Objective metrics for hand-sewn bowel anastomoses can differentiate novice from expert surgeons.

BACKGROUND: Assessing performance automatically in a virtual reality trainer or from recorded videos is advantageous but needs validated objective metrics. The purpose of this study is to obtain expert consensus and validate task-specific metrics developed for assessing performance in double-layered end-to-end anastomosis. MATERIALS AND METHODS: Subjects were recruited into expert (PGY 4-5, colorectal surgery residents, and attendings) and novice (PGY 1-3) groups. Weighted average scores of experts for each metric item, completion time, and the total scores computed using global and task-specific metrics were computed for assessment. RESULTS: A total of 43 expert surgeons rated our task-specific metric items with weighted averages ranging from 3.33 to 4.5 on a 5-point Likert scale. A total of 20 subjects (10 novices and 10 experts) participated in validation study. The novice group completed the task significantly more slowly than the experienced group (37.67 ± 7.09 vs 25.47 ± 7.82 min, p = 0.001). In addition, both the global rating scale (23.47 ± 4.28 vs 28.3 ± 3.85, p = 0.016) and the task-specific metrics showed a significant difference in performance between the two groups (38.77 ± 2.83 vs 42.58 ± 4.56 p = 0.027) following partial least-squares (PLS) regression. Furthermore, PLS regression showed that only two metric items (Stay suture tension and Tool handling) could reliably differentiate the performance between the groups (20.41 ± 2.42 vs 24.28 ± 4.09 vs, p = 0.037). CONCLUSIONS: Our study shows that our task-specific metrics have significant discriminant validity and can be used to evaluate the technical skills for this procedure.

Impact of Patient-Reported Penicillin Allergy on Antibiotic Prophylaxis and Surgical Site Infection Among Patients Undergoing Colorectal Surgery.

