The difficulty with localization of rectal cancer after neoadjuvant chemoradiation therapy.

Neoadjuvant chemoradiation therapy (NCRT) has become the standard treatment for locally advanced rectal cancer. Subsequent downstaging can make identification of the primary tumor challenging. Complete pathologic response rates of 8 per cent to 27 per cent are seen with current NCRT regimen. Two patients were referred to our institution after NCRT and subsequent low anterior resection in whom no residual cancer was found in the resected specimen but who manifested cancer in the distal rectum in the early postoperative period. Resection of a locally advanced rectal cancer after NCRT associated with significant tumor shrinkage is facilitated by the surgeon's evaluation with proctoscopy and tumor tattooing before the initiation of NCRT. After NCRT, preoperative proctoscopy, distal rectal evaluation after a sphincter sparing procedure in the operating room, and thorough specimen evaluation help to insure that the surgeon has removed the rectal cancer with an appropriate margin. These cases emphasize how important it is for the surgeon to be involved in the staging phase of managing the patient with rectal cancer.

Rectosigmoid intussusception through the anus mimicking rectal prolapse.

Intussusception of the colon usually occurs in infants and children. Although rectal prolapse is not uncommon, presentation of more proximal segments of large bowel through the anus is extremely rare. We report two cases of rectosigmoid intussusception in which sigmoid colon intussusception was diagnosed as rectal prolapse preoperatively.

Current management of diverticulitis.

Diverticulitis is classified as uncomplicated or complicated, i.e., associated with perforation, fistula, or obstruction. CT allows more reliable characterization of an acute attack of diverticulitis. Medical management is reserved for uncomplicated diverticulitis and the initial phase of treatment of diverticulitis associated with abscess formation. Percutaneous abscess drainage is a major advance, which permits one-stage resection in a majority of cases. Diverticulitis associated with free perforation can be selectively managed with resection and primary anastomosis, although a Hartmann resection is likely to be performed. A fistula associated with diverticulitis can usually be managed with a one-stage resection. Obstruction can be managed selectively with resection with on-table bowel preparation, primary anastomosis, and proximal diversion. Laparoscopic techniques permit successful performance of elective resections most of the time. Hand assistance is of particular value when the patient has dense fibrosis.

Attitudes of surgical specialists toward venous thromboembolism prophylaxis in surgical patients.

Venous thromboembolism (VTE) and pulmonary embolism are serious and potentially life-threatening complications in surgical patients; however, the risk can effectively be lessened using appropriate pharmaceutical and mechanical prophylaxis. Due to the variability in opinions and indications for VTE prophylaxis, proposed guidelines for VTE prophylaxis stratified according to patient- and procedure-oriented risk factors were widely circulated. We investigated to what extent these guidelines were accepted by 147 university and community-based surgeons in mid-America and how the recommendations for prophylaxis compared with recent past surgical practice performed on 5285 patients in Kentucky in 2004. Attitudes varied widely with respect to practice sites, modes, and specialty. Actual practices used in the Surgical Care Improvement Project 2004 varied even more widely and were at substantial variance from recommendations and current Centers for Medicare and Medicaid Services quality measures.

Patient safety and quality in surgery.

Patient safety and quality of care are inextricably linked. Surgery encompasses such a wide spectrum of diagnosis, treatment, postoperative care, and outpatient follow-up of so many illnesses that quality improvement and patient safety opportunities are numerous and potentially overwhelming. The study of error can be applied across all components of the care process, and offers many points of study to improve patient safety. A fundamental premise is that appropriate and safely delivered health care is less expensive. In our current climate, this emphasis on quality and safety will remain a high priority. Surgeon leadership at all levels is key to our professional viability.

The use of tissue flaps as an adjunct to pelvic surgery.

BACKGROUND: The clinical problems of advanced malignancy with invasion of cancers into adjacent organs or structures, fistulizing complications from radiation therapy, postoperative infections, and delayed postoperative healing continue to challenge pelvic surgeons, regardless of subspecialty. The use of autologous muscle and myocutaneous flaps has been applied to the management and prevention of these clinical problems and found to be most helpful. METHODS: Records of patients undergoing abdominopelvic procedures in a single unit during the 15-year period from 1990 to 2005 were reviewed, and patients undergoing autologous tissue flaps were reviewed with respect to indications, complications, and outcomes. RESULTS: Thirty-four patients underwent 35 autologous muscle or myocutaneous flaps for the following indications: large anticipated defects in primary or reoperative cancer surgery (13 patients); malignant, traumatic, inflammatory, or radiation-induced fistulae (12 patients); excision of (an) adjacent organ(s) with need for reconstruction (7 patients); and chronic nonhealing pelvic wounds (2 patients). Wound complications occurred in 41% of patients; however, primary healing of flaps occurred in 88% of patients. CONCLUSIONS: The use of autologous tissue flaps in select patients can be a useful adjunct in pelvic surgery in dealing with a wide variety of problems, specifically in filling large defects, providing vascularized tissue for fistula closure, and avoiding delayed wound healing commonly seen after high-dose radiation.

