Colon and Rectal

Enteral contrast did not augment the accuracy of computed tomography in appendectomy patients, compared with intravenous contrast CT alone, according to a large multihospital study published in Annals of Surgery.

"Enteral contrast should be eliminated in IV-enhanced CT scans performed for suspected appendicitis," said Dr. Frederick Drake at the University of Washington Medical Center in Seattle and his associates. "We conclude that IV contrast alone is sufficient for the diagnosis of appendicitis in a wide variety of hospitals, outside of tertiary centers and strict research protocols."

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The investigators studied 9,047 adults who underwent nonelective appendectomies at 56 hospitals in the state of Washington during a 2-year period. Patients were identified through the Surgical Care Outcomes and Assessment Program (SCOAP), which is based on direct reviews of clinical records and captures more than 85% of nonelective appendectomies performed in the state, the researchers said (Ann. Surg. 2014;260:311-6).

The primary outcome measure was concordance between a patient’s final pathology and the final radiologic report, they said.

Almost 90% of patients underwent CT before surgery. Among these patients, 54% received only IV contrast and 28.5% received both IV and enteral contrast, said the investigators. After controlling for age, sex, comorbidities, weight, hospital type, and perforation, they found no significant difference in concordance rates for IV-only contrast versus IV with enteral contrast (odds ratio, 0.95; 95% confidence interval, 0.72-1.25). Pathology and radiographic findings correlated in 90% of patients who received IV and enteral contrast, and in 90.4% of patients who received only IV contrast, they added, noting that eliminating enteral contrast could improve patients’ safety and comfort, and the efficiency of emergency departments.

The Life Discovery Fund of Washington State, the Agency for Healthcare Research and Quality, and the National Institutes of Health funded the research. The authors reported having no conflicts of interest.

Enteral contrast did not augment the accuracy of computed tomography in appendectomy patients, compared with intravenous contrast CT alone, according to a large multihospital study published in Annals of Surgery.

"Enteral contrast should be eliminated in IV-enhanced CT scans performed for suspected appendicitis," said Dr. Frederick Drake at the University of Washington Medical Center in Seattle and his associates. "We conclude that IV contrast alone is sufficient for the diagnosis of appendicitis in a wide variety of hospitals, outside of tertiary centers and strict research protocols."

© decade3d/Thinkstockphotos

The investigators studied 9,047 adults who underwent nonelective appendectomies at 56 hospitals in the state of Washington during a 2-year period. Patients were identified through the Surgical Care Outcomes and Assessment Program (SCOAP), which is based on direct reviews of clinical records and captures more than 85% of nonelective appendectomies performed in the state, the researchers said (Ann. Surg. 2014;260:311-6).

The primary outcome measure was concordance between a patient’s final pathology and the final radiologic report, they said.

Almost 90% of patients underwent CT before surgery. Among these patients, 54% received only IV contrast and 28.5% received both IV and enteral contrast, said the investigators. After controlling for age, sex, comorbidities, weight, hospital type, and perforation, they found no significant difference in concordance rates for IV-only contrast versus IV with enteral contrast (odds ratio, 0.95; 95% confidence interval, 0.72-1.25). Pathology and radiographic findings correlated in 90% of patients who received IV and enteral contrast, and in 90.4% of patients who received only IV contrast, they added, noting that eliminating enteral contrast could improve patients’ safety and comfort, and the efficiency of emergency departments.

The Life Discovery Fund of Washington State, the Agency for Healthcare Research and Quality, and the National Institutes of Health funded the research. The authors reported having no conflicts of interest.

Enteral contrast did not augment the accuracy of computed tomography in appendectomy patients, compared with intravenous contrast CT alone, according to a large multihospital study published in Annals of Surgery.

"Enteral contrast should be eliminated in IV-enhanced CT scans performed for suspected appendicitis," said Dr. Frederick Drake at the University of Washington Medical Center in Seattle and his associates. "We conclude that IV contrast alone is sufficient for the diagnosis of appendicitis in a wide variety of hospitals, outside of tertiary centers and strict research protocols."

© decade3d/Thinkstockphotos

The investigators studied 9,047 adults who underwent nonelective appendectomies at 56 hospitals in the state of Washington during a 2-year period. Patients were identified through the Surgical Care Outcomes and Assessment Program (SCOAP), which is based on direct reviews of clinical records and captures more than 85% of nonelective appendectomies performed in the state, the researchers said (Ann. Surg. 2014;260:311-6).

The primary outcome measure was concordance between a patient’s final pathology and the final radiologic report, they said.

Almost 90% of patients underwent CT before surgery. Among these patients, 54% received only IV contrast and 28.5% received both IV and enteral contrast, said the investigators. After controlling for age, sex, comorbidities, weight, hospital type, and perforation, they found no significant difference in concordance rates for IV-only contrast versus IV with enteral contrast (odds ratio, 0.95; 95% confidence interval, 0.72-1.25). Pathology and radiographic findings correlated in 90% of patients who received IV and enteral contrast, and in 90.4% of patients who received only IV contrast, they added, noting that eliminating enteral contrast could improve patients’ safety and comfort, and the efficiency of emergency departments.

The Life Discovery Fund of Washington State, the Agency for Healthcare Research and Quality, and the National Institutes of Health funded the research. The authors reported having no conflicts of interest.

In an urban colorectal surgery department, a near-doubling in the proportion of surgical procedures performed laparoscopically accompanied significant declines in both severe postoperative morbidity and conversions to laparotomy, in a 14-year, single-hospital study reported in Annals of Surgery.

"This study demonstrated that a laparoscopic approach is a safe and effective alternative to open surgery" for management of inflammatory bowel disease (IBD), wrote Dr. León Maggiori and his associates at the Assistance Publique-Hôpitaux de Paris.

©avatavat/thinkstockphotos.com

"Associated postoperative morbidity was comparable to reported rates after open approach," the researchers added.

Dr. Maggiori and his associates studied 790 consecutive intestinal resections for IBD performed on 633 patients between June 1998 and July 2012. About two-thirds of the procedures were for Crohn’s disease, and one-third were for ulcerative colitis, the investigators said (Ann. Surg. 2014;260:305-10). The proportion of laparoscopically performed procedures rose from 42% to 80% during the study period (P less than .001), and the trend occurred both for Crohn’s and for ulcerative colitis cases, they added.

As surgeons accrued experience, the rate of complex cases performed laparoscopically also approximately doubled (from 16% to 33%; P less than .023), the researchers said. Furthermore, the mean adjusted risk of conversion to open surgery fell significantly (from 18% to 6%; P less than .001), as did the rate of severe postoperative morbidity (from 14% to 8%; P less than .001).

In all, 12% of laparoscopic cases required conversion, most often because of abscesses or fistulas found during surgery or difficulty dissecting adhesions, the investigators said. Thirteen percent of laparoscopies led to severe postoperative morbidity, defined as Clavien-Dindo grade 3 or 4 complications, they added. The single postoperative death occurred in a patient who developed peritonitis and septic shock 3 days after laparoscopic colectomy with ileosigmoidostomy, the researchers said.

The hospital now uses laparoscopy as the standard approach for surgical management of IBD, except in cases of complicated acute colitis, Dr. Maggiori and his associates said.

The limited number of straight open surgical cases meant that they could not directly be compared with laparoscopy, said the investigators, adding that they lacked data on long-term outcomes because many patients underwent surgery in 2008 or later.

The Association François Aupetit partially funded the study. The authors reported having no conflicts of interest.

In an urban colorectal surgery department, a near-doubling in the proportion of surgical procedures performed laparoscopically accompanied significant declines in both severe postoperative morbidity and conversions to laparotomy, in a 14-year, single-hospital study reported in Annals of Surgery.

"This study demonstrated that a laparoscopic approach is a safe and effective alternative to open surgery" for management of inflammatory bowel disease (IBD), wrote Dr. León Maggiori and his associates at the Assistance Publique-Hôpitaux de Paris.

©avatavat/thinkstockphotos.com

"Associated postoperative morbidity was comparable to reported rates after open approach," the researchers added.

Dr. Maggiori and his associates studied 790 consecutive intestinal resections for IBD performed on 633 patients between June 1998 and July 2012. About two-thirds of the procedures were for Crohn’s disease, and one-third were for ulcerative colitis, the investigators said (Ann. Surg. 2014;260:305-10). The proportion of laparoscopically performed procedures rose from 42% to 80% during the study period (P less than .001), and the trend occurred both for Crohn’s and for ulcerative colitis cases, they added.

As surgeons accrued experience, the rate of complex cases performed laparoscopically also approximately doubled (from 16% to 33%; P less than .023), the researchers said. Furthermore, the mean adjusted risk of conversion to open surgery fell significantly (from 18% to 6%; P less than .001), as did the rate of severe postoperative morbidity (from 14% to 8%; P less than .001).

In all, 12% of laparoscopic cases required conversion, most often because of abscesses or fistulas found during surgery or difficulty dissecting adhesions, the investigators said. Thirteen percent of laparoscopies led to severe postoperative morbidity, defined as Clavien-Dindo grade 3 or 4 complications, they added. The single postoperative death occurred in a patient who developed peritonitis and septic shock 3 days after laparoscopic colectomy with ileosigmoidostomy, the researchers said.

The hospital now uses laparoscopy as the standard approach for surgical management of IBD, except in cases of complicated acute colitis, Dr. Maggiori and his associates said.

