Colon and Rectal

Patients with postoperative delirium have significantly worse preoperative short-term cognitive performance and significantly greater long-term cognitive decline, compared with patients without delirium, according to Sharon K. Inouye, MD, and her associates.

In a prospective cohort study of 560 patients aged 70 years and older, 134 patients were selected for the delirium group and 426 for the nondelirium group. The delirium group had a significantly greater decline (–1.03 points) at 1 month, compared with those without delirium (P = .003). After cognitive function had recovered at 2 months, there were no significant differences between groups (P = 0.99). After 2 months, both groups decline on average; however, the delirium group declined significantly more (–1.07) in adjusted mean scores at 36 months (P =.02).

©Wavebreakmedia Ltd/thinkstockphotos.com

From baseline to 36 months, there was a significant change for the delirium group (–1.30, P less than .01) and no significant change for the group without delirium (–0.23, P = .30). Researchers noted that the effect of delirium remains undiminished after consecutive rehospitalizations, intercurrent illnesses, and major postoperative complications were controlled for.

The patients underwent major noncardiac surgery, such as total hip or knee replacement, open abdominal aortic aneurysm repair, colectomy, and lower-extremity arterial bypass.

“This study provides a novel presentation of the biphasic relationship of delirium and cognitive trajectory, both its well-recognized acute effects but also long-term effects,” the researchers wrote. “Our results suggest that after a period of initial recovery, patients with delirium experience a substantially accelerated trajectory of cognitive aging.”

Read the full study in Alzheimer’s & Dementia: The Journal of the Alzheimer’s Association (doi:10.1016/j.jalz.2016.03.005).

[email protected]

Patients with postoperative delirium have significantly worse preoperative short-term cognitive performance and significantly greater long-term cognitive decline, compared with patients without delirium, according to Sharon K. Inouye, MD, and her associates.

In a prospective cohort study of 560 patients aged 70 years and older, 134 patients were selected for the delirium group and 426 for the nondelirium group. The delirium group had a significantly greater decline (–1.03 points) at 1 month, compared with those without delirium (P = .003). After cognitive function had recovered at 2 months, there were no significant differences between groups (P = 0.99). After 2 months, both groups decline on average; however, the delirium group declined significantly more (–1.07) in adjusted mean scores at 36 months (P =.02).

©Wavebreakmedia Ltd/thinkstockphotos.com

From baseline to 36 months, there was a significant change for the delirium group (–1.30, P less than .01) and no significant change for the group without delirium (–0.23, P = .30). Researchers noted that the effect of delirium remains undiminished after consecutive rehospitalizations, intercurrent illnesses, and major postoperative complications were controlled for.

The patients underwent major noncardiac surgery, such as total hip or knee replacement, open abdominal aortic aneurysm repair, colectomy, and lower-extremity arterial bypass.

“This study provides a novel presentation of the biphasic relationship of delirium and cognitive trajectory, both its well-recognized acute effects but also long-term effects,” the researchers wrote. “Our results suggest that after a period of initial recovery, patients with delirium experience a substantially accelerated trajectory of cognitive aging.”

Read the full study in Alzheimer’s & Dementia: The Journal of the Alzheimer’s Association (doi:10.1016/j.jalz.2016.03.005).

[email protected]

Patients with postoperative delirium have significantly worse preoperative short-term cognitive performance and significantly greater long-term cognitive decline, compared with patients without delirium, according to Sharon K. Inouye, MD, and her associates.

In a prospective cohort study of 560 patients aged 70 years and older, 134 patients were selected for the delirium group and 426 for the nondelirium group. The delirium group had a significantly greater decline (–1.03 points) at 1 month, compared with those without delirium (P = .003). After cognitive function had recovered at 2 months, there were no significant differences between groups (P = 0.99). After 2 months, both groups decline on average; however, the delirium group declined significantly more (–1.07) in adjusted mean scores at 36 months (P =.02).

©Wavebreakmedia Ltd/thinkstockphotos.com

From baseline to 36 months, there was a significant change for the delirium group (–1.30, P less than .01) and no significant change for the group without delirium (–0.23, P = .30). Researchers noted that the effect of delirium remains undiminished after consecutive rehospitalizations, intercurrent illnesses, and major postoperative complications were controlled for.

The patients underwent major noncardiac surgery, such as total hip or knee replacement, open abdominal aortic aneurysm repair, colectomy, and lower-extremity arterial bypass.

“This study provides a novel presentation of the biphasic relationship of delirium and cognitive trajectory, both its well-recognized acute effects but also long-term effects,” the researchers wrote. “Our results suggest that after a period of initial recovery, patients with delirium experience a substantially accelerated trajectory of cognitive aging.”

Read the full study in Alzheimer’s & Dementia: The Journal of the Alzheimer’s Association (doi:10.1016/j.jalz.2016.03.005).

[email protected]

LOS ANGELES – In the clinical experience of Dr. Ian C. Lavery, prevention efforts are the best defense against local recurrence of rectal cancer.

“This means adjuvant treatment, if necessary, neoadjuvant treatment, and a meticulous surgical operation,” Dr. Lavery of the department of colorectal surgery at the Cleveland Clinic said at the annual meeting of the American Society of Colon and Rectal Surgeons. “If the circumferential resection margin is negative, the local recurrence rate is 10% or less. If it’s positive, local recurrence goes up to 78%. Even when we attempt to do the perfect total mesorectal excision, local recurrence is in the order of 4%.”

Selective use of radiotherapy in the neoadjuvant setting appears to be reducing the incidence of local recurrence, “certainly in the short term,” he added. “In the long term, I’m not sure we know the true answer to that yet. Using other techniques like washing the rectal stump out, the use of stapling, and en-bloc resection if necessary [can help prevention efforts].”

The incidence of local rectal cancer recurrence is reported to be between 3% and 50%, but neither curative nor palliative treatment is standardized. “When you get local recurrence after a rectal cancer operation, it’s a disaster,” Dr. Lavery said. “It may cause intractable pain, bleeding, perforation, obstruction, and sepsis – all incredibly difficult things to manage.”

Patients who develop a local recurrence of rectal cancer are often asymptomatic. A digital rectal exam (DRE) may or may not identify a recurrence and carcinoembryonic antigen levels are helpful on some occasions. According to Dr. Lavery, optimal surveillance consists of a clinical examination including DRE, endoscopy, blood tests, CT scans, MRI, and PET scans. “If they were all to be done routinely it would increase the detection earlier rather than later,” he said.

CT and MRI appear to be about 85% accurate but both modalities are “very poor at detecting peritoneal disease,” he said. PET scans for recurrent carcinoma have been shown to change the management in 20%-56% of cases (Ann Surg Oncol. 1997 Dec; 4:613-20).

While follow-up of patients who have undergone surgery for local rectal cancer is generally favored, there is no consensus on what the ideal follow-up timeline should be. “In my opinion, the more intensive follow-up is going to be better than the cursory conventional follow-up examination,” Dr. Lavery said. “One of the big reasons for that is the vast majority of recurrences are extraluminal so they may be difficult to feel. Doing endoscopy, you can’t see them if they’re extraluminal.”

The goal in treating recurrent rectal cancer is to improve quality of life, he continued, as the common symptoms include obstruction, pain, bleeding, bowel discharge, or perforation/abscess. Optimal treatment involves striving for tumor-free margins after the operation. “This may require en bloc resection of an adjacent prostate, bladder, lateral pelvic wall,” he said. “But clinically and radiologically, it’s very difficult to identify those patients that have a potentially R0 resection.”

Curative treatment is possible if the recurrence is locally resectable and the patient has minimal comorbidities. “The potential morbidity after the surgery has to be acceptable, considering the severity of the problem that we’re dealing with,” Dr. Lavery noted. “Distant disease also complicates the issue.”

Reasons to avoid resection include rigid tumor fixation, leg lymphedema, major vessel encasement, bilateral ureteric involvement, extensive para-aortic lymph node involvement, and radicular pain. “If you embark on one of these cases, you want to make it at least the first if not the only case of the day,” Dr. Lavery advised. “Anticipate the need for assistance during the operation, but above all, make sure you have optimal exposure to do the surgery.” He reported having no financial disclosures.

[email protected]

LOS ANGELES – In the clinical experience of Dr. Ian C. Lavery, prevention efforts are the best defense against local recurrence of rectal cancer.

“This means adjuvant treatment, if necessary, neoadjuvant treatment, and a meticulous surgical operation,” Dr. Lavery of the department of colorectal surgery at the Cleveland Clinic said at the annual meeting of the American Society of Colon and Rectal Surgeons. “If the circumferential resection margin is negative, the local recurrence rate is 10% or less. If it’s positive, local recurrence goes up to 78%. Even when we attempt to do the perfect total mesorectal excision, local recurrence is in the order of 4%.”

Selective use of radiotherapy in the neoadjuvant setting appears to be reducing the incidence of local recurrence, “certainly in the short term,” he added. “In the long term, I’m not sure we know the true answer to that yet. Using other techniques like washing the rectal stump out, the use of stapling, and en-bloc resection if necessary [can help prevention efforts].”

The incidence of local rectal cancer recurrence is reported to be between 3% and 50%, but neither curative nor palliative treatment is standardized. “When you get local recurrence after a rectal cancer operation, it’s a disaster,” Dr. Lavery said. “It may cause intractable pain, bleeding, perforation, obstruction, and sepsis – all incredibly difficult things to manage.”

Patients who develop a local recurrence of rectal cancer are often asymptomatic. A digital rectal exam (DRE) may or may not identify a recurrence and carcinoembryonic antigen levels are helpful on some occasions. According to Dr. Lavery, optimal surveillance consists of a clinical examination including DRE, endoscopy, blood tests, CT scans, MRI, and PET scans. “If they were all to be done routinely it would increase the detection earlier rather than later,” he said.

