Impact of Preoperative Factors in Patients With IBD on Postoperative Length of Stay: A National Surgical Quality Improvement Program-Inflammatory Bowel Disease Collaborative Analysis.

BACKGROUND: Patients with IBD are challenging to manage perioperatively because of disease complexity and multiple comorbidities. OBJECTIVE: To identify whether preoperative factors and operation type were associated with extended postoperative length of stay after IBD-related surgery, defined by 75th percentile or greater (n = 926; 30.8%). DESIGN: This was a cross-sectional study based on a retrospective multicenter database. SETTING: The National Surgery Quality Improvement Program-Inflammatory Bowel Disease Collaborative captured data from 15 high-volume sites. PATIENTS: A total of 3008 patients with IBD (1710 with Crohn's disease and 1291 with ulcerative colitis) with a median postoperative length of stay of 4 days (interquartile range, 3-7) from March 2017 to February 2020. MAIN OUTCOME MEASURES: The primary outcome was extended postoperative length of stay. RESULTS: On multivariable logistic regression, increased odds of extended postoperative length of stay were associated with multiple demographic and clinical factors (model p < 0.001, area under receiver operating characteristic curve = 0.85). Clinically significant contributors that increased postoperative length of stay were rectal surgery (vs colon; OR, 2.13; 95% CI, 1.52-2.98), new ileostomy (vs no ileostomy; OR, 1.50; 95% CI, 1.15-1.97), preoperative hospitalization (OR, 13.45; 95% CI, 10.15-17.84), non-home discharge (OR, 4.78; 95% CI, 2.27-10.08), hypoalbuminemia (OR, 1.66; 95% CI, 1.27-2.18), and bleeding disorder (OR, 2.42; 95% CI, 1.22-4.82). LIMITATIONS: Retrospective review of only high-volume centers. CONCLUSIONS: Patients with IBD who were preoperatively hospitalized, who had non-home discharge, and who underwent rectal surgery had the highest odds of extended postoperative length of stay. Associated patient characteristics included bleeding disorder, hypoalbuminemia, and ASA classes 3 to 5. Chronic corticosteroid, immunologic, small molecule, and biologic agent use were insignificant on multivariable analysis. See Video Abstract. IMPACTO DE LOS FACTORES PREOPERATORIOS EN PACIENTES CON ENFERMEDAD INFLAMATORIA INTESTINAL EN LA DURACIN DE LA ESTANCIA POSTOPERATORIA UN ANLISIS COLABORATIVO DEL PROGRAMA NACIONAL DE MEJORA DE LA CALIDAD QUIRRGICAENFERMEDAD INFLAMATORIA INTESTINAL: ANTECEDENTES:Los pacientes con enfermedad inflamatoria intestinal son difíciles de manejar perioperatoriamente debido a la complejidad de la enfermedad y a múltiples comorbilidades.OBJETIVO:Este estudio tuvo como objetivo identificar si los factores preoperatorios y el tipo de operación se asociaron con una estadía postoperatoria prolongada después de una cirugía relacionada con enfermedad inflamatoria intestinal, definida por el percentil 75 o mayor (n = 926, 30.8%).DISEÑO:Este fue un estudio transversal basado en una base de datos multicéntrica retrospectiva.ESCENARIO:Datos capturados de quince sitios de alto volumen en El Programa Nacional de Mejoramiento de la Calidad de la Cirugía-Enfermedad Intestinal Inflamatoria en colaboración.PACIENTES:Un total de 3,008 pacientes con enfermedad inflamatoria intestinal (1,710 con enfermedad de Crohn y 1,291 con colitis ulcerosa) con una mediana de estancia postoperatoria de 4 días (RIC 3-7) desde marzo de 2017 hasta febrero de 2020.PRINCIPALES MEDIDAS DE RESULTADO:El resultado primario fue la extensión de la estancia postoperatoria.RESULTADOS:En la regresión logística multivariable, el aumento de las probabilidades de prolongar la estancia postoperatoria se asoció con múltiples factores demográficos y clínicos (modelo p<0.001, área bajo la curva ROC - 0.85). Los contribuyentes clínicamente significativos que aumentaron la duración de la estancia postoperatoria fueron la cirugía rectal (frente al colon) (OR 2.13, IC del 95 %: 1.52 a 2.98), una nueva ileostomía (frente a ninguna ileostomía) (OR 1.50, IC del 95 %: 1.15 a 1.97), hospitalización preoperatoria (OR 13.45, IC 95% 10.15-17.84), alta no domiciliaria (OR 4.78, IC 95% 2.27-10.08), hipoalbuminemia (OR 1.66, IC 95% 1.27-2.18) y trastorno hemorrágico (OR 2.42, IC 95% 1.22-4.82).LIMITACIONES:Revisión retrospectiva de solo centros de alto volumen.CONCLUSIONES:Los pacientes con enfermedad inflamatoria intestinal que fueron hospitalizados antes de la operación, que tuvieron alta no domiciliaria y que se sometieron a cirugía rectal tuvieron las mayores probabilidades de prolongar la estancia postoperatoria. Las características asociadas de los pacientes incluyeron trastorno hemorrágico, hipoalbuminemia y clases ASA 3-5. El uso crónico de corticosteroides, inmunológicos, agentes de moléculas pequeñas y de agentes biológicos no fue significativo en el análisis multivariable. (Traducción-Dr. Jorge Silva Velazco ).

