Readmissions With Dehydration After Ileostomy Creation: Rethinking Risk Factors.

BACKGROUND: Twenty-nine percent of postileostomy discharges are readmitted, most commonly because of dehydration. However, there is a lack of detailed data specifically evaluating factors associated with readmission with dehydration. In addition, patients with a history of an ileostomy have often been excluded from previous studies and therefore represent a group of understudied ileostomates. OBJECTIVE: This study aimed to evaluate factors available at discharge associated with 30-day readmission for dehydration, rather than all-cause readmissions. DESIGN: This was a retrospective cohort study. SETTING: Study patients received ileostomies at a tertiary academic medical center from 2014 to 2016. PATIENTS: Patients with a preexisting ileostomy that was not recreated per the operative note were excluded, whereas those who received a new ileostomy were included. MAIN OUTCOME MEASURE: The primary outcome measured was 30-day readmission for dehydration as defined by objective clinical criteria. RESULTS: A total of 262 patients underwent ileostomy creation and were discharged alive. Twenty-five percent were ≥65 years of age, 53% were men, 14% had a history of ileostomy, 18% had a creatinine >1.0 on discharge, and 26% had high ileostomy output at any time during the index admission. Among all ileostomates, the all-cause readmission rate was 30%. Mean days to readmission for any cause was 8.5, whereas for dehydration it was 11.6 days. Of the readmissions, 37% were readmitted with a diagnosis of dehydration, and dehydration was the sole reason in 26%. Among those with dehydration, the most common length of stay was 2 days. In multivariable logistic regression, 30-day readmission with dehydration was associated with older age, male sex, history of an ileostomy, high ileostomy output during index admission, and a discharge creatinine >1.0. LIMITATIONS: This study was limited by its retrospective design. CONCLUSIONS: Ileostomy dehydration efforts have focused on new ileostomy patients; however, our data suggest that patients with a history of an ileostomy are actually at risk for readmission with dehydration. Further studies aimed at the reduction of readmission with dehydration after ileostomy are warranted and should include patients with a history of an ileostomy. See Video Abstract at http://links.lww.com/DCR/A643.

The role of splenectomy in management of splenic B-cell lymphomas.

INTRODUCTION: Splenic B-cell lymphomas are rare and understudied entities. Splenectomy is frequently required for specific pathological diagnosis in patients with splenic B-cell lymphomas other than classical hairy cell leukemia (cHCL), and can be effective and durable therapy. Our study investigated the diagnostic and therapeutic role of splenectomy for non-cHCL indolent splenic B-cell lymphomas. METHODS: Observational study of patients with non-cHCL splenic B-cell lymphoma undergoing splenectomy between 1 August 2011 and 1 August 2021 at the University of Rochester Medical Center. The comparison cohort was patients categorized as having non-cHCL splenic B-cell lymphoma who did not undergo splenectomy. RESULTS: Forty-nine patients (median age 68 years) had splenectomy (SMZL n = 33, HCLv n = 9, SDRPL n = 7) with median follow up of 3.9 years post splenectomy. One patient had fatal post-operative complications. Post-operative hospitalization was ≤ 4 days for 61% and ≤ 10 days for 94% of patients. Splenectomy was initial therapy for 30 patients. Of the 19 patients who had previous medical therapy, splenectomy changed their lymphoma diagnosis in 5 (26%). Twenty-one patients without splenectomy were clinically categorized as having non-cHCL splenic B-cell lymphoma. Nine required medical treatment for progressive lymphoma and of these 3 (33%) required re-treatment for lymphoma progression compared to 16% of patients following first line splenectomy. CONCLUSION: Splenectomy is useful for the diagnosis of non-cHCL splenic B-cell lymphomas with comparable risk/benefit profile and remission duration to medical therapy. Patients with suspected non-cHCL splenic lymphomas should be considered for referral to a high-volume center with experience in performing splenectomies for definitive diagnosis and treatment.

Laparoscopic appendectomy is safe and efficacious for the elderly: an analysis using the National Surgical Quality Improvement Project database.

