Motivations and Barriers Toward Implementation of a Rectal Cancer Synoptic Operative Report: A Process Evaluation.

BACKGROUND: The use of synoptic reporting has been shown to improve documentation of critical information and provide added value related to data access and extraction, data reliability, relevant detail, and completeness of information. Surgeon acceptance and adoption of synoptic reports has lagged behind other specialties. OBJECTIVE: This study aimed to evaluate the process of implementing a synoptic operative report. DESIGN: This study was a mixed-methods process evaluation including surveys and qualitative interviews. SETTINGS: This study focused on colorectal surgery practices across the United States. PATIENTS: Twenty-eight board-certified colorectal surgeons were included. INTERVENTIONS: The synoptic operative report for rectal cancer was implemented. MAIN OUTCOME MEASURES: Acceptability, feasibility, and usability were measured by Likert-type survey questions and followed up with individual interviews to elicit experiences with implementation as well as motivations and barriers to use. RESULTS: Among all study participants, 28 surgeons completed the electronic survey (76% response rate) and 21 (57%) completed the telephone interview. Mean usability was 4.14 (range, 1-5; SE, 0.15), mean feasibility was 3.90 (SE, 0.15), and acceptability was 3.98 (SE, 0.18). Participants indicated that substantial administrative and technical support were necessary but not always available for implementation, and many were frustrated by the need to change their workflow. LIMITATIONS: Most surgeon participants were male, white, had >12 years in practice, and used Epic electronic medical record systems. Therefore, they may not represent the perspectives of all US colon and rectal surgeons. In addition, as the synoptic operative report is implemented more broadly across the United States, it will be important to consider variations in the process by electronic medical record system. CONCLUSIONS: The synoptic operative report for rectal cancer was easy to implement and incorporate into workflow, in general, but surgeons remained concerned about additional burden without immediate and tangible value. Despite recognizing benefits, many participants indicated they only implemented the synoptic operative report because it was mandated by the National Accreditation Program for Rectal Cancer. See Video Abstract at http://links.lww.com/DCR/B735MOTIVACIONES Y BARRERAS HACIA LA IMPLEMENTACIÓN DE UN INFORME OPERATIVO SINÓPTICO DE CÁNCER RECTAL: UNA EVALUACIÓN DEL PROCESOANTECEDENTES:Se ha demostrado que el uso de informes sinópticos mejora la documentación de información crítica y proporciona un valor agregado relacionado con el acceso y extracción de datos, la confiabilidad de los datos, los detalles relevantes y la integridad de la información. La aceptación y adopción de informes sinópticos por parte de los cirujanos se ha quedado rezagada con respecto a otras especialidades.OBJETIVO:Evaluar el proceso de implementación de un informe operativo sinóptico.DISEÑO:Evaluación de procesos de métodos mixtos que incluyen encuestas y entrevistas cualitativas.AJUSTES:Prácticas de cirugía colorrectal en los Estados Unidos.PACIENTES:Veintiocho cirujanos colorrectales certificados por la junta.INTERVENCIONES:Implementación del informe operatorio sinóptico de cáncer de recto.PRINCIPALES MEDIDAS DE RESULTADO:Aceptabilidad, viabilidad y usabilidad medidas por preguntas de encuestas tipo Likert y seguidas con entrevistas individuales para obtener experiencias con la implementación, así como motivaciones y barreras para el uso.RESULTADOS:Entre todos los participantes del estudio, 28 cirujanos completaron la encuesta electrónica (tasa de respuesta del 76%) y 21 (57%) completaron la entrevista telefónica. La usabilidad media fue 4,14 (rango = 1-5, error estándar (EE) = 0,15), la factibilidad media fue 3,90 (EE = 0,15) y la aceptabilidad fue 3,98 (EE = 0,18). Los participantes indicaron que se necesitaba un apoyo administrativo y técnico sustancial, pero que no siempre estaba disponible para la implementación y muchos se sintieron frustrados por la necesidad de cambiar su flujo de trabajo.LIMITACIONES:La mayoría de los cirujanos participantes eran hombres, blancos, tenían >12 años en la práctica y usaban sistemas de registros médicos electrónicos de Epic. Por lo tanto, es posible que no representen las perspectivas de todos los cirujanos de colon y recto de EE. UU. Además, a medida que el informe operativo sinóptico se implemente de manera más amplia en los EE. UU., Será importante considerar las variaciones en el proceso por sistema EMR.CONCLUSIONES:El informe quirúrgico sinóptico para el cáncer de recto fue en general fácil de implementar e incorporar en el flujo de trabajo, pero los cirujanos seguían preocupados por la carga adicional sin valor inmediato y tangible. A pesar de reconocer los beneficios, muchos participantes indicaron que solo implementaron el informe operativo sinóptico porque era un mandato del Programa Nacional de Acreditación para el Cáncer de Recto. Consulte Video Resumen en http://links.lww.com/DCR/B735 (Traducción-Dr. Xavier Delgadillo).

