31.01 Racial Disparities in Treatment for Rectal Cancer Persist at Minority Serving Hospitals

Posted on January 31, 2019

P. Lu1,2, R. E. Scully1, Q. Trinh2,3, A. C. Fields1, R. Bleday1, J. E. Goldberg1, A. H. Haider1,2, N. Melnitchouk1,2  1Brigham And Women’s Hospital,Department Of Surgery,Boston, MA, USA 2Center for Surgery and Public Health,Brigham And Women’s Hospital,Boston, MA, USA 3Brigham And Women’s Hospital,Department Of Urologic Surgery,Boston, MA, USA

Introduction:

Racial disparities have been shown to exist in the treatment of rectal cancers with black patients having poorer survival and less adequate treatment compared to white patients. Minority serving hospitals (MSH) provide healthcare to a disproportionately large percent of minority patients in the United States. To better understand the cause of these disparities, we examined outcomes of rectal cancer patients treated at MSH using the National Cancer Database (NCDB). 

Methods:
NCDB was queried (2004-2014), and patients diagnosed with stage 2 or 3 rectal adenocarcinoma were identified. Racial case mix distribution was calculated at the institutional level and MSH were defined as those within the top decile of black and Hispanic patients. Standard of care (SOC) was defined by undergoing adequate surgery (low anterior resection, abdominoperineal resection or pelvic exenteration), chemotherapy, and radiation. A Cox proportional hazards model was used to evaluate adjusted risk of death and an adjusted logistic regression model was created for receipt of SOC. Analyses were clustered by facility.

Results:

60,855 patients were identified with stage 2 or 3 rectal adenocarcinoma. 55,727 (91.6%) patients were treated at non-MSH, and 5,128 (8.4%) were treated at MSH. Adjusting for age, gender, comorbidies, tumor stage, insurance, education, and income, black (OR 0.66 95%CI 0.55-0.80 p<0.001), white (OR 0.70 95% CI 0.61-0.80 p<0.001), and Hispanic (OR 0.68 95%CI 0.53-0.86 p<0.001) individuals were each less likely to receive SOC at MSH vs non-MSH. In unadjusted survival analysis, risk of death was significantly higher at MSH vs non-MSH for black individuals but not for white individuals (Figure 1). When adjusting for receipt of SOC, patient characteristics, and disease specific variables this difference was no longer seen (HR 1.03 95%CI 0.92-1.17 p=0.59).  In adjusted analysis of the overall group, black individuals had a significantly higher risk of mortality (HR 1.20 95%CI 1.14-1.26 p<0.001) compared to white individuals. This was persistent despite inclusion of receipt of SOC in the model (HR 1.16 95%CI 1.10-1.23 p<0.001).

Conclusions:

Treatment at MSH institutions was associated with significantly decreased odds of receipt of SOC for rectal adenocarcinoma across racial groups. Survival was worse for black individuals compared to white in both unadjusted and adjusted analyses. However, in adjusted analysis there was no difference in mortality for black individuals in MSH vs non-MSH when receipt of SOC was included in the model.  Further studies are needed to examine the racial disparity that persists in rectal cancer treatment, and address barriers facing MSH in providing rectal cancer SOC to all.

24.10 Dietary Aryl Hydrocarbon Receptor Ligands Shape the Composition and Function of the Microbiota

Posted on January 31, 2019

K. M. Brawner1, W. Van Der Pol2, L. Duck3, V. Yeramilli1, L. Smythies3, C. Morrow4, C. Elson3, C. Martin1  1University Of Alabama at Birmingham,Surgery,Birmingham, Alabama, USA 2University Of Alabama at Birmingham,Center For Clinical And Translational Science,Birmingham, Alabama, USA 3University Of Alabama at Birmingham,Medicine,Birmingham, Alabama, USA 4University Of Alabama at Birmingham,Cell, Developmental, And Integrative Biology,Birmingham, Alabama, USA

Introduction: Proper immune responses to gut microbes are mediated through host-cell receptor signaling. The aryl hydrocarbon receptor (Ahr) is engaged by microbial-derived tryptophan (Trp) derivatives to contribute to the development of a functional intestinal barrier.  We have shown that removal of dietary sources of Ahr ligands results in decreased fecal immunoglobulin (Ig) A levels. The effect of dietary Ahr ligand manipulation on intestinal microbiome composition and function is largely unknown. 

Methods: We randomly assigned mouse littermates to a conventional diet or an Ahr ligand-free diet.  DNA from fecal samples was isolated for 16S rRNA gene sequencing or fecal samples were cultured anaerobically. Faecalibaculum rodentium was grown anaerobically in broth with or without carbohydrates and supplemented or not with Trp.  Ahr ligands in F. rodentium –conditioned supernatants were measured by luciferase assay.   An in vitro model of IgA transcytosis was used to determine if fecal microbiota from Ahr ligand-free diet mice and F. rodentium-conditioned supernatants are capable of degrading IgA.  For gene expression analysis, RNA was harvested from primary epithelial cells used in IgA transcytosis assays.

Results: We observed a global alteration of fecal microbiota upon dietary Ahr ligand deprivation.  Mice on the Ahr ligand-free diet harbored a microbiota that was less diverse compared to mice on the conventional diet. The most common DNA sequence from the combined dataset of both groups of mice belonged to the genus Allobaculum. This genus was enriched in the feces of mice on the Ahr ligand-free diet.  The Allobaculum sequences in our dataset were most closely related to F. rodentium. Compared with non-conditioned broth, F. rodentium-conditioned supernatant contained lower amounts of Ahr ligands.  Cultured fecal bacteria from mice on the Ahr ligand-free diet, but not the conventional diet, were able to degrade IgA.  Finally, F. rodentium-conditioned supernatant was also capable of IgA degradation without affecting IgA transcytosis.

Conclusion: Here we show that removal of dietary Ahr ligands alters the composition and function of intestinal microbiota.  The ability of F. rodentium-conditioned supernatants to degrade Ahr ligands suggests Allobaculum thrives in an environment in which Ahr is inactive.  Our IgA transcytosis experiments indicate a cause and effect relationship between altered microbiota and reduced fecal IgA on the Ahr ligand-free diet.  We also show that F. rodentium is capable of IgA degradation, recapitulating our results from cultures of whole fecal samples.  To our knowledge, this is the first time a specific commensal species has been implicated in Ahr ligand and IgA degradation.        

 

24.09 Intra-tumor Heterogeneity is Associated with Immune Response and Improved Survival in Colon Cancer

Posted on January 31, 2019

A. L. Butash1, T. Kawaguchi2, L. Yan3, Q. Qi3, X. Peng3, M. Asaoka1, G. Mann1, E. Otsuji2, K. Takabe1  1Roswell Park Cancer Institute,Department Of Surgery,Buffalo, NY, USA 2Kyoto Prefectural University of Medicine,Department of Surgery,Kyoto, KYOTO, Japan 3Roswell Park Cancer Institute,Department Of Bioinformatics And Biostatistics,Buffalo, NY, USA

Introduction:
Tumor heterogeneity arises from differences among cancer cells that are inherited during cell division.  It implies the coexistence of sub-populations of cancer cells that differ in their genetic, phenotypic, or behavioral characteristics. Several studies have documented a role for intra-tumor heterogeneity (ITH) in driving tumor progression and treatment resistance in colon cancer. However, ITH, especially related to intra-tumor immune microenvironment, is not well examined in colon cancers.  In this study, we aim to examine the association of ITH and immune gene signatures and its clinical relevance in colon cancers.

