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Discharging select diverticulitis patients from the ED found to be acceptable
CORONADO, CALIF. – Among patients diagnosed with diverticulitis via CT scan in the emergency department who were discharged home, only 13% required a return visit to the hospital, results from a long-term retrospective analysis demonstrated.
“In select patients whose assessment includes a CT scan, discharge to home from the emergency department with treatment for diverticulitis is safe,” study author Anne-Marie Sirany, MD, said at the annual meeting of the Western Surgical Association.
A few years ago, researchers conducted a randomized trial to evaluate the treatment of uncomplicated diverticulitis (Ann Surg. 2014;259[1]:38-44). Patients were diagnosed with diverticulitis in the emergency department and randomized to either hospital admission or outpatient management at home. The investigators found no significant differences between the readmission rates of the inpatient and outpatient groups, but the health care costs were three times lower in the outpatient group. Dr. Sirany and her associates set out to compare the outcomes of patients diagnosed with and treated for diverticulitis in the emergency department who were discharged to home, versus those who were admitted to the hospital. They reviewed the medical records of 240 patients with a primary diagnosis of diverticulitis by CT scan who were evaluated in the emergency department at one of four hospitals and one academic medical center from September 2010 to January 2012. The primary outcome was hospital readmission or return to the emergency department within 30 days, while the secondary outcomes were recurrent diverticulitis or surgical resection for diverticulitis.
The mean age of the 240 patients was 59 years, 45% were men, 22% had a Charlson Comorbidity Index (CCI) of greater than 2, and 7.5% were on steroids or immunosuppressant medications. More than half (62%) were admitted to the hospital, while the remaining 38% were discharged home on oral antibiotics. Compared with patients discharged home, those admitted to the hospital were more likely to be older than age 65 (43% vs. 24%, respectively; P = .003), have a CCI of 2 or greater (28% vs. 13%; P = .007), were more likely to be on immunosuppressant or steroid medications (11% vs. 1%; P = .003), show extraluminal air on CT (30% vs. 7%; P less than .0001), or show abscess on CT (19% vs. 1%; P less than .0001). “Of note: We did not have any patients who had CT scan findings of pneumoperitoneum who were discharged home, and 48% of patients admitted to the hospital had uncomplicated diverticulitis,” she said.
After a median follow-up of 37 months, no significant differences were observed between patients discharged to home and those admitted to the hospital in readmission or return to the emergency department (13% vs. 14%), recurrent diverticulitis (23% in each group), or in colon resection at subsequent encounter (16% vs. 19%). “Among patients discharged to home, only one patient required emergency surgery, and this was 20 months after their index admission,” Dr. Sirany said. “We think that the low rate of readmission in patients discharged home demonstrates that this is a safe approach to management of patients with diverticulitis, when using information from the CT scan.”
Closer analysis of patients who were discharged home revealed that six patients had extraluminal air on CT scan, three of whom returned to the emergency department or were admitted to the hospital. In addition, 11% of those with uncomplicated diverticulitis returned to the emergency department or were admitted to the hospital.
Dr. Sirany acknowledged certain limitations of the study, including its retrospective design, a lack of complete follow-up for all patients, and the fact that it included patients with recurrent diverticulitis. “Despite the limitations, we recommend that young, relatively healthy patients, with uncomplicated findings on CT scan, can be discharged to home and managed as an outpatient,” she said. “In an era where there’s increasing attention to health care costs, we need to think more critically about which patients need to be admitted for management of uncomplicated diverticulitis.” She reported having no financial disclosures.
[email protected]
CORONADO, CALIF. – Among patients diagnosed with diverticulitis via CT scan in the emergency department who were discharged home, only 13% required a return visit to the hospital, results from a long-term retrospective analysis demonstrated.
“In select patients whose assessment includes a CT scan, discharge to home from the emergency department with treatment for diverticulitis is safe,” study author Anne-Marie Sirany, MD, said at the annual meeting of the Western Surgical Association.
A few years ago, researchers conducted a randomized trial to evaluate the treatment of uncomplicated diverticulitis (Ann Surg. 2014;259[1]:38-44). Patients were diagnosed with diverticulitis in the emergency department and randomized to either hospital admission or outpatient management at home. The investigators found no significant differences between the readmission rates of the inpatient and outpatient groups, but the health care costs were three times lower in the outpatient group. Dr. Sirany and her associates set out to compare the outcomes of patients diagnosed with and treated for diverticulitis in the emergency department who were discharged to home, versus those who were admitted to the hospital. They reviewed the medical records of 240 patients with a primary diagnosis of diverticulitis by CT scan who were evaluated in the emergency department at one of four hospitals and one academic medical center from September 2010 to January 2012. The primary outcome was hospital readmission or return to the emergency department within 30 days, while the secondary outcomes were recurrent diverticulitis or surgical resection for diverticulitis.
The mean age of the 240 patients was 59 years, 45% were men, 22% had a Charlson Comorbidity Index (CCI) of greater than 2, and 7.5% were on steroids or immunosuppressant medications. More than half (62%) were admitted to the hospital, while the remaining 38% were discharged home on oral antibiotics. Compared with patients discharged home, those admitted to the hospital were more likely to be older than age 65 (43% vs. 24%, respectively; P = .003), have a CCI of 2 or greater (28% vs. 13%; P = .007), were more likely to be on immunosuppressant or steroid medications (11% vs. 1%; P = .003), show extraluminal air on CT (30% vs. 7%; P less than .0001), or show abscess on CT (19% vs. 1%; P less than .0001). “Of note: We did not have any patients who had CT scan findings of pneumoperitoneum who were discharged home, and 48% of patients admitted to the hospital had uncomplicated diverticulitis,” she said.
After a median follow-up of 37 months, no significant differences were observed between patients discharged to home and those admitted to the hospital in readmission or return to the emergency department (13% vs. 14%), recurrent diverticulitis (23% in each group), or in colon resection at subsequent encounter (16% vs. 19%). “Among patients discharged to home, only one patient required emergency surgery, and this was 20 months after their index admission,” Dr. Sirany said. “We think that the low rate of readmission in patients discharged home demonstrates that this is a safe approach to management of patients with diverticulitis, when using information from the CT scan.”
Closer analysis of patients who were discharged home revealed that six patients had extraluminal air on CT scan, three of whom returned to the emergency department or were admitted to the hospital. In addition, 11% of those with uncomplicated diverticulitis returned to the emergency department or were admitted to the hospital.
Dr. Sirany acknowledged certain limitations of the study, including its retrospective design, a lack of complete follow-up for all patients, and the fact that it included patients with recurrent diverticulitis. “Despite the limitations, we recommend that young, relatively healthy patients, with uncomplicated findings on CT scan, can be discharged to home and managed as an outpatient,” she said. “In an era where there’s increasing attention to health care costs, we need to think more critically about which patients need to be admitted for management of uncomplicated diverticulitis.” She reported having no financial disclosures.
[email protected]
CORONADO, CALIF. – Among patients diagnosed with diverticulitis via CT scan in the emergency department who were discharged home, only 13% required a return visit to the hospital, results from a long-term retrospective analysis demonstrated.
“In select patients whose assessment includes a CT scan, discharge to home from the emergency department with treatment for diverticulitis is safe,” study author Anne-Marie Sirany, MD, said at the annual meeting of the Western Surgical Association.
A few years ago, researchers conducted a randomized trial to evaluate the treatment of uncomplicated diverticulitis (Ann Surg. 2014;259[1]:38-44). Patients were diagnosed with diverticulitis in the emergency department and randomized to either hospital admission or outpatient management at home. The investigators found no significant differences between the readmission rates of the inpatient and outpatient groups, but the health care costs were three times lower in the outpatient group. Dr. Sirany and her associates set out to compare the outcomes of patients diagnosed with and treated for diverticulitis in the emergency department who were discharged to home, versus those who were admitted to the hospital. They reviewed the medical records of 240 patients with a primary diagnosis of diverticulitis by CT scan who were evaluated in the emergency department at one of four hospitals and one academic medical center from September 2010 to January 2012. The primary outcome was hospital readmission or return to the emergency department within 30 days, while the secondary outcomes were recurrent diverticulitis or surgical resection for diverticulitis.
The mean age of the 240 patients was 59 years, 45% were men, 22% had a Charlson Comorbidity Index (CCI) of greater than 2, and 7.5% were on steroids or immunosuppressant medications. More than half (62%) were admitted to the hospital, while the remaining 38% were discharged home on oral antibiotics. Compared with patients discharged home, those admitted to the hospital were more likely to be older than age 65 (43% vs. 24%, respectively; P = .003), have a CCI of 2 or greater (28% vs. 13%; P = .007), were more likely to be on immunosuppressant or steroid medications (11% vs. 1%; P = .003), show extraluminal air on CT (30% vs. 7%; P less than .0001), or show abscess on CT (19% vs. 1%; P less than .0001). “Of note: We did not have any patients who had CT scan findings of pneumoperitoneum who were discharged home, and 48% of patients admitted to the hospital had uncomplicated diverticulitis,” she said.
After a median follow-up of 37 months, no significant differences were observed between patients discharged to home and those admitted to the hospital in readmission or return to the emergency department (13% vs. 14%), recurrent diverticulitis (23% in each group), or in colon resection at subsequent encounter (16% vs. 19%). “Among patients discharged to home, only one patient required emergency surgery, and this was 20 months after their index admission,” Dr. Sirany said. “We think that the low rate of readmission in patients discharged home demonstrates that this is a safe approach to management of patients with diverticulitis, when using information from the CT scan.”
Closer analysis of patients who were discharged home revealed that six patients had extraluminal air on CT scan, three of whom returned to the emergency department or were admitted to the hospital. In addition, 11% of those with uncomplicated diverticulitis returned to the emergency department or were admitted to the hospital.
Dr. Sirany acknowledged certain limitations of the study, including its retrospective design, a lack of complete follow-up for all patients, and the fact that it included patients with recurrent diverticulitis. “Despite the limitations, we recommend that young, relatively healthy patients, with uncomplicated findings on CT scan, can be discharged to home and managed as an outpatient,” she said. “In an era where there’s increasing attention to health care costs, we need to think more critically about which patients need to be admitted for management of uncomplicated diverticulitis.” She reported having no financial disclosures.
[email protected]
AT WSA 2016
Key clinical point:
Major finding: After a median follow-up of 37 months, no significant differences were observed between patients discharged to home and those admitted to the hospital in readmission or return to the emergency department (13% vs. 14%, respectively).
Data source: A retrospective review of 240 patients with a primary diagnosis of diverticulitis by CT scan who were evaluated in the emergency department at one of four hospitals and one academic medical center from September 2010 to January 2012.
Disclosures: Dr. Sirany reported having no financial disclosures.
Emergent colon cancer resection does not negatively affect patient outcomes
CORONADO, CALIF. – With the exception of patients that present with perforation, emergent resection of colon cancers does not appear to adversely affect operative outcomes or patient survival, a 3-year analysis of data showed.
At the annual meeting of the Western Surgical Association, Jason W. Smith, MD, said that of the estimated 106,100 new cases of colon cancer each year, 6%-30% of patients have symptoms or late complications related to the disease that require an emergency intervention, often leading to dismal outcomes. “The problem with many existing studies of emergent colon cancer resections is that they tend to throw everybody into one large group, making it difficult to compare some of these patients,” said Dr. Smith, a trauma surgeon in the department of surgery at the University of Louisville (Ky.) School of Medicine. “Our thought was, if we provide an appropriate oncologic resection at the time of our initial management in these patients when they come to the emergency department, can we affect the similar rate of overall outcomes for these patients with regard to their cancer prognosis?”
