Type I/type III collagen ratio associated with diverticulitis of the colon in young patients.

BACKGROUND: The incidence of diverticulitis in young patients is rising, whereas the type I:III collagen ratio of the colon decreases with age. Perhaps a lower type I:III collagen ratio in younger patients may predispose these patients to the development of the disease. METHOD: The purpose of this study was to evaluate the collagen content and type I:III collagen ratio in patients with diverticulitis versus a control group. Patients who underwent a colon resection were identified. Three groups of patients were created for analysis: those with diverticulitis aged <50 y, >50 y, and a control group. Tissue samples were stained with Sirius red/fast green and photographed. Photos analysis was performed to quantify the amount of type I collagen and type III collagen. The type I:III collagen ratio was calculated for each patient and compared. RESULTS: The quantity of type I collagen and type III collagen was higher in patients with diverticulitis aged >50 y (P = 0.04 and P < 0.0001, respectively); however, the collagen ratio was greatest in those patients with diverticulitis aged <50 y (P = 0.01). Further analysis demonstrated a significant higher type I:III ratio in all patients aged less than 50 y compared with all patients aged over 50 y (P = 0.04). CONCLUSIONS: Our study demonstrated that diverticulitis in the younger patient was not associated with a lower type I:III collagen ratio. It appears that the decrease in collagen ratio of the colon with age is associated with an increase in type III collagen deposition.

Cellular changes of the colon after mechanical bowel preparation.

BACKGROUND: The purpose of this study was to evaluate the effect of mechanical bowel preparation (MBP) on the intracellular environment, specifically evaluating butyrate transport, within the colon of the Sprague-Dawley rat. METHODS: Sixty-eight Sprague-Dawley rats were randomized to either an MBP group (n = 34) or a control group (n = 34). Twenty-four hours after the completion of the MBP, both groups were euthanized, and the colons were harvested. The level of cellular apoptosis was investigated after DNA fragmentation, poly(ADP-ribose) polymerase cleavage, and caspase assays. Western blot analysis was performed to measure the expression of the butyrate transporter protein, monocarboxylate transporters 1, and proliferating cell nuclear antigen (a marker for tissue proliferation). Immunohistochemical staining was performed to further investigate cellular proliferation. Statistical significance (P < 0.05) was determined using two-tailed t-test. RESULTS: Apoptosis was detected without significant differences in both groups. Western Blot analysis demonstrated that the expression of the monocarboxylate transporters 1 protein is downregulated in the MBP group (10.18 ± 3.09) compared with the control group (16.73 ± 7.39, P = 0.001), and proliferating cell nuclear antigen levels showed a decrease in cellular proliferation in the MBP group (13.35 ± 5.88) compared with the control (20.07 ± 7.55, P = 0.018). Immunohistochemistry confirmed a decrease in cellular proliferation after MBP with 23.4 ± 7.8% of the cells staining positive for Ki-67 in the MBP group versus 28.6 ± 7.9% in the control group (P = 0.006). CONCLUSIONS: MBP has a negative impact on cellular proliferation and intracellular transport of butyrate within the rat colon, not related to apoptosis. This is the first study to demonstrate the intracellular effects that MBP has on the rat colon.

Developing the Ready Military Medical Force: military-specific training in Graduate Medical Education.

Introduction: Graduate Medical Education plays a critical role in training the next generation of military physicians, ensuring they are ready to uphold the dual professional requirements inherent to being both a military officer and a military physician. This involves executing the operational duties as a commissioned leader while also providing exceptional medical care in austere environments and in harm's way. The purpose of this study is to review prior efforts at developing and implementing military unique curricula (MUC) in residency training programs. Methods: We performed a literature search in PubMed (MEDLINE), Embase, Web of Science, and the Defense Technical Information Center through August 8, 2023, including terms "graduate medical education" and "military." We included articles if they specifically addressed military curricula in residency with terms including "residency and operational" or "readiness training", "military program", or "military curriculum". Results: We identified 1455 articles based on title and abstract initially and fully reviewed 111. We determined that 64 articles met our inclusion criteria by describing the history or context of MUC, surveys supporting MUC, or military programs or curricula incorporated into residency training or military-specific residency programs. Conclusion: We found that although there have been multiple attempts at establishing MUC across training programs, it is difficult to create a uniform curriculum that can be implemented to train residents to a single standard across services and specialties.

