Opioid Utilization in Outpatient Anorectal Surgery: An Opportunity for Improvement.

INTRODUCTION: The opioid epidemic has resulted in close examination of postsurgical prescribing patterns. Little is known about postoperative opioid use in outpatient anorectal procedures. This study evaluated patient opioid use and created prescribing recommendations for these procedures. METHODS: One hundred and four patients undergoing outpatient anorectal procedures from January to May 2018 were surveyed on opioid consumption, surgical experience, and pain satisfaction. Patients were grouped into three tiers based on opioid usage. Multivariable models were used to determine factors associated with poor pain control. RESULTS: Patient satisfaction with pain control was 85.6%. Twenty five percent of patients reported leftover medication and 9.6% of patients requested opioid refills. Opioid prescribing recommendations were generated for each tier using 50th percentile with interquartile ranges. On multivariable modeling, the high-tier group was associated with poorer pain control. CONCLUSIONS: We created opioid quantity prescribing guidelines for common outpatient anorectal procedures. A multimodal approach to pain control utilizing nonopioids may reduce healthcare utilization.

Impact of Postoperative Complications on Oncologic Outcomes After Rectal Cancer Surgery: An Analysis of the US Rectal Cancer Consortium.

BACKGROUND: Postoperative complications (POCs) are associated with worse oncologic outcomes in several cancer types. The implications of complications after rectal cancer surgery are not well studied. METHODS: The United States Rectal Cancer Consortium (2007-2017) was reviewed for primary rectal adenocarcinoma patients who underwent R0/R1 resection. Ninety-day POCs were categorized as major or minor and were grouped into infectious, cardiopulmonary, thromboembolic, renal, or intestinal dysmotility. Primary outcomes were overall survival (OS) and recurrence-free survival (RFS). RESULTS: Among 1136 patients, the POC rate was 46% (n = 527), with 63% classified as minor and 32% classified as major. Of all POCs, infectious complications comprised 20%, cardiopulmonary 3%, thromboembolic 5%, renal 9%, and intestinal dysmotility 19%. Compared with minor or no POCs, major POCs were associated with both worse RFS and worse OS (both p < 0.01). Compared with no POCs, a single POC was associated with worse RFS (p < 0.01), while multiple POCs were associated with worse OS (p = 0.02). Regardless of complication grade, infectious POCs were associated with worse RFS (p < 0.01), while cardiopulmonary and thromboembolic POCs were associated with worse OS (both p < 0.01). Renal POCs were associated with both worse RFS (p < 0.001) and worse OS (p = 0.01). After accounting for pathologic stage, neoadjuvant therapy, and final margin status, Multivariable analysis (MVA) demonstrated worse outcomes with cardiopulmonary, thromboembolic, and renal POCs for OS (cardiopulmonary: hazard ratio [HR] 3.6, p = 0.01; thromboembolic: HR 19.4, p < 0.01; renal: HR 2.4, p = 0.01), and renal and infectious POCs for RFS (infectious: HR 2.1, p < 0.01; renal: HR 3.2, p < 0.01). CONCLUSIONS: Major complications after proctectomy for cancer are associated with decreased RFS and OS. Given the association of infectious complications and postoperative renal dysfunction with earlier recurrence of disease, efforts must be directed towards defining best practices and standardizing care.

Perioperative Blood Transfusions Are Associated With Worse Overall Survival But Not Disease-Free Survival After Curative Rectal Cancer Resection: A Propensity Score-Matched Analysis.

