The role of rectal magnetic resonance imaging in accurate localization and designation of colorectal cancer for optimal management: Case study.

Colorectal cancer, developing from malignant transformation of the distal gut epithelium, is the second leading cause of cancer death in the United States. We present a gentleman in his 60s who was diagnosed with colorectal cancer during a routine screening colonoscopy with no evidence of distant metastasis on subsequent staging with positron emission tomography and computed tomography (PET-CT). The outside rectal MR (magnetic resonance) imaging report localized a mass to the upper rectum. Review of the MRI at an institutional, Multidisciplinary Tumor Board designated the tumor as "rectosigmoid," straddling the rectosigmoid junction at the level of the "sigmoid take-off" (STO) or alternatively at the level of the last sigmoid artery take-off (SAT) at the origin of the superior rectal artery. The anatomic differentiation between upper rectal and lower sigmoid colon cancers carries clinical importance which is highlighted in this case report and brief literature review. Optimal anatomic localization of colorectal cancers helps direct the clinical team to tailor an individualized patient care plan.

Surgical and Interventional Management of Lung Metastasis: Surgical Assessment, Resection, Ablation, Percutaneous Interventions.

The lungs are the second most common site of metastases for colorectal cancer after the liver. Pulmonary metastases can be identified at the time of diagnosis of the primary tumor, or metachronously. About 20% of patients with colorectal cancer will develop pulmonary metastases. The best options for treatment include a multidisciplinary treatment approach consisting of surgical resection whenever possible, and chemotherapy. Surgical options most often include minimally invasive segmentectomy or wedge resection, while patients unable to have surgery may benefit from radio frequency ablation or radiation treatment. Prognosis is dependent on preoperative carcinoembryonic antigen level, number, and location of metastatic lesions, and resectability of primary tumor. Overall, pulmonary metastases are best treated by complete resection whenever possible.

Evaluation of Medicare Reimbursement and Surgical Patterns for Male and Female Colorectal Surgeons.

INTRODUCTION: There are documented differences in salary for male and female surgeons. Understanding the differences in the clinical practice, composition of male and female surgeons may provide a better understanding of reimbursement differences. We aim to evaluate the differences of Medicare reimbursement for different categories of clinical practice for male and female colorectal surgeons. METHODS: This retrospective cohort study compared Medicare claims made by male and female board-certified colorectal surgeons from the Medicare Provider Utilization and Payment Data between 2013 and 2017. Medicare claims were categorized by surgeon gender. Submitted claims were evaluated based on the following seven procedure categories: open abdominal surgery, laparoscopic abdominal surgery, anorectal surgery, diagnostic endoscopy, therapeutic endoscopy, and inpatient/outpatient services. The main outcomes were number of charges submitted by clinical activity category and procedural code variation billed through Medicare. Secondary outcome was category of procedure activity that each surgeon cohort had participated in. RESULTS: A total of 62,866 claims were reviewed, of which 10,058 (16.0%) were made by female surgeons and 52,808 (84.0%) were made by male surgeons. On average, male surgeons submitted more claims per year, a greater variety of claims per year, and higher revenue generating claims than female surgeons (P < 0.001). CONCLUSIONS: Male and female colorectal surgeons may participate in different categories of clinical activities that result in male surgeons performing more and higher relative value units-generating activity than female surgeons.

Clinical Tools for Rectal Cancer Response Assessment following Neoadjuvant Treatment in the Era of Organ Preservation.

Local tumor response evaluation following neoadjuvant treatment(s) in rectal adenocarcinoma requires a multi-modality approach including physical and endoscopic evaluations, rectal protocoled MRI, and cross-sectional imaging. Clinical tumor response exists on a spectrum from complete clinical response (cCR), defined as the absence of clinical evidence of residual tumor, to near-complete response (nCR), which assumes a significant reduction in tumor burden but with increased uncertainty of residual microscopic disease, to incomplete clinical response (iCR), which incorporates all responses less than nCR that is not progressive disease. This article aims to review the clinical tools currently routinely available to evaluate treatment response and offers a potential management approach based on the extent of local tumor response.

