An endoscopic mucosal grading system is predictive of leak in stapled rectal anastomoses.

BACKGROUND: Anastomotic leak is a devastating postoperative complication following rectal anastomoses associated with significant clinical and oncological implications. As a result, there is a need for novel intraoperative methods that will help predict anastomotic leak. METHODS: From 2011 to 2014, patient undergoing rectal anastomoses by colorectal surgeons at our institution underwent prospective application of intraoperative flexible endoscopy with mucosal grading. Retrospective review of patient medical records was performed. After creation of the colorectal anastomosis, application of a three-tier endoscopic mucosal grading system occurred. Grade 1 was defined as circumferentially normal appearing peri-anastomotic mucosa. Grade 2 was defined as ischemia or congestion involving <30% of either the colon or rectal mucosa. Grade 3 was defined as ischemia or congestion involving >30% of the colon or rectal mucosa or ischemia/congestion involving both sides of the staple line. RESULTS: From 2011 to 2014, a total of 106 patients were reviewed. Grade 1 anastomoses were created in 92 (86.7%) patients and Grade 2 anastomoses were created in 10 (9.4%) patients. All 4 (3.8%) Grade 3 patients underwent immediate intraoperative anastomosis takedown and re-creation, with subsequent re-classification as Grade 1. Demographic and comorbidity data were similar between Grade 1 and Grade 2 patients. Anastomotic leak rate for the entire cohort was 12.2%. Grade 1 patients demonstrated a leak rate of 9.4% (9/96) and Grade 2 patients demonstrated a leak rate of 40% (4/10). Multivariate logistic regression associated Grade 2 classification with an increased risk of anastomotic leak (OR 4.09, 95% CI 1.21-13.63, P = 0.023). CONCLUSION: Endoscopic mucosal grading is a feasible intraoperative technique that has a role following creation of a rectal anastomosis. Identification of a Grade 2 or Grade 3 anastomosis should provoke strong consideration for immediate intraoperative revision.

Respiratory complications after colonic procedures in chronic obstructive pulmonary disease: does laparoscopy offer a benefit?

BACKGROUND: Patients with severe chronic obstructive pulmonary disease (COPD) are at a higher risk for postoperative respiratory complications. Despite the benefits of a minimally invasive approach, laparoscopic pneumoperitoneum can substantially reduce functional residual capacity and raise alveolar dead space, potentially increasing the risk of respiratory failure which may be poorly tolerated by COPD patients. This raises controversy as to whether open techniques should be preferentially employed in this population. METHODS: The American College of Surgeons National Surgical Quality Improvement Program (NSQIP) database from 2011 to 2014 was used to examine the clinical data from patients with COPD who electively underwent laparoscopic and open colectomy. Patients defined as having COPD demonstrated either functional disability, chronic use of bronchodilators, prior COPD-related hospitalization, or reduced forced expiratory reserve volumes on lung testing (FEV1 <75%). Demographic data and preoperative characteristics were compared. Linear and logistic regressions were utilized to perform multivariate analysis and determine risk-adjusted outcomes. RESULTS: Of the 4397 patients with COPD, 53.8% underwent laparoscopic colectomy (LC) while 46.2% underwent open colectomy (OC). The LC and OC groups were similar with respect to demographic data and preoperative comorbidities. Equivalent frequencies of exertional dyspnea (LC 35.4 vs OC 37.7%, P = 0.11) were noted. After multivariate risk adjustment, OC demonstrated an increased rate of overall respiratory complications including pneumonia, reintubation, and prolonged ventilator dependency when compared to LC (OR 1.60, 95% CI 1.30-1.98, P < 0.01). OC was associated with longer length of stay (10 ± 8 vs. 6.7 ± 7 days, P < 0.01) and higher readmission (OR 1.36, 95% CI 1.09-1.68, P < 0.01) compared to LC. CONCLUSION: Despite the potential risks of laparoscopic pneumoperitoneum in the susceptible COPD population, a minimally invasive approach was associated with lower risk of postoperative respiratory complications, shorter length of stay, and decrease in postoperative morbidity.

