Cost Benefit of Implementing Enhanced Recovery After Surgery (ERAS) Program in Colorectal Surgery: A Single Institution Study

COLON AND RECTAL SURGERY

A National Problem: Understaging of Rectal Cancer Patients Is Associated with Positive Circumferential Margins and Worse Survival Adan Z Becerra, Zhaomin Xu, MD, Christian P Probst, MD, Christopher T Aquina, MD, Mohamedtaki A Tejani, MD, Bradley J Hensley, MD, MBA, Katia Noyes, PhD, MPH, John R Monson, MD, MB BCH, FRCS, FACS, Fergal Fleming, MD University of Rochester Medical Center, Rochester, NY

INTRODUCTION: Various cell types of the gastrointestinal tract express matrix metalloproteinases (MMPs) and their tissue inhibitors (TIMPs). It has been proposed that the imbalance between these enzymes and their inhibitors can lead to extracellular matrix remodeling, mucosal damage and structural changes in the colonic tissue. Therefore we wanted to explore and compare the expression levels of several members of the MMP and TIMP family in ulcerative colitis (UC) and diverticulitis in patients who underwent a surgical colon resection. METHODS: Messenger RNA (mRNA) expression levels were compared using real-time PCR in both inflamed and non-inflamed bowel specimens from patients with active UC (n¼20) or diverticulitis (n¼23) and without these diseases (Control, n¼25).

INTRODUCTION: Previous studies have reported marked variation in rectal cancer management in the US. The purpose of this study was to compare clinical staging with pathological staging and identify factors associated with variation in hospital-specific rates of under/overstaging. We also assessed the impact of under/ overstaging on outcomes.

RESULTS: In both UC and diverticulitis, MMP-1, and TIMP-2 transcript levels were higher than in Control. Interestingly, UC samples but not diverticulitis specimens showed significantly higher MMP-2, -3, -9, -10 and -13 mRNA expression. In diverticulitis, however, MMP-28 transcript levels, as well as TIMP-1, and -3 mRNA expression was significantly increased when compared to both UC and Control. Generally, the highest levels of the MMPs were found in the inflamed areas of UC and diverticulitis, while TIMPs were more upregulated in the adjacent, non-diseased areas, compared to diseased UC and diverticulitis specimens.

METHODS: The 2006-2012 National Cancer Data Base was queried for clinical stage I-IV rectal cancer patients who underwent resection without neoadjuvant chemoradiation. A multilevel multinomial logistic model was used to identify factors associated with understaging vs overstaging vs correctly staging, and estimate risk-adjusted hospital-specific rates of under/overstaging. Separate multivariable analyses assessed the effect of under/overstaging on positive circumferential resection margins (CRM), receipt of adjuvant chemoradiation, and 5-year overall survival.

CONCLUSIONS: UC and diverticulitis have a different MMP and TIMP expression pattern with a generally stronger and wider array of MMP activity in UC. The pharmacological regulation of these enzymes and their natural tissue inhibitors may hold promise to more effective and personalized therapies.

RESULTS: Among 15,288 patients, the rates of under/overstaging were 20% and 6%, respectively. Rates of understaging increased from 13%-21% from 2006-2012. Factors associated with understaging included no insurance, older age, histology, comorbidities, and advanced clinical stage. Case-mix and hospital-level predictors explained little of the overall hospital variation in understaging. After risk-adjustment, an 11-fold difference in the rate of understaging was observed across hospitals (range¼6%-67%). Understaging was independently associated with receipt of adjuvant chemoradiation (OR¼3.89, 95%CI¼3.78,4.02). Despite this, understaging was associated with positive CRM (OR¼1.22, 95%CI¼1.04,1.41) and worse overall survival (HR¼2.01, 95%CI¼1.79,2.22).

Cost Benefit of Implementing Enhanced Recovery After Surgery (ERAS) Program in Colorectal Surgery: A Single Institution Study Piyush Aggarwal, MBBS, Tonia M Young-Fadok, MD, FACS Mayo Clinic, Phoenix, AZ INTRODUCTION: ERAS is an evidence based program combining multi-modality perioperative interventions to decrease hospital stay and morbidity after surgery. We evaluated the impact of an ERAS protocol on hospital costs of patients undergoing colorectal surgery.

CONCLUSIONS: Deficiencies in rectal cancer management in the US begin with clinical staging, which dictates the patient’s treatment modality. This failure to provide optimal care at the start of cancer care is associated with worse survival and requires urgent attention.

METHODS: Data from division of colorectal surgery, Mayo Clinic, AZ was compiled from 1st quarter after ERAS was implemented (July-September 2013) and compared to the equivalent quarter the prior year (July-September 2012). Average direct costs of the peri-operative period were analyzed and compared. Cohorts from 2 periods were matched with regards to their demographics, diagnosis, and type of surgery performed. Sub-group analyses were done to check for cost savings in different types of surgery.

