Colon and Rectal

Permanent sacral nerve stimulation looked promising in a prospective, randomized controlled study to reduce symptoms in a select group of 21 adults with diarrhea-predominant or mixed irritable bowel syndrome.

In this crossover trial, all patients had sacral nerve stimulators implanted. One group had the stimulator turned on for 1 month and off the next month, while the other group had the opposite – the stimulator was off and then on during those same time periods. Active stimulation improved symptom scores as measured by the Gastrointestinal Symptom Rating Scale – Irritable Bowel Syndrome (GSRS-IBS).

The median change in symptom scores between months 1 and 2 differed significantly between the two groups. In the group that had the stimulator on and then off, symptom scores increased by a median of 12 points. In the group that had the stimulator off and then on, scores decreased by a median of 18 points, Janne L. Fassov, Ph.D., and associates reported.

One year later, with sacral nerve stimulation continuing and data available from 19 patients, the median GSRS-IBS score of 25 was significantly lower than the median symptom score of 62 at baseline, reported Dr. Fassov of Aarhus (Denmark) University Hospital.

The Annals of Surgery published the findings online ahead of print (2014 Feb. 6 [doi:10.1097/SLA.000000000000559]).

The investigators recruited 43 patients from their tertiary care institution who had failed standard treatments for diarrhea-predominant or mixed irritable bowel syndrome. After undergoing a percutaneous nerve evaluation under general anesthesia, they underwent 3 weeks of stimulation using a test electrode connected to an external neurostimulator. Thirty-one patients who had at least a 30% reduction in GSRS-IBS symptom scores during the 3-week test period were offered permanent implantation of the neurostimulator. Patients worked with a nurse specialist for 1-20 months after implantation to individually optimize the stimulator settings for best symptom control before being randomized in the current study.

Two patients who became pregnant and three who withdrew consent did not get stimulators. Five of 26 patients with permanent implantation were excluded from the results, two because of gastric bypass procedures before the crossover month, one who was mentally unstable, and two who refused to have the stimulator turned off because of its excellent effects.

Although patients and investigators were not told when the stimulators were on or off, patients usually could sense when they were on, so the study was not truly blinded.

One of the 21 remaining patients withdrew from the study before finishing it after needing morphine to relieve abdominal pain during the month that the neurostimulator was off.

In the 20 patients who completed the study, quality of life scores on the Irritable Bowel Syndrome Impact Scale (IBS-IS) improved during the month with stimulation. When stimulation went from on to off, IBS-IS scores increased by a median of 16 points. When stimulation went from off to on, IBS-IS scores decreased by a median of 42 points. The difference in median changes between the two groups was statistically significant.

Scores improved significantly with stimulation in all five domains of the symptom scale (pain, bloating, constipation, diarrhea, and satiety) and in all five domains of the quality of life scale (fatigue, daily impaired activities, sleep, emotional distress, and eating habits).

Ten device-related adverse events in seven patients included elective revision of the lead for suspected migration in two patients, persistent postoperative pain at the implantation site requiring relocation of the pacemaker in three patients, recurrent cystitis in one patient that resolved with triple voiding, and spontaneously resolving postoperative pain at the implantation site in four patients.

Sacral nerve stimulation is a well-established, cost-effective treatment for fecal incontinence, and the effects of stimulation for inflammatory bowel disease in this study were similar to those that have been reported for fecal incontinence, the investigators noted. Because minor complications are common with sacral nerve stimulation, this treatment should be reserved for patients with inflammatory bowel disease who do not respond to pharmacotherapy, they suggested.

Medtronic provided its neurostimulators for the study free of charge. Some of Dr. Fassov’s associates in the study have been speakers and/or advisers for Medtronic. The Danish Council for Strategic Research funded the study.

sboschert@frontlinemedcom.com

On Twitter @sherryboschert

Permanent sacral nerve stimulation looked promising in a prospective, randomized controlled study to reduce symptoms in a select group of 21 adults with diarrhea-predominant or mixed irritable bowel syndrome.

In this crossover trial, all patients had sacral nerve stimulators implanted. One group had the stimulator turned on for 1 month and off the next month, while the other group had the opposite – the stimulator was off and then on during those same time periods. Active stimulation improved symptom scores as measured by the Gastrointestinal Symptom Rating Scale – Irritable Bowel Syndrome (GSRS-IBS).

The median change in symptom scores between months 1 and 2 differed significantly between the two groups. In the group that had the stimulator on and then off, symptom scores increased by a median of 12 points. In the group that had the stimulator off and then on, scores decreased by a median of 18 points, Janne L. Fassov, Ph.D., and associates reported.

One year later, with sacral nerve stimulation continuing and data available from 19 patients, the median GSRS-IBS score of 25 was significantly lower than the median symptom score of 62 at baseline, reported Dr. Fassov of Aarhus (Denmark) University Hospital.

The Annals of Surgery published the findings online ahead of print (2014 Feb. 6 [doi:10.1097/SLA.000000000000559]).

The investigators recruited 43 patients from their tertiary care institution who had failed standard treatments for diarrhea-predominant or mixed irritable bowel syndrome. After undergoing a percutaneous nerve evaluation under general anesthesia, they underwent 3 weeks of stimulation using a test electrode connected to an external neurostimulator. Thirty-one patients who had at least a 30% reduction in GSRS-IBS symptom scores during the 3-week test period were offered permanent implantation of the neurostimulator. Patients worked with a nurse specialist for 1-20 months after implantation to individually optimize the stimulator settings for best symptom control before being randomized in the current study.

Two patients who became pregnant and three who withdrew consent did not get stimulators. Five of 26 patients with permanent implantation were excluded from the results, two because of gastric bypass procedures before the crossover month, one who was mentally unstable, and two who refused to have the stimulator turned off because of its excellent effects.

Although patients and investigators were not told when the stimulators were on or off, patients usually could sense when they were on, so the study was not truly blinded.

One of the 21 remaining patients withdrew from the study before finishing it after needing morphine to relieve abdominal pain during the month that the neurostimulator was off.

In the 20 patients who completed the study, quality of life scores on the Irritable Bowel Syndrome Impact Scale (IBS-IS) improved during the month with stimulation. When stimulation went from on to off, IBS-IS scores increased by a median of 16 points. When stimulation went from off to on, IBS-IS scores decreased by a median of 42 points. The difference in median changes between the two groups was statistically significant.

Scores improved significantly with stimulation in all five domains of the symptom scale (pain, bloating, constipation, diarrhea, and satiety) and in all five domains of the quality of life scale (fatigue, daily impaired activities, sleep, emotional distress, and eating habits).

Ten device-related adverse events in seven patients included elective revision of the lead for suspected migration in two patients, persistent postoperative pain at the implantation site requiring relocation of the pacemaker in three patients, recurrent cystitis in one patient that resolved with triple voiding, and spontaneously resolving postoperative pain at the implantation site in four patients.

Sacral nerve stimulation is a well-established, cost-effective treatment for fecal incontinence, and the effects of stimulation for inflammatory bowel disease in this study were similar to those that have been reported for fecal incontinence, the investigators noted. Because minor complications are common with sacral nerve stimulation, this treatment should be reserved for patients with inflammatory bowel disease who do not respond to pharmacotherapy, they suggested.

Medtronic provided its neurostimulators for the study free of charge. Some of Dr. Fassov’s associates in the study have been speakers and/or advisers for Medtronic. The Danish Council for Strategic Research funded the study.

sboschert@frontlinemedcom.com

On Twitter @sherryboschert

Permanent sacral nerve stimulation looked promising in a prospective, randomized controlled study to reduce symptoms in a select group of 21 adults with diarrhea-predominant or mixed irritable bowel syndrome.

In this crossover trial, all patients had sacral nerve stimulators implanted. One group had the stimulator turned on for 1 month and off the next month, while the other group had the opposite – the stimulator was off and then on during those same time periods. Active stimulation improved symptom scores as measured by the Gastrointestinal Symptom Rating Scale – Irritable Bowel Syndrome (GSRS-IBS).

The median change in symptom scores between months 1 and 2 differed significantly between the two groups. In the group that had the stimulator on and then off, symptom scores increased by a median of 12 points. In the group that had the stimulator off and then on, scores decreased by a median of 18 points, Janne L. Fassov, Ph.D., and associates reported.

One year later, with sacral nerve stimulation continuing and data available from 19 patients, the median GSRS-IBS score of 25 was significantly lower than the median symptom score of 62 at baseline, reported Dr. Fassov of Aarhus (Denmark) University Hospital.

The Annals of Surgery published the findings online ahead of print (2014 Feb. 6 [doi:10.1097/SLA.000000000000559]).

The investigators recruited 43 patients from their tertiary care institution who had failed standard treatments for diarrhea-predominant or mixed irritable bowel syndrome. After undergoing a percutaneous nerve evaluation under general anesthesia, they underwent 3 weeks of stimulation using a test electrode connected to an external neurostimulator. Thirty-one patients who had at least a 30% reduction in GSRS-IBS symptom scores during the 3-week test period were offered permanent implantation of the neurostimulator. Patients worked with a nurse specialist for 1-20 months after implantation to individually optimize the stimulator settings for best symptom control before being randomized in the current study.

Two patients who became pregnant and three who withdrew consent did not get stimulators. Five of 26 patients with permanent implantation were excluded from the results, two because of gastric bypass procedures before the crossover month, one who was mentally unstable, and two who refused to have the stimulator turned off because of its excellent effects.

Although patients and investigators were not told when the stimulators were on or off, patients usually could sense when they were on, so the study was not truly blinded.

One of the 21 remaining patients withdrew from the study before finishing it after needing morphine to relieve abdominal pain during the month that the neurostimulator was off.

In the 20 patients who completed the study, quality of life scores on the Irritable Bowel Syndrome Impact Scale (IBS-IS) improved during the month with stimulation. When stimulation went from on to off, IBS-IS scores increased by a median of 16 points. When stimulation went from off to on, IBS-IS scores decreased by a median of 42 points. The difference in median changes between the two groups was statistically significant.

Scores improved significantly with stimulation in all five domains of the symptom scale (pain, bloating, constipation, diarrhea, and satiety) and in all five domains of the quality of life scale (fatigue, daily impaired activities, sleep, emotional distress, and eating habits).

Ten device-related adverse events in seven patients included elective revision of the lead for suspected migration in two patients, persistent postoperative pain at the implantation site requiring relocation of the pacemaker in three patients, recurrent cystitis in one patient that resolved with triple voiding, and spontaneously resolving postoperative pain at the implantation site in four patients.

Sacral nerve stimulation is a well-established, cost-effective treatment for fecal incontinence, and the effects of stimulation for inflammatory bowel disease in this study were similar to those that have been reported for fecal incontinence, the investigators noted. Because minor complications are common with sacral nerve stimulation, this treatment should be reserved for patients with inflammatory bowel disease who do not respond to pharmacotherapy, they suggested.

