- Email: [email protected]
Emergent Colectomy in Patients Undergoing Surgery for Diverticulitis
Vol. 223, No. 4S2, October 2016
than in LAP (6.02.5 d, p¼0.081). In terms of pathological examination, positive circumferential resection margin (1 mm) was noted in 1 (1.0%) patient in RAP, 3 (2.9%) patients in LAP (compared to RAP, p¼0.369), and 1 (1.0%) patient in OS (compared to RAP, p¼1.000). The tumor differentiation, histological type, pT and pN stage were similar in three groups. The number of harvested lymph node was also similar in RAP (16.25.2), LAP (16.06.3, compared to RAP, p¼0.799) and OS (16.24.3, compared to RAP, p¼0.939). No patients died during postoperative period in the 3 groups. And RAP had significantly lower complication rate (13.3%) than LAP (25.0%, p¼0.032) and OS (28.6%, p¼0.007), mainly in reducing urinary retention/infection (RAP 2.9%, LAP 9.6%, OS 7.6%; RAP vs LAP, P¼0.043; RAP vs OS, p¼0.121). CONCLUSIONS: Robot-assisted APRs were safe, and reproduce the equivalent surgical quality of conventional laparoscopic and open surgery. Also, it provided less injury and faster functional recovery. Slow Neostigmine Infusions for Colonic Pseudoobstruction (Ogilvie Syndrome) Andreas M Kaiser, MD, FACS, FASCRS, Jason B Weiss, MD, Megan R Linnebur, MD, Michael Parker, MD, Timothy F Feldmann, MD, David R Rosen, MD University of Southern California, Los Angeles, CA INTRODUCTION: Colonic pseudoobstruction (Ogilvie syndrome) is a megacolon without mechanical obstruction resulting from acquired diffuse dysmotility under triggering circumstances. We aimed at reviewing our experience with this condition and hypothesized that repeated slow neostigmine infusions are successful and tolerated without cardiovascular side effects. METHODS: Retrospective review of inpatients with Ogilvie syndrome from 2004-2014. Data collection included demographics, disease duration, and primary outcome measures: overall response to conservative treatment, need for endoscopic or surgical intervention, and treatment safety profile. RESULTS: 39 patients (m/f 23/16) with median age 61 (range 23-94) were treated for Ogilvie syndrome (OS) in 10 years. Triggering conditions were cardiac (30.7%), hepatobiliary (18%), orthopedic (10.3%), vascular (7.7%), neurological (5.1%), and various in 20.5%. 38.5% of patients had underlying diabetes. In 10.3% and 2.6% respectively, OS was associated with C-difficile or nongangrenous colonic ischemia. Median cecal and transverse colon diameter was 9.3 cm (range 5.5-17) and 7 cm (4.5-15), respectively. Initial diagnostic/decompressive colonoscopy was carried out in 47%, of which 65% redeveloped distention. 67% of all patients were successfully treated with intravenous neostigmine infusions cycles (2 mg/2-4 hours, 3.6 cycles, range 1-17 cycles) and achieved lasting decompression. Despite a number of frail cardiac patients, no bradycardia <56 was recorded. Only 1 patient with progressive distention perforated and required a resection.
Scientific Poster Presentations: 2016 Clinical Congress
e89
CONCLUSIONS: Ogilvie syndrome is frequently superimposed on major other health issues. Colonoscopy is important for initial assessment/decompression, but pharmacological treatment with slow neostigmine infusions is safe and provides a lasting effect without hemodynamic impact or bradycardia. Specific Factors Predict the Risk for Urgent/ Emergent Colectomy in Patients Undergoing Surgery for Diverticulitis Neda Valizadeh, Dr, MD, Kunal Suradkar, MD, Cheng-Ta Lai, Daniel L Feingold, MD, Ravi P Kiran, MD Columbia University Medical Center, New York, NY INTRODUCTION: The aim of this study is to identify preoperative characteristics that may determine the need for emergency surgery for diverticulitis and assess postoperative outcomes for these patients when compared to elective surgery METHODS: All patients included in the American College of Surgeons NSQIP targeted colectomy database from 2012 to 2013 who underwent partial and total colectomy with a diagnosis of diverticulitis were included. Preoperative characteristics and 30-day postoperative outcomes were evaluated for patients who underwent elective surgery when compared to emergent/urgent surgery. Table. Preoperative Characteristics and Postoperative Outcomes for Patients Who Underwent Emergent/ Urgent vs Elective Colectomy Variables and complications
BMI<18.5 Age > 65 Steroid use prior to surgery Diabetes mellitus ASA class 3,4,5 Postop ileus Ostomy creation Mortality Sepsis
Emergent/ urgent volectomy, %
Elective colectomy
p Value
65.8 35.7
27 23.4
<0.0001 <0.0001
53.9 42.6 65.5 28.0 62.8 5.2 9.0
26.4 27.6 34.0 8.3 4.0 0.2 2.6
<0.0001 <0.0001 <0.0001 <0.0001 <0.0001 <0.0001 <0.0001
RESULTS: Of 8708 patients with diverticular disease, 2444 (28.1%) underwent emergent/urgent colectomy. Patients who underwent emergent/urgent colectomy had greater preoperative steroid use, diabetes mellitus, disseminated cancer, chronic renal failure, hypertension, chronic heart failure, chronic liver disease, chronic obstructive pulmonary disease, and dependent functional health status (p<0001). There were more patients with age >65 years, BMI <18.5 kg/m2 (p<0001) and smoking history (p<0.05) in emergent/urgent colectomy group. After performing multivariable analysis, preoperative steroid use, weight loss >10%, BMI <18kg/m2, smoking, age >65, and comorbid conditions like cancer, hypertension, COPD, CHF, CRF, and CLD were associated with higher rate of emergent/urgent surgery.
