Comparison of lumen-apposing metal stents versus endoscopic balloon dilation for the management of benign colorectal anastomotic strictures.

BACKGROUND AND AIMS: Limited data exist evaluating lumen-apposing metal stents (LAMSs) with endoscopic balloon dilation (EBD) for the treatment of benign colorectal anastomotic strictures (BCASs). This study compares outcomes of both interventions. METHODS: Patients with left-sided BCAS treated with LAMSs versus EBD were identified retrospectively. The primary outcome was a composite of crossover to another intervention to achieve clinical success or recurrence requiring reintervention. RESULTS: Twenty-nine patients (11 LAMS and 18 EBD) were identified with longer follow-up in the EBD group (734 vs 142 days; P = .003). No significant differences were found in the composite outcome, technical success, clinical success, or components of composite outcome. With LAMS, there was a nonsignificant trend toward fewer procedures (2.4 vs 3.3; P = .06) and adverse events (0% vs 16.7%; P = .26). CONCLUSIONS: LAMS appears to be as effective as EBD for the treatment of BCAS but may require fewer procedures and may be safer than EBD.

Role of Adjuvant Chemotherapy After Curative Resection in Stage II and III Rectal Cancer.

INTRODUCTION: Patients with resected locally advanced rectal cancer (LARC) and an incomplete total mesorectal excision (TME) have worse oncologic outcomes. The associations between TME grade, adjuvant therapy receipt, and oncologic outcomes have not been well-studied. We aimed to determine the association between adjuvant chemotherapy and oncologic outcomes in patients who underwent neoadjuvant chemoradiation (CRT) or short-course radiotherapy (SCRT) followed by proctectomy and to evaluate this association stratified by TME grade. MATERIALS AND METHODS: We analyzed a retrospective multi-institutional cohort of primary LARC patients diagnosed between 2010 and 2018 who received neoadjuvant CRT/SCRT followed by proctectomy. Complete TME was defined as complete mesorectal excision, and noncomplete TME was defined as near-complete or incomplete TME. We used adjusted Cox proportional hazards regression to test the association between adjuvant chemotherapy and mortality or locoregional recurrence (LRR) across groups. RESULTS: We identified 746 eligible patients. On final pathology, 101 (13.5%) had noncomplete and 645 (86.5%) had complete TME. Rates of adjuvant chemotherapy receipt were similar between noncomplete and complete TME groups (70.3% and 69.5%, respectively). Mean follow-up interval was 35 mo. Adjuvant chemotherapy was associated with lower risk of mortality (HR 0.27, 95% CI 0.19-0.39, P < 0.001); the same association existed when stratifying patients by TME grade. For patients with a complete TME, adjuvant chemotherapy was associated with lower LRR (HR 0.08, 95% CI 0.01-0.56, P = 0.01). The LRR model for the noncomplete TME group did not converge due to few captured recurrences. CONCLUSIONS: These data show an association between adjuvant chemotherapy and positive outcomes in LARC patients receiving neoadjuvant CRT/SCRT followed by proctectomy.

Association of Surgical Approaches and Outcomes in Total Mesorectal Excision and Margin Status for Rectal Cancer.

INTRODUCTION: Despite being a key metric with a significant correlation with the outcomes of patients with rectal cancer, the optimal surgical approach for total mesorectal excision (TME) has not yet been identified. The aim of this study was to assess the association of the surgical approach on the quality of TME and surgical margins and to characterize the surgical and long-term oncologic outcomes in patients undergoing robotic, laparoscopic, and open TME for rectal cancer. METHODS: Patients with primary, nonmetastatic rectal adenocarcinoma who underwent either lower anterior resection or abdominoperineal resection via robotic (Rob), laparoscopic (Lap), or open approaches were selected from the US Rectal Cancer Consortium database (2007-2017). Quasi-Poisson regression analysis with backward selection was used to investigate the relationship between the surgical approach and outcomes of interest. RESULTS: Among the 664 patients included in the study, the distribution of surgical approaches was as follows: 351 (52.9%) underwent TME via the open approach, 159 (23.9%) via the robotic approach, and 154 (23.2%) via the laparoscopic approach. There were no significant differences in baseline demographics among the three cohorts. The laparoscopic cohort had fewer patients with low rectal cancer (<6 cm from the anal verge) than the robotic and open cohorts (Lap 28.6% versus Rob 59.1% versus Open 45.6%, P = 0.015). Patients who underwent Rob and Lap TME had lower intraoperative blood loss compared with the Open approach (Rob 200 mL [Q1, Q3: 100.0, 300.0] versus Lap 150 mL [Q1, Q3: 75.0, 250.0] versus Open 300 mL [Q1, Q3: 150.0, 600.0], P < 0.001). There was no difference in the operative time (Rob 243 min [Q1, Q3: 203.8, 300.2] versus Lap 241 min [Q1, Q3: 186, 336] versus Open 226 min [Q1, Q3: 178, 315.8], P = 0.309) between the three approaches. Postoperative length of stay was shorter with robotic and laparoscopic approach compared to open approach (Rob 5.0 d [Q1, Q3: 4, 8.2] versus Lap 5 d [Q1, Q3: 4, 8] versus Open 7.0 d [Q1, Q3: 5, 9], P < 0.001). There was no statistically significant difference in the quality of TME between the robotic, laparoscopic, and open approaches (79.2%, 64.9%, and 64.7%, respectively; P = 0.46). The margin positivity rate, a composite of circumferential margin and distal margin, was higher with the robotic and open approaches than with the laparoscopic approach (Rob 8.2% versus Open 6.6% versus Lap 1.9%, P = 0.17), Rob versus Lap (odds ratio 0.21; 95% confidence interval 0.05, 0.83) and Rob versus Open (odds ratio 0.5; 95% confidence interval 0.22, 1.12). There was no difference in long-term survival, including overall survival and recurrence-free survival, between patients who underwent robotic, laparoscopic, or open TME (Figure 1). CONCLUSIONS: In patients undergoing surgery with curative intent for rectal cancer, we did not observe a difference in the quality of TME between the robotic, laparoscopic, or open approaches. Robotic and open TME compared to laparoscopic TME were associated with higher margin positivity rates in our study. This was likely due to the higher percentage of low rectal cancers in the robotic and open cohorts. We also reported no significant differences in overall survival and recurrence-free survival between the aforementioned surgical techniques.

Association of omental pedicled flap with anastomotic leak following low anterior resection for rectal cancer.

BACKGROUND AND OBJECTIVES: Anastomotic leak following colorectal anastomosis adversely impacts short-term, oncologic, and quality-of-life outcomes. This study aimed to assess the impact of omental pedicled flap (OPF) on anastomotic leak among patients undergoing low anastomotic resection (LAR) for rectal cancer using a multi-institutional database. METHODS: Adult rectal cancer patients in the US Rectal Cancer Consortium, who underwent a LAR for stage I-III rectal cancer with or without an OPF were included. Patients with missing data for surgery type and OPF use were excluded from the analysis. The primary outcome was the development of anastomotic leaks. Multivariable logistic regression was used to determine the association. RESULTS: A total of 853 patients met the inclusion criteria and OPF was used in 106 (12.4%) patients. There was no difference in age, sex, or tumor stage of patients who underwent OPF versus those who did not. OPF use was not associated with an anastomotic leak (p = 0.82), or operative blood loss (p = 0.54) but was associated with an increase in the operative duration [ß = 21.42 (95% confidence interval = 1.16, 41.67) p = 0.04]. CONCLUSIONS: Among patients undergoing LAR for rectal cancer, OPF use was associated with an increase in operative duration without any impact on the rate of anastomotic leak.

Prophylactic defunctioning stomas improve clinical outcomes of anastomotic leak following rectal cancer resections: An analysis of the US Rectal Cancer Consortium.