Medtronic provided its neurostimulators for the study free of charge. Some of Dr. Fassov’s associates in the study have been speakers and/or advisers for Medtronic. The Danish Council for Strategic Research funded the study.

sboschert@frontlinemedcom.com

On Twitter @sherryboschert

SCOTTSDALE, ARIZ. – Comanaging neurosurgical patients requires a delicate dance between primary practitioners, surgeons, anesthesiologists, and, in some cases, the makers of implantable neurostimulators, according to perioperative medicine specialists.

Special considerations with patients scheduled for neurosurgical procedures include hypertension, fever, hyponatremia, and risk of deep vein thromboembolism (DVT) and coagulopathies, said Dr. Richard Huh, director of the inpatient medical consultation service at Rush University Medical Center in Chicago, at a meeting on perioperative medicine sponsored by the University of Miami.

For example, hospitalists are typically involved in the management of blood pressure in neurosurgery patients because of the importance of controlling intracranial pressure, Dr. Huh noted.

"The trick is for the blood pressure not to get too high or too low. The Handbook of Neurosurgery suggests a goal of 140 over 90 [mm Hg]," he said.

Patients with acute subarachnoid hemorrhage are at risk for vasospasm, most frequently within 7-10 days of hemorrhage. Hypovolemia is a common cause of vasospasm and should be avoided. Medications such as nimodipine (Nimotop) can help prevent this complication.

Patients undergoing spinal procedures tend to have low blood pressure from acute blood loss or intravenous pain medications, and may require hold parameters on medications to avoid complications from hypotension.

However, on the day following spinal surgery, some patients develop hypertension, and may require additional medications for BP control.

Hyponatremia

The reported prevalence of hyponatremia in hospitalized patients ranges from 1%-7%, and the rate is even higher in neurosurgical patients, possibility because the brain’s response to changes in osmolality. Clinicians managing neurosurgical patients should be aware of the syndrome of inappropriate antidiuretic hormone secretion (SIADH) and cerebral salt wasting, Dr. Huh said.

Cerebral salt wasting may be cause by damaged brain cells that affect sympathetic neural input to the kidneys, decreasing sodium resorption and an increase in atrial natriuretic peptide and brain natriuretic peptide.

The syndrome looks similar to SIADH, with high urinary sodium and osmolality, low serum osmolality, and decreased serum uric acid. But cerebral salt wasting is distinguished from SIADH by the presence of hypovolemia. Cerebral salt wasting is treated with saline and/or salt tablets.

DVT

Neurosurgical patients are at increased risk for DVT and pulmonary embolism compared with the general postoperative population. However, 2012 guidelines on antithrombotic therapy from the American College of Chest Physicians recommend against pharmacologic prophylaxis except for high risk patients, such as patients with intracranial masses. Dr. Huh said.

Implantable neurostimulators

Patients with implanted devices such as deep-brain stimulators for control of Parkinson’s disease, hypoglossal nerve stimulators for severe sleep apnea, or vagal nerve stimulators for epilepsy also require special consideration throughout the perioperative period.

Issues to consider when managing a patient with an implantable device include the device site and its proximity to the planned surgical field, indication for the device, comorbidities, and the patient’s goals for treatment, said Dr. Deborah Richman, section chief of preoperative services at Stony Brook (New York) University Medical Center.

"What do we do with device itself? This is a team approach, and we find that it’s best coordinated by our nurses in the preop holding area, because they know what time the surgery is, they have the device company rep’s phone number, they make sure the patient is there on time, and they put everything together to prevent delays on the day of surgery," she said.

In general, device manufacturers recommend turning devices off, and to turn the amplitude down to zero to prevent accidental activation of magnetic on-off switches.

The distance from the surgery to the pulse generator should be a minimum of 20 cm, and electrocautery, if used, should be bipolar rather than monopolar, Dr. Richman said.

Patients with implanted devices will also require prophylactic antibiotics to prevent potential bacterial seeding of the device or leads, she said,

Coordination of perioperative care "is best done with clinical management pathways, so that when you have one of these patients who present to you, you have a checklist that includes the device company’s phone number, and it’s an easy go-to, so that you don’t have to start from scratch each time," she concluded.

Dr. Huh and Dr. Richman reported having no financial disclosures.

SCOTTSDALE, ARIZ. – Comanaging neurosurgical patients requires a delicate dance between primary practitioners, surgeons, anesthesiologists, and, in some cases, the makers of implantable neurostimulators, according to perioperative medicine specialists.

Special considerations with patients scheduled for neurosurgical procedures include hypertension, fever, hyponatremia, and risk of deep vein thromboembolism (DVT) and coagulopathies, said Dr. Richard Huh, director of the inpatient medical consultation service at Rush University Medical Center in Chicago, at a meeting on perioperative medicine sponsored by the University of Miami.

For example, hospitalists are typically involved in the management of blood pressure in neurosurgery patients because of the importance of controlling intracranial pressure, Dr. Huh noted.

"The trick is for the blood pressure not to get too high or too low. The Handbook of Neurosurgery suggests a goal of 140 over 90 [mm Hg]," he said.

Patients with acute subarachnoid hemorrhage are at risk for vasospasm, most frequently within 7-10 days of hemorrhage. Hypovolemia is a common cause of vasospasm and should be avoided. Medications such as nimodipine (Nimotop) can help prevent this complication.

Patients undergoing spinal procedures tend to have low blood pressure from acute blood loss or intravenous pain medications, and may require hold parameters on medications to avoid complications from hypotension.

However, on the day following spinal surgery, some patients develop hypertension, and may require additional medications for BP control.

Hyponatremia

The reported prevalence of hyponatremia in hospitalized patients ranges from 1%-7%, and the rate is even higher in neurosurgical patients, possibility because the brain’s response to changes in osmolality. Clinicians managing neurosurgical patients should be aware of the syndrome of inappropriate antidiuretic hormone secretion (SIADH) and cerebral salt wasting, Dr. Huh said.

Cerebral salt wasting may be cause by damaged brain cells that affect sympathetic neural input to the kidneys, decreasing sodium resorption and an increase in atrial natriuretic peptide and brain natriuretic peptide.

The syndrome looks similar to SIADH, with high urinary sodium and osmolality, low serum osmolality, and decreased serum uric acid. But cerebral salt wasting is distinguished from SIADH by the presence of hypovolemia. Cerebral salt wasting is treated with saline and/or salt tablets.

DVT

Neurosurgical patients are at increased risk for DVT and pulmonary embolism compared with the general postoperative population. However, 2012 guidelines on antithrombotic therapy from the American College of Chest Physicians recommend against pharmacologic prophylaxis except for high risk patients, such as patients with intracranial masses. Dr. Huh said.

Implantable neurostimulators

Patients with implanted devices such as deep-brain stimulators for control of Parkinson’s disease, hypoglossal nerve stimulators for severe sleep apnea, or vagal nerve stimulators for epilepsy also require special consideration throughout the perioperative period.

Issues to consider when managing a patient with an implantable device include the device site and its proximity to the planned surgical field, indication for the device, comorbidities, and the patient’s goals for treatment, said Dr. Deborah Richman, section chief of preoperative services at Stony Brook (New York) University Medical Center.

"What do we do with device itself? This is a team approach, and we find that it’s best coordinated by our nurses in the preop holding area, because they know what time the surgery is, they have the device company rep’s phone number, they make sure the patient is there on time, and they put everything together to prevent delays on the day of surgery," she said.

In general, device manufacturers recommend turning devices off, and to turn the amplitude down to zero to prevent accidental activation of magnetic on-off switches.

The distance from the surgery to the pulse generator should be a minimum of 20 cm, and electrocautery, if used, should be bipolar rather than monopolar, Dr. Richman said.

Patients with implanted devices will also require prophylactic antibiotics to prevent potential bacterial seeding of the device or leads, she said,

Coordination of perioperative care "is best done with clinical management pathways, so that when you have one of these patients who present to you, you have a checklist that includes the device company’s phone number, and it’s an easy go-to, so that you don’t have to start from scratch each time," she concluded.

Dr. Huh and Dr. Richman reported having no financial disclosures.

SCOTTSDALE, ARIZ. – Comanaging neurosurgical patients requires a delicate dance between primary practitioners, surgeons, anesthesiologists, and, in some cases, the makers of implantable neurostimulators, according to perioperative medicine specialists.

Special considerations with patients scheduled for neurosurgical procedures include hypertension, fever, hyponatremia, and risk of deep vein thromboembolism (DVT) and coagulopathies, said Dr. Richard Huh, director of the inpatient medical consultation service at Rush University Medical Center in Chicago, at a meeting on perioperative medicine sponsored by the University of Miami.

For example, hospitalists are typically involved in the management of blood pressure in neurosurgery patients because of the importance of controlling intracranial pressure, Dr. Huh noted.

"The trick is for the blood pressure not to get too high or too low. The Handbook of Neurosurgery suggests a goal of 140 over 90 [mm Hg]," he said.

Patients with acute subarachnoid hemorrhage are at risk for vasospasm, most frequently within 7-10 days of hemorrhage. Hypovolemia is a common cause of vasospasm and should be avoided. Medications such as nimodipine (Nimotop) can help prevent this complication.

Patients undergoing spinal procedures tend to have low blood pressure from acute blood loss or intravenous pain medications, and may require hold parameters on medications to avoid complications from hypotension.

However, on the day following spinal surgery, some patients develop hypertension, and may require additional medications for BP control.

Hyponatremia

The reported prevalence of hyponatremia in hospitalized patients ranges from 1%-7%, and the rate is even higher in neurosurgical patients, possibility because the brain’s response to changes in osmolality. Clinicians managing neurosurgical patients should be aware of the syndrome of inappropriate antidiuretic hormone secretion (SIADH) and cerebral salt wasting, Dr. Huh said.

Cerebral salt wasting may be cause by damaged brain cells that affect sympathetic neural input to the kidneys, decreasing sodium resorption and an increase in atrial natriuretic peptide and brain natriuretic peptide.

The syndrome looks similar to SIADH, with high urinary sodium and osmolality, low serum osmolality, and decreased serum uric acid. But cerebral salt wasting is distinguished from SIADH by the presence of hypovolemia. Cerebral salt wasting is treated with saline and/or salt tablets.

DVT

Neurosurgical patients are at increased risk for DVT and pulmonary embolism compared with the general postoperative population. However, 2012 guidelines on antithrombotic therapy from the American College of Chest Physicians recommend against pharmacologic prophylaxis except for high risk patients, such as patients with intracranial masses. Dr. Huh said.

Implantable neurostimulators

Patients with implanted devices such as deep-brain stimulators for control of Parkinson’s disease, hypoglossal nerve stimulators for severe sleep apnea, or vagal nerve stimulators for epilepsy also require special consideration throughout the perioperative period.

Issues to consider when managing a patient with an implantable device include the device site and its proximity to the planned surgical field, indication for the device, comorbidities, and the patient’s goals for treatment, said Dr. Deborah Richman, section chief of preoperative services at Stony Brook (New York) University Medical Center.

"What do we do with device itself? This is a team approach, and we find that it’s best coordinated by our nurses in the preop holding area, because they know what time the surgery is, they have the device company rep’s phone number, they make sure the patient is there on time, and they put everything together to prevent delays on the day of surgery," she said.

In general, device manufacturers recommend turning devices off, and to turn the amplitude down to zero to prevent accidental activation of magnetic on-off switches.

