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Lap surgery not to blame for post-appy infection in children
BOSTON – Operative approach, as previously suggested, was not a significant predictor of postappendectomy organ space infection in children, according to a large, national database analysis.
Instead, organ space infection appears to be associated with largely nonmodifiable factors of disease severity, preoperative sepsis, and long operative duration, Dr. Fergal J. Fleming said at the annual meeting of the American Surgical Association.
"It would appear that the die is cast with respect to the risk of organ space infection at the time of presentation," he said. "This would suggest that our focus, in terms of quality improvement, should be on identifying patients at highest risk for complications."
The study findings are important because laparoscopic appendectomy has become widely accepted in children and adults, but has also been associated with increased odds of intra-abdominal abscess formation in adults (Ann. Surg. 2010;252:895-900), said Dr. Fleming, a colorectal surgeon at the University of Rochester (N.Y.) Medical Center.
To determine the effect of surgical approach on organ space infection (OSI) in children, Dr. Fleming and his associates analyzed 5,097 children, aged 2-18 years, undergoing open or laparoscopic appendectomy for acute appendicitis in the 2012 ACS National Surgical Quality Improvement Program (ACS NSQIP) pediatric database. The approach was laparoscopic in 4,514 patients (88.5%) and open in 583 patients.
OSI occurred in only 155 children (3%), but accounted for more than half of reoperations and nearly two-thirds of readmissions at 30 days, Dr. Fleming reported.
The unadjusted OSI rate was 0.9% (31/3,613) for uncomplicated appendicitis and 8.4% (124/1,484) for complicated appendicitis, which was a significant difference (P less than .001).
OSI rates did not differ significantly between laparoscopic and open surgery for uncomplicated appendicitis (0.8% vs. 1.7%; P = .160) and complicated appendicitis (8.7% vs. 7.3%; P = .415), defined by abscess, perforation, or sepsis.
In multivariable logistic regression analysis, complicated appendicitis was again the major factor associated with OSI (adjusted odds ratio, 4.85), he said. Other significant drivers were wound class III/IV (OR, 4.17), preoperative sepsis (OR, 2.19), and operative time of 60 minutes or more (OR, 2.15).
The model, which controlled for age, sex, pulmonary comorbidity, obesity, and emergency operations, had excellent predictive ability, with a c-statistic of 0.837, Dr. Fleming said.
He acknowledged that baseline differences between the two groups suggested that sicker children may have been selected as candidates for open surgery. Compared with the laparoscopic group, the open surgery group had significantly higher rates of preoperative sepsis/septic shock (24.7% vs. 14.7%), complicated appendicitis (58.8% vs. 25.3%), and emergency surgery (74.4% vs. 62%; all P values less than .001).
"Now that your group has identified these perioperative risk factors for children undergoing emergency appendectomy, do you have any guidelines for pediatric surgeons on how to follow their patients postop to identify organ space infections earlier?" asked discussant Dr. Paul Colombani, Children’s Surgeon-in Charge, Johns Hopkins Hospital, Baltimore.
Dr. Fleming suggested a bundle for high-risk patients that could include predischarge education for parents and patients, an early clinic visit before postoperative day 9, and a structured telephone call on day 2 or 3 post discharge to run through risk factors such as low-grade fever, malaise, and diarrhea. He noted that high-risk patients represented less than 15% of the cohort, but 80% of OSI events.
Dr. Fleming reported having no financial disclosures.
The complete manuscript of this study and its presentation at the American Surgical Association’s 134th Annual Meeting, April 2014, in Boston, is anticipated to be published in Annals of Surgery, pending editorial review.
BOSTON – Operative approach, as previously suggested, was not a significant predictor of postappendectomy organ space infection in children, according to a large, national database analysis.
Instead, organ space infection appears to be associated with largely nonmodifiable factors of disease severity, preoperative sepsis, and long operative duration, Dr. Fergal J. Fleming said at the annual meeting of the American Surgical Association.
"It would appear that the die is cast with respect to the risk of organ space infection at the time of presentation," he said. "This would suggest that our focus, in terms of quality improvement, should be on identifying patients at highest risk for complications."
The study findings are important because laparoscopic appendectomy has become widely accepted in children and adults, but has also been associated with increased odds of intra-abdominal abscess formation in adults (Ann. Surg. 2010;252:895-900), said Dr. Fleming, a colorectal surgeon at the University of Rochester (N.Y.) Medical Center.
To determine the effect of surgical approach on organ space infection (OSI) in children, Dr. Fleming and his associates analyzed 5,097 children, aged 2-18 years, undergoing open or laparoscopic appendectomy for acute appendicitis in the 2012 ACS National Surgical Quality Improvement Program (ACS NSQIP) pediatric database. The approach was laparoscopic in 4,514 patients (88.5%) and open in 583 patients.
OSI occurred in only 155 children (3%), but accounted for more than half of reoperations and nearly two-thirds of readmissions at 30 days, Dr. Fleming reported.
The unadjusted OSI rate was 0.9% (31/3,613) for uncomplicated appendicitis and 8.4% (124/1,484) for complicated appendicitis, which was a significant difference (P less than .001).
OSI rates did not differ significantly between laparoscopic and open surgery for uncomplicated appendicitis (0.8% vs. 1.7%; P = .160) and complicated appendicitis (8.7% vs. 7.3%; P = .415), defined by abscess, perforation, or sepsis.
In multivariable logistic regression analysis, complicated appendicitis was again the major factor associated with OSI (adjusted odds ratio, 4.85), he said. Other significant drivers were wound class III/IV (OR, 4.17), preoperative sepsis (OR, 2.19), and operative time of 60 minutes or more (OR, 2.15).
The model, which controlled for age, sex, pulmonary comorbidity, obesity, and emergency operations, had excellent predictive ability, with a c-statistic of 0.837, Dr. Fleming said.
He acknowledged that baseline differences between the two groups suggested that sicker children may have been selected as candidates for open surgery. Compared with the laparoscopic group, the open surgery group had significantly higher rates of preoperative sepsis/septic shock (24.7% vs. 14.7%), complicated appendicitis (58.8% vs. 25.3%), and emergency surgery (74.4% vs. 62%; all P values less than .001).
"Now that your group has identified these perioperative risk factors for children undergoing emergency appendectomy, do you have any guidelines for pediatric surgeons on how to follow their patients postop to identify organ space infections earlier?" asked discussant Dr. Paul Colombani, Children’s Surgeon-in Charge, Johns Hopkins Hospital, Baltimore.
Dr. Fleming suggested a bundle for high-risk patients that could include predischarge education for parents and patients, an early clinic visit before postoperative day 9, and a structured telephone call on day 2 or 3 post discharge to run through risk factors such as low-grade fever, malaise, and diarrhea. He noted that high-risk patients represented less than 15% of the cohort, but 80% of OSI events.
Dr. Fleming reported having no financial disclosures.
The complete manuscript of this study and its presentation at the American Surgical Association’s 134th Annual Meeting, April 2014, in Boston, is anticipated to be published in Annals of Surgery, pending editorial review.
BOSTON – Operative approach, as previously suggested, was not a significant predictor of postappendectomy organ space infection in children, according to a large, national database analysis.
Instead, organ space infection appears to be associated with largely nonmodifiable factors of disease severity, preoperative sepsis, and long operative duration, Dr. Fergal J. Fleming said at the annual meeting of the American Surgical Association.
"It would appear that the die is cast with respect to the risk of organ space infection at the time of presentation," he said. "This would suggest that our focus, in terms of quality improvement, should be on identifying patients at highest risk for complications."
The study findings are important because laparoscopic appendectomy has become widely accepted in children and adults, but has also been associated with increased odds of intra-abdominal abscess formation in adults (Ann. Surg. 2010;252:895-900), said Dr. Fleming, a colorectal surgeon at the University of Rochester (N.Y.) Medical Center.
To determine the effect of surgical approach on organ space infection (OSI) in children, Dr. Fleming and his associates analyzed 5,097 children, aged 2-18 years, undergoing open or laparoscopic appendectomy for acute appendicitis in the 2012 ACS National Surgical Quality Improvement Program (ACS NSQIP) pediatric database. The approach was laparoscopic in 4,514 patients (88.5%) and open in 583 patients.
OSI occurred in only 155 children (3%), but accounted for more than half of reoperations and nearly two-thirds of readmissions at 30 days, Dr. Fleming reported.
The unadjusted OSI rate was 0.9% (31/3,613) for uncomplicated appendicitis and 8.4% (124/1,484) for complicated appendicitis, which was a significant difference (P less than .001).
OSI rates did not differ significantly between laparoscopic and open surgery for uncomplicated appendicitis (0.8% vs. 1.7%; P = .160) and complicated appendicitis (8.7% vs. 7.3%; P = .415), defined by abscess, perforation, or sepsis.
In multivariable logistic regression analysis, complicated appendicitis was again the major factor associated with OSI (adjusted odds ratio, 4.85), he said. Other significant drivers were wound class III/IV (OR, 4.17), preoperative sepsis (OR, 2.19), and operative time of 60 minutes or more (OR, 2.15).
The model, which controlled for age, sex, pulmonary comorbidity, obesity, and emergency operations, had excellent predictive ability, with a c-statistic of 0.837, Dr. Fleming said.
He acknowledged that baseline differences between the two groups suggested that sicker children may have been selected as candidates for open surgery. Compared with the laparoscopic group, the open surgery group had significantly higher rates of preoperative sepsis/septic shock (24.7% vs. 14.7%), complicated appendicitis (58.8% vs. 25.3%), and emergency surgery (74.4% vs. 62%; all P values less than .001).
"Now that your group has identified these perioperative risk factors for children undergoing emergency appendectomy, do you have any guidelines for pediatric surgeons on how to follow their patients postop to identify organ space infections earlier?" asked discussant Dr. Paul Colombani, Children’s Surgeon-in Charge, Johns Hopkins Hospital, Baltimore.
Dr. Fleming suggested a bundle for high-risk patients that could include predischarge education for parents and patients, an early clinic visit before postoperative day 9, and a structured telephone call on day 2 or 3 post discharge to run through risk factors such as low-grade fever, malaise, and diarrhea. He noted that high-risk patients represented less than 15% of the cohort, but 80% of OSI events.
Dr. Fleming reported having no financial disclosures.
The complete manuscript of this study and its presentation at the American Surgical Association’s 134th Annual Meeting, April 2014, in Boston, is anticipated to be published in Annals of Surgery, pending editorial review.
AT THE ASA ANNUAL MEETING
Major finding: OSI rates did not differ significantly between laparoscopic and open surgery for uncomplicated appendicitis (0.8% vs. 1.7%, respectively) and complicated appendicitis (8.7% vs. 7.3%), defined by abscess, perforation, or sepsis.
Data source: A retrospective analysis of 5,097 children undergoing appendectomy in the NSQIP database.
Disclosures: Dr. Fleming reported having no financial disclosures.
Aspirin Sensitivity Signals Asthma Severity
MADRID – Aspirin sensitivity was strongly associated with asthma severity and the presence of chronic rhinosinusitis with nasal polyps in a prospective, multicenter study.
"Aspirin sensitivity may be considered a clinical marker for severe asthma and for the presence of chronic rhinosinusitis with nasal polyps, and a potential marker for united airway disease," Dr. José Antonio Castillo reported at the world congress of the American College of Chest Physicians.
Aspirin-exacerbated respiratory disease is commonly associated with chronic rhinosinusitis (CRS) with nasal polyps, but little information is available on the correlation between aspirin sensitivity and severe asthma.
To evaluate the presence of aspirin sensitivity and CRS with nasal polyps in a cohort of asthmatic patients, pulmonologists and ear, nose, and throat specialists at 23 hospitals in Spain and Latin America recruited 492 patients, aged 18-70 years, attending outpatient clinics with the diagnosis of asthma for at least 1 year. Aspirin sensitivity was assessed by clinical history and/or aspirin challenge, and CRS with nasal polyps was assessed by nasal symptoms, nasal endoscopy, and sinus computed tomography (CT) scan.
Among 473 evaluable patients, 72 (15%) were aspirin sensitive, 14.6% had no nasosinal disease, 12.6% nonallergic rhinitis, 36.8% allergic rhinitis, 16.6% CRS without nasal polyps, and 19.4% CRS with nasal polyps.
*Aspirin-intolerant asthma was strongly related to asthma severity. In all, 3 of the 72 (4.2%) aspirin-intolerant patients were classified as having intermittent asthma (odds ratio, 1); 17 (23.6%) as mild persistent (OR, 4.3); 21 (29.2%) as moderate persistent (OR, 4.3); and 31 (43%) as severe persistent asthma, which was statistically significant (OR, 7.8; P less than .05), reported Dr. Castillo, with the pneumology service at Chiron Dexeus University Hospital, Barcelona.
The presence of CRS with nasal polyps was also significantly associated (38.9%; 28/72 patients) with aspirin sensitivity (OR, 9.05; P less than .001).
Aspirin sensitivity was present in 4.5% of patients with no nasosinal disease, 18.6% of those with nonallergic rhinitis, 9.2% with allergic rhinitis, 17.5% with CRS with no nasal polyps, and 29.8% with CRS and nasal polyps.
Further, patients with aspirin-intolerant asthma showed significantly higher Lund & McKay CT scores than aspirin-tolerant asthmatic patients, according to the poster presentation.
The current results perhaps could be validated by matching aspirin sensitivity with a biomarker of severe asthma, that is, periostin, but are such that they already use aspirin sensitivity as a clinical marker of severe asthma, Dr. Castillo said in an interview.
Patients in the study had a mean age of 45 years and a mean body mass index of 26.9 kg/m2 (range, 16.8-49.8 kg/m2); 70.5% were female, and 9.6% were smokers.
Asthma was intermittent in 85 patients, mild persistent in 122, moderate persistent in 154, and severe persistent in 131, according to Global Initiative for Asthma (GINA) severity criteria.
Dr. Castillo and his coauthors reported no financial disclosures.
*This article was updated 4/7/14
MADRID – Aspirin sensitivity was strongly associated with asthma severity and the presence of chronic rhinosinusitis with nasal polyps in a prospective, multicenter study.
"Aspirin sensitivity may be considered a clinical marker for severe asthma and for the presence of chronic rhinosinusitis with nasal polyps, and a potential marker for united airway disease," Dr. José Antonio Castillo reported at the world congress of the American College of Chest Physicians.
Aspirin-exacerbated respiratory disease is commonly associated with chronic rhinosinusitis (CRS) with nasal polyps, but little information is available on the correlation between aspirin sensitivity and severe asthma.
To evaluate the presence of aspirin sensitivity and CRS with nasal polyps in a cohort of asthmatic patients, pulmonologists and ear, nose, and throat specialists at 23 hospitals in Spain and Latin America recruited 492 patients, aged 18-70 years, attending outpatient clinics with the diagnosis of asthma for at least 1 year. Aspirin sensitivity was assessed by clinical history and/or aspirin challenge, and CRS with nasal polyps was assessed by nasal symptoms, nasal endoscopy, and sinus computed tomography (CT) scan.
