Transanal Hemorrhoidal Dearterialization With Mucopexy Versus Ferguson Hemorrhoidectomy for Prolapsed Internal Hemorrhoids: A Multicenter Prospective Study.

OBJECTIVE: To compare transanal hemorrhoidal dearterialization (THD) with mucopexy to Ferguson hemorrhoidectomy in terms of recurrence rates and quality of life. BACKGROUND: There is uncertainty regarding the durability of the therapeutic effect of THD with mucopexy compared with Ferguson hemorrhoidectomy in terms of recurrence rates. METHODS: This was a multicenter prospective study. Participating surgeons performed the operation they knew best enrolling 10 patients each. Surgeons' unedited videos were reviewed by an independent expert. Patients with prolapsed internal hemorrhoids in at least 3 columns were eligible. The primary endpoint was recurrence rates defined as prolapsing internal hemorrhoids. Patient-reported outcomes and satisfaction were evaluated with Pain Scale and Brief Pain Inventory, Fecal Incontinence Quality Of Life (FIQOL), Cleveland Clinic Incontinence, Constipation, Short-Form 12 scores, and Patient satisfaction (4-point Likert) scale. RESULTS: Twenty surgeons enrolled 197 patients. THD patients had lower Visual pain scores at postoperative day (POD) 1 (6.2 vs 8.3, P =0.047), POD7 (4.5 vs 7.7, P =0.021), POD14 (2.8 vs 5.3, P <0.001), and medication use at POD14 (23% vs 58%, P <0.001). Median follow-up was 3.1 (1.0-5.5) years. Recurrence rates did not differ between the study arms (5.9% vs 2.4%, P =0.253). Patient satisfaction rate was higher after THD at POD14 (76.4% vs 52.5%, P =0.031) and 3 months (95.1% vs 63.3%, P =0.029), but did not differ at 6 months (91.7% vs 88%, P =0.228) and 1 year (94.2% vs 88%, P =0.836). CONCLUSION: THD with mucopexy was associated with improved patient-reported outcomes and quality of life as compared with Ferguson hemorrhoidectomy with nonsignificantly different recurrence rates.

Trends in Open, Laparoscopic, and Robotic Approaches to Colorectal Operations.

The use of robotic approach has gained momentum in colorectal surgery. We analyzed the trends in the adoption of robotic-assisted platform (RAP) for colorectal surgery over a 6-year period (2013-2018) using the American College of Surgeons National Surgical Quality Improvement Project. We assessed yearly prevalence of robotic, laparoscopic, and open approaches, and evaluated trends in the adoption of RAP across age, gender, BMI, and American Society of Anesthesiology (ASA) subgroups. Overall, the frequency of open, laparoscopic, and robotic approach was 36%, 46.8%, and 7.8%, respectively. While the use of laparoscopic cases remained stable over the study period, the prevalence of RAP increased from 2.8% to 11.4%. This was accompanied by a concomitant decline in the use of open approach, from 40.8% to 33%. The use of RAP also increased across all age, gender, BMI, and ASA subgroups. Robotic-assisted platform is increasingly utilized for higher risk, older, and obese patients, allowing more patients to receive minimally invasive colorectal surgery.

Multiple High-Risk Features for Stage II Colon Carcinoma Portends Worse Survival Than Stage III Disease.

