The Learning Curve for Advanced Endoscopy for Colorectal Lesions: A Surgeon's Experience at a High-Volume Center.

BACKGROUND: Advanced endoscopy can be used for the complete removal of large colorectal polyps. To date, few surgeons perform advanced endoscopy, and it is unknown how many procedures are needed to reach proficiency. OBJECTIVE: This study aimed to determine the learning curve for colorectal advanced endoscopy. DESIGN: Retrospective. SETTING: Tertiary referral center. PATIENTS: We queried a prospectively maintained institutional database of advanced endoscopy performed by a high-volume colorectal surgeon between 2011 and 2018. MAIN OUTCOME MEASURES: Advanced endoscopy characteristics were compared for 6 chronological intervals. Primary end points were the rates of complications and polyp recurrence. Secondary end point was the change in polyp removal rate (mm/h) over time. RESULTS: A total of 207 patients underwent advanced endoscopy for a single colorectal polyp. The median polyp size was 30 (4-70) mm, 61.5% were located in the right colon, and 8.8% were malignant. The mean procedure time was 77 (range, 16-320) minutes. Immediate colon resection occurred in 25 patients because of suspicion of cancer or concern for perforation and was excluded from the learning curve analysis. The remaining 182 advanced endoscopy procedures were divided into intervals of 30 procedures. The median removal rate was highest in the last interval and in the endoscopy suite. A removal rate of 30 mm/h was achieved after performing 100 cases. The complication rate (bleeding or return to operating room) was 12.1% and was similar across intervals. The readmission rate was 11.5%, and 6.6% of 6-month follow-up colonoscopies showed polyp recurrence at the resection site. LIMITATIONS: Retrospective design and single surgeon. CONCLUSION: The learning curve for achieving proficiency with advanced endoscopy in the colon and rectum required a minimum of 100 cases with a low complication rate, low polyp recurrence rate, high en bloc resection rate, and a polyp removal rate of 30 mm/h. See Video Abstract at http://links.lww.com/DCR/C162 .LA CURVA DE APRENDIZAJE DE LA ENDOSCOPIA AVANZADA PARA LESIONES COLORRECTALES: LA EXPERIENCIA DE UN CIRUJANO EN UN CENTRO DE ALTO VOLUMENANTECEDENTES:La endoscopia avanzada se puede utilizar para la extirpación completa de pólipos colorrectales grandes. Hasta la fecha, pocos cirujanos realizan endoscopia avanzada y se desconoce cuántos procedimientos se necesitan para alcanzar la competencia.OBJETIVO:Determinar la curva de aprendizaje de la endoscopia colorrectal avanzada.DISEÑO:Retrospectivo.AJUSTE:Centro de referencia terciario.PACIENTES:Consultamos una base de datos institucional mantenida prospectivamente de endoscopia avanzada realizada por un cirujano colorrectal de alto volumen entre 2011 y 2018.PRINCIPALES MEDIDAS DE RESULTADO:Se compararon las características de la endoscopia avanzada en seis intervalos cronológicos. Los puntos finales primarios fueron las tasas de complicaciones y recurrencia de pólipos. El criterio de valoración secundario fue el cambio en la tasa de eliminación de pólipos (mm/h) a lo largo del tiempo.RESULTADOS:Un total de 207 pacientes se sometieron a una endoscopia avanzada por un solo pólipo colorrectal. La mediana del tamaño de los pólipos fue de 30 (4-70) mm, el 61,5% se ubicaron en el colon derecho y el 8,8% fueron malignos. El tiempo medio del procedimiento fue de 77 (rango: 16-320) minutos. La resección inmediata del colon ocurrió en 25 pacientes debido a la sospecha de cáncer o preocupación por la perforación y fueron excluidos del análisis de la curva de aprendizaje. Los restantes 182 procedimientos de endoscopia avanzada se dividieron en intervalos de 30 procedimientos. La mediana de la tasa de extirpación fue más alta en el último intervalo y en la sala de endoscopia. Se logró una tasa de extirpación de 30 mm/hr después de realizar 100 casos. La tasa de complicaciones (sangrado o retorno al quirófano) fue del 12,1% y fue similar en todos los intervalos. La tasa de reingreso fue del 11,5% y el 6,6% de las colonoscopias de seguimiento a los 6 meses mostraron recurrencia de pólipos en el sitio de la resección.LIMITACIONES:Diseño retrospectivo, cirujano único.CONCLUSIÓN:La curva de aprendizaje para lograr el dominio de la endoscopia avanzada en el colon y el recto requiere un mínimo de 100 casos con una baja tasa de complicaciones, baja tasa de recurrencia de pólipos, alta tasa de resección en bloque y una tasa de eliminación de pólipos de 30 mm/h. Consulte el Video Resumen en http://links.lww.com/DCR/C162 . (Traducción-Dr. Yesenia.Rojas-Khalil ).