The distance from the surgery to the pulse generator should be a minimum of 20 cm, and electrocautery, if used, should be bipolar rather than monopolar, Dr. Richman said.

Patients with implanted devices will also require prophylactic antibiotics to prevent potential bacterial seeding of the device or leads, she said,

Coordination of perioperative care "is best done with clinical management pathways, so that when you have one of these patients who present to you, you have a checklist that includes the device company’s phone number, and it’s an easy go-to, so that you don’t have to start from scratch each time," she concluded.

Dr. Huh and Dr. Richman reported having no financial disclosures.

SCOTTSDALE, ARIZ. – Early hospital readmissions are not good for patients and can be terrible for a hospital’s bottom line, but at least one cause of readmission – urinary retention after surgery – can be significantly reduced.

"Postoperative urinary retention is a prevalent and mostly avoidable complication," said Dr. Sarita Khemani, a surgical comanagement hospitalist at Stanford (Calif.) University Medical Center.

Postoperative urinary retention can be defined as the inability to void in the presence of symptoms or bladder distension. However, as some patients may retain urine without feeling symptoms or the urge to void, it can also be defined as the inability to void with a bladder volume greater than 500 mL, or the presence of a postvoid residual volume greater than 200 mL on bladder scan, she said at a meeting on perioperative medicine sponsored by the University of Miami.

Identify high-risk patients

"For management, identifying the high-risk patient is very important," said Dr. Khemani.

She and her colleagues are working to develop a scoring system for identifying patients at risk for postoperative retention, she noted.

Depending on the risk factor, patients may require continued use of benign prostatic hyperplasia (BPH) medications (a strategy currently under clinical investigation), multimodal anesthesia, monitoring of IV fluids during and after surgery, and, when necessary, catheterization.

Frontline Medical News

"There is really no consensus as to what is the best catheterization strategy we should use when it comes to urinary retention," Dr. Khemani said.

Low-risk patients undergoing outpatient procedures can be safely sent home without voiding, she said. High-risk patients undergoing ambulatory surgery can be managed with intermittent catheterization.

Patients who are undergoing major but uncomplicated surgery but are at low risk for postoperative retention do not generally need to have Foley catheters placed before surgery. Indwelling catheters should be limited, if possible, to 24 hours after surgery, and the patient can be managed with bladder scans every 6 hours if needed.

Patients scheduled for extensive, complicated procedures and those at high risk may require an indwelling catheter for up to 5 days after surgery. Studies have shown that in these patients early catheter removal actually increases the risk for postoperative urinary retention, Dr. Khemani said.

"It really needs to be followed by bladder scanning very closely, every 6 hours, to try to prevent overdistention and complications after that," she said.

The incidence of postoperative urinary retention among general surgery patients is 3.8%, but can range as high 70% after orthopedic surgery, 50% after anorectal procedures, 40% following spinal surgeries, and 38% after herniorrhaphy, Dr. Khemani said.

Preoperative risk factors for urinary retention after surgery include age over 50; male sex; history of retention; BPH; history of diabetes, stroke, or spinal lesions; or use of drugs such anticholinergic agents or beta-blockers.

Intraoperative and postoperative risk factors include the type and duration of surgery, anesthesia (especially spinal and epidural anethesias), systemic analgesia with opioids (especially patient-controlled analgesia, or PCA), and the use of intraoperative intravenous fluids. High IV fluid infusion causes rapid distention of the bladder detrusor muscles, leading to inability of the muscles to contract after surgery, Dr. Khemani noted.

Complications of postoperative urinary retention can include:

• Autonomic responses to bladder distention, leading to effects such as bradycardia, hypotension, vomiting, and delirium in some elderly patients.

• Infectious complications – urinary tract infections, sepsis, and joint infections.

• Prolonged need for catheterization.

• Bladder dysfunction.

A recent systematic review of drugs for treatment of urinary retention after surgery in adults found that of seven studies involving a total of 494 patients, neither cholinergic agents, alpha blockers, nor sedatives made a significant difference in reducing the incidence of retention. Only prostaglandins, and only when those agents were given intravesically, appeared to offer any benefit, the authors found.

"At this point we definitely need more studies to look at pharmacological alternatives to catheterization for treatment and prevention of this condition," Dr. Khemani concluded.

She reported having no financial disclosures.

SCOTTSDALE, ARIZ. – Early hospital readmissions are not good for patients and can be terrible for a hospital’s bottom line, but at least one cause of readmission – urinary retention after surgery – can be significantly reduced.

"Postoperative urinary retention is a prevalent and mostly avoidable complication," said Dr. Sarita Khemani, a surgical comanagement hospitalist at Stanford (Calif.) University Medical Center.

Postoperative urinary retention can be defined as the inability to void in the presence of symptoms or bladder distension. However, as some patients may retain urine without feeling symptoms or the urge to void, it can also be defined as the inability to void with a bladder volume greater than 500 mL, or the presence of a postvoid residual volume greater than 200 mL on bladder scan, she said at a meeting on perioperative medicine sponsored by the University of Miami.

Identify high-risk patients

"For management, identifying the high-risk patient is very important," said Dr. Khemani.

She and her colleagues are working to develop a scoring system for identifying patients at risk for postoperative retention, she noted.

Depending on the risk factor, patients may require continued use of benign prostatic hyperplasia (BPH) medications (a strategy currently under clinical investigation), multimodal anesthesia, monitoring of IV fluids during and after surgery, and, when necessary, catheterization.

Frontline Medical News

"There is really no consensus as to what is the best catheterization strategy we should use when it comes to urinary retention," Dr. Khemani said.

Low-risk patients undergoing outpatient procedures can be safely sent home without voiding, she said. High-risk patients undergoing ambulatory surgery can be managed with intermittent catheterization.

Patients who are undergoing major but uncomplicated surgery but are at low risk for postoperative retention do not generally need to have Foley catheters placed before surgery. Indwelling catheters should be limited, if possible, to 24 hours after surgery, and the patient can be managed with bladder scans every 6 hours if needed.

Patients scheduled for extensive, complicated procedures and those at high risk may require an indwelling catheter for up to 5 days after surgery. Studies have shown that in these patients early catheter removal actually increases the risk for postoperative urinary retention, Dr. Khemani said.

"It really needs to be followed by bladder scanning very closely, every 6 hours, to try to prevent overdistention and complications after that," she said.

The incidence of postoperative urinary retention among general surgery patients is 3.8%, but can range as high 70% after orthopedic surgery, 50% after anorectal procedures, 40% following spinal surgeries, and 38% after herniorrhaphy, Dr. Khemani said.

Preoperative risk factors for urinary retention after surgery include age over 50; male sex; history of retention; BPH; history of diabetes, stroke, or spinal lesions; or use of drugs such anticholinergic agents or beta-blockers.

Intraoperative and postoperative risk factors include the type and duration of surgery, anesthesia (especially spinal and epidural anethesias), systemic analgesia with opioids (especially patient-controlled analgesia, or PCA), and the use of intraoperative intravenous fluids. High IV fluid infusion causes rapid distention of the bladder detrusor muscles, leading to inability of the muscles to contract after surgery, Dr. Khemani noted.

Complications of postoperative urinary retention can include:

• Autonomic responses to bladder distention, leading to effects such as bradycardia, hypotension, vomiting, and delirium in some elderly patients.

• Infectious complications – urinary tract infections, sepsis, and joint infections.

• Prolonged need for catheterization.

• Bladder dysfunction.

A recent systematic review of drugs for treatment of urinary retention after surgery in adults found that of seven studies involving a total of 494 patients, neither cholinergic agents, alpha blockers, nor sedatives made a significant difference in reducing the incidence of retention. Only prostaglandins, and only when those agents were given intravesically, appeared to offer any benefit, the authors found.

"At this point we definitely need more studies to look at pharmacological alternatives to catheterization for treatment and prevention of this condition," Dr. Khemani concluded.

She reported having no financial disclosures.

SCOTTSDALE, ARIZ. – Early hospital readmissions are not good for patients and can be terrible for a hospital’s bottom line, but at least one cause of readmission – urinary retention after surgery – can be significantly reduced.

"Postoperative urinary retention is a prevalent and mostly avoidable complication," said Dr. Sarita Khemani, a surgical comanagement hospitalist at Stanford (Calif.) University Medical Center.

Postoperative urinary retention can be defined as the inability to void in the presence of symptoms or bladder distension. However, as some patients may retain urine without feeling symptoms or the urge to void, it can also be defined as the inability to void with a bladder volume greater than 500 mL, or the presence of a postvoid residual volume greater than 200 mL on bladder scan, she said at a meeting on perioperative medicine sponsored by the University of Miami.

Identify high-risk patients

"For management, identifying the high-risk patient is very important," said Dr. Khemani.

She and her colleagues are working to develop a scoring system for identifying patients at risk for postoperative retention, she noted.

Depending on the risk factor, patients may require continued use of benign prostatic hyperplasia (BPH) medications (a strategy currently under clinical investigation), multimodal anesthesia, monitoring of IV fluids during and after surgery, and, when necessary, catheterization.

Frontline Medical News

"There is really no consensus as to what is the best catheterization strategy we should use when it comes to urinary retention," Dr. Khemani said.

Low-risk patients undergoing outpatient procedures can be safely sent home without voiding, she said. High-risk patients undergoing ambulatory surgery can be managed with intermittent catheterization.

Patients who are undergoing major but uncomplicated surgery but are at low risk for postoperative retention do not generally need to have Foley catheters placed before surgery. Indwelling catheters should be limited, if possible, to 24 hours after surgery, and the patient can be managed with bladder scans every 6 hours if needed.

Patients scheduled for extensive, complicated procedures and those at high risk may require an indwelling catheter for up to 5 days after surgery. Studies have shown that in these patients early catheter removal actually increases the risk for postoperative urinary retention, Dr. Khemani said.

"It really needs to be followed by bladder scanning very closely, every 6 hours, to try to prevent overdistention and complications after that," she said.

The incidence of postoperative urinary retention among general surgery patients is 3.8%, but can range as high 70% after orthopedic surgery, 50% after anorectal procedures, 40% following spinal surgeries, and 38% after herniorrhaphy, Dr. Khemani said.

Preoperative risk factors for urinary retention after surgery include age over 50; male sex; history of retention; BPH; history of diabetes, stroke, or spinal lesions; or use of drugs such anticholinergic agents or beta-blockers.

Intraoperative and postoperative risk factors include the type and duration of surgery, anesthesia (especially spinal and epidural anethesias), systemic analgesia with opioids (especially patient-controlled analgesia, or PCA), and the use of intraoperative intravenous fluids. High IV fluid infusion causes rapid distention of the bladder detrusor muscles, leading to inability of the muscles to contract after surgery, Dr. Khemani noted.

Complications of postoperative urinary retention can include:

• Autonomic responses to bladder distention, leading to effects such as bradycardia, hypotension, vomiting, and delirium in some elderly patients.

• Infectious complications – urinary tract infections, sepsis, and joint infections.

• Prolonged need for catheterization.

• Bladder dysfunction.

