Evolution of laparoscopic ileal pouch-anal anastomosis: impact of enhanced recovery program, medication changes, and staged approaches on outcomes.

BACKGROUND: Although laparoscopic Ileal pouch-anal anastomosis (IPAA) has become the gold standard in restorative proctocolectomy, surgical techniques have experienced minimal changes. In contrast, substantial shifts in perioperative care, marked by the enhanced recovery program (ERP), modifications in steroid use, and a shift to a 3-staged approach, have taken center stage. METHODS: Data extracted from our prospective IPAA database focused on the first 100 laparoscopic IPAA cases (historic group) and the latest 100 cases (modern group), aiming to measure the effect of these evolutions on postoperative outcomes. RESULTS: The historic IPAA group had more 2-staged procedures (92% proctocolectomy), whereas the modern group had a higher number of 3-staged procedures (86% proctectomy) (P < .001). Compared with patients in the modern group, patients in the historic group were more likely to be on steroids (5% vs 67%, respectively; P < .001) or immunomodulators (0% vs 31%, respectively; P < .001) at surgery. Compared with the historic group, the modern group had a shorter operative time (335.5 ± 78.4 vs 233.8 ± 81.6, respectively; P < .001) and length of stay (LOS; 5.4 ± 3.1 vs 4.2 ± 1.6 days, respectively; P < .001). Compared with the modern group, the historic group exhibited a higher 30-day morbidity rate (20% vs 33%, respectively; P = .04) and an elevated 30-day readmission rate (9% vs 21%, respectively; P = .02). Preoperative steroids use increased complications (odds ratio [OR], 3.4; P = .01), whereas 3-staged IPAA reduced complications (OR, 0.3; P = .03). ERP was identified as a factor that predicted shorter stays. CONCLUSION: Although ERP effectively reduced the LOS in IPAA surgery, it failed to reduce complications. Conversely, adopting a 3-staged IPAA approach proved beneficial in reducing morbidity, whereas preoperative steroid use increased complications.

Robotic modified Sugarbaker technique for parastomal hernia repair: a standardized approach.

Parastomal hernia (PSH) is a prevalent long-term morbidity associated with stoma construction, and the optimal operative management remains uncertain. This study addresses the need for a standardized approach to symptomatic PSH repair, focusing on the robotic-assisted modified Sugarbaker technique with composite permanent mesh. The study, conducted in a high-volume colon and rectal surgery referral practice, outlines a systematic approach to patient selection, surgical procedures, and postoperative care. Preoperative evaluations include detailed medical and surgical histories, impact assessments of PSH, and oncological history reviews. The surgical technique involves the Da Vinci Xi™ robotic platform for adhesiolysis, hernia content reduction, stoma revision if needed, narrowing of the enlarged stoma trephine, lateralization of the stoma limb of bowel, and securing the mesh to the abdominal wall. Outcomes are reported for 102 patients undergoing robotic parastomal hernia repair from January 2021 to July 2023. Conversion to open surgery occurred in only one case (0.9%). Postoperative complications affected 39.2% of patients, with ileus being the most frequent (24.5%). Recurrence was observed in 5.8% of cases during an average follow-up of 10 months. In conclusion, parastomal hernia, a common complication post-stoma creation, demands surgical intervention. The robotic-assisted modified Sugarbaker repair technique, as outlined in this paper, offers promising results in terms of feasibility and outcomes.

Timing and Location of Venous Thromboembolisms After Surgery for Inflammatory Bowel Disease.

INTRODUCTION: Patients with inflammatory bowel disease are reported to be at elevated risk for postoperative venous thromboembolism (VTE). The rate and location of these VTE complications is unclear. METHODS: Patients with ulcerative colitis (UC) or Crohn's disease (CD) undergoing intestinal operations between January 2006 and March 2021 were identified from the medical record at a single institution. The overall incidence of VTEs and their anatomic location were determined to 90 days postoperatively. RESULTS: In 2716 operations in patients with UC, VTE prevalence was 1.95% at 1-30 days, 0.74% at 31-60 days, and 0.48% at 90 days (P < 0.0001). Seventy two percent of VTEs within the first 30 days were in the portomesenteric system, and this remained the location for the majority of VTE events at 31-60 and 61-90 days postoperatively. In the first 30 days, proctectomies had the highest incidence of VTEs (2.5%) in patients with UC. In 2921 operations in patients with CD, VTE prevalence was 1.43%, 0.55%, and 0.41% at 1-30 days, 31-60 days, and 61-90 days, respectively (P < 0.0001). Portomesenteric VTEs accounted for 31% of all VTEs within 30 days postoperatively. In the first 30 days, total abdominal colectomies had the highest incidence of VTEs (2.5%) in patients with CD. CONCLUSIONS: The majority of VTEs within 90 days of surgery for UC and Crohn's are diagnosed within the first 30 days. The risk of a VTE varies by the extent of the operation performed, with portomesenteric VTE representing a substantial proportion of events.

Risk factors for surgical site infections and trends in skin closure technique after diverting loop ileostomy reversal: A multi-institutional analysis.

BACKGROUND: Surgical site infections (SSIs) are one of the most common complications following diverting loop ileostomy (DLI) closures. This study assesses SSIs after DLI closure and the temporal trends in skin closure technique. METHODS: A retrospective review was conducted using the American College of Surgeons National Surgical Quality Improvement Program database for adult patients who underwent a DLI closure between 2012 and 2021 across a multistate health system. Skin closure technique was categorized as primary, primary â€‹+ â€‹drain, or purse-string closure. The primary outcome was SSI at the former DLI site. RESULTS: A SSI was diagnosed in 5.7% of patients; 6.9% for primary closure, 5.7% for primary closure â€‹+ â€‹drain, and 2.7% for purse-string closure (p â€‹= â€‹0.25). A diagnosis of Crohn's disease, diverticular disease, and increasing operative time were significant risk factors for SSIs. There was a positive trend in the use of purse-string closure over time (p â€‹< â€‹0.0001). CONCLUSIONS: This study identified a low SSI rate after DLI closure which did not vary significantly based on skin closure technique. Utilization of purse-string closure increased over time.