BACKGROUND: High-risk features in stage II colon cancer worsen survival and serve as an impetus for adjuvant chemotherapy. Limited data exist on the effect of multiple high-risk features on survival. OBJECTIVE: The study aimed to compare the survival of 0, 1, or multiple high-risk features in stage II to stage III colon cancer. DESIGN: Patients with stage II and III colon cancer diagnosed between 2010 and 2016 were identified using the Survival, Epidemiology, and End Results database. Patients with stage II colon cancer were then classified according to the presence of 0, 1, or 2 or more of the following high-risk features: pathologic T4, perineural invasion, fewer than 12 lymph nodes assessed, or poor histologic differentiation. Overall survival and cause-specific survival were calculated. Each group was then stratified on the basis of whether chemotherapy was given. SETTINGS: This study used the Survival, Epidemiology, and End Results database (2010-2016). PATIENTS: Patients who had stage II or III colon cancer were included. MAIN OUTCOME MEASURES: The primary outcome measures were 5-year overall survival and cause-specific survival. RESULTS: A total of 65,831 patients were studied. Of these, 18,056 patients with stage II cancer had 0 high-risk features, 9426 had 1 high-risk feature, and 3503 had 2 or more high-risk features. There were 34,842 patients diagnosed with stage III disease. The 5-year overall survival and cause-specific survival for patients with stage II cancer with 2 or more high-risk features (49.2%, 59.5%) were lower than those without high-risk features (74.9%, 90.7%), with 1 high-risk feature (67.1%, 82.4%), or stage III disease (59.1%, 68.1%; p < 0.05). Although chemotherapy is associated with improved cause-specific survival in stage III disease, it is associated with worse cause-specific survival in patients with stage II disease. LIMITATIONS: This study being a retrospective database analysis is the main limitation. Also, lymphovascular invasion, margin status, and clinical obstruction or perforation were absent from the dataset. CONCLUSIONS: Multiple high-risk features in stage II colon cancer predict worse survival than lymph node metastasis. Chemotherapy is associated with adverse cause-specific survival in patients with stage II disease. Further study into this group should focus on the type and duration of adjuvant therapy and biological features of these tumors. See Video Abstract at http://links.lww.com/DCR/B929 . MLTIPLES CARACTERSTICAS DE ALTO RIESGO PARA EL CARCINOMA DE COLON EN ESTADIO II PRESAGIAN PEOR SUPERVIVENCIA QUE LA ENFERMEDAD EN ESTADIO III: ANTECEDENTES:Las características de alto riesgo en el cáncer de colon en estadio II empeoran la supervivencia y sirven como impulso para la quimioterapia adyuvante. Existen datos limitados sobre el efecto de múltiples características de alto riesgo en la supervivencia.OBJETIVO:Comparar la supervivencia de cero, una o múltiples características de alto riesgo en el cáncer de colon en estadio II con la enfermedad en estadio III.DISEÑO:Los pacientes con cáncer de colon en estadio II y III diagnosticados entre 2010 y 2016 se identificaron mediante la base de datos de supervivencia, epidemiología y resultados finales. Luego, los pacientes en etapa II se clasificaron según la presencia de cero, 1 o 2+ de las siguientes características de alto riesgo: T4 patológico, invasión perineural, menos de 12 ganglios linfáticos evaluados (< 12 ganglios linfáticos) o mala diferenciación histológica. Se calculó la supervivencia observada y específica de la causa. Luego, cada grupo se estratificó en función de si se administró quimioterapia.ESCENARIO:Este estudio utilizó la base de datos de supervivencia, epidemiología y resultados finales, 2010-2016.PACIENTES:Los pacientes tenían cáncer de colon en estadio II o III.PRINCIPALES MEDIDAS DE RESULTADO:La medida principal fue la supervivencia observada a 5 años y la supervivencia por causa específica.RESULTADOS:Se estudiaron un total de 65,831 pacientes. 18,056 pacientes estaban en estadio II sin características de alto riesgo, 9.426 con 1 característica de alto riesgo y 3.503 con 2+ características de alto riesgo. Hubo 34.842 pacientes a los que se les diagnosticó enfermedad en estadio III. La supervivencia observada a los 5 años y la supervivencia específica de la causa para los pacientes con cáncer en estadio II con 2+ características de alto riesgo (49.2 %, 59.5 %) fueron más bajas, en comparación con aquellos sin características de alto riesgo (74.9 %, 90.7 %), con 1 característica de alto riesgo (67.1 %, 82.4 %) o enfermedad en estadio III (59.1 %, 68.1 %) (p < 0.05). Si bien la quimioterapia se asocia con una mejor supervivencia por causa específica en la enfermedad en estadio III, se asocia con una peor supervivencia por causa específica en pacientes con enfermedad en estadio II.LIMITACIONES:Este es un análisis de base de datos retrospectivo. La invasión linfovascular, el estado de los márgenes y la obstrucción o perforación clínicas estaban ausentes en la base de datos.CONCLUSIONES:Múltiples características de alto riesgo en el cáncer de colon en estadio II predicen una peor supervivencia que la metástasis en los ganglios linfáticos. La quimioterapia se asocia con una supervivencia específica de causa adversa en pacientes con enfermedad en estadio II. El estudio adicional de este grupo deberá centrarse en el tipo y la duración de la terapia adyuvante y las características biológicas de estos tumores. Consulte Video Resumen en http://links.lww.com/DCR/B929 . (Traducción-Dr. Jorge Silva Velazco ).

Minimally Invasive Surgery is Associated with Improved Outcomes Following Urgent Inpatient Colectomy.

