Effect of care continuity on mortality of patients readmitted after colorectal surgery.

BACKGROUND: Postoperative readmission after colorectal resection is common. It is unknown whether patients who receive readmission care from the surgeon who performed the index surgery have improved mortality. This study evaluated whether postdischarge continuity of care, defined at the hospital and surgeon level, was associated with decreased mortality after colorectal surgery. METHODS: The Statewide Planning and Research Cooperative System was queried for patients who had colorectal resections from 2004 to 2014, and were readmitted within 30 days of discharge. Propensity-adjusted logistic regression analysis was used to evaluate the association between 30-day mortality and readmission care continuity. RESULTS: A total of 20 016 patients readmitted within 30 days of discharge were eligible for analysis. Some 39·5 per cent of readmitted patients experienced hospital and surgeon care continuity, 47·1 per cent hospital but not surgeon continuity, 1·0 per cent surgeon but not hospital continuity, and 12·4 per cent neither hospital nor surgeon care continuity. A total of 1349 patients (6·7 per cent) died within 30 days of readmission. Patients readmitted with absence of surgeon but not of hospital care continuity had 2·04 (95 per cent c.i. 1·72 to 2·42) times the risk of 30-day mortality compared with those who experienced surgeon and hospital continuity. Absence of both surgeon and hospital care continuity was associated with 2·65 (2·18 to 3·30) times the risk of death compared with presence of both. CONCLUSION: Readmission after colorectal resection not under the care of the index operating surgeon is associated with an increased risk of 30-day mortality. Addressing processes of care that are affected by surgeon care continuity may decrease surgical deaths.

Population-based study of outcomes following an initial acute diverticular abscess.

BACKGROUND: Studies examining long-term outcomes following resolution of an acute diverticular abscess have been limited to single-institution chart reviews. This observational cohort study compared outcomes between elective colectomy and non-operative management following admission for an initial acute diverticular abscess. METHODS: The Statewide Planning and Research Cooperative System was queried for unscheduled admissions for an initial acute diverticular abscess in 2002-2010. Bivariable and propensity-matched multivariable analyses compared stoma rates and use of healthcare in patients who had an elective resection and those receiving non-operative management. Diverticulitis recurrence rates were analysed for non-operative management. RESULTS: Among 10 342 patients with an initial acute diverticular abscess, one-third (3270) underwent surgical intervention within 30 days despite initial non-operative management. Of the remaining 7072 patients, 1660 had an elective colectomy within 6 months. Of 5412 patients receiving non-operative management, 1340 (24·8 per cent) had recurrence of diverticulitis within 5 years (median 278 (i.q.r. 93·5-707) days to recurrence). Elective colectomy was associated with higher stoma rates (10·0 per cent, compared with 5·7 per cent for non-operative observation, P < 0·001; odds ratio 1·88, 95 per cent c.i. 1·50 to 2·36), as well as more inpatient hospital days for diverticulitis-related admissions (mean 8·0 versus 4·6 days respectively, P < 0·001; incidence rate ratio (IRR) 2·16, 95 per cent c.i. 1·89 to 2·47) and higher mean diverticulitis-related cost (€70 107 versus €24 490, P < 0·001; IRR 3·11, 2·42 to 4·01). CONCLUSION: Observation without elective colectomy following resolution of an initial diverticular abscess is a reasonable option with lower healthcare costs than operation.

Association between operative approach and complications in patients undergoing Hartmann's reversal.