A recent systematic review of drugs for treatment of urinary retention after surgery in adults found that of seven studies involving a total of 494 patients, neither cholinergic agents, alpha blockers, nor sedatives made a significant difference in reducing the incidence of retention. Only prostaglandins, and only when those agents were given intravesically, appeared to offer any benefit, the authors found.

"At this point we definitely need more studies to look at pharmacological alternatives to catheterization for treatment and prevention of this condition," Dr. Khemani concluded.

She reported having no financial disclosures.

MIAMI BEACH* – There appears to be no difference in the rate of anastomotic leak in pancreaticogastrostomy compared with pancreaticojejunostomy reconstruction after a Whipple procedure, but pancreaticogastrostomy does appear to increase the risk of some serious postoperative complications, a study found.

"We didn’t show any significant differences in terms of leaks, severity of leaks, or even overall complications," Dr. Jan Grendar said at the annual meeting of the Americas Hepato-Pancreato-Biliary Association. "But we did show a significant difference in complications of Clavien grades III-V severity. This anastomosis just did a little bit worse in terms of severe complications."

Grade III Clavien complications are those that require a second invasive procedure, like reoperation or drainage, with local or general anesthesia. Grade IV complications are more serious – they include organ failures such as renal failure requiring hemodialysis, heart failure, and liver failure, and intubation. The Grade V complication is patient death.

Dr. Grendar, a surgical resident at the University of Calgary (Alta.), and his colleagues randomized 98 patients with benign or malignant pancreatic disease to either of the two reconstruction techniques after a Whipple procedure. Pancreaticojejunostomy (PJ) is the procedure typically performed in North America. Pancreaticogastrostomy (PG) is typically performed in Europe. The hepatobiliary pancreatic surgeons and residents at the university, however, have become adept at this second procedure and employ it as an alternative reconstruction, depending on the characteristics of the pancreas discovered during surgery. They most often use it on patients who have a soft pancreas or small pancreatic duct.

All of the patients in the study had a pancreatic or periampullary neoplasm that appeared resectable on preoperative imaging. There were no differences in baseline patient characteristics. The mean age was 64 in the PG group and 68 in the PJ group. The median Charlson comorbidity index score was 2.

The intraoperative outcomes were mostly similar. Gland mobilization occurred significantly more often in the PG group (31 vs. 18 mm). Significantly fewer PG patients had a two-layer anastomosis (77% vs. 94%). The mean pancreatic duct size was smaller in the PG patients (3.8 vs. 4.3 mm), but this wasn’t statistically significant. Significantly fewer PG patients had a pancreatic duct stent placed (22% vs. 83%).

Postoperative outcomes included pancreatic fistula, any postoperative complications, severe complications, and length of stay.

There was no difference between the groups in Clavien grade complications separately, but significantly more PG patients had severe, Clavien grade III-V complications (31% vs. 12%). But these didn’t affect the mean length of stay, which was similar between the groups (17 vs. 14 days).

In a multivariate analysis, only having a soft pancreas significantly increased the risk of developing a pancreatic fistula (odds ratio, 5.87). Female gender significantly decreased the risk (OR, 0.31). This most likely represents a correlation between pancreatic texture and patient sex rather than a true protective property of being female. Having a soft pancreas also significantly increased the risk of any postoperative complications (OR, 3.08).

Several factors significantly increased the risk of a severe complication. These included a baseline American Society of Anesthesiologists grade of 2 or 3 (OR, 12.75 and 29.56, respectively). Being randomized to the PJ procedure significantly decreased the risk of a severe complication (OR, 0.11).

"Unlike the European centers that report different outcomes, these results are coming from a center that wasn’t very enthusiastic about this type of reconstruction prior to this study," Dr. Grendar said in an interview. "Despite the initial preference, high-risk patients in Calgary, those with soft pancreatic glands and small pancreatic ducts, are now likely to be offered a pancreaticogastrostomy"

Dr. Grendar said he had no relevant financial disclosures.

msullivan@frontlinemedcom.com

*Correction, 3/11/2014: An earlier version of the article misstated the name of the city where the AHPBA meeting took place.

MIAMI BEACH* – There appears to be no difference in the rate of anastomotic leak in pancreaticogastrostomy compared with pancreaticojejunostomy reconstruction after a Whipple procedure, but pancreaticogastrostomy does appear to increase the risk of some serious postoperative complications, a study found.

"We didn’t show any significant differences in terms of leaks, severity of leaks, or even overall complications," Dr. Jan Grendar said at the annual meeting of the Americas Hepato-Pancreato-Biliary Association. "But we did show a significant difference in complications of Clavien grades III-V severity. This anastomosis just did a little bit worse in terms of severe complications."

Grade III Clavien complications are those that require a second invasive procedure, like reoperation or drainage, with local or general anesthesia. Grade IV complications are more serious – they include organ failures such as renal failure requiring hemodialysis, heart failure, and liver failure, and intubation. The Grade V complication is patient death.

Dr. Grendar, a surgical resident at the University of Calgary (Alta.), and his colleagues randomized 98 patients with benign or malignant pancreatic disease to either of the two reconstruction techniques after a Whipple procedure. Pancreaticojejunostomy (PJ) is the procedure typically performed in North America. Pancreaticogastrostomy (PG) is typically performed in Europe. The hepatobiliary pancreatic surgeons and residents at the university, however, have become adept at this second procedure and employ it as an alternative reconstruction, depending on the characteristics of the pancreas discovered during surgery. They most often use it on patients who have a soft pancreas or small pancreatic duct.

All of the patients in the study had a pancreatic or periampullary neoplasm that appeared resectable on preoperative imaging. There were no differences in baseline patient characteristics. The mean age was 64 in the PG group and 68 in the PJ group. The median Charlson comorbidity index score was 2.

The intraoperative outcomes were mostly similar. Gland mobilization occurred significantly more often in the PG group (31 vs. 18 mm). Significantly fewer PG patients had a two-layer anastomosis (77% vs. 94%). The mean pancreatic duct size was smaller in the PG patients (3.8 vs. 4.3 mm), but this wasn’t statistically significant. Significantly fewer PG patients had a pancreatic duct stent placed (22% vs. 83%).

Postoperative outcomes included pancreatic fistula, any postoperative complications, severe complications, and length of stay.

There was no difference between the groups in Clavien grade complications separately, but significantly more PG patients had severe, Clavien grade III-V complications (31% vs. 12%). But these didn’t affect the mean length of stay, which was similar between the groups (17 vs. 14 days).

In a multivariate analysis, only having a soft pancreas significantly increased the risk of developing a pancreatic fistula (odds ratio, 5.87). Female gender significantly decreased the risk (OR, 0.31). This most likely represents a correlation between pancreatic texture and patient sex rather than a true protective property of being female. Having a soft pancreas also significantly increased the risk of any postoperative complications (OR, 3.08).

Several factors significantly increased the risk of a severe complication. These included a baseline American Society of Anesthesiologists grade of 2 or 3 (OR, 12.75 and 29.56, respectively). Being randomized to the PJ procedure significantly decreased the risk of a severe complication (OR, 0.11).

"Unlike the European centers that report different outcomes, these results are coming from a center that wasn’t very enthusiastic about this type of reconstruction prior to this study," Dr. Grendar said in an interview. "Despite the initial preference, high-risk patients in Calgary, those with soft pancreatic glands and small pancreatic ducts, are now likely to be offered a pancreaticogastrostomy"

Dr. Grendar said he had no relevant financial disclosures.

msullivan@frontlinemedcom.com

*Correction, 3/11/2014: An earlier version of the article misstated the name of the city where the AHPBA meeting took place.

MIAMI BEACH* – There appears to be no difference in the rate of anastomotic leak in pancreaticogastrostomy compared with pancreaticojejunostomy reconstruction after a Whipple procedure, but pancreaticogastrostomy does appear to increase the risk of some serious postoperative complications, a study found.

"We didn’t show any significant differences in terms of leaks, severity of leaks, or even overall complications," Dr. Jan Grendar said at the annual meeting of the Americas Hepato-Pancreato-Biliary Association. "But we did show a significant difference in complications of Clavien grades III-V severity. This anastomosis just did a little bit worse in terms of severe complications."

Grade III Clavien complications are those that require a second invasive procedure, like reoperation or drainage, with local or general anesthesia. Grade IV complications are more serious – they include organ failures such as renal failure requiring hemodialysis, heart failure, and liver failure, and intubation. The Grade V complication is patient death.

Dr. Grendar, a surgical resident at the University of Calgary (Alta.), and his colleagues randomized 98 patients with benign or malignant pancreatic disease to either of the two reconstruction techniques after a Whipple procedure. Pancreaticojejunostomy (PJ) is the procedure typically performed in North America. Pancreaticogastrostomy (PG) is typically performed in Europe. The hepatobiliary pancreatic surgeons and residents at the university, however, have become adept at this second procedure and employ it as an alternative reconstruction, depending on the characteristics of the pancreas discovered during surgery. They most often use it on patients who have a soft pancreas or small pancreatic duct.

All of the patients in the study had a pancreatic or periampullary neoplasm that appeared resectable on preoperative imaging. There were no differences in baseline patient characteristics. The mean age was 64 in the PG group and 68 in the PJ group. The median Charlson comorbidity index score was 2.

The intraoperative outcomes were mostly similar. Gland mobilization occurred significantly more often in the PG group (31 vs. 18 mm). Significantly fewer PG patients had a two-layer anastomosis (77% vs. 94%). The mean pancreatic duct size was smaller in the PG patients (3.8 vs. 4.3 mm), but this wasn’t statistically significant. Significantly fewer PG patients had a pancreatic duct stent placed (22% vs. 83%).

Postoperative outcomes included pancreatic fistula, any postoperative complications, severe complications, and length of stay.

There was no difference between the groups in Clavien grade complications separately, but significantly more PG patients had severe, Clavien grade III-V complications (31% vs. 12%). But these didn’t affect the mean length of stay, which was similar between the groups (17 vs. 14 days).

In a multivariate analysis, only having a soft pancreas significantly increased the risk of developing a pancreatic fistula (odds ratio, 5.87). Female gender significantly decreased the risk (OR, 0.31). This most likely represents a correlation between pancreatic texture and patient sex rather than a true protective property of being female. Having a soft pancreas also significantly increased the risk of any postoperative complications (OR, 3.08).

Several factors significantly increased the risk of a severe complication. These included a baseline American Society of Anesthesiologists grade of 2 or 3 (OR, 12.75 and 29.56, respectively). Being randomized to the PJ procedure significantly decreased the risk of a severe complication (OR, 0.11).

"Unlike the European centers that report different outcomes, these results are coming from a center that wasn’t very enthusiastic about this type of reconstruction prior to this study," Dr. Grendar said in an interview. "Despite the initial preference, high-risk patients in Calgary, those with soft pancreatic glands and small pancreatic ducts, are now likely to be offered a pancreaticogastrostomy"

Dr. Grendar said he had no relevant financial disclosures.

msullivan@frontlinemedcom.com

*Correction, 3/11/2014: An earlier version of the article misstated the name of the city where the AHPBA meeting took place.

