Use of dynamic tissue system adhesive skin closure device and multi-tissue platform porcine xenograft to achieve primary closure after wide local excision of a melanoma.

BACKGROUND: Wide local excision with sentinel lymph node biopsy has been the standard of care for melanoma with a Breslow depth greater than 1 mm. Wide local excision with 1- to 2-cm margins can result in large wounds that cannot be primarily closed. Traditionally, management has included reconstruction with autologous flaps and skin grafting. CASE REPORT: The authors of this case report achieved successful closure of a large posterior calf wound after 2-cm-wide local excision of the melanoma biopsy site in a 61-year-old male. The dermal lesion was a Clark level IV superficial spreading malignant melanoma with Breslow depth of 1.1 mm. Wound closure was achieved with a DTS adhesive skin closure device coupled with MTP xenograft powder as a healing adjunct. CONCLUSION: The results of this patient's case indicate that DTS adhesive skin closure device should be considered as an additional option for the closure of large defects following wide local excision in the management of melanoma.

Use of a dynamic tissue system and biological xenograft in complex traumatic wound closure.

OBJECTIVE: Asymmetrical dimensions and nonlinear margins of a multilayered traumatic wound often preclude healing via primary intention. We present the case of an otherwise healthy 21-year-old male who sustained trauma following a boating accident. METHOD: The patient sustained three lacerations to the posterior thighs from the boat propeller. The most extensive wound measured 25×10×6cm of muscle extrusion with a divot fracture involving the posterior femur. RESULTS: Primary closure and restoration of muscle biomechanics was achieved using a combination of a dynamic tissue system (DTS) and porcine urinary bladder matrix (PUBM) xenograft. After 24 days of treatment in hospital, the patient was discharged without the need for home health, outpatient wound care, or ongoing negative pressure wound therapy. The patient recovered full function of the legs and was cleared for participation in all activities. CONCLUSION: This complex traumatic boat propeller injury presented many challenges, including a transverse orientation on the extremity, degree of muscle injury/extrusion, and significant soft tissue loss. The combined application of a DTS with PUBM biological xenograft achieved a primary myocutaneous closure without the need for skin graft or flap reconstruction by plastic surgery.

Crush injury with significant soft tissue loss managed utilising biological and dynamic tissue systems: a case study.

Major traumatic crush injuries are difficult to manage, with high morbidity, requiring prolonged, complex treatment with many procedures. Free-flap reconstruction is often used yet full functionality still may not be regained. In this case study of a traumatic crush injury of the anterior distal tibia, ankle and foot of a 48-year-old male patient, we opted for an alternative management strategy using a combination of a dynamic tissue system (DTS) and biological xenografts (porcine urinary bladder matrix and a multi-tissue platform). The DTS was kept in place in an outpatient setting for four weeks postoperatively and removed after that time. At the 3-month follow-up, the wound was significantly smaller at about 15% of the original size. The wound healed completely before 6-month follow-up. Our patient's traumatic crush injury was successfully healed using an alternative management strategy, DTS and biologic xenografts.

Patient Outcomes in Laparoscopic Appendectomy With Acute Surgical Care Model Compared to Traditional Call.

INTRODUCTION: Shift-based models for acute surgical care (ACS), where surgical emergencies are treated by a dedicated team of surgeons working shifts, without a concurrent elective practice, are becoming more common nationwide. We compared the outcomes for appendectomy, one of the most common emergency surgical procedures, between the traditional (TRAD) call and ACS model at the same institution during the same time frame. METHODS: A retrospective review of patients who underwent laparoscopic appendectomy for acute appendicitis during 2017-2018. ACS and TRAD-patient demographics, clinical presentation, operative details, and outcomes were compared using independent sample t-tests, Wilcoxon rank-sum tests and Fisher's exact or χ2 tests. Multiple exploratory regression models were constructed to examine the effects of confounding variables. RESULTS: Demographics, clinical presentation, and complication rates were similar between groups except for a longer duration of symptoms prior to arrival in the TRAD group (Δ = 0.5 d, P = 0.006). Time from admission to operating room (Δ = -1.85 h, P = 0.003), length of hospital stay (Δ = -2.0 d, P < 0.001), and total cost (Δ = $ -2477.02, P < 0.001) were significantly lower in the ACS group compared to the TRAD group. Furthermore, perforation rates were lower in ACS (8.3% versus 28.6%, P = 0.003). Differences for the outcomes remained significant even after controlling for duration of symptoms prior to arrival (P < 0.05). CONCLUSIONS: Acute appendicitis managed using the ACS shift-based model seems to be associated with reduced time to operation, hospital stay, and overall cost, with equivalent success rates, compared to TRAD.

