Colonic Stent Use by Indication and Patient Outcomes: A Nationwide Inpatient Sample Study.

BACKGROUND: Colonic stent placement can avoid urgent surgery for large bowel obstruction in selected patients. Population-wide stent utilization patterns and outcomes are unknown. MATERIALS AND METHODS: Using retrospective, population-based, Nationwide Inpatient Sample data, we studied patients with colonic stents discharged during 2010-2015. The primary outcome was ostomy creation during the same hospitalization. Other outcomes were perforation or peritonitis, and in-hospital death. Associations of outcomes with stent indication were investigated, adjusting for patient-, admission-, and hospital characteristics. We estimated annual population-wide stent use volumes. RESULTS: Of 4257 patients with stent placement (52% male, mean age 64.6 years), 9.9% had non-metastatic colon cancer, 12.9% metastatic colon cancer, 37.8% extracolonic malignancy (ECM), and 39.3% had benign obstruction. In 8.1% of patients, ostomy creation surgery was performed. Perforation or peritonitis occurred in 16.7%, and in-hospital death in 4.5%. Relative to ECM, ostomy creation was several-fold more likely among nonmetastatic colon cancer (adjusted odds ratio (OR) 3.4; 95%CI, 2.1-5.5), metastatic colon cancer (adjusted OR 2.5; 95%CI, 1.7-3.7), and benign obstruction patients (adjusted OR 3.1; 95%CI, 2.1-4.7). Benign obstruction was associated with high risk of perforation/peritonitis (adjusted OR 3.1 relative to non-metastatic CC (95%CI, 2.1-4.5)). Perforation/peritonitis was highly associated with inpatient death (adjusted OR 6.8 (95%CI, 4.9-9.5)). Annually, about 3,580 patients underwent stent placement, with benign obstruction showing an increasing trend (P=0.0002). CONCLUSIONS: Over 75% of stent placements were done for patients with benign disease and ECM obstruction. Subsequent ostomy creation during the hospitalization was least likely among ECM patients. Rates of perforation/peritonitis in benign obstructions were concerningly high. (22.2%).

Cost-effectiveness Evaluation of Laparoscopic Versus Robotic Minimally Invasive Colectomy.

OBJECTIVE: Evaluate the cost-effectiveness of open, laparoscopic, and robotic colectomy. BACKGROUND: The use of robotic-assisted colon surgery is increasing. Robotic technology is more expensive and whether a robotically assisted approach is cost-effective remains to be determined. METHODS: A decision-analytic model was constructed to evaluate the 1-year costs and quality-adjusted time between robotic, laparoscopic, and open colectomy. Model inputs were derived from available literature for costs, quality of life (QOL), and outcomes. Results are presented as incremental cost-effectiveness ratios (ICERs), defined as incremental costs per quality-adjusted life year (QALY) gained. One-way and probabilistic sensitivity analyses were performed to test the effect of clinically reasonable variations in the inputs on our results. RESULTS: Open colectomy cost more and achieved lower QOL than robotic and laparoscopic approaches. From the societal perspective, robotic colectomy costs $745 more per case than laparoscopy, resulting in an ICER of $2,322,715/QALY because of minimal differences in QOL. From the healthcare sector perspective, robotics cost $1339 more per case with an ICER of $4,174,849/QALY. In both models, laparoscopic colectomy was more frequently cost-effective across a wide range of willingness-to-pay thresholds. Sensitivity analyses suggest robotic colectomy becomes cost-effective at $100,000/QALY if robotic disposable instrument costs decrease below $1341 per case, robotic operating room time falls below 172 minutes, or robotic hernia rate is less than 5%. CONCLUSIONS: Laparoscopic and robotic colectomy are more cost-effective than open resection. Robotics can surpass laparoscopy in cost-effectiveness by achieving certain thresholds in QOL, instrument costs, and postoperative outcomes. With increased use of robotic technology in colorectal surgery, there is a burden to demonstrate these benefits.

Operative Incision and Drainage for Perirectal Abscesses: What Are Risk Factors for Prolonged Length of Stay, Reoperation, and Readmission?

