Selection of Robotic Bariatric Surgery Candidates: a Nationwide Analysis.

INTRODUCTION: This study aims to identify risk factors associated with 30-day major complications, readmission, and delayed discharge for patients undergoing robotic bariatric surgery. METHODS: From the metabolic and bariatric surgery and accreditation quality improvement program (2015-2018) datasets, adult patients who underwent elective robotic bariatric operations were included. Predictors for 30-day major complications, readmission, and delayed discharge (hospital stay ≥ 3 days) were identified using univariable and multivariable analyses. RESULTS: Major complications in patients undergoing robotic bariatric surgery were associated with both pre-operative and intraoperative factors including pre-existing cardiac morbidity (OR = 1.41, CI = [1.09-1.82]), gastroesophageal reflux disease [GERD] (OR = 1.23, CI = [1.11-1.38]), pulmonary embolism (OR = 1.51, CI = [1.02-2.22]), prior bariatric surgery (OR = 1.66, CI = [1.43-1.94]), increased operating time (OR = 1.003, CI = [1.002-1.004]), gastric bypass or duodenal switch (OR = 1.58, CI = [1.40-1.79]), and intraoperative drain placement (OR = 1.28, CI = [1.11-1.47]). With regard to 30-day readmission, non-white race (OR = 1.25, CI = [1.14-1.39]), preoperative hyperlipidemia (OR = 1.16, CI = [1.14-1.38]), DVT (OR = 1.48, CI = [1.10-1.99]), therapeutic anticoagulation (OR = 1.48, CI = [1.16-1.89]), limited ambulation (OR = 1.33, CI = [1.01-1.74]), and dialysis (OR = 2.14, CI = [1.13-4.09]) were significantly associated factors. Age ≥ 65 (OR = 1.18, CI = [1.04-1.34]), female gender (OR = 1.21, CI = [1.10-1.32]), hypertension (OR = 1.08, CI = [1.01-1.15]), renal insufficiency (OR = 2.32, CI = [1.69-3.17]), COPD (OR = 1.49, CI = [1.23-1.82]), sleep apnea (OR = 1.10, CI = [1.03-1.18]), oxygen dependence (OR = 1.47, CI = [1.10-2.0]), steroid use (OR = 1.26, CI = [1.02-1.55]), IVC filter (OR = 1.52, CI = [1.15-2.0]), and BMI ≥ 40 (OR = 1.12, CI = [1.04-1.21]) were risk factors associated with delayed discharge. CONCLUSION: When selecting patients for bariatric surgery, surgeons early in their learning curve for utilizing robotics should avoid individuals with pre-existing cardiac or renal morbidities, venous thromboembolism, and limited functional status. Patients who have had previous bariatric surgery or require technically demanding operations are at higher risk for complications. An evidence-based approach in selecting bariatric candidates may potentially minimize the overall costs associated with adopting the technology.

Implementation of the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program and outcomes of bariatric surgery.

INTRODUCTION: This study evaluates the performance of bariatric surgery prior to and after the implementation of Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP). METHODS: The eras prior to (2007-2015) and after (2016-2018) the transition to MBSAQIP were compared for patients, operations and outcomes using adjusted logistic regression estimates. RESULTS: Thirty-day surgical (6%vs.2.9%,p < 0.01) and medical (3.4%vs.1.7%,p < 0.01) complications rates were reduced over the period 2007 through 2018. Th use of sleeve gastrectomy has steadily increased from 2010 to 2018 (14%vs.66.6%,p < 0.01). The proportion of patients who were discharged early continued to rise (9.8%vs.46.9%,p < 0.01) from 2007 to 2018. The MBSAQIP period was associated with reduced odds for 30-day surgical (OR = 0.86,CI = [0.81-0.91]) and medical (OR = 0.81,CI = [0.75-0.88]) complications. Implementation of the MBSAQIP was also predictive of early discharge (OR = 1.93,CI = [1.90-2.00]). CONCLUSION: The type of bariatric procedure, in addition to trends in morbidity and hospital stays, gradually changed from 2007 to 2018. Our findings suggest that outcomes of bariatric operations have improved over the past decade. The MBSAQIP era is associated with lower rates of complications and greater likelihood of early discharge, independent of the procedure type.

Multiplexed single-cell analysis reveals prognostic and nonprognostic T cell types in human colorectal cancer.

