Celeste Y. Kang

Risk Factors for Anastomotic Leakage After Anterior Resection for Rectal Cancer

BACKGROUND The risk factors for anastomotic leak (AL) after anterior resection have been evaluated in several studies and remain controversial as the findings are often inconsistent or inconclusive. OBJECTIVE To analyze the risk factors for AL after anterior resection in patients with rectal cancer. DESIGN Retrospective analysis. SETTING The Nationwide Inpatient Sample 2006 to 2009. PATIENTS A total of 72 055 patients with rectal cancer who underwent elective anterior resection. MAIN OUTCOME MEASURES To build a predictive model for AL using demographic characteristics and preadmission comorbidities, the lasso algorithm for logistic regression was used to select variables most predictive of AL. RESULTS The AL rate was 13.68%. The AL group had higher mortality vs the non-AL group (1.78% vs 0.74%). Hospital length of stay and cost were significantly higher in the AL group. Laparoscopic and open resections with a diverting stoma had a higher incidence of AL than those without a stoma (15.97% vs 13.25%). Multivariate analysis revealed that weight loss and malnutrition, fluid and electrolyte disorders, male sex, and stoma placement were associated with a higher risk of AL. The use of laparoscopy was associated with a lower risk of AL. Postoperative ileus, wound infection, respiratory/renal failure, urinary tract infection, pneumonia, deep vein thrombosis, and myocardial infarction were independently associated with AL. CONCLUSIONS Anastomotic leak after anterior resection increased mortality rates and health care costs. Weight loss and malnutrition, fluid and electrolyte disorders, male sex, and stoma placement independently increased the risk of leak. Laparoscopy independently decreased the risk of leak. Further studies are needed to delineate the significance of these findings.

Outcomes of laparoscopic colorectal surgery: data from the Nationwide Inpatient Sample 2009.

BACKGROUND Specific International Classification of Diseases, Ninth Revision, codes for laparoscopic procedures introduced in 2008 allow a more accurate evaluation of laparoscopic colorectal surgery. METHODS Using the Nationwide Inpatient Sample 2009, a retrospective analysis of surgical colorectal cancer and diverticulitis patients was conducted. Logistic regression was used to estimate odds ratios comparing the outcomes of laparoscopic, open, and converted surgery. RESULTS A total of 121,910 patients underwent resection for cancer and diverticulitis, 35.41% of whom underwent laparoscopic surgery. Compared with open surgery, laparoscopic surgery had lower postoperative complication rates, lower mortality, shorter hospital stays, and lower costs. Compared to open surgery, laparoscopic surgery independently decreased mortality, postoperative anastomotic leak, urinary tract infection, ileus or obstruction, pneumonia, respiratory failure, and wound infection. Converted surgery was independently associated with anastomotic leak, wound infection, ileus or obstruction, and urinary tract infection. CONCLUSIONS Laparoscopic colorectal surgery has lower postoperative complications, lower mortality, lower costs, and shorter hospital stays. Conversion had higher complications compared with laparoscopy. The use of laparoscopy should increase with efforts to minimize conversion.

Surgery for gallstone ileus: a nationwide comparison of trends and outcomes.

Introduction:Gallstone ileus is a mechanical bowel obstruction caused by a biliary calculus originating from a bilioenteric fistula. Because of the limited number of reported cases, the optimal surgical method of treatment has been the subject of ongoing debate. Methods:A retrospective review of the Nationwide Inpatient Sample from 2004 to 2009 was performed for gallstone ileus cases treated surgically by enterotomy with stone extraction alone (ES), enterotomy and cholecystectomy with fistula closure (EF), bowel resection alone (BR), and bowel resection with fistula closure (BF). Patient demographics, hospital factors, comorbidities, and postoperative outcomes were reported. Multivariate analysis was performed comparing mortality, morbidity, length of stay, and total cost for the different procedure types. Results:Of the estimated 3,452,536 cases of mechanical bowel obstruction from 2004 to 2009, 3268 (0.095%) were due to gallstone ileus—an incidence lower than previously reported. The majority of patients were elderly women (>70%). ES was the most commonly performed procedure (62% of patients) followed by EF (19% of cases). In 19%, a bowel resection was required. The most common complication was acute renal failure (30.44% of cases). In-hospital mortality was 6.67%. On multivariate analysis, EF and BR were independently associated with higher mortality than ES [(odds ratio [OR] = 2.86; confidence interval [CI]: 1.16–7.07) and (OR = 2.96; CI: 1.26–6.96) respectively]. BR was also associated with a higher complication rate, OR = 1.98 (CI: 1.13–3.46). Conclusions:Gallstone ileus is a rare surgical disease affecting mainly the elderly female population. Mortality rates appear to be lower than previously reported in the literature. Enterotomy with stone extraction alone appears to be associated with better outcomes than more invasive techniques.

