JAMA Surgery Online First

Possible Overuse of 3-Stage Procedures for Active Ulcerative Colitis Three-Stage Procedures for Ulcerative Colitis

Hicks CW, Hodin RA, Bordeianou L. — Wed, 22 May 2013 00:00:00 GMT

Importance

There is an assumption that patients treated with 3-stage procedures for active ulcerative colitis are undergoing a safer surgical approach and thus spared the complications associated with a 2-stage procedure. However, there is a paucity of data addressing the validity of this assumption, and the optimal staging approach for patients traditionally considered at high risk for anastomotic leak remains unclear.

Objectives

To identify factors associated with 3- vs 2-stage procedures and to determine their impact on surgical outcomes.

Design

Retrospective analysis of patients who underwent 2-stage or 3-stage ileal pouch–anal anastomosis (IPAA) surgery for active ulcerative colitis due to failure of medical management over a 10.5-year period (September 1, 2000, to March 30, 2011). The mean (SEM) follow-up was 5.15 (0.24) years (range, 0.26-11.09 years).

Setting

Single large academic medical center.

Patients

One hundred forty-four patients treated with 3- or 2-stage IPAA surgery for active ulcerative colitis. Among these patients, 77 were male and 67 were female. The mean (SEM) age was 34.6 (1.0) years (range, 11-67 years). Of the 144 patients, 116 (80.6%) had a 2-stage procedure and 28 (19.4%) had a 3-stage procedure.

Interventions

Two-stage vs 3-stage IPAA procedures for active ulcerative colitis.

Main Outcomes and Measures

Factors leading to decision for 3-stage procedure, postoperative outcomes with 3-stage vs 2-stage procedures, and risks for complications in patients undergoing 3-stage vs 2-stage procedures.

Results

Of 144 patients, only 19.4% had a 3-stage procedure. Decision to perform a 3-stage vs 2-stage procedure was affected by emergent status (P < .001) and hemodynamic instability (P = .04) but not by age, sex, body mass index, use of steroids, or use of anti–tumor necrosis factor agents. For patients with 2-stage procedures, multivariate regression revealed that the number of perioperative complications was affected by surgeon experience (P = .02) but not by emergent status, use of steroids, or use of anti–tumor necrosis factor agents. Two-stage procedures were associated with more perioperative complications on univariate analysis (P = .05), but multivariate regression suggested that this difference was due to surgeon experience (P = .02) rather than to creation of an IPAA at the first operation (P = .55). Importantly, 2-stage procedures did not change the risk of anastomotic leak when all operations were taken into account (odds ratio = 1.09; P = .94). In the long term (mean [SEM], 5.2 [0.2] years), patients who underwent 2-stage surgery had a lower risk of anal stricture (odds ratio = 8.21; P = .01) and no differences in fistula or abscess formation or in pouch failure.

Conclusions and Relevance

In patients with active ulcerative colitis, use of steroids and anti–tumor necrosis factor agents alone do not appear to justify the decision to avoid IPAA creation at the first operation provided that it is performed by a high-volume inflammatory bowel disease surgeon.

Antireflux Surgery in Patients With Chronic Cough and Abnormal Proximal Exposure as Measured by Hypopharyngeal Multichannel Intraluminal Impedance Antireflux Surgery in Patients With Chronic Cough

Hoppo T, Komatsu Y, Jobe BA. — Wed, 22 May 2013 00:00:00 GMT

Importance

Chronic cough is a laryngeal symptom that can be caused by gastroesophageal reflux disease; however, treatment outcome has been difficult to predict because of the lack of an objective testing modality that accurately detects reflux-related cough.

Objective

To define the patterns of reflux and assess the outcome of antireflux surgery (ARS) in patients with chronic cough who were selected using hypopharyngeal multichannel intraluminal impedance (HMII).

Design

Review of prospectively collected data.

Setting

Tertiary care university hospital.

Participants

Patients with chronic cough, which was defined as persistent cough (≥8 weeks) of unknown cause.

