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One Veterans Affairs Medical Center’s Experience with Colorectal Carcinoma
Purpose: This study was performed in order to evaluate if patients were offered or received appropriate workup and treatment according to colon cancer stage. Rectal cancer was diagnosed in 3 and colon cancer in 81 patients over 5 years. Patients were diagnosed with stage I in 26 cases (30%), stage II in 21 cases (25%), stage III in 15 cases (17.9 %), stage IV in 21 cases (25%), and 1 patient TIS (0.1%).
Methods: The study was designed as a retrospective single institution (JJP VAMC ) chart review of all patients who were diagnosed with colorectal cancer from 1/1/2008-12/31/2012 which included a total of 86 patients. NCCN guidelines 2014 were used as reference for workup, treatment and surveillance according to TNM classification. Data elements included the following: pre-operative CEA/ CT chest, abdomen, pelvis, colonoscopy; surgical resection and chemotherapy; follow up CEA, CT, colonoscopy. Excluded patients included those who eloped or were permanently lost follow up.
Results: Complete workup was done in 64% cases, incomplete in 36% cases without significant difference from 2008-2012. Incomplete workup defined as: missing CT chest (in 100% of those cases CXR was done and without mass suggestive for metastasis) 11 cases, CEA 3 cases, CT abdomen, pelvis and chest in 1 case, and both CT and CEA in 7 cases. Stage IV colorectal carcinoma patients were tested for KRAS/BRAF in 10 cases (47.6%; 3 KRAS positive, 7 negative) and not tested in 11 cases (52.4%). However, there has been progressive improvement in following guidelines for testing of KRAS from 2008-2012 from 45% (2008), 50% (2009), 75% (2010), 75% (2011) to 100% in 2012.
Treatment was found to have 100% compliance with NCCN guidelines according to TNM classification. Surveillance according to NCCN guidelines was in full compliance in 59 cases (77.7%), incomplete follow up in 17 cases (22.3%) with missing CT chest or CEA, and from which only 1 patient was missing follow up colonoscopy (1.3%).
Conclusions: Complete compliance with 100% appropriate therapy was offered to veterans at one VA according to NCCN guidelines from 2008-2012. Aside from omitting CT chest when replaced by normal CXR, workup was complete in 90% of cases. Improvement in testing for KRAS/BRAF in stage IV colorectal carcinoma was done over the years with achievement of 100% in 2012. Surveillance was satisfactory as incomplete follow up was found in only 20%. Given the future emphasis on cancer survivorship, a focus on adherence to surveillance should be a strong part of the VA’s future goals.
Purpose: This study was performed in order to evaluate if patients were offered or received appropriate workup and treatment according to colon cancer stage. Rectal cancer was diagnosed in 3 and colon cancer in 81 patients over 5 years. Patients were diagnosed with stage I in 26 cases (30%), stage II in 21 cases (25%), stage III in 15 cases (17.9 %), stage IV in 21 cases (25%), and 1 patient TIS (0.1%).
Methods: The study was designed as a retrospective single institution (JJP VAMC ) chart review of all patients who were diagnosed with colorectal cancer from 1/1/2008-12/31/2012 which included a total of 86 patients. NCCN guidelines 2014 were used as reference for workup, treatment and surveillance according to TNM classification. Data elements included the following: pre-operative CEA/ CT chest, abdomen, pelvis, colonoscopy; surgical resection and chemotherapy; follow up CEA, CT, colonoscopy. Excluded patients included those who eloped or were permanently lost follow up.
Results: Complete workup was done in 64% cases, incomplete in 36% cases without significant difference from 2008-2012. Incomplete workup defined as: missing CT chest (in 100% of those cases CXR was done and without mass suggestive for metastasis) 11 cases, CEA 3 cases, CT abdomen, pelvis and chest in 1 case, and both CT and CEA in 7 cases. Stage IV colorectal carcinoma patients were tested for KRAS/BRAF in 10 cases (47.6%; 3 KRAS positive, 7 negative) and not tested in 11 cases (52.4%). However, there has been progressive improvement in following guidelines for testing of KRAS from 2008-2012 from 45% (2008), 50% (2009), 75% (2010), 75% (2011) to 100% in 2012.
Treatment was found to have 100% compliance with NCCN guidelines according to TNM classification. Surveillance according to NCCN guidelines was in full compliance in 59 cases (77.7%), incomplete follow up in 17 cases (22.3%) with missing CT chest or CEA, and from which only 1 patient was missing follow up colonoscopy (1.3%).
Conclusions: Complete compliance with 100% appropriate therapy was offered to veterans at one VA according to NCCN guidelines from 2008-2012. Aside from omitting CT chest when replaced by normal CXR, workup was complete in 90% of cases. Improvement in testing for KRAS/BRAF in stage IV colorectal carcinoma was done over the years with achievement of 100% in 2012. Surveillance was satisfactory as incomplete follow up was found in only 20%. Given the future emphasis on cancer survivorship, a focus on adherence to surveillance should be a strong part of the VA’s future goals.