Optimizing opioid prescriptions after laparoscopic appendectomy and cholecystectomy

Background: There has been an increase in opioid usage and opioid-related deaths. Opioids prescribed to surgical patients have similarly increased. The aim of this study was to assess opioid consumption in patients undergoing laparoscopic appendectomy (LA) and laparoscopic cholecystectomy (LC) and to determine whether a standardized prescription could affect opioid consumption without affecting patient satisfaction. Methods: Patients undergoing LA or LC were recruited prospectively during 2 time periods (April to June 2017 and November 2017 to January 2018). In the first phase, surgeons continued their usual postoperative analgesia prescribing patterns. In the second phase, a standardized prescription was implemented. Patients were contacted by telephone and a questionnaire was completed for both phases of the study. The primary outcome was the quantity of opioids prescribed and consumed. Results: In the first phase, 166 patients who underwent LC or LA were recruited. The median number of prescribed opioid tablets was 20 and the median number consumed was 2. Ninety-five percent of patients reported satisfaction with their analgesia. Based on these results, a standardized prescription for multimodal analgesia was implemented for the second phase, consisting of 10 opioid tablets. In the second phase, 129 patients who underwent LA or LC were recruited. There was a significant decrease in the median number of opioid pills filled (10) and consumed (0), with no difference in reported satisfaction with analgesia. Conclusion: Patients are prescribed an excess of opioids after LA or LC. Implementation of a standardized prescription based on a quality improvement intervention was effective at decreasing the number of opioids prescribed and consumed.

Contexte: On a observé une augmentation de la consommation d'opioïdes, ainsi qu'une hausse des décès associés à ces substances. On a aussi constaté une augmentation semblable dans la prescription d'opioïdes aux patients ayant subi une chirurgie. La présente étude visait à évaluer la consommation d'opioïdes chez les personnes ayant subi une appendicectomie par laparoscopie (AL) ou une cholécystectomie par laparoscopie (CL), de même qu'à déterminer si une ordonnance normalisée pouvait modifier la consommation d'opioïdes sans nuire à la satisfaction des patients. Méthodes: Des patients devant subir une AL ou une CL ont été recrutés de façon prospective entre avril et juin 2017 et entre novembre 2017 et janvier 2018. Durant la première phase de l'étude, les chirurgiens ont maintenu leurs habitudes de prescription d'analgésie postopératoire. Durant la deuxième phase, toutefois, ils devaient avoir recours à une ordonnance normalisée. Dans les 2 phases de l'étude, les patients ont été joints par téléphone et un questionnaire a été rempli. Le principal résultat à l'étude était la quantité d'opioïdes prescrits et consommés. Résultats: Pour la première phase de l'étude, 166 patients ont été recrutés. Les nombres médians de comprimés prescrits et consommés étaient de 20 et de 2, respectivement. De tous les patients, 95 % se sont dits satisfaits de leur analgésie. Pour la deuxième phase, une ordonnance normalisée d'analgésie multimodale, qui comptait 10 comprimés, a été mise en place, et 129 patients ont été recrutés. On a alors observé une diminution significative du nombre médian de comprimés remis (10) et consommés (0), et aucune différence quant au degré de satisfaction déclaré. Conclusion: Les patients se voient prescrire trop d'opioïdes après une AL ou une CL. La création d'une ordonnance normalisée dans le cadre d'une intervention d'amélioration de la qualité a réduit efficacement le nombre de comprimés d'opioïdes prescrits et consommés.

Sessile Serrated Polyposis: Not an Inherited Syndrome?