BACKGROUND: Perirectal abscess is a common problem. Despite a seemingly simple disease to manage, clinical outcomes of perirectal abscesses can vary significantly given the wide array of patients who are susceptible to this disease. OBJECTIVE: Our aims were to evaluate the outcomes after operative incision and drainage for perirectal abscess and to examine factors associated with length of stay, reoperations, and readmissions. DESIGN: This was a retrospective analysis of the National Surgical Quality Improvement Program database. SETTINGS: The study was conducted with hospitals participating in the surgical database. PATIENTS: Adult patients undergoing outpatient perirectal abscess procedures from 2011 through 2016 were included. MAIN OUTCOME MEASURES: Study outcomes were length of stay, reoperation, and readmission. RESULTS: We identified 2358 patients undergoing incision and drainage for perirectal abscesses. Approximately 35% of patients required hospital stay. Reoperations occurred in 3.4%, with median time to reoperation of 15.5 days. The majority of reoperations (79.7%) were performed for additional incision and drainage. Readmissions rate was 3.0%, with median time to readmission of 10.5 days. Common indications for readmissions included recurrent/persistent abscess (41.4%) and fever/sepsis (8.6%). Risk factors for hospitalization in multivariable analysis were preoperative sepsis, bleeding disorder, and non-Hispanic black and Hispanic races. For reoperations, risk factors included morbid obesity, preoperative sepsis, and dependent functional status. Lastly, for readmissions, female sex, steroid/immunosuppression, and dependent functional status were significant risk factors. LIMITATIONS: The study was limited by its retrospective analysis and potential selection bias in decisions on hospital stay, reoperation, and readmission. CONCLUSIONS: Suboptimal outcomes after outpatient operative incision and drainage for perirectal abscesses are not uncommon in the United States. In the era of value-based care, additional work is needed to optimize use outcomes for high-risk patients undergoing perirectal incision and drainage. Strategies to prevent inadequate drainage at the time of the initial operative incision and drainage (ie, use of imaging modalities and thorough examination under anesthesia) are warranted to improve patient outcomes. See Video Abstract at http://links.lww.com/DCR/B229. INCISIÓN Y DRENAJE QUIRÚRGICOS DE ABSCESOS PERIRRECTALES: CUALES SON LOS FACTORES DE RIESGO PARA UNA ESTADÍA PROLONGADA, REINTERVENCIÓN Y READMISION?: Los abscesos perirrectales son un problema frecuente. A pesar que parecen ser una afección aparentemente simple de manejar, los resultados clínicos de la incisión y drenaje quirúrgicos pueden variar significativamente dada la amplia variedad de pacientes susceptibles de sufrir esta afección.Evaluar los resultados después de la incisión y el drenaje quirúrgicos de un absceso perirrectal y analizar los factores asociados con la duración de la hospitalización, la reoperación y la readmisión.Análisis retrospectivo de la base de datos del Programa Americano de Mejora de la Calidad Quirúrgica.Hospitales que participan en la base de datos quirúrgica.Pacientes adultos sometidos a incisión y drenaje quirúrgico ambulatorio de un absceso perirrectal desde 2011 hasta 2016.Los resultados del estudio fueron la duración de la hospitalización, la reoperación y el reingreso.Fueron estudiados 2,358 pacientes sometidos a incisión y drenaje por abscesos perirrectales. Aproximadamente el 35% de los pacientes requirieron hospitalización. Las reoperaciones ocurrieron en 3.4% con una mediana de tiempo de reoperación de 15.5 días. La mayoría de las reoperaciones (79.7%) se realizaron para una incisión y drenaje adicionales. La tasa de reingreso fue del 3.0% con una mediana de tiempo de reingreso de 10.5 días. Las indicaciones comunes para los reingresos incluyeron abscesos recurrentes / persistentes (41.4%) y fiebre / sepsis (8.6%). Los factores de riesgo para la hospitalización en el análisis multivariable fueron sepsis preoperatoria, trastorno hemorrágico, raza negra no hispánica y raza hispana. Para las reoperaciones, los factores de riesgo incluyeron obesidad mórbida, sepsis preoperatoria y estado funcional dependiente. Por último, para los reingresos, el sexo femenino, uso de corticoides / inmunosupresores y un estadío funcional dependiente fueron factores de riesgo significativos.Análisis retrospectivo y posible sesgo de selección en las decisiones sobre hospitalización, reoperación y reingreso.Un resultado poco satisfactorio después de la incisión quirúrgica el drenaje de abscesos perirrectales ambulatoriamente no son infrecuentes en los Estados Unidos. En la era de la atención basada en los resultados, se necesita mucho más trabajo para optimizar los mismos en pacientes de alto riesgo sometidos a incisión y drenaje perirrectales. Las estrategias para prevenir el drenaje inadecuado en el momento de la incisión quirúrgica inicial y el drenaje (es decir, el uso de modalidades de imágenes, un examen completo bajo anestesia) son una garantía para mejorar los resultados en estos pacientes. Consulte Video Resumen en http://links.lww.com/DCR/B229.

