ACS Clinical Congress

WASHINGTON – Laparoscopic gastrostomy in adults was associated with fewer complications than open gastrostomy in the same population, according to data presented at the annual clinical congress of the American College of Surgeons.

In a retrospective study of data from 2,883 patients, taken from the 2005-2010 National Surgical Quality Improvement Program (NSQIP) database, Dr. Rachel Van Dusen and her colleagues reviewed a variety of outcomes, including wound, pulmonary, renal, cardiac, and thromboembolic, in patients who underwent either a laparoscopic (n = 382), open (n = 2,112), or percutaneous endoscopic gastrostomy (PEG) (n = 389).

Either laparoscopic or open gastrostomies are performed in patients for whom PEG, the standard of care, is unfeasible. Dr. Van Dusen, of George Washington University, Washington, said that theirs was the first study to measure the association between all three procedures and complications in the adult gastrostomy patient population.

The average age of patients was 58 years in the laparoscopic cohort, 62 years in the open group, and 65 years in the PEG group. The patients were at least 18 years old. The laparoscopic group was 88.8% white and 69.4% female; the open group, 80.7% white and 58.2% female; and the PEG group, 85.2% and 57.6%, respectively.

A stepwise logistic regression analysis of patient characteristics in all three cohorts indicated that at baseline, open gastrostomy patients tended, among other factors, to have serum albumin levels less than 3 g/dL (44%), sepsis (35.7%), diabetes (20.4%), a body mass index of 20 kg/m² or less (27.8%), and ascites (9.0%); in addition, 27% of patients were undergoing chemotherapy.

In a similar analysis, laparoscopic patients were seen to be less ill at baseline: Only 20.4% had low albumin levels, diabetes and sepsis levels were just under 16%, BMI was between 20 and 40, 2.9% were ascitic, and only 1.3% were receiving chemotherapy.

Complications in each group were reviewed according to either wound or organ system. PEG patients had the fewest overall complications (22.4%), with none that were comparatively significant. However, there were several significant differences in complication rates between the laparoscopic and open gastrostomy cohorts.

Pulmonary complications occurred in 23.2% of the open gastrostomy group, compared with 9.7% of the laparoscopic group (multivariate odds ratio, 1.97). Also in the open gastrostomy group, 2.5% had renal complications, compared with 0.5% of the laparoscopic patients (mOR, 4.48). Sepsis was found in 13.5% of the open group and 5.8% of the laparoscopic group (mOR 1.72).

Open gastrostomy patients, when compared with the PEG group, had twice the odds of experiencing wound events (mOR, 2.10) and a 1.5 times greater chance of having sepsis (mOR, 1.51). No significant differences were found between other complications.

"We surmise that the reason the higher rate of infection was associated with the open gastrostomy [patients] is the increase in fascial violation and the exposure of the soft tissues," said Dr. Van Dusen. "The increase in pulmonary problems may be related to poor pulmonary toilet from more postoperative pain, and more septic issues may be related to more significant fluid shifts during laparotomy."

Dr. Van Dusen concluded that while PEG remains the best method of enteral access, laparoscopic gastrostomy is superior to open gastrostomy.

Dr. Van Dusen did not have any relevant disclosures.

wmcknight@frontlinemedcom.com

WASHINGTON – Laparoscopic gastrostomy in adults was associated with fewer complications than open gastrostomy in the same population, according to data presented at the annual clinical congress of the American College of Surgeons.

In a retrospective study of data from 2,883 patients, taken from the 2005-2010 National Surgical Quality Improvement Program (NSQIP) database, Dr. Rachel Van Dusen and her colleagues reviewed a variety of outcomes, including wound, pulmonary, renal, cardiac, and thromboembolic, in patients who underwent either a laparoscopic (n = 382), open (n = 2,112), or percutaneous endoscopic gastrostomy (PEG) (n = 389).

Either laparoscopic or open gastrostomies are performed in patients for whom PEG, the standard of care, is unfeasible. Dr. Van Dusen, of George Washington University, Washington, said that theirs was the first study to measure the association between all three procedures and complications in the adult gastrostomy patient population.

The average age of patients was 58 years in the laparoscopic cohort, 62 years in the open group, and 65 years in the PEG group. The patients were at least 18 years old. The laparoscopic group was 88.8% white and 69.4% female; the open group, 80.7% white and 58.2% female; and the PEG group, 85.2% and 57.6%, respectively.

A stepwise logistic regression analysis of patient characteristics in all three cohorts indicated that at baseline, open gastrostomy patients tended, among other factors, to have serum albumin levels less than 3 g/dL (44%), sepsis (35.7%), diabetes (20.4%), a body mass index of 20 kg/m² or less (27.8%), and ascites (9.0%); in addition, 27% of patients were undergoing chemotherapy.

In a similar analysis, laparoscopic patients were seen to be less ill at baseline: Only 20.4% had low albumin levels, diabetes and sepsis levels were just under 16%, BMI was between 20 and 40, 2.9% were ascitic, and only 1.3% were receiving chemotherapy.

Complications in each group were reviewed according to either wound or organ system. PEG patients had the fewest overall complications (22.4%), with none that were comparatively significant. However, there were several significant differences in complication rates between the laparoscopic and open gastrostomy cohorts.

Pulmonary complications occurred in 23.2% of the open gastrostomy group, compared with 9.7% of the laparoscopic group (multivariate odds ratio, 1.97). Also in the open gastrostomy group, 2.5% had renal complications, compared with 0.5% of the laparoscopic patients (mOR, 4.48). Sepsis was found in 13.5% of the open group and 5.8% of the laparoscopic group (mOR 1.72).

Open gastrostomy patients, when compared with the PEG group, had twice the odds of experiencing wound events (mOR, 2.10) and a 1.5 times greater chance of having sepsis (mOR, 1.51). No significant differences were found between other complications.

"We surmise that the reason the higher rate of infection was associated with the open gastrostomy [patients] is the increase in fascial violation and the exposure of the soft tissues," said Dr. Van Dusen. "The increase in pulmonary problems may be related to poor pulmonary toilet from more postoperative pain, and more septic issues may be related to more significant fluid shifts during laparotomy."

Dr. Van Dusen concluded that while PEG remains the best method of enteral access, laparoscopic gastrostomy is superior to open gastrostomy.

Dr. Van Dusen did not have any relevant disclosures.

wmcknight@frontlinemedcom.com

WASHINGTON – Laparoscopic gastrostomy in adults was associated with fewer complications than open gastrostomy in the same population, according to data presented at the annual clinical congress of the American College of Surgeons.

In a retrospective study of data from 2,883 patients, taken from the 2005-2010 National Surgical Quality Improvement Program (NSQIP) database, Dr. Rachel Van Dusen and her colleagues reviewed a variety of outcomes, including wound, pulmonary, renal, cardiac, and thromboembolic, in patients who underwent either a laparoscopic (n = 382), open (n = 2,112), or percutaneous endoscopic gastrostomy (PEG) (n = 389).

Either laparoscopic or open gastrostomies are performed in patients for whom PEG, the standard of care, is unfeasible. Dr. Van Dusen, of George Washington University, Washington, said that theirs was the first study to measure the association between all three procedures and complications in the adult gastrostomy patient population.

The average age of patients was 58 years in the laparoscopic cohort, 62 years in the open group, and 65 years in the PEG group. The patients were at least 18 years old. The laparoscopic group was 88.8% white and 69.4% female; the open group, 80.7% white and 58.2% female; and the PEG group, 85.2% and 57.6%, respectively.

A stepwise logistic regression analysis of patient characteristics in all three cohorts indicated that at baseline, open gastrostomy patients tended, among other factors, to have serum albumin levels less than 3 g/dL (44%), sepsis (35.7%), diabetes (20.4%), a body mass index of 20 kg/m² or less (27.8%), and ascites (9.0%); in addition, 27% of patients were undergoing chemotherapy.

In a similar analysis, laparoscopic patients were seen to be less ill at baseline: Only 20.4% had low albumin levels, diabetes and sepsis levels were just under 16%, BMI was between 20 and 40, 2.9% were ascitic, and only 1.3% were receiving chemotherapy.

Complications in each group were reviewed according to either wound or organ system. PEG patients had the fewest overall complications (22.4%), with none that were comparatively significant. However, there were several significant differences in complication rates between the laparoscopic and open gastrostomy cohorts.

Pulmonary complications occurred in 23.2% of the open gastrostomy group, compared with 9.7% of the laparoscopic group (multivariate odds ratio, 1.97). Also in the open gastrostomy group, 2.5% had renal complications, compared with 0.5% of the laparoscopic patients (mOR, 4.48). Sepsis was found in 13.5% of the open group and 5.8% of the laparoscopic group (mOR 1.72).

Open gastrostomy patients, when compared with the PEG group, had twice the odds of experiencing wound events (mOR, 2.10) and a 1.5 times greater chance of having sepsis (mOR, 1.51). No significant differences were found between other complications.

"We surmise that the reason the higher rate of infection was associated with the open gastrostomy [patients] is the increase in fascial violation and the exposure of the soft tissues," said Dr. Van Dusen. "The increase in pulmonary problems may be related to poor pulmonary toilet from more postoperative pain, and more septic issues may be related to more significant fluid shifts during laparotomy."

Dr. Van Dusen concluded that while PEG remains the best method of enteral access, laparoscopic gastrostomy is superior to open gastrostomy.

Dr. Van Dusen did not have any relevant disclosures.

wmcknight@frontlinemedcom.com

WASHINGTON – Elderly patients who undergo laparoscopic colon surgery are significantly more likely to be discharged back to their homes than to a long-term care facility.

In a retrospective study of almost 10,000 elderly patients, 12.5% of those who had a laparoscopic procedure went to a nursing home, compared with 20% of those who had open surgery. In a multivariate analysis, laparoscopic surgery was associated with a significant, 39% decrease in the risk of being discharged to a nursing home, Dr. Richard Liu said at the annual clinical congress of the American College of Surgeons.

"For patients in their early 70s who do not have advanced disease or significant comorbidities, laparoscopic colon cancer resection is an option not only to prolong survival but also to preserve quality of life," said Dr. Liu, a surgical resident at Dalhousie University, Halifax, N.S.

The study highlights some important differences in the ways surgeons and patients perceive surgical outcomes. Surgeons and researchers often focus on 5-year survival rates and short-term morbidity and mortality, Dr. Liu said. But prior research done by his group found that immediate quality of life was at least as important to elderly patients – and sometimes more so.

"We have looked at elderly patients in our emergency services and followed up with them several times after admission," he said in an interview. "A common theme that came up was quality of life after hospitalization. Some were actually refusing to have operations for fear of what might become of them afterward."