Among 473 evaluable patients, 72 (15%) were aspirin sensitive, 14.6% had no nasosinal disease, 12.6% nonallergic rhinitis, 36.8% allergic rhinitis, 16.6% CRS without nasal polyps, and 19.4% CRS with nasal polyps.
*Aspirin-intolerant asthma was strongly related to asthma severity. In all, 3 of the 72 (4.2%) aspirin-intolerant patients were classified as having intermittent asthma (odds ratio, 1); 17 (23.6%) as mild persistent (OR, 4.3); 21 (29.2%) as moderate persistent (OR, 4.3); and 31 (43%) as severe persistent asthma, which was statistically significant (OR, 7.8; P less than .05), reported Dr. Castillo, with the pneumology service at Chiron Dexeus University Hospital, Barcelona.
The presence of CRS with nasal polyps was also significantly associated (38.9%; 28/72 patients) with aspirin sensitivity (OR, 9.05; P less than .001).
Aspirin sensitivity was present in 4.5% of patients with no nasosinal disease, 18.6% of those with nonallergic rhinitis, 9.2% with allergic rhinitis, 17.5% with CRS with no nasal polyps, and 29.8% with CRS and nasal polyps.
Further, patients with aspirin-intolerant asthma showed significantly higher Lund & McKay CT scores than aspirin-tolerant asthmatic patients, according to the poster presentation.
The current results perhaps could be validated by matching aspirin sensitivity with a biomarker of severe asthma, that is, periostin, but are such that they already use aspirin sensitivity as a clinical marker of severe asthma, Dr. Castillo said in an interview.
Patients in the study had a mean age of 45 years and a mean body mass index of 26.9 kg/m2 (range, 16.8-49.8 kg/m2); 70.5% were female, and 9.6% were smokers.
Asthma was intermittent in 85 patients, mild persistent in 122, moderate persistent in 154, and severe persistent in 131, according to Global Initiative for Asthma (GINA) severity criteria.
Dr. Castillo and his coauthors reported no financial disclosures.
*This article was updated 4/7/14
MADRID – Aspirin sensitivity was strongly associated with asthma severity and the presence of chronic rhinosinusitis with nasal polyps in a prospective, multicenter study.
"Aspirin sensitivity may be considered a clinical marker for severe asthma and for the presence of chronic rhinosinusitis with nasal polyps, and a potential marker for united airway disease," Dr. José Antonio Castillo reported at the world congress of the American College of Chest Physicians.
Aspirin-exacerbated respiratory disease is commonly associated with chronic rhinosinusitis (CRS) with nasal polyps, but little information is available on the correlation between aspirin sensitivity and severe asthma.
To evaluate the presence of aspirin sensitivity and CRS with nasal polyps in a cohort of asthmatic patients, pulmonologists and ear, nose, and throat specialists at 23 hospitals in Spain and Latin America recruited 492 patients, aged 18-70 years, attending outpatient clinics with the diagnosis of asthma for at least 1 year. Aspirin sensitivity was assessed by clinical history and/or aspirin challenge, and CRS with nasal polyps was assessed by nasal symptoms, nasal endoscopy, and sinus computed tomography (CT) scan.
Among 473 evaluable patients, 72 (15%) were aspirin sensitive, 14.6% had no nasosinal disease, 12.6% nonallergic rhinitis, 36.8% allergic rhinitis, 16.6% CRS without nasal polyps, and 19.4% CRS with nasal polyps.
*Aspirin-intolerant asthma was strongly related to asthma severity. In all, 3 of the 72 (4.2%) aspirin-intolerant patients were classified as having intermittent asthma (odds ratio, 1); 17 (23.6%) as mild persistent (OR, 4.3); 21 (29.2%) as moderate persistent (OR, 4.3); and 31 (43%) as severe persistent asthma, which was statistically significant (OR, 7.8; P less than .05), reported Dr. Castillo, with the pneumology service at Chiron Dexeus University Hospital, Barcelona.
The presence of CRS with nasal polyps was also significantly associated (38.9%; 28/72 patients) with aspirin sensitivity (OR, 9.05; P less than .001).
Aspirin sensitivity was present in 4.5% of patients with no nasosinal disease, 18.6% of those with nonallergic rhinitis, 9.2% with allergic rhinitis, 17.5% with CRS with no nasal polyps, and 29.8% with CRS and nasal polyps.
Further, patients with aspirin-intolerant asthma showed significantly higher Lund & McKay CT scores than aspirin-tolerant asthmatic patients, according to the poster presentation.
The current results perhaps could be validated by matching aspirin sensitivity with a biomarker of severe asthma, that is, periostin, but are such that they already use aspirin sensitivity as a clinical marker of severe asthma, Dr. Castillo said in an interview.
Patients in the study had a mean age of 45 years and a mean body mass index of 26.9 kg/m2 (range, 16.8-49.8 kg/m2); 70.5% were female, and 9.6% were smokers.
Asthma was intermittent in 85 patients, mild persistent in 122, moderate persistent in 154, and severe persistent in 131, according to Global Initiative for Asthma (GINA) severity criteria.
Dr. Castillo and his coauthors reported no financial disclosures.
*This article was updated 4/7/14
Intraoperative wound anesthetic cut chronic pain after hip replacement
PARIS – Adding local anesthetic to the wound during total hip replacement surgery for osteoarthritis reduced chronic pain, according to a double-blind, randomized controlled trial.
At 12 months postoperative, the number of patients with severe pain was 8.6% with standard care, compared with 1.4% among those who also received 60 mL of 0.25% bupivacaine with lidocaine (Xylocaine) 1% with adrenaline 100 mcg/20 mL injected directly into the wound prior to closure.
The difference was statistically significant (P = .004; odds ratio, 10.19), but the confidence intervals were wide (95% C.I., 2.10-49.55) because of the small number of patients with severe pain, Vikki Wylde, Ph.D., said at the World Congress on Osteoarthritis.
She noted that 7%-23% of patients report moderate to severe chronic pain in the long term after total hip replacement, according to a recent systematic review (BMJ Open 2012:2:e000435), and that the severity of postoperative pain is a known risk factor for chronic postsurgical pain.
Local anesthetic wound infiltration has been shown to be effective at reducing the severity of acute postoperative pain after total hip replacement (J. Am Coll. Surg. 2006:203:914-32), but this is the first double-blind trial to assess its long-term effects.
Investigators at high-volume orthopedic centers in the United Kingdom randomly assigned 322 patients undergoing total hip replacement for osteoarthritis to standard care (spinal anesthesia with or without general anesthesia) alone or with local anesthetic infiltration. The primary outcome was WOMAC (Western Ontario and McMaster Universities Osteoarthritis Index) pain scale scores at 12 months postoperatively.
Use of in-patient analgesia or length of hospitalization did not differ between the groups, said Dr. Wylde, a research associate with the University of Bristol, England. Acute postoperative pain severity was also similar, except that patients in the intervention group reported less severe pain on postoperative night 2 (P = .008). This was unexpected, but the study was not powered to detect differences in these secondary measures, and no conclusions can be drawn from these data, she said at the meeting, sponsored by the Osteoarthritis Research Society International.
There were no differences in other secondary measures including the WOMAC function or stiffness scales or in ICOAP (Intermittent and Constant Osteoarthritis Pain) scores.
Local anesthetic infiltration, however, significantly reduced neuropathic pain at 12 months, as assessed using the PainDETECT questionnaire, Dr. Wylde said.
"Our study suggests that local anesthetic infiltration is unlikely to change long-term pain outcomes for the majority of patients, but potentially can improve pain relief for a small number of patients who may otherwise go on to develop severe long-term pain after surgery," she concluded.
In a separate interview, Dr. Jeffrey Katz, codirector, Brigham Spine Center, Brigham & Women’s Hospital and professor at Harvard Medical School, both in Boston, said the study was very interesting mechanistically and potentially interesting from a public health standpoint because there are about 400,000 hips done a year in the United States and thus 4,000 or so of these patients are having chronic pain. Moreover, the problem of chronic pain after surgery is even more common in the knee than in the hip.
"The difference in severe pain of 8% vs. 1% or 2% is a striking difference, but it’s a small incidence, and so it does bear replication," he added. "I thought it was a very exciting study and think it’s important information for folks to begin to work with and might change practice."
Dr. Wylde reported funding from the National Institute for Health Research, London.
PARIS – Adding local anesthetic to the wound during total hip replacement surgery for osteoarthritis reduced chronic pain, according to a double-blind, randomized controlled trial.
At 12 months postoperative, the number of patients with severe pain was 8.6% with standard care, compared with 1.4% among those who also received 60 mL of 0.25% bupivacaine with lidocaine (Xylocaine) 1% with adrenaline 100 mcg/20 mL injected directly into the wound prior to closure.
The difference was statistically significant (P = .004; odds ratio, 10.19), but the confidence intervals were wide (95% C.I., 2.10-49.55) because of the small number of patients with severe pain, Vikki Wylde, Ph.D., said at the World Congress on Osteoarthritis.
She noted that 7%-23% of patients report moderate to severe chronic pain in the long term after total hip replacement, according to a recent systematic review (BMJ Open 2012:2:e000435), and that the severity of postoperative pain is a known risk factor for chronic postsurgical pain.
Local anesthetic wound infiltration has been shown to be effective at reducing the severity of acute postoperative pain after total hip replacement (J. Am Coll. Surg. 2006:203:914-32), but this is the first double-blind trial to assess its long-term effects.
Investigators at high-volume orthopedic centers in the United Kingdom randomly assigned 322 patients undergoing total hip replacement for osteoarthritis to standard care (spinal anesthesia with or without general anesthesia) alone or with local anesthetic infiltration. The primary outcome was WOMAC (Western Ontario and McMaster Universities Osteoarthritis Index) pain scale scores at 12 months postoperatively.
Use of in-patient analgesia or length of hospitalization did not differ between the groups, said Dr. Wylde, a research associate with the University of Bristol, England. Acute postoperative pain severity was also similar, except that patients in the intervention group reported less severe pain on postoperative night 2 (P = .008). This was unexpected, but the study was not powered to detect differences in these secondary measures, and no conclusions can be drawn from these data, she said at the meeting, sponsored by the Osteoarthritis Research Society International.
There were no differences in other secondary measures including the WOMAC function or stiffness scales or in ICOAP (Intermittent and Constant Osteoarthritis Pain) scores.
Local anesthetic infiltration, however, significantly reduced neuropathic pain at 12 months, as assessed using the PainDETECT questionnaire, Dr. Wylde said.
"Our study suggests that local anesthetic infiltration is unlikely to change long-term pain outcomes for the majority of patients, but potentially can improve pain relief for a small number of patients who may otherwise go on to develop severe long-term pain after surgery," she concluded.
In a separate interview, Dr. Jeffrey Katz, codirector, Brigham Spine Center, Brigham & Women’s Hospital and professor at Harvard Medical School, both in Boston, said the study was very interesting mechanistically and potentially interesting from a public health standpoint because there are about 400,000 hips done a year in the United States and thus 4,000 or so of these patients are having chronic pain. Moreover, the problem of chronic pain after surgery is even more common in the knee than in the hip.
"The difference in severe pain of 8% vs. 1% or 2% is a striking difference, but it’s a small incidence, and so it does bear replication," he added. "I thought it was a very exciting study and think it’s important information for folks to begin to work with and might change practice."
Dr. Wylde reported funding from the National Institute for Health Research, London.
PARIS – Adding local anesthetic to the wound during total hip replacement surgery for osteoarthritis reduced chronic pain, according to a double-blind, randomized controlled trial.
At 12 months postoperative, the number of patients with severe pain was 8.6% with standard care, compared with 1.4% among those who also received 60 mL of 0.25% bupivacaine with lidocaine (Xylocaine) 1% with adrenaline 100 mcg/20 mL injected directly into the wound prior to closure.
The difference was statistically significant (P = .004; odds ratio, 10.19), but the confidence intervals were wide (95% C.I., 2.10-49.55) because of the small number of patients with severe pain, Vikki Wylde, Ph.D., said at the World Congress on Osteoarthritis.
She noted that 7%-23% of patients report moderate to severe chronic pain in the long term after total hip replacement, according to a recent systematic review (BMJ Open 2012:2:e000435), and that the severity of postoperative pain is a known risk factor for chronic postsurgical pain.
Local anesthetic wound infiltration has been shown to be effective at reducing the severity of acute postoperative pain after total hip replacement (J. Am Coll. Surg. 2006:203:914-32), but this is the first double-blind trial to assess its long-term effects.
Investigators at high-volume orthopedic centers in the United Kingdom randomly assigned 322 patients undergoing total hip replacement for osteoarthritis to standard care (spinal anesthesia with or without general anesthesia) alone or with local anesthetic infiltration. The primary outcome was WOMAC (Western Ontario and McMaster Universities Osteoarthritis Index) pain scale scores at 12 months postoperatively.
Use of in-patient analgesia or length of hospitalization did not differ between the groups, said Dr. Wylde, a research associate with the University of Bristol, England. Acute postoperative pain severity was also similar, except that patients in the intervention group reported less severe pain on postoperative night 2 (P = .008). This was unexpected, but the study was not powered to detect differences in these secondary measures, and no conclusions can be drawn from these data, she said at the meeting, sponsored by the Osteoarthritis Research Society International.
There were no differences in other secondary measures including the WOMAC function or stiffness scales or in ICOAP (Intermittent and Constant Osteoarthritis Pain) scores.
Local anesthetic infiltration, however, significantly reduced neuropathic pain at 12 months, as assessed using the PainDETECT questionnaire, Dr. Wylde said.
"Our study suggests that local anesthetic infiltration is unlikely to change long-term pain outcomes for the majority of patients, but potentially can improve pain relief for a small number of patients who may otherwise go on to develop severe long-term pain after surgery," she concluded.
In a separate interview, Dr. Jeffrey Katz, codirector, Brigham Spine Center, Brigham & Women’s Hospital and professor at Harvard Medical School, both in Boston, said the study was very interesting mechanistically and potentially interesting from a public health standpoint because there are about 400,000 hips done a year in the United States and thus 4,000 or so of these patients are having chronic pain. Moreover, the problem of chronic pain after surgery is even more common in the knee than in the hip.
"The difference in severe pain of 8% vs. 1% or 2% is a striking difference, but it’s a small incidence, and so it does bear replication," he added. "I thought it was a very exciting study and think it’s important information for folks to begin to work with and might change practice."
Dr. Wylde reported funding from the National Institute for Health Research, London.
AT OARSI 2014
Major finding: Severe pain at 12 months was reduced from 8.6% with standard care to 1.4% with the addition of local anesthetic wound infiltration (P = .004).
Data source: Double-blind, randomized controlled trial in 322 patients undergoing total hip replacement for osteoarthritis.
Disclosures: Dr. Wylde reported funding from the National Institute for Health Research, London.
PCPs waffle in referrals for total joint replacement
PARIS – Primary care physicians are only moderately confident about which patients to refer for total hip or knee replacement, according to cross-sectional survey of 218 physicians.
One-quarter (27.4%) were unsure about the risks of total joint arthroplasty (TJA), and 44.3% reported they were discouraged from referring patients for TJA because of a lack of clarity about surgical indications.
