Presentation, treatment, and prognosis of colorectal adenosquamous carcinoma: A contemporary analysis of the surveillance, epidemiology, and end results database.

INTRODUCTION: Colorectal adenosquamous carcinoma (ASC) represents <0.1% of colorectal cancers. Due to its rarity, there is paucity of data regarding its prognosis and treatment compared to other colorectal cancers. The aim of the study was to evaluate presentation, treatment and prognosis of colorectal ASC in comparison to adenocarcinoma (AC) and squamous cell carcinoma (SCC). METHODS: Adult patients diagnosed with colorectal AC, SCC, and ASC between 2000 and 2017 were identified using Surveillance, Epidemiology, and End Results database. RESULTS: Among the 446,132 patients diagnosed with colorectal cancer, 0.06% had ASC and were more likely to present with higher T stage and distant metastases compared to AC and SCC (p < 0.001). Major surgery was the primary treatment for colonic ASC, while for rectal ASC, chemotherapy and/or radiation were mainly utilized. Localized and distant colonic ASC had an unadjusted 5-year cause-specific survival that was worse than AC, while rectal ASC had the worst survival across all stages. CONCLUSION: Colorectal ASC usually present with advanced stage and have overall worse prognosis. Standardization of treatment strategies may improve survival in colorectal ASC.

Optimizing Bariatric Surgery outcomes: the impact of preoperative elevated hemoglobin A1c levels on composite perioperative outcome measures.

INTRODUCTION: The use of bariatric surgery in the management of obesity and its related morbidity has significantly increased in the US over the past decade. There is a lack of data on the impact of optimal preoperative glycemic control on the morbidity and mortality following bariatric surgery. The aim of this study was to analyze the impact of hemoglobin (Hb) A1c > 7 on outcomes among patients undergoing Roux-en-Y gastric bypass (RYGB) or sleeve gastrectomy (SG). METHODS: Data were extracted from the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (2017) and limited to patients undergoing an elective laparoscopic RYGB or SG. Multivariable logistic regression was conducted to adjust for other preoperative variables. RESULTS: A total number of 31,060 (69.3%) patients underwent SG, while 13,754 (30.7%) received RYGB. Patients who were older, male, non-Hispanic, smokers, and those with a higher American Society of Anesthesiologist Classification (ASA) score were more likely to have elevated HbA1c levels. Compared to individuals with normal HbA1c levels, patients with elevated levels had no significant difference in mortality (p = 0.902) but did have a difference in composite morbidity and mortality (p < 0.001). On multivariable analysis, elevated HbA1c, older age, increasing body mass index (BMI), elevated creatinine, longer operations, African American race, receiving RYGB, and having a trainee as surgical assistant were found to increase the odds of having an adverse outcome. No significant difference was found within smoking status, sex, ASA Classification, robotic vs laparoscopic, or if a second attending surgeon was assisting. CONCLUSIONS: HbA1c levels and presence of trainees in the OR are modifiable preoperative risk factors for adverse events following bariatric surgery. Improving preoperative glycemic control may be an effective and achievable quality improvement measure.

Additional procedures performed during elective colon surgery and their adverse impact on postoperative outcomes.

BACKGROUND: The need for additional procedures during a segmental elective colectomy is considered to lead to increased postoperative morbidity, but there have been few data that have validated and quantified this risk. PURPOSE: We hypothesized that patients having additional procedures performed during a segmental colectomy have worse outcomes compared to patients undergoing a colectomy alone. PATIENTS AND METHODS: All patients in the American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) database who underwent an elective open or laparoscopic segmental colectomy during 2005-2009 and met the inclusion criteria were analyzed. Using current procedural terminology (CPT) codes, patients were stratified into three groups. Group 1 only had CPT codes for a colectomy. Group 2 had additional CPT codes for procedures that were considered related to the colectomy, such as splenic flexure mobilization and endoscopy or a relatively minor procedure such as an appendectomy. Group 3 included patients that had additional procedures performed along with a segmental colectomy. Serious morbidity, overall morbidity, return to the operating room, and death were calculated and compared for each group. RESULTS: There were 25,996 patients in the open and 20,396 patients in the laparoscopic colectomy group. Thirty-six percent of patients in the open colectomy group vs. 18 % in the laparoscopic colectomy group had additional procedures performed. After adjustment for available differences in the groups, patients undergoing open and laparoscopic segmental colectomy along with an additional procedure had worse postoperative outcomes compared to patients undergoing a colectomy alone. LIMITATIONS: The study is limited by the possibility of coding errors in the ACS NSQIP database leading to a case ascertainment bias and a selection bias given the observational nature of the study. It also could not differentiate between additional procedures that were planned or incidental at the time of surgery. CONCLUSIONS: A proportion of patients undergoing elective open and laparoscopic segmental colon resections undergo additional procedures that adversely impact postoperative outcomes. This is mainly related to the type of additional procedures performed and therefore should be accounted for when counseling patients about the risks of surgery and in comparisons of outcomes.

The effect of model fidelity on colonoscopic skills acquisition. A randomized controlled study.