Transversus Abdominis Plane Block in Laparoscopic Colorectal Surgery: A Systematic Review.

BACKGROUND: Multimodal analgesia is important for postoperative recovery in laparoscopic colorectal surgery. Multiple randomized controlled trials have investigated the use of transversus abdominis plane local anesthetic infiltration as a method of decreasing postoperative pain and opioid consumption, with variable results. OBJECTIVE: This study aimed to examine the overall effect of transversus abdominis plane block in postoperative pain, opioid use, and speed of recovery in laparoscopic colorectal surgery. DATA SOURCES: A literature search was done with PubMed, EMBASE, Web of Knowledge, and Cochrane Library. Only randomized controlled trials were selected for review. INTERVENTIONS: Transversus abdominis plane local anesthetic infiltration versus no intervention, saline, or other techniques in laparoscopic colorectal surgeries was investigated. MAIN OUTCOME MEASURES: The primary outcome measured was postoperative pain on day 1, at rest or with activity. The secondary outcomes measured were postoperative pain beyond day 1, consumptions of opioid, and length of hospital stay. RESULTS: Eight clinical trials including 649 patients between 2013 and 2018 were included. Resting pain scores within 2 hours (standardized mean difference, -0.53; p = 0.01), 4 hours (standardized mean difference, -0.42; p = 0.004), and 6 hours (standardized mean difference, -0.47; p = 0.03) showed statistically significant reduction. Six studies including 413 patients demonstrated lower cumulative opioid consumption within 24 hours after surgery (standardized mean difference, -0.82; p = 0.01). Five studies including 357 patients did not show a significant difference in length of stay (standardized mean difference, -0.04; p = 0.82). LIMITATIONS: Local anesthetic used in block varied in type and quantity across different studies. There were heterogeneities in pain score measurements and opioid consumption. Patient populations may be different among studies. CONCLUSIONS: Transversus abdominis block can lead to a lower pain score at rest within the first 6 hours and reduce opioid consumption within the first 24 hours. See Video Abstract at http://links.lww.com/DCR/A997.

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

BACKGROUND: Hospital readmission is common after ileostomy formation and frequently associated with dehydration. OBJECTIVE: This study was conducted to evaluate a previously published intervention to prevent dehydration and readmission. DESIGN: This is a randomized controlled trial. SETTING: This study was conducted in 3 hospitals within a single health care system. PATIENTS: Patients undergoing elective or nonelective ileostomy as part of their operative procedure were selected. INTERVENTION: Surgeons, advanced practice providers, inpatient and outpatient nurses, and wound ostomy continence nurses participated in a robust ileostomy education and monitoring program (Education Program for Prevention of Ileostomy Complications) based on the published intervention. After informed consent, patients were randomly assigned to a postoperative compliance surveillance and prompting strategy that was directed toward the care team, versus usual care. OUTCOME MEASURES: Unplanned hospital readmission within 30 days of discharge, readmission for dehydration, acute renal failure, estimated direct costs, and patient satisfaction were the primary outcomes measured. RESULTS: One hundred patients with an ileostomy were randomly assigned. The most common indications were rectal cancer (n = 26) and ulcerative colitis (n = 21), and 12 were emergency procedures. Although intervention patients had better postdischarge phone follow-up (90% vs 72%; p = 0.025) and were more likely to receive outpatient intravenous fluids (25% vs 6%; p = 0.008), they had similar overall hospital readmissions (20.4% vs 19.6%; p = 1.0), readmissions for dehydration (8.2% vs 5.9%; p = 0.71), and acute renal failure events (10.2% vs 3.9%; p = 0.26). Multivariable analysis found that weekend discharges to home were significantly associated with readmission (OR, 4.5 (95% CI, 1.2-16.9); p = 0.03). Direct costs and patient satisfaction were similar. LIMITATIONS: This study was limited by the heterogeneous patient population and by the potential effect of the intervention on providers taking care of patients randomly assigned to usual care. CONCLUSIONS: A surveillance strategy to ensure compliance with an ileostomy education program tracked patients more closely and was cost neutral, but did not result in decreased hospital readmissions compared with usual care. See Video Abstract at http://links.lww.com/DCR/A812.