PURPOSE: Anastomotic leak (AL) is a complication of low anterior resection (LAR) that results in substantial morbidity. There is immense interest in evaluating immediate postoperative and long-term oncologic outcomes in patients who undergo diverting loop ileostomies (DLI). The purpose of this study is to understand the relationship between fecal diversion, AL, and oncologic outcomes. METHODS: This is a retrospective multicenter cohort study using patient data obtained from the US Rectal Cancer Consortium database compiled from six academic institutions. The study population included patients with rectal adenocarcinoma undergoing LAR. The primary outcome was the incidence of AL among patients who did or did not receive DLI during LAR. Secondary outcomes included risk factors for AL, receipt of adjuvant therapy, 3-year overall survival, and 3-year recurrence. RESULTS: Of 815 patients, 38 (4.7%) suffered AL after LAR. Patients with AL were more likely to be male, have unintentional preoperative weight loss, and are less likely to undergo DLI. On multivariable analysis, DLI remained protective against AL (p < 0.001). Diverted patients were less likely to undergo future surgical procedures including additional ostomy creation, completion proctectomy, or pelvic washout for AL. Subgroup analysis of 456 patients with locally advanced disease showed that DLI was correlated with increased receipt of adjuvant therapy for patients with and without AL on univariate analysis (SHR:1.59; [95% CI 1.19-2.14]; p = 0.002), but significance was not met in multivariate models. CONCLUSION: Lack of DLI and preoperative weight loss was associated with anastomotic leak. Fecal diversion may improve the timely initiation of adjuvant oncologic therapy. The long-term outcomes following routine diverting stomas warrant further study.

Polygenic Risk Prediction in Diverticulitis.

OBJECTIVE: To derive and validate a polygenic risk score (PRS) to predict the occurrence and severity of diverticulitis and to understand the potential for incorporation of a PRS in current decision-making. BACKGROUND: PRS quantifies genetic variation into a continuous measure of risk. There is a need for improved risk stratification to guide surgical decision-making that could be fulfilled by PRS. It is unknown how surgeons might integrate PRS in decision-making. METHODS: We derived a PRS with 44 single-nucleotide polymorphisms associated with diverticular disease in the UK Biobank and validated this score in the Michigan Genomics Initiative (MGI). We performed a discrete choice experiment of practicing colorectal surgeons. Surgeons rated the influence of clinical factors and a hypothetical polygenic risk prediction tool. RESULTS: Among 2812 MGI participants with diverticular disease, 1964 were asymptomatic, 574 had mild disease, and 274 had severe disease. PRS was associated with occurrence and severity. Patients in the highest PRS decile were more likely to have diverticulitis [odds ratio (OR)=1.84; 95% confidence interval (CI), 1.42-2.38)] and more likely to have severe diverticulitis (OR=1.61; 95% CI, 1.04-2.51) than the bottom 50%. Among 213 surveyed surgeons, extreme disease-specific factors had the largest utility (3 episodes in the last year, +74.4; percutaneous drain, + 69.4). Factors with strongest influence against surgery included 1 lifetime episode (-63.3), outpatient management (-54.9), and patient preference (-39.6). PRS was predicted to have high utility (+71). CONCLUSIONS: A PRS derived from a large national biobank was externally validated, and found to be associated with the incidence and severity of diverticulitis. Surgeons have clear guidance at clinical extremes, but demonstrate equipoise in intermediate scenarios. Surgeons are receptive to PRS, which may be most useful in marginal clinical situations. Given the current lack of accurate prognostication in recurrent diverticulitis, PRS may provide a novel approach for improving patient counseling and decision-making.

Predictors and Outcomes of Upstaging in Rectal Cancer Patients Who Did Not Receive Preoperative Therapy.

BACKGROUND: Preoperative chemoradiation is indicated for clinical stage II and III rectal cancers; however, the accuracy of clinical staging with preoperative imaging is imperfect. OBJECTIVE: The study aimed to better characterize the incidence and management of clinical and pathologic stage discordances in patients who did not receive preoperative chemoradiation. DESIGN: This was a retrospective cohort analysis. SETTINGS: The source of data was the National Cancer Database from 2006 to 2015. PATIENTS: We identified patients who underwent resection with curative intent for clinical stage I rectal adenocarcinoma without preoperative chemotherapy or radiation. MAIN OUTCOME MEASURES: We evaluated the characteristics of "upstaged" patients-those with T3/T4 tumors found on pathology (pathologic stage II) and/or with positive regional nodes in the resection specimen (pathologic stage III) compared with those patients who were not upstaged (pathologic stage I). We then used a mixed-effects multivariable survival model to compare overall survival between these groups. RESULTS: Among 7818 clinical stage I rectal cancer patients who did not receive preoperative therapy, tumor upstaging occurred in 819 (10.6%) and nodal upstaging occurred in 1612 (20.8%). Upstaged patients were more likely than those not upstaged to have higher grade tumors and positive margins. Survival was worse in upstaged patients (hazard ratio [HR], 1.64; 95% CI, 1.4-1.9) but improved among those upstaged patients who received either chemotherapy (HR, 0.71; 95% CI, 0.6-0.9) or chemoradiation (HR, 0.62; 95% CI, 0.5-0.7). LIMITATIONS: In addition to the inherent limitations of a retrospective cohort study, the National Cancer Database does not record functional outcomes, local recurrence, or disease-specific survival, so we are restricted to the evaluation of overall survival as an oncologic outcome. CONCLUSIONS: Inaccurate preoperative staging remains a common clinical challenge in the management of rectal cancer. Survival among upstaged patients is improved among those who receive recommended postoperative chemotherapy and/or chemoradiation, yet many patients do not receive guideline-concordant care. See Video Abstract at https://links.lww.com/DCR/B999 . PREDICTORES Y RESULTADOS DE SOBRE ESTADIFICACIN EN PACIENTES CON CNCER DE RECTO QUE NO RECIBIERON TERAPIA PREOPERATORIA: ANTECEDENTES:La quimio radiación preoperatoria está indicada para los estadios clínicos II y III del cáncer rectal; sin embargo, la precisión de la estadificación clínica con imágenes preoperatorias es imperfecta.OBJETIVO:El objetivo fue mejorar la caracterización de la incidencia y el manejo de la discordancia del estadio clínico y patológico en pacientes que no recibieron quimio radiación preoperatoria.DISEÑO:Este fue un análisis de cohorte retrospectivo.CONFIGURACIÓN:La fuente de datos fue de la Base de datos Nacional del Cáncer entre los años 2006-2015.PACIENTES:Identificamos pacientes que fueron sometidos a resección con intención curativa por adenocarcinoma rectal en estadio clínico I, sin quimioterapia o radiación preoperatoria.PRINCIPALES MEDIDAS DE RESULTADO:Evaluamos las características de los pacientes "sobre estadificados": aquellos con tumores T3/T4 encontrados en patología (estadio patológico II) y/o con ganglios regionales positivos en la muestra de resección (estadio patológico III), en comparación con aquellos pacientes que no fueron sobre estadificados (estadio patológico I). Luego usamos un modelo de supervivencia multivariable de efectos mixtos para comparar la supervivencia general entre estos grupos.RESULTADOS:De entre 7818 pacientes con cáncer de recto, en estadio clínico I, y que no recibieron tratamiento preoperatorio, se produjo una sobre estadificación tumoral en 819 (10,6%) y una sobre estadificación ganglionar en 1612 (20,8%). Los pacientes sobre estadificados tenían más probabilidades que los no sobre estadificados de tener tumores de mayor grado y márgenes positivos. La supervivencia fue peor en los pacientes sobre estadificados (HR 1,64, IC del 95% [1,4, 1,9]), pero mejoró entre los pacientes sobre estadificados que recibieron quimioterapia (HR 0,71, IC del 95% [0,6, 0,9]) o quimio radiación (HR 0,62, 95% IC [0,5, 0,7]).LIMITACIONES:Además de las limitaciones inherente a un estudio de cohorte de tipo retrospectivo, la Base de datos Nacional del Cáncer no registra resultados funcionales, la recurrencia local o la supervivencia específica de la enfermedad, por lo que estamos restringidos a la evaluación de la supervivencia general como un resultado oncológico.CONCLUSIONES:La estadificación preoperatoria inexacta sigue siendo un desafío clínico común en el tratamiento del cáncer de recto. La supervivencia entre los pacientes con sobre estadificación mejora en aquellos que reciben la quimioterapia y/o quimio radioterapia postoperatoria recomendada, aunque muchos pacientes no reciben atención acorde con las guías. Consulte Video Resumen en http://links.lww.com/DCR/B999 . (Traducción-Dr. Osvaldo Gauto ).

High Complication Rate After Early Ileostomy Closure: Early Termination of the Short Versus Long Interval to Loop Ileostomy Reversal After Pouch Surgery Randomized Trial.

