Mark H. Hanna

Preoperative Leukocytosis in Colorectal Cancer Patients

BACKGROUND Preoperative asymptomatic leukocytosis has been reported as a factor that affects morbidity of surgical patients. We sought to identify the relationship between asymptomatic preoperative leukocytosis and postoperative complications in elective colorectal cancer surgery. STUDY DESIGN The NSQIP database was used to examine the clinical data of patients who had preoperative leukocytosis (white blood cell count more than 11,000/μL) and colorectal cancer resection from 2005 to 2013. Patients with preoperative sepsis, recent steroid use, disseminated cancer, renal failure, pneumonia, and emergently admitted patients were excluded from the study. Multivariate regression analysis was performed to identify outcomes of preoperative leukocytosis. RESULTS We evaluated a total of 59,805 patients with a diagnosis of colorectal cancer who underwent colorectal resection. The rate of preoperative asymptomatic leukocytosis was 5.6%. Asymptomatic leukocytosis was associated with preoperative serum albumin level (adjusted odds ratio [AOR] 0.58, p < 0.01) and blood urea nitrogen/creatinine ratio (AOR 1.01, p < 0.01). Preoperative asymptomatic leukocytosis had significant associations with increased mortality (AOR 1.76, p < 0.01) and morbidity of patients (AOR 1.26, p < 0.01). Postsurgical complications that had the strongest associations with asymptomatic leukocytosis were cardiac arrest (AOR 1.78, p = 0.03) and unplanned intubation (AOR 1.61, p < 0.01). Also, infectious complications were significantly higher in patients with leukocytosis (AOR 1.18, p = 0.01). CONCLUSIONS Preoperative asymptomatic leukocytosis has a prevalence of 5.6% in colorectal cancer resections and carries a significant increased risk of mortality and morbidity. Asymptomatic leukocytosis is associated with preoperative dehydration and malnutrition. Further studies are indicated to validate and explain these findings.

Implications of preoperative hypoalbuminemia in colorectal surgery.

Serum albumin has traditionally been used as a quantitative measure of a patients nutritional status because of its availability and low cost. While malnutrition has a clear definition within both the American and European Societies for Parenteral and Enteral Nutrition clinical guidelines, individual surgeons often determine nutritional status anecdotally. Preoperative albumin level has been shown to be the best predictor of mortality after colorectal cancer surgery. Specifically in colorectal surgical patients, hypoalbuminemia significantly increases the length of hospital stay, rates of surgical site infections, enterocutaneous fistula risk, and deep vein thrombosis formation. The delay of surgical procedures to allow for preoperative correction of albumin levels in hypoalbuminemic patients has been shown to improve the morbidity and mortality in patients with severe nutritional risk. The importance of preoperative albumin levels and the patients chronic inflammatory state on the postoperative morbidity and mortality has led to the development of a variety of surgical scoring systems to predict outcomes efficiently. This review attempts to provide a systematic overview of albumin and its role and implications in colorectal surgery.

Impact of chronic steroid use on outcomes of colorectal surgery

BACKGROUND Steroid use has been recognized as a factor which has various effects on multiple organs. We aim to investigate the association between chronic steroid use and postoperative complications after colorectal surgery. METHODS The National Surgical Quality Improvement Program database was used to examine the clinical data of patients undergoing colorectal resection during 2005 to 2013. Multivariate regression analysis was performed to investigate outcomes of patients with chronic steroid use. RESULTS We sampled a total of 147,121 patients who underwent colorectal resection. Of these, 11,195 (7.6%) had a history of chronic steroid use. Patients who had chronic steroid use had a higher risk of preoperative sepsis (adjusted odds ratio [AOR]: 1.41, P < .01), hypoalbuminemia (AOR: 1.49, P < .01), bleeding disorders (AOR: 1.54, P < .01), and diabetes (AOR: 1.11, P = .01). Chronic steroid use was associated with a significant increase in the mortality and morbidity of patients (AOR: 1.56 and 1.25, respectively, P < .01). CONCLUSIONS Patients with a chronic steroid use have a high risk of preoperative malnutrition, diabetes, bleeding disorders, and sepsis. A history of chronic steroid use was associated with a significant increase in the mortality and morbidity of patients.