High frequency of anti-DSG 2 antibodies in post COVID-19 serum samples.

BACKGROUND: There is growing recognition that COVID-19 does cause cardiac sequelae. The underlying mechanisms involved are still poorly understood to date. Viral infections, including COVID-19, have been hypothesized to contribute to autoimmunity, by exposing previously hidden cryptic epitopes on damaged cells to an activated immune system. Given the high incidence of cardiac involvement seen in COVID-19, our aim was to determine the frequency of anti-DSG2 antibodies in a population of post COVID-19 patients. METHODS AND RESULTS: 300 convalescent serum samples were obtained from a group of post COVID-19 infected patients from October 2020 to February 2021. 154 samples were drawn 6 months post-COVID-19 infection and 146 samples were drawn 9 months post COVID infection. 17 samples were obtained from the same patient at the 6- and 9- month mark. An electrochemiluminescent-based immunoassay utilizing the extracellular domain of DSG2 for antibody capture was used. The mean signal intensity of anti-DSG2 antibodies in the post COVID-19 samples was significantly higher than that of a healthy control population (19 ± 83.2 in the post-COVID-19 sample vs. 2.1 ± 7.2 (p < 0. 0001) in the negative control healthy population). Of note, 29.3% of the post COVID-19 infection samples demonstrated a signal higher than the 90th percentile of the control population and 8.7% were higher than the median found in ARVC patients. The signal intensity between the 6-month and 9-month samples did not differ significantly. CONCLUSIONS: We report for the first time that recovered COVID-19 patients demonstrate significantly higher and sustained levels of anti-DSG2 autoantibodies as compared to a healthy control population, comparable to that of a diagnosed ARVC group.

Appendiceal inflammation in colectomy is independently correlated with early pouchitis following ileal pouch anal anastomosis in ulcerative colitis and indeterminate colitis.

BACKGROUND: Appendiceal inflammation in colectomy is one of the histologic predictors of pouchitis in ulcerative colitis (UC) following ileal pouch anal anastomosis (IPAA). Fecal calprotectin level has been shown to increase 2 months prior to the onset of pouchitis. We evaluated whether inflammation and calprotectin expression in appendiceal specimens correlate with early-onset pouchitis in UC and indeterminate colitis (IC). MATERIALS AND METHODS: IPAA (2000-2018) cases with appendix blocks available in colectomy specimens were identified (n = 93, 90 UC, 3 IC). Histologic features thought to predict pouchitis were evaluated. The degree of appendiceal inflammation was scored. Calprotectin immunostain was performed on the appendix blocks and the extent of mucosal staining was quantified. Electronic medical records were reviewed for demographics, smoking history, clinical pouchitis, time of onset of pouchitis, and clinical and endoscopic components of the Pouchitis Disease Activity Index (PDAI) score. Follow-up pouch biopsies were reviewed and scored to generate histologic PDAI score, when available. RESULTS: Among the patients with clinical pouchitis (n = 73), moderate to severe appendiceal inflammation independently correlated with earlier pouchitis compared to no/mild inflammation (median time to pouchitis 12.0 vs. 23.8, log rank p = 0.016). Calprotectin staining correlated with inflammatory scores of the appendix (Spearman's rho, r = 0.630, p < 0.001) but not with early pouchitis (p > 0.05). CONCLUSIONS: The presence of moderate to severe appendiceal inflammation at the time of colectomy was associated with a shorter time to pouchitis following IPAA. Calprotectin immunostain may be used to demonstrate the presence of inflammation in the appendix but its role in predicting early pouchitis remains limited.

IFN-γ and IL-17A regulate intestinal crypt production of CXCL10 in the healthy and inflamed colon.

