Prospective randomized comparison of three-dimensional (3D) versus conventional laparoscopy in total colectomy for ulcerative colitis.

BACKGROUND: 3D laparoscopy has been proposed with the aim of improving the depth perception and overall operative performance. To aim of this study is to compare 3D laparoscopy with conventional 2D laparoscopy in terms of operative time and visual parameters. METHODS: This is a prospective, randomized, single-center trial designed to determine 10% reduction in the mean operative time. Ulcerative colitis patients >18 years of age who underwent laparoscopic total abdominal colectomy with end ileostomy between 2015 and 2020 were included. Patients were randomized into 3D and 2D laparoscopy groups. Duration of operation and surgeons' evaluation of the visualization system were the primary outcomes. RESULTS: Fifty-three subjects (26 in 2D, 27 in 3D group) were included in the analysis, with 56% being male. Mean age and body mass index were 40 (16.3) years and 23.5 (4.7) kg/m2 , respectively. Twenty-five subjects underwent single port laparoscopic surgery, of whom 13 were in 3D and 12 in 2D group. Mean operative time was 75.3 (30.8) versus 82.7 (38.6) minutes (P = 0.4) for 3D and 2D groups, respectively. Operative times spent for individual steps were comparable. Post-operative minor complications (8 in 3D versus 8 in 2D, P = 1) and median number of times for scope maintenance were also similar between the groups. 69% of the visual evaluation survey results favoured 3D over 2D (P = 0.014). CONCLUSION: Three-dimensional laparoscopy for total colectomy in ulcerative colitis patients is safe and feasible option providing better visualization with no difference in operative time.

Do surface morphology and pit pattern have a role in predicting cancer for colon polyps in North America?

BACKGROUND: The surface morphology of colorectal polyps is well correlated with submucosal invasion in Eastern Countries but not in North America. We aimed to investigate associations between the Paris classification, surface morphology, and Kudo pit pattern to submucosal invasion in advanced endoscopic resection techniques. METHODS: We retrospectively analyzed prospectively collected data of consecutive advanced endoscopic procedures conducted by a single surgeon between August 2017 and October 2018. The data included patients' demographics, the endoscopic finding of polyps (Paris, Kudo, and surface morphology), and pathology results. RESULTS: The study consisted of 138 lesions, and the mean age was 67 ± 10 years. The most common polyp locations were cecum (n = 41, 30%) followed by ascending colon (n = 28, 20%), and sigmoid colon (n = 18, 13%).The median polyp size was 30 mm (25-40). The en-bloc resection rate was 96%, and 11 (8%) polyps had adenocarcinoma with submucosal invasion. Nine patients (6.5%) had late bleeding, and 3 (2.2%) perforation occurred. Polyps with pit pattern of Kudo IV (n = 4, 36.4%) and Kudo V (n = 6, 54.5%) were associated with submucosal invasion. CONCLUSIONS: Surface morphology and pit pattern can predict submucosal invasion in the North American patient population. Polyp morphology may aid polyp selection for advanced endoscopic interventions.

Does milk of magnesia impact length of hospital stay after major colorectal resection.

BACKGROUNDS: Milk of magnesia (MoM) has been reported to accelerate return of bowel function following surgery. However, there is insufficient evidence regarding the impact of MoM on postoperative recovery after colorectal surgery. We aimed to determine the impact of MoM on postoperative length of stay in patients undergoing colorectal surgery. METHODS: All patients who underwent colorectal resection without an ileostomy between 2015 and 2018 were included. Patients were divided into two groups based on whether postoperative MoM (MoM) was administered or not, according to surgeons' prescribing preferences. Consecutive patients of surgeons who prescribe MoM were included in the MoM group, while consecutive patients of surgeons who prefer not to prescribe MoM served as the control group. Age, gender, preoperative comorbidities, surgical approach, length of stay, readmission, postoperative complications and mortality were evaluated and compared between the groups. RESULTS: A total of 3292 patients were included; 523 (15.9%) patients were prescribed MoM. Patients in the MoM group were found to be significantly older, with higher BMI and ASA class, and more often undergoing operations for cancer resection or colostomy creations, than the control group. Postoperative complications were comparable between the groups. On multivariable linear regression, MoM use was associated with a 14.1% reduction in length of stay (MoM group 4 (2; 8), control group 5 (3; 8 P = 0.006)). CONCLUSION: MoM as adjunct medication in the postoperative period following colorectal surgery is associated with reduced length of stay, without an increase in postoperative complications.

