Ahmed M. Al-Mazrou

Characterization of Readmission by Day of Rehospitalization After Colorectal Surgery

BACKGROUND: Factors associated with readmission stratified by the day of postdischarge rehospitalization after colorectal surgery have not been characterized previously. OBJECTIVE: The purpose of this study was to identify factors leading to readmission on a day-to-day basis after discharge from colorectal surgery. DESIGN: This was a retrospective analysis of patients readmitted within 30-days after colorectal surgery. Reasons and factors associated with readmission each day after discharge were evaluated. Early readmitted patients (day 0–5 postdischarge) were compared with those readmitted later (day 6–29 postdischarge). SETTINGS: The study was conducted at a tertiary center. PATIENTS: Patients included those who had undergone primary colorectal resection from the American College of Surgeons National Surgical Quality Improvement Program (2012–2013). MAIN OUTCOME MEASURES: The study intended to identify factors associated with any early versus late hospital readmission and to evaluate diagnoses for unplanned readmissions on a day-to-day basis after discharge. RESULTS: For 69,222 elective colorectal procedures, 7476 patients (10.8%) were readmitted to the hospital within 30 days. Early (median, 3 days) and late (median, 11 days) readmissions were 3278 (43.8%) and 4198 (56.2%). Except for sex, patient demographics were similar between groups. Neurologic comorbidity; wound disruption; sepsis or septic shock; unplanned reintubation and reoperation; anastomotic leak and ileus; and neurological, cardiovascular, and pulmonary complications were significantly higher in the early readmission, whereas disseminated malignancy, stoma creation, and renal/urological complications were significantly higher in the late readmission group. On multivariable analysis, early readmission was significantly associated with male patients, wound disruption, sepsis or septic shock, reoperation, reintubation, and postoperative neurological complications. Disseminated malignancy, ostomy creation, and postoperative renal dysfunction/urological infection were associated with delayed readmission. LIMITATIONS: Thirty-day readmissions and reasons for unplanned rehospitalizations were evaluated. CONCLUSIONS: Differing factors are associated with early versus late readmission after colorectal resection. These data suggest that early readmission is intricately related to patient and operative complexity and hence may be inevitable, whereas delayed hospital presentation is associated with identifiable perioperative predictors at the time of discharge and hence more likely to be targetable.

Impact of preoperative steroid or immunosuppressant use on short-term outcomes following colectomy in Crohn’s disease patients

AbstractBackgroundnEvaluating the impact of steroid or immunosuppressants (SI) therapy prior to colectomy in Crohn’s disease (CD) patients on postoperative septic and colectomy-specific outcomes using the American College of Surgeons (ACS)–National Surgical Quality Improvement Program (NSQIP)-targeted colectomy database.MethodsAll CD patients undergoing colectomy were retrieved from the 2012–2013 NSQIP-targeted database. Thirty-day postoperative outcomes were compared for patients who were on steroids or immunosuppressants (SI) within the 30xa0days prior to colectomy to the others using univariable and multivariable analyses.ResultsOf 2208 CD patients, 1387 (63%) were on SI. Patients in the SI group were younger, and a greater proportion underwent laparoscopic surgery (pxa0<xa00.05). SI use was associated with a higher rate of sepsis (7.6 vs. 5.2%), anastomotic leak (5.6 vs. 3.5%), and return to operating room (6.8 vs. 3.3%). On multivariable analysis, SI was associated with sepsis, septic shock, and anastomotic leak [odds ratioxa0=xa01.58, 95% confidence interval 1.09–2.27].ConclusionsThese results suggest that SI use within 30xa0days of colectomy is associated with a higher rate of sepsis and septic shock and anastomotic leak in CD patients. Withholding SI prior to surgery, or the selective use of an ostomy to mitigate the consequences of a leak and hence sepsis need due consideration prior to surgery.

Epidural analgesia in the era of enhanced recovery: time to rethink its use?