BACKGROUND: Surgical site infections are a major preventable source of morbidity, mortality, and increased health care expenditures after colorectal surgery. Patients with penicillin allergy may not receive the recommended preoperative antibiotics, putting them at increased risk for surgical site infections. OBJECTIVE: This study aimed to evaluate the impact of patient-reported penicillin allergy on preoperative antibiotic prophylaxis and surgical site infection rates among patients undergoing major colon and rectal procedures. DESIGN: This is a retrospective observational study. SETTING: This study was conducted at a tertiary teaching hospital in Dallas. PATIENTS: Adults undergoing colectomy or proctectomy between July 2012 and July 2019 were included. MAIN OUTCOME MEASURES: The primary outcomes measured were preoperative antibiotic choice and surgical site infection. RESULTS: Among 2198 patients included in the study, 12.26% (n = 307) reported a penicillin allergy. Patients with penicillin allergy were more likely to be white (82%) and female (54%; p < 0.01). The most common type of allergic reaction reported was rash (36.5%), whereas 7.2% of patients reported anaphylaxis. Patients with self-reported penicillin allergy were less likely to receive beta-lactam antibiotics than patients who did not report a penicillin allergy (79.8% vs 96.7%, p < 0.001). Overall, 143 (6.5%) patients had surgical site infections. On multivariable logistic regression, there was no difference in rates of surgical site infection between patients with penicillin allergy vs those without penicillin allergy (adjusted OR 1.14; 95% CI, 0.71-1.82). LIMITATIONS: A limitation of this study was its retrospective study design. CONCLUSIONS: Self-reported penicillin allergy among patients undergoing colorectal surgery is common; however, only a small number of these patients report any serious adverse reactions. Patients with self-reported penicillin allergy are less likely to receive beta-lactam antibiotics and more likely to receive non-beta-lactam antibiotics. However, this does not affect the rate of surgical site infection among these patients, and these patients can be safely prescribed non-beta-lactam antibiotics without negatively impacting surgical site infection rates. See Video Abstract at http://links.lww.com/DCR/B838 .IMPACTO DE LA ALERGIA A LA PENICILINA INFORMADA POR EL PACIENTE EN LA PROFILAXIS ANTIBIÓTICA Y LA INFECCIÓN DEL SITIO OPERATORIO ENTRE PACIENTES DE CIRUGÍA COLORECTAL. ANTECEDENTES: Las infecciones del sitio operatorio son una de las principales fuentes prevenibles de morbilidad, mortalidad y aumento del gasto sanitario después de cirugía colorrectal. Es posible que los pacientes con alergia a la penicilina no reciban los antibióticos preoperatorios recomendados, lo que los pone en mayor riesgo de infecciones en el sitio operatorio. OBJETIVO: Este estudio tuvo como objetivo evaluar el impacto de la alergia a la penicilina informada por el paciente sobre la profilaxis antibiótica preoperatoria y las tasas de infección del sitio operatorio entre pacientes sometidos a procedimientos mayores de colon y recto. DISEO: Estudio observacional retrospectivo. AJUSTE: Hospital universitario terciario en Dallas. PACIENTES: Adultos sometidos a colectomía o proctectomía entre julio de 2012 a julio de 2019. PRINCIPALES MEDIDAS DE DESENLACE: Elección de antibióticos preoperatorios e infección del sitio operatorio. RESULTADOS: Entre los 2198 pacientes incluidos en el estudio, el 12,26% (n = 307) informó alergia a la penicilina. Los pacientes con alergia a la penicilina tenían más probabilidades de ser blancos (82%) y mujeres (54%) ( p < 0,01). El tipo más común de reacción alérgica notificada fue erupción cutánea (36,5%), mientras que el 7,2% de los pacientes notificó anafilaxia. Los pacientes con alergia a la penicilina autoinformada tenían menos probabilidades de recibir antibióticos betalactámicos en comparación con los pacientes que no informaron alergia a la penicilina (79,8% frente a 96,7%, p < 0,001). En general, hubo 143 (6,5%) pacientes con infecciones del sitio operatorio. En la regresión logística multivariable no hubo diferencias en las tasas de infección del sitio operatorio entre los pacientes con alergia a la penicilina frente a los que no tenían alergia a la penicilina (razón de probabilidades ajustada 1,14; intervalo de confianza del 95%, 0,71-1,82). LIMITACIONES: Diseño de estudio retrospectivo. CONCLUSIONES: La alergia a la penicilina autoinformada entre los pacientes de cirugía colorrectal es común, sin embargo, solo un pequeño número de estos pacientes informan reacciones adversas graves. Los pacientes con alergia a la penicilina autoinformada tienen menos probabilidades de recibir antibióticos betalactámicos y más probabilidades de recibir antibióticos no betalactámicos. Sin embargo, esto no afecta la tasa de infección del sitio quirúrgico entre estos pacientes y se les puede recetar de forma segura con antibióticos no betalactámicos sin afectar negativamente las tasas de infección del sitio quirúrgico. Consulte Video Resumen en http://links.lww.com/DCR/B838 . (Traducción-Dr. Juan Carlos Reyes ).

Development of the Breast Surgical Oncology Fellowship in the United States.

The surgical treatment of breast cancer has rapidly evolved over the past 50 years, progressing from Halsted's radical mastectomy to a public campaign of surgical options, aesthetic reconstruction, and patient empowerment. Sparked by the research of Dr. Bernard Fisher and the first National Surgical Adjuvant Breast and Bowel Project trial in 1971, the field of breast surgery underwent significant growth over the next several decades, enabling general surgeons to limit their practices to the breast. High surgical volumes eventually led to the development of the first formal breast surgical oncology fellowship in a large community-based hospital at Baylor University Medical Center in 1982. The establishment of the American Society of Breast Surgeons, as well as several landmark clinical trials and public campaign efforts, further contributed to the advancement of breast surgery. In 2003, the Society of Surgical Oncology (SSO), in partnership with the American Society of Breast Surgeons and the American Society of Breast Disease, approved its first fellowship training program in breast surgical oncology. Since that time, the number of American fellowship programs has increased to approximately 60 programs, focusing not only on training in breast surgery, but also in medical oncology, radiation oncology, pathology, breast imaging, and plastic and reconstructive surgery. This article focuses on the happenings in the United States that led to the transition of breast surgery from a subset of general surgery to its own specialized field.

