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Early outcomes after elective colorectal surgery in end stage renal disease (ESRD) vs non-ESRD Patients
Vol. 221, No. 4S2, October 2015
the low risk of lymphatic spread and increased treatment morbidity. This study examined the quality-of-life benefits and risks of local excision compared with results after colectomy, for low- and high-risk T1 colonic cancer. METHODS: Decision analysis using a Markov simulation model was performed: patients were managed with either local excision (advanced therapeutic endoscopy) or colectomy. Lesions were considered high-risk according to accepted national guidelines. Probabilities and utilities were derived from published data. Hypothetical cohorts of 65- and 80-year-old, fit and unfit patients with low- or high-risk T1 colonic cancer were studied. The primary outcome was quality-adjusted life expectancy (QALE) in life-years (QALYs). RESULTS: In low-risk T1 colonic neoplasia, local excision increases QALE by 2.72 QALYS for fit 65-year olds (15.5% increase over surgery) and by 0.93 for unfit 80-year-olds (20.9% increase). For high-risk T1 cancers, the QALE benefit for local excision is 1.82 QALYs for fit 65-year-olds (10.5% improvement) and 0.82 for unfit 80-year-olds (18.6% improvement). In sensitivity analysis, colectomy was only preferred for 65-year-old patients, when risk of recurrence following local excision exceeded 17.3%.
Scientific Poster Presentations: 2015 Clinical Congress
e59
compared to non-ESRD patients. Perioperative outcomes were similar in ESRD and non-ESRD patients with matched preoperative characteristics. Active smoking was a significant predictor of postoperative wound infection (aOR: 1.31; 95% CI: 1.26-1.37; p<0.001) and death (aOR: 1.29; 95% CI: 1.11-1.51; p<0.001). CONCLUSIONS: The higher postoperative complications and mortality of elective colorectal surgery in ESRD patients is not due to hemodialysis dependence but rather the results of their associated severe comorbidities. Surgeons should emphasize on careful perioperative management and maximization for this group of patients to ensure good outcomes. Effect of surgical approach on venous thromboembolism in inflammatory bowel disease patients Deborah S Keller, MD, Sean J Langenfeld, MD, FACS, Daniel E Lomelin, MPH, Dmitry Oleynikov, MD, FACS, Eric M Haas, MD, FACS, FASCRS Colorectal Surgical Associates, Houston, TX; University of Nebraska Medical Center, Omaha, NE
CONCLUSIONS: Under a wide range of assumptions, for all patient cohorts, local excision is a viable treatment option for both low- and high-risk T1 colonic cancer. Investigation of methods to facilitate local excision of T1 colonic neoplasia appears warranted.
INTRODUCTION: Inflammatory bowel disease (IBD) patients have a significantly higher risk of venous thromboembolism (VTE) after abdominal surgery. However, no previous work assessed the impact of minimally invasive surgery on VTE in this population. Our goal was to evaluate the prevalence and predictors of VTE in IBD patients undergoing laparoscopic vs open colorectal surgery.
Early outcomes after elective colorectal surgery in end stage renal disease (ESRD) vs non-ESRD Patients Isibor Arhuidese, MD, MPH, Mahmoud Malas, MD, MHS, FACS, Tammam Obeid, MD, Umair Qazi, MD, MPH, Nita Ahuja, MD, FACS, Jonathan E Efron, MD, FACS Johns Hopkins Medical Institution, Baltimore, MD
METHODS: The ACS NSQIP database was reviewed for patients undergoing elective abdominal surgery for IBD from 2006-2012. Cases were stratified by laparoscopic or open operative approach. Groups were stringently case-matched to eliminate confounding. The main outcome measures were prevalence, time from surgery to VTE, and predictive factors of VTE in each cohort.
