Biomedical subjects

Conor P Delaney

Publications and source records attributed to Conor P Delaney.

At least 19 recordsLinked to original sources

PubMed2006

Colorectal cancer in a population with endemic Schistosoma mansoni: is this an at-risk population?

PURPOSE: Chronic infection with schistosomiasis has been clearly associated with the development of bladder cancer, and infestation is associated with a high incidence of colorectal cancer in endemic populations. Despite this association, the potential role of alterations in tumor suppressor genes colorectal cancers has never been evaluated in an endemically infected population. The aim of this paper was to compare histopathologic and genetic changes in schistosomal colitis-associated colorectal cancer (SCC) with colorectal cancer in a group of patients from the same population not affected by the disease (NDCC). MATERIALS AND METHODS: Sixty patients were included in this study: SCC-40, NDCC-20. Data collected included age, sex, clinical presentation, presence of synchronous tumors, histopathology, and clinical stage. p53, DCC (deleted in colorectal cancer gene), and mismatch repair genes (MLH1 and MSH2) were studied using immunohistochemical staining. RESULTS: Patients with SCC were significantly younger than the NDCC group (34.52+/-11.22 years vs 50.73+/-12.75 years, p=0.02). Mucinous adenocarcinoma occurred significantly more frequently in SCC (35 vs 10%, p=0.02). SCC tumors were more frequently stage III or IV, and significantly more synchronous tumors were present in the affected group (SCC-8/40 vs NDCC-1/20, p=0.05). p53 staining was far more frequent in SCC (SCC-32/40 vs NDCC-8/20, p=0.006). DCC expression was similar in two groups. There were only four cases, three in SCC and one in NDCC, that showed microsatellite instability. CONCLUSION: The data suggest that schistosomal colitis is more commonly associated with earlier onset of multicentric colorectal cancer, high percentage of mucinous adenocarcinoma, and presents at an advanced stage. The identification of a higher incidence of altered p53 expression in the SCC group raises the possibility of an association between schistosomiasis and alterations in p53 activation as an inciting event in colorectal cancer development.

Adenocarcinoma↗

PubMed2006

Perioperative blood transfusions increase infectious complications after ileoanal pouch procedures (IPAA).

BACKGROUND AND PURPOSE: Assessment of risk factors associated with the use of perioperative allogeneic blood transfusion and the effect of transfusion on infectious complications after ileal pouch-anal anastomosis (IPAA). METHODS: All patients included had IPAA with ileostomy. They were divided into two groups: transfused (TRAN); nontransfused (NON). Data included age, gender, preoperative anemia (Hgb <9 l g/dl), operative blood loss, transfusion volume, incidence of postoperative infectious or anastomotic complications, and length of stay (LOS). RESULTS: The 1,202 patients eligible for the study were divided into: TRAN = 240 patients and NON = 962 patients. The patient age, sex, and preoperative steroid use were similar in both groups. Significantly, more patients in the TRAN group were anemic preoperatively (32 vs 11%; p<0.05) and the preoperative Hgb level was significantly lower in the TRAN (12.07; p<0.05 vs 13.34 g/dl). Transfusion was required more frequently in anemic patients (p<0.001). The overall infection rate was significantly higher in the TRAN (48.75 vs 11.22%, p<0.001), Anastomotic separation (10.83 vs 3.32%, TRAN and NON, respectively; p<0.001) and fistula formation percentage (20.8 vs 4.46%, TRAN and NON, respectively; p<0.001) was significantly higher in the TRAN group. Pelvic sepsis also occurred more frequent in TRAN (22.9 vs 4.2%, TRAN and NON, respectively; p<0.001). The incidence of any infectious complication at any site was higher in anemic patients irrespective of transfusion status (18.2 vs 2.8%, p<0.05). Transfusion was the only significant independent risk factor for postoperative infections. LOS was adversely affected by an infectious complication (9 vs 7 days, p<0.001). CONCLUSIONS: Preoperative anemia is a significant risk factor for perioperative transfusion with significant increase in postoperative infectious complications and anastomotic complications after IPAA. Strategies to correct preoperative anemia, refine indications for transfusion, and define the use of blood salvage techniques may be helpful in decreasing this risk.