Colorectal Lymphoma: A Contemporary Case Series.

BACKGROUND: Colon and rectal lymphomas are rare and can occur in the context of posttransplant lymphoproliferative disorder. Evidence-based management guidelines are lacking. OBJECTIVE: The purpose of this study was to characterize the presentation, diagnosis, and management of colorectal lymphoma and to identify differences within the transplant population. DESIGN: This was a retrospective review of patients evaluated for colorectal lymphoma between 2000 and 2017. Patients were identified through clinical note queries. SETTINGS: Four hospitals within a single health system were included. PATIENTS: Fifty-two patients (64% men; mean age = 64 y; range, 26-91 y) were identified. No patient had <3 months of follow-up. Eight patients (15%) had posttransplant lymphoproliferative disorder. MAIN OUTCOME MEASURES: Overall survival, recurrence, and complications in treatment pathway were measured. RESULTS: Most common presentations were rectal bleeding (27%), abdominal pain (23%), and diarrhea (23%). The most common location was the cecum (62%). Most frequent histologies were diffuse large B-cell lymphoma (48%) and mantle cell lymphoma (25%). Posttransplant lymphoproliferative disorder occurred in the cecum (n = 4) and rectum (n = 4). Twenty patients (38%) were managed with chemotherapy; 25 patients (48%) underwent primary resection. Mass lesions had a higher risk of urgent surgical resection (35% vs 8%; p = 0.017). Three patients (15%) treated with chemotherapy presented with perforation requiring emergency surgery. Overall survival was 77 months (range, 25-180 mo). Patients with cecal involvement had longer overall survival (96 vs 26 mo; p = 0.038); immunosuppressed patients had shorter survival (16 vs 96 mo; p = 0.006). Survival in patients treated with surgical management versus chemotherapy was similar (67 vs 105 mo; p = 0.62). LIMITATIONS: This was a retrospective chart review, with data limited by the contents of the medical chart. This was a small sample size. CONCLUSIONS: Colorectal lymphoma is rare, with variable treatment approaches. Patients with noncecal involvement and chronic immunosuppression had worse overall survival. Patients with mass lesions, particularly cecal masses, are at higher risk to require urgent intervention, and primary resection should be considered. See Video Abstract at http://links.lww.com/DCR/A929.

Combined Hartmann's Reversal and Abdominal Wall Reconstruction: Defining Postoperative Morbidity.

BACKGROUND: Ventral hernias are common after Hartmann's procedure and add complexity to Hartmann's reversal. Colostomy reversal and abdominal wall reconstruction may be performed in a staged or concurrent fashion, although data are limited as to which strategy is optimal. We aimed to define the complication profile of concurrent abdominal wall reconstruction with colostomy reversal as compared to either procedure alone. MATERIALS AND METHODS: For this retrospective cohort study, we used the National Surgery Quality Improvement Project Database from 2012 to 2015. All patients undergoing elective colostomy reversal, abdominal wall reconstruction with component separation, or combined colostomy reversal with component separation were identified. Propensity score matching was used to compare outcomes among similar patients undergoing colostomy reversal alone versus combined procedure. Groups were evaluated for postoperative morbidity including reoperation. RESULTS: We identified 11,689 patients; 6951 (64%) underwent component separation alone, 4563 (35%) colostomy reversal alone, and 175 (1%) combined component separation and colostomy reversal. The combined group, as compared to colostomy reversal alone, showed an increased overall complication rate (39% versus 25%; P < 0.01) and increased rate of reoperation (9% versus 5%; P = 0.03). Differences in overall complication rate (43% versus 24%; P < 0.01) and reoperation rate (9% versus 3%; P = 0.03) persisted on propensity matched analysis. CONCLUSIONS: This analysis shows that in patients undergoing colostomy takedown, concurrent abdominal wall reconstruction is associated with increased morbidity including increased rate of reoperation, even when controlling for patient factors. Consideration may be given to a staged approach.

