Low-Dose Rivaroxaban as Extended Prophylaxis Reduces Postdischarge Venous Thromboembolism in Patients With Malignancy and IBD.

BACKGROUND: Despite guidelines suggesting the use of extended prophylaxis for prevention of venous thromboembolism in patients with colorectal cancer and perhaps IBD, routine use is low and scant data exist regarding oral forms of therapy. OBJECTIVE: The purpose was to compare the incidence of postdischarge venous thromboembolism in patients given extended prophylaxis with low-dose rivaroxaban. DESIGN: We used propensity matching to compare pre- and postintervention analyses from a 2-year period before instituting extended prophylaxis. SETTING: All colorectal patients at a single institution were prospectively considered for extended prophylaxis. PATIENTS: Patients with a diagnosis of IBD or colorectal cancer who underwent operative resection were included. INTERVENTIONS: Those considered for extended prophylaxis were prescribed 10 mg of rivaroxaban for 30 days postsurgery. MAIN OUTCOME MEASURES: The primary outcome was venous thromboembolism incidence 30 days postdischarge. The secondary outcome was bleeding rates, major or minor. RESULTS: Of the 498 patients considered for extended prophylaxis, 363 were discharged with rivaroxaban, 81 on baseline anticoagulation, and 54 without anticoagulation. Propensity-matched cohorts based on stoma creation, operative approach, procedure type, and BMI were made to 174 historical controls. After excluding cases of inpatient venous thromboembolism, postoperative rates were lower in the prospective cohort (4.8% vs 0.6%, p = 0.019). In the prospective group, 36 episodes of bleeding occurred, 26 (7.2%) were discharged with rivaroxaban, 8 (9.9%) discharged on other anticoagulants, and 2 (3.7%) with no postoperative anticoagulation. Cases of major bleeding were 1.1% (4/363) in the rivaroxaban group, and each required intervention. LIMITATIONS: The study was limited to a single institution and did not include a placebo arm. CONCLUSIONS: Among patients with IBD and colorectal cancer, extended prophylaxis with low-dose rivaroxaban led to a significant decrease in postdischarge thromboembolic events with a low bleeding risk profile. See Video Abstract . RIVAROXABN EN DOSIS BAJAS COMO PROFILAXIS PROLONGADA REDUCE LA TROMBOEMBOLIA VENOSA POSTERIOR AL ALTA, EN PACIENTES CON NEOPLASIAS MALIGNAS Y ENFERMEDAD INFLAMATORIA INTESTINAL: ANTECEDENTES:A pesar de las normas que sugieren el uso de profilaxis extendida para la prevención del tromboembolismo venoso en pacientes con cáncer colorrectal y tal vez enfermedad inflamatoria intestinal, el uso rutinario es bajo y existen escasos datos sobre las formas orales de terapia.OBJETIVO:Comparar la incidencia de tromboembolismo venoso posterior al alta, en pacientes que recibieron profilaxis prolongada con dosis bajas de rivaroxabán.DISEÑO:Utilizamos el emparejamiento de propensión para comparar un análisis previo y posterior a la intervención de un período de 2 años antes de instituir la profilaxis extendida.AJUSTE:Todos los pacientes colorrectales en una sola institución fueron considerados prospectivamente para profilaxis extendida.PACIENTES:Incluidos pacientes con diagnóstico de enfermedad inflamatoria intestinal o cáncer colorrectal sometidos a resección quirúrgica.INTERVENCIONES:A los considerados para profilaxis extendida se les prescribió 10 mg de rivaroxabán durante 30 días postoperatorios.PRINCIPALES MEDIDAS DE RESULTADO:El resultado primario fue la incidencia de tromboembolismo venoso 30 días después del alta. El resultado secundario fueron las tasas de hemorragia, mayor o menor.RESULTADOS:De los 498 pacientes considerados para profilaxis extendida, 363 fueron dados de alta con rivaroxabán, 81 con anticoagulación inicial y 54 sin anticoagulación. Se realizaron cohortes emparejadas por propensión basadas en la creación de la estoma, abordaje quirúrgico, tipo de procedimiento y el índice de masa corporal en 174 controles históricos. Después de excluir los casos de tromboembolismo venoso hospitalizado, las tasas posoperatorias fueron más bajas en la cohorte prospectiva (4,8% frente a 0,6%, p = 0,019). En el grupo prospectivo ocurrieron 36 episodios de hemorragia, 26 (7,2%) fueron dados de alta con rivaroxaban, 8 (9,9%) fueron dados de alta con otros anticoagulantes y 2 (3,7%) sin anticoagulación posoperatoria. Los casos de hemorragia mayor fueron del 1,1% (4/363) en el grupo de rivaroxabán y cada uno requirió intervención.LIMITACIONES:Limitado a una sola institución y no incluyó un grupo de placebo.CONCLUSIONES:Entre los pacientes con enfermedad inflamatoria intestinal y cáncer colorrectal, la profilaxis extendida con dosis bajas de rivaroxabán condujo a una disminución significativa de los eventos tromboembólicos posteriores al alta, con un perfil de riesgo de hemorragia bajo. (Traducción-Dr. Fidel Ruiz Healy).