Perfusion Assessment in Left-Sided/Low Anterior Resection (PILLAR III): A Randomized, Controlled, Parallel, Multicenter Study Assessing Perfusion Outcomes With PINPOINT Near-Infrared Fluorescence Imaging in Low Anterior Resection.

BACKGROUND: Indocyanine green fluoroscopy has been shown to improve anastomotic leak rates in early phase trials. OBJECTIVE: We hypothesized that the use of fluoroscopy to ensure anastomotic perfusion may decrease anastomotic leak after low anterior resection. DESIGN: We performed a 1:1 randomized controlled parallel study. Recruitment of 450 to 1000 patients was planned over 2 years. SETTINGS: This was a multicenter trial. PATIENTS: Included patients were those undergoing resection defined as anastomosis within 10 cm of the anal verge. INTERVENTION: Patients underwent standard evaluation of tissue perfusion versus standard in conjunction with perfusion evaluation using indocyanine green fluoroscopy. MAIN OUTCOME MEASURES: Primary outcome was anastomotic leak, with secondary outcomes of perfusion assessment and the rate of postoperative abscess requiring intervention. RESULTS: This study was concluded early because of decreasing accrual rates. A total of 25 centers recruited 347 patients, of whom 178 were randomly assigned to perfusion and 169 to standard. The groups had comparable tumor-specific and patient-specific demographics. Neoadjuvant chemoradiation was performed in 63.5% of perfusion and 65.7% of standard (p > 0.05). Mean level of anastomosis was 5.2 ± 3.1 cm in perfusion compared with 5.2 ± 3.3 cm in standard (p > 0.05). Sufficient visualization of perfusion was reported in 95.4% of patients in the perfusion group. Postoperative abscess requiring surgical management was reported in 5.7% of perfusion and 4.2% of standard (p = 0.75). Anastomotic leak was reported in 9.0% of perfusion compared with 9.6% of standard (p = 0.37). On multivariate regression analysis, there was no difference in anastomotic leak rates between perfusion and standard (OR = 0.845 (95% CI, 0.375-1.905); p = 0.34). LIMITATIONS: The predetermined sample size to adequately reduce the risk of type II error was not achieved. CONCLUSIONS: Successful visualization of perfusion can be achieved with indocyanine green fluoroscopy. However, no difference in anastomotic leak rates was observed between patients who underwent perfusion assessment versus standard surgical technique. In experienced hands, the addition of routine indocyanine green fluoroscopy to standard practice adds no evident clinical benefit. See Video Abstract at http://links.lww.com/DCR/B560. VALORACIN DE LA IRRIGACIN DE LADO IZQUIERDO/RESECCIN ANTERIOR BAJA PILAR III UN ESTUDIO ALEATORIZADO, CONTROLADO, PARALELO Y MULTICNTRICO QUE EVALA LOS RESULTADOS DE LA IRRIGACIN CON PINPOINT IMGENES DE FLUORESCENCIA CERCANA AL INFRARROJO EN LA RESECCIN ANTERIOR BAJA: ANTECEDENTES:Se ha demostrado que la fluoroscopia con verde de indocianina mejora las tasas de fuga anastomótica en ensayos en fases iniciales.OBJETIVO:Nuestra hipótesis es que la utilización de fluoroscopia para asegurar la irrigación anastomótica puede disminuir la fuga anastomótica luego de una resección anterior baja.DISEÑO:Realizamos un estudio paralelo, controlado, aleatorizado 1:1. Se planificó el reclutamiento de 450-1000 pacientes durante 2 años.AMBITO:Multicéntrico.PACIENTES:Pacientes sometidos a resección definida como una anastomosis dentro de los 10cm del margen anal.INTERVENCIÓN:Pacientes que se sometieron a la evaluación estándar de la irrigación tisular contra la estándar en conjunto con la valoración de la irrigación mediante fluoroscopia con verde indocianina.PRINCIPALES VARIABLES EVALUADAS:El principal resultado fue la fuga anastomótica, y los resultados secundarios fueron la evaluación de la perfusión y la tasa de absceso posoperatorio que requirió intervención.RESULTADOS:Este estudio se cerró anticipadamente debido a la disminución de las tasas de acumulación. Un total de 25 centros reclutaron a 347 pacientes, de los cuales 178 fueron, de manera aleatoria, asignados a perfusión y 169 a estándar. Los grupos tenían datos demográficos específicos del tumor y del paciente similares. Recibieron quimio-radioterapia neoadyuvante el 63,5% de la perfusión y el 65,7% del estándar (p> 0,05). La anastomosis estuvo en un nivel promedio de 5,2 + 3,1 cm en perfusión en comparación con 5,2 + 3,3 cm en estándar (p> 0,05). Se reportó una visualización suficiente de la perfusión en el 95,4% de los pacientes del grupo de perfusión. El absceso posoperatorio que requirió tratamiento quirúrgico fue de 5,7% de los perfusion y en el 4,2% del estándar (p = 0,75). Se informó fuga anastomótica en el 9,0% de la perfusión en comparación con el 9,6% del estándar (p = 0,37). En el análisis de regresión multivariante, no hubo diferencias en las tasas de fuga anastomótica entre la perfusión y el estándar (OR 0,845; IC del 95% (0,375; 1,905); p = 0,34).LIMITACIONES:No se logró el tamaño de muestra predeterminado para reducir satisfactoriamente el riesgo de error tipo II.CONCLUSIÓN:Se puede obtener una visualización adecuada de la perfusión con ICG-F. Sin embargo, no se observaron diferencias en las tasas de fuga anastomótica entre los pacientes que se sometieron a evaluación de la perfusión versus la técnica quirúrgica estándar. En manos expertas, agregar ICG-F a la rutina de la práctica estándar no agrega ningún beneficio clínico evidente. Consulte Video Resumen en http://links.lww.com/DCR/B560. (Traducción-Dr Juan Antonio Villanueva-Herrero).