Fertility and Pregnancy: How Do These Affect Family Planning and Surgeon Health?

There are unique considerations to fertility and pregnancy for women surgeons. Women surgeons often decide to delay pregnancy and childbearing due to concerns of conflict with work and training. This is particularly true for surgical trainees who face many obstacles, including bias from peers and program directors, and work-life conflict. As such, rates of infertility are higher compared with the general population. Women surgeons require assisted reproductive technologies more often than the general population. During pregnancy, there are also additional occupational hazards that are unique to a surgical career. Overall, we must be aware of these issues to support surgeons who decide to become parents during a surgical career.

Bowel Preparation for Elective Hartmann Operation: Analysis of the National Surgical Quality Improvement Program Database.

Background: Use of pre-operative bowel preparation in colorectal resection has not been examined solely in patients who have had colorectal resection with primary colostomy (Hartmann procedure). We aimed to evaluate the association of bowel preparations with short-term outcomes after non-emergent Hartmann procedure. Patients and Methods: The National Surgical Quality Improvement Program Participant Use File colectomy database was queried for patients who had elective open or laparoscopic Hartmann operation. Patients were grouped by pre-operative bowel preparation: no bowel preparation, oral antibiotic agents, mechanical preparation, or both mechanical and oral antibiotic agent preparation (combined). Propensity analysis was performed, and outcomes were compared by type of pre-operative bowel preparation. The primary outcome was rate of any surgical site infection (SSI). Secondary outcomes included overall complication, re-operation, re-admission, Clostridioides difficile colitis, and length of stay. Results: Of the 4,331 records analyzed, 2,040 (47.1%) patients received no preparation, 251 (4.4%) received oral antibiotic preparation, 1,035 (23.9%) received mechanical bowel preparation, and 1,005 (23.2%) received combined oral antibiotic and mechanical bowel preparation. After propensity adjustment, rates of any SSI, overall complication, and length of hospital stay varied significantly between pre-operative bowel regimens (p < 0.005). The use of combined bowel preparation was associated with decreased rate of SSI, overall complication, and length of stay. No difference in rate of re-operation or post-operative Clostridioides difficile infection was observed based on bowel preparation. Conclusions: Compared with no pre-operative bowel preparation, any bowel preparation was associated with reduced rate of SSI, but not rate of re-operation or post-operative Clostridioides difficile infection.

A retrospective study of the effects of minimally invasive colorectal surgery on Patient Safety Indicators across a five-hospital system.

BACKGROUND: The Agency for Healthcare Research and Quality uses Patient Safety Indicators (PSI) to gauge quality of care and patient safety in hospitals. PSI 90 is a weighted combination of several PSIs that primarily comprises perioperative events. This score can affect reimbursement through Medicare and hospital quality ratings. Minimally invasive surgery (MIS) has been shown to decrease adverse events and outcomes. We sought to evaluate individual PSI and PSI 90 outcomes of minimally invasive versus open colorectal surgeries using a large medical database from 5 hospitals. METHODS: A health system administrative database including all inpatients from 5 acute care hospitals was queried based on ICD 10 PC codes for colon and rectal surgery procedures performed between January 2, 2018 and December 31, 2019. Surgeries were labeled as MIS (laparoscopic) or open colorectal resection surgery. Patient demographics, health information, and case characteristics were analyzed with respect to surgical approach and PSI events. Statistical relationships between surgical approach and PSI were investigated using univariate methods and multivariate logarithmic regression analysis. PSIs of interest were PSI 8, PSI 9 PSI 11, PSI 12, and PSI 13. RESULTS: There were 1382 operations identified, with 861 (62%) being open and 521 (38%) being minimally invasive. Logistic modeling showed no significant difference between the 2 groups for PSI 3, 6, or 8 through 15. CONCLUSION: Understanding PSI 90 and its components is important to enhance perioperative patient care and optimize reimbursement rates. We showed that MIS, despite providing known clinical benefits, may not affect scores in the PSI 90. Surgical approach may have little effect on PSIs, and other patient and system components that are more important to these outcome measures should be pursued.