Purpose: This study was performed in order to evaluate if patients were offered or received appropriate workup and treatment according to colon cancer stage. Rectal cancer was diagnosed in 3 and colon cancer in 81 patients over 5 years. Patients were diagnosed with stage I in 26 cases (30%), stage II in 21 cases (25%), stage III in 15 cases (17.9 %), stage IV in 21 cases (25%), and 1 patient TIS (0.1%).
Methods: The study was designed as a retrospective single institution (JJP VAMC ) chart review of all patients who were diagnosed with colorectal cancer from 1/1/2008-12/31/2012 which included a total of 86 patients. NCCN guidelines 2014 were used as reference for workup, treatment and surveillance according to TNM classification. Data elements included the following: pre-operative CEA/ CT chest, abdomen, pelvis, colonoscopy; surgical resection and chemotherapy; follow up CEA, CT, colonoscopy. Excluded patients included those who eloped or were permanently lost follow up.
Results: Complete workup was done in 64% cases, incomplete in 36% cases without significant difference from 2008-2012. Incomplete workup defined as: missing CT chest (in 100% of those cases CXR was done and without mass suggestive for metastasis) 11 cases, CEA 3 cases, CT abdomen, pelvis and chest in 1 case, and both CT and CEA in 7 cases. Stage IV colorectal carcinoma patients were tested for KRAS/BRAF in 10 cases (47.6%; 3 KRAS positive, 7 negative) and not tested in 11 cases (52.4%). However, there has been progressive improvement in following guidelines for testing of KRAS from 2008-2012 from 45% (2008), 50% (2009), 75% (2010), 75% (2011) to 100% in 2012.
Treatment was found to have 100% compliance with NCCN guidelines according to TNM classification. Surveillance according to NCCN guidelines was in full compliance in 59 cases (77.7%), incomplete follow up in 17 cases (22.3%) with missing CT chest or CEA, and from which only 1 patient was missing follow up colonoscopy (1.3%).
Conclusions: Complete compliance with 100% appropriate therapy was offered to veterans at one VA according to NCCN guidelines from 2008-2012. Aside from omitting CT chest when replaced by normal CXR, workup was complete in 90% of cases. Improvement in testing for KRAS/BRAF in stage IV colorectal carcinoma was done over the years with achievement of 100% in 2012. Surveillance was satisfactory as incomplete follow up was found in only 20%. Given the future emphasis on cancer survivorship, a focus on adherence to surveillance should be a strong part of the VA’s future goals.
Bundled preventive care reduced surgical site infections
Implementing a systematic bundle of prevention strategies reduced the absolute rate of superficial surgical site infections after colorectal surgery by 14% at one institution.
The findings came from a retrospective study of data from 2008 through 2012 on 559 patients who underwent major elective colorectal surgery at Duke University, Durham, N.C., either before the implementation of the preventive bundle on July 1, 2011 (62% of patients) or afterward (38%). Among all patients, the rate of superficial surgical site infection was 25% before the bundled care and 6% afterward, Dr. Jeffrey E. Keenan and his associates reported.
To eliminate any significant differences in patient demographics, baseline characteristics, or procedure-specific factors that might affect the surgical site infection rate, they conducted a propensity-matched comparison of 212 patients from each of the pre- and postbundling groups. The surgical site infection rate was 19.3% before implementation of bundled preventive services and 5.7% with bundled care, a significant difference of 13.6%, reported Dr. Keenan of the university.
The results were published online in JAMA Surgery (2014 Aug. 27 [doi:10.1001/jamasurg.2014.346]).
Among secondary outcomes, sepsis rates were significantly higher in the pre–bundled-care period, compared with the bundled-care period, both in the unadjusted cohort (10% vs. 2%, respectively) and in the comparison of matched patients (8% vs. 2%, respectively).
The bundle of care was a multidisciplinary effort involving surgeons, anesthesiologists, clinic nurses, operating room staff, unit nurses, house staff, and hospital midlevel providers led by a colorectal surgeon who met monthly with the various groups to review infection rates and address issues with delivering the bundled strategies.
Designed by colorectal surgeons at the university, the bundle included giving patients educational materials before surgery on preventing surgical site infection. The patients received instructions and materials for a full-body chlorhexidine gluconate shower the night before surgery. The bundled-care team adopted a standardized polyethylene glycol 33350 bowel preparation with oral antibiotics (neomycin sulfate and erythromycin). All patients without allergy received a single 1-g dose of ertapenem sodium for preoperative antibiotic prophylaxis within 1 hour of incision. Patients with an allergy received ciprofloxacin HCl and metronidazole phosphate as an alternative.
Standardized preparation of the surgical field involved use of a 2% chlorhexidine gluconate–70% isopropyl alcohol solution. A wound protector was used during surgery for open incision. Only essential personnel were allowed in and out of the operating room. Anesthesiologists paid close attention to maintaining normothermia and euglycemia. Surgeons and scrub staff changed gowns and gloves at the time of wound closure. A dedicated wound closure tray was used to close the fascia and skin, and a sterile occlusive dressing was placed over the incision following closure. The dressing was removed within 48 hours of surgery, and the wound was washed daily with chlorhexidine. Patients being discharged were given materials and instructions to continue the chlorhexidine washes for 1 week after surgery.
