Bews, Katherine A.

Lay SummaryEnterovesical fistula in Crohn’s disease that require surgery may be managed safely laparoscopically with similar morbidity to open repair and a shorter length of stay. Preoperative biologic exposure does not affect surgical morbidity.

Objective To compare the perioperative outcomes of transvaginal/perineal and abdominal approaches to rectovaginal fistula (RVF) repair using a national multicenter cohort. Methods The American College of Surgeons National Surgical Quality Improvement Program database was utilized to identify women undergoing RVF repair from 2005 to 2016. Emergent cases and those with concomitant bowel diversion were excluded. Baseline patient demographics, procedure characteristics, 30-day postoperative complications, return to the operating room, and readmission were evaluated. Baseline characteristics were compared across surgical approach. Multivariable logistic regression models identified preoperative characteristics independently associated with postoperative complications. Results A total of 2288 women underwent RVF repair: 1560 (68.2%) via transvaginal/perineal approach and 728 (31.8%) via abdominal approach. Patients undergoing transvaginal/perineal repair were significantly younger (median age, 46 years vs 63 years), with lower American Society for Anesthesiologist (ASA) scores, and less frequency of diabetes mellitus, dyspnea, severe chronic obstructive pulmonary disease, hypertension, disseminated cancer, and bleeding disorders (all P < 0.01). Those undergoing abdominal repair had higher rates of major complications (25.8% vs 8.7%), minor complications (13.5% vs 6.3%), and readmission (13.2% vs 7.8%). On multivariable analyses, ASA Class 3/4, disseminated cancer, and hematocrit <30% ( P < 0.01) were associated with major complications in both groups. Conclusions Patients undergoing RVF repair via abdominal approach were older with more comorbidities and had higher postoperative complications rates, likely secondary to underlying differences in the treated populations. Irrespective of surgical approach, ASA class, disseminated cancer, and preoperative anemia were associated with higher postoperative morbidity. This may enhance preoperative counseling and allow for careful patient selection.

AbstractBackground and ObjectiveWhether bowel preparation utilization rates or effectiveness varies based on tumor location is unknown.MethodsThe 2012–2016 American College of Surgeons National Surgical Quality Improvement Program Colectomy Targeted participant user file was queried for patients undergoing elective colorectal resection for cancer. Bowel preparation was classified as combined, mechanical bowel preparation alone, oral antibiotic alone, or none. Cochran–Armitage tests were used for trend analysis. Multivariable analyses stratified by tumor location were performed for the outcome of anastomotic leak. An additional multivariable model including all tumor locations assessed for interaction between bowel preparation and tumor location on an anastomotic leak.ResultsA total of 29,739 operations were included and the anastomotic leak rate was 1.9% with combined preparation versus 4.0% without preparation. Combined bowel preparation utilization increased over time as tumor location became more distal (both p < .0001). However, the adjusted effect of combined bowel preparation on anastomotic leak risk reduction did not differ by individual tumor location or across all tumor locations (p = .43 for interaction).ConclusionThough the utilization rate of combined bowel preparation increased as tumor location became more distal, its risk‐reducing effect remained similar. Quality improvement initiatives should focus on increased utilization of combined bowel preparation with an emphasis on tumors in the ascending colon.

