Preoperative Risk Factors for Adverse Events in Adults Undergoing Bowel Resection for Inflammatory Bowel Disease: 15-Year Assessment of the American College of Surgeons National Surgical Quality Improvement Program.

INTRODUCTION: Older adults with inflammatory bowel disease (IBD) are at higher risk for postoperative complications as compared to their younger counterparts; however, factors contributing to this are unknown. We assessed risk factors associated with adverse IBD-related surgical outcomes, evaluated trends in emergency surgery, and explored differential risks by age. METHODS: Using the American College of Surgeons National Surgical Quality Improvement Program database, we identified adults ≥18 years of age who underwent an IBD-related intestinal resection from 2005 to 2019. Our primary outcome included a 30-day composite of mortality, readmission, reoperation, and/or major postoperative complication. RESULTS: Overall, 49,746 intestinal resections were performed with 9,390 (18.8%) occurring among older adults with IBD. Nearly 37% of older adults experienced an adverse outcome as compared to 28.1% among younger adults with IBD ( P < 0.01). Among all adults with IBD, the presence of preoperative sepsis (adjusted odds ratio [aOR], 2.08; 95% confidence interval [CI] 1.94-2.24), malnutrition (aOR, 1.22; 95% CI 1.14-1.31), dependent functional status (aOR, 6.92; 95% CI 4.36-11.57), and requiring emergency surgery (aOR, 1.50; 95% CI 1.38-1.64) increased the odds of an adverse postoperative outcome, with similar results observed when stratifying by age. Furthermore, 8.8% of surgeries among older adults were emergent, with no change observed over time ( P = 0.16). DISCUSSION: Preoperative factors contributing to the risk of an adverse surgical outcome are similar between younger and older individuals with IBD, and include elements such as malnutrition and functional status. Incorporating these measures into surgical decision-making can reduce surgical delays in older individuals at low risk and help target interventions in those at high risk, transforming care for thousands of older adults with IBD.

Standardization of ileoanal J-pouch surgery technique: Quality assessment of minimally invasive ileoanal J-pouch surgery videos.

BACKGROUND: Ileal pouch anal anastomosis is a complex procedure associated with significant morbidity, with several complications after ileal pouch anal anastomosis surgery leading to pouch failure. The aim of the study is to evaluate the heterogeneity surrounding the technique of ileoanal J-pouch surgery by assessing the safety and quality of published online peer-reviewed surgical videos. METHODS: Ileal pouch anal anastomosis videos published on peer-reviewed surgical journals and video channels were edited and anonymized to demonstrate specific steps of the surgical procedure: mobilization and division of the rectum, formation of the ileoanal J-pouch reservoir, anastomosis, and lengthening techniques. The anonymized videos were presented to a group of reviewers with expertise in ileal pouch anal anastomosis blinded to the names and affiliations of the surgeons performing the procedure. Primary outcome was the rate of interobserver variability in the assessment of specific technical steps of the ileal pouch anal anastomosis surgery procedure. Secondary outcome was the appropriateness of the use of surgical videos review as an assessment tool for ileal pouch anal anastomosis surgery, measured as rate of reviewers being unable to answer for poor video quality. RESULTS: In total, 29 video fragments were distributed, and 13 assessors completed a 60-item survey, organized in 7 major domains. The survey completion rate was 93.4%. Out of a total 729 answers, in 23 (3.2%) the reviewers indicated they were unable to comment due to poor video image, and in 48 (6.5%) were unable to comment due to the particular step not being shown in the procedure. The proportion of assessors rating rectal mobilization technically appropriate ranged from 30.7% to 92.3% and from 7.7% to 69.2% for safety. The level of rectal division was considered appropriate in 0 to 53.8% of the videos, whereas the stapling technique used for rectal division was appropriate in 0 to 70% of the videos. CONCLUSION: Our study assessed published peer-reviewed videos on ileal pouch anal anastomosis surgery and reported heterogeneity in the safety of the demonstrated techniques. Blind assessment of published peer-reviewed ileal pouch anal anastomosis videos reported a high rate of unsafe or inappropriate technique for rectal mobilization and transection in the reviewed videos, with fair interobserver agreement among reviewers. There is a need for consensus on what is considered safe and appropriate in ileal pouch anal anastomosis surgery. Peer review of ileal pouch anal anastomosis surgery videos could facilitate training and accreditation in this complex procedure.

Ileal Pouch Excision can Be Performed With Similar Outcomes in Obese Patients Compared to Nonobese Counterparts: An Assessment From American College of Surgeons National Surgical Quality Improvement Program.