BACKGROUND: The effects of blood transfusions on oncologic outcomes after surgery remain inconclusive. Thus, we examined the association between receiving a perioperative blood transfusion and oncologic outcomes in patients undergoing curative rectal cancer resection. OBJECTIVE: The purpose of this study was to assess the association between receiving a perioperative blood transfusion with disease-free and overall survival in patients undergoing curative resection of clinical stage I to III rectal cancer. We hypothesized that blood transfusion is associated with worse disease-free and overall survival in this patient cohort. DESIGN: This was a retrospective cohort study using a propensity score-matched analysis. SETTINGS: The study involved 6 tertiary academic medical centers in the United States contributing to the United States Rectal Cancer Consortium. PATIENTS: Patients who underwent curative resection for rectal cancer from 2010 to 2018 were included. MAIN OUTCOME MEASURES: The primary outcome was disease-free survival. The secondary outcomes were overall survival, intensive care unit length of stay, hospital length of stay, surgical site infection, and readmission. RESULTS: Of the 924 patients eligible for matching, 312 patients were matched, including 100 patients who received a transfusion and 212 who did not. In a propensity score-matched analysis, receiving a perioperative blood transfusion was not associated with worse 5-year disease-free survival (transfused, 78%; not transfused, 83%; p = 0.32) but was associated with worse 5-year overall survival (transfused 65% vs not transfused 86%; p < 0.001) and increased hospital length of stay (transfused, 9.9 d; not transfused, 7.6 d; p = 0.001). LIMITATIONS: Despite propensity matching, confounding may remain. Propensity matching may limit the power to detect a difference in disease-free survival. CONCLUSIONS: Receiving a perioperative blood transfusion is not associated with worse disease-free survival but is associated with worse overall survival. Such findings are important for clinicians and patients to understand when considering perioperative blood transfusions. See Video Abstract at http://links.lww.com/DCR/B531. LAS TRANSFUSIONES DE SANGRE PERIOPERATORIAS SE ASOCIAN CON UNA PEOR SOBREVIDA GLOBAL, PERO NO CON LA SOBREVIDA LIBRE DE ENFERMEDAD POSTERIOR A LA RESECCIN CURATIVA DEL CNCER DE RECTO UN PUNTAJE DE PROPENSIN POR ANLISIS DE CONCORDANCIA: ANTECEDENTES:El impacto de las transfusiones de sangre en los resultados oncológicos posteriores a la cirugía no son concluyentes. Por lo anterior, estudiamos la asociación entre recibir una transfusión de sangre perioperatoria y los resultados oncológicos en pacientes llevados a resección curativa de cáncer de recto.OBJETIVO:El propósito de este estudio fue evaluar la asociación entre recibir una transfusión de sangre perioperatoria con la sobrevida libre de enfermedad y la sobrevida general en pacientes llevados a resección curativa de cáncer de recto en estadio clínico I-III. Nuestra hipótesis es que la transfusión de sangre se asocia con una peor sobrevida global y libre de enfermedad en esta cohorte de pacientes.DISEÑO:Es un estudio de cohorte retrospectivo que utilizó un puntaje de propensión por análisis de concordancia.AMBITO:El estudio se realizó en seis centros médicos académicos de tercer nivel en los Estados Unidos que contribuían al Consorcio de Cáncer de Recto de los Estados Unidos.PACIENTES:Se incluyeron pacientes que fueron llevados a resección curativa por cáncer de recto entre 2010 y 2018.PRINCIPALES VARIABLES EVALUADAS:El objeitvo principal fue la sobrevida libre de enfermedad. Los objetivos secundarios fueron la sobrevida global, el tiempo de estancia en la unidad de cuidados intensivos, el tiempo de la estancia hospitalaria, la infección del sitio quirúrgico y el reingreso.RESULTADOS:De los 924 pacientes elegibles para el emparejamiento, se emparejaron 312 pacientes, incluidos 100 pacientes que recibieron una transfusión y 212 que no. En el puntaje de propensión por análisis de concordancia, recibir una transfusión de sangre perioperatoria no se asoció con una peor sobrevida libre de enfermedad a 5 años (TRANSFUSIÓN 78%; NO TRANSFUSIÓN 83%; p = 0,32), pero se asoció con una peor sobrevida global a 5 años (TRANSFUSION 65% vs NO TRANSFUSION 86%; p <0,001) y aumento de la estancia hospitalaria (TRANSFUSIÓN 9,9 días; NO TRANSFUSION 7,6 días; p = 0,001).LIMITACIONES:A pesar de la concordancia de propensión, pueden existir desviaciones. El emparejamiento de propensión puede limitar el poder para detectar una diferencia en la sobrevida libre de enfermedad.CONCLUSIONES:Recibir una transfusión de sangre perioperatoria no se asocia con una peor sobrevida libre de enfermedad, pero sí con una peor sobrevida global. Es importante que los médicos y los pacientes comprendan estos hallazgos al considerar las transfusiones de sangre perioperatorias. Consulte Video Resumen en http://links.lww.com/DCR/B531. (Traducción-Dr Lisbeth Alarcon-Bernes).

Long-term bowel dysfunction and decision regret in diverticulitis: A mixed methods study.

