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Iqbal A, Rojas-Khalil Y, Waldon A, Parikh-Amin P, Garcia-Chavez HJ, Hartley BW, Keeling SS, Erstad DJ, Rosengart TK, Read TE. Two-Center Validation of a Novel Quality Improvement Protocol to Avoid Postileostomy Morbidity Using Home Intravenous Fluids and Structured Daily Calls. Dis Colon Rectum 2025; 68:457-465. [PMID: 40079659 DOI: 10.1097/dcr.0000000000003629] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/15/2025]
Abstract
BACKGROUND New ileostomates have higher rates of dehydration and readmission compared to patients undergoing other colorectal procedures. OBJECTIVE We aimed to show the efficacy of a novel ileostomy-specific quality improvement protocol at an academic center with subsequent validation at another academic center. DESIGN Prospective cohort study. SETTING Baylor College of Medicine (Houston, TX) and University of Florida Health (Gainesville, Florida). PATIENTS Patients who underwent elective ileostomy creation were enrolled in 2 phases: phase I (efficacy phase) from 2011 to 2018 at the University of Florida and phase II (validation phase) from 2018 to 2024 at Baylor College of Medicine. INTERVENTIONS New ileostomates received an indwelling intravenous line postoperatively. After discharge, daily home visits and administration of intravenous fluid infusions were completed by a registered nurse, and daily phone calls were made for counseling and medication adjustment by an advanced practice provider. MAIN OUTCOME MEASURES Length of stay, readmission rate, complication rate, and cost of care. RESULTS A total of 600 patients were enrolled in the study. There was a significant improvement in postprotocol from preprotocol in hospital length of stay (University of Florida: 3 vs 8 days; Baylor College of Medicine: 2.1 vs 6.9 days, p < 0.01), readmission rates (University of Florida: 9% vs 56%; Baylor College of Medicine: 7% vs 40%, p < 0.01), cost of care (University of Florida: $19,700 vs $53,300; Baylor College of Medicine: $18,100 vs $47,856, p < 0.01), and complication rates (University of Florida: 19% vs 65%; Baylor College of Medicine: 17% vs 46%, p < 0.01). If readmitted, the length of stay and cost decreased by 81% and 83%, respectively. No line-related complication was noted. LIMITATIONS This study was not randomized. Resource and insurance limitations may be an impediment to protocol implementation for austere settings. CONCLUSIONS Implementation of a novel ileostomy-specific standardized protocol to avoid morbidity from dehydration by implementing home intravenous infusions in conjunction with comprehensive outpatient education and phone follow-up significantly improved the quality of care by decreasing the length of stay, readmissions, complications, and cost of care. These results were validated at another institution. See Video Abstract. VALIDACIN EN DOS CENTROS DE UN NOVEDOSO PROTOCOLO DE MEJORA DE LA CALIDAD PARA EVITAR LA MORBILIDAD POSILEOSTOMA MEDIANTE LQUIDOS INTRAVENOSOS A DOMICILIO Y LLAMADAS DIARIAS ESTRUCTURADAS ANTECEDENTES:Los nuevos ileostomizados presentan tasas más elevadas de deshidratación y reingreso en comparación con los pacientes sometidos a otros procedimientos colorrectales.OBJETIVO:Nuestro objetivo era demostrar la eficacia de un nuevo protocolo de mejora de la calidad específico para la ileostomía en un centro académico, con su posterior validación en otro centro académico.DISEÑO:Estudio de cohortes prospectivo.LUGAR:Baylor College of Medicine (Houston, Texas); University of Florida Health (Gainesville, Florida).PACIENTES:Los pacientes sometidos a creación electiva de ileostomía se inscribieron en dos fases; Fase I (fase de eficacia) de 2011 a 2018 en la Universidad de Florida y Fase II (fase de validación) de 2018 a 2024 en el Baylor College of Medicine.INTERVENCIONES:Los nuevos ileostomizados recibieron una vía intravenosa permanente en el postoperatorio. Después del alta, se completaron visitas domiciliarias diarias y administración de infusiones de líquidos intravenosos por parte de una enfermera registrada y llamadas telefónicas diarias para asesoramiento y ajuste de la medicación por parte de un Proveedor de Práctica Avanzada.PRINCIPALES MEDIDAS DE RESULTADO:Duración de la estancia, tasa de reingresos, tasa de complicaciones y costo de la atención.RESULTADOS:Un total de 600 pacientes participaron en el estudio. Hubo una mejora significativa en la duración de la estancia hospitalaria (Universidad de Florida: 3 frente a 8 días; Baylor College of Medicine: 2,1 frente a 6,9 días, p < 0,01), las tasas de readmisión (University of Florida: 9% frente a 56%; Baylor College of Medicine: 7% frente a 40%, p < 0,01), costo de la atención (Universidad de Florida: 19.700 $ frente a 53.300 $; Facultad de Medicina Baylor: 18.100 $ frente a 47.856 $, p < 0,01) y tasas de complicaciones (Universidad de Florida: 19% frente a 65%; Baylor College of Medicine: 17% frente a 46%, p < 0,01). En caso de reingreso, la duración de la estancia y el costo disminuyeron en un 81% y un 83%, respectivamente. No se observó ninguna complicación relacionada con la vía.LIMITACIONES:Este estudio no fue aleatorizado. Las limitaciones de recursos y seguros pueden ser un impedimento en la implementación del protocolo para entornos austeros.CONCLUSIONES:La aplicación de un novedoso protocolo estandarizado específico de la ileostomía para evitar la morbilidad por deshidratación, mediante la aplicación de infusiones intravenosas domiciliarias junto con una amplia educación ambulatoria y seguimiento telefónico, mejoró significativamente la calidad de la atención al disminuir la duración de la estancia, los reingresos, las complicaciones y el costo de la atención. Estos resultados se validaron en otra institución. (Traducción-Yesenia Rojas-Khalil).
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Affiliation(s)
- Atif Iqbal
- Department of Surgery, Baylor College of Medicine, Houston, Texas
| | | | - Ashley Waldon
- Department of Surgery, Baylor College of Medicine, Houston, Texas
| | | | | | | | | | - Derek J Erstad
- Department of Surgery, Baylor College of Medicine, Houston, Texas
| | - Todd K Rosengart
- Department of Surgery, Baylor College of Medicine, Houston, Texas
| | - Thomas E Read
- Department of Surgery, University of Florida College of Medicine, Gainesville, Florida
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Rubio-Chavez A, Chang DC, Kunitake H, Ricciardi R, Vranceanu AM, Cooper Z, Ritchie C, Cauley CE. Aging Disparities in Ostomy Surgery. J Surg Res 2025; 306:488-495. [PMID: 39874931 DOI: 10.1016/j.jss.2024.12.048] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2024] [Revised: 11/20/2024] [Accepted: 12/25/2024] [Indexed: 01/30/2025]
Abstract
INTRODUCTION Little is known about the association between age and fecal ostomy surgery trends over time. We aim to 1) determine the rate of fecal ostomy operations over time and 2) compare rates of colostomy formation between patients older and younger than 65 y. MATERIALS AND METHODS Retrospective multi-institutional cohort study of patients ≥18 y who underwent colorectal resection between 2003 and 2014 using the Nationwide Inpatient Sample database. Patients were identified using International Classification of Diseases, 9th edition Procedural Codes. A difference-in-difference analysis was performed to evaluate the differences in colostomy formation between age groups. RESULTS Out of 819,441 adult patients who underwent major colorectal resection, 136,840 (16.6%) required ostomy formation. Median age was 63 y (interquartile range 51-74), 50% were female. Overall, 82,606 (10.0%) patients underwent a colostomy formation and 54,234 (6.6%) an ileostomy formation. Rates of colostomy formation decreased (13.2%-7.1% in <65 and 14.0%-7.2% in ≥65). Incidence of ileostomy formation increased for both age groups (6.1%-9.9% in <65 and 3.8%-6.3% in ≥65). The difference-in-difference analysis showed that the decline in colostomy formation was less pronounced among the older adult cohort (odds ratio 0.49, 95% confidence interval 0.47-0.50) than those <65 (odds ratio 0.42, 95% confidence interval 0.41-0.44). CONCLUSIONS Incidence of colostomy formation decreased in both groups over the study period. In contrast, the decline in colostomy formation was slower among older adults. This highlights a significant change in surgical trends across the United States with increasing rates of ileostomy use. Appropriate resource allocation and support are vital to the recovery of this growing surgical patient population.
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Affiliation(s)
- Atziri Rubio-Chavez
- Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - David C Chang
- Codman Center for Clinical Effectiveness in Surgery, Mass General Research Institute, Harvard Medical School, Boston, Massachusetts
| | - Hiroko Kunitake
- Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Rocco Ricciardi
- Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Ana-Maria Vranceanu
- Department of Psychiatry, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Zara Cooper
- Department of Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts; The Center for Surgery and Public Health, Brigham and Women's Hospital, Boston, Massachusetts; Harvard Medical School, Marcus Institute for Aging Research, Boston, Massachusetts
| | - Christine Ritchie
- Mongan Institute Center for Aging and Serious Illness, Massachusetts General Hospital, Boston, Massachusetts
| | - Christy E Cauley
- Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts; Mongan Institute Center for Aging and Serious Illness, Massachusetts General Hospital, Boston, Massachusetts.
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Sheffer HF, Bruce M, McLeod C, Richman J, Hardiman K, Chu D, Bhatia S, Hollis R. High risk populations for unplanned healthcare utilization following ostomy construction. Am J Surg 2025; 239:115799. [PMID: 38890038 PMCID: PMC11638406 DOI: 10.1016/j.amjsurg.2024.115799] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2024] [Accepted: 06/12/2024] [Indexed: 06/20/2024]
Abstract
BACKGROUND Patients with a new ostomy have high rates of unplanned healthcare utilization (UPHU). We used machine learning to assess which factors contributed the most to UPHU after ostomy construction. METHODS We retrospectively studied new ostomy patients between 2018 and 2021 at a single institution. The primary outcome was UPHU within 60 days of discharge. Factors that contributed the most to UPHU were assessed using a classification tree machine learning method. RESULTS Among 318 patients, 30.8 % of patients had an UPHU event. The classification tree identified diabetes mellitus as the most important factor associated with UPHU: 56 % of diabetics had UPHU. Smoking history was the next most important factor: 77 % of diabetics who smoked had UPHU. Patients who had diabetes, smoked, and had chronic kidney disease had the highest UPHU rate at 86 %. DISCUSSION Unplanned healthcare utilization after ostomy construction is highest among patients with diabetes, smoking history, and chronic kidney disease.
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Affiliation(s)
| | - Madi Bruce
- Department of Surgery, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Chandler McLeod
- Department of Surgery, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Joshua Richman
- Department of Surgery, University of Alabama at Birmingham, Birmingham, AL, USA; Institute for Cancer Outcomes and Survivorship, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Karin Hardiman
- Department of Surgery, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Daniel Chu
- Department of Surgery, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Smita Bhatia
- Institute for Cancer Outcomes and Survivorship, University of Alabama at Birmingham, Birmingham, AL, USA; Division of Pediatric Hematology-Oncology, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Robert Hollis
- Department of Surgery, University of Alabama at Birmingham, Birmingham, AL, USA; Institute for Cancer Outcomes and Survivorship, University of Alabama at Birmingham, Birmingham, AL, USA.
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Yagyu T, Hamada M, Hatta M, Kobayashi T, Matsumi Y, Inada R, Matsumoto T, Oishi M. Impact of the Diverting Stoma on Renal Function. Dis Colon Rectum 2024; 67:1576-1583. [PMID: 39260442 DOI: 10.1097/dcr.0000000000003517] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 09/13/2024]
Abstract
BACKGROUND Although loop ileostomy as a diverting stoma has been considered to affect renal dysfunction, few reports have compared loop colostomy with loop ileostomy regarding renal function. This is an important issue in the current setting of increased opportunities to perform surgery on patients with poor renal function. OBJECTIVE This study aimed to reveal the effect of ileostomy on renal dysfunction compared to colostomy after sphincter-preserving rectal surgery. DESIGN This study was a retrospective analysis. We compared preoperative and postoperative values of blood urea nitrogen, serum creatinine, and estimated glomerular filtration rate. SETTINGS The study was conducted at a single academic institution in Osaka, Japan. PATIENTS From October 2013 to November 2021, 135 consecutive patients who underwent rectal surgery with diverting stoma were included. MAIN OUTCOME MEASURES Differences in pre- and postoperative renal function values by stoma creation site in patients with preoperative chronic kidney disease. Risk factors for patients with newly developed kidney disease after stoma creation. RESULTS In the preoperative chronic kidney disease (+) patients, the differences between the pre- and postoperative values of blood urea nitrogen ( p = 0.047) and serum creatinine ( p = 0.028) were higher than in the preoperative chronic kidney disease (-) patients. In the preoperative chronic kidney disease (+) patients, ileostomy was significantly associated with an elevation of the serum creatinine value ( p = 0.025) and a decrease in estimated glomerular filtration rate value ( p = 0.041) from preoperative values compared with that of colostomy. In multivariate analysis, ileostomy (OR; 7.443, p = 0.011) and hypertension (4.226, p = 0.008) were independent risk factors of newly developed kidney disease postoperatively. LIMITATIONS Limitations to our study include its retrospective nature and bias because of the stoma site being determined by each surgeon. CONCLUSIONS We should take care to choose diverting stoma especially in patients with a risk of kidney dysfunction. See Video Abstract . IMPACTO DE UNA OSTOMA DE DERIVACIN SOBRE LA FUNCIN RENAL ANTECEDENTES:Apesar de haberse considerado que la ileostomía en asa de derivación afecta la función renal, pocos informes han comparado la colostomía de asa con la ileostomía de asa y ambas con respecto a la función renal. Esta es un problema importante en el contexto actual de mayores oportunidades para realizar cirugía en pacientes con función renal deficitaria.OBJETIVO:El presente estudio tiene como objetivo revelar el efecto de la ileostomía en asa sobre la función renal comparada con la colostomía en asa después de una cirugía rectal con preservación de esfínteres.DISEÑO:Estudio de análisis retrospectivo. Comparamos los valores de nitrógeno ureico en sangre en el pre-operatorio y el post-operatorio, la creatinina sérica y la tasa estimada de filtración glomerular.AJUSTES:Estudio lleavado a cabo en una sola institución académica en Osaka, Japón.PACIENTES:Desde octubre de 2013 hasta noviembre de 2021, se incluyeron consecutivamente 135 pacientes sometidos a cirugía rectal con ostomía de derivación.PRINCIPALES MEDIDAS DE RESULTADO:Las diferencias en los valores de la función renal pre y post-operatorias según el sitio de creación de las ostomía en pacientes con enfermedad renal crónica pre-operatoria. También los factores de riesgo para pacientes con enfermedad renal reciente después de la creación de una ostomía.RESULTADOS:En los pacientes con enfermedad renal crónica pre-operatoria (+), las diferencias entre los valores pre y post en el nitrógeno ureico en sangre (p = 0,047) y los valores de creatinina sérica (p = 0,028) fueron mayores que en los pacientes con enfermedad renal crónica pre-operatoria (+) y los pacientes con enfermedad renal (-).En los pacientes con enfermedad renal crónica (+) pre-operatoria, la ileostomía se asoció significativamente con una elevación del valor de creatinina sérica (p = 0,025) y una disminución en el valor estimado de la tasa de filtración glomerular (p = 0,041) con respecto al valor pre-operatorio en comparación con el de la colostomía.En el análisis multivariado, la ileostomía (Odds Ratio; 7,443, p = 0,011) y la hipertensión (4,226, P = 0,008) fueron factores de riesgo independientes de nueva enfermedad renal en el post-operatorio.LIMITACIONES:Las limitaciones de nuestro estudio incluyen su naturaleza retrospectiva y el sesgo debido a que cada cirujano determina el sitio de la confección ostomial.CONCLUSIÓN:Se debe tener cuidado en elegir el tipo de ostomía derivativa especialmente en pacientes con riesgo de disfunción renal. (Traducción-Dr. Xavier Delgadillo ).