Methods:
Integrated genomic and clinical data was collected from colon cancer patients in The Cancer Genome Atlas (TCGA). ITH was estimated by calculating Mutant Allele Tumor Heterogeneity (MATH) using computational analyses. Intra-tumor immune signatures and tumor infiltrating immune cell composition were calculated using integrated transcriptomics and CIBERSORT or TIMER, respectively. Clinical relevance was assessed by Kaplan-Meier survival curve. 

Results:
Colorectal tumors with high ITH were found to have fewer activated CD4 T-cells (p<0.0074) and CD8 T-cells (p<0.0084) when compared to tumors with low ITH. A similar trend was seen with decreased expression of immune checkpoint molecules; such as PD-1, PDL-1, CTLA4, and LAG3 (p<0.01, p<0.0067, p<0.023, p<0.005 respectively) in tumors with high ITH, reflecting the overall decreased presence of immune cells. Expression of cytolytic molecules; PRF1 (p<0.0046) and GZMA (p<0.00059), as well as the immune cytolytic activity (p<0.0023) were also lower in tumors with high ITH. We also retrieved a genomic classifier created of >200,000 microsatellite loci to identify microsatellite instability (MSI), and found that MSI-high tumors showed lower ITH, suggesting that genomic instability could be associated with intra-tumor heterogeneity. MSI-high tumors were associated with low ITH (p<0.0001). Gene Set Enrichment Analysis (GSEA) demonstrated that enrichment of immune-response gene sets was observed in the lower ITH tumors. Low MATH was associated with improved overall survival (OS) while high MATH demonstrated worse survival (p<0.029), as well as disease-free survival (p<0.0093). In right sided colorectal tumors, low ITH was associated with improved survival (p<0.0023), but this trend was not observed with left sided colorectal tumors in this patient population.

Conclusion:
We found that low ITH was associated with enhanced intra-tumor immunogenicity or immune response and is prognostic of improved survival in colon cancer. Our study is in agreement with the notion that ITH is determined by tumor immune microenvironment including anti-tumor immunity, which is expected to have future implications for clinical application. 
 

24.08 Effects of Plant Based Enteral Nutrition Formula on Colonic Gene Expression in a Murine Colitis Model

Posted on January 31, 2019

R. G. Ramos1, M. Rogers1,2, A. Yeh1,2, J. Tian1,2, B. Firek1,2, E. Novak1,2, K. Mollen1,2, M. Morowitz1,2  1University Of Pittsburg,Surgery,Pittsburgh, PA, USA 2Children’s Hospital Of Pittsburgh Of UPMC,Pediatric Surgery,Pittsburgh, PA, USA

Introduction:

The beneficial effects of a high fiber diet on epithelial integrity, immune reactivity, and bacterial diversity have been well documented in the medical literature. Previously we have shown that when compared to standard mouse chow or conventional enteral nutrition (CEN), plant based enteral nutrition (PBEN) formulas significantly decrease disease activity in murine colitis models. To define the mechanisms underlying this beneficial effect, we utilize RNA Seq to compare colonic gene expression in mice with colitis on different nutritional regimens.

Methods:

Four groups of four C57BL6 male mice each were fed regular mouse chow, PBEN (Liquid Hope), CEN1 (PediaSure), or CEN2 (Vital) for 7 days. On day 8, 2% dextran sodium sulfate (DSS) was started. On day 12, mice were sacrificed and colon was preserved for RNA-seq analysis. Colonic gene expression was characterized with RNA-seq and reference matched with KEGG. R software with vegan package was used for analysis. False discovery rate (FDR) was used to adjust for multiple hypothesis testing, logarithmic fold change (LFC) was used to measure effect size, statistical significance was defined as a p value < .05.

Results:

As we have seen previously, weight loss and disease activity scores were significantly lower in PBEN animals (see figure). RNA Seq of whole colon tissue from each dietary group demonstrated a statistically significant change in transcription of the following pathways in the PBEN colitis group: interleukin 17 (IL-17) and tumor necrosis factor α  (TNF-α ) signaling, vitamin A metabolism, nucleotide binding oligomerization domain domain-like receptors (NOD), and inflammatory bowel disease (IBD) associated pathways. A twofold change in expression levels was identified in the following pathways with LFC, upregulated genes include: Gasdermin-C4 (Gsdmc4), antigen peptide transporter 1 (Tap1), aldehyde dehydrogenase family 1 subfamily A2 (Ald1a2), UDP-Glucuronosyltransferase-2B7 (UGT2B7), members of major histocompatibility complex II (MHC), signal transducer and activator of transcription 1 (STAT1), capase 1 (Casp1), caspase 4 (Casp4), and mitofusin 2 (Mfn2). Downregulated genes include: TNF ligand superfamily member 11 and 14 (RANKL and LIGHT), IL-17 receptor A (IL17RA), interleukin 1 beta (IL-1β ) and interleukin 6 (IL-6).

Conclusion:

The downregulated TNF-α  signaling (RANKL and LIGHT) and IL-17 signaling (IL17RA, IL-1β  and IL-6) pathways, along with the upregulated vitamin A metabolism (Ald1a2 and UGT2B7), IBD (MHC II and STAT1) and NOD (Casp1, Casp4, and Mfn2) pathways offer a biologically plausible explanation of the molecular mechanisms underlying PBEN’s beneficial effects on epithelial integrity and inflammation.

24.05 Myofibroblast-Derived Angiogenin Regulates Tumor Growth in a Mouse Model of Colorectal Cancer

Posted on January 31, 2019

R. Plummer1, T. Liu1, N. Ciomek2, J. Yoo1  1Tufts Medical Center,Surgery,Boston, MA, USA 2Tufts Medical Center,Pathology,Boston, MA, USA

Introduction:   The myofibroblast (MFB) is an inportant stromal cell of the GI tract that has been implicated in the pathophysiology of colorectal cancer (CRC).  Angiogenin (ANG), a secreted 14-kDa member of the ribonuclease superfamily, enhances cell growth and survival.  We recently reported that ANG regulates cell signaling events within the MFB, but the impact of MFB-derived ANG on CRC has not been previously studied.  Our goal was to evaluate the role of MFB-derived ANG on CRC growth in a novel mouse model involving orthotopic implantation of primary CRC and MFB cells via murine colonoscopy.  