Stoma Retraction in Super-Morbidly Obese Patient Leading to Class IV Midline Wound: A Cautionary Tale.

Stoma creation is often necessary for fecal diversion in general surgery. The creation of stomas involves mobilization of either the large or small intestine through the abdominal wall to allow for the passage of waste that traverses the intestinal tract. Among the complications of stoma creation, particularly in obese patients, is stoma retraction, whereby the stoma retracts greater than 5 mm from the skin. This is often accompanied by extensive dermal dehiscence, which can lead to significant leakage resulting in infection. Here, we present the case of a super-morbidly obese female patient with an end ileostomy following total colectomy in which abdominal closure was not initially achieved. The stoma became retracted and dehisced leading to continued contamination of the open abdomen, necessitating multiple abdominal washouts. Injection of 300 units of botulinum toxin A (BTA) was administered into the abdominal wall muscles later the day of her index operation. An Abdominal Wall Reapproximation Anchor (ABRA) dynamic tissue system (DTS) was utilized successfully in subsequent operations for primary myofascial closure. Heavy continuous contamination of the midline wound through the subcutaneous cleft between the retracted ileostomy and midline surgical wound was treated with intensive wound care, strict bed rest, nothing to eat or drink (NPO), and total parenteral nutrition (TPN). Post-operative stoma complications occur frequently, and stoma retraction is commonly encountered, especially in the obese. The patient presented in this case study had multiple risk factors which led to a complicated treatment course. Successful primary myofascial closure and complete healing of the midline surgical wound highlights the importance of a patient-tailored multimodal approach.

Mammographically Occult Invasive Lobular Carcinoma With Intradermal Invasion.

While shortcomings in the detection of invasive lobular carcinoma (ILC) continue to be studied, research is ongoing to determine detection rates using current breast imaging modalities in combination with physical examination findings. In the following case report, we describe the rare presentation of a patient diagnosed by punch biopsy with grade III, estrogen receptor (ER)-/progesterone receptor (PR)-positive invasive lobular carcinoma with intradermal invasion. This patient presented with findings similar to inflammatory breast cancer (IBC) including pain in the left nipple, skin warmth, and erythema circumferentially encompassing approximately two-thirds of the left breast. This case study is of significance as, to date, it is the first report of an invasive lobular carcinoma that presented clinically as inflammatory breast cancer and was occult on both diagnostic mammography and ultrasound. While imaging remains the primary method of breast cancer detection, it is important to note that clinical findings of dermal invasion of the breast may prompt further investigation with a biopsy and close follow-up, regardless of imaging results.

Rethinking Routine Intensive Care After Cytoreductive Surgery With Heated Intraperitoneal Chemotherapy: The Fiscal Argument.

BACKGROUND: Patients undergoing cytoreductive surgery (CRS) with hyperthermic intraperitoneal chemotherapy (HIPEC) are frequently admitted to the intensive care unit (ICU) for mitigation of potential complications, although ICU length of stay (LOS) is a significant driver of cost. This study asked whether a fiscal argument could be made for the selective avoidance of ICU admission after CRS/HIPEC. METHODS: Prospective data for select low-risk patients (e.g., lower peritoneal cancer index [PCI]) admitted to the intermediate care unit (IMC) instead of the ICU after CRS/HIPEC were matched with a historic cohort routinely admitted to the ICU. Cohort comparisons and the impact of the intervention on cost were assessed. RESULTS: The study matched 81 CRS/HIPEC procedures to form a cohort of 49 pre- and 15 post-intervention procedures for patients with similar disease burdens (mean PCI, 8 ± 6.7 vs. 7 ± 5.1). The pre-intervention patients stayed a median of 1 day longer in the ICU (1 day [IQR, 1-1 day] vs. 0 days [IQR, 0-0 days]) and had a longer LOS (8 days [IQR, 7-11 days] vs. 6 days [IQR, 5.5-9 days]). Complications and complication severity did not differ statistically. The median total hospital cost was lower after intervention ($30,845 [IQR, $30,181-$37,725] vs. $41,477 [IQR, $33,303-$51,838]), driven by decreased indirect fixed cost ($8984 [IQR, $8643-$11,286] vs. $14,314 [IQR, $12,206-$18,266]). In a weighted multiple variable linear regression analysis, the intervention was associated with a savings of $2208.68 per patient. CONCLUSIONS: Selective admission to the IMC after CRS/HIPEC was associated with $2208.68 in savings per patient without added risk. In this era of cost-conscious practice of medicine, these data highlight an opportunity to decrease cost by more than 5% for patients undergoing CRS/HIPEC.