The limited number of straight open surgical cases meant that they could not directly be compared with laparoscopy, said the investigators, adding that they lacked data on long-term outcomes because many patients underwent surgery in 2008 or later.

The Association François Aupetit partially funded the study. The authors reported having no conflicts of interest.

In an urban colorectal surgery department, a near-doubling in the proportion of surgical procedures performed laparoscopically accompanied significant declines in both severe postoperative morbidity and conversions to laparotomy, in a 14-year, single-hospital study reported in Annals of Surgery.

"This study demonstrated that a laparoscopic approach is a safe and effective alternative to open surgery" for management of inflammatory bowel disease (IBD), wrote Dr. León Maggiori and his associates at the Assistance Publique-Hôpitaux de Paris.

©avatavat/thinkstockphotos.com

"Associated postoperative morbidity was comparable to reported rates after open approach," the researchers added.

Dr. Maggiori and his associates studied 790 consecutive intestinal resections for IBD performed on 633 patients between June 1998 and July 2012. About two-thirds of the procedures were for Crohn’s disease, and one-third were for ulcerative colitis, the investigators said (Ann. Surg. 2014;260:305-10). The proportion of laparoscopically performed procedures rose from 42% to 80% during the study period (P less than .001), and the trend occurred both for Crohn’s and for ulcerative colitis cases, they added.

As surgeons accrued experience, the rate of complex cases performed laparoscopically also approximately doubled (from 16% to 33%; P less than .023), the researchers said. Furthermore, the mean adjusted risk of conversion to open surgery fell significantly (from 18% to 6%; P less than .001), as did the rate of severe postoperative morbidity (from 14% to 8%; P less than .001).

In all, 12% of laparoscopic cases required conversion, most often because of abscesses or fistulas found during surgery or difficulty dissecting adhesions, the investigators said. Thirteen percent of laparoscopies led to severe postoperative morbidity, defined as Clavien-Dindo grade 3 or 4 complications, they added. The single postoperative death occurred in a patient who developed peritonitis and septic shock 3 days after laparoscopic colectomy with ileosigmoidostomy, the researchers said.

The hospital now uses laparoscopy as the standard approach for surgical management of IBD, except in cases of complicated acute colitis, Dr. Maggiori and his associates said.

The limited number of straight open surgical cases meant that they could not directly be compared with laparoscopy, said the investigators, adding that they lacked data on long-term outcomes because many patients underwent surgery in 2008 or later.

The Association François Aupetit partially funded the study. The authors reported having no conflicts of interest.

A hospital’s program to enhance recovery after colorectal surgery cut length of stay by 3 days and saved up to $4,800 per patient without increasing postoperative morbidity or 30-day readmission rates, investigators reported online July 23 in JAMA Surgery.

The study extends the evidence base for colorectal enhanced recovery after surgery (ERAS) programs to community hospital settings, said Dr. Cristina Geltzeiler of Oregon Health and Science University in Portland and her associates.

The investigators studied practice patterns and patient outcomes for 1 year before and 2 years after starting a colorectal ERAS program for 244 patients. The program featured preadmission patient education, preoperative bowel preparation for left-sided and rectal procedures, use of intrathecal spinal anesthetics, conservative fluid management, minimal use of narcotics, and early resumption of oral intake and ambulation after surgery, the researchers reported (JAMA Surg. 2014 July 23 [doi: 10.1001/jamasurg.2014.675]). Discharge criteria did not change, they noted.

After program implementation, use of laparoscopy increased by almost 30% (from 57.4% to 88.8%; P less than .001) and length of stay fell by 3 days (from 6.7 to 3.7 days; P less than .001), while 30-day readmission rates did not increase (17.6% vs. 12.5%), the investigators reported.

The percentage of patients who used postoperative narcotic analgesia also fell substantially (from 63.2% to 15%; P less than .001), as did duration of narcotic use (from 67.8 hours to 47.1 hours; P = .02), ileus (from 13.2% to 2.5% of patients; P = .02) and intra-abdominal infections (from 7.4% to 2.5% of patients; P = .24), the investigators said. Outcomes did not differ significantly for patients with colorectal cancer, they added.

"Development and implementation of the program required multidisciplinary collaboration among surgeons, nursing staff, anesthesia providers, pharmacists, operating room staff, clinics, and preadmission services," said Dr. Geltzeiler and her associates. To gain program buy-in, leaders organized discussions and presentations of published ERAS literature, and also used clear, consistent messaging about expectations for patients’ activity, diet, and pain management throughout the perioperative period, the researchers added.

A trend toward referring patients to a smaller pool of colorectal specialists during the study period could have affected results, the investigators noted. They added that rates of superficial wound infection were probably underreported because such infections tend to occur after discharge.

The authors reported no funding sources or conflicts of interest.

A hospital’s program to enhance recovery after colorectal surgery cut length of stay by 3 days and saved up to $4,800 per patient without increasing postoperative morbidity or 30-day readmission rates, investigators reported online July 23 in JAMA Surgery.

The study extends the evidence base for colorectal enhanced recovery after surgery (ERAS) programs to community hospital settings, said Dr. Cristina Geltzeiler of Oregon Health and Science University in Portland and her associates.

The investigators studied practice patterns and patient outcomes for 1 year before and 2 years after starting a colorectal ERAS program for 244 patients. The program featured preadmission patient education, preoperative bowel preparation for left-sided and rectal procedures, use of intrathecal spinal anesthetics, conservative fluid management, minimal use of narcotics, and early resumption of oral intake and ambulation after surgery, the researchers reported (JAMA Surg. 2014 July 23 [doi: 10.1001/jamasurg.2014.675]). Discharge criteria did not change, they noted.

After program implementation, use of laparoscopy increased by almost 30% (from 57.4% to 88.8%; P less than .001) and length of stay fell by 3 days (from 6.7 to 3.7 days; P less than .001), while 30-day readmission rates did not increase (17.6% vs. 12.5%), the investigators reported.

The percentage of patients who used postoperative narcotic analgesia also fell substantially (from 63.2% to 15%; P less than .001), as did duration of narcotic use (from 67.8 hours to 47.1 hours; P = .02), ileus (from 13.2% to 2.5% of patients; P = .02) and intra-abdominal infections (from 7.4% to 2.5% of patients; P = .24), the investigators said. Outcomes did not differ significantly for patients with colorectal cancer, they added.

"Development and implementation of the program required multidisciplinary collaboration among surgeons, nursing staff, anesthesia providers, pharmacists, operating room staff, clinics, and preadmission services," said Dr. Geltzeiler and her associates. To gain program buy-in, leaders organized discussions and presentations of published ERAS literature, and also used clear, consistent messaging about expectations for patients’ activity, diet, and pain management throughout the perioperative period, the researchers added.

A trend toward referring patients to a smaller pool of colorectal specialists during the study period could have affected results, the investigators noted. They added that rates of superficial wound infection were probably underreported because such infections tend to occur after discharge.

The authors reported no funding sources or conflicts of interest.

A hospital’s program to enhance recovery after colorectal surgery cut length of stay by 3 days and saved up to $4,800 per patient without increasing postoperative morbidity or 30-day readmission rates, investigators reported online July 23 in JAMA Surgery.

The study extends the evidence base for colorectal enhanced recovery after surgery (ERAS) programs to community hospital settings, said Dr. Cristina Geltzeiler of Oregon Health and Science University in Portland and her associates.

The investigators studied practice patterns and patient outcomes for 1 year before and 2 years after starting a colorectal ERAS program for 244 patients. The program featured preadmission patient education, preoperative bowel preparation for left-sided and rectal procedures, use of intrathecal spinal anesthetics, conservative fluid management, minimal use of narcotics, and early resumption of oral intake and ambulation after surgery, the researchers reported (JAMA Surg. 2014 July 23 [doi: 10.1001/jamasurg.2014.675]). Discharge criteria did not change, they noted.

After program implementation, use of laparoscopy increased by almost 30% (from 57.4% to 88.8%; P less than .001) and length of stay fell by 3 days (from 6.7 to 3.7 days; P less than .001), while 30-day readmission rates did not increase (17.6% vs. 12.5%), the investigators reported.

The percentage of patients who used postoperative narcotic analgesia also fell substantially (from 63.2% to 15%; P less than .001), as did duration of narcotic use (from 67.8 hours to 47.1 hours; P = .02), ileus (from 13.2% to 2.5% of patients; P = .02) and intra-abdominal infections (from 7.4% to 2.5% of patients; P = .24), the investigators said. Outcomes did not differ significantly for patients with colorectal cancer, they added.

"Development and implementation of the program required multidisciplinary collaboration among surgeons, nursing staff, anesthesia providers, pharmacists, operating room staff, clinics, and preadmission services," said Dr. Geltzeiler and her associates. To gain program buy-in, leaders organized discussions and presentations of published ERAS literature, and also used clear, consistent messaging about expectations for patients’ activity, diet, and pain management throughout the perioperative period, the researchers added.

A trend toward referring patients to a smaller pool of colorectal specialists during the study period could have affected results, the investigators noted. They added that rates of superficial wound infection were probably underreported because such infections tend to occur after discharge.

The authors reported no funding sources or conflicts of interest.

The use of minimally invasive surgery for appendectomy, colectomy, hysterectomy, and lung lobectomy varies widely in the United States, even though the complication rates were lower from each procedure than with open surgery, results from a large retrospective study demonstrated.

