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. 
 

06.09 A National Study of Early Readmissions Following Colostomy Creation

Posted on January 31, 2019

H. Xing1, Y. Sanaiha1, Y. Seo1, H. Khoury1, S. E. Rudasill1, A. L. Mardock1, R. Morchi2, P. Benharash1  1David Geffen School Of Medicine, University Of California At Los Angeles,Cardiothoracic Surgery,Los Angeles, CA, USA 2University Of California – Irvine,General Surgery,Orange, CA, USA

Introduction:
Ostomy creation is a common colorectal procedure that is associated with significant postoperative complications. However, unplanned rehospitalization, a surrogate for quality of care, following colostomy creation remains generally unexplored. The present study aimed to characterize the short-term readmissions following colostomy creation and identify the associated outcomes and resource utilization with a national cohort.

Methods:
The Nationwide Readmissions Database (NRD), an all-payer hospitalization database, was used to identify patients who received a colostomy from 2010 to 2015. Patients were stratified by discharge-to-readmission interval: Immediate (within 7 days) and Delayed (8-30 days). Logistic regression analysis was used to account for patient, hospital, and operative characteristics and to identify predictors of readmission.

Results:
Of an estimated 284,600 patients who received colostomy during the study period, 14.1% were readmitted within 30 days: 5.8% Immediate and 8.3% Delayed. At index hospitalization, Immediate patients were younger (63.3 vs 64.2 y, p<0.001) and had a lower Elixhauser comorbidity index (3.86 vs 3.96, p=0.01). Compared to the Delayed group, the Immediate cohort had a higher incidence of diverticular disease (34.5 vs 31.7%, p<0.001), lower rates of secondary gastrointestinal malignancy (8.3 vs 9.5%, p=0.032), and similar incidence of colon cancer, inflammatory bowel disease (IBD), and intestinal obstruction at initial hospitalization. The Immediate group was more likely to be readmitted for gastrointestinal complications (32.3 vs 28.6%, p<0.001), including a higher incidence of intestinal obstruction (11.7 vs 9.1%, p<0.001), stoma repair (2.3 vs 1.5%, p<0.001), and lysis of peritoneal adhesions (2.6 vs 2.1%, p=0.046). However, the Immediate group had a lower incidence of dehydration (12.2 vs 14.0%, p=0.002), acute kidney injury (16.0 vs 18.9%, p<0.001), and stoma closure (0.7 vs 1.0%, p=0.04) during readmission. The Immediate group experienced a higher readmission mortality rate (6.5 vs 5.5%, p=0.02), length of rehospitalization (8.5 vs 7.7 d, p<0.001), and cost ($16,508 vs 15,321, p=0.001). After adjusting for patient and hospital factors, IBD (OR 1.24, 95% CI 1.06-1.44) was associated with increased odds of Immediate readmission.

Conclusion:
In this national study, 14% of patients who underwent colostomy creation were readmitted within 30 days of discharge. Early readmissions were more likely to be related to gastrointestinal adverse events, including intestinal obstruction and stoma complications requiring repair. Patients admitted within 7 days of discharge experienced a higher unadjusted readmission mortality, length, and costs compared to those readmitted within 8-30 days. Diagnosis of IBD was associated with higher odds of readmission. Targeted readmission reduction programs for patients rehospitalized soon after discharge may improve clinical outcomes and the value of care.

06.08 The Relationship Between Patient Activation And Surgical Outcomes: A Pilot Study

Posted on January 31, 2019

T. C. Dumitra1, N. Mayo1,2, P. Kaneva1, J. Mata1, J. F. Fiore1, A. S. Liberman1,3, P. Charlebois1,3, B. Stein1,3, L. Lee1,3, G. M. Fried1, L. S. Feldman1  2McGill University,Department Of Epidemiology,Montreal, QC, Canada 3McGill University,Colorectal Surgery,Montreal, QC, Canada 1McGill University,General Surgery,Montreal, QC, Canada

Introduction:
Patient activation is defined as a patient’s knowledge, skills, beliefs and confidence to manage their own health care. In patients with chronic medical conditions, there is a strong association between high levels of activation and improved healthcare outcomes, higher patient satisfaction, lower resource utilization and lower costs. However, there is very little evidence on the role of patient activation in surgical patients. The goal of this study was to estimate the extent to which low preoperative activation predicts emergency department (ED) visits and postoperative outcomes after colorectal surgery.

