Telenursing and Remote Patient Monitoring in Cardiovascular Health.

Background: Since the decline in death rates from cardiovascular diseases has slowed down recently, promoting cardiovascular health in patients and the general public has become more important than ever, particularly for elder and rural patients. This study is a collaborative effort between a regional health network in Virginia and associated organizations to implement and assess telenursing and remote patient monitoring (RPM) to help home care patients better manage their own cardiovascular related diseases and promote sustainable health delivery options. Method: Eighty cardiovascular patients with diabetes, congestive heart failure, or both who had a recent disease-related hospital stay were enrolled in the RPM program to receive services, including care coordination, coaching, referral for behavioral health, and aging-related services for 90+ days. The program used telenursing and RPM through home care monitoring equipment to coach patients on effective measures to stay compliant with posthospitalization regimens, track and evaluate readmissions, and assess physiological status and mental health. Result: There was a decline in hospital admissions of 65%, 85% for observations and related inpatient services for enrolled CVD patients in the RPM program. In addition, the longer the patient was enrolled the less likely they were to readmit. The program saved ∼$615,127 in patient claims costs and had net savings of $390,296, ∼173% of the total program expenses. Discussion: Evidence showed that 90+ day enrollments are sufficient for realization of readmissions and Emergency Department reductions, increased health care access, and lower costs. This resulted from consistent monitoring using the technology to alert nurses and care coordinators who were able to respond and facilitate patients accessing care in the most helpful and generally less costly care environment. Conclusion: The study has confirmed that care coordination and RPM are effective in supporting self-management of chronic conditions and cost reductions through telenursing and RPM.

Specialization Reduces Costs Associated With Colon Cancer Care: A Cost Analysis.

BACKGROUND: Colorectal surgeons have been reported to have superior outcomes to general surgeons in the management of colon cancer, but it is unclear whether this leads to a difference in costs associated with cancer care. OBJECTIVE: This study aimed to investigate whether colorectal surgeons versus general surgeons performing elective colectomies for colon cancer resulted in cost savings. DESIGN: A decision analysis model was built to evaluate the cost of care. One-way and Monte Carlo sensitivity analyses were performed to test the assumptions of the model. SETTING: Data for the model were taken from previously published studies. PATIENTS: This study included a simulated cohort of patients undergoing elective colectomy for colon cancer. MAIN OUTCOME MEASURES: Total cost of care from the societal and health care system perspectives. RESULTS: In the base case scenario, from the societal perspective, colectomy performed by a colorectal surgeon costs $38,798 during the 5-year window versus $46,571 when performed by a general surgeon (net savings, $7773). From the health care system perspective, surgery performed by a colorectal surgeon costs $25,125 versus surgery performed by a general surgeon, which costs $29,790 (net savings, $4665). In probabilistic sensitivity analyses, surgeries performed by colorectal surgeons were cost saving or equivalent to those performed by general surgeons in 997 of 1000 simulations in the societal perspective and 989 of 1000 simulations in the health care system perspective. Overall, this finding was primarily driven by differences in reported overall recurrence rates and patient loss of productivity. LIMITATIONS: The limitation of this study was reliance on published data, some of which included rectal cancer cases. CONCLUSIONS: In our decision analysis model, elective colectomies for colon cancer had lower associated costs when performed by colorectal versus general surgeons. See Video Abstract at http://links.lww.com/DCR/B974 . LA ESPECIALIZACIN REDUCE LOS COSTOS ASOCIADOS CON LA ATENCIN DEL CNCER DE COLON UN ANLISIS DE COSTOS: ANTECEDENTES: Se ha informado que los cirujanos colorrectales obtienen mejores resultados que los cirujanos generales en el tratamiento del cáncer de colon, pero no está claro si esto conduce a una diferencia en los costos asociados con la atención del cáncer.OBJETIVO: Investigar si los cirujanos colorrectales que realizan colectomías electivas para el cáncer de colon generaron ahorros de costos en comparación con los cirujanos generales.DISEÑO: Se construyó un modelo de análisis de decisiones para evaluar el costo de la atención. Se realizaron análisis de sensibilidad unidireccional y de Monte Carlo para probar los supuestos del modelo.AJUSTE: Los datos para el modelo se tomaron de estudios publicados previamente.PACIENTES: Una cohorte simulada de pacientes sometidos a colectomía electiva por cáncer de colon.PRINCIPALES MEDIDAS DE RESULTADO: Costo total de la atención y desde la perspectiva de la sociedad y del sistema de salud.RESULTADOS: El escenario del caso base incluyó suposiciones sobre las diferencias en los resultados, incluida la recurrencia general y local, el porcentaje de recurrencia operable, la mortalidad a los 30 días, la duración de la estadía, el porcentaje de cirugía mínimamente invasiva, las complicaciones y los costos asociados. En el escenario de caso base, desde la perspectiva social, la colectomía con un cirujano colorrectal costó $38 798 durante la ventana de cinco años, frente a $46 571 con un cirujano general (ahorros netos, $7 773). Desde la perspectiva del sistema de atención médica, la cirugía realizada por un cirujano colorrectal fue de $25 125 frente a $29 790 con la cirugía realizada por un cirujano general (ahorro neto, $4665). En los análisis de sensibilidad de probabilidad, los cirujanos colorrectales ahorraron costos o fueron equivalentes a los cirujanos generales en 997 de 1000 simulaciones en la perspectiva social y 989 de 1000 simulaciones en la perspectiva del sistema de salud. En general, este hallazgo se debió principalmente a las diferencias en las tasas de recurrencia generales informadas y la pérdida de productividad de los pacientes.LIMITACIONES: Dependencia de los datos publicados, algunos de los cuales incluyeron casos de cáncer de rectoCONCLUSIONES: En nuestro modelo de análisis de decisiones, las colectomías electivas por cáncer de colon tuvieron menores costos asociados cuando las realizaron cirujanos colorrectales versus generales. Consulte Video Resumen en http://links.lww.com/DCR/B974 . (Traducción-Dr Yolanda Colorado).