During intestinal inflammation, immature cells within the intestinal crypt are called upon to replenish lost epithelial cell populations, promote tissue regeneration, and restore barrier integrity. Inflammatory mediators including TH1/TH17-associated cytokines influence tissue health and regenerative processes, yet how these cytokines directly influence the colon crypt epithelium and whether the crypt remains responsive to these cytokines during active damage and repair, remain unclear. Here, using laser-capture microdissection and primary colon organoid culture, we show that the cytokine milieu regulates the ability of the colonic crypt epithelium to participate in proinflammatory signaling. IFN-γ induces the TH1-recruiting, proinflammatory chemokine CXCL10/IP10 in primary murine intestinal crypt epithelium. CXCL10 was also induced in colonic organoids derived from mice with active, experimentally induced colitis, suggesting that the crypt can actively secrete CXCL10 in select cytokine environments during colitis. Colon expression of cxcl10 further increased during infectious and noninfectious colitis in Il17a-/- mice, demonstrating that IL-17A exerts a negative effect on CXCL10 in vivo. Furthermore, IL-17A directly antagonized CXCL10 production in ex vivo organoid cultures derived from healthy murine colons. Interestingly, direct antagonism of CXCL10 was not observed in organoids derived from colitic mouse colons bearing active lesions. These data, highlighting the complex interplay between the cytokine milieu and crypt epithelia, demonstrate proinflammatory chemokines can be induced within the colonic crypt and suggest the crypt remains responsive to cytokine modulation during inflammation.NEW & NOTEWORTHY Upon damage, the intestinal epithelium regenerates to restore barrier function. Here we observe that the local colonic cytokine milieu controls the production of procolitic chemokines within the crypt base and colon crypts remain responsive to cytokines during inflammation. IFN-γ promotes, while IL-17 antagonizes, CXCL10 production in healthy colonic crypts, while responses to cytokines differ in inflamed colon epithelium. These data reveal novel insight into colon crypt responses and inflammation-relevant alterations in signaling.

Frequency of Plexiform Fibromyxoma relative to gastrointestinal stromal tumor: A single center study.

Plexiform Fibromyxoma (PF) is an exceedingly rare mesenchymal tumor of the gastric antrum that was first described in 2007. PF is a close mimic of gastrointestinal stromal tumor (GIST) clinically and histopathologically, but the frequency of PF relative to GIST is unknown. Moreover, although likely benign, long-term follow-up of PF is limited due to its recent description and rarity. PF has not been reported in distal jejunum. 118 primary GISTs that were surgically resected at our center (2000-2019) were retrieved. The patients' age, gender, clinical presentation, tumor location, size and number, and the presence or absence of metastasis, were documented. Risk of progressive disease was assessed according to the published GIST risk stratification model. Two unique cases of PF were compared. One gastric PF has been followed-up for 8 years, and the other occurred in the distal jejunum. In the latter, the PF diagnosis was rendered after the case was re-reviewed for the study. Clinical presentation resembled GIST in both PF cases. 14% of GISTs showed high risk features or were clinically malignant, whereas the PF patient with 8-year follow-up was free of disease. Based on this study, PF may be under-recognized, with 1 to 2% (1.7%) of GIST-like tumors possibly representing PF. PF may involve variable segments of intestine similar to GIST. Given the remarkable clinical and histopathologic overlap with GIST but differing outcomes, awareness and cognizance of this rare entity, plexiform fibromyxoma, is required for proper patient care.

A Population-wide study of electrocardiographic (ECG) norms and the effect of demographic and anthropometric factors on selected ECG characteristics in young, Southeast Asian males-results from the Singapore Armed Forces ECG (SAFE) study.

BACKGROUND: Routine use of pre-participation electrocardiograms (ECGs) has been used by the Singapore Armed Forces, targeting early detection of significant cardiac diseases. We aim to describe the impact of demographic and anthropometric factors on ECG variables and establish a set of electrocardiographic reference ranges specific to a young male multiethnic Southeast Asian cohort. METHODS AND RESULTS: Between November 1, 2009, and December 31, 2014, 144,346 young male conscripts underwent pre-participation screening that included a 12-lead ECG, demographic and anthropometric measurements. The Chinese population had the longest PR interval (146.7 ± 19.7 vs. 145.21 ± 19.2 in Malays vs. 141.2 ± 18.8 ms in Indians), QRS duration (94.5 ± 9.8 vs. 92.6 ± 9.7 in Malays vs. 92.5 ± 9.4 ms in Indians) and QTcB interval (408.3 ± 21.3 vs. 403.5 ± 21.6 in Malays vs. 401.2 ± 21.4 ms in Indians) (all p < 0.001). Body mass index (BMI) >25 kg/m2 and body fat >25% were independently associated with lower prevalence of increased QRS voltage on ECG. Systolic blood pressure of >140 mmHg or diastolic blood pressure of >90 mmHg independently increased the prevalence of increased QRS voltage on ECG. CONCLUSIONS: Electrocardiographic parameters vary across different ethnicities and in comparison with international norms. In our population, diagnosis of increased QRS voltage by ECG is less prevalent with obesity and increased body fat. Further analysis of gold standard measurements for the diagnosis of LVH in our population is ongoing, to improve the accuracy of the ECG screening process.