Effects of Colorectal Surgery Classification on Reported Postoperative Surgical Site Infections.

BACKGROUND: Current procedural terminology (CPT) for colon and rectal surgery lacks procedural granularity and misclassification rates are unknown. However, they are used in performance measurement, for example, in surgical site infection (SSI). The objective of this study was to determine whether American College of Surgeons National Surgical Quality Improvement Program (NSQIP) abstraction methods accurately classify types of colorectal operations and, by extension, reported SSI rates. MATERIALS AND METHODS: This was a retrospective study conducted at a single tertiary care center. The colectomy- and proctectomy-targeted NSQIP database from January 2011 to July 2016 was used to perform a semiautomated reclassification (SAR) of all colectomy and proctectomy cases performed by colorectal surgeons. The primary outcome was the difference in perioperative SSI rates by case classification method. RESULTS: Thousand sixty-three patients underwent a colectomy or proctectomy during the study period with a mean age of 55.7 (SD = 16.7) years. Use of the NSQIP classification scheme resulted in 849 colectomy and 214 proctectomy cases. Use of the SAR method resulted in 650 colectomy cases and 413 proctectomy cases (P < 0.001), a 23.4% reclassification of colectomy cases. The group of cases classified as colectomy by SAR had a lower rate of deep/organ space infections than those classified as colectomy by NSQIP (4.5% versus 7.1%, P = 0.034). CONCLUSIONS: These findings highlight the challenges of CPT code-based patient classification and subsequent outcomes analysis. Expanding the CPT system to more accurately represent colorectal operations would allow for more representative reported outcomes, thus enabling benchmarking and quality improvement.

Deep Immune Profiling of an Arginine-Enriched Nutritional Intervention in Patients Undergoing Surgery.

Application of high-content immune profiling technologies has enormous potential to advance medicine. Whether these technologies reveal pertinent biology when implemented in interventional clinical trials is an important question. The beneficial effects of preoperative arginine-enriched dietary supplements (AES) are highly context specific, as they reduce infection rates in elective surgery, but possibly increase morbidity in critically ill patients. This study combined single-cell mass cytometry with the multiplex analysis of relevant plasma cytokines to comprehensively profile the immune-modifying effects of this much-debated intervention in patients undergoing surgery. An elastic net algorithm applied to the high-dimensional mass cytometry dataset identified a cross-validated model consisting of 20 interrelated immune features that separated patients assigned to AES from controls. The model revealed wide-ranging effects of AES on innate and adaptive immune compartments. Notably, AES increased STAT1 and STAT3 signaling responses in lymphoid cell subsets after surgery, consistent with enhanced adaptive mechanisms that may protect against postsurgical infection. Unexpectedly, AES also increased ERK and P38 MAPK signaling responses in monocytic myeloid-derived suppressor cells, which was paired with their pronounced expansion. These results provide novel mechanistic arguments as to why AES may exert context-specific beneficial or adverse effects in patients with critical illness. This study lays out an analytical framework to distill high-dimensional datasets gathered in an interventional clinical trial into a fairly simple model that converges with known biology and provides insight into novel and clinically relevant cellular mechanisms.

Predictors of postoperative urinary retention after colorectal surgery.

