Reliability and validity of multicentre surveillance of surgical site infections after colorectal surgery.

BACKGROUND: Surveillance is the cornerstone of surgical site infection prevention programs. The validity of the data collection and awareness of vulnerability to inter-rater variation is crucial for correct interpretation and use of surveillance data. The aim of this study was to investigate the reliability and validity of surgical site infection (SSI) surveillance after colorectal surgery in the Netherlands. METHODS: In this multicentre prospective observational study, seven Dutch hospitals performed SSI surveillance after colorectal surgeries performed in 2018 and/or 2019. When executing the surveillance, a local case assessment was performed to calculate the overall percentage agreement between raters within hospitals. Additionally, two case-vignette assessments were performed to estimate intra-rater and inter-rater reliability by calculating a weighted Cohen's Kappa and Fleiss' Kappa coefficient. To estimate the validity, answers of the two case-vignettes questionnaires were compared with the answers of an external medical panel. RESULTS: 1111 colorectal surgeries were included in this study with an overall SSI incidence of 8.8% (n = 98). From the local case assessment it was estimated that the overall percent agreement between raters within a hospital was good (mean 95%, range 90-100%). The Cohen's Kappa estimated for the intra-rater reliability of case-vignette review varied from 0.73 to 1.00, indicating substantial to perfect agreement. The inter-rater reliability within hospitals showed more variation, with Kappa estimates ranging between 0.61 and 0.94. In total, 87.9% of the answers given by the raters were in accordance with the medical panel. CONCLUSIONS: This study showed that raters were consistent in their SSI-ascertainment (good reliability), but improvements can be made regarding the accuracy (moderate validity). Accuracy of surveillance may be improved by providing regular training, adapting definitions to reduce subjectivity, and by supporting surveillance through automation.

Motivations and Barriers Toward Implementation of a Rectal Cancer Synoptic Operative Report: A Process Evaluation.

BACKGROUND: The use of synoptic reporting has been shown to improve documentation of critical information and provide added value related to data access and extraction, data reliability, relevant detail, and completeness of information. Surgeon acceptance and adoption of synoptic reports has lagged behind other specialties. OBJECTIVE: This study aimed to evaluate the process of implementing a synoptic operative report. DESIGN: This study was a mixed-methods process evaluation including surveys and qualitative interviews. SETTINGS: This study focused on colorectal surgery practices across the United States. PATIENTS: Twenty-eight board-certified colorectal surgeons were included. INTERVENTIONS: The synoptic operative report for rectal cancer was implemented. MAIN OUTCOME MEASURES: Acceptability, feasibility, and usability were measured by Likert-type survey questions and followed up with individual interviews to elicit experiences with implementation as well as motivations and barriers to use. RESULTS: Among all study participants, 28 surgeons completed the electronic survey (76% response rate) and 21 (57%) completed the telephone interview. Mean usability was 4.14 (range, 1-5; SE, 0.15), mean feasibility was 3.90 (SE, 0.15), and acceptability was 3.98 (SE, 0.18). Participants indicated that substantial administrative and technical support were necessary but not always available for implementation, and many were frustrated by the need to change their workflow. LIMITATIONS: Most surgeon participants were male, white, had >12 years in practice, and used Epic electronic medical record systems. Therefore, they may not represent the perspectives of all US colon and rectal surgeons. In addition, as the synoptic operative report is implemented more broadly across the United States, it will be important to consider variations in the process by electronic medical record system. CONCLUSIONS: The synoptic operative report for rectal cancer was easy to implement and incorporate into workflow, in general, but surgeons remained concerned about additional burden without immediate and tangible value. Despite recognizing benefits, many participants indicated they only implemented the synoptic operative report because it was mandated by the National Accreditation Program for Rectal Cancer. See Video Abstract at http://links.lww.com/DCR/B735MOTIVACIONES Y BARRERAS HACIA LA IMPLEMENTACIÓN DE UN INFORME OPERATIVO SINÓPTICO DE CÁNCER RECTAL: UNA EVALUACIÓN DEL PROCESOANTECEDENTES:Se ha demostrado que el uso de informes sinópticos mejora la documentación de información crítica y proporciona un valor agregado relacionado con el acceso y extracción de datos, la confiabilidad de los datos, los detalles relevantes y la integridad de la información. La aceptación y adopción de informes sinópticos por parte de los cirujanos se ha quedado rezagada con respecto a otras especialidades.OBJETIVO:Evaluar el proceso de implementación de un informe operativo sinóptico.DISEÑO:Evaluación de procesos de métodos mixtos que incluyen encuestas y entrevistas cualitativas.AJUSTES:Prácticas de cirugía colorrectal en los Estados Unidos.PACIENTES:Veintiocho cirujanos colorrectales certificados por la junta.INTERVENCIONES:Implementación del informe operatorio sinóptico de cáncer de recto.PRINCIPALES MEDIDAS DE RESULTADO:Aceptabilidad, viabilidad y usabilidad medidas por preguntas de encuestas tipo Likert y seguidas con entrevistas individuales para obtener experiencias con la implementación, así como motivaciones y barreras para el uso.RESULTADOS:Entre todos los participantes del estudio, 28 cirujanos completaron la encuesta electrónica (tasa de respuesta del 76%) y 21 (57%) completaron la entrevista telefónica. La usabilidad media fue 4,14 (rango = 1-5, error estándar (EE) = 0,15), la factibilidad media fue 3,90 (EE = 0,15) y la aceptabilidad fue 3,98 (EE = 0,18). Los participantes indicaron que se necesitaba un apoyo administrativo y técnico sustancial, pero que no siempre estaba disponible para la implementación y muchos se sintieron frustrados por la necesidad de cambiar su flujo de trabajo.LIMITACIONES:La mayoría de los cirujanos participantes eran hombres, blancos, tenían >12 años en la práctica y usaban sistemas de registros médicos electrónicos de Epic. Por lo tanto, es posible que no representen las perspectivas de todos los cirujanos de colon y recto de EE. UU. Además, a medida que el informe operativo sinóptico se implemente de manera más amplia en los EE. UU., Será importante considerar las variaciones en el proceso por sistema EMR.CONCLUSIONES:El informe quirúrgico sinóptico para el cáncer de recto fue en general fácil de implementar e incorporar en el flujo de trabajo, pero los cirujanos seguían preocupados por la carga adicional sin valor inmediato y tangible. A pesar de reconocer los beneficios, muchos participantes indicaron que solo implementaron el informe operativo sinóptico porque era un mandato del Programa Nacional de Acreditación para el Cáncer de Recto. Consulte Video Resumen en http://links.lww.com/DCR/B735 (Traducción-Dr. Xavier Delgadillo).

