Continuous Compartment Pressure Monitoring Allows the Early Detection of Compartment Syndrome After Arterial Revascularization.

Compartment syndrome (CS) occurs in several clinical scenarios. Reperfusion injury and tissue swelling are common causes. This can occur after trauma but also is seen post revascularization of extremities. CS is a difficult diagnosis to make in a timely fashion that avoids permanent tissue damage. The treatment for CS is immediate fasciotomy, but fasciotomy is not a complication-free procedure. Previous care pathways usually resulted in fasciotomy being performed in a disproportionate number of normal legs. These false positives and prophylactic releases are costly to the health system because of protracted hospital stays and increased surgery numbers. The desirable tool for surgeons would be one that decreases false positives and negatives while ensuring a diagnosis in a timely fashion with true positives. A new technology that allows continuous pressure monitoring seems to be the best aid to make a diagnosis. We present our experience in decreasing the time to diagnosis in a CS case post revascularization despite the neurological blockade.

Does a multimodal prehabilitation program improve sleep quality and duration in patients undergoing colorectal resection for cancer? Pilot randomized control trial.

Sleep difficulties are a common symptom in cancer patients at different stages of treatment trajectory and may lead to numerous negative consequences for which management is required. This pilot Randomized Controlled Trial (RCT) aims to assess the potential effectiveness of home-based prehabilitation intervention (prehab) on sleep quality and parameters compared to standard care (SOC) in colorectal cancer patients during the preoperative period and up to 8 weeks after the surgery. One hundred two participants (48.3% female, mean age 65 years) scheduled for elective resection of colorectal cancer were randomized to the prehab (n = 50) or the SOC (n = 52) groups. Recruitment and retention rates were 54% and 72%, respectively. Measures were completed at the baseline and preoperative, 4- and 8-week after-surgery follow-ups. Our mixed models' analyses revealed no significant differences between groups observed over time for all subjective and objective sleep parameters. A small positive change was observed in the perceived sleep quality only at the preoperative time point for the prehabilitation group compared to the SOC group, with an effect size d = 0.11 and a confidence interval (CI) between - 2.1 and - 0.1, p = .048. Prehab group patients with high anxiety showed a significant improvement in the rate of change of sleep duration over time compared to the SOC group, with a difference of 110 min between baseline and 8 weeks after surgery (d = 0.51, 95% CI: 92.3 to 127.7, p = .02). Multimodal prehabilitation intervention is feasible in colorectal cancer patients and may improve sleep duration for patients with high anxiety symptoms. Future large-scale RCTs are needed to confirm our results.

Predictive Factors for Successful Same-Day Discharge After Minimally Invasive Colectomy and Stoma Reversal.

BACKGROUND: Same-day discharge after minimally invasive colorectal surgery is a safe, effective practice in specific patients that can enhance the efficiency of enhanced recovery pathways. OBJECTIVE: To identify predictive factors associated with success or failure of same-day discharge. DESIGN: Prospective cohort study from January 2020 to March 2023. SETTINGS: Tertiary colorectal center. PATIENTS: Adult patients eligible for same-day discharge with remote postdischarge follow-up included those with minimal comorbidities, residing near the hospital, having sufficient home support, and owning a mobile device. INTERVENTIONS: Patients were discharged on the day of surgery upon meeting specific criteria, including adequate pain control, tolerance of oral intake, independent mobility, urination, and the absence of complications. Successful same-day discharge was defined as discharge on the day of surgery without unplanned visits in the first 72 hours. MAIN OUTCOME MEASURES: Factors associated with successful or failed same-day discharge after minimally invasive colorectal surgery. RESULTS: A total of 175 patients (85.3%) were discharged on the day of surgery, with 14 patients (8%) having an unplanned visit within 72 hours. Overall, 161 patients (78.5%) were categorized as same-day discharge success and 44 patients (21.5%) as same-day discharge failure. The same-day discharge failure group had a higher Charlson Comorbidity Index (3.7 vs 2.8, p = 0.03). Mean length of stay (0.8 vs 3.0, p = 0.00), 30-day complications (10% vs 48%, p = 0.00), and readmissions (8% vs 27%, p = 0.00) were higher in the same-day discharge failure group. Regression analysis showed that failed same-day discharge was associated with higher comorbidities (OR 0.79; 95% CI, 0.66-0.95) and prolonged postanesthesia care unit time (OR 0.99; 95% CI, 0.99-0.99). Individuals who received a regional nerve block (OR 4.1; 95% CI, 1.2-14) and those who did not consume postoperative opioids (OR 4.6; 95% CI, 1-21) were more likely to have successful same-day discharge. LIMITATIONS: Single-center study. CONCLUSIONS: Our findings indicate that comorbidities and prolonged postanesthesia care unit stays were associated with same-day discharge failure, whereas regional nerve blocks and minimal postoperative opioids were related to success. These factors may inform future research aiming to enhance colorectal surgery recovery protocols. See Video Abstract . FACTORES PREDICTIVOS PARA UN ALTA EXITOSA EL MISMO DA DESPUS DE UNA COLECTOMA MNIMAMENTE INVASIVA Y REVERSIN DEL ESTOMA: ANTECEDENTES:El alta el mismo día después de una cirugía colorrectal mínimamente invasiva es una práctica segura y eficaz en pacientes específicos que puede mejorar la eficiencia de las vías de recuperación mejoradas.OBJETIVO:Identificar factores predictivos asociados con el éxito o fracaso del alta el mismo día.DISEÑO:Estudio de cohorte prospectivo del 01/2020 al 03/2023.AJUSTES:Centro colorrectal terciario.PACIENTES:Los pacientes adultos elegibles para el alta el mismo día con seguimiento remoto posterior al alta incluyeron aquellos con comorbilidades mínimas, que residían cerca del hospital, tenían suficiente apoyo en el hogar y poseían un dispositivo móvil.INTERVENCIONES:Los pacientes fueron dados de alta el día de la cirugía al cumplir con criterios específicos, incluido un control adecuado del dolor, tolerancia a la ingesta oral, movilidad independiente, micción y ausencia de complicaciones. El alta exitosa el mismo día se definió como el alta el día de la cirugía sin visitas no planificadas en las primeras 72 horas.PRINCIPALES MEDIDAS DE RESULTADO:Factores asociados con el alta exitosa o fallida el mismo día después de una cirugía colorrectal mínimamente invasiva.RESULTADOS:Un total de 175 (85,3%) pacientes fueron dados de alta el día de la cirugía y 14 (8%) pacientes tuvieron una visita no planificada dentro de las 72 horas. En total, 161 (78,5%) pacientes se clasificaron como éxito del alta el mismo día y 44 (21,5%) pacientes como fracaso del alta el mismo día. El grupo de fracaso del alta el mismo día tuvo un índice de comorbilidad de Charlson más alto (3,7, 2,8, p = 0,03). La duración media de la estancia hospitalaria (0,8, 3,0, p = 0,00), las complicaciones a los 30 días (10%, 48%, p = 0,00) y los reingresos (8%, 27%, p = 0,00) fueron mayores en el mismo día grupo de fallo de descarga. El análisis de regresión mostró que el alta fallida el mismo día se asoció con mayores comorbilidades (OR 0,79; IC del 95 %: 0,66; 0,95) y tiempo prolongado en la unidad de cuidados postanestésicos (OR 0,99; IC del 95 %: 0,99; 0,99). Las personas que recibieron un bloqueo nervioso regional (OR 4,1; IC del 95 %: 1,2, 14) y aquellos que no consumieron opioides posoperatorios (OR 4,6, IC del 95 %: 1-21) tuvieron más probabilidades de tener éxito en el mismo día -descarga.LIMITACIONES:Estudio unicéntrico.CONCLUSIONES:Nuestros hallazgos indican que las comorbilidades y las estancias prolongadas en la unidad de cuidados postanestésicos se asociaron con el fracaso del alta el mismo día, mientras que los bloqueos nerviosos regionales y los opioides postoperatorios mínimos se relacionaron con el éxito. Estos factores pueden informar investigaciones futuras destinadas a mejorar los protocolos de recuperación de la cirugía colorrectal. (Traducción-Yesenia Rojas-Khalil ).