Case Report of Surgical Management of Duodenal Perforation Secondary to Stent in a Patient With Gastric Outlet Obstruction Due to a Rare Neuroendocrine Adenocarcinoma of Duodenum.

Neuroendocrine adenocarcinomas of the duodenum comprise a rare subset of neuroendocrine tumors and commonly present with symptoms of gastric outlet obstruction (GOO). Most of the time, patients are recommended a GI bypass in the setting of metastatic disease. In a small subset of patients who prefer a non-operative approach or are poor surgical candidates, duodenal stenting can often accomplish similar results as surgery. However, duodenal stenting is associated with numerous complications, including duodenal stent migration and, less commonly, duodenal perforation. We present a case where duodenal stenting resulted in a perforation of the second portion of the duodenum that ultimately required a definitive pancreaticoduodenectomy.

Surgeons Maintain Better Focus Working 12-Hour Shifts Compared to 24-Hour Calls.

BACKGROUND: In this quality improvement project, we analyzed surgeon focus and attention utilizing a visual tracking device. We hypothesized that surgeons maintained better focus working 12-hour shifts compared to 24-hour calls. MATERIALS AND METHODS: A prospective, quality improvement project was performed on surgery residents, medical students, and attending physicians working at a busy, tertiary referral, safety-net hospital with Level 1 trauma and burn centers. A visual tracking system was used to measure visual attention before and after a 12-hour, in-house shift and a 24-hour, surgical in-house call. A pupil tracker was utilized to measure attention impairment. Individual performance was rated on a scale of 0 to 6: Severely Impaired- 0; Impaired- 1; Low Average- 2; Average- 3; Above Average- 4; High Average- 5; Superior- 6. Data were analyzed for homogeneity. The Wilcoxon Ranked Sum was used to assess for statistically significant differences between focus scores in the same group of individuals before and after shifts and/or calls. The Mann-Whitney U test was used to compare differences in focus between 12 and 24 hour in-house shifts and/or calls. RESULTS: A total of 21 surgeons provided a total of 61 visual tracking tests for analysis. Results were found to be nonhomogeneous. The project population was 46% men with a median age of 31 years IQR (28-33). General surgery residents accounted for 48 tests, medical students for 2, and attending surgeons for 11. Average hours of self-reported sleep before the shift/call was 6 (IQR; 6-7). There was almost no overall change in focus in individuals before and after a 12-hour, in-house shift -0.06 (SD 1.9), while after a 24- hour, in-house call, focus decreased by almost 2 full grades -1.8 (SD 1.6) (p = 0.013). There was no statistically significant difference in focus found between 12-hour day shift and 12-hour night shift. CONCLUSIONS: Twelve-hour shifts appear to preserve focus in surgeons better compared with 24- hour, in-house calls. More research is needed to establish the optimal time of surgeon focus maintenance and shift duration.

Surgical Management of Gallstone Ileus: A Clinical Case Report.

A 74-year-old female with a past medical history of hypertension, osteoarthritis, osteoporosis, bladder suspension, and right hip surgery presented with a one-day history of cramping abdominal pain, intermittent vomiting, and obstipation. Bowel obstruction was confirmed with imaging, and the decision was made to proceed to the operating room for an exploratory laparotomy. During the procedure, a gallstone was found in the terminal ileum and was removed.

