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Alterations in taste, smell common after gastric bypass
Alterations in taste and smell, including aversions to many foods, are common following gastric bypass surgery, according to a report published online in Obesity Surgery.
Most of the literature regarding gastric bypass outcomes has focused on the safety and efficacy of the procedures, while patient-reported measures such as changes in taste and smell have received comparatively little attention. The few studies that have examined this issue report high rates of alterations in taste, smell, and food preferences, affecting anywhere from 45% to 82% of patients; these changes were transient in most patients but persisted long term in approximately one-third of those affected, said Dr. Lisa Graham of the department of surgery at Leicester (England) Royal Infirmary and her associates.
They assessed such changes in a cohort study involving 103 patients who underwent Roux-en-Y gastric bypass surgery at their hospital during a 12-year period and completed a detailed questionnaire a median of 19 months afterward (range, 1-120 months). The median age of these participants was 45 years (range, 23-63 years).
A total of 75 patients (73%) reported a change in their sense of taste and 43 (42%) reported a change in their sense of smell after surgery. There was no clear pattern of change: Some patients reported that foods smelled or tasted stronger while some said they were blander, and the types of foods affected included meats, fish, starches, vegetables, fruit, dairy, and sweets, the investigators said (Obes. Surg. 2014 March 8 [doi:10.1007/s11695-014-1221-2]).
Many said that they now have strong aversions to certain foods, with 33% reporting that they could no longer tolerate the smell or taste of meats including beef, chicken, lamb, and pork. A total of 12% said that they were averse to the smell or taste of pasta, rice, and breads, and 11% said they couldn’t tolerate the smell or taste of milk, yogurt, cheese, or eggs.
The mechanism underlying these alterations is not yet known. "It is likely that a combination of gut hormone and central nervous system effects accounts for the observed changes in sensory function after weight loss surgery," Dr. Graham and her associates said.
The investigators had no relevant conflicts of interest.
Alterations in taste and smell, including aversions to many foods, are common following gastric bypass surgery, according to a report published online in Obesity Surgery.
Most of the literature regarding gastric bypass outcomes has focused on the safety and efficacy of the procedures, while patient-reported measures such as changes in taste and smell have received comparatively little attention. The few studies that have examined this issue report high rates of alterations in taste, smell, and food preferences, affecting anywhere from 45% to 82% of patients; these changes were transient in most patients but persisted long term in approximately one-third of those affected, said Dr. Lisa Graham of the department of surgery at Leicester (England) Royal Infirmary and her associates.
They assessed such changes in a cohort study involving 103 patients who underwent Roux-en-Y gastric bypass surgery at their hospital during a 12-year period and completed a detailed questionnaire a median of 19 months afterward (range, 1-120 months). The median age of these participants was 45 years (range, 23-63 years).
A total of 75 patients (73%) reported a change in their sense of taste and 43 (42%) reported a change in their sense of smell after surgery. There was no clear pattern of change: Some patients reported that foods smelled or tasted stronger while some said they were blander, and the types of foods affected included meats, fish, starches, vegetables, fruit, dairy, and sweets, the investigators said (Obes. Surg. 2014 March 8 [doi:10.1007/s11695-014-1221-2]).
Many said that they now have strong aversions to certain foods, with 33% reporting that they could no longer tolerate the smell or taste of meats including beef, chicken, lamb, and pork. A total of 12% said that they were averse to the smell or taste of pasta, rice, and breads, and 11% said they couldn’t tolerate the smell or taste of milk, yogurt, cheese, or eggs.
The mechanism underlying these alterations is not yet known. "It is likely that a combination of gut hormone and central nervous system effects accounts for the observed changes in sensory function after weight loss surgery," Dr. Graham and her associates said.
The investigators had no relevant conflicts of interest.
Alterations in taste and smell, including aversions to many foods, are common following gastric bypass surgery, according to a report published online in Obesity Surgery.
Most of the literature regarding gastric bypass outcomes has focused on the safety and efficacy of the procedures, while patient-reported measures such as changes in taste and smell have received comparatively little attention. The few studies that have examined this issue report high rates of alterations in taste, smell, and food preferences, affecting anywhere from 45% to 82% of patients; these changes were transient in most patients but persisted long term in approximately one-third of those affected, said Dr. Lisa Graham of the department of surgery at Leicester (England) Royal Infirmary and her associates.
They assessed such changes in a cohort study involving 103 patients who underwent Roux-en-Y gastric bypass surgery at their hospital during a 12-year period and completed a detailed questionnaire a median of 19 months afterward (range, 1-120 months). The median age of these participants was 45 years (range, 23-63 years).
A total of 75 patients (73%) reported a change in their sense of taste and 43 (42%) reported a change in their sense of smell after surgery. There was no clear pattern of change: Some patients reported that foods smelled or tasted stronger while some said they were blander, and the types of foods affected included meats, fish, starches, vegetables, fruit, dairy, and sweets, the investigators said (Obes. Surg. 2014 March 8 [doi:10.1007/s11695-014-1221-2]).
Many said that they now have strong aversions to certain foods, with 33% reporting that they could no longer tolerate the smell or taste of meats including beef, chicken, lamb, and pork. A total of 12% said that they were averse to the smell or taste of pasta, rice, and breads, and 11% said they couldn’t tolerate the smell or taste of milk, yogurt, cheese, or eggs.
The mechanism underlying these alterations is not yet known. "It is likely that a combination of gut hormone and central nervous system effects accounts for the observed changes in sensory function after weight loss surgery," Dr. Graham and her associates said.
The investigators had no relevant conflicts of interest.
FROM OBESITY SURGERY
Major finding: 73% of patients reported a change in taste and 42% a change in smell after gastric bypass surgery, including many who said that they became averse to meats, fish, vegetables, fruits, starches, dairy products, or sweets.
Data source: A retrospective cohort study in 103 patients who underwent Roux-en-Y gastric bypass at a single English hospital during a 12-year period.
Disclosures: The investigators had no relevant conflicts of interest.
One-third of elective colectomies fail to meet indications
BOSTON – Though progress is being made in reducing surgery for diverticulitis, one in three elective colectomies failed to meet current indications in a prospective study.
Among 1,102 patients in Washington state with an episode-based indication for elective surgery, the proportion with three or more prior episodes of diverticulitis increased from 42% in 2010 to 58% in 2012 (P = .007), while the proportion failing to meet either complication- or episode-based indications decreased from 41.3% to 29.6% (P = .002).
"Still, there remains a significant and persistent portion of cases being done in Washington that do not meet established guidelines," Dr. Vlad V. Simianu said at the annual meeting of the American Surgical Association.
The study involved 2,031 patients having elective resection for diverticulitis in 2010-2012 in 49 hospitals in Washington state’s voluntary Surgical Care and Outcomes Assessment Program (SCOAP), which captures about 80% of the surgical volume in the state. Their mean age was 58.8 years, 24% were younger than 50 years, and most were healthy, with only 27% having a Charlson Comorbidity Index score of 1 or more.
Washington has seen a dramatic threefold increase in elective colectomy for diverticulitis over the last 13 years, despite evolving recommendations, observed Dr. Simianu, a general surgery resident and research fellow at the University of Washington, Seattle. The 2006 American Society of Colon and Rectal Surgeons (ASCRS) guidelines, which were used for the study end points, said elective surgery can be safely delayed until three or more acute episodes of uncomplicated diverticulitis. The ASCRS just updated its guidelines again (Dis. Colon Rectum 2014;57:284-94) and now strongly recommend that the decision to proceed to elective colectomy after recovery from uncomplicated acute diverticulitis "be individualized."
Among all 2,031 patients in the study, a clinical indication for surgery was present in 23.3% (chronic fistula 10.5%, stricture 5.4%, bleeding 2.4%, and other 5%), while 55% of the 1,102 patients with an episode-based indication had three or more episodes.
In 2010, 22% of all patients had at least three prior episodes, 17% had chronic complications, and 23% had neither. This compares with 37.7%, 18%.6%, and 16.7% in 2012.
Possible explanations for the rise in guideline-concordant cases are that surgeons are documenting their indications more carefully or are delaying more operations until three or more acute episodes, Dr. Simianu said. Indeed, there was a significant decrease in the number of cases with missing indications in the clinical record over the study period (38% vs. 27%; P = .007).
The persistence of cases not meeting indications could be because the adoption of laparoscopy has lowered the threshold for surgeons to offer colectomy, similar to what has happened with laparoscopic cholecystectomy, he said. A laparoscopic operation was performed in 60% of the patients.
Other possible explanations are that the guidelines don’t capture all relevant indications, like persistent symptoms or pain, or that evolving evidence and guidelines are forcing some surgeons to wait before they change their practice, Dr. Simianu said.
"Nonetheless, we view this as an educational opportunity in our state to give feedback to surgeons in our network," he said.
Notably, the rate of elective and emergency resections per year did not increase significantly over the study period at 28 high-volume hospitals, performing at least 10 colectomies yearly. Data, however, were incomplete or missing, in 30.4% of cases.
Discussant Dr. Conor Delaney, chief of colorectal surgery at University Hospitals Case Medical Center, Cleveland, said it was good to see that the percentage of cases performed for three or more episodes rose across all age groups in the final year of the study, suggesting that the SCOAP intervention is likely working.
"It is still shocking to see 30 or 40% of cases being performed for fewer than three attacks," he said, adding that the 30% of patients who had surgery without appropriate indications "may really be, very much a best-case scenario."
He also asked whether the investigators could identify hospitals inside and outside SCOAP that were less likely to follow guidelines and how they dealt with patients who may have had appropriate single-attack surgery because of nonresolution of symptoms or inadequate drainage.
Dr. Simianu said it wasn’t possible to determine indications for hospitals outside the SCOAP network, but that participating hospitals followed a normal distribution. High-volume hospitals were "sort of middle of the road," while four or five low-volume hospitals were outliers and never or always met indications.
In response to the second query, he said their clinical indications included an "other" category that captured appropriate first-attack patients and that about 1% of surgery was performed for an abscess.
The next phase of research will be to go into surgeons’ offices to speak with surgeons and patients to try and quantify the missing indications, Dr. Simianu said.
Dr. Simianu reported funding from the National Institute of Diabetes and Digestive and Kidney Disease, the Agency for Healthcare Research & Quality, and Life Sciences Discovery Fund. Three co-authors reported serving as an advisor, consultant, or speaker for pharmaceutical and device firms.
The complete manuscript of this study and its presentation at the American Surgical Association’s 134th Annual Meeting, April 2014, in Boston, Mass., is anticipated to be published in the Annals of Surgery, pending editorial review.
BOSTON – Though progress is being made in reducing surgery for diverticulitis, one in three elective colectomies failed to meet current indications in a prospective study.
Among 1,102 patients in Washington state with an episode-based indication for elective surgery, the proportion with three or more prior episodes of diverticulitis increased from 42% in 2010 to 58% in 2012 (P = .007), while the proportion failing to meet either complication- or episode-based indications decreased from 41.3% to 29.6% (P = .002).
"Still, there remains a significant and persistent portion of cases being done in Washington that do not meet established guidelines," Dr. Vlad V. Simianu said at the annual meeting of the American Surgical Association.
The study involved 2,031 patients having elective resection for diverticulitis in 2010-2012 in 49 hospitals in Washington state’s voluntary Surgical Care and Outcomes Assessment Program (SCOAP), which captures about 80% of the surgical volume in the state. Their mean age was 58.8 years, 24% were younger than 50 years, and most were healthy, with only 27% having a Charlson Comorbidity Index score of 1 or more.
Washington has seen a dramatic threefold increase in elective colectomy for diverticulitis over the last 13 years, despite evolving recommendations, observed Dr. Simianu, a general surgery resident and research fellow at the University of Washington, Seattle. The 2006 American Society of Colon and Rectal Surgeons (ASCRS) guidelines, which were used for the study end points, said elective surgery can be safely delayed until three or more acute episodes of uncomplicated diverticulitis. The ASCRS just updated its guidelines again (Dis. Colon Rectum 2014;57:284-94) and now strongly recommend that the decision to proceed to elective colectomy after recovery from uncomplicated acute diverticulitis "be individualized."
Among all 2,031 patients in the study, a clinical indication for surgery was present in 23.3% (chronic fistula 10.5%, stricture 5.4%, bleeding 2.4%, and other 5%), while 55% of the 1,102 patients with an episode-based indication had three or more episodes.
In 2010, 22% of all patients had at least three prior episodes, 17% had chronic complications, and 23% had neither. This compares with 37.7%, 18%.6%, and 16.7% in 2012.
Possible explanations for the rise in guideline-concordant cases are that surgeons are documenting their indications more carefully or are delaying more operations until three or more acute episodes, Dr. Simianu said. Indeed, there was a significant decrease in the number of cases with missing indications in the clinical record over the study period (38% vs. 27%; P = .007).
The persistence of cases not meeting indications could be because the adoption of laparoscopy has lowered the threshold for surgeons to offer colectomy, similar to what has happened with laparoscopic cholecystectomy, he said. A laparoscopic operation was performed in 60% of the patients.