Dr. Liu’s study comprised 9,416 patients from the U.S. National Inpatient Sample database. All were older than 70 years (mean age 79) and all were living independently at home. They underwent elective colon surgery during 2009-2010 for either cancer or a resection. The primary outcome was discharge back to home or to a long-term care facility. None of the patients were discharged to home health care or to hospice.

Most of the group (61%) had open surgery; the remainder had laparoscopy. Of those who had open surgery, 20% were discharged to a nursing facility, compared with 12.5% of the laparoscopy group – a significant difference.

Laparoscopy significantly decreased the chance of a nursing home admission by 39% in a multivariate analysis that controlled for age, sex, race, comorbidity score, cancer stage, income and insurance, and hospital size.

Factors significantly associated with nursing home discharge included advancing age and cancer stage.

Generally speaking, open surgery is physically more trying for elderly patients. A difficult recovery could be just enough to tip them over the edge from independent living, Dr. Liu said.

Dr. Liu had no financial disclosures.

msullivan@frontlinemedcom.com

WASHINGTON – Elderly patients who undergo laparoscopic colon surgery are significantly more likely to be discharged back to their homes than to a long-term care facility.

In a retrospective study of almost 10,000 elderly patients, 12.5% of those who had a laparoscopic procedure went to a nursing home, compared with 20% of those who had open surgery. In a multivariate analysis, laparoscopic surgery was associated with a significant, 39% decrease in the risk of being discharged to a nursing home, Dr. Richard Liu said at the annual clinical congress of the American College of Surgeons.

"For patients in their early 70s who do not have advanced disease or significant comorbidities, laparoscopic colon cancer resection is an option not only to prolong survival but also to preserve quality of life," said Dr. Liu, a surgical resident at Dalhousie University, Halifax, N.S.

The study highlights some important differences in the ways surgeons and patients perceive surgical outcomes. Surgeons and researchers often focus on 5-year survival rates and short-term morbidity and mortality, Dr. Liu said. But prior research done by his group found that immediate quality of life was at least as important to elderly patients – and sometimes more so.

"We have looked at elderly patients in our emergency services and followed up with them several times after admission," he said in an interview. "A common theme that came up was quality of life after hospitalization. Some were actually refusing to have operations for fear of what might become of them afterward."

Dr. Liu’s study comprised 9,416 patients from the U.S. National Inpatient Sample database. All were older than 70 years (mean age 79) and all were living independently at home. They underwent elective colon surgery during 2009-2010 for either cancer or a resection. The primary outcome was discharge back to home or to a long-term care facility. None of the patients were discharged to home health care or to hospice.

Most of the group (61%) had open surgery; the remainder had laparoscopy. Of those who had open surgery, 20% were discharged to a nursing facility, compared with 12.5% of the laparoscopy group – a significant difference.

Laparoscopy significantly decreased the chance of a nursing home admission by 39% in a multivariate analysis that controlled for age, sex, race, comorbidity score, cancer stage, income and insurance, and hospital size.

Factors significantly associated with nursing home discharge included advancing age and cancer stage.

Generally speaking, open surgery is physically more trying for elderly patients. A difficult recovery could be just enough to tip them over the edge from independent living, Dr. Liu said.

Dr. Liu had no financial disclosures.

msullivan@frontlinemedcom.com

WASHINGTON – Elderly patients who undergo laparoscopic colon surgery are significantly more likely to be discharged back to their homes than to a long-term care facility.

In a retrospective study of almost 10,000 elderly patients, 12.5% of those who had a laparoscopic procedure went to a nursing home, compared with 20% of those who had open surgery. In a multivariate analysis, laparoscopic surgery was associated with a significant, 39% decrease in the risk of being discharged to a nursing home, Dr. Richard Liu said at the annual clinical congress of the American College of Surgeons.

"For patients in their early 70s who do not have advanced disease or significant comorbidities, laparoscopic colon cancer resection is an option not only to prolong survival but also to preserve quality of life," said Dr. Liu, a surgical resident at Dalhousie University, Halifax, N.S.

The study highlights some important differences in the ways surgeons and patients perceive surgical outcomes. Surgeons and researchers often focus on 5-year survival rates and short-term morbidity and mortality, Dr. Liu said. But prior research done by his group found that immediate quality of life was at least as important to elderly patients – and sometimes more so.

"We have looked at elderly patients in our emergency services and followed up with them several times after admission," he said in an interview. "A common theme that came up was quality of life after hospitalization. Some were actually refusing to have operations for fear of what might become of them afterward."

Dr. Liu’s study comprised 9,416 patients from the U.S. National Inpatient Sample database. All were older than 70 years (mean age 79) and all were living independently at home. They underwent elective colon surgery during 2009-2010 for either cancer or a resection. The primary outcome was discharge back to home or to a long-term care facility. None of the patients were discharged to home health care or to hospice.

Most of the group (61%) had open surgery; the remainder had laparoscopy. Of those who had open surgery, 20% were discharged to a nursing facility, compared with 12.5% of the laparoscopy group – a significant difference.

Laparoscopy significantly decreased the chance of a nursing home admission by 39% in a multivariate analysis that controlled for age, sex, race, comorbidity score, cancer stage, income and insurance, and hospital size.

Factors significantly associated with nursing home discharge included advancing age and cancer stage.

Generally speaking, open surgery is physically more trying for elderly patients. A difficult recovery could be just enough to tip them over the edge from independent living, Dr. Liu said.

Dr. Liu had no financial disclosures.

msullivan@frontlinemedcom.com

WASHINGTON – Women surgeons have significantly fewer children, bear them later, and are three times more likely to use assisted reproductive techniques to achieve pregnancy, compared with the general U.S. population.

The findings probably speak to the time it takes to launch a surgical career, leading to delayed childbearing and the physiologic problems that accompany advanced maternal age, Dr. Elizabeth A. Phillips said in a poster at the annual clinical congress of the American College of Surgeons.

"Our survey found that 32% of women surgeons had difficulty with fertility at some point in their childbearing career, compared with 11% of women in the general population," said Dr. Phillips of Boston Medical Center. "When we compared the rates of fertility services to [national] data, we saw that 15% of women surgeons used assisted reproduction, compared to just 5% of the U.S. population."

She conducted an anonymous, 199-question survey on reproductive health, which was distributed to female surgeon interest groups in the areas of general surgery, gynecology, neurosurgery, ophthalmology, orthopedics, otolaryngology, plastic surgery, podiatry, and urology. She received 1,021 replies, which she compared with data from the CDC National Survey for Family Growth from 2006-2010, and the National Institutes of Health.

Of the total responses, 784 women had attempted to become pregnant. Of these, 251 (32%) reported fertility problems. Most of these (210; 84%) underwent a fertility work-up; 76% then attempted pregnancy using some form of assisted reproductive technology (ART). These women bore 185 children.

Most surgeons reported unexplained infertility (70%). Other causes were anovulation (23%); advanced maternal age or premature ovarian failure (22%); polycystic ovarian disease (19%); endometriosis (13%); and recurrent miscarriage (12%). Male factor infertility contributed to 19% of the cases.

Specialties with the highest rates of infertility were otolaryngology (29%), general surgery (22%), and orthopedics (18%).

Surgeons conceived at a significantly older age than the general population (33 vs. 23 years) did and had significantly fewer children (1.4 vs. 2.6 national average). Among those who used ART, the average maternal age at birth was even older – 35 years.

There may be several reasons why women surgeons may turn to ART so much more frequently than do nonsurgeons, Dr. Phillips said in an interview. "One theory is that female surgeons have different relationships with fertility specialists, where they are receiving treatment that would not be offered for another 45-year-old who walked into the office. They also may have the financial means to pay for this treatment."

The survey brings up the question of how women surgeons should factor childbearing into their already busy, stressful lives, she said.

"With so many more women going into surgical subspecialties, should we have family planning tracks? Is there some way to encourage women who want to become pregnant to do so during training, or shortly thereafter?"

"I’ve talked to surgeons who have been pregnant during training, residency, and practice, and by far, the best time to have a child seemed to be during residency, when there were more people to absorb the absence. But most women will say, ‘There’s never a perfect time.’ It’s something that, if it’s a goal in life, you simply have to make it a priority."

Dr. Phillips won the ACS Award for Best Scientific Poster presentation by Junior Investigator. She had no financial disclosures.

msullivan@frontlinemedcom.com

WASHINGTON – Women surgeons have significantly fewer children, bear them later, and are three times more likely to use assisted reproductive techniques to achieve pregnancy, compared with the general U.S. population.

The findings probably speak to the time it takes to launch a surgical career, leading to delayed childbearing and the physiologic problems that accompany advanced maternal age, Dr. Elizabeth A. Phillips said in a poster at the annual clinical congress of the American College of Surgeons.

"Our survey found that 32% of women surgeons had difficulty with fertility at some point in their childbearing career, compared with 11% of women in the general population," said Dr. Phillips of Boston Medical Center. "When we compared the rates of fertility services to [national] data, we saw that 15% of women surgeons used assisted reproduction, compared to just 5% of the U.S. population."

She conducted an anonymous, 199-question survey on reproductive health, which was distributed to female surgeon interest groups in the areas of general surgery, gynecology, neurosurgery, ophthalmology, orthopedics, otolaryngology, plastic surgery, podiatry, and urology. She received 1,021 replies, which she compared with data from the CDC National Survey for Family Growth from 2006-2010, and the National Institutes of Health.

Of the total responses, 784 women had attempted to become pregnant. Of these, 251 (32%) reported fertility problems. Most of these (210; 84%) underwent a fertility work-up; 76% then attempted pregnancy using some form of assisted reproductive technology (ART). These women bore 185 children.

Most surgeons reported unexplained infertility (70%). Other causes were anovulation (23%); advanced maternal age or premature ovarian failure (22%); polycystic ovarian disease (19%); endometriosis (13%); and recurrent miscarriage (12%). Male factor infertility contributed to 19% of the cases.

Specialties with the highest rates of infertility were otolaryngology (29%), general surgery (22%), and orthopedics (18%).

Surgeons conceived at a significantly older age than the general population (33 vs. 23 years) did and had significantly fewer children (1.4 vs. 2.6 national average). Among those who used ART, the average maternal age at birth was even older – 35 years.

There may be several reasons why women surgeons may turn to ART so much more frequently than do nonsurgeons, Dr. Phillips said in an interview. "One theory is that female surgeons have different relationships with fertility specialists, where they are receiving treatment that would not be offered for another 45-year-old who walked into the office. They also may have the financial means to pay for this treatment."

The survey brings up the question of how women surgeons should factor childbearing into their already busy, stressful lives, she said.

"With so many more women going into surgical subspecialties, should we have family planning tracks? Is there some way to encourage women who want to become pregnant to do so during training, or shortly thereafter?"