A subgroup analysis of patients who underwent surgery after implementation of the bundled care showed that variable direct costs were 36% higher (after multivariable adjustment) in patients who developed surgical site infection, and patients with infection stayed 72% longer in the hospital, Dr. Keenan reported. Average variable direct costs were $13,253 in patients with superficial surgical site infection and $9,779 in those who did not develop infection. Lengths of stay during the index admission averaged 8 days with infection and 5 days without infection.
It is unlikely that any one part of the preventive bundle was responsible for the reduced infection rate and costs, though it’s impossible to tell, the investigators said. More likely, the framework of bundling preventive strategies supported reliable delivery of multiple preventive measures with high fidelity, they suggested.
Dr. Keenan reported having no relevant financial disclosures.
On Twitter @sherryboschert
The study by Dr. Keenan and several separate recent studies support the idea that surgical site infections after colorectal surgery can be prevented by management based on published evidence, best practice guidelines, and culture change, according to Dr. Ira L. Leeds and Dr. Elizabeth C. Wick.
This involves implementing "processes that span the continuum of care from before surgery through postoperative recovery, and these interventions are far more complex than the Surgical Care Improvement Program measures now held as the gold standard for surgical quality reporting," they wrote (JAMA Surgery 2014 Aug. 27 [doi:10.1001/jamasurg.2014.389]).
The studies also suggest that the subspecialty of colorectal surgery is well situated for developing models of care starting from the patient care level rather than from a typical top-down approach, they added. "The tribelike culture of medicine means that many of the fixes to the health care system will need to come at the unit level rather than [through] institutional, systemic solutions," Dr. Leeds and Dr. Wick wrote.
Their remarks were published in a commentary simultaneously with the publication of Dr. Keenan’s study. Dr. Leeds and Dr. Wick are at the Johns Hopkins University, Baltimore. They reported having no financial disclosures.
The study by Dr. Keenan and several separate recent studies support the idea that surgical site infections after colorectal surgery can be prevented by management based on published evidence, best practice guidelines, and culture change, according to Dr. Ira L. Leeds and Dr. Elizabeth C. Wick.
This involves implementing "processes that span the continuum of care from before surgery through postoperative recovery, and these interventions are far more complex than the Surgical Care Improvement Program measures now held as the gold standard for surgical quality reporting," they wrote (JAMA Surgery 2014 Aug. 27 [doi:10.1001/jamasurg.2014.389]).
The studies also suggest that the subspecialty of colorectal surgery is well situated for developing models of care starting from the patient care level rather than from a typical top-down approach, they added. "The tribelike culture of medicine means that many of the fixes to the health care system will need to come at the unit level rather than [through] institutional, systemic solutions," Dr. Leeds and Dr. Wick wrote.
Their remarks were published in a commentary simultaneously with the publication of Dr. Keenan’s study. Dr. Leeds and Dr. Wick are at the Johns Hopkins University, Baltimore. They reported having no financial disclosures.
The study by Dr. Keenan and several separate recent studies support the idea that surgical site infections after colorectal surgery can be prevented by management based on published evidence, best practice guidelines, and culture change, according to Dr. Ira L. Leeds and Dr. Elizabeth C. Wick.
This involves implementing "processes that span the continuum of care from before surgery through postoperative recovery, and these interventions are far more complex than the Surgical Care Improvement Program measures now held as the gold standard for surgical quality reporting," they wrote (JAMA Surgery 2014 Aug. 27 [doi:10.1001/jamasurg.2014.389]).
The studies also suggest that the subspecialty of colorectal surgery is well situated for developing models of care starting from the patient care level rather than from a typical top-down approach, they added. "The tribelike culture of medicine means that many of the fixes to the health care system will need to come at the unit level rather than [through] institutional, systemic solutions," Dr. Leeds and Dr. Wick wrote.
Their remarks were published in a commentary simultaneously with the publication of Dr. Keenan’s study. Dr. Leeds and Dr. Wick are at the Johns Hopkins University, Baltimore. They reported having no financial disclosures.
Implementing a systematic bundle of prevention strategies reduced the absolute rate of superficial surgical site infections after colorectal surgery by 14% at one institution.
The findings came from a retrospective study of data from 2008 through 2012 on 559 patients who underwent major elective colorectal surgery at Duke University, Durham, N.C., either before the implementation of the preventive bundle on July 1, 2011 (62% of patients) or afterward (38%). Among all patients, the rate of superficial surgical site infection was 25% before the bundled care and 6% afterward, Dr. Jeffrey E. Keenan and his associates reported.
To eliminate any significant differences in patient demographics, baseline characteristics, or procedure-specific factors that might affect the surgical site infection rate, they conducted a propensity-matched comparison of 212 patients from each of the pre- and postbundling groups. The surgical site infection rate was 19.3% before implementation of bundled preventive services and 5.7% with bundled care, a significant difference of 13.6%, reported Dr. Keenan of the university.