Methods:
A secondary analysis of data obtained from a randomized trial completed in 2017 at the McGill University Health Center was performed. Adult patients who underwent scheduled colorectal surgery were included. Patient activation was measured using the Patient Activation Measure (PAM) at baseline and before hospital discharge, and classified as high or low. Primary outcome was 30-day ED visits. Secondary outcomes included enhanced recovery pathway adherence, complications and patient satisfaction. Characteristics were compared between patients with high and low activation using Chi-square, Fisher’s exact test, t-test or ANOVA when appropriate. Multiple logistic regression determined the independent effect of low baseline activation on ED visits, adjusted for age, gender, comorbidity index, diagnosis and complications.

Results:
A total of 97 patients were included in the study cohort, of which 14% (n=14) had a low baseline level of activation. Patient characteristics were similar between the two activation groups. Patients in the high activation group had higher adherence to postoperative care processes on postoperative day 1 (66% vs 47%, p=0.004), and felt more informed and more motivated (p<0.005) in their care. More patients with high activation had a length of stay < 3 days compared to low activation patients (37% vs 7%, p=0.021). There was no difference in the incidence of postoperative complications (47% in high vs 43% in low activation). A higher number of patients had low levels of activation at hospital discharge compared to preop (30% vs 14% p=0.009). There was no difference in the percentage of patients with at least one ED visits between the two groups (21% in high vs 20% in low group, p=0.548). On multiple regression, only 30-day postoperative complications predicted ED visits (OR 19.4, 95%CI 3.8-98.1).

Conclusion:
This pilot study suggests that levels of activation do not predict ED use after discharge in patients undergoing colorectal surgery. However, highly activated patients have a higher adherence to care pathways, tend to be discharged sooner after surgery, and feel more informed and more motivated in their care. Patient activation levels decreased in the immediate postoperative period. Further studies in a larger cohort of surgical patients is warranted.
 

06.07 Anal Cancer Treatment is Associated with Stable Overall Bowel Function and Quality of Life

Posted on January 31, 2019

D. J. Kent1, J. J. Blank1, K. Y. Hu1, T. J. Ridolfi1, K. A. Kudwig1, Y. Liu1, L. E. Rein1, C. Y. Peterson1  1Medical College Of Wisconsin,Division Of Colorectal Surgery,Milwaukee, WI, USA

Introduction:
Anal cancer is most often treated with the Nigro protocol, a combined chemoradiation (CRT) regimen. Pelvic radiation can lead to long-term sphincter damage, decreasing bowel function. Wide local excision (WLE) can be used for small tumors and leaves anal sphincter muscles intact. A Salvage Abdominoperineal Resection (APR) is used for persistent or recurrent tumors and results in a permanent colostomy. There is a relative absence of research exploring bowel function and quality of life after treatments for anal cancer. We posit that bowel function in CRT anal cancer patients will worsen after treatment but will then improve over time with recovery. We aim to explore the relationship between bowel function and quality of life after any anal cancer treatment over time.

Methods:
The EQ-5D-5L quality of life survey (QOL) and the Memorial Sloan-Kettering Cancer Center Bowel Function Index (BFI) are administered at each appointment with Colorectal Surgery at Medical College of Wisconsin. We conducted a retrospective review of patients treated at our institution for anal squamous cell carcinoma from 1/1/2008 to 1/30/2018. We collected BFI, QOL, demographics, treatment used, and timeline of care. Patients were stratified by treatment as WLE, CRT, or Salvage APR. Statistical analysis used Fisher’s exact test, Kruskal-Wallis test, Spaghetti plot, mixed linear effects modeling and regression analysis.

Results:
There were 59 patients seen within the first 5 years after treatment. The average age was 58 (SD = 11.6) and there ­were 37 (63%) women. Forty-two patients underwent CRT, 10 underwent WLE and 7 patients required Salvage APR. There were no differences in comorbidities. Over 5 years after treatment, CRT patients' BFI scores remained stable with slight upward trend in the first 3 years and then a return to baseline. WLE patients showed stable BFI scores. Salvage APR patients had decreasing BFI scores in the first 3 years after treatment (Figure 1A). Mixed effects modeling assuming linear effect showed no significant difference in BFI or QOL scores between groups (Figures 1B, 1C). Univariate linear regression did not identify any predictors of poor bowel function.

