Jeannette Y. Wick, RPh, MBA, FASCP

Colorectal surgery is very common in the United States, and readmission because of complications has been a challenge for surgeons.

These surgeries address colorectal cancer, ulcerative colitis, Crohn's disease, mechanical bowel obstruction and recurrent diverticulitis. Considered "dirty" surgery, major reconstruction of the gastrointestinal tract is often a necessity.

With all types of insurers beginning to integrate postoperative (PO) outcomes into value-based purchasing programs, hospitals are wary of the proposed penalties they may incur if patients are readmitted. This has created a research impetus.

A group of investigators from Stanford School of Medicine in Palo Alto, CA, recently assessed adverse events in colorectal surgical patients. Using 4 years of data from the Nationwide Inpatient Sample database, they identified 1,100,184 colorectal patients who underwent major surgery. They searched for inpatient adverse event identified by Agency for Healthcare Research and Quality’s patient safety indicators (PSIs).

Among these patients, 2.7% developed PSI during their hospital stays.

The researchers noted that patients who had surgery for ischemic colitis were at significantly elevated risks of pressure ulcer, failure to rescue, central line bloodstream infection, embolism/deep vein thrombosis, and sepsis.

Patients with ischemic colitis were 1.84 times more likely to develop a PO than cancer patients. The investigators attributed the high risk to ischemic colitis's associations with vascular compromise of the colonic mucosa and resulting immune barrier function compromise.

Patients who underwent procedures for benign polyps were at lowest risk for POs.

Although increasing age, black race, and public insurance (e.g. Medicare and Medicaid) were associated with increases risk of adverse event, patient demographic and clinical characteristics were significantly less reliable predictors of PO than procedure indication or diagnostic category.  

Surgeons and their teams have worked hard to reduce the rate of adverse event in colorectal surgery, but adverse events continue to be common. These investigators promoted the need for rigorous risk adjustment and quality improvement strategies for high-risk populations. They also recommended that insurers needed to pay attention to detail when they design financial incentives and penalties for colorectal surgery.

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Readmission because of complications from colorectal surgery has been a challenge for surgeons.

Colorectal Surgery: Ischemic Colitis is Highest Risk

Opioid-induced testosterone deficiency decreases libido and worsens quality of life and body composition. Opioids down-regulate the hypothalamic—pituitary–gonadal axis to produce near-castrate testosterone levels, while also suppressing adrenocorticotropic hormone secretion from the anterior pituitary.

In patients who develop deficiency, testosterone supplementation improves pain relief, lean body mass, and body fat composition.

Opioids inhibit insulin release via opioid receptors on the pancreatic beta cells. Both opioids and testosterone increase premature coronary artery disease risk.

 published a study in its August 2016 issue , indicating testosterone replacement treatment for opioid-induced androgen deficient males does not worsen metabolic and inflammatory markers.

The study enrolled 64 non-diabetic men between 18 and 64 years old to receive at least 20 mg of hydrocodone per day — or its morphine dose equivalent &mdash; for at least 4 weeks to treat non-cancer pain with testosterone levels lower than 12 nmol/L. Participants applied either 5 grams of testosterone gel or a matched placebo daily for 3 months.

The researchers measured total testosterone levels and collected metabolic parameters, inflammatory markers, and oral glucose tolerance tests after 14 weeks.

Testosterone replacement for 14 weeks did not worsen testosterone-deficient patients' metabolic and cardiovascular health. The testosterone-treated patients’ total testosterone levels more than tripled (7.7 nmol/L to 27 nmol/L) into a target range of 17 to 34.7 nmol/L.

Testosterone improved pain sensitivity, sexual desire, and quality of life.

Patient lipid profiles, fasting insulin and glucose, leptin, and C-reactive protein laboratory values were similar in both arms. Cardiovascular risk was unchanged between groups although the study was underpowered to confirm this finding.