SAN FRANCISCO – The incidence of colorectal cancer is rising sharply among younger adults in the United States, a study showed.

Researchers analyzed Surveillance, Epidemiology, and End Results (SEER) data for 383,241 patients in whom colorectal cancer was diagnosed between 1975 and 2010.

The results showed that the age-adjusted incidence rate of colorectal cancer fell steadily among patients aged 50 years and older at diagnosis, lead author Dr. Christina E. Bailey, a surgical oncology fellow at the M.D. Anderson Cancer Center in Houston, reported in a poster session at the annual Gastrointestinal Cancers Symposium. But the rate rose among younger patients.

The annual percentage change in the age-adjusted incidence rate of colorectal cancer during the 35-year period was a significant –0.92 in the cohort overall. In stratified analyses, the annual percentage change fell significantly among patients aged 50-74 at diagnosis (–0.97), and aged 75 years and older at diagnosis (–1.15). But it rose among patients aged 35-49 at diagnosis (0.41) and especially among patients aged 20-34 at diagnosis (1.99).

The findings were similar for colon cancer separately (with strongest results seen for disease that was distant at diagnosis) and for rectal/rectosigmoid cancer separately.

A predictive model suggested that if the observed trends persist between 2010 and 2030, the incidences of colon cancer and of rectal/rectosigmoid cancer will rise by 90% and 124%, respectively, among 20- to 34-year-olds, and by 28% and 46%, respectively, among 35- to 49-year-olds.

Much of the decreasing incidence among older adults "can be attributed to the fact that screening is recommended beginning at the age of 50," Dr. Bailey commented in an interview.

"We saw dramatic rises in the predicted incidences of both colon and rectal cancer in our younger cohort that point out that further studies need to be done to determine why this is happening and what can we do now to prevent this trajectory from occurring in the future," she said at the symposium, sponsored by the American Society of Clinical Oncology.

Likely explanations for this sharp uptick, she suggested, include increasing population levels of obesity and physical inactivity, and consumption of a diet high in fat and red meat – factors implicated as risks for colorectal cancer.

Another possibility is that primary care physicians are now more alert for this cancer in young patients with symptoms such as rectal bleeding, which previously may have been attributed to conditions such as hemorrhoids, delaying diagnosis until an older age.

Recommendations still call for routine colorectal cancer screening only in those patients younger than age 50 who have risk factors such as familial adenomatous polyposis and Lynch syndrome, Dr. Bailey noted. And even though the incidence is rising in the younger age groups, it is still considerably lower than it is among people aged 50 years and older.

Dr. Bailey said she had no relevant financial disclosures.

SAN FRANCISCO – The incidence of colorectal cancer is rising sharply among younger adults in the United States, a study showed.

Researchers analyzed Surveillance, Epidemiology, and End Results (SEER) data for 383,241 patients in whom colorectal cancer was diagnosed between 1975 and 2010.

The results showed that the age-adjusted incidence rate of colorectal cancer fell steadily among patients aged 50 years and older at diagnosis, lead author Dr. Christina E. Bailey, a surgical oncology fellow at the M.D. Anderson Cancer Center in Houston, reported in a poster session at the annual Gastrointestinal Cancers Symposium. But the rate rose among younger patients.

The annual percentage change in the age-adjusted incidence rate of colorectal cancer during the 35-year period was a significant –0.92 in the cohort overall. In stratified analyses, the annual percentage change fell significantly among patients aged 50-74 at diagnosis (–0.97), and aged 75 years and older at diagnosis (–1.15). But it rose among patients aged 35-49 at diagnosis (0.41) and especially among patients aged 20-34 at diagnosis (1.99).

The findings were similar for colon cancer separately (with strongest results seen for disease that was distant at diagnosis) and for rectal/rectosigmoid cancer separately.

A predictive model suggested that if the observed trends persist between 2010 and 2030, the incidences of colon cancer and of rectal/rectosigmoid cancer will rise by 90% and 124%, respectively, among 20- to 34-year-olds, and by 28% and 46%, respectively, among 35- to 49-year-olds.

Much of the decreasing incidence among older adults "can be attributed to the fact that screening is recommended beginning at the age of 50," Dr. Bailey commented in an interview.

"We saw dramatic rises in the predicted incidences of both colon and rectal cancer in our younger cohort that point out that further studies need to be done to determine why this is happening and what can we do now to prevent this trajectory from occurring in the future," she said at the symposium, sponsored by the American Society of Clinical Oncology.

Likely explanations for this sharp uptick, she suggested, include increasing population levels of obesity and physical inactivity, and consumption of a diet high in fat and red meat – factors implicated as risks for colorectal cancer.

Another possibility is that primary care physicians are now more alert for this cancer in young patients with symptoms such as rectal bleeding, which previously may have been attributed to conditions such as hemorrhoids, delaying diagnosis until an older age.

Recommendations still call for routine colorectal cancer screening only in those patients younger than age 50 who have risk factors such as familial adenomatous polyposis and Lynch syndrome, Dr. Bailey noted. And even though the incidence is rising in the younger age groups, it is still considerably lower than it is among people aged 50 years and older.

Dr. Bailey said she had no relevant financial disclosures.

SAN FRANCISCO – The incidence of colorectal cancer is rising sharply among younger adults in the United States, a study showed.

Researchers analyzed Surveillance, Epidemiology, and End Results (SEER) data for 383,241 patients in whom colorectal cancer was diagnosed between 1975 and 2010.

The results showed that the age-adjusted incidence rate of colorectal cancer fell steadily among patients aged 50 years and older at diagnosis, lead author Dr. Christina E. Bailey, a surgical oncology fellow at the M.D. Anderson Cancer Center in Houston, reported in a poster session at the annual Gastrointestinal Cancers Symposium. But the rate rose among younger patients.

The annual percentage change in the age-adjusted incidence rate of colorectal cancer during the 35-year period was a significant –0.92 in the cohort overall. In stratified analyses, the annual percentage change fell significantly among patients aged 50-74 at diagnosis (–0.97), and aged 75 years and older at diagnosis (–1.15). But it rose among patients aged 35-49 at diagnosis (0.41) and especially among patients aged 20-34 at diagnosis (1.99).

The findings were similar for colon cancer separately (with strongest results seen for disease that was distant at diagnosis) and for rectal/rectosigmoid cancer separately.

A predictive model suggested that if the observed trends persist between 2010 and 2030, the incidences of colon cancer and of rectal/rectosigmoid cancer will rise by 90% and 124%, respectively, among 20- to 34-year-olds, and by 28% and 46%, respectively, among 35- to 49-year-olds.

Much of the decreasing incidence among older adults "can be attributed to the fact that screening is recommended beginning at the age of 50," Dr. Bailey commented in an interview.

"We saw dramatic rises in the predicted incidences of both colon and rectal cancer in our younger cohort that point out that further studies need to be done to determine why this is happening and what can we do now to prevent this trajectory from occurring in the future," she said at the symposium, sponsored by the American Society of Clinical Oncology.

Likely explanations for this sharp uptick, she suggested, include increasing population levels of obesity and physical inactivity, and consumption of a diet high in fat and red meat – factors implicated as risks for colorectal cancer.

Another possibility is that primary care physicians are now more alert for this cancer in young patients with symptoms such as rectal bleeding, which previously may have been attributed to conditions such as hemorrhoids, delaying diagnosis until an older age.

Recommendations still call for routine colorectal cancer screening only in those patients younger than age 50 who have risk factors such as familial adenomatous polyposis and Lynch syndrome, Dr. Bailey noted. And even though the incidence is rising in the younger age groups, it is still considerably lower than it is among people aged 50 years and older.

Dr. Bailey said she had no relevant financial disclosures.

As C-reactive protein levels and erythrocyte sedimentation rates go up in patients with inflammatory bowel disease, the risk of colorectal cancer goes up, too, a finding that suggests a role for both as markers of colon cancer risk, Boston investigators reported in a prospective study published online Jan. 6 in Clinical Gastroenterology and Hepatology.

The team divided 3,145 IBD patients into quartiles based on median C-reactive protein (CRP) levels, and 4,008 others into quartiles based on median erythrocyte sedimentation rates (ESR), then followed them for a median of 6 years.

On multivariate analysis, there was a significant increase in the risk of colorectal cancer (CRC) across quartiles of CRP elevation (P for trend = .017). Higher median ESR was also independently associated with higher risk of CRC across quartiles (P for trend = .007) (Clin. Gastroenterol. Hepatol. 2014 Jan. 6 [doi: 10.1016/j.cgh.2013.12.030]).

"This association adds another clinical variable to help stratify patients into risk categories. There is an important need to identify high-risk subgroups that may benefit from continued intensive surveillance strategies while allowing for less frequent colonoscopies in patients at low risk of CRC. We believe that our findings ... suggest that an individual patient’s severity of inflammation may be helpful in further personalizing surveillance recommendations," and might even help monitor other outcomes, including treatment response, said the authors, led by Dr. Ashwin Ananthakrishnan, a gastroenterologist at Massachusetts General Hospital, Boston.

After adjustment for age, sex, race, IBD type, and other factors, the patients in the highest CRP quartile had more than double the risk of colorectal cancer compared with those in the lowest quartile (OR 2.72, 95% CI 0.95-7.76). The strength of association was similar in men and women, and in Crohn’s disease and ulcerative colitis.

Similarly, patients in the highest ESR quartile had double the risk compared with those in the lowest (OR 2.06, 95% CI 1.14-3.74). The correlation was strongest in ulcerative colitis patients and men.

The median CRP values in each of the quartiles were 0.8, 2.7, 7.5, and 32.8 mg/L. In the ESR group, the median quartile values were 7, 14, 25, and 50 mm/hr.

Overall, 33 patients in the CRP cohort and 102 patients in the ESR cohort developed colorectal cancer at a median age of 55 years. The median number of CRP measurements was three, and median number of ESR measurements six. More than half the subjects were women, most were white, and ulcerative colitis was slightly more common than was Crohn’s disease.

Adjusting for number of colonoscopies, intensity of health care utilization, use of corticosteroids, and other factors did not change results for either the CRP or ESR cohorts.

The National Institutes of Health funded the work. The investigators have no disclosures.

aotto@frontlinemedcom.com

As C-reactive protein levels and erythrocyte sedimentation rates go up in patients with inflammatory bowel disease, the risk of colorectal cancer goes up, too, a finding that suggests a role for both as markers of colon cancer risk, Boston investigators reported in a prospective study published online Jan. 6 in Clinical Gastroenterology and Hepatology.

The team divided 3,145 IBD patients into quartiles based on median C-reactive protein (CRP) levels, and 4,008 others into quartiles based on median erythrocyte sedimentation rates (ESR), then followed them for a median of 6 years.

On multivariate analysis, there was a significant increase in the risk of colorectal cancer (CRC) across quartiles of CRP elevation (P for trend = .017). Higher median ESR was also independently associated with higher risk of CRC across quartiles (P for trend = .007) (Clin. Gastroenterol. Hepatol. 2014 Jan. 6 [doi: 10.1016/j.cgh.2013.12.030]).