BACKGROUND: Despite increasing use of laparoscopic appendectomy, data demonstrating outcomes of this technique exclusively among the elderly population are scarce. This study aimed to compare 30-day postoperative morbidity and length of hospital stay among elderly patients after appendectomy. METHODS: Appendicitis patients older than 65 years were extracted from the National Surgical Quality Improvement Project (NSQIP) database. Demographics and rates of complications for patients undergoing open and laparoscopic appendectomies were compared. Uni- and multivariate analyses adjusted for differences between groups compared the end points of major and minor complications as well as the days of hospital stay after initial surgery. RESULTS: A total of 3,335 patients underwent appendectomy, with 2,235 patients (67%) receiving a laparoscopic procedure. The open appendectomy patients were significantly older and more likely to have various preoperative comorbidities (p<0.05). No difference in median operative time between the two techniques was found. Both required 51 min (p=0.11). The open cases had higher rates of both major and minor postoperative complications than the laparoscopic cases (p<0.0001), both overall and before discharge. Multivariate analysis showed no association between operative approach and major complications, and a reduced risk of minor complications with laparoscopy. Length of surgical stay was longer for the open group than for the laparoscopically treated group (median, 4 days vs 2 days; p<0.05). After adjustment, laparoscopy still was significantly associated with a shorter hospital stay than open appendectomy (p<0.0001). CONCLUSIONS: Laparoscopic appendectomy is a safe procedure for elderly patients. During the 30-day postoperative period, no correlation with major complications was found, and the findings showed a beneficial association with regard to minor complications. After adjustment for perioperative factors, laparoscopy is associated with a shorter hospital stay than open appendectomy.

How much do we need to worry about venous thromboembolism after hospital discharge? A study of colorectal surgery patients using the National Surgical Quality Improvement Program database.

PURPOSE: It is well recognized that the increased risk of a postoperative venous thrombotic event extends beyond the inpatient treatment period. The purpose of this study was to determine the 30-day incidence and risk factors associated with the occurrence of early postdischarge symptomatic venous thromboembolic events in patients who have undergone major colorectal surgery. METHODS: The National Surgical Quality Improvement Program database was queried for patients who had undergone a colon or rectal resection during the study period (2005-2008). Patient demographics, preoperative risk factors, and operative variables were recorded. The primary outcomes were occurrence of deep venous thrombosis requiring therapy or pulmonary embolism within 30 days after initial surgery. The occurrence of postdischarge venous thromboembolic events was calculated from the days to primary outcome and days from operation to discharge. Univariate and multivariate linear regression models incorporating pre- and intraoperative variables as well as the occurrence of a major or minor complication were used to evaluate the effect of these clinical factors on the early postdischarge venous thromboembolic event rate. RESULTS: A total of 52,555 patients were included in the initial analysis. A total of 240 deep venous thromboses were diagnosed in the postdischarge setting giving a postdischarge incidence of 0.47%. One hundred thirty cases of a pulmonary embolus were diagnosed (0.26% incidence) with 30 patients having a concurrent deep venous thrombosis and pulmonary embolus. The overall cumulative postdischarge symptomatic venous thromboembolic incidence was 0.67% (n = 340). Obesity, preoperative steroid use, "bleeding disorder," ASA class III, and postoperative (major and minor) complications were all independently associated with an increased risk of an early postdischarge venous thromboembolic event. CONCLUSION: This study has identified risk factors that may help stratify patients into different risk profiles and offer prolonged prophylaxis to patients at increased risk on the basis of preoperative risk factors and postoperative complications.

Impact of hospital volume on surgical outcome for head and neck cancer.

The objective of this study was to define the prognostic significance of surgical center case volume on outcome for head and neck cancer (HNC). Florida cancer registry and inpatient hospital data were queried for HNC diagnosed from 1998 to 2002. Of the 11,160 operative cases of HNC identified, 35.3% were treated at low-volume centers (LVCs), 32.7% in intermediate-volume centers (IVC), and 32.1% at high-volume centers (HVC). A larger proportion of high-grade tumors (27.9%) and lesions over 30 mm (39.7%) were resected at HVC (p < 0.001). Median survival was 61 months for HVC, 52 months for IVC, and 47 months for LVC (p < 0.001). Univariate analysis demonstrated significantly improved survival at HVC for low-, medium-, and high-grade tumors, small tumors (<30 mm), and for cancers of the parotid, larynx, and pharynx. On multivariate analysis, corrected for patient comorbidities, treatment at a HVC was a significant independent predictor of improved survival (HR = 1.25, p = 0.001). We conclude that HNC patients treated at HVC have significantly better long-term survival and cure rates. Where possible, patients with large (>30 mm), high-grade or parotid, larynx, and pharynx tumors should be evaluated and offered care at a high-volume center.