Of the 117 patients in the emergent group, 35 had a perforation and 82 had an emergent resection. In an unmatched analysis comparing perforation, emergent resection, and elective resection, the patients who presented with a perforation had a much higher Charlson Comorbidity Index (CCI) score and a higher American Society of Anesthesiologists (ASA) class. They tended to be on vasopressors or suffering from inflammatory response related to their perforation, they had lower levels of blood pressure and hemoglobin, and they had much higher rates of 30-day mortality and overall 30-day morbidity, compared with their counterparts in the other two groups. Of the eight deaths that occurred in patients with colon perforation, four were related to sepsis and multiple organ failure, one to respiratory failure/acute respiratory distress syndrome, one to acute MI, one to exacerbation of chronic lung disease, and one to transition to palliative care due to cancer diagnosis. “So the overall predominance of the deaths associated in the first 30 days were related to the inflammatory responses associated with that perforation, not specific to the cancer itself,” Dr. Smith said. At the same time, the ASA and CCI scores were not different between those with morbidity/mortality and those who survived. “So it’s difficult to identify these patients out of the gate,” he said.
When the researchers more closely examined data from patients with a perforation, 27 of 35 (77%) survived at 30 days. Survival at 1, 2, and 3 years was 78%, 57%, and 43%, respectively. “This is a mixture of stage II and stage IV patients, so they’re difficult to compare and difficult to standardize across the board,” Dr. Smith noted. “But what you see is that their survival is not significantly different related to their disease if you discount the inflammatory process. Our initial thought was that for these perforated cancers, what we really need to do is provide the appropriate oncologic resection management [in order to] get the same oncologic outcomes.”
Next, the researchers compared the 82 patients who presented without a perforation but required an emergent operation with 82 of the elective surgery patients, matched for age, gender, the CCI, ASA class, oncology stage, and body mass index. There were no differences between the two groups in terms of R0 resection, the number of lymph nodes sampled, or estimated blood loss. However, compared with patients in the elective resection group, those in the emergent resection group had higher rates of ostomy placement (30% vs. 10%, respectively; P = .01), and a longer hospital length of stay (an average of 18 vs. 12 days; P = .0007). “Most of that difference occurred on the front end of hospital stays,” Dr. Smith said. “Their postoperative days were not significantly different.”
As for long-term outcomes, more than 90% of all patients in both groups received chemotherapy within the first year postprocedure, and overall time to initiation of chemotherapy was not significantly different in the emergent vs. elective groups (6.6 vs. 5.5 weeks, respectively; P = .43). However, patients suffering postsurgical complications had an increased risk of delayed chemotherapy.
In a risk-adjusted analysis, overall survival at 3 years was not different between the emergent and elective operation groups (hazard ratio, 1.1; P = .54). Similarly, disease-free survival was not different at 3 years between the two groups (HR, 1.06; P = .84). Independent predictors of poor long-term outcome included age greater than 70 (HR, 1.45; P less than 0.03); elevated ASA class (HR, 2.99 for class III vs. class I-II; P = .08; and HR, 7.45 for ASA class IV vs. I-II; P = .03); presence of residual disease (HR, 3.08; P less than .001), and advanced cancer stage.
He acknowledged certain limitations of the study, including the fact that it was a blinded retrospective cohort with the potential for unrecognized bias, and that it measured 3-year survival instead of 5-year survival data.
“Emergent resection of nonperforated colon cancers does not appear to adversely affect operative outcomes or patient survival when proper oncologic principles are applied to their initial management,” Dr. Smith concluded. “Outcome differences in patients suffering perforation may correlate with the physiologic derangements associated with the perforation rather than the oncologic disease; thus, every effort should be made to provide an appropriate oncologic operation.” He reported having no financial disclosures.
[email protected]
CORONADO, CALIF. – With the exception of patients that present with perforation, emergent resection of colon cancers does not appear to adversely affect operative outcomes or patient survival, a 3-year analysis of data showed.
At the annual meeting of the Western Surgical Association, Jason W. Smith, MD, said that of the estimated 106,100 new cases of colon cancer each year, 6%-30% of patients have symptoms or late complications related to the disease that require an emergency intervention, often leading to dismal outcomes. “The problem with many existing studies of emergent colon cancer resections is that they tend to throw everybody into one large group, making it difficult to compare some of these patients,” said Dr. Smith, a trauma surgeon in the department of surgery at the University of Louisville (Ky.) School of Medicine. “Our thought was, if we provide an appropriate oncologic resection at the time of our initial management in these patients when they come to the emergency department, can we affect the similar rate of overall outcomes for these patients with regard to their cancer prognosis?”
Of the 117 patients in the emergent group, 35 had a perforation and 82 had an emergent resection. In an unmatched analysis comparing perforation, emergent resection, and elective resection, the patients who presented with a perforation had a much higher Charlson Comorbidity Index (CCI) score and a higher American Society of Anesthesiologists (ASA) class. They tended to be on vasopressors or suffering from inflammatory response related to their perforation, they had lower levels of blood pressure and hemoglobin, and they had much higher rates of 30-day mortality and overall 30-day morbidity, compared with their counterparts in the other two groups. Of the eight deaths that occurred in patients with colon perforation, four were related to sepsis and multiple organ failure, one to respiratory failure/acute respiratory distress syndrome, one to acute MI, one to exacerbation of chronic lung disease, and one to transition to palliative care due to cancer diagnosis. “So the overall predominance of the deaths associated in the first 30 days were related to the inflammatory responses associated with that perforation, not specific to the cancer itself,” Dr. Smith said. At the same time, the ASA and CCI scores were not different between those with morbidity/mortality and those who survived. “So it’s difficult to identify these patients out of the gate,” he said.
When the researchers more closely examined data from patients with a perforation, 27 of 35 (77%) survived at 30 days. Survival at 1, 2, and 3 years was 78%, 57%, and 43%, respectively. “This is a mixture of stage II and stage IV patients, so they’re difficult to compare and difficult to standardize across the board,” Dr. Smith noted. “But what you see is that their survival is not significantly different related to their disease if you discount the inflammatory process. Our initial thought was that for these perforated cancers, what we really need to do is provide the appropriate oncologic resection management [in order to] get the same oncologic outcomes.”
Next, the researchers compared the 82 patients who presented without a perforation but required an emergent operation with 82 of the elective surgery patients, matched for age, gender, the CCI, ASA class, oncology stage, and body mass index. There were no differences between the two groups in terms of R0 resection, the number of lymph nodes sampled, or estimated blood loss. However, compared with patients in the elective resection group, those in the emergent resection group had higher rates of ostomy placement (30% vs. 10%, respectively; P = .01), and a longer hospital length of stay (an average of 18 vs. 12 days; P = .0007). “Most of that difference occurred on the front end of hospital stays,” Dr. Smith said. “Their postoperative days were not significantly different.”
As for long-term outcomes, more than 90% of all patients in both groups received chemotherapy within the first year postprocedure, and overall time to initiation of chemotherapy was not significantly different in the emergent vs. elective groups (6.6 vs. 5.5 weeks, respectively; P = .43). However, patients suffering postsurgical complications had an increased risk of delayed chemotherapy.
In a risk-adjusted analysis, overall survival at 3 years was not different between the emergent and elective operation groups (hazard ratio, 1.1; P = .54). Similarly, disease-free survival was not different at 3 years between the two groups (HR, 1.06; P = .84). Independent predictors of poor long-term outcome included age greater than 70 (HR, 1.45; P less than 0.03); elevated ASA class (HR, 2.99 for class III vs. class I-II; P = .08; and HR, 7.45 for ASA class IV vs. I-II; P = .03); presence of residual disease (HR, 3.08; P less than .001), and advanced cancer stage.
He acknowledged certain limitations of the study, including the fact that it was a blinded retrospective cohort with the potential for unrecognized bias, and that it measured 3-year survival instead of 5-year survival data.
“Emergent resection of nonperforated colon cancers does not appear to adversely affect operative outcomes or patient survival when proper oncologic principles are applied to their initial management,” Dr. Smith concluded. “Outcome differences in patients suffering perforation may correlate with the physiologic derangements associated with the perforation rather than the oncologic disease; thus, every effort should be made to provide an appropriate oncologic operation.” He reported having no financial disclosures.
[email protected]
CORONADO, CALIF. – With the exception of patients that present with perforation, emergent resection of colon cancers does not appear to adversely affect operative outcomes or patient survival, a 3-year analysis of data showed.
At the annual meeting of the Western Surgical Association, Jason W. Smith, MD, said that of the estimated 106,100 new cases of colon cancer each year, 6%-30% of patients have symptoms or late complications related to the disease that require an emergency intervention, often leading to dismal outcomes. “The problem with many existing studies of emergent colon cancer resections is that they tend to throw everybody into one large group, making it difficult to compare some of these patients,” said Dr. Smith, a trauma surgeon in the department of surgery at the University of Louisville (Ky.) School of Medicine. “Our thought was, if we provide an appropriate oncologic resection at the time of our initial management in these patients when they come to the emergency department, can we affect the similar rate of overall outcomes for these patients with regard to their cancer prognosis?”
Of the 117 patients in the emergent group, 35 had a perforation and 82 had an emergent resection. In an unmatched analysis comparing perforation, emergent resection, and elective resection, the patients who presented with a perforation had a much higher Charlson Comorbidity Index (CCI) score and a higher American Society of Anesthesiologists (ASA) class. They tended to be on vasopressors or suffering from inflammatory response related to their perforation, they had lower levels of blood pressure and hemoglobin, and they had much higher rates of 30-day mortality and overall 30-day morbidity, compared with their counterparts in the other two groups. Of the eight deaths that occurred in patients with colon perforation, four were related to sepsis and multiple organ failure, one to respiratory failure/acute respiratory distress syndrome, one to acute MI, one to exacerbation of chronic lung disease, and one to transition to palliative care due to cancer diagnosis. “So the overall predominance of the deaths associated in the first 30 days were related to the inflammatory responses associated with that perforation, not specific to the cancer itself,” Dr. Smith said. At the same time, the ASA and CCI scores were not different between those with morbidity/mortality and those who survived. “So it’s difficult to identify these patients out of the gate,” he said.
When the researchers more closely examined data from patients with a perforation, 27 of 35 (77%) survived at 30 days. Survival at 1, 2, and 3 years was 78%, 57%, and 43%, respectively. “This is a mixture of stage II and stage IV patients, so they’re difficult to compare and difficult to standardize across the board,” Dr. Smith noted. “But what you see is that their survival is not significantly different related to their disease if you discount the inflammatory process. Our initial thought was that for these perforated cancers, what we really need to do is provide the appropriate oncologic resection management [in order to] get the same oncologic outcomes.”
Next, the researchers compared the 82 patients who presented without a perforation but required an emergent operation with 82 of the elective surgery patients, matched for age, gender, the CCI, ASA class, oncology stage, and body mass index. There were no differences between the two groups in terms of R0 resection, the number of lymph nodes sampled, or estimated blood loss. However, compared with patients in the elective resection group, those in the emergent resection group had higher rates of ostomy placement (30% vs. 10%, respectively; P = .01), and a longer hospital length of stay (an average of 18 vs. 12 days; P = .0007). “Most of that difference occurred on the front end of hospital stays,” Dr. Smith said. “Their postoperative days were not significantly different.”
As for long-term outcomes, more than 90% of all patients in both groups received chemotherapy within the first year postprocedure, and overall time to initiation of chemotherapy was not significantly different in the emergent vs. elective groups (6.6 vs. 5.5 weeks, respectively; P = .43). However, patients suffering postsurgical complications had an increased risk of delayed chemotherapy.
In a risk-adjusted analysis, overall survival at 3 years was not different between the emergent and elective operation groups (hazard ratio, 1.1; P = .54). Similarly, disease-free survival was not different at 3 years between the two groups (HR, 1.06; P = .84). Independent predictors of poor long-term outcome included age greater than 70 (HR, 1.45; P less than 0.03); elevated ASA class (HR, 2.99 for class III vs. class I-II; P = .08; and HR, 7.45 for ASA class IV vs. I-II; P = .03); presence of residual disease (HR, 3.08; P less than .001), and advanced cancer stage.