The results were published online in JAMA Surgery (2014 Aug. 27 [doi:10.1001/jamasurg.2014.346]).
Among secondary outcomes, sepsis rates were significantly higher in the pre–bundled-care period, compared with the bundled-care period, both in the unadjusted cohort (10% vs. 2%, respectively) and in the comparison of matched patients (8% vs. 2%, respectively).
The bundle of care was a multidisciplinary effort involving surgeons, anesthesiologists, clinic nurses, operating room staff, unit nurses, house staff, and hospital midlevel providers led by a colorectal surgeon who met monthly with the various groups to review infection rates and address issues with delivering the bundled strategies.
Designed by colorectal surgeons at the university, the bundle included giving patients educational materials before surgery on preventing surgical site infection. The patients received instructions and materials for a full-body chlorhexidine gluconate shower the night before surgery. The bundled-care team adopted a standardized polyethylene glycol 33350 bowel preparation with oral antibiotics (neomycin sulfate and erythromycin). All patients without allergy received a single 1-g dose of ertapenem sodium for preoperative antibiotic prophylaxis within 1 hour of incision. Patients with an allergy received ciprofloxacin HCl and metronidazole phosphate as an alternative.
Standardized preparation of the surgical field involved use of a 2% chlorhexidine gluconate–70% isopropyl alcohol solution. A wound protector was used during surgery for open incision. Only essential personnel were allowed in and out of the operating room. Anesthesiologists paid close attention to maintaining normothermia and euglycemia. Surgeons and scrub staff changed gowns and gloves at the time of wound closure. A dedicated wound closure tray was used to close the fascia and skin, and a sterile occlusive dressing was placed over the incision following closure. The dressing was removed within 48 hours of surgery, and the wound was washed daily with chlorhexidine. Patients being discharged were given materials and instructions to continue the chlorhexidine washes for 1 week after surgery.
A subgroup analysis of patients who underwent surgery after implementation of the bundled care showed that variable direct costs were 36% higher (after multivariable adjustment) in patients who developed surgical site infection, and patients with infection stayed 72% longer in the hospital, Dr. Keenan reported. Average variable direct costs were $13,253 in patients with superficial surgical site infection and $9,779 in those who did not develop infection. Lengths of stay during the index admission averaged 8 days with infection and 5 days without infection.
It is unlikely that any one part of the preventive bundle was responsible for the reduced infection rate and costs, though it’s impossible to tell, the investigators said. More likely, the framework of bundling preventive strategies supported reliable delivery of multiple preventive measures with high fidelity, they suggested.
Dr. Keenan reported having no relevant financial disclosures.
On Twitter @sherryboschert
Implementing a systematic bundle of prevention strategies reduced the absolute rate of superficial surgical site infections after colorectal surgery by 14% at one institution.
The findings came from a retrospective study of data from 2008 through 2012 on 559 patients who underwent major elective colorectal surgery at Duke University, Durham, N.C., either before the implementation of the preventive bundle on July 1, 2011 (62% of patients) or afterward (38%). Among all patients, the rate of superficial surgical site infection was 25% before the bundled care and 6% afterward, Dr. Jeffrey E. Keenan and his associates reported.
To eliminate any significant differences in patient demographics, baseline characteristics, or procedure-specific factors that might affect the surgical site infection rate, they conducted a propensity-matched comparison of 212 patients from each of the pre- and postbundling groups. The surgical site infection rate was 19.3% before implementation of bundled preventive services and 5.7% with bundled care, a significant difference of 13.6%, reported Dr. Keenan of the university.
The results were published online in JAMA Surgery (2014 Aug. 27 [doi:10.1001/jamasurg.2014.346]).
Among secondary outcomes, sepsis rates were significantly higher in the pre–bundled-care period, compared with the bundled-care period, both in the unadjusted cohort (10% vs. 2%, respectively) and in the comparison of matched patients (8% vs. 2%, respectively).
The bundle of care was a multidisciplinary effort involving surgeons, anesthesiologists, clinic nurses, operating room staff, unit nurses, house staff, and hospital midlevel providers led by a colorectal surgeon who met monthly with the various groups to review infection rates and address issues with delivering the bundled strategies.
Designed by colorectal surgeons at the university, the bundle included giving patients educational materials before surgery on preventing surgical site infection. The patients received instructions and materials for a full-body chlorhexidine gluconate shower the night before surgery. The bundled-care team adopted a standardized polyethylene glycol 33350 bowel preparation with oral antibiotics (neomycin sulfate and erythromycin). All patients without allergy received a single 1-g dose of ertapenem sodium for preoperative antibiotic prophylaxis within 1 hour of incision. Patients with an allergy received ciprofloxacin HCl and metronidazole phosphate as an alternative.
Standardized preparation of the surgical field involved use of a 2% chlorhexidine gluconate–70% isopropyl alcohol solution. A wound protector was used during surgery for open incision. Only essential personnel were allowed in and out of the operating room. Anesthesiologists paid close attention to maintaining normothermia and euglycemia. Surgeons and scrub staff changed gowns and gloves at the time of wound closure. A dedicated wound closure tray was used to close the fascia and skin, and a sterile occlusive dressing was placed over the incision following closure. The dressing was removed within 48 hours of surgery, and the wound was washed daily with chlorhexidine. Patients being discharged were given materials and instructions to continue the chlorhexidine washes for 1 week after surgery.
