Uptake of Total Mesorectal Excision and Total Mesorectal Excision Grading for Rectal Cancer: A Statewide Study.

BACKGROUND: Total mesorectal excision is associated with decreased local recurrence and improved disease-free survival following rectal cancer resection. The extent to which total mesorectal excision has been adopted in the United States is unknown. OBJECTIVE: We sought to assess trends in total mesorectal excision performance and grading in Michigan hospitals. DESIGN: This is a retrospective cohort study from the Michigan Surgical Quality Collaborative. Trends in total mesorectal excision performance and grade assignment were analyzed by using χ tests and linear regression. SETTINGS: Participating hospitals (initially 14 hospitals, now 38) abstracted medical records data for rectal cancer cases from 2007 to 2016. PATIENTS: Patients who underwent rectal cancer resection were included. MAIN OUTCOME MEASURE: The main outcome measures were surgeon-documented total mesorectal excision performance and pathologist-reported total mesorectal excision grade. RESULTS: Of 510 rectal cancer cases, 367 (72.0%) had surgeon-reported total mesorectal excision performance and 78 (15.3%) had pathologist-reported total mesorectal excision grade. Between-hospital variability in total mesorectal excision performance ranged from 0% to 97% and total mesorectal excision grading ranged from 0% to 90%. Total mesorectal excision grading was associated with a higher likelihood of also having adequate lymph node assessment (88.5% versus 71.9%, p = 0.002). There has been a statistically significant trend toward an increase in total mesorectal excision grading in the original 14 hospitals (p = 0.001), but not in the complete cohort of all hospitals (p = 0.057). LIMITATIONS: This is a retrospective cohort design with sampled rectal cancer cases. In addition, there is insufficient granularity to capture all factors associated with total mesorectal excision performance or grade assignment. CONCLUSIONS: The rates of total mesorectal excision performance and grade assignment are widely variable throughout the state of Michigan. Overall, grade assignment remains very low. This suggests an opportunity for quality improvement projects to increase total mesorectal excision performance and grading, involving both the surgeons and pathologists for effective implementation. See Video Abstract at http://links.lww.com/DCR/B53. IMPLEMENTACIÓN DE LA ESCISIÓN MESORRECTAL TOTAL Y LA CLASIFICACIÓN POR ESCISIÓN MESORRECTAL TOTAL PARA EL CÁNCER RECTAL: UN ESTUDIO A NIVEL ESTATAL.: La escisión mesorrectal total se asocia con una menor recurrencia local y una mejor supervivencia libre de enfermedad después de la resección del cáncer rectal. Se desconoce hasta que punto se ha adoptado la escisión mesorrectal total en los Estados Unidos.Se intento evaluar las tendencias en el rendimiento y la clasificación de la escisión mesorrectal total en los hospitales de Michigan.Este es un estudio de cohorte retrospectivo de la "Michigan Surgical Quality Collaborative". Las tendencias en el rendimiento de la escisión mesorrectal total y la asignación de grado se analizaron mediante pruebas de chi-cuadrada y regresión lineal.Los hospitales participantes (inicialmente 14 hospitales, ahora 38) extrajeron datos de registros médicos de los casos de cáncer rectal desde 2007 hasta 2016.Pacientes que se sometieron a resección de cáncer rectal.Las principales medidas de resultado fueron el rendimiento de la escisión mesorrectal total documentado por el cirujano y el grado de escisión mesorrectal total informada por el patólogo.De 510 casos de cáncer rectal, 367 (72.0%) tenían un rendimiento de escisión mesorrectal total reportado por el cirujano y 78 (15.3%) tenían un grado de escisión mesorrectal total reportado por el patólogo. La variabilidad entre hospitales en el rendimiento de la escisión mesorrectal total varió del 0 al 97% y la clasificación de la escisión mesorrectal total varió del 0 al 90%. La clasificación de la escisión mesorrectal total se asoció con una mayor probabilidad de tener también una evaluación adecuada de los ganglios linfáticos (88.5% versus 71.9%, p = 0.002). Ha habido una tendencia estadísticamente significativa hacia un aumento en la clasificación de la escisión mesorrectal total en los 14 hospitales originales (p = 0.001), pero no en la cohorte completa de todos los hospitales (p = 0.057).Diseño de cohorte retrospectivo con casos de cáncer rectal muestreados. Además, no hay suficiente granularidad para capturar todos los factores asociados con el rendimiento de la escisión mesorrectal total o la asignación de grados.Las tasas de rendimiento de escisión mesorrectal total y asignación de grado son muy variables en todo el estado de Michigan. En general, la asignación de calificaciones sigue siendo muy baja. Esto sugiere una oportunidad para que los proyectos de mejora de la calidad aumenten el rendimiento y la clasificación de la escisión mesorrectal total, involucrando tanto a los cirujanos como a los patólogos para una implementación efectiva. Vea el resumen del video en http://links.lww.com/DCR/B53.