Increased in-hospital mortality and emergent cases in patients with stage IV cancer.

BACKGROUND: Cancer patients in the USA are still being treated with aggressive, life-prolonging interventions. Palliative care services remain vastly underutilized despite surges in both quality and quantity of programs. We evaluated surgical outcomes of metastatic cancer patients to question whether palliative care may be a better option. STUDY DESIGN: We queried the 2014 National Surgical Quality Improvement Program database (NSQIP) for patients with a diagnosis of malignancy (ICD 9 Codes 145.00 to 200.00). Cases were divided into metastatic and non-metastatic cancer. Demographic data including preoperative, intraoperative, and postoperative factors, as well as complications and comorbidities were compared between these two groups. Independent t testing was used to compare continuous variables. Chi-square testing was used to compare categorical variables. Multiple logistic regression was used to assess for predictors of mortality in metastatic cancer. RESULTS: A total of 80,275 cancer patients were analyzed, 11.8% (9423) of whom had metastatic disease. In-hospital mortality rate was found to be 4 times higher among patients with metastatic cancer (2.1% vs. 0.5%; P = < 0.0001). Of those metastatic cancer patients that died while in hospital, 18.5% had an emergency surgery performed. After adjusting for confounders, dyspnea at rest/moderate exertion (OR 5.7/2.4; 95% CI 2.7/1.6 to 11.9/3.7; P < 0.0001) was found to be the most significant predictor of in hospital mortality in stage IV cancer patients. CONCLUSION: Aggressive treatment in advanced cancer patients contributes to alarmingly high in-hospital mortality. Improved, deliberate communication of palliative care options with patients is exceedingly conducive to enhancing end-of-life cancer care.

Dyspnoea at rest predictor of increased in-hospital mortality in metastatic cancer patients undergoing emergent surgery in United States.

BACKGROUND: Dyspnoea is an extremely common finding in patients presenting with metastatic cancer and can be caused by cancer progression, treatment toxicity or pathology secondary to deteriorating overall health. In this study, we decided to analyse post-operative outcomes to understand if dyspnoea is a significant prognostic predictor of in-hospital mortality in patients with stage IV cancer who underwent emergent surgery in the United States. METHODS: We performed a search of the 2014 National Surgical Quality Improvement Program database (NSQIP) for patients with a diagnosis of malignancy (ICD-9 Codes 145.00-200.00). Cases were divided into two groups: metastatic cancer and non-metastatic cancer. Demographical data including preoperative, intraoperative and postoperative factors, as well as data regarding complications and comorbidities were compared between these two groups. Independent t-testing was used to compare continuous variables. Chi-square testing was used to compare categorical variables. Multiple logistic regression was used to assess for predictors of mortality in metastatic cancer. Mortality was adjusted for demographics, comorbid conditions and perioperative factors. RESULTS: Referring to the NSQIP database, a total of 80,275 cancer patients were analysed, 11.8% (9,423) of whom had metastatic cancer. Dyspnoea at rest/moderate exertion (OR 5.7/2.4; 95% CI 2.7/1.6-11.9/3.7; p < 0.0001) were found to be the biggest predictors of in-hospital mortality in stage IV cancer patients who underwent emergent surgery. CONCLUSION: Dyspnoea at rest and with moderate exertion may be used as predictors of in-hospital mortality for metastatic cancer patients undergoing emergent surgery.

A decade of intraoperative ultrasound guided breast conservation for margin negative resection - Radioactive, and magnetic, and Infrared Oh My .

