Close margin of adverse histologic factors with a negative primary tumor margin is not associated with increased locoregional recurrence in colon cancer.

PURPOSE: Locoregional recurrence after resection of colon cancer is increased when primary tumor margin is positive (<1 â€‹mm). Data is limited regarding the risk of locoregional recurrence with close margin (<1 â€‹mm) of histologic factors, such as intravascular tumor, intranodal tumor, tumor deposits, or extranodal extension. We hypothesized that close margin of these factors doesn't affect locoregional recurrence. METHODS: A retrospective review of all colon cancer surgical resections for adenocarcinoma from 2007 to 2020 was performed. Inclusion criteria were specimens with a negative primary tumor margin but a close margin of adverse histologic factors, defined as intravascular tumor, intranodal tumor, tumor deposits, or extranodal extension within 1 â€‹mm of a mesenteric or circumferential margin. RESULTS: Among 4435 pathology reports reviewed, 45 (1 â€‹%) of cases met inclusion criteria. Average follow-up was 38 months. The adverse histologic factor was identified as intranodal tumor in 24 (53 â€‹%) cases, intravascular tumor in 8 (17.8 â€‹%), tumor deposits in 5 (11.1 â€‹%), and more than one pathologic feature in 6 (13.3 â€‹%). There were 9 (20 â€‹%) recurrences; 6 (13 â€‹%) had distant recurrences only, 2 (4 â€‹%) patients had locoregional recurrences only, and 1 (2 â€‹%) patient had both locoregional and distant recurrence. The adverse histologic factor in these three patients was intravascular in two and both intravascular and intranodal in one. CONCLUSION: Based on our results, we do not have evidence that the presence of intravascular tumor, intranodal tumor, tumor deposits, or extranodal extension within 1 â€‹mm of a mesenteric or circumferential margin is associated with increased risk of locoregional recurrence.

Association Between Surgeon Technical Skills and Patient Outcomes.

Importance: Postoperative complications remain common after surgery, but little is known about the extent of variation in operative technical skill and whether variation is associated with patient outcomes. Objectives: To examine the (1) variation in technical skill scores of practicing surgeons, (2) association between technical skills and patient outcomes, and (3) amount of variation in patient outcomes explained by a surgeon's technical skill. Design, Setting, and Participants: In this quality improvement study, 17 practicing surgeons submitted a video of a laparoscopic right hemicolectomy that was then rated by at least 10 blinded peer surgeons and 2 expert raters. The association between surgeon technical skill scores and risk-adjusted outcomes was examined using data from the American College of Surgeons National Surgical Quality Improvement Program. The association between technical skill scores and outcomes was examined for colorectal procedures and noncolorectal procedures (ie, assessed on whether technical skills demonstrated during colectomy were associated with patient outcomes across other cases). In addition, the proportion of patient outcomes explained by technical skill scores was examined using robust regression techniques. The study was conducted from September 23, 2016, to February 10, 2018; data analysis was performed from November 2018 to January 2019. Exposures: Colorectal and noncolorectal procedures. Main Outcomes and Measures: Any complication, mortality, unplanned hospital readmission, unplanned reoperation related to principal procedure, surgical site infection, and death or serious morbidity. Results: Of the 17 surgeons included in the study, 13 were men (76%). The participants had a range from 1 to 28 years in surgical practice (median, 11 years). Based on 10 or more reviewers per video and with a maximum quality score of 5, overall technical skill scores ranged from 2.8 to 4.6. From 2014 to 2016, study participants performed a total of 3063 procedures (1120 colectomies). Higher technical skill scores were significantly associated with lower rates of any complication (15.5% vs 20.6%, P = .03; Spearman rank-order correlation coefficient r = -0.54, P = .03), unplanned reoperation (4.7% vs 7.2%, P = .02; r = -0.60, P = .01), and a composite measure of death or serious morbidity (15.9% vs 21.4%, P = .02; r = -0.60, P = .01) following colectomy. Similar associations were found between colectomy technical skill scores and patient outcomes for all types of procedures performed by a surgeon. Overall, technical skill scores appeared to account for 25.8% of the variation in postcolectomy complication rates and 27.5% of the variation when including noncolectomy complication rates. Conclusions and Relevance: The findings of this study suggest that there is wide variation in technical skill among practicing surgeons, accounting for more than 25% of the variation in patient outcomes. Higher colectomy technical skill scores appear to be associated with lower complication rates for colectomy and for all other procedures performed by a surgeon. Efforts to improve surgeon technical skills may result in better patient outcomes.

Colorectal Surgery Resident Participation in Screening Colonoscopies: How Does It Impact Quality?

