Surgery Improves Patient-Reported Outcomes in Patients with Intestinal and Pancreatic NETs: A Prospective Analysis.

BACKGROUND: Incorporation of patient-reported outcomes such as health-related quality of life has become increasingly important in the management of chronic diseases such as cancer. In this prospective study, we examined the effect of surgical resection on quality of life in patients with intestinal and pancreatic neuroendocrine tumors (NETs). METHODS: Thirty-two patients underwent NET resection at our institution from January 2020 to January 2022. All patients completed the 12-item short-form quality-of-life survey prior to surgery, as well as at the 3-, 6-, and 12-month postoperative time points. The presence and severity of specific carcinoid syndrome symptoms (diarrhea, flushing, and abdominal pain) were also recorded during pre- and postoperative appointments. RESULTS: Patients experienced significant increases in both mental and physical health after surgery. Mental health scores significantly increased at all three time points (baseline: 51.33; 3-month: 53.17, p = 0.02; 6-month: 57.20, p < 0.001; 12-month: 57.34, p = 0.002), and physical health scores increased at 6 and 12 months (baseline: 50.39; 6-month: 53.16, p = 0.04; 12-month: 55.02, p = 0.003). Younger patients benefited more in terms of physical health, while older patients had more significant increases in mental health. Patients with metastatic disease, larger primary tumors, and those receiving medical therapy had lower baseline quality-of-life scores and greater improvements after surgery. The vast majority of patients in this study also experienced alleviation of carcinoid syndrome symptoms. CONCLUSIONS: In addition to prolonging survival, resection of intestinal and pancreatic NETs leads to significantly improved patient-reported quality of life.

The effect of percentage of ideal body weight on outcomes in ileo-anal pull through for ulcerative colitis.

PURPOSE: Ileo-anal pull through (IAPT) is a commonly performed operation for the surgical management of ulcerative colitis. The effect of body weight on outcomes for patients undergoing this operation has not been extensively studied. METHODS: This was a prospective cohort study at a single tertiary care inflammatory bowel disease (IBD) center. A total of 457 patients who were operated on at the Mount Sinai Medical Center between 1983 and 2015 were included. Demographic characteristics, the patients' body weight at the time of IAPT, and postoperative outcome data were collected. RESULTS: For each patient, body weight was calculated as a percentage of the ideal body weight (IBW) for that patient's height. The mean percentage of ideal body weight was 93.9% with a standard deviation of 20%. The range for the population was 53.1 to 175%. Four hundred forty (96%) of the patients had a weight within two standard deviations of the mean, indicating a normal distribution. Seventy-nine patients developed a Clavien-Dindo class III complication necessitating a procedural treatment. The most common of these was a stricture at the anastomotic site (n = 54). Our study identified an association between a percentage of ideal body weight in the lowest quartile of our population and development of an anastomotic stricture. This association was statistically significant on multivariate analysis. CONCLUSION: Low body weight at the time of ileo-anal pull through for treatment of UC may be a risk factor for development of anastomotic stricture requiring dilation.

The Successful Implementation of a Laparoscopic Simulation Training Program in the Dominican Republic.

INTRODUCTION: Mount Sinai Hospital in New York introduced a laparoscopic surgery simulation center to a public hospital in Santiago, Dominican Republic to determine the feasibility of training programs in low-and-middle income countries (LMICs). METHODS: In August 2018, recruitment and preliminary data were collected at the Hospital Jose Maria Cabral y Báez in Santiago, Dominican Republic. The simulation room consists of three simulation stations. Residents were required to practice 1 h/wk guided by a general surgery postgraduate year 3 (PGY3) Mount Sinai resident. Number of hours practiced was self-reported and follow-up data was collected in June 2019. The study endpoints include times on three simulated laparoscopic tasks including peg-transfer, precision cutting, and intracorporeal knot tying. Wilcoxon-signed rank tests were used for statistical analysis. RESULTS: The partnership between hospitals allowed for successful integration into the Dominican general surgery training. Over 10 mo, residents averaged 25 h of practice (range: 8-35 h; SD 9.95 h). In total, 85% of the residents participated in the study (5 postgraduate year 1 [PGY1], 2 postgraduate year 2 [PGY2], and 4 postgraduate year 3 [PGY3]). Resident median simulation times significantly improved for precision cutting (3:49 min versus 2:09 min, P = 0.002) and intracorporeal knot tying (5:20 min versus 2:47 min, P = 0.037). There was neither significant difference in peg-transfer times nor performance between resident years (P = 0.12). CONCLUSIONS: This study demonstrates the successful integration of a laparoscopic simulation program into an LMIC surgical resident training program. With commitment from local institutions and external resources, establishing laparoscopic simulation centers are feasible and expandable, thereby allowing general surgery residents in other LMICs, the opportunity to improve their laparoscopic skills.