High-definition colonoscopy increases adenoma detection rate.

BACKGROUND: The adenoma detection rate (ADR) is a quality indicator for colonoscopy. High-definition (HD) imaging has been reported to increase polyp detection rates. OBJECTIVE: The primary objective of this study was to compare polyp detection rate (PDR) and adenoma detection rate (ADR) before and after the implementation of HD colonoscopy. METHODS: A retrospective chart review was performed on patients aged 48-55 years old, who underwent first-time screening colonoscopy. The first group underwent standard-definition (SD) colonoscopy in the first 6 months of 2011. The second group underwent screening with HD colonoscopy during the first 6 months of 2012. We compared age, gender, PDR, ADR, and average sizes of adenomatous polyps between gastroenterologist and colorectal surgeon and among physicians themselves. Statistical analysis was performed with Fischer's exact test and Pearson Chi-square. RESULTS: A total of 1268 patients were involved in the study (634 in each group). PDR (35.6 vs. 48.2 %, p < 0.001) and ADR (22.2 vs. 30.4 %, p = 0.02) were higher in the HD group. The average size of an adenomatous polyp was the same in the two groups (0.58 vs. 0.57, p = 0.69). However, this difference was not seen among colorectal surgeons PDR (35.7 vs. 37 %, p = 0.789), ADR (22.9 vs. 24.5 % p = 0.513), but clearly seen among gastroenterologist, PDR (35.6 vs. 53.1 % p < 0.001) and ADR (21.9 vs. 32.9 % p < 0.001). When polyps were categorized into size groups, there was no difference in ADR between the two timeframes (<5 mm in size (41.5 vs. 35.4 %), 5-10 mm (49.3 vs. 60.1 %) and >10 mm (9.2 vs. 4.5 %), p = 0.07). Polyps were most commonly seen in the sigmoid colon (26.1 vs. 24.7 %). There was no difference in the rate of synchronous polyp detection between modalities (25.6 vs. 29 %, p = 0.51). Withdrawal time was the same in both procedure (9.2 vs. 8.5 min, p = 0.10). CONCLUSION: Screening colonoscopy with high-definition technology significantly improved both PDR and ADR. In addition, high-definition colonoscopy may be particularly useful and advantageous among less experienced endoscopists in various community settings. However, there needs to be application to specific patient populations in future studies to assess for any statistical differences between standard- and high-definition modalities to determine clinical utility.

Risk factors for readmission after elective colectomy: postoperative complications are more important than patient and operative factors.

