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Understanding Palliative Interventions in Patients with End-Stage Colorectal Cancer
Vol. 223, No. 4S1, October 2016
Along with modern chemotherapeutics, there may be a role for PTR to improve survival for stage IV colon cancer patients. Impact of Anti-Tumor Necrosis Factor Alpha Therapy on Postoperative Outcomes in the Surgical Management of Crohn’s Disease Afif N Kulaylat, MD, Audrey S Kulaylat, MD, Eric W Schaefer, Andrew Tinsley, MD, Emmanuelle D Williams, MD, Walter A Koltun, MD, FACS, FASCRS, Christopher S Hollenbeak, PhD, Evangelos Messaris, MD, PhD, FACS, FASCRS Penn State Hershey Medical Center, Hershey, PA INTRODUCTION: Anti-tumor necrosis factor alpha (anti-TNFa) agents have become integral to the management of Crohn’s disease. Despite their use, patients in whom medical therapy fails will require surgical intervention. Controversy remains regarding the impact of anti-TNFa agents on postoperative outcomes. Our aim was to evaluate the influence of anti-TNFa agents on postoperative outcomes in patients with Crohn’s disease. METHODS: Patients (18 years of age) with Crohn’s disease (ICD9: 555.0-555.2, 555.9), undergoing surgical intervention between 2005 and 2013, were identified using the Truven MarketScanÒ database. For each surgical classification, 30-day postoperative complications, emergency department (ED) visits, readmissions, and reinterventions were analyzed by preoperative anti-TNFa therapy groups using multivariable logistic regression models that also adjusted for age, sex, comorbidities, preoperative use of steroids and immunomodulators, and emergency status. Among patients who received anti-TNFa therapy, the timing of therapy was analyzed for each outcome using univariable logistic regression models. RESULTS: There were 7,215 patients with Crohn’s disease identified undergoing surgery: small intestine (n¼4,468), colectomies (n¼1,301), rectal (n¼609), stoma (n¼415), and combination (n¼422). Preoperative drug therapy included anti-TNFa agents (27.6%), steroids (32.7%), and immunomodulators (19.3%). Among all procedures, the postoperative complication rate was 17.6%, the reintervention rate was 3.1%, the ED return visit rate was 17.6%, and the readmission rate was 13.5%. In multivariate analysis, receipt of anti-TNFa was not significantly associated with these postoperative outcomes, nor was the timing of preoperative anti-TNFa therapy for patients who received the therapy. CONCLUSIONS: In the management of Crohn’s disease, preoperative anti-TNFa therapy does not worsen postoperative outcomes in patients requiring surgical intervention. Use of Subcutaneous Drains after Reversal of Ileostomy and Colostomy: A Preliminary Single Center Study Geoffrey Bellini, MD, Elie Sutton, MD, Linda Njoh, Vesna Cekic, Ziad Kronfol, MD, Brett Howe, MD, Amanda Feigel, MD, Richard L Whelan, MD, FACS, FASCRS Mount Sinai West-St. Luke’s, New York, NY
Scientific Forum Abstracts
S37
INTRODUCTION: Ileostomy and colostomy closure, like colectomy, have a high superficial surgical site infection (sSSI) rate. This study’s purpose was to determine if adding a subcutaneous drain to primary wound closure lowered the SSI rate after stomal reversal (SR). METHODS: An IRB-approved database and hospital/office charts were reviewed for SRs done by 1 surgeon between 2009 and 2015. From August 2014 on, either a Jackson-Pratt drain (JP) or small Penrose drain (series of drain segments vertically oriented from fascial surface to skin at intervals along incision and sutured to the skin with staples between) was placed in SR wounds for 7 to 10 days. The sSSI rate was determined; chi-square and Fisher’s exact test were used to compare and evaluate results. RESULTS: Eighty-two patients underwent SR (54 without drains, 66%; 28 with drains, 34%); the breakdown of colostomy and ileostomy SRs between groups was similar (without drain: 21%, 79%; with drain: 25%, 75%). All wounds were primarily closed. There were more superficial SSIs in the no drain group (9/54, 16.7%) than in the drain group (0/28, 0%, p¼0.0181) (Table). There was no difference in length of stay or other short-term outcomes. Univariate analysis showed no differences regarding age, BMI, initial diagnosis, stoma type, and Charlson morbidity scores. On multivariate analysis, drain use was the only factor associated with a lower sSSI rate (p<0.05). Table. Univariate analysis of SR patients
Superficial SSI rate No Yes Sex Male Female Initial surgical indication Neoplasm Benign other Diverticulitis Type of reversal Ileostomy Colostomy
No drain, n
Drain, n
45
28 0
32 22
18 10
28 12 14
12 9 7
44 10
21 7
p Value
0.0181
0.8119
0.6003
0.569