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Affiliation(s)
- Takuki Yagyu
- Department of Gastrointestinal Surgery, Kansai Medical University Hospital, Hirakata, Japan
| | - Madoka Hamada
- Department of Gastrointestinal Surgery, Kansai Medical University Hospital, Hirakata, Japan
| | - Masahiko Hatta
- Department of Gastrointestinal Surgery, Kansai Medical University Hospital, Hirakata, Japan
| | - Toshinori Kobayashi
- Department of Gastrointestinal Surgery, Kansai Medical University Hospital, Hirakata, Japan
| | - Yuki Matsumi
- Department of Gastrointestinal Surgery, Kansai Medical University Hospital, Hirakata, Japan
- Department of Gastroenterological Surgery, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama, Japan
| | - Ryo Inada
- Department of Gastrointestinal Surgery, Kansai Medical University Hospital, Hirakata, Japan
- Department of Gastroenterological Surgery, Kochi Health Sciences Centre, Kochi, Japan
| | - Tomoko Matsumoto
- Department of Gastrointestinal Surgery, Kansai Medical University Hospital, Hirakata, Japan
- Department of Gastroenterological Surgery, Coloproctology Center Takano Hospital, Kumamoto, Japan
| | - Masaharu Oishi
- Department of Gastrointestinal Surgery, Kansai Medical University Hospital, Hirakata, Japan
- Oishi Clinic, Minoh, Japan
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Ficarino H, Moses C, Wood L, Byrd G, Bhatia S, Chu D, Hollis R. The Readability, Understandability, and Suitability of Online Resources for Ostomy Care. J Wound Ostomy Continence Nurs 2024; 51:471-477. [PMID: 39588816 PMCID: PMC11601952 DOI: 10.1097/won.0000000000001125] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2024]
Abstract
PURPOSE the purpose of this study was to evaluate the content, readability, understandability, and suitability of online resources for patient specific ostomy care. DESIGN Retrospective cohort study. SUBJECT AND SETTING Online websites for ostomy care designed for patients. METHODS Ostomy care websites designed for patients were identified by querying three online search engines. Content areas were established following assessment of all websites by two reviewers. Readability of each website was determined using the Flesch Reading Ease Test and the Simple Measure of Gobbledygook (SMOG) index. Understandability was measured using the Patient Education Materials Assessment Tool (PEMAT), and suitability was determined using the Suitability Assessment of Materials (SAM). Chi-Square and rank sum tests were used to compare these measures across website type and by number of content areas. RESULTS Twenty-three websites met inclusion criteria; 26.1% were for-profit, 13% were government, 26.1% were academic, and 34.8% were non-profit. Nineteen content areas were identified including themes related to pouching, bathing, physical activity, managing output, lifestyle, mental health, and eating. The median number of content areas covered was 8.5 [interquartile range (IQR) 4-13]. The most common content areas were changing/emptying a pouching system (82.6% of websites), preventing/managing peristomal skin irritation (78.3%), eating (60.9%), and odor management (60.9%). Less than 27% of websites had content on irrigation, blockage/constipation, and body image. Readability scores using the Flesch Reading Ease (mean 58, IQR 54.7-69.5) and SMOG Index (mean 9.1, IQR 7.6-9.9) correlated to a high-school or "fairly difficult" reading level. The mean PEMAT measuring understandability was 80 (IQR 78.9-84.0). The mean SAM score checking for suitability (literacy demand, graphics, layout and type, learning stimulation and motivation and cultural appropriateness) was 55% (IQR 48.4%-61.3%), indicating "adequate material." A greater number of content areas on the websites were associated with worse readability (SMOG and Flesch Reading Ease scores) than websites presenting fewer content areas (P = .001 & P < .001, respectively). CONCLUSIONS We found significant variability in the content, readability, understandability, and suitability of online materials for ostomy care. Websites with more content areas were associated with worse readability.
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Affiliation(s)
- Hannah Ficarino
- Hannah Ficarino, MD, Department of Surgery, University of Alabama at Birmingham, Birmingham, Alabama
- Cara Moses, MD, Department of Surgery, University of Alabama at Birmingham, Birmingham, Alabama
- Lauren Wood, MSPH, Department of Surgery, University of Alabama at Birmingham, Birmingham, Alabama
- Gabby Byrd, HS, Department of Surgery, University of Alabama at Birmingham, Birmingham, Alabama
- Smita Bhatia, MD MPH, Division of Pediatric Hematology-Oncology, Institute for Cancer Outcomes and Survivorship, University of Alabama at Birmingham, Birmingham, Alabama
- Daniel Chu, MD MSPH, Department of Surgery, University of Alabama at Birmingham, Birmingham, Alabama
- Robert Hollis IV, MD MSPH, Department of Surgery, Institute for Cancer Outcomes and Survivorship, University of Alabama at Birmingham, Birmingham, Alabama
| | - Cara Moses
- Hannah Ficarino, MD, Department of Surgery, University of Alabama at Birmingham, Birmingham, Alabama
- Cara Moses, MD, Department of Surgery, University of Alabama at Birmingham, Birmingham, Alabama
- Lauren Wood, MSPH, Department of Surgery, University of Alabama at Birmingham, Birmingham, Alabama
- Gabby Byrd, HS, Department of Surgery, University of Alabama at Birmingham, Birmingham, Alabama
- Smita Bhatia, MD MPH, Division of Pediatric Hematology-Oncology, Institute for Cancer Outcomes and Survivorship, University of Alabama at Birmingham, Birmingham, Alabama
- Daniel Chu, MD MSPH, Department of Surgery, University of Alabama at Birmingham, Birmingham, Alabama
- Robert Hollis IV, MD MSPH, Department of Surgery, Institute for Cancer Outcomes and Survivorship, University of Alabama at Birmingham, Birmingham, Alabama
| | - Lauren Wood
- Hannah Ficarino, MD, Department of Surgery, University of Alabama at Birmingham, Birmingham, Alabama
- Cara Moses, MD, Department of Surgery, University of Alabama at Birmingham, Birmingham, Alabama
- Lauren Wood, MSPH, Department of Surgery, University of Alabama at Birmingham, Birmingham, Alabama
- Gabby Byrd, HS, Department of Surgery, University of Alabama at Birmingham, Birmingham, Alabama
- Smita Bhatia, MD MPH, Division of Pediatric Hematology-Oncology, Institute for Cancer Outcomes and Survivorship, University of Alabama at Birmingham, Birmingham, Alabama
- Daniel Chu, MD MSPH, Department of Surgery, University of Alabama at Birmingham, Birmingham, Alabama
- Robert Hollis IV, MD MSPH, Department of Surgery, Institute for Cancer Outcomes and Survivorship, University of Alabama at Birmingham, Birmingham, Alabama
| | - Gabby Byrd
- Hannah Ficarino, MD, Department of Surgery, University of Alabama at Birmingham, Birmingham, Alabama
- Cara Moses, MD, Department of Surgery, University of Alabama at Birmingham, Birmingham, Alabama
- Lauren Wood, MSPH, Department of Surgery, University of Alabama at Birmingham, Birmingham, Alabama
- Gabby Byrd, HS, Department of Surgery, University of Alabama at Birmingham, Birmingham, Alabama
- Smita Bhatia, MD MPH, Division of Pediatric Hematology-Oncology, Institute for Cancer Outcomes and Survivorship, University of Alabama at Birmingham, Birmingham, Alabama
- Daniel Chu, MD MSPH, Department of Surgery, University of Alabama at Birmingham, Birmingham, Alabama
- Robert Hollis IV, MD MSPH, Department of Surgery, Institute for Cancer Outcomes and Survivorship, University of Alabama at Birmingham, Birmingham, Alabama
| | - Smita Bhatia
- Hannah Ficarino, MD, Department of Surgery, University of Alabama at Birmingham, Birmingham, Alabama
- Cara Moses, MD, Department of Surgery, University of Alabama at Birmingham, Birmingham, Alabama
- Lauren Wood, MSPH, Department of Surgery, University of Alabama at Birmingham, Birmingham, Alabama
- Gabby Byrd, HS, Department of Surgery, University of Alabama at Birmingham, Birmingham, Alabama
- Smita Bhatia, MD MPH, Division of Pediatric Hematology-Oncology, Institute for Cancer Outcomes and Survivorship, University of Alabama at Birmingham, Birmingham, Alabama
- Daniel Chu, MD MSPH, Department of Surgery, University of Alabama at Birmingham, Birmingham, Alabama
- Robert Hollis IV, MD MSPH, Department of Surgery, Institute for Cancer Outcomes and Survivorship, University of Alabama at Birmingham, Birmingham, Alabama
| | - Daniel Chu
- Hannah Ficarino, MD, Department of Surgery, University of Alabama at Birmingham, Birmingham, Alabama
- Cara Moses, MD, Department of Surgery, University of Alabama at Birmingham, Birmingham, Alabama
- Lauren Wood, MSPH, Department of Surgery, University of Alabama at Birmingham, Birmingham, Alabama
- Gabby Byrd, HS, Department of Surgery, University of Alabama at Birmingham, Birmingham, Alabama
- Smita Bhatia, MD MPH, Division of Pediatric Hematology-Oncology, Institute for Cancer Outcomes and Survivorship, University of Alabama at Birmingham, Birmingham, Alabama
- Daniel Chu, MD MSPH, Department of Surgery, University of Alabama at Birmingham, Birmingham, Alabama
- Robert Hollis IV, MD MSPH, Department of Surgery, Institute for Cancer Outcomes and Survivorship, University of Alabama at Birmingham, Birmingham, Alabama
| | - Robert Hollis
- Hannah Ficarino, MD, Department of Surgery, University of Alabama at Birmingham, Birmingham, Alabama
- Cara Moses, MD, Department of Surgery, University of Alabama at Birmingham, Birmingham, Alabama
- Lauren Wood, MSPH, Department of Surgery, University of Alabama at Birmingham, Birmingham, Alabama
- Gabby Byrd, HS, Department of Surgery, University of Alabama at Birmingham, Birmingham, Alabama
- Smita Bhatia, MD MPH, Division of Pediatric Hematology-Oncology, Institute for Cancer Outcomes and Survivorship, University of Alabama at Birmingham, Birmingham, Alabama
- Daniel Chu, MD MSPH, Department of Surgery, University of Alabama at Birmingham, Birmingham, Alabama
- Robert Hollis IV, MD MSPH, Department of Surgery, Institute for Cancer Outcomes and Survivorship, University of Alabama at Birmingham, Birmingham, Alabama
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Bradley SE, Vitous CA, Marzoughi M, Dualeh SHA, Rivard SJ, Duby A, Hendren S, Suwanabol PA. Patient adherence to an oral rehydration solution intervention to prevent dehydration following ileostomy creation: A qualitative study. Am J Surg 2024; 233:120-124. [PMID: 38448319 DOI: 10.1016/j.amjsurg.2024.02.045] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2024] [Revised: 02/14/2024] [Accepted: 02/27/2024] [Indexed: 03/08/2024]
Abstract
BACKGROUND Patients undergoing surgery for ileostomy creation frequently experience postoperative dehydration and subsequent renal injury. The use of oral rehydration solutions (ORS) has been shown to prevent dehydration, but compliance may be variable. METHODS Semi-structured qualitative interviews were conducted with 17 patients who received a postoperative hydration kit and dehydration education to assess barriers and facilitators to compliance with ORS kit instructions. RESULTS Qualitative analysis revealed five themes affecting patient adherence to the ORS intervention: (1) patient's perception of the effectiveness of the ORS solution, (2) existing co-morbidities, (3) kit quality and taste of the ORS product, (4) quality of the dehydration education, and (5) social support. CONCLUSIONS Given that patient adherence can greatly affect the success of an ORS intervention, the design of future ORS interventions should emphasize the educational component, the "patient friendliness" of the ORS kit, and ways that social supports can be leveraged to increase adherence.
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Affiliation(s)
- Sarah E Bradley
- Center for Health Outcomes and Policy, University of Michigan, Ann Arbor, MI, USA.
| | - C Ann Vitous
- Center for Health Outcomes and Policy, University of Michigan, Ann Arbor, MI, USA
| | | | - Shukri H A Dualeh
- Center for Health Outcomes and Policy, University of Michigan, Ann Arbor, MI, USA; Department of Surgery, University of Michigan, Ann Arbor, MI, USA
| | - Samantha J Rivard
- Department of Surgery, University of Massachusetts Memorial Medical Center, Worcester, MA, USA
| | - Ashley Duby
- Center for Health Outcomes and Policy, University of Michigan, Ann Arbor, MI, USA; Department of Surgery, University of Michigan, Ann Arbor, MI, USA
| | - Samantha Hendren
- Center for Health Outcomes and Policy, University of Michigan, Ann Arbor, MI, USA; Department of Surgery, University of Michigan, Ann Arbor, MI, USA
| | - Pasithorn A Suwanabol
- Center for Health Outcomes and Policy, University of Michigan, Ann Arbor, MI, USA; Department of Surgery, University of Michigan, Ann Arbor, MI, USA
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Boyd T, Araka EB, Kochar B, Ananthakrishnan AN. Differences in Management and Outcomes of Older and Younger Adults with Acute Severe Ulcerative Colitis. J Crohns Colitis 2024; 18:570-577. [PMID: 37897720 PMCID: PMC11037104 DOI: 10.1093/ecco-jcc/jjad183] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/18/2023] [Indexed: 10/30/2023]
Abstract
BACKGROUND Older adults with ulcerative colitis [UC] have greater morbidity than younger adults. The goal of this study was to investigate differences in the management and outcomes of older and younger patients hospitalised with severe UC. METHODS We conducted a retrospective cohort study of patients hospitalised for acute severe ulcerative colitis requiring intravenous steroids. We compared outcomes of adults aged ≥65 years with outcomes of younger patients. Primary study outcomes included frequency and timing of medical and surgical rescue therapy during the hospitalisation, postoperative complications, frailty, and mortality outcomes up to 1 year following the hospitalisation. RESULTS Our cohort included 63 older adults [≥65 years] and 137 younger adults [14-64 years]. Despite similar disease severity at hospitalisation, older adults were half as likely to receive medical rescue therapy (odds ratio 0.45, 95% confidence interval [CI] 0.22-0.91). This difference was more striking among the frailest older adults. Older patients were similarly likely to undergo surgery but were more likely to undergo urgent or emergent procedures [50%] compared with younger patients [13%] [p <0.004]. The fraction of older adults at high risk for frailty increased from 33% pre-hospitalisation to 42% post-hospitalisation. Nearly one-third [27.8%] of older adults died within 1 year of hospitalisation, with half the deaths among older adults being attributable to UC or complications of UC. CONCLUSIONS In comparison with younger patients, older adults had lower frequency use of medical rescue therapy, higher rates of emergency surgery, and increased mortality within 1 year. Further research is needed to optimise care pathways in this population.
