Nationwide volume-outcome relationship concerning in-hospital mortality and failure-to-rescue in surgery of sigmoid diverticulitis.

PURPOSE: A correlation between the hospital volume and outcome is described for multiple entities of oncological surgery. To date, this has not been analyzed for the surgical treatment of sigmoid diverticulitis. The aim of this study was to explore the impact of the annual caseload per hospital of colon resection on the postoperative incidence of complications, failure to rescue, and mortality in patients with diverticulitis. METHODS: Patients receiving colorectal resection independent from the diagnosis from 2012 to 2017 were selected from a German nationwide administrative dataset. The hospitals were grouped into five equal caseload quintiles (Q1-Q5 in ascending caseload order). The outcome analysis was focused on patients receiving surgery for sigmoid diverticulitis. RESULTS: In total, 662,706 left-sided colon resections were recorded between 2012 and 2017. Of these, 156,462 resections were performed due to sigmoid diverticulitis and were included in the analysis. The overall in-house mortality rate was 3.5%, ranging from 3.8% in Q1 (mean of 9.5 procedures per year) to 3.1% in Q5 (mean 62.8 procedures per year; p < 0.001). Q5 hospitals revealed a risk-adjusted odds ratio of 0.85 (95% CI 0.78-0.94; p < 0.001) for in-hospital mortality compared to Q1 during multivariable logistic regression analysis. High-volume centers showed overall lower complication rates, whereas the failure-to-rescue did not differ significantly. CONCLUSION: Surgical treatment of sigmoid diverticulitis in high-volume colorectal centers shows lower postoperative mortality rates and fewer postoperative complications.

Increased Transumbilical Incision Complication Rates With Laparoscopic Colorectal Resection: A Single-center Propensity Score-matched Cohort Study.

AIM: To evaluate the complication rates and risk factors associated with transumbilical incision (TUI) and comprehensively examine differences according to the procedures using propensity score matching. PATIENTS AND METHODS: The study involved 737 patients who underwent laparoscopic procedures between 2009 and 2017 (Japanese University-Hospital-Medical-Information-Network Clinical Trials Resistry No. 000040653). The occurrences of superficial surgical site infection (SSI) and TUI hernia were analyzed. RESULTS: SSI occurred in 17 patients (2.31%) and hernia occurred in 29 (3.93%). Multivariate analysis revealed that female sex and diabetes mellitus were correlated with incisional hernia. Propensity score-matching analysis was performed to compare those who underwent colorectal resection with those who underwent other resections; the results showed that the former had a significantly higher rate of TUI hernia (p<0.001), as well as a significantly higher incidence of SSI (p=0.004). CONCLUSION: A significant higher incidence of SSI and TUI hernia in laparoscopic colorectal resection was found. The construction of the TUI was feasible with rationality.

Tasas de colectomía en colitis ulcerosa 15 años después del diagnóstico. Datos de la cohorte Navarra 2001-2003 / Colectomy rate in ulcerative colitis 15 years after diagnosis: Results from the 2001-2003 Navarra cohort

Introducción: Conocer la historia natural de la colitis ulcerosa (CU) es esencial para entender la evolución de la enfermedad, evaluar el impacto de las distintas estrategias terapéuticas e identificar factores de mal pronóstico. Uno de los aspectos más relevantes, en este sentido, es la necesidad de cirugía.Objetivos: Analizar la tasa de incidencia de colectomía (TIC) desde el diagnóstico hasta el fin de seguimiento (31 de diciembre del 2017) e identificar factores predictivos de colectomía.Material y métodos: Estudio retrospectivo que incluye los pacientes con diagnóstico definitivo (DD) de CU o colitis inclasificable (CI) en la cohorte Navarra 2001 a 2003.Resultados: Incluimos 174 pacientes con DD de CU (E2 42,8% - E3 26,6%) y cinco de CI: 44,1% mujeres, mediana edad 39,2 años (rango siete a 88), mediana de seguimiento 15,7 años. Se intervienen ocho pacientes (TIC tres colectomías/103pac/a): tres al debut (< 1 mes), dos en los primeros dos años, dos a los cinco años y uno a los 12 años de evolución. Todos habían recibido esteroides, cinco inmunomoduladores y dos biológicos. En siete (87%) la cirugía fue urgente y la indicación, megacolon en tres (37,5%), brote grave en tres (37,5%) y fallo a tratamiento médico en dos (25%). En cinco casos (62,5%) se realizó un reservorio ileoanal y en tres una ileostomía definitiva. En el análisis univariante, los pacientes con pérdida > 5 kg e ingreso al debut presentaron una menor supervivencia libre de colectomía.Conclusiones: En nuestra serie, las tasas de colectomía son más bajas que las comunicadas habitualmente, mayoritariamente se realizan en los primeros cinco años de evolución y se indican con carácter urgente

