Hemorrhoidectomy: Does Age Make a Difference?

BACKGROUND: Grade II and III hemorrhoids often require a multimodal approach that may ultimately culminate in surgical resection. Age and overall medical conditioning around the time of diagnosis can often impact the decision. OBJECTIVE: The objective of this study was to evaluate patients with a diagnosis of symptomatic grade II or grade III hemorrhoids and determine progression to hemorrhoidectomy based on age and the time interval between diagnosis and surgical intervention. DESIGN: A retrospective cohort study. SETTINGS: Group practice at a single institution. PATIENTS: Patients aged 18 to 75 years with grade II or grade III internal hemorrhoids between 2015 and 2020 were included. Patients with thrombosed hemorrhoids or surgical contraindications to hemorrhoidectomy were excluded. A total of 961 patients met inclusion criteria for grade II (n = 442) and III (n = 519) hemorrhoids. INTERVENTION: Treatments included hemorrhoidectomy, in-office procedures, and/or medical management. MAIN OUTCOME MEASURES: Baseline demographics, treatment choices, and time to hemorrhoidectomy (if applicable) were stratified and analyzed on the basis of hemorrhoid grade (grade II and III) and age groupings that were predetermined by the authors (18-30, 31-50, and 51-75 years). RESULTS: Patients with grade III versus grade II hemorrhoids were more likely to choose hemorrhoidectomy as the initial treatment management (27.6% vs 4.1%). Patients in the age groups of 18 to 30 and 30 to 50 years were more likely to choose hemorrhoidectomy as the initial treatment management compared to those in the age group of 51 to 75 years (23.5% and 22% vs 12.8%). In patients who were initially treated with medical management or office-based procedures and then progressed to hemorrhoidectomy, no significant differences in the length of time to hemorrhoidectomy were noted on the basis of hemorrhoid grade or age. LIMITATIONS: Data only looked at age groups and their treatment selection. Personal biases of surgeon and patient may alter results. CONCLUSIONS: Our study shows that the younger population tends to seek hemorrhoidectomy first over the older population. See Video Abstract . HEMORROIDECTOMA LA EDAD MARCA LA DIFERENCIA: ANTECEDENTES:Las hemorroides de grado II y III a menudo requieren un abordaje multimodal que en última instancia puede culminar en una resección quirúrgica. La edad y el estado médico general en el momento del diagnóstico a menudo pueden afectar la decisión.OBJETIVO:El objetivo de este estudio fue evaluar a pacientes con diagnóstico de hemorroides sintomáticas grado II o grado III y determinar la progresión a hemorroidectomía en función de la edad y el intervalo de tiempo entre el diagnóstico y la intervención quirúrgica.DISEÑO:Estudio de cohorte retrospectivo.ESCENARIO:Práctica grupal en una sola institución.PACIENTES:Se incluyó a pacientes de 18 a 75 años con hemorroides internas de grado II o III entre 2015 y 2020. Se excluyeron los pacientes con hemorroides trombosadas o contraindicaciones quirúrgicas para hemorroidectomía. Un total de 961 pacientes cumplieron los criterios de inclusión para hemorroides de Grado II (n=442) y III (n=519).INTERVENCIÓN:Los tratamientos incluyeron hemorroidectomía, procedimientos en el consultorio y/o manejo médico.PRINCIPALES MEDIDAS DE RESULTADO:Los datos demográficos iniciales, las opciones de tratamiento y el tiempo hasta la hemorroidectomía (si corresponde) se estratificaron y analizaron según el grado de hemorroides (grado II y III) y los grupos de edad predeterminados por los autores (18-30, 31-50). y 51-75).RESULTADOS:Los pacientes con hemorroides de Grado III versus Grado II tuvieron más probabilidades de elegir la hemorroidectomía como tratamiento inicial (27,6% versus 4,1%). Los pacientes de los grupos de edad de 18 a 30 y de 30 a 50 años tenían más probabilidades de elegir la hemorroidectomía como tratamiento inicial en comparación con los de 51 a 75 años (23,5% y 22% frente a 12,8%). En los pacientes que inicialmente fueron tratados con manejo médico o procedimientos en el consultorio y luego progresaron a hemorroidectomía, no se observaron diferencias significativas en el tiempo hasta la hemorroidectomía según el grado o la edad de las hemorroides.LIMITACIONES:Los datos solo analizan los grupos de edad y su selección de tratamiento. Los sesgos personales del cirujano y del paciente pueden alterar los resultados.CONCLUSIÓN:Nuestro estudio muestra que la población más joven tiende a buscar primero la hemorroidectomía que la población de mayor edad. (Traducción-Dr. Felipe Bellolio ).

