ACS Clinical Congress

CHICAGO – Diverting loop ileostomy may be a better option than urgent colectomy as the first surgical step for medically refractory severe ulcerative colitis and Crohn’s disease.

Investigators from the University of California, Los Angeles, have found that ileostomy gives patients a chance to recover from their acute illness – and their colons a chance to heal – so they’re in better shape for definitive surgery further down the road, if it’s even needed (J Am Coll Surg. 2015 Oct;221[4]:S37-S38).

“Urgent colectomy is standard practice for medically refractory severe ulcerative and Crohn’s colitis. However, immunosuppression and malnutrition can result in significant morbidity. This change in management strategy does not eliminate the potential need for definitive surgery, but it does allow for the more extensive procedure to be performed in an elective setting under optimized conditions, thereby improving clinical outcomes,” said the investigators, led by Dr. Amy Lightner, formerly of UCLA but now a colorectal surgery fellow at the Mayo Clinic in Rochester, Minn.

There were just eight patients in the series, so the results are tentative. Six had ulcerative colitis (UC) and two had Crohn’s disease (CD). On presentation, the patients were tachycardic, febrile, malnourished, and anemic, with severe mucosal disease confirmed by endoscopy. Steroids, immunomodulators, and biologics no longer helped. Overall, the patients were too sick to go home, but not quite sick enough for the ICU. Their average age was 29 years.

They underwent a single-incision, laparoscopic diverting loop ileostomy, which took about 45 minutes. The technique, and perhaps the thinking behind it, are similar to one gaining popularity for Clostridium difficile colitis, but without the colonic lavage.

Within 24-48 hours postop, tachycardia and fevers resolved, and patients tolerated oral intake. Narcotic use dropped, and bloody stools became less frequent, and then ceased in all but one patient. Within a month, the average hemoglobin level had climbed from a baseline of 9 g/dL to 11.5 g/dL, and average albumin from 2.5 g/dL to 4 g/dL. Within 2 months, patients’ bowels looked pink and healthy on repeat endoscopy.

“It was a remarkable turnaround. Within 48 hours, they looked markedly different. We are having very good results with this, and it’s much better for patients” than is colectomy during acute illness. “It’s a good change in management,” Dr. Lightner said.

After months of follow-up, two patients, one with UC and one with CD, haven’t needed a colectomy and are maintained on biologics. The other UC patients have had ileal pouch-anal anastomosis. The other CD patient had a subsequent ileorectal anastomosis. Patients were able to undergo those procedures laparoscopically and “have done really well,” Dr. Lightner said.

It’s unclear why loop ileostomy seems so helpful. Perhaps it has something to do with shifts in bacterial populations or decompression of the colon. Maybe it’s just about giving the colon a rest, she said.

The investigators will continue to study the approach. Since the initial report, 8 more patients have joined the series, for a current total of 16. “We are still seeing good results,” Dr. Lightner said.

Dr. Lightner has no disclosures, and there was no outside funding for the work.

[email protected]

CHICAGO – Diverting loop ileostomy may be a better option than urgent colectomy as the first surgical step for medically refractory severe ulcerative colitis and Crohn’s disease.

Investigators from the University of California, Los Angeles, have found that ileostomy gives patients a chance to recover from their acute illness – and their colons a chance to heal – so they’re in better shape for definitive surgery further down the road, if it’s even needed (J Am Coll Surg. 2015 Oct;221[4]:S37-S38).

“Urgent colectomy is standard practice for medically refractory severe ulcerative and Crohn’s colitis. However, immunosuppression and malnutrition can result in significant morbidity. This change in management strategy does not eliminate the potential need for definitive surgery, but it does allow for the more extensive procedure to be performed in an elective setting under optimized conditions, thereby improving clinical outcomes,” said the investigators, led by Dr. Amy Lightner, formerly of UCLA but now a colorectal surgery fellow at the Mayo Clinic in Rochester, Minn.