CT and MRI appear to be about 85% accurate but both modalities are “very poor at detecting peritoneal disease,” he said. PET scans for recurrent carcinoma have been shown to change the management in 20%-56% of cases (Ann Surg Oncol. 1997 Dec; 4:613-20).

While follow-up of patients who have undergone surgery for local rectal cancer is generally favored, there is no consensus on what the ideal follow-up timeline should be. “In my opinion, the more intensive follow-up is going to be better than the cursory conventional follow-up examination,” Dr. Lavery said. “One of the big reasons for that is the vast majority of recurrences are extraluminal so they may be difficult to feel. Doing endoscopy, you can’t see them if they’re extraluminal.”

The goal in treating recurrent rectal cancer is to improve quality of life, he continued, as the common symptoms include obstruction, pain, bleeding, bowel discharge, or perforation/abscess. Optimal treatment involves striving for tumor-free margins after the operation. “This may require en bloc resection of an adjacent prostate, bladder, lateral pelvic wall,” he said. “But clinically and radiologically, it’s very difficult to identify those patients that have a potentially R0 resection.”

Curative treatment is possible if the recurrence is locally resectable and the patient has minimal comorbidities. “The potential morbidity after the surgery has to be acceptable, considering the severity of the problem that we’re dealing with,” Dr. Lavery noted. “Distant disease also complicates the issue.”

Reasons to avoid resection include rigid tumor fixation, leg lymphedema, major vessel encasement, bilateral ureteric involvement, extensive para-aortic lymph node involvement, and radicular pain. “If you embark on one of these cases, you want to make it at least the first if not the only case of the day,” Dr. Lavery advised. “Anticipate the need for assistance during the operation, but above all, make sure you have optimal exposure to do the surgery.” He reported having no financial disclosures.

[email protected]

LOS ANGELES – In the clinical experience of Dr. Ian C. Lavery, prevention efforts are the best defense against local recurrence of rectal cancer.

“This means adjuvant treatment, if necessary, neoadjuvant treatment, and a meticulous surgical operation,” Dr. Lavery of the department of colorectal surgery at the Cleveland Clinic said at the annual meeting of the American Society of Colon and Rectal Surgeons. “If the circumferential resection margin is negative, the local recurrence rate is 10% or less. If it’s positive, local recurrence goes up to 78%. Even when we attempt to do the perfect total mesorectal excision, local recurrence is in the order of 4%.”

Selective use of radiotherapy in the neoadjuvant setting appears to be reducing the incidence of local recurrence, “certainly in the short term,” he added. “In the long term, I’m not sure we know the true answer to that yet. Using other techniques like washing the rectal stump out, the use of stapling, and en-bloc resection if necessary [can help prevention efforts].”

The incidence of local rectal cancer recurrence is reported to be between 3% and 50%, but neither curative nor palliative treatment is standardized. “When you get local recurrence after a rectal cancer operation, it’s a disaster,” Dr. Lavery said. “It may cause intractable pain, bleeding, perforation, obstruction, and sepsis – all incredibly difficult things to manage.”

Patients who develop a local recurrence of rectal cancer are often asymptomatic. A digital rectal exam (DRE) may or may not identify a recurrence and carcinoembryonic antigen levels are helpful on some occasions. According to Dr. Lavery, optimal surveillance consists of a clinical examination including DRE, endoscopy, blood tests, CT scans, MRI, and PET scans. “If they were all to be done routinely it would increase the detection earlier rather than later,” he said.

CT and MRI appear to be about 85% accurate but both modalities are “very poor at detecting peritoneal disease,” he said. PET scans for recurrent carcinoma have been shown to change the management in 20%-56% of cases (Ann Surg Oncol. 1997 Dec; 4:613-20).

While follow-up of patients who have undergone surgery for local rectal cancer is generally favored, there is no consensus on what the ideal follow-up timeline should be. “In my opinion, the more intensive follow-up is going to be better than the cursory conventional follow-up examination,” Dr. Lavery said. “One of the big reasons for that is the vast majority of recurrences are extraluminal so they may be difficult to feel. Doing endoscopy, you can’t see them if they’re extraluminal.”

The goal in treating recurrent rectal cancer is to improve quality of life, he continued, as the common symptoms include obstruction, pain, bleeding, bowel discharge, or perforation/abscess. Optimal treatment involves striving for tumor-free margins after the operation. “This may require en bloc resection of an adjacent prostate, bladder, lateral pelvic wall,” he said. “But clinically and radiologically, it’s very difficult to identify those patients that have a potentially R0 resection.”

Curative treatment is possible if the recurrence is locally resectable and the patient has minimal comorbidities. “The potential morbidity after the surgery has to be acceptable, considering the severity of the problem that we’re dealing with,” Dr. Lavery noted. “Distant disease also complicates the issue.”

Reasons to avoid resection include rigid tumor fixation, leg lymphedema, major vessel encasement, bilateral ureteric involvement, extensive para-aortic lymph node involvement, and radicular pain. “If you embark on one of these cases, you want to make it at least the first if not the only case of the day,” Dr. Lavery advised. “Anticipate the need for assistance during the operation, but above all, make sure you have optimal exposure to do the surgery.” He reported having no financial disclosures.

[email protected]

LOS ANGELES – The use of locoregional tissue flaps in combination with abdominoperineal resection was associated with higher rates of perioperative complications, longer hospital stays, and higher total hospital charges, compared with patients who did not undergo tissue flap reconstruction, an analysis of national data showed.

The findings come at a time when closure of perineal wounds with tissue flaps is an increasingly common approach, especially in academic institutions, Dr. Nicole Lopez said at the annual meeting of the American Society of Colon and Rectal Surgeons. “The role of selection bias in this [study] is difficult to determine, but I think it’s important that we clarify the utility of this technique before more widespread adoption of the approach,” she said.

According to Dr. Lopez of the department of surgery at the University of North Carolina, Chapel Hill, perineal wound complications can occur in 16%-49% of patients undergoing abdominoperineal resection. Contributing factors include noncollapsible dead space, bacterial contamination, wound characteristics, and patient comorbidities.

In an effort to identify national trends in the use of tissue flaps in patients undergoing abdominoperineal resection for rectal or anal cancer, as well as the effect of this approach on perioperative complications, length of stay, and total hospital charges, Dr. Lopez and her associates used the National Inpatient Sample to identify patients aged 18-80 years who were treated between 2000 and 2013. They excluded patients undergoing nonelective procedures or additional pelvic organ resections. Patients who received a tissue flap were compared with those who did not.

Dr. Lopez reported results from 298 patients who received a tissue flap graft and 12,107 who did not. Variables significantly associated with receiving a tissue flap, compared with not receiving one, were being male (73% vs. 66%, respectively; P =. 01), having anal cancer (32% vs. 11%; P less than .0001), being a smoker (34% vs. 23%; P less than .0001), undergoing the procedure in a large hospital (75% vs. 67%; P = .003), and undergoing the procedure in an urban teaching hospital (89% vs. 53%; P less than .0001).

The researchers also found that the number of concurrent tissue flaps performed rose significantly during the study period, from 0.4% in 2000 to 6% in 2013 (P less than .0001). “This was most noted in teaching institutions, compared with nonteaching institutions,” Dr. Lopez said.

Bivariate analysis revealed that, compared with patients who did not receive tissue flaps, those who did had higher rates of postoperative complications (43% vs. 33%, respectively; P less than .0001), a longer hospital stay (mean of 9 vs. 7 days; P less than .001), and higher total hospital charges (mean of $67,200 vs. $42,300; P less than .001). These trends persisted on multivariate analysis. Specifically, patients who received tissue flaps were 4.14 times more likely to have wound complications, had a length of stay that averaged an additional 2.78 days, and had $28,000 more in total hospital charges.

“The extended duration of the study enables evaluation of trends over time, and this is the first study that analyzes the costs associated with these procedures,” Dr. Lopez said. She acknowledged certain limitations of the study, including its retrospective, nonrandomized design and the potential for selection bias. In addition, the National Inpatient Sample “is susceptible to coding errors, a lack of patient-specific oncologic history, and the inability to assess postdischarge occurrences, since this only looks at inpatient stays.”

Dr. Lopez reported having no financial disclosures.

[email protected]

LOS ANGELES – The use of locoregional tissue flaps in combination with abdominoperineal resection was associated with higher rates of perioperative complications, longer hospital stays, and higher total hospital charges, compared with patients who did not undergo tissue flap reconstruction, an analysis of national data showed.

The findings come at a time when closure of perineal wounds with tissue flaps is an increasingly common approach, especially in academic institutions, Dr. Nicole Lopez said at the annual meeting of the American Society of Colon and Rectal Surgeons. “The role of selection bias in this [study] is difficult to determine, but I think it’s important that we clarify the utility of this technique before more widespread adoption of the approach,” she said.

According to Dr. Lopez of the department of surgery at the University of North Carolina, Chapel Hill, perineal wound complications can occur in 16%-49% of patients undergoing abdominoperineal resection. Contributing factors include noncollapsible dead space, bacterial contamination, wound characteristics, and patient comorbidities.

In an effort to identify national trends in the use of tissue flaps in patients undergoing abdominoperineal resection for rectal or anal cancer, as well as the effect of this approach on perioperative complications, length of stay, and total hospital charges, Dr. Lopez and her associates used the National Inpatient Sample to identify patients aged 18-80 years who were treated between 2000 and 2013. They excluded patients undergoing nonelective procedures or additional pelvic organ resections. Patients who received a tissue flap were compared with those who did not.

Dr. Lopez reported results from 298 patients who received a tissue flap graft and 12,107 who did not. Variables significantly associated with receiving a tissue flap, compared with not receiving one, were being male (73% vs. 66%, respectively; P =. 01), having anal cancer (32% vs. 11%; P less than .0001), being a smoker (34% vs. 23%; P less than .0001), undergoing the procedure in a large hospital (75% vs. 67%; P = .003), and undergoing the procedure in an urban teaching hospital (89% vs. 53%; P less than .0001).