"I’ve talked to surgeons who have been pregnant during training, residency, and practice, and by far, the best time to have a child seemed to be during residency, when there were more people to absorb the absence. But most women will say, ‘There’s never a perfect time.’ It’s something that, if it’s a goal in life, you simply have to make it a priority."

Dr. Phillips won the ACS Award for Best Scientific Poster presentation by Junior Investigator. She had no financial disclosures.

msullivan@frontlinemedcom.com

WASHINGTON – Women surgeons have significantly fewer children, bear them later, and are three times more likely to use assisted reproductive techniques to achieve pregnancy, compared with the general U.S. population.

The findings probably speak to the time it takes to launch a surgical career, leading to delayed childbearing and the physiologic problems that accompany advanced maternal age, Dr. Elizabeth A. Phillips said in a poster at the annual clinical congress of the American College of Surgeons.

"Our survey found that 32% of women surgeons had difficulty with fertility at some point in their childbearing career, compared with 11% of women in the general population," said Dr. Phillips of Boston Medical Center. "When we compared the rates of fertility services to [national] data, we saw that 15% of women surgeons used assisted reproduction, compared to just 5% of the U.S. population."

She conducted an anonymous, 199-question survey on reproductive health, which was distributed to female surgeon interest groups in the areas of general surgery, gynecology, neurosurgery, ophthalmology, orthopedics, otolaryngology, plastic surgery, podiatry, and urology. She received 1,021 replies, which she compared with data from the CDC National Survey for Family Growth from 2006-2010, and the National Institutes of Health.

Of the total responses, 784 women had attempted to become pregnant. Of these, 251 (32%) reported fertility problems. Most of these (210; 84%) underwent a fertility work-up; 76% then attempted pregnancy using some form of assisted reproductive technology (ART). These women bore 185 children.

Most surgeons reported unexplained infertility (70%). Other causes were anovulation (23%); advanced maternal age or premature ovarian failure (22%); polycystic ovarian disease (19%); endometriosis (13%); and recurrent miscarriage (12%). Male factor infertility contributed to 19% of the cases.

Specialties with the highest rates of infertility were otolaryngology (29%), general surgery (22%), and orthopedics (18%).

Surgeons conceived at a significantly older age than the general population (33 vs. 23 years) did and had significantly fewer children (1.4 vs. 2.6 national average). Among those who used ART, the average maternal age at birth was even older – 35 years.

There may be several reasons why women surgeons may turn to ART so much more frequently than do nonsurgeons, Dr. Phillips said in an interview. "One theory is that female surgeons have different relationships with fertility specialists, where they are receiving treatment that would not be offered for another 45-year-old who walked into the office. They also may have the financial means to pay for this treatment."

The survey brings up the question of how women surgeons should factor childbearing into their already busy, stressful lives, she said.

"With so many more women going into surgical subspecialties, should we have family planning tracks? Is there some way to encourage women who want to become pregnant to do so during training, or shortly thereafter?"

"I’ve talked to surgeons who have been pregnant during training, residency, and practice, and by far, the best time to have a child seemed to be during residency, when there were more people to absorb the absence. But most women will say, ‘There’s never a perfect time.’ It’s something that, if it’s a goal in life, you simply have to make it a priority."

Dr. Phillips won the ACS Award for Best Scientific Poster presentation by Junior Investigator. She had no financial disclosures.

msullivan@frontlinemedcom.com

WASHINGTON – Although general surgeons perform the majority of rectal resections in the United States, their patients have more severe postoperative complications, longer lengths of stay, higher hospital costs, and higher mortality rates than do those of colorectal surgeons.

A review of more than 60,000 cases over a 6-year period found that patients who had been operated on by a general surgeon had a 42% increase in the risk of mortality. They stayed in the hospital an average 1 day longer than the patients of colorectal surgeons, and had bills more than $1,000 higher. Although their overall complication rate was lower, general surgeons’ patients tended to have more severe complications, including pulmonary complications and surgical site infections, Dr. Marc Casasanta said at the annual clinical congress of the American College of Surgeons.

Dr. Casasanta of the University of Texas, Houston, extracted his data from the Premier Perspective database, the largest inpatient database in the United States. His analysis included 60,412 nonemergent rectal resections performed from 2005 to 2011.

Most of these (74%) were performed by general surgeons, with colorectal surgeons performing the remainder. Adverse outcomes examined included length and cost of hospital admission, overall complications and severe complications, and mortality.

There were several significant differences in the patient populations. General surgeons had older patients (63 vs. 61 years), and their patients tended to be sicker, with less minor disease severity (31% vs. 35%) and more major (29% vs. 17%) and extreme disease severity (8% vs. 6%).

Colorectal surgeons treated significantly more patients with inflammatory bowel disease (10% vs. 4%). They worked exclusively in urban hospitals, compared with 87% of general surgeons. Half of colorectal surgeons worked in teaching hospitals versus 37% of general surgeons.

The mean overall length of stay was a little more than 8 days. The mean hospital cost was $19,093.The overall complication rate was 29%, and mortality was 1.5%.

Complications varied significantly by surgeon specialty. General surgeons had significantly higher rates of digestive complications (including anastomotic problems), as well as pulmonary complications, lower-extremity thromboembolism, shock, and surgical site infections, including intra-abdominal infections.

The univariate analysis identified several patient characteristics significantly associated with poor outcomes, including age older than 62 years (odds ratio, 1.43), female gender (OR, 1.23), major disease severity (OR, 4.7), extreme disease severity (OR, 23), and a diagnosis of inflammatory bowel disease (OR, 1.41).

Other significant risk factors were being treated in a rural hospital (OR 1.29), being treated in a teaching hospital (OR, 1.08), and having a general surgeon (OR, 1.16). Having a colorectal surgeon decreased the risk of a poor outcome by 14%.

In the multivariate analysis, patients of general surgeons were 13% less likely to have any complication and 20% less likely to have ileus. But these patients were also significantly more likely to have severe complications, including pulmonary problems (13%) and surgical site infections (11%).

The length of stay was about 1 day longer, and hospitals costs were $1,122 more expensive. Patients of general surgeons were 42% more likely to die.

Dr. Casasanta said he had no relevant financial disclosures. However, Dr. Eric Haas, the primary investigator, said he has been a consultant for Applied Medical; and has received consulting fees, research funding, and honoraria from Intuitive Surgical.

msullivan@frontlinemedcom.com

WASHINGTON – Although general surgeons perform the majority of rectal resections in the United States, their patients have more severe postoperative complications, longer lengths of stay, higher hospital costs, and higher mortality rates than do those of colorectal surgeons.

A review of more than 60,000 cases over a 6-year period found that patients who had been operated on by a general surgeon had a 42% increase in the risk of mortality. They stayed in the hospital an average 1 day longer than the patients of colorectal surgeons, and had bills more than $1,000 higher. Although their overall complication rate was lower, general surgeons’ patients tended to have more severe complications, including pulmonary complications and surgical site infections, Dr. Marc Casasanta said at the annual clinical congress of the American College of Surgeons.

Dr. Casasanta of the University of Texas, Houston, extracted his data from the Premier Perspective database, the largest inpatient database in the United States. His analysis included 60,412 nonemergent rectal resections performed from 2005 to 2011.

Most of these (74%) were performed by general surgeons, with colorectal surgeons performing the remainder. Adverse outcomes examined included length and cost of hospital admission, overall complications and severe complications, and mortality.

There were several significant differences in the patient populations. General surgeons had older patients (63 vs. 61 years), and their patients tended to be sicker, with less minor disease severity (31% vs. 35%) and more major (29% vs. 17%) and extreme disease severity (8% vs. 6%).

Colorectal surgeons treated significantly more patients with inflammatory bowel disease (10% vs. 4%). They worked exclusively in urban hospitals, compared with 87% of general surgeons. Half of colorectal surgeons worked in teaching hospitals versus 37% of general surgeons.

The mean overall length of stay was a little more than 8 days. The mean hospital cost was $19,093.The overall complication rate was 29%, and mortality was 1.5%.

Complications varied significantly by surgeon specialty. General surgeons had significantly higher rates of digestive complications (including anastomotic problems), as well as pulmonary complications, lower-extremity thromboembolism, shock, and surgical site infections, including intra-abdominal infections.

The univariate analysis identified several patient characteristics significantly associated with poor outcomes, including age older than 62 years (odds ratio, 1.43), female gender (OR, 1.23), major disease severity (OR, 4.7), extreme disease severity (OR, 23), and a diagnosis of inflammatory bowel disease (OR, 1.41).

Other significant risk factors were being treated in a rural hospital (OR 1.29), being treated in a teaching hospital (OR, 1.08), and having a general surgeon (OR, 1.16). Having a colorectal surgeon decreased the risk of a poor outcome by 14%.

In the multivariate analysis, patients of general surgeons were 13% less likely to have any complication and 20% less likely to have ileus. But these patients were also significantly more likely to have severe complications, including pulmonary problems (13%) and surgical site infections (11%).

The length of stay was about 1 day longer, and hospitals costs were $1,122 more expensive. Patients of general surgeons were 42% more likely to die.

Dr. Casasanta said he had no relevant financial disclosures. However, Dr. Eric Haas, the primary investigator, said he has been a consultant for Applied Medical; and has received consulting fees, research funding, and honoraria from Intuitive Surgical.

msullivan@frontlinemedcom.com

WASHINGTON – Although general surgeons perform the majority of rectal resections in the United States, their patients have more severe postoperative complications, longer lengths of stay, higher hospital costs, and higher mortality rates than do those of colorectal surgeons.

A review of more than 60,000 cases over a 6-year period found that patients who had been operated on by a general surgeon had a 42% increase in the risk of mortality. They stayed in the hospital an average 1 day longer than the patients of colorectal surgeons, and had bills more than $1,000 higher. Although their overall complication rate was lower, general surgeons’ patients tended to have more severe complications, including pulmonary complications and surgical site infections, Dr. Marc Casasanta said at the annual clinical congress of the American College of Surgeons.

Dr. Casasanta of the University of Texas, Houston, extracted his data from the Premier Perspective database, the largest inpatient database in the United States. His analysis included 60,412 nonemergent rectal resections performed from 2005 to 2011.

Most of these (74%) were performed by general surgeons, with colorectal surgeons performing the remainder. Adverse outcomes examined included length and cost of hospital admission, overall complications and severe complications, and mortality.

There were several significant differences in the patient populations. General surgeons had older patients (63 vs. 61 years), and their patients tended to be sicker, with less minor disease severity (31% vs. 35%) and more major (29% vs. 17%) and extreme disease severity (8% vs. 6%).

