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1.
Surg Endosc ; 2020 Apr 22.
Artigo em Inglês | MEDLINE | ID: mdl-32323018

RESUMO

INTRODUCTION: We analyzed the risk of morbidity and mortality in laparoscopic (Lap) conversion for colorectal surgery across a group of subspecialist surgeons with expertise in minimally invasive techniques. METHODS: We reviewed prospective data patients who underwent abdominopelvic procedures from 7/1/2007 to 12/31/2016 at a tertiary care facility. We identified procedures that were converted from Lap to open (Lap converted). Lap converted procedures were matched to Lap completed and open procedures based on elective versus urgent and surgeon. We also abstracted patient demographics and outcomes at 30 days using the American College of Surgeons National Surgical Quality Improvement Program defined adverse event list. We analyzed outcomes across these groups (Lap converted, Lap completed, open procedures) with x2 and t tests and used the Bonferroni Correction to account for multiple statistical testing. RESULTS: From a database of 12,454 procedures, we identified 100 Lap converted procedures and matched them to 305 open procedures and 339 Lap completed procedures. In our dataset of abdominopelvic procedures, Lap techniques were attempted in 49 ± 1%. We noted a higher risk of aggerate morbidity following open procedures (33 ± 10) as compared to Lap converted (29 ± 17%) and the matched Lap completed procedures (18 ± 8%; p < 0.001). Converted cases had the longest operative time (222 ± 102 min), compared to lap completed (177 ± 110), and open procedures (183 ± 89). There were no differences in mortality, sepsis complications, anastomotic leaks, or unplanned returns to the operating room across the three operative groups. CONCLUSIONS: Although aggregate morbidity of Lap converted procedures is higher than in Lap completed procedures, it remains less than in matched open procedures. Compared to Lap completed procedures, the additional morbidity of Lap converted procedures appears to be related to additional surgical site infection risk. Our data suggest that surgeons should not necessarily be influenced by additional complications associated with conversion when contemplating complex laparoscopic colorectal procedures.

2.
Dis Colon Rectum ; 63(6): 842-849, 2020 Jun.
Artigo em Inglês | MEDLINE | ID: mdl-32118624

RESUMO

BACKGROUND: The optimal strategy for colonic polyps not amenable to traditional endoscopic polypectomy is unknown. Endoscopic step up is a promising strategy for definitive treatment. OBJECTIVE: The purpose of this study was to determine whether endoscopic step up leads to improved outcomes and decreased costs compared with planned colectomy for endoscopically unresectable colon polyps. DESIGN: This was a retrospective review of a prospective database. SETTING: The study was conducted at a tertiary referral center. PATIENTS: Consecutive patients referred for endoscopically unresectable colon polyps 15 to 50 mm in size were included. INTERVENTIONS: Patients underwent planned colectomy or endoscopic step up at the surgeon's discretion. Endoscopic step up began with diagnostic colonoscopy in the operating room. If the polyp was amenable to endoscopic removal, endoscopic mucosal resection or endoscopic submucosal dissection was performed with progression to combined endoscopic-laparoscopic surgery or laparoscopic colectomy, as indicated. MAIN OUTCOME MEASURES: The primary outcome was 30-day adverse events. We also examined length of stay, hospital charges, insurer payments, and polyp recurrence. RESULTS: A total of 52 patients underwent planned colectomy (48 laparoscopic), and 38 underwent endoscopic step up (28 endoscopic mucosal resection, 2 endoscopic submucosal dissection, 6 combined endoscopic-laparoscopic surgery, and 2 colectomy). Compared with planned colectomy, endoscopic step-up patients had fewer complications (13% vs 33%; p = 0.03) and shorter length of stay (median, 0 vs 4 d; p < 0.001). There was 1 readmission in the endoscopic step-up group and 5 in the planned colectomy group. Endoscopic step-up patients had lower hospital costs ($4790 vs $13,004; p < 0.001) and insurer payments ($2431 vs $19,951; p < 0.001). One-year polyp recurrence-free survival was 84% (95% CI, 67%-93%) in endoscopic step-up patients. All of the recurrences were benign, <1 cm, and managed endoscopically. LIMITATIONS: The study was limited by its nonrandomized design and short follow-up. CONCLUSIONS: An endoscopic step-up approach to colon polyps is associated with less morbidity, decreased healthcare costs, and colon preservation in 95% of patients. Additional studies are needed to evaluate long-term quality of life and polyp recurrence in this group. See Video Abstract at http://links.lww.com/DCR/B188. ENDOSCOPIC STEP UP: UNA ALTERNATIVA A COLECTOMíA PARA PRESERVACIóN DE COLON CON LOS PROPóSITOS DE MEJORAR RESULTADOS Y REDUCIR COSTOS EN PACIENTES CON PóLIPOS NEOPLáSICOS AVANZADOS: Se desconoce la estrategia óptima para los pólipos de colon no susceptibles a la polipectomia endoscópica tradicional. Endoscopic Step Up es una estrategia prometedora para el tratamiento definitivo.Determinar si Endoscopic Step Up produce mejores resultados y menores costos en comparación con la colectomía programada para pólipos de colon endoscópicamente no resecables.Revisión retrospectiva de una base de datos prospectiva.Centro de referencia de tercer nivel.Pacientes consecutivos remitidos para pólipos de colon endoscópicamente irresecables de tamaño 15-50 mm.Los pacientes se sometieron a colectomía programada o Endoscópico Step Up a discreción del cirujano. Endoscopic Step Up comenzó con una colonoscopia diagnóstica en el quirófano. Si el pólipo era susceptible de extirpación endoscópica, la resección endoscópica de la mucosa o la disección submucosa endoscópica se realizaba con progresión a cirugía endoscópica-laparoscópica combinada o colectomía laparoscópica, según a cosnideraciones clínicas en el transoperatorio.El resultado primario fue los eventos adversos a 30 días. Duración de la estadía hospitalaria, los cargos hospitalarios, los pagos de las aseguradoras y la recurrencia de pólipos también fueron examinados.Un total de 52 pacientes se sometieron a colectomía programada (48 laparoscópicas) y 38 se sometieron a Endoscopic Step Up (28 resección endoscópica de la mucosa, 2 disección submucosa endoscópica, 6 cirugía endoscópica-laparoscópica combinada y 2 colectomía). En comparación con la colectomía programada los pacientes endoscópicos Step Up tuvieron menos complicaciones (13% versus 33%, p = 0.03) y una estadía hospitalaria más corta (mediana 0 versus 4 días, p <0.001). Hubo 1 reingreso hospitalario en el grupo Endoscopic Step Up y 5 en el grupo de colectomía programada. Los pacientes endoscópicos Step Up tuvieron costos hospitalarios más bajos ($ 4,790 versus $ 13,004, p <0,001) y pagos de la aseguradora ($ 2,431 versus $ 19,951, p <0,001). La supervivencia libre de recurrencia de pólipos a un año fue del 84% (IC 95% 67-93) en pacientes endoscópicos Step Up. Todas las recurrencias fueron benignas, <1 cm, y manejadas endoscópicamente.Diseño no aleatorizado y seguimiento corto.El abordaje endoscópico Step Up para pólipos de colon se asocia con menos morbilidad, disminución de los costos de atención médica y preservación del colon en el 95% de los pacientes. Se ocupan más estudios para evaluar la calidad de vida a largo plazo y la recurrencia de pólipos en este grupo. Consulte Video Resumen en http://links.lww.com/DCR/B188. (Traducción-Dr Adrián Ortega Robles).