Advances in treatment of colorectal cancer.

The purpose of this review is to provide the practicing surgeon with an outline of several significant developments in colorectal cancer treatment that have affected the care of patients. This review is not intended to report on every important publication of the past few years nor is it intended to be encyclopedic. The author simply hopes to provide a useful reference for surgeons in their daily practice.

Addition of "near-miss" cases enhances a quality improvement conference.

Medical error is a prominent public issue today. Surgeons, for many decades, have conducted regular and meaningful reviews of most untoward events, which deserve improvement. "Near-miss" is a useful focus for such a conference, in that it avoids a focus on ultimate personal guilt and minimizes exposure to litigation (ie, a nonevent).

Advances in the surgical treatment of colon and rectal cancer.

A family history of colorectal cancer is the basis for risk stratification and allows reliable screening recommendations for individual patients. It is also the starting point for diagnosing hereditary forms of colorectal cancer. The surgical implications of treating hereditary nonpolyposis colorectal cancer and familial adenomatous polyposis are briefly described. Laparoscopic colectomy and sentinel node biopsies are new techniques with potential application in the treatment of colon cancer. For rectal cancer, advances have resulted in better preoperative staging and improved oncologic and functional outcomes. Surgical intervention for recurrent colorectal cancer requires careful patient selection and a multidisciplinary approach. The evaluation and treatment of patients with different patterns of recurrent colorectal cancer is described.

Mortality after elective colon resection: the search for outcomes that define quality in surgical practice.

BACKGROUND: Process measures constitute the focal point of surgical quality studies. High levels of compliance with such processes have not correlated with improved outcomes. Wide ranges of reported hospital death rates led us to hypothesize that survival after elective colon resection would be a legitimate outcomes measure for quality of surgical practice. STUDY DESIGN: We studied risk-adjusted hospital mortality rates of 85,260 patients in teaching hospitals as reported to the University HealthSystem Consortium (UHC) January 1, 2005 to March 31, 2011. Data were analyzed by institution and surgeon (deidentified). There were 34,504 patients from the HealthCare Utilization Project (HCUP, 2007-2008), who provided a comparison group for nonteaching hospitals. Surgeons with less than 1 year of reported data were excluded. RESULTS: Elective colon resection mortality rates were densely concentrated around 1.56% for teaching hospitals and at 1.08% for defined surgeons. HCUP data demonstrated a 1.38% nonteaching hospital mortality rate. Neither hospital nor surgeon volume were determinants of mortality, and lower volume entities displayed the widest mortality variations. Among 193 teaching hospitals, there were 6 outliers (4.1%), defined as >2 standard deviations (SDs) above the mean. Similarly, 32 of 681 individual surgeons (4.7%) had a risk-adjusted hospital mortality rate >2SDs above the mean. CONCLUSIONS: Elective colon resection is a safe procedure in both teaching hospitals and nonteaching hospitals, with an impressively homogenous mean mortality rate of 1.56% in teaching hospitals, and 1.38% in nonteaching hospitals. We reject our original hypothesis because the data do not sufficiently discriminate to permit the use of death after elective colon resection as a differentiating quality measure; however, the data do identify individual poor performers. Poor performing institutions/surgeons should seek extramural guidance to improve their outcomes or discontinue performing such operations.

Venous thromboembolism in elective operations: balancing the choices.

BACKGROUND: Venous thromboembolism (VTE) is a recognized cause of morbidity and mortality in hospitalized patients and is reported to account for 250,000 deaths annually. Recent shifts in prophylaxis administration are occurring among surgical specialty groups after observing a lower rate of VTE among patients undergoing elective operation. We report the incidence of VTE from 3 sources to provide an estimate of the true risk of the complication in elective surgery. METHODS: Data from the Surgical Care Improvement Project (SCIP), University HealthSystem Consortium (UHC), and Kentucky Cabinet for Health and Family Services (CHFS) databases were queried for 2004 for the same operative patient groups. RESULTS: Of 5,285 operations performed within SCIP 2004, the incidences of deep venous thrombosis (DVT) and pulmonary embolus (PE) were 0.4% and 0.3%, respectively, with no reported deaths. Of 966,474 operations recorded in the UHC 2004 data, rates of DVT and PE were 1.2% and 0.5%, respectively. The incidence rates of DVT and PE among 20,563 patients in the CHFS 2004 database were 0.5% and 0.3%, respectively, and included 3 deaths. CONCLUSION: VTE and associated mortality rates are extremely low in these 3 large data sources. We believe patients will benefit from an ongoing assessment of real need and complications of carefully risk-adjusted VTE prophylaxis.

Planned delayed operation for barium extravasation into the peritoneal cavity.

BACKGROUND: Extravasation of barium into the peritoneal cavity occurs rarely but has lethal results. CASE: We describe a case of extravasation from the small bowel that was initially managed medically before a planned, delayed operation. We discuss the benefit/risk of delayed operation and reoperation.