Anal Cryptoglandular Suppuration: Evidence-Based Management.

Anal suppurative processes are commonly encountered in surgical practice. While the initial therapeutic intervention is philosophically straightforward (incision and drainage), drainage of the appropriate space and treatment of the subsequent fistula in ano require a thorough understanding of perianal anatomy and nuanced decision making. Balancing the risk of fecal incontinence with simple fistulotomy versus the higher risk of fistula recurrence with all sphincter-sparing fistula treatments can be a challenge for surgeons and patients alike.

Surgical Emergencies in Inflammatory Bowel Disease.

Inflammatory bowel disease (IBD) patients are at risk for undergoing emergency surgery for fulminant disease, toxic megacolon, bowel perforation, intestinal obstruction, or uncontrolled gastrointestinal hemorrhage. Unfortunately, medical advancements have failed to significantly decrease rates of emergency surgery for IBD. It is therefore important for all acute care and colorectal surgeons to understand the unique considerations owed to this often-challenging patient population.

Declining Military Surgical Cases and the Impact on Military Surgical Graduate Medical Education.

BACKGROUND: Several studies have indicated a decline in the number, types, and complexity of surgical procedures within military treatment facilities (MTFs). This study aims to determine what effect, if any, these downward trends have had on the relationship between the military health system (MHS) and surgical graduate medical education. METHODS: Graduating chief resident final ACGME case logs from 4 of thirteen military general surgery programs were evaluated from 2015 to 2020. The proportion of total cases performed by residents at military institutions were compared on a year over year basis. RESULTS: The proportion of cases performed within the military hospitals declined 3.27% each year between 2015 and 2020 (P < .0001) in 4 MTFs. All individual hospitals had significant declines in case volume except one (William Beaumont Army Medical Center) which increased 6.05% with each year, but also increased the number of MTF partnerships within its program (P < .0001). CONCLUSIONS: There has been a statistically significant decline over time in the proportion of cases logged by residents within the studied military treatment facilities. Investment into military hospitals to increase case numbers, case diversity, and complexity and/or acceptance of this gradual decline with greater shifting of educational workload onto civilian hospitals is required.

Analysis of Outcomes Associated With Outpatient Management of Nonoperatively Treated Patients With Appendicitis.

Importance: In the Comparison of Outcomes of Antibiotic Drugs and Appendectomy (CODA) trial, which found antibiotics to be noninferior, approximately half of participants randomized to receive antibiotics had outpatient management with hospital discharge within 24 hours. If outpatient management is safe, it could increase convenience and decrease health care use and costs. Objective: To assess the use and safety of outpatient management of acute appendicitis. Design, Setting, and Participants: This cohort study, which is a secondary analysis of the CODA trial, included 776 adults with imaging-confirmed appendicitis who received antibiotics at 25 US hospitals from May 1, 2016, to February 28, 2020. Exposures: Participants randomized to antibiotics (intravenous then oral) could be discharged from the emergency department based on clinician judgment and prespecified criteria (hemodynamically stable, afebrile, oral intake tolerated, pain controlled, and follow-up confirmed). Outpatient management and hospitalization were defined as discharge within or after 24 hours, respectively. Main Outcomes and Measures: Outcomes compared among patients receiving outpatient vs inpatient care included serious adverse events (SAEs), appendectomies, health care encounters, satisfaction, missed workdays at 7 days, and EuroQol 5-dimension (EQ-5D) score at 30 days. In addition, appendectomy incidence among outpatients and inpatients, unadjusted and adjusted for illness severity, was compared. Results: Among 776 antibiotic-randomized participants, 42 (5.4%) underwent appendectomy within 24 hours and 8 (1.0%) did not receive their first antibiotic dose within 24 hours, leaving 726 (93.6%) comprising the study population (median age, 36 years; range, 18-86 years; 462 [63.6%] male; 437 [60.2%] White). Of these participants, 335 (46.1%; site range, 0-89.2%) were discharged within 24 hours, and 391 (53.9%) were discharged after 24 hours. Over 7 days, SAEs occurred in 0.9 (95% CI, 0.2-2.6) per 100 outpatients and 1.3 (95% CI, 0.4-2.9) per 100 inpatients; in the appendicolith subgroup, SAEs occurred in 2.3 (95% CI, 0.3-8.2) per 100 outpatients vs 2.8 (95% CI, 0.6-7.9) per 100 inpatients. During this period, appendectomy occurred in 9.9% (95% CI, 6.9%-13.7%) of outpatients and 14.1% (95% CI, 10.8%-18.0%) of inpatients; adjusted analysis demonstrated a similar difference in incidence (-4.0 percentage points; 95% CI, -8.7 to 0.6). At 30 days, appendectomies occurred in 12.6% (95% CI, 9.1%-16.7%) of outpatients and 19.0% (95% CI, 15.1%-23.4%) of inpatients. Outpatients missed fewer workdays (2.6 days; 95% CI, 2.3-2.9 days) than did inpatients (3.8 days; 95% CI, 3.4-4.3 days) and had similar frequency of return health care visits and high satisfaction and EQ-5D scores. Conclusions and Relevance: These findings support that outpatient antibiotic management is safe for selected adults with acute appendicitis, with no greater risk of complications or appendectomy than hospital care, and should be included in shared decision-making discussions of patient preferences for outcomes associated with nonoperative and operative care. Trial Registration: ClinicalTrials.gov Identifier: NCT02800785.