BACKGROUND: In patients with ulcerative colitis who undergo IPAA, a diverting ileostomy is used to diminish the severity of anastomotic complications. Typically, the ileostomy is closed after an interval of 2 to 4 months. The safety of earlier closure of the ileostomy after pouch surgery is unknown. OBJECTIVE: This study aimed to compare postoperative outcomes in patients randomly assigned to early (7-12 days) or late (≥8 weeks) ileostomy closure after ileal pouch construction. DESIGN: This was a multicenter, prospective randomized trial. SETTING: The study was conducted at colorectal surgical units at select United States hospitals. PATIENTS: Adults with ulcerative colitis who underwent 2- or 3-stage proctocolectomy with IPAA were included. MAIN OUTCOME MEASURES: The primary outcomes included Comprehensive Complication Index at 30 days after ileostomy closure. The secondary outcomes included complications, severe complications, reoperations, and readmissions within 30 days of ileostomy closure. RESULTS: The trial was stopped after interim analysis because of a high rate of complications after early ileostomy closure. Among 36 patients analyzed, 1 patient (3%) had unplanned proctectomy with end-ileostomy. Of the remaining 35 patients, 28 patients (80%) were clinically eligible for early closure and underwent radiologic assessment. There were 3 radiologic failures. Of the 25 remaining patients, 22 patients (88%) were randomly assigned to early closure (n = 10) or late closure (n = 12), and 3 patients were excluded. Median Comprehensive Complication Index was 14.8 (0-54) and 0 (0-23) after early and late closure (p = 0.02). One or more complications occurred in 7 patients (70%) after early closure and in 2 patients (17%) after late closure (p = 0.01)' and complications were severe in 3 patients (30%) after early closure and 0 patients after late closure (p = 0.04). Reoperation was required in 1 patient (10%) and 0 patients (p = 0.26) after early closure and readmission was required in 7 patients (70%) and 1 patient (8%) after late closure (p = 0.003). LIMITATIONS: This study was limited by early study closure and selection bias. CONCLUSIONS: Early closure of a diverting ileostomy in patients with ulcerative colitis who underwent IPAA is associated with an unacceptably high rate of complications. See Video Abstract at http://links.lww.com/DCR/C68. ALTA TASA DE COMPLICACIONES DESPUS DEL CIERRE PRECOZ DE LA ILEOSTOMA TERMINACIN TEMPRANA DEL ENSAYO ALEATORIZADO DE INTERVALO CORTO VERSUS LARGO PARA LA REVERSIN DE LA ILEOSTOMA EN ASA DESPUS DE LA CIRUGA DE RESERVORIO ILEAL: ANTECEDENTES:En los pacientes con colitis ulcerosa que se someten a una anastomosis del reservorio ileoanal, se utiliza una ileostomía de derivación para disminuir la gravedad de las complicaciones de la anastomosis. Por lo general, la ileostomía se cierra después de un intervalo de 2 a 4 meses. Se desconoce la seguridad del cierre más temprano de la ileostomía después de la cirugía de reservorio.OBJETIVO:Comparar los resultados posoperatorios en pacientes asignados al azar al cierre temprano (7-12 días) o tardío (≥ 8 semanas) de la ileostomía después de la construcción de un reservorio ileal.DISEÑO:Este fue un ensayo aleatorizado prospectivo multicéntrico.ESCENARIO:El estudio se realizó en unidades quirúrgicas colorrectales en hospitales seleccionados de los Estados Unidos.PACIENTES:Se incluyeron adultos con colitis ulcerosa que se sometieron a proctocolectomía en 2 o 3 tiempos con anastomosis ileoanal con reservorio.PRINCIPALES MEDIDAS DE RESULTADO:Los resultados primarios incluyeron el Índice Integral de Complicaciones a los 30 días después del cierre de la ileostomía. Los resultados secundarios incluyeron complicaciones, complicaciones graves, reoperaciones y readmisiones dentro de los 30 días posteriores al cierre de la ileostomía.RESULTADOS:El ensayo se detuvo después del análisis interino debido a una alta tasa de complicaciones después del cierre temprano de la ileostomía. Entre los 36 pacientes analizados, 1 (3%) tuvo una proctectomía no planificada con ileostomía terminal. De los 35 pacientes restantes, 28 (80%) fueron clínicamente elegibles para el cierre temprano y se sometieron a una evaluación radiológica. Hubo 3 fracasos radiológicos. De los 25 pacientes restantes, 22 (88 %) se asignaron al azar a cierre temprano (n = 10) o tardío (n = 12) y 3 fueron excluidos. La mediana del Índice Integral de Complicaciones fue de 14,8 (0-54) y 0 (0-23) después del cierre temprano y tardío (p = 0,02). Una o más complicaciones ocurrieron en 7 pacientes (70%) después del cierre temprano y 2 (17%) pacientes después del cierre tardío (p = 0,01) y fueron graves en 3 (30%) y 0 pacientes, respectivamente (p = 0,04). Requirieron reintervención en 1 (10%) y 0 (p = 0,26) y reingreso en 7 (70%) y 1 (8%) pacientes (p = 0,003).LIMITACIONES:Este estudio estuvo limitado por el cierre temprano del estudio; sesgo de selección.CONCLUSIONES:El cierre temprano de una ileostomía de derivación en pacientes con colitis ulcerosa con anastomosis de reservorio ileoanal se asocia con una tasa inaceptablemente alta de complicaciones. Consulte Video Resumen en http://links.lww.com/DCR/C68. (Traducción-Dr. Felipe Bellolio).

Does Anesthesia Quality Improvement Participation Lead to Incremental Savings in a Surgical Quality Collaborative Population? A Retrospective Observational Study.

BACKGROUND: The Anesthesiology Performance Improvement and Reporting Exchange (ASPIRE) Collaborative Quality Initiative (CQI) was launched as a partnership among hospitals to measure quality, review evidence-based practices, and improve anesthesia-related outcomes. Cost savings and improved patient outcomes have been associated with surgical CQI participation, but the impact of an anesthesia CQI on health care cost has not been thoroughly assessed. In this study, we evaluated whether participation in an anesthesia CQI led to health care savings. We hypothesized that ASPIRE participation is associated with reduced total episode payments for payers and major, high-volume procedures included in the Michigan Value Collaborative (MVC) registry. METHODS: In this retrospective observational study, we compared MVC episode payment data from Group 1 ASPIRE hospitals, the first cluster of 8 Michigan hospitals to join ASPIRE in January 2015, to non-ASPIRE matched control hospitals. MVC computes price-standardized, risk-adjusted payments for patients insured by Blue Cross Blue Shield of Michigan Preferred Provider Organization, Blue Care Network Health Maintenance Organization, and Medicare Fee-for-Service plans. Episodes from 2014 comprised the pre-ASPIRE time period, and episodes from June 2016 to July 2017 constituted the post-ASPIRE time period. We performed a difference-in-differences analysis to evaluate whether ASPIRE implementation was associated with greater reduction in total episode payments compared to the change in the control hospitals during the same time periods. RESULTS: We found a statistically significant reduction in total episode (-$719; 95% CI [-$1340 to -$97]; P = .023) payments at the 8 ASPIRE hospitals (N = 17,852 cases) compared to the change observed in 8 matched non-ASPIRE hospitals (N = 12,987 cases) for major, high-volume surgeries, including colectomy, colorectal cancer resection, gastrectomy, esophagectomy, pancreatectomy, hysterectomy, joint replacement (knee and hip), and hip fracture repair. In secondary analyses, 30-day postdischarge (-$354; 95% CI [-$582 to -$126]; P = .002) payments were also significantly reduced in ASPIRE hospitals compared to non-ASPIRE controls. Subgroup analyses revealed a significant reduction in total episode payments for joint replacements (-$860; 95% CI [-$1222 to -$499]; P < .001) at ASPIRE-participating hospitals. Sensitivity analyses including patient-level covariates also showed consistent results. CONCLUSIONS: Participation in an anesthesiology CQI, ASPIRE, is associated with lower total episode payments for selected major, high-volume procedures. This analysis supports that participation in an anesthesia CQI can lead to reduced health care payments.

Venous thromboembolism prophylaxis following colorectal surgery: a survey of American Society of Colon and Rectal Surgery (ASCRS) member surgeons.