Adult↗

PubMed2006

Does immunostaining effectively upstage colorectal cancer by identifying micrometastatic nodal disease?

PURPOSE: Measure the association between the incidence of primary tumor staining and the identification of mediastinal lymph node (MLN) using cytokeratins, NM23, DCC-positive tumors, and vascular endothelial growth factor (VEGF) expression in T(2) and T(3)/N(0) colorectal cancers. The impact of MLN on both recurrence and survival was assessed. MATERIALS AND METHODS: There were 153 CORC patients (T(2), T(3)/N(0)) selected from a prospectively accrued database. All patients had been staged by routine histopathology after a curative resection and no patients received adjuvant chemotherapy. The primary tumors (PT) were assessed with a panel of immunohistochemical stains (cytokeratin, DCC, Nm23, and VEGF). If the PT was positive, the regional nodes were assessed with that marker(s). For any positive tumor marker, all lymph nodes (LNs, mean of 12.6+/-4.2) were stained for this marker. RESULTS: Patient age ranged from 38 to 86 years with a mean age of 61.56+/-25.56 years. Mean follow-up was 72.1+/-32.4 months. Recurrence rate of the whole group was 19/153 (12.4%) and the mean time to recurrence was 37.6+/-23.6 months (15 to 77 months). Crude mortality was 39.9%, while the cancer specific mortality was 11.2% after the whole follow-up period. The relationship between PT staining and MLNs was: cytokeratin-PT 143 (93.5%)/MLN 9 (6.3%); NM23-PT 51 (33.3%)/MLN 3 (5.9%); DCC-PT 79 (53%)/MLN 3 (3.8%); and VEGF-PT 72 (47%)/MLN 4 (5.6%). Nineteen (12.4%) patients experienced tumor recurrence. No correlation exist between PT and/or MLN staining and either recurrence or survival. No patient with MLN with any stain experienced a recurrence. There was no advantage to using an individual stain or all four stains. CONCLUSION: Immunohistochemical stains for PT and focused analysis of regional nodes did not improve prediction of survival or recurrence. Sentinel LN evaluation and the provision of adjuvant chemotherapy in node-negative patients should be questioned and not be utilized outside of a research protocol.

Adult↗

PubMed2006

Long-term outcome and quality of life after continent ileostomy.

INTRODUCTION: This study was designed to evaluate long-term outcomes for patients undergoing Kock continent ileostomy, identify factors associated with adverse outcomes, and compare changes in quality of life after removal of the reservoir. METHODS: The records of all patients (n = 330) undergoing continent ileostomy at the Cleveland Clinic Foundation between 1974 and 2001 were reviewed. Patient-related, intraoperative, and postoperative factors were evaluated as predictor variables of long-term pouch survival. Quality of life was evaluated using the continent ileostomy surgery follow-up questionnaire and the Cleveland Global Quality of Life scale (n = 216). These were compared between patients with continent ileostomy (n = 181) and patients who underwent removal of the continent ileostomy and conversion to an end stoma (n = 35). RESULTS: The median patient follow-up was 11 (range, 1-27) years. The median revision-free pouch interval was 14 (95 percent confidence interval, 11-17) months. The 10-year and 20-year pouch survival was 87 and 77 percent, respectively. Patients had an average of 3.7(range, 1-28) complications and 2.9 (range, 1-27) pouch revisions during follow-up. On multivariate analysis, Crohn's disease (hazard ratio = 4.5), female gender (hazard ratio = 2.4), fistula development (hazard ratio = 3), and body mass index (hazard ratio = 2.4 per 5 unit increase) were independent predictors of pouch failure. Quality of life measurements for patients with a continent ileostomy were higher on all scales in comparison with patients who had the Kock reservoir and then reverted to a Brooke ileostomy. CONCLUSIONS: Despite the associated morbidity with continent ileostomy surgery, long-term results and quality of life were encouraging. Continent ileostomy may be offered as an attractive long-term option to select patients whose only alternative is an end ileostomy.

Adolescent↗

PubMed2006

Postoperative upper and lower gastrointestinal recovery and gastrointestinal morbidity in patients undergoing bowel resection: pooled analysis of placebo data from 3 randomized controlled trials.

