A Collaborative for Implementation of an Evidence-Based Clinical Pathway for Enhanced Recovery in Colon and Rectal Surgery in an Affiliated Network of Healthcare Organizations.

BACKGROUND: In 2015 the Mayo Clinic Care Network (MCCN), in an effort to extend medical knowledge and share these best practices, embarked on an education mission to diffuse the clinical practice redesign involving the practice of colon and rectal surgery at Mayo Clinic (Rochester, Minnesota) to members of the MCCN. They elected to use a collaborative framework in an attempt to transfer knowledge to multiple teams in an efficient and supportive manner. METHODS: Eight MCCN members assembled a multidisciplinary team, which participated in both a didactic learning session delivered by frontline experts, as well as follow-up remote sessions regarding Mayo Clinic's enhanced recovery pathway for colon and rectal surgery. Teams departed the group session with established immediate next steps, communication plans, and an awareness of potential barriers and strategies for mitigation. Monthly coaching calls followed in an effort to help all teams meet their time line and overall goals. Finally, all participants met again after six months to report their clinical outcomes, as well their unique individual organization's successes and barriers encountered. RESULTS: Participating teams felt overwhelmingly that the collaborative program exceeded their expectations and equipped them with the tools to be successful. They also felt that the extended support provided by the Mayo Clinic team was essential, and the collaboration with other members markedly enhanced their experience. Importantly, all teams were able to successfully reduce length of stay, which was the desired main clinical outcome. DISCUSSION: The collaborative format was instrumental in the rapid diffusion and successful implementation of a transformative practice redesign involving colorectal surgical care of patients.

Natural history of pancreatic cancer recurrence following "curative" resection in athymic mice.

OBJECTIVE: We present a mouse model of pancreatic cancer recurrence following "curative" resection using a novel technique of implanting red fluorescent protein transfected tumor cells within a hyaluronan-based synthetic extracellular matrix into the distal pancreas of nude mice. Following "curative" pancreatic resection, we demonstrate postoperative disease recurrence by fluorescence imaging. METHODS: Forty athymic nude mice underwent pancreatic injection with red fluorescent protein transfected MiaPaCa-2 or AsPc-1 cells suspended in a synthetic extracellular matrix. In 20 animals, the distal pancreas and primary tumor were resected at 2 or 5 wk following injection. The remaining 20 mice underwent sham resection. Eight weeks following resection, necropsy and fluorescence imaging were performed to assess disease recurrence. RESULTS: At exploration, 39 of 40 mice had primary tumors. Eighteen of 20 mice were eligible for curative resection. Eight weeks following "curative" resection, 10 of 18 mice had recurrent disease. Of these, six developed local recurrence, two had distant metastases, and two had both. CONCLUSIONS: Using an orthotopic animal model, we are able to reliably develop primary tumors, safely perform "curative" resection, and demonstrate a 56% recurrence rate 8 wk following resection. We confirmed disease-free resection using fluorescence imaging. This model may prove useful for preclinical adjuvant therapeutic trials.

Magnetic attraction leading to a small bowel obstruction in a child.

Foreign body ingestion in small children is common yet only 1% of cases require operative management of associated complications (Arana et al. in Eur J Pediatr 160:468-472, 2001). A 6-year-old boy was referred to our institution with a 12 h history of abdominal pain. This pain was diffuse and crampy in nature and associated with multiple episodes of non-bilious, non-bloody emesis. On evaluation he was stable and his abdomen demonstrated slight distention and tenderness without peritoneal signs. Plain abdominal radiographs demonstrated some distended loops of small bowel and a radio-opaque foreign object within the mid-abdomen. A small bowel obstruction secondary to foreign body ingestion was diagnosed and an emergent laparotomy performed. Upon exploration, a transition zone was noted near the ileocecal valve. Further exploration revealed the obstruction to be caused secondary to the apposition of two small (8 mm) magnets, one in the proximal ileum and the other near the ileocecal valve, resulting in an internal hernia. The magnets were easily separated relieving the obstruction and both were removed via two small bowel enterotomies. After being presented with the magnets, his parents suspected that they came from the clothes of a Polly Pocket (Mattel, Inc., El Segundo, CA) doll. The patient had an uneventful post-operative course and was discharged to home on the second post-operative day. This case demonstrates the complications that may occur with multiple magnet ingestion. It highlights the need for close observation and early surgical intervention in children with a suspected history of foreign body ingestion, a clinical picture of gastrointestinal distress, and radiographic evidence of a radio-opaque foreign object.