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Assessment of Quality of Life in Patients treated with Sitz Bath for Benign Anorectal Disorders
COLON AND RECTAL SURGERY
CONCLUSIONS: Anastomotic leaks remain an important complication contributing to greater morbidity and mortality. However, after risk-adjustment, little variation was observed when comparing anastomotic leak rates between hospitals and surgeons suggesting patient factors remain dominant. This argues against the use of anastomotic leak rates for surgeon rankings.
Anastomotic Leaks: Should We Be Pointing Fingers? Bradley J Hensley, MD, MBA, Robert N Cooney, MD, FACS, Nicholas J Hellenthal, MD, FACS, Christopher T Aquina, MD, Zhaomin Xu, MD, Katia Noyes, PhD, MPH, John R Monson, MD, MB BCH, FRCS, FACS, Fergal Fleming, MD University of Rochester Medical Center Rochester, NY
Assessment of Quality of Life in Patients treated with Sitz Bath for Benign Anorectal Disorders Siddharth P Dubhashi, PhD, FACRSI, Krishna J Parmar Dr DY Patil Medical College, Hospital and Research Centre Pune, India, Mahatma Gandhi Medical College and Hospital, Jaipur, India
INTRODUCTION: Surgeons consider anastomotic leaks as an important quality metric after colectomy. This study examines patient, hospital, and surgeon characteristics including volume to investigate factors associated with anastomotic leak and variation in leak rates across 14 hospitals and 135 surgeons in NY State. METHODS: The Upstate New York Surgical Quality Improvement Program is a collaborative that collects colectomy metrics in addition to National Surgical Quality Improvement Program data. Colectomy cases from January 2010 to June 2015 were captured and cases without anastomoses were excluded. Surgeon volumes were grouped into tertiles based on number of resections captured. Bivariate and mixed-effects logistic regression analyses were performed to identify factors associated with anastomotic leak.
INTRODUCTION: Anorectal Disorders generate significant patient discomfort and disability.There is an increasing consensus regarding the centrality of patient’s point of view in monitoring medical care outcomes. This study assesses the effect of use of sitz bath as a treatment modality on the quality of life (QoL) of patients with benign anorectal disorders. METHODS: Prospective study of 240 patients (4 main groups: 1. anal fissure, 2. haemorrhoids, 3. post-fistulectomy and 4. postopen haemorrhoidectomy, 60 patients each). Each divided into 3 sub-groups- A1: warm sitz bath, A2: cold sitz bath, B: no sitz bath. QoL assessed on admission and 15 days after hospital discharge, using 36-item short form health survey, comprising of 8 scales-physical functioning (PF), physical problems (RP), body pain (BP), general health perceptions (GH),emotional problems (RE), energy/fatigue (EF), social functioning (SF), emotional wellbeing (EW).
RESULTS: The analysis included 2,463 patients who underwent colectomy, of which 57.8% underwent laparoscopic surgery. Overall, 106 patients (4.3%) had an anastomotic leak of which 63.2% necessitated reoperation. Patients with leaks tended to have a greater length of stay (20.6 days), readmission within 30-days (33.0%), and death within 30-days (6.6%). Risk factors associated with anastomotic leak included male sex (OR¼1.56, CI¼ 1.04, 2.39), BMI30 (OR¼1.64, CI¼ 1.05, 2.59), and pre-operative SIRS/sepsis/shock (OR¼2.23, CI¼ 1.10, 4.35). Surgeon volume was not significant for anastomotic leak. After controlling for patient, surgeon, volume, and hospital-level factors, the adjusted anastomotic leak rates ranged from 1.9% to 2.2% for hospitals and 1.7% to 2.8% for surgeons.
RESULTS: There was no statistically significant difference in overall QoL scores among the three sub-groups, as well as when compared between ’on admission’ and ’15 days after discharge’. However, statistically significant improvement was evident in EW and BP components in Group 1, EW, and EF components in Group 2, EF, BP, and SF components in Group 3, EW, SF, and BP components in Group 4.
