Ravi P. Kiran

Combined preoperative mechanical bowel preparation with oral antibiotics significantly reduces surgical site infection, anastomotic leak, and ileus after colorectal surgery.

OBJECTIVESnTo clarify whether bowel preparation use or its individual components [mechanical bowel preparation (MBP)/oral antibiotics] impact specific outcomes after colorectal surgery.nnnMETHODSnNational Surgical Quality Improvement Program-targeted colectomy data initiated in 2012 capture information on the use/type of bowel preparation and colorectal-specific complications. For patients undergoing elective colorectal resection, the impact of preoperative MBP and antibiotics (MBP+/ABX+), MBP alone (MBP+/ABX-), and no bowel preparation (no-prep) on outcomes, particularly anastomotic leak, surgical site infection (SSI), and ileus, were evaluated using unadjusted/adjusted logistic regression analysis.nnnRESULTSnOf 8442 patients, 2296 (27.2%) had no-prep, 3822 (45.3%) MBP+/ABX-, and 2324 (27.5%) MBP+/ABX+. Baseline characteristics were similar; however, there were marginally more patients with prior sepsis, ascites, steroid use, bleeding disorders, and disseminated cancer in no-prep. MBP with or without antibiotics was associated with reduced ileus [MBP+/ABX+: odds ratio (OR) = 0.57, 95% confidence interval (CI): 0.48-0.68; MBP+/ABX-: OR = 0.78, 95% CI: 0.68-0.91] and SSI [MBP+/ABX+: OR = 0.39, 95% CI: 0.32-0.48; MBP+/ABX-: OR = 0.80, 95% CI: 0.69-0.93] versus no-prep. MBP+/ABX+ was also associated with lower anastomotic leak rate than no-prep [OR = 0.45 (95% CI: 0.32-0.64)]. On multivariable analysis, MBP with antibiotics, but not without, was independently associated with reduced anastomotic leak (OR = 0.57, 95% CI: 0.35-0.94), SSI (OR = 0.40, 95% CI: 0.31-0.53), and postoperative ileus (OR = 0.71, 95% CI: 0.56-0.90).nnnCONCLUSIONSnThese data clarify the near 50-year debate whether bowel preparation improves outcomes after colorectal resection. MBP with oral antibiotics reduces by nearly half, SSI, anastomotic leak, and ileus, the most common and troublesome complications after colorectal surgery.

Risk of anastomotic leak after laparoscopic versus open colectomy.

BackgroundAnastomotic leak following colorectal surgery is associated with significant morbidity and mortality. With the widespread adoption of laparoscopy, data from initial clinical trials evaluating the efficacy of laparoscopic when compared to open surgery may not currently be generalizable. We assess the risk of anastomotic leak after laparoscopic versus open colorectal resection using a nationwide database with standardized definitions.MethodsThe 2012–2013 ACS-NSQIP targeted colectomy data were queriedxa0for all elective colorectal resections. Characteristics were compared for those patients undergoing laparoscopic versus open operations. Univariable and multivariable analyses, followed by a propensity score-matched analysis, were performed to assess the impact of laparoscopy on the development of an anastomotic leak.ResultsOf 23,568 patients, 3.4xa0% developed an anastomotic leak. Laparoscopic surgery was associated with a leak rate of 2.8xa0% (nxa0=xa0425) and open surgery, 4.5xa0% (nxa0=xa0378, pxa0<xa00.0001). Patients who developed a leak were more likely to die within 30xa0days of surgery (5.7 vs. 0.6xa0%, pxa0<xa00.0001). Patients who underwent laparoscopic surgery compared to open were younger (61 vs. 63xa0years, pxa0=xa00, pxa0=xa00.045) and with fewer comorbidities. On univariable analysis laparoscopic surgery was associated with reduced odds of developing an anastomotic leak (OR 0.60, pxa0<xa00.0001), and this remained after adjusting for all significant preoperative and disease-related confounders (OR 0.69, 95xa0% CI 0.58–0.82). A propensity score-matched analysis confirmed benefit of laparoscopic surgery over open surgery for anastomotic leak.ConclusionLaparoscopic colectomy is safe and associated with reduced odds of developing an anastomotic leak following colectomy when controlling for patient-, disease- and procedure-related factors.