Effect of preoperative versus postoperative use of transversus abdominis plane block with plain 0.25 % bupivacaine on postoperative opioid use: a retrospective study.

BACKGROUND: Enhanced recovery protocols optimize pain control via multimodal approaches that include transversus abdominis plane (TAP) block. The aim of this study was to evaluate the effect of preoperative vs. postoperative plain 0.25 % bupivacaine TAP block on postoperative opioid use after colorectal surgery. METHODS: A retrospective cohort study comparing postoperative opioid use in patients who received preoperative (n = 240) vs. postoperative (n = 22) plain 0.25 % bupivacaine TAP blocks. The study was conducted in a single tertiary care institution and included patients who underwent colorectal resections between August 2018 and January 2020. The primary outcome of the study was postoperative opioid use. Secondary outcomes included operative details, length of stay, reoperation, and readmission rates. RESULTS: Patients who received postoperative plain 0.25 % bupivacaine TAP blocks were less likely to require postoperative patient-controlled analgesia (PCA) (59.1 % vs. 83.3 %; p = 0.012) and opioid medications on discharge (6.4 % vs. 16.9 %; p = 0.004) relative to patients who received preoperative TAP. When needed, a significantly smaller amount of opioid was prescribed to the postoperative group (84.5 vs. 32.0 mg, p = 0.047). No significant differences were noted in the duration of postoperative PCA use, amount of oral opioid use, and length of stay. CONCLUSIONS: Plain 0.25 % bupivacaine TAP block administered postoperatively was associated with significantly lower need for postoperative PCA and discharge opioid medications. The overall hospital length of stay was not affected by the timing of TAP block. Because of the limited sample size in this study, conclusions cannot be generalized, and more research will be required.

Safety of Transrectal or Transvaginal Drainage of Pelvic Abscesses / Segurança da drenagem transretal ou transvaginal de abscessos pélvicos

Abstract Objective The literature on the safety and long-term sequelae of transrectal and transvaginal drainage of pelvic abscesses is limited. We evaluated the outcomes and safety of pelvic abscess drainage by interventional radiology at our institution. Methods After obtaining institutional review board approval, we retrospectively evaluated the outcomes of transrectal and transvaginal pelvic abscesses drainage using computed tomography, endorectal ultrasound, and or fluoroscopy. Results The study included 26 patients, with an age range of 24 to 88 years old, out of whom 53.8% were men. A total of 46.1% of the participants were African Americans and 26.9% were Caucasians. The average body mass index was 28.4 (range: 15.6 to 41.9). The most common etiology was penetrating abdominal injury (27%), followed by appendectomy (23%), diverticular disease (11.5%), anastomotic leak (11.5%), and disorders of gynecological causes (11.5%). The mean abscess diameter was 6.3 cm (range: 3.3 to 10.0 cm). Transrectal drainage was performed in all except one patient who had a transvaginal drainage. Transrectal ultrasound was used for drainage in 92.3% cases, and fluoroscopy was used as an additional imaging modality in 75% of the cases. An 8- or 10-Fr pigtail catheter was used in>80% of the patients. Drains were removed between 2 and 7 days in 92.3% of the cases. The average follow-up was 30.4 months (range: 1 to 107 months), and no long-term complications were reported. Only one patient required subsequent operative intervention for an anastomotic leak. Conclusions Pelvic abscess drainage by transrectal route using radiological guidance is a safe and effective procedure.