CONCLUSIONS: The use of subcutaneous drains in SRs was associated with a significantly lower rate of sSSIs; these results suggest that routine drain use may be justified. A larger prospective study is indicated. Understanding Palliative Interventions in Patients with End-Stage Colorectal Cancer Stephanie Ramkumar, MD, Shuyin V Liang, MD, Rebecca M Prince, MBBS, FRACP, Adena S Scheer, Julie Hallet, MD, Rebecca K Wong, Monica Krzyzanowska, Paul Kortan, Camilla Zimmermann, MD, PhD, Alexandra M Easson, MD, FACS University of Toronto, Toronto, ON
S38
Scientific Forum Abstracts
INTRODUCTION: Few studies have explored the treatment trajectory of patients with end-stage colorectal cancer (ESCRC) in the months before their death. An understanding of the palliative interventions will help with resource allocation to better meet the needs of these patients. METHODS: This is a retrospective cohort study of consecutive patients with ESCRC who were referred to the palliative care program at a comprehensive cancer center between 2000 and 2010. All interventions from the time of diagnosis were reviewed, and the date patients were deemed incurable was determined. Interventions collected include surgery, endoscopy, and interventional radiology (IR). Descriptive statistics and chi-square test were used. RESULTS: Of 546 patients (372 colon, 174 rectal), 50.2% were male, and median age was 62.6 years. More patients with colon cancer were stage IV at diagnosis compared with rectal cancer patients (42.4% vs 23.2%, p<0.0001). Although similar numbers of patients had palliative surgery and endoscopy between the 2 groups (p¼0.92), significantly more patients in the colon group had palliative IR procedures (25.7% vs 7.0% p<0.0001). In the months before death, 28% of patients underwent palliative surgery, with stoma creation, and segmental resection being most common. There were 10.6% of patients who underwent palliative IR procedures, with percutaneous biliary drain, Tenckhoff catheter insertion, and nephrostomy tube insertion the most common. CONCLUSIONS: Invasive procedures are frequently performed for patients with ESCRC. The needs are similar between patients with colon and rectal cancer. These findings demonstrate that invasive procedures play an important role in the course of illness after the patient is deemed incurable. Updated NSQIP Frailty Index Adam P Johnson, MD, MPH, Sarah Koller, MD, Emily A Busch, MD, Matthew M Philp, MD, Howard M Ross, MD, FACS, FASCRS, Scott W Cowan, MD, Henry A Pitt, MD, FACS Lewis Katz School of Medicine at Temple University, Philadelphia, PA, Thomas Jefferson University Hospital, Philadelphia, PA INTRODUCTION: The Frailty Index (FI), based on the theory of “accumulating deficits,” was introduced in the Canadian Study of Health and Aging. Subsequently, this original index was modified (mFI) and validated with NSQIP variables. However, some of the mFI variables have been retired. Therefore, the aim of this analysis was to update the NSQIP frailty index (NFI). METHODS: The 2012 to 2014 ACS-NSQIP colectomy Participant Use Data File was used. Development (60%) and validation (40%) samples were randomly chosen. Using logistic regression modeling for death or serious morbidity (DSM), a weight for 15 potential variables was based on rounded odds ratios (ORs). The updated NFI uses
J Am Coll Surg
the product of the relative variable weights, and a cutoff value was determined to define frailty and compare outcomes. RESULTS: Of 114,189 patients, 18,292 (16%) experienced DSM. The relative weights of the 9 highest weighted NFI variables include 2 each for dependent status, transfer from chronic-care facility, congestive heart failure, COPD, dialysis, disseminated cancer, ascites, hypoalbuminemia, and 4 for American Society of Anesthesiologists IV/V. The NFI demonstrated good predictability for DSM in the development and validations samples (c-statistic 0.72 and 0.71, respectively). A cutoff value of 8 for a weighted product score identified 9,821 (8.4%) frail patients. Mortality (24% vs 1.6%), serious morbidity (69% vs 24%) and multiple other outcomes (Table) were significantly greater (p<0.001) in frail patients. Table. 30-d postoperative occurrences
Non-frail Frail Total (n¼104,368) (n¼9,821) (n¼114,189)
Mortality, n (%) Any morbidity, n (%) Serious morbidity, n (%)
1,716 (1.6) 24,885 (24) 12,388 (12)
2,388 (24)* 6,806 (69)* 4,878 (50)*
4,104 (3.5) 31,691 (28) 17,266 (15)
Any infectiondsuperficial, deep, organ space, n (%) Pneumonia, n (%) Respiratory failure, n (%)
12,125 (12)
1,517 (15)*
13,642 (12)
2,388 (2.3) 3,003 (2.9)
1,394 (14)* 2,888 (29)*
3,782 (3.3) 5,891 (5.2)
Bleeding requiring a transfusion, n (%) Any venous thromboembolismddeep vein thrombosis, pulmonary embolism, n (%) Sepsis or septic shock, n (%)
10,076 (9.7) 1,929 (1.8)
4,051 (41)* 502 (5.1)*
14,127 (12) 2,431 (2.1)
7,319 (7.0)
3,330 (34)*
10,649 (9.3)
*p<0.001 vs non-frail patients.