Decreased Use of Sphincter-Preserving Procedures Among African Americans with Rectal Cancer.

BACKGROUND: Improved multimodality rectal cancer treatment has increased the use of sphincter-preserving surgery. This study sought to determine whether African American (AA) patients with rectal cancer receive sphincter-preserving surgery at the same rate as non-AA patients. METHODS: The study used the Nationwide Inpatient Sample for years 1998-2012 to compare AA and non-AA patients with rectal cancer undergoing low anterior resection or abdominoperineal resection. The logistic regression model was used to adjust for age, gender, admission type, Elixhauser comorbidity index, and hospital factors such as size, location (urban vs.rural), teaching status, and procedure volume. RESULTS: The search identified 22,697 patients, 1600 of whom were identified as AA. After adjustment for age and gender, the analysis showed that AA patients were less likely to undergo sphincter-preserving surgery than non-AA patients [odds ratio (OR) 0.70; 95% confidence interval (CI) 0.63-0.78; p < 0.0001). After further adjustment for the Elixhauser comorbidity index, admission type, hospital-specific factors, and insurance status, the analysis showed that AA patients still were less likely to undergo sphincter-preserving surgery (OR 0.78; 95% CI 0.70-0.87; p < 0.0001). Although the proportion of non-AA patients undergoing sphincter-preserving surgery increased during the study period (p = 0.0003), this trend was not significant for the AA patients (p = 0.13). CONCLUSION: In this data analysis, the AA patients with rectal cancer had lower rates of sphincter-preserving surgery than the non-AA patients, even after adjustment for patient- and hospital-specific factors. Further work is required to elucidate why. Eliminating racial disparities in rectal cancer treatment should continue to be a priority for the surgical community.

Long-term Risk of Urinary Adverse Events in Curatively Treated Patients With Rectal Cancer: A Population-Based Analysis.

BACKGROUND: Treatment modalities for rectal cancer, including radiation, are associated with urinary adverse effects. OBJECTIVE: The purpose of this study was to determine the influence of surgery and radiation therapy for rectal cancer on long-term urinary complications. DESIGN: Using the Surveillance Epidemiology and End Results-Medicare data set from the United States, patients with rectal cancer older than 66 years of age who underwent rectal resection between 1992 and 2007 were stratified into treatment groups that accounted for surgical resection and the timing of radiation therapy, if used. A control group of patients who did not have rectal cancer were matched by age, sex, demographics, and comorbidities. The primary outcome was a urinary adverse event defined as a relevant urinary diagnosis with an associated procedure. Patients with rectal cancer in different treatment groups were compared with control patients using a propensity-adjusted, multivariable Cox regression analysis. SETTINGS: The study was conducted with the Surveillance Epidemiology and End Results-Medicare data set from the United States at our institution. RESULTS: Of the 11,068 patients with rectal cancer, 56.2% had surgical resection alone, 21.7% received preoperative radiation, and 22.1% received postoperative radiation. The median follow-up for all of the groups of patients was >2 years. All of the groups of patients with rectal cancer were more likely to develop a urinary adverse event compared with control subjects. Adjusted HRs were 2.28 (95% CI, 2.02-2.57) for abdominoperineal resection alone, 2.24 (95% CI, 1.79-2.80) for preoperative radiation and surgical resection, 2.04 (95% CI, 1.70-2.44) for surgical resection and postoperative radiation, and 1.69 (95% CI, 1.52-1.89) for low anterior resection alone. LIMITATIONS: Treatment patterns are somewhat outdated, with a large proportion of patients receiving postoperative radiation. The data did not allow for accurate assessment of urinary tract infections or mild urinary retention that is not managed with a procedure. CONCLUSIONS: Rectal cancer surgery with or without radiation is associated with a higher risk of urinary complications requiring procedures. Patients who undergo low anterior resection without radiation tend toward the lowest risk for a urinary adverse event.

Does Hospital Transfer Impact Outcomes After Colorectal Surgery?

