Daniel O. Herzig

Utilization of laparoscopic colectomy in the United States before and after the clinical outcomes of surgical therapy study group trial.

Objective: To evaluate the utilization of laparoscopic colectomy (LC) in the United States before and after prospective data supported its use for the treatment of colon cancer. Methods: The Nationwide Inpatient Sample 2001–2003 [before Clinical Outcomes of Surgical Therapy (COST)] and 2005–2007 (after COST) was queried for elective colectomies for both benign and malignant disease. The COST trial was published in 2004; therefore, 2004 data were excluded. Univariate analyses including patient-specific, hospital-specific, and outcome variables were performed. Multivariate logistic regression models and subset analyses were used to evaluate these variables and operative approach by time frame. Results: The query yielded 741,817 elective colectomies (684,969 open and 56,848 laparoscopic). The percentage of elective colectomies performed laparoscopically has increased over time. Laparoscopic colectomy for benign disease increased from 6.2% in 2001–2003 to 11.8% in 2005–2007, while those for colon cancer have increased by a larger percentage, 2.3% to 8.9%. In a multivariate model of patients with colon cancer, the odds ratio (OR) for having a laparoscopic approach after COST was 4.55 (confidence interval 3.81–5.44) compared with before COST. In contrast, for benign disease, the OR was 2.10 (confidence interval 1.79–2.46). Factors predictive of having a laparoscopic approach for cancer have changed very little over time: Patients are more likely to be male, insured, live in areas with the highest incomes, and undergo resection at urban teaching hospitals. Conclusions: Within 3 years after publication of the COST trial, the use of laparoscopic resection for colon cancer approached that of benign disease. However, almost 90% of cases are still performed open and utilization remains influenced by socioeconomic factors.

Dramatic decreases in mortality from laparoscopic colon resections based on data from the Nationwide Inpatient Sample.

OBJECTIVE To determine the mortality rate and associated factors for laparoscopic and open colectomy as derived from the Nationwide Inpatient Sample database. DESIGN Retrospective cohort. SETTING Nationwide Inpatient Sample database. PATIENTS Between 2002 and 2007, the Nationwide Inpatient Sample estimated 1,314,696 patients underwent colectomy in the United States. Most (n = 1,231,184) were open, but 83,512 were laparoscopic. Patients who underwent a laparoscopic procedure that was converted to open were analyzed within the laparoscopic group on an intention-to-treat basis. MAIN OUTCOME MEASURE Mortality rate. Using a logistic regression model, patient and institutional characteristics were analyzed and evaluated for significant associations with in-hospital mortality. RESULTS In a multivariate analysis, significant predictors of increased mortality included older age, male sex, lower socioeconomic status, comorbidities, and emergency or transfer admission. Additionally, a laparoscopic approach was an independent predictor of decreased mortality when compared with open colectomy (relative risk, 0.51; P < .001). CONCLUSION Even when controlling for comorbidities, socioeconomic status, practice setting, and admission type, laparoscopy is an independent predictor of decreased mortality for colon resection.

Laparoscopic converted to open colectomy: predictors and outcomes from the Nationwide Inpatient Sample.

BACKGROUND Early in their learning curve, surgeons need to appropriately select patients to avoid conversion from laparoscopic to an open colectomy. METHODS Using the Nationwide Inpatient Sample, laparoscopic and laparoscopic converted to open colectomies performed between 2002 and 2007 were compared. We evaluated patient and institutional characteristics to find significant predictors and outcomes of conversion. RESULTS Between 2002 and 2007, the rate of conversion was high, ranging from 35.7% to 38.0%. Multivariate predictors of conversion included obesity, diverticulitis, inflammatory bowel disease, constipation, metastatic disease, nonelective admission, left or transverse colectomy, intraoperative complication, lower socioeconomic status, uninsured status, and rural hospital location. A colectomy for benign colon polyps was less likely to be converted. Conversion to an open colectomy did not increase inpatient mortality. CONCLUSIONS Predictors of conversion from open to laparoscopic colectomy were found from a national database reflecting all US laparoscopic colectomies. Conversion did not increase inpatient mortality.

Management of colonic injuries in the combat theater.