"This study has important implications for quality improvement," researchers led by Dr. Martin A. Makary, professor of surgery at Johns Hopkins University, Baltimore, wrote. "Based on our findings, many hospitals have an opportunity to decrease surgical complications by increasing utilization of minimally invasive surgery."

Photo by Staff Sgt. Samuel Bendet, U.S. Air Force/ Wikimedia Commons

To investigate the levels of variation in the use of minimally invasive surgery across the United States, Dr. Makary and his associates used the National Inpatient Sample database, which is administered by the Agency for Healthcare Research & Quality, to evaluate hospitalizations at hospitals that performed at least 10 of these procedures in 2010. The sample included 1,051 hospitals in 45 states, and was limited to appendectomy, colectomy, hysterectomy, and lung lobectomy. The researchers used a propensity score model to calculate the predicted proportion of minimally invasive operations for each hospital based on patient characteristics. For each procedure, they categorized hospitals as low, medium, or high based on their actual to predicted proportion of minimally invasive surgery use (BMJ 2014;349:g4198).

On average, the use of minimally invasive surgery by the hospitals sampled was 71% for appendectomy, 28% for colectomy, 13% for hysterectomy, and 32% for lung lobectomy. Overall surgical complications for minimally invasive surgery, compared with open surgery, were, respectively, for appendectomy: 3.94% vs. 7.90% (P less than .001); colectomy: 13.8% vs. 35.8% (P less than .001); hysterectomy: 4.69% vs. 6.64% (P less than .001); and lung lobectomy: 17.1% vs. 25.4% (P less than .05). "In our analysis using Agency for Healthcare Research & Quality patient safety indicators for surgical care, we noted fewer wound, infectious, thrombotic, pulmonary, and mortality complications associated with minimally invasive surgery," the researchers wrote. "Based on our findings, increased hospital utilization of minimally invasive surgery at many U.S. hospitals represents a tremendous opportunity to prevent surgical site infection events."

The use of minimally invasive surgery was highly variable among the sampled hospitals. In fact, some never used minimally invasive surgery for some of the four procedures, while others used minimally invasive surgery for more than 75% of these procedures. Factors associated with the use of minimally invasive surgery were urban location, large hospital size, teaching hospital, and, for certain procedures, the hospital being located in the Midwest, South, or West.

"This [regional] disparity may be due to the broad range of surgical services some surgeons in rural areas are required to provide, and a scarcity of surgical specialists in such areas with advanced skills in minimally invasive surgery. Alternatively, the disparity may be a function of a lack of patient awareness about surgical options, decreased competition for patients, or a lack of minimally invasive surgery equipment, staff, or support in rural areas," the researchers wrote.

The findings of underutilization of minimally invasive surgery may also have something to do with a training gap.

"One reason that hospitals may be underperforming minimally invasive surgery is variability in appropriate training in residency and fellowship," Dr. Makary and his associates wrote. "One strategy that hospitals may consider in managing surgeons who cannot or choose not to acquire skills for performing minimally invasive surgery is to create a division of labor where patients who are not candidates for minimally invasive surgery are cared for by these surgeons. Increased standardization of competencies in minimally invasive surgery in surgical residency is needed to tackle wide variations in training."

The researchers acknowledged certain limitations of the study, including the fact that administrative claims data "can have incomplete coding, particularly of preexisting conditions," they wrote. "Another limitation is the lack of information available in the database for physician factors, such as laparoscopic training and experience that may influence the choice of procedure."

The researchers stated that they had no relevant financial conflicts to disclose.

[email protected]

The use of minimally invasive surgery for appendectomy, colectomy, hysterectomy, and lung lobectomy varies widely in the United States, even though the complication rates were lower from each procedure than with open surgery, results from a large retrospective study demonstrated.

"This study has important implications for quality improvement," researchers led by Dr. Martin A. Makary, professor of surgery at Johns Hopkins University, Baltimore, wrote. "Based on our findings, many hospitals have an opportunity to decrease surgical complications by increasing utilization of minimally invasive surgery."

Photo by Staff Sgt. Samuel Bendet, U.S. Air Force/ Wikimedia Commons

To investigate the levels of variation in the use of minimally invasive surgery across the United States, Dr. Makary and his associates used the National Inpatient Sample database, which is administered by the Agency for Healthcare Research & Quality, to evaluate hospitalizations at hospitals that performed at least 10 of these procedures in 2010. The sample included 1,051 hospitals in 45 states, and was limited to appendectomy, colectomy, hysterectomy, and lung lobectomy. The researchers used a propensity score model to calculate the predicted proportion of minimally invasive operations for each hospital based on patient characteristics. For each procedure, they categorized hospitals as low, medium, or high based on their actual to predicted proportion of minimally invasive surgery use (BMJ 2014;349:g4198).

On average, the use of minimally invasive surgery by the hospitals sampled was 71% for appendectomy, 28% for colectomy, 13% for hysterectomy, and 32% for lung lobectomy. Overall surgical complications for minimally invasive surgery, compared with open surgery, were, respectively, for appendectomy: 3.94% vs. 7.90% (P less than .001); colectomy: 13.8% vs. 35.8% (P less than .001); hysterectomy: 4.69% vs. 6.64% (P less than .001); and lung lobectomy: 17.1% vs. 25.4% (P less than .05). "In our analysis using Agency for Healthcare Research & Quality patient safety indicators for surgical care, we noted fewer wound, infectious, thrombotic, pulmonary, and mortality complications associated with minimally invasive surgery," the researchers wrote. "Based on our findings, increased hospital utilization of minimally invasive surgery at many U.S. hospitals represents a tremendous opportunity to prevent surgical site infection events."

The use of minimally invasive surgery was highly variable among the sampled hospitals. In fact, some never used minimally invasive surgery for some of the four procedures, while others used minimally invasive surgery for more than 75% of these procedures. Factors associated with the use of minimally invasive surgery were urban location, large hospital size, teaching hospital, and, for certain procedures, the hospital being located in the Midwest, South, or West.

"This [regional] disparity may be due to the broad range of surgical services some surgeons in rural areas are required to provide, and a scarcity of surgical specialists in such areas with advanced skills in minimally invasive surgery. Alternatively, the disparity may be a function of a lack of patient awareness about surgical options, decreased competition for patients, or a lack of minimally invasive surgery equipment, staff, or support in rural areas," the researchers wrote.

The findings of underutilization of minimally invasive surgery may also have something to do with a training gap.

"One reason that hospitals may be underperforming minimally invasive surgery is variability in appropriate training in residency and fellowship," Dr. Makary and his associates wrote. "One strategy that hospitals may consider in managing surgeons who cannot or choose not to acquire skills for performing minimally invasive surgery is to create a division of labor where patients who are not candidates for minimally invasive surgery are cared for by these surgeons. Increased standardization of competencies in minimally invasive surgery in surgical residency is needed to tackle wide variations in training."

The researchers acknowledged certain limitations of the study, including the fact that administrative claims data "can have incomplete coding, particularly of preexisting conditions," they wrote. "Another limitation is the lack of information available in the database for physician factors, such as laparoscopic training and experience that may influence the choice of procedure."

The researchers stated that they had no relevant financial conflicts to disclose.

[email protected]

The use of minimally invasive surgery for appendectomy, colectomy, hysterectomy, and lung lobectomy varies widely in the United States, even though the complication rates were lower from each procedure than with open surgery, results from a large retrospective study demonstrated.

"This study has important implications for quality improvement," researchers led by Dr. Martin A. Makary, professor of surgery at Johns Hopkins University, Baltimore, wrote. "Based on our findings, many hospitals have an opportunity to decrease surgical complications by increasing utilization of minimally invasive surgery."

Photo by Staff Sgt. Samuel Bendet, U.S. Air Force/ Wikimedia Commons

To investigate the levels of variation in the use of minimally invasive surgery across the United States, Dr. Makary and his associates used the National Inpatient Sample database, which is administered by the Agency for Healthcare Research & Quality, to evaluate hospitalizations at hospitals that performed at least 10 of these procedures in 2010. The sample included 1,051 hospitals in 45 states, and was limited to appendectomy, colectomy, hysterectomy, and lung lobectomy. The researchers used a propensity score model to calculate the predicted proportion of minimally invasive operations for each hospital based on patient characteristics. For each procedure, they categorized hospitals as low, medium, or high based on their actual to predicted proportion of minimally invasive surgery use (BMJ 2014;349:g4198).

On average, the use of minimally invasive surgery by the hospitals sampled was 71% for appendectomy, 28% for colectomy, 13% for hysterectomy, and 32% for lung lobectomy. Overall surgical complications for minimally invasive surgery, compared with open surgery, were, respectively, for appendectomy: 3.94% vs. 7.90% (P less than .001); colectomy: 13.8% vs. 35.8% (P less than .001); hysterectomy: 4.69% vs. 6.64% (P less than .001); and lung lobectomy: 17.1% vs. 25.4% (P less than .05). "In our analysis using Agency for Healthcare Research & Quality patient safety indicators for surgical care, we noted fewer wound, infectious, thrombotic, pulmonary, and mortality complications associated with minimally invasive surgery," the researchers wrote. "Based on our findings, increased hospital utilization of minimally invasive surgery at many U.S. hospitals represents a tremendous opportunity to prevent surgical site infection events."

