The Role of Autologous Flap Reconstruction in Patients with Crohn's Disease Undergoing Abdominoperineal Resection.

BACKGROUND: Patients with symptomatic Crohn's disease who undergo abdominoperineal resection can experience impaired postoperative wound healing. This results in significant morbidity, burdensome dressing changes, and increased postoperative pain. When abdominoperineal resection is performed for oncological reasons, autologous flap reconstruction is occasionally performed to optimize wound healing and reconstruction outcomes. However, the role of flap reconstruction after abdominoperineal resection for Crohn's disease has not been established. OBJECTIVE: This study examines the utility of flap reconstruction in patients with symptomatic Crohn's disease undergoing abdominoperineal resection. We hypothesize that patients with immediate flap reconstruction after abdominoperineal resection will demonstrate improved wound healing. DESIGN: This study is a retrospective chart review. SETTINGS: Eligible patients at our institution were identified from 2010 to 2018 by using a combination of Current Procedural Terminology, International Classification of Diseases, Ninth Revision, and International Classification of Diseases, Tenth Revision codes. PATIENTS: Of 40 adult patients diagnosed with Crohn's disease, 20 underwent abdominoperineal resection only and 20 underwent abdominoperineal resection with flap reconstruction. INTERVENTIONS: Immediate autologous flap reconstruction was performed after abdominoperineal resection. MAIN OUTCOME MEASURES: The primary outcomes measured were the presence of postoperative perineal wounds and postoperative wound care burden. RESULTS: Patients in the abdominoperineal resection with flap reconstruction group demonstrated significantly worse preoperative disease traits, including fistula burden, than patients in the abdominoperineal resection only group. A lower number of patients tended to be associated with a persistent perineal wound in the flap group at 30 days (abdominoperineal resection with flap reconstruction = 55% vs abdominoperineal resection only = 70%; p = 0.327) and at 6 months (abdominoperineal resection with flap reconstruction = 25% vs abdominoperineal resection only = 40%; p = 0.311) postoperatively. There was also a trend toward a lower incidence of complications in the flap group. Patients in the abdominoperineal resection with flap reconstruction group tended to experience lower postoperative pain than patients in the abdominoperineal resection only group. LIMITATIONS: This retrospective cohort study was limited by its reliance on data in electronic medical records, and by its small sample size and the fact that it was a single-institution study. CONCLUSIONS: In select patients who have severe perianal fistulizing Crohn's disease, there may be a benefit to immediate flap reconstruction after abdominoperineal resection to lower postoperative wound care burden without significant intraoperative or postoperative risk. In addition, flap reconstruction may lead to lower postoperative pain. See Video Abstract at http://links.lww.com/DCR/B416. EL ROL DE LA RECONSTRUCCIN CON COLGAJO AUTLOGO EN PACIENTES CON ENFERMEDAD DE CROHN SOMETIDOS A RESECCIN ABDOMINOPERINEAL: ANTECEDENTES:Los pacientes con enfermedad de Crohn sintomática que se someten a una resección abdominoperineal pueden experimentar una curación posoperatoria deficiente de la herida. Esto da como resultado una morbilidad significativa, cambios de apósito molestos y un aumento del dolor posoperatorio. Cuando se realiza una resección abdominoperineal por razones oncológicas, ocasionalmente se realiza una reconstrucción con colgajo autólogo para optimizar los resultados de la curación y reconstrucción de la herida. Sin embargo, no se ha establecido la función de la reconstrucción con colgajo después de la resección abdominoperineal para la enfermedad de Crohn.OBJETIVO:Este estudio examina la utilidad de la reconstrucción con colgajo en pacientes con enfermedad de Crohn sintomática sometidos a resección abdominoperineal. Presumimos que los pacientes con reconstrucción inmediata con colgajo después de la resección abdominoperineal demostrarán una mejor curación de la herida.DISEÑO:Revisión retrospectiva de expedientes.MARCO:Los pacientes elegibles en nuestra institución se identificaron entre 2010 y 2018 mediante una combinación de los códigos de Terminología actual de procedimientos, Clasificación internacional de enfermedades 9 y Clasificación internacional de enfermedades 10.PACIENTES:Cuarenta pacientes adultos diagnosticados con enfermedad de Crohn que se someten a resección abdominoperineal solamente (APR-solo = 20) y resección abdominoperineal con reconstrucción con colgajo (APR-colgajo = 20).INTERVENCIÓN (ES):Reconstrucción inmediata con colgajo autólogo después de la resección abdominoperineal.MEDIDAS DE RESULTADOS PRINCIPALES:Presencia de herida perineal posoperatoria y carga de cuidado de la herida posoperatoria.RESULTADOS:Los pacientes del grupo APR-colgajo demostraron rasgos de enfermedad preoperatoria significativamente peores, incluida la carga de la fístula, en comparación con los pacientes del grupo APR-solo. Un número menor de pacientes tendió a asociarse con una herida perineal persistente en el grupo de colgajo a los 30 días (APR-colgajo = 55% vs APR-solo = 70%; p = 0.327) y 6 meses (APR-colgajo = 25% vs APR-solo = 40%; p = 0.311) postoperatoriamente. También hubo una tendencia hacia una menor incidencia de complicaciones en el grupo APR-colgajo. Los pacientes del grupo APR-colgajo tendieron a experimentar menos dolor posoperatorio en comparación con el grupo APR-solo.LIMITACIONES:Estudio de cohorte retrospectivo basado en datos de historias clínicas electrónicas. Tamaño de muestra pequeño y estudio de una sola institución.CONCLUSIONES:En pacientes seleccionados que tienen enfermedad de Crohn fistulizante perianal grave, la reconstrucción inmediata del colgajo después de la resección abdominoperineal puede beneficiar a reducir la carga posoperatoria del cuidado de la herida sin riesgo intraoperatorio o posoperatorio significativo. Además, la reconstrucción con colgajo puede resultar un dolor posoperatorio menor. Consulte Video Resumen en http://links.lww.com/DCR/B416.

