Carol-Ann Vasilevsky

The incidence of recurrent abscesses or fistula-in-ano following anorectal suppuration

To determine whether primary fistulotomy should be performed at the time of incision and drainage of anorectal abscesses, a retrospective study of 117 patients who underwent incision and drainage of anorectal abscesses was conducted to ascertain what percentage of patients would subsequently develop a fistula-in-ano or recurrent abscess. None of the patients treated for intersphincteric abscesses developed recurrences. Of the 83 patients with perianal or ischiorectal abscesses, nine (11 per cent) developed recurrent abscesses and 31 (37 per cent) developed persistent fistula-in-ano for a combined persistence or recurrence rate of 48 per cent. These data support the policy of secondary fistulotomy to avoid division of sphincter muscle in the 52 per cent of patients who would not need it. In addition, the vast majority of perianal and ischiorectal abscesses can be drained under local anesthesia and hence a general anesthetic and hospital admission are obviated.

Risk factors for mortality following emergency colectomy for fulminant Clostridium difficile infection.

PURPOSE: This study evaluated risk factors for mortality after emergency colectomy for fulminant Clostridium difficile infection. METHODS: Retrospective study of 130 cases of Clostridium difficile infection that required a colectomy between 1994 and 2007 in four hospitals of Quebec, Canada. Primary outcome was 30-day mortality. RESULTS: Twenty-five cases underwent colectomy in 1994 to 2002, 41 in 2003, 40 in 2004, and 24 in 2005 to 2007. Common indications were septic shock (41 percent) and nonresponse to medical treatment (39 percent). Overall, 30-day mortality was 37 percent. Mortality increased with age but was not influenced by comorbidities burden. Mortality correlated with preoperative lactate (≤2.1 mmol/L: 26 percent; 2.2-4.9 mmol/L: 52 percent; ≥5.0 mmol/L: 75 percent, P < 0.001), leukocytosis (<20.0 × 109/L: 32 percent; 20.0-49.9 × 109/L: 33 percent; ≥50.0 × 109/L: 73 percent, P = 0.008), albumin (≥25 g/L: 19 percent; 15-24 g/L: 38 percent; <15 g/L: 52 percent, P = 0.04) and renal failure. In multivariate analysis, risk factors for mortality were age (per year, adjusted odds ratio: 1.03, 95 percent confidence interval: 1.00-1.06), preoperative lactate greater than or equal to 5.0 mmol/L (adjusted odds ratio: 10.32, 95 percent confidence interval: 2.59-41.1), leukocytosis greater than or equal to 50.0 ×109/L (adjusted odds ratio: 3.68, 95 percent confidence interval: 0.92-14.8) and albumin less than 15 g/L (adjusted odds ratio, 6.57, 95 percent confidence interval: 1.31-33.1). CONCLUSIONS: Incidence of Clostridium difficile infection-related emergency colectomies increased 20-fold during the epidemic. Postoperative mortality can be predicted by simple laboratory parameters. Three-fourths of patients with leukocytosis greater or equal to 50.0 ×109/L or lactate greater or equal to 5.0 mmol/L died. When possible, emergency colectomy should be performed earlier.

Experience with stapling in rectal surgery.

This review evaluates the use of the circular stapling device for the creation of colorectal anastomoses. It emphasizes the meticulous attention to detail that is needed to minimize intra- and postoperative complications.

Is There a Role for Oral Antibiotic Preparation Alone Before Colorectal Surgery? Acs-nsqip Analysis by Coarsened Exact Matching

BACKGROUND: Recent studies demonstrated reduced postoperative complications using combined mechanical bowel and oral antibiotic preparation before elective colorectal surgery. OBJECTIVE: The aim of this study was to assess the impact of these 2 interventions on surgical site infections, anastomotic leak, ileus, major morbidity, and 30-day mortality in a large cohort of elective colectomies. DESIGN: This is a retrospective comparison of 30-day outcomes using the American College of Surgeons National Surgical Quality Improvement Program colectomy-targeted database with coarsened exact matching. SETTINGS: Interventions were performed in hospitals participating in the national surgical database. PATIENTS: Adult patients who underwent elective colectomy from 2012 to 2014 were included. INTERVENTIONS: Preoperative bowel preparations were evaluated. MAIN OUTCOME MEASURES: The primary outcomes measured were surgical site infections, anastomotic leak, postoperative ileus, major morbidity, and 30-day mortality. RESULTS: A total of 40,446 patients were analyzed: 13,219 (32.7%), 13,935 (34.5%), and 1572 (3.9%) in the no-preparation, mechanical bowel preparation alone, and oral antibiotic preparation alone groups, and 11,720 (29.0%) in the combined preparation group. After matching, 9800, 1461, and 8819 patients remained in the mechanical preparation, oral antibiotic preparation, and combined preparation groups for comparison with patients without preparation. On conditional logistic regression of matched patients, oral antibiotic preparation alone was protective of surgical site infection (OR, 0.63; 95% CI, 0.45–0.87), anastomotic leak (OR, 0.60; 95% CI, 0.34–0.97), ileus (OR, 0.79; 95% CI, 0.59–0.98), and major morbidity (OR, 0.73; 95% CI, 0.55–0.96), but not mortality (OR, 0.32; 95% CI, 0.08–1.18), whereas a regimen of combined oral antibiotics and mechanical bowel preparation was protective for all 5 major outcomes. When directly compared with oral antibiotic preparation alone, the combined regimen was not associated with any difference in any of the 5 postoperative outcomes. LIMITATIONS: This study was limited by its retrospective design with heterogeneous data. CONCLUSIONS: Oral antibiotic preparation alone significantly reduced surgical site infection, anastomotic leak, postoperative ileus, and major morbidity after elective colorectal surgery. A combined regimen of oral antibiotics and mechanical bowel preparation offered no superiority when compared with oral antibiotics alone for these outcomes. See Video Abstract at http://links.lww.com/DCR/A358.