Objectives: The use of minimally invasive techniques for urgent colectomies remains understudied. This study compares short-term outcomes following urgent minimally invasive colectomies to those following open colectomies. Methods & Procedures: The American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) colectomy database was queried between January 1, 2013 and December 31, 2018. Patients who underwent elective and emergency colectomies, based on the respective NSQIP variables, were excluded. The remaining patients were divided into two groups, minimally invasive surgery (MIS) and open. MIS colectomies with unplanned conversion to open were included in the MIS group. Baseline characteristics and 30-day outcomes were compared using univariable and multivariable regression analyses. Results: A total of 29,345 patients were included in the study; 12,721 (43.3%) underwent MIS colectomy, while 16,624 (56.7%) underwent open colectomy. Patients undergoing MIS colectomy were younger (60.6 vs 63.8 years) and had a lower prevalence of either American Society of Anesthesiology (ASA) IV (9.9 vs 15.5%) or ASA V (0.08% vs 2%). After multivariable analysis, MIS colectomy was associated with lower odds of mortality (odds ratio = 0.75, 95% confidence interval: 0.61, 0.91 95% confidence interval), and most short-term complications recorded in the ACS NSQIP. While MIS colectomies took longer to perform (161 vs 140 min), the length of stay was shorter (12.2 vs 14.1 days). Conclusions: MIS colectomy affords better short-term complication rates and a reduced length of stay compared to open colectomy for patients requiring urgent surgery. If feasible, minimally invasive colectomy should be offered to patients necessitating urgent colon resection.

Laparoscopic Colectomy for Acute Diverticulitis in the Urgent Setting is Associated with Similar Outcomes to Open.

PURPOSE/BACKGROUND: The role of minimally invasive surgery (MIS) for the surgical treatment of diverticular disease is evolving. The aim of this study is to compare the outcomes of MIS colectomy to those of open surgery for patients with acute diverticulitis requiring urgent surgery. METHODS: The American college of Surgeons National Surgical Quality Improvement Project database was queried for all patients undergoing an urgent colectomy for acute diverticulitis between 2013 and 2018. The patients were then divided into 2 groups: MIS and open. Baseline characteristics and short-term outcomes were compared using univariable and multivariable regression analyses. RESULTS/OUTCOMES: 3487 patients were included in the analysis. Of these, 1272 (36.5%) underwent MIS colectomy and 2215 (63.5%) underwent open colectomy. Patients undergoing MIS colectomy were younger (58.7 vs 61.9 years) and less likely to be American Society of Anesthesiologists Classification (ASA) III (52.5 vs 57.9%) or IV (6.3 vs 10.5%). After adjusting for baseline differences, the odds of mortality for MIS and open groups were similar. While there was no difference in short-term complications between groups, the odds of developing an ileus were lower following MIS colectomy (OR .61, 95% CI: .49, .76). Both total length of stay (LOS) (12.3 vs 13.9 days) and post-operative LOS (7.6 days vs 9.5 days) were shorter for MIS colectomy. Minimally invasive surgery colectomy added an additional 40 minutes of operative time (202.2 vs 160.1 min). CONCLUSION/DISCUSSION: Minimally invasive surgery colectomy appears to be safe for patients requiring urgent surgical management for acute diverticulitis. Decreased incidence of ileus and shorter LOS may justify any additional operative time for MIS colectomy in suitable candidates.

Urgent Inpatient Colectomy Carries a Higher Morbidity and Mortality Than Elective Surgery.

BACKGROUND: Emergency colorectal surgery confers a higher risk of adverse outcomes compared to elective surgery. Few studies have examined the outcomes after urgent colectomies, typically defined as those performed at the index admission, but not performed at admission in an emergency fashion. The aim of this study is to evaluate the risk of adverse outcomes following urgent inpatient colorectal surgery. MATERIALS AND METHODS: All adult patients undergoing colectomy between 2013 and 2017 in the ACS NSQIP were included in the analysis. Patients were grouped into Elective, Urgent and Emergency groups. The Urgent group was further stratified by time from admission to surgery. Baseline characteristics and 30 day outcomes were compared between the Elective, Urgent and Emergency groups using univariable and multivariable analyses. RESULTS: 104,486 patients underwent elective colorectal resection. 23,179 underwent urgent while 22,241 had emergency resections. Patients undergoing urgent colectomy presented with increased comorbidities, and experienced higher mortality (2.5-4.1%, AOR 2.3 (1.9 - 2.8)) compared to elective surgery (0.4%). Urgent colectomy was an independent risk factor for the majority of short term complications documented in NSQIP. Moreover, patients undergoing urgent colectomy more than a week following admission had an increased risk of bleeding, deep venous thrombosis, pulmonary embolism, urinary tract infection, and prolonged hospitalization. CONCLUSION: Urgent colectomies are associated with a greater risk of adverse outcomes compared to elective surgery. Urgent status is an independent risk factor for post operative mortality and morbidity. Further characterization of this patient population and their specific challenges may help ameliorate these adverse events.

