Robotic left-stapled total intracorporeal bowel anastomosis versus stapled partial extracorporeal anastomosis: operative technical description and outcomes.

BACKGROUND: Although there is extensive literature on robotic total intracorporeal anastomosis (TICA) for right colon resection, left total ICA using the da Vinci Xi robotic platform has only been described in short case series previously. In this study, we report on the largest cohort of robotic left total ICA, provide a description of our institution's techniques, and compare outcomes to robotic left partial extracorporeal anastomosis (PECA). METHODS: Patients who underwent robotic left colectomy for any underlying pathology from July 1, 2016 through April 30, 2020 were identified by procedure code. A technical description is provided for two unique techniques performed at our institution. Outcomes included operative time, length of stay, supply cost, post-operative ileus, post-operative morbidity and mortality and need for complete mobilization of the splenic flexure. RESULTS: From a review of our institution's data, 83 robotic TICA cases were identified and 76 robotic PECA cases were identified. Common procedures included low anterior resection, sigmoidectomy, left hemicolectomy, and rectopexy with resection. TICA was associated with significantly shorter intraoperative time compared to PECA. CONCLUSIONS: Our series shows that TICA is a safe and feasible technique that does not increase the risk of adverse outcomes. Using either the anvil-forward or anvil-backward technique, we were able to reliably reproduce this method in a total of 83 patients undergoing left colon resection for either benign or malignant diseases.

Experience with 10 years of a robotic surgery program at an Academic Medical Center.

BACKGROUND: Few studies have examined robotic surgery from a programmatic standpoint, yet this is how hospitals evaluate return on investment clinically and fiscally. This study examines the 10-year experience of a robotic program at a single academic institution. STUDY DESIGN: All robotic operations performed at our institution from August 2005 to December 2016 were reviewed. Data were collected from the robotic system and hospital databases. RESULTS: A total of 3485 robotic operations were performed. Yearly case volume nearly quadrupled. There have been 37 robotic-trained surgeons in 5 specialties performing 53 different operations. Rate of conversion to open was 4.2%. American Society of Anesthesiologists (ASA) class increased over time, with ASA class 3 increasing from 20% of patients to 45% of patients. Average case time in 2005 was 453 min, but decreased by 46% to 246 min by 2007, then remained relatively stable (range 226-247). Operating efficiency improved, with room time and case time decreasing by 9% in the past 4 years. Average cost for robotic supplies was $1519 per case. Additional costs per case related to equipment and contracts totaled an average of $11,822. Average length of stay (LOS) for robotic cases was 3.3 days, compared to 3.0 days for laparoscopic and 7.0 for open. Cost per day for admission after robotic surgery was 1.7 times greater than the cost of open or laparoscopic surgery. Total admission costs of robotic operations were 1.5 times those of laparoscopic surgery, but less than open operations. Readmissions following robotic cases were lower than open (15% v 26%, p < 0.0001). CONCLUSIONS: Over 10 years, the use of robotic technology has grown significantly at our institution, with good fiscal and clinical outcomes. Operating room costs are high; however, efficiency has improved, LOS is shorter, admission costs are lower than open operations, and readmission rates are lower.

Multiquadrant surgery in the robotic era: a technical description and outcomes for da Vinci Xi robotic subtotal colectomy and total proctocolectomy.