Interventions

Hypopharyngeal multichannel intraluminal impedance with a specialized catheter to detect laryngopharyngeal reflux and high-esophageal reflux (reflux 2 cm distal to the upper esophageal sphincter) and ARS.

Main Outcomes and Measures

Abnormal proximal exposure was defined as laryngopharyngeal reflux occurring 1 or more times per day and/or high-esophageal reflux occurring 5 or more times per day. The outcomes of ARS included symptomatic improvement.

Results

From October 2009 to June 2011, a total of 314 symptomatic patients underwent HMII. Of this population, 49 patients (15 men, 34 women; median age, 57 years) were identified as having chronic cough. Of the 49 participants, 23 of 44 patients (52%) had objective findings of gastroesophageal reflux disease, such as esophagitis. Abnormal proximal exposure was discovered in 36 of the 49 patients (73%). Of 16 patients with abnormal proximal exposure who subsequently underwent ARS, 13 patients (81%) had resolution of cough and 3 patients (19%) had significant improvement at a median follow-up of 4.6 months (range, 0.5-13 months).

Conclusions and Relevance

A highly selective group of patients with idiopathic chronic cough may have abnormal proximal exposure to gastroesophageal reflux documented by HMII that would have not been detected with conventional pH testing. Thus, HMII is likely to improve the sensitivity of laryngopharyngeal reflux diagnosis and better elucidate those who will respond to antireflux surgery.

Antireflux Surgery, a Cough Medicine Difficult to Swallow for Most Physicians Comment on “Antireflux Surgery in Patients With Chronic Cough and Abnormal Proximal Exposure as Measured by Hypopharyngeal Multichannel Intraluminal Impedance” ARS Difficult to Swallow

Patti MG. — Wed, 22 May 2013 00:00:00 GMT

This study by Hoppo and colleagues stresses many important aspects of the diagnosis and treatment of patients with chronic cough of unknown origin.

Hospital-Specific Risk Factors for Filter Fever Hospital-Specific Risk Factors for Filter Fever

Knudson M. — Wed, 22 May 2013 00:00:00 GMT

Importance:

The extent to which vena cava filter (VCF) use varies between hospitals in the management of acute venous thromboembolism (VTE) is not clear.

Methods:

We conducted a retrospective observational study that compared the frequency of VCF use among California hospitals from January 1, 2006, through December 31, 2010. Using administrative hospital discharge data, we followed explicit criteria to identify nontrauma patients with acute VTE, and determined the frequency of VCF placement in each of the hospitals that admitted more than 55 VTE patients. Multivariable hierarchical regression models to predict VCF use included important clinical and demographic variables as fixed effects and hospital as a random effect.

Results:

Among the 263 hospitals included, 130 643 acute VTE hospitalizations occurred with the placement of 19 537 VCFs (14.95%). Variation in the percentage of acute VTE hospitalizations that included VCF placement was very high, from 0% to 38.96% (interquartile range, 6.23%-18.14%), with 18.49% of the observed variation due to differences among the hospitals that provided care. Significant clinical predictors of VCF use included acute bleeding at the time of admission (odds ratio, 3.4 [95% CI, 3.2-3.6]), a major operation after admission for VTE (3.4 [3.3-3.5]), presence of metastatic cancer (1.7 [1.6-1.8]), and extreme severity of illness (2.5 [2.3-2.7] vs mild). Insertion of VCFs occurred more frequently than expected in 109 hospitals and less frequently in 59. Hospital characteristics associated with VCF use included a small number of beds (odds ratio, 0.2 [95% CI, 0.2-0.4], <100 vs >400 beds), a rural location (0.4 [0.2-0.5]), and other private vs Kaiser hospitals (1.5 [1.1-2.0]). Use of VCFs varied widely even in geographically proximate areas.

Conclusions and Relevance:

The frequency of VCF use in patients with acute VTE varied widely and depended on which hospital provided the care, even after adjusting for clinical and socioeconomic factors. Further research is needed to determine whether this variation is associated with local cultural differences between hospitals or with differences in the availability of interventional radiologists or specialists, or whether it reflects the absence of high-quality evidence that VCFs are effective.