BACKGROUND: Colon resections are associated with substantial risk for morbidity and readmissions, and these have become markers for quality of care. OBJECTIVE: The purpose of this study was to determine risk factors for readmissions after elective colectomies to improve patient care and better understand the complex issues associated with readmissions. DESIGN: This was an analysis of the prospective, statewide, multicenter Michigan Surgical Quality Collaborative database. SETTINGS: The analysis was conducted at academic and community medical centers in the state of Michigan. PATIENTS: Elective laparoscopic and open ileocolic and segmental colectomies from 2008 through 2010 were included. MAIN OUTCOME MEASURES: Univariate analysis and a multivariate logistic regression model were used to determine influence of patient characteristics, operative factors, and postoperative complications on the incidence of 30-day postoperative readmission. RESULTS: The readmission rate among 4013 cases was 7.3% (N = 293). On the basis of multivariate logistic regression, the top 3 significant risk factors associated with readmission were stroke (OR, 10.0 [95% CI, 2.70-37.0]; p = 0.001), venous thromboembolism (OR, 6.5 [95% CI, 3.7-11.3]; p < 0.0001), and organ-space surgical site infection (OR, 5.6 [95% CI, 3.4-9.4]; p < 0.0001). Important factors that contributed to readmission risk but were not found to be independent predictors of readmission included diabetes mellitus, preoperative steroids, smoking, cardiac comorbidities, age >80 years, anastomotic leaks, fascial dehiscence, sepsis, pneumonia, unplanned intubation, and length of stay. LIMITATIONS: The Michigan Surgical Quality Collaborative is a large database, and true causal relations are difficult to determine; reason for readmission is not recorded in the database. CONCLUSIONS: Postoperative complications account for the majority of risk factors behind readmissions after elective colectomy, whereas preoperative risk factors have less direct influence. Current strategies addressing readmission rates should focus on reducing preventable complications.

Influence of intravenous opioid dose on postoperative ileus.

BACKGROUND: Intravenous opioids represent a major component in the pathophysiology of postoperative ileus (POI). However, the most appropriate measure and threshold to quantify the association between opioid dose (eg, average daily, cumulative, maximum daily) and POI remains unknown. OBJECTIVE: To evaluate the relationship between opioid dose, POI, and length of stay (LOS) and identify the opioid measure that was most strongly associated with POI. METHODS: Consecutive patients admitted to a community teaching hospital who underwent elective colorectal surgery by any technique with an enhanced-recovery protocol postoperatively were retrospectively identified. Patients were excluded if they received epidural analgesia, developed a major intraabdominal complication or medical complication, or had a prolonged workup prior to surgery. Intravenous opioid doses were quantified and converted to hydromorphone equivalents. Classification and regression tree (CART) analysis was used to determine the dosing threshold for the opioid measure most associated with POI and define high versus low use of opioids. Risk factors for POI and prolonged LOS were determined through multivariate analysis. RESULTS: The incidence of POI in 279 patients was 8.6%. CART analysis identified a maximum daily intravenous hydromorphone dose of 2 mg or more as the opioid measure most associated with POI. Multivariate analysis revealed maximum daily hydromorphone dose of 2 mg or more (p = 0.034), open surgical technique (p = 0.045), and days of intravenous narcotic therapy (p = 0.003) as significant risk factors for POI. Variables associated with increased LOS were POI (p < 0.001), maximum daily hydromorphone dose of 2 mg or more (p < 0.001), and age (p = 0.005); laparoscopy (p < 0.001) was associated with a decreased LOS. CONCLUSIONS: Intravenous opioid therapy is significantly associated with POI and prolonged LOS, particularly when the maximum hydromorphone dose per day exceeds 2 mg. Clinicians should consider alternative, nonopioid-based pain management options when this occurs.

Serum adiponectin, resistin, and circulating soluble receptor for advanced glycation end products in colectomy patients.

AIM: Surgical trauma and associated complications are frequently related to physiological stress during colectomy. This study evaluated the response of adiponectin, resistin, and circulating soluble receptor for advanced glycation end products (sRAGE) in colectomy patients with or without an enhanced recovery protocol. METHOD: Serum samples were collected from 44 colectomy patients at 3 timframes. The surgical procedures were laparoscopic (LAP), hand-assisted laparoscopic (HALS), or open colectomy (OPEN). Adiponectin, resistin, and sRAGE levels were determined by ELISA. Repeated measures ANOVA was applied and P values < 0.05 were considered significant. RESULTS: A total of 132 (44 × 3) sera were used for analysis. Levels of adiponectin was significantly decreased between PREOP and POD3 (P < 0.001). Conversely, concentrations of resistin significantly increased from PREOP to POD1 and returned to baseline value by POD3 (P < 0.001). Serum sRAGE levels were significantly higher in LAP in comparison with HALS (P = 0.004) and OPEN (P < 0.001). sRAGE levels were significantly higher in sera of patients that underwent ERP (P < 0.001). CONCLUSIONS: Serum adiponectin, resistin, and sRAGE have the potential to develop into a panel of stress markers. Higher sRAGE levels in sera of LAP and ERP patients may be indicative of a protective and syngeristic role for colectomy recovery.