Defining the Role of Minimally Invasive Proctectomy for Locally Advanced Rectal Adenocarcinoma.

OBJECTIVE: National examination of open proctectomy (OP), laparoscopic proctectomy (LP), and robotic proctectomy (RP) in pathological outcomes and overall survival (OS). BACKGROUND: Surgical management for rectal adenocarcinoma is evolving towards utilization of LP and RP. However, the oncological impacts of a minimally invasive approach to rectal cancer have yet to be defined. METHODS: Retrospective review of the National Cancer Database identified patients with nonmetastatic locally advanced rectal adenocarcinoma from 2010 to 2014, who underwent neoadjuvant chemoradiation, surgical resection, and adjuvant therapy. Cases were stratified by surgical approach. Multivariate analysis was used to compare pathological outcomes. Cox proportional-hazard modeling and Kaplan-Meier analyses were used to estimate long-term OS. RESULTS: Of 6313 cases identified, 53.8% underwent OP, 31.8% underwent LP, and 14.3% underwent RP. Higher-volume academic/research and comprehensive community centers combined to perform 80% of laparoscopic cases and 83% of robotic cases. In an intent-to-treat model, multivariate analysis demonstrated superior circumferential margin negativity rates with LP compared with OP (odds ratio 1.34, 95% confidence interval 1.02-1.77, P = 0.036). Cox proportional-hazard modeling demonstrated a lower death hazard ratio for LP compared with OP (hazard ratio 0.81, 95% confidence interval 0.67-0.99, P = 0.037). Kaplan-Meier analysis demonstrated a 5-year OS of 81% in LP compared with 78% in RP and 76% in OP (P = 0.0198). CONCLUSION: In the hands of experienced colorectal specialists treating selected patients, LP may be a valuable operative technique that is associated with oncological benefits. Further exploration of pathological outcomes and long-term survival by means of prospective randomized trials may offer more definitive conclusions regarding comparisons of open and minimally invasive technique.

Incidence, Risk Factors, and Trends of Motor Peripheral Nerve Injury After Colorectal Surgery: Analysis of the National Surgical Quality Improvement Program Database.

BACKGROUND: Motor peripheral nerve injury is a rare but serious event after colorectal surgery, and a nationwide study of this complication is lacking. OBJECTIVE: The purpose of this study was to report the incidence, trends, and risk factors of motor peripheral nerve injury during colorectal surgery. DESIGN: The National Surgical Quality Improvement Program database was surveyed for motor peripheral nerve injury complicating colorectal procedures. Risk factors for this complication were identified using logistic regression analysis. SETTINGS: The study used a national database. PATIENTS: Patients undergoing colorectal resection between 2005 and 2013 were included. MAIN OUTCOME MEASURES: The incidence, trends, and risk factors for motor peripheral nerve injury complicating colorectal procedures were measured. RESULTS: We identified 186,936 colorectal cases, of which 50,470 (27%) were performed laparoscopically. Motor peripheral nerve injury occurred in 122 patients (0.065%). Injury rates declined over the study period, from 0.025% in 2006 to <0.010% in 2013 (p < 0.001). Patients with motor peripheral nerve injury were younger (mean ± SD; 54.02 ± 15.41 y vs 61.56 ± 15.95 y; p < 0.001), more likely to be obese (BMI ≥30; 43% vs 31%; p = 0.003), and more likely to have received radiotherapy (12.3% vs 4.7%; p < 0.001). Nerve injury was also associated with longer operative times (277.16 ± 169.79 min vs 176.69 ± 104.80 min; p < 0.001) and was less likely to be associated with laparoscopy (p = 0.043). Multivariate analysis revealed that increasing operative time was associated with nerve injury (OR = 1.04 (95% CI, 1.03-1.04)), whereas increasing age was associated with a protective effect (OR = 0.80 (95% CI, 0.71-0.90)). LIMITATIONS: This study was limited by its retrospective nature. CONCLUSIONS: Motor peripheral nerve injury during colorectal procedures is uncommon (0.065%), and its rate declined significantly over the study period. Prolonged operative time is the strongest predictor of motor peripheral nerve injury during colorectal procedures. Instituting and documenting measures to prevent nerve injury is imperative; however, special attention to this complication is necessary when surgeons contemplate long colorectal procedures.

