Andrew-Paul Deeb

Tobacco Smoking and Postoperative Outcomes After Colorectal Surgery.

Objective: The aim of this study was to delineate the impact of smoking on postoperative outcomes after colorectal resection for malignant and benign processes. Background: Studies to date have implicated smoking as a risk factor for increased postoperative complications. However, there is a paucity of data on the effects of smoking after colorectal surgery and in particular for malignant compared with benign processes. Methods: The American College of Surgeons National Surgical Quality Improvement Program (2005–2010) database was queried for patients undergoing elective major colorectal resection for colorectal cancer, diverticular disease, or inflammatory bowel disease. Risk-adjusted 30-day outcomes were assessed and compared between patient cohorts identified as never-smokers, ex-smokers, and current smokers. Primary outcomes of incisional infections, infectious and major complications, and mortality were evaluated using regression modeling adjusting for patient characteristics and comorbidities. Results: A total of 47,574 patients were identified, of which 26,333 had surgery for colorectal cancer, 14,019 for diverticular disease, and 7222 for inflammatory bowel disease. More than 60% of patients had never smoked, 20.4% were current smokers, and 19.2% were ex-smokers. After adjustment, current smokers were at a significantly increased risk of postoperative morbidity [odds ratio (OR), 1.3; 95% confidence interval (CI), 1.21–1.40] and mortality (OR, 1.5; 95% CI, 1.11–1.94) after colorectal surgery. This finding persisted across malignant and benign diagnoses and also demonstrated a significant dose-dependent effect when stratifying by pack-years of smoking. Conclusions: Smoking increases the risk of complications after all types of major colorectal surgery, with the greatest risk apparent for current smokers. A concerted effort should be made toward promoting smoking cessation in all patients scheduled for elective colorectal surgery.

Closure of defunctioning loop ileostomy is associated with considerable morbidity.

Aim  An elective defunctioning ileostomy is commonly employed to attenuate the morbidity that may arise from distal anastomotic leakage. The magnitude of risk associated with subsequent ileostomy closure is difficult to estimate as many of the data arise from small series. This study looked at the rate of complications and predictive factors in a large series of patients.

Outcomes Associated With Resident Involvement in Partial Colectomy

BACKGROUND: Surgical cases that include trainees are associated with worse outcomes in comparison with those that include attending surgeons alone. OBJECTIVE: This study aimed to identify whether resident involvement in partial colectomy was associated with worse outcomes when evaluated by surgical approach and resident experience. DESIGN: This is a retrospective study using the National Surgical Quality Improvement Program database. SETTINGS: This study evaluates cases included in the National Surgical Quality Improvement Program database. PATIENTS: All patients were included who underwent partial colectomy including both open and laparoscopic approaches. INTERVENTIONS: Residents were involved. MAIN OUTCOME MEASURES: The primary outcome measures were the association of resident involvement and major complication events, minor complication events, unplanned return to operating room, and operative time. RESULTS: Cases with residents were associated with major complications (OR 1.18, CI 1.09–1.27, p < 0.001) on multivariate analysis. However, after including operative time in the model only open cases involving fifth year residents were still associated with major complications (OR 1.13, p = 0.037). Resident involvement was associated with increased likelihood of minor complications (OR 1.3, p < 0.001) and an increased risk of unplanned return to the operating room (OR 1.20, p < 0.001). Operative time was longer for cases with residents on average by 33.7 minutes and 27 minutes for open and laparoscopic cases. LIMITATIONS: This study was limited by its retrospective design and lack of data on teachings status, case complexity, and intraoperative evaluation of technique. CONCLUSIONS: Resident involvement in partial colectomies is associated with an increased major complications, minor complications, likelihood of return to the operating room, and operative time.

A laparoscopic approach reduces short-term complications and length of stay following ileocolic resection in Crohn's disease: An analysis of outcomes from the NSQIP database

Aim  Studies to date examining the impact of laparoscopy in resection for Crohns disease on short‐term morbidity have been limited by small study populations. The aim of this study was to establish the impact of the operative approach (laparoscopic or open) on outcomes after ileocolic resection for Crohn’s disease.

Association between operative approach and complications in patients undergoing Hartmann's reversal.

Complications following reversal of Hartmanns procedure are common, with morbidity rates of up to 50 per cent, and a mortality rate as high as 10 per cent. This is based on case series with heterogeneous data collection and analysis. This study determined risk factors for complications following Hartmanns reversal.

Visceral obesity, not elevated BMI, is strongly associated with incisional hernia after colorectal surgery.