BACKGROUND: The oncologic goal of margin-negative breast conservation requires adequate localization of tumor. Intraoperative ultrasound remains most feasible but under-utilized method to localize the tumor and assess margins. METHODS: A prospectively maintained breast cancer database over a decade was queried for margin status in breast cancer patients undergoing breast conservation. Techniques of tumor localization, margin re-excision and closest margins were analyzed. Rate of conversion to mastectomy was determined. RESULTS: Of the 945 breast cancer patients treated at a university-based Breast Center of Excellence between January 1, 2009 and December 31, 2018, 149(15.8%) had ductal carcinoma in situ; 712(75.3%) had invasive ductal carcinoma, and 63(6.7%) had invasive lobular carcinoma. Clinical stage distribution was: T1 = 372(39.4%); T2 = 257(27.2%); T3 = 87(9.2%). Five hundred and eighty three (61.7%) patients underwent breast conservation. The median (25th -75th centile) closest margin was 6(2.5, 10.0) mm. Thirty five (6.0%) patients underwent margin re-excision, of which 9(25%) were converted to mastectomy. Tumor localization was achieved with ultrasound in 521(89.4%) patients and with wire localization in 62(10.6%) patients. The median (25th-75th centile) closest margin with wire localization was 5.0(2.0, 8.5) mm versus 5.0 (2.0, 8.0) mm with ultrasound guidance [p = 0.6635]. The re-excision rate with wire localization was 14.5% versus 4.9% with ultrasound guidance [p = 0.0073]. The unadjusted Odds Ratio (95% CI) for margin revision in wire localized group compared with ultrasound was 3.2 (7.14, 1.42) [p = 0.0045]; multivariate adjusted OR (95%) was 4(9.09, 1.7) [p = 0.0013]. CONCLUSIONS: Ultrasound guidance for localization of breast cancer remains the most effective option for margin negative breast conservation.

Yellow-Gold Polarized Light Microscopy May Improve Accuracy of Pathological Staging of Colorectal Adenocarcinoma.

Introduction Polarized light (PL) has been used in pathology for multiple reasons, including the demonstration of foreign bodies, the evaluation of crystals, and the demonstration of fibrosis. We incidentally found that yellow-gold polarization routinely occurs surrounding desmoplastic scar tissue abutting the invasive glands of colonic adenocarcinoma. We hypothesized that evaluating the use of polarized light over a series of invasive adenocarcinomas of the large intestine might produce evidence of its utility. Methods Large intestinal resections with invasive adenocarcinoma were reviewed with yellow-gold polarized light microscopy by two surgical pathologists postoperatively between January 2017 and March 2019. Specimens were examined under yellow-gold polarized light to evaluate invasion from the submucosa into the muscularis propria, from the muscularis propria into pericolic fat, and to the serosa. The diagnosed location, T stage, history of radiotherapy, mucinous features, and grade were recorded. Photographs were taken when images were deemed to be of value. The two-tailed Fisher's exact test was used to compare the invasion detection of the tumor into fat in scar tissue in colorectal cancer. Results A total of 75 large intestinal resections with invasive adenocarcinoma from 75 patients were accessioned. Concerning the initial stage, three (4%) were T1, nine (12%) were T2, 46 (61%) were T3, and 17 (22%) were T4. A history of previous radiation treatment was seen in 10 (13%). Two (2%) were poorly differentiated. Nine (12%) were mucinous carcinomas; mucinous areas were seen to pose difficulty in 12 (16%). Overall, one out of nine, initially staged as T2, was upstaged to T3 (11%), with the addition of yellow-gold polarized light microscopy. One tumor was downstaged from T2 to T1 (11%). For many T2 and T3 tumors, invasion into the muscularis propria was better defined by yellow-gold polarized light. Conclusion Yellow-gold polarized light microscopy may be a useful adjunct to conventional microscopy in more precisely staged pathological colorectal cancer specimens.

Low Rate of SARS-CoV-2 Infection in Adults With Active Cancer Diagnosis in a Nonendemic Region in the United States.

