Long-term Outcomes Following Colectomy and Liver Transplantation for Inflammatory Bowel Disease with Primary Sclerosing Cholangitis.

OBJECTIVE: To investigate the long-term outcomes of patients with combined primary sclerosing cholangitis/inflammatory bowel disease (PSC-IBD) undergoing both liver transplantation (LT) and total abdominal colectomy (TAC). SUMMARY BACKGROUND DATA: The fraction of patients with PSC-IBD that require both LT and TAC is small, thereby limiting significant conclusions regarding long-term outcomes. METHODS: Adult and pediatric patients from nine centers from the US IBD Surgery Collaborative who underwent staged LT and TAC for PSC-IBD were included. Long-term outcomes, including survival, were assessed. RESULTS: Among 127 patients, 66 underwent TAC-before-LT, with a median time from TAC to LT of 7.9 yrs, while 61 underwent LT-before-TAC, with a median time from LT to TAC of 4.4 years. Median patient survival post TAC was significantly worse in those undergoing LT-before-TAC (16.0 yrs vs. 42.6 yrs, P=0.007), while post LT survival was not impacted by the order of TAC and LT (21.6 yrs vs. 22.0 yrs, P=0.81). Patients undergoing TAC for medically refractory disease had a higher incidence of recurrent PSC (rPSC) (P=0.02) and biliary complications (0.09) compared to those undergoing TAC for oncologic indications. Definitive TAC reconstruction with either end ileostomy or ileal-pouch anal anastomosis (IPAA) did not impact post-LT or post-TAC outcomes. CONCLUSIONS: Long term survival in PSC-IBD was contingent upon progression to LT and was not impacted by the need for TAC. PSC-IBD patients undergoing TAC for medically refractory disease had a higher incidence of rPSC and biliary complications. The use of IPAA in PSC-IBD was a viable alternative to end ileostomy.

Ketamine intolerance in patients on enhanced recovery after surgery protocols undergoing colorectal operations.

BACKGROUND: Ketamine is used in enhanced recovery after surgery (ERAS) protocols because of its beneficial antihyperalgesic and antitolerance effects. However, adverse effects such as hallucinations, sedation, and diplopia could limit ketamine's utility. The main objective of this study was to identify rates of ketamine side effects in postoperative patients after colorectal surgery and, secondarily, to compare short-term outcomes between patients receiving ketamine analgesia and controls. METHODS: This was a retrospective observational cohort study. Subjects were adults who underwent ERAS protocol-guided colorectal surgery at a large, integrated health system. Patients were grouped into ketamine-receiving and preketamine cohorts. Patients receiving ketamine were divided into tolerant and intolerant groups. Propensity score-adjusted models tested multivariate associations of ketamine tolerance/intolerance vs control group. RESULTS: A total of 732 patients underwent colorectal surgery within the ERAS program before ketamine's introduction (control). After ketamine's introduction, 467 patients received the medication. Intolerance was seen in 29% of ketamine recipients, and the most common side effect was diplopia. Demographics and surgical variables did not differ between cohorts. Multivariate models revealed no significant differences in hospital stays. Pain scores in the first 24 hours after surgery were slightly higher in patients receiving ketamine. Opiate consumption after surgery was lower for both ketamine tolerant and ketamine intolerant cohorts than for controls. CONCLUSION: Rates of ketamine intolerance are high, which can limit its use and potential effectiveness. Ketamine analgesia significantly reduced opiate consumption without increasing hospital stays after colorectal surgery, regardless of whether it was tolerated.

Colorectal cancer genetic referral: Are we doing enough?

