Christopher T. Aquina

Extended Intervals after Neoadjuvant Therapy in Locally Advanced Rectal Cancer: The Key to Improved Tumor Response and Potential Organ Preservation

BACKGROUND Many rectal cancer patients experience tumor downstaging and some are found to achieve a pathologic complete response (pCR) after neoadjuvant chemoradiotherapy (nCRT). Previous data suggest that there is an association between the time interval from nCRT completion to surgery and tumor response rates, including pCR. However, these studies have been primarily from single institutions with small sample sizes. The aim of this study was to examine the relationship between a longer interval after nCRT and pCR in a nationally representative cohort of rectal cancer patients. STUDY DESIGN Clinical stage II to III rectal cancer patients undergoing nCRT with a documented surgical resection were selected from the 2006 to 2011 National Cancer Data Base. Multivariable logistic regression analysis was used to assess the association between the nCRT-surgery interval time (<6 weeks, 6 to 8 weeks, >8 weeks) and the odds of pCR. The relationship between nCRT-surgery interval, surgical morbidity, and tumor downstaging was also examined. RESULTS Overall, 17,255 patients met the inclusion criteria. An nCRT-surgery interval time >8 weeks was associated with higher odds of pCR (odds ratio [OR] 1.12, 95% CI 1.01 to 1.25) and tumor downstaging (OR 1.11, 95% CI 1.02 to 1.25). The longer time delay was also associated with lower odds of 30-day readmission (OR 0.82, 95% CI 0.70 to 0.92). CONCLUSIONS An nCRT-surgery interval time >8 weeks results in increased odds of pCR, with no evidence of associated increased surgical complications compared with an interval of 6 to 8 weeks. These data support implementation of a lengthened interval after nCRT to optimize the chances of pCR and perhaps add to the possibility of ultimate organ preservation (nonoperative management).

Parastomal Hernia: A Growing Problem with New Solutions

Parastomal hernia is one of the most common complications following stoma creation and its prevalence is only expected to increase. It often leads to a decrease in the quality of life for patients due to discomfort, pain, frequent ostomy appliance leakage, or peristomal skin irritation and can result in significantly increased healthcare costs. Surgical technique for parastomal hernia repair has evolved significantly over the past two decades with the introduction of new types of mesh and laparoscopic procedures. The use of prophylactic mesh in high-risk patients at the time of stoma creation has gained attention in lieu of several promising studies that have emerged in the recent days. This review will attempt to demonstrate the burden that parastomal hernias present to patients, surgeons, and the healthcare system and also provide an overview of the current management and surgical techniques at both preventing and treating parastomal hernias. i 2014 S. Karger AG, Basel

Disease severity, not operative approach, drives organ space infection after pediatric appendectomy.

Objective:This study examines patient and operative factors associated with organ space infection (OSI) in children after appendectomy, specifically focusing on the role of operative approach. Background:Although controversy exists regarding the risk of increased postoperative intra-abdominal infections after laparoscopic appendectomy, this approach has been largely adopted in the treatment of pediatric acute appendicitis. Methods:Children aged 2 to 18 years undergoing open or laparoscopic appendectomy for acute appendicitis were selected from the 2012 American College of Surgeons Pediatric National Surgical Quality Improvement Program database. Univariate analysis compared patient and operative characteristics with 30-day OSI and incisional complication rates. Factors with a P value of less than 0.1 and clinical importance were included in the multivariable logistic regression models. A P value less than 0.05 was considered significant. Results:For 5097 children undergoing appendectomy, 4514 surgical procedures (88.6%) were performed laparoscopically. OSI occurred in 155 children (3%), with half of these infections developing postdischarge. Significant predictors for OSI included complicated appendicitis, preoperative sepsis, wound class III/IV, and longer operative time. Although 5.2% of patients undergoing open surgery developed OSI (odds ratio = 1.82; 95% confidence interval, 1.21–2.76; P = 0.004), operative approach was not associated with increased relative odds of OSI (odds ratio = 0.99; confidence interval, 0.64–1.55; P = 0.970) after adjustment for other risk factors. Overall, the model had excellent predictive ability (c-statistic = 0.837). Conclusions:This model suggests that disease severity, not operative approach, as previously suggested, drives OSI development in children. Although 88% of appendectomies in this population were performed laparoscopically, these findings support utilization of the surgeons preferred surgical technique and may help guide postoperative counsel in high-risk children.