Impact of Interhospital Transfer on Outcomes in Non-emergency Colorectal Surgery.

BACKGROUND: A paucity of data exists on the impact of transfer status on outcomes for patients undergoing non-emergency (urgent) colorectal surgery. This study characterized transferred patients undergoing urgent colorectal surgery and determined which patient comorbidities significantly contributed to poor outcomes. METHODS: The American College of Surgeons National Surgical Quality Improvement Program database from 2012 to 2013 was used. Urgent direct admissions undergoing colon, rectum, or small bowel operations were compared to urgent transfers using bivariate and multivariable analysis models. Primary outcomes were overall complications, hospital length of stay, and mortality. RESULTS: A total of 82,151 admissions were analyzed. After multivariable analysis, direct admission patients had nearly similar risk of complications (RR = 0.95; 95% CI 0.91-0.99) and length of hospital stay (7% shorter; 95% CI 4-9%), as well as no difference in mortality (RR = 0.94; 95% CI 0.80-1.11). CONCLUSIONS: Transfer status alone confers minimal risk toward higher complication rates and longer hospital length of stay in patients undergoing urgent colorectal surgery, and the poor outcomes observed in this cohort are largely due to patient comorbidities and disease severity. Our results suggest that outcomes in transferred colorectal surgery patients undergoing urgent operations depend mainly on operative acuity and clinical factors, and to a lesser degree transfer status.

Rectal ulcer and pseudomalignant epithelial changes after prostate seed brachytherapy: A rare complication with a diagnostic pitfall.

BACKGROUND: Implant brachytherapy (IBT) is a well-recognized treatment modality for early stage prostate cancer. Rectal ulcer and rectourethral fistula complicating IBT may cause an alteration of the normal anatomic landmarks. In this context, pseudomalignant radiation-induced changes within prostatic epithelium may be misinterpreted as a primary rectal malignancy. Such challenging and misleading findings have not been described, and may not be recognized as such. MATERIALS AND METHODS: We present the clinical and pathologic aspects of two patients who underwent IBT for low stage prostate cancer that was complicated by deep rectal ulcer. Both patients underwent extensive palliative surgical resection for disease control. RESULTS: The histologic changes in both cases were noteworthy for extensive necrosis and inflammation of the prostate, associated with loss of recto-prostatic anatomical landmarks. Prostatic glands showed striking radiation-induced atypia and pseudomalignant epithelial changes extending to the rectal ulcer bed, with no residual viable tumor. The first patient had undergone a biopsy of the rectal ulcer bed that was misinterpreted as a rectal adenocarcinoma prior to surgery. The similarity between atypical glands of the biopsy and the benign prostatic tissue with radiation-induced atypia in resection specimen confirmed their benign nature. CONCLUSIONS: Deep rectal ulcer complicating IBT may lead to distortion of the normal recto-prostatic anatomical landmarks, resulting in detection of pseudo-malignant prostatic glands at the ulcer base. Such findings may be mistaken for a primary rectal malignancy in limited biopsy material if not familiar to the pathologist.

Local and systemic Th17 immune response associated with advanced stage colon cancer.

BACKGROUND: Little is known about how the immunologic microenvironment changes during tumor progression and metastatic spread. Recently, murine models have shown the T-helper 17 (Th17) pathway to play an important role in promoting colorectal cancer (CRC). The purpose of this study was to compare cytokine profiles in the tumor microenvironment of CRC between local disease (stages I/II) and advanced disease (stages III/IV), and to determine whether these changes were manifest in the systemic circulation of patients with advanced disease. MATERIALS AND METHODS: Serum and tissue cytokine profiles were assayed among patients with documented adenocarcinoma before surgical resection at a single institution from September 2014 to February 2015. Using the Bio-Plex Pro Human Th17 Cytokine Assay Kit (Bio-Rad Laboratories), the concentrations of multiple cytokines were determined. Multiple logistic regression analyses were used to evaluate the association between TNM staging and cytokine levels. RESULTS: A total of 33 patients with documented adenocarcinoma were included. None of the patients received neoadjuvant chemotherapy. American Joint Commission on Cancer TNM classification was used. Advanced disease was associated with elevated tumor levels of tumor necrosis factor-alpha, interleukin (IL)-4, IL-10, IL-17A, and IL-17F, and only stage IV showed elevated systemic levels of Th17-associated cytokines IL-17F, IL-23, and IL-25. CONCLUSIONS: The Th17 pathway likely has important mechanistic implications in human CRC. Metastatic disease was associated with elevated Th17-associated cytokines both in colonic tissue and systemically. These changes in systemic expression of Th17-associated cytokines could establish novel pathways for CRC and warrant further investigation.