Introduction: Knowing the natural history of ulcerative colitis (UC) is essential to understand the course of the disease, assess the impact of different treatment strategies and identify poor prognostic factors. One of the most significant matters in this regard is the need for surgery.Objectives: To analyse the Colectomy Incidence Rate (CIR) from diagnosis to end of follow-up (31/12/2017) and identify predictive factors for colectomy.Material and methods: A retrospective study enrolling patients with a definitive diagnosis (DD) of UC or Unclassified Colitis (UnC) in the 2001-03 Navarra cohort.Results: We enrolled 174 patients with a DD of UC (E2 42.8%; E3 26.6%) and 5 patients with a DD of UnC: 44.1% women, median age 39.2 years (range 7-88) and median follow-up 15.7 years. A total of 8 patients underwent surgery (CIR 3 colectomies/103 patient-years: 3 at initial diagnosis (<1 month), 2 in the first 2 years, 2 at 5 years from diagnosis and 1 at 12 years from diagnosis. All had previously received steroids; 5 had received immunomodulators and 2 had received biologics. In 7 patients (87%), surgery was performed on an emergency basis. The indication was megacolon in 3 (37.5%), severe flare-up in 3 (37.5%) and medical treatment failure in 2 (25%). In 5 cases (62.5%), an ileoanal pouch was made, and in 3 cases, a definitive ileostomy was performed. In the univariate analysis, patients with loss of more than 5 kg at diagnosis and admission at diagnosis had a lower rate of colectomy-free survival.Conclusions: In our series, colectomy rates are lower than usually reported. Most colectomies were performed in the first 5 years following diagnosis and had an emergency indication

What Is the Optimal Elective Colectomy for Splenic Flexure Cancer: End of the Debate? A Multicenter Study From the GRECCAR Group With a Propensity Score Analysis.

BACKGROUND: The optimal elective colectomy in patients with splenic flexure tumor is debated. OBJECTIVE: This study aimed to compare splenic flexure colectomy, left hemicolectomy, and subtotal colectomy for perioperative, histological, and survival outcomes in this setting. DESIGN: This is a multicenter retrospective cohort study. SETTING: Patients diagnosed with nonmetastatic splenic flexure tumor who underwent elective colectomy were included. PATIENTS: Between 2006 and 2014, 313 consecutive patients were operated on in 15 French Research Group of Rectal Cancer Surgery centers. INTERVENTIONS: Propensity score weighting was performed to compare short- and long-term outcomes. MAIN OUTCOME MEASURES: The primary end point was disease-free survival. Secondary end points included overall survival, quality of surgical resection, overall postoperative morbidity, surgical postoperative morbidity, and rate of anastomotic leakage. RESULTS: The most performed surgery was splenic flexure colectomy (59%), followed by subtotal colectomy (23%) and left hemicolectomy (18%). Subtotal colectomy was more often performed by laparotomy compared with splenic flexure colectomy and left hemicolectomy (93% vs 61% vs 56%, p < 0.0001), and was associated with a longer operative time (260 minutes (120-460) vs 180 minutes (68-440) vs 217 minutes (149-480), p < 0.0001). Postoperative morbidity was similar between the 3 groups, but the median length of hospital stay was significantly longer after subtotal colectomy (13 days (5-56) vs 10 (4-175) vs 9 (4-55), p = 0.0007). The median number of harvested lymph nodes was significantly higher after subtotal colectomy compared with splenic flexure colectomy and left hemicolectomy (24 (8-90) vs 15 (1-81) vs 16 (3-52), p < 0.0001). The rate of stage III disease and the number of patients treated by adjuvant chemotherapy were similar between the 3 groups. There was no difference in terms of disease-free survival and overall survival between the 3 procedures. LIMITATIONS: The study was limited by its retrospective design. CONCLUSIONS: In the elective setting, splenic flexure colectomy is safe and oncologically adequate for patients with nonmetastatic splenic flexure tumor. However, given the oncological clearance after splenic flexure colectomy, it seems that the debate is not completely closed. See Video Abstract at http://links.lww.com/DCR/B703. CUL ES LA COLECTOMA ELECTIVA PTIMA PARA EL CNCER DE NGULO ESPLNICO FIN DEL DEBATE UN ESTUDIO MULTICNTRICO DEL GRUPO GRECCAR CON UN ANLISIS DE PUNTAJE DE PROPENSIN: ANTECEDENTES:La colectomía electiva óptima en pacientes con tumores del ángulo esplénico continua en debate.OBJETIVO:Comparar la colectomía de ángulo esplénico, hemicolectomía izquierda y colectomía subtotal para los resultados perioperatorios, histológicos y de supervivencia en este escenario.DISEÑO:Estudio de cohorte retrospectivo multicéntrico.ESCENARIO:Se incluyeron pacientes diagnosticados de tumores del ángulo esplénico no metastásicos que se sometieron a colectomía electiva.PACIENTES:Entre 2006 y 2014, 313 pacientes consecutivos fueron intervenidos en 15 centros GRECCAR.INTERVENCIONES:Se realizó una ponderación del puntaje de propensión para comparar los resultados a corto y largo plazo.PRINCIPALES MEDIDAS DE RESULTADO:El criterio de valoración principal fue la supervivencia libre de enfermedad. Los criterios de valoración secundarios incluyeron la supervivencia general, la calidad de la resección quirúrgica, la morbilidad posoperatoria general, la morbilidad posoperatoria quirúrgica y la tasa de fuga anastomótica.RESULTADOS:La cirugía más realizada fue la colectomía del ángulo esplénico (59%), seguida de la colectomía subtotal (23%) y la hemicolectomía izquierda (18%). La colectomía subtotal se realizó con mayor frecuencia mediante laparotomía en comparación con la colectomía de ángulo esplénico y la hemicolectomía izquierda (93% frente a 61% frente a 56%, p <0.0001), y se asoció con un tiempo quirúrgico más prolongado (260 min [120-460] frente a 180 min [68-440] frente a 217 min [149-480], p <0.0001). La morbilidad posoperatoria fue similar entre los tres grupos, pero la duración media de la estancia hospitalaria fue significativamente más prolongada después de la colectomía subtotal (13 días [5-56] frente a 10 [4-175] frente a 9 [4-55], p = 0.0007). La mediana del número de ganglios linfáticos extraídos fue significativamente mayor después de la colectomía subtotal en comparación con la colectomía del ángulo esplénico y la hemicolectomía izquierda (24 [8-90] frente a 15 [1-81] frente a 16 [3-52], p <0.0001). La tasa de enfermedad en estadio III y el número de pacientes tratados con quimioterapia adyuvante fueron similares entre los 3 grupos. No hubo diferencias en términos de supervivencia libre de enfermedad y supervivencia general entre los 3 procedimientos.LIMITACIONES:El estudio estuvo limitado por su diseño retrospectivo.CONCLUSIONES:En un escenario electivo, la colectomía del ángulo esplénico es segura y oncológicamente adecuada para pacientes con tumores del ángulo esplénico no metastásicos. Sin embargo, dado el aclaramiento oncológico tras la colectomía del ángulo esplénico, parece que el debate no está completamente cerrado. Consulte Video Resumen en http://links.lww.com/DCR/B703.

