Ahmad Elnahas

The impact of preoperative steroid use on short-term outcomes following surgery for inflammatory bowel disease

BACKGROUND Inflammatory bowel disease (IBD) patients are frequently treated with steroids prior to surgery. We characterized the association between preoperative steroid use and postoperative complications in a large prospective cohort. METHODS We identified patients who underwent major IBD-related abdominal surgery in the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) between 2005 and 2012. We compared the risk of postoperative complications and 30-day mortality between preoperative steroid users and non-users. RESULTS We identified 8260 Crohns disease (CD) and 7235 ulcerative colitis (UC) patients who underwent major abdominal surgery. Preoperative steroid use was associated with higher risk of postoperative complications, excluding death, in both CD (22.6% vs. 18.5%, P<0.0001) and UC (30.1% vs. 22.5%, P<0.0001). The adjusted odds ratio for any postoperative complication associated with steroids was 1.26 (95% CI: 1.12-1.41) for CD and 1.44 (95% CI: 1.28-1.61) for UC. Infectious complications were more frequent with steroid use in both CD (15.2% vs. 12.9%, P=0.004) and UC (19.4% vs. 15.6%, P<0.0001), specifically intra-abdominal infections and sepsis. Steroid use was associated with increased risk of venous thromboembolism (VTE) in both CD (OR, 1.66; 95% CI: 1.17-2.35) and UC (OR, 2.66; 95% CI: 2.01-3.53). 30-day mortality did not differ among steroid users and non-users (6.8/1000 vs. 5.8/1000, P=0.58 for CD; 13.5/1000 vs. 15.2/1000, P=0.55 for UC). CONCLUSIONS Preoperative steroids are associated with higher risk of postoperative sepsis and VTE in IBD. Increased infectious control measures and VTE prophylaxis may reduce adverse events.

The neutrophil-to-lymphocyte ratio predicts major perioperative complications in patients undergoing colorectal surgery

The objective of the study was to evaluate the association between the neutrophil‐to‐lymphocyte ratio (NLR) and the occurrence of perioperative complications in patients undergoing colorectal surgery.

Comparison of robotic and laparoscopic colorectal resections with respect to 30-day perioperative morbidity.

BACKGROUND Robotic surgery has emerged as a minimally invasive alternative to traditional laparoscopy. Robotic surgery addresses many of the technical and ergonomic limitations of laparoscopic surgery, but the literature regarding clinical outcomes in colorectal surgery is limited. We sought to compare robotic and laparoscopic colorectal resections with respect to 30-day perioperative outcomes. METHODS The American College of Surgeons National Surgical Quality Improvement Program database was used to identify all patients who underwent robotic or laparoscopic colorectal surgery in 2013. We performed a logistic regression analysis to compare intraoperative variables and 30-day outcomes. RESULTS There were 8392 patients who underwent laparoscopic colorectal surgery and 472 patients who underwent robotic colorectal surgery. The robotic cohort had a lower incidence of unplanned intraoperative conversion (9.5% v. 13.7%, p = 0.008). There were no significant differences between robotic and laparoscopic surgery with respect to other intraoperative and postoperative outcomes, such as operative duration, length of stay, postoperative ileus, anastomotic leak, venous thromboembolism, wound infection, cardiac complications and pulmonary complications. On multivariable analysis, robotic surgery was protective for unplanned conversion, while male sex, malignancy, Crohn disease and diverticular disease were all associated with open conversion. CONCLUSION Robotic colorectal surgery has comparable 30-day perioperative morbidity to laparoscopic surgery and may decrease the rate of intraoperative conversion in select patients.

The effect of mechanical bowel preparation on anastomotic leaks in elective left-sided colorectal resections.