Sigmoid Colectomy for Acute Diverticulitis in Immunosuppressed vs Immunocompetent Patients: Outcomes From the ACS-NSQIP Database.

BACKGROUND: The management of acute diverticulitis in immunosuppressed patients is increasingly debated. The appropriate timing and type of operation remains controversial. OBJECTIVE: This study examines the impact of immunosuppression on mortality and morbidity following colectomies for diverticulitis in the emergency and elective settings. DESIGN SETTINGS: With the use of the American College of Surgeons National Surgical Quality Improvement Program database, the outcomes of immunosuppressed compared with immunocompetent patients who underwent colectomy for acute diverticulitis were compared. PATIENTS: The multi-institutional database was queried for patients who underwent colectomy for acute diverticulitis from 2005 to 2012. MAIN OUTCOMES MEASURES: The impact of immunosuppression on mortality, major morbidity, organ space infection, infectious complications, and wound dehiscence was assessed. RESULTS: Of 26,987 patients, 1332 were immunosuppressed and 25,655 were immunocompetent; 4271 patients had emergency (596 immunosuppressed and 3675 immunocompetent) and 22,716 patients had elective (736 immunosuppressed and 21,980 immunocompetent) colectomies for diverticulitis. In both groups, mortality and major morbidity were significantly higher in the emergency (immunosuppressed 16% and 45%, immunocompetent 4% and 28%) compared with the elective setting (immunosuppressed 2% and 25%, immunocompetent 0.4% and 12%), p < 0.001. On multivariate regression for the emergency setting, immunosuppression significantly increased mortality (OR, 1.79; 95% CI, 1.17–2.75) and did not significantly increase morbidity. On multivariate regression for the elective setting, mortality was similar in immunosuppressed and immunocompetent groups; however, major morbidity (OR, 1.46; 95% CI, 1.17–1.83) and wound dehiscence (OR, 2.69; 95% CI, 1.63–4.42) were significantly increased in immunosuppressed compared with immunocompetent patients. LIMITATIONS: The retrospective design and standardized outcomes are based on heterogeneous data. CONCLUSIONS: Emergency colectomy for diverticulitis is associated with higher mortality in immunosuppressed than in immunocompetent patients, whereas elective colectomy is associated with comparable mortality. In the elective setting, immunosuppressed compared with immunocompetent patients are at increased risk of major morbidity and wound dehiscence.

Clinical and Economic Impact of an Enhanced Recovery Pathway for Open and Laparoscopic Rectal Surgery

BACKGROUND The short-term benefits of laparoscopy for rectal surgery are equivocal. The objective of this study was to determine the clinical and economic impact of an enhanced recovery pathway (ERP) for laparoscopic and open rectal surgery. MATERIALS AND METHODS All patients who underwent elective rectal resection with primary anastomosis between January 2009 and March 2012 at two tertiary-care, university-affiliated institutions were identified. Patients who met inclusion criteria were divided into four groups, according to surgical approach (laparoscopic [lap] or open) and perioperative management (ERP or conventional care [CC]). Length of stay (LOS), postoperative complications, and hospital costs were compared. RESULTS A total of 381 patients were included in the analysis (201 open-CC, 34 lap-CC, 38 open-ERP, and 108 lap-ERP). Patients were mostly similar at baseline. ERPs significantly reduced median LOS after both open cases (open-CC 10 days versus open-ERP 7.5 days, P = .003) and laparoscopic cases (lap-CC 5 days versus lap-ERP 4.5 days, P = .046). ERPs also reduced variability in LOS compared with CC. There was no difference in postoperative complications with the use of ERPs (open-CC 51% versus open-ERP 50%, P = .419; lap-CC 32% versus lap-ERP 36%, P = .689). On multivariate analysis, both ERP (-3.6 days [95% confidence interval, CI -6.0 to -1.3]) and laparoscopy (-3.6 days [95% CI -5.9 to -1.0]) were independently associated with decreased LOS. Overall costs were only lower when lap-ERP was compared with open-CC (mean difference -2420 CAN

Outcomes of Ileal Pouch Excision: an American College of Surgeons National Surgical Quality Improvement Program Analysis

[95% CI -5628 to -786]). CONCLUSIONS ERPs reduced LOS after rectal resections, and the combination of laparoscopy and ERPs significantly reduced overall costs compared to when neither strategy was used.

Ileoanal anastomosis with reservoirs: complications and long-term results.

Background This study aimed to define the incidence and risk factors of postoperative morbidity and mortality after pouch excision (PE).