Anastomotic leaks represent one of the most alarming complications following any gastrointestinal anastomosis due to the substantial effects on post-operative morbidity and mortality of the patient ...with long-lasting effects on the functional and oncologic outcomes. There is a lack of consensus related to the definition of an anastomotic leak, with a variety of options for prevention and management. A number of patient-related and technical risk factors have been found to be associated with the development of an anastomotic leak and have inspired the development of various preventative measures and technologies. The International Multispecialty Anastomotic Leak Global Improvement Exchange group was convened to establish a consensus on the definition of an anastomotic leak as well as to discuss the various diagnostic, preventative, and management measures currently available.
Background
Current guidelines recommend extended venothromboembolism (VTE) prophylaxis for most patients following colorectal cancer surgery, but provider uptake has been limited. The purpose of this ...study was to identify thresholds for when such extended prophylaxis (ePpx) may be value-appropriate.
Methods
All colorectal cancer postoperative discharges were identified within a private payer administrative database (MarketScan® 2010–2014, IBM Truven Health Analytics). Outcomes of interest were VTE event rate, mortality, and overall costs of care. The data along with published literature were used as parameter estimations for a decision analysis model with probabilistic sensitivity analysis.
Results
We identified 22,463 colorectal cancer surgical patients (4.0% with ePpx) that served as the parameter estimates for the decision model with a VTE event rate of 0.2%. Decision analysis demonstrated that prescribing ePpx was dominated by usual practice with the former having higher probability-adjusted incremental costs ($1078.68 per person) and lower probability-adjusted benefits (− 0.000098 quality adjusted life years). Broad sensitivity analysis found that probability of a VTE event, bleeding case fatality rate, and probability of an ePpx-associated bleeding event were the primary effectors of the model. VTE event rates of greater than 3.0% benefited from prescribing ePpx to all patients.
Conclusions
Very few patients are discharged on ePpx following colorectal cancer surgery despite its endorsement by national guidelines. A decision analysis model does not support the use of ePpx except in cases of markedly high VTE rates. Clinical guidance could be improved by further recognizing the role of risk stratification in the determination of high-risk patients requiring ePpx.
Introduction
The increased use of minimally invasive surgery in the management of colorectal cancer has led to a renewed focus on how certain factors, such as insurance status, impact the equitable ...distribution of both laparoscopic and robotic surgery. Our goal was to analyze surgical wait times between robotic, laparoscopic, and open approaches, and to determine whether insurance status impacts timely access to treatment.
Methods
After IRB approval, adult patients from the National Cancer Database with a diagnosis of colorectal cancer were identified (2010–2016). Patients who underwent radiation therapy, neoadjuvant chemotherapy, had wait times of 0 days from diagnosis to surgery, or had metastatic disease were excluded. Primary outcomes were days from cancer diagnosis to surgery and days from surgery to adjuvant chemotherapy. Multivariable Poisson regression analysis was performed.
Results
Among 324,784 patients, 5.9% underwent robotic, 47.5% laparoscopic, and 46.7% open surgery. Patients undergoing robotic surgery incurred the longest wait times from diagnosis to surgery (29.5 days robotic vs. 21.7 laparoscopic vs. 17.2 open,
p
< 0.001), but the shortest wait times from surgery to adjuvant chemotherapy (48.9 days robotic vs. 49.9 laparoscopic vs. 54.8 open,
p
< 0.001). On adjusted analysis, robotic surgery was associated with a 1.46 × longer wait time to surgery (IRR 1.462, 95% CI 1.458–1.467,
p
< 0.001), but decreased wait time to adjuvant chemotherapy (IRR 0.909, 95% CI 0.905–0.913,
p
< 0.001) compared to an open approach. Private insurance was associated with decreased wait times to surgery (IRR 0.966, 95% CI 0.962–0.969,
p
< 0.001) and adjuvant chemotherapy (IRR 0.862, 95% CI 0.858–0.865,
p
< 0.001) compared to Medicaid.
Conclusion
Though patients undergoing robotic surgery experienced delays from diagnosis to surgery, they tended to initiate adjuvant chemotherapy sooner compared to those undergoing open or laparoscopic approaches. Private insurance was independently associated not only with access to robotic surgery, but also shorter wait times during all stages of treatment.