The researchers also found that the number of concurrent tissue flaps performed rose significantly during the study period, from 0.4% in 2000 to 6% in 2013 (P less than .0001). “This was most noted in teaching institutions, compared with nonteaching institutions,” Dr. Lopez said.

Bivariate analysis revealed that, compared with patients who did not receive tissue flaps, those who did had higher rates of postoperative complications (43% vs. 33%, respectively; P less than .0001), a longer hospital stay (mean of 9 vs. 7 days; P less than .001), and higher total hospital charges (mean of $67,200 vs. $42,300; P less than .001). These trends persisted on multivariate analysis. Specifically, patients who received tissue flaps were 4.14 times more likely to have wound complications, had a length of stay that averaged an additional 2.78 days, and had $28,000 more in total hospital charges.

“The extended duration of the study enables evaluation of trends over time, and this is the first study that analyzes the costs associated with these procedures,” Dr. Lopez said. She acknowledged certain limitations of the study, including its retrospective, nonrandomized design and the potential for selection bias. In addition, the National Inpatient Sample “is susceptible to coding errors, a lack of patient-specific oncologic history, and the inability to assess postdischarge occurrences, since this only looks at inpatient stays.”

Dr. Lopez reported having no financial disclosures.

[email protected]

LOS ANGELES – The use of locoregional tissue flaps in combination with abdominoperineal resection was associated with higher rates of perioperative complications, longer hospital stays, and higher total hospital charges, compared with patients who did not undergo tissue flap reconstruction, an analysis of national data showed.

The findings come at a time when closure of perineal wounds with tissue flaps is an increasingly common approach, especially in academic institutions, Dr. Nicole Lopez said at the annual meeting of the American Society of Colon and Rectal Surgeons. “The role of selection bias in this [study] is difficult to determine, but I think it’s important that we clarify the utility of this technique before more widespread adoption of the approach,” she said.

According to Dr. Lopez of the department of surgery at the University of North Carolina, Chapel Hill, perineal wound complications can occur in 16%-49% of patients undergoing abdominoperineal resection. Contributing factors include noncollapsible dead space, bacterial contamination, wound characteristics, and patient comorbidities.

In an effort to identify national trends in the use of tissue flaps in patients undergoing abdominoperineal resection for rectal or anal cancer, as well as the effect of this approach on perioperative complications, length of stay, and total hospital charges, Dr. Lopez and her associates used the National Inpatient Sample to identify patients aged 18-80 years who were treated between 2000 and 2013. They excluded patients undergoing nonelective procedures or additional pelvic organ resections. Patients who received a tissue flap were compared with those who did not.

Dr. Lopez reported results from 298 patients who received a tissue flap graft and 12,107 who did not. Variables significantly associated with receiving a tissue flap, compared with not receiving one, were being male (73% vs. 66%, respectively; P =. 01), having anal cancer (32% vs. 11%; P less than .0001), being a smoker (34% vs. 23%; P less than .0001), undergoing the procedure in a large hospital (75% vs. 67%; P = .003), and undergoing the procedure in an urban teaching hospital (89% vs. 53%; P less than .0001).

The researchers also found that the number of concurrent tissue flaps performed rose significantly during the study period, from 0.4% in 2000 to 6% in 2013 (P less than .0001). “This was most noted in teaching institutions, compared with nonteaching institutions,” Dr. Lopez said.

Bivariate analysis revealed that, compared with patients who did not receive tissue flaps, those who did had higher rates of postoperative complications (43% vs. 33%, respectively; P less than .0001), a longer hospital stay (mean of 9 vs. 7 days; P less than .001), and higher total hospital charges (mean of $67,200 vs. $42,300; P less than .001). These trends persisted on multivariate analysis. Specifically, patients who received tissue flaps were 4.14 times more likely to have wound complications, had a length of stay that averaged an additional 2.78 days, and had $28,000 more in total hospital charges.

“The extended duration of the study enables evaluation of trends over time, and this is the first study that analyzes the costs associated with these procedures,” Dr. Lopez said. She acknowledged certain limitations of the study, including its retrospective, nonrandomized design and the potential for selection bias. In addition, the National Inpatient Sample “is susceptible to coding errors, a lack of patient-specific oncologic history, and the inability to assess postdischarge occurrences, since this only looks at inpatient stays.”

Dr. Lopez reported having no financial disclosures.

[email protected]

LOS ANGELES – The size of anorectal gastrointestinal stroma tumors is the most important determinant of survival following resection, results from an analysis of national data showed.

In addition, preoperative chemotherapy appears to improve survival rate in patients with tumors 5 cm in size or greater.

Anorectal gastrointestinal stromal tumors (GISTs) are rare, making up about 3% of all GIST cases, lead study author Dr. Alexander T. Hawkins reported at the annual meeting of the American Society of Colon and Rectal Surgeons. However, “optimal management remains elusive with questions regarding the role of local excision and the use of preoperative chemotherapy,” said Dr. Hawkins of the section of colon and rectal surgery at Washington University in St. Louis.

In an effort to determine the impact of tumor size, the benefits of using neoadjuvant imatinib, and the impact of a surgical approach, the researchers used the National Cancer Database (NCD) to identify 333 cases of anorectal GIST from 1998 through 2012. The NCD collects data from more than 1,500 cancer centers in the United States, and it’s estimated to account for 70% of all newly diagnosed cases of cancer.

Dr. Alexander Hawkins

The mean age of patients was 62 years, the median tumor size was 4 cm, 47% had a high-grade tumor, six presented with metastatic disease, and the overall 5-year survival rate was 78%. Of the 333 cases, 163 underwent local excision, 158 underwent radical excision, and 12 had no resection data. Of the radical excision cases, 89 had tumors of 5 cm in size or larger, while 69 had tumors of less than 5 cm in size.

Tumors treated with local resection tended to be smaller, compared with those treated by radical resection (a median of 2.5 cm vs. a median of 6.2 cm, respectively; P less than .001). Bivariate analysis revealed that patients who underwent treatment with local resection had a shorter hospital length of stay (a median of 0 vs. 7 days; P less than .001), but similar rates of 30-day readmission (5.5% vs. 4.4%, P = .65), 30-day mortality (0.6% vs. 1.3%, P = .54) and 90-day mortality (1.2% vs. 2.5%, P = .38). The rates of 5-year survival were higher in the local resection group (80.1% vs. 74.1%, P = .04).

Multivariable survival analysis revealed that advanced age (HR, 2.41) and tumor size greater than 5 cm (HR 2.48; P = .004) were associated with increased mortality. When Dr. Hawkins and his associates evaluated the role of chemotherapy, patients who received preoperative chemotherapy had a 5-year survival of 76.7%, compared with 50.4% in those who did not (P = .04). However, in this same group, chemotherapy did not improve the rate of margin-negative resection (80% vs. 78.6%, P = .88).

Dr. Hawkins also reported that, compared with patients who underwent radical resection, those who underwent local resection had lower rates of preoperative chemotherapy (9.2% vs. 25.3%, respectively; P = .0001) and smaller median tumor size (2.5 cm vs. 6.2 cm, P less than .0001). For tumors smaller than 5 cm in size, there was no difference in 5-year survival by surgical approach (82.3% vs. 82.6%, P = .71).

“Size in the most important determinant of survival after resection of anorectal GIST,” Dr. Hawkins concluded. “For smaller tumors, local excision may be an adequate therapy. Perhaps our most important finding is that preoperative chemotherapy appears to result in improved survival for large tumors treated with radical resection.”

Dr. Hawkins reported having no relevant financial disclosures.

[email protected]

LOS ANGELES – The size of anorectal gastrointestinal stroma tumors is the most important determinant of survival following resection, results from an analysis of national data showed.

In addition, preoperative chemotherapy appears to improve survival rate in patients with tumors 5 cm in size or greater.

Anorectal gastrointestinal stromal tumors (GISTs) are rare, making up about 3% of all GIST cases, lead study author Dr. Alexander T. Hawkins reported at the annual meeting of the American Society of Colon and Rectal Surgeons. However, “optimal management remains elusive with questions regarding the role of local excision and the use of preoperative chemotherapy,” said Dr. Hawkins of the section of colon and rectal surgery at Washington University in St. Louis.

In an effort to determine the impact of tumor size, the benefits of using neoadjuvant imatinib, and the impact of a surgical approach, the researchers used the National Cancer Database (NCD) to identify 333 cases of anorectal GIST from 1998 through 2012. The NCD collects data from more than 1,500 cancer centers in the United States, and it’s estimated to account for 70% of all newly diagnosed cases of cancer.

Dr. Alexander Hawkins

The mean age of patients was 62 years, the median tumor size was 4 cm, 47% had a high-grade tumor, six presented with metastatic disease, and the overall 5-year survival rate was 78%. Of the 333 cases, 163 underwent local excision, 158 underwent radical excision, and 12 had no resection data. Of the radical excision cases, 89 had tumors of 5 cm in size or larger, while 69 had tumors of less than 5 cm in size.

Tumors treated with local resection tended to be smaller, compared with those treated by radical resection (a median of 2.5 cm vs. a median of 6.2 cm, respectively; P less than .001). Bivariate analysis revealed that patients who underwent treatment with local resection had a shorter hospital length of stay (a median of 0 vs. 7 days; P less than .001), but similar rates of 30-day readmission (5.5% vs. 4.4%, P = .65), 30-day mortality (0.6% vs. 1.3%, P = .54) and 90-day mortality (1.2% vs. 2.5%, P = .38). The rates of 5-year survival were higher in the local resection group (80.1% vs. 74.1%, P = .04).