BACKGROUND: This study had aimed to describe long-term decision regret, bowel dysfunction, and the overall quality of life in patients with diverticulitis, and to determine if elective colectomy was associated with these patient-reported outcome measures. METHODS: This mixed-methods, survey-based study was administered to a national cohort of patients in the United States with diverticulitis. We measured decision regret (Brehaut Decision Regret), bowel dysfunction (Low Anterior Resection Syndrome score), and the overall quality of life (EuroQol 5 Dimension) in this population. We asked open-ended questions to elucidate factors that influenced patients' choices between elective colectomy and observation. RESULTS: Among the 614 respondents, 294 (48%) chose between colectomy and observational management, 94 (15%) had surgery, and 157 (26%) had major Low Anterior Resection Syndrome. Of the 294 that chose between colectomy and observational management, 51 (17%) experienced decision regret. Colectomy was associated with an average decrease in the Brehaut Decision Regret score by 6 points but was not associated with a categorical measure of decision regret (Brehaut Score ≥50). Bowel dysfunction and overall quality of life were not significantly associated with colectomy. Disease-related factors, psychosocial factors, and interactions with physicians were commonly cited as reasons for pursuing colectomy or observational management. CONCLUSION: Patients with self-reported diverticulitis describe high levels of decision regret and bowel dysfunction regardless of chosen management strategy. Physicians should be aware that psychosocial factors can strongly influence a patient's choice between colectomy and observational management. We advocated for future prospective studies using patient reported outcome metrics to improve outcomes in diverticulitis.

What's the magic number? Impact of time to initiation of treatment for rectal cancer.

BACKGROUND: National guidelines, including the National Accreditation Program for Rectal Cancer, recommend initiation of rectal cancer treatment within 60 days of diagnosis; however, the effect of timely treatment initiation on oncologic outcomes is unclear. The purpose of this study was to evaluate the impact on oncologic outcomes of initiation of rectal cancer treatment within 60 days of diagnosis. METHODS: This was a retrospective review of stage II/III rectal cancer patients performed using the United States Rectal Cancer Consortium, a collaboration of 6 academic medical centers. Patients with clinical stage II/III rectal cancer who underwent radical resection between January 1, 2010 and December 31, 2018 were included. The primary exposure was treatment initiation, defined as either resection or initiation of chemotherapy or chemoradiotherapy, within 60 days of diagnosis. The primary outcome was disease recurrence, and the secondary outcome was all-cause mortality. RESULTS: A total of 1,031 patients meeting inclusion criteria were included in the analysis. Treatment was initiated within 60 days of diagnosis in 830 patients (80.5%) and after 60 days in 201 patients (20.3%). In multivariable logistic regression, older age, non-White race, and residence greater than 100 miles from the treatment center were significantly associated with delay in treatment beyond 60 days. In survival analysis, 167 patients (16.2%) experienced recurrent disease, and 127 patients (12.3%) died of any cause. In an adjusted model accounting for pathologic staging, treatment sequence, distance to care, age, comorbidities, treatment center, and receipt of adjuvant chemotherapy, neither progression-free survival nor all-cause mortality was significantly associated with timely initiation of therapy with hazard ratios of 1.09 (0.70, 1.69) and 1.03 (0.63, 1.66), respectively. CONCLUSION: This study found no difference in oncologic outcomes with initiation of treatment beyond 60 days.

Approved drugs ezetimibe and disulfiram enhance mitochondrial Ca2+ uptake and suppress cardiac arrhythmogenesis.

BACKGROUND AND PURPOSE: Treatment of cardiac arrhythmia remains challenging due to severe side effects of common anti-arrhythmic drugs. We previously demonstrated that mitochondrial Ca2+ uptake in cardiomyocytes represents a promising new candidate structure for safer drug therapy. However, druggable agonists of mitochondrial Ca2+ uptake suitable for preclinical and clinical studies are still missing. EXPERIMENTAL APPROACH: Herewe screened 727 compounds with a history of use in human clinical trials in a three-step screening approach. As a primary screening platform we used a permeabilized HeLa cell-based mitochondrial Ca2+ uptake assay. Hits were validated in cultured HL-1 cardiomyocytes and finally tested for anti-arrhythmic efficacy in three translational models: a Ca2+ overload zebrafish model and cardiomyocytes of both a mouse model for catecholaminergic polymorphic ventricular tachycardia (CPVT) and induced pluripotent stem cell derived cardiomyocytes from a CPVT patient. KEY RESULTS: We identifiedtwo candidate compounds, the clinically approved drugs ezetimibe and disulfiram, which stimulate SR-mitochondria Ca2+ transfer at nanomolar concentrations. This is significantly lower compared to the previously described mitochondrial Ca2+ uptake enhancers (MiCUps) efsevin, a gating modifier of the voltage-dependent anion channel 2, and kaempferol, an agonist of the mitochondrial Ca2+ uniporter. Both substances restored rhythmic cardiac contractions in a zebrafish cardiac arrhythmia model and significantly suppressed arrhythmogenesis in freshly isolated ventricular cardiomyocytes from a CPVT mouse model as well as induced pluripotent stem cell derived cardiomyocytes from a CPVT patient. CONCLUSION AND IMPLICATIONS: Taken together we identified ezetimibe and disulfiram as novel MiCUps and efficient suppressors of arrhythmogenesis and as such as, promising candidates for future preclinical and clinical studies.