Patient Factors Associated With Appendectomy Within 30 Days of Initiating Antibiotic Treatment for Appendicitis.

IMPORTANCE: Use of antibiotics for the treatment of appendicitis is safe and has been found to be noninferior to appendectomy based on self-reported health status at 30 days. Identifying patient characteristics associated with a greater likelihood of appendectomy within 30 days in those who initiate antibiotics could support more individualized decision-making. OBJECTIVE: To assess patient factors associated with undergoing appendectomy within 30 days of initiating antibiotics for appendicitis. DESIGN, SETTING, AND PARTICIPANTS: In this cohort study using data from the Comparison of Outcomes of Antibiotic Drugs and Appendectomy (CODA) randomized clinical trial, characteristics among patients who initiated antibiotics were compared between those who did and did not undergo appendectomy within 30 days. The study was conducted at 25 US medical centers; participants were enrolled between May 3, 2016, and February 5, 2020. A total of 1552 participants with acute appendicitis were randomized to antibiotics (776 participants) or appendectomy (776 participants). Data were analyzed from September 2020 to July 2021. EXPOSURES: Appendectomy vs antibiotics. MAIN OUTCOMES AND MEASURES: Conditional logistic regression models were fit to estimate associations between specific patient factors and the odds of undergoing appendectomy within 30 days after initiating antibiotics. A sensitivity analysis was performed excluding participants who underwent appendectomy within 30 days for nonclinical reasons. RESULTS: Of 776 participants initiating antibiotics (mean [SD] age, 38.3 [13.4] years; 286 [37%] women and 490 [63%] men), 735 participants had 30-day outcomes, including 154 participants (21%) who underwent appendectomy within 30 days. After adjustment for other factors, female sex (odds ratio [OR], 1.53; 95% CI, 1.01-2.31), radiographic finding of wider appendiceal diameter (OR per 1-mm increase, 1.09; 95% CI, 1.00-1.18), and presence of appendicolith (OR, 1.99; 95% CI, 1.28-3.10) were associated with increased odds of undergoing appendectomy within 30 days. Characteristics that are often associated with increased risk of complications (eg, advanced age, comorbid conditions) and those clinicians often use to describe appendicitis severity (eg, fever: OR, 1.28; 95% CI, 0.82-1.98) were not associated with odds of 30-day appendectomy. The sensitivity analysis limited to appendectomies performed for clinical reasons provided similar results regarding appendicolith (adjusted OR, 2.41; 95% CI, 1.49-3.91). CONCLUSIONS AND RELEVANCE: This cohort study found that presence of an appendicolith was associated with a nearly 2-fold increased risk of undergoing appendectomy within 30 days of initiating antibiotics. Clinical characteristics often used to describe severity of appendicitis were not associated with odds of 30-day appendectomy. This information may help guide more individualized decision-making for people with appendicitis.

