New barrier attire regulations in the operating room: A mandate without basis?

BACKGROUND: Recent AHRQ/Joint Commission guidelines mandate additional barrier attire for all operating room personnel to target infection. The scientific basis for this is unclear. STUDY DESIGN: Patients undergoing abdominal surgery at our institution were identified from institutional NSQIP database before and after March 2016, when guidelines were implemented. Patient-level variables were compared for the pre- and post-implementation groups. Multivariable regression evaluated associations between implementation and surgical site infection (SSI) and other outcomes. RESULTS: 1122 patients (including 60.9% laparoscopic and 16.4% bowel resection procedures) were included. There were 607 patients post-implementation and 515 pre-implementation; cohorts were similar in risk factors for SSI. Fifty-seven patients developed SSI. On multivariable analysis, laparoscopy, bowel resection and operating duration, but not barrier attire, were associated with SSI. Implementation of attire did not significantly impact SSI (p = 0.4), hospital readmission (p = 0.4), or reoperation (p = 0.9). CONCLUSIONS: These data question the rationale for the new more stringent operating room attire guidelines which burden hospitals with additional cost, time and resources, and could detract efforts to target important factors that really influence outcomes.

Ethical considerations regarding the implementation of new technologies and techniques in surgery.

Ethical considerations relevant to the implementation of new surgical technologies and techniques are explored and discussed in practical terms in this statement, including (1) How is the safety of a new technology or technique ensured?; (2) What are the timing and process by which a new technology or technique is implemented at a hospital?; (3) How are patients informed before undergoing a new technology or technique?; (4) How are surgeons trained and credentialed in a new technology or technique?; (5) How are the outcomes of a new technology or technique tracked and evaluated?; and (6) How are the responsibilities to individual patients and society at large balanced? The following discussion is presented with the intent to encourage thought and dialogue about ethical considerations relevant to the implementation of new technologies and new techniques in surgery.

Colorectal cancer in patients under 50 years of age: a retrospective analysis of two institutions' experience.

AIM: To investigate the epidemiological characteristics of colorectal cancer (CRC) in patients under 50 years of age across two institutions. METHODS: Records of patients under age 50 years of age who had CRC surgery over a 16 year period were assessed at two institutions. The following documents where reviewed: admission notes, operative notes, and discharge summaries. The main study variables included: age, presenting symptoms, family history, tumor location, operation, stage/differentiation of disease, and post operative complications. Stage of disease was classified according to the American Joint Committee on Cancer TNM staging system: tumor depth; node status; and metastases. RESULTS: CRC was found in 180 patients under age 50 years (87 females, 93 males; mean age 41.4 ± 6.2 years). Young patients accounted for 11.2% of cases during a 6 year period for which the full data set was available. Eight percent had a 1(st) degree and 12% a 2(nd) degree family CRC history. Almost all patients (94%) were symptomatic at diagnosis; common symptoms included: bleeding (59%), obstruction (9%), and abdominal/rectal pain (35%). Evaluation was often delayed and bleeding frequently attributed to hemorrhoids. Advanced stage CRC (Stage 3 or 4) was noted in 53% of patients. Most tumors were distal to the splenic flexure (77%) and 39% involved the rectum. Most patients (95%) had segmental resections; 6 patients had subtotal/total colectomy. Poorly differentiated tumors were noted in 12% and mucinous lesions in 19% of patients of which most had Stage 3 or 4 disease. Twenty-two patients (13%) developed recurrence and/or progression of disease to date. Three patients (ages 42, 42 and 49 years) went on to develop metachronous primary colon cancers within 3 to 4 years of their initial resection. CONCLUSION: CRC was common in young patients with no family history. Young patients with symptoms merit a timely evaluation to avoid presentation with late stage CRC.

John Jones, M.D.: pioneer, patriot, and founder of American surgery.