BACKGROUND: Postoperative venous thromboembolism (VTE) is associated with significant morbidity. Evidence from other surgical specialties demonstrate inadequate use of extended VTE prophylaxis following cancer surgery. While guidelines recommend extended VTE prophylaxis for patients undergoing surgery for colorectal cancer (CRC), it is unknown to what extent colon and rectal surgeons adhere to these recommendations. METHODS: An 18-question online survey was distributed to all surgeon members of the American Society of Colon and Rectal Surgeons (ASCRS). The survey was designed to capture knowledge, attitudes, and practices regarding ASCRS VTE prevention guidelines. Questions were also designed to elucidate barriers to adopting these guidelines. RESULTS: The survey was distributed to 2,316 ASCRS-member surgeons and there were 201 complete responses (8.7% response rate). Most respondents (136/201, 68%) reported that they were familiar with ASCRS VTE prevention guidelines and used them to guide their practice. Extended VTE prophylaxis was reported to be routinely prescribed by the majority of surgeons following CRC resection (109/201, 54%), with an additional 27% reporting selective prescribing (55/201). The most frequently reported reasons for not prescribing extended VTE chemoprophylaxis following CRC resection included patient compliance and insurance/copay issues. CONCLUSION: Most ASCRS-member surgeon respondents reported that they are familiar with ASCRS VTE prevention guidelines, though only 54% surgeons reported routinely prescribing extended VTE prophylaxis following CRC surgery. Patient compliance and insurance issues were identified as the most common barriers. Targeted interventions at the surgeon, patient, and payer level are required to increase the use of extended VTE prophylaxis following CRC resection.

Cost Consequences of Age and Comorbidity in Accelerated Postoperative Discharge After Colectomy.

BACKGROUND: Prospective payment models have incentivized reductions in length of stay after surgery. The benefits of abbreviated postoperative hospitalization could be undermined by increased readmissions or postacute care use, particularly for older adults or those with comorbid conditions. OBJECTIVE: The purpose of this study was to determine whether hospitals with accelerated postsurgical discharge accrue total episode savings or incur greater postdischarge payments among patients stratified by age and comorbidity. DESIGN: This was a retrospective cross-sectional study. SETTING: National data from the 100% Medicare Provider Analysis and Review files for July 2012 to June 2015 were used. PATIENTS: We included Medicare beneficiaries undergoing elective colectomy and stratified the cohort by age (65-69, 70-79, ≥80 y) and Elixhauser comorbidity score (low: ≤0; medium: 1-5; and high: >5). Patients were categorized by the hospital's mode length of stay, reflecting "usual" care. MAIN OUTCOMES MEASURES: In a multilevel model, we compared mean total episode payments and components thereof among age and comorbidity categories, stratified by hospital mode length of stay. RESULTS: Among 88,860 patients, mean total episode payments were lower in shortest versus longest length of stay hospitals across all age and comorbidity strata and were similar between age groups (65-69 y: $28,951 vs $30,566, p = 0.014; 70-79 y: $31,157 vs $32,044, p = 0.073; ≥80 y: $33,779 vs $35,771, p = 0.005) but greater among higher comorbidity (low: $23,107 vs $24,894, p = 0.001; medium: $30,809 vs $32,282, p = 0.038; high: $44,097 vs $46641, p < 0.001). Postdischarge payments were similar among length-of-stay hospitals by age (65-69 y: ∆$529; 70-79 y: ∆$291; ≥80 y: ∆$872, p = 0.25) but greater among high comorbidity (low: ∆$477; medium: ∆$480; high: ∆$1059; p = 0.02). LIMITATIONS: Administrative data do not capture patient-level factors that influence postacute care use (preference, caregiver availability). CONCLUSIONS: Hospitals achieving shortest length of stay after surgery accrue lower total episode payments without a compensatory increase in postacute care spending, even among patients at oldest age and with greatest comorbidity. See Video Abstract at http://links.lww.com/DCR/B624. CONSECUENCIAS DE LA EDAD Y LAS COMORBILIDADES ASOCIADAS, EN EL COSTO DE LA ATENCIN EN PACIENTES SOMETIDOS A COLECTOMA EN PROGRAMAS DE ALTA POSOPERATORIA ACELERADA: ANTECEDENTES:Los modelos de pago prospectivo, han sido un incentivo para reducir la estancia hospitalaria después de la cirugía. Los beneficios de una hospitalización posoperatoria "abreviada" podrían verse afectados por un aumento en los reingresos o en la necesidad de cuidados postoperatorios tempranos luego del periodo agudo, particularmente en los adultos mayores o en aquellos con comorbilidades.OBJETIVO:Determinar si los hospitales que han establecido protocolos de alta posoperatoria "acelerada" generan un ahorro en cada episodio de atención o incurren en mayores gastos después del alta, entre los pacientes estratificados por edad y por comorbilidades.DISEÑO:Estudio transversal retrospectivo.AJUSTE:Revisión a partir de la base de datos nacional del 100% de los archivos del Medicare Provider Analysis and Review desde julio de 2012 hasta junio de 2015.PACIENTES:Se incluye a los beneficiarios de Medicare a quienes se les practicó una colectomía electiva. La cohorte se estratificó por edad (65-69 años, 70-79, ≥80) y por la puntuación de comorbilidad de Elixhauser (baja: ≤0; media: 1-5; y alta: > 5). Los pacientes se categorizaron de acuerdo con la modalidad de la duración de la estancia hospitalaria del hospital, lo que representa lo que se considera es una atención usual para dicho centro.PRINCIPALES MEDIDAS DE RESULTADO:En un modelo multinivel, comparamos la media de los pagos por episodio y los componentes de los mismos, entre las categorías de edad y comorbilidad, estratificados por la modalidad de la duración de la estancia hospitalaria.RESULTADOS:En los 88,860 pacientes, los pagos promedio por episodio fueron menores en los hospitales con una modalidad de estancia más corta frente a los de mayor duración, en todos los estratos de edad y comorbilidad, y fueron similares entre los grupos de edad (65-69: $28,951 vs $30,566, p = 0,014; 70-79: $31,157 vs $32,044, p = 0,073; ≥ 80 $33,779 vs $35,771, p = 0,005), pero mayor entre los pacientes con comorbilidades más altas (baja: $23,107 vs $24,894, p = 0,001; media $30,809 vs $32,282, p = 0,038; alta: $44,097 vs $46,641, p <0,001). Los pagos generados luego del alta hospitalaria fueron similares con relación a la estancia hospitalaria de los diferentes hospitales con respecto a la edad (65-69 años: ∆ $529; 70-79 años: ∆ $291; ≥80 años: ∆ $872, p = 0,25), pero mayores en aquellos con más alta comorbilidad (baja ∆ $477, medio ∆ $480, alto ∆ $1059, p = 0,02).LIMITACIONES:Las bases de datos administrativas no capturan los factores del paciente que influyen en el cuidado luego del estado posoperatorio agudo (preferencia, disponibilidad del proveedor del cuidado).CONCLUSIONES:Los hospitales que logran una estancia hospitalaria más corta después de la cirugía, acumulan pagos más bajos por episodio, sin un incremento compensatorio del gasto en la atención pos-aguda, incluso entre pacientes de mayor edad y con mayor comorbilidad. Consulte Video Resumen en http://links.lww.com/DCR/B624. (Traducción-Dr Eduardo Londoño-Schimmer).

Correlation of Colorectal Surgical Skill With Patient Outcomes: A Cautionary Tale.

