Value of an interactive phone application in an established enhanced recovery program.

PURPOSE: An interactive mobile phone application was added to an established Enhanced Recovery After Surgery (ERAS) program to determine the impact on ERAS compliance as well as clinical outcomes. METHODS: We identified patients undergoing elective colorectal surgery enrolled in our ERAS program from February 2017 to July 2018. Patients enrolled in a phone application were compared with those not enrolled in terms of age, sex, diagnosis, operative approach, bowel preparation, oral intake and solid food intake, ERAS pathway adherence, and clinical outcomes. RESULTS: A total of 289 patients were included: 147 enrolled and 142 not enrolled in the phone application. The mean age of enrollees was 53.0 years, compared with 58.3 years for the non-enrollees (p = 0.003). The mean ERAS pathway medication adherence for enrollees was 82.1% versus 76.8% for those not enrolled (p = 0.005). The mean LOS and SSI rates for those enrolled versus not enrolled in the phone application was 4.4 days versus 6.4 days (p = 0.006) and 3.4% versus 11.3% (p = 0.019), respectively. There was no significant difference in readmission rates between enrollees and non-enrollees (15% versus 10.6%, p = 0.345). The mean total cost of patients enrolled was $11,560; total cost of those not enrolled was $13,946 (p = 0.024). CONCLUSIONS: Use of an interactive phone application is associated with improved medication ERAS adherence along with significant reduction in length of stay and SSI rates without increasing total cost.

Adenoma detection rate metrics in colorectal cancer surveillance colonoscopy.

BACKGROUND: A target goal for screening adenoma detection rate (S-ADR) of ≥ 25% has been set to define high-quality colonoscopy performance. However, there is no current accepted target goal for ADR in colorectal cancer (CRC) surveillance. This makes quality assessment challenging when physicians perform cancer surveillance colonoscopy but minimal screening procedures. METHODS: In this cohort study, consecutive colonoscopies performed at either Rush University Medical Center or Rush Oak Park Hospital by a gastroenterologist or colorectal surgeon in average risk screening population and CRC surveillance population were reviewed retrospectively from 2006 to 2012 and prospectively from 2013 to 2016. ADR in first surveillance colonoscopy following surgical resection of CRC (CRC-ADR) was reported in high-quality detectors (HQD) or low-quality detectors (LQD) based on achievement of 25% ADR in consecutive screening colonoscopy in average risk patients. Pearson's correlation was used to describe the association between individual S-ADR and CRC-ADR for colonoscopists. RESULTS: There was a very strong positive correlation (r = 0.88, p = 0.002) between ADR in average risk screening and first time CRC surveillance. For HQD as defined by S-ADR ≥ 25% (n = 10 colonoscopists), the CRC-ADR was 37.7% (78/207, SD 8%) which was very similar to their respective S-ADR of 33.4% (816/2440, p = 0.22). For LQD (n = 5 colonoscopists), the CRC-ADR was 20.2% (40/198) which was similar to their respective S-ADR of 20.1% (119/591, p = 0.99). The CRC-ADR was significantly higher for HQD than for LQD (37.7 vs. 20.2%, p < 0.0001). CONCLUSIONS: The major finding of this study is a defined CRC-ADR for HQD based on the ability to achieve S-ADR ≥ 25%. S-ADR strongly correlates with CRC-ADR. CRC-ADR is quite similar to the colonoscopists' respective S-ADR for both HQD and LQD. For colonoscopists who perform limited screening colonoscopies but do perform CRC surveillance colonoscopies, ADR metrics similar to S-ADR to assess quality in colonoscopy could be considered.

Radiographic staging practices of newly diagnosed colorectal cancer vary according to medical specialty.

