Evaluating the association of the new National Surgical Quality Improvement Program modified 5-factor frailty index with outcomes in elective colorectal surgery.

BACKGROUND: The 5-factor modified frailty index (mFI-5) is a new, NSQIP-based, predictive tool for mortality and postoperative complications. The mFI-5's predictive ability has been validated within the large-scale NSQIP database but applicability in institutional databases has not been investigated. We sought to assess the association between the mFI-5 and morbidity/mortality at the institutional level. METHODS: A divisional database was queried for 2017 elective colorectal resections and an mFI-5 calculated. The main outcome measure was the association and predictive value of the mFI-5 with major morbidity/mortality and minor complications. Univariable analyses were performed via the Cochran-Armitage Test and Cramer's V. Logistic regression evaluated the relationship between the mFI-5 and morbidity/mortality while accounting for demographics and pre-operative risk factors. Receiver operating characteristic (ROC) curves were plotted to visualize the predictive strength for outcomes. RESULTS: Four hundred and twelve patients were analyzed. 8.7% had major morbidity/mortality and 31.6% minor complications. The mFI-5 categorized patients into 0 (n = 335), 1 (n = 58), and 2+ (n = 19) groups. Univariable analysis showed a higher mFI-5 was associated significantly with major morbidity/mortality (P = 0.004), but not minor (P = 0.281). Multivariable logistic regression showed a strong association between an mFI-5 score of 2+ with major complications (Major: OR = 4.616, CI [1.442-14.776], P = 0.010). ROC curves showed the mFI-5 was poor for predicting outcomes and performed better when other risk factors were added to the model. CONCLUSION: The mFI-5 tool has an independent association with major morbidity/mortality in an institutional dataset for elective colorectal surgery, but is not predictive. Its predictive ability is enhanced when other patient-specific risk factors are incorporated.

Predictors of complications from stoma closure in elective colorectal surgery: an assessment from the American College of Surgeons National Surgical Quality Improvement Program (ACSNSQIP).

BACKGROUND: There is significant morbidity after diverting ileostomy closure, so identifying predictors of complications could be of great benefit. The aim of our study was to evaluate the incidence and risk factors for postoperative morbidity after elective ileostomy closure. METHODS: The ACS-NSQIP dataset was evaluated for elective ileostomy closures from 1/1/2015 to 12/31/2016. Demographic characteristics, operative, and postoperative outcomes were evaluated. The primary outcome was 30-day major morbidity (Clavien class III and greater). Secondary outcomes were rates and predictors of major morbidity, superficial site infection (SSI), reoperation, and readmission from multivariate logistic regression modeling. RESULTS: We retrospectively evaluated 1885 patients. The median operative time was 65 (IQR 50-90) minutes and median length of stay was 3 (IQR 2-5) days. Major morbidity was recorded in 6.7%, including mortality (1.0%), deep/organ space SSI (2.6%), dehiscence (0.8%), reintubation (0.5%), sepsis (1.7%), septic shock (0.8%), and reoperation (3.7%). Readmission was recorded in 9.7% and 6.2% had SSI. Multivariate logistic regression showed male sex (OR 1.584; 95% CI 1.068-2.347; p = 0.022) and longer operative time (OR 1.004; 95% CI 1.001-1.007; p = 0.009) were among those variables associated with increased odds of major morbidity. Dyspnea (OR 2.431; 95% CI 1.139-5.094; p = 0.021) and longer operative time (OR 1.003; 95% CI 1.001-1.007; p = 0.034) were among the independent risk factors for SSI. Male sex (OR 2.246; 95% CI 1.297-3.892; p = 0.004, chronic obstructive pulmonary disease (OR 2.959; 95% CI 1.153-7.591; p = 0.024), and longer operative time (OR 1.005; 95% CI 1.001-1.009; p = 0.011) were associated with increased odds of reoperation. Chronic obstructive pulmonary disease (OR 2.578; 95% CI 1.338-4.968; p = 0.005), wound infection (OR 2.680; 95% CI 1.043-6.890; p = 0.041), and inflammatory bowel disease (OR 2.565; 95% CI 1.203-5.463; p = 0.015) were associated with increased odds of readmission. CONCLUSIONS: Elective stoma closure has significant risk of morbidity. Patients with longer operative times were at increased risk for major morbidity, overall SSI, and reoperation. From the analysis, factors specifically associated with major morbidity, overall infectious complications, readmissions, and reoperations were identified. This information can be used to prospectively prepare for these high-risk patients, potentially improving postoperative outcomes.

