Incidence of colon resections is increasing in the younger populations: should an early initiation of colon cancer screening be implemented?

INTRODUCTION: The American Cancer Society recently lowered the recommended age for screening of colorectal cancer (CRC) to age 45 due to recent data showing increased incidence of CRC in younger populations. The purpose of this study was to evaluate if younger patients have increased likelihood of resection for CRC through the use of a statewide longitudinal database. METHODS: The New York SPARCS administrative database was used to identify all patients with diagnosis of colon cancer undergoing colorectal resections from 2000 to 2016. Patients were divided into seven age groups. Patients' characteristics, demographics, co-morbidities, and complications were evaluated. Chi-square test was used to compare patients' characteristics, comorbidities and complications among age groups. The linear trend of colon resection in different age groups over years was examined using log-linear Poisson regression models with year as an explanatory variable, as well as using multivariable logistic regression models after adjusting for patients' gender, race, payment, region, any comorbidity and any complication. RESULTS: There were 73,697 colon resection surgeries extracted from 2000 to 2016. Younger age was significantly associated with increased colorectal cancer resection over time. Patients age 21-70 had a significantly increasing trend over the years (age group 21-30: RR 1.06, p-value < 0.0001; age group 31-40: RR 1.04, p < 0.0001; age group 41-50: RR 1.04, p < 0.0001; age group 51-60: RR 1.02. p < 0.0001); age group 61-70: RR 1.01, p = 0.0012). Patient age > 70 was significantly associated with decreasing trend of colorectal cancer resection over the years (age group 71-80: RR 0.98, p < 0.0001 and age group > 80: RR 0.99, p-value < 0.0001). Such trends also existed after further adjustment for patients' characteristics, any comorbidity and any complication. CONCLUSION: Over the years, younger patients have an increased trend of undergoing colorectal resections for cancer, with up to a 6% yearly increase over the studied period. New screening initiation guidelines should be considered and awareness among clinicians and the general public should be increased.

Factors Associated with Repeated Health Resource Utilization in Patients with Diverticulitis.

Conservative management trends in diverticulitis may lead to increased hospitalizations secondary to repeated attacks. The study aimed to characterize trends in management and risk-assess patients with diverticulitis that required multiple admissions to identify high utilizers. A total of 265,724 patients with diverticulitis were identified from 1995 to 2014 from the New York SPARCS database. Patients with ≥2 hospital admissions were stratified across demographics, comorbidities, insurance status, and surgical intervention. In total, 42,850 patients had ≥2 hospital admissions. Risk factors for ≥2 admissions included younger age, White race, obesity, hypertension, pulmonary disease, hypothyroidism, rheumatoid arthritis, and depression. Fifty-two percent of these patients went on to have surgery. The percentage of elective cases increased from 59 to 70 %, while emergent cases conversely decreased from 41 to 30 %. One in five patients admitted with diverticulitis required two or more admissions. Numerous patient factors were correlated with increased risk of readmission. These factors may be used to guide treatment decisions and help reduce economic burden in frequent utilizers. Trends in surgery rates for these patients could reflect improved treatment options and/or changing clinical practice patterns.

20-Year Trends in the Management of Diverticulitis Across New York State: an Analysis of 265,724 Patients.

INTRODUCTION: Management of acute diverticulitis (AD) has considerably changed over time. This study evaluates practice patterns for diverticulitis across demographic populations in New York State. METHODS: Two hundred sixty-five thousand seven hundred twenty-four patients with acute diverticulitis were analyzed from 1995 to 2014 from the New York-Statewide Planning and Research Cooperative System database. The likelihood of having surgery over time was compared across patient demographic subgroups using logistic regression models to calculate estimated odds ratio with their 95 % confidence intervals. Using Chi-square test and Welch's t test, categorical and continuous variables were compared. RESULTS: From 1995 to 2014, there was an increase in newly diagnosed diverticulitis patients while the proportion of those patients undergoing operative management steadily decreased (31 to 10 %, p < 0.0001). Of those receiving surgery, emergent surgeries decreased (58 to 47 %, p < 0.0001) while elective surgeries increased (42 to 53 %, p < 0.0001) with the odds of having emergency surgery decreasing by 4 % annually (OR 0.96 (0.95-0.97), p < 0.0001). With the exception of patients greater than 80 years old, these linear trends were substantiated across patient subgroups. CONCLUSIONS: Over the past 20 years in New York State, there has been an increase in diverticulitis diagnoses and hospital admissions, with a decrease in surgeries performed reflecting a shift towards conservative management and more effective antibiotic treatment.