The impact of patient activation on the effectiveness of digital health remote post-discharge follow-up and same-day-discharge after elective colorectal surgery.

BACKGROUND: Low patient activation (PA) is associated with worse postoperative outcomes, however, its impact on the effectiveness of digital health interventions is unknown. We sought to determine the impact of PA on the effectiveness of digital health application for remote post-discharge follow-up for patients undergoing elective colectomy. METHODS: Data analysis included a control cohort (CC) of patients undergoing elective colorectal surgery from 10/2017 to 04/2018 without the digital health intervention and a digital application cohort (DAC) that received a smart phone application for remote post-discharge follow-up from 03/2021 to 08/2022, including a subset of same-day discharge (SDD) patients. PA was measured using the Patient Activation Measure (PAM; score 0-100) and categorized into low (< 55.1) and high (≥ 55.1). The PAM was administered 4-6 weeks before surgery in the DAC group and on postoperative day (POD) 1 in the CC group. The main outcome measure was 30-day emergency department (ED) visits. RESULTS: A total of 164 patients were included (89DAC with 50 SDD, 75CC), with no differences in patient characteristics other than more stoma closures in the DAC group. Overall, 77% of patients had high PA level, with no difference between CC and DAC (77% vs. 81%, p = 0.25). There was no difference in ED visits between CC and DAC (19% vs. 18%, p = 0.90). Overall, low PA was associated more ED visits (29% vs 14%, p = 0.04). In the SDD subgroup, low PA patients had more ED visits (38% vs. 7%, p = 0.015). PA level did not affect app usage metrics. On multiple regression, only low PA remained independently associated with ED visits (OR 3.42, 95%CI 1.27, 9.24). CONCLUSION: Low PA remains an important predictor of surgical outcomes after elective colorectal surgery regardless of the use of a digital health application for remote post-discharge follow-up. This suggests that improving PA levels may improve postoperative outcomes.

Association Between Physical Activity, Sedentary Behaviors, and Sleep-Related Outcomes Among Cancer Survivors: a Cross-Sectional Study.

BACKGROUND: Limited research has examined the association between moderate to vigorous physical activity (MVPA), sedentary behavior (SB), and sleep-related outcomes in cancer survivors. Therefore, this study aimed to examine these associations using a nationally representative sample of US adults. METHODS: Data from the 2005-2018 National Health and Nutrition Examination Survey (NHANES) were analyzed. A total of 3229 adults with cancer histories were included. Physical activity was measured through accelerometry, and questions on daily activities, sedentary time, and sleep were collected during the household interview. Weighted multivariable analyses were conducted after accounting for the complex sampling design of the NHANES dataset. RESULTS: After adjustments, physical activity and SB outcomes were associated with several self-reported sleep-related parameters. Increases in minutes of self-reported MVPA and SB were associated with a decreased likelihood of reporting ≥ 8 h of sleep (OR = 0.92, 95% CI = 0.86, 0.99 and OR = 0.88, 95% CI = 0.82, 0.95). Converse associations were found between device-measured MVPA and SB with the likelihood of reporting often/always feeling overly sleepy during the day (OR = 0.86, 95% CI = 0.75 and OR = 1.13, 95% CI = 1.05, respectively). However, an increased likelihood of waking up too early in the morning (OR = 1.22, 95% CI = 1.04) was observed with increases in minutes of device-measured MVPA. CONCLUSIONS: A sensible strategy to decrease the frequency of sedentary breaks and increase minutes of physical activity throughout the day may reduce sleep complaints reported in cancer survivors.

The impact of restorative proctectomy versus permanent colostomy on health-related quality of life after rectal cancer surgery using the patient-generated index.

BACKGROUND: The impact of bowel dysfunction versus colostomy on quality of life after rectal cancer surgery is poorly understood. BACKGROUND: To evaluate the quality of life after rectal cancer surgery in patients with colostomy versus restorative proctectomy. METHODS: A mixed-methods study measuring quality of life using the Patient-Generated Index, patients were asked to list up to 5 areas of their life affected by their surgery. Areas were then weighted according to patients' preferences for improvement to generate a score from 0-100. The areas reported by patients were linked to the International Classification of Functioning for content analysis. Bowel dysfunction was measured using the low anterior resection syndrome score, and patients were then grouped according to (1) colostomy, (2) no/minor, or (3) major low anterior resection syndrome. Quality of life was compared between groups. RESULTS: Overall, 121 patients were included (colostomy n = 39, restorative proctectomy n = 82). There were no differences in demographics, neoadjuvant radiotherapy, or time to follow-up between groups. In the restorative proctectomy group, 53% had no/minor, and 47% had major low anterior resection syndrome. Overall, patients with colostomy had significantly lower quality-of-life scores than those with restorative proctectomy. However, patients with major low anterior resection syndrome scored similarly to those with colostomy. On content analysis, patients with colostomies reported more problems with sexual function, body image, and sports. Patients with restorative proctectomy reported more problems with sleep, using transportation, and taking care of themselves. CONCLUSION: Colostomy has a more detrimental impact on quality of life than restorative proctectomy. However, bowel dysfunction severity is important to consider. The patient experience between treatments differs.