Analysis of the impact of EEA stapler size on risk of anastomotic complications in colorectal anastomosis: does size matter?

BACKGROUND: Colorectal anastomotic complications are dreaded and dramatically affect outcomes. Causes are multifactorial, with the size of the end-to-end anastomosis (EEA) stapler a modifiable factor and potential target for risk reduction. Our goal was to examine the impact of the EEA stapler size on the risk of anastomotic complications in left-sided colorectal resections. METHODS: A prospective divisional database was reviewed for consecutive elective left-sided resections with a colorectal anastomosis using an EEA stapler from January 2013 May 2018 inclusive. Patients were stratified into 25-29 mm or 30-33 mm cohorts. Patient and disease demographics, operative variables, and postoperative outcomes were evaluated. The main outcome measures were the rate and factors associated with anastomotic complications. RESULTS: Four hundred seventy-three cases were evaluated, 185 ( 39.1%) were in the 25-29 mm group and 288 (60.9%) in the 30-33 mm group. Patients were comparable in demographics and operative variables. More males were anastomosed with the 30-33 mm than with the 25-29 mm stapler (57.6% vs 28.6%, p < 0.01). Significantly more patients developed an anastomotic stricture with the 25-29 mm than with the 30-33 mm staplers (7.1% vs. 2.1%; p = 0.007). There was no significant difference in leak rates or reoperation/interventions between groups. On logistic regression, neither gender, operative indication nor approach were associated with anastomotic leak, readmission, or reoperation/intervention. Stapler size remained significantly associated with stricture (p = 0.032). CONCLUSIONS: The 25-29 mm EEA staplers were associated with an increased rate of anastomotic stricture compared to 30-33 mm staplers in left-sided colorectal anastomoses. As stapler size is a simple process measure that is easily modifyable, this is a potential target for improving anastomotic complication rates. Further controlled trials may help assess the impact of stapler size on improving patient and quality outcomes.

Impact of surgical approach on short-term oncological outcomes and recovery following low anterior resection for rectal cancer.

AIM: The aim was to evaluate the influence of operative approach for low anterior resection (LAR) on oncological and postoperative outcomes. Minimally invasive surgical approaches are increasingly used for the treatment of rectal cancer with mixed outcomes. METHOD: We compared patients undergoing LAR in the National Cancer Database between 2010 and 2015 by surgical approach. Multivariable regression was used to identify risk factors associated with conversion rate, prolonged length of stay (LOS) and 30-day unplanned readmission. RESULTS: During the study period, 41 282 patients underwent LAR: 6035 robotic-assisted (RLAR) (14.6%), 13 826 laparoscopic (LLAR) (33.5%) and 21 421 open (OLAR) (51.9%). In propensity score matched analysis, RLAR compared to LLAR was associated with shorter LOS (6.3 vs 6.8 days, P < 0.0001), lower risk of prolonged LOS (22.1% vs 25.6%, P < 0.0001) and lower rate of conversion to open (7.5% vs 14.95%, P < 0.0001). Compared to OLAR, RLAR had shorter LOS (6.3 vs 7.8 days, P < 0.0001) and less prolonged LOS (14.1% vs. 20.9%, P < 0.0001). In multivariable analysis, for conversion to open, the laparoscopic approach was one of the risk factors; for prolonged LOS, conversion to open and non-robotic approaches (i.e. LLAR and OLAR) were risk factors; and for unplanned 30-day readmission, conversions and prolonged LOS were risk factors. CONCLUSIONS: For patients with rectal cancer, RLAR shows recovery benefits over both open and laparoscopic LAR with reduced conversion to open compared with LLAR and less prolonged LOS compared with LLAR and OLAR. RLAR is associated with short-term oncological outcomes comparable to OLAR, supporting its use in minimally invasive surgery for rectal cancer.