Increased Incidence of Surgical Site Infection in IBD Patients.

BACKGROUND: Surgical site infection is a key hospital-level patient safety indicator. All risk factors for surgical site infection are not always taken into account and adjusted for. OBJECTIVE: This study aimed to measure the impact of IBD in comparison with diverticulitis and colorectal cancer on the national rates of surgical site infection. DESIGN: The American College of Surgeons National Surgical Quality Improvement Project database was queried for all patients undergoing elective colectomy for colon cancer, diverticulitis, and IBD from 2008 through 2012. OUTCOME MEASURES: The association between surgical site infection and IBD patients was assessed. Patient demographics, rates of surgical site infection, wound class, return to operating room, and various patient characteristics were analyzed. Logistic regression was performed to determine the association with surgical site infection. RESULTS: The query yielded 71,845 patients undergoing elective colectomy. Of these patients, 42,132 had colon cancer, 22,143 had diverticulitis, and 7570 had IBD. The rate of surgical site infection was 12.0% for colon cancer, 12.8% for diverticulitis, and 18.0% for IBD. Return to operating room within 30 days was 7.3% for IBD patients, 4.4% for patients with diverticulitis, and 4.9% for patients with colorectal cancer. Return to operating room within 30 days had the highest correlation to surgical site infection in both univariate and multivariable analysis. Other associative factors for surgical site infection common to both analyses included diabetes mellitus, smoking, open procedures, and obesity. LIMITATIONS: This study was limited by the data collection errors inherent to large databases, exclusion of emergent operations, and the inability to identify patients taking immunosuppressive agents. CONCLUSIONS: Patients with IBD undergoing elective colectomy have significantly increased rates of surgical site infection, specifically deep and organ/space infections. Given this information, risk adjustment models for surgical site infection may need to include IBD in their calculation.

Failing to Prepare Is Preparing to Fail: A Single-Blinded, Randomized Controlled Trial to Determine the Impact of a Preoperative Instructional Video on the Ability of Residents to Perform Laparoscopic Right Colectomy.

BACKGROUND: Laparoscopic colorectal resection is an index case for advanced skills training, yet many residents struggle to reach proficiency by graduation. Current methods to reduce the learning curve for residents remain expensive, time consuming, and poorly validated. OBJECTIVE: The purpose of this study was to assess the impact of the addition of a preprocedural instructional video to improve the ability of a general surgery resident to perform laparoscopic right colectomy when compared with standard preparation. DESIGN: This was a single-blinded, randomized control study. SETTINGS: Four university-affiliated teaching hospitals were included in the study. PARTICIPANTS: General surgery residents in postgraduation years 2 through 5 participated. INTERVENTION: Residents were randomly assigned to preparation with a narrated instructional video versus standard preparation. MAIN OUTCOME MEASURES: Resident performance, scored by a previously validated global assessment scale, was measured. RESULTS: Fifty-four residents were included. Half (n = 27) were randomly assigned to view the training video and half (n = 27) to standard preparation. There were no differences between groups in terms of training level or previous operative experience or in patient demographics (all p > 0.05). Groups were similar in the percentage of the case completed by residents (p = 0.39) and operative time (p = 0.74). Residents in the video group scored significantly higher in total score (mean: 46.8 vs 42.3; p = 0.002), as well as subsections directly measuring laparoscopic skill (vascular control mean: 11.3 vs 9.7, p < 0.001; mobilization mean: 7.6 vs. 7.0, p = 0.03) and overall performance score (mean: 4.0 vs 3.1; p < 0.001). Statistical significance persisted across training levels. LIMITATIONS: There is potential for Hawthorne effect, and the study is underpowered at the individual postgraduate year level. CONCLUSIONS: The simple addition of a brief, narrated preprocedural video to general surgery resident case preparation significantly increased trainee ability to successfully perform a laparoscopic right colectomy. In an era of shortened hours and less exposure to cases, incorporating a brief but effective instructional video before surgery may improve the learning curve of trainees and ultimately improve safety.

Laparoscopic sigmoid colectomy for complicated diverticulitis is safe: review of 576 consecutive colectomies.