BACKGROUND: Complications following reversal of Hartmann's procedure are common, with morbidity rates of up to 50 per cent, and a mortality rate as high as 10 per cent. This is based on case series with heterogeneous data collection and analysis. This study determined risk factors for complications following Hartmann's reversal. METHODS: Patients who underwent elective open and laparoscopic Hartmann's reversal were identified from the American College of Surgeons National Surgical Quality Improvement Program database (2005-2010). The programme collects patient demographics, preoperative medical history, clinical findings and laboratory investigations. Postdischarge data were obtained by a certified reviewer. Complications were categorized as major, septic or incisional. Risk-adjusted 30-day outcomes were assessed by univariable and multivariable analyses, adjusting for patient characteristics, co-morbidity and operative approach. RESULTS: During the study period 7996 patients had a Hartmann's procedure and 2567 cases of Hartmann's reversal were identified, including 336 laparoscopic procedures (13·1 per cent). Major, septic and incisional complication rates were 13·3, 8·5 and 15·7 per cent respectively, with a mortality rate of 0·5 per cent. A laparoscopic approach was found to be independently associated with fewer major (odds ratio (OR) 0·53, 95 per cent confidence interval 0·34 to 0·81), septic (OR 0·48, 0·27 to 0·83) and incisional (OR 0·54, 0·37 to 0·80) complications. A history of chronic obstructive pulmonary disease (OR 1·78-2·00), steroid use (OR 1·75), body mass index at least 30 kg/m² (OR 1·48), diabetes (OR 1·40), smoking (OR 1·33-1·40), American Society of Anesthesiologists fitness grade III and IV (OR 1·46-1·48) and prolonged operating time (OR 1·02) were other factors associated with complications. CONCLUSION: A laparoscopic approach to Hartmann's reversal was associated with fewer complications than open surgery in this highly selected group of patients.

Closure of defunctioning loop ileostomy is associated with considerable morbidity.

AIM: An elective defunctioning ileostomy is commonly employed to attenuate the morbidity that may arise from distal anastomotic leakage. The magnitude of risk associated with subsequent ileostomy closure is difficult to estimate as many of the data arise from small series. This study looked at the rate of complications and predictive factors in a large series of patients. METHODS: The National Surgical Quality Improvement Program database was queried for patients who had an elective closure of ileostomy between 2005 and 2010. Patient demographics, preoperative risk factors and operative variables were recorded. The primary outcome was occurrence of major (mortality, sepsis, return to the operating room, renal failure, major cardiac, neurological or respiratory episode) or minor (wound infection, urinary tract infection) complications within 30 days. Univariate and multivariate regression was used to evaluate the effect of these clinical factors on the complication rate. RESULTS: In total, 5401 patients underwent closure of ileostomy, of whom 502 (9.3%) patients had major complications. The incidence of minor complications was 8.4% (452 patients). There were 32 (0.6%) deaths. American Society of Anesthesiologists grade, functional status, prolonged operative time, history of chronic obstructive pulmonary disease, dialysis and disseminated cancer were independent predictors of major complications. There was no significant increase in complication rates in patients over the age of 80. Major complications were associated with a significant increase in postoperative stay (13.9 vs 4.7 days, P < 0.0001). CONCLUSION: Closure of ileostomy is associated with a significant complication rate. It may use as many resources as the primary surgery and is not a minor follow-up operation.

It's the procedure not the patient: the operative approach is independently associated with an increased risk of complications after rectal prolapse repair.

AIM: This study compares 30-day outcomes following rectal prolapse repair, examining potential surgical and patient factors associated with perioperative complications. METHOD: Using the NSQIP database, patients with rectal prolapse were categorized by surgical approach to repair (perineal or abdominal) and abdominal cases were further subdivided by procedure (resection compared with rectopexy alone). Univariate and multivariate analyses compared major and minor complication rates between the groups. RESULTS: Of 1275 patients, the perineal group (n=706, 55%) was older, with more comorbidity, than those undergoing an abdominal procedure. There were fewer minor (odd ratio (OR)=0.35; 95% confidence interval (CI), 0.20-0.60; P=0.0038) and major complications (OR=0.46; 95% CI, 0.31-0.80; P=0.0038) in the perineal compared with the abdominal cohort. There was a significant increase in major complications amongst patients undergoing a resection compared with rectopexy only (OR=2.15; 95% CI, 1.10-4.41; P=0.0299). There was no difference in major complications between abdominal rectopexy and a perineal approach, but the latter had a lower chance of minor complications (OR=0.47; 95% CI, 0.24-0.94; P=0.0287). CONCLUSION: A perineal approach is safer than an abdominal approach to the treatment of rectal prolapse. Regarding an abdominal operation, rectopexy has fewer major complications than resection.