BACKGROUND: Discharge on postoperative day 3 after laparoscopic colorectal resections is now common, and same-day discharge has been proposed recently as an option. OBJECTIVE: The purpose of this study was to determine the safety of same-day and next-day discharge after laparoscopic colorectal surgery and to delineate which characteristics may make a patient eligible for this pathway. DESIGN: This was a retrospective cohort study. SETTINGS: The American College of Surgeons National Surgical Quality Improvement Project Targeted Colectomy Participant User File was used. PATIENTS: Patients underwent elective laparoscopic colorectal resection and were discharged without complications on or before postoperative day 5 (early discharge: postoperative day 0 or 1, intermediate: postoperative day 2, standard: postoperative day 3 to 5). MAIN OUTCOME MEASURES: Early readmission (on or before postoperative day 7), anastomotic leak, ileus, and overall readmission were measured. RESULTS: Of 36,526 patients total, 906 (2.5%) were discharged on postoperative day 0 or 1. Patients discharged on postoperative day 0/1 tended to have shorter-duration operations, a diagnostic indication more commonly of benign neoplasm, and underwent less low pelvic anastomoses. The readmission rate within 7 days was only 2%. Overall rates of anastomotic leak (0.6% early, 1.0% intermediate, 1.2% standard), ileus (1.9% early, 1.5% intermediate, 2.1% standard), and readmission (early 4.8%, intermediate 5.1%, standard 5.8%) were equivalent to decreased in patients discharged early versus those discharged in the intermediate or standard discharge groups. On multivariable analysis, dismissal day remained a noncontributory-to-protective factor against anastomotic leak, ileus, and readmission. LIMITATIONS: Specific follow-up pathways used were unknown, and selection bias exists in deciding what day patients can be discharged. CONCLUSIONS: Discharge on the same day or next day after surgery was not associated with increased risk compared with discharge on postoperative day 3 to 5, and it did not result in a high rate of early readmissions. Increased use of expedited discharge pathways would reduce hospital costs and resource use. See Video Abstract at http://links.lww.com/DCR/B331. ¿Es razonable el alta el mismo día o al día siguiente, después de la colectomía laparoscópica en pacientes seleccionados ANTECEDENTES: Es común el alta hospitalaria en el 3er día postoperatorio, después de resecciones colorrectales laparoscópicas. Recientemente se ha propuesto como una opción, el alta el mismo día. OBJETIVO: Determinar la seguridad de alta el mismo día o al día siguiente después de la cirugía colorrectal laparoscópica, y delinear qué características pueden hacer que un paciente sea elegible para esta vía. DISEÑO: Estudio de cohorte retrospectivo. AJUSTES: American College of Surgeons National Surgical Quality Improvement Project Targeted Colectomy Participant User File. PACIENTES: Se sometieron a resección colorrectal laparoscópica electiva, y se dieron de alta sin complicaciones durante el 5° día postoperatorio o antes (alta temprana: día 0 o 1 postoperatorio; intermedia: día 2 postoperatorio; estándar: día 3-5 postoperatorio). PRINCIPALES MEDIDAS DE RESULTADO: Reingreso temprano (en o antes del día 7 postoperatorio), fuga anastomótica, íleo y reingreso general. RESULTADOS: De 36,526 pacientes en total, 906 (2.5%) fueron dados de alta en el día 0 o 1 postoperatorio. Los pacientes dados de alta en el día 0/1 postoperatorio, tendieron a presentar operaciones de menor duración, indicación diagnóstica más frecuente de neoplasia benigna, y sometidos a menos anastomosis de pelvis baja. La tasa de readmisión dentro de los siete días, fue del 2%. Las tasas generales de fuga anastomótica (0.6% temprana, 1.0% intermedia, 1.2% estándar), íleo (1.9% temprana, 1.5% intermedia, 2.1% estándar) y reingreso (temprana 4.8%, intermedia 5.1%, estándar 5.8%) fueron equivalentes a la disminución en pacientes dados de alta temprana, versus aquellos dados de alta en los grupos intermedia o estándar. En el análisis multivariable, el día de alta no contribuyó al factor protector contra la fuga anastomótica, el íleo y el reingreso. LIMITACIONES: Se desconocen las vías de seguimiento específicas utilizadas y existe un sesgo de selección al decidir en qué día se puede dar de alta a los pacientes. CONCLUSIONES: El alta el mismo día o al día siguiente después de la cirugía, no se asoció con un mayor riesgo, en comparación con el alta en el postoperatorio en los días 3-5, y no dio lugar a una alta tasa de reingresos tempranos. Mayor utilización de las vías de alta acelerada, reducirían costos hospitalarios y utilización de recursos. Consulte Video Resumen en http://links.lww.com/DCR/B331. (Traducción—Dr Fidel Ruiz Healy)