Does Rectoanal Intussusception Limit Improvements in Clinical Outcome and Quality of Life After Sacral Nerve Stimulation for Fecal Incontinence?

BACKGROUND: Sacral nerve stimulation is a treatment option for severe, medically refractory fecal incontinence, although its use in patients with anatomic abnormalities remains controversial. OBJECTIVE: This study aimed to determine whether patients with rectoanal intussusception achieve similar benefits from device implantation to patients without rectoanal intussusception. DESIGN: Retrospective review of a prospectively maintained database. Demographics and clinical data were collected for each patient, including preoperative pelvic floor testing. Defecographies were reanalyzed in a blinded manner. Preoperative rectoanal intussusception was determined on the basis of the Oxford system (grade III-IV vs not; grade V excluded). SETTINGS: Academic-affiliated pelvic health center. PATIENTS: All patients undergoing sacral nerve stimulation for fecal incontinence between July 2011 and July 2019. MAIN OUTCOME MEASURES: Cleveland Clinic Florida Incontinence/Wexner Scores, Fecal Incontinence Severity Indices, and Fecal Incontinence Quality of Life Indices at 1 year. RESULTS: One hundred sixty-nine patients underwent sacral nerve stimulation for fecal incontinence during the study period. The average age was 60.3 years and 91% were female. Forty-six patients (27.2%) had concomitant rectoanal intussusception (38 patients [22.5%] grade III and 8 patients [4.7%] grade IV). Before surgery, patients reported an average of 10.8 accidents per week and a Wexner score of 15.7, with no difference between patients with and without rectoanal intussusception ( p = 0.22 and 0.95). At 1 year after surgery, the average Wexner score was 9.5. There was no difference in postoperative Wexner scores (10.4 vs 9.2, p = 0.23) or improvement over time between patients with and without rectoanal intussusception (-6.7 vs -5.7, p = 0.40). Similarly, there was no difference in quality of life or frequency of incontinence to liquid or solid stool. LIMITATIONS: Single-institution, moderate sample size, incomplete survey response. CONCLUSIONS: Concomitant rectoanal intussusception does not appear to affect clinical outcomes or quality of life after sacral nerve stimulation for fecal incontinence. Appropriate patients with fecal incontinence and rectoanal intussusception can be considered for sacral nerve stimulation placement. See Video Abstract at http://links.lww.com/DCR/C192 . LA INTUSUSCEPCIN RECTOANAL LIMITA LAS MEJORAS EN EL RESULTADO CLNICO Y LA CALIDAD DE VIDA DESPUS DE LA NEUROESTIMULACION SACRA PARA LA INCONTINENCIA FECAL: ANTECEDENTES:La neuroestimulación sacra es una opción de tratamiento para la incontinencia fecal grave refractaria al tratamiento médico, aunque su uso en pacientes con anomalías anatómicas sigue siendo controvertido.OBJETIVO:Determinar si los pacientes con intususcepción rectoanal logran beneficios similares de la implantación del dispositivo a los pacientes sin intususcepción rectoanal.DISEÑO:Revisión retrospectiva de una base de datos mantenida prospectivamente. Se recopilaron datos demográficos y clínicos de cada paciente, incluidas las pruebas preoperatorias del piso pélvico. Las defecografías se volvieron a analizar de forma ciega. La intususcepción rectoanal preoperatoria se determinó según el sistema de Oxford (grado III-IV vs. no; grado V excluido).ESCENARIO:Centro académico de salud pélvica.PACIENTES:Todos los pacientes sometidos a neuroestimulación sacra por incontinencia fecal entre julio de 2011 y julio de 2019.PRINCIPALES MEDIDAS DE RESULTADO:Cleveland Clinic Florida Incontinence/Wexner Scores, Índices de gravedad de la incontinencia fecal, Índices de calidad de vida de la incontinencia fecal al año.RESULTADOS:169 pacientes se sometieron a neuroestimulación sacra por incontinencia fecal durante el período de estudio. La edad promedio fue de 60.3 años y el 91% eran mujeres. Cuarenta y seis pacientes (27.2%) tenían intususcepción rectoanal concomitante (38 [22.5%] grado III y 8 [4.7%] grado IV). Antes de la cirugía, los pacientes informaron un promedio de 10.8 accidentes por semana y una puntuación de Wexner de 15.7 sin diferencia entre pacientes con y sin intususcepción rectoanal (p = 0.22 y 0.95). Un año después de la cirugía, la puntuación promedio de Wexner fue de 9.5. No hubo diferencia en las puntuaciones de Wexner posoperatorias (10.4 frente a 9.2, p = 0.23) o mejoría con el tiempo entre los pacientes con y sin intususcepción rectoanal (-6.7 frente a -5.7, p = 0.40). De manera similar, no hubo diferencia en la calidad de vida o la frecuencia de incontinencia de heces líquidas o sólidas.LIMITACIONES:Institución única, tamaño de muestra moderado, respuesta de encuesta incompleta.CONCLUSIÓN:La intususcepción rectoanal concomitante no parece afectar los resultados clínicos o la calidad de vida después de la neuroestimulación sacra para la incontinencia fecal. Los pacientes apropiados con incontinencia fecal e intususcepción rectoanal pueden ser considerados para la neuroestimulación sacra. Consulte Video Resumen en http://links.lww.com/DCR/C192(Traducción-Dr. Jorge Silva Velazco ).

Connecting Dementia Caregivers to Recommended Services: Care to Plan.

