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The Risk-Benefit Ratio: Comment on “Outcomes and Costs of Elective Surgery for Diverticular Disease”

The Risk-Benefit Ratio: Comment on “Outcomes and Costs of Elective Surgery for Diverticular Disease” Van Arendonk et al1 used the Nationwide Inpatient Sample database to evaluate outcomes for colon surgery based on the disease being treated: colon cancer (CC), diverticular disease (DD), or inflammatory bowel disease (IBD). They conclude that elective resection for DD, when the analysis is adjusted for demographic and clinical characteristics, is associated with a higher morbidity and mortality rate than that seen when operating because of CC and that these data should then be used to question the advisability of offering routine elective colectomy after successful nonoperative management of acute diverticulitis. The underlying concept or assumption seems to be that many patients being offered elective resection for DD do not really need the operation, since recent data and guidelines would suggest that the course of their disease may not ultimately take them to a middle-of-the-night emergency operation for perforation that routinely involves a stoma and the subsequent operation to reestablish gastrointestinal tract continuity. The implication is that, before we offer an elective resection for DD, we should be aware that the risk of such an undertaking may be greater than we appreciate, suggesting that perhaps we should stand down, observe, treat expectantly, and not operate so frequently. I assume we are to suppose that the sequelae of DD—inflammation, distortion of tissue planes, thick mesentery, etc—make surgery riskier and that, since the natural course of the disease is such that complications may not arise after an episode or two, why operate? The problem with these data is that they are derived from an administrative database that simply does not provide enough detail to allow us to make any of these assumptions or draw these conclusions. There are no data on the indication for operation for these patients. Were they offered an operation because they had had 1 episode of acute diverticulitis that resolved after a week of oral antibiotic treatment or an episode that lasted for months and was treated with repeated courses of antibiotics, or did they have 5 or 6 episodes over a 2-year period that completely disrupted their life? How many of these patients had experienced a perforation with abscess that was treated with percutaneous drainage, had endured multiple episodes that resulted in a stricture through which a scope could not be passed, or had developed a colovesical or colovaginal fistula that required operation to resolve? All of these situations are managed “electively,” and all of these situations might, “by assumption,” lead to an operation that would be technically more demanding and complicated—with higher mortality and morbidity rates—than an operation for a small sigmoid tumor, where the anatomy is clearly visible and the field is pristine. When it comes to offering surgery—a treatment that has a very real morbidity and mortality rate—we surgeons need to be in a mode of constantly evaluating and reevaluating our outcomes, so that we can accurately communicate to patients the risk-benefit ratio for the treatments we are offering. We need the most accurate data we can find to guide us in these discussions. We are not convinced that data generated by administrative database queries is always accurate and valid given that these databases are not constructed for this purpose. The details simply are not there. Back to top Article Information Correspondence: Dr Ludwig, Department of Surgery, Medical College of Wisconsin, 9200 W Wisconsin Ave, Milwaukee, WI 53226. Published Online: December 17, 2012. doi:10.1001/jamasurg.2013.1106 Conflict of Interest Disclosures: None reported. References 1. Van Arendonk KJ, Tymitz KM, Gearhart SL, Stem M, Lidor AO. Outcomes and costs of elective surgery for diverticular disease: a comparison with other diseases requiring colectomy [published online December 17, 2012]. JAMA Surg. 2013;148(4):316-321Google ScholarCrossref http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png JAMA Surgery American Medical Association

The Risk-Benefit Ratio: Comment on “Outcomes and Costs of Elective Surgery for Diverticular Disease”

Ludwig, Kirk A.; Kosinski, Lauren A.
JAMA Surgery , Volume 148 (4) – Apr 1, 2013
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The Risk-Benefit Ratio: Comment on “Outcomes and Costs of Elective Surgery for Diverticular Disease”