There were just eight patients in the series, so the results are tentative. Six had ulcerative colitis (UC) and two had Crohn’s disease (CD). On presentation, the patients were tachycardic, febrile, malnourished, and anemic, with severe mucosal disease confirmed by endoscopy. Steroids, immunomodulators, and biologics no longer helped. Overall, the patients were too sick to go home, but not quite sick enough for the ICU. Their average age was 29 years.

They underwent a single-incision, laparoscopic diverting loop ileostomy, which took about 45 minutes. The technique, and perhaps the thinking behind it, are similar to one gaining popularity for Clostridium difficile colitis, but without the colonic lavage.

Within 24-48 hours postop, tachycardia and fevers resolved, and patients tolerated oral intake. Narcotic use dropped, and bloody stools became less frequent, and then ceased in all but one patient. Within a month, the average hemoglobin level had climbed from a baseline of 9 g/dL to 11.5 g/dL, and average albumin from 2.5 g/dL to 4 g/dL. Within 2 months, patients’ bowels looked pink and healthy on repeat endoscopy.

“It was a remarkable turnaround. Within 48 hours, they looked markedly different. We are having very good results with this, and it’s much better for patients” than is colectomy during acute illness. “It’s a good change in management,” Dr. Lightner said.

After months of follow-up, two patients, one with UC and one with CD, haven’t needed a colectomy and are maintained on biologics. The other UC patients have had ileal pouch-anal anastomosis. The other CD patient had a subsequent ileorectal anastomosis. Patients were able to undergo those procedures laparoscopically and “have done really well,” Dr. Lightner said.

It’s unclear why loop ileostomy seems so helpful. Perhaps it has something to do with shifts in bacterial populations or decompression of the colon. Maybe it’s just about giving the colon a rest, she said.

The investigators will continue to study the approach. Since the initial report, 8 more patients have joined the series, for a current total of 16. “We are still seeing good results,” Dr. Lightner said.

Dr. Lightner has no disclosures, and there was no outside funding for the work.

[email protected]

CHICAGO – Diverting loop ileostomy may be a better option than urgent colectomy as the first surgical step for medically refractory severe ulcerative colitis and Crohn’s disease.

Investigators from the University of California, Los Angeles, have found that ileostomy gives patients a chance to recover from their acute illness – and their colons a chance to heal – so they’re in better shape for definitive surgery further down the road, if it’s even needed (J Am Coll Surg. 2015 Oct;221[4]:S37-S38).

“Urgent colectomy is standard practice for medically refractory severe ulcerative and Crohn’s colitis. However, immunosuppression and malnutrition can result in significant morbidity. This change in management strategy does not eliminate the potential need for definitive surgery, but it does allow for the more extensive procedure to be performed in an elective setting under optimized conditions, thereby improving clinical outcomes,” said the investigators, led by Dr. Amy Lightner, formerly of UCLA but now a colorectal surgery fellow at the Mayo Clinic in Rochester, Minn.

There were just eight patients in the series, so the results are tentative. Six had ulcerative colitis (UC) and two had Crohn’s disease (CD). On presentation, the patients were tachycardic, febrile, malnourished, and anemic, with severe mucosal disease confirmed by endoscopy. Steroids, immunomodulators, and biologics no longer helped. Overall, the patients were too sick to go home, but not quite sick enough for the ICU. Their average age was 29 years.

They underwent a single-incision, laparoscopic diverting loop ileostomy, which took about 45 minutes. The technique, and perhaps the thinking behind it, are similar to one gaining popularity for Clostridium difficile colitis, but without the colonic lavage.

Within 24-48 hours postop, tachycardia and fevers resolved, and patients tolerated oral intake. Narcotic use dropped, and bloody stools became less frequent, and then ceased in all but one patient. Within a month, the average hemoglobin level had climbed from a baseline of 9 g/dL to 11.5 g/dL, and average albumin from 2.5 g/dL to 4 g/dL. Within 2 months, patients’ bowels looked pink and healthy on repeat endoscopy.