3.
Surg Endosc ; 2020 Feb 03.
Artigo em Inglês | MEDLINE | ID: mdl-32016518

RESUMO

BACKGROUND: National Colorectal Cancer Awareness Month occurs each March to promote awareness and screening for colorectal cancer. The effectiveness of this public health campaign is unknown. The aim of this study was to determine the impact of National Colorectal Cancer Awareness Month on rates of screening endoscopies and on public interest in colorectal cancer. METHODS: To examine the impact of National Colon Cancer Awareness Month on screening endoscopy rates, the National Endoscopy Database was retrospectively reviewed from 2002 through 2014. A time series of monthly number of colorectal cancer screening endoscopies per endoscopist in the data set was evaluated. To examine public interest in colorectal cancer, Google Trends data were collected on the monthly rates of terms related to colorectal cancer from January 2004 to July 2019. Impact of the month on screening endoscopies and public interest was assessed through an analysis of variance. Seasonality was tested for by how well a sinusoidal model fit the time series as opposed to a linear model utilizing a sum-of-squares F test. RESULTS: Review of National Endoscopy Database yielded 1,398,996 endoscopies, 94% were colonoscopies and 6% sigmoidoscopies, with 47% for colorectal cancer screening. Colorectal cancer screening endoscopy rates were not impacted by the month of the year, and these rates had no seasonality. However, Google searches related to colorectal cancer were significantly impacted by month of the year, specifically March, with significant seasonality observed in the data. CONCLUSIONS: National Colorectal Cancer Awareness Month is associated with an increased public interest in colorectal cancer based on user Google search trends. Yet, this has not translated into a demonstrable increase in the rates of screening. This presents an opportunity to capitalize on this increased public interest and harness this enthusiasm into increased screening.

4.
Dis Colon Rectum ; 63(5): 646-654, 2020 May.
Artigo em Inglês | MEDLINE | ID: mdl-32032203

RESUMO

BACKGROUND: Diverticulitis is separated into complicated and uncomplicated, based on the patient's presentation at the time of his or her initial attack of acute diverticulitis. OBJECTIVE: The aim of this study was to identify risk factors for persistent complex diverticulitis, defined as an abscess, fistula, or stricture, at the time of elective surgery, and to characterize outcomes in this patient population. DESIGN: This was a retrospective review of 2010 to 2016 in the American College of Surgeons National Surgical Quality Improvement Project database. SETTINGS: Individuals diagnosed with diverticulitis who underwent elective surgery were included. PATIENTS: A total of 1502 patients underwent elective surgery for diverticulitis, of which 559 (37%) patients had a surgical indication of persistent complex diverticulitis. INTERVENTIONS: We performed logistic regression analysis to identify risk factors for complex diverticulitis and evaluated a new prediction model. MAIN OUTCOME MEASURES: The predictive factors of persistent complex diverticulitis for elective colon resection were measured. RESULTS: The patients with complex diverticulitis were older (p < 0.001), had worse functional status (p < 0.001), more comorbidities (diabetes mellitus and hypertension), and a higher Charlson Comorbidity Index (2.7 vs 1.6, p < 0.001). They were more likely to have a history of tobacco or alcohol use (p < 0.001) and to be malnourished. Interestingly, patients found to have persistent complex diverticulitis did not have more episodes than patients with uncomplicated cases did (p = 0.67). Surgical time was longer in complex diverticulitis, and the patients were more likely to require diverting stomas and concurrent resections of adjacent structures. The area under the curve from the test set was (0.75; 95% CI, 0.72-0.78), sensitivity and specificity were 0.890 (95% CI, 0.870-0.891) and 0.450 (95% CI, 0.410-0.490). LIMITATIONS: The study was limited by its retrospective review and observational bias. CONCLUSIONS: Patients undergoing elective surgery for complex diverticulitis did not have more episodes. Instead, complex diverticulitis may be a reflection of a complicated patient, suggesting that complicated patients should have a different algorithm of care at the time of their initial presentation with diverticulitis to prevent the development of complex disease. See Video Abstract at http://links.lww.com/DCR/B183. ¿PODEMOS PREDECIR DIVERTICULITIS QUIRÚRGICAMENTE COMPLEJA EN CASOS ELECTIVOS?: La diverticulitis se divide en complicada y sin complicaciones, según la presentación del paciente en el momento de su ataque inicial de diverticulitis aguda.El objetivo de este estudio fue identificar los factores de riesgo para la diverticulitis compleja persistente, definida como un absceso, fístula o estenosis, en el momento de la cirugía electiva, y caracterizar los resultados en esta población de pacientes.Esta fue una revisión retrospectiva del 2010-2016 en la base de datos del Proyecto de Mejora de la Calidad Quirúrgica Nacional del Colegio Estadounidense de Cirujanos.Se incluyeron individuos diagnosticados con diverticulitis que se sometieron a cirugía electiva.1502 pacientes fueron sometidos a cirugía electiva por diverticulitis, de los cuales 559 (37%) pacientes tenían una indicación quirúrgica de diverticulitis compleja persistente.Realizamos un análisis de regresión logística para identificar los factores de riesgo de diverticulitis compleja y evaluamos un nuevo modelo de predicción.Se midieron los factores predictivos de diverticulitis compleja persistente para la resección de colon electiva.Los pacientes con diverticulitis compleja eran mayores (p <0,001), tenían un peor estado funcional (p <0,001), más comorbilidades (diabetes e hipertensión) y un índice de comorbilidad de Charlson más alto (2,7 frente a 1,6, p <0,001). Tenían más probabilidades de tener antecedentes de consumo de tabaco o alcohol (p <0.001) y estar desnutridos. Curiosamente, los pacientes con diverticulitis compleja persistente no tuvieron más episodios que los pacientes sin complicaciones (p = 0,67). El tiempo quirúrgico fue más largo en la diverticulitis compleja y era más probable que requirieran estomas para desvio y resecciones concurrentes de estructuras adyacentes. El área bajo la curva de prueba fue (0.75, intervalo de confianza del 95% 0.72-0.78), la sensibilidad y la especificidad fueron 0.890 (intervalo de confianza del 95%; 0.870-0.891) y 0.450 (intervalo de confianza del 95%; 0.410-0.490), respectivamente.El estudio estuvo limitado por su revisión retrospectiva y sesgo observacional.Los pacientes sometidos a cirugía electiva por diverticulitis compleja no tuvieron más episodios. En cambio, la diverticulitis compleja puede ser un reflejo de un paciente complicado, lo que sugiere que los pacientes complicados deben tener un algoritmo de atención diferente al momento de su presentación inicial con diverticulitis para prevenir el desarrollo de una enfermedad compleja. Consulte Video Resumen en http://links.lww.com/DCR/B183. (Traducción-Dr. Yesenia Rojas-Kahlil).