Short-term effectiveness and safety of tofacitinib in ulcerative colitis - real world data from tertiary medical centers in Israel.

BACKGROUND: We sought to define the effectiveness and safety of tofacitinib in a real-world (RW) cohort of Israeli patients with moderate to severe ulcerative colitis (UC). METHODS: This was a multi-center retrospective observational cohort study (2019-2020) to assess the effectiveness and safety of tofacitinib induction and maintenance therapy up to 26 weeks. Clinical response and remission were defined as a reduction in Simple Clinical Colitis Activity Index (SCCAI) or partial Mayo score (PMS) of ≥3 points, and SCCAI ≤2 or a PMS ≤1, respectively. RESULTS: We included 73 patients, 47% male; median age 26 years [IQR: 19.5-39.5], disease duration 7 years [IQR: 2.5-14.5], follow-up 7.1 months [IQR: 3-12], 91% biologics-experienced, and 74% ≥ 2-biologics. Half of patients used concomitant corticosteroids (CS). Overall, 56.1% discontinued therapy due to either lack of response and/or adverse events (AEs), median time to discontinuation - 9.7 months [IQR 3.4-16]. Overall, response, remission, and CS-free-remission were achieved in 47.6%, 20.6%, and 17.5% of patients, respectively. At early maintenance (week 26), response, remission, and CS-free-remission were achieved in 65%, 22.5%, and 20% of patients, respectively. At week 26, tofacitinib 10 mg BID was still used in 43%. Seventeen patients (23.2%) had an adverse event including herpes zoster- 2.7%, hospitalization- 12.3%, and colectomy- 2.7%. CONCLUSIONS: Tofacitinib was effective in achieving CS-free-remission in about 1/5 of highly biologics -experienced patients with UC. Despite a considerable proportion of patients maintained on tofacitinib 10 mg bid, it was well tolerated and safe. Earlier positioning of tofacitinib in the therapeutic algorithm may result in improved outcomes.

Can the American College of Surgeons National Surgical Quality Improvement Program Risk Calculator Predict Outcomes for Urgent Colectomies?

BACKGROUND: The American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) Risk Calculator (RC) predicts postoperative outcomes using 19 risk factors, including operative acuity. Acuity is defined by the calculator as emergent or elective only. The objective of this study is to evaluate the RC's accuracy in urgent (nonelective/nonemergent) cases. METHODS: This is a retrospective review of the NSQIP data for patients who underwent urgent colectomies at a single tertiary care center over a 4-year period. Each urgent case was entered into the RC as both elective and emergent, and predicted outcomes were compared to actual postoperative outcomes. Receiver operating characteristic (ROC) curves were used when sufficient statistical power was present and the area under the curve (AUC) was calculated. RESULTS: A total of 301 urgent colectomy patients were evaluated, representing 19% of all colectomies performed at our institution during the study period. Of the 15 possible postoperative outcomes, the RC showed high predictive value only for mortality (AUC elective .8467; emergent .8451) and discharge to a nursing/rehabilitation facility (AUC elective .8089; emergent .8105). The RC showed no predictive value for 6 outcomes and the remainder lacked statistical power to draw conclusions. DISCUSSION: While the calculator predicted mortality and discharge to a nursing/rehabilitation facility, it did not accurately predict complications for urgent colectomies. Future versions of the calculator should focus on improving the predictive value by including urgent cases as a separate category.

Defining a minimum hospital volume threshold for minimally invasive colon cancer resections.

BACKGROUND: Laparoscopic colectomy is considered the standard of care in colon cancer treatment when appropriate expertise is available. However, guidelines do not delineate what experience is required to implement this approach safely and effectively. This study aimed to establish a data-derived, hospital-level annual volume threshold for laparoscopic colectomy at which patient outcomes are optimized. METHODS: This evaluation included 44,157 stage I to III adenocarcinoma patients aged ≥40 years who underwent laparoscopic colon resection between 2010 and 2015 within the National Cancer Database. The primary outcome was overall survival, with 30- and 90-day mortality, duration of stay, days to receipt of chemotherapy, and number of lymph nodes examined as secondary. Segmented logistic and Cox regression models were used to identify volume thresholds which optimized these outcomes. RESULTS: In hospitals performing ≥30 laparoscopic colectomies per year there were incremental improvements in overall survival for each additional resection beyond 30. Hospitals performing ≥30 procedures/year demonstrated improved 30-day mortality (1.3% vs 1.7%, P < .001), 90-day mortality (2.3% vs 2.9%, P < .001), and overall survival (84.3% vs 82.3%, P < .001). Those hospitals performing <30 procedures/year had no significant benefit in overall survival. Thresholds were not identified for any other outcomes. Results were comparable in colon cancer patients with stage IV or multiple cancers. CONCLUSION: A high-volume hospital threshold of ≥30 cases/year for laparoscopic colectomies is associated with improved patient survival and outcomes. A minimum volume standard may help providers determine which approach is most suitable for their hospital's practice as open procedures may yield better oncologic results in low volume settings.