A laparoscopic approach reduces short-term complications and length of stay following ileocolic resection in Crohn's disease: an analysis of outcomes from the NSQIP database.

AIM: Studies to date examining the impact of laparoscopy in resection for Crohn's disease on short-term morbidity have been limited by small study populations. The aim of this study was to establish the impact of the operative approach (laparoscopic or open) on outcomes after ileocolic resection for Crohn's disease. METHOD: Ileocolic resections for Crohn's disease were identified using Current Procedural Terminology (CPT) and International Classification of Disease, Ninth Revision, Clinical Modification (ICD-9-CM) codes from the National Surgical Quality Improvement Program (NSQIP) database (2005-2009). Complications were categorized as major (organ system damage and systemic sepsis) or minor (incisional and urinary infections). Multivariate 30-day outcomes and length of stay were determined using linear models adjusting for patient characteristics, comorbidities and operative approach. RESULTS: Of 1917 ileocolic resections, 644 (34%) were performed laparoscopically. At baseline, the open group was significantly older, had more comorbidities, higher American Society of Anesthesiology (ASA) classes, and more intra-operative transfusions (all variables, P<0.05). On multivariate analysis, laparoscopic ileocolic resections were associated with a decrease in major (OR=0.629, 95% CI: 0.430-0.905, P=0.014) and minor (OR=0.576, 95% CI: 0.405-0.804, P=0.002) complications compared with open resections. Laparoscopy was associated with a significant reduction in adjusted length of stay compared with the open approach (-1.08±0.29 days, P=0.0002). CONCLUSION: After adjusting for comorbidities and perioperative factors, such as preoperative sepsis, higher ASA class and higher transfusion rates in the open group, laparoscopic ileocolic resection for Crohn's disease was found to be a safer choice than the open approach, resulting in fewer complications and length of stay. All other things being equal, such patients should be offered the laparoscopic approach as a first-choice option.

Patient and surgeon factors are associated with the use of laparoscopy in appendicitis.

AIM: The use of a minimally invasive approach to treat appendicitis has yet to be universally accepted. The objective of this study was to examine recent trends in Ireland in the surgical management of acute appendicitis. METHOD: Data were obtained from the Irish Hospital In-Patient Enquiry system for patients discharged with a diagnosis of appendicitis between 1999 and 2007. An anonymous postal survey was sent to all general surgeons of consultant and registrar level in Ireland to assess current attitudes to the use of laparoscopic appendectomy. RESULTS: The use of laparoscopic appendectomy increased throughout the study and was the most common approach for appendectomy in 2007. Multivariate analysis revealed age under 50 years (OR = 1.51), female sex (OR = 2.84) and residence in high-density population areas (OR = 4.15) as predictive factors for undergoing laparoscopic appendectomy in the most recent year of the study. While 97% of surgeons reported current use of laparoscopy in patients with acute right iliac fossa pain, in most cases it was selective. Surgeons in university teaching hospitals (42 of 77; 55%) were more likely to report using laparoscopic appendectomy for all cases of appendicitis than those in regional (six of 23; 26%) or general (13 of 53; 25%) hospitals (P = 0.048). CONCLUSION: This study has demonstrated a significant increase in laparoscopic appendectomy, yet a variety of patient and surgeon factors contribute to the choice of procedure. Differences in the perception of benefit of the laparoscopic approach amongst surgeons appears to be an important factor in determining the operative approach for appendectomy.

The management of right iliac fossa pain - is timing everything?