Conclusion:
Bowel function after anal cancer treatment remains stable over time and does not significantly vary between treatment modalities. Quality of life is preserved with all treatment options. The study is limited by few patients with pre-treatment BFI and QOL scores and high variability in scores between patients which could have skewed long-term results. Understanding how treatment impacts bowel function compared to pre-treatment function would be meaningful and we plan to further investigate patients with pre-treatment scores to investigate this.

06.06 Transanal Local Excision for T2 Rectal Cancer Persists Despite National Clinical Guidelines

Posted on January 31, 2019

O. K. Jawitz1, M. Adam2, M. Turner1, J. Migaly1  1Duke University Medical Center,Department Of Surgery,Durham, NC, USA 2University Of Pittsburgh,Department Of Surgery,Pittsburgh, PA, USA

Introduction:  Despite clinical guidelines classifying T2 rectal cancer as a contraindication for transanal local excision due to unacceptably high rates of local recurrence, it is a practice that persists clinically. It is unknown how this practice has changed in recent years.

Methods:  The 2004-2015 National Cancer Database (NCDB) was queried for patients with pathologic stage T2 rectal adenocarcinoma who underwent surgical intervention. Patients were stratified into transabdominal resection and transanal local excision cohorts on univariate and multivariate analyses. Postoperative survival was compared between groups using Kaplan-Meier and Cox Proportional Hazard models. The proportion of cases performed as local excision was evaluated by year. 

Results:  A total of 34,243 patients met inclusion criteria, including 30,507 patients (89.1%) who underwent resection and 3,736 patients (10.9%) who underwent transanal local excision. In unadjusted analysis, patients who underwent local excision were older (median age 69.7 vs. 63.2, p<0.001), more likely to have government insurance (64.0% vs. 49.6%, p<0.001), and were less likely to undergo radiation therapy (41.5% vs 59.7%, p<0.001) or chemotherapy (37.8% vs. 63.1%, p<0.001). Transabdominal resection patients had improved postoperative survival on Kaplan-Meier analysis (Figure, p<0.001). On multivariate Cox Proportional Hazard regression, local excision remained an independent predictor of patient mortality (HR 1.28, p<0.001). 

Conclusion:  Transanal local excision for T2 rectal cancer is associated with decreased survival and is not supported by national clinical guidelines. Despite this fact, it is a practice that has persisted at a relatively stable frequency over the past twelve years. Patients who undergo transanal local excision with the addition of chemoradiation may achieve survival rates similar to those who undergo transabdominal resection without the addition of chemoradiation.

06.05 Presentation, Treatment, and Prognosis of Colorectal Adenosquamous Cell Carcinoma

Posted on January 31, 2019

X. Gao1, P. Goffredo1, A. Kahl1, A. Beck1, M. Charlton1, I. Hassan1  1University Of Iowa,Iowa City, IA, USA

Introduction:  Colorectal adenosquamous cell carcinoma (ASC) is an extremely rare histologic entity, representing <0.1% of all colorectal cancers. There are few data regarding its natural history and prognosis, most of which come from small institutional series and case reports. The aim of this study was to evaluate the presentation, treatment, and prognosis of colorectal ASC and compare it to colorectal adenocarcinoma (AC) and squamous cell carcinoma (SCC) in a large national database.

Methods: Patients diagnosed with colorectal AC, SCC, and ASC between 1973 and 2015 were identified from the Surveillance, Epidemiology, and End Results data. Patient, disease, and treatment characteristics were analyzed with chi-squared tests. Joinpoint regression was used to analyze cancer incidences. Cause-specific and overall survivals were calculated with Kaplan Meier curves.