CONCLUSIONS: An updated NSQIP Frailty Index has been developed and validated in 2012e2014 colectomy patients. Further validation in additional recent NSQIP cohorts will aid future research on frailty as well as judgments by surgeons and patients regarding operative risk. Variation in Use of a Minimally Invasive Approach for Colectomy: Time to Teach Old Dogs New Tricks? Christopher T Aquina, MD, Christian P Probst, MD, Bradley J Hensley, MD, MBA, Adan Z Becerra, Zhaomin Xu, MD, James C Iannuzzi, MD, MPH, Katia Noyes, PhD, MPH, John R Monson, MD, MB BCH, FRCS, FACS, Fergal Fleming, MD University of Rochester Medical Center, Rochester, NY INTRODUCTION: Laparoscopy is associated with decreased analgesic use, shorter length of stay, and faster postoperative recovery. This study sought to identify factors explaining variation in the use of minimally invasive surgery (MIS) for colectomy. METHODS: New York’s Statewide Planning and Research Cooperative System was queried for elective colectomies from 2009 to 2014 for neoplastic, diverticular, or inflammatory bowel disease. Mixed-effects analyses were performed assessing factors as well as
Along with modern chemotherapeutics, there may be a role for PTR to improve survival for stage IV colon cancer patients. Impact of Anti-Tumor Necrosis Factor Alpha Therapy on Postoperative Outcomes in the Surgical Management of Crohn’s Disease Afif N Kulaylat, MD, Audrey S Kulaylat, MD, Eric W Schaefer, Andrew Tinsley, MD, Emmanuelle D Williams, MD, Walter A Koltun, MD, FACS, FASCRS, Christopher S Hollenbeak, PhD, Evangelos Messaris, MD, PhD, FACS, FASCRS Penn State Hershey Medical Center, Hershey, PA INTRODUCTION: Anti-tumor necrosis factor alpha (anti-TNFa) agents have become integral to the management of Crohn’s disease. Despite their use, patients in whom medical therapy fails will require surgical intervention. Controversy remains regarding the impact of anti-TNFa agents on postoperative outcomes. Our aim was to evaluate the influence of anti-TNFa agents on postoperative outcomes in patients with Crohn’s disease. METHODS: Patients (18 years of age) with Crohn’s disease (ICD9: 555.0-555.2, 555.9), undergoing surgical intervention between 2005 and 2013, were identified using the Truven MarketScanÒ database. For each surgical classification, 30-day postoperative complications, emergency department (ED) visits, readmissions, and reinterventions were analyzed by preoperative anti-TNFa therapy groups using multivariable logistic regression models that also adjusted for age, sex, comorbidities, preoperative use of steroids and immunomodulators, and emergency status. Among patients who received anti-TNFa therapy, the timing of therapy was analyzed for each outcome using univariable logistic regression models. RESULTS: There were 7,215 patients with Crohn’s disease identified undergoing surgery: small intestine (n¼4,468), colectomies (n¼1,301), rectal (n¼609), stoma (n¼415), and combination (n¼422). Preoperative drug therapy included anti-TNFa agents (27.6%), steroids (32.7%), and immunomodulators (19.3%). Among all procedures, the postoperative complication rate was 17.6%, the reintervention rate was 3.1%, the ED return visit rate was 17.6%, and the readmission rate was 13.5%. In multivariate analysis, receipt of anti-TNFa was not significantly associated with these postoperative outcomes, nor was the timing of preoperative anti-TNFa therapy for patients who received the therapy. CONCLUSIONS: In the management of Crohn’s disease, preoperative anti-TNFa therapy does not worsen postoperative outcomes in patients requiring surgical intervention. Use of Subcutaneous Drains after Reversal of Ileostomy and Colostomy: A Preliminary Single Center Study Geoffrey Bellini, MD, Elie Sutton, MD, Linda Njoh, Vesna Cekic, Ziad Kronfol, MD, Brett Howe, MD, Amanda Feigel, MD, Richard L Whelan, MD, FACS, FASCRS Mount Sinai West-St. Luke’s, New York, NY
