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BACKGROUND: Patients with liver disease undergoing colectomy have higher rates of complications and mortality. The Albumin-Bilirubin score is a recently developed system, established to predict outcomes after hepatectomy, that accounts for liver dysfunction. METHODS: All patients undergoing colectomy were identified in the 2015-2018 American College of Surgeons National Surgical Quality Improvement Program colectomy-targeted database. Demographics and outcomes were compared between patients with Albumin-Bilirubin Grade 1 vs. 2/3. Multivariable regression was performed for outcomes including colorectal-specific complications. Areas under the receiver operative characteristic curves were calculated to determine accuracy of the Albumin-Bilirubin score. RESULTS: Of 86,273 patients identified, 48% (N = 41,624) were Albumin-Bilirubin Grade 1, 45% (N = 38,370) Grade 2 and 7% (N = 6,279) Grade 3. Patents with Grade 2/3 compared to Grade 1 had significantly increased mortality (7.2% vs. 0.9%, p < 0.001) and serious morbidity (31% vs. 12%, p < 0.001). Colorectal-specific complications including anastomotic leak (3.7% vs. 2.8%, p < 0.001) and prolonged ileus (26% vs. 14%, p < 0.001) were higher in patients with Grade 2/3. Grade 2/3 had increased risk of mortality (odds ratio 3.07, p < 0.001) and serious morbidity (1.78, p < 0.001). Albumin-Bilirubin had excellent accuracy in predicting mortality (area under the curve 0.81, p < 0.001) and serious morbidity (0.70, p < 0.001). CONCLUSION: Albumin-Bilirubin is easily calculated using only serum albumin and total bilirubin values. Grade 2/3 is associated with increased rates of mortality and morbidity following colectomy. Albumin-Bilirubin can be applied to risk-stratify patients prior to colectomy.
Subject(s)
Bilirubin , Colectomy , Liver Diseases , Postoperative Complications , Serum Albumin , Humans , Colectomy/methods , Colectomy/adverse effects , Male , Female , Bilirubin/blood , Middle Aged , Aged , Serum Albumin/analysis , Serum Albumin/metabolism , Postoperative Complications/blood , Postoperative Complications/epidemiology , Liver Diseases/surgery , Liver Diseases/blood , Liver Diseases/mortality , Retrospective Studies , ROC Curve , Anastomotic Leak/blood , Anastomotic Leak/etiology , Anastomotic Leak/epidemiology , Ileus/etiology , Ileus/blood , Predictive Value of Tests , Treatment OutcomeABSTRACT
BACKGROUND: Preoperative opioid use has shown association with worse outcomes after surgery. However, little is known about the effect of preoperative benzodiazepines with and without opioids. The aim of this study was to determine the influence of preoperative substance use on outcomes after abdominal surgery. STUDY DESIGN: Patients undergoing abdominal operations including ventral hernia, colectomy, hysterectomy, cholecystectomy, appendectomy, nephrectomy, and hiatal hernia were identified in an opioid surgical steward program by a regional NSQIP consortium between 2019 and 2021. American College of Surgeons NSQIP data were linked with custom substance use variables created by the collaborative. Univariable and multivariable analyses were performed for 30-day outcomes. RESULTS: Of 4,439 patients, 64% (n = 2,847) were women, with a median age of 56 years. The most common operations performed were hysterectomy (22%), ventral hernia repair (22%), and colectomy (21%). Preoperative opioid use was present in 11% of patients (n = 472), 10% (n = 449) were on benzodiazepines, and 2.3% (n = 104) were on both. Serious morbidity was significantly (p < 0.001) increased in patients on preoperative opioids (16% vs 7.9%) and benzodiazepines (14% vs 8.3%) compared with their naïve counterpart and this effect was amplified in patients on both substances (20% vs 7.5%). Multivariable regression analyses reveal that preoperative substance use is an independent risk factor (p < 0.01) for overall morbidity and serious morbidity. CONCLUSIONS: Preoperative opioid and benzodiazepine use are independent risk factors that contribute to postoperative morbidity. This influence on surgical outcomes is exacerbated when patients are on both substances.
