A virtual reality endoscopic simulator augments general surgery resident cancer education as measured by performance improvement.

Colorectal cancer is the second most common cause of death in the USA. The need for screening colonoscopies, and thus adequately trained endoscopists, particularly in rural areas, is on the rise. Recent increases in required endoscopic cases for surgical resident graduation by the Surgery Residency Review Committee (RRC) further emphasize the need for more effective endoscopic training during residency to determine if a virtual reality colonoscopy simulator enhances surgical resident endoscopic education by detecting improvement in colonoscopy skills before and after 6 weeks of formal clinical endoscopic training. We conducted a retrospective review of prospectively collected surgery resident data on an endoscopy simulator. Residents performed four different clinical scenarios on the endoscopic simulator before and after a 6-week endoscopic training course. Data were collected over a 5-year period from 94 different residents performing a total of 795 colonoscopic simulation scenarios. Main outcome measures included time to cecal intubation, "red out" time, and severity of simulated patient discomfort (mild, moderate, severe, extreme) during colonoscopy scenarios. Average time to intubation of the cecum was 6.8 min for those residents who had not undergone endoscopic training versus 4.4 min for those who had undergone endoscopic training (p < 0.001). Residents who could be compared against themselves (pre vs. post-training), cecal intubation times decreased from 7.1 to 4.3 min (p < 0.001). Post-endoscopy rotation residents caused less severe discomfort during simulated colonoscopy than pre-endoscopy rotation residents (4 vs. 10%; p = 0.004). Virtual reality endoscopic simulation is an effective tool for both augmenting surgical resident endoscopy cancer education and measuring improvement in resident performance after formal clinical endoscopic training.

Does primary anastomosis with diversion have any advantages over Hartmann's procedure in acute diverticulitis?.

BACKGROUND: The optimal treatment for acute complicated diverticulitis is still a matter of debate. We evaluated outcomes of primary anastomosis with proximal diversion (PAD) versus Hartman's procedure (HP) in acute diverticulitis. METHODS: Using the National Inpatient Sample database, we examined the clinical data of patients who underwent an urgent open colorectal resection (sigmoidectomy or anterior resection) for acute diverticulitis from 2002 to 2007 in the United States. We evaluated patient characteristics, patient comorbidities, perioperative complications, in-hospital mortality, length of hospital stay and total hospital charges between two groups. RESULTS: A total of 99,259 patients underwent urgent surgery for acute diverticulitis during these years (Primary anastomosis without diversion: 39.3%; HP: 57.3% and PAD: 3.4%). The overall complication rate was lower in the PAD group compared with the HP group (PAD: 39.06% vs. HP: 40.84%; p = 0.04). Patients in the HP group had a shorter mean length of stay (12.5 vs.14.4 days, p < 0.001) and lower mean hospital costs (USD 65,037 vs. USD 73,440, p < 0.01) compared with the PAD group. Mortality was higher in the HP group (4.82 vs. 3.99%, p = 0.03). CONCLUSION: PAD has improved outcomes compared with HP, and should be considered in patients who are deemed candidates for two-stage operations for acute diverticulitis.

Timing of radiation therapy, lymph node retrieval, and survival in rectal cancer.