BACKGROUND: With increasing public reporting of outcomes and bundled payments, hospitals and providers are scrutinized for morbidity and mortality. The impact of patient transfer before colorectal surgery has not been well characterized in a risk-adjusted fashion. OBJECTIVE: We hypothesized that hospital-to-hospital transfer would independently predict morbidity and mortality beyond traditional predictor variables. DESIGN: We constructed a retrospective cohort of 158,446 patients who underwent colorectal surgery using the 2009-2013 American College of Surgeons National Surgical Quality Improvement Program database. SETTINGS: The study was conducted at a tertiary care hospital. PATIENTS: All of the patients who underwent colorectal surgery during the study period were included. Patients were excluded for unknown transfer status or transfer from a chronic care facility. MAIN OUTCOME MEASURES: Baseline characteristics were compared by transfer status. Multivariate logistic regression was used to evaluate the impact of transfer on major complications and mortality. RESULTS: A total of 7259 operations (4.6%) were performed after transfer. Transferred patients had higher rates of complications (p < 0.0001) with significant differences in unplanned endotracheal reintubation, bleeding, organ-space surgical site infection, wound dehiscence, postoperative sepsis, cardiac arrest requiring cardiopulmonary resuscitation, deep venous thrombosis, and myocardial infarction. Transferred patients also had longer hospital stays (9 vs 6 days; p < 0.0001) and a higher risk of death (13.2% vs 2.6%; p < 0.0001). On multivariate analysis, transferred patients had higher mortality rates despite risk adjustment (OR = 1.13 (95% CI, 1.02-1.25); p = 0.019) and were also more likely to have serious complications (OR = 1.12 (95% CI, 1.06-1.19); p < 0.001). LIMITATIONS: We were unable to analyze outcomes beyond 30 days, and we did not have information on preoperative evaluation or the reason for patient transfer. CONCLUSIONS: Hospital-to-hospital transfer independently contributed to patient morbidity and mortality in patients undergoing colorectal surgery. The impact of hospital transfer must be considered when evaluating surgeon and hospital performance, because the increased risk of serious complications or death is not fully accounted for by traditional methods.

Strategies for handling missing clinical data for automated surgical site infection detection from the electronic health record.

Proper handling of missing data is important for many secondary uses of electronic health record (EHR) data. Data imputation methods can be used to handle missing data, but their use for analyzing EHR data is limited and specific efficacy for postoperative complication detection is unclear. Several data imputation methods were used to develop data models for automated detection of three types (i.e., superficial, deep, and organ space) of surgical site infection (SSI) and overall SSI using American College of Surgeons National Surgical Quality Improvement Project (NSQIP) Registry 30-day SSI occurrence data as a reference standard. Overall, models with missing data imputation almost always outperformed reference models without imputation that included only cases with complete data for detection of SSI overall achieving very good average area under the curve values. Missing data imputation appears to be an effective means for improving postoperative SSI detection using EHR clinical data.

Colorectal Surgery Outcomes in Chronic Dialysis Patients: An American College of Surgeons National Surgical Quality Improvement Program Study.

BACKGROUND: More than 450,000 US patients with end-stage renal disease currently dialyze. The risk of morbidity and mortality for these patients after colorectal surgery has been incompletely described. OBJECTIVE: We analyzed the 30-day morbidity and mortality rates of chronic dialysis patients who underwent colorectal surgery. DESIGN: This was a retrospective analysis. SETTINGS: Hospitals that participate in the American College of Surgeons National Surgical Quality Improvement Program were included. PATIENTS: The study included adult patients who underwent emergency or elective colon or rectal resection between 2009 and 2014. MAIN OUTCOME MEASURES: Baseline characteristics were compared by dialysis status. The impact of chronic dialysis on 30-day mortality and serious postoperative morbidity was examined using multivariate logistic regression. RESULTS: We identified 128,757 patients who underwent colorectal surgery in the American College of Surgeons National Surgical Quality Improvement Program database. Chronic dialysis patients accounted for 1% (n = 1285) and were more likely to be older (65.4 vs 63.2 years; p < 0.0001), black (27.2% vs 8.7%; p < 0.0001), preoperatively septic (22.1% vs 7.1%; p < 0.0001), require emergency surgery (52.0% vs 14.7%; p < 0.0001), have ischemic bowel (15.7% vs 1.6%; p < 0.0001), or have perforation/peritonitis (15.5% vs 4.2%; p < 0.0001). Chronic dialysis patients were also less likely to have a laparoscopic procedure (17.3% vs 45.0%; p < 0.0001). Chronic dialysis patients had higher unadjusted mortality (22.4% vs 3.3%; p < 0.0001), serious postoperative morbidity (47.9% vs 18.8%; p < 0.0001), and median length of stay (9 vs 6 days; p < 0.0001). In emergent cases (n = 19,375), multivariate logistic regression models demonstrated a higher risk of mortality for dialysis patients (OR = 1.73 (95% CI, 1.38-2.16)) but not for serious morbidity. Models for elective surgery demonstrated a similar effect on mortality (OR = 2.47 (95% CI, 1.75-3.50)) but also demonstrated a higher risk of serious morbidity (OR = 1.28 (95% CI, 1.04-1.56)). LIMITATIONS: The postoperative 30-day window may underestimate the true incidence of serious morbidity and mortality. CONCLUSIONS: Chronic dialysis patients undergoing elective or emergent colorectal procedures have a higher risk-adjusted mortality.