PURPOSE: Combat injuries are more often associated with blast, penetrating, and high-energy mechanisms than civilian trauma, generating controversy about the management of combat colonic injury. Despite implementation of mandatory colostomy in World War II, recent civilian data suggest that primary repair without diversion is safe and feasible. This study describes the modern management of battle-related colonic injuries and seeks to determine whether management strategy affects early complications. METHODS: Records from the combat theater (downrange) and tertiary referral center in Germany were retrospectively reviewed from 2005 to 2006. Patient characteristics, management strategy, treatment course, and early complications were recorded. Comparison groups by management strategy were as follows: primary repair, diversion, and damage control. RESULTS: A total of 133 (97% male) patients sustained colonic injuries from penetrating (71%), blunt (5%), and blast (23%) mechanisms. Average injury severity score was 21 and length of stay in the referral center was 7.1 days. Injury distribution was 21% ascending, 21% descending, 15% transverse, 27% sigmoid, and 25% rectum. Downrange complications for primary repair, initial ostomy, and damage control groups were 14%, 15%, and 30%, respectively. On discharge from the center, 62% of patients had undergone a diversion. The complication rate was 18% overall and was unrelated to management strategy (P = .16). Multivariate analysis did not identify independent predictors of complications. CONCLUSION: Early complications were similar by mechanism, anatomic location, severity of injury, and management strategy. More diversions were performed for rectosigmoid injury. Good surgical judgment allows for low morbidity and supports primary repair in selected cases. Damage control surgery is effective in a multinational theater of operations.

Effect of surgical approach on 30-day mortality and morbidity after elective colectomy: a NSQIP study.

PurposeThe aim of this study was to evaluate the laparoscopic approach and pre- and postoperative conditions as predictors of 30-day mortality and morbidity in elective colectomy.MethodsElective colectomies were identified in the 2005–2008 American College of Surgeons National Surgical Quality Improvement Program database. Multivariate logistic regression was used to model 30-day mortality and morbidity following elective colectomy. Propensity scores were calculated to decrease selection bias.ResultsDuring the period studied, 14,321 patients underwent open colectomy and 10,409 underwent laparoscopic colectomy. Factors that significantly influenced mortality included male gender [odds ratio (OR) 1.4, confidence interval (CI) 1.07–1.9]; age (OR 1.07, CI 1.05–1.08); comorbidities including dyspnea, ascites, congestive heart failure, dialysis, or disseminated cancer; and postoperative conditions including reintubation (OR 2.6, CI 1.6–4.0), renal failure (OR 3.8, CI 2.1–6.9), stroke (OR 6.44, CI 2.4–17.6), and septic shock (OR 13.1, CI 8.76–19.4). While laparoscopy was not independently associated with mortality, it was associated with decreased postoperative morbidity including reintubation (OR 0.74, CI 0.59–0.91), renal failure (OR 0.60, CI 0.4–0.91), septic shock (OR 0.74, CI 0.59–0.92), wound infection (OR 0.58, CI0.44–0.77), and pneumonia (OR 0.71, CI 0.59–0.86).ConclusionsBased on this analysis, laparoscopy was associated with a decrease in 30-day postoperative morbidity for colectomy. However, after adjusting for preoperative comorbidities and postoperative morbidities, laparoscopy did not independently influence mortality after colectomy.

Disparities in the treatment of colon cancer in octogenarians

BACKGROUND Disparities in healthcare for the elderly are understudied, despite the increasing proportion of patients over 80 years of age. Advanced age is a principal risk factor for colorectal adenocarcinoma, but there are few data to guide treatment in the elderly patient population. METHODS We performed a retrospective review of prospectively gathered data on 10,433 patients diagnosed with primary colon tumors between 1998 and 2004. We compared demographics, stage at diagnosis, and initial treatment between patients younger than 80 years and those age 80 years or older. RESULTS Patients who were >or=80 years old made up 30% of the database. Older patients were less likely to have colectomy for advanced or metastatic disease than younger patients. Patients who were >or=80 years of age had fewer lymph nodes removed than younger patients (11 vs 10, P <.01). Older patients were significantly less likely to receive chemotherapy for every stage of colon cancer than younger patients. When older patients did get chemotherapy, it was more likely to be with a single agent. Multivariate analysis revealed that predictors of receiving chemotherapy for patients >or=80 years of age include living in an urban county, younger age, and worse stage at diagnosis. CONCLUSIONS Older patients make up a large portion of the patients treated for colon cancer and are treated less aggressively. While some of the treatment difference may be explained by medical factors, demographic factors affect treatment decisions as well.

