Stefan D. Holubar

Current strategies in the management of intra-abdominal abscesses in Crohn's disease.

Crohns disease is characterized by inflammation that involves the full thickness of the bowel wall, which can lead to serious complications including intra-abdominal and pelvic abscesses. The combination of an intra-abdominal abscess with active Crohns disease poses a particular dilemma for the treating physician, who must weigh the benefits of using immunosuppressive therapies for the inflammatory bowel disease against the risks of immunosuppression in the presence of serious abdominal infection. Traditionally, Crohns-related abscesses were managed with early surgery, which often involved external drainage procedures, bowel resection, and the creation of diverting ostomies in acutely ill patients. Today such abscesses often can be managed initially with antibiotics and percutaneous drainage, with evaluation for the need for delayed surgery in selected patients. With delayed surgery performed electively, the surgeon frequently can resect the diseased bowel and create a primary anastomosis, thus avoiding emergency operations and multistage procedures. In highly selected cases, surgery might be avoided entirely. This report reviews the literature on the pathophysiology and management of intra-abdominal abscesses in Crohns disease (including the roles of percutaneous drainage, immunosuppressive therapy, and surgery), and provides a suggested approach to the management of patients with this difficult problem.

Assessment of Colon Cancer Literacy in Screening Colonoscopy Patients: A Validation Study

BACKGROUND Few, if any, instruments assess disease-specific health literacy in colon cancer patients. We aimed to validate the Assessment of Colon Cancer Literacy (ACCL) compared with a standard health literacy test, the Newest Vital Sign (NVS). MATERIALS AND METHODS A convenience sample of screening colonoscopy patients was surveyed. General health literacy was assessed with the NVS and colon cancer literacy with the ACCL. Contingency table analysis was performed. Results are frequency (proportion) or mean. RESULTS Sixty-one subjects completed our survey, mean age 64 ± 9 y, 33 (54%) were women, 28 (46%) had a college degree, 38 (62%) had prior colonoscopy, and 19 (31%) worked in healthcare. The sensitivity and specificity of NVS to identify limited colon cancer literacy was 45.7% and 86.7%, respectively, while the sensitivity and specificity of ACCL to identify limited general health literacy was 91.3% and 34.2%, respectively. CONCLUSIONS The ACCL is a valid, sensitive measure of health literacy. Furthermore, given its focus on clinically relevant content, this instrument may facilitate discussion of diagnosis, treatment, and prognosis with colon cancer patients. ACCL is a novel, valid health literacy instrument that may aid gastroenterologists, colorectal surgeons, and medical oncologists in optimizing patient education.

American Society for Enhanced Recovery (ASER) and Perioperative Quality Initiative (POQI) joint consensus statement on prevention of postoperative infection within an enhanced recovery pathway for elective colorectal surgery

BackgroundColorectal surgery (CRS) patients are an at-risk population who are particularly vulnerable to postoperative infectious complications. Infectious complications range from minor infections including simple cystitis and superficial wound infections to life-threatening situations such as lobar pneumonia or anastomotic leak with fecal peritonitis. Within an enhanced recovery pathway (ERP), there are multiple approaches that can be used to reduce the risk of postoperative infections.MethodsWith input from a multidisciplinary, international group of experts and through a focused (non-systematic) review of the literature, and use of a modified Delphi method, we achieved consensus surrounding the topic of prevention of postoperative infection in the perioperative period for CRS patients.DiscussionAs a part of the first Perioperative Quality Initiative (POQI-1) workgroup meeting, we sought to develop a consensus statement describing a comprehensive, yet practical, approach for reducing postoperative infections, specifically for CRS within an ERP. Surgical site infection (SSI) is the most common postoperative infection. To reduce SSI, we recommend routine use of a combined isosmotic mechanical bowel preparation with oral antibiotics before elective CRS and that infection prevention strategies (also called bundles) be routinely implemented as part of colorectal ERPs. We recommend against routine use of abdominal drains. We also give consensus guidelines for reducing pneumonia, urinary tract infection, and central line-associated bloodstream infection (CLABSI).

Anti-Tumor Necrosis Factor-α Antibody Therapy Management Before and After Intestinal Surgery for Inflammatory Bowel Disease: A CCFA Position Paper.

Abstract:Biologic therapy with anti–tumor necrosis factor (TNF)-&agr; antibody medications has become part of the standard of care for medical therapy for patients with inflammatory bowel disease and may help to avoid surgery in some. However, many of these patients will still require surgical intervention in the form of bowel resection and anastomosis or ostomy formation for the treatment of their disease. Postsurgical studies suggest up to 30% of patients with inflammatory bowel disease may be on or have used anti–TNF-&agr; antibody medications for disease management preoperatively. Significant controversy exists regarding the potential deleterious impact of these medications on the outcomes of surgery, specifically overall and/or infectious complications. In this position statement, we systematically reviewed the literature regarding the potential risk of anti–TNF-&agr; antibody use in the perioperative period, offer recommendations based both on the best-available evidence and expert opinion on the use and timing of anti–TNF-&agr; antibody therapy in the perioperative period, and discuss whether or not the presence of these medications should lead to an alteration in surgical technique such as temporary stoma formation.