Subject(s)
Hernia, Ventral , Opioid-Related Disorders , Humans , Female , Middle Aged , Male , Analgesics, Opioid/therapeutic use , Benzodiazepines/therapeutic use , Hernia, Ventral/surgery , Postoperative Complications/etiology , Treatment Outcome , Retrospective StudiesABSTRACT
BACKGROUND: Endoscope controllers are traditionally a one-size-fits-all design. However, this design may not fit the modern workforce in endoscopy-related fields. Our study aims to determine if endoscopic controller size, independent of user dexterity, affects user proficiency. METHODS: 54 endoscopically naive participants completed a baseline dexterity test, followed by large-controller endoscopic and small-controller bronchoscopic simulation exercises. Participants were stratified by surgical glove size (≥7.5 and < 7.5) and gender. RESULTS: Endoscopy time was longer in participants with <7.5 size gloves (p = 0.01) and in females (p < 0.001). However, participants with glove size <7.5 had better dexterity measures (p = 0.04). There was no difference in bronchoscopy time based on glove size (p = 0.61). CONCLUSIONS: Participants with larger hands were more proficient with the larger controller despite being less dexterous than their counterparts. This advantage was less pronounced with the smaller controller. Our findings suggest that endoscopic controllers should be modified in design to accommodate all providers.
Subject(s)
Endoscopy , Hand , Female , Humans , Computer SimulationABSTRACT
OBJECTIVE: Colorectal surgery is a core component of general surgery. The volume of colorectal surgery performed by general surgery residents throughout training has not been studied. This study aims to analyze trends observed in colorectal-specific case numbers logged by general surgery residents over 16 years. DESIGN: Case number data for general surgery residents was extracted from the publicly available, annually published Accreditation Council for Graduate Medical Education (ACGME) database from 2003 to 2019. Cases were categorized as open or laparoscopic colectomy/proctectomy, colectomy with ileoanal pull-thru, abdomino-perineal resection (APR), transanal rectal tumor excision (TRE), anorectal procedure, colonoscopy, and total colorectal cases. The average case numbers per category was calculated for each year. Linear regression analyzed trends in case categories for all residents and those logged as surgeon chief and junior residents. SETTING: ACGME accredited general surgery residency programs. PARTICIPANTS: Not applicable. RESULTS: General surgery residents reported increased numbers of all, chief, and junior resident colorectal cases over the study period (124.5-173.7 cases/yr; 38.4-53.0 cases/yr; 86.4-120.6 cases/yr, all pâ¯=â¯0.00). Average cases for all, chief, and junior residents have increased for laparoscopic colectomy/proctectomy (4.6-26.4 cases/year; 2.7-12.9 cases/year; 2.0-13.5 cases/year, all pâ¯=â¯0.00), anorectal surgeries (26.7-37.7 cases/year; 5.4-9.9 cases/year; 21.3-27.8 cases/year, all pâ¯=â¯0.00), and colonoscopies (35.9-70.6 cases/year, pâ¯=â¯0.00; 6.6-14.1 cases/year, pâ¯=â¯0.01; 29.4-56.5 cases/year, pâ¯=â¯0.00). Average cases for all, chief, and junior residents have decreased for open colectomy/proctectomy (52.0-34.9 cases/year; 21.2-14.3 cases/year; 30.9-20.6 cases/year, all pâ¯=â¯0.00), APR (3.3-2.7 cases/year, pâ¯=â¯0.00; 1.8-1.3 cases/year, pâ¯=â¯0.00; 1.5-1.4 cases/year, pâ¯=â¯0.02), TRE (1.9-1.1 cases/year; 0.7-0.4 cases/year; 1.2-0.6 cases/year, all pâ¯=â¯0.00). Ileoanal pull-thru did not demonstrate a linear trend. CONCLUSIONS: The increase in exposure to colectomies/proctectomies, anorectal procedures and colonoscopies is encouraging, as these common colorectal operations will be encountered in general surgery practice. The observed low case numbers for TRE, APR, and ileoanal pull-thru suggest a need for specialized training.