The benefits of a low dose complex carbohydrate/citrulline electrolyte solution for preoperative carbohydrate loading: Focus on glycemic variability.

BACKGROUND: Perioperative insulin resistance is associated with significant hyperglycemia-related morbidity in patients undergoing major surgery. We sought to assess the effect of preoperative loading with a low-dose maltodextrin/citrulline solution compared to a commercially available sports drink on glycemic levels in an established colorectal enhanced recovery program. METHODS: Retrospective analysis was undertaken of elective non-diabetic colectomies and enterectomies from January 2016-March 2017. Cohorts included simple (SIM) and complex carbohydrate (COM) groups. Statistical analysis was performed with linear and logarithmic regression. RESULTS: 83 patients were included (42 SIM, 41 COM). SIM group was older (61.7 vs 52.7 p = 0.012) Glycemic variability was less in the COM group (7.6% vs 21.4% P = 0.034). The frequency of hyperglycemia, postoperative complications, and length of stay trended higher in the SIM group. CONCLUSIONS: This retrospective analysis identifies significant improvement in the perioperative glycemic variability with preoperative low dose complex carbohydrate loading compared to simple carbohydrate loading in colorectal surgery patients.

Incremental cost of complications in colectomy: a warranty guided approach to surgical quality improvement.

BACKGROUND: We assessed the warranty cost for colectomy at a single institution, as defined by the additional cost of treating complications distributed across all patients treated. METHODS: All segmental colectomies from July 8 to June 12 were reviewed for 0, 1, 2, and ≥3 complications. Warranty cost is defined as follows: ([mean additional cost of the case with complication(s) - mean base case cost] × number of episodes)/total population. RESULTS: Thousand four hundred twenty-two colectomies were analyzed. The lowest cost case was a laparoscopic resection with 0 complications ($7,739 ± 4,150). Warranty costs were less for laparoscopic versus open colectomy (0 - $0, 1 - $128, 2 - $66, ≥3 - $248 vs 0 - $1,036, 1 - $501, 2 - $520, ≥3 - $1,971). This was true for costs associated with readmission ($303 vs $1,519). Emergency status and elderly status also impacted warranty costs. CONCLUSIONS: The data demonstrate that warranty costs were highest with open colectomy, emergency cases, and the elderly. These data can be used to measure both quality and cost impact of mitigation strategies.

Laparoscopic proctectomy: oncologic considerations.

The role of laparoscopic proctectomy in rectal cancer has not clearly been defined. Publications on long-term outcomes after laparoscopic proctectomy is lacking and there is a wide variation of practice patterns of rectal cancer management. Current data supports the feasibility of laparoscopic proctectomy for rectal cancer but due to surgeon, patient and tumor related factors open technique may be favored. Current series suggest that laparoscopic proctectomy can be performed with similar oncologic adequacy with regards to, circumferential resection margin, distal margin, local recurrence and quality of life. Ongoing trials will provide evidence clarifying the role of laparoscopic proctectomy in rectal cancer. Until then, high-level laparoscopic skills and meticulous preoperative evaluation of both patient and tumor can identify appropriate candidates.

Outcomes of ileocolic resection and right hemicolectomies for Crohn's patients in comparison with non-Crohn's patients and the impact of perioperative immunosuppressive therapy with biologics and steroids on inpatient complications.