Venous Thromboembolism in Patients Admitted for IBD: An Enterprise-Wide Experience of 86,000 Hospital Encounters.

BACKGROUND: Recommendations regarding venous thromboembolism prophylaxis in patients admitted to the hospital for IBD continue to evolve. OBJECTIVE: This study aimed to determine the 90-day rate and risk factors of deep venous thromboembolism and pulmonary embolism in cohorts of patients with IBD admitted to medical and surgical services. DESIGN: This was a retrospective review. SETTING: The study was conducted at a quaternary IBD referral center. PATIENTS: The study included adult patients ( > 18 y of age) with a known diagnosis of either ulcerative colitis or Crohn's disease who had an inpatient hospital admission for IBD between January 1, 2002, and January 1, 2020. MAIN OUTCOME MEASURES: The primary outcome measures were 90-day rate of deep venous thromboembolism and pulmonary embolism among admitted patients. RESULTS: A total of 86,276 hospital admissions from 16,551 patients with IBD occurred between January 1, 2002, and January 1, 2020. A total of 35,992 patients (41.7%) were given subcutaneous heparin for venous thromboembolism prophylaxis, and 8188 patients (9.49%) were given enoxaparin for venous thromboembolism prophylaxis during the inpatient hospital admission. From the date of hospital admission, the 90-day rate of deep venous thromboembolism was 4.3% (n = 3664); of these, 1731 patients (47%) were diagnosed during the admission and 1933 patients (53%) were diagnosed after discharge. From the date of hospital admission, the 90-day rate of pulmonary embolism was 2.4% (n = 2040); of these, 960 patients (47%) were diagnosed during admission and 1080 patients (53%) were diagnosed after discharge. LIMITATIONS: The study was limited by its retrospective nature and unmeasured severity of the disease. CONCLUSIONS: Patients admitted for IBD had a 90-day deep venous thromboembolism event rate of 4.3% and pulmonary embolism event rate of 2.4%. More than half of the events occurred after discharge, and venous thromboembolism events were higher among patients with IBD admitted to a medical service than those admitted to a surgical service. See Video Abstract at http://links.lww.com/DCR/B947 . TROMBOEMBOLIA VENOSA EN PACIENTES INGRESADOS CON ENFERMEDAD INFLAMATORIA INTESTINAL UNA EXPERIENCIA EN TODA LA EMPRESA DE ENCUENTROS HOSPITALARIOS: ANTECEDENTES:Recomendaciones sobre la profilaxis de tromboembolia venosa en pacientes ingresados con enfermedad inflamatoria intestinal (EII) continúa evolucionando.OBJETIVO:Determinar la tasa a 90 días y los factores de riesgo de tromboembolia venosa profunda y embolia pulmonar en cohortes de pacientes ingresados con EII médico y quirúrgico.DISEÑO:Esta fue una revisión retrospectiva.AJUSTE:El estudio se llevó a cabo en un centro cuaternario de derivación de EII.PACIENTES:Se incluyeron pacientes adultos (> 18 años) con diagnóstico conocido de colitis ulcerosa o enfermedad de Crohn que fueron hospitalizados por EII entre el 1 de Enero de 2002 y el 1 de Enero de 2020.PRINCIPALES MEDIDAS DE RESULTADOS:Las medidas principales fueron la tasa de tromboembolia venosa profunda a 90 días y la embolia pulmonar entre los pacientes ingresados.RESULTADOS:Un total de 86.276 ingresos hospitalarios de 16.551 pacientes con EII ocurrieron entre el 1 de Enero de 2002 y el 1 de Enero de 2020. A un total de 35.992 (41,7%) se les administró heparina subcutánea para profilaxis de tromboembolia venosa y a 8.188 (9,49%) se les administró enoxaparina para profilaxis de tromboembolia venosa durante el ingreso hospitalario. A partir de la fecha de ingreso hospitalario, la tasa de tromboembolia venosa profunda a 90 días fue del 4,3% (n = 3.664); de estos 1.731 (47%) se diagnosticaron durante el ingreso y 1.933 (53%) se diagnosticaron después del alta. Desde la fecha de ingreso hospitalario, la tasa de embolia pulmonar a los 90 días fue de 2,4% (n = 2.040); De estos, 960 (47%) fueron diagnosticados durante el ingreso y 1.080 (53%) fueron diagnosticados después del alta.LIMITACIONES:El estudio fue retrospectivo y no se midió la gravedad de la enfermedad.CONCLUSIÓNES:Los pacientes ingresados por EII tuvieron una tasa de tromboembolia venosa profunda y de eventos de embolia pulmonar de 4,3% y 2,4%, respectivamente, a 90 días. Más de la mitad de los eventos ocurrieron después del alta y los eventos de TEV fueron más altos entre los pacientes de EII médicos que quirúrgicos. Consulte Video Resumen en http://links.lww.com/DCR/B947 . (Traducción- Dr. Yesenia Rojas-Khalil ).