Subject(s)
Colorectal Neoplasms , Colorectal Surgery , General Surgery , Internship and Residency , Accreditation , Clinical Competence , Colorectal Surgery/education , Education, Medical, Graduate , General Surgery/education , Humans , United States , WorkloadABSTRACT
BACKGROUND: Routine preoperative laboratory testing is not recommended for American Society of Anesthesiologists classification 1 or 2 patients before low-risk ambulatory surgery. METHODS: The 2017 National Surgical Quality Improvement Program data set was retrospectively queried for American Society of Anesthesiologists class 1 and 2 patients who underwent low-risk, elective outpatient anorectal, breast, endocrine, gynecologic, hernia, otolaryngology, oral-maxillofacial, orthopedic, plastic/reconstructive, urologic, and vascular operations. Preoperative laboratory testing was defined as any chemistry, hematology, coagulation, or liver function studies obtained ≤30 days preoperatively. Demographics, comorbidities, and outcomes were compared between those with and without testing. The numbers needed to test to prevent serious morbidity or any complication were calculated. Laboratory testing costs were estimated using Centers for Medicare and Medicaid Services data. RESULTS: Of 111,589 patients studied, 57,590 (51.6%) received preoperative laboratory testing; 26,709 (46.4%) had at least 1 abnormal result. Factors associated with receiving preoperative laboratory testing included increasing age, female sex, non-White race/ethnicity, American Society of Anesthesiologists class 2, diabetes, dyspnea, hypertension, obesity, and steroid use. Mortality did not differ between patients with and without testing. The complication rate was 2.5% among tested patients and 1.7% among patients without tests (P < .01). The numbers needed to test was 599 for serious morbidity and 133 for any complication. An estimated $373 million annually is spent on preoperative laboratory testing in this population. CONCLUSION: Despite American Society of Anesthesiologists guidelines, a majority of American Society of Anesthesiologists class 1 and 2 patients undergo preoperative laboratory testing before elective low-risk outpatient surgery. The differences in the rates of complications between patients with and without testing is low. Preoperative testing should be used more judiciously in this population, which may lead to cost savings.
Subject(s)
Ambulatory Surgical Procedures , Diagnostic Tests, Routine/standards , Elective Surgical Procedures , Preoperative Care/standards , Quality Improvement , Adult , Cost Savings , Diagnostic Tests, Routine/economics , Female , Guideline Adherence , Humans , Male , Middle Aged , Practice Guidelines as Topic , Preoperative Care/economics , Retrospective Studies , Risk Factors , Treatment OutcomeABSTRACT
BACKGROUND: Many low-risk patients receive preoperative laboratory testing (PLT) prior to elective outpatient surgery, with no effect on postoperative outcomes. This has not been studied in patients undergoing anorectal surgery. The aim of this study was to determine if PLT in this population was predictive of perioperative complications. MATERIALS AND METHODS: The 2015-2018 National Surgical Quality Improvement Program (NSQIP) databases were queried for elective ambulatory anorectal surgeries. PLT was defined as chemistry, hematology, coagulation, or liver function studies obtained ≤30 days preoperatively. American Society of Anesthesiologists (ASA) class 1 and 2 patients were included who underwent elective, ambulatory, benign anorectal surgery. Patient demographics, comorbidities, and postoperative outcomes were compared between those who did and did not receive PLT. Postoperative outcomes were defined as wound-related, procedure-related, major complications, unplanned readmission, and death occurring within 30 days. Multivariate regression analysis determined patient characteristics predictive of receiving testing. RESULTS: Of 3309 patients studied, 48.6% received PLT. On multivariate analysis, older age, female sex, Black race, ASA class 2, and comorbidities were predictive of receiving testing. The complication rates were similar between patients who did and did not receive testing (4.3% versus 3.5%, P = 0.22). CONCLUSIONS: PLT is performed in over half of low-risk patients receiving elective anorectal surgery. There was no difference in the rate of postoperative complications between patients who received testing or not, nor with normal versus abnormal results. PLT can be used more judiciously in this population.