Purpose: Guidelines are published for referral to genetic counseling and multigene panel genetic testing for colorectal cancer. We hypothesize that these guidelines are not recognized in practice, resulting in the underreferral of patients to genetic counseling. We aimed to investigate the clinical impact of these guidelines. Methods: This was a retrospective cohort study conducted using a single academic-institution colorectal cancer patient registry. The registry included all patients ≥18 years old with a pathologic diagnosis of colon cancer, rectal cancer, or polyposis from January 2018 to January 2020 with complete chart data to determine inclusion into the genetic referral cohort. Results: Out of 225 colon cancer patients, 92 met criteria for referral to genetic testing, but only 56 patients obtained referral and 39 completed testing. For rectal cancer, 29 out of 127 patients met criteria for referral, but only 11 obtained referral and 8 completed testing. Actionable variants, defined as pathogenic or likely pathogenic, were identified in 18 colon cancer and 5 rectal cancer patients. Age made a significant difference in the referral rate for colon cancer (P = 0.02) but not rectal cancer (P > 0.05). Conclusion: Our study demonstrates poor adherence to guideline-based genetic testing. These data emphasize the need for more consistent referral to genetic testing for diagnosis of underlying inherited cancer syndromes.

Long-term Outcomes of the Kono-S Anastomosis: A Multicenter Study.

BACKGROUND: Postoperative recurrence remains a significant problem in Crohn's disease, and the mesentery is implicated in the pathophysiology. The Kono-S anastomosis was designed to exclude the mesentery from a wide anastomotic lumen, limit luminal distortion and fecal stasis, and preserve innervation and vascularization. OBJECTIVE: To review postoperative complications and long-term outcomes of the Kono-S anastomosis in a large series of consecutive unselected patients with Crohn's disease. DESIGN: Retrospective study of prospectively collected patients. SETTINGS: Four tertiary referral centers. PATIENTS: Consecutive patients with Crohn's disease who underwent resection with Kono-S anastomosis between May 2010 and June 2022. INTERVENTIONS: Extracorporeal handsewn Kono-S anastomosis. MAIN OUTCOME MEASURES: Postoperative outcomes and recurrence defined as endoscopic, clinical, laboratory, or surgical, including endoscopic, intervention. RESULTS: A total of 262 consecutive patients (53.4% male) were included. The mean duration of disease at surgery was 145.1 months. One hundred thirty-five patients (51.5%) had previous abdominal surgery for Crohn's disease. Forty-four patients (17%) were actively smoking and 150 (57.3%) were on biologic therapy. Anastomotic failure occurred in 4 (1.5%), with 2 patients requiring reoperation (0.7%). Sixteen patients had postoperative surgical site infection (6.1%). With a median follow-up of 49.4 months, 20 patients (7.6%) were found to have surgical recurrence. In the multivariate analysis, perianal disease (OR = 2.83, p = 0.001), urgent/emergent surgery (OR = 3.23, p = 0.007), and postoperative use of steroids (OR = 2.29, p = 0.025) were associated with increased risk of overall