Effect of Incisional Negative Pressure Wound Therapy on Surgical Site Infections in High-Risk Reoperative Colorectal Surgery: A Randomized Controlled Trial.

BACKGROUND: Colorectal resections have relatively high rates of surgical site infections causing significant morbidity. Incisional negative pressure wound therapy was introduced to improve wound healing of closed surgical incisions and to prevent surgical site infections. OBJECTIVE: This randomized controlled trial aimed to investigate the effect of incisional NPWT on superficial surgical site infections in high-risk, open, reoperative colorectal surgery. DESIGN: This was a single-center randomized controlled trial conducted between July 2015-October 2020. Patients were randomly assigned to incisional negative pressure wound therapy or standard gauze dressing with a 1:1 ratio. A total of 298 patients were included. SETTINGS: This study was conducted at the colorectal surgery department of a tertiary-level hospital. PATIENTS: This study included patients older than 18 years who underwent elective reoperative open colorectal resections. Patients were excluded who had open surgery within the past 3 months, who had active surgical site infection, and who underwent laparoscopic procedures. MAIN OUTCOME MEASURES: The primary outcome was superficial surgical site infection within 30 days. Secondary outcomes were deep and organ-space surgical site infections within 7 days and 30 days, postoperative complications, and length of hospital stay. RESULTS: A total of 149 patients were included in each arm. The mean age was 51 years, and 49.5% were women. Demographics, preoperative comorbidities, and preoperative albumin levels were comparable between the groups. Overall, most surgeries were performed for IBD, and 77% of the patients had an ostomy fashioned during the surgery. No significant difference was found between the groups in 30-day superficial surgical site infection rate (14.1% in control versus 9.4% in incisional negative pressure wound therapy; p = 0.28). Deep and organ-space surgical site infections rates at 7 and 30 days were also comparable between the groups. Postoperative length of stay and complication rates (Clavien-Dindo grade) were also comparable between the groups. LIMITATIONS: The patient population included in the trial consisted of a selected group of high-risk patients. CONCLUSIONS: Incisional negative pressure wound therapy was not associated with reduced superficial surgical site infection or overall complication rates in patients undergoing high-risk reoperative colorectal resections. See Video Abstract at http://links.lww.com/DCR/B956 . EFECTO DE LA TERAPIA DE HERIDA INSICIONAL CON PRESIN NEGATIVA EN INFECCIONES DEL SITIO QUIRRGICO EN CIRUGA COLORRECTAL REOPERATORIA DE ALTO RIESGO UN ENSAYO CONTROLADO ALEATORIZADO: ANTECEDENTES:Las resecciones colorrectales tienen tasas relativamente altas de infecciones del sitio quirúrgico que causan una morbilidad significativa. La terapia de heridas incisionales con presión negativa se introdujo para mejorar la cicatrización de las heridas de incisiones quirúrgicas cerradas y para prevenir infecciones del sitio quirúrgico.OBJETIVO:El objetivo de este ensayo controlado y aleatorizado fue investigar el efecto de la terapia de herida incisional con presión negativa en infecciones superficiales del sitio quirúrgico en cirugía colorrectal re operatoria, abierta y de alto riesgo.DISEÑO:Ensayo controlado y aleatorizado de un solo centro entre julio de 2015 y octubre de 2020. Los pacientes fueron aleatorizados para recibir tratamiento para heridas incisionales con presión negativa o vendaje de gasa estándar en una proporción de 1:1. Se incluyeron un total de 298 pacientes.AJUSTE:Este estudio se realizó en el departamento de cirugía colorrectal de un hospital de tercer nivel.PACIENTES:Se incluyeron pacientes mayores de 18 años que se fueron sometidos a resecciones colorrectales abiertas, re operatorias y electivas. Se excluyeron aquellos pacientes que tuvieron cirugía abierta en los últimos 3 meses, con infección activa del sitio quirúrgico y que fueron sometidos a procedimientos laparoscópicos.PRINCIPALES MEDIDAS DE RESULTADO:El resultado primario fue infección superficial del sitio quirúrgico dentro de los 30 días. Los resultados secundarios fueron infecciones del sitio quirúrgico profundas y del espacio orgánico dentro de los 7 y 30 días, las complicaciones posoperatorias y la duración de la estancia hospitalaria.RESULTADOS:Se incluyeron un total de 149 pacientes en cada brazo. La edad media fue de 51 años y el 49,5% fueron mujeres. La demografía, las comorbilidades preoperatorias y los niveles de albúmina preoperatoria fueron comparables entre los grupos. En general, la mayoría de las cirugías fueron realizadas por enfermedad inflamatoria intestinal y al 77 % de los pacientes se les confecciono una ostomía durante la cirugía. No hubo diferencias significativas entre los grupos en la tasa de infección del sitio quirúrgico superficial a los 30 días (14,1 % en el control frente a 9,4 % en el tratamiento de herida incisional con presión negativa, p = 0,28). Las tasas de infecciones del sitio quirúrgico profundas y del espacio orgánico a los 7 y 30 días también fueron comparables entre los grupos. La duración de la estancia postoperatoria y las tasas de complicaciones (Clavien-Dindo Graduacion) también fueron comparables entre los grupos.LIMITACIONES:La población de pacientes incluida en el ensayo consistió en un grupo seleccionado de pacientes de alto riesgo.CONCLUSIONES:Video Resumen en http://links.lww.com/DCR/B956 . (Traducción-Dr. Osvaldo Gauto ).