INTRODUCTION: The impact of end stage renal disease (ESRD) on outcomes after elective colorectal surgery (CRS) is largely unreported. In this study, we evaluate perioperative outcomes after CRS in a matched cohort of ESRD and non-ESRD patients. METHODS: We studied all patients who had elective CRS in the American College of Surgeons National Surgical Quality Improvement Program from January 2005 to December, 2013. Univariate, multivariate and propensity score matched analyses were employed to compare postoperative outcomes. RESULTS: Of the 156,645 elective CRSs carried out, 50% were open and 949 (1%) were performed in patients with ESRD. Mean age was 62 (SD: 15.4) years. The majority of patients were female (52%) and white (78%). The most common surgeries were partial colectomies (43%), low pelvic anastomoses (24%) and ileo-colic resections (20%). The prevalence of diabetes mellitus (44 vs 14%), congestive heart failure (7 vs 1%), chronic obstructive pulmonary disease (10 vs 5%), myocardial infarction (3 vs 0.5%) and functional dependence (20 vs 4%) was greater in ESRD
RESULTS: 1,582 patients were evaluated in each group. VTE rates (1.7% laparoscopic vs 1.5% open; p¼0.569) and median time to VTE (9 days; p¼0.865) were similar across groups. Laparoscopic surgery was associated with a longer operative time (200 vs 171.5 min; p<0.001) and total anesthesia time (269 vs 232 min; p<0.001) than open surgery. Length of stay (LOS) was significantly shorter in the laparoscopic group (median 5 vs 7 days; p<0.001). Independent predictors of VTE were preoperative steroid use (OR 2.95, CI 1.57-5.54; p¼0.001), preoperative transfusion (OR 5.34, CI 1.43-19.96; p<0.001), operative time (OR 1.11, CI 1.03-1.20; p<0.001), and LOS (OR 1.05, CI 1.031.07; p<0.001). Laparoscopic approach (p¼0.907) and smoking (p¼0.666) did not impact odds of VTE. CONCLUSIONS: In a matched sample, laparoscopy did not reduce the VTE rate or independently impact incidence. Most VTE occurred after discharge. These results highlight the need for postoperative prophylaxis in IBD patients regardless of approach.
the low risk of lymphatic spread and increased treatment morbidity. This study examined the quality-of-life benefits and risks of local excision compared with results after colectomy, for low- and high-risk T1 colonic cancer. METHODS: Decision analysis using a Markov simulation model was performed: patients were managed with either local excision (advanced therapeutic endoscopy) or colectomy. Lesions were considered high-risk according to accepted national guidelines. Probabilities and utilities were derived from published data. Hypothetical cohorts of 65- and 80-year-old, fit and unfit patients with low- or high-risk T1 colonic cancer were studied. The primary outcome was quality-adjusted life expectancy (QALE) in life-years (QALYs). RESULTS: In low-risk T1 colonic neoplasia, local excision increases QALE by 2.72 QALYS for fit 65-year olds (15.5% increase over surgery) and by 0.93 for unfit 80-year-olds (20.9% increase). For high-risk T1 cancers, the QALE benefit for local excision is 1.82 QALYs for fit 65-year-olds (10.5% improvement) and 0.82 for unfit 80-year-olds (18.6% improvement). In sensitivity analysis, colectomy was only preferred for 65-year-old patients, when risk of recurrence following local excision exceeded 17.3%.
Scientific Poster Presentations: 2015 Clinical Congress
e59
compared to non-ESRD patients. Perioperative outcomes were similar in ESRD and non-ESRD patients with matched preoperative characteristics. Active smoking was a significant predictor of postoperative wound infection (aOR: 1.31; 95% CI: 1.26-1.37; p<0.001) and death (aOR: 1.29; 95% CI: 1.11-1.51; p<0.001). CONCLUSIONS: The higher postoperative complications and mortality of elective colorectal surgery in ESRD patients is not due to hemodialysis dependence but rather the results of their associated severe comorbidities. Surgeons should emphasize on careful perioperative management and maximization for this group of patients to ensure good outcomes. Effect of surgical approach on venous thromboembolism in inflammatory bowel disease patients Deborah S Keller, MD, Sean J Langenfeld, MD, FACS, Daniel E Lomelin, MPH, Dmitry Oleynikov, MD, FACS, Eric M Haas, MD, FACS, FASCRS Colorectal Surgical Associates, Houston, TX; University of Nebraska Medical Center, Omaha, NE
CONCLUSIONS: Under a wide range of assumptions, for all patient cohorts, local excision is a viable treatment option for both low- and high-risk T1 colonic cancer. Investigation of methods to facilitate local excision of T1 colonic neoplasia appears warranted.
