Outpatient colectomy-a dream or reality?

Whereas the advancement of minimally invasive surgical techniques and enhanced recovery after surgery (ERAS) pathways for partial colectomies has shortened postoperative length of stay, the ideal length of stay after partial colectomy with or without diverting loop ileostomy is still up for debate. This article examines the safety and efficacy of discharging select patients home from day surgery following partial colectomy. We performed a retrospective review of 7 patients who underwent partial colectomy at one tertiary care center from December 2020 to August 2021. None of our cases suffered complications such as anastomotic leak, surgical site infection, or bowel obstruction or required admission to the hospital. One patient was seen in the emergency department on postoperative day 1 for nausea and vomiting and was managed as an outpatient. A second patient required a fluid bolus in the clinic for high ileostomy output. In conclusion, our study suggests that appropriately selected patients can be successfully managed in the outpatient setting without increased complications following partial colectomy when preoperative preparation and education are put in place alongside our colon ERAS pathway and minimally invasive surgical techniques.

Prophylactic ureteral catheter placement for minimally invasive colorectal surgery.

Ureteral catheter placement for identification of ureters during colorectal surgery has been a controversial subject with ill-defined indications. We present a case of ureteral catheter placement wherein the patient required readmission for renal failure with intervention under local anesthesia. This case highlights the importance of patient selection for catheter placement and clinical follow-up, as well as the need for prospective studies to determine the risk-benefit ratio of preoperative catheters.

Evaluation of the Educational Environment of a Cadaver Course in Robotic Colorectal Surgery: A Cross-sectional Study.

BACKGROUND: The educational environment is a crucial metric of medical education that affects the course participants' motivation, achievement, happiness and success. The aim of this study was to evaluate the educational environment of a cadaver course in robotic colorectal surgery by comparing the perceptions of the participating residents to those of the participating surgeons. METHODS: This was a cross-sectional study carried out in 2017. Participants from the U.S. and Europe attended a course using eight fresh frozen cadaver torsos with no prior abdominal surgery. After course completion, participants anonymously completed 50-item Dundee Ready Educational Environment Measure (DREEM) questionnaires to evaluate five components of the educational environment: perception of learning, perception of teachers, academic self-perception, perception of atmosphere, and social self-perception. Internal consistency of the questionnaire was assessed using Cronbach's alpha coefficient. Mean scores were compared using an independent samples t-test. RESULTS: Twenty of 24 participants completed the DREEM questionnaire, consisting of 9 residents and 11 surgeons (12 from the U.S., 8 from Europe). The internal consistency of the questionnaire was excellent (alpha=0.97). The mean total score was excellent for both residents and surgeons, and the difference between the groups was not significant (154.1±25.8 vs. 168.1±18.9, p=0.197). Perception of learning was significantly better among surgeons ("teaching highly thought of") than among residents ("a more positive perception") (40.5±3.6 vs. 35.7±5.6, p=0.04). CONCLUSIONS: This study suggests that the residents' perception of learning may have been negatively influenced by the participation of surgeons in the same cadaver station.

Impact of complications on length of stay in elective laparoscopic colectomies.

BACKGROUND: Length of hospital stay (LOS) is an indirect measure of surgical quality and a surrogate for cost. The impact of postoperative complications on LOS following elective colorectal surgery is not well defined. The purpose of this study is to determine the contribution of specific complications towards LOS in elective laparoscopic colectomy patients. MATERIALS AND METHODS: American College of Surgeon's National Surgical Quality Improvement Program database (2011-2014) was queried for patients undergoing elective laparoscopic partial colectomy with primary anastomosis. Demographics, specific 30 d postoperative complications and LOS, were evaluated. A negative binomial regression adjusting for demographic variables and complications was performed to explore the impact of individual complications on LOS, significance set at P < 0.05. RESULTS: A total of 42,365 patients were evaluated, with an overall median LOS 4.0 d (interquartile range, 3.0-5.0). Unplanned reoperation and pneumonia each increase LOS by 50%; superficial surgical site infections (SSIs), organ space SSI sepsis, urinary tract infection, ventilation >48 h, pulmonary embolism, and myocardial infarction each increase LOS by at least 25% (P < 0.0001). When accounting for additional LOS and rate of complications, unplanned reoperation, bleeding requiring transfusion within 72 h, and superficial SSIs were the highest impact complications. CONCLUSIONS: In laparoscopic colectomy, each complication uniquely impacts LOS, and therefore cost. Utilizing this model, individual hospitals can implement pathways targeting specific complication profiles to improve care and minimize health care cost.