Case Volume and Readiness to Deploy: Clinical Opportunities for Active-Duty Surgeons Outside of Military Hospitals.

BACKGROUND: The Military Health System (MHS) uses a readiness program that identifies the knowledge, skills, and abilities (KSAs) necessary for surgeons to provide combat casualty care. Operative productivity is assigned an objective score based on case type and complexity and totaled to assess overall readiness. As of 2019, only 10.1% of surgeons met goal readiness threshold. At one tertiary military treatment facility (MTF), leadership has taken an aggressive approach toward increasing readiness by forming military training agreements (MTAs) and allowing Off Duty Employment (ODE). We sought to quantify the efficacy of this approach. STUDY DESIGN: Operative logs from 2021 were obtained from surgeons assigned to the MTF. Operations were assigned CPT codes and processed through the KSA calculator (Deloitte; London, UK). Each surgeon was then surveyed to identify time away from clinical duties for deployment or military training. RESULTS: Nine surgeons were present in 2021 and spent an average of 10.1 weeks (19.5%) abroad. Surgeons performed 2,348 operations (Average [Avg] 261 ± 95) including 1,575 (Avg 175; 67.1%) at the MTF, 606 (Avg 67.3; 25.8%) at MTAs, and 167 (Avg 18.6, 7.1%) during ODE. Adding MTA and ODE caseloads increased KSA scores by 56% (17,765 ± 7,889 vs 11,391 ± 8,355). Using the MHS threshold of 14,000, 3 of 9 (33.3%) surgeons met the readiness threshold from MTF productivity alone. Including all operations, 7 of 9 (77.8%) surgeons met threshold. CONCLUSIONS: Increased use of MTAs and ODE significantly augments average caseloads. These operations provide considerable benefit and result in surgeon readiness far exceeding the MHS average. Military leadership can maximize the chances of meeting readiness goals by encouraging clinical opportunities outside the MTF.

Utilizing the Army Physical Fitness Test as a Primary Outcome in Surgical Clinical Research.

Functional data as part of clinical outcomes such as Activities of Daily Living and Quality of Life (QOL) frequently depend on surveys and are thus inherently limited by self-reporting and patient subjectivity. Specifically, the 12-Item Short Form Survey (SF-12), 36-Item Short Form Survey (SF-36), and Carolinas Comfort Scale are validated instruments for assessing medical and surgical QOL outcomes. However, performance-based measures of disability are lacking. We propose the Army Physical Fitness Test (APFT) as a novel clinical measure of function following surgical intervention. We believe that studies using the APFT as a surgical outcome can potentially provide novel, relevant insights that may guide the utilization of specific surgical interventions and that the use of APFT data in surgical research will meet contemporary ethical standards.

Committee on Surgical Combat Casualty Care position statement on the use of single surgeon teams and invited commentaries.

BACKGROUND: Over the last 20 years of war, there has been an operational need for far forward surgical teams near the point of injury. Over time, the medical footprint of these teams has decreased and the utilization of mobile single surgeon teams (SSTs) by the Services has increased. The increased use of SSTs is because of a tactical mobility requirement and not because of proven noninferiority of clinical outcomes. Through an iterative process, the Committee on Surgical Combat Casualty Care (CoSCCC) reviewed the utilization of SSTs and developed an expert-opinion consensus statement addressing the risks of SST utilization and proposed mitigation strategies. METHODS: A small triservice working group of surgeons with deployment experience, to include SST deployments, developed a statement regarding the risks and benefits of SST utilization. The draft statement was reviewed by a working group at the CoSCCC meeting November 2021 and further refined. This was followed by an extensive iterative review process, which was conducted to ensure that the intended messaging was clear to senior medical leaders and operational commanders. The final draft was voted on by the entire CoSCCC membership. To inform the civilian trauma community, commentaries were solicited from civilian trauma leaders to help put this practice into context and to further the discussion in both military and civilian trauma communities. RESULTS: After multiple revisions, the SST statement was finalized in January 2022 and distributed to the CoSCCC membership for a vote. Of 42 voting members, there were three nonconcur votes. The SST statement underwent further revisions to address CoSCCC voting membership comments. Statement commentaries from the President of the American Association for the Surgery for Trauma, the chair of the Committee on Trauma, the Medical Director of the Military Health System Strategic Partnership with the American College of Surgeons and a recently retired military surgeon we included to put this military relevant statement into a civilian context and further delineate the risks and benefits of including the trauma care paradigm in the Department of Defense (DoD) deployed trauma system. CONCLUSION: The use of SSTs has a role in the operational environment; however, operational commanders must understand the tradeoff between tactical mobility and clinical capabilities. As SST tactical mobility increases, the ability of teams to care for multiple casualty incidents or provide sustained clinical operations decreases. The SST position statement is a communication tool to inform operational commanders and military medical leaders on the use of these teams on current and future battlefields.