Colectomy rate in ulcerative colitis 15 years after diagnosis: Results from the 2001-2003 Navarra cohort. / Tasas de colectomía en colitis ulcerosa 15 años después del diagnóstico. Datos de la cohorte Navarra 2001-2003.

INTRODUCTION: Knowing the natural history of ulcerative colitis (UC) is essential to understand the course of the disease, assess the impact of different treatment strategies and identify poor prognostic factors. One of the most significant matters in this regard is the need for surgery. OBJECTIVES: To analyse the Colectomy Incidence Rate (CIR) from diagnosis to end of follow-up (31/12/2017) and identify predictive factors for colectomy. MATERIAL AND METHODS: A retrospective study enrolling patients with a definitive diagnosis (DD) of UC or Unclassified Colitis (UnC) in the 2001-03 Navarra cohort. RESULTS: We enrolled 174 patients with a DD of UC (E2 42.8%; E3 26.6%) and 5 patients with a DD of UnC: 44.1% women, median age 39.2 years (range 7-88) and median follow-up 15.7 years. A total of 8 patients underwent surgery (CIR 3 colectomies/103 patient-years: 3 at initial diagnosis (<1 month), 2 in the first 2 years, 2 at 5 years from diagnosis and 1 at 12 years from diagnosis. All had previously received steroids; 5 had received immunomodulators and 2 had received biologics. In 7 patients (87%), surgery was performed on an emergency basis. The indication was megacolon in 3 (37.5%), severe flare-up in 3 (37.5%) and medical treatment failure in 2 (25%). In 5 cases (62.5%), an ileoanal pouch was made, and in 3 cases, a definitive ileostomy was performed. In the univariate analysis, patients with loss of more than 5 kg at diagnosis and admission at diagnosis had a lower rate of colectomy-free survival. CONCLUSIONS: In our series, colectomy rates are lower than usually reported. Most colectomies were performed in the first 5 years following diagnosis and had an emergency indication.

A Simple Emergency Department-Based Score Predicts Complex Hospitalization in Patients with Inflammatory Bowel Disease.

BACKGROUND AND AIMS: Thirty percent of inflammatory bowel disease (IBD) patients hospitalized with flare require salvage therapy or surgery. Additionally, 40% experience length of stay (LOS) > 7 days. No emergency department (ED)-based indices exist to predict these adverse outcomes at admission for IBD flare. We examined whether clinical, laboratory, and endoscopic markers at presentation predicted prolonged LOS, inpatient colectomy, or salvage therapy in IBD patients admitted with flare. METHODS: Patients with ulcerative colitis (UC) or colonic involvement of Crohn's disease (CD) hospitalized with flare and tested for Clostridioides difficile infection (CDI) between 2010 and 2020 at two urban academic centers were studied. The primary outcome was complex hospitalization, defined as: LOS > 7 days, inpatient colectomy, or inpatient infliximab or cyclosporine. A nested k-fold cross-validation identified predictive factors of complex hospitalization. RESULTS: Of 164 IBD admissions, 34% (56) were complex. Predictive factors included: tachycardia in ED triage (odds ratio [OR] 3.35; confidence interval [CI] 1.79-4.91), hypotension in ED triage (3.45; 1.79-5.11), hypoalbuminemia at presentation (2.54; 1.15-3.93), CDI (2.62; 1.02-4.22), and endoscopic colitis (4.75; 1.75-5.15). An ED presentation score utilizing tachycardia and hypoalbuminemia predicted complex hospitalization (area under curve 0.744; CI 0.671-0.816). Forty-four of 48 (91.7%) patients with a presentation score of 0 (heart rate < 99 and albumin ≥ 3.4 g/dL) had noncomplex hospitalization. CONCLUSIONS: Over 90% of IBD patients hospitalized with flare with an ED presentation score of 0 did not require salvage therapy, inpatient colectomy, or experience prolonged LOS. A simple ED-based score may provide prognosis at a juncture of uncertainty in patient care.

Effectiveness of adalimumab for ulcerative colitis: A multicentre, retrospective study of clinical practice in Italy.

BACKGROUND: Adalimumab is used to treat ulcerative colitis, but additional effectiveness and safety data are needed. PATIENTS AND METHODS: This retrospective study considered adults with ulcerative colitis treated with adalimumab at 19 hospitals. Clinical data were collected from the start of treatment, after 2, 6 and 12 months, and at the last visit. Outcome measures of effectiveness were treatment duration, reasons for discontinuation and colectomy. RESULTS: We studied 381 patients treated with adalimumab for a median of 12.1 months. Disease activity at the start of treatment was moderate to severe in 262 cases (68.8%) and endoscopic activity was moderate to severe in 339 cases (89.0%). At week 8, clinical responses were observed in 177 cases (46.5%) and clinical remission in 136 cases (35.7%). At 12 months, remission was observed in 128 cases (33.6%). Overall, 44 patients required colectomy, and 170 patients (44.6%) were still taking adalimumab when data were collected. Variables associated with adalimumab discontinuation were concomitant steroid treatment, severe clinical-endoscopic activity at baseline, need for adalimumab intensification and drug-related adverse events. Variables associated with colectomy were concomitant steroid treatment and high baseline C-reactive protein. CONCLUSION: Adalimumab is safe and effective for the treatment of ulcerative colitis.