BACKGROUND: National quality initiatives have mandated the earlier removal of urinary catheters after surgery to decrease urinary tract infection rates. A potential unintended consequence is an increased postoperative urinary retention rate. OBJECTIVE: The aim of this study was to determine the incidence and risk factors for postoperative urinary retention after colorectal surgery. DESIGN: This was a prospective observational study. SETTINGS: A colorectal unit within a single institution was the setting for this study. PATIENTS: Adults undergoing elective colorectal operations were included. INTERVENTIONS: Urinary catheters were removed on postoperative day 1 for patients undergoing abdominal operations, and on day 3 for patients undergoing pelvic operations. Postvoid residual and retention volumes were measured. MAIN OUTCOME MEASURES: The primary outcomes measured were urinary retention and urinary tract infection. RESULTS: The overall urinary retention rate was 22.4% (22.8% in the abdominal group, 21.9% in the pelvic group) and was associated with longer operative time and increased perioperative fluid administration. Mean operative time for those with retention was 2.8 hours and, for those without retention, the mean operative time 2.2 hours (abdominal group 2 hours vs 1.4 hours, pelvic group 3.9 hours vs 3.1 hours, p ≤ 0.02). Patients with retention received a mean of 2.7L during the operation, whereas patients without retention received 1.8L (abdominal group 1.9L vs 1.4L, pelvic group 3.6L vs 2.2L, p < 0.01). In the abdominal group, patients with and without retention also received different fluid volumes on postoperative days 1 (2.2L vs 1.7L, p = 0.004) and 2 (1.6L vs 1L, p = 0.05). Laparoscopic abdominal group had a 40% retention rate in comparison with 12% in the open abdominal group (p = 0.004). Age, sex, preoperative radiation therapy, preoperative prostatism, preoperative diagnosis, and level of anastomosis were not associated with retention. The urinary tract infection rate was 4.9%. LIMITATION: The lack of documentation of preoperative urinary function was a limitation of this study. CONCLUSIONS: The practice of earlier urinary catheter removal must be balanced with operative time and fluid volume to avoid high urinary retention rates. Also important is increased vigilance for the early detection of retention.

Free transverse rectus abdominis myocutaneous flap reconstruction of a massive lumbosacral defect using superior gluteal artery perforator vessels.

Despite significant advances in reconstructive surgery, the repair of massive lumbosacral defects poses significant challenges. When the extent of soft tissue loss, tumor resection, and/or radiation therapy preclude the use of traditional local options, such as gluteal advancement flaps or pedicled thigh flaps, then distant flaps are required. We report a case of a 64-year-old male who presented with a large sacral Marjolin's ulcer secondary to recurrent pilonidal cysts and ulcerations. The patient underwent wide local composite resection, which resulted in a wound measuring 450 cm(2) with exposed rectum and sacrum. The massive defect was successfully covered with a free transverse rectus abdominis myocutaneous flap, providing a well-vascularized skin paddle and obviating the need for a latissimus flap with skin graft. The free-TRAM flap proved to be a very robust flap in this situation and would be one of our flaps of choice for similar defects.

Elucidating the fundamental fibrotic processes driving abdominal adhesion formation.

Adhesions are fibrotic scars that form between abdominal organs following surgery or infection, and may cause bowel obstruction, chronic pain, or infertility. Our understanding of adhesion biology is limited, which explains the paucity of anti-adhesion treatments. Here we present a systematic analysis of mouse and human adhesion tissues. First, we show that adhesions derive primarily from the visceral peritoneum, consistent with our clinical experience that adhesions form primarily following laparotomy rather than laparoscopy. Second, adhesions are formed by poly-clonal proliferating tissue-resident fibroblasts. Third, using single cell RNA-sequencing, we identify heterogeneity among adhesion fibroblasts, which is more pronounced at early timepoints. Fourth, JUN promotes adhesion formation and results in upregulation of PDGFRA expression. With JUN suppression, adhesion formation is diminished. Our findings support JUN as a therapeutic target to prevent adhesions. An anti-JUN therapy that could be applied intra-operatively to prevent adhesion formation could dramatically improve the lives of surgical patients.

Surgical and molecular characterization of primary and metastatic disease in a neuroendocrine tumor arising in a tailgut cyst.

Neuroendocrine tumors (NETs) arising from tailgut cysts are a rare but increasingly reported entity with gene expression profiles that may be indicative of the gastrointestinal cell of origin. We present a case report describing the unique pathological and genomic characteristics of a tailgut cyst NET that metastasized to liver. The histologic and immunohistochemical findings were consistent with a well-differentiated NET. Genomic testing indicates a germline frameshift in BRCA1 and a few somatic mutations of unknown significance. Transcriptomic analysis suggests an enteroendocrine L cell in the tailgut as a putative cell of origin. Genomic profiling of a rare NET and metastasis provides insight into its origin, development, and potential therapeutic options.