Treatment of obstructed defecation.

Obstructed defecation is a common problem that adversely affects the quality of life for many patients. Known causes of obstructed defecation include pelvic dyssynergy, rectocele, rectal intussusception, enterocele, pelvic organ prolapse, and overt rectal prolapse. Management of this condition requires an understanding of urinary, defecatory, and sexual function to achieve an optimal outcome. The goal of surgical treatment is to restore the various pelvic organs to their appropriate anatomic positions. However, there is a poor correlation between anatomic and functional results. As the pelvis contains many structures, a pelvic support or function defect frequently affects other pelvic organs. Optimal outcomes can only be achieved by selecting appropriate treatment modalities that address all of the components of a patient's problem.

Colonoscopic injection for murine solid cecal cancer model.

BACKGROUND: The validity of current animal colon cancer models is questionable. This study was performed to evaluate whether colonoscopic injection of a murine colon cancer cell line into the cecal wall of immunocompetent rats leads to a solid tumor. METHODS: A bolus of bowel prep was given to BD-IX rats. Anesthesia was injected intraperitoneally. Video fiberscope allowed for irrigation and suction. Failure was inability to reach/inject cecum. Procedure was performed by four surgeons; 100 µl of colon tumor cell suspension (DHD/K12TRb; 10 million cells in 0.1 ml) was injected into cecal wall with 23-gauge needle placed on 3 mm wire resulting in a blister. Rats were allowed to recover. Solid tumor growth was measured at scheduled necropsy at 4 weeks. Sample size (107 rats: type I error 0.05; power 80%) was based on a pilot study. Data were presented as median (range). RESULTS: A total of 107 male BD-IX retired breeders weighing 356 g (range 256-432 g) underwent colonoscopy with submucosal injection of cecal wall. A single solid cecal cancer was identified in 98 (91.5%) rats at scheduled necropsy. Histology confirmed adenocarcinoma with tumor size of 4 mm (range 2.6-8.4 mm). Peritoneal carcinomatosis was found in ten (9.3%) rats. Distant metastases were found in three (2.8%) rats. Complications occurred in four (3.8%) rats: two aspirations and two colon perforations. CONCLUSIONS: A solid cecal tumor without carcinomatosis or metastasis has been developed by colonoscopic injection of a rat colon cancer cell line in 79% of immunocompetent rats.

Simulated laparoscopic sigmoidectomy training: responsiveness of surgery residents.

PURPOSE: This study aimed to evaluate the responsiveness of surgery residents to simulated laparoscopic sigmoidectomy training. METHODS: Residents underwent simulated laparoscopic sigmoidectomy training for previously tattooed sigmoid cancer with use of disposable abdominal trays in a hybrid simulator to perform a seven-step standardized technique. After baseline testing and training, residents were tested with predetermined proficiency criteria. Content validity was defined as the extent to which outcome measures departed from clinical reality. Content-valid measures of trays were evaluated by two blinded raters. Simulator-generated metrics included path length and smoothness of instrument movements. Responsiveness was defined as change in performance over time and was assessed by comparing baseline testing with unmentored final testing. RESULTS: For eight weeks, eight postgraduate year 3/4 residents performed 34 resections. Overall operating time (67 vs. 37 min; P = 0.005), flexure (10 vs. 5 min; P = 0.005), inferior mesenteric vessel (8 vs. 5 min; P = 0.04), and ureter (7 vs. 1 min; P = 0.003) times improved significantly. Content-valid measures from trays remained unchanged. Path length (27,155.2 mm) and smoothness (3,575.5 cm/s3) of instrument movement remained unchanged. There were two bowel perforations and 19 anastomotic leaks. Leak rate decreased from 87% to 12.5%. Strong correlation was found between path length and smoothness of instrument movements (r = 0.9; P < 0.001). There was no correlation between simulator-generated metrics and content-valid outcome measures. Interrater reliability was 1.0 for all measures except anastomotic leak (k = 0.56). There was a linear relationship between residents' clinical advanced laparoscopic case volume and responsiveness (r = -0.7; P = 0.04). CONCLUSIONS: Simulated laparoscopic sigmoidectomy training affected responsiveness in surgery residents with significantly decreased operating time and anastomotic leak rate.