BACKGROUND: Common colorectal procedures that require access to all quadrants of the abdomen are subtotal colectomy (STC) and total proctocolectomy (TPC). These are frequently performed with a surgical robot, but multiquadrant operations have unique challenges during robot-assisted surgery. METHODS: Patients who underwent robotic STC or TPC with the da Vinci Xi surgical robot at our institution from July 1, 2016 through June 30, 2019 were identified by diagnosis and procedure codes. A technical description is provided for the techniques utilized at our institution. Outcomes included operative times (OT), supply cost and length of stay. Associated morbidity and mortality was also analyzed. RESULTS: From a review of our institution's robotic surgery data, 37 cases were identified that utilized the described technique. Of these cases, 21 were robotic STC and 16 were TPC. Total mean OT was 276.86 min (SD ± 119.49). Mean OT was further analyzed by year, which demonstrated an overall decrease in OT from 350.91 min (SD ± 46.38) in 2016 to 221.43 min (SD ± 16.46) in 2018 (p = 0.008). A total of 21 cases were performed prior to 2018. Overall OT for STC was 222.81 min (SD ± 14.54) compared to overall TPC OT 347.81 min (SD ± 34.35). Median length of stay was 5 days [25th and 75th percentiles 4, 6, respectively]. There was no 30-day mortality and only one return to operating room for mesenteric bleeding. There was a low risk of mortality associated with this technique. CONCLUSIONS: The current study provides the largest cohort of patients assessed who have undergone multiquadrant robotic STC or TPC. The study provides a detailed description of the technique utilized at our institution. There was no associated 30-day mortality and a low risk of morbidity. The data suggest that the learning curve for improved operative time is between 15 and 20 cases.

General surgery training in the era of robotic surgery: a qualitative analysis of perceptions from resident and attending surgeons.

BACKGROUND: The use of the surgical robot has increased annually since its introduction, especially in general surgery. Despite the tremendous increase in utilization, there are currently no validated curricula to train residents in robotic surgery, and the effects of robotic surgery on general surgery residency training are not well defined. In this study, we aim to explore the perceptions of resident and attending surgeons toward robotic surgery education in general surgery residency training. METHODS: We performed a qualitative thematic analysis of in-person, one-on-one, semi-structured interviews with general surgery residents and attending surgeons at a large academic health system. Convenient and purposeful sampling was performed in order to ensure diverse demographics, experiences, and opinions were represented. Data were analyzed continuously, and interviews were conducted until thematic saturation was reached, which occurred after 20 residents and seven attendings. RESULTS: All interviewees agreed that dual consoles are necessary to maximize the teaching potential of the robotic platform, and the importance of simulation and simulators in robotic surgery education is paramount. However, further work to ensure proper access to simulation resources for residents is necessary. While most recognize that bedside-assist skills are essential, most think its educational value plateaus quickly. Lastly, residents believe that earlier exposure to robotic surgery is necessary and that almost every case has a portion that is level-appropriate for residents to perform on the robot. CONCLUSIONS: As robotic surgery transitions from novelty to ubiquity, the importance of effective general surgery robotic surgery training during residency is paramount. Through in-depth interviews, this study provides examples of effective educational tools and techniques, highlights the importance of simulation, and explores opinions regarding the role of the resident in robotic surgery education. We hope the insights gained from this study can be used to develop and/or refine robotic surgery curricula.

Frequent rectal gastrointestinal stromal tumor recurrences in the imatinib era: Retrospective analysis of an International Patient Registry.

INTRODUCTION: Rectal gastrointestinal stromal tumor (GIST) is rare and comprises about 3% of GIST. METHODS: Registry data was collected by the Life Raft Group June 1976 to November 2017. All patients had a histologic GIST diagnosis. Demographic, clinicopathologic, and clinical outcome data were patient reported. Recurrence-free survival (RFS) was analyzed using the Kaplan-Meier method and Cox regression analysis. RESULTS: Of 1798 patients in the database, 48 had localized rectal GIST (2.7%). Patients were frequently male (58.3%) and non-Hispanic whites (58.3%). Median age at diagnosis was 52 years. Most patients (77%) were diagnosed in the imatinib era (2001 to current). Over half (54.2%) of the cohort had mutation testing and all profiled tumors possessed KIT mutations (exon 9: 7.7%, exon 11: 88.5%, and exon 13: 3.8%). Most evaluable patients (26/28; 92.9%) had high-risk disease (modified NIH criteria) and nearly all patients (95.8%) received imatinib. Median follow-up was 8.8 years (range, 0.3-30.7) and overall RFS was 8.0 years (95% CI, 2.9-13.1). Thirty-two percent (12/37) of patients in the post-imatinib era developed recurrent disease. Diagnosis in the imatinib era was associated with improved RFS (HR = 0.22, 95% CI, 0.08-0.62; P = .004) in the multivariable model. CONCLUSION: We find that disease recurrence remains prevalent in one-third of patients treated during the imatinib-era.