e90
J Am Coll Surg
Scientific Poster Presentations: 2016 Clinical Congress
Mortality (5.2% vs 0.2%) and infectious and non-infectious complications were higher after non-elective colectomy. On multivariable analysis controlling for comorbidity, emergent/urgent surgery was still associated with higher rate of mortality [OR¼14.5,95% CI 7.85-26.80], stoma creation [OR¼3.10, 95% CI 2.77-3.48] longer hospital stay [OR¼6.11,95% CI 3.76-9.93]. CONCLUSIONS: These data suggest that patients with comorbid conditions with episodes of diverticulitis may in fact be the population who might best benefit from a lower threshold for an elective colectomy. Burden of Surgical Complications: Contribution of Long-Term Costs by ClavienDindo Classification Maria Widmar, MD, Paul Strombom, MD, Metin Keskin, MD, Renee L Gennarelli, Elena Elkin, PhD, Martin R Weiser, MD, Philip B Paty, MD, FACS, JJ Smith, MD, PhD, Garrett M Nash, MD, MPH, FACS, FASCRS, Julio E Garcia-Aguilar, MD, PhD, FACS, FASCRS Memorial Sloan-Kettering Cancer Center, Mount Sinai School of Medicine, New York, NY INTRODUCTION: The Clavien-Dindo classification (CD) of surgical complications is based on utilization during the perioperative period. Our purpose was to model the long-term burden of complications through cost and to determine if these were well-represented by CD. METHODS: We identified all patients who had colectomy without an ostomy for colonic pathology at our institution between 2009 and 2014. We graded complications according to CD. We estimated 90-day costs using institutional and homecare provider data, and imputed missing costs using multiple imputation methods. Day of surgery costs were subtracted in order to focus on the costs associated with complications. Cost estimates were converted to average Medicare reimbursement. Only attributable costs and complications were used, including all costs and complications within 30 days, and those directly related to surgery after that. A linear regression model was used to analyze the relationship between highest complication grade and 90-day costs. RESULTS: The cohort included 1,815 patients. There were 1,483 complications in 787 patients. The most prevalent complications were grade 1 (29%) and 2 (49%). Total 90-day costs varied by highest CD grade (p<0.001). Grade 1 complications incurred higher postdischarge costs than Grade 2s. In all patients with complications, post-discharge costs accounted for 53% to 60% of total costs (Table). Table. 31-90 day cost
Post-discharge cost
30-day cost
Total 90-day cost
Highest CD grade
Pts
Mean*
SE
Mean*
SE
Mean*
Mean
SE
None
1028
2,333 (40%)
114
3,042 (52%)
148
3,520 (60%)
88
5,854
160
1
231
3,931 (41%)
335
5,688 (60%)
425
5,570 (59%)
250
9,501
470
2
390
3,369 (31%)
220
5,804 (53%)
321
7,610 (69%)
267 10,979
379
3+
166 10,055 (37%) 1086 14,510 (53%) 1241 17,124 (63%) 1120
* Percentage of the total 90-day costs
SE
27,174 1766
CONCLUSIONS: A substantial proportion of costs attributable to low-grade complications occur after discharge and 30 days. Analyses using a short-term horizon likely underestimate the burden associated with surgical complications. Though highest CD grade predicts total costs, there is significant overlap in the long-term burden among the most common CD grades. Effect of Using Seprafilm on Patients Who Have Undergone Ileal Pouch Anal Anastomosis: A Case-matched Analysis Xhileta Xhaja, James M Church, MD, FACS Cleveland Clinic, Cleveland, OH INTRODUCTION: Seprafilm is safe and effective in reducing the incidence of postoperative adhesions and adhesive small bowel obstruction (SBO) after major abdominal procedures. However, no studies have been conducted to look at the effect of seprafilm on patients that undergo ileal pouch-anal anastomosis (IPAA). We aimed to evaluate incidence of SBO in patients after IPAA surgery with use of Seprafilm. METHODS: Data of consecutive patients undergoing IPAA surgery from 1996 to 2005 were retrieved from prospectively maintained IRB approved pouch database. Patients with incomplete medical records were excluded. Patients were classified into 2 groups; seprafilm and non-seprafilm. Groups were matched (1:1) for sex, length of