Gracilis muscle interposition for the treatment of rectourethral, rectovaginal, and pouch-vaginal fistulas: results in 53 patients.

BACKGROUND: The aim of this study was to review our experience with gracilis muscle interposition for complex perineal fistulas. MATERIAL AND METHODS: A retrospective review of all patients who underwent repair of perineal fistula using the gracilis muscle between 1995 and 2007 was undertaken. Patients were divided into 2 groups according to the fistula type by gender: females (rectovaginal and pouch-vaginal) and males (rectourethral). RESULTS: Gracilis interposition was performed in 53 patients. Seventeen women underwent 19 gracilis interpositions for 15 rectovaginal and 2 pouch-vaginal fistulas; 76% had a mean of (1-4) (mean of 2) prior failed attempt at repair. Eight patients experienced at least one postoperative complication. Two women required a second gracilis interposition. Thirty-three percent of the Crohn's disease-associated fistulas successfully healed; 75% without Crohn's successfully healed.Thirty-six males underwent gracilis interposition for rectourethral fistulas, mainly due to prostate cancer treatment; 13 (36%) had a mean of 1.5 (range 1-3) failed prior repairs. Seventeen patients experienced postoperative complications. The initial success rate in men with rectourethral fistulas was 78%. After successful second procedures in 8 patients, the overall clinical healing rate was 97%. CONCLUSION: The gracilis muscle transposition is a safe and effective method of treating complex perianal fistulas.

Management of nonhealing perineal wounds.

The manifestations of perianal Crohn's disease vary from primary lesions such as skin tags and fissures, to diffuse septic destruction of tissue and sphincter muscle. These manifestations are often persistent and refractory to surgical treatment; however, a more disappointing scenario is when the treatment itself results in a chronic wound. The ideal approach for management involves basic surgical principles, careful patient selection, and realistic expectations. Choice of appropriate procedure, effective elimination of sepsis, thorough evaluation to rule out concomitant systemic disease, and appropriate use of fecal diversion are each an important principle. If proctectomy is necessary, several strategies such as intersphincteric dissection, avoidance of fecal contamination, and appropriate wound closure, are effective in diminishing the postoperative morbidity of an unhealed perineal wound. When an unhealed perineal wound develops in a patient with Crohn's disease, the initial management is conservative. When surgical treatment is necessary, success depends on careful patient selection, optimizing the patient's condition, elimination of sepsis, and choice of an effective technique for healing.

Recurrence of a solitary fibrous tumor of the pleura: a case report.

We report a case of an 80-year-old female with two prior thoracotomies for benign solitary fibrous tumor of the pleura (SFTP) presenting with a two-month history of shortness of breath. Computed tomography revealed a pleural-based recurrence and operative excision revealed multiple adherent tumors throughout the thoracic cavity. Pathologic examination demonstrated malignant degeneration of this previously benign tumor. We consider the importance of recurrence of benign SFTP and the significance of surgical care and follow up of patients with this rare tumor.

Requirement for hourly Glasgow Coma Scores in the emergency department: process or outcome based?

BACKGROUND: The lack of hourly Glasgow Coma Score (GCS) documentation in trauma patients while in the emergency department (ED) is frequently cited by American College of Surgeons (ACS) Trauma Center Verification Review Committee site visitors. The basis for this requirement is unclear. We suspected that hourly recording of GCS has no impact on patient outcome. METHODS: The trauma registry of a 300-bed ACS-verified, state-designated Level II trauma center was reviewed retrospectively for head trauma patients over 16 years of age. Demographic data, field and ED GCS, presence or absence of hourly GCS in the ED, objective injury scores, complications, discharge status, and hospital length of stay were determined. RESULTS: A total of 463 patients were identified. Hourly GCS was recorded in the ED in 244 (53%) patients. No significant difference was found in the Trauma and Injury Severity Score or the Abbreviated Injury Score of the head between those who had hourly GCS recorded and those who did not. Patients who had hourly GCS recorded were significantly younger, 42.3 +/- 19.7 years vs 53.9 +/- 24.9 years for those who did not have hourly GCS recorded (P < 0.001). Seventy percent (126/179) of patients involved in a motorcycle or motor vehicle crash had hourly GCS recorded while only 39% (69/175) of patients admitted for falls had hourly GCS (P < 0.001). There were no differences in mortality or complication rates between the groups. CONCLUSION: The recording of hourly GCS on head injured patients is reflective of the initial presentation of the patient and not an objective evaluation of the patient. The presence or absence of hourly GCS in the ED was not associated with any increase in complications or mortality. The ACS should reevaluate the requirement for hourly recording of GCS in trauma patients.