Table. Mixed Effects Multivariable Logistic Regression Analysis Evaluating Factors Associated with Anastomotic Leak after Colectomy Variable
Gender Male Comorbidities BMI 30 SIRS, sepsis or shock Primary diagnosis Colon cancer Diverticular disease Peritonitis/abscess/perforation
Odds Ratio (95% CI)
1.56 (1.04, 2.39) 1.64 (1.05, 2.59) 2.23 (1.10, 4.35) Reference 0.47 (0.23, 0.91) 0.05 (0.00, 0.33)
Table.
p Value
0.040 0.032 0.024
Group
QoL Score
1. Anal Fissure
Admission
2. Haemorrhoids
3. Post fistulectomy
2815.33 ± 305.32 2877.33±327.68
Sub-group B, Mean SD 2819.17± 287.31
2848.33± 363.32 2907.33±321.36
2885.37±289.43
Admission
2925.67±433.33
2812.17±433.61
15 days after discharge
3041.13±295.69
Admission
Admission 4. Post haemorrhoidectomy 15 days after discharge
Note: Model also controls for age, disseminated cancer, elective surgery, ASA class, minimally invasive surgery, operative time, surgeon case volume and other primary diagnosis including rectal cancer, IBD, obstruction, benign tumor, vascular insufficiency, and fistula which were not statistically significant (p<0.05).
Sub-group A2, Mean SD
15 days after discharge
15 days after discharge
0.036 <0.001
Sub-group A1, Mean SD
2522±674.53 2503±256.28 2215.87±474.37 2302±494.07
2968±173.99 3157± 187.39 2437.53±475.43
3037.23±422 2541.50 ±431.69
2443.33±362.16
2510.67±355.25
2137.33±313
2078.17±218.79
2238.33±377.11
2118.83±200.17
CONCLUSIONS: Assessment of QoL in patients with anorectal disorders is challenging. Sitz bath does not produce a significant
e82
http://dx.doi.org/10.1016/j.jamcollsurg.2016.08.211 ISSN 1072-7515/16
Vol. 223, No. 4S2, October 2016
impact on the clinical course of disease. A noteworthy improvement is evident in EW and SF components of QoL. In an era of industry driven ’treatment packages’, it is definitely worth considering the potential use of a natural source like water in management of common surgical ailments. Can the Infection Rate be Reduced in Patients Who Have Implantation of a Sacral Nerve Stimulator for Fecal Incontinence? Maria Emilia Carvalho e Carvalho, MD, Tracy L Hull, MD, FACS, Massarat Zutshi, MBBS, FACS, Brooke H Gurland, MD, FACS Cleveland Clinic Foundation, Cleveland, OH INTRODUCTION: Bundle protocols have been proven to decrease wound infection rates. Minimal literature exists regarding infection rates and antibiotic recommendations for sacral nerve stimulators (SNS) implanted for fecal incontinence. The aim of this study was to evaluate our short term infection rates before and after implementing a new infection reduction protocol for SNS. METHODS: Patients undergoing SNS between 2011-2016 were included in an IRB approved study. In January 2015 we changed our SNS device implantation protocol to include one dose of IV Vancomycin before each implant stage, meticulous skin preparation with ChloraPrepÒ, and less device manipulation. Furthermore, a cordless device became available for use between stage I and II and the external device was secluded under the dressing. Before the standardization, various antibiotic regiments were used. We compared 30-day infections rates before and after the bundle protocol. RESULTS: Ninety-four total patients; 76 (81%) women, mean age of 57 (28-90) years were included. Seventy patients had SNS implanted prior to our infection reduction protocol, and 4 (5.7%) developed wound infections within 30 daysd2 in each stage of SNS. Enterococcus faecalis and methicillin resistant Staphylococcus aureus (MRSA), and 2 with Pseudomonas aeruginosa were cultured. In the 24 patients implanted after the new bundle protocol, no wound infections occurred. CONCLUSIONS: As seen in others surgeries, implantation of a standardized bundle protocol in SNS patients shows a trend to reduce wound infections. Since only 24 patients had been implanted after our change, more patients are needed to verify our results.