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.

Large Variation in Blood Transfusion Use After Colorectal Resection: A Call to Action.

BACKGROUND: Perioperative blood transfusions are associated with an increased risk of adverse postoperative outcomes through immunomodulatory effects. OBJECTIVE: The purpose of this study was to identify factors associated with variation in blood transfusion use after elective colorectal resection and associated postoperative infectious complications DESIGN: This was a retrospective cohort study. SETTINGS: The study included elective colorectal resections in New York State from 2001 to 2013. PATIENTS: The study cohort consists of 125,160 colorectal resections. Patients who were admitted nonelectively or who were admitted before the date of surgery were excluded. MAIN OUTCOME MEASURES: Receipt of a perioperative allogeneic red blood cell transfusion and the secondary end points of postoperative pneumonia, surgical site infection, intra-abdominal abscess, and sepsis were measured. RESULTS: The overall rate of perioperative blood transfusion for the study cohort was 13.9%. The unadjusted blood transfusion rates ranged from 2.4% to 58.7% for individual surgeons and 2.9% to 32.8% for individual hospitals. After controlling for patient-, surgeon-, and hospital-level factors in a 3-level mixed-effects multivariable model, significant variation was still present across both surgeons (p < 0.0001) and hospitals (p < 0.0001), with a 16.8-fold difference in adjusted blood transfusion rates across surgeons and a 13.2-fold difference in adjusted blood transfusion rates across hospitals. Receipt of a blood transfusion was also independently associated with pneumonia (OR = 3.23 (95% CI, 2.92–3.57)), surgical site infection (OR = 2.27 (95% CI, 2.14–2.40)), intra-abdominal abscess (OR = 2.72 (95% CI, 2.41–3.07)), and sepsis (OR = 4.51 (95% CI, 4.11–4.94)). LIMITATIONS: Limitations include the retrospective design and the possibility of miscoding within administrative data. CONCLUSIONS: Large surgeon- and hospital-level variations in perioperative blood transfusion use for patients undergoing colorectal resection are present despite controlling for patient-, surgeon-, and hospital-level factors. In addition, receipt of a blood transfusion was independently associated with an increased risk of postoperative infectious complications. These findings support the creation and implementation of perioperative blood transfusion protocols aimed at limiting unwarranted variation.

Missed Opportunity: Laparoscopic Colorectal Resection Is Associated With Lower Incidence of Small Bowel Obstruction Compared to an Open Approach.

Objective: To investigate the effect of a laparoscopic approach on the rate of adhesion-related small bowel obstruction (SBO) following colorectal resection. Background: Currently, there is little compelling evidence with regard to rates of SBO after laparoscopic versus open abdominal surgery. Few studies have compared risk-adjusted rates of SBO following laparoscopic and open colorectal resection. Methods: The Statewide Planning and Research Cooperative System was queried for elective colorectal resections in New York State from 2003 to 2010. A propensity score was calculated to account for selection bias between choice of laparoscopic versus open resection. Bivariate and multivariable competing-risks models were constructed to assess patient, hospital, surgeon, and operative characteristics associated with SBO and operation for SBO within 3 years of resection. Results: Among 69,303 patients who underwent elective colorectal resection (26% laparoscopic, 74% open), 5.3% of patients developed SBO and 2% of patients underwent an operation for SBO. After controlling for other risk factors and conducting an intention-to-treat analysis, open resection was associated with a higher risk of both SBO [hazard ratio (HR) 1.14, 95% confidence interval (CI) 1.03–1.26] and operation for SBO (HR 1.12, 95% CI 0.94–1.32). This effect was even greater when characterizing laparoscopic-to-open conversions as an open approach (SBO: HR 1.34, 95% CI 1.20–1.49; SBO operation: HR 1.35, 95% CI 1.12–1.63). Most other independent risk factors were nonmodifiable and included age <60, female sex, black race, higher comorbidity burden, previous surgery, inflammatory bowel disease, and procedure type. Conclusions: Open colorectal resection increases the risk of SBO compared with laparoscopy. Increased utilization of a laparoscopic approach has the potential to achieve a significant reduction in the incidence of SBO following colorectal resection.

High Variability in Nosocomial Clostridium difficile Infection Rates Across Hospitals After Colorectal Resection.

