RESUMEN
PURPOSE: Few studies have assessed patient-reported outcomes following colorectal surgery. The absence of this information makes it difficult to inform patients about the near-term effects of surgery, beyond outcomes assessed by traditional clinical measures. This study was designed to provide information about the effects of colorectal surgery on physical, mental, and social well-being outcomes. METHODS: The NIH Patient-Reported Outcomes Measurement Information System (PROMIS®) Assessment Center was used to collect patient responses prior to surgery and at their routine postoperative visit. Four domains were selected based on patient consultation and clinical experience: depression, pain interference, ability to participate in social roles and activities, and interest in sexual activity. Multilevel random coefficient models were used to assess the change in scores during the follow-up period and to assess the statistical significance of differences in trends over time associated with key clinical measures. RESULTS: In total, 142 patients were consented, with 107 patients completing pre- and postoperative assessments (75%). Preoperative assessments were typically completed 1 month prior to surgery (mean 29.5 days before, SD = 19.7) and postoperative assessments 1 month after surgery (mean 30.7 days after, SD = 9.2), with a mean of 60.3 days between assessment dates. Patients demonstrated no statistically significant changes in scores for pain interference (-0.18 points, p = 0.80) or the ability to participate in social roles and activities (0.44 points, p = 0.55), but had significant decreases in depression scores between pre- and postoperative assessments (-1.6 points, p = 0.03) and near significant increases in scores for interest in sex (1.5 points, p = 0.06). Pain interference scores for patients with neoadjuvant chemotherapy significantly increased (3.5 points, p = 0.03). Scores for the interest in sex domain decreased (worsened) for patients with oncologic etiology (-3.7 points, p = 0.03). No other differences in score trends by patient characteristics were large enough to be statistically significant at the p < 0.05 threshold. CONCLUSION: These data suggest that the majority of patients quickly return to baseline physical, mental, and social function following colorectal surgery. This information can be used preoperatively to counsel patients about the typical impact of colorectal surgery on quality of life.
Asunto(s)
Neoplasias Colorrectales/rehabilitación , Neoplasias Colorrectales/cirugía , Procedimientos Quirúrgicos del Sistema Digestivo/rehabilitación , Evaluación del Resultado de la Atención al Paciente , Medición de Resultados Informados por el Paciente , Adulto , Anciano , Neoplasias Colorrectales/epidemiología , Neoplasias Colorrectales/psicología , Depresión/epidemiología , Femenino , Humanos , Masculino , Persona de Mediana Edad , Proyectos Piloto , Complicaciones Posoperatorias/epidemiología , Periodo Posoperatorio , Calidad de VidaRESUMEN
BACKGROUND: Surgical site infection is common following colorectal surgery, yet the incidence varies widely. CDC criteria include "diagnosis by attending physician," which can be subjective. Alternatively, the ASEPSIS score is an objective scoring system based on the presence of clinical findings. OBJECTIVE: The aim of this study is to compare the interrater reliability of the ASEPSIS score vs CDC definitions in identifying surgical site infection. DESIGN: This 24-month prospective study used serial photography of the wound. Three attending surgeons independently reviewed blinded photographic/clinical data. SETTINGS: This study was conducted at an academic institution. PATIENTS: Patients undergoing elective colorectal surgery were selected. INTERVENTIONS: Surgeons assigned an ASEPSIS score and identified surgical site infection by using CDC definitions. The interrater reliability of ASEPSIS and the CDC criteria were compared by using the κ statistic. These data were also compared with the institutional National Surgical Quality Improvement Program database. RESULTS: One hundred seventy-one patients were included. Four surgical site infections (2.4%) were identified by the National Surgical Quality Improvement Program. Data from the surgeons demonstrated significantly higher yet discrepant rates of infection by the CDC criteria, at 6.2%, 7.4%, and 14.1% with a κ of 0.55 indicating modest interrater agreement. Alternatively, the ASEPSIS assessments demonstrated excellent interrater agreement between surgeons with 96% agreement (2.4%, 2.4%, and 3.6%) and a κ of 0.83. LIMITATIONS: This was a single-institution study. CONCLUSIONS: This study demonstrates the relatively poor reliability of CDC definitions for surgical site infections in comparison with an objective scoring system. These findings could explain the wide variability in the literature and raise concern for the comparison of institutional surgical site infection rates as a quality indicator. Alternatively, an objective scoring system, like the ASEPSIS score, may yield more reliable measures for comparison.
Asunto(s)
Enfermedades del Colon/cirugía , Cirugía Colorrectal/normas , Procedimientos Quirúrgicos del Sistema Digestivo , Fotograbar , Infección de la Herida Quirúrgica/diagnóstico , Centros Médicos Académicos , Anciano , Centers for Disease Control and Prevention, U.S. , Colectomía , Neoplasias Colorrectales/cirugía , Divertículo/cirugía , Procedimientos Quirúrgicos Electivos , Enterostomía , Femenino , Humanos , Enfermedades Inflamatorias del Intestino/cirugía , Laparoscopía , Masculino , Persona de Mediana Edad , Variaciones Dependientes del Observador , Estudios Prospectivos , Reproducibilidad de los Resultados , Estados UnidosRESUMEN
BACKGROUND: Population-based studies historically report underutilization of a resection in patients with colorectal metastases to the liver. Recent data suggest limitations of the methods in the historical analysis. The present study examines trends in a hepatic resection and survival among Medicare recipients with hepatic metastases. METHODS: Medicare recipients with incident colorectal cancer diagnosed between 1991 and 2009 were identified in the SEER(Surveillance, Epidemiology and End Results)-Medicare dataset. Patients were stratified into historical (1991-2001) and current (2002-2009) cohorts. Analyses compared treatment, peri-operative outcomes and survival. RESULTS: Of 31.574 patients with metastatic colorectal cancer to the liver, 14,859 were in the current cohort treated after 2002 and 16,715 comprised the historical control group. The overall proportion treated with a hepatic resection increased significantly during the study period (P < 0.001) with pre/post change from 6.5% pre-2002 to 7.5% currently (P < 0.001). Over time, haemorrhagic and infectious complications declined (both P ≤ 0.047), but 30-day mortality was similar (3.5% versus 3.9%, P = 0.660). After adjusting for predictors of survival, the use of a hepatic resection [hazard ratio (HR) = 0.40, 95% confidence interval (CI): 0.38-0.42, P < 0.001] and treatment after 2002 (HR = 0.88, 95% CI: 0.86-0.90, P < 0.001) were associated with a reduced risk of death. CONCLUSIONS: Case identification using International Classification of Diseases, 9th Revision (ICD-9) codes is imperfect; however, comparison of trends over time suggests an improvement in multimodality therapy and survival in patients with colorectal metastases to the liver.