BACKGROUND: This analysis examines gastrointestinal recovery in patients who underwent bowel resection (BR) in 3 recent trials. METHODS: Patients who underwent BR in the placebo groups of 3 randomized, double-blind, phase III, parallel-group, multicenter alvimopan efficacy trials were analyzed. RESULTS: Most patients tolerated solid food and had a bowel movement by postoperative day 4. The majority of patients were discharged from the hospital by day 6, but 24.4% required a prolonged hospital stay or readmission. The incidence of nausea was highest on the day of surgery and decreased thereafter, whereas vomiting was uncommon on the day of surgery but increased slightly on postoperative days 1 to 6. The incidence of postoperative nasogastric tube insertion was highest (12%) on day 2. CONCLUSIONS: This analysis provides valuable clinical insight into gastrointestinal recovery after BR in a large homogenous patient population receiving multimodal care.

Aged↗

PubMed2006

Multivariable analysis of factors associated with hospital readmission after intestinal surgery.

BACKGROUND: Readmission rates after major abdominal surgery have a significant impact on hospital costs and quality of care. Identification of risk factors for readmission may improve postoperative care and discharge plans. METHODS: One hundred fifty consecutive patients readmitted within 30 days of discharge after intestinal surgery (RD) were compared with matched nonreadmitted patients. Patient-related (demographic, comorbidity, medications), disease-related (diagnosis, type of surgery), and perioperative course variables were collected for logistic regression analysis. RESULTS: RD was associated with chronic obstructive pulmonary disease (odds ratio [OR] 7.12 and 95% confidence interval [CI] 1.4-37.6), worse functional capacity class (OR 2.02 and CI 1.15-3.56), previous anticoagulant therapy (OR 4.85 and CI 1.2-19.7), steroid treatment, and discharge to a facility other than home (OR 4.35 and CI 0.97-20.0, P = .055). In patients with intestinal perforation, RD rate was decreased (OR 0.3 and CI 0.1-0.9), but this was associated with a longer primary hospital stay (median 8 vs. 6 days, P = .12). RD causes included surgical site septic complications (33%), ileus and/or small-bowel obstruction (23%), medical complications (24%), and others (20%). CONCLUSIONS: Functional capacity, chronic obstructive pulmonary disease, previous anticoagulant therapy, perioperative steroids, and discharge destination are independent predictors of RD. Disease-related factors have minor impact on RD rates. Improving functional status before surgery, decreasing the adverse impact of steroids, and/or stratifying perioperative anticoagulant use may decrease unexpected readmissions in this patient population.

Case-Control Studies↗

PubMed2006

A critical analysis of laparoscopic colectomy at a single institution: lessons learned after 1000 cases.

BACKGROUND: A critical outcome analysis of a large, single-institution experience provides a better frame of reference for an assessment of the role of laparoscopic colectomy for colorectal pathology. METHODS: Review of a prospectively gathered database was performed of a consecutive series of laparoscopic colectomy patients who were operated on by 2 surgeons at a single institution (tertiary referral center) using standardized techniques and care plans. Patients were assessed for operative indications, type of resection, operative time, conversion, complications, duration of stay, and readmission within 30 days. RESULTS: One thousand consecutive patients undergoing laparoscopic colectomy from January 1999 thru June 2004 were analyzed. The types of resections were right colectomy = 314, left/sigmoid colectomy/anterior resection = 435, total colectomy = 61, total proctocolectomy = 14, and other = 176. The indications for surgery were diverticular disease = 285, colorectal neoplasia = 285, inflammatory bowel disease = 172, rectal prolapse = 81, and other = 177. The conversion rate was 11.4%. The mean operative time was 112 +/- 45 minutes for all resections. The mean duration of hospitalization for all patients was 3.7 +/- 3.8. The overall complication rate was 9.9%, with the most frequent complications being ileus 2.8%, pulmonary 1.6%, cardiac 1.4%, and wound infection 2.6%. The 30-day readmission rate was 9.1%, and the most frequent reasons for readmission were ileus/small-bowel obstruction, intra-abdominal infection, and anastomotic leak. CONCLUSIONS: This largest single-institution experience with laparoscopic colectomy confirms the benefits of a standardized approach including shorter hospital rehabilitation and low rates of cardiopulmonary and wound complications. Efforts must be directed at improving access to training in laparoscopic colectomy techniques so that patients can benefit from this new technology.