Methods:   After isoflurane anesthesia, a colonoscopy was performed with endoscopic microinjection of a cell suspension that contained genetically defined (ApcΔ /Δ ;Kras G12D/+;Trp53Δ /Δ ) primary mouse CRC cells (1×104-4×104) into 8-10 week-old wild-type (WT) and ANG-knockout (ANG-KO) C57BL/6 mice.  In a second set of experiments, CRC cells (4×104) were injected with primary syngeneic WT or ANG-KO MFB (2×105) into WT and ANG-KO C57BL/6 mice.  A follow-up colonoscopy was performed weekly for 4 weeks with photo and video documentation.  Tumor size was graded based on tumor diameter relative to colon circumference (grade 1=just detectable; grade2=1/8; grade3=1/4; grade 4=1/2).  Endoscopic data was correlated with anatomic/histologic findings.  

Results:  A total of 37 mice were injected with a survival rate of 94%.  Injected CRC cells successfully implanted in colon submucosa of WT immune-competent mice and grew in a dose-dependent fashion (Week 1: 5×103 – grade 0, 1×104 – grade 1, 4×104 – grade 1.4, n=17 total) that persisted over 4 weeks.  However, injected CRC cells at all concentrations failed to grow in ANG-KO mice over 4 weeks (grade 0, n=8).  Compared to injection of CRC cells alone, co-injection of CRC with WT MFB in WT mice led to enhanced tumor growth (Week 1: grade 3.3, n=4).  Tumor growth was unchanged following co-injection of CRC with WT MFB in ANG-KO mice (Week 1: grade 3.1, n=4).  However, there was significantly diminished tumor growth following co-injection of CRC with ANG-KO MFB in ANG-KO mice (Week 1: grade 1.5, n=4).

Conclusion:  Orthotopic implantation of CRC leads to dose-dependent tumor growth in WT mice but no growth in ANG-KO mice, suggesting that ANG is required for tumor growth.  WT MFB enhances tumor growth when orthotopically co-injected with primary CRC in WT mice.  This effect can be sustained when host ANG is absent (ANG-KO mice) but MFB-derived ANG (WT MFB) is still present.  However, the loss of both host ANG (ANG-KO mice) and MFB-derived ANG (ANG-KO MFB) resulted in markedly reduced tumor formation and growth. These results suggest that MFB enhances CRC growth through a mechanism that involves MFB-derived ANG.

24.02 Plasminogen, collagenolytic bacteria and anastomotic leak: prevention via tranexamic acid enema

Posted on January 31, 2019

R. A. Jacobson1,2, A. Williamson2, S. Gaines2, K. Wienholts3, B. D. Shogan2, O. Zaborina2, J. C. Alverdy2  1Rush University Medical Center,Surgery,Chicago, IL, USA 2University Of Chicago,Surgery,Chicago, IL, USA 3Radboud University,Nijmegen, Netherlands

Introduction: The protease plasminogen (PLG) and its activator urokinase play a critical role in regulating collagen remodeling during gastrointestinal healing. We have previously shown that colonization of anastomotic tissue by collagenolytic Enterococcus faecalis can cause anastomotic leak (AL). We have recently discovered that E. faecalis can cause overactivation of PLG. The aims of this study were to: 1) determine the mechanism of PLG activation in bacterial-mediated AL pathogenesis, and 2) analyze the ability of tranexamic acid (TXA), a suppressor of PLG activation, to prevent AL caused by bacterial pathogens.

Methods: Activation of PLG and pro-urokinase (puPA) by collagenoltyic E. faecalis V583 and mutant strains lacking the collagenase genes gelE and sprE was measured using fluorogenic assays.  In an established model of colorectal AL caused by collagenolytic bacteria, mice received either TXA or vehicle control on postoperative days 1, 2 and 3 via enema. Anastomoses were evaluated on postoperative day 8 using anastomotic healing score (AHS – 0: perfectly healed; 1 – flimsy adhesions; 2 – dense adhesions; 3 – abscess; 4 gross disruption).  Fluorescence microscopy was used to demonstrate the temporospatial dynamics of PLG deposition and the impact of TXA on this process.

Results: Wild type E. faecalis activated puPA to a greater extent than mutants deficient in GelE, SprE, or both; activation was partially rescued when mutant strains were complemented with their deficient genes (Fig 1A). In the presence of puPA, the parent strain activated more PLG than mutants (Fig 1B). The presence of TXA inhibited the ability of E. faecalis to bind (flow cytometric data not shown) and activate PLG (497.8±20.1 RFU/s 0 TXA vs 272.1±7.3 10mM TXA, p<.05). When applied to our mouse model of E. faecalis-induced AL, TXA reduced the incidence of leak compared to vehicle (AHS 2.7±0.7 vehicle vs 1.4±0.5 TXA). Rescue of AL with TXA was redemonstrated in our model of P. aeruginosa-induced leak (AHS 1.6±0.5 vs 3.8±0.4, p<.05). Fluorescence microscopy demonstrated qualitatively less PLG at the anastomotic site when mice received TXA compared to vehicle control (Fig 1C).

Conclusion: To our knowledge this is the first mechanistic description of PLG activation by E. faecalis and its involvement in AL. Our data demonstrate microbial PLG activation is a novel, plausible and generalizable mechanism for pathogen-mediated AL. TXA limits the ability of pathogens to activate PLG and disrupt the anastomosis. TXA is inexpensive and FDA approved for use in elective surgery; its local delivery to the anastomotic site may be a promising approach to prevent AL in high risk anastomoses.

16.01 Are you ready? Assessing Readiness to Implement Enhanced Recovery After Surgery

Posted on January 31, 2019

L. J. Kreutzer1, M. F. McGee1,2,3, S. Oberoi3, K. Y. Bilimoria1,2,3, J. K. Johnson1,2  1Northwestern University,Surgical Outcomes And Quality Improvement Center,Chicago, IL, USA 2Feinberg School Of Medicine – Northwestern University,Chicago, IL, USA 3Northwestern Memorial Hospital,Chicago, IL, USA

Introduction: Enhanced Recovery After Surgery (ERAS) is an evidence-based intervention to improve patient outcomes, yet hospitals often underestimate the complexity of implementation. To be most effective, the intervention needs to be context-specific and often requires adaptations so that it is appropriate to the setting and available resources. Organizational and unit-level readiness for change, including the extent to which organizational members are prepared to implement a new intervention, is often overlooked. Our objective was to develop and test a tool to assess hospital readiness to implement ERAS for patients undergoing colorectal procedures.

 

Methods: We developed a Readiness to Implement Core Components of Enhanced Recovery (RECOVER) Tool based on a literature review and our prior experience implementing ERAS. The RECOVER Tool is dual purpose, designed to (1) provide a practical planning tool for the implementation team and (2) collect baseline data of hospital willingness and perceived ability to change practice. The RECOVER Tool includes 4 sections. Section 1 captures information about the hospital’s implementation task force. Section 2 inventories the components of ERAS and identifies implementation willingness. Sections 3 and 4 use a 5-point Likert scale of agreement to assess areas where the task force perceives a need for guidance in implementation and where individual units may need assistance in implementation and in changing behavior. Five hospitals within one health system were asked to complete the RECOVER Tool. Sections 1 and 2 were emailed to representatives from each hospital for completion. Members of the task force from each hospital received sections 3 and 4 through REDCap.

 

Results: The response rate for sections 1 and 2 was 100%. Of the task force members who received a link to complete sections 3 and 4 through REDCap, 60.3% (44 out of 73) completed the survey. The hospital-specific survey response rates ranged from 46.2% to 66.7%.