Prolonged postoperative ileus-definition, risk factors, and predictors after surgery.

BACKGROUND: Postoperative ileus (POI) remains an inevitable consequence of abdominal surgery. Although the pathogenesis of delayed gastrointestinal transit in the postoperative period has been the subject of considerable study, a clinically useful definition of what constitutes a pathologically prolonged ileus has yet to be established. The objectives of this study were to describe a definition for an abnormally prolonged ileus and to identify risk factors and predictors of prolonged ileus in patients undergoing abdominal surgery. MATERIALS AND METHODS: Over a 12-month period 88 patients who had abdominal surgery were retrospectively reviewed. The association of clinical factors with the duration of POI was examined with statistical tests. RESULTS: The mean time to commencing the consumption of unrestricted clear fluids after surgery was 2.3 +/- SD 1.6 days. The median duration of POI was 5 days (median 6 days), with an interquartile range of 3-6 days. Univariate regression analysis demonstrated significant correlations between duration of POI and estimated blood loss (EBL), total surgical time, and total opiate dose (TOD) (p = 0.009, p = 0.045, and p = 0.041, respectively). Multiple regression analysis identified EBL and TOD as independent predictors of duration of POI. CONCLUSIONS: We have identified two risk factors (EBL and TOD) that are independently associated with duration of POI. Our data suggest that with the definition of abnormal prolonged postoperative ileus as the number of days above the 3rd quartile, an ileus greater than 6 days serves as a better clinical definition of prolonged POI than 3 days, the measure that has previously been suggested.

Molecular predictors of lymph node metastasis in colon cancer: increased risk with decreased thymidylate synthase expression.

TNM staging in colon cancer has several limitations. Prognostic molecular markers are now being developed to address these limitations. The aim of this study was to identify a combination of genes and markers whose expression is predictive of nodal status and outcome in colon cancer. The expression of 12 genetic markers were examined in 66 node-positive and 65 node-negative T3 colon cancers. Gene expression was quantified using real-time polymerase chain reaction. Microsatellite instability status was available through the registry. Association with lymph node status was examined using univariate and multivariate logistic regression. Thymidylate synthase expression was statistically significantly associated with lymph node status (odds ratio 0.36; 95% confidence interval: 0.16-0.81). Microsatellite instability and the other genes were not associated with nodal status. Multiple logistic regression did not identify a significant multivariate predictive model. Decreased expression of thymidylate synthase is associated with a higher risk of lymph node metastasis in patients with T3 colon cancers. Microsatellite instability and the expression of other genes are not predictive of nodal status in this population. Thymidylate synthase gene expression may help identify patients at greater risk for progression of disease.

Cost-saving effect of treatment algorithm for chronic anal fissure: a prospective analysis.