American Proctology Before 1899, Part 2: The Rise of the Rectal Specialists.

Joseph M. Mathews' study at St. Mark's Hospital (London) in the 1877 to 1878 winter was followed shortly by a landmark move toward specialization in the United States: Mathews' heading of a Special Commission on Rectal Diseases appointed at the 23rd Annual Session of the Kentucky State Medical Society, held April 2 to 4, 1878. Various "rectal specialists," under various makeshift titles, were lecturing and publishing by the mid-1890s. The world's first proctologic journal, published between 1894 and 1898, was Mathews' Medical Quarterly, from its inception interpellating a community of colleagues.

Colorectal surgery surgical site infection prevention practices in British Columbia.

Surgical site infections (SSI) pose significant morbidity after colorectal surgery. We sought to document current practices in colorectal surgery SSI prevention in British Columbia (BC). Reporting the current provincial landscape on SSI prevention helps to understand the foundation upon which improvements can take place. We surveyed all BC surgeons performing elective colon and rectal resections, and 97 surveys were completed (60% response rate). Eighty-six per cent of respondent hospitals tracked SSI rates. The reported superficial SSI was less than 5% and the anastomotic leak/organ space rate was less than 10%. All respondents gave preoperative prophylactic antibiotics, with 24% continuing antibiotics postoperatively; 62% are using oral antibiotics (OAB) and mechanical bowel preparation (MBP) and 29% use MBP without OAB. Areas for improvement include OAB with MBP and discontinuing prophylactic antibiotics postoperatively, as recommended by the World Health Organization.

A Prospective Randomized Trial of Surgeon-Administered Intraoperative Transversus Abdominis Plane Block With Bupivacaine Against Liposomal Bupivacaine: The TINGLE Trial.