Robotic transanal minimally invasive surgery (TAMIS) with the newest robotic surgical platform: a multi-institutional North American experience.

BACKGROUND: Transanal minimally invasive surgery (TAMIS) offers intra-luminal full-thickness excision of rectal neoplasia. Robotic TAMIS (RT) allows for greater versatility in motion while operating in the limited space of the rectum. We present our experience with this technique in practice using the DaVinci Xi™ platform. METHOD: This is a multi-institutional retrospective analysis for patient undergoing Robotic TAMIS for resection of rectal lesions at two tertiary referral hospitals in the United States. Morbidity, mortality, anatomic measurement, and final pathology were analyzed. RESULTS: Thirty-four patients planned for Robotic TAMIS were identified. Average follow-up was 188 days. The average BMI was 29.5 ± 5.9. All patients had an American Society of Anesthesiologist (ASA) Class of 2 or greater and 21 (62%) were ASA 3 or greater. Rectal lesions located from 2 to 15 cm from the dentate line were successfully resected. Lesions up to 4.5 cm in the longest dimension were successfully resected. The average operative time was 100 ± 70 min, which correlated to a robotic console time of 76 ± 67 min. Patients were placed in Lithotomy in 32 (94%) cases and were prone in only 2 (6%) cases. There were no intraoperative complications or conversions to another technique. The only postoperative complication was a medically managed Clostridium difficile infection in 1 patient. Three patients were upstaged to T2 on final pathology and underwent successful formal resections. BMI was a statistically significant predictor of a longer operation. CONCLUSIONS: With increased reach and operative range of motion, Robotic TAMIS is a safe and effective method for excising low-risk rectal neoplasia with a wide range of anatomical measurements. Higher BMI is a significant predictor of a longer and likely more challenging operation.

Preoperative malnutrition with mild hypoalbuminemia associated with postoperative mortality and morbidity of colorectal cancer: a propensity score matching study.

BACKGROUND: Malnutrition with hypoalbuminemia (albumin < 35 g/L) is an important factor in predicting risks associated with colorectal cancer surgery. However, there is limited data about the effects of mild hypoalbuminemia with small decreases in albumin on postoperative complications. METHODS: This is a retrospective study using the multi-institutional, nationally validated database of the American College of Surgeons-National Surgical Quality Improvement Program (ACS-NSQIP) to investigate mild hypoalbuminemia and its association with postoperative mortality and morbidity by using a propensity score matching method. RESULTS: In a group of 30,676 colorectal cancer patients who received surgery, 5230 had mild hypoalbuminemia (< 35 and > =30 g/L) and 21,310 had normal albumin levels (> = 35 g/L). Significant differences were noted in 21 clinical characteristics between the two groups. After 1:2 propensity score matching postoperative mortality was significantly associated with mild hypoalbuminemia (OR = 1.74; p < 0.001). There were significant associations between mild hypoalbuminemia and 11 postoperative morbidities including deep vein thrombosis, pulmonary embolism, superficial and deep surgical site infection, pneumonia, septic shock, ventilator> 48 h, blood transfusion, return to operating room, stroke and re-intubation. Mild hypoalbuminemia was also associated with overall complication (B = 0.064, p < 0.001) and length of total hospital stay (B = 2.236, p < 0.001). CONCLUSIONS: In colorectal cancer, this is the first propensity score matching study of malnutrition with mild hypoalbuminemia which demonstrates that a mild decrease in serum albumin contributes significantly to poor postoperative outcome.