The use of minimally invasive surgery was highly variable among the sampled hospitals. In fact, some never used minimally invasive surgery for some of the four procedures, while others used minimally invasive surgery for more than 75% of these procedures. Factors associated with the use of minimally invasive surgery were urban location, large hospital size, teaching hospital, and, for certain procedures, the hospital being located in the Midwest, South, or West.

"This [regional] disparity may be due to the broad range of surgical services some surgeons in rural areas are required to provide, and a scarcity of surgical specialists in such areas with advanced skills in minimally invasive surgery. Alternatively, the disparity may be a function of a lack of patient awareness about surgical options, decreased competition for patients, or a lack of minimally invasive surgery equipment, staff, or support in rural areas," the researchers wrote.

The findings of underutilization of minimally invasive surgery may also have something to do with a training gap.

"One reason that hospitals may be underperforming minimally invasive surgery is variability in appropriate training in residency and fellowship," Dr. Makary and his associates wrote. "One strategy that hospitals may consider in managing surgeons who cannot or choose not to acquire skills for performing minimally invasive surgery is to create a division of labor where patients who are not candidates for minimally invasive surgery are cared for by these surgeons. Increased standardization of competencies in minimally invasive surgery in surgical residency is needed to tackle wide variations in training."

The researchers acknowledged certain limitations of the study, including the fact that administrative claims data "can have incomplete coding, particularly of preexisting conditions," they wrote. "Another limitation is the lack of information available in the database for physician factors, such as laparoscopic training and experience that may influence the choice of procedure."

The researchers stated that they had no relevant financial conflicts to disclose.

[email protected]

In patients with colorectal cancer, laparoscopic resection reduced total hospital stay by a median of 2 days, compared with open surgery, researchers reported online May 5 in the Journal of Clinical Oncology.

However, laparoscopy did not significantly improve physical fatigue at 1 month, compared with open surgery, and it did not affect other secondary clinical outcomes, said Prof. Robin Kennedy of St. Mark’s Hospital, Harrow, England, and his associates.

The researchers conducted a multicenter, randomized trial of 204 patients with colorectal cancer, of whom 103 underwent laparoscopic resection and 101 had open surgery within a standardized enhanced recovery program (J. Clin. Oncol. 2014 May 5 [doi: 10.1200/JCO.2013.54.3694]).

Median total hospital stay was significantly shorter in the laparoscopy group (5 days; interquartile range, 4-9 days) vs. the open surgery group (7 days; IQR, 5-11 days; P = .033), the investigators reported. However, 1-month physical fatigue scores on the Multidimensional Fatigue Inventory 20 were similar between the two groups (mean for laparoscopy patients, 12.28; 95% confidence interval, 11.37-13.19; mean for open surgery patients, 12.05; 95% CI, 11.14-12.96; adjusted mean difference, –0.23; 95% CI, –1.52-1.07), the researchers reported. Other outcomes also were similar, including quality of the specimens based on central pathologic review, the researchers said.

The findings contradicted those of prior studies in which shorter duration of hospital stay correlated with less "pain, ileus, and other complications, leading to earlier mobilization, feeding, and recovery," the researchers noted. They recommended more studies to determine whether the similarities between other outcomes were due to a lack of power or truly indicated comparable short-term recoveries.

The research was funded by Cancer Research UK, the National Institute for Health Research, Ethicon Endo-Surgery Europe, the Medical Research Council ConDuCT Hub, and Yorkshire Cancer Research. The authors reported that they had no relevant conflicts of interest.

In patients with colorectal cancer, laparoscopic resection reduced total hospital stay by a median of 2 days, compared with open surgery, researchers reported online May 5 in the Journal of Clinical Oncology.

However, laparoscopy did not significantly improve physical fatigue at 1 month, compared with open surgery, and it did not affect other secondary clinical outcomes, said Prof. Robin Kennedy of St. Mark’s Hospital, Harrow, England, and his associates.

The researchers conducted a multicenter, randomized trial of 204 patients with colorectal cancer, of whom 103 underwent laparoscopic resection and 101 had open surgery within a standardized enhanced recovery program (J. Clin. Oncol. 2014 May 5 [doi: 10.1200/JCO.2013.54.3694]).

Median total hospital stay was significantly shorter in the laparoscopy group (5 days; interquartile range, 4-9 days) vs. the open surgery group (7 days; IQR, 5-11 days; P = .033), the investigators reported. However, 1-month physical fatigue scores on the Multidimensional Fatigue Inventory 20 were similar between the two groups (mean for laparoscopy patients, 12.28; 95% confidence interval, 11.37-13.19; mean for open surgery patients, 12.05; 95% CI, 11.14-12.96; adjusted mean difference, –0.23; 95% CI, –1.52-1.07), the researchers reported. Other outcomes also were similar, including quality of the specimens based on central pathologic review, the researchers said.

The findings contradicted those of prior studies in which shorter duration of hospital stay correlated with less "pain, ileus, and other complications, leading to earlier mobilization, feeding, and recovery," the researchers noted. They recommended more studies to determine whether the similarities between other outcomes were due to a lack of power or truly indicated comparable short-term recoveries.

The research was funded by Cancer Research UK, the National Institute for Health Research, Ethicon Endo-Surgery Europe, the Medical Research Council ConDuCT Hub, and Yorkshire Cancer Research. The authors reported that they had no relevant conflicts of interest.

In patients with colorectal cancer, laparoscopic resection reduced total hospital stay by a median of 2 days, compared with open surgery, researchers reported online May 5 in the Journal of Clinical Oncology.

However, laparoscopy did not significantly improve physical fatigue at 1 month, compared with open surgery, and it did not affect other secondary clinical outcomes, said Prof. Robin Kennedy of St. Mark’s Hospital, Harrow, England, and his associates.

The researchers conducted a multicenter, randomized trial of 204 patients with colorectal cancer, of whom 103 underwent laparoscopic resection and 101 had open surgery within a standardized enhanced recovery program (J. Clin. Oncol. 2014 May 5 [doi: 10.1200/JCO.2013.54.3694]).

Median total hospital stay was significantly shorter in the laparoscopy group (5 days; interquartile range, 4-9 days) vs. the open surgery group (7 days; IQR, 5-11 days; P = .033), the investigators reported. However, 1-month physical fatigue scores on the Multidimensional Fatigue Inventory 20 were similar between the two groups (mean for laparoscopy patients, 12.28; 95% confidence interval, 11.37-13.19; mean for open surgery patients, 12.05; 95% CI, 11.14-12.96; adjusted mean difference, –0.23; 95% CI, –1.52-1.07), the researchers reported. Other outcomes also were similar, including quality of the specimens based on central pathologic review, the researchers said.

The findings contradicted those of prior studies in which shorter duration of hospital stay correlated with less "pain, ileus, and other complications, leading to earlier mobilization, feeding, and recovery," the researchers noted. They recommended more studies to determine whether the similarities between other outcomes were due to a lack of power or truly indicated comparable short-term recoveries.

The research was funded by Cancer Research UK, the National Institute for Health Research, Ethicon Endo-Surgery Europe, the Medical Research Council ConDuCT Hub, and Yorkshire Cancer Research. The authors reported that they had no relevant conflicts of interest.

Laparoscopic-assisted colonoscopic polypectomy works as well as standard laparoscopic hemicolectomy to remove difficult to reach polyps in the right colon, with fewer complications and shorter hospital stays, according to data from a recent trial.

Instead of taking out a section of the ascending colon to remove the polyp, a surgeon uses a laparoscope to mobilize and position the right colon during laparoscopic-assisted colonoscopic polypectomy (LACP) so that an endoscopist can reach, snare, and remove it.

The team randomized 14 patients to LACP and 14 to laparoscopic hemicolectomy (LHC). The LACP group had shorter mean operating times (95 vs. 179 min.), less blood loss (13 vs. 63 mL), and required less intravenous fluid (2.1 vs. 3.1 L). LACP patients were also quicker to pass flatus (1.44 vs. 2.88 days), resume solid food (1.69 vs. 3.94 days), and leave the hospital (2.63 vs. 4.94 days), all statistically significant differences.

One LACP patient required conversion to LHC, while four LHC patients required conversion to laparotomy. There were no significant between-group differences in postoperative complications, readmissions, or second operations.

"That ability to remove polyps with LACP was as effective and safe as the standard laparoscopic hemicolectomy ... and patients were discharged from the hospital earlier. We think this is a very exciting change in how we deal with these difficult to remove colon polyps," said Dr. Jonathan Buscaglia, director of advanced endoscopy at Stony Brook (N.Y.) University.

There are a few case series in the literature about the technique, but uptake seems to have been slow so far. "I think the biggest roadblock is the ability of a surgeon to coordinate with a gastroenterologist. You need good working relationships, and schedules able to accommodate [both]. That’s not always easy, depending on where one works," Dr. Buscaglia said at a teleconference in advance of the annual Digestive Disease Week.

The patients in the trial had benign polyps with lift signs and generally tubular or tubulovillous adenomas. The groups were evenly matched for age, sex, body mass index, American Society of Anesthesiologists physical status, and previous abdominal surgery, plus polyp morphology, location, size, and histology.

It’s too soon after the procedures for serial surveillance colonoscopies and to know if any of the patients went on to develop cancer after their operations.

The right side is technically an easier place for laparoscopic surgeons to operate; with the left colon, operators have to worry more about diverticulitis, scarring, and tight anatomy. Even so, LACP may still be useful. "We are looking forward to conducting" a larger, possibly multicenter study on its application to polyps "in all areas of the colon," Dr. Buscaglia said.