The current mixed methods, embedded study evaluated the use of an online tool (Care to Plan [CtP]) that generates tailored service and support recommendations for dementia caregivers as well as information that can connect dementia caregiver users to recommended resources. Forty-three dementia caregivers identified in a health care system were randomly assigned to receive either CtP or usual care. The embedded, mixed methods design resulted in no quantitative, direct evidence for CtP's efficacy. Qualitative data revealed important insights into facilitators of and barriers to CtP use. Qualitative data also demonstrated that CtP helped caregivers obtain a better awareness of their needs and experiences. Clinicians may find CtP useful as an initial tool to spur memory care/case management and facilitate conversations about caregivers' needs and resources to meet individualized challenges. [Journal of Gerontological Nursing, 49(10), 5-11.].

Total Neoadjuvant Therapy Versus Standard Neoadjuvant Chemoradiation in Patients with Locally Advanced Rectal Cancer: A Comparison of Short- and Long-term Oncologic Outcomes.

OBJECTIVE: To evaluate the impact of neoadjuvant multi-agent systemic chemotherapy and radiation (TNT) vs neoadjuvant single-agent chemoradiation (nCRT) and multi-agent adjuvant chemotherapy on overall survival (OS), tumor downstaging, and circumferential resection margin (CRM) status in patients with locally advanced rectal cancer. SUMMARY OF BACKGROUND DATA: Outside of clinical trials and small institutional reports, there is a paucity of data regarding the short and long-term oncologic impact of TNT as compared to nCRT. METHODS: Adult patients with stage II-III rectal adenocarcinoma were identified in the National Cancer Database [2006-2015]. RESULTS: Out of 8,548 patients, 36% received TNT and 64% nCRT. In the cohort, 13% had a pCR and 20% a neoadjuvant rectal (NAR) score <8. In multivariable analysis, as compared to nCRT, TNT demonstrated numerically higher pCR rates ( P = 0.05) but had similar incidence of positive CRM ( P = 0.11). Similar results were observed with NAR scores <8 as the primary endpoint. After adjusting for confounders, OS was comparable between the 2 groups. Additional factors independently associated with lower OS included male gender, uninsured status, low income status, high comorbidity score, poorly differentiated tumors, abdominoperineal resection, and positive surgical margins (all P <0.01). In separate models, both pCR and a NAR score <8 were associated with improved OS. CONCLUSION: In this national cohort, TNT was not associated with better survival and/or CRM negative status in comparison with nCRT, despite numerically higher downstaging rates. Further refinement of patient selection and treatment regimens are needed to establish effective neoadjuvant platforms to improve outcomes of patients with rectal cancer.

Selective type & screen for elective colectomy based on a transfusion risk score may generate substantial cost savings.

BACKGROUND: Preoperative type and screen are currently recommended for all patients undergoing colectomy. We aimed to identify risk factors for transfusion and define a low-risk cohort of patients undergoing colectomy in whom type and screen may be safely avoided. METHODS: We identified all patients undergoing elective colectomy in the National Surgical Quality Improvement Project-Targeted Colectomy files from 2012 to 2016. Patients transfused preoperatively and those undergoing other concurrent major abdominal procedures were excluded. We compared patients who received blood transfusion on the day of surgery to those who did not. Half of the cohort was randomly selected for development of a points-based model predicting blood transfusion on the day of surgery. This model was then validated using the remaining patients. RESULTS: Of 61,964 patients undergoing colectomy, 3128 (5%) patients were transfused with 1290 (2.1%) occurring on the day of surgery. Preoperative anemia was the strongest predictor of blood transfusion on the day of surgery. Among patients with hematocrit > 35%, day of surgery transfusion risk was 0.8%; 99% of patients with hematocrit > 35% had a score 20 or less. Selective type and screen for patients with score ≤ 20 or hematocrit > 35% would avoid type and screen in 91% and 81% of patients, respectively. CONCLUSION: Transfusion following elective colectomy is rare and can be accurately predicted by preoperative patient characteristics. Selective type and screen based on these parameters have the potential to prevent operative delays and lower cost.

Mental health and physical activity in vocational education and training schools students: a population-based survey.

BACKGROUND: The prevalence of young people not adhering to the World Health Organization (WHO) physical activity guidelines is high, especially among students in vocational education and training, compared to fellow peers. Also, low levels of mental health have been found in this group, however, to a lesser degree than peers in general education. As positive mental health aspects have more generally been found to be associated with increased likelihood of physical activity in young people, this study examined the association between mental health and physical activity among Danish students in vocational education and training. METHODS: Students in vocational education and training (N = 5277, mean age 24.3 years, range 15.8-64.0 years) responded to a national representative survey assessing four aspects of mental health (well-being, self-efficacy, self-esteem and life satisfaction) and physical activity. Physical activity was dichotomized as adherence to the WHO minimum guidelines or not. Logistic regression was used to examine if each mental health aspect was associated with physical activity in crude and adjusted models. RESULTS: A positive dose-response association was found between all aspects of mental health and adherence to WHO physical activity guidelines. However, the association between self-esteem and physical activity was modified by gender, with a dose-response relationship found only among males. CONCLUSIONS: Higher levels of positive mental health were associated with better odds of achieving WHO physical activity guidelines in a dose-response-manner. Prospective studies are needed to further elucidate the causal relationship between mental health and physical activity. Future interventions must pay attention to differential gender effects.

Rectovaginal Fistulas Secondary to Obstetrical Injury.

Rectovaginal fistula (RVF), defined as any abnormal connection between the rectum and the vagina, is a complex and debilitating condition. RVF can occur for a variety of reasons, but frequently develops following obstetric injury. Patients with suspected RVF require thorough evaluation, including history and physical examination, imaging, and objective evaluation of the anal sphincter complex. Prior to attempting repair, sepsis must be controlled and the tract allowed to mature over a period of 3 to 6 months. All repair techniques involve reestablishing a healthy, well-vascularized rectovaginal septum, either through reconstruction with local tissue or tissue transfer via a pedicled flap. The selection of a specific repair technique is determined by the level of the fistula tract and the status of the anal sphincter. Despite best efforts, recurrence is common and should be discussed with patients prior to repair. As the ultimate goal of RVF repair is to minimize symptoms and maximize quality of life, patients should help to direct their own care based on the risks and benefits of available treatment options.