Clinical outcomes in colorectal cancer (CRC) correlate with T cell infiltrates, but the specific contributions of heterogenous T cell types remain unclear. To investigate the diverse function of T cells in CRC, we profiled 37,931 T cells from tumors and adjacent normal colon of 16 patients with CRC with respect to transcriptome, TCR sequence, and cell surface markers. Our analysis identified phenotypically and functionally distinguishable effector T cell types. We employed single-cell gene signatures from these T cell subsets to query the TCGA database to assess their prognostic significance. We found 2 distinct cytotoxic T cell types. GZMK+KLRG1+ cytotoxic T cells were enriched in CRC patients with good outcomes. GNLY+CD103+ cytotoxic T cells with a dysfunctional phenotype were not associated with good outcomes, despite coexpression of CD39 and CD103, markers that denote tumor reactivity. We found 2 distinct Treg subtypes associated with opposite outcomes. While total Tregs were associated with good outcomes, CD38+ Tregs were associated with bad outcomes independently of stage and possessed a highly suppressive phenotype, suggesting that they inhibit antitumor immunity in CRC. These findings highlight the potential utility of these subpopulations in predicting outcomes and support the potential for novel therapies directed at CD38+ Tregs or CD8+CD103+ T cells.

Minimally invasive versus open duodenal switch: a nationwide retrospective analysis.

INTRODUCTION: This study aims to characterize the variability in clinical outcomes between open, laparoscopic, and robotic Duodenal Switch (DS). METHODS: From the Metabolic and Bariatric Surgery and Accreditation Quality Improvement Program, patients who underwent DS (2015-2018) were identified. Open DS was compared to laparoscopic and robotic approaches with for patients factors, perioperative characteristics, and 30-day postoperative outcomes. Logistic regression estimates were used to characterize variables associated with surgical site infections, bleeding, reoperation, readmission, and early discharge (hospital stay of ≤ one day). RESULTS: Of 7649 cases, 411 (5.4%) were open, 5722 (74.8%) were laparoscopic, and 1515 (19.8%) were robotic DS. Open DS patients were more often older (≥ 65 years:4.7% vs. 4.3% vs. 2.1%, p < 0.01) and had lower body mass index (< 40 kg/m2:16.3% vs. 10.5% vs. 9.9%, p < 0.01). The co-morbidities were mainly comparable between the three groups. Open DS was more often without skilled assistance (35.3% vs. 12.1% vs. 5.3%, p < 0.01), revisional (41.4% vs. 20.5% vs. 21.3%, p < 0.01), and performed concurrently with other operations. Robotic DS surgery was more often longer (≥ 140 min:64.4% vs. 39.2% vs. 86.9%, p < 0.01). Post-operatively, open DS was associated with higher rates of surgical site infection (7.1% vs. 2% vs. 2.8%, p < 0.01), bleeding (2.4% vs. 0.7% vs. 0.9%, p = 0.001), reoperation (6.6% vs. 3.6% vs. 4.4%, p = 0.01), and readmission (12.4% vs. 6.8% vs. 8.3%, p = < 0.01). Patients undergoing robotic DS were more often discharged early (0.5% vs. 1% vs. 7.8%, p < 0.01). In the regression analyses, minimally invasive DS was associated with lower odds for wound infections (OR = 0.3,CI = [0.2-0.5]), bleeding (OR = 0.4,CI = [0.2-0.8]), and readmission (OR = 0.6,CI = [0.4-0.8]), as well as greater likelihood of early discharge (OR = 5.6 CI = [1.3-23.0]). CONCLUSION: Open DS is associated with greater risk for complications and excessive resource utilization when compared to minimally invasive approaches. Laparoscopic and robotic techniques should be prioritized in performing DS, despite the complexity of the procedure.

Robotic Duodenal Switch Is Associated with Outcomes Comparable to those of Laparoscopic Approach.

