Glasgow, Amy E.

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.

Background Age, tumor size and location, overall health, and patient preference are primary considerations driving treatment decision-making for intracranial meningiomas. However, even for the same individual patient, treatment recommendations may vary between centers and providers. Objective To study associations between geography, disease presentation, and management of intracranial meningioma in the United States. Methods The population-based Surveillance, Epidemiology, and End Results(SEER) data were queried between 2004 and 2014 for cases of intracranial meningioma. Results A total of 65,808 patients with intracranial meningioma were identified. Univariate analyses demonstrated strong associations between geographic location, age, and size of tumor at presentation. The mean age for all registries was 64.2 years, with a range from 62.0 (Utah registry) to 66.6 (Detroit registry). The greatest proportion of small tumors (<1 cm) were identified in the Utah registry (13.9% of tumors), while the greatest proportion of large tumors (> 4cm) were noted in the Hawaii registry (30.7% of tumors). Multivariable analysis demonstrated that the impact of geography on treatment selection was just as important as other established variables. For example, the distribution in tumor size between New Mexico and Greater California registries is nearly identical; however, the odds ratio for surgery was 1.5 times greater for the New Mexico population. Conclusion These data suggest that disease presentation and treatment are significantly influenced by regional referral patterns, provider or institutional treatment preferences, and regional availability of subspecialty expertise. Understanding such biases is important for patients, referring physicians, and treatment providers in an effort to provide balanced counseling and treatment.

Objective/Hypothesis The aim of the study was to determine the impact of race on disease presentation and treatment of intracranial meningioma in the United States. Study Design This study comprised of the analysis of a national population-based tumor registry. Methods Analysis of the surveillance, epidemiology, and end results (SEER) database was performed, including all patients identified with a diagnosis of intracranial meningioma. Associations between race, disease presentation, treatment strategy, and overall survival were analyzed in a univariate and multivariable model. Results A total of 65,973 patients with intracranial meningiomas were identified. Of these, 45,251 (68.6%) claimed white, 7,796 (12%) black, 7,154 (11%) Hispanic, 4,902 (7%) Asian, and 870 (1%) patients reported “other-unspecified” or “other-unknown.” The median annual incidence of disease was lowest among black (3.43 per 100,000 persons) and highest among white (9.52 per 100,000 persons) populations (p < 0.001). Overall, Hispanic patients were diagnosed at the youngest age and white patients were diagnosed at the oldest age (mean of 59 vs. 66 years, respectively; p < 0.001). Compared with white populations, black, Hispanic, and Asian populations were more likely to present with larger tumors (p < 0.001). After controlling for tumor size, age, and treatment center in a multivariable model, Hispanic patients were more likely to undergo surgery than white, black, and Asian populations. Black populations had the poorest disease specific and overall survival rates at 5 years following surgery compared with other groups. Conclusion Racial differences among patients with intracranial meningioma exist within the United States. Understanding these differences are of vital importance toward identifying potential differences in the biological basis of disease or alternatively inequalities in healthcare delivery or access Further studies are required to determine which factors drive differences in tumor size, age, annual disease incidence, and overall survival between races.

