Colorectal Neoplasia among Patients with and without Human Immunodeficiency Virus.

BACKGROUND: Increasing availability of highly active antiretroviral therapy (HAART) for human immunodeficiency virus (HIV) has led to prolonged survival and rising incidence of non-HIV-defining cancers among patients with HIV. Compared with the general population, risk of colorectal cancer may differ among those with HIV due to immunosuppression, oncogenic viral coinfections, and higher prevalence of risk factors. METHODS: We identified patients (age ≥50 years) diagnosed with HIV, prescribed HAART for ≥6 months, and receiving care in two large health care systems in Dallas, TX. Patients received a first colonoscopy between January 2009 and December 2017. We calculated a standardized prevalence ratio as the ratio of observed to expected number of advanced neoplasia (high-risk adenoma or colorectal cancer) using an age- and sex-matched cohort of patients without HIV (n = 10,250). RESULTS: Among patients with HIV (n = 839), about two thirds (60.1%) had normal findings at colonoscopy; 6.8% had hyperplastic polyps only, 20.4% had low-risk adenomas, 11.7% had high-risk adenomas, and 1.1% had colorectal cancer. Prevalence of advanced neoplasia was similar between patients with and without HIV, with a standardized prevalence ratio of 0.99 (95% confidence interval, 0.81-1.19). CONCLUSIONS: There was no difference in the prevalence of colorectal neoplasia between patients with and without HIV. IMPACT: Patients with HIV appear to have similar risk of colorectal neoplasia compared to those without HIV and can therefore follow average-risk colorectal cancer screening guidelines.

Evaluation of Wound Photography for Remote Postoperative Assessment of Surgical Site Infections.

Importance: Surgeons are increasingly interested in using mobile and online applications with wound photography to monitor patients after surgery. Early work using remote care to diagnose surgical site infections (SSIs) demonstrated improved diagnostic accuracy using wound photographs to augment patients' electronic reports of symptoms, but it is unclear whether these findings are reproducible in real-world practice. Objective: To determine how wound photography affects surgeons' abilities to diagnose SSIs in a pragmatic setting. Design, Setting, and Participants: This prospective study compared surgeons' paired assessments of postabdominal surgery case vignettes with vs without wound photography for detection of SSIs. Data for case vignettes were collected prospectively from May 1, 2007, to January 31, 2009, at Erasmus University Medical Center, Rotterdam, the Netherlands, and from July 1, 2015, to February 29, 2016, at Vanderbilt University Medical Center, Nashville, Tennessee. The surgeons were members of the American Medical Association whose self-designated specialty is general, abdominal, colorectal, oncologic, or vascular surgery and who completed internet-based assessments from May 21 to June 10, 2016. Intervention: Surgeons reviewed online clinical vignettes with or without wound photography. Main Outcomes and Measures: Surgeons' diagnostic accuracy, sensitivity, specificity, confidence, and proposed management with respect to SSIs. Results: A total of 523 surgeons (113 women and 410 men; mean [SD] age, 53 [10] years) completed a mean of 2.9 clinical vignettes. For the diagnosis of SSIs, the addition of wound photography did not change accuracy (863 of 1512 [57.1%] without and 878 of 1512 [58.1%] with photographs). Photographs decreased sensitivity (from 0.58 to 0.50) but increased specificity (from 0.56 to 0.63). In 415 of 1512 cases (27.4%), the addition of wound photography changed the surgeons' assessment (215 of 1512 [14.2%] changed from incorrect to correct and 200 of 1512 [13.2%] changed from correct to incorrect). Surgeons reported greater confidence when vignettes included a wound photograph compared with vignettes without a wound photograph, regardless of whether they correctly identified an SSI (median, 8 [interquartile range, 6-9] vs median, 8 [interquartile range, 7-9]; P < .001) but they were more likely to undertriage patients when vignettes included a wound photograph, regardless of whether they correctly identified an SSI. Conclusions and Relevance: In a practical simulation, wound photography increased specificity and surgeon confidence, but worsened sensitivity for detection of SSIs. Remote evaluation of patient-generated wound photographs may not accurately reflect the clinical state of surgical incisions. Effective widespread implementation of remote postoperative assessment with photography may require additional development of tools, participant training, and mechanisms to verify image quality.

Heller myotomy versus Heller myotomy with Dor fundoplication for achalasia: long-term symptomatic follow-up of a prospective randomized controlled trial.