"This association adds another clinical variable to help stratify patients into risk categories. There is an important need to identify high-risk subgroups that may benefit from continued intensive surveillance strategies while allowing for less frequent colonoscopies in patients at low risk of CRC. We believe that our findings ... suggest that an individual patient’s severity of inflammation may be helpful in further personalizing surveillance recommendations," and might even help monitor other outcomes, including treatment response, said the authors, led by Dr. Ashwin Ananthakrishnan, a gastroenterologist at Massachusetts General Hospital, Boston.

After adjustment for age, sex, race, IBD type, and other factors, the patients in the highest CRP quartile had more than double the risk of colorectal cancer compared with those in the lowest quartile (OR 2.72, 95% CI 0.95-7.76). The strength of association was similar in men and women, and in Crohn’s disease and ulcerative colitis.

Similarly, patients in the highest ESR quartile had double the risk compared with those in the lowest (OR 2.06, 95% CI 1.14-3.74). The correlation was strongest in ulcerative colitis patients and men.

The median CRP values in each of the quartiles were 0.8, 2.7, 7.5, and 32.8 mg/L. In the ESR group, the median quartile values were 7, 14, 25, and 50 mm/hr.

Overall, 33 patients in the CRP cohort and 102 patients in the ESR cohort developed colorectal cancer at a median age of 55 years. The median number of CRP measurements was three, and median number of ESR measurements six. More than half the subjects were women, most were white, and ulcerative colitis was slightly more common than was Crohn’s disease.

Adjusting for number of colonoscopies, intensity of health care utilization, use of corticosteroids, and other factors did not change results for either the CRP or ESR cohorts.

The National Institutes of Health funded the work. The investigators have no disclosures.

aotto@frontlinemedcom.com

As C-reactive protein levels and erythrocyte sedimentation rates go up in patients with inflammatory bowel disease, the risk of colorectal cancer goes up, too, a finding that suggests a role for both as markers of colon cancer risk, Boston investigators reported in a prospective study published online Jan. 6 in Clinical Gastroenterology and Hepatology.

The team divided 3,145 IBD patients into quartiles based on median C-reactive protein (CRP) levels, and 4,008 others into quartiles based on median erythrocyte sedimentation rates (ESR), then followed them for a median of 6 years.

On multivariate analysis, there was a significant increase in the risk of colorectal cancer (CRC) across quartiles of CRP elevation (P for trend = .017). Higher median ESR was also independently associated with higher risk of CRC across quartiles (P for trend = .007) (Clin. Gastroenterol. Hepatol. 2014 Jan. 6 [doi: 10.1016/j.cgh.2013.12.030]).

"This association adds another clinical variable to help stratify patients into risk categories. There is an important need to identify high-risk subgroups that may benefit from continued intensive surveillance strategies while allowing for less frequent colonoscopies in patients at low risk of CRC. We believe that our findings ... suggest that an individual patient’s severity of inflammation may be helpful in further personalizing surveillance recommendations," and might even help monitor other outcomes, including treatment response, said the authors, led by Dr. Ashwin Ananthakrishnan, a gastroenterologist at Massachusetts General Hospital, Boston.

After adjustment for age, sex, race, IBD type, and other factors, the patients in the highest CRP quartile had more than double the risk of colorectal cancer compared with those in the lowest quartile (OR 2.72, 95% CI 0.95-7.76). The strength of association was similar in men and women, and in Crohn’s disease and ulcerative colitis.

Similarly, patients in the highest ESR quartile had double the risk compared with those in the lowest (OR 2.06, 95% CI 1.14-3.74). The correlation was strongest in ulcerative colitis patients and men.

The median CRP values in each of the quartiles were 0.8, 2.7, 7.5, and 32.8 mg/L. In the ESR group, the median quartile values were 7, 14, 25, and 50 mm/hr.

Overall, 33 patients in the CRP cohort and 102 patients in the ESR cohort developed colorectal cancer at a median age of 55 years. The median number of CRP measurements was three, and median number of ESR measurements six. More than half the subjects were women, most were white, and ulcerative colitis was slightly more common than was Crohn’s disease.

Adjusting for number of colonoscopies, intensity of health care utilization, use of corticosteroids, and other factors did not change results for either the CRP or ESR cohorts.

The National Institutes of Health funded the work. The investigators have no disclosures.

aotto@frontlinemedcom.com

Discharging patients with uncomplicated diverticulitis from the emergency department on antibiotics was just as effective as hospitalization – and cost about a third as much, based on a study conducted in Spain.

Dr. Sebastiano Biondi and his colleagues conducted their randomized, parallel-group study at five hospitals. The cohort consisted of 132 adults, mean age 56 years, who presented to the emergency department with localized abdominal pain. All had an abdominal CT scan and received intravenous antibiotics, either an initial IV infusion of 1 g of amoxicillin per 125 mg of clavulanic acid, or, in the case of those with a penicillin allergy, ciprofloxacin 200 mg and metronidazole 500 mg.

Half of the patients were then assigned to either inpatient or outpatient antibiotic treatment. The admitted patients continued to receive IV antibiotics and fluids for 36-48 hours until they tolerated oral feeding. The outpatients were discharged on oral amoxicillin and clavulanic acid (875 mg per 125 mg every 8 hours) or, in those with penicillin allergy, the combination of ciprofloxacin (500 mg every 12 hours) and metronidazole (500 mg every 8 hours).

The study’s main endpoint was treatment failure rate (persistence, increase, or recurrence of abdominal pain and/or fever; inflammatory bowel obstruction; or the need for radiological abscess drainage or immediate surgery due to complicated diverticulitis). Patients were followed every day for 5 days, and then interviewed on day 14. Before the final follow-up at 60 days, patients underwent a colonoscopy to rule out malignancy.

Seven patients (5%) were readmitted due to treatment failure: 4 (6%) in the inpatient group and three (4.5%) in the outpatient group. The difference was not statistically significant. No one needed emergency surgery as part of readmission, and there were no deaths.

A quality of life assessment found that hospitalized patients reported a significantly higher level of physical health during the first 2 weeks of treatment, but that difference disappeared after 14 days.

Total treatment costs were significantly less in the outpatient group, with an average savings of $1,840 per patient ($895 for outpatient care compared with $2,735 for inpatient care). Almost all of that cost difference was due to hospital bed cost, with an average stay of 4 days.

"The outpatient protocol of this study is applicable to a selected group of patients with uncomplicated diverticulitis," Dr. Biondi reported in the January issue of Annals of Surgery (doi: 10.1097/SLA.0b013e3182965a11).

Widespread adoption of outpatient treatment could have a profound effect on the cost of treating diverticulitis, an ever more common gastrointestinal problem, said Dr. Biondi of the University of Barcelona and his coauthors. "According to data from the National Hospital Discharge Survey, diverticular disease is responsible for 314,000 hospital admissions per year in the United States, and the estimated annual cost in 1998 was about $2.6 billion."

The Spanish Ministry of Health funded the trial. The authors had no financial conflicts.

msullivan@frontlinemedcom.com

Discharging patients with uncomplicated diverticulitis from the emergency department on antibiotics was just as effective as hospitalization – and cost about a third as much, based on a study conducted in Spain.

Dr. Sebastiano Biondi and his colleagues conducted their randomized, parallel-group study at five hospitals. The cohort consisted of 132 adults, mean age 56 years, who presented to the emergency department with localized abdominal pain. All had an abdominal CT scan and received intravenous antibiotics, either an initial IV infusion of 1 g of amoxicillin per 125 mg of clavulanic acid, or, in the case of those with a penicillin allergy, ciprofloxacin 200 mg and metronidazole 500 mg.

Half of the patients were then assigned to either inpatient or outpatient antibiotic treatment. The admitted patients continued to receive IV antibiotics and fluids for 36-48 hours until they tolerated oral feeding. The outpatients were discharged on oral amoxicillin and clavulanic acid (875 mg per 125 mg every 8 hours) or, in those with penicillin allergy, the combination of ciprofloxacin (500 mg every 12 hours) and metronidazole (500 mg every 8 hours).

The study’s main endpoint was treatment failure rate (persistence, increase, or recurrence of abdominal pain and/or fever; inflammatory bowel obstruction; or the need for radiological abscess drainage or immediate surgery due to complicated diverticulitis). Patients were followed every day for 5 days, and then interviewed on day 14. Before the final follow-up at 60 days, patients underwent a colonoscopy to rule out malignancy.

Seven patients (5%) were readmitted due to treatment failure: 4 (6%) in the inpatient group and three (4.5%) in the outpatient group. The difference was not statistically significant. No one needed emergency surgery as part of readmission, and there were no deaths.

A quality of life assessment found that hospitalized patients reported a significantly higher level of physical health during the first 2 weeks of treatment, but that difference disappeared after 14 days.

Total treatment costs were significantly less in the outpatient group, with an average savings of $1,840 per patient ($895 for outpatient care compared with $2,735 for inpatient care). Almost all of that cost difference was due to hospital bed cost, with an average stay of 4 days.

"The outpatient protocol of this study is applicable to a selected group of patients with uncomplicated diverticulitis," Dr. Biondi reported in the January issue of Annals of Surgery (doi: 10.1097/SLA.0b013e3182965a11).

Widespread adoption of outpatient treatment could have a profound effect on the cost of treating diverticulitis, an ever more common gastrointestinal problem, said Dr. Biondi of the University of Barcelona and his coauthors. "According to data from the National Hospital Discharge Survey, diverticular disease is responsible for 314,000 hospital admissions per year in the United States, and the estimated annual cost in 1998 was about $2.6 billion."

The Spanish Ministry of Health funded the trial. The authors had no financial conflicts.

msullivan@frontlinemedcom.com

Discharging patients with uncomplicated diverticulitis from the emergency department on antibiotics was just as effective as hospitalization – and cost about a third as much, based on a study conducted in Spain.

Dr. Sebastiano Biondi and his colleagues conducted their randomized, parallel-group study at five hospitals. The cohort consisted of 132 adults, mean age 56 years, who presented to the emergency department with localized abdominal pain. All had an abdominal CT scan and received intravenous antibiotics, either an initial IV infusion of 1 g of amoxicillin per 125 mg of clavulanic acid, or, in the case of those with a penicillin allergy, ciprofloxacin 200 mg and metronidazole 500 mg.

Half of the patients were then assigned to either inpatient or outpatient antibiotic treatment. The admitted patients continued to receive IV antibiotics and fluids for 36-48 hours until they tolerated oral feeding. The outpatients were discharged on oral amoxicillin and clavulanic acid (875 mg per 125 mg every 8 hours) or, in those with penicillin allergy, the combination of ciprofloxacin (500 mg every 12 hours) and metronidazole (500 mg every 8 hours).

The study’s main endpoint was treatment failure rate (persistence, increase, or recurrence of abdominal pain and/or fever; inflammatory bowel obstruction; or the need for radiological abscess drainage or immediate surgery due to complicated diverticulitis). Patients were followed every day for 5 days, and then interviewed on day 14. Before the final follow-up at 60 days, patients underwent a colonoscopy to rule out malignancy.

Seven patients (5%) were readmitted due to treatment failure: 4 (6%) in the inpatient group and three (4.5%) in the outpatient group. The difference was not statistically significant. No one needed emergency surgery as part of readmission, and there were no deaths.