INTRODUCTION/PURPOSE: This study evaluates the outcomes of robotic duodenal switch (RDS) when compared to conventional laparoscopy (LDS). MATERIALS AND METHODS: Using the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP), patients who underwent RDS were compared to those of LDS (2015-2018) for perioperative characteristics and thirty-day postoperative outcomes. Operative complexity, complications, and resource utilization trends were plotted over the included years for the two approaches. Multivariable analysis was conducted to characterize the impact of each approach on these outcomes. RESULTS: Of 7235 minimally invasive operations, 5720 (79.1%) were LDS while 1515 (20.9%) were RDS. Intraoperative endoscopy, anastomosis testing, and shorter operative duration were associated with LDS. RDS group had more concomitant procedures with less attending assistance. The odds ratios of organ space infection and sepsis were equivalent. RDS increased the odds ratios for venous thromboembolism [VTE] (odds ratio [OR] = 2.3, 95% confidence interval [CI] = 1.1-4.8, p = 0.02) and early discharge (OR = 7.3, CI = 4.9-10.9, p < 0.01). The difference in wound infection between LDS and RDS has been decreasing (1.5% and 1.5% in 2018 from 2.3% and 4.1% in 2015, respectively) over the years. Similarly, the decreasing trends were noted for systemic infections. CONCLUSION: While the development of VTE after RDS was higher, most of the other complications were comparable between LDS and RDS in this study. RDS may reduce the need for advanced intraoperative assistance and minimize hospital stay in select cases, without increasing morbidity. The recent trends suggest a gradual decrease in the variations between LDS and RDS outcomes over time.

Stratification of Readmission after Bariatric Surgery by Day of Post-Discharge Presentation.

INTRODUCTION/PURPOSE: Reasons of postoperative readmissions may vary based on the timing of rehospitalization. This study characterizes predictors and causes for readmission after bariatric surgery on day-to-day basis after discharge. MATERIALS AND METHODS: Using the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program data, patients who underwent Roux-en-Y gastric bypass or sleeve gastrectomy were identified. Perioperative factors of early readmissions (post-discharge days 0-9) were compared to those of late readmissions (post-discharge days 10-30). Multivariable analysis was conducted to identify predictors of early versus late readmissions. Reasons for readmissions were characterized on day-to-day basis. RESULTS: Of 509,631 operations, 19,061 (3.7%) cases were readmitted. Of these, 9666 (50.7%) were early, while 9395 (49.3%) were late readmissions. White race (OR = 1.2, CI = [1.1-1.3]), revisional surgery (OR = 1.2, CI = [1.1-1.4]), Roux-en-Y gastric bypass (OR = 1.2, CI = [1.1-1.3]), pulmonary complication (OR = 1.8, CI = [1.5-2.3]), bleeding (OR = 2, CI = [1.6-2.6]), and post-acute care (OR = 1.8, CI = [1.2-2.6]) were predictors of early readmission. Late readmission was associated with body mass index ≥ 40 (CI = 0.83, OR = [0.77-0.89]), renal/urological complication (OR = 0.6, CI = [0.5-0.8]), and deep vein thrombosis (OR = 0.5, CI = [0.4-0.6]). PO intolerance or dehydration/electrolyte imbalance was the most common readmission reason, peaking on post-discharge days 19-30. Pain, medical complications, obstruction, and bleeding were causes of early readmissions. However, venous thromboembolism readmissions peaked after post-discharge day 9. CONCLUSION: Complex bariatric operations and patients who require post-discharge extended care are associated with early readmissions. Such readmissions are due to early post-discharge complications. However, late readmissions are driven by interrelated risk factors and complications. These findings suggest that targeting patients at risk for delayed rehospitalization is the most efficient approach to minimize readmissions after bariatric surgery.

Short-term outcomes after self-expandable metal stent insertion for obstructing colon cancer: a retrospective cohort study.

BACKGROUND: Self-expanding metal stents (SEMS) are used as a bridge to surgery for colon cancer patients as an alternative to emergency surgery. Currently, there is a paucity of literature from Saudi Arabia on the preoperative usage of SEMS. OBJECTIVE: Determine whether SEMS are associated with a higher rate of complications. DESIGN: Retrospective cohort study SETTINGS: Tertiary care hospital in Saudi Arabia. PATIENTS AND METHODS: In patients diagnosed with obstructing colon cancer, up-front surgical resection was compared with insertion of SEMS followed by surgical resection between the years 2009 and 2013. MAIN OUTCOME MEASURES: Rate of stent-related short-term complications. Secondary endpoint, postoperative complications. SAMPLE SIZE: 65. RESULTS: Twenty-four (36.9%) patients underwent SEMS placement; 41 (63.1%) underwent primary surgery. The median (interquartile range) hospital stay was significantly higher among the SEMS group (13 [8.5] days versus 7 [3] days in the primary surgery group, P<.001). Five patients (20.8%) in the SEMS group developed complications: 2 (8.3%) perforations, 2 (8.3%) obstructions, and 1 (4.2%) stent migrations. CONCLUSION: SEMS is associated with longer hospital stays and short-term serious complications. Further research should be conducted, preferably with a larger sample size. LIMITATIONS: Retrospective design, small sample size. CONFLICT OF INTEREST: None.