BACKGROUND: Lymph node retrieval is an independent prognostic factor for survival in rectal cancer. Preoperative radiotherapy has been shown to impact the number of lymph nodes retrieved. OBJECTIVE: This study aimed to analyze colorectal cancer-specific mortality and overall mortality associated with the number of lymph nodes retrieved in relation to use and timing of radiotherapy. DESIGN: This study was designed as a retrospective analysis. SETTINGS: Analysis of the California Cancer Registry was conducted. PATIENTS: Patients with rectal cancer from 1994 to 2006 with a follow-up until January 2008 were included. MAIN OUTCOME MEASURES: The number of lymph nodes (1-3, 4-6, 7-11, ≥ 12) stratified by stage (I, II, and III) was analyzed based on radiotherapy status (no radiotherapy, preoperative radiotherapy, and postoperative radiotherapy). Multivariate colorectal cancer-specific survival and overall mortality analyses were performed using Cox proportional-hazard ratios. RESULTS: A total of 17,670 incident cases of stage I, II, and III rectal cancer were identified. The number of lymph nodes retrieved in cases receiving preoperative radiotherapy was lower than others. In stage II cases receiving preoperative radiotherapy, retrieval of 7 to 11 lymph nodes (compared with 0 lymph nodes retrieved as a reference) reached the nadir of colorectal cancer-specific mortality benefit (HR = 0.39, 95% CI, 0.28-0.56) and overall mortality (HR = 0.62, 95% CI, 0.48-0.80). In stage II cases with no radiotherapy or postoperative radiotherapy, retrieval of ≥ 12 lymph nodes remained the strongest prognosticator of colorectal cancer-specific mortality (HR = 0.34, 95% CI, 0.25-0.46; HR = 0.36, 95% CI, 0.24-0.53 respectively). LIMITATIONS: : The California Cancer Registry does not include radiation dose and duration, chemotherapy type and dosage, margin status and surgeon characteristics, and stated reasons for lower number of lymph nodes retrieved or patient-related factors. In addition, no central pathology laboratory was used. CONCLUSIONS: In stage II rectal cancer cases receiving preoperative radiotherapy vs either postoperative or no radiotherapy, a lower threshold of lymph node retrieval may be sufficient to evaluate prognosis and to guide further therapy.

Outcomes of laparoscopic versus open colectomy in elective surgery for diverticulitis.

BACKGROUND: The role of laparoscopy in the management of diverticular disease is evolving. Concerns were raised in the past because laparoscopic resection for diverticulitis is often difficult and occasionally hazardous. This study was undertaken to evaluate the difference in overall outcomes between elective open and laparoscopic surgery with or without anastomosis for diverticulitis. METHODS: Using the National Inpatient Sample (NIS) database, clinical data of patients who underwent elective open and laparoscopic surgery (lap) for diverticulitis from 2002 to 2007 were collected and analyzed. Patients who underwent emergent surgery were excluded. RESULTS: A total of 124,734 patients underwent elective surgery for diverticulitis: open, 110,172 (88.3%); lap, 14,562 (11.7%). The overall intraoperative complication rate was significantly lower in the laparoscopy group (0.63% vs. 1.15%, P < 0.01). However, there was no significant difference observed in ureteral injury between groups (open, 0.17%; lap, 0.12%, P = 0.15). All evaluated postoperative complications (ileus, abdominal abscess, leak, wound infection, bowel obstruction, urinary tract infection, pneumonia, respiratory failure, venous thromboembolism) were significantly higher for the open procedures. The laparoscopy group had a shorter mean hospital stay (lap, 5.06 days; open, 6.68 days, P < 0.01) and lower total hospital charges (lap, $36,389; open, $39,406, P < 0.01) than the open group. Also, mortality was four times higher in the open group (open, 0.54%; lap, 0.13%, P < 0.01). CONCLUSIONS: The laparoscopic operation was associated with lower morbidity, lower mortality, shorter hospital stay, and lower hospital charges compared to the open operation for diverticulitis. Elective laparoscopic surgery for diverticulitis is safe and can be considered the preferred operative option.

No visible scar (NVIS) colectomy: a new approach to minimal access surgery to the colon.