Statistical, Clinical, Methodological Evaluation of Local Recurrence Following Transanal Total Mesorectal Excision for Rectal Cancer: A Systematic Review.

BACKGROUND: A recent Norwegian moratorium challenged the status quo of transanal total mesorectal excision for rectal cancer by reporting increased early multifocal local recurrences. OBJECTIVE: The aim of this systematic review and meta-analysis was to evaluate the local recurrence rates following transanal total mesorectal excision as well as to assess statistical, clinical, and methodological bias in reports published to date. DATA SOURCES: The PubMed and MEDLINE (via Ovid) databases were systematically searched. STUDY SELECTION: Descriptive or comparative studies reporting rates of local recurrence at a median follow-up of 6 months (or more) after transanal total mesorectal excision were included. INTERVENTIONS: Patients underwent transanal total mesorectal excision. MAIN OUTCOME MEASURES: Local recurrence was any recurrence located in the pelvic surgery site. The untransformed proportion method of 1-arm meta-analysis was utilized. Untransformed percent proportion with 95% confidence interval was reported. Ad hoc meta-regression with the Omnibus test was utilized to assess risk factors for local recurrence. Among-study heterogeneity was evaluated: statistically by I2 and τ2, clinically by summary tables, and methodologically by a 33-item questionnaire. RESULTS: Twenty-nine studies totaling 2906 patients were included. The pooled rate of local recurrence was 3.4% (2.7%-4.0%) at an average of 20.1 months with low statistical heterogeneity (I2 = 0%). Meta-regression yielded no correlation between complete total mesorectal excision quality (p = 0.855), circumferential resection margin (p = 0.268), distal margin (p = 0.886), and local recurrence rates. Clinical heterogeneity was substantial. Methodological heterogeneity was linked to the excitement of novelty, loss aversion, reactivity to criticism, indication for transanal total mesorectal excision, nonprobability sampling, circular reasoning, misclassification, inadequate follow-up, reporting bias, conflict of interest, and self-licensing. LIMITATIONS: The studies included had an observational design and limited sample and follow-up. CONCLUSION: This systematic review found a pooled rate of local recurrence of 3.4% at 20 months. However, given the substantial clinical and methodological heterogeneity across the studies, the evidence for or against transanal total mesorectal excision is inconclusive at this time.

Buschke-Lowenstein Tumors: A Review and Proposed Classification System.

ABSTRACT: Buschke-Lowenstein (B-L) tumors or giant condylomata are large fungating lesions that are caused by human papillomavirus (HPV) and develop in the anogenital region. Although uncommon, physicians and surgeons who treat sexually transmitted diseases or other diseases involving the anogenital area will encounter these patients. The purpose of this study is to review the current literature regarding these lesions. We evaluated every published study in PubMed and Embase from 1925 to 2020, concentrating on the clinical data included in each report, such as presentation and treatment. We also evaluated each work for any definition used and found that there is no accepted definition for these lesions. As such, we provide an inclusive, workable definition. In addition, there are many misconceptions about B-L that continue to be propogated as more case reports are published every year. After evaluating every published case, we refute the fact that these lesions have a high mortality or a high malignancy rate. Furthermore, we refute that these lesions are synonymous with verrucous carcinoma. In addition to a definition, we also propose a simple grading system that we hope can be used to assist in the study and management of these patients moving forward. Although the literature is very heterogenous regarding B-L, they are caused by HPV and are distinct from verrucous carcinoma. Because of the majority of information is based on case reports, the literature concentrates on treatment, but more work is clearly needed to delineate the association with specific HPV types and optimal management of this disease.

Failure of nonoperative management in patients with acute diverticulitis complicated by abscess: a systematic review.

BACKGROUND: The aim of this study was to assess failure rates following nonoperative management of acute diverticulitis complicated by abscess and trends thereof. METHOD: Pubmed, MEDLINE, EMBASE, CINAHL, Cochrane Library, and Web of Science were systematically searched. Nonoperative management was defined as a combination of nil per os, IV fluids, IV antibiotics, CT scan-guided percutaneous drainage, and total parenteral nutrition. The primary endpoint was failure of nonoperative management defined as persistent or worsening abscess and/or sepsis, development of new complications, such as peritonitis, ileus, or colocutaneous fistula, and urgent surgery within 30-90 days of index admission. Data were stratified by three arbitrary time intervals: 1986-2000, 2000-2010, and after 2010. The primary outcome was calculated for those groups and compared. RESULTS: Thirty-eight of forty-four eligible studies published between 1986 and 2019 were included in the quantitative synthesis of data (n = 2598). The pooled rate of failed nonoperative management was 16.4% (12.6%, 20.2%) at 90 days. In studies published in 2000-2010 (n = 405), the pooled failure rate was 18.6% (10.5%, 26.7%). After 2000 (n = 2140), the pooled failure rate was 15.3% (10.7%, 20%). The difference was not statistically significant (p = 0.725). After controlling for heterogeneity in the definition of failure of nonoperative management, subgroup analysis yielded the pooled rate of failure of 21.8% (16.1%, 27.4%). CONCLUSION: This meta-analysis found that failure rates following nonoperative management of acute diverticulitis complicated by abscess did not significantly decrease over the past three decades. The general quality of published data and the level and certainty of evidence produced were low.