Statistical Process Control (SPC) to drive improvement in length of stay after colorectal surgery.

BACKGROUND: Novel quality improvement(QI) methods are needed to optimize healthcare costs and value. Our goal was to determine if Statistical Process Control(SPC), an industrial QI tool, could transform length of stay(LOS) into a process measure, identify outliers, and their impact on surgical outcomes. METHODS: SPC was performed on an institutional colorectal resection database 1/1/13-5/1/2018 to identify outliers and compare outcome variables across outliers and non-outliers. Control charts analyzed the process performance of LOS over time. Control limits were set at ±â€¯1 standard deviation(SD) from the mean. Measures were stable within these limits. RESULTS: LOS was stable, with consistent annual rates and variation of outliers. Outliers had identifiable causes of variation that were significantly different from non-outliers(p < 0.05). The variation resulted in more complications, readmissions, and reoperations in outliers(p < 0.05). CONCLUSIONS: SPC can be applied to LOS, a stable process measure with decreasing variability over time, and easy outlier identification. Identifying outliers can facilitate targeted quality improvement.

Sustained positive impact of ACS-NSQIP program on outcomes after colorectal surgery over the last decade.

BACKGROUND: We evaluate trends in outcomes after colorectal resection over the decade of the introduction of ACS-NSQIP as well as of targeted-colectomy information. STUDY DESIGN: From 2007 to 2016, patients undergoing non-emergent colorectal procedures were included. Demographics, operative complexity (American Society of Anesthesiologists and wound classes); complications, early (<5 days) discharge and mortality were plotted over years. Outcomes after introduction of colectomy-targeted datasets (2013-2016) were compared to those prior (2007-2012). Multivariable analyses were performed to evaluate the impact of colectomy-targeted data on outcomes. RESULTS: Of 310,632 included procedures, 131,122(42.2%) and 179,510(57.8%) were performed before and after the introduction of colectomy-targeted variables respectively. Most complications including surgical site and urinary tract infections, sepsis, septic shock, venous thromboembolism, respiratory complications, reoperation and mortality reduced over time with increased early discharge. On multivariable analysis, introduction of colectomy-targeted data was associated with lower surgical site (OR = 0.78,95%CI = [0.77-0.80]); systemic (OR = 0.94,95%CI = [0.91-0.98]) and urinary tract (OR = 0.70,95%CI = [0.67-0.74]) infections; reoperation (OR = 0.88,95%CI = [0.85-0.91]) and early discharge (OR = 1.60,95%CI = [1.57-1.63]). CONCLUSION: Over its first decade of introduction, ACS-NSQIP has been associated with improved outcomes after colorectal surgery. The introduction of colectomy-targeted data has further improved outcomes.

Alvimopan Significantly Reduces Length of Stay and Costs Following Colorectal Resection and Ostomy Reversal Even Within an Enhanced Recovery Protocol.