Restorative proctocolectomy with ileal pouch-anal anastomosis in elderly patients - is advanced age a contraindication?

AIM: We aimed to determine pouch function and retention rate for restorative proctocolectomy with ileal pouch-anal anastomosis (IPAA) for ulcerative colitis (UC) in elderly patients. METHODS: We identified patients over 50 years old subjected to IPAA for confirmed pathological UC from 1980 until 2016. Patients were grouped according to age: 50-59, 60-69 and 70+ years. Short and long-term outcomes and quality of life (QOL) were compared among the groups. RESULTS: Six hundred and one patients were identified (399 (66.4%) between 50-59 181 (30.1%) between 60-69, and 21 (3.5%) over 70 years of age). More males were in the 70+ arm, and more two-stage procedures were performed in this group. Wound infection increased with age (P = 0.023). There was a trend of more fistula and pouchitis in the 70+ patients (P = 0.052 and P = 0.055, respectively). Pouch failure rate increased with age, and it was statistically significant in the 70+ cohort (P = 0.015). Multivariate stepwise logistic regression showed that pelvic sepsis (HR 4.8 (95% CI 1.5-15.4), P = 0.009), fistula (HR 6.0 (95% CI 1.7-21.5), and mucosectomy with handsewn anastomosis (HR 4.5 (95% CI 1.4-14.7)), were independently associated with pouch failure. No difference was observed in the QOL among the groups, but pouch function was better for patients younger than 60 years. CONCLUSION: In elderly patients with UC, IPAA may be offered with reasonable functional outcomes, and ileal pouch retention rates, as an alternative to the permanent stoma. Stapled anastomosis increases the chance of pouch retention and should be recommended as long as the distal rectum does not carry dysplasia.

A Comparison of Perineal Myocutaneous Flaps Following Abdominoperineal Excision of the Rectum for Anorectal Pathology.