BACKGROUND: High BMI is often used as a proxy for obesity and has been considered a risk factor for the development of an incisional hernia after abdominal surgery. However, BMI does not accurately reflect fat distribution. OBJECTIVE: The purpose of this work was to investigate the relationship among different obesity measurements and the risk of incisional hernia. DESIGN: This was a retrospective cohort study. SETTINGS: The study included a single academic institution in New York from 2003 to 2010. PATIENTS: The study consists of 193 patients who underwent colorectal cancer resection. MAIN OUTCOME MEASURES: Preoperative CT scans were used to measure visceral fat volume, subcutaneous fat volume, total fat volume, and waist circumference. A diagnosis of incisional hernia was made either through physical examination in medical chart documentation or CT scan. RESULTS: Forty-one patients (21.2%) developed an incisional hernia. The median time to hernia was 12.4 months. After adjusting for patient and surgical characteristics using Cox regression analysis, visceral obesity (HR 2.04, 95% CI 1.07–3.91) and history of an inguinal hernia (HR 2.40, 95% CI 1.09–5.25) were significant risk factors for incisional hernia. Laparoscopic resection using a transverse extraction site led to a >75% reduction in the risk of incisional hernia (HR 0.23, 95% CI 0.07–0.76). BMI > 30 kg/m2 was not significantly associated with incisional hernia development. LIMITATIONS: Limitations include the retrospective design without standardized follow-up to detect hernias and the small sample size attributed to inadequate or unavailable CT scans. CONCLUSIONS: Visceral obesity, history of inguinal hernia, and location of specimen extraction site are significantly associated with the development of an incisional hernia, whereas BMI is poorly associated with hernia development. These findings suggest that a lateral transverse location is the incision site of choice and that new strategies, such as prophylactic mesh placement, should be considered in viscerally obese patients.

Outcome of the dynamic helical hip screw system for intertrochanteric hip fractures in the elderly patients.

Introduction: The dynamic helical hip system (DHHS; Synthes, Paoli, Pennsylvania) differs from the standard dynamic sliding hip screw (SHS) in that in preparing for its insertion, reaming of the femoral head is not performed, thereby preserving bone stock. It also requires less torque for insertion of the helical screw. The associated plate has locking options to allow locking screw fixation in the femoral shaft, thereby decreasing the chance of the plate pulling off. While biomechanical studies have shown improved resistance to cutout and increased rotational stability of the femoral head fragment when compared with traditional hip lag screws, there is limited information on clinical outcome of the implant available in the literature. Methods: We report a single surgeon series of 87 patients who were treated for their per-trochanteric hip fractures with this implant to evaluate their clinical outcome and compare it with a cohort of 344 patients who were treated with the standard SHS. All data were prospectively collected, most as part of a structured Geriatric Fracture Care Program. Results: The 2 groups were similar demographically, and medically, with similar rates of in-hospital complications and implant failure. Failure in the DHHS group was attributable to use of the implant outside its indications and repeated fall of the patient. Conclusion: This limited case series showed that the DHHS outcomes are comparable with that of the SHS. Whether there is any benefit to its use will require larger, prospective randomized controlled trials.

Tu1754 Rectal Prolapse Repair: Laparoscopic or Perineal Approach?

Introduction: Primary anastomosis with or without proximal diversion is increasingly applied to pts requiring urgent colectomy for complicated disease of the sigmoid colon. Conversely, the Hartmann procedure (HP) is now often restricted to patients who are unstable or otherwise ill suited to primary anastomosis. As such, pts who are evaluated for Hartmann takedown often have formidable comorbities and considerable judgment is often required in pt selection. We sought to define the complication rate of Hartmann takedown in this setting. Methods: A prospective complication database was searched for consecutive adult patients undergoing colostomy takedown with colorectal anastomosis (HP) at an academic teaching hospital from 1/1/02 to 12/31/10. Demographics, BMI, ASA classification, interval between Hartmann procedure and subsequent takedown, surgical indication, surgeon volume and specialty, length of stay and complications were recorded. Fishers exact test was used to identify risk factors for postoperative complications. Results: 104 pts underwent Hartmann reversal by 16 different surgeons; 7 of these surgeons did 4 or fewer procedures during the study period. 39 pts had their original Hartmann procedure done elsewhere; 38 of these reversals were done by a colorectal surgeon. During the same time period, 334 patients underwent a Hartmann procedure at our institution. 77/104 pts (74%) had their HP for complicated diverticulitis; anastomotic leak was the second most common indication. The median age was 61 years (31-84 yrs) and the interval from Hartmann procedure to reversal ranged from 87-1489 days. Only 8 pts (7.7%) had an ASA of 1 and at least 30 patients required a concomitant ventral hernia repair. 30 pts (29%) had complications and 12 (11%) had two or more complications (Table 1). There were two deaths, four anastomotic leaks, and seven patients had inadvertent enterotomies. Only ASA status predicted postop complications (p=.01) Conclusions: Hartmann takedown is a morbid operation with a substantial risk of inadvertent enterotomy and serious complications. Excluding cases referred from elsewhere, there were more than fivefold the number of Hartmann procedures than takedowns performed during the study period. This suggests that Hartmann procedures are largely restricted to patients who are poor candidates for takedown and that their colostomy is highly likely to be permanent. Table 1: Complications (n=30 pts)