BACKGROUND: Our prior randomized controlled trial of Heller myotomy alone versus Heller plus Dor fundoplication for achalasia from 2000 to 2004 demonstrated comparable postoperative resolution of dysphagia but less gastroesophageal reflux after Heller plus Dor. Patient-reported outcomes are needed to determine whether the findings are sustained long-term. METHODS: We actively engaged participants from the prior randomized cohort, making up to six contact attempts per person using telephone, mail, and electronic messaging. We collected patient-reported measures of dysphagia and gastroesophageal reflux using the Dysphagia Score and the Gastroesophageal Reflux Disease-Health-Related Quality of Life (GERD-HRQL) instrument. Patient-reported re-interventions for dysphagia were verified by obtaining longitudinal medical records. RESULTS: Among living participants, 27/41 (66%) were contacted and all completed the follow-up study at a mean of 11.8 years postoperatively. Median Dysphagia Scores and GERD-HRQL scores were slightly worse for Heller than Heller plus Dor but were not statistically different (6 vs 3, p = 0.08 for dysphagia, 15 vs 13, p = 0.25 for reflux). Five patients in the Heller group and 6 in Heller plus Dor underwent re-intervention for dysphagia with most occurring more than five years postoperatively. One patient in each group underwent redo Heller myotomy and subsequent esophagectomy. Nearly all patients (96%) would undergo operation again. CONCLUSIONS: Long-term patient-reported outcomes after Heller alone and Heller plus Dor for achalasia are comparable, providing support for either procedure.

Hidden Morbidity of Ventral Hernia Repair with Mesh: As Concerning as Common Bile Duct Injury?

BACKGROUND: Ventral hernia repair with mesh is increasingly common, but the incidence of long-term complications that necessitate mesh explantation is unknown. We aimed to determine the epidemiology of mesh explantation after ventral hernia repair and to compare this with common bile duct injury, a dreaded complication of laparoscopic cholecystectomy. STUDY DESIGN: We evaluated a retrospective cohort of patients undergoing ventral hernia repair by linking the all-payers State Inpatient Databases and State Ambulatory Surgery Databases for New York, California, and Florida. We followed patients longitudinally from 2005 to 2011 for the primary end point of mesh explantation, designated by concurrent procedure codes for ventral hernia repair and foreign body removal. We determined time to mesh explantation and calculated cumulative costs for surgical care, comparing these with historical data for common bile duct injury. RESULTS: During the study period, 619,751 patients underwent at least one ventral hernia repair (91% open, 9% laparoscopic). In a mean follow-up of 3 years, 438 patients (0.07%) had mesh removed at a median of 346 days after repair. Median cumulative cost for patients requiring mesh explantation was $21,889 vs $6,983 without (p < 0.01). Rates of mesh explantation and costs were on par with laparoscopic common bile duct injury, based on published data, but occurred later in the postoperative course. CONCLUSIONS: By this conservative estimate, complications of ventral hernia repair with implantable mesh are comparably as frequent as for common bile duct injury, but occur later in a patient's experience. Long-term follow-up is critically necessary to fully understand the ramifications of implanted devices.

Using Quality Improvement Principles to Enhance Long-Term Completion of Patient-Reported Outcomes after Ventral Hernia Repair.

BACKGROUND: Ventral hernia repair (VHR) is a commonly performed surgical procedure. Unfortunately, long-term prospective information about quality of life and outcomes after VHR has been challenging to obtain. Decoupling follow-up from clinical visits via patient-reported outcomes (PROs) has been proposed as a means of achieving better long-term assessments after VHR. The Americas Hernia Society Quality Collaborative (AHSQC) is a national quality improvement (QI) effort in hernia repair that uses PROs to obtain long-term follow-up. However, the modality of PRO engagement to maximize participation has not been well established. A formal QI initiative was undertaken to determine if long-term PRO follow-up could be increased at a single AHSQC site by adding telephone communication to email communication for long-term postoperative VHR assessment. METHODS: Between September 2015 and July 2016, the long-term (greater than 1 year) AHSQC PRO completion rates after VHR at our institution were analyzed using plan-do-study-act cycles. Two interventions were implemented: contacting patients by telephone and changing timing of telephone calls. RESULTS: Two hundred thirty-two patients were identified, of whom 99 (42.7%) met eligibility criteria. Before this initiative, the long-term PRO completion rate was 16.3% in postoperative VHR patients. The completion rate after introducing telephone calls (intervention 1) was 35.7% and after changing the timing of telephone calls (intervention 2), was 55.1%. The mean participation rate was 45.4% (± 9.7%). CONCLUSIONS: A telephone-based approach markedly improved long-term PRO participation rates in postoperative VHR patients. Ultimately, a combination of email and telephone communication may be necessary to achieve higher levels of PRO follow-up in the VHR population.