BACKGROUND: Failed pouches may tend to be managed with only a loop ileostomy in obese patients due to some safety concerns. The effect of obesity on ileal pouch excision outcomes is poorly studied. In our study, we aimed to assess the short-term outcomes after ileal pouch excision in obese patients compared to their nonobese counterparts. METHODS: The patients who underwent pouch excision between 2005 and 2017 were included using ACS-NSQIP participant user files. The operative outcomes were compared between obese (BMI ≥30 kg/m2) and nonobese (BMI<30 kg/m2) groups. RESULTS: There were 507 pouch excision patients included of which eighty (15.7%) of them were obese. Physical status of the obese patients tended to be worse (ASA>3, 56.3 vs 42.9%, P = .027). There were more patients who had diabetes mellitus (DM) and hypertension (HT) in the obese group (26.3% vs. 11.2%, P = .015; 11.3 vs. 4.4%, P < .001, respectively). Operative time was similar between 2 groups (mean ± SD, 275 ± 111 vs. 252±111 minutes, P = .084). Deep incisional SSI was more commonly observed in the obese group (7.5 vs 2.8%, P = .038). In multivariate analysis, only deep incisional SSI was found to be independently associated with obesity (OR: 2.79, 95% CI: 1.02-7.67). Obese patients were readmitted more frequently than nonobese counterparts (28.3 vs 16%, P = .035). The length of hospital stay was comparable [median (IQR), 7 (4-13.5) vs. 7 (5-11) days, P = .942]. CONCLUSION: Ileal pouch excision can be performed in obese patients with largely similar outcomes compared to their nonobese counterparts although obesity is associated with a higher rate of deep space infection.

Crohn Disease Active Inflammation Assessment with Iodine Density from Dual-Energy CT Enterography: Comparison with Histopathologic Analysis.

Background Dual-energy CT enterography (DECTE) has been shown to be useful in characterizing Crohn disease activity compared with clinical markers of inflammation but, to the knowledge of the authors, comparison has not been made with histopathologic specimens. Purpose To compare mucosal iodine density obtained at DECTE from Crohn disease-affected bowel with histopathologic specimens from surgically resected ileocolectomy bowel segments or terminal ileum colonoscopic biopsies in the same patients. Materials and Methods This was a retrospective study. Bowel segments in adults with Crohn disease who underwent DECTE from January 2017 to April 2019 within 90 days of ileocolectomy or colonoscopy were retrospectively evaluated with prototype software allowing the semiautomatic determination of inner hyperdense bowel wall (mucosal) mean iodine density, normalized to the aorta. Mean normalized iodine density and clinical activity indexes (Crohn Disease Activity Index [CDAI] and Harvey-Bradshaw Index [HBI]) were compared with histologic active inflammation grades by using two-tailed t tests. Receiver operating characteristic curves were generated for mean normalized iodine density, CDAI, and HBI to determine sensitivity, specificity, and accuracy. A P value less than .05 was considered to indicate statistical significance. Results The following 16 patients were evaluated (mean age, 41 years ± 14 [standard deviation]): 10 patients (five men, five women; mean age, 41 years ± 15) with 19 surgical resection specimens and six patients with terminal ileum colonoscopic mucosal biopsies (four men, two women; mean age, 43 years ± 14). Mean normalized iodine density was 16.5% ± 5.7 for bowel segments with no active inflammation (n = 8) and 34.7% ± 9.7 for segments with any active inflammation (n = 17; P < .001). A 20% mean normalized iodine density threshold had sensitivity, specificity, and accuracy of 17 of 17 (100%; 95% CI: 80.5, 100), six of eight (75%; 95% CI: 35, 97), and 23 of 25 (92%; 95% CI: 74, 99), respectively, for active inflammation. Clinical indexes were similar for patients with and without active inflammation at histopathologic analysis (CDAI score, 261 vs 251, respectively [P = .77]; HBI score, 7.8 vs 6.4, respectively [P = .36]). Conclusion Iodine density from dual-energy CT enterography may be used as a radiologic marker of Crohn disease activity as correlated with histopathologic analysis. © RSNA, 2021 See also the editorial by Ohliger in this issue.

Nomogram-Derived Prediction of Postoperative Ileus after Colectomy: An Assessment from Nationwide Procedure-Targeted Cohort.