College of American Pathologists Tumor Regression Grading System for Long-Term Outcome in Patients with Locally Advanced Rectal Cancer.

BACKGROUND: The National Comprehensive Cancer Network's Rectal Cancer Guideline Panel recommends American Joint Committee of Cancer and College of American Pathologists (AJCC/CAP) tumor regression grading (TRG) system to evaluate pathologic response to neoadjuvant chemoradiotherapy for locally advanced rectal cancer (LARC). Yet, the clinical significance of the AJCC/CAP TRG system has not been fully defined. MATERIALS AND METHODS: This was a multicenter, retrospectively recruited, and prospectively maintained cohort study. Patients with LARC from one institution formed the discovery set, and cases from external independent institutions formed a validation set to verify the findings from discovery set. Overall survival (OS), disease-free survival (DFS), local recurrence-free survival (LRFS), and distant metastasis-free survival (DMFS) were assessed by Kaplan-Meier analysis, log-rank test, and Cox regression model. RESULTS: The discovery set (940 cases) found, and the validation set (2,156 cases) further confirmed, that inferior AJCC/CAP TRG categories were closely /ccorrelated with unfavorable survival (OS, DFS, LRFS, and DMFS) and higher risk of disease progression (death, accumulative relapse, local recurrence, and distant metastasis) (all p < .05). Significantly, pairwise comparison revealed that any two of four TRG categories had the distinguished survival and risk of disease progression. After propensity score matching, AJCC/CAP TRG0 category (pathological complete response) patients treated with or without adjuvant chemotherapy displayed similar survival of OS, DFS, LRFS, and DMFS (all p > .05). For AJCC/CAP TRG1-3 cases, adjuvant chemotherapy treatment significantly improved 3-year OS (90.2% vs. 84.6%, p < .001). Multivariate analysis demonstrated the AJCC/CAP TRG system was an independent prognostic surrogate. CONCLUSION: AJCC/CAP TRG system, an accurate prognostic surrogate, appears ideal for further strategizing adjuvant chemotherapy for LARC. IMPLICATIONS FOR PRACTICE: The National Comprehensive Cancer Network recommends the American Joint Committee of Cancer and College of American Pathologists (AJCC/CAP) tumor regression grading (TRG) four-category system to evaluate the pathologic response to neoadjuvant treatment for patients with locally advanced rectal cancer; however, the clinical significance of the AJCC/CAP TRG system has not yet been clearly addressed. This study found, for the first time, that any two of four AJCC/CAP TRG categories had the distinguished long-term survival outcome. Importantly, adjuvant chemotherapy may improve the 3-year overall survival for AJCC/CAP TRG1-3 category patients but not for AJCC/CAP TRG0 category patients. Thus, AJCC/CAP TRG system, an accurate surrogate of long-term survival outcome, is useful in guiding adjuvant chemotherapy management for rectal cancer.

What Are the Cost Drivers for the Major Bowel Bundled Payment Care Improvement Initiative?