Clinical Competence↗

PubMed2006

Risk factors for diseases of ileal pouch-anal anastomosis after restorative proctocolectomy for ulcerative colitis.

BACKGROUND & AIMS: Although pouchitis is considered the most common adverse sequela of ileal pouch-anal anastomosis (IPAA), inflammatory and noninflammatory conditions other than pouchitis are increasingly being recognized. The risk factors for these non-pouchitis conditions, including Crohn's disease (CD) of the pouch, cuffitis, and irritable pouch syndrome (IPS), have not been studied. The aim of this study was to assess risk factors for inflammatory and noninflammatory diseases of IPAA in a tertiary care setting. METHODS: The study consisted of 240 consecutive patients who were classified as having healthy pouches (N = 49), pouchitis (N = 61), CD of the pouch (N = 39), cuffitis (N = 41), or IPS (N =50). Demographic and clinical features were assessed to determine risk factors for each of these conditions by using logistic regression analysis. RESULTS: Risk factors remaining in the final logistic regression models were for pouchitis: IPAA indication for dysplasia (odds ratio [OR], 3.89; 95% confidence interval [CI], 1.69-8.98), never having smoked (OR, 5.09; 95% CI, 1.01-25.69), no use of anti-anxiety agents (OR, 5.19; 95% CI, 1.45-18.59), or use of NSAIDs (OR, 3.24; 95% CI, 1.71-6.13); for CD of the pouch: a long duration of IPAA (OR, 1.20; 95% CI, 1.12-1.30) and current smoking (OR, 4.77; 95% CI, 1.39-16.25); for cuffitis: arthralgias (OR, 4.13; 95% CI, 1.91-8.94) and younger age (OR, 1.16; 95% CI, 1.01-1.33); and for IPS: use of antidepressants (OR, 4.17, 95% CI, 1.95-8.92) or anti-anxiety agents (OR, 3.21; 95% CI, 1.34-7.47). CONCLUSIONS: The majority of risk factors for the 4 inflammatory and noninflammatory conditions of IPAA are different, suggesting that each of these diseases has a different etiology and pathogenesis. The identification and modification of these risk factors might help patients and clinicians to make a preoperative decision for IPAA, reduce IPAA-related morbidity, and improve response to treatment.

Adult↗

PubMed2006

Colonic abnormalities on CT in adult hospitalized patients with Clostridium difficile colitis: prevalence and significance of findings.

OBJECTIVE: The purpose of this study was to determine the prevalence of an abnormal colon on CT in adult inpatients with Clostridium difficile colitis, compare the clinical presentation of these patients, and determine whether CT findings predicted the need for surgical treatment. MATERIALS AND METHODS: Over a 21-month period, 152 of 572 inpatients with C. difficile colitis were identified and had CT scans performed within 2 weeks of the diagnosis. These were independently and retrospectively reviewed by two reviewers. Those with colonic wall thickness greater than 4 mm were considered positive (CT-positive patients) and were further reviewed for specific findings in the colon. All 152 patients with CT scans were also retrospectively reviewed using the hospital information system for certain clinical parameters, admitting diagnoses, and reasons for scanning. The following were compared using several statistical tests: clinical parameters in CT-positive and CT-negative patients and surgical and nonsurgical groups to determine if positive scans or surgical treatment could be clinically predicted; specific CT findings in CT-positive patients to see if an association was found with clinical parameters or surgical treatment; and admitting diagnoses and reasons for scanning in scanned and unscanned populations to see which patients were more likely to undergo CT. RESULTS: Seventy-six (50%) of 152 scanned hospitalized patients with C. difficile colitis were CT-positive. These patients most often had segmental involvement (50 [66%] of 76 patients), with the rectum (60 [82%] of 73 patients) and sigmoid colon (61 [82%] of 74 patients) most often affected. Positive scans were associated with increased WBC, abdominal pain, and diarrhea. Patients with signs and symptoms of infection or abdominal complaints were more likely to be scanned. No statistical correlation was found between specific CT findings and clinical parameters or clinical parameters and patients requiring surgery. There was no predictive value of specific CT findings for surgical treatment. CONCLUSION: Half of the patients scanned had an abnormal CT, with segmental colonic disease more common than diffuse. Positive scans were more likely in patients with leukocytosis, abdominal pain, and fever. Specific CT findings did not correlate with clinical parameters and could not predict surgical treatment.