Unplanned readmission after appendectomy

BACKGROUND Unplanned readmission of patients who undergo appendectomy is a relatively frequent occurrence. Our aim was to report the most common reasons and the predictors of unplanned readmission after appendectomy. METHODS The National Surgical Quality Improvement Program database was used to examine the clinical data of patients undergoing emergent and/or urgent appendectomy during 2012 to 2013. Multivariate regression analysis was performed to identify the predictors of unplanned readmission. RESULTS We evaluated a total of 46,960 patients who underwent appendectomy. Of these, 18.5% had perforated appendicitis. Overall, 1,755 (3.7%) of patients had an unplanned readmission. The most common reasons for readmission were intra-abdominal infection (27.3%), nonspecific abdominal pain (7.9%), and paralytic ileus (4.6%). Factors such as perforated appendicitis (adjusted odds ratio [AOR], 1.38; P < .01), preoperative sepsis (AOR, 1.30; P < .01), and dirty surgical wound (AOR, 1.91; P < .01) were associated with unplanned readmission. CONCLUSIONS Overall, 3.7% of patients who underwent emergent appendectomy had an unplanned readmission. Intra-abdominal infections and nonspecific abdominal pain are the most common reasons for readmission. Unplanned readmissions are predominantly related to postoperative complications and severity of disease.

Surgical site infection impact of pelvic exenteration procedure

We sought to investigate morbidity and infectious complications following pelvic exenteration (PEx) and compare infectious complications of patients undergoing PEx and conventional rectal resections.

Randomized Clinical Trial of Epidural Compared with Conventional Analgesia after Minimally Invasive Colorectal Surgery

BACKGROUND The effectiveness of thoracic epidural analgesia (EA) vs conventional IV analgesia (IA) after minimally invasive surgery is still unproven. We designed a randomized controlled trial comparing EA with IA after minimally invasive colorectal surgery. STUDY DESIGN A total of 87 patients who underwent minimally invasive colorectal procedures at a single institution between 2011 and 2014 were enrolled. Eight patients were excluded and 38 were randomized to EA and 41 to IA. Pain was assessed with the Visual Analogue Scale and quality of life with the Overall Benefit of Analgesia Score daily until discharge. RESULTS Mean age was 57 ± 14 years, 43% of patients were female, and mean BMI was 28.6 ± 6 kg/m2. The 2 groups were similar in demographic characteristics and distribution of diagnoses and procedures. Epidural analgesia had a higher incidence of hypotensive systolic blood pressure (<90 mmHg) episodes (9 vs 2; p < 0.05) and a trend toward longer Foley catheter duration (3 ± 2 days vs 2 ± 4 days; p > 0.05). Epidural and IA had equivalent mean lengths of stay (4 ± 3 days vs 4 ± 3 days), daily Visual Analogue Scale scores (2.4 ± 2.0 vs 3.0 ± 2.0), and Overall Benefit of Analgesia Scores (3.2 ± 2.0 vs 3.2 ± 2.0), and similar time to start oral diet (2.8 ± 2 days vs 2.2 ± 1 days). Epidural analgesia patients used a higher total dose of narcotics (147.5 ± 192.0 mg vs 98.1 ± 112.0 mg; p > 0.05). Epidural and IV analgesia had equivalent total hospital charges (

Contemporary management of anastomotic leak after colon surgery: assessing the need for reoperation

144,991 ±

Outcomes of colon resection in patients with metastatic colon cancer

67,636 vs

Minimally Invasive Procedures for Rare Rectal Conditions: Complex Rectourethral Fistulas and Retrorectal Tumors

141,339 ±

Robotic Low Anterior and Abdominoperineal Resection: Hybrid Technique

75,579; p > 0.05). CONCLUSIONS This study indicates that EA has no added clinical benefit in patients undergoing minimally invasive colorectal surgery. A trend toward higher total narcotics use and complications with EA was demonstrated.