Other possible explanations are that the guidelines don’t capture all relevant indications, like persistent symptoms or pain, or that evolving evidence and guidelines are forcing some surgeons to wait before they change their practice, Dr. Simianu said.
"Nonetheless, we view this as an educational opportunity in our state to give feedback to surgeons in our network," he said.
Notably, the rate of elective and emergency resections per year did not increase significantly over the study period at 28 high-volume hospitals, performing at least 10 colectomies yearly. Data, however, were incomplete or missing, in 30.4% of cases.
Discussant Dr. Conor Delaney, chief of colorectal surgery at University Hospitals Case Medical Center, Cleveland, said it was good to see that the percentage of cases performed for three or more episodes rose across all age groups in the final year of the study, suggesting that the SCOAP intervention is likely working.
"It is still shocking to see 30 or 40% of cases being performed for fewer than three attacks," he said, adding that the 30% of patients who had surgery without appropriate indications "may really be, very much a best-case scenario."
He also asked whether the investigators could identify hospitals inside and outside SCOAP that were less likely to follow guidelines and how they dealt with patients who may have had appropriate single-attack surgery because of nonresolution of symptoms or inadequate drainage.
Dr. Simianu said it wasn’t possible to determine indications for hospitals outside the SCOAP network, but that participating hospitals followed a normal distribution. High-volume hospitals were "sort of middle of the road," while four or five low-volume hospitals were outliers and never or always met indications.
In response to the second query, he said their clinical indications included an "other" category that captured appropriate first-attack patients and that about 1% of surgery was performed for an abscess.
The next phase of research will be to go into surgeons’ offices to speak with surgeons and patients to try and quantify the missing indications, Dr. Simianu said.
Dr. Simianu reported funding from the National Institute of Diabetes and Digestive and Kidney Disease, the Agency for Healthcare Research & Quality, and Life Sciences Discovery Fund. Three co-authors reported serving as an advisor, consultant, or speaker for pharmaceutical and device firms.
The complete manuscript of this study and its presentation at the American Surgical Association’s 134th Annual Meeting, April 2014, in Boston, Mass., is anticipated to be published in the Annals of Surgery, pending editorial review.
BOSTON – Though progress is being made in reducing surgery for diverticulitis, one in three elective colectomies failed to meet current indications in a prospective study.
Among 1,102 patients in Washington state with an episode-based indication for elective surgery, the proportion with three or more prior episodes of diverticulitis increased from 42% in 2010 to 58% in 2012 (P = .007), while the proportion failing to meet either complication- or episode-based indications decreased from 41.3% to 29.6% (P = .002).
"Still, there remains a significant and persistent portion of cases being done in Washington that do not meet established guidelines," Dr. Vlad V. Simianu said at the annual meeting of the American Surgical Association.
The study involved 2,031 patients having elective resection for diverticulitis in 2010-2012 in 49 hospitals in Washington state’s voluntary Surgical Care and Outcomes Assessment Program (SCOAP), which captures about 80% of the surgical volume in the state. Their mean age was 58.8 years, 24% were younger than 50 years, and most were healthy, with only 27% having a Charlson Comorbidity Index score of 1 or more.
Washington has seen a dramatic threefold increase in elective colectomy for diverticulitis over the last 13 years, despite evolving recommendations, observed Dr. Simianu, a general surgery resident and research fellow at the University of Washington, Seattle. The 2006 American Society of Colon and Rectal Surgeons (ASCRS) guidelines, which were used for the study end points, said elective surgery can be safely delayed until three or more acute episodes of uncomplicated diverticulitis. The ASCRS just updated its guidelines again (Dis. Colon Rectum 2014;57:284-94) and now strongly recommend that the decision to proceed to elective colectomy after recovery from uncomplicated acute diverticulitis "be individualized."
Among all 2,031 patients in the study, a clinical indication for surgery was present in 23.3% (chronic fistula 10.5%, stricture 5.4%, bleeding 2.4%, and other 5%), while 55% of the 1,102 patients with an episode-based indication had three or more episodes.
In 2010, 22% of all patients had at least three prior episodes, 17% had chronic complications, and 23% had neither. This compares with 37.7%, 18%.6%, and 16.7% in 2012.
Possible explanations for the rise in guideline-concordant cases are that surgeons are documenting their indications more carefully or are delaying more operations until three or more acute episodes, Dr. Simianu said. Indeed, there was a significant decrease in the number of cases with missing indications in the clinical record over the study period (38% vs. 27%; P = .007).
The persistence of cases not meeting indications could be because the adoption of laparoscopy has lowered the threshold for surgeons to offer colectomy, similar to what has happened with laparoscopic cholecystectomy, he said. A laparoscopic operation was performed in 60% of the patients.
Other possible explanations are that the guidelines don’t capture all relevant indications, like persistent symptoms or pain, or that evolving evidence and guidelines are forcing some surgeons to wait before they change their practice, Dr. Simianu said.
"Nonetheless, we view this as an educational opportunity in our state to give feedback to surgeons in our network," he said.
Notably, the rate of elective and emergency resections per year did not increase significantly over the study period at 28 high-volume hospitals, performing at least 10 colectomies yearly. Data, however, were incomplete or missing, in 30.4% of cases.
Discussant Dr. Conor Delaney, chief of colorectal surgery at University Hospitals Case Medical Center, Cleveland, said it was good to see that the percentage of cases performed for three or more episodes rose across all age groups in the final year of the study, suggesting that the SCOAP intervention is likely working.
"It is still shocking to see 30 or 40% of cases being performed for fewer than three attacks," he said, adding that the 30% of patients who had surgery without appropriate indications "may really be, very much a best-case scenario."
He also asked whether the investigators could identify hospitals inside and outside SCOAP that were less likely to follow guidelines and how they dealt with patients who may have had appropriate single-attack surgery because of nonresolution of symptoms or inadequate drainage.
Dr. Simianu said it wasn’t possible to determine indications for hospitals outside the SCOAP network, but that participating hospitals followed a normal distribution. High-volume hospitals were "sort of middle of the road," while four or five low-volume hospitals were outliers and never or always met indications.
In response to the second query, he said their clinical indications included an "other" category that captured appropriate first-attack patients and that about 1% of surgery was performed for an abscess.
The next phase of research will be to go into surgeons’ offices to speak with surgeons and patients to try and quantify the missing indications, Dr. Simianu said.
Dr. Simianu reported funding from the National Institute of Diabetes and Digestive and Kidney Disease, the Agency for Healthcare Research & Quality, and Life Sciences Discovery Fund. Three co-authors reported serving as an advisor, consultant, or speaker for pharmaceutical and device firms.
The complete manuscript of this study and its presentation at the American Surgical Association’s 134th Annual Meeting, April 2014, in Boston, Mass., is anticipated to be published in the Annals of Surgery, pending editorial review.
AT THE ASA ANNUAL MEETING
Major finding: The proportion of cases failing to meet either clinical or episode-based indications was 41.3% in 2010 and 29.6% in 2012 (P = .007).
Data source: A prospective study of 2,031 elective colectomies for diverticulitis at 49 hospitals in SCOAP.
Disclosures: Dr. Simianu reported funding from the National Institute of Diabetes and Digestive and Kidney Disease, the Agency for Healthcare Research & Quality, and Life Sciences Discovery Fund. Three coauthors reported serving as an adviser, consultant, or speaker for pharmaceutical and device firms.
Data derail dogma of elective diverticulitis surgery
BOSTON – The risks of readmission and emergency surgery are low for patients with acute diverticulitis initially managed nonoperatively, a population-based, competing risk analysis found.
At a median of 3.9 years (range, 1.7-6.4 years) after discharge among 14,124 patients, only 8% required urgent readmission. Of these, 22% went on to urgent surgery and 20%, to elective surgery after additional episodes.
Among the remaining 12,981 patients with no urgent readmissions, 9% went on to elective surgery, 13% died of other causes, and 78% had no events in follow-up, Dr. Debbie Li said at the annual meeting of the American Surgical Association.
The 5-year cumulative incidence was 9% for readmission, 1.9% for emergency surgery, and 14.1% for all-cause mortality.
"Elective colectomy may not be warranted for the majority of patients in the absence of chronic symptoms or multiple frequent recurrences," she said.
Elective colectomy has traditionally been recommended for patients at high risk for future recurrence and emergency surgery based on the indications of age less than 50 years, complicated disease including perforation and abscess, and two or more episodes of uncomplicated disease. Evidence is building, however, to challenge these indications, and guidelines are evolving, said Dr. Li, a general surgery resident at the University of Toronto.
The current study used administrative data to identify all patients in Ontario, Canada, treated nonoperatively at first hospitalization for diverticulitis from 2002 to 2012. Time-to-event and competing-risk regression analyses were performed, with data adjusted for such potential confounders as sex, medical comorbidity, neighborhood income quintile, rural residency, and calendar year of index admission.
Data are limited on the natural history of diverticulitis, and the few population-based studies that have been conducted have not accounted for competing risks such as elective colectomy or death, Dr. Li said.
The patients’ median age was 59 years, 79% had uncomplicated index disease, 18% had complicated disease (abscess, fistula, and perforation) with no abscess drain, and 3% had complicated disease with an abscess drain.
Young patients had more readmissions than those 50 years and older (10.5% vs. 8.4%; P less than .001), but not more emergency surgery (1.8% vs. 2.0%; P = .52), she said.
For patients older than 50 years, the risk of death by other causes was 10 times the risk of an emergency surgery for diverticulitis (19.5% vs. 2%).
Patients with complicated rather than uncomplicated index disease had more readmissions (12% vs. 8.2%; P less than .001) and urgent surgery (4.3% vs. 1.4%; P less than .001).
In adjusted analyses, young age was associated with more readmissions (hazard ratio, 1.24), but not subsequent emergency surgery (HR, 0.83). Complicated disease (HR, 3.15) and multiple recurrences (HR, 2.41) predicted an increased risk for emergency surgery.
"Young age, complicated disease, and multiple recurrences do infer increased relative risk, but the vast majority (85%) of such patients remain recurrence free," Dr. Li said.
Invited discussant Dr. David Schoetz, professor of surgery, Tufts University, Boston, said, "While it’s reassuring that even complicated diverticulitis can be safely managed without subsequent operation, there still must be a subgroup who should be offered early surgery."
With disease severity more common in younger patients and overall mortality less than 1%, perhaps aggressive surgery would be justified in those younger than 50 years, he suggested.
Dr. Li responded that an administrative database is unable to capture clinical nuances such as which patients had ongoing symptoms, chronic persistent disease, or reduced quality of life, and that a prospective trial would be needed to identify which subgroup of patients will need aggressive surgery.
Older patients, those with more complicated disease, and those with greater medical comorbidities are more likely to undergo urgent surgery, according to ongoing analyses of roughly 4,000 patients, treated during the same time period, but excluded from the current analysis because they underwent surgery at index admission. Previously published work also suggests that patients with a higher body mass index have poorer outcomes.
A recent systematic review of diverticulitis surgery (JAMA Surg. 2014;149:292-303) reported that complicated recurrence after an episode of uncomplicated diverticulitis is rare, occurring in less than 5% of cases. The authors called for existing guidelines to be updated and said that decisions to proceed with elective surgery should be based instead on patient-reported frequency and severity of symptoms.
The complete manuscript of this study and its presentation at the American Surgical Association’s 134th annual meeting, April 2014, in Boston, is anticipated to be published in the Annals of Surgery, pending editorial review.
Dr. Li and her coauthors reported no relevant financial disclosures.
urgent surgery, elective surgery, Dr. Debbie Li, American Surgical Association, colectomy, abscess, fistula, perforation, abscess drain, Young patients,
BOSTON – The risks of readmission and emergency surgery are low for patients with acute diverticulitis initially managed nonoperatively, a population-based, competing risk analysis found.
At a median of 3.9 years (range, 1.7-6.4 years) after discharge among 14,124 patients, only 8% required urgent readmission. Of these, 22% went on to urgent surgery and 20%, to elective surgery after additional episodes.
Among the remaining 12,981 patients with no urgent readmissions, 9% went on to elective surgery, 13% died of other causes, and 78% had no events in follow-up, Dr. Debbie Li said at the annual meeting of the American Surgical Association.
The 5-year cumulative incidence was 9% for readmission, 1.9% for emergency surgery, and 14.1% for all-cause mortality.
"Elective colectomy may not be warranted for the majority of patients in the absence of chronic symptoms or multiple frequent recurrences," she said.
Elective colectomy has traditionally been recommended for patients at high risk for future recurrence and emergency surgery based on the indications of age less than 50 years, complicated disease including perforation and abscess, and two or more episodes of uncomplicated disease. Evidence is building, however, to challenge these indications, and guidelines are evolving, said Dr. Li, a general surgery resident at the University of Toronto.
The current study used administrative data to identify all patients in Ontario, Canada, treated nonoperatively at first hospitalization for diverticulitis from 2002 to 2012. Time-to-event and competing-risk regression analyses were performed, with data adjusted for such potential confounders as sex, medical comorbidity, neighborhood income quintile, rural residency, and calendar year of index admission.