Surgery for rectal cancer performed at teaching hospitals improves survival and preserves continence.

We sought to compare the outcomes of teaching and community hospitals on long-term outcomes for patients with rectal cancer. All rectal adenocarcinomas treated in Florida from 1994 to 2000 were examined. Overall, 5,925 operative cases were identified. Teaching hospitals treated 12.5% of patients with a larger proportion of regionally advanced, metastatic disease, as well as high-grade tumors. Five- and 10-year overall survival rates at teaching hospitals were 64.8 and 53.9%, compared to 59.1 and 50.5% at community hospitals (P = 0.002). The greatest impact on survival was observed for the highest stage tumors: patients with metastatic rectal adenocarcinoma experienced 5- and 10-year survival rates of 30.5 and 26.6% at teaching hospitals compared to 19.6 and 17.4% at community hospitals (P = 0.009). Multimodality therapy was most frequently administered in teaching hospitals as was low anterior resection. On multivariate analysis, treatment at a teaching hospital was a significant independent predictor of improved survival (hazard ratio = 0.834, P = 0.005). Rectal cancer patients treated at teaching hospitals have significantly better survival than those treated at community-based hospitals. Patients with high-grade tumors or advanced disease should be provided the opportunity to be treated at a teaching hospital.

Mesenteric venous thrombophlebitis--septic thrombophlebitis of the inferior mesenteric vein: an unusual manifestation of diverticulitis.

We report a case of a 57-year-old female patient who presented with fever, abdominal pain, and bacteremia. A CT scan demonstrated sigmoid diverticulitis and air within the inferior mesenteric vein. The patient underwent exploratory laparotomy and sigmoid colectomy. She was discharged without complications. Septic thrombophlebitis of the inferior mesenteric vein is a rare complication of diverticulitis. It may manifest as bacteremia not responding to intravenous antibiotics. CT scan findings are diagnostic, and include evidence of intraluminal gas within the inferior mesenteric vein. As with any case of complicated diverticulitis, the treatment is surgical resection of the involved colon.

Economic evaluation of minimally invasive colectomy.

BACKGROUND: We performed a cost-benefit analysis of minimally invasive colectomy (MIC) with the appreciation that this approach extends the duration of the operation and requires additional instruments and equipment when compared with the open procedure. These negatives may be offset by decreased pain, earlier initiation of oral feeding, and a shorter hospitalization. STUDY DESIGN: We reviewed operating room records of all open colectomies (OCs) and MICs performed at Strong Memorial Hospital between January 1, 2000, and March 31, 2004, as defined by CPT codes. Operating room times, total operating room costs, lengths of hospital stay, and total hospital costs were calculated for each procedure. RESULTS: Sixty-eight right hemicolectomies (54 OCs and 14 MICs) were performed. Operating room time was significantly longer for MIC compared with OC (214 +/- 41 minutes versus 170 +/- 56 minutes, p = 0.01). Length of hospital stay was shorter for MIC compared with OC (4.5 +/- 1.3 days versus 7.4 +/- 2.5 days, p = 0.004). There were 131 left hemicolectomies (104 OCs and 27 MICs) performed. Operating room time was significantly longer for left MIC compared with left OC (256 +/- 46 minutes versus 213 +/- 60 minutes, p = 0.005). Length of hospital stay was shorter for left MIC than for left OC (4.4 +/- 1.3 days versus 7.9 +/- 3.0 days, p = 0.001). Total hospital costs were significantly lower for MIC compared with OC (8,580 US dollars +/- 1,358 US dollars versus 10,303 US dollars +/- 3,299 US dollars, p = 0.046). CONCLUSIONS: MIC is associated with a significantly longer operating room time and a shorter hospital stay than OC. Operating room cost is significantly higher for MIC, but total hospital cost is lower. MIC is cost effective and results in significant savings to the health-care system.