recurrence. LIMITATIONS: Retrospective study and variability of perioperative medical therapy. CONCLUSIONS: This study showed very low postoperative complication rates despite the complexity of the patient population. There was a low rate of surgical recurrence, likely due to the intrinsic advantages of the anastomotic configuration and the low rate of postoperative septic complications. In experienced hands, the Kono-S anastomosis is a safe technique with very promising short- and long-term results. Randomized controlled trials are underway to validate this study's findings. See Video Abstract . RESULTADO A LARGO PLAZO DE LA ANASTOMOSIS KONOS UN ESTUDIO MULTICNTRICO: ANTECEDENTES:La recurrencia posoperatoria sigue siendo un problema importante en la enfermedad de Crohn y el mesenterio está implicado en la fisiopatología. La anastomosis Kono-S fue diseñada para excluir el mesenterio de una anastomosis amplia, limitar la distorsión luminal y la estasis fecal y preservar la inervación y vascularización.OBJETIVO:Revisar las complicaciones posoperatorias y los resultados a largo plazo de la anastomosis Kono-S en una gran serie de pacientes consecutivos no seleccionados con enfermedad de Crohn.DISEÑO:Estudio retrospectivo de pacientes recolectados prospectivamente.ESCENARIO:Cuatro centros de referencia terciarios.PACIENTES:Pacientes consecutivos con enfermedad de Crohn sometidos a resección con anastomosis Kono-S entre mayo de 2010 y junio de 2022.INTERVENCIONES:Anastomosis Kono-S extracorpórea manual.PRINCIPALES MEDIDAS DE RESULTADO:Resultados posoperatorios y recurrencia definidos como endoscópicos, clínicos, de laboratorio o quirúrgicos, incluida la intervención endoscópica.RESULTADOS:Se incluyeron un total de 262 pacientes consecutivos (53,4% varones). La duración media de la enfermedad al momento de la cirugía fue de 145,1 meses. Ciento treinta y cinco pacientes (51,5%) habían tenido cirugía abdominal previa por enfermedad de Crohn. Cuarenta y cuatro pacientes (17%) eran fumadores activos y 150 (57,3%) estaban en tratamiento biológico. Se produjo filtración anastomótica en 4 (1,5%) y 2 pacientes requirieron reoperación (0,7%). Dieciséis pacientes tuvieron infección postoperatoria del sitio quirúrgico (6,1%). Con una mediana de seguimiento de 49,4 meses, se encontró que 20 pacientes (7,6%) tuvieron recurrencia quirúrgica. En el análisis multivariado, la enfermedad perianal (OR = 2,83, p = 0,001), la cirugía urgente/emergente (OR = 3,23, p = 0,007), el uso postoperatorio de esteroides (OR = 2,29, p = 0,025) se asociaron con un mayor riesgo de recurrencia general.LIMITACIÓN:Estudio retrospectivo. Variabilidad del tratamiento médico perioperatorio.CONCLUSIONES:Nuestro estudio mostró tasas de complicaciones postoperatorias muy bajas a pesar de la complejidad de la población de pacientes. Hubo una baja tasa de recurrencia quirúrgica, probablemente debido a las ventajas intrínsecas de la configuración anastomótica y la baja tasa de complicaciones sépticas posoperatorias. En manos experimentadas, la anastomosis Kono-S es una técnica segura con resultados muy prometedores a corto y largo plazo. Se están realizando estudios randomizados controlados para validar nuestros hallazgos. (Traducción-Dr. Felipe Bellolio ).