A National study on the adoption of laparoscopic colorectal surgery in the elderly population: current state and value proposition.

BACKGROUND: The economic and clinical benefits of laparoscopic colorectal surgery are proven, yet may be underutilized in appropriate cases, especially in the elderly. Since the elderly constitute the greatest colorectal surgical volume, our goal was to identify trends in utilization and impact of laparoscopy in this cohort. METHODS: A national review of elective inpatient colorectal resections from the Premier Inpatient Database between 2010 and 2015 was performed. Patients were included if elderly (≥ 65 years), then grouped into open or laparoscopic procedures. The main outcome measures were trends in utilization by approach and total costs for the episode of care, length of stay (LOS), readmission, and complications by approach in the elderly. Multivariable regression models controlled for differences across platforms, adjusting for patient demographic, comorbidities and hospital characteristics. RESULTS: In 70,655 elderly patients evaluated, laparoscopic adoption remained lower than open throughout the study period. Rates increased until 2013, then declined, with increasing rates of open surgery. Laparoscopy was associated with significantly lower mean total costs ($4012 less/case), complications and readmissions (36% and 33% less, respectively), and shorter LOS (2.6 less days) than open cases (all p < 0.0001). When complications occurred, they were less severe and the readmission episodes were less costly with laparoscopy than open colorectal surgery. CONCLUSION: The adoption of laparoscopy in the elderly has lagged behind open surgery and even declined in recent years despite being associated with improved clinical outcomes and reduced cost. With this tremendous value proposition to increase use of laparoscopic surgery in the elderly, further work needs to evaluate root causes of the disparity.

Management of iatrogenic perforation during colonoscopy in ulcerative colitis patients: a survey of gastroenterologists and colorectal surgeons.

PURPOSE: Patients with ulcerative colitis, a high-risk group for the development of colon cancer, undergo colonoscopy more frequently than the general population. This increase in endoscopic evaluation also exposes these patients to an increased risk of complications, including iatrogenic perforation. Our survey study aims to determine factors that affect the management choices for iatrogenic perforations for ulcerative colitis patients in remission and identify areas of consensus among general gastroenterologists, inflammatory bowel disease specialists, and colorectal surgeons. METHODS: An anonymous, cross-sectional survey was performed using an online platform. A matrix questionnaire posed five clinical scenarios with six management options for an iatrogenic perforation in ulcerative colitis patients with varying disease distribution, disease activity, and maintenance regimens. RESULTS: One hundred thirty-eight general gastroenterologists, 35 inflammatory bowel disease specialists, and 174 colorectal surgeons responded to the survey; 47, 41, and 23%, respectively, answered they did not feel comfortable managing perforations in ulcerative colitis patients in remission. We found the greatest concordance among gastroenterologists and colorectal surgeons in cases of perforation in ulcerative colitis with a history of dysplasia; the majority of respondents chose staged total proctocolectomy with ileal pouch anal anastomosis. We found discordance in decision making for ulcerative colitis in remission without dysplasia, with perforation occurring in colitis involved and uninvolved areas. CONCLUSION: Our survey revealed that a significant fraction of gastroenterologists and colorectal surgeons are uncomfortable managing iatrogenic colonic perforations in ulcerative colitis patients. We have identified knowledge and practice gaps in defining the optimal management of iatrogenic perforations in ulcerative colitis patients.

An observational study of the timing of surgery, use of laparoscopy and outcomes for acute cholecystitis in the USA and UK.