BACKGROUND: Transversus abdominis plane blocks are increasingly used to achieve opioid-sparing analgesia after colorectal surgery. Traditionally, bupivacaine was the long-acting analgesic of choice, but the addition of dexamethasone and/or epinephrine to bupivacaine may extend block duration. Liposomal bupivacaine has also been suggested to achieve an extended analgesia duration of 72 hours but is significantly more expensive. OBJECTIVE: The purpose of this study was to compare pain control between laparoscopic transversus abdominis plane blocks using liposomal bupivacaine versus bupivacaine with epinephrine and dexamethasone. DESIGN: This was a parallel-group, single-institution, randomized clinical trial. SETTINGS: The study was conducted at a single tertiary medical center. PATIENTS: Consecutive patients between October 2018 to October 2019, ages 18 to 90 years, undergoing minimally invasive colorectal surgery with multimodal analgesia were included. INTERVENTIONS: Patients were randomly assigned 1:1 to receive a laparoscopic transversus abdominis plane block with liposomal bupivacaine or bupivacaine with epinephrine and dexamethasone. MAIN OUTCOME MEASURES: The primary outcome was total oral morphine equivalents administered in the first 48 hours postoperatively. Secondary outcomes included pain scores, time to ambulation and solid diet, hospital length of stay, and complications. RESULTS: A total of 102 patients (50 men) with a median age of 42 years (interquartile range, 29-60 y) consented and were randomly assigned. The primary end point, total oral morphine equivalents administered in the first 48 hours, was not significantly different between the liposomal bupivacaine group (median = 69 mg) and the bupivacaine with epinephrine and dexamethasone group (median = 47 mg; difference in medians = 22 mg, (95% CI, -17 to 49 mg); p = 0.60). There were no significant differences in pain scores, time to ambulation, time to diet tolerance, time to bowel movement, length of stay, overall complications, or readmission rate between groups. There were no treatment-related adverse outcomes. LIMITATIONS: This study was not placebo controlled or blinded. CONCLUSIONS: This first randomized trial comparing laparoscopic transversus abdominis plane block with liposomal bupivacaine or bupivacaine with epinephrine and dexamethasone showed that a liposomal bupivacaine block does not provide superior or extended analgesia in the era of standardized multimodal analgesia protocols.See Video Abstract at http://links.lww.com/DCR/B533. ESTUDIO PROSPECTIVO Y RANDOMIZADO DE BLOQUEO DEL PLANO MUSCULAR TRANSVERSO DEL ABDOMEN REALIZADO POR EL CIRUJANO CON BUPIVACANA VERSUS BUPIVACANA LIPOSOMAL ESTUDIO TINGLE: ANTECEDENTES:El bloqueo anestésico del plano muscular transverso del abdomen se utiliza cada vez más para lograr una analgesia con menos consumo de opioides después de cirugía colorrectal. Tradicionalmente, la Bupivacaína era el analgésico de acción prolongada de elección, pero al agregarse Dexametasona y/o Adrenalina a la Bupivacaína se puede prolongar la duración del bloqueo. También se ha propuesto que la Bupivacaína liposomal logra una duración prolongada de la analgesia de 72 horas, pero es significativamente más cara.OBJETIVO:Comparar el control del dolor entre bloqueo laparoscópico del plano de los transversos del abdomen usando Bupivacaína liposomal versus Bupivacaína con Adrenalina y Dexametasona.DISEÑO:Estudio clínico prospectivo y randomizado de una sola institución en grupos paralelos.AJUSTE:Centro médico terciario único.PACIENTES:Todos aquellos pacientes entre 18 y 90 años sometidos a cirugía colorrectal mínimamente invasiva con analgesia multimodal, entre octubre de 2018 a octubre de 2019 incluidos de manera consecutiva.INTERVENCIONES:Los pacientes fueron seleccionados aleatoriamente 1:1 para recibir un bloqueo laparoscópico del plano de los transversos del abdomen con Bupivacaína liposomal o Bupivacaína con Adrenalina y Dexametasona.PRINCIPALES MEDIDAS DE RESULTADO:El resultado primario fue el total de equivalentes de morfina oral administradas en las primeras 48 horas después de la operación. Los resultados secundarios incluyeron puntuaciones de dolor, inicio de dieta sólida, tiempo de inicio a la deambulación, la estadía hospitalaria y las complicaciones.RESULTADOS:Un total de 102 pacientes (50 hombres) con una mediana de edad de 42 años (IQR 29-60) fueron incluidos aleatoriamente. El criterio de valoración principal, equivalentes de morfina oral total administrada en las primeras 48 horas, no fue significativamente diferente entre el grupo de Bupivacaína liposomal (mediana = 69 mg) y el grupo de Bupivacaína con Adrenalina y Dexametasona (mediana = 47 mg; diferencia en medianas = 22 mg, IC del 95% [-17] - 49 mg, p = 0,60). No hubo diferencias significativas en las puntuaciones de dolor, tiempo de inicio a la deambulación, el tiempo de tolerancia a la dieta sólida, el tiempo hasta el primer evacuado intestinal, la duración de la estadía hospitalaria, las complicaciones generales o la tasa de readmisión entre los grupos. No hubo resultados adversos relacionados con el tratamiento.LIMITACIONES:Este estudio no fue controlado con placebo ni de manera cegada.CONCLUSIONES:Este primer estudio prospectivo y randomizado que comparó el bloqueo del plano de los músculos transversos del abdomen por vía laparoscópica, utilizando Bupivacaína liposomal o Bupivacaína con Adrenalina y Dexametasona, demostró que el bloqueo de Bupivacaína liposomal no proporciona ni mejor analgesia ni un efecto mas prolongado.Consulte Video Resumen en http://links.lww.com/DCR/B533.

Postoperative Pain After Enhanced Recovery Pathway Robotic Colon and Rectal Surgery: Does Specimen Extraction Site Matter?