Testosterone improved opioid pain relief without short-term negative effects on metabolic and cardiovascular markers in testosterone deficient patients. The researchers suggest that larger studies over longer periods are needed to detect minor differences in laboratory findings and cardiovascular risk between groups.

Opioid prescribers should consider the endocrine effects and consider medications from other classes in patients experiencing opioid-induced testosterone deficiency.

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The opioid-induced deficiency worsens quality of life and body composition.

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Bariatric surgery is the most effective treatment for overweight and obese diabetic patients who have failed lifestyle and pharmacotherapy interventions. It decreases cardiovascular risk factors, improves diabetes control, and increases quality adjusted life years cost effectively.

Beginning in 1991, guidelines set by the National Institutes of Health (NIH) focused on benchmark body mass index values as exclusive indications for bariatric surgery. At that time, NIH recommended surgical treatment for healthy patients with a body mass index (BMI) value of 40 or more and patients with one or more comorbidities and a BMI value of at least 35.

By 2009, experts at the first Diabetes Surgery Summit were proposing aggressive bariatric surgery selection (diabetics with a BMI greater than 30) and the research published since then supports this recommendation.

 published an article in its August 2016 issue recognizing the Diabetes Surgery Summit II guidelines incorporated disease severity and control, instead of BMI alone, into bariatric surgery indications.

The summit gathering, a meeting of 48 key opinion leaders, compared randomized controlled trials to draft a disease-based guideline including bariatric surgery. The summit surveyed the burgeoning body of evidence to determine glycemic effect durability, surgical risk, impact on cardiovascular risk factors, and cost-effectiveness of bariatric surgery.

Short and mid-term outcomes following bariatric surgery were comparable independent of BMI. Surgery improved diabetes control by both weight-dependent and independent mechanisms.

The Diabetes Surgery Summit II guidelines suggested providers consider surgical options for poorly controlled class I obese diabetic patients. Most diabetics have a BMI values less than 35; this recommendation broadens the indicated population greatly.

More than 40 medical and surgical societies endorsed these guidelines.

Bariatric surgery aids obese diabetic patients who were ineligible under the 1991 NIH recommendations. Future studies should clarify specific criteria for surgery and the effect on macro- and microvascular diabetic complications.

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Recent research supports an aggressive bariatric BMI-based surgery selection.

Increasing Eligibility for Bariatric Surgery

Management of type 1 diabetes mellitus (T1DM) is a full-time job, and in addition to the day-to-day management, T1DM patients face a higher risk of diabetic ketoacidosis (DKA), the primary cause of morbidity and mortality among children with T1DM.

 indicated that recent emergency department (ED) visits and missed quarterly endocrinologist appointments could help predict DKA hospitalizations.

Researchers from the Stanford University School of Medicine conducted a retrospective analysis of children with T1DM enrolled in California Children’s Services (CCS), a form of Medicaid.

The study reviewed paid claims for 5263 enrolled children from 2009 to 2012 for exposure to 2 types of outpatient care: (1) maintenance care and (2) acute care. Of those enrolled, 878 (16.7%) children were hospitalized during the study period.

A novel finding in this study was that patients who were seen at an ED had an increased likelihood of DKA during the next 14 days. This suggested that timely outpatient appointments should be made to prevent possible hospitalization.

The second major finding was that patients who had missed a quarterly endocrinology visit (within the last 120 days) had a higher risk of DKA hospitalization. This finding supports a 1997 study by the Joslin Diabetes Center and shows a need of future research in different patient populations to strengthen the associations.

The author suggested that more than 50% of diabetic children were not meeting the recommendation for quarterly subspecialty care for various reasons. Missed appointments should trigger management strategies aimed to prevent DKA, such as renewed education, care coordination, and patient- or family-focused behavioral interventions.

The team acknowledged that further research into the role of outpatient care and the prevention of DKA is needed to verify their findings and to provide guidelines that will improve care and outcomes for these patients.

Managing of type 1 diabetes mellitus (T1DM) is a full-time job.

Jeannette Y. Wick, RPh, MBA, FASCP

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