Statin medications are associated with decreased risk of sepsis and anastomotic leaks after rectal resections.

BACKGROUND: This study was designed to determine the effect of statins on colorectal postoperative complications related to sepsis. Previous studies have reported conflicting results. METHODS: This is a retrospective propensity score analysis of postoperative outcomes from a large regional database of patients who underwent elective colorectal resection from June 2012-July 2015. RESULTS: 7285 patients met inclusion criteria: 34.5% received statins. Propensity score matching revealed that patients taking statins had reduced risk of sepsis (3.75% vs 5.32%, p = .03). Subgroup analysis revealed that this difference was driven by patients undergoing rectal resections. Among the rectal resection group, anastomotic leaks were more common in the non-statins group (4.1% vs. 1.3%, p = .01). There was no significant difference between those taking statins and those not on statin medications with respect to composite SSI or 30-day mortality. CONCLUSIONS: Statin medications are associated with decreased risk of sepsis after colorectal surgery and anastomotic leaks after rectal resection. Future studies should focus on medication type, dosage, and duration to confirm these results and identify patient populations that would benefit most from statin therapy.

The Effect of Formal Robotic Residency Training on the Adoption of Minimally Invasive Surgery by Young Colorectal Surgeons.

OBJECTIVE: The minimally invasive approach to colorectal surgery is still underused. Only 50% to 60% of colectomies and 10% to 20% of rectal resections for cancer are performed laparoscopically. The increasing adoption of the robotic platform for colorectal surgery warrants re-evaluation of minimally invasive surgery (MIS) training techniques. Although considering lessons learned from past laparoscopic training, a standardized national robotic training program for colon and rectal surgery residents was developed and implemented in 2011. The objective of this study was to assess the effect of this program on the usage of MIS in practice following residency training. DESIGN: An internet-based 18 question survey was sent to all colon and rectal surgeons who graduated from ACGME-approved colon and rectal surgery residencies from 2013 to 2016. The survey questions were designed to determine MIS practice patterns for young colon and rectal surgeons after residency training for those who participated in the standardized national robotics training course when compared to those who did not participate. Grouped bar charts with error bars are presented along with summary statistics to offer a descriptive overview of training experiences by cohort. SETTING/PARTICIPANTS: This study is a survey of colon and rectal surgeons who completed colon and rectal surgery residencies to include all 52 programs across the United States. RESULTS: The overall survey response rate was 37.2% (109 of 293). Most (79.8%) of the colon and rectal surgery resident respondents participated in the formal robotic training course. The average respondent reported that 84% of colectomy cases and 74.8% of rectal resections done after residency training by all respondents were by the MIS approach. The laparoscopic approach was most prevalent for colectomies for both course participants (laparoscopic 55.1%, hand assisted lap 14.5%, and robotic 15.7%) and nonparticipants (laparoscopic 53.8%, hand assisted lap 12.3%, and robotic 15.9%). For rectal resections, the robotic approach was the preferred option for course participants (laparoscopic 24.5%, hand assist lap 14.0%, and robotic 39.2%) whereas laparoscopic and open approaches were used more often by nonparticipants (laparoscopic 36.8%, hand assist lap 8.0%, robotic 26.8%, and open 28.4%). Barriers to robotic implementation included lack of robotic mentors, inadequate robotic assistance, and the preference for the laparoscopic approach. CONCLUSION: The usage of MIS by young recently fellowship-trained colorectal surgeons is higher than previously reported. The proportion of rectal cases done robotically is higher compared to colon cases and with an apparent decrease in open rather than laparoscopic surgery, suggesting selective usage of robotic surgery for more challenging cases in the pelvis. Methods to more effectively increase the usage of minimally invasive approaches in colorectal surgery warrant further evaluation.

Comparison of arteriovenous fistulas and arteriovenous grafts in patients with favorable vascular anatomy and equivalent access to health care: is a reappraisal of the Fistula First Initiative indicated?

BACKGROUND: Initiatives to increase arteriovenous fistula (AVF) use are based on studies that show that AVFs require fewer interventions and have better patency than arteriovenous grafts (AVGs). Because patients who receive AVFs typically have more favorable vascular anatomy and are referred earlier for access placement than those who receive AVGs, the advantages of AVF might be overestimated. We compared outcomes for AVFs and AVGs in patients with equivalent vascular anatomy who were on dialysis via catheter at the time of vascular access placement. STUDY DESIGN: The study included patients who underwent placement of a first-time AVF or AVG between 2006 and 2009, who were on dialysis via catheter at the time of access placement, and who had favorable arterial and venous (>3 mm) anatomy. Outcomes for AVF and AVG were compared. RESULTS: Eighty-nine AVF and 59 AVG patients met study inclusion criteria. Similar secondary patency was achieved by AVG and AVF at 12 (72% vs 71%) and 24 months (57% vs 62%), respectively (p = 0.96). The number of interventions required to maintain patency for AVF (n = 1; range 0 to 10) and AVG (n = 1; range 0 to 11) were not different (p = 0.36). However, the number of catheter days to first access use was more than doubled in the AVF group (median 81 days) compared with the AVG group (median 38 days; p < 0.001). CONCLUSIONS: For patients who are receiving dialysis via catheter at the time of access placement, the maturation time, risk of nonmaturation, and interventions required to achieve a functional AVF can negate its benefits over AVG. A fistula first approach might not always apply to patients who are already on dialysis when referred for chronic access placement.