He acknowledged certain limitations of the study, including the fact that it was a blinded retrospective cohort with the potential for unrecognized bias, and that it measured 3-year survival instead of 5-year survival data.
“Emergent resection of nonperforated colon cancers does not appear to adversely affect operative outcomes or patient survival when proper oncologic principles are applied to their initial management,” Dr. Smith concluded. “Outcome differences in patients suffering perforation may correlate with the physiologic derangements associated with the perforation rather than the oncologic disease; thus, every effort should be made to provide an appropriate oncologic operation.” He reported having no financial disclosures.
[email protected]
AT WSA 2016
Key clinical point:
Major finding: In a risk-adjusted analysis, overall survival at 3 years was not different between the emergent and elective operation groups (HR, 1.1; P = .54).
Data source: A retrospective review of 548 elective and emergent colectomies for colon cancer performed at the University of Louisville (Ky.) from 2011 to 2015.
Disclosures: Dr. Smith reported having no financial disclosures.
In era of infliximab, ulcerative colitis surgical outcomes worsen
WASHINGTON – The era of powerful biologics has led to unforeseen surgical outcomes in patients with ulcerative colitis.
Patients undergoing surgery for ulcerative colitis now are 38% more likely to die in the hospital than they were 15 years ago, before infliximab and other biologics were adopted as medical therapy for the disease. A database review covering 18 years found that other surgical outcomes are worse, too, Jonathan Abelson, MD, said at the annual clinical congress of the American College of Surgeons.
“These very powerful agents could be completely eliminating the need for surgery in patients with mild disease, leaving surgery for those who have very advanced disease and didn’t respond well to medical therapy,” said Dr. Abelson, a clinical research fellow at New York–Presbyterian Hospital, N.Y. “We are operating now only on patients with very severe disease, not the wider range of patients we had 15 years ago, when there weren’t as effective medical options.”
He and his colleagues used the New York Statewide Planning and Research Cooperative System (SPARCS) database to identify 7,070 patients who had undergone bowel resection for ulcerative colitis during two epochs: prebiologics (1995-2005) and postbiologics (2006-2013). The cohorts were about evenly split in numbers.
There were some statistically significant differences in baseline characteristics. Patients in epoch 2 were about a year older (51 vs. 50 years). Significantly more of them had at least two major comorbidities (28% vs. 18%). Minimally invasive surgery was significantly more common in epoch 2 (28% vs. 3%).
Significantly more surgeries in epoch 2 were staged into three or more procedures (14% vs. 9%). This finding probably reflects the level of disease severity in those presenting for surgery or the fact that they underwent surgery after recently receiving biologics, Dr. Abelson said.
“One of the limits of this study is that we don’t know exactly the reasons for these one-, two-, or three-stage surgeries. The theory is that patients who were more ill at presentation are more likely to have a multistaged surgery. Another reason could be that if they are on these powerful immunosuppressive regimens, the surgeon might be concerned about not healing well from a definitive one- or two-stage surgery.”
He then conducted a multivariate analysis that controlled for baseline factors, including a variety of individual comorbid conditions. In this analysis, patients in epoch 2 were 38% more likely to die in the hospital and 51% more likely to experience a major postoperative event, like shock, pulmonary embolism, stroke, or heart attack. The chance of a surgical complication was increased by 39%, and these patients were 25% more likely to need a transfusion during surgery than those from epoch 1.
The poorer outcomes held for an at least an entire year after surgery, Dr. Abelson said. At 1 year, patients in epoch 2 were 36% more likely to have a readmission than those in epoch 1. Major events and procedural complications were both 46% more likely. Patients were also 36% more likely to require an additional procedure.
“These are not the outcomes we want to see, especially in this era when our surgical techniques have improved so much,” Dr. Abelson said. “If what this represents, though, is that we are now operating on a higher-risk population, we can’t just say, ‘Well, that’s how it’s going to be.’ We need to figure out how to minimize morbidity and mortality in this high-risk patient population.”
One goal, he suggested, would be to assess response to a biologic regimen earlier in the hopes of determining who will respond well, and moving ahead with surgery in those who don’t.
This is a tough sell for patients, he said.
“There is a big fear of this surgery. It usually requires a temporary ileostomy and a stoma bag, and patients are terrified of that. There have been a few studies demonstrating that earlier referral to surgery improves quality of life; living with advanced ulcerative colitis can be extremely difficult and patients often feel a lot better after we remove their diseased colon. But getting there is a challenge.”
Dr. Abelson had no financial disclosures.
[email protected]
On Twitter @Alz_Gal
WASHINGTON – The era of powerful biologics has led to unforeseen surgical outcomes in patients with ulcerative colitis.
Patients undergoing surgery for ulcerative colitis now are 38% more likely to die in the hospital than they were 15 years ago, before infliximab and other biologics were adopted as medical therapy for the disease. A database review covering 18 years found that other surgical outcomes are worse, too, Jonathan Abelson, MD, said at the annual clinical congress of the American College of Surgeons.
“These very powerful agents could be completely eliminating the need for surgery in patients with mild disease, leaving surgery for those who have very advanced disease and didn’t respond well to medical therapy,” said Dr. Abelson, a clinical research fellow at New York–Presbyterian Hospital, N.Y. “We are operating now only on patients with very severe disease, not the wider range of patients we had 15 years ago, when there weren’t as effective medical options.”
He and his colleagues used the New York Statewide Planning and Research Cooperative System (SPARCS) database to identify 7,070 patients who had undergone bowel resection for ulcerative colitis during two epochs: prebiologics (1995-2005) and postbiologics (2006-2013). The cohorts were about evenly split in numbers.
There were some statistically significant differences in baseline characteristics. Patients in epoch 2 were about a year older (51 vs. 50 years). Significantly more of them had at least two major comorbidities (28% vs. 18%). Minimally invasive surgery was significantly more common in epoch 2 (28% vs. 3%).
Significantly more surgeries in epoch 2 were staged into three or more procedures (14% vs. 9%). This finding probably reflects the level of disease severity in those presenting for surgery or the fact that they underwent surgery after recently receiving biologics, Dr. Abelson said.
“One of the limits of this study is that we don’t know exactly the reasons for these one-, two-, or three-stage surgeries. The theory is that patients who were more ill at presentation are more likely to have a multistaged surgery. Another reason could be that if they are on these powerful immunosuppressive regimens, the surgeon might be concerned about not healing well from a definitive one- or two-stage surgery.”
He then conducted a multivariate analysis that controlled for baseline factors, including a variety of individual comorbid conditions. In this analysis, patients in epoch 2 were 38% more likely to die in the hospital and 51% more likely to experience a major postoperative event, like shock, pulmonary embolism, stroke, or heart attack. The chance of a surgical complication was increased by 39%, and these patients were 25% more likely to need a transfusion during surgery than those from epoch 1.
The poorer outcomes held for an at least an entire year after surgery, Dr. Abelson said. At 1 year, patients in epoch 2 were 36% more likely to have a readmission than those in epoch 1. Major events and procedural complications were both 46% more likely. Patients were also 36% more likely to require an additional procedure.
“These are not the outcomes we want to see, especially in this era when our surgical techniques have improved so much,” Dr. Abelson said. “If what this represents, though, is that we are now operating on a higher-risk population, we can’t just say, ‘Well, that’s how it’s going to be.’ We need to figure out how to minimize morbidity and mortality in this high-risk patient population.”
One goal, he suggested, would be to assess response to a biologic regimen earlier in the hopes of determining who will respond well, and moving ahead with surgery in those who don’t.
This is a tough sell for patients, he said.
“There is a big fear of this surgery. It usually requires a temporary ileostomy and a stoma bag, and patients are terrified of that. There have been a few studies demonstrating that earlier referral to surgery improves quality of life; living with advanced ulcerative colitis can be extremely difficult and patients often feel a lot better after we remove their diseased colon. But getting there is a challenge.”
Dr. Abelson had no financial disclosures.
[email protected]
On Twitter @Alz_Gal
WASHINGTON – The era of powerful biologics has led to unforeseen surgical outcomes in patients with ulcerative colitis.
Patients undergoing surgery for ulcerative colitis now are 38% more likely to die in the hospital than they were 15 years ago, before infliximab and other biologics were adopted as medical therapy for the disease. A database review covering 18 years found that other surgical outcomes are worse, too, Jonathan Abelson, MD, said at the annual clinical congress of the American College of Surgeons.
“These very powerful agents could be completely eliminating the need for surgery in patients with mild disease, leaving surgery for those who have very advanced disease and didn’t respond well to medical therapy,” said Dr. Abelson, a clinical research fellow at New York–Presbyterian Hospital, N.Y. “We are operating now only on patients with very severe disease, not the wider range of patients we had 15 years ago, when there weren’t as effective medical options.”
He and his colleagues used the New York Statewide Planning and Research Cooperative System (SPARCS) database to identify 7,070 patients who had undergone bowel resection for ulcerative colitis during two epochs: prebiologics (1995-2005) and postbiologics (2006-2013). The cohorts were about evenly split in numbers.
There were some statistically significant differences in baseline characteristics. Patients in epoch 2 were about a year older (51 vs. 50 years). Significantly more of them had at least two major comorbidities (28% vs. 18%). Minimally invasive surgery was significantly more common in epoch 2 (28% vs. 3%).
Significantly more surgeries in epoch 2 were staged into three or more procedures (14% vs. 9%). This finding probably reflects the level of disease severity in those presenting for surgery or the fact that they underwent surgery after recently receiving biologics, Dr. Abelson said.
“One of the limits of this study is that we don’t know exactly the reasons for these one-, two-, or three-stage surgeries. The theory is that patients who were more ill at presentation are more likely to have a multistaged surgery. Another reason could be that if they are on these powerful immunosuppressive regimens, the surgeon might be concerned about not healing well from a definitive one- or two-stage surgery.”
He then conducted a multivariate analysis that controlled for baseline factors, including a variety of individual comorbid conditions. In this analysis, patients in epoch 2 were 38% more likely to die in the hospital and 51% more likely to experience a major postoperative event, like shock, pulmonary embolism, stroke, or heart attack. The chance of a surgical complication was increased by 39%, and these patients were 25% more likely to need a transfusion during surgery than those from epoch 1.
The poorer outcomes held for an at least an entire year after surgery, Dr. Abelson said. At 1 year, patients in epoch 2 were 36% more likely to have a readmission than those in epoch 1. Major events and procedural complications were both 46% more likely. Patients were also 36% more likely to require an additional procedure.
“These are not the outcomes we want to see, especially in this era when our surgical techniques have improved so much,” Dr. Abelson said. “If what this represents, though, is that we are now operating on a higher-risk population, we can’t just say, ‘Well, that’s how it’s going to be.’ We need to figure out how to minimize morbidity and mortality in this high-risk patient population.”
One goal, he suggested, would be to assess response to a biologic regimen earlier in the hopes of determining who will respond well, and moving ahead with surgery in those who don’t.
This is a tough sell for patients, he said.
“There is a big fear of this surgery. It usually requires a temporary ileostomy and a stoma bag, and patients are terrified of that. There have been a few studies demonstrating that earlier referral to surgery improves quality of life; living with advanced ulcerative colitis can be extremely difficult and patients often feel a lot better after we remove their diseased colon. But getting there is a challenge.”
Dr. Abelson had no financial disclosures.
[email protected]
On Twitter @Alz_Gal
AT THE ACS CLINICAL CONGRESS
Key clinical point:
Major finding: Patients are 38% more likely to die in the hospital than they were 15 years ago.