How to Develop a Leadership Training Program.

Leadership training is an essential component of faculty development and resident training. Characteristics of leaders include growth mindset, curiosity, humility, selflessness, intrinsic motivation, hunger to achieve, insight, collaboration, harmony, introversion and analytical approach (inherited) and emotional intelligence, empathy, flexibility, adaptability, conflict management, resilience, interpersonal skills, and judgment (learned). Training for each of these characteristics will enhance the leadership abilities of the surgical department.

Leadership in the Setting of the Operating Room Surgical Team.

Leadership in the operating room requires the ability to adopt different styles under specific circumstances. Transformational leadership grows the team. The style used to guide the team can vary; coercive, visionary, affiliative, democratic, pacesetting, and coaching are all important styles in team leadership. The ability to adapt to different needs in the operating room by using the appropriate style is leadership.

Why is the Surgical Leader also a Manager?

The surgeon acts as a manager in the operating room, ward, classroom, and in daily life to control time. Skills cross all boundaries of medicine with specific needs in each area. Without leadership skills the nonmedical aspect of practice becomes more difficult and can make the physician less successful. Learning to manage, therefore, becomes critical.

Leadership and Ethics: Virtue Ethics as a Model for Leadership Development.

Leaders are held to the highest of standards in both performance and ethics. The same is true for leaders in medicine. Thus, medical leaders must give attention to ethical development as well as performance development. Virtue ethics provide a way for the leader to develop ethically. Virtue ethics is the oldest form of ethics. Although other ethical approaches focus on external considerations, virtue ethics focuses on the inward development of character. Following the examples of virtuous people and developing habits of virtue are critical with this approach. The cardinal virtues of prudence, courage, temperance, and justice are considered the most important. Specific virtue lists have also been developed for medical practitioners. All of these virtues can contribute to the enhancement of leadership skills. The virtue approach is especially helpful for leaders because it motivates one to excel in whatever endeavor pursued, whether medicine, leadership, relationships, or life.

Leadership in Surgical Residency.