BACKGROUND: Flap-based reconstruction following abdominoperineal resection has been used to address the resultant soft tissue defect and reduce postoperative wound complications. Vertical rectus abdominis myocutaneous flaps have been the traditional choice, but locoregional flaps have attracted attention in minimally invasive resection because they avoid additional abdominal dissection. However, few data exist comparing flap types. OBJECTIVE: To compare outcomes for different types of perineal reconstruction in patients undergoing abdominoperineal resection exclusively for anorectal pathology. DESIGN: This was a retrospective comparative study. SETTING: This study was conducted at a large, tertiary referral institution. PATIENTS: Following Institutional Review Board approval, prospectively maintained clinical and financial databases were interrogated and cross-referenced for patients undergoing proctectomy or abdominoperineal resection with flap reconstruction from 2007 to 2018. Patients with primary gynecological or urological pathology were excluded. MAIN OUTCOME MEASURES: The primary outcome was flap complication rate. Secondary outcomes included perineal hernia rate, donor site complications, emergency department consult after discharge, readmission <90 days, and length of stay. Data were analyzed using univariate and multivariate techniques. RESULTS: A total of 135 patients (79 female, median age 58 years) were included: 68 rectus, 52 gluteal, and 15 gracilis flap reconstructions. Median follow-up was 46 months. Rates of both major and minor flap complications were similar for rectus and gluteal flaps, even when controlling for differences between groups via multivariate analysis ( p > 0.9), including extent of resection and use of mesh. For all flaps, American Society of Anesthesiology score ≥3 was the only independent predictor of major, but not minor, flap complications. For rectus and gluteal flaps, smoking, female sex, and American Society of Anesthesiology score ≥3 were independent predictors of major flap complications ( p < 0.05). LIMITATIONS: This study was limited by its retrospective nature and potential selection bias associated with flap choice; it was also impossible to quantify defect size. CONCLUSION: Gluteal flaps have similar complication rates to rectus flaps and may be considered for patients who are otherwise suitable for minimally invasive abdominoperineal resection. See Video Abstract at http://links.lww.com/DCR/B866 .Una comparación de los colgajos miocutáneos perineales después de la escisión abdominoperineal del recto para patología anorectal. ANTECEDENTES: La reconstrucción con colgajo después de la resección abdominoperineal se ha utilizado para abordar el defecto de tejido blando resultante y reducir las complicaciones postoperatorias de la herida. Los colgajos miocutáneos verticales del recto abdominal han sido la elección tradicional, pero los colgajos locorregionales han atraído la atención en la resección mínimamente invasiva porque evitan la disección abdominal adicional. Sin embargo, existen pocos datos que comparen los tipos de colgajos.

Colonic disease recurrence following proctectomy with end colostomy for anorectal Crohn's disease.

AIM: In patients with anorectal Crohn's disease, it remains uncertain whether a total proctocolectomy with end ileostomy or proctectomy with end colostomy should be recommended due to the unknown rate of disease recurrence in the remaining colon. METHODS: A retrospective review of all patients with a known diagnosis of Crohn's disease who underwent a proctectomy with end colostomy for distal Crohn's disease between January 1, 2010 and January 1, 2019 at two IBD referral centres was conducted. Data collected included patient demographics, surgical variables at the time of proctectomy, and postoperative clinical, endoscopic and surgical recurrence rates. RESULTS: A total of 63 patients were included; mean age was 47 years (SD 15 years) and 32 (50.8%) were female. The majority of patients underwent a proctectomy with end colostomy (n = 56; 88.9%) while the remaining seven patients (11.1%) underwent a proctectomy with end colostomy and concurrent ileocectomy. A total of 55 patients (87.3%) had proctitis, 51 (81%) had perianal fistulating disease, and 34 (54%) had anal canal stenosis or ulceration. Most patients had medically refractory disease (n = 54; 85.7%) versus neoplasia (n = 9; 14.3%). The median length of long-term follow-up was 17.7 months (IQR: 4.72, 38.7 months). During that time, 14 (22.2%) experienced clinical recurrence, 10 of 34 evaluated (29.4%) had endoscopic recurrence, and 3 (4.76%) required a completion total abdominal colectomy for recurrent medically refractory disease in the colon. CONCLUSION: Colonic recurrence remains low following proctectomy and descending colostomy suggesting this operative management strategy is reasonable in Crohn's patients with distal disease.

No need to watch the clock: persistence during laparoscopic sigmoidectomy for diverticular disease.

BACKGROUND: Laparoscopic sigmoidectomy is the preferred approach in the elective surgical management of diverticulitis. However, it is unclear if the benefits of laparoscopy persist when operative times are prolonged. We aimed to investigate if the recovery benefits associated with laparoscopy are retained when operative times are long. METHODS: A retrospective review of a prospectively maintained database of patients who underwent elective laparoscopic sigmoidectomy from 2010-2015 at a single academic tertiary institution was performed. Operative times among laparoscopic completed cases were divided into quartiles, and patient outcomes were compared between the groups. RESULTS: A total of 466 patients (median age: 58 ± 11.6 years, 58% females) underwent sigmoidectomy: 430 completed laparoscopically and 36 (7.7%) converted. Median operative time in laparoscopically completed cases was 188 min (IQR 154-230). There were no differences in morbidity (P = 0.52) or readmission rates (P = 0.22) among the quartiles. The 2nd and 4th operative time quartiles were associated with significantly longer length of stay (LOS) when compared to the fastest quartile (P = 0.003 and P = 0.002, respectively), but there was no increase in LOS as operative times progressed between the 2nd, 3rd, and 4th quartiles. LOS after conversion was longer but did not reach statistical significance when compared to laparoscopically completed operations in the longest quartile (5.0 vs 6.5 days, P = 0.075) CONCLUSIONS: Our data do not support preemptive conversion of laparoscopic sigmoidectomy to avoid prolonged operative times. As long as progress is safely being made, surgeons are justified to continue pursuing laparoscopic completion.