5.
Clin Colorectal Cancer ; 19(1): e8-e17, 2020 Mar.
Artigo em Inglês | MEDLINE | ID: mdl-31899147

RESUMO

BACKGROUND: The impact of primary tumor site on overall survival in patients with stage IV colorectal cancer (CRC) with single-organ metastases to the liver or lung has not been studied. Furthermore, the prognostic significance of commonly tested genetic variants such as KRAS mutation and microsatellite instability (MSI) are not well-described in this population. MATERIALS AND METHODS: This National Cancer Database was used to identify 38,328 patients with CRC that presented with synchronous metastases to the liver or lung between 2010 and 2014. The primary outcome was overall survival, and groups were compared using Kaplan-Meier analyses and Cox proportional hazard models. RESULTS: On unadjusted analysis, median survival was significantly longer for patients with lung metastases compared with those with liver metastases for left-sided (27 vs. 25 months; P = .02) and right-sided CRC (19 vs. 15 months; P < .001), whereas rectosigmoid and rectal cancers showed no difference. On multivariate analysis, patients with liver metastases demonstrated worse survival compared with those with lung metastasis (hazard ratio, 1.37; 95% confidence interval, 1.31-1.43; P < .001). These trends were confirmed in patients that received chemotherapy but did not have their primary tumor or metastases resected. In patients with genetic testing, both KRAS mutants and MSI tumors had worse survival in left-sided and rectal tumors with liver metastases, but had similar survival to KRAS wild type tumors and microsatellite stable tumors, respectively, across other primary site and metastatic patterns. CONCLUSIONS: For patients with single-organ metastases to the liver or lung, primary tumor site has an impact on overall survival. Further, KRAS mutation and MSI status are of prognostic importance in selected patients with single-organ metastases.