BACKGROUND Routine preoperative mechanical bowel preparation (MBP) for left-sided colorectal resections remains controversial. This study aims to evaluate the association between MBP and 30-day anastomotic leaks. METHODS A retrospective cohort study was conducted using data from the National Surgical Quality Improvement Program from 2011 to 2012. Multiple imputation was used for missing data, and a multivariable logistic regression was performed to adjust for clinically relevant variables. A propensity score-adjusted model was performed as a sensitivity analysis. RESULTS A total of 2,581 patients (57%) received preoperative MBP, whereas 1,935 (43%) did not. The 30-day anastomotic leak rate with and without preoperative MBP was 3.1% and 5.1%, respectively. After covariate adjustment, MBP omission was significantly associated with a 40% increased odds of 30-day anastomotic leaks (odds ratio 1.41, P = .04, 95% confidence interval 1.01 to 1.93). CONCLUSIONS MBP omission was associated with a higher rate of 30-day anastomotic leaks. A large, well-designed, randomized controlled trial is needed to further evaluate this relationship.

Safety of next-day discharge following laparoscopic sleeve gastrectomy

BACKGROUND The safety of next-day discharge after laparoscopic sleeve gastrectomy (SG) for the treatment of morbid obesity has not been well studied. The objective of this study was to determine if next-day discharge after laparoscopic SG was comparable to standard discharge (i.e., postoperative day [POD] 2) with respect to the rate of 30-day adverse events. METHODS A retrospective cohort analysis was performed. Patients were selected if they underwent a laparoscopic SG for morbid obesity between 2010 and 2012 and discharged on either POD 1 or 2. The primary outcome was the 30-day adverse event rate, which was a composite endpoint of complications, mortality, or reoperations. A multivariable logistic regression was performed to determine an adjusted odds ratio (OR) of 30-adverse events for next-day discharge. RESULTS There were 2982 (37.4%) and 4985 (62.6%) patients discharged on POD 1 and 2, respectively. Both groups were comparable with respect to clinical characteristics. The adjusted OR for 30-day adverse events with next-day discharge was .75 (P = .08, 95% CI [.55-1.04]). Preoperative hypertension and dyspnea were significant predictors of adverse events for next-day discharge. CONCLUSION Based on data from the ACS-NSQIP registry, laparoscopic SG patients discharged on POD 1 did not have a worse rate of 30-day adverse events compared to the POD 2 group. Appropriate perioperative evaluation may help surgeons implement next-day discharge for select patients after uncomplicated laparoscopic SG.

Is quality important to our patients? The relationship between surgical outcomes and patient satisfaction

Background With greater transparency in health system reporting and increased reliance on patient-centred outcomes, patient satisfaction has become a priority in delivering quality care. We sought to explore the relationship between patient satisfaction and short-term outcomes in patients undergoing general surgical procedures. Methods Satisfaction surveys were distributed to patients following discharge from the general surgery service at an academic hospital between June 2012 and March 2015. Short-term clinical outcomes were obtained from the American College of Surgeons National Surgical Quality Improvement Program database. Patients rated their level of satisfaction on a 5-point Likert scale, and ordered logistic regression model was used to determine predictors of high patient satisfaction. Results 757 patient satisfaction surveys were completed. The mean age of patients surveyed was 52.2 years; 60.0% of patients were female. The majority of patients underwent a laparoscopic procedure (85.9%) and were admitted as inpatients following surgery (72%). 91.5% of patients rated satisfaction of 4–5, and 95.0% said they would recommend the service. The odds of overall satisfaction were lower in patients who had complications (OR: 0.52, 95% CI 0.31 to 0.87) and 30-day readmission (OR: 0.35, 95% CI 0.17 to 0.70). Having elective surgery was associated with higher odds of satisfaction (OR: 1.62, 95% CI 1.07 to 2.47). Conclusions We found a significant association between patient satisfaction and both 30-day readmission and the occurrence of postoperative surgical complications. Given this association, further study is warranted to evaluate patient satisfaction as a healthcare quality indicator.

The effect of a simultaneous versus a staged resection of metastatic colorectal cancer on time to adjuvant chemotherapy: LE SOUDER et al.

Patients with colorectal cancer with synchronous liver metastases may undergo a staged or a simultaneous resection. This study aimed to determine whether the time to adjuvant chemotherapy was delayed in patients undergoing a simultaneous resection.

