Justin A. Maykel

Crohn's colitis: The incidence of dysplasia and adenocarcinoma in surgical patients

PurposeData supporting an increased risk of colorectal cancer in patients with Crohn’s colitis are inconsistent. Despite this, clinical recommendations regarding colonoscopic screening and surveillance for patients with Crohn’s colitis are extrapolated from chronic ulcerative colitis protocols. The primary aim of our study was to determine the incidence of dysplasia and carcinoma in pathology specimens of patients undergoing segmental or total colectomy for Crohn’s disease of the large bowel. In addition, we sought to identify risk factors associated with the development of dysplasia and carcinoma.MethodsWe performed a retrospective review of all patients operated on at our institution for Crohn’s colitis between January 1992 and May 2004. Data were retrieved from patient charts, operative notes, and pathology reports. Logistic regression was used to model the probability of having dysplasia or adenocarcinoma.ResultsTwo hundred twenty-two patients (138 females) who underwent surgical resection for the treatment of Crohn’s colitis were included in the study. Mean age at surgery was 41 (range, 15–82) years and the mean duration of disease was 10 (range, 0–53) years. There were five cases of dysplasia (2.3 percent) and six cases of adenocarcinoma (2.7 percent). Three patients with dysplasia and one with adenocarcinoma were diagnosed on preoperative colonoscopy; while the other cases were discovered incidentally on pathologic examination of resected specimens. Factors associated with the presence of dysplasia or adenocarcinoma included older age at diagnosis (38.2 vs. 30.3 years, P = 0.02), longer disease duration (16.0 vs. 10.1 years, P = 0.05), and disease extent (90 percent extensive vs. 59 percent limited, P = 0.05).ConclusionsPatients with severe Crohn’s colitis requiring surgery are at significant risk for developing dysplasia and adenocarcinoma, particularly when diagnosed at an older age, after longer disease duration, and with more extensive colon involvement.

The impact of obesity on outcomes following major surgery for Crohn's disease: an American College of Surgeons National Surgical Quality Improvement Program assessment.

BACKGROUND: Whereas Crohns disease is traditionally thought to represent a wasting disease, little is currently known about the incidence and impact of obesity in this patient cohort. OBJECTIVE: This study aimed to evaluate the perioperative outcomes in patients with Crohns disease who were obese vs those who were not obese undergoing major abdominal surgery. DESIGN: This study is a retrospective review of the American College of Surgeons National Surgical Quality Improvement Program database (2005–2008). Risk-adjusted 30-day outcomes were assessed by the use of regression modeling accounting for patient characteristics, comorbidities, and surgical procedures. PATIENTS: Included were all patients with Crohns disease who were undergoing abdominal operations. MAIN OUTCOME MEASURE: The primary outcomes measured were short-term perioperative outcomes. Obesity was defined as a BMI of 30 or greater. RESULTS: We identified 2319 patients (mean age, 41.6 y; 55% female). Of these patients, 379 (16%) met obesity criteria, 2% were morbidly obese, and 0.3% were super obese. Rates of obesity significantly increased each year over the study period. Twenty-five percent of the surgeries were performed laparoscopically (obese 21% vs nonobese 26%). Six percent were emergent, with no difference in patients with obesity. Operative times were significantly longer among patients with obesity (177 min) compared with patients who were not obese (164 min). After adjusting for differences in comorbidities and steroid use, overall perioperative morbidity was significantly higher in the obese cohort (32% vs 22% nonobese; OR 1.9). In addition, the rates of postoperative complications increased directly with rising BMI. Irrespective of procedure type, the patients who were obese were significantly more likely to experience wound infections (OR 1.7), which increased even further in patients who were morbidly obese (BMI >40; OR 7.1). By specific operation, postoperative morbidity was increased in patients with obesity following colectomies with primary anastomosis for both open and laparoscopic approaches (OR 2.9 and OR 3.8). Cardiac, pulmonary, and renal complications as well as overall mortality did not differ significantly based on BMI. LIMITATIONS: This study was limited by being a retrospective review, and by using data limited to the American College of Surgeons National Surgical Quality Improvement Program database. CONCLUSION: Increasing BMI adversely affects perioperative morbidity in patients with Crohns disease.

Diagnosis and Management of Symptomatic Hemorrhoids

Hemorrhoidal disease is a common problem that is managed by various physicians, ranging from primary care providers to surgeons. This article reviews the pathophysiology, clinical presentation, and updated treatment of hemorrhoids, including nonoperative options, office-based procedures, and surgical interventions from standard excision to stapled hemorrhoidopexy and Doppler-guided ligation. The article also covers complications and provides guidance for special circumstances, such as pregnancy, hemorrhoidal crisis, and inflammatory bowel disease.