Slow and Steady Wins the Race: A Solid Case for a 3-Stage Approach in Ulcerative Colitis.

BACKGROUND: Approximately 10% to 20% of patients with ulcerative colitis require surgery during their disease course, of which the most common is the staged restorative proctocolectomy with IPAA. OBJECTIVE: The aim was to compare the rates of anastomotic leaks among all staged restorative proctocolectomy with IPAA procedures. DESIGN: This was a retrospective cohort study. SETTINGS: This study was conducted at a single tertiary care IBD center. PATIENTS: All patients with ulcerative colitis or IBD-unspecified who underwent a primary total proctocolectomy with IPAA for medically refractory disease or dysplasia between 2008 and 2017 were identified. MAIN OUTCOME MEASURES: The primary outcome was anastomotic leak within a 6-month postoperative period. Univariate and multivariate logistic regression were used to compare patients with and without anastomotic leaks. RESULTS: The sample was composed of 584 nonemergent patients, of whom 50 (8.6%) underwent 1-stage, 162 (27.7%) underwent 2-stage, 58 (9.9%) underwent modified 2-stage, and 314 (53.7%) underwent a 3-stage total proctocolectomy with IPAA. The primary indication was medically refractory disease in 488 patients and dysplasia/cancer in 101 patients. Anastomotic leak occurred in 10 patients (3.2%) after 3-stage, 14 patients (8.6%) after 2-stage, 6 patients (10.3%) after modified 2-stage, and 10 patients (20.0%) after a 1-stage procedure. A 3-stage procedure had fewer leaks and additional procedures for leaks compared with 1- and modified 2-stage procedures (p < 0.03). The 3-stage procedure had fewer combined anastomotic leaks and pelvic abscesses than all of the other staged procedures (p < 0.05). LIMITATIONS: This study was limited by its retrospective design and evolving electronic medical charts system. CONCLUSIONS: The 3-stage total proctocolectomy with IPAA is the optimal staged method in ulcerative colitis to reduce leaks and related complications. See Video Abstract at http://links.lww.com/DCR/B693. LENTO Y CONSTANTE GANA LA CARRERA UN CASO SLIDO PARA UN ENFOQUE DE TRES ETAPAS EN LA COLITIS ULCEROSA: ANTECEDENTES:Aproximadamente el 10-20% de los pacientes con colitis ulcerosa requieren cirugía durante el curso de su enfermedad, de los cuales la más común es la proctocolectomía restauradora escalonada con anastomosis con bolsa ileo-anal.OBJETIVO:El objetivo fue comparar las tasas de fugas anastomóticas entre todos los procedimientos de proctocolectomía restauradora por etapas con procedimiento de anastomosis con bolsa ileo-anal.DISEÑO:Este fue un estudio de cohorte retrospectivo.ENTORNO CLÍNICO:Este estudio se llevó a cabo en un único centro de atención terciaria de tercer nivel para enfermedades inflamatorias del intestino.PACIENTES:Se identificaron todos los pacientes con colitis ulcerosa o enfermedad inflamatoria intestinal inespecífica que se sometieron a una proctocolectomía total primaria mas anastomosis con bolsa ileo-anal por enfermedad médicamente refractaria o displasia entre 2008 y 2017.PRINCIPALES MEDIDAS DE RESULTADO:El resultado primario fue la fuga anastomótica dentro de un período posoperatorio de seis meses. Se utilizó regresión logística univariante y multivariante para comparar pacientes con y sin fugas anastomóticas.RESULTADOS:La muestra estuvo compuesta por 584 pacientes no emergentes, de los cuales 50 (8,6%) se sometieron a una etapa, 162 (27,7%) se sometieron a dos etapas, 58 (9,9%) se sometieron a modificación en dos etapas y 314 (53,7%) se sometieron a una proctocolectomía total en tres tiempos mas anastomosis con bolsa ileo-anal. La indicación principal fue enfermedad médicamente refractaria en 488 pacientes y displasia / cáncer en 101 pacientes. Se produjo una fuga anastomótica en 10 (3,2%) pacientes después de tres etapas, 14 (8,6%) pacientes después de dos etapas, 6 (10,3%) pacientes después de dos etapas modificadas y 10 (20,0%) pacientes después de una etapa procedimiento. Un procedimiento de tres etapas tuvo menos fugas y procedimientos adicionales para las fugas en comparación con los procedimientos de una y dos etapas modificadas (p <0.03). El procedimiento de tres etapas tuvo menos fugas anastomóticas y abscesos pélvicos combinados que todos los demás procedimientos por etapas (p <0,05).LIMITACIONES:Este estudio estuvo limitado por su diseño retrospectivo y su sistema de registros médicos electrónicos en evolución.CONCLUSIONES:La proctocolectomía total en tres etapas mas anastomosis con bolsa ileo-anal es el método óptimo por etapas en la colitis ulcerosa para reducir las fugas y las complicaciones relacionadas. Consulte Video Resumen en http://links.lww.com/DCR/B693.