Enterocutaneous fistula after emergency general surgery: Mortality, readmission, and financial burden.

BACKGROUND: The burden of enterocutaneous fistula (ECF) after emergency general surgery (EGS) has not been rigorously characterized. We hypothesized that ECF would be associated with higher rates of postdischarge mortality and readmissions. METHODS: Using the 2016 National Readmission Database, we conducted a retrospective study of adults presenting for gastrointestinal (GI) surgery. Cases were defined as emergent if they were nonelective admissions with an operation occurring on hospital day 0 or 1. We used International Classification of Diseases, 10th Revision, code K63.2 (fistula of intestine) to identify postoperative fistula. We measured mortality rates and 30- and 90-day readmission rates censuring discharges occurring in December or from October to December, respectively. RESULTS: A total of 135,595 patients underwent emergency surgery; 1,470 (1.1%) developed ECF. Mortality was higher in EGS patients with ECF than in those without (10.1% vs. 5.4%; odds ratio [OR], 1.99; 95% confidence interval [CI], 1.67-2.36) among patients who survived the index admission. Readmission rates were higher for EGS patients with ECF than without at 30 days (31.0% vs. 12.6%; OR, 3.12; 95% CI, 2.76-3.54) and at 90 days (51.1% vs. 20.1%; OR, 4.15; 95% CI, 3.67-4.70). Similar increases were shown in elective GI surgery. CONCLUSIONS: Enterocutaneous fistula after GI EGS is associated with significantly increased odds of mortality and readmission, with rates continuing to climb out to at least 90 days. Processes of care designed to mitigate risk in this high-risk cohort should be developed. LEVEL OF EVIDENCE: Prognostic and Epidemiological Study, Level III.

Navigating reimbursement for home parenteral nutrition.

Reimbursement for home parenteral nutrition (HPN) is important for nutrition support clinicians to understand. This intent of this review is to provide nutrition support clinicians knowledge on navigating through the structured requirements of diagnosis driven billing to receive reimbursement for services related to HPN, provide information on coding, provide practical tips for surviving a Medicare billing audit, and discuss challenges of Medicare guidelines seen in clinical practice.

Health care resource use and costs in Crohn's disease before and after infliximab therapy.

BACKGROUND: Infliximab therapy in patients with Crohn's disease decreases resource use; however, the overall impact on health-related expenditures is unclear, especially beyond one year of study. METHODS: A retrospective analysis of economic data one and two years before and after infliximab therapy was performed using patients who served as their own controls. Total health care resource use and direct health care costs were compared for patients with or without fistulae. RESULTS: Patients with one (n=66) and two (n=39) years of economic data before and after infliximab treatment had their resource use and direct health care costs estimated. In the year following initiation of infliximab therapy, there were significant decreases in health care use, reflected in total hospital days (495 to 155 [P<0.05]), inpatient colonoscopies (46 to 24 [P<0.05]), outpatient colonoscopies (58 to 33 [P<0.05]) and major surgeries (10 to 2 [P<0.05]). Direct health care costs of inpatient costs for luminal (-$1,747 [P<0.05]) and fistulizing disease (-$2,530 [P<0.05]), major surgeries (-$1240 [P<0.05]) and outpatient colonoscopies (-$184 [P<0.05]) were also significantly reduced before and after infliximab therapy. Total direct health care costs, including the drug cost of infliximab, increased ($21,416 [P<0.05]). In general, the trends in health care costs analyzed over four consecutive years paralleled the two consecutive-year analysis.  CONCLUSION: Infliximab therapy in patients with Crohn's disease resulted in a significant decrease in both resource use and health care costs, but an increase in total direct health care costs once the cost of infliximab was added.

