Peter E. Miller

A practical mortality risk score for emergent colectomy.

BACKGROUND: Critically ill patients requiring emergent colectomy have significant mortality risk. OBJECTIVE: A national administrative database was used to compose a simple scoring scheme for predicting in-hospital mortality risk. DESIGN: The 2007 to 2009 Nationwide Inpatient Sample was queried to identify patients requiring nonelective colectomy. Multivariable binary logistic regression analysis was used to identify predictors that increased mortality. Each predictor was given a point value, based on the corresponding logit, the sum of which constituted a risk score. The scoring system was tested by using k-partitions cross-validation. SETTINGS: This study is based on database analysis. PATIENTS: A total of 338,348 cases were identified. Mean age was 64, and 53% of the patients were women. MAIN OUTCOME MEASURES: The primary outcomes measured were mortality and risk score development. RESULTS: The overall mortality risk was 9%. Regression analysis identified the following risk factors and assigned points: acute renal failure (6), hemodialysis (6), age >65 (4), peripheral vascular disease (4), myocardial infarction (4), chronic obstructive pulmonary disease (2), cardiac arrhythmia (1), and congestive heart failure (1). The maximum score observed was 26 (of a possible 28), which corresponded to 100% mortality. Receiver operator characteristic analysis showed an area under the curve of 0.81. LIMITATIONS: This study was limited because of its retrospective nature, and because it used database data with variability in coding among participating institutions. CONCLUSIONS: With the use of a simple 8-variable scoring system, inpatient mortality estimates can be made for patients requiring emergent colectomy. When used judiciously, it can be used as a tool when counseling patients and family both before and after surgery.

Stenting for obstructing colon cancer: fewer complications and colostomies.

Background and Objectives: Colonic stenting has been used in the setting of malignant obstruction to avoid an emergent colectomy. We sought to determine whether preoperative placement of a colonic stent decreases morbidity and the rate of colostomy formation. Methods: Cases of obstructing sigmoid, rectosigmoid, and rectal cancer from January 1, 2010, to December 31, 2011, were identified in the Nationwide Inpatient Sample (NIS) database. All patients were treated at hospitals in the United States, and the database generated national estimates. Postoperative complications, mortality, and the rate of colostomy formation were analyzed. Results: Of the estimated 7891 patients who presented with obstructing sigmoid, rectosigmoid, or rectal cancer necessitating intervention, 12.1% (n = 956) underwent placement of a colonic stent, and the remainder underwent surgery without stent placement. Of the patients who underwent stenting, 19.9% went on to have colon resection or stoma creation during the same admission. Patients who underwent preoperative colonic stent placement had a lower rate of total postoperative complications (10.5% vs 21.7%; P < .01). There was no significant difference in mortality (4.7% vs 4.2%; P = .69). The rate of colostomy formation was more than 2-fold higher in patients who did not undergo preoperative stenting (42.5% vs 19.5%; P < .01). Preoperative stenting was associated with increased use of laparoscopy (32.6% vs 9.7%; P < .01). Conclusions: Our study characterizes the national incidence of preoperative placement of a colonic stent in the setting of malignant obstruction. Preoperative stent placement is associated with lower postoperative complications and a lower rate of colostomy formation. The results support the hypothesis that stenting as a bridge to surgery may benefit patients by converting an emergent surgery into an elective one.

Current State of Colorectal Surgery Training: A Survey of Program Directors, Current and Recently Matched Colorectal Residents, and Recent Colorectal Graduates.

BACKGROUND: Colorectal residency has become one of the more competitive postgraduate training opportunities; however, little information is available to guide potential applicants in gauging their competitiveness. OBJECTIVE: The aim of this study was to identify the current trends colorectal residency training and to identify what factors are considered most important in ranking a candidate highly. We hypothesized that there was a difference in what program directors, current and recently matched colorectal residents, and recent graduates consider most important in making a candidate competitive for a colorectal residency position. DESIGN: Three 10-question anonymous surveys were sent to 59 program directors, 87 current and recently matched colorectal residents, and 119 recent graduates in March 2015. SETTINGS: The study was conducted as an anonymous internet survey. MAIN OUTCOME MEASURES: Current trends in applying for a colorectal residency, competitiveness of recent colorectal residents, factors considered most important in ranking a candidate highly, and what future colorectal surgeons can expect after finishing their training were measured. RESULTS: The study had an overall response rate of 43%, with 28 (47%) of 59 program directors, 46 (53%) of 87 current and recently matched colorectal residents, and 39 (33%) of 119 recent graduates responding. The majority of program directors felt that a candidate’s performance during the interview process was the most important factor in making a candidate competitive, followed by contact from a colleague, letters of recommendation, American Board of Surgery In-Training Exam scores, and number of publications/presentations. The majority of current and recently matched colorectal residents felt that a recommendation/telephone call from a colleague was the most important factor, whereas the majority of recent graduates favored letters of recommendation as the most important factor in ranking a candidate highly. LIMITATIONS: Limitations to the study include its small sample size, selection bias, responder bias, and misclassification bias. CONCLUSIONS: There are differences in what program directors and current/recent residents consider most important in making an applicant competitive for colorectal residency.