Robotic-assisted adrenalectomy using da Vinci Xi vs. Si: are there differences?

Da Vinci Xi, the fourth generation platform, was released in 2014 and introduced as the successor to the Si platform for minimal invasive surgery. We reviewed our experience with robotic-assisted adrenalectomy and compared peri-operative outcomes using the da Vinci robot model Xi vs. Si. Since June of 2014, 85 consecutive patients underwent robotic-assisted adrenalectomy by a high-volume adrenal surgeon at our institution. Patients were divided into two groups: Xi group (n = 25) and Si group (n = 60). The average anesthesia time was 145.8 min for the Xi group and 170.4 min for the Si group (p = 0.001). The mean procedure time for the Xi group (skin to skin) was 92.1 min and for the Si group it was 122.5 min (p = 0.001). The average docking time for the Xi group was 18.2 min and for the Si group 20.3 min (p = 0.04). The average consumables fees for the Xi group were $1246 and for the Si group $1106 (p = 0.04). The calculated relative costs for the Xi group were $3375 and for the Si group $3527 (p = 0.03). The average post-operative hospital stay for the Xi group was 1.6 days and for the Si group 1.7 days (p = 0.18). Robotic-assisted adrenalectomy using the da Vinci Xi system is effective and efficient. This study shows that outcomes were similar between Xi and Si groups.

Evaluation of Wound Photography for Remote Postoperative Assessment of Surgical Site Infections.

Importance: Surgeons are increasingly interested in using mobile and online applications with wound photography to monitor patients after surgery. Early work using remote care to diagnose surgical site infections (SSIs) demonstrated improved diagnostic accuracy using wound photographs to augment patients' electronic reports of symptoms, but it is unclear whether these findings are reproducible in real-world practice. Objective: To determine how wound photography affects surgeons' abilities to diagnose SSIs in a pragmatic setting. Design, Setting, and Participants: This prospective study compared surgeons' paired assessments of postabdominal surgery case vignettes with vs without wound photography for detection of SSIs. Data for case vignettes were collected prospectively from May 1, 2007, to January 31, 2009, at Erasmus University Medical Center, Rotterdam, the Netherlands, and from July 1, 2015, to February 29, 2016, at Vanderbilt University Medical Center, Nashville, Tennessee. The surgeons were members of the American Medical Association whose self-designated specialty is general, abdominal, colorectal, oncologic, or vascular surgery and who completed internet-based assessments from May 21 to June 10, 2016. Intervention: Surgeons reviewed online clinical vignettes with or without wound photography. Main Outcomes and Measures: Surgeons' diagnostic accuracy, sensitivity, specificity, confidence, and proposed management with respect to SSIs. Results: A total of 523 surgeons (113 women and 410 men; mean [SD] age, 53 [10] years) completed a mean of 2.9 clinical vignettes. For the diagnosis of SSIs, the addition of wound photography did not change accuracy (863 of 1512 [57.1%] without and 878 of 1512 [58.1%] with photographs). Photographs decreased sensitivity (from 0.58 to 0.50) but increased specificity (from 0.56 to 0.63). In 415 of 1512 cases (27.4%), the addition of wound photography changed the surgeons' assessment (215 of 1512 [14.2%] changed from incorrect to correct and 200 of 1512 [13.2%] changed from correct to incorrect). Surgeons reported greater confidence when vignettes included a wound photograph compared with vignettes without a wound photograph, regardless of whether they correctly identified an SSI (median, 8 [interquartile range, 6-9] vs median, 8 [interquartile range, 7-9]; P < .001) but they were more likely to undertriage patients when vignettes included a wound photograph, regardless of whether they correctly identified an SSI. Conclusions and Relevance: In a practical simulation, wound photography increased specificity and surgeon confidence, but worsened sensitivity for detection of SSIs. Remote evaluation of patient-generated wound photographs may not accurately reflect the clinical state of surgical incisions. Effective widespread implementation of remote postoperative assessment with photography may require additional development of tools, participant training, and mechanisms to verify image quality.