When asked how confident they were in deciding which patients should be referred to orthopedic surgery for consideration of hip or knee replacement, the average response was 6.9 on a 10-point scale from "not at all" to "highly confident," indicating a moderate level of confidence, Esther* Waugh, Ph.D., reported at the World Congress on Osteoarthritis.
"The results suggest the need for increased guidance for primary care physicians regarding which patient, and when, total joint arthroplasty should be considered," she concluded. "While lack of confidence does not necessarily equate with decreased competence, additional clarity may result in enhanced physician confidence, improved decision making, and ultimately better surgical outcomes through better patient selection of appropriate candidates."
A total of 376 primary care physicians (PCPs) were recruited from among those providing care to participants of an established community cohort with symptomatic hip or knee osteoarthritis (OA) in Ontario, Canada, with 218 (58%) completing the standardized questionnaire by mail or online.
One-third reported seeing more than 10 moderate to severe hip/knee OA patients in the previous 2 weeks.
Most had been in practice for more than 15 years (77%), were in group practice (63%), and were older than age 50 years (65%). One-third practiced in a rural location, and 31% had more than 10 TJA referrals per year.
Interestingly, total hip and total knee arthroplasty was perceived as "very effective" by 53% and 40% of physicians, respectively, according to Dr. Waugh of the physical therapy department at the University of Toronto.
Still, TJA was viewed as carrying high risks of death by 11.3%, of complications by 35%, and need for revision surgery by 12.3%.
Lower confidence in referring patients for TJA was independently associated with lack of clarity about surgical indications (P less than .0001; parameter estimate, –1.02) and female sex (P = .02; parameter estimate, –0.54), in multiple linear regression analysis.
Both factors were associated with fewer years of practice, she noted. Female physicians were significantly more likely to report fewer years of practice (P less than .0001), fewer OA patients (P = .0004), practicing in a group practice (P = .003), urban practice location (P = .003), and being unsure about risks (P = .02).
Confidence was not associated with uncertainty of TJA risks, volume of OA patients in the prior 2 weeks, group practice, years of practice, or rural practice setting, Dr. Waugh reported at the meeting, sponsored by the Osteoarthritis Research Society International.
Prior research by the University of Toronto team demonstrated underuse of total joint arthroplasty, but concerns have recently been raised regarding possible overuse, particularly in younger patients. In Canada, PCPs are responsible for referrals to orthopedic surgery for TJA. Thus, "inappropriate under- or overuse of TJA may be a consequence of uncertainty among PCPs about indications for TJA," the authors noted in the poster presentation
Conflict of interest disclosures were not available at press time.
*Correction, 5/8/2014: An earlier version of this story misspelled Dr. Esther Waugh's name.
PARIS – Primary care physicians are only moderately confident about which patients to refer for total hip or knee replacement, according to cross-sectional survey of 218 physicians.
One-quarter (27.4%) were unsure about the risks of total joint arthroplasty (TJA), and 44.3% reported they were discouraged from referring patients for TJA because of a lack of clarity about surgical indications.
When asked how confident they were in deciding which patients should be referred to orthopedic surgery for consideration of hip or knee replacement, the average response was 6.9 on a 10-point scale from "not at all" to "highly confident," indicating a moderate level of confidence, Esther* Waugh, Ph.D., reported at the World Congress on Osteoarthritis.
"The results suggest the need for increased guidance for primary care physicians regarding which patient, and when, total joint arthroplasty should be considered," she concluded. "While lack of confidence does not necessarily equate with decreased competence, additional clarity may result in enhanced physician confidence, improved decision making, and ultimately better surgical outcomes through better patient selection of appropriate candidates."
A total of 376 primary care physicians (PCPs) were recruited from among those providing care to participants of an established community cohort with symptomatic hip or knee osteoarthritis (OA) in Ontario, Canada, with 218 (58%) completing the standardized questionnaire by mail or online.
One-third reported seeing more than 10 moderate to severe hip/knee OA patients in the previous 2 weeks.
Most had been in practice for more than 15 years (77%), were in group practice (63%), and were older than age 50 years (65%). One-third practiced in a rural location, and 31% had more than 10 TJA referrals per year.
Interestingly, total hip and total knee arthroplasty was perceived as "very effective" by 53% and 40% of physicians, respectively, according to Dr. Waugh of the physical therapy department at the University of Toronto.
Still, TJA was viewed as carrying high risks of death by 11.3%, of complications by 35%, and need for revision surgery by 12.3%.
Lower confidence in referring patients for TJA was independently associated with lack of clarity about surgical indications (P less than .0001; parameter estimate, –1.02) and female sex (P = .02; parameter estimate, –0.54), in multiple linear regression analysis.
Both factors were associated with fewer years of practice, she noted. Female physicians were significantly more likely to report fewer years of practice (P less than .0001), fewer OA patients (P = .0004), practicing in a group practice (P = .003), urban practice location (P = .003), and being unsure about risks (P = .02).
Confidence was not associated with uncertainty of TJA risks, volume of OA patients in the prior 2 weeks, group practice, years of practice, or rural practice setting, Dr. Waugh reported at the meeting, sponsored by the Osteoarthritis Research Society International.
Prior research by the University of Toronto team demonstrated underuse of total joint arthroplasty, but concerns have recently been raised regarding possible overuse, particularly in younger patients. In Canada, PCPs are responsible for referrals to orthopedic surgery for TJA. Thus, "inappropriate under- or overuse of TJA may be a consequence of uncertainty among PCPs about indications for TJA," the authors noted in the poster presentation
Conflict of interest disclosures were not available at press time.
*Correction, 5/8/2014: An earlier version of this story misspelled Dr. Esther Waugh's name.
PARIS – Primary care physicians are only moderately confident about which patients to refer for total hip or knee replacement, according to cross-sectional survey of 218 physicians.
One-quarter (27.4%) were unsure about the risks of total joint arthroplasty (TJA), and 44.3% reported they were discouraged from referring patients for TJA because of a lack of clarity about surgical indications.
When asked how confident they were in deciding which patients should be referred to orthopedic surgery for consideration of hip or knee replacement, the average response was 6.9 on a 10-point scale from "not at all" to "highly confident," indicating a moderate level of confidence, Esther* Waugh, Ph.D., reported at the World Congress on Osteoarthritis.
"The results suggest the need for increased guidance for primary care physicians regarding which patient, and when, total joint arthroplasty should be considered," she concluded. "While lack of confidence does not necessarily equate with decreased competence, additional clarity may result in enhanced physician confidence, improved decision making, and ultimately better surgical outcomes through better patient selection of appropriate candidates."
A total of 376 primary care physicians (PCPs) were recruited from among those providing care to participants of an established community cohort with symptomatic hip or knee osteoarthritis (OA) in Ontario, Canada, with 218 (58%) completing the standardized questionnaire by mail or online.
One-third reported seeing more than 10 moderate to severe hip/knee OA patients in the previous 2 weeks.
Most had been in practice for more than 15 years (77%), were in group practice (63%), and were older than age 50 years (65%). One-third practiced in a rural location, and 31% had more than 10 TJA referrals per year.
Interestingly, total hip and total knee arthroplasty was perceived as "very effective" by 53% and 40% of physicians, respectively, according to Dr. Waugh of the physical therapy department at the University of Toronto.
Still, TJA was viewed as carrying high risks of death by 11.3%, of complications by 35%, and need for revision surgery by 12.3%.
Lower confidence in referring patients for TJA was independently associated with lack of clarity about surgical indications (P less than .0001; parameter estimate, –1.02) and female sex (P = .02; parameter estimate, –0.54), in multiple linear regression analysis.
Both factors were associated with fewer years of practice, she noted. Female physicians were significantly more likely to report fewer years of practice (P less than .0001), fewer OA patients (P = .0004), practicing in a group practice (P = .003), urban practice location (P = .003), and being unsure about risks (P = .02).
Confidence was not associated with uncertainty of TJA risks, volume of OA patients in the prior 2 weeks, group practice, years of practice, or rural practice setting, Dr. Waugh reported at the meeting, sponsored by the Osteoarthritis Research Society International.
Prior research by the University of Toronto team demonstrated underuse of total joint arthroplasty, but concerns have recently been raised regarding possible overuse, particularly in younger patients. In Canada, PCPs are responsible for referrals to orthopedic surgery for TJA. Thus, "inappropriate under- or overuse of TJA may be a consequence of uncertainty among PCPs about indications for TJA," the authors noted in the poster presentation
Conflict of interest disclosures were not available at press time.
*Correction, 5/8/2014: An earlier version of this story misspelled Dr. Esther Waugh's name.
AT OARSI 2014
Major finding: Lack of clarity about indications thwarted 44.3% of primary care physicians from referring patients for arthroplasty.
Data source: A cross-sectional survey of 218 primary care physicians.
Disclosures: Conflict of interest disclosures were not available at press time.
Men have more major complications after hip, knee replacement
PARIS – After total hip or knee replacement, men are at higher risk than women for heart attack, infection, and revision surgery, according to a large database analysis.
The elevated risk was particularly apparent following total knee arthroplasty (TKA), Dr. Gillian Hawker said at the World Congress on Osteoarthritis.
Prior research suggests that younger patients and males who have joint replacement are at higher risk of certain complications such as early revision, and that joint replacement is underutilized in women.
Based on the current study, underuse of total joint arthroplasty among women versus men does not appear to be explained by higher surgical risk, she said.
The investigators used administrative databases to analyze 97,445 patients who underwent primary, elective total joint arthroplasty in Ontario, Canada, between 2002 and 2009. In all, 59,564 patients (39% male) underwent TKA and 37,881 patients (46% male) had total hip arthroplasty.
Knee arthroplasty
Men had more acute myocardial infarctions within 90 days of undergoing TKA than did women (1.1% vs. 0.8%), more infection within 2 years of surgery (1.1% vs. 0.7%), and more revision TKA within 2 years (1.5% vs. 1%), said Dr. Hawker, professor of medicine at the University of Toronto and physician-in-chief of medicine, Women’s College Hospital, Toronto.
At baseline, the men were similar in age to women, but less likely to be frail (4% vs. 6.7%) and more likely to have a Charlson Comorbidity Index score of 2 or more (5.7% vs. 3.4%).
In Cox regression analysis, the risk for acute MI was significantly increased (hazard ratio, 1.79; P less than .0001) after adjustment for age, sex, income quartile, rurality, frailty, Charlson score, and hospital volume, she said.
Men were also at significantly increased risk for infection (HR, 1.67; P less than .0001) and revision TKA within 2 years (HR, 1.49; P less than .0001), after further adjustment for surgeon volume.
The investigators, led by colleague and orthopedic surgery resident Bheeshma Ravi, Ph.D., postulate that the increased risk of infection and revision among men is due to the high-impact activities that men may engage in after their prosthesis.
No sex differences were found for venous thromboembolism within 90 days or periprosthetic fracture within 2 years.
Hip arthroplasty
Men undergoing total hip replacement had higher rates of early acute MI than women (0.9% vs. 0.7%), but lower rates of periprosthetic fracture within 2 years (0.3% vs. 0.5%), Dr. Hawker said.
At baseline, male patients were younger than their female counterparts (65 years vs. 70 years) and less likely to be frail (3.5% vs. 6.6%), but more likely to have a Charlson score of 2 or more (5.3% vs. 3.7%).
After full adjustment, men were at significantly increased risk for acute MI (HR, 1.64; P less than .0001) and reduced risk for periprosthetic fracture (HR, 0.52; P = .0005), Dr. Hawker said at the meeting, which was sponsored by the Osteoarthritis Research Society International.
"We think the potential explanations for acute MI after both hip and knee replacement may be additional cardiovascular risk factors," she said. "We did not control for preexisting cardiovascular risk; that is something we are doing now."
The study excluded patients who had a pre–joint replacement fragility fracture, but because of the quality of the data postoperatively and the availability of drug benefit data, "we don’t feel we have adequate control for the presence of osteoporosis," Dr. Hawker observed.
No differences were found between sexes in the hip replacement cohort for infection, death, venous thromboembolism, dislocation, or revision.
Session comoderator Dr. Martin Englund, of Lund (Sweden) University, commented that the study was well conducted and the findings very interesting, but he cautioned against generalizing the results too broadly.
"We have seen before, that results from Sweden are not necessarily the same as in North America," he said in an interview. "I’m sure these results are probably very generalizable in Canada and in that type of health care setting, but may not be the same elsewhere. ... These are also things that might change over time. So we just need to keep monitoring outcomes and repeating these studies and adjust our treatment to what we find."
Dr. Ravi reported fellowship support from the University of Toronto, Canadian Institutes of Health Research, and Women’s College Research Institute.
PARIS – After total hip or knee replacement, men are at higher risk than women for heart attack, infection, and revision surgery, according to a large database analysis.
The elevated risk was particularly apparent following total knee arthroplasty (TKA), Dr. Gillian Hawker said at the World Congress on Osteoarthritis.
Prior research suggests that younger patients and males who have joint replacement are at higher risk of certain complications such as early revision, and that joint replacement is underutilized in women.
Based on the current study, underuse of total joint arthroplasty among women versus men does not appear to be explained by higher surgical risk, she said.
The investigators used administrative databases to analyze 97,445 patients who underwent primary, elective total joint arthroplasty in Ontario, Canada, between 2002 and 2009. In all, 59,564 patients (39% male) underwent TKA and 37,881 patients (46% male) had total hip arthroplasty.
Knee arthroplasty
Men had more acute myocardial infarctions within 90 days of undergoing TKA than did women (1.1% vs. 0.8%), more infection within 2 years of surgery (1.1% vs. 0.7%), and more revision TKA within 2 years (1.5% vs. 1%), said Dr. Hawker, professor of medicine at the University of Toronto and physician-in-chief of medicine, Women’s College Hospital, Toronto.
At baseline, the men were similar in age to women, but less likely to be frail (4% vs. 6.7%) and more likely to have a Charlson Comorbidity Index score of 2 or more (5.7% vs. 3.4%).
In Cox regression analysis, the risk for acute MI was significantly increased (hazard ratio, 1.79; P less than .0001) after adjustment for age, sex, income quartile, rurality, frailty, Charlson score, and hospital volume, she said.
Men were also at significantly increased risk for infection (HR, 1.67; P less than .0001) and revision TKA within 2 years (HR, 1.49; P less than .0001), after further adjustment for surgeon volume.
The investigators, led by colleague and orthopedic surgery resident Bheeshma Ravi, Ph.D., postulate that the increased risk of infection and revision among men is due to the high-impact activities that men may engage in after their prosthesis.
No sex differences were found for venous thromboembolism within 90 days or periprosthetic fracture within 2 years.
Hip arthroplasty
Men undergoing total hip replacement had higher rates of early acute MI than women (0.9% vs. 0.7%), but lower rates of periprosthetic fracture within 2 years (0.3% vs. 0.5%), Dr. Hawker said.
At baseline, male patients were younger than their female counterparts (65 years vs. 70 years) and less likely to be frail (3.5% vs. 6.6%), but more likely to have a Charlson score of 2 or more (5.3% vs. 3.7%).