When should we add a diverting loop ileostomy to laparoscopic ileocolic resection for primary Crohn's disease?

BACKGROUND: The aims of this study were to determine risk factors for morbidity associated with laparoscopic ileocolic resection (LICR) for Crohn's disease (CD) and whether the addition of a diverting ileostomy is associated with reduced morbidity. METHODS: Patients undergoing LICR for primary CD at our institution from 2005 to 2015 included in a prospectively maintained database were assessed. The decision to perform a diverting ileostomy was left at the discretion of the operating surgeon. Demographics, disease-related, and treatment-related variables were evaluated using univariate and multivariate analyses as possible factors associated with diverting ileostomy creation and 30-day perioperative septic complications (anastomotic leaks and/or abscess). Use of any immunosuppressive medication was defined as use of steroids, biologics, and immunomodulators either alone or in combination. RESULTS: For 409 patients, mortality was nil, overall morbidity rate was 40.6%, conversion rate 9.3%, and septic morbidity rate 7.6%. A diverting stoma was created in 22% of cases and was independently associated with BMI < 18.5 kg/m2 (P = 0.001), low serum albumin levels (P = 0.006), and longer operative time (P = 0.003). Use of any immunosuppressive medication was the only variable independently associated with septic complications, both in the overall population (OR 2.7, P = 0.036) and in the subgroup of undiverted patients (OR 3.1, P = 0.031). There was no association between septic morbidity and ileostomy creation, anastomotic configuration, penetrating disease, combined procedures (other resection or strictureplasty), BMI, albumin levels, and operative times. CONCLUSIONS: LICR is safe in selected cases of complex penetrating disease, including when combined procedures are necessary. Our data are unable to prove that a diverting stoma is associated with reduced morbidity.

Recurrence with malignancy after endoscopic resection of large colon polyps with high-grade dysplasia: incidence and risk factors.

BACKGROUND: In the West, piecemeal endoscopic resection remains the primary treatment for large colon polyps (LCP), as most recurrences are believed to be benign and resectable with follow-up endoscopy. However, invasive malignancy at the site of prior piecemeal endoscopic mucosal resection has been reported in the Asian literature. This study aims to identify the incidence of and the risk factors for local recurrence with malignancy after endoscopic resection of LCP with high-grade dysplasia (HGD). METHODS: In this retrospective cohort study, we identified patients undergoing complete endoscopic resection of LCPs (≥ 20 mm) with HGD at the Cleveland Clinic between January 2000 and December 2016. Demographic, endoscopic, and pathologic data were collected. All subsequent endoscopic and pathology reports were reviewed to identify recurrence. The cumulative incidence of malignancy at the polypectomy site was determined and univariate analysis was performed to assess risk factors. RESULTS: A total of 254 LCPs with HGD were resected in 229 patients. Mean polyp size was 29.2 mm. There were 138 lesions resected in piecemeal fashion and 116 en-bloc. After a median follow-up of 28.7 months for the entire cohort, local recurrence with malignancy was diagnosed in six cases. Median time to malignancy diagnosis was 28.5 months. All malignant cases occurred after piecemeal resection and none after en-bloc resection (HR 11.4; 95% CI 0.48-273). CONCLUSION: Malignancy after endoscopic resection of LCPs with HGD is uncommon and may be associated with piecemeal resection. When possible, en-bloc resection should be the goal for the management of LCPs.

Enhanced Recovery Pathway Benefits Patients Undergoing Nonelective Colorectal Surgery.