The investigators have no disclosures.

[email protected]

Laparoscopic-assisted colonoscopic polypectomy works as well as standard laparoscopic hemicolectomy to remove difficult to reach polyps in the right colon, with fewer complications and shorter hospital stays, according to data from a recent trial.

Instead of taking out a section of the ascending colon to remove the polyp, a surgeon uses a laparoscope to mobilize and position the right colon during laparoscopic-assisted colonoscopic polypectomy (LACP) so that an endoscopist can reach, snare, and remove it.

The team randomized 14 patients to LACP and 14 to laparoscopic hemicolectomy (LHC). The LACP group had shorter mean operating times (95 vs. 179 min.), less blood loss (13 vs. 63 mL), and required less intravenous fluid (2.1 vs. 3.1 L). LACP patients were also quicker to pass flatus (1.44 vs. 2.88 days), resume solid food (1.69 vs. 3.94 days), and leave the hospital (2.63 vs. 4.94 days), all statistically significant differences.

One LACP patient required conversion to LHC, while four LHC patients required conversion to laparotomy. There were no significant between-group differences in postoperative complications, readmissions, or second operations.

"That ability to remove polyps with LACP was as effective and safe as the standard laparoscopic hemicolectomy ... and patients were discharged from the hospital earlier. We think this is a very exciting change in how we deal with these difficult to remove colon polyps," said Dr. Jonathan Buscaglia, director of advanced endoscopy at Stony Brook (N.Y.) University.

There are a few case series in the literature about the technique, but uptake seems to have been slow so far. "I think the biggest roadblock is the ability of a surgeon to coordinate with a gastroenterologist. You need good working relationships, and schedules able to accommodate [both]. That’s not always easy, depending on where one works," Dr. Buscaglia said at a teleconference in advance of the annual Digestive Disease Week.

The patients in the trial had benign polyps with lift signs and generally tubular or tubulovillous adenomas. The groups were evenly matched for age, sex, body mass index, American Society of Anesthesiologists physical status, and previous abdominal surgery, plus polyp morphology, location, size, and histology.

It’s too soon after the procedures for serial surveillance colonoscopies and to know if any of the patients went on to develop cancer after their operations.

The right side is technically an easier place for laparoscopic surgeons to operate; with the left colon, operators have to worry more about diverticulitis, scarring, and tight anatomy. Even so, LACP may still be useful. "We are looking forward to conducting" a larger, possibly multicenter study on its application to polyps "in all areas of the colon," Dr. Buscaglia said.

The investigators have no disclosures.

[email protected]

Laparoscopic-assisted colonoscopic polypectomy works as well as standard laparoscopic hemicolectomy to remove difficult to reach polyps in the right colon, with fewer complications and shorter hospital stays, according to data from a recent trial.

Instead of taking out a section of the ascending colon to remove the polyp, a surgeon uses a laparoscope to mobilize and position the right colon during laparoscopic-assisted colonoscopic polypectomy (LACP) so that an endoscopist can reach, snare, and remove it.

The team randomized 14 patients to LACP and 14 to laparoscopic hemicolectomy (LHC). The LACP group had shorter mean operating times (95 vs. 179 min.), less blood loss (13 vs. 63 mL), and required less intravenous fluid (2.1 vs. 3.1 L). LACP patients were also quicker to pass flatus (1.44 vs. 2.88 days), resume solid food (1.69 vs. 3.94 days), and leave the hospital (2.63 vs. 4.94 days), all statistically significant differences.

One LACP patient required conversion to LHC, while four LHC patients required conversion to laparotomy. There were no significant between-group differences in postoperative complications, readmissions, or second operations.

"That ability to remove polyps with LACP was as effective and safe as the standard laparoscopic hemicolectomy ... and patients were discharged from the hospital earlier. We think this is a very exciting change in how we deal with these difficult to remove colon polyps," said Dr. Jonathan Buscaglia, director of advanced endoscopy at Stony Brook (N.Y.) University.

There are a few case series in the literature about the technique, but uptake seems to have been slow so far. "I think the biggest roadblock is the ability of a surgeon to coordinate with a gastroenterologist. You need good working relationships, and schedules able to accommodate [both]. That’s not always easy, depending on where one works," Dr. Buscaglia said at a teleconference in advance of the annual Digestive Disease Week.

The patients in the trial had benign polyps with lift signs and generally tubular or tubulovillous adenomas. The groups were evenly matched for age, sex, body mass index, American Society of Anesthesiologists physical status, and previous abdominal surgery, plus polyp morphology, location, size, and histology.

It’s too soon after the procedures for serial surveillance colonoscopies and to know if any of the patients went on to develop cancer after their operations.

The right side is technically an easier place for laparoscopic surgeons to operate; with the left colon, operators have to worry more about diverticulitis, scarring, and tight anatomy. Even so, LACP may still be useful. "We are looking forward to conducting" a larger, possibly multicenter study on its application to polyps "in all areas of the colon," Dr. Buscaglia said.

The investigators have no disclosures.

[email protected]

Alterations in taste and smell, including aversions to many foods, are common following gastric bypass surgery, according to a report published online in Obesity Surgery.

Most of the literature regarding gastric bypass outcomes has focused on the safety and efficacy of the procedures, while patient-reported measures such as changes in taste and smell have received comparatively little attention. The few studies that have examined this issue report high rates of alterations in taste, smell, and food preferences, affecting anywhere from 45% to 82% of patients; these changes were transient in most patients but persisted long term in approximately one-third of those affected, said Dr. Lisa Graham of the department of surgery at Leicester (England) Royal Infirmary and her associates.

© Siri Stafford/Thinkstock

They assessed such changes in a cohort study involving 103 patients who underwent Roux-en-Y gastric bypass surgery at their hospital during a 12-year period and completed a detailed questionnaire a median of 19 months afterward (range, 1-120 months). The median age of these participants was 45 years (range, 23-63 years).

A total of 75 patients (73%) reported a change in their sense of taste and 43 (42%) reported a change in their sense of smell after surgery. There was no clear pattern of change: Some patients reported that foods smelled or tasted stronger while some said they were blander, and the types of foods affected included meats, fish, starches, vegetables, fruit, dairy, and sweets, the investigators said (Obes. Surg. 2014 March 8 [doi:10.1007/s11695-014-1221-2]).

Many said that they now have strong aversions to certain foods, with 33% reporting that they could no longer tolerate the smell or taste of meats including beef, chicken, lamb, and pork. A total of 12% said that they were averse to the smell or taste of pasta, rice, and breads, and 11% said they couldn’t tolerate the smell or taste of milk, yogurt, cheese, or eggs.

The mechanism underlying these alterations is not yet known. "It is likely that a combination of gut hormone and central nervous system effects accounts for the observed changes in sensory function after weight loss surgery," Dr. Graham and her associates said.

The investigators had no relevant conflicts of interest.

Alterations in taste and smell, including aversions to many foods, are common following gastric bypass surgery, according to a report published online in Obesity Surgery.

Most of the literature regarding gastric bypass outcomes has focused on the safety and efficacy of the procedures, while patient-reported measures such as changes in taste and smell have received comparatively little attention. The few studies that have examined this issue report high rates of alterations in taste, smell, and food preferences, affecting anywhere from 45% to 82% of patients; these changes were transient in most patients but persisted long term in approximately one-third of those affected, said Dr. Lisa Graham of the department of surgery at Leicester (England) Royal Infirmary and her associates.

© Siri Stafford/Thinkstock

They assessed such changes in a cohort study involving 103 patients who underwent Roux-en-Y gastric bypass surgery at their hospital during a 12-year period and completed a detailed questionnaire a median of 19 months afterward (range, 1-120 months). The median age of these participants was 45 years (range, 23-63 years).

A total of 75 patients (73%) reported a change in their sense of taste and 43 (42%) reported a change in their sense of smell after surgery. There was no clear pattern of change: Some patients reported that foods smelled or tasted stronger while some said they were blander, and the types of foods affected included meats, fish, starches, vegetables, fruit, dairy, and sweets, the investigators said (Obes. Surg. 2014 March 8 [doi:10.1007/s11695-014-1221-2]).

Many said that they now have strong aversions to certain foods, with 33% reporting that they could no longer tolerate the smell or taste of meats including beef, chicken, lamb, and pork. A total of 12% said that they were averse to the smell or taste of pasta, rice, and breads, and 11% said they couldn’t tolerate the smell or taste of milk, yogurt, cheese, or eggs.

The mechanism underlying these alterations is not yet known. "It is likely that a combination of gut hormone and central nervous system effects accounts for the observed changes in sensory function after weight loss surgery," Dr. Graham and her associates said.

The investigators had no relevant conflicts of interest.

Alterations in taste and smell, including aversions to many foods, are common following gastric bypass surgery, according to a report published online in Obesity Surgery.

Most of the literature regarding gastric bypass outcomes has focused on the safety and efficacy of the procedures, while patient-reported measures such as changes in taste and smell have received comparatively little attention. The few studies that have examined this issue report high rates of alterations in taste, smell, and food preferences, affecting anywhere from 45% to 82% of patients; these changes were transient in most patients but persisted long term in approximately one-third of those affected, said Dr. Lisa Graham of the department of surgery at Leicester (England) Royal Infirmary and her associates.