BACKGROUND: Since 2008, multiple guidelines have endorsed incorporation of chest CT in the radiographic staging assessment of newly diagnosed colorectal cancer (CRC). Radiographic staging practices performed after CRC is detected have not been studied. OBJECTIVE: To evaluate radiographic staging practices for newly diagnosed CRC between gastroenterologists versus non-gastroenterologists. DESIGN: Observational cohort study. SETTING: Single, tertiary-care referral center. PATIENTS: Patients newly diagnosed with a T1 or higher stage CRC at time of colonoscopy between 2008 and 2013. INTERVENTIONS: Radiographic staging. MAIN OUTCOME MEASUREMENTS: Radiographic preoperative staging examinations ordered by gastroenterologists in comparison to those ordered by non-gastroenterology specialists. RESULTS: This study included 277 patients with CRC newly diagnosed by colonoscopy. There were 141 total ordering physicians (68 gastroenterologists and 73 non-gastroenterologists). The majority of preoperative radiographic staging was performed by gastroenterologists (59.2% of patients, n = 164). Colorectal surgeons managed staging in 28.7% of patients (n = 47). Gastroenterologists were more likely to omit a staging chest CT than were non-gastroenterologists (64.6% vs 46.9%; P < .001). Physician practice setting, rectal location of tumor, and advanced endoscopic appearance of tumors were predictors of chest CT inclusion. LIMITATIONS: Single center, moderate sample size of both providers and patients. CONCLUSION: Gastroenterologists more frequently ordered the initial radiographic staging studies in newly diagnosed CRC patients. However, gastroenterologists were less likely to include chest CT in the initial staging of CRC despite current guideline recommendations to do so. If confirmed with further studies, educational efforts to improve compliance and standardization may be needed.

Management of chronic intractable constipation in children.

BACKGROUND: Chronic intractable constipation (CIC) is a debilitating disease that is challenging to manage. Treatment options in children include medications, enemas, and surgical management in selected cases. METHOD: We reviewed medical records of pediatric patients diagnosed as having CIC at Tufts Medical Center from 2005 to 2012. Demographic variables, diagnostic procedures, and medical and surgical outcomes were collected. Clinical outcome was defined using the Rome III criteria. RESULTS: A total of 14 patients were included in the study (10 boys). The age range was 10 to 21 years. All of the patients had the diagnosis of CIC. Eleven patients had cecostomy placement. During the follow-up period, 10 patients underwent total abdominal colectomy with ileorectal anastomosis, 1 had total colectomy with ileostomy, and 1 had partial colectomy with colorectal anastomosis. Successful clinical outcome was reported in 7 patients with 3 patients reporting persistent fecal incontinence. Colonic motility studies were performed on 12 patients (colonic neuropathy in 11 patients and normal study in 1 patient). Defecography was consistent with isolated pelvic floor dysfunction in 1 patient, abnormal motility and anatomy in 1 patient, pelvic floor dysfunction and abnormal motility in 2 patients, and found abnormal motility only in 5. Defecography study was normal in 5 patients. All of the patients with abnormal colonic manometry underwent a surgical procedure. CONCLUSIONS: Anorectal manometry, colonic manometry, and defecography help in understanding the pathophysiology of defecation disorders in children. The majority of patients with abnormal colonic manometry underwent TAC-IRA. There was no statistical correlation between individual investigations (anorectal manometry, colonic manometry, and defecography) with surgical intervention (P > 0.35). TAC-IRA may be safe and useful intervention in a subset of patients when other treatment options have failed.

Intraoperative small bowel length measurements and analysis of demographic predictors of increased length.

Few studies have measured small bowel length (SBL) in live humans and many textbooks base their "normal" SBL values on cadaver data. Here, we present a series of intraoperative SBL measurements and analyze predictors of increased length. SBL from ligament of Treitz to ileocecal valve was measured in patients undergoing laparotomy for colorectal resection. Patients with Crohn's disease and those who had undergone prior bowel resections were excluded. In the 240 patients studied, mean SBL was 506 ± 105 (285-845) cm. Height was positively associated with increased SBL (P < 0.001) and men had longer SBL than women (533 vs. 482 cm, P < 0.001). A multivariate linear regression model using patient sex, age, height and weight was significant (P = 0.001) and the predictors explained 8% of the variance in SBL. In this model, only height was independently predictive of increased SBL (P = 0.03). Correlation results differed between sexes. In men, height correlated with increased SBL (r = 0.20; P = 0.03), whereas in women it did not. In men, age had a positive correlation with SBL at a trend level (r = 0.17; P = 0.08), whereas in women age had a negative correlation with SBL (r = -0.18; P = 0.04). The mean SBL was 506 cm in live patients, as compared with the 600-700 cm range derived from prior cadaver studies. Male sex and height had positive correlations with SBL. SBL may decrease with age in women but not in men.