Data are limited on the natural history of diverticulitis, and the few population-based studies that have been conducted have not accounted for competing risks such as elective colectomy or death, Dr. Li said.
The patients’ median age was 59 years, 79% had uncomplicated index disease, 18% had complicated disease (abscess, fistula, and perforation) with no abscess drain, and 3% had complicated disease with an abscess drain.
Young patients had more readmissions than those 50 years and older (10.5% vs. 8.4%; P less than .001), but not more emergency surgery (1.8% vs. 2.0%; P = .52), she said.
For patients older than 50 years, the risk of death by other causes was 10 times the risk of an emergency surgery for diverticulitis (19.5% vs. 2%).
Patients with complicated rather than uncomplicated index disease had more readmissions (12% vs. 8.2%; P less than .001) and urgent surgery (4.3% vs. 1.4%; P less than .001).
In adjusted analyses, young age was associated with more readmissions (hazard ratio, 1.24), but not subsequent emergency surgery (HR, 0.83). Complicated disease (HR, 3.15) and multiple recurrences (HR, 2.41) predicted an increased risk for emergency surgery.
"Young age, complicated disease, and multiple recurrences do infer increased relative risk, but the vast majority (85%) of such patients remain recurrence free," Dr. Li said.
Invited discussant Dr. David Schoetz, professor of surgery, Tufts University, Boston, said, "While it’s reassuring that even complicated diverticulitis can be safely managed without subsequent operation, there still must be a subgroup who should be offered early surgery."
With disease severity more common in younger patients and overall mortality less than 1%, perhaps aggressive surgery would be justified in those younger than 50 years, he suggested.
Dr. Li responded that an administrative database is unable to capture clinical nuances such as which patients had ongoing symptoms, chronic persistent disease, or reduced quality of life, and that a prospective trial would be needed to identify which subgroup of patients will need aggressive surgery.
Older patients, those with more complicated disease, and those with greater medical comorbidities are more likely to undergo urgent surgery, according to ongoing analyses of roughly 4,000 patients, treated during the same time period, but excluded from the current analysis because they underwent surgery at index admission. Previously published work also suggests that patients with a higher body mass index have poorer outcomes.
A recent systematic review of diverticulitis surgery (JAMA Surg. 2014;149:292-303) reported that complicated recurrence after an episode of uncomplicated diverticulitis is rare, occurring in less than 5% of cases. The authors called for existing guidelines to be updated and said that decisions to proceed with elective surgery should be based instead on patient-reported frequency and severity of symptoms.
The complete manuscript of this study and its presentation at the American Surgical Association’s 134th annual meeting, April 2014, in Boston, is anticipated to be published in the Annals of Surgery, pending editorial review.
Dr. Li and her coauthors reported no relevant financial disclosures.
BOSTON – The risks of readmission and emergency surgery are low for patients with acute diverticulitis initially managed nonoperatively, a population-based, competing risk analysis found.
At a median of 3.9 years (range, 1.7-6.4 years) after discharge among 14,124 patients, only 8% required urgent readmission. Of these, 22% went on to urgent surgery and 20%, to elective surgery after additional episodes.
Among the remaining 12,981 patients with no urgent readmissions, 9% went on to elective surgery, 13% died of other causes, and 78% had no events in follow-up, Dr. Debbie Li said at the annual meeting of the American Surgical Association.
The 5-year cumulative incidence was 9% for readmission, 1.9% for emergency surgery, and 14.1% for all-cause mortality.
"Elective colectomy may not be warranted for the majority of patients in the absence of chronic symptoms or multiple frequent recurrences," she said.
Elective colectomy has traditionally been recommended for patients at high risk for future recurrence and emergency surgery based on the indications of age less than 50 years, complicated disease including perforation and abscess, and two or more episodes of uncomplicated disease. Evidence is building, however, to challenge these indications, and guidelines are evolving, said Dr. Li, a general surgery resident at the University of Toronto.
The current study used administrative data to identify all patients in Ontario, Canada, treated nonoperatively at first hospitalization for diverticulitis from 2002 to 2012. Time-to-event and competing-risk regression analyses were performed, with data adjusted for such potential confounders as sex, medical comorbidity, neighborhood income quintile, rural residency, and calendar year of index admission.
Data are limited on the natural history of diverticulitis, and the few population-based studies that have been conducted have not accounted for competing risks such as elective colectomy or death, Dr. Li said.
The patients’ median age was 59 years, 79% had uncomplicated index disease, 18% had complicated disease (abscess, fistula, and perforation) with no abscess drain, and 3% had complicated disease with an abscess drain.
Young patients had more readmissions than those 50 years and older (10.5% vs. 8.4%; P less than .001), but not more emergency surgery (1.8% vs. 2.0%; P = .52), she said.
For patients older than 50 years, the risk of death by other causes was 10 times the risk of an emergency surgery for diverticulitis (19.5% vs. 2%).
Patients with complicated rather than uncomplicated index disease had more readmissions (12% vs. 8.2%; P less than .001) and urgent surgery (4.3% vs. 1.4%; P less than .001).
In adjusted analyses, young age was associated with more readmissions (hazard ratio, 1.24), but not subsequent emergency surgery (HR, 0.83). Complicated disease (HR, 3.15) and multiple recurrences (HR, 2.41) predicted an increased risk for emergency surgery.
"Young age, complicated disease, and multiple recurrences do infer increased relative risk, but the vast majority (85%) of such patients remain recurrence free," Dr. Li said.
Invited discussant Dr. David Schoetz, professor of surgery, Tufts University, Boston, said, "While it’s reassuring that even complicated diverticulitis can be safely managed without subsequent operation, there still must be a subgroup who should be offered early surgery."
With disease severity more common in younger patients and overall mortality less than 1%, perhaps aggressive surgery would be justified in those younger than 50 years, he suggested.
Dr. Li responded that an administrative database is unable to capture clinical nuances such as which patients had ongoing symptoms, chronic persistent disease, or reduced quality of life, and that a prospective trial would be needed to identify which subgroup of patients will need aggressive surgery.
Older patients, those with more complicated disease, and those with greater medical comorbidities are more likely to undergo urgent surgery, according to ongoing analyses of roughly 4,000 patients, treated during the same time period, but excluded from the current analysis because they underwent surgery at index admission. Previously published work also suggests that patients with a higher body mass index have poorer outcomes.
A recent systematic review of diverticulitis surgery (JAMA Surg. 2014;149:292-303) reported that complicated recurrence after an episode of uncomplicated diverticulitis is rare, occurring in less than 5% of cases. The authors called for existing guidelines to be updated and said that decisions to proceed with elective surgery should be based instead on patient-reported frequency and severity of symptoms.
The complete manuscript of this study and its presentation at the American Surgical Association’s 134th annual meeting, April 2014, in Boston, is anticipated to be published in the Annals of Surgery, pending editorial review.
Dr. Li and her coauthors reported no relevant financial disclosures.
urgent surgery, elective surgery, Dr. Debbie Li, American Surgical Association, colectomy, abscess, fistula, perforation, abscess drain, Young patients,
urgent surgery, elective surgery, Dr. Debbie Li, American Surgical Association, colectomy, abscess, fistula, perforation, abscess drain, Young patients,
AT ASA 2014
Key clinical point: As recurrence is very rare, conservative nonoperative treatment should be considered first.
Major finding: The 5-year cumulative incidence was 9% for readmission, 1.9% for emergency surgery, and 14.1% for all-cause mortality.
Data source: A population-based, competing risk analysis of 14,124 patients with initial nonoperative management of diverticulitis.
Disclosures: Dr. Li and her coauthors reported no relevant financial disclosures.
Sacral nerve stimulation reduced irritable bowel symptoms
Permanent sacral nerve stimulation looked promising in a prospective, randomized controlled study to reduce symptoms in a select group of 21 adults with diarrhea-predominant or mixed irritable bowel syndrome.
In this crossover trial, all patients had sacral nerve stimulators implanted. One group had the stimulator turned on for 1 month and off the next month, while the other group had the opposite – the stimulator was off and then on during those same time periods. Active stimulation improved symptom scores as measured by the Gastrointestinal Symptom Rating Scale – Irritable Bowel Syndrome (GSRS-IBS).
The median change in symptom scores between months 1 and 2 differed significantly between the two groups. In the group that had the stimulator on and then off, symptom scores increased by a median of 12 points. In the group that had the stimulator off and then on, scores decreased by a median of 18 points, Janne L. Fassov, Ph.D., and associates reported.
One year later, with sacral nerve stimulation continuing and data available from 19 patients, the median GSRS-IBS score of 25 was significantly lower than the median symptom score of 62 at baseline, reported Dr. Fassov of Aarhus (Denmark) University Hospital.
The Annals of Surgery published the findings online ahead of print (2014 Feb. 6 [doi:10.1097/SLA.000000000000559]).
The investigators recruited 43 patients from their tertiary care institution who had failed standard treatments for diarrhea-predominant or mixed irritable bowel syndrome. After undergoing a percutaneous nerve evaluation under general anesthesia, they underwent 3 weeks of stimulation using a test electrode connected to an external neurostimulator. Thirty-one patients who had at least a 30% reduction in GSRS-IBS symptom scores during the 3-week test period were offered permanent implantation of the neurostimulator. Patients worked with a nurse specialist for 1-20 months after implantation to individually optimize the stimulator settings for best symptom control before being randomized in the current study.
Two patients who became pregnant and three who withdrew consent did not get stimulators. Five of 26 patients with permanent implantation were excluded from the results, two because of gastric bypass procedures before the crossover month, one who was mentally unstable, and two who refused to have the stimulator turned off because of its excellent effects.
Although patients and investigators were not told when the stimulators were on or off, patients usually could sense when they were on, so the study was not truly blinded.
One of the 21 remaining patients withdrew from the study before finishing it after needing morphine to relieve abdominal pain during the month that the neurostimulator was off.
In the 20 patients who completed the study, quality of life scores on the Irritable Bowel Syndrome Impact Scale (IBS-IS) improved during the month with stimulation. When stimulation went from on to off, IBS-IS scores increased by a median of 16 points. When stimulation went from off to on, IBS-IS scores decreased by a median of 42 points. The difference in median changes between the two groups was statistically significant.
Scores improved significantly with stimulation in all five domains of the symptom scale (pain, bloating, constipation, diarrhea, and satiety) and in all five domains of the quality of life scale (fatigue, daily impaired activities, sleep, emotional distress, and eating habits).
Ten device-related adverse events in seven patients included elective revision of the lead for suspected migration in two patients, persistent postoperative pain at the implantation site requiring relocation of the pacemaker in three patients, recurrent cystitis in one patient that resolved with triple voiding, and spontaneously resolving postoperative pain at the implantation site in four patients.
Sacral nerve stimulation is a well-established, cost-effective treatment for fecal incontinence, and the effects of stimulation for inflammatory bowel disease in this study were similar to those that have been reported for fecal incontinence, the investigators noted. Because minor complications are common with sacral nerve stimulation, this treatment should be reserved for patients with inflammatory bowel disease who do not respond to pharmacotherapy, they suggested.
Medtronic provided its neurostimulators for the study free of charge. Some of Dr. Fassov’s associates in the study have been speakers and/or advisers for Medtronic. The Danish Council for Strategic Research funded the study.
On Twitter @sherryboschert
Permanent sacral nerve stimulation looked promising in a prospective, randomized controlled study to reduce symptoms in a select group of 21 adults with diarrhea-predominant or mixed irritable bowel syndrome.
In this crossover trial, all patients had sacral nerve stimulators implanted. One group had the stimulator turned on for 1 month and off the next month, while the other group had the opposite – the stimulator was off and then on during those same time periods. Active stimulation improved symptom scores as measured by the Gastrointestinal Symptom Rating Scale – Irritable Bowel Syndrome (GSRS-IBS).
The median change in symptom scores between months 1 and 2 differed significantly between the two groups. In the group that had the stimulator on and then off, symptom scores increased by a median of 12 points. In the group that had the stimulator off and then on, scores decreased by a median of 18 points, Janne L. Fassov, Ph.D., and associates reported.
One year later, with sacral nerve stimulation continuing and data available from 19 patients, the median GSRS-IBS score of 25 was significantly lower than the median symptom score of 62 at baseline, reported Dr. Fassov of Aarhus (Denmark) University Hospital.
The Annals of Surgery published the findings online ahead of print (2014 Feb. 6 [doi:10.1097/SLA.000000000000559]).
The investigators recruited 43 patients from their tertiary care institution who had failed standard treatments for diarrhea-predominant or mixed irritable bowel syndrome. After undergoing a percutaneous nerve evaluation under general anesthesia, they underwent 3 weeks of stimulation using a test electrode connected to an external neurostimulator. Thirty-one patients who had at least a 30% reduction in GSRS-IBS symptom scores during the 3-week test period were offered permanent implantation of the neurostimulator. Patients worked with a nurse specialist for 1-20 months after implantation to individually optimize the stimulator settings for best symptom control before being randomized in the current study.