INTRODUCTION: The mortality rate in cancer patients with SARS-CoV-2 has been cited to be as high as 13% amidst a global pandemic. Here we present the prevalence of SARS-CoV-2 in adult patients with active cancer in a nonendemic cancer center at the time of the study. METHODS: All adult patients with an active history of cancer undergoing any elective surgery were screened for SARS-CoV-2 symptoms, including fever ≥ 38 degrees Celsius, chills, dyspnea, cough, sputum production, pharyngitis, myalgia/arthralgia, headache, anosmia, and nasal discharge. Both symptomatic and asymptomatic patients were tested for SARS-CoV-2 preoperatively via nasopharyngeal swab within 48 hours of surgery using an RT-PCR assay. Active cancer was defined as receipt of chemotherapy and/or radiation within 1 year of the SARS-CoV-2 test. Deidentified, institutional review board-exempt patient data were analyzed with IBM Statistical Package for the Social Sciences (SPSS) Version 26. RESULTS: Between March 16, 2020 and June 30, 2020, a total of 227 patients were tested preoperatively for SARS-CoV-2. Median age was 64.0 years (range 21 to 90). The majority of the cohort were White. Only 2 patients (0.8%) were positive for SARS-CoV-2. One 73-year-old woman undergoing hip replacement had Stage IV breast cancer and a 75-year-old man undergoing port placement had Stage IV retroperitoneal leiomyosarcoma. Neither patient had symptoms of SARS-CoV-2, underwent hospitalization for SARS-CoV-2, or proceeded to have the scheduled surgery after the positive test results until a 14-day quarantine period and a subsequent negative test result. Both patients subsequently received the procedures they were originally scheduled for with no complications. CONCLUSION: Careful consideration of resource allocation and treatment limitations for cancer patients should occur in lower endemic regions.

Helicopter versus ground ambulance: review of national database for outcomes in survival in transferred trauma patients in the USA.

BACKGROUND: Trauma care has improved substantially in the last decade. The emphasis of the Golden Hour in trauma care has encouraged the creation of faster transport and earlier prehospital intervention. Despite the clear time-saving advantage helicopter emergency medical services (HEMS) held over ground ambulances (GAs) in the past, advances in prehospital care over the last decade have created uncertainty as to whether HEMS transport is still associated with improved patient outcomes. We aimed to determine whether air transportation was associated with better outcomes compared with ground transportation. We hypothesized that air transportation is associated with better patient outcomes. METHODS: A retrospective review was performed on the National Trauma Data Bank in 2014 on patients transferred either by helicopter or ground ambulance. Demographic information, mean length of stay, mean ventilator days, and mortality rate was abstracted. All transferred patients and patients with missing information were excluded. χ2 test was performed to analyze categorical variables and independent t-test was performed to analyze continuous variables. A logistic regression was performed to ascertain the effects of Glasgow Coma Scale score, mechanism of injury (blunt vs penetrating), age, gender, Injury Severity Score (ISS), and method of transportation (HEMS vs GA) on the likelihood of mortality. RESULTS: A total of 469 407 transferred trauma patients were analyzed. Mortality appeared to be increased in trauma patients transported by helicopter ambulance (6.0%) versus GA (2.9%) (p<0.001). However, after adjusting for age, ISS, and gender, trauma patients who were transferred by helicopter were 57.0% less likely to die than those transferred by GA (95% CI 0.41 to 0.44, p<0.0001). CONCLUSION: The results of this study demonstrate that despite improvements in trauma care, patients have improved survival if transported by helicopter ambulance. LEVEL OF EVIDENCE AND STUDY TYPE: Level IV; Therapeutic/Care Management.

Literature Review of Current Management of Colorectal Liver Metastasis.

Colorectal cancer is a leading cause of cancer mortality in the United States, and metastasis to the liver is a frequent sequela. Currently, surgical resection is the best option for curative treatment and/or long-term survival after colorectal liver metastasis (CRLM), but unfortunately, not all patients are surgical candidates. Alternative and adjunct therapies commonly used in the treatment of CRLM include chemotherapy, biologic therapy, radio-embolization, and radiofrequency ablation. The aim of this review was to report the various treatment modalities and outcomes currently used in the treatment of CRLM.

Laparoscopic colectomies associated with decreased retrieval of 12 or more lymph nodes compared to open in elective colon cancer surgery.