The First Study Evaluating the Safety of Pre-Surgery Administration of Metformin in Patients with Colorectal and other Gastrointestinal Cancers and Effect on Cancer Stem Cells.

BACKGROUND: The cancer stem cell (CSC) hypothesis of tumor genesis suggests that unlike most cancer cells within tumor CSC resist chemotherapy and can regenerate various cell types in tumor thereby causing relapse. Hence drugs that selectively target CSC may offer great promise for cancer therapy especially when combined with chemotherapy. Current treatment options for colorectal cancer (CRC) and other gastrointestinal (GI) tumors rely on combination of surgical resection, cytotoxic and targeted drugs. Recent findings showed that metformin, an ant diabetic drug was associated with a significantly lower risk of CRC (0.63 [0.47 - 0.84]; P = 0.002) in patients with type 2 diabetes. We therefore hypothesize that administration of metformin will reduce CSC. METHODS: Patients with CRC and other GI cancers undergoing resection were enrolled. Metformin was administered at 500 mg orally twice daily for up to 14 days and terminated 24 hours, prior to planned surgery. Both tumor and normal tissue was procured. Adverse events (AEs) were graded according to NCI CTCAE Version 3.0. Primary objective was to establish the safety of administering metformin prior to resection. Secondary objective was to evaluate the effects of metformin on the expression of CSC markers by measuring relative mRNA levels of CD133, OCT4 and NANOG by RT-PCR and immunohistochemistry. RESULTS: A total of 10 patients (4 Male; 6 Female) received metformin. Grade 3 AEs included anemia, hypoalbuminemia, alanine aminotransferase elevation, abdominal pain and nausea but none of these were related to metformin. No hypoglycemia and lactic acidosis were observed. No unexpected post-operative complications were witnessed. Comparison of markers of CCSC results showed that expression of CD133, OCT4 and NANOG expression were decreased following metformin. CONCLUSIONS: Our pilot study showed feasibility of metformin before surgery in GI cancers and indicated impact on CSC. This preliminary data warrants further investigation in a larger randomized placebo-control study to assess these markers and their correlation with survival.

The digital rectal examination scoring system (DRESS).

PURPOSE: Assessment of anal sphincter tone is a critical part of anorectal examination, yet no standardized, quantifiable method for describing anal sphincter tone on digital rectal examination exists. We developed a novel scoring system for anal sphincter tone using a scale of 0 to 5 for both resting pressure and squeeze pressure. The score ranges from 0 = no discernable pressure to 5 = extremely tight and 3 = normal. We hypothesized that the digital rectal examination scoring system (DRESS) score would correlate with anorectal manometry pressures. METHODS: Three hundred three patients (mean age, 51 y; range, 28-86 y) who had a DRESS score and a concurrent manometry test (1998-2008) were identified from a prospective database. Means of 4 quadrant manometry at rest and with squeeze were compared with the resting pressure and squeeze pressure DRESS scores at each point from 0 to 5. Box plots for manometry results by DRESS score were graphed. ANOVA using a significance level of α = .05 tested whether each of the DRESS scores were different from one another. Spearman rank correlation coefficients assessed associations between manometry and DRESS results. RESULTS: Manometric pressures (mmHg; mean ± SEM) for DRESS resting pressure values 0 to 5 were 20.6 ± 2.1, 38.5 ± 2.0, 47.8 ± 1.6, 72.3 ± 1.5, 94.4 ± 2.9, and 128.0 ± 6.7, respectively. Pressures for DRESS squeeze pressure values 0 to 5 were 45.9 ± 5.6, 66.5 ± 3.2, 108.2 ± 4.9, 156.3 ± 4.5, 238.6 ± 9.8, and 368.2 ± 49.1. Box plots demonstrated clear differences between each DRESS score and positive progression from 0 to 5 for both resting pressure and squeeze pressure. ANOVA analysis showed a significant difference in mean manometry measurements at all levels of digital rectal examination, both for resting pressure and squeeze pressure (P < .001). Spearman rank correlations showed a strong positive correlation between the DRESS values and manometry pressures with coefficients of 0.82 for resting pressure and 0.81 for squeeze pressure. CONCLUSIONS: The DRESS score correlated very well with manometry pressures for resting pressure and squeeze pressure. The DRESS system may be a useful description of anal sphincter resting pressure and squeeze pressure in the clinical setting. Further validation may support adoption of the DRESS system as part of the standard anorectal examination.