Postoperative ileus (POI) is a clinical burden to health-care system. This study aims to evaluate the incidence and predictors of POI in patients undergoing colectomy and create a nomogram by using recently released procedure-targeted nationwide database. Patients who underwent elective colectomy in 2012 and 2013 were identified from American College of Surgeons National Surgical Quality Improvement Program using the new procedure-targeted database. Demographics, comorbidities, and 30-day postoperative outcomes were evaluated. Variables in the final stepwise multiple logistic regression model for each outcome were selected in a stepwise fashion using Akaike's information criterion. A nomogram was created to aid in the calculation of POI risk for individual patients. A total of 29,201 patients met the inclusion criteria; 3834 (13.1%) developed POI with a male predominance (55.9%). Patients who developed ileus had longer length of hospital stay (11 vs 5 days; P < 0.001) and operative time (200 vs 174 minutes; P < 0.001). In the stepwise logistic regression model, the following variables were found to be independent risk factors for POI: older age (P < 0.001), male gender (P < 0.001), American Society of Anesthesiologists class III/IV (P < 0.001), open approach (P < 0.001), preoperative septic conditions (P < 0.001), omission of oral antibiotic before surgery (P < 0.001), right colectomy or total colectomy vs other procedures (P < 0.001), smoking (P = 0.001), decreased preoperative serum albumin level (P < 0.001), and prolonged operating time (P < 0.001). All postoperative complications were more frequently occurred in patients with POI. The nomogram accurately predicted POI with a concordant index for this model of 0.69. The use of minimal invasive techniques, control of preoperative septic conditions, oral antibiotic bowel preparation and shorter operative time are associated with a decreased rate of POI. External validation is essential for the confirmation and further evaluation of our logistic regression model and nomogram.

Predictors of Anastomotic Leak in Elderly Patients After Colectomy: Nomogram-Based Assessment From the American College of Surgeons National Surgical Quality Program Procedure-Targeted Cohort.

BACKGROUND: Elderly patients undergoing colorectal surgery have increasingly become under scrutiny by accounting for the largest fraction of geriatric postoperative deaths and a significant proportion of all postoperative complications, including anastomotic leak. OBJECTIVE: This study aimed to determine predictors of anastomotic leak in elderly patients undergoing colectomy by creating a novel nomogram for simplistic prediction of anastomotic leak risk in a given patient. DESIGN: This study was a retrospective review. SETTINGS: The database review of the American College of Surgeons National Surgical Quality Improvement Program was conducted at a single institution. PATIENTS: Patients aged ≥65 years who underwent elective segmental colectomy with an anastomosis at different levels (abdominal or low pelvic) in 2012-2013 were identified from the multi-institutional procedure-targeted database. MAIN OUTCOME MEASURES: We constructed a stepwise multiple logistic regression model for anastomotic leak as an outcome; predictors were selected in a stepwise fashion using the Akaike information criterion. The validity of the nomogram was externally tested on elderly patients (≥65 years of age) from the 2014 American College of Surgeons National Surgical Quality Improvement Program colectomy-targeted database. RESULTS: A total of 10,392 patients were analyzed, and anastomotic leak occurred in 332 (3.2%). Of the patients who developed anastomotic leak, 192 (57.8%) were men (p < 0.001). Based on unadjusted analysis, factors associated with an increased risk of anastomotic leak were ASA score III and IV (p < 0.001), chronic obstructive pulmonary disease (p = 0.004), diabetes mellitus (p = 0.003), smoking history (p = 0.014), weight loss (p = 0.013), previously infected wound (p = 0.005), omitting mechanical bowel preparation (p = 0.005) and/or preoperative oral antibiotic use (p < 0.001), and wounds classified as contaminated or dirty/infected (p = 0.008). Patients who developed anastomotic leak had a longer length of hospital stay (17 vs 7 d; p < 0.001) and operative time (191 vs 162 min; p < 0.001). A multivariate model and nomogram were created. LIMITATIONS: This study was limited by its retrospective nature and short-term follow-up (30 d). CONCLUSIONS: An accurate prediction of anastomotic leak affecting morbidity and mortality after colorectal surgery using the proposed nomogram may facilitate decision making in elderly patients for healthcare providers.

Considering Value in Rectal Cancer Surgery: An Analysis of Costs and Outcomes Based on the Open, Laparoscopic, and Robotic Approach for Proctectomy.