Understanding the Impact of Bowel Dysfunction on Quality of Life After Rectal Cancer Surgery From the Patient's Perspective.

BACKGROUND: Bowel dysfunction is an important consequence of rectal cancer surgery' and the specific quality-of-life domains that are affected remain unclear and unaddressed by generic surveys. OBJECTIVE: This study aimed to identify quality-of-life domains most affected by rectal cancer surgery. DESIGN: Qualitative content analysis. SETTINGS: Semistructured interviews conducted by telephone with patients recruited from a single university-affiliated colorectal referral center. PATIENTS: Adult patients were included if they underwent rectal cancer surgery with sphincter preservation from July 2017 to July 2020. Patients were excluded if their surgery was <1 year since the recruitment date, received a permanent stoma, or developed recurrence or metastasis. MAIN OUTCOME MEASURES: Bowel dysfunction was evaluated via the low anterior resection syndrome score. Interview transcripts were coded by 2 independent reviewers and evaluated for concordance. Qualitative content analysis was used to identify themes, and their frequency of occurrence was quantified (percent total number of interviews). RESULTS: A total of 54 patient interviews were conducted. Analysis revealed 5 quality-of-life-related themes impacted by bowel dysfunction: experiencing psychological and emotional stress, challenging roles and relationships within society, encountering physical limitations, restricting leisure and recreational activities, and learning self-empowerment and adapting to change. Patients with minor and major bowel dysfunction were more likely to report disruption to their social activities and their role as a sexual partner versus those with no bowel dysfunction. Patients with major bowel dysfunction were more likely to report effects on sleep versus those with no and minor bowel dysfunction. LIMITATIONS: Single center, self-reported, and observer bias. CONCLUSION: The impact of bowel dysfunction on quality of life includes a wide range of themes that extend beyond traditional measures. These results may help better inform patients in the preoperative setting and serve as a basis for the development of a more patient-centered quality-of-life survey. COMPRENDER EL IMPACTO DE LA DISFUNCIN INTESTINAL EN LA CALIDAD DE VIDA DESPUS DE LA CIRUGA DE CNCER DE RECTO DESDE LA PERSPECTIVA DEL PACIENTE: ANTECEDENTES:La disfunción intestinal es una consecuencia importante de la cirugía del cáncer de recto y los dominios específicos de la calidad de vida que se ven afectados siguen sin estar claros y sin abordarse en las encuestas genéricas.OBJETIVO:Identificar los dominios de calidad de vida más afectados por la cirugía del cáncer de recto.DISEÑO:Análisis cualitativo de contenido.ÁMBITOS:Entrevistas semiestructuradas realizadas por teléfono con pacientes reclutados de un único centro de referencia colorrectal afiliado a una universidad.PACIENTES:Pacientes adultos intervenidos de cáncer de recto con preservación de esfínter del 07/2017 al 07/2020. Los pacientes fueron excluidos si su cirugía fue <1 año desde la fecha de reclutamiento, recibieron un estoma permanente o desarrollaron recurrencia o metástasis.PRINCIPALES MEDIDAS DE RESULTADO:La disfunción intestinal se evaluó a través de la puntuación del síndrome de resección anterior baja. Dos revisores independientes codificaron las transcripciones de las entrevistas y evaluaron su concordancia. Se utilizó el análisis de contenido cualitativo para identificar los temas, cuantificando su frecuencia de aparición (porcentaje del número total de entrevistas).RESULTADOS:Se realizaron un total de 54 entrevistas a pacientes. El análisis reveló cinco temas relacionados con la calidad de vida afectados por la disfunción intestinal: experimentar estrés psicológico y emocional, roles y relaciones desafiantes dentro de la sociedad, encontrar limitaciones físicas, restringir actividades recreativas y de ocio, y autoempoderamiento y adaptación al cambio. Los pacientes con disfunción intestinal menor y mayor tenían más probabilidades de informar la interrupción de las actividades sociales y el papel como pareja sexual en comparación con aquellos sin disfunción intestinal. Los pacientes con disfunción intestinal importante tenían más probabilidades de informar efectos sobre el sueño en comparación con aquellos sin disfunción intestinal o con disfunción intestinal menor.LIMITACIONES:Sesgo de un solo centro, autoinformado y observador.CONCLUSIÓN:El impacto de la disfunción intestinal en la calidad de vida incluye una amplia gama de temas que se extienden más allá de las medidas tradicionales. Estos resultados pueden ayudar a informar mejor a los pacientes en el entorno preoperatorio y servir como base para el desarrollo de una encuesta de calidad de vida más centrada en el paciente. (Traducción-Dr. Yesenia Rojas-Khalil ).

A Mobile Phone App Improves Patient-Physician Communication and Reduces Emergency Department Visits After Colorectal Surgery.