BACKGROUND: Alvimopan accelerates GI recovery after colorectal resection. Data on real-world cost-effectiveness have been mixed. OBJECTIVE: This study aimed to evaluate if adding alvimopan to an enhanced recovery pathway reduces length of stay. DESIGN: Patients undergoing colorectal resection or ostomy reversal for the year before and after the introduction of alvimopan were evaluated. SETTING: This study was conducted at a single academic medical center. PATIENTS: Patients undergoing elective colorectal resection (488) or ostomy reversal (148) were included. MAIN OUTCOME MEASURES: The primary outcomes measured were length of stay and prolonged length of stay defined as >75th percentile for each procedure. RESULTS: Two hundred eighty-six patients (45%) received alvimopan. Alvimopan and no-alvimopan groups had similar demographics, comorbidities, operative indication, and case mix. In the alvimopan group, more of the colorectal resections were laparoscopic (87% vs 79%, p = 0.015). Length of stay was reduced with alvimopan (6.2 vs 4.9 days, p = 0.003), and this effect persisted when controlling for procedure type, approach, and ASA class (decreased length of stay by 1.0 day, p = 0.014). The alvimopan group had lower risk of prolonged length of stay (14.7% vs 23.1%, p = 0.007) and ileus (10.8% vs 16.2%, p = 0.05). On multivariable analysis, no alvimopan use (OR, 1.8; 95% CI, 1.2-2.7), ASA ≥3 (OR, 2.0; 95% CI, 1.3-3.1), and history of cardiac surgery (OR, 2.8; 95% CI, 1.2-6.5) were significant predictors of prolonged length of stay. Alvimopan use was associated with a lower risk of infectious complications other than surgical site infection (2.8% vs 6.7%, p = 0.025), and did not increase risk of any adverse outcomes. The addition of alvimopan to the protocol resulted in cost savings of $708.39 per patient. LIMITATIONS: Data collected from a single center limit external validity. CONCLUSIONS: The introduction of alvimopan to a postoperative protocol following elective colorectal resection or ostomy reversal significantly reduces length of stay and is associated with cost savings even within an enhanced recovery protocol. See Video Abstract at http://links.lww.com/DCR/A911.

Exploring the Differences Between Early and Traditional Diet Advancement in Postoperative Feeding Outcomes in Patients With an Ileostomy or Colostomy.

BACKGROUND: We assessed the differences in postoperative feeding outcomes when comparing early and traditional diet advancement in patients who had an ostomy creation. METHODS: At a U.S. tertiary care hospital, data from patients who underwent an ileostomy or colostomy creation from June 1, 2013, to April 30, 2017 were extracted from an institutional database. Patients who received early diet advancement (postoperative days 0 and 1) were compared with traditional diet advancement (postoperative day 2 and later) for demographics, preoperative risk factors, and operative features. The postoperative feeding outcomes included time to first flatus and ostomy output. Mann-Whitney U tests determined bivariate differences in postoperative feeding outcomes between groups. Poisson regression was used to adjust for unequal baseline characteristics. RESULTS: Data from 255 patients were included; 204 (80.0%) received early diet advancement, and 51 (20.0%) had traditional diet advancement. Time to first flatus and time to first ostomy output were significantly shorter in the early compared with traditional diet advancement group (median difference of 1 day for both flatus and ostomy output, P < 0.001). Adjusting for baseline group differences (American Society for Anesthesiology Physical Status Classification System, surgical approach, resection and ostomy type) maintained the significant findings for both time to first flatus (ß = 1.32, P = 0.01) and time to first ostomy output (ß = 1.41, P < 0.001). CONCLUSIONS: Early diet advancement is associated with earlier return of flatus and first ostomy output compared with traditional diet advancement after the creation of an ileostomy or colostomy.

Epidural analgesia in the era of enhanced recovery: time to rethink its use?

BACKGROUND: Previous assessments of the impact of epidural analgesia (EA) on outcomes after colorectal surgery were related to the period before widespread implementation of the enhanced recovery after surgery (ERAS) protocols. This study evaluates the impact of EA on postoperative recovery after colectomy using recent multicenter data. METHODS: Patients who underwent elective colectomy from the American College of Surgeons (ACS) National Surgical Quality Improvement Program (NSQIP) data (2014-2015) were identified. Demographics, comorbidities, diagnosis, procedure type and approach, and postoperative complications associated with EA were assessed. Impact of EA on postoperative ileus, length of stay (LOS), and prolonged LOS (defined as LOS > 75 percentile) was evaluated for all, open, and laparoscopic cases using univariable and multivariable analyses. RESULTS: Of 9045 elective colectomy procedures, 3081 (34.1%) received EA. Epidural analgesia was associated with greater rates of postoperative ileus (15.9% vs. 10.8%, p < 0.0001), superficial (5.5% vs. 4%, p = 0.001) and deep (1.8% vs. 0.6%, p < 0.0001) wound infections, pulmonary embolism (0.8% vs. 0.4%, p = 0.004), deep vein thrombosis (1.3% vs. 0.7%, p = 0.01), sepsis/septic shock (4.6% vs. 3.1%, p < 0.0001), unplanned reintubation (1.5% vs. 0.8%, p = 0.003), cardiac complications (1.2% vs. 0.7%, p = 0.03), and transfusion (9.1% vs. 5.9%, p < 0.0001). Postoperative length of stay (LOS) [mean (SD), days: 6.7(6.2) vs. 5(4.5) days, p < 0.0001] was greater for EA. On multivariable analysis, EA had no impact on postoperative ileus for all and laparoscopic cases. However, EA increased the likelihood for ileus (OR 1.34, 95% CI 1.02-1.78) after open colectomy alone. Similarly, EA did not influence prolonged LOS for all and laparoscopic cases but was independently associated with prolonged LOS after open colectomy (OR 1.4, 95% CI 1.1-1.8). CONCLUSION: Epidural analgesia was not associated with improved recovery after elective colectomy in the era of ERAS.