Laparoscopic right hemicolectomy: short- and long-term outcomes of intracorporeal versus extracorporeal anastomosis.

BACKGROUND: The use of laparoscopy for right hemicolectomy has gained popularity allowing the option of a totally laparoscopic intracorporeal anastomosis (IA) for intestinal reconstruction. This technique may alleviate some of the technical limitations that a surgeon faces with a laparoscopic-assisted extracorporeal anastomosis (EA). METHODS: A retrospective chart review of 195 consecutive patients who underwent laparoscopic right hemicolectomy by four colorectal surgeons at three institutions from March 2005 to June 2014 was performed. Multivariate regression analysis was used to compare postoperative and oncologic outcomes. RESULTS: A total of 195 patients underwent laparoscopic right hemicolectomy over the study period, with 86 (44 %) patients receiving IA and 109 (56 %) patients receiving an EA. The most common indication for surgery in both groups was cancer: 56 (65 %) of IA cases and 57 (52 %) of EA cases. IA had a significantly higher rate of minor complications but no difference in serious complications compared to EA. Conversion to open resection was higher in EA. Using multivariate analysis to compare IA versus EA, there was no significant difference in length of stay, return of bowel function, risk of anastomotic leak, risk of intraabdominal abscess or risk of wound complications. Amongst cancer resections, there was no significant difference in the median number of lymph nodes harvested (18 LNs in IA group vs. 19 LNs in EA group, P > 0.05). There was also no significant difference in overall survival and disease-free survival at 5.7 years between the two groups. CONCLUSIONS: IA in laparoscopic right hemicolectomy is associated with similar postoperative and oncologic outcomes compared to EA. IA may possess advantages in terms of conversion and flexibility of specimen extraction, but this is counterbalanced by a higher incidence of minor complications. These findings suggest that IA represents a valid technique in the arsenal of the experienced colorectal surgeon without compromising outcomes.

The use of indocyanine green fluorescence to assess anastomotic perfusion during robotic assisted laparoscopic rectal surgery.

BACKGROUND: Decreased blood perfusion at an intestinal anastomosis may contribute to postoperative anastomotic leak (AL) resulting in substantial morbidity and mortality. Near-infrared (NIR) laparoscopy in conjunction with indocyanine green (ICG) allows for visualization of the microcirculation before formation of the anastomosis, thereby allowing the surgeon to choose the point of transection at an optimally perfused area. METHODS: This is a retrospective case-control analysis examining the effectiveness of NIR + ICG in reducing the rate of AL after low anterior resection (LAR) for rectal cancer. Records of patients undergoing robot-assisted LAR for rectal cancer with and without ICG were analyzed for the years 2011 and 2012. RESULTS: Among the 40 patients who underwent robotic LAR, NIR + ICG was used in 16 cases (41 %). Male patients accounted for the majority of cases in both groups (74 %). The median level of the anastomosis was 3.5 cm in the NIR + ICG group and 5.5 cm in the control group. There was no difference in the use of diverting ileostomy. In 3 patients (19 %), the use of NIR + ICG resulted in revision of the proximal bowel (colonic) transection point before formation of the anastomosis. The distal transection point was never revised. The rate of AL in the NIR + ICG group was 6 % versus 18 % in control group. CONCLUSIONS: ICG fluorescence may play a role in anastomotic tissue perfusion assessment and affect the AL rate. Larger prospective studies are needed to further validate this novel technology.

Timing of radiation therapy, lymph node retrieval, and survival in rectal cancer.