BACKGROUND: The current opioid crisis has motivated surgeons to critically evaluate ways to balance postoperative pain while decreasing opioid use and thereby reducing opioids available for community diversion. The longest incision for robotic colorectal surgery is the specimen extraction site incision. Intracorporeal techniques allow specimen extraction to be at any location. OBJECTIVE: This study was designed to determine whether the Pfannenstiel location is associated with less pain and opioid use than other abdominal wall specimen extraction sites. DESIGN: This was a retrospective cohort study. SETTINGS: The study was conducted with a prospectively maintained colorectal surgery database (July 2018 through October 2019). PATIENTS: Patients with enhanced recovery robotic colorectal resections with specimen extraction were included. MAIN OUTCOME MEASURES: Propensity score weighting was used to derive adjusted rates for numeric pain scores, inpatient opioid use, opioids prescribed at discharge, opioid refills after discharge, and other related outcomes. For comparing outcomes between groups, p values were calculated using weighted χ2, Fisher exact, and t tests. RESULTS: There were 137 cases (70.9%) with Pfannenstiel extraction site incisions and 56 (29.0%) at other locations (7 midline, 49 off-midline). There was no significant difference in transversus abdominis plane blocks and epidural analgesia use between groups. Numeric pain scores, overall benefit of analgesia scores, inpatient postoperative opioid use, opioids prescribed at discharge and taken after discharge, and opioid refills were not significantly different between groups. Nonopioid pain analgesics (acetaminophen, nonsteroidal anti-inflammatory drugs, and gabapentin) prescribed at discharge were significantly less in the Pfannenstiel group (90.19% vs 98.45%; p = 0.006). Postoperative complications and readmissions were not different between groups. LIMITATIONS: This study was conducted at a single institution. CONCLUSIONS: The Pfannenstiel incision as the specimen extraction site choice in minimally invasive surgery is associated with similar postoperative pain and opioid use as extraction sites in other locations for patients having robotic colorectal resections. Specimen extraction sites may be chosen based on patient factors other than pain and opioid use. See Video Abstract at http://links.lww.com/DCR/B495. DOLOR POSTOPERATORIO DESPUS DE VAS DE RECUPERACIN MEJORADA EN CIRUGA ROBTICA DE COLON Y RECTO IMPORTA EL LUGAR DE EXTRACCIN DE LA MUESTRA: ANTECEDENTES:La actual crisis de opioides ha motivado a los cirujanos a evaluar críticamente, formas para equilibrar el dolor postoperatorio, disminuyendo el uso de opioides y por lo tanto, disminuyendo opioides disponibles para el desvío comunitario. La incisión más amplia en cirugía colorrectal robótica, es la incisión del sitio de extracción de la muestra. Las técnicas intracorpóreas permiten que la extracción de la muestra se realice en cualquier sitio.OBJETIVO:El estudio fue diseñado para determinar si la ubicación del Pfannenstiel está asociada con menos dolor y uso de opioides, a otros sitios de extracción de la muestra en la pared abdominal.DISEÑO:Estudio de cohorte retrospectivo.AJUSTES:Estudio de base de datos de cirugía colorrectal mantenida prospectivamente (7/2018 a 10/2019).PACIENTES:Se incluyeron resecciones robóticas colorrectales con recuperación mejorada y extracción de muestras.PRINCIPALES MEDIDAS DE RESULTADO:Se utilizó la ponderación del puntaje de propensión para derivar las tasas ajustadas para los puntajes numéricos de dolor, uso de opioides en pacientes hospitalizados, opioides recetados al alta, recarga de opioides después del alta y otros resultados relacionados. Para comparar los resultados entre los grupos, los valores p se calcularon utilizando chi-cuadrado ponderado, exacto de Fisher y pruebas t.RESULTADOS:Hubo 137 (70,9%) casos con incisiones en el sitio de extracción de Pfannenstiel y 56 (29,0%) en otras localizaciones (7 en la línea media, 49 fuera de la línea media). No hubo diferencias significativas en los bloqueos del plano transverso del abdomen y el uso de analgesia epidural entre los grupos. Las puntuaciones numéricas de dolor, puntuaciones de beneficio general de la analgesia, uso postoperatorio de opioides en pacientes hospitalizados, opioides recetados al alta y tomados después del alta, y las recargas de opioides, no fueron significativamente diferentes entre los grupos. Los analgésicos no opioides (acetaminofén, antiinflamatorios no esteroideos, gabapentina) prescritos al alta, fueron significativamente menores en el grupo de Pfannenstiel (90,19% frente a 98,45%, p = 0,006). Las complicaciones postoperatorias y los reingresos, no fueron diferentes entre los grupos.LIMITACIONES:Una sola institución.CONCLUSIÓN:La incisión de Pfannenstiel como sitio de extracción de la muestra en cirugía mínimamente invasiva, se asocia con dolor postoperatorio y uso de opioides similar, a otros sitios de extracción en pacientes sometidos a resecciones robóticas colorrectales. Sitios de extracción de la muestra, pueden elegirse en función de factores del paciente distintos al dolor y uso de opioides. Consulte Video Resumen en http://links.lww.com/DCR/B495.).

Reduced duration of stay after elective colorectal surgery during the peak phase of COVID-19 pandemic: A positive effect of infection risk awareness?