Epidural analgesia in laparoscopic colorectal surgery: A Nationwide analysis of use and outcomes

IMPORTANCE The use of epidural analgesia in laparoscopic colorectal surgery has demonstrated superiority over conventional analgesia in controlling pain. Controversy exists, however, regarding its cost-effectiveness and its effect on postoperative outcomes. OBJECTIVES To examine the use of epidural analgesia in laparoscopic colorectal surgery at the national level and to compare its outcomes with those of conventional analgesia. DESIGN, SETTING, AND PARTICIPANTS This is a retrospective review of laparoscopic colorectal cases performed with or without epidural analgesia for cancer, diverticular disease, and benign polyps. Patient demographic characteristics, disease and procedure types, and hospital settings were listed for patients in the epidural and conventional analgesia groups. A 1 to 4 case-matched analysis was performed, matching for patient demographic characteristics, hospital setting, indications, and procedure type. Data were obtained from the Nationwide Inpatient Sample between January 1, 2002, and December 31, 2010. MAIN OUTCOMES AND MEASURES Total hospital charge, length of stay, mortality, pneumonia, respiratory failure, urinary tract infection, urinary retention, anastomotic leak, and postoperative ileus. RESULTS A total of 191576 laparoscopic colorectal cases were identified during the study period. Epidural analgesia was used in 4102 cases (2.14%). Epidurals were more likely to be used in large teaching hospitals, cancer cases, and rectal operations. On case-matched analysis, epidural analgesia was associated with a longer hospital stay by 0.60 day (P=.003), higher hospital charges by

Predictive Factors of In-Hospital Mortality in Colon and Rectal Surgery

3732.71 (P=.02), and higher rate of urinary tract infection (odds ratio=1.81; P=.05). Epidural analgesia did not affect the incidence of respiratory failure, pneumonia, anastomotic leak, ileus, or urinary retention. CONCLUSIONS AND RELEVANCE The perioperative use of epidural analgesia in laparoscopic colorectal surgery is limited in the United States. While epidural analgesia appears to be safe, it comes with higher hospital charges, longer hospital stay, and a higher incidence of urinary tract infections.

A Nationwide Analysis of Laparoscopy in High-Risk Colorectal Surgery Patients

BACKGROUND Knowledge of the independent risk factors for mortality in colon and rectal surgery can aid surgeons in surgical decision making and in providing patients with appropriate information about the risks of surgery. This study endeavors to identify the risk factors for mortality that are associated with colon and rectal surgery. STUDY DESIGN Using the Nationwide Inpatient Sample database, we examined the clinical data of patients who underwent colon and rectal resection from 2006 to 2008. Multivariate regression analysis was performed to identify factors predictive of in-hospital mortality. RESULTS A total of 975,825 patients underwent colon and rectal resection during this period. Overall, the rate of in-hospital mortality was 4.50% (elective surgery, 1.42% vs emergent surgery, 8.76%; p < 0.01). Mortality was lower after laparoscopic compared with open operation (1.43% vs 4.74%; p < 0.01). Using multivariate regression analysis, significant risk factors for in-hospital mortality were emergent surgery (adjusted odds ratio [AOR] = 3.53), liver disease (AOR = 3.02), age older than 65 years (AOR = 2.92), total colectomy (AOR = 2.88), chronic renal failure (AOR = 2.37), malignant tumor (AOR = 2.0), open operation (AOR = 1.85), peripheral vascular disease (AOR = 1.81), diverticulitis (AOR = 1.77), transverse colectomy (AOR = 1.43), chronic lung disease (AOR = 1.41), ulcerative colitis (AOR = 1.40), left colectomy (AOR = 1.31), alcohol abuse (AOR = 1.21), male sex (AOR = 1.12), nonteaching hospital (AOR = 1.11), and African-American race (AOR = 1.09). There was no association between hypertension, diabetes, congestive heart failure, obesity, smoking, proctectomy, sigmoidectomy, or Crohn disease and in-hospital mortality. CONCLUSIONS In patients undergoing colorectal surgery, emergent surgery, liver disease, total colectomy, age older than 65 years, chronic renal failure, and malignant tumor are the major risk factors for in-hospital mortality.