Evaluation of intraperitoneal placement of absorbable and nonabsorbable barrier coated mesh secured with fibrin sealant in a New Zealand white rabbit model.

BACKGROUND: This study aimed to evaluate the acute and chronic fixation strength of fibrin sealant (FS) as an alternative method of fixation for laparoscopic ventral hernia repair (LVHR). METHODS: Representative mesh types for LVHR included one nonabsorbable barrier mesh (Composix) and three absorbable barrier meshes (Sepramesh, Proceed, and Parietex composite). Macroporous polypropylene mesh (Prolite Ultra) served as the control mesh. Three methods of fixation were used, namely, 0-polypropylene suture+FS (ARTISS 4 IU), FS alone (ARTISS), and tacks alone, to secure 3×4-cm pieces of mesh (10 of each combination) to the peritoneal surface of New Zealand white rabbit abdominal wall. After 2 h of incubation at 37 °C, specimens underwent acute testing. Subsequently, a chronic phase was completed using the aforementioned fixation methods (10 of each combination), in which two 4×4-cm pieces of mesh were secured intraperitoneally in each of 75 New Zealand white rabbits, which survived 8 weeks until they were sacrificed. A transparent grid overlay was used to measure the mesh and adhesion area. Adhesion tenacity was characterized using the Garrard adhesion scale. In both the acute and chronic samples, a 3×3-cm area of mesh-tissue interface underwent lap shear testing at a rate of 0.42 mm/s using a tensiometer (Instron 5542). The maximum load sustained by the mesh-tissue construct was recorded as the acute fixation strength in newtons (N). Data are given as means±standard error of the mean. Statistical significance (p<0.05) was determined using a one-way analysis of variance (ANOVA) with Fisher's least significant difference (LSD) posttest or a nonparametric Kruskal-Wallis test (adhesion scores). RESULTS: The acute fixation strength was significantly greater for all the meshes secured with either suture+FS or tacks alone than for FS alone (p<0.001 for all comparisons). All the meshes except Proceed demonstrated greater acute fixation strength with suture+FS than with tacks alone (p≤0.016). Composix achieved greater acute fixation with suture+FS than all the other meshes (p≤0.022). Acute fixation with suture + FS was greater for Parietex Composite and ProLite Ultra than for Proceed (p≤0.015). When the animals were sacrificed, 48 of 50 meshes fixed with FS alone were insufficiently affixed to the abdominal wall, which may have resulted in hernia recurrence in a hernia model. The chronic fixation strength was greater for all the mesh types with either suture+FS or tacks only than with FS alone (p≤0.0005). The chronic fixation strength was greater with suture+FS than with tacks for Proceed and ProLite Ultra (p≤0.013). Neither mesh area nor adhesion tenacity differed significantly with any mesh/fixation method combination. CONCLUSIONS: In a chronic rabbit model of LVHR, fixation strength with FS alone was inadequate for selected nonabsorbable and absorbable barrier-coated meshes. The acute and chronic fixation strengths of suture+FS were equivalent or superior to the fixation strength of tacks alone. Using a combination of suture and FS for mesh fixation in LVHR may provide adequate fixation while decreasing postoperative pain due to spiral titanium tacks. In this preclinical series, mesh secured to the peritoneal surface by FS alone may have led to early recurrence.