Antibiotics alone instead of percutaneous drainage as initial treatment of large diverticular abscess

BackgroundThere are limited data assessing the effectiveness of antibiotics as sole initial therapy in patients with large diverticular abscess. The aim of our study was to compare outcomes of selected patients treated with initial antibiotics alone versus percutaneous drainage.MethodsAll patients with diverticular abscess ≥3xa0cm in diameter treated in our institution in 1994–2012 with percutaneous drainage or antibiotics alone followed by surgery were identified from an institutional diverticular disease database. Groups were compared based on patient and disease characteristics, treatment failures and postoperative outcomes.ResultsThirty-two patients were treated with antibiotics alone because of either technically impossible percutaneous drainage (nxa0=xa015) or surgeon preference (nxa0=xa017) while 114 underwent percutaneous drainage. Failure of initial treatment required urgent surgery in 8 patients with persistent symptoms during treatment with antibiotics alone (25xa0%) and in 21 patients (18xa0%) after initial percutaneous drainage (pxa0=xa00.21). Reasons for urgent surgery after percutaneous drainage were persistent symptoms (nxa0=xa016), technical failure of percutaneous drainage (nxa0=xa04) and small bowel injury (nxa0=xa01). Patients treated with antibiotics had a significantly smaller abscess diameter (5.9 vs. 7.1xa0cm, pxa0=xa00.001) and shorter interval from initial treatment to sigmoidectomy (mean 50 vs. 80xa0days, pxa0=xa00.02). The Charlson comorbidity index, initial treatment failure rates, postoperative mortality, overall morbidity, length of hospital stay during treatments, and overall and permanent stoma rates were comparable in the two groups. Postoperative complications following antibiotics alone were significantly less severe than after percutaneous drainage based on the Clavien–Dindo classification (pxa0=xa00.04).ConclusionsSelected patients with diverticular abscess can be initially treated with antibiotics without adverse consequences on their outcomes.

Bowel Preparation: Are Antibiotics Necessary for Colorectal Surgery?

The goal of bowel preparation is to facilitate safe surgery and reduce postoperative complications. The use of antibiotic prophylaxis in colorectal surgery is essential, not controversial. Historical evidence supports the use of oral antibiotics in combination with mechanical cleansing for the reduction of infectious complications. Prophylactic intravenous antibiotic administration at induction in cleancontaminated surgery is now both routine and mandatory. Oral and intravenous antibiotics with mechanical bowel preparation show improved colectomy-specific outcomes compared with no preparation or mechanical bowel preparation plus intravenous antibiotics alone.

An observational study of the timing of surgery, use of laparoscopy and outcomes for acute cholecystitis in the USA and UK

BackgroundEvidence supports early laparoscopic cholecystectomy for acute cholecystitis. Differences in treatment patterns between the USA and UK, associated outcomes and resource utilization are not well understood.MethodsIn this retrospective, observational study using national administrative data, emergency patients admitted with acute cholecystitis were identified in England (Hospital Episode Statistics 1998–2012) and USA (National Inpatient Sample 1998–2011). Proportions of patients who underwent emergency cholecystectomy, utilization of laparoscopy and associated outcomes including length of stay (LOS) and complications were compared. The effect of delayed treatment on subsequent readmissions was evaluated for England.ResultsPatients with a diagnosis of acute cholecystitis totaled 1,191,331 in the USA vs. 288 907 in England. Emergency cholecystectomy was performed in 628,395 (52.7% USA) and 45,299 (15.7% England) over the time period. Laparoscopy was more common in the USA (82.8 vs. 37.9%; pu2009<u20090.001). Pre-treatment (1 vs. 2xa0days; pu2009<u20090.001) and total ( 4 vs. 7xa0days; pu2009<u20090.001) LOS was lower in the USA. Overall incidence of bile duct injury was higher in England than the USA (0.83 vs. 0.43%; pu2009<u20090.001), but was no different following laparoscopic surgery (0.1%). In England, 40.5% of patients without an immediate cholecystectomy were subsequently readmitted with cholecystitis. An additional 14.5% were admitted for other biliary complications, amounting to 2.7 readmissions per patient in the year following primary admission.ConclusionThis study highlights management practices for acute cholecystitis in the USA and England. Despite best evidence, index admission laparoscopic cholecystectomy is performed less in England, which significantly impacts subsequent healthcare utilization.

30-day mortality after elective colorectal surgery can reasonably be predicted

AbstractBackgroundnThe aim of the present study was to develop a clinically relevant, accurate and usable risk assessment scoring system solely for colorectal cancer patients undergoing elective resection.MethodsAll colorectal resections for colorectal cancer 2006–2012 were identified from the American College of Surgeons Quality Improvement Program. Independent risk factors for 30-day mortality after elective surgery were identified using univariable and multivariable logistic regression. A points-calculator based on factors most strongly associated with mortality and accurately predicting risk of mortality was developed.ResultsFifty-nine thousand nine hundred eighty-six patients underwent elective colorectal cancer surgery, and 1096 (1.8xa0%) died within 30xa0days. On multivariable analysis, the strongest risk factors for mortality were age ≥65xa0years [odds ratio (OR) 2.17, 95xa0% confidence interval (CI) 1.61–2.92], American Society of Anesthesiologists score ≥3 (OR 1.77, 95xa0% CI 1.29–2.42), renal failure (OR 3.15, 95xa0% CI 1.01–9.77), disseminated cancer (OR 2.56, 95xa0% CI 1.96–3.35), hypoalbuminemia (OR 2.84, 95xa0% CI 2.21–3.65), preoperative ascites (OR 3.17, 95xa0% CI 2.07–4.87), heart failure (OR 2.08, 95xa0% CI 1.35–3.20) and functional status (OR 2.05, 95xa0% CI 1.56–2.70). A model that accurately predicted risk of mortality was created using forward stepwise logistic regression and externally validated (area under the curve 0.826). This allowed for development of an eight-factor predictive score; maximum points conferred mortality of 96.1xa0% (pxa0<xa00.0001).ConclusionsA simple preoperative scoring system predicting 30-day mortality with good capability may allow better preoperative risk assessment, optimization and decision-making.