BACKGROUND: Hospital-acquired Clostridium difficile infection is associated with adverse patient outcomes and high medical costs. The incidence and severity of C. difficile has been rising in both medical and surgical patients. OBJECTIVE: Our aim was to assess risk factors and variation associated with the development of nosocomial C. difficile colitis among patients undergoing colorectal resection. DESIGN: This was a retrospective cohort study. SETTINGS: The study included segmental colectomy and proctectomy cases in New York State from 2005 to 2013. PATIENTS: The study cohort included 150,878 colorectal resections. Patients with a documented previous history of C. difficile infection or residence outside of New York State were excluded. MAIN OUTCOME MEASURES: A diagnosis of C. difficile colitis either during the index hospital stay or on readmission within 30 days was the main measure. RESULTS: C. difficile colitis occurred in 3323 patients (2.2%). Unadjusted C. difficile colitis rates ranged from 0% to 11.3% among surgeons and 0% to 6.8% among hospitals. After controlling for patient, surgeon, and hospital characteristics using mixed-effects multivariable analysis, significant unexplained variation in C. difficile rates remained present across hospitals but not surgeons. Patient factors explained only 24% of the total hospital-level variation, and known surgeon and hospital-level characteristics explained an additional 8% of the total hospital-level variation. Therefore, ≈70% of the hospital variation in C. difficile infection rates remained unexplained by captured patient, surgeon, and hospital factors. Furthermore, there was an ≈5-fold difference in adjusted C. difficile rates across hospitals. LIMITATIONS: A limited set of hospital and surgeon characteristics was available. CONCLUSIONS: Colorectal surgery patients appear to be at high risk for C. difficile infection, and alarming variation in nosocomial C. difficile infection rates currently exists among hospitals after colorectal resection. Given the high morbidity and cost associated with C. difficile colitis, adopting institutional quality improvement programs and maintaining strict prevention strategies are of the utmost importance.

Association Among Blood Transfusion, Sepsis, and Decreased Long-term Survival After Colon Cancer Resection.

Objective: To investigate the potential additive effects of blood transfusion and sepsis on colon cancer disease-specific survival, cardiovascular disease-specific survival, and overall survival after colon cancer surgery. Background: Perioperative blood transfusions are associated with infectious complications and increased risk of cancer recurrence through systemic inflammatory effects. Furthermore, recent studies have suggested an association among sepsis, subsequent systemic inflammation, and adverse cardiovascular outcomes. However, no study has investigated the association among transfusion, sepsis, and disease-specific survival in postoperative patients. Methods: The New York State Cancer Registry and Statewide Planning and Research Cooperative System were queried for stage I to III colon cancer resections from 2004 to 2011. Propensity-adjusted survival analyses assessed the association of perioperative allogeneic blood transfusion, sepsis, and 5-year colon cancer disease-specific survival, cardiovascular disease-specific survival, and overall survival. Results: Among 24,230 patients, 29% received a transfusion and 4% developed sepsis. After risk adjustment, transfusion and sepsis were associated with worse colon cancer disease-specific survival [(+)transfusion: hazard ratio (HR) 1.19, 95% confidence interval (CI) 1.09–1.30; (+)sepsis: HR 1.84, 95% CI 1.44–2.35; (+)transfusion/(+)sepsis: HR 2.27, 95% CI 1.87–2.76], cardiovascular disease-specific survival [(+)transfusion: HR 1.18, 95% CI 1.04–1.33; (+)sepsis: HR 1.63, 95% CI 1.14–2.31; (+)transfusion/(+)sepsis: HR 2.04, 95% CI 1.58–2.63], and overall survival [(+)transfusion: HR 1.21, 95% CI 1.14–1.29; (+)sepsis: HR 1.76, 95% CI 1.48–2.09; (+)transfusion/(+)sepsis: HR 2.36, 95% CI 2.07–2.68] relative to (−)transfusion/(−)sepsis. Additional analyses suggested an additive effect with those who both received a blood transfusion and developed sepsis having even worse survival. Conclusions: Perioperative blood transfusions are associated with shorter survival, independent of sepsis, after colon cancer resection. However, receiving a transfusion and developing sepsis has an additive effect and is associated with even worse survival. Restrictive perioperative transfusion practices are a possible strategy to reduce sepsis rates and improve survival after colon cancer surgery.

Risk Factors for Postdischarge Venothromboembolism After Colorectal Resection.