BACKGROUND: Lymph node retrieval is an independent prognostic factor for survival in rectal cancer. Preoperative radiotherapy has been shown to impact the number of lymph nodes retrieved. OBJECTIVE: This study aimed to analyze colorectal cancer-specific mortality and overall mortality associated with the number of lymph nodes retrieved in relation to use and timing of radiotherapy. DESIGN: This study was designed as a retrospective analysis. SETTINGS: Analysis of the California Cancer Registry was conducted. PATIENTS: Patients with rectal cancer from 1994 to 2006 with a follow-up until January 2008 were included. MAIN OUTCOME MEASURES: The number of lymph nodes (1-3, 4-6, 7-11, ≥ 12) stratified by stage (I, II, and III) was analyzed based on radiotherapy status (no radiotherapy, preoperative radiotherapy, and postoperative radiotherapy). Multivariate colorectal cancer-specific survival and overall mortality analyses were performed using Cox proportional-hazard ratios. RESULTS: A total of 17,670 incident cases of stage I, II, and III rectal cancer were identified. The number of lymph nodes retrieved in cases receiving preoperative radiotherapy was lower than others. In stage II cases receiving preoperative radiotherapy, retrieval of 7 to 11 lymph nodes (compared with 0 lymph nodes retrieved as a reference) reached the nadir of colorectal cancer-specific mortality benefit (HR = 0.39, 95% CI, 0.28-0.56) and overall mortality (HR = 0.62, 95% CI, 0.48-0.80). In stage II cases with no radiotherapy or postoperative radiotherapy, retrieval of ≥ 12 lymph nodes remained the strongest prognosticator of colorectal cancer-specific mortality (HR = 0.34, 95% CI, 0.25-0.46; HR = 0.36, 95% CI, 0.24-0.53 respectively). LIMITATIONS: : The California Cancer Registry does not include radiation dose and duration, chemotherapy type and dosage, margin status and surgeon characteristics, and stated reasons for lower number of lymph nodes retrieved or patient-related factors. In addition, no central pathology laboratory was used. CONCLUSIONS: In stage II rectal cancer cases receiving preoperative radiotherapy vs either postoperative or no radiotherapy, a lower threshold of lymph node retrieval may be sufficient to evaluate prognosis and to guide further therapy.

Evaluation of Pelvic Anastomosis by Endoscopic and Contrast Studies Prior to Ileostomy Closure: Are Both Necessary? A Single Institution Review.

Contrast enema is the gold standard technique for evaluating a pelvic anastomosis (PA) prior to ileostomy closure. With the increasing use of flexible endoscopic modalities, the need for contrast studies may be unnecessary. The objective of this study is to compare flexible endoscopy and contrast studies for anastomotic inspection prior to defunctioning stoma reversal. Patients with a protected PA undergoing ileostomy closure between July 2014 and June 2019 at our institution were retrospectively identified. Demographics and clinical outcomes in patients undergoing preoperative evaluation with endoscopic and/or contrast studies were analyzed. We identified 207 patients undergoing ileostomy closure. According to surgeon's preference, 91 patients underwent only flexible endoscopy (FE) and 100 patients underwent both endoscopic and contrast evaluation (FE + CE) prior to reversal. There was no significant difference in pelvic anastomotic leak (2.2% vs. 1%), anastomotic stricture (1.1% vs. 6%), pelvic abscess (2.2% vs. 3.0%), or postoperative anastomotic complications (4.4% vs. 9%) between groups FE and FE + CE (P > .05). Flexible endoscopy alone appears to be an acceptable technique for anastomotic evaluation prior to ileostomy closure. Further studies are needed to determine the effectiveness of different diagnostic modalities for pelvic anastomotic inspection.

Ileocolic Resection for Crohn's Disease: A Minimally Invasive Approach Claims Its Place.