BACKGROUND: Researchers are searching in vain for a coherent genetic explanation for serrated polyposis. We hypothesize that there is no consistent monogenetic inheritance. OBJECTIVE: The purpose of this study was to describe the serrated polyposis phenotype, assessing features of mendelian inheritance, and to compare these features with patients with a solitary sessile serrated lesion. DESIGN: This was a retrospective review of a prospectively maintained database comparing patients with serrated polyposis versus solitary sessile serrated lesions. SETTINGS: The study was conducted at a single-institution tertiary referral center. PATIENTS: Patients with serrated polyposis meeting World Health Organization criteria type I (≥5 serrated polyps proximal to the sigmoid, ≥2 of which are ≥10 mm in diameter) and isolated sessile serrated lesions were included MAIN OUTCOME MEASURES:: Disease phenotype was the main outcome measured. RESULTS: A total of 46 serrated polyposis patients were identified. Median age of first sessile serrated lesion was 66 years (interquartile range, 42-70 y). A total of 60.3% were current or past smokers (mean = 38.6 packs per year). Serrated polyposis patients had a higher number of all types of polyps (26.3 vs 4.4) and a higher rate of high-grade dysplasia (19.6% vs 3.7%) compared with patients with a solitary sessile serrated lesion. A total of 36.2% of patients had personal history of noncolorectal cancers, including skin, prostate, breast, thyroid, and renal cell cancers and leukemia. In addition, 32.6% had a family history of colorectal cancer in first- or second-degree relatives; these cancers were not young age of onset. Breast and prostate cancers were also common (family history of any cancer, 83.0%). Ten patients underwent genetic testing: 4 had negative panels, 1 had a pathogenic variant in MSH2, 1 an IVS7 deletion in PTEN, 2 negative APC sequencing (1 negative MYH), and 1 a pathogenic variant in Chek2. LIMITATIONS: RNF4 was not sequenced. Genetic analysis was performed on a subset of patients. CONCLUSIONS: The rate of associated cancers suggests an underlying genetic predisposition to disordered growth, but serrated polyposis does not have typical features of dominant inheritance. The association with smoking suggests that familial/environmental factors play a role. See Video Abstract at http://links.lww.com/DCR/B84. POLIPOSIS SERRADA SÉSIL: ¿NO ES UN SÍNDROME HEREDITARIO?: Los investigadores están buscando en vano una explicación genética coherente para la póliposis serrados. Suponemos que no existe una herencia monogenética consistente.1) Describir el fenotipo de póliposis serrada, evaluando las características de la herencia mendeliana, 2) comparar estas características con pacientes con una lesión serrada sésil solitaria.Revisión retrospectiva de una base de datos mantenida prospectivamente que compara pacientes con póliposis serrada versus lesiones serradas sésiles solitarias.Institución única, centro de referencia terciario.Pacientes con póliposis serrada que cumplen con los Criterios de la Organización Mundial de la Salud Tipo I (≥ 5 pólipos serrados proximales al sigmoideo, ≥2 de los cuales tienen ≥10 mm de diámetro) y lesiones serradas sésiles aisladas.Fenotipo de la enfermedad.Se identificaron un total de 46 pacientes con póliposis serrada. La edad mediana de la primera lesión serrada sésil fue de 66 años (RIC: 42-70 años). El 60.3% eran fumadores actuales o pasados (medio 38.6 paquetes / año). Los pacientes con póliposis serrada tuvieron un mayor número de todos los tipos de pólipos (26.3 versus 4.4) y una mayor tasa de displasia de alto grado (19.6% versus 3.7%) en comparación con los pacientes con una lesión serrada sésil solitaria. El 36.2% de los pacientes tenían antecedentes personales de cánceres no colorectales, incluyendo los cánceres de piel, próstata, mama, tiroides, células renales y leucemia. El 32.6% tenía antecedentes familiares de cáncer colorectal en familiares de primer o segundo grado; estos cánceres no eran de inicio de edad temprana. El cáncer de mama y próstata también fue frecuente (antecedentes familiares de cualquier tipo de cáncer: 83.0%). 10 pacientes se sometieron a pruebas genéticas: 4 tenían paneles negativos, 1 tenía una variante patogénica en MSH2, 1 una eliminación IVS7 en PTEN, 2 secuenciación APC negativa (1 MYH negativa) y 1 variante patogénica en Chek2.RNF4 no fue secuenciado. El análisis genético se realizó en un subconjunto de pacientes.La tasa de cánceres asociados sugiere una predisposición genética subyacente al crecimiento desordenado, pero la póliposis serrada no tiene características típicas de herencia dominante. La asociación con el tabaquismo sugiere que los factores familiares / ambientales juegan un papel. Consulte Video Resumen en http://links.lww.com/DCR/B84. (Traducción-Dr. Yesenia Rojas-Khalil).

Conditional Survival After IPAA for Ulcerative and Indeterminate Colitis: Does Long-term Pouch Survival Improve or Worsen With Time?