Results: There were a total of 663,161 cases of which 0.07% were ASC and 0.4% were SCC. Since 2000, the incidences of colorectal AC and ASC have decreased while the incidence of SCC has increased (p<0.05). Among ASC patients, the mean age was 68 years, with 47% being male, and 81% White. Patients with ASC were more likely to present with higher T stage, positive lymph nodes, and metastatic disease than patients with AC or SCC (all p<0.001). For localized and regional disease, colon ASC was more frequently treated with major surgery (with or without chemotherapy and radiation), similar to colon AC and SCC. Rectal ASC appeared to have more variation in management strategies including different combinations of local excision, radical resection, chemotherapy, and radiation. In the colon, localized and regional ASC had an unadjusted 5-year cause-specific survival that was between AC and SCC while in the rectum, ASC had the worst survival. Metastatic colorectal ASC had the lowest cause specific survival compared to metastatic AC and SCC (Table 1).

Conclusion: Colorectal ASC presents at a more advanced stage compared to AC and SCC. For localized and regional ASC, survival patterns are different in the colon versus the rectum compared to the other two histologies. These outcomes might reflect differences in management approaches. The majority of colonic ASC were consistently treated with surgical resection, while a greater variability in treatment regimens was observed for rectal ASC. Standardizing the treatment of localized and regional rectal ASC based on radical resection with or without chemoradiation could improve survival.

 

06.04 Negative Pressure Wound Therapy is Beneficial in the Treatment of Pilonidal Disease

Posted on January 31, 2019

E. Bianchi1, T. Adegboyega1, S. Shih1, C. Zhang1, D. E. Rivadeneira1  1Huntington Hospital/Northwell Health,Colon & Rectal Surgery,Huntington, NY, USA

Introduction:  

There are multiple surgical approaches to the treatment of Pilonidal Sinus Disease (PSD). All are associated with wound complications including surgical site infections (SSI), dehiscence, and recurrence. Negative Pressure Wound Therapy (NPWT) has been reported to decrease wound complications after surgery.  We report our experience with NPWT after excision with primary closure of PSD

Methods:
We report 65 consecutive patients that underwent excision of pilonidal sinus disease with primary closure and placement of Negative Pressure Wound Therapy dressing. NPWT was places over the closed incision for 3-7 days at -120mm hg. We compare these results with 65 patients consecutive patients prior to using NPWT who underwent excision PSD with primary closure. Both groups studied where well matched and there was no difference in Age, sex, OR time, Blood loss, incisions size. Early period complications (wound site infection, wound dehiscence, abscess, hematoma and seroma formation) developing within 30 days of operation was recorded from the medical files. Data were analyzed using SPSS ver. 12.0 (SPSS Inc., Chicago, IL, USA). Comparison of groups was done with ANOVA

Results:

Mean age of patients was 25.4 ± 5.7 years and the male: female ratio was 4:1. Operation time did not differ between groups. Significant decrease in early wound complications occurred in those patients treated with NPWT, 11% (6/65,) compared to those patients that did not have NPWT, 25% (16/65) p, <0.001.  Surgical site infection was significantly decreased in the NPWT group, 4.6% (3/65) compared to those who did not have NPWT 15% (10/65), p<0.001.  Recurrence of pilonidal disease was significantly decreased in the NPWT patients 3% (2/65) compared to non-NPWT 12% (8/65), p<0.0001.

Conclusion:

The use of negative pressure wound therapy (NPWT) is beneficial in patients undergoing excision and primary closure of pilonidal sinus disease. NPWT leads to a decrease in early wound complications including wound seroma, dehiscence and SSI. In addition NPWT also significantly resulted in a decrease in recurrence of disease.We recommend the use of NPWT in the surgical management of pilonidal disease.

06.03 Utility of Restaging Patients with Stage II/III Rectal Cancer Following Neoadjuvant Chemo/XRT

Posted on January 31, 2019

L. E. Hendrick1, J. D. Buckner1, W. M. Guerrero1, D. Shibata1, N. M. Hinkle1, J. J. Monroe1, E. S. Glazer1, J. L. Deneve1, P. V. Dickson1  1University of Tennessee Health Science Center,Department Of Surgery,Memphis, TN, USA

Introduction:

In the United States, patients with clinical stage II or III rectal cancer typically receive neoadjuvant chemoradiation therapy (chemo/XRT) over a 5-6 week period followed by a 6-10 week break prior to proctectomy. The chemotherapy administered with radiation is delivered at radio-sensitizing doses. Thus, it is essentially standard for these patients to have a 3-month window between initial staging and primary tumor resection, while potential systemic disease is left untreated.  The purpose of the current study was to evaluate the utilization of restaging studies in detection of disease progression during this window.