Multivariable survival analysis revealed that advanced age (HR, 2.41) and tumor size greater than 5 cm (HR 2.48; P = .004) were associated with increased mortality. When Dr. Hawkins and his associates evaluated the role of chemotherapy, patients who received preoperative chemotherapy had a 5-year survival of 76.7%, compared with 50.4% in those who did not (P = .04). However, in this same group, chemotherapy did not improve the rate of margin-negative resection (80% vs. 78.6%, P = .88).

Dr. Hawkins also reported that, compared with patients who underwent radical resection, those who underwent local resection had lower rates of preoperative chemotherapy (9.2% vs. 25.3%, respectively; P = .0001) and smaller median tumor size (2.5 cm vs. 6.2 cm, P less than .0001). For tumors smaller than 5 cm in size, there was no difference in 5-year survival by surgical approach (82.3% vs. 82.6%, P = .71).

“Size in the most important determinant of survival after resection of anorectal GIST,” Dr. Hawkins concluded. “For smaller tumors, local excision may be an adequate therapy. Perhaps our most important finding is that preoperative chemotherapy appears to result in improved survival for large tumors treated with radical resection.”

Dr. Hawkins reported having no relevant financial disclosures.

[email protected]

LOS ANGELES – The size of anorectal gastrointestinal stroma tumors is the most important determinant of survival following resection, results from an analysis of national data showed.

In addition, preoperative chemotherapy appears to improve survival rate in patients with tumors 5 cm in size or greater.

Anorectal gastrointestinal stromal tumors (GISTs) are rare, making up about 3% of all GIST cases, lead study author Dr. Alexander T. Hawkins reported at the annual meeting of the American Society of Colon and Rectal Surgeons. However, “optimal management remains elusive with questions regarding the role of local excision and the use of preoperative chemotherapy,” said Dr. Hawkins of the section of colon and rectal surgery at Washington University in St. Louis.

In an effort to determine the impact of tumor size, the benefits of using neoadjuvant imatinib, and the impact of a surgical approach, the researchers used the National Cancer Database (NCD) to identify 333 cases of anorectal GIST from 1998 through 2012. The NCD collects data from more than 1,500 cancer centers in the United States, and it’s estimated to account for 70% of all newly diagnosed cases of cancer.

Dr. Alexander Hawkins

The mean age of patients was 62 years, the median tumor size was 4 cm, 47% had a high-grade tumor, six presented with metastatic disease, and the overall 5-year survival rate was 78%. Of the 333 cases, 163 underwent local excision, 158 underwent radical excision, and 12 had no resection data. Of the radical excision cases, 89 had tumors of 5 cm in size or larger, while 69 had tumors of less than 5 cm in size.

Tumors treated with local resection tended to be smaller, compared with those treated by radical resection (a median of 2.5 cm vs. a median of 6.2 cm, respectively; P less than .001). Bivariate analysis revealed that patients who underwent treatment with local resection had a shorter hospital length of stay (a median of 0 vs. 7 days; P less than .001), but similar rates of 30-day readmission (5.5% vs. 4.4%, P = .65), 30-day mortality (0.6% vs. 1.3%, P = .54) and 90-day mortality (1.2% vs. 2.5%, P = .38). The rates of 5-year survival were higher in the local resection group (80.1% vs. 74.1%, P = .04).

Multivariable survival analysis revealed that advanced age (HR, 2.41) and tumor size greater than 5 cm (HR 2.48; P = .004) were associated with increased mortality. When Dr. Hawkins and his associates evaluated the role of chemotherapy, patients who received preoperative chemotherapy had a 5-year survival of 76.7%, compared with 50.4% in those who did not (P = .04). However, in this same group, chemotherapy did not improve the rate of margin-negative resection (80% vs. 78.6%, P = .88).

Dr. Hawkins also reported that, compared with patients who underwent radical resection, those who underwent local resection had lower rates of preoperative chemotherapy (9.2% vs. 25.3%, respectively; P = .0001) and smaller median tumor size (2.5 cm vs. 6.2 cm, P less than .0001). For tumors smaller than 5 cm in size, there was no difference in 5-year survival by surgical approach (82.3% vs. 82.6%, P = .71).

“Size in the most important determinant of survival after resection of anorectal GIST,” Dr. Hawkins concluded. “For smaller tumors, local excision may be an adequate therapy. Perhaps our most important finding is that preoperative chemotherapy appears to result in improved survival for large tumors treated with radical resection.”

Dr. Hawkins reported having no relevant financial disclosures.

[email protected]

LOS ANGELES – The inpatient use of infliximab for severe ulcerative colitis does not avoid the need for colectomy in patients who fail steroid therapy, results from a single-center study demonstrated.

In an interview at the annual meeting of the American Society of Colon and Rectal Surgeons, lead study author Dr. Rachel E. Andrew, a third-year resident in the department of surgery at Penn State Hershey Medical Center in Hershey, Pa., said that despite recent interest in providing inpatient infliximab as an alternative to surgery for those with steroid-refractory disease, 82% of those who received salvage infliximab went on to undergo a total abdominal colectomy during the same admission.

“Our findings suggest that inpatient infliximab was not effective at improving the severity of colitis in these patients,” she said. “Further, infliximab was unreliable in avoiding the need for a total colectomy in this population of ulcerative colitis patients. One difference between our study and those previously published on this subject is that our study focuses on patients with a severity of colitis that resulted in their admission to a surgery service. In terms of evaluating the benefit of infliximab and providing a reliable avoidance of colectomy, we feel that this population of ulcerative colitis patients would be most appropriate to evaluate this issue. This possible difference in patient population may explain the difference in our study findings and those previously published.”

The researchers compared colectomy rates in 173 patients with severe ulcerative colitis who were admitted to the colorectal surgery service at Penn State Hershey Medical Center. Their mean age was 41 years, with 155 (90%) treated with high-dose steroids alone, and with 18 (10%) having received inpatient infliximab as salvage therapy due to a lack of response to steroids alone. Of the patients who received high-dose steroids alone, 81 (52%) required total colectomy, compared with 14 (82%) who received infliximab salvage therapy (P = .046).

The researchers observed no statistically significant differences between the two groups regarding rates of hospital readmission, superficial, deep and organ space surgical-site infections, unplanned return to the operating room, and all complication rates (P greater than .05). Among patients who required total colectomy, hospital costs were 27% higher among those who received infliximab compared with those who received high-dose steroids alone (a mean of $19,880 vs. $14,492, respectively), but because of the small sample size of the infliximab cohort this difference did not reach statistical significance.

“In our institution, salvage infliximab has not been shown to be effective,” Dr. Andrew said. “One key difference between our findings and other studies is that our study population had a high colectomy rate; 82% is much higher than the approximately 30% colectomy rate described in many reports from colleagues in gastroenterology. While there are several potential explanations for our higher rate of colectomy, including the potential concerns that surgeons might be inclined to opt for surgery more readily than non-surgical providers, it is likely that the patients in our study had more severe forms of colitis. It might be the case that there are certain severities of colitis that are beyond the ability of infliximab to salvage, which would be an important issue in selecting which patients to provide inpatient infliximab, so as to not unnecessarily delay surgery, increase hospital costs and to avoid escalating the degree of immunosuppression without a reasonable likelihood of clinical improvement.”

Dr. Andrew reported having no financial disclosures.

[email protected]

LOS ANGELES – The inpatient use of infliximab for severe ulcerative colitis does not avoid the need for colectomy in patients who fail steroid therapy, results from a single-center study demonstrated.

In an interview at the annual meeting of the American Society of Colon and Rectal Surgeons, lead study author Dr. Rachel E. Andrew, a third-year resident in the department of surgery at Penn State Hershey Medical Center in Hershey, Pa., said that despite recent interest in providing inpatient infliximab as an alternative to surgery for those with steroid-refractory disease, 82% of those who received salvage infliximab went on to undergo a total abdominal colectomy during the same admission.

“Our findings suggest that inpatient infliximab was not effective at improving the severity of colitis in these patients,” she said. “Further, infliximab was unreliable in avoiding the need for a total colectomy in this population of ulcerative colitis patients. One difference between our study and those previously published on this subject is that our study focuses on patients with a severity of colitis that resulted in their admission to a surgery service. In terms of evaluating the benefit of infliximab and providing a reliable avoidance of colectomy, we feel that this population of ulcerative colitis patients would be most appropriate to evaluate this issue. This possible difference in patient population may explain the difference in our study findings and those previously published.”

The researchers compared colectomy rates in 173 patients with severe ulcerative colitis who were admitted to the colorectal surgery service at Penn State Hershey Medical Center. Their mean age was 41 years, with 155 (90%) treated with high-dose steroids alone, and with 18 (10%) having received inpatient infliximab as salvage therapy due to a lack of response to steroids alone. Of the patients who received high-dose steroids alone, 81 (52%) required total colectomy, compared with 14 (82%) who received infliximab salvage therapy (P = .046).

The researchers observed no statistically significant differences between the two groups regarding rates of hospital readmission, superficial, deep and organ space surgical-site infections, unplanned return to the operating room, and all complication rates (P greater than .05). Among patients who required total colectomy, hospital costs were 27% higher among those who received infliximab compared with those who received high-dose steroids alone (a mean of $19,880 vs. $14,492, respectively), but because of the small sample size of the infliximab cohort this difference did not reach statistical significance.

“In our institution, salvage infliximab has not been shown to be effective,” Dr. Andrew said. “One key difference between our findings and other studies is that our study population had a high colectomy rate; 82% is much higher than the approximately 30% colectomy rate described in many reports from colleagues in gastroenterology. While there are several potential explanations for our higher rate of colectomy, including the potential concerns that surgeons might be inclined to opt for surgery more readily than non-surgical providers, it is likely that the patients in our study had more severe forms of colitis. It might be the case that there are certain severities of colitis that are beyond the ability of infliximab to salvage, which would be an important issue in selecting which patients to provide inpatient infliximab, so as to not unnecessarily delay surgery, increase hospital costs and to avoid escalating the degree of immunosuppression without a reasonable likelihood of clinical improvement.”