Adult↗

PubMed2005

Laparoscopic surgery for inflammatory bowel disease.

Laparoscopic surgery has recently been gaining acceptance as an alternative approach for patients with inflammatory bowel disease. There is increasing evidence demonstrating the multiple potential benefits of laparoscopy including faster recovery, reduced costs, and lower morbidity. For patients with acute colitis, a laparoscopic subtotal colectomy and end ileostomy have been shown to be feasible and safe in experienced hands. When indicated, many of these patients may be able to safely undergo a subsequent laparoscopic approach for construction of an ileo-anal pouch. Although still controversial, an elective laparoscopic restorative proctocolectomy with ileo-anal pouch anastomosis has also been shown to be feasible with functional outcomes at least similar to those obtained with an open approach. However, larger randomized series of patients are needed with longer follow-up in order to draw definite conclusions. For Crohn's disease, a laparoscopic approach is ideal for stoma creation. In addition, laparoscopic ileo-colectomy is arguably the preferred approach for patients with terminal ileal disease. Some experienced laparoscopic groups have also applied laparoscopic techniques for more complicated cases with recurrent disease or disease-related complications, such as fistulous disease. Other short-term benefits of a laparoscopic approach may include a decreased incidence of ventral hernias, decreased incidence of small bowel obstruction, and faster recovery. These benefits may also have significant economic impact. In contrast to earlier reports, there is reliable evidence that conversion is not associated with a poorer outcome. A policy of starting most suitable cases laparoscopically may offer patients the potential benefits of a laparoscopic approach without increasing morbidity.

Colitis, Ulcerative↗

PubMed2005

Diagnosis-related group assignment in laparoscopic and open colectomy: financial implications for payer and provider.

PURPOSE: In carefully matched patients, the length of hospital stay after laparoscopic colectomy is shorter than after open surgery. Higher operating room costs for laparoscopic surgery are offset by lower costs for hospitalization because of less utilization of pharmacy, laboratory, and nursing services. Clinical outcome is comparable. We examined the effect of the surgical approach for colectomy (open vs. laparoscopic) regarding the reasons for disease-related group assignment to disease-related group 148, and institutional cost under Part A of the U.S. Medicare system. METHODS: Colectomy patients were assigned to either disease-related group 148 (colorectal resection with complications) or disease-related group 149 (colorectal resection without complications) with significant institutional reimbursement implications (disease-related group 149, US 8,310 dollars; disease-related group 148, US 20,291 dollars). A total of 100 consecutive disease-related group 148 patients undergoing laparoscopic colectomy from July 2000 to September 2002 were identified from a prospective database and case-matched with 100 patients undergoing open colectomy. Patients were matched for gender, age, operative procedure, and pathology. A certified coder determined the reason(s) for disease-related group 148 assignment, which were grouped into: preoperative comorbidity, a combination of preoperative comorbidity/postoperative complications, or postoperative complications alone. RESULTS: Significantly more lapararoscopy patients were assigned to disease-related group 148 solely because of preoperative comorbidities (62 percent vs. 21 percent; P < 0.0001). Significantly more patients in the open surgery group were classified as disease-related group 148 solely because of postoperative complications (22 percent vs. 42 percent; P < 0.0001). An additional group of patients were assigned to the disease-related group 148 category based on a combination of preoperative and postoperative diagnoses (16 percent vs. 37 percent). The mean direct hospital costs were significantly less for laparoscopy patients (US 3971 dollars vs. US 5997 dollars; P = 0.0095). Increased cost to Part A of Medicare for 20 open surgery patients who "migrated" to disease-related group 148 because of postoperative complications was US 239,620 dollars. CONCLUSIONS: Our data are the first to demonstrate that disease related group assignment can change solely because of a differential rate of postoperative complications for two competing operative techniques. This change occurred at twice the rate for open colectomy and resulted in significantly increased cost to the insurer under a prospective payment program. The savings to the institution coupled with the shortened length of stay offset the potential loss in revenue to the institution.