Predictive factors of early bowel obstruction in colon and rectal surgery: data from the Nationwide Inpatient Sample, 2006-2008.

BackgroundDue to safety concerns, the use of laparoscopy in high-risk colorectal surgery patients has been limited. Small reports have demonstrated the benefit of laparoscopy in this population; however, large comparative studies are lacking.Study DesignA retrospective review of the Nationwide Inpatient Sample 2009 was conducted. Patients undergoing elective colorectal resections for benign and malignant pathology were included in the high-risk group if they had at least two of the following criteria: age > 70, obesity, smoking, anemia, congestive heart failure, valvular disease, diabetes mellitus, chronic pulmonary, kidney and liver disease. Using multivariate logistic regression, the outcomes of laparoscopic surgery were compared to open and converted surgery.ResultsOf 145,600 colorectal surgery cases, 32.79% were high-risk. High-risk patients had higher mortality, hospital charges, and longer hospital stay compared to low-risk patients. The use of laparoscopy was lower in the high-risk group with higher conversion rates. In high-risk patients, compared to open surgery, laparoscopy was associated with lower mortality (OR = 0.60), shorter hospital stay, lower charges, decreased respiratory failure (OR = 0.53), urinary tract infection (OR = 0.64), anastomotic leak (OR = 0.69) and wound complications (OR = 0.46). Conversion to open surgery was not associated with higher mortality.ConclusionsLaparoscopy in high-risk colorectal patients is safe and may demonstrate advantages compared to open surgery.

Robotic-assisted colorectal surgery in the United States: a nationwide analysis of trends and outcomes.

BACKGROUND Early postoperative bowel obstruction is associated with considerable morbidity and mortality after colorectal surgery. We evaluated the impact of patient characteristics, patient comorbidities, pathology, resection site, surgical technique, admission type, and teaching hospital status on the incidence of in-hospital bowel obstruction after colorectal surgery. STUDY DESIGN Using the Nationwide Inpatient Sample database, we examined the clinical data of patients who underwent colorectal resection from 2006 to 2008. Regression analyses were performed to identify factors predictive of in-hospital bowel obstruction. RESULTS A total of 975,825 patients underwent colorectal resection during this period. Overall, the rate of postoperative bowel obstruction was 8.65% (elective surgery: 5.32% vs emergent surgery: 13.26%; p < 0.01). Bowel obstruction was less frequent after laparoscopic procedures compared with open procedures (6.61% vs 8.81%; p < 0.01). Using multivariate regression analysis, Crohn disease (adjusted odds ratio [AOR] = 12.32), emergent surgery (AOR = 2.54), malignant tumor (AOR = 1.84), diverticulitis (AOR = 1.45), age older than 65 years (AOR = 1.22), female sex (AOR = 1.14), history of alcohol abuse (AOR = 1.12), transverse colectomy (AOR = 1.11), peripheral vascular disease (AOR = 1.07), left colectomy (AOR = 1.06), chronic lung disease (AOR = 1.05), open procedure (AOR = 1.05), African-American race (AOR = 1.03), and teaching hospital (AOR = 1.02) were associated with a higher risk of in-hospital bowel obstruction. There was no association between hypertension, diabetes, congestive heart failure, chronic renal failure, liver disease, obesity, smoking, proctectomy or total colectomy, and early bowel obstruction. CONCLUSIONS Early bowel obstruction is a relatively common complication after colorectal surgery. Crohn disease patients had a 12-fold higher incidence of early bowel obstruction, and emergent surgery and malignancy were relevant predictors of early bowel obstruction.