After full adjustment, men were at significantly increased risk for acute MI (HR, 1.64; P less than .0001) and reduced risk for periprosthetic fracture (HR, 0.52; P = .0005), Dr. Hawker said at the meeting, which was sponsored by the Osteoarthritis Research Society International.
"We think the potential explanations for acute MI after both hip and knee replacement may be additional cardiovascular risk factors," she said. "We did not control for preexisting cardiovascular risk; that is something we are doing now."
The study excluded patients who had a pre–joint replacement fragility fracture, but because of the quality of the data postoperatively and the availability of drug benefit data, "we don’t feel we have adequate control for the presence of osteoporosis," Dr. Hawker observed.
No differences were found between sexes in the hip replacement cohort for infection, death, venous thromboembolism, dislocation, or revision.
Session comoderator Dr. Martin Englund, of Lund (Sweden) University, commented that the study was well conducted and the findings very interesting, but he cautioned against generalizing the results too broadly.
"We have seen before, that results from Sweden are not necessarily the same as in North America," he said in an interview. "I’m sure these results are probably very generalizable in Canada and in that type of health care setting, but may not be the same elsewhere. ... These are also things that might change over time. So we just need to keep monitoring outcomes and repeating these studies and adjust our treatment to what we find."
Dr. Ravi reported fellowship support from the University of Toronto, Canadian Institutes of Health Research, and Women’s College Research Institute.
PARIS – After total hip or knee replacement, men are at higher risk than women for heart attack, infection, and revision surgery, according to a large database analysis.
The elevated risk was particularly apparent following total knee arthroplasty (TKA), Dr. Gillian Hawker said at the World Congress on Osteoarthritis.
Prior research suggests that younger patients and males who have joint replacement are at higher risk of certain complications such as early revision, and that joint replacement is underutilized in women.
Based on the current study, underuse of total joint arthroplasty among women versus men does not appear to be explained by higher surgical risk, she said.
The investigators used administrative databases to analyze 97,445 patients who underwent primary, elective total joint arthroplasty in Ontario, Canada, between 2002 and 2009. In all, 59,564 patients (39% male) underwent TKA and 37,881 patients (46% male) had total hip arthroplasty.
Knee arthroplasty
Men had more acute myocardial infarctions within 90 days of undergoing TKA than did women (1.1% vs. 0.8%), more infection within 2 years of surgery (1.1% vs. 0.7%), and more revision TKA within 2 years (1.5% vs. 1%), said Dr. Hawker, professor of medicine at the University of Toronto and physician-in-chief of medicine, Women’s College Hospital, Toronto.
At baseline, the men were similar in age to women, but less likely to be frail (4% vs. 6.7%) and more likely to have a Charlson Comorbidity Index score of 2 or more (5.7% vs. 3.4%).
In Cox regression analysis, the risk for acute MI was significantly increased (hazard ratio, 1.79; P less than .0001) after adjustment for age, sex, income quartile, rurality, frailty, Charlson score, and hospital volume, she said.
Men were also at significantly increased risk for infection (HR, 1.67; P less than .0001) and revision TKA within 2 years (HR, 1.49; P less than .0001), after further adjustment for surgeon volume.
The investigators, led by colleague and orthopedic surgery resident Bheeshma Ravi, Ph.D., postulate that the increased risk of infection and revision among men is due to the high-impact activities that men may engage in after their prosthesis.
No sex differences were found for venous thromboembolism within 90 days or periprosthetic fracture within 2 years.
Hip arthroplasty
Men undergoing total hip replacement had higher rates of early acute MI than women (0.9% vs. 0.7%), but lower rates of periprosthetic fracture within 2 years (0.3% vs. 0.5%), Dr. Hawker said.
At baseline, male patients were younger than their female counterparts (65 years vs. 70 years) and less likely to be frail (3.5% vs. 6.6%), but more likely to have a Charlson score of 2 or more (5.3% vs. 3.7%).
After full adjustment, men were at significantly increased risk for acute MI (HR, 1.64; P less than .0001) and reduced risk for periprosthetic fracture (HR, 0.52; P = .0005), Dr. Hawker said at the meeting, which was sponsored by the Osteoarthritis Research Society International.
"We think the potential explanations for acute MI after both hip and knee replacement may be additional cardiovascular risk factors," she said. "We did not control for preexisting cardiovascular risk; that is something we are doing now."
The study excluded patients who had a pre–joint replacement fragility fracture, but because of the quality of the data postoperatively and the availability of drug benefit data, "we don’t feel we have adequate control for the presence of osteoporosis," Dr. Hawker observed.
No differences were found between sexes in the hip replacement cohort for infection, death, venous thromboembolism, dislocation, or revision.
Session comoderator Dr. Martin Englund, of Lund (Sweden) University, commented that the study was well conducted and the findings very interesting, but he cautioned against generalizing the results too broadly.
"We have seen before, that results from Sweden are not necessarily the same as in North America," he said in an interview. "I’m sure these results are probably very generalizable in Canada and in that type of health care setting, but may not be the same elsewhere. ... These are also things that might change over time. So we just need to keep monitoring outcomes and repeating these studies and adjust our treatment to what we find."
Dr. Ravi reported fellowship support from the University of Toronto, Canadian Institutes of Health Research, and Women’s College Research Institute.
AT OARSI 2014
Major finding: Men had more acute MIs within 90 days after total knee arthroplasty than did women (1.1% vs. 0.8%), more infection within 2 years of surgery (1.1% vs. 0.7%), and more revision surgery within 2 years (1.5% vs. 1%). After total hip replacement, men had a higher rate of early acute MI (0.9% vs. 0.7%), but less periprosthetic fracture within 2 years (0.3% vs. 0.5%).
Data source: Database analysis of 97,445 patients who received primary, elective hip or knee arthroplasty.
Disclosures: Dr. Ravi reported fellowship support from the University of Toronto, Canadian Institutes of Health Research, and Women’s College Research Institute.
Study backs bariatric surgery center accreditation
BOSTON – The Centers for Medicare & Medicaid Services may have dropped its accreditation requirement for bariatric surgery centers, but that hasn’t stopped the flow of data calling into question that decision.
A new analysis of 72,615 patients at 145 U.S. hospitals found that, compared with unaccredited centers, accredited centers have significantly decreased mortality (0.07% vs. 0.13%; P = .019) and improved failure to rescue rates (0.55% vs. 0.97%; P = .046).
They also have fewer complications (11.3% vs. 12.3%; P = .001) and lower average total costs ($42,212 vs. $51,189; P less than .0001).
"We found improved outcomes for these bariatric surgery patients," study author Dr. John M. Morton of Stanford (Calif.) University Medical Center said at the annual meeting of the American Surgical Association.
The September 2013 determination by CMS that "continuing the requirement for certification for bariatric surgery facilities would not improve health outcomes for Medicare beneficiaries" has been opposed by several medical societies, which cited results from 7 of 10 studies supporting accreditation.
Among the most outspoken supporters are the American Society for Metabolic and Bariatric Surgery (ASMBS) and the American College of Surgeons (ACS), which jointly manage a certification program.
During a discussion of the results, Dr. John Kellum Jr. of the Virginia Commonwealth University, Richmond, remarked, "I do wonder though if we aren’t raising a straw dog, which is somewhat self-serving. If you look at the P values, they’re very tiny."
He also pointed to regional variances in performance identified by the analysis and said, "In my opinion, the real advantage of accreditation is the record keeping that goes with it."
Dr. Morton responded, "I think your last point is exactly right. The ability to maintain the data and collect them allows you to have quality improvement. You can’t manage what you don’t measure. . . . Mortality has become pretty rare in bariatric surgery, but I think it’s what I’d call a sentinel event."
The current analysis comprised 62% of bariatric surgery discharges from 62% of hospitals in 2010-2011 in the Nationwide Inpatient Sample database, the largest all-payer, nonfederal database in the U.S.
The 66 unaccredited hospitals and 79 accredited hospitals had similar mean volumes (279 patients vs. 265 patients). Significantly more unaccredited hospitals were teaching hospitals (66.2% vs. 58%), while significantly more accredited hospitals were high-volume centers (81% vs. 53%), defined as at least 125 gastric bypass cases yearly.
Most patients (83%) underwent surgery at accredited hospitals, with both accredited and unaccredited hospitals favoring laparoscopic Roux-en-Y gastric bypass surgery (60.3%; 69.5%) followed by lap band surgery (25.7%; 15.6%), and laparoscopic sleeve gastrectomy (14% vs. 14.8%).
In multivariable regression analysis, procedure type did not exert an influence on outcomes. Unaccredited status, however, was a positive predictor of in-hospital complication (odds ratio, 1.09; P = .005) and in-hospital mortality (OR, 2.26; P = .007), Dr. Morton reported. The analysis controlled for teaching status; hospital high-volume status; patient age, sex, race, insurance, and Charlson Comorbidity Index score.
Discussant Dr. Bruce M. Wolfe of Oregon Health and Science University, Portland, asked whether the analysis could speak to the suggestion that accreditation has limited access to care and whether it will be possible to acquire the data necessary to satisfy the doubts of CMS and others regarding the value of bariatric surgery accreditation.
Dr. Morton said that with more than 729 bariatric surgery centers in the United States, there is "ample opportunity to access care," and that no study to date has shown that any of the accreditation programs has decreased the number of surgeries being performed. If anything, two studies have shown an increase.
He observed that it would be difficult to get definitive randomized trial evidence on the value of accreditation because all hospitals will have to deal with the accreditation process independent of CMS. The "hope, belief, and desire" is for a single accreditation process where there is less administrative burden for hospitals and a single reporting scheme, as may exist currently with the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP).
"I believe CMS will rightly take a look at what’s happened since they have suspended the certification process," Dr. Morton said. "They have created a natural experiment that bears further scrutiny to see what happens to these Medicare patients after the withdrawal of the certification for them."
Dr. Morton reported having no financial disclosures.
The complete manuscript of this study and its presentation at the American Surgical Association’s 134th annual meeting, April 2014, in Boston is anticipated to be published in the Annals of Surgery, pending editorial review.
BOSTON – The Centers for Medicare & Medicaid Services may have dropped its accreditation requirement for bariatric surgery centers, but that hasn’t stopped the flow of data calling into question that decision.
A new analysis of 72,615 patients at 145 U.S. hospitals found that, compared with unaccredited centers, accredited centers have significantly decreased mortality (0.07% vs. 0.13%; P = .019) and improved failure to rescue rates (0.55% vs. 0.97%; P = .046).
They also have fewer complications (11.3% vs. 12.3%; P = .001) and lower average total costs ($42,212 vs. $51,189; P less than .0001).
"We found improved outcomes for these bariatric surgery patients," study author Dr. John M. Morton of Stanford (Calif.) University Medical Center said at the annual meeting of the American Surgical Association.
The September 2013 determination by CMS that "continuing the requirement for certification for bariatric surgery facilities would not improve health outcomes for Medicare beneficiaries" has been opposed by several medical societies, which cited results from 7 of 10 studies supporting accreditation.
Among the most outspoken supporters are the American Society for Metabolic and Bariatric Surgery (ASMBS) and the American College of Surgeons (ACS), which jointly manage a certification program.
During a discussion of the results, Dr. John Kellum Jr. of the Virginia Commonwealth University, Richmond, remarked, "I do wonder though if we aren’t raising a straw dog, which is somewhat self-serving. If you look at the P values, they’re very tiny."
He also pointed to regional variances in performance identified by the analysis and said, "In my opinion, the real advantage of accreditation is the record keeping that goes with it."
Dr. Morton responded, "I think your last point is exactly right. The ability to maintain the data and collect them allows you to have quality improvement. You can’t manage what you don’t measure. . . . Mortality has become pretty rare in bariatric surgery, but I think it’s what I’d call a sentinel event."
The current analysis comprised 62% of bariatric surgery discharges from 62% of hospitals in 2010-2011 in the Nationwide Inpatient Sample database, the largest all-payer, nonfederal database in the U.S.
The 66 unaccredited hospitals and 79 accredited hospitals had similar mean volumes (279 patients vs. 265 patients). Significantly more unaccredited hospitals were teaching hospitals (66.2% vs. 58%), while significantly more accredited hospitals were high-volume centers (81% vs. 53%), defined as at least 125 gastric bypass cases yearly.
Most patients (83%) underwent surgery at accredited hospitals, with both accredited and unaccredited hospitals favoring laparoscopic Roux-en-Y gastric bypass surgery (60.3%; 69.5%) followed by lap band surgery (25.7%; 15.6%), and laparoscopic sleeve gastrectomy (14% vs. 14.8%).
In multivariable regression analysis, procedure type did not exert an influence on outcomes. Unaccredited status, however, was a positive predictor of in-hospital complication (odds ratio, 1.09; P = .005) and in-hospital mortality (OR, 2.26; P = .007), Dr. Morton reported. The analysis controlled for teaching status; hospital high-volume status; patient age, sex, race, insurance, and Charlson Comorbidity Index score.
Discussant Dr. Bruce M. Wolfe of Oregon Health and Science University, Portland, asked whether the analysis could speak to the suggestion that accreditation has limited access to care and whether it will be possible to acquire the data necessary to satisfy the doubts of CMS and others regarding the value of bariatric surgery accreditation.
Dr. Morton said that with more than 729 bariatric surgery centers in the United States, there is "ample opportunity to access care," and that no study to date has shown that any of the accreditation programs has decreased the number of surgeries being performed. If anything, two studies have shown an increase.
He observed that it would be difficult to get definitive randomized trial evidence on the value of accreditation because all hospitals will have to deal with the accreditation process independent of CMS. The "hope, belief, and desire" is for a single accreditation process where there is less administrative burden for hospitals and a single reporting scheme, as may exist currently with the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP).
"I believe CMS will rightly take a look at what’s happened since they have suspended the certification process," Dr. Morton said. "They have created a natural experiment that bears further scrutiny to see what happens to these Medicare patients after the withdrawal of the certification for them."
Dr. Morton reported having no financial disclosures.
The complete manuscript of this study and its presentation at the American Surgical Association’s 134th annual meeting, April 2014, in Boston is anticipated to be published in the Annals of Surgery, pending editorial review.
BOSTON – The Centers for Medicare & Medicaid Services may have dropped its accreditation requirement for bariatric surgery centers, but that hasn’t stopped the flow of data calling into question that decision.
A new analysis of 72,615 patients at 145 U.S. hospitals found that, compared with unaccredited centers, accredited centers have significantly decreased mortality (0.07% vs. 0.13%; P = .019) and improved failure to rescue rates (0.55% vs. 0.97%; P = .046).
They also have fewer complications (11.3% vs. 12.3%; P = .001) and lower average total costs ($42,212 vs. $51,189; P less than .0001).
"We found improved outcomes for these bariatric surgery patients," study author Dr. John M. Morton of Stanford (Calif.) University Medical Center said at the annual meeting of the American Surgical Association.
The September 2013 determination by CMS that "continuing the requirement for certification for bariatric surgery facilities would not improve health outcomes for Medicare beneficiaries" has been opposed by several medical societies, which cited results from 7 of 10 studies supporting accreditation.