Surgical training can be compared with a functioning military unit with chain of command, responsibility/accountability relationship, and graduated leadership assignments. Proficiency, commitment, communication, consistency, ownership, relationships, confidence, humility, feedback and evaluation, exemplary behavior, empathy, and humanity are all aspects of leadership. Leadership skills developed in the protected environment of residency are the basis for a successful career.

Informal Leadership in Health Care.

Informal leaders in nursing, medical specialties, and administration positively impact the success of an institution. Developing all members of the team as leader then becomes important, especially in the area of nursing. The result is less need for management and control and more individual self-motivated participation in quality improvement.

Types of Leadership and How to Use Them in Surgical Areas.

Surgery is a very complex, changing, and, sometimes, threatening environment. Emotional intelligence is a key skill for surgical leaders. Authoritarian, hierarchical, transactional, transformational, adaptive, situational, and servant-shepherd leadership can all be used in surgical leadership. Patient care must be the priority for surgical leaders.

Women in Leadership.

The role of a surgeon is inherently that of a leader and as women become a larger minority in surgical specialties, the next step becomes greater representation of women in positions of surgical leadership. Leadership is a relationship of granting and claiming wherein society must accept that women are deserving of leadership and women must realize their rightfulness to lead. Implicit gender bias undermines this relationship by perpetuating traditional gender norms of women as followers and not as leaders. Though female representation in academia and leadership has increased over the past few decades, this process is unacceptably slow, in part due to manifestations of implicit bias including discrimination within academia, pay inequality, and lack of societal support for childbearing and childcare. The women who have achieved leadership roles are testament to woman's rightfulness to lead and their presence serves to encourage other young professional women that success is possible despite these challenges.

Linking Emotional Intelligence to Successful Health Care Leadership: The Big Five Model of Personality.

Research has identified emotional intelligence as the ability to understand and manage emotions. This is especially important for surgical leaders who must interact constructively with teams, administrators, patients, colleagues, and the community. Conventional intelligence emphasizes the rational and analytical brain. When one becomes aware of emotional intelligence, it adds to the repertoire of the surgical leader. It gives them insight into the dynamics of interpersonal relationships. This will allow the surgeon to control the emotional side of communication. Specifically, emotional intelligence focuses on self-awareness, self-management, social skills, and resiliency. With these skills, they are able to modulate their leadership style, allowing for increased conflict management and persuasiveness, more effective change management, and consensus-building. Emotional intelligence is not innate; these are learned skills. With practice and attention, it is possible to acquire the skills to enhance relationships.

Surgical Leadership.

There are few topics of more importance in health care today than surgical leadership. The surgical leader will need to organize and maintain a collective effort if the organization is going to be effective. Health care teams work in a volatile, uncertain, complex, and ambiguous ecosystem. Therefore, surgeons must develop skills beyond the operating room. The facilitative leader will lead from the middle, not the top. They will empower coworkers to participate in creating a vision by building consensus, developing teams, clarifying roles, and earning the loyalty and trust of their colleagues. Surgical leaders will use communication as the vehicle for their success, including intentional listening, asking open-ended questions, and creating dialog instead of argumentative exchanges. The future of health care belongs to the physicians who are investing the time and effort today to become leaders.

Immersive virtual reality-based training improves response in a simulated operating room fire scenario.

BACKGROUND: SAGES FUSE curriculum provides didactic knowledge on OR fire prevention. The objective of this study is to evaluate the impact of an immersive virtual reality (VR)-based OR fire training simulation system in combination with FUSE didactics. METHODS: The study compared a control with a simulation group. After a pre-test questionnaire that assessed the baseline knowledge, both groups were given didactic material that consists of a 10-min presentation and reading materials about precautions and stopping an OR fire from the FUSE manual. The simulation group practiced on the OR fire simulation for one session that consisted of five trials within a week from the pre-test. One week later, both groups were reassessed using a questionnaire. A week after the post-test both groups also participated in a simulated OR fire scenario while their performance was videotaped for assessment. RESULTS: A total of 20 subjects (ten per group) participated in this IRB approved study. Median test scores for the control group increased from 5.5 to 9.00 (p = 0.011) and for the simulation group it increased from 5.0 to 8.5 (p = 0.005). Both groups started at the same baseline (pre-test, p = 0.529) and reached similar level in cognitive knowledge (post-test, p = 0.853). However, when tested in the mock OR fire scenario, 70% of the simulation group subjects were able to perform the correct sequence of steps in extinguishing the simulated fire whereas only 20% subjects in the control group were able to do so (p = 0.003). The simulation group was better than control group in correctly identifying the oxidizer (p = 0.03) and ignition source (p = 0.014). CONCLUSIONS: Interactive VR-based hands-on training was found to be a relatively inexpensive and effective mode for teaching OR fire prevention and management scenarios.