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Affiliation(s)
- Taylor Boyd
- Harvard Medical School, Harvard University, Boston, MA, USA
- Division of Gastroenterology, Massachusetts General Hospital, Boston, MA, USA
| | | | - Bharati Kochar
- Harvard Medical School, Harvard University, Boston, MA, USA
- Division of Gastroenterology, Massachusetts General Hospital, Boston, MA, USA
| | - Ashwin N Ananthakrishnan
- Harvard Medical School, Harvard University, Boston, MA, USA
- Division of Gastroenterology, Massachusetts General Hospital, Boston, MA, USA
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Westfall KM, Rivard SJ, Suwanabol PA, Albright JJ, Ramm CA, Cleary RK. Postoperative Oral Rehydration and Regimented Follow-up Decrease Readmissions After Colorectal Surgery That Includes Ileostomies. Dis Colon Rectum 2024; 67:313-321. [PMID: 37703205 DOI: 10.1097/dcr.0000000000002935] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 09/15/2023]
Abstract
BACKGROUND Ileostomies constitute 15% to 43% of readmissions after colorectal surgery, often due to dehydration and acute kidney injury. Prior institutional interventions decreased readmissions but not among patients who underwent new ileostomies. OBJECTIVE To evaluate readmissions among patients who underwent new ileostomies after postoperative oral rehydration solution and standardized clinic visits. DESIGN Retrospective analysis of prospective database. SETTINGS Enhanced recovery colorectal surgery service. PATIENTS Patients who underwent new ileostomy before and after intervention. INTERVENTIONS Postoperative oral rehydration solution and postdischarge clinic visits with review of inputs/outputs, antimotility and appliance needs, and trained nurse reeducation 4 to 7 days after discharge, 30 days postoperatively, and every 1 to 2 weeks thereafter as needed. MAIN OUTCOME MEASURES Readmission rate due to dehydration/acute kidney injury (primary), emergency department visits, and readmission rates overall and for specific diagnoses. Analysis used univariate and weighted techniques. RESULTS A total of 312 patients (199 preintervention; 113 postintervention) were included, with a mean age of 59.0 years. Patients were predominantly White (94.9%) and evenly split between men and women. The most common diagnosis was diverticulitis (43.3%). The most common procedure was high anterior resection (38.8%), followed by low anterior resection (16.35%). Patient and procedure characteristics were well matched between groups. Multivariate analysis demonstrated that readmission rate due to dehydration/acute kidney injury significantly decreased between pre- and postintervention study groups (45.7% vs 16.5%, p = 0.039). Emergency department visits due to dehydration/acute kidney injury (12.0% vs 1.7%, p < 0.001) and readmissions from all causes (24.33% vs 10.6%, p = 0.005) also significantly decreased. Other complications were not significantly different between groups. Average stoma output 24 hours before (776 vs 625 mL, p = 0.005) and after (993 vs 890 mL, p = 0.025) discharge was significantly decreased in the postintervention group. LIMITATIONS Retrospective single-center study. CONCLUSIONS An oral rehydration solution and frequent standardized postdischarge visits led by trained nursing staff decreased readmissions and emergency department visits among patients who underwent new ileostomies after colorectal surgery. See Video Abstract . LA REHIDRATACIN ORAL POSOPERATORIA Y EL SEGUIMIENTO REGLAMENTADO REDUCEN LOS REINGRESOS EN PACIENTES DE CIRUGA COLORRECTAL CON ILEOSTOMAS ANTECEDENTES:Las ileostomías constituyen del 15 al 43% de los reingresos después de la cirugía colorrectal, a menudo debido a la deshidratación y la lesión renal aguda. Las intervenciones institucionales previas redujeron los reingresos, pero no entre los pacientes con nuevas ileostomías.OBJETIVO:Evaluar los reingresos entre pacientes con nuevas ileostomías después del uso de solución de rehidratación oral postoperatoria y visitas clínicas estandarizadas.DISEÑO:Análisis retrospectivo de base de datos prospectiva.AJUSTES:Servicio de cirugía colorrectal de recuperación mejorada.PACIENTES:Pacientes con ileostomía nueva antes y después de la intervención.INTERVENCIÓN(ES):Solución de rehidratación oral posoperatoria y visitas clínicas posteriores al alta con revisión de entradas/salidas, antimotilidad y necesidades de aparatos, y reeducación de enfermeras capacitadas 4-7 días después del alta, 30 días después de la operación y cada 1-2 semanas después, según sea necesario.PRINCIPALES MEDIDAS DE RESULTADO:Tasa de readmisión debido a deshidratación/lesión renal aguda (primaria), tasa de urgencias y de readmisión en general y para diagnósticos específicos. El análisis utilizó técnicas univariadas y ponderadas.RESULTADOS:Se incluyeron un total de 312 pacientes (199 preintervención; 113 postintervención), con una edad media de 59,0 años. Los pacientes eran predominantemente blancos (94,9%) y se dividieron equitativamente entre hombres y mujeres. El diagnóstico más frecuente fue diverticulitis (43,3%). El procedimiento más común fue la resección anterior alta (38,8 %) seguida de la resección anterior baja (16,35 %). Las características del paciente y del procedimiento coincidieron bien entre los grupos. El análisis multivariante demostró que la tasa de reingreso debido a deshidratación/lesión renal aguda disminuyó significativamente entre los grupos de estudio antes y después de la intervención (45,7 % frente a 16,5 %, p = 0,039). Las visitas a urgencias por deshidratación/insuficiencia renal aguda (12,0 % frente a 1,7 %, p < 0,001) y los reingresos por todas las causas (24,33 % frente a 10,6 %, p = 0,005) también disminuyeron significativamente. Otras complicaciones no fueron significativamente diferentes entre los grupos. El gasto medio del estoma 24 horas antes (776 ml frente a 625 ml, p = 0,005) y después (993 ml frente a 890 ml, p = 0,025) del alta disminuyó significativamente en el grupo posterior a la intervención.LIMITACIONES:Estudio retrospectivo de centro único.CONCLUSIONES:Una solución de rehidratación oral y frecuentes visitas estandarizadas posteriores al alta dirigidas por personal de enfermería capacitado redujeron los reingresos y las visitas al servicio de urgencias entre los pacientes con nuevas ileostomías después de la cirugía colorrectal. ( Traducción-Dr. Yolanda Colorado ).
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Affiliation(s)
| | - Samantha J Rivard
- Division of Colon and Rectal Surgery, University of Michigan, Ann Arbor, Michigan
| | | | - Jeremy J Albright
- Biostatistics and Epidemiology Methods Consulting, Ann Arbor, Michigan
| | - Carole A Ramm
- Department of Academic Research, St Joseph Mercy Hospital, Ann Arbor, Michigan
| | - Robert K Cleary
- Department of Surgery, St Joseph Mercy Hospital, Ann Arbor, Michigan
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Maksimkin AI, Bagatelia ZA, Kulushev VM, Gordienko EN, Lebedko MS, Anikina SS, Shin EP. [Morphological predictors of water-electrolyte disorders in patients with preventive ileostomy after rectal resection for cancer]. Khirurgiia (Mosk) 2024:16-28. [PMID: 38634580 DOI: 10.17116/hirurgia202404116] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/19/2024]
Abstract
OBJECTIVE To analyze morphological changes in wall of functioning and non-functioning small intestine in patients with preventive ileostomy and to determine histological predictors of water-electrolyte disorders. MATERIAL AND METHODS We prospectively analyzed 57 patients >18 years old who underwent rectal resection with preventive ileostomy between January 2022 and November 2023. Anthropometric data included gender, age, body mass index, ECOG and ASA classes. Complications associated with large losses through ileostomy were water-electrolyte disorders, dehydration and acute renal failure with repeated hospitalization. Morphological analysis implied intraoperative full-layer biopsy of small intestine on anterior abdominal wall (ileostomy). Intraoperative biopsy of efferent and afferent loops was also carried out. Tissue samples were examined by light microscopy. We analyzed mean height of mucous membrane villi and depth of crypts, as well as their ratio. Fibrosis and swelling of submucosa were evaluated too. The results were analyzed in the SPSS Statistics 20 software. RESULTS Mean height of intestinal villi <465 microns (p=0.028), ratio of their height to crypt depth <4.38 (p=0.034) and submucosal fibrosis (p=0.031) significantly affected malabsorption and readmission of patients. The risk of readmission was 11.5 and 5.5 times higher in univariate analysis. Multivariate analysis revealed in-hospital dehydration with resumption of infusion therapy as a predictor of readmission (p=0.046). CONCLUSION Ileostomy is a certain stress for the patient's body. Not every patient is able for adaptation. One of the adaptation mechanisms is hypertrophy of mucous membrane villi involved in digestion. This mechanism is less pronounced in patients with repeated hospitalizations. Preoperative morphological examination of ileum mucosa may be an additional objective predictor of possible complications of preventive ileostomy.
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Affiliation(s)
- A I Maksimkin
- Russian Medical Academy of Continuing Professional Education, Moscow, Russia
| | - Z A Bagatelia
- Russian Medical Academy of Continuing Professional Education, Moscow, Russia
- Botkin Moscow City Clinical Hospital, Moscow, Russia
| | - V M Kulushev
- Botkin Moscow City Clinical Hospital, Moscow, Russia
| | - E N Gordienko
- Botkin Moscow City Clinical Hospital, Moscow, Russia
| | - M S Lebedko
- Botkin Moscow City Clinical Hospital, Moscow, Russia
| | - S S Anikina
- Botkin Moscow City Clinical Hospital, Moscow, Russia
| | - E P Shin
- Russian University of Medicine, Moscow, Russia
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Butler LR, Chen KA, Hsu J, Kapadia MR, Gomez SM, Farrell TM. Predicting readmission after bariatric surgery using machine learning. Surg Obes Relat Dis 2023; 19:1236-1244. [PMID: 37455158 PMCID: PMC12057647 DOI: 10.1016/j.soard.2023.05.025] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2023] [Accepted: 05/27/2023] [Indexed: 07/18/2023]
Abstract
BACKGROUND While bariatric surgery is an effective method for achieving long-term weight loss, postoperative readmissions are associated with negative clinical outcomes and significant costs. OBJECTIVES We aimed to use machine learning (ML) algorithms to predict readmissions and compare results to logistic regression. SETTING Hospitals participating in the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program, United States. METHODS Patients who underwent sleeve gastrectomy (SG), Roux-en-Y gastric bypass (RYGB), and biliopancreatic diversion with duodenal switch between 2016 and 2020 were selected from the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP) database. Patient variables reported by the MBSAQIP database were analyzed by ML algorithms random forest (RF), gradient boosting (XGB), and deep neural networks (NN), and the results of the predictive models were compared to logistic regression using area under the receiver operating characteristic curve (AUROC). RESULTS Our study included 863,348 patients, of which 39,068 (4.52%) were readmitted. AUROC scores were XGB .785 (95% CI .784-.786), RF .785 (95% CI .784-.785), and NN .754 (95% CI .753-.754), compared with .62 (95% CI .62-.621) for logistic regression (LR) (P < .001). The sensitivity and specificity for XGB, the best performing model, were 73.81% and 70%, compared with 52.94% and 70% for logistic regression. The most important variables were intervention or reoperation prior to discharge, unplanned ICU admission, initial procedure, and the intraoperative transfusion. CONCLUSIONS ML demonstrates significant advantages over logistic regression when predicting 30-day readmission following bariatric surgery. With external validation, models could identify the best candidates for early discharge or targeted postdischarge resources.
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Affiliation(s)
- Logan R Butler
- Department of Surgery, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina.
| | - Kevin A Chen
- Department of Surgery, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Justin Hsu
- Department of Surgery, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Muneera R Kapadia
- Department of Surgery, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Shawn M Gomez
- Joint Department of Biomedical Engineering, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Timothy M Farrell
- Department of Surgery, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
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Brady RRW, Scott J, Grieveson S, Aibibula M, Cawson M, Marks T, Page J, Artignan A, Boisen EB. Complications and Healthcare Costs Associated With the First Year Following Colostomy and Ileostomy Formation: A Retrospective Study. J Wound Ostomy Continence Nurs 2023; 50:475-483. [PMID: 37966075 DOI: 10.1097/won.0000000000001028] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2023]
Abstract
PURPOSE The purpose of this study was to evaluate clinical and economic outcomes during the first year following ostomy formation. DESIGN Single-center retrospective audit. SUBJECTS AND SETTING The sample comprised 200 patients who underwent surgery leading to ileostomy or colostomy at a large English National Health Service (NHS) Trust. METHODS Clinical complications, medicine prescriptions, and interactions with healthcare services were reported over 12 months postsurgery, and interactions with the NHS were matched to the closest NHS unit cost to determine mean patient cost. RESULTS The most common ostomy-related surgical site complications were high output (35.0%; n = 70), followed by moderate/severe peristomal skin complications (24.5%; n = 49) and bleeding (23.5%; n = 47). Ostomy management-related complications included general difficulties with ostomy management (50.0%; n = 100) and leakage-related mild peristomal skin issues (48.5%; n = 97). Clinical complication rates were highest in the first quarter following ostomy formation, except parastomal hernia, which increased in incidence over time. Ileostomy patients more frequently experienced high output, acute renal failure, and ostomy management-related complications and had increased length of inpatient admission. However, healthcare resource use was high in both groups, with a median of 13 inpatient admission days and 12 outpatient contacts overall within the first year. Mean cost per patient was £20,444.60 (US $26,018.41); 90.5% of these costs were attributed to ostomy-related factors. CONCLUSIONS Patients are likely to experience at least one clinical complication following intestinal ostomy formation and have multiple interactions with the NHS. While a number of complications are more frequent in patients with ileostomies, both groups experienced considerable costs within the first year following surgery associated with ostomy management and recovery.
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Affiliation(s)
- Richard R W Brady
- Richard R. W. Brady, FRCSEd, MD, Newcastle Centre for Bowel Disease Research Group, Newcastle Hospitals and Newcastle University, Royal Victoria Hospital, Newcastle, United Kingdom
- Julia Scott, Newcastle Centre for Bowel Disease Research Group, Newcastle Hospitals and Newcastle University, Royal Victoria Hospital, Newcastle, United Kingdom
- Stephanie Grieveson, Newcastle Centre for Bowel Disease Research Group, Newcastle Hospitals and Newcastle University, Royal Victoria Hospital, Newcastle, United Kingdom
- Miriayi Aibibula, PhD, Coloplast Ltd, Peterborough, United Kingdom
- Matthew Cawson, MEnt, Coloplast Ltd, Peterborough, United Kingdom
- Tatjana Marks, MSc, Costello Medical Consulting Ltd, London, United Kingdom
- Jennifer Page, BSc, Costello Medical Consulting Ltd, Manchester, United Kingdom
- Audrey Artignan, MPhil, Costello Medical Consulting Ltd, Cambridge, United Kingdom
- Esben Bo Boisen, MSc, Coloplast A/S, Humlebaek, Denmark
| | - Julia Scott
- Richard R. W. Brady, FRCSEd, MD, Newcastle Centre for Bowel Disease Research Group, Newcastle Hospitals and Newcastle University, Royal Victoria Hospital, Newcastle, United Kingdom
- Julia Scott, Newcastle Centre for Bowel Disease Research Group, Newcastle Hospitals and Newcastle University, Royal Victoria Hospital, Newcastle, United Kingdom
- Stephanie Grieveson, Newcastle Centre for Bowel Disease Research Group, Newcastle Hospitals and Newcastle University, Royal Victoria Hospital, Newcastle, United Kingdom
- Miriayi Aibibula, PhD, Coloplast Ltd, Peterborough, United Kingdom
- Matthew Cawson, MEnt, Coloplast Ltd, Peterborough, United Kingdom
- Tatjana Marks, MSc, Costello Medical Consulting Ltd, London, United Kingdom
- Jennifer Page, BSc, Costello Medical Consulting Ltd, Manchester, United Kingdom
- Audrey Artignan, MPhil, Costello Medical Consulting Ltd, Cambridge, United Kingdom
- Esben Bo Boisen, MSc, Coloplast A/S, Humlebaek, Denmark
| | - Stephanie Grieveson
- Richard R. W. Brady, FRCSEd, MD, Newcastle Centre for Bowel Disease Research Group, Newcastle Hospitals and Newcastle University, Royal Victoria Hospital, Newcastle, United Kingdom
- Julia Scott, Newcastle Centre for Bowel Disease Research Group, Newcastle Hospitals and Newcastle University, Royal Victoria Hospital, Newcastle, United Kingdom
- Stephanie Grieveson, Newcastle Centre for Bowel Disease Research Group, Newcastle Hospitals and Newcastle University, Royal Victoria Hospital, Newcastle, United Kingdom
- Miriayi Aibibula, PhD, Coloplast Ltd, Peterborough, United Kingdom
- Matthew Cawson, MEnt, Coloplast Ltd, Peterborough, United Kingdom
- Tatjana Marks, MSc, Costello Medical Consulting Ltd, London, United Kingdom
- Jennifer Page, BSc, Costello Medical Consulting Ltd, Manchester, United Kingdom
- Audrey Artignan, MPhil, Costello Medical Consulting Ltd, Cambridge, United Kingdom
- Esben Bo Boisen, MSc, Coloplast A/S, Humlebaek, Denmark
| | - Miriayi Aibibula
- Richard R. W. Brady, FRCSEd, MD, Newcastle Centre for Bowel Disease Research Group, Newcastle Hospitals and Newcastle University, Royal Victoria Hospital, Newcastle, United Kingdom
- Julia Scott, Newcastle Centre for Bowel Disease Research Group, Newcastle Hospitals and Newcastle University, Royal Victoria Hospital, Newcastle, United Kingdom
- Stephanie Grieveson, Newcastle Centre for Bowel Disease Research Group, Newcastle Hospitals and Newcastle University, Royal Victoria Hospital, Newcastle, United Kingdom
- Miriayi Aibibula, PhD, Coloplast Ltd, Peterborough, United Kingdom
- Matthew Cawson, MEnt, Coloplast Ltd, Peterborough, United Kingdom
- Tatjana Marks, MSc, Costello Medical Consulting Ltd, London, United Kingdom
- Jennifer Page, BSc, Costello Medical Consulting Ltd, Manchester, United Kingdom
- Audrey Artignan, MPhil, Costello Medical Consulting Ltd, Cambridge, United Kingdom
- Esben Bo Boisen, MSc, Coloplast A/S, Humlebaek, Denmark