BACKGROUND: Colorectal cancer is the third most commonly diagnosed cancer worldwide. Lymph node (LN) retrieval is a key factor for pathologic staging and prognosis of colorectal cancer. Increase in number of LNs removal suggests improvement in tumour clearance and decrease in metastatic spread. Studies have suggested that excising 12 or more LNs during colectomy in patients with colon cancer is associated with improved survival. To date, there have been no studies to determine whether minimally invasive surgery affects the ability to retrieve 12+ LNs in elective colon cancer surgery. Therefore, we elected to determine whether a difference exists on the ability to retrieve 12+ nodes in elective colon cancer colectomies performed open versus laparoscopic. METHODS: The National Surgical Quality Improvement Program (NSQIP) Procedure Specific Colectomy database was analysed for the year 2014-2015. Inclusion criteria were colon cancer (ICD-9 Code 153.9), age greater than 18 years. Exclusion criteria were missing data. Data abstracted included patient demographics, type of operation performed and number of LNs retrieved. The patients were categorised based on their elective colon cancer colectomies such as laparoscopic or open. Binary logistic regression was used to identify confounding variables in the retrieval of 12+ LNs. RESULTS: After accounting for missing cases, a total of 18,792 patients with a diagnosis of colon cancer were analysed. Twelve or more LNs were retrieved in 88% (16,538) of patients, Among them, 2,516 patients underwent laparoscopic colectomy and 5,284 patients underwent open colectomy. The difference was not statistically significant for the average number of LNs retrieved among both the groups. Open operative approach compared to the laparoscopic approach was associated with 15% greater odds of retrieval of >12 LNs (OR 1.148; 95% CI (1.035-1.272); p = 0.008). CONCLUSION: The majority of colectomies such as open or laparoscopic are able to retrieve 12 or more LNs. However, there are greater odds of retrieving more than 12 LNs with the open approach compared to the laparoscopic approach. By allowing for more LN retrieval, open colectomies suggest improvement in tumour clearance and decrease metastatic spread. Additional research is needed to further investigate the specific factors influencing the ability to retrieve an adequate number of LNs, such as viewing angles provided with an open approach versus laparoscopic approach.

Decreased opioid consumption and enhance recovery with the addition of IV Acetaminophen in colorectal patients: a prospective, multi-institutional, randomized, double-blinded, placebo-controlled study (DOCIVA study).

BACKGROUND: We hypothesized that administration of IV acetaminophen alone would reduce the opioid consumption in post-operative colorectal surgery and reduce the side effects of narcotics. METHODS: Patients were randomized to receive either IV acetaminophen or placebo in addition to opioid PCA. Primary endpoints evaluated were opioid consumption and pain visual analogue scale score (PVASS) during first 48 h post-operatively. Secondary endpoints evaluated were time of return of GI function (ROGIF), time to diet ordered (TTDO), length of hospital stay (LOHS), and occurrence of ileus. RESULTS: 105 patients were enrolled and 97 remained in the study after exclusion (control group n = 50; study group n = 47). Mean ± SEs of opioid consumption in the study group was 21.5 ± 1.8 mg of morphine equivalent (ME) and 35.0 ± 3.3 mg ME at 24 and 48 h, respectively, versus 36.4 ± 4.1 mg ME and 59.7 ± 6.7 mg ME in the control group (p = 0.002 and 0.002). PVASS levels were lower in the study group at all intervals at 3, 8, 24, and 48 h (p = 0.02, 0.006, < 0.01, and 0.02). ROGIF, TTDO, and LOHS were also found to be lower in the study group (p ≤ 0.01, < 0.01, and 0.002). The rate of ileus was reduced by using IV acetaminophen (22% vs 2.1%; p = 0.004). CONCLUSIONS: IV acetaminophen helps to reduce opioid consumption for patients undergoing colorectal surgery. Additionally, there appears to be a shortened length of hospital stay, better pain control, reduced time to return of bowel function, and lower rate of post-operative ileus in patients receiving IV acetaminophen.

Case Report of Foreign Body Stuck in Esophagus with Failure of Endoscopic Management in a Man with a History of Pica.

This is a case report of foreign body ingestion in a 55-year-old intellectually disabled man with a history of pica and previous removal of ten plastic gloves from his rectum four months prior to this presentation. The patient presented after ingesting plastic gloves which formed large, rigid esophageal and gastric bezoars that were not amenable to endoscopic removal. An exploratory laparotomy and gastrostomy was performed, and a 10 × 4.5 × 2 cm gastric bezoar consisting of rigid plastic gloves was removed without complication. Special considerations must be taken when considering the ingestion of nonfood items in the intellectually disabled population as these cases may not present classically with symptoms of a gastric bezoar.