Evidence-based medicine suggests that in the management of chronic anal fissure (CAF), lateral internal sphincterotomy (LIS) is far more effective than medical treatment in lowering the anal sphincter tone and curing the fissure. In the current study, we developed a treatment algorithm from topical nitroglycerin (NTG) to botulinum toxin type A (Botox [BTX]) to LIS and analyzed its cost benefit by calculating the effective and potential costs based on the treatment success and the rate of avoided surgeries. Patients presenting between November 2003 and December 2004 with CAF and symptoms for greater than 3 months were prospectively treated according to a treatment algorithm which started with (1) topical NTG, in case of failure (2) injection of BTX, thus limiting (3) surgery to those who failed both nonsurgical options or at any point chose the surgical approach. Based on the primary end points of fissure healing or surgery, we calculated the true cost (algorithm) and the potential incremental cost (BTX plus surgery or surgery in all patients, respectively). Sixty-seven patients with CAF (25 men and 42 women; median duration of symptoms, 16 weeks) were treated according to the algorithm. NTG alone was successful in fissure healing in 31 of 67 patients (46.2%). Two developed a recurrent fissure and then received BTX as part of the protocol. Of the 36 patients who failed NTG trial, 3 requested surgery; the others were treated with BTX, which was successful in 84.8%. Five patients (15.2%) failed BTX and subsequently required surgery. The overall surgery rate in the whole study group was 11.9%, whereas CAF healed in 88.1% of our patients with medical treatment alone. Cost for NTG is $10; for 100 units BTX, $528; and for outpatient surgery, $1119. The total cost for these 67 patients therefore was $33,252 ($290 for NTG, $20,580 for NTG plus BTX, $3,357 for NTG plus LIS, and $9,025 for NTG plus BTX plus LIS). If all patients had received BTX with a 15% failure rate, the total cost would have been $56,688 (70.3% cost increase). If all patients had undergone surgery as initial/only treatment, the total cost would have been $74,973 (125% cost increase). Our treatment algorithm for CAF with stepwise escalation can avoid surgery in 88% of the patients. It is highly cost-efficient and resulted in savings of 41% (compared with BTX plus LIS) and up to 70% (compared with surgery in all patients), respectively.

Laparoscopic versus open appendectomy: a prospective randomized double-blind study.

SUMMARY BACKGROUND DATA: The value of laparoscopy in appendicitis is not established. Studies suffer from multiple limitations. Our aim is to compare the safety and benefits of laparoscopic versus open appendectomy in a prospective randomized double blind study. METHODS: Two hundred forty-seven patients were analyzed following either laparoscopic or open appendectomy. A standardized wound dressing was applied blinding both patients and independent data collectors. Surgical technique was standardized among 4 surgeons. The main outcome measures were postoperative complications. Secondary outcome measures included evaluation of pain and activity scores at base line preoperatively and on every postoperative day, as well as resumption of diet and length of stay. Activity scores and quality of life were assessed on short-term follow-up. RESULTS: There was no mortality. The overall complication rate was similar in both groups (18.5% versus 17% in the laparoscopic and open groups respectively), but some early complications in the laparoscopic group required a reoperation. Operating time was significantly longer in the laparoscopic group (80 minutes versus 60 minutes; P = 0.000) while there was no difference in the pain scores and medications, resumption of diet, length of stay, or activity scores. At 2 weeks, there was no difference in the activity or pain scores, but physical health and general scores on the short-form 36 (SF36) quality of life assessment forms were significantly better in the laparoscopic group. Appendectomy for acute or complicated (perforated and gangrenous) appendicitis had similar complication rates, regardless of the technique (P = 0.181). CONCLUSIONS: Unlike other minimally invasive procedures, laparoscopic appendectomy did not offer a significant advantage over open appendectomy in all studied parameters except quality of life scores at 2 weeks. It also took longer to perform. The choice of the procedure should be based on surgeon or patient preference.

The management of complicated diverticulitis and the role of computed tomography.