“It was a remarkable turnaround. Within 48 hours, they looked markedly different. We are having very good results with this, and it’s much better for patients” than is colectomy during acute illness. “It’s a good change in management,” Dr. Lightner said.

After months of follow-up, two patients, one with UC and one with CD, haven’t needed a colectomy and are maintained on biologics. The other UC patients have had ileal pouch-anal anastomosis. The other CD patient had a subsequent ileorectal anastomosis. Patients were able to undergo those procedures laparoscopically and “have done really well,” Dr. Lightner said.

It’s unclear why loop ileostomy seems so helpful. Perhaps it has something to do with shifts in bacterial populations or decompression of the colon. Maybe it’s just about giving the colon a rest, she said.

The investigators will continue to study the approach. Since the initial report, 8 more patients have joined the series, for a current total of 16. “We are still seeing good results,” Dr. Lightner said.

Dr. Lightner has no disclosures, and there was no outside funding for the work.

[email protected]

CHICAGO – Last-minute colectomy isn’t the way to go for Clostridium difficile–induced toxic megacolon; outcomes are better with a timely loop ileostomy and colonic lavage.

University of Pittsburgh surgery professor Dr. Brian Zuckerbraun, a pioneer of the technique, explained the procedure and its benefits in an interview at the annual Clinical Congress of the American College of Surgeons.

[email protected]

CHICAGO – Last-minute colectomy isn’t the way to go for Clostridium difficile–induced toxic megacolon; outcomes are better with a timely loop ileostomy and colonic lavage.

University of Pittsburgh surgery professor Dr. Brian Zuckerbraun, a pioneer of the technique, explained the procedure and its benefits in an interview at the annual Clinical Congress of the American College of Surgeons.

[email protected]

CHICAGO – Last-minute colectomy isn’t the way to go for Clostridium difficile–induced toxic megacolon; outcomes are better with a timely loop ileostomy and colonic lavage.

University of Pittsburgh surgery professor Dr. Brian Zuckerbraun, a pioneer of the technique, explained the procedure and its benefits in an interview at the annual Clinical Congress of the American College of Surgeons.

[email protected]

CHICAGO – Ketamine is a safe and simple alternative to epidural anesthesia for pain control in the setting of multiple rib fractures, investigators from the Jacobi Medical Center in the Bronx (N.Y.) concluded after reviewing their experience with the drug.

Epidural analgesia has been the standard for controlling pain after multiple rib fractures, but epidurals are sometimes contraindicated in trauma, especially with back and neck injuries. There’s also a bleeding risk, and the need for an on-call anesthesia team to place them, something not all hospitals have.

Those problems – and the success Jacobi surgeons reported with ketamine pain control after thoracotomy – led the hospital to switch to a ketamine-based rib fracture protocol in 2007.

“As far as we know, we are the only people doing this routinely for multiple rib fractures,” Dr. Joelle Getrajdman, a second-year surgery resident at the medical center, said at the annual clinical congress of the American College of Surgeons.

Patients there with two or more rib fractures get a low-dose peripheral intravenous infusion of ketamine 0.05 mg/kg per hour while in the ICU and step-down unit, along with other pain medications as indicated. The hospital discontinues ketamine once patients leave the step-down unit to prevent diversion for illicit use.

To see how well the protocol has worked, the investigators reviewed all 128 adult trauma patients who received ketamine for multiple rib fractures from 2007 to 2014.

These patients were 60 years old on average, with a median of six rib fractures, many of them bilateral. Almost half had injury severity scores above 15, and most had chest Abbreviated Injury Scores of at least 3. Pneumo- and hemothoraces were common. Patients spent a mean of 6 days in the surgical ICU and 13 days in the hospital.

Along with ketamine, almost all had a morphine or hydromorphone (Dilaudid) patient-controlled analgesia (PCA) pumps, more than half received IV ketorolac (Toradol), and about 40% IV Tylenol. Only 14% had paravertebral or intercostal blocks.