The Prognostic Significance of Pretreatment Hematologic Parameters in Patients Undergoing Resection for Colorectal Cancer.

OBJECTIVES: The prognostic value of several hematologic parameters, including platelet, lymphocyte, and neutrophil counts, has been studied in a variety of solid tumors. In this study, we examined the significance of inflammatory markers and their prognostic implications in patients with colorectal cancer (CRC). MATERIALS AND METHODS: Patients with stage I-III CRC who underwent surgical resection at the Stanford Cancer Institute between 2005 and 2009 were included. Patients were excluded if they did not have preoperative complete blood counts performed within 1 month of surgical resection, underwent preoperative chemotherapy or radiation, had metastatic disease at diagnosis, or had another previous malignancy. We included 129 eligible patients with available preoperative complete blood counts in the final analysis. RESULTS: A preoperative neutrophil-to-lymphocyte ratio of>3.3 was significantly associated with worse disease-free (DFS) and overall survival (OS) (P=0.009, 0.003), as was a preoperative lymphocyte-to-monocyte ratio of ≤2.6 (P=0.01, 0.002). Preoperative lymphopenia (P=0.002) was associated with worse OS but not DFS (P=0.09). In addition, preoperative thrombocytosis was associated with worse DFS (P=0.006) and OS (P=0.010). Preoperative leukocytosis was associated with worse OS (P=0.048) but not DFS (P=0.49). Preoperative hemoglobin was neither associated with OS (P=0.24) or DFS (P=0.15). CONCLUSIONS: Pretreatment lymphopenia, thrombocytosis, a decreased lymphocyte-to-monocyte ratio, and an elevated neutrophil-to-lymphocyte ratio independently predict for worse OS in patients with CRC.

Gastrointestinal mucormycosis requiring surgery in adults with hematologic malignant tumors: literature review.

BACKGROUND: Gastrointestinal mucormycosis is associated with high mortality rates. Appropriate and early antifungal therapy and prompt surgical intervention are essential. METHOD: Case report and literature review. RESULTS: Nineteen case reports were reviewed describing adults with hematologic malignant tumors who developed intestinal mucormycosis and underwent surgery. The overall survival rate was 50%. CONCLUSION: Intestinal mucormycosis is an infection associated with a high mortality rate although adults with underlying hematologic malignant have improved outcomes compared with other groups.

Single-cell dissection of transcriptional heterogeneity in human colon tumors.

Cancer is often viewed as a caricature of normal developmental processes, but the extent to which its cellular heterogeneity truly recapitulates multilineage differentiation processes of normal tissues remains unknown. Here we implement single-cell PCR gene-expression analysis to dissect the cellular composition of primary human normal colon and colon cancer epithelia. We show that human colon cancer tissues contain distinct cell populations whose transcriptional identities mirror those of the different cellular lineages of normal colon. By creating monoclonal tumor xenografts from injection of a single (n = 1) cell, we demonstrate that the transcriptional diversity of cancer tissues is largely explained by in vivo multilineage differentiation and not only by clonal genetic heterogeneity. Finally, we show that the different gene-expression programs linked to multilineage differentiation are strongly associated with patient survival. We develop two-gene classifier systems (KRT20 versus CA1, MS4A12, CD177, SLC26A3) that predict clinical outcomes with hazard ratios superior to those of pathological grade and comparable to those of microarray-derived multigene expression signatures.

Mechanical bowel preparation in intestinal surgery: a meta-analysis and review of the literature.