Colorectal Surveillance after Segmental Resection for Young Onset Colorectal Cancer: Is There Evidence for Extended Resection? Vanessa N Kozak, MD, Matthew F Kalady, MD, FACS, Maysoon M Gamaleldin, MD, Jennifer Liang, MD, James M Church, MD, FACS Cleveland Clinic Foundation, Cleveland, OH
Scientific Poster Presentations: 2016 Clinical Congress
e83
INTRODUCTION: Although sporadic colorectal cancer (CRC) mainly affects patients older than 50, recent data show increases in incidence in those younger than that. Such patients are theoretically at high risk of metachronous neoplasia and may be candidates for extended, partially prophylactic, colectomy. This study aims to define the risk of metachronous cancer/adenomas during follow-up of young patients who underwent segmental colectomy for CRC. METHODS: A CRC database was queried for patients younger than 50 undergoing surgery from 1994 to 2010. Primary endpoints were the frequency of extended resections and rates of metachronous cancer and high-risk adenomas during follow-up. Patients diagnosed with hereditary cancer or inflammatory bowel disease were excluded. We also excluded patients with less than 12 months follow-up. RESULTS: There were 284 young patients with a resectable primary tumor, of which 280 (98.6%) underwent segmental resection, 3 (1%) extended and 1 (0.4%) local. Endoscopic follow-up was available for 150 of the patients who had segmental colectomy and median follow-up time was 86 months (range, 14-259). Out of these 150 patients, 4 (2.7%) developed metachronous colonic adenocarcinoma at 24, 71, 163 and 228 months after index surgery. Thirty additional patients had at least one adenoma identified during surveillance, and 3 had sessile serrated polyps. Out of the 3 patients undergoing extended resection, none had metachronous cancer or advanced adenomas at an average follow-up of 17 years. CONCLUSIONS: A segmental colectomy or proctectomy is adequate treatment for patients presenting with colorectal cancer under age 50, as long as endoscopic surveillance continues.
Comparison of Single-Port vs Multi-Port vs Direct View Completion Proctectomy with Ileal Pouch Anal Anastomosis Wanglin Li, Emre Gorgun, MD, FACS, Meagan M Costedio, MD, Hermann P Kessler, MD, PhD, FACS, Luca Stocchi, MD, FACS, Feza H Remzi, MD, FACS, FASCRS FTSS (Hon) Cleveland Clinic, Cleveland, OH INTRODUCTION: The aim of this study was to compare the shortterm and long-term outcomes of single-port (S), multi-port laparoscopic (M) and direct view (D) completion proctectomy (CP) with ileal-pouch anal anastomosis (IPAA) and diverting loop ileostomy. METHODS: Patients who underwent either S, M or D group CP with IPAA for UC between 2009 and 2014 were identified from an IRB-approved, prospectively institutional database. RESULTS: A total of 183 patients were mean age of 3714 years. There were 18 (9.8%) patients in S, 67 (36.6%) in M and 98(53.6%) in D group. Groups were comparable in preoperative characteristics and demographics except age (p¼0.001). Conversion to open was only in 3 patients in the multiport laparoscopic group with no statistical difference among the groups. Single
CONCLUSIONS: Anastomotic leaks remain an important complication contributing to greater morbidity and mortality. However, after risk-adjustment, little variation was observed when comparing anastomotic leak rates between hospitals and surgeons suggesting patient factors remain dominant. This argues against the use of anastomotic leak rates for surgeon rankings.
Anastomotic Leaks: Should We Be Pointing Fingers? Bradley J Hensley, MD, MBA, Robert N Cooney, MD, FACS, Nicholas J Hellenthal, MD, FACS, Christopher T Aquina, MD, Zhaomin Xu, MD, Katia Noyes, PhD, MPH, John R Monson, MD, MB BCH, FRCS, FACS, Fergal Fleming, MD University of Rochester Medical Center Rochester, NY
Assessment of Quality of Life in Patients treated with Sitz Bath for Benign Anorectal Disorders Siddharth P Dubhashi, PhD, FACRSI, Krishna J Parmar Dr DY Patil Medical College, Hospital and Research Centre Pune, India, Mahatma Gandhi Medical College and Hospital, Jaipur, India
INTRODUCTION: Surgeons consider anastomotic leaks as an important quality metric after colectomy. This study examines patient, hospital, and surgeon characteristics including volume to investigate factors associated with anastomotic leak and variation in leak rates across 14 hospitals and 135 surgeons in NY State. METHODS: The Upstate New York Surgical Quality Improvement Program is a collaborative that collects colectomy metrics in addition to National Surgical Quality Improvement Program data. Colectomy cases from January 2010 to June 2015 were captured and cases without anastomoses were excluded. Surgeon volumes were grouped into tertiles based on number of resections captured. Bivariate and mixed-effects logistic regression analyses were performed to identify factors associated with anastomotic leak.