ACS-NSQIP risk calculator predicts cohort but not individual risk of complication following colorectal resection.

OBJECTIVE: Compare the ACS-NSQIP risk calculator with institutional risk for colorectal surgery. METHODS: Actual and predicted outcomes were compared for both cohort and individuals. RESULTS: For the cohort, the risk calculator was accurate for 7/8 outcomes; there were more serious complications than predicted (19.4 vs 14.7%, p < 0.05). Risk calculator Brier scores and null Brier scores were comparable. PATIENTS: with better outcomes than predicted were current smokers (OR 4.3 95% CI 1.2-15.4), ASA ≥ 3 (OR 10.4, 95% CI 2.8-39.2), underwent total/subtotal colectomy (OR 3.5, 95% CI 1.1-12.2) or operated by Surgeon 2 (OR 2.9, 95% CI 1.4-11.6). Patients with serious complications who had low predicted risk had low ASA (OR 10.5, 95% CI 1.3-82.6), and underwent operation by Surgeon 2 (OR 11.8, 95% CI 2.5, 55.2). LIMITATIONS: Single center study, sample size may bias subgroup analyses. CONCLUSIONS: The ACS NSQIP calculator did not predict outcome better than sample risk.

Readmissions after colorectal surgery: not all are equal.

PURPOSE: This study aims to assess factors associated with preventable readmissions after colorectal resection. METHODS: All readmissions following colorectal resection from May 2013 to May 2016 at an academic medical center were reviewed. Readmissions that could be prevented were identified. Factors associated with preventable readmission were assessed using logistic regression. RESULTS: Of 686 patients discharged during the study period, there were 75 patients (11%) with unplanned readmission. Twenty-nine readmissions (39%) were preventable-these readmissions were due to dehydration or acute kidney injury, pain, ostomy complications, and gastrointestinal bleeding. On regression analysis, the strongest preoperative risk factors associated with preventable readmission were urgent or emergent operation (OR 4.0, 95% CI 1.6-9.9), recent myocardial infarction (OR 2.9, 95% CI 1.0-9.0), total or subtotal colectomy (OR 2.8, 95% CI 1.1-7.3), and American Society of Anesthesiologist score ≥ 3 (OR 2.2, 95% CI 1.0-4.7). Intraoperative risk factors associated with preventable readmission included intraoperative stapler complication (OR 24.2, 95% CI 1.5-397). Postoperative risk factors associated with preventable readmission included postoperative arrhythmia (OR 5.6, 95% CI 2.0-16.1), and postoperative anemia (OR 2.6, 95% CI 1.2-5.7). On multivariable analysis while controlling for procedure type, urgent or emergent operation (OR 2.9, 95% CI 1.1-8.2), intraoperative stapler complication (OR 37.5, 95% CI 2.3-627.8), and postoperative arrhythmia (OR 4, 95% CI 1.3-12.8) remained statistically significant. CONCLUSION: Approximately 40% of readmissions following colorectal surgery are potentially preventable. Since specific patients and factors that are associated with preventable readmission can be identified, resources should be targeted to factors associated with preventable readmissions.

Alvimopan, Regardless of Ileus Risk, Significantly Impacts Ileus, Length of Stay, and Readmission After Intestinal Surgery.