Impact of the COVID-19 pandemic on the management of colorectal cancer in Denmark.

INTRODUCTION: The COVID-19 pandemic has had a global impact on cancer care but the extent to which this has affected the management of colorectal cancer (CRC) in different countries is unknown. CRC management in Denmark was thought to have been relatively less impacted than in other nations during the first wave of the pandemic. The aim of this study was to determine the pandemic's impact on CRC in Denmark. METHODS: The Danish national cancer registry identified patients with newly diagnosed with CRC from 1 March 2020 to 1 August 2020 (pandemic interval) and corresponding dates in 2019 (prepandemic interval). Data regarding clinicopathological demographics and perioperative outcomes were retrieved and compared between the two cohorts. RESULTS: Total CRC diagnoses (201 versus 359 per month, P = 0.008) and screening diagnoses (38 versus 80 per month, P = 0.016) were both lower in the pandemic interval. The proportions of patients presenting acutely and the stage at presentation were, however, unaffected. For those patients having surgery, both colonic and rectal cancer operations fell to about half the prepandemic levels: colon (187 (i.q.r. 183-188) to 96 (i.q.r. 94-112) per month, P = 0.032) and rectal cancers (63 (i.q.r. 59-75) to 32 (i.q.r. 28-42) per month, P = 0.008). No difference was seen in surgical practice or postoperative 30-day mortality rate (colon 2.2 versus 2.2 per cent, P = 0.983; rectal 1.0 versus 2.9 per cent, P = 0.118) between the cohorts. Treatment during the pandemic interval was not independently associated with death at 30 or 90 days. CONCLUSION: The initial wave of the COVID-19 pandemic reduced the number of new diagnoses made and number of operations but had limited impact on technique or outcomes of CRC care in Denmark.

Laparoscopic versus open resection in patients with locally advanced colon cancer.

BACKGROUND: Surgical resection of locally advanced colon cancer (LACC) is challenging due to tumor size and the frequent need for multivisceral resection. The role of laparoscopic resection in LACC is controversial. This study aims to compare outcomes for laparoscopic versus open surgery in LACC. METHODS: A population-based retrospective review was conducted of patients treated at a Provincial Cancer Center for LACC from 2005 to 2015. Patients with non-metastatic T4 colon cancers were included. Descriptive, survival, and recurrence analyses were used. RESULTS: In all, 1,328 patients were reviewed, 23% of whom had laparoscopic surgery. A greater number of T4b tumors were removed via an open approach (35.9% vs 12.7%, P < .001). Positive resection margins occurred in 7.5% of laparoscopic and 16.5% of open cases (P < .001), and multivisceral resection was required in 11.0% and 27.7% (P < .001), respectively. Median follow-up was 37 months (interquartile range [IQR] 17-64) during which 48.6% patients died and 42.1% developed recurrence: locoregional (15.0%), distant (35.3%), peritoneal (11.4%). Age, right-sided tumors, nodal status, and laparoscopic approach were independent predictors of peritoneal recurrence. Overall survival (OS) (73 vs 61 months, P = .188) and recurrence-free survival (RFS) (39 vs 31 months, P = .288) were similar with both approaches. Age, nodal, and margin status were predictive of OS and RFS. CONCLUSION: Open surgical approach is used more frequently when tumors invade adjacent organs or require multivisceral resections. When employed, laparoscopic approach had similar rates of survival and recurrence compared with open approach, but was an independent predictor of peritoneal recurrence. Careful patient selection in operative approach is suggested.

Laparoscopic colorectal resections during the COVID-19 pandemic - business as usual?

INTRODUCTION: To analyse the outcomes of major colorectal resections performed during the COVID-19 pandemic, to assess safety and explore all precautionary measures. METHOD: All patients who underwent major elective colorectal resections at St Helens and Knowsley Teaching Hospital NHS Trust between 24th March 2020 (the date that the Royal Colleges of Surgery produced their guidelines re operating during the pandemic) and 17th April 2020 were analysed from a prospectively maintained database. The primary outcome was 7-day mortality and secondary outcomes were the development of a positive COVID-19 test consequent to hospital stay and the overall complication rate. RESULTS: In this 24 day time frame 27 patients (17 males) underwent elective colorectal resections at St Helens and Knowsley NHS Trust. The median age was 69 (41-84) years and median ASA was 2 (1-3). The median Body Mass Index was 30 (21-40.7). Twenty-five patients underwent surgery for cancer and two patients had urgent resections for low-grade sepsis secondary to diverticular colovesical fistulae. 24 patients underwent laparoscopic colorectal resections and 3 patients underwent planned open surgery. 7-day mortality was 0%, and no patients/staff contracted COVID-19 during the post-operative period. The overall complication rate was 14.8%. At a median follow-up of 29 (17-44) days via telephone, there have been no reported COVID-19 related symptoms in any of these patients. CONCLUSION: Our experience demonstrated that it was possible to undertake laparoscopic colorectal resections despite the COVID-19 pandemic posing a major threat to humanity, providing that adequate and stringent precautions are undertaken.

The impact of colectomy on the course of extraintestinal manifestations in Swiss inflammatory bowel disease cohort study patients.