All hospitals indicated willingness to implement ERAS. Four of the five hospitals struggled with: 1) setting specific goals for implementing ERAS; 2) assigning or clarifying task force roles; 3) gaining buy-in from leadership, 4) engaging IT; and 5) engaging analytics/statistical support.

At the department-level, perceptions of readiness were strong overall across departments; however, one hospital department identified a need to strengthen the ability to adapt quickly when making changes to the way the department works.

 

Conclusion: Assessing readiness to implement a complex intervention, such as ERAS, provides an opportunity to gain insight into perceived barriers to implementation. Furthermore, tools can be tailored to strengthen targeted areas to support hospitals’ implementation process by giving insight into key implementation outcomes: acceptability, feasibility, and appropriateness.

100.20 The Impact of Enhanced Recovery After Surgery (ERAS) on the Costs of Elective Colorectal Surgery

Posted on January 31, 2019

A. N. Khanijow1, L. E. Goss1, M. S. Morris1, J. A. Cannon1, G. D. Kennedy1, J. S. Richman1, D. I. Chu1  1University Of Alabama at Birmingham,Department Of Surgery, Division Of Gastrointestinal Surgery,Birmingham, Alabama, USA

Introduction:  ERAS pathways are standardized perioperative care programs that improve postoperative surgical outcomes, including reduced length of stay and readmissions. As more US hospitals adopt ERAS programs, evaluating its impact on healthcare costs is increasingly important in order to determine the value of implementing ERAS protocols. The purpose of this study was to assess the cost of an ERAS program for colorectal surgery through a retrospective analysis comparing surgeries done before ERAS and with ERAS.

Methods:  ERAS was implemented at a tertiary-care single-institution in January 2015. Variable cost data, the costs that vary with care decisions, were collected from the institution's financial department for the surgical inpatient stay for patients undergoing elective colorectal surgery from 2012-2014 (pre-ERAS) and 2015-2017 (ERAS). Costs were adjusted for inflation to 2017 US dollars using the Producer Price Index. Variable costs (overall and by categories) were compared using Wilcoxon tests between the two cohorts and with stratification by severity of illness (SOI) into minor, moderate, major, and extreme.

Results: Of 1,692 elective colorectal surgeries, pre-ERAS procedures (n=389) and ERAS procedures (n=1,303) had median total variable costs per surgery of $7,495.32 and $6,386.71, respectively; a difference of $1,108.61 (p<0.001). Additionally, comparing the average total variable costs between the two groups showed procedures with ERAS saved $128.51 (p<0.001). When comparing costs by categories, significantly (p<0.001) decreased median costs for ERAS surgeries were seen in the following: nursing ($670.29), surgery ($353.88), anesthesiology ($246.59), pharmacy ($75.31), and lab costs ($45.96). Mean variable costs by these categories followed a similar trend with significant cost savings per procedure in ERAS surgeries for the following: surgery ($487.49), anesthesiology ($238.59), nursing ($16.05), and lab costs ($7.19). Of note, mean variable pharmacy costs per surgery were significantly more expensive with the ERAS protocol ($342.17, p<0.001). Median variable costs stratified by SOI were consistent with the overall analysis, revealing significant savings in median total variable costs and in the same cost categories for the ERAS cohorts with mild and moderate SOIs, compared to the pre-ERAS cohort.

Conclusion: ERAS implementation at a large institution resulted in reduced median and mean variable costs associated with hospital stay, showing that ERAS implementation can have both clinical and financial benefits.

 

07.04 Malpractice Litigation and Colorectal Procedures

Posted on January 31, 2019

G. E. Savulionyte1,2, F. Saeed1, K. Oh1,2, H. M. Ross1  1Temple University,Department Of Surgery,Philadelpha, PA, USA 2State University Of New York At Buffalo,Department Of Surgery,Buffalo, NY, USA

Introduction:

Medical malpractice presents a challenge for the delivery and cost of healthcare provided by physicians. Little prior work has been done to investigate malpractice litigation in the context of colorectal procedures. The purpose of this study is to elucidate the outcomes and associated factors of malpractice involving colorectal procedures.

Methods:

Key phrases “colon and surgery” and “rectal and surgery” were searched in the national legal database Westlaw. Search was limited to all state and federal cases up to and including the year 2017. Inclusion criteria were cases with allegations involving a colorectal procedure. Cases involving workers compensation, prisoner negligence, social security, failure to diagnose colorectal pathology, colonoscopies, and pediatric procedures were excluded. Chi-square or fisher-exact tests were performed for sub-analysis.

Results:

A total of 4294 cases were reviewed, and 201 cases were included in the final analysis. Most commonly named physicians were general surgeons (63%, 127/201), followed by colorectal surgeons (17%, 34/201), other surgical specialists (7%, 13/201), primary care physicians (6%, 12/201), and EM physicians (2%, 2/201). Pre-operative allegations were cited in 31% (62/201) of cases, intra-operative allegations in 45% (91/201) of cases, and post-operative allegations in 36% (73/201) of cases. Of known verdicts, 81% (110/135) were in favor of the defendants, followed by 16% (21/135) plaintiff verdicts and 3% (4/135) mixed verdicts. Most procedures performed involved the colon (66%, 129/195). Out of total cases with known complications, most included anastomotic leak (17%, 25/146) and infection/sepsis (16%, 24/146). Death of the patient occurred in 29% (58/201) of cases. No significant differences were found between defendant and plaintiff verdicts for case type, patient sex, and death of patient.

Conclusions:

This study is the most comprehensive review of medico-legal outcomes and associated factors involving colorectal procedures in the United States. Most cases involved general surgeons, with intraoperative complications as the leading cause of suit. Verdicts mostly favored the defendants. Common complications were anastomotic leaks and infection/sepsis. Sub-analysis suggests that patient death does not influence the verdict of a case. Understanding this data has implications for improving clinical practice involving colorectal procedures, which can lead to better healthcare and a reduction in cost associated with malpractice suits.

06.20 Outcomes After Operative Management Of Anastomotic Leaks

Posted on January 31, 2019

S. Trinidad1, S. Haile2, S. Kelly2, H. Prince1, C. Divino1  1Mount Sinai Hospital,Surgery,New York, NY, USA 2Icahn School of Medicine at Mount Sinai,New York, NY, USA

Introduction:   Anastomotic leaks (AL) remain a highly morbid complication of colorectal surgery. This study sought to evaluate and compare outcomes between the two main operative approaches to AL: proximal diversion with loop ileostomy or anastomotic takedown with an end ostomy.

Methods:  A retrospective observational study was conducted on 79 patients presenting to the Mount Sinai Hospital between January 2009 and July 2016 who had an AL following ileocolic or colorectal surgery who were managed with either proximal diversion (n=50) or resection and end ostomy (n=29). Patient charts were data-mined for preoperative, operative and post-operative factors. Patients were followed for at least 6 months with a median of 2.5 years. Factors were compared with chi-square and t-test analyses.