Association of dialysis with adverse postoperative outcomes in colorectal cancer-an analysis of ACS-NSQIP.

PURPOSE: Dialysis is an important factor in predicting the risk associated with cardiovascular and general abdominal surgery. The association between cancer patients and dialysis was also studied, and in particular, the effects of dialysis on the postoperative outcomes of colorectal cancer which has not been widely reported in the literature. METHODS: This is a retrospective, multi-institutional study of the American College of Surgeons-National Surgical Quality Improvement Program (ACS-NSQIP) database, investigating preoperative dialysis status and its association with postoperative mortality and morbidity. RESULTS: Among 42,403 colorectal cancer patients, 265 patients (0.6 %) were receiving dialysis. Patients undergoing dialysis had a higher risk of re-intubation (6.8 %, p < 0.001), on ventilator-support more than 48 h (7.2 %, p < 0.001), and sepsis (7.2 %, p < 0.05). Deep surgical site infection (adjusted odds ratio = 2.09), pneumonia (adjusted odds ratio = 1.86), and septic shock (adjusted odds ratio = 1.9) were significantly associated with dialysis status. The postoperative mortality rate of dialysis patients was 8.3 % (p < 0.001) and had significant association in a multivariate Cox proportional hazard model (hazard ratio = 1.63, p = 0.026). Total length of hospital stay (coefficient = 3.5, p < 0.001) and overall complication (coefficient = 0.134, p < 0.001) were prominent in the dialysis groups. The rate of laparoscopic surgery in dialysis and non-dialysis patients was 33 and 42 %, respectively (odds ratio = 0.693, p = 0.005). CONCLUSIONS: In colorectal cancer, dialysis status significantly contributes to postoperative morbidity, length of total hospital stay, and mortality. In addition, the rates of preventable infection and pulmonary complications were shown to require more careful attention in the hospital setting, and particularly in dialysis patients. Preoperative dialysis patients are less likely than non-dialysis patients to undergo a minimally invasive approach.

Preoperative malnutrition assessments as predictors of postoperative mortality and morbidity in colorectal cancer: an analysis of ACS-NSQIP.

BACKGROUND: Nutritional status is an important factor in predicting the risk associated with surgery for cancer patients. This is especially true in colorectal cancer. Many nutritional assessments are used in clinical practice, but those assessments are rarely evaluated for their ability to predict postoperative outcome. METHODS: This is a retrospective, multi-institutional study of the ACS-NSQIP database, investigating preoperative nutrition status and its association with postoperative mortality and morbidity. RESULTS: The prevalence of malnutrition is higher in colorectal cancer, when compared with other most common cancers. Among 42,483 colorectal cancer patients postoperative mortality was significantly associated with hypoalbuminemia (hazard ratio = 3.064, p < 0.001), body weight loss (hazard ratio = 1.229, p = 0.033) and body mass index of <18.5 kg/m(2) (hazard ratio = 1.797, p < 0.001). Only hypoalbuminemia significantly predicted all postoperative complications, even in further multivariate logistic regression analyses (p < 0.001). Multiple regression analysis showed that the hypoalbuminemia group had the highest coefficient in significant association with length of total hospital stay (B = 3.585, p < 0.001) and overall complication (B = 0.119, p < 0.001). CONCLUSIONS: In colorectal cancer, malnutrition significantly contributes to postoperative mortality, morbidity and length of total hospital stay. Hypoalbuminemia, with levels below 3.5 g/dl, serves as an excellent assessment tool and preoperative predictor of postoperative outcomes.

Risk Factors Associated with Postoperative Outcomes in Diverticular Disease Undergoing Elective Colectomy-A Retrospective Cohort Study from the ACS-NSQIP Database.