Cost-effectiveness Evaluation of Laparoscopic Versus Robotic Minimally Invasive Colectomy.

OBJECTIVE: Evaluate the cost-effectiveness of open, laparoscopic, and robotic colectomy. BACKGROUND: The use of robotic-assisted colon surgery is increasing. Robotic technology is more expensive and whether a robotically assisted approach is cost-effective remains to be determined. METHODS: A decision-analytic model was constructed to evaluate the 1-year costs and quality-adjusted time between robotic, laparoscopic, and open colectomy. Model inputs were derived from available literature for costs, quality of life (QOL), and outcomes. Results are presented as incremental cost-effectiveness ratios (ICERs), defined as incremental costs per quality-adjusted life year (QALY) gained. One-way and probabilistic sensitivity analyses were performed to test the effect of clinically reasonable variations in the inputs on our results. RESULTS: Open colectomy cost more and achieved lower QOL than robotic and laparoscopic approaches. From the societal perspective, robotic colectomy costs $745 more per case than laparoscopy, resulting in an ICER of $2,322,715/QALY because of minimal differences in QOL. From the healthcare sector perspective, robotics cost $1339 more per case with an ICER of $4,174,849/QALY. In both models, laparoscopic colectomy was more frequently cost-effective across a wide range of willingness-to-pay thresholds. Sensitivity analyses suggest robotic colectomy becomes cost-effective at $100,000/QALY if robotic disposable instrument costs decrease below $1341 per case, robotic operating room time falls below 172 minutes, or robotic hernia rate is less than 5%. CONCLUSIONS: Laparoscopic and robotic colectomy are more cost-effective than open resection. Robotics can surpass laparoscopy in cost-effectiveness by achieving certain thresholds in QOL, instrument costs, and postoperative outcomes. With increased use of robotic technology in colorectal surgery, there is a burden to demonstrate these benefits.

FAMILIES: an effective healthcare intervention for caregivers of community dwelling people living with dementia.

Objectives: Caregiving for a person with dementia (PWD) carries increased risk of poorer health and quality of life. Non-pharmacological interventions improve outcomes for caregivers of PWDs. We evaluated the efficacy of a modified New York University Caregiver Intervention (NYUCI), named FAMILIES, delivered to spousal and non-spousal caregivers of PWDs from diverse etiologies in a reduced number of sessions.Methods: Participants were 122 primary caregivers for community dwelling PWDs in Virginia. The intervention included two individual and four family/group counseling sessions that integrated dementia education, coping skills and behavioral management training, emotional support, and identification of family and community resources. Assessment of depression, caregiver well-being and burden, and caregiver reactions to the behavioral symptoms of dementia (BSD) were completed at baseline, the sixth session, and 6-month follow-up.Results: Symptoms of depression (p < .001) and caregiver burden (p = .001) and caregivers' capacity to effectively manage their reactions to BSD (p = .003), significantly improved at the sixth session. Benefits were maintained at 6-month follow-up. Being married and female predicted improvement in caregiver burden; being male and living in a rural area predicted reduced risk of depression. Caregivers reported that the intervention was helpful and had a positive impact on the PWD.Conclusions: Modifications to the NYUCI did not diminish its efficacy. Caregivers in FAMILIES experienced improvements in depressive symptoms, caregiver burden, and their ability to effectively manage their reactions to BSD. Systemic support for implementing FAMILIES could have a broad impact on caregivers, PWDs, and the healthcare system.

Transversus Abdominis Plane Block in Laparoscopic Colorectal Surgery: A Systematic Review.

BACKGROUND: Multimodal analgesia is important for postoperative recovery in laparoscopic colorectal surgery. Multiple randomized controlled trials have investigated the use of transversus abdominis plane local anesthetic infiltration as a method of decreasing postoperative pain and opioid consumption, with variable results. OBJECTIVE: This study aimed to examine the overall effect of transversus abdominis plane block in postoperative pain, opioid use, and speed of recovery in laparoscopic colorectal surgery. DATA SOURCES: A literature search was done with PubMed, EMBASE, Web of Knowledge, and Cochrane Library. Only randomized controlled trials were selected for review. INTERVENTIONS: Transversus abdominis plane local anesthetic infiltration versus no intervention, saline, or other techniques in laparoscopic colorectal surgeries was investigated. MAIN OUTCOME MEASURES: The primary outcome measured was postoperative pain on day 1, at rest or with activity. The secondary outcomes measured were postoperative pain beyond day 1, consumptions of opioid, and length of hospital stay. RESULTS: Eight clinical trials including 649 patients between 2013 and 2018 were included. Resting pain scores within 2 hours (standardized mean difference, -0.53; p = 0.01), 4 hours (standardized mean difference, -0.42; p = 0.004), and 6 hours (standardized mean difference, -0.47; p = 0.03) showed statistically significant reduction. Six studies including 413 patients demonstrated lower cumulative opioid consumption within 24 hours after surgery (standardized mean difference, -0.82; p = 0.01). Five studies including 357 patients did not show a significant difference in length of stay (standardized mean difference, -0.04; p = 0.82). LIMITATIONS: Local anesthetic used in block varied in type and quantity across different studies. There were heterogeneities in pain score measurements and opioid consumption. Patient populations may be different among studies. CONCLUSIONS: Transversus abdominis block can lead to a lower pain score at rest within the first 6 hours and reduce opioid consumption within the first 24 hours. See Video Abstract at http://links.lww.com/DCR/A997.

Locally Excised T1 Rectal Cancers: Need for Specialized Surveillance Protocols.