BACKGROUND: Performing colonoscopies is an integral component of colorectal surgery residency training. There exists a paucity of literature regarding colonoscopy quality metrics with colorectal trainee involvement. OBJECTIVE: This study aimed to investigate the effect of colorectal surgery resident participation on quality metrics in screening colonoscopy. DESIGN: Screening colonoscopies performed between August 1, 2016, and July 31, 2018, were queried from a prospectively maintained institutional database. Data were cross-checked with resident case logs to verify colonoscopies with resident participation. SETTING: This study was conducted by the colorectal surgery department at a tertiary level hospital in the United States. PATIENTS: Consecutive, asymptomatic patients aged ≥45 years, undergoing screening colonoscopy, were selected. MAIN OUTCOME MEASURES: The quality parameters measured included overall, male, and female adenoma detection rates; total examination time; withdrawal time; cecal intubation rate; quality of bowel preparation; complications; and medication dosage. RESULTS: A total of 4594 patients were included in the study with a mean age of 60.5 ± 8.4 years (range, 45-91); 51.7% were women. Overall, 4186 of the colonoscopies were performed without resident participation, and 408 were performed with resident participation. Scope insertion, withdrawal, and total examination times were longer in the resident group. Cecal intubation rate, polypectomy rate, sex-specific and overall adenoma detection rates, and complication rates were similar between the groups. In the multivariate model, trainee involvement had no significant impact on adenoma detection rate. In addition, the trainee group utilized a higher mean dose of fentanyl. LIMITATIONS: The retrospective nature of the data with possible coding errors of the database and the inability to quantify the amount of resident participation and to clarify the degree of attending surgeon assistance and oversight were limitations of the study. CONCLUSIONS: Colorectal surgery resident participation in screening colonoscopy takes longer and appears safe, while achieving all national quality metrics without compromising adenoma detection rates. Changes in colonoscopy scheduling in regard to length of time may prove beneficial when there is resident participation. See Video Abstract at http://links.lww.com/DCR/B43. PARTICIPACIÓN DE LOS RESIDENTES DE CIRUGÍA COLORRECTAL EN COLONOSCOPIAS DE CRIBADO: ¿CÓMO AFECTA LA CALIDAD?: La realización de colonoscopias es un componente integral del entrenamiento de residencia en cirugía colorrectal. Existe una escasez de literatura con respecto a las medidas de calidad de la colonoscopia con la participación de los aprendices colorrectales.Investigar el efecto de la participación de residentes de cirugía colorrectal en las medidas de calidad en la colonoscopia de cribado.Las colonoscopias de cribado realizadas entre el 1 de agosto de 2016 y el 31 de julio de 2018 se consultaron desde una base de datos institucional mantenida prospectivamente. Los datos se cotejaron con registros de casos de residentes para verificar las colonoscopias con participación de residentes.Departamento de cirugía colorrectal en un hospital de tercer nivel de los Estados Unidos.Pacientes consecutivos, asintomáticos, edad ≥45 años, sometidos a colonoscopia de detección.Parámetros de calidad que incluyen tasas generales de detección de adenoma en hombres y mujeres, tiempo total de examen, tiempo de retiro, tasa de intubación cecal, calidad de la preparación intestinal, complicaciones y dosis de medicamentos.Se incluyeron un total de 4.594 pacientes en el estudio con una edad media de 60,5 ± 8,4 años (rango, 45-91) y 51,7% mujeres. En total 4,186 de las colonoscopias se realizaron sin participación de los residentes y 408 se realizaron con la participación de los residentes. Los tiempos de inserción, retiro y examen total del alcance fueron más largos en el grupo residentes. La tasa de intubación cecal, la tasa de polipectomía, las tasas de detección de adenoma específicos de género y generales, y las tasas de complicaciones fueron similares entre los grupos. En el modelo multivariado, la participación de los aprendices no tuvo un impacto significativo en la tasa de detección de adenoma. Además, el grupo de aprendices utilizó una dosis media más alta de fentanilo.Carácter retrospectivo de los datos con posibles errores de codificación de la base de datos. Incapacidad para cuantificar la cantidad de participación de los residentes y para aclarar el grado de asistencia y supervisión del cirujano.La participación de los residentes de cirugía colorrectal en la colonoscopia de cribado lleva más tiempo y parece segura, mientras se logran todas las medidas de calidad nacionales sin comprometer las tasas de detección de adenoma. Los cambios en la programación de la colonoscopia con respecto al período de tiempo pueden ser beneficiosos cuando hay participación de residentes. Vea el resumen del video en http://links.lww.com/DCR/B43.

Extended Venous Thromboembolism Prophylaxis After Elective Surgery for IBD Patients: Nomogram-Based Risk Assessment and Prediction from Nationwide Cohort.