BACKGROUND: Emergency visits after colorectal surgery are common and require significant health care resources. However, many visits may be avoidable with alternative access to care. Mobile health technologies can facilitate patient access to health care providers. OBJECTIVE: We hypothesized that a mobile app for postdischarge monitoring with patient-provider communication ability would reduce emergency visits after elective abdominopelvic colorectal surgery. DESIGN: This is a prospective cohort study with a regression analysis after coarsened exact matching. SETTING: The study was conducted at a single colorectal referral center from May 2019 to September 2020. PATIENTS: A total of 114 patients were recruited to the intervention and were matched to a retrospective cohort of 608 patients from the 24 months before the study. All patients were managed according to an enhanced recovery pathway. INTERVENTIONS: A mobile phone app comprised of patient education material, daily questionnaires assessing postdischarge recovery, and patient-provider chat function was used. MAIN OUTCOME MEASURES: The primary outcomes included potentially preventable 30-day emergency visits defined according to a validated algorithm. Secondary outcomes included length of stay, complications, total emergency department visits, readmissions, and app usability. RESULTS: Coarsened-exact matching resulted in a matched sample of 94 prospective intervention patients and 256 retrospective control patients. The prospective group was associated with fewer preventable emergency department visits (incidence rate ratio 0.34; p = 0.043) and shorter length of stay (-1.62 days; p = 0.011). There were no differences in 30-day complications, total number of emergency visits, or readmissions. Patient-reported usability of the mobile app was high, with 88% of patients reporting that the app improved their ability to communicate with their surgeon. LIMITATIONS: We did not account for patient activation or perform a cost-analysis. CONCLUSION: Use of a mobile app was associated with fewer potentially preventable emergency visits and shorter length of stay after major elective colorectal surgery, which may be due to enhanced postdischarge monitoring and patient-provider communication. See Video Abstract at http://links.lww.com/DCR/B878 . APLICACIN DE TELFONO MVIL MEJORA LA COMUNICACIN ENTRE MDICO Y PACIENTE Y REDUCE LAS VISITAS AL DEPARTAMENTO DE EMERGENCIAS DESPUS DE CIRUGA COLORECTAL: ANTECEDENTES:Las visitas de emergencia después de la cirugía colorrectal son frecuentes y requieren importantes recursos sanitarios. Sin embargo, muchas visitas pueden evitarse con un acceso alternativo a la atención. Las tecnologías de salud móviles pueden facilitar el acceso de los pacientes a los proveedores de atención médica.OBJETIVO:Se planteó la hipótesis de que una aplicación móvil para el seguimiento posterior al alta con capacidad de comunicación entre el paciente y el médico reduciría las visitas de emergencia después de cirugía colorrectal abdominopélvica electiva.DISEÑO:Este es un estudio de cohorte prospectivo con un análisis de regresión después de un emparejamiento exacto aproximado.ENTORNO CLINICO:El estudio se llevó a cabo en un solo centro de referencia colorrectal entre 05/2019 y 09/2020.PACIENTES:Se reclutó un total de 114 pacientes para la intervención y se emparejaron con una cohorte retrospectiva de 608 pacientes de los 24 meses anteriores al estudio. Todos los pacientes fueron tratados con protocolo de enhanced recovery .INTERVENCIONES:Se utilizó una aplicación para teléfono móvil compuesta de material educativo para el paciente, cuestionarios diarios que evalúan la recuperación posterior al alta y una función de chat entre el paciente y el médico.PRINCIPALES MEDIDAS DE RESULTADO:Los resultados primarios incluyeron visitas a la emergencia en 30 días potencialmente prevenibles, definidas según un algoritmo validado. Los resultados secundarios incluyeron la duración de la estancia, complicaciones, total de visitas al departamento de emergencias, reingresos y la usabilidad de la aplicación.RESULTADOS:El emparejamiento aproximado-exacto resultó en una muestra emparejada de 94 APP + y 256 APP-. APP + se asoció con menos visitas evitables al servicio de urgencias (IRR 0,34, p = 0,043) y una estancia más corta (-1,62 días, p = 0,011). No hubo diferencias en las complicaciones a los 30 días, número total de visitas de emergencia y reingresos. La usabilidad de la aplicación móvil informada por los pacientes fue alta, y el 88% de los pacientes informaron que la aplicación mejoró su capacidad para comunicarse con su cirujano.LIMITACIONES:No contabilizamos la activación del paciente ni realizamos un análisis de costos.CONCLUSIÓNES:El uso de una aplicación móvil se asoció con menos visitas a la emergencia potencialmente prevenibles y una estadía más corta después de una gran cirugía colorrectal electiva, lo que puede deberse a una mejor monitorización posterior al alta y a la comunicación entre el paciente y el médico. Consulte Video Resumen en http://links.lww.com/DCR/B878 . (Traducción-Dr. Francisco M. Abarca-Rendon ).

Bowel stimulation before loop ileostomy closure to reduce postoperative ileus: a multicenter, single-blinded, randomized controlled trial.

INTRODUCTION: The objective of this study was to evaluate the impact of preoperative bowel stimulation on the development of postoperative ileus (POI) after loop ileostomy closure. METHODS: This was a multicenter, randomized controlled trial (NCT025596350) including adult (≥ 18 years old) patients who underwent elective loop ileostomy closure at 7 participating hospitals. Participants were randomly assigned (1:1) using a centralized computer-generated sequence with block randomization to either preoperative bowel stimulation or no stimulation (control group). Bowel stimulation consisted of 10 outpatient sessions within the 3 weeks prior to ileostomy closure and was performed by trained Enterostomal Therapy nurses. The primary outcome was POI, defined as an intolerance to oral food in the absence of clinical or radiological signs of obstruction, on or after postoperative day 3, that either (a) required nasogastric tube insertion; or (b) was associated with two of the following: nausea/vomiting, abdominal distension, or the absence of flatus. RESULTS: Between January 2017 and November 2020, 101 patients were randomized, and 5 patients never underwent ileostomy closure; thus, 96 patients (47 stimulated vs. 49 control) were analyzed according to a modified intention-to-treat protocol. Baseline characteristics were well balanced in both groups. The incidence of POI was lower among patients randomized to stimulation (6.4% vs. 24.5%, p = 0.034; unadjusted RR: 0.26, 95% CI 0.078-0.87). Stimulated patients also had earlier median time to first flatus (2.0 days (1.0-2.0) vs. 2.0 days (2.0-3.0), p = 0.025), were more likely to pass flatus on postoperative day 1 (46.8% vs. 22.4%, p = 0.022), and had a shorter median postoperative hospital stay (3.0 days (2.0-3.5) vs. 4.0 days (2.0-6.0), p = 0.003). CONCLUSIONS: Preoperative bowel stimulation via the efferent limb of the ileostomy reduced POI after elective loop ileostomy closure.

A retrospective analysis of early discharge following minimally invasive colectomy in an enhanced recovery pathway.