Accuracy of colonoscopic localization.

BACKGROUND: The objective of this study was to evaluate the accuracy of preoperative colonoscopic localization of colonic lesions. Localization of the colonic lesion plays a key role in determining the type of operation a patient may require. Inaccurate localization may result in removal of the wrong segment of colon and/or a change in the operation performed. METHODS: A retrospective review of patients who had a colon resection by a single surgeon after preoperative colonoscopic localization between 1991 and 2008 was performed. A comparison of the preoperative colonoscopic localization and the final intraoperative localization was made. Clinical and demographic information was gathered to determine accuracy rates and identify predictive factors. RESULTS: Three hundred and seventy-four patients were included and 184 (49%) were male. The mean age was 61.6 years. Three hundred and sixty-two (97%) patients underwent colon resection for cancer. Fifteen (4%) patients had nonconcordant colonoscopic and intraoperative findings. Fourteen of the 15 (93%) were resected for cancer and 1 for inflammatory bowel disease (IBD). Seven (47%) lesions were inaccurately localized in the sigmoid colon, four (27%) in the descending colon, two (13%) in the ascending colon, one (7%) in the rectum, and one (7%) lesion was not visualized preoperatively. Eleven of the 15 (73%) patients with nonconcordant localization had a modification of their planned procedure. Ten patients underwent a different segmental colectomy and one patient had an extended resection. CONCLUSION: Preoperative colonoscopic localization of colorectal lesions was reasonably accurate (96%) in this large series. The majority of inaccurately identified lesions occurred in the sigmoid and descending colon. Erroneous localization, even though not common, can result in significant changes in the intraoperative plan and the ultimate outcome. Therefore, every effort should be made to localize the lesion before surgery, especially when thought to be in the left or sigmoid colon, to reduce the need for intraoperative localization efforts, the need for an intraoperative change in procedure, and the risk of a surprise for the patient after surgery.

Longer Operative Time and Intraoperative Blood Transfusion Are Associated with Postoperative Anastomotic Leak after Lower Gastrointestinal Surgery.

Anastomotic leak after lower gastrointestinal surgery is a complication with potential for high morbidity, mortality, and increased costs. A single-institution retrospective chart review was performed on all patients who underwent lower gastrointestinal surgery between June 2009 and June 2013. Fifty-seven variables were included in our analysis and their association with postoperative anastomotic leak was examined. Nine hundred fifty-two patients underwent 983 lower gastrointestinal anastomoses with an overall leak rate in this series of 6 per cent. Type of intestinal anastomosis created (P < 0.00005), operative indication (P < 0.015), operation performed (P < 0.014), intraoperative blood transfusion (P < 0.017), and intraoperative surgical drain placement (P < 0.022) were all predictive of anastomotic leak. Anastomotic leak rate increased by 1.3 times for every additional hour in the operating room after three hours. Both increasing operation time and intraoperative blood transfusions were associated with an increased rate of anastomotic leak. When operative time extends beyond three hours or in those cases were blood transfusions are given, surgeons should consider taking steps to minimize the risks of a potential anastomotic leak.

Effect of protected research time on ABSITE scores during general surgery residency.

BACKGROUND: Objective - To determine whether residents with one or more years of dedicated research time (Research Residents, RR) improved their ABSITE scores compared to those without (Non-Research Residents, N-RR). METHODS: A retrospective review of general surgery residents' ABSITE scores from 1995 to 2016 was performed. RR were compared to N-RR. Additional analysis of At Risk (AR) v Not At Risk residents (NAR) (35th percentile as PGY1-2) was also performed. RESULTS: Cohort - 147 residents (34 RR and 113 N-RR). There were no differences in initial ABSITE scores (p = 0.47). By definition, the AR group had lower scores than NAR. Overall, post-research RR v PGY-4 N-RR scores did not differ (p = 0.84). Only the AR residents improved their scores (p = 0.0009 v NAR p = 0.42), regardless of research group (p = 0.70). CONCLUSION: Protected research time did not improve residents' ABSITE scores, regardless of initial scores. At Risk residents improved regardless of research group status.