Ileocolic resection is the most common operation performed for Crohn's disease patients with terminal ileum involvement. We sought to evaluate the outcomes in Crohn's disease patients who underwent open ileocolic resection (OIC) and laparoscopic ileocolic resection (LIC) by using the ACS-NSQIP database from 2006 to 2015. Of 5670 patients, 48.3 per cent (2737) patients had OIC and 51.7 per cent (2933) had LIC. The number of LIC increased from 40 per cent in 2006 to 60.7 per cent in 2015. Moreover, the annual number of LIC surgeries has exceeded the number of OIC surgeries since 2013. Patients in the LIC group had shorter hospital length of stay compared with OIC group (6 ± 5 days vs 8.6 ± 8 days, P < 0.01). The LIC procedure also had shorter operation time compared with OIC (148 ± 58 vs 153 ± 76 minutes, P = 0.01). Overall morbidity (15.8% vs 25.3%, AOR: 0.54, confidence interval (CI): 0.46-0.62, P < 0.01), serious morbidity (10.9% vs 18%, AOR: 0.55, CI: 0.46-0.65, P < 0.01), and SSI (9.9% vs 15.5%, AOR: 0.59, CI: 0.49-0.70, P < 0.01) rates were lower in the LIC group than the OIC group. We demonstrated that in Crohn's disease patients, LIC has improved outcomes for ileocolic resection compared with OIC and has been chosen as the preferential treatment approach for most patients.

Randomized Clinical Trial of Epidural Compared with Conventional Analgesia after Minimally Invasive Colorectal Surgery.

BACKGROUND: The effectiveness of thoracic epidural analgesia (EA) vs conventional IV analgesia (IA) after minimally invasive surgery is still unproven. We designed a randomized controlled trial comparing EA with IA after minimally invasive colorectal surgery. STUDY DESIGN: A total of 87 patients who underwent minimally invasive colorectal procedures at a single institution between 2011 and 2014 were enrolled. Eight patients were excluded and 38 were randomized to EA and 41 to IA. Pain was assessed with the Visual Analogue Scale and quality of life with the Overall Benefit of Analgesia Score daily until discharge. RESULTS: Mean age was 57 ± 14 years, 43% of patients were female, and mean BMI was 28.6 ± 6 kg/m2. The 2 groups were similar in demographic characteristics and distribution of diagnoses and procedures. Epidural analgesia had a higher incidence of hypotensive systolic blood pressure (<90 mmHg) episodes (9 vs 2; p < 0.05) and a trend toward longer Foley catheter duration (3 ± 2 days vs 2 ± 4 days; p > 0.05). Epidural and IA had equivalent mean lengths of stay (4 ± 3 days vs 4 ± 3 days), daily Visual Analogue Scale scores (2.4 ± 2.0 vs 3.0 ± 2.0), and Overall Benefit of Analgesia Scores (3.2 ± 2.0 vs 3.2 ± 2.0), and similar time to start oral diet (2.8 ± 2 days vs 2.2 ± 1 days). Epidural analgesia patients used a higher total dose of narcotics (147.5 ± 192.0 mg vs 98.1 ± 112.0 mg; p > 0.05). Epidural and IV analgesia had equivalent total hospital charges ($144,991 ± $67,636 vs $141,339 ± $75,579; p > 0.05). CONCLUSIONS: This study indicates that EA has no added clinical benefit in patients undergoing minimally invasive colorectal surgery. A trend toward higher total narcotics use and complications with EA was demonstrated.

Colorectal Surgery in Patients with HIV and AIDS: Trends and Outcomes over a 10-Year Period in the USA.

BACKGROUND: HIV has become a chronic disease, which may render this population more prone to developing the colorectal pathologies that typically affect older Americans. METHODS: A retrospective review of the Nationwide Inpatient Sample was performed to identify patients who underwent colon and rectal surgery from 2001 to 2010. Multivariate analysis was used to evaluate outcomes among the general population, patients with HIV, and patients with AIDS. RESULTS: Hospital admissions for colon and rectal procedures of patients with HIV/AIDS grew at a faster rate than all-cause admissions of patients with HIV/AIDS, with mean yearly increases of 17.8 and 2.1 %, respectively (p < 0.05). Patients with HIV/AIDS undergoing colon and rectal operations for cancer, polyps, diverticular disease, and Clostridium difficile were younger than the general population (51 vs. 65 years; p < 0.01). AIDS was independently associated with increased odds of mortality (OR 2.11; 95 % CI 1.24, 3.61), wound complications (OR 1.53; 95 % CI 1.09, 2.17), and pneumonia (OR 2.02; 95 % CI 1.33, 3.08). Risk-adjusted outcomes of colorectal surgery in patients with HIV did not differ significantly from the general population. CONCLUSION: Postoperative outcomes in patients with HIV are similar to the general population, while patients with AIDS have a higher risk of mortality and certain complications.