BACKGROUND AND AIMS: Extraintestinal manifestations are reported to occur in up to 45% of inflammatory bowel disease (IBD) patients during the course of disease. It is unknown whether colectomy reduces the rate of de novo extraintestinal manifestations (EIMs) or impacts on severity of EIMs following a parallel versus independent disease course from underlying IBD. METHODS: Using data from the Swiss Inflammatory Bowel Disease Cohort Study we aimed to analyse the course of EIMs in ulcerative colitis (UC) and Crohn's disease (CD) patients undergoing colectomy during the cohort's prospective follow-up. RESULTS: One hundred and twenty-one IBD patients (33 CD, 81 UC and seven unclassified) underwent colectomy during prospective follow-up in the Swiss Inflammatory Bowel Disease Cohort Study. Within the 114 patients with UC or CD any EIM was reported in 40 (nine CD and 31 UC) patients. Activity of EIMs ceased entirely after colectomy in 21 patients (52.5%). Complete cessation of EIM after colectomy was higher in patients with UC versus CD with 58.1% versus 33.3%. After colectomy, 29 out of the 114 patients (25.4%) experienced any EIM. Two thirds of these (19 patients) represented persisting EIMs, while in one third (10 patients) EIM represented a de-novo event after colectomy. Overall, 13.5% of IBD patients developed a de-novo EIM after colectomy. CONCLUSIONS: In IBD patients undergoing colectomy, EIMs present prior to surgery will persist in about half of patients. Complete cessation of EIM after colectomy may be less common in CD than in UC. In patients who never experienced EIMs prior to colectomy de-novo manifestations thereafter should be expected in up to one in seven patients.

Stratification of risk of progression to colectomy in ulcerative colitis via measured and predicted gene expression.

An important goal of clinical genomics is to be able to estimate the risk of adverse disease outcomes. Between 5% and 10% of individuals with ulcerative colitis (UC) require colectomy within 5 years of diagnosis, but polygenic risk scores (PRSs) utilizing findings from genome-wide association studies (GWASs) are unable to provide meaningful prediction of this adverse status. By contrast, in Crohn disease, gene expression profiling of GWAS-significant genes does provide some stratification of risk of progression to complicated disease in the form of a transcriptional risk score (TRS). Here, we demonstrate that a measured TRS based on bulk rectal gene expression in the PROTECT inception cohort study has a positive predictive value approaching 50% for colectomy. Single-cell profiling demonstrates that the genes are active in multiple diverse cell types from both the epithelial and immune compartments. Expression quantitative trait locus (QTL) analysis identifies genes with differential effects at baseline and week 52 follow-up, but for the most part, differential expression associated with colectomy risk is independent of local genetic regulation. Nevertheless, a predicted polygenic transcriptional risk score (PPTRS) derived by summation of transcriptome-wide association study (TWAS) effects identifies UC-affected individuals at 5-fold elevated risk of colectomy with data from the UK Biobank population cohort studies, independently replicated in an NIDDK-IBDGC dataset. Prediction of gene expression from relatively small transcriptome datasets can thus be used in conjunction with TWASs for stratification of risk of disease complications.

Long-term Implications of Persistent Diverticulitis: A Retrospective Cohort Study of 915 Patients.