Prolonged treatment with angiostatin reduces metastatic burden during radiation therapy.

Ionizing radiation (IR) and concomitant angiostatin (AS) produce greater than additive local antitumor effects. We examined whether prolonged AS treatment added to IR reduces proliferation of lung metastases from LLC primary tumors. Flank tumors were treated with 40 Gy with or without AS (25 mg/kg/day). IR plus a 14-day course of AS improved local tumor control and blocked the increase in lung weights observed in the group receiving IR plus a 2-day course of AS group. Animals treated with prolonged AS exhibited no increase in lung weight and no macrometastases. These findings suggest that long-term treatment with antiangiogenic compounds may be effective in preventing metastases from IR-treated tumors as well as increasing the local antitumor effects of radiotherapy.

Forphenicinol enhances the antitumor effects of cyclophosphamide in a model of squamous cell carcinoma.

We examined the interaction between forphenicinol (FPL) and cyclophosphamide (CPA) or ionizing radiation (IR) on the growth of murine squamous cell carcinoma tumors SCCVII. Primary tumors were established in C3H mice by injecting SCCVII tumor cells subcutaneously into the right hind limb. FPL (100 mg/kg for 8 days) and/or CPA (25 mg/kg twice) were administered by intraperitoneal injection. Tumors were irradiated to a total dose of 40 Gy (eight 5-Gy fractions). SCCVII tumor growth was inhibited by FPL (P=0.054), IR (P=0.003) and CPA (P<0.001) compared with control. The combination of FPL and CPA inhibited tumor growth additively compared with either treatment alone in both small- and large-volume tumors. FPL did not significantly enhance the antitumor effects of IR, however, when CPA+FPL were combined with IR, significant tumor growth inhibition was observed compared with FPL alone (P<0.001), CPA alone (P=0.002) and IR alone (P=0.002). Due to its low toxicity profile, FPL may be combined with CPA, IR and other cytotoxic therapies to potentially enhance the therapeutic ratio.

Dual induction of the Epo-Egr-TNF-alpha- plasmid in hypoxic human colon adenocarcinoma produces tumor growth delay.

Gene therapy is a modality for the treatment of solid tumors that involves the introduction of a suicide gene into the tumor cells. Genetic radiotherapy involves the placement of a radiation-sensitive promoter upstream from a suicide gene. Because of their irregular vasculature some solid tumors are chronically hypoxic and hence are resistant to conventional treatment with chemotherapy and ionizing radiation (IR). The purpose of this study was to demonstrate that regional tumor hypoxia could be exploited to improve local tumor control. The cDNA coding the erythropoietin hypoxia-responsive element (EPO) was placed upstream from the Egr-TNF-alpha construct. WIDR human colon adenocarcinoma cells were injected into the right hind limb of nude mice and treated with Epo-Egr-TNF-alpha plasmid with or without IR. Tumor volumes were measured by calipers and tumor necrosis factor (TNF)-alpha content of the tumor was determined by enzyme-linked immunosorbent assay. Treatment with the combined regimen of Epo-Egr-TNF-alpha plasmid + IR resulted in significant tumor growth delay. Tumor TNF-alpha content was increased by 30 per cent in the combined treatment group compared with each treatment alone. Regional tumor hypoxia can be exploited successfully to induce tumor growth delay, enhance local control, and enhance the therapeutic ratio.

The impact of operative approach in elective splenectomy: a multivariate analysis of outcomes from the NSQIP database.

PURPOSE: Laparoscopy is an increasingly prevalent choice for elective splenectomy but it carries an inconsistent documentation of complications. This study examines 30-day postoperative outcomes after open (OS) and laparoscopic (LS) splenectomy. METHODS: Elective splenectomies were extracted from the National Surgical Quality Improvement Program database. Multivariate analysis determined factors associated with complications and an increased postoperative length of stay (LOS). RESULTS: There were a total of 1583 splenectomies with 991 (63.0%) laparoscopic cases. On univariate analysis, the LS group had fewer major (10.6% vs. 18.8%, P<0.0001) and minor complications (2.6% vs. 7.1%, P<0.0001). Adjusting for baseline differences, LS was not associated with an increase in major complications [odds ratio (OR), 0.76; 95% confidence interval, 0.54-1.08; P = 0.1255] but offered a decrease in minor complications (OR, 0.41; 95% confidence interval, 0.24-0.69; P = 0.0010) coupled with a decrease in postoperative LOS of 1.89 ± 0.30 days (P<0.0001) compared with OS. CONCLUSIONS: After accounting for comorbidities and intraoperative factors, laparoscopy remains a safe choice for elective splenectomy with fewer complications and shorter LOS.