Results:  The diverted group had a higher percentage of patients with a history of cancer (58% vs 31%, p=0.021) and though not statistically significant a seemingly higher percentage of pelvic anastomosis (84% vs 55%, p=0.086) and a higher rate of laparoscopic approach (70% vs 38%, p=0.055) while the end ostomy group seemed to have a higher percentage of patients with a history of IBD (55% vs 34%, p=0.066). Regarding outcomes, the mortality rate was seemingly higher in the end ostomy group (8% vs 2%, p=0.235) but this was not statistically significant and limited by small sample size (n =2 and 1 respectively). The diverted group had a shorter median LOS (14 vs 22 days, p<0.000). Though not statistically significant, the diverted group had a higher reversal rate (80% vs 65%, p=0.15) but also had a higher rate of stricture formation (12% vs 0%, p=0.052),) and higher rate of dehydration (8% vs 4%, p=0.12). The rates of SSI, recurrent abscess and reoperation were similar between the groups.

Conclusion:  Several preoperative factors were associated with which operation was ultimately chosen, particularly the location of the anastomosis and a history of cancer and IBD. There also seemed to be a difference in the approach to each operation, with a higher rate of laparoscopy in the proximal diversion group. Lastly, there were several notable differences in outcomes. Patients undergoing diversion had a shorter LOS and though only approaching statistical significance, also seemed to have a greater likelihood of reversal but higher rates of stricture formation and dehydration. These results are limited by the small sample size but nevertheless demonstrate key differences in outcomes between the two groups that can help guide operative management of AL.

 

 

06.19 Surgical Resection for Primary Rectal Lymphoma, Support for Local Excision?

Posted on January 31, 2019

L. H. Maguire1, T. M. Geiger2, R. Muldoon2, M. B. Hopkins2, M. M. Ford2, A. T. Hawkins2  1University Of Michigan,Colorectal Surgery,Ann Arbor, MI, USA 2Vanderbilt University Medical Center,Colorectal Surgery,Nashville, TN, USA

Introduction: Primary rectal lymphoma is an uncommon and heterogeneous malignancy. Due to its rarity, few data exist to guide treatment or counsel patients. Surgery can be considered a primary treatment or an element of multidisciplinary therapy, but there exists little evidence beyond the case report level on the short and long term outcomes of surgical treatment of rectal lymphoma. Here we present the largest series to date of patients undergoing non-palliative surgery for rectal lymphoma. We hypothesize that there will be no difference in overall survival between patients undergoing local or radical resection.

Methods: The National Cancer Data Base (NCDB) was queried for all cases of primary rectal lymphoma between years 2004 and 2014 who underwent resection.  Exclusion criteria included patients with Stage IV disease and those operated on for palliation. Patients were categorized by resection approach-local (LR) or radical (RR).  Approach, along with demographic, histologic, hospital level and treatment factors were analyzed for effect on survival with Cox Proportional Hazard analysis.

Results:After applying exclusion criteria, 233 patients were identified. Mean age was 63 (IQR 53-73) and 57% of the population was female. The most three most common histologic subtypes were Marginal (44%), Diffuse Large B-Cell (DLBCL) (20%) and Follicular Lymphoma (17%). 87% underwent local resection including endoscopic and transanal procedures. Age, sex, race, Charlson comorbidity score, or facility type were not significantly different between patients undergoing local versus radical resection, but local resection patients were significantly more likely to be Stage I (81% versus 55%, p =0.001). There was no significant difference in R0 resection (LR:38% vs RR: 58%; p=0.07), adjuvant chemotherapy (LR:18% vs RR: 29%; p=0.22), or adjuvant radiation (LR:21% vs RR: 16%; p=0.63)  between the groups. 5-year overall survival was 79%, and there was no significant difference in approach (LR:81% versus RR: 56%, p =0.06) (Figure 1). However, DLBCL type was associated with poorer survival (Marginal: 87% , DLBCL: 55%, Follicular: 85%; p<0.001). Multivariable analysis did not identify an association between surgical approach and overall survival.

Conclusion:Surgical resection of rectal lymphoma is rare. Without evidence-based guidelines, treatment is individualized to patient and tumor characteristics. We present the largest series of surgical rectal lymphoma patients, but given the rarity of the disease our study is limited by retrospective approach and small patient numbers. Our data support consideration of local resection when possible, given the lack of convincing survival benefit of radical surgery or R0 resection.

 

06.18 Psychiatric Disorders in Colorectal Cancer Patients & Short-Term Clinical Outcomes

Posted on January 31, 2019

E. Vo1, S. S. Awad1,2, H. S. Tran Cao1,2, N. N. Massarweh1,2, D. S. Lee1,2, C. Y. Chai1,2  1Baylor College Of Medicine,Michael E DeBakey Department Of Surgery,Houston, TX, USA 2Michael E. DeBakey Veterans Affairs Medical Center,Operative Care Line,Houston, TX, USA

Introduction:   Studies have shown that anxiety and depression negatively affect wound healing, surgical site infection (SSI), length of hospital stay (LOS) and adherence to medical treatment.  Psychiatric disorders are also associated with worse outcomes in cancer patients due to delays in diagnosis, disparities in access to care, differential treatment and poor compliance.  To determine the impact of psychiatric disorders on short-term clinical outcomes in colorectal cancer patients, we reviewed our institutional data.

Methods:   A retrospective review of colorectal surgery database at a single institution was performed between Oct 2013 to Sep 2016.  Patients who underwent a surgical treatment for left colon or rectal cancer were selected. Demographics, presence of psychiatric disorders not including substance abuse or dementia, SSI, anastomotic leak, LOS, cancer stage at diagnosis, 30-day readmission and delay in adjuvant therapy (>60 days) were reviewed.  Variables between patients with psychiatric disorders and those without were compared using univariate analysis with significance set at p <0.05.

Results:  A total of 100 patients met our criteria.  41 patients had a documented psychiatric disorder at the time of preoperative visit.  The most common diagnoses were depression, anxiety and post-traumatic disorder.  No significant differences were noted between two groups regarding age, race, BMI, preoperative serum albumin, cancer stage at diagnosis, surgical approach (open vs minimally invasive), SSI, LOS, readmission, and delay in adjuvant therapy.  However, patients with psychiatric disorders had a higher ASA score (p=0.04) and a greater rate of anastomotic leak rate (15% vs 0%, p=0.004)

Conclusion:  A significant number of patients were already suffering from psychiatric disorders when presenting with a colorectal cancer diagnosis in this veteran patient population.  Even though the short-term clinical outcomes appeared similar between two groups, the anastomotic leak rate was higher in patients with psychiatric conditions.  Multimodal prehabilitation including a psychological component may improve clinical outcomes and identify high-risk patients.  In addition, further investigation should be made examining long-term oncological outcomes in these patients.

06.17 Analysis of Outcomes in Open, Laparoscopic and Robotic Low Anterior Resection for Colorectal Cancer

Posted on January 31, 2019

M. I. Orloff1, J. Lu1, S. Kolakowski1, D. Vyas1, A. Dayama1  1San Joaquin General Hospital,Surgery,French Camp, CA, USA

Introduction:  Surgical resection with curative intent is the cornerstone of treatment of colorectal cancer. In this study, we sought to compare oncologic and 30-day perioperative outcomes following open, laparoscopic and robotic low anterior resection (LAR) without diverting ostomy for colorectral cancer.