Recommendations for elective colectomies after recovery from uncomplicated acute diverticulitis should be individualized. The kinds of associated risk factors that should be considered for this approach remain undetermined. The aim of this study was to identify the risk factors associated with postoperative outcomes in patients with diverticular disease after receiving an elective colectomy. This is a retrospective study using the multi-institutional, nationally validated database of the American College of Surgeons-National Surgical Quality Improvement Program (ACS-NSQIP). The patients who were diagnosed with diverticular disease and received an elective colectomy were included in our risk factor analyses. Postoperative mortality, morbidity, and overall complications were measured. Univariate and multivariate analyses were used to demonstrate the risk factors. We analyzed 30,468 patients with diverticular disease, 67% of whom received an elective colectomy. The rate of 30-day mortality was 0.2%, and superficial surgical site infection was the most common postoperative morbidity (7.2%) in the elective colectomies. The independent risk factors associated with overall complications were age ≥ 75, BMI ≥ 30, smoking status, dyspnea, hypertension, current kidney dialysis, chronic steroid use, ASA III, and open colectomy. In laparoscopic colectomy, 67.5% of the elective colectomies, the associated risk factors associated with overall complications still included age ≥ 75, smoking, hypertension, chronic steroid use, and ASA III. Identification of patient-specific risk factors may inform the decision-making process for elective colectomy and reduce the postoperative complications after mitigation of those risk factors.

Autologous Fat Grafting: an Emerging Treatment Option for Complex Anal Fistulas.

BACKGROUND: Autologous fat grafting (AFG) has shown promise in the treatment of complex wounds, with trials reporting good healing rates and safety profile. We aim to investigate the role of AFG in managing complex anorectal fistulas. METHODS: This was a retrospective review of a prospectively maintained IRB-approved database. We examined the rates of symptom improvement, clinical closure of fistula tracts, recurrence, complications, and worsening fecal incontinence. Perianal disease activity index (PDAI) was obtained for patients undergoing combination of AFG and fistula plug treatment. RESULTS: In total, 52 unique patients underwent 81 procedures, of which Crohn's was present in 34 (65.4%) patients. The majority of patients previously underwent more common treatments such as endorectal advancement flap or ligation of intersphincteric fistula tract. Fat-harvesting sites and processing technique were selected by the plastic surgeons based on availability of trunk fat deposits. When analyzing patients by their last procedure, 41 (80.4%) experienced symptom improvement, and 29 (64.4%) experienced clinical closure of all fistula tracts. Recurrence rate was 40.4%, and complication rate was 15.4% (7 postoperative abscesses requiring I&D and 1 bleeding episode ligated at bedside). The abdomen was the most common site of lipoaspirate harvest at 63%, but extremities were occasionally used. There were no statistically significant differences in outcomes when comparing single graft treatment to multiple treatments, Crohn's and non-Crohn's, different methods of fat preparation, and diversion. CONCLUSION: AFG is a versatile procedure that can be done in conjunction with other therapies and does not interfere with future treatments if recurrence occurs. It is a promising and affordable method to safely address complex fistulas.

Outcomes for a Large Cohort of Patients with Rectal Neuroendocrine Tumors: an Analysis of the National Cancer Database.

BACKGROUND: Rectal neuroendocrine tumors comprise 20% of neuroendocrine tumors in the alimentary tract, but there is controversy surrounding the optimal management of this disease. The purpose of this study is to better define treatment for patients with rectal neuroendocrine tumors. METHODS: Using the National Cancer Database, we analyzed patients with rectal neuroendocrine tumors between 2004 and 2015. Patients with metastatic disease and missing treatment data were excluded. We examined overall survival stratified by tumor size, treatment type, and presence of positive lymph nodes using Kaplan-Meier analysis with log-rank test. Cox proportional hazard regression model was performed to identify factors associated with overall survival. RESULTS: In total, 17,448 patients with rectal neuroendocrine tumors were identified; 16,531 of these patients met inclusion criteria. The majority of patients had tumors ≤ 10 mm (9216 patients, 79.8%), and approximately 90% underwent local excision. The probability of 5-year overall survival was significantly higher for patients with smaller tumors (≤ 10 mm: 94.1% 11-20 mm: 85.7%, > 20 mm: 71.8%; p < 0.001) and those with no positive lymph nodes (91.4% versus 53.3%, p < 0.001). The probability of 5-year overall survival differed based on treatment modality (local excision: 93.6%, radical resection: 79.1%, observation alone: 77.1%; p < 0.001). On multivariable Cox regression, when compared to local excision, radical resection was not associated with a difference in overall survival but observation alone was associated with significantly worse OS (HR = 2.750, p < 0.001). CONCLUSIONS: There is a significant difference in overall survival between patients who underwent local excision versus observation alone. Excision of the tumor should be offered to all patients with rectal neuroendocrine tumors who are appropriate surgical candidates, regardless of the tumor size.