A subgroup analysis of patients who underwent surgery after implementation of the bundled care showed that variable direct costs were 36% higher (after multivariable adjustment) in patients who developed surgical site infection, and patients with infection stayed 72% longer in the hospital, Dr. Keenan reported. Average variable direct costs were $13,253 in patients with superficial surgical site infection and $9,779 in those who did not develop infection. Lengths of stay during the index admission averaged 8 days with infection and 5 days without infection.
It is unlikely that any one part of the preventive bundle was responsible for the reduced infection rate and costs, though it’s impossible to tell, the investigators said. More likely, the framework of bundling preventive strategies supported reliable delivery of multiple preventive measures with high fidelity, they suggested.
Dr. Keenan reported having no relevant financial disclosures.
On Twitter @sherryboschert
FROM JAMA SURGERY
Key clinical point: Bundled preventive care significantly reduced surgical site infection after colorectal surgery.
Major finding: Superficial surgical site infection occurred in about 19% before and about 6% after implementing bundled care.
Data source: A retrospective study of 559 patients undergoing colorectal surgery, 62% before bundled-care implementation.
Disclosures: Dr. Keenan reported having no relevant financial disclosures.
Fast Facts: Metastatic Colorectal Cancer
To read more about this topic, read "Metastatic Colorectal Cancer."
▶Patients with limited metastatic disease to the liver or lungs may be eligible for complete resection upfront or after neoadjuvant therapy, and many will have long PFS or even cure
▶Metastatic colon cancer can affect up to 50% of patients diagnosed with the disease
▶Appropriate evaluation of the extent of the disease and patients' general health by a multidisciplinary team will determine goals of treatment
▶Patients with widely metastatic disease will benefit from different systemic chemotherapy regimens given sequentially and punctuated by "chemo holidays." With this strategy, survival can be doubled or tripled
▶Managing toxicity from systemic chemotherapy is paramount to maintain QOL. Myelosuppression, mucositis, cold-induced neuropathy, fatigue, and rash are the most common AEs and can be managed to maintain QOL
▶Hypertensive crisis, bleeding or thrombosis, GI perforation, and RPLS should prompt the discontinuation of bevacizumab and similar drugs
▶Biologic agents, such as antiangiogenic and anti-EGFR agents, when used with chemotherapy, added some benefit but their effect was not equal across treatment regimens
▶5-FU is considered the staple for all chemotherapy regimens used in this disease. The addition of irinotecan or oxaliplatin to 5-FU improved RRs and PFS but did not always result in improvement of OS.
To read more about this topic, read "Metastatic Colorectal Cancer."
▶Patients with limited metastatic disease to the liver or lungs may be eligible for complete resection upfront or after neoadjuvant therapy, and many will have long PFS or even cure
▶Metastatic colon cancer can affect up to 50% of patients diagnosed with the disease
▶Appropriate evaluation of the extent of the disease and patients' general health by a multidisciplinary team will determine goals of treatment
▶Patients with widely metastatic disease will benefit from different systemic chemotherapy regimens given sequentially and punctuated by "chemo holidays." With this strategy, survival can be doubled or tripled
▶Managing toxicity from systemic chemotherapy is paramount to maintain QOL. Myelosuppression, mucositis, cold-induced neuropathy, fatigue, and rash are the most common AEs and can be managed to maintain QOL
▶Hypertensive crisis, bleeding or thrombosis, GI perforation, and RPLS should prompt the discontinuation of bevacizumab and similar drugs
▶Biologic agents, such as antiangiogenic and anti-EGFR agents, when used with chemotherapy, added some benefit but their effect was not equal across treatment regimens
▶5-FU is considered the staple for all chemotherapy regimens used in this disease. The addition of irinotecan or oxaliplatin to 5-FU improved RRs and PFS but did not always result in improvement of OS.
To read more about this topic, read "Metastatic Colorectal Cancer."
▶Patients with limited metastatic disease to the liver or lungs may be eligible for complete resection upfront or after neoadjuvant therapy, and many will have long PFS or even cure
▶Metastatic colon cancer can affect up to 50% of patients diagnosed with the disease
▶Appropriate evaluation of the extent of the disease and patients' general health by a multidisciplinary team will determine goals of treatment
▶Patients with widely metastatic disease will benefit from different systemic chemotherapy regimens given sequentially and punctuated by "chemo holidays." With this strategy, survival can be doubled or tripled
▶Managing toxicity from systemic chemotherapy is paramount to maintain QOL. Myelosuppression, mucositis, cold-induced neuropathy, fatigue, and rash are the most common AEs and can be managed to maintain QOL
▶Hypertensive crisis, bleeding or thrombosis, GI perforation, and RPLS should prompt the discontinuation of bevacizumab and similar drugs
▶Biologic agents, such as antiangiogenic and anti-EGFR agents, when used with chemotherapy, added some benefit but their effect was not equal across treatment regimens
▶5-FU is considered the staple for all chemotherapy regimens used in this disease. The addition of irinotecan or oxaliplatin to 5-FU improved RRs and PFS but did not always result in improvement of OS.