Fourteen patients (10.9%) developed pneumonia, and four (3.1%) died, which compares favorably with outcomes in patients receiving epidurals. Historically, epidural analgesia for multiple traumatic rib fractures has been associated with about an 18% pneumonia rate, and about 9% mortality.

Ketamine side effects were minimal; none of the patients had hallucinations or tachycardia, and three (2.3%) were hypotensive on the drug.

Jacobi’s database did not record how many times patients used their PCA pumps, so the study did not have a direct measure of pain control. The investigators plan to look into this question prospectively.

Even so, when patients hurt from rib fractures, they breathe shallowly, which puts them at risk for pneumonia and death. “We have lower rates” of both than with epidurals, “so you could extrapolate that we must be controlling pain better,” Dr. Getrajdman said.

Ketamine at high doses is an anesthetic, but at lower doses it’s an antagonist of N-methyl-D-aspartate (NMDA), and a mild opioid receptor agonist, “so we can give patients the same amount of morphine but achieve a higher analgesic effect,” she said.

Ketamine had been the subject of intense interest in recent years for pain control in a wide variety of settings, as well as for psychiatric and other problems. Clinicaltrials.gov currently lists 138 open investigations of the drug.

Among them is a randomized trial from the Medical College of Wisconsin pitting ketamine against placebo for rib fracture pain following blunt trauma.

Dr. Getrajdman has no disclosures, and there was no outside funding for the work.

[email protected]

CHICAGO – Ketamine is a safe and simple alternative to epidural anesthesia for pain control in the setting of multiple rib fractures, investigators from the Jacobi Medical Center in the Bronx (N.Y.) concluded after reviewing their experience with the drug.

Epidural analgesia has been the standard for controlling pain after multiple rib fractures, but epidurals are sometimes contraindicated in trauma, especially with back and neck injuries. There’s also a bleeding risk, and the need for an on-call anesthesia team to place them, something not all hospitals have.

Those problems – and the success Jacobi surgeons reported with ketamine pain control after thoracotomy – led the hospital to switch to a ketamine-based rib fracture protocol in 2007.

“As far as we know, we are the only people doing this routinely for multiple rib fractures,” Dr. Joelle Getrajdman, a second-year surgery resident at the medical center, said at the annual clinical congress of the American College of Surgeons.

Patients there with two or more rib fractures get a low-dose peripheral intravenous infusion of ketamine 0.05 mg/kg per hour while in the ICU and step-down unit, along with other pain medications as indicated. The hospital discontinues ketamine once patients leave the step-down unit to prevent diversion for illicit use.

To see how well the protocol has worked, the investigators reviewed all 128 adult trauma patients who received ketamine for multiple rib fractures from 2007 to 2014.

These patients were 60 years old on average, with a median of six rib fractures, many of them bilateral. Almost half had injury severity scores above 15, and most had chest Abbreviated Injury Scores of at least 3. Pneumo- and hemothoraces were common. Patients spent a mean of 6 days in the surgical ICU and 13 days in the hospital.

Along with ketamine, almost all had a morphine or hydromorphone (Dilaudid) patient-controlled analgesia (PCA) pumps, more than half received IV ketorolac (Toradol), and about 40% IV Tylenol. Only 14% had paravertebral or intercostal blocks.

Fourteen patients (10.9%) developed pneumonia, and four (3.1%) died, which compares favorably with outcomes in patients receiving epidurals. Historically, epidural analgesia for multiple traumatic rib fractures has been associated with about an 18% pneumonia rate, and about 9% mortality.

Ketamine side effects were minimal; none of the patients had hallucinations or tachycardia, and three (2.3%) were hypotensive on the drug.

Jacobi’s database did not record how many times patients used their PCA pumps, so the study did not have a direct measure of pain control. The investigators plan to look into this question prospectively.

