Background

There are limited data regarding the criteria for prophylactic treatment of venous thromboembolism (VTE) after hospital discharge. We sought to identify risk factors of post-hospital discharge VTE events following colorectal surgery.

Methods

The NSQIP database was utilized to examine patients developed VTE after hospital discharge following colorectal surgery during 2005-2013. Multivariate analysis using logistic regression was performed to quantify risk factors of VTE after discharge.

Results

We evaluated a total of 219,477 patients underwent colorectal resections. The overall incidence of VTE was 2.1 % (4556). 33.8 % (1541) of all VTE events occurred after hospital discharge. The length of postoperative hospitalization had a strong association with post-discharge VTE, with the highest risk in patients who were hospitalized for more than 1 week after operation (AOR 9.08, P < 0.01). Other factors associated with post-discharge VTE included chronic steroid use (AOR 1.81, P < 0.01), stage 4 colorectal cancer (AOR 1.40, P = 0.03), obesity (AOR 1.37, P < 0.01), age >70 (AOR 1.21, P = 0.04), and open surgery (AOR 1.36, P < 0.01). Patients who were hospitalized for more than 1 week after an open colorectal resections had a 12 times higher risk of post-discharge VTE event compared to patients hospitalized less than 4 days after a laparoscopic resection (AOR 12.34, P < 0.01).

Conclusions

VTE is uncommon following colorectal resections; however, a significant proportion occurs after patients are discharged from the hospital (33.8 %). The length of postoperative hospitalization appears to have a strong association with post-discharge VTE. High-risk patients may benefit from continued VTE prophylaxis after discharge.

There is limited data analyzing ventilator dependency by operative diagnoses and types of the procedures performed in colorectal surgery. We sought to identify predictive factors of ventilator dependency in colorectal surgery and investigate complication rates across various colorectal procedures. The National Surgical Quality Improvement Program database was used to examine the clinical data of patients with ventilator dependency for more than 48 hours after colorectal resection during 2005-2013. Multivariate regression analysis was performed to identify predictors of ventilator dependency. A total of 219,716 patients who underwent colorectal resection were identified. The rate of ventilator dependency was 3.9 per cent. The rate varied significantly based on patient diagnosis; with the highest rate seen in patients with acute mesenteric ischemia (25.9%). The highest risk of ventilator dependency according to the patients indication of surgery, type of the procedure, and preoperative factors exist in lower gastrointestinal bleeding [adjusted odds ratio (AOR): 77.44, P < 0.01], total colectomy (AOR: 1.58, P = 0.04), and American Society of Anesthesiologists classification of three or greater (AOR: 2.52, P < 0.01). Also, serum albumin level (AOR: 0.67, P < 0.01) seems to be associated with ventilator dependency. The overall rate of ventilator dependency is 3.9 per cent in colorectal surgery. However, depending on the indication for surgery, rates can be as high as 25.9 per cent. American Society of Anesthesiologist score can predict the risk of postoperative ventilator dependency in patients undergoing colorectal surgery. Serum albumin level is reversely associated with postoperative ventilator dependency.

Importance

Retrorectal tumors are rare lesions that comprise a multitude of histologic types. Reports are limited to small single-institution case series, and recommendations on the ideal surgical approaches are lacking.

Objective

The purpose of the study was to provide a comprehensive review of the epidemiology, pathologic subtypes, surgical approaches, and clinical outcomes of retrorectal tumors.

Evidence review

We conducted a review of the literature using PubMed and searched the reference lists of published studies.

Results

A total of 341 studies comprising 1708 patients were included. Overall, 68 % of patients were female. The mean age was 44.6 ± 13.7 years. Of all patients, 1194 (70 %) had benign lesions, and 514 patients (30 %) had malignant tumors. Congenital tumors (60.5 %) were the most frequent histologic type. Other pathologic types were neurogenic tumors (14.8 %), osseous tumors (3.1 %), inflammatory tumors (2.6 %), and miscellaneous tumors (19.1 %). Biopsy was performed in 27 % of the patients. Of these patients, incorrect diagnoses occurred in 44 %. An anterior surgical approach (AA) was performed in 299 patients (35 %); a posterior approach (PA) was performed in 443 (52 %), and a combined approach (CA) was performed in 119 patients (14 %). The mean length of stay (LOS) of PA was 7 ± 5 days compared to 8 ± 7 days for AA and 11 ± 7 days for CA (p < 0.05). The overall morbidity rate was 13.2 %: 19.3 % associated with anterior approach, 7.2 % associated with posterior approach, and 24.7 % after a combined approach (p < 0.05). Overall postoperative recurrence rate was 21.6 %; 6.7 % after an anterior approach, 26.6 % after a posterior approach, and 28.6 % after a combined approach (p < 0.05). A minimally invasive approach (MIS) was employed in 83 patients. MIS provided shorter hospital stays than open surgery (4 ± 2 vs. 9 ± 7 days; p < 0.05). Differences in complication rate were 19.8 % in MIS and 12.2 % in open surgery and not statistically significant.