6.
Dis Colon Rectum ; 63(2): 207-216, 2020 02.
Artigo em Inglês | MEDLINE | ID: mdl-31914113

RESUMO

BACKGROUND: Functional outcomes following J-pouch for ulcerative colitis have been studied, but lack standardization in which symptoms are reported. Furthermore, the selection of symptoms studied has not been patient centered. OBJECTIVE: This study aimed to utilize a validated bowel function survey to determine which symptoms are present after J-pouch creation, and whether patients display a functional profile similar to low anterior resection syndrome. DESIGN: This study is a retrospective analysis of a prospectively maintained single-center database. SETTINGS: This study was conducted at the colorectal surgery center of a tertiary care academic hospital PATIENTS:: Included were 159 patients with J-pouch, ≥6 months after ileostomy reversal. MAIN OUTCOME MEASURES: The primary outcomes were individual answers to the Memorial Sloan Kettering Cancer Center Bowel Function Instrument. The original Bowel Function Instrument validation cohort was used as an historical comparison (n = 127). RESULTS: The mean total Bowel Function Instrument score for the J-pouch cohort was 59.9 ± 9.7 compared with a reported average score of 63.7 ± 11.6 for patients with low anterior resection in the validation cohort (p < 0.001), indicating worse bowel function in patients with J-pouch. When evaluating the Bowel Function Instrument subscales, patients with J-pouch reported frequency subscale scores of 18.2 ± 3.8, diet scores of 12.2 ± 3.8, and urgency scores of 15.9 ± 3.7, compared with 21.7 ± 4.5 (p < 0.001), 14.1 ± 3.7 (p < 0.001), and 15.0 ± 3.9 (p = 0.04) for patients undergoing rectal resection. Furthermore, 90.4% of patients with J-pouch state that they are sometimes, rarely, or never able to wait 15 minutes to get to the toilet. In addition, 56.4% of patients report having another bowel movement within 15 minutes of the last bowel movement, sometimes, always, or most of the time, and 50.6% of patients say that they sometimes, rarely, or never feel like their bowels have been totally emptied after a bowel movement. LIMITATIONS: This study is limited because it took place at a single center and the Bowel Function Instrument was only validated for patients undergoing rectal resection. CONCLUSIONS: Patients that undergo J-pouch surgery exhibit a constellation of bowel function symptoms that is more complex than fecal incontinence and frequency alone, despite the focus on these functional outcomes in the literature. See Video Abstract at http://links.lww.com/DCR/B73. LA FUNCIÓN INTESTINAL DESPUÉS DE LA BOLSA EN J PUEDE SER MÁS COMPLEJA DE LO QUE SE APRECIABA ANTERIORMENTE: UN ANÁLISIS EXHAUSTIVO PARA RESALTAR LAS BRECHAS DE CONOCIMIENTO EXISTENTES: Se han estudiado los resultados funcionales después de la bolsa en J para la colitis ulcerosa, pero carecen de estandarización en la que se informen los síntomas. Además, la selección de los síntomas estudiados no se ha centrado en el paciente.Utilizar una encuesta validada de la función intestinal para determinar qué síntomas están presentes después de la bolsa en J y si los pacientes muestran un perfil funcional similar al síndrome de resección anterior baja.Análisis retrospectivo de una base de datos de un solo centro mantenida prospectivamente.Centro de cirugía colorrectal de un hospital académico de atención terciaria.159 pacientes con bolsa en J, ≥6 meses después de la reversión de ileostomía.Instrumento para la función intestinal del "Memorial Sloan Kettering Cancer Center"; cohorte de validación original de instrumentos de función intestinal utilizada como comparación histórica (n = 127).La puntuación media total del instrumento de función intestinal para la cohorte de bolsa J fue 59.9 ± 9.7 en comparación con un puntaje promedio reportado de 63.7 ± 11.6 para pacientes con resección anterior baja en la cohorte de validación (p < 0.001), lo que indica peor función intestinal en pacientes con bolsa en J. Al evaluar las subescalas del instrumento de función intestinal, los pacientes con bolsa en J informaron puntuaciones de subescala de frecuencia de 18.2 ± 3.8, puntuaciones de dieta de 12.2 ± 3.8 y puntuaciones de urgencia de 15.9 ± 3.7, en comparación con 21.7 ± 4.5 (p < 0.001), 14.1 ± 3.7 (p < 0.001) y 15.0 ± 3.9 (p = 0.04) respectivamente para pacientes con resección rectal. Además, el 90.4% de los pacientes con bolsa en J afirman que a veces, rara vez o nunca pueden esperar 15 minutos para llegar al baño. Además, el 56.4% de los pacientes reportan haber tenido otra evacuación intestinal dentro de los 15 minutos posteriores a la última evacuación intestinal, a veces, siempre o la mayor parte del tiempo, y el 50.6% de los pacientes dicen que a veces, rara vez o nunca sienten que sus intestinos han sido vaciados totalmente después de una evacuación intestinal.Estudio en un solo centro, instrumento de función intestinal validado solo para pacientes con resección rectalLos pacientes que se someten a una bolsa en J exhiben una constelación de síntomas de la función intestinal que es más compleja que la incontinencia fecal y la frecuencia sola, a pesar del enfoque en estos resultados funcionales en la literatura.Consulte Video Resumen en http://links.lww.com/DCR/B73. (Traducción-Dr. Gonzalo Federico Hagerman).


Assuntos
Colite Ulcerativa/cirurgia , Bolsas Cólicas/efeitos adversos , Defecação/fisiologia , Complicações Pós-Operatórias/epidemiologia , Adulto , Análise por Conglomerados , Incontinência Fecal/epidemiologia , Feminino , Humanos , Ileostomia/tendências , Masculino , Pessoa de Meia-Idade , Período Perioperatório/efeitos adversos , Estudos Prospectivos , Estudos Retrospectivos , Índice de Gravidade de Doença , Estados Unidos/epidemiologia
8.
Surg Endosc ; 2019 Dec 16.
Artigo em Inglês | MEDLINE | ID: mdl-31844971

RESUMO

BACKGROUND: While the ACOSOG and ALaCaRT trials found that laparoscopic resections for rectal cancer failed to demonstrate non-inferiority of pathologic outcomes when compared with open resections, the COLOR II and COREAN studies demonstrated non-inferiority of clinical outcomes, leading to uncertainty regarding the value of minimally invasive (MIS) techniques in rectal cancer surgery. We analyzed differences in pathologic and clinical outcomes between open versus MIS resections for rectal cancer. METHODS: We identified patients who underwent resection for stage II or III rectal adenocarcinoma from the National Cancer Database (2010-2015). Surgical approach was categorized as open or MIS (laparoscopic or robotic). Logistic regression and Cox proportional hazard analysis were used to assess differences in outcomes and survival. Analysis was performed in an intention-to-treat fashion. RESULTS: A total of 31,190 patients who underwent rectal adenocarcinoma resection were identified, of whom 52.8% underwent open resection and 47.2% underwent MIS resection (31.0% laparoscopic, 16.2% robotic). After adjustment for patient, tumor, and institutional characteristics, MIS approaches were associated with significantly decreased risk of positive circumferential resection margins (OR 0.82, 95% CI 0.72-0.94), increased likelihood of harvesting ≥ 12 lymph nodes (OR 1.12, 95% CI 1.04-1.21), shorter length of stay (OR 0.57, 95% CI 0.53-0.62), and improved overall survival (HR 0.90, 95% CI 0.83-0.98). CONCLUSIONS: MIS approaches to rectal cancer resection were associated with improved pathologic and clinical outcomes when compared to the open approach. In this nationwide, facility-based sample of cancer cases in the United States, our data suggest superiority of MIS techniques for rectal cancer treatment.

