts to minimize opioid prescriptions after surgery through legislation could result in unintended consequences. Recognition of this result is important to effectively reduce opioid prescriptions after surgery. See Video Abstract at http://links.lww.com/DCR/B96. UNA CONSECUENCIA NO DESEADA DE UNA NUEVA LEGISLACIÓN DE OPIOIDES: La Ley de Sustancias Controladas se promulgó con el fin de reducir el abuso y el uso indebido de analgésicos opioides. Sin embargo, los efectos de esta regulación en los patrones de prescripción de los proveedores aún no se han realizado.Se intento identificar los cambios en los patrones de prescripción de opioides de una práctica quirúrgica colorrectal electiva como resultado de este cambio legislativo.Este es un estudio retrospectivo de pacientes sometidos a cirugía colorrectal electiva. Los pacientes fueron agrupados intencionalmente en el Grupo A (1 de enero de 2012 al 5 de octubre de 2014) y el Grupo B (6 de octubre de 2014 al 31 de diciembre de 2016) para capturar el período que rodea la nueva legislación.Se evaluaron a los pacientes sometidos a cirugía colorrectal electiva en un solo centro académico durante un período de 5 años.Hubo 443 pacientes que se sometieron a cirugía colorrectal electiva entre 2012-2016.La medida de resultado primaria fue el equivalente de miligramos de morfina total de los analgésicos prescritos al momento del alta. Las medidas de resultado secundarias incluyeron el número total de píldoras prescritas, el equivalente total de miligramos de morfina de la medicación para el dolor en las prescripciones posteriores y las puntuaciones numéricas de dolor postoperatorio.Se encontró que los pacientes en el Grupo B tenían un equivalente de miligramos de morfina total total mayor prescrito al alta (719 [DE 593] v. 660 [DE 548], p = 0.03), cantidad total promedio de píldoras prescritas al alta (98 [SD 106] v. 87 [SD 63], p = 0.05), y la cantidad total promedio de píldoras recetadas como recetas posteriores (77 [SD 117] v. 68 [SD 83], p = 0.05) en comparación con el Grupo A. En análisis multivariable, el Grupo B fue un predictor significativo de mayores equivalentes de morfina en miligramos totales prescritos al alta en comparación con el grupo A (p = 0.01).Este estudio está limitado por el análisis de una sola instituciónLos esfuerzos para minimizar las recetas de opioides después de la cirugía a través de la legislación podrían tener consecuencias no deseadas. El reconocimiento de este resultado es importante para reducir eficazmente las recetas de opioides después de la cirugía. Consulte Video Resumen en http://links.lww.com/DCR/B96.

Implementation of an Enhanced Recovery Protocol Is Associated With On-Time Initiation of Adjuvant Chemotherapy in Colorectal Cancer.