Abstract

Van Arendonk et al1 used the Nationwide Inpatient Sample database to evaluate outcomes for colon surgery based on the disease being treated: colon cancer (CC), diverticular disease (DD), or inflammatory bowel disease (IBD). They conclude that elective resection for DD, when the analysis is adjusted for demographic and clinical characteristics, is associated with a higher morbidity and mortality rate than that seen when operating because of CC and that these data should then be used to...
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Publisher
American Medical Association
Copyright
Copyright © 2013 American Medical Association. All Rights Reserved.
ISSN
2168-6254
eISSN
2168-6262
DOI
10.1001/jamasurg.2013.1106
Publisher site
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Abstract

Van Arendonk et al1 used the Nationwide Inpatient Sample database to evaluate outcomes for colon surgery based on the disease being treated: colon cancer (CC), diverticular disease (DD), or inflammatory bowel disease (IBD). They conclude that elective resection for DD, when the analysis is adjusted for demographic and clinical characteristics, is associated with a higher morbidity and mortality rate than that seen when operating because of CC and that these data should then be used to question the advisability of offering routine elective colectomy after successful nonoperative management of acute diverticulitis. The underlying concept or assumption seems to be that many patients being offered elective resection for DD do not really need the operation, since recent data and guidelines would suggest that the course of their disease may not ultimately take them to a middle-of-the-night emergency operation for perforation that routinely involves a stoma and the subsequent operation to reestablish gastrointestinal tract continuity. The implication is that, before we offer an elective resection for DD, we should be aware that the risk of such an undertaking may be greater than we appreciate, suggesting that perhaps we should stand down, observe, treat expectantly, and not operate so frequently. I assume we are to suppose that the sequelae of DD—inflammation, distortion of tissue planes, thick mesentery, etc—make surgery riskier and that, since the natural course of the disease is such that complications may not arise after an episode or two, why operate? The problem with these data is that they are derived from an administrative database that simply does not provide enough detail to allow us to make any of these assumptions or draw these conclusions. There are no data on the indication for operation for these patients. Were they offered an operation because they had had 1 episode of acute diverticulitis that resolved after a week of oral antibiotic treatment or an episode that lasted for months and was treated with repeated courses of antibiotics, or did they have 5 or 6 episodes over a 2-year period that completely disrupted their life? How many of these patients had experienced a perforation with abscess that was treated with percutaneous drainage, had endured multiple episodes that resulted in a stricture through which a scope could not be passed, or had developed a colovesical or colovaginal fistula that required operation to resolve? All of these situations are managed “electively,” and all of these situations might, “by assumption,” lead to an operation that would be technically more demanding and complicated—with higher mortality and morbidity rates—than an operation for a small sigmoid tumor, where the anatomy is clearly visible and the field is pristine. When it comes to offering surgery—a treatment that has a very real morbidity and mortality rate—we surgeons need to be in a mode of constantly evaluating and reevaluating our outcomes, so that we can accurately communicate to patients the risk-benefit ratio for the treatments we are offering. We need the most accurate data we can find to guide us in these discussions. We are not convinced that data generated by administrative database queries is always accurate and valid given that these databases are not constructed for this purpose. The details simply are not there. Back to top Article Information Correspondence: Dr Ludwig, Department of Surgery, Medical College of Wisconsin, 9200 W Wisconsin Ave, Milwaukee, WI 53226. Published Online: December 17, 2012. doi:10.1001/jamasurg.2013.1106 Conflict of Interest Disclosures: None reported. References 1. Van Arendonk KJ, Tymitz KM, Gearhart SL, Stem M, Lidor AO. Outcomes and costs of elective surgery for diverticular disease: a comparison with other diseases requiring colectomy [published online December 17, 2012]. JAMA Surg. 2013;148(4):316-321Google ScholarCrossref

Journal

JAMA Surgery – American Medical Association

Published: Apr 1, 2013

Keywords: surgical procedures, elective

References

  • Outcomes and costs of elective surgery for diverticular disease: a comparison with other diseases requiring colectomy [published online December 17, 2012].
    Van Arendonk KJ; Tymitz KM; Gearhart SL; Stem M; Lidor AO