Background The goal of this study was to compare surgical site infection (SSI) rates between laparoscopic (LAP) and open colorectal surgery using the National Surgical Quality Improvement Program ...(NSQIP) database. Study Design We identified patients included in the NSQIP database from 2006 to 2007 who underwent LAP and open colorectal surgery. SSI rates were compared for the 2 groups. Association between patient demographics, diagnosis, type of procedure, comorbidities, laboratory values, intraoperative factors, and SSI within 30 days of surgery, were determined using a logistic regression analysis. Results Among 10,979 patients undergoing colorectal surgery (LAP 31.1%, open 68.9%), the SSI rate was 14.0% (9.5% LAP vs 16.1% open, p < 0.001). LAP patients were younger (p < 0.001), with lower American Society of Anesthesiologists (ASA) scores (p < 0.001) and comorbidities (p = 0.001) involving benign and inflammatory conditions rather than malignancy (p < 0.001), but operative time was greater (p = 0.001). On multivariate analysis age, ASA ≥3, smoking, diabetes, operative time >180 minutes, appendicitis or diverticulitis, and regional enteritis diseases were found to be significantly associated with high SSI; the LAP approach was associated with a reduced SSI rate. Conclusions The LAP approach is independently associated with a reduced SSI when compared with open surgery and should, when feasible, be considered for colon and rectal conditions.
Background Many rectal cancer patients experience tumor downstaging and some are found to achieve a pathologic complete response (pCR) after neoadjuvant chemoradiotherapy (nCRT). Previous data ...suggest that there is an association between the time interval from nCRT completion to surgery and tumor response rates, including pCR. However, these studies have been primarily from single institutions with small sample sizes. The aim of this study was to examine the relationship between a longer interval after nCRT and pCR in a nationally representative cohort of rectal cancer patients. Study Design Clinical stage II to III rectal cancer patients undergoing nCRT with a documented surgical resection were selected from the 2006 to 2011 National Cancer Data Base. Multivariable logistic regression analysis was used to assess the association between the nCRT–surgery interval time (<6 weeks, 6 to 8 weeks, >8 weeks) and the odds of pCR. The relationship between nCRT–surgery interval, surgical morbidity, and tumor downstaging was also examined. Results Overall, 17,255 patients met the inclusion criteria. An nCRT–surgery interval time >8 weeks was associated with higher odds of pCR (odds ratio OR 1.12, 95% CI 1.01 to 1.25) and tumor downstaging (OR 1.11, 95% CI 1.02 to 1.25). The longer time delay was also associated with lower odds of 30-day readmission (OR 0.82, 95% CI 0.70 to 0.92). Conclusions An nCRT–surgery interval time >8 weeks results in increased odds of pCR, with no evidence of associated increased surgical complications compared with an interval of 6 to 8 weeks. These data support implementation of a lengthened interval after nCRT to optimize the chances of pCR and perhaps add to the possibility of ultimate organ preservation (nonoperative management).
Background Data regarding the long-term outcomes of restorative proctocolectomy and ileal pouch anal anastomosis including pouch function and quality of life in the pediatric population are limited ...in pediatric patients. Study Design Indications for surgery, complications, long-term function, and quality of life were evaluated in pediatric patients undergoing ileal pouch anal anastomosis. Assessment of quality of life was performed using the Cleveland Global Quality of Life score. Results There were 433 patients with a mean age of 18.04 ± 2.9 years. Final pathologic diagnoses were ulcerative colitis or indeterminate colitis (78.3%), familial adenomatous polyposis (15.7%), Crohn's disease (5.1%), and others (0.9%). There were 237 patients (54.7%) who underwent total proctocolectomy and ileal pouch anal anastomosis; 196 (45.3%) underwent initial subtotal colectomy followed by completion proctectomy with ileal pouch anal anastomosis. Anastomosis was stapled in 352 patients (81.3%) and hand-sewn in 81 (18.7%) patients. Mean follow-up was 108.5 ± 78.4 months. At the most recent follow-up, mean Cleveland Global Quality of Life score was 0.8 ± 0.2 and numbers of daytime and night-time bowel movements were 5.3 ± 3.1 and 1.6 ± 1.3, respectively. The majority of the patients (86.8%) were fully continent or only complained of rare incontinence. Most patients had no seepage (day, 84.3%; night, 72.4%) and did not wear any pads (day, 89.3%; night, 84.3%). Most denied dietary (71.3%), social (84.8%), work (85.7%), or sexual restrictions (87.6%) at the time of last follow-up. There were 92.7% of patients who said they would undergo ileal pouch anal anastomosis again and 95.2% would recommend surgery to others. Conclusions Restorative proctocolectomy with ileal pouch anal anastomosis can be performed in pediatric patients with acceptable morbidity and is associated with good long-term results in terms of gastrointestinal function, quality of life, and patient satisfaction.