INTRODUCTION: Laparoscopic resection of diverticular disease is typically offered to selected patients. We present the outcomes of laparoscopic colectomy in consecutive patients suffering from either simple diverticulitis (SD) or complicated diverticulitis (CD). PURPOSE: To examine the outcomes of laparoscopic sigmoid colectomy for complicated diverticulitis. METHODS: Between December 2001 and May 2013, all patients with diverticulitis requiring elective operation were offered laparoscopic sigmoid colectomy as the initial approach. All cases were managed at a large tertiary care center on the colorectal surgery service. Preoperative, intraoperative, and postoperative variables were prospectively entered into the colorectal surgery service database (CRSD) and analyzed retrospectively. RESULTS: Of the 576 patients in the CRSD, 139 (24.1%) had CD. The overall conversion rate was 12.8% (n = 74). The average BMI was 29.8 kg/m(2). The conversion rate for CD was 12.2%. The return of bowel function time was delayed in the CD group when compared to the SD group (3.1 vs 3.8 days, p = 0.04). The hospital length of stay (HLOS) was similar between the groups (5.1 vs 5.8 days, p = 0.08). The overall anastomotic leak rate was 2.1% (n = 12). Patients undergoing laparoscopic resection for SD had a postoperative complication rate of 10.0% (n = 38), whereas those with CD had a postoperative morbidity rate of 19.6% (n = 24). CD patients who had conversion to an open procedure had an even higher rate of postoperative complications (29.4%, n = 5, p = 0.35). On non-parsimonious multivariate adjustment, only CD (RR 1.96, 95% CI 1.11-3.46, p = 0.02) was found to be an independent risk factor for the development of postoperative complications. CONCLUSIONS: Complicated diverticulitis did not affect the conversion rate to an open procedure. However, patients with CD are prone to postoperative complications. The laparoscopic approach to sigmoid colectomy is safe and preferable in experienced hands.

Risk of catheter-associated deep venous thrombosis in inflammatory bowel disease.

BACKGROUND: Inflammatory bowel disease confers a hypercoagulable state. A large number of these patients require central venous access in the form of peripherally inserted central catheters for long-term intravenous therapies. Our clinical observations suggested that these patients had a higher incidence of catheter-associated deep venous thrombosis than that of the general population. OBJECTIVE: The aim of this study was to examine the relationship between IBD and catheter-associated deep venous thrombosis. DESIGN: A retrospective chart review was conducted of all patients who underwent peripherally inserted central catheter line placement between 2009 and 2011. SETTING: This study was performed at a single-institution tertiary referral center. PATIENTS: All patients who underwent peripherally inserted central catheter line placement were identified. OUTCOME MEASURES: The risk of catheter-associated deep venous thrombosis in IBD patients was assessed. This risk was compared with known risk factors such as malnutrition, malignancy, diabetes mellitus, and tobacco use. Multivariate analysis was performed. Catheter size, indication for placement, and vein location of catheter-associated deep venous thrombosis were identified in the IBD population. RESULTS: There were 7179 peripherally inserted central catheter lines placed during the study period; the overall incidence of catheter-associated deep venous thrombosis was 2.1% (148/7179). The incidence of catheter-associated deep venous thrombosis among patients with IBD was 6.8% (9/132). The incidence of catheter-associated deep venous thrombosis among non-IBD patients was 1.9% (139/7047) (relative risk, 3.5; 95% CI, 1.8-6.6; p < 0.001). The incidence of catheter-associated deep venous thrombosis was increased for patients with malnutrition (4.8%, 30/628, p < 0.001) and increasing age (95% CI, 1.01-1.12; p = 0.02). There was no increased incidence of catheter-associated deep venous thrombosis for patients with diabetes mellitus (1.6%, 25/1574, p < 0.14), malignancy (2.8%, 30/1041, p = 0.06), or tobacco use (1.6%, 31/1938, p = 0.10). After multivariate analysis, IBD, malnutrition, and increasing age were found to be significant risk factors for the development of catheter-associated deep venous thrombosis. LIMITATIONS: The inability to track the number of catheter days, the inaccuracy of administrative data, the lack of outpatient follow-up, and the small number of events in the study cohort were limitations of this study. CONCLUSIONS: This is the first study to demonstrate IBD as an independent risk factor to the development of catheter-associated deep venous thrombosis. The placement of a peripherally inserted central catheter line in IBD should be utilized selectively.

Use of a 5-Item Modified Frailty Index for Assessing Outcomes After Hartmann's Reversal: An ACS-NSQIP Study.