Data source: The 18-year database review comprised more than 7,000 surgeries.
Disclosures: Dr. Abelson had no financial disclosures.
A Better Way to Predict Colorectal Cancer Relapse?
Carcinoembryonic antigen (CEA) is often used as a marker for relapse in colorectal cancer. But in as many as 40% of recurrences, the serum CEA shows unmeasurable elevations. And some patients with resected colorectal cancer (CRC) have transient elevations of CEA levels; the false-positive rate during follow-up has been as high as 16%, say researchers from Kaohsiung Medical University, Taiwan. They propose “a more powerful tool”: a membrane array-based multigene biomarker assay, or biomarker chip, which detects circulating tumor cells in the peripheral blood.
Related: Colorectal Carcinoma and Emerging Targeted Therapies
The researchers conducted a study in 298 patients with CRC to test that alternative. The patients were enrolled after radical curative resection for primary CRC tumor; 82 were stage I, 102 were stage II, and 114 were stage III. Patients were followed for a median of 28.4 months, every 3 months for 3 years, then every 6 months. At each follow-up visit, laboratory studies included serum CEA levels. Elevated CEA levels were defined as 2 consecutive measurements of >5 ng/mL at a 3-month interval.
During the study period, 48 patients (16.1%) had postoperative relapse, and 26 (8.7%) died. Of all 298 patients, 62 (20.8%) had a total biomarker chip score higher than the cutoff value. Of the 48 who relapsed, 42 (87.5%) showed positive biochip results prior to relapse.
The positive biochip results were significantly associated with postoperative relapse. In fact, the biomarker chip was better for predicting relapse than were the postoperative serum CEA levels with higher sensitivity (87.5% vs 60.4%), specificity (92.0% vs 83.2%), positive predictive value (67.7% vs 40.8%), negative predictive value (97.5% vs 91.6%), and accuracy (91.3% vs 79.5%).
Moreover, the biochip predicted relapse “considerably earlier” than did CEA levels (10.7 vs 2.8 months). The researchers note that CRC-related deaths are largely attributable to clinical relapse. The sooner a relapse is diagnosed, the more amenable the tumor may be to resection, increasing the likelihood of long-term survival.
In sum, the biomarker chip would be a more accurate tool for predicting relapse, the researchers say. They also suggest that, in clinical practice, combining the 2 tests could enhance confidence in the diagnosis.
Source:
Chang YT, Huang MY, Huang CW, et al. PLoS One. 2016;11(10):e0163264.
doi: 10.1371/journal.pone.0163264.
Carcinoembryonic antigen (CEA) is often used as a marker for relapse in colorectal cancer. But in as many as 40% of recurrences, the serum CEA shows unmeasurable elevations. And some patients with resected colorectal cancer (CRC) have transient elevations of CEA levels; the false-positive rate during follow-up has been as high as 16%, say researchers from Kaohsiung Medical University, Taiwan. They propose “a more powerful tool”: a membrane array-based multigene biomarker assay, or biomarker chip, which detects circulating tumor cells in the peripheral blood.
Related: Colorectal Carcinoma and Emerging Targeted Therapies
The researchers conducted a study in 298 patients with CRC to test that alternative. The patients were enrolled after radical curative resection for primary CRC tumor; 82 were stage I, 102 were stage II, and 114 were stage III. Patients were followed for a median of 28.4 months, every 3 months for 3 years, then every 6 months. At each follow-up visit, laboratory studies included serum CEA levels. Elevated CEA levels were defined as 2 consecutive measurements of >5 ng/mL at a 3-month interval.
During the study period, 48 patients (16.1%) had postoperative relapse, and 26 (8.7%) died. Of all 298 patients, 62 (20.8%) had a total biomarker chip score higher than the cutoff value. Of the 48 who relapsed, 42 (87.5%) showed positive biochip results prior to relapse.
The positive biochip results were significantly associated with postoperative relapse. In fact, the biomarker chip was better for predicting relapse than were the postoperative serum CEA levels with higher sensitivity (87.5% vs 60.4%), specificity (92.0% vs 83.2%), positive predictive value (67.7% vs 40.8%), negative predictive value (97.5% vs 91.6%), and accuracy (91.3% vs 79.5%).
Moreover, the biochip predicted relapse “considerably earlier” than did CEA levels (10.7 vs 2.8 months). The researchers note that CRC-related deaths are largely attributable to clinical relapse. The sooner a relapse is diagnosed, the more amenable the tumor may be to resection, increasing the likelihood of long-term survival.
In sum, the biomarker chip would be a more accurate tool for predicting relapse, the researchers say. They also suggest that, in clinical practice, combining the 2 tests could enhance confidence in the diagnosis.
Source:
Chang YT, Huang MY, Huang CW, et al. PLoS One. 2016;11(10):e0163264.
doi: 10.1371/journal.pone.0163264.
Carcinoembryonic antigen (CEA) is often used as a marker for relapse in colorectal cancer. But in as many as 40% of recurrences, the serum CEA shows unmeasurable elevations. And some patients with resected colorectal cancer (CRC) have transient elevations of CEA levels; the false-positive rate during follow-up has been as high as 16%, say researchers from Kaohsiung Medical University, Taiwan. They propose “a more powerful tool”: a membrane array-based multigene biomarker assay, or biomarker chip, which detects circulating tumor cells in the peripheral blood.
Related: Colorectal Carcinoma and Emerging Targeted Therapies
The researchers conducted a study in 298 patients with CRC to test that alternative. The patients were enrolled after radical curative resection for primary CRC tumor; 82 were stage I, 102 were stage II, and 114 were stage III. Patients were followed for a median of 28.4 months, every 3 months for 3 years, then every 6 months. At each follow-up visit, laboratory studies included serum CEA levels. Elevated CEA levels were defined as 2 consecutive measurements of >5 ng/mL at a 3-month interval.
During the study period, 48 patients (16.1%) had postoperative relapse, and 26 (8.7%) died. Of all 298 patients, 62 (20.8%) had a total biomarker chip score higher than the cutoff value. Of the 48 who relapsed, 42 (87.5%) showed positive biochip results prior to relapse.
The positive biochip results were significantly associated with postoperative relapse. In fact, the biomarker chip was better for predicting relapse than were the postoperative serum CEA levels with higher sensitivity (87.5% vs 60.4%), specificity (92.0% vs 83.2%), positive predictive value (67.7% vs 40.8%), negative predictive value (97.5% vs 91.6%), and accuracy (91.3% vs 79.5%).
Moreover, the biochip predicted relapse “considerably earlier” than did CEA levels (10.7 vs 2.8 months). The researchers note that CRC-related deaths are largely attributable to clinical relapse. The sooner a relapse is diagnosed, the more amenable the tumor may be to resection, increasing the likelihood of long-term survival.
In sum, the biomarker chip would be a more accurate tool for predicting relapse, the researchers say. They also suggest that, in clinical practice, combining the 2 tests could enhance confidence in the diagnosis.
Source:
Chang YT, Huang MY, Huang CW, et al. PLoS One. 2016;11(10):e0163264.
doi: 10.1371/journal.pone.0163264.
Study eyes anastomotic failure in stapled vs. hand-sewn techniques
WAIKOLOA, HAWAII – The risk of anastomotic failure among emergency general surgery patients requiring bowel resection and anastomosis stands at 12.5% and is similar between stapled and hand-sewn techniques, results from a multicenter analysis demonstrated.
Surgeons participating in the study, known as Stapled vs. Handsewn: A Prospective Emergency Surgery Study (SHAPES), “appear to be performing hand-sewn techniques in patients who have a higher burden of disease,” Brandon R. Bruns, MD, said at the annual meeting of the American Association for the Surgery of Trauma. “Without adjustment and despite being performed in a more ill population, there was no difference in failure rate between hand-sewn and stapled techniques. After modeling, only being managed with an open abdomen and contamination at initial operation were associated with anastomotic failure.”
For SHAPES, which is the largest study of its kind and was sponsored by the AAST Multi-Institutional Studies Committee, Dr. Bruns and his associates set out to prospectively evaluate anastomotic failure rates for hand-sewn and stapled anastomoses in patients undergoing urgent/emergent operations. A 1999 study by Seattle researchers found that stapled techniques seemed to be associated with anastomotic failure (J Trauma. 1999;47[3]:500-08). Two years later, the same researchers pooled 4-year retrospective data from four trauma centers and concluded that again, hand-sewn techniques appeared to be superior to stapled techniques after traumatic bowel resection and anastomosis (J Trauma. 2001;51[6]:1054-61). Also in 2001, AAST sponsored a multi-institutional study that examined the same question, this time in penetrative colonic injury. Investigators found no difference in complications between the two groups (J Trauma. 2002;52[1]:117-21). They did, however, find a 22.7% overall incidence of colon-related complications.
“With this background we hypothesized that anastomotic failure rate would be high for emergency general surgery patients undergoing bowel resection and anastomosis,” said Dr. Bruns, an acute care surgeon at the R. Adams Cowley Shock Trauma Center at the University of Maryland Medical Center, Baltimore. “We also hypothesized that failure rates would be higher for stapled techniques, compared with hand-sewn.”
The SHAPES researchers prospectively enrolled 595 patients at 15 medical centers in the United States who underwent urgent/emergent bowel resection for emergency general surgery pathology between July 22, 2013, and Dec. 31, 2015. The patients were grouped by hand-sewn vs. stapled anastomoses and demographic and clinical variables were collected. The primary outcome was anastomotic failure. As in other studies, anastomotic failure was evaluated at the anastomosis level. Multivariable logistic regression was done, controlling for age and risk factors for anastomotic failure.
Dr. Bruns reported that the 595 patients had 649 anastomoses. Of these, 61% were stapled and 39% were hand-sewn. The mean age of patients was 62 years, 51% were male, and the overall mortality rate was 7.7%. More than two-thirds of the patients (35%) had more than one indication for operative intervention. The most common single indication for operation was small bowel obstruction, at 23%. The majority of the anastomoses were small bowel to small bowel (72%), while 21% were small bowel to large bowel, and 7% were large bowel to large bowel. There were a total of 81 anastomotic failures, for a rate of 12.5%.
When the researchers compared the hand-sewn and stapled groups, they were similar with respect to sex and age, with higher Charlson comorbidity indices in stapled and a higher body mass index in the hand-sewn group. They also observed a lower hemoglobin, higher INR, higher lactate, lower albumin, and worse renal function in the hand-sewn group, compared with the stapled group. Moreover, hand-sewn anastomotic techniques were performed more frequently in patients that were on vasopressor support. “Despite patients receiving hand-sewn techniques, having worse laboratory values, and more intraoperative vasopressors, the two techniques had equivalent failure rates, at 15.4% for hand-sewn and 10.6% for stapled,” Dr. Bruns said. “Patients with hand-sewn techniques had longer hospital length of stay, longer ICU length of stay, and a significantly higher mortality, compared with those who underwent stapled techniques. Interestingly and different from most other studies on the topic, operating time between the two groups was equivalent.”
On multivariate regression, the presence of contamination at initial bowel resection (OR 1.96) and the patient being managed with an open abdomen (OR 2.53) were independently associated with anastomotic failure, while the type of anastomosis (hand-sewn vs. stapled) was not.
The researchers also conducted a subanalysis of 165 patients managed with an open abdomen who had bowel resection and anastomosis. These patients had higher BMIs, higher lactates, higher INRs, and more negative base deficits, compared with those who were not managed with an open abdomen. “Perhaps not unexpectedly, open abdomen patients were more likely to be on vasopressor agents,” Dr. Bruns said. “They had longer hospital lengths of stay, more ICU days, and an 18.2% overall mortality. Overall there was an almost 22% anastomotic failure rate in patients managed with an open abdomen, compared with an 8.5% rate in patients managed with non-open techniques.” Comparing hand-sewn and stapled techniques, there was no difference in failure rate in patients managed with an open abdomen (25.2% vs. 17.5%, respectively; P = .20).