John Jones was a pioneer of American Surgery. Born in Long Island, New York in 1729, he received his medical degree in France from the University of Rheims. He returned to the colonies and helped to establish the medical school that would later become Columbia University's College of Physicians and Surgeons where he was appointed the first Professor of Surgery in the New World. He used his position to assert that surgeons trained in America should be familiar with all facets of medicine and not be mere technicians. Before the outbreak of the American Revolution, he wrote a surgical field manual, which was the first medical text published in America. A believer in the principles of the American Revolution, he would go on to count Benjamin Franklin and George Washington as his patients. Despite achieving many firsts in American medicine, his influence on surgical training is his most enduring legacy.

Prospective study of ambulation after open and laparoscopic colorectal resection.

PURPOSE: Open and laparoscopic surgical approaches each have specific advantages. This study compares ambulation, hospital length of stay (LOS), and incision length after open and laparoscopic colorectal resection. METHODS: All consecutive patients undergoing colorectal resection over a 2 year period ending August 2002 were followed prospectively. Ambulation, LOS, and incision length were recorded. Hybrid low anterior resection (LAR) patients had laparoscopic splenic flexure takedown, vessel ligation, and proximal rectal mobilization followed by planned inferior laparotomy to complete the case. Groups were compared using Student's t test. RESULTS: Equivalent open and laparoscopic groups were comparable in terms of gender, age, body mass index, ASA class, indication for operation, and resection performed. Seventy open colectomy patients were compared with 99 laparoscopic-assisted colectomy patients. On average, patients in the open and laparoscopic groups ambulated 67 and 390 feet, respectively, on postoperative day 1 (P < .001), 290 and 752 feet on day 2 (P < .001), and 495 and 965 feet on day 3 (P < .001). The average LOS in the open group was 9.3 days compared with 5.9 days in the laparoscopic group (P < .001). The average incision length in the open group was 19.7 cm compared with 5.3 cm in the laparoscopic group (P < .001). Seventeen open LAR patients were compared with 30 hybrid LAR patients. On average, patients in the open and hybrid groups ambulated 22 and 150 feet, respectively, on postoperative day 1 (P = .003), 105 and 433 feet on day 2 (P = .003), and 369 and 488 feet on day 3 (P = .43). The average LOS in the open group was 10 days compared with 8.5 days in the hybrid group (P = .46). The average incision length in the open group was 19.8 cm compared with 10.8 cm in the hybrid group (P < .001). When all 216 patients were considered, the 91 patients with incisions shorter than 8 cm (average 4.6 cm) ambulated 396, 752, and 956 feet on consecutive days whereas the 125 patients with incisions 8 cm or longer (average 16.9 cm, P < .001) ambulated 101, 334, and 521 feet on consecutive days (all P values <.001). Average LOS in the <8-cm group was 6 days compared with 8.9 days in the > or =8-cm group (P < .001). CONCLUSIONS: Patients undergoing minimal-access colorectal surgery ambulated significantly further than equivalent open patients in the early postoperative period and had a shorter LOS.

Major abdominal surgery increases plasma levels of vascular endothelial growth factor: open more so than minimally invasive methods.

INTRODUCTION: Vascular endothelial growth factor (VEGF) is a potent inducer of angiogenesis that is necessary for wound healing and also promotes tumor growth. It is anticipated that plasma levels would increase after major surgery and that such elevations may facilitate tumor growth. This study's purpose was to determine plasma VEGF levels before and early after major open and minimally invasive abdominal surgery. METHODS: Colorectal resection for cancer (n = 139) or benign pathology (n = 48) and gastric bypass for morbid obesity (n = 40) were assessed. Similar numbers of open and laparoscopic patients were studied for each indication. Plasma samples were obtained preoperatively and on postoperative days (POD) 1 and 3. VEGF levels were determined via ELISA. The following statistical methods were used: Fisher exact test, unmatched Student t test, Wilcoxon's matched pairs test, and the Mann Whitney U Test with P < 0.05 considered significant. RESULTS: The mean preoperative VEGF level of the cancer patients was significantly higher than baseline level of benign colon patients. Regardless of indication or surgical method, on POD3, significantly elevated mean VEGF levels were noted for each subgroup. In addition, on POD1, open surgery patients for all 3 indications had significantly elevated VEGF levels; no POD1 differences were noted for the closed surgery patients. At each postoperative time point for each procedure and indication, the open group's VEGF levels were significantly higher than that of the matching laparoscopic group. VEGF elevations correlated with incision length for each indication. CONCLUSION: As a group colon cancer patients prior to surgery have significantly higher mean VEGF levels than patients without tumors. Also, both open and closed colorectal resection and gastric bypass are associated with significantly elevated plasma VEGF levels early after surgery. This elevation is significantly greater and occurs earlier in open surgery patients. The duration and clinical importance of this finding is uncertain but merits further study.