Early removal of urinary catheters after rectal surgery is associated with increased urinary retention.

BACKGROUND: Urinary retention after rectal resection is common and managed prophylactically by prolonging urinary catheterization. However, because indwelling urinary catheterization is a well-established risk factor for urinary tract infection, the ideal timing for urinary catheter removal following a rectal resection is unknown. OBJECTIVE: We hypothesized that early urinary catheter removal (on or before postoperative day 2) would be associated with urinary retention. DESIGN: This study is a retrospective review of medical records. SETTING: This study was conducted at a colorectal surgery service at a tertiary care academic teaching hospital. PATIENTS: Adults undergoing rectal resection operations by colorectal surgeons in 2005 to 2010 were selected. MAIN OUTCOME MEASURE: The primary outcome measured was urinary retention. RESULTS: Of 205 patients included, 41 (20%) developed urinary retention. Male sex (OR, 3.9; 95% CI, 1.7-9), increased intraoperative intravenous fluid (OR for each liter, 1.2; 95% CI, 1.04-1.48), and urinary catheter removal on postoperative day 2 or earlier (OR, 3.8; 95% CI, 1.4-10.5) were associated with urinary retention on multivariable analysis. Early catheter removal was not associated with decreased urinary tract infection rates (p = 0.29) but was associated with shorter length of stay (6.5 vs 8.9 days; p = 0.005). LIMITATIONS: The retrospective nature of this study did not allow for a precise definition of urinary retention. Preoperative urinary function was not available, and the patient sample was heterogeneous, including several indications for rectal resection. Urinary catheters were not removed per protocol and therefore subject to bias. The study is likely underpowered to detect differences in urinary tract infection between urinary catheter removal groups. CONCLUSION: In patients undergoing rectal resection, we found that urinary catheter removal on or before postoperative day 2 was associated with urinary retention (see Video, Supplemental Digital Content 1, http://links.lww.com/DCR/A172).

Relationship between model for end-stage liver disease score and 30-day outcomes for patients undergoing elective colorectal resections: an American college of surgeons-national surgical quality improvement program study.

BACKGROUND: Patients with liver disease face significant risk of complications and death when considering elective colorectal resection for benign or malignant indications. OBJECTIVE: We sought to determine the relationship between Model of End-Stage Liver Disease score and 30-day outcomes in patients undergoing elective colorectal resections. DESIGN: This was a retrospective cohort study. SETTINGS: The study included hospitals participating in the National Surgical Quality Improvement Program. PATIENTS: Adult patients who underwent elective colorectal resection from 2005 to 2011 were identified from the National Surgical Quality Improvement Program database. Patients missing laboratory values necessary to calculate the Model of End-Stage Liver Disease score were excluded (61% of 81,346 patients identified). MAIN OUTCOME MEASURES: Differences in patient- and disease-related characteristics by Model of End-Stage Liver Disease categories were assessed with χ analyses. Thirty-day mortality and major morbidity were examined using logistic regression. RESULTS: Of 31,950 patients undergoing elective colorectal resections (14% including proctectomy), most (60%) were performed for colon or rectal cancer; other benign indications included diverticulitis (20%), polyp (10%), and IBD (10%). A total of 58% of patients had a Model of End-Stage Liver Disease score of ≥7. Increasing scores were associated with older age; higher BMI; higher ASA class; lower albumin level; and higher incidence of diabetes mellitus, pulmonary and cardiac disease, hypertension, and dependent functional status. In univariate analysis, patients with higher scores had a greater risk of 30-day mortality (score = 6 (0.69%); 7-11 (1.62%); 11-15 (4.52%); >15, (5.01%); p < 0.0001). After controlling for other comorbidities, Model of End-Stage Liver Disease score remained a significant predictor of 30-day mortality, major complications, and respiratory complications. LIMITATIONS: This was a retrospective analysis of administrative data, limiting some access to clinically relevant data. CONCLUSIONS: Consistent with previous reports, patients with higher Model of End-Stage Liver Disease scores have a significantly higher risk of death and major morbidity in the 30 days after elective colorectal resection (see Video, Supplemental Digital Content, http://links.lww.com/DCR/A180).