Colectomy↗

PubMed2005

Is laparoscopic colectomy applicable to patients with body mass index >30? A case-matched comparative study with open colectomy.

PURPOSE: The benefits of early postoperative recovery, reduced postoperative pain, pulmonary dysfunction, and hospitalization after laparoscopic colectomy may improve outcome over open colectomy in obese patients. This case-matched study compares outcomes after open and laparoscopic colectomy. METHODS: A total of 94 laparoscopic colectomy patients with a body mass index >30 (Jan 1999-June 2003) were identified from a prospective database and matched to open colectomy cases for age, gender, body mass index, American Society of Anesthesiologists class, procedure, indication, and date of surgery. Operating time, length of stay, conversion, intraoperative and postoperative complications, reoperation, 30-day readmission rate, and costs were compared. Data are presented as means +/- standard deviations, and appropriate statistical tests were used. RESULTS: The two groups were matched for age (P = 0.06), gender (P = 1), American Society of Anesthesiologists class (P = 0.2), body mass index (P = 0.4), indication for surgery (P = 1), and procedure (P = 1). By using intention-to-treat-type analysis, there was no difference in median operating time (100 vs. 110 (mean, 123 vs. 112) minutes; P = 0.1), complications (21 vs. 24 percent; P = 0.74), readmission (17 vs. 10.6 percent; P = 0.3), reoperation rates (6.4 vs. 4.3 percent; P = 0.75), or direct costs (median, US. 3,368 dollars vs. US 3,552 dollars; mean, US 4,003 dollars vs. US 4,037 dollars; P = 0.14) between laparoscopic colectomy or open colectomy; however, the median length of stay (3 vs. 5.5 (mean, 3.8 vs. 5.8) days; P = 0.0001) was significantly shorter after laparoscopic colectomy. Twenty-eight patients required conversion for adhesions (n = 11), bleeding (n = 3), obesity-hindering vision or dissection (n = 9), large phlegmon or tumor (n = 4), and ureteric injury (n = 1). The mean operating time for conversions was 142 minutes and length of stay was 6.4 days. Compared with laparoscopically completed cases, the median length of stay (5 vs. 2 (mean, 6.4 vs. 2.8) days; P = 0.0001) and median operating times (150 vs. 95 (mean, 142 vs. 115) minutes; P = 0.02) were significantly higher in the converted group, but there was no difference in the complication (P = 0.8), readmission (P = 1), or reoperation (P = 0.7) rates. Compared with open colectomy, the operating time (P = 0.02) was significantly higher in the converted group but there were no significant differences in the length of stay (P = 0.18), complication (P = 1), readmission (P = 0.35), or reoperative (P = 1) rates. CONCLUSIONS: Laparoscopic colectomy can be performed safely in obese patients, with shorter postoperative recovery than that with open colectomy. Although obesity is associated with a high conversion rate, outcome in these converted cases is comparable to the matched open cases.

Body Mass Index↗

PubMed2005

Phase III trial of alvimopan, a novel, peripherally acting, mu opioid antagonist, for postoperative ileus after major abdominal surgery.

PURPOSE: Postoperative ileus presents significant clinical challenges that potentially prolong hospital stay, contribute to readmission, and increase morbidity. There is no approved treatment for postoperative ileus. Alvimopan is a novel, peripherally acting, mu opioid receptor antagonist currently in development for the management of postoperative ileus. METHODS: Patients undergoing partial colectomy or simple or radical hysterectomy were randomized to receive alvimopan 6 mg (n = 152), alvimopan 12 mg (n = 146), or placebo (n = 153) orally 2 hours before surgery and twice daily thereafter until discharge or for up to seven days. The primary efficacy end point, time to return of gastrointestinal function, was a composite measure of passage of flatus or stool and tolerating solid food. Secondary end points included time to the hospital discharge order written. Adverse events were monitored throughout the study. RESULTS: Mean time to gastrointestinal recovery was significantly reduced in patients treated with alvimopan 6 mg vs. placebo (hazard ratio = 1.45; P = 0.003), with a smaller reduction seen with alvimopan 12 mg (hazard ratio = 1.28; P = 0.059). Mean time to the hospital discharge order written was significantly accelerated in patients treated with alvimopan 6 mg (hazard ratio = 1.50; P < 0.001). The most common treatment-emergent adverse events across all treatment groups were nausea, vomiting, and hypotension; the incidence of nausea and vomiting was reduced by 53 percent in the alvimopan 12-mg group. CONCLUSIONS: In patients undergoing major abdominal surgery, alvimopan accelerated gastrointestinal recovery and time to the hospital discharge order written compared with placebo and was well tolerated.