A 10-year single-institutional study of the biofragmentable anastomosis ring.

BACKGROUND: The biofragmentable anastomosis ring (BAR) was introduced by Hardy in 1985 as a simple alternative to sutured or stapled intestinal anastomosis. METHODS: The aim of this study was to analyze complications related to the use of the BAR in elective intraperitoneal intestinal anastomosis to identify technical aspects important in the safe use of the device. The BAR was used by a single surgeon over a 10-year period. Three hundred fifty sequential intraperitoneal anastomoses were performed in 346 patients. There were 12 enteroenteric, 2 gastrojejunal, 199 enterocolic, and 137 colocolic anastomoses. RESULTS: There was 1 suture line recurrent carcinoma but no strictures. There were 11 complications that appeared related to construction of the anastomosis, 2 of them resulting in death. The 2 patients who died both had cirrhosis with ascites. Eight patients required re-exploration for suspected anastomotic complications. Six of them recovered and were discharged. CONCLUSION: The BAR appears to be a safe alternative to sutured or stapled bowel anastomosis provided certain precautions are taken in its use.

Safety and reliability of tattooing colorectal neoplasms prior to laparoscopic resection.

Accurate tumor localization is critical to performing minimally invasive colorectal resection. This study reviews the safety and reliability of tattooing colorectal neoplasms prior to laparoscopic resection. We retrospectively reviewed 50 consecutive patients with colorectal neoplasms who underwent endoscopic tattooing prior to laparoscopic resection. Data were obtained from medical charts, endoscopy records, and pathology reports. No complications related to endoscopy or tattooing were incurred. Five neoplasms (10%) were in the ascending colon, five (10%) were in the transverse colon, eight (16%) were in the descending colon, 23 (46%) were in the sigmoid colon, and nine (18%) were in the rectum. Tattoos were visualized intraoperatively and accurately localized the neoplasm in 44 patients (88%). Six patients (12%) did not have tattoos visualized laparoscopically and required intraoperative localization. On average, the pathology specimens in this series had a 15 cm proximal margin, a 12 cm distal margin, and 15 lymph nodes. In the context of laparoscopic colorectal resection, preoperative endoscopic tattooing is a safe and reliable method of tumor localization in most cases. Localizing colon and proximal rectal lesions with tattoos may be preferable to other localization techniques including intraoperative endoscopy.

Depletion of circulating insulin-like growth factor binding protein 3 after open surgery is associated with high interleukin-6 levels.