Improvement in educational effectiveness of morbidity and mortality conferences with structured presentation and analysis of complications.

PURPOSE: Although morbidity and mortality (M & M) conferences are cornerstones of surgical teaching, they are not consistent in their educational quality. The current study examines the content and process of M & M presentations by surgical residents and hypothesizes that a structured format for these presentations can improve teaching and learning. METHODS: The educational effectiveness of M & M conferences was assessed through the observation of case presentations, questionnaires to residents measuring learning from presentations, and an anonymous survey of residents regarding perceptions of the effectiveness of conferences. A structured presentation format was devised to address the deficits noted from these assessments and subsequently introduced to all residents and faculty. M & M conferences were then reassessed using the 3 methods. RESULTS: Forty M & M presentations by surgical residents were observed before the implementation of the standardized format, and 35 presentations were observed after the changes. Observation of presentations noted significant changes in residents clearly presenting causes of complications and proposing strategies for practice change. Questionnaires of residents demonstrated improved ability to specify the causes of complications after implementation of the new format (mean rating, 4.56 vs 3.11, p < 0.05) as well as to identify specific ways to avoid the complication in the future (mean, 4.31 vs 3.42, p < 0.05). Online survey results also demonstrated improved resident perception of the specificity of content covered during M & M conferences as well as in their opinions regarding the discussion process. CONCLUSIONS: A structured format for M & M presentations is a practical tool to help residents analyze complications systematically and identify steps for potential changes consistently in clinical practice. Such a format also leads to improved learning for other residents participating in these conferences. Without structured presentations, M & M conferences fail to deliver clear educational messages regarding surgical complications.

Duplication cyst of the sigmoid colon.

A 21-year-old male with developmental delay presented with abdominal pain of two days' duration. He was afebrile and his abdomen was soft with mild diffuse tenderness. There were no peritoneal signs. Plain x-ray demonstrated a large air-filled structure in the right upper quadrant. Computed tomography of the abdomen revealed a 9 x 8 cm structure adjacent to the hepatic flexure containing an air-fluid level. It did not contain oral contrast and had no apparent communication with the colon. At operation, the cystic lesion was identified as a duplication cyst of the sigmoid colon that was adherent to the right upper quadrant. The cyst was excised with a segment of the sigmoid colon and a stapled colo-colostomy was performed. Recovery was uneventful. Final pathology was consistent with a duplication cyst of the sigmoid colon. The cyst was attached to the colon but did not communicate with the lumen.

Inflammatory myofibroblastic tumors.

INTRODUCTION: Inflammatory myofibroblastic tumors (IMT) while uncommon may arise within numerous organs. Historically, the literature regarding IMT has been confined to small one organ case series, with few reviews encompassing multiple anatomic sites, and little data regarding adjuvant treatment. METHODS: A review of patients with IMT treated at two large academic medical centers over a 15-year period was undertaken. Patient demographics, pathologic diagnoses, and pertinent clinical data were obtained. RESULTS: Forty-four cases of pathologically confirmed IMT were identified. Tumor locations included multiple anatomic sites. Therapies included complete resection, incomplete resection, observation, or chemotherapy, and/or radiation. Five patients underwent adjuvant chemotherapy and/or radiation therapy following surgery (14%) for local aggressiveness of the tumor, invasion, positive margins, or location of tumor that was not amenable to surgical resection. A second, concomitant, histologically distinct, neoplasm was identified in five cases. Of the patients who underwent treatment three local recurrences were noted (8%) and occurred in patients with partial resection without adjuvant chemo- or radiotherapy. CONCLUSIONS: Inflammatory myofibroblastic tumors may be a locally aggressive and destructive neoplasm. Tumor recurrence is unusual following complete surgical resection or organ-preserving combined modality therapy.