BACKGROUND: Identification of risk factors for postoperative venous thromboembolism is an important step to reduce the morbidity associated with this potentially preventable complication after elective surgery for patients with IBD. OBJECTIVE: This study aimed to determine the risk factors for 30-day venous thromboembolism after abdominal surgery for patients with venous thromboembolism, identify potential indications for extended thromboprophylaxis, and develop a nomogram for prediction of risk. DESIGN: This is a retrospective cohort study from a prospectively collected database. SETTING: The American College of Surgeons National Surgical Quality Improvement Program Participant User File from 2005 to 2016 was used for data analysis. PATIENTS: All patients with IBD undergoing elective abdominopelvic bowel surgery were included. MAIN OUTCOME MEASURES: The primary outcomes were the incidence of in-hospital and postdischarge venous thromboembolism within 30 days of the index abdominopelvic surgery. RESULTS: A total of 24,182 patients met the inclusion criteria. Thirty-day total and postdischarge rates of venous thromboembolism were 2.5% (n = 614) and 1% (n =252). Forty-one percent (252/614) of venous thromboembolism events occurred after hospital discharge. Univariate analysis assessed 37 variables for association with study outcomes. On multivariate logistic regression analysis, older age, steroid use, bleeding disorders, open surgery, hypertension, longer operative time, and preoperative hospitalization were associated with venous thromboembolism before discharge and also postoperative transfusion, steroid use, pelvic and enterocutaneous fistula surgery, and longer operative time were associated with venous thromboembolism after discharge. A nomogram was constructed for each outcome, translating multivariate model parameter estimates into a visual scoring system where the estimated probability of venous thromboembolism can be calculated. LIMITATIONS: This study was limited by its retrospective nature and the limitations inherent to a database. CONCLUSION: Given the higher risk of venous thromboembolism in patients with IBD after elective abdominopelvic surgery compared with other indications, an accurate prediction of venous thromboembolism before and after discharge using the proposed nomogram can facilitate decision making for individualized extended thromboprophylaxis in the preoperative setting as a screening tool. See Video Abstract at http://links.lww.com/DCR/A711.

Laparoscopic colectomy in the obese, morbidly obese, and super morbidly obese: when does weight matter?

PURPOSE: Previous studies have demonstrated that obese patients (BMI >30) undergoing laparoscopic colectomy have longer operative times and increased complications when compared to non-obese cohorts. However, there is little data that specifically evaluates the outcomes of obese patients based on the degree of their obesity. The aim of this study was to evaluate the impact of increasing severity of obesity on patients undergoing laparoscopic colectomy. METHODS: A retrospective review was performed of all patients undergoing laparoscopic colectomy between 1996 and 2013. Patients were classified according to their BMI as obese (BMI 30.0-39.9), morbidly obese (BMI 40.0-49.9), and super obese (BMI >50). Main outcome measures included conversion rate, operative time, estimated blood loss, post-operative complications, and length of stay. RESULTS: There were 923 patients who met inclusion criteria. Overall, 604 (65.4%), 257 (27.9%), and 62 (6.7%) were classified as obese (O), morbidly obese (MO), and super obese (SO), respectively. Clinicopathologic characteristics were similar among the three groups. The SO group had significantly higher conversion rates (17.7 vs. 7 vs. 4.8%; P = 0.031), longer average hospital stays (7.1 days vs. 4.9 vs. 3.4; P = 0.001), higher morbidity (40.3 vs. 16.3 vs. 12.4%; P = 0.001), and longer operative times (206 min vs. 184 vs. 163; P = 0.04) compared to the MO and O groups, respectively. The anastomotic leak rate in the SO (4.8%; P = 0.027) and MO males (4.1%; P = 0.033) was significantly higher than MO females (2.2%) and all obese patients (1.8%). CONCLUSION: Increasing severity of obesity is associated with worse perioperative outcomes following laparoscopic colectomy.

The American Society of Colon and Rectal Surgeons Assessment Tool for Performance of Laparoscopic Colectomy.

