Publications

IMPORTANCE

With an aging population, preoperative assessment of the frail older adult requires evaluation beyond simply accounting for chronic diseases. Impaired cognition is a recognized characteristic of the frail older adult.

OBJECTIVE

To examine the effect of preoperative impaired sensorium (IS) on general surgical outcomes.

DESIGN, SETTING, AND PARTICIPANTS

Retrospective cohort study using data between January 2005 and December 2010 at academic and community hospitals participating in the American College of Surgeons National Surgical Quality Improvement Program. Patients undergoing nonemergent general surgical operations were studied. Multivariable logistic regression involving 45 preoperative patient-level risk factors and comorbidities was used to calculate the conditional probability of having IS. Patients having and not having preoperative IS were matched on their propensity scores using a 1:1 greedy matching technique. Propensity score matching resulted in almost all (n = 1765) patients with IS uniquely matching to a patient without IS, resulting in a cohort size of 3530. Complication rates between patients with and without IS were compared.

MAIN OUTCOMES AND MEASURES

Rates of postoperative complications and death following nonemergent general surgical operations.

RESULTS

In total, 294 037 patients were studied, of whom 1771 (0.6%) had preoperative IS. Patients with IS were older and had more significant preoperative risk factors and comorbidities. As a result, unadjusted analysis found that 22 of 23 postoperative complications were significantly more likely to occur in patients with IS. Within the matched cohort, rates of postoperative pneumonia, ventilator dependence, progressive renal insufficiency, urinary tract infection, stroke, venous thromboembolism, and postoperative death continued to be significantly (P < .05) elevated in patients with IS.

CONCLUSIONS AND RELEVANCE

Impaired sensorium significantly increases postoperative morbidity and mortality independent of other preoperative risk factors and comorbidities following nonemergent general surgical operations. Incorporation of impaired cognitive function into routine preoperative risk assessment and decision making could be an important addition to traditional risk assessment strategies.

BACKGROUND

The poorly healing perineal wound is a significant complication of abdominoperineal resection. The authors examined criteria for immediate flap coverage of the perineum and long-term cross-sectional surgical outcomes.

METHODS

Patients who underwent abdominoperineal resection or pelvic exenteration for anorectal cancer were retrospectively analyzed. Demographic characteristics, premorbid and oncologic data, surgical treatment, reconstruction method, and recovery were recorded. Outcomes of successful wound healing, surgical complications necessitating intervention (admission or return to the operating room), and progression to chronic wounds were assessed.

RESULTS

The authors identified 214 patients who underwent this procedure from 1995 to 2013. Forty-seven patients received pedicled flaps and had higher rates of recurrence and reoperation, active smoking, Crohn disease, human immunodeficiency virus, and anal cancers, and had higher American Joint Committee on Cancer tumor stages. Thirty-day complication rates were equivalent in the two groups. There were no complete flap losses or reconstructive failures. Perineal wound complication rates were marginally but not significantly higher in the flap group (55 percent versus 41 percent; p = 0.088). Infectious complications, readmissions for antibiotics, and operative revision were more frequent in the flap cohort. A larger proportion of the primary closure cohort developed chronic draining perineal wounds (23.3 versus 8.5 percent; p = 0.025).

CONCLUSIONS

Immediate flap coverage of the perineum was less likely to progress to a chronic draining wound, but had higher local infectious complication rates. The authors attribute this to increased comorbidity in the selected patient population, reflecting the surgical decision making in approaching these high-risk closures and ascertainment bias in diagnosis of infectious complications with multidisciplinary examination.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Risk, III.

BACKGROUND

Evidence from single-center studies suggests that ileal pouch-anal anastomosis (IPAA) can be safely performed in selected older patients with ulcerative colitis. The impact of age and frailty on surgical outcomes and hospital length of stay after IPAA has not been examined.

METHODS

We identified all patients with ulcerative colitis who underwent total proctocolectomy or completion proctectomy with IPAA in the National Surgery Quality Improvement Program database from 2005-2012. We examined the associations of age and frailty trait count with length of hospital stay and surgical complications using multivariate regression.

RESULTS

IPAA was performed in 2493 patients with ulcerative colitis. Thirty-day mortality was 0.2% (n = 6). The majority of patients had no serious postoperative complications (age ≤50 y: 79.5%, age 51-60 y: 80.4%, and age >60 y: 79.1%). After multivariate risk adjustment, patients aged >60 y had a similar mean number of complications as patients aged ≤50 y (0.31 versus 0.35, P = 0.47) and a 0.8-d longer mean length of hospital stay (7.4 versus 8.2 d, P = 0.035). Compared to patients with zero frailty traits, a frailty trait count ≥1 was associated with a similar mean number of complications (0.31 versus 0.34, P = 0.36) and length of hospital stay (7.4 versus 7.7 d, P = 0.25).

CONCLUSIONS

In this analysis of patients undergoing IPAA at National Surgery Quality Improvement Program hospitals, surgical complications were not substantially increased in older patients or those with frailty traits. Older age was associated with a small increase in hospital length of stay. These findings suggest that IPAA is safe in selected older adults with ulcerative colitis.