Preoperative Immuno-Nutrition and Complications After Colorectal Surgery: Results of a 2-Year Prospective Study.

INTRODUCTION: Preoperative immuno-nutrition has been associated with reductions in infectious complications and length of stay, but remains unstudied in the setting of an enhanced recovery protocol. The objective was to evaluate outcomes after elective colorectal surgery with the addition of a preoperative immuno-nutrition supplement. METHODS: In October 2017, all major colorectal surgeries were given an arginine-based supplement prior to surgery. The control group consisted of cases within the same enhanced recovery protocol from three years prior. The primary outcome was a composite of overall morbidity. Secondary outcomes were infectious complications and length of stay with subgroup analysis based on degrees of malnutrition. RESULTS: Of 826 patients, 514 were given immuno-nutrition prospectively and no differences in complication rates (21.5% versus 23.9%, P = 0.416) or surgical site infections (SSIs) (6.4% versus 6.9%, P = 0.801) were observed. Hospitalization was slightly shorter in the immuno-nutrition cohort (5.0 [3.0, 7.0], versus 5.5 days [3.6, 7.9], P = 0.002). There was a clinically insignificant difference in prognostic nutrition index scores between cohorts (35.2 ± 5.6 versus 36.1 ± 5.0, P = 0.021); however, subgroup analysis (< 33, 34-38 and > 38) failed to demonstrate an association with complications (P = 0.275) or SSIs (P = 0.640) and immuno-nutrition use. CONCLUSIONS: Complication rates and SSIs were unchanged with the addition of immuno-nutrition before elective colorectal surgery. The association with length of stay is small and without clinical significance; therefore, the routine use of immuno-nutrition in this setting is of questionable benefit.

Effect of Doxycycline-Release Anastomotic Augmentation Ring on Porcine Colorectal Anastomosis.

INTRODUCTION: Collagen degradation can lead to early postoperative weakness in colorectal anastomosis. Matrix metalloproteinase inhibitors (MMPIs) are shown to decrease collagen breakdown and enhance healing in anastomosis in animal models. Here, we evaluated the effectiveness of a novel anastomotic augmentation ring (AAR) that releases doxycycline, an MMPI, from a poly(lactic-co-glycolic) acid ring in porcine anastomoses. METHODS: Two end-to-end stapled colorectal anastomoses were performed in 20 Yorkshire-Hampshire pigs. AAR was randomly incorporated into either the proximal or distal anastomosis as treatment, while nonaugmented anastomosis served as a control. Animals were then euthanized on days 3, 4, and 5 before anastomosis explantation and burst pressure measurement. Each anastomosis site was also collected for histology, hydroxyproline content, and gene expression microarray analyses. RESULTS: No abscess or anastomotic leak was detected. Average burst pressures were not significantly different at any time point. There is no statistical difference in collagen content between the treatment group and controls. Gene expression analysis revealed no statistically significant in differentially expressed genes. However, genes related to inflammation, such as C-C motif chemokine ligand 11 (CCL11), CD70, and C-X-C motif chemokine ligand 10 (CXCL10), were upregulated (not statistically significant) in AAR compared to non-AAR anastomosis sites on days 3 and 4. CONCLUSIONS: This pilot study shows that doxycycline-release AAR is feasible and safe. While burst pressure and collagen content did not change significantly with doxycycline treatment, upregulating genes related to the inflammatory process for pathogen and debris clearance in AAR may improve the early stage of colorectal anastomotic healing.

Use of a standardized discharge checklist with daily post-operative C-reactive protein monitoring does not impact readmission rates after colon and rectal surgery.

PURPOSE: Elevated CRP has been associated with infectious complications after colorectal surgery but has not been evaluated in a prospective fashion as part of a discharge checklist. The objective of this study was to evaluate the effectiveness of a multi-component "discharge criteria checklist" that included daily use of CRP in decreasing hospital readmission rates after colorectal surgery. METHODS: This is a prospective before and after study design that included consecutive patients undergoing major colorectal operations at a single university-affiliated community hospital over a 2-year period. The primary outcome was inpatient or emergency department readmission after 30 days. Selected pre- and peri-operative factors associated with readmissions were then examined in a multivariate analysis model. RESULTS: The study included a total of 1546 patients. Surgical indications were inflammatory bowel disease (15%), colorectal cancer (24%), and benign disease (60%); 9.5% were emergencies. The readmission rates for each group were similar, 17.3% and 17.0%, for the control and discharge checklist groups, respectively (p=0.88). On multivariate analysis of the discharge checklist group dataset, only age, sex, surgical acuity and operating time were statistically significant risk factors. The difference of median CRP values on the day of discharge of those readmitted compared to those not readmitted (35 vs 32 mg/L) was not statistically significant (p=0.28). CONCLUSIONS: The institution of a "discharge checklist" did not impact post-operative hospital readmissions. Not only were readmissions unchanged by the use of a CRP threshold at discharge, but CRP levels at the time of discharge were not associated with readmissions.