Scientific Forum Abstracts
S37
INTRODUCTION: Ileostomy and colostomy closure, like colectomy, have a high superficial surgical site infection (sSSI) rate. This study’s purpose was to determine if adding a subcutaneous drain to primary wound closure lowered the SSI rate after stomal reversal (SR). METHODS: An IRB-approved database and hospital/office charts were reviewed for SRs done by 1 surgeon between 2009 and 2015. From August 2014 on, either a Jackson-Pratt drain (JP) or small Penrose drain (series of drain segments vertically oriented from fascial surface to skin at intervals along incision and sutured to the skin with staples between) was placed in SR wounds for 7 to 10 days. The sSSI rate was determined; chi-square and Fisher’s exact test were used to compare and evaluate results. RESULTS: Eighty-two patients underwent SR (54 without drains, 66%; 28 with drains, 34%); the breakdown of colostomy and ileostomy SRs between groups was similar (without drain: 21%, 79%; with drain: 25%, 75%). All wounds were primarily closed. There were more superficial SSIs in the no drain group (9/54, 16.7%) than in the drain group (0/28, 0%, p¼0.0181) (Table). There was no difference in length of stay or other short-term outcomes. Univariate analysis showed no differences regarding age, BMI, initial diagnosis, stoma type, and Charlson morbidity scores. On multivariate analysis, drain use was the only factor associated with a lower sSSI rate (p<0.05). Table. Univariate analysis of SR patients
Superficial SSI rate No Yes Sex Male Female Initial surgical indication Neoplasm Benign other Diverticulitis Type of reversal Ileostomy Colostomy
No drain, n
Drain, n
45
28 0
32 22
18 10
28 12 14
12 9 7
44 10
21 7
p Value
0.0181
0.8119
0.6003
0.569
CONCLUSIONS: The use of subcutaneous drains in SRs was associated with a significantly lower rate of sSSIs; these results suggest that routine drain use may be justified. A larger prospective study is indicated. Understanding Palliative Interventions in Patients with End-Stage Colorectal Cancer Stephanie Ramkumar, MD, Shuyin V Liang, MD, Rebecca M Prince, MBBS, FRACP, Adena S Scheer, Julie Hallet, MD, Rebecca K Wong, Monica Krzyzanowska, Paul Kortan, Camilla Zimmermann, MD, PhD, Alexandra M Easson, MD, FACS University of Toronto, Toronto, ON
S38
Scientific Forum Abstracts
INTRODUCTION: Few studies have explored the treatment trajectory of patients with end-stage colorectal cancer (ESCRC) in the months before their death. An understanding of the palliative interventions will help with resource allocation to better meet the needs of these patients. METHODS: This is a retrospective cohort study of consecutive patients with ESCRC who were referred to the palliative care program at a comprehensive cancer center between 2000 and 2010. All interventions from the time of diagnosis were reviewed, and the date patients were deemed incurable was determined. Interventions collected include surgery, endoscopy, and interventional radiology (IR). Descriptive statistics and chi-square test were used. RESULTS: Of 546 patients (372 colon, 174 rectal), 50.2% were male, and median age was 62.6 years. More patients with colon cancer were stage IV at diagnosis compared with rectal cancer patients (42.4% vs 23.2%, p<0.0001). Although similar numbers of patients had palliative surgery and endoscopy between the 2 groups (p¼0.92), significantly more patients in the colon group had palliative IR procedures (25.7% vs 7.0% p<0.0001). In the months before death, 28% of patients underwent palliative surgery, with stoma creation, and segmental resection being most common. There were 10.6% of patients who underwent palliative IR procedures, with percutaneous biliary drain, Tenckhoff catheter insertion, and nephrostomy tube insertion the most common. CONCLUSIONS: Invasive procedures are frequently performed for patients with ESCRC. The needs are similar between