BACKGROUND: Outcomes after total abdominal colectomy with ileosigmoid or ileorectal anastomosis for Crohn’s colitis and risk factors for requirement of a permanent ileostomy remain poorly understood, particularly in the biologic era. OBJECTIVE: This study aimed to determine long-term ostomy-free survival after ileosigmoid or ileorectal anastomosis for Crohn’s colitis and potential risk factors for requirement of an ileostomy. DESIGN: This is a retrospective cohort study. SETTING: This study was conducted at a single-institution IBD tertiary referral center. PATIENTS: Patients diagnosed with Crohn’s disease and undergoing ileosigmoid or ileorectal anastomosis between 2006 and 2018 were selected. MAIN OUTCOME MEASURE: Long-term ostomy-free survival and hazard ratios of potential predictors of ileostomy requirement were the primary outcomes measured. RESULTS: One hundred nine patients (56% female) underwent ileosigmoid or ileorectal anastomosis for Crohn’s disease. The majority of surgical procedures were completed in 2 or 3 stages (53%). The indication for total abdominal colectomy was predominantly medically refractory disease (77%), with dysplasia the second leading indication (13%). At an overall mean follow-up of 3 years, 16 patients had undergone either proctectomy or diversion with the rectum in situ. This resulted in ostomy-free survival estimates at 5 and 10 years of 78% (95% CI, 68-90) and 58% (95% CI, 35–94). A positive distal microscopic margin was the only risk factor for later requirement of a permanent ileostomy (HR, 5.4; 95% CI, 1.7–17.2). LIMITATIONS: This study is limited because it is a retrospective study at a tertiary referral center. CONCLUSIONS: Long-term ostomy-free survival can be achieved in the majority of patients who undergo restoration of intestinal continuity after total abdominal colectomy for Crohn’s colitis. A positive distal microscopic margin was independently associated with long-term anastomotic failure, and it should be accounted for when risk stratifying patients for postoperative prophylactic medical therapy. See Video Abstract at http://links.lww.com/DCR/B111. ¿QUÉ FACTORES ESTÁN ASOCIADOS CON LA EVENTUAL NECESIDAD DE UNA ILEOSTOMÍA DESPUÉS DE UNA COLECTOMÍA ABDOMINAL TOTAL Y UNA ANASTOMOSIS ILEOSIGMOIDEA O ILEORRECTAL PARA LA COLITIS DE CROHN EN LA ERA BIOLÓGICA? ANTECEDENTES: Los resultados después de la colectomía abdominal total con anastomosis ileosigmoidea o ileorrectal para la colitis de Crohn y los factores de riesgo para el requerimiento de una ileostomía permanente siguen siendo poco conocidos, particularmente en la era biológica. OBJETIVO: Determinar la supervivencia a largo plazo sin ostomía después de una anastomosis ileosigmoidea o ileorrectal para la colitis de Crohn y los factores de riesgo potenciales para la necesidad de una ileostomía. DISEÑO: Estudio de cohorte retrospectivo. AJUSTE: Centro de referencia de tercel nivel para enfermedad inflamatoria intestinal de una sola institución. PACIENTES: Pacientes diagnosticados con enfermedad de Crohn y sometidos a anastomosis ileosigmoidea o ileorrectal entre 2006 y 2018 MEDIDA DE RESULTADO PRINCIPAL: Supervivencia a largo plazo sin ostomías y cocientes de riesgo de predictores potenciales de requerimiento de ileostomía RESULTADOS: 109 pacientes (56% mujeres) se sometieron a anastomosis ileosigmoidea o ileorrectal por enfermedad de Crohn. La mayoría de los procedimientos quirúrgicos se completaron en 2 o 3 etapas (53%). La indicación de colectomía abdominal total fue predominantemente enfermedad médicamente refractaria (77%), con displasia la segunda indicación principal (13%). En un seguimiento medio general de 3 años, 16 pacientes se habían sometido a una proctectomía o a una derivación con el recto in situ. Esto dio como resultado estimaciones de supervivencia sin ostomía a los 5 y 10 años de 78% (intervalo de confianza del 95%: 68–90) y 58% (intervalo de confianza del 95%: 35–94), respectivamente. Un margen microscópico distal positivo fue el único factor de riesgo para el requerimiento posterior de una ileostomía permanente (razón de riesgo: 5.4; intervalo de confianza del 95%, 1.7–17.2). LIMITACIONES: Estudio retrospectivo en un centro de referencia de tercer nivel. CONCLUSIONES: La supervivencia a largo plazo sin ostomía se puede lograr en la mayoría de los pacientes que se someten a la restauración de la continuidad intestinal después de la colectomía abdominal total por colitis de Crohn. Un margen microscópico distal positivo se asoció de forma independiente con la insuficiencia anastomótica a largo plazo, y debe tenerse en cuenta cuando se trata de pacientes con estratificación de riesgo para el tratamiento médico profiláctico postoperatorio. Consulte Video Resumen en http://links.lww.com/DCR/B111.