 

Methods:  We reviewed the ACS-NSQIP targeted colectomy database from 2014-2016 to identify patients who underwent LAR. We excluded non-cancerous pathology, LAR with diverting ostomy, hybrid operative approaches, and patients with missing data on anastomotic leak and lymph nodes harvested. Primary outcomes were margin status, number of lymph nodes harvested, anastomotic leak and 30-day mortality. Multivariate analysis was used to determine the association between operation approach, anastomotic leak, and mortality.

 

Results:A total of 5,367 patients met our inclusion criteria – 2119 underwent open LAR, 2432 underwent laparoscopic LAR and 816 underwent robotic LAR. There was no difference in the average number of nodes harvested (19.1 open, 19.7 laparoscopic, 20.0 robotic, P 0.06) (Table 1A). There were no cases of positive margins in any of the patients. Operative time was greater in robotic LAR compared to laparoscopic and open surgeries (open 215 minutes (mins), laparoscopic, 219 mins, robotic 266 mins, P < 0.01). Length of stay was greater in open LAR (open 7.9 days (d), laparoscopic 5.1 d, robotic 5.0 d, P < 0.01). There was no difference in rates of anastomotic leak (open 4.7%, laparoscopic 3.7%, robotic 5.4%, P 0.06) (Table 1B). Laparoscopic and robotic LAR was associated with significantly lower mortality, compared to open (open 1.4%, laparoscopic 0.5%, robotic 0.1%, p < 0.01). On multivariate analysis, there was no association between operative technique and anastomotic leak (Table 1c). Multivariate analysis showed that laparoscopic LAR was associated with a statistically lower mortality compared to open LAR (OR 0.42, CI 0.20 – 0.87). 

Conclusion: Review of a contemporary national database reveals equivalent oncologic outcomes among patients who undergo open, laparoscopic and robotic LAR for colorectal cancer. However, laparoscopic and robotic LAR are associated with less postoperative morbidity, shorter length of stay and lower mortality.

 

06.16 Patient Perspectives on Post-Discharge Pain Management After Colorectal Surgery

Posted on January 31, 2019

C. Johnson Jr.1, I. Marques1, A. Liwo1, L. Wood1, L. Goss1, J. Richman1, E. Malone1, J. Cannon1, M. Morris1, G. Kennedy1, D. Chu1  1University Of Alabama at Birmingham,Division Of Gastrointestinal Surgery,Birmingham, Alabama, USA

Introduction: Opioids are commonly used in post-discharge pain management. Patient perspectives and behaviors in the post-discharge setting are poorly understood however, and may be important to consider in efforts to reduce over-prescription of opioids. We aimed to characterize patient perspectives and behaviors with post-discharge pain management after major colorectal surgery.

Methods: Patients undergoing colorectal surgery were recruited at their 2-week follow-up appointment from October 2017 to April 2018 at a single institution. Participants were surveyed with a six-item questionnaire focused on the use, perspectives and perceived adequacy of post-discharge pain management. Patient demographics, hospital length of stay (LOS) and 30-day readmissions were recorded. Patients were stratified into two groups: perceived adequate vs. non-adequate pain control. A comparison of age, race, baseline pain medication, a request of additional pain medicine at post-operative follow-up, type of discharge pain medication, hospital LOS and 30-day readmission was performed between the two groups.  Statistical analysis was done using Fishers’s exact tests and t-tests. 

Results: 
58 patients completed the surveys. The majority of patients in this study were white (71%), and were not on baseline pain medication (56%); half were female (50%) and a plurality had private insurance (47%). The most commonly prescribed medication was a high potency pain medication (Oxycodone, Percocet or Norco; 77%) with the remainder receiving tramadol alone (17%), or a combination of an opioid medication and tramadol (6.4%). Inadequate pain control was reported in 14% of patients. There was no difference in race, baseline pain medication, request of additional pain prescriptions at the follow-up appointment, LOS, or 30-day readmission between patients that had their pain controlled vs patients that did not. Individuals who thought their pain was not managed properly were more likely to have been discharged with a high potency prescription (100% vs 66% p = 0.003) and more likely to be younger (mean 45.9 vs 60.7, p=0.01). 

Conclusion: 
The majority of patients reported adequate postoperative pain control.  Patients who reported inadequate pain control were younger and more likely to receive higher potency prescription at discharge. No association was found between race, length of stay or readmission rates and patient’s perspective on post-operative pain control. Additional research is needed to understand the reasoning that underscores high potency discharge pain medication prescriptions in some patients and how age impacts a patient’s perspective on pain management.
 

06.15 Sarcopenia Increases Postoperative Complications in Colorectal Cancer Patients Undergoing Surgery

Posted on January 31, 2019

C. S. Lau1, N. Ghalyaie1,2, R. S. Chamberlain1,2  1Abrazo Central Hospital, Abrazo Community Health Network,Phoenix, AZ, USA 2Cancer Surgical Services Division, Valley Surgical Clinics,Phoenix, AZ, USA

Introduction:  Colorectal cancer is the third leading cause of cancer-related deaths in the United States, accounting for over 50,000 deaths a year. Colorectal resection is the standard treatment for most colorectal cancer patients, and carries well-known risks including anastomotic leak, abscess, wound infection, etc.  Sarcopenia is the progressive loss of skeletal muscle mass and strength, and is common in colorectal cancer patients. This meta-analysis assesses the impact of sarcopenia on colorectal cancer patient surgical outcomes.

Methods:  A comprehensive literature search of all published studies evaluating the impact of sarcopenia in colorectal cancer patients undergoing surgery was conducted using PubMed, Cochrane Central Registries of Controlled Studies, and Google Scholar. Keywords searched included combinations of ‘sarcopenia’, ‘colorectal cancer’, ‘surgery’, and ‘outcomes’. Outcomes analyzed included total complications, major complications (Clavien-Dindo grade ≥3), anastomotic leaks, in-hospital/30-day mortality, 30-day readmission rates, and length of stay.

Results: Twelve studies including 2,787 patients (1,306 sarcopenic and 1,481 non-sarcopenic) were analyzed. Sarcopenia was associated with significantly higher rates of total complications (OR 1.856; 95% CI, 1.426-2.415, p<0.001), but not major complications graded Clavien-Dindo ≥3 (OR 1.635; 95% CI, 0.891-3.001; p=0.112) or anastomotic leaks (OR 0.806; 95% CI, 0.529-1.229; p=0.317). Sarcopenia was also associated with significantly higher rates of mortality (OR 3.439; 95% CI, 1.718-6.884; p<0.001) and longer lengths of stay (MD 1.491 days; 95% CI, 0.715-2.268; p<0.001). No significant increase in 30-day readmission rates was observed (OR 1.740; 95% CI, 0.830-3.646; p=0.142). 