INTRODUCTION: Despite several meta-analyses and randomized controlled trials showing no benefit to patients, mechanical bowel preparation (MBP) remains the standard of practice for patients undergoing elective colorectal surgery. METHODS: We performed a systematic review of the literature of trials that prospectively compared MBP with no MBP for patients undergoing elective colorectal resection. We searched MEDLINE, LILACS, and SCISEARCH, abstracts of pertinent scientific meetings and reference lists for each article found. Experts in the field were queried as to knowledge of additional reports. Outcomes abstracted were anastomotic leaks and wound infections. Meta-analysis was performed using Peto Odds ratio. RESULTS: Of 4,601 patients (13 trials), 2,304 received MBP (Group 1) and 2,297 did not (Group 2). Anastomotic leaks occurred in 97(4.2%) patients in Group 1 and in 81(3.5%) patients in Group 2 (Peto OR = 1.214, CI 95%:0.899-1.64, P = 0.206). Wound infections occurred in 227(9.9%) patients in Group 1 and in 201(8.8%) patients in Group 2 (Peto OR = 1.156, CI 95%:0.946-1.413, P = 0.155). DISCUSSION: This meta-analysis demonstrates that MBP provides no benefit to patients undergoing elective colorectal surgery, thus, supporting elimination of routine MBP in elective colorectal surgery. CONCLUSION: In conclusion, MBP is of no benefit to patients undergoing elective colorectal resection and need not be recommended to meet "standard of care."

Dartos muscle interposition flap for the treatment of rectourethral fistulas.

PURPOSE: Rectourethral fistula is a rare complication of pelvic surgery, trauma, or inflammation. The many techniques for repairing these fistulas vary in their success rates. Our goal was to describe the use of a dartos muscle interposition flap for repair of these fistulas. METHODS: We performed a retrospective review of eight patients who underwent repair of a rectourethral fistula with a dartos muscle interposition flap. We describe the success rate and patient-related factors that may have affected success. The technique of dartos muscle interposition is described and compared with other previously described techniques. RESULTS: Six of eight patients had healing of their fistulas documented by follow-up cystogram. CONCLUSIONS: Dartos muscle interposition is a straightforward technique that can result in successful fistula repair but should not be used in patients with risk factors for poor wound healing, such as an immunocompromised state or previous radiation therapy.

Phenotypic characterization of human colorectal cancer stem cells.

Recent observations indicate that, in several types of human cancer, only a phenotypic subset of cancer cells within each tumor is capable of initiating tumor growth. This functional subset of cancer cells is operationally defined as the "cancer stem cell" (CSC) subset. Here we developed a CSC model for the study of human colorectal cancer (CRC). Solid CRC tissues, either primary tissues collected from surgical specimens or xenografts established in nonobese diabetic/severe combined immunodeficient (NOD/SCID) mice, were disaggregated into single-cell suspensions and analyzed by flow cytometry. Surface markers that displayed intratumor heterogeneous expression among epithelial cancer cells were selected for cell sorting and tumorigenicity experiments. Individual phenotypic cancer cell subsets were purified, and their tumor-initiating properties were investigated by injection in NOD/SCID mice. Our observations indicate that, in six of six human CRC tested, the ability to engraft in vivo in immunodeficient mice was restricted to a minority subpopulation of epithelial cell adhesion molecule (EpCAM)(high)/CD44+ epithelial cells. Tumors originated from EpCAM(high)/CD44+ cells maintained a differentiated phenotype and reproduced the full morphologic and phenotypic heterogeneity of their parental lesions. Analysis of the surface molecule repertoire of EpCAM(high)/CD44+ cells led to the identification of CD166 as an additional differentially expressed marker, useful for CSC isolation in three of three CRC tested. These results validate the stem cell working model in human CRC and provide a highly robust surface marker profile for CRC stem cell isolation.

Transperineal repair of persistent rectovaginal fistulas using an acellular cadaveric dermal graft (AlloDerm).

A number of surgical techniques have been described to treat rectovaginal fistulas. Recurrent or persistent fistulas after previous repair can be particularly difficult to treat. We report a novel technique used to successfully repair rectovaginal fistulas after failed mucosal advancement flap procedures using a transperineal-layered closure with an interposed graft of acellular cadaveric dermis (Alloderm).

Sexually transmitted parasitic diseases.

An increasing number of diseases are recognized as being sexually transmitted. The majority of these are bacterial or viral in nature; however, several protozoan and nematode infections can also be transmitted by sexual activity. For most of these diseases, the primary mode of transmission is nonsexual in nature, but sexual activity that results in fecal-oral contact can lead to transmission of these agents. Two parasitic diseases commonly transmitted by sexual contact are amebiasis and giardiasis. The management of these conditions is discussed.