9.
Dis Colon Rectum ; 62(11): 1283-1293, 2019 11.
Artigo em Inglês | MEDLINE | ID: mdl-31567917

RESUMO

BACKGROUND: Extramammary Paget's disease is an uncommon intraepidermal adenocarcinoma with poorly defined clinical implications. OBJECTIVE: The purpose of this research was to estimate the risk of second primary neoplasms in patients with extramammary Paget's disease. DESIGN: This was a retrospective analysis of the Surveillance, Epidemiology, and End Results Registry (1973-2014). SETTINGS: The study included population-based cancer registries from the United States. PATIENTS: Patients who were diagnosed with anogenital Paget's disease were included. MAIN OUTCOME MEASURES: Risk of second primary development was measured. RESULTS: We identified 108 patients with anal Paget's disease, 421 patients with male genital (scrotum or penis) Paget's, and 1677 patients with female genital (vagina or vulva) Paget's. Median follow-up time was 5.9 years. The risk of developing colorectal adenocarcinoma was 18.5% for patients with anal Paget's disease. Eighty percent of colorectal adenocarcinoma diagnoses were synchronous (within 2 mo) to anal Paget's diagnoses, whereas metachronous tumors occurred at a median time of 2.4 years. Of patients with anal Paget's disease, 8.3% developed an anal adenocarcinoma or nonsmall cell cancer. In male patients with genital Paget's, the risk of proximal genitourinary malignancy was 9.7%, scrotal or testicular adenocarcinoma was 0.4%, and penile or scrotal squamous carcinoma was 1.7%. In female patients with genital Paget's, the risk of proximal genitourinary malignancy was 3.0%, vaginal or vulvar adenocarcinoma was 1.4%, and vaginal or vulvar squamous neoplasm was 1.0%. Five-year overall survival was 59.7%, 73.5%, and 80.7% in patients with anal, male genital, and female genital Paget's (p < 0.001). LIMITATIONS: The registry did not record surveillance schedule, provider specialty, or nonprocedural therapies for extramammary Paget's disease. CONCLUSIONS: In the largest published cohort of patients with extramammary Paget's disease, patients with anal Paget's had a much higher risk of both proximal and local neoplasms as compared with patients with genital Paget's. Patients with anal Paget's also experienced worse survival as compared with those with purely genital Paget's. See Video Abstract at http://links.lww.com/DCR/B20. ALTO RIESGO DE NEOPLASIAS PROXIMALES Y LOCALES EN 2206 PACIENTES CON ENFERMEDAD DE PAGET EXTRAMAMARIA ANOGENITAL:: La enfermedad de Paget extramamaria es un adenocarcinoma intraepidérmico poco frecuente con implicaciones clínicas poco definidas.Estimar el riesgo de segundas neoplasias primarias en pacientes con enfermedad de Paget extramamaria.Análisis retrospectivo del Registro de Vigilancia, Epidemiología y Resultados Finales (1973-2014).Registros de base poblacional en cáncer de los Estados Unidos.Pacientes que fueron diagnosticados con enfermedad de Paget anogenital.Riesgo de desarrollo un cáncer primario adicional.Se identificaron 108 pacientes con Paget anal, 421 pacientes con Paget genital masculino (escroto o pene) y 1677 pacientes con Paget genital femenino (vagina o vulva). Tiempo mediano de seguimiento fue de 5,9 años. El riesgo de desarrollar adenocarcinoma colorrectal fue del 18,5% para los pacientes con Paget anal. El ochenta por ciento de los diagnósticos de adenocarcinoma colorrectal fueron sincrónicos (dentro de los 2 meses) a los diagnósticos de Paget anal, mientras que los tumores metacrónicos ocurrieron en un tiempo promedio de 2,4 años. De los pacientes con Paget anal, el 8.3% desarrolló un adenocarcinoma anal o cáncer de células no pequeñas. En los pacientes masculinos con Paget genital, el riesgo de malignidad genitourinaria proximal fue del 9,7%, el adenocarcinoma escrotal o testicular fue del 0,4% y el carcinoma escamoso del pene o escroto fue del 1,7%. En pacientes femeninas con Paget genital, el riesgo de malignidad genitourinaria proximal fue de 3.0%, el adenocarcinoma vaginal o vulvar fue de 1.4% y la neoplasia escamosa vaginal o vulvar fue de 1.0%. La supervivencia general a cinco años fue del 59.7%, 73.5% y 80.7% en pacientes con anal, genital masculino y genital femenino, respectivamente (p <0.001).El registro no señalo el cronograma de vigilancia, la especialidad del proveedor o las terapias sin procedimiento para la enfermedad de Paget extramamaria.En la cohorte más grande publicada de pacientes con enfermedad de Paget extramamaria, los pacientes con Paget anal demostraron un riesgo mucho mayor de neoplasias proximales y locales en comparación con los pacientes con Paget genital. Los pacientes con Paget anal además demostraron una peor supervivencia en comparación con aquellos con Paget aislada genital. Vea el Resumen del Video en http://links.lww.com/DCR/B20.


Assuntos
Adenocarcinoma , Neoplasias do Ânus , Neoplasias dos Genitais Femininos , Neoplasias dos Genitais Masculinos , Segunda Neoplasia Primária , Doença de Paget Extramamária , Adenocarcinoma/epidemiologia , Adenocarcinoma/patologia , Assistência ao Convalescente/estatística & dados numéricos , Idoso de 80 Anos ou mais , Neoplasias do Ânus/epidemiologia , Neoplasias do Ânus/patologia , Epiderme/patologia , Feminino , Neoplasias dos Genitais Femininos/epidemiologia , Neoplasias dos Genitais Femininos/patologia , Neoplasias dos Genitais Masculinos/epidemiologia , Neoplasias dos Genitais Masculinos/patologia , Humanos , Masculino , Massachusetts/epidemiologia , Estadiamento de Neoplasias , Segunda Neoplasia Primária/epidemiologia , Segunda Neoplasia Primária/patologia , Doença de Paget Extramamária/epidemiologia , Doença de Paget Extramamária/patologia , Sistema de Registros/estatística & dados numéricos , Estudos Retrospectivos , Medição de Risco , Análise de Sobrevida
10.
Eur J Nucl Med Mol Imaging ; 46(11): 2260-2269, 2019 Oct.
Artigo em Inglês | MEDLINE | ID: mdl-31359108

RESUMO

PURPOSE: The primary aim of the present study was to evaluate if PET/MR induced management changes versus standard of care imaging (SCI) in treated colorectal cancer patients. The secondary aim was to assess the staging performance of PET/MR and of SCI versus the final oncologic stage. METHODS: Treated CRC patients who underwent PET/MR with 18F-FDG and SCI between January 2016 and October 2018 were enrolled in this retrospective study. Their medical records were evaluated to ascertain if PET/MR had impacted on their clinical management versus SCI. The final oncologic stage, as reported in the electronic medical record, was considered the true stage of disease. RESULTS: A total of 39 patients who underwent 42 PET/MR studies were included, mean age 56.7 years (range 39-75 years), 26 males, and 13 females. PET/MR changed clinical management 15/42 times (35.7%, standard error ± 7.4%); these 15 changes in management were due to upstaging in 9/42 (21.5%) and downstaging in 6/42 (14.2%). The differences in management prompted by SCI versus PET/MR were statistically significant, and PET/MR outperformed SCI (P value < 0.001; odds ratio = 2.8). In relation to the secondary outcome, PET/MR outperformed the SCI in accuracy of oncologic staging (P value = 0.016; odds ratio = 4.6). CONCLUSIONS: PET/MR is a promising imaging tool in the evaluation of treated CRC and might change the management in these patients. However, multicenter prospective studies with larger patient samples are required in order to confirm these preliminary results.