Primary intestinal lymphoma in patients with inflammatory bowel disease: A descriptive series from the prebiologic therapy era

Background: Primary intestinal lymphoma in the setting of inflammatory bowel disease (IBD) is uncommon and may be associated with immune suppressive therapy. We report clinical features and outcomes in patients with both conditions prior to use of biologic therapy. Methods: All patients with primary intestinal lymphoma and IBD at our institution from 1960‐2000 were retrospectively identified. Data reported are frequency (proportion) or median (interquartile range). Kaplan‐Meier analysis was performed. Results: Fifteen patients were identified: 14 (93%) were male, 10 (66%) had Crohns disease. Median age at diagnosis of IBD and lymphoma was 30 (22‐51) and 47 (28‐68) years, respectively, with bloody diarrhea the most common presenting symptom for each diagnosis. Lymphoma location was colorectal in nine (60%), small bowel in four (27%), and one (6.25%) each: stomach, duodenum, and ileal pouch. Treatments were surgery plus chemotherapy (n = 6), surgery alone (n = 3), chemotherapy alone (n = 2), chemotherapy and radiation (n = 1), surgery and radiation (n = 1); two patients died before treatment. Most patients (n = 11, 73%) were Ann Arbor stages I or II. Large cell B‐type histology was most common (n = 9, 60%). Three patients died within 30 days of lymphoma diagnosis. Survival free of death from lymphoma at 1‐ and 5‐years was 78% and 63%, respectively, and was associated with advanced lymphoma stage (P = 0.004). Conclusions: Diagnosis and treatment of primary intestinal lymphoma in patients with IBD can be challenging and requires a high index of suspicion. Optimal survival requires multimodality therapy.(Inflamm Bowel Dis 2010;)

Patients with Ulcerative Colitis Are More Concerned About Complications of Their Disease than Side Effects of Medications.

Background:Patients with ulcerative colitis (UC) are often fearful about medication side effects and how the disease will affect their future. Our aim was to better understand what aspects of UC, and UC management, are most concerning to patients, and how they would like to be informed about treatment options. Methods:A Web-based survey was sent to UC patients throughout the United States and Australia. In addition to standard closed-response questions, audio clips were embedded in the survey and respondents showed their strength of agreement or disagreement using moment-to-moment affect-trace methodology. Standard quantitative analysis was used for the survey results, and cluster analysis was performed on the affect-trace responses. Results:A total of 460 patients with UC (370 patients from the United States and 90 patients from Australia) responded to the survey. Of them, 53% of the respondents were women, with a mean age of 49 (range 19–81) years. Most patients (87%) wanted to share treatment decision making with their doctors. The majority, 98%, wanted more than just a basic understanding of their disease. Patients were most concerned about the risk of colorectal cancer (37%), and the possible need for an ileostomy (29%). Only 14% of patients indicated that side effects from medications were their biggest concern. On affect-trace analysis, the most divergence in opinion centered on the appropriate timing for colectomy. Conclusions:To facilitate informed treatment decisions for UC patients, in addition to reviewing the benefits and risks of medications, it is also important to discuss the best strategies for decreasing the risk of colectomy and colorectal cancer.

Minimally invasive surgery for inflammatory bowel disease.

Abstract:Surgical management of inflammatory bowel disease is a challenging endeavor given infectious and inflammatory complications, such as fistula, and abscess, complex often postoperative anatomy, including adhesive disease from previous open operations. Patients with Crohns disease and ulcerative colitis also bring to the table the burden of their chronic illness with anemia, malnutrition, and immunosuppression, all common and contributing independently as risk factors for increased surgical morbidity in this high-risk population. However, to reduce the physical trauma of surgery, technologic advances and worldwide experience with minimally invasive surgery have allowed laparoscopic management of patients to become standard of care, with significant short- and long-term patient benefits compared with the open approach. In this review, we will describe the current state-of the-art for minimally invasive surgery for inflammatory bowel disease and the caveats inherent with this practice in this complex patient population. Also, we will review the applicability of current and future trends in minimally invasive surgical technique, such as laparoscopic “incisionless,” single-incision laparoscopic surgery (SILS), robotic-assisted, and other techniques for the patient with inflammatory bowel disease. There can be no doubt that minimally invasive surgery has been proven to decrease the short- and long-term burden of surgery of these chronic illnesses and represents high-value care for both patient and society.

Telephone follow-up to a mail survey: when to offer an interview compared to a reminder call

BackgroundUsing a different mode of contact on the final follow-up to survey non-respondents is an identified strategy to increase response rates. This study was designed to determine if a reminder phone call or a phone interview as a final mode of contact to a mailed survey works better to increase response rates and which strategy is more cost effective.MethodsA randomized study was embedded within a survey study of individuals treated with ulcerative colitis conducted in March 2009 in Olmsted County, Minnesota. After two mail contacts, non-respondents were randomly assigned to either a reminder telephone call or a telephone interview. Average cost per completed interview and response rates were compared between the two experimental conditions.ResultsThe response rate in the reminder group and the interview did not differ where we considered both a completed survey and a signed form a complete (24% vs. 29%, p = 0.08). However, if such a signed form was not required, there was a substantial advantage to completing the interview over the phone (24% vs. 43%, p < 0.0001). The reminder group on average cost

Application of Total Care Time and Payment per Unit Time Model for Physician Reimbursement for Common General Surgery Operations

27.00 per completed survey, while the interview group on average cost

Drivers of cost after surgical and medical therapy for chronic ulcerative colitis: a nested case-cohort study in Olmsted County, Minnesota.

53.00 per completed survey when a signed form was required and