© Siri Stafford/Thinkstock

They assessed such changes in a cohort study involving 103 patients who underwent Roux-en-Y gastric bypass surgery at their hospital during a 12-year period and completed a detailed questionnaire a median of 19 months afterward (range, 1-120 months). The median age of these participants was 45 years (range, 23-63 years).

A total of 75 patients (73%) reported a change in their sense of taste and 43 (42%) reported a change in their sense of smell after surgery. There was no clear pattern of change: Some patients reported that foods smelled or tasted stronger while some said they were blander, and the types of foods affected included meats, fish, starches, vegetables, fruit, dairy, and sweets, the investigators said (Obes. Surg. 2014 March 8 [doi:10.1007/s11695-014-1221-2]).

Many said that they now have strong aversions to certain foods, with 33% reporting that they could no longer tolerate the smell or taste of meats including beef, chicken, lamb, and pork. A total of 12% said that they were averse to the smell or taste of pasta, rice, and breads, and 11% said they couldn’t tolerate the smell or taste of milk, yogurt, cheese, or eggs.

The mechanism underlying these alterations is not yet known. "It is likely that a combination of gut hormone and central nervous system effects accounts for the observed changes in sensory function after weight loss surgery," Dr. Graham and her associates said.

The investigators had no relevant conflicts of interest.

BOSTON – Though progress is being made in reducing surgery for diverticulitis, one in three elective colectomies failed to meet current indications in a prospective study.

Among 1,102 patients in Washington state with an episode-based indication for elective surgery, the proportion with three or more prior episodes of diverticulitis increased from 42% in 2010 to 58% in 2012 (P = .007), while the proportion failing to meet either complication- or episode-based indications decreased from 41.3% to 29.6% (P = .002).

"Still, there remains a significant and persistent portion of cases being done in Washington that do not meet established guidelines," Dr. Vlad V. Simianu said at the annual meeting of the American Surgical Association.

The study involved 2,031 patients having elective resection for diverticulitis in 2010-2012 in 49 hospitals in Washington state’s voluntary Surgical Care and Outcomes Assessment Program (SCOAP), which captures about 80% of the surgical volume in the state. Their mean age was 58.8 years, 24% were younger than 50 years, and most were healthy, with only 27% having a Charlson Comorbidity Index score of 1 or more.

Patrice Wendling/Frontline Medical News

Washington has seen a dramatic threefold increase in elective colectomy for diverticulitis over the last 13 years, despite evolving recommendations, observed Dr. Simianu, a general surgery resident and research fellow at the University of Washington, Seattle. The 2006 American Society of Colon and Rectal Surgeons (ASCRS) guidelines, which were used for the study end points, said elective surgery can be safely delayed until three or more acute episodes of uncomplicated diverticulitis. The ASCRS just updated its guidelines again (Dis. Colon Rectum 2014;57:284-94) and now strongly recommend that the decision to proceed to elective colectomy after recovery from uncomplicated acute diverticulitis "be individualized."

Among all 2,031 patients in the study, a clinical indication for surgery was present in 23.3% (chronic fistula 10.5%, stricture 5.4%, bleeding 2.4%, and other 5%), while 55% of the 1,102 patients with an episode-based indication had three or more episodes.

In 2010, 22% of all patients had at least three prior episodes, 17% had chronic complications, and 23% had neither. This compares with 37.7%, 18%.6%, and 16.7% in 2012.

Possible explanations for the rise in guideline-concordant cases are that surgeons are documenting their indications more carefully or are delaying more operations until three or more acute episodes, Dr. Simianu said. Indeed, there was a significant decrease in the number of cases with missing indications in the clinical record over the study period (38% vs. 27%; P = .007).

The persistence of cases not meeting indications could be because the adoption of laparoscopy has lowered the threshold for surgeons to offer colectomy, similar to what has happened with laparoscopic cholecystectomy, he said. A laparoscopic operation was performed in 60% of the patients.

Other possible explanations are that the guidelines don’t capture all relevant indications, like persistent symptoms or pain, or that evolving evidence and guidelines are forcing some surgeons to wait before they change their practice, Dr. Simianu said.

"Nonetheless, we view this as an educational opportunity in our state to give feedback to surgeons in our network," he said.

Notably, the rate of elective and emergency resections per year did not increase significantly over the study period at 28 high-volume hospitals, performing at least 10 colectomies yearly. Data, however, were incomplete or missing, in 30.4% of cases.

Discussant Dr. Conor Delaney, chief of colorectal surgery at University Hospitals Case Medical Center, Cleveland, said it was good to see that the percentage of cases performed for three or more episodes rose across all age groups in the final year of the study, suggesting that the SCOAP intervention is likely working.

"It is still shocking to see 30 or 40% of cases being performed for fewer than three attacks," he said, adding that the 30% of patients who had surgery without appropriate indications "may really be, very much a best-case scenario."

He also asked whether the investigators could identify hospitals inside and outside SCOAP that were less likely to follow guidelines and how they dealt with patients who may have had appropriate single-attack surgery because of nonresolution of symptoms or inadequate drainage.

Dr. Simianu said it wasn’t possible to determine indications for hospitals outside the SCOAP network, but that participating hospitals followed a normal distribution. High-volume hospitals were "sort of middle of the road," while four or five low-volume hospitals were outliers and never or always met indications.

In response to the second query, he said their clinical indications included an "other" category that captured appropriate first-attack patients and that about 1% of surgery was performed for an abscess.

The next phase of research will be to go into surgeons’ offices to speak with surgeons and patients to try and quantify the missing indications, Dr. Simianu said.

Dr. Simianu reported funding from the National Institute of Diabetes and Digestive and Kidney Disease, the Agency for Healthcare Research & Quality, and Life Sciences Discovery Fund. Three co-authors reported serving as an advisor, consultant, or speaker for pharmaceutical and device firms.

The complete manuscript of this study and its presentation at the American Surgical Association’s 134th Annual Meeting, April 2014, in Boston, Mass., is anticipated to be published in the Annals of Surgery, pending editorial review.

[email protected]

BOSTON – Though progress is being made in reducing surgery for diverticulitis, one in three elective colectomies failed to meet current indications in a prospective study.

Among 1,102 patients in Washington state with an episode-based indication for elective surgery, the proportion with three or more prior episodes of diverticulitis increased from 42% in 2010 to 58% in 2012 (P = .007), while the proportion failing to meet either complication- or episode-based indications decreased from 41.3% to 29.6% (P = .002).

"Still, there remains a significant and persistent portion of cases being done in Washington that do not meet established guidelines," Dr. Vlad V. Simianu said at the annual meeting of the American Surgical Association.

The study involved 2,031 patients having elective resection for diverticulitis in 2010-2012 in 49 hospitals in Washington state’s voluntary Surgical Care and Outcomes Assessment Program (SCOAP), which captures about 80% of the surgical volume in the state. Their mean age was 58.8 years, 24% were younger than 50 years, and most were healthy, with only 27% having a Charlson Comorbidity Index score of 1 or more.

Patrice Wendling/Frontline Medical News

Washington has seen a dramatic threefold increase in elective colectomy for diverticulitis over the last 13 years, despite evolving recommendations, observed Dr. Simianu, a general surgery resident and research fellow at the University of Washington, Seattle. The 2006 American Society of Colon and Rectal Surgeons (ASCRS) guidelines, which were used for the study end points, said elective surgery can be safely delayed until three or more acute episodes of uncomplicated diverticulitis. The ASCRS just updated its guidelines again (Dis. Colon Rectum 2014;57:284-94) and now strongly recommend that the decision to proceed to elective colectomy after recovery from uncomplicated acute diverticulitis "be individualized."

Among all 2,031 patients in the study, a clinical indication for surgery was present in 23.3% (chronic fistula 10.5%, stricture 5.4%, bleeding 2.4%, and other 5%), while 55% of the 1,102 patients with an episode-based indication had three or more episodes.

In 2010, 22% of all patients had at least three prior episodes, 17% had chronic complications, and 23% had neither. This compares with 37.7%, 18%.6%, and 16.7% in 2012.

Possible explanations for the rise in guideline-concordant cases are that surgeons are documenting their indications more carefully or are delaying more operations until three or more acute episodes, Dr. Simianu said. Indeed, there was a significant decrease in the number of cases with missing indications in the clinical record over the study period (38% vs. 27%; P = .007).

The persistence of cases not meeting indications could be because the adoption of laparoscopy has lowered the threshold for surgeons to offer colectomy, similar to what has happened with laparoscopic cholecystectomy, he said. A laparoscopic operation was performed in 60% of the patients.

Other possible explanations are that the guidelines don’t capture all relevant indications, like persistent symptoms or pain, or that evolving evidence and guidelines are forcing some surgeons to wait before they change their practice, Dr. Simianu said.

"Nonetheless, we view this as an educational opportunity in our state to give feedback to surgeons in our network," he said.

Notably, the rate of elective and emergency resections per year did not increase significantly over the study period at 28 high-volume hospitals, performing at least 10 colectomies yearly. Data, however, were incomplete or missing, in 30.4% of cases.

Discussant Dr. Conor Delaney, chief of colorectal surgery at University Hospitals Case Medical Center, Cleveland, said it was good to see that the percentage of cases performed for three or more episodes rose across all age groups in the final year of the study, suggesting that the SCOAP intervention is likely working.