Enterocutaneous fistula complicating trauma laparotomy: a major resource burden.

Enterocutaneous fistula (ECF) is an uncommon and poorly studied postoperative complication. The objective of this study was to analyze the incidence and resource utilization of patients who developed an ECF after trauma laparotomy. All patients with an ECF occurring after trauma laparotomy at a Level I trauma center were identified through a review of both the Trauma Registry and the Morbidity and Mortality reports for a 9-year period ending in December 2006. Each ECF case was matched with a control (non-ECF) that did not develop this complication after laparotomy. The matching criteria were: age, gender, mechanism of injury, Injury Severity Score, Abbreviated Injury Score, and damage control laparotomy requiring an open abdomen. Outcomes analyzed were intensive care unit (ICU) and hospital length of stay, mortality, and total hospital charges. During the 9-year period, of 2373 acute trauma laparotomies performed, 36 (1.5%) patients developed an enterocutaneous fistula, and were matched to 36 controls. Patients with an ECF were 31 +/- 12 years of age, were 97 per cent male, had a mean Injury Severity Score of 21 +/- 10, and 75 per cent were penetrating. Eighty-nine per cent of the ECF patients had a hollow viscus injury. The most common was colon (69%), followed by small bowel (53%), duodenum (36%), and stomach (19%). Fifty-six per cent of the ECF patients had multiple hollow viscus injuries. The development of an ECF was associated with significantly increased ICU length of stay (28.5 +/- 30.5 vs 7.6 +/- 9.3 days, P = 0.004), hospital length of stay (82.1 +/- 100.8 vs 16.2 +/- 17.3 days, P < 0.001), and hospital charges ($539,309 vs $126,996, P < 0.001). In conclusion, the development of an enterocutaneous fistula after laparotomy for trauma resulted in a significant impact on resource utilization including longer ICU and hospital length of stay and higher hospital charges. Further investigation into the prevention and treatment of this costly complication is warranted.

A cost-effectiveness analysis of fistula treatment in the abdominal region using a new integrated fistula and wound management system.

OBJECTIVE: To evaluate wear time and costs of a new fistula and wound management system (FWMS) compared to standard fistula treatments. METHODS: Data were collected from 22 patients with an abdominal fistula recruited from 5 sites in the United States. This economic evaluation was based on a cost-effectiveness analysis with wear time, material costs, and labor costs taken into account. RESULTS: A longer wear time for each pouch as well as simpler handling by nurses amounted to an average lower cost of $83 per day of treatment with the FWMS. A large variation was observed in the collected data. However, the sensitivity analysis showed that 77% of patients achieved a cost reduction when changing to the FWMS. CONCLUSION: The FWMS was less costly than traditional methods for managing abdominal fistula, probably due to longer wear time and less time spent on each pouching session.

Effects of fistula on healthcare costs and utilization for patients with Crohn's disease treated in a managed care environment.

BACKGROUND: Fistulas are a common complication of Crohn's disease (CD) and are difficult to treat effectively. This study aimed to assess the effects of fistula on annual costs of healthcare and resource utilization for patients with CD. METHODS: A retrospective analysis, using the PharMetrics database, of patients with a diagnosis of CD from January 1, 2000 through June 30, 2005 was conducted. Using paid claim amounts, healthcare costs and resource utilization were compared for patients with and without fistula in the year following diagnosis. Further analysis compared costs for adult, pediatric, and older adult patients with and without fistula. RESULTS: This analysis included 13,454 patients with CD, of whom 12,683 (94.3%) had no diagnosis of fistula. The total median (range) cost per patient was higher for the fistula cohort ($10,863 [$0-$1,307,019]) than the nonfistula cohort ($6268 [$0-$1,181,485]), driven mainly by higher hospital and surgery costs. Median healthcare costs and resource utilization rates were generally higher for patients with fistula compared with those without fistula in all 3 age groups, with some of the largest differences observed in the pediatric cohort. CONCLUSIONS: Fistulas are often a difficult and costly complication of CD. This study determined that patients with fistulizing CD have higher healthcare costs and resource consumption than patients without fistula. Use of therapies that heal fistulas may help deter some of the high costs and intensive resource utilization found in this study. Economic analyses need to account for these issues when assessing the cost-effectiveness of therapies targeting fistulizing disease.