A quality of life assessment found that hospitalized patients reported a significantly higher level of physical health during the first 2 weeks of treatment, but that difference disappeared after 14 days.

Total treatment costs were significantly less in the outpatient group, with an average savings of $1,840 per patient ($895 for outpatient care compared with $2,735 for inpatient care). Almost all of that cost difference was due to hospital bed cost, with an average stay of 4 days.

"The outpatient protocol of this study is applicable to a selected group of patients with uncomplicated diverticulitis," Dr. Biondi reported in the January issue of Annals of Surgery (doi: 10.1097/SLA.0b013e3182965a11).

Widespread adoption of outpatient treatment could have a profound effect on the cost of treating diverticulitis, an ever more common gastrointestinal problem, said Dr. Biondi of the University of Barcelona and his coauthors. "According to data from the National Hospital Discharge Survey, diverticular disease is responsible for 314,000 hospital admissions per year in the United States, and the estimated annual cost in 1998 was about $2.6 billion."

The Spanish Ministry of Health funded the trial. The authors had no financial conflicts.

msullivan@frontlinemedcom.com

NATIONAL HARBOR, MD. – Pregnancy occurred in more than half of infertile women who had a segmental laparoscopic bowel resection for endometriosis.

Of 155 women, 96 (62%) conceived after the surgery. Most of these pregnancies (71 of 96; 74%) were spontaneous, Dr. Rosa Maria Neme reported at a meeting sponsored by AAGL.

The prospective study included women treated during 2009-2012 at the University of São Paulo, Brazil, said Dr. Neme, director of the university’s endometriosis center. The patients were a mean of 32 years old.

Most (92%) had bowel symptoms, including pain during defecation, diarrhea and constipation, abdominal bloating, and dyschezia. Endometriosis-related symptoms were present in all, and included dysmenorrhea, nonmenstrual pelvic pain and dyspareunia, tenesmus, cyclic rectal bleeding, lower back pain, and asthenia.

An associated infertility was present in 62% (155), with a mean duration of 18 months. Most patients (78%) had already undergone some form of fertility treatment before surgery and 69% had undergone a previous surgery for pelvic pain.

All of the patients had a torus bowel resection. A number of other procedures also were performed during the surgery, including extensive ureterolysis (80%), ovarian cystectomy (70%), partial vaginal resection (20%), and appendectomy (20%).

The mean operative time was 117 minutes. There were no conversions to open surgery, no transfusions, and no intra- or postoperative complications. The mean length of stay was 3 days. The pathology of all resected lesions was stromal and glandular endometriosis.

After the surgery, 96 pregnancies occurred among the subgroup with infertility (62%). The median time to conception was 8 months. The majority of pregnancies were spontaneous (71), with the rest achieved by in vitro fertilization. There were four miscarriages.

A quality of life survey was conducted at 6 months. By that time, dysmenorrhea, dyspareunia and pain on defecation, intestinal cramping, diarrhea and constipation had disappeared in all women.

Dr. Neme had no financial disclosures.

msullivan@frontlinemedcom.com

NATIONAL HARBOR, MD. – Pregnancy occurred in more than half of infertile women who had a segmental laparoscopic bowel resection for endometriosis.

Of 155 women, 96 (62%) conceived after the surgery. Most of these pregnancies (71 of 96; 74%) were spontaneous, Dr. Rosa Maria Neme reported at a meeting sponsored by AAGL.

The prospective study included women treated during 2009-2012 at the University of São Paulo, Brazil, said Dr. Neme, director of the university’s endometriosis center. The patients were a mean of 32 years old.

Most (92%) had bowel symptoms, including pain during defecation, diarrhea and constipation, abdominal bloating, and dyschezia. Endometriosis-related symptoms were present in all, and included dysmenorrhea, nonmenstrual pelvic pain and dyspareunia, tenesmus, cyclic rectal bleeding, lower back pain, and asthenia.

An associated infertility was present in 62% (155), with a mean duration of 18 months. Most patients (78%) had already undergone some form of fertility treatment before surgery and 69% had undergone a previous surgery for pelvic pain.

All of the patients had a torus bowel resection. A number of other procedures also were performed during the surgery, including extensive ureterolysis (80%), ovarian cystectomy (70%), partial vaginal resection (20%), and appendectomy (20%).

The mean operative time was 117 minutes. There were no conversions to open surgery, no transfusions, and no intra- or postoperative complications. The mean length of stay was 3 days. The pathology of all resected lesions was stromal and glandular endometriosis.

After the surgery, 96 pregnancies occurred among the subgroup with infertility (62%). The median time to conception was 8 months. The majority of pregnancies were spontaneous (71), with the rest achieved by in vitro fertilization. There were four miscarriages.

A quality of life survey was conducted at 6 months. By that time, dysmenorrhea, dyspareunia and pain on defecation, intestinal cramping, diarrhea and constipation had disappeared in all women.

Dr. Neme had no financial disclosures.

msullivan@frontlinemedcom.com

NATIONAL HARBOR, MD. – Pregnancy occurred in more than half of infertile women who had a segmental laparoscopic bowel resection for endometriosis.

Of 155 women, 96 (62%) conceived after the surgery. Most of these pregnancies (71 of 96; 74%) were spontaneous, Dr. Rosa Maria Neme reported at a meeting sponsored by AAGL.

The prospective study included women treated during 2009-2012 at the University of São Paulo, Brazil, said Dr. Neme, director of the university’s endometriosis center. The patients were a mean of 32 years old.

Most (92%) had bowel symptoms, including pain during defecation, diarrhea and constipation, abdominal bloating, and dyschezia. Endometriosis-related symptoms were present in all, and included dysmenorrhea, nonmenstrual pelvic pain and dyspareunia, tenesmus, cyclic rectal bleeding, lower back pain, and asthenia.

An associated infertility was present in 62% (155), with a mean duration of 18 months. Most patients (78%) had already undergone some form of fertility treatment before surgery and 69% had undergone a previous surgery for pelvic pain.

All of the patients had a torus bowel resection. A number of other procedures also were performed during the surgery, including extensive ureterolysis (80%), ovarian cystectomy (70%), partial vaginal resection (20%), and appendectomy (20%).

The mean operative time was 117 minutes. There were no conversions to open surgery, no transfusions, and no intra- or postoperative complications. The mean length of stay was 3 days. The pathology of all resected lesions was stromal and glandular endometriosis.

After the surgery, 96 pregnancies occurred among the subgroup with infertility (62%). The median time to conception was 8 months. The majority of pregnancies were spontaneous (71), with the rest achieved by in vitro fertilization. There were four miscarriages.

A quality of life survey was conducted at 6 months. By that time, dysmenorrhea, dyspareunia and pain on defecation, intestinal cramping, diarrhea and constipation had disappeared in all women.

Dr. Neme had no financial disclosures.

msullivan@frontlinemedcom.com

PHOENIX – A new model based on clinical, hospital, and operative factors predicted the risk of ureteral injury among patients undergoing colorectal surgery.

Using data from the Nationwide Inpatient Sample, which includes more than 2 million patients in the United States, researchers retrospectively studied patients undergoing surgery in the United States between 2001 and 2010 for colorectal cancer, polyps, diverticular disease, or inflammatory bowel disease.

Less than 1% of patients sustained a ureteral injury, but the incidence rose significantly during the study period and injured patients had sharply higher rates of complications, researchers reported at the annual meeting of the American Society of Colon and Rectal Surgeons.

Eight factors were independently associated with the risk of ureteral injury. A predictive model incorporating these factors had an area under the receiver operating characteristic curve of 0.73. The model-predicted probability of injury ranged from 0.1% to 1.65%, depending on hospital factors, disease type, and procedure type, said Dr. Wissam J. Halabi, a research fellow at the University of California-Irvine, Orange.

Patients had higher adjusted odds of ureteral injury if they had rectal cancer (odds ratio, 1.85), adhesions (OR, 1.83), and metastatic cancer (OR, 1.76); if they had lost weight (OR, 1.08); and if they underwent surgery at a teaching hospital (OR, 1.05). On the other hand, patients had lower odds of injury if they had a laparoscopic procedure (OR, 0.91), a transverse colectomy (OR, 0.90), or a right hemicolectomy (OR, 0.43).

With the new predictive model incorporating these factors, the probability of injury ranged from 0.1% for patients undergoing laparoscopic right hemicolectomy to 1.65% for patients having all five adverse risk factors.

"Diverticulitis did not appear as a predictor in our model," Dr. Halabi said. "As for radiation, one of our predictors was metastatic cancer. So this goes for any cancer at advanced stage that has spread to lymph nodes or distant organ metastasis. In the case of rectal cancer, those are most likely to have received radiation therapy. So part of this effect of radiation therapy was apparent in the metastatic cancer group predictor."

Analyses were based on 2,165,848 colorectal surgery procedures. The overall rate of ureteral injury was 0.28%, he reported.

There was a significant 24% increase in the rate during the study period, from 2.5 per 1,000 cases in 2001-2005 to 3.1 per 1,000 cases in 2006-2010.

On average, the patients sustaining injury were younger and were more likely to be female and to have metastatic cancer, to be immunosuppressed, and to have had weight loss. They were less likely to have certain major comorbidities, such as diabetes and hypertension.

"Interestingly, obesity was similar in the two groups," Dr. Halabi commented.

Patients who sustained ureteral injuries had longer hospital stays and higher rates of a variety of postoperative complications, such as anastomotic leak and acute renal failure, but in-hospital mortality was statistically indistinguishable.

In adjusted analysis, patients with ureteral injury were significantly more likely to die (OR, 1.45) and to experience complications (OR, 1.66), and they had a longer hospital stay (+3.65 days) and total hospital charges (+$31,497).

Ureteral injuries "affect a relatively younger and healthier population. However, they have a significant and dramatic impact on outcomes," he added. "This predictive model can be used for risk stratification and counseling."

Dr. Halabi disclosed no relevant conflicts of interest.

PHOENIX – A new model based on clinical, hospital, and operative factors predicted the risk of ureteral injury among patients undergoing colorectal surgery.

Using data from the Nationwide Inpatient Sample, which includes more than 2 million patients in the United States, researchers retrospectively studied patients undergoing surgery in the United States between 2001 and 2010 for colorectal cancer, polyps, diverticular disease, or inflammatory bowel disease.

Less than 1% of patients sustained a ureteral injury, but the incidence rose significantly during the study period and injured patients had sharply higher rates of complications, researchers reported at the annual meeting of the American Society of Colon and Rectal Surgeons.

Eight factors were independently associated with the risk of ureteral injury. A predictive model incorporating these factors had an area under the receiver operating characteristic curve of 0.73. The model-predicted probability of injury ranged from 0.1% to 1.65%, depending on hospital factors, disease type, and procedure type, said Dr. Wissam J. Halabi, a research fellow at the University of California-Irvine, Orange.