"It is still shocking to see 30 or 40% of cases being performed for fewer than three attacks," he said, adding that the 30% of patients who had surgery without appropriate indications "may really be, very much a best-case scenario."

He also asked whether the investigators could identify hospitals inside and outside SCOAP that were less likely to follow guidelines and how they dealt with patients who may have had appropriate single-attack surgery because of nonresolution of symptoms or inadequate drainage.

Dr. Simianu said it wasn’t possible to determine indications for hospitals outside the SCOAP network, but that participating hospitals followed a normal distribution. High-volume hospitals were "sort of middle of the road," while four or five low-volume hospitals were outliers and never or always met indications.

In response to the second query, he said their clinical indications included an "other" category that captured appropriate first-attack patients and that about 1% of surgery was performed for an abscess.

The next phase of research will be to go into surgeons’ offices to speak with surgeons and patients to try and quantify the missing indications, Dr. Simianu said.

Dr. Simianu reported funding from the National Institute of Diabetes and Digestive and Kidney Disease, the Agency for Healthcare Research & Quality, and Life Sciences Discovery Fund. Three co-authors reported serving as an advisor, consultant, or speaker for pharmaceutical and device firms.

The complete manuscript of this study and its presentation at the American Surgical Association’s 134th Annual Meeting, April 2014, in Boston, Mass., is anticipated to be published in the Annals of Surgery, pending editorial review.

[email protected]

BOSTON – Though progress is being made in reducing surgery for diverticulitis, one in three elective colectomies failed to meet current indications in a prospective study.

Among 1,102 patients in Washington state with an episode-based indication for elective surgery, the proportion with three or more prior episodes of diverticulitis increased from 42% in 2010 to 58% in 2012 (P = .007), while the proportion failing to meet either complication- or episode-based indications decreased from 41.3% to 29.6% (P = .002).

"Still, there remains a significant and persistent portion of cases being done in Washington that do not meet established guidelines," Dr. Vlad V. Simianu said at the annual meeting of the American Surgical Association.

The study involved 2,031 patients having elective resection for diverticulitis in 2010-2012 in 49 hospitals in Washington state’s voluntary Surgical Care and Outcomes Assessment Program (SCOAP), which captures about 80% of the surgical volume in the state. Their mean age was 58.8 years, 24% were younger than 50 years, and most were healthy, with only 27% having a Charlson Comorbidity Index score of 1 or more.

Patrice Wendling/Frontline Medical News

Washington has seen a dramatic threefold increase in elective colectomy for diverticulitis over the last 13 years, despite evolving recommendations, observed Dr. Simianu, a general surgery resident and research fellow at the University of Washington, Seattle. The 2006 American Society of Colon and Rectal Surgeons (ASCRS) guidelines, which were used for the study end points, said elective surgery can be safely delayed until three or more acute episodes of uncomplicated diverticulitis. The ASCRS just updated its guidelines again (Dis. Colon Rectum 2014;57:284-94) and now strongly recommend that the decision to proceed to elective colectomy after recovery from uncomplicated acute diverticulitis "be individualized."

Among all 2,031 patients in the study, a clinical indication for surgery was present in 23.3% (chronic fistula 10.5%, stricture 5.4%, bleeding 2.4%, and other 5%), while 55% of the 1,102 patients with an episode-based indication had three or more episodes.

In 2010, 22% of all patients had at least three prior episodes, 17% had chronic complications, and 23% had neither. This compares with 37.7%, 18%.6%, and 16.7% in 2012.

Possible explanations for the rise in guideline-concordant cases are that surgeons are documenting their indications more carefully or are delaying more operations until three or more acute episodes, Dr. Simianu said. Indeed, there was a significant decrease in the number of cases with missing indications in the clinical record over the study period (38% vs. 27%; P = .007).

The persistence of cases not meeting indications could be because the adoption of laparoscopy has lowered the threshold for surgeons to offer colectomy, similar to what has happened with laparoscopic cholecystectomy, he said. A laparoscopic operation was performed in 60% of the patients.

Other possible explanations are that the guidelines don’t capture all relevant indications, like persistent symptoms or pain, or that evolving evidence and guidelines are forcing some surgeons to wait before they change their practice, Dr. Simianu said.

"Nonetheless, we view this as an educational opportunity in our state to give feedback to surgeons in our network," he said.

Notably, the rate of elective and emergency resections per year did not increase significantly over the study period at 28 high-volume hospitals, performing at least 10 colectomies yearly. Data, however, were incomplete or missing, in 30.4% of cases.

Discussant Dr. Conor Delaney, chief of colorectal surgery at University Hospitals Case Medical Center, Cleveland, said it was good to see that the percentage of cases performed for three or more episodes rose across all age groups in the final year of the study, suggesting that the SCOAP intervention is likely working.

"It is still shocking to see 30 or 40% of cases being performed for fewer than three attacks," he said, adding that the 30% of patients who had surgery without appropriate indications "may really be, very much a best-case scenario."

He also asked whether the investigators could identify hospitals inside and outside SCOAP that were less likely to follow guidelines and how they dealt with patients who may have had appropriate single-attack surgery because of nonresolution of symptoms or inadequate drainage.

Dr. Simianu said it wasn’t possible to determine indications for hospitals outside the SCOAP network, but that participating hospitals followed a normal distribution. High-volume hospitals were "sort of middle of the road," while four or five low-volume hospitals were outliers and never or always met indications.

In response to the second query, he said their clinical indications included an "other" category that captured appropriate first-attack patients and that about 1% of surgery was performed for an abscess.

The next phase of research will be to go into surgeons’ offices to speak with surgeons and patients to try and quantify the missing indications, Dr. Simianu said.

Dr. Simianu reported funding from the National Institute of Diabetes and Digestive and Kidney Disease, the Agency for Healthcare Research & Quality, and Life Sciences Discovery Fund. Three co-authors reported serving as an advisor, consultant, or speaker for pharmaceutical and device firms.

The complete manuscript of this study and its presentation at the American Surgical Association’s 134th Annual Meeting, April 2014, in Boston, Mass., is anticipated to be published in the Annals of Surgery, pending editorial review.

[email protected]

BOSTON – The risks of readmission and emergency surgery are low for patients with acute diverticulitis initially managed nonoperatively, a population-based, competing risk analysis found.

At a median of 3.9 years (range, 1.7-6.4 years) after discharge among 14,124 patients, only 8% required urgent readmission. Of these, 22% went on to urgent surgery and 20%, to elective surgery after additional episodes.

Among the remaining 12,981 patients with no urgent readmissions, 9% went on to elective surgery, 13% died of other causes, and 78% had no events in follow-up, Dr. Debbie Li said at the annual meeting of the American Surgical Association.

Patrice Wendling/Frontline Medical News

The 5-year cumulative incidence was 9% for readmission, 1.9% for emergency surgery, and 14.1% for all-cause mortality.

"Elective colectomy may not be warranted for the majority of patients in the absence of chronic symptoms or multiple frequent recurrences," she said.

Elective colectomy has traditionally been recommended for patients at high risk for future recurrence and emergency surgery based on the indications of age less than 50 years, complicated disease including perforation and abscess, and two or more episodes of uncomplicated disease. Evidence is building, however, to challenge these indications, and guidelines are evolving, said Dr. Li, a general surgery resident at the University of Toronto.

The current study used administrative data to identify all patients in Ontario, Canada, treated nonoperatively at first hospitalization for diverticulitis from 2002 to 2012. Time-to-event and competing-risk regression analyses were performed, with data adjusted for such potential confounders as sex, medical comorbidity, neighborhood income quintile, rural residency, and calendar year of index admission.

Data are limited on the natural history of diverticulitis, and the few population-based studies that have been conducted have not accounted for competing risks such as elective colectomy or death, Dr. Li said.

The patients’ median age was 59 years, 79% had uncomplicated index disease, 18% had complicated disease (abscess, fistula, and perforation) with no abscess drain, and 3% had complicated disease with an abscess drain.

Young patients had more readmissions than those 50 years and older (10.5% vs. 8.4%; P less than .001), but not more emergency surgery (1.8% vs. 2.0%; P = .52), she said.

For patients older than 50 years, the risk of death by other causes was 10 times the risk of an emergency surgery for diverticulitis (19.5% vs. 2%).

Patients with complicated rather than uncomplicated index disease had more readmissions (12% vs. 8.2%; P less than .001) and urgent surgery (4.3% vs. 1.4%; P less than .001).

In adjusted analyses, young age was associated with more readmissions (hazard ratio, 1.24), but not subsequent emergency surgery (HR, 0.83). Complicated disease (HR, 3.15) and multiple recurrences (HR, 2.41) predicted an increased risk for emergency surgery.

"Young age, complicated disease, and multiple recurrences do infer increased relative risk, but the vast majority (85%) of such patients remain recurrence free," Dr. Li said.

Invited discussant Dr. David Schoetz, professor of surgery, Tufts University, Boston, said, "While it’s reassuring that even complicated diverticulitis can be safely managed without subsequent operation, there still must be a subgroup who should be offered early surgery."

With disease severity more common in younger patients and overall mortality less than 1%, perhaps aggressive surgery would be justified in those younger than 50 years, he suggested.

Dr. Li responded that an administrative database is unable to capture clinical nuances such as which patients had ongoing symptoms, chronic persistent disease, or reduced quality of life, and that a prospective trial would be needed to identify which subgroup of patients will need aggressive surgery.