OBJECTIVE: The aim of our study was to determine if an enhanced recovery pathway (ERP) can successfully be applied in nonelective colorectal surgery. BACKGROUND: ERPs have been shown to reduce hospital length of stay (LOS), complications, and costs after elective colorectal surgery. Yet, little data exist regarding the benefits of ERPs in patients undergoing nonelective colorectal surgery. We hypothesized that ERP implementation in a nonelective colorectal surgery population is associated with decreased postoperative LOS. METHODS: A prospectively-maintained database was used to identify consecutive patients undergoing colorectal surgery after emergency room (ER) or hospital transfer admissions over a period from 2 years before until 1 year after implementation of a comprehensive ERP. The primary endpoint was LOS. Secondary endpoints included total LOS [TLOS = postoperative LOS + LOS of readmission(s)], readmission rates, complication rates, 30-day mortality, and hospital costs. Univariate and multivariate analyses were performed to assess the relationship between ERP implementation and LOS. RESULTS: We identified 269 pre-ERP and 135 ERP patients fulfilling the inclusion criteria. Admit source (ER 43.4% vs transfers 56.7%), Charlson comorbidity index, American Society of Anesthesiologists (ASA) status, diagnosis (inflammatory bowel disease 45.8%, malignancy 19.6%, benign intestinal obstructions 10.4%, diverticulitis 9.4%, others 10.4%), and blood loss were comparable (P > 0.05) between the cohorts. Pre-ERP patients had a higher number of previous abdominal surgeries, whereas post-ERP patients had more laparoscopy and more compliance with ERP elements. ERP patients had a shorter postoperative LOS [6 (4, 10) vs 7 (5, 12) days; P = 0.0007]. Hospital costs were 13.4% lower (P = 0.004). Postoperative 30-day morbidity, mortality, and readmissions were comparable, although reoperation rate was higher in the ERP group. On multivariate analysis, ERP implementation and laparoscopy were the only modifiable variables independently associated with shorter LOS, whereas longer operative times and higher ASA classification were associated with longer LOS. CONCLUSIONS: Patients undergoing nonelective colorectal surgery after ER or hospital transfer admission benefit from the use of an ERP, demonstrating decreased LOS and costs without an increase in complications.

Can an Academic RVU Model Balance the Clinical and Research Challenges in Surgery?

OBJECTIVE: The purpose of this study is to identify perceptions of academic surgeons regarding academic productivity and assess its relationship to clinical productivity. We hypothesized that these perceptions would vary based on respondent characteristics including clinical activity and leadership roles. DESIGN: This retrospective, survey-based study was performed from August 26, 2019 to September 26, 2019. SETTING: The setting was academic surgical departments across the US. PARTICIPANTS: The survey instrument was administered to faculty members of the Association of Program Directors in Surgery. A total of 105 academic surgeons responded. RESULTS: Most respondents were Program Directors (59%) of general surgery programs. Of the participants, 30% identified as Professor, 36% as Associate Professor, and 15% as Assistant Professor. Respondents agreed that multiple academic pursuits or factors should count towards academic productivity including the following (in descending order): completing a first-authored manuscript (98.8%), completing a senior-authored manuscript (97.7%), chairing a national committee (94.1%), serving on a national committee (88.2%), completing a second-authored manuscript (88.0%), completing a first lecture (83.7%), completing a middle-authored manuscript (71.8%), completing a lecture (whether or not repeated) (70.9%), impact factor of journal (60.7%), and attendance at grand rounds (57.0%). Perspectives did not vary significantly based on surgeon demographics, clinical setting, or leadership role (p > 0.05). CONCLUSIONS: Perceptions regarding what constitutes academic productivity and merit a reduction in clinical expectation are remarkably similar across multiple surgeon characteristics including demographics, academic title, leadership role, and practice environment.

Effect of Intravenous Acetaminophen on Postoperative Hypoxemia After Abdominal Surgery: The FACTOR Randomized Clinical Trial.

Importance: Opioid-induced ventilatory depression and hypoxemia is common, severe, and often unrecognized in postoperative patients. To the extent that nonopioid analgesics reduce opioid consumption, they may decrease postoperative hypoxemia. Objective: To test the hypothesis that duration of hypoxemia is less in patients given intravenous acetaminophen than those given placebo. Design, Setting, and Participants: Randomized, placebo-controlled, double-blind trial conducted at 2 US academic hospitals among 570 patients who were undergoing abdominal surgery, enrolled from February 2015 through October 2018 and followed up until February 2019. Interventions: Participants were randomized to receive either intravenous acetaminophen, 1 g (n = 289), or normal saline placebo (n = 291) starting at the beginning of surgery and repeated every 6 hours until 48 postoperative hours or hospital discharge, whichever occurred first. Main Outcomes and Measures: The primary outcome was the total duration of hypoxemia (hemoglobin oxygen saturation [Spo2] <90%) per hour, with oxygen saturation measured continuously for 48 postoperative hours. Secondary outcomes were postoperative opioid consumption, pain (0- 10-point scale; 0: no pain; 10: the most pain imaginable), nausea and vomiting, sedation, minimal alveolar concentration of volatile anesthetic, fatigue, active time, and respiratory function. Results: Among 580 patients randomized (mean age, 49 years; 48% women), 570 (98%) completed the trial. The primary outcome, median duration with Spo2 of less than 90%, was 0.7 (interquartile range [IQR], 0.1-5.1) minutes per hour among patients in the acetaminophen group and 1.1 (IQR, 0.1-6.6) minutes per hour among patients in the placebo group (P = .29), with an estimated median difference of -0.04 (95% CI,-0.18 to 0.11) minutes per hour. None of the 8 secondary end points differed significantly between the acetaminophen and placebo groups. Mean pain scores within initial 48 postoperative hours were 4.2 (SD, 1.8) in the acetaminophen group and 4.4 (SD, 1.8) in the placebo group (difference, -0.28; 95% CI, -0.71 to 0.15); median opioid use in morphine equivalents was 50 mg (IQR, 18-122 mg) and 58 mg (IQR, 24-151 mg) , respectively, with a ratio of geometric means of 0.86 (95% CI, 0.61-1.21). Conclusions and Relevance: Among patients who underwent abdominal surgery, use of postoperative intravenous acetaminophen, compared with placebo, did not significantly reduce the duration of postoperative hypoxemia over 48 hours. The study findings do not support the use of intravenous acetaminophen for this purpose. Trial Registration: ClinicalTrials.gov Identifier: NCT02156154.