Two patients who became pregnant and three who withdrew consent did not get stimulators. Five of 26 patients with permanent implantation were excluded from the results, two because of gastric bypass procedures before the crossover month, one who was mentally unstable, and two who refused to have the stimulator turned off because of its excellent effects.
Although patients and investigators were not told when the stimulators were on or off, patients usually could sense when they were on, so the study was not truly blinded.
One of the 21 remaining patients withdrew from the study before finishing it after needing morphine to relieve abdominal pain during the month that the neurostimulator was off.
In the 20 patients who completed the study, quality of life scores on the Irritable Bowel Syndrome Impact Scale (IBS-IS) improved during the month with stimulation. When stimulation went from on to off, IBS-IS scores increased by a median of 16 points. When stimulation went from off to on, IBS-IS scores decreased by a median of 42 points. The difference in median changes between the two groups was statistically significant.
Scores improved significantly with stimulation in all five domains of the symptom scale (pain, bloating, constipation, diarrhea, and satiety) and in all five domains of the quality of life scale (fatigue, daily impaired activities, sleep, emotional distress, and eating habits).
Ten device-related adverse events in seven patients included elective revision of the lead for suspected migration in two patients, persistent postoperative pain at the implantation site requiring relocation of the pacemaker in three patients, recurrent cystitis in one patient that resolved with triple voiding, and spontaneously resolving postoperative pain at the implantation site in four patients.
Sacral nerve stimulation is a well-established, cost-effective treatment for fecal incontinence, and the effects of stimulation for inflammatory bowel disease in this study were similar to those that have been reported for fecal incontinence, the investigators noted. Because minor complications are common with sacral nerve stimulation, this treatment should be reserved for patients with inflammatory bowel disease who do not respond to pharmacotherapy, they suggested.
Medtronic provided its neurostimulators for the study free of charge. Some of Dr. Fassov’s associates in the study have been speakers and/or advisers for Medtronic. The Danish Council for Strategic Research funded the study.
On Twitter @sherryboschert
Permanent sacral nerve stimulation looked promising in a prospective, randomized controlled study to reduce symptoms in a select group of 21 adults with diarrhea-predominant or mixed irritable bowel syndrome.
In this crossover trial, all patients had sacral nerve stimulators implanted. One group had the stimulator turned on for 1 month and off the next month, while the other group had the opposite – the stimulator was off and then on during those same time periods. Active stimulation improved symptom scores as measured by the Gastrointestinal Symptom Rating Scale – Irritable Bowel Syndrome (GSRS-IBS).
The median change in symptom scores between months 1 and 2 differed significantly between the two groups. In the group that had the stimulator on and then off, symptom scores increased by a median of 12 points. In the group that had the stimulator off and then on, scores decreased by a median of 18 points, Janne L. Fassov, Ph.D., and associates reported.
One year later, with sacral nerve stimulation continuing and data available from 19 patients, the median GSRS-IBS score of 25 was significantly lower than the median symptom score of 62 at baseline, reported Dr. Fassov of Aarhus (Denmark) University Hospital.
The Annals of Surgery published the findings online ahead of print (2014 Feb. 6 [doi:10.1097/SLA.000000000000559]).
The investigators recruited 43 patients from their tertiary care institution who had failed standard treatments for diarrhea-predominant or mixed irritable bowel syndrome. After undergoing a percutaneous nerve evaluation under general anesthesia, they underwent 3 weeks of stimulation using a test electrode connected to an external neurostimulator. Thirty-one patients who had at least a 30% reduction in GSRS-IBS symptom scores during the 3-week test period were offered permanent implantation of the neurostimulator. Patients worked with a nurse specialist for 1-20 months after implantation to individually optimize the stimulator settings for best symptom control before being randomized in the current study.
Two patients who became pregnant and three who withdrew consent did not get stimulators. Five of 26 patients with permanent implantation were excluded from the results, two because of gastric bypass procedures before the crossover month, one who was mentally unstable, and two who refused to have the stimulator turned off because of its excellent effects.
Although patients and investigators were not told when the stimulators were on or off, patients usually could sense when they were on, so the study was not truly blinded.
One of the 21 remaining patients withdrew from the study before finishing it after needing morphine to relieve abdominal pain during the month that the neurostimulator was off.
In the 20 patients who completed the study, quality of life scores on the Irritable Bowel Syndrome Impact Scale (IBS-IS) improved during the month with stimulation. When stimulation went from on to off, IBS-IS scores increased by a median of 16 points. When stimulation went from off to on, IBS-IS scores decreased by a median of 42 points. The difference in median changes between the two groups was statistically significant.
Scores improved significantly with stimulation in all five domains of the symptom scale (pain, bloating, constipation, diarrhea, and satiety) and in all five domains of the quality of life scale (fatigue, daily impaired activities, sleep, emotional distress, and eating habits).
Ten device-related adverse events in seven patients included elective revision of the lead for suspected migration in two patients, persistent postoperative pain at the implantation site requiring relocation of the pacemaker in three patients, recurrent cystitis in one patient that resolved with triple voiding, and spontaneously resolving postoperative pain at the implantation site in four patients.
Sacral nerve stimulation is a well-established, cost-effective treatment for fecal incontinence, and the effects of stimulation for inflammatory bowel disease in this study were similar to those that have been reported for fecal incontinence, the investigators noted. Because minor complications are common with sacral nerve stimulation, this treatment should be reserved for patients with inflammatory bowel disease who do not respond to pharmacotherapy, they suggested.
Medtronic provided its neurostimulators for the study free of charge. Some of Dr. Fassov’s associates in the study have been speakers and/or advisers for Medtronic. The Danish Council for Strategic Research funded the study.
On Twitter @sherryboschert
FROM ANNALS OF SURGERY
Major finding: Median symptom scores worsened by 12 points between months when the stimulator was on and then off and improved by 18 points between months when the stimulator was off and then on, a significant difference.
Data source: A prospective, randomized, controlled crossover study of 21 patients with diarrhea-predominant or mixed irritable bowel syndrome at a single institution.
Disclosures: Medtronic provided the neurostimulators for the study free of charge and some of Dr. Fassov’s associates in the study have been speakers and/or advisers for Medtronic. The Danish Council for Strategic Research funded the study.
Strong nerves, teamwork key in managing neurosurgical patients, devices
SCOTTSDALE, ARIZ. – Comanaging neurosurgical patients requires a delicate dance between primary practitioners, surgeons, anesthesiologists, and, in some cases, the makers of implantable neurostimulators, according to perioperative medicine specialists.
Special considerations with patients scheduled for neurosurgical procedures include hypertension, fever, hyponatremia, and risk of deep vein thromboembolism (DVT) and coagulopathies, said Dr. Richard Huh, director of the inpatient medical consultation service at Rush University Medical Center in Chicago, at a meeting on perioperative medicine sponsored by the University of Miami.
For example, hospitalists are typically involved in the management of blood pressure in neurosurgery patients because of the importance of controlling intracranial pressure, Dr. Huh noted.
"The trick is for the blood pressure not to get too high or too low. The Handbook of Neurosurgery suggests a goal of 140 over 90 [mm Hg]," he said.
Patients with acute subarachnoid hemorrhage are at risk for vasospasm, most frequently within 7-10 days of hemorrhage. Hypovolemia is a common cause of vasospasm and should be avoided. Medications such as nimodipine (Nimotop) can help prevent this complication.
Patients undergoing spinal procedures tend to have low blood pressure from acute blood loss or intravenous pain medications, and may require hold parameters on medications to avoid complications from hypotension.
However, on the day following spinal surgery, some patients develop hypertension, and may require additional medications for BP control.
Hyponatremia
The reported prevalence of hyponatremia in hospitalized patients ranges from 1%-7%, and the rate is even higher in neurosurgical patients, possibility because the brain’s response to changes in osmolality. Clinicians managing neurosurgical patients should be aware of the syndrome of inappropriate antidiuretic hormone secretion (SIADH) and cerebral salt wasting, Dr. Huh said.
Cerebral salt wasting may be cause by damaged brain cells that affect sympathetic neural input to the kidneys, decreasing sodium resorption and an increase in atrial natriuretic peptide and brain natriuretic peptide.
The syndrome looks similar to SIADH, with high urinary sodium and osmolality, low serum osmolality, and decreased serum uric acid. But cerebral salt wasting is distinguished from SIADH by the presence of hypovolemia. Cerebral salt wasting is treated with saline and/or salt tablets.
DVT
Neurosurgical patients are at increased risk for DVT and pulmonary embolism compared with the general postoperative population. However, 2012 guidelines on antithrombotic therapy from the American College of Chest Physicians recommend against pharmacologic prophylaxis except for high risk patients, such as patients with intracranial masses. Dr. Huh said.
Implantable neurostimulators
Patients with implanted devices such as deep-brain stimulators for control of Parkinson’s disease, hypoglossal nerve stimulators for severe sleep apnea, or vagal nerve stimulators for epilepsy also require special consideration throughout the perioperative period.
Issues to consider when managing a patient with an implantable device include the device site and its proximity to the planned surgical field, indication for the device, comorbidities, and the patient’s goals for treatment, said Dr. Deborah Richman, section chief of preoperative services at Stony Brook (New York) University Medical Center.
"What do we do with device itself? This is a team approach, and we find that it’s best coordinated by our nurses in the preop holding area, because they know what time the surgery is, they have the device company rep’s phone number, they make sure the patient is there on time, and they put everything together to prevent delays on the day of surgery," she said.
In general, device manufacturers recommend turning devices off, and to turn the amplitude down to zero to prevent accidental activation of magnetic on-off switches.
The distance from the surgery to the pulse generator should be a minimum of 20 cm, and electrocautery, if used, should be bipolar rather than monopolar, Dr. Richman said.
Patients with implanted devices will also require prophylactic antibiotics to prevent potential bacterial seeding of the device or leads, she said,
Coordination of perioperative care "is best done with clinical management pathways, so that when you have one of these patients who present to you, you have a checklist that includes the device company’s phone number, and it’s an easy go-to, so that you don’t have to start from scratch each time," she concluded.
Dr. Huh and Dr. Richman reported having no financial disclosures.
SCOTTSDALE, ARIZ. – Comanaging neurosurgical patients requires a delicate dance between primary practitioners, surgeons, anesthesiologists, and, in some cases, the makers of implantable neurostimulators, according to perioperative medicine specialists.
Special considerations with patients scheduled for neurosurgical procedures include hypertension, fever, hyponatremia, and risk of deep vein thromboembolism (DVT) and coagulopathies, said Dr. Richard Huh, director of the inpatient medical consultation service at Rush University Medical Center in Chicago, at a meeting on perioperative medicine sponsored by the University of Miami.
For example, hospitalists are typically involved in the management of blood pressure in neurosurgery patients because of the importance of controlling intracranial pressure, Dr. Huh noted.
"The trick is for the blood pressure not to get too high or too low. The Handbook of Neurosurgery suggests a goal of 140 over 90 [mm Hg]," he said.
Patients with acute subarachnoid hemorrhage are at risk for vasospasm, most frequently within 7-10 days of hemorrhage. Hypovolemia is a common cause of vasospasm and should be avoided. Medications such as nimodipine (Nimotop) can help prevent this complication.
Patients undergoing spinal procedures tend to have low blood pressure from acute blood loss or intravenous pain medications, and may require hold parameters on medications to avoid complications from hypotension.
However, on the day following spinal surgery, some patients develop hypertension, and may require additional medications for BP control.
Hyponatremia
The reported prevalence of hyponatremia in hospitalized patients ranges from 1%-7%, and the rate is even higher in neurosurgical patients, possibility because the brain’s response to changes in osmolality. Clinicians managing neurosurgical patients should be aware of the syndrome of inappropriate antidiuretic hormone secretion (SIADH) and cerebral salt wasting, Dr. Huh said.
Cerebral salt wasting may be cause by damaged brain cells that affect sympathetic neural input to the kidneys, decreasing sodium resorption and an increase in atrial natriuretic peptide and brain natriuretic peptide.
The syndrome looks similar to SIADH, with high urinary sodium and osmolality, low serum osmolality, and decreased serum uric acid. But cerebral salt wasting is distinguished from SIADH by the presence of hypovolemia. Cerebral salt wasting is treated with saline and/or salt tablets.
DVT
Neurosurgical patients are at increased risk for DVT and pulmonary embolism compared with the general postoperative population. However, 2012 guidelines on antithrombotic therapy from the American College of Chest Physicians recommend against pharmacologic prophylaxis except for high risk patients, such as patients with intracranial masses. Dr. Huh said.
Implantable neurostimulators
Patients with implanted devices such as deep-brain stimulators for control of Parkinson’s disease, hypoglossal nerve stimulators for severe sleep apnea, or vagal nerve stimulators for epilepsy also require special consideration throughout the perioperative period.
