Joseph C. Carmichael

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.

Robotic surgery: colon and rectum.

Although robotic technology aims to obviate some of the limitations of conventional laparoscopic surgery, the role of robotics in colorectal surgery is still largely undefined and different with respect to its application in abdominal versus pelvic surgery. This review aims to elucidate current developments in colorectal robotic surgery.In colon surgery, robotic techniques are associated with longer operative times and higher costs compared with laparoscopic surgery. However, robotics provides a stable camera platform and articulated instruments that are not subject to human tremors. Because of these advantages, robotic systems can play a role in complex procedures such as the dissection of lymph nodes around major vessels. In addition robot-assisted hand-sewn intracorporeal anastomoses can be easily performed by the surgeon, without a substantial need for a competent assistant. At present, although the short-term outcomes and oncological adequacy of robotic colon resection have been observed to be acceptable, the long-term outcomes of robotic colon resection remain unknown.In rectal surgery, robotic-assisted surgery for rectal cancer can be carried out safely and in accordance with current oncological principles. However, to date, the impact of robotic rectal surgery on the long-term oncological outcomes of minimally invasive total mesorectal excision remains undetermined. Robotic total mesorectal excision may allow for better preservation of urinary and sexual functions, and robotic surgery may attenuate the learning curve for laparoscopic rectal resection. However, a major drawback to robotic rectal surgery is the high cost involved.Large-scale prospective randomized clinical trials such as the international randomized trial ROLARR are required to establish the benefits of robotic rectal surgery.

Clostridium Difficile Colitis in the United States: A Decade of Trends, Outcomes, Risk Factors for Colectomy, and Mortality after Colectomy

BACKGROUND Clostridium difficile colitis (CDC) is a major health concern in the United States (US), with earlier reports demonstrating a rising incidence. Studies analyzing predictors for total colectomy and mortality after colectomy are limited by small numbers. STUDY DESIGN The Nationwide Inpatient Sample (NIS) 2001 to 2010 was retrospectively reviewed for CDC trends, the associated colectomy and mortality rates. Patient and hospital variables were used in the LASSO algorithm for logistic regression with 10-fold cross validation to build a predictive model for colectomy requirement and mortality after colectomy. The association of colectomy day with mortality was also examined on multivariable logistic regression analysis. RESULTS An estimated 2,773,521 discharges with a diagnosis of CDC were identified in the US over a decade. Colectomy was required in 19,374 cases (0.7%), with an associated mortality of 30.7%. Compared with the 2001 to 2005 period, the 2006 to 2010 period witnessed a 47% increase in the rate of CDC and a 32% increase in the rate of colectomies. The LASSO algorithm identified the following predictors for colectomy: coagulopathy (odds ratio [OR] 2.71), weight loss (OR 2.25), teaching hospitals (OR 1.37), fluid or electrolyte disorders (OR 1.31), and large hospitals (OR 1.18). The predictors of mortality after colectomy were: coagulopathy (OR 2.38), age greater than 60 years (OR 1.97), acute renal failure (OR 1.67), respiratory failure (OR 1.61), sepsis (OR 1.40), peripheral vascular disease (OR 1.39), and congestive heart failure (OR 1.25). Surgery more than 3 days after admission was associated with higher mortality rates (OR 1.09; 95% CI 1.05 to 1.14; p < 0.05). CONCLUSIONS Clostridium difficile colitis is increasing in the US, with an associated increase in total colectomies. Mortality rates after colectomy remain elevated. Progression to colectomy and mortality thereafter are associated with several patient and hospital factors. Knowledge of these risk factors may help in risk-stratification and counseling.

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

Surgical outcomes of hyperthermic intraperitoneal chemotherapy: analysis of the american college of surgeons national surgical quality improvement program.

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.

