Ravi P. Kiran

Do preoperative factors predict subsequent diagnosis of Crohn’s disease after ileal pouch‐anal anastomosis for ulcerative or indeterminate colitis?

Aim  The aim of this study was to determine preoperative clinical factors associated with subsequent diagnosis revision to Crohn’s disease (CD) following total proctocolectomy with ileal pouch‐anal anastomosis (IPAA) for ulcerative colitis (UC) or indeterminate colitis (IC) patients.

Outcomes of Pregnancies for Women Undergoing Endoscopy While They Were Pregnant: A Nationwide Cohort Study

BACKGROUND & AIMS Endoscopy is an integral part of the investigation and management of gastrointestinal disease. We aimed to examine outcomes of pregnancies for women who underwent endoscopy during their pregnancy. METHODS We performed a nationwide population-based cohort study, linking data from the Swedish Medical Birth Registry (for births from 1992 through 2011) with those from the Swedish Patient Registry. We identified 3052 pregnancies exposed to endoscopy (2025 upper endoscopies, 1109 lower endoscopies, and 58 endoscopic retrograde cholangiopancreatographies). Using Poisson regression, we calculated adjusted relative risks (ARRs) for adverse outcomes of pregnancy according to endoscopy status using 1,589,173 unexposed pregnancies as reference. To consider the effects of disease activity, we examined pregnancy outcomes (preterm birth, stillbirth, small for gestational age, or congenital malformations) in women who underwent endoscopy just before or after pregnancy. Secondary outcome measures included induction of labor, low birth weight (<2500 g), cesarean section, Apgar score <7 at 5 minutes, and neonatal death within 28 days. To consider intrafamilial factors, we compared pregnancies within the same mother. RESULTS Exposure to any endoscopy during pregnancy was associated with an increased risk of preterm birth (ARR, 1.54; 95% confidence interval [CI], 1.36-1.75) or small for gestational age (ARR, 1.30; 95% CI, 1.07-1.57) but not of congenital malformation (ARR, 1.00; 95% CI, 0.83-1.20) or stillbirth (ARR, 1.45; 95% CI, 0.87-2.40). None of the 15 stillbirths to women with endoscopy occurred <2 weeks after endoscopy. ARRs were independent of trimester. Compared to women with endoscopy <1 year before or after pregnancy, endoscopy during pregnancy was associated with preterm birth (ARR, 1.16) but not with small for gestational age (ARR, 1.19), stillbirth (ARR, 1.11), or congenital malformation (ARR, 0.90). Restricting the study population to women having an endoscopy during pregnancy or before/after, and only analyzing data from women without a diagnosis of inflammatory bowel disease, celiac disease, or liver disease, endoscopy during pregnancy was not linked to preterm birth (ARR, 1.03; 95% CI, 0.84-1.27). Comparing births within the same mother, for which only 1 birth had been exposed to endoscopy, we found no association between endoscopy and gestational age or birth weight. CONCLUSIONS In a nationwide population-based cohort study, we found endoscopy during pregnancy to be associated with increased risk of preterm birth or small for gestational age, but not of congenital malformation or stillbirth. However, these risks are small and likely due to intrafamilial factors or disease activity.

Survival outcome of operated and non-operated elderly patients with rectal cancer: A Surveillance, Epidemiology, and End Results analysis

BACKGROUND With an ageing population, surgery is increasingly offered to elderly patients with rectal cancer, although outcomes for the oldest patients remain poorly defined. This study aimed to determine whether operative intervention improves outcome in elderly patients. METHOD Patients aged 18+ years diagnosed with rectal adenocarcinoma between 1998 and 2009 were identified from the Surveillance, Epidemiology, and End Results database. The primary endpoint was adjusted hazard ratios (HR) for 5-year cancer specific survival (CSS); the secondary endpoint was 5-year overall survival (OS). RESULTS With increasing age, patients were less likely to undergo surgery, receive a complete stage or receive neoadjuvant radiotherapy. CSS and OS increasingly diverged with age in patients undergoing surgery. Those aged 80+ had reduced CSS compared to those aged 70-79 years (stages I-III, respective adjusted HR 2.14, 1.58, 1.48, all p < 0.001). However, stage II patients aged 80+ treated with resection and neoadjuvant therapy had similar survival to those aged 70-79 years (adjusted HR 1.26, p = 0.149). For only patients aged 80+ years, those treated non-operatively had lower survival than those undergoing surgery, who in turn had the best survival when treated with neoadjuvant radiotherapy (adjusted HR 0.74, p = 0.001). CONCLUSION Contrary to common expectation, in patients aged over 80 with rectal cancer, surgery with or without other modalities was associated with better survival than non-operative treatment. Despite selection bias in this observational study, these findings support consideration of maximal therapy regardless of age in selected patients deemed to be fit, since this leads to outcomes equivalent to younger patients.