Issues to consider when managing a patient with an implantable device include the device site and its proximity to the planned surgical field, indication for the device, comorbidities, and the patient’s goals for treatment, said Dr. Deborah Richman, section chief of preoperative services at Stony Brook (New York) University Medical Center.
"What do we do with device itself? This is a team approach, and we find that it’s best coordinated by our nurses in the preop holding area, because they know what time the surgery is, they have the device company rep’s phone number, they make sure the patient is there on time, and they put everything together to prevent delays on the day of surgery," she said.
In general, device manufacturers recommend turning devices off, and to turn the amplitude down to zero to prevent accidental activation of magnetic on-off switches.
The distance from the surgery to the pulse generator should be a minimum of 20 cm, and electrocautery, if used, should be bipolar rather than monopolar, Dr. Richman said.
Patients with implanted devices will also require prophylactic antibiotics to prevent potential bacterial seeding of the device or leads, she said,
Coordination of perioperative care "is best done with clinical management pathways, so that when you have one of these patients who present to you, you have a checklist that includes the device company’s phone number, and it’s an easy go-to, so that you don’t have to start from scratch each time," she concluded.
Dr. Huh and Dr. Richman reported having no financial disclosures.
SCOTTSDALE, ARIZ. – Comanaging neurosurgical patients requires a delicate dance between primary practitioners, surgeons, anesthesiologists, and, in some cases, the makers of implantable neurostimulators, according to perioperative medicine specialists.
Special considerations with patients scheduled for neurosurgical procedures include hypertension, fever, hyponatremia, and risk of deep vein thromboembolism (DVT) and coagulopathies, said Dr. Richard Huh, director of the inpatient medical consultation service at Rush University Medical Center in Chicago, at a meeting on perioperative medicine sponsored by the University of Miami.
For example, hospitalists are typically involved in the management of blood pressure in neurosurgery patients because of the importance of controlling intracranial pressure, Dr. Huh noted.
"The trick is for the blood pressure not to get too high or too low. The Handbook of Neurosurgery suggests a goal of 140 over 90 [mm Hg]," he said.
Patients with acute subarachnoid hemorrhage are at risk for vasospasm, most frequently within 7-10 days of hemorrhage. Hypovolemia is a common cause of vasospasm and should be avoided. Medications such as nimodipine (Nimotop) can help prevent this complication.
Patients undergoing spinal procedures tend to have low blood pressure from acute blood loss or intravenous pain medications, and may require hold parameters on medications to avoid complications from hypotension.
However, on the day following spinal surgery, some patients develop hypertension, and may require additional medications for BP control.
Hyponatremia
The reported prevalence of hyponatremia in hospitalized patients ranges from 1%-7%, and the rate is even higher in neurosurgical patients, possibility because the brain’s response to changes in osmolality. Clinicians managing neurosurgical patients should be aware of the syndrome of inappropriate antidiuretic hormone secretion (SIADH) and cerebral salt wasting, Dr. Huh said.
Cerebral salt wasting may be cause by damaged brain cells that affect sympathetic neural input to the kidneys, decreasing sodium resorption and an increase in atrial natriuretic peptide and brain natriuretic peptide.
The syndrome looks similar to SIADH, with high urinary sodium and osmolality, low serum osmolality, and decreased serum uric acid. But cerebral salt wasting is distinguished from SIADH by the presence of hypovolemia. Cerebral salt wasting is treated with saline and/or salt tablets.
DVT
Neurosurgical patients are at increased risk for DVT and pulmonary embolism compared with the general postoperative population. However, 2012 guidelines on antithrombotic therapy from the American College of Chest Physicians recommend against pharmacologic prophylaxis except for high risk patients, such as patients with intracranial masses. Dr. Huh said.
Implantable neurostimulators
Patients with implanted devices such as deep-brain stimulators for control of Parkinson’s disease, hypoglossal nerve stimulators for severe sleep apnea, or vagal nerve stimulators for epilepsy also require special consideration throughout the perioperative period.
Issues to consider when managing a patient with an implantable device include the device site and its proximity to the planned surgical field, indication for the device, comorbidities, and the patient’s goals for treatment, said Dr. Deborah Richman, section chief of preoperative services at Stony Brook (New York) University Medical Center.
"What do we do with device itself? This is a team approach, and we find that it’s best coordinated by our nurses in the preop holding area, because they know what time the surgery is, they have the device company rep’s phone number, they make sure the patient is there on time, and they put everything together to prevent delays on the day of surgery," she said.
In general, device manufacturers recommend turning devices off, and to turn the amplitude down to zero to prevent accidental activation of magnetic on-off switches.
The distance from the surgery to the pulse generator should be a minimum of 20 cm, and electrocautery, if used, should be bipolar rather than monopolar, Dr. Richman said.
Patients with implanted devices will also require prophylactic antibiotics to prevent potential bacterial seeding of the device or leads, she said,
Coordination of perioperative care "is best done with clinical management pathways, so that when you have one of these patients who present to you, you have a checklist that includes the device company’s phone number, and it’s an easy go-to, so that you don’t have to start from scratch each time," she concluded.
Dr. Huh and Dr. Richman reported having no financial disclosures.
AT THE PERIOPERATIVE MEDICINE SUMMIT
Major finding: Neurosurgical procedures are associated with increased risk for complications, such as hyponatremia and deep vein thromboembolism, compared with general surgeries.
Data source: Reviews of recommendations on the perioperative management of neurosurgical patients and those with implanted neurostimulating devices.
Disclosures: Dr. Huh and Dr. Richman reported having no financial disclosures.
Defining patients’ risk helps prevent postop urinary retention
SCOTTSDALE, ARIZ. – Early hospital readmissions are not good for patients and can be terrible for a hospital’s bottom line, but at least one cause of readmission – urinary retention after surgery – can be significantly reduced.
"Postoperative urinary retention is a prevalent and mostly avoidable complication," said Dr. Sarita Khemani, a surgical comanagement hospitalist at Stanford (Calif.) University Medical Center.
Postoperative urinary retention can be defined as the inability to void in the presence of symptoms or bladder distension. However, as some patients may retain urine without feeling symptoms or the urge to void, it can also be defined as the inability to void with a bladder volume greater than 500 mL, or the presence of a postvoid residual volume greater than 200 mL on bladder scan, she said at a meeting on perioperative medicine sponsored by the University of Miami.
Identify high-risk patients
"For management, identifying the high-risk patient is very important," said Dr. Khemani.
She and her colleagues are working to develop a scoring system for identifying patients at risk for postoperative retention, she noted.
Depending on the risk factor, patients may require continued use of benign prostatic hyperplasia (BPH) medications (a strategy currently under clinical investigation), multimodal anesthesia, monitoring of IV fluids during and after surgery, and, when necessary, catheterization.
"There is really no consensus as to what is the best catheterization strategy we should use when it comes to urinary retention," Dr. Khemani said.
Low-risk patients undergoing outpatient procedures can be safely sent home without voiding, she said. High-risk patients undergoing ambulatory surgery can be managed with intermittent catheterization.
Patients who are undergoing major but uncomplicated surgery but are at low risk for postoperative retention do not generally need to have Foley catheters placed before surgery. Indwelling catheters should be limited, if possible, to 24 hours after surgery, and the patient can be managed with bladder scans every 6 hours if needed.
Patients scheduled for extensive, complicated procedures and those at high risk may require an indwelling catheter for up to 5 days after surgery. Studies have shown that in these patients early catheter removal actually increases the risk for postoperative urinary retention, Dr. Khemani said.
"It really needs to be followed by bladder scanning very closely, every 6 hours, to try to prevent overdistention and complications after that," she said.
The incidence of postoperative urinary retention among general surgery patients is 3.8%, but can range as high 70% after orthopedic surgery, 50% after anorectal procedures, 40% following spinal surgeries, and 38% after herniorrhaphy, Dr. Khemani said.
Preoperative risk factors for urinary retention after surgery include age over 50; male sex; history of retention; BPH; history of diabetes, stroke, or spinal lesions; or use of drugs such anticholinergic agents or beta-blockers.
Intraoperative and postoperative risk factors include the type and duration of surgery, anesthesia (especially spinal and epidural anethesias), systemic analgesia with opioids (especially patient-controlled analgesia, or PCA), and the use of intraoperative intravenous fluids. High IV fluid infusion causes rapid distention of the bladder detrusor muscles, leading to inability of the muscles to contract after surgery, Dr. Khemani noted.
Complications of postoperative urinary retention can include:
• Autonomic responses to bladder distention, leading to effects such as bradycardia, hypotension, vomiting, and delirium in some elderly patients.
• Infectious complications – urinary tract infections, sepsis, and joint infections.
• Prolonged need for catheterization.
• Bladder dysfunction.
A recent systematic review of drugs for treatment of urinary retention after surgery in adults found that of seven studies involving a total of 494 patients, neither cholinergic agents, alpha blockers, nor sedatives made a significant difference in reducing the incidence of retention. Only prostaglandins, and only when those agents were given intravesically, appeared to offer any benefit, the authors found.
"At this point we definitely need more studies to look at pharmacological alternatives to catheterization for treatment and prevention of this condition," Dr. Khemani concluded.
She reported having no financial disclosures.
SCOTTSDALE, ARIZ. – Early hospital readmissions are not good for patients and can be terrible for a hospital’s bottom line, but at least one cause of readmission – urinary retention after surgery – can be significantly reduced.
"Postoperative urinary retention is a prevalent and mostly avoidable complication," said Dr. Sarita Khemani, a surgical comanagement hospitalist at Stanford (Calif.) University Medical Center.
Postoperative urinary retention can be defined as the inability to void in the presence of symptoms or bladder distension. However, as some patients may retain urine without feeling symptoms or the urge to void, it can also be defined as the inability to void with a bladder volume greater than 500 mL, or the presence of a postvoid residual volume greater than 200 mL on bladder scan, she said at a meeting on perioperative medicine sponsored by the University of Miami.
Identify high-risk patients
"For management, identifying the high-risk patient is very important," said Dr. Khemani.
She and her colleagues are working to develop a scoring system for identifying patients at risk for postoperative retention, she noted.
Depending on the risk factor, patients may require continued use of benign prostatic hyperplasia (BPH) medications (a strategy currently under clinical investigation), multimodal anesthesia, monitoring of IV fluids during and after surgery, and, when necessary, catheterization.
"There is really no consensus as to what is the best catheterization strategy we should use when it comes to urinary retention," Dr. Khemani said.
Low-risk patients undergoing outpatient procedures can be safely sent home without voiding, she said. High-risk patients undergoing ambulatory surgery can be managed with intermittent catheterization.
Patients who are undergoing major but uncomplicated surgery but are at low risk for postoperative retention do not generally need to have Foley catheters placed before surgery. Indwelling catheters should be limited, if possible, to 24 hours after surgery, and the patient can be managed with bladder scans every 6 hours if needed.
Patients scheduled for extensive, complicated procedures and those at high risk may require an indwelling catheter for up to 5 days after surgery. Studies have shown that in these patients early catheter removal actually increases the risk for postoperative urinary retention, Dr. Khemani said.
"It really needs to be followed by bladder scanning very closely, every 6 hours, to try to prevent overdistention and complications after that," she said.
The incidence of postoperative urinary retention among general surgery patients is 3.8%, but can range as high 70% after orthopedic surgery, 50% after anorectal procedures, 40% following spinal surgeries, and 38% after herniorrhaphy, Dr. Khemani said.
Preoperative risk factors for urinary retention after surgery include age over 50; male sex; history of retention; BPH; history of diabetes, stroke, or spinal lesions; or use of drugs such anticholinergic agents or beta-blockers.
Intraoperative and postoperative risk factors include the type and duration of surgery, anesthesia (especially spinal and epidural anethesias), systemic analgesia with opioids (especially patient-controlled analgesia, or PCA), and the use of intraoperative intravenous fluids. High IV fluid infusion causes rapid distention of the bladder detrusor muscles, leading to inability of the muscles to contract after surgery, Dr. Khemani noted.
Complications of postoperative urinary retention can include:
• Autonomic responses to bladder distention, leading to effects such as bradycardia, hypotension, vomiting, and delirium in some elderly patients.
• Infectious complications – urinary tract infections, sepsis, and joint infections.
• Prolonged need for catheterization.
• Bladder dysfunction.
A recent systematic review of drugs for treatment of urinary retention after surgery in adults found that of seven studies involving a total of 494 patients, neither cholinergic agents, alpha blockers, nor sedatives made a significant difference in reducing the incidence of retention. Only prostaglandins, and only when those agents were given intravesically, appeared to offer any benefit, the authors found.
"At this point we definitely need more studies to look at pharmacological alternatives to catheterization for treatment and prevention of this condition," Dr. Khemani concluded.
She reported having no financial disclosures.
SCOTTSDALE, ARIZ. – Early hospital readmissions are not good for patients and can be terrible for a hospital’s bottom line, but at least one cause of readmission – urinary retention after surgery – can be significantly reduced.
"Postoperative urinary retention is a prevalent and mostly avoidable complication," said Dr. Sarita Khemani, a surgical comanagement hospitalist at Stanford (Calif.) University Medical Center.