Local excision versus radical resection in patients with rectal neuroendocrine tumours: a propensity score match analysis.

BACKGROUND: The rectum is a common site for neuroendocrine tumours of the gastrointestinal tract. Diagnosis of these tumours has been increasing in recent years, highlighting the need to better define treatment options for patients with rectal neuroendocrine tumours (rNETs). METHODS: We performed a retrospective analysis using the National Cancer Database (2004-2014) to compare overall survival (OS) between local excision (LE) and radical resection (RR). To minimize bias, we performed three propensity score-matched comparisons stratified by tumour size: <10 mm, 10-20 mm, >20 mm. We compared OS by Kaplan-Meier analysis. We also examined margin status and postoperative outcomes for each comparison. RESULTS: A total of 12 996 patients underwent surgical treatment for rNET. There was no significant difference in probability of 10-year OS between LE and RR for patients with tumours <10 mm (88.6% versus 83.8%, P = 0.631, respectively) and tumours 10-20 mm (69.5% versus 69.3%, P = 0.226, respectively). In patients with tumours >20 mm, probability of 10-year OS was significantly longer in the LE group (76.5% versus 37.0%, P < 0.001). For all tumour sizes <10 mm and >20 mm, RR had significantly higher rates of 30-day readmission and negative margins. In subset analysis, there was no difference in OS for patients with positive margins after LE versus negative margins after RR for all tumour size groups. CONCLUSIONS: Our findings suggest that LE is a reasonable treatment option in patients with rNETs, especially for patients with high perioperative risk. Limitations to this study include its retrospective nature and inability to analyse surgeon decision-making.

Making the Jump: A Qualitative Analysis on the Transition From Bedside Assistant to Console Surgeon in Robotic Surgery Training.

OBJECTIVE: To determine barriers associated with the transition from bedside assistant to console surgeon for general surgery residents in the era of robotic surgery in general surgery training. DESIGN: Qualitative thematic analysis using one-on-one interviews of general surgery residents and attendings conducted between June 2018 and February 2019. SETTING: An urban, academic, multihospital general surgery residency program with a robust robotic surgery program. PARTICIPANTS: Convenient and purposeful sampling was performed to ensure a variety of resident graduate-years and attending subspecialties were represented. Sample size was determined by data saturation, which occurred after 20 resident and 7 attending interviews. RESULTS: Residents identified the low volume of general surgery robotic cases, the infrequency of exposure to robotic surgery, and attending comfort with robotic surgery (and with teaching on the robot) as potential barriers in the transition from bedside assistant to console surgeon. Residents had to find a replacement bedside assistant in order to be the console surgeon, which was challenging. In addition, residents felt that the current culture surrounding robotic surgery is very hierarchal, limiting their exposure. Attendings' trust in the residents' console skills was a major determining factor in allowing residents on the console. CONCLUSIONS: Most robotic surgery education curricula are sequential, requiring the resident to progress from bedside assistant to console surgeon. Unfortunately, there are many potential barriers for residents in the transition from bedside assistant to console surgeon. Some barriers apply to general surgery training overall, but are amplified in robotic surgery, while others are unique to robotic surgery education. Recognition of, and rectifying, these barriers may increase resident participation as the console surgeon.