BACKGROUND: Local excision of T1 rectal cancers helps avoid major surgery, but the frequency and pattern of recurrence may be different than for patients treated with total mesorectal excision. OBJECTIVE: This study aims to evaluate pattern, frequency, and means of detection of recurrence in a closely followed cohort of patients with locally excised T1 rectal cancer. DESIGN: This study is a retrospective review. SETTINGS: Patients treated by University of Minnesota-affiliated physicians, 1994 to 2014, were selected. PATIENTS: Patients had pathologically confirmed T1 rectal cancer treated with local excision and had at least 3 months of follow-up. INTERVENTIONS: Patients underwent local excision of T1 rectal cancer, followed by multimodality follow-up with physical examination, CEA, CT, endorectal ultrasound, and proctoscopy. MAIN OUTCOME MEASURES: The primary outcomes measured were the presence of local recurrence and the means of detection of recurrence. RESULTS: A total of 114 patients met the inclusion criteria. The local recurrence rate was 11.4%, and the rate of distant metastasis was 2.6%. Local recurrences occurred up to 7 years after local excision. Of the 14 patients with recurrence, 10 of the recurrences were found by ultrasound and/or proctoscopy rather than by traditional methods of surveillance such as CEA or imaging. Of these 10 patients, 4 had an apparent scar on proctoscopy, and ultrasound alone revealed findings concerning for recurrent malignancy. One had recurrent malignancy demonstrated on ultrasound, but no concurrent proctoscopy was performed. LIMITATIONS: This was a retrospective review, and the study was conducted at an institution where endorectal ultrasound is readily available. CONCLUSIONS: Locally excised T1 rectal cancers should have specific surveillance guidelines distinct from stage I cancers treated with total mesorectal excision. These guidelines should incorporate a method of local surveillance that should be extended beyond the traditional 5-year interval of surveillance. An ultrasound or MRI in addition to or instead of flexible sigmoidoscopy or proctoscopy should also be strongly considered. See Video Abstract at http://links.lww.com/DCR/A979. CÁNCERES RECTALES T1 EXTIRPADOS LOCALMENTE: NECESIDAD DE PROTOCOLOS DE VIGILANCIA ESPECIALIZADOS: La escisión local de los cánceres de recto T1 ayuda a evitar una cirugía mayor, pero la frecuencia y el patrón de recurrencia pueden ser diferentes a los de los pacientes tratados con escisión mesorectal total. OBJETIVO: Evaluar el patrón, la frecuencia y los medios de detección de recidiva en una cohorte de pacientes con cáncer de recto T1 extirpado localmente bajo un régimen de seguimiento especifico. DISEÑO:: Revisión retrospectiva. AJUSTES: Pacientes tratados por hospitales afiliados a la Universidad de Minnesota, 1994-2014 PACIENTES:: Pacientes con cáncer de recto T1 confirmado patológicamente, tratados con escisión local y con al menos 3 meses de seguimiento. INTERVENCIONES: Extirpación local del cáncer de recto T1, con un seguimiento multimodal incluyendo examen físico, antígeno carcinoembrionario (CEA), TC, ecografía endorrectal y proctoscopia. PRINCIPALES MEDIDAS DE RESULTADO: Presencia de recurrencia local y medios de detección de recurrencia. RESULTADOS: Un total de 114 pacientes cumplieron con los criterios de inclusión. La tasa de recurrencia local fue del 11,4% y la tasa de metástasis a distancia fue del 2,6%. Las recurrencias locales se presentaron hasta 7 años después de la escisión local. De los 14 pacientes con recurrencia, 10 de las recurrencias se detectaron por ultrasonido y / o proctoscopia en lugar de los métodos tradicionales de vigilancia, como CEA o imágenes. De estos diez pacientes, cuatro tenían una cicatriz aparente en la proctoscopia y el ultrasonido solo reveló hallazgos relacionados con tumores malignos recurrentes. En una ecografía se demostró malignidad recurrente, pero no se realizó proctoscopia concurrente. LIMITACIONES: Revisión retrospectiva; estudio realizado en una institución donde se dispone fácilmente de ultrasonido endorrectal CONCLUSIONES:: Los cánceres de recto T1 extirpados localmente deben tener una vigilancia específica distinta de los cánceres en etapa I tratados con TME. El régimen de seguimiento deberá de extender más allá del intervalo tradicional de 5 años de vigilancia. También se debe considerar la posibilidad de realizar una ecografía o una resonancia magnética (IRM) además de la sigmoidoscopía flexible o la proctoscopía. Vea el Resumen del video en http://links.lww.com/DCR/A979.

Combined Hartmann's Reversal and Abdominal Wall Reconstruction: Defining Postoperative Morbidity.

BACKGROUND: Ventral hernias are common after Hartmann's procedure and add complexity to Hartmann's reversal. Colostomy reversal and abdominal wall reconstruction may be performed in a staged or concurrent fashion, although data are limited as to which strategy is optimal. We aimed to define the complication profile of concurrent abdominal wall reconstruction with colostomy reversal as compared to either procedure alone. MATERIALS AND METHODS: For this retrospective cohort study, we used the National Surgery Quality Improvement Project Database from 2012 to 2015. All patients undergoing elective colostomy reversal, abdominal wall reconstruction with component separation, or combined colostomy reversal with component separation were identified. Propensity score matching was used to compare outcomes among similar patients undergoing colostomy reversal alone versus combined procedure. Groups were evaluated for postoperative morbidity including reoperation. RESULTS: We identified 11,689 patients; 6951 (64%) underwent component separation alone, 4563 (35%) colostomy reversal alone, and 175 (1%) combined component separation and colostomy reversal. The combined group, as compared to colostomy reversal alone, showed an increased overall complication rate (39% versus 25%; P < 0.01) and increased rate of reoperation (9% versus 5%; P = 0.03). Differences in overall complication rate (43% versus 24%; P < 0.01) and reoperation rate (9% versus 3%; P = 0.03) persisted on propensity matched analysis. CONCLUSIONS: This analysis shows that in patients undergoing colostomy takedown, concurrent abdominal wall reconstruction is associated with increased morbidity including increased rate of reoperation, even when controlling for patient factors. Consideration may be given to a staged approach.