The Effect of Chronic Preoperative Opioid Use on Surgical Site Infections, Length of Stay, and Readmissions.

BACKGROUND: Chronic opioid use in the United States is a well-recognized public health concern with many negative downstream consequences. Few data exist regarding the use of preoperative opioids in relation to outcomes after elective colorectal surgery. OBJECTIVE: The purpose of this study was to determine if chronic opioid use before colorectal surgery is associated with a detriment in postoperative outcomes. DESIGN: This is a retrospective review of administrative data supplemented by individual chart review. SETTING: This study was conducted in a single-institution, multisurgeon, community colorectal training practice. PATIENTS: All patients undergoing elective colorectal surgery over a 3-year time frame (2011-2014) were selected. MAIN OUTCOME MEASURES: Opioid use was stratified based on total dose of morphine milligram equivalents (naive, sporadic use (>0-15 mg/day), regular use (>15-45 mg/day), and frequent use (>45 mg/day)). Primary outcomes were surgical site infections, length of hospital stay, and readmissions. RESULTS: Of the 923 patients, 23% (n = 213) were using opioids preoperatively. The preoperative opioid group contained more women (p = 0.047), underwent more open surgery (p = 0.003), had more nonmalignant indications (p = 0.013), and had a higher ASA classification (p = 0.003). Although median hospital stay was longer (4.7 days vs 4.0, p < 0.001), there was no difference in any surgical site infections (10.3% vs 7.1%, p = 0.123) or readmissions (14.2% vs 14.1%, p=0.954). Multivariable analysis identified preoperative opioid use (17.0% longer length of stay; 95% CI, 6.8%-28.2%) and ASA 3 or 4 (27.2% longer length of stay; 95% CI, 17.1-38.3) to be associated with an increase in length of stay. LIMITATIONS: Retrospectively abstracted opioid use and small numbers limit the conclusions regarding any dose-related responses on outcomes. CONCLUSIONS: Although preoperative opioid use was not associated with an increased rate of surgical site infections or readmissions, it was independently associated with an increased hospital length of stay. Innovative perioperative strategies will be necessary to eliminate these differences for patients on chronic opioids. See Video Abstract at http://links.lww.com/DCR/B280. EFECTOS DEL CONSUMO CRÓNICO DE OPIOIDES EN EL PREOPERATORIO CON RELACIÓN A LAS INFECCIONES DE LA HERIDA QUIRÚRGICA, LA DURACIÓN DE LA ESTADÍA Y LA READMISIÓN: El consumo crónico de opioides en los Estados Unidos es un problema de salud pública bien reconocido a causa de sus multiples consecuencias negativas ulteriores. Existen pocos datos sobre el consumo de opioides en el preoperatorio relacionado con los resultados consecuentes a una cirugía colorrectal electiva.El propósito es determinar si el consumo crónico de opioides antes de la cirugía colorrectal se asocia con un detrimento en los resultados postoperatorios.Revisión retrospectiva de datos administrativos complementada por la revisión de un gráfico individual.Ejercicio durante la formación de multiples residentes en cirugía colorrectal enTodos los pacientes de cirugía colorrectal electiva durante un período de 3 años (2011-2014).El uso de opioides se estratificó en función de la dosis total de equivalentes de miligramos de morfínicos (uso previo, uso esporádico [> 0-15 mg / día], uso regular (> 15-45 mg / día) y uso frecuente (> 45 mg / día)). Los resultados primarios fueron las infecciones de la herida quirúrgica, la duración de la estadía hospitalaria y la readmisión.De los 923 pacientes, el 23% (n = 213) consumían opioides antes de la operación. El grupo con opioides preoperatorios tenía más mujeres (p = 0.047), se sometió a una cirugía abierta (p = 0.003), tenía mas indicaciones no malignas (p = 0.013) y tenía una clasificación ASA más alta (p = 0.003). Aunque la mediana de la estadía hospitalaria fue más larga (4,7 días frente a 4,0; p <0,001), no hubo diferencia en ninguna infección de la herida quirúrgica (10,3% frente a 7,1%, p = 0,123) o las readmisiones (14,2% frente a 14,1%, p = 0,954). El análisis multivariable identificó que el uso de opioides preoperatorios (17.0% más larga LOS; IC 95%: 6.8%, 28.2%) y ASA 3 o 4 (27.2% más larga LOS; IC 95%: 17.1, 38.3) se asocia con un aumento en LOS.La evaluación retrospectiva poco precisa del consumo de opioides y el pequeño número de casos limitan las conclusiones sobre cualquier respuesta relacionada con la dosis - resultado.Si bien el consumo de opioides preoperatorios no se asoció con un aumento en la tasa de infecciones de la herida quirúrgica o las readmisiones, ella se asoció de forma independiente con un aumento de la LOS hospitalaria. Serán necesarias estrategias perioperatorias innovadoras para eliminar estas diferencias en los pacientes consumidores cronicos de opioides. Consulte Video Resumen en http://links.lww.com/DCR/B280.