Among the most outspoken supporters are the American Society for Metabolic and Bariatric Surgery (ASMBS) and the American College of Surgeons (ACS), which jointly manage a certification program.
During a discussion of the results, Dr. John Kellum Jr. of the Virginia Commonwealth University, Richmond, remarked, "I do wonder though if we aren’t raising a straw dog, which is somewhat self-serving. If you look at the P values, they’re very tiny."
He also pointed to regional variances in performance identified by the analysis and said, "In my opinion, the real advantage of accreditation is the record keeping that goes with it."
Dr. Morton responded, "I think your last point is exactly right. The ability to maintain the data and collect them allows you to have quality improvement. You can’t manage what you don’t measure. . . . Mortality has become pretty rare in bariatric surgery, but I think it’s what I’d call a sentinel event."
The current analysis comprised 62% of bariatric surgery discharges from 62% of hospitals in 2010-2011 in the Nationwide Inpatient Sample database, the largest all-payer, nonfederal database in the U.S.
The 66 unaccredited hospitals and 79 accredited hospitals had similar mean volumes (279 patients vs. 265 patients). Significantly more unaccredited hospitals were teaching hospitals (66.2% vs. 58%), while significantly more accredited hospitals were high-volume centers (81% vs. 53%), defined as at least 125 gastric bypass cases yearly.
Most patients (83%) underwent surgery at accredited hospitals, with both accredited and unaccredited hospitals favoring laparoscopic Roux-en-Y gastric bypass surgery (60.3%; 69.5%) followed by lap band surgery (25.7%; 15.6%), and laparoscopic sleeve gastrectomy (14% vs. 14.8%).
In multivariable regression analysis, procedure type did not exert an influence on outcomes. Unaccredited status, however, was a positive predictor of in-hospital complication (odds ratio, 1.09; P = .005) and in-hospital mortality (OR, 2.26; P = .007), Dr. Morton reported. The analysis controlled for teaching status; hospital high-volume status; patient age, sex, race, insurance, and Charlson Comorbidity Index score.
Discussant Dr. Bruce M. Wolfe of Oregon Health and Science University, Portland, asked whether the analysis could speak to the suggestion that accreditation has limited access to care and whether it will be possible to acquire the data necessary to satisfy the doubts of CMS and others regarding the value of bariatric surgery accreditation.
Dr. Morton said that with more than 729 bariatric surgery centers in the United States, there is "ample opportunity to access care," and that no study to date has shown that any of the accreditation programs has decreased the number of surgeries being performed. If anything, two studies have shown an increase.
He observed that it would be difficult to get definitive randomized trial evidence on the value of accreditation because all hospitals will have to deal with the accreditation process independent of CMS. The "hope, belief, and desire" is for a single accreditation process where there is less administrative burden for hospitals and a single reporting scheme, as may exist currently with the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP).
"I believe CMS will rightly take a look at what’s happened since they have suspended the certification process," Dr. Morton said. "They have created a natural experiment that bears further scrutiny to see what happens to these Medicare patients after the withdrawal of the certification for them."
Dr. Morton reported having no financial disclosures.
The complete manuscript of this study and its presentation at the American Surgical Association’s 134th annual meeting, April 2014, in Boston is anticipated to be published in the Annals of Surgery, pending editorial review.
AT THE ASA ANNUAL MEETING
Major finding: Compared with unaccredited centers, accredited centers have significantly decreased mortality (0.07% vs. 0.13%; P = .019) and improved failure to rescue rates (0.55% vs. 0.97%; P = .046).
Data source: An analysis of 72,615 patients at 145 U.S. hospitals in the Nationwide Inpatient Sample database.
Disclosures: Dr. Morton reported having no financial disclosures.
One-third of elective colectomies fail to meet indications
BOSTON – Though progress is being made in reducing surgery for diverticulitis, one in three elective colectomies failed to meet current indications in a prospective study.
Among 1,102 patients in Washington state with an episode-based indication for elective surgery, the proportion with three or more prior episodes of diverticulitis increased from 42% in 2010 to 58% in 2012 (P = .007), while the proportion failing to meet either complication- or episode-based indications decreased from 41.3% to 29.6% (P = .002).
"Still, there remains a significant and persistent portion of cases being done in Washington that do not meet established guidelines," Dr. Vlad V. Simianu said at the annual meeting of the American Surgical Association.
The study involved 2,031 patients having elective resection for diverticulitis in 2010-2012 in 49 hospitals in Washington state’s voluntary Surgical Care and Outcomes Assessment Program (SCOAP), which captures about 80% of the surgical volume in the state. Their mean age was 58.8 years, 24% were younger than 50 years, and most were healthy, with only 27% having a Charlson Comorbidity Index score of 1 or more.
Washington has seen a dramatic threefold increase in elective colectomy for diverticulitis over the last 13 years, despite evolving recommendations, observed Dr. Simianu, a general surgery resident and research fellow at the University of Washington, Seattle. The 2006 American Society of Colon and Rectal Surgeons (ASCRS) guidelines, which were used for the study end points, said elective surgery can be safely delayed until three or more acute episodes of uncomplicated diverticulitis. The ASCRS just updated its guidelines again (Dis. Colon Rectum 2014;57:284-94) and now strongly recommend that the decision to proceed to elective colectomy after recovery from uncomplicated acute diverticulitis "be individualized."
Among all 2,031 patients in the study, a clinical indication for surgery was present in 23.3% (chronic fistula 10.5%, stricture 5.4%, bleeding 2.4%, and other 5%), while 55% of the 1,102 patients with an episode-based indication had three or more episodes.
In 2010, 22% of all patients had at least three prior episodes, 17% had chronic complications, and 23% had neither. This compares with 37.7%, 18%.6%, and 16.7% in 2012.
Possible explanations for the rise in guideline-concordant cases are that surgeons are documenting their indications more carefully or are delaying more operations until three or more acute episodes, Dr. Simianu said. Indeed, there was a significant decrease in the number of cases with missing indications in the clinical record over the study period (38% vs. 27%; P = .007).
The persistence of cases not meeting indications could be because the adoption of laparoscopy has lowered the threshold for surgeons to offer colectomy, similar to what has happened with laparoscopic cholecystectomy, he said. A laparoscopic operation was performed in 60% of the patients.
Other possible explanations are that the guidelines don’t capture all relevant indications, like persistent symptoms or pain, or that evolving evidence and guidelines are forcing some surgeons to wait before they change their practice, Dr. Simianu said.
"Nonetheless, we view this as an educational opportunity in our state to give feedback to surgeons in our network," he said.
Notably, the rate of elective and emergency resections per year did not increase significantly over the study period at 28 high-volume hospitals, performing at least 10 colectomies yearly. Data, however, were incomplete or missing, in 30.4% of cases.
Discussant Dr. Conor Delaney, chief of colorectal surgery at University Hospitals Case Medical Center, Cleveland, said it was good to see that the percentage of cases performed for three or more episodes rose across all age groups in the final year of the study, suggesting that the SCOAP intervention is likely working.
"It is still shocking to see 30 or 40% of cases being performed for fewer than three attacks," he said, adding that the 30% of patients who had surgery without appropriate indications "may really be, very much a best-case scenario."
He also asked whether the investigators could identify hospitals inside and outside SCOAP that were less likely to follow guidelines and how they dealt with patients who may have had appropriate single-attack surgery because of nonresolution of symptoms or inadequate drainage.
Dr. Simianu said it wasn’t possible to determine indications for hospitals outside the SCOAP network, but that participating hospitals followed a normal distribution. High-volume hospitals were "sort of middle of the road," while four or five low-volume hospitals were outliers and never or always met indications.
In response to the second query, he said their clinical indications included an "other" category that captured appropriate first-attack patients and that about 1% of surgery was performed for an abscess.
The next phase of research will be to go into surgeons’ offices to speak with surgeons and patients to try and quantify the missing indications, Dr. Simianu said.
Dr. Simianu reported funding from the National Institute of Diabetes and Digestive and Kidney Disease, the Agency for Healthcare Research & Quality, and Life Sciences Discovery Fund. Three co-authors reported serving as an advisor, consultant, or speaker for pharmaceutical and device firms.
The complete manuscript of this study and its presentation at the American Surgical Association’s 134th Annual Meeting, April 2014, in Boston, Mass., is anticipated to be published in the Annals of Surgery, pending editorial review.
BOSTON – Though progress is being made in reducing surgery for diverticulitis, one in three elective colectomies failed to meet current indications in a prospective study.
Among 1,102 patients in Washington state with an episode-based indication for elective surgery, the proportion with three or more prior episodes of diverticulitis increased from 42% in 2010 to 58% in 2012 (P = .007), while the proportion failing to meet either complication- or episode-based indications decreased from 41.3% to 29.6% (P = .002).
"Still, there remains a significant and persistent portion of cases being done in Washington that do not meet established guidelines," Dr. Vlad V. Simianu said at the annual meeting of the American Surgical Association.
The study involved 2,031 patients having elective resection for diverticulitis in 2010-2012 in 49 hospitals in Washington state’s voluntary Surgical Care and Outcomes Assessment Program (SCOAP), which captures about 80% of the surgical volume in the state. Their mean age was 58.8 years, 24% were younger than 50 years, and most were healthy, with only 27% having a Charlson Comorbidity Index score of 1 or more.
Washington has seen a dramatic threefold increase in elective colectomy for diverticulitis over the last 13 years, despite evolving recommendations, observed Dr. Simianu, a general surgery resident and research fellow at the University of Washington, Seattle. The 2006 American Society of Colon and Rectal Surgeons (ASCRS) guidelines, which were used for the study end points, said elective surgery can be safely delayed until three or more acute episodes of uncomplicated diverticulitis. The ASCRS just updated its guidelines again (Dis. Colon Rectum 2014;57:284-94) and now strongly recommend that the decision to proceed to elective colectomy after recovery from uncomplicated acute diverticulitis "be individualized."
Among all 2,031 patients in the study, a clinical indication for surgery was present in 23.3% (chronic fistula 10.5%, stricture 5.4%, bleeding 2.4%, and other 5%), while 55% of the 1,102 patients with an episode-based indication had three or more episodes.
In 2010, 22% of all patients had at least three prior episodes, 17% had chronic complications, and 23% had neither. This compares with 37.7%, 18%.6%, and 16.7% in 2012.
Possible explanations for the rise in guideline-concordant cases are that surgeons are documenting their indications more carefully or are delaying more operations until three or more acute episodes, Dr. Simianu said. Indeed, there was a significant decrease in the number of cases with missing indications in the clinical record over the study period (38% vs. 27%; P = .007).
The persistence of cases not meeting indications could be because the adoption of laparoscopy has lowered the threshold for surgeons to offer colectomy, similar to what has happened with laparoscopic cholecystectomy, he said. A laparoscopic operation was performed in 60% of the patients.
Other possible explanations are that the guidelines don’t capture all relevant indications, like persistent symptoms or pain, or that evolving evidence and guidelines are forcing some surgeons to wait before they change their practice, Dr. Simianu said.
"Nonetheless, we view this as an educational opportunity in our state to give feedback to surgeons in our network," he said.
Notably, the rate of elective and emergency resections per year did not increase significantly over the study period at 28 high-volume hospitals, performing at least 10 colectomies yearly. Data, however, were incomplete or missing, in 30.4% of cases.
Discussant Dr. Conor Delaney, chief of colorectal surgery at University Hospitals Case Medical Center, Cleveland, said it was good to see that the percentage of cases performed for three or more episodes rose across all age groups in the final year of the study, suggesting that the SCOAP intervention is likely working.
"It is still shocking to see 30 or 40% of cases being performed for fewer than three attacks," he said, adding that the 30% of patients who had surgery without appropriate indications "may really be, very much a best-case scenario."
He also asked whether the investigators could identify hospitals inside and outside SCOAP that were less likely to follow guidelines and how they dealt with patients who may have had appropriate single-attack surgery because of nonresolution of symptoms or inadequate drainage.
Dr. Simianu said it wasn’t possible to determine indications for hospitals outside the SCOAP network, but that participating hospitals followed a normal distribution. High-volume hospitals were "sort of middle of the road," while four or five low-volume hospitals were outliers and never or always met indications.
In response to the second query, he said their clinical indications included an "other" category that captured appropriate first-attack patients and that about 1% of surgery was performed for an abscess.
The next phase of research will be to go into surgeons’ offices to speak with surgeons and patients to try and quantify the missing indications, Dr. Simianu said.
Dr. Simianu reported funding from the National Institute of Diabetes and Digestive and Kidney Disease, the Agency for Healthcare Research & Quality, and Life Sciences Discovery Fund. Three co-authors reported serving as an advisor, consultant, or speaker for pharmaceutical and device firms.
The complete manuscript of this study and its presentation at the American Surgical Association’s 134th Annual Meeting, April 2014, in Boston, Mass., is anticipated to be published in the Annals of Surgery, pending editorial review.
BOSTON – Though progress is being made in reducing surgery for diverticulitis, one in three elective colectomies failed to meet current indications in a prospective study.
Among 1,102 patients in Washington state with an episode-based indication for elective surgery, the proportion with three or more prior episodes of diverticulitis increased from 42% in 2010 to 58% in 2012 (P = .007), while the proportion failing to meet either complication- or episode-based indications decreased from 41.3% to 29.6% (P = .002).
"Still, there remains a significant and persistent portion of cases being done in Washington that do not meet established guidelines," Dr. Vlad V. Simianu said at the annual meeting of the American Surgical Association.
The study involved 2,031 patients having elective resection for diverticulitis in 2010-2012 in 49 hospitals in Washington state’s voluntary Surgical Care and Outcomes Assessment Program (SCOAP), which captures about 80% of the surgical volume in the state. Their mean age was 58.8 years, 24% were younger than 50 years, and most were healthy, with only 27% having a Charlson Comorbidity Index score of 1 or more.
Washington has seen a dramatic threefold increase in elective colectomy for diverticulitis over the last 13 years, despite evolving recommendations, observed Dr. Simianu, a general surgery resident and research fellow at the University of Washington, Seattle. The 2006 American Society of Colon and Rectal Surgeons (ASCRS) guidelines, which were used for the study end points, said elective surgery can be safely delayed until three or more acute episodes of uncomplicated diverticulitis. The ASCRS just updated its guidelines again (Dis. Colon Rectum 2014;57:284-94) and now strongly recommend that the decision to proceed to elective colectomy after recovery from uncomplicated acute diverticulitis "be individualized."
Among all 2,031 patients in the study, a clinical indication for surgery was present in 23.3% (chronic fistula 10.5%, stricture 5.4%, bleeding 2.4%, and other 5%), while 55% of the 1,102 patients with an episode-based indication had three or more episodes.
In 2010, 22% of all patients had at least three prior episodes, 17% had chronic complications, and 23% had neither. This compares with 37.7%, 18%.6%, and 16.7% in 2012.
