RESUMO
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.
Assuntos
Colectomia , Doenças do Colo/cirurgia , Falência Renal Crônica/terapia , Complicações Pós-Operatórias/etiologia , Doenças Retais/cirurgia , Reto/cirurgia , Diálise Renal/efeitos adversos , Adulto , Idoso , Colectomia/mortalidade , Doenças do Colo/complicações , Doenças do Colo/mortalidade , Feminino , Humanos , Falência Renal Crônica/complicações , Modelos Logísticos , Masculino , Pessoa de Meia-Idade , Avaliação de Resultados em Cuidados de Saúde , Complicações Pós-Operatórias/epidemiologia , Melhoria de Qualidade , Doenças Retais/complicações , Doenças Retais/mortalidade , Estudos Retrospectivos , Risco Ajustado , Fatores de RiscoRESUMO
Preoperative risk assessment of potential kidney transplant recipients often fails to adequately balance risk related to underlying comorbidities with the beneficial impact of kidney transplantation. We sought to develop a simple scoring system based on factors known at the time of patient assessment for placement on the waitlist to predict likelihood of severe adverse events 1 year post-transplant. The tool includes four components: age, cardiopulmonary factors, functional status, and metabolic factors. Pre-transplant factors strongly associated with severe adverse events include diabetic (OR: 3.76, P<.001), coronary artery disease (OR: 3.45, P<.001), history of CABG/PCI (OR 3.1, P=.001), and peripheral vascular disease (OR 2.74, P=.008).The score was evaluated by calculation of concordance index. The C statistic of 0.74 for the risk stratification group was considered good discrimination in the validation cohort (N=127) compared to the development cohort (N=368). The pre-transplant risk group was highly predictive of severe adverse events (OR 2.36, P<.001). Patients stratified into the above average-risk group were four times more likely to experience severe adverse events compared to average-risk patients, while patients in the high-risk group were nearly 11 times more likely to experience severe adverse events. The pre-transplant risk stratification tool is a simple scoring scheme using easily obtained preoperative characteristics that can meaningfully stratify patients in terms of post-transplant risk and may ultimately guide patient selection and inform the counseling of potential kidney transplant recipients.
Assuntos
Técnicas de Apoio para a Decisão , Indicadores Básicos de Saúde , Transplante de Rim , Complicações Pós-Operatórias/diagnóstico , Adulto , Idoso , Feminino , Humanos , Modelos Logísticos , Masculino , Pessoa de Meia-Idade , Complicações Pós-Operatórias/etiologia , Distribuição Aleatória , Reprodutibilidade dos Testes , Estudos Retrospectivos , Medição de Risco , Fatores de RiscoRESUMO
BACKGROUND: The ligation of the intersphincteric fistula tract procedure, a sphincter-preserving technique, aims to obtain complete, durable healing, while preserving fecal continence in the treatment of transsphincteric anal fistulas. OBJECTIVE: This was a systematic review to evaluate the outcomes of the originally described (classic) ligation of the intersphincteric fistula tract procedure and the identified technical variations of the procedure. DATA SOURCES: PubMed, Web of Science, and the archive of Diseases of the Colon & Rectum were searched with the terms "ligation of intersphincteric fistula" and "ligation of intersphincteric fistula tract." STUDY SELECTION: Original, English-language studies reporting the primary healing rate for each technical variation of the ligation of the intersphincteric fistula tract procedure were included. Studies were excluded when the technique used was unclear or when primary healing rate was reported in a pooled manner including outcomes from multiple technical variations of the ligation of the intersphincteric fistula tract procedure. INTERVENTION: Outcomes associated with all of the technical variations of the ligation of the intersphincteric fistula tract procedure were investigated. MAIN OUTCOME MEASURES: The main outcome measured was primary healing rate. Secondary outcome measures included time to healing, changes in continence, and risk factors for failure. RESULTS: In all, 26 studies met criteria for review, including 1 randomized controlled trial and 25 cohort/case series. Seven technical variations of the ligation of the intersphincteric fistula tract procedure were identified and classified according to the surgical technique. Primary healing rates ranged from 47% to 95%. LIMITATIONS: The levels of evidence available in the published works are relatively low, as indicated by the Oxford Center for Evidence-Based Medicine evidence levels. CONCLUSIONS: The ligation of the intersphincteric fistula tract procedure is a promising treatment option for transsphincteric fistulas, with reasonable success rates and minimal impact on continence. The true efficacy of the procedure is unknown because of the number of technical variations and the pooled results reported in the literature.