Sigmoidectomy for Diverticulitis-A Propensity-Matched Comparison of Minimally Invasive Approaches.

BACKGROUND: As the availability and use of robotic surgery increases, current data suggest comparable outcomes to laparoscopic surgery but at an increased cost. Elective sigmoid resection for diverticular disease is the most common colorectal application of robotic surgery and there is limited comparative data specifically for this indication. METHODS: We identified all elective cases of laparoscopic- and robot-assisted surgery for diverticular disease among a practice of 7 colorectal surgeons within an established enhanced recovery protocol. We performed propensity matching based on surgical indications (recurrent disease, ongoing symptoms, or fistula), stoma creation, and body mass index to create a matched cohort. Our primary outcomes were return of bowel function, length of stay, opioid use, and pain scores during the first 72 h postoperatively. Secondary outcomes were operative room and hospital charges. RESULTS: From 2011 to 2016, 69 robotic cases were propensity matched from a group of 222 laparoscopic cases to create a 1:1 case ratio that was equivalent in terms of patient demographics and operative indications. Time to first bowel movement was slightly quicker in the robotic group (1 [1] versus 2 [1.5], P = 0.09), while length of stay (3.5 [1.6] versus 3.6 [1.4] d, P = 0.64) was equivalent. Pain scores were lower in the robotic group on day 0 (4.6 versus 6.1, P = 0.0001), but similar on day 1 and day 2 (4.3 versus 4.1, P = 0.62 and 3.8 versus 3.3, P = 0.19). There was no difference in postoperative 72-h opioid use between groups (110.8 MME [144.5] versus 97.4 MME [101.5], P = 0.70). In the robotic arm operating room charges were slightly more ($2835 ± $394 versus $2196 ± $359, P < 0.0001), but total hospital charges were over significantly increased ($41,159 [$7840] versus $25,761 [$11,689], P < 0.0001). CONCLUSIONS: Via a carefully matched cohort of elective sigmoid resection for diverticular disease at a single community institution, we have demonstrated that laparoscopic- and robotic-assisted surgery result in clinically equivalent return of bowel function, length of stay, postoperative pain, and opioid use.

Diverticulitis recurrence after percutaneous abscess drainage.

PURPOSE: Recurrent diverticulitis has been reported in 30-50% of patients who recover from an episode of diverticular-associated abscess. Our aim was to review the outcomes of patients who underwent non-operative management after percutaneous drainage (PD) of colonic diverticular abscess. METHODS: All patients with a diverticular-associated abscess were identified between 2001 and 2012. Individual charts were queried for peri-procedural data and follow-up. The most recent follow-up data were acquired via the electronic medical record or telephone call. RESULTS: A total of 165 patients underwent PD of diverticular-associated abscesses. Abscess locations were pelvic (n = 122), abdominal (n = 36), and both (n = 7), while median abscess size was 6.1 ± 2.2 cm. One hundred eighteen patients clinically improved following non-operative management, and 81 of these patients did not undergo subsequent colonic resection within 4 months of PD. Of these, 8 died within 12 months. Among the remaining 73 patients, there were no significant differences in demographics or abscess variables compared to those who underwent elective surgery within 4 months. Only 7 of 73 patients had documented episodes of recurrences, while 22 patients later had elective surgery (1.1 ± 1.2 years from the index case). Five-year colectomy-free survival was 55% (95%CI 42-66%), while the recurrence-free survival at 5 years was 77% (95%CI 65-86%). All recurrences were managed non-operatively initially and one patient went on to have elective resection. CONCLUSION: A sizable number of patients successfully recover from complicated diverticulitis following PD. Subsequent non-operative management carries an acceptable risk for recurrent episodes and may be considered as a reasonable management option.

High-definition colonoscopy increases adenoma detection rate.