BACKGROUND: While elective surgery was shut down in most settings during the 2019 novel coronavirus pandemic, some referral centers were designated as surgery hubs. We sought to investigate how the pandemic scenario impacted the quality of a long-established enhanced recovery protocol colorectal surgery program in 2 referral centers, designated as colorectal surgery hubs, located in the epicentral Italian regions hardest hit by the pandemic. METHODS: We compared short-term outcomes of patients undergoing major colorectal surgery with a long-established enhanced recovery protocol during the coronavirus disease 2019 outbreak occurred in 2020 (group A) with the correspondent timeframe of 2019 (group B). Primary outcomes were morbidity and mortality, duration of stay, and readmission rate. RESULTS: One hundred and thirty-six patients underwent major colorectal surgery in group A and 173 in group B. Postoperative complications and readmission rate were comparable between the 2 groups. Oncologic case-log was predominant in group A compared with group B (73.5 vs 61%; P = .01). A significantly shorter overall duration of stay was found in group A (P < .001). Uncomplicated patients of group A had a shorter duration of stay when compared with uncomplicated patients of group B (P = .008). CONCLUSION: Under special precautionary measures, major colorectal surgery can be undertaken on elective basis even during coronavirus disease 2019 pandemic with reasonable results. A reduction of duration of stay within a long-established enhanced recovery protocol colorectal surgery program was observed during the coronavirus disease 2019 pandemic occurred in 2020 in comparison with the correspondent timeframe of the previous year without compromising short-term outcomes. The pandemic uncovered the positive impact of patients' commitment to reducing duration of stay as the empowered risk awareness likely promoted their compliance to the enhanced recovery protocol.

Impact of the COVID-19 pandemic on the detection and management of colorectal cancer in England: a population-based study.

BACKGROUND: There are concerns that the COVID-19 pandemic has had a negative effect on cancer care but there is little direct evidence to quantify any effect. This study aims to investigate the impact of the COVID-19 pandemic on the detection and management of colorectal cancer in England. METHODS: Data were extracted from four population-based datasets spanning NHS England (the National Cancer Cancer Waiting Time Monitoring, Monthly Diagnostic, Secondary Uses Service Admitted Patient Care and the National Radiotherapy datasets) for all referrals, colonoscopies, surgical procedures, and courses of rectal radiotherapy from Jan 1, 2019, to Oct 31, 2020, related to colorectal cancer in England. Differences in patterns of care were investigated between 2019 and 2020. Percentage reductions in monthly numbers and proportions were calculated. FINDINGS: As compared to the monthly average in 2019, in April, 2020, there was a 63% (95% CI 53-71) reduction (from 36 274 to 13 440) in the monthly number of 2-week referrals for suspected cancer and a 92% (95% CI 89-95) reduction in the number of colonoscopies (from 46 441 to 3484). Numbers had just recovered by October, 2020. This resulted in a 22% (95% CI 8-34) relative reduction in the number of cases referred for treatment (from a monthly average of 2781 in 2019 to 2158 referrals in April, 2020). By October, 2020, the monthly rate had returned to 2019 levels but did not exceed it, suggesting that, from April to October, 2020, over 3500 fewer people had been diagnosed and treated for colorectal cancer in England than would have been expected. There was also a 31% (95% CI 19-42) relative reduction in the numbers receiving surgery in April, 2020, and a lower proportion of laparoscopic and a greater proportion of stoma-forming procedures, relative to the monthly average in 2019. By October, 2020, laparoscopic surgery and stoma rates were similar to 2019 levels. For rectal cancer, there was a 44% (95% CI 17-76) relative increase in the use of neoadjuvant radiotherapy in April, 2020, relative to the monthly average in 2019, due to greater use of short-course regimens. Although in June, 2020, there was a drop in the use of short-course regimens, rates remained above 2019 levels until October, 2020. INTERPRETATION: The COVID-19 pandemic has led to a sustained reduction in the number of people referred, diagnosed, and treated for colorectal cancer. By October, 2020, achievement of care pathway targets had returned to 2019 levels, albeit with smaller volumes of patients and with modifications to usual practice. As pressure grows in the NHS due to the second wave of COVID-19, urgent action is needed to address the growing burden of undetected and untreated colorectal cancer in England. FUNDING: Cancer Research UK, the Medical Research Council, Public Health England, Health Data Research UK, NHS Digital, and the National Institute for Health Research Oxford Biomedical Research Centre.

The Impact of Transversus Abdominis Plane Block Within an Enhanced Recovery After Surgery Protocol on Length of Stay.