Adult↗

PubMed2005

Randomized controlled trial comparing the controlled rehabilitation with early ambulation and diet pathway versus the controlled rehabilitation with early ambulation and diet with preemptive epidural anesthesia/analgesia after laparotomy and intestinal resection.

BACKGROUND: Multimodal postoperative care regimens accelerate recovery after abdominal surgery. The benefit of thoracic epidural (TE) analgesia over patient-controlled analgesia (PCA) remains unproven when used with a fast-track postoperative care plan. METHODS: Fifty-six patients undergoing major intestinal resection, and on a fast-track postoperative care plan, were randomized to preemptive TE or PCA. Patients were evaluated at standard time points for pain score, quality of life (Short Form-36), and complications. Oral analgesia was substituted for TE and PCA on the second postoperative day. Discharge criteria were identical for both groups. RESULTS: Six patients (20.6%) had a failed epidural. There was no difference in length of stay (5.8 versus 6.2 days, TE versus PCA, P = .55), total length of stay (including readmissions), pain scores, quality of life, complications, or hospital costs at any time point. CONCLUSION: TE offers no advantage over PCA for patients undergoing major intestinal resections who are on a fast-track postoperative care plan using PCA.

Adult↗

PubMed2005

Evaluation of the learning curve in laparoscopic colorectal surgery: comparison of right-sided and left-sided resections.

OBJECTIVE: To provide a multidimensional analysis of the learning curve in major laparoscopic colonic and rectal surgery and compare outcomes between right-sided versus left-sided resections. SUMMARY BACKGROUND DATA: The laparoscopic learning curve is known to vary between surgeons, may be influenced by the patient selection and operative complexity, and requires appropriate case-mix adjustment. METHODS: This is a descriptive single-center study using routinely collected clinical data from 900 patients undergoing laparoscopic surgery between November 1991 and April 2003. Outcome measures included operation time, conversion rate (CR), and readmission and postoperative complication rates. Multifactorial logistic regression analysis was used to identify patient-, surgeon-, and procedure-related factors associated with conversion of laparoscopic to open surgery. A risk-adjusted Cumulative Sum (CUSUM) model was used for evaluating the learning curve for right and left-sided resections. RESULTS: The conversion rate for right-sided colonic resections was 8.1% (n = 457) compared with 15.3% for left-sided colorectal resections (n = 443). Independent predictors of conversion of laparoscopic to open surgery were the body mass index (BMI) (odds ratio [OR] = 1.07 per unit increase), ASA grade (OR = 1.63 per unit increase), type of resection (left colorectal versus right colonic procedures, OR = 1.5), presence of intra-abdominal abscess (OR = 5.0) or enteric fistula (OR = 4.6), and surgeon's experience (OR 0.9 per 10 additional cases performed). Having adjusted for case-mix, the CUSUM analysis demonstrated a learning curve of 55 cases for right-sided colonic resections versus 62 cases for left-sided resections. Median operative time declined with operative experience (P<0.001). Readmission rates and postoperative complications remained unchanged throughout the series and were not dependent on operative experience. CONCLUSIONS: Conversion rates for laparoscopic colectomy are dependent on a multitude of factors that require appropriate adjustment including the learning curve (operative experience) for individual surgeons. The laparoscopic model described can be used as the basis for performance monitoring between or within institutions.

Adult↗

PubMed2005

Comprehensive evaluation of inflammatory and noninflammatory sequelae of ileal pouch-anal anastomoses.