BACKGROUND: Delayed initiation of adjuvant chemotherapy negatively impacts long-term survival in patients with colorectal cancer. Colorectal enhanced recovery protocols result in decreased complications and length of stay; however, the impact of enhanced recovery on the timing of adjuvant chemotherapy remains unknown. OBJECTIVE: This study aimed to identify factors associated with on-time delivery of adjuvant chemotherapy after colorectal cancer surgery, hypothesizing that implementation of an enhanced recovery protocol would result in more patients receiving on-time chemotherapy. DESIGN: This was a retrospective cohort study comparing the rate of on-time adjuvant chemotherapy delivery after colorectal cancer resection before and after implementation of an enhanced recovery protocol. SETTINGS: The study was conducted at a large academic medical center. PATIENTS: All of the patients who underwent nonemergent colorectal cancer resections for curative intent from January 2010 to June 2017, excluding patients who had no indication for adjuvant chemotherapy, had received preoperative systemic chemotherapy, or did not have medical oncology records available were included. MAIN OUTCOME MEASURES: Patients before and enhanced recovery were compared, with the rate of on-time adjuvant chemotherapy delivery as the primary outcome. Adjuvant chemotherapy delivery was considered on time if initiated ≤8 weeks postoperatively, and treatment was considered delayed or omitted if initiated >8 weeks postoperatively (delayed) or never received (omitted). Multivariable logistic regression identified predictors of on-time chemotherapy delivery. RESULTS: A total of 363 patients met inclusion criteria, with 189 patients (52.1%) undergoing surgery after enhanced recovery implementation. Groups differed in laparoscopic approach and median procedure duration, both of which were higher after enhanced recovery. Significantly more patients received on-time chemotherapy after enhanced recovery implementation (p = 0.007). Enhanced recovery was an independent predictor of on-time adjuvant chemotherapy (p = 0.014). LIMITATIONS: The study was limited by its retrospective and nonrandomized before-and-after design. CONCLUSIONS: Enhanced recovery was associated with receiving on-time adjuvant chemotherapy. As prompt initiation of adjuvant chemotherapy improves survival in colorectal cancer, future investigation of long-term oncologic outcomes is necessary to evaluate the potential impact of enhanced recovery on survival. See Video Abstract at http://links.lww.com/DCR/B21. LA IMPLEMENTACIÓN DE UN PROTOCOLO DE RECUPERACIÓN ACELERADA SE ASOCIA CON EL INICIO A TIEMPO DE QUIMIOTERAPIA ADYUVANTE EN CÁNCER COLORRECTAL:: El inicio tardío de la quimioterapia adyuvante afecta negativamente la supervivencia a largo plazo en pacientes con cáncer colorrectal. Los protocolos de recuperación acelerada colorrectales dan lugar a una disminución de las complicaciones y la duración de estancia hospitalaria; sin embargo, el impacto de la recuperación acelerada en el momento de inicio de quimioterapia adyuvante sigue siendo desconocido.Este estudio tuvo como objetivo identificar los factores asociados con la administración a tiempo de la quimioterapia adyuvante después de la cirugía de cáncer colorrectal, con la hipótesis de que la implementación de un protocolo de recuperación acelerada daría lugar a que más pacientes reciban quimioterapia a tiempo.Estudio de cohorte retrospectivo que compara la tasa de administración de quimioterapia adyuvante a tiempo después de la resección del cáncer colorrectal antes y después de la implementación de un protocolo de recuperación acelerada.Centro médico académico grande.Todos los pacientes que se sometieron a resecciones de cáncer colorrectal no emergentes con intención curativa desde enero de 2010 hasta junio de 2017, excluyendo a los pacientes que no tenían indicación de quimioterapia adyuvante, que recibieron quimioterapia sistémica preoperatoria o no tenían registros médicos de oncología disponibles.Los pacientes se compararon antes y después de la implementación de la recuperación acelerada, con la tasa de administración de quimioterapia adyuvante a tiempo como el resultado primario. La administración de quimioterapia adyuvante se consideró a tiempo si se inició ≤8 semanas después de la operación, y el tratamiento se consideró retrasado / omitido si se inició> 8 semanas después de la operación (retrasado) o nunca fue recibido (omitido). La regresión logística multivariable identificó predictores de administración de quimioterapia a tiempo.363 pacientes cumplieron con los criterios de inclusión, con 189 (52.1%) pacientes sometidos a cirugía después de la implementación de recuperación acelerada. Los grupos difirieron en el abordaje laparoscópico y la duración media del procedimiento; ambos factores fueron mayores después de la recuperación acelerada. Significativamente más pacientes recibieron quimioterapia a tiempo después de la implementación de recuperación acelerada (p = 0.007). La recuperación acelerada fue un factor predictivo independiente de quimioterapia adyuvante a tiempo (p = 0.014).Diseño retrospectivo, tipo ¨antes y después¨ no aleatorizado.La recuperación acelerada se asoció con la recepción de quimioterapia adyuvante a tiempo. Debido a que el inicio rápido de la quimioterapia adyuvante mejora la supervivencia en el cáncer colorrectal, en el futuro será necesario investigar los resultados oncológicos a largo plazo para evaluar el impacto potencial de la recuperación acelerada en la supervivencia. Vea el Resumen en Video en http://links.lww.com/DCR/B21.

Colon and rectal surgery surgical site infection reduction bundle: To improve is to change.

BACKGROUND: Despite the introduction of the Surgical Care Improvement Project, surgical site infections remain a source of morbidity. The aim of this study was to determine the value of implementing a colorectal bundle on SSI rates. METHODS: Between 2011 and 2016 a total of 1351 patients underwent colorectal operations. Patients were grouped into pre-implementation (Group A, January 1, 2011-December 31, 2012), implementation (Group B, January 1, 2013-December 31, 2014) and post-implementation (Group C, January 1, 2015-December 31, 2016). Primary endpoints were superficial SSI, deep SSI, wound separation and total SSI. RESULTS: After the bundle was implemented, there was a significant reduction in superficial (6.6%-4%, p < 0.05), deep (3.7%-1.1%, p < 0.05), and total SSI rates (10.9%-4.7%, p < 0.05). Comparing Group A to Group C there was a decrease in total SSI (9.4%-4.7%, p < 0.05). CONCLUSION: Implementation of the bundle resulted in a reduction in overall SSI rates particularly as compliance increased. This study offers evidence that small changes can lead to significant decreases in surgical site infections.