Even so, when patients hurt from rib fractures, they breathe shallowly, which puts them at risk for pneumonia and death. “We have lower rates” of both than with epidurals, “so you could extrapolate that we must be controlling pain better,” Dr. Getrajdman said.

Ketamine at high doses is an anesthetic, but at lower doses it’s an antagonist of N-methyl-D-aspartate (NMDA), and a mild opioid receptor agonist, “so we can give patients the same amount of morphine but achieve a higher analgesic effect,” she said.

Ketamine had been the subject of intense interest in recent years for pain control in a wide variety of settings, as well as for psychiatric and other problems. Clinicaltrials.gov currently lists 138 open investigations of the drug.

Among them is a randomized trial from the Medical College of Wisconsin pitting ketamine against placebo for rib fracture pain following blunt trauma.

Dr. Getrajdman has no disclosures, and there was no outside funding for the work.

[email protected]

CHICAGO – Ketamine is a safe and simple alternative to epidural anesthesia for pain control in the setting of multiple rib fractures, investigators from the Jacobi Medical Center in the Bronx (N.Y.) concluded after reviewing their experience with the drug.

Epidural analgesia has been the standard for controlling pain after multiple rib fractures, but epidurals are sometimes contraindicated in trauma, especially with back and neck injuries. There’s also a bleeding risk, and the need for an on-call anesthesia team to place them, something not all hospitals have.

Those problems – and the success Jacobi surgeons reported with ketamine pain control after thoracotomy – led the hospital to switch to a ketamine-based rib fracture protocol in 2007.

“As far as we know, we are the only people doing this routinely for multiple rib fractures,” Dr. Joelle Getrajdman, a second-year surgery resident at the medical center, said at the annual clinical congress of the American College of Surgeons.

Patients there with two or more rib fractures get a low-dose peripheral intravenous infusion of ketamine 0.05 mg/kg per hour while in the ICU and step-down unit, along with other pain medications as indicated. The hospital discontinues ketamine once patients leave the step-down unit to prevent diversion for illicit use.

To see how well the protocol has worked, the investigators reviewed all 128 adult trauma patients who received ketamine for multiple rib fractures from 2007 to 2014.

These patients were 60 years old on average, with a median of six rib fractures, many of them bilateral. Almost half had injury severity scores above 15, and most had chest Abbreviated Injury Scores of at least 3. Pneumo- and hemothoraces were common. Patients spent a mean of 6 days in the surgical ICU and 13 days in the hospital.

Along with ketamine, almost all had a morphine or hydromorphone (Dilaudid) patient-controlled analgesia (PCA) pumps, more than half received IV ketorolac (Toradol), and about 40% IV Tylenol. Only 14% had paravertebral or intercostal blocks.

Fourteen patients (10.9%) developed pneumonia, and four (3.1%) died, which compares favorably with outcomes in patients receiving epidurals. Historically, epidural analgesia for multiple traumatic rib fractures has been associated with about an 18% pneumonia rate, and about 9% mortality.

Ketamine side effects were minimal; none of the patients had hallucinations or tachycardia, and three (2.3%) were hypotensive on the drug.

Jacobi’s database did not record how many times patients used their PCA pumps, so the study did not have a direct measure of pain control. The investigators plan to look into this question prospectively.

Even so, when patients hurt from rib fractures, they breathe shallowly, which puts them at risk for pneumonia and death. “We have lower rates” of both than with epidurals, “so you could extrapolate that we must be controlling pain better,” Dr. Getrajdman said.

Ketamine at high doses is an anesthetic, but at lower doses it’s an antagonist of N-methyl-D-aspartate (NMDA), and a mild opioid receptor agonist, “so we can give patients the same amount of morphine but achieve a higher analgesic effect,” she said.

Ketamine had been the subject of intense interest in recent years for pain control in a wide variety of settings, as well as for psychiatric and other problems. Clinicaltrials.gov currently lists 138 open investigations of the drug.