Colorectal surgeons treated significantly more patients with inflammatory bowel disease (10% vs. 4%). They worked exclusively in urban hospitals, compared with 87% of general surgeons. Half of colorectal surgeons worked in teaching hospitals versus 37% of general surgeons.

The mean overall length of stay was a little more than 8 days. The mean hospital cost was $19,093.The overall complication rate was 29%, and mortality was 1.5%.

Complications varied significantly by surgeon specialty. General surgeons had significantly higher rates of digestive complications (including anastomotic problems), as well as pulmonary complications, lower-extremity thromboembolism, shock, and surgical site infections, including intra-abdominal infections.

The univariate analysis identified several patient characteristics significantly associated with poor outcomes, including age older than 62 years (odds ratio, 1.43), female gender (OR, 1.23), major disease severity (OR, 4.7), extreme disease severity (OR, 23), and a diagnosis of inflammatory bowel disease (OR, 1.41).

Other significant risk factors were being treated in a rural hospital (OR 1.29), being treated in a teaching hospital (OR, 1.08), and having a general surgeon (OR, 1.16). Having a colorectal surgeon decreased the risk of a poor outcome by 14%.

In the multivariate analysis, patients of general surgeons were 13% less likely to have any complication and 20% less likely to have ileus. But these patients were also significantly more likely to have severe complications, including pulmonary problems (13%) and surgical site infections (11%).

The length of stay was about 1 day longer, and hospitals costs were $1,122 more expensive. Patients of general surgeons were 42% more likely to die.

Dr. Casasanta said he had no relevant financial disclosures. However, Dr. Eric Haas, the primary investigator, said he has been a consultant for Applied Medical; and has received consulting fees, research funding, and honoraria from Intuitive Surgical.

msullivan@frontlinemedcom.com

WASHINGTON – Colon cancer screening with sigmoidoscopy alone could miss up to 50% of colon polyps in older patients.

As people age, polyps seem to develop more and more proximally, Dr. Victor Tsirline said at the annual clinical congress of the American College of Surgeons. His review of more than 120,000 colonoscopies found that a flexible sigmoidoscopy alone could miss 44% of polyps in patients aged 60-69 years and 50% in those aged 70-79 years.

"We found that proximal colon polyps are more frequent with advanced age than previously considered," said Dr. Tsirline of Carolinas Medical Center, Charlotte, N.C. "So if this is true, what happens if we use sigmoidoscopy instead of colonoscopy? If we had, we would have missed 22,800 polyps, and 16,800 of those would have been adenomatous. In [patients 59 and younger] 32%-36% would be missed and in the older patients, 45%-50%."

Dr. Tsirline obtained his data from the Provation MD endoscopy transcription system. He obtained information on 120,365 colonoscopies that were performed from 2003 to 2011.

He cross-referenced this with CoPathPlus, a pathology reporting system. This allowed him to cross-reference polyp pathology (adenoma vs. hyperplasia) by computer algorithm. There was complete information available on 43,833 polyps.

Because of the large sample size, he set his level of statistical significance at P = less than 0.01.

The patients in the study were aged 20-90 years. Of the entire group of procedures, 53,492 colonoscopies (44%) identified polyps. Most studies (64%) found a single polyp; 25% found two, and 11% found three or more. A subset of the colonoscopies was only for average risk screening (44,806). Of these, 46% identified polyps.

Overall, 48% of polyps were adenomatous; 37% were hyperplastic. Pathology was not available for the remainder.

The polyps were fairly evenly distributed throughout the colon: rectum, 18%; sigmoid, 26%; descending, 14%; transverse, 16%; ascending, 15%; cecum, 11%.

However, when broken down by patient age, the distribution changed significantly. With every advancing decade of life, patients were:

• 22% less likely to have polyps in the rectum or sigmoid.

• 7% more likely to have polyps in the descending colon.

• 19% more likely to have polyps in the transverse colon.

• 30% more likely to have polyps in the ascending colon.

• 22% more likely to have polyps in the cecum.

All of these risks were statistically significant, and they held for both adenomatous and hyperplastic polyps.

The findings led Dr. Tsirline to conclude that flexible sigmoidoscopy should not be relied upon as an effective colon cancer screening method in patients older than 60 years. The U.S. Preventive Services Task Force states that sigmoidoscopy every 5 years combined with high-sensitivity fecal occult blood testing every 3 years is an adequate screening alternative.

"From this study, it’s pretty apparent that sigmoidoscopy should not be used for colon cancer screening in older patients," he said.

During a discussion, Dr. Tsirline fielded a question about screening the very elderly – patients in their 80s and 90s. The study group did include a small number of these patients, he said.

"I think the argument for not screening older individuals is based on the question of whether finding a colon cancer would change anything. Most people think the risks of screening and treatment would outweigh the benefits. Yes, you may find anything, but what are you going to do about it?"

Dr. Tsirline had no financial disclosures.

msullivan@frontlinemedcom.com

WASHINGTON – Colon cancer screening with sigmoidoscopy alone could miss up to 50% of colon polyps in older patients.

As people age, polyps seem to develop more and more proximally, Dr. Victor Tsirline said at the annual clinical congress of the American College of Surgeons. His review of more than 120,000 colonoscopies found that a flexible sigmoidoscopy alone could miss 44% of polyps in patients aged 60-69 years and 50% in those aged 70-79 years.

"We found that proximal colon polyps are more frequent with advanced age than previously considered," said Dr. Tsirline of Carolinas Medical Center, Charlotte, N.C. "So if this is true, what happens if we use sigmoidoscopy instead of colonoscopy? If we had, we would have missed 22,800 polyps, and 16,800 of those would have been adenomatous. In [patients 59 and younger] 32%-36% would be missed and in the older patients, 45%-50%."

Dr. Tsirline obtained his data from the Provation MD endoscopy transcription system. He obtained information on 120,365 colonoscopies that were performed from 2003 to 2011.

He cross-referenced this with CoPathPlus, a pathology reporting system. This allowed him to cross-reference polyp pathology (adenoma vs. hyperplasia) by computer algorithm. There was complete information available on 43,833 polyps.

Because of the large sample size, he set his level of statistical significance at P = less than 0.01.

The patients in the study were aged 20-90 years. Of the entire group of procedures, 53,492 colonoscopies (44%) identified polyps. Most studies (64%) found a single polyp; 25% found two, and 11% found three or more. A subset of the colonoscopies was only for average risk screening (44,806). Of these, 46% identified polyps.

Overall, 48% of polyps were adenomatous; 37% were hyperplastic. Pathology was not available for the remainder.

The polyps were fairly evenly distributed throughout the colon: rectum, 18%; sigmoid, 26%; descending, 14%; transverse, 16%; ascending, 15%; cecum, 11%.

However, when broken down by patient age, the distribution changed significantly. With every advancing decade of life, patients were:

• 22% less likely to have polyps in the rectum or sigmoid.

• 7% more likely to have polyps in the descending colon.

• 19% more likely to have polyps in the transverse colon.

• 30% more likely to have polyps in the ascending colon.

• 22% more likely to have polyps in the cecum.

All of these risks were statistically significant, and they held for both adenomatous and hyperplastic polyps.

The findings led Dr. Tsirline to conclude that flexible sigmoidoscopy should not be relied upon as an effective colon cancer screening method in patients older than 60 years. The U.S. Preventive Services Task Force states that sigmoidoscopy every 5 years combined with high-sensitivity fecal occult blood testing every 3 years is an adequate screening alternative.

"From this study, it’s pretty apparent that sigmoidoscopy should not be used for colon cancer screening in older patients," he said.

During a discussion, Dr. Tsirline fielded a question about screening the very elderly – patients in their 80s and 90s. The study group did include a small number of these patients, he said.

"I think the argument for not screening older individuals is based on the question of whether finding a colon cancer would change anything. Most people think the risks of screening and treatment would outweigh the benefits. Yes, you may find anything, but what are you going to do about it?"

Dr. Tsirline had no financial disclosures.

msullivan@frontlinemedcom.com

WASHINGTON – Colon cancer screening with sigmoidoscopy alone could miss up to 50% of colon polyps in older patients.

As people age, polyps seem to develop more and more proximally, Dr. Victor Tsirline said at the annual clinical congress of the American College of Surgeons. His review of more than 120,000 colonoscopies found that a flexible sigmoidoscopy alone could miss 44% of polyps in patients aged 60-69 years and 50% in those aged 70-79 years.

"We found that proximal colon polyps are more frequent with advanced age than previously considered," said Dr. Tsirline of Carolinas Medical Center, Charlotte, N.C. "So if this is true, what happens if we use sigmoidoscopy instead of colonoscopy? If we had, we would have missed 22,800 polyps, and 16,800 of those would have been adenomatous. In [patients 59 and younger] 32%-36% would be missed and in the older patients, 45%-50%."

Dr. Tsirline obtained his data from the Provation MD endoscopy transcription system. He obtained information on 120,365 colonoscopies that were performed from 2003 to 2011.

He cross-referenced this with CoPathPlus, a pathology reporting system. This allowed him to cross-reference polyp pathology (adenoma vs. hyperplasia) by computer algorithm. There was complete information available on 43,833 polyps.

Because of the large sample size, he set his level of statistical significance at P = less than 0.01.

The patients in the study were aged 20-90 years. Of the entire group of procedures, 53,492 colonoscopies (44%) identified polyps. Most studies (64%) found a single polyp; 25% found two, and 11% found three or more. A subset of the colonoscopies was only for average risk screening (44,806). Of these, 46% identified polyps.

Overall, 48% of polyps were adenomatous; 37% were hyperplastic. Pathology was not available for the remainder.

The polyps were fairly evenly distributed throughout the colon: rectum, 18%; sigmoid, 26%; descending, 14%; transverse, 16%; ascending, 15%; cecum, 11%.

However, when broken down by patient age, the distribution changed significantly. With every advancing decade of life, patients were:

• 22% less likely to have polyps in the rectum or sigmoid.

• 7% more likely to have polyps in the descending colon.

• 19% more likely to have polyps in the transverse colon.

• 30% more likely to have polyps in the ascending colon.

• 22% more likely to have polyps in the cecum.

All of these risks were statistically significant, and they held for both adenomatous and hyperplastic polyps.

The findings led Dr. Tsirline to conclude that flexible sigmoidoscopy should not be relied upon as an effective colon cancer screening method in patients older than 60 years. The U.S. Preventive Services Task Force states that sigmoidoscopy every 5 years combined with high-sensitivity fecal occult blood testing every 3 years is an adequate screening alternative.

"From this study, it’s pretty apparent that sigmoidoscopy should not be used for colon cancer screening in older patients," he said.