Resumo Objetivo A literatura sobre a segurança e as sequelas no longo prazo da drenagem transretal e transvaginal do abscesso pélvico é limitada. Avaliamos os resultados e a segurança da drenagem do abscesso pélvico por radiologia intervencionista em nossa instituição. Métodos Após obter a aprovação do conselho de revisão institucional, avaliamos retrospectivamente os resultados da drenagem de abscessos pélvicos transretais e transvaginais por meio de tomografia computadorizada, ultrassom endorretal, e/ou fluoroscopia. Resultados Participaram do estudo 26 pacientes, com faixa etária de 24 a 88 anos, dos quais 53,8% eram homens. Um total de 46,1% eram afro-descendentes, e 26,9% eram brancos. O índice de massa corporal médio foi de 28,4 (gama: 15,6 a 41,9). A etiologia mais comum foi lesão abdominal penetrante (27%), seguida de apendicectomia (23%), doença diverticular (11,5%), fístula anastomótica (11,5%) e distúrbios de causas ginecológicas (11,5%). O diâmetro médio do abscesso foi de 6,3 cm(gama: 3,3 a 10,0 cm). A drenagem transretal foi realizada em todos os pacientes, com exceção de uma, que foi submetida a uma drenagem transvaginal. A ultrassonografia transretal foi utilizada para drenagem em 92,3% dos casos, e a fluoroscopia como modalidade adicional de imagem, em 75% dos casos. Um catéter duplo J de 8 ou 10 Fr foi usado em>80% dos pacientes. Os drenos foram retirados entre 2 e 7 dias em 92,3% dos casos. O acompanhamentomédio foi de 30,4meses (gama: 1 a 107 meses), e nenhuma complicação de longo prazo foi relatada. Apenas um paciente necessitou de intervenção cirúrgica subsequente para um vazamento anastomótico. Conclusão A drenagem do abscesso pélvico por via transretal com orientação radiológica é um procedimento seguro e eficaz.

Risk Factors for Surgical Site Infection After Laparoscopic Colectomy: An NSQIP Database Analysis.

BACKGROUND: Surgical site infection (SSI) is a common complication after colon surgery. This study aimed to evaluate risk factors for SSI and its types in laparoscopic colectomy patients using the American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) database. MATERIALS AND METHODS: The NSQIP database was queried for patients undergoing laparoscopic colectomy from 2011 through 2017. Univariate analysis and multivariable logistic regression were used to evaluate risk factors associated with any SSI, superficial SSI, deep-incisional SSI, and organ-space SSI. RESULTS: Of 72,519 patients, 4906 cases of SSI were identified: 2276 superficial SSI, 357 deep-incisional SSI, and 2483 organ-space SSI. Risk factors associated with superficial SSI were admission before procedure (adjusted odds ratio [AOR] = 1.31; 95% confidence interval [CI] 1.17-1.47; P < 0.01), smoking (AOR = 1.29; 95% CI 1.16-1.44; P < 0.01), and higher body mass index (AOR = 1.24 for every 5 kg/m2 increase; 95% CI 1.20-1.27; P < 0.01). Deep-incisional SSI was associated with steroid use (AOR = 1.81; 95% CI 1.31-2.49; P < 0.01), admission before procedure (AOR = 1.66; 95% CI 1.30-2.13; P < 0.01), and smoking (AOR = 1.50; 95% CI 1.17-1.94; P < 0.01). Risk factors associated with organ-space SSI were wound class (AOR = 2.45 for class 4 versus ≤ 2; 95% CI 2.16-2.78; P < 0.01), chemotherapy within 90 d (AOR = 1.57; 95% CI 1.33-1.84; P < 0.01), and steroid use (AOR = 1.46; 95% CI 1.29-1.65; P < 0.01). Receipt of an oral antibiotic prep preoperatively was the strongest factor associated with SSI. CONCLUSIONS: SSI types in patients undergoing laparoscopic colectomy have different risk factors. Modifiable risk factors may provide an opportunity to reduce SSI risk and its associated morbidity.