Sixth Annual Enhanced Recovery After Surgery Symposium highlights: work in progress or standard care?

Enhanced Recovery After Surgery (ERAS) protocols have demonstrated effectiveness in accelerating patient recovery and improving outcomes. Since the systemwide implementation of ERAS protocols at Baylor Scott & White Health, an annual multidisciplinary conference has provided a review of outcomes and advancements in the ERAS program. This meeting, coined the ERAS symposium, allows providers who utilize recovery protocols to collaborate with national and international leaders in the field to improve the clinical care of patients. The sixth annual ERAS symposium was held on February 10, 2023, and provided key presentations that discussed the latest results from ERAS efforts across multiple surgical specialties along with updates in anesthesia, nursing, and nutrition. A summary of those presentations, which included perioperative glycemic control, misconceptions in pain management, and emerging ERAS protocols in different surgical specialties, is provided to document the system progress.

Predictive factors of first-time failure on the American Board of Colorectal Surgery certifying and qualifying examinations.

Objective: To discover if first-attempt failure of the American Board of Colon and Rectal Surgery (ABCRS) board examination is associated with surgical training or personal demographic characteristics. Methods: Current colon and rectal surgery program directors in the United States were contacted via email. Deidentified records of trainees from 2011 to 2019 were requested. Analysis was performed to identify associations between individual risk factors and failure on the ABCRS board examination on the first attempt. Results: Seven programs contributed data, totaling 67 trainees. The overall first-time pass rate was 88% (n = 59). Several variables demonstrated potential for association, including Colon and Rectal Surgery In-Training Examination (CARSITE) percentile (74.5 vs 68.0, P = 0.09), number of major cases in colorectal residency (245.0 vs 219.2, P = 0.16), >5 publications during colorectal residency (75.0% vs 25.0%, P = 0.19), and first-time passage of the American Board of Surgery certifying examination (92.5% vs 7.5%, P = 0.18). Conclusion: The ABCRS board examination is a high-stakes test, and training program factors may be predictive of failure. Although several factors showed potential for association, none reached statistical significance. Our hope is that by increasing our data set, we will identify statistically significant associations that can potentially benefit future trainees in colon and rectal surgery.

Intestinal hypomotility due to longitudinal enterotomy can be alleviated by transverse closure.

BACKGROUND: Heineke-Mikulicz (HM) strictureplasty is commonly used to treat short stenoses in Crohn's disease. However, the degree to which intestinal motility is maintained remains unclear. We compared the peristalsis and transport capacity of the sutured intestines with HM configuration and transverse (TS) and longitudinal (LS) incisions. METHODS: The intestinal diameter, intraluminal pressure, and bead transit time of each sutured group were compared with that of the non-treatment (NT) group in the isolated proximal colon of rats. Propulsive contractions were induced using hydroxy-?-sanshool (HAS), a constituent of Japanese pepper. RESULTS: There was no change in the intestinal diameter between HM, TS, and NT groups ; however, it was significantly narrowed at the suture site and its distal side in the LS group. After HAS administration, the intestinal diameter at the suture site in the HM group was higher than that in the LS group. The intraluminal pressure was higher and the transit time was shorter in the HM group compared to those in the LS group. CONCLUSIONS: The HM configuration, which widens the incision site and distal diameter and shortens the cut surface of the circular muscle in the longitudinal direction, may help maintain basal and HAS-induced intestinal peristalsis and motility. J. Med. Invest. 70 : 180-188, February, 2023.

Peritoneal cell-free DNA as a sensitive biomarker for detection of peritoneal metastasis in colorectal cancer: a prospective diagnostic study: A prospective diagnostic study.

BACKGROUND: The detection of peritoneal metastasis (PM) is limited by current imaging tools. In this prospective study, we aimed to evaluate the sensitivity and specificity of peritoneal cell-free DNA (cfDNA) for diagnosis of PM. METHODS: Colorectal cancer (CRC) patients with/without PM were enrolled. The cfDNA experimental personnel and statists were blinded to the diagnosis of PM. Ultradeep sequencing covering large genomic regions (35000X, Next-generation sequencing) of cfDNA in peritoneal lavage fluid (FLD) and matched tumor tissues was performed. RESULTS: A total of 64 cases were recruited prospectively and 51 were enrolled into final analysis. In training cohort, 100% (17/17) PM patients obtained positive FLD cfDNA, comparing to 5/23 (21.7%) in patients without PM. Peritoneal cfDNA had a high sensitivity of 100% and specificity of 77.3% for diagnosis of PM (AUC: 0.95). In validation group of 11, 5/6 (83%) patients with PM obtained positive FLD cfDNA, comparing to 0/5 in non-PM (P = 0.031) with a sensitivity of 83.3% and specificity of 100%. Positive FLD cfDNA was associated with poor recurrence-free survival (P = 0.013) and was preceding radiographic evidence of recurrence. CONCLUSIONS: Peritoneal cfDNA is a promising sensitive biomarker for earlier detection of PM in CRC than current radiological tools. It can potentially guide selection for targeted therapies and serve as a surrogate instead of laparoscopic explore in the future. Trial Registration Chinese Clinical Trial Registry at chictr.org.cn (ChiCTR2000035400). URL: http://www.chictr.org.cn/showproj.aspx?proj=57626.

Surgical priorities in abdominal Crohn's disease.