Among them is a randomized trial from the Medical College of Wisconsin pitting ketamine against placebo for rib fracture pain following blunt trauma.

Dr. Getrajdman has no disclosures, and there was no outside funding for the work.

[email protected]

CHICAGO – Tranexamic acid was not independently associated with any infection within 30 days of injury in U.S. soldiers undergoing trauma surgery, a case-control study showed.

The antifibrinolytic has been used for years to reduce morbidity and the risk of death associated with hemorrhage in the military setting. Tranexamic acid (TXA) made its way into the civilian setting after the 2010 provocative CRASH-2 trial in adult trauma patients.

Because TXA (Cyklokapron, Lysteda) also has anti-inflammatory properties, Dr. Clayton Lewis of Brooke Army Medical Center in San Antonio and his colleagues decided to evaluate the effect of TXA on the development of posttraumatic infections, including time to first infection, in combat casualties.

The findings were presented at the annual clinical congress of the American College of Surgeons, where we caught up with Dr. Lewis for an interview.

Dr. Lewis reported having no relevant financial disclosures.

[email protected]

CHICAGO – Tranexamic acid was not independently associated with any infection within 30 days of injury in U.S. soldiers undergoing trauma surgery, a case-control study showed.

The antifibrinolytic has been used for years to reduce morbidity and the risk of death associated with hemorrhage in the military setting. Tranexamic acid (TXA) made its way into the civilian setting after the 2010 provocative CRASH-2 trial in adult trauma patients.

Because TXA (Cyklokapron, Lysteda) also has anti-inflammatory properties, Dr. Clayton Lewis of Brooke Army Medical Center in San Antonio and his colleagues decided to evaluate the effect of TXA on the development of posttraumatic infections, including time to first infection, in combat casualties.

The findings were presented at the annual clinical congress of the American College of Surgeons, where we caught up with Dr. Lewis for an interview.

Dr. Lewis reported having no relevant financial disclosures.

[email protected]

CHICAGO – Tranexamic acid was not independently associated with any infection within 30 days of injury in U.S. soldiers undergoing trauma surgery, a case-control study showed.

The antifibrinolytic has been used for years to reduce morbidity and the risk of death associated with hemorrhage in the military setting. Tranexamic acid (TXA) made its way into the civilian setting after the 2010 provocative CRASH-2 trial in adult trauma patients.

Because TXA (Cyklokapron, Lysteda) also has anti-inflammatory properties, Dr. Clayton Lewis of Brooke Army Medical Center in San Antonio and his colleagues decided to evaluate the effect of TXA on the development of posttraumatic infections, including time to first infection, in combat casualties.

The findings were presented at the annual clinical congress of the American College of Surgeons, where we caught up with Dr. Lewis for an interview.

Dr. Lewis reported having no relevant financial disclosures.

[email protected]

CHICAGO – The odds of emergency surgery were sevenfold higher in dialysis-dependent patients undergoing colorectal surgery than patients with renal insufficiency not on dialysis or those with normal renal function.

Dialysis patients were also far less likely to undergo laparoscopic surgery and to be rescued from death if they experienced a complication.

These are just some of the results of a retrospective study involving 156,645 elective colorectal surgery cases selected as a poster of exceptional merit here at the annual clinical congress of the American College of Surgeons.

Dialysis patients are known to be at high risk for postoperative complications, but few studies have evaluated outcomes after colorectal surgery in these patients or distinguished them from patients with non–dialysis dependent renal insufficiency (NDDRI) or normal renal function (NRF), observed study author Dr. Isibor Arhuidese of Johns Hopkins University in Baltimore.

Indeed, when the researchers compared these three groups, perioperative mortality and morbidity after elective colorectal surgery was the worst in dialysis patients.

Absolute perioperative mortality was highest for dialysis patients vs. NDDRI and NRF patients after open (13.4% vs. 4.8% vs. 2%; P less than .001) and laparoscopic (8% vs. 2% vs. 0.6%; P less than .001) surgery.