Collagen type I:III ratio of the gastroesophageal junction in patients with paraesophageal hernias.

BACKGROUND: The purpose of this study was to examine the biological environment of the esophageal hiatus through analysis of the collagen content within the gastrohepatic ligament (GHL), gastrophrenic ligament (GPL), and phrenoesophageal ligament (PEL) in patients with type I hiatal hernias (HH) and type III paraesophageal hernias (PEH). METHODS: A control group (N=10) and patients with type I HH (N=10) and type III PEH (N=10) were included in the analysis. Specimens of the GHL, PEL, and GPL were collected intraoperatively. Slides stained with sirius red/fast green were created and ten photos at 400×magnification were taken of each specimen. Axiovision 4.7 (Zeiss) photo analysis software was employed for quantification of collagen I (red) and III (green) by calculating color area (µm2). Statistical significance (p<0.05) was determined using a one-way ANOVA and Fisher's LSD post-test. RESULTS: Cross-polarization microscopy revealed that the collagen I content was similar in the three study groups for the GHL, greater in the type III PEH group and in the control group compared to the type I HH group for the PEL, and greater in the type III PEH group compared to control group for the GPL. Collagen III quantity was greater in the control group than in the type I HH group for each ligament, and greater in the GHL and PEL when compared to the type III PEH group. Type III PEH patients had greater collagen III quantity than did type I HH patients for each ligament. Collagen type I:III ratio of the GHL was greater in both hernia groups compared to the control group. Type III PEH patients contained a higher I:III ratio than both the control and type I HH groups with respect to the PEL. There was no difference in the ratio with evaluation of the GPL for the three groups. CONCLUSION: Evaluation of the esophageal hiatus revealed that patients with PEH have a different biological environment with regard to collagen content compared to control patients. The collagen I:III ratio of the study groups was equal to or greater than the control group. Collagen deficiency in the GE junction supporting ligaments does not appear to be an etiology of PEH formation.

Clinical outcomes of atypical extra-esophageal reflux symptoms following laparoscopic antireflux surgery.

INTRODUCTION: While it is well established that antireflux surgery is effective in relieving typical gastroesophageal reflux disease (GERD) symptoms such as heartburn and regurgitation, it is currently unclear whether atypical symptoms (cough, hoarseness, wheeze) foreshadow a less satisfactory outcome following laparoscopic antireflux surgery (LARS). The purpose of this study is to critically analyze the clinical outcomes of atypical symptoms in patients undergoing LARS. METHODS: Patients scheduled for LARS for GERD were prospectively enrolled over a 7-year period; all subjects underwent preoperative high-resolution manometry (HRM) and had evidence of GERD on ambulatory pH study. Cough, wheeze, and hoarseness were considered atypical symptoms. During preoperative and postoperative examinations, patients completed detailed foregut symptomatology questionnaires, using both 5-point Likert and 10-point visual analog scales (VAS) to document typical as well as atypical symptoms. Atypical symptom burden was calculated as a sum of VAS for the three atypical symptoms, termed the atypical score (ATS). HRM patterns were grouped into normal, spastic, and hypomotile. Statistical significance (p < 0.05) was determined using paired t-test, and analysis of variance with post hoc least significant difference (LSD). RESULTS: One hundred thirteen patients (age 49 ± 1.26 years, range 20-84 years, M:F 47:66) with mean follow-up of 28 ± 2.31 months (range 1-92 months) fulfilled inclusion criteria, having mean modified DeMeester score of 45.5 ± 2.78. Heartburn was noted in 84.1%, while atypical symptoms of some degree were reported by 92.0% (104 patients). Heartburn improved from a preoperative score of 7.1 ± 0.54 to 0.9 ± 0.24 after LARS, and ATS improved from 8.9 ± 0.71 to 2.2 ± 0.42. Significant improvements were noted for all atypical symptoms analyzed (p < 0.0001 for each). Improvement in atypical symptoms was least in the presence of hypomotility features on HRM (21.7% improvement), compared with normal motility (72.4%) and spastic features (83.9%). Preoperative atypical score (p < 0.0001) and esophageal hypomotility (p = 0.04) demonstrated a linear relationship with postoperative atypical score. CONCLUSIONS: In an unselected cohort of patients undergoing LARS, atypical GERD symptoms improved as significantly as typical symptoms. Symptom improvement was significantly lower in the presence of esophageal hypomotility and with higher symptomatic state. Therefore, patients with severe atypical symptoms or hypomotile esophagus may not achieve the same clinical satisfaction from LARS.