BACKGROUND: Evidence supports early laparoscopic cholecystectomy for acute cholecystitis. Differences in treatment patterns between the USA and UK, associated outcomes and resource utilization are not well understood. METHODS: In this retrospective, observational study using national administrative data, emergency patients admitted with acute cholecystitis were identified in England (Hospital Episode Statistics 1998-2012) and USA (National Inpatient Sample 1998-2011). Proportions of patients who underwent emergency cholecystectomy, utilization of laparoscopy and associated outcomes including length of stay (LOS) and complications were compared. The effect of delayed treatment on subsequent readmissions was evaluated for England. RESULTS: Patients with a diagnosis of acute cholecystitis totaled 1,191,331 in the USA vs. 288 907 in England. Emergency cholecystectomy was performed in 628,395 (52.7% USA) and 45,299 (15.7% England) over the time period. Laparoscopy was more common in the USA (82.8 vs. 37.9%; p < 0.001). Pre-treatment (1 vs. 2 days; p < 0.001) and total ( 4 vs. 7 days; p < 0.001) LOS was lower in the USA. Overall incidence of bile duct injury was higher in England than the USA (0.83 vs. 0.43%; p < 0.001), but was no different following laparoscopic surgery (0.1%). In England, 40.5% of patients without an immediate cholecystectomy were subsequently readmitted with cholecystitis. An additional 14.5% were admitted for other biliary complications, amounting to 2.7 readmissions per patient in the year following primary admission. CONCLUSION: This study highlights management practices for acute cholecystitis in the USA and England. Despite best evidence, index admission laparoscopic cholecystectomy is performed less in England, which significantly impacts subsequent healthcare utilization.

Rectal trauma injuries: outcomes from the U.S. National Trauma Data Bank.

BACKGROUND: There is a  lack of general consensus and a little published data regarding the management of trauma-related rectal injuries and outcomes. The aim of the present study was to evaluate the surgical management and corresponding outcomes for this patient cohort, using a nationwide trauma database. METHODS: Rectal injuries and procedures performed over a 2-year period (2013 and 2014) were identified through ICD-9 clinical modification codes, from the United States National Trauma Data Bank. Patient factors, management variables, and outcomes were evaluated. RESULTS: Of 1.7 million patients, 1472 (0.1%) sustained a rectal injury; 81% male, median age 30 years (range 16-89 years) and 60% due to penetrating trauma. Seven hundred and seventy-eight (52.8%) had an isolated extraperitoneal injury and 694 (47.2%) had isolated Intraperitoneal or combined intra- and extraperitoneal injuries. Overall, 726 patients (49.3%) underwent fecal diversion. Injuries following blunt trauma were associated with higher injury severity scores (ISS), lower stoma rates, longer hospital and intensive-care unit (ICU) stay, and higher mortality rates than penetrating trauma (all p ≤ 0.001). Patients with stoma formation had lower mortality than undiverted patients (8.6 vs. 4.0%, p < 0.001) despite a higher ISS and more intraperitoneal injuries, but longer hospital and ICU stay (all p ≤ 0.001). On multivariate regression analysis, older age, higher ISS, intraperitoneal injury, and return to the ICU were independently associated with higher rates of mortality, while stoma formation was associated with a lower mortality rate. For isolated extraperitoneal rectal injuries, 494 patients (63.5%) were managed by resection/repair without stoma and had significantly lower overall postoperative morbidity rates (12.7 vs. 30.2%, p = 0.009) and shorter hospital stay (14 vs. 23 days, p < 0.001), than those who underwent resection/repair + stoma (n = 284; 36.5%), despite no significant difference in ISS (29 vs. 27, p = 0.780). There was no significant difference in mortality. CONCLUSIONS: Our results showed that trauma-related rectal injuries are rare and there is wide variation in their management. These data support a low threshold for stoma formation in patients with intraperitoneal or combined injuries, while suggesting that isolated extraperitoneal defects may be safely managed without fecal diversion.

Healing of the perineal wound after proctectomy in Crohn's disease patients: only preoperative perineal sepsis predicts poor outcome.