Crohn's disease is a chronic disorder associated with a high rate of recurrence and morbidity. New therapies have been developed over the last few decades that have improved both induction of remission and lowered recurrence rates which led to improved outcomes. An overarching set of principles connects these therapies with prevention of recurrence being the top priority. To achieve the best outcomes, patients must be carefully chosen, optimized, and the correct surgery performed by an experienced and multidisciplinary team at the appropriate time. We seek to outline the current evidence-based approach to the surgical management of Crohn's disease.

Protective ileostomy creation after anterior resection of the rectum: Shared decision-making or still subjective?

AIM: The choice of whether to perform protective ileostomy (PI) after anterior resection (AR) is mainly guided by risk factors (RFs) responsible for the development of anastomotic leakage (AL). However, clear guidelines about PI creation are still lacking in the literature and this is often decided according to the surgeon's preferences, experiences or feelings. This qualitative study aims to investigate, by an open-ended question survey, the individual surgeon's decision-making process regarding PI creation after elective AR. METHOD: Fifty four colorectal surgeons took part in an electronic survey to answer the questions and describe what usually led their decision to perform PI. A content analysis was used to code the answers. To classify answers, five dichotomous categories (In favour/Against PI, Listed/Unlisted RFs, Typical/Atypical, Emotions/Non-emotions, Personal experience/No personal experience) have been developed. RESULTS: Overall, 76% of surgeons were in favour of PI creation and 88% considered listed RFs in the question of whether to perform PI. Atypical answers were reported in 10% of cases. Emotions and personal experience influenced surgeons' decision-making process in 22% and 49% of cases, respectively. The most frequently considered RFs were the distance of the anastomosis from the anal verge (96%), neoadjuvant chemoradiotherapy (88%), a positive intraoperative leak test (65%), blood loss (37%) and immunosuppression therapy (35%). CONCLUSION: The indications to perform PI following rectal cancer surgery lack standardization and evidence-based guidelines are required to inform practice. Until then, expert opinion can be helpful to assist the decision-making process in patients who have undergone AR for adenocarcinoma.

Primary Colorectal Cancer.

Over the last few decades, the colorectal surgery world has seen a paradigm shift in the care of patients. The introduction of minimally invasive techniques led to the development of procedures resulting in reduced patient morbidity and hospital stay. The vetting process of minimally invasive colorectal surgery involved rigorous studies to ensure that oncologic outcomes were not being compromised. In this chapter, we discuss the most relevant randomized controlled trials that support the practice of minimally invasive colorectal surgery. The multimodal treatment of rectal cancer has developed rapidly, resulting in improved survival and decreased morbidity and mortality. In this review, we also present the latest evidence behind the multidisciplinary approach to rectal cancer.

Helena's Many Daughters: More Mitogenome Diversity behind the Most Common West Eurasian mtDNA Control Region Haplotype in an Extended Italian Population Sample.

The high number of matching haplotypes of the most common mitochondrial (mt)DNA lineages are considered to be the greatest limitation for forensic applications. This study investigates the potential to solve this constraint by massively parallel sequencing a large number of mitogenomes that share the most common West Eurasian mtDNA control region (CR) haplotype motif (263G 315.1C 16519C). We augmented a pilot study on 29 to a total of 216 Italian mitogenomes that represents the largest set of the most common CR haplotype compiled from a single country. The extended population sample confirmed and extended the huge coding region diversity behind the most common CR motif. Complete mitogenome sequencing allowed for the detection of 163 distinct haplotypes, raising the power of discrimination from 0 (CR) to 99.6% (mitogenome). The mtDNAs were clustered into 61 named clades of haplogroup H and did not reveal phylogeographic trends within Italy. Rapid individualization approaches for investigative purposes are limited to the most frequent H clades of the dataset, viz. H1, H3, and H7.

Ancient DNA at the edge of the world: Continental immigration and the persistence of Neolithic male lineages in Bronze Age Orkney.