Postoperative Venous Thromboembolism in Colon and Rectal Cancer: Do Tumor Location and Operation Matter?

BACKGROUND: Existing venous thromboembolism (VTE) risk scores help identify patients at increased risk of postoperative VTE who warrant extended prophylaxis in the first 30 days. However, these methods do not address factors unique to colorectal surgery, wherein the tumor location and operation performed vary widely. VTE risk may extend past 30 days. Therefore, we aimed to determine the roles of tumor location and operation in VTE development and evaluate VTE incidence through 90 days postoperatively. STUDY DESIGN: Adult patients undergoing surgery for colorectal cancer between January 1, 2005, and December 31, 2021, at a single institution were identified. Patients were then stratified by cancer location and by operative extent. VTEs were identified using diagnosis codes in the electronic medical record and consisted of extremity deep venous thromboses, portomesenteric venous thromboses, and pulmonary emboli. RESULTS: A total of 6,844 operations were identified (72% segmental colectomy, 22% proctectomy, 6% total (procto)colectomy), and tumor location was most commonly in the ascending colon (32%), followed by the rectum (31%), with other locations less common (sigmoid 16%, rectosigmoid junction 9%, transverse colon 7%, descending colon 5%). The cumulative incidence of any VTE was 3.1% at 90 days with a relatively steady increase across the entire 90-day interval. Extremity deep venous thromboses were the most common VTE type, accounting for 37% of events, and pulmonary emboli and portomesenteric venous thromboses made up 33% and 30% of events, respectively. More distal tumor locations and more anatomically extensive operations had higher VTE rates. CONCLUSIONS: When considering extended VTE prophylaxis after colorectal surgery, clinicians should account for the operation performed and the location of the tumor. Further study is necessary to determine the optimal length of VTE prophylaxis in high-risk individuals.

Improved postoperative blood glucose control through implementation of clinical pharmacist driven glycemic management model after colorectal surgery.

BACKGROUND: Poor postoperative glycemic control has been linked with higher mortality, cardiovascular complications, stroke, infection, impaired wound healing, and increased length of stay. METHODS: This multicenter, retrospective study of colorectal surgery patients with Type 2 Diabetes Mellitus evaluated the difference in mean blood glucose levels postoperatively in a pharmacist driven glycemic management model vs standard of care. Secondary objectives assessed hyperglycemic events, severe hyperglycemia, hypoglycemia, postoperative infection, and rates of endocrinology consults. RESULTS: 186 patients were included, 120 in the pharmacist driven cohort and 66 in the standard of care. The pharmacist managed cohort demonstrated significantly lower mean blood glucose (133.9 vs 148.3 mg/dL, 95% CI [-17 to -11] p < 0.001), significantly fewer hyperglycemic events (9.6% vs 20.5%, p < 0.0001), and non-significant reduction of hypoglycemic events (0.7% vs 1.2%, p = 0.1443). CONCLUSIONS: Expansion of the postoperative care team by utilizing pharmacists to manage postoperative blood glucose resulted in improved glycemic control.

Validation of a left-sided colectomy anastomotic leak risk score and assessment of diversion practices.

BACKGROUND: A left-sided anastomotic leak risk score was previously developed and internally but not externally validated. METHODS: Left-sided colectomy anastomotic leak risk scores were calculated for patients within the ACS NSQIP Colectomy Targeted PUF from 2017 to 2018 and institutional NSQIP databases at three hospitals from 2011 to 2019. The calibration and discrimination of the risk score was assessed. RESULTS: A total of 21,116 patients (ACS NSQIP) and 485 patients (institutional NSQIP) were identified. Anastomotic leak rate was 2.8% and 2.9% respectively. C-statistic in the ACS NSQIP cohort was 0.61 and 0.64 in the institutional cohort compared to 0.66 in the original development cohort. Strong visual correspondence existed between predicted and observed anastomotic leak rates in the ACS NSQIP cohort. CONCLUSIONS: The left-sided anastomotic leak risk score was validated in two new populations. Use of the score would aid in the decision of when to perform a diverting stoma.

Bowel Dysfunction after Low Anterior Resection for Colorectal Cancer: A Frequent Late Effect of Surgery Infrequently Treated.

BACKGROUND: The development of major low anterior resection syndrome (LARS) after low anterior resection is severely detrimental to quality of life, yet awareness of it by clinicians and patients and the frequency of treatment of LARS is unclear. STUDY DESIGN: Patients who underwent low anterior resection for sigmoid or rectal cancer at a tertiary center between 2007 and 2017 (n = 798) were surveyed in 2019 to assess LARS symptoms and report medications or treatment received for LARS. LARS scores were calculated (score range 0-42) and normalized to published data on LARS prevalence in the general population in Europe, stratified by age (<50 or ≥50) and sex. RESULTS: Of the 594 patients (74%) who returned the survey, 255 (43%) were identified as having major LARS (LARS score ≥30). This prevalence was significantly higher than published normative data from Denmark and Amsterdam when stratified by age greater than or less than 50 and sex. Patients with major LARS infrequently reported current use of first-line therapies (antidiarrheal medications 32%, fiber supplements 16%, and both 13%). Only 3% reported receiving second-line therapy of transanal irrigations and/or pelvic floor rehabilitation, and only 