Conclusion: Sarcopenia among colorectal cancer patients undergoing surgery is associated with a significant increase in total complications, mortality, and length of stay. Sarcopenia is a poor prognostic factor in colorectal cancer patients undergoing surgery, and preoperative muscle mass assessments may have significant value in predicting and improving patient outcomes. 

 

06.14 Predictors of Enhanced Recovery After Surgery (ERAS) Failure

Posted on January 31, 2019

L. Theiss1, F. Gleason1, S. Baker1, A. Ali2, T. Wahl1, L. Wood1, L. Goss1, M. S. Morris1, J. A. Cannon1, G. D. Kennedy1, D. I. Chu1  1University Of Alabama at Birmingham,Department Of Surgery,Birmingham, Alabama, USA 2University Of Alabama at Birmingham,School Of Medicine,Birmingham, Alabama, USA

Introduction:  The implementation of enhanced recovery after surgery (ERAS) pathways has lead to multifactorial improvements in patient care, including reduction of hospital length-of-stay. Despite many successes, some patients do not benefit from this approach. We sought to identify risk factors associated with ERAS failure. We hypothesized that preoperative health status and surgical acuity would predispose patients to ERAS failure.

Methods: Patients undergoing elective colorectal surgery under ERAS from 2015 to 2017 were stratified into ERAS failure or non-failure. ERAS failure was defined as an observed postoperative length of stay (pLOS) that was at least 1-day greater than the expected pLOS calculated by the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) Surgical Risk Calculator. Chi-square and Wilcoxon Rank Sums were used to compare group characteristics. An adjusted analysis was performed via a generalized regression model.

Results: Of 683 ERAS patients, 508 patients (74%) succeeded with ERAS and 175 patients (24%) failed ERAS. Demographics such as age, gender, and race did not significantly vary between groups. On unadjusted comparison, patients who failed ERAS were more likely to be admitted urgently (p<0.01), have a dependent functional status (p=0.02), and have lost >10% of their body weight in the 6 months prior to surgery (p<0.01). Patients who failed ERAS were also more likely to have a diagnosis of IBD (p<0.01), undergo surgery for a benign indication (p<0.01), and undergo operations involving the small bowel and stoma creation (p<0.01). Complications of significance during hospitalization associated with ERAS failure included clostridium difficile infection, myocardial infarction, respiratory failure requiring intubation and mechanical ventilation, organ space surgical site infection, pneumonia, intraoperative anemia requiring transfusion, and urinary tract infection (p value for all ≤0.04). On adjustment for covariate differences, independent factors associated with ERAS failure included elective vs. urgent admission type (OR 0.07, CI 0.01-0.3, p<0.01) and significant postoperative complication occurrences (OR 2.53, CI 1.33-4.82, p<0.01).

Conclusion: In an analysis of 683 ERAS patients, preoperative risk factors affected patient outcomes, but largely postoperative complications drove ERAS failure. Independent risk factors for ERAS failure were urgent admission type and significant postoperative complications. Opportunities may exist for further targeted interventions within these higher-risk groups to improve patient outcomes.

06.13 Survival after Chemotherapy is not Worse for Mucinous vs Non-mucinous Resected Stage 3 Colon Cancer

Posted on January 31, 2019

B. Powers1,2, S. Felder1,2, I. Imanirad1,2, S. Dineen1,2  1Moffitt Cancer Center And Research Institute,GI Oncology,Tampa, FL, USA 2University Of South Florida College Of Medicine,Department Of Oncologic Sciences,Tampa, FL, USA

Introduction: Adjuvant chemotherapy (ACT) improves survival in curatively resected Stage 3 colon adenocarcinoma patients and is routinely recommended.  However, the relative efficacy of ACT for histologic subtypes remains unclear, with some considering ACT less effective in those with mucinous histology.

Methods: Utilizing the National Cancer Database (NCDB), we identified patients with stage 3 colon adenocarcinoma undergoing curative resection (2004-2015). Patients with appendiceal, rectosigmoid, and rectal adenocarcinoma were excluded. The primary outcome was overall survival (OS). Multivariate Cox regression was performed to evaluate the impact of chemotherapy on OS while adjusting for demographic, anatomic and pathologic factors.

Results: A total of 109,688 stage 3 colon adenocarcinoma patients undergoing colectomy were identified, of whom 99,021 had follow-up for survival analysis.  Patients with non-mucinous, mucinous, and signet ring cell (SRC) comprised 96,096 (86.7%), 12,297 (11.2%) and 2,295 (2.1%) of the study population, respectively.  Receipt of ACT for stage 3 patients was similar between groups (70.8%, 69.5%, 68.3%, respectively). ACT significantly improved OS in all histologic subtypes. In univariate analysis, the Hazard Ratio (HR) for OS for non-mucinous tumors was 0.87, 95% (CI) [0.44-0.89], p<0.001, and for SRC, HR 1.71, CI [1.62-1.82], p<0.001.  In multivariate analysis, there was no difference in OS between non-mucinous and mucinous stage 3 patients receiving ACT (p=0.87, CI [0.97-1.02]. The HR for SRC was 1.30, p<0.001, CI [1.22-1.38].

When stratified by histology, stage 3 patients with mucinous tumors who received ACT had decreased hazard of death compared to those who did not receive ACT, HR 0.41, CI [0.39-0.44]. Sidedness was not associated with survival in this cohort. Stage 3 patients with non-mucinous tumors receiving ACT also had decreased hazard of death compared to those patients who did not receive ACT, HR 0.35, CI [0.34-0.36]. In this cohort, patients with a left-sided tumor had a statistically significant decreased hazard of death compared to patients with right-sided tumors, HR 0.89, CI 0.87-0.91. On multivariate analysis, increased T and N stage, higher grade, Black race, increased age, and positive margin status were associated with a higher hazard of death for both histologies.

Conclusion: Non-mucinous and mucinous resected Stage 3 colon cancers treated with ACT demonstrated similar OS. Histologic subtype is an important factor in determining prognosis as SRC histology has significantly reduced survival compared to mucinous and non-mucinous subtypes. When stratified by histologic type, chemotherapy conferred a 65% and 59% improved survival for non-mucinous and mucinous tumors. The findings suggest that Stage 3 mucinous colon cancer realize a similar therapeutic benefit from ACT as those patients with non-mucinous colon cancer.

06.12 Gracilis flap reconstruction following abdominoperineal resection and proctocolectomy

Posted on January 31, 2019

O. M. DeLozier1, Z. E. Stiles1, J. M. Monroe1, P. V. Dickson1, J. L. Deneve1, A. Mathew1, D. Shibata1, R. M. Chandler1, S. W. Behrman1  1Univeristy Of Tennessee Health Science Center,Surgery,Memphis, TN, USA

Introduction:
Vascularized pedicle flap reconstruction of the perineal defect following abdominoperineal resection (APR) or proctocolectomy (PC) can reduce pelvic wound complications.  We assessed outcomes utilizing pedicle-based gracilis flap reconstruction (GFR) in the setting of immunosuppressant therapy, fistulous disease, and neoadjuvant chemoradiation.

Methods:
Patients undergoing APR or PC with GFR were retrospectively reviewed.  Analysis included diagnoses, comorbidities, preoperative chemoradiation and immunosuppression, along with donor and recipient site complications.