Background The aim of this study was to compare outcomes after primary hand-sewn versus stapled ileal pouch-anal anastomosis (IPAA). Methods Patients undergoing a primary IPAA (1983–2007) were ...identified from a prospective pelvic pouch database. Differences between group A (hand-sewn) and group B (stapled) for pre-operative and peri-operative factors, complications, functional outcomes, and quality of life (QOL) were investigated. Results Of 3,382 patients with a primary IPAA, 3,109 were included. Median follow-up was 7.1 years (0.1–24). Mean age was 37.9 ± 13.2 years. Overall, 1,741 patients (56%) were male. Group A ( n = 474) and group B ( n = 2635) had similar age ( P = .28), sex ( P = .8), albumin level ( P = .74), prior colectomy ( P = .98), and use of steroids ( P = .1). Group A had a greater use of ileostomy ( P = .001) and a longer duration of stay ( P < .001). Group B had a greater body mass index ( P < .001) and J-pouch ( P ≤ .001). Wound infection ( P = .42) and pouchitis ( P = .59) were similar. Anastomotic stricture ( P = .002), septic complications ( P = .019), bowel obstruction ( P = .027), and pouch failure ( P < .001) were greater in group A. At most recent follow-up, bowel frequency ( P = .74) and rate of urgency were similar ( P = .71). A greater proportion of patients in group A described incontinence ( P < .001), seepage ( P < .001), pad usage ( P < .001), dietary ( P < .001), social ( P < .001), and work restrictions ( P = .025). The Cleveland Global QOL score ( P = .018) was greater in group B. Conclusion Patients undergoing a stapled IPAA had better outcomes and QOL than those undergoing a hand-sewn IPAA.
The incidence of inflammatory bowel disease is increasing and despite advances in medical therapy, patients continue to require operations for complications of their disease. Minimally invasive ...surgical options have impacted postoperative morbidity dramatically with reduction of pain, length of stay and adhesion formation, but additionally, this population of patients are not only concerned with successful operative therapy but also the ability to return to their lifestyle and cosmetics. Laparoscopic and robotic surgery for Crohn's disease has proven to benefit patients with ileocolic or colonic disease, however complicated disease with phlegmon, abscess or fistulae is best served with a hybrid approach. Ulcerative colitis treatment has seen advancements with laparoscopic and robotic platforms, however the benefits of minimally invasive surgery must be balanced with producible and durable outcomes.
Objective:
Analyze our long-term experience with a less-popularized but stalwart approach, the stapled end-to-side ileocolic anastomosis.
Background:
The choice of technical approach to ileocolic ...anastomosis after ileocecal resection for Crohn’s disease affects surgical outcomes and recurrence. Yet, despite heterogeneous data from different anastomotic configurations, there remains no clear guidance as to the optimal technique.
Methods:
In a retrospective cohort design, patients undergoing ileocolic anastomosis in the setting of Crohn’s disease between 2016 and 2021 at two institutions were identified. Patient characteristics and surgical outcomes in terms of recurrence (surgical, clinical, and endoscopic) were studied.
Results:
In total, 211 patients were included. Before surgery, 80% were exposed to at least 1 cycle of systemic steroids and 71% had at least 1 biologic agent; 60% exhibited penetrating disease and 38% developed an intra-abdominal abscess. After surgery, one anastomosis leaked (0.5%). Over 2.4 years of follow-up (IQR = 1.3–3.9), surgical recurrence was 0.9%. Two-year overall recurrence-free and endoscopic recurrence-free survivals were 74% and 85% (95% CI = 68–81 and 80–91), respectively. The adjusted hazard ratio of endoscopic recurrence was 3.0 (95% CI = 1.4–6.2) for males and 5.2 (1.2–22) for patients who received systemic steroids before the surgery.
Conclusion:
The stapled end-to-side anastomosis is an efficient, reliable, and reproducible approach to maintain bowel continuity after ileocecal resection with durable outcomes. Our outcomes demonstrate low rates of disease recurrence and stand favorably in comparison to other more technically complex or protracted anastomotic approaches. This anastomosis is an ideal reconstructive approach after ileocecal resection for Crohn’s disease.
Purpose The aim of this study is to determine if resident involvement in a large cohort of laparoscopic colorectal surgery (LCS) cases negatively impacts outcomes and ultimately increases costs. ...Methods The American College of Surgeons National Surgical Quality Improvement Program database was queried for patients who underwent LCS between 2005 and 2010. Patients were classified into two groups: postgraduate year (PGY; resident involvement) or Attending Only. A subgroup analysis was then conducted among the individual PGY levels (1–2, 3–5, ≥6) and Attending Only group. Results A total of 4,836 patients were included in the PGY group and 2,418 in the Attending Only group. Mean operative time (163.9 ± 66.7 vs. 140.7 ± 67.2 minutes, P < .001) and length of hospital stay (5.8 ± 5.4 vs. 5.6 ± 5.4 days, P = .015) were significantly longer in the PGY group. Surgical and nonsurgical complications and overall morbidity and mortality rates were similar between the two groups. Each individual PGY group was associated with longer operative time ( P < .001), and PGY ≥ 6 was associated with an increased length of stay ( P < .001). Conclusion Although resident participation in LCS does not affect overall mortality or morbidity, it may negatively impact hospital costs through increased operative time and length of hospital stay. Early and intensive laparoscopy training may be necessary for improving residents' laparoscopy skills before their involvement in LCS.