Enteral contrast did not add diagnostic benefit in suspected appendicitis
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."
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."
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."
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.
FROM ANNALS OF SURGERY
Key clinical point: Enteral contrast is not of additional diagnostic benefit in appendectomy patients undergoing intravenous contrast computed tomography.
Major finding: After adjustment for age, sex, comorbidities, weight, hospital type, and perforation, there was no significant difference in rates of pathologic and radiologic concordance for patients who underwent IV-only contrast CT versus IV and enteral contrast CT (odds ratio, 0.95; 95% confidence interval, 0.72-1.25).
Data Source: Prospective cohort study of 9,047 adults who underwent nonelective appendectomies at 56 hospitals in the state of Washington between Jan. 1, 2010, and Dec. 31, 2011.
Disclosures: 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.
Laparoscopy found effective alternative to open IBD surgery
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.
"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.
"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.
"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.
FROM ANNALS OF SURGERY
Key clinical point: Laparoscopic approaches are becoming standard for the surgical management of inflammatory bowel disease (IBD), except in cases of complicated acute colitis.
Major finding: The proportion of IBD procedures performed laparoscopically increased from 42% to 80% (P less than .001). The rate of complex laparoscopies also increased (P = .023), while the mean adjusted risks of conversion and severe postoperative morbidity dropped (P less than .001 for both).
Data source: Prospective analysis of 790 consecutive resections for IBD performed during a 14-year period, including 574 (73%) laparoscopic procedures.
Disclosures: The Association François Aupetit partially funded the study. The authors reported having no conflicts of interest.
ERAS program for colorectal surgery cut length of stay, costs in community setting
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.
FROM JAMA SURGERY
Key clinical point: Enhanced recovery after surgery (ERAS) programs appear to be feasible for colorectal surgery patients in a community hospital setting.
Major finding: 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%).
Data source: Prospective cohort study of 244 patients undergoing elective colorectal surgery before or after ERAS program implementation.
Disclosures: The authors reported no funding sources or conflicts of interest.
Hospital use of minimally invasive surgery shows disparity in surgical care nationwide
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."
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.
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."
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.
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."
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.
FROM THE BRITISH MEDICAL JOURNAL
Key clinical point: Hospital use of minimally invasive surgical procedures appears to vary widely in the United States.
Major Finding:. 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.
Data Source: An analysis of data from the National Inpatient Sample in 2010 that included 1,051 hospitals in 45 states, and was limited to appendectomy, colectomy, hysterectomy, and lung lobectomy.
Disclosures: The authors stated that they had no relevant financial conflicts to disclose.
Pasireotide decreases incidence of postoperative fistula
The somatostatin analogue pasireotide reduced postoperative pancreatic fistula leak or abscess by 56%, compared with placebo, a randomized study has determined.
Pasireotide (Signifor) was effective after both pancreaticoduodenectomy and distal pancreatectomy, whether or not the pancreatic duct was dilated, Dr. Peter J. Allen and his colleagues wrote in the May 21 issue of the New England Journal of Medicine (N. Engl. J. Med. 2014;370:2014-22).
In those patients who did develop fistulas or leaks, pasireotide was associated with fewer grade 3 occurrences.
"These results suggest that ... not only were many leaks and fistulas prevented, but when they did occur they were less clinically relevant," wrote Dr. Allen of the Memorial Sloan Kettering Cancer Center, New York, and his coauthors.
The study randomized 300 patients to subcutaneous injections of either placebo or pasireotide twice daily for 7 days after pancreatic surgery. The primary endpoint was the development of a pancreatic leak, fistula, or abscess of at least grade 3. Secondary endpoints included the overall rate of pancreatic complications (all grades) and the rate of grade B or grade C pancreatic fistula.
Patients were a mean of 64 years old. Most (73%) underwent a pancreaticoduodenectomy. The average length of stay for these patients was about 10 days. The active group received 900 mcg of pasireotide subcutaneously twice daily for 7 days, beginning on the morning of surgery.
Mean postoperative serum glucose levels were significantly higher in patients taking pasireotide (258 mg/dL vs. 215 mg/dL). Readmission occurred in significantly fewer pasireotide patients (17% vs. 29%).
Significantly fewer of those taking the active drug were able to finish the entire course of 14 doses (76% vs. 86% given placebo). The lower completion rate was mostly due to nausea and vomiting, which caused 26 patients in the active group and 3 in the placebo group to withdraw from the study.
A leak or fistula of grade 3 or higher developed in 45 patients. The outcome was significantly less common among those taking pasireotide than among those on placebo (9% vs. 21%; relative risk, 0.44). "This corresponded to an absolute risk reduction of 11.7 percentage points," with a number needed to treat of 8, the investigators said.