Evaluation of acute fixation strength for mechanical tacking devices and fibrin sealant versus polypropylene suture for laparoscopic ventral hernia repair.

BACKGROUND: The purpose of this comparative study is to evaluate the acute fixation strength of mechanical tacking devices and fibrin sealant against polypropylene suture for laparoscopic ventral hernia repair. METHODS: Three metallic mechanical tacking devices (ProTack, Salute, EndoANCHOR), 4 absorbable tacking devices (AbsorbaTack, PermaSorb, I-Clip, and SorbaFix), and 2 types of fibrin sealant (Tisseel, Artiss) were compared with 0-polypropylene suture. Three constructs from each device or an amount of sealant sufficient to cover a 3 × 3 cm(2) area were used to affix a 4 × 3 cm piece of absorbable barrier-coated mesh (Proceed, Ethicon, Inc) to the peritoneal surface of porcine abdominal wall. Ten samples were completed for each fixation modality. Acute fixation strength was measured via a lap shear test on an Instron tensiometer. RESULTS: Acute fixation strength was significantly greater for suture (59.7 7.2 N) compared with all laparoscopic tacking devices and to fibrin sealant (P < .001 for all comparisons). Protack (29.5 ± 2.8 N) was stronger than Absorbatack (13.2 ± 3.7 N; P = .029). Protack, Permasorb, SorbaFix, and I-clip were stronger than fibrin sealant (P < .05 for all comparisons). CONCLUSIONS: The acute fixation strengths of metallic or absorbable tacks as well as fibrin sealant are all significantly less than that achieved with polypropylene suture. These factors should be considered in selecting the type of mechanical fixation for patients undergoing laparoscopic ventral hernia repair.

Survival trends in children with hepatoblastoma.

PURPOSE: Hepatoblastoma (HB) is a relatively rare pediatric malignancy. In this study, we present demographic data and a survival analysis from the largest patient cohort with HB reported to date. METHODS: The surveillance, epidemiology, and end results database was queried from 1973 to 2005 for all patients diagnosed with HB. Kaplan-Meier survival analysis was conducted to determine actuarial survival. Cox regression analysis was performed to determine hazard ratios (HR) for prognostic variables. RESULTS: During the study period, 459 patients with HB were identified. Overall 1-, 3-, and 5-year survival rates for the entire patient cohort were 76, 63, and 60%, respectively. Five-year survival improved over time from 36 (1973-1982) to 63% (1983-2005). Predictors of poor survival include: age 2 years and greater (HR 1.566), black race (HR 1.910), diagnosis prior to 1983 (HR 3.327), inability to perform surgical resection (HR 3.857), regional disease (HR 1.939), and distant disease (HR 3.196). CONCLUSIONS: Hepatoblastoma continues to challenge surgeons and oncologists. Most children are diagnosed early in life and undergo surgical resection whenever possible. With the advent of efficacious chemotherapy, survival has improved. Older children, black patients, and those who present with advanced disease tend to have poor outcomes. Surgical resection is the single most important predictor of survival.

Overall Survival Associated With Ileostomy Closure in Patients With Rectal Cancer Before and After Adjuvant Therapy.