Health-economic analysis: cost-effectiveness of scheduled maintenance treatment with infliximab for Crohn's disease--modelling outcomes in active luminal and fistulizing disease in adults.

BACKGROUND: Infliximab has been shown to be efficacious in moderate-to-severe Crohn's disease (CD). AIM: To evaluate the cost-effectiveness of scheduled maintenance treatment with infliximab in luminal and fistulizing CD patients. METHODS: Markov models were constructed to simulate the progression of adult CD patients with and without fistulae during treatment with infliximab (5 mg/kg). Transitions were estimated from published clinical trials of infliximab. Standard care, comprising immunomodulators and/or corticosteroids was used as a comparator. An average weight of 60 kg was used to estimate the dose of infliximab. The costs and outcomes were discounted at 3.5% over 5 years. The primary effectiveness measurement was quality-adjusted life years (QALYs) estimated using EQ-5D. One-way and probabilistic sensitivity analyses were performed by varying the infliximab efficacy estimates, costs and utilities. RESULTS: The incremental cost per QALY gained was pound 26,128 in luminal CD and pound 29,752 in fistulizing CD at 5 years. Results were robust and remained in the range of pound 23,752- pound 38,848 for luminal CD and pound 27,047- pound 44,206 for fistulizing CD. Patient body weight was the most important factor affecting cost-effectiveness. CONCLUSION: Eight-week scheduled maintenance treatment with infliximab is a cost-effective treatment for adult patients suffering from active luminal or fistulizing CD.

Fistuloclysis can successfully replace parenteral feeding in the nutritional support of patients with enterocutaneous fistula.

BACKGROUND: Use of total parenteral nutrition (TPN) in patients with acute intestinal failure due to enteric fistulation might be avoided if a simpler means of nutritional support was available. The aim of this study was to determine whether feeding via an intestinal fistula (fistuloclysis) would obviate the need for TPN. METHODS: Fistuloclysis was attempted in 12 patients with jejunocutaneous or ileocutaneous fistulas with mucocutaneous continuity. Feeding was achieved by inserting a gastrostomy feeding tube into the intestine distal to the fistula. Infusion of enteral feed was increased in a stepwise manner, without reinfusion of chyme, until predicted nutritional requirements could be met by a combination of fistuloclysis and regular diet, following which TPN was withdrawn. Energy requirements and nutritional status were assessed before starting fistuloclysis and at the time of reconstructive surgery. RESULTS: Fistuloclysis replaced TPN entirely in 11 of 12 patients. Nutritional status was maintained for a median of 155 (range 19-422) days until reconstructive surgery could be safely undertaken in nine patients. Two patients who did not undergo surgery remained nutritionally stable over at least 9 months. TPN had to be recommenced in one patient. There were no complications associated with fistuloclysis. CONCLUSION: Fistuloclysis appears to provide effective nutritional support in selected patients with enterocutaneous fistula.

Somatostatin versus octreotide in the treatment of patients with gastrointestinal and pancreatic fistulas.

BACKGROUND AND PURPOSE: Gastrointestinal and pancreatic fistulas are characterized as serious complications following abdominal surgery, with a reported incidence of up to 27% and 46%, respectively. Fistula formation results in prolonged hospitalization, increased morbidity/mortality and increased treatment costs. Conservative and surgical approaches are both employed in the management of these fistulas. The purpose of the present study was to assess, evaluate and compare the potential clinical benefit and cost effectiveness of pharmacotherapy (somatostatin versus its analogue octreotide) versus conventional therapy. PATIENTS AND METHODS: Fifty-one patients with gastrointestinal or pancreatic fistulas were randomized to three treatment groups: 19 patients received 6000 IU/day of somatostatin intravenously, 17 received 100 microg of octreotide three times daily subcutaneously and 15 patients received only standard medical treatment. RESULTS: The fistula closure rate was 84% in the somatostatin group, 65% in the octreotide group and 27% in the control group. These differences were of statistical significance (P=0.007). Overall mortality rate was less than 5% and statistically significant differences in mortality among the three groups could not be established. Overall, treatment with somatostatin and octreotide was more cost effective than conventional therapy (control group), and somatostatin was more cost effective than octreotide. The average hospital stay was 21.6 days, 27.0 and 31.5 days for the somatostatin, octreotide and control groups, respectively. CONCLUSIONS: Data suggest that pharmacotherapy reduces the costs involved in fistula management (by reducing hospitalization) and also offers increased spontaneous closure rate. Further prospective studies focusing on the above parameters are needed to demonstrate the clinicoeconomic benefits.