INTRODUCTION: Anorectal Disorders generate significant patient discomfort and disability.There is an increasing consensus regarding the centrality of patient’s point of view in monitoring medical care outcomes. This study assesses the effect of use of sitz bath as a treatment modality on the quality of life (QoL) of patients with benign anorectal disorders. METHODS: Prospective study of 240 patients (4 main groups: 1. anal fissure, 2. haemorrhoids, 3. post-fistulectomy and 4. postopen haemorrhoidectomy, 60 patients each). Each divided into 3 sub-groups- A1: warm sitz bath, A2: cold sitz bath, B: no sitz bath. QoL assessed on admission and 15 days after hospital discharge, using 36-item short form health survey, comprising of 8 scales-physical functioning (PF), physical problems (RP), body pain (BP), general health perceptions (GH),emotional problems (RE), energy/fatigue (EF), social functioning (SF), emotional wellbeing (EW).
RESULTS: The analysis included 2,463 patients who underwent colectomy, of which 57.8% underwent laparoscopic surgery. Overall, 106 patients (4.3%) had an anastomotic leak of which 63.2% necessitated reoperation. Patients with leaks tended to have a greater length of stay (20.6 days), readmission within 30-days (33.0%), and death within 30-days (6.6%). Risk factors associated with anastomotic leak included male sex (OR¼1.56, CI¼ 1.04, 2.39), BMI30 (OR¼1.64, CI¼ 1.05, 2.59), and pre-operative SIRS/sepsis/shock (OR¼2.23, CI¼ 1.10, 4.35). Surgeon volume was not significant for anastomotic leak. After controlling for patient, surgeon, volume, and hospital-level factors, the adjusted anastomotic leak rates ranged from 1.9% to 2.2% for hospitals and 1.7% to 2.8% for surgeons.
RESULTS: There was no statistically significant difference in overall QoL scores among the three sub-groups, as well as when compared between ’on admission’ and ’15 days after discharge’. However, statistically significant improvement was evident in EW and BP components in Group 1, EW, and EF components in Group 2, EF, BP, and SF components in Group 3, EW, SF, and BP components in Group 4.
Table. Mixed Effects Multivariable Logistic Regression Analysis Evaluating Factors Associated with Anastomotic Leak after Colectomy Variable
Gender Male Comorbidities BMI 30 SIRS, sepsis or shock Primary diagnosis Colon cancer Diverticular disease Peritonitis/abscess/perforation
Odds Ratio (95% CI)
1.56 (1.04, 2.39) 1.64 (1.05, 2.59) 2.23 (1.10, 4.35) Reference 0.47 (0.23, 0.91) 0.05 (0.00, 0.33)
Table.
p Value
0.040 0.032 0.024
Group
QoL Score
1. Anal Fissure
Admission
2. Haemorrhoids
3. Post fistulectomy
2815.33 ± 305.32 2877.33±327.68
Sub-group B, Mean SD 2819.17± 287.31
2848.33± 363.32 2907.33±321.36
2885.37±289.43
Admission
2925.67±433.33
2812.17±433.61
15 days after discharge
3041.13±295.69
Admission
Admission 4. Post haemorrhoidectomy 15 days after discharge
Note: Model also controls for age, disseminated cancer, elective surgery, ASA class, minimally invasive surgery, operative time, surgeon case volume and other primary diagnosis including rectal cancer, IBD, obstruction, benign tumor, vascular insufficiency, and fistula which were not statistically significant (p<0.05).
Sub-group A2, Mean SD
15 days after discharge
15 days after discharge
0.036 <0.001
Sub-group A1, Mean SD
2522±674.53 2503±256.28 2215.87±474.37 2302±494.07
2968±173.99 3157± 187.39 2437.53±475.43
3037.23±422 2541.50 ±431.69
2443.33±362.16
2510.67±355.25
2137.33±313
2078.17±218.79
2238.33±377.11
2118.83±200.17
CONCLUSIONS: Assessment of QoL in patients with anorectal disorders is challenging. Sitz bath does not produce a significant
e82
http://dx.doi.org/10.1016/j.jamcollsurg.2016.08.211 ISSN 1072-7515/16
Vol. 223, No. 4S2, October 2016
impact on the clinical course of disease. A noteworthy improvement is evident in EW and SF components of QoL. In an era of industry driven ’treatment packages’, it is definitely worth considering the potential use of a natural source like water in management of common surgical ailments. Can the Infection Rate be Reduced in Patients Who Have Implantation of a Sacral Nerve Stimulator for Fecal Incontinence? Maria Emilia Carvalho e Carvalho, MD, Tracy L Hull, MD, FACS, Massarat Zutshi, MBBS, FACS, Brooke H Gurland, MD, FACS Cleveland Clinic Foundation, Cleveland, OH INTRODUCTION: Bundle protocols have been proven to decrease wound infection rates. Minimal literature exists regarding infection rates and antibiotic recommendations for sacral nerve stimulators (SNS) implanted for fecal incontinence. The aim of this study was to evaluate our short term infection rates before and after implementing a new infection reduction protocol for SNS. METHODS: Patients undergoing SNS between 2011-2016 were included in an IRB approved study. In January 2015 we changed our SNS device implantation protocol to include one dose of IV Vancomycin before each implant stage, meticulous skin preparation with ChloraPrepÒ, and less device manipulation. Furthermore, a cordless device became available for use between stage I and II and the external device was secluded under the dressing. Before the standardization, various antibiotic regiments were used. We compared 30-day infections rates before and after the bundle protocol. RESULTS: Ninety-four total patients; 76 (81%) women, mean age of 57 (28-90) years were included. Seventy patients had SNS implanted prior to our infection reduction protocol, and 4 (5.7%) developed wound infections within 30 daysd2 in each stage of SNS. Enterococcus faecalis and methicillin resistant Staphylococcus aureus (MRSA), and 2 with Pseudomonas aeruginosa were cultured. In the 24 patients implanted after the new bundle protocol, no wound infections occurred. CONCLUSIONS: As seen in others surgeries, implantation of a standardized bundle protocol in SNS patients shows a trend to reduce wound infections. Since only 24 patients had been implanted after our change, more patients are needed to verify our results.