Postoperative urinary retention can be defined as the inability to void in the presence of symptoms or bladder distension. However, as some patients may retain urine without feeling symptoms or the urge to void, it can also be defined as the inability to void with a bladder volume greater than 500 mL, or the presence of a postvoid residual volume greater than 200 mL on bladder scan, she said at a meeting on perioperative medicine sponsored by the University of Miami.
Identify high-risk patients
"For management, identifying the high-risk patient is very important," said Dr. Khemani.
She and her colleagues are working to develop a scoring system for identifying patients at risk for postoperative retention, she noted.
Depending on the risk factor, patients may require continued use of benign prostatic hyperplasia (BPH) medications (a strategy currently under clinical investigation), multimodal anesthesia, monitoring of IV fluids during and after surgery, and, when necessary, catheterization.
"There is really no consensus as to what is the best catheterization strategy we should use when it comes to urinary retention," Dr. Khemani said.
Low-risk patients undergoing outpatient procedures can be safely sent home without voiding, she said. High-risk patients undergoing ambulatory surgery can be managed with intermittent catheterization.
Patients who are undergoing major but uncomplicated surgery but are at low risk for postoperative retention do not generally need to have Foley catheters placed before surgery. Indwelling catheters should be limited, if possible, to 24 hours after surgery, and the patient can be managed with bladder scans every 6 hours if needed.
Patients scheduled for extensive, complicated procedures and those at high risk may require an indwelling catheter for up to 5 days after surgery. Studies have shown that in these patients early catheter removal actually increases the risk for postoperative urinary retention, Dr. Khemani said.
"It really needs to be followed by bladder scanning very closely, every 6 hours, to try to prevent overdistention and complications after that," she said.
The incidence of postoperative urinary retention among general surgery patients is 3.8%, but can range as high 70% after orthopedic surgery, 50% after anorectal procedures, 40% following spinal surgeries, and 38% after herniorrhaphy, Dr. Khemani said.
Preoperative risk factors for urinary retention after surgery include age over 50; male sex; history of retention; BPH; history of diabetes, stroke, or spinal lesions; or use of drugs such anticholinergic agents or beta-blockers.
Intraoperative and postoperative risk factors include the type and duration of surgery, anesthesia (especially spinal and epidural anethesias), systemic analgesia with opioids (especially patient-controlled analgesia, or PCA), and the use of intraoperative intravenous fluids. High IV fluid infusion causes rapid distention of the bladder detrusor muscles, leading to inability of the muscles to contract after surgery, Dr. Khemani noted.
Complications of postoperative urinary retention can include:
• Autonomic responses to bladder distention, leading to effects such as bradycardia, hypotension, vomiting, and delirium in some elderly patients.
• Infectious complications – urinary tract infections, sepsis, and joint infections.
• Prolonged need for catheterization.
• Bladder dysfunction.
A recent systematic review of drugs for treatment of urinary retention after surgery in adults found that of seven studies involving a total of 494 patients, neither cholinergic agents, alpha blockers, nor sedatives made a significant difference in reducing the incidence of retention. Only prostaglandins, and only when those agents were given intravesically, appeared to offer any benefit, the authors found.
"At this point we definitely need more studies to look at pharmacological alternatives to catheterization for treatment and prevention of this condition," Dr. Khemani concluded.
She reported having no financial disclosures.
AT THE PERIOPERATIVE MEDICINE SUMMIT
Major finding: The incidence of postoperative urinary retention may be as high as 70% after orthopedic procedures.
Data source: Review of evidence on the risk factors, prevention, and treatment of postoperative urinary retention.
Disclosures: Dr. Khemani reported having no financial disclosures.
Outcomes similar for two reconstruction techniques, except for risk of severe complications
MIAMI BEACH* – There appears to be no difference in the rate of anastomotic leak in pancreaticogastrostomy compared with pancreaticojejunostomy reconstruction after a Whipple procedure, but pancreaticogastrostomy does appear to increase the risk of some serious postoperative complications, a study found.
"We didn’t show any significant differences in terms of leaks, severity of leaks, or even overall complications," Dr. Jan Grendar said at the annual meeting of the Americas Hepato-Pancreato-Biliary Association. "But we did show a significant difference in complications of Clavien grades III-V severity. This anastomosis just did a little bit worse in terms of severe complications."
Grade III Clavien complications are those that require a second invasive procedure, like reoperation or drainage, with local or general anesthesia. Grade IV complications are more serious – they include organ failures such as renal failure requiring hemodialysis, heart failure, and liver failure, and intubation. The Grade V complication is patient death.
Dr. Grendar, a surgical resident at the University of Calgary (Alta.), and his colleagues randomized 98 patients with benign or malignant pancreatic disease to either of the two reconstruction techniques after a Whipple procedure. Pancreaticojejunostomy (PJ) is the procedure typically performed in North America. Pancreaticogastrostomy (PG) is typically performed in Europe. The hepatobiliary pancreatic surgeons and residents at the university, however, have become adept at this second procedure and employ it as an alternative reconstruction, depending on the characteristics of the pancreas discovered during surgery. They most often use it on patients who have a soft pancreas or small pancreatic duct.
All of the patients in the study had a pancreatic or periampullary neoplasm that appeared resectable on preoperative imaging. There were no differences in baseline patient characteristics. The mean age was 64 in the PG group and 68 in the PJ group. The median Charlson comorbidity index score was 2.
The intraoperative outcomes were mostly similar. Gland mobilization occurred significantly more often in the PG group (31 vs. 18 mm). Significantly fewer PG patients had a two-layer anastomosis (77% vs. 94%). The mean pancreatic duct size was smaller in the PG patients (3.8 vs. 4.3 mm), but this wasn’t statistically significant. Significantly fewer PG patients had a pancreatic duct stent placed (22% vs. 83%).
Postoperative outcomes included pancreatic fistula, any postoperative complications, severe complications, and length of stay.
There was no difference between the groups in Clavien grade complications separately, but significantly more PG patients had severe, Clavien grade III-V complications (31% vs. 12%). But these didn’t affect the mean length of stay, which was similar between the groups (17 vs. 14 days).
In a multivariate analysis, only having a soft pancreas significantly increased the risk of developing a pancreatic fistula (odds ratio, 5.87). Female gender significantly decreased the risk (OR, 0.31). This most likely represents a correlation between pancreatic texture and patient sex rather than a true protective property of being female. Having a soft pancreas also significantly increased the risk of any postoperative complications (OR, 3.08).
Several factors significantly increased the risk of a severe complication. These included a baseline American Society of Anesthesiologists grade of 2 or 3 (OR, 12.75 and 29.56, respectively). Being randomized to the PJ procedure significantly decreased the risk of a severe complication (OR, 0.11).
"Unlike the European centers that report different outcomes, these results are coming from a center that wasn’t very enthusiastic about this type of reconstruction prior to this study," Dr. Grendar said in an interview. "Despite the initial preference, high-risk patients in Calgary, those with soft pancreatic glands and small pancreatic ducts, are now likely to be offered a pancreaticogastrostomy"
Dr. Grendar said he had no relevant financial disclosures.
*Correction, 3/11/2014: An earlier version of the article misstated the name of the city where the AHPBA meeting took place.
MIAMI BEACH* – There appears to be no difference in the rate of anastomotic leak in pancreaticogastrostomy compared with pancreaticojejunostomy reconstruction after a Whipple procedure, but pancreaticogastrostomy does appear to increase the risk of some serious postoperative complications, a study found.
"We didn’t show any significant differences in terms of leaks, severity of leaks, or even overall complications," Dr. Jan Grendar said at the annual meeting of the Americas Hepato-Pancreato-Biliary Association. "But we did show a significant difference in complications of Clavien grades III-V severity. This anastomosis just did a little bit worse in terms of severe complications."
Grade III Clavien complications are those that require a second invasive procedure, like reoperation or drainage, with local or general anesthesia. Grade IV complications are more serious – they include organ failures such as renal failure requiring hemodialysis, heart failure, and liver failure, and intubation. The Grade V complication is patient death.
Dr. Grendar, a surgical resident at the University of Calgary (Alta.), and his colleagues randomized 98 patients with benign or malignant pancreatic disease to either of the two reconstruction techniques after a Whipple procedure. Pancreaticojejunostomy (PJ) is the procedure typically performed in North America. Pancreaticogastrostomy (PG) is typically performed in Europe. The hepatobiliary pancreatic surgeons and residents at the university, however, have become adept at this second procedure and employ it as an alternative reconstruction, depending on the characteristics of the pancreas discovered during surgery. They most often use it on patients who have a soft pancreas or small pancreatic duct.
All of the patients in the study had a pancreatic or periampullary neoplasm that appeared resectable on preoperative imaging. There were no differences in baseline patient characteristics. The mean age was 64 in the PG group and 68 in the PJ group. The median Charlson comorbidity index score was 2.
The intraoperative outcomes were mostly similar. Gland mobilization occurred significantly more often in the PG group (31 vs. 18 mm). Significantly fewer PG patients had a two-layer anastomosis (77% vs. 94%). The mean pancreatic duct size was smaller in the PG patients (3.8 vs. 4.3 mm), but this wasn’t statistically significant. Significantly fewer PG patients had a pancreatic duct stent placed (22% vs. 83%).
Postoperative outcomes included pancreatic fistula, any postoperative complications, severe complications, and length of stay.
There was no difference between the groups in Clavien grade complications separately, but significantly more PG patients had severe, Clavien grade III-V complications (31% vs. 12%). But these didn’t affect the mean length of stay, which was similar between the groups (17 vs. 14 days).
In a multivariate analysis, only having a soft pancreas significantly increased the risk of developing a pancreatic fistula (odds ratio, 5.87). Female gender significantly decreased the risk (OR, 0.31). This most likely represents a correlation between pancreatic texture and patient sex rather than a true protective property of being female. Having a soft pancreas also significantly increased the risk of any postoperative complications (OR, 3.08).
Several factors significantly increased the risk of a severe complication. These included a baseline American Society of Anesthesiologists grade of 2 or 3 (OR, 12.75 and 29.56, respectively). Being randomized to the PJ procedure significantly decreased the risk of a severe complication (OR, 0.11).
"Unlike the European centers that report different outcomes, these results are coming from a center that wasn’t very enthusiastic about this type of reconstruction prior to this study," Dr. Grendar said in an interview. "Despite the initial preference, high-risk patients in Calgary, those with soft pancreatic glands and small pancreatic ducts, are now likely to be offered a pancreaticogastrostomy"
Dr. Grendar said he had no relevant financial disclosures.
*Correction, 3/11/2014: An earlier version of the article misstated the name of the city where the AHPBA meeting took place.
MIAMI BEACH* – There appears to be no difference in the rate of anastomotic leak in pancreaticogastrostomy compared with pancreaticojejunostomy reconstruction after a Whipple procedure, but pancreaticogastrostomy does appear to increase the risk of some serious postoperative complications, a study found.
"We didn’t show any significant differences in terms of leaks, severity of leaks, or even overall complications," Dr. Jan Grendar said at the annual meeting of the Americas Hepato-Pancreato-Biliary Association. "But we did show a significant difference in complications of Clavien grades III-V severity. This anastomosis just did a little bit worse in terms of severe complications."
Grade III Clavien complications are those that require a second invasive procedure, like reoperation or drainage, with local or general anesthesia. Grade IV complications are more serious – they include organ failures such as renal failure requiring hemodialysis, heart failure, and liver failure, and intubation. The Grade V complication is patient death.
Dr. Grendar, a surgical resident at the University of Calgary (Alta.), and his colleagues randomized 98 patients with benign or malignant pancreatic disease to either of the two reconstruction techniques after a Whipple procedure. Pancreaticojejunostomy (PJ) is the procedure typically performed in North America. Pancreaticogastrostomy (PG) is typically performed in Europe. The hepatobiliary pancreatic surgeons and residents at the university, however, have become adept at this second procedure and employ it as an alternative reconstruction, depending on the characteristics of the pancreas discovered during surgery. They most often use it on patients who have a soft pancreas or small pancreatic duct.
All of the patients in the study had a pancreatic or periampullary neoplasm that appeared resectable on preoperative imaging. There were no differences in baseline patient characteristics. The mean age was 64 in the PG group and 68 in the PJ group. The median Charlson comorbidity index score was 2.
The intraoperative outcomes were mostly similar. Gland mobilization occurred significantly more often in the PG group (31 vs. 18 mm). Significantly fewer PG patients had a two-layer anastomosis (77% vs. 94%). The mean pancreatic duct size was smaller in the PG patients (3.8 vs. 4.3 mm), but this wasn’t statistically significant. Significantly fewer PG patients had a pancreatic duct stent placed (22% vs. 83%).
Postoperative outcomes included pancreatic fistula, any postoperative complications, severe complications, and length of stay.
There was no difference between the groups in Clavien grade complications separately, but significantly more PG patients had severe, Clavien grade III-V complications (31% vs. 12%). But these didn’t affect the mean length of stay, which was similar between the groups (17 vs. 14 days).