BackgroundPrevious assessments of the impact of epidural analgesia (EA) on outcomes after colorectal surgery were related to the period before widespread implementation of the enhanced recovery after surgery (ERAS) protocols. This study evaluates the impact of EA on postoperative recovery after colectomy using recent multicenter data.MethodsPatients who underwent elective colectomy from the American College of Surgeons (ACS) National Surgical Quality Improvement Program (NSQIP) data (2014–2015) were identified. Demographics, comorbidities, diagnosis, procedure type and approach, and postoperative complications associated with EA were assessed. Impact of EA on postoperative ileus, length of stay (LOS), and prolonged LOS (defined as LOSu2009>u200975 percentile) was evaluated for all, open, and laparoscopic cases using univariable and multivariable analyses.ResultsOf 9045 elective colectomy procedures, 3081 (34.1%) received EA. Epidural analgesia was associated with greater rates of postoperative ileus (15.9% vs. 10.8%, pu2009<u20090.0001), superficial (5.5% vs. 4%, pu2009=u20090.001) and deep (1.8% vs. 0.6%, pu2009<u20090.0001) wound infections, pulmonary embolism (0.8% vs. 0.4%, pu2009=u20090.004), deep vein thrombosis (1.3% vs. 0.7%, pu2009=u20090.01), sepsis/septic shock (4.6% vs. 3.1%, pu2009<u20090.0001), unplanned reintubation (1.5% vs. 0.8%, pu2009=u20090.003), cardiac complications (1.2% vs. 0.7%, pu2009=u20090.03), and transfusion (9.1% vs. 5.9%, pu2009<u20090.0001). Postoperative length of stay (LOS) [mean (SD), days: 6.7(6.2) vs. 5(4.5) days, pu2009<u20090.0001] was greater for EA. On multivariable analysis, EA had no impact on postoperative ileus for all and laparoscopic cases. However, EA increased the likelihood for ileus (OR 1.34, 95% CI 1.02–1.78) after open colectomy alone. Similarly, EA did not influence prolonged LOS for all and laparoscopic cases but was independently associated with prolonged LOS after open colectomy (OR 1.4, 95% CI 1.1–1.8).ConclusionEpidural analgesia was not associated with improved recovery after elective colectomy in the era of ERAS.

Management of iatrogenic perforation during colonoscopy in ulcerative colitis patients: a survey of gastroenterologists and colorectal surgeons

PurposePatients with ulcerative colitis, a high-risk group for the development of colon cancer, undergo colonoscopy more frequently than the general population. This increase in endoscopic evaluation also exposes these patients to an increased risk of complications, including iatrogenic perforation. Our survey study aims to determine factors that affect the management choices for iatrogenic perforations for ulcerative colitis patients in remission and identify areas of consensus among general gastroenterologists, inflammatory bowel disease specialists, and colorectal surgeons.MethodsAn anonymous, cross-sectional survey was performed using an online platform. A matrix questionnaire posed five clinical scenarios with six management options for an iatrogenic perforation in ulcerative colitis patients with varying disease distribution, disease activity, and maintenance regimens.ResultsOne hundred thirty-eight general gastroenterologists, 35 inflammatory bowel disease specialists, and 174 colorectal surgeons responded to the survey; 47, 41, and 23%, respectively, answered they did not feel comfortable managing perforations in ulcerative colitis patients in remission. We found the greatest concordance among gastroenterologists and colorectal surgeons in cases of perforation in ulcerative colitis with a history of dysplasia; the majority of respondents chose staged total proctocolectomy with ileal pouch anal anastomosis. We found discordance in decision making for ulcerative colitis in remission without dysplasia, with perforation occurring in colitis involved and uninvolved areas.ConclusionOur survey revealed that a significant fraction of gastroenterologists and colorectal surgeons are uncomfortable managing iatrogenic colonic perforations in ulcerative colitis patients. We have identified knowledge and practice gaps in defining the optimal management of iatrogenic perforations in ulcerative colitis patients.

Robotic ventral mesh rectopexy - a video vignette

Correction of rectal prolapse by traditional suture rectopexy or resection rectopexy may predispose patients to constipation or anastomosis-related complications [1] [2]. The nerve sparing ventral mesh rectopexy for internal rectal prolapse allows for correction of multiple anatomical defects [3]. In this video, we describe the technical steps in performing ventral mesh rectopexy using a robotic platform [4] [5], on a fifty eight year old woman with internal rectal prolapse. n nThis article is protected by copyright. All rights reserved.