BACKGROUND: Right iliac fossa (RIF) pain remains the commonest clinical dilemma encountered by general surgeons. We prospectively audited the management of acute RIF pain, examining the relationship between symptom duration, use of pre-operative radiological imaging and patient outcome. METHODS: Over a six-month period, 302 patients, median age 18 years, 59% female, were admitted with RIF pain. Symptoms, clinical findings and laboratory results were documented. Patient management, timing of radiological investigations and operations, and outcome were recorded prospectively. RESULTS: Non-specific abdominal pain (26%), gynaecological (22%) and miscellaneous causes (14%) accounted for most admissions. Ultimately, 119 patients (39%) had appendicitis. Anorexia, tachycardia or rebound tenderness in the RIF significantly predicted a final diagnosis of appendicitis. Patients with perforated appendicitis (n = 29) had a longer duration of pre-hospital symptoms (median 50h) compared to those with simple appendicitis (median 17 h) (p<0.001). The use of pre-operative imaging resulted in an increased time to surgery but was not associated with increased post-operative morbidity or perforated appendicitis. CONCLUSION: The majority of patients presenting to hospital with RIF pain did not have appendicitis. Increased duration of pre-hospital symptoms was the main factor associated with perforated appendicitis. However, increased in-hospital time to theatre was not associated with perforated appendicitis or post-operative morbidity.

Vascular trauma in an Irish regional hospital.

BACKGROUND: Vascular trauma is a common cause of mortality and morbidity worldwide. There are few accurate quantitative data available presently on the nature and outcome of these injuries. The aim of this study was to determine the incidence, aetiology, management and outcome of vascular injuries which required surgical intervention at a regional vascular unit. METHODS: All patients who suffered a vascular injury requiring surgical intervention between January 1992 and December 2005 were included. RESULTS: A total of 35 patients who underwent operative intervention for vascular trauma were reviewed. There were 26 men and 9 women with a median age of 26 years (range 3-80 years). Road traffic accidents accounted for 15 (43%) of all cases and 16 patients (47%) had an associated fracture. The brachial artery was most frequently injured, constituting 36% of all cases. Interposition grafting using the autogenous long saphenous vein was the most common procedure performed (11 patients). Eleven patients required a secondary procedure while the overall limb amputation rate was 8.5%. There was one mortality following an IVC injury. Seventy-four per cent of the cohort was asymptomatic at last follow-up. CONCLUSION: While vascular trauma is relatively uncommon in our catchment area it can be successfully managed. Most of the cases occur in young fit patients.

Management and outcome in patients following head injury admitted to an Irish Regional Hospital.

PRIMARY OBJECTIVE: Each year in Ireland, 11 000 patients are admitted to hospital with a traumatic brain injury (TBI) but there are no data on subsequent disability in such patients. The objective of this study was to assess the management and outcome in patients of working age admitted with TBI to the unit. METHODS: Two hundred and sixteen patients admitted with TBI aged 16-65 were identified. Self-reported incidence of disability and access to appropriate services was assessed using the Glasgow outcome scale and a problem-orientated questionnaire. RESULTS: Eighty-five per cent of patients eligible for review agreed to participate. The majority of injuries (86%) were mild. An intracranial injury was identified on 35% of CT brain scans performed. Patients with an abnormality on CT scanning were more likely to report difficulties with headache, concentration and memory at time of follow-up. When questioned, 34% of patients still perceived difficulties since their injury. Of this group, 60% didn't receive any input from rehabilitation services. One year post-injury, 11% of patients remained unfit for work. CONCLUSION: A significant number of patients, even with mild TBI, continue to suffer sequelae from their injury augmented by difficulty in accessing appropriate rehabilitation services.

Current trends in the management of acute appendicitis.

BACKGROUND: While laparoscopic appendectomy (LA) has become established in the diagnosis and treatment of acute appendicitis, its utilisation compared to open appendectomy (OA) is variable. AIM: To compare the utilisation and outcome of laparoscopic (LA) versus OA in an Irish regional hospital setting. METHOD: Retrospective review of OA and LA performed from 2003 to 2005. RESULTS: Intention-to-treat analysis of 787 patients in this study revealed that 149 patients (19%) had LA and 638 patients (81%) had OA. Consultants were significantly more likely than trainees to undertake a LA (P < 0.0001). Twenty-two complications (2.8%) were recorded in the post-operative period. The overall negative appendectomy rate by histopathology was 17% with no significant difference between the rate in the LA group (19%) and the OA (17%) group. CONCLUSION: Mean length of stay and complication rate were comparable between the LA and OA groups.