Maintaining Wellness and Instilling Resilience in General Surgeons.

Obtaining wellness and enhancing resilience will be increasingly more important for General Surgeons. Although these concepts are not new, the increased complexity of health care delivery has elevated the importance of these essential attributes. Instilling these practices should be emphasized during surgery residency and be modeled by surgical educators and surgeon leaders. The enhanced emphasis of wellness and resiliency is a positive step forward; however, more must be accomplished to ensure the well-being of a particularly group of vulnerable physicians. This chapter discusses the history and scientific theory behind wellness and resiliency, as well as practical suggestions for consideration.

Postoperative outcomes of Bascom cleft lift for pilonidal disease: A single-center experience.

INTRODUCTION: Limited data exists regarding outcomes for the Bascom cleft lift procedure for pilonidal disease. METHODS: Single-center retrospective review of patients who underwent a Bascom cleft lift from 2013 to 2018. Univariate analysis was performed to determine associations between patient-specific characteristics and post-operative complications. Postoperative complications were categorized as major or minor. Multivariate analysis was performed to identify predictors of postoperative complications. RESULTS: 235 patients were included. Forty-five percent were obese and 24% were active smokers. Minor complications occurred in 34.5% (81); major complications occurred in 19.1% (45). The recurrence rate was 4.7% (11). Smoking was not associated with postoperative complications. Obesity was independently associated with higher rates of both minor (OR 2.6, p = 0.001) and major (OR 2.3, p = 0.001) complications. DISCUSSION: Wound complications are common after Bascom cleft lift. Obesity is an independent predictor of postoperative complications. Obese patients should be appropriately counseled regarding their increased risk prior to surgery.

Appendiceal Neoplasms.

Appendiceal neoplasms are identified in 0.9 to 1.4% of appendiceal specimens, and the incidence is increasing. It has long been professed that neuroendocrine tumors (formerly carcinoids) are the most common neoplastic process of the appendix; recent data, however, has suggested a shift in epidemiology. Our intent is to distill the complex into an algorithm, and, in doing so, enable the surgeon to seamlessly maneuver through operative decisions, treatment strategies, and patient counseling. The algorithm for evaluation and treatment is complex, often starts from the nonspecific presenting complaint of appendicitis, and relies heavily on often subtle histopathologic differences.

Is Modern Medical Management Changing Ultimate Patient Outcomes in Inflammatory Bowel Disease?

BACKGROUND: The impact of modern medical management of inflammatory bowel disease (IBD) on surgical necessity and outcomes remains unclear. We hypothesized that surgery rates have decreased while outcomes have worsened due to operating on "sicker" patients since the introduction of biologic medications. METHODS: The Nationwide Inpatient Sample and ICD-9-CM codes were used to identify inpatient admissions for Crohn's disease and ulcerative colitis. Trends in IBD nutrition, surgeries, and postoperative complications were determined. RESULTS: There were 191,743 admissions for IBD during the study period. Surgery rates were largely unchanged over the study period, ranging from 9 to 12 % of admissions in both Crohn's disease and ulcerative colitis. The rate of poor nutrition increased by 67 % in ulcerative colitis and by 83 % in Crohn's disease. Rates of postoperative anastomotic leak (10.2-13.9 %) were unchanged over the years. Postoperative infection rates decreased by 17 % in Crohn's disease (18 % in 2003 to 15 % in 2012; P < 0.001) but did not show a trend in any direction in ulcerative colitis. CONCLUSIONS: Rates of IBD surgery have remained stable while postoperative infectious complications have remained stable or decreased since the implementation of biologic therapies. We identified an increase in poor nutrition in surgical patients.

Right-Sided Diverticulitis Requiring Colectomy: an Evolving Demographic? A Review of Surgical Outcomes from the National Inpatient Sample Database.