IMPORTANCE

Lower extremity revascularization often seeks to allow patients with peripheral arterial disease to maintain the ability to walk, a key aspect of functional independence. Surgical outcomes in patients with high levels of functional dependence are poorly understood.

OBJECTIVE

To determine functional status trajectories, changes in ambulatory status, and survival after lower extremity revascularization in nursing home residents.

DESIGN

Using full Medicare claims data for 2005 to 2009, we identified nursing home residents who underwent lower extremity revascularization. With the Minimum Data Set for Nursing Homes activities of daily living summary score, we examined changes in their ambulatory and functional status after surgery. We identified patient and surgery characteristics associated with a composite measure of clinical and functional failure-death or nonambulatory status 1 year after surgery.

SETTING

All nursing homes in the United States participating in Medicare or Medicaid.

PARTICIPANTS

Nursing home residents who underwent lower extremity revascularization.

MAIN OUTCOMES AND MEASURES

Functional status, ambulatory status, and death.

RESULTS

During the study period, 10,784 long-term nursing home residents underwent lower extremity revascularization. Prior to surgery, 75% of the residents were not walking; 40% had experienced functional decline. One year after surgery, 51% of patients had died, 28% were nonambulatory, and 32% had sustained functional decline. Among 1672 residents who were ambulatory before surgery, 63% had died or were nonambulatory at 1 year; among 7188 who were nonambulatory, 89% had died or were nonambulatory. After multivariate adjustment, factors independently associated with death or nonambulatory status were 80 years or older (adjusted hazard ratio [AHR], 1.28; 95% CI, 1.16-1.40), cognitive impairment (AHR, 1.23; 95% CI, 1.18-1.29), congestive heart failure (AHR, 1.16; 95% CI, 1.11-1.22), renal failure (AHR, 1.09; 95% CI, 1.04-1.14), emergent surgery (AHR, 1.29; 95% CI, 1.23-1.35), nonambulatory status before surgery (AHR, 1.88; 95% CI, 1.78-1.99), and decline in activities of daily living before surgery (AHR, 1.23; 95% CI, 1.18-1.28).

CONCLUSIONS AND RELEVANCE

Of nursing home residents in the United States who undergo lower extremity revascularization, few are alive and ambulatory 1 year after surgery. Most who were still alive had gained little, if any, function.

BACKGROUND

Repair of grade 3 and grade 4 ventral hernias is a distinct challenge, given the potential for infection, and the comorbid nature of the patient population. This study evaluates our institutional outcomes when performing single-stage repair of these hernias, with biologic mesh for abdominal wall reinforcement.

METHODS

A prospectively maintained database was reviewed for all patients undergoing repair of grade 3 (potentially contaminated) or grade 4 (infected) hernias, as classified by the Ventral Hernia Working Group. All those patients undergoing repair with component separation techniques and biologic mesh reinforcement were included. Patient demographics, comorbidities, and postoperative complications were analyzed. Univariate analysis was performed to define factors predictive of hernia recurrence and wound complications.

RESULTS

A total of 41 patients underwent single-stage repair of grade 3 and grade 4 hernias during a 4-year period. The overall postoperative wound infection rate was 15%, and hernia recurrence rate was 12%. Almost all recurrences were seen in grade 4 hernia repairs, and in those patients undergoing bridging repair of the hernia. One patient required removal of the biologic mesh. Those factors predicting hernia recurrence were smoking (P = 0.023), increasing body mass index (P = 0.012), increasing defect size (P = 0.010), and bridging repair (P = 0.042). No mesh was removed due to perioperative infection. Mean follow-up time for this patient population was 25 months.

CONCLUSIONS

Single-stage repair of grade 3 hernias performed with component separation and biologic mesh reinforcement is effective and offers a low recurrence rate. Furthermore, the use of biologic mesh allows for avoidance of mesh explantation in instances of wound breakdown or infection. Bridging repairs are associated with a high recurrence rate, as is single-stage repair of grade 4 hernias.

BACKGROUND

Historically, older patients with ulcerative colitis were not considered candidates for ileal pouch-anal anastomosis. However, more recent evidence suggests that this procedure can be performed in older patients with acceptable surgical and functional results.

OBJECTIVE

The purpose of this work was to determine whether older age is independently associated with surgical procedure type among patients with ulcerative colitis in a large national database.

DESIGN

This was a cross-sectional analysis of ulcerative colitis patients undergoing end ileostomy or IPAA, grouped by age.

SETTINGS

This study was conducted in a university teaching hospital.

PATIENTS

Patients with ulcerative colitis who underwent total proctocolectomy or completion proctectomy with either IPAA or end ileostomy from 2005 to 2012 in the American College of Surgeons National Surgery Quality Improvement Program database were included in this study.

MAIN OUTCOME MEASURES

The primary outcome was procedure type (end ileostomy or IPAA). Patient factors associated with procedure type, including age and trends over time, were examined using multivariate logistic regression.