follow-up, type of pouch (J-pouch vs S-pouch), and type of anastomosis (handsawn vs stapled). Bowel obstruction was defined clinically and radiologically. Univariable analysis and Kaplan-Meier curves were used for group comparison. RESULTS: After applying the matching criteria, 708 patients were identified (354 patients in each group). Out of 128 patients (18%) that develop SBO after their IPAA surgery, 75/354 patients (21.2%) were in the Seprafilm and 53/354 (15%) in the non-seprafilm group (p¼0.032). From the obstructed patients, 26 needed laparotomy (13 seprafilm, 13 non-sepraflim, p¼0.32), 4 patients required bowel obstruction (2 seprafilm, 2 non-seprafilm, p¼1.00) and 20 patients needed lysis of adhesions (11 sepraflim, 9 non-seprafilm, p¼0.72). There were no significant differences between groups in short-term complication, or in pouch failure, pouchites, or sepsis. Table. SBO after IPPA surgery Outcome Obstruction within time
Year 1 2 3 5 10
Seprafilm 14.1% (10.9-18.2) 17.0% (13.4-21.3) 18.1% (14.5-22.5) 20.6% (16.8-25.2) 21.2% (17.3-25.8)
Non-seprafilm 11.6% (8.7e15.4) 12.1% (9.2-16.1) 12.7% (9.7-16.7%) 14.4% (11.2-18.5) 15.0% (11.6-19.1)
p Value 0.039
CONCLUSIONS: There is no advantage in using seprafilm for construction of ileal pouch and anastomosis in terms of preventing bowel obstruction.
than in LAP (6.02.5 d, p¼0.081). In terms of pathological examination, positive circumferential resection margin (1 mm) was noted in 1 (1.0%) patient in RAP, 3 (2.9%) patients in LAP (compared to RAP, p¼0.369), and 1 (1.0%) patient in OS (compared to RAP, p¼1.000). The tumor differentiation, histological type, pT and pN stage were similar in three groups. The number of harvested lymph node was also similar in RAP (16.25.2), LAP (16.06.3, compared to RAP, p¼0.799) and OS (16.24.3, compared to RAP, p¼0.939). No patients died during postoperative period in the 3 groups. And RAP had significantly lower complication rate (13.3%) than LAP (25.0%, p¼0.032) and OS (28.6%, p¼0.007), mainly in reducing urinary retention/infection (RAP 2.9%, LAP 9.6%, OS 7.6%; RAP vs LAP, P¼0.043; RAP vs OS, p¼0.121). CONCLUSIONS: Robot-assisted APRs were safe, and reproduce the equivalent surgical quality of conventional laparoscopic and open surgery. Also, it provided less injury and faster functional recovery. Slow Neostigmine Infusions for Colonic Pseudoobstruction (Ogilvie Syndrome) Andreas M Kaiser, MD, FACS, FASCRS, Jason B Weiss, MD, Megan R Linnebur, MD, Michael Parker, MD, Timothy F Feldmann, MD, David R Rosen, MD University of Southern California, Los Angeles, CA INTRODUCTION: Colonic pseudoobstruction (Ogilvie syndrome) is a megacolon without mechanical obstruction resulting from acquired diffuse dysmotility under triggering circumstances. We aimed at reviewing our experience with this condition and hypothesized that repeated slow neostigmine infusions are successful and tolerated without cardiovascular side effects. METHODS: Retrospective review of inpatients with Ogilvie syndrome from 2004-2014. Data collection included demographics, disease duration, and primary outcome measures: overall response to conservative treatment, need for endoscopic or surgical intervention, and treatment safety profile. RESULTS: 39 patients (m/f 23/16) with median age 61 (range 23-94) were treated for Ogilvie syndrome (OS) in 10 years. Triggering conditions were cardiac (30.7%), hepatobiliary (18%), orthopedic (10.3%), vascular (7.7%), neurological (5.1%), and various in 20.5%. 38.5% of patients had underlying diabetes. In 10.3% and 2.6% respectively, OS was associated with C-difficile or nongangrenous colonic ischemia. Median cecal and transverse colon diameter was 9.3 cm (range 5.5-17) and 7 cm (4.5-15), respectively. Initial diagnostic/decompressive colonoscopy was carried out in 47%, of which 65% redeveloped distention. 67% of all patients were successfully treated with intravenous neostigmine infusions cycles (2 mg/2-4 hours, 3.6 cycles, range 1-17 cycles) and achieved lasting decompression. Despite a number of frail cardiac patients, no bradycardia <56 was recorded. Only 1 patient with progressive distention perforated and required a resection.