11.
Am Surg ; 85(5): 462-465, 2019 May 01.
Artigo em Inglês | MEDLINE | ID: mdl-31126356

RESUMO

In this study, we determine outcomes after nonoperative treatment of appendicitis. First, we abstracted data for patients discharged with a diagnosis of appendicitis from a tertiary care facility from August 1, 2007, through June 30, 2017. For patients treated nonoperatively, we collected additional medical treatment for appendicitis, future surgical treatment, and date of last follow-up. In our study, we identified 487 patients treated for appendicitis. From this group, 66 patients were successfully treated nonoperatively. Eight patients (12%) had an interval appendectomy at a mean follow-up time of two months. Of the 58 remaining patients, 20 (34%) did not have any further appendicitis-related issues over a mean follow-up period of 25 months. A total of 38 (66%) had recurring or additional concerns requiring further treatment or emergent surgery within a mean time of four months. A large proportion, 76 per cent (n = 29), required unscheduled or emergent appendectomy. There were more patients diagnosed with an abscess (55%) in the group that had further appendicitis issues. In conclusion, nonoperative treatment of appendicitis is associated with significant likelihood of future appendicitis-related treatment or emergency surgery (66%). In addition, patients diagnosed with an abscess are at particularly high risk of future appendicitis-related issues.


Assuntos
Apendicite/terapia , Adulto , Apendicectomia , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Recidiva , Estudos Retrospectivos , Fatores de Tempo , Resultado do Tratamento
12.
Dis Colon Rectum ; 62(6): e36, 2019 06.
Artigo em Inglês | MEDLINE | ID: mdl-31094973
13.
Dis Colon Rectum ; 62(5): e22-e23, 2019 05.
Artigo em Inglês | MEDLINE | ID: mdl-30964798
15.
Int J Colorectal Dis ; 34(3): 491-499, 2019 Mar.
Artigo em Inglês | MEDLINE | ID: mdl-30610435

RESUMO

PURPOSE: Many surgeons assume 3-stage ileal pouch-anal anastomosis (IPAA) is safer than 2-stage IPAA in patients with active ulcerative colitis (UC), although recent data suggest outcomes are comparable. This study aimed to compare perioperative complications, late complications, and functional outcomes after 2- versus 3-stage IPAA in patients with active UC. METHODS: A retrospective review was conducted of patients who underwent 2- or 3-stage IPAA for active UC from 2000 to 2015 in a high-volume institution. Patients completed quality-of-life surveys 6 months following ileostomy reversal. Perioperative and late complications were recorded. Outcomes were compared with the Fisher exact test, and multivariable logistic regression was used to adjust for potential confounders. RESULTS: We identified 212 patients who underwent 2- or 3-stage IPAA for active UC, of whom 157 patients (74.1%) underwent 2-stage procedures and 55 (25.9%) underwent 3-stage procedures. More patients undergoing 2-stage procedures were taking immunomodulators preoperatively (46.3% vs. 23.1%, p = 0.01), but there was no difference in use of steroids (p = 0.09) or biologic agents (p = 0.85). Three-stage procedures were more likely to be urgent (78.6% vs. 30.2%, p < 0.001). There were no differences in perioperative complications (p = 0.50), anastomotic leak (p = 0.94), pouchitis (p = 0.45), pouch failure (p = 0.46), perceived quality of life (p = 0.68), number of bowel movements per day (p = 0.27), or sexual satisfaction (p = 0.21) between the 2- and 3-stage groups. CONCLUSIONS: Patients undergoing 2-stage compared to 3-stage IPAA for active ulcerative colitis have comparable outcomes and quality of life following ileostomy reversal. Two-stage IPAA appears to be safe and appropriate, even in high-risk patients.


Assuntos
Canal Anal/cirurgia , Colite Ulcerativa/patologia , Colite Ulcerativa/cirurgia , Bolsas Cólicas , Proctocolectomia Restauradora , Qualidade de Vida , Adulto , Anastomose Cirúrgica , Estudos de Coortes , Feminino , Humanos , Masculino , Análise Multivariada , Estadiamento de Neoplasias , Complicações Pós-Operatórias/etiologia , Estudos Retrospectivos , Inquéritos e Questionários , Fatores de Tempo , Resultado do Tratamento
16.
Dis Colon Rectum ; 62(2): 241-247, 2019 02.
Artigo em Inglês | MEDLINE | ID: mdl-30640836

RESUMO

BACKGROUND: Hospital readmission and anastomotic leak following colorectal resection have a negative impact on patients, surgeons, and the health care system. Novel markers of patients unlikely to experience these complications are of value in avoiding readmission. OBJECTIVE: This study aimed to determine the predictive value of C-reactive protein for readmission and anastomotic leak within 30 days following colorectal resection. DESIGN: This is a retrospective review of a prospectively compiled single-institution database. PATIENTS: From January 1, 2013, to July 20, 2017, consecutive patients undergoing elective colorectal resection with anastomosis without the presence of proximal intestinal stoma, who had C-reactive protein measured on postoperative day 3, were included. MAIN OUTCOME MEASURES: The primary outcome measured was the predictive value of C-reactive protein measured on postoperative day 3 for readmission or anastomotic leak within 30 days after colorectal resection. RESULTS: Of the 752 patients examined, 73 (10%) were readmitted within 30 days of surgery and 17 (2%) had an anastomotic leak. Mean C-reactive protein in patients who neither had an anastomotic leak nor were readmitted (127 ± 77 mg/L) was lower than for patients who were readmitted (157 ± 96 mg/L, p = 0.002) and lower than for patients who had an anastomotic leak (228 ± 123 mg/L, p = 0.0000002). The area under the receiver operating characteristic curve for the diagnostic accuracy of C-reactive protein for readmission was 0.59, with a cutoff value of 145 mg/L, generating a 93% negative predictive value. The area under the curve for the diagnostic accuracy of C-reactive protein for anastomotic leak was 0.76, with a cutoff value of 147 mg/L generating a 99% negative predictive value. LIMITATIONS: This study was limited by its retrospective design and because all patients were treated at a single center. CONCLUSIONS: Patients with a C-reactive protein below 145 mg/L on postoperative day 3 after colorectal resection have a low likelihood of readmission within 30 days, and a very low likelihood of anastomotic leak. See Video Abstract at http://links.lww.com/DCR/A761.