“An overall mortality rate of 8% and an anastomotic complication rate of 12.5% should emphasize the dire needs for these operations and the need for meticulous operative as well as surgically directed perioperative care in these patients,” the invited discussant, Gregory Jurkovich, MD, professor of surgery at the Davis Medical Center, University of California, said at the meeting. “We as surgeons must pay attention to all aspects of care in these patients.”
Dr. Bruns acknowledged certain limitations of the study, including the fact that it was not a randomized, controlled trial. Also, “surgeon preference did dictate the type of anastomosis that was created, and the patient and surgeon populations were heterogeneous,” he said. “The multivariable model was limited by missing laboratory data, likely given the urgent nature of some of the operative procedures.”
He reported having no financial disclosures.
WAIKOLOA, HAWAII – The risk of anastomotic failure among emergency general surgery patients requiring bowel resection and anastomosis stands at 12.5% and is similar between stapled and hand-sewn techniques, results from a multicenter analysis demonstrated.
Surgeons participating in the study, known as Stapled vs. Handsewn: A Prospective Emergency Surgery Study (SHAPES), “appear to be performing hand-sewn techniques in patients who have a higher burden of disease,” Brandon R. Bruns, MD, said at the annual meeting of the American Association for the Surgery of Trauma. “Without adjustment and despite being performed in a more ill population, there was no difference in failure rate between hand-sewn and stapled techniques. After modeling, only being managed with an open abdomen and contamination at initial operation were associated with anastomotic failure.”
For SHAPES, which is the largest study of its kind and was sponsored by the AAST Multi-Institutional Studies Committee, Dr. Bruns and his associates set out to prospectively evaluate anastomotic failure rates for hand-sewn and stapled anastomoses in patients undergoing urgent/emergent operations. A 1999 study by Seattle researchers found that stapled techniques seemed to be associated with anastomotic failure (J Trauma. 1999;47[3]:500-08). Two years later, the same researchers pooled 4-year retrospective data from four trauma centers and concluded that again, hand-sewn techniques appeared to be superior to stapled techniques after traumatic bowel resection and anastomosis (J Trauma. 2001;51[6]:1054-61). Also in 2001, AAST sponsored a multi-institutional study that examined the same question, this time in penetrative colonic injury. Investigators found no difference in complications between the two groups (J Trauma. 2002;52[1]:117-21). They did, however, find a 22.7% overall incidence of colon-related complications.
“With this background we hypothesized that anastomotic failure rate would be high for emergency general surgery patients undergoing bowel resection and anastomosis,” said Dr. Bruns, an acute care surgeon at the R. Adams Cowley Shock Trauma Center at the University of Maryland Medical Center, Baltimore. “We also hypothesized that failure rates would be higher for stapled techniques, compared with hand-sewn.”
The SHAPES researchers prospectively enrolled 595 patients at 15 medical centers in the United States who underwent urgent/emergent bowel resection for emergency general surgery pathology between July 22, 2013, and Dec. 31, 2015. The patients were grouped by hand-sewn vs. stapled anastomoses and demographic and clinical variables were collected. The primary outcome was anastomotic failure. As in other studies, anastomotic failure was evaluated at the anastomosis level. Multivariable logistic regression was done, controlling for age and risk factors for anastomotic failure.
Dr. Bruns reported that the 595 patients had 649 anastomoses. Of these, 61% were stapled and 39% were hand-sewn. The mean age of patients was 62 years, 51% were male, and the overall mortality rate was 7.7%. More than two-thirds of the patients (35%) had more than one indication for operative intervention. The most common single indication for operation was small bowel obstruction, at 23%. The majority of the anastomoses were small bowel to small bowel (72%), while 21% were small bowel to large bowel, and 7% were large bowel to large bowel. There were a total of 81 anastomotic failures, for a rate of 12.5%.
When the researchers compared the hand-sewn and stapled groups, they were similar with respect to sex and age, with higher Charlson comorbidity indices in stapled and a higher body mass index in the hand-sewn group. They also observed a lower hemoglobin, higher INR, higher lactate, lower albumin, and worse renal function in the hand-sewn group, compared with the stapled group. Moreover, hand-sewn anastomotic techniques were performed more frequently in patients that were on vasopressor support. “Despite patients receiving hand-sewn techniques, having worse laboratory values, and more intraoperative vasopressors, the two techniques had equivalent failure rates, at 15.4% for hand-sewn and 10.6% for stapled,” Dr. Bruns said. “Patients with hand-sewn techniques had longer hospital length of stay, longer ICU length of stay, and a significantly higher mortality, compared with those who underwent stapled techniques. Interestingly and different from most other studies on the topic, operating time between the two groups was equivalent.”
On multivariate regression, the presence of contamination at initial bowel resection (OR 1.96) and the patient being managed with an open abdomen (OR 2.53) were independently associated with anastomotic failure, while the type of anastomosis (hand-sewn vs. stapled) was not.
The researchers also conducted a subanalysis of 165 patients managed with an open abdomen who had bowel resection and anastomosis. These patients had higher BMIs, higher lactates, higher INRs, and more negative base deficits, compared with those who were not managed with an open abdomen. “Perhaps not unexpectedly, open abdomen patients were more likely to be on vasopressor agents,” Dr. Bruns said. “They had longer hospital lengths of stay, more ICU days, and an 18.2% overall mortality. Overall there was an almost 22% anastomotic failure rate in patients managed with an open abdomen, compared with an 8.5% rate in patients managed with non-open techniques.” Comparing hand-sewn and stapled techniques, there was no difference in failure rate in patients managed with an open abdomen (25.2% vs. 17.5%, respectively; P = .20).
“An overall mortality rate of 8% and an anastomotic complication rate of 12.5% should emphasize the dire needs for these operations and the need for meticulous operative as well as surgically directed perioperative care in these patients,” the invited discussant, Gregory Jurkovich, MD, professor of surgery at the Davis Medical Center, University of California, said at the meeting. “We as surgeons must pay attention to all aspects of care in these patients.”
Dr. Bruns acknowledged certain limitations of the study, including the fact that it was not a randomized, controlled trial. Also, “surgeon preference did dictate the type of anastomosis that was created, and the patient and surgeon populations were heterogeneous,” he said. “The multivariable model was limited by missing laboratory data, likely given the urgent nature of some of the operative procedures.”
He reported having no financial disclosures.
WAIKOLOA, HAWAII – The risk of anastomotic failure among emergency general surgery patients requiring bowel resection and anastomosis stands at 12.5% and is similar between stapled and hand-sewn techniques, results from a multicenter analysis demonstrated.
Surgeons participating in the study, known as Stapled vs. Handsewn: A Prospective Emergency Surgery Study (SHAPES), “appear to be performing hand-sewn techniques in patients who have a higher burden of disease,” Brandon R. Bruns, MD, said at the annual meeting of the American Association for the Surgery of Trauma. “Without adjustment and despite being performed in a more ill population, there was no difference in failure rate between hand-sewn and stapled techniques. After modeling, only being managed with an open abdomen and contamination at initial operation were associated with anastomotic failure.”
For SHAPES, which is the largest study of its kind and was sponsored by the AAST Multi-Institutional Studies Committee, Dr. Bruns and his associates set out to prospectively evaluate anastomotic failure rates for hand-sewn and stapled anastomoses in patients undergoing urgent/emergent operations. A 1999 study by Seattle researchers found that stapled techniques seemed to be associated with anastomotic failure (J Trauma. 1999;47[3]:500-08). Two years later, the same researchers pooled 4-year retrospective data from four trauma centers and concluded that again, hand-sewn techniques appeared to be superior to stapled techniques after traumatic bowel resection and anastomosis (J Trauma. 2001;51[6]:1054-61). Also in 2001, AAST sponsored a multi-institutional study that examined the same question, this time in penetrative colonic injury. Investigators found no difference in complications between the two groups (J Trauma. 2002;52[1]:117-21). They did, however, find a 22.7% overall incidence of colon-related complications.
“With this background we hypothesized that anastomotic failure rate would be high for emergency general surgery patients undergoing bowel resection and anastomosis,” said Dr. Bruns, an acute care surgeon at the R. Adams Cowley Shock Trauma Center at the University of Maryland Medical Center, Baltimore. “We also hypothesized that failure rates would be higher for stapled techniques, compared with hand-sewn.”
The SHAPES researchers prospectively enrolled 595 patients at 15 medical centers in the United States who underwent urgent/emergent bowel resection for emergency general surgery pathology between July 22, 2013, and Dec. 31, 2015. The patients were grouped by hand-sewn vs. stapled anastomoses and demographic and clinical variables were collected. The primary outcome was anastomotic failure. As in other studies, anastomotic failure was evaluated at the anastomosis level. Multivariable logistic regression was done, controlling for age and risk factors for anastomotic failure.
Dr. Bruns reported that the 595 patients had 649 anastomoses. Of these, 61% were stapled and 39% were hand-sewn. The mean age of patients was 62 years, 51% were male, and the overall mortality rate was 7.7%. More than two-thirds of the patients (35%) had more than one indication for operative intervention. The most common single indication for operation was small bowel obstruction, at 23%. The majority of the anastomoses were small bowel to small bowel (72%), while 21% were small bowel to large bowel, and 7% were large bowel to large bowel. There were a total of 81 anastomotic failures, for a rate of 12.5%.
When the researchers compared the hand-sewn and stapled groups, they were similar with respect to sex and age, with higher Charlson comorbidity indices in stapled and a higher body mass index in the hand-sewn group. They also observed a lower hemoglobin, higher INR, higher lactate, lower albumin, and worse renal function in the hand-sewn group, compared with the stapled group. Moreover, hand-sewn anastomotic techniques were performed more frequently in patients that were on vasopressor support. “Despite patients receiving hand-sewn techniques, having worse laboratory values, and more intraoperative vasopressors, the two techniques had equivalent failure rates, at 15.4% for hand-sewn and 10.6% for stapled,” Dr. Bruns said. “Patients with hand-sewn techniques had longer hospital length of stay, longer ICU length of stay, and a significantly higher mortality, compared with those who underwent stapled techniques. Interestingly and different from most other studies on the topic, operating time between the two groups was equivalent.”
On multivariate regression, the presence of contamination at initial bowel resection (OR 1.96) and the patient being managed with an open abdomen (OR 2.53) were independently associated with anastomotic failure, while the type of anastomosis (hand-sewn vs. stapled) was not.
The researchers also conducted a subanalysis of 165 patients managed with an open abdomen who had bowel resection and anastomosis. These patients had higher BMIs, higher lactates, higher INRs, and more negative base deficits, compared with those who were not managed with an open abdomen. “Perhaps not unexpectedly, open abdomen patients were more likely to be on vasopressor agents,” Dr. Bruns said. “They had longer hospital lengths of stay, more ICU days, and an 18.2% overall mortality. Overall there was an almost 22% anastomotic failure rate in patients managed with an open abdomen, compared with an 8.5% rate in patients managed with non-open techniques.” Comparing hand-sewn and stapled techniques, there was no difference in failure rate in patients managed with an open abdomen (25.2% vs. 17.5%, respectively; P = .20).
“An overall mortality rate of 8% and an anastomotic complication rate of 12.5% should emphasize the dire needs for these operations and the need for meticulous operative as well as surgically directed perioperative care in these patients,” the invited discussant, Gregory Jurkovich, MD, professor of surgery at the Davis Medical Center, University of California, said at the meeting. “We as surgeons must pay attention to all aspects of care in these patients.”