BACKGROUND: The adenoma detection rate (ADR) is a quality indicator for colonoscopy. High-definition (HD) imaging has been reported to increase polyp detection rates. OBJECTIVE: The primary objective of this study was to compare polyp detection rate (PDR) and adenoma detection rate (ADR) before and after the implementation of HD colonoscopy. METHODS: A retrospective chart review was performed on patients aged 48-55 years old, who underwent first-time screening colonoscopy. The first group underwent standard-definition (SD) colonoscopy in the first 6 months of 2011. The second group underwent screening with HD colonoscopy during the first 6 months of 2012. We compared age, gender, PDR, ADR, and average sizes of adenomatous polyps between gastroenterologist and colorectal surgeon and among physicians themselves. Statistical analysis was performed with Fischer's exact test and Pearson Chi-square. RESULTS: A total of 1268 patients were involved in the study (634 in each group). PDR (35.6 vs. 48.2 %, p < 0.001) and ADR (22.2 vs. 30.4 %, p = 0.02) were higher in the HD group. The average size of an adenomatous polyp was the same in the two groups (0.58 vs. 0.57, p = 0.69). However, this difference was not seen among colorectal surgeons PDR (35.7 vs. 37 %, p = 0.789), ADR (22.9 vs. 24.5 % p = 0.513), but clearly seen among gastroenterologist, PDR (35.6 vs. 53.1 % p < 0.001) and ADR (21.9 vs. 32.9 % p < 0.001). When polyps were categorized into size groups, there was no difference in ADR between the two timeframes (<5 mm in size (41.5 vs. 35.4 %), 5-10 mm (49.3 vs. 60.1 %) and >10 mm (9.2 vs. 4.5 %), p = 0.07). Polyps were most commonly seen in the sigmoid colon (26.1 vs. 24.7 %). There was no difference in the rate of synchronous polyp detection between modalities (25.6 vs. 29 %, p = 0.51). Withdrawal time was the same in both procedure (9.2 vs. 8.5 min, p = 0.10). CONCLUSION: Screening colonoscopy with high-definition technology significantly improved both PDR and ADR. In addition, high-definition colonoscopy may be particularly useful and advantageous among less experienced endoscopists in various community settings. However, there needs to be application to specific patient populations in future studies to assess for any statistical differences between standard- and high-definition modalities to determine clinical utility.

Does CD10 Expression Predict Lymph Node Metastasis in Colorectal Cancer?

BACKGROUND: Accurate preoperative prediction of lymph node status would be a revolutionary adjunct in treating colorectal cancer. The immunohistochemical marker CD10 has been suggested recently to have a predictive capacity for lymph node involvement in colorectal cancer. OBJECTIVE: The aim of our study was to evaluate the relationship between the presence of the CD10 molecular marker and lymph node metastasis in a US patient population using previously banked colorectal cancer specimens. DESIGN: This was a retrospective study. SETTINGS: The study was conducted at a single academic institution. PATIENTS: Included were specimens from 191 patients, with cancer stages ranging from T1N0 to T3N2. MAIN OUTCOME MEASURES: The relationship between CD10 and different clinicopathologic parameters was assessed, as well as the ability to predict lymph node metastasis by itself and in conjunction with lymphovascular invasion. RESULTS: CD10 was significantly correlated with left-sided colon cancers (p = 0.01) and the presence of mucinous histology and had a relatively high specificity (75.7%) for lymph node metastasis. CD10 did not correlate with lymph node status (p = 0.33) or enhance the ability of lymphovascular invasion to predict lymphatic metastasis in our patient population. Sensitivity and specificity of lymphovascular invasion alone for lymph node metastasis were 62.8% and 93.6%, whereas adding CD10 status resulted in a sensitivity of 70.6% and specificity of 69.3%. Multivariate analysis revealed only lymphovascular invasion as a predictor of lymph node metastasis in our patient population. LIMITATIONS: This study was primarily limited by its small sample size and retrospective nature. CONCLUSIONS: In our patient population, CD10 status was not significantly associated with lymph node metastasis, and it was no better than lymphovascular invasion alone when predicting lymph node status.

Development of The American Society of Colon and Rectal Surgeons' Rectal Cancer Surgery Checklist.

BACKGROUND: There is excellent evidence that surgical safety checklists contribute to decreased morbidity and mortality. OBJECTIVE: The purpose of this study was to develop a surgical checklist composed of the key phases of care for patients with rectal cancer. DESIGN: A consensus-oriented decision-making model involving iterative input from subject matter experts under the auspices of The American Society of Colon and Rectal Surgeons was designed. SETTINGS: The study was conducted through meetings and discussion to consensus. PATIENTS: Patient data were extracted from an initial literature review. MAIN OUTCOME MEASURES: The checklist was measured by its ability to improve care in complex rectal surgery cases by reducing the possibility of omission through the division of treatment into 3 distinct phases. RESULTS: The process generated a 25-item checklist covering the spectrum of care for patients with rectal cancer who were undergoing surgery. LIMITATIONS: The study was limited by its lack of prospective validation. CONCLUSIONS: The American Society of Colon and Rectal Surgeons rectal cancer surgery checklist is composed of the essential elements of preoperative, intraoperative, and postoperative care that must be addressed during the surgical treatment of patients with rectal cancer.

Risk factors for readmission after elective colectomy: postoperative complications are more important than patient and operative factors.