BACKGROUND: Previous analyses evaluating alvimopan included patients at varying risk for ileus after intestinal resection, which may have precluded its widespread adoption. We assess the early and delayed effects of alvimopan in patients stratified by risk for ileus after intestinal and colon resection. METHODS: From the Premier Perspective database, patients with elective small and large bowel resections from 2012 to 2014 were identified. Multivariable analysis identified 14 perioperative risk factors for postoperative ileus. Within low- (0-4 factors), intermediate- (5 factors), and high-risk (6-12 factors) ileus categories, alvimopan and no-alvimopan patients were propensity-score matched for demographics, morbidities, diagnosis, surgery and approach, postoperative complications, surgeon specialty, and hospital features. In-hospital postoperative ileus, length of stay, discharge destination, and ileus-related readmission were compared. RESULTS: Of 52,948 patients, 15,719 (29.7%) received alvimopan. Risk for ileus in low- (18,784), intermediate- (14,370), and high-risk (19,794) categories was 8.9, 13, and 22% (p ≤ .0001) respectively. After matching, alvimopan was associated with significantly reduced in-hospital postoperative ileus in all (low, 6%; intermediate, 9.4%; and high risk, 16.2%) categories. Hospital stay and 30-, 60-, and 90-day postdischarge ileus were also significantly lower with alvimopan. For low-risk patients, alvimopan increased discharge to home, while 90-day emergency readmission was reduced. CONCLUSIONS: Alvimopan, regardless of ileus risk, improves ileus, hospital stay, and ileus-related readmission after intestinal resection and these effects are sustained over the long term. Since fewer than a third of patients currently receive alvimopan, its routine adoption with small and large intestinal resection will significantly impact patients and health systems.

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

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

Effect of Inclusion of Oral Antibiotics with Mechanical Bowel Preparation on the Risk of Clostridium Difficile Infection After Colectomy.

BACKGROUND/PURPOSE: While the use of oral antibiotic (OA) for bowel preparation is gaining popularity, it is unknown whether it increases the risk of Clostridium difficile infection (CDI). This study aimed to evaluate the impact of OA on the development of CDI after colectomy. METHODS: Patients who underwent colectomy from the ACS-NSQIP data (2015 and 2016) were included. Patients who received OA as bowel preparation were compared to those who did not with respect to demographics, comorbidities, primary diagnosis, procedure type and approach, and 30-day postoperative complications. Multivariable analysis was performed to characterize the association between OA and CD infection after colectomy. A sub-group analysis was also conducted for patients who did not develop any postoperative infectious complication. RESULTS: Of 36,374 included patients, 18,177 (50%) received OA and 527 (1.4%) developed CDI for the whole cohort. OA group had more younger, functionally independent and obese patients with lower American Society of Anesthesiologists and wound class. Smoking, diabetes, hypertension, dyspnea or ventilator-dependence, congestive heart failure, disseminated cancer, bleeding disorder, and perioperative transfusion were significantly higher for non-OA group. Mechanical bowel preparation, minimally invasive surgery, conversion to open and operative duration ≥ 180 min were more prevalent in the OA group. The OA group had significantly reduced occurrence of CDI; superficial, deep, and organ space infections; wound disruption; anastomotic leak; reoperation; and infections including sepsis, septic shock, pneumonia, and urinary tract infection. On multivariable analysis, OA reduced the odds for CDI after colectomy (OR = 0.6, 95% CI = [0.5-0.8]). For patients who did not develop infectious postoperative complications, OA was associated with lower risk of CDI (OR = 0.7, CI = [0.5-0.9]). While complications, reoperation, and readmission rates were the same, postoperative ileus and hospital stay were significantly lower for those who developed CDI after receiving OA when compared to non-OA. CONCLUSION: The use of OA as bowel preparation may reduce, rather than increase, the risk of 30-day CDI after colectomy. This effect may partly be due to the other recovery advantages associated with oral antibiotics. These data further support current data recommending the use of oral antibiotics for bowel preparation before colectomy.

The effect of hospital familiarity with complex procedures on overall healthcare burden.

BACKGROUND: This study aimed to evaluate variations in prolonged outcome after proctectomy based on hospital volume. STUDY DESIGN: From the Premier Perspective database (2012-2014), hospital volumes for proctectomy of benign and malignant conditions were classified as low, intermediate and high. Hospitals were grouped into tertiles. Impact of procedure volume on in-hospital as well as 90-day post-discharge complications, length of stay, discharge destination and costs was evaluated. RESULTS: Of 9306 proctectomy procedures, 6960 occurred at high, 1695 at intermediate and 651 at low volume hospitals. After adjustment, high volume institutions were associated with lower in-hospital surgical complications while low volume centers had higher ninety-day post-discharge medical and surgical complications (p < .05 for all). High volume centers had a shorter hospital stay while the need for extended care facility was higher in low volume centers (p < .05 for all). Healthcare costs were higher for low volume hospitals. CONCLUSION: These data suggest that variations in outcomes and costs after complex procedures such as proctectomy exist and are related to institutional familiarity with a procedure.