| | - Matthew Cawson
- Richard R. W. Brady, FRCSEd, MD, Newcastle Centre for Bowel Disease Research Group, Newcastle Hospitals and Newcastle University, Royal Victoria Hospital, Newcastle, United Kingdom
- Julia Scott, Newcastle Centre for Bowel Disease Research Group, Newcastle Hospitals and Newcastle University, Royal Victoria Hospital, Newcastle, United Kingdom
- Stephanie Grieveson, Newcastle Centre for Bowel Disease Research Group, Newcastle Hospitals and Newcastle University, Royal Victoria Hospital, Newcastle, United Kingdom
- Miriayi Aibibula, PhD, Coloplast Ltd, Peterborough, United Kingdom
- Matthew Cawson, MEnt, Coloplast Ltd, Peterborough, United Kingdom
- Tatjana Marks, MSc, Costello Medical Consulting Ltd, London, United Kingdom
- Jennifer Page, BSc, Costello Medical Consulting Ltd, Manchester, United Kingdom
- Audrey Artignan, MPhil, Costello Medical Consulting Ltd, Cambridge, United Kingdom
- Esben Bo Boisen, MSc, Coloplast A/S, Humlebaek, Denmark
| | - Tatjana Marks
- Richard R. W. Brady, FRCSEd, MD, Newcastle Centre for Bowel Disease Research Group, Newcastle Hospitals and Newcastle University, Royal Victoria Hospital, Newcastle, United Kingdom
- Julia Scott, Newcastle Centre for Bowel Disease Research Group, Newcastle Hospitals and Newcastle University, Royal Victoria Hospital, Newcastle, United Kingdom
- Stephanie Grieveson, Newcastle Centre for Bowel Disease Research Group, Newcastle Hospitals and Newcastle University, Royal Victoria Hospital, Newcastle, United Kingdom
- Miriayi Aibibula, PhD, Coloplast Ltd, Peterborough, United Kingdom
- Matthew Cawson, MEnt, Coloplast Ltd, Peterborough, United Kingdom
- Tatjana Marks, MSc, Costello Medical Consulting Ltd, London, United Kingdom
- Jennifer Page, BSc, Costello Medical Consulting Ltd, Manchester, United Kingdom
- Audrey Artignan, MPhil, Costello Medical Consulting Ltd, Cambridge, United Kingdom
- Esben Bo Boisen, MSc, Coloplast A/S, Humlebaek, Denmark
| | - Jennifer Page
- Richard R. W. Brady, FRCSEd, MD, Newcastle Centre for Bowel Disease Research Group, Newcastle Hospitals and Newcastle University, Royal Victoria Hospital, Newcastle, United Kingdom
- Julia Scott, Newcastle Centre for Bowel Disease Research Group, Newcastle Hospitals and Newcastle University, Royal Victoria Hospital, Newcastle, United Kingdom
- Stephanie Grieveson, Newcastle Centre for Bowel Disease Research Group, Newcastle Hospitals and Newcastle University, Royal Victoria Hospital, Newcastle, United Kingdom
- Miriayi Aibibula, PhD, Coloplast Ltd, Peterborough, United Kingdom
- Matthew Cawson, MEnt, Coloplast Ltd, Peterborough, United Kingdom
- Tatjana Marks, MSc, Costello Medical Consulting Ltd, London, United Kingdom
- Jennifer Page, BSc, Costello Medical Consulting Ltd, Manchester, United Kingdom
- Audrey Artignan, MPhil, Costello Medical Consulting Ltd, Cambridge, United Kingdom
- Esben Bo Boisen, MSc, Coloplast A/S, Humlebaek, Denmark
| | - Audrey Artignan
- Richard R. W. Brady, FRCSEd, MD, Newcastle Centre for Bowel Disease Research Group, Newcastle Hospitals and Newcastle University, Royal Victoria Hospital, Newcastle, United Kingdom
- Julia Scott, Newcastle Centre for Bowel Disease Research Group, Newcastle Hospitals and Newcastle University, Royal Victoria Hospital, Newcastle, United Kingdom
- Stephanie Grieveson, Newcastle Centre for Bowel Disease Research Group, Newcastle Hospitals and Newcastle University, Royal Victoria Hospital, Newcastle, United Kingdom
- Miriayi Aibibula, PhD, Coloplast Ltd, Peterborough, United Kingdom
- Matthew Cawson, MEnt, Coloplast Ltd, Peterborough, United Kingdom
- Tatjana Marks, MSc, Costello Medical Consulting Ltd, London, United Kingdom
- Jennifer Page, BSc, Costello Medical Consulting Ltd, Manchester, United Kingdom
- Audrey Artignan, MPhil, Costello Medical Consulting Ltd, Cambridge, United Kingdom
- Esben Bo Boisen, MSc, Coloplast A/S, Humlebaek, Denmark
| | - Esben Bo Boisen
- Richard R. W. Brady, FRCSEd, MD, Newcastle Centre for Bowel Disease Research Group, Newcastle Hospitals and Newcastle University, Royal Victoria Hospital, Newcastle, United Kingdom
- Julia Scott, Newcastle Centre for Bowel Disease Research Group, Newcastle Hospitals and Newcastle University, Royal Victoria Hospital, Newcastle, United Kingdom
- Stephanie Grieveson, Newcastle Centre for Bowel Disease Research Group, Newcastle Hospitals and Newcastle University, Royal Victoria Hospital, Newcastle, United Kingdom
- Miriayi Aibibula, PhD, Coloplast Ltd, Peterborough, United Kingdom
- Matthew Cawson, MEnt, Coloplast Ltd, Peterborough, United Kingdom
- Tatjana Marks, MSc, Costello Medical Consulting Ltd, London, United Kingdom
- Jennifer Page, BSc, Costello Medical Consulting Ltd, Manchester, United Kingdom
- Audrey Artignan, MPhil, Costello Medical Consulting Ltd, Cambridge, United Kingdom
- Esben Bo Boisen, MSc, Coloplast A/S, Humlebaek, Denmark
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Scientific and Clinical Abstracts From WOCNext® 2023: Las Vegas, Nevada ♦ June 4-7, 2023. J Wound Ostomy Continence Nurs 2023; 50:S1-S78. [PMID: 37632270 DOI: 10.1097/won.0000000000000980] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/21/2023]
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Loria A, Z Becerra A, D Melucci A, Ghaffar A, Croft A, A Hanchett V, K Temple L, J Fleming F. Major renal morbidity following elective rectal cancer resection by the type of diverting ostomy. Colorectal Dis 2023; 25:404-412. [PMID: 36237178 DOI: 10.1111/codi.16375] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/14/2022] [Revised: 09/14/2022] [Accepted: 10/03/2022] [Indexed: 12/13/2022]
Abstract
AIM Patients with rectal cancer often undergo faecal diversion, yet the existing literature cursorily reports renal sequelae by the type of ostomy. We aimed to determine whether the presence of an ileostomy or colostomy was associated with postoperative renal morbidity. METHODS We identified patients with rectal cancer undergoing elective resection with primary anastomosis without diversion, with an ileostomy and with a colostomy by 21 possible procedures in the colectomy- and proctectomy-specific National Surgical Quality Improvement Program files. The odds of major renal events (renal failure [dialysis initiated] or progressive renal insufficiency [>2 mg/dl increase in creatinine without dialysis]), progressive renal insufficiency alone and readmissions were assessed using propensity score weighting and logistic regression. RESULTS Of 15 075 patients (63.7% Stage II-III, 85.7% creatinine values obtained ≤30 days preoperatively), 37.7% were not diverted, 39.5% had an ileostomy and 22.9% a colostomy. Compared to non-diverted patients, diversion was associated with major renal events (ileostomy, odds ratio [OR] 2.1, 95% confidence interval [CI] 1.6-2.9; colostomy, OR 1.8, 95% CI 1.3-2.5), progressive renal insufficiency (ileostomy, OR 2.5, 95% CI 1.7-3.5; colostomy, OR 2.0, 95% CI 1.4-2.9), readmissions for renal failure (ileostomy, OR 3.2, 95% CI 2.1-5.0; colostomy, OR 2.5, 95% CI 1.6-4.1) and readmissions for fluid/electrolyte abnormalities (ileostomy, OR 2.3, 95% CI 1.6-3.3; colostomy, OR 1.8, 95% CI 1.2-2.6). CONCLUSION Diverting ostomies after elective rectal cancer resection are strongly associated with renal morbidity. The decision to divert is complex, and it is unclear whether select patients may benefit from a colostomy from a renal perspective.
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Affiliation(s)
- Anthony Loria
- University of Rochester Medical Center, Department of Surgery, New York, USA
- University of Rochester Medical Center, Surgical Health Outcomes and Research Enterprise (SHORE), Department of Surgery, New York, USA
| | - Adan Z Becerra
- Rush University Medical Center, Department of Surgery, Chicago, Illinois, USA
| | - Alexa D Melucci
- University of Rochester Medical Center, Department of Surgery, New York, USA
- University of Rochester Medical Center, Surgical Health Outcomes and Research Enterprise (SHORE), Department of Surgery, New York, USA
| | - Aqsa Ghaffar
- University of Rochester Medical Center, Department of Surgery, New York, USA
| | - Ashley Croft
- University of Rochester Medical Center, Department of Surgery, New York, USA
| | - Virginia A Hanchett
- University of Rochester Medical Center, Department of Surgery, New York, USA
| | - Larissa K Temple
- University of Rochester Medical Center, Department of Surgery, New York, USA
- University of Rochester Medical Center, Surgical Health Outcomes and Research Enterprise (SHORE), Department of Surgery, New York, USA
| | - Fergal J Fleming
- University of Rochester Medical Center, Department of Surgery, New York, USA
- University of Rochester Medical Center, Surgical Health Outcomes and Research Enterprise (SHORE), Department of Surgery, New York, USA
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Pencovich N, Silverman JS, Horesh N, Nevo N, Eshkenazy R, Kent I, Ram E, Nachmany I. Readmission with acute kidney injury following ileostomy: patterns and predictors of a common phenomenon. Langenbecks Arch Surg 2023; 408:96. [PMID: 36805819 DOI: 10.1007/s00423-023-02842-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2022] [Accepted: 02/13/2023] [Indexed: 02/23/2023]
Abstract
PURPOSE Ileostomy is associated with various complications, often necessitating rehospitalization. High-output ileostomy is common and may lead to acute kidney injury (AKI). Here we describe the temporal pattern of readmission with AKI following ileostomy formation and identify risk factors. METHODS Patients that underwent formation of ileostomy between 2008 and 2021 were included in this study. Readmission with AKI with high output ileostomy was defined as readmission with serum creatinine > 1.5-fold compared to the level at discharge or latest baseline (at least stage-1 AKI according to Kidney Disease: Improving Global Outcome (KDIGO) criteria), accompanied by ileostomy output > 1000 ml in 24 h. Patient characteristics and perioperative course were assessed to identify predictors for readmission with AKI. RESULTS Of 1191 patients who underwent ileostomy, 198 (16.6%) were readmitted with a high output stoma and AKI. The mean time to readmission with AKI was 98.97 ± 156.36 days. Eighty-six patients (43.4%) had early readmission (within 30 days), and 66 (33%) were readmitted after more than 90 days. Over 90% of patients had more than one readmission, and 110 patients (55%) had 5 or more. Patient-related predictors for readmission with AKI were age > 65, body mass index > 30 kg/m2, and hypertension. Factors related to the postoperative course were AKI with creatinine > 2 mg/dl, postoperative hemoglobin < 8 g/dl or blood transfusion, albumin < 20 g/dl, high output stoma and need for loperamide, and length of hospital stay > 20 days. Factors related to early versus late readmissions and multiple readmissions were also analyzed. CONCLUSIONS Readmission with AKI following ileostomy formation is a consequential event with distinct risk factors. Acknowledging these risk factors is the foundation for designing interventions aiming to reduce frequency of AKI readmissions in predisposed patient populations.
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Affiliation(s)
- Niv Pencovich
- Department of General Surgery and Transplantation, Faculty of Medicine, Sheba Medical Center, Tel-Aviv University, Tel-Hashomer, Tel-Aviv, Israel.
| | - Jacob Samuel Silverman
- Department of General Surgery and Transplantation, Faculty of Medicine, Sheba Medical Center, Tel-Aviv University, Tel-Hashomer, Tel-Aviv, Israel
| | - Nir Horesh
- Department of General Surgery and Transplantation, Faculty of Medicine, Sheba Medical Center, Tel-Aviv University, Tel-Hashomer, Tel-Aviv, Israel
| | - Nadav Nevo
- Department of General Surgery, Faculty of Health Sciences, Assuta Medical Center, Ashdod, Ben-Gurion University of the Negev, Beer-Sheva, Israel
| | - Rony Eshkenazy
- Department of General Surgery and Transplantation, Faculty of Medicine, Sheba Medical Center, Tel-Aviv University, Tel-Hashomer, Tel-Aviv, Israel
| | - Ilan Kent
- Department of General Surgery and Transplantation, Faculty of Medicine, Sheba Medical Center, Tel-Aviv University, Tel-Hashomer, Tel-Aviv, Israel
| | - Edward Ram
- Department of General Surgery and Transplantation, Faculty of Medicine, Sheba Medical Center, Tel-Aviv University, Tel-Hashomer, Tel-Aviv, Israel
| | - Ido Nachmany
- Department of General Surgery and Transplantation, Faculty of Medicine, Sheba Medical Center, Tel-Aviv University, Tel-Hashomer, Tel-Aviv, Israel
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15
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Michońska I, Polak-Szczybyło E, Sokal A, Jarmakiewicz-Czaja S, Stępień AE, Dereń K. Nutritional Issues Faced by Patients with Intestinal Stoma: A Narrative Review. J Clin Med 2023; 12:jcm12020510. [PMID: 36675439 PMCID: PMC9862496 DOI: 10.3390/jcm12020510] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2022] [Revised: 12/14/2022] [Accepted: 01/06/2023] [Indexed: 01/11/2023] Open
Abstract
The incidences of colorectal cancer and inflammatory bowel diseases are increasing in the developed countries of Western Europe and North America, and consequently, the prevalence rate of temporary or permanent stomas has increased in recent years. Nevertheless, the amount of research in the nutrition field in the case of patients with stoma is rather limited. This review article aims to assess the impact of nutrition on an intestinal stoma and possible sequelae resolved with nutritional therapy. The research analyses conducted thus far indicate a significantly increased risk of developing malnutrition, vitamin deficiency (especially group B), and an increased number of discharges from the stoma and its relevance with abnormalities found in electrolyte concentrations.
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16
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Plonkowski A, Allison C, Philipson P, Brady RRW. Risk factors associated with readmission within 30 days following stoma surgery: Development of a 'traffic light' prediction model. Colorectal Dis 2022; 25:747-756. [PMID: 36411954 DOI: 10.1111/codi.16423] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/09/2022] [Revised: 10/30/2022] [Accepted: 11/03/2022] [Indexed: 11/23/2022]
Abstract
AIM Patients undergoing stoma surgery have a higher risk for early readmission. Some patients may benefit from closer postdischarge surveillance to provide early detection of complications and timely intervention. However, there is a paucity of validated tools to identify those at higher risk of readmission. Here, we aim to determine the independent risk factors associated with readmission within 30 days of discharge following stoma surgery, attempt to validate previous predictive models and develop a novel prediction tool. METHOD A retrospective review of 423 patients who underwent ileostomy or colostomy stoma formation at a UK tertiary colorectal centre between 2019 and 2021. Univariate, multivariate and logistic regression analyses were used to analyse a large number of demographics and risk factors and the association with readmission. RESULTS This study cohort included 220 ileostomy and 203 colostomy patients. Of these, 87 (20.6%) were readmitted within 30 days of discharge following index surgery. A large number of demographics were evaluated for association with readmission. Readmission was associated with chronic heart failure (p < 0.05), postoperative stoma-specific complications (bleeding, p = 0.02; high-output stoma, p = 0.01) and those with a loop ileostomy (34.0% vs. 18.6%; p = 0.01). A previous predictive model was ineffective in this cohort, therefore a simplified 'traffic light' risk scoring system was developed and found to have improved discrimination. CONCLUSION Readmission following stoma formation is associated with key variables that could provide the means to triage, risk score and potentially predict readmissions. We found that a novel and simplified scoring system may provide improved prediction.
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Affiliation(s)
- Alexander Plonkowski
- Newcastle Centre for Bowel Disease Research Group, Royal Victoria Infirmary, Newcastle Hospitals, Newcastle upon Tyne, UK
| | - Callum Allison
- Newcastle Centre for Bowel Disease Research Group, Royal Victoria Infirmary, Newcastle Hospitals, Newcastle upon Tyne, UK
| | - Pete Philipson
- School of Mathematics, Statistics and Physics, Newcastle University, Newcastle upon Tyne, UK
| | - Richard R W Brady
- Newcastle Centre for Bowel Disease Research Group, Royal Victoria Infirmary, Newcastle Hospitals, Newcastle upon Tyne, UK
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17
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Chen KA, Joisa CU, Stitzenberg KB, Stem J, Guillem JG, Gomez SM, Kapadia MR. Development and Validation of Machine Learning Models to Predict Readmission After Colorectal Surgery. J Gastrointest Surg 2022; 26:2342-2350. [PMID: 36070116 PMCID: PMC10081888 DOI: 10.1007/s11605-022-05443-5] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/12/2022] [Accepted: 08/18/2022] [Indexed: 01/31/2023]
Abstract
BACKGROUND Readmission after colorectal surgery is common and often implies complications for patients and costs for hospitals. Previous works have created predictive models using logistic regression for this outcome but have shown limited accuracy. Machine learning has shown promise in improving predictions by identifying non-linear patterns in data. We sought to create a more accurate predictive model for readmission after colorectal surgery using machine learning. METHODS Patients who underwent colorectal surgery were identified in the National Quality Improvement Program (NSQIP) database including years 2012-2019 and split into training, validation, and test sets. The primary outcome was readmission within 30 days of surgery. Three types of machine learning models were created, including random forest (RF), gradient boosting (XGB), and neural network (NN). A logistic regression (LR) model was also created for comparison. Model performance was evaluated using area under the receiver operating characteristic curve (AUROC). RESULTS The dataset included 213,827 patients after application of exclusion criteria. A total of 23,083 (10.8%) of patients experienced readmission. NN obtained an AUROC of 0.751 (95% CI 0.743-0.759), compared with 0.684 (95% CI 0.676-0.693) for LR. RF and XGB performed similarly with AUROCs of 0.749 (95% CI 0.741-0.757) and 0.745 (95% CI 0.737-0.753) respectively. Ileus, index admission length of stay, organ-space surgical site infection present at time of surgery, and ostomy placement were identified as the most contributory variables. CONCLUSIONS Machine learning approaches outperformed traditional statistical methods in the prediction of readmission after colorectal surgery. After external validation, this improved prediction model could be used to target interventions to reduce readmission rate.