BACKGROUND: There is increasing evidence to support discharge prior to gastrointestinal recovery following colorectal surgery. Furthermore, many patients are discharged early despite being excluded from an ambulatory colectomy pathway. The objective of this study was to determine the outcomes of patients discharged early following laparoscopic colectomy in an enhanced recovery pathway (ERP). METHODS: A retrospective review of all adult patients undergoing elective laparoscopic colectomy at a single university-affiliated colorectal referral center (08/2017-06/2021) was performed. Patients were included if they had undergone elective laparoscopic colectomy or ileostomy closure and excluded if they had been enrolled in an ambulatory colectomy pathway. Patients were then divided into three groups: LOS =1 day, LOS 2-3 days, and LOS 4+ days. The main outcomes were 30-day emergency room (ER) visits and readmissions. Reasons for inpatient stay per post-operative day (POD) were also recorded. RESULTS: A total of 497 patients were included [LOS1 n = 63 (13%), LOS2-3 n = 284 (57%), and LOS4+ n = 150 (30%)]. There were no differences in patient characteristics, diagnosis, or procedure between the groups. Patients were discharged with gastrointestinal recovery (GI-3) in 54% LOS1 vs. 98% LOS2-3 vs. 100% LOS4+ (p<0.001). Shorter procedure duration, transversus abdominus plane block, and lower opioid requirements were associated with shorter LOS (p<0.001). The absence of flatus was the most common reason to keep patients hospitalized: 61% on POD1, 21% on POD2, and 8% on POD3 (p<0.001). There were no differences in 30-day emergency visits, or readmission between the groups. In the LOS1 group, there were no differences in outcomes between patients with full return of bowel function at discharge compared to those without. CONCLUSION: Discharge on POD1 was not associated with increased emergency department use, complications, or readmissions. Importantly, full return of bowel function at discharge did not affect outcomes. There may be potential to expand eligibility criteria for ambulatory colectomy protocol.

The impact of bowel dysfunction on health-related quality of life after rectal cancer surgery: a systematic review.

BACKGROUND: Symptoms of bowel dysfunction after sphincter-preserving rectal cancer surgery have an important impact on health-related quality of life (HRQOL), but that relationship is complex. A better understanding of this relationship allows for better informed shared decision-making about surgery. Our objective was to perform a systematic review to determine which HRQOL domains are most affected by postoperative bowel dysfunction. METHODS: A systematic review of the CINAHL, Cochrane Library, Embase, Medline, PsycInfo, PubMed, Web of Science, and Scopus databases was performed according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. We included studies that evaluated bowel function after sphincter-preserving rectal cancer surgery and assessed HRQOL using a validated instrument. The quality of HRQOL analysis was assessed using an 11-item checklist. The main outcome was the impact bowel dysfunction had on global and domain specific quality-of-life indices. The impact was evaluated for clinical relevance using the Minimum Clinical Important Difference (MCID) for each specific HRQOL instrument. RESULTS: Out of 952 unique citations, 103 studies were full-text reviews. Eighteen studies met the inclusion criteria (4 prospective cohorts and 9 cross-sectional studies). Of the 15 studies with long-term follow-up, the time to assessment after surgery ranged from 1.2 to 14.6 years. The low anterior resection syndrome score and European Organization for Research and Treatment core quality-of-life questionnaire (EORTC QLQ-C30) were the most commonly used instruments. Medium and large magnitudes in MCID were seen for global health, social functioning, emotional functioning, fatigue, diarrhea, and financial difficulties. Among included studies, the most consistently reported functional domains affected by bowel function were social functioning and emotional functioning. CONCLUSIONS: Following sphincter-preserving rectal cancer surgery, poor bowel function mainly affects the social and emotional functional domains of HRQOL, which in turn impact global scores. This finding can help inform patients about expected changes in HRQOL after rectal cancer surgery and facilitate individualized treatment decisions.

Trajectory of change of low anterior resection syndrome over time after restorative proctectomy for rectal adenocarcinoma.

BACKGROUND: Restorative proctectomy for rectal cancer is associated with a high incidence of low anterior resection syndrome (LARS), but few studies report longitudinal results for bowel function. The aim of our study was to examine the trajectory of change of LARS over the first 18 months after restorative proctectomy for rectal cancer. METHODS: A prospective database measuring functional outcomes in rectal cancer patients from a single university-affiliated specialist colorectal referral center from 10/2018 to 03/2020 was queried. Patients were included in this study if they underwent restorative proctectomy for rectal cancer and had at least three assessments in the first 18 months after primary surgery or after closure of proximal diversion. Bowel function was assessed using the LARS score, administered at every surveillance follow-up after restoration of bowel continuity. Latent-class growth curve (trajectory) analysis was used to identify different trajectories of LARS changes over the first 18 months and group patients into these trajectory groups. These groups were then compared to identify predictors for each trajectory. RESULTS: A total of 95 patients were included (63 males, mean age. 61.3 ± 12.5 years). Trajectory analysis identified three distinct trajectory groups. Group 1 had stable minimal LARS over time (26%). Group 2 had early LARS scores consistent with the minor LARS category and improved with time (28%). Group 3 had persistently high LARS scores (45%). Neoadjuvant therapy, intersphincteric resection, and proximal diversion were more common in group 3. CONCLUSIONS: We identified three main trajectories of change of LARS in the 18 months after restorative proctectomy. These data may be used to better inform patients of their expected postoperative bowel function.

Enhanced Recovery 2.0 - Same Day Discharge With Mobile App Follow-up After Minimally Invasive Colorectal Surgery.

OBJECTIVE: To investigate the feasibility of SDD protocol with postdischarge follow-up using a mobile phone app in patients undergoing elective minimally-invasive colectomy. SUMMARY OF BACKGROUND DATA: Discharge before gastrointestinal recovery and use of mobile health technology for remote follow-up may allow for SDD after minimally-invasive colectomy within an ERP. METHODS: Adult patients undergoing elective laparoscopic colectomy or loop ileostomy reversal from February 2020 to November 2020 were screened for eligibility. Patients were eligible if they lived within a 30-minute drive from the hospital, had an adequate support system at home, and owned a smart phone. Patients were discharged from the recovery room on the day of surgery based on set criteria with postdischarge remote follow-up using a mobile application. Feasibility was defined as discharge on the day of surgery without emergency department (ED) visit or readmission within the first 3 days. 30-day complications, ED visits, and readmissions were compared to a non-SDD historical cohort (May 2019-March 2020) also remotely followed-up using the same mobile phone app (standard ERP group). RESULTS: A total of 48 patients were recruited to SDD, of which 77% were discharged on the day of surgery without subsequent ED visit in the first 72 hours. There were 11 patients that could not be discharged, including 7 for failure of discharge criteria and 4 for intraoperative complications/concerns. Overall 30-day complications in the SDD group (17%) was similar to the standard ERP group (15%, P = 0.813). ED visits (SDD10% vs standard ERP8%, P = 0.664) and readmissions (6% vs 4%, P = 0.681) were also similar. CONCLUSIONS AND RELEVANCE: Findings from this study support the feasibility of a SDD protocol in select patients undergoing minimally-invasive colorectal resection. SDD colectomy protocols may represent the next evolution of ERP and postoperative recovery.