In a multivariate analysis, only having a soft pancreas significantly increased the risk of developing a pancreatic fistula (odds ratio, 5.87). Female gender significantly decreased the risk (OR, 0.31). This most likely represents a correlation between pancreatic texture and patient sex rather than a true protective property of being female. Having a soft pancreas also significantly increased the risk of any postoperative complications (OR, 3.08).
Several factors significantly increased the risk of a severe complication. These included a baseline American Society of Anesthesiologists grade of 2 or 3 (OR, 12.75 and 29.56, respectively). Being randomized to the PJ procedure significantly decreased the risk of a severe complication (OR, 0.11).
"Unlike the European centers that report different outcomes, these results are coming from a center that wasn’t very enthusiastic about this type of reconstruction prior to this study," Dr. Grendar said in an interview. "Despite the initial preference, high-risk patients in Calgary, those with soft pancreatic glands and small pancreatic ducts, are now likely to be offered a pancreaticogastrostomy"
Dr. Grendar said he had no relevant financial disclosures.
*Correction, 3/11/2014: An earlier version of the article misstated the name of the city where the AHPBA meeting took place.
AT AHPBA 2014
Major finding: Severe complications occurred in significantly more Whipple patients who had a pancreaticogastrostomy reconstruction than a pancreaticojejunostomy (31% vs. 12%).
Data source: A randomized study involving 98 patients.
Disclosures: Dr. Grendar said he had no relevant financial disclosures.
Colorectal cancer incidence rising sharply among younger adults
SAN FRANCISCO – The incidence of colorectal cancer is rising sharply among younger adults in the United States, a study showed.
Researchers analyzed Surveillance, Epidemiology, and End Results (SEER) data for 383,241 patients in whom colorectal cancer was diagnosed between 1975 and 2010.
The results showed that the age-adjusted incidence rate of colorectal cancer fell steadily among patients aged 50 years and older at diagnosis, lead author Dr. Christina E. Bailey, a surgical oncology fellow at the M.D. Anderson Cancer Center in Houston, reported in a poster session at the annual Gastrointestinal Cancers Symposium. But the rate rose among younger patients.
The annual percentage change in the age-adjusted incidence rate of colorectal cancer during the 35-year period was a significant –0.92 in the cohort overall. In stratified analyses, the annual percentage change fell significantly among patients aged 50-74 at diagnosis (–0.97), and aged 75 years and older at diagnosis (–1.15). But it rose among patients aged 35-49 at diagnosis (0.41) and especially among patients aged 20-34 at diagnosis (1.99).
The findings were similar for colon cancer separately (with strongest results seen for disease that was distant at diagnosis) and for rectal/rectosigmoid cancer separately.
A predictive model suggested that if the observed trends persist between 2010 and 2030, the incidences of colon cancer and of rectal/rectosigmoid cancer will rise by 90% and 124%, respectively, among 20- to 34-year-olds, and by 28% and 46%, respectively, among 35- to 49-year-olds.
Much of the decreasing incidence among older adults "can be attributed to the fact that screening is recommended beginning at the age of 50," Dr. Bailey commented in an interview.
"We saw dramatic rises in the predicted incidences of both colon and rectal cancer in our younger cohort that point out that further studies need to be done to determine why this is happening and what can we do now to prevent this trajectory from occurring in the future," she said at the symposium, sponsored by the American Society of Clinical Oncology.
Likely explanations for this sharp uptick, she suggested, include increasing population levels of obesity and physical inactivity, and consumption of a diet high in fat and red meat – factors implicated as risks for colorectal cancer.
Another possibility is that primary care physicians are now more alert for this cancer in young patients with symptoms such as rectal bleeding, which previously may have been attributed to conditions such as hemorrhoids, delaying diagnosis until an older age.
Recommendations still call for routine colorectal cancer screening only in those patients younger than age 50 who have risk factors such as familial adenomatous polyposis and Lynch syndrome, Dr. Bailey noted. And even though the incidence is rising in the younger age groups, it is still considerably lower than it is among people aged 50 years and older.
Dr. Bailey said she had no relevant financial disclosures.
SAN FRANCISCO – The incidence of colorectal cancer is rising sharply among younger adults in the United States, a study showed.
Researchers analyzed Surveillance, Epidemiology, and End Results (SEER) data for 383,241 patients in whom colorectal cancer was diagnosed between 1975 and 2010.
The results showed that the age-adjusted incidence rate of colorectal cancer fell steadily among patients aged 50 years and older at diagnosis, lead author Dr. Christina E. Bailey, a surgical oncology fellow at the M.D. Anderson Cancer Center in Houston, reported in a poster session at the annual Gastrointestinal Cancers Symposium. But the rate rose among younger patients.
The annual percentage change in the age-adjusted incidence rate of colorectal cancer during the 35-year period was a significant –0.92 in the cohort overall. In stratified analyses, the annual percentage change fell significantly among patients aged 50-74 at diagnosis (–0.97), and aged 75 years and older at diagnosis (–1.15). But it rose among patients aged 35-49 at diagnosis (0.41) and especially among patients aged 20-34 at diagnosis (1.99).
The findings were similar for colon cancer separately (with strongest results seen for disease that was distant at diagnosis) and for rectal/rectosigmoid cancer separately.
A predictive model suggested that if the observed trends persist between 2010 and 2030, the incidences of colon cancer and of rectal/rectosigmoid cancer will rise by 90% and 124%, respectively, among 20- to 34-year-olds, and by 28% and 46%, respectively, among 35- to 49-year-olds.
Much of the decreasing incidence among older adults "can be attributed to the fact that screening is recommended beginning at the age of 50," Dr. Bailey commented in an interview.
"We saw dramatic rises in the predicted incidences of both colon and rectal cancer in our younger cohort that point out that further studies need to be done to determine why this is happening and what can we do now to prevent this trajectory from occurring in the future," she said at the symposium, sponsored by the American Society of Clinical Oncology.
Likely explanations for this sharp uptick, she suggested, include increasing population levels of obesity and physical inactivity, and consumption of a diet high in fat and red meat – factors implicated as risks for colorectal cancer.
Another possibility is that primary care physicians are now more alert for this cancer in young patients with symptoms such as rectal bleeding, which previously may have been attributed to conditions such as hemorrhoids, delaying diagnosis until an older age.
Recommendations still call for routine colorectal cancer screening only in those patients younger than age 50 who have risk factors such as familial adenomatous polyposis and Lynch syndrome, Dr. Bailey noted. And even though the incidence is rising in the younger age groups, it is still considerably lower than it is among people aged 50 years and older.
Dr. Bailey said she had no relevant financial disclosures.
SAN FRANCISCO – The incidence of colorectal cancer is rising sharply among younger adults in the United States, a study showed.
Researchers analyzed Surveillance, Epidemiology, and End Results (SEER) data for 383,241 patients in whom colorectal cancer was diagnosed between 1975 and 2010.
The results showed that the age-adjusted incidence rate of colorectal cancer fell steadily among patients aged 50 years and older at diagnosis, lead author Dr. Christina E. Bailey, a surgical oncology fellow at the M.D. Anderson Cancer Center in Houston, reported in a poster session at the annual Gastrointestinal Cancers Symposium. But the rate rose among younger patients.
The annual percentage change in the age-adjusted incidence rate of colorectal cancer during the 35-year period was a significant –0.92 in the cohort overall. In stratified analyses, the annual percentage change fell significantly among patients aged 50-74 at diagnosis (–0.97), and aged 75 years and older at diagnosis (–1.15). But it rose among patients aged 35-49 at diagnosis (0.41) and especially among patients aged 20-34 at diagnosis (1.99).
The findings were similar for colon cancer separately (with strongest results seen for disease that was distant at diagnosis) and for rectal/rectosigmoid cancer separately.
A predictive model suggested that if the observed trends persist between 2010 and 2030, the incidences of colon cancer and of rectal/rectosigmoid cancer will rise by 90% and 124%, respectively, among 20- to 34-year-olds, and by 28% and 46%, respectively, among 35- to 49-year-olds.
Much of the decreasing incidence among older adults "can be attributed to the fact that screening is recommended beginning at the age of 50," Dr. Bailey commented in an interview.
"We saw dramatic rises in the predicted incidences of both colon and rectal cancer in our younger cohort that point out that further studies need to be done to determine why this is happening and what can we do now to prevent this trajectory from occurring in the future," she said at the symposium, sponsored by the American Society of Clinical Oncology.
Likely explanations for this sharp uptick, she suggested, include increasing population levels of obesity and physical inactivity, and consumption of a diet high in fat and red meat – factors implicated as risks for colorectal cancer.
Another possibility is that primary care physicians are now more alert for this cancer in young patients with symptoms such as rectal bleeding, which previously may have been attributed to conditions such as hemorrhoids, delaying diagnosis until an older age.
Recommendations still call for routine colorectal cancer screening only in those patients younger than age 50 who have risk factors such as familial adenomatous polyposis and Lynch syndrome, Dr. Bailey noted. And even though the incidence is rising in the younger age groups, it is still considerably lower than it is among people aged 50 years and older.
Dr. Bailey said she had no relevant financial disclosures.
AT THE GASTROINTESTINAL CANCERS SYMPOSIUM
Major finding: Between 2010 and 2030, the incidences of colon and rectal/rectosigmoid cancer are predicted to rise by 90% and 124% among 20- to 34-year-olds and by 28% and 46% among 35- to 49-year-olds.
Data source: A retrospective cohort study of 383,241 patients with colorectal cancer diagnosed between 1975 and 2010.
Disclosures: Dr. Bailey reported no relevant financial conflicts.
Inflammatory markers associated with IBD colon cancer risk
As C-reactive protein levels and erythrocyte sedimentation rates go up in patients with inflammatory bowel disease, the risk of colorectal cancer goes up, too, a finding that suggests a role for both as markers of colon cancer risk, Boston investigators reported in a prospective study published online Jan. 6 in Clinical Gastroenterology and Hepatology.
The team divided 3,145 IBD patients into quartiles based on median C-reactive protein (CRP) levels, and 4,008 others into quartiles based on median erythrocyte sedimentation rates (ESR), then followed them for a median of 6 years.
On multivariate analysis, there was a significant increase in the risk of colorectal cancer (CRC) across quartiles of CRP elevation (P for trend = .017). Higher median ESR was also independently associated with higher risk of CRC across quartiles (P for trend = .007) (Clin. Gastroenterol. Hepatol. 2014 Jan. 6 [doi: 10.1016/j.cgh.2013.12.030]).
"This association adds another clinical variable to help stratify patients into risk categories. There is an important need to identify high-risk subgroups that may benefit from continued intensive surveillance strategies while allowing for less frequent colonoscopies in patients at low risk of CRC. We believe that our findings ... suggest that an individual patient’s severity of inflammation may be helpful in further personalizing surveillance recommendations," and might even help monitor other outcomes, including treatment response, said the authors, led by Dr. Ashwin Ananthakrishnan, a gastroenterologist at Massachusetts General Hospital, Boston.
After adjustment for age, sex, race, IBD type, and other factors, the patients in the highest CRP quartile had more than double the risk of colorectal cancer compared with those in the lowest quartile (OR 2.72, 95% CI 0.95-7.76). The strength of association was similar in men and women, and in Crohn’s disease and ulcerative colitis.
Similarly, patients in the highest ESR quartile had double the risk compared with those in the lowest (OR 2.06, 95% CI 1.14-3.74). The correlation was strongest in ulcerative colitis patients and men.
The median CRP values in each of the quartiles were 0.8, 2.7, 7.5, and 32.8 mg/L. In the ESR group, the median quartile values were 7, 14, 25, and 50 mm/hr.
Overall, 33 patients in the CRP cohort and 102 patients in the ESR cohort developed colorectal cancer at a median age of 55 years. The median number of CRP measurements was three, and median number of ESR measurements six. More than half the subjects were women, most were white, and ulcerative colitis was slightly more common than was Crohn’s disease.
Adjusting for number of colonoscopies, intensity of health care utilization, use of corticosteroids, and other factors did not change results for either the CRP or ESR cohorts.
The National Institutes of Health funded the work. The investigators have no disclosures.
As C-reactive protein levels and erythrocyte sedimentation rates go up in patients with inflammatory bowel disease, the risk of colorectal cancer goes up, too, a finding that suggests a role for both as markers of colon cancer risk, Boston investigators reported in a prospective study published online Jan. 6 in Clinical Gastroenterology and Hepatology.
The team divided 3,145 IBD patients into quartiles based on median C-reactive protein (CRP) levels, and 4,008 others into quartiles based on median erythrocyte sedimentation rates (ESR), then followed them for a median of 6 years.
On multivariate analysis, there was a significant increase in the risk of colorectal cancer (CRC) across quartiles of CRP elevation (P for trend = .017). Higher median ESR was also independently associated with higher risk of CRC across quartiles (P for trend = .007) (Clin. Gastroenterol. Hepatol. 2014 Jan. 6 [doi: 10.1016/j.cgh.2013.12.030]).