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Affiliation(s)
- Kevin A Chen
- Department of Surgery, University of North Carolina, 100 Manning Drive, Burnett Womack Building, Suite 4038, Chapel Hill, NC, 27599, USA
| | - Chinmaya U Joisa
- Joint Department of Biomedical Engineering, University of North Carolina, 10202C Mary Ellen Jones Building, Chapel Hill, NC, 27599, USA
| | - Karyn B Stitzenberg
- Department of Surgery, University of North Carolina, 100 Manning Drive, Burnett Womack Building, Suite 4038, Chapel Hill, NC, 27599, USA
| | - Jonathan Stem
- Department of Surgery, University of North Carolina, 100 Manning Drive, Burnett Womack Building, Suite 4038, Chapel Hill, NC, 27599, USA
| | - Jose G Guillem
- Department of Surgery, University of North Carolina, 100 Manning Drive, Burnett Womack Building, Suite 4038, Chapel Hill, NC, 27599, USA
| | - Shawn M Gomez
- Joint Department of Biomedical Engineering, University of North Carolina, 10202C Mary Ellen Jones Building, Chapel Hill, NC, 27599, USA
| | - Muneera R Kapadia
- Department of Surgery, University of North Carolina, 100 Manning Drive, Burnett Womack Building, Suite 4038, Chapel Hill, NC, 27599, USA.
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The American Society of Colon and Rectal Surgeons Clinical Practice Guidelines for Ostomy Surgery. Dis Colon Rectum 2022; 65:1173-1190. [PMID: 35616386 DOI: 10.1097/dcr.0000000000002498] [Citation(s) in RCA: 27] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
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Climent M, Biondo S. Ileostomy closure: is timing of the essence? Tech Coloproctol 2022; 26:847-849. [PMID: 35941259 DOI: 10.1007/s10151-022-02673-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Affiliation(s)
- M Climent
- Colorectal Unit, Department of General and Digestive Surgery, Bellvitge University Hospital, University of Barcelona, and IDIBELL (Bellvitge Biomedical Investigation Institute), C/Feixa Llarga S/N, L'Hospitalet de Llobregat, 08907, Barcelona, Spain
| | - S Biondo
- Colorectal Unit, Department of General and Digestive Surgery, Bellvitge University Hospital, University of Barcelona, and IDIBELL (Bellvitge Biomedical Investigation Institute), C/Feixa Llarga S/N, L'Hospitalet de Llobregat, 08907, Barcelona, Spain.
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20
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Decreasing Readmissions After Ileostomy Creation Through a Perioperative Quality Improvement Program. Dis Colon Rectum 2022; 65:e797-e804. [PMID: 35421028 DOI: 10.1097/dcr.0000000000002256] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
BACKGROUND Readmission after ileostomy creation in patients undergoing colorectal surgery creates a significant burden on health care cost and patient quality of care, with a 30-day readmission rate of 40%. OBJECTIVE This study aimed to evaluate the implementation of our perioperative quality improvement program, Decreasing Readmissions After Ileostomy Creation. DESIGN Perioperative interventions were administered to patients who underwent ileostomy creation. SETTINGS A single tertiary care academic center. PATIENTS Eighty patients participated in this program from February 2020 to January 2021. MAIN OUTCOME MEASURES The primary outcomes measured were 30-day readmission rates and causes of readmission, which were compared to a historical national database. Descriptive statistics were used to evaluate the effectiveness of this quality improvement program. RESULTS Eighty patients were enrolled in this prospective quality improvement program. The mean age was 52 (±15.06) years. The most common indication for patients undergoing creation of an ileostomy was colorectal cancer (40%; n = 32). The overall 30-day readmission rate was 8.75% (n = 7) throughout the study period, which was significantly lower than historical cohort data (20.10%; p = 0.01). Among the 7 readmitted patients, 3 (3.75%) were readmitted due to dehydration. The most significant associated risk factor for all-cause readmission was urgent/emergent operative status, which was associated with an increased risk of readmission ( p = 0.01). The 3 readmitted patients with dehydration had a mean Dehydration Readmission After Ileostomy Prediction risk score of 11.71 points, compared to 9.59 points in nondehydrated patients, who did not require readmission ( p = 0.38). LIMITATIONS This study is limited by its small sample size (N = 80). CONCLUSIONS The Decreasing Readmissions After Ileostomy Creation program has been successful in reducing both the all-cause readmission rate and readmission due to dehydration both within an academic tertiary care referral center and in comparison with historical readmission rates. See Video Abstract at http://links.lww.com/DCR/B894 . DISMINUCIN DE LA READMISIN DESPUS DE LA CREACIN DE UNA ILEOSTOMA MEDIANTE UN PROGRAMA DE MEJORA DE LA CALIDAD PERIOPERATORIA ANTECEDENTES:La readmisión después de la creación de una ileostomía en pacientes de cirugía colorrectal crea una carga significativa sobre el costo de la atención médica y la calidad de la atención del paciente, con una tasa de readmisión a los 30 días que llega al 40%.OBJETIVO:Este estudio tiene como objetivo evaluar la implementación de nuestro programa de mejora de la calidad perioperatoria que disminuyen los reingresos después de la creación de ileostomía.DISEÑO:Se administraron intervenciones perioperatorias a pacientes que se sometieron a la creación de una ileostomía.AJUSTE:Se trataba de un único centro académico de atención terciaria.PACIENTES:Participaron 80 pacientes en este programa desde febrero de 2020 hasta enero de 2021.PRINCIPALES MEDIDAS DE RESULTADO:Los principales resultados medidos fueron las tasas de reingreso a los 30 días y las causas de reingreso, que se compararon con una base de datos histórica nacional. Se utilizaron estadísticas descriptivas para evaluar la eficacia de este programa de mejora de la calidad.RESULTADOS:Ochenta pacientes se inscribieron en este programa prospectivo de mejora de la calidad. La edad media fue de 52 (± 15,06) años. La indicación más común para los pacientes que se sometieron a la creación de una ileostomía fue el cáncer colorrectal (40%, n = 32). La tasa general de reingreso a los 30 días fue del 8,75% (n = 7) durante todo el período de estudio, lo que fue significativamente más bajo que los datos históricos de la cohorte (20,10%, p = 0,01). Entre los 7 pacientes readmitidos, tres (3,75%) fueron readmitidos por deshidratación. El factor de riesgo asociado más significativo para la readmisión por todas las causas fue el estado operatorio urgente / emergencia, que se asoció con un mayor riesgo de readmisión (p = 0,01). Los tres pacientes readmitidos con deshidratación tuvieron una puntuación de riesgo promedio de readmisión por deshidratación después de la predicción de ileostomía de 11,71 puntos, en comparación con los pacientes no deshidratados, que no requirieron readmisión (media, 9,59 puntos, p = 0,38).LIMITACIONES:Este estudio está limitado por su pequeño tamaño de muestra (n = 80).CONCLUSIONES:El programa de disminución de las readmisiones después de la creación de una ileostomía ha logrado reducir tanto la tasa de readmisión por todas las causas como la readmisión por deshidratación, tanto dentro de un centro académico de referencia de atención terciaria como en comparación con las tasas históricas de readmisión. Consulte Video Resumen en http://links.lww.com/DCR/B894 . (Traducción-Dr Yolanda Colorado ).
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21
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Babakhanlou R, Larkin K, Hita AG, Stroh J, Yeung SC. Stoma-related complications and emergencies. Int J Emerg Med 2022; 15:17. [PMID: 35534817 PMCID: PMC9082897 DOI: 10.1186/s12245-022-00421-9] [Citation(s) in RCA: 25] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2022] [Accepted: 04/29/2022] [Indexed: 11/10/2022] Open
Abstract
AbstractStoma creations are common procedures in surgical specialties. They can be created either as a temporary or a permanent measure. Despite advancements in surgical technique and stoma care, complications are common. Patients experiencing stoma-related complications often present to the emergency department. Emergency physicians are not expected to be stoma experts, yet they are often the first point of contact for patients experiencing stoma-related complications. Accordingly, emergency physicians should be familiar with the types of stomas and complications and emergencies associated with them so that they can appropriately address the problems related to stomas. This article will provide a review of emergencies and complications associated with ileostomies, colostomies, and urostomies.
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22
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Scientific and Clinical Abstracts From WOCNext® 2022: Fort Worth, Texas ♦ June 5-8, 2022. J Wound Ostomy Continence Nurs 2022; 49:S1-S99. [PMID: 35639023 DOI: 10.1097/won.0000000000000882] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
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23
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Assessment of the importance of ostomy patients' understanding of dietary and lifestyle recommendations. NUTR HOSP 2022; 39:610-614. [PMID: 35485373 DOI: 10.20960/nh.03906] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/02/2022] Open
Abstract
OBJECTIVE the objective of our study was to evaluate the level of understanding of ostomy patients regarding lifestyle, diet, and high output stoma (HOS) management recommendations provided by healthcare professionals. METHOD a prospective study to follow up ostomy patients at nutritional consultations was designed. The follow-up process was performed 7-10 days after hospital discharge and again one month later. At the first visit, patients were instructed in the detection and management of HOS. At the second visit, the level of understanding of the training received was assessed using an evaluation questionnaire. A descriptive analysis of the answers to each of the questionnaire's items was performed. Fisher's exact test was used to evaluate differences in the level of understanding recorded with the questionnaire. RESULTS a total of 35 patients were recruited; 71.4 % did not provide correct answers to all the questions. There were no significant differences in the correctness of the answers to the questionnaire according to education level. CONCLUSIONS many patients do not adequately understand the information provided by healthcare professionals and this could have a negative impact on the incidence of clinical complications.
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Rieser CJ, Alvikas J, Phelos H, Hall LB, Zureikat AH, Lee A, Ongchin M, Holtzman MP, Pingpank JF, Bartlett DL, Choudry MHA. Failure to Thrive Following Cytoreduction and Hyperthermic Intraperitoneal Chemotherapy: Causes and Consequences. Ann Surg Oncol 2022; 29:2630-2639. [PMID: 34988834 DOI: 10.1245/s10434-021-11100-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2021] [Accepted: 11/01/2021] [Indexed: 11/18/2022]
Abstract
BACKGROUND Failure to thrive (FTT) is a complex syndrome of nutritional failure and functional decline. Readmission for FTT following cytoreductive surgery and hyperthermic intraperitoneal chemotherapy (CRS HIPEC) is common but underexamined. This study aims to determine features, risk factors, and prognostic significance of FTT following CRS HIPEC. PATIENTS AND METHODS We reviewed patients who underwent CRS HIPEC from 2010 to 2018 at our institution. Patients were categorized into no readmission, FTT readmission, and other readmission. FTT was determined by coding and chart review. We compared baseline characteristics, oncologic data, perioperative outcomes, and survival among the three cohorts. RESULTS Of 1068 discharges examined, 379 patients (36%) were readmitted within 90 days, of which 134 (12.5%) were labeled as FTT. Patients with FTT readmission had worse preoperative functional status, higher rates of malnutrition, more complex resections, longer hospital stays, and more postoperative complications (all p < 0.001). Ostomy creation [relative risk ratio (RRR) 4.06], in-hospital venous thromboembolism (VTE), discharge to nursing home (RRR 2.48), pre-CRS HIPEC chemotherapy (RRR 1.98), older age (RRR 1.84), and female gender (RRR 1.69) were all independent predictors for FTT readmission on multinomial regression (all p < 0.01). FTT readmission was associated with worse median overall survival on multivariate analysis [hazard ratio (HR) 1.60, p < 0.001] after controlling for oncologic, perioperative, and baseline factors. CONCLUSIONS FTT is common following CRS HIPEC and appears to be associated with baseline patient characteristics, operative burden, and postoperative complications. Perioperative strategies for improving nutrition and activity, along with early recognition and intervention in FTT may improve patient outcomes.
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Affiliation(s)
- Caroline J Rieser
- Division of Surgical Oncology, Koch Regional Perfusion Center, University of Pittsburgh, Pittsburgh, PA, USA.
| | - Jurgis Alvikas
- Division of Surgical Oncology, Koch Regional Perfusion Center, University of Pittsburgh, Pittsburgh, PA, USA
| | - Heather Phelos
- Department of Surgery, University of Pittsburgh, Pittsburgh, PA, USA
| | - Lauren B Hall
- Division of Surgical Oncology, Koch Regional Perfusion Center, University of Pittsburgh, Pittsburgh, PA, USA
| | - Amer H Zureikat
- Division of Surgical Oncology, Koch Regional Perfusion Center, University of Pittsburgh, Pittsburgh, PA, USA
| | - Andrew Lee
- Division of Surgical Oncology, Koch Regional Perfusion Center, University of Pittsburgh, Pittsburgh, PA, USA
| | - Melanie Ongchin
- Division of Surgical Oncology, Koch Regional Perfusion Center, University of Pittsburgh, Pittsburgh, PA, USA
| | - Matthew P Holtzman
- Division of Surgical Oncology, Koch Regional Perfusion Center, University of Pittsburgh, Pittsburgh, PA, USA
| | - James F Pingpank
- Division of Surgical Oncology, Koch Regional Perfusion Center, University of Pittsburgh, Pittsburgh, PA, USA
| | - David L Bartlett
- AHN Cancer Institute, Allegheny Health Network, Pittsburgh, PA, USA
| | - M Haroon A Choudry
- Division of Surgical Oncology, Koch Regional Perfusion Center, University of Pittsburgh, Pittsburgh, PA, USA
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25
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Overall readmissions and readmissions related to dehydration after creation of an ileostomy: a systematic review and meta-analysis. Tech Coloproctol 2022; 26:333-349. [PMID: 35192122 PMCID: PMC9018644 DOI: 10.1007/s10151-022-02580-6] [Citation(s) in RCA: 28] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/27/2021] [Accepted: 01/18/2022] [Indexed: 12/19/2022]
Abstract
Background Hospital readmissions after creation of an ileostomy are common and come with a high clinical and financial burden. The aim of this review with pooled analysis was to determine the incidence of dehydration-related and all-cause readmissions after formation of an ileostomy, and the associated costs.
Methods A systematic literature search was conducted for studies reporting on dehydration-related and overall readmission rates after formation of a loop or end ileostomy between January 1990 and April 2021. Analyses were performed using R Statistical Software Version 3.6.1.
Results The search yielded 71 studies (n = 82,451 patients). The pooled incidence of readmissions due to dehydration was 6% (95% CI 0.04–0.09) within 30 days, with an all-cause readmission rate of 20% (CI 95% 0.18–0.23). Duration of readmissions for dehydration ranged from 2.5 to 9 days. Average costs of dehydration-related readmission were between $2750 and $5924 per patient. Other indications for readmission within 30 days were specified in 15 studies, with a pooled incidence of 5% (95% CI 0.02–0.14) for dehydration, 4% (95% CI 0.02–0.08) for stoma outlet problems, and 4% (95% CI 0.02–0.09) for infections. Conclusions One in five patients are readmitted with a stoma-related complication within 30 days of creation of an ileostomy. Dehydration is the leading cause for these readmissions, occurring in 6% of all patients within 30 days. This comes with high health care cost for a potentially avoidable cause. Better monitoring, patient awareness and preventive measures are required. Supplementary Information The online version contains supplementary material available at 10.1007/s10151-022-02580-6.