Body Mass Index Significantly Impacts Outcomes of Colorectal Surgery.

There are limited data regarding the association between body mass index (BMI) and colorectal surgery outcomes. We sought to evaluate the effect of BMI on short-term surgical outcomes in colon and rectal surgery patients in the United States. The American College of Surgeons National Surgery Quality Improvement Project database was used to identify all patients who underwent colon or rectal resection from 2005 to 2013. Multivariate regression analysis was used to assess the independent effect of BMI on outcomes. A total of 206,360 patients underwent colorectal resection during the study period. Of these, 3.2 per cent of patients were underweight (BMI < 18.5), 23.8 per cent patients were normal weight (18.5 ≤ BMI < 25), 26.5 per cent were overweight (25 ≤ BMI < 30), 25.2 per cent were obese (30 ≤ BMI < 40), and 5.3 per cent were morbidly obese (BMI ≥ 40). Underweight patients had longer length of stay (confidence interval: 2.70-3.49, P < 0.001) and higher mortality (adjusted odds ratio: 1.45, P < 0.01) compared with patients with a normal BMI. Morbidly obese patients had the highest overall morbidity rate compared with normal BMI patients (adjusted odds ratio: 1.53, confidence interval: 1.42-1.64, P < 0.01). BMI is associated with outcomes in colon and rectal surgery patients. Underweight and morbidly obese patients have a significantly increased risk of postsurgical complications compared with those with normal BMI.

Outcomes of Bowel Resection in Patients with Crohn's Disease.

There is limited data regarding outcomes of bowel resection in patients with Crohn's disease. We sought to investigate complications of such patients after bowel resection. The Nationwide Inpatient Sample databases were used to examine the clinical data of Crohn's patients who underwent bowel resection during 2002 to 2012. Multivariate regression analysis was performed to investigate outcomes of such patients. We sampled a total of 443,950 patients admitted with the diagnosis of Crohn's disease. Of these, 20.5 per cent had bowel resection. Among patients who had bowel resection, 51 per cent had small bowel Crohn's disease, 19.4 per cent had large bowel Crohn's disease, and 29.6 per cent had both large and small bowel Crohn's disease. Patients with large bowel disease had higher mortality risk compared with small bowel disease [1.8% vs 1%, adjusted odds ratio (AOR): 2.42, P < 0.01]. Risks of postoperative renal failure (AOR: 1.56, P < 0.01) and respiratory failure (AOR: 1.77, P < 0.01) were higher in colonic disease compared with small bowel disease but postoperative enteric fistula was significantly higher in patients with small bowel Crohn's disease (AOR: 1.90, P < 0.01). Of the patients admitted with the diagnosis of Crohn's disease, 20.5 per cent underwent bowel resection during 2002 to 2012. Although colonic disease has a higher mortality risk, small bowel disease has a higher risk of postoperative fistula.

Effects of ascites on outcomes of colorectal surgery in congestive heart failure patients.