Endorectal Advancement Flaps for Perianal Fistulae in Crohn's Disease: Careful Patient Selection Leads to Optimal Outcomes.

BACKGROUND: Anorectal fistulae resultant from Crohn's disease (CD) is a clinical challenge. The advent of immune therapy (IT) has altered the way in which fistulae have responded to treatment. Endorectal advancement flap (ERAF) is a surgical procedure that is used to treat complex fistulae. We have employed ERAF as our second stage treatment of choice in this patient population. Our aim was to determine the success of ERAF in treating perianal fistulas in patients with CD in an era of IT. METHODS: Multicenter retrospective review from 2007 to 2017 of all patients with CD and a perianal fistulae who underwent ERAF. RESULTS: Forty-one flaps were performed in 39 patients with perianal CD with an average follow-up of 797 days. There were no significant differences in patient demographics; however, all patients who were diverted at the time of surgery had successful healing. Of patients, 73.2% were on IT at an average of 380 days prior to surgery. The duration of single-agent therapy was associated with better healing rates (p = 0.03). The overall failure rate was 19.5% (n = 8). Six patients underwent secondary techniques for fistulae closure; five were successful. In combination with the patients who did not initially fail, the overall healing rate was 92.6%. CONCLUSIONS: This study demonstrates several factors that may improve fistulae closure for CD patients. Patients who were diverted prior to surgery did not have a fistulae recurrence. Patients who were on IT longer prior to ERAF were more likely to achieve successful closure.

Postoperative Outcomes in Vedolizumab-Treated Patients Undergoing Major Abdominal Operations for Inflammatory Bowel Disease: Retrospective Multicenter Cohort Study.

Background: Vedolizumab is now widely available for the treatment of moderate to severe ulcerative colitis (UC) and Crohn's disease (CD). We sought to quantify the rates of postoperative complications with preoperative vedolizumab compared with anti-tumor necrosis factor (anti-TNF) therapy. Methods: A multicenter retrospective review of adult inflammatory bowel disease (IBD) patients who underwent an abdominal operation between May 20, 2014, and December 31, 2015, was performed. The study cohort was comprised of patients who had received vedolizumab within 12 weeks of their abdominal operation, and the control cohort was IBD patients who had received anti-TNF therapy. Results: A total of 146 patients received vedolizumab within 12 weeks before an abdominal operation (64% female; n = 93; median age, 33 years; range, 15-74 years), and 289 patients received anti-TNF therapy (49% female; n = 142; median age, 36 years; range, 17-73 years). Vedolizumab-treated patients were younger (P = 0.015) and were more likely to have taken corticosteroids (P < 0.01) within the 12 weeks before surgery. Vedolizumab-treated patients had a significantly increased risk of any postoperative surgical site infection (SSI; P < 0.01), superficial SSI (P < 0.01), deep space SSI (P = 0.39), and mucocutaneous separation of the diverting stoma (P < 0.00) as compared with patients taking anti-TNF therapy. On multivariate analysis, after adjusting for body mass index, steroids at the time of operation, and institution, exposure to vedolizumab remained a significant predictor of postoperative SSI (P < 0.01). Conclusions: We observed that vedolizumab-treated patients were at significantly increased risk of postoperative SSIs after a major abdominal operation, as compared with anti-TNF-treated patients.

Assessment of the Addition of Hypoalbuminemia to ACS-NSQIP Surgical Risk Calculator in Colorectal Cancer.