Preoperative Immuno-Nutrition and Complications After Colorectal Surgery: Results of a 2-Year Prospective Study.

INTRODUCTION: Preoperative immuno-nutrition has been associated with reductions in infectious complications and length of stay, but remains unstudied in the setting of an enhanced recovery protocol. The objective was to evaluate outcomes after elective colorectal surgery with the addition of a preoperative immuno-nutrition supplement. METHODS: In October 2017, all major colorectal surgeries were given an arginine-based supplement prior to surgery. The control group consisted of cases within the same enhanced recovery protocol from three years prior. The primary outcome was a composite of overall morbidity. Secondary outcomes were infectious complications and length of stay with subgroup analysis based on degrees of malnutrition. RESULTS: Of 826 patients, 514 were given immuno-nutrition prospectively and no differences in complication rates (21.5% versus 23.9%, P = 0.416) or surgical site infections (SSIs) (6.4% versus 6.9%, P = 0.801) were observed. Hospitalization was slightly shorter in the immuno-nutrition cohort (5.0 [3.0, 7.0], versus 5.5 days [3.6, 7.9], P = 0.002). There was a clinically insignificant difference in prognostic nutrition index scores between cohorts (35.2 ± 5.6 versus 36.1 ± 5.0, P = 0.021); however, subgroup analysis (< 33, 34-38 and > 38) failed to demonstrate an association with complications (P = 0.275) or SSIs (P = 0.640) and immuno-nutrition use. CONCLUSIONS: Complication rates and SSIs were unchanged with the addition of immuno-nutrition before elective colorectal surgery. The association with length of stay is small and without clinical significance; therefore, the routine use of immuno-nutrition in this setting is of questionable benefit.

Induction and Purification of C. difficile Phage Tail-Like Particles.

Due to the inherent limitations of conventional antibiotics for the treatment of C. difficile infection (CDI), there is a growing interest in the development of alternative treatment strategies. Both bacteriophages and R-type bacteriocins, also known as phage tail-like particles (PTLPs), show promise as potential antibacterial alternatives for treating CDI. Similar to bacteriophages, but lacking a viral capsid and genome, PTLPs remain capable of killing target bacteria. Here we describe our experience in the induction and purification of C. difficile PTLPs. These methods have been optimized to allow production of concentrated, non-contractile, and non-aggregated samples for both sensitivity testing and structural electron microscopy studies.

Combined Medical and Surgical Approach Improves Healing of Septic Perianal Crohn's Disease.

BACKGROUND: Septic perianal Crohn's disease (SPCD) is a treatment challenge in spite of tumor necrosis factor antagonists (anti-TNF). Our aim was to define the success of SPCD management with a combined medical and surgical approach and to identify clinical and genetic factors predictive of healing. STUDY DESIGN: A retrospective chart review of patients with SPCD treated at the Penn State Milton S Hershey Medical Center was done. Primary end point was complete healing (ie normal clinical exam and no pain for at least 6 months). Genetic analysis of 185 single nucleotide polymorphisms associated with Crohn's disease was performed in 78 patients. RESULTS: One hundred and thirty-five episodes of SPCD were identified in 114 patients with a mean follow-up of 77 ± 7.4 months. Overall, 80 of 135 episodes healed (59.3%) and did not differ between those receiving anti-TNF and not (60.4% vs 56.8%). There appeared to be a consistent improved heal rate in each subcategory of surgically managed patients that received anti-TNF. Female sex was significantly predictive of healing in only those receiving anti-TNF agents (63.6% vs 25.0%; p = 0.0005). Twenty-two (19.3%) patients ultimately received a permanent diversion with either a total proctocolectomy or completion proctectomy. Multivariate analysis suggested several single nucleotide polymorphisms in Crohn's disease-associated genes to be possibly associated with healing, but lost significance after Bonferroni correction. CONCLUSIONS: Overall, there is an approximate 60% rate of healing SPCD using a combined medical and surgical approach. About 20% of SPCD patients will require a permanent stoma. There were no clear genetic predictors of healing SPCD.