Background: Revision total hip arthroplasty (revision THA) occurs for a wide variety of indications and in the United States it is coded under Diagnosis-Related Groups (DRGs) 466, 467, and 468, which do not account for revision etiology, a potentially substantial driver of cost. This study investigates revision THA costs and 30-day complications by indication, both locally and nationally. Methods: Hospitalization costs and complication rates for 1,422 aseptic revision THAs performed at a high-volume center between 2009 and 2014 were retrospectively reviewed. Additionally, charges for 28,133 revision THAs in the National Inpatient Sample (NIS) were converted to costs using the Healthcare Cost and Utilization Project cost-to-charge ratios, and 30-day complication rates for 3,224 revision THAs were obtained with use of the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP). Costs and complications were compared between revision THAs performed for fracture, wear/loosening, and dislocation/instability with use of simultaneous and pairwise comparisons and a multivariable model accounting for American Society of Anesthesiologists (ASA) score, age, and sex. Results: Local hospitalization costs for fracture (median, $25,672) were significantly higher than those for wear/loosening ($20,228; p < 0.001) or dislocation/instability ($17,911; p < 0.001), with differences remaining significant even after adjusting for patient comorbidities (p < 0.001). NIS costs for fracture (median, $27,596) were higher than those for other aseptic indications (wear/loosening: $21,176, p < 0.001; dislocation/instability: $16,891, p< 0.001). Local 30-day orthopaedic complication rates for fracture (20.7%) were higher those than for dislocation/instability (9.0%; p = 0.007) and similar to those for wear/loosening (17.6%; p = 0.434). Nationally, combined medical and surgical complication rates for fracture (71.3% of patients with ≥1 complication) were significantly higher than those for wear/loosening (35.2%; p < 0.001) or dislocation/instability (35.1%; p < 0.001). Conclusions: Hospitalization costs for revision THA for fracture were 33% to 48% higher than for all other aseptic revision THAs, both locally and nationally. This increased cost persisted even after multivariable comorbidity adjustment, the current DRG basis for stratifying revision THA reimbursement. Additionally, 30-day complication rates suggest that increased resource utilization for fracture patients continues even after discharge. Indication-specific coding and reimbursement systems are necessary to maintain sustainable access to revision THA for all patients. Level of Evidence: Prognostic Level III . See Instructions for Authors for a complete description of levels of evidence.

Objectives The objective of this study was to evaluate perioperative complications in women who underwent minimally invasive sacrocolpopexy (MISC) versus mesh-augmented vaginal repair (vaginal mesh) for pelvic organ prolapse. Methods We identified patients undergoing MISC and vaginal mesh via Current Procedural Terminology codes from the American College of Surgeons National Surgical Quality Improvement Program database from 2005 to 2016. Those undergoing concomitant hysterectomy were excluded. Univariate analyses were performed to compare baseline characteristics and 30-day complications. Multivariable logistic regression models were constructed to assess the association between surgical approach and complications, prolonged hospitalization, reoperation, and blood transfusion. A multivariable Cox proportional hazard model was used to evaluate hospital readmission. Results A total of 5722 patients were identified (2573 MISC [45%], 3149 vaginal mesh [55%]). Those undergoing MISC repairs had a significantly lower rate of urinary tract infection (3.1 vs 4.2%; P = 0.03) and blood transfusion (0.5 vs 1.4%; P < 0.001). There was no difference in reoperation rate (1.3 vs 1.6%; P = 0.35). Multivariable analysis showed no significant association of MISC with overall (odds ratio [OR], 0.91; P = 0.44), major (OR, 1.30; P = 0.31), or minor complication (OR, 0.85; P = 0.26). There were lower odds of receiving a blood transfusion (OR, 0.44; P = 0.02) and higher odds of prolonged hospitalization (>2 days; OR, 1.47; P = 0.003) for the MISC group. There was no difference in reoperation (OR, 0.79; P = 0.38) or hospital readmissions (hazard ratio, 1.25, P = 0.32). Conclusions Minimally invasive sacrocolpopexy was associated with a lower rate of blood transfusion than transvaginal mesh placement. There was no significant difference in 30-day complication rates, reoperation, or readmission between these prolapse procedures when performed without concomitant hysterectomy.