Subject(s)
Ambulatory Surgical Procedures , Elective Surgical Procedures , Ambulatory Surgical Procedures/adverse effects , Elective Surgical Procedures/adverse effects , Female , Humans , Patient Readmission , Postoperative Complications/diagnosis , Postoperative Complications/epidemiology , Postoperative Complications/etiology , Preoperative Care/adverse effects , Retrospective Studies , Risk , Risk FactorsABSTRACT
BACKGROUND: Pathologic hemorrhoids are common among adults age 45-65. Hemorrhoids are characterized as internal or external, and grades 1-4 based on severity. The type and grade dictate treatment, with surgical treatment reserved for grades 3/4. The aim of this study is to compare clinical outcomes of various surgical treatments. METHODS: A systematic review was conducted to identify randomized clinical trials that compare surgical treatments for grade 3/4 hemorrhoids. A Bayesian network meta-analysis was done using NetMetaXL and WinBUGS. RESULTS: A total of 26 studies with 3137 participants and 14 surgical treatments for grade 3/4 hemorrhoids were included. Pain was less in patients with techniques such as laser (OR 0.34, CI 0.01-6.51), infrared photocoagulation (OR 0.38, CI 0.02-5.61), and stapling (OR 0.48, CI 0.19-1.25), compared to open and closed hemorrhoidectomies. There was less recurrence with Starion (OR 0.01, CI 0.00-0.46) and harmonic scalpel (OR 0.00, CI 0.00-0.49), compared to infrared photocoagulation and transanal hemorrhoidal dearterialization. Fewer postoperative clinical complications were seen with infrared photocoagulation (OR 0.04, CI 0.00-2.54) and LigaSure (OR 0.16, CI 0.03-0.79), compared to suture ligation and open hemorrhoidectomy. With Doppler-guided (OR 0.26, CI 0.05-1.51) and stapled (OR 0.36, CI 0.15-0.84) techniques, patients return to work earlier when compared to open hemorrhoidectomy and laser. CONCLUSION: There are multiple favorable techniques without a clear "gold standard" based on current literature. Open discussion should be had between patients and physicians to guide individualized care.
Subject(s)
Hemorrhoidectomy , Hemorrhoids , Adult , Aged , Bayes Theorem , Hemorrhoidectomy/adverse effects , Hemorrhoids/surgery , Humans , Ligation , Middle Aged , Surgical Stapling/adverse effects , Treatment OutcomeABSTRACT
The COVID-19 global pandemic is changing the practice of oncologic surgery. Accustomed to fighting cancer with all available means, surgeons are now being asked to delay treatment or make use of alternate strategies to conserve resources. Telemedicine is being widely employed. We present our thoughts on this topic and where we might be in the next several months.
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BACKGROUND: Controversy exists regarding the impact of preoperative bowel preparation on patients undergoing colorectal surgery. This is due to previous research studies, which fail to demonstrate protective effects of mechanical bowel preparation against postoperative complications. However, in recent studies, combination therapy with oral antibiotics (OAB) and mechanical bowel preparation seems to be beneficial for patients undergoing an elective colorectal operation. AIM: To determine the association between preoperative bowel preparation and postoperative anastomotic leak management (surgical vs non-surgical). METHODS: Patients with anastomotic leak after colorectal surgery were identified from the 2013 and 2014 Colectomy Targeted American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database and were employed for analysis. Every patient was assigned to one of three following groups based on the type of preoperative bowel preparation: first group-mechanical bowel preparation in combination with OAB, second group-mechanical bowel preparation alone, and third group-no preparation. RESULTS: A total of 652 patients had anastomotic leak after a colectomy from January 1, 2013 through December 31, 2014. Baseline characteristics were assessed and found that there were no statistically significant differences between the three groups in terms of age, gender, American Society of Anesthesiologists score, and other preoperative characteristics. A χ 2 test of homogeneity was conducted and there was no statistically/clinically significant difference between the three categories of bowel preparation in terms of reoperation. CONCLUSION: The implementation of mechanical bowel preparation and antibiotic use in patients who are going to undergo a colon resection does not influence the treatment of any possible anastomotic leakage.