BACKGROUND: Current guidelines recommend extended-duration thromboprophylaxis for all abdominal oncologic resections. However, other high-risk patients may benefit from extended thromboprophylaxis. OBJECTIVE: The purpose of this study was to identify risk factors for postdischarge venothromboembolism after colorectal procedures. DESIGN: This was a retrospective cohort study. DATA SOURCES: The New York Statewide Planning and Research Cooperative System database (2005–2013) was the data source for this study. STUDY SELECTION: Colon and rectal resections were evaluated. Cases with in-hospital mortality or length of stay ≥30 days were excluded. MAIN OUTCOME MEASURES: Postdischarge venothromboembolism was defined at 30-days after the procedure requiring representation to the emergency department or hospital admission with a new diagnosis of venothromboembolism using International Classification of Diseases, Ninth Revision, codes. Factors associated with postdischarge venothromboembolism were then evaluated using a hierarchical bivariate analysis. A hierarchical mixed-effects model was created using a manual stepwise approach assessing variables meeting p < 0.1 on bivariate analysis. RESULTS: Among 128,163 patients, postdischarge venothromboembolism occurred in 0.7% (n = 789) of the population. Multiple factors were associated with postdischarge venothromboembolism on bivariate analysis. On multivariable analysis, benign conditions requiring operative intervention remained at high risk, with ulcerative colitis imparting an 93% increased odds when compared with other resections (OR, 1.93 (95% CI: 1.30–2.86); p = 0.001). Advanced malignancies (stages III and IV) were associated with increased postdischarge venothromboembolism risk, whereas stage I and II malignancies were not. The only protective factor was a laparoscopic procedure (OR, 0.80 (95% CI: 0.67–0.95); p = 0.010). There was no significant difference in procedure type after controlling for primary diagnosis. LIMITATIONS: This was a retrospective analysis of administrative data with inherent limitations. Only patients who presented with postdischarge venothromboembolism to a hospital within New York State were captured. CONCLUSIONS: This study identifies risk factors for postdischarge venothromboembolism and suggests that ulcerative colitis increases risk for postdischarge venothromboembolism whereas Crohn’s disease does not. Ulcerative colitis postdischarge venothromboembolism rates exceeded even those of malignancy, suggesting that a future study is necessary to determine the efficacy of extended duration thromboprophylaxis in high-risk benign conditions, such as ulcerative colitis.

Patients With Adhesive Small Bowel Obstruction Should Be Primarily Managed by a Surgical Team.

Objective: To evaluate the impact of a primary medical versus surgical service on healthcare utilization and outcomes for adhesive small bowel obstruction (SBO) admissions. Summary Background Data: Adhesive-SBO typically requires hospital admission and is associated with high healthcare utilization and costs. Given that most patients are managed nonoperatively, many patients are admitted to medical hospitalists. However, comparisons of outcomes between primary medical and surgical services have been limited to small single-institution studies. Methods: Unscheduled adhesive-SBO admissions in NY State from 2002 to 2013 were identified using the Statewide Planning and Research Cooperative System. Bivariate and mixed-effects regression analyses were performed assessing factors associated with healthcare utilization and outcomes for SBO admissions. Results: Among 107,603 admissions for adhesive-SBO (78% nonoperative, 22% operative), 43% were primarily managed by a medical attending and 57% were managed by a surgical attending. After controlling for patient, physician, and hospital-level factors, management by a medical service was independently associated with longer length of stay [IRR = 1.39, 95% confidence interval (CI) = 1.24, 1.56], greater inpatient costs (IRR = 1.38, 95% = 1.21, 1.57), and a higher rate of 30-day readmission (OR = 1.32, 95% CI = 1.22, 1.42) following nonoperative management. Similarly, of those managed operatively, management by a medicine service was associated with a delay in time to surgical intervention (IRR = 1.84, 95% CI = 1.69, 2.01), extended length of stay (IRR=1.36, 95% CI = 1.25, 1.49), greater inpatient costs (IRR = 1.38, 95% CI = 1.11, 1.71), and higher rates of 30-day mortality (OR = 1.92, 95% CI = 1.50, 2.47) and 30-day readmission (OR = 1.13, 95% CI = 0.97, 1.32). Conclusions: This study suggests that management of patients presenting with adhesive-SBO by a primary medical team is associated with higher healthcare utilization and worse perioperative outcomes. Policies favoring primary management by a surgical service may improve outcomes and reduce costs for patients admitted with adhesive-SBO.