Results:
Forty-one patients underwent GFR for rectal cancer (n=31) inflammatory bowel disease (n=7), or severe fistulizing disease (n=3) .  Mean age was 60, BMI was 26.8, and serum albumin was 3.3.  Nineteen (46%) patients used tobacco.  Ten patients (24%) were immunosuppressed, and 27 (66%) underwent preoperative chemoradiation.  Nineteen (46%) flaps were unilateral, and 22 (54%) were bilateral.  Twenty (49%) patients had minor wound complications, treated with dressing changes or antibiotics (2 donor, 18 perineal).  Eight (20%) patients had major complications (2 donor, 6 perineal), with 3 (7%) patients requiring reoperation for flap necrosis or abscess.  The three threatened flaps were unilateral, and salvaged with debridement and drainage, one requiring reinforcement with a gracilis flap from the contralateral thigh. Thigh donor site morbidity was minimal, occurring in 4 (10%) patients, all managed non-operatively.  Patients with major complications were older (57 vs 68 years old, p=0.07), but, otherwise, similar regarding BMI, serum albumin, tobacco use, operative time, and blood loss in this series of 41 patients.

Conclusion:
In high-risk perineal wounds, gracilis flap offers durable reconstruction with acceptably low morbidity.  Donor site complications were rare, and all managed non-operatively.  A minimal number of flaps were threatened, and all were salvaged with operative intervention.  The three threatened flaps were unilateral, perhaps suggesting superiority of bilateral flaps.
 

06.11 Standardization Leads to Decreased Opioid Prescriptions at Discharge for Colorectal Surgery Patients

Posted on January 31, 2019

D. Livingston-Rosanoff1, B. Rademacher1, E. Lawson1  1University Of Wisconsin,Colorectal Surgery,Madison, WI, USA

Introduction:  Overprescribing of opioids by surgeons contributes to the opioid epidemic by putting patients at risk of new opioid dependence and creating a supply of opioids that may be diverted into the community with the potential for misuse. The objective of our study was to determine if implementation of standardized recommendations for opioid prescribing would result in a decreased quantity of pills prescribed at discharge for patients undergoing colectomy or diverting loop ileostomy reversal. In addition, we sought to determine if our set recommendations were sufficient or excessive, as measured by number of pills consumed by patients and need for refills.

Methods:  In September 2017, standardized recommendations for the quantity of 5mg oxycodone pills prescribed at discharge were implemented for patients undergoing colectomy (40 pills) and diverting loop ileostomy reversal (20 pills) on a colorectal surgery service in an academic center. Prescribing habits before and after implementation were compared by recording the quantity of pills prescribed to patients and frequency of refills between April-May 2017 (before implementation) and between April-May 2018 (after implementation). Use of post-discharge opioids in 2018 was quantified through a survey administered at the postoperative follow-up clinic visit.

Results: 43 patients in 2017 and 45 patients in 2018 underwent colectomy, while 25 patients in 2017 and 21 patients in 2018 underwent ileostomy reversal. From 2017 to 2018, the median number of pills prescribed at discharge decreased from 30 (range 10-80) to 20 (range 5-90) for colectomy and from 30 (range 10-75) to 25 (range 10-60) for ileostomy reversal. There was no change in the number of colectomy patients seeking refills (2% vs 0%, p=0.114), but there was an increase in refills among patients undergoing ileostomy reversal (4% vs 29%, p=0.014). The clinic survey was completed by 20 colectomy and 10 ileostomy reversal patients in 2018. Almost half of patients did not fill their opioid prescription at discharge (45% colectomy, 40% ileostomy reversal). Of patients who did fill their prescription, many used fewer than 5 pills (45% colectomy, 33% ileostomy reversal).

Conclusion: Implementation of standardized recommendations for opioid prescriptions at discharge was associated with a decrease in the median number of pills prescribed for patients undergoing colectomy or ileostomy reversal. There is variation in the use of opioids after discharge, especially for patients undergoing ileostomy reversal, with some patients requesting refills while other patients take few or no opioids at all. Better predictive strategies and reinforcement of standardized recommendations are needed to further decrease overprescribing of opioids at discharge.

 

06.10 Delay of Surgical Intervention in Ischemic Colitis Leads to Higher Rate of Morbidity and Mortality

Posted on January 31, 2019

M. Baldawi1, M. Baldawi1, M. Al-Jubouri1, M. Osman1, J. Ortiz1, F. C. Brunicardi1, M. Nazzal1  1University Of Toledo Medical Center,Department Of Surgery,Toledo, OH, USA

Introduction: Ischemic colitis is an injury to the colon as a result of reduced blood flow. It ranges from mild inflammation that mandates medical treatment to full thickness necrosis requiring surgical intervention. The aim of our study is to determine the impact of delay of surgical intervention on postoperative morbidity and mortality among surgically managed patients with ischemic colitis.

Methods:  A retrospective cohort study of ischemic colitis patients who underwent colorectal resection was performed. Patients were selected by ICD9/ICD10 codes of ischemic colitis and CPT codes of colorectal resection from the American College of Surgeons National Surgical Quality and Improvement Program (ACS NSQIP) database for the time period between 2011 to 2016. Patients were then classified according to the time interval between admission and surgical intervention (No delay, 1-day delay and ≥2 days delay), and these groups were compared for the rate of 30-day postoperative complications. Univariate analysis was performed using Chi-square and ANOVA tests while a binary logistic regression and Analysis of Covariance (ANCOVA) tests were utilized in the multivariate analysis.

Results: Of 3,726 patients, 1,681 (45.1%) underwent surgery at the day of admission, 839 (22.5%) underwent surgery 1 day after admission and 1,206 (32.4%) underwent surgery ≥2 days after admission. In comparison to No delay group, 1-day and ≥2 days delay groups had higher rates of 30-day mortality (26.7% and 26.2% vs 19.1%, p<0.001), pneumonia (13.7% and 14.9% vs 10.7%, p<0.001), unplanned intubation (12% and 10% vs 8.6%, p=0.021), mechanical ventilation >48 hours (34% and 34.9% vs 26.6%, p<0.001), acute kidney injury (8.5% and 5.8% vs 3.7%, p<0.001), UTI (4.4% and 5% vs 2.9%. P=0.01), blood transfusion (38.9% and 45.8% vs 30.5%, p<0.001) and DVT (3.7% and 3.8% vs 2%, p=0.008). Multivariate analysis confirms delay of surgery as an independent predictor of 30-day mortality, pneumonia, mechanical ventilation >48 hours, acute kidney injury, UTI, blood transfusion and DVT (p<0.05). ANCOVA with multiple pairwise comparison test revealed an increase in average postoperative stay with increase in delay of surgery (11.4 days in No delay, 12.7 days in 1-day delay and 14.7 days in ≥2 days delay, p<0.05).

Conclusion: Delay of colorectal resection in patients with ischemic colitis leads to higher complications including pneumonia, prolonged mechanical ventilation, acute kidney injury, UTI, blood transfusion, DVT, postoperative length of stay and death. 
 

« Previous Page
Next Page »