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BACKGROUND: Relationships between high-volume surgeons and improved postoperative outcomes have been well documented. Colorectal procedures are often performed by general surgeons, particularly in emergent settings, and may form a large component of their practice. The influence of subspecialized training on outcomes after emergent colon surgery, however, is not well described. OBJECTIVE: The purpose of this study was to determine whether subspecialty training in colorectal surgery is associated with differences in postoperative outcomes after emergency colectomy. DESIGN: This was a retrospective cohort study. SETTINGS: Three tertiary care hospitals participating in the National Surgical Quality Improvement Project were included. PATIENTS: Patients undergoing emergent colon resections were identified at each institution and stratified by involvement of either a colorectal surgeon or a general or acute care surgeon. MAIN OUTCOME MEASURES: Propensity score matching was used to isolate the effect of surgeon specialty on the primary outcomes, including postoperative morbidity, mortality, length of stay, and the need for unplanned major reoperation, in comparable cohorts of patients. RESULTS: A total of 889 cases were identified, including 592 by colorectal and 297 by general/acute care surgeons. After propensity score matching, cases performed by colorectal surgeons were associated with significantly lower rates of 30-day mortality (6.7% vs 16.4%; p = 0.001), postoperative morbidity (45.0% vs 56.7%; p = 0.009), and unplanned major reoperation (9.7% vs 16.4%; p = 0.04). In addition, length of stay was ≈4.4 days longer among patients undergoing surgery by general/acute care surgeons (p < 0.001). LIMITATIONS: This study was limited by its retrospective design, with potential selection bias attributed to referral patterns. CONCLUSIONS: After controlling for underlying disease states and illness severity, emergent colon resections performed by colorectal surgeons were associated with significantly lower rates of postoperative morbidity and mortality when compared with noncolorectal surgeons. These findings may have implications for referral patterns for institutions. See Video Abstract at http://links.lww.com/DCR/A767.
Subject(s)
Colectomy , Colorectal Surgery , General Surgery , Specialization , Adolescent , Adult , Aged , Aged, 80 and over , Emergencies , Female , Humans , Male , Middle Aged , Outcome Assessment, Health Care , Propensity Score , Quality Assurance, Health Care , Quality Improvement , Retrospective Studies , United States , Young AdultABSTRACT
OBJECTIVE: The objective of this study was to determine the relationship between bowel preparation and surgical site infections (SSIs), and also other postoperative complications, after elective colorectal surgery. BACKGROUND: SSI is a major source of postoperative morbidity/costs after colorectal surgery. The value of preoperative bowel preparation to prevent SSI remains controversial. METHODS: We analyzed 32,359 patients who underwent elective colorectal resections in the American College of Surgeons National Surgery Quality Improvement Program database from 2012 to 2014. Univariable and multivariable analyses were performed; propensity adjustment using patient/procedure characteristics was used to account for nonrandom receipt of bowel preparation. RESULTS: 26.7%, 36.6%, 3.8%, and 32.9% of patients received no bowel preparation, mechanical bowel preparation (MBP), oral antibiotics (OA), and MBPâ+âOA, respectively. After propensity adjustment, MBP was not associated with decreased risk of SSI compared with no bowel preparation. In contrast, both OA and OAâ+âMBP were associated with decreased risk of any SSI (adjusted odds ratio 0.49, 95% confidence interval 0.38-0.64; and adjusted odds ratio 0.45, 95% confidence interval 0.40-0.50, respectively) compared with no bowel preparation. OA and MBPâ+âOA were associated with decreased risks of anastomotic leak, postoperative ileus, readmission, and also shorter length of stay (all P < 0.05). Bowel preparation was not associated with increased risk of cardiac/renal complications compared with no preparation. CONCLUSIONS: The use of MBP alone before elective colorectal resection to prevent SSI is ineffective and should be abandoned. In contrast, OA and MBPâ+âOA are associated with decreased risks of SSI and are not associated with increased risks of other adverse outcomes compared with no preparation. Prospective studies to determine the efficacy of OA are warranted; in the interim, MBPâ+âOA should be used routinely before elective colorectal resection to prevent SSI.