BACKGROUND: The lack of consensus for performance assessment of laparoscopic colorectal resection is a major impediment to quality improvement. OBJECTIVE: The purpose of this study was to develop and assess the validity of an evaluation tool for laparoscopic colectomy that is feasible for wide implementation. DESIGN: During the pilot phase, a small group of experts modified previous assessment tools by watching videos for laparoscopic right colectomy with the following categories of experience: novice (less than 20 cases), intermediate (50-100 cases), and expert (more than 500 cases). After achieving sufficient reliability (κ > 0.8), a user-friendly tool was validated among a large group of blinded, trained experts. SETTING: The study was conducted through the American Society of Colon and Rectal Surgeons Operative Competency Evaluation Committee. PATIENTS: Raters were from the Operative Competency Evaluation Committee of the American Society of Colon and Rectal Surgeons. MAIN OUTCOME MEASURES: Assessment tool reliability and internal consistency were measured. RESULTS: From October 2014 through February 2015, 4 groups of 5 raters blinded to surgeon skill level evaluated 6 different laparoscopic right colectomy videos (novice = 2, intermediate = 2, expert = 2). The overall Cronbach α was 0.98 (>0.9 = excellent internal consistency). The intraclass correlation for the overall assessment was 0.93 (range, 0.77-0.93) and was >0.74 (excellent) for each step. The average scores (scale, 1-5) for experts were significantly better than those in the intermediate category, with a mean (SD) of 4.51 (0.56) versus 2.94 (0.56; p = 0.003). Videos in the intermediate group scored more favorably than beginner videos for each individual step and overall performance (mean (SD) = 3.00 (0.32) vs 1.78 (0.42); p = 0.006). LIMITATIONS: The study was limited by rater bias to technique and style. CONCLUSIONS: The unique and robust methodology in this trial produced an assessment tool that was feasible for raters to use when assessing videotaped laparoscopic right hemicolectomies. The potential applications for this new tool are widespread, including both training and evaluation of competence at the attending level. See Video Abstract at http://links.lww.com/DCR/A369, http://links.lww.com/DCR/A370, http://links.lww.com/DCR/A371.

Reprocessed bipolar energy for laparoscopic colectomy: Is it worth it?

BACKGROUND: Reprocessed (re-sterilized) bipolar energy devices represent one effort to reduce operative costs. METHODS: Between January 2014 to October 2015, 76 patients underwent laparoscopic colectomy using a reprocessed bipolar energy device and were case-matched to 76 patients from a prospectively-maintained database from November 2012 to December 2013 when an identical, new device was used. Outcomes included reprocessed device safety, efficiency and hospital costs. RESULTS: There was no difference in patient demographics, operative times or failed pedicle ligation requiring intervention between groups (all P > 0.05). In 19.7% of reprocessed cases, the surgeon opened an additional new device after dissatisfaction with the reprocessed instrument. Operating room costs and total costs were less for the reprocessed device group (all P < 0.05). CONCLUSION: Reprocessed bipolar energy devices were associated with savings in operative expenses, however, larger studies are warranted due to the high surgeon dissatisfaction regarding safety concerns with the reprocessed equipment.

Pharmacogenetics-guided analgesics in major abdominal surgery: Further benefits within an enhanced recovery protocol.

OBJECTIVE: Effective, narcotic sparing analgesia is a major component of Enhanced Recovery Protocols (ERP), however the risk of poor analgesia and opioid related side effects (ORADE) remains an issue related to poor outcomes and satisfaction, and is strongly related to the risk of narcotic dependence after surgery. A variety of genes can impact narcotic and non-steroidal (NSAID) drug efficacy including: the CYP family (drug metabolism-narcotics and NSAID), or COMT/ABCB1/OPRM1 (functional receptor and transport activity for analgesia vs side effects). The purpose of this study was to perform the first assessment of the impact of a pharmacogenetics (PGx) guided selection of analgesics following major abdominal surgery within an ERP. METHODS: A consecutive series of open and laparoscopic colorectal resections or major ventral hernia repair (PGx group) had a guided analgesic protocol based upon assessment of CYP1A2, CYP2C19, CYP2C9, CYP2D6, CYP3A4, CYP3A5, COMT, OPRM1, and ABCB1 genes. Study patients were compared to a recent historical series of patients (H group) managed using our well validated ERP. The primary outcome measure was the Overall Benefit of Analgesia Score (OBAS). Pain scores were also assessed. RESULTS: The data demonstrated a similar mix of procedures and gender between groups and more than half of the PGx group had revised analgesia from the standard ERP. The PGx group demonstrated significantly lower OBAS scores (p = 0.0.1) from POD1 (3.8 vs 5.4) through POD 5 (3.0 vs 4.5) Analgesia was also superior for the PGx group from POD1 through POD 5 (p = 0.04). CONCLUSION: Pharmacogenetics guidance resulted in frequent modifications of the analgesic program, resulting in excellent analgesia with a 50% reduction in narcotic consumption, and a reduced incidence of analgesic related side effects compared to our standard ERP. These data suggest further improvement in ERP resulting from a patient centric analgesic, reduced narcotic regimen which provides early and durable pain control with fewer narcotic related side effects.

Alvimopan in the setting of colorectal resection with an ostomy: To use or not to use?