Open, intraperitoneal, ventral hernia repair: lessons learned from laparoscopy.

Recent literature suggests that laparoscopic repair of ventral hernias may have very low recurrence rates. However, laparoscopy may not be feasible in certain situations. We describe an open technique that uses the tension-free retrofascial principles of laparoscopic repair without the need for subcutaneous flaps. Through an incision in the hernia, the peritoneum is entered and adhesions are taken down. A piece of DualMesh (W.L. Gore & Associates, Inc, Newark, Del) is trimmed to fit with a 5-cm circumferential overlap. A vertical incision is made in the mid portion of the mesh. The mesh is fixed in an intraperitoneal retrofascial position using GORE-TEX sutures (W.L. Gore & Associates, Inc). The sutures are brought through the abdominal wall using a laparoscopic suture passer and tied into place on one side of the mesh. That side is then tacked to the posterior fascia with a spiral tacking device. The other side is sutured into place in a similar fashion and then tacked to the fascia by passing the spiral tacking device through the incision in the mesh. The mesh incision is closed with a running GORE-TEX suture. The overlying tissues are closed in layers.

Antithrombin in the treatment of burn trauma.

Antithrombin (AT) is a natural anticoagulant with anti-inflammatory properties that has demonstrated value in sepsis, disseminated intravascular coagulation and in burn and inhalation injury. With high doses, AT may decrease blood loss during eschar excision, reducing blood transfusion requirements. There are no human randomized, placebo-controlled studies, which have tested the true benefit of this agent in these conditions. Two main forms of AT are either plasma-derived AT (phAT) and recombinant AT (rhAT). Major ovine studies in burn and smoke inhalation injury have utilized rhAT. There have been no studies which have either translated the basic rhAT research in burn trauma, or determined the tolerance and pharmacokinetics of rhAT concentrate infusions in burn patients. Advantages of rhAT infusions are no risk of blood borne diseases and lower cost. However, the majority of human burn patient studies have been conducted utilizing phAT. Recent Japanese clinical trials have started using phAT in abdominal sepsis successfully. This review examines the properties of both phAT and rhAT, and analyzes studies in which they have been utilized. We believe that it is time to embark on a randomized placebo-controlled multi-center trial to establish the role of AT in both civilian and military patients with burn trauma.

Systems-based practice: learning the concepts using a teamwork competition model.

BACKGROUND: Systems-based practice (SBP) is a core competency of the Accreditation Council for Graduate Medical Education (ACGME) that must be integrated into residency training. We sought to develop a method to improve resident understanding using a teamwork competition model. METHODS: The residents were given a pretest to assess their understanding of SBP followed by a didactic lecture. They were then divided into teams to solve a programmatic "problem" in the residency. Each team had to prove that their solution best fulfilled the expectations of SBP. Their solutions were then presented at a departmental conference followed by a post-test to evaluate knowledge. RESULTS: In the pretest, 33% of the residents understood what SBP meant and only 15% knew the components of SBP. In the post-test, this increased to 85% and 89%, respectively. CONCLUSIONS: SBP is a competency mandated by the Accreditation Council for Graduate Medical Education in residency training. Using a novel approach, we were able to improve the residents' understanding of SBP.

Enterocolic fistula due to a rectal stent: Case report and literature review.

INTRODUCTION: Self-expanding metal stents (SEMS) are successfully being used to acutely relieve obstructing colorectal cancers; yet, their use does not come without complications. PRESENTATION OF CASE: We present a case in which a patient with a recurrent obstructing sigmoid carcinoma underwent colonic stenting for acute decompression. Two months after stent placement, an enterocolic fistula formed from erosion of the upper end of the stent. DISCUSSION: An extensive literature review revealed that fistula formation, as a complication of stent placement, is rarely reported. Presentation of the case is followed by a review of complications that may arise following SEMS placement, with a focus on enterocolic fistulae. To our knowledge, this work provides the most extensive review of the subject to date. CONCLUSION: SEMS provide an effective, safe, and less invasive option for patients when used in the appropriate clinical context. Further reports of enterocolic fistulae as a complication of SEMS placement are necessary in order to better understand this potential adverse event.