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

IMPORTANCE Hyperthermic intraperitoneal chemotherapy (HIPEC) and cytoreductive surgery have been shown to benefit selected patients with peritoneal carcinomatosis. However, these procedures are associated with high morbidity and mortality. Available data investigating the outcomes of HIPEC are mostly limited to single-center studies. To date, there have been few large-scale studies investigating the postoperative outcomes of HIPEC. OBJECTIVE To determine the associated 30-day morbidity and mortality of cytoreductive surgery-HIPEC in the treatment of metastatic and primary peritoneal cancer in American College of Surgeons National Surgical Quality Improvement Program centers. DESIGN, SETTING, AND PARTICIPANTS A retrospective review of HIPEC cases performed for primary and metastatic peritoneal cancer diagnoses was conducted. The cytoreductive surgical procedures were sampled, and disease processes were identified. Patient demographics, intraoperative occurrences, and postoperative complications were reviewed from the American College of Surgeons National Surgical Quality Improvement Program from 2005-2011. MAIN OUTCOMES AND MEASURES Thirty-day mortality and morbidity. RESULTS Of the cancers identified among the 694 sampled cases, 14% of patients had appendiceal cancer, 11% had primary peritoneal cancer, and 8% had colorectal cancer. The American Society of Anesthesiologists classification was 3 for 70% of patients. The average operative time was 7.6 hours, with 15% of patients requiring intraoperative transfusions. Postoperative bleeding (17%), septic shock (16%), pulmonary complications (15%), and organ-space infections (9%) were the most prevalent postoperative complications. The average length of stay was 13 days, with a 30-day readmission rate of 11%. The rate of reoperation was 10%, with an overall mortality rate of 2%. CONCLUSIONS AND RELEVANCE American College of Surgeons National Surgical Quality Improvement Program hospitals performing HIPEC have acceptable rates of morbidity and mortality.

Ureteral injuries in colorectal surgery: An analysis of trends, outcomes, and risk factors over a 10-year period in the United States

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.

Management of Ischemic Colitis

BACKGROUND: Iatrogenic ureteral injuries during colorectal surgical procedures are rare. Little is known about their incidence, associated outcomes, and predisposing factors. OBJECTIVE: The purpose of this study was to examine the trends of iatrogenic ureteral injuries in the United States over a decade, as well as their outcomes and risk factors. DESIGN: This was a retrospective study. SETTINGS: The nationwide inpatient sample from 2001 to 2010 was analyzed. PATIENTS: Included were patients with colorectal cancer, benign polyps, diverticular disease, or inflammatory bowel disease undergoing colorectal surgery. MAIN OUTCOME MEASURES: Trends of iatrogenic ureteral injuries occurring in colon and rectal surgical procedures were examined over a 10-year period. Mortality, morbidity, length of stay and total charge associated with ureteral injuries were analyzed on multivariate analysis. Finally, a predictive model for ureteral injuries was built using patient, hospital, and operative variables. RESULTS: An estimated 2,165,848 colorectal surgical procedures were performed in the United States over the study period, and 6027 ureteral injuries were identified (0.28%). The rate of ureteral injuries was higher in the second half of the decade (2006-2010) compared with the first half (2001-2005; 3.1/1000 vs 2.5/1000; p < 0.001). Ureteral injuries were independently associated with higher mortality (OR, 1.45; p < 0.05), morbidity (OR, 1.66; p < 0.001), longer length of stay (mean difference, 3.65 days; p < 0.001), and higher hospital charges by

Variations in Laparoscopic Colectomy Utilization in the United States

31,497 (p< 0.001). Risk factors for ureteral injuries included rectal cancer (OR, 1.85), adhesions (OR, 1.83), metastatic cancer (OR, 1.76), weight loss/malnutrition (OR, 1.08), and teaching hospitals (OR, 1.05). Protective factors included the use of laparoscopy (OR, 0.91), transverse colectomy (OR, 0.90), and right colectomy (OR, 0.43). LIMITATIONS: This was a retrospective study from an administrative database. CONCLUSIONS: Iatrogenic ureteral injuries are rare complications in colorectal surgery; however, their incidence appears to be rising. Ureteral injuries are associated with higher mortality, morbidity, hospital charge, and length of stay, and their incidence can be predicted by several factors.