BACKGROUND: Previous work has demonstrated a correlation between video ratings of surgical skill and clinical outcomes. Some have proposed the use of video review for technical skill assessment, credentialing, and quality improvement. OBJECTIVE: Before its adoption as a quality measure for colorectal surgeons, we must first determine whether video-based skill assessments can predict patient outcomes among specialty surgeons. DESIGN: Twenty-one surgeons submitted one representative video of a minimally invasive colectomy. Each video was edited to highlight key steps and then rated by 10 peer surgeons using a validated American Society of Colon and Rectal Surgeons assessment tool. Linking surgeons' ratings to a validated surgical outcomes registry, we assessed the relationship between skill and risk-adjusted complication rates. SETTINGS: The study was conducted with the Michigan Surgical Quality Collaborative, a statewide collaborative including 70 community, academic, and tertiary hospitals. PATIENTS: Patients included those who underwent minimally invasive colorectal resection performed by the participating surgeons. MAIN OUTCOME MEASURES: Main outcome measures included 30-day risk-adjusted postoperative complications. RESULTS: The average technical skill rating for each surgeon ranged from 2.6 to 4.6. Risk-adjusted complication rate per surgeon ranged from 9.9% to 33.1%. Patients of surgeons in the bottom quartile of overall skill ratings were older and more likely to have hypertension or to smoke; patients of surgeons in the top quartile were more likely to be immunosuppressed or have an ASA score of 3 or higher. After patient- and surgery-specific risk adjustment, there was no statistically significant difference in complication rates between the bottom and top quartile surgeons (17.5% vs 16.8%, respectively, p = 0.41). LIMITATIONS: Limitations included retrospective cohort design with short-term follow-up of sampled cases. Videos were edited to highlight key steps, and reviewers did not undergo training to establish norms. CONCLUSIONS: Our study demonstrates that video-based peer rating of minimally invasive colectomy was not correlated with postoperative complications among specialty surgeons. As such, the adoption of video review for use in credentialing should be approached with caution. See Video Abstract at http://links.lww.com/DCR/B802.CORRELACIÓN ENTRE LA HABILIDAD QUIRÚRGICA COLORRECTAL Y LOS RESULTADOS OBTENIDOS EN EL PACIENTE: RELATO PRECAUTORIOANTECEDENTES:Trabajos anteriores han demostrado una correlación entre la video-calificación de la habilidad quirúrgica y los resultados clínicos. Algunos autores han propuesto el uso de la revisión de videos para la evaluación de la habilidad técnica, la acreditación y la mejoría en la calidad quirúrgica.OBJETIVO:Antes de su adopción como medida de calidad entre los cirujanos colorrectales, primero debemos determinar si las evaluaciones de habilidades basadas en video pueden predecir los resultados clínicos de los pacientes entre cirujanos especializados.DISEÑO:Veintiún cirujanos enviaron un video representativo de una colectomía mínimamente invasiva. Cada video fue editado para resaltar los pasos clave y luego fué calificado por 10 cirujanos revisores utilizando una herramienta de evaluación validada por la ASCRS. Al vincular las calificaciones de los cirujanos al registro de resultados quirúrgicos aprobado, evaluamos la relación entre la habilidad y las tasas de complicaciones ajustadas al riesgo.AJUSTE:Colaboración en todo el estado incluyendo 70 hospitales comunitarios, académicos y terciarios, el Michigan Surgical Quality Collaborative.PACIENTES:Todos aquellos sometidos a resección colorrectal mínimamente invasiva realizada por los cirujanos participantes.MEDIDA DE RESULTADO PRINCIPAL:Complicaciones posoperatorias ajustadas al riesgo a los 30 días.RESULTADOS:La calificación de la habilidad técnica promedio de cada cirujano osciló entre 2.6 y 4.6. La tasa de complicaciones ajustada al riesgo por cirujano osciló entre el 9,9% y el 33,1%. Los pacientes operados por los cirujanos del cuartil inferior de las calificaciones generales de habilidades eran fumadores y añosos, y tambiés más propensos a la hipertensión arterial. Los pacientes operados por los cirujanos del cuartil superior tenían más probabilidades de ser inmunosuprimidos o tener una puntuación ASA> = 3. Después del ajuste de riesgo específico de la cirugía y el paciente, no hubo diferencias estadísticamente significativas en las tasas de complicaciones entre los cirujanos del cuartil inferior y superior (17,5% frente a 16,8%, respectivamente, p = 0,41).LIMITACIONES:Diseño de cohortes retrospectivo con seguimiento a corto plazo de los casos muestreados. Los videos se editaron para resaltar los pasos clave y los revisores no recibieron capacitación para establecer normas.CONCLUSIONES:Nuestro estudio demuestra que la evaluación realizada por los revisores basada en el video de la colectomía mínimamente invasiva no se correlacionó con las complicaciones post-operatorias entre los cirujanos especialistas. Por tanto, la adopción de la revisión del video quirúrgico para su uso en la acreditación profesional, debe abordarse con mucha precaución. Consulte Video Resumen en http://links.lww.com/DCR/B802. (Traducción-Dr. Xavier Delgadillo).

Wide Variation in Surgical Spending Within Hospital Systems: A Missed Opportunity for Bundled Payment Success.

OBJECTIVE: We sought to measure the extent of variation in episode spending around total hip replacement within and across hospital systems. SUMMARY OF BACKGROUND DATA: Bundled payment programs are pressuring hospitals to reduce spending on surgery. Meanwhile, many hospitals are joining larger health systems with the stated goal of improved care at lower cost. METHODS: Cross-sectional study of fee-for-service Medicare patients undergoing total hip replacement in 2016 at hospital systems identified in the American Hospital Association Annual Survey. We calculated risk- and reliability-adjusted average 30-day episode payments at the hospital and system level. RESULTS: Average episode payments varied nearly as much within hospital systems ($2515 between the lowest- and highest-cost hospitals, 95% confidence interval $2272-$2,758) as they did between the lowest- and highest-cost quintiles of systems ($2712, 95% confidence interval $2545-$2879). Variation was driven by post-acute care utilization. Many systems have concentrated hip replacement volume at relatively high-cost hospitals. CONCLUSIONS: Given the wide variation in surgical spending within health systems, we propose tailored strategies for systems to maximize savings in bundled payment programs.

Clinical and Economic Outcomes of Enhanced Recovery Dissemination in Michigan Hospitals.

OBJECTIVE: To evaluate real-world effects of enhanced recovery protocol (ERP) dissemination on clinical and economic outcomes after colectomy. SUMMARY BACKGROUND DATA: Hospitals aiming to accelerate discharge and reduce spending after surgery are increasingly adopting perioperative ERPs. Despite their efficacy in specialty institutions, most studies have lacked adequate control groups and diverse hospital settings and have considered only in-hospital costs. There remain concerns that accelerated discharge might incur unintended consequences. METHODS: Retrospective, population-based cohort including patients in 72 hospitals in the Michigan Surgical Quality Collaborative clinical registry (N = 13,611) and/or Michigan Value Collaborative claims registry (N = 14,800) who underwent elective colectomy, 2012 to 2018. Marginal effects of ERP on clinical outcomes and risk-adjusted, price-standardized 90-day episode payments were evaluated using mixed-effects models to account for secular trends and hospital performance unrelated to ERP. RESULTS: In 24 ERP hospitals, patients Post-ERP had significantly shorter length of stay than those Pre-ERP (5.1 vs 6.5 days, P < 0.001), lower incidence of complications (14.6% vs 16.9%, P < 0.001) and readmissions (10.4% vs 11.3%, P = 0.02), and lower episode payments ($28,550 vs $31,192, P < 0.001) and postacute care ($3,384 vs $3,909, P < 0.001). In mixed-effects adjusted analyses, these effects were significantly attenuated-ERP was associated with a marginal length of stay reduction of 0.4 days (95% confidence interval 0.2-0.6 days, P = 0.001), and no significant difference in complications, readmissions, or overall spending. CONCLUSIONS: ERPs are associated with small reduction in postoperative length of hospitalization after colectomy, without unwanted increases in readmission or postacute care spending. The real-world effects across a variety of hospitals may be smaller than observed in early-adopting specialty centers.

Impact of Postoperative Complications on Oncologic Outcomes After Rectal Cancer Surgery: An Analysis of the US Rectal Cancer Consortium.

BACKGROUND: Postoperative complications (POCs) are associated with worse oncologic outcomes in several cancer types. The implications of complications after rectal cancer surgery are not well studied. METHODS: The United States Rectal Cancer Consortium (2007-2017) was reviewed for primary rectal adenocarcinoma patients who underwent R0/R1 resection. Ninety-day POCs were categorized as major or minor and were grouped into infectious, cardiopulmonary, thromboembolic, renal, or intestinal dysmotility. Primary outcomes were overall survival (OS) and recurrence-free survival (RFS). RESULTS: Among 1136 patients, the POC rate was 46% (n = 527), with 63% classified as minor and 32% classified as major. Of all POCs, infectious complications comprised 20%, cardiopulmonary 3%, thromboembolic 5%, renal 9%, and intestinal dysmotility 19%. Compared with minor or no POCs, major POCs were associated with both worse RFS and worse OS (both p < 0.01). Compared with no POCs, a single POC was associated with worse RFS (p < 0.01), while multiple POCs were associated with worse OS (p = 0.02). Regardless of complication grade, infectious POCs were associated with worse RFS (p < 0.01), while cardiopulmonary and thromboembolic POCs were associated with worse OS (both p < 0.01). Renal POCs were associated with both worse RFS (p < 0.001) and worse OS (p = 0.01). After accounting for pathologic stage, neoadjuvant therapy, and final margin status, Multivariable analysis (MVA) demonstrated worse outcomes with cardiopulmonary, thromboembolic, and renal POCs for OS (cardiopulmonary: hazard ratio [HR] 3.6, p = 0.01; thromboembolic: HR 19.4, p < 0.01; renal: HR 2.4, p = 0.01), and renal and infectious POCs for RFS (infectious: HR 2.1, p < 0.01; renal: HR 3.2, p < 0.01). CONCLUSIONS: Major complications after proctectomy for cancer are associated with decreased RFS and OS. Given the association of infectious complications and postoperative renal dysfunction with earlier recurrence of disease, efforts must be directed towards defining best practices and standardizing care.

