Postoperative Handheld Gastric Point-of-Care Ultrasound and Delayed Bowel Function.

BACKGROUND: Delayed bowel function (DBF) following intra-abdominal surgery is a common problem that contributes to postoperative complications and prolonged length of stay. Use of a handheld gastric point-of-care ultrasound (GPOCUS) can identify a full vs empty stomach in the postoperative period. We hypothesized that the findings of a full stomach identified on a postoperative day 1 (POD1) GPOCUS exam would predict an increased risk of delayed bowel function. STUDY DESIGN: A blinded, prospective cohort study was performed. Postoperative colorectal surgery patients were identified as having either a full or empty stomach based on previously published definitions. GPOCUS examinations were performed on POD1 using a handheld ultrasound device, and the clinicians were blinded to the results. Demographic and perioperative data were collected. The primary outcome variable was gastrointestinal-3 (GI-3) recovery, defined as time to tolerance of diet and either flatus or bowel movement. RESULTS: Fifty-six patients agreed to participate in the study; fifty were eligible and included. Eighteen patients' stomachs were identified as full on POD1 GPOCUS examination, and thirty-two were identified as empty. No significant demographic or perioperative differences existed between groups. Patients with full stomachs had significantly delayed GI-3 recovery (4 vs 1 days, p < 0.0001) and longer length of stay (5 vs 3 days, p < 0.0001). Full-stomach patients also had significantly more emesis and nasogastric tube (NGT) placement (both p < 0.05). CONCLUSIONS: GPOCUS performed on POD1 can predict DBF, length of stay, likelihood of emesis, and NGT placement. Use of handheld devices for GPOCUS showed promise for the identification of patients at high risk for DBF and could provide an opportunity for pre-emptive intervention.

The Effect of Commonly Used Local Anesthetic on Bacterial Growth.

INTRODUCTION: Liposomal bupivacaine (LB) has emerged as a superior form of local anesthetic across numerous surgical subspecialties. The purpose of this study is to evaluate the ex-vivo antimicrobial effects of LB in comparison with traditional local anesthetics. METHODS: A standardized inoculum of bacteria commonly associated with surgical site infection was inoculated into a suspension of 1% lidocaine, 0.25% bupivacaine, Exparel (proprietary liposomally packaged 1.3% bupivacaine), and normal saline as a growth control. RESULTS: In all five bacteria tested, the medium inoculated with traditional local anesthetics reduced growth to a greater degree than LB-inoculated plates. Both conventional local anesthetics reduced the growth of all bacteria when compared with the control with the exception of methicillin-susceptible Staphylococcus aureus growth in bupivacaine. LB-inoculated plates had equivalent growth to the control in all plates with the exception of Escherichia coli plates which demonstrated superior growth. CONCLUSIONS: The results of this simple ex-vivo model suggest that the liposomal packaging of bupivacaine may decrease this local anesthetic's innate antibacterial properties.

Reducing colorectal surgical site infections: a novel, resident-driven, quality initiative.

BACKGROUND: Surgical site infections (SSIs) cause significant patient morbidity and increase costs. This work prospectively examines our institutional effort to reduce SSIs through a resident-driven quality initiative. METHODS: A general surgery resident-championed, evidenced-based care bundle for patients undergoing colorectal surgery at a single academic institution was developed using attending mentorship. National Surgical Quality Improvement Program definitions for SSIs were used. Data were collected prospectively and bundle compliance was monitored using a checklist. The primary outcome compared SSIs before and after implementation. RESULTS: In the 2 years preceding standardization, 489 colorectal surgery cases were performed. SSIs occurred in 68 patients (13.9% SSI rate). Following implementation of the bundle, 212 cases were performed with 10 SSIs (4.7% SSI rate, P < .01). Multivariate logistic regression analysis found a decrease in superficial and overall SSIs (odds ratio .17, 95% confidence interval .05 to .59; odds ratio .31, 95% confidence interval .14 to .68). CONCLUSIONS: These data demonstrate that resident-driven initiatives to improve quality of care can be a swift and effective way to enact change. We observed significantly decreased SSIs with a renewed focus on evidence-based, standardized patient care.

Anal warts and anal intradermal neoplasia.