Orkney was a major cultural center during the Neolithic, 3800 to 2500 BC. Farming flourished, permanent stone settlements and chambered tombs were constructed, and long-range contacts were sustained. From ∼3200 BC, the number, density, and extravagance of settlements increased, and new ceremonial monuments and ceramic styles, possibly originating in Orkney, spread across Britain and Ireland. By ∼2800 BC, this phenomenon was waning, although Neolithic traditions persisted to at least 2500 BC. Unlike elsewhere in Britain, there is little material evidence to suggest a Beaker presence, suggesting that Orkney may have developed along an insular trajectory during the second millennium BC. We tested this by comparing new genomic evidence from 22 Bronze Age and 3 Iron Age burials in northwest Orkney with Neolithic burials from across the archipelago. We identified signals of inward migration on a scale unsuspected from the archaeological record: As elsewhere in Bronze Age Britain, much of the population displayed significant genome-wide ancestry deriving ultimately from the Pontic-Caspian Steppe. However, uniquely in northern and central Europe, most of the male lineages were inherited from the local Neolithic. This suggests that some male descendants of Neolithic Orkney may have remained distinct well into the Bronze Age, although there are signs that this had dwindled by the Iron Age. Furthermore, although the majority of mitochondrial DNA lineages evidently arrived afresh with the Bronze Age, we also find evidence for continuity in the female line of descent from Mesolithic Britain into the Bronze Age and even to the present day.

Long-term Oncological Outcome of Segmental Versus Extended Colectomy for Colorectal Cancer in Crohn's Disease: Results from an International Multicentre Study.

BACKGROUND AND AIMS: Crohn's disease increases colorectal cancer risk, with high prevalence of synchronous and metachronous cancers. Current guidelines for colorectal cancer in Crohn's disease recommend pan-proctocolectomy. The aim of this study was to evaluate oncological outcomes of a less invasive surgical approach. METHODS: This was a retrospective database analysis of Crohn's disease patients with colorectal cancer undergoing surgery at selected European and US tertiary centres. Outcomes of segmental colectomy were compared with those of extended colectomy, total colectomy, and pan-proctocolectomy. Primary outcome was progression-free survival. Secondary outcomes included overall survival, synchronous and metachronous colorectal cancer, and major postoperative complications. RESULTS: Ninety-nine patients were included: 66 patients underwent segmental colectomy and 33 extended colectomy. Segmental colectomy patients were older [p = 0.0429], had less extensive colitis [p = 0.0002] and no preoperatively identified synchronous lesions [p = 0.0109].Median follow-up was 43 [31-62] months. There was no difference in unadjusted progression-free survival [p = 0.2570] or in overall survival [p = 0.4191] between segmental and extended colectomy. Multivariate analysis adjusting for age, sex, ASA score, and AJCC staging, confirmed no difference for progression-free survival (hazard ratio [HR] 1.00, p = 0.9993) or overall survival [HR 0.77, p = 0.6654]. Synchronous and metachronous cancers incidence was 9% and 1.5%, respectively. Perioperative mortality was nil and major complications were comparable [7.58% vs 6.06%, p = 0.9998]. CONCLUSIONS: Segmental colectomy seems to offer similar long-term outcomes to more extensive surgery. Incidence of synchronous and metachronous cancers appears much lower than previously described. Further prospective studies are warranted to confirm these results.

Impact of Patient-Reported Penicillin Allergy on Antibiotic Prophylaxis and Surgical Site Infection Among Patients Undergoing Colorectal Surgery.