Prolonged thromboprophylaxis with low molecular weight heparin for abdominal or pelvic surgery.

BACKGROUND: This an update of the review first published in 2009.Major abdominal and pelvic surgery carries a high risk of venous thromboembolism (VTE). The efficacy of thromboprophylaxis with low molecular weight heparin (LMWH) administered during the in-hospital period is well-documented, but the optimal duration of prophylaxis after surgery remains controversial. Some studies suggest that patients undergoing major abdominopelvic surgery benefit from prolongation of the prophylaxis up to 28 days after surgery. OBJECTIVES: To evaluate the efficacy and safety of prolonged thromboprophylaxis with LMWH for at least 14 days after abdominal or pelvic surgery compared with thromboprophylaxis administered during the in-hospital period only in preventing late onset VTE. SEARCH METHODS: We performed electronic searches on 28 October 2017 in the Cochrane Central Register of Controlled Trials, MEDLINE, Embase, LILACS and registered trials (Clinicaltrials.gov October 28, 2017 and World Health Organization International Clinical Trials Registry Platform (ICTRP) 28 October 2017). Abstract books from major congresses addressing thromboembolism were handsearched from 1976 to 28 October 2017, as were reference lists from relevant studies. SELECTION CRITERIA: We assessed randomized controlled clinical trials (RCTs) comparing prolonged thromboprophylaxis (≥ fourteen days) with any LMWH agent with placebo, or other methods, or both to thromboprophylaxis during the admission period only. The population consisted of persons undergoing abdominal or pelvic surgery for both benign and malignant pathology. The outcome measures included VTE (deep venous thrombosis (DVT) or pulmonary embolism (PE)) as assessed by objective means (venography, ultrasonography, pulmonary ventilation/perfusion scintigraphy, spiral computed tomography (CT) scan or autopsy). We excluded studies exclusively reporting on clinical diagnosis of VTE without objective confirmation. DATA COLLECTION AND ANALYSIS: Review authors identified studies and extracted data. Outcomes were VTE (DVT or PE) assessed by objective means. Safety outcomes were defined as bleeding complications and mortality within three months after surgery. Sensitivity analyses were also performed with unpublished studies excluded, and with study participants limited to those undergoing solely open and not laparoscopic surgery. We used a fixed-effect model for analysis. MAIN RESULTS: We identified seven RCTs (1728 participants) evaluating prolonged thromboprophylaxis with LMWH compared with control or placebo. The searches resulted in 1632 studies, of which we excluded 1528. One hundred and four abstracts, eligible for inclusion, were assessed of which seven studies met the inclusion criteria.For the primary outcome, the incidence of overall VTE after major abdominal or pelvic surgery was 13.2% in the control group compared to 5.3% in the patients receiving out-of-hospital LMWH (Mantel Haentzel (M-H) odds ratio (OR) 0.38, 95% confidence interval (CI) 0.26 to 0.54; I2 = 28%; moderate-quality evidence).For the secondary outcome of all DVT, seven studies, n = 1728, showed prolonged thromboprophylaxis with LMWH to be associated with a statistically significant reduction in the incidence of all DVT (M-H OR 0.39, 95% CI 0.27 to 0.55; I2 = 28%; moderate-quality evidence).We found a similar reduction when analysis was limited to incidence in proximal DVT (M-H OR 0.22, 95% CI 0.10 to 0.47; I2 = 0%; moderate-quality evidence).The incidence of symptomatic VTE was also reduced from 1.0% in the control group to 0.1% in patients receiving prolonged thromboprophylaxis, which approached significance (M-H OR 0.30, 95% CI 0.08 to 1.11; I2 = 0%; moderate-quality evidence).No difference in the incidence of bleeding between the control and LMWH group was found, 2.8% and 3.4%, respectively (M-H OR 1.10, 95% CI 0.67 to 1.81; I2 = 0%; moderate-quality evidence).No difference in mortality between the control and LMWH group was found, 3.8% and 3.9%, respectively (M-H OR 1.15, 95% CI 0.72 to 1.84; moderate-quality evidence).Estimates of heterogeneity ranged between 0% and 28% depending on the analysis, suggesting low or unimportant heterogeneity. AUTHORS' CONCLUSIONS: Prolonged thromboprophylaxis with LMWH significantly reduces the risk of VTE compared to thromboprophylaxis during hospital admittance only, without increasing bleeding complications or mortality after major abdominal or pelvic surgery. This finding also holds true for DVT alone, and for both proximal and symptomatic DVT. The quality of the evidence is moderate and provides moderate support for routine use of prolonged thromboprophylaxis. Given the low heterogeneity between studies and the consistent and moderate evidence of a decrease in risk for VTE, our findings suggest that additional studies may help refine the degree of risk reduction but would be unlikely to significantly influence these findings. This updated review provides additional evidence and supports the previous results reported in the 2009 review.

Prolonged thromboprophylaxis with low molecular weight heparin for abdominal or pelvic surgery.