Surgical Wound Misclassification to Clean From Clean-Contaminated in Common Abdominal Operations.

BACKGROUND: Wound classification helps predict wound-related complications and is useful in stratifying surgical site infection reporting. We sought to evaluate misclassification among commonly performed surgeries that are at least clean-contaminated. MATERIALS AND METHODS: The National Surgical Quality Improvement Program database was queried from 2005 to 2016 by Current Procedural Terminology codes identifying common surgeries that are, by definition, not clean: colectomy, cholecystectomy, hysterectomy, and appendectomy. Univariate analysis and multivariate logistic regression were performed. RESULTS: Of the 1,208,544 operative cases reviewed, 22,925 (1.90%) were misclassified as clean. Hysterectomy was the most commonly misclassified operation (3.11%), and colectomy the least (0.82%). Misclassification was higher in laparoscopic cases (1.92% versus 1.82%; P < 0.01). Misclassification increased from 2005 to 2016 (0.22% versus 3.11%; P < 0.01). Misclassified patients were younger (46.7 versus 47.7 y; P < 0.01); had lower rates of hypertension, chronic obstructive pulmonary disease, smoking history, and steroid use (P < 0.01); and had shorter length of stay (2.2 versus 3.2 d; P < 0.01), lower 30-d readmission rates (3.7% versus 5.0%; P < 0.01), and less surgical site infections (1.7% versus 3.4%; P < 0.01). Open hysterectomy was the most significant positive predictor for misclassification (odds ratio 3.34; P < 0.01). Open appendectomy was the most significant negative predictor (odds ratio 0.20; P < 0.01). CONCLUSIONS: There is an increasing trend of misclassifying wounds as clean. Misclassified patients have better outcomes, and misclassification may be affected by patient characteristics, operative approach, and type of procedure rather than reflecting the true infectious burden. Further research is warranted.

Is Loop Ileostomy in Patients with Cecal Bascule a Viable Option?

BACKGROUND: Cecal bascule, initially described in 1899 by Treves, is the rarest form of cecal volvulus and represents a phenomenon when a redundant and distended cecum folds anteriorly over the ascending colon causing an intestinal obstruction. Patients with cerebral palsy are at increased risk for this condition. CASE PRESENTATION: We present a 28-year-old male with cerebral palsy, functionally dependent in all activities of daily living, who had undergone a loop ileostomy for cecal bascule. He then presented to our emergency department with a large loop ileostomy prolapse, which was the result of an inverted prolapsed cecum through the efferent ileostomy limb. He underwent a right hemicolectomy with end ileostomy and transverse mucous fistula creation through the previous ostomy site. He progressed well appropriately postoperatively and was discharged home. CONCLUSIONS: While cecal bascule is a rare form of bowel obstruction, patients with cerebral palsy are at an increased risk for this condition. The treatment options are numerous and are primarily surgical. Diverting loop ileostomy alone is not a recommended treatment. A high index of suspicion is warranted in all cases of large bowel obstruction to minimize risk of recurrence, morbidity, and mortality for patients afflicted by this condition.

Current Status of the Radiologic Assessment of Diverticular Disease.

Radiologic assessment plays a vital role in the management of diverticulitis. It not only helps in the diagnosis, but also helps to guide the management. As technology has progressed, different modalities have offered insight into the treatment of this disease process. Through various trials and studies, certain modalities stand above the rest in terms of sensitivity and specificity. Computed tomography (CT) imaging has also proved to help us guide the management through a grading system. Newer studies show us the advantages of other modalities such as ultrasound and magnetic resonance imaging (MRI). Though there is much research yet to be done with these modalities, they do show a lot of potential.

Laparoscopic colectomy significantly decreases length of stay compared with open operation.