RESULTS

Among 3635 patients with ulcerative colitis, 28.2% underwent end ileostomy and 71.8% underwent IPAA. Older patients were more likely to undergo end ileostomy than patients ≤50 years of age after adjustment for sex, smoking, BMI, frailty trait count, and ASA class (p < 0.001). The odds of end ileostomy decreased by 12% per year between 2005 and 2012 in patients aged 61 to 70 years compared with patients ≤50 years of age (adjusted OR, 0.88 per year; p = 0.021).

LIMITATIONS

We were unable to analyze other potentially important determinants of procedure type, such as surgeon, patient preference, and anal sphincter integrity.

CONCLUSIONS

Age remains strongly associated with procedure type. The use of end ileostomy, however, is decreasing over time in patients 61 to 70 years of age as evidence accumulates that IPAA is an acceptable option for older patients with ulcerative colitis (see Video, Supplemental Digital Content 1, http://links.lww.com/DCR/A191).

IMPORTANCE

Regulatory limits on consumer cost sharing permit wide variation in the prices charged for screening and diagnostic tests such as colonoscopy. Employers are experimenting with reference payment initiatives that offer full insurance coverage at low-priced facilities but require substantial cost sharing if patients select high-priced alternatives.

OBJECTIVE

To ascertain the effect of reference payment on facility choice, insurer spending, consumer cost sharing, and procedural complications for colonoscopy.

DESIGN, SETTING, AND PARTICIPANTS

The California Public Employees' Retirement System (CalPERS) implemented reference payment in January 2012. We obtained data on 21 644 CalPERS enrollees who underwent colonoscopy in the 3 years prior to implementation and on 13 551 patients in the 2 years after implementation. Control group data were obtained on 258 616 Anthem Blue Cross enrollees who underwent colonoscopy and who were not subject to reference payment initiatives during this 5-year period.

MAIN OUTCOMES AND MEASURES

Consumer choice of facility, price paid per procedure, total insurer spending, consumer cost sharing, and procedural complications.

EXPOSURES

Choices, prices, and complications were compared for CalPERS and Anthem patients before and after implementation of reference payments, using difference-in-difference multivariable regressions to adjust for patient demographic characteristics and comorbidities, procedure indications, and geographic location.

RESULTS

Utilization of low-priced facilities for CalPERS members increased from 68.6% in 2009 to 90.5% in 2013. After adjusting for patient demographic characteristics, comorbidities, and other factors, the implementation of reference payment increased use of low-priced facilities by 17.6 percentage points (95% CI, 11.8 to 23.4; P < .001). The mean price paid for colonoscopy for the CalPERS population increased from $1587 (95% CI, $1555-$1618) in 2009 to $1716 (95% CI, $1678-$1753) in 2011 and then decreased to $1508 (95% CI, $1469-$1548) in 2013 for patients subject to reference payment. After adjustment for other relevant factors, reference payment was responsible for a 21.0% (95% CI, -26.0% to -15.6%, P < .001) reduction in the price. Reference payment was associated with a small but statistically insignificant decline in procedural complications, from 2.1% in 2009 to 2.0% in 2013 (P = .47). In the first 2 years after implementation, CalPERS saved $7.0 million (28%) on spending for the procedure.

CONCLUSIONS AND RELEVANCE

Implementation of reference payment for colonoscopy was associated with reduced spending and no change in complications.

BACKGROUND

Although social support is important for quality of life in patients undergoing surgery for ulcerative colitis, the impact of surgery on patient relationships is not known.

OBJECTIVE

We examined relationship parameters in patients with ulcerative colitis and their partners before and 6 months after surgery.

DESIGN

This was a prospective cohort in which we performed an exploratory analysis.

SETTINGS

Patients were enrolled from an academic medical center.

PATIENTS

Surgical patients with ulcerative colitis and their partners were invited to participate.

INTERVENTIONS

Patients underwent proctocolectomy in 1, 2, or 3 stages.

MAIN OUTCOME MEASURES

We measured quality of life and sexual function in patients, as well as relationship quality, empathy, and sexual satisfaction in patients and partners before and 6 months after surgery using validated questionnaires.

RESULTS

The study sample consisted of 74 participants, including 37 patients (25 men and 12 women) and their opposite-sex partners. Quality of life improved significantly in male and female patients after surgery. Sexual function scores also improved after surgery in male and female patients; however, the changes reached statistical significance in male patients only. Sexual satisfaction scores improved significantly after surgery in female patients and their partners. There was little change in relationship quality or empathy after surgery, with the exception of slightly improved relationship quality reported by male partners. In general, patients and partners reported levels of relationship quality and empathy similar to normative populations.

LIMITATIONS

This study included a small, highly selected sample.

CONCLUSIONS

Male and female patients with ulcerative colitis have high-quality relationships that are not negatively affected by surgical treatment. Changes in sexual function do not necessarily coincide with changes in sexual satisfaction in this patient population. Future studies should evaluate the effect of high-quality relationships on surgical outcomes.