Possible explanations for the rise in guideline-concordant cases are that surgeons are documenting their indications more carefully or are delaying more operations until three or more acute episodes, Dr. Simianu said. Indeed, there was a significant decrease in the number of cases with missing indications in the clinical record over the study period (38% vs. 27%; P = .007).
The persistence of cases not meeting indications could be because the adoption of laparoscopy has lowered the threshold for surgeons to offer colectomy, similar to what has happened with laparoscopic cholecystectomy, he said. A laparoscopic operation was performed in 60% of the patients.
Other possible explanations are that the guidelines don’t capture all relevant indications, like persistent symptoms or pain, or that evolving evidence and guidelines are forcing some surgeons to wait before they change their practice, Dr. Simianu said.
"Nonetheless, we view this as an educational opportunity in our state to give feedback to surgeons in our network," he said.
Notably, the rate of elective and emergency resections per year did not increase significantly over the study period at 28 high-volume hospitals, performing at least 10 colectomies yearly. Data, however, were incomplete or missing, in 30.4% of cases.
Discussant Dr. Conor Delaney, chief of colorectal surgery at University Hospitals Case Medical Center, Cleveland, said it was good to see that the percentage of cases performed for three or more episodes rose across all age groups in the final year of the study, suggesting that the SCOAP intervention is likely working.
"It is still shocking to see 30 or 40% of cases being performed for fewer than three attacks," he said, adding that the 30% of patients who had surgery without appropriate indications "may really be, very much a best-case scenario."
He also asked whether the investigators could identify hospitals inside and outside SCOAP that were less likely to follow guidelines and how they dealt with patients who may have had appropriate single-attack surgery because of nonresolution of symptoms or inadequate drainage.
Dr. Simianu said it wasn’t possible to determine indications for hospitals outside the SCOAP network, but that participating hospitals followed a normal distribution. High-volume hospitals were "sort of middle of the road," while four or five low-volume hospitals were outliers and never or always met indications.
In response to the second query, he said their clinical indications included an "other" category that captured appropriate first-attack patients and that about 1% of surgery was performed for an abscess.
The next phase of research will be to go into surgeons’ offices to speak with surgeons and patients to try and quantify the missing indications, Dr. Simianu said.
Dr. Simianu reported funding from the National Institute of Diabetes and Digestive and Kidney Disease, the Agency for Healthcare Research & Quality, and Life Sciences Discovery Fund. Three co-authors reported serving as an advisor, consultant, or speaker for pharmaceutical and device firms.
The complete manuscript of this study and its presentation at the American Surgical Association’s 134th Annual Meeting, April 2014, in Boston, Mass., is anticipated to be published in the Annals of Surgery, pending editorial review.
AT THE ASA ANNUAL MEETING
Major finding: The proportion of cases failing to meet either clinical or episode-based indications was 41.3% in 2010 and 29.6% in 2012 (P = .007).
Data source: A prospective study of 2,031 elective colectomies for diverticulitis at 49 hospitals in SCOAP.
Disclosures: Dr. Simianu reported funding from the National Institute of Diabetes and Digestive and Kidney Disease, the Agency for Healthcare Research & Quality, and Life Sciences Discovery Fund. Three coauthors reported serving as an adviser, consultant, or speaker for pharmaceutical and device firms.
High-dose steroids tame post-EVAR inflammation
BOSTON – Preoperative high-dose methylprednisolone dramatically reduced inflammation and enhanced recovery after endovascular aortic repair without increased morbidity in a prospective, double-blinded randomized study.
The primary outcome of modified systemic inflammatory response syndrome (SIRS) developed in 92% on placebo and 27% given methylprednisolone (relative risk, 0.29; P less than .001).
The effect was particularly striking in patients with three or more SIRS criteria, with an overall number needed to treat of 1.5, Dr. Henrik Kehlet said at the annual meeting of the American Surgical Association.
Tempering the postoperative inflammatory response with methylprednisolone also significantly trimmed hospital stays from 3 to 2 days (P less than .001) and morphine requirements from 10 mg to 0 mg (P less than .001).
Medical morbidity was reduced in the methylprednisolone group, but not significantly (23% vs. 36%; P = .1), as was surgical morbidity (20% vs. 21%; P = 1.0).
Importantly, there was no sign of an increase in diagnosed (23% vs. 17%) or treated (1% vs. 3%) endoleaks on computed tomography scan among 146 patients evaluable at 3 months’ follow-up, said Dr. Kehlet, professor of perioperative therapy and head of the surgical pathophysiology section at Rigshospitalet, Copenhagen University, and the oft-described "father" of rapid recovery.
About 40%-60% of patients undergoing endovascular aortic repair (EVAR) will develop postoperative SIRS. Although there is limited surgical injury with the minimally invasive procedure, there is still a stress response because the prosthesis releases proinflammatory mediators from the thrombus in the aortic aneurysm, he explained.
Invited discussant Dr. Basil Pruitt of the division of trauma at the University of Texas Health Science Center, San Antonio, observed that the findings take on added import in light of a 7,500-patient study presented at the recent American College of Cardiology meeting showing that methylprednisolone conferred no significant benefit and was associated with a 15% increased risk of postoperative heart attack plus death when given during cardiac surgery with cardiopulmonary bypass. He also questioned whether the glucocorticosteroid lowered the metabolic rate, as this would impair wound healing, or induced hypoglycemia or glucose intolerance.
"Do those findings and the concerns noted above simply define patient groups in whom methylprednisolone should not be infused preoperatively or, alternatively, do they define a threshold of physiologic or operative insult beyond which the effect of methylprednisolone is outweighed by the magnitude of injury and the associated systemic inflammatory response syndrome?" he asked.
Dr. Kehlet responded that he was unable to determine why that particular abstract found increased morbidity, but noted that the same authors previously published a systematic review (Eur. Heart J. 2008;29:2592-600) supporting reduced morbidity with steroid use in cardiopulmonary bypass.
He added, "The effect may depend on the type of injury, as you mention; cardiopulmonary bypass [is] a very special injury with many mediators of the stress response, compared to other surgical operations. We need more studies. And, finally, if you want to find out about the real outcomes, you must integrate the pharmacologic intervention with an optimized, fast-track setup."
Dr. Kehlet said they did not measure metabolic rate, but that no clinical problem was observed in the limited number of diabetics (n = 22) in their study. This finding is also supported by a huge, multicenter Dutch trial, in which intraoperative high-dose dexamethasone was associated with higher postoperative glucose levels in cardiopulmonary bypass patients, but had no effect on diabetes in subgroup analyses or on the primary endpoint of major morbidity at 30 days (JAMA 2012;308:1761-7).
For Dr. Kehlet's single-center, double-blinded study, 153 patients undergoing EVAR for abdominal aortic aneurysm were randomly assigned to receive a preoperative single dose of placebo or what was described as a single "old-fashioned sepsis dose of methylprednisolone" at 30 mg/kg. The two groups were similar at baseline with respect to age, comorbidities, aneurysm size, thrombus volume, EVAR procedures, and blood loss.
A modified version of SIRS was assessed during the first 4 days after surgery and defined by two or more of the following criteria: fever of more than 38° C (100.4° F) or less than 36° C (96.8° F), heart rate of more than 90 beats per minute, respiratory rate of more than 20 breaths per minute or arterial carbon dioxide tension of less than 4.3 kPa (32.25 mm Hg), and a C-reactive protein (CRP) level of more than 75 mg/L. The traditional fourth SIRS criterion of leukocytosis was replaced with CRP level because glucocorticoids always lead to leukocytosis, Dr. Kehlet noted.
Among 150 evaluable patients, high-dose methylprednisolone almost completely eliminated the proinflammatory activities of interleukin (IL)-6 (186 pg/mL vs. 20 mg/dL; P less than .001), IL-8, and CRP.
Among other inflammatory parameters, methylprednisolone reduced soluble tumor necrosis factor receptor 1 levels, but did not modify the d-dimer response, metalloproteinase-9, or myeloperoxidase, he said.
By 3 months, mortality was similar at 3% in the methylprednisolone group and 1% in the placebo group (P less than .5).
"What we don’t know is what the optimal dose-response relationship is because we used a very high dose and, of course, this was only 150 patients, so the safety issues cannot be answered based on this study, but the results are promising for future large-scale studies in this interesting operation," Dr. Kehlet concluded.
Dr. Kehlet and his coauthors reported no financial disclosures.
The complete manuscript of this study and its presentation at the American Surgical Association’s 134th annual meeting, April 2014, in Boston, is anticipated to be published in the Annals of Surgery, pending editorial review.
BOSTON – Preoperative high-dose methylprednisolone dramatically reduced inflammation and enhanced recovery after endovascular aortic repair without increased morbidity in a prospective, double-blinded randomized study.
The primary outcome of modified systemic inflammatory response syndrome (SIRS) developed in 92% on placebo and 27% given methylprednisolone (relative risk, 0.29; P less than .001).
The effect was particularly striking in patients with three or more SIRS criteria, with an overall number needed to treat of 1.5, Dr. Henrik Kehlet said at the annual meeting of the American Surgical Association.
Tempering the postoperative inflammatory response with methylprednisolone also significantly trimmed hospital stays from 3 to 2 days (P less than .001) and morphine requirements from 10 mg to 0 mg (P less than .001).
Medical morbidity was reduced in the methylprednisolone group, but not significantly (23% vs. 36%; P = .1), as was surgical morbidity (20% vs. 21%; P = 1.0).
Importantly, there was no sign of an increase in diagnosed (23% vs. 17%) or treated (1% vs. 3%) endoleaks on computed tomography scan among 146 patients evaluable at 3 months’ follow-up, said Dr. Kehlet, professor of perioperative therapy and head of the surgical pathophysiology section at Rigshospitalet, Copenhagen University, and the oft-described "father" of rapid recovery.
About 40%-60% of patients undergoing endovascular aortic repair (EVAR) will develop postoperative SIRS. Although there is limited surgical injury with the minimally invasive procedure, there is still a stress response because the prosthesis releases proinflammatory mediators from the thrombus in the aortic aneurysm, he explained.
Invited discussant Dr. Basil Pruitt of the division of trauma at the University of Texas Health Science Center, San Antonio, observed that the findings take on added import in light of a 7,500-patient study presented at the recent American College of Cardiology meeting showing that methylprednisolone conferred no significant benefit and was associated with a 15% increased risk of postoperative heart attack plus death when given during cardiac surgery with cardiopulmonary bypass. He also questioned whether the glucocorticosteroid lowered the metabolic rate, as this would impair wound healing, or induced hypoglycemia or glucose intolerance.
"Do those findings and the concerns noted above simply define patient groups in whom methylprednisolone should not be infused preoperatively or, alternatively, do they define a threshold of physiologic or operative insult beyond which the effect of methylprednisolone is outweighed by the magnitude of injury and the associated systemic inflammatory response syndrome?" he asked.
Dr. Kehlet responded that he was unable to determine why that particular abstract found increased morbidity, but noted that the same authors previously published a systematic review (Eur. Heart J. 2008;29:2592-600) supporting reduced morbidity with steroid use in cardiopulmonary bypass.
He added, "The effect may depend on the type of injury, as you mention; cardiopulmonary bypass [is] a very special injury with many mediators of the stress response, compared to other surgical operations. We need more studies. And, finally, if you want to find out about the real outcomes, you must integrate the pharmacologic intervention with an optimized, fast-track setup."
Dr. Kehlet said they did not measure metabolic rate, but that no clinical problem was observed in the limited number of diabetics (n = 22) in their study. This finding is also supported by a huge, multicenter Dutch trial, in which intraoperative high-dose dexamethasone was associated with higher postoperative glucose levels in cardiopulmonary bypass patients, but had no effect on diabetes in subgroup analyses or on the primary endpoint of major morbidity at 30 days (JAMA 2012;308:1761-7).
For Dr. Kehlet's single-center, double-blinded study, 153 patients undergoing EVAR for abdominal aortic aneurysm were randomly assigned to receive a preoperative single dose of placebo or what was described as a single "old-fashioned sepsis dose of methylprednisolone" at 30 mg/kg. The two groups were similar at baseline with respect to age, comorbidities, aneurysm size, thrombus volume, EVAR procedures, and blood loss.
A modified version of SIRS was assessed during the first 4 days after surgery and defined by two or more of the following criteria: fever of more than 38° C (100.4° F) or less than 36° C (96.8° F), heart rate of more than 90 beats per minute, respiratory rate of more than 20 breaths per minute or arterial carbon dioxide tension of less than 4.3 kPa (32.25 mm Hg), and a C-reactive protein (CRP) level of more than 75 mg/L. The traditional fourth SIRS criterion of leukocytosis was replaced with CRP level because glucocorticoids always lead to leukocytosis, Dr. Kehlet noted.
Among 150 evaluable patients, high-dose methylprednisolone almost completely eliminated the proinflammatory activities of interleukin (IL)-6 (186 pg/mL vs. 20 mg/dL; P less than .001), IL-8, and CRP.
Among other inflammatory parameters, methylprednisolone reduced soluble tumor necrosis factor receptor 1 levels, but did not modify the d-dimer response, metalloproteinase-9, or myeloperoxidase, he said.
By 3 months, mortality was similar at 3% in the methylprednisolone group and 1% in the placebo group (P less than .5).
"What we don’t know is what the optimal dose-response relationship is because we used a very high dose and, of course, this was only 150 patients, so the safety issues cannot be answered based on this study, but the results are promising for future large-scale studies in this interesting operation," Dr. Kehlet concluded.
Dr. Kehlet and his coauthors reported no financial disclosures.
The complete manuscript of this study and its presentation at the American Surgical Association’s 134th annual meeting, April 2014, in Boston, is anticipated to be published in the Annals of Surgery, pending editorial review.
BOSTON – Preoperative high-dose methylprednisolone dramatically reduced inflammation and enhanced recovery after endovascular aortic repair without increased morbidity in a prospective, double-blinded randomized study.
The primary outcome of modified systemic inflammatory response syndrome (SIRS) developed in 92% on placebo and 27% given methylprednisolone (relative risk, 0.29; P less than .001).
The effect was particularly striking in patients with three or more SIRS criteria, with an overall number needed to treat of 1.5, Dr. Henrik Kehlet said at the annual meeting of the American Surgical Association.
Tempering the postoperative inflammatory response with methylprednisolone also significantly trimmed hospital stays from 3 to 2 days (P less than .001) and morphine requirements from 10 mg to 0 mg (P less than .001).
Medical morbidity was reduced in the methylprednisolone group, but not significantly (23% vs. 36%; P = .1), as was surgical morbidity (20% vs. 21%; P = 1.0).
Importantly, there was no sign of an increase in diagnosed (23% vs. 17%) or treated (1% vs. 3%) endoleaks on computed tomography scan among 146 patients evaluable at 3 months’ follow-up, said Dr. Kehlet, professor of perioperative therapy and head of the surgical pathophysiology section at Rigshospitalet, Copenhagen University, and the oft-described "father" of rapid recovery.
About 40%-60% of patients undergoing endovascular aortic repair (EVAR) will develop postoperative SIRS. Although there is limited surgical injury with the minimally invasive procedure, there is still a stress response because the prosthesis releases proinflammatory mediators from the thrombus in the aortic aneurysm, he explained.