Older patients, those with more complicated disease, and those with greater medical comorbidities are more likely to undergo urgent surgery, according to ongoing analyses of roughly 4,000 patients, treated during the same time period, but excluded from the current analysis because they underwent surgery at index admission. Previously published work also suggests that patients with a higher body mass index have poorer outcomes.

A recent systematic review of diverticulitis surgery (JAMA Surg. 2014;149:292-303) reported that complicated recurrence after an episode of uncomplicated diverticulitis is rare, occurring in less than 5% of cases. The authors called for existing guidelines to be updated and said that decisions to proceed with elective surgery should be based instead on patient-reported frequency and severity of symptoms.

The complete manuscript of this study and its presentation at the American Surgical Association’s 134th annual meeting, April 2014, in Boston, is anticipated to be published in the Annals of Surgery, pending editorial review.

Dr. Li and her coauthors reported no relevant financial disclosures.

[email protected]

BOSTON – The risks of readmission and emergency surgery are low for patients with acute diverticulitis initially managed nonoperatively, a population-based, competing risk analysis found.

At a median of 3.9 years (range, 1.7-6.4 years) after discharge among 14,124 patients, only 8% required urgent readmission. Of these, 22% went on to urgent surgery and 20%, to elective surgery after additional episodes.

Among the remaining 12,981 patients with no urgent readmissions, 9% went on to elective surgery, 13% died of other causes, and 78% had no events in follow-up, Dr. Debbie Li said at the annual meeting of the American Surgical Association.

Patrice Wendling/Frontline Medical News

The 5-year cumulative incidence was 9% for readmission, 1.9% for emergency surgery, and 14.1% for all-cause mortality.

"Elective colectomy may not be warranted for the majority of patients in the absence of chronic symptoms or multiple frequent recurrences," she said.

Elective colectomy has traditionally been recommended for patients at high risk for future recurrence and emergency surgery based on the indications of age less than 50 years, complicated disease including perforation and abscess, and two or more episodes of uncomplicated disease. Evidence is building, however, to challenge these indications, and guidelines are evolving, said Dr. Li, a general surgery resident at the University of Toronto.

The current study used administrative data to identify all patients in Ontario, Canada, treated nonoperatively at first hospitalization for diverticulitis from 2002 to 2012. Time-to-event and competing-risk regression analyses were performed, with data adjusted for such potential confounders as sex, medical comorbidity, neighborhood income quintile, rural residency, and calendar year of index admission.

Data are limited on the natural history of diverticulitis, and the few population-based studies that have been conducted have not accounted for competing risks such as elective colectomy or death, Dr. Li said.

The patients’ median age was 59 years, 79% had uncomplicated index disease, 18% had complicated disease (abscess, fistula, and perforation) with no abscess drain, and 3% had complicated disease with an abscess drain.

Young patients had more readmissions than those 50 years and older (10.5% vs. 8.4%; P less than .001), but not more emergency surgery (1.8% vs. 2.0%; P = .52), she said.

For patients older than 50 years, the risk of death by other causes was 10 times the risk of an emergency surgery for diverticulitis (19.5% vs. 2%).

Patients with complicated rather than uncomplicated index disease had more readmissions (12% vs. 8.2%; P less than .001) and urgent surgery (4.3% vs. 1.4%; P less than .001).

In adjusted analyses, young age was associated with more readmissions (hazard ratio, 1.24), but not subsequent emergency surgery (HR, 0.83). Complicated disease (HR, 3.15) and multiple recurrences (HR, 2.41) predicted an increased risk for emergency surgery.

"Young age, complicated disease, and multiple recurrences do infer increased relative risk, but the vast majority (85%) of such patients remain recurrence free," Dr. Li said.

Invited discussant Dr. David Schoetz, professor of surgery, Tufts University, Boston, said, "While it’s reassuring that even complicated diverticulitis can be safely managed without subsequent operation, there still must be a subgroup who should be offered early surgery."

With disease severity more common in younger patients and overall mortality less than 1%, perhaps aggressive surgery would be justified in those younger than 50 years, he suggested.

Dr. Li responded that an administrative database is unable to capture clinical nuances such as which patients had ongoing symptoms, chronic persistent disease, or reduced quality of life, and that a prospective trial would be needed to identify which subgroup of patients will need aggressive surgery.

Older patients, those with more complicated disease, and those with greater medical comorbidities are more likely to undergo urgent surgery, according to ongoing analyses of roughly 4,000 patients, treated during the same time period, but excluded from the current analysis because they underwent surgery at index admission. Previously published work also suggests that patients with a higher body mass index have poorer outcomes.

A recent systematic review of diverticulitis surgery (JAMA Surg. 2014;149:292-303) reported that complicated recurrence after an episode of uncomplicated diverticulitis is rare, occurring in less than 5% of cases. The authors called for existing guidelines to be updated and said that decisions to proceed with elective surgery should be based instead on patient-reported frequency and severity of symptoms.

The complete manuscript of this study and its presentation at the American Surgical Association’s 134th annual meeting, April 2014, in Boston, is anticipated to be published in the Annals of Surgery, pending editorial review.

Dr. Li and her coauthors reported no relevant financial disclosures.

[email protected]

BOSTON – The risks of readmission and emergency surgery are low for patients with acute diverticulitis initially managed nonoperatively, a population-based, competing risk analysis found.

At a median of 3.9 years (range, 1.7-6.4 years) after discharge among 14,124 patients, only 8% required urgent readmission. Of these, 22% went on to urgent surgery and 20%, to elective surgery after additional episodes.

Among the remaining 12,981 patients with no urgent readmissions, 9% went on to elective surgery, 13% died of other causes, and 78% had no events in follow-up, Dr. Debbie Li said at the annual meeting of the American Surgical Association.

Patrice Wendling/Frontline Medical News

The 5-year cumulative incidence was 9% for readmission, 1.9% for emergency surgery, and 14.1% for all-cause mortality.

"Elective colectomy may not be warranted for the majority of patients in the absence of chronic symptoms or multiple frequent recurrences," she said.

Elective colectomy has traditionally been recommended for patients at high risk for future recurrence and emergency surgery based on the indications of age less than 50 years, complicated disease including perforation and abscess, and two or more episodes of uncomplicated disease. Evidence is building, however, to challenge these indications, and guidelines are evolving, said Dr. Li, a general surgery resident at the University of Toronto.

The current study used administrative data to identify all patients in Ontario, Canada, treated nonoperatively at first hospitalization for diverticulitis from 2002 to 2012. Time-to-event and competing-risk regression analyses were performed, with data adjusted for such potential confounders as sex, medical comorbidity, neighborhood income quintile, rural residency, and calendar year of index admission.

Data are limited on the natural history of diverticulitis, and the few population-based studies that have been conducted have not accounted for competing risks such as elective colectomy or death, Dr. Li said.

The patients’ median age was 59 years, 79% had uncomplicated index disease, 18% had complicated disease (abscess, fistula, and perforation) with no abscess drain, and 3% had complicated disease with an abscess drain.

Young patients had more readmissions than those 50 years and older (10.5% vs. 8.4%; P less than .001), but not more emergency surgery (1.8% vs. 2.0%; P = .52), she said.

For patients older than 50 years, the risk of death by other causes was 10 times the risk of an emergency surgery for diverticulitis (19.5% vs. 2%).

Patients with complicated rather than uncomplicated index disease had more readmissions (12% vs. 8.2%; P less than .001) and urgent surgery (4.3% vs. 1.4%; P less than .001).

In adjusted analyses, young age was associated with more readmissions (hazard ratio, 1.24), but not subsequent emergency surgery (HR, 0.83). Complicated disease (HR, 3.15) and multiple recurrences (HR, 2.41) predicted an increased risk for emergency surgery.

"Young age, complicated disease, and multiple recurrences do infer increased relative risk, but the vast majority (85%) of such patients remain recurrence free," Dr. Li said.

Invited discussant Dr. David Schoetz, professor of surgery, Tufts University, Boston, said, "While it’s reassuring that even complicated diverticulitis can be safely managed without subsequent operation, there still must be a subgroup who should be offered early surgery."

With disease severity more common in younger patients and overall mortality less than 1%, perhaps aggressive surgery would be justified in those younger than 50 years, he suggested.

Dr. Li responded that an administrative database is unable to capture clinical nuances such as which patients had ongoing symptoms, chronic persistent disease, or reduced quality of life, and that a prospective trial would be needed to identify which subgroup of patients will need aggressive surgery.

Older patients, those with more complicated disease, and those with greater medical comorbidities are more likely to undergo urgent surgery, according to ongoing analyses of roughly 4,000 patients, treated during the same time period, but excluded from the current analysis because they underwent surgery at index admission. Previously published work also suggests that patients with a higher body mass index have poorer outcomes.

A recent systematic review of diverticulitis surgery (JAMA Surg. 2014;149:292-303) reported that complicated recurrence after an episode of uncomplicated diverticulitis is rare, occurring in less than 5% of cases. The authors called for existing guidelines to be updated and said that decisions to proceed with elective surgery should be based instead on patient-reported frequency and severity of symptoms.

The complete manuscript of this study and its presentation at the American Surgical Association’s 134th annual meeting, April 2014, in Boston, is anticipated to be published in the Annals of Surgery, pending editorial review.

Dr. Li and her coauthors reported no relevant financial disclosures.

[email protected]