Pasireotide was significantly more effective than placebo in surgical subgroups, including pancreaticoduodenectomy (RR, 0.49) and distal pancreatectomy (RR, 0.32). The effect was also positive whether the pancreatic duct was dilated (RR, 0.11) or nondilated (RR, 0.55).
The secondary outcome (grade B or C postoperative fistula) occurred in 37 patients (12%). In the pasireotide group, there were 12 grade B fistulas and no grade C fistulas. In the placebo group, there were 20 grade B and 5 grade C fistulas.
Overall 60-day mortality was 0.7% (one death in each treatment group). Grade 3 and 4 complications were common, occurring in 92% of the pasireotide group and 90% of the placebo group. Most of these were expected postoperative serum abnormalities.
The investigators said that the other approved somatostatin analogue, octreotide, has not been clearly associated with pancreatic leak reduction. They suggested that pasireotide may be more effective because it has a longer half-life and binds to four of the five somatostatin-receptor subtypes, rather than just two, as octreotide does.
They added that the octreotide studies were conducted before 2005, when there was no consistent definition of postoperative pancreatic fistula. Therefore, they concluded, the extant data cannot be used to identify octreotide efficacy in this application.
Pasireotide, which is made by Novartis Pharmaceuticals, is currently approved as an injection for the treatment of Cushing’s disease patients who cannot be helped through surgery.
Novartis Pharmaceuticals sponsored the trial. Dr. Allen received Novartis grant funding but had no other financial ties with the company.
The somatostatin analogue pasireotide reduced postoperative pancreatic fistula leak or abscess by 56%, compared with placebo, a randomized study has determined.
Pasireotide (Signifor) was effective after both pancreaticoduodenectomy and distal pancreatectomy, whether or not the pancreatic duct was dilated, Dr. Peter J. Allen and his colleagues wrote in the May 21 issue of the New England Journal of Medicine (N. Engl. J. Med. 2014;370:2014-22).
In those patients who did develop fistulas or leaks, pasireotide was associated with fewer grade 3 occurrences.
"These results suggest that ... not only were many leaks and fistulas prevented, but when they did occur they were less clinically relevant," wrote Dr. Allen of the Memorial Sloan Kettering Cancer Center, New York, and his coauthors.
The study randomized 300 patients to subcutaneous injections of either placebo or pasireotide twice daily for 7 days after pancreatic surgery. The primary endpoint was the development of a pancreatic leak, fistula, or abscess of at least grade 3. Secondary endpoints included the overall rate of pancreatic complications (all grades) and the rate of grade B or grade C pancreatic fistula.
Patients were a mean of 64 years old. Most (73%) underwent a pancreaticoduodenectomy. The average length of stay for these patients was about 10 days. The active group received 900 mcg of pasireotide subcutaneously twice daily for 7 days, beginning on the morning of surgery.
Mean postoperative serum glucose levels were significantly higher in patients taking pasireotide (258 mg/dL vs. 215 mg/dL). Readmission occurred in significantly fewer pasireotide patients (17% vs. 29%).
Significantly fewer of those taking the active drug were able to finish the entire course of 14 doses (76% vs. 86% given placebo). The lower completion rate was mostly due to nausea and vomiting, which caused 26 patients in the active group and 3 in the placebo group to withdraw from the study.
A leak or fistula of grade 3 or higher developed in 45 patients. The outcome was significantly less common among those taking pasireotide than among those on placebo (9% vs. 21%; relative risk, 0.44). "This corresponded to an absolute risk reduction of 11.7 percentage points," with a number needed to treat of 8, the investigators said.
Pasireotide was significantly more effective than placebo in surgical subgroups, including pancreaticoduodenectomy (RR, 0.49) and distal pancreatectomy (RR, 0.32). The effect was also positive whether the pancreatic duct was dilated (RR, 0.11) or nondilated (RR, 0.55).
The secondary outcome (grade B or C postoperative fistula) occurred in 37 patients (12%). In the pasireotide group, there were 12 grade B fistulas and no grade C fistulas. In the placebo group, there were 20 grade B and 5 grade C fistulas.
Overall 60-day mortality was 0.7% (one death in each treatment group). Grade 3 and 4 complications were common, occurring in 92% of the pasireotide group and 90% of the placebo group. Most of these were expected postoperative serum abnormalities.
The investigators said that the other approved somatostatin analogue, octreotide, has not been clearly associated with pancreatic leak reduction. They suggested that pasireotide may be more effective because it has a longer half-life and binds to four of the five somatostatin-receptor subtypes, rather than just two, as octreotide does.
They added that the octreotide studies were conducted before 2005, when there was no consistent definition of postoperative pancreatic fistula. Therefore, they concluded, the extant data cannot be used to identify octreotide efficacy in this application.
Pasireotide, which is made by Novartis Pharmaceuticals, is currently approved as an injection for the treatment of Cushing’s disease patients who cannot be helped through surgery.
Novartis Pharmaceuticals sponsored the trial. Dr. Allen received Novartis grant funding but had no other financial ties with the company.
The somatostatin analogue pasireotide reduced postoperative pancreatic fistula leak or abscess by 56%, compared with placebo, a randomized study has determined.