Role of mFI-5 in predicting geriatric outcomes in laparoscopic cholecystectomy.

BACKGROUND: Frailty is the age-related decline contributing to adverse outcome vulnerability. This study assesses the modified 5-factor frailty index's (mFI-5) ability to predict geriatric cholecystectomy outcomes. METHODS: Laparoscopic cholecystectomy patients ages ≥65 were identified from the American College of Surgeons' National Surgical Quality Improvement Program database (2018-2020). MFI-5 variables include hypertension, congestive heart failure, chronic obstructive pulmonary disease, diabetes, and functional status. Groups were stratified according to the number of comorbidities: mFI â€‹= â€‹0, mFI â€‹= â€‹1, mFI≥2. RESULTS: 32,481 cases included 27.6% mFI â€‹= â€‹0, 46.4% mFI â€‹= â€‹1, 26.0% mFI≥2. Highest frailty correlated with increased discharges to not home (OR 1.88, p â€‹< â€‹0.01). Non-independent functional status was associated with mortality (OR 7.32), prolonged length of stay (LOS) (5.69), pneumonia (4.90), sepsis (3.78), readmission (2.60) (p â€‹< â€‹0.01). AUCs were calculated for prolonged LOS (0.89), discharges to not home (0.85), mortality (0.83), pneumonia (0.76), sepsis (0.76). CONCLUSIONS: Healthcare teams can use mFI-5 to target at-risk cholecystectomy patients and proactively intervene to avoid complications.

Diabetes as a Risk Factor for Perforated Appendicitis: A National Analysis.

BACKGROUND: A few important risk factors play into rates of perforation following acute appendicitis. Diabetes may be an additional risk factor due to various systemic complications that may contribute to perforation and additional adverse outcomes following acute appendicitis, all of which currently remains unknown in the United States. METHODS: Adult patients with acute appendicitis under 65 years of age were identified from the National Inpatient Sample between 2012 and 2014 and the distribution of baseline variables was examined across diabetic status using Rao-Scott chi square and student's t-test. A propensity score match was implemented for a conditional logistic regression that assessed differences in rates of perforation, outcomes, as well as postoperative complications. RESULTS: Among all patients with acute appendicitis, approximately 7% had diabetes. Diabetics were more likely to experience perforated appendicitis (odds ratio 95% confidence interval 1.093 (1.029, 1.160); P = .0036), experience a longer length of stay (1.540 (1.434, 1.654); P < .0001), receive an open appendectomy (1.139 (1.05, 1.236); P = .0018), and experience postoperative cardiovascular complications (2.103 (1.325, 3.340)); P = .0016). DISCUSSION: Diabetic adult patients under 65 years of age with acute appendicitis experience higher rates in perforation, a longer length of stay, more open surgical approach, and cardiovascular postoperative complications. Diabetes should be one of many risk factors considered in the evaluation and management of perforation following acute appendicitis.

Emergent Subtotal Colectomies Have Higher Leak Rates in Subsequent J-Pouch Stages.