A US Rectal Cancer Consortium Study of Inferior Mesenteric Artery Versus Superior Rectal Artery Ligation: How High Do We Need to Go?

BACKGROUND: The optimal level of pedicle ligation during proctectomy for rectal cancer, either at the origin of the inferior mesenteric artery or the superior rectal artery, is still debated. OBJECTIVE: The objective was to determine whether superior rectal artery ligation portends equivalent technical or oncologic outcomes. DESIGN: This was a retrospective analysis of a rectal cancer database (2007-2017). SETTINGS: The study was conducted at 6 tertiary referral centers in the United States (Emory University, University of Michigan, University of Pittsburgh Medical Center, The Ohio State University Wexner Medical Center, Vanderbilt University Medical Center, and Washington University School of Medicine in St. Louis). PATIENTS: Patients with primary, nonmetastatic rectal cancer who underwent low anterior resection or abdominoperineal resection were included. MAIN OUTCOME MEASURES: Anastomotic leak, lymph node harvest, locoregional recurrence-free survival, recurrence-free survival, and overall survival were measured. RESULTS: Of 877 patients, 86% (n = 755) received an inferior mesenteric artery ligation, whereas 14% (n = 122) received a superior rectal artery ligation. A total of 12%, 33%, 24%, and 31% were pathologic stage 0, I, II, and III. Median follow-up was 31 months. Superior rectal artery ligation was associated with a similar anastomotic leak rate compared with inferior mesenteric artery ligation (9% vs 8%; p = 1.0). The median number of lymph nodes removed was identical (15 vs 15; p = 0.38). On multivariable analysis accounting for relevant clinicopathologic factors, superior rectal artery ligation was not associated with increased anastomotic leak rate, worse lymph node harvest, or worse locoregional recurrence-free survival, recurrence-free survival, or overall survival (all p values >0.1). LIMITATIONS: This was a retrospective design. CONCLUSIONS: Compared with inferior mesenteric artery ligation, superior rectal artery ligation is not associated with either worse technical or oncologic outcomes. Given the potential risks of inadequate blood flow to the proximal limb of the anastomosis and autonomic nerve injury, we advocate for increased use of superior rectal artery ligation. See Video Abstract at http://links.lww.com/DCR/B646. ESTUDIO DEL CONSORCIO DE CNCER DE RECTO DE ESTADOS UNIDOS DE LIGADURA BAJA DE LA ARTERIA MESENTRICA INFERIOR CONTRA LIGADURA ALTA DE LA ARTERIA MESENTRICA INFERIOR QU TAN ALTO DEBEMOS EXTENDERNOS: ANTECEDENTES:el nivel óptimo de la ligadura del pedículo en la proctectomía para el cáncer de recto, ya sea en el origen de la arteria mesentérica inferior o en la arteria rectal superior aún no esta definido.OBJETIVO:El objetivo era determinar si la ligadura de la arteria rectal superior pronostica resultados técnicos u oncológicos similares.DISEÑO:Análisis retrospectivo de una base de datos de cáncer de recto (2007-2017).ESCENARIO:el estudio se realizó en seis centros de referencia de tercer nivel en los Estados Unidos (Universidad de Emory, Universidad de Michigan, Centro médico de la Universidad de Pittsburgh, Centro médico Wexner de la Universidad Estatal de Ohio, Centro médico de la Universidad de Vanderbilt y Escuela de Medicina de la Universidad de Washington en St. Louis).PACIENTES:Se incluyeron pacientes con cáncer de recto primario no metastásico que se sometieron a resección anterior baja o resección abdominoperineal.PRINCIPALES VARIABLES ANALIZADAS:Se midió la fuga anastomótica, los ganglios linfáticos recuperados, la sobrevida sin recidiva locorregional, la sobrevida sin recidiva y la sobrevida global.RESULTADOS:De 877 pacientes, en el 86% (n = 755) se realizó una ligadura de la arteria mesentérica inferior, y en el 14% (n = 122) se realizó una ligadura de la arteria rectal superior. El 12%, 33%, 24% y 31% estaban en estadio patológico 0, I, II y III respectivamente. La mediana de seguimiento fue de 31 meses. La ligadura de la arteria rectal superior se asoció con una tasa de fuga anastomótica similar a la ligadura de la arteria mesentérica inferior (9 vs 8%, p = 1,0). La mediana del número de ganglios linfáticos extirpados fue idéntica (15 contra 15, p = 0,38). En el análisis multivariado que tiene en cuenta los factores clínico-patológicos relevantes, la ligadura de la arteria rectal superior no se asoció con una mayor tasa de fuga anastomótica, una peor cosecha de ganglios linfáticos o una peor sobrevida libre de recurrencia locorregional, sobrevida libre de recurrencia o sobrevida global (todos p> 0,1).LIMITACIONES:Diseño retrospectivo.CONCLUSIONES:En comparación con la ligadura de la arteria mesentérica inferior, la ligadura de la arteria rectal superior no se asocia a peores resultados técnicos ni oncológicos. Debido a los riesgos potenciales de un flujo sanguíneo inadecuado del muñon proximal de la anastomosis y la lesión de los nervios autonómicos, proponemos una mayor realización de la ligadura de la arteria rectal superior. Consulte Video Resumen en http://links.lww.com/DCR/B646.

Perioperative Blood Transfusions Are Associated With Worse Overall Survival But Not Disease-Free Survival After Curative Rectal Cancer Resection: A Propensity Score-Matched Analysis.

BACKGROUND: The effects of blood transfusions on oncologic outcomes after surgery remain inconclusive. Thus, we examined the association between receiving a perioperative blood transfusion and oncologic outcomes in patients undergoing curative rectal cancer resection. OBJECTIVE: The purpose of this study was to assess the association between receiving a perioperative blood transfusion with disease-free and overall survival in patients undergoing curative resection of clinical stage I to III rectal cancer. We hypothesized that blood transfusion is associated with worse disease-free and overall survival in this patient cohort. DESIGN: This was a retrospective cohort study using a propensity score-matched analysis. SETTINGS: The study involved 6 tertiary academic medical centers in the United States contributing to the United States Rectal Cancer Consortium. PATIENTS: Patients who underwent curative resection for rectal cancer from 2010 to 2018 were included. MAIN OUTCOME MEASURES: The primary outcome was disease-free survival. The secondary outcomes were overall survival, intensive care unit length of stay, hospital length of stay, surgical site infection, and readmission. RESULTS: Of the 924 patients eligible for matching, 312 patients were matched, including 100 patients who received a transfusion and 212 who did not. In a propensity score-matched analysis, receiving a perioperative blood transfusion was not associated with worse 5-year disease-free survival (transfused, 78%; not transfused, 83%; p = 0.32) but was associated with worse 5-year overall survival (transfused 65% vs not transfused 86%; p < 0.001) and increased hospital length of stay (transfused, 9.9 d; not transfused, 7.6 d; p = 0.001). LIMITATIONS: Despite propensity matching, confounding may remain. Propensity matching may limit the power to detect a difference in disease-free survival. CONCLUSIONS: Receiving a perioperative blood transfusion is not associated with worse disease-free survival but is associated with worse overall survival. Such findings are important for clinicians and patients to understand when considering perioperative blood transfusions. See Video Abstract at http://links.lww.com/DCR/B531. LAS TRANSFUSIONES DE SANGRE PERIOPERATORIAS SE ASOCIAN CON UNA PEOR SOBREVIDA GLOBAL, PERO NO CON LA SOBREVIDA LIBRE DE ENFERMEDAD POSTERIOR A LA RESECCIN CURATIVA DEL CNCER DE RECTO UN PUNTAJE DE PROPENSIN POR ANLISIS DE CONCORDANCIA: ANTECEDENTES:El impacto de las transfusiones de sangre en los resultados oncológicos posteriores a la cirugía no son concluyentes. Por lo anterior, estudiamos la asociación entre recibir una transfusión de sangre perioperatoria y los resultados oncológicos en pacientes llevados a resección curativa de cáncer de recto.OBJETIVO:El propósito de este estudio fue evaluar la asociación entre recibir una transfusión de sangre perioperatoria con la sobrevida libre de enfermedad y la sobrevida general en pacientes llevados a resección curativa de cáncer de recto en estadio clínico I-III. Nuestra hipótesis es que la transfusión de sangre se asocia con una peor sobrevida global y libre de enfermedad en esta cohorte de pacientes.DISEÑO:Es un estudio de cohorte retrospectivo que utilizó un puntaje de propensión por análisis de concordancia.AMBITO:El estudio se realizó en seis centros médicos académicos de tercer nivel en los Estados Unidos que contribuían al Consorcio de Cáncer de Recto de los Estados Unidos.PACIENTES:Se incluyeron pacientes que fueron llevados a resección curativa por cáncer de recto entre 2010 y 2018.PRINCIPALES VARIABLES EVALUADAS:El objeitvo principal fue la sobrevida libre de enfermedad. Los objetivos secundarios fueron la sobrevida global, el tiempo de estancia en la unidad de cuidados intensivos, el tiempo de la estancia hospitalaria, la infección del sitio quirúrgico y el reingreso.RESULTADOS:De los 924 pacientes elegibles para el emparejamiento, se emparejaron 312 pacientes, incluidos 100 pacientes que recibieron una transfusión y 212 que no. En el puntaje de propensión por análisis de concordancia, recibir una transfusión de sangre perioperatoria no se asoció con una peor sobrevida libre de enfermedad a 5 años (TRANSFUSIÓN 78%; NO TRANSFUSIÓN 83%; p = 0,32), pero se asoció con una peor sobrevida global a 5 años (TRANSFUSION 65% vs NO TRANSFUSION 86%; p <0,001) y aumento de la estancia hospitalaria (TRANSFUSIÓN 9,9 días; NO TRANSFUSION 7,6 días; p = 0,001).LIMITACIONES:A pesar de la concordancia de propensión, pueden existir desviaciones. El emparejamiento de propensión puede limitar el poder para detectar una diferencia en la sobrevida libre de enfermedad.CONCLUSIONES:Recibir una transfusión de sangre perioperatoria no se asocia con una peor sobrevida libre de enfermedad, pero sí con una peor sobrevida global. Es importante que los médicos y los pacientes comprendan estos hallazgos al considerar las transfusiones de sangre perioperatorias. Consulte Video Resumen en http://links.lww.com/DCR/B531. (Traducción-Dr Lisbeth Alarcon-Bernes).