BACKGROUND: Multimodal, narcotic-sparing analgesic strategies are an important part of enhanced recovery after surgery protocols. Within such protocols, regional anesthetics have proven to be superior to narcotics. OBJECTIVE: This study aimed to evaluate the impact of the transversus abdominis plane block within an enhanced recovery after surgery protocol on length of stay. DESIGN: A retrospective analysis of patients who underwent colorectal surgery in 2015 to 2016 was completed. The primary end points for this analysis were total length of stay and total narcotics consumed during hospitalization. Length of stay and total narcotic use were compared for patients who received a transversus abdominis plane block versus those that did not. DATA SOURCE: The data were obtained from the data warehouse of a university teaching hospital. SETTINGS: This study took place at a university teaching hospital. PATIENTS: The patients were 18 years or older. MAIN OUTCOME MEASURES: The primary outcomes measured were length of stay and the total narcotics used. RESULTS: A total of 347 patients underwent colorectal procedures under the enhanced recovery protocol. Among these, 186 (54%) received a transversus abdominis plane block. Overall, the mean length of stay was 5.8 days (SD ±5.6), and median length of stay was 4 days. These values compare to a mean length of stay of 9.6 days and median length of stay of 7 days before implementing the enhanced recovery protocol. Patients who received a transversus abdominis plane block had a mean length of stay of 5.1 days compared to 6.6 days for those who did not receive one (p < 0.01). Patients who received a transversus abdominis plane block consumed 736.5 morphine milligram equivalents of opioids compared to 1150.3 morphine milligram equivalents of opioid consumed by those without a transversus abdominis plane block (p < 0.05), a 36% decrease in opioid use. When comparing patients who had a mean length of stay of 4 days with those whose length of stay was >4 days, there was an 80% decrease in opioid use. The readmission rate was 7.8%. LIMITATIONS: The lack of randomization of patients was a limitation of this study. CONCLUSION: The use of transversus abdominis plane block in the setting of a well-structured enhanced recovery protocol was associated with a statistically significant decrease in length of stay by 1.5 days and a 36% decrease in narcotic use. See Video Abstract at http://links.lww.com/DCR/B432. IMPACTO DE LA ANESTESIA DEL PLANO MUSCULAR DE LOS TRANSVERSOS ABDOMINALES EN LA ESTADA DENTRO UN PROTOCOLO ERAS: ANTECEDENTES:La estrategia analgésica multimodal que consume poco medicamento de tipo narcótico es parte importante en los protocolos de recuperación mejorada postoperatoria. Dentro de dichos protocolos, los anestésicos regionales han demostrado ser superiores a la administración de medicamentos narcóticos.OBJETIVO:Estudiar el impacto del bloqueo del plano muscular de los transversos del abdomen sobre la duración de la estadía dentro de un protocolo de recuperación mejorada postoperatoria.DISEÑO:Se realizó un análisis retrospectivo de los pacientes que se sometieron a cirugía colorrectal entre 2015-2016. Los criterios principales de valoración en el presente análisis fueron la duración total de la estadía y el total de medicamentos narcóticos consumidos durante la hospitalización. Se comparó la duración de la estadía y el uso total de narcóticos en los pacientes que recibieron un bloqueo anestésico del plano muscular de los transversos del abdomen con los que no lo recibieron.FUENTE DE DATOS:Banco de datos de un hospital universitario docente.AMBIENTE:Hospital Universitario Docente.PACIENTES:Adultos desde los 18 años o mayores.PRINCIPALES MEDIDAS DE RESULTADO:Duración de la estadía, cantidad total de medicamentos narcóticos administrados.RESULTADOS:Un total de 347 pacientes se sometieron a procedimientos colorrectales bajo el protocolo ERAS. Entre ellos, 186 (54%) recibieron un bloqueo del plano muscular de los transversos del abdomen. En la globalidad, la duración media de la estadía fué de 5,8 días (DE ± 5,6) y la duración media de la estadía fué de 4 días. Estos resultados fueron comparados con la estadía media de 9,6 días y una estadía media de 7 días antes de implementar el protocolo ERAS. Los pacientes que recibieron un bloqueo del plano muscular de los transversos del abdomen tuvieron una estadía media de 5,1 días en comparación con los 6,6 días de los que no recibieron el mencionado bloqueo (p <0,01). Los pacientes que recibieron el bloqueo del plano muscular consumieron 736,5 miligramos de morfina o su equivalente en opioides, comparados con los 1150,3 de aquellos sin bloqueo del plano muscular (p <0,05) lo que significó una disminución del 36% en la administración de opioides. Al comparar los pacientes que tuvieron una estadía media de 4 días con aquellos cuya estadía fue mayor a 4 días, se evidenció una disminución en el 80% de la administración de opioides. La tasa de reingreso fue del 7,8%.LIMITACIONES:Estudio sin sin aleatorización de pacientes.CONCLUSIÓN:El bloqueo anestésico del plano muscular de los transversos del abdomen dentro un contexto protocolar tipo ERAS o de recuperación mejorada bien estructurada, se asoció con la disminución estadísticamente significativa de la duración de la estadía en 1,5 días y una disminución del 36% en la administración de medicamentos narcóticos. Consulte Video Resumen en http://links.lww.com/DCR/B432.