BACKGROUND: Postoperative ileus (POI) is a major cause of morbidity, increased length of stay (LOS) and hospital cost after colorectal surgery. Alvimopan is a µ-opioid antagonist used to accelerate upper and lower gastrointestinal function after bowel resection. We hypothesized that alvimopan would reduce LOS in patients undergoing colorectal resection with stoma, a situation that has not been evaluated. METHODS: A retrospective review (2010-2015) identified 58 patients who underwent colorectal resection for benign or malignant disease with stoma creation and received alvimopan. They were case-matched to 58 non-alvimopan patients based on age, BMI, baseline comorbidities, stoma type created and surgical approach. We compared overall LOS, incidence of POI and other postoperative complications. RESULTS: There were equal numbers of laparoscopic (N = 18) and open resections (N = 40) in the alvimopan group and non-alvimopan group. There were also equal numbers of patients with an ileostomy (N = 37) or colostomy (N = 21) in each group. Overall, 41 patients underwent resection for malignant disease in the alvimopan group compared to 37 in the non-alvimopan group. There was a significant reduction in median LOS overall (alvimopan 5 (4-7) versus control 6 (4.75-9.25) days, P = 0.03). While the 6-day median LOS was similar for patients undergoing ileostomy creation (P = 0.25), alvimopan patients had a 3-day decreased median LOS that approached statistical significance (P = 0.06). The overall 30-day complication rate was higher in the control group (41.4 vs. 51.7%, P = 0.26), but the readmission rate within 30 days was higher in the alvimopan group (19 vs. 13.8%, P = 0.45). Neither of these differences reached statistically significance. CONCLUSION: The use of alvimopan in patients undergoing colorectal resection with stoma is associated with a significantly shorter LOS, but the increased readmission rate warrants further study. Based on these data, alvimopan should be evaluated in a controlled setting for patients undergoing colorectal resection with colostomy creation.

Prospective Case Series of a Novel Minimally Invasive Bipolar Coagulation System in the Treatment of Grade I and II Internal Hemorrhoids.

Background Existing nonsurgical procedures for the treatment of grade I and II internal hemorrhoids are often painful, technically demanding, and often necessitate multiple applications. This study prospectively assessed the safety and efficacy of the HET Bipolar System, a novel minimally invasive device, in the treatment of symptomatic grade I and II internal hemorrhoids. Methods Patients with symptomatic grade I or II internal hemorrhoids despite medical management underwent hemorrhoidal ligation with the HET Bipolar System. Endpoints included resolution or improvement of hemorrhoidal bleeding and/or prolapse from baseline, recurrent or refractory symptoms, and pain. Results Twenty patients were treated with the HET Bipolar System. Two were lost to follow-up. Refractory or recurrent bleeding was present in 8 of 18 (44.4%), 4 of 11 (36.4%), and 4 of 8 (50.0%) patients, and prolapse was reported by 1 of 18 (5.6%), 4 of 11 (36.4%), and 1/7 (14.3%) of patients at 1, 3, and 6 months, respectively. Bleeding improved from baseline in 88.2%, 81.8%, and 87.5% of patients, and resolution of baseline prolapse was seen in 11 of 11 (100%), 4 of 7 (57.1%), and 5 of 5 (100%) patients at the same intervals. Thirteen of 18 (72.2%) patients did not require additional treatment for their symptoms. Conclusions The HET Bipolar System is safe and easy to use with short-term effectiveness comparable to that of currently used techniques for the treatment of symptomatic grade I and II internal hemorrhoids. It may be an effective alternative to rubber band ligation in patients with larger internal hemorrhoids and those with hemorrhoids close to the dentate line in which banding may produce debilitating pain.

Failing to Prepare Is Preparing to Fail: A Single-Blinded, Randomized Controlled Trial to Determine the Impact of a Preoperative Instructional Video on the Ability of Residents to Perform Laparoscopic Right Colectomy.

BACKGROUND: Laparoscopic colorectal resection is an index case for advanced skills training, yet many residents struggle to reach proficiency by graduation. Current methods to reduce the learning curve for residents remain expensive, time consuming, and poorly validated. OBJECTIVE: The purpose of this study was to assess the impact of the addition of a preprocedural instructional video to improve the ability of a general surgery resident to perform laparoscopic right colectomy when compared with standard preparation. DESIGN: This was a single-blinded, randomized control study. SETTINGS: Four university-affiliated teaching hospitals were included in the study. PARTICIPANTS: General surgery residents in postgraduation years 2 through 5 participated. INTERVENTION: Residents were randomly assigned to preparation with a narrated instructional video versus standard preparation. MAIN OUTCOME MEASURES: Resident performance, scored by a previously validated global assessment scale, was measured. RESULTS: Fifty-four residents were included. Half (n = 27) were randomly assigned to view the training video and half (n = 27) to standard preparation. There were no differences between groups in terms of training level or previous operative experience or in patient demographics (all p > 0.05). Groups were similar in the percentage of the case completed by residents (p = 0.39) and operative time (p = 0.74). Residents in the video group scored significantly higher in total score (mean: 46.8 vs 42.3; p = 0.002), as well as subsections directly measuring laparoscopic skill (vascular control mean: 11.3 vs 9.7, p < 0.001; mobilization mean: 7.6 vs. 7.0, p = 0.03) and overall performance score (mean: 4.0 vs 3.1; p < 0.001). Statistical significance persisted across training levels. LIMITATIONS: There is potential for Hawthorne effect, and the study is underpowered at the individual postgraduate year level. CONCLUSIONS: The simple addition of a brief, narrated preprocedural video to general surgery resident case preparation significantly increased trainee ability to successfully perform a laparoscopic right colectomy. In an era of shortened hours and less exposure to cases, incorporating a brief but effective instructional video before surgery may improve the learning curve of trainees and ultimately improve safety.