OBJECTIVE: The aim of the study was to compare value (outcomes/costs) of proctectomy in patients with rectal cancer by 3 approaches: open, laparoscopic, and robotic. BACKGROUND: The role of minimally invasive proctectomy in rectal cancer is controversial. In the era of value-based medicine, costs must be considered along with outcomes. METHODS: Primary rectal cancer patients undergoing curative intent proctectomy at our institution between 2010 and 2014 were included. Patients were grouped by approach [open surgery, laparoscopic surgery, and robotic surgery (RS)] on an intent-to-treat basis. Groups were compared by direct costs of hospitalization for the primary resection, 30-day readmissions, and ileostomy closure and for short-term outcomes. RESULTS: A total of 488 patients were evaluated; 327 were men (67%), median age was 59 (27-93) years, and restorative procedures were performed in 333 (68.2%). Groups were similar in demographics, tumor characteristics, and treatment details. Significant outcome differences between groups were found in operative and anesthesia times (longer in the RS group), and in estimated blood loss, intraoperative transfusion, length of stay, and postoperative complications (all higher in the open surgery group). No significant differences were found in short-term oncologic outcomes. Direct cost of the hospitalization for primary resection and total direct cost (including readmission/ileostomy closure hospitalizations) were significantly greater in the RS group. CONCLUSIONS: The laparoscopic and open approaches to proctectomy in patients with rectal cancer provide similar value. If robotic proctectomy is to be widely applied in the future, the costs of the procedure must be reduced.

Comparison of straight vs hand-assisted laparoscopic colectomy: an assessment from the NSQIP procedure-targeted cohort.

BACKGROUND: The perioperative outcomes of patients who underwent straight laparoscopic (LAP) vs hand-assisted laparoscopic (HALS) surgery were compared using a recently released procedure-targeted database. METHODS: The 2012 colectomy-targeted American College of Surgeons National Surgical Quality Improvement Program database was used and patients were classified into 2 groups according to the final surgical approach: LAP vs HALS. Demographics, comorbidities, and 30-day outcomes were compared. RESULTS: A total of 7,843 patients met the inclusion criteria. There were 4,656 (59%) patients in LAP colectomy and 3,187 (41%) in HALS colectomy groups. Groups were comparable in terms of preoperative characteristics and demographics. Mean operative time was slightly longer in LAP group (178 ± 86 vs 171 ± 84 minutes, P < .001). After covariate-adjustment analysis, the overall morbidity, superficial surgical site infection, and ileus rates remained slightly higher in HALS group. CONCLUSIONS: Both straight laparoscopic and hand-assisted approaches are used in colorectal surgery and may complement each other in challenging cases. Implementing the best approach to decrease postoperative complication rates and increase use of minimally invasive techniques may play a role in improving patient care and overall quality.

A novel data collection and monitoring system for health status measures in patients undergoing lateral internal sphincterotomy: The Knowledge Program (TKP).

BACKGROUND/OBJECTIVE: The Knowledge Program (TKP) allows prospective data collection during routine clinical practice. The aim of this study was to evaluate the efficacy and feasibility of TKP for capturing and monitoring health status measures in patients undergoing lateral internal sphincterotomy (LIS). METHODS: TKP data of patients undergoing LIS from December 2008 to May 2013 were retrieved. Health status measures including the Cleveland Global Quality of Life (CGQL), European Quality of Life Index (EQ-5D), Fecal Incontinence Severity Index (FISI), anorectal pain scores, and satisfaction questions were evaluated in the study. RESULTS: A total of 500 patients underwent LIS within the study period. Overall patient numbers responding to the health status measures in the pre- and postoperative period were as follows: CGQL: 112 preoperatively, 53 postoperatively; EQ-5D: 112 preoperatively, 55 postoperatively; FISI: 102 preoperatively, 30 postoperatively; and anorectal pain score: 107 preoperatively, 45 postoperatively. Among the responders, the number of patients who completed the health status measures both pre- and postoperatively was as follows: EQ-5D: 31, CGQL: 28, anorectal pain: 24, and FISI: 15. A total of 30 patients completed postoperative satisfaction and recommendation questions. Postoperative earliest (p = 0.02) and most recent (p = 0.01) anorectal pain visual analog scores were significantly lower than the preoperative measurements. The earliest postoperative EQ-5D scores were significantly higher than their preoperative values (p = 0.02). The majority of patients who completed the surveys said they were satisfied (70% and 67%) and would recommended (73% and 70%) LIS to others undergoing postoperative earliest and most recent follow up. CONCLUSION: LIS reduces anorectal pain without worsening quality of life. TKP captures information directly from patients and records it to a database which may reduce the risk of information loss or alteration.

Does laparoscopy reduce splenic injuries during colorectal resections? An assessment from the ACS-NSQIP database.