Bacterial and Fungal Microbiota Changes Distinguish C. difficile Infection from Other Forms of Diarrhea: Results of a Prospective Inpatient Study.

This study sought to characterize the bacterial and fungal microbiota changes associated with Clostridium difficile infection (CDI) among inpatients with diarrhea, in order to further explain the pathogenesis of this infection as well as to potentially guide new CDI therapies. Twenty-four inpatients with diarrhea were enrolled, 12 of whom had CDI. Each patient underwent stool testing for CDI prior to being treated with difficile-directed antibiotics, when appropriate. Clinical data was obtained from the medical record, while each stool sample underwent 16S rRNA and ITS sequencing for bacterial and fungal elements. An analysis of microbial community structures distinct to the CDI population was also performed. The results demonstrated no difference between the CDI and non-CDI cohorts with respect to any previously reported CDI risk factors. Butyrogenic bacteria were enriched in both CDI and non-CDI patients. A previously unreported finding of increased numbers of Akkermansia muciniphila in CDI patients was observed, an organism which degrades mucin and which therefore may provide a selective advantage toward CDI. Fungal elements of the genus Penicillium were predominant in CDI; these organisms produce antibacterial chemicals which may resist recovery of healthy microbiota. The most frequent CDI microbial community networks involved Peptostreptococcaceae and Enterococcus, with decreased population density of Bacteroides. These results suggest that the development of CDI is associated with microbiota changes which are consistently associated with CDI in human subjects. These gut taxa contribute to the intestinal dysbiosis associated with C. difficile infection.

Outcomes of early ileocolectomy after percutaneous drainage for perforated ileocolic Crohn's disease.

BACKGROUND: The optimal treatment for an intra-abdominal abscess/infection secondary to perforating ileocolic Crohn's disease (PCD) is unclear. METHODS: Forty-seven consecutive PCD patients treated via an institutional protocol of ileocolectomy after a 7-day period of percutaneous abscess drainage were retrospectively compared with 160 consecutive patients who underwent an elective ileocolectomy for Crohn's disease (ECD) between 1992 and 2014. Outcomes were compared using univariate analysis and propensity score matching. RESULTS: Univariate analysis demonstrated significant differences in ileostomy rates (PCD: 48.9% vs ECD: 18.8%; P = .001), 30-day readmissions (PCD: 38.3% vs ECD: 18.8%; P = .01), and overall 30-day postoperative complications (PCD: 29.8% vs ECD: 15%; P = .03). After matching, a statistically significant difference was retained in ileostomy rates (P = .02) and 30-day readmissions (P = .01). CONCLUSIONS: Early operative intervention after percutaneous drainage in perforating CD may be associated with a high incidence of diversions and readmissions.

Single-Site Laparoscopic Colorectal Surgery Provides Similar Clinical Outcomes Compared With Standard Laparoscopic Surgery: An Analysis of 626 Patients.

BACKGROUND: Compared with standard laparoscopy, single-site laparoscopic colorectal surgery may potentially offer advantages by creating fewer surgical incisions and providing a multifunctional trocar. Previous comparisons, however, have been limited by small sample sizes and selection bias. OBJECTIVE: The purpose of this study was to compare 60-day outcomes between standard laparoscopic and single-site laparoscopic colorectal surgery patients undergoing elective and urgent surgeries. DESIGN: This was an unselected, retrospective cohort study comparing patients who underwent elective and unplanned standard laparoscopic or single-site laparoscopic colorectal resections for benign and malignant disease between 2008 and 2014. Outcomes were compared using univariate analyses. SETTINGS: This study was conducted at a single institution. PATIENTS: A total of 626 consecutive patients undergoing laparoscopic colorectal surgery were included. MAIN OUTCOME MEASURES: Morbidity and mortality rates within 60 postoperative days were measured. RESULTS: A total of 318 (51%) and 308 patients (49%) underwent standard laparoscopic and single-site laparoscopic procedures. No significant differences were noted in mean operative time (standard laparoscopy, 182.1 ± 81.3 vs single-site laparoscopy, 177.0 ± 86.5; p = 0.30) or postoperative length of stay (standard laparoscopy, 4.8 ± 3.4 vs single-site laparoscopy, 5.5 ± 6.9; p = 0.14). Conversions to laparotomy and 60-day readmissions were also similar for both cohorts across all of the procedures performed. A significant difference was identified in the number of patients who developed postoperative complications (standard laparoscopy, 19.2% vs single-site laparoscopy, 10.7%; p = 0.004), especially with respect to surgical-site infections (standard laparoscopy, 11.3% vs single-site laparoscopy, 5.8%; p = 0.02). LIMITATIONS: This was a retrospective, single institution study. CONCLUSIONS: Single-site laparoscopic colorectal surgery demonstrates similar results to standard laparoscopic colorectal surgery with regard to operative time, length of stay, and readmissions. Single-site laparoscopic colorectal surgery may provide advantages in limiting the development of certain complications, such as superficial surgical-site infections.