Graphic Abstract
Management of radiation proctitis Sarin, Ankit; Safar, Bashar
Gastroenterology clinics of North America,
12/2013, Letnik:
42, Številka:
4
Journal Article
Recenzirano
Radiation damage to the rectum following radiotherapy for pelvic malignancies can range from acute dose-limiting side effects to major morbidity affecting health-related quality of life. No standard ...guidelines exist for diagnosis and management of radiation proctitis. This article reviews the definitions, staging, and clinical features of radiation proctitis, and summarizes the modalities available for the treatment of acute and chronic radiation proctitis. Because of the paucity of well-controlled, blinded, randomized studies, it is not possible to fully assess the comparative efficacy of the different approaches to management. However, the evidence and rationale for use of the different strategies are presented.
Preoperative radiation therapy with 5-fluorouracil chemotherapy is a standard of care for cT3-4 rectal cancer. Studies incorporating additional cytotoxic agents demonstrate increased morbidity with ...little benefit. We evaluate a template that: (1) includes the benefits of preoperative radiation therapy on local response/control; (2) provides preoperative multidrug chemotherapy; and (3) avoids the morbidity of concurrent radiation therapy and multidrug chemotherapy.
Patients with cT3-4, any N, any M rectal cancer were eligible. Patients were confirmed to be candidates for pelvic surgery, provided response was sufficient. Preoperative treatment was 5 fractions radiation therapy (25 Gy to involved mesorectum, 20 Gy to elective nodes), followed by 4 cycles of FOLFOX 5-fluorouracil, oxaliplatin, leucovorin. Extirpative surgery was performed 4 to 9 weeks after preoperative chemotherapy. Postoperative chemotherapy was at the discretion of the medical oncologist. The principal objectives were to achieve T stage downstaging (ypT < cT) and preoperative grade 3+ gastrointestinal morbidity equal to or better than that of historical controls.
76 evaluable cases included 7 cT4 and 69 cT3; 59 (78%) cN+, and 7 cM1. Grade 3 preoperative GI morbidity occurred in 7 cases (9%) (no grade 4 or 5). Sphincter-preserving surgery was performed on 57 (75%) patients. At surgery, 53 patients (70%) had ypT0-2 residual disease, including 21 (28%) ypT0 and 19 (25%) ypT0N0 (complete response); 24 (32%) were ypN+. At 30 months, local control for all evaluable cases and freedom from disease for M0 evaluable cases were, respectively, 95% (95% confidence interval CI: 89%-100%) and 87% (95% CI: 76%-98%). Cases were subanalyzed by whether disease met requirements for the recently activated PROSPECT trial for intermediate-risk rectal cancer. Thirty-eight patients met PROSPECT eligibility and achieved 16 ypT0 (42%), 15 ypT0N0 (39%), and 33 ypT0-2 (87%).
This regimen achieved response and morbidity rates that compare favorably with those of conventionally fractionated radiation therapy and concurrent chemotherapy.
Background
Robotic surgery is attractive for resection of low rectal cancer due to greater dexterity and visualization, but its benefit is poorly understood. We aimed to determine if operative ...approach impacts radial margin positivity (RMP) and postoperative outcomes among patients undergoing abdominoperineal resection (APR).
Methods
This was a retrospective cohort study of patients from the National Surgical Quality Improvement Program who underwent APR for low rectal cancer from 2016 to 2019. Patients were stratified by operative approach: robotic, laparoscopic, and open APR (R-APR, L-APR, and O-APR). Emergent cases were excluded. The primary outcome was RMP. 30-day postoperative outcomes were also evaluated, using logistic regression analysis.
Results
Among 1,807 patients, 452 (25.0%) underwent R-APR, 474 (26.2%) L-APR, and 881 (48.8%) O-APR. No differences regarding RMP (13.5% R-APR vs. 10.8% L-APR vs. 12.3% O-APR,
p
= 0.44), distal margin positivity, positive nodes, readmission, or operative time were observed between operative approaches. Adjusted analysis confirmed that operative approach did not predict RMP (
p
> 0.05 for all). Risk factors for RMP included American Society of Anesthesiologists (ASA) classification III (ASA I-II ref; OR 1.46,
p
= 0.039), pT3-4 stage (T0-2 ref, OR 4.02,
p
< 0.001), pN2 stage (OR 1.98,
p
= 0.004), disseminated cancer (OR 1.90,
p
= 0.002), and lack of preoperative radiation (OR 1.98,
p
< 0.01).
Conclusions
No difference in RMP was observed among R-APR, L-APR, and O-APR. Postoperatively, R-APR yielded greater benefit when compared to O-APR, but was comparable to that of L-APR. Minimally invasive surgery may be an appropriate option and worthy consideration for patients with distal rectal cancer requiring APR.
Background
Although previous studies have examined frailty as a potential predictor of adverse surgical outcomes, little is reported on its application. We sought to assess the impact of the 5-item ...modified frailty index (mFI) on morbidity in patients undergoing combined colorectal and liver resections.