BACKGROUND: Nearly half of all incidental splenectomies caused by iatrogenic splenic injury occur during colorectal surgery. This study evaluates factors associated with incidental splenic procedures during colorectal surgery and their impact on short-term outcomes using a nationwide database. METHODS: Patients who underwent colorectal resections between 2005 and 2012 were identified from the American College of Surgeons National Surgical Quality Improvement Program database according to Current Procedural Terminology codes. Patients were classified into two groups based on whether they underwent a concurrent incidental splenic procedure at the time of the colorectal procedure. All splenic procedures except a preoperatively intended splenectomy performed in conjunction with colon or rectal resections were considered as incidental. Perioperative and short-term (30 day) outcomes were compared between the groups. RESULTS: In total, 93633 patients who underwent colon and/or rectal resection were identified. Among these, 215 patients had incidental splenic procedures (153 open splenectomy, 17 laparoscopic splenectomy, 36 splenorraphy, and 9 partial splenectomy). Open colorectal resections were associated with a significantly increased likelihood of incidental splenic procedures (OR 6.58, p < 0.001) compared to laparoscopic surgery. Incidental splenic procedures were associated with increased length of total hospital stay (OR 1.25, p < 0.001), mechanical ventilation dependency (OR 1.62, p = 0.02), transfusion requirement (OR: 3.84, p < 0.001), re-operation requirement (OR 1.7, p = 0.005), and sepsis (OR: 2.03, p = 0.001). Short-term advantages of splenic salvage (splenorraphy or partial splenectomy) included shorter length of total hospital stay (p = 0.001) and decreased need for re-operation (p < 0.001). CONCLUSIONS: Incidental splenic procedures during colorectal resections are associated with worse short-term outcomes. Use of the laparoscopic technique decreases the need for incidental splenic procedures.

Outcomes associated with resident involvement in laparoscopic colorectal surgery suggest a need for earlier and more intensive resident training.

PURPOSE: The aim of this study is to determine if resident involvement in a large cohort of laparoscopic colorectal surgery (LCS) cases negatively impacts outcomes and ultimately increases costs. METHODS: The American College of Surgeons National Surgical Quality Improvement Program database was queried for patients who underwent LCS between 2005 and 2010. Patients were classified into two groups: postgraduate year (PGY; resident involvement) or Attending Only. A subgroup analysis was then conducted among the individual PGY levels (1-2, 3-5, ≥6) and Attending Only group. RESULTS: A total of 4,836 patients were included in the PGY group and 2,418 in the Attending Only group. Mean operative time (163.9 ± 66.7 vs. 140.7 ± 67.2 minutes, P < .001) and length of hospital stay (5.8 ± 5.4 vs. 5.6 ± 5.4 days, P = .015) were significantly longer in the PGY group. Surgical and nonsurgical complications and overall morbidity and mortality rates were similar between the two groups. Each individual PGY group was associated with longer operative time (P < .001), and PGY ≥ 6 was associated with an increased length of stay (P < .001). CONCLUSION: Although resident participation in LCS does not affect overall mortality or morbidity, it may negatively impact hospital costs through increased operative time and length of hospital stay. Early and intensive laparoscopy training may be necessary for improving residents' laparoscopy skills before their involvement in LCS.

Anal transitional zone neoplasia in patients with familial adenomatous polyposis after restorative proctocolectomy and IPAA: incidence, management, and oncologic and functional outcomes.

BACKGROUND: Restorative proctocolectomy and IPAA in patients with familial adenomatous polyposis may leave residual anal transitional zone mucosa that is prone to neoplasia. OBJECTIVE: The aim of this study was to evaluate the long-term control of neoplasia at the IPAA, the functional outcomes, and the influence of anastomotic technique on these results. DESIGN: : This research is a retrospective cohort study from a prospective database. SETTING: The investigation took place in a high-volume specialized colorectal surgery department. PATIENTS: Patients with familial adenomatous polyposis who underwent IPAA between 1983 and 2010 were included. MAIN OUTCOME MEASURES: The primary outcomes measured were functional outcomes, quality of life, and the incidence of neoplasia in the anal transitional zone. RESULTS: Eighty-six patients underwent mucosectomy and 174 underwent stapled anastomosis with mean 155 ± 99 and 95 ± 70 months follow-up. Eighteen patients (20.9%) in the mucosectomy group and 59 patients (33.9%) in the stapled group developed anal transitional zone adenomas (p = 0.03). One of 86 (1.2%) patients undergoing mucosectomy and 3 of 174 (1.7%) patients undergoing stapled anastomosis developed cancer in the anal transitional zone (p > 0.05). Three of these patients underwent an abdominoperineal resection, but one who refused abdominoperineal resection underwent transanal excision with neoileoanal anastomosis. Patients undergoing a mucosectomy had a significantly higher rate of anastomotic stricture, but other complications were similar. Incontinence, seepage, and pad usage were higher in the mucosectomy group. Cleveland global quality-of-life score was 0.8 ± 0.2 in patients with handsewn anastomoses and 0.8 ± 0.3 in patients with a stapled anastomoses (p > 0.05). LIMITATIONS: This study was limited by its nonrandomized retrospective design. CONCLUSIONS: Risk for the development of adenomas in the anal transitional zone is higher after a stapled IPAA than after a mucosectomy with handsewn anastomosis. However, control of anal transitional zone neoplasia results in a similar risk of cancer development. Because the stapled procedure is associated with better long-term functional outcomes than a mucosectomy, stapled IPAA is the preferable procedure for most patients with familial adenomatous polyposis.