BACKGROUND: Risk factors for pouch survival may or may not have a linear relationship with pouch loss over time. Conditional survival is a method to describe these nonlinear time-to-event relationships by reporting the expected survival at various time points. OBJECTIVE: The aim of this study was to calculate conditional pouch survival based on occurrence of risk factors for pouch loss. DESIGN: This was a retrospective study from an institutional database. SETTINGS: The study was conducted at the Cleveland Clinic Foundation. PATIENTS: Patients with ulcerative or indeterminate colitis who underwent index IPAA construction between 1986 and 2016 were included. MAIN OUTCOME MEASURES: Patients were stratified based on postoperative anastomotic leak, abscess, or fistula occurrence. The Kaplan-Meier method with conditional survival was used to estimate overall and cause-specific survival at 10 years. RESULTS: A total of 3468 patients underwent IPAA during the study period. The overall 10-year pouch survival rate was 0.94 (95% CI, 0.93-0.95), and after 1 year the conditional pouch survival increased to 0.95 (95% CI, 0.94-0.96), after 3 years to 0.97 (95% CI, 0.96-0.98), and after 5 years to 0.98 (95% CI, 0.98-0.99). A total of 122 patients (3.5%) developed anastomotic leak, and the 10-year IPAA survival in patients with leak was 0.85 (95% CI, 0.77-0.93). In this group, after 1 year of pouch survival, the conditional pouch survival increased to 0.89 (95% CI, 0.82-0.96) and after 3 years to 0.98 (95% CI, 0.94-1.00). A similar pattern was seen for IPAA with postoperative abscess. The conditional survival curve was stable over time for patients with a fistula. LIMITATIONS: This was a retrospective, single-institution study. CONCLUSIONS: Overall conditional pouch survival improved over time for patients with postoperative anastomotic leak and abscess. These novel findings can be useful to counsel patients regarding expectations for long-term pouch survival even if they develop leaks and abscesses. See Video Abstract at http://links.lww.com/DCR/B217. SUPERVIVENCIA CONDICIONAL DESPUÉS DE ANASTOMOSIS CON BOLSA ÍLEO ANAL, PARA COLITIS ULCERATIVA E INDETERMINADA: ¿LA SOBREVIDA DE LA BOLSA A LARGO PLAZO, MEJORA O EMPEORA CON EL TIEMPO?: Los factores de riesgo para la sobrevida de la bolsa, pueden o no tener una relación lineal con la pérdida de la bolsa y con el tiempo. La supervivencia condicional es un método para describir estas relaciones no lineales de tiempo, hasta el evento informando la supervivencia esperada en varios puntos de tiempo.El objetivo de este estudio fue calcular la supervivencia condicional de la bolsa, en función de aparición de factores de riesgo para la pérdida de bolsa.Estudio retrospectivo de una base de datos institucional.Cleveland Clinic Foundation.Pacientes con colitis ulcerativa o indeterminada, sometidos a una anastomosis de bolsa íleo anal, de 1986 a 2016.Los pacientes fueron estratificados en función de la fuga anastomótica postoperatoria, absceso o aparición de fístula. El método de Kaplan Meier con supervivencia condicional, se utilizó para estimar la supervivencia general y la causa específica a los 10 años.Un total de 3.468 pacientes fueron sometidos a anastomosis ileal con bolsa anal durante el período de estudio. La tasa de supervivencia global de la bolsa a 10 años, fue de 0,94 (0,93 a 0,95), y después de 1 año, la supervivencia condicional de la bolsa aumentó a 0,95 (0,94 a 0,96), después de 3 años a 0,97 (0,96 a 0,98) y después de 5 años a 0.98 (0.98 - 0.99). Un total de 122 (3,5%) pacientes desarrollaron fuga anastomótica, y la supervivencia de la anastomosis de bolsa íleo anal a 10 años en pacientes con fuga fue de 0,85 (IC del 95%: 0,77 a 0,93). En este grupo, después de 1 año de supervivencia de la bolsa, la supervivencia condicional de la bolsa aumentó a 0,89 (IC del 95%: 0,82 a 0,96), y después de 3 años a 0,98 (IC del 95%: 0,94 a 1). Se observó un patrón similar para la anastomosis de bolsa íleo anal con absceso postoperatorio. La curva de supervivencia condicional fue estable en el tiempo para los pacientes con una fístula.Estudio retrospectivo, de una sola institución.La supervivencia condicional global de la bolsa, mejoró con el tiempo para pacientes con fuga anastomótica postoperatoria y absceso. Estos nuevos hallazgos pueden ser útiles para aconsejar a los pacientes con respecto a las expectativas de supervivencia de la bolsa a largo plazo, incluso si desarrollan fugas y abscesos. Consulte Video Resumen http://links.lww.com/DCR/B217. (Traducción-Dr Fidel Ruiz Healy).

Postoperative opioid-prescribing patterns among surgeons and residents at university-affiliated hospitals: a survey study

Background: Overprescribing of opioids to patients following surgery is a public health concern, as unused pills may be diverted and contribute to opioid misuse and dependence. The objectives of this study were to determine current opioid-prescribing patterns for common surgical procedures, factors that affect surgeons' prescribing behaviour and their perceived ability to manage patients with opioid use disorder. Methods: Survey participants included all consultant and trainee surgeons at the University of Toronto. The survey, which was administered electronically, included 52 multiple-choice, rank-order and open-text questions eliciting information on current prescribing patterns, prescribing of adjunct pain medications, and education and other factors related to opioid prescribing. Staff surgeons were also asked about how they manage patients with a suspected opioid issue. Results: Eighty surgical trainees and 40 staff surgeons responded to the survey (response rate 32%). Five staff surgeons (12%) felt adequately educated to prescribe pain medications (including opioids) at discharge. Staff surgeons prescribed Tylenol 3 more frequently than other opioids. Twenty (51%) of 39 staff surgeons reported that they sought further help for their patients when an opioid use disorder was suspected. Conclusion: Our results support existing studies showing a large degree of variability in postoperative opioid prescribing. Institutional guidelines have been shown to be effective in curbing excessive opioid prescribing without increasing unnecessary emergency department visits for uncontrolled pain. Thus, there is an opportunity to develop institutional guidelines to educate surgical teams in the prescribing of opioids and about services available for patients with a substance use disorder.

