Marc Zerey

The burden of Clostridium difficile in surgical patients in the United States.

BACKGROUND Clostridium difficile colitis is the predominant hospital-acquired gastrointestinal infection in the United States and has emerged as an important nosocomial cause of morbidity and death. Although several institutional studies have examined the effects of C. difficile on hospitalized patients, its nationwide impact on surgical patients has yet to be defined. METHODS To provide a national estimate of the burden of C. difficile, we performed a five-year retrospective analysis of the Agency for Healthcare Research and Qualitys National Inpatient Sample Database, which represents a stratified 20% sample of hospitals in the United States, from 1999 to 2003. All surgical inpatient discharge data from 997 hospitals in 37 states were analyzed to determine the association of C. difficile infections with patient demographics, hospital characteristics, surgical procedure, length of stay (LOS), total charges, and in-hospital mortality rate. Univariate analysis was performed to identify any association between the presence of C. difficile infection and the outcome variables using chi-square contingency table analysis or the Student t-test following the exclusion of patients with other medical complications. Multivariate regression analysis was used to determine whether the presence of C. difficile infection was an independent predictor of increased LOS, total charges, and in-hospital mortality rate when controlling for surgery type, age, sex, payor, and hospital characteristics. RESULTS Clostridium difficile infection was reported as a discharge diagnosis for 8,113 (0.52%) of all 1,553,597 inpatients who had undergone a general surgical procedure. The incidence increased significantly in 2002 (34% higher than in 2001; p < 0.0001). The following patient and hospital characteristics were associated with the highest incidence of C. difficile infection (all p < 0.0001): Age > 64 years (0.95%); Medicare beneficiary status (0.94%); north-eastern hospital location (0.73%); and large (0.55%), urban (0.56%), or teaching hospital (0.61%). Patients undergoing an emergency operation were at higher risk than those having operations performed electively (0.8% vs. 0.3%; p < 0.0001). Colectomy, small-bowel resection, and gastric resection were associated with the highest risk of C. difficile infection (incidence after colectomy 1.11%; odds ratio [OR] 2.77, 95% confidence interval [CI] 2.65, 2.89, p < 0.0001; small-bowel resection 1.17%, OR 2.40, 95% CI 2.26, 2.54, p < 0.0001; gastric resection 1.02%, OR 2.26, 95% CI 2.03, 2.52, p < 0.0001). Patients undergoing cholecystectomy and appendectomy had the lowest risk of C. difficile infection (cholecystectomy 0.41%, OR 0.37, 95% CI 0.35, 0.39, p < 0.0001; appendectomy 0.20%, OR 0.45, 95% CI 0.42, 0.49, p < 0.0001). Multivariable analysis demonstrated that C. difficile was an independent predictor of LOS, which increased by 16.0 days (95% CI 15.6, 16.4 days; p < 0.0001) in the presence of infection. Total charges increased by

SAGES evidence-based guidelines for the laparoscopic resection of curable colon and rectal cancer.

77,483 (95% CI

Colonoscopy in the very elderly: a review of 157 cases

75,174,

Minimally Invasive Management of Colon Cancer

79,793; p < 0.0001), and there was a 3.4-fold increase in the mortality rate (95% CI 3.02, 3.77; p < 0.0001) compared with patients who did not acquire C. difficile. CONCLUSIONS Epidemiologic data suggest that the incidence of C. difficile infection is increasing in U.S. surgical patients and that the infection is most prevalent after emergency operations and among patients having intestinal tract resections. Infection with C. difficile is an independent predictor of increased LOS, total charges, and mortality rate after surgery and represents a considerable burden to both patients and hospitals. Preventing C. difficile infection offers a potentially significant improvement in patient outcomes, as well as a reduction in hospital costs and resource expenditures.

Outcomes of adrenal cortical carcinoma in the United States

Both the quality of the evidence and the strength of the recommendation for each of the recommendations below were assessed according to the GRADE system [6] (see Table 1). There is a four-tier system for judging quality of evidence [very low (⊕), low (⊕⊕), moderate (⊕⊕⊕), or high (⊕⊕⊕⊕)] and a two-tier system for determining the strength of a recommendation (weak or strong). Additional definitions are provided by SAGES in “The Definitions Document: A Reference for Use of SAGES Guidelines.” Table 1 GRADE system for rating the quality of evidence for SAGES guidelines Quality of evidence Definition Symbol used High quality Further research is very unlikely to alter confidence in the estimate of impact Open image in new window Moderate quality Further research is likely to alter confidence in the estimate of impact and may change the estimate Open image in new window Low quality Further research is very likely to alter confidence in the estimate of impact and is likely to change the estimate Open image in new window Very low quality Any estimate of impact is uncertain Open image in new window GRADE recommendations based on the quality of evidence for SAGES guidelines Strong It is very certain that benefit exceeds risk for the option considered Weak Risk and benefit well balanced, patients and providers faced with differing clinical situations likely would make different choices, or benefits available but not certain regarding the option considered Adapted from Guyatt et al. [6]

Management of Infections of Polytetrafluoroethylene-Based Mesh

BackgroundColonoscopy is currently the best diagnostic modality for evaluating colonic diseases but studies of its use in the very elderly are limited.MethodsA single-institution review of all patients aged 85 years or older who underwent colonoscopy from June 2003 to June 2005 was performed. Parameters evaluated included indications for colonoscopy, findings, ability to perform a complete colonoscopy, and immediate and delayed (≤21 days) complications.ResultsA total of 157 patients aged 85 years or older (median = 87, range = 85–99) underwent colonoscopy during the two-year period. The cecal intubation rate was 90%. Number of cancers detected/indications for colonoscopy include gross or occult bleeding per rectum, 3/51 (5.9%); abnormal physical exam, 1/2 (50%); abnormal abdominal computed tomography, 3/5 (60%); anemia, 1/25 (4.0%); screening, 0/14; previous history of colonic malignancy, 0/10; previous history of polyps, 0/21; change in bowel habits, 0/5; family history of colonic malignancy, 0/6; abdominal pain, 0/4; diarrhea, 0/6; fecal impaction, 0/2; unknown, 0/6. Immediate complications included hemorrhage at a polypectomy site in one patient that was controlled endoscopically, one episode of bradycardia, and one incident of atrial fibrillation. There were no delayed complications resulting from colonoscopy.ConclusionsOur data suggest that colonoscopy can be safely and successfully performed in the very elderly. In patients with symptoms or suggestive radiographic findings, cancer was detected in 4.0%–60% of cases. No cases of cancer were discovered in those patients who were asymptomatic.

Laparoscopic management of adhesive small bowel obstruction. Discussion

One of the most controversial issues in minimally invasive surgery has been the implementation of laparoscopic techniques for the curative resection of colorectal malignancies. Initial concerns included the potential violation of oncologic principles, the effects of carbon dioxide, and the phenomenon of port site tumor recurrence. Basic science research and large randomized controlled trials are now demonstrating that these fears were unjustified. Long-term outcomes of laparoscopic colon resection compared with open colon resection for malignancy are comparable, and there may even be a survival benefit for a subset of patients who undergo laparoscopic resection.