During a discussion, Dr. Tsirline fielded a question about screening the very elderly – patients in their 80s and 90s. The study group did include a small number of these patients, he said.

"I think the argument for not screening older individuals is based on the question of whether finding a colon cancer would change anything. Most people think the risks of screening and treatment would outweigh the benefits. Yes, you may find anything, but what are you going to do about it?"

Dr. Tsirline had no financial disclosures.

msullivan@frontlinemedcom.com

WASHINGTON – Delays in esophageal cancer surgery after a course of neoadjuvant chemotherapy and radiation were associated with more surgical complications and worse survival, based on the results of a retrospective study presented at the annual clinical congress of the American College of Surgeons.

Clinicians should focus on "prehabilitating" their patients, completing their neoadjuvant therapy and recommending esophagectomy as soon as clinically feasible, Dr. Nicholas Teman said.

Dr. Teman and his colleagues at the University of Michigan, Ann Arbor, reviewed prospectively collected data from the period of 1999-2010 on 457 patients treated at a single site. All patients underwent neoadjuvant chemotherapy and radiation with a subsequent esophagectomy; patients who underwent salvage esophagectomies were excluded from the analysis.

Outcome measures included postoperative pulmonary adverse events, anastomotic leaks, pathologic response, and mortality.

The mean time to surgery after chemotherapy and radiation was 50 days, ranging between 10 and 523 days. The most common reasons for surgical delays were patient deconditioning, noncompliance, seeking a second opinion, and complications stemming from neoadjuvant therapies.

When the time from completion of neoadjuvant therapy to surgery was analyzed as a continuous variable, there were no differences in postoperative complications and mortality. Similarly, postoperative staging and pathologic response were not significantly different.

Additionally, outcomes did not significantly differ for those who had surgery within 8 weeks of completing chemotherapy and radiation and those who had surgery after 8 weeks.

However, when time to surgery was used to place patients into quintiles of 8 weeks or less (n = 345), 9-12 weeks (n = 58), 13-16 weeks (n = 27), 17-26 weeks (n = 19), and 27 or more weeks (n = 8), there were significant differences in pulmonary complications (P = .05) and anastomotic leaks (P = .02), and a trend toward worse mortality between the quintiles (P = .09). No significant differences in pathologic response were noted in the quintiles.

Predictors of higher long-term mortality were lower pretreatment weight (P = .04), tobacco use (P = .05), higher pretreatment stage (P = .004), and failure to complete neoadjuvant treatment (P = .003).

One limitation of the study was that the neoadjuvant therapies were not standardized. A shorter time to surgery was predicted if chemotherapy included cisplatin (P = .04) or taxol (P = .001), and if there were increasing chemotherapy cycles. Chemotherapy that included 5-flourouracil was associated with longer times to surgery (P less than .001).

Dr. Teman and his associates reported no relevant disclosures.

wmcknight@frontlinemedcom.com

WASHINGTON – Delays in esophageal cancer surgery after a course of neoadjuvant chemotherapy and radiation were associated with more surgical complications and worse survival, based on the results of a retrospective study presented at the annual clinical congress of the American College of Surgeons.

Clinicians should focus on "prehabilitating" their patients, completing their neoadjuvant therapy and recommending esophagectomy as soon as clinically feasible, Dr. Nicholas Teman said.

Dr. Teman and his colleagues at the University of Michigan, Ann Arbor, reviewed prospectively collected data from the period of 1999-2010 on 457 patients treated at a single site. All patients underwent neoadjuvant chemotherapy and radiation with a subsequent esophagectomy; patients who underwent salvage esophagectomies were excluded from the analysis.

Outcome measures included postoperative pulmonary adverse events, anastomotic leaks, pathologic response, and mortality.

The mean time to surgery after chemotherapy and radiation was 50 days, ranging between 10 and 523 days. The most common reasons for surgical delays were patient deconditioning, noncompliance, seeking a second opinion, and complications stemming from neoadjuvant therapies.

When the time from completion of neoadjuvant therapy to surgery was analyzed as a continuous variable, there were no differences in postoperative complications and mortality. Similarly, postoperative staging and pathologic response were not significantly different.

Additionally, outcomes did not significantly differ for those who had surgery within 8 weeks of completing chemotherapy and radiation and those who had surgery after 8 weeks.

However, when time to surgery was used to place patients into quintiles of 8 weeks or less (n = 345), 9-12 weeks (n = 58), 13-16 weeks (n = 27), 17-26 weeks (n = 19), and 27 or more weeks (n = 8), there were significant differences in pulmonary complications (P = .05) and anastomotic leaks (P = .02), and a trend toward worse mortality between the quintiles (P = .09). No significant differences in pathologic response were noted in the quintiles.

Predictors of higher long-term mortality were lower pretreatment weight (P = .04), tobacco use (P = .05), higher pretreatment stage (P = .004), and failure to complete neoadjuvant treatment (P = .003).

One limitation of the study was that the neoadjuvant therapies were not standardized. A shorter time to surgery was predicted if chemotherapy included cisplatin (P = .04) or taxol (P = .001), and if there were increasing chemotherapy cycles. Chemotherapy that included 5-flourouracil was associated with longer times to surgery (P less than .001).

Dr. Teman and his associates reported no relevant disclosures.

wmcknight@frontlinemedcom.com

WASHINGTON – Delays in esophageal cancer surgery after a course of neoadjuvant chemotherapy and radiation were associated with more surgical complications and worse survival, based on the results of a retrospective study presented at the annual clinical congress of the American College of Surgeons.

Clinicians should focus on "prehabilitating" their patients, completing their neoadjuvant therapy and recommending esophagectomy as soon as clinically feasible, Dr. Nicholas Teman said.

Dr. Teman and his colleagues at the University of Michigan, Ann Arbor, reviewed prospectively collected data from the period of 1999-2010 on 457 patients treated at a single site. All patients underwent neoadjuvant chemotherapy and radiation with a subsequent esophagectomy; patients who underwent salvage esophagectomies were excluded from the analysis.

Outcome measures included postoperative pulmonary adverse events, anastomotic leaks, pathologic response, and mortality.

The mean time to surgery after chemotherapy and radiation was 50 days, ranging between 10 and 523 days. The most common reasons for surgical delays were patient deconditioning, noncompliance, seeking a second opinion, and complications stemming from neoadjuvant therapies.

When the time from completion of neoadjuvant therapy to surgery was analyzed as a continuous variable, there were no differences in postoperative complications and mortality. Similarly, postoperative staging and pathologic response were not significantly different.

Additionally, outcomes did not significantly differ for those who had surgery within 8 weeks of completing chemotherapy and radiation and those who had surgery after 8 weeks.

However, when time to surgery was used to place patients into quintiles of 8 weeks or less (n = 345), 9-12 weeks (n = 58), 13-16 weeks (n = 27), 17-26 weeks (n = 19), and 27 or more weeks (n = 8), there were significant differences in pulmonary complications (P = .05) and anastomotic leaks (P = .02), and a trend toward worse mortality between the quintiles (P = .09). No significant differences in pathologic response were noted in the quintiles.

Predictors of higher long-term mortality were lower pretreatment weight (P = .04), tobacco use (P = .05), higher pretreatment stage (P = .004), and failure to complete neoadjuvant treatment (P = .003).

One limitation of the study was that the neoadjuvant therapies were not standardized. A shorter time to surgery was predicted if chemotherapy included cisplatin (P = .04) or taxol (P = .001), and if there were increasing chemotherapy cycles. Chemotherapy that included 5-flourouracil was associated with longer times to surgery (P less than .001).

Dr. Teman and his associates reported no relevant disclosures.

wmcknight@frontlinemedcom.com

WASHINGTON – Despite better excess weight loss outcomes from the biliopancreatic diversion with duodenal switch, the Roux-en-Y gastric bypass procedure was associated with better nutritional outcomes in the superobese, according to the results of a prospective cohort study presented at this year’s American College of Surgeons Clinical Congress.

Investigators retrospectively analyzed data collected prospectively from 350 consecutive superobese patients, who underwent either biliopancreatic diversion with duodenal switch (BPD/DS; n = 198) or Roux-en-Y gastric bypass surgery (RYGB; n = 152), and compared long-term nutritional outcomes in each cohort. The research was conducted by Dr. Marc Ward and his colleagues at the University of Chicago, who presented the results.

The cohorts were self-selected and equally distributed across the sexes; each group’s mean age was just under 41 years. The mean body mass index (BMI) in the BPD/DS group was 59 kg/m² and was 56 kg/m² in RYGB. The preoperative body weight in the BPD/DS group was higher than that in the RYGB group (range, 267 lbs to 597 lbs. vs. 240 lbs to 505 lbs, respectively).

Although the BPD/DS had higher morbidity and mortality rates than did the RYGB, as well as more complications, such as altered bowel habits, the BPD/DS is associated with better comorbidity resolution independent of weight loss, and up to 20% greater excess weight loss in superobese patients. Superobesity is defined as having a BMI of 50 kg/m² and above.

Because the reduction in intestinal absorptive surface area in BPD/DS is greater than in RYGB, the researchers theorized that the resultant nutritional deficiencies might be clinically significant enough to consider when counseling patients on procedure selection.

At seven postoperative follow-up points between 6 months and 8 years, the investigators obtained a variety of nutritional parameters from each group. Patients were given nutritional supplementation as clinically indicated.

Dr. Ward said that while he and his colleagues expected the BPD/DS group to have lower nutritional values, "We didn’t expect that 75% of our patients would have, at 4 years out, a below-normal level of vitamin A, compared to 23% in the RYGB patients."

There were similar surprises for other nutritional markers: At all time points, the BPD/DS group also had significantly more nutritional deficiencies than did the RYGB group in fat-soluble vitamins D and E, and in minerals selenium and zinc. Between years 1 and 3, iron values were near parity at about 20%, although the BPD/DS group was still more deficient, and at year 8 had more than double the rate of iron deficiency as RYGB patients.

Values for albumin, vitamin B₁₂, ferritin, folate, and parathyroid hormone, however, were not significantly different between the two groups. Dr. Ward said that low nutritional values in patients, "does not necessarily mean they are developing symptoms or can’t be treated with supplementation."

Only one RYGB patient underwent revision because of insufficient weight loss, whereas five BPD/DS patients underwent revision, all for malnutrition.

"It’s absolutely crucial for people who elect to have a duodenal switch operation to have long-term, life-long nutritional follow-up," Dr. Ward told the audience. He also said that clinicians should closely evaluate their patients’ level of commitment to compliance over the long-term when discussing bariatric procedures.

wmcknight@frontlinemedcom.com

WASHINGTON – Despite better excess weight loss outcomes from the biliopancreatic diversion with duodenal switch, the Roux-en-Y gastric bypass procedure was associated with better nutritional outcomes in the superobese, according to the results of a prospective cohort study presented at this year’s American College of Surgeons Clinical Congress.