Methods:

We performed a single institution retrospective review of patients with clinical stage II/III rectal cancer from 2005-17. Data were abstracted for demographics, initial staging modalities, type and timing of neoadjuvant therapy, restaging modalities and time interval to restaging, surgical management, and adjuvant therapy. We excluded patients with clinical stage I or IV disease, inadequate/incomplete clinical staging, and those receiving short-course or no pre-operative chemo/XRT.  Characteristics of patients that developed metastatic disease were examined.  Statistical analysis was performed with bivariate analysis using Fischer’s exact test (significance level set at p<0.05).

Results:

We identified 176 patients with clinical stage II (65, 37%) or III (111, 63%) rectal adenocarcinoma that completed neoadjuvant chemo/XRT.  Among these, 110 patients underwent some form of restaging study either pre-operatively or within 30 days following proctectomy and before adjuvant therapy.  Restaging included CT CAP in 101 (57%), MRI pelvis in 16 (9%), EUS in 9 (5%), PET/CT in 4 (2%), proctoscopy in 9 (5%), and multiple modalities in 23 (13%). Gender, age, race, insurance status, clinical stage, histologic grade, and tumor location (high vs mid vs low) were similar between patients who did and did not have restaging performed (p>0.05). Among all patients restaged, 6 (5.5%) had newly detected distant metastases including liver (2), lung (3), and multiple sites (1). No patient was found to have local progression on restaging. Of the patients with progression, metastases were detected on CT CAP in 5 and PET/CT in 1. Gender, age, race, insurance status, clinical stage, histologic grade, and tumor location (high vs mid vs low) were similar between patients with and without identification of disease progression (p>0.05).    

Conclusion:

In patients with clinical stage II/III rectal cancer who undergo standard neoadjuvant chemo/XRT, peri-operative restaging with CT CAP and/or PET/CT detects new metastases in a small percentage of patients.  Future investigation with multi-institutional collaboration to include a larger patient cohort may help better identify clinicopathologic factors predictive of detecting disease progression.

06.02 The Effect of Immunosuppression on Emergency Colectomy Outcomes: A National Analysis

Posted on January 31, 2019

M. W. El Hechi1, A. Mendoza1, J. Lee1, N. Saillant1, M. Rosenthal1, P. Fagenholz1, D. King1, G. Velmahos1, H. Kaafarani1  1Massachusetts General Hospital,Division Of Trauma, Emergency Surgery & Surgical Critical Care,Boston, MA, USA

Introduction:

The impact of immunosuppression on the outcomes of emergent surgery remains largely unknown. We aimed to examine the effect of chronic immunosuppression on mortality and morbidity of patients undergoing emergent colectomies.

Methods:

The Colectomy-Targeted American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) from 2012 to 2016 was analyzed for the study. All patients older than 18 undergoing emergent colectomies were included except those with a diagnosis of inflammatory bowel disease. Immunosuppression is defined by the ACS-NSQIP as the regular administration of oral/parenteral corticosteroid medications or immunosuppressants for a chronic condition within the 30 days prior to the operative procedure. Univariate analyses were initially performed comparing immunosuppressed and immunocompetent patients. Backward stepwise multivariable models were then created to identify the independent impact of immunosuppression on 30-day mortality, morbidity and 30 postoperative complications, as well as hospital length of stay, controlling for all demographics, comorbidities, preoperative laboratory values, as well as intraoperative and procedure-related factors. 