BACKGROUND: Colon resections are associated with substantial risk for morbidity and readmissions, and these have become markers for quality of care. OBJECTIVE: The purpose of this study was to determine risk factors for readmissions after elective colectomies to improve patient care and better understand the complex issues associated with readmissions. DESIGN: This was an analysis of the prospective, statewide, multicenter Michigan Surgical Quality Collaborative database. SETTINGS: The analysis was conducted at academic and community medical centers in the state of Michigan. PATIENTS: Elective laparoscopic and open ileocolic and segmental colectomies from 2008 through 2010 were included. MAIN OUTCOME MEASURES: Univariate analysis and a multivariate logistic regression model were used to determine influence of patient characteristics, operative factors, and postoperative complications on the incidence of 30-day postoperative readmission. RESULTS: The readmission rate among 4013 cases was 7.3% (N = 293). On the basis of multivariate logistic regression, the top 3 significant risk factors associated with readmission were stroke (OR, 10.0 [95% CI, 2.70-37.0]; p = 0.001), venous thromboembolism (OR, 6.5 [95% CI, 3.7-11.3]; p < 0.0001), and organ-space surgical site infection (OR, 5.6 [95% CI, 3.4-9.4]; p < 0.0001). Important factors that contributed to readmission risk but were not found to be independent predictors of readmission included diabetes mellitus, preoperative steroids, smoking, cardiac comorbidities, age >80 years, anastomotic leaks, fascial dehiscence, sepsis, pneumonia, unplanned intubation, and length of stay. LIMITATIONS: The Michigan Surgical Quality Collaborative is a large database, and true causal relations are difficult to determine; reason for readmission is not recorded in the database. CONCLUSIONS: Postoperative complications account for the majority of risk factors behind readmissions after elective colectomy, whereas preoperative risk factors have less direct influence. Current strategies addressing readmission rates should focus on reducing preventable complications.

Bleeding After Hemorrhoidectomy in Patients on Anticoagulation Medications.

BACKGROUND: Post-hemorrhoidectomy bleeding is a serious complication after hemorrhoidectomy. In the setting of a new wave of anticoagulants, we aimed to investigate the relationship of post-operative anticoagulation timing and delayed bleeding. METHODS: We performed a retrospective analysis of all patients undergoing hemorrhoidectomy at a single institution over a 10-year period. Fisher's exact and Wilcoxon Rank Sum tests were utilized to test for association between delayed bleeding and anticoagulation use. RESULTS: Between January 2011 and October 2020, 1469 hemorrhoidectomies were performed. A total of 216 (14.7%) were taking platelet inhibitors and 56 (3.8%) other anticoagulants. Delayed bleeding occurred in 5.2% (n = 76) of which 47% (n = 36) required operative intervention. Mean time to bleeding was 8.7 days (SD ±5.9). Time to bleeding was longer in those taking antiplatelet inhibitors vs. non-platelet inhibitors vs. none (11 vs. 8 vs. 7 days, P = .05). Among anticoagulants (n = 56), novel oral anticoagulants were more common than warfarin (57% vs 43%) and had a nonsignificant increase in delayed bleeding (31% vs 16%, P = .21). Later restart (>3 days) of novel anticoagulants after surgery was associated with increased bleeding (10.5% vs 61.5%, P=.005). On multivariable analysis, only anticoagulation use (OR 4.5, 95% CI: 2.1-10.0), male sex (OR 1.8, 95% CI: 1.1-2.9), and operative oversewing (OR 3.5, 95% CI: 1.8-6.9) were associated with delayed bleeding. CONCLUSION: Post-hemorrhoidectomy bleeding is more likely to occur with patients on anticoagulation. Later restart times within the first week after surgery was not associated with a decrease in bleeding.

Continuing medical education, maintenance of certification, and physician reentry.

Continuing medical education serves a central role in the licensure and certification for practicing physicians. This chapter explores the different modalities that constitute CME along with their effectiveness, including simulation and best education practices. The evolution to maintenance of certification and the requirements for both the American Board of Surgery and the American Board of Colon and Rectal Surgery are delineated. Further progress in the education of practicing surgeons is evidenced through the introduction of laparoscopic colectomy and the improvements made from the introduction of laparoscopic cholecystectomy. Finally, reentry of physicians into practice following a voluntary leave of absence, a new and challenging issue for surgeons, is also discussed.

Ileal Pouch Anal Anastomosis (IPAA) for colitis; development of Crohn's and Pouchitis.

BACKGROUND: Chronic pouchitis and Crohn's disease after Ileal pouch anal anastomosis (IPAA) for ulcerative colitis could be a larger issue than previously reported. METHODS: All patients receiving care for their IPAA over a 10-year period at a community hospital were included. Primary outcomes were incidence of Crohn's disease and pouchitis. RESULTS: The study included 380 IPAA patients. Indication for pouch creation was either UC (n = 362) or indeterminate colitis (n = 18). Cumulative incidence of Crohn's was 19.5%. Five-, 10- and 20-year incidence of Crohn's was 3.4%, 8.4% and 16.9%. Chronic pouchitis occurred in 28.7%. Mean time to pouchitis and Crohn's diagnosis was 8.4 (SD ± 8.0) and 11.6 (SD ± 7.5) years. Pouch failure occurred in 12.4%. Patients who developed Crohn's were more likely to suffer pouchitis and pouch failure (OR 3.5, 95%CI 2.0-6.0 and 5.3, 95%CI 2.8-10.1). CONCLUSION: During long term follow up, almost 20% are diagnosed with Crohn's contributing significantly to pouch failure.