BACKGROUND: The aim of our study was to assess perineal wound healing in patients with Crohn's disease (CD) who undergo proctectomy or proctocolectomy with end ileostomy and to evaluate the influence of various factors including types of perineal dissection on eventual wound healing. METHODS: Data for patients with CD who underwent proctectomy or total proctocolectomy with end ileostomy from 1995 to 2012 were reviewed. The relationship between perineal wound healing and demographics, patient characteristics, and other factors was assessed using univariate and multivariate analyses. RESULTS: The perineal wound healed by 12 weeks in 72 (52.9%) out of 136 patients (63.2% female, mean age 41 ± 13 years); delayed healing occurred in 35 patients (25.7%), and in 29 patients (21.3%), there was non-healing. On multivariate analysis, the only factor associated with delayed healing and non-healing was preoperative perineal sepsis (p = 0.001). CONCLUSIONS: After proctectomy or proctocolectomy for CD, perineal wound healing is poor and poses a particular challenge for patients with preoperative perineal sepsis. These findings support a preoperative discussion regarding CD patients that examines potential outcomes and the consideration of measures such as the initial creation of defunctioning ostomy or control/drainage of local sepsis prior to proctectomy.

Impact of preoperative steroid or immunosuppressant use on short-term outcomes following colectomy in Crohn's disease patients.

BACKGROUND: Evaluating the impact of steroid or immunosuppressants (SI) therapy prior to colectomy in Crohn's disease (CD) patients on postoperative septic and colectomy-specific outcomes using the American College of Surgeons (ACS)-National Surgical Quality Improvement Program (NSQIP)-targeted colectomy database. METHODS: All CD patients undergoing colectomy were retrieved from the 2012-2013 NSQIP-targeted database. Thirty-day postoperative outcomes were compared for patients who were on steroids or immunosuppressants (SI) within the 30 days prior to colectomy to the others using univariable and multivariable analyses. RESULTS: Of 2208 CD patients, 1387 (63%) were on SI. Patients in the SI group were younger, and a greater proportion underwent laparoscopic surgery (p < 0.05). SI use was associated with a higher rate of sepsis (7.6 vs. 5.2%), anastomotic leak (5.6 vs. 3.5%), and return to operating room (6.8 vs. 3.3%). On multivariable analysis, SI was associated with sepsis, septic shock, and anastomotic leak [odds ratio = 1.58, 95% confidence interval 1.09-2.27]. CONCLUSIONS: These results suggest that SI use within 30 days of colectomy is associated with a higher rate of sepsis and septic shock and anastomotic leak in CD patients. Withholding SI prior to surgery, or the selective use of an ostomy to mitigate the consequences of a leak and hence sepsis need due consideration prior to surgery.

Benefit of mechanical bowel preparation prior to elective colorectal surgery: current insights.

BACKGROUND: Back in the 1970s, the administration of oral antibiotics combined with mechanical bowel preparation prior to colorectal surgery was considered standard procedure and adopted widely. Subsequent evidence suggested that bowel cleansing was unnecessary, even harmful, and hence was abandoned. Most recent evidence, however, suggests that full preparation significantly improves a spectrum of colectomy-specific postoperative outcomes. PURPOSE: The purpose of this review was to describe existing literature regarding the optimal bowel preparation regimen prior to elective colorectal resection. In addition, we evaluate the available evidence on each component-oral antibiotics, mechanical bowel preparation and intravenous antibiotics, with regard to short-term postoperative outcomes. CONCLUSIONS: Current best evidence suggests that colorectal resection should be preceded by a combination of oral antibiotics, mechanical bowel preparation and intravenous antibiotics at induction. Further randomized controlled trials are required due to a paucity of level 1 evidence.

30-day mortality after elective colorectal surgery can reasonably be predicted.