Invited discussant Dr. Basil Pruitt of the division of trauma at the University of Texas Health Science Center, San Antonio, observed that the findings take on added import in light of a 7,500-patient study presented at the recent American College of Cardiology meeting showing that methylprednisolone conferred no significant benefit and was associated with a 15% increased risk of postoperative heart attack plus death when given during cardiac surgery with cardiopulmonary bypass. He also questioned whether the glucocorticosteroid lowered the metabolic rate, as this would impair wound healing, or induced hypoglycemia or glucose intolerance.
"Do those findings and the concerns noted above simply define patient groups in whom methylprednisolone should not be infused preoperatively or, alternatively, do they define a threshold of physiologic or operative insult beyond which the effect of methylprednisolone is outweighed by the magnitude of injury and the associated systemic inflammatory response syndrome?" he asked.
Dr. Kehlet responded that he was unable to determine why that particular abstract found increased morbidity, but noted that the same authors previously published a systematic review (Eur. Heart J. 2008;29:2592-600) supporting reduced morbidity with steroid use in cardiopulmonary bypass.
He added, "The effect may depend on the type of injury, as you mention; cardiopulmonary bypass [is] a very special injury with many mediators of the stress response, compared to other surgical operations. We need more studies. And, finally, if you want to find out about the real outcomes, you must integrate the pharmacologic intervention with an optimized, fast-track setup."
Dr. Kehlet said they did not measure metabolic rate, but that no clinical problem was observed in the limited number of diabetics (n = 22) in their study. This finding is also supported by a huge, multicenter Dutch trial, in which intraoperative high-dose dexamethasone was associated with higher postoperative glucose levels in cardiopulmonary bypass patients, but had no effect on diabetes in subgroup analyses or on the primary endpoint of major morbidity at 30 days (JAMA 2012;308:1761-7).
For Dr. Kehlet's single-center, double-blinded study, 153 patients undergoing EVAR for abdominal aortic aneurysm were randomly assigned to receive a preoperative single dose of placebo or what was described as a single "old-fashioned sepsis dose of methylprednisolone" at 30 mg/kg. The two groups were similar at baseline with respect to age, comorbidities, aneurysm size, thrombus volume, EVAR procedures, and blood loss.
A modified version of SIRS was assessed during the first 4 days after surgery and defined by two or more of the following criteria: fever of more than 38° C (100.4° F) or less than 36° C (96.8° F), heart rate of more than 90 beats per minute, respiratory rate of more than 20 breaths per minute or arterial carbon dioxide tension of less than 4.3 kPa (32.25 mm Hg), and a C-reactive protein (CRP) level of more than 75 mg/L. The traditional fourth SIRS criterion of leukocytosis was replaced with CRP level because glucocorticoids always lead to leukocytosis, Dr. Kehlet noted.
Among 150 evaluable patients, high-dose methylprednisolone almost completely eliminated the proinflammatory activities of interleukin (IL)-6 (186 pg/mL vs. 20 mg/dL; P less than .001), IL-8, and CRP.
Among other inflammatory parameters, methylprednisolone reduced soluble tumor necrosis factor receptor 1 levels, but did not modify the d-dimer response, metalloproteinase-9, or myeloperoxidase, he said.
By 3 months, mortality was similar at 3% in the methylprednisolone group and 1% in the placebo group (P less than .5).
"What we don’t know is what the optimal dose-response relationship is because we used a very high dose and, of course, this was only 150 patients, so the safety issues cannot be answered based on this study, but the results are promising for future large-scale studies in this interesting operation," Dr. Kehlet concluded.
Dr. Kehlet and his coauthors reported no financial disclosures.
The complete manuscript of this study and its presentation at the American Surgical Association’s 134th annual meeting, April 2014, in Boston, is anticipated to be published in the Annals of Surgery, pending editorial review.
AT ASA 2014
Major finding: Systemic inflammatory response syndrome developed in 92% on placebo and 27% given methylprednisolone (relative risk, 0.29; P less than .001).
Data source: A single-center, randomized double-blinded study in 153 patients undergoing EVAR for abdominal aortic aneurysm.
Disclosures: Dr. Kehlet and his coauthors reported no financial disclosures.
Data derail dogma of elective diverticulitis surgery
BOSTON – The risks of readmission and emergency surgery are low for patients with acute diverticulitis initially managed nonoperatively, a population-based, competing risk analysis found.
At a median of 3.9 years (range, 1.7-6.4 years) after discharge among 14,124 patients, only 8% required urgent readmission. Of these, 22% went on to urgent surgery and 20%, to elective surgery after additional episodes.
Among the remaining 12,981 patients with no urgent readmissions, 9% went on to elective surgery, 13% died of other causes, and 78% had no events in follow-up, Dr. Debbie Li said at the annual meeting of the American Surgical Association.
The 5-year cumulative incidence was 9% for readmission, 1.9% for emergency surgery, and 14.1% for all-cause mortality.
"Elective colectomy may not be warranted for the majority of patients in the absence of chronic symptoms or multiple frequent recurrences," she said.
Elective colectomy has traditionally been recommended for patients at high risk for future recurrence and emergency surgery based on the indications of age less than 50 years, complicated disease including perforation and abscess, and two or more episodes of uncomplicated disease. Evidence is building, however, to challenge these indications, and guidelines are evolving, said Dr. Li, a general surgery resident at the University of Toronto.
The current study used administrative data to identify all patients in Ontario, Canada, treated nonoperatively at first hospitalization for diverticulitis from 2002 to 2012. Time-to-event and competing-risk regression analyses were performed, with data adjusted for such potential confounders as sex, medical comorbidity, neighborhood income quintile, rural residency, and calendar year of index admission.
Data are limited on the natural history of diverticulitis, and the few population-based studies that have been conducted have not accounted for competing risks such as elective colectomy or death, Dr. Li said.
The patients’ median age was 59 years, 79% had uncomplicated index disease, 18% had complicated disease (abscess, fistula, and perforation) with no abscess drain, and 3% had complicated disease with an abscess drain.
Young patients had more readmissions than those 50 years and older (10.5% vs. 8.4%; P less than .001), but not more emergency surgery (1.8% vs. 2.0%; P = .52), she said.
For patients older than 50 years, the risk of death by other causes was 10 times the risk of an emergency surgery for diverticulitis (19.5% vs. 2%).
Patients with complicated rather than uncomplicated index disease had more readmissions (12% vs. 8.2%; P less than .001) and urgent surgery (4.3% vs. 1.4%; P less than .001).
In adjusted analyses, young age was associated with more readmissions (hazard ratio, 1.24), but not subsequent emergency surgery (HR, 0.83). Complicated disease (HR, 3.15) and multiple recurrences (HR, 2.41) predicted an increased risk for emergency surgery.
"Young age, complicated disease, and multiple recurrences do infer increased relative risk, but the vast majority (85%) of such patients remain recurrence free," Dr. Li said.
Invited discussant Dr. David Schoetz, professor of surgery, Tufts University, Boston, said, "While it’s reassuring that even complicated diverticulitis can be safely managed without subsequent operation, there still must be a subgroup who should be offered early surgery."
With disease severity more common in younger patients and overall mortality less than 1%, perhaps aggressive surgery would be justified in those younger than 50 years, he suggested.
Dr. Li responded that an administrative database is unable to capture clinical nuances such as which patients had ongoing symptoms, chronic persistent disease, or reduced quality of life, and that a prospective trial would be needed to identify which subgroup of patients will need aggressive surgery.
Older patients, those with more complicated disease, and those with greater medical comorbidities are more likely to undergo urgent surgery, according to ongoing analyses of roughly 4,000 patients, treated during the same time period, but excluded from the current analysis because they underwent surgery at index admission. Previously published work also suggests that patients with a higher body mass index have poorer outcomes.
A recent systematic review of diverticulitis surgery (JAMA Surg. 2014;149:292-303) reported that complicated recurrence after an episode of uncomplicated diverticulitis is rare, occurring in less than 5% of cases. The authors called for existing guidelines to be updated and said that decisions to proceed with elective surgery should be based instead on patient-reported frequency and severity of symptoms.
The complete manuscript of this study and its presentation at the American Surgical Association’s 134th annual meeting, April 2014, in Boston, is anticipated to be published in the Annals of Surgery, pending editorial review.
Dr. Li and her coauthors reported no relevant financial disclosures.
urgent surgery, elective surgery, Dr. Debbie Li, American Surgical Association, colectomy, abscess, fistula, perforation, abscess drain, Young patients,
BOSTON – The risks of readmission and emergency surgery are low for patients with acute diverticulitis initially managed nonoperatively, a population-based, competing risk analysis found.
At a median of 3.9 years (range, 1.7-6.4 years) after discharge among 14,124 patients, only 8% required urgent readmission. Of these, 22% went on to urgent surgery and 20%, to elective surgery after additional episodes.
Among the remaining 12,981 patients with no urgent readmissions, 9% went on to elective surgery, 13% died of other causes, and 78% had no events in follow-up, Dr. Debbie Li said at the annual meeting of the American Surgical Association.
The 5-year cumulative incidence was 9% for readmission, 1.9% for emergency surgery, and 14.1% for all-cause mortality.
"Elective colectomy may not be warranted for the majority of patients in the absence of chronic symptoms or multiple frequent recurrences," she said.
Elective colectomy has traditionally been recommended for patients at high risk for future recurrence and emergency surgery based on the indications of age less than 50 years, complicated disease including perforation and abscess, and two or more episodes of uncomplicated disease. Evidence is building, however, to challenge these indications, and guidelines are evolving, said Dr. Li, a general surgery resident at the University of Toronto.
The current study used administrative data to identify all patients in Ontario, Canada, treated nonoperatively at first hospitalization for diverticulitis from 2002 to 2012. Time-to-event and competing-risk regression analyses were performed, with data adjusted for such potential confounders as sex, medical comorbidity, neighborhood income quintile, rural residency, and calendar year of index admission.
Data are limited on the natural history of diverticulitis, and the few population-based studies that have been conducted have not accounted for competing risks such as elective colectomy or death, Dr. Li said.
The patients’ median age was 59 years, 79% had uncomplicated index disease, 18% had complicated disease (abscess, fistula, and perforation) with no abscess drain, and 3% had complicated disease with an abscess drain.
Young patients had more readmissions than those 50 years and older (10.5% vs. 8.4%; P less than .001), but not more emergency surgery (1.8% vs. 2.0%; P = .52), she said.
For patients older than 50 years, the risk of death by other causes was 10 times the risk of an emergency surgery for diverticulitis (19.5% vs. 2%).
Patients with complicated rather than uncomplicated index disease had more readmissions (12% vs. 8.2%; P less than .001) and urgent surgery (4.3% vs. 1.4%; P less than .001).
In adjusted analyses, young age was associated with more readmissions (hazard ratio, 1.24), but not subsequent emergency surgery (HR, 0.83). Complicated disease (HR, 3.15) and multiple recurrences (HR, 2.41) predicted an increased risk for emergency surgery.
"Young age, complicated disease, and multiple recurrences do infer increased relative risk, but the vast majority (85%) of such patients remain recurrence free," Dr. Li said.
Invited discussant Dr. David Schoetz, professor of surgery, Tufts University, Boston, said, "While it’s reassuring that even complicated diverticulitis can be safely managed without subsequent operation, there still must be a subgroup who should be offered early surgery."
With disease severity more common in younger patients and overall mortality less than 1%, perhaps aggressive surgery would be justified in those younger than 50 years, he suggested.
Dr. Li responded that an administrative database is unable to capture clinical nuances such as which patients had ongoing symptoms, chronic persistent disease, or reduced quality of life, and that a prospective trial would be needed to identify which subgroup of patients will need aggressive surgery.
Older patients, those with more complicated disease, and those with greater medical comorbidities are more likely to undergo urgent surgery, according to ongoing analyses of roughly 4,000 patients, treated during the same time period, but excluded from the current analysis because they underwent surgery at index admission. Previously published work also suggests that patients with a higher body mass index have poorer outcomes.
A recent systematic review of diverticulitis surgery (JAMA Surg. 2014;149:292-303) reported that complicated recurrence after an episode of uncomplicated diverticulitis is rare, occurring in less than 5% of cases. The authors called for existing guidelines to be updated and said that decisions to proceed with elective surgery should be based instead on patient-reported frequency and severity of symptoms.
The complete manuscript of this study and its presentation at the American Surgical Association’s 134th annual meeting, April 2014, in Boston, is anticipated to be published in the Annals of Surgery, pending editorial review.
Dr. Li and her coauthors reported no relevant financial disclosures.
BOSTON – The risks of readmission and emergency surgery are low for patients with acute diverticulitis initially managed nonoperatively, a population-based, competing risk analysis found.
At a median of 3.9 years (range, 1.7-6.4 years) after discharge among 14,124 patients, only 8% required urgent readmission. Of these, 22% went on to urgent surgery and 20%, to elective surgery after additional episodes.
Among the remaining 12,981 patients with no urgent readmissions, 9% went on to elective surgery, 13% died of other causes, and 78% had no events in follow-up, Dr. Debbie Li said at the annual meeting of the American Surgical Association.
The 5-year cumulative incidence was 9% for readmission, 1.9% for emergency surgery, and 14.1% for all-cause mortality.
"Elective colectomy may not be warranted for the majority of patients in the absence of chronic symptoms or multiple frequent recurrences," she said.
Elective colectomy has traditionally been recommended for patients at high risk for future recurrence and emergency surgery based on the indications of age less than 50 years, complicated disease including perforation and abscess, and two or more episodes of uncomplicated disease. Evidence is building, however, to challenge these indications, and guidelines are evolving, said Dr. Li, a general surgery resident at the University of Toronto.
The current study used administrative data to identify all patients in Ontario, Canada, treated nonoperatively at first hospitalization for diverticulitis from 2002 to 2012. Time-to-event and competing-risk regression analyses were performed, with data adjusted for such potential confounders as sex, medical comorbidity, neighborhood income quintile, rural residency, and calendar year of index admission.
Data are limited on the natural history of diverticulitis, and the few population-based studies that have been conducted have not accounted for competing risks such as elective colectomy or death, Dr. Li said.
The patients’ median age was 59 years, 79% had uncomplicated index disease, 18% had complicated disease (abscess, fistula, and perforation) with no abscess drain, and 3% had complicated disease with an abscess drain.
Young patients had more readmissions than those 50 years and older (10.5% vs. 8.4%; P less than .001), but not more emergency surgery (1.8% vs. 2.0%; P = .52), she said.
For patients older than 50 years, the risk of death by other causes was 10 times the risk of an emergency surgery for diverticulitis (19.5% vs. 2%).
Patients with complicated rather than uncomplicated index disease had more readmissions (12% vs. 8.2%; P less than .001) and urgent surgery (4.3% vs. 1.4%; P less than .001).
In adjusted analyses, young age was associated with more readmissions (hazard ratio, 1.24), but not subsequent emergency surgery (HR, 0.83). Complicated disease (HR, 3.15) and multiple recurrences (HR, 2.41) predicted an increased risk for emergency surgery.