Comparison of the Expression of Metalloproteinases and their Tissue Inhibitors in Ulcerative Colitis and Colon Diverticulitis Zoltan Nemeth, MD, PhD, Patricia Barratt-Stopper, Addison S Hicks, Louis T Difazio, Jr, MD, FACS, Rolando H Rolandelli, MD, FACS Morristown Medical Center, Morristown, NJ

RESULTS: Both cohorts were similar in age, diagnosis, and surgery type. In the ERAS group, more operations were performed laparoscopically. There was decrease in average length of stay (7.7 vs 4.9, p¼<0.001), patients with complications (47.9% vs 29.7%,

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http://dx.doi.org/10.1016/j.jamcollsurg.2016.08.019 ISSN 1072-7515/16

Vol. 223, No. 4S2, October 2016

Scientific Forum: 2016 Clinical Congress

p¼0.06) and readmission rate (22.5 vs 12.1%, p¼0.08) in the ERAS group compared to pre-ERAS group. There were average savings of $7,130 (p<0.05) per patient when ERAS protocol was followed. More savings were seen in the open group ($8,415, p<0.05) compared to laparoscopic group ($4,494, p¼0.115). In the sub-group analysis, all surgery types showed decrease in overall cost except for total colectomy. CONCLUSIONS: Implementation of an ERAS protocol resulted in decreased length of stay, postoperative complications and readmission rates. This was associated with cost savings for the patient’s hospital stay. Does Mucinous Rectal Adenocarcinoma Benefit from Neoadjuvant Chemoradiation? Tareq M Hassan, MD, Leonardo C Duraes, MD, PhD, Luca Stocchi, MD, FACS, Hermann P Kessler, MD, PhD, FACS Cleveland Clinic Foundation, Cleveland, OH INTRODUCTION: The purpose of this study was to compare clinical results of mucinous and non-mucinous rectal adenocarcinoma, and to assess the effectiveness of neoadjuvant chemoradiotherapy (CRT) on mucinous rectal adenocarcinoma for clinical stage III patients. METHODS: An institutional database was queried to identify patients with clinical stage III rectal adenocarcinoma confirmed by pelvic imaging, operated on curatively between 2000 and 2012. Exclusion criteria were emergent operations, inflammatory bowel disease, and hereditary colorectal neoplasia. Patients were divided into 2 groups according to their neoadjuvant treatment. Mucinous (M) and non-mucinous (NM) adenocarcinomas were compared to each-other. Univariate, multivariate, and KaplanMeier survival statistical analyses were performed. RESULTS: Out of 220 patients, 181 patients received CRT (23 M vs 158 NM), and 39 patients did not receive CRT (4 M vs 35 NM) Table. Oncologic Outcomes for Clinical Stage III Patients with Mucinous Compared to Non-Mucinous Rectal Adenocarcinoma Mucinous Patients who received neoadjuvant chemoradiation (n¼181) n 5-y overall survival % (CI) 5-y disease free survival % (CI) 5-y cancer specific survival % (CI) 5-y recurrence % (CI) Patients who did not receive neoadjuvant chemo-radiation (n¼39) n 5-y overall survival % (CI) 5-y disease free survival % (CI) 5-y cancer specific survival % (CI) 5-y recurrence % (CI)

Non-mucinous p Value

due to comorbidities and patients’ preference. Compared to M, NM patients had greater down-staging after CRT, and presented with lower post CRT pathological staging (yp stage I - 7.7% vs 35%, yp stage II - 27% vs 26.5%, and yp stage III - 65.4% vs 38.6% for M and NM respectively). Among patients who received CRT, M had worse overall survival and cancer specific survival than NM. On the other hand, no difference in oncologic outcomes was found between NM and M in patients who did not receive CRT (Table). CONCLUSIONS: In mucinous rectal adenocarcinoma, the indication for neoadjuvant therapy has to be balanced carefully with potential side effects, as less favorable oncologic outcomes are observed. Education Program for Prevention of Ileostomy Complications (EPPIC): A Randomized Trial Mary R Kwaan, MD, MPH, FACS, Sarah W Grahn, MD, FACS, Ann C Lowry, MD, FACS, Marc C Osborne, MD, Genevieve B Melton, MD, PhD, FACS, Wolfgang B Gaertner, MD, Sarah A Vogler, MD, MBA, Robert D Madoff, MD, FACS University of Minnesota, Minneapolis, MN, Colon and Rectal Surgery Associates, Ltd, St Paul, MN INTRODUCTION: Hospital readmission is common after ileostomy formation. Using a randomized study design, we sought to evaluate a published intervention to prevent hospital readmission. METHODS: Surgeons, advanced practice providers (APP), inpatient and outpatient RNs, and wound ostomy continence nurses (WOCN) at 3 hospitals were educated about the published intervention. After informed consent, patients were randomized to a postoperative compliance surveillance strategy or usual care (Table). New ileostomies were eligible. The primary outcome was unplanned hospital readmission within 30 days of discharge. Risk factors for readmission were assessed using logistic regression.

Compliance surveillance intervention American College of Surgeons ostomy home skills kit and video series Routine postoperative WOCN consultation

23 45.5 39.8 54.9 49.1

(24.4-64.5) (17.5-61.4) (29.9-74.2) (21.6-71.8)

158 71.3 60.9 83.4 68.9

(62.9-78.1) (52.5-68.3) (75.5-88.9) (60.5-75.9)

0.005 0.058 0.0005 0.12

4 42.9 42.9 71.4 57.1

(9.8-73.4) (9.8-73.4) (25.8-91.9) (17.2-83.7)

35 67.2 51.8 87.4 64.8

(51.0-79.0) (36.4-65.2) (71.2-94.8) (47.4-77.7)

0.23 0.7 0.19 0.54

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Educational session by surgeons for inpatient and outpatient RNs and WOCNs Expectation for teaching using updated educational brochure Study personnel remind the inpatient RN with a reminder to assess patient progress with education prior to discharge Study personnel ask inpatient RN to administer ileostomy quiz to patient Study personnel prompt either outpatient RN or APP to complete telephone follow up after patient discharge Study personnel request outpatient RN or APP to describe the patients’ ileostomy output volume

Usual care American College of Surgeons ostomy home skills kit and video series Routine postoperative WOCN consultation Educational session by surgeons for inpatient and outpatient RNs and WOCNs Expectation for teaching using updated educational brochure