In a select group of patients meeting strict clinical criteria and undergoing ileal pouch-anal anastomosis, the omission of a diverting ileostomy offers cost savings to the hospital.

PURPOSE: Ileal pouch-anal anastomosis is the standard care for the majority of patients with ulcerative colitis or familial adenomatous polyposis requiring surgery. The aim of this study is to determine whether the omission of an ileostomy in patients undergoing ileal pouch surgery offers cost savings to the hospital. METHODS: Patients who underwent open ileal pouch-anal anastomosis between 2000 and 2007 were identified. They were grouped according to the absence or presence of an ileostomy at the time of their surgery. Direct costs were calculated from the hospital's accounting database. Costs analyzed included those from the index surgery, ileostomy closure, and 6-month complications. RESULTS: Cost data were available for 835 patients undergoing ileal pouch-anal anastomosis. Seven hundred fifteen (86%) had a diverting ileostomy, and the ileostomy was omitted in 120 (14%). Patients without an ileostomy had a longer length of stay (8.7 vs 6.0 days; P < .001) and a 15% greater cost (P < .001) at the time of index surgery than did those with an ileostomy. There was no significant difference between the 2 groups in costs related to complications. The total costs, including ileal pouch-anal anastomosis, ileostomy closure, and complications, were 25% greater in the ileostomy group than in the group who had the ileostomy omitted at the index surgery ($9176 (+/- 6559) vs $11,451 (+/- 8791); P < .001). CONCLUSION: The above data shows that in a select group of patients meeting well-defined clinical criteria, the omission of a diverting ileostomy will provide significant cost savings for the hospital.

Ileal pouch prolapse: prevalence, management, and outcomes.

AIM: The study aim is to review the prevalence, management, and outcomes for patients diagnosed with ileal pouch prolapse after restorative proctocolectomy. MATERIALS AND METHODS: Patients were identified retrospectively from a prospectively maintained pouch database. Parameters analyzed included presenting symptoms, indications for pouch surgery, type of ileal pouch-anal anastomosis, treatment modalities, and outcomes. RESULTS: Of 3,176 patients who underwent ileal pouch surgery, 11 were diagnosed with pouch prolapse (0.3%). Seven had full-thickness prolapse and four mucosal prolapse. Six were male, and five were female. Indication for index surgery was ulcerative colitis (nine patients), familial adenomatous polyposis (one patient), and colonic inertia (one patient). Median age at pouch prolapse was 34 years. Median time from index surgery to prolapse diagnosis was 2 years. Two patients with mucosal prolapse responded to conservative management; two required mucosal excisions. An abdominal approach was successful in four out of seven patients with full thickness prolapse. The three failures subsequently underwent continent ileostomy formation and prompted us to add biological mesh to future pouchpexy repairs. CONCLUSIONS: Pouch prolapse is rare, and there are no obvious predisposing factors. Mucosal prolapse may be treated by stool bulking or a local perineal procedure. Full thickness prolapse requires definitive surgery and is associated with risk of pouch loss.

Does the learning curve during laparoscopic colectomy adversely affect costs?