BACKGROUND: There are limited data regarding the effects of ascites on outcome of patients undergoing colorectal resection. We sought to identify complications related to ascites. METHODS: The National Surgical Quality Improvement Program database was used to evaluate congestive heart failure (CHF) patients who had ascites before colorectal resection between 2005 and 2012. Multivariate regression analysis was performed to identify affected outcomes. RESULTS: We sampled a total of 2,178 patients who suffered CHF and underwent colorectal resection, of which 195 (9%) had preoperative ascites. The mortality rate of patients who had preoperative ascites was 46.2% compared to 25.7% for patients without ascites (adjusted odd ratio [AOR], 3.38; P < .01). Complications affected by ascites include (P < .05) ventilator dependency (AOR, 2.40), acute renal failure (AOR, 2.18), and wound disruption (AOR, 2.44; P < .05). There was no increase in superficial surgical site infection rate in patients with ascites (AOR, 1.01; P = .9). CONCLUSIONS: The presence of ascites in CHF patients is associated with increased mortality in patients undergoing colorectal surgery. There is no correlation between ascites and surgical site infection but wound disruption increases in the presence of ascites.

Risk factors of postoperative myocardial infarction after colorectal surgeries.

There are limited data regarding the specific risk factors of postoperative myocardial infarction (MI) in patients undergoing colorectal resectional surgery. We sought to identify risk factors of acute MI after colorectal resection operations. The National Inpatient Sample database was used to identify patients who had postoperative MI after colorectal resection operations between 2002 and 2010. Statistical analysis was performed to identify factors predictive of postoperative MI. We sampled a total of 2,513,124 patients undergoing colorectal resection, of whom 38,317 (1.5%) sustained a postoperative MI. Patients with postoperative MI had associated 28.5 per cent in-hospital mortality. Risk factors identified include (P < 0.01): history of congestive heart failure (odds ratio [OR], 8.18), chronic renal failure (OR, 3.86), age 70 years or older (OR, 3.68), peripheral vascular disorders (OR, 2.93), fluid and electrolyte disorders (OR, 2.69), emergency admission (OR, 2.56), preoperative weight loss (OR, 2.49), cardiac valvular disease (OR, 2.46), chronic lung disease (OR, 1.75), deficiency anemia (OR, 1.22), colorectal cancer (OR, 1.77), and hypertension (OR, 1.14). Postoperative MI occurs in less than 2 per cent of colorectal resections. However, patients sustaining postoperative MI are over six times more likely to die. Congestive heart failure and chronic renal failure are the strongest predictors of postoperative MI.

Preoperative Leukocytosis in Colorectal Cancer Patients.

BACKGROUND: Preoperative asymptomatic leukocytosis has been reported as a factor that affects morbidity of surgical patients. We sought to identify the relationship between asymptomatic preoperative leukocytosis and postoperative complications in elective colorectal cancer surgery. STUDY DESIGN: The NSQIP database was used to examine the clinical data of patients who had preoperative leukocytosis (white blood cell count more than 11,000/µL) and colorectal cancer resection from 2005 to 2013. Patients with preoperative sepsis, recent steroid use, disseminated cancer, renal failure, pneumonia, and emergently admitted patients were excluded from the study. Multivariate regression analysis was performed to identify outcomes of preoperative leukocytosis. RESULTS: We evaluated a total of 59,805 patients with a diagnosis of colorectal cancer who underwent colorectal resection. The rate of preoperative asymptomatic leukocytosis was 5.6%. Asymptomatic leukocytosis was associated with preoperative serum albumin level (adjusted odds ratio [AOR] 0.58, p < 0.01) and blood urea nitrogen/creatinine ratio (AOR 1.01, p < 0.01). Preoperative asymptomatic leukocytosis had significant associations with increased mortality (AOR 1.76, p < 0.01) and morbidity of patients (AOR 1.26, p < 0.01). Postsurgical complications that had the strongest associations with asymptomatic leukocytosis were cardiac arrest (AOR 1.78, p = 0.03) and unplanned intubation (AOR 1.61, p < 0.01). Also, infectious complications were significantly higher in patients with leukocytosis (AOR 1.18, p = 0.01). CONCLUSIONS: Preoperative asymptomatic leukocytosis has a prevalence of 5.6% in colorectal cancer resections and carries a significant increased risk of mortality and morbidity. Asymptomatic leukocytosis is associated with preoperative dehydration and malnutrition. Further studies are indicated to validate and explain these findings.

Predictive Factors of Ventilator Dependency after Colon and Rectal Surgery.