INTRODUCTION: Current literature tends not to adjust for biases in patient selection attributable to comorbidities that could provide alternate explanations for length of stay differences in laparoscopic versus open colectomy. We hypothesized that utilizing the National Surgical Quality Improvement Program (NSQIP) dataset and acuity adjustment methods would demonstrate an independent improvement in length of stay for laparoscopic colectomy. METHODS: We used CPT coding to select all colectomies in NSQIP public use files from 2005-2009. Outlier status for surgical length of stay (SLOS) was defined as >75th percentile. Logistic regression analysis was used to predict this outlier status and linear regression to directly predict SLOS. Acuity adjustment was performed by using the most prevalent variables from multiple NSQIP annual reports. This work was done under the approval of our institutional review board and the data use agreement of the American College of Surgeons. Data were analyzed by using SPSS(®). RESULTS: A total of 45,645 colectomies were reviewed, of which 12,455 (27.3%) were laparoscopic. The 75th percentile for SLOS was 11 days. This implied that 9,249 (27.9%) of the open colectomies were outliers, whereas only 1,152 (9.2%) of laparoscopic colectomies were outliers (p < 0.001). When optimizing a simple linear regression to predict SLOS, using common acuity adjustors (i.e., age, functional status, wound category, etc.), the variable marking open procedures consistently had a coefficient of 1.8, implying that open procedures increased SLOS by 1.8 days (p < 0.001). Utilizing logistic regression to predict outlier status, open colectomies were associated with an odds ratio of 3.79 for outlier status (p < 0.001), thus implying an independent effect on SLOS. CONCLUSIONS: These results indicate that laparoscopic colectomy independently decreases SLOS compared with open colectomy. This study is unique in using statistical methods to control for selection bias of patients who might be more "surgically fit."

A randomized study comparing corticosteroid injection to corticosteroid iontophoresis for lateral epicondylitis.

PURPOSE: We designed a prospective, randomized study to evaluate the effects of iontophoresis delivery of dexamethasone versus corticosteroid injection therapy on patient outcomes. METHODS: We randomized 82 patients to 10 mg dexamethasone via iontophoresis using a self-contained patch with a 24-hour battery; 10 mg dexamethasone injection; or 10 mg triamcinolone injection. All patients received the same hand therapy protocol. Primary outcomes tracked were change in grip strength (flexion vs extension), pain, and function scores on a validated questionnaire. The secondary outcome was return-to-work status. Patients were evaluated at baseline, completion of physical therapy, and 6-month follow-up. RESULTS: The iontophoresis patients had statistically significant improvement in grip strength at the conclusion of hand therapy compared with baseline. They were also more likely to get back to work without restriction. By 6-month follow-up, all groups had equivalent results for all measured outcomes. CONCLUSIONS: Dexamethasone via iontophoresis produced short-term benefits because for this group grip strength and unrestricted return to work were significantly better. This study suggests that this iontophoresis technique for delivery of corticosteroid may be considered a treatment option for patients with lateral epicondylitis. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic II.

Anorectal melanoma.

Anorectal melanoma is a disease that can be difficult to diagnose because of its unclear presentation. After diagnosis, the main treatment available is surgical resection. Sentinel lymph node mapping has an unclear role in its management. Adjuvant therapy has long been recommended; however, there are no strong data to support its use. Prognostic factors to help gauge survival are also not clear; nevertheless, there is a strong association between stage of disease and histologic perineal invasion. Anorectal melanoma is a very rare disease with a dismal prognosis.

Lift-assisted offset lithotomy: positioning for transurethral operations in morbidly obese.

The incidence of morbid obesity is rapidly increasing in the United States. This presents a unique challenge in the diagnosis, management, and surgical treatment of urologic disease. The use of the lithotomy position for transurethral procedures is often not possible because of the body habitus and equipment-specific weight limitations. During positioning, it becomes imperative to maintain the safety of both the patient and the operating room personnel. We present a new, bariatric lift-assisted positioning technique used in the management of a 311-kg morbidly obese man with high-grade, superficial, papillary urothelial carcinoma.