INTRODUCTION: There remains a paucity of recent data on right-sided colonic diverticulitis, especially those undergoing colectomy. We sought to describe the clinical features of patients undergoing both a laparoscopic and open surgery for right-sided diverticulitis. METHODS: This study is a review of all cases of a right colectomy or ileocecectomy for diverticulitis from the National Inpatient Sample (NIS) from 2006 to 2012. Demographics, comorbidities, and postoperative outcomes were identified for all cases. A comparative analysis of a laparoscopic versus open approach was performed. RESULTS: We identified 2233 admissions (laparoscopic = 592; open = 1641) in the NIS database. The majority of cases were Caucasian (67 %), with 6 % of NIS cases identified as Asian/Pacific Islander. The overall morbidity and in-hospital mortality rates were 24 and 2.7 %, respectively. The conversion rate from a laparoscopic to open procedure was 34 %. Postoperative complications were greater in the open versus laparoscopic cohorts (25 vs. 19 %, p < 0.01), with pulmonary complications as the highest (7.0 vs. 1.7 %; p < 0.01). CONCLUSION: This investigation represents one of the largest cohorts of colon resections to treat right-sided diverticulitis in the USA. In this series, right-sided diverticulitis undergoing surgery occurred most commonly in the Caucasian population and is most often approached via an open surgical technique; however, laparoscopy is a safe and feasible option.

Screening or Symptoms? How Do We Detect Colorectal Cancer in an Equal Access Health Care System?

BACKGROUND: Detection of colorectal cancer ideally occurs at an early stage through proper screening. We sought to establish methods by which colorectal cancers are diagnosed within an equal access military health care population and evaluate the correlation between TNM stage at colorectal cancer diagnosis and diagnostic modality (i.e., symptomatic detection vs screen detection). MATERIALS AND METHODS: A retrospective chart review of all newly diagnosed colorectal cancer patients from January 2007 to August 2014 was conducted at the authors' equal access military institution. We evaluated TNM stage relative to diagnosis by screen detection (fecal occult blood test, flexible sigmoidoscopy, CT colonography, colonoscopy) or symptomatic evaluation (diagnostic colonoscopy or surgery). RESULTS: Of 197 colorectal cancers diagnosed (59 % male; mean age 62 years), 50 (25 %) had stage I, 47 (24 %) had stage II, 70 (36 %) had stage III, and 30 (15 %) had stage IV disease. Twenty-five percent of colorectal cancers were detected via screen detection (3 % by fecal occult blood testing (FOBT), 0.5 % by screening CT colonography, 17 % by screening colonoscopy, and 5 % by surveillance colonoscopy). One hundred forty-eight (75 %) were diagnosed after onset of signs or symptoms. The preponderance of these was advanced-stage disease (stages III-IV), although >50 % of stage I-II disease also had signs or symptoms at diagnosis. The most common symptoms were rectal bleeding (45 %), abdominal pain (35 %), and change in stool caliber (27 %). The most common overall sign was anemia (60 %). Screening FOBT (odds ratio (OR) 8.7, 95 % confidence interval (CI) 1.0-78.3; P = 0.05) independently predicted early diagnosis with stage I-II disease. Patient gender and ethnicity were not associated with cancer stage at diagnosis. CONCLUSIONS: Despite equal access to colorectal cancer screening, diagnosis after development of symptomatic cancer remains more common. Fecal occult blood screen detection is associated with early stage at colorectal cancer diagnosis and is the focus for future initiatives.

Fluorescence Angiography in Colorectal Resection.