There is limited data analyzing ventilator dependency by operative diagnoses and types of the procedures performed in colorectal surgery. We sought to identify predictive factors of ventilator dependency in colorectal surgery and investigate complication rates across various colorectal procedures. The National Surgical Quality Improvement Program database was used to examine the clinical data of patients with ventilator dependency for more than 48 hours after colorectal resection during 2005-2013. Multivariate regression analysis was performed to identify predictors of ventilator dependency. A total of 219,716 patients who underwent colorectal resection were identified. The rate of ventilator dependency was 3.9 per cent. The rate varied significantly based on patient diagnosis; with the highest rate seen in patients with acute mesenteric ischemia (25.9%). The highest risk of ventilator dependency according to the patients indication of surgery, type of the procedure, and preoperative factors exist in lower gastrointestinal bleeding [adjusted odds ratio (AOR): 77.44, P < 0.01], total colectomy (AOR: 1.58, P = 0.04), and American Society of Anesthesiologists classification of three or greater (AOR: 2.52, P < 0.01). Also, serum albumin level (AOR: 0.67, P < 0.01) seems to be associated with ventilator dependency. The overall rate of ventilator dependency is 3.9 per cent in colorectal surgery. However, depending on the indication for surgery, rates can be as high as 25.9 per cent. American Society of Anesthesiologist score can predict the risk of postoperative ventilator dependency in patients undergoing colorectal surgery. Serum albumin level is reversely associated with postoperative ventilator dependency.

Early Outcome of Treatment of Chronic Mesenteric Ischemia.

There are limited data regarding long-term outcomes of chronic mesenteric ischemia (CMI) of the intestine. We sought to identify treatment outcomes of CMI. The NIS database was used to identify patients admitted for the diagnosis of CMI between 2002 and 2012. Multivariate analysis using logistic regression was performed to quantify outcomes of CMI. A total of 160,889 patients were admitted for chronic vascular insufficiency of intestine; of which 7,906 patients underwent surgical/endovascular treatment for CMI. Among patients who underwent surgery 62 per cent had endovascular treatment and 38 per cent had open vascular treatment. Need of open surgery (adjusted odds ratio (AOR): 5.13, P < 0.01) and age ≥70 years (AOR: 3.41, P < 0.01) had strong associations with mortality of patients. Open vascular treatment has higher mortality (AOR: 5.07, P < 0.01) and morbidity (AOR: 2.14, P < 0.01). However, endovascular treatment had higher risk of postoperative wound hematoma (AOR: 2.81, P < 0.01). Most patients admitted for CMI are treated with endovascular treatment. Endovascular treatment has the advantage of lower mortality and morbidity. Need to open surgery and age ≥70 years have strong associations with mortality of patients.

Impact of chronic steroid use on outcomes of colorectal surgery.

BACKGROUND: Steroid use has been recognized as a factor which has various effects on multiple organs. We aim to investigate the association between chronic steroid use and postoperative complications after colorectal surgery. METHODS: The National Surgical Quality Improvement Program database was used to examine the clinical data of patients undergoing colorectal resection during 2005 to 2013. Multivariate regression analysis was performed to investigate outcomes of patients with chronic steroid use. RESULTS: We sampled a total of 147,121 patients who underwent colorectal resection. Of these, 11,195 (7.6%) had a history of chronic steroid use. Patients who had chronic steroid use had a higher risk of preoperative sepsis (adjusted odds ratio [AOR]: 1.41, P < .01), hypoalbuminemia (AOR: 1.49, P < .01), bleeding disorders (AOR: 1.54, P < .01), and diabetes (AOR: 1.11, P = .01). Chronic steroid use was associated with a significant increase in the mortality and morbidity of patients (AOR: 1.56 and 1.25, respectively, P < .01). CONCLUSIONS: Patients with a chronic steroid use have a high risk of preoperative malnutrition, diabetes, bleeding disorders, and sepsis. A history of chronic steroid use was associated with a significant increase in the mortality and morbidity of patients.