Procalcitonin as an early marker in the detection of anastomotic intestinal leak in a Universitary Hospital of Bogotá / Procalcitonina como um marcador precoce na detecção de vazamento anastomótico intestinal em um Hospital Universitário de Bogotá

ABSTRACT Introduction: Anastomotic leakage is a complication of intestinal anastomosis, with an incidence of 2%-7% in centers of experience. To be able to achieve an early detection, serological markers such as Procalcitonin were included. Methods: Descriptive retrospective cohort study of patients taken to colorectal surgery with intestinal anastomosis, the objective is to estimate association between procalcitonin (≥2 ng/dl) as an early inflammatory marker and anastomotic leakage in a Coloproctological Service of a highest level of health care hospital, between September 2017 and January 2019. Results: Cohort of 237 patients, 51% women (18-89 years), with multiple comorbidities in 81% of patients, colon cancer was the most operated pathology (53.1%). Laparoscopic approach was the most applied 60.34%, colorectal anastomosis was the most frequently performed (47.26%). Ileocolic anastomosis presented a higher frequency (43.75%-n:7) of dehiscence. Anastomotic leakage was associated with a serum procalcitonin positive 3 days postoperatively (p-value <0.05). Patients with a positive result had 4.28 times higher risk of presenting an anastomotic leak, compared to this risk in those patients with negative results 3 days postoperatively, this association was statistically significant 95% CI (1.34-14.16); p value <0.05. Conclusion: Anastomotic leakage is a source of morbidity in patients taken to intestinal anastomosis. It's necessary to guarantee an early diagnosis of this complication, prevent abscesses and secondary peritonitis, providing adequate treatment and even reducing the associated mortality. We recommend including the procalcitonin in the assessment protocol on the third day of postoperative follow-up.

RESUMO Introdução: O vazamento anastomótico é uma complicação da anastomose intestinal, com uma incidência de 2% a 7% em centros com experiência. Para conseguir uma detecção precoce, foram incluídos marcadores sorológicos como a Procalcitonina. Métodos: Estudo de coorte descritivo e retrospectivo de pacientes submetidos à cirurgia colorretal com anastomose intestinal, cujo objetivo é estimar a associação entre os níveis de procalcitonina (≥ 2 ng/dL) como marcador inflamatório precoce e vazamento anastomótico em um Serviço de Coloproctologia de alto nível de atenção à saúde hospitalar, entre setembro de 2017 a janeiro de 2019. Resultados: Coorte de 237 pacientes, 51% mulheres (18−9 anos), com múltiplas comorbidades em 81% dos pacientes, sendo o câncer de cólon a patologia mais operada (53,1%). A abordagem laparoscópica foi a mais utilizada, em 60,34%, e a anastomose colorretal foi a mais frequentemente realizada (47,26%). A anastomose ileocólica apresentou a maior frequência (43,75%, n = 7) de deiscências. O vazamento anastomótico foi associado a procalcitonina sérica positiva 3 dias após a cirurgia (p < 0,05). Pacientes com resultado positivo tinham um risco 4,28 vezes maior de apresentar vazamento anastomótico, em comparação com esse mesmo risco nos pacientes com resultado negativo 3 dias após a cirurgia, sendo essa associação estatisticamente significativa, (IC95%:1,34−14,16); p < 0,05. Conclusão: O vazamento anastomótico é fonte de morbidade em pacientes encaminhados para anastomose intestinal. É necessário garantir o diagnóstico precoce desta complicação, prevenir abscessos e peritonites secundárias, proporcionando tratamento adequado e até mesmo reduzindo a mortalidade associada. Recomendamos incluir a procalcitonina no protocolo de avaliação no terceiro dia de seguimento pós-operatório.

Analyzing the prevalence of proctological diseases in HIV-positive and -negative patients / Análise da prevalência de doenças proctológicas em pacientes HIV positivo e negativo

ABSTRACT Objective: To compare proctological diseases in HIV-positive and -negative patients. Method: Prospective study conducted in the proctology outpatient clinic at Instituto de Infectologia Emílio Ribas from 2013 through 2019. All of them underwent anamnesis and proctological examination and were divided into two groups (HIV+ and HIV−). The groups were then compared with regard to age, sex, diagnosis, and whether or not there was any indication for surgery. Results: 485 HIV + patients (41.9%) (Group I) and 672 HIV− (58.1%) (Group II). The mean age in Group I was 42.8 years, and 404 (83.3%) of the patients were males. In Group II, the mean age was 48.3 years, and 396 (59%) patients were females. In comparing the groups, a statistically significant difference was found regarding sex, age, and diagnosis. The incidence of hemorrhoid and anal skin tags was higher in group II and that of condyloma acuminata was higher in in Group I (p < 0.001). In Group I, condyloma acuminata was more prevalent, but in those with CD4 levels above 500 cells/mm3, the diagnoses were more similar to those in the population without HIV. Conclusions: Proctological diseases were found to be similar but have different incidences. The incidences of diseases in HIV− and + patients tend to approach each other as CD4 level increases.