Pasireotide (Signifor) was effective after both pancreaticoduodenectomy and distal pancreatectomy, whether or not the pancreatic duct was dilated, Dr. Peter J. Allen and his colleagues wrote in the May 21 issue of the New England Journal of Medicine (N. Engl. J. Med. 2014;370:2014-22).
In those patients who did develop fistulas or leaks, pasireotide was associated with fewer grade 3 occurrences.
"These results suggest that ... not only were many leaks and fistulas prevented, but when they did occur they were less clinically relevant," wrote Dr. Allen of the Memorial Sloan Kettering Cancer Center, New York, and his coauthors.
The study randomized 300 patients to subcutaneous injections of either placebo or pasireotide twice daily for 7 days after pancreatic surgery. The primary endpoint was the development of a pancreatic leak, fistula, or abscess of at least grade 3. Secondary endpoints included the overall rate of pancreatic complications (all grades) and the rate of grade B or grade C pancreatic fistula.
Patients were a mean of 64 years old. Most (73%) underwent a pancreaticoduodenectomy. The average length of stay for these patients was about 10 days. The active group received 900 mcg of pasireotide subcutaneously twice daily for 7 days, beginning on the morning of surgery.
Mean postoperative serum glucose levels were significantly higher in patients taking pasireotide (258 mg/dL vs. 215 mg/dL). Readmission occurred in significantly fewer pasireotide patients (17% vs. 29%).
Significantly fewer of those taking the active drug were able to finish the entire course of 14 doses (76% vs. 86% given placebo). The lower completion rate was mostly due to nausea and vomiting, which caused 26 patients in the active group and 3 in the placebo group to withdraw from the study.
A leak or fistula of grade 3 or higher developed in 45 patients. The outcome was significantly less common among those taking pasireotide than among those on placebo (9% vs. 21%; relative risk, 0.44). "This corresponded to an absolute risk reduction of 11.7 percentage points," with a number needed to treat of 8, the investigators said.
Pasireotide was significantly more effective than placebo in surgical subgroups, including pancreaticoduodenectomy (RR, 0.49) and distal pancreatectomy (RR, 0.32). The effect was also positive whether the pancreatic duct was dilated (RR, 0.11) or nondilated (RR, 0.55).
The secondary outcome (grade B or C postoperative fistula) occurred in 37 patients (12%). In the pasireotide group, there were 12 grade B fistulas and no grade C fistulas. In the placebo group, there were 20 grade B and 5 grade C fistulas.
Overall 60-day mortality was 0.7% (one death in each treatment group). Grade 3 and 4 complications were common, occurring in 92% of the pasireotide group and 90% of the placebo group. Most of these were expected postoperative serum abnormalities.
The investigators said that the other approved somatostatin analogue, octreotide, has not been clearly associated with pancreatic leak reduction. They suggested that pasireotide may be more effective because it has a longer half-life and binds to four of the five somatostatin-receptor subtypes, rather than just two, as octreotide does.
They added that the octreotide studies were conducted before 2005, when there was no consistent definition of postoperative pancreatic fistula. Therefore, they concluded, the extant data cannot be used to identify octreotide efficacy in this application.
Pasireotide, which is made by Novartis Pharmaceuticals, is currently approved as an injection for the treatment of Cushing’s disease patients who cannot be helped through surgery.
Novartis Pharmaceuticals sponsored the trial. Dr. Allen received Novartis grant funding but had no other financial ties with the company.
FROM NEJM
Key clinical point: Pasireotide reduced the incidence of postoperative pancreatic fistula, leak, or abscess.
Major finding: Compared with placebo, pasireotide reduced the rate of fistula, leak, or abscess by 56%.
Data source: The randomized, placebo-controlled study included 300 patients.
Disclosures: Novartis Pharmaceuticals sponsored the trial. Dr. Allen received Novartis grant funding but had no other financial ties with the company.
Laparoscopic surgery cut length of hospital stay in colorectal cancer
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.
FROM THE JOURNAL OF CLINICAL ONCOLOGY
Key clinical finding: Laparoscopy should be considered over open surgery for colorectal cancer.
Major finding: Median total hospital stay was significantly shorter when patients underwent laparoscopy (5 days; interquartile range, 4-9 days) vs. open surgery (7 days; IQR, 5-11 days; P = .033).
Data source: Multicenter randomized trial of 204 patients with colorectal cancer, of whom 103 underwent laparoscopic resection and 101 had open surgery.
Disclosures: 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 means shorter hospital stays
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.
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.
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.
FROM DDW 2014
Major finding: Compared with those undergoing laparoscopic hemicolectomy, patients whose right-colon polyps are removed by laparoscopic-assisted colonoscopic polypectomy have shorter mean operating times (95 min. vs. 179 min.), lose less blood (13 vs. 63 mL), and require less intravenous fluid (2.1 vs. 3.1 L). LACP patients are 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).
Data source: Randomized, unblinded trial in 28 patients with benign right-colon polyps.
Disclosures: The investigators have no disclosures.