Dr. Bruns acknowledged certain limitations of the study, including the fact that it was not a randomized, controlled trial. Also, “surgeon preference did dictate the type of anastomosis that was created, and the patient and surgeon populations were heterogeneous,” he said. “The multivariable model was limited by missing laboratory data, likely given the urgent nature of some of the operative procedures.”
He reported having no financial disclosures.
AT THE AAST ANNUAL MEETING
Key clinical point: In patients requiring emergency bowel resection and anastomosis, surgeons appear to be performing hand-sewn techniques in patients who have a higher burden of disease.
Major finding: There were 81 anastomotic failures in the study group, for a rate of 12.5%.
Data source: A prospective evaluation of 595 patients at 15 medical centers in the United States who underwent urgent/emergent bowel resection for emergency general surgery pathology between July 22, 2013, and Dec. 31, 2015.
Disclosures: Dr. Bruns reported having no financial disclosures.
Colorectal Screening: Available but Underused
The U.S. health care system has the capacity to screen as many as 80% of eligible adults for colorectal cancer, which would meet national goals for 2018. Unfortunately, not enough people are getting screened: Only half of adults in the U.S. are up-to-date on screening, according to the CDC.
Related: Are Periodic Endoscopies Useful for Patients Under 40?
To find out whether the screening capacity would be up to the task, CDC researchers estimated the number of colonoscopies or fecal immunochemical tests (FITs) that would be necessary every year to screen 80% of adults aged between 50 and 75 years. To accomplish this goal by 2024, the researchers say a national screening program that began in 2014 would need about 47 million FIT procedures and 5.1 million colonoscopies annually, using FIT as the primary screening test. About 11 to 13 million colonoscopies would be needed if a colonoscopy-only screening program were used.
Related: Do Age and Gender Matter in Colorectal Cancer?
The researchers also used data from the 2012 Survey of Endoscopic Capacity, which estimated that about 15 million colonoscopies were performed in 2012 and 10.5 million more could be performed every year.
“Colorectal cancer is the second leading cancer killer for men and women in the U.S.,” said Djenaba Joseph, MD, MPH, medical director of CDC’s colorectal cancer control program and lead author of the study paper, “but it doesn’t have to be.”
The U.S. health care system has the capacity to screen as many as 80% of eligible adults for colorectal cancer, which would meet national goals for 2018. Unfortunately, not enough people are getting screened: Only half of adults in the U.S. are up-to-date on screening, according to the CDC.
Related: Are Periodic Endoscopies Useful for Patients Under 40?
To find out whether the screening capacity would be up to the task, CDC researchers estimated the number of colonoscopies or fecal immunochemical tests (FITs) that would be necessary every year to screen 80% of adults aged between 50 and 75 years. To accomplish this goal by 2024, the researchers say a national screening program that began in 2014 would need about 47 million FIT procedures and 5.1 million colonoscopies annually, using FIT as the primary screening test. About 11 to 13 million colonoscopies would be needed if a colonoscopy-only screening program were used.
Related: Do Age and Gender Matter in Colorectal Cancer?
The researchers also used data from the 2012 Survey of Endoscopic Capacity, which estimated that about 15 million colonoscopies were performed in 2012 and 10.5 million more could be performed every year.
“Colorectal cancer is the second leading cancer killer for men and women in the U.S.,” said Djenaba Joseph, MD, MPH, medical director of CDC’s colorectal cancer control program and lead author of the study paper, “but it doesn’t have to be.”
The U.S. health care system has the capacity to screen as many as 80% of eligible adults for colorectal cancer, which would meet national goals for 2018. Unfortunately, not enough people are getting screened: Only half of adults in the U.S. are up-to-date on screening, according to the CDC.
Related: Are Periodic Endoscopies Useful for Patients Under 40?
To find out whether the screening capacity would be up to the task, CDC researchers estimated the number of colonoscopies or fecal immunochemical tests (FITs) that would be necessary every year to screen 80% of adults aged between 50 and 75 years. To accomplish this goal by 2024, the researchers say a national screening program that began in 2014 would need about 47 million FIT procedures and 5.1 million colonoscopies annually, using FIT as the primary screening test. About 11 to 13 million colonoscopies would be needed if a colonoscopy-only screening program were used.
Related: Do Age and Gender Matter in Colorectal Cancer?
The researchers also used data from the 2012 Survey of Endoscopic Capacity, which estimated that about 15 million colonoscopies were performed in 2012 and 10.5 million more could be performed every year.
“Colorectal cancer is the second leading cancer killer for men and women in the U.S.,” said Djenaba Joseph, MD, MPH, medical director of CDC’s colorectal cancer control program and lead author of the study paper, “but it doesn’t have to be.”
Enhanced recovery protocol for colectomy patients reduced hospital stay
SAN DIEGO – Multihospital collaboration and implementation of enhanced recovery have the potential to improve outcomes, in particular, length of hospital stay, results from a pilot study showed.
“Given the importance of patient engagement, enhanced recovery has the potential to improve patient experience and provide high-value health care,” Julia R. Berian, MD, said at the American College of Surgeons/National Surgical Quality Improvement Program National Conference.
Dr. Berian, the James C. Thompson Geriatric Surgery Research Fellow at the University of Chicago Medical Center, presented findings from the Enhanced Recovery in NSQIP (ERIN) Pilot, a collaborative effort by 16 ACS-NSQIP hospitals to improve length of stay in patients who undergo colectomy, a procedure that has been shown to have an adverse event rate of 28.9% and an average length of stay of 9.8 days for those who experience an adverse event (J Am Coll Surg. 2008; 207[5]:698-704).
Implementation of the ERIN Pilot showed reductions in length of hospital stay and morbidity among colectomy patients. The average length of stay decreased by 1.2 days (from a mean of 6.6 among preimplementation cases to 5.4 days among post implementation cases; P less than .0001). Morbidity also decreased from 14% to 11% (P = .01), but the rate of readmission was 11% for both pre- and postimplementation cases. In the adjusted model, the enhanced recovery protocol decreased the risk of prolonged length of stay by 40% (odds ratio, 0.6; 95% confidence interval, 0.5-0.8).
For the ERIN Pilot, she and her associates participated in monthly conference calls for collaborative experience and expert guidance from project leaders Julie Thacker, MD, and Liane Feldman, MD. Enhanced recovery protocols were tailored to each individual hospital. Data were collected before and after implementation using 14 novel ERIN variables, including preoperative elements such as defining expectations and minimizing starvation, intraoperative variables such as optimizing fluid management and minimizing surgical trauma, and postoperative elements such as aggressive adherence to best practices including feeding, early ambulation, and minimizing the use of tethers such as urinary catheters.
The researchers evaluated procedure-targeted colectomy cases performed between July 2013 and June 2015, and excluded emergency cases or those with preoperative sepsis. They used bivariate analysis and multivariate logistic regression with forward selection, and the outcome of interest, prolonged hospital length of stay, was specified by the standard ACS NSQIP definition: greater than the 75th percentile of uncomplicated cases.
Dr. Berian reported results from 2,523 colectomies performed prior to implementation of the ERIN Pilot process and 823 colectomies performed after implementation of the process. The researchers observed no differences between the preimplementation and postimplementation cases in terms of sex, preoperative functional status, hypertension, renal failure, ascites, diabetes, disseminated cancer, or use of steroids for inflammatory bowel disease. However, compared with preimplementation colectomies, a significantly higher proportion of postimplementation cases were white (77% vs. 68%, respectively), had heart failure (2.8% vs. 1.2%), had chronic obstructive pulmonary disease (7.8% vs. 5.3%), were American Society of Anesthesiologists (ASA) class 1 and 2 ( 50.2% vs. 44.7%), were smokers (21.6% vs. 16.7%), had unintentional weight loss (7.7% vs. 5.7%), had used mechanical bowel prep (77% vs. 53%), and used more oral antibiotics (68% vs. 33%).
On the other hand, compared with preimplementation cases, there were significantly fewer bleeding disorders in the postimplementation colectomies (3.9% vs. 6.4%), as well as fewer cases with preoperative systemic inflammatory response syndrome (2.9% vs. 5.4%) and open surgery approaches (31.7% vs. 42.3%).
Dr. Berian disclosed that her fellowship position is funded by the John A. Hartford Foundation.
SAN DIEGO – Multihospital collaboration and implementation of enhanced recovery have the potential to improve outcomes, in particular, length of hospital stay, results from a pilot study showed.
“Given the importance of patient engagement, enhanced recovery has the potential to improve patient experience and provide high-value health care,” Julia R. Berian, MD, said at the American College of Surgeons/National Surgical Quality Improvement Program National Conference.
Dr. Berian, the James C. Thompson Geriatric Surgery Research Fellow at the University of Chicago Medical Center, presented findings from the Enhanced Recovery in NSQIP (ERIN) Pilot, a collaborative effort by 16 ACS-NSQIP hospitals to improve length of stay in patients who undergo colectomy, a procedure that has been shown to have an adverse event rate of 28.9% and an average length of stay of 9.8 days for those who experience an adverse event (J Am Coll Surg. 2008; 207[5]:698-704).
Implementation of the ERIN Pilot showed reductions in length of hospital stay and morbidity among colectomy patients. The average length of stay decreased by 1.2 days (from a mean of 6.6 among preimplementation cases to 5.4 days among post implementation cases; P less than .0001). Morbidity also decreased from 14% to 11% (P = .01), but the rate of readmission was 11% for both pre- and postimplementation cases. In the adjusted model, the enhanced recovery protocol decreased the risk of prolonged length of stay by 40% (odds ratio, 0.6; 95% confidence interval, 0.5-0.8).
For the ERIN Pilot, she and her associates participated in monthly conference calls for collaborative experience and expert guidance from project leaders Julie Thacker, MD, and Liane Feldman, MD. Enhanced recovery protocols were tailored to each individual hospital. Data were collected before and after implementation using 14 novel ERIN variables, including preoperative elements such as defining expectations and minimizing starvation, intraoperative variables such as optimizing fluid management and minimizing surgical trauma, and postoperative elements such as aggressive adherence to best practices including feeding, early ambulation, and minimizing the use of tethers such as urinary catheters.
The researchers evaluated procedure-targeted colectomy cases performed between July 2013 and June 2015, and excluded emergency cases or those with preoperative sepsis. They used bivariate analysis and multivariate logistic regression with forward selection, and the outcome of interest, prolonged hospital length of stay, was specified by the standard ACS NSQIP definition: greater than the 75th percentile of uncomplicated cases.
Dr. Berian reported results from 2,523 colectomies performed prior to implementation of the ERIN Pilot process and 823 colectomies performed after implementation of the process. The researchers observed no differences between the preimplementation and postimplementation cases in terms of sex, preoperative functional status, hypertension, renal failure, ascites, diabetes, disseminated cancer, or use of steroids for inflammatory bowel disease. However, compared with preimplementation colectomies, a significantly higher proportion of postimplementation cases were white (77% vs. 68%, respectively), had heart failure (2.8% vs. 1.2%), had chronic obstructive pulmonary disease (7.8% vs. 5.3%), were American Society of Anesthesiologists (ASA) class 1 and 2 ( 50.2% vs. 44.7%), were smokers (21.6% vs. 16.7%), had unintentional weight loss (7.7% vs. 5.7%), had used mechanical bowel prep (77% vs. 53%), and used more oral antibiotics (68% vs. 33%).
On the other hand, compared with preimplementation cases, there were significantly fewer bleeding disorders in the postimplementation colectomies (3.9% vs. 6.4%), as well as fewer cases with preoperative systemic inflammatory response syndrome (2.9% vs. 5.4%) and open surgery approaches (31.7% vs. 42.3%).
Dr. Berian disclosed that her fellowship position is funded by the John A. Hartford Foundation.
SAN DIEGO – Multihospital collaboration and implementation of enhanced recovery have the potential to improve outcomes, in particular, length of hospital stay, results from a pilot study showed.