BACKGROUND: A diverting loop ileostomy is commonly constructed to protect a distal anastomosis after proctectomy for rectal cancer. Little data are available on whether closing the ileostomy before or after adjuvant chemotherapy affects survival. METHODS: We conducted a retrospective review of patients with rectal cancer who underwent a low anterior resection with diverting loop ileostomy followed by adjuvant chemotherapy at Ochsner Medical Center. The primary outcome was the long-term survival in patients who had their loop ileostomies closed before chemotherapy (BC) vs after chemotherapy (AC). RESULTS: Seventy-two patients were identified (22 in the BC group vs 50 in the AC group). No difference in mean age (BC 59.5 ± 9.8 vs AC 59.2 ± 12.6, P=0.9) or preoperative clinical stage was seen between study groups. The mean interval from ileostomy creation to closure was significantly shorter in the BC group vs AC group (16.9 ± 14.5 weeks vs 33.6 ± 18.1 weeks, P=0.0001). Follow-up data revealed a similar mean duration from surgery to last contact (BC 50.6 ± 23.6 months vs AC 43.5 ± 22.1 months, P=0.23) and similar overall survival (BC 86% vs AC 70%, P=0.23) between groups. CONCLUSION: Long-term survival was similar in patients who underwent ileostomy closure before and after adjuvant therapy following low anterior resection for rectal cancer. While this study was underpowered, it adds additional insight to an area of surgery lacking significant data. The timing of ileostomy closure should be individualized for each patient.

Tribromoethanol-medetomidine combination provides a safe and reversible anesthetic effect in Sprague-Dawley rats.

Tribromoethanol typically is used alone as a general anesthetic agent for rodent surgeries. In the present study, the alpha2-adrenergic agonists xylazine and medetomidine were combined with tribromoethanol to examine their use as alternate and safe anesthetic regimes in rats. We also tested the effect of atipamezole, an alpha2-adrenergic antagonist, in reversing the anesthetic effect of the tribromoethanol-medetomidine combination. Male Sprague-Dawley rats were used to evaluate the effects of tribromoethanol (400 mg/kg intraperitoneally [i.p.]) or tribromoethanol (150 mg/kg) and medetomidine (0.5 mg/kg i.p.). Tribromoethanol (400 mg/kg)-treated rats were anesthetized for an average of 10 min, whereas rats that received tribromoethanol (150 mg/kg) and medetomidine (0.5 mg/kg) remained anesthetized for an average of 55 min. Recovery time was approximately 6 min for the tribromoethanol (400 mg/kg) group compared with 21 min for the animals that received tribromoethanol and medetomidine. In a second study, three groups of rats were given tribromoethanol (150 mg/kg) and medetomidine (0.5 mg/kg). Group 1 received atipamezole (an alpha2-antagonist; 2.5 mg/kg i.p.) 10 min after anesthetic induction, and group 2 received the same dosage at 20 min post-induction. Group 3 was allowed to recover without atipamezole treatment. The anesthetic effects in animals from groups 1 and 2 were reversed after administration of atipamezole, whereas group 3 remained anesthetized. This study demonstrates the safe and effective use of tribromoethanol-medetomidine as an anesthetic in the rat.

Extraintestinal Manifestations Associated with Inflammatory Bowel Disease.

Inflammatory bowel disease (IBD) affects multiple organ systems outside of the gastrointestinal tract. The clinician treating patients with IBD should be acutely aware of the diagnosis and treatment of extraintestinal manifestations in order to decrease morbidity. The management can be difficult and often times requires a multidisciplinary approach. Future research investigating the pathophysiology, diagnosis, and treatment is needed to further the care of these patients.

Surgical management and associated complications of penetrating rectal injuries sustained in Iraq and Afghanistan.

PURPOSE: The aim of this study was to analyze the surgical management and associated complications of penetrating rectal injuries sustained in Operation Iraqi Freedom and Operation Enduring Freedom. METHODS: A retrospective review was performed using the Joint Theater Trauma Registry. U.S. military personnel injured in Iraq and Afghanistan from October 2003 to November 2008 were included. The surgical management of rectal injuries was evaluated, specifically looking at the utilization of diversion with ostomy, distal washout, and presacral drainage. Complications were compared between the treatment groups. RESULTS: 57 patients who sustained a penetrating rectal injury were included in this study. Surgical management included diversion and ostomy alone in 34 patients (60%), diversion and distal washout in 11 patients (19%), diversion and drainage in 8 patients (14%), and diversion, distal washout, and drainage in 4 patients (7%). Complications were identified in 21% of patients. There were no deaths in the study group. Logistical regression failed to show a correlation between postoperative complications with either distal washout (p = 0.33) or presacral drainage (p = 0.9). CONCLUSIONS: The majority of patients were successfully managed with fecal diversion alone, suggesting that drainage and distal washout may be unnecessary steps in the management of high-velocity, penetrating rectal injuries.