BACKGROUND: The aim of the present study was to develop a clinically relevant, accurate and usable risk assessment scoring system solely for colorectal cancer patients undergoing elective resection. METHODS: All colorectal resections for colorectal cancer 2006-2012 were identified from the American College of Surgeons Quality Improvement Program. Independent risk factors for 30-day mortality after elective surgery were identified using univariable and multivariable logistic regression. A points-calculator based on factors most strongly associated with mortality and accurately predicting risk of mortality was developed. RESULTS: Fifty-nine thousand nine hundred eighty-six patients underwent elective colorectal cancer surgery, and 1096 (1.8 %) died within 30 days. On multivariable analysis, the strongest risk factors for mortality were age ≥65 years [odds ratio (OR) 2.17, 95 % confidence interval (CI) 1.61-2.92], American Society of Anesthesiologists score ≥3 (OR 1.77, 95 % CI 1.29-2.42), renal failure (OR 3.15, 95 % CI 1.01-9.77), disseminated cancer (OR 2.56, 95 % CI 1.96-3.35), hypoalbuminemia (OR 2.84, 95 % CI 2.21-3.65), preoperative ascites (OR 3.17, 95 % CI 2.07-4.87), heart failure (OR 2.08, 95 % CI 1.35-3.20) and functional status (OR 2.05, 95 % CI 1.56-2.70). A model that accurately predicted risk of mortality was created using forward stepwise logistic regression and externally validated (area under the curve 0.826). This allowed for development of an eight-factor predictive score; maximum points conferred mortality of 96.1 % (p < 0.0001). CONCLUSIONS: A simple preoperative scoring system predicting 30-day mortality with good capability may allow better preoperative risk assessment, optimization and decision-making.

Antibiotics alone instead of percutaneous drainage as initial treatment of large diverticular abscess.

BACKGROUND: There are limited data assessing the effectiveness of antibiotics as sole initial therapy in patients with large diverticular abscess. The aim of our study was to compare outcomes of selected patients treated with initial antibiotics alone versus percutaneous drainage. METHODS: All patients with diverticular abscess ≥3 cm in diameter treated in our institution in 1994-2012 with percutaneous drainage or antibiotics alone followed by surgery were identified from an institutional diverticular disease database. Groups were compared based on patient and disease characteristics, treatment failures and postoperative outcomes. RESULTS: Thirty-two patients were treated with antibiotics alone because of either technically impossible percutaneous drainage (n = 15) or surgeon preference (n = 17) while 114 underwent percutaneous drainage. Failure of initial treatment required urgent surgery in 8 patients with persistent symptoms during treatment with antibiotics alone (25 %) and in 21 patients (18 %) after initial percutaneous drainage (p = 0.21). Reasons for urgent surgery after percutaneous drainage were persistent symptoms (n = 16), technical failure of percutaneous drainage (n = 4) and small bowel injury (n = 1). Patients treated with antibiotics had a significantly smaller abscess diameter (5.9 vs. 7.1 cm, p = 0.001) and shorter interval from initial treatment to sigmoidectomy (mean 50 vs. 80 days, p = 0.02). The Charlson comorbidity index, initial treatment failure rates, postoperative mortality, overall morbidity, length of hospital stay during treatments, and overall and permanent stoma rates were comparable in the two groups. Postoperative complications following antibiotics alone were significantly less severe than after percutaneous drainage based on the Clavien-Dindo classification (p = 0.04). CONCLUSIONS: Selected patients with diverticular abscess can be initially treated with antibiotics without adverse consequences on their outcomes.

The minimally invasive approach is associated with reduced surgical site infections in obese patients undergoing proctectomy.