Does patient rurality predict quality colon cancer care?: A population-based study.

BACKGROUND: More than 50 million people reside in rural America. However, the impact of patient rurality on colon cancer care has been incompletely characterized, despite its known impact on screening. OBJECTIVE: Our study sought to examine the impact of patient rurality on quality and comprehensive colon cancer care. DESIGN: We constructed a retrospective cohort of 123,129 patients with stage 0 to IV colon cancer. Rural residence was established based on the patient medical service study area designated by the registry. SETTINGS: The study was conducted using the 1996-2008 California Cancer Registry. PATIENTS: All of the patients diagnosed between 1996 and 2008 with tumors located in the colon were eligible for inclusion in this study. MAIN OUTCOME MEASURES: Baseline characteristics were compared by rurality status. Multivariate regression models then were used to examine the impact of rurality on stage in the entire cohort, adequate lymphadenectomy in stage I to III disease, and receipt of chemotherapy for stage III disease. Proportional-hazards regression was used to examine the impact of rurality on cancer-specific survival. RESULTS: Of all of the patients diagnosed with colon cancer, 18,735 (15%) resided in rural areas. Our multivariate models demonstrate that rurality was associated with later stage of diagnosis, inadequate lymphadenectomy in stage I to III disease, and lower likelihood of receiving chemotherapy for stage III disease. In addition, rurality was associated with worse cancer-specific survival. LIMITATIONS: We could not account for socioeconomic status directly, although we used insurance status as a surrogate. Furthermore, we did not have access to treatment location or distance traveled. We also could not account for provider or hospital case volume, patient comorbidities, or complications. CONCLUSIONS: A significant portion of patients treated for colon cancer live in rural areas. Yet, rural residence is associated with modest differences in stage, adherence to quality measures, and survival. Future endeavors should help improve care to this vulnerable population (see video, Supplemental Digital Content 1, http://links.lww.com/DCR/A143).

Increasing Rates of Bowel Resection Surgery for Stricturing Crohn's Disease in the Biologic Era.

BACKGROUND: The era of biologics is associated with declining rates of surgery for Crohn's disease (CD), but the impact on surgery for stricturing CD is unknown. Our study aimed to assess nationwide trends in bowel resection surgery for obstruction in CD since the introduction of infliximab for CD in 1998. METHODS: Using the Nationwide Inpatient Sample, we performed a nationwide analysis, identifying patients hospitalized for CD who underwent bowel resection for an indication of obstruction between 1998 and 2020 (era of biologics). Longitudinal trends in all CD-related resections and resection for obstruction were evaluated. Multivariable logistic regression identified patient and hospital characteristics associated with bowel resection surgery for obstruction. RESULTS: Hospitalizations for all CD-related resections decreased from 12.0% of all hospitalizations in 1998 to 6.9% in 2020, while hospitalizations for CD-related resection for obstructive indication increased from 1.3% to 2.0%. The proportion of resections for obstructive indication amongst all CD-related bowel resections increased from 10.8% in 1998 to 29.1% in 2020. In the multivariable models stratified by elective admission, the increasing year was associated with risk of resection for obstructive indication regardless of urgency (nonelective model: odds ratio, 1.01; 95% CI, 1.00-1.02; elective model: odds ratio, 1.06; 95% CI, 1.04-1.08). CONCLUSIONS: In the era of biologics, our findings demonstrate a decreasing annual rate of CD-related bowel resections but an increase in resection for obstructive indication. Our findings highlight the effect of medical therapy on surgical rates overall but suggest limited impact of current medical therapy on need of resection for stricturing disease.

In our nationwide analysis, rates of bowel resection for patients with Crohn's disease have declined since the approval of infliximab in 1998. However, rates of resection for obstruction in patients with Crohn's disease continue to increase.