Long-term Implications of Persistent Diverticulitis: A Retrospective Cohort Study of 915 Patients.

BACKGROUND: Persistent (or ongoing) diverticulitis is a well-recognized outcome after treatment for acute sigmoid diverticulitis; however, its definition, incidence, and risk factors, as well as its long-term implications, remain poorly described. OBJECTIVE: The purpose of this study was to assess the incidence, risk factors, and long-term outcomes of persistent diverticulitis. DESIGN: This was a retrospective cohort study. SETTINGS: Two university-affiliated hospitals in Montreal, Quebec, Canada were included. PATIENTS: The study was composed of consecutive patients managed nonoperatively for acute sigmoid diverticulitis. INTERVENTION: Nonoperative management of acute sigmoid diverticulitis was involved. MAIN OUTCOME MEASURES: Persistent diverticulitis, defined as inpatient or outpatient treatment for signs and symptoms of ongoing diverticulitis within the first 60 days after treatment of the index episode, was measured. RESULTS: In total, 915 patients were discharged after an index episode of diverticulitis managed nonoperatively. Seventy-five patients (8.2%; 95% CI, 6.5%-10.2%) presented within 60 days with persistent diverticulitis. Factors associated with persistent diverticulitis were younger age (adjusted OR = 0.98 (95% CI, 0.96-0.99)), immunosuppression (adjusted OR = 2.02 (95% CI, 1.04-3.88)), and abscess (adjusted OR = 2.05 (95% CI, 1.03-3.92)). Among the 75 patients with persistent disease, 42 (56.0%) required hospital admission, 6 (8.0%) required percutaneous drainage, and 5 (6.7%) required resection. After a median follow-up of 39.0 months (range, 17.0-67.3 mo), the overall recurrence rate in the entire cohort was 31.3% (286/910). After excluding patients who were managed operatively for their persistent episode of diverticulitis, the cumulative incidence of recurrent diverticulitis (log-rank: p < 0.001) and sigmoid colectomy (log-rank: p < 0.001) were higher among patients who experienced persistent diverticulitis after the index episode. After adjustment for relevant patient and disease factors, persistent diverticulitis was associated with higher hazards of recurrence (adjusted HR = 1.94 (95% CI, 1.37-2.76) and colectomy (adjusted HR = 5.11 (95% CI, 2.96-8.83)). LIMITATIONS: The study was limited by its observational study design and modest sample size. CONCLUSIONS: Approximately 10% of patients experience persistent diverticulitis after treatment for an index episode of diverticulitis. Persistent diverticulitis is a poor prognostic factor for long-term outcomes, including recurrent diverticulitis and colectomy. See Video Abstract at http://links.lww.com/DCR/B593. REPERCUSIONES A LARGO PLAZO DE LA DIVERTICULITIS PERSISTENTE ESTUDIO DE UNA COHORTE RETROSPECTIVA DE PACIENTES: ANTECEDENTES:La diverticulitis persistente (o continua) es un resultado bien conocido posterior al tratamiento de la diverticulitis aguda del sigmoides; sin embargo, la definición, incidencia y factores de riesgo, así como sus repercusiones a largo plazo siguen estando descritas de manera deficiente.OBJETIVO:Evaluar la incidencia, los factores de riesgo y los resultados a largo plazo de la diverticulitis persistente.DISEÑO:Estudio de una cohorte retrospectiva.AMBITO:Dos hospitales universitarios afiliados en Montreal, Quebec, Canadá.PACIENTES:pacientes consecutivos tratados sin cirugia por diverticulitis aguda del sigmoides.INTERVENCIÓN:Tratamiento no quirúrgico de la diverticulitis aguda del sigmoides.PRINCIPALES RESULTADOS EVALUADOS:Diverticulitis persistente, definida como tratamiento hospitalario o ambulatorio por signos y síntomas de diverticulitis continua dentro de los primeros 60 días posteriores al tratamiento del episodio índice.RESULTADOS:Un total de 915 pacientes fueron dados de alta posterior al episodio índice de diverticulitis tratados sin cirugia. Setenta y cinco pacientes (8,2%; IC del 95%: 6,5-10,2%) presentaron diverticulitis persistente dentro de los 60 días. Los factores asociados con la diverticulitis persistente fueron una edad menor (aOR: 0,98, IC del 95%: 0,96-0,99), inmunosupresión (aOR: 2,02, IC del 95%: 1,04-3,88) y abscesos (aOR: 2,05, IC del 95%: 1,03-3,92). Entre los 75 pacientes con enfermedad persistente, 42 (56,0%) requirieron ingreso hospitalario, 6 (8,0%) drenaje percutáneo y 5 (6,7%) resección. Posterior a seguimiento medio de 39,0 (17,0-67,3) meses, la tasa global de recurrencia de toda la cohorte fue del 31,3% (286/910). Después de excluir a los pacientes que fueron tratados quirúrgicamente por su episodio persistente de diverticulitis, la incidencia acumulada de diverticulitis recurrente (rango logarítmico: p <0,001) y colectomía sigmoidea (rango logarítmico: p <0,001) fue mayor entre los pacientes que experimentaron diverticulitis persistente después el episodio índice. Posterior al ajuste de factores importantes de la enfermedad y del paciente, la diverticulitis persistente se asoció con mayores riesgos de recurrencia (aHR: 1,94, IC 95% 1,37-2,76) y colectomía (aHR: 5,11, IC 95% 2,96-8,83).LIMITACIONES:Diseño de estudio observacional, un modesto tamaño de muestra.CONCLUSIONES:Aproximadamente el 10% de los pacientes presentan diverticulitis persistente después del tratamiento del episodio índice de diverticulitis. La diverticulitis persistente, en sus resultados a largo plazo, es un factor de mal pronóstico, donse se inlcuye la diverticulitis recurente y colectomía. Consulte Video Resumen en http://links.lww.com/DCR/B593.

Exercise intervention in cancer patients with sleep disturbances scheduled for elective surgery: Systematic review.