BACKGROUND: Primary colorectal lymphoma is rare, representing 0.2% to 0.6% of all colorectal cancers. Because of its low incidence and histologic variety, no treatment guidelines exist. OBJECTIVE: The purpose was to report the experience of primary colorectal lymphoma in an institutional and a national cohort. DESIGN: This was a retrospective cohort study. SETTINGS: The study was conducted with institutional data composed of 3 tertiary referral centers and national data. PATIENTS: Patients with primary colorectal lymphoma were identified within the Mayo Clinic (1990–2016) and the Surveillance, Epidemiology, and End Results database (1990–2014). MAIN OUTCOME MEASURES: Primary outcomes were overall and 5-year survival. RESULTS: For the institutional cohort (N = 82), 5-year survival was 79.9%. Five-year survival was higher for rectal (88.4%) than for colon tumors (77.2%; p = 0.004). On multivariable analysis, age <50 years was associated with higher overall survival ( p = 0.04). Left-sided colon masses and aggressive histological subtypes were associated with worse survival (0.04 and 0.03). No effect of treatment modality on survival was noted. For the national cohort (N = 2942), 5-year survival was 58.4%. Five-year survival for rectal tumors was 61.0% and 57.8% for colon tumors. On multivariable analysis, factors associated with improved survival were age <70 y, ( p < 0.0001), female sex ( p = 0.005), right-sided masses ( p = 0.02), and diagnoses after 2000 compared with 1990–1999 ( p < 0.0001). Aggressive pathology ( p < 0.0001) and stage III or stage IV presentation compared with stage I ( p = 0.02 and p < 0.0001) were associated with worse survival. LIMITATIONS: The institutional cohort was limited by sample size to describe treatment effect on survival. A major limitation of the national cohort was the ability to describe treatment modalities other than surgery, including chemotherapy and/or no additional treatment. CONCLUSIONS: Poorer survival was noted in elderly patients and in those with aggressive pathology. An overall survival advantage was seen in women in the national cohort. Currently, optimal strategies should follow a patient-centered multidisciplinary approach. See Video Abstract at http://links.lww.com/DCR/A807. LINFOMA COLORECTAL PRIMARIO: EXPERIENCIA INSTITUCIONAL Y REVISIÓN DE UNA BASE DE DATOS NACIONAL ANTECEDENTES: El linfoma colorectal primario es poco frecuente, representando del 0.2% al 0.6% de todos los cánceres colorectales. Debido a su baja incidencia y variedad histológica, no existen guías de tratamiento. OBJETIVO: El propósito fue reportar la experiencia en linfoma colorectal primario en una cohorte institucional y una nacional. DISEÑO: Este fue un estudio de cohorte retrospectivo. ESCENARIO: El estudio se realizó con datos institucionales provenientes de 3 centros de referencia terciarios y datos nacionales. PACIENTES: Se identificaron pacientes con linfoma colorectal primario en la base de datos de la Clínica Mayo (1990–2016) y en la base de datos de vigilancia, epidemiología y resultados finales [Surveillance, Epidemiology, and End Results database (1990–2014)]. PRINCIPALES MEDIDAS DE RESULTADO: Los resultados primarios fueron la sobrevida general y a 5 años. RESULTADOS: Para la cohorte institucional (N = 82), la sobrevida a 5 años fue de 79.9%. La sobrevida a cinco años fue mayor en tumores rectales (88.4%) que en los de colon (77.2%; p = 0.004). En el análisis multivariable, la edad <50 años se asoció con una mayor sobrevida general (p = 0,04). Las masas de colon izquierdo y los subtipos histológicos agresivos se asociaron con una peor sobrevida (0.04 y 0.03). No se observó ningún efecto según la modalidad de tratamiento en la sobrevida. Para la cohorte nacional (N = 2942), la sobrevida a 5 años fue del 58.4%. La sobrevida a cinco años fue de 61.0% para los tumores rectales y 57.8% para los tumores de colon. En el análisis multivariable, los factores asociados con una mayor sobrevida fueron edad <70 años, (p <0.0001), sexo femenino (p = 0.005), masas derechas (p = 0.02) y los casos diagnósticados después del año 2000 comparados con los de 1990–1999 (p <0.0001). Histopatología agresiva (p <0.0001) y presentación en estadio III o estadio IV en comparación con estadio I (p = 0.02 y p <0.0001) se asociaron con una peor sobrevida. LIMITACIONES: La cohorte institucional estuvo limitada por el tamaño de la muestra para describir el efecto del tratamiento en la sobrevida. Una limitación mayor en la cohorte nacional fue la habilidad para describir modalidades de tratamiento distintas a la cirugía, incluyendo quimioterapia y/o ningún tratamiento adicional. CONCLUSIONES: Una menor sobrevida fue documentada en pacientes de edad avanzada y en aquellos con histopatología agresiva. Se observó ventaja en cuanto a sobrevida general en las mujeres de la cohorte nacional. Actualmente, las estrategias óptimas deben de seguir un abordaje multidisciplinario centrado en cada paciente. Vea el abstract en video en http://links.lww.com/DCR/A807.