BACKGROUND: Intraoperative laser fluorescence angiography is a relatively new tool that can be used by colorectal surgeons to ensure adequate perfusion to bowel that remains after resection. It has been used mostly to determine an appropriate point of transection of the proximal bowel, as well as to ensure perfusion after the anastomosis has been constructed. We propose a different use of the technology in complex cases to ensure the ability to safely transect a major vascular pedicle and to ensure that perfusion will remain adequate. OBJECTIVE: The purpose of this article is to describe a new use for fluorescence angiography technology. DESIGN: This is a technical note. SETTINGS: The work was conducted at a tertiary care military medical center. PATIENTS: Patients included individuals requiring oncologic colorectal resection where the status of 1 major vascular pedicle was unknown or impaired. MAIN OUTCOME MEASURES: We assessed perfusion after occlusion of a major vascular pedicle for the short term in hospital outcomes. RESULTS: Adequate studies were obtained, and perfusion was maintained in both patients. Oncologic resections were performed, and short-term outcomes were comparable with any individual undergoing these procedures. LIMITATIONS: This study was limited because it is early experience that was not performed in the setting of a scientific investigation. CONCLUSIONS: Application of intraoperative fluorescence angiography in this setting appears to be safe and may assist the surgeon in estimating reliable vascular perfusion in patients such as these who require oncologic colorectal resection.

Can sepsis predict deep venous thrombosis in colorectal surgery?

BACKGROUND: Little data exist regarding the impact of sepsis on deep venous thrombosis (DVT) in colorectal surgery patients. We sought to elucidate this relationship. METHODS: Current Procedural Terminology codes were used to identify patients who underwent colorectal surgery as reported to the National Surgical Quality Improvement Program in 2010. The relationship between DVT and sepsis was then explored in a matched population. RESULTS: Of the 26,554 patients who underwent colorectal surgery, 462 (1.7%) developed a DVT. The largest dependent correlations with DVT were malnutrition (33% vs 57%), emergency operation (15% vs 31%), open operation (58% vs 78%), and prolonged ventilator requirement (5% vs 24%; all P < .001). After propensity score matching, urosepsis (.5% vs 1.9%), organ/space sepsis (1.1% vs 4.8%), pneumosepsis (.5% vs 5.8%), and overall perioperative sepsis (18% vs 39%; all P ≤ .04) were associated with DVT. The strongest independent predictor of DVT was pneumosepsis (odds ratio 15.9, 95% confidence interval 3.7 to 67.2, P < .001). CONCLUSION: Perioperative sepsis is a significant risk factor for postoperative DVT in the colorectal surgery population.

Have we progressed in the surgical literature? Thirty-year trends in clinical studies in 3 surgical journals.

BACKGROUND: We practice in an era of evidence-based medicine. In 1993, Solomon and McLeod published an article examining study designs in 3 surgical journals from 1980 and 1990. OBJECTIVE: The purpose of this study was to evaluate subsequent 30-year trends in the quality of selected literature. DESIGN: All of the articles from Diseases of the Colon & Rectum, Surgery, and the British Journal of Surgery during 2000 and 2010 were classified by study design. Nonclinical studies were substratified by animal/laboratory, surgical technique, editorial/review, or miscellaneous articles. Clinical articles were categorized as case or comparative studies, further categorized by study design, and rated on a 10-point scale to determine strength. We compared interobserver reliability using a random sample. SETTING: This study was conducted at 3 North American medical centers. PATIENTS: Patients described in the scope of the literature were included in this study. MAIN OUTCOME MEASURES: Frequency, type, and strength of study design were measured. RESULTS: We evaluated 1911 articles (967 clinical; 17% comparative). There was a significant increase in multicenter clinical studies (from 12% to 27%; p < 0.0001) and mean study population (from 326 to 6775; p < 0.05). Studies using administrative data increased from 14% to 43% (p < 0.0001). Case reports decreased from 16% to 7% of all clinical studies (p < 0.001), whereas the percentage of comparative studies increased from 14% to 21% (p = 0.001). The percentage of randomized controlled trials did not increase significantly (8.5% in 2000; 10.0% in 2010; p = 0.44). The mean 10-point score for comparative studies was 6.7 for both years (p = 0.50). There was good interobserver agreement in the classification of studies (κ = 0.70) and moderate agreement in scoring comparative studies (κ = 0.47). LIMITATIONS: This descriptive study cannot fully account for the reasons behind the identified differences. CONCLUSIONS: Comparative and multicenter studies, mean study population, and the use of administrative data increased from 2000 to 2010. This suggests that increased use of administrative databases has allowed larger populations of patients from more institutions to be studied and may be more generalizable. Researchers should strive toward improving the level of evidence (see Video, Supplemental Digital Content 1, http://links.lww.com/DCR/A167).