Contexte: La surprescription d'opioïdes aux patients après une chirurgie représente un problème de santé publique car il y a un risque que les comprimés inutilisés soient détournés et utilisés à mauvais escient, voire qu'ils causent la dépendance. Cette étude avait pour objectif d'identifier les modes actuels de prescription des opioïdes pour les chirurgies courantes, les facteurs qui influent sur les habitudes de prescription des chirurgiens et leur capacité perçue à prendre en charge les cas de mésusage des opioïdes. Méthodes: Les participants au sondage étaient tous les chirurgiens en poste et en formation à l'Université de Toronto. Ce sondage administré par voie électronique comprenait 52 questions (choix multiples, échelles ordinales et ouvertes) qui visaient à recueillir des renseignements sur les modes actuels de prescription, la prescription d'analgésiques d'appoint, l'enseignement au patient et autres éléments relatifs à la prescription des opioïdes. Les chirurgiens en poste ont aussi été interrogés sur leur gestion des cas présumés de mésusage des opioïdes. Résultats: Quatre-vingt chirurgiens en formation et 40 chirurgiens en poste ont répondu au sondage (taux de réponse, 32 %). Cinq chirurgiens en poste (12 %) se sont estimés adéquatement renseignés sur la façon de prescrire les analgésiques, (y compris les opioïdes) au moment du congé. Les chirurgiens en poste prescrivaient Tylenol 3 fois plus souvent que d'autres opioïdes. Vingt (51 %) chirurgiens en poste sur 39 ont dit consulter s'ils avaient besoin d'aide pour la prise en charge de patients soupçonnés de présenter un problème de mésusage des opioïdes. Conclusion: Nos résultats viennent étayer les conclusions d'études existantes selon lesquelles les modes de prescription des opioïdes en postopératoire varient grandement. Il a été démontré que l'adoption de lignes directrices institutionnelles permet de limiter efficacement la surprescription des opioïdes sans accroître indument le nombre de consultations aux urgences pour douleur non maîtrisée. Il y a donc là une possibilité d'adopter à plus grande échelle les lignes directrices institutionnelles pour sensibiliser les équipes chirurgicales à l'utilisation judicieuse des opioïdes et à l'existence des services à l'intention des patients qui présentent un problème de mésusage.

Survival and peri-operative outcomes among patients with rectal cancer: the role of prior radiotherapy due to prostate cancer.

PURPOSE: Patients with rectal cancer (RCa) and prior radiation for prostate cancer (PCa) are clinically complicated and may have worse outcomes than other RCa patients. This study investigates the impact of previous radiation for PCa on survival for patients with RCa. METHOD: We conducted a population-based study identifying men who underwent surgical treatment of RCa from 2002 to 2010. Patients were classified into three cohorts: no prior PCa, prior PCa treated without radiotherapy, and prior PCa treated with radiotherapy. The primary outcome was overall survival. Secondary outcomes included RCa surgical approach, ICU admission, length of stay, ER visits, and delayed formation of a new stoma. RESULTS: Seven thousand ninety-six men underwent surgery for RCa; 6867 patients had no prior PCa, 58 had prior PCa treated without radiotherapy, and 171 had prior PCa treated with radiotherapy. The 5-year overall survival was 62% (95% CI 61-64%) for patients without prior PCa, 46% (95% CI 25-65%) for patients with prior PCa treated without radiotherapy, and 42% (95% CI 29-54%) for patients with prior PCa treated with radiotherapy (p < 0.0001). In multivariable analysis, patients with prior PCa treated with radiotherapy were at increased risk of death (aHR 1.38, 95% CI 1.12-1.69) compared to those without prior PCa. Furthermore, patients with prior PCa treated with radiotherapy had a significantly increased risk of resection with permanent stoma. CONCLUSIONS: Prior radiotherapy for PCa is a poor prognostic factor in RCa patients with significantly increased risk of death. Additionally, patients with prior radiotherapy for PCa are more likely to require a permanent stoma.

Opioid Use After Discharge in Postoperative Patients: A Systematic Review.

BACKGROUND: Over the past 2 decades, there has been an increase in opioid use and subsequently, opioid deaths. The amount of opioid prescribed to surgical patients has also increased. The aim of this systematic review was to determine postdischarge opioid consumption in surgical patients compared with the amount of opioid prescribed. Secondary outcomes included adequacy of pain control and disposal methods for unused opioids. OBJECTIVE: The objective of this study is to characterize postdischarge opioid consumption and prescription patterns in surgical patients. METHODS: A systematic search in MEDLINE and EMBASE identified 11 patient survey studies reporting on postdischarge opioid use in 3525 surgical patients. RESULTS: The studies reported on a variety of surgical operations, including abdominal surgery, orthopedic procedures, tooth extraction, and dermatologic procedures. The majority of patients consumed 15 pills or less postdischarge. The proportion of used opioids ranged from 5.6% to 59.1%, with an outlier of 90.1% in pediatric spinal fusion patients. Measured pain scores of those taking opioids ranged between 2 and 5 out of 10 and the majority of patients were satisfied with their pain control. Seventy percent of patients kept the excess opioids. Where planned disposal methods were reported, between 4% and 59% of patients planned proper disposal. CONCLUSION: This study suggests that surgical patients are using substantially less opioid than prescribed. There is a lack of awareness regarding proper disposal of leftover medication, leaving excess opioid that may be used inappropriately by the patient or others. Education for providers and clinical practice guidelines that provide guidance on prescription of outpatient of opioids are required.