Minimally invasive colon resection is associated with a persistent increase in plasma PlGF levels following cancer resection.

BACKGROUND: Minimally invasive colorectal resection (MICR) is associated with persistently elevated plasma VEGF levels that may stimulate angiogenesis in residual tumor foci. Placenta growth factor (PlGF) stimulates neovascularization in tumors by modulating VEGF's effects. This study's purpose was to determine the impact of MICR on blood PlGF levels in cancer patients (Study A) and to compare PreOp levels in patients with cancer and benign (BEN) disease (Study B). METHODS: Blood samples were collected preoperatively, on postoperative day (POD) 1, POD 3, and at various time points 2-4 weeks after surgery. Samples from 7-day periods after POD 6 were bundled to allow analysis. Plasma PlGF levels were determined via ELISA, results reported as mean±SD, and data analyzed via t test. Significance was set at p<0.008 after Bonferroni correction. RESULTS: Study A: 76 colorectal cancer (CRC) patients had MICR (laparoscopic, 59%; hand-assisted, 41%). The mean length of stay was 5.8±2.1 days. The mean PreOp PlGF level was 15.4±4.3 pg/ml. Significantly increased levels were noted on POD 1 (25.8±7.7 pg/ml, p<0.001), POD 3 (22.9±6.7, p<0.001), POD 7-13 (19.2±5.1, p<0.001), and POD 14-20 (19.5±6.7, p<0.002). The mean POD 21-27 level was not significantly different from baseline. Study B included 126 CRC and 111 BEN patients. PreOp levels were higher in the CRC patients (15.6±5.3 pg/ml) than in the BEN group (13.5±5.5 pg/ml, p=0.001). CONCLUSIONS: PlGF levels are elevated for 3 weeks after MICR and PreOp plasma levels are higher in CRC patients than in BEN disease patients. The cause of the postoperative increase is unclear. The persistently higher blood levels of PlGF and VEGF after MICR may stimulate angiogenesis in residual tumor foci. Further studies regarding late blood protein alterations after surgery appear to be indicated.

Minimally invasive colorectal resection is associated with a transient increase in plasma hepatocyte growth factor levels early after surgery for colon cancer.

INTRODUCTION: Surgery's impact on blood levels of hepatocyte growth factor (HGF), a potent angiogenic factor, is unknown. Preoperative (PreOp) HGF blood levels are elevated in patients with colorectal cancer (CRC) and correlate with disease stage and prognosis. This study's purpose was to determine plasma HGF levels after minimally invasive colorectal resection (MICR) in patients with CRC. METHODS: Clinical and operative data were collected. Blood samples were obtained in all patients PreOp and on postoperative day (POD) 1 and 3; in some, samples were taken during weeks 2 and 3 after MICR. Late samples were bundled into 7-day time blocks. HGF levels were determined via enzyme-linked immunosorbent assay in duplicate. Student's t test was used to analyze the data (significance, P < .0125 after Bonferroni correction). RESULTS: A total of 28 CRC patients who underwent MICR were studied. Most had right, sigmoid, or left segmental colectomy. The mean plasma HGF level was higher on POD 1 (2417 ± 1476 pg/mL, P < .001) and POD 3 (2081 ± 1048 pg/mL, P < .001) when compared with PreOp levels (1045 ± 406 pg/mL). Plasma levels were back to baseline by the second (1100 ± 474 pg/mL, P = .64) and third postoperative weeks (1010 ± 327 pg/mL, P = .51). CONCLUSION: MICR for CRC is associated with a 1.9- to 2.3-fold increase in plasma HGF levels during the first 3 PODs after which levels normalize. This transient increase may briefly promote angiogenesis and the growth of residual tumor cells.

A statewide assessment of surgical site infection following colectomy: the role of oral antibiotics.

OBJECTIVE: To determine the utility of adding oral nonabsorbable antibiotics to the bowel prep prior to elective colon surgery. SUMMARY BACKGROUND DATA: Bowel preparation prior to colectomy remains controversial. We hypothesized that mechanical bowel preparation with oral antibiotics (compared with without) was associated with lower rates of surgical site infection (SSI). METHODS: Twenty-four Michigan hospitals participated in the Michigan Surgical Quality Collaborative-Colectomy Best Practices Project. Standard perioperative data, bowel preparation process measures, and Clostridium difficile colitis outcomes were prospectively collected. Among patients receiving mechanical bowel preparation, a logistic regression model generated a propensity score that allowed us to match cases differing only in whether or not they had received oral antibiotics. RESULTS: Overall, 2011 elective colectomies were performed over 16 months. Mechanical bowel prep without oral antibiotics was administered to 49.6% of patients, whereas 36.4% received a mechanical prep and oral antibiotics. Propensity analysis created 370 paired cases (differing only in receiving oral antibiotics). Patients receiving oral antibiotics were less likely to have any SSI (4.5% vs. 11.8%, P = 0.0001), to have an organ space infection (1.8% vs. 4.2%, P = 0.044) and to have a superficial SSI (2.6% vs. 7.6%, P = 0.001). Patients receiving bowel prep with oral antibiotics were also less likely to have a prolonged ileus (3.9% vs. 8.6%, P = 0.011) and had similar rates of C. difficile colitis (1.3% vs. 1.8%, P = 0.58). CONCLUSIONS: Most patients in Michigan receive mechanical bowel preparation prior to elective colectomy. Oral antibiotics may reduce the incidence of SSI.