BACKGROUND AND AIMS: Ileal pouch-anal anastomosis (IPAA) improves quality of life (QOL) for ulcerative colitis patients who require surgery. Crohn's disease (CD) of the pouch, pouchitis, cuffitis, and irritable pouch syndrome (IPS) have an adverse impact on physical and psychological well-being, which can compromise the gain in QOL after the surgery. Their clinical, endoscopic, and histologic features have not been fully characterized. The aim of this study was to compare demographic, clinical, endoscopic, and histologic features between CD of the pouch, pouchitis, cuffitis, IPS, and normal pouches. METHODS We enrolled 124 patients: normal pouches (N = 26), CD of the pouch (N = 23), pouchitis (N = 22), cuffitis (N = 21), and IPS (N = 32). Symptomatology, endoscopy, histology, and the Cleveland Global QOL and the Irritable Bowel Syndrome-QOL scores were compared among the groups. RESULTS: Univariate analysis of demographic and clinical data showed a possible association between NSAID use and pouchitis, extraintestinal manifestation and cuffitis, and antidepressant use and IPS. There were no differences in the Pouchitis Disease Activity Index symptom scores between the disease groups, with an exception of bleeding, which occurred almost exclusively in cuffitis. Endoscopy was useful in discriminating between CD of the pouch, pouchitis, cuffitis, and normal pouches or IPS. Patients with diseased IPAA had worse QOL scores. CONCLUSIONS: Symptoms largely overlapped among the disease groups of IPAA. Endoscopy is valuable for diagnosis. Inflammatory or noninflammatory sequelae of IPAA adversely affected patients' QOL.

Adult↗

PubMed2005

Alvimopan.

Alvimopan is a synthetic peripherally restricted mu-receptor opioid antagonist. Alvimopan has a greater affinity for the mu-receptor than the kappa- or sigma-opioid receptors (Ki = 0.77 nM). The polarity of the molecule limits gastrointestinal absorption and central nervous system penetration. It has limited systemic bioavailability and higher affinity for the mu-opioid receptor than naloxone (Ki = 3.7 nM). Completed Phase III trials suggest efficacy in accelerating the recovery of gastrointestinal function after abdominal surgery. Adverse events with all doses have been similar to placebo groups. Further efficacy in alleviating opioid-induced bowel dysfunction in patients with chronic opioid usage has also been demonstrated. This evidence-based review assesses this new drug and discusses its potential role in clinical practice.

Abdomen↗

PubMed2004

POSSUM, p-POSSUM, and Cr-POSSUM: implementation issues in a United States health care system for prediction of outcome for colon cancer resection.

PURPOSE: The Physiologic and Operative Severity Score for the enUmeration of Mortality and morbidity (POSSUM), Portsmouth revision (p)-POSSUM, and colorectal (Cr)-POSSUM scoring systems were developed as audit tools for comparing outcomes in surgical and colorectal patients on the basis of operative risk assessment. The aim of this study was to evaluate the applicability of these systems to a cohort of colon cancer patients undergoing surgery in the United States. METHODS: POSSUM factors from 890 consecutive patients undergoing major surgical procedures for colon cancer in nine United States hospitals over a two-year period from January 2000 through December 2001 were prospectively collected. The observed over the expected hospital mortality was compared by means of the POSSUM, p-POSSUM, and Cr-POSSUM scoring systems. The effect of missing data on the utility of this process for outcome assessment was assessed with three methods for data imputation. RESULTS: The number of resections per institution ranged from 13 to 437. The observed mortality rate ranged from 0.8 percent to 15.4 percent among the institutions, with an overall operative mortality of 2.3 percent. The POSSUM, p-POSSUM, and Cr-POSSUM predicted mortality was 10.7 percent, 11.2 percent, and 4.9 percent, respectively. The POSSUM and p-POSSUM models overpredicted mortality in all institutions ( P < 0.01), whereas the Cr-POSSUM demonstrated an observed over expected hospital mortality ratio of >1 in three institutions. The calculations were unaffected by the various methods of inserting missing data. CONCLUSION: An apparent overprediction of mortality for colon cancer resection was evident with all three POSSUM variants. This implies that a calibration process is required for use of these variants in the United States health care system. Missing data may be treated as normal values without influencing outcome. The Cr-POSSUM appeared to be the most promising audit tool for colorectal cancer surgery; however, it will require further refinement to provide process control graphs for identification of potential outliers and improvement in the quality of care in the United States.

Adolescent↗