INTRODUCTION: Inflammatory bowel disease (IBD) patients have a significantly higher risk of venous thromboembolism (VTE) after abdominal surgery. However, no previous work assessed the impact of minimally invasive surgery on VTE in this population. Our goal was to evaluate the prevalence and predictors of VTE in IBD patients undergoing laparoscopic vs open colorectal surgery.
Early outcomes after elective colorectal surgery in end stage renal disease (ESRD) vs non-ESRD Patients Isibor Arhuidese, MD, MPH, Mahmoud Malas, MD, MHS, FACS, Tammam Obeid, MD, Umair Qazi, MD, MPH, Nita Ahuja, MD, FACS, Jonathan E Efron, MD, FACS Johns Hopkins Medical Institution, Baltimore, MD
METHODS: The ACS NSQIP database was reviewed for patients undergoing elective abdominal surgery for IBD from 2006-2012. Cases were stratified by laparoscopic or open operative approach. Groups were stringently case-matched to eliminate confounding. The main outcome measures were prevalence, time from surgery to VTE, and predictive factors of VTE in each cohort.
INTRODUCTION: The impact of end stage renal disease (ESRD) on outcomes after elective colorectal surgery (CRS) is largely unreported. In this study, we evaluate perioperative outcomes after CRS in a matched cohort of ESRD and non-ESRD patients. METHODS: We studied all patients who had elective CRS in the American College of Surgeons National Surgical Quality Improvement Program from January 2005 to December, 2013. Univariate, multivariate and propensity score matched analyses were employed to compare postoperative outcomes. RESULTS: Of the 156,645 elective CRSs carried out, 50% were open and 949 (1%) were performed in patients with ESRD. Mean age was 62 (SD: 15.4) years. The majority of patients were female (52%) and white (78%). The most common surgeries were partial colectomies (43%), low pelvic anastomoses (24%) and ileo-colic resections (20%). The prevalence of diabetes mellitus (44 vs 14%), congestive heart failure (7 vs 1%), chronic obstructive pulmonary disease (10 vs 5%), myocardial infarction (3 vs 0.5%) and functional dependence (20 vs 4%) was greater in ESRD
RESULTS: 1,582 patients were evaluated in each group. VTE rates (1.7% laparoscopic vs 1.5% open; p¼0.569) and median time to VTE (9 days; p¼0.865) were similar across groups. Laparoscopic surgery was associated with a longer operative time (200 vs 171.5 min; p<0.001) and total anesthesia time (269 vs 232 min; p<0.001) than open surgery. Length of stay (LOS) was significantly shorter in the laparoscopic group (median 5 vs 7 days; p<0.001). Independent predictors of VTE were preoperative steroid use (OR 2.95, CI 1.57-5.54; p¼0.001), preoperative transfusion (OR 5.34, CI 1.43-19.96; p<0.001), operative time (OR 1.11, CI 1.03-1.20; p<0.001), and LOS (OR 1.05, CI 1.031.07; p<0.001). Laparoscopic approach (p¼0.907) and smoking (p¼0.666) did not impact odds of VTE. CONCLUSIONS: In a matched sample, laparoscopy did not reduce the VTE rate or independently impact incidence. Most VTE occurred after discharge. These results highlight the need for postoperative prophylaxis in IBD patients regardless of approach.