Development of The American Society of Colon and Rectal Surgeons' Rectal Cancer Surgery Checklist.

BACKGROUND: There is excellent evidence that surgical safety checklists contribute to decreased morbidity and mortality. OBJECTIVE: The purpose of this study was to develop a surgical checklist composed of the key phases of care for patients with rectal cancer. DESIGN: A consensus-oriented decision-making model involving iterative input from subject matter experts under the auspices of The American Society of Colon and Rectal Surgeons was designed. SETTINGS: The study was conducted through meetings and discussion to consensus. PATIENTS: Patient data were extracted from an initial literature review. MAIN OUTCOME MEASURES: The checklist was measured by its ability to improve care in complex rectal surgery cases by reducing the possibility of omission through the division of treatment into 3 distinct phases. RESULTS: The process generated a 25-item checklist covering the spectrum of care for patients with rectal cancer who were undergoing surgery. LIMITATIONS: The study was limited by its lack of prospective validation. CONCLUSIONS: The American Society of Colon and Rectal Surgeons rectal cancer surgery checklist is composed of the essential elements of preoperative, intraoperative, and postoperative care that must be addressed during the surgical treatment of patients with rectal cancer.

Impaired outcome colitis-associated rectal cancer versus sporadic cancer.

BACKGROUND: The surgical management of colitis-associated rectal cancer (CARC) is not well defined. This study determines outcomes after surgery for CARC compared with sporadic rectal cancer. MATERIALS AND METHODS: This is a retrospective cohort study comparing 27 patients with CARC with 54 matched patients with sporadic cancer. Matching criteria included age, gender, neoadjuvant chemoradiation, and American Joint Committee on Cancer stage. Outcome measures were disease-free and overall survival, tumor characteristics, and postoperative morbidity. RESULTS: Compared to those with sporadic rectal cancer, patients with CARC underwent proctocolectomy more frequently (21 [78%] versus 6 [22%] P < 0.001) and were more likely to have mucinous tumors (11 [40.7%] versus 12 [22.3%] P = 0.03). Overall 3-y survival was significantly reduced in CARC patients compared with patients with sporadic rectal cancer. Those with CARC undergoing segmental proctectomy only demonstrated reduced overall and disease-free survival compared to patients with sporadic rectal cancer and to colitis patients undergoing proctocolectomy (P = 0.002). CONCLUSIONS: Patients with CARC undergoing proctectomy demonstrate reduced disease-free survival versus those undergoing proctocolectomy, and versus patients with sporadic rectal cancer undergoing proctectomy. These findings warrant further study and suggest that proctocolectomy should be considered the preferred surgical approach for CARC.

The impact of bowel preparation on the severity of anastomotic leak in colon cancer patients.

BACKGROUND AND OBJECTIVES: The routine use of preoperative bowel preparation (BP) is heavily debated in the colorectal surgery literature. To date, no study has investigated the effect preoperative BP has on patients with an established anastomotic leak. We therefore seek to compare the severity of patient morbidity and mortality in patients with a known anastomotic leak based on type of preoperative BP using the Targeted Colectomy American College of Surgeons National Surgery Quality Improvement Program (ACS-NSQIP). METHODS: All elective colon cancer operations performed with primary anastomosis were identified within the targeted colectomy database from 2012 to 2013. Patients who experienced a postoperative anastomotic leak were identified and stratified based on preoperative BP. Variables that had an association with mechanical BP at P < 0.10 were included in a multivariate logistic regression model to determine if BP was independently associated with postoperative morbidity and mortality. RESULTS: A total of 6,297 patients underwent elective colon resection with primary anastomosis for colon cancer. Two hundred and nineteen (3.5%) patients experienced an anastomotic leak. Thirty-day wound morbidity and mortality was not worse in patients who underwent preoperative BP. CONCLUSIONS: BP is not associated with worse patients outcomes in those patients with an established anastomotic leak following elective colon research with primary anastomosis. J. Surg. Oncol. 2016;114:810-813. © 2016 2016 Wiley Periodicals, Inc.