Concurrent risk-reduction surgery in patients with increased lifetime risk for breast and ovarian cancer: an analysis of the National Surgical Quality Improvement Program (NSQIP) database

BackgroundPatients with genetic susceptibility to breast and ovarian cancer are eligible for risk-reduction surgery. Surgical morbidity of risk-reduction mastectomy (RRM) with concurrent bilateral salpingo-oophorectomy (BSO) is unknown. Outcomes in these patients were compared to patients undergoing RRM without BSO using a large multi-institutional database.MethodsA retrospective cohort analysis was conducted using the American College of Surgeon’s National Surgical Quality Improvement Program (NSQIP) 2007–2016 datasets, comparing postoperative morbidity between patients undergoing RRM with patients undergoing RRM with concurrent BSO. Patients with genetic susceptibility to breast/ovarian cancer undergoing risk-reduction surgery were identified. The primary outcome was 30-day postoperative major morbidity. Secondary outcomes included surgical site infections, reoperations, readmissions, length of stay, and venous thromboembolic events. A multivariate analysis was performed to determine predictors of postoperative morbidity and the adjusted effect of concurrent BSO on morbidity.ResultsOf the 5470 patients undergoing RRM, 149 (2.7%) underwent concurrent BSO. The overall rate of major morbidity and postoperative infections was 4.5% and 4.6%, respectively. There was no significant difference in the rate of postoperative major morbidity (4.5% vs 4.7%, p = 0.91) or any of the secondary outcomes between patients undergoing RRM without BSO vs. those undergoing RRM with concurrent BSO. Multivariable analysis showed Body Mass Index (OR 1.05; p < 0.001) and smoking (OR 1.78; p = 0.003) to be the only predictors associated with major morbidity. Neither immediate breast reconstruction (OR 1.02; p = 0.93) nor concurrent BSO (OR 0.94; p = 0.89) were associated with increased postoperative major morbidity.ConclusionThis study demonstrated that RRM with concurrent BSO was not associated with significant additional morbidity when compared to RRM without BSO. Therefore, this joint approach may be considered for select patients at risk for both breast and ovarian cancer.

Gastrointestinal Obstruction in the Bypass Patient

The objective of this chapter is to explore the various causes of gastrointestinal obstruction in the post-gastric bypass patient. Anatomic alterations following Roux-en-Y gastric bypass surgery can result in bowel obstructions that pose both a diagnostic and therapeutic dilemma for surgeons. The risk of progression to bowel ischemia because of delayed treatment underscores the importance of properly identifying and treating bowel obstructions early in this patient population.

Mo1579 Is Early Discharge Following Elective Surgery for Colon Cancer Safe? an Analysis of Short-Term Outcomes

preoperative oral antibiotics do not decrease the incidence of postoperative surgical site infection (SSI) in patients who did not receive a mechanical bowel prep prior to segmental colectomy. Methods: We performed a retrospective review of 185 patients who underwent a segmental colectomy without mechanical bowel prep by a group of 4 colorectal surgeons at a single academic medical center from July 2011 July 2013. A total of 66 patients received preoperative Neomycin and Flagyl in addition to perioperative IV antibiotics, while 119 received perioperative IV antibiotics alone. Oral antibiotics were given at the discretion of the attending surgeon. The primary outcome was postoperative surgical site infection. Multivariate logistic regression was performed to control for patient and surgical factors associated with surgical site infection. Results: A total of 66 patients received preoperative Neomycin and Flagyl, while 119 patients did not. The two groups were equally matched, with two exceptions. There was a higher proportion of cases performed laparoscopically in the group that did not receive oral antibiotics (75.7% versus 49.6%, p= 0.001), and the diagnosis of diabetes was more prevalent in the group that did not receive oral antibiotics (21.2% versus 10.1%, p=0.0031). Postoperative surgical site infection occurred in 10.9% of patients who received Neomycin and Flagyl and 10.6% percent of those who did not (p=0.95). Multivariate analysis of surgical and patient factors indicated that estimated blood loss (OR = 3.76 95% CI = 1.24-11.36), and perioperative steroid use (OR = 7.7 95% CI = 1.34-44.8) were associated with postoperative SSI. When controlling for patient and surgical factors, preoperative Neomycin and Flagyl did not decrease the incidence of SSI (OR = 0.75, 95% CI = 0.026-2.19). Conclusion: In the absence of mechanical bowel prep, preoperative oral antibiotics do not reduce the incidence of surgical site infection following segmental colectomy.