Conclusions and relevance

Retrorectal tumors are most commonly benign in etiology, of a congenital nature, and have a female predominance. Complete surgical resection is the cornerstone of retrorectal tumor management. A minimal access surgery approach, when feasible, appears to be a safe option for the management of retrorectal tumors, with shorter operative time and length of stay.

Background

Prolonged ileus is one of the most common postoperative complications after colorectal surgery. We sought to investigate the predictors of prolonged ileus following elective colon resections procedures.

Methods

The national participant user files of NSQIP databases were utilized to examine the clinical outcomes of patients undergoing elective colon resection during 2012-2013. Multivariate regression analysis was performed to investigate predictors of prolonged ileus. Prolonged ileus was defined as no return of bowel function in 7 days.

Results

We sampled a total of 27,560 patients who underwent colon resections; of these, 3497 (12.7%) patients had prolonged ileus. Patients with ileocolonic anastomosis (ICA) had a significantly higher rate of prolonged ileus compared to patients with colorectal anastomosis (CRA) (15 vs. 11.5%, AOR 1.25, P < 0.01). Prolonged ileus was significantly associated with intra-abdominal infections (13 vs. 2.8%, AOR 2.56, P < 0.01) and anastomotic leakage (12 vs. 2.4%, AOR 2.50, P < 0.01). Factors such as preoperative sepsis (AOR 1.63, P < 0.01), disseminated cancer (AOR 1.24, P = 0.01), and chronic obstructive pulmonary disease (AOR 1.27, P = 0.02) were associated with an increased risk of prolonged ileus, whereas oral antibiotic bowel preparation (AOR 0.77, P < 0.01) and laparoscopic surgery (AOR 0.51, P < 0.01) are associated with decreased prolonged ileus risk.

Conclusions

Prolonged ileus is a common condition following colon resection, with an incidence of 12.7%. Among colon surgeries, colectomy with ICA resulted in the highest rate of postoperative prolonged ileus. Prolonged ileus is positively associated with anastomotic leak and intra-abdominal infections; thus, a high index of suspicion must be had in all patients with prolonged postoperative ileus.

Background

Unplanned readmission of patients who undergo appendectomy is a relatively frequent occurrence. Our aim was to report the most common reasons and the predictors of unplanned readmission after appendectomy.

Methods

The National Surgical Quality Improvement Program database was used to examine the clinical data of patients undergoing emergent and/or urgent appendectomy during 2012 to 2013. Multivariate regression analysis was performed to identify the predictors of unplanned readmission.

Results

We evaluated a total of 46,960 patients who underwent appendectomy. Of these, 18.5% had perforated appendicitis. Overall, 1,755 (3.7%) of patients had an unplanned readmission. The most common reasons for readmission were intra-abdominal infection (27.3%), nonspecific abdominal pain (7.9%), and paralytic ileus (4.6%). Factors such as perforated appendicitis (adjusted odds ratio [AOR], 1.38; P < .01), preoperative sepsis (AOR, 1.30; P < .01), and dirty surgical wound (AOR, 1.91; P < .01) were associated with unplanned readmission.

Conclusions

Overall, 3.7% of patients who underwent emergent appendectomy had an unplanned readmission. Intra-abdominal infections and nonspecific abdominal pain are the most common reasons for readmission. Unplanned readmissions are predominantly related to postoperative complications and severity of disease.

Background

We sought to investigate morbidity and infectious complications following pelvic exenteration (PEx) and compare infectious complications of patients undergoing PEx and conventional rectal resections.

Methods

The NSQIP database was utilized to examine the clinical data of patients undergoing elective rectal resections during 2005-2013. Multivariate regression analysis was used to compare postoperative complications of patients who underwent PEx and proctectomy procedure.

Results

We sampled a total of 7,950 patients who underwent rectal resection. Of these, 303 (3.8%) patients underwent pelvic exenteration. Mortality, morbidity, and infectious complications of patients who underwent pelvic exenteration were 1.7%, 65.7%, and 42.6%, respectively. Patients who underwent PEx had a significantly higher rate of morbidity (AOR: 2.01, P < 0.01), overall infectious complications (AOR: 1.49, P < 0.01), hemorrhagic complications (AOR: 3.36, P < 0.01), and surgical site infections (SSI) (AOR: 1.23, P = 0.04) compared to patients who underwent proctectomy. Return to operation room (AOR: 4.99, P < 0.01), obesity (AOR: 1.43, P < 0.01), disseminated cancer (AOR: 1.30, P = 0.01) were significantly associated with SSI complications.