Radiomic Texture and Shape Descriptors of the Rectal Environment on Post-Chemoradiation T2-Weighted MRI are Associated with Pathologic Tumor Stage Regression in Rectal Cancers: A Retrospective, Multi-Institution Study.

(1) Background: The relatively poor expert restaging accuracy of MRI in rectal cancer after neoadjuvant chemoradiation may be due to the difficulties in visual assessment of residual tumor on post-treatment MRI. In order to capture underlying tissue alterations and morphologic changes in rectal structures occurring due to the treatment, we hypothesized that radiomics texture and shape descriptors of the rectal environment (e.g., wall, lumen) on post-chemoradiation T2-weighted (T2w) MRI may be associated with tumor regression after neoadjuvant chemoradiation therapy (nCRT). (2) Methods: A total of 94 rectal cancer patients were retrospectively identified from three collaborating institutions, for whom a 1.5 or 3T T2w MRI was available after nCRT and prior to surgical resection. The rectal wall and the lumen were annotated by an expert radiologist on all MRIs, based on which 191 texture descriptors and 198 shape descriptors were extracted for each patient. (3) Results: Top-ranked features associated with pathologic tumor-stage regression were identified via cross-validation on a discovery set (n = 52, 1 institution) and evaluated via discriminant analysis in hold-out validation (n = 42, 2 institutions). The best performing features for distinguishing low (ypT0-2) and high (ypT3-4) pathologic tumor stages after nCRT comprised directional gradient texture expression and morphologic shape differences in the entire rectal wall and lumen. Not only were these radiomic features found to be resilient to variations in magnetic field strength and expert segmentations, a quadratic discriminant model combining them yielded consistent performance across multiple institutions (hold-out AUC of 0.73). (4) Conclusions: Radiomic texture and shape descriptors of the rectal wall from post-treatment T2w MRIs may be associated with low and high pathologic tumor stage after neoadjuvant chemoradiation therapy and generalized across variations between scanners and institutions.

Shanghai international consensus on diagnosis and comprehensive treatment of colorectal liver metastases (version 2019).

The liver is the most common anatomical site for hematogenous metastases from colorectal cancer. Therefore effective treatment of liver metastases is one of the most challenging elements in the management of colorectal cancer. However, there is rare available clinical consensus or guideline only focusing on colorectal liver metastases. After six rounds of discussion by 195 clinical experts of the Shanghai International Consensus Expert Group on Colorectal Liver Metastases (SINCE) from 29 countries or regions, the Shanghai Consensus has been finally completed, based on current research and expert experience. The consensus emphasized the principle of multidisciplinary team, provided detailed diagnosis approaches, and guided precise local and systemic treatments. This Shanghai Consensus might be of great significance to standardized diagnosis and treatment of colorectal liver metastases all over the world.

COVID-19 Outbreak and Surgical Practice: Unexpected Fatality in Perioperative Period.

: Little is known about surgical practice in the initial phase of coronavirus disease 2019 (COVID-19) global crisis. This is a retrospective case series of 4 surgical patients (cholecystectomy, hernia repair, gastric bypass, and hysterectomy) who developed perioperative complications in the first few weeks of COVID-19 outbreak in Tehran, Iran in the month of February 2020. COVID-19 can complicate the perioperative course with diagnostic challenge and a high potential fatality rate. In locations with widespread infections and limited resources, the risk of elective surgical procedures for index patient and community may outweigh the benefit.