BACKGROUND: This an update of the review first published in 2009.Major abdominal and pelvic surgery carries a high risk of venous thromboembolism (VTE). The efficacy of thromboprophylaxis with low molecular weight heparin (LMWH) administered during the in-hospital period is well-documented, but the optimal duration of prophylaxis after surgery remains controversial. Some studies suggest that patients undergoing major abdominopelvic surgery benefit from prolongation of the prophylaxis up to 28 days after surgery. OBJECTIVES: To evaluate the efficacy and safety of prolonged thromboprophylaxis with LMWH for at least 14 days after abdominal or pelvic surgery compared with thromboprophylaxis administered during the in-hospital period only in preventing late onset VTE. SEARCH METHODS: We performed electronic searches on 28 October 2017 in the Cochrane Central Register of Controlled Trials, MEDLINE, Embase, LILACS and registered trials (Clinicaltrials.gov October 28, 2017 and World Health Organization International Clinical Trials Registry Platform (ICTRP) 28 October 2017). Abstract books from major congresses addressing thromboembolism were handsearched from 1976 to 28 October 2017, as were reference lists from relevant studies. SELECTION CRITERIA: We assessed randomized controlled clinical trials (RCTs) comparing prolonged thromboprophylaxis (≥ fourteen days) with any LMWH agent with placebo, or other methods, or both to thromboprophylaxis during the admission period only. The population consisted of persons undergoing abdominal or pelvic surgery for both benign and malignant pathology. The outcome measures included VTE (deep venous thrombosis (DVT) or pulmonary embolism (PE)) as assessed by objective means (venography, ultrasonography, pulmonary ventilation/perfusion scintigraphy, spiral computed tomography (CT) scan or autopsy). We excluded studies exclusively reporting on clinical diagnosis of VTE without objective confirmation. DATA COLLECTION AND ANALYSIS: Review authors identified studies and extracted data. Outcomes were VTE (DVT or PE) assessed by objective means. Safety outcomes were defined as bleeding complications and mortality within three months after surgery. Sensitivity analyses were also performed with unpublished studies excluded, and with study participants limited to those undergoing solely open and not laparoscopic surgery. We used a fixed-effect model for analysis. MAIN RESULTS: We identified seven RCTs (1728 participants) evaluating prolonged thromboprophylaxis with LMWH compared with control or placebo. The searches resulted in 1632 studies, of which we excluded 1528. One hundred and four abstracts, eligible for inclusion, were assessed of which seven studies met the inclusion criteria.For the primary outcome, the incidence of overall VTE after major abdominal or pelvic surgery was 13.2% in the control group compared to 5.3% in the patients receiving out-of-hospital LMWH (Mantel Haentzel (M-H) odds ratio (OR) 0.38, 95% confidence interval (CI) 0.26 to 0.54; I2 = 28%; moderate-quality evidence).For the secondary outcome of all DVT, seven studies, n = 1728, showed prolonged thromboprophylaxis with LMWH to be associated with a statistically significant reduction in the incidence of all DVT (M-H OR 0.39, 95% CI 0.27 to 0.55; I2 = 28%; moderate-quality evidence).We found a similar reduction when analysis was limited to incidence in proximal DVT (M-H OR 0.22, 95% CI 0.10 to 0.47; I2 = 0%; moderate-quality evidence).The incidence of symptomatic VTE was also reduced from 1.0% in the control group to 0.1% in patients receiving prolonged thromboprophylaxis (M-H OR 0.30, 95% CI 0.08 to 1.11; I2 = 0%; moderate-quality evidence).No difference in the incidence of bleeding between the control and LMWH group was found, 2.8% and 3.4%, respectively (M-H OR 1.10, 95% CI 0.67 to 1.81; I2 = 0%; moderate-quality evidence).No difference in mortality between the control and LMWH group was found, 3.8% and 3.9%, respectively (M-H OR 1.15, 95% CI 0.72 to 1.84; moderate-quality evidence).Estimates of heterogeneity ranged between 0% and 28% depending on the analysis, suggesting low or unimportant heterogeneity. AUTHORS' CONCLUSIONS: Prolonged thromboprophylaxis with LMWH significantly reduces the risk of VTE compared to thromboprophylaxis during hospital admittance only, without increasing bleeding complications or mortality after major abdominal or pelvic surgery. This finding also holds true for DVT alone, and for both proximal and symptomatic DVT. The quality of the evidence is moderate and provides moderate support for routine use of prolonged thromboprophylaxis. Given the low heterogeneity between studies and the consistent and moderate evidence of a decrease in risk for VTE, our findings suggest that additional studies may help refine the degree of risk reduction but would be unlikely to significantly influence these findings. This updated review provides additional evidence and supports the previous results reported in the 2009 review.

Patient Satisfaction and Quality of Life with Enhanced Recovery Protocols.

While studies have demonstrated the benefits of Enhanced Recovery after Surgery (ERAS) programs in reducing length of stay and costs without increasing complications, fewer studies have evaluated patient satisfaction and quality of life (QOL) with enhanced recovery protocols. The aim of this project was to summarize the literature comparing satisfaction and quality of life after colorectal surgery following treatment within an ERAS protocol to standard postoperative care. The available evidence suggests patients suffer no detriment to satisfaction or quality of life with use of ERAS protocols, and may suffer less fatigue and return to activities sooner. Most publications reported no adverse effects on postoperative pain. However, a limited number of studies suggest patients may experience increased early postoperative pain with ERAS pathways, particularly following open colorectal procedures. Future research should focus on potential improvements in ERAS protocols to better manage postoperative pain. Overall, the evidence supports more widespread implementation of ERAS pathways in colorectal surgery.

A Randomized, Controlled Trial of 3.0 mg of Liraglutide in Weight Management.