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Uribe AA, Weaver TE, Echeverria-Villalobos M, Periel L, Shi H, Fiorda-Diaz J, Gonzalez-Zacarias A, Abdel-Rasoul M, Li L. Perioperative Morbidity and Complications in Patients With an Established Ileostomy Undergoing Major Abdominal Surgery: A Retrospective Study. Front Surg 2021; 8:757269. [PMID: 34957201 PMCID: PMC8692261 DOI: 10.3389/fsurg.2021.757269] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2021] [Accepted: 10/25/2021] [Indexed: 11/13/2022] Open
Abstract
Background: Recently formed ileostomies may produce an average of 1,200 ml of watery stool per day, while an established ileostomy output varies between 600-800 ml per day. The reported incidence of renal impartment in patients with ileostomy is 8-20%, which could be caused by dehydration (up to 50%) or high output stoma (up to 40%). There is a lack of evidence if an ileostomy could influence perioperative fluid management and/or surgical outcomes. Methods: Subjects aged ≥18 years old with an established ileostomy scheduled to undergo an elective non-ileostomy-related major abdominal surgery under general anesthesia lasting more than 2 h and requiring hospitalization were included in the study. The primary outcome was to assess the incidence of perioperative complications within 30 days after surgery. Results: A total of 552 potential subjects who underwent non-ileostomy-related abdominal surgery were screened, but only 12 were included in the statistical analysis. In our study cohort, 66.7% of the subjects were men and the median age was 56 years old (interquartile range [IQR] 48-59). The median time from the creation of ileostomy to the qualifying surgery was 17.7 months (IQR: 8.3, 32.6). The most prevalent comorbidities in the study group were psychiatric disorders (58.3%), hypertension (50%), and cardiovascular disease (41.7%). The most predominant surgical approach was open (8 [67%]). The median surgical and anesthesia length was 3.4 h (IQR: 2.5, 5.7) and 4 h (IQR: 3, 6.5), respectively. The median post-anesthesia care unit (PACU) stay was 2 h (IQR:0.9, 3.1), while the median length of hospital stay (LOS) was 5.6 days (IQR: 4.1, 10.6). The overall incidence of postoperative complications was 50% (n = 6). Two subjects (16.7%) had a moderate surgical wound infection, and two subjects (16.7%) experienced a mild surgical wound infection. In addition, one subject (7.6%) developed a major postoperative complication with atrial fibrillation in conjunction with moderate hemorrhage. Conclusions: Our findings suggest that the presence of a well-established ileostomy might not represent a relevant risk factor for significant perioperative complications related to fluid management or hospital readmission. However, the presence of peristomal skin complications could trigger a higher incidence of surgical wound infections.
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Affiliation(s)
- Alberto A. Uribe
- Department of Anesthesiology, The Ohio State University Medical Center, Columbus, OH, United States
| | - Tristan E. Weaver
- Department of Anesthesiology, The Ohio State University Medical Center, Columbus, OH, United States
| | | | - Luis Periel
- Department of Anesthesiology, The Ohio State University Medical Center, Columbus, OH, United States
| | - Haixia Shi
- Department of Anesthesiology, The Ohio State University Medical Center, Columbus, OH, United States
| | - Juan Fiorda-Diaz
- Department of Anesthesiology, The Ohio State University Medical Center, Columbus, OH, United States
| | - Alicia Gonzalez-Zacarias
- Department of Anesthesiology, The Ohio State University Medical Center, Columbus, OH, United States
| | - Mahmoud Abdel-Rasoul
- Center for Biostatistics, Department of Biomedical Informatics, The Ohio State University Medical Center, Columbus, OH, United States
| | - Lin Li
- Department of Anesthesiology, The Ohio State University Medical Center, Columbus, OH, United States
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Ellis CT, Maykel JA. Defining Anastomotic Leak and the Clinical Relevance of Leaks. Clin Colon Rectal Surg 2021; 34:359-365. [PMID: 34853555 DOI: 10.1055/s-0041-1735265] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
Surgeons universally dread gastrointestinal anastomotic leaks, yet the precise definition is not widely agreed on despite international consensus guidelines. Likewise, leaks are not uniformly reported which makes comparisons across studies flawed. Leak rates range from 1 to 3% for ileocolonic, 0.5 to 18% for colorectal, and 5 to 19% for coloanal anastomoses. The sequelae of an anastomotic leak vary but generally correlate with the need for a change in clinical management, from minimal changes to the need for reoperation. Short- and long-term outcomes can be life-altering or life-threatening. Temporary or permanent stomas may be necessary and low pelvic anastomotic leaks may affect bowel function. For cancer patients, leaks can delay treatment and negatively affect oncologic outcomes. In Crohn's patients, leaks are associated with higher recurrence rates. In essence, the lack of agreement on the definition of an anastomotic leak inhibits meaningful understand of its epidemiology, prevention, and treatment.
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Affiliation(s)
- Clayton Tyler Ellis
- Division of Colorectal Surgery, Hiram C. Polk, Jr., MD, Department of Surgery, University of Louisville, Louisville, Kentucky
| | - Justin A Maykel
- Division of Colorectal Surgery, Department of Surgery, University of Massachusetts, Worcester, Massachusetts
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Prognostic factors for complications after loop ileostomy reversal. Tech Coloproctol 2021; 26:45-52. [PMID: 34751847 DOI: 10.1007/s10151-021-02538-0] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/31/2021] [Accepted: 10/12/2021] [Indexed: 10/19/2022]
Abstract
BACKGROUND Defunctioning ileostomy creation and closure are both associated with morbidity. There is little data available about complications after ileostomy closure. The aim of this study was to evaluate morbidity related to loop ileostomy closure (LIC) and to determine if patients with postoperative complications in primary surgery suffer from more postoperative complications during stoma closure. METHODS This was a retrospective study on prospectively registered consecutive patients undergoing elective LIC in a single centre in Spain between April 2010 and December 2017. Baseline characteristics, postoperative complications after primary surgery and after stoma closure were recorded. Primary surgery included any colorectal resection, elective or urgent associated with a diverting loop ileostomy either as a protective stoma or rescue procedure. A logistic regression model was used to assess the effects of baseline variables and postoperative complications after primary surgery on the existence of postoperative complications related to LIC. RESULTS Four hundred and twenty-eight patients (288 men, median age 64.5 years [IQR 55.1-72.3 years]) were included in the study, and 37.4%, developed complications after LIC. The most common was paralytic ileus. Only chronic kidney disease (OR 2.31; 95% CI 1.03-5.33, p = 0.043), existence of postoperative complications after primary surgery (OR 2.25; 95% CI 1.41-3.66, p = < 0.001) and ileostomy closure later than 10 months after primary surgery (OR 1.52; 95% CI 1.00-2.33, p = 0.049) were statistically significant in the multivariate analysis. CONCLUSIONS Patients with chronic kidney disease, those who had any complication after primary surgery and those who had LIC > 10 months after primary surgery have a significantly higher risk of developing postoperative complications.
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Miswan NH, Chan CS, Ng CG. Predictive modelling of hospital readmission: Evaluation of different preprocessing techniques on machine learning classifiers. INTELL DATA ANAL 2021. [DOI: 10.3233/ida-205468] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Hospital readmission is a major cost for healthcare systems worldwide. If patients with a higher potential of readmission could be identified at the start, existing resources could be used more efficiently, and appropriate plans could be implemented to reduce the risk of readmission. Therefore, it is important to predict the right target patients. Medical data is usually noisy, incomplete, and inconsistent. Hence, before developing a prediction model, it is crucial to efficiently set up the predictive model so that improved predictive performance is achieved. The current study aims to analyse the impact of different preprocessing methods on the performance of different machine learning classifiers. The preprocessing applied by previous hospital readmission studies were compared, and the most common approaches highlighted such as missing value imputation, feature selection, data balancing, and feature scaling. The hyperparameters were selected using Bayesian optimisation. The different preprocessing pipelines were assessed using various performance metrics and computational costs. The results indicated that the preprocessing approaches helped improve the model’s prediction of hospital readmission.
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Affiliation(s)
- Nor Hamizah Miswan
- Centre of Image and Signal Processing, Department of Artificial Intelligence, Faculty of Computer Science and Information Technology, University of Malaya, Kuala Lumpur, Malaysia
- Department of Mathematical Sciences, Faculty of Science and Technology, Universiti Kebangsaan Malaysia, UKM Bangi, Selangor, Malaysia
| | - Chee Seng Chan
- Centre of Image and Signal Processing, Department of Artificial Intelligence, Faculty of Computer Science and Information Technology, University of Malaya, Kuala Lumpur, Malaysia
| | - Chong Guan Ng
- Department of Psychological Medicine, Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia
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Impact of a nutrition consultation on the rate of high output stoma-related readmission: an ambispective cohort study. Sci Rep 2021; 11:16620. [PMID: 34404862 PMCID: PMC8371098 DOI: 10.1038/s41598-021-96136-7] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2020] [Accepted: 08/02/2021] [Indexed: 11/12/2022] Open
Abstract
The aims of this study were to assess the impact of a follow-up nutrition consultation for ostomy patients on the rate of high output stoma (HOS)-related readmissions, as well as on the detection of poor nutritional status and their management, and to determine the associated economic impact. A single-centre ambispective cohort study was conducted in which all adult patients undergoing intestinal resection and stoma creation were recruited. Two nutrition consultations were established for early follow-up after hospital discharge and patients were prospectively included. Additionally, a retrospective search was carried out to include a control group. In both groups, a 12-month follow-up was conducted to record readmissions associated with high output stoma. A multivariate logistic regression was performed. Statistical significance level was established at p < 0.05. 170 patients were recruited, 85 patients in each cohort. Demographic data and clinical characteristics were recorded. A significant difference was observed in HOS-related readmissions, with readmission rates of 28.6% vs 10.3% in the retrospective and prospective cohort, respectively. At the first follow-up consultation, 50.5% of patients presented some degree of protein-calorie malnutrition. A statistically significant improvement in nutritional status was observed in the second evaluation. The intervention carried out resulted in a total saving of €24,175. Early follow-up of patients after discharge resulted in a significant reduction in the rate of HOS-related readmissions and allowed to identify a high percentage of patients with malnutrition. The cost analysis showed the process to be a cost-effective improvement.
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Bai D, Li L, Shen Z, Huang T, Wang Q, Wang Y, Zhang Y, Guo Z, Li K, Xiao JA. Risk factors for developing high-output ileostomy in CRC patients: a retrospective study. BMC Surg 2021; 21:300. [PMID: 34174862 PMCID: PMC8235810 DOI: 10.1186/s12893-021-01288-y] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2020] [Accepted: 06/06/2021] [Indexed: 12/31/2022] Open
Abstract
BACKGROUND Anastomotic leakage is one of the most serious postoperative complications of rectal cancer. Prophylactic ileostomy has been widely used to reduce the risk and severity of complications of anastomotic leakage. However, prophylactic ileostomy itself has some complications, and ileostomy high output syndrome (HOS) is one of them. This study was performed to explore the risk factors of HOS in ileostomy. METHODS A total of 114 patients with HOS were screened out from 494 eligible ileostomy patients in the last 5 years. The relationship between HOS and the clinicopathological data was analyzed using the Chi-square test and Fisher's exact probability. Multivariate analysis was performed by logistic regression. RESULTS The incidence of HOS was 23.07% in this study. Dehydration was the most common symptom of HOS (37.7%). There was no clear correlation between HOS occurrence with sex, age, gross typing, histological grade, tumor location, lymph node metastasis, and TNM stage (p > 0.05). The incidence of HOS was 14/18 in inflammatory bowel disease patients, 18/28 in diabetes mellitus patients, and 23/72 in neoadjuvant chemoradiotherapy patients, 13/17 in total colectomy and abdominal infection patients. Multivariate analysis showed that they are risk factors for HOS (p < 0.05). CONCLUSION HOS occurred occasionally but rarely studied and lacks attention. Inflammatory bowel disease, diabetes mellitus, neoadjuvant radiotherapy chemotherapy, total colectomy and abdominal infection are the risk factors for HOS.
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Affiliation(s)
- Dongxiao Bai
- Department of Surgery, Anyang Tumor Hospital, No. 1 Huanbin North Road, Anyang, 455000, Henan, China
| | - Lei Li
- Department of Surgery, Anyang Tumor Hospital, No. 1 Huanbin North Road, Anyang, 455000, Henan, China
| | - Zhiling Shen
- Department of Surgery, Anyang Tumor Hospital, No. 1 Huanbin North Road, Anyang, 455000, Henan, China
| | - Tianchen Huang
- Department of Surgery, Anyang Tumor Hospital, No. 1 Huanbin North Road, Anyang, 455000, Henan, China
| | - Qingbing Wang
- Department of Surgery, Anyang Tumor Hospital, No. 1 Huanbin North Road, Anyang, 455000, Henan, China
| | - Yanjun Wang
- Department of Surgery, Anyang Tumor Hospital, No. 1 Huanbin North Road, Anyang, 455000, Henan, China
| | - Yong Zhang
- Department of Surgery, Anyang Tumor Hospital, No. 1 Huanbin North Road, Anyang, 455000, Henan, China
| | - Zhipeng Guo
- Department of Surgery, Anyang Tumor Hospital, No. 1 Huanbin North Road, Anyang, 455000, Henan, China
| | - Kan Li
- Department of Surgery, Anyang Tumor Hospital, No. 1 Huanbin North Road, Anyang, 455000, Henan, China
| | - Jian An Xiao
- Department of Surgery, Anyang Tumor Hospital, No. 1 Huanbin North Road, Anyang, 455000, Henan, China.
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Van Butsele J, Bislenghi G, D'Hoore A, Wolthuis AM. Readmission after rectal resection in the ERAS-era: is a loop ileostomy the Achilles heel? BMC Surg 2021; 21:267. [PMID: 34044794 PMCID: PMC8161575 DOI: 10.1186/s12893-021-01242-y] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2021] [Accepted: 05/10/2021] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND Rectal resection surgery is often followed by a loop ileostomy creation. Despite improvements in surgical technique and development of enhanced recovery after surgery (ERAS) protocols, the readmission-rate after rectal resection is still estimated to be around 30%. The purpose of this study was to identify risk factors for readmission after rectal resection surgery. This study also investigated whether elderly patients (≥ 65 years old) dispose of a distinct patient profile and associated risk factors for readmission. METHODS This is a retrospective study of prospectively collected data from patients who consecutively underwent rectal resection for cancer within an ERAS protocol between 2011 and 2016. The primary study endpoint was 90-day readmission. Patients with and without readmission within 90 days were compared. Additional subgroup analysis was performed in patients ≥ 65 years old. RESULTS A total of 344 patients were included, and 25% (n = 85) were readmitted. Main reasons for readmission were acute renal insufficiency (24%), small bowel obstruction (20%), anastomotic leakage (15%) and high output stoma (11%). In multivariate logistic regression, elevated initial creatinine level (cut-off values: 0.67-1.17 mg/dl) (OR 1.95, p = 0.041) and neoadjuvant radiotherapy (OR 2.63, p = 0.031) were significantly associated with readmission. For ileostomy related problems, elevated initial creatinine level (OR 2.76, p = 0.021) was identified to be significant. CONCLUSION Recovery after rectal resection within an ERAS protocol is hampered by the presence of a loop ileostomy. ERAS protocols should include stoma education and high output stoma prevention.
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Affiliation(s)
- Johanna Van Butsele
- Department of Abdominal Surgery, University Hospital Gasthuisberg, Leuven, Belgium
| | - Gabriele Bislenghi
- Department of Abdominal Surgery, University Hospital Gasthuisberg, Leuven, Belgium
| | - André D'Hoore
- Department of Abdominal Surgery, University Hospital Gasthuisberg, Leuven, Belgium
| | - Albert M Wolthuis
- Department of Abdominal Surgery, University Hospital Gasthuisberg, Leuven, Belgium.
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Liu C, Bhat S, Sharma P, Yuan L, O'Grady G, Bissett I. Risk factors for readmission with dehydration after ileostomy formation: A systematic review and meta-analysis. Colorectal Dis 2021; 23:1071-1082. [PMID: 33539646 DOI: 10.1111/codi.15566] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/17/2020] [Revised: 01/26/2021] [Accepted: 01/28/2021] [Indexed: 12/12/2022]
Abstract
AIM Ileostomy formation is a commonly performed procedure with substantial associated morbidity. Patients with an ileostomy experience high rates of unplanned hospital readmission with dehydration, and such events have a long-term health and economic impact. Reports of the significant risk factors associated with these readmissions have been inconsistent. This study aimed to identify the significant risk factors for readmission with dehydration following ileostomy formation. METHOD A systematic search was conducted using the Medline, Embase, Cochrane and CINAHL databases. All original research articles reporting risk factors for readmission with dehydration following ileostomy formation in adults were included. The primary outcome was the pooled risk ratio of clinically relevant variables potentially associated with dehydration-related readmission following ileostomy formation. The secondary outcome was the incidence of dehydration-related readmission. RESULTS Ten studies (27 089 patients) were included. The incidences of 30- and 60-day readmission with dehydration were 5.0% (range 2.1%-13.2%) and 10.3% (range 7.3%-14.1%), respectively. Eight variables were found to be significantly associated with dehydration-related readmission: age ≥65 years, body mass index ≥30 kg/m2 , diabetes mellitus, hypertension, renal comorbidity, regular diuretic use, ileal pouch-anal anastomosis procedure and length of stay after index admission. A preoperative diagnosis of colorectal cancer was less likely to result in readmission with dehydration. CONCLUSION Readmission with dehydration following ileostomy formation is a significant issue with several risk factors. Awareness of these risk factors will help inform the design of future studies addressing risk prediction, allow risk stratification of ileostomates and aid in the development of personalized prevention strategies.