Colorectal Surveillance after Segmental Resection for Young Onset Colorectal Cancer: Is There Evidence for Extended Resection? Vanessa N Kozak, MD, Matthew F Kalady, MD, FACS, Maysoon M Gamaleldin, MD, Jennifer Liang, MD, James M Church, MD, FACS Cleveland Clinic Foundation, Cleveland, OH
Scientific Poster Presentations: 2016 Clinical Congress
e83
INTRODUCTION: Although sporadic colorectal cancer (CRC) mainly affects patients older than 50, recent data show increases in incidence in those younger than that. Such patients are theoretically at high risk of metachronous neoplasia and may be candidates for extended, partially prophylactic, colectomy. This study aims to define the risk of metachronous cancer/adenomas during follow-up of young patients who underwent segmental colectomy for CRC. METHODS: A CRC database was queried for patients younger than 50 undergoing surgery from 1994 to 2010. Primary endpoints were the frequency of extended resections and rates of metachronous cancer and high-risk adenomas during follow-up. Patients diagnosed with hereditary cancer or inflammatory bowel disease were excluded. We also excluded patients with less than 12 months follow-up. RESULTS: There were 284 young patients with a resectable primary tumor, of which 280 (98.6%) underwent segmental resection, 3 (1%) extended and 1 (0.4%) local. Endoscopic follow-up was available for 150 of the patients who had segmental colectomy and median follow-up time was 86 months (range, 14-259). Out of these 150 patients, 4 (2.7%) developed metachronous colonic adenocarcinoma at 24, 71, 163 and 228 months after index surgery. Thirty additional patients had at least one adenoma identified during surveillance, and 3 had sessile serrated polyps. Out of the 3 patients undergoing extended resection, none had metachronous cancer or advanced adenomas at an average follow-up of 17 years. CONCLUSIONS: A segmental colectomy or proctectomy is adequate treatment for patients presenting with colorectal cancer under age 50, as long as endoscopic surveillance continues.
Comparison of Single-Port vs Multi-Port vs Direct View Completion Proctectomy with Ileal Pouch Anal Anastomosis Wanglin Li, Emre Gorgun, MD, FACS, Meagan M Costedio, MD, Hermann P Kessler, MD, PhD, FACS, Luca Stocchi, MD, FACS, Feza H Remzi, MD, FACS, FASCRS FTSS (Hon) Cleveland Clinic, Cleveland, OH INTRODUCTION: The aim of this study was to compare the shortterm and long-term outcomes of single-port (S), multi-port laparoscopic (M) and direct view (D) completion proctectomy (CP) with ileal-pouch anal anastomosis (IPAA) and diverting loop ileostomy. METHODS: Patients who underwent either S, M or D group CP with IPAA for UC between 2009 and 2014 were identified from an IRB-approved, prospectively institutional database. RESULTS: A total of 183 patients were mean age of 3714 years. There were 18 (9.8%) patients in S, 67 (36.6%) in M and 98(53.6%) in D group. Groups were comparable in preoperative characteristics and demographics except age (p¼0.001). Conversion to open was only in 3 patients in the multiport laparoscopic group with no statistical difference among the groups. Single