Conclusion

Postoperative morbidity and infectious complication are significantly higher after PEx procedure. Return to operation room, obesity, and disseminated cancer are strongly associated with surgical site infections complications in rectal surgery. Specific consideration to infectious complications is recommended for these patients.

Background

Patients with advanced colorectal cancer have a high incidence of postoperative complications. We sought to identify outcomes of patients who underwent resection for colon cancer by cancer stage.

Methods

The National Surgical Quality Improvement Program database was used to evaluate all patients who underwent colon resection with a diagnosis of colon cancer from 2012 to 2014. Multivariate logistic regression analysis was performed to investigate patient outcomes by cancer stage.

Results

A total of 7,786 colon cancer patients who underwent colon resection were identified. Of these, 10.8% had metastasis at the time of operation. Patients with metastatic disease had significantly increased risks of perioperative morbidity (adjusted odds ratio [AOR]: 1.44, P = .01) and mortality (AOR: 3.72, P = .01). Patients with metastatic disease were significantly younger (AOR: .99, P < .01) had a higher American Society of Anesthesiologists score (AOR: 1.29, P < .2) and had a higher rate of emergent operation (AOR: 1.40, P < .01).

Conclusions

Overall, 10.8% of patients undergoing colectomy for colon cancer have metastatic disease. Postoperative morbidity and mortality are significantly higher than in patients with localized disease.

Background

There are limited data regarding the outcomes of patients with preoperative weight loss. We sought to identify complications associated with preoperative weight loss in colorectal surgery.

Methods

The National Surgical Quality Improvement Program database was used to examine the clinical data of patients undergoing colorectal resection from 2005 to 2012 who had unintentional preoperative weight loss (more than 10% in 6 months of surgery). Multivariate analysis was performed to quantify the association of weight loss with postoperative complications.

Results

We sampled a total of 79,696 patients who were admitted nonemergently for colorectal resection. The rate of preoperative unintentional weight loss was 3%. There were associations between preoperative weight loss with preoperative hypoalbuminemia (serum albumin level < 3.5 g/dL) (adjusted odds ratio [AOR] 2.58, P < .01). Postoperative mortality (AOR 1.74, P < .01) and complications of myocardial infarction (AOR 1.97, P = .03) and ventilator dependency (AOR 1.54, P = .03) had strong associations with weight loss.

Conclusions

A history of unintentional weight loss can be used to predict mortality and morbidity rates and as a marker for nutritional assessment in colorectal surgery. Cardiopulmonary complications have significant association with preoperative weight loss.

Background

The use of laparoscopy for right hemicolectomy has gained popularity allowing the option of a totally laparoscopic intracorporeal anastomosis (IA) for intestinal reconstruction. This technique may alleviate some of the technical limitations that a surgeon faces with a laparoscopic-assisted extracorporeal anastomosis (EA).

Methods

A retrospective chart review of 195 consecutive patients who underwent laparoscopic right hemicolectomy by four colorectal surgeons at three institutions from March 2005 to June 2014 was performed. Multivariate regression analysis was used to compare postoperative and oncologic outcomes.

Results

A total of 195 patients underwent laparoscopic right hemicolectomy over the study period, with 86 (44 %) patients receiving IA and 109 (56 %) patients receiving an EA. The most common indication for surgery in both groups was cancer: 56 (65 %) of IA cases and 57 (52 %) of EA cases. IA had a significantly higher rate of minor complications but no difference in serious complications compared to EA. Conversion to open resection was higher in EA. Using multivariate analysis to compare IA versus EA, there was no significant difference in length of stay, return of bowel function, risk of anastomotic leak, risk of intraabdominal abscess or risk of wound complications. Amongst cancer resections, there was no significant difference in the median number of lymph nodes harvested (18 LNs in IA group vs. 19 LNs in EA group, P > 0.05). There was also no significant difference in overall survival and disease-free survival at 5.7 years between the two groups.

Conclusions

IA in laparoscopic right hemicolectomy is associated with similar postoperative and oncologic outcomes compared to EA. IA may possess advantages in terms of conversion and flexibility of specimen extraction, but this is counterbalanced by a higher incidence of minor complications. These findings suggest that IA represents a valid technique in the arsenal of the experienced colorectal surgeon without compromising outcomes.