BACKGROUND: Obesity is a chronic disease with serious health consequences, but weight loss is difficult to maintain through lifestyle intervention alone. Liraglutide, a glucagon-like peptide-1 analogue, has been shown to have potential benefit for weight management at a once-daily dose of 3.0 mg, injected subcutaneously. METHODS: We conducted a 56-week, double-blind trial involving 3731 patients who did not have type 2 diabetes and who had a body-mass index (BMI; the weight in kilograms divided by the square of the height in meters) of at least 30 or a BMI of at least 27 if they had treated or untreated dyslipidemia or hypertension. We randomly assigned patients in a 2:1 ratio to receive once-daily subcutaneous injections of liraglutide at a dose of 3.0 mg (2487 patients) or placebo (1244 patients); both groups received counseling on lifestyle modification. The coprimary end points were the change in body weight and the proportions of patients losing at least 5% and more than 10% of their initial body weight. RESULTS: At baseline, the mean (±SD) age of the patients was 45.1±12.0 years, the mean weight was 106.2±21.4 kg, and the mean BMI was 38.3±6.4; a total of 78.5% of the patients were women and 61.2% had prediabetes. At week 56, patients in the liraglutide group had lost a mean of 8.4±7.3 kg of body weight, and those in the placebo group had lost a mean of 2.8±6.5 kg (a difference of -5.6 kg; 95% confidence interval, -6.0 to -5.1; P<0.001, with last-observation-carried-forward imputation). A total of 63.2% of the patients in the liraglutide group as compared with 27.1% in the placebo group lost at least 5% of their body weight (P<0.001), and 33.1% and 10.6%, respectively, lost more than 10% of their body weight (P<0.001). The most frequently reported adverse events with liraglutide were mild or moderate nausea and diarrhea. Serious events occurred in 6.2% of the patients in the liraglutide group and in 5.0% of the patients in the placebo group. CONCLUSIONS: In this study, 3.0 mg of liraglutide, as an adjunct to diet and exercise, was associated with reduced body weight and improved metabolic control. (Funded by Novo Nordisk; SCALE Obesity and Prediabetes NN8022-1839 ClinicalTrials.gov number, NCT01272219.).

Prolonged thromboprophylaxis with low molecular weight heparin for abdominal or pelvic surgery.

BACKGROUND: This an update of the review first published in 2009.Major abdominal and pelvic surgery carries a high risk of venous thromboembolism (VTE). The efficacy of thromboprophylaxis with low molecular weight heparin (LMWH) administered during the in-hospital period is well-documented, but the optimal duration of prophylaxis after surgery remains controversial. Some studies suggest that patients undergoing major abdominopelvic surgery benefit from prolongation of the prophylaxis up to 28 days after surgery. OBJECTIVES: To evaluate the efficacy and safety of prolonged thromboprophylaxis with LMWH for at least 14 days after abdominal or pelvic surgery compared with thromboprophylaxis administered during the in-hospital period only in preventing late onset VTE. SEARCH METHODS: We performed electronic searches on 28 October 2017 in the Cochrane Central Register of Controlled Trials, MEDLINE, Embase, LILACS and registered trials (Clinicaltrials.gov October 28, 2017 and World Health Organization International Clinical Trials Registry Platform (ICTRP) 28 October 2017). Abstract books from major congresses addressing thromboembolism were handsearched from 1976 to 28 October 2017, as were reference lists from relevant studies. SELECTION CRITERIA: We assessed randomized controlled clinical trials (RCTs) comparing prolonged thromboprophylaxis (≥ fourteen days) with any LMWH agent with placebo, or other methods, or both to thromboprophylaxis during the admission period only. The population consisted of persons undergoing abdominal or pelvic surgery for both benign and malignant pathology. The outcome measures included VTE (deep venous thrombosis (DVT) or pulmonary embolism (PE)) as assessed by objective means (venography, ultrasonography, pulmonary ventilation/perfusion scintigraphy, spiral computed tomography (CT) scan or autopsy). We excluded studies exclusively reporting on clinical diagnosis of VTE without objective confirmation. DATA COLLECTION AND ANALYSIS: Review authors identified studies and extracted data. Outcomes were VTE (DVT or PE) assessed by objective means. Safety outcomes were defined as bleeding complications within three months after surgery. Sensitivity analyses were also performed with unpublished studies excluded, and with study participants limited to those undergoing solely open and not laparoscopic surgery. We used a fixed-effect model for analysis. MAIN RESULTS: We identified seven RCTs (1728 participants) evaluating prolonged thromboprophylaxis with LMWH compared with control or placebo. The searches resulted in 1632 studies, of which we excluded 1528. One hundred and four abstracts, eligible for inclusion, were assessed of which seven studies met the inclusion criteria.For the primary outcome, the incidence of overall VTE after major abdominal or pelvic surgery was 13.2% in the control group compared to 5.3% in the patients receiving out-of-hospital LMWH (Mantel Haentzel (M-H) odds ratio (OR) 0.38, 95% confidence interval (CI) 0.26 to 0.54; I2 = 28%; seven studies, n = 1728; moderate-quality evidence).For the secondary outcome of all DVT, seven studies, n = 1728, showed prolonged thromboprophylaxis with LMWH to be associated with a statistically significant reduction in the incidence of all DVT (M-H OR 0.39, 95% CI 0.27 to 0.55; I2 = 28%; moderate-quality evidence).We found a similar reduction when analysis was limited to incidence in proximal DVT (M-H OR 0.22, 95% CI 0.10 to 0.47; I2 = 0%; moderate-quality evidence).The incidence of symptomatic VTE was also reduced from 1.0% in the control group to 0.1% in patients receiving prolonged thromboprophylaxis (M-H OR 0.30, 95% CI 0.08 to 1.11; I2 = 0%; moderate-quality evidence).No difference in the incidence of bleeding between the control and LMWH group was found, 2.8% and 3.4%, respectively (HM-H OR 1.10, 95% CI 0.67 to 1.81; I2 = 0%; seven studies, n = 2239; moderate-quality evidence).Estimates of heterogeneity ranged between 0% and 28% depending on the analysis, suggesting low or unimportant heterogeneity. AUTHORS' CONCLUSIONS: Prolonged thromboprophylaxis with LMWH significantly reduces the risk of VTE compared to thromboprophylaxis during hospital admittance only, without increasing bleeding complications after major abdominal or pelvic surgery. This finding also holds true for DVT alone, and for both proximal and symptomatic DVT. The quality of the evidence is moderate and provides moderate support for routine use of prolonged thromboprophylaxis. Given the low heterogeneity between studies and the consistent and moderate evidence of a decrease in risk for VTE, our findings suggest that additional studies may help refine the degree of risk reduction but would be unlikely to significantly influence these findings. This updated review provides additional evidence and supports the previous results reported in the 2009 review.