BACKGROUND: The purpose of this study was to compare medication use and complication rates between Crohn's disease (CD) and non-CD patients undergoing ileocolic resections and right hemicolectomies. METHODS: A review of patients who underwent ileocolic resections and right hemicolectomies from January 1, 2003, through December 31, 2010, was performed. Data collected included demographics and clinical information, biologics use (eg, infliximab, adalimumab), other medication use (eg, steroids), complications, and mortality. RESULTS: There were 791 records reviewed, with 93 CD patients. There was no significant difference in major or minor complications, anastomotic leaks, operating room time, or postoperative ileus occurrence between the CD and non-CD groups (P > .05). Use of biologics and steroids were significantly higher among the CD patients. Mortality, age, and American Society of Anesthesiologists score were significantly higher in the non-CD group. CONCLUSIONS: Ileocolic resections and right hemicolectomies in CD patients are not associated with an increase in complication rates even when the patients use steroids and biologics in the preoperative period.

Hidradenitis suppurativa and pruritus ani.

Hidradenitis suppurativa (HS) is a chronic debilitating disorder that can affect any areas bearing apocrine glands. Perineal HS is associated with high morbidity compared with other anatomic regions. Early-stage disease may mimic various other forms of cutaneous disorders, but as HS progresses pathognomonic skin changes occur. Clinical stage can guide the therapeutic approach, but the lowest recurrence rate is obtained by removing all involved skin and subcutaneous fat. Pruritus ani is a complex disease with a multitude of etiologies. Its management can be frustrating and disappointing for the patient and doctor alike. The key is to start with simple treatment options focusing on perianal hygiene and avoidance of the most common offending foods and beverages. If these measures fail, topical medications should be attempted before graduating to perianal injections of methylene blue as a last resort.

Introduction of alvimopan into an enhanced recovery protocol for colectomy offers benefit in open but not laparoscopic colectomy.

INTRODUCTION: Alvimopan coupled with an enhanced recovery protocol (ERP) has been shown to reduce length of stay (LOS) after open colectomy, but its role after laparoscopy remains unknown. This study evaluated alvimopan with an established ERP for laparoscopic (LAP), hand-assisted laparoscopic (HAL), and open colectomy. MATERIALS AND METHODS: Consecutive patients who underwent elective colectomy by any technique were retrospectively identified. Patients were excluded if they developed a major intra-abdominal complication, medical complication, or had a complex preoperative evaluation. Patients were stratified into 4 groups based on the surgical approach (open/HAL vs. LAP) and the use of alvimopan. All patients were managed by using an ERP. The incidence of postoperative ileus (POI) and LOS were compared between alvimopan and control groups for each surgical approach. RESULTS: There were 282 patients. Demographics were similar across the 4 groups. The mean number of alvimopan doses administered was 6.7±2.6. For patients in the open/HAL group (n=149), the incidence of primary ileus was 9.5% (7/74) and 16% (12/75) for alvimopan and control patients, respectively (P=.231). A significant decrease in LOS was noted with alvimopan (5.6±2.5 vs. 6.8±3.3 days, P=.009). For patients after LAP (n=133), there was no significance difference in POI with or without alvimopan (3.9% [3/76] vs. 3.5% [2/57], P=1.00). There was no difference in LOS (3.9±1 vs. 3.7±1.4 days, P=.305). CONCLUSION: The addition of alvimopan to an established ERP will lead to improvement in clinical outcomes in patients after open/HAL colectomy. The benefit of alvimopan after LAP remains negligible.

Citrulline: a potential immunomodulator in sepsis.