Three complications were significantly associated with death in dialysis patients: myocardial infarction (adjusted odds ratio, 48.6; P = .027), bleeding (aOR, 14.5; P = .025), and sepsis or septic shock (aOR, 8.7; P = .001).

It is not enough to simply identify dialysis dependence as a predictor of poor outcomes, but one must identify targets for improvement in surgical care, Dr. Arhuidese stressed.

Dr. Arhuidese reported having no relevant conflicts of interest.

[email protected]

On Twitter @pwendl

CHICAGO – The odds of emergency surgery were sevenfold higher in dialysis-dependent patients undergoing colorectal surgery than patients with renal insufficiency not on dialysis or those with normal renal function.

Dialysis patients were also far less likely to undergo laparoscopic surgery and to be rescued from death if they experienced a complication.

These are just some of the results of a retrospective study involving 156,645 elective colorectal surgery cases selected as a poster of exceptional merit here at the annual clinical congress of the American College of Surgeons.

Dialysis patients are known to be at high risk for postoperative complications, but few studies have evaluated outcomes after colorectal surgery in these patients or distinguished them from patients with non–dialysis dependent renal insufficiency (NDDRI) or normal renal function (NRF), observed study author Dr. Isibor Arhuidese of Johns Hopkins University in Baltimore.

Indeed, when the researchers compared these three groups, perioperative mortality and morbidity after elective colorectal surgery was the worst in dialysis patients.

Absolute perioperative mortality was highest for dialysis patients vs. NDDRI and NRF patients after open (13.4% vs. 4.8% vs. 2%; P less than .001) and laparoscopic (8% vs. 2% vs. 0.6%; P less than .001) surgery.

Three complications were significantly associated with death in dialysis patients: myocardial infarction (adjusted odds ratio, 48.6; P = .027), bleeding (aOR, 14.5; P = .025), and sepsis or septic shock (aOR, 8.7; P = .001).

It is not enough to simply identify dialysis dependence as a predictor of poor outcomes, but one must identify targets for improvement in surgical care, Dr. Arhuidese stressed.

Dr. Arhuidese reported having no relevant conflicts of interest.

[email protected]

On Twitter @pwendl

CHICAGO – The odds of emergency surgery were sevenfold higher in dialysis-dependent patients undergoing colorectal surgery than patients with renal insufficiency not on dialysis or those with normal renal function.

Dialysis patients were also far less likely to undergo laparoscopic surgery and to be rescued from death if they experienced a complication.

These are just some of the results of a retrospective study involving 156,645 elective colorectal surgery cases selected as a poster of exceptional merit here at the annual clinical congress of the American College of Surgeons.

Dialysis patients are known to be at high risk for postoperative complications, but few studies have evaluated outcomes after colorectal surgery in these patients or distinguished them from patients with non–dialysis dependent renal insufficiency (NDDRI) or normal renal function (NRF), observed study author Dr. Isibor Arhuidese of Johns Hopkins University in Baltimore.

Indeed, when the researchers compared these three groups, perioperative mortality and morbidity after elective colorectal surgery was the worst in dialysis patients.

Absolute perioperative mortality was highest for dialysis patients vs. NDDRI and NRF patients after open (13.4% vs. 4.8% vs. 2%; P less than .001) and laparoscopic (8% vs. 2% vs. 0.6%; P less than .001) surgery.

Three complications were significantly associated with death in dialysis patients: myocardial infarction (adjusted odds ratio, 48.6; P = .027), bleeding (aOR, 14.5; P = .025), and sepsis or septic shock (aOR, 8.7; P = .001).

It is not enough to simply identify dialysis dependence as a predictor of poor outcomes, but one must identify targets for improvement in surgical care, Dr. Arhuidese stressed.

Dr. Arhuidese reported having no relevant conflicts of interest.

[email protected]

On Twitter @pwendl