BACKGROUND: Intra-abdominal sepsis complicates <10% of ileocolic resections for Crohn’s disease, but the impact of combination immunosuppression and repeat resection on its development remains unknown. OBJECTIVE: The purpose of this study was to determine risk factors for intra-abdominal sepsis after ileocolic resection, specifically examining the role of combination immunosuppression and repeat intestinal resection. DESIGN: This was a retrospective review of patient records from 2007 to 2017. SETTINGS: The study was conducted at a single-institution IBD tertiary referral center. PATIENTS: Patients with a diagnosis of Crohn’s disease who were undergoing ileocolic resection with primary anastomosis were included. Diverted patients were excluded. MAIN OUTCOME MEASURES: Preoperative and intraoperative variables, including preoperative immunosuppressive regimens and previous intestinal resection, were evaluated as potential risk factors for intra-abdominal sepsis. RESULTS: A total of 621 patients (55% women) underwent ileocolic resection for Crohn’s disease; 393 (63%) were first-time resections. The rate of 30-day intra-abdominal sepsis was 8% (n = 50). On univariate analysis, triple immunosuppression (combination of a corticosteroid, immunomodulator, and biological) and previous intestinal resection were significantly associated with intra-abdominal sepsis. Both risk factors remained significant on multivariable analysis (OR for triple immunosuppression (vs none) = 3.53 (95% CI, 1.27–9.84); previous intestinal resection OR = 2.27 (95% CI, 1.25–4.13)). A significant trend was seen between an increasing number of these risk factors (triple immunosuppression and previous intestinal resection) and rate of intra-abdominal sepsis (5%, 12%, and 22% for 0, 1, and 2 risk factors; p < 0.01). A trend was observed between increasing number of previous intestinal resections and the rate of intra-abdominal sepsis (p < 0.01). LIMITATIONS: This study is limited by its single-institution tertiary referral center scope. CONCLUSIONS: Combination immunosuppression and previous intestinal resection were both associated with the development of intra-abdominal sepsis. In light of these results, surgeons should consider the effects of combination immunosuppression and a history of previous intestinal resection, in addition to other risk factors, when deciding which patients warrant temporary intestinal diversion. See Video Abstract at http://links.lww.com/DCR/A664.

Abstract BACKGROUND Return to the operating room (ROR) has been put forth by the National Quality Forum and the American College of Surgeons as a surgical quality indicator. However, current quality metrics fail to consider the nature and etiology of the ROR. OBJECTIVE To provide a comprehensive description of all reoperations after neurosurgical procedures and assess the validity of ROR as a quality measure in neurosurgery. METHODS We retrospectively analyzed all neurosurgical procedures performed in a high-volume, tertiary care academic medical center between June 1, 2014 and December 31, 2016. Based on a system constructed and validated at our institution, we classified RORs into (a) unplanned related, (b) planned return due to complications, (c) planned-staged return, or (d) unrelated return. RESULTS A total of 9200 unique neurosurgical cases were identified, of which 788 had an ROR within 45 d (8.6%). Median time to ROR (interquartile range) was 9 d (4-15). Specifically, 4.2% were planned-staged returns, 3.4% were unplanned related, 0.3% were unrelated, and 0.6% were planned because of previous complications. Cranial procedures had the highest unplanned ROR rate (4.2%), followed by spinal (2.8%) and peripheral nerve (0.4%). The most common reason for an unplanned ROR was wound complication/surgical site infection (34.3%), followed by hematoma evacuation (13.9%) and cerebrospinal fluid (CSF) leak (11.3%). CONCLUSION Unplanned RORs were relatively rare and most commonly associated with wound complication, postoperative hematoma, and CSF leak. To better reflect surgical quality, ROR metrics should indicate whether the return was planned or unrelated.