“Given the importance of patient engagement, enhanced recovery has the potential to improve patient experience and provide high-value health care,” Julia R. Berian, MD, said at the American College of Surgeons/National Surgical Quality Improvement Program National Conference.
Dr. Berian, the James C. Thompson Geriatric Surgery Research Fellow at the University of Chicago Medical Center, presented findings from the Enhanced Recovery in NSQIP (ERIN) Pilot, a collaborative effort by 16 ACS-NSQIP hospitals to improve length of stay in patients who undergo colectomy, a procedure that has been shown to have an adverse event rate of 28.9% and an average length of stay of 9.8 days for those who experience an adverse event (J Am Coll Surg. 2008; 207[5]:698-704).
Implementation of the ERIN Pilot showed reductions in length of hospital stay and morbidity among colectomy patients. The average length of stay decreased by 1.2 days (from a mean of 6.6 among preimplementation cases to 5.4 days among post implementation cases; P less than .0001). Morbidity also decreased from 14% to 11% (P = .01), but the rate of readmission was 11% for both pre- and postimplementation cases. In the adjusted model, the enhanced recovery protocol decreased the risk of prolonged length of stay by 40% (odds ratio, 0.6; 95% confidence interval, 0.5-0.8).
For the ERIN Pilot, she and her associates participated in monthly conference calls for collaborative experience and expert guidance from project leaders Julie Thacker, MD, and Liane Feldman, MD. Enhanced recovery protocols were tailored to each individual hospital. Data were collected before and after implementation using 14 novel ERIN variables, including preoperative elements such as defining expectations and minimizing starvation, intraoperative variables such as optimizing fluid management and minimizing surgical trauma, and postoperative elements such as aggressive adherence to best practices including feeding, early ambulation, and minimizing the use of tethers such as urinary catheters.
The researchers evaluated procedure-targeted colectomy cases performed between July 2013 and June 2015, and excluded emergency cases or those with preoperative sepsis. They used bivariate analysis and multivariate logistic regression with forward selection, and the outcome of interest, prolonged hospital length of stay, was specified by the standard ACS NSQIP definition: greater than the 75th percentile of uncomplicated cases.
Dr. Berian reported results from 2,523 colectomies performed prior to implementation of the ERIN Pilot process and 823 colectomies performed after implementation of the process. The researchers observed no differences between the preimplementation and postimplementation cases in terms of sex, preoperative functional status, hypertension, renal failure, ascites, diabetes, disseminated cancer, or use of steroids for inflammatory bowel disease. However, compared with preimplementation colectomies, a significantly higher proportion of postimplementation cases were white (77% vs. 68%, respectively), had heart failure (2.8% vs. 1.2%), had chronic obstructive pulmonary disease (7.8% vs. 5.3%), were American Society of Anesthesiologists (ASA) class 1 and 2 ( 50.2% vs. 44.7%), were smokers (21.6% vs. 16.7%), had unintentional weight loss (7.7% vs. 5.7%), had used mechanical bowel prep (77% vs. 53%), and used more oral antibiotics (68% vs. 33%).
On the other hand, compared with preimplementation cases, there were significantly fewer bleeding disorders in the postimplementation colectomies (3.9% vs. 6.4%), as well as fewer cases with preoperative systemic inflammatory response syndrome (2.9% vs. 5.4%) and open surgery approaches (31.7% vs. 42.3%).
Dr. Berian disclosed that her fellowship position is funded by the John A. Hartford Foundation.
AT THE ACS NSQIP NATIONAL CONFERENCE
Key clinical point: A multihospital enhanced recovery process for colectomy patients decreased length of stay and morbidity.
Major finding: After implementation of an enhanced recovery protocol in colectomy patients, the average hospital length of stay decreased by 1.2 days (from a mean of 6.6 days among preimplementation cases to 5.4 days among post implementation cases; P less than .0001). Morbidity also decreased from 14% to 11% (P = .01).
Data source: An analysis of 2,523 colectomies performed prior to implementation of the Enhanced Recovery in NSQIP (ERIN) Pilot process and 823 colectomies performed after implementation of the process.
Disclosures: Dr. Berian disclosed that her fellowship position is funded by the John A. Hartford Foundation.
Are Periodic Endoscopies Useful for Patients Under 40?
Endoscopies do not necessarily help catch early gastric cancer in young people, say researchers from Severance Hospital, Seoul, and Hanyang University, Guri, both in Korea.
In countries such as Korea and Japan, where the researchers say Helicobacter pylori is endemic and gastric cancer is prevalent, screening for gastric cancer is recommended for people aged ≥ 40 years. In a previous study, they found that biennial endoscopies increased the diagnosis of gastric neoplasms, including gastric cancer and adenoma, at an early stage in people aged ≥ 40 years. Noting that disease-free status and overall survival of younger patients with gastric cancer are dependent on the cancer’s stage at diagnosis, as is the case with middle-aged patients, they wanted to find out whether earlier periodic endoscopies would be useful.
Related:Clarifying the Links Between Gallbladder Disease and Cancer
In their study, 101 patients underwent screening endoscopy within 24 months after receiving their gastric cancer diagnosis. Another 463 had not had an endoscopy within 2 years. Overall, 65% to 68% had early gastric cancer, but the researchers found no significant difference between the 2 groups. However, the proportion of lesions that were treated with endoscopic submucosal dissection (ESD) differed according to the interval: 9.8% for ≤ 24 and 4.5% for ≥ 24 months.
The only factor associated with early gastric cancer was gastrointestinal symptoms at the time of diagnosis.
Related: How Much Is Too Much Cancer Screening?
Performing an earlier endoscopy detected gastric cancer at a smaller size (23.8 mm in the ≤ 24-month group vs 30.5 mm in the ≥ 24-month group), which could facilitate treatment with ESD, the researchers say. They suggest that although not necessarily influencing early diagnosis, periodic endoscopies may help increase the proportion of lesions treated with ESD.
Source:
Park CH, Kim EH, Chung H, et al. PLoS One. 2016;11(7):e0159759.
doi: 10.1371/journal.pone.0159759.
Endoscopies do not necessarily help catch early gastric cancer in young people, say researchers from Severance Hospital, Seoul, and Hanyang University, Guri, both in Korea.
In countries such as Korea and Japan, where the researchers say Helicobacter pylori is endemic and gastric cancer is prevalent, screening for gastric cancer is recommended for people aged ≥ 40 years. In a previous study, they found that biennial endoscopies increased the diagnosis of gastric neoplasms, including gastric cancer and adenoma, at an early stage in people aged ≥ 40 years. Noting that disease-free status and overall survival of younger patients with gastric cancer are dependent on the cancer’s stage at diagnosis, as is the case with middle-aged patients, they wanted to find out whether earlier periodic endoscopies would be useful.
Related:Clarifying the Links Between Gallbladder Disease and Cancer
In their study, 101 patients underwent screening endoscopy within 24 months after receiving their gastric cancer diagnosis. Another 463 had not had an endoscopy within 2 years. Overall, 65% to 68% had early gastric cancer, but the researchers found no significant difference between the 2 groups. However, the proportion of lesions that were treated with endoscopic submucosal dissection (ESD) differed according to the interval: 9.8% for ≤ 24 and 4.5% for ≥ 24 months.
The only factor associated with early gastric cancer was gastrointestinal symptoms at the time of diagnosis.
Related: How Much Is Too Much Cancer Screening?
Performing an earlier endoscopy detected gastric cancer at a smaller size (23.8 mm in the ≤ 24-month group vs 30.5 mm in the ≥ 24-month group), which could facilitate treatment with ESD, the researchers say. They suggest that although not necessarily influencing early diagnosis, periodic endoscopies may help increase the proportion of lesions treated with ESD.
Source:
Park CH, Kim EH, Chung H, et al. PLoS One. 2016;11(7):e0159759.
doi: 10.1371/journal.pone.0159759.
Endoscopies do not necessarily help catch early gastric cancer in young people, say researchers from Severance Hospital, Seoul, and Hanyang University, Guri, both in Korea.
In countries such as Korea and Japan, where the researchers say Helicobacter pylori is endemic and gastric cancer is prevalent, screening for gastric cancer is recommended for people aged ≥ 40 years. In a previous study, they found that biennial endoscopies increased the diagnosis of gastric neoplasms, including gastric cancer and adenoma, at an early stage in people aged ≥ 40 years. Noting that disease-free status and overall survival of younger patients with gastric cancer are dependent on the cancer’s stage at diagnosis, as is the case with middle-aged patients, they wanted to find out whether earlier periodic endoscopies would be useful.
Related:Clarifying the Links Between Gallbladder Disease and Cancer
In their study, 101 patients underwent screening endoscopy within 24 months after receiving their gastric cancer diagnosis. Another 463 had not had an endoscopy within 2 years. Overall, 65% to 68% had early gastric cancer, but the researchers found no significant difference between the 2 groups. However, the proportion of lesions that were treated with endoscopic submucosal dissection (ESD) differed according to the interval: 9.8% for ≤ 24 and 4.5% for ≥ 24 months.
The only factor associated with early gastric cancer was gastrointestinal symptoms at the time of diagnosis.
Related: How Much Is Too Much Cancer Screening?
Performing an earlier endoscopy detected gastric cancer at a smaller size (23.8 mm in the ≤ 24-month group vs 30.5 mm in the ≥ 24-month group), which could facilitate treatment with ESD, the researchers say. They suggest that although not necessarily influencing early diagnosis, periodic endoscopies may help increase the proportion of lesions treated with ESD.
Source:
Park CH, Kim EH, Chung H, et al. PLoS One. 2016;11(7):e0159759.
doi: 10.1371/journal.pone.0159759.
Simple colon surgery bundle accelerated outcomes improvement
SAN DIEGO – Implementation of a simple colon bundle decreased the rate of colonic and enteric resections faster, compared with improvements seen for other procedures, according to a study that involved 23 hospitals in Tennessee.
At the American College of Surgeons/National Surgical Quality Improvement Program National Conference, Brian J. Daley, MD, discussed findings from an analysis conducted by members of the Tennessee Surgical Quality Collaborative (TSQC), which he described as “a collection of surgeons who put aside their hospital and regional affiliations to work together to help each other and to help our fellow Tennesseans.” Established in 2008 with member hospitals, the TSQC has grown to 23 member hospitals, including 18 community hospitals and 5 academic medical centers. It provides data on nearly 600 surgeons across the state. “While this only represents about half of the surgical procedures in the state, there is sufficient statistical power to make comments about our surgical performance,” said Dr. Daley of the department of surgery at the University of Tennessee Medical Center, Knoxville.
To quantify TSQC’s impact on surgical outcomes, surgeons at the member hospitals evaluated the TSQC colon bundle, which was developed in 2012 and implemented in 2013. It bundles four processes of care: maintaining intraoperative oxygen delivery, maintaining a temperature of 36° C, making sure the patient’s blood glucose is normal, and choosing the appropriate antibiotics. “We kept it simple: easy, not expensive, and hopefully helpful,” Dr. Daley said.
With other procedures as a baseline, they used statistical analyses to determine if implementation of the bundle led to an incremental acceleration of reduced complications, compared with other improvements observed in other procedures. “To understand our outcomes, we needed to prove three points: that the trend improved [a negative trend in the resection rate], that this negative trend was more negative than trends for other comparator procedures, and that the trend for intercept was not equal to the comparator in any way,” Dr. Daley explained.
Following adoption of the bundle, he and his associates observed that the rate of decrease in postoperative recurrences was greater in colectomy, compared with that for all other surgical procedures (P less than .001 for both the trend and the intercept statistical models). Adoption of the bundle also positively impacted decreases in postoperative recurrences among enterectomy cases (P less than .001 for both the trend and the intercept statistical models).