Management of pediatric patients with refractory constipation who fail cecostomy.

BACKGROUND: Antegrade continence enema (ACE) is a recognized therapeutic option in the management of pediatric refractory constipation. Data on the long-term outcome of patients who fail to improve after an ACE-procedure are lacking. PURPOSE: To describe the rate of ACE bowel management failure in pediatric refractory constipation, and the management and long term outcome of these patients. METHODS: Retrospective analysis of a cohort of patients that underwent ACE-procedure and had at least 3-year-follow-up. Detailed analysis of subsequent treatment and outcome of those patients with a poor functional outcome was performed. RESULTS: 76 patients were included. 12 (16%) failed successful bowel management after ACE requiring additional intervention. Mean follow-up was 66.3 (range 35-95 months) after ACE-procedure. Colonic motility studies demonstrated colonic neuropathy in 7 patients (58%); abnormal motility in 4 patients (33%), and abnormal left-sided colonic motility in 1 patient (9%). All 12 patients were ultimately treated surgically. Nine patients (75%) had marked clinical improvement, whereas 3 patients (25%) continued to have poor function issues at long term follow-up. CONCLUSIONS: Colonic resection, either segmental or total, led to improvement or resolution of symptoms in the majority of patients who failed cecostomy. However, this is a complex and heterogeneous group and some patients will have continued issues.

Topical tacrolimus for parastomal pyoderma gangrenosum: a report of two cases.

Pyoderma gangrenosum (PG) is an idiopathic, ulcerative, inflammatory dermatologic condition that occurs in patients with systemic diseases such as inflammatory bowel disease (IBD). This inflammatory skin disorder is presumably caused by an autoimmune mechanism and the diagnosis is one of exclusion. PG is not a common condition but it is thought to account for approximately 50% of chronic parastomal ulcers. Refractory parastomal PG (PPG) occurs in patients with inactive disease or after bowel resection. Multiple medical treatments, ranging from topical agents for mild disease to systemic immunosuppressive therapy for severe disease, have been used with varying rates of success. Using topical tacrolimus, an immunosuppressant that inhibits T-lymphocyte proliferation, and meticulous stoma care can result in successful treatment. Two women (ages 59 and 62 years) with a history of ulcerative colitis and colon resection presented with parastomal ulcers consistent with PPG. The 59-year patient presented with a painful 2 cm x 2 cm parastomal ulcer that improved following daily application of topical tacrolimus 0.1%. The 62-year old woman first was prescribed daily appliance changes and application of topical triamcinolone 0.5% to her 3-cm ulcer. The ulcer increased in size and treatment was changed to daily application of tacrolimus 0.1%. After 2 months and a reduction in ulcer size and severity, the dosage was changed to daily application of tacrolimus 0.03%. Both patients reported resolution of pain and itching, the most common symptoms of PPG, and no adverse effects were observed. The encouraging results observed in these two cases confirm that tacrolimus helps resolve PPG lesions even at concentrations previously thought to be ineffective. Additional studies to help clinicians optimize care of these painful lesions are needed.

Paradoxical inflammatory reaction to Seprafilm: case report and review of the literature.

This report describes a paradoxical inflammatory reaction to Seprafilm caused by extensive adhesion formation early in the postoperative period. A female patient had development of small bowel obstruction immediately after an uneventful low anterior resection for rectal carcinoma with placement of Seprafilm. The obstruction did not improve with nonoperative therapy. At laparotomy, extensive adhesions necessitating bowel resection and ileostomy were noted. Pathology results showed a giant cell foreign body reaction to Seprafilm. A literature search yielded only two other instances of adverse reactions to Seprafilm. The information provided by this and other atypical reports suggests that further studies aimed at identifying the incidence and pathophysiological mechanisms for such paradoxical reactions are needed.

Urachal remnant small bowel obstruction: report of two adult cases.

This report describes two separate cases of adult patients with intestinal obstruction caused by an urachal remnant. While reports of infected urachal cysts causing intra-abdominal pathology are not uncommon, intestinal obstruction caused by urachal remnants is exceedingly rare in the pediatric population and has never been described in adults. Both of these patients required surgical intervention with excision of the urachal remnant and subsequent resolution of the small bowel obstruction.