Can sepsis predict deep venous thrombosis in colorectal surgery?

BACKGROUND: Little data exist regarding the impact of sepsis on deep venous thrombosis (DVT) in colorectal surgery patients. We sought to elucidate this relationship. METHODS: Current Procedural Terminology codes were used to identify patients who underwent colorectal surgery as reported to the National Surgical Quality Improvement Program in 2010. The relationship between DVT and sepsis was then explored in a matched population. RESULTS: Of the 26,554 patients who underwent colorectal surgery, 462 (1.7%) developed a DVT. The largest dependent correlations with DVT were malnutrition (33% vs 57%), emergency operation (15% vs 31%), open operation (58% vs 78%), and prolonged ventilator requirement (5% vs 24%; all P < .001). After propensity score matching, urosepsis (.5% vs 1.9%), organ/space sepsis (1.1% vs 4.8%), pneumosepsis (.5% vs 5.8%), and overall perioperative sepsis (18% vs 39%; all P ≤ .04) were associated with DVT. The strongest independent predictor of DVT was pneumosepsis (odds ratio 15.9, 95% confidence interval 3.7 to 67.2, P < .001). CONCLUSION: Perioperative sepsis is a significant risk factor for postoperative DVT in the colorectal surgery population.

Multivisceral resection for advanced rectal cancer: outcomes and experience at a single institution.

BACKGROUND: Multivisceral resection is often required in the treatment of locally advanced rectal cancers. Such resections are relatively rare and oncologic outcomes, especially when sphincter preservation is performed, are not fully demonstrated. METHODS: A retrospective review was conducted of patients who underwent multivisceral resection for locally advanced rectal cancer with and without sphincter preservation. RESULTS: Sixty-one patients underwent multivisceral resection for rectal cancer from 2005 to 2013 with a median follow-up of 27.8 months. Five-year overall and disease-free survival were 49.2% and 45.3%, respectively. Thirty-four patients (55.7%) had sphincter-sparing operations with primary coloanal anastomosis and temporary stoma. There was no significant difference in overall or disease-free survival, or recurrence with sphincter preservation compared with those with permanent stoma. CONCLUSIONS: Multivisceral resection for locally advanced rectal cancer has acceptable oncologic and clinical outcomes. Sphincter preservation and subsequent reestablishment of gastrointestinal continuity does not impact oncologic outcomes and should be considered in many patients.

High-resolution anoscopy or expectant management for anal intraepithelial neoplasia for the prevention of anal cancer: is there really a difference?

BACKGROUND: High-resolution anoscopy has been shown to improve identification of anal intraepithelial neoplasia but a reduction in progression to anal squamous-cell cancer has not been substantiated when serial high-resolution anoscopy is compared with traditional expectant management. OBJECTIVE: The aim of this study was to compare high-resolution anoscopy versus expectant management for the surveillance of anal intraepithelial neoplasia and the prevention of anal cancer. DESIGN: This is a retrospective review of all patients who presented with anal squamous dysplasia, positive anal Pap smears, or anal squamous-cell cancer from 2007 to 2013. SETTING: This study was performed in the colorectal department of a university-affiliated, tertiary care hospital. PATIENTS: Included patients had biopsy-proven anal intraepithelial neoplasia from 2007 to 2013. INTERVENTIONS: Patients were treated with high-resolution anoscopy with ablation or standard anoscopy with ablation. Both groups were treated with imiquimod and followed every 6 months indefinitely. MAIN OUTCOME MEASURES: The incidence of anal squamous-cell cancer in each group was the primary end point. RESULTS: From 2007 to 2013, 424 patients with anal squamous dysplasia were seen in the clinic (high-resolution anoscopy, 220; expectant management, 204). Three patients (high-resolution anoscopy, 1; expectant management, 2) progressed to anal squamous-cell cancer; 2 were noncompliant with follow-up and with HIV treatment, and the third was allergic to imiquimod and refused to take topical 5-fluorouracil. The 5-year progression rate was 6.0% (95% CI, 1.5-24.6) for expectant management and 4.5% (95% CI, 0.7-30.8) for high-resolution anoscopy (p = 0.37). LIMITATIONS: This was a retrospective review. There is potential for selection and referral bias. Because of the rarity of the outcome, the study may be underpowered. CONCLUSIONS: Patients with squamous-cell dysplasia followed with expectant management or high-resolution anoscopy rarely develop squamous-cell cancer if they are compliant with the protocol. The cost, morbidity, and value of high-resolution anoscopy should be further evaluated in lieu of these findings.