BACKGROUND: This study aimed to investigate whether the learning curve during laparoscopic colectomy is associated with increased costs compared with the procedure after the learning curve has been achieved. METHODS: The direct costs for patients undergoing laparoscopic colectomy during the learning curve (group A) and after the attainment of proficiency by two colorectal surgeons performing the procedure (group B) between 2001 and 2007 were compared. The learning curve was defined as the first 40 laparoscopic colectomy cases for each surgeon. The distribution of cases for the surgeons ensured that cost-related differences were not influenced by lead time bias of cases performed during the learning curve. RESULTS: The study involved 80 group A and 74 group B patients. Groups A and B were similar in terms of age (P = 0.7), gender (P = 0.5), American Society of Anesthesiologists (ASA) score (P = 0.5), body mass index (P = 0.3), diagnosis (P = 0.8), previous abdominal surgery (P = 0.07), and comorbidity (P = 0.4). The two groups also were similar with regard to performance of anastomosis (P = 0.2) or resection (P = 0.6), conversion to open surgery (P = 0.7), postoperative morbidity (P = 0.6), readmission (P = 0.1), reoperation rate (P = 0.6), and hospital length of stay (P = 0.6). The operation time was significantly longer for group A (P = 0.01). The total direct costs (P = 0.7) and the operating room (P = 0.6), nursing (P = 0.7), pharmacy (P = 0.9), radiology (P = 1), and professional (P = 0.051) costs were however similar between the two groups. CONCLUSIONS: As expected, laparoscopic colectomy during the learning curve period is associated with prolonged operating time. Concerns pertaining to increased conversions, complications, and direct costs during this period were not substantiated in this study.

Laparoscopic versus open colectomy for patients with American Society of Anesthesiology (ASA) classifications 3 and 4: the minimally invasive approach is associated with significantly quicker recovery and reduced costs.

BACKGROUND: Conceivably, the benefits of earlier recovery associated with a minimally invasive technique used in laparoscopic colectomy (LC) may be amplified for patients with comorbid disease. The dearth of evidence supporting the safety of laparoscopy for these patients led to a comparison of outcomes between LC and open colectomy (OC) for patients with American Society of Anesthesiology (ASA) classifications 3 and 4. METHODS: Data for all ASA 3 and 4 patients who underwent elective LC were reviewed from a prospectively maintained laparoscopic database. The patients who underwent LC were matched with OC patients by age, gender, diagnosis, year, and type of surgery. Estimated blood loss, operation time, time to return of bowel function, length of hospital stay, readmission rate, and 30-day complication and mortality rates were compared using chi-square, Fisher's exact, and Wilcoxon tests as appropriate. A p value <0.05 was considered statistically significant. RESULTS: In this study, 231 LCs were matched with 231 OCs. The median age of the patients was 68 years, and 234 (51%) of the patients were male. There were 44 (19%) conversions from LC to OC. More patients in the OC group had undergone previous major laparotomy (5 vs. 15%; p < 0.001). Estimated blood loss, return of bowel function, length of hospital stay, and total direct costs were decreased in the LC group. Wound infection was significantly greater with OC (p = 0.02). When patients with previous major laparotomy were excluded, the two groups had similar overall morbidity. The other benefits of LC, however, persisted. CONCLUSION: The findings show that LC is a safe option for patients with a high ASA classification. The LC approach is associated with faster postoperative recovery, lower morbidity rates, and lower hospital costs than the OC approach.

Operative strategies for diverticular peritonitis: a decision analysis between primary resection and anastomosis versus Hartmann's procedures.

OBJECTIVE: To compare primary resection and anastomosis (PRA) with and without defunctioning stoma to Hartmann's procedure (HP) as the optimal operative strategy for patients presenting with Hinchey stage III-IV, perforated diverticulitis. SUMMARY BACKGROUND DATA: The choice of operation for perforated diverticulitis lies between HP and PRA. Postoperative mortality and morbidity can be high, and the long-term consequences life-altering, with no established criteria guiding clinicians towards selecting a particular procedure. METHODS: Probability estimates for 6879 patients with Hinchey III-IV perforated diverticulitis were obtained from two databases (n = 204), supplemented by expert opinion and summary data from 12 studies (n = 6675) published between 1980 and 2005. The primary outcome was quality-adjusted life-years (QALYs) gained from each strategy. Factors considered were the risk of permanent stoma, morbidity, and mortality from the primary or reversal operations. Decision analysis from the patient's perspective was used to calculate the optimal operative strategy and sensitivity analysis performed. RESULTS: A total of 135 PRA, 126 primary anastomoses with defunctioning stoma (PADS), and 6619 Hartmann's procedures (HP) were considered. The probability of morbidity and mortality was 55% and 30% for PRA, 40% and 25% for PADS, and 35% and 20% for HP, respectively. Stomas remained permanent in 27% of HP and in 8% of PADS. Analysis revealed the optimal strategy to be PADS with 9.98 QALYs, compared with 9.44 QALYs after HP and 9.02 QALYs after PRA. Complications after PRA reduced patients QALYs to a baseline of 2.713. Patients with postoperative complications during both primary and reversal operations for PADS and HP had QALYs of 0.366 and 0.325, respectively. HP became the optimal strategy only when risk of complications after PRA and PADS reached 50% and 44%, respectively. CONCLUSION: Primary anastomosis with defunctioning stoma may be the optimal strategy for selected patients with diverticular peritonitis as may represent a good compromise between postoperative adverse events, long-term quality of life and risk of permanent stoma. HP may be reserved for patients with risk of complications >40% to 50% after consideration of long-term implications.