BACKGROUND: Surgical site infections are a major preventable source of morbidity, mortality, and increased health care expenditures after colorectal surgery. Patients with penicillin allergy may not receive the recommended preoperative antibiotics, putting them at increased risk for surgical site infections. OBJECTIVE: This study aimed to evaluate the impact of patient-reported penicillin allergy on preoperative antibiotic prophylaxis and surgical site infection rates among patients undergoing major colon and rectal procedures. DESIGN: This is a retrospective observational study. SETTING: This study was conducted at a tertiary teaching hospital in Dallas. PATIENTS: Adults undergoing colectomy or proctectomy between July 2012 and July 2019 were included. MAIN OUTCOME MEASURES: The primary outcomes measured were preoperative antibiotic choice and surgical site infection. RESULTS: Among 2198 patients included in the study, 12.26% (n = 307) reported a penicillin allergy. Patients with penicillin allergy were more likely to be white (82%) and female (54%; p < 0.01). The most common type of allergic reaction reported was rash (36.5%), whereas 7.2% of patients reported anaphylaxis. Patients with self-reported penicillin allergy were less likely to receive beta-lactam antibiotics than patients who did not report a penicillin allergy (79.8% vs 96.7%, p < 0.001). Overall, 143 (6.5%) patients had surgical site infections. On multivariable logistic regression, there was no difference in rates of surgical site infection between patients with penicillin allergy vs those without penicillin allergy (adjusted OR 1.14; 95% CI, 0.71-1.82). LIMITATIONS: A limitation of this study was its retrospective study design. CONCLUSIONS: Self-reported penicillin allergy among patients undergoing colorectal surgery is common; however, only a small number of these patients report any serious adverse reactions. Patients with self-reported penicillin allergy are less likely to receive beta-lactam antibiotics and more likely to receive non-beta-lactam antibiotics. However, this does not affect the rate of surgical site infection among these patients, and these patients can be safely prescribed non-beta-lactam antibiotics without negatively impacting surgical site infection rates. See Video Abstract at http://links.lww.com/DCR/B838 .IMPACTO DE LA ALERGIA A LA PENICILINA INFORMADA POR EL PACIENTE EN LA PROFILAXIS ANTIBIÓTICA Y LA INFECCIÓN DEL SITIO OPERATORIO ENTRE PACIENTES DE CIRUGÍA COLORECTAL. ANTECEDENTES: Las infecciones del sitio operatorio son una de las principales fuentes prevenibles de morbilidad, mortalidad y aumento del gasto sanitario después de cirugía colorrectal. Es posible que los pacientes con alergia a la penicilina no reciban los antibióticos preoperatorios recomendados, lo que los pone en mayor riesgo de infecciones en el sitio operatorio. OBJETIVO: Este estudio tuvo como objetivo evaluar el impacto de la alergia a la penicilina informada por el paciente sobre la profilaxis antibiótica preoperatoria y las tasas de infección del sitio operatorio entre pacientes sometidos a procedimientos mayores de colon y recto. DISEO: Estudio observacional retrospectivo. AJUSTE: Hospital universitario terciario en Dallas. PACIENTES: Adultos sometidos a colectomía o proctectomía entre julio de 2012 a julio de 2019. PRINCIPALES MEDIDAS DE DESENLACE: Elección de antibióticos preoperatorios e infección del sitio operatorio. RESULTADOS: Entre los 2198 pacientes incluidos en el estudio, el 12,26% (n = 307) informó alergia a la penicilina. Los pacientes con alergia a la penicilina tenían más probabilidades de ser blancos (82%) y mujeres (54%) ( p < 0,01). El tipo más común de reacción alérgica notificada fue erupción cutánea (36,5%), mientras que el 7,2% de los pacientes notificó anafilaxia. Los pacientes con alergia a la penicilina autoinformada tenían menos probabilidades de recibir antibióticos betalactámicos en comparación con los pacientes que no informaron alergia a la penicilina (79,8% frente a 96,7%, p < 0,001). En general, hubo 143 (6,5%) pacientes con infecciones del sitio operatorio. En la regresión logística multivariable no hubo diferencias en las tasas de infección del sitio operatorio entre los pacientes con alergia a la penicilina frente a los que no tenían alergia a la penicilina (razón de probabilidades ajustada 1,14; intervalo de confianza del 95%, 0,71-1,82). LIMITACIONES: Diseño de estudio retrospectivo. CONCLUSIONES: La alergia a la penicilina autoinformada entre los pacientes de cirugía colorrectal es común, sin embargo, solo un pequeño número de estos pacientes informan reacciones adversas graves. Los pacientes con alergia a la penicilina autoinformada tienen menos probabilidades de recibir antibióticos betalactámicos y más probabilidades de recibir antibióticos no betalactámicos. Sin embargo, esto no afecta la tasa de infección del sitio quirúrgico entre estos pacientes y se les puede recetar de forma segura con antibióticos no betalactámicos sin afectar negativamente las tasas de infección del sitio quirúrgico. Consulte Video Resumen en http://links.lww.com/DCR/B838 . (Traducción-Dr. Juan Carlos Reyes ).