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Affiliation(s)
- Chen Liu
- Department of Surgery, University of Auckland, Auckland, New Zealand
| | - Sameer Bhat
- Department of Surgery, University of Auckland, Auckland, New Zealand
| | - Puja Sharma
- Department of Surgery, University of Auckland, Auckland, New Zealand
| | - Lance Yuan
- Department of Surgery, University of Auckland, Auckland, New Zealand
| | - Gregory O'Grady
- Department of Surgery, University of Auckland, Auckland, New Zealand
| | - Ian Bissett
- Department of Surgery, University of Auckland, Auckland, New Zealand
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Kim NE, Hall JF. Risk Factors for Readmission after Ileostomy Creation: an NSQIP Database Study. J Gastrointest Surg 2021; 25:1010-1018. [PMID: 32207078 DOI: 10.1007/s11605-020-04549-y] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/25/2019] [Accepted: 02/13/2020] [Indexed: 01/31/2023]
Abstract
BACKGROUND Ileostomy creation is associated with excess readmissions following colorectal surgery. This study identifies risk factors for readmission in patients undergoing ileostomy creation and identifies areas of clinical intervention to reduce readmission. METHODS We used the NSQIP dataset including colectomy specific data to include 39,380 patients who underwent ileostomy creation between 2012 and 2017. We conducted univariate and multivariable analysis to identify predictors of surgery-related 30-day readmissions. Our multivariate model included surgery type (total abdominal colectomy, partial colectomy, enterectomy, or pelvic dissection), gender, age, race, ethnicity, preoperative renal failure, dialysis, transfusion, ascites, ventilator dependence, diabetes, ASA class, functional status, emergency case, SSI, wound disruption, postoperative renal insufficiency, postoperative sepsis, discharge destination, and wound class. RESULTS A total of 5718 (14.52%) patients were readmitted within 30 days. After multivariate analysis, factors associated with readmission were gender, age, Hispanic ethnicity, dialysis, transfusion, ventilator dependence, diabetes, emergency case, SSI, postoperative renal insufficiency, postoperative sepsis, and discharge to a skilled facility. Patients who had enterectomy and partial colectomies were less likely to be readmitted than patients who had a pelvic procedure. Patients with postoperative renal insufficiency or renal failure were much more likely to be readmitted. CONCLUSION Factors associated with readmission included the type of procedure and postoperative complications such as SSI, sepsis, and renal failure. Efforts to reduce readmission should focus on patients undergoing concomitant pelvic procedures as well as avoidance and management of common complications in this group of patients.
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Affiliation(s)
- Na Eun Kim
- General Surgery Department, Boston Medical Center, 88 East Newton C515, Boston, MA, 02118, USA.
| | - Jason F Hall
- Colon & Rectal Surgery and Colorectal Surgery Department, Boston Medical Center, Boston, MA, USA
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Austin EJ, Neukirch J, Ong TD, Simpson L, Berger GN, Keller CS, Flum DR, Giusti E, Azen J, Davidson GH. Development and Implementation of a Complex Health System Intervention Targeting Transitions of Care from Hospital to Post-acute Care. J Gen Intern Med 2021; 36:358-365. [PMID: 32869191 PMCID: PMC7878619 DOI: 10.1007/s11606-020-06140-2] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/03/2019] [Accepted: 08/12/2020] [Indexed: 11/26/2022]
Abstract
BACKGROUND Failure of effective transitions of care following hospitalization can lead to excess days in the hospital, readmissions, and adverse events. Evidence identifies both patient and system factors that influence poor care transitions, yet health systems struggle to translate evidence into complex interventions that have a meaningful impact on care transitions. OBJECTIVE We report on our experience developing, pilot testing, and evaluating a complex intervention (Addressing Complex Transitions program, or ACT program) that aims to improve care transitions for complex patients. DESIGN Following the Medical Research Council (MRC) framework, we engaged in iterative, stakeholder-driven work to develop a complex care intervention, assess feasibility and pilot methods, evaluate the intervention in practice, and facilitate ongoing implementation monitoring and dissemination. PARTICIPANTS Patients receiving care from UW Medicine's health system including 4 hospitals and 20-site Post-Acute Care network. INTERVENTION Literature review and prospective data collection activities informed ACT program design. ACT program components include a tailored risk calculator that provides real-time scoring of transitions of care risk factors, a multidisciplinary team with the capacity to address complex barriers to safe transitions, and enhanced discharge workflows to improve care transitions for complex patients. KEY MEASURES Program evaluation metrics included estimated hospital days saved and program acceptance by care team members. KEY RESULTS During the 6-month pilot, 565 patients were screened and 97 enrolled in the ACT program. An estimated 664 hospital days were saved for the index admission of ACT program participants. Analysis of pre/post-hospital utilization for ACT program participants showed an estimated 3227 fewer hospital days after ACT program enrollment. CONCLUSIONS Health systems need to address increasingly difficult challenges in care delivery. The use of evidence-based frameworks, such as the MRC framework, can guide systems to design complex interventions that respond to their local context and stakeholder needs.
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Affiliation(s)
- Elizabeth J. Austin
- Surgical Outcomes Research Center, University of Washington , Seattle, WA USA
- Department of Surgery, University of Washington, Seattle, WA USA
| | - Jen Neukirch
- UW Medicine Post-Acute Care, University of Washington, Seattle, WA USA
| | - Thuan D. Ong
- UW Medicine Post-Acute Care, University of Washington, Seattle, WA USA
- Division of Gerontology and Geriatric Medicine, University of Washington, Seattle, WA USA
| | - Louise Simpson
- UW Medicine Post-Acute Care, University of Washington, Seattle, WA USA
| | - Gabrielle N. Berger
- Division of General Internal Medicine, University of Washington, Seattle, WA USA
| | - Carolyn Sy Keller
- Division of General Internal Medicine, University of Washington, Seattle, WA USA
| | - David R Flum
- Surgical Outcomes Research Center, University of Washington , Seattle, WA USA
- Department of Surgery, University of Washington, Seattle, WA USA
| | - Elaine Giusti
- Center for Clinical Excellence, University of Washington, Seattle, WA USA
| | - Jennifer Azen
- Division of General Internal Medicine, University of Washington, Seattle, WA USA
| | - Giana H. Davidson
- Surgical Outcomes Research Center, University of Washington , Seattle, WA USA
- Department of Surgery, University of Washington, Seattle, WA USA
- UW Medicine Post-Acute Care, University of Washington, Seattle, WA USA
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Rieser CJ, Hall LB, Kang E, Zureikat AH, Holtzman MP, Pingpank JF, Bartlett DL, Choudry MHA. Predischarge Prediction of Readmission After Cytoreductive Surgery and Hyperthermic Intraperitoneal Chemotherapy: Derivation and Validation of a Risk Prediction Score. Ann Surg Oncol 2021; 28:5287-5296. [PMID: 33486643 PMCID: PMC8349345 DOI: 10.1245/s10434-020-09547-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2020] [Accepted: 12/13/2020] [Indexed: 11/18/2022]
Abstract
BACKGROUND Ninety-day hospital readmission rates following cytoreductive surgery and hyperthermic intraperitoneal chemotherapy (CRS/HIPEC) range from 20 to 40%. OBJECTIVE The aim of this study was to develop and validate a simple score to predict readmissions following CRS/HIPEC. STUDY DESIGN Using a prospectively maintained database, we retrospectively reviewed clinicopathologic, perioperative, and day-of-discharge data for patients undergoing CRS/HIPEC for peritoneal surface malignancies between 2010 and 2018. In-hospital mortalities and discharges to hospice were excluded. Multivariate logistic regression was utilized to identify predictors of unplanned readmission, with three-quarters of the sample randomly selected as the derivation cohort and one-quarter as the validation cohort. Using regression coefficient-based scoring methods, we developed a weighted 7-factor, 10-point predictive score for risk of readmission. RESULTS Overall, 1068 eligible discharges were analyzed; 379 patients were readmitted within 90 days (35.5%). Seven factors were associated with readmission: stoma creation, Peritoneal Cancer Index score ≥ 15, hyponatremia, in-hospital major complication, preoperative chemotherapy, anemia, and discharge to nursing home. In the validation cohort, 25 patients (9.2%) were categorized as high risk for readmission, with a predicted rate of readmission of 69.3% and an observed rate of 76.0%. The score had fair discrimination (area under the curve 0.70) and good calibration (Hosmer-Lemeshow goodness-of-fit p-value of 0.77). CONCLUSION Our proposed risk score, easily obtainable on day of discharge, distinguishes patients at high risk for readmission over 90 days following CRS/HIPEC. This score has the potential to target high-risk individuals for intensive follow-up and other interventions.
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Affiliation(s)
- Caroline J Rieser
- Division of Surgical Oncology, Koch Regional Perfusion Center, University of Pittsburgh, Pittsburgh, PA, USA.
| | - Lauren B Hall
- Division of Surgical Oncology, Koch Regional Perfusion Center, University of Pittsburgh, Pittsburgh, PA, USA
| | - Eliza Kang
- Division of Surgical Oncology, Koch Regional Perfusion Center, University of Pittsburgh, Pittsburgh, PA, USA
| | - Amer H Zureikat
- Division of Surgical Oncology, Koch Regional Perfusion Center, University of Pittsburgh, Pittsburgh, PA, USA
| | - Matthew P Holtzman
- Division of Surgical Oncology, Koch Regional Perfusion Center, University of Pittsburgh, Pittsburgh, PA, USA
| | - James F Pingpank
- Division of Surgical Oncology, Koch Regional Perfusion Center, University of Pittsburgh, Pittsburgh, PA, USA
| | - David L Bartlett
- AHN Cancer Institute, Allegheny Health Network, Pittsburgh, PA, USA
| | - M Haroon A Choudry
- Division of Surgical Oncology, Koch Regional Perfusion Center, University of Pittsburgh, Pittsburgh, PA, USA
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Improved 30-Day Surgical Outcomes in Ostomates Using a Remote Monitoring and Care Management Program: An Observational Study. Dis Colon Rectum 2020; 63:e581-e586. [PMID: 33149029 DOI: 10.1097/dcr.0000000000001838] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
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Creation and Institutional Validation of a Readmission Risk Calculator for Elective Colorectal Surgery. Dis Colon Rectum 2020; 63:1436-1445. [PMID: 32969887 DOI: 10.1097/dcr.0000000000001674] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
BACKGROUND Readmissions reflect adverse patient outcomes, and clinicians currently lack accurate models to predict readmission risk. OBJECTIVE We sought to create a readmission risk calculator for use in the postoperative setting after elective colon and rectal surgery. DESIGN Patients were identified from 2012-2014 American College of Surgery-National Surgical Quality Improvement Program data. A model was created with 60% of the National Surgical Quality Improvement Program sample using multivariable logistic regression to stratify patients into low/medium- and high-risk categories. The model was validated with the remaining 40% of the National Surgical Quality Improvement Program sample and 2016-2018 institutional data. SETTINGS The study included both national and institutional data. PATIENTS Patients who underwent elective abdominal colon or rectal resection were included. MAIN OUTCOME MEASURES The primary outcome was readmission within 30 days of surgery. Secondary outcomes included reasons for and time interval to readmission. RESULTS The model discrimination (c-statistic) was 0.76 ((95% CI, 0.75-0.76); p < 0.0001) in the National Surgical Quality Improvement Program model creation cohort (n = 50,508), 0.70 ((95% CI, 0.69-0.70); p < 0.0001) in the National Surgical Quality Improvement Program validation cohort (n = 33,714), and 0.62 ((95% CI, 0.54-0.70); p = 0.04) in the institutional cohort (n = 400). High risk was designated as ≥8.7% readmission risk. Readmission rates in National Surgical Quality Improvement Program and institutional data were 10.7% and 8.8% overall; of patients predicted to be high risk, observed readmission rate was 22.1% in the National Surgical Quality Improvement Program and 12.4% in the institutional cohorts. Overall median interval from surgery to readmission was 14 days in the National Surgical Quality Improvement Program and 11 days institutionally. The most common reasons for readmission were organ space infection, bowel obstruction/paralytic ileus, and dehydration in both the National Surgical Quality Improvement Program and institutional data. LIMITATIONS This was a retrospective observational review. CONCLUSIONS For patients who undergo elective colon and rectal surgery, use of a readmission risk calculator developed for postoperative use can identify high-risk patients for potential amelioration of modifiable risk factors, more intensive outpatient follow-up, or planned readmission. See Video Abstract at http://links.lww.com/DCR/B284. CREACIÓN Y VALIDACIÓN INSTITUCIONAL DE UNA CALCULADORA DE RIESGO DE REINGRESO PARA CIRUGÍA COLORRECTAL ELECTIVE: Los reingresos reflejan resultados adversos de los pacientes y los médicos actualmente carecen de modelos precisos para predecir el riesgo de reingreso.Intentamos crear una calculadora de riesgo de readmisión para su uso en el entorno postoperatorio después de una cirugía electiva de colon y recto.Los pacientes que se sometieron a una resección electiva del colon abdominal o rectal se identificaron a partir de los datos del Programa Nacional de Mejora de la Calidad Quirúrgica (ACS-NSQIP) del Colegio Americano de Cirugia Nacional 2012-2014. Se creó un modelo con el 60% de la muestra NSQIP utilizando regresión logística multivariable para estratificar a los pacientes en categorías de riesgo bajo / medio y alto. El modelo fue validado con el 40% restante de la muestra NSQIP y datos institucionales 2016-2018.El estudio incluyó datos tanto nacionales como institucionales.El resultado primario fue el reingreso dentro de los 30 días de la cirugía. Los resultados secundarios incluyeron razones e intervalo de tiempo para el reingreso.La discriminación del modelo (estadística c) fue de 0,76 (IC del 95%: 0,75-0,76, p < 0,0001) en la cohorte de creación del modelo NSQIP (n = 50,508), 0,70 (IC del 95%: 0,69-0,70, p < 0,0001) en la cohorte de validación NSQIP (n = 33,714), y 0,62 (IC del 95%: 0,54-0,70, p = 0,04) en la cohorte institucional (n = 400). Alto riesgo se designó como > 8,7% de riesgo de readmisión. Las tasas de readmisión en NSQIP y los datos institucionales fueron del 10,7% y del 8,8% en general; de pacientes con riesgo alto, la tasa de reingreso observada fue del 22.1% en el NSQIP y del 12.4% en las cohortes institucionales. El intervalo medio general desde la cirugía hasta el reingreso fue de 14 días en NSQIP y 11 días institucionalmente. Las razones más comunes para el reingreso fueron infección del espacio orgánico, obstrucción intestinal / íleo paralítico y deshidratación tanto en NSQIP como en datos institucionales.Esta fue una revisión observacional retrospectiva.Para los pacientes que se someten a cirugía electiva de colon y recto, el uso de una calculadora de riesgo de reingreso desarrollada para el uso postoperatorio puede identificar a los pacientes de alto riesgo para una posible mejora de los factores de riesgo modificables, un seguimiento ambulatorio más intensivo o un reingreso planificado. Consulte Video Resumen en http://links.lww.com/DCR/B284. (Traducción-Dr Yesenia Rojas-Khalil).
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Lee N, Lee SY, Kim CH, Kwak HD, Ju JK, Kim HR. The Relationship Between High-Output Stomas, Postoperative Ileus, and Readmission After Rectal Cancer Surgery With Diverting Ileostomy. Ann Coloproctol 2020; 37:44-50. [PMID: 32972101 PMCID: PMC7989563 DOI: 10.3393/ac.2020.08.03] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/01/2020] [Accepted: 08/03/2020] [Indexed: 02/07/2023] Open
Abstract
Purpose This study aimed to evaluate the relationship between high-output stomas (HOSs), postoperative ileus (POI), and readmission after rectal cancer surgery with diverting ileostomy. Methods We included 302 patients with rectal cancer who underwent restorative resection with diverting ileostomy between January 2011 and December 2015. HOSs were defined as stomas with ≥ 2,000 mL/day output. We analyzed predictive factors for readmission of these patients. Results Forty-eight patients (15.9%) had HOSs during the hospital stay, and 41 patients (13.6%) experienced POI. HOSs were strongly associated with POI (45.8% vs. 7.5%, P < 0.001). The all-cause readmission rate was 16.9%, with 19 (6.3%) and 20 (6.6%) experiencing ileus and acute kidney injury, respectively. HOSs (27.1% vs. 15.0%, P = 0.040) and POI (34.1% vs. 14.2%, P = 0.002) were associated with all-cause readmission, and POI was associated with readmission with ileus (17.1% vs. 4.6%, P = 0.007). POI was an independent risk factor for all-cause readmission (adjusted odds ratio [OR], 2.640; 95% confidence interval [CI], 1.162 to 6.001; P = 0.020) and readmission with ileus (adjusted OR = 3.869; 95% CI 1.387 to 10.792; P = 0.010). Conclusion POI was associated with readmission, particularly for subsequent ileus, in patients with diverting ileostomy. We should make efforts to reduce POI, such as strong control of HOSs, to prevent readmission.