A cost-conscious approach to robotic adrenalectomy.

In recent years, the use of robotic-assisted adrenalectomy (RA) has increased; however, many surgeons question its reported higher cost. In this study, we review our experience and strategies to reduce the cost of RA comparing it to Laparoscopic adrenalectomy (LA). Since May of 2010, 122 consecutive patients underwent minimally invasive adrenalectomy (58 RAs and 64 LA) by a high-volume adrenal surgeon at our institution. A cost analysis was performed for RA versus LA. Cost calculations included anesthesia professional fee, procedure time and consumables fees. The calculated relative costs were $3527 for RA and $3430 for LA (p = 0.59). The average anesthesia time was 172.4 and 178.3 min for RA and LA, respectively (p = 0.40). The mean procedure times (skin-skin) were 124.4 min for RA and 129.1 min for LA (p = 0.50). Procedure time for the retroperitoneal approach was significantly shorter than the transabdominal approach for both the RA (101.2 vs. 126.6 min, p = 0.001) and LA group (104.4 vs. 135.4 min, p = 0.001). The average consumables fees were $1106 for RA versus $1009 for LA (p = 0.62). The average post-operative hospital stay was 1.7 days for RA and 1.9 days for LA (p = 0.18). This study shows that anesthesia and procedure times for RA were similar to those of LA. It also demonstrates that limiting the number of robotic instruments and energy devices while utilizing an experienced surgical team can keep the costs of RA comparable to those of LA.

Robotic retroperitoneoscopic adrenalectomy: useful modifications of the described posterior approach.

Herein we describe a technique modification of the robotic posterior retroperitoneoscopic adrenalectomy (RPRA). Three patients presented to our clinic with adrenal lesions. The average BMI and tumor size was 29.3 kg/m2 and 4.6 cm, respectively. All had prior major abdominal procedures. Long robotic trocars were used. A 5-mm assistant port was added and the number of robotic instrument use was minimized. The average total operation time was 136 min, average docking time was 14.7 min and the average console time was 108.7 min. Blood loss was minimal and there were no complications. In patients with prior history of extensive abdominal procedures, RPRA is safe and effective when performed by surgeons with PRA and robotic experience. Long robotic trocars effectively minimized external robotic arm collisions. Adding a 5-mm assistant trocar maximized the first assistant and console surgeon abilities. Limiting the number of robotic instruments and energy devices contained cost.

Using Quality Improvement Principles to Enhance Long-Term Completion of Patient-Reported Outcomes after Ventral Hernia Repair.

BACKGROUND: Ventral hernia repair (VHR) is a commonly performed surgical procedure. Unfortunately, long-term prospective information about quality of life and outcomes after VHR has been challenging to obtain. Decoupling follow-up from clinical visits via patient-reported outcomes (PROs) has been proposed as a means of achieving better long-term assessments after VHR. The Americas Hernia Society Quality Collaborative (AHSQC) is a national quality improvement (QI) effort in hernia repair that uses PROs to obtain long-term follow-up. However, the modality of PRO engagement to maximize participation has not been well established. A formal QI initiative was undertaken to determine if long-term PRO follow-up could be increased at a single AHSQC site by adding telephone communication to email communication for long-term postoperative VHR assessment. METHODS: Between September 2015 and July 2016, the long-term (greater than 1 year) AHSQC PRO completion rates after VHR at our institution were analyzed using plan-do-study-act cycles. Two interventions were implemented: contacting patients by telephone and changing timing of telephone calls. RESULTS: Two hundred thirty-two patients were identified, of whom 99 (42.7%) met eligibility criteria. Before this initiative, the long-term PRO completion rate was 16.3% in postoperative VHR patients. The completion rate after introducing telephone calls (intervention 1) was 35.7% and after changing the timing of telephone calls (intervention 2), was 55.1%. The mean participation rate was 45.4% (± 9.7%). CONCLUSIONS: A telephone-based approach markedly improved long-term PRO participation rates in postoperative VHR patients. Ultimately, a combination of email and telephone communication may be necessary to achieve higher levels of PRO follow-up in the VHR population.