PURPOSE: Acute diverticulitis is a disease with a wide clinical spectrum, ranging from a phlegmon (stage Ia), to localized abscesses (stages Ib and II), to free perforation with purulent (stage III) or feculent peritonitis (stage IV). While there is little debate about the best treatment for mild episodes and/or very severe episodes, uncertainty persists about the optimal management for intermediate stages (Ib and II). The aim of our study was therefore to define the role of computed tomography (CT) and to analyze its impact on the management of acute diverticulitis. METHODS: We retrospectively analyzed 511 patients (296 males, 215 females) admitted for acute diverticulitis between January 1994 and December 2003. Excluded were patients with stoma reversal only, "diverticulitis" mimicked by cancer, or significantly deficient patient records. Patients were analyzed either as a whole or subgrouped according to age (<40 yr, >40 yr). A modified Hinchey classification was used to stage the severity of acute diverticulitis. RESULTS: In 99 patients (19.4%), an abscess was found (74 pericolic, 25 pelvic, median diameter: 4.0 cm). CT-guided drainage was performed in 16 patients, one failure requiring a two-stage operation. Whereas conservative treatment failed in 6.8% in patients without abscess or perforation, 22.2% of patients with an abscess required an urgent resection (68.2%, one-stage, 31.8%, two-stage). Recurrence rates were 13% for mild cases, as compared to 41.2% in patients with a pelvic abscess (stage II) treated conservatively with/without CT-guided drainage. Of all surgical cases, resection/primary anastomosis was achieved in 73.6% with perioperative mortality of 1.1% and leak rate was 2.1%. CONCLUSIONS: CT evidence of a diverticular abscess has a prognostic impact as it correlates with a high risk of failure from nonoperative management regardless of the patient's age. After treatment of diverticulitis with CT evidence of an abscess, physicians should strongly consider elective surgery in order to prevent recurrent diverticulitis.

Management of retained colorectal foreign bodies: predictors of operative intervention.

PURPOSE: This study was designed to review experience at our hospital with retained colorectal foreign bodies. METHODS: We reviewed the consultation records at Los Angeles County + University of Southern California General Hospital from October 1993 through October 2002. Ninety-three cases of transanally introduced, retained foreign bodies were identified in 87 patients. Data collected included patient demographics, extraction method, location, size and type of foreign body, and postextraction course. RESULTS: Of 93 cases reviewed, there were 87 individuals who presented with first-time episodes of having a retained colorectal foreign body. For these patients, bedside extraction was successful in 74 percent. Ultimately, 23 patients were taken to the operating room for removal of their foreign body. In total, 17 examinations under anesthesia and 8 laparotomies were performed (2 patients initially underwent an anesthetized examination before laparotomy). In the eight patients who underwent exploratory laparotomy, only one had successful delivery of the foreign object into the rectum for transanal extraction. The remainder required repair of perforated bowel or retrieval of the foreign body via a colotomy. In our review, a majority of cases had objects retained within the rectum; the rest were located in the sigmoid colon. Fifty-five percent of patients (6/11) presenting with a foreign body in the sigmoid colon required operative intervention vs. 24 percent of patients (17/70) with objects in their rectum (P = 0.04). CONCLUSIONS: This is the largest single institution series of retained colorectal foreign bodies. Although foreign objects located in the sigmoid colon can be retrieved at the bedside, these cases are more likely to require operative intervention.

Use of high-dose-rate brachytherapy in the management of locally recurrent rectal cancer.

INTRODUCTION: Locally recurrent rectal cancer is associated with poor quality of life and has justified aggressive surgical and adjuvant approaches to control the disease. This study was designed to evaluate the use of fractionated perioperative high-dose-rate brachytherapy in association with wide surgical excision (debulking). Our hypothesis is that this combined therapy can help control locally recurrent rectal cancer. METHODS: Patients with biopsy-proven locally recurrent rectal cancer that could not be completely removed surgically were considered candidates for this procedure. All patients had abdominal exploration, aggressive tumor debulking, and placement of afterloading brachytherapy catheters. Patients underwent simulation on postoperative Day 3 and received 1,200 to 2,500 (mean, 1,888) cGy of fractionated high-dose-rate brachytherapy between postoperative Days 3 and 5. All patients had involvement of the lateral pelvic sidewall and/or the sacrum. RESULTS: Twenty-seven patients (18 males) aged 32 to 79 years underwent therapy. Follow-up ranged from 18 to 93 (mean, 50) months and was available in 27 patients. Ten patients (37 percent) were alive at the time of this report. Nine patients are without evidence of disease. Five patients (18 percent) died of non-cancer-related causes without evidence of recurrent disease. Five complications potentially related to treatment (3 abscesses, 2 fistulas) occurred in five patients. CONCLUSION: High-dose radiation brachytherapy delivers high-dose, highly controlled, focused radiation to specific sites of disease, thereby minimizing injury to normal tissues. The results in this series suggest increased local control, better palliation, and increased salvage of patients.