"Young age, complicated disease, and multiple recurrences do infer increased relative risk, but the vast majority (85%) of such patients remain recurrence free," Dr. Li said.
Invited discussant Dr. David Schoetz, professor of surgery, Tufts University, Boston, said, "While it’s reassuring that even complicated diverticulitis can be safely managed without subsequent operation, there still must be a subgroup who should be offered early surgery."
With disease severity more common in younger patients and overall mortality less than 1%, perhaps aggressive surgery would be justified in those younger than 50 years, he suggested.
Dr. Li responded that an administrative database is unable to capture clinical nuances such as which patients had ongoing symptoms, chronic persistent disease, or reduced quality of life, and that a prospective trial would be needed to identify which subgroup of patients will need aggressive surgery.
Older patients, those with more complicated disease, and those with greater medical comorbidities are more likely to undergo urgent surgery, according to ongoing analyses of roughly 4,000 patients, treated during the same time period, but excluded from the current analysis because they underwent surgery at index admission. Previously published work also suggests that patients with a higher body mass index have poorer outcomes.
A recent systematic review of diverticulitis surgery (JAMA Surg. 2014;149:292-303) reported that complicated recurrence after an episode of uncomplicated diverticulitis is rare, occurring in less than 5% of cases. The authors called for existing guidelines to be updated and said that decisions to proceed with elective surgery should be based instead on patient-reported frequency and severity of symptoms.
The complete manuscript of this study and its presentation at the American Surgical Association’s 134th annual meeting, April 2014, in Boston, is anticipated to be published in the Annals of Surgery, pending editorial review.
Dr. Li and her coauthors reported no relevant financial disclosures.
urgent surgery, elective surgery, Dr. Debbie Li, American Surgical Association, colectomy, abscess, fistula, perforation, abscess drain, Young patients,
urgent surgery, elective surgery, Dr. Debbie Li, American Surgical Association, colectomy, abscess, fistula, perforation, abscess drain, Young patients,
AT ASA 2014
Key clinical point: As recurrence is very rare, conservative nonoperative treatment should be considered first.
Major finding: The 5-year cumulative incidence was 9% for readmission, 1.9% for emergency surgery, and 14.1% for all-cause mortality.
Data source: A population-based, competing risk analysis of 14,124 patients with initial nonoperative management of diverticulitis.
Disclosures: Dr. Li and her coauthors reported no relevant financial disclosures.
Soluble ST2 predicts ARDS ICU mortality
MADRID – Elevated levels of the soluble ST2 protein were associated with higher intensive care unit mortality in patients with acute respiratory distress syndrome in a prospective pilot study.
Among 62 patients, median soluble ST2 levels were significantly higher among ICU nonsurvivors than survivors on day 1 of acute respiratory distress syndrome (ARDS) onset (4,934 pg/mL vs. 1,007 pg/mL) and at day 3 (5,720 pg/mL vs. 823 pg/mL), Dr. Marina Garcia de Acilu reported at CHEST World Congress 2014.
The soluble form of the ST2 [interleukin-1 (IL-1) receptor-like 1] protein, and its ligand, IL-33, have come under increased scrutiny in recent years for their potential role in the pathogenesis of various pulmonary diseases including ARDS.
ST2 concentrations have been reported to be elevated in patients with asthma, pulmonary fibrosis, and eosinophilic pneumonia, and were shown in the PRIDE (ProBNP Investigation of Dyspnea in the Emergency Department) study to predict 1-year survival among acutely dyspneic patients with pulmonary disorders admitted to the emergency department (Am. J. Clin. Pathol. 2008;130:578-584) from September 2012 to September 2013. Their median APACHE II (Acute Physiology and Chronic Health Evaluation II) score was 24 (range 19-29) and their median age was 61 years. ICU mortality was 41%.
No significant differences were seen in IL-33 concentrations on day 1 or 3 between survivors and those who died, reported Dr. Garcia de Acilu of Vall d’Hebron University Hospital, Barcelona.
An ST2 level on day 1 of at least 3,672 pg/mL, however, accurately identified patients who died (area under the operator curve 0.96; P less than .01), and outperformed traditional APACHE and SOFA (Sequential Organ Failure Assessment) scores, with a sensitivity of 86% and specificity of 100%.
Patients with an ST2 level below this threshold on day 1 had significantly higher survival rates in a Kaplan-Meier survival analysis.
In addition, an ST2 level above 3,672 pg/mL on day 1 was the only variable in multivariate analysis associated with ICU mortality, increasing the risk of death more than 14-fold (hazard ratio, 14.7), Dr. Garcia de Acilu reported in the poster presentation.
"In ARDS patients, ST2 may be considered a useful early biomarker for prognosis, by identifying high-risk-of-death patients," the authors concluded. "Further studies, using ST2 clinically, should be performed to assess the added value in specific subpopulations or in the presence of some comorbidities."
ST2 may also prove useful as a therapeutic strategy. A recent study, also out of Barcelona, reported that human mesenchymal stem cells, genetically engineered to produce soluble ST2, further prevented IL-33 induction, but also enhanced IL-10 expression in a murine acute lung injury model. This synergy led to a substantial decrease in lung airspace inflammation and vascular leakage (Am. J. Respir. Cell Mol. Biol. 2013:49:552-62).
"This study also illustrates the potential role for targeting ST2 as a therapy for airway disorders," senior author Dr. Jordi Rello, chief of critical care at Vall d’Hebron University Hospital, said in an interview.
Dr. Garcia de Acilu and her coauthors reported no financial disclosures.
Dr. Eleanor Summerhill, FCCP, comments: A recently discovered
member of the IL-1 superfamily of cytokines, IL-33 has been shown to
have multiple immunomodulatory effects, but predominately induces the
T–helper cell (TH-2) pathway. The soluble isoform of the IL-1 receptor
(ST2) acts as a "decoy receptor" for IL-33, dampening the
pro-inflammatory response. A growing body of evidence suggests that
plasma levels of ST2 may serve as a useful biomarker in cardiac,
rheumatologic, and pulmonary disease, including asthma, pulmonary
fibrosis, eosinophilic pneumonia, and ALI/ARDS.
Dr. Garcia-Acilu
and colleagues recently reported the results of a small, single-center
study evaluating the prognostic value of soluble ST2 levels on day 1 in
patients with ARDS, and found that the use of this biomarker
outperformed both the APACHE II and SOFA scores in predicting mortality.
There is also some evidence in the literature that modulation of
soluble ST2 levels may be useful as a therapeutic modality.
This
is a very exciting new area of investigation with significant potential
impact on the future management of patients with ARDS.
Dr. Eleanor Summerhill, FCCP, comments: A recently discovered
member of the IL-1 superfamily of cytokines, IL-33 has been shown to
have multiple immunomodulatory effects, but predominately induces the
T–helper cell (TH-2) pathway. The soluble isoform of the IL-1 receptor
(ST2) acts as a "decoy receptor" for IL-33, dampening the
pro-inflammatory response. A growing body of evidence suggests that
plasma levels of ST2 may serve as a useful biomarker in cardiac,
rheumatologic, and pulmonary disease, including asthma, pulmonary
fibrosis, eosinophilic pneumonia, and ALI/ARDS.
Dr. Garcia-Acilu
and colleagues recently reported the results of a small, single-center
study evaluating the prognostic value of soluble ST2 levels on day 1 in
patients with ARDS, and found that the use of this biomarker
outperformed both the APACHE II and SOFA scores in predicting mortality.
There is also some evidence in the literature that modulation of
soluble ST2 levels may be useful as a therapeutic modality.
This
is a very exciting new area of investigation with significant potential
impact on the future management of patients with ARDS.
Dr. Eleanor Summerhill, FCCP, comments: A recently discovered
member of the IL-1 superfamily of cytokines, IL-33 has been shown to
have multiple immunomodulatory effects, but predominately induces the
T–helper cell (TH-2) pathway. The soluble isoform of the IL-1 receptor
(ST2) acts as a "decoy receptor" for IL-33, dampening the
pro-inflammatory response. A growing body of evidence suggests that
plasma levels of ST2 may serve as a useful biomarker in cardiac,
rheumatologic, and pulmonary disease, including asthma, pulmonary
fibrosis, eosinophilic pneumonia, and ALI/ARDS.
Dr. Garcia-Acilu
and colleagues recently reported the results of a small, single-center
study evaluating the prognostic value of soluble ST2 levels on day 1 in
patients with ARDS, and found that the use of this biomarker
outperformed both the APACHE II and SOFA scores in predicting mortality.
There is also some evidence in the literature that modulation of
soluble ST2 levels may be useful as a therapeutic modality.
This
is a very exciting new area of investigation with significant potential
impact on the future management of patients with ARDS.
MADRID – Elevated levels of the soluble ST2 protein were associated with higher intensive care unit mortality in patients with acute respiratory distress syndrome in a prospective pilot study.
Among 62 patients, median soluble ST2 levels were significantly higher among ICU nonsurvivors than survivors on day 1 of acute respiratory distress syndrome (ARDS) onset (4,934 pg/mL vs. 1,007 pg/mL) and at day 3 (5,720 pg/mL vs. 823 pg/mL), Dr. Marina Garcia de Acilu reported at CHEST World Congress 2014.
The soluble form of the ST2 [interleukin-1 (IL-1) receptor-like 1] protein, and its ligand, IL-33, have come under increased scrutiny in recent years for their potential role in the pathogenesis of various pulmonary diseases including ARDS.
ST2 concentrations have been reported to be elevated in patients with asthma, pulmonary fibrosis, and eosinophilic pneumonia, and were shown in the PRIDE (ProBNP Investigation of Dyspnea in the Emergency Department) study to predict 1-year survival among acutely dyspneic patients with pulmonary disorders admitted to the emergency department (Am. J. Clin. Pathol. 2008;130:578-584) from September 2012 to September 2013. Their median APACHE II (Acute Physiology and Chronic Health Evaluation II) score was 24 (range 19-29) and their median age was 61 years. ICU mortality was 41%.
No significant differences were seen in IL-33 concentrations on day 1 or 3 between survivors and those who died, reported Dr. Garcia de Acilu of Vall d’Hebron University Hospital, Barcelona.
An ST2 level on day 1 of at least 3,672 pg/mL, however, accurately identified patients who died (area under the operator curve 0.96; P less than .01), and outperformed traditional APACHE and SOFA (Sequential Organ Failure Assessment) scores, with a sensitivity of 86% and specificity of 100%.
Patients with an ST2 level below this threshold on day 1 had significantly higher survival rates in a Kaplan-Meier survival analysis.
In addition, an ST2 level above 3,672 pg/mL on day 1 was the only variable in multivariate analysis associated with ICU mortality, increasing the risk of death more than 14-fold (hazard ratio, 14.7), Dr. Garcia de Acilu reported in the poster presentation.
"In ARDS patients, ST2 may be considered a useful early biomarker for prognosis, by identifying high-risk-of-death patients," the authors concluded. "Further studies, using ST2 clinically, should be performed to assess the added value in specific subpopulations or in the presence of some comorbidities."
ST2 may also prove useful as a therapeutic strategy. A recent study, also out of Barcelona, reported that human mesenchymal stem cells, genetically engineered to produce soluble ST2, further prevented IL-33 induction, but also enhanced IL-10 expression in a murine acute lung injury model. This synergy led to a substantial decrease in lung airspace inflammation and vascular leakage (Am. J. Respir. Cell Mol. Biol. 2013:49:552-62).
"This study also illustrates the potential role for targeting ST2 as a therapy for airway disorders," senior author Dr. Jordi Rello, chief of critical care at Vall d’Hebron University Hospital, said in an interview.
Dr. Garcia de Acilu and her coauthors reported no financial disclosures.
MADRID – Elevated levels of the soluble ST2 protein were associated with higher intensive care unit mortality in patients with acute respiratory distress syndrome in a prospective pilot study.
Among 62 patients, median soluble ST2 levels were significantly higher among ICU nonsurvivors than survivors on day 1 of acute respiratory distress syndrome (ARDS) onset (4,934 pg/mL vs. 1,007 pg/mL) and at day 3 (5,720 pg/mL vs. 823 pg/mL), Dr. Marina Garcia de Acilu reported at CHEST World Congress 2014.
The soluble form of the ST2 [interleukin-1 (IL-1) receptor-like 1] protein, and its ligand, IL-33, have come under increased scrutiny in recent years for their potential role in the pathogenesis of various pulmonary diseases including ARDS.
ST2 concentrations have been reported to be elevated in patients with asthma, pulmonary fibrosis, and eosinophilic pneumonia, and were shown in the PRIDE (ProBNP Investigation of Dyspnea in the Emergency Department) study to predict 1-year survival among acutely dyspneic patients with pulmonary disorders admitted to the emergency department (Am. J. Clin. Pathol. 2008;130:578-584) from September 2012 to September 2013. Their median APACHE II (Acute Physiology and Chronic Health Evaluation II) score was 24 (range 19-29) and their median age was 61 years. ICU mortality was 41%.
No significant differences were seen in IL-33 concentrations on day 1 or 3 between survivors and those who died, reported Dr. Garcia de Acilu of Vall d’Hebron University Hospital, Barcelona.
An ST2 level on day 1 of at least 3,672 pg/mL, however, accurately identified patients who died (area under the operator curve 0.96; P less than .01), and outperformed traditional APACHE and SOFA (Sequential Organ Failure Assessment) scores, with a sensitivity of 86% and specificity of 100%.
Patients with an ST2 level below this threshold on day 1 had significantly higher survival rates in a Kaplan-Meier survival analysis.
In addition, an ST2 level above 3,672 pg/mL on day 1 was the only variable in multivariate analysis associated with ICU mortality, increasing the risk of death more than 14-fold (hazard ratio, 14.7), Dr. Garcia de Acilu reported in the poster presentation.
"In ARDS patients, ST2 may be considered a useful early biomarker for prognosis, by identifying high-risk-of-death patients," the authors concluded. "Further studies, using ST2 clinically, should be performed to assess the added value in specific subpopulations or in the presence of some comorbidities."
ST2 may also prove useful as a therapeutic strategy. A recent study, also out of Barcelona, reported that human mesenchymal stem cells, genetically engineered to produce soluble ST2, further prevented IL-33 induction, but also enhanced IL-10 expression in a murine acute lung injury model. This synergy led to a substantial decrease in lung airspace inflammation and vascular leakage (Am. J. Respir. Cell Mol. Biol. 2013:49:552-62).
"This study also illustrates the potential role for targeting ST2 as a therapy for airway disorders," senior author Dr. Jordi Rello, chief of critical care at Vall d’Hebron University Hospital, said in an interview.
Dr. Garcia de Acilu and her coauthors reported no financial disclosures.
AT CHEST WORLD CONGRESS 2014
Major finding: Median soluble ST2 levels were significantly higher among ICU nonsurvivors than survivors at day 1 (4,934 pg/mL vs. 1,007 pg/mL) and day 3 (5,720 pg/mL vs. 823 pg/mL).
Data source: A prospective study in 62 patients with ARDS
Disclosures: The investigators reported no financial disclosures.