The aim of this study was to evaluate the benefit of adding hypoalbuminemia to the American College of Surgeons-National Surgical Quality Improvement Program (ACS-NSQIP) Surgical Risk Calculator when predicting postoperative outcomes in colorectal cancer patients.The ACS-NSQIP Surgical Risk Calculator offers qualified risk evaluation in surgical decision-making and informed patient consent. To date, malnutrition defined as hypoalbuminemia, an important independent surgical risk factor in colorectal cancer, is not included.This is a retrospective, multi-institutional study of ACS-NSQIP patients (n = 18,532) who received colorectal surgery from 2009 to 2012. Models were constructed for predicting postoperative mortality and morbidity using the risk factors of the ACS-NSQIP Surgical Risk Calculator before and after adding hypoalbuminemia as a risk factor. The 2 models' performance was then compared using c-statistics and Brier scores. The ACS-NSQIP database in 2008 was used for validation of the created models.The prevalence of hypoalbuminemia (27.8%) is higher in colorectal cancer, when compared with other most common cancers. In univariate analyses, hypoalbuminemia was significantly associated with postoperative mortality and morbidity in colorectal cancer patients. In multivariate logistic regression analyses, 15 postoperative complications, including mortality and serious morbidities, were significantly predicted by hypoalbuminemia. Most of the models with hypoalbuminemia showed better performance and validation in predicting postoperative complications than those without hypoalbuminemia.In colorectal cancer, hypoalbuminemia, with levels below 3.5 g/dL, serves as an excellent assessment tool and preoperative predictor of postoperative outcomes. When combined with hypoalbuminemia as a risk factor, the ACS-NSQIP Surgical Risk Calculator offers more accurate information and estimation of surgical risks to patients and surgeons when choosing treatment options.

Safety of early mobilization of patients with blunt solid organ injuries.

BACKGROUND: Many surgeons believe that early mobilization of patients with blunt solid organ injuries increases the risk of delayed hemorrhage. OBJECTIVE: To determine whether there is an association between the day of mobilization and rates of delayed hemorrhage from blunt solid organ injuries. DESIGN: Retrospective cohort study. Univariate and multivariate analyses were performed to determine the association of mobilization with delayed hemorrhage of a solid organ requiring laparotomy. SETTING: Level I trauma center. PATIENTS: Adults with blunt renal, hepatic, or splenic injuries were identified from a trauma registry. MAIN OUTCOME MEASURES: Medical records were used to determine the day of mobilization and to identify patients with delayed hemorrhage requiring laparotomy. RESULTS: Four hundred fifty-four patients with blunt solid organ injuries were admitted to the hospital for nonoperative management. Failure rates of nonoperative management were 4.0%, 1.0%, and 7.1% for renal, hepatic, and splenic injuries, respectively. No patients with renal or hepatic injuries failed secondary to delayed hemorrhage. Ten patients (5.5%) with splenic injuries failed secondary to delayed hemorrhage. Eighty-four percent of patients with renal injuries, 80% with hepatic injuries, and 77% with splenic injuries were mobilized within 72 hours of admission. Day of mobilization was not associated with delayed splenic rupture in multivariate analysis (odds ratio, 0.97; 95% confidence interval, 0.90-1.05). CONCLUSIONS: The timing of mobilization of patients with blunt solid organ injuries does not seem to contribute to delayed hemorrhage requiring laparotomy. Protocols incorporating periods of strict bed rest are unnecessary.

Spatial and temporal regulation of 3-phosphoinositides by PI 3-kinase and PTEN mediates chemotaxis.

We have investigated the mechanisms of leading edge formation in chemotaxing Dictyostelium cells. We demonstrate that while phosphatidylinositol 3-kinase (PI3K) transiently translocates to the plasma membrane in response to chemoattractant stimulation and to the leading edge in chemotaxing cells, PTEN, a negative regulator of PI3K pathways, exhibits a reciprocal pattern of localization. By uniformly localizing PI3K along the plasma membrane, we show that chemotaxis pathways are activated along the lateral sides of cells and PI3K can initiate pseudopod formation, providing evidence for a direct instructional role of PI3K in leading edge formation. These findings provide evidence that differential subcellular localization and activation of PI3K and PTEN is required for proper chemotaxis.