BACKGROUND: Sepsis leads to a complex systemic response of cytokines (both pro- and anti-inflammatory) and more recently recognized adipokine mediators. Endothelial nitric oxide (NO) may be a key component in regulating this response, but the pharmacologic manipulation of endothelial NO via L-arginine supplementation or inhibitors has provided inconsistent clinical data related to outcomes. These failures are related to the metabolism of L-arginine in the liver, toxicity of L-arginine, and asymmetric dimethylarginine inhibition, all of which may explain the "arginine paradox." L-citrulline (CIT) offers a potentially valuable means of supplementing arginine and therefore impacting favorably NO availability. The goal of this study was to determine whether CIT supplementation altered the systemic response of mediators and cytokines in a rat model of sepsis with varying degrees of severity. METHODS: Sepsis was induced with 2 models of cecal ligation and puncture (CLP) of varying severity in Wistar rats. CIT supplementation was provided to half the animals as 8% CIT-supplemented feed for 3 weeks. Baseline mediator levels were assessed in the Wistar rats followed by comparison of the following groups at days 0, 1, and 3: sham-operated; CLP 8-mm (localized); and CLP 12-mm (extensive). The following analyses were performed in the groups: interleukin-6 (IL-6), IL-8, IL-10, resistin, and adiponectin levels (enzyme-linked immunosorbent assay performed in duplicate). L-arginine and CIT were measured with high-performance liquid chromatography combined with mass spectrometry. RESULTS: Ninety-eight Wistar rats were evaluated, and survival was similar in both sepsis models with and without CIT. Serum IL-6 levels were lower in the CIT/CLP 8-mm group compared to the standard rat chow (STD)/CLP 8-mm group (41 vs 117 pg/mL; P = .011) on postoperative day 3. Serum IL-8 and IL-10 responses were similar across all groups. Serum resistin levels were lower in the CIT/CLP 12-mm group compared to the STD/CLP 12-mm group in the more severe sepsis model on day 3 (19 vs 38 ng/mL; P < .0001). The levels of serum L-arginine were greater in the CIT-supplemented animals compared to STD rodent diet animals before surgical insult (86.3 vs 294.0 µM; P = .004). Adiponectin was not affected by CIT supplementation. CONCLUSION: CIT may decrease the proinflammatory mediator response (IL-6 and resistin) without impairing the secretion of anti-inflammatory mediators (IL-10 and adiponectin) and thereby provide a safe means of immunomodulation that preserves the anti-inflammatory mediator response.

Optimal follow-up to curative colon and rectal cancer surgery: how and for how long?

In 2009, the projected incidence for colon and rectal cancers in the United States was 106,100 and 40,870, respectively, and approximately 75% of these patients were treated with curative intent. Surveillance or follow-up after colon and rectal cancer resection serves multiple purposes; however, the primary argument supporting the validity of surveillance is the detection of metachronous and recurrent cancers amenable to curative treatment. The surveillance may provide some comfort for cancer survivors who can be informed that they have no evidence of disease.

Postoperative ileus: it costs more than you expect.

BACKGROUND: The clinical impact of postoperative ileus (POI) after colectomy is difficult to quantify financially because of administrative coding limitations. Accurate data are important to allow pharmaco-economic analysis of methods aimed at reducing POI. The aim of this study was to assess the financial impact of POI for the 30-day episode of care for colectomy. STUDY DESIGN: We reviewed all colectomy patients at our institution from July 2007 to June 2008. Primary POI was defined as more than three episodes of emesis with return to NPO diet status and/or reinsertion of nasogastric tube; secondary POI was associated with intraabdominal complications. Readmission for gastrointestinal failure was defined as delayed POI (no radiologic or surgical identification of small bowel obstruction). All other complications requiring readmission were grouped together for analysis. Data reviewed included primary admission and readmission costs, reason for readmission, intervention, index and total length of stay, narcotic use, time to ambulation, and time to enteral feeds. RESULTS: One hundred eighty-six colectomies were eligible for analysis, with 45 cases (38 primary and 7 secondary) of POI during the index admission. The total cost was significantly higher for patients with POI ($16,612 versus $8,316; p < 0.05). However, readmission costs were not statistically different for delayed POI and other complications ($3,546 versus $6,705). CONCLUSIONS: POI occurred in 24% (84% primary) of colectomy patients and disproportionately affected cost at the index admission. Interestingly, delayed POI was similar in cost to readmission for other serious adverse surgical complications.