Management of complex polyps of the colon and rectum.

PUPRPOSE: Benign polyps that are technically challenging and unsafe to remove via polypectomy are known as complex polyps. Concerns regarding safety and completeness of resection dictate they undergo advanced endoscopic techniques, such as endoscopic mucosal resection or surgery. We provide a comprehensive overview of complex polyps and current treatment options. METHODS: A review of the English literature was conducted to identifyarticles describing the management of complex polyps of the colon and rectum. RESULTS: Endoscopic mucosal resection is the standard of care for the majority of complex polyps. Only polyps that fail endoscopic mucosal resection or are highly suspicious of invasive cancer but which cannot be removed endoscopically warrant surgery. CONCLUSION: Several factors influence the treatment of a complex polyp; therefore, there cannot be a "one-size-fitsall" approach. Treatment should be tailored to the lesion's characteristics, the risk of adverse events, and the resources available to the treating physician.

Oncologic Outcomes Following Laparoscopic versus Open Resection of pT4 Colon Cancer: A Systematic Review and Meta-analysis.

BACKGROUND: Locally advanced colon cancer is considered a relative contraindication for laparoscopic resection, and clinical trials addressing the oncologic safety are lacking. OBJECTIVE: The aim of this study was to synthesize the oncologic outcomes associated with laparoscopic versus conventional open surgery for locally advanced colon cancers. DATA SOURCES: We systematically searched Medline, Embase, Central, and ClinicalTrials.gov. STUDY SELECTION: Two reviewers independently screened the literature for controlled trials or observational studies comparing curative-intent laparoscopic and open surgery for colon cancer. Studies were included if it was possible to determine outcomes for the T4 colon cancers separately, either reported in the article or calculated with individual patient data. INTERVENTIONS: Included studies were systematically reviewed and assessed for risk of bias. Meta-analyses were done by using random-effects models. MAIN OUTCOME MEASURES: Outcomes of interest were disease-free survival, overall survival, resection margins, and lymph node harvest. RESULTS: Of 2878 identified studies, 5 observational studies met eligibility criteria with a total of 1268 patients (675 laparoscopic, 593 open). There was no significant difference in overall survival (HR, 1.28; 95% CI, 0.94-1.72), disease-free survival (HR, 1.20; 95% CI, 0.90-1.61), or positive surgical margins (OR, 1.16; 95% CI, 0.58-2.32) between the groups. The open group had a larger lymph node retrieval (pooled mean difference, 2.26 nodes; 95% CI, 0.58-3.93). The pooled rate of conversion from laparoscopy to an open procedure was 18.6% (95% CI, 9.3%-27.9%). LIMITATIONS: These results are limited by the inherent selection bias in the included nonrandomized studies. CONCLUSIONS: Based on the available literature, minimally invasive resection of selected locally advanced colon cancer is oncologically safe. There is a small increase in lymph node harvest with open resections, but it is unclear whether this is clinically significant. Surgeons should be prepared for a significant rate of conversion to laparotomy as required to perform en bloc resection.

Comparison of robotic and laparoscopic colorectal resections with respect to 30-day perioperative morbidity.

BACKGROUND: Robotic surgery has emerged as a minimally invasive alternative to traditional laparoscopy. Robotic surgery addresses many of the technical and ergonomic limitations of laparoscopic surgery, but the literature regarding clinical outcomes in colorectal surgery is limited. We sought to compare robotic and laparoscopic colorectal resections with respect to 30-day perioperative outcomes. METHODS: The American College of Surgeons National Surgical Quality Improvement Program database was used to identify all patients who underwent robotic or laparoscopic colorectal surgery in 2013. We performed a logistic regression analysis to compare intraoperative variables and 30-day outcomes. RESULTS: There were 8392 patients who underwent laparoscopic colorectal surgery and 472 patients who underwent robotic colorectal surgery. The robotic cohort had a lower incidence of unplanned intraoperative conversion (9.5% v. 13.7%, p = 0.008). There were no significant differences between robotic and laparoscopic surgery with respect to other intraoperative and postoperative outcomes, such as operative duration, length of stay, postoperative ileus, anastomotic leak, venous thromboembolism, wound infection, cardiac complications and pulmonary complications. On multivariable analysis, robotic surgery was protective for unplanned conversion, while male sex, malignancy, Crohn disease and diverticular disease were all associated with open conversion. CONCLUSION: Robotic colorectal surgery has comparable 30-day perioperative morbidity to laparoscopic surgery and may decrease the rate of intraoperative conversion in select patients.