BACKGROUND: Half of all patients with an end colostomy after sigmoid colectomy (Hartmann's procedure) never undergo Hartmann's reversal, frequently secondary to frailty. This retrospective cohort study evaluates the utility of a five-item modified frailty index (mFI-5) in predicting post-operative outcomes after Hartmann's reversal. METHODS: The National Surgery Quality Improvement Program (NSQIP) database captured patients with elective Hartmann's reversals from 2011 to 2020. Clinical covariates were evaluated with univariate analysis and modified Poisson regression to determine association with overall morbidity, overall mortality, and extended length of stay (eLOS) when categorized by mFI-5 score. RESULTS: 15,172 patients underwent elective Hartmann's reversal (91.6% open and 8.4% laparoscopic). Patients were grouped by mFI-5 score (0: 48.7%, 1: 38.2%, ≥ 2: 13.1%). Adjusted multivariable analysis showed frail patients (mFI-5≥2) had increased overall mortality (OR 2.23, 95% CI 1.21-4.11), morbidity (OR 1.23, 95% CI 1.12-1.35), and eLOS (OR 1.12, 95% 1.02-1.23). Among frail patients, a laparoscopic approach was associated with decreased overall morbidity (OR .64, 95% CI 0.56-.73) and decreased eLOS (OR .46, 95% CI 0.39-.54) when compared to open approach. DISCUSSION: An mFI-5 of ≥2 was associated with greater morbidity, mortality, and eLOS following Hartmann's reversal. However, there were no mortality or eLOS differences in patients with an mFI-5 of 1 and only a 14% increase in any morbidity, making these patients potentially good candidates for Hartmann's reversal. Furthermore, laparoscopic surgery was associated with a protective effect for overall morbidity and eLOS, potentially mitigating some of the risk associated with higher frailty scores.

Psychiatric Diagnoses Are Associated With Postoperative Disparities in Patients Undergoing Major Colorectal Operations.

BACKGROUND: Over 50% of hospitalized patients have comorbid psychiatric diagnoses, resulting in increased risk of morbidity such as longer lengths of stay, worse health-related quality of life, and increased mortality. However, data regarding colorectal surgery postoperative outcomes in patients with psychiatric diagnoses (PD) are limited. METHODS: We queried a single institution's National Surgical Quality Improvement Program from 2013-2019 for major colorectal procedures. Postsurgical outcomes for patients with and without PD were compared. Primary outcomes were prolonged length of stay (pLOS) and 30-day readmission. RESULTS: From a total of 1447 patients, 402 (27.8%) had PD. PD had more smokers (20.9% vs 15%) and higher mean body mass index (29.1 kg/m2 vs 28.2 kg/m2). Bivariate outcomes showed more surgical site infections (SSI) (10.2% vs 6.12%), reoperation (9.45% vs 6.35%), and pLOS (34.8% vs 29.0%) (all P values <.05) in the PD group. On multivariate analysis, PD had higher likelihood of reoperation (OR 1.53, 95% CI: [1.02-2.80]) and SSI (OR 1.82, 95% CI: [1.25-2.66]). DISCUSSION: Psychiatric diagnoses are a risk factor for adverse outcomes after colorectal procedures. Further studies are needed to evaluate the benefit of perioperative mental health support services for these patients.

Detection of Ischemic Colitis on Routine Lower Endoscopy and Its Implications After Repair of Ruptured Abdominal Aortic Aneurysm.

BACKGROUND: Ischemic colitis (IC) is a known significant complication after repair of a ruptured abdominal aortic aneurysm (rAAA). Lower endoscopy (colonoscopy or flexible sigmoidoscopy) is a helpful adjunct to aid decision making for surgical exploration. We believe routine use of lower endoscopy after rAAA repair provides better patient care through expeditious diagnosis and surgical care. METHODS: We performed a retrospective chart review of rAAA repairs from 2008 to 2019. All patients undergo screening lower endoscopy after rAAA repair at our institution. The incidence of IC, mortality, and diagnostic characteristics of routine lower endoscopy was analyzed. RESULTS: Of these, 182 patients underwent rAAA repair, among which 139 (76%) underwent routine lower endoscopy. Ischemic colitis of any grade was diagnosed in 25% of patients. The 30-day mortality was 11% compared to 19% in those without lower endoscopy. The presence of IC portended a 4-fold increase in mortality rate compared to those without (26% vs 6%, P = .005). Surgical exploration rate was 8% after routine lower endoscopy. Grade III ischemia on lower endoscopy had a sensitivity of 50% (95% CI 12-88) and specificity of 99% (95% CI 94-100) for transmural necrosis. DISCUSSION: We found increased incidence of IC and reliable diagnostic characteristics of routine lower endoscopy in predicting the presence of transmural colonic ischemia. There was decreased mortality with use of routine lower endoscopy but this was not statistically significant.

Diagnostic yield and repeat biopsies in rectal and nonrectal colorectal adenocarcinoma: Are we hedging on rectal biopsies?