BACKGROUND: While laparoscopic colorectal resection may be underused in technically challenging circumstances, the minimally invasive approach may in fact maximally benefit patients at the greatest risk of complications. Obesity and proctectomy pose particular technical challenges during laparoscopic resection and are also associated with the greatest risks of complications, especially surgical site infections (SSIs). We evaluated the role of laparoscopy in minimizing SSI in such patients. METHODS: From the American College of Surgeons-National Surgical Quality Improvement Program database, outcomes for obese [body mass index (BMI) ≥ 30 kg/m(2)] and non-obese (BMI < 30 kg/m(2)) patients undergoing colectomy or proctectomy between 2006 and 2011 by the laparoscopic (laparoscopic colectomy, laparoscopic proctectomy) or open (open colectomy, open proctectomy) approaches were compared. A univariate analysis was used to determine the influence of laparoscopic surgery within each group on SSI, and a multivariate analysis evaluated the influence of laparoscopy on SSI for obese patients undergoing proctectomy. RESULTS: OC patients were more likely than OP, LC, and LP, respectively, to undergo emergency operation and have an American Society of Anesthesiologists (ASA) score of 3-5. Overall SSI rates after OC, OP, LC, and LP were 15.2, 17.6, 8.6, and 10.1 %, respectively (p < 0.001), and for obese patients, the rates were 18.7, 22.3, 10.7, and 13.3 % (p < 0.001). On univariate analysis, open surgery, obesity, proctectomy, younger age, race, steroid use, diabetes, chronic obstructive pulmonary disease, prior wound infection, transfusion history, previous operation within 30 days, coronary artery or vascular disease, ASA class 3-5, tobacco use, resident involvement, male gender, albumin <3.5 g/dL, and emergent operation were associated with a higher risk of SSI. Laparoscopy reduced the risk of SSI by at least 35 % across all BMI classes and procedures, an effect that persisted on multivariate analysis even in obese patients undergoing proctectomy. CONCLUSIONS: In colorectal surgery, an already high-risk outlier for SSI, obesity and proctectomy are associated with the highest risk of SSI. Despite the particular technical challenges of laparoscopy in these circumstances, the minimally invasive approach attenuates the risk of SSI in these high-risk patients and thus should be strongly considered during treatment planning.

The impact of mesenteric tension on pouch outcome and quality of life in patients undergoing restorative proctocolectomy.

AIM: The study aimed to establish a method for the measurement of mesenteric tension after ileal pouch-anal anastomosis (IPAA) and to evaluate the impact of tension on clinical outcome and quality of life. METHODS: All consecutive patients undergoing an open IPAA from July 2008 to October 2009 were prospectively enrolled. After the creation of the anastomosis, mesenteric tension was estimated by the surgeon in the operating room on a 10-point scale (1, least tension; 10, most tension). The association was analysed between mesenteric tension defined as low (1-2), medium (3-7) and high (8-10) and postoperative complications and quality of life (Cleveland Clinic Global Scale). RESULTS: A mesenteric tension score was obtained in 134 patients (71 men, 53.0%). Median age was 38.5 (29.3-47.0) years. Fifty-six patients (41.8%) had a low, 59 (44.0%) a medium and 19 (14.2%) a high degree of mesenteric tension. Patients with a high mesenteric tension had a shorter anal transitional zone, a longer distance from the upper border of the symphysis pubis to the apex of the small bowel loop designated for the ileoanal anastomosis, a thinner abdominal wall at the stoma site and a longer distance from the pouch to the ileostomy. The proportion of patients with high mesenteric tension was less after stapled anastomosis. On long-term follow-up, patients with high mesenteric tension were more likely to suffer from anastomotic stricture and pouch failure. Pouch function was not influenced by mesenteric tension. CONCLUSION: High mesenteric tension after IPAA is adversely associated with postoperative complications and pouch survival.

Venous thromboembolism in colorectal surgery: skip SCIP or comply?