BACKGROUND: La chirurgie robotique est de plus en plus utilisée comme option de rechange peu effractive à la laparoscopie classique. La robotique permet de remédier à bon nombre des restrictions techniques et ergonomiques de la chirurgie laparoscopique, mais peu d'articles font état des résultats cliniques en chirurgie colorectale. Nous avons donc cherché à comparer les 2 techniques de résection colorectale en ce qui concerne les résultats peropératoires dans les 30 jours suivant l'intervention. METHODS: À l'aide de base de données du National Surgical Quality Improvement Program de l'American College of Surgeons, nous avons recensé tous les patients ayant subi une résection colorectale par chirurgie laparoscopique ou robotique en 2013. Nous avons ensuite mené une analyse de régression logistique pour comparer des variables peropératoires et les résultats après 30 jours. RESULTS: En tout, 8392 patients avaient subi une chirurgie colorectale par laparoscopie pendant la période visée, et 472 avaient subi une intervention par chirurgie robotique. Le second groupe avait une incidence plus faible de conversion peropératoire imprévue (9,5 % par rapport à 13,7 %; p = 0,008). On n'a relevé aucune différence significative entre les 2 types d'intervention quant aux autres résultats peropératoires et postopératoires, soit la durée de l'intervention, la durée du séjour à l'hôpital et la survenue d'un iléus, d'une fuite anastomotique, d'une thromboembolie veineuse, d'une infection de la plaie ou de complications cardiaques ou pulmonaires. D'après l'analyse multivariables, la chirurgie robotique préviendrait les conversions imprévues, tandis que le sexe masculin, la présence d'une tumeur maligne, la maladie de Crohn et la diverticulose colique étaient associés à une conversion peropératoire. CONCLUSION: Les taux de morbidité peropératoire après 30 jours pour une résection colorectale par chirurgie robotique et une intervention par chirurgie laparoscopique sont comparables. La chirurgie robotique pourrait de plus réduire le taux de conversion peropératoire chez certains patients.

Primary linitis plastica of the entire colon in a background of ulcerative colitis: a case report.

We present a case report of colorectal cancer arising in a young patient with ulcerative colitis of only 6 years duration. The pathology was unusual with extensive pancolonic involvement in a lintitis plastica fashion. This case represents a clinical example where colon cancer occurred prior to the onset of recommended screening according to guidelines regarding patients with ulcerative colitis.

Advanced endoscopic resections in the treatment of malignant colorectal lesions: Are early oncological outcomes impacted?

BACKGROUND: Limited data exists on the impact of advanced endoscopic resections on early oncological outcomes of malignant colorectal lesions, especially in the presence of perforation. METHODS: Retrospective chart review of patients who underwent advanced endoscopic resections and had adenocarcinoma was performed. The primary endpoint was cancer recurrence. RESULTS: 63 patients were included. Mean age was 64.6 years with 58.7% of the patients being male. Mean BMI was 30.2 kg/m2 12 patients underwent advanced endoscopic resections followed by surveillance, 5 patients had conversion to surgery due to intra-procedural perforation, and 5 patients due to incomplete resection. 41 patients underwent salvage surgery following a median of 5.4 weeks of initial endoscopic resection. Neither local nor distant recurrence was observed within a median follow-up of 21.2 months. CONCLUSION: Advanced endoscopic procedures do not have negative impact on the early oncological outcomes of patients with malignant colorectal lesions, even in the presence of perforation.

Consensus Statement for the Prescription of Pain Medication at Discharge after Elective Adult Surgery.

This Consensus Statement provides recommendations on the prescription of pain medication at discharge from hospital for opioid-naïve adult patients who undergo elective surgery. It encourages health care providers (surgeons, anesthesiologists, nurses/nurse practitioners, pain teams, pharmacists, allied health professionals, and trainees) to (1) use nonopioid therapies and reduce the prescription of opioids so that fewer opioid pills are available for diversion and (2) educate patients and their families/caregivers about pain management options after surgery to optimize quality of care for postoperative pain. These recommendations apply to opioid-naïve adult patients who undergo elective surgery. This consensus statement is intended for use by health care providers involved in the management and care of surgical patients. A modified Delphi process was used to reach consensus on the recommendations. First, the authors conducted a scoping review of the literature to determine current best practices and existing guidelines. From the available literature and expertise of the authors, a draft list of recommendations was created. Second, the authors asked key stakeholders to review and provide feedback on several drafts of the document and attend an in-person consensus meeting. The modified Delphi stakeholder group included surgeons, anesthesiologists, residents, fellows, nurses, pharmacists, and patients. After multiple iterations, the document was deemed complete. The recommendations are not graded because they are mostly based on consensus rather than evidence.