RESUMO Objetivo: Comparar as doenças proctológicas nos pacientes HIV positivos e negativos. Método: Estudo prospectivo realizado no ambulatório de proctologia do Instituto de Infectologia Emílio Ribas de 2013 a 2019. Todos foram submetidos a anamnese e exame proctológico, e divididos em dois grupos (HIV+ e HIV−) sendo comparados em relação a idade, sexo, diagnóstico e se havia ou não indicação cirúrgica. Resultados: 485 pacientes HIV+ (41.9%) (Grupo I) e 672 HIV negativos (58.1%) (Grupo II). A média de idade do Grupo I foi 42.8 anos sendo 404 (83.3%) do masculino. No grupo II, a média de idade foi de 48.3 anos, sendo 396 (59%) do sexo feminino. Comparando os grupos, houve diferença estatisticamente significante em relação ao sexo, idade e diagnóstico. Houve maior incidência de hemorróida e plicoma no Grupo II e condilomas acuminados no Grupo I (p < 0.001). No Grupo I, o condiloma acuminado foi mais prevalente, porém naqueles com CD4 acima de 500 células/mm3, os diagnósticos se aproximaram da população sem HIV. Conclusão: As doenças proctológicas foram semelhantes, com incidências diferentes. A incidências das doenças de pacientes HIV− e + tendem a se aproximar na medida que o nível do CD4 aumenta.

Early Follow-up After Colorectal Surgery Reduces Postdischarge Emergency Department Visits.

BACKGROUND: Thirty-day readmissions, emergency department visits, and observation stays are common after colorectal surgery (9%-25%, 8%-12%, and 3%-5%), yet it is unknown to what extent planned postdischarge care can decrease the frequency of emergency department visits. OBJECTIVE: This study's aim was to determine whether early follow-up with the surgical team reduces 30-day emergency department visits. DESIGN: This retrospective cohort study used a central data repository of clinical and administrative data for 2013 through 2018. SETTING: This study was conducted in a large statewide health care system (10 affiliated hospitals, >300 practices). PATIENTS: All adult patients undergoing colorectal surgery were included unless they had a length of stay <1 day or died during the index hospitalization. INTERVENTION: Early (<10 days after discharge) versus late (≥10 days) follow-up at the outpatient surgery clinic, or no outpatient surgery clinic follow-up, was assessed. MAIN OUTCOME MEASURES: The primary outcome measured was the time to 30-day postdischarge emergency department visit. RESULTS: Our cohort included 3442 patients undergoing colorectal surgery; 38% of patients had an early clinic visit. Overall, 11% had an emergency department encounter between 11 and 30 days after discharge. Those with early follow-up had decreased emergency department encounters (adjusted HR 0.13; 95% CI, 0.08-0.22). An early clinic visit within 10 days, compared to 14 days, prevented an additional 142 emergency department encounters. Nationwide, this could potentially prevent 8433 unplanned visits each year with an estimated cost savings of $49 million annually. LIMITATIONS: We used retrospective data and were unable to assess for health care utilization outside our health system. CONCLUSIONS: Early follow-up within 10 days of adult colorectal surgery is associated with decreased subsequent emergency department encounters. See Video Abstract at http://links.lww.com/DCR/B330. EL SEGUIMIENTO TEMPRANO DESPUÉS DE LA CIRUGÍA COLORRECTAL REDUCE LAS VISITAS AL SERVICIO DE URGENCIAS POSTERIOR AL ALTA: Los readmisión a los treinta días, las visitas al servicio de urgencias y las estancias de observación son comunes después de la cirugía colorrectal, 9-25%, 8-12% y 3-5%, respectivamente. Sin embargo, se desconoce en qué medida la atención planificada posterior al alta puede disminuir la frecuencia de las visitas al servicio de urgencias.Determinar si el seguimiento temprano con el equipo quirúrgico reduce las visitas a 30 días al servicio de urgencias.Este estudio de cohorte retrospectivo utilizó un depósito central de datos clínicos y administrativos para 2013-2018.Gran sistema de salud estatal (10 hospitales afiliados,> 300 consultorios).Se incluyeron todos los pacientes adultos de cirugía colorrectal a menos que tuvieran una estadía <1 día o murieran durante el índice de hospitalización.Temprano (<10 días después del alta) versus tardío (≥10 días) o sin seguimiento en la clínica de cirugía ambulatoria.Tiempo para la visita al servicio de urgencias a 30 días después del alta.Nuestra cohorte incluyó 3.442 pacientes de cirugía colorrectal; El 38% de los pacientes tuvieron una visita temprana a clínica. En total, el 11% tuvo un encuentro con el servicio de urgencias entre 11 y 30 días después de ser dado de alta. Aquellos con seguimiento temprano disminuyeron las visitas al servicio de urgencias (HR 0,13; IC del 95%: 0,08 a 0,22). Además, una visita temprana a la clínica en un plazo de 10 días, en comparación con 14 días, evitó 142 encuentros adicionales en el servicio de urgencias. A nivel nacional, esto podría prevenir 8.433 visitas no planificadas cada año con un ahorro estimado de $ 49 millones anuales.Utilizamos datos retrospectivos y no pudimos evaluar la utilización de la atención médica fuera de nuestro sistema de salud.El seguimiento temprano dentro de los 10 días de la cirugía colorrectal en adultos se asocia con una disminución de los encuentros posteriores en el servicio de urgencias. Consulte Video Resumen en http://links.lww.com/DCR/B330. (Traducción-Dr. Gonzalo Hagerman).