Assuntos
Fístula Anastomótica/epidemiologia , Proteína C-Reativa/metabolismo , Colectomia , Readmissão do Paciente/estatística & dados numéricos , Protectomia , Idoso , Fístula Anastomótica/metabolismo , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Período Pós-Operatório , Prognóstico , Estudos Retrospectivos , Medição de Risco
17.
Surg Infect (Larchmt) ; 20(1): 35-38, 2019 Jan.
Artigo em Inglês | MEDLINE | ID: mdl-30234435

RESUMO

BACKGROUND: Surgical site infection (SSI) remains a persistent and morbid problem in colorectal surgery. A novel surgical device that combines barrier surgical wound protection and continuous surgical wound irrigation was evaluated in a cohort of elective colorectal surgery patients. A retrospective analysis was performed comparing rates of SSI observed in a prospective cohort study with the predicted rate of SSI using the American College of Surgeons (ACS) National Surgical Quality Improvement Program (NSQIP) Risk Calculator. PATIENTS AND METHODS: A prospective multi-center study of colectomy patients was conducted using a study device for surgical site retraction and protection, as well as irrigation of the incision. Patients were followed for 30 days after the surgical procedure to assess for SSI. After completion of the study, patients' characteristics were inserted into the ACS-NSQIP Risk Calculator to determine the predicted rate of SSI for the given patient population and compared with the observed rate in the study. RESULTS: A total of 108 subjects were enrolled in the study. The observed rate of SSI in the prospective study using the novel device was 3.7% (4/108). The predicted rate of SSI in the same patient population utilizing the ACS-NSQIP Risk Calculator was estimated to be 9.5%. This demonstrated a 61% difference (3.7% vs. 9.5%, p = 0.04) in SSI from the NSQIP predicted rate with the use of the irrigating surgical wound protection and retraction device. CONCLUSIONS: These data suggest the use of a novel surgical wound protection device seems to reduce the rate of SSIs in colorectal surgery.


Assuntos
Colectomia/efeitos adversos , Colectomia/métodos , Infecção da Ferida Cirúrgica/epidemiologia , Infecção da Ferida Cirúrgica/prevenção & controle , Irrigação Terapêutica/métodos , Adulto , Idoso , Idoso de 80 Anos ou mais , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Estudos Prospectivos , Resultado do Tratamento
18.
Dis Colon Rectum ; 62(1): 63-70, 2019 01.
Artigo em Inglês | MEDLINE | ID: mdl-30451749

RESUMO

BACKGROUND: Many patients with fecal incontinence report coexisting constipation. This subset of patients has not been well characterized or understood. OBJECTIVE: The purpose of this study was to report the frequency of fecal incontinence with concurrent constipation and to compare quality-of-life outcomes of patients with fecal incontinence with and without constipation. DESIGN: This was a prospective cohort study. Survey data, including Fecal Incontinence Severity Index, Constipation Severity Instrument, Fecal Incontinence Quality of Life survey (categorized as lifestyle, coping, depression, and embarrassment), Pelvic Organ Prolapse Inventory and Urinary Distress Inventory surveys, and anorectal physiology testing were obtained. SETTINGS: The study was conducted as a single-institution study from January 2007 to January 2017. PATIENTS: Study patients had fecal incontinence presented to a tertiary pelvic floor center. MAIN OUTCOME MEASURES: Quality-of-life survey findings were measured. RESULTS: A total of 946 patients with fecal incontinence were identified, and 656 (69.3%) had coexisting constipation. Patients with fecal incontinence with constipation were less likely to report a history of pregnancy (89.2% vs 91.4%; p = 0.001) or complicated delivery, such as requiring instrumentation (9.1% vs 18.1%; p = 0.005), when compared with patients with isolated fecal incontinence. Patients with fecal incontinence with constipation had higher rates of coexisting pelvic organ prolapse (Pelvic Organ Prolapse Inventory: 18.4 vs 8.2; p < 0.01), higher rates of urinary incontinence (Urinary Distress Inventory: 30.2 vs 23.4; p = 0.01), and higher pressure findings on manometry; intussusception on defecography was common. Patients with fecal incontinence with concurrent constipation had less severe incontinence scores at presentation (21.0 vs 23.8; p < 0.001) and yet lower overall health satisfaction (28.9% vs 42.5%; p < 0.001). Quality-of-life scores declined as constipation severity increased for lifestyle, coping, depression, and embarrassment. LIMITATIONS: This was a single-institution study, and surgeon preference could bias population and anorectal physiology testing. CONCLUSIONS: Patients with fecal incontinence with concurrent constipation represent a different disease phenotype and have different clinical and anorectal physiology test findings and worse overall quality of life. Treatment of these patients requires careful consideration of prolapse pathology with coordinated treatment of coexisting disorders. See Video Abstract at http://links.lww.com/DCR/A783.