Phage tail-like particles kill Clostridium difficile and represent an alternative to conventional antibiotics.

BACKGROUND: Current Clostridium difficile infection (CDI) antibiotic regimens have become increasingly ineffective at achieving cure and preventing recurrence. A recently developed alternative to conventional antibiotics are phage tail-like particles (PTLPs), which are proteins that are morphologically similar to bacteriophages and are produced by C difficile. This study examines the in vitro killing spectrum of a previously unreported PTLP isolated from a clinical isolate of C difficile. METHODS: Using patient-derived samples from an institutional review board-approved C difficile tissue bank, a ribotype 078 C difficile isolate was anaerobically incubated on blood agar plates that were preswabbed with norfloxacin to induce the production of PTLPs. Concentrated PTLP populations were confirmed using transmission electron microscopy. Using a standard lawn spot approach, bactericidal activity was assessed as indicated by a clearing within the bacterial lawn. The PTLP genomic cluster was also fully sequenced and open reading frames were annotated according to predicted function. RESULTS: PTLPs were assessed using 64 patient-derived C difficile isolates of varying ribotypes. PTLPs demonstrated complete bactericidal activity in 21 of 25 ribotype 027 isolates with partial activity in 2 of the 25. Complete bactericidal activity was not demonstrated against any other ribotype or non-difficile bacteria, suggesting a species and ribotype specificity. Functional genes, which may be necessary for killing, were identified within the PTLP genetic locus. CONCLUSION: PTLPs demonstrate capability in eradicating C difficile in vitro, and with further development, may represent an organism-specific, microbiome-sparing therapy for CDI.

Volumetric fat ratio and not body mass index is predictive of ileocolectomy outcomes in Crohn's disease patients.

BACKGROUND: Crohn's disease (CD) patients are typically underweight; however, a growing cohort of overweight CD patients is emerging. The current study investigates whether body mass index (BMI) or volumetric fat parameters can be used to predict morbidity after ileocolectomy for CD. METHODS: One hundred and forty-three CD patients who underwent elective ileocolectomy were identified from our Inflammatory Bowel Disease (IBD) Registry. Patient demographics and operative outcomes were recorded. Visceral (VA) and subcutaneous (SA) adiposity and abdominal circumference (AC) were analyzed on preoperative CT scans using Aquarius iNtuition software. A visceral/subcutaneous ratio (VSR) was calculated. RESULTS: BMI correlated with SA (p = 0.0001), VA (p = 0.0001) and AC (p = 0.0001) but not VSR (p > 0.05). BMI, VA and AC did not predict surgical morbidity (p > 0.05). In multivariate regression analysis, family history of IBD (p = 0.009), high American Society of Anesthesiologists score (p = 0.02) and increased VSR (p = 0.03) were independent predictors of postoperative morbidity. CONCLUSIONS: The visceral/subcutaneous fat ratio is a more reliable predictor of postoperative outcomes in CD patients undergoing ileocolectomy than conventional adiposity markers such as BMI. Preoperative calculation of the visceral/subcutaneous fat ratio offers the opportunity to optimize high-risk surgical patients, thus improving outcomes.

An interleukin-4 polymorphism is associated with susceptibility to Clostridium difficile infection in patients with inflammatory bowel disease: results of a retrospective cohort study.