Assuntos
Ligadura/métodos , Fístula Retal/cirurgia , Canal Anal/cirurgia , Doença de Crohn/complicações , Doença de Crohn/cirurgia , Medicina Baseada em Evidências , Humanos , Fístula Retal/etiologia , Recidiva , Telas Cirúrgicas , Resultado do Tratamento , CicatrizaçãoRESUMO
BACKGROUND: Hospital readmission is increasingly perceived as a marker of quality and is poorly investigated in patients receiving colorectal surgery. OBJECTIVE: The objective of this study was to describe patterns and etiology of readmission, to determine the rate of readmission, and to identify risk factors for readmission after colorectal surgery. DESIGN: This study is a retrospective medical chart review. Significant (p < 0.1) preoperative and perioperative factors associated with readmission on univariate analysis were examined in a multivariable model. SETTING: The investigation was conducted in a tertiary care hospital. PATIENTS: Patients included adults undergoing major colorectal operations by colorectal surgeons at the University of Minnesota in 2008-2009. MAIN OUTCOME MEASURES: The primary outcome measure was hospital readmission at 60 days. RESULTS: The study included 220 patients. Common surgical indications were inflammatory bowel disease (21%), colorectal cancer (39%), and diverticular disease (13%), and 11% were emergencies. Readmissions at 60 days occurred in 25% (n = 54), mostly because of major complications (57%), nonspecific nausea, vomiting and/or pain (18%), dehydration (11%), and wound infections (11%). Predictors of readmission in multivariable analysis were major complications (OR, 13.0), female sex (OR, 5.9), prednisone use (OR, 4.3), BMI ≥30 (OR, 2.6), and preoperative weight loss (OR, 3.4). Age and comorbidity (Charlson score) were not predictors. LIMITATIONS: This was a retrospective study at a single institution, with a small sample size. CONCLUSIONS: Predictors of readmission were major complications and immediate preoperative condition of the patients. Comorbidity profiling does not capture readmission risk. Because most readmissions relate to complications, further efforts to prevent these will improve readmission rates.
Assuntos
Colectomia , Doenças do Colo/cirurgia , Readmissão do Paciente/estatística & dados numéricos , Complicações Pós-Operatórias/terapia , Período Pré-Operatório , Doenças Retais/cirurgia , Reto/cirurgia , Adulto , Idoso , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Modelos Estatísticos , Análise Multivariada , Avaliação de Resultados em Cuidados de Saúde , Complicações Pós-Operatórias/epidemiologia , Estudos Retrospectivos , Fatores de RiscoRESUMO
OBJECTIVE: Our aim was to compare urban and rural non-accidental trauma for trends and characterize where injury prevention efforts can be focused. Pediatric trauma patients (age 0-14 years) at two level I adult and pediatric trauma centers, one rural and one urban, were included and data from the trauma registries at each center was abstracted. RESULTS: Of 857 pediatric admissions, 10% of injuries were considered non-accidental. The mean age for all non-accidental trauma patients was significantly lower than the overall pediatric trauma population (2.6 vs. 7.7 years, P < 0.001). Significantly more fatalities occurred in the non-accidental trauma cohort (5.7% vs. 1% P = 0.007). In nearly half of all non-accidental trauma patients, the primary insurance was government programs (49%) and 46% were commercial insurance. The proportion of government insurance in non-accidental trauma was higher in both urban and rural cohorts. There were similar rates of urban and rural patients sustaining non-accidental trauma who were uninsured (6.5 vs. 5.3%). Patients that were younger, in a rural location, and receiving government insurance were at higher risk of non-accidental trauma on univariable analysis. However, only age remained an independent predictor on multivariable analysis.
Assuntos
População Rural , População Urbana , Ferimentos e Lesões/epidemiologia , Adolescente , Criança , Pré-Escolar , Humanos , Lactente , Recém-Nascido , Escala de Gravidade do Ferimento , Masculino , Estudos Retrospectivos , Centros de Traumatologia , Ferimentos e Lesões/terapiaRESUMO
BACKGROUND: Inpatient treatment of patients with colon diverticulitis represents a significant financial and clinical burden to the health care system and patients. The aim of this study was to compare patients with diverticulitis in the emergency department (ED), who were discharged to home vs admitted to the hospital. STUDY DESIGN: We reviewed all patients evaluated in the ED of a metropolitan health system, with the primary diagnosis of diverticulitis (ICD-9 562.11), from 2010 through 2012. Only patients diagnosed with CT and those with follow-up were included. RESULTS: We identified 240 patients; 132 (55%) were women and mean age was 59.1 years (SD 16.1 years). Imaging findings included extraluminal air (21%), pericolic or pelvic abscess (12%), free fluid (16%), and pneumoperitoneum (6%). One hundred forty-four (60%) were admitted to the hospital and 96 (40%) were discharged to home on oral antibiotics. Patients admitted to the hospital were more likely to be older than 65 years (p = 0.0007), have a Charlson comorbidity score ≥ 2 (p = 0.0025), to be on steroids or immunosuppression (p = 0.0019), and have extraluminal air (p < 0.0001) or diverticular abscess (p < 0.0001) on imaging. Median follow-up for all patients was 36.5 months (interquartile range 25.2 to 43 months). Among patients discharged from the ED, 12.5% returned to the ED or were readmitted within 30 days, with only 1 patient (1%) requiring emergency surgery, but not until 20 months later. Patients admitted to the hospital had similar rates of readmission (15%; p = 0.65). CONCLUSIONS: Patients diagnosed with uncomplicated diverticulitis in the emergency room can be safely discharged home on oral antibiotics, as long as CT findings are included in the decision-making process. Patients with complicated diverticulitis on CT scan should be admitted to the hospital with surgical consultation.