Molecular markers for colon diagnosis, prognosis and targeted therapy

Colorectal adenocarcinoma (CRC), the second leading cancer‐related death in the United States, remains a global public health issue. Sporadic CRC is considered the result of sequential mucosal changes from normal colonic mucosa to adenocarcinoma. Efforts in understanding the molecular pathways leading to CRC tumorigenesis may lead to identifying novel, individually tailored therapeutic targets for patients. In this review, we focus on well‐published prognostic and predictive markers in CRC and examine their role in clinical practice. J. Surg. Oncol. 2015 111:96–102.

Addressing the Appropriateness of Elective Colon Resection for Diverticulitis: A Report From the SCOAP CERTAIN Collaborative

Objective:To assess the reported indications for elective colon resection for diverticulitis and concordance with professional guidelines. Background:Despite modern professional guidelines recommending delay in elective colon resection beyond 2 episodes of uncomplicated diverticulitis, the incidence of elective colectomy has increased dramatically in the last 2 decades. Whether surgeons have changed their threshold for recommending a surgical intervention is unknown. In 2010, Washington States Surgical Care and Outcomes Assessment Program initiated a benchmarking and education initiative related to the indications for colon resection. Methods:Prospective cohort study evaluating indications from chronic complications (fistula, stricture, bleeding) or the number of previously treated diverticulitis episodes for patients undergoing elective colectomy at 1 of 49 participating hospitals (2010–2013). Results:Among 2724 patients (58.7 ± 13 years; 46% men), 29.4% had a chronic complication indication (15.6% fistula, 7.4% stricture, 3.0% bleeding, 5.8% other). For the 70.5% with an episode-based indication, 39.4% had 2 or fewer episodes, 56.5% had 3 to 10 episodes, and 4.1% had more than 10 episodes. Thirty-one percent of patients failed to meet indications for either a chronic complication or 3 or more episodes. Over the 4 years, the proportion of patients with an indication of 3 or more episodes increased from 36.6% to 52.7% (P < 0.001) whereas the proportion of those who failed to meet either clinical or episode-based indications decreased from 38.4% to 26.4% (P < 0.001). The annual rate of emergency resections did not increase significantly, varying from 5.6 to 5.9 per year (P = 0.81). Conclusions:Adherence to a guideline based on 3 or more episodes for elective colectomy increased concurrently with a benchmarking and peer-to-peer messaging initiative. Improving adherence to professional guidelines related to appropriate care is critical and can be facilitated by quality improvement collaboratives.

Use and outcomes of emergent laparoscopic resection for acute diverticulitis

BACKGROUND The use and outcomes of laparoscopic sigmoid resection during emergency admissions for diverticulitis are unknown. METHODS The Nationwide Inpatient Sample was queried for colorectal resections performed for diverticulitis during emergent hospital admissions (2003-2007). Univariate and multivariate analyses including patient, hospital, and outcome variables were performed. RESULTS A national estimate of 67,645 resections (4% laparoscopic) was evaluated. The rate of conversion to open operation was 55%. Ostomies were created in 66% of patients, 67% open and 41% laparoscopic. Laparoscopy was not a predictor of mortality (odds ratio [OR] =.70; confidence interval [CI], .32-1.53). Laparoscopy predicted routine discharge (OR = 1.31; CI, 1.06-1.63) and a decreased length of stay (absolute days = -.78; CI, -1.19 to -.37). There was no difference in the cost of hospitalization between the 2 groups (P = .45). CONCLUSIONS In acute diverticulitis, urgent laparoscopic resection decreases the length of stay. However, it is associated with a high conversion rate, no cost savings, and no difference in mortality.

Loss of expression of the cancer stem cell marker aldehyde dehydrogenase 1 correlates with advanced-stage colorectal cancer

BACKGROUND Colorectal cancer (CRC) progression is mediated by cancer stem cells (CSCs). We sought to determine if the expression of the CSC marker aldehyde dehydrogenase 1 (ALDH1) in CRC tumors varies by American Joint Committee on Cancer stage or correlates to clinical outcomes. METHODS Primary and metastatic CRC samples from 96 patients were immunostained with antibodies to ALDH1 and imaged to evaluate marker expression. The percentage of ALDH1(+) cells was correlated to clinical outcomes. RESULTS ALDH1 was overexpressed in CRC tumors compared with nonneoplastic tissue. Marker expression was highest in nonmetastatic tumors. The loss of expression was associated with advanced stage and metastatic disease. No significant correlation was found between ALDH1 expression and metastasis, recurrence, or survival. CONCLUSIONS ALDH1 was highly expressed in nonmetastatic CRC, but expression was lost with advancing stage. ALDH1 could be an effective therapeutic target in early CRC but not late-stage disease. No correlation was found between ALDH1 and disease prognosis.