Investigators retrospectively analyzed data collected prospectively from 350 consecutive superobese patients, who underwent either biliopancreatic diversion with duodenal switch (BPD/DS; n = 198) or Roux-en-Y gastric bypass surgery (RYGB; n = 152), and compared long-term nutritional outcomes in each cohort. The research was conducted by Dr. Marc Ward and his colleagues at the University of Chicago, who presented the results.

The cohorts were self-selected and equally distributed across the sexes; each group’s mean age was just under 41 years. The mean body mass index (BMI) in the BPD/DS group was 59 kg/m² and was 56 kg/m² in RYGB. The preoperative body weight in the BPD/DS group was higher than that in the RYGB group (range, 267 lbs to 597 lbs. vs. 240 lbs to 505 lbs, respectively).

Although the BPD/DS had higher morbidity and mortality rates than did the RYGB, as well as more complications, such as altered bowel habits, the BPD/DS is associated with better comorbidity resolution independent of weight loss, and up to 20% greater excess weight loss in superobese patients. Superobesity is defined as having a BMI of 50 kg/m² and above.

Because the reduction in intestinal absorptive surface area in BPD/DS is greater than in RYGB, the researchers theorized that the resultant nutritional deficiencies might be clinically significant enough to consider when counseling patients on procedure selection.

At seven postoperative follow-up points between 6 months and 8 years, the investigators obtained a variety of nutritional parameters from each group. Patients were given nutritional supplementation as clinically indicated.

Dr. Ward said that while he and his colleagues expected the BPD/DS group to have lower nutritional values, "We didn’t expect that 75% of our patients would have, at 4 years out, a below-normal level of vitamin A, compared to 23% in the RYGB patients."

There were similar surprises for other nutritional markers: At all time points, the BPD/DS group also had significantly more nutritional deficiencies than did the RYGB group in fat-soluble vitamins D and E, and in minerals selenium and zinc. Between years 1 and 3, iron values were near parity at about 20%, although the BPD/DS group was still more deficient, and at year 8 had more than double the rate of iron deficiency as RYGB patients.

Values for albumin, vitamin B₁₂, ferritin, folate, and parathyroid hormone, however, were not significantly different between the two groups. Dr. Ward said that low nutritional values in patients, "does not necessarily mean they are developing symptoms or can’t be treated with supplementation."

Only one RYGB patient underwent revision because of insufficient weight loss, whereas five BPD/DS patients underwent revision, all for malnutrition.

"It’s absolutely crucial for people who elect to have a duodenal switch operation to have long-term, life-long nutritional follow-up," Dr. Ward told the audience. He also said that clinicians should closely evaluate their patients’ level of commitment to compliance over the long-term when discussing bariatric procedures.

wmcknight@frontlinemedcom.com

WASHINGTON – Despite better excess weight loss outcomes from the biliopancreatic diversion with duodenal switch, the Roux-en-Y gastric bypass procedure was associated with better nutritional outcomes in the superobese, according to the results of a prospective cohort study presented at this year’s American College of Surgeons Clinical Congress.

Investigators retrospectively analyzed data collected prospectively from 350 consecutive superobese patients, who underwent either biliopancreatic diversion with duodenal switch (BPD/DS; n = 198) or Roux-en-Y gastric bypass surgery (RYGB; n = 152), and compared long-term nutritional outcomes in each cohort. The research was conducted by Dr. Marc Ward and his colleagues at the University of Chicago, who presented the results.

The cohorts were self-selected and equally distributed across the sexes; each group’s mean age was just under 41 years. The mean body mass index (BMI) in the BPD/DS group was 59 kg/m² and was 56 kg/m² in RYGB. The preoperative body weight in the BPD/DS group was higher than that in the RYGB group (range, 267 lbs to 597 lbs. vs. 240 lbs to 505 lbs, respectively).

Although the BPD/DS had higher morbidity and mortality rates than did the RYGB, as well as more complications, such as altered bowel habits, the BPD/DS is associated with better comorbidity resolution independent of weight loss, and up to 20% greater excess weight loss in superobese patients. Superobesity is defined as having a BMI of 50 kg/m² and above.

Because the reduction in intestinal absorptive surface area in BPD/DS is greater than in RYGB, the researchers theorized that the resultant nutritional deficiencies might be clinically significant enough to consider when counseling patients on procedure selection.

At seven postoperative follow-up points between 6 months and 8 years, the investigators obtained a variety of nutritional parameters from each group. Patients were given nutritional supplementation as clinically indicated.

Dr. Ward said that while he and his colleagues expected the BPD/DS group to have lower nutritional values, "We didn’t expect that 75% of our patients would have, at 4 years out, a below-normal level of vitamin A, compared to 23% in the RYGB patients."

There were similar surprises for other nutritional markers: At all time points, the BPD/DS group also had significantly more nutritional deficiencies than did the RYGB group in fat-soluble vitamins D and E, and in minerals selenium and zinc. Between years 1 and 3, iron values were near parity at about 20%, although the BPD/DS group was still more deficient, and at year 8 had more than double the rate of iron deficiency as RYGB patients.

Values for albumin, vitamin B₁₂, ferritin, folate, and parathyroid hormone, however, were not significantly different between the two groups. Dr. Ward said that low nutritional values in patients, "does not necessarily mean they are developing symptoms or can’t be treated with supplementation."

Only one RYGB patient underwent revision because of insufficient weight loss, whereas five BPD/DS patients underwent revision, all for malnutrition.

"It’s absolutely crucial for people who elect to have a duodenal switch operation to have long-term, life-long nutritional follow-up," Dr. Ward told the audience. He also said that clinicians should closely evaluate their patients’ level of commitment to compliance over the long-term when discussing bariatric procedures.

wmcknight@frontlinemedcom.com

WASHINGTON – A program to enhance recovery from bowel surgery significantly decreased the incidence rate of both postoperative ileus and 30-day readmission.

Early walking and postoperative alimentation, beginning with three times on postop day 1, drove the improved outcomes, Dr. Terrence Loftus reported at the annual clinical congress of the American College of Surgeons.

His 3-year retrospective study compared outcomes before and after the program was implemented. In addition to confirming the benefits, the study says something about how change becomes part of a systemwide culture, said Dr. Loftus, medical director of surgical services and clinical resources for Banner Health, Phoenix.

"When you see a before-and-after picture, it gives you the sense that change is like clicking on a light switch, and then everything starts happening. In reality, it’s not. It’s something that catches on over time. It’s a social process that gets passed along. It’s not Dr. Loftus coming in and showing a few slides and saying, ‘Okay, now this is what you have to do.’ It’s surgeons having conversations in the lounge and saying, ‘I tried this and it worked. You should try it too.’ "

In 2010, Banner Health System’s Surgery Clinical Consensus Group decided to tackle the system’s less-than-stellar rates of postoperative ileus and readmission among patients who had bowel surgery.

While there are a number of published enhanced-care pathways, Dr. Loftus found a wide variety of applications over Banner Health’s large medical system. "In some places, people didn’t even know about them, and in others they were using their own version," he said. "We needed a systemwide approach to recovery – something that would be useful over a large, heterogeneous health care system."

The Banner consensus group came up with the Bowel Surgery Strategic Initiative, a program implemented in 19 hospitals spread over six states, covered by 119 surgeons. The system was widely diversified, including everything from an 18-bed critical access unit to a large 600-bed level I trauma center.

Michele G. Sullivan/IMNG Medical Media

"The surgeons ranged from solo private practice, to group practices, hospital employed, and locum tenens, so you can begin to understand the wide diversity of practices and environments we were trying to implement this in," Dr. Loftus said.

The first step was to develop a literature-based GI care pathway that could be widely implemented. The group’s first version had 80 steps – vastly too many.

The final program was based on just two drivers: early alimentation and early ambulation. Eating began with the earliest possible removal of the nasogastric tube (if present), 200-250 cc of oral intake on postoperative day 1, and a progressively advancing diet. Ambulation started with getting up and walking three times on postop day 1, with progressively increasing physical activity.

The team studied a 3-year period spanning 18 months on either side of the implementation date of July 2011. The analysis included 5,000 patients who had undergone elective small- or large-bowel surgery during that time period.

Dr. Loftus said there was a significant increase in both ambulation and alimentation. Before the program, the mean ambulation rate was 53%; that increased to 73% afterward. Alimentation increased from 51% to 71%. The composite of both drivers increased from 53% to 72%.

There were associated improvements in most of the clinical outcomes assessed. Overall, the complication rate decreased significantly, from 36% to 29%. Gastrointestinal complications fell from 27% to 21%, with the incidence of postoperative ileus declining from 27% to 21%. Pulmonary complications also decreased significantly, from 8% to 5.6%.

Thirty-day readmission declined from 14% to 12% – also a significant decrease. This was expected, Dr. Loftus said, because most of the readmissions were due to paralytic ileus.

Length of stay, however, was not significantly affected. There was no change in mortality.

The project also illuminated the importance of a facility’s own professional culture. Chart audits found that some facilities were only ambulating patients about a third of the time that it was ordered – even though nursing estimated the rate at 80% and surgeons at 70%.

Facilities that had particularly good postintervention outcomes were already ahead of the game before the project. "These already had a culture of activity. Nursing was getting patients up on day 1, and they set up their schedules in a way that says, ‘These patients will get up. We are going to do this no matter what.’ "

Dr. Loftus had no financial disclosures.

msullivan@frontlinemedcom.com

WASHINGTON – A program to enhance recovery from bowel surgery significantly decreased the incidence rate of both postoperative ileus and 30-day readmission.

Early walking and postoperative alimentation, beginning with three times on postop day 1, drove the improved outcomes, Dr. Terrence Loftus reported at the annual clinical congress of the American College of Surgeons.

His 3-year retrospective study compared outcomes before and after the program was implemented. In addition to confirming the benefits, the study says something about how change becomes part of a systemwide culture, said Dr. Loftus, medical director of surgical services and clinical resources for Banner Health, Phoenix.

"When you see a before-and-after picture, it gives you the sense that change is like clicking on a light switch, and then everything starts happening. In reality, it’s not. It’s something that catches on over time. It’s a social process that gets passed along. It’s not Dr. Loftus coming in and showing a few slides and saying, ‘Okay, now this is what you have to do.’ It’s surgeons having conversations in the lounge and saying, ‘I tried this and it worked. You should try it too.’ "

In 2010, Banner Health System’s Surgery Clinical Consensus Group decided to tackle the system’s less-than-stellar rates of postoperative ileus and readmission among patients who had bowel surgery.