"This association adds another clinical variable to help stratify patients into risk categories. There is an important need to identify high-risk subgroups that may benefit from continued intensive surveillance strategies while allowing for less frequent colonoscopies in patients at low risk of CRC. We believe that our findings ... suggest that an individual patient’s severity of inflammation may be helpful in further personalizing surveillance recommendations," and might even help monitor other outcomes, including treatment response, said the authors, led by Dr. Ashwin Ananthakrishnan, a gastroenterologist at Massachusetts General Hospital, Boston.
After adjustment for age, sex, race, IBD type, and other factors, the patients in the highest CRP quartile had more than double the risk of colorectal cancer compared with those in the lowest quartile (OR 2.72, 95% CI 0.95-7.76). The strength of association was similar in men and women, and in Crohn’s disease and ulcerative colitis.
Similarly, patients in the highest ESR quartile had double the risk compared with those in the lowest (OR 2.06, 95% CI 1.14-3.74). The correlation was strongest in ulcerative colitis patients and men.
The median CRP values in each of the quartiles were 0.8, 2.7, 7.5, and 32.8 mg/L. In the ESR group, the median quartile values were 7, 14, 25, and 50 mm/hr.
Overall, 33 patients in the CRP cohort and 102 patients in the ESR cohort developed colorectal cancer at a median age of 55 years. The median number of CRP measurements was three, and median number of ESR measurements six. More than half the subjects were women, most were white, and ulcerative colitis was slightly more common than was Crohn’s disease.
Adjusting for number of colonoscopies, intensity of health care utilization, use of corticosteroids, and other factors did not change results for either the CRP or ESR cohorts.
The National Institutes of Health funded the work. The investigators have no disclosures.
As C-reactive protein levels and erythrocyte sedimentation rates go up in patients with inflammatory bowel disease, the risk of colorectal cancer goes up, too, a finding that suggests a role for both as markers of colon cancer risk, Boston investigators reported in a prospective study published online Jan. 6 in Clinical Gastroenterology and Hepatology.
The team divided 3,145 IBD patients into quartiles based on median C-reactive protein (CRP) levels, and 4,008 others into quartiles based on median erythrocyte sedimentation rates (ESR), then followed them for a median of 6 years.
On multivariate analysis, there was a significant increase in the risk of colorectal cancer (CRC) across quartiles of CRP elevation (P for trend = .017). Higher median ESR was also independently associated with higher risk of CRC across quartiles (P for trend = .007) (Clin. Gastroenterol. Hepatol. 2014 Jan. 6 [doi: 10.1016/j.cgh.2013.12.030]).
"This association adds another clinical variable to help stratify patients into risk categories. There is an important need to identify high-risk subgroups that may benefit from continued intensive surveillance strategies while allowing for less frequent colonoscopies in patients at low risk of CRC. We believe that our findings ... suggest that an individual patient’s severity of inflammation may be helpful in further personalizing surveillance recommendations," and might even help monitor other outcomes, including treatment response, said the authors, led by Dr. Ashwin Ananthakrishnan, a gastroenterologist at Massachusetts General Hospital, Boston.
After adjustment for age, sex, race, IBD type, and other factors, the patients in the highest CRP quartile had more than double the risk of colorectal cancer compared with those in the lowest quartile (OR 2.72, 95% CI 0.95-7.76). The strength of association was similar in men and women, and in Crohn’s disease and ulcerative colitis.
Similarly, patients in the highest ESR quartile had double the risk compared with those in the lowest (OR 2.06, 95% CI 1.14-3.74). The correlation was strongest in ulcerative colitis patients and men.
The median CRP values in each of the quartiles were 0.8, 2.7, 7.5, and 32.8 mg/L. In the ESR group, the median quartile values were 7, 14, 25, and 50 mm/hr.
Overall, 33 patients in the CRP cohort and 102 patients in the ESR cohort developed colorectal cancer at a median age of 55 years. The median number of CRP measurements was three, and median number of ESR measurements six. More than half the subjects were women, most were white, and ulcerative colitis was slightly more common than was Crohn’s disease.
Adjusting for number of colonoscopies, intensity of health care utilization, use of corticosteroids, and other factors did not change results for either the CRP or ESR cohorts.
The National Institutes of Health funded the work. The investigators have no disclosures.
FROM CLINICAL GASTROENTEROLOGY AND HEPATOLOGY
Major finding: The risk of colorectal cancer is more than double for IBD patients with the highest quartile values of CRP (P for trend = .017) and ESR (P for trend = .007).
Data Source: Prospective, longitudinal study of 7,153 adult IBD patients.
Disclosures: The work was funded by the National Institutes of Health. The investigators have no disclosures.
Outpatient diverticulitis therapy cures patients, saves money
Discharging patients with uncomplicated diverticulitis from the emergency department on antibiotics was just as effective as hospitalization – and cost about a third as much, based on a study conducted in Spain.
Dr. Sebastiano Biondi and his colleagues conducted their randomized, parallel-group study at five hospitals. The cohort consisted of 132 adults, mean age 56 years, who presented to the emergency department with localized abdominal pain. All had an abdominal CT scan and received intravenous antibiotics, either an initial IV infusion of 1 g of amoxicillin per 125 mg of clavulanic acid, or, in the case of those with a penicillin allergy, ciprofloxacin 200 mg and metronidazole 500 mg.
Half of the patients were then assigned to either inpatient or outpatient antibiotic treatment. The admitted patients continued to receive IV antibiotics and fluids for 36-48 hours until they tolerated oral feeding. The outpatients were discharged on oral amoxicillin and clavulanic acid (875 mg per 125 mg every 8 hours) or, in those with penicillin allergy, the combination of ciprofloxacin (500 mg every 12 hours) and metronidazole (500 mg every 8 hours).
The study’s main endpoint was treatment failure rate (persistence, increase, or recurrence of abdominal pain and/or fever; inflammatory bowel obstruction; or the need for radiological abscess drainage or immediate surgery due to complicated diverticulitis). Patients were followed every day for 5 days, and then interviewed on day 14. Before the final follow-up at 60 days, patients underwent a colonoscopy to rule out malignancy.
Seven patients (5%) were readmitted due to treatment failure: 4 (6%) in the inpatient group and three (4.5%) in the outpatient group. The difference was not statistically significant. No one needed emergency surgery as part of readmission, and there were no deaths.
A quality of life assessment found that hospitalized patients reported a significantly higher level of physical health during the first 2 weeks of treatment, but that difference disappeared after 14 days.
Total treatment costs were significantly less in the outpatient group, with an average savings of $1,840 per patient ($895 for outpatient care compared with $2,735 for inpatient care). Almost all of that cost difference was due to hospital bed cost, with an average stay of 4 days.
"The outpatient protocol of this study is applicable to a selected group of patients with uncomplicated diverticulitis," Dr. Biondi reported in the January issue of Annals of Surgery (doi: 10.1097/SLA.0b013e3182965a11).
Widespread adoption of outpatient treatment could have a profound effect on the cost of treating diverticulitis, an ever more common gastrointestinal problem, said Dr. Biondi of the University of Barcelona and his coauthors. "According to data from the National Hospital Discharge Survey, diverticular disease is responsible for 314,000 hospital admissions per year in the United States, and the estimated annual cost in 1998 was about $2.6 billion."
The Spanish Ministry of Health funded the trial. The authors had no financial conflicts.
Discharging patients with uncomplicated diverticulitis from the emergency department on antibiotics was just as effective as hospitalization – and cost about a third as much, based on a study conducted in Spain.
Dr. Sebastiano Biondi and his colleagues conducted their randomized, parallel-group study at five hospitals. The cohort consisted of 132 adults, mean age 56 years, who presented to the emergency department with localized abdominal pain. All had an abdominal CT scan and received intravenous antibiotics, either an initial IV infusion of 1 g of amoxicillin per 125 mg of clavulanic acid, or, in the case of those with a penicillin allergy, ciprofloxacin 200 mg and metronidazole 500 mg.
Half of the patients were then assigned to either inpatient or outpatient antibiotic treatment. The admitted patients continued to receive IV antibiotics and fluids for 36-48 hours until they tolerated oral feeding. The outpatients were discharged on oral amoxicillin and clavulanic acid (875 mg per 125 mg every 8 hours) or, in those with penicillin allergy, the combination of ciprofloxacin (500 mg every 12 hours) and metronidazole (500 mg every 8 hours).
The study’s main endpoint was treatment failure rate (persistence, increase, or recurrence of abdominal pain and/or fever; inflammatory bowel obstruction; or the need for radiological abscess drainage or immediate surgery due to complicated diverticulitis). Patients were followed every day for 5 days, and then interviewed on day 14. Before the final follow-up at 60 days, patients underwent a colonoscopy to rule out malignancy.
Seven patients (5%) were readmitted due to treatment failure: 4 (6%) in the inpatient group and three (4.5%) in the outpatient group. The difference was not statistically significant. No one needed emergency surgery as part of readmission, and there were no deaths.
A quality of life assessment found that hospitalized patients reported a significantly higher level of physical health during the first 2 weeks of treatment, but that difference disappeared after 14 days.
Total treatment costs were significantly less in the outpatient group, with an average savings of $1,840 per patient ($895 for outpatient care compared with $2,735 for inpatient care). Almost all of that cost difference was due to hospital bed cost, with an average stay of 4 days.
"The outpatient protocol of this study is applicable to a selected group of patients with uncomplicated diverticulitis," Dr. Biondi reported in the January issue of Annals of Surgery (doi: 10.1097/SLA.0b013e3182965a11).
Widespread adoption of outpatient treatment could have a profound effect on the cost of treating diverticulitis, an ever more common gastrointestinal problem, said Dr. Biondi of the University of Barcelona and his coauthors. "According to data from the National Hospital Discharge Survey, diverticular disease is responsible for 314,000 hospital admissions per year in the United States, and the estimated annual cost in 1998 was about $2.6 billion."
The Spanish Ministry of Health funded the trial. The authors had no financial conflicts.
Discharging patients with uncomplicated diverticulitis from the emergency department on antibiotics was just as effective as hospitalization – and cost about a third as much, based on a study conducted in Spain.
Dr. Sebastiano Biondi and his colleagues conducted their randomized, parallel-group study at five hospitals. The cohort consisted of 132 adults, mean age 56 years, who presented to the emergency department with localized abdominal pain. All had an abdominal CT scan and received intravenous antibiotics, either an initial IV infusion of 1 g of amoxicillin per 125 mg of clavulanic acid, or, in the case of those with a penicillin allergy, ciprofloxacin 200 mg and metronidazole 500 mg.
Half of the patients were then assigned to either inpatient or outpatient antibiotic treatment. The admitted patients continued to receive IV antibiotics and fluids for 36-48 hours until they tolerated oral feeding. The outpatients were discharged on oral amoxicillin and clavulanic acid (875 mg per 125 mg every 8 hours) or, in those with penicillin allergy, the combination of ciprofloxacin (500 mg every 12 hours) and metronidazole (500 mg every 8 hours).
The study’s main endpoint was treatment failure rate (persistence, increase, or recurrence of abdominal pain and/or fever; inflammatory bowel obstruction; or the need for radiological abscess drainage or immediate surgery due to complicated diverticulitis). Patients were followed every day for 5 days, and then interviewed on day 14. Before the final follow-up at 60 days, patients underwent a colonoscopy to rule out malignancy.
Seven patients (5%) were readmitted due to treatment failure: 4 (6%) in the inpatient group and three (4.5%) in the outpatient group. The difference was not statistically significant. No one needed emergency surgery as part of readmission, and there were no deaths.
A quality of life assessment found that hospitalized patients reported a significantly higher level of physical health during the first 2 weeks of treatment, but that difference disappeared after 14 days.
Total treatment costs were significantly less in the outpatient group, with an average savings of $1,840 per patient ($895 for outpatient care compared with $2,735 for inpatient care). Almost all of that cost difference was due to hospital bed cost, with an average stay of 4 days.
"The outpatient protocol of this study is applicable to a selected group of patients with uncomplicated diverticulitis," Dr. Biondi reported in the January issue of Annals of Surgery (doi: 10.1097/SLA.0b013e3182965a11).
Widespread adoption of outpatient treatment could have a profound effect on the cost of treating diverticulitis, an ever more common gastrointestinal problem, said Dr. Biondi of the University of Barcelona and his coauthors. "According to data from the National Hospital Discharge Survey, diverticular disease is responsible for 314,000 hospital admissions per year in the United States, and the estimated annual cost in 1998 was about $2.6 billion."
The Spanish Ministry of Health funded the trial. The authors had no financial conflicts.
FROM ANNALS OF SURGERY
Major finding: Compared with inpatients, those with uncomplicated diverticulitis treated as outpatients had similarly low rates of treatment failure (4.5% vs. 6%), with a cost savings of $1,840 for each outpatient treatment.
Data source: The randomized, parallel-group study comprised 132 patients.
Disclosures: The Spanish Ministry of Health funded the study. The authors had no financial conflicts.