PURPOSE: The most common surgery for ulcerative colitis (UC) is the staged restorative proctocolectomy with ileal pouch-anal anastomosis (IPAA). On occasion, an emergent first-stage subtotal colectomy must be performed. The purpose of this study was to compare rates of postoperative complications in three-stage IPAA patients who underwent emergent vs non-emergent first-stage subtotal colectomies in the subsequent staged procedures. METHODS: This was a retrospective chart review conducted at a single tertiary care inflammatory bowel disease (IBD) center. All UC or IBD-Unspecified patients who underwent a three-stage IPAA between 2008 and 2017 were identified. Emergent surgery was defined as that performed on an inpatient who had perforation, toxic megacolon, uncontrolled hemorrhage, or septic shock. The primary outcomes were the presence of anastomotic leak, obstruction, bleeding, and the need for reoperation for each within a 6-month postoperative period of the second (RPC with IPAA and DLI) and third surgical stages (ileostomy reversal). RESULTS: A total of 342 patients underwent a three-stage IPAA, of which 30 (9.4%) had emergent first-stage operations. Patients who underwent an emergent STC were more likely to have a post-operative anastomotic leak and need an additional procedure following the subsequent second and third-staged operations on both univariate and multivariate analysis (p < 0.05). No difference was found for obstruction, wound infection, intra-abdominal abscess, or bleeding (p > 0.05). CONCLUSION: Three-stage IPAA patients with emergent first-stage subtotal colectomies were more likely to have a post-operative anastomotic leak and need an additional procedure for a leak following the subsequent second- and third-stage operations.

Resection Prolongs Overall Survival for Nonmetastatic Midgut Small Bowel Neuroendocrine Tumors: A National Cancer Data Base Study.

OBJECTIVES: This study aimed to understand if resection (RS) for nonmetastatic small bowel neuroendocrine tumors (SBNETs) prolongs 5-year overall survival. METHODS: Patients from National Cancer Data Base with primary histologically confirmed SBNETs from 2007 to 2016 were included. Patients younger than 18 years, with the disease in the duodenum/Meckel diverticulum or metastatic disease were excluded. We assessed 5-year survival rates using Kaplan-Meier curves and multivariate Cox proportional hazards regression after RS, nonresection surgical management (NRS), or no resection (NR). Multivariate models were adjusted with age, sex, race, insurance, Charlson-Deyo comorbidity score, academic facility, primary tumor location, clinical T, clinical N, stage, and grade. RESULTS: We identified 4180 patients. On average, patients were 64 years old (standard deviation, 12 years), male (53%), and White (84%). The majority received RS (91.8%) as opposed to NRS (4.0%) or NR (4.2%). Patients who received RS versus NR had increased survival rates (84.2% vs 73.9%; univariate log-rank, P < 0.0001; multivariate hazard ratio, 0.73; 95% confidence interval, 0.53-0.99; P = 0.04). No statistical difference in survival was observed for NRS versus NR. CONCLUSIONS: To our knowledge, this is the first national study to evaluate survival after RS for nonmetastatic SBNETs. Results suggest that RS of SBNETs may prolong 5-year survival.

Early Ambulation is Associated with Improved Outcomes Following Colorectal Surgery.

BACKGROUND: The Enhanced Recovery After Surgery (ERAS) society lists early mobilization as one of their recommendations for improving patient outcomes following colorectal surgery. The level of supporting evidence, however, is relatively weak, and furthermore, the ERAS guidelines do not clearly define "early" mobilization. In this study, we define mobilization in terms of time to first ambulation after surgery and develop an outcome-based cutoff for early mobilization. METHODS: This is a retrospective cohort study comprised of 291 patients who underwent colorectal operations at a large, academic medical center from June to December 2019. Three cutoffs (12 hours, 24 hours, and 48 hours) were used to divide patients into early and late ambulation groups for each cutoff, and statistical analysis was performed to determine differences in postoperative outcomes between the corresponding groups. RESULTS: Multivariate analysis showed no difference between the early and late ambulation groups for the 12-hour and 48-hour cutoffs; however, ambulation before 24 hours was associated with a decreased rate of severe complications as well as fewer adverse events overall. Patients who ambulated within 24 hours had a 4.1% rate of severe complications and a 22.1% rate of experiencing some adverse event (complication, return to the emergency department, and/or readmission). In comparison, 11.8% of patients who ambulated later experienced a severe complication (P = 0.026), while 36.1% of patients experienced some adverse event (P = 0.011). CONCLUSIONS: Ambulation within 24 hours after colorectal surgery is associated with improved postoperative outcomes, particularly a decreased rate of severe complications.