PURPOSE: We have previously shown that plasma from open, but not laparoscopic-assisted, surgery patients has increased mitogenic activity for colon cancer cells. Decreased insulin-like growth factor binding protein 3 levels, most likely the result of an open surgery-induced proteolytic activity, may account for this finding. Plasma proteases are activated by interleukin-6. This study was designed to investigate plasma insulin-like growth factor binding protein 3 and interleukin-6 levels after major open or laparoscopic-assisted surgery. METHODS: EDTA plasma was obtained from 24 patients undergoing resection for colonic adenocarcinoma. Insulin-like growth factor binding protein 3 was detected by Western blot analysis and enzyme-linked immunosorbent assay. Interleukin-6 levels were determined by enzyme-linked immunosorbent assay. The effect of insulin-like growth factor binding protein 3 on tumor growth was tested using HCT116 cells. RESULTS: In patients undergoing open surgery, enzyme-linked immunosorbent assay revealed a significant decrease in total insulin-like growth factor binding protein 3 levels on postoperative Day 1 (915.6 +/- 378.5 ng/ml) compared with preoperative levels (1267.5 +/- 407.9 ng/ml; P < 0.001). Western blots revealed a decrease in the levels of intact insulin-like growth factor binding protein 3. In patients undergoing laparoscopic-assisted surgery, levels of total and intact insulin-like growth factor binding protein 3 before surgery (1088.9 +/- 232.5 ng/ml) and on postoperative Day 1 (1,202.3 +/- 285.6 ng/ml) were comparable with no significant changes in Western blot analysis. Interleukin-6 levels were undetectable preoperatively. On postoperative Day 1, interleukin-6 concentration was higher in open surgery group (434.8 +/- 506.6 pg/ml) compared with laparoscopic-assisted surgery group (100.9 +/- 60.2 pg/ml; P < 0.0001), and correlated significantly with a decrease in plasma insulin-like growth factor binding protein 3 after open surgery (r = 0.81; P < 0.0001). CONCLUSIONS: A significant decrease in both total and free insulin-like growth factor binding protein 3 occurs after open but not laparoscopic colectomy. There is an associated increase in the levels of interleukin-6. It remains to be proven that the interleukin-6 elevations are responsible for the low insulin-like growth factor binding protein 3 level seen after open surgery.

Colorectal cancer surveillance after age 65 years.

BACKGROUND: It would be valuable to determine whether or not asymptomatic patients 60 to 65 years of age with normal colonoscopies should continue to undergo serial colorectal cancer surveillance examinations. METHODS: Data were obtained from retrospective review of our existing database. Additional data were obtained from patients' medical records, office charts, and pathology reports. In situ endoscopic measurements were performed using a biopsy forceps that was 7 mm when fully extended. RESULTS: Over the past 25 years, 699 asymptomatic patients between 60 and 65 years of age underwent colonoscopies which revealed no pathology. As part of their routine continuing colorectal surveillance and without any prior abnormal endoscopic findings, 56 of these patients underwent a total of 123 colonoscopies after age 65. Thirty-seven patients (66%) had surveillance colonoscopies that continued to be normal while 13 patients (23%) were diagnosed with colorectal adenomas and 6 patients (11%) were found to have hyperplastic polyps. No cancers were discovered. CONCLUSIONS: Patients over the age of 65 should continue to undergo colorectal surveillance even if prior examinations have been negative.

Plasma from patients undergoing major open surgery stimulates in vitro tumor growth: Lower insulin-like growth factor binding protein 3 levels may, in part, account for this change.

BACKGROUND: Plasma from laparotomized mice has been shown to stimulate in vitro tumor growth when compared to results with preoperative plasma. This study assessed the effect of plasma from patients who underwent major open (OS) or laparoscopic surgery (LS) on in vitro tumor cell growth. METHODS: Eighty-four patients undergoing major abdominal surgery were studied (45 OS, 39 LS). Peripheral blood was collected preoperatively (PreOP) and on days 1 (POD1) and 3 (POD3) after operation. HT29 human colon cancer cells were plated with samples of the plasma. Proliferation was assessed by cell counts and the bromodeoxyuridine incorporation assay. Insulin-like growth factor binding protein 3 was detected in plasma by Western blot analysis. RESULTS: Increased mitogenic activity was noted in POD1 OS plasma when compared to PreOP OS plasma results (P <.005). This increase correlated with the length of incision (r = 0.58, P <.01). No differences were noted when the PreOP LS and POD1 LS results were compared or for any of the POD3 versus PreOP comparisons. CONCLUSIONS: Major OS is associated with alterations in plasma composition that promote HT29 tumor cell proliferation in vitro. As shown, this effect was due, at least in part, to surgery-related depletion of insulin-like growth factor binding protein 3 in peripheral blood.