Incidence and prognostic influence of lymph node micrometastases in rectal cancer.

AIMS: The aim of this study was to determine the rate of lymph node micrometastases and evaluate their prognostic significance in rectal cancer. METHODS: Patients with either Dukes A or B rectal carcinoma who had undergone curative resection by either low anterior resection or abdominal perineal resection between 1991 and 2000 were selected from a prospectively collated database. None of the patients had metastasis at the time of surgery and none received adjuvant or neoadjuvant therapy. A single section from each lymph node was stained with haematoxylin and eosin (H+E) and with CAM 5.2 by immunohistochemistry. Statistical analyses were performed with Chi-square test. RESULTS: A total of 774 lymph nodes with a median of 14 lymph nodes per patient were examined, from a cohort of 56 patients with a median age of 66 years. In the 56 patients in whom lymph node metastases were not detected by haematoxylin-eosin staining, cytokeratin staining was positive in 15 lymph nodes from 10 patients. Nine patients had disease recurrence at a median follow-up of 98 months. The presence of lymph node micrometastases by immunohistochemistry did not predict either disease-free (p=0.44) or overall survival (p=0.63). CONCLUSION: Immunohistochemical staining detects micrometastases in rectal cancer which are not observed with H+E staining. However, no significant relationship was observed between disease relapse and rectal micrometastases detected by immunohistochemistry.

Inverse relationship between ER-beta and SRC-1 predicts outcome in endocrine-resistant breast cancer.

The oestrogen receptor (ER) interacts with coactivator proteins to modulate genes central to breast tumour progression. Oestrogen receptor is encoded for by two genes, ER-alpha and ER-beta. Although ER-alpha has been well characterized, the role of ER-beta as a prognostic indicator remains unresolved. To determine isoform-specific expression of ER and coexpression with activator proteins, we examined the expression and localisation of ER-alpha, ER-beta and the coactivator protein steroid receptor coactivator 1 (SRC-1) by immunohistochemistry and immunofluorescence in a cohort of human breast cancer patients (n=150). Relative levels of SRC-1 in primary breast cultures derived from patient tumours in the presence of beta-oestradiol and tamoxifen was assessed using Western blotting (n=14). Oestrogen receptor-beta protein expression was associated with disease-free survival (DFS) and inversely associated with the expression of HER2 (P=0.0008 and P<0.0001, respectively), whereas SRC-1 was negatively associated with DFS and positively correlated with HER2 (P<0.0001 and P<0.0001, respectively). Steroid receptor coactivator 1 protein expression was regulated in response to beta-oestradiol or tamoxifen in 57% of the primary tumour cell cultures. Protein expression of ER-beta and SRC-1 was inversely associated (P=0.0001). The association of ER-beta protein expression with increased DFS and its inverse relationship with SRC-1 suggests a role for these proteins in predicting outcome in breast cancer.

Expression of SRC-1, AIB1, and PEA3 in HER2 mediated endocrine resistant breast cancer; a predictive role for SRC-1.