BACKGROUND & OBJECTIVES: Sleep disturbance is one of the patients' major complaints after major surgery and can impair postoperative recovery. Pre-operative exercise has been shown to increase functional capacity and resilience in cancer patients; scarce knowledge is available on the effects of pre-operative exercise on sleep disturbances. This systematic review aims to determine the impact of pre-operative exercise training alone or as part of multimodal prehabilitation on sleep disturbances and sleep quality in cancer patients. METHODS: A systematic search including Biosis, Cochrane Library and CENTRAL, EMBASE, MEDLINE, and clinical trial registries (clinicaltrials.gov, International Clinical Trials Registry Platform) was performed to identify studies involving a pre-operative exercise intervention in cancer patients awaiting surgery. Trials had to contain at least one sleep measure, assessed subjectively and objectively were included in the systematic review. The quality of the included trials was assessed using the Cochrane Risk of Bias Tool for assessing the risk of bias in randomized trials tool and the ROBINS-I tool for evaluating the risk of bias in non-randomized studies. RESULTS: Seven studies were included (1 RCT, 2 non-RCTs and 4 single-arm design). Due to substantial heterogeneity in the interventions across studies, a meta-analysis was not conducted. The available empirical evidence on the presurgical effect of exercise on sleep outcomes is scarce and, overall, suggests that it has a limited effect. Besides, non-significant improvement of the pre-operative exercise on sleep was unique to the studies that used subjective measures to assess sleep disturbances changes during cancer treatment. CONCLUSION: There are conflicting results and a lack of quality data proving the pre-operative exercise on sleep quality and disturbances. More research is needed in the pre-operative period using clinical sleep disturbances such as insomnia as an inclusion criterion, subjectively and objectively assessed.

Interactive online informational and peer support application for patients with low anterior resection syndrome: patient survey and protocol for a multicentre randomized controlled trial.

AIM: Low anterior resection syndrome (LARS) refers to a constellation of bowel symptoms that affect the majority of patients following restorative proctectomy. LARS is associated with poorer quality of life (QoL), and can lead to distress, anxiety and isolation. Peer support could be an important resource for people living with LARS, helping them normalize and validate their experience. The aim of this work is to describe the development of an interactive online informational and peer support app for LARS and the protocol for a randomized controlled trial. METHOD: A multicentre, randomized, assessor-blind, parallel-groups pragmatic trial will involve patients from five large colorectal surgery practices across Canada. The trial will evaluate the impact of an interactive online informational and peer support app for LARS, consisting of LARS informational modules and a closed forum for peers and trained peer support mentors, on patient-reported outcomes of people living with LARS. The primary outcome will be global QoL at 6 months following app exposure. The treatment effect on global QoL will be modelled using generalized estimating equations. Secondary outcomes will include patient activation and bowel function as measured by LARS scores. RESULTS: In order to better understand patients' interest and preferences for an online peer support intervention for LARS, we conducted a single institution cross-sectional survey study of rectal cancer survivors. In total, 35/69 (51%) participants reported interest in online peer support for LARS. Age <65 years (OR 9.1; 95% CI 2.3-50) and minor/major LARS (OR 20; 95% CI 4.2-100) were significant predictors of interest in LARS online peer support. CONCLUSION: There is significant interest in the use of online peer support for LARS among younger patients and those with significant bowel dysfunction. Based on results of the needs assessment study, the app content and features were modified reflect patients' needs and preferences. We are now in an optimal position to rigorously test the potential effects of this initiative on patient-centered outcomes using a randomized controlled trial.

Development and Validation of a Clinical Risk Score for Intensive Care Resource Utilization After Colon Cancer Surgery: a Practical Guide to the Selection of Patients During COVID-19.

BACKGROUND: The purpose of this study was to develop and validate a prediction model and clinical risk score for Intensive Care Resource Utilization after colon cancer surgery. METHODS: Adult (≥ 18 years old) patients from the 2012 to 2018 ACS-NSQIP colectomy-targeted database who underwent elective colon cancer surgery were identified. A prediction model for 30-day postoperative Intensive Care Resource Utilization was developed and transformed into a clinical risk score based on the regression coefficients. Model performance was assessed using the area under the receiver operating characteristic curve (AUC) and Hosmer-Lemeshow goodness-of-fit test. The model was validated in a separate test set of similar patients. RESULTS: In total, 54,893 patients underwent an elective colon cancer resection, of which 1224 (2.2%) required postoperative Intensive Care Resource Utilization. The final prediction model retained six variables: age (≥ 70; OR 1.90, 95% CI 1.68-2.14), sex (male; OR 1.73, 95% CI 1.54-1.95), American Society of Anesthesiologists score (III/IV; OR 2.52, 95% CI 2.15-2.95), cardiorespiratory disease (yes; OR 2.22, 95% CI 1.94-2.53), functional status (dependent; OR 2.81, 95% CI 2.22-3.56), and operative approach (open surgery; OR 1.70, 95% CI 1.51-1.93). The model demonstrated good discrimination (AUC = 0.73). A clinical risk score was developed, and the risk of requiring postoperative Intensive Care Resource Utilization ranged from 0.03 (0 points) to 19.0% (8 points). The model performed well on test set validation (AUC = 0.73). CONCLUSION: A prediction model and clinical risk score for postoperative Intensive Care Resource Utilization after colon cancer surgery was developed and validated.

Association Between Patient Activation and Health Care Utilization After Thoracic and Abdominal Surgery.

Importance: Increased patient activation (PA) (ie, knowledge, skills, motivation, confidence to participate in care) may result in improved outcomes, especially in surgical settings. Objective: To estimate the extent to which PA is associated with 30-day postdischarge unplanned health care utilization after major thoracic or abdominal surgery. Design, Setting, and Participants: This cohort study was performed at 2 centers of a tertiary care hospital network between October 2017 and January 2019. Adult patients undergoing thoracic or abdominal surgery were included. Of 880 patients assessed for eligibility, 692 were deemed eligible, of whom 34 declined to participate, 1 withdrew consent, and 4 were excluded after consent. Exposures: Patient activation was measured immediately after surgery during the initial admission using the Patient Activation Measure (score range, 0-100). Patients were dichotomized into low and high PA groups using previously described thresholds (Patient Activation Measure score, ≤55.1). Main Outcomes and Measures: The primary outcome was unplanned 30-day postdischarge health care utilization (composite including emergency department and outpatient clinic visits and/or hospital readmission). Secondary outcomes were length of stay, 30-day emergency department visits, 30-day readmissions, and postoperative complications. Results: A total of 653 patients admitted for thoracic, general, colorectal, and gynecologic surgery were included in the study (mean [SD] age, 58 [15] years; 369 women [56%]; 366 [56%] had minimally invasive surgery; 52 [8%] had emergency surgery), of which 152 (23%) had a low level of PA. Baseline characteristics were similar between patients with low- and high-level PA. Low PA was associated with unplanned health care utilization (odds ratio [OR], 3.15; 95% CI, 2.05-4.86; P < .001), emergency department visits (OR, 1.64; 95% CI, 1.02-2.64; P = .04), complications (OR, 1.63; 95% CI, 1.11-2.41; P = .01), and length of stay (adjusted mean difference, 1.19 days; 95% CI, 0.06-2.33; P = .04). Low PA was not associated with a higher risk of readmission (adjusted OR, 1.04; 95% CI, 0.56-1.93; P = .90). Conclusions and Relevance: In this study, low level of PA was associated with postdischarge unplanned health care use, hospital stay, and complications after major surgery. Identification of patients with low activation may allow the implementation of interventions to improve health care knowledge and support self-management postdischarge.