Dr. Andrew reported having no financial disclosures.

[email protected]

LOS ANGELES – The inpatient use of infliximab for severe ulcerative colitis does not avoid the need for colectomy in patients who fail steroid therapy, results from a single-center study demonstrated.

In an interview at the annual meeting of the American Society of Colon and Rectal Surgeons, lead study author Dr. Rachel E. Andrew, a third-year resident in the department of surgery at Penn State Hershey Medical Center in Hershey, Pa., said that despite recent interest in providing inpatient infliximab as an alternative to surgery for those with steroid-refractory disease, 82% of those who received salvage infliximab went on to undergo a total abdominal colectomy during the same admission.

“Our findings suggest that inpatient infliximab was not effective at improving the severity of colitis in these patients,” she said. “Further, infliximab was unreliable in avoiding the need for a total colectomy in this population of ulcerative colitis patients. One difference between our study and those previously published on this subject is that our study focuses on patients with a severity of colitis that resulted in their admission to a surgery service. In terms of evaluating the benefit of infliximab and providing a reliable avoidance of colectomy, we feel that this population of ulcerative colitis patients would be most appropriate to evaluate this issue. This possible difference in patient population may explain the difference in our study findings and those previously published.”

The researchers compared colectomy rates in 173 patients with severe ulcerative colitis who were admitted to the colorectal surgery service at Penn State Hershey Medical Center. Their mean age was 41 years, with 155 (90%) treated with high-dose steroids alone, and with 18 (10%) having received inpatient infliximab as salvage therapy due to a lack of response to steroids alone. Of the patients who received high-dose steroids alone, 81 (52%) required total colectomy, compared with 14 (82%) who received infliximab salvage therapy (P = .046).

The researchers observed no statistically significant differences between the two groups regarding rates of hospital readmission, superficial, deep and organ space surgical-site infections, unplanned return to the operating room, and all complication rates (P greater than .05). Among patients who required total colectomy, hospital costs were 27% higher among those who received infliximab compared with those who received high-dose steroids alone (a mean of $19,880 vs. $14,492, respectively), but because of the small sample size of the infliximab cohort this difference did not reach statistical significance.

“In our institution, salvage infliximab has not been shown to be effective,” Dr. Andrew said. “One key difference between our findings and other studies is that our study population had a high colectomy rate; 82% is much higher than the approximately 30% colectomy rate described in many reports from colleagues in gastroenterology. While there are several potential explanations for our higher rate of colectomy, including the potential concerns that surgeons might be inclined to opt for surgery more readily than non-surgical providers, it is likely that the patients in our study had more severe forms of colitis. It might be the case that there are certain severities of colitis that are beyond the ability of infliximab to salvage, which would be an important issue in selecting which patients to provide inpatient infliximab, so as to not unnecessarily delay surgery, increase hospital costs and to avoid escalating the degree of immunosuppression without a reasonable likelihood of clinical improvement.”

Dr. Andrew reported having no financial disclosures.

[email protected]

LOS ANGELES – Treatment with neoadjuvant chemotherapy leads to significant downstaging in a selected group of patients with advanced colon cancer, results from a large registry study showed.

“Neoadjuvant chemotherapy is already established as a treatment strategy in several other types of cancers, such as breast cancer, gastric cancer, and rectal cancer,” lead study author Dr. Moniek Verstegen said at the annual meeting of the American Society of Colon and Rectal Surgeons. “It reduces tumor size and promotes resectability. In colon cancer, however, this treatment strategy is relatively new and not applied very often.”

©BluePlanetEarth/thinkstockphotos.com

Preliminary results from the ongoing FOxTROT trial in the United Kingdom showed that preoperative chemotherapy for radiologically staged, locally advanced, operable primary colon cancer is feasible, with acceptable toxicity and perioperative morbidity, but long-term results are not yet available. The aim of the current study was to see how often neoadjuvant chemotherapy is used in the Netherlands for stage II and III colon cancer and to assess the tumor and nodal downsizing effects. Moreover, perioperative results and long-term outcomes were compared between those treated with neoadjuvant chemotherapy and those who were treated with adjuvant chemotherapy for locally advanced colon cancer.

The researchers searched the Netherlands Cancer Registry from 2008-2012 to identify 24,944 patients diagnosed with stage II and III colon cancer. Dr. Verstegen, a researcher in the department of surgery at Radboud University Medical Center, Nijmegen, Netherlands, reported results from 85 patients who received neoadjuvant chemotherapy and 2,216 who received adjuvant chemotherapy (the control group). Both groups were similar in terms of age (a median of about 65 years), gender, localization of the primary tumor, differentiation grade, morphology, and clinical T and N stage. Multivisceral resections were performed significantly more often in the neoadjuvant group, compared with the control group (21% vs. 5%, respectively; P less than .001). There were no differences between groups in the number of complete resections, nor in the rate of complications. Furthermore, no patient died within 30 days of neoadjuvant chemotherapy after surgery.

Tumor downstaging was observed in 47% of patients treated with neoadjuvant chemotherapy and there were three complete responses. At the same time, nodal downstaging was observed in 50% of patients treated with neoadjuvant chemotherapy. The 3-year overall survival was 73% in both groups.

Dr. Verstegen acknowledged certain limitations of the study, including its retrospective design and the lack of data on recurrences and disease-free survival. “Neoadjuvant chemotherapy seems to be a safe treatment strategy, since we have low postoperative morbidity and mortality rates,” she concluded. “We see comparable outcomes compared to the control group. Prospective trials are needed to confirm the safety and value of neoadjuvant chemotherapy.”

Dr. Verstegen reported having no financial disclosures.

[email protected]

LOS ANGELES – Treatment with neoadjuvant chemotherapy leads to significant downstaging in a selected group of patients with advanced colon cancer, results from a large registry study showed.

“Neoadjuvant chemotherapy is already established as a treatment strategy in several other types of cancers, such as breast cancer, gastric cancer, and rectal cancer,” lead study author Dr. Moniek Verstegen said at the annual meeting of the American Society of Colon and Rectal Surgeons. “It reduces tumor size and promotes resectability. In colon cancer, however, this treatment strategy is relatively new and not applied very often.”

©BluePlanetEarth/thinkstockphotos.com

Preliminary results from the ongoing FOxTROT trial in the United Kingdom showed that preoperative chemotherapy for radiologically staged, locally advanced, operable primary colon cancer is feasible, with acceptable toxicity and perioperative morbidity, but long-term results are not yet available. The aim of the current study was to see how often neoadjuvant chemotherapy is used in the Netherlands for stage II and III colon cancer and to assess the tumor and nodal downsizing effects. Moreover, perioperative results and long-term outcomes were compared between those treated with neoadjuvant chemotherapy and those who were treated with adjuvant chemotherapy for locally advanced colon cancer.

The researchers searched the Netherlands Cancer Registry from 2008-2012 to identify 24,944 patients diagnosed with stage II and III colon cancer. Dr. Verstegen, a researcher in the department of surgery at Radboud University Medical Center, Nijmegen, Netherlands, reported results from 85 patients who received neoadjuvant chemotherapy and 2,216 who received adjuvant chemotherapy (the control group). Both groups were similar in terms of age (a median of about 65 years), gender, localization of the primary tumor, differentiation grade, morphology, and clinical T and N stage. Multivisceral resections were performed significantly more often in the neoadjuvant group, compared with the control group (21% vs. 5%, respectively; P less than .001). There were no differences between groups in the number of complete resections, nor in the rate of complications. Furthermore, no patient died within 30 days of neoadjuvant chemotherapy after surgery.

Tumor downstaging was observed in 47% of patients treated with neoadjuvant chemotherapy and there were three complete responses. At the same time, nodal downstaging was observed in 50% of patients treated with neoadjuvant chemotherapy. The 3-year overall survival was 73% in both groups.

Dr. Verstegen acknowledged certain limitations of the study, including its retrospective design and the lack of data on recurrences and disease-free survival. “Neoadjuvant chemotherapy seems to be a safe treatment strategy, since we have low postoperative morbidity and mortality rates,” she concluded. “We see comparable outcomes compared to the control group. Prospective trials are needed to confirm the safety and value of neoadjuvant chemotherapy.”

Dr. Verstegen reported having no financial disclosures.

[email protected]

LOS ANGELES – Treatment with neoadjuvant chemotherapy leads to significant downstaging in a selected group of patients with advanced colon cancer, results from a large registry study showed.

“Neoadjuvant chemotherapy is already established as a treatment strategy in several other types of cancers, such as breast cancer, gastric cancer, and rectal cancer,” lead study author Dr. Moniek Verstegen said at the annual meeting of the American Society of Colon and Rectal Surgeons. “It reduces tumor size and promotes resectability. In colon cancer, however, this treatment strategy is relatively new and not applied very often.”

©BluePlanetEarth/thinkstockphotos.com

Preliminary results from the ongoing FOxTROT trial in the United Kingdom showed that preoperative chemotherapy for radiologically staged, locally advanced, operable primary colon cancer is feasible, with acceptable toxicity and perioperative morbidity, but long-term results are not yet available. The aim of the current study was to see how often neoadjuvant chemotherapy is used in the Netherlands for stage II and III colon cancer and to assess the tumor and nodal downsizing effects. Moreover, perioperative results and long-term outcomes were compared between those treated with neoadjuvant chemotherapy and those who were treated with adjuvant chemotherapy for locally advanced colon cancer.

The researchers searched the Netherlands Cancer Registry from 2008-2012 to identify 24,944 patients diagnosed with stage II and III colon cancer. Dr. Verstegen, a researcher in the department of surgery at Radboud University Medical Center, Nijmegen, Netherlands, reported results from 85 patients who received neoadjuvant chemotherapy and 2,216 who received adjuvant chemotherapy (the control group). Both groups were similar in terms of age (a median of about 65 years), gender, localization of the primary tumor, differentiation grade, morphology, and clinical T and N stage. Multivisceral resections were performed significantly more often in the neoadjuvant group, compared with the control group (21% vs. 5%, respectively; P less than .001). There were no differences between groups in the number of complete resections, nor in the rate of complications. Furthermore, no patient died within 30 days of neoadjuvant chemotherapy after surgery.