Objective The aim of this study was to compare the perioperative morbidity of minimally invasive sacrocolpopexy (MISC) and nonmesh apical vaginal surgeries for repair of vaginal vault prolapse using data from a contemporary nationwide cohort. Methods The American College of Surgeons' National Surgical Quality Improvement Program database was used to identify women who underwent apical prolapse surgery via vaginal approach or MISC from 2010 to 2016. Those undergoing concomitant hysterectomy or transvaginal mesh placement were excluded. Associations of surgical approach with 30-day complications, prolonged hospitalization, and reoperation were evaluated using logistic regression. Readmission within 30 days was calculated using the person-years method and Cox proportional hazards models. Results Overall, 6390 women underwent surgery, including 3852 (60%) via vaginal approach and 2538 (40%) via MISC. Patients undergoing MISC were younger ( P < 0.0001) and less likely to have hypertension ( P = 0.04) or chronic obstructive pulmonary disease ( P = 0.008), with lower American Society of Anesthesiologists scores ( P < 0.0001) and higher preoperative hematocrit ( P = 0.009). The MISC cohort had a lower unadjusted rates of minor complications (3.9% vs 5.6%; P = 0.004), urinary tract infection (3.3% vs 4.8%; P = 0.004), and prolonged hospitalization (5.2% vs 7.9%; P < 0.0001), with a higher rate of nephrologic ( P = 0.01) complications. On multivariable analysis, there were no significant associations of MISC with the risk of 30-day complications (odds ratio [OR], 1.51; 95% confidence interval [CI], 0.92–2.51; P = 0.11), prolonged hospitalization (OR, 0.96; 95% CI, 0.76–1.21; P = 0.72), readmission (HR 1.03; 95% CI, 0.71–1.49; P = 0.88), or reoperation (OR, 0.95; 95% CI, 0.57–1.60; P = 0.86). Conclusions Minimally invasive sacrocolpopexy is associated with similar rates of 30-day complications, prolonged hospitalization, readmission, and reoperation compared with nonmesh vaginal surgeries for apical prolapse.

Objective: To determine the relative or combined effects of Crohn disease (CD) and ulcerative colitis (UC) and the operation performed on postoperative venous thromboembolism (VTE) to better guide recommendations on extended VTE prophylaxis. Summary Background Data: There is growing evidence to suggest patients with inflammatory bowel disease have an increased risk of postoperative VTE, but prior studies have not accounted for the operation performed nor acknowledged differences between CD and UC. Methods: The American College of Surgeons National Surgical Quality Improvement Project database from 2005 to 2016 was queried for patients with a diagnosis of CD, UC, malignancy, or benign disease (diverticular disease, Clostridium difficile) undergoing major abdominal surgery. Operations with a VTE rate >3% were designated high risk. Operation-specific univariate and multivariable logistic regression analyses were conducted. Results: A total of 231,718 operations were analyzed with 4426 patients experiencing a VTE (1.9%). The overall rate of VTE ranged widely based on the operation performed from 0.7% for enterostomy closure to 5.3% for open subtotal colectomy. Seven operations met our threshold of 3% to be considered high risk. For each operation, postoperative VTE rates were similar regardless of diagnostic indication when performed in the elective setting. However, when performed emergently, the same operations had significantly higher VTE rates. Compared with the malignancy and benign disease groups, neither CD nor UC was associated with increased odds of VTE after any operation. Conclusions: Postoperative VTE risk varies widely by the operation performed, and a diagnostic indication of CD or UC does not play a role. Extended duration VTE prophylaxis should be considered in all patients undergoing high-risk operations, regardless of their underlying diagnosis.