Methods
Adult patients who underwent combined colorectal and liver resections were identified using the ACS-NSQIP database (2005–2015). The 5-item mFI consists of history of chronic obstructive pulmonary disease, congestive heart failure, hypertension, diabetes, and partial/total dependence. Patients were stratified into three groups: mFI 0, 1, or ≥ 2. The impact of the mFI on primary outcomes (30-day overall and serious morbidity) was assessed using multivariable logistic regression. Subgroup analyses by age and hepatectomy type was also performed.
Results
A total of 1928 patients were identified: 55.1% with mFI = 0, 33.2% with mFI = 1, and 11.7% with mFI ≥ 2. 75.9% of patients underwent wedge resection/segmentectomy (84.6% colon, 15.4% rectum), and 24.1% underwent hemihepatectomy (88.8% colon, 11.2% rectum). On unadjusted analysis, patients with mFI ≥ 2 had significantly greater rates of overall and serious morbidity, regardless of age and hepatectomy type. These findings were consistent with the multivariable analysis, where patients with mFI ≥ 2 had increased odds of overall morbidity (OR 1.41, 95% CI 1.02–1.96,
p
= 0.037) and were more than twice likely to experience serious morbidity (OR 2.12, 95% CI 1.47–3.04,
p
< 0.001).
Conclusions
The 5-item mFI is significantly associated with 30-day morbidity in patients undergoing combined colorectal and liver resections. It is a tool that can guide surgeons preoperatively in assessing morbidity risk in patients undergoing concomitant resections.
Background
Prior randomized trials showed comparable short-term outcomes between open and minimally invasive proctectomy (MIP) for rectal cancer. We hypothesize that short-term outcomes for MIP have ...improved as surgeons have become more experienced with this technique.
Methods
Rectal cancer patients who underwent elective abdominoperineal resection (APR) or low anterior resection (LAR) were included from the American College of Surgeons National Surgical Quality Improvement Program database (2016–2018). Patients were stratified based on intent-to-treat protocol: open (O-APR/LAR), laparoscopic (L-APR/LAR), robotic (R-APR/LAR), and hybrid (H-APR/LAR). Multivariable logistic regression analysis was used to assess the impact of operative approach on 30-day morbidity.
Results
A total of 4471 procedures were performed (43.41% APR and 36.59% LAR); O-APR 42.72%, L-APR 20.99%, R-APR 16.79%, and H-APR 19.51%; O-LAR 31.48%, L-LAR 26.34%, R-LAR 17.48%, and H-LAR 24.69%. Robotic APR and LAR were associated with shortest length of stay and significantly lower conversion rate. After adjusting for other factors, lap, robotic and hybrid APR and LAR were associated with decreased risk of overall morbidity when compared to open approach. R-APR and H-APR were associated with decreased risk of serious morbidity. No difference in the risk of serious morbidity was observed between the four LAR groups.
Conclusion
Appropriate selection of patients for MIP can result in better short-term outcomes, and consideration for MIP surgery should be made.
Purpose
There has been a noted reluctance to offer laparoscopic surgery to Crohn’s Disease patients due to the potential risks, and high rate, of converting the procedure to open. The purpose of this ...study was to compare clinical outcomes between Crohn’s Disease patients undergoing a planned open colectomy, to those undergoing a laparoscopic colectomy that was converted to open.
Methods
Crohn’s Disease patients undergoing an elective colectomy were identified using the ACS-NSQIP database (2012–2019). Patients were stratified based on operative approach: open, laparoscopic, and laparoscopic converted to open. Multivariable logistic regression was used to assess the impact of conversion to open on overall and serious postoperative morbidity.
Results
Among 8039 elective colectomies, 40.5% were performed open, 46.9% were completed laparoscopically, and 12.6% were converted to open. The conversion rate among all laparoscopic cases was 21.3%. On unadjusted analysis, conversion to open demonstrated similar rates of overall morbidity (
P
= 0.355) and serious morbidity (
P
= 0.724) compared to a planned open approach. On multivariable analysis, conversion to open was not associated with increased odds of overall morbidity (OR 1.12, 95% CI 0.94–1.30,
P
= 0.238) or serious morbidity (OR 1.20, 95% CI 0.98–1.46,
P
= 0.074), when compared to an open approach.
Conclusion
Among Crohn’s Disease patients, cases converted from laparoscopic to open exhibited similar outcomes as a planned open approach. Despite the limitations associated with this retrospective study, our findings suggest that laparoscopic surgery may be safely pursued among Crohn’s Disease patients, as the risks of conversion are potentially balanced by the benefits of laparoscopic surgery.
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