BACKGROUND: Persistent (or ongoing) diverticulitis is a well-recognized outcome after treatment for acute sigmoid diverticulitis; however, its definition, incidence, and risk factors, as well as its long-term implications, remain poorly described. OBJECTIVE: The purpose of this study was to assess the incidence, risk factors, and long-term outcomes of persistent diverticulitis. DESIGN: This was a retrospective cohort study. SETTINGS: Two university-affiliated hospitals in Montreal, Quebec, Canada were included. PATIENTS: The study was composed of consecutive patients managed nonoperatively for acute sigmoid diverticulitis. INTERVENTION: Nonoperative management of acute sigmoid diverticulitis was involved. MAIN OUTCOME MEASURES: Persistent diverticulitis, defined as inpatient or outpatient treatment for signs and symptoms of ongoing diverticulitis within the first 60 days after treatment of the index episode, was measured. RESULTS: In total, 915 patients were discharged after an index episode of diverticulitis managed nonoperatively. Seventy-five patients (8.2%; 95% CI, 6.5%-10.2%) presented within 60 days with persistent diverticulitis. Factors associated with persistent diverticulitis were younger age (adjusted OR = 0.98 (95% CI, 0.96-0.99)), immunosuppression (adjusted OR = 2.02 (95% CI, 1.04-3.88)), and abscess (adjusted OR = 2.05 (95% CI, 1.03-3.92)). Among the 75 patients with persistent disease, 42 (56.0%) required hospital admission, 6 (8.0%) required percutaneous drainage, and 5 (6.7%) required resection. After a median follow-up of 39.0 months (range, 17.0-67.3 mo), the overall recurrence rate in the entire cohort was 31.3% (286/910). After excluding patients who were managed operatively for their persistent episode of diverticulitis, the cumulative incidence of recurrent diverticulitis (log-rank: p < 0.001) and sigmoid colectomy (log-rank: p < 0.001) were higher among patients who experienced persistent diverticulitis after the index episode. After adjustment for relevant patient and disease factors, persistent diverticulitis was associated with higher hazards of recurrence (adjusted HR = 1.94 (95% CI, 1.37-2.76) and colectomy (adjusted HR = 5.11 (95% CI, 2.96-8.83)). LIMITATIONS: The study was limited by its observational study design and modest sample size. CONCLUSIONS: Approximately 10% of patients experience persistent diverticulitis after treatment for an index episode of diverticulitis. Persistent diverticulitis is a poor prognostic factor for long-term outcomes, including recurrent diverticulitis and colectomy. See Video Abstract at http://links.lww.com/DCR/B593. REPERCUSIONES A LARGO PLAZO DE LA DIVERTICULITIS PERSISTENTE ESTUDIO DE UNA COHORTE RETROSPECTIVA DE PACIENTES: ANTECEDENTES:La diverticulitis persistente (o continua) es un resultado bien conocido posterior al tratamiento de la diverticulitis aguda del sigmoides; sin embargo, la definición, incidencia y factores de riesgo, así como sus repercusiones a largo plazo siguen estando descritas de manera deficiente.OBJETIVO:Evaluar la incidencia, los factores de riesgo y los resultados a largo plazo de la diverticulitis persistente.DISEÑO:Estudio de una cohorte retrospectiva.AMBITO:Dos hospitales universitarios afiliados en Montreal, Quebec, Canadá.PACIENTES:pacientes consecutivos tratados sin cirugia por diverticulitis aguda del sigmoides.INTERVENCIÓN:Tratamiento no quirúrgico de la diverticulitis aguda del sigmoides.PRINCIPALES RESULTADOS EVALUADOS:Diverticulitis persistente, definida como tratamiento hospitalario o ambulatorio por signos y síntomas de diverticulitis continua dentro de los primeros 60 días posteriores al tratamiento del episodio índice.RESULTADOS:Un total de 915 pacientes fueron dados de alta posterior al episodio índice de diverticulitis tratados sin cirugia. Setenta y cinco pacientes (8,2%; IC del 95%: 6,5-10,2%) presentaron diverticulitis persistente dentro de los 60 días. Los factores asociados con la diverticulitis persistente fueron una edad menor (aOR: 0,98, IC del 95%: 0,96-0,99), inmunosupresión (aOR: 2,02, IC del 95%: 1,04-3,88) y abscesos (aOR: 2,05, IC del 95%: 1,03-3,92). Entre los 75 pacientes con enfermedad persistente, 42 (56,0%) requirieron ingreso hospitalario, 6 (8,0%) drenaje percutáneo y 5 (6,7%) resección. Posterior a seguimiento medio de 39,0 (17,0-67,3) meses, la tasa global de recurrencia de toda la cohorte fue del 31,3% (286/910). Después de excluir a los pacientes que fueron tratados quirúrgicamente por su episodio persistente de diverticulitis, la incidencia acumulada de diverticulitis recurrente (rango logarítmico: p <0,001) y colectomía sigmoidea (rango logarítmico: p <0,001) fue mayor entre los pacientes que experimentaron diverticulitis persistente después el episodio índice. Posterior al ajuste de factores importantes de la enfermedad y del paciente, la diverticulitis persistente se asoció con mayores riesgos de recurrencia (aHR: 1,94, IC 95% 1,37-2,76) y colectomía (aHR: 5,11, IC 95% 2,96-8,83).LIMITACIONES:Diseño de estudio observacional, un modesto tamaño de muestra.CONCLUSIONES:Aproximadamente el 10% de los pacientes presentan diverticulitis persistente después del tratamiento del episodio índice de diverticulitis. La diverticulitis persistente, en sus resultados a largo plazo, es un factor de mal pronóstico, donse se inlcuye la diverticulitis recurente y colectomía. Consulte Video Resumen en http://links.lww.com/DCR/B593.

Impact of frailty on clinical outcomes and resource use following emergency general surgery in the United States.

BACKGROUND: Frailty has been recognized as an independent risk factor for inferior outcomes, but its effect on emergency general surgery (EGS) is understudied. OBJECTIVE: The purpose of the present study was to define the impact of frailty on risk-adjusted mortality, non-home discharge, and readmission following EGS operations. METHODS: Adults undergoing appendectomy, cholecystectomy, small bowel resection, large bowel resection, repair of perforated ulcer, or laparotomy within two days of an urgent admission were identified in the 2016-2017 Nationwide Readmissions Database. Frailty was defined using diagnosis codes corresponding to the Johns Hopkins Adjusted Clinical Groups frailty indicator. Multivariable regression was used to study in-hospital mortality and non-home discharge by operation, and Kaplan Meier analysis to study freedom from unplanned readmission at up to 90-days follow-up. RESULTS: Among 655,817 patients, 11.9% were considered frail. Frail patients most commonly underwent large bowel resection (37.3%) and cholecystectomy (29.2%). After adjustment, frail patients had higher mortality rates for all operations compared to nonfrail, including those most commonly performed (11.9% [95% CI 11.4-12.5%] vs 6.0% [95% CI 5.8-6.3%] for large bowel resection; 2.3% [95% CI 2.0-2.6%] vs 0.2% [95% CI 0.2-0.2%] for cholecystectomy). Adjusted non-home discharge rates were higher for frail compared to nonfrail patients following all operations, including large bowel resection (68.1% [95% CI 67.1-69.0%] vs 25.9% [95% CI 25.2-26.5%]) and cholecystectomy (33.7% [95% CI 32.7-34.7%] vs 2.9% [95% CI 2.8-3.0%]). Adjusted hospitalization costs were nearly twice as high for frail patients. On Kaplan-Meier analysis, frail patients had greater unplanned readmissions (log rank P<0.001), with 1 in 4 rehospitalized within 90 days. CONCLUSIONS: Frail patients have inferior clinical outcomes and greater resource use following EGS, with the greatest absolute differences following complex operations. Simple frailty assessments may inform expectations, identify patients at risk of poor outcomes, and guide the need for more intensive postoperative care.

Changes in chronic idiopathic ulcerative colitis epidemiological pattern in Mexico in a tertiary care hospital.