Propensity Score-Matched Analysis of Clinical and Financial Outcomes After Robotic and Laparoscopic Colorectal Resection.

PURPOSE: The study aims to evaluate the clinical and financial outcomes of the use of robotic when compared to laparoscopic colorectal surgery and any changes in these over time. METHODS: From the Premier Perspective database, patients who underwent elective laparoscopic and robotic colorectal resections from 2012 to 2014 were included. Laparoscopic colorectal resections were propensity score matched to robotic cases for patient, disease, procedure, surgeon specialty, and hospital type and volume. The two groups were compared for conversion, hospital stay, 30-day post-discharge readmission, mortality, and complications. Direct, cumulative, and total (including 30-day post-discharge) costs were evaluated. Clinical and financial outcomes were also separately assessed for each of the included years. RESULTS: Of 36,701 patients, 32,783 (89.3%) had laparoscopic colorectal resection and 3918 (10.7%) had robotic colorectal resection; 4438 procedures (2219 in each group) were propensity score matched. For the entire period, conversion to open approach (4.7 vs. 3.7%, p = 0.1) and hospital stay (mean days [SD] 6 [5.3] vs. 5 [4.6], p = 0.2) were comparable between robotic and laparoscopic procedures. Surgical and medical complications were also the same for the two groups. However, the robotic approach was associated with lower readmission (6.3 vs. 4.8%, p = 0.04). Wound or abdominal infection (4.7 vs. 2.3%, p = 0.01) and respiratory complications (7.4 vs. 4.7%, p = 0.02) were significantly lower for the robotic group in the final year of inclusion, 2014. Direct, cumulative, and total (including 30-day post-discharge) costs were significantly higher for robotic surgery. The difference in costs between the two approaches reduced over time (direct cost difference: 2012, $2698 vs. 2013, $2235 vs. 2014, $1402). CONCLUSION: Robotic colorectal surgery can be performed with comparable clinical outcomes to laparoscopy. With greater use of the technology, some further recovery benefits may be evident. The robotic approach is more expensive but cost differences have been diminishing over time.

Use of an ACE inhibitor or angiotensin receptor blocker is a major risk factor for dehydration requiring readmission in the setting of a new ileostomy.

PURPOSE: Diverting ileostomies help prevent major complications related to anastomoses after colorectal resection but can cause metabolic derangement and hypovolemia, leading to readmission. This paper aims to determine whether angiotensin-converting enzyme inhibitor (ACEi) or angiotensin receptor blocker (ARB) use increased the risk of readmission, or readmission specifically for dehydration after new ileostomy creation. METHODS: Retrospective analysis of patients undergoing diverting ileostomy at a tertiary-care hospital, 2009-2015. Primary outcome was 60-day readmission for dehydration; secondary outcomes included 60-day readmission for any cause, or for infection obstruction. RESULTS: Ninety-nine patients underwent diverting ileostomy creation, 59% with a primary diagnosis of colorectal cancer. The 60-day readmission rate was 36% (n = 36). Of readmitted patients, 39% (n = 14) were admitted for dehydration. Other readmission reasons were infection (33%) and obstruction (3%). The majority (64%, n = 9) of patients readmitted for dehydration were taking either an ACEi or an ARB. Compared to patients not readmitted for dehydration, those who were readmitted for dehydration were more likely to be on an ACEi or an ARB (11/85, 13% vs. 9/14, 64%). After controlling for covariates, ACEi or ARB use was significantly associated with risk of readmission (p < 0.0001, odds ratio = 13.56, 95% confidence interval 3.54-51.92,). No other diuretic agent was statistically associated with readmission for dehydration. CONCLUSIONS: ACEi and ARB use is a significant risk factor for readmission for dehydration following diverting ileostomy creation. Consideration should be given to withholding these medications after ileostomy creation to reduce this risk.