Patients had higher adjusted odds of ureteral injury if they had rectal cancer (odds ratio, 1.85), adhesions (OR, 1.83), and metastatic cancer (OR, 1.76); if they had lost weight (OR, 1.08); and if they underwent surgery at a teaching hospital (OR, 1.05). On the other hand, patients had lower odds of injury if they had a laparoscopic procedure (OR, 0.91), a transverse colectomy (OR, 0.90), or a right hemicolectomy (OR, 0.43).

With the new predictive model incorporating these factors, the probability of injury ranged from 0.1% for patients undergoing laparoscopic right hemicolectomy to 1.65% for patients having all five adverse risk factors.

"Diverticulitis did not appear as a predictor in our model," Dr. Halabi said. "As for radiation, one of our predictors was metastatic cancer. So this goes for any cancer at advanced stage that has spread to lymph nodes or distant organ metastasis. In the case of rectal cancer, those are most likely to have received radiation therapy. So part of this effect of radiation therapy was apparent in the metastatic cancer group predictor."

Analyses were based on 2,165,848 colorectal surgery procedures. The overall rate of ureteral injury was 0.28%, he reported.

There was a significant 24% increase in the rate during the study period, from 2.5 per 1,000 cases in 2001-2005 to 3.1 per 1,000 cases in 2006-2010.

On average, the patients sustaining injury were younger and were more likely to be female and to have metastatic cancer, to be immunosuppressed, and to have had weight loss. They were less likely to have certain major comorbidities, such as diabetes and hypertension.

"Interestingly, obesity was similar in the two groups," Dr. Halabi commented.

Patients who sustained ureteral injuries had longer hospital stays and higher rates of a variety of postoperative complications, such as anastomotic leak and acute renal failure, but in-hospital mortality was statistically indistinguishable.

In adjusted analysis, patients with ureteral injury were significantly more likely to die (OR, 1.45) and to experience complications (OR, 1.66), and they had a longer hospital stay (+3.65 days) and total hospital charges (+$31,497).

Ureteral injuries "affect a relatively younger and healthier population. However, they have a significant and dramatic impact on outcomes," he added. "This predictive model can be used for risk stratification and counseling."

Dr. Halabi disclosed no relevant conflicts of interest.

PHOENIX – A new model based on clinical, hospital, and operative factors predicted the risk of ureteral injury among patients undergoing colorectal surgery.

Using data from the Nationwide Inpatient Sample, which includes more than 2 million patients in the United States, researchers retrospectively studied patients undergoing surgery in the United States between 2001 and 2010 for colorectal cancer, polyps, diverticular disease, or inflammatory bowel disease.

Less than 1% of patients sustained a ureteral injury, but the incidence rose significantly during the study period and injured patients had sharply higher rates of complications, researchers reported at the annual meeting of the American Society of Colon and Rectal Surgeons.

Eight factors were independently associated with the risk of ureteral injury. A predictive model incorporating these factors had an area under the receiver operating characteristic curve of 0.73. The model-predicted probability of injury ranged from 0.1% to 1.65%, depending on hospital factors, disease type, and procedure type, said Dr. Wissam J. Halabi, a research fellow at the University of California-Irvine, Orange.

Patients had higher adjusted odds of ureteral injury if they had rectal cancer (odds ratio, 1.85), adhesions (OR, 1.83), and metastatic cancer (OR, 1.76); if they had lost weight (OR, 1.08); and if they underwent surgery at a teaching hospital (OR, 1.05). On the other hand, patients had lower odds of injury if they had a laparoscopic procedure (OR, 0.91), a transverse colectomy (OR, 0.90), or a right hemicolectomy (OR, 0.43).

With the new predictive model incorporating these factors, the probability of injury ranged from 0.1% for patients undergoing laparoscopic right hemicolectomy to 1.65% for patients having all five adverse risk factors.

"Diverticulitis did not appear as a predictor in our model," Dr. Halabi said. "As for radiation, one of our predictors was metastatic cancer. So this goes for any cancer at advanced stage that has spread to lymph nodes or distant organ metastasis. In the case of rectal cancer, those are most likely to have received radiation therapy. So part of this effect of radiation therapy was apparent in the metastatic cancer group predictor."

Analyses were based on 2,165,848 colorectal surgery procedures. The overall rate of ureteral injury was 0.28%, he reported.

There was a significant 24% increase in the rate during the study period, from 2.5 per 1,000 cases in 2001-2005 to 3.1 per 1,000 cases in 2006-2010.

On average, the patients sustaining injury were younger and were more likely to be female and to have metastatic cancer, to be immunosuppressed, and to have had weight loss. They were less likely to have certain major comorbidities, such as diabetes and hypertension.

"Interestingly, obesity was similar in the two groups," Dr. Halabi commented.

Patients who sustained ureteral injuries had longer hospital stays and higher rates of a variety of postoperative complications, such as anastomotic leak and acute renal failure, but in-hospital mortality was statistically indistinguishable.

In adjusted analysis, patients with ureteral injury were significantly more likely to die (OR, 1.45) and to experience complications (OR, 1.66), and they had a longer hospital stay (+3.65 days) and total hospital charges (+$31,497).

Ureteral injuries "affect a relatively younger and healthier population. However, they have a significant and dramatic impact on outcomes," he added. "This predictive model can be used for risk stratification and counseling."

Dr. Halabi disclosed no relevant conflicts of interest.

The addition of a transversus abdominis plane block to standard enhanced recovery pathway protocols decreased lengths of stay to less than 3 days in roughly two-thirds of patients who underwent laparoscopic colectomy, findings from a small study showed.

To determine the impact of a TAP block on rates of discharge for colorectal laparoscopic surgery, researchers at University Hospitals Case Medical Center in Cleveland observed 100 consecutive patients who underwent the elective procedure performed over a 1-year period by the same experienced laparoscopic colorectal surgeon. The TAP block was administered at the conclusion of the laparoscopic procedure.

The mean age of the study population was 60.5 years, and 62 were female. The mean body mass index was 28.4 kg/m². Surgical indications in two-thirds of patients included colorectal cancer or polyp. One-third of patients had an inflammatory condition such as diverticulitis, ulcerative colitis, or Crohn’s disease, said Dr. Joanne Favuzza and Dr. Conor P. Delaney (J. Am. Coll. Surg. 2013;217:503-6).

The investigators found that 62% of patients were discharged within 48 hours, with 27% being discharged on day 1. No operative mortality was reported, and only one patient experienced a complication post discharge. Two patients were readmitted, both having had lengths of stay exceeding 48 hours.

Incidence rates of complication or readmission were not significantly affected by the block. Eight patients experienced postoperative complications: one patient on the second day post surgery, another patient on the third day, and the rest after the fourth day. Three patients had complications involving the ileus or lower-bowel obstruction, four patients had anastomotic or gastrointestinal bleed, and one had a urinary tract infection.

"This study demonstrated that the addition of a TAP block to an established ERP can reproducibly reduce length of stay to less than 3 days," wrote Dr. Favuzza and Dr. Delaney, who also noted that a prospective randomized controlled trial is underway to further evaluate the benefits of TAP blocks to ERP in colorectal surgery.

Dr. Favuzza reported no relevant disclosures. Dr. Delaney is a paid a consultant to Adolor Corp., Ferring Pharmaceuticals, and Pacira Pharmaceuticals.

wmcknight@frontlinemedcom.com

The addition of a transversus abdominis plane block to standard enhanced recovery pathway protocols decreased lengths of stay to less than 3 days in roughly two-thirds of patients who underwent laparoscopic colectomy, findings from a small study showed.

To determine the impact of a TAP block on rates of discharge for colorectal laparoscopic surgery, researchers at University Hospitals Case Medical Center in Cleveland observed 100 consecutive patients who underwent the elective procedure performed over a 1-year period by the same experienced laparoscopic colorectal surgeon. The TAP block was administered at the conclusion of the laparoscopic procedure.

The mean age of the study population was 60.5 years, and 62 were female. The mean body mass index was 28.4 kg/m². Surgical indications in two-thirds of patients included colorectal cancer or polyp. One-third of patients had an inflammatory condition such as diverticulitis, ulcerative colitis, or Crohn’s disease, said Dr. Joanne Favuzza and Dr. Conor P. Delaney (J. Am. Coll. Surg. 2013;217:503-6).

The investigators found that 62% of patients were discharged within 48 hours, with 27% being discharged on day 1. No operative mortality was reported, and only one patient experienced a complication post discharge. Two patients were readmitted, both having had lengths of stay exceeding 48 hours.

Incidence rates of complication or readmission were not significantly affected by the block. Eight patients experienced postoperative complications: one patient on the second day post surgery, another patient on the third day, and the rest after the fourth day. Three patients had complications involving the ileus or lower-bowel obstruction, four patients had anastomotic or gastrointestinal bleed, and one had a urinary tract infection.

"This study demonstrated that the addition of a TAP block to an established ERP can reproducibly reduce length of stay to less than 3 days," wrote Dr. Favuzza and Dr. Delaney, who also noted that a prospective randomized controlled trial is underway to further evaluate the benefits of TAP blocks to ERP in colorectal surgery.

Dr. Favuzza reported no relevant disclosures. Dr. Delaney is a paid a consultant to Adolor Corp., Ferring Pharmaceuticals, and Pacira Pharmaceuticals.

wmcknight@frontlinemedcom.com

The addition of a transversus abdominis plane block to standard enhanced recovery pathway protocols decreased lengths of stay to less than 3 days in roughly two-thirds of patients who underwent laparoscopic colectomy, findings from a small study showed.

To determine the impact of a TAP block on rates of discharge for colorectal laparoscopic surgery, researchers at University Hospitals Case Medical Center in Cleveland observed 100 consecutive patients who underwent the elective procedure performed over a 1-year period by the same experienced laparoscopic colorectal surgeon. The TAP block was administered at the conclusion of the laparoscopic procedure.

The mean age of the study population was 60.5 years, and 62 were female. The mean body mass index was 28.4 kg/m². Surgical indications in two-thirds of patients included colorectal cancer or polyp. One-third of patients had an inflammatory condition such as diverticulitis, ulcerative colitis, or Crohn’s disease, said Dr. Joanne Favuzza and Dr. Conor P. Delaney (J. Am. Coll. Surg. 2013;217:503-6).

The investigators found that 62% of patients were discharged within 48 hours, with 27% being discharged on day 1. No operative mortality was reported, and only one patient experienced a complication post discharge. Two patients were readmitted, both having had lengths of stay exceeding 48 hours.

Incidence rates of complication or readmission were not significantly affected by the block. Eight patients experienced postoperative complications: one patient on the second day post surgery, another patient on the third day, and the rest after the fourth day. Three patients had complications involving the ileus or lower-bowel obstruction, four patients had anastomotic or gastrointestinal bleed, and one had a urinary tract infection.

"This study demonstrated that the addition of a TAP block to an established ERP can reproducibly reduce length of stay to less than 3 days," wrote Dr. Favuzza and Dr. Delaney, who also noted that a prospective randomized controlled trial is underway to further evaluate the benefits of TAP blocks to ERP in colorectal surgery.

Dr. Favuzza reported no relevant disclosures. Dr. Delaney is a paid a consultant to Adolor Corp., Ferring Pharmaceuticals, and Pacira Pharmaceuticals.

wmcknight@frontlinemedcom.com