Novel operative anoscope for Ferguson hemorrhoidectomy: a feasibility study and comparative cohort analysis.

BACKGROUND: Operative hemorrhoidectomy can result in pain and altered continence from excessive excision of anoderm or surrounding tissue. We assessed a novel low-profile slotted anoscope to determine if the device would promote safe dissection, lessen trauma, and reduce operative times for hemorrhoidectomy. METHODS: Patients requiring hemorrhoidectomy (June 2008 - January 2010) underwent a prospective phase-2 trial evaluating a new operating anoscope (CAD, Ethicon Endosurgery, Cincinnati, OH). Demographics and perioperative end points including bleeding, pain, fecal incontinence, stenosis, and symptom recurrence were analyzed at 4 weeks, 3 months, 6 months, and 1 year postoperatively. We compared these to patients undergoing hemorrhoidectomy (February 2010 - November 2012) with a traditional Hill-Ferguson anoscope (THF). RESULTS: 40 patients (CAD, 20 vs THF, 20) were included. Presenting symptoms were similar, whereas mean duration of symptoms was longer for CAD (41.2 ± 8.4 vs 27 ± 9.5 months; P < .05). Estimated blood loss was lower for CAD [8.3 mL (range = 2-40 mL) vs 11.3 mL THF (range = 5-35 mL; P = .87)]. Mean operative times were lower for the CAD than the THF group (15.6 ± 3.4 vs 26.1 ± 4.1 minutes; P < .05). Visual analog pain scores were non-significantly increased in the THF group at 4 weeks (P = .23). At 3 months, 6 months, and 1 year, there was no difference in continence. CONCLUSION: The CAD anoscope reduced operative times for modified Ferguson (closed) hemorrhoidectomy when compared with traditional retractors. There was no difference in incontinence or pain between groups.

The effect of transversus abdominis plane blocks on postoperative pain in laparoscopic colorectal surgery: a prospective, randomized, double-blind trial.

BACKGROUND: Superior early pain control has been suggested with transversus abdominis plane blocks, but evidence-based recommendations for transversus abdominis plane blocks and their effects on patient outcomes are lacking. OBJECTIVE: The aim of this study was to determine whether transversus abdominis plane blocks improve early postoperative outcomes in patients undergoing laparoscopic colorectal resection already on an optimized enhanced recovery pathway. DESIGN: This study is based on a prospective, randomized, double-blind controlled trial. SETTINGS: The trial was conducted at a tertiary referral center. PATIENTS: Patients undergoing elective laparoscopic colorectal resection were selected. INTERVENTIONS(S): Patients were randomly assigned to receive either a transversus abdominis plane block or a placebo placed intraoperatively under laparoscopic guidance. All followed a standardized enhanced recovery pathway. Patient demographics, perioperative procedures, and postoperative outcomes were collected. MAIN OUTCOME MEASURES: Postoperative pain and nausea/vomiting scores in the postanesthesia care unit and department, opioid use, length of stay, and 30-day readmission rates were measured. RESULTS: The trial randomly assigned 41 patients to the transversus abdominis plane block group and 38 patients to the control group. Demographic, clinical, and procedural data were not significantly different. In the postanesthesia care unit, the transversus abdominis plane block group had significantly lower pain scores (p < 0.01) and used fewer opioids (p < 0.01) than the control group; postoperative nausea/vomiting scores were comparable (p = 0.99). The transversus abdominis plane group had significantly lower pain scores on postoperative day 1 (p = 0.04) and throughout the study period (p < 0.01). There was no significant difference between groups in postoperative opioid use (p = 0.65) or nausea/vomiting (p = 0.79). The length of stay (median, 2 days experimental, 3 days control; p = 0.50) and readmission rate (7% experimental, 5% control, p = 0.99) was similar across cohorts. LIMITATIONS: This study was conducted a single center. CONCLUSIONS: Transversus abdominis plane blocks improved immediate short-term opioid use and pain outcomes. Pain improvement was durable throughout the hospital stay. However, the blocks did not translate into less overall narcotic use, shorter length of stay, or lower readmission rates.

Factors influencing disease recurrence after ileocolic resection in adult and pediatric onset Crohn's disease.