The impact of an acute care surgery team on general surgery residency.

BACKGROUND: Acute care surgical teams (ACSTs) have limited data in residency. We sought to determine the impact of an ACST on the depth and breadth of general surgery resident training. METHODS: One year prior to and after implementation of an ACST, Accreditation Council for Graduate Medical Education case logs spanning multiple postgraduate year levels were compared for numbers, case types, and complexity. RESULTS: We identified 6,009 cases, including 2,783 after ACST implementation. ACSTs accounted for 752 cases (27%), with 39.2% performed laparoscopically. ACST cases included biliary (19.4%), skin/soft tissue (10%), hernia (9.8%), and appendix (6.5%). Second-year residents performed a lower percentage of laparoscopic cases after the creation of the ACST (20.4% vs 26.3%; P = .003), while chief residents performed a higher percentage (42.1 vs 37.4; P = .04). Case numbers and complexity following ACST development were unchanged within all year groups (P > .1). CONCLUSION: ACST in a residency program does not sacrifice resident case complexity, diversity, or volume.

Standard laparoscopic trocars for the treatment of tension pneumothorax: a superior alternative to needle decompression.

BACKGROUND: Needle thoracostomy (NT) is a commonly taught intervention for tension pneumothorax (tPTX) but has a high failure rate. We hypothesize that standard 5-mm laparoscopic trocars may be a safe and more effective alternative. METHODS: Thirty episodes of tPTX and 27 episodes of tension-induced pulseless electrical activity (PEA) were induced in five adult swine using thoracic CO2 insufflation via balloon trocar. Tension was defined as a 50% decrease in cardiac output. Chest decompression was performed with 5-mm laparoscopic trocars for the treatment of both tPTX with hemodynamic compromise and tension-induced PEA. The lungs and heart were inspected and graded at necropsy for trocar-related injury. Results were also compared with success rates with NT in the same model. RESULTS: The placement of a 5-mm trocar rapidly and immediately relieved tension physiology in 100% of the cases. Mean arterial pressure, cardiac output, central venous pressure, and pulmonary capillary wedge pressure all returned to baseline within 1 minute of trocar placement. Adequate perfusion was restored in 100% of tension-induced PEA cases within 30 seconds of trocar placement. There was no evidence of trocar-related heart or lung damage in any of the experimental animals at necropsy (mean injury scores, 0 for both). Five-millimeter trocars significantly outperformed standard NT for both tPTX and tension-induced PEA arrest. CONCLUSION: tPTX and tension-induced PEA can be safely and effectively treated with chest decompression using 5-mm laparoscopic trocars. This technique may serve as a more rapid and reliable alternative to needle decompression.

Acute coagulopathy in a porcine venous hemorrhage and ischemia reperfusion model.

BACKGROUND: Injury-related coagulopathy is a complex process. We analyzed coagulation in a swine model of shock using rotational thromboelastometry (ROTEM). METHODS: Forty-eight swine underwent laparotomy, 35% hemorrhage, supraceliac aortic cross-clamp, then reperfusion and resuscitation. ROTEM measurements and standard labs were taken at baseline and 6 hours into resuscitation. RESULTS: Clot formation time (98 vs 53 seconds, P = .001) and international normalized ratio (1.67 vs 1.01, P < .001) were prolonged after resuscitation. Maximum clot firmness (61 vs 72 mm, P < .001) and fibrinogen levels (94 vs 165, P < .001) declined significantly during resuscitation. Despite decreased fibrinogen levels, there was no significant increase in fibrinolysis as measured by maximum lysis (3.9% vs 3.8%, P = .99). CONCLUSIONS: ROTEM demonstrated the development of an acute coagulopathy. The most significant impacts on coagulopathy were seen with clot initiation and fibrin polymerization. Clot strength decreased over time, although there was little impact on clot breakdown because of fibrinolysis.