Patients with rectal cancer undergo more repeat biopsies compared to those with nonrectal colon cancer prior to management. We investigated the factors driving the higher frequency of repeat biopsies in patients with rectal cancer. We compared clinicopathologic features of diagnostic and nondiagnostic (in regard to invasion) rectal (n = 64) and colonic (n = 57) biopsies from colorectal cancer patients and characterized corresponding resections. Despite similar diagnostic yield, repeat biopsy was more common in rectal carcinoma, especially in patients receiving neoadjuvant therapy (p < 0.05). The presence of desmoplasia (odds ratio 12.9, p < 0.05) was a strong predictor of making a diagnosis of invasion in both rectal and nonrectal colon cancer biopsies. Diagnostic biopsies had more desmoplasia, intramucosal carcinoma component and marked inflammation, and less low-grade dysplasia component (p < 0.05). Diagnostic yield of biopsy was higher for tumors with high-grade tumor budding, mucosal involvement by high-grade dysplasia/intramucosal carcinoma without low-grade dysplasia and diffuse surface desmoplasia irrespective of tumor location. Sample size, amount of benign tissue, appearance, and T stage did not affect diagnostic yield. Repeat biopsy of rectal cancer is primarily driven by management implications. Diagnostic yield in colorectal cancer biopsies is multifactorial and is not due to differing pathologists' diagnostic approach per tumor site. For rectal tumors, a multidisciplinary strategic approach is warranted to avoid repeat biopsy when unnecessary.

Left Ventricular Ejection Fraction Association with Acute Ischemic Stroke Outcomes in Patients Undergoing Thrombolysis.

(1) Background: Little is known about how left ventricular systolic dysfunction (LVSD) affects functional and clinical outcomes in acute ischemic stroke (AIS) patients undergoing thrombolysis; (2) Methods: A retrospective observational study conducted between 2006 and 2018 included 937 consecutive AIS patients undergoing thrombolysis. LVSD was defined as left ventricular ejection fraction (LVEF) < 50%. Univariate and multivariate binary logistic regression analysis was performed for demographic characteristics. Ordinal shift regression was used for functional modified Rankin Scale (mRS) outcome at 3 months. Survival analysis of mortality, heart failure (HF) admission, myocardial infarction (MI) and stroke/transient ischemic attack (TIA) was evaluated with a Cox-proportional hazards model; (3) Results: LVSD patients in comparison with LVEF ≥ 50% patients accounted for 190 and 747 patients, respectively. LVSD patients had more comorbidities including diabetes mellitus (100 (52.6%) vs. 280 (37.5%), p < 0.001), atrial fibrillation (69 (36.3%) vs. 212 (28.4%), p = 0.033), ischemic heart disease (130 (68.4%) vs. 145 (19.4%), p < 0.001) and HF (150 (78.9%) vs. 46 (6.2%), p < 0.001). LVSD was associated with worse functional mRS outcomes at 3 months (adjusted OR 1.41, 95% CI 1.03-1.92, p = 0.030). Survival analysis identified LVSD to significantly predict all-cause mortality (adjusted HR [aHR] 3.38, 95% CI 1.74-6.54, p < 0.001), subsequent HF admission (aHR 4.23, 95% CI 2.17-8.26, p < 0.001) and MI (aHR 2.49, 95% CI 1.44-4.32, p = 0.001). LVSD did not predict recurrent stroke/TIA (aHR 1.15, 95% CI 0.77-1.72, p = 0.496); (4) Conclusions: LVSD in AIS patients undergoing thrombolysis was associated with increased all-cause mortality, subsequent HF admission, subsequent MI and poorer functional outcomes, highlighting a need to optimize LVEF.

Single-incision versus standard multiport laparoscopic colectomy: a multicenter, case-controlled comparison.

OBJECTIVE: The aim of this study was to compare single-incision laparoscopic colectomy (SILC) to multiport laparoscopic colectomy (MLC) when performed by experienced laparoscopic surgeons. BACKGROUND: Recent case reports and single institution series have demonstrated the feasibility of SILC. Few comparative studies for MLC and SILC have been reported. METHODS: Patients from 5 institutions undergoing SILC were entered into an IRB approved database from November 2008 to March 2010. SILC patients were matched with those undergoing MLC for gender, age, disease, surgery, BMI, and surgeon. The primary endpoint was length of stay and secondary endpoints included operative time, conversion, complications and postoperative pain scores. RESULTS: Three hundred thirty patients (SILC = 165, MLC = 165) were evaluated. Operative time (135 ± 45 min vs. 133 ± 56 min; P = 0.85) and length of stay (4.6 ± 1.6 vs. 4.3 ± 1.4; P = 0.35) were not significantly different. Maximum postoperative day one pain scores were significantly less for SILC (4.9 vs. 5.6; P = 0.005). Eighteen (11%) patients undergoing SILC were converted to multiport laparoscopy. There was no statistical difference between groups for conversions to laparotomy, complications, re-operations, or re-admissions. CONCLUSIONS: SILC is feasible when performed on select patients by surgeons with extensive laparoscopic experience. Outcomes were similar to MLC, except for a reduction in peak pain score on the first postoperative day. Prospective randomized trials should be performed before incorporation of this technology into routine surgical care.