BACKGROUND: The Bundled Payments for Care Improvement initiative links payments for service beneficiaries during an episode of care (limited to 90 days from index surgery discharge). OBJECTIVE: The purpose of this study was to identify drivers of costs/payments for the major bowel Bundled Payments for Care Improvement initiative. DESIGN: Discharges from the Medicare Standard Analytic Files of hospitals participating in the major bowel bundle of the Bundled Payments for Care Improvement initiative were analyzed. SETTINGS: The study was conducted at 4 tertiary care centers. PATIENTS: All patients in diagnostic related groups of 329, 330, or 331 treated at eligible facilities between September 1, 2012, and September 30, 2014, were included. MAIN OUTCOME MEASURES: We calculated all costs/payments for the bundled period, that is, 3 days before surgery, the index hospitalization including surgery, and the 90-day postoperative period. We then determined costs for laparoscopic versus open procedures using International Classification of Diseases, Ninth Revision, procedure codes for each of the diagnostic related groups, as well as in aggregate. Last, we calculated differential impact of cost drivers on overall total episode costs. RESULTS: In the cohort of hospitals participating in the major bowel Bundled Payments for Care Improvement initiative, open procedures ($45,073) cost 1.6 times more than laparoscopic. For the lowest complexity diagnostic related group (331), performance of the procedure with open techniques was the largest total episode cost driver, because use of postdischarge services remained low. In the highest complexity diagnostic related group (329), readmission costs, skilled nursing facilities costs, and home health services costs were the greatest cost drivers after hospital services. LIMITATIONS: The analyses are limited by the retrospective nature of the study. CONCLUSIONS: These results indicate that efforts to safely perform open procedures with laparoscopic techniques would be most effective in reducing costs for lower complexity diagnostic related groups, whereas efforts to impact readmission and postdischarge service use would be most impactful for the higher complexity diagnostic related groups. See Video Abstract at http://links.lww.com/DCR/B420. ¿CUÁLES SON LOS FACTORES DETERMINANTES DE LOS COSTOS DE LA INICIATIVA DE MEJORA DE LA ATENCIÓN DE PAGOS COMBINADOS PARA EL INTESTINO MAYOR?: La iniciativa de pagos combinados para la mejora de la atención (BPCI) vincula los pagos para los beneficiarios del servicio durante un episodio de atención (limitado a 90 días desde el alta hospitalaria de la cirugía índice).Identificar los factores determinantes de los costos / pagos de la iniciativa BPCI intestinal mayor.Análisis de altas de los Archivos Analíticos Estándar de Medicare de los hospitales que participan en el paquete intestinal principal de la iniciativa BPCI.Todos los pacientes en Grupos Relacionados con el Diagnóstico (GRD) de 329, 330 o 331 tratados en instalaciones elegibles desde el 1 de Septiembre de 2012 hasta el 30 de Septiembre de 2014.Calculamos todos los costos / pagos para el período combinado, es decir, tres días antes de la cirugía, el índice de hospitalización incluida la cirugía y el período posoperatorio de 90 días. Luego, determinamos los costos de los procedimientos laparoscópicos versus abiertos utilizando códigos de procedimiento ICD-9 para cada uno de los GRD, así como en conjunto. Por último, calculamos el impacto diferencial de los generadores de costos sobre los costos totales del episodio.En la cohorte de hospitales que participan en la iniciativa BPCI del intestino principal, los procedimientos abiertos ($ 45.073) cuestan 1,6 veces más que los laparoscópicos. Para el GRD de menor complejidad (331), la realización del procedimiento con técnicas abiertas fue el mayor factor de costo total del episodio, ya que la utilización de los servicios posteriores al alta se mantuvo baja. En el GRD de mayor complejidad (329), los costos de readmisión, los costos de las instalaciones de enfermería especializada y los costos de los servicios de salud en el hogar fueron los mayores factores de costo después de los servicios hospitalarios.Los análisis están limitados por la naturaleza retrospectiva del estudio.Estos resultados indican que los esfuerzos para realizar procedimientos abiertos de manera segura con técnicas laparoscópicas serían más efectivos para reducir los costos de los GRD de menor complejidad, mientras que los esfuerzos para impactar la readmisión y la utilización del servicio posterior al alta serían más impactantes para los GRD de mayor complejidad. See Video Abstract at http://links.lww.com/DCR/B420.

Delayed Surgery Does Not Increase Risk in Urgent Colectomy for Ulcerative Colitis.

BACKGROUND: Medical management is the cornerstone of therapy for ulcerative colitis (UC). In the setting of fulminant disease, hospitalized patients may undergo medical rescue therapy (MRT) or urgent surgery. We hypothesized that delayed attempts at MRT result in increased morbidity and mortality following urgent surgery for UC. OBJECTIVE: The aim is to assess the outcomes for patients requiring urgent, inpatient surgery for UC in a prompt or delayed fashion. DESIGN: The American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) general and colectomy-specific databases from 2013 to 2016 were queried. Urgent surgery was defined as nonelective, nonemergency surgery. Patients were divided into prompt and delayed groups based on time from admission to surgery of <48 hours or >48 hours. Baseline characteristics and 30-day outcomes were compared using univariate and multivariate analyses. SETTING: The ACS NSQIP database from 2013 to 2016 was evaluated. PATIENTS: Adult patients undergoing nonelective, nonemergency colectomy for UC. MAIN OUTCOME MEASURES: 30-day morbidity and mortality. RESULTS: 921 patients underwent urgent inpatient surgery for UC. In univariate analysis, there was no significant difference between prompt and delayed surgery for wound infection, sepsis, return to operating room, or readmission. LIMITATIONS: Retrospective study of a quality improvement database. Patients who underwent successful MRT did not receive surgery, so are not included in the database. CONCLUSIONS: Delaying surgery to further attempt MRT does not alter short-term outcomes and may allow conversion to elective future surgery. Contrarily, medical optimization does not improve short-term outcomes.