The use of endoluminal vacuum (E-Vac) therapy in the management of upper gastrointestinal leaks and perforations.

INTRODUCTION: Upper intestinal leaks and perforations are associated with high morbidity and mortality rates. Despite the growing experience using endoscopically placed stents, the treatment of these leaks and perforations remain a challenge. Endoluminal vacuum (E-Vac) therapy is a novel treatment that has been successfully used in Germany to treat upper gastrointestinal leaks and perforations. There currently are no reports on its use in the USA. METHODS: E-Vac therapy was used to treat 11 patients with upper gastrointestinal leaks and perforations from September 2013 to September 2014. Five patients with leaks following sleeve gastrectomy were excluded from this study. A total of six patients were treated with E-Vac therapy; these included: (n = 2) iatrogenic esophageal perforations, (n = 1) iatrogenic esophageal and gastric perforations, (n = 1) iatrogenic gastric perforation, (n = 1) gastric staple line leak following a surgical repair of a traumatic gastric perforation, and (n = 1) esophageal perforation due to an invasive fungal infection. Four patients had failed an initial surgical repair prior to starting E-Vac therapy. RESULTS: All six patients (100 %) had complete closure of their perforation or leak after an average of 35.8 days of E-Vac therapy requiring 7.2 different E-Vac changes. No deaths occurred in the 30 days following E-Vac therapy. One patient died following complete closure of his perforation and transfer to an acute care facility due to an unrelated complication. There were no complications directly related to the use of E-Vac therapy. Only one patient had any symptoms of dysphagia. This patient had severe dysphagia from an esophagogastric anastomotic stricture prior to her iatrogenic perforations. Following E-Vac therapy, her dysphagia had actually improved and she could now tolerate a soft diet. CONCLUSIONS: E-Vac therapy is a promising new method in the treatment of upper gastrointestinal leaks and perforations. Current successes need to be validated through future prospective controlled studies.

High Rate of Positive Circumferential Resection Margins Following Rectal Cancer Surgery: A Call to Action.

OBJECTIVES: To identify predictors of positive circumferential resection margin following rectal cancer resection in the United States. BACKGROUND: Positive circumferential resection margin is associated with a high rate of local recurrence and poor morbidity and mortality for rectal cancer patients. Prior study has shown poor compliance with national rectal cancer guidelines, but whether this finding is reflected in patient outcomes has yet to be shown. METHODS: Patients who underwent resection for stage I-III rectal cancer were identified from the 2010-2011 National Cancer Database. The primary outcome was a positive circumferential resection margin. The relationship between patient, hospital, tumor, and treatment-related characteristics was analyzed using bivariate and multivariate analysis. RESULTS: A positive circumferential resection margin was noted in 2859 (17.2%) of the 16,619 patients included. Facility location, clinical T and N stage, histologic type, tumor size, tumor grade, lymphovascular invasion, perineural invasion, type of operation, and operative approach were significant predictors of positive circumferential resection margin on multivariable analysis. Total proctectomy had nearly a 30% increased risk of positive margin compared with partial proctectomy (OR 1.293, 95%CI 1.185-1.411) and a laparoscopic approach had nearly 22% less risk of a positive circumferential resection margin compared with an open approach (OR 0.882, 95%CI 0.790-0.985). CONCLUSIONS: Despite advances in surgical technique and multimodality therapy, rates of positive circumferential resection margin remain high in the United States. Several tumor and treatment characteristics were identified as independent risk factors, and advances in rectal cancer care are necessary to approach the outcomes seen in other countries.