“We were able to demonstrate that our TSQC bundle paid dividends in improving colectomy outcomes,” Dr. Daley concluded. “We have seen these efforts spill over into enterectomy. From this we can also infer that participation in the collaborative improves outcomes and is imperative to maintain the acceleration in surgical improvement.”
Dr. Daley reported that he and his coauthors had no relevant financial disclosures.
SAN DIEGO – Implementation of a simple colon bundle decreased the rate of colonic and enteric resections faster, compared with improvements seen for other procedures, according to a study that involved 23 hospitals in Tennessee.
At the American College of Surgeons/National Surgical Quality Improvement Program National Conference, Brian J. Daley, MD, discussed findings from an analysis conducted by members of the Tennessee Surgical Quality Collaborative (TSQC), which he described as “a collection of surgeons who put aside their hospital and regional affiliations to work together to help each other and to help our fellow Tennesseans.” Established in 2008 with member hospitals, the TSQC has grown to 23 member hospitals, including 18 community hospitals and 5 academic medical centers. It provides data on nearly 600 surgeons across the state. “While this only represents about half of the surgical procedures in the state, there is sufficient statistical power to make comments about our surgical performance,” said Dr. Daley of the department of surgery at the University of Tennessee Medical Center, Knoxville.
To quantify TSQC’s impact on surgical outcomes, surgeons at the member hospitals evaluated the TSQC colon bundle, which was developed in 2012 and implemented in 2013. It bundles four processes of care: maintaining intraoperative oxygen delivery, maintaining a temperature of 36° C, making sure the patient’s blood glucose is normal, and choosing the appropriate antibiotics. “We kept it simple: easy, not expensive, and hopefully helpful,” Dr. Daley said.
With other procedures as a baseline, they used statistical analyses to determine if implementation of the bundle led to an incremental acceleration of reduced complications, compared with other improvements observed in other procedures. “To understand our outcomes, we needed to prove three points: that the trend improved [a negative trend in the resection rate], that this negative trend was more negative than trends for other comparator procedures, and that the trend for intercept was not equal to the comparator in any way,” Dr. Daley explained.
Following adoption of the bundle, he and his associates observed that the rate of decrease in postoperative recurrences was greater in colectomy, compared with that for all other surgical procedures (P less than .001 for both the trend and the intercept statistical models). Adoption of the bundle also positively impacted decreases in postoperative recurrences among enterectomy cases (P less than .001 for both the trend and the intercept statistical models).
“We were able to demonstrate that our TSQC bundle paid dividends in improving colectomy outcomes,” Dr. Daley concluded. “We have seen these efforts spill over into enterectomy. From this we can also infer that participation in the collaborative improves outcomes and is imperative to maintain the acceleration in surgical improvement.”
Dr. Daley reported that he and his coauthors had no relevant financial disclosures.
SAN DIEGO – Implementation of a simple colon bundle decreased the rate of colonic and enteric resections faster, compared with improvements seen for other procedures, according to a study that involved 23 hospitals in Tennessee.
At the American College of Surgeons/National Surgical Quality Improvement Program National Conference, Brian J. Daley, MD, discussed findings from an analysis conducted by members of the Tennessee Surgical Quality Collaborative (TSQC), which he described as “a collection of surgeons who put aside their hospital and regional affiliations to work together to help each other and to help our fellow Tennesseans.” Established in 2008 with member hospitals, the TSQC has grown to 23 member hospitals, including 18 community hospitals and 5 academic medical centers. It provides data on nearly 600 surgeons across the state. “While this only represents about half of the surgical procedures in the state, there is sufficient statistical power to make comments about our surgical performance,” said Dr. Daley of the department of surgery at the University of Tennessee Medical Center, Knoxville.
To quantify TSQC’s impact on surgical outcomes, surgeons at the member hospitals evaluated the TSQC colon bundle, which was developed in 2012 and implemented in 2013. It bundles four processes of care: maintaining intraoperative oxygen delivery, maintaining a temperature of 36° C, making sure the patient’s blood glucose is normal, and choosing the appropriate antibiotics. “We kept it simple: easy, not expensive, and hopefully helpful,” Dr. Daley said.
With other procedures as a baseline, they used statistical analyses to determine if implementation of the bundle led to an incremental acceleration of reduced complications, compared with other improvements observed in other procedures. “To understand our outcomes, we needed to prove three points: that the trend improved [a negative trend in the resection rate], that this negative trend was more negative than trends for other comparator procedures, and that the trend for intercept was not equal to the comparator in any way,” Dr. Daley explained.
Following adoption of the bundle, he and his associates observed that the rate of decrease in postoperative recurrences was greater in colectomy, compared with that for all other surgical procedures (P less than .001 for both the trend and the intercept statistical models). Adoption of the bundle also positively impacted decreases in postoperative recurrences among enterectomy cases (P less than .001 for both the trend and the intercept statistical models).
“We were able to demonstrate that our TSQC bundle paid dividends in improving colectomy outcomes,” Dr. Daley concluded. “We have seen these efforts spill over into enterectomy. From this we can also infer that participation in the collaborative improves outcomes and is imperative to maintain the acceleration in surgical improvement.”
Dr. Daley reported that he and his coauthors had no relevant financial disclosures.
AT THE ACS NSQIP NATIONAL CONFERENCE
Key clinical point: Adoption of a colon bundle by a collaborative of Tennessee hospitals improved certain colectomy outcomes.
Major finding: Following adoption of a colon bundle, the rate of decrease in postoperative recurrences was greater in colectomy than for all other surgical procedures (P less than .001 for both the trend and the intercept statistical models).
Data source: An analysis conducted by members of the Tennessee Surgical Quality Collaborative, which included 23 hospitals in the state.
Disclosures: The researchers reported having no relevant financial disclosures.
Strollin’ the Colon: A Collaborated Effort to Provide Education and Screening Outreach for the Improvement of Awareness, Access, and Early Detection of Colorectal Cancer
Purpose: In 2015, the New Mexico VA Health Care System completion of colorectal cancer screening fell below the national VA average of 82%. The facility Healthcare Effectiveness Data and Information Set (HEDIS) mean aggregated data for Colorectal Cancer Screening was 74.14%. This presents an alarming truth: the failure to screen 25% of the Veteran population served.
The projects purpose stands to improve quality outcomes through the early detection and prevention of colorectal cancer by increasing provider and Veteran awareness.
Relevant Background/Problem: Colorectal cancer is the third leading cause of cancer deaths and remains preventable through appropriate and timely screening. In 2012, 134,784 people in the United States were diagnosed with colorectal cancer, of which 51,516 people died.
Barriers leading to low screening compliance include knowledge deficits, fear, access, and common myths and misconceptions. Providers and Veterans fail to understand the difference of recommended screening anddiagnostic guidelines; available prevention/ detection options/ personal risk factors; ultimately neglecting screening completion due to lack of symptoms.
Methods: We held an Outreach Colorectal Cancer Awareness Fair for the community. A 20-foot long inflatable colon, depicting various stages of abnormalities was brought in. Attendees completed screening questionnaires, focusing on risk factors/ history/ symptoms. These were reviewed on site with providers, and appropriate care was ordered: colonoscopy or FIT testing. Various educational booths served to provide education using evidence-based data. Follow-up letters and calls after the event served to increase Veteran compliance. The local news station showcased the VAMC in a positive light.
Results: We had 355 attendees. 104 Veterans completed screening. 71% of Veterans were identified as needing further diagnostic testing based on provider assessment. 6 Veterans were given FIT packets on that day; an additional 17 were later identified based on review of forms (total 22%). Initial return rate of FIT cards was 83%, exceeding facility norm, and 51 Veterans were scheduled for colonoscopy (49%).
Implications: The overall outcome from this event has been to greatly improve attitudes from the level of the patient and employee volunteers to the community and upper management: improving the overall awareness to screening and diagnostic modalities for colorectal cancer.
Purpose: In 2015, the New Mexico VA Health Care System completion of colorectal cancer screening fell below the national VA average of 82%. The facility Healthcare Effectiveness Data and Information Set (HEDIS) mean aggregated data for Colorectal Cancer Screening was 74.14%. This presents an alarming truth: the failure to screen 25% of the Veteran population served.
The projects purpose stands to improve quality outcomes through the early detection and prevention of colorectal cancer by increasing provider and Veteran awareness.
Relevant Background/Problem: Colorectal cancer is the third leading cause of cancer deaths and remains preventable through appropriate and timely screening. In 2012, 134,784 people in the United States were diagnosed with colorectal cancer, of which 51,516 people died.
Barriers leading to low screening compliance include knowledge deficits, fear, access, and common myths and misconceptions. Providers and Veterans fail to understand the difference of recommended screening anddiagnostic guidelines; available prevention/ detection options/ personal risk factors; ultimately neglecting screening completion due to lack of symptoms.
Methods: We held an Outreach Colorectal Cancer Awareness Fair for the community. A 20-foot long inflatable colon, depicting various stages of abnormalities was brought in. Attendees completed screening questionnaires, focusing on risk factors/ history/ symptoms. These were reviewed on site with providers, and appropriate care was ordered: colonoscopy or FIT testing. Various educational booths served to provide education using evidence-based data. Follow-up letters and calls after the event served to increase Veteran compliance. The local news station showcased the VAMC in a positive light.
Results: We had 355 attendees. 104 Veterans completed screening. 71% of Veterans were identified as needing further diagnostic testing based on provider assessment. 6 Veterans were given FIT packets on that day; an additional 17 were later identified based on review of forms (total 22%). Initial return rate of FIT cards was 83%, exceeding facility norm, and 51 Veterans were scheduled for colonoscopy (49%).
Implications: The overall outcome from this event has been to greatly improve attitudes from the level of the patient and employee volunteers to the community and upper management: improving the overall awareness to screening and diagnostic modalities for colorectal cancer.
Purpose: In 2015, the New Mexico VA Health Care System completion of colorectal cancer screening fell below the national VA average of 82%. The facility Healthcare Effectiveness Data and Information Set (HEDIS) mean aggregated data for Colorectal Cancer Screening was 74.14%. This presents an alarming truth: the failure to screen 25% of the Veteran population served.
The projects purpose stands to improve quality outcomes through the early detection and prevention of colorectal cancer by increasing provider and Veteran awareness.
Relevant Background/Problem: Colorectal cancer is the third leading cause of cancer deaths and remains preventable through appropriate and timely screening. In 2012, 134,784 people in the United States were diagnosed with colorectal cancer, of which 51,516 people died.
Barriers leading to low screening compliance include knowledge deficits, fear, access, and common myths and misconceptions. Providers and Veterans fail to understand the difference of recommended screening anddiagnostic guidelines; available prevention/ detection options/ personal risk factors; ultimately neglecting screening completion due to lack of symptoms.
Methods: We held an Outreach Colorectal Cancer Awareness Fair for the community. A 20-foot long inflatable colon, depicting various stages of abnormalities was brought in. Attendees completed screening questionnaires, focusing on risk factors/ history/ symptoms. These were reviewed on site with providers, and appropriate care was ordered: colonoscopy or FIT testing. Various educational booths served to provide education using evidence-based data. Follow-up letters and calls after the event served to increase Veteran compliance. The local news station showcased the VAMC in a positive light.
Results: We had 355 attendees. 104 Veterans completed screening. 71% of Veterans were identified as needing further diagnostic testing based on provider assessment. 6 Veterans were given FIT packets on that day; an additional 17 were later identified based on review of forms (total 22%). Initial return rate of FIT cards was 83%, exceeding facility norm, and 51 Veterans were scheduled for colonoscopy (49%).
Implications: The overall outcome from this event has been to greatly improve attitudes from the level of the patient and employee volunteers to the community and upper management: improving the overall awareness to screening and diagnostic modalities for colorectal cancer.