While there are a number of published enhanced-care pathways, Dr. Loftus found a wide variety of applications over Banner Health’s large medical system. "In some places, people didn’t even know about them, and in others they were using their own version," he said. "We needed a systemwide approach to recovery – something that would be useful over a large, heterogeneous health care system."

The Banner consensus group came up with the Bowel Surgery Strategic Initiative, a program implemented in 19 hospitals spread over six states, covered by 119 surgeons. The system was widely diversified, including everything from an 18-bed critical access unit to a large 600-bed level I trauma center.

Michele G. Sullivan/IMNG Medical Media

"The surgeons ranged from solo private practice, to group practices, hospital employed, and locum tenens, so you can begin to understand the wide diversity of practices and environments we were trying to implement this in," Dr. Loftus said.

The first step was to develop a literature-based GI care pathway that could be widely implemented. The group’s first version had 80 steps – vastly too many.

The final program was based on just two drivers: early alimentation and early ambulation. Eating began with the earliest possible removal of the nasogastric tube (if present), 200-250 cc of oral intake on postoperative day 1, and a progressively advancing diet. Ambulation started with getting up and walking three times on postop day 1, with progressively increasing physical activity.

The team studied a 3-year period spanning 18 months on either side of the implementation date of July 2011. The analysis included 5,000 patients who had undergone elective small- or large-bowel surgery during that time period.

Dr. Loftus said there was a significant increase in both ambulation and alimentation. Before the program, the mean ambulation rate was 53%; that increased to 73% afterward. Alimentation increased from 51% to 71%. The composite of both drivers increased from 53% to 72%.

There were associated improvements in most of the clinical outcomes assessed. Overall, the complication rate decreased significantly, from 36% to 29%. Gastrointestinal complications fell from 27% to 21%, with the incidence of postoperative ileus declining from 27% to 21%. Pulmonary complications also decreased significantly, from 8% to 5.6%.

Thirty-day readmission declined from 14% to 12% – also a significant decrease. This was expected, Dr. Loftus said, because most of the readmissions were due to paralytic ileus.

Length of stay, however, was not significantly affected. There was no change in mortality.

The project also illuminated the importance of a facility’s own professional culture. Chart audits found that some facilities were only ambulating patients about a third of the time that it was ordered – even though nursing estimated the rate at 80% and surgeons at 70%.

Facilities that had particularly good postintervention outcomes were already ahead of the game before the project. "These already had a culture of activity. Nursing was getting patients up on day 1, and they set up their schedules in a way that says, ‘These patients will get up. We are going to do this no matter what.’ "

Dr. Loftus had no financial disclosures.

msullivan@frontlinemedcom.com

WASHINGTON – A program to enhance recovery from bowel surgery significantly decreased the incidence rate of both postoperative ileus and 30-day readmission.

Early walking and postoperative alimentation, beginning with three times on postop day 1, drove the improved outcomes, Dr. Terrence Loftus reported at the annual clinical congress of the American College of Surgeons.

His 3-year retrospective study compared outcomes before and after the program was implemented. In addition to confirming the benefits, the study says something about how change becomes part of a systemwide culture, said Dr. Loftus, medical director of surgical services and clinical resources for Banner Health, Phoenix.

"When you see a before-and-after picture, it gives you the sense that change is like clicking on a light switch, and then everything starts happening. In reality, it’s not. It’s something that catches on over time. It’s a social process that gets passed along. It’s not Dr. Loftus coming in and showing a few slides and saying, ‘Okay, now this is what you have to do.’ It’s surgeons having conversations in the lounge and saying, ‘I tried this and it worked. You should try it too.’ "

In 2010, Banner Health System’s Surgery Clinical Consensus Group decided to tackle the system’s less-than-stellar rates of postoperative ileus and readmission among patients who had bowel surgery.

While there are a number of published enhanced-care pathways, Dr. Loftus found a wide variety of applications over Banner Health’s large medical system. "In some places, people didn’t even know about them, and in others they were using their own version," he said. "We needed a systemwide approach to recovery – something that would be useful over a large, heterogeneous health care system."

The Banner consensus group came up with the Bowel Surgery Strategic Initiative, a program implemented in 19 hospitals spread over six states, covered by 119 surgeons. The system was widely diversified, including everything from an 18-bed critical access unit to a large 600-bed level I trauma center.

Michele G. Sullivan/IMNG Medical Media

"The surgeons ranged from solo private practice, to group practices, hospital employed, and locum tenens, so you can begin to understand the wide diversity of practices and environments we were trying to implement this in," Dr. Loftus said.

The first step was to develop a literature-based GI care pathway that could be widely implemented. The group’s first version had 80 steps – vastly too many.

The final program was based on just two drivers: early alimentation and early ambulation. Eating began with the earliest possible removal of the nasogastric tube (if present), 200-250 cc of oral intake on postoperative day 1, and a progressively advancing diet. Ambulation started with getting up and walking three times on postop day 1, with progressively increasing physical activity.

The team studied a 3-year period spanning 18 months on either side of the implementation date of July 2011. The analysis included 5,000 patients who had undergone elective small- or large-bowel surgery during that time period.

Dr. Loftus said there was a significant increase in both ambulation and alimentation. Before the program, the mean ambulation rate was 53%; that increased to 73% afterward. Alimentation increased from 51% to 71%. The composite of both drivers increased from 53% to 72%.

There were associated improvements in most of the clinical outcomes assessed. Overall, the complication rate decreased significantly, from 36% to 29%. Gastrointestinal complications fell from 27% to 21%, with the incidence of postoperative ileus declining from 27% to 21%. Pulmonary complications also decreased significantly, from 8% to 5.6%.

Thirty-day readmission declined from 14% to 12% – also a significant decrease. This was expected, Dr. Loftus said, because most of the readmissions were due to paralytic ileus.

Length of stay, however, was not significantly affected. There was no change in mortality.

The project also illuminated the importance of a facility’s own professional culture. Chart audits found that some facilities were only ambulating patients about a third of the time that it was ordered – even though nursing estimated the rate at 80% and surgeons at 70%.

Facilities that had particularly good postintervention outcomes were already ahead of the game before the project. "These already had a culture of activity. Nursing was getting patients up on day 1, and they set up their schedules in a way that says, ‘These patients will get up. We are going to do this no matter what.’ "

Dr. Loftus had no financial disclosures.

msullivan@frontlinemedcom.com

WASHINGTON – The nonopioid pain reliever alvimopan significantly decreased the incidence of postoperative ileus and shortened hospital stay among bowel surgery patients who took the drug as part of an existing accelerated recovery program.

Compared with patients who took placebo, those who took alvimopan left the hospital about 1 day sooner. In addition to the decrease in ileus, patients experienced a quicker return to normal bowel function, including time to first flatus and first bowel movement, Dr. Robert Moesinger said at the annual clinical congress of the American College of Surgeons.

"Alvimopan augmented the already improved outcomes we had seen with our validated recovery pathway, in both laparoscopic- and open-surgery patients," said Dr. Moesinger of Intermountain Healthcare, Salt Lake City. "Given the very diverse nature of our health care system, with multiple types of hospitals and surgeons, we feel these data are widely applicable and we are very comfortable recommending its routine use for patients having elective bowel surgery."

Dr. Moesinger and his colleagues conducted a randomized, placebo-controlled trial of alvimopan in 248 such patients. Those taking the study drug received 12 mg before surgery; after surgery, they received 12 mg twice a day until discharge.

The primary endpoint was postoperative length of stay. Secondary endpoints included the incidence of postoperative ileus, time to first flatus and first bowel movement, tolerance of solid food, total hospital and pharmacy costs, nasogastric tube reinsertion, 30-day readmission rates, and anastomotic leak.

The patients’ mean age was 61 years. There were no significant differences in any of their baseline demographics or clinical characteristics. Because of a statistical fluke, the placebo group did contain significantly more open-surgery patients than the alvimopan group (34% vs. 20%). The rest of the patients had laparoscopic surgery. Patients had an average of nine doses of the study drug.

The mean length of stay was 4 days in the alvimopan group and 5 in the placebo group – a significant difference.

There was significantly less postoperative ileus in the alvimopan group (2% vs. 10%). Significantly fewer of those taking the study drug needed a nasogastric tube reinserted (2% vs. 9%). The rates of 30-day readmission, reoperation, and anastomotic leak were similar in both groups. The mean time to first bowel movement was about 1 day sooner in the alvimopan group.

The median hospital cost was $10,832 for the alvimopan group and $11,924 for the placebo group – a significant difference. The median total pharmacy cost was $476 vs. $501; this difference was not significant.

Because Cubist Pharmaceuticals, which makes alvimopan, provided the study drug at no cost, the overall cost analysis cannot be considered complete, Dr. Moesinger noted. However, the pharmacy cost for a similar course of the drug would be $84. Figuring that cost into the total saved for each admission ($1,686) still yielded a net financial benefit of $930 per patient, he said.

Dr. Moesinger had no financial disclosures.

msullivan@frontlinemedcom.com

WASHINGTON – The nonopioid pain reliever alvimopan significantly decreased the incidence of postoperative ileus and shortened hospital stay among bowel surgery patients who took the drug as part of an existing accelerated recovery program.

Compared with patients who took placebo, those who took alvimopan left the hospital about 1 day sooner. In addition to the decrease in ileus, patients experienced a quicker return to normal bowel function, including time to first flatus and first bowel movement, Dr. Robert Moesinger said at the annual clinical congress of the American College of Surgeons.

"Alvimopan augmented the already improved outcomes we had seen with our validated recovery pathway, in both laparoscopic- and open-surgery patients," said Dr. Moesinger of Intermountain Healthcare, Salt Lake City. "Given the very diverse nature of our health care system, with multiple types of hospitals and surgeons, we feel these data are widely applicable and we are very comfortable recommending its routine use for patients having elective bowel surgery."

Dr. Moesinger and his colleagues conducted a randomized, placebo-controlled trial of alvimopan in 248 such patients. Those taking the study drug received 12 mg before surgery; after surgery, they received 12 mg twice a day until discharge.

The primary endpoint was postoperative length of stay. Secondary endpoints included the incidence of postoperative ileus, time to first flatus and first bowel movement, tolerance of solid food, total hospital and pharmacy costs, nasogastric tube reinsertion, 30-day readmission rates, and anastomotic leak.

The patients’ mean age was 61 years. There were no significant differences in any of their baseline demographics or clinical characteristics. Because of a statistical fluke, the placebo group did contain significantly more open-surgery patients than the alvimopan group (34% vs. 20%). The rest of the patients had laparoscopic surgery. Patients had an average of nine doses of the study drug.

The mean length of stay was 4 days in the alvimopan group and 5 in the placebo group – a significant difference.