Scientific Poster Presentations: 2016 Clinical Congress
e89
CONCLUSIONS: Ogilvie syndrome is frequently superimposed on major other health issues. Colonoscopy is important for initial assessment/decompression, but pharmacological treatment with slow neostigmine infusions is safe and provides a lasting effect without hemodynamic impact or bradycardia. Specific Factors Predict the Risk for Urgent/ Emergent Colectomy in Patients Undergoing Surgery for Diverticulitis Neda Valizadeh, Dr, MD, Kunal Suradkar, MD, Cheng-Ta Lai, Daniel L Feingold, MD, Ravi P Kiran, MD Columbia University Medical Center, New York, NY INTRODUCTION: The aim of this study is to identify preoperative characteristics that may determine the need for emergency surgery for diverticulitis and assess postoperative outcomes for these patients when compared to elective surgery METHODS: All patients included in the American College of Surgeons NSQIP targeted colectomy database from 2012 to 2013 who underwent partial and total colectomy with a diagnosis of diverticulitis were included. Preoperative characteristics and 30-day postoperative outcomes were evaluated for patients who underwent elective surgery when compared to emergent/urgent surgery. Table. Preoperative Characteristics and Postoperative Outcomes for Patients Who Underwent Emergent/ Urgent vs Elective Colectomy Variables and complications
BMI<18.5 Age > 65 Steroid use prior to surgery Diabetes mellitus ASA class 3,4,5 Postop ileus Ostomy creation Mortality Sepsis
Emergent/ urgent volectomy, %
Elective colectomy
p Value
65.8 35.7
27 23.4
<0.0001 <0.0001
53.9 42.6 65.5 28.0 62.8 5.2 9.0
26.4 27.6 34.0 8.3 4.0 0.2 2.6
<0.0001 <0.0001 <0.0001 <0.0001 <0.0001 <0.0001 <0.0001
RESULTS: Of 8708 patients with diverticular disease, 2444 (28.1%) underwent emergent/urgent colectomy. Patients who underwent emergent/urgent colectomy had greater preoperative steroid use, diabetes mellitus, disseminated cancer, chronic renal failure, hypertension, chronic heart failure, chronic liver disease, chronic obstructive pulmonary disease, and dependent functional health status (p<0001). There were more patients with age >65 years, BMI <18.5 kg/m2 (p<0001) and smoking history (p<0.05) in emergent/urgent colectomy group. After performing multivariable analysis, preoperative steroid use, weight loss >10%, BMI <18kg/m2, smoking, age >65, and comorbid conditions like cancer, hypertension, COPD, CHF, CRF, and CLD were associated with higher rate of emergent/urgent surgery.