Assessment of operative risk in colorectal cancer surgery: the Cleveland Clinic Foundation colorectal cancer model.

INTRODUCTION: Predictive models play a pivotal role in the provision of risk-adjusted, operative mortality rates. The purpose of the study was to describe the development of a dedicated prognostic index for quantifying operative risk in colorectal cancer surgery. METHODS: Data were collected from 5,034 consecutive patients undergoing major surgery in a single center from October 1976 to July 2002. Primary end point was 30-day operative mortality. A multilevel Bayesian logistic regression model was developed to adjust for case-mix and accommodate the variability of outcomes between surgeons. The model was internally validated (split-sample) and tested using measures of discrimination, calibration, and subgroup analysis. RESULTS: The patients' median age was 66 (range, 18-98) years. Operative mortality was 2.3 percent with no significant variability between surgeons or through time. Multivariate analysis identified the following independent risk factors: age (odds ratio = 1.5 per 10-year increase), American Society of Anesthesiologists grade (odds ratio for ASA II, III, IV-V vs. I = 2.6, 4.3, 6.8), TNM staging (odds ratio for Stage IV vs. I-III = 2.6), mode of surgery (odds ratio for urgent vs. nonurgent = 2.1) no-cancer resection vs. cancer resection (odds ratio = 4.5), and hematocrit level. The model offered adequate discrimination (area under receiver operator characteristic curve = 0.801) and excellent agreement between observed and model-predicted outcomes over ten major colorectal procedures (P = 0.191). CONCLUSIONS: The colorectal cancer model provided an accurate means of estimating risk for individual patients in the preoperative setting. It has important implications in everyday practice, because it may be used as an adjunct in the process of informed consent and for monitoring surgical performance through time.

A cost-effectiveness analysis of diagnostic strategies for symptomatic patients with ileal pouch-anal anastomosis.

OBJECTIVE: Pouchitis is often diagnosed based on symptoms and empirically treated with antibiotics (treat-first strategy). However, symptom assessment alone is not reliable for diagnosis, and an initial evaluation with pouch endoscopy (test-first strategy) has been shown to be more accurate. Cost-effectiveness of these strategies has not been compared. The aim of this study was to compare cost-effectiveness of different clinical approaches for patients with symptoms suggestive of pouchitis. METHODS: Pouchitis was defined as pouchitis disease activity index scores > or =7. The frequency of pouchitis in symptomatic patients with ileal pouch was estimated to be 51%; the efficacy for initial therapy with metronidazole (MTZ) and ciprofloxacin (CIP) was 75% and 85%, respectively. Cost estimates were obtained from Medicare reimbursement data. RESULTS: Six competing strategies (MTZ trial, CIP trial, MTZ-then-CIP trial, CIP-then-MTZ trial, pouch endoscopy with biopsy, and pouch endoscopy without biopsy) were modeled in a decision tree. Costs per correct diagnosis with appropriate treatment were $194 for MTZ trial, $279 for CIP trial, $208 for MTZ-then-CIP trial, $261 for CIP-then-MTZ trial, $352 for pouch endoscopy with biopsy, and $243 for pouch endoscopy without biopsy. Of the two strategies with the lowest cost, the pouch endoscopy without biopsy strategy costs $50 more per patient than the MTZ trial strategy but results in an additional 15 days for early diagnosis and thus initiation of appropriate treatment (incremental cost-effectiveness ratio $3 per additional day gained). The results of base-case analysis were robust in sensitivity analyses. CONCLUSIONS: Although the MTZ-trial strategy had the lowest cost, the pouch endoscopy without biopsy strategy was most cost-effective. Therefore, based on its relatively low cost and the avoidance of both diagnostic delay and adverse effects associated with unnecessary antibiotics, pouch endoscopy without biopsy is the recommended strategy among those tested for the diagnosis of pouchitis.