BACKGROUND: Factors influencing recurrence of ileocecal Crohn's disease (CD) after surgical resection may differ between adolescents and adults. METHODS: CD patients who underwent ileocecectomy were retrospectively divided into pediatric onset (age at diagnosis ≤ 16 years, n = 34) and adult onset (>16, n = 108) patients to evaluate differences in risks of endoscopic and clinical recurrence. RESULTS: In 142 patients, rates of any recurrence, endoscopic recurrence, and clinical recurrence at 5 years were 78%, 88%, and 65%, respectively. Risks of recurrence were similar between groups. Younger patients were more likely to be on immunologics preoperatively and more likely to be started on immunoprophylaxis postoperatively. Immediate postoperative prophylaxis was predictive of delayed clinical recurrence only in the older group. CONCLUSIONS: Despite increased preoperative and postoperative immunoprophylaxis in younger patients, recurrence rates of CD after ileocecectomy do not differ between these groups. Immediate postoperative prophylaxis was predictive of delayed clinical recurrence only in patients with adult onset CD.

The impact of an acute care surgery team on general surgery residency.

BACKGROUND: Acute care surgical teams (ACSTs) have limited data in residency. We sought to determine the impact of an ACST on the depth and breadth of general surgery resident training. METHODS: One year prior to and after implementation of an ACST, Accreditation Council for Graduate Medical Education case logs spanning multiple postgraduate year levels were compared for numbers, case types, and complexity. RESULTS: We identified 6,009 cases, including 2,783 after ACST implementation. ACSTs accounted for 752 cases (27%), with 39.2% performed laparoscopically. ACST cases included biliary (19.4%), skin/soft tissue (10%), hernia (9.8%), and appendix (6.5%). Second-year residents performed a lower percentage of laparoscopic cases after the creation of the ACST (20.4% vs 26.3%; P = .003), while chief residents performed a higher percentage (42.1 vs 37.4; P = .04). Case numbers and complexity following ACST development were unchanged within all year groups (P > .1). CONCLUSION: ACST in a residency program does not sacrifice resident case complexity, diversity, or volume.

Cost-effectiveness of laparoscopy in rectal cancer.

BACKGROUND: There is an increasing trend to use laparoscopy for rectal cancer surgery. Although laparoscopic and open rectal resections appear oncologically equivalent, there is little information on the cost of different surgical approaches. With the current health care crisis and the importance of optimizing health care resources and patient outcomes, the cost of care is an important factor. OBJECTIVE: The aim of this study was to evaluate the cost-effectiveness of laparoscopy in rectal cancer. DESIGN: This was a case-matched study. SETTINGS: This study was conducted at a tertiary referral center. PATIENTS: Patients undergoing elective rectal cancer resection between 2007 and 2012 were selected. METHODS: A review of a prospective database for elective laparoscopic rectal cancer resections was performed. Laparoscopic cases were matched to open cases based on age, BMI, operative procedure, and diagnostic-related group. MAIN OUTCOME MEASURES: The primary outcomes measured were the cost of care, hospital length of stay, discharge disposition, readmission, postoperative complications, and mortality rates. RESULTS: Two hundred fifty-four matched cases were included in the analysis: 125 laparoscopic (49%) and 129 open (51%). The cTNM stage (p = 0.39), tumor distance from the anal verge (p = 0.07), and rate of neoadjuvant therapy received between the laparoscopic and open groups were similar (p = 0.12). Operating time (p< 0.01) and cost per operating room minute (p = 0.04) were significantly higher in the open group. The groups were oncologically equivalent, based on circumferential resection margin (p = 0.15). The laparoscopic group had a significantly shorter length of stay (p < 0.01) and lower total hospital cost (p < 0.01). Postoperative complications, 30-day readmission, reoperation, and mortality rates were similar. However, significantly more patients undergoing open resection required intensive care unit care (p = 0.03), skilled nursing (p = 0.03), or home care services (p < 0.01) at discharge. LIMITATIONS: This investigation was conducted at a single institution and it is a retrospective study with potential bias. CONCLUSIONS: Laparoscopy is cost-effective for rectal cancer surgery, improving both health care expenditures and patient outcomes. For selected patients, laparoscopic rectal cancer resection can reduce length of stay, operating time, and resource utilization.

Future directions for the early detection of colorectal cancer recurrence.

Surgical resection remains a mainstay of treatment and is highly effective for localized colorectal cancer. However, ~30-40% of patients develop recurrence following surgery and 40-50% of recurrences are apparent within the first few years after initial surgical resection. Several variables factor into the ultimate outcome of these patients, including the extent of disease, tumor biology, and patient co-morbidities. Additionally, the time from initial treatment to the development of recurrence is strongly associated with overall survival, particularly in patients who recur within one year of their surgical resection. Current post-resection surveillance strategies involve physical examination, laboratory, endoscopic and imaging studies utilizing various high and low-intensity protocols. Ultimately, the goal is to detect recurrence as early as possible, and ideally in the asymptomatic localized phase, to allow initiation of treatment that may still result in cure. While current strategies have been effective, several efforts are evolving to improve our ability to identify recurrent disease at its earliest phase. Our aim with this article is to briefly review the options available and, more importantly, examine emerging and future options to assist in the early detection of colon and rectal cancer recurrence.