Population-Based Analysis of Adherence to Postdischarge Extended Venous Thromboembolism Prophylaxis After Colorectal Resection.

BACKGROUND: Prevention of venous thromboembolism after colorectal surgery remains challenging. National guidelines endorse thromboembolism prophylaxis for 4 weeks after colorectal cancer resection. Expert consensus favors extended prophylaxis after IBD surgery. The actual frequency of prescription after resection remains unknown. OBJECTIVE: This study aimed to assess prescription of extended, postdischarge venous thromboembolism prophylaxis after resection in Michigan. DESIGN: This is a retrospective review of elective colorectal resections within a statewide collaborative receiving postdischarge, extended-duration prophylaxis. SETTING: This study was conducted between October 2015 and February 2018 at an academic center. PATIENTS: A total of 5722 patients (2171 with colorectal cancer, 266 with IBD, and 3285 with other). MAIN OUTCOME MEASURES: We compared the prescription of extended, postdischarge prophylaxis over time, between hospitals and by indication. RESULTS: Of 5722 patients, 373 (6.5%) received extended-duration prophylaxis after discharge. Use was similar between patients undergoing surgery for cancer (282/2171, 13.0%) or IBD (31/266, 11.7%, p = 0.54), but was significantly more common for both patients undergoing surgery for cancer or IBD in comparison with patients with other indications (60/3285, 1.8%, p < 0.001). Use increased significantly among patients with cancer (6.8%-16.8%, p < 0.001) and patients with IBD (0%-15.1%, p < 0.05) over the study period. For patients with other diagnoses, use was rare and did not vary significantly (1.5%-2.3%, p = 0.49). Academic centers and large hospitals (>300 beds) were significantly more likely to prescribe extended-duration prophylaxis for all conditions (both p < 0.001), with the majority of prophylaxis concentrated at only a few hospitals. LIMITATIONS: This study was limited by the lack of assessment of actual adherence, small number of observed venous thromboembolism events, small sample of patients with IBD, and restriction to the state of Michigan. CONCLUSIONS: The use of extended-duration venous thromboembolism prophylaxis after discharge is increasing, but remains uncommon in most hospitals. Efforts to improve adherence may require quality implementation initiatives or targeted payment incentives. See Video Abstract at http://links.lww.com/DCR/B193. ANÁLISIS POBLACIONAL DE LA ADHERENCIA A LA PROFILAXIS ANTI-TROMBÓTICA EXTENDIDA (TEV) EN PACIENTES DE ALTA LUEGO DE UNA RESECCIÓN COLORECTAL.: La prevención del tromboembolismo venoso después de cirugía colorrectal sigue siendo un desafío. Las guías nacionales han aprobado la profilaxia del tromboembolismo durante cuatro semanas luego de una resección de cáncer colorrectal. El consenso de expertos favorece la profilaxia extendida solamente después de la cirugía por enfermedad inflamatoria intestinal. La frecuencia real de prescripción después de la resección colorrectal sigue siendo desconocida.Evaluar la prescripción de profilaxia prolongada de tromboembolismo venoso después del alta luego de una resección colorrectal en Michigan.Revisión retrospectiva de las resecciones colorrectales electivas seguidas de una profilaxia de larga duración con el apoyo de todo el estado (MI).Este estudio se realizó entre octubre de 2015 y febrero de 2018 en un solo centro académico.Un universo de 5722 pacientes operados (2171 por cáncer colorrectal, 266 por enfermedad inflamatoria intestinal, 3285 por otros diagnósticos).Se comparó la prescripción de profilaxia prolongada después del alta según la duración, los hospitales y la indicación.De 5722 pacientes, 373 (6.5%) recibieron profilaxia de duración prolongada después del alta. El uso fue similar entre pacientes sometidos a cirugía por cáncer (282/2171, 13.0%) o enfermedad inflamatoria intestinal (31/266, 11.7%, p = 0.54), pero fue significativamente más común para ambos en comparación con pacientes con otras indicaciones (60/3285, 1.8%, p < 0.001). El uso aumentó significativamente entre pacientes con cáncer (6.8% a 16.8% (p < 0.001)) y en pacientes con enfermedad inflamatoria intestinal (0% a 15.1%, p < 0.05) durante el período de estudio. Para pacientes con otros diagnósticos, su utilización fue rara y no varió significativamente (1.5% a 2.3%, p = 0.49). Los centros académicos y los grandes hospitales (>300 camas) tenían mayor probabilidad de prescribir la profilaxia de duración extendida en todas las afecciones (ambas p < 0.001), pero la mayoría de las profilaxis se concentraron el algunos pocos grandes hospitales.Este estudio estuvo limitado por la falta de evaluación de actuales adherentes, por el pequeño número de eventos tromboembólicos venosos observados, por la pequeña muestra de pacientes con enfermedad inflamatoria intestinal y debido a ciertas restricciones en el estado de Michigan.El uso de profilaxia para el tromboembolismo venoso de duración prolongada después del alta está en aumento, pero su uso sigue siendo poco frecuente en la mayoría de los hospitales. Los esfuerzos para mejorar la adherencia al tratamiento pueden requerir iniciativas de mejoría en la calidad o incentivos específicos de reembolso. Consulte Video Resumen en http://links.lww.com/DCR/B193. (Traducción-Dr. Xavier Delgadillo).

Long-term Functional Decline After High-Risk Elective Colorectal Surgery in Older Adults.