INTRODUCTION: Colonoscopic simulators offer the opportunity for skill acquisition in the preclinical setting. Currently available simulators vary widely with respect to level of fidelity and technological sophistication. Despite the belief that more realistic is better, there is a paucity of evidence regarding the relative effectiveness of simulator fidelity (high vs low) on the acquisition of basic colonoscopic skills. We hypothesized that novice learners can acquire basic colonoscopic skills using simulators, however fidelity of the simulator does not make a difference. METHODS: We randomly assigned novice third-year and fourth-year medical students to practice on either a low-fidelity or high-fidelity colonoscopy model. The low-fidelity model used is described in the module 16 of the American College of Surgeons/Association of Program Directors in Surgery surgical skills curriculum for residents, Phase 1: basic or core skills and tasks < http://elearning.facs.org/mod/resource/view.php?1d=450 >. The high-fidelity model was the AccuTouch colonoscopy simulator, Immersion Medical (AccuTouch CS) that has 6 different simulated scenarios for diagnostic colonoscopy (level 1-6). Both groups had 16 students and were given standard instruction by an expert with respect to the procedure and instrument handling on both models. Both groups were pretested and posttested on level 1 of the AccuTouch CS. The high-fidelity group practiced on level 2 and 4 of the AccuTouch CS, whereas the low-fidelity group practiced on the low-fidelity model for 2 sessions of 1 hour each. The computer-based evaluation parameters available on the AccuTouch CS were used to compare performances. RESULTS: Both groups had similar demographics. There were no significant differences in the baseline performances of either group. Each group demonstrated significant improvement for insertion time and percentage of mucosa visualized. However, there were no significant differences between the groups on posttesting on any of the measured parameters. CONCLUSIONS: Colonoscopic skill training on a low-fidelity model appears to be as effective as high-fidelity model training for basic endoscopic skill acquisition for novice learners.

True benefit or selection bias: an analysis of laparoscopic versus open splenectomy from the ACS-NSQIP.

BACKGROUND: By virtue of the benefits associated with minimally invasive approaches, laparoscopic splenectomy (LS) is believed to have better patient-related outcomes compared to open splenectomy (OS). However, there are limited data directly comparing the two techniques. METHODS: Patients who underwent elective LS and OS between 2005 and 2010 were identified from the public use file of the ACS-NSQIP database using the Current Procedural Terminology codes 38120 and 38100. Patients who had concomitant procedures were excluded. Because of the nonrandom assignment of surgical techniques, a selection bias could have been responsible for the differences in patient outcomes. Therefore, patient characteristics and comorbidities that were available and could have been potential confounders were compared and regression analysis was performed to determine independent risk factors associated with serious and overall morbidity as well as mortality. RESULTS: During the study period 1,644 and 851 patients underwent LS and OS, respectively. Compared to patients who underwent LS, patients who had OS had a longer median length of hospital stay (3 vs. 6 days, P < 0.0001) and higher incidences of serious (7 vs. 17 %, P < 0.0001) and overall morbidity (12 vs. 25 %, P < 0.0001) and mortality (1.4 vs. 3.3 %, P = 0.02). However, there were certain significant differences in the characteristics and comorbidities of the patients that could have confounded outcomes. On regression analysis, OS was not associated with higher mortality (OR = 1.43, 95 % CI 0.7-2.7, P = 0.28) but was associated with higher serious morbidity (OR = 1.8, 95 % CI 1.4-2.3, P = 0.001) and overall morbidity (OR = 2.0, 95 % CI 1.6-2.4, P = 0.0001). CONCLUSION: After adjusting for available confounders, patients who underwent LS had lower morbidity and similar mortality rates. Although certain confounders such as previous surgical history, underlying pathology, and spleen size could still have potentially influenced outcomes, the data suggest that patient outcomes after LS are excellent and when technically possible a minimally invasive technique should be the preferred approach for splenectomy.

Does resident involvement effect surgical times and complication rates during laparoscopic appendectomy for uncomplicated appendicitis? An analysis of 16,849 cases from the ACS-NSQIP.

BACKGROUND: Controversy exists regarding whether resident involvement during surgery impacts patient outcomes. We compared surgical times and perioperative complications of patients undergoing laparoscopic appendectomy with and without residents. METHODS: Patients undergoing laparoscopic appendectomy for uncomplicated acute appendicitis during 2005 to 2008 were identified from the American College of Surgeons National Surgical Quality Improvement Program database. RESULTS: During the study period, 16,849 patients underwent laparoscopic appendectomy for uncomplicated appendicitis (residents participated in 68% of procedures). There were no statistical and/or clinically meaningful differences between median age, sex, body mass index, American Society of Anesthesiology score, and morbidity probability between the 2 groups, suggesting that case mix was not a significant confounder. Patients undergoing laparoscopic appendectomy with residents compared with patients undergoing laparoscopic appendectomy without residents had a higher incidence of serious and overall morbidity and longer surgical times. However, surgical times and complications were similar between residents in postgraduate years 1 to 5. CONCLUSIONS: Regardless of the postgraduate year level, resident involvement resulted in a clinically appreciable increase in surgical times and a statistically significant increase in certain complications.

Single incision laparoscopic right hemicolectomy for colon cancer: less is more?

Single incision laparoscopic colectomy has been reported to be safe and feasible using several techniques and devices. The authors' report their experience with a single incision laparoscopic colectomy performed in a lateral to medical fashion using a commercially developed access device with standard laparoscopic instruments.

Laparoscopic splenopexy for wandering spleen: case report and review of the literature.

Wandering spleen is a rare condition in which the spleen lacks retroperitoneal fixation, thus its vascular pedicle can twist resulting in ischemia. Although splenectomy has traditionally been used for this condition, splenopexy is increasingly used in the pediatric population to anchor the spleen and preserve splenic function. We report an unusual case of wandering spleen in an adult with chronic torsion managed with laparoscopic splenopexy, suggesting splenic preservation is possible in adults with this presentation as well.