There was significantly less postoperative ileus in the alvimopan group (2% vs. 10%). Significantly fewer of those taking the study drug needed a nasogastric tube reinserted (2% vs. 9%). The rates of 30-day readmission, reoperation, and anastomotic leak were similar in both groups. The mean time to first bowel movement was about 1 day sooner in the alvimopan group.

The median hospital cost was $10,832 for the alvimopan group and $11,924 for the placebo group – a significant difference. The median total pharmacy cost was $476 vs. $501; this difference was not significant.

Because Cubist Pharmaceuticals, which makes alvimopan, provided the study drug at no cost, the overall cost analysis cannot be considered complete, Dr. Moesinger noted. However, the pharmacy cost for a similar course of the drug would be $84. Figuring that cost into the total saved for each admission ($1,686) still yielded a net financial benefit of $930 per patient, he said.

Dr. Moesinger had no financial disclosures.

msullivan@frontlinemedcom.com

WASHINGTON – The nonopioid pain reliever alvimopan significantly decreased the incidence of postoperative ileus and shortened hospital stay among bowel surgery patients who took the drug as part of an existing accelerated recovery program.

Compared with patients who took placebo, those who took alvimopan left the hospital about 1 day sooner. In addition to the decrease in ileus, patients experienced a quicker return to normal bowel function, including time to first flatus and first bowel movement, Dr. Robert Moesinger said at the annual clinical congress of the American College of Surgeons.

"Alvimopan augmented the already improved outcomes we had seen with our validated recovery pathway, in both laparoscopic- and open-surgery patients," said Dr. Moesinger of Intermountain Healthcare, Salt Lake City. "Given the very diverse nature of our health care system, with multiple types of hospitals and surgeons, we feel these data are widely applicable and we are very comfortable recommending its routine use for patients having elective bowel surgery."

Dr. Moesinger and his colleagues conducted a randomized, placebo-controlled trial of alvimopan in 248 such patients. Those taking the study drug received 12 mg before surgery; after surgery, they received 12 mg twice a day until discharge.

The primary endpoint was postoperative length of stay. Secondary endpoints included the incidence of postoperative ileus, time to first flatus and first bowel movement, tolerance of solid food, total hospital and pharmacy costs, nasogastric tube reinsertion, 30-day readmission rates, and anastomotic leak.

The patients’ mean age was 61 years. There were no significant differences in any of their baseline demographics or clinical characteristics. Because of a statistical fluke, the placebo group did contain significantly more open-surgery patients than the alvimopan group (34% vs. 20%). The rest of the patients had laparoscopic surgery. Patients had an average of nine doses of the study drug.

The mean length of stay was 4 days in the alvimopan group and 5 in the placebo group – a significant difference.

There was significantly less postoperative ileus in the alvimopan group (2% vs. 10%). Significantly fewer of those taking the study drug needed a nasogastric tube reinserted (2% vs. 9%). The rates of 30-day readmission, reoperation, and anastomotic leak were similar in both groups. The mean time to first bowel movement was about 1 day sooner in the alvimopan group.

The median hospital cost was $10,832 for the alvimopan group and $11,924 for the placebo group – a significant difference. The median total pharmacy cost was $476 vs. $501; this difference was not significant.

Because Cubist Pharmaceuticals, which makes alvimopan, provided the study drug at no cost, the overall cost analysis cannot be considered complete, Dr. Moesinger noted. However, the pharmacy cost for a similar course of the drug would be $84. Figuring that cost into the total saved for each admission ($1,686) still yielded a net financial benefit of $930 per patient, he said.

Dr. Moesinger had no financial disclosures.

msullivan@frontlinemedcom.com

WASHINGTON (IMNG) – A British study suggests that it is experience, not specialty, that makes the endoscopist.

The review of more than 2,000 colonoscopies performed in 1 year determined that gastroenterologists and surgeons had identical colonoscopy completion and adverse-event outcomes, Dr. Camille Yvon reported at the annual congress of the American College of Surgeons.

Dr. Yvon, of the Medway Maritime NHS Hospital in Gillingham, England, reported the results of an audit conducted at the Kent facility from March 2011 to March 2012. It was based on prospectively collected data and was designed to compare clinical outcomes among a group of 10 physicians who were performing endoscopies during that time. Included were five consultant colorectal surgeons, one senior trust grade surgeon, and four consultant gastroenterologists.

All of the clinicians were certified by the U.K. Joint Advisory Group on Endoscopy (JAG). The group requires clinicians to complete a mentored training period and to meet specific safety and quality standards, including the following:

• 90% completion rate for colonoscopies (entering the cecum).

• Adenoma detection rate more than 10%.

• Polyp recovery more than 90%.

• Good-quality bowel prep more than 90%.

• Colonoscopy perforation rate less than 1/1,000.

• Postpolypectomy bleeding requiring transfusion less than 1/100.

• Postpolypectomy perforation rate less than 1/500.

• Flexible sigmoidoscopy perforation rate less than 1/5,000.

To become JAG accredited, physicians must be supervised by an accredited physician while performing at least 200 procedures, 100 of which were in the past year; 75% must have been colonoscopies. Certification assessment is done by two different people on two different occasions.

The audit comprised 2,058 colonoscopies. The measured outcomes were number of colonoscopies per clinician, cecal intubation rate of at least 90%, perforation rate of less than 1/1,000, and a less than 1/100 rate of postpolypectomy bleeding requiring a transfusion.

Of the total number of colonoscopies, 1,237 were done by the surgeons and the rest by the gastroenterologists. Clinicians performed an average of 205 procedures per year (range, 105-448 per year). Gastroenterologists performed an average of 205 per year, while surgeons performed an average of 206.

The overall cecal intubation rate was 94%. The average rate for both surgeons and gastroenterologists was also 94%.

There were no perforations during the study period. There were two instances of severe postpolypectomy bleeding (0.09%). However, Dr. Yvon reported, the number was too small for any meaningful statistical analysis.

Dr. Yvon had no financial disclosures.

msullivan@frontlinemedcom.com

WASHINGTON (IMNG) – A British study suggests that it is experience, not specialty, that makes the endoscopist.

The review of more than 2,000 colonoscopies performed in 1 year determined that gastroenterologists and surgeons had identical colonoscopy completion and adverse-event outcomes, Dr. Camille Yvon reported at the annual congress of the American College of Surgeons.

Dr. Yvon, of the Medway Maritime NHS Hospital in Gillingham, England, reported the results of an audit conducted at the Kent facility from March 2011 to March 2012. It was based on prospectively collected data and was designed to compare clinical outcomes among a group of 10 physicians who were performing endoscopies during that time. Included were five consultant colorectal surgeons, one senior trust grade surgeon, and four consultant gastroenterologists.

All of the clinicians were certified by the U.K. Joint Advisory Group on Endoscopy (JAG). The group requires clinicians to complete a mentored training period and to meet specific safety and quality standards, including the following:

• 90% completion rate for colonoscopies (entering the cecum).

• Adenoma detection rate more than 10%.

• Polyp recovery more than 90%.

• Good-quality bowel prep more than 90%.

• Colonoscopy perforation rate less than 1/1,000.

• Postpolypectomy bleeding requiring transfusion less than 1/100.

• Postpolypectomy perforation rate less than 1/500.

• Flexible sigmoidoscopy perforation rate less than 1/5,000.

To become JAG accredited, physicians must be supervised by an accredited physician while performing at least 200 procedures, 100 of which were in the past year; 75% must have been colonoscopies. Certification assessment is done by two different people on two different occasions.

The audit comprised 2,058 colonoscopies. The measured outcomes were number of colonoscopies per clinician, cecal intubation rate of at least 90%, perforation rate of less than 1/1,000, and a less than 1/100 rate of postpolypectomy bleeding requiring a transfusion.

Of the total number of colonoscopies, 1,237 were done by the surgeons and the rest by the gastroenterologists. Clinicians performed an average of 205 procedures per year (range, 105-448 per year). Gastroenterologists performed an average of 205 per year, while surgeons performed an average of 206.

The overall cecal intubation rate was 94%. The average rate for both surgeons and gastroenterologists was also 94%.

There were no perforations during the study period. There were two instances of severe postpolypectomy bleeding (0.09%). However, Dr. Yvon reported, the number was too small for any meaningful statistical analysis.

Dr. Yvon had no financial disclosures.

msullivan@frontlinemedcom.com

WASHINGTON (IMNG) – A British study suggests that it is experience, not specialty, that makes the endoscopist.

The review of more than 2,000 colonoscopies performed in 1 year determined that gastroenterologists and surgeons had identical colonoscopy completion and adverse-event outcomes, Dr. Camille Yvon reported at the annual congress of the American College of Surgeons.

Dr. Yvon, of the Medway Maritime NHS Hospital in Gillingham, England, reported the results of an audit conducted at the Kent facility from March 2011 to March 2012. It was based on prospectively collected data and was designed to compare clinical outcomes among a group of 10 physicians who were performing endoscopies during that time. Included were five consultant colorectal surgeons, one senior trust grade surgeon, and four consultant gastroenterologists.

All of the clinicians were certified by the U.K. Joint Advisory Group on Endoscopy (JAG). The group requires clinicians to complete a mentored training period and to meet specific safety and quality standards, including the following:

• 90% completion rate for colonoscopies (entering the cecum).

• Adenoma detection rate more than 10%.

• Polyp recovery more than 90%.

• Good-quality bowel prep more than 90%.

• Colonoscopy perforation rate less than 1/1,000.

• Postpolypectomy bleeding requiring transfusion less than 1/100.

• Postpolypectomy perforation rate less than 1/500.

• Flexible sigmoidoscopy perforation rate less than 1/5,000.

To become JAG accredited, physicians must be supervised by an accredited physician while performing at least 200 procedures, 100 of which were in the past year; 75% must have been colonoscopies. Certification assessment is done by two different people on two different occasions.

The audit comprised 2,058 colonoscopies. The measured outcomes were number of colonoscopies per clinician, cecal intubation rate of at least 90%, perforation rate of less than 1/1,000, and a less than 1/100 rate of postpolypectomy bleeding requiring a transfusion.

Of the total number of colonoscopies, 1,237 were done by the surgeons and the rest by the gastroenterologists. Clinicians performed an average of 205 procedures per year (range, 105-448 per year). Gastroenterologists performed an average of 205 per year, while surgeons performed an average of 206.

The overall cecal intubation rate was 94%. The average rate for both surgeons and gastroenterologists was also 94%.

There were no perforations during the study period. There were two instances of severe postpolypectomy bleeding (0.09%). However, Dr. Yvon reported, the number was too small for any meaningful statistical analysis.

Dr. Yvon had no financial disclosures.

msullivan@frontlinemedcom.com