INTRODUCTION: Minimally invasive surgery continues to revolutionize surgical standards with trends toward further minimalization and improved cosmesis. Approaches such as laparoendoscopic single-site surgery (LESS) and natural orifice translumenal endoscopic surgery (NOTES) have thus emerged. The authors devised an alternative method for a more efficient approach to minimally invasive surgery called no visible scar (NVIS). This study describes NVIS and its ability to provide operative capacity and outcomes similar to other minimal access techniques, but with improved cosmesis and possibly decreased associated complications. METHODS: This is a retrospective analysis of patients undergoing colectomy between June 2009 and March 2010 to evaluate our outcomes with the NVIS technique (surgical approach via a 4-5 cm suprapubic site for inserting trocars/multiport and specimen extraction, with a 5-mm umbilical incision for a single trocar). Outcome measures included intraoperative complications, postoperative morbidity, and cosmetic outcome. RESULTS: Ten patients with a mean age of 60.3 years underwent NVIS colectomy. The average operating time was 161.3 minutes with a mean blood loss of 56.5 mL. There were no conversions to open surgery. One patient required additional trocar placement. No perioperative complications were encountered. On follow-up, no wound complications were noted and all patients appeared satisfied with their cosmetic outcome. One patient was readmitted for a low-grade fever, but the NVIS technique was not identified as a contributor. CONCLUSION: NVIS is a safe and feasible minimal access alternative, which improves cosmesis and may decrease complications associated with other minimally invasive techniques. Further analysis in a larger patient population is warranted to support our findings.

A tale of two (anal fistula) plugs: is there a difference in short-term outcomes?

Treatment of complex anal fistulas presents an ongoing challenge to colorectal surgeons. The anal fistula plug is an attractive definitive option due to its minimal risk of incontinence, simple design, and easy application. Our objective was to compare the Cook Surgisis AFP plug and the newer Gore Bio-A plug in the management of complex anal fistulas. A retrospective chart review of patients treated with Cook and Gore fistula plugs between August 2007 and December 2009 was performed. Success was defined as closure of all external openings and absence of drainage and abscess formation. Twelve Cook patients underwent 16 plug insertions and 10 Gore patients underwent 11 plug insertions. The overall procedural success rate in the Gore group was 54.5 per cent (6 of 11) versus 12.5 per cent (2 of 16) in the Cook group. The reasons for failure were unknown in the majority of patients and plug dislodgement in two patients. Our short-term results with the Gore fistula plug suggest a higher procedural success rate in comparison to the Cook plug. Patients should be cautioned regarding potentially high failure rates; however, longer follow-up and a larger patient population are needed to confirm significant differences in fistula plug efficacy.

A disease-based comparison of liver transplantation outcomes.

An increasing demand for transplant donor organs has made optimal allocation of resources a priority. Our objective was to evaluate outcomes for orthotopic liver transplantation (OLT) performed in the United States. A query of the United Network for Organ Sharing registry between 1988 and 2007 was performed for patients who underwent OLT for all etiologies. Patients were stratified by pathology necessitating OLT and clinical and pathologic factors were compared. Multivariate Cox-regression analysis was used to assess the association of pathology with survival. Of 61,823 patients, 33 per cent (n = 20,305) of OLTs were secondary to hepatitis C virus, 21 per cent autoimmune disease, 17 per cent alcohol-induced injury, 11 per cent cryptogenic cirrhosis, 8 per cent hepatocellular carcinoma (HCC), 6 per cent hepatitis B virus, and 4 per cent metabolic disease. Patients with autoimmune disease and HCC demonstrated the best and worst survival, respectively, after OLT (median survival 16.0 vs 6.4 yrs, respectively, P < 0.001). By multivariate analysis, OLT for HCC was significantly associated with poorer overall survival (hazard ratio [HR] 2.19, 95% confidence interval [CI]: 2.02-2.37, P < 0.001). Our results indicate that outcomes for liver transplantation vary by primary hepatic pathology with HCC patients having the poorest overall survival. To optimize organ allocation for all patients with end-stage liver disease, a better understanding of poor survival for HCC is necessary.

Case of intestinal tuberculosis mimicking Crohn's disease.

BACKGROUND: Intestinal tuberculosis can closely mimic Crohn's disease and colon cancer. Presented here is a case of intestinal tuberculosis that closely mimicked both. CASE REPORT: A 23 year old Hispanic female presented with several months of weight loss, recurrent fever, and emesis. The patient did not have pulmonary symptoms or radiographic evidence of tuberculosis. Colonoscopy evaluation with biopsy of the affected bowel segments were thought to be consistent with either colon cancer or Crohn's Disease. Acid fast bacilli staining and histological analysis did not display evidence of tuberculosis on two separate occasions. The patient developed colonic obstruction acutely during the course of treatment requiring resection of the affected bowel segment. Acid fast staining of the resected lymph nodes was positive and submucosal caseating granulomas were identified histologically, consistent with intestinal tuberculosis. CONCLUSIONS: Intestinal tuberculosis remains a diagnostic challenge. Consideration of the disease should be maintained in equivocal cases.