Minimally invasive colorectal resection is associated with a rapid and sustained decrease in plasma levels of epidermal growth factor (EGF) in the colon cancer setting.

BACKGROUND: Epidermal growth factor (EGF) stimulates tumor growth directly via tumor cell EGF receptors or indirectly via its proangiogenic effects. This study's purpose was to determine the impact of minimally invasive colorectal resection (MICR) on postoperative (postop) plasma EGF levels in the colorectal cancer (CRC) and benign disease settings and to see if preoperative (PreOp) EGF levels are altered in cancer patients. METHODS: MICR patients with benign pathology (n = 40) and CRC (n = 48) had blood samples taken PreOp and on postoperative days (POD) 1 and 3. In some patients, late samples were taken between POD7 and POD60; these were bundled into 7-day blocks and considered as single time points. EGF levels were determined by enzyme-linked immunosorbent assay (ELISA) and results were reported as mean ± SD after logarithmic transformation. The Student t test was used (p < 0.008 after Bonferroni correction). RESULTS: The cancer and benign groups were comparable except for age. The mean PreOp CRC plasma EGF level (122.9 ± 75.9 pg/ml) was significantly higher than that of the benign group (85.3 ± 38.5 pg/ml) (p = 0.015). The cancer group's EGF levels were significantly decreased on POD1 and POD3 and for the POD31-55 time point (mean EGF level = 63.1 ± 42.2 (n = 10). The benign group's POD3 and POD7-14 EGF levels were significantly lower than the PreOp level; later levels returned toward baseline. Small late sample size limited analysis. CONCLUSION: Plasma EGF levels are significantly higher in cancer patients. MICR is associated with a significant decrease in EGF levels early postop in both cancer and benign settings. Unlike the benign group, EGF blood levels in cancer patients remain low during the second postop month. A larger study with more late samples is needed to verify these results. EGF may have value as a tumor marker.

Surgical management of stomal prolapse - Is there a superior approach to repair?

BACKGROUND: Stomal prolapse is an uncommon complication related to ostomy creation without comparative studies to suggest an optimal approach. Our aim was to assess long-term recurrence rates following surgical repair, specifically local repair vs. laparotomy. METHODS: We conducted a retrospective review of patients who underwent surgical correction of a prolapsed stoma by dedicated colorectal surgeons. The primary outcome was recurrence. We evaluated perioperative risk factors for long-term recurrence, focusing on the surgical approach. RESULTS: Over 12 years, 23 patients underwent 37 surgeries (median follow-up 24 months, range 1-126). Repeat operations for recurrence were performed in 43.5% of patients, 80% within one year. Recurrence was similar regardless of the surgical approach; 43.6% local repair vs 42.9% laparotomy (p = 0.41). Age, sex, body mass index, smoking status, ASA score, type of stoma, and urgency of repair were not associated with recurrence. Re-recurrence resulting in a third operation, occurred in 50% of patients. CONCLUSION: Operative repair of stomal prolapse, regardless of approach, is associated with high recurrence rates. No identifiable factors were associated with recurrence.

What predicts successful nonoperative management with botulinum toxin for anal fissure?

BACKGROUND: Botulinum toxin has been established as a non-surgical alternative for chronic anal fissures. There is a paucity of data regarding which patients benefit most from this intervention. METHODS: We retrospectively collected data from all cases of chronic anal fissures treated with botulinum toxin over seven years to identify predictors of success. Non-responders were defined as any subsequent surgery or reporting satisfaction as poor or fair. RESULTS: Of 91 patients, 60% (n = 55) were responders and 26% (n = 25) underwent subsequent surgery. There were significantly more females among responders (78% vs. 55%, p = 0.02). A higher body mass index tended towards significance among non-responders (30 ± 7 vs. 27 ± 6, p = 0.08). High satisfaction at the first visit was associated with no subsequent surgery (18% vs. 45%, p = 0.002). CONCLUSIONS: Botulinum toxin can be successfully used to treat anal fissures in a majority of patients. Primary predictors of success were female sex, satisfaction at the first post-procedure visit and there was a tendency towards a lower body mass index.