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Affiliation(s)
- Naa Lee
- Department of Surgery, Chonnam National University Hwasun Hospital, Chonnam National University Medical School, Hwasun, Korea
| | - Soo Young Lee
- Department of Surgery, Chonnam National University Hwasun Hospital, Chonnam National University Medical School, Hwasun, Korea
| | - Chang Hyun Kim
- Department of Surgery, Chonnam National University Hwasun Hospital, Chonnam National University Medical School, Hwasun, Korea
| | - Han Deok Kwak
- Department of Surgery, Chonnam National University Hospital, Chonnam National University Medical School, Gwangju, Korea
| | - Jae Kyun Ju
- Department of Surgery, Chonnam National University Hospital, Chonnam National University Medical School, Gwangju, Korea
| | - Hyeong Rok Kim
- Department of Surgery, Chonnam National University Hwasun Hospital, Chonnam National University Medical School, Hwasun, Korea
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New prediction tool—LIST—with improved prediction accuracy for 30-day readmission rates in patients with head and neck cancer after major cancer surgery. Oral Oncol 2020; 108:104772. [DOI: 10.1016/j.oraloncology.2020.104772] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2020] [Revised: 04/14/2020] [Accepted: 05/01/2020] [Indexed: 12/29/2022]
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Liu C, Bhat S, O'Grady G, Bissett I. Re-admissions after ileostomy formation: a retrospective analysis from a New Zealand tertiary centre. ANZ J Surg 2020; 90:1621-1626. [PMID: 32808425 DOI: 10.1111/ans.16076] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2020] [Accepted: 05/21/2020] [Indexed: 12/19/2022]
Abstract
BACKGROUND Ileostomy formation is a commonly performed procedure in colorectal surgery. The morbidity associated with ileostomies is substantial, particularly for unplanned hospital re-admissions and re-admissions with dehydration. Studies of post-ileostomy re-admissions from an Australasian institution are currently lacking. This retrospective study aimed to quantify the 60-day re-admission rate after ileostomy formation in a New Zealand tertiary centre and to determine the predictive factors. METHODS The surgical database of Auckland City Hospital was searched for all patients aged ≥18 years with a new ileostomy formed between first January 2015 and first January 2019. Patient electronic medical records were reviewed to obtain data regarding the primary outcome of re-admissions within 60 days of discharge, as well as patient and operative variables. Multivariate regression analysis was performed to identify independent predictors of all-cause re-admissions and re-admissions with dehydration. RESULTS A total of 246 patients with 266 ileostomy formations were included. The 60-day re-admission rate was 29.3%, with dehydration present in 27.0% of these re-admissions. Renal impairment at discharge (odds ratio 2.819, 95% confidence interval 1.087-7.310) and the presence of at least one Clavien-Dindo 1 complication (odds ratio 2.268, 95% confidence interval 1.301-3.954) were independently associated with all-cause re-admission. The independent predictors of re-admission with dehydration were renal impairment at discharge, codeine prescribed on discharge, Charlson Comorbidity Index and body mass index. CONCLUSION Unplanned hospital re-admission following ileostomy formation is a significant issue in the New Zealand patient population. Some patient groups are at particularly high risk, such as those with renal impairment at discharge.
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Affiliation(s)
- Chen Liu
- Department of Surgery, University of Auckland, Auckland, New Zealand
| | - Sameer Bhat
- Department of Surgery, University of Auckland, Auckland, New Zealand
| | - Gregory O'Grady
- Department of Surgery, University of Auckland, Auckland, New Zealand
| | - Ian Bissett
- Department of Surgery, University of Auckland, Auckland, New Zealand
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Effectiveness of the Ileostomy Pathway in Reducing Readmissions for Dehydration: Does It Stand the Test of Time? Dis Colon Rectum 2020; 63:1151-1155. [PMID: 32692076 DOI: 10.1097/dcr.0000000000001627] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
BACKGROUND The ileostomy pathway, introduced in 2011, has proved to be successful in eliminating hospital readmissions for high-output ileostomy or dehydration in the following period of 7 months in a single institution. However, it is unclear whether this short-term success, immediately after the initiation of the program, can be sustainable in the long term. OBJECTIVE The aim of this study was to assess the efficacy and the durability of the ileostomy pathway in reducing readmissions for dehydration over a longer period of time. DESIGN This was a retrospective review of the patients who entered into the ileostomy pathway, since its introduction on March 1, 2011, until January 31, 2015. SETTINGS This study was conducted at a tertiary academic center. PATIENTS Patients undergoing colorectal surgery with the creation of a new end or loop ileostomy were included. INTERVENTION The long-term sustainability of the ileostomy pathway was assessed. MAIN OUTCOME MEASURES The primary end point was readmission within 30 days after discharge for a high-output ileostomy or dehydration. RESULTS A total of 393 patients (male n = 195, female n = 198, median age 52 (18-87) years) were included: 161 prepathway and 232 on-pathway. Overall 30-day postdischarge readmission rates decreased from 35.4% to 25.9% (p = 0.04). Readmissions due to high output and/or dehydration dropped from 15.5% to 3.9% (p < 0.001). Readmissions due to small-bowel obstructions dropped from 9.9% to 4.3%, (p = 0.03). LIMITATIONS The possible limitations of the study included a nonrandomized comparison of the patient groups and those patients who were possibly admitted to different institutions. CONCLUSIONS The present ileostomy pathway decreases readmissions for high-output ileostomy and dehydration in patients with new ileostomies and is durable in the long term. See Video Abstract at http://links.lww.com/DCR/B233. EFICACIA DE VÍA DE ILEOSTOMÍA PARA REDUCIR LOS REINGRESOS POR DESHIDRATACIÓN: ¿RESISTE LA PRUEBA DEL TIEMPO?: La vía de ileostomía, introducida en 2011, ha demostrado ser exitosa en la eliminación de reingresos hospitalarios por ileostomía de alto rendimiento o deshidratación, por un período de 7 meses, en una sola institución. Sin embargo, no se ha aclarado si el éxito es a corto plazo, inmediatamente después del inicio del programa, y de que pueda ser sostenible a largo plazo.El objetivo de este estudio fue evaluar la eficacia y la durabilidad de la vía de ileostomía, para disminuir los reingresos por deshidratación, durante un período de tiempo más largo.Esta fue una revisión retrospectiva de pacientes que ingresaron a la vía de ileostomía, desde su introducción el 1 de marzo de 2011 hasta el 31 de enero de 2015.Este estudio se realizó en un centro académico terciario.Se incluyeron pacientes sometidos a cirugía colorrectal con la creación de una nueva ileostomía de extremo o asa.Evaluar la sostenibilidad de la vía de ileostomía a largo plazo.El punto final primario fue el reingreso dentro de los 30 días posteriores al alta, por una ileostomía de alto gasto o deshidratación.Se incluyeron un total de 393 pacientes (hombres n = 195, mujeres n = 198, edad media 52 [18-87] años), 161 antes de la vía y 232 en la vía. En general, las tasas de reingreso después del alta a 30 días, disminuyeron de 35.4% a 25.9% (p = 0.04). Los reingresos por alto rendimiento y / o deshidratación, disminuyeron del 15.5% al 3.9% (p < 0.001). Los reingresos debidos a obstrucciones del intestino delgado, disminuyeron del 9.9% al 4.3% (p = 0.03).Las posibles limitaciones del estudio incluyeron una comparación no aleatoria de los grupos de pacientes, y de aquellos pacientes que posiblemente fueron admitidos en diferentes instituciones.La vía de ileostomía disminuye los reingresos por ileostomía de alto gasto y deshidratación, en nuevos pacientes con ileostomía, y es duradera a largo plazo. Consulte Video Resumen en http://links.lww.com/DCR/B233.
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Preoperative opioid use is associated with increased risk of postoperative complications within a colorectal-enhanced recovery protocol. Surg Endosc 2020; 35:2067-2074. [PMID: 32394171 DOI: 10.1007/s00464-020-07603-7] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2019] [Accepted: 04/28/2020] [Indexed: 12/18/2022]
Abstract
BACKGROUND As the opioid epidemic escalates, preoperative opioid use has become increasingly common. Recent studies associated preoperative opioid use with postoperative morbidity. However, limited study of its impact on patients within enhanced recovery protocols (ERP) exists. We assessed the impact of preoperative opioid use on postoperative complications among colorectal surgery patients within an ERP, hypothesizing that opioid-exposed patients would be at increased risk of complications. METHODS Elective colorectal cases from August 2013 to June 2017 were reviewed in a retrospective cohort study comparing preoperative opioid-exposed patients to opioid-naïve patients. Postoperative complications were defined as a composite of complications captured by the American College of Surgeons National Surgical Quality Improvement Program. Logistic regression identified risk factors for postoperative complications. RESULTS 707 patients were identified, including 232 (32.8%) opioid-exposed patients. Opioid-exposed patients were younger (57.9 vs 61.9 years; p < 0.01) and more likely to smoke (27.6 vs 17.1%; p < 0.01). Laparoscopic procedures were less common among opioid-exposed patients (44.8 vs 58.1%; p < 0.01). Median morphine equivalents received were higher in opioid-exposed patients (65.0 vs 20.1 mg; p < 0.01), but compliance to ERP elements was otherwise equivalent. Postoperative complications were higher among opioid-exposed patients (28.5 vs 15.0%; p < 0.01), as was median length of stay (4.0 vs 3.0 days; p < 0.01). Logistic regression identified multiple patient- and procedure-related factors independently associated with postoperative complications, including preoperative opioid use (p = 0.001). CONCLUSION Preoperative opioid use is associated with increased risk of postoperative complications in elective colorectal surgery patients within an ERP. These results highlight the negative impact of opioid use, suggesting an opportunity to further reduce the risk of surgical complications through ERP expansion to include preoperative mitigation strategies for opioid-exposed patients.
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Lowenfeld L, Cologne KG. Postoperative Considerations in Inflammatory Bowel Disease. Surg Clin North Am 2019; 99:1095-1109. [PMID: 31676050 DOI: 10.1016/j.suc.2019.08.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
Treatment of inflammatory bowel disease (IBD) is often multidimensional, requiring both medical and surgical therapies at different times throughout the course of the disease. Both medical and surgical treatments may be used in the acute setting, during a flare, or in a more elective maintenance role. These treatments should be planned as complementary and synergistic. Gastroenterologists and colorectal surgeons should collaborate to create a cohesive treatment plan, arranging the sequence and timing of various treatments. This article reviews the anticipated postoperative recovery after surgical treatment of IBD, possible postoperative complications, and considerations of timing surgery with medical therapy.
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Affiliation(s)
- Lea Lowenfeld
- Surgery, Division of Colorectal Surgery, University of Southern California Keck School of Medicine, 1441 Eastlake Avenue, Suite 7418, Los Angeles, CA 90033, USA
| | - Kyle G Cologne
- Surgery, Division of Colorectal Surgery, University of Southern California Keck School of Medicine, 1441 Eastlake Avenue, Suite 7418, Los Angeles, CA 90033, USA.
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Can we better predict readmission for dehydration following creation of a diverting loop ileostomy: development and validation of a prediction model and web-based risk calculator. Surg Endosc 2019; 34:3118-3125. [PMID: 31451920 DOI: 10.1007/s00464-019-07069-2] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2019] [Accepted: 08/15/2019] [Indexed: 02/08/2023]
Abstract
BACKGROUND Dehydration is the most common morbidity following creation of a diverting loop ileostomy (DLI). We aimed to develop and validate a prediction model and web-based risk calculator for readmission for dehydration following DLI creation. METHODS After institutional review board approval, we retrospectively reviewed the American College of Surgeons-National Surgical Quality Improvement Program (ACS-NSQIP) database between 2012 and 2017. Adult patients (> 18 years) who underwent DLI with a resection for colorectal cancer, inflammatory bowel disease, or diverticulitis were identified. Patient demographics, operative and postoperative data were collected. The final prediction model, developed in 60% of the cohort (training set) and which modeled the 30-day cumulative incidence of readmission for dehydration, was selected using highest area under the receiver operating curve (AUC) criterion. Model calibration was assessed with the Hosmer-Lemeshow goodness-of-fit test. The model was then assessed in validation and test sets, using 20% of the cohort for each. RESULTS Of 25,638 patients in the ACS-NSQIP database who met inclusion criteria, 15,222 patients were randomly selected for the training set. The incidence of readmission for dehydration in this cohort was 2.1%. The final model with the highest AUC retained 12 candidate variables: age, sex, smoking status, diabetes, hypertension, American Society of Anesthesiologists score, type of admission, underlying diagnosis, procedure performed, operative time, index admission length of stay, and major morbidity. The model demonstrated good discrimination (AUC 0.76, 95% CI 0.74-0.79) and the Hosmer-Lemeshow goodness-of-fit test confirmed good calibration (p = 0.50). Five-thousand and seventy-three patients were available for the validation and test sets, respectively, and the model remained strong in both the validation and test sets (AUCs of 0.73 and 0.73, respectively). The prediction model was then converted into a web-based risk calculator. CONCLUSIONS A prediction model and web-based risk calculator for readmission for dehydration after DLI creation was developed and validated, demonstrating good predictive capabilities.
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Vergara-Fernández O, Trejo-Avila M, Santes O, Solórzano-Vicuña D, Salgado-Nesme N. Predictors of dehydration and acute renal failure in patients with diverting loop ileostomy creation after colorectal surgery. World J Clin Cases 2019; 7:1805-1813. [PMID: 31417926 PMCID: PMC6692275 DOI: 10.12998/wjcc.v7.i14.1805] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/04/2019] [Revised: 06/17/2019] [Accepted: 06/27/2019] [Indexed: 02/05/2023] Open
Abstract
BACKGROUND Despite the potential benefits of fecal diversion after low pelvic anastomosis in colorectal surgery, diverting loop ileostomy construction is related to significant rates of complications.
AIM To determine potential predictors of high output related complications in patients with diverting loop ileostomy creation after colorectal surgery.
METHODS Patients who underwent open and laparoscopic colorectal surgery requiring a diverting loop ileostomy from January 2010 to March 2018 were retrospectively analyzed. We included patients older than 18 years, who underwent colorectal surgery with primary low pelvic anastomosis, and with the creation of a diverting loop ileostomy, at elective or emergency settings for the treatment of benign or malignant conditions. Univariate and multivariate logistic regression analysis was used to determine the effect of the potential predictors on the rate of high output related complications. The high output related complications were dehydration and acute renal failure that required visits to the emergency department and hospitalizations.
RESULTS Of the 102 patients included in the study, 23.5% (n = 24) suffered high output related complications. In this group of patients at least one visit to the emergency department (mean 1.6), and at least one readmission to the hospital was needed. The factors associated with high-output ileostomy, in the univariate analysis, were: urgent surgical intervention (OR = 2.6; P = 0.047), the development of postoperative complications (OR = 3; P = 0.024), have ulcerative colitis (OR = 4.8; P = 0.017), use of steroids (OR = 4.3; P = 0.010), mean output at discharge greater than 1000 mL/24 h (OR = 3.2; P = 0.016), and use of loperamide at discharge (OR = 2.8; P = 0.032). Multivariate logistic regression analysis identified two independent risk factors for high output related complications: ulcerative colitis [OR = 7.6 (95%CI: 1.81-31.95); P = 0.006], and ileostomy output at discharge ≥ 1000 mL/24 h [OR = 3.3 (1.18-9.37); P = 0.023].
CONCLUSION In our study, patients with ulcerative colitis and those with an ileostomy output above 1000 mL/24 h at discharge, were at increased risk of high output related complications.
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Affiliation(s)
- Omar Vergara-Fernández
- Department of Colorectal Surgery, Instituto Nacional de Ciencias Médicas y Nutrición “Salvador Zubirán”, Mexico City 14080, Mexico
| | - Mario Trejo-Avila
- Department of Colorectal Surgery, Instituto Nacional de Ciencias Médicas y Nutrición “Salvador Zubirán”, Mexico City 14080, Mexico
| | - Oscar Santes
- Department of Colorectal Surgery, Instituto Nacional de Ciencias Médicas y Nutrición “Salvador Zubirán”, Mexico City 14080, Mexico
| | - Danilo Solórzano-Vicuña
- Department of Colorectal Surgery, Instituto Nacional de Ciencias Médicas y Nutrición “Salvador Zubirán”, Mexico City 14080, Mexico
| | - Noel Salgado-Nesme
- Department of Colorectal Surgery, Instituto Nacional de Ciencias Médicas y Nutrición “Salvador Zubirán”, Mexico City 14080, Mexico
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