BACKGROUND: Chronic idiopathic ulcerative colitis (CIUC) is a disease with multifactorial chronic inflammation of the colonic mucosa. Its prevalence ranges from 37.5-250/100,000 in North America to 10-500/100,000 in Europe. In Mexico, there are studies that show an increase in the frequency of new cases. The purpose of this work was to identify possible changes in CIUC behavior in a referral hospital. METHODS: New ulcerative colitis (UC) cases confirmed by histopathology from January 2007 to December 2014 were included. Clinical and demographic data were collected through the review of medical records and direct interview in order to compare them with a previous study conducted at the same institution from January 1986 to December 2006. RESULTS: A total of 189 patients were included. Mean number of UC annual new cases was 23.6. The study included 95 male patients (50 %) and 94 female patients (50 %), with an average age of 44.6 years at diagnosis. The frequency of pancolitis was 77 %, in comparison with 59 % in the previous period. Extra-intestinal manifestations (EIM) were present in 55.8 % and colectomies in 5.2 %. CONCLUSION: There is a lower mean of annual new cases; however, some characteristics of the disease have changed over time: there is an increased frequency of pancolitis and EIM, as well as a decrease in the rate of colectomies.

ANTECEDENTES: La colitis ulcerosa crónica idiopática (CUCI) es una enfermedad con inflamación crónica de la mucosa del colon de origen multifactorial. El objetivo de este trabajo es identificar posibles cambios en el comportamiento de la CUCI en un hospital de referencia. MÉTODOS: Se incluyeron nuevos casos de CUCI confirmados por histopatología de enero del 2007 a diciembre del 2014. RESULTADOS: Se incluyeron un total de 189 pacientes. La media de nuevos casos anuales de CUCI fue de 23.6. Este estudio incorpora 95 pacientes de sexo masculino (50 %) y 94 de sexo femenino (50 %), con una edad promedio al diagnóstico de 44.6 años. La frecuencia de pancolitis fue del 77 %, en comparación con el 59 % en el periodo anterior. Las manifestaciones extraintestinales (MEI) estuvieron presentes en el 55.8 % y las colectomías en el 5.2 %. CONCLUSIÓN: Algunas características de la enfermedad han cambiado con el tiempo: aumento de la frecuencia de pancolitis y MEI, así como disminución de la tasa de colectomías.

Rectal Cancer Incidence is Low Following Rectal Diversion or Subtotal Colectomy for IBD: Results of a Population-based Study.

BACKGROUND AND AIMS: Following subtotal colectomy or diversion for medically refractory inflammatory bowel disease [IBD], completion proctectomy has been recommended to reduce the risk of rectal cancer. However, this recommendation is based on low-quality evidence. Our objectives were to estimate the cumulative incidence of rectal cancer and evaluate if surveillance endoscopy reduces the risk of rectal cancer. METHODS: We performed a population-based retrospective cohort study in Ontario, Canada, of all patients undergoing either subtotal colectomy or diversion for medically refractory IBD over 1991-2015. We excluded patients with a previous history of colorectal cancer or previous rectal resection, and those with <1 year of observation. We calculated the rate of incident rectal cancer using a competing risks model, and evaluated the effect of surveillance endoscopy on the rate of rectal cancer. RESULTS: In all, 3700 patients were included with a median follow-up of 4.3 years. Of this cohort, 47% underwent rectal resection or restoration of gastrointestinal [GI] continuity during the observation period; 40 patients were diagnosed with rectal cancer, with a cumulative incidence of rectal cancer of 0.81% (95% confidence interval [CI] 0.53%, 1.20%) and 1.86% [95% CI 1.29%, 2.61%] at 10 and 20 years, respectively. Surveillance endoscopy was associated with a lower rate of rectal cancer (subhazard ratio [sHR] 0.37, 95% CI 0.16, 0.82, p = 0.014]. CONCLUSIONS: Among patients with a retained rectum following surgery for IBD, the risk of rectal cancer is low and appears to be lower when surveillance endoscopy is performed. Expectant management with surveillance endoscopy may be a reasonable alternative to completion proctectomy in selected patients.

Differences in effectiveness and use of laparoscopic surgery in locally advanced colon cancer patients.

Patients with locally advanced colon cancer have worse outcomes. Guidelines of various organizations are conflicting about the use of laparoscopic colectomy (LC) in locally advanced colon cancer. We determined whether patient outcomes of LC and open colectomy (OC) for locally advanced (T4) colon cancer are comparable in all colon cancer patients, T4a versus T4b patients, obese versus non-obese patients, and tumors located in the ascending, descending, and transverse colon. We used data from the 2013-2015 American College of Surgeons' National Surgical Quality Improvement Program. Patients were diagnosed with nonmetastatic pT4 colon cancer, with or without obstruction, and underwent LC (n = 563) or OC (n = 807). We used a composite outcome score (mortality, readmission, re-operation, wound infection, bleeding transfusion, and prolonged postoperative ileus); length of stay; and length of operation. Patients undergoing LC exhibited a composite outcome score that was 9.5% lower (95% CI - 15.4; - 3.5) versus those undergoing OC. LC patients experienced a 11.3% reduction in postoperative ileus (95% CI - 16.0; - 6.5) and an average of 2 days shorter length of stay (95% CI - 2.9; - 1.0). Patients undergoing LC were in the operating room an average of 13.5 min longer (95% CI 1.5; 25.6). We found no evidence for treatment heterogeneity across subgroups (p > 0.05). Patients with locally advanced colon cancer who receive LC had better overall outcomes and shorter lengths of stay compared with OC patients. LC was equally effective in obese/nonobese patients, in T4a/T4b patients, and regardless of the location of the tumor.