patients with colon and rectal cancer. These findings demonstrate that invasive procedures play an important role in the course of illness after the patient is deemed incurable. Updated NSQIP Frailty Index Adam P Johnson, MD, MPH, Sarah Koller, MD, Emily A Busch, MD, Matthew M Philp, MD, Howard M Ross, MD, FACS, FASCRS, Scott W Cowan, MD, Henry A Pitt, MD, FACS Lewis Katz School of Medicine at Temple University, Philadelphia, PA, Thomas Jefferson University Hospital, Philadelphia, PA INTRODUCTION: The Frailty Index (FI), based on the theory of “accumulating deficits,” was introduced in the Canadian Study of Health and Aging. Subsequently, this original index was modified (mFI) and validated with NSQIP variables. However, some of the mFI variables have been retired. Therefore, the aim of this analysis was to update the NSQIP frailty index (NFI). METHODS: The 2012 to 2014 ACS-NSQIP colectomy Participant Use Data File was used. Development (60%) and validation (40%) samples were randomly chosen. Using logistic regression modeling for death or serious morbidity (DSM), a weight for 15 potential variables was based on rounded odds ratios (ORs). The updated NFI uses
J Am Coll Surg
the product of the relative variable weights, and a cutoff value was determined to define frailty and compare outcomes. RESULTS: Of 114,189 patients, 18,292 (16%) experienced DSM. The relative weights of the 9 highest weighted NFI variables include 2 each for dependent status, transfer from chronic-care facility, congestive heart failure, COPD, dialysis, disseminated cancer, ascites, hypoalbuminemia, and 4 for American Society of Anesthesiologists IV/V. The NFI demonstrated good predictability for DSM in the development and validations samples (c-statistic 0.72 and 0.71, respectively). A cutoff value of 8 for a weighted product score identified 9,821 (8.4%) frail patients. Mortality (24% vs 1.6%), serious morbidity (69% vs 24%) and multiple other outcomes (Table) were significantly greater (p<0.001) in frail patients. Table. 30-d postoperative occurrences
Non-frail Frail Total (n¼104,368) (n¼9,821) (n¼114,189)
Mortality, n (%) Any morbidity, n (%) Serious morbidity, n (%)
1,716 (1.6) 24,885 (24) 12,388 (12)
2,388 (24)* 6,806 (69)* 4,878 (50)*
4,104 (3.5) 31,691 (28) 17,266 (15)
Any infectiondsuperficial, deep, organ space, n (%) Pneumonia, n (%) Respiratory failure, n (%)
12,125 (12)
1,517 (15)*
13,642 (12)
2,388 (2.3) 3,003 (2.9)
1,394 (14)* 2,888 (29)*
3,782 (3.3) 5,891 (5.2)
Bleeding requiring a transfusion, n (%) Any venous thromboembolismddeep vein thrombosis, pulmonary embolism, n (%) Sepsis or septic shock, n (%)
10,076 (9.7) 1,929 (1.8)
4,051 (41)* 502 (5.1)*
14,127 (12) 2,431 (2.1)
7,319 (7.0)
3,330 (34)*
10,649 (9.3)
*p<0.001 vs non-frail patients.
CONCLUSIONS: An updated NSQIP Frailty Index has been developed and validated in 2012e2014 colectomy patients. Further validation in additional recent NSQIP cohorts will aid future research on frailty as well as judgments by surgeons and patients regarding operative risk. Variation in Use of a Minimally Invasive Approach for Colectomy: Time to Teach Old Dogs New Tricks? Christopher T Aquina, MD, Christian P Probst, MD, Bradley J Hensley, MD, MBA, Adan Z Becerra, Zhaomin Xu, MD, James C Iannuzzi, MD, MPH, Katia Noyes, PhD, MPH, John R Monson, MD, MB BCH, FRCS, FACS, Fergal Fleming, MD University of Rochester Medical Center, Rochester, NY INTRODUCTION: Laparoscopy is associated with decreased analgesic use, shorter length of stay, and faster postoperative recovery. This study sought to identify factors explaining variation in the use of minimally invasive surgery (MIS) for colectomy. METHODS: New York’s Statewide Planning and Research Cooperative System was queried for elective colectomies from 2009 to 2014 for neoplastic, diverticular, or inflammatory bowel disease. Mixed-effects analyses were performed assessing factors as well as