BACKGROUND: The Surgical Care Improvement Project (SCIP) includes recommendations for mechanical and pharmacologic venous thromboembolism (VTE) prophylaxis after colorectal surgery. Compliance with these recommendations is publicly reported and included in current pay for performance plans. Presently, there is limited evidence to support compliance with these recommendations. AIM: To determine the incidence of venous thromboembolic events in colorectal surgery patients who did or did not receive the recommended pharmacologic prophylaxis. METHODS: We performed a retrospective analysis of prospectively accrued data from a single-center, tertiary care, colorectal surgery department. The main outcome measure was the occurrence of venous thromboembolic events and the need for blood transfusion after surgery. RESULTS: Of 674 patients, 613(91%) received the recommended pharmacologic VTE prophylaxis and 61 (9%) did not. Diagnosis, patient variables, and type of surgery performed were similar in each group while operative time was increased in the compliant group (251 vs. 194 min, p < 0.05). In the compliant and noncompliant groups, the incidence of extremity deep venous thrombosis was 2.8 and 8.2% (p = 0.04), the incidence of pulmonary embolus 1.1 and 3.3% (p = 0.19), the incidence of portomesenteric venous thrombosis 2.6 and 4.9% (p = 0.38), and the incidence of any VTE 5.4 and 13.1% (p = 0.02), respectively. The use of perioperative red blood cell transfusions in the two groups was 9.1 and 14.8%, p = 0.17. In the subgroup analysis of open cases, there were no statistical differences in the occurrence of any type or combination of VTE. CONCLUSIONS: Compliance with SCIP recommendations for pharmacologic VTE prophylaxis decreased the incidence of VTE after colorectal surgery with no increase in the use of perioperative transfusion. Colorectal surgeons who elect to skip these recommendations may jeopardize both the reputational score and financial reimbursement of their hospital and may put their patients at unnecessary risk for a preventable postoperative complication.

Establishing the optimum lymph node yield for diagnosis of stage III rectal cancer.

BACKGROUND: The optimum lymph node yield for tumour staging following surgery for rectal cancer remains controversial. This study aimed to determine the optimum number of lymph nodes needed to accurately determine stage III rectal cancer. METHODS: Sixty-three thousand three hundred and eighty-one patients from the surveillance, epidemiology and end resulted database, who underwent surgery for rectal adenocarcinoma in 1995-2009, were included. The primary outcome was detection of stage III rectal cancer, assessed by multivariable logistic regression. RESULTS: Each additional node examined increased the chance of stage III diagnosis by 3.9% (adjusted odds ratio 1.039, p < 0.001). Optimum histopathological stage was reached following retrieval of 18 nodes in patients treated without neoadjuvant radiotherapy (n = 49,162) and 16 nodes in those treated with neoadjuvant radiotherapy (n = 14,219). For stage I and II cancer, retrieval of a minimum of 8 and 14 nodes, respectively, was associated with optimum five-year overall survival. For stage III cancer, increasing number of positive lymph nodes and increasing lymph node ratio (>0.5) were independent negative predictors of survival; total lymph node yield did not correlate with survival. CONCLUSIONS: Eighteen lymph nodes for those treated without neoadjuvant radiotherapy and 16 nodes for those treated with it were needed to prevent stage migration in rectal cancer. These findings provide further evidence of the importance of the technique of proctectomy and of careful pathologic assessment.

Results from an American Society of Colon and Rectal Surgeons survey on the management of young-onset colorectal cancer.

BACKGROUND: Young patients with colorectal cancer (CRC) present a diagnostic and clinical challenge. The aim of our study was to survey the approaches to preoperative evaluation and clinical management of young patients with CRC by colorectal surgeons in North America. METHODS: A standard electronic survey was sent to the members of the American Society of Colon and Rectal Surgeons. The survey polled management decisions in various clinical scenarios for CRC patients less than 50 years old. Survey responses were collated and analyzed. RESULTS: One hundred ninety surgeons responded and 140 completed the entire survey (response rate 10%). Eighty percent of surgeons would offer preoperative genetic testing if the patient's family met the Amsterdam criteria compared to only 67% if the criteria were not met. Of those offering preoperative tumor testing, 48% test microsatellite instability, 19% mismatch repair protein expression by immunohistochemistry, and 24% offer both. Decisions regarding the extent of the resection for cancer were dependent on family history: Most members (86%) would perform a segmental colectomy for CRC in a patient without family history. Eighty-four percent of respondents would offer a total abdominal colectomy if preoperative tests indicated Lynch syndrome. When questioned about MYH-associated polyposis, only 27% recognized the appropriate diagnosis. CONCLUSIONS: Among the American Society of Colon and Rectal Surgeons, family history influences preoperative testing and surgical management decisions. A significant portion of surgeons do not offer preoperative genetic testing, despite implications on operative management, postoperative surveillance, and screening of family members.