Surgeon Volume and Elective Resection for Colon Cancer: An Analysis of Outcomes and Use of Laparoscopy

BACKGROUND Surgeon volume may be an important predictor of quality and cost outcomes. We evaluated the association between surgeon volume and quality and cost of surgical care in patients with colon cancer. STUDY DESIGN We performed a retrospective study of patients who underwent resection for colon cancer, using data from the University HealthSystem Consortium from 2008 to 2011. Outcomes evaluated included use of laparoscopy, ICU admission, postoperative complications, length of stay, and total direct hospital costs by surgeon volume. Surgeon volume was categorized according to high (HVS), medium (MVS), and low (LVS) average annual volumes. RESULTS A total of 17,749 patients were included in this study. The average age of the cohort was 65 years and 51% of patients were female. After adjustment for potential confounders, compared with LVS, HVS and MVS were more likely to use laparoscopy (HVS, odds ratio [OR] 1.27, 95% CI 1.15, 1.39; MVS, OR 1.16 95% CI 1.65, 1.26). Postoperative complications were significantly lower in patients operated on by HVS than LVS (OR 0.77 95% CI 0.76, 0.91). The HVS patients were less likely to require reoperation than those in the LVS group (OR 0.70, 95% CI 0.53, 0.92) Total direct costs were

Early Detection of Colorectal Cancer Recurrence in Patients Undergoing Surgery with Curative Intent: Current Status and Challenges

927 (95% CI -

Clinical and financial impact of hospital readmissions after colorectal resection: predictors, outcomes, and costs.

1,567 to -

Identifying Risk Factors for Renal Failure and Myocardial Infarction Following Colorectal Surgery

287) lower in the HVS group compared with the LVS group. CONCLUSIONS Higher quality, lower cost care was achieved by HVS in patients undergoing surgery for colon cancer. An assessment of differences in processes of care by surgeon volume may help further define the mechanism for this observed association.

Current Approaches and Challenges for Monitoring Treatment Response in Colon and Rectal Cancer

Despite advances in neoadjuvant and adjuvant therapy, attention to proper surgical technique, and improved pathological staging for both the primary and metastatic lesions, almost half of all colorectal cancer patients will develop recurrent disease. More concerning, this includes ~25% of patients with theoretically curable node-negative, non-metastatic Stage I and II disease. Given the annual incidence of colorectal cancer, approximately 150,000 new patients are candidates each year for follow-up surveillance. When combined with the greater population already enrolled in a surveillance protocol, this translates to a tremendous number of patients at risk for recurrence. It is therefore imperative that strategies aim for detection of recurrence as early as possible to allow initiation of treatment that may still result in cure. Yet, controversy exists regarding the optimal surveillance strategy (high-intensity vs. traditional), ideal testing regimen, and overall effectiveness. While benefits may involve earlier detection of recurrence, psychological welfare improvement, and greater overall survival, this must be weighed against the potential disadvantages including more invasive tests, higher rates of reoperation, and increased costs. In this review, we will examine the current options available and challenges surrounding colorectal cancer surveillance and early detection of recurrence.

The impact of age on colorectal cancer incidence, treatment, and outcomes in an equal-access health care system.

BACKGROUND:After passage of the Affordable Care Act, 30 -day hospital readmissions have come under greater scrutiny. Excess readmissions for certain medical conditions and procedures now result in penalizations on all Medicare reimbursements. OBJECTIVE:The purpose of this work was to define the risk factors, outcomes, and costs of 30-day readmissions after colorectal surgery. DESIGN:Adults undergoing colorectal surgery were studied using data from the University HealthSystem Consortium. Univariate and multivariable analyses were used to identify patient-related risk factors for, and 30-day outcomes of, readmission after colorectal surgery. SETTINGS:This study was conducted at an academic hospital and its affiliates. PATIENTS:Adults ≥18 years of age who underwent colorectal surgery for cancer, diverticular disease, IBD, or benign tumors between 2008 and 2011 were included in this study. MAIN OUTCOME MEASURES:Readmission within 30 days of index discharge was the main outcome measured. RESULTS:A total of 70,484 patients survived the index hospitalization after colorectal surgery; 9632 (13.7%) were readmitted within 30 days of discharge. The strongest independent predictors of readmission were length of stay ≥4 days (OR 1.44; 95% CI 1.32–1.57), stoma (OR 1.54; 95% CI 1.46–1.51), and discharge to skilled nursing (OR 1.62; 95% CI 1.49–1.76) or rehabilitation facility (OR 2.93; 95% CI 2.53–3.40). Of those readmitted, half of the readmissions occurred within 7 days, 13% required the intensive care unit, 6% had a reoperation, and 2% died during the readmission stay. The median combined total direct hospital cost was more than 2 times higher (

Working with Existing Databases

26,917 vs