Can a Post-Discharge Telephone Call Reduce Hospital Readmission after Colorectal Surgery? A Prospective Study

BACKGROUND: Hospital readmission after major colorectal surgery is a major economic burden and a benchmark of quality care by government agencies. We hypothesized that a post-discharge telephone follow-up (TFU) could reduce readmission after abdominal colorectal surgery. METHODS: Consecutive patients undergoing abdominal colorectal surgery over the 4-month period ending Oct 2016 were prospectively evaluated. A structured TFU call during the 4-day period after hospital discharge evaluating the patient’s clinical status and possible interventions to avoid readmission was conducted by a second-year medical student, supervised by two board certified colorectal surgeons. Readmission rates were compared to a control group undergoing abdominal colorectal surgery by the same surgeons not receiving TFU over the prior 12-month period. Low-complexity surgery was defined as small bowel resection, right colectomy, creation or revision of ileostomy or colostomy. High-complexity surgery included left or total colectomy, or proctectomy with or without diversion. Groups were compared using Fisher\u27s exact test. RESULTS: The TFU patient group (n=74) and control patient group (n=134) were well matched in all clinical and operative characteristics except for case complexity. TFU group patients were more likely to undergo low-complexity surgery (n=41;55%) compared to control group patients (n=35;26%) (p=0.001). Readmission rates in the TFU patient group (n=9; 12%) and control patient group (n=26; 19%) were comparable (p=.25). For patients undergoing high-complexity surgery, readmission rates were not statistically different between the TFU patients (n=6;18%) and control patients (n=14; 14%). For patients undergoing low-complexity surgery, readmission rates were significantly lower in the TFU patient group (n=3;7%) compared to the control patient group (n=12;34%) (p=0.004). CONCLUSIONS: A simple, post discharge medical student-led phone call signficantly reduced the rate of readmission after low-complexity but not high-complexity colorectal surgery. Readmission after high-complexity colorectal surgery appears unpreventable. We recommend early post-discharge telephone follow-up to reduce readmission after abdominal colorectal surgery

Long-term Oncological Outcome of Segmental Versus Extended Colectomy for Colorectal Cancer in Crohn's Disease: Results from an International Multicentre Study

Background and Aims Crohn's disease increases colorectal cancer risk, with high prevalence of synchronous and metachronous cancers. Current guidelines for colorectal cancer in Crohn's disease recommend pan-proctocolectomy. The aim of this study was to evaluate oncological outcomes of a less invasive surgical approach. Methods This was a retrospective database analysis of Crohn's disease patients with colorectal cancer undergoing surgery at selected European and US tertiary centres. Outcomes of segmental colectomy were compared with those of extended colectomy, total colectomy, and pan-proctocolectomy. Primary outcome was progression-free survival. Secondary outcomes included overall survival, synchronous and metachronous colorectal cancer, and major postoperative complications. Results Ninety-nine patients were included: 66 patients underwent segmental colectomy and 33 extended colectomy. Segmental colectomy patients were older [p = 0.0429], had less extensive colitis [p = 0.0002] and no preoperatively identified synchronous lesions [p = 0.0109]. Median follow-up was 43 [31-62] months. There was no difference in unadjusted progression-free survival [p = 0.2570] or in overall survival [p = 0.4191] between segmental and extended colectomy. Multivariate analysis adjusting for age, sex, ASA score, and AJCC staging, confirmed no difference for progression-free survival (hazard ratio [HR] 1.00, p = 0.9993) or overall survival [HR 0.77, p = 0.6654]. Synchronous and metachronous cancers incidence was 9% and 1.5%, respectively. Perioperative mortality was nil and major complications were comparable [7.58% vs 6.06%, p = 0.9998]. Conclusions Segmental colectomy seems to offer similar long-term outcomes to more extensive surgery. Incidence of synchronous and metachronous cancers appears much lower than previously described. Further prospective studies are warranted to confirm these results

The role of SIRT1 and SIRT6 in epigenetic regulation of genome stability under stress

[eng] The Sirtuin family of NAD+-dependent enzymes plays a key role in the maintenance of genome integrity upon stress. Sirtuins coordinate the response to different forms of stress at different levels and have been involved in a wide range of processes directly linked to tumorigenesis such as genome stability, cell cycle regulation, apoptosis, senescence and DNA repair. The main objective of this work was to deepen the role of Sirtuins in genome stability and cancer. This has been fulfilled through the development of two specific objectives: First, to define the factors that contribute to the role of SIRT6 in tumorigenesis. Second, to decipher the role of SIRT1 in DNA damage signaling and repair. SIRT6 is an important regulator of genome stability and metabolic homeostasis and has been shown to work as a tumor suppressor. This antitumoral activity is directly associated to the epigenetic silencing of a specific set of genes involved in glucose metabolism, but little is known about the partners of SIRT6 in this functional context. Previous studies of the group identified two histone H3K9 specific histone methyltransferases (HMTs) Suv39h1 and G9a, as interaction partners of SIRT6. Both Suv39h1 and G9a are responsible for methylation of H3K9, a hallmark of heterochromatin organization, transcriptional repression, and epigenetic silencing. Several studies have shown correlation of altered expression of Suv39h1 and G9a in cancer. In the first specific objective of the thesis, we studied the functional relationship between SIRT6 and Suv39h1 as well G9a to provide evidence about the mechanism behind the described tumor suppressor activity of SIRT6. Our results support a direct Sirtuins have been also implicated in the regulation of the DNA damage response (DDR) signaling, and DNA repair, being SIRT1 is the best studied Sirtuin in this functional context. In the second specific objective, we studied the role of SIRT1 in DNA damage signaling. SIRT1-deficient cells show impairment of the DDR, which result in an increased genome instability and decreased levels of yH2AX

Anal Fissure

Anal fissure is one of the most common anorectal problems. Anal fissure is largely associated with high anal sphincter pressures and most treatment options are based on reducing anal pressures. Conservative management, using increased fiber and warm baths, results in healing of approximately half of all anal fissures. In fissures that fail conservative care, various pharmacologic and surgical options offer satisfactory cure rates. Lateral internal sphincterotomy remains the gold standard for definitive management of anal fissure. This review outlines the key points in the presentation, pathophysiology, and management of anal fissure