Comparison of outcomes for patients with primary sclerosing cholangitis associated with ulcerative colitis and Crohn’s disease

Background: The comparative outcomes of ulcerative colitis (UC) and Crohn’s disease (CD) in patients with primary sclerosing cholangitis (PSC) are unclear; the aim of our study was to make an objective comparison. Methods: A total of 273 patients with PSC and inflammatory bowel disease (223 with UC and 50 with CD) were included. Clinical and demographic variables were obtained. Results: The PSC risk score was similar for both groups. The median follow-up period in patients with PSC-UC was 12 years (range 0–38) and that for PSC-CD was 14 years (range 1–36). The median number of disease flares per year was higher in PSC-UC patients than in the PSC-CD group [1vs.0 (ranges 0–20 and 0–9, respectively); P < 0.001]. More patients with UC developed colon neoplasia than CD (35.9% vs.18%; P = 0.009). On proportional hazards analysis for the risk of colectomy, UC patients had a 12% higher risk for colectomy [hazard ratio (HR) = 0.88; 95% confidence interval (CI) 0.51–1.51; P = 0.64]. Liver transplantation for PSC was associated with decreased risk (HR = 0.57; 95% CI 0.37–0.89; P = 0.013), while colon neoplasia increased the risk (HR = 3.83; 95% CI 2.63–5.58; P < 0.001) for colectomy. On proportional hazards analysis for the risk of colon neoplasia, UC patients had 56% higher risk of developing colon neoplasia than CD (HR = 0.44; 95% CI 0.16–1.25; P = 0.12). Conclusions: PSC patients with CD appear to be associated with a lower risk of colon neoplasia and colectomy than PSC patients with UC.

Failure of efforts to contain costs of care after colorectal procedures: Nationwide trends in length of stay, costs and post-acute care utilization

BACKGROUND This study aims to report trends in healthcare resource utilization and costs after colorectal surgery in the US. METHODS From all-payer inpatient data, patients who were discharged after elective colorectal procedures (2002-2011) were identified. Trends in postoperative hospital stay, costs and post-acute care were evaluated. RESULTS Of 251,583 included patients, median length of stay was 6 days. Trends over time suggested a progressive reduction in hospital stay after surgery until 2008 after which there was an increase (6.6 days in 2002, 5.9 days in 2008 and 6.1 days in 2010). Costs (peak:2011,

Factors influencing discharge disposition after colectomy

51,731) and post-acute care (peak:2011, 19.4%) continued to increase throughout. CONCLUSIONS While length of stay over the last decade reduced, a further reduction may not be feasible. Meanwhile, inpatient costs as well as the use of post-acute care programs have continued to rise. Healthcare planning needs to focus on patients who cannot be discharged early, and more comprehensively evaluate the interplay between length of stay, readmissions, inpatient and post-acute care utilization if we are to contain overall healthcare costs.

Alvimopan, Regardless of Ileus Risk, Significantly Impacts Ileus, Length of Stay, and Readmission After Intestinal Surgery