Results:

Out of a total of 16,782 patients undergoing an emergency colectomy, 15,826 were included. The median age was 66 years, 7241 (45.7%) were male, and 1280 (8.1%) were immunosuppressed. Compared to immunocompetent patients, immunosuppressed patients were more likely to be female (58.3% vs 53.9%, p=0.003) and have higher ASA scores (III-V) (95.3% vs 71.3%, p <0.001), less likely to undergo laparoscopic surgery (12% vs. 19.6%, p<0.001), and less likely to have primary anastomosis without diverting loop ileostomy (33.4% vs 55.4%, p-value). In both groups, procedures were most often wound classified as “Dirty” (70%and 50%, p<0.001), and most often performed for colonic perforation as an indication (70% and 46%, <0.001). At 30-days, the immunosuppressed patients had a higher mortality (21% vs. 10%p <0.001), higher morbidity (70% vs. 52%, p<0.001), and a longer median length of stay (12 vs. 9 days, p <0.001). On multivariable analyses, adjusting for all aforementioned variables, immunosuppression was independently correlated with more than 25% increase in mortality (OR = 1.26, 95% CI. 1.02-1.56) and overall morbidity (OR = 1.29, 95% CI. 1.08-1.53). Immunosuppression was associated with twice the risk of wound dehiscence (OR = 2.07,95% CI. 1.48-2.89), and 31% increase in unplanned intubation (OR = 1.31, 95% CI. 1.04-1.67). 

Conclusion:

Immunosuppression is independently associated with more than 25% increase in 30-day mortality and morbidity (especially wound dehiscence) for patients undergoing emergent colectomy. Such information is essential for preoperative patient counseling and to mitigate such increased postoperative risks.
 

06.01 Opioid, Anxiolytic, and Antidepressant Use Results in Worse Outcomes After Colorectal Surgery

Posted on January 31, 2019

N. Jackson1, J. Castle1, D. Davenport1, J. Patel1, J. Hourigan1, S. Beck1, A. Bhakta1  1University Of Kentucky,Colorectal Surgery,Lexington, KY, USA

Introduction:

Colorectal resections are increasing. Unfortunately, many of these patients are on multiple medications, including opioids (OPD), anxiolytics (AXM) and antidepressants (ADM). No literature exists on the relationship of these medications to postoperative outcomes following colorectal surgery. The purpose of this study was to evaluate the impact of pre-operative use of OPD, AXM, and ADM on post-operative outcomes following colorectal surgery.

Methods:

The American College of Surgeons National Surgical Quality Improvement Project (ACS-NSQIP) database was queried for all patients undergoing colectomy at a university-based tertiary care hospital from January 1, 2013 to December 31, 2016. Retrospective chart review was performed to gather demographic data, preoperative use of OPD, AXM, and ADM, intraoperative variables, and postoperative outcomes. Stepwise regression models were utilized to assess the impact of preoperative OPD, AXM, and ADM use on postoperative complications. Rates of 30-day morbidity and mortality in patients on preoperative OPD, AXM, and ADM medications following colorectal procedures were assessed.

Results:

The query yielded 1201 patients, 30.2% (n=363) took OPD preoperatively, 18.4% (n=221) used AXM, and 28.3% (n=340) used ADM. Patients on these medications had significantly increased rates of adverse outcomes (OPD 44.4% vs 30.1% naive, p≤0.001; AXM 43.0% vs 32.9% naive, p≤0.001; ADM 40.6% vs 32.4% naive, p≤0.01). These patients had increased incidence of intra-abdominal infection (OPD: 21.5% vs 15.2% naive, p≤0.01, AXM: 23.1% vs 15.7% naive, p≤0.01, ADM: 22.4% vs 15.0% naive, p<0.05) and prolonged intubation or unplanned reintubation (OPD: 11.0% vs 6.3% naive, p≤0.01, AXM: 12.2% vs 6.7% naive, p≤0.01, ADM: 10.9% vs 6.5% naive, p<0.05). Patients on OPD and AXM had hospital lengths of stay prolonged by 2 days (p≤0.001). Those taking OPD had higher rates of readmission (17.9% vs 11.0% naive, p≤0.01) and more likely to require ostomy creation (51.5% vs 37.8% naive, p≤0.001).  On multivariate regression, OPD and AXM use were associated with increased 30-day morbidity and mortality following colorectal procedures (OR: 1.48, p≤0.01; OR: 1.47, p<0.05, respectively). 

Conclusion:

Preoperative OPD, AXM and ADM use is associated with increased adverse outcomes, 30-day morbidity and mortality following colorectal surgery. These medications should be considered in preoperative planning and be adjusted for in postoperative measures.
 

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