Cette déclaration de consensus fait des recommandations pour la prescription d'analgésiques à la sortie de l'hôpital pour les patients adultes n'ayant jamais pris d'opiacés et qui subissent une intervention chirurgicale non urgente. Elle encourage les prestataires de soins de santé (chirurgiens, anesthésiologistes, infirmières et infirmiers, infirmières et infirmiers praticiens, équipes antidouleur, pharmaciens, professionnels de la santé et stagiaires) à (1) utiliser des traitements non opiacés et à réduire la prescription d'opiacés afin de réduire le nombre de pilules opiacées pouvant être détournées; et (2) à éduquer les patients, ainsi que leurs familles et soignants, sur les options de prise en charge de la douleur après l'opération afin d'optimiser la qualité des soins pour la douleur postopératoire.Ces recommandations s'appliquent aux patients adultes n'ayant jamais pris d'opioïdes et qui subissent une intervention chirurgicale non urgente. Cette déclaration de consensus est destinée à être utilisée par les prestataires de soins de santé impliqués dans la prise en charge des patients opérés et les soins qui leur sont apportés.Un processus Delphi modifié a été utilisé pour parvenir à un consensus sur les recommandations. Tout d'abord, les auteurs ont procédé à une de la portée de la littérature afin de déterminer les pratiques exemplaires actuelles et les lignes directrices existantes. À partir de la littérature disponible et de l'expertise des auteurs, une liste provisoire de recommandations a été créée. Ensuite, les auteurs ont demandé aux principales parties prenantes d'examiner et de commenter plusieurs versions préliminaires du document et d'assister à une réunion de consensus en personne. Le groupe des parties prenantes du processus Delphi modifié comprenait des chirurgiens, des anesthésiologistes, des résidents, des fellows, des infirmières et infirmiers, des pharmaciens et des patients. Après de multiples itérations, le document a été jugé complet. Les recommandations n'ont pas été notées car elles étaient fondées sur un consensus plutôt que sur des données probantes.

Elective Abdominal Surgery for Inflammatory Bowel Disease.

Elective abdominal surgery for inflammatory bowel disease is common. Surgery for Crohn's disease is not curative, and treatment must be individualized to the disease process. Surgery for ulcerative colitis generally is curative but consideration of patient-specific factors is important for staging of the procedure and determining whether ileal pouch-anal anastomosis is appropriate.

Can congenital pulmonary airway malformation be distinguished from Type I pleuropulmonary blastoma based on clinical and radiological features?

BACKGROUND: The management of congenital cystic lung lesions is controversial. Arguments for routine resection during infancy include the possibility of the lesion being Type I pleuropulmonary blastoma (PPB) rather than a cystic congenital pulmonary airway malformation (CPAM). We aimed to identify clinical and radiological features that might distinguish between CPAM and PPB and to develop a diagnostic algorithm based on these features. METHODS: All recorded cases of Type I PPB were retrieved from the International PPB Registry and compared with an institutional cohort of children undergoing resection of CPAM (2002-2013) that was noted at some stage to be at least partially cystic. Regression models were created to identify variables that might differentiate CPAM from PPB. Odds ratio (OR) and positive predictive value (PPV) were calculated for each variable and a decision algorithm developed. RESULTS: In 112 cases of Type I PPB and 103 of CPAM, factors favoring a diagnosis of CPAM included prenatal detection (OR 89.4), systemic feeding vessel (OR 61.7), asymptomatic (OR 8.0), and hyperinflated lung (OR 6.6). Factors favoring a diagnosis of PPB included bilateral or multisegment involvement (OR 2.4). A decision algorithm that helps to identify lesions requiring resection and those which can be safely observed is presented. CONCLUSION: Clinical and radiological features can help to differentiate between CPAM and PPB. Our algorithm allows identification of children at higher risk of PPB in whom we would recommend resection and those at low risk in whom continued close observation is safe.

Regional variation in the use of surgery in Ontario.

BACKGROUND: Regional variation in the use of surgery implies that there is uncertainty regarding appropriate use. The objectives of this study were to identify which surgical procedures are most commonly performed in the province of Ontario and measure the extent of variation in the use of surgical procedures across Ontario counties. METHODS: We used the Canadian Institute for Health Information Discharge Abstract Database, Same Day Surgery Database and National Ambulatory Care Reporting System to retrieve information on all inpatient and day surgery visits in Ontario between Apr. 1, 2002, and Mar. 31, 2011. We identified the 84 most common procedures according to Canadian Classification of Interventions codes. We calculated rates of use for each procedure throughout the 49 Ontario counties and then calculated measures of variation (quartile ratio and systematic component of variation) in use between the counties. RESULTS: Colonoscopy was the most commonly performed procedure during the study period, with an average adjusted rate of 2012 per 100 000 population. The procedure with the highest measure of variation was iridectomy, with a quartile ratio of 6.7, followed by colposcopy (5.2), cervical biopsy (4.2) and femoral arteriography (4.1). These procedures were less commonly performed. Common procedures such as colonoscopy, cataract extraction and vaginal delivery had lower quartile ratios. Analysis using the systematic component of variation as the measure of variation gave similar results. INTERPRETATION: Colonoscopy was the most commonly performed procedure in Ontario, and cataract extraction was the most common surgical procedure. Procedures with the highest measures of variation between counties tended to be those that occurred less commonly in Ontario, and common procedures were associated with less regional variation.