The Impact of a Colorectal Care Bundle for Surgical Site Infections at an Academic Disproportionate Share Hospital With a Level I Trauma Center.

OBJECTIVES: Colorectal care bundles for surgical site infections (CRCB-SSIs) have been shown to reduce SSIs following elective colorectal surgery (CRS). There are limited data evaluating the effect of CRCB-SSI at Academic Disproportionate Share Hospitals (ADSH) with significant rates of urgent and emergent cases. METHODS: A CRCB-SSI was implemented in April 2016. We reviewed medical records of all patients undergoing colon resections between August 2015 and December 2017. Patients were divided into preimplementation and postimplementation groups. The primary endpoint was the SSI rate, and the secondary endpoint included types of SSI (superficial, deep, organ space). Univariable and multivariable analyses were performed. A subset analysis was performed in elective cases. RESULTS: We analyzed a total of 417 patients. Of these, 116 (28%) and 301 (72%) patients were in the preimplementation and postimplementation groups, respectively. The rate of SSI decreased from 30.1% to 15.9% in the postimplementation group (P = .0012); however, it was not statistically significant after adjusting for baseline differences (relative risk [RR] 0.65; 95% CI 0.41-1.02).The elective subset included 219 patients. The rate of SSI in this cohort decreased from 25% to 10.5% in the postimplementation group (P = .0012) and remained significant following multivariable analysis (RR 0.41, 95% CI 0.19- 0.88). There were no differences in the subtypes of SSI. DISCUSSION: While the CRCB-SSI was effective in decreasing the postoperative SSI rate for elective cases, its effect on the overall patient population was limited. CRCB-SSIs are not enough to bring SSI rates to accepted rates in high-risk patients such as those seen at ADSH.

Clinical efficacy and quality of life after transrectal natural orifice specimen extraction for the treatment of middle and upper rectal cancer.

BACKGROUND: Laparoscopic anterior resection with natural orifice specimen extraction (NOSE) avoids extra abdominal extraction incision during colorectal surgery. Some surgeons realized the benefits of NOSE on clinical efficacy. We compared the clinical efficacy of laparoscopic NOSE, laparoscopic non-NOSE and open surgery (OS) for short-term recovery and quality of life (QoL). METHODS: A single randomized controlled trial of NOSE for middle and upper rectal cancer between April 2014 and February 2018. Preoperative and postoperative clinical variables were analyzed and compared between the groups. Preoperative and 6 months postoperative QoL was assessed with the SF-36 QoL questionnaire. RESULTS: A total of 378 patients were enrolled, 334 patients randomly divided into NOSE group (n=104), non-NOSE group (n=119), OS group (n=111). The NOSE group was superior to the other two groups on the QoL after surgery. The NOSE group had the lowest postoperative VAS score between three groups. The postoperative time for bowel function recovery and the length of hospital stay was statistically significantly different among the three groups, with the NOSE group having the shortest time. The incidence of postoperative complications was lower in the NOSE group (12/104, 11.5%) than in the non-NOSE group (20/119, 16.8%), the difference was statistically significant. The Kaplan-Meier (K-M) survival curve showed no statistically significant difference in the disease-free survival (DFS) rate between the three groups. CONCLUSIONS: Comparing NOSE to non-NOSE and OS, the NOSE had significantly better functional recovery and better QoL. The NOSE group had a significant lower surgical complication rate than the non-NOSE group.

International consensus definition of low anterior resection syndrome.