Repeatability and reproducibility of deep-learning-based liver volume and Couinaud segment volume measurement tool.

PURPOSE: Volumetric and health assessment of the liver is crucial to avoid poor post-operative outcomes following liver resection surgery. No current methods allow for concurrent and accurate measurement of both Couinaud segmental volumes for future liver remnant estimation and liver health using non-invasive imaging. In this study, we demonstrate the accuracy and precision of segmental volume measurements using new medical software, Hepatica™. METHODS: MRI scans from 48 volunteers from three previous studies were used in this analysis. Measurements obtained from Hepatica™ were compared with OsiriX. Time required per case with each software was also compared. The performance of technicians and experienced radiologists as well as the repeatability and reproducibility were compared using Bland-Altman plots and limits of agreement. RESULTS: High levels of agreement and lower inter-operator variability for liver volume measurements were shown between Hepatica™ and existing methods for liver volumetry (mean Dice score 0.947 ± 0.010). A high consistency between technicians and experienced radiologists using the device for volumetry was shown (± 3.5% of total liver volume) as well as low inter-observer and intra-observer variability. Tight limits of agreement were shown between repeated Couinaud segment volume (+ 3.4% of whole liver), segmental liver fibroinflammation and segmental liver fat measurements in the same participant on the same scanner and between different scanners. An underestimation of whole-liver volume was observed between three non-reference scanners. CONCLUSION: Hepatica™ produces accurate and precise whole-liver and Couinaud segment volume and liver tissue characteristic measurements. Measurements are consistent between trained technicians and experienced radiologists.

Development and Validation of an Image-based Deep Learning Algorithm for Detection of Synchronous Peritoneal Carcinomatosis in Colorectal Cancer.

OBJECTIVE: The aim of this study was to build a SVM classifier using ResNet-3D algorithm by artificial intelligence for prediction of synchronous PC. BACKGROUND: Adequate detection and staging of PC from CRC remain difficult. METHODS: The primary tumors in synchronous PC were delineated on preoperative contrast-enhanced computed tomography (CT) images. The features of adjacent peritoneum were extracted to build a ResNet3D + SVM classifier. The performance of ResNet3D + SVM classifier was evaluated in the test set and was compared to routine CT which was evaluated by radiologists. RESULTS: The training set consisted of 19,814 images from 54 patients with PC and 76 patients without PC. The test set consisted of 7837 images from 40 test patients. The ResNet-3D spent only 34 seconds to analyze the test images. To increase the accuracy of PC detection, we have built a SVM classifier by integrating ResNet-3D features with twelve PC-specific features (P < 0.05). The ResNet3D + SVM classifier showed accuracy of 94.11% with AUC of 0.922 (0.912-0.944), sensitivity of 93.75%, specificity of 94.44%, positive predictive value (PPV) of 93.75%, and negative predictive value (NPV) of 94.44% in the test set. The performance was superior to routine contrast-enhanced CT (AUC: 0.791). CONCLUSIONS: The ResNet3D + SVM classifier based on deep learning algorithm using ResNet-3D framework has shown great potential in prediction of synchronous PC in CRC.