Tumor downstaging was observed in 47% of patients treated with neoadjuvant chemotherapy and there were three complete responses. At the same time, nodal downstaging was observed in 50% of patients treated with neoadjuvant chemotherapy. The 3-year overall survival was 73% in both groups.

Dr. Verstegen acknowledged certain limitations of the study, including its retrospective design and the lack of data on recurrences and disease-free survival. “Neoadjuvant chemotherapy seems to be a safe treatment strategy, since we have low postoperative morbidity and mortality rates,” she concluded. “We see comparable outcomes compared to the control group. Prospective trials are needed to confirm the safety and value of neoadjuvant chemotherapy.”

Dr. Verstegen reported having no financial disclosures.

[email protected]

SAN DIEGO – Inpatient infliximab rescue for severe, steroid-refractory ulcerative colitis is more likely to work if patients receive a second infusion 3 days after the first, according to a review of 55 University of Michigan, Ann Arbor, patients.

The traditional approach is one inpatient 5-mg/kg infusion, followed by either colectomy or subsequent outpatient infusions, depending on response. In 2013, physicians at the university began offering a second infusion at 72 hours to patients whose C-reactive protein (CRP) levels did not drop below 0.7 mg/dL after their first infusion, and they also began opting more often for 10-mg/kg dosing.

The review found that 90-day colectomy-free survival was 50% in the 16 accelerated-dosing patients, up from 10.2% in the 36 patients treated with the traditional approach (P less than .001). The finding has led to a new, more aggressive infliximab protocol for inpatient ulcerative colitis.

Among patients who did undergo colectomies, postoperative complications were similar between the two groups. But for reasons that are not clear, 30-day postoperative readmission rates were higher in accelerated patients (58% vs. 25%).

In an interview at the annual Digestive Disease Week, lead investigator Dr. Shail Govani of the University of Michigan explained the thinking behind the new approach, how CRP/albumin ratios come into play, and how to counsel patients in light of the findings.

 [email protected]

SAN DIEGO – Inpatient infliximab rescue for severe, steroid-refractory ulcerative colitis is more likely to work if patients receive a second infusion 3 days after the first, according to a review of 55 University of Michigan, Ann Arbor, patients.

The traditional approach is one inpatient 5-mg/kg infusion, followed by either colectomy or subsequent outpatient infusions, depending on response. In 2013, physicians at the university began offering a second infusion at 72 hours to patients whose C-reactive protein (CRP) levels did not drop below 0.7 mg/dL after their first infusion, and they also began opting more often for 10-mg/kg dosing.

The review found that 90-day colectomy-free survival was 50% in the 16 accelerated-dosing patients, up from 10.2% in the 36 patients treated with the traditional approach (P less than .001). The finding has led to a new, more aggressive infliximab protocol for inpatient ulcerative colitis.

Among patients who did undergo colectomies, postoperative complications were similar between the two groups. But for reasons that are not clear, 30-day postoperative readmission rates were higher in accelerated patients (58% vs. 25%).

In an interview at the annual Digestive Disease Week, lead investigator Dr. Shail Govani of the University of Michigan explained the thinking behind the new approach, how CRP/albumin ratios come into play, and how to counsel patients in light of the findings.

 [email protected]

SAN DIEGO – Inpatient infliximab rescue for severe, steroid-refractory ulcerative colitis is more likely to work if patients receive a second infusion 3 days after the first, according to a review of 55 University of Michigan, Ann Arbor, patients.

The traditional approach is one inpatient 5-mg/kg infusion, followed by either colectomy or subsequent outpatient infusions, depending on response. In 2013, physicians at the university began offering a second infusion at 72 hours to patients whose C-reactive protein (CRP) levels did not drop below 0.7 mg/dL after their first infusion, and they also began opting more often for 10-mg/kg dosing.

The review found that 90-day colectomy-free survival was 50% in the 16 accelerated-dosing patients, up from 10.2% in the 36 patients treated with the traditional approach (P less than .001). The finding has led to a new, more aggressive infliximab protocol for inpatient ulcerative colitis.

Among patients who did undergo colectomies, postoperative complications were similar between the two groups. But for reasons that are not clear, 30-day postoperative readmission rates were higher in accelerated patients (58% vs. 25%).

In an interview at the annual Digestive Disease Week, lead investigator Dr. Shail Govani of the University of Michigan explained the thinking behind the new approach, how CRP/albumin ratios come into play, and how to counsel patients in light of the findings.

 [email protected]

LOS ANGELES – Implementation of a perioperative protocol designed to enhance recovery in patients undergoing elective laparoscopic colorectal surgery decreased hospital length of stay, the rate of complications, and overall direct costs, results from a single-center study showed.

“Until recently patients undergoing colorectal surgery were counseled to accept a 20%-25% risk of complications and a 7- to 10-day postoperative stay in the hospital,” lead study author Dr. Daniel S. Lavy said at the annual meeting of the American Society of Colon and Rectal Surgeons. “Studies from the 1990s have shown that length of stay rates improved when one single component of care was changed.”

©Andrei Malov/Thinkstock

Dr. Lavy of the department of surgery at Monmouth Medical Center, Long Branch, N.J., discussed results from a study of Enhanced Recovery After Surgery (ERAS), which he described as “a multimodal perioperative care pathway designed to achieve early recovery for patients undergoing major surgery. Many of its elements challenge existing surgical doctrine, including optimizing nutrition, standardized nonnarcotic and anesthetic regimens, early mobilization, and early initiation of enteral feeding.” The protocol also includes multimodal analgesia aimed at reducing the use of narcotics by intravenous Toradol (ketorolac), intravenous Tylenol (acetaminophen), and a transverse abdominis plane block; preoperative intravenous Solu-Medrol (methylprednisolone); prevention of fluid overload; preoperative and postoperative Entereg (alvimopan); preoperative enteral feedings and early postoperative diet initiation; and aggressive postoperative rehabilitation.

In an effort to evaluate the impact of the protocol in patients undergoing colorectal surgery, Dr. Lavy and his associates analyzed records from 283 elective laparoscopic colon procedures performed at Monmouth Medical Center from July 2013 to December 2015, a time period that included 11 months prior to implementation of ERAS and 18 months after implementation. The data were analyzed using control charts to assess for process changes, while open or emergent procedures were excluded from review. Key measures assessed included hospital length of stay, direct hospital costs, 30-day readmissions, and complications.

Dr. Lavy reported that following implementation of the ERAS protocol, the median length of stay decreased from 3.8 days to 2.8 days; the median direct hospital costs fell 8.5%, resulting in a savings of $876 per case; and the complication rate dropped from 20% to 16%. No changes were observed in the 30-day readmission rate, which held steady at 8%.

“This multifaceted approach has decreased hospital stay, decreased hospital cost and complication rate, did not change the 30-day readmission rate, and maintained patient safety while improving patient care,” Dr. Lavy said. “We suggest research be conducted to determine how this pathway can be altered to further improve quality of care given to patients while simultaneously reducing hospital costs. Also, these methods may be able to be applied to other surgical subspecialties, including ob.gyn., orthopedics, and urology.”

Dr. Lavy reported having no relevant financial disclosures.

[email protected]

LOS ANGELES – Implementation of a perioperative protocol designed to enhance recovery in patients undergoing elective laparoscopic colorectal surgery decreased hospital length of stay, the rate of complications, and overall direct costs, results from a single-center study showed.

“Until recently patients undergoing colorectal surgery were counseled to accept a 20%-25% risk of complications and a 7- to 10-day postoperative stay in the hospital,” lead study author Dr. Daniel S. Lavy said at the annual meeting of the American Society of Colon and Rectal Surgeons. “Studies from the 1990s have shown that length of stay rates improved when one single component of care was changed.”

©Andrei Malov/Thinkstock

Dr. Lavy of the department of surgery at Monmouth Medical Center, Long Branch, N.J., discussed results from a study of Enhanced Recovery After Surgery (ERAS), which he described as “a multimodal perioperative care pathway designed to achieve early recovery for patients undergoing major surgery. Many of its elements challenge existing surgical doctrine, including optimizing nutrition, standardized nonnarcotic and anesthetic regimens, early mobilization, and early initiation of enteral feeding.” The protocol also includes multimodal analgesia aimed at reducing the use of narcotics by intravenous Toradol (ketorolac), intravenous Tylenol (acetaminophen), and a transverse abdominis plane block; preoperative intravenous Solu-Medrol (methylprednisolone); prevention of fluid overload; preoperative and postoperative Entereg (alvimopan); preoperative enteral feedings and early postoperative diet initiation; and aggressive postoperative rehabilitation.

In an effort to evaluate the impact of the protocol in patients undergoing colorectal surgery, Dr. Lavy and his associates analyzed records from 283 elective laparoscopic colon procedures performed at Monmouth Medical Center from July 2013 to December 2015, a time period that included 11 months prior to implementation of ERAS and 18 months after implementation. The data were analyzed using control charts to assess for process changes, while open or emergent procedures were excluded from review. Key measures assessed included hospital length of stay, direct hospital costs, 30-day readmissions, and complications.

Dr. Lavy reported that following implementation of the ERAS protocol, the median length of stay decreased from 3.8 days to 2.8 days; the median direct hospital costs fell 8.5%, resulting in a savings of $876 per case; and the complication rate dropped from 20% to 16%. No changes were observed in the 30-day readmission rate, which held steady at 8%.