e90
J Am Coll Surg
Scientific Poster Presentations: 2016 Clinical Congress
Mortality (5.2% vs 0.2%) and infectious and non-infectious complications were higher after non-elective colectomy. On multivariable analysis controlling for comorbidity, emergent/urgent surgery was still associated with higher rate of mortality [OR¼14.5,95% CI 7.85-26.80], stoma creation [OR¼3.10, 95% CI 2.77-3.48] longer hospital stay [OR¼6.11,95% CI 3.76-9.93]. CONCLUSIONS: These data suggest that patients with comorbid conditions with episodes of diverticulitis may in fact be the population who might best benefit from a lower threshold for an elective colectomy. Burden of Surgical Complications: Contribution of Long-Term Costs by ClavienDindo Classification Maria Widmar, MD, Paul Strombom, MD, Metin Keskin, MD, Renee L Gennarelli, Elena Elkin, PhD, Martin R Weiser, MD, Philip B Paty, MD, FACS, JJ Smith, MD, PhD, Garrett M Nash, MD, MPH, FACS, FASCRS, Julio E Garcia-Aguilar, MD, PhD, FACS, FASCRS Memorial Sloan-Kettering Cancer Center, Mount Sinai School of Medicine, New York, NY INTRODUCTION: The Clavien-Dindo classification (CD) of surgical complications is based on utilization during the perioperative period. Our purpose was to model the long-term burden of complications through cost and to determine if these were well-represented by CD. METHODS: We identified all patients who had colectomy without an ostomy for colonic pathology at our institution between 2009 and 2014. We graded complications according to CD. We estimated 90-day costs using institutional and homecare provider data, and imputed missing costs using multiple imputation methods. Day of surgery costs were subtracted in order to focus on the costs associated with complications. Cost estimates were converted to average Medicare reimbursement. Only attributable costs and complications were used, including all costs and complications within 30 days, and those directly related to surgery after that. A linear regression model was used to analyze the relationship between highest complication grade and 90-day costs. RESULTS: The cohort included 1,815 patients. There were 1,483 complications in 787 patients. The most prevalent complications were grade 1 (29%) and 2 (49%). Total 90-day costs varied by highest CD grade (p<0.001). Grade 1 complications incurred higher postdischarge costs than Grade 2s. In all patients with complications, post-discharge costs accounted for 53% to 60% of total costs (Table). Table. 31-90 day cost
Post-discharge cost
30-day cost
Total 90-day cost
Highest CD grade
Pts
Mean*
SE
Mean*
SE
Mean*
Mean
SE
None
1028
2,333 (40%)
114
3,042 (52%)
148
3,520 (60%)
88
5,854
160
1
231
3,931 (41%)
335
5,688 (60%)
425
5,570 (59%)
250
9,501
470
2
390
3,369 (31%)
220
5,804 (53%)
321
7,610 (69%)
267 10,979
379
3+
166 10,055 (37%) 1086 14,510 (53%) 1241 17,124 (63%) 1120
* Percentage of the total 90-day costs
SE
27,174 1766
CONCLUSIONS: A substantial proportion of costs attributable to low-grade complications occur after discharge and 30 days. Analyses using a short-term horizon likely underestimate the burden associated with surgical complications. Though highest CD grade predicts total costs, there is significant overlap in the long-term burden among the most common CD grades. Effect of Using Seprafilm on Patients Who Have Undergone Ileal Pouch Anal Anastomosis: A Case-matched Analysis Xhileta Xhaja, James M Church, MD, FACS Cleveland Clinic, Cleveland, OH INTRODUCTION: Seprafilm is safe and effective in reducing the incidence of postoperative adhesions and adhesive small bowel obstruction (SBO) after major abdominal procedures. However, no studies have been conducted to look at the effect of seprafilm on patients that undergo ileal pouch-anal anastomosis (IPAA). We aimed to evaluate incidence of SBO in patients after IPAA surgery with use of Seprafilm. METHODS: Data of consecutive patients undergoing IPAA surgery from 1996 to 2005 were retrieved from prospectively maintained IRB approved pouch database. Patients with incomplete medical records were excluded. Patients were classified into 2 groups; seprafilm and non-seprafilm. Groups were matched (1:1) for sex, length of follow-up, type of pouch (J-pouch vs S-pouch), and type of anastomosis (handsawn vs stapled). Bowel obstruction was defined clinically and radiologically. Univariable analysis and Kaplan-Meier curves were used for group comparison. RESULTS: After applying the matching criteria, 708 patients were identified (354 patients in each group). Out of 128 patients (18%) that develop SBO after their IPAA surgery, 75/354 patients (21.2%) were in the Seprafilm and 53/354 (15%) in the non-seprafilm group (p¼0.032). From the obstructed patients, 26 needed laparotomy (13 seprafilm, 13 non-sepraflim, p¼0.32), 4 patients required bowel obstruction (2 seprafilm, 2 non-seprafilm, p¼1.00) and 20 patients needed lysis of adhesions (11 sepraflim, 9 non-seprafilm, p¼0.72). There were no significant differences between groups in short-term complication, or in pouch failure, pouchites, or sepsis. Table. SBO after IPPA surgery Outcome Obstruction within time
Year 1 2 3 5 10
Seprafilm 14.1% (10.9-18.2) 17.0% (13.4-21.3) 18.1% (14.5-22.5) 20.6% (16.8-25.2) 21.2% (17.3-25.8)
Non-seprafilm 11.6% (8.7e15.4) 12.1% (9.2-16.1) 12.7% (9.7-16.7%) 14.4% (11.2-18.5) 15.0% (11.6-19.1)
p Value 0.039
CONCLUSIONS: There is no advantage in using seprafilm for construction of ileal pouch and anastomosis in terms of preventing bowel obstruction.