Older frail prehabilitated patients who cannot attain a 400 m 6-min walking distance before colorectal surgery suffer more postoperative complications.

INTRODUCTION: Recent efforts to prehabilitate intermediately frail and frail (Fried frailty criteria ≥2) elective colorectal cancer patients did not influence clinical nor functional outcomes. The objective of this secondary analysis was to describe the subset of intermediately frail and frail prehabilitated patients who could not attain a minimum 400 m (a prognostic cut-point used in other patient populations) 6-min walking distance (6MWD) before elective surgery. MATERIALS AND METHODS: Secondary analysis of a randomized controlled trial. Patients participated in multimodal prehabilitation at home and in-hospital for approximately four weeks before colorectal surgery. Primary outcome was incidence of postoperative complications within 30 days of hospital discharge. RESULTS: Sixty percent of the patients who participated in prehabilitation did not reach a minimum walking distance of 400 m in 6 min before surgery. Compared to the group that attained ≥400 m 6MWD (n = 19), the <400 m group (n = 28) were older, had higher percent body fat, lower physical function, lower self-reported physical activity, higher American Society of Anesthesiologists (ASA) classification, and twice as many were in critical need of a nutrition intervention at baseline. No group differences were observed regarding frailty status (P = 0.775). Sixty-one percent of the <400 m 6MWD group experienced at least one complication within 30 days of surgery compared to 21% in the ≥400 m group (P = 0.009). CONCLUSION: Several preoperative characteristics were identified in the <400 m 6MWD group that could be useful in screening and targeting future prehabilitative treatments. Future trials should investigate use of a 400 m standard for the 6MWD as a minimal treatment target for prehabilitation.

Conditional risk of diverticulitis after non-operative management.

BACKGROUND: The objective of this study was to describe conditional recurrence-free survival (RFS) of patients after an index episode of diverticulitis managed without surgery, and to estimate the difference in conditional RFS for diverticulitis according to specific risk factors. METHODS: This was a multicentre retrospective cohort study including all patients managed without surgery for acute sigmoid diverticulitis at two university-affiliated hospitals in Montreal, Quebec, Canada. Conditional RFS for diverticulitis was estimated over 10 years of follow-up. A Cox proportional hazards model was performed at the index episode and again 2 years later. RESULTS: In total, 991 patients were included for analysis. The 1, 2- and 3-year actuarial diverticulitis RFS rates were 81·1, 71·5 and 67·5 per cent respectively. Compared with the 1-year actuarial RFS rate of 81·1 per cent, the 1-year conditional RFS increased with each additional year survived recurrence-free, reaching 96·0 per cent after surviving the first 4 years recurrence-free. A similar phenomenon was observed for 2-year diverticulitis conditional RFS. Lower age (hazard ratio (HR) 0·98, 95 per cent c.i. 0·98 to 0·99), Charlson Co-morbidity Index score of 2 or above (HR 1·78, 1·32 to 2·39) and immunosuppression (HR 1·85, 1·38 to 2·48) were independently associated with recurrence of diverticulitis from the index episode. At 2 years from the index episode, immunosuppression was no longer associated with diverticulitis recurrence (HR 1·02, 0·50 to 2·09). CONCLUSION: The conditional RFS of patients with diverticulitis improved with each year that was survived recurrence-free. Although several factors at index presentation may be associated with early recurrence, the conditional probability of recurrence according to many of these risk factors converged with time.

ANTECEDENTES: El objetivo de este estudio fue describir la supervivencia condicional libre de recidiva de diverticulitis (diverticulitis recurrence-free survival, Div-RFS) en pacientes tras un episodio de diverticulitis tratado de forma conservadora, y calcular la diferencia en la Div-RFS condicional de acuerdo con factores de riesgo específicos. MÉTODOS: Estudio de cohorte retrospectivo multicéntrico que incluyó a todos los pacientes tratados de forma no quirúrgica por diverticulitis sigmoidea aguda en dos hospitales afiliados a la universidad en Montreal, Quebec, Canadá. La supervivencia condicional libre de recidiva de la diverticulitis se calculó durante 10 años de seguimiento. Se realizó un análisis mediante un modelo de riesgos proporcionales de Cox en el episodio índice y nuevamente 2 años después. RESULTADOS: En total, se incluyeron 991 pacientes en el análisis. La Div-RFS actuarial a 1, 2 y 3 años fue del 81,1%, 71,5% y 67,5%, respectivamente. En comparación con la Div-RFS actuarial a 1 año del 81,1%, la Div-RFS condicional a 1 año aumentó con cada año adicional sobrevivido sin recidiva, alcanzando el 96,0% después de sobrevivir los primeros 4 años sin recidiva. Se observó un fenómeno similar para Div-RFS condicional a los 2 años. Una menor edad (cociente de riesgos instantáneos, hazard ratio, HR: 0,98; i.c. del 95%: 0,98 a 0,99), la puntuación de comorbilidad de Charlson ≥ 2 (HR: 1,78; i.c. del 95%: 1,32 a 2,39) y la inmunosupresión (HR: 1,85; i.c. del 95%: 1,38 a 2,48) se asociaron de forma independiente con la recidiva de la diverticulitis desde el episodio índice. En la regresión de Cox a los 2 años del episodio índice, la inmunosupresión ya no se asoció con recidiva de diverticulitis (HR: 1,02; i.c. del 95% 0,50-2,09). CONCLUSIÓN: La Div-RFS condicional mejoró con cada año de supervivencia sin recidiva. Si bien varios factores en la presentación del episodio índice pueden estar asociados con una recidiva precoz, la probabilidad condicional de recidiva en relación con muchos de estos factores de riesgo coincidió con el tiempo.