Trends in diverticulitis management in the United States from 2002 to 2007.

OBJECTIVE: To demonstrate the recent trends of admission and surgical management for diverticulitis in the United States. DESIGN: Retrospective database analysis. SETTING: The National Inpatient Sample database. PATIENTS: Patients admitted to the hospital for diverticulitis from 2002 to 2007. MAIN OUTCOME MEASURES: Patient characteristics, surgical approach, and mortality were evaluated for elective or emergent admission. RESULTS: A total of 1,073,397 patients were admitted with diverticulitis (emergent: 78.3%, elective: 21.7%). The emergent admission rate increased by 9.5% over the study period. For emergent patients, 12.2% underwent urgent surgical resection and 87.8% were treated with nonoperative methods (percutaneous abscess drainage: 1.88% and medical treatment: 85.92%). There was only a 4.3% increase in urgent surgical resections, while elective surgical resections increased by 38.7.%. The overall rate of elective laparoscopic colon resection was 10.5%. Elective laparoscopic surgery nearly doubled from 6.9% in 2002 to 13.5% in 2007 (P < .001). Primary anastomosis rates increased for elective resections over time (92.1% in 2002 to 94.5% in 2007; P < .001). For urgent open operation, use of colostomy decreased significantly from 61.2% in 2002 to 54.0% in 2007 (P < .001). In-hospital mortality significantly decreased in both elective and urgent surgery (elective: 0.53% in 2002 to 0.44% in 2007; P = .001; urgent: 4.5% in 2002 to 2.5% in 2007; P < .001). CONCLUSION: Diverticulitis continues to be a source of significant morbidity in the United States. However, our data show a trend toward increased use of laparoscopic techniques for elective operations and primary anastomosis for urgent operations.

The use of a compression device as an alternative to hand-sewn and stapled colorectal anastomoses: is three a crowd?

BACKGROUND: The NiTi CAR™ 27 is a newer device that uses compression to create an anastomosis. An analysis of this device in the creation of colorectal anastomoses in humans has yet to be reported in the USA. METHODS: A non-randomized, prospective pilot study of the NiTi CAR™ 27 device in patients undergoing a left-sided colectomy between March 2008 and August 2009 was performed. RESULTS: Twenty-three patients (9 men and 14 women) underwent a left-sided colectomy and compression anastomosis with the CAR™ 27 device. Minor morbidities, 3 of 23 (13%) patients, included one small postoperative abscess requiring antibiotics alone and two postoperative anastomotic strictures requiring balloon dilation. Major morbidities, 1 of 23 (4%) patients, included a partial anastomotic dehiscence/leak requiring surgical dismantling of the anastomosis and diversion. CONCLUSION: The CAR™ 27 device shows promise as a safe and effective alternative for the creation of colorectal anastomoses. However, studies in a larger patient population are warranted to demonstrate equivalence of this device.

Incidence and risk factors of venous thromboembolism in colorectal surgery: does laparoscopy impart an advantage?

OBJECTIVES: Laparoscopy is increasingly used in colon and rectal procedures. However, little is known regarding the incidence of venous thromboembolism (VTE) in laparoscopic colorectal (LC) compared with that in open colorectal (OC) procedures. We aimed to compare the incidences and to highlight the risk factors of developing VTE after LC and OC surgery. DESIGN: Analysis of the Nationwide Inpatient Sample data from 2002 through 2006. SETTING: National database. PATIENTS: Patients who underwent elective LC and OC surgery from 2002 through 2006. MAIN OUTCOMES MEASURE: Incidence of VTE during initial hospitalization after LC and OC surgery; VTE classified by surgical site, pathology type, and at-risk patient population. RESULTS: Over a 60-month period, 149,304 patients underwent LC or OC resection. Overall, the incidence of VTE was significantly higher in OC cases (2036 of 141,456 [1.44%]) compared with the incidence in LC cases (65 of 7848 [0.83%]) (P < .001). When stratified according to pathologic condition and surgical site, the overall rate of VTE was highest in patients with inflammatory bowel disease and in those undergoing rectal resections. Patients who underwent OC surgery were almost twice as likely to develop VTE compared with patients who underwent LC surgery. We also identified malignancy, obesity, and congestive heart failure as statistically significant (P < .05) risk factors for VTE in OC and LC surgery. CONCLUSIONS: On the basis of data from a large clinical data set, the incidence of perioperative VTE is lower after LC than after OC surgery. These findings may help colorectal surgeons use appropriate VTE prophylaxis for patients undergoing colorectal procedures.