Factors associated with degree of tumour response to neo-adjuvant radiotherapy in rectal cancer and subsequent corresponding outcomes

BACKGROUNDnTumour response to neo-adjuvant radiotherapy for rectal cancer varies significantly between patients, as classified by Tumour Regression Grade (TRG 0-3), with 0 equating to pathological complete response (pCR) and 3 denoting minimal/no response. pCR is associated with significantly better local recurrence rates and survival, but is achieved in only 20-30% of patients. The literature contains limited data reporting factors predictive of tumour response and corresponding outcomes according to degree of regression.nnnMETHODSnAll patients with rectal cancer who received neo-adjuvant radiotherapy, entered into the National Cancer Database (NCDB) in 2009-2013, were included. Data were analysed on procedure performed, tumour details, pathological findings, chemo-radiotherapy regimens, patient demographics, outcomes and survival. Multivariate regression analysis was used to identify factors independently associated with pCR.nnnRESULTSnOf 13,742 patients, 32.4% achieved pCR/TRG0 (4452). Factors associated with pCR (vs. TRG3) included adenocarcinoma rather than mucinous adenocarcinoma histology; well/moderately differentiated grade; lower clinical tumour (cT1, cT2, cT3) and nodal (N0 and N1) stage, and the addition of neo-adjuvant chemotherapy. Elevated CEA levels were associated with TRG3. pCR patients had higher rates of local excision, shorter mean length of stay and lower unplanned readmission rates, than TRG3. R0 resection rates and overall survival were significantly higher in all grades of regression, compared to TRG3 (pxa0<xa00.0001).nnnCONCLUSIONnTumour regression correlates with outcomes. Identifying factors predictive of response may facilitate higher pCR rates, the tailoring of therapy, and improve outcomes.

Anorectal Anatomy and Applied Anatomy

A detailed knowledge of anorectal anatomy is essential for both accurate clinical diagnosis and safe, effective therapeutic intervention. This chapter aims to provide residents at all levels with the essential anatomical knowledge required for the clinical assessment and operative management of patients with anorectal symptoms and disease. Detailed anatomy of the rectum and anal canal is covered, along with clinical assessment, examination in clinic, operating room techniques, and an anatomical approach to the management of common benign anorectal conditions. After having read this chapter, the resident will be well informed for practice in both the clinic and operating room settings.

Adherence to colonoscopy at 1 year following resection of localized colon cancer: a retrospective cohort study

Background: For patients with stages I-III colon cancer who have undergone surgical resection, guidelines recommend surveillance colonoscopy at 1 year. However, limited data exist on adherence and associated factors. We aimed to determine the rate of adherence to surveillance colonoscopy at 1 year among nonmetastatic colon cancer patients who underwent resection and factors associated with adherence. Methods: In this population-based retrospective cohort study, the Surveillance, Epidemiology, and End Results (SEER)–Medicare database was used. We identified patients with stages I-III colon cancer who underwent surgical resection and survived >3 years without recurrence (no chemotherapy after 8 months) from 2002–2011. Our primary outcome was a colonoscopy claim 10–15 months after resection. We used multivariable regression analysis to assess associations between sociodemographic and clinical factors and receipt of timely colonoscopy. Results: Among 28,732 patients who survived >3 years without recurrence, 7967 (28%) did not undergo colonoscopy; 12,033 (42%) had it at one year, with 3159 (11%) before 10 months and 5573 (19%) after 15 months. Decreased adherence was associated with older age; being male versus female; being black or Hispanic versus white; higher tumor stage; left-sided tumors versus right sided; and increased comorbidities. Chemotherapy receipt was associated with increased adherence (odds ratio 2.06; 95% confidence interval 1.88–2.24). Conclusions: In a large population-based sample of individuals aged ⩾ 65 years, only 42% of colon cancer survivors underwent 1-year surveillance colonoscopy. Demographic and clinical factors were associated with adherence.