“This multifaceted approach has decreased hospital stay, decreased hospital cost and complication rate, did not change the 30-day readmission rate, and maintained patient safety while improving patient care,” Dr. Lavy said. “We suggest research be conducted to determine how this pathway can be altered to further improve quality of care given to patients while simultaneously reducing hospital costs. Also, these methods may be able to be applied to other surgical subspecialties, including ob.gyn., orthopedics, and urology.”

Dr. Lavy reported having no relevant financial disclosures.

[email protected]

LOS ANGELES – Implementation of a perioperative protocol designed to enhance recovery in patients undergoing elective laparoscopic colorectal surgery decreased hospital length of stay, the rate of complications, and overall direct costs, results from a single-center study showed.

“Until recently patients undergoing colorectal surgery were counseled to accept a 20%-25% risk of complications and a 7- to 10-day postoperative stay in the hospital,” lead study author Dr. Daniel S. Lavy said at the annual meeting of the American Society of Colon and Rectal Surgeons. “Studies from the 1990s have shown that length of stay rates improved when one single component of care was changed.”

©Andrei Malov/Thinkstock

Dr. Lavy of the department of surgery at Monmouth Medical Center, Long Branch, N.J., discussed results from a study of Enhanced Recovery After Surgery (ERAS), which he described as “a multimodal perioperative care pathway designed to achieve early recovery for patients undergoing major surgery. Many of its elements challenge existing surgical doctrine, including optimizing nutrition, standardized nonnarcotic and anesthetic regimens, early mobilization, and early initiation of enteral feeding.” The protocol also includes multimodal analgesia aimed at reducing the use of narcotics by intravenous Toradol (ketorolac), intravenous Tylenol (acetaminophen), and a transverse abdominis plane block; preoperative intravenous Solu-Medrol (methylprednisolone); prevention of fluid overload; preoperative and postoperative Entereg (alvimopan); preoperative enteral feedings and early postoperative diet initiation; and aggressive postoperative rehabilitation.

In an effort to evaluate the impact of the protocol in patients undergoing colorectal surgery, Dr. Lavy and his associates analyzed records from 283 elective laparoscopic colon procedures performed at Monmouth Medical Center from July 2013 to December 2015, a time period that included 11 months prior to implementation of ERAS and 18 months after implementation. The data were analyzed using control charts to assess for process changes, while open or emergent procedures were excluded from review. Key measures assessed included hospital length of stay, direct hospital costs, 30-day readmissions, and complications.

Dr. Lavy reported that following implementation of the ERAS protocol, the median length of stay decreased from 3.8 days to 2.8 days; the median direct hospital costs fell 8.5%, resulting in a savings of $876 per case; and the complication rate dropped from 20% to 16%. No changes were observed in the 30-day readmission rate, which held steady at 8%.

“This multifaceted approach has decreased hospital stay, decreased hospital cost and complication rate, did not change the 30-day readmission rate, and maintained patient safety while improving patient care,” Dr. Lavy said. “We suggest research be conducted to determine how this pathway can be altered to further improve quality of care given to patients while simultaneously reducing hospital costs. Also, these methods may be able to be applied to other surgical subspecialties, including ob.gyn., orthopedics, and urology.”

Dr. Lavy reported having no relevant financial disclosures.

[email protected]

LOS ANGELES – A multicenter of patients who had low anterior resection with stapled anastomosis for rectal cancer found no clinical or economic benefit in routinely sending anastomotic doughnuts for histopathological evaluation.

“Several small studies outside the United States have found no benefit in histologic examination of anastomotic stapler doughnuts,” lead study author Dr. Jeremy Sugrue said at the annual meeting of the American Society of Colon and Rectal Surgeons. “We wanted to see if this held true in our population.”

Dr. Sugrue, of the division of colon and rectal surgery in the department of surgery at the University of Illinois at Chicago, and his associates performed a retrospective review of 486 patients who underwent a low anterior resection with stapled anastomosis for rectal cancer between 2002 and 2015 at three medical institutions. The primary outcome was pathologic findings in the doughnuts and their impact on patient management. Secondary outcomes included tumor characteristics that may influence how often a surgeon may send a doughnut to pathology, along with approximate cost.

The mean age of the 486 patients was 60 years, 55% were male, and the mean gross distal margin of the primary tumor specimen was 2.9 cm. “The majority of tumors were located in the middle rectum, and the rest were evenly distributed between the lower rectum, upper rectum, and rectosigmoid regions,” said Dr. Sugrue, who is a general surgery resident. About half of the patients received neoadjuvant radiation or chemotherapy.

Benign findings were found in 33 patients. Among these, 16 had inflammatory changes, including 12 who had nonspecific changes, 3 who had changes from radiation, and 1 had inflammatory bowel disease changes. In addition, 13 patients with benign findings had polyps in their doughnuts (10 hyperplastic and 3 adenomatous), while 4 patients had miscellaneous changes including two cases of vessel micro calcification, one case of diverticuli, and one case of melanosis coli.

Among the 412 patients with malignant findings, 410 (99.5%) had no cancer in the doughnuts and no cancer at the distal resection margin in the primary tumor specimens. “In the two patients where we found cancer in the doughnuts, these patients also had a positive distal margin,” Dr. Sugrue said. “We did not find any patients with a positive distal margin and a negative doughnut. Likewise, we did not find any patients with a negative distal margin or an unexpectedly positive doughnut.”

The researchers also found that patients with low rectal tumors were significantly more likely to have their doughnut sent to pathology, compared with those with rectosigmoid tumors. “However, when we looked at distal margin comparing patients who had doughnuts reported on pathology with those who did not, there was no statistically significant difference,” Dr. Sugrue said. After averaging pathology professional fees and technical fees across all three institutions, he and his associates determined that doughnuts add $643 in cost when processed by pathology as a unique specimen.

Limitations of the study, he said, include its retrospective design, “which inherently introduces selection bias, and we did not perform a precise cost-benefit analysis.”

Dr. Sugrue reported having no financial disclosures.

[email protected]

LOS ANGELES – A multicenter of patients who had low anterior resection with stapled anastomosis for rectal cancer found no clinical or economic benefit in routinely sending anastomotic doughnuts for histopathological evaluation.

“Several small studies outside the United States have found no benefit in histologic examination of anastomotic stapler doughnuts,” lead study author Dr. Jeremy Sugrue said at the annual meeting of the American Society of Colon and Rectal Surgeons. “We wanted to see if this held true in our population.”

Dr. Sugrue, of the division of colon and rectal surgery in the department of surgery at the University of Illinois at Chicago, and his associates performed a retrospective review of 486 patients who underwent a low anterior resection with stapled anastomosis for rectal cancer between 2002 and 2015 at three medical institutions. The primary outcome was pathologic findings in the doughnuts and their impact on patient management. Secondary outcomes included tumor characteristics that may influence how often a surgeon may send a doughnut to pathology, along with approximate cost.

The mean age of the 486 patients was 60 years, 55% were male, and the mean gross distal margin of the primary tumor specimen was 2.9 cm. “The majority of tumors were located in the middle rectum, and the rest were evenly distributed between the lower rectum, upper rectum, and rectosigmoid regions,” said Dr. Sugrue, who is a general surgery resident. About half of the patients received neoadjuvant radiation or chemotherapy.

Benign findings were found in 33 patients. Among these, 16 had inflammatory changes, including 12 who had nonspecific changes, 3 who had changes from radiation, and 1 had inflammatory bowel disease changes. In addition, 13 patients with benign findings had polyps in their doughnuts (10 hyperplastic and 3 adenomatous), while 4 patients had miscellaneous changes including two cases of vessel micro calcification, one case of diverticuli, and one case of melanosis coli.

Among the 412 patients with malignant findings, 410 (99.5%) had no cancer in the doughnuts and no cancer at the distal resection margin in the primary tumor specimens. “In the two patients where we found cancer in the doughnuts, these patients also had a positive distal margin,” Dr. Sugrue said. “We did not find any patients with a positive distal margin and a negative doughnut. Likewise, we did not find any patients with a negative distal margin or an unexpectedly positive doughnut.”

The researchers also found that patients with low rectal tumors were significantly more likely to have their doughnut sent to pathology, compared with those with rectosigmoid tumors. “However, when we looked at distal margin comparing patients who had doughnuts reported on pathology with those who did not, there was no statistically significant difference,” Dr. Sugrue said. After averaging pathology professional fees and technical fees across all three institutions, he and his associates determined that doughnuts add $643 in cost when processed by pathology as a unique specimen.

Limitations of the study, he said, include its retrospective design, “which inherently introduces selection bias, and we did not perform a precise cost-benefit analysis.”

Dr. Sugrue reported having no financial disclosures.

[email protected]

LOS ANGELES – A multicenter of patients who had low anterior resection with stapled anastomosis for rectal cancer found no clinical or economic benefit in routinely sending anastomotic doughnuts for histopathological evaluation.

“Several small studies outside the United States have found no benefit in histologic examination of anastomotic stapler doughnuts,” lead study author Dr. Jeremy Sugrue said at the annual meeting of the American Society of Colon and Rectal Surgeons. “We wanted to see if this held true in our population.”

Dr. Sugrue, of the division of colon and rectal surgery in the department of surgery at the University of Illinois at Chicago, and his associates performed a retrospective review of 486 patients who underwent a low anterior resection with stapled anastomosis for rectal cancer between 2002 and 2015 at three medical institutions. The primary outcome was pathologic findings in the doughnuts and their impact on patient management. Secondary outcomes included tumor characteristics that may influence how often a surgeon may send a doughnut to pathology, along with approximate cost.

The mean age of the 486 patients was 60 years, 55% were male, and the mean gross distal margin of the primary tumor specimen was 2.9 cm. “The majority of tumors were located in the middle rectum, and the rest were evenly distributed between the lower rectum, upper rectum, and rectosigmoid regions,” said Dr. Sugrue, who is a general surgery resident. About half of the patients received neoadjuvant radiation or chemotherapy.