BACKGROUND: Low anterior resection syndrome (LARS) is pragmatically defined as disordered bowel function after rectal resection leading to a detriment in quality of life. This broad characterization does not allow for precise estimates of prevalence. The LARS score was designed as a simple tool for clinical evaluation of LARS. Although the LARS score has good clinical utility, it may not capture all important aspects that patients may experience. The aim of this collaboration was to develop an international consensus definition of LARS that encompasses all aspects of the condition and is informed by all stakeholders. METHODS: This international patient-provider initiative used an online Delphi survey, regional patient consultation meetings and an international consensus meeting. Three expert groups participated: patients, surgeons and other health professionals from five regions (Australasia, Denmark, Spain, Great Britain and Ireland, and North America) and in three languages (English, Spanish and Danish). The primary outcome measured was the priorities for the definition of LARS. RESULTS: Three hundred and twenty-five participants (156 patients) registered. The response rates for successive rounds of the Delphi survey were 86%, 96% and 99%. Eighteen priorities emerged from the Delphi survey. Patient consultation and consensus meetings refined these priorities to eight symptoms and eight consequences that capture essential aspects of the syndrome. Sampling bias may have been present, in particular, in the patient panel because social media was used extensively in recruitment. There was also dominance of the surgical panel at the final consensus meeting despite attempts to mitigate this. CONCLUSIONS: This is the first definition of LARS developed with direct input from a large international patient panel. The involvement of patients in all phases has ensured that the definition presented encompasses the vital aspects of the patient experience of LARS. The novel separation of symptoms and consequences may enable greater sensitivity to detect changes in LARS over time and with intervention.

International Consensus Definition of Low Anterior Resection Syndrome.

BACKGROUND: Low anterior resection syndrome is pragmatically defined as disordered bowel function after rectal resection leading to a detriment in quality of life. This broad characterization does not allow for precise estimates of prevalence. The low anterior resection syndrome score was designed as a simple tool for clinical evaluation of low anterior resection syndrome. Although the low anterior resection syndrome score has good clinical utility, it may not capture all important aspects that patients may experience. OBJECTIVE: The aim of this collaboration was to develop an international consensus definition of low anterior resection syndrome that encompasses all aspects of the condition and is informed by all stakeholders. DESIGN: This international patient-provider initiative used an online Delphi survey, regional patient consultation meetings, and an international consensus meeting. PARTICIPANTS: Three expert groups participated: patients, surgeons, and other health professionals from 5 regions (Australasia, Denmark, Spain, Great Britain and Ireland, and North America) and in 3 languages (English, Spanish, and Danish). MAIN OUTCOME MEASURE: The primary outcome measured was the priorities for the definition of low anterior resection syndrome. RESULTS: Three hundred twenty-five participants (156 patients) registered. The response rates for successive rounds of the Delphi survey were 86%, 96%, and 99%. Eighteen priorities emerged from the Delphi survey. Patient consultation and consensus meetings refined these priorities to 8 symptoms and 8 consequences that capture essential aspects of the syndrome. LIMITATIONS: Sampling bias may have been present, in particular, in the patient panel because social media was used extensively in recruitment. There was also dominance of the surgical panel at the final consensus meeting despite attempts to mitigate this. CONCLUSIONS: This is the first definition of low anterior resection syndrome developed with direct input from a large international patient panel. The involvement of patients in all phases has ensured that the definition presented encompasses the vital aspects of the patient experience of low anterior resection syndrome. The novel separation of symptoms and consequences may enable greater sensitivity to detect changes in low anterior resection syndrome over time and with intervention.

Basic Science, Epidemiology, and Screening for Anal Intraepithelial Neoplasia and Its Relationship to Anal Squamous Cell Cancer.

Despite the progress made in the reduction of squamous cell carcinoma of the cervix, the incidence of anal squamous cell carcinoma (ASCC) has been increasing since 1992. While it remains an uncommon disease, the prevalence is climbing steadily. Among human immunodeficiency virus (HIV)-infected adults, especially men who have sex with men, ASCC is one of the more common non-AIDS-defining malignancies. The precursor lesion, anal intraepithelial neoplasia (AIN), is prevalent in the HIV-infected population. More than 90% of ASCCs are related to human papilloma virus (HPV), oncogenic types (HPV 16, 18). While the biology of HPV-related intraepithelial neoplasia is consistent in the anogenital area, the natural history of AIN is poorly understood and is not identical to cervical intraepithelial neoplasia (CIN). CIN is also considered an AIDS-defining malignancy, and the methods for screening and prevention of AIN are derived from the CIN literature. This article will discuss the epidemiology of ASCC and its association with HPV and the life cycle of the HPV, and the molecular changes that lead to clearance, productive infection, latency, and persistence. The immunology of HPV infection will discuss natural immunity, humoral and cellular immunity, and how the HPV virus evades and interferes with these mechanisms. We will also discuss high-risk factors for developing AIN in high-risk patient populations with relation to infections (HIV, HPV, and chlamydia infections), prolonged immunocompromised people, and sexual behavior and tobacco abuse. We will also discuss the pre- and post-HAART era and its effect on AINs and ASCC. Finally, we will discuss the importance of anal cytology and high-resolution anoscopy with and without biopsy in this high-risk population.