Assuntos
Constipação Intestinal/complicações , Constipação Intestinal/diagnóstico , Incontinência Fecal/complicações , Incontinência Fecal/diagnóstico , Fenótipo , Qualidade de Vida , Índice de Gravidade de Doença , Adulto , Idoso , Estudos de Casos e Controles , Constipação Intestinal/fisiopatologia , Incontinência Fecal/fisiopatologia , Feminino , Indicadores Básicos de Saúde , Humanos , Masculino , Pessoa de Meia-Idade , Estudos Prospectivos
19.
Dis Colon Rectum ; 62(1): 56-62, 2019 01.
Artigo em Inglês | MEDLINE | ID: mdl-30451752

RESUMO

BACKGROUND: Recently, there has been a trend toward surgical management of internal intussusception despite an unclear correlation with constipation symptoms. OBJECTIVE: This study characterizes constipation in patients with obstructed defecation syndrome and identifies whether internal intussusception or other diagnoses such as irritable bowel syndrome may be contributing to symptoms. DESIGN: Patients evaluated for obstructed defecation at a pelvic floor disorder center were studied from a prospectively maintained database. With the use of defecography, patients were classified by Oxford Rectal Prolapse Grade. Coexisting disorders such as enterocele, rectocele, and dyssynergia were also identified. The presence of irritable bowel syndrome was defined using Rome IV criteria, and constipation severity was quantified with the Varma constipation severity instrument. SETTINGS: This study was conducted at a tertiary care university medical center (Massachusetts General Hospital). PATIENTS: The study included 317 consecutive patients with defecography imaging and a completed constipation severity instrument survey from May 2007 to July 2016. MAIN OUTCOME MEASURES: The primary outcome measures were the Varma Constipation Severity Instrument overall score and obstructed defecation subscale score. RESULTS: Of 317 patients evaluated, 95 (30.0%) had no internal intussusception, 126 (39.7%) had intra-rectal intussusception, and 96 (30.3%) had intra-anal intussusception. There was no association between rising grade of internal intussusception and either overall constipation score or obstructed defecation subscale score. Irritable bowel syndrome was associated with an increase in overall constipation score and obstructed defecation subscale score (40.5 ± 13.6 vs 36.0 ± 15.1, p = 0.007, and 22.3 ± 5.8 vs 20.0 ± 6.6, p < 0.001). Multivariate regression found irritable bowel syndrome and dyssynergia to be associated with a significant increase in obstructed defecation subscale scores. LIMITATIONS: The study was limited because it was an observational study from a single center. CONCLUSIONS: Patients referred for surgical management of obstructive defecation syndrome should be screened and treated for irritable bowel syndrome and dyssynergia before considering surgical intervention. See Video Abstract at http://links.lww.com/DCR/A782.


Assuntos
Constipação Intestinal/etiologia , Intussuscepção/complicações , Síndrome do Intestino Irritável/complicações , Distúrbios do Assoalho Pélvico/complicações , Doenças Retais/complicações , Adulto , Idoso , Feminino , Humanos , Intussuscepção/diagnóstico , Síndrome do Intestino Irritável/diagnóstico , Modelos Lineares , Masculino , Pessoa de Meia-Idade , Distúrbios do Assoalho Pélvico/diagnóstico , Estudos Prospectivos , Doenças Retais/diagnóstico , Fatores de Risco
20.
Dis Colon Rectum ; 62(1): 71-78, 2019 01.
Artigo em Inglês | MEDLINE | ID: mdl-30451762

RESUMO

BACKGROUND: Current guidelines accept partial colectomy and primary anastomosis with proximal diversion for select patients with perforated diverticulitis based on low-quality evidence. OBJECTIVE: This study aimed to compare the effect of operative approach and surgeon training on outcomes following urgent/emergent colectomy for diverticulitis. DESIGN: This is a statewide retrospective cohort study. SETTING: Data were obtained from the New York State all-payer sample from 2000 to 2014. PATIENTS: All patients who underwent an urgent/emergent sigmoid colectomy for diverticulitis with creation of an end colostomy or primary anastomosis with proximal diversion were included. We excluded all patients age <18 years, with IBD, colorectal cancer, ischemic colitis, or elective operations. MAIN OUTCOME MEASURES: The main outcomes measured were postoperative in-hospital mortality and complications, RESULTS:: A total of 10,780 patients underwent urgent/emergent colectomy for diverticulitis: 10,600 (98.3%) received a Hartmann procedure and 180 (1.7%) received primary anastomosis with proximal diversion. Colorectal surgeons performed 6.0% of all operations. Utilization of primary anastomosis with proximal diversion was greater among colorectal surgeons but remained low overall (4.2% vs 1.5%; p < 0.001). Postoperative mortality was 2-fold greater when noncolorectal surgeons performed primary anastomosis vs Hartmann procedure (15% vs 7.4%; p < 0.001) and 1.4 times greater among noncolorectal surgeons than among colorectal surgeons (7.5% vs 5.3%; p = 0.04). On multivariable logistic regression (adjusting for patient demographics/characteristics, year, hospital academic status, and surgeon training) primary anastomosis with proximal diversion remained associated with increased mortality (OR, 2.7; 95% CI,1.7-4.4; p < 0.001), complications (OR, 1.8; 95% CI, 1.3-2.5; p < 0.001), and reoperation (OR, 3.4; 95% CI, 1.8-6.3; p < 0.001), whereas colorectal board certification was associated with decreased mortality (OR, 0.66; 95% CI, 0.46-0.95; p = 0.03). LIMITATIONS: Selection bias secondary to retrospective nature and absence of disease severity were limitations of this study. CONCLUSIONS: Despite current recommendations for primary anastomosis with proximal diversion for perforated diverticulitis, this operation in New York State was associated with increased postoperative morbidity and mortality when performed by general surgeons. Given that the majority of urgent/emergent colectomies for diverticulitis are not performed by colorectal surgeons, guidelines for operative management of perforated diverticulitis should be reevaluated. See Video Abstract at http://links.lww.com/DCR/A772.


Assuntos
Colectomia/métodos , Cirurgia Colorretal/educação , Doença Diverticular do Colo/cirurgia , Cirurgia Geral/educação , Padrões de Prática Médica/estatística & dados numéricos , Doença Aguda , Adolescente , Adulto , Idoso , Idoso de 80 Anos ou mais , Anastomose Cirúrgica , Colectomia/educação , Colectomia/estatística & dados numéricos , Emergências , Feminino , Mortalidade Hospitalar , Humanos , Modelos Logísticos , Masculino , Pessoa de Meia-Idade , New York , Complicações Pós-Operatórias/epidemiologia , Complicações Pós-Operatórias/etiologia , Guias de Prática Clínica como Assunto , Estudos Retrospectivos , Resultado do Tratamento , Adulto Jovem
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