For the last five millennia we have been dealing with the annoyance of verrucas. Anogenital human papillomavirus (HPV) infection is the most common sexually transmitted disease in the United States and is increasing in incidence. As in other gastrointestinal conditions, HPV infection can lead to a stepwise transition from normal cells to dysplastic cells and then to invasive anal cancer. Knowledge of the natural history of HPV infection, risk factors, diagnostic tools, and therapeutic methods gives us the tools to adequately prevent, evaluate, treat, and counsel our patients. In this review, the authors detail the diagnosis, management, and treatment of anal condyloma and anal intraepithelial neoplasia with a focus on prevention, early detection, and treatment using current data and technology.

Anastomotic leak rate after low anterior resection for rectal cancer after chemoradiation therapy.

Anastomotic leak may be the most concerning complication after colorectal anastomosis. To compare open with laparoscopic rectal resection, we must have accurate leak rates in patients who have received neoadjuvant chemoradiation therapy to serve as a benchmark for comparison. All patients who had preoperative chemoradiation therapy with rectal resection and low pelvic anastomosis for cancer in a single colorectal practice over a 7-year period were retrospectively reviewed. All patients had proximal diversion and a contrast enema study before stoma reversal. Eighty-seven consecutive patients were included in the study. Average age was 58 years. Fifty-nine per cent of patients were male. Sixty-six per cent were smokers. Pathologic T stage was 5 per cent T0, 16 per cent T1, 28 per cent T2, 47 per cent T3, and 5 per cent T4. Seventy-five per cent of patients were pathologically lymph node-negative. Average time to stoma reversal was 122 days. Total anastomotic leak rate was 10.3 per cent (8% clinical leaks). Five (56%) patients with leak successfully underwent reversal of their diverting stoma (average time to reversal, 290 days). Patients who had the complication of anastomotic leakage had less likelihood of stoma reversal and a significantly prolonged time to stoma reversal.

Outcomes of low anterior resection anastomotic leak after preoperative chemoradiation therapy for rectal cancer.

Anastomotic leak remains a major cause of morbidity and mortality after colorectal surgery, especially with low anastomoses. The aim of this study was to assess outcomes of patients who developed an anastomotic leak after low anterior resection of the rectum for rectal cancer. An Institutional Review Board-approved retrospective review of 89 consecutive patients undergoing open low anterior resection with primary anastomosis for cancer of the mid/lower rectum at a single institution between January 2001 and December 2008 was performed. All patients received neoadjuvant chemotherapy and radiation therapy. Proximal diversion was performed in all patients. Perioperative data were collected and analyzed with attention to management and outcomes after development of anastomotic leak. Nine patients (10.1%) developed anastomotic leak. Mean age was 62 years. Mean tumor level was 4.8 cm above the anal verge. Symptomatic anastomotic leak developed in seven (78%) patients. Percutaneous drainage was performed in five (55.6%) patients with an average of 4.4 procedures required for management of anastomotic leak. Five (55.6%) patients required reoperation. Only two procedures (25%) involved laparotomy. No operative procedures were performed emergently. There were no mortalities. Excluding one patient who received completion proctectomy for local recurrence, restoration of intestinal continuity was achieved in five (63%) of eight patients. Mean time to stoma closure was 289 days. The potentially lethal complication of anastomotic leak after low anterior resection for rectal cancer can be managed expectantly and electively in patients who are proximally diverted with the expectation of stoma reversal in the long term.

Thermal diffusion probe analysis of perfusion changes in vascular occlusions of rabbit pedicle flaps.

BACKGROUND: The purpose of this study was to show the efficacy of a novel tissue blood flow measuring device in an animal model. Thermal diffusion technology evaluates changes in perfusion in small volumes of tissue. METHODS: The thermal diffusion probe device is a long, 0.9-mm-diameter flexible catheter with two thermistors, which are placed directly into the tissue; it excites an active thermistor to a constant temperature slightly above the tissue baseline and collects data on the power dissipated in the active thermistor. It also continuously monitors the baseline tissue temperature using an additional passive thermistor placed outside the heated field. In this study, rabbit epigastric pedicle flaps were instrumented with two thermal diffusion probes (peripheral and deep) to continuously monitor flap perfusion. RESULTS: Twenty-five vascular occlusion studies were performed in 16 flaps. Blood vessel occlusions (arterial, venous, and arteriovenous) were easily detectable with this system. Waveforms for arterial and arteriovenous occlusions differed from those for venous occlusions. Probes in both peripheral and deep tissue locations were sensitive to changes in tissue perfusion. CONCLUSION: Thermal diffusion probes may provide a useful clinical method for monitoring flap perfusion.