Subject(s)
Anti-Bacterial Agents/administration & dosage , Cathartics/administration & dosage , Colon/surgery , Elective Surgical Procedures/adverse effects , Preoperative Care/methods , Rectum/surgery , Surgical Wound Infection/prevention & control , Administration, Oral , Aged , Antibiotic Prophylaxis , Comparative Effectiveness Research , Female , Humans , Male , Middle Aged , Postoperative Complications/prevention & control , Preoperative Care/standards , Retrospective Studies , Risk FactorsABSTRACT
BACKGROUND: The American College of Surgeons NSQIP has developed a risk calculator (RC) to assist patients and surgeons with difficult decisions. The aim of this analysis was to determine the accuracy of the RC in patients undergoing elective and emergent colorectal operations. STUDY DESIGN: From January 2013 through December 2015, seventy-five patients undergoing emergent colorectal operations were paired by date with 75 patients having elective colorectal operations. Patient data were entered into the RC. Actual postoperative outcomes, derived from NSQIP data, were compared with those predicted by the RC. RESULTS: Emergent and elective patients differed (p < 0.05) with respect to age, functional status, American Society of Anesthesiologists class, steroid use, wound class, COPD, and chronic renal insufficiency. The RC accurately predicted outcomes in elective patients. Outcomes were significantly worse (p < 0.05) after the emergent operations. In emergent cases, the RC underestimated serious complications and length of stay and overestimated discharge to a skilled nursing facility (all p < 0.05). CONCLUSIONS: The American College of Surgeons NSQIP RC accurately predicts outcomes for elective colorectal operations. Predicted and actual outcomes are significantly better in patients undergoing elective colon operations compared with those undergoing emergent procedures. The RC should be used with caution in emergent cases, as it has the potential to underestimate serious complications and length of stay, and overestimate discharge to skilled nursing facility. Refinement of the tool to include procedure complexity and diagnosis terms might improve its accuracy in emergent cases.
Subject(s)
Clinical Competence , Colorectal Surgery , Elective Surgical Procedures/standards , Emergency Medicine , Quality Improvement , Risk Assessment/methods , Surgeons/standards , Female , Humans , Male , Middle Aged , Reproducibility of Results , Retrospective Studies , Risk Factors , United StatesABSTRACT
BACKGROUND: More than 5-8 % of endoscopically removed rectal polyps presumed to be benign contain invasive carcinoma. Tattooing has been advocated for follow-up localization of the resection site. Despite proven benefits, the authors propose that tattooing is not routinely performed when benign-appearing rectal polyps are endoscopically excised, thereby confounding management when invasive cancer is found. The secondary goal of the study was to determine the frequency of localization, polyp characteristics, and accuracy of predicting malignant potential at the authors' institution. METHODS: All patients with rectal neoplasia discovered during endoscopic polypectomy from 1 January 2003 to 1 August 2010 were retrospectively identified from Temple University Hospital's Tumor Registry. Demographic and clinical data were extracted from medical records including polyp size, gross appearance, pathology, resection margins, location based on preoperative colonoscopy, initial removal technique, tattoo performance, and ensuing procedures. RESULTS: During the study period, 49 patients had colonoscopic excision of presumed benign rectal polyps with ensuing diagnosis of neoplasia in the specimen. The malignant histology included adenocarcinoma (n = 5), carcinoma in situ (n = 21), carcinoid (n = 22), and composite carcinoid (n = 1). Only two polyps were tattooed at the initial polypectomy. Three polyps were "suspicious for malignancy." None of the suspicious polyps were tattooed. One of the suspicious lesions was an adenocarcinoma, and the remaining two were benign. The distance from the anal verge was noted in only seven patients. The predominant excision technique was hot snare polypectomy (n = 29). None of the incomplete polyp excisions for 15 patients were "suspicious for malignancy" or tattooed. Several strategies were used to manage incomplete resections including surveillance (40 %), repeat colonoscopic polypectomy (27 %), and surgery (33 %). CONCLUSIONS: Most malignant rectal polyps are neither diagnosed nor tattooed at initial colonoscopy. Moreover, the distance of the polyp from the anal verge is rarely measured, and gross characteristics are not well described. Tattooing of all endoscopically excised rectal polypectomy sites would avoid confounding of subsequent identification and management.