Asunto(s)
COVID-19/epidemiología , Servicio de Urgencia en Hospital/estadística & datos numéricos , Pandemias , Procedimientos Quirúrgicos Operativos/estadística & datos numéricos , Servicio de Urgencia en Hospital/organización & administración , Utilización de Instalaciones y Servicios , Prioridades en Salud , Humanos , Ontario/epidemiología , SARS-CoV-2Asunto(s)
COVID-19/epidemiología , Accesibilidad a los Servicios de Salud/organización & administración , Pandemias , Servicio de Cirugía en Hospital/organización & administración , Servicio de Cirugía en Hospital/estadística & datos numéricos , Procedimientos Quirúrgicos Ambulatorios/estadística & datos numéricos , Procedimientos Quirúrgicos Electivos/estadística & datos numéricos , Servicio de Urgencia en Hospital/estadística & datos numéricos , Utilización de Instalaciones y Servicios , Humanos , Ontario/epidemiología , SARS-CoV-2RESUMEN
AIM: In patients with incurable metastatic colorectal cancer (mCRC), resection of the primary tumour is debated; however, patients with intact primaries may be at a higher risk of complications requiring surgery when receiving treatment with bevacizumab. Our aim was to estimate the risk of nonelective colorectal surgery in patients undergoing bevacizumab therapy for mCRC and evaluate the association between intact primary tumours and risk of nonelective surgery. METHOD: We designed a population-based, retrospective cohort study using administrative and cancer registry data in Ontario, Canada. We included patients with mCRC who received bevacizumab from 1 January 2008 to 31 December 2014. The primary outcome was nonelective colorectal surgery after initiation of bevacizumab. We determined the cumulative incidence of nonelective colorectal surgery among patients with previously resected and unresected primaries, accounting for the competing risk of death. We explored the relationship between previous resection of the primary and need for nonelective surgery using a cause-specific hazards model, controlling for patient, tumour and treatment factors. RESULTS: We identified 1840 (32.7%) patients with intact primaries and 3784 (67.3%) patients with prior resection. The cumulative incidence of nonelective surgery 1 year after initiating bevacizumab for all patients was 3.9% (95% CI 3.4-4.5%). One-year cumulative incidence was higher in those with intact primaries than in those with resected primaries (6.1% vs 2.9%, P < 0.0001). After adjustment, an intact primary remained strongly associated with nonelective colorectal surgery (hazard ratio = 2.89, 95% CI 2.32-3.61; P < 0.0001). CONCLUSION: Bevacizumab is associated with a low but meaningful risk for serious gastrointestinal complications, necessitating vigilance, particularly among patients with an intact primary tumour.
Asunto(s)
Neoplasias Colorrectales , Cirugía Colorrectal , Protocolos de Quimioterapia Combinada Antineoplásica , Bevacizumab/efectos adversos , Neoplasias Colorrectales/tratamiento farmacológico , Neoplasias Colorrectales/cirugía , Humanos , Ontario/epidemiología , Estudios RetrospectivosRESUMEN
PURPOSE: Despite the frequency with which inguinal hernia repairs (IHR) are performed, the real-world comparative effectiveness of laparoscopic versus open repairs is not well established. We compared the rate of recurrent inguinal hernia after laparoscopic and open mesh procedures. METHODS: We designed a population-based retrospective cohort study using linked administrative databases including adult patients in Ontario, Canada, who underwent primary IHR from April 1, 2003 to December 31, 2012. Patients were followed to August 31, 2014. Our primary outcome was reoperation for recurrent IHR, with covariate adjustment using Cox proportional hazards modeling. We constructed separate models to evaluate the effect of surgeon caseload on recurrence rates. RESULTS: We identified 93,501 adults undergoing primary IHR (85.4% open with mesh and 14.6% laparoscopic) with a median follow-up of 5.5 years. The 5-year cumulative risk of recurrent IHR was 2.0% in the open group and 3.4% in the laparoscopic group. After adjusting for patient and surgeon factors, we found that patients who underwent laparoscopic repair had a higher risk of recurrent IHR than those who underwent open repair when annual surgeon volume in the preceding year was ≤25 technique-specific cases (HR 1.76; 95% CI 1.45-2.13) or 26-50 technique-specific cases (HR 1.78; 95% CI 1.08-2.93). Few high-volume laparoscopic surgeons (> 50 cases/year) could be identified. Laparoscopic IHR did not carry a higher risk of recurrence for patients whose surgeons had performed > 50 technique-specific cases in the preceding year (HR 1.21; 95% CI 0.45-3.26). CONCLUSION: Laparoscopic IHR is generally associated with a higher risk of recurrence than open IHR. Though high-volume surgeons may be able to achieve equivalent results with laparoscopic and open techniques, few surgeons in our study population met this volume criterion for laparoscopic repairs.