Benign findings were found in 33 patients. Among these, 16 had inflammatory changes, including 12 who had nonspecific changes, 3 who had changes from radiation, and 1 had inflammatory bowel disease changes. In addition, 13 patients with benign findings had polyps in their doughnuts (10 hyperplastic and 3 adenomatous), while 4 patients had miscellaneous changes including two cases of vessel micro calcification, one case of diverticuli, and one case of melanosis coli.

Among the 412 patients with malignant findings, 410 (99.5%) had no cancer in the doughnuts and no cancer at the distal resection margin in the primary tumor specimens. “In the two patients where we found cancer in the doughnuts, these patients also had a positive distal margin,” Dr. Sugrue said. “We did not find any patients with a positive distal margin and a negative doughnut. Likewise, we did not find any patients with a negative distal margin or an unexpectedly positive doughnut.”

The researchers also found that patients with low rectal tumors were significantly more likely to have their doughnut sent to pathology, compared with those with rectosigmoid tumors. “However, when we looked at distal margin comparing patients who had doughnuts reported on pathology with those who did not, there was no statistically significant difference,” Dr. Sugrue said. After averaging pathology professional fees and technical fees across all three institutions, he and his associates determined that doughnuts add $643 in cost when processed by pathology as a unique specimen.

Limitations of the study, he said, include its retrospective design, “which inherently introduces selection bias, and we did not perform a precise cost-benefit analysis.”

Dr. Sugrue reported having no financial disclosures.

[email protected]

LOS ANGELES – There is no difference in 30-day outcomes for patients undergoing emergency surgery for acute diverticulitis with primary anastomosis with or without proximal diversion, results from an analysis of national data showed.

“Traditionally, patients undergoing emergency surgery for diverticulitis were offered a Hartmann’s procedure,” lead study author Dr. Nathan Hite said at the annual meeting of the American Society of Colon and Rectal Surgeons. “Studies have suggested that resection with primary anastomosis and proximal diversion is a safe alternative to this procedure. That’s attractive because it’s usually a quicker operation and puts less physiologic stress on the patient. It still requires a trip to the operating room, an inpatient hospital stay, and carries a complication rate of up to 20%.”

In an effort to determine if there was a difference between 30-day outcomes in patients treated with resection and primary anastomosis with or without primary diversion, the researchers queried the American College of Surgeons National Quality Improvement Program (ACS-NSQIP) database from 2005 to 2013 to identify patients with a diagnosis of diverticula, diverticulosis, or diverticulosis of colon without bleeding who underwent emergency operations. They divided patients into two groups: 1,912 who underwent resection and primary anastomosis without proximal diversion (group 1) and 123 who underwent resection and primary anastomosis with proximal diversion (group 2). Both open and laparoscopic operations were included.

Dr. Hite, of the department of colon and rectal surgery at Ochsner Medical Center, Metairie, La., reported that the mean age of patients in groups 1 and 2 was 62 and 59 years, respectively. There were no differences in gender distribution but women were significantly older in both groups (P less than .0006). No significant differences between groups 1 and 2 were observed with respect to body mass index (29.1 vs. 28.1 kg/m², respectively; P = .11), preoperative albumin (3.3 vs. 3.5 g/dL), preoperative hematocrit (35% vs. 28%), preoperative white blood count (13.4 vs. 13.7 x 10^3/mcL), or functional status (P = .71). Although patients in group 2 did not appear to be sicker at the time of surgery in terms of ASA class or wound class, they did have a higher incidence of diabetes and smoking, compared with their counterparts in group 1.

As for postoperative complications, there were no significant differences between groups 1 and 2 in the incidence of superficial skin infection (141 vs. 7; P = .76), organ space infection (36 vs. 5; P = .09), septic shock (126 vs. 3; P = .18), pulmonary embolism (20 vs. 3; P = .15), cerebrovascular accident (7 vs. 0; P = .5), myocardial infarction (15 vs. 0; P = .32), or death (88 vs. 2; P = .51). Patients in group 2 did have a significantly longer operating time, compared with those in group 1 (158 vs. 133 minutes; P less than .0001).

“Ultimately, the decision to perform a proximal diversion [or not] depends on many factors,” Dr. Hite concluded. “But our study suggests that if the patient is an appropriate candidate for reanastomosis, a diverting ostomy may be safely omitted.” He reported having no financial disclosures.

[email protected]

LOS ANGELES – There is no difference in 30-day outcomes for patients undergoing emergency surgery for acute diverticulitis with primary anastomosis with or without proximal diversion, results from an analysis of national data showed.

“Traditionally, patients undergoing emergency surgery for diverticulitis were offered a Hartmann’s procedure,” lead study author Dr. Nathan Hite said at the annual meeting of the American Society of Colon and Rectal Surgeons. “Studies have suggested that resection with primary anastomosis and proximal diversion is a safe alternative to this procedure. That’s attractive because it’s usually a quicker operation and puts less physiologic stress on the patient. It still requires a trip to the operating room, an inpatient hospital stay, and carries a complication rate of up to 20%.”

In an effort to determine if there was a difference between 30-day outcomes in patients treated with resection and primary anastomosis with or without primary diversion, the researchers queried the American College of Surgeons National Quality Improvement Program (ACS-NSQIP) database from 2005 to 2013 to identify patients with a diagnosis of diverticula, diverticulosis, or diverticulosis of colon without bleeding who underwent emergency operations. They divided patients into two groups: 1,912 who underwent resection and primary anastomosis without proximal diversion (group 1) and 123 who underwent resection and primary anastomosis with proximal diversion (group 2). Both open and laparoscopic operations were included.

Dr. Hite, of the department of colon and rectal surgery at Ochsner Medical Center, Metairie, La., reported that the mean age of patients in groups 1 and 2 was 62 and 59 years, respectively. There were no differences in gender distribution but women were significantly older in both groups (P less than .0006). No significant differences between groups 1 and 2 were observed with respect to body mass index (29.1 vs. 28.1 kg/m², respectively; P = .11), preoperative albumin (3.3 vs. 3.5 g/dL), preoperative hematocrit (35% vs. 28%), preoperative white blood count (13.4 vs. 13.7 x 10^3/mcL), or functional status (P = .71). Although patients in group 2 did not appear to be sicker at the time of surgery in terms of ASA class or wound class, they did have a higher incidence of diabetes and smoking, compared with their counterparts in group 1.

As for postoperative complications, there were no significant differences between groups 1 and 2 in the incidence of superficial skin infection (141 vs. 7; P = .76), organ space infection (36 vs. 5; P = .09), septic shock (126 vs. 3; P = .18), pulmonary embolism (20 vs. 3; P = .15), cerebrovascular accident (7 vs. 0; P = .5), myocardial infarction (15 vs. 0; P = .32), or death (88 vs. 2; P = .51). Patients in group 2 did have a significantly longer operating time, compared with those in group 1 (158 vs. 133 minutes; P less than .0001).

“Ultimately, the decision to perform a proximal diversion [or not] depends on many factors,” Dr. Hite concluded. “But our study suggests that if the patient is an appropriate candidate for reanastomosis, a diverting ostomy may be safely omitted.” He reported having no financial disclosures.

[email protected]

LOS ANGELES – There is no difference in 30-day outcomes for patients undergoing emergency surgery for acute diverticulitis with primary anastomosis with or without proximal diversion, results from an analysis of national data showed.

“Traditionally, patients undergoing emergency surgery for diverticulitis were offered a Hartmann’s procedure,” lead study author Dr. Nathan Hite said at the annual meeting of the American Society of Colon and Rectal Surgeons. “Studies have suggested that resection with primary anastomosis and proximal diversion is a safe alternative to this procedure. That’s attractive because it’s usually a quicker operation and puts less physiologic stress on the patient. It still requires a trip to the operating room, an inpatient hospital stay, and carries a complication rate of up to 20%.”

In an effort to determine if there was a difference between 30-day outcomes in patients treated with resection and primary anastomosis with or without primary diversion, the researchers queried the American College of Surgeons National Quality Improvement Program (ACS-NSQIP) database from 2005 to 2013 to identify patients with a diagnosis of diverticula, diverticulosis, or diverticulosis of colon without bleeding who underwent emergency operations. They divided patients into two groups: 1,912 who underwent resection and primary anastomosis without proximal diversion (group 1) and 123 who underwent resection and primary anastomosis with proximal diversion (group 2). Both open and laparoscopic operations were included.

Dr. Hite, of the department of colon and rectal surgery at Ochsner Medical Center, Metairie, La., reported that the mean age of patients in groups 1 and 2 was 62 and 59 years, respectively. There were no differences in gender distribution but women were significantly older in both groups (P less than .0006). No significant differences between groups 1 and 2 were observed with respect to body mass index (29.1 vs. 28.1 kg/m², respectively; P = .11), preoperative albumin (3.3 vs. 3.5 g/dL), preoperative hematocrit (35% vs. 28%), preoperative white blood count (13.4 vs. 13.7 x 10^3/mcL), or functional status (P = .71). Although patients in group 2 did not appear to be sicker at the time of surgery in terms of ASA class or wound class, they did have a higher incidence of diabetes and smoking, compared with their counterparts in group 1.

As for postoperative complications, there were no significant differences between groups 1 and 2 in the incidence of superficial skin infection (141 vs. 7; P = .76), organ space infection (36 vs. 5; P = .09), septic shock (126 vs. 3; P = .18), pulmonary embolism (20 vs. 3; P = .15), cerebrovascular accident (7 vs. 0; P = .5), myocardial infarction (15 vs. 0; P = .32), or death (88 vs. 2; P = .51). Patients in group 2 did have a significantly longer operating time, compared with those in group 1 (158 vs. 133 minutes; P less than .0001).

“Ultimately, the decision to perform a proximal diversion [or not] depends on many factors,” Dr. Hite concluded. “But our study suggests that if the patient is an appropriate candidate for reanastomosis, a diverting ostomy may be safely omitted.” He reported having no financial disclosures.

[email protected]