BackgroundFactors associated with discharge destination after colectomy despite accounting for surgical morbidity have not previously been well characterized. This study aims to evaluate perioperative predictors for extended care after complicated and uncomplicated colectomy.MethodsPatients admitted from home for elective colectomy were identified from the American College of Surgeons, National Surgical Quality Improvement Program, 2012–2013 general and colectomy-targeted datasets. Patients who were discharged home (DH) were compared to those discharged to facility (DF) for patient, disease, treatment, and pre-discharge postoperative adverse events. Patients without any 30-day postoperative complication were similarly compared.ResultsOf 19,527 patients undergoing elective colectomy, 18,128 (92.8%) were discharged home and 1399 (7.2%) patients to other facilities. When there was no postoperative complication, these rates were 96.3 and 3.7%, respectively. On multivariable analysis, factors associated with DF included female gender, functional dependence, weight loss, ASA class ≥ 3, open and stoma surgery, and development of postoperative complications. For patients without postoperative complications, increasing age, functional dependence, and ASA score ≥ 3 were associated with DF. Preoperative bowel preparation, albumin, a minimally invasive surgical approach, and length of stay < 5 days were significantly associated with reduced DF.ConclusionThe majority of perioperative factors associated with extended care after colectomy are patient driven. The adoption of oral antibiotics as bowel preparation, minimally invasive surgery, and accelerated recovery protocols may reduce post-acute care placement after elective colectomy.

The Failed J Pouch

BackgroundPrevious analyses evaluating alvimopan included patients at varying risk for ileus after intestinal resection, which may have precluded its widespread adoption. We assess the early and delayed effects of alvimopan in patients stratified by risk for ileus after intestinal and colon resection.MethodsFrom the Premier Perspective database, patients with elective small and large bowel resections from 2012 to 2014 were identified. Multivariable analysis identified 14 perioperative risk factors for postoperative ileus. Within low- (0–4 factors), intermediate- (5 factors), and high-risk (6–12 factors) ileus categories, alvimopan and no-alvimopan patients were propensity-score matched for demographics, morbidities, diagnosis, surgery and approach, postoperative complications, surgeon specialty, and hospital features. In-hospital postoperative ileus, length of stay, discharge destination, and ileus-related readmission were compared.ResultsOf 52,948 patients, 15,719 (29.7%) received alvimopan. Risk for ileus in low- (18,784), intermediate- (14,370), and high-risk (19,794) categories was 8.9, 13, and 22% (p ≤ .0001) respectively. After matching, alvimopan was associated with significantly reduced in-hospital postoperative ileus in all (low, 6%; intermediate, 9.4%; and high risk, 16.2%) categories. Hospital stay and 30-, 60-, and 90-day postdischarge ileus were also significantly lower with alvimopan. For low-risk patients, alvimopan increased discharge to home, while 90-day emergency readmission was reduced.ConclusionsAlvimopan, regardless of ileus risk, improves ileus, hospital stay, and ileus-related readmission after intestinal resection and these effects are sustained over the long term. Since fewer than a third of patients currently receive alvimopan, its routine adoption with small and large intestinal resection will significantly impact patients and health systems.

Reducing the Risk of Infection in the Elective and Emergent Colectomy Patient

The development and refinement of proctectomy with ileal pouch-anal anastomosis (IPAA) since its introduction in the 1970s has made it the optimal procedure of choice in patients with chronic ulcerative colitis and patients with familial adenomatous polyposis. However, it is a procedure that can be associated with significant morbidity. Pouch failure due to infection, mechanical, or functional disability represents a challenge to both surgeon and patient. Practicing surgeons who deal with revisional pouch surgery face a variety of intraoperative, postoperative, and reoperative challenges. Success requires a strategy that includes critical planning, preparation, specialized surgical techniques, and experience to achieve long-term success, minimize the adverse consequences of IPAA-related complications, and ensure solutions and hope to patients.

Propensity Score-Matched Analysis of Clinical and Financial Outcomes After Robotic and Laparoscopic Colorectal Resection

Abstract Colorectal surgery is associated with a greater risk for infections than most other surgical specialities and is considered an outlier for surgical site infections (SSI). Reducing the incidence of infections, especially SSIs, remains a major challenge in colorectal surgery. Prevention of SSIs can be achieved by several methods, including optimized preoperative patient preparation, perioperative bowel preparation, strict adherence to antibiotic prophylaxis guidelines, increased intraoperative oxygen delivery, wound irrigation, maintenance of intraoperative normothermia, and postoperative glycemic control. Prevention of urinary tract infections can be achieved by early urinary catheter removal and sterile intraoperative catheter placement. Respiratory infections can be prevented by smoking cessation, early postoperative mobilization, pulmonary care with use of incentive spirometry, coughing and deep breathing, oral care, and head-of-bed elevation.