Background Several factors predictive of readmission after colorectal surgery have been identified. Although often grouped together in readmission studies, colon and rectal resections differ in many ...ways. The aim of this study was to identify factors associated with readmission after rectal resection. Study Design We performed a retrospective, single-center cohort study of 565 patients who underwent rectal resections at a tertiary referral center in 2010 and 2011. The main outcomes measure was readmission within 30 days. Univariate comparison between readmitted and nonreadmitted patients was followed by a stepwise logistic regression to identify independent risk factors for readmission. Results There were 105 patients (18.6%) readmitted. Indication (inflammatory bowel disease IBD, p = 0.008), type of operation (pelvic pouch surgery, p = 0.02), use of laparoscopy (readmission 27.8% vs 14%, p < 0.001), and length of operation (p < 0.001) were associated with a higher readmission rate on univariate analysis. Neither preoperative chemoradiation (p = 0.89) nor American Society of Anesthesiologists class (p = 0.09) was associated with readmission. Logistic regression showed use of laparoscopy (odds ratio OR 1.94, 95% CI 1.23 to 3.07), initial diagnosis of IBD (OR 1.84, 95% CI 1.17 to 2.93), and length of operation (OR 1.09, 95% CI 1.03 to 1.16 per 30 minutes) to be independent risk factors. Risks of readmission were 6.7%, 13.4%, 27.4%, and 27.4% with 0, 1, 2, or 3 positive risk factors, respectively. Conclusions Readmission after rectal resection is associated with the indication for surgery and the operative technique used. Optimization of factors related to the underlying pathology and careful appraisal of the operative technique may result in decreased readmission after proctectomy.
Background Annual surveillance colonoscopy to detect colon cancer is recommended for patients with primary sclerosing cholangitis (PSC) and ulcerative colitis (UC). Limited data currently support ...these recommendations. Objective To study whether a relationship exists between the severity and duration of PSC and the risk of colon cancer and dysplasia (colon neoplasia). Design Retrospective, longitudinal study. Setting Tertiary-care referral center. Patients Information pertaining to duration of PSC, UC, requirement for orthotopic liver transplantation, and time to diagnosis of colon neoplasia was obtained for patients with PSC and UC. Patients were evaluated and followed-up from 1985 to 2011 at a single institution. Main Outcome Measurements Association between the severity and duration of PSC-UC and the time of occurrence of colon neoplasia. Results Of 167 patients with a combined diagnosis of PSC-UC, 55 had colonic neoplasia on colonoscopy. Colonic neoplasia occurred more frequently within 2 years of a combined diagnosis of PSC-UC (6.6/100 patient-years of follow-up) than after 8 years from PSC-UC (2.7/100 patient-years of follow-up). On proportional hazards analysis, older age at PSC diagnosis (hazard ratio 1.23 for every 5 years; 95% confidence interval, 1.03-1.34; P = .014) increased the risk of colon neoplasia. Limitations Retrospective study. Conclusion In this study, the severity of PSC was not significantly associated with the risk of colon neoplasia. Patients with PSC and UC have a high risk of colon neoplasia soon after the coexistence of the two diseases is discovered. Older age at PSC diagnosis increases this risk.
Background The aim of this study was to develop a novel prognostic model that captures complex interplay among clinical and histologic factors to predict survival of patients with colorectal cancer ...after a radical potentially curative resection. Study Design Survival data of 2,505 colon cancer and 2,430 rectal cancer patients undergoing radical colorectal resection between 1969 and 2007 were analyzed by random forest technology. The effect of TNM and non-TNM factors such as histologic grade, lymph node ratio (number positive/number resected), type of operation, neoadjuvant and adjuvant treatment, American Society of Anesthesiologists (ASA) class, and age in staging and prognosis were evaluated. A forest of 1,000 random survival trees was grown using log-rank splitting. Competing risk-adjusted random survival forest methods were used to maximize survival prediction and produce importance measures of the predictor variables. Results Competing risk-adjusted 5-year survival after resection of colon and rectal cancer was dominated by pT stage (ie, tumor infiltration depth) and lymph node ratio. Increased lymph node ratio was associated with worse survival within the same pT stage for both colon and rectal cancer patients. Whereas survival for colon cancer was affected by ASA grade, the type of resection and neoadjuvant therapy had a strong effect on rectal cancer survival. A similar pattern in predicted survival rates was observed for patients with fewer than 12 lymph nodes examined. Our model suggests that lymph node ratio remains a significant predictor of survival in this group. Conclusions A novel data-driven methodology predicts the survival times of patients with colorectal cancer and identifies patterns of cancer characteristics. The methods lead to stage groupings that could redefine the composition of TNM in a simple and orderly way. The higher predictive power of lymph node ratio as compared with traditional pN lymph node stage has specific implications and may address the important question of accuracy of staging in patients when fewer than 12 nodes are identified in the resection specimen.
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