BACKGROUND: Although most surgical outcomes research focuses on clinical end points and complications, older adult patients may value functional outcomes more. However, little is known about the risk of long-term functional disability after colorectal procedures. OBJECTIVE: The purpose of this research was to understand the incidence and likelihood of functional decline after high-risk (ie, ≥1% inpatient mortality) colorectal operations both without and with complications. DESIGN: This was a retrospective matched cohort study. SETTINGS: The Health and Retirement Study, a nationally representative, longitudinal survey of adults >50 years of age, collects data on functional status, cognition, and demographics, among other topics. The survey was linked with Medicare claims and National Death Index data from 1992 to 2012. PATIENTS: Patients ≥65 years of age who underwent elective high-risk colorectal surgery with functional status measured before and after surgery were included. These patients were matched 1:3 to survey respondents who did not undergo major surgery, based on propensity scores. MAIN OUTCOME MEASURES: Functional decline, the primary outcome, was defined as an increase in the number of activities of daily living and instrumental activities of daily living requiring assistance before and after surgery. Using logistic regression, we examined whether surgery without or with complications was associated with functional decline. RESULTS: We identified 289 patients who underwent high-risk colorectal surgery and 867 matched control subjects. Of the surgery patients, 90 (31%) experienced a complication. Compared with the control subjects, surgery patients experienced greater likelihood of functional decline (without complications: OR = 1.82 (95% CI, 1.22-2.71), and with complications: OR = 2.96 (95% CI, 1.70-5.14)). Increasing age also predicted greater odds of functional decline (OR = 2.09, per decade (95% CI, 1.57-2.80)). LIMITATIONS: The functional measures were self-reported by survey participants. CONCLUSIONS: High-risk colorectal surgery, without or with complications, is associated with increased likelihood of functional decline in older adults. Patient-centered decision-making should include discussion of expected functional outcomes and long-term disability. See Video Abstract at http://links.lww.com/DCR/B78. PÉRDIDA DE LA FUNCIONALIDAD A LARGO PLAZO LUEGO DE CIRUGÍA ELECTIVA COLORRECTAL DE ALTO RIESGO EN EL PACIENTE AÑOSO: Aunque en la mayoría de las investigaciones los resultados quirúrgicos se centran en los puntos finales clínicos y las complicaciones, actualmente se pueden valorar los resultados funcionales en el paciente añoso. Sin embargo, se sabe poco sobre el riesgo de la discapacidad funcional a largo plazo después de un procedimiento colorrectal.Comprender la incidencia y la probabilidad del deterioro funcional después de operaciones colorrectales de alto riesgo (es decir, ≥1% de mortalidad hospitalaria) con y sin complicaciones.Estudio de cohorte emparejado retrospectivo.El seguimiento longitudinal representativo a nivel nacional en adultos de >50 años y que recopila datos sobre su estado funcional, su estado cognitivo y su demografía, entre otros temas es el llamado "Estudio de Salud en jubilados." La encuesta se vinculó con los reclamos de Medicare y los datos del Índice Nacional de Defunciones entre 1992 y 2012.Aquellos de ≥65 años que se sometieron a cirugía colorrectal electiva de alto riesgo con un estado funcional medido antes y después de la cirugía. Estos pacientes se compararon 1: 3 con los encuestados que no se sometieron a cirugía mayor, según puntajes de propensión.La disminución functional como resultado primario, se definió como un aumento en el número de actividades de la vida diaria y actividades instrumentales de la vida diaria que requieren asistencia antes y después de la cirugía. Mediante la regresión logística, evaluamos si la cirugía sin complicaciones y/o con complicaciones se asoció con un deterioro funcional.Identificamos 289 pacientes que se sometieron a cirugía colorrectal de alto riesgo y 867 controles pareados. De los pacientes de cirugía, 90 (31%) experimentaron algun tipo de complicación. En comparación con los controles, los pacientes de cirugía experimentaron una mayor probabilidad de deterioro funcional (sin complicaciones: OR 1.82, IC 95% 1.22-2.71, y con complicaciones: OR 2.96, IC 95% 1.70-5.14). El aumento de la edad también predijo mayores probabilidades en el deterioro funcional (OR 2.09, por década, IC 95% 1.57-2.80).Las medidas funcionales fueron autoinformadas por los participantes de la encuesta.La cirugía colorrectal de alto riesgo, con o sin complicaciones, se asocia con una mayor probabilidad de deterioro funcional en adultos mayores. La toma de decisiones centradas en el paciente deben incluir la discusión de los resultados funcionales esperados y la discapacidad a largo plazo. Vea el resumen del video en http://links.lww.com/DCR/B78.

Achieving the High-Value Colectomy: Preventing Complications or Improving Efficiency.

BACKGROUND: There is increased focus on the value of surgical care. Postoperative complications decrease value, but it is unknown whether high-value hospitals spend less than low-value hospitals in cases without complications. Previous studies have not evaluated both expenditures and validated outcomes in the same patients, limiting the understanding of interactions between clinical performance, efficient utilization of services, and costliness of surgical episodes. OBJECTIVE: This study aimed to identify payment differences between low- and high-value hospitals in colectomy cases without adverse outcomes using a linked data set of multipayer claims and validated clinical outcomes. DESIGN: This is a retrospective observational cohort study. We assigned each hospital a value score (ratio of cases without adverse outcome to mean episode payment). We stratified hospitals into tertiles by value and used analysis of variance tests to compare payments between low- and high-value hospitals, first for all cases, and then cases without adverse outcome. SETTING: January 2012 to December 2016, this investigation used clinical registry data from 56 hospitals participating in the Michigan Surgical Quality Collaborative, linked with 30-day episode payments from the Michigan Value Collaborative. PATIENTS: A total of 2947 patients undergoing elective colectomy were selected. MAIN OUTCOME MEASURES: The primary outcome measured was risk-adjusted, price-standardized 30-day episode payments. RESULTS: The mean adjusted complication rate was 31% (±10.7%) at low-value hospitals and 14% (±4.6%) at high-value hospitals (p < 0.001). Low-value hospitals were paid $3807 (17%) more than high-value hospitals ($22,271 vs $18,464, p < 0.001). Among cases without adverse outcome, payments were still $2257 (11%) higher in low-value hospitals ($19,424 vs $17,167, p = 0.04). LIMITATIONS: This study focused on outcomes and did not consider processes of care as drivers of value. CONCLUSIONS: In elective colectomy, high-value hospitals achieve lower episode payments than low-value hospitals for cases without adverse outcome, indicating mechanisms for increasing value beyond reducing complications. Worthwhile targets to optimize value in elective colectomy may include enhanced recovery protocols or other interventions that increase efficiency in all phases of care. See Video Abstract at http://links.lww.com/DCR/B56. LOGRANDO LA COLECTOMÍA DE ALTO VALOR: PREVINIENDO COMPLICACIONES O MEJORANDO LA EFICIENCIA: Hay un mayor enfoque en el valor de la atención quirúrgica. Las complicaciones postoperatorias disminuyen el valor, pero se desconoce si en los casos sin complicaciones, los hospitales de alto valor gastan menos que los hospitales de bajo valor. Estudios anteriores no han evaluado ambos gastos y validado resultados en los mismos pacientes, limitando la comprensión de las interacciones entre el rendimiento clínico, utilización eficiente de los servicios y costos de los episodios quirúrgicos.Identificar las diferencias de pago entre los hospitales de alto y bajo valor, en casos de colectomía sin resultados adversos, utilizando un conjunto de datos vinculados de reclamos de pago múltiple y resultados clínicos validados.Estudio de cohorte observacional retrospectivo. Asignamos a cada hospital una puntuación de valor (proporción de casos sin resultado adverso al pago medio del episodio). Estratificamos los hospitales por valor en terciles y utilizamos el análisis de pruebas de varianza para comparar los pagos entre hospitales de bajo y alto valor, primero para todos los casos y luego casos sin resultados adversos.De enero del 2012 a diciembre del 2016, utilizando datos de registro clínico de 56 hospitales que participan en el Michigan Surgical Quality Collaborative, vinculado con pagos de episodios de 30 días, del Michigan Value Collaborative.Un total de 2947 pacientes con colectomía electiva.Pagos por episodio de 30 días, ajustados al riesgo y estandarizados por precio.La tasa media de complicación ajustada fue de 31% (±10.7%) en hospitales de bajo valor y 14% (±4.6%) en hospitales de alto valor (p < 0.001). A los hospitales de bajo valor se les pagó $3807 (17%) más que a los hospitales de alto valor ($22,271 frente a $18,464, p < 0.001). Entre los casos sin resultados adversos, los pagos fueron de $2257 (11%) más altos en hospitales de bajo valor ($19,424 vs $17,167, p = 0.04).Este estudio se centró en los resultados y no se consideraron a los procesos de atención, como impulsores de valor.En la colectomía electiva, los hospitales de alto valor logran pagos de episodios más bajos, que en los hospitales de bajo valor con casos sin resultados adversos, indicando mecanismos para aumentar el valor, más allá que la reducción de complicaciones. Objetivos valiosos para optimizar el valor de la colectomía electiva, pueden incluir mejoras en los protocolos de recuperación, así como otras intervenciones que aumenten la eficiencia en todas las fases de la atención. Vea el resumen del video en http://links.lww.com/DCR/B56.