Effect of race on thyroid cancer care in an equal access healthcare system.

BACKGROUND: Thyroid cancer is more likely to present at an advanced age with larger tumor size in black patients. The aim of this study was to assess the influence of race on the presentation, treatment, and survival in an equal access healthcare system. METHODS: This retrospective study included all black and white patients with thyroid cancer who were treated at a Department of Defense facility from 1986 to 2008. Patients' age, tumor size, lymph node status, treatment, and survival were compared. RESULTS: A total of 4,625 patients were identified. There was no difference between black and white patients in regards to age at presentation, tumor size, use of surgical and/or radiation therapy, and overall 5-year survival rate. Black patients had a lower rate of lymph node involvement. CONCLUSIONS: In an equal access healthcare system, black patients have similar disease presentation, undergo similar treatment, and have the same survival as white patients.

Best resident poster award: evaluation of anastomotic techniques for laparoscopic resection of isolated small intestine pathology.

BACKGROUND: The purpose of this study was to compare perioperative outcomes for intracorporeal versus extracorporeal anastomotic techniques for isolated laparoscopic small-intestine resection. METHODS: A retrospective database was created for all adult patients who underwent a laparoscopic segmental small-intestine resection. Patients with inflammatory bowel disease or requiring an ileocolectomy were excluded. RESULTS: Laparoscopic resection was performed in 52 patients (ratio of men:women, 30:22) with a mean age of 47 ± 21 years. A laparoscopic intracorporeal anastomosis was performed in 30 patients (58%), and an extracorporeal anastomosis was performed in 22 patients (42%). There was no difference in mean operating room time, estimated blood loss, perioperative complication rate, or length of stay between the 2 groups. Ten patients had a complication, and 5 patients experienced a Clavien grade II or greater complication. CONCLUSIONS: Laparoscopic segmental small-bowel resection using either intracorporeal or extracorporeal anastomotic techniques is equally efficacious for pathology isolated to the small bowel.

Perirectal abscess infections related to MRSA: a prevalent and underrecognized pathogen.

BACKGROUND: Methicillin-resistant Staphylococcus aureus (MRSA) is not a commonly recognized pathogen isolated from perirectal abscesses. Complex perirectal abscesses of MRSA origin may present a significant challenge to the physician and result in treatment failure. The aim of our study was to determine the prevalence of MRSA in our patient population with perirectal abscesses and whether antibiotics coverage, if given, was adequate. METHODS: We conducted a retrospective study of all adult patients who presented with a perirectal abscess. The bacteriology of the cultures taken from more than 100 patients during an 8-year period was examined. The prevalence of MRSA was specifically analyzed, and the sensitivities of the organisms isolated were then compared with any antibiotics prescribed to determine the adequacy of coverage. RESULTS: In all, 124 patients were treated for perirectal abscess during the 8-year period. Fifty-nine percent of patients were taken to the operating room for incision and drainage, 52% of the patients had cultures taken of the abscess, and 35% of patients were given antibiotics coupled with incision and drainage. The antibiotics offered adequate coverage when compared with the sensitivities of the organisms 73% of the time. The prevalence of MRSA in our patient population was 19%, and when this organism was cultured, the patient only received adequate coverage 33% of the time. CONCLUSION: The presence of MRSA in perirectal abscesses is underrecognized. Recent data has shown that incision and drainage combined with antibiotics offers a superior outcome in soft tissue abscesses caused by this organism. If cultures are not routinely taken at the time of incision and drainage, the institutional incidents of MRSA will remain unknown. Physicians must recognize that MRSA is a potential organism present in perirectal abscesses when considering antimicrobial therapy for complex abscesses.