Gefahr der Anastomoseninsuffizienz nach laparoskopischer und offener kolorektaler Resektion

ZusammenfassungFragestellung und HintergrundTritt nach kolorektalen Operationen eine Anastomoseninsuffizienz auf, so geht diese mit einer erheblichen Morbidität und Mortalität einher. Mit dem zunehmenden Einsatz laparoskopischer Verfahren liegen jetzt Daten erster klinischer Studien vor, in denen die Wirksamkeit der laparoskopischen und offenen Operationstechnik vergleichend untersucht wurden. Allerdings ist eine Generalisierung dieser Daten nicht uneingeschränkt möglich. Wir untersuchten das Risiko einer Anastomoseninsuffizienz nach laparoskopischer und offener kolorektaler Resektion unter Verwendung von Daten einer nationalen Datenbank in den USA, die standardisierte Definitionen verwendete.Patienten und MethodikIn der NSQIP-Datenbank der ACS erfolgte eine Suche nach allen zwischen 2012 und 2013 erfassten elektiven kolorektalen Resektionen. Die Charakteristika der Patienten, die sich einer laparoskopischen Operation unterzogen, wurden mit denen von Patienten mit offener Operation verglichen. Der Einfluss des laparoskopischen Vorgehens auf die Entwicklung einer Anastomoseninsuffizienz wurde mithilfe univariabler und multivariabler Analysen und einer anschließenden Propensity-Score-Matching-Analyse beurteilt.ErgebnisseVon den insgesamt 23.568 Patienten entwickelten 3,4u2009% eine Anastomoseninsuffizienz. Die Anastomoseninsuffizienzrate betrug bei laparoskopischer Operationstechnik 2,8u2009% (nxa0= 425) und beim offenen Vorgehen 4,5u2009% (nxa0= 378; pxa0< 0,0001). Patienten, die eine Leckage entwickelten, hatten ein höheres Risiko, innerhalb von 30xa0Tagen nach dem Eingriff zu versterben (5,7 vs. 0,6u2009%; pxa0< 0,0001). Patienten, die laparoskopisch operiert wurden, waren im Vergleich zu Patienten mit offener Operation jünger und hatten weniger Komorbiditäten (61 vs. 63xa0Jahre; pxa0= 0; pxa0= 0,045). In der univariablen Analyse ging das laparoskopische Verfahren mit einer geringeren Wahrscheinlichkeit der Entwicklung einer Anastomoseninsuffizienz einher (OR 0,60; pxa0< 0,0001). Diese Assoziation bleibt auch nach Adjustierung für alle relevanten präoperativen und krankheitsbezogenen Störgrößen erhalten (OR 0,69; 95u2009% CI 0,58–0,82). Eine Propensity-Score-Matching-Analyse bestätigt den Vorteil der laparoskopischen gegenüber der offenen Operation hinsichtlich des Auftretens einer Anastomoseninsuffizienz.SchlussfolgerungDie laparoskopische kolorektale Resektion ist ein sicheres Verfahren und geht auch nach Ausgleich von patienten-, krankheits- und verfahrensbezogenen Faktoren mit einer geringeren Wahrscheinlichkeit der Entwicklung einer Anastomoseninsuffizienz einher.AbstractBackgroundAnastomotic leak following colorectal surgery is associated with significant morbidity and mortality. With then widespread adoption of laparoscopy, data from initial clinical trials evaluating the efficacy of laparoscopic whenn compared to open surgery may not currently be generalizable. We assess the risk of anastomotic leak after laparoscopicn versus open colorectal resection using axa0nationwide database with standardized definitions.MethodsThe 2012–2013 ACS-NSQIP targeted colectomy data were queried for all elective colorectal resections. Characteristics were compared for those patients undergoing laparoscopic versus open operations. Univariable and multivariable analyses, followed by axa0propensity score-matched analysis, were performed to assess the impact of laparoscopy on the development of an anastomotic leak.ResultsOf 23,568 patients, 3.4% developed an anastomotic leak. Laparoscopic surgery was associated with axa0leak rate of 2.8% (nxa0= 425) and open surgery, 4.5% (nxa0= 378, p <0.0001). Patients who developed axa0leak were more likely to die within 30xa0days of surgery (5.7 vs 0.6%, p <0.0001). Patients who underwent laparoscopic surgery compared to open were younger (61 vs 63xa0years, pxa0= 0, pxa0= 0.045) and with fewer comorbidities. On univariable analysis laparoscopic surgery was associated with reduced odds of developing an anastomotic leak (OR 0.60, p <0.0001), and this remained after adjusting for all significant preoperative and disease-related confounders (OR 0.69, 95% CI 0.58–0.82). A propensity score-matched analysis confirmed benefit of laparoscopic surgery over open surgery for anastomotic leak.ConclusionLaparoscopic colectomy is safe and associated with reduced odds of developing an anastomotic leak following colectomy when controlling for patient-, disease and procedure-related factors.