Assuntos
Antibacterianos/uso terapêutico , Doença Diverticular do Colo/diagnóstico por imagem , Doença Diverticular do Colo/tratamento farmacológico , Serviço Hospitalar de Emergência , Alta do Paciente/estatística & dados numéricos , Tomografia Computadorizada por Raios X , Comorbidade , Diagnóstico Diferencial , Doença Diverticular do Colo/cirurgia , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Readmissão do Paciente/estatística & dados numéricos , Recidiva , Estudos RetrospectivosRESUMO
BACKGROUND: The majority of colorectal complications after kidney transplantation reportedly occur <1 year of transplant. We aimed to identify differences in complications in the early and late posttransplant period. METHODS: We retrospectively reviewed kidney transplant recipients undergoing colorectal resection from 1 June 2000 to 1 June 2012 at a single institution, comparing patients by posttransplant year (<1 vs. >1 year). Measured outcomes included major complications, postoperative length of stay, perioperative mortality, reoperations, and readmissions. RESULTS: We identified 45 patients aged 31-77 (median 55). Gastrointestinal malignancy (31 %), diverticular disease (24 %), and ischemic colitis (16 %) were the most common indications for surgery. The early group (n = 9) had more cases of ischemic colitis (44 vs. 6 %, p = 0.01), emergent operations (100 vs. 33 %, p = 0.0003), blood transfusion (78 vs. 31 %, p = 0.02), longer length of stay (23.2 ± 12 vs. 11.7 ± 10 days, p = 0.02), and higher mortality rate (33 vs. 6 %, p = 0.05 compared to the late group (n = 36)). There were no significant differences in major complications, reoperations, or readmissions. CONCLUSIONS: Kidney transplant recipients undergoing colorectal resection <1 year of transplant have a higher incidence of emergency surgery and ischemic colitis compared with those with >1 year posttransplant. Despite these findings, patients with grafts <1 year had a similar postoperative complication rate to patients with grafts >1 year.
Assuntos
Cirurgia Colorretal/efeitos adversos , Gastroenteropatias/cirurgia , Transplante de Rim/métodos , Complicações Pós-Operatórias/fisiopatologia , Adulto , Idoso , Estudos de Coortes , Colite Ulcerativa/diagnóstico , Colite Ulcerativa/cirurgia , Neoplasias Colorretais/diagnóstico , Neoplasias Colorretais/cirurgia , Cirurgia Colorretal/métodos , Cirurgia Colorretal/mortalidade , Divertículo do Colo/diagnóstico , Divertículo do Colo/cirurgia , Feminino , Seguimentos , Gastroenteropatias/diagnóstico , Gastroenteropatias/mortalidade , Rejeição de Enxerto , Sobrevivência de Enxerto , Humanos , Transplante de Rim/mortalidade , Masculino , Pessoa de Meia-Idade , Complicações Pós-Operatórias/mortalidade , Estudos Retrospectivos , Medição de Risco , Taxa de Sobrevida , Fatores de Tempo , Resultado do TratamentoRESUMO
BACKGROUND: Colorectal surgical procedures have a high rate of surgical site infection (SSI), and obesity has been implicated as a predictor of such infection. We hypothesized that abdominal wall thickness (AWT), as a metric of obesity, would predict postoperative superficial and deep incisional SSI after colorectal surgery, and conducted a study to assess superficial and deep incisional SSI and its relationship to abdominal wall thickness. METHODS: To measure pre-operative AWT through cross-sectional imaging, and to analyze its relationship to SSI, we conducted a retrospective study at a single academic medical center of patients who had had colorectal resection for any indication in 2008 and 2009. RESULTS: We identified 143 patients for inclusion in the study. Superficial or deep incisional SSI occurred in 43 patients (30%). Abdominal wall thickness at the midpoint between the umbilicus and pubis was associated with SSI (OR 1.03; p=0.014). Body-mass index (BMI) was also significantly associated with SSI (OR 1.08; p=0.014). Other significant (p<0.05) predictors of SSI by univariate analysis included a history of soft tissue infection, a surgical wound classification of 3 or 4, and lack of compliance with perioperative antibiotic guidelines. In a multivariable analysis of factors that were statistically significantly associated with SSI in univariate comparisons, lack of appropriate preoperative antibiotic administration independently predicted SSI (OR 4.33; 95% CI 1.08-17.40), but AWT and BMI were not significantly associated with SSI. CONCLUSIONS: Surgical site infection is common after colorectal surgery. Increased AWT predicts SSI by univariate analysis. Our findings could guide further studies of interventions that may decrease the risk of SSIs in patients with a thick abdominal wall.