Outcomes of right vs. left colectomy for colon cancer.

BACKGROUND: Right colectomy (RC) is generally believed to be a simpler operation with better outcomes than left colectomy (LC). Our study was primarily intended to compare patient characteristics and perioperative outcomes between RC and LC in colon cancer patients, and secondarily to identify factors that increase the risk of developing postoperative abdominal abscess and/or anastomotic leak. METHODS: Using the 2007 Nationwide Inpatient Sample database, we evaluated patients who underwent elective RC and LC for colon cancer. RESULTS: A total of 50,799 patients underwent elective RC and LC for malignancy during 2007 (RC, 63.5%; LC, 36.5%). Overall, 9.6% were performed laparoscopically (RC, 9.7% vs. LC, 9.5%, P = 0.39). The majority of patients were Caucasian; 54.2% of RC and 46.5% LC patients were female (P < 0.01). RC patients were older (mean age, 70.8 vs. 65.8 years, P < 0.01) and had more comorbidities. While LC had more overall intraoperative complications (RC, 0.30% vs. LC, 1.32%, P < 0.01), RC had higher overall incidence of postoperative complications (28.43% vs. 26.75%, P < 0.01). Mean length of hospital stay (RC, 7.37 days vs. LC, 7.38 days) and in-hospital mortality (RC, 1.37% vs. LC, 1.49%) were similar in both groups. Multivariate analysis identified Native American race [adjusted odd ratio (AOR), 2.02], chronic renal failure (AOR, 1.97), congestive heart failure (AOR, 1.72), chronic pulmonary disease (AOR, 1.40), metastatic disease (AOR, 1.34), male gender (AOR, 1.23), and LC (AOR, 1.12) all independently increased the risk of abscess and/or leak. CONCLUSIONS: RC patients were older and had more comorbidities and postoperative complications. Patient characteristics and comorbidities were more important in determining overall postoperative complications than anastomotic types.

Factors predictive of venous thromboembolism in bariatric surgery.

Venous thromboembolism (VTE) is a significant cause of morbidity and mortality in bariatric surgery. The aim of this study was to evaluate the effect of patient characteristics, payer type, comorbidities, and surgical techniques on development of VTE in bariatric surgery. Using the National Inpatient Sample (NIS) database from 2006 to 2008, clinical data of 304,515 morbidly obese patients who underwent bariatric surgery were examined. Multiple regression analysis was performed to identify factors predictive of VTE. The overall rate of in-hospital VTE was 0.17 per cent, with the highest rate of VTE observed in open gastric bypass (0.45%). The VTE rate was significantly lower in laparoscopic compared with open gastric bypass (0.13% vs 0.45%, respectively, P < 0.01) and in nongastric bypass compared with gastric bypass procedures (0.06% vs 0.21%, respectively, P < 0.01). Alcohol abuse [odds ratio (OR): 8.7], open operation (OR: 2.5), gastric bypass procedures (OR: 2.4), renal failure (OR: 2.3), congestive heart failure (OR: 2.0), male gender (OR: 1.5), and chronic lung disease (OR: 1.4) were associated with a higher rate of VTE. This study identified several significant risk factors for development of VTE in bariatric surgery. To minimize the risk of VTE, surgeons may consider these factors in selection of appropriate prophylaxis and bariatric surgical options.