BACKGROUND: Clinical studies have suggested that patients with inflammatory bowel disease (IBD) are at greater risk for developing Clostridium difficile infection (CDI). The purpose of this study was to identify single-nucleotide polymorphisms (SNPs) associated with CDI among IBD patients. METHODS: This retrospective cohort study used our biobank to compare patients with IBD who developed CDI (IBD-CDI) with those who had never contracted CDI (IBD-nCDI). Patients were genotyped for 384 IBD-associated SNPs by microarray. Student t, chi-square, and Fisher exact tests were used. Multivariate logistic regression with Bonferroni correction was used for genotype analysis. RESULTS: Twenty IBD-CDI (14 with Crohn disease; 6 with ulcerative colitis) and 152 IBD-nCDI (47 CD/105 UC) patients were identified. The interleukin-4-associated SNP rs2243250 was associated with the development of CDI (raw P = .00005/corrected P = .02), with 15 of 20 (75%) CDI-IBD patients harboring the at-risk "A" allele versus 52 of 152 (34%) of IBD-nCDI. When we compared Crohn disease and ulcerative colitis patients separately, rs2243250 initially was associated with CDI in both groups, although clinical relevance was lost after Bonferroni correction. CONCLUSION: The interleukin-4 gene-associated SNP rs2243250 was strongly associated with CDI in our IBD population. This SNP may allow for the identification of IBD patients at greater risk for CDI.

Proton pump inhibitors induce changes in colonocyte gene expression that may affect Clostridium difficile infection.

BACKGROUND: Proton pump inhibitors seem to promote Clostridium difficile infection (CDI). Although the current literature suggests that this association is mediated through gastric acid suppression, there has been little investigation into whether a direct effect on expression of colonocyte genes may also have a role. The aim of this study was to investigate the effect of omeprazole on genome-wide gene expression in a human colonic cell line. METHODS: T84 cell monolayers were treated with acid-activated omeprazole at 0, 1, 10, or 100 µmol/L for 48 hours. Cells were lysed and total RNA samples were reverse transcribed and used to generate biotinylated cRNA. Whole-genome transcript expression levels were then quantified using an Illumina HT-12 BeadChip microarray targeting 25,440 genes. Transcripts with a stringent minimum absolute fold change of 1.5 and an adjusted nominal P value <.05 (false discovery) were identified as being differentially expressed. RESULTS: Significant changes in expression were observed for 322 colonocyte transcripts, including genes with potential implications for susceptibility to CDI. These genes include roles in cell junctions, toxin susceptibility, and bile acid metabolism and transport. CONCLUSION: Omeprazole treatment decreases the expression of genes that have important functions in colonocyte integrity. Such impairment in colonocyte function may promote CDI.

Predictors of intensive care unit admission after total joint arthroplasty.

Total joint arthroplasty (TJA) is a relatively safe orthopedic procedure. However, complications do occur, and some may necessitate admission to the intensive care unit (ICU). Our purpose was to determine risk factors associated with admittance to ICU after TJA. We evaluated 22,343 primary and revision total hip and knee arthroplasties from 1999 to 2008. One hundred thirty patients were admitted to the ICU. Cases were matched 1:2 for date of surgery, surgeon, and type of surgery. The causes for admission to ICU were recorded. Independent risk factors for ICU admission were smoking, cemented arthroplasty, general anesthesia, allogenic transfusion, higher C-reactive protein, lower hemoglobin level, higher body mass index, and older age. Proper identification and management of these "at-risk" patients may decrease the incidence of ICU admittance after TJA.

Developing a comprehensive electronic adverse event reporting system in an academic health center.

BACKGROUND: In September 2000 University of Missouri Health Care (MUHC) conducted an assessment of patient safety activities. At least six separate data systems for reporting adverse events, with multiple conflicting paper reports, were found during this analysis. The disparate nature of these systems and their inability to be linked ensured that few systemic prevention activities were undertaken. In January 2001 an interdisciplinary team was convened with the goal of creating a comprehensive approach to patient safety reporting and resolution. IMPLEMENTATION: A secure, Web-based system, the MUHC Patient Safety Network System (PSN), was created that allows staff, physicians, patients, families, and visitors to report comments, adverse events, and near-miss events from any computer in the hospital and from home, using the Internet. Anonymous reporting is an option for near-miss events. Reports are immediately available to department managers responsible for resolution; managers are alerted to the presence of a report by e-mail. As a result, a pilot study performed in two MUHC intensive care units documented dramatic reductions in resolution time using the PSN. The pilot also demonstrated an increased willingness to report by physicians and respiratory therapists. Training was accomplished in the fall of 2001, and the PSN was successfully implemented throughout the hospital on January 1, 2002. NEXT STEPS: Implementation of the PSN has recently been extended to all ambulatory care settings. An additional component of the PSN that is being built will allow physicians to report complications.