BACKGROUND: In human breast cancer, the growth factor receptor HER2 is associated with disease progression and resistance to endocrine treatment. Growth factor induced mitogen activated protein kinase activity can phosphorylate not only the oestrogen receptor, but also its coactivator proteins AIB1 and SRC-1. AIM: To determine whether insensitivity to endocrine treatment in HER2 positive patients is associated with enhanced expression of coactivator proteins, expression of the HER2 transcriptional regulator, PEA3, and coregulatory proteins, AIB1 and SRC-1, was assessed in a cohort of patients with breast cancer of known HER2 status. METHODS: PEA3, AIB1, and SRC-1 protein expression in 70 primary breast tumours of known HER2 status (HER2 positive, n = 35) and six reduction mammoplasties was assessed using immunohistochemistry. Colocalisation of PEA3 with AIB1 and SRC-1 was determined using immunofluorescence. Expression of PEA3, AIB1, and SRC-1 was correlated with clinicopathological parameters. RESULTS: In primary breast tumours expression of PEA3, AIB1, and SRC-1 was associated with HER2 status (p = 0.0486, p = 0.0444, and p = 0.0012, respectively). In the HER2 positive population, PEA3 expression was associated with SRC-1 (p = 0.0354), and both PEA3 and SRC-1 were significantly associated with recurrence on univariate analysis (p = 0.0345; p<0.0001). On multivariate analysis, SRC-1 was significantly associated with disease recurrence in HER2 positive patients (p = 0.0066). CONCLUSION: Patients with high expression of HER2 in combination with SRC-1 have a greater probability of recurrence on endocrine treatment compared with those who are HER2 positive but SRC-1 negative. SRC-1 may be an important predictive indicator and therapeutic target in breast cancer.

Surgical intervention in screen-detected patients versus symptomatic patients with breast cancer.

OBJECTIVES: The impact of population-based screening for breast cancer on the rate of breast-conserving surgery has not been established. We sought to evaluate whether surgical intervention in patients with screen-detected breast cancer differed from those with clinically detected tumours. SETTINGS: St Vincent's University Hospital and the BreastCheck Merrion Unit, part of the Irish National Breast Screening Programme, were the setting for the study. METHODS: A total of 902 patients referred for surgery to St Vincent's University Hospital over a four-year period (2000-2003) were studied. Patients with breast cancers detected during the prevalent round of screening (n=325) were compared with patients presenting with symptomatic disease (n=577). The operative procedure, nature of axillary surgery and histopathological findings were recorded in each case. RESULTS: There was an increase in breast-conserving therapy in the screened population compared with symptomatic cases (68% screened versus 53% symptomatic; p<0.0001), with a corresponding reduction in axillary clearance rates (65% screened versus 81% symptomatic; p<0.0001). Nodal positivity was similar following correction for size in all tumours >1 cm, regardless of method of detection. Sentinel node biopsy was successfully undertaken in 39% of tumours <2 cm (T1 tumours) [corrected] in the screening population. CONCLUSIONS: The screened population was statistically more likely to have breast-conserving therapy than the symptomatic group. Sentinel node biopsy has evolved into an acceptable alternative to axillary clearance in T1 cancers, particularly in screen-detected cases.

Intraoperative margin assessment and re-excision rate in breast conserving surgery.

AIM: The aim of this study was to assess the efficacy of intraoperative margin assessment in obtaining clear margins in conserving surgery for breast cancer. METHODS: Two hundred and twenty patients undergoing wide local excision (WLE) for core biopsy proven primary invasive breast cancer, during a 30 months period, were included in the study. Following surgical excision the breast specimen was orientated with sutures, inked using India ink and coloured pigments and incised to identify the tumour, maintaining orientation. The distance to the individual radial margins were estimated macroscopically by the pathologist and conveyed intraoperatively to the surgeon. A macroscopic tumour-margin distance of less than 10 mm was considered compromised and the margin(s) in question was then excised if feasible. RESULTS: Eighty-one patients (37%) were judged to have compromised margins following intraoperative macroscopic evaluation and had at least one margin re-excised. Sixteen of the 81 patients (20%) in this subgroup had compromised margins on microscopy and required a second operation. One hundred and thirty-nine patients (63%) were deemed to have clear margins intraoperatively, subsequently confirmed on microscopic examination in 135 patients (97%). Intraoperative macroscopic assessment of margin status was associated with 9.1% of patients requiring a second operation. In the absence of intraoperative assessment of margin status a further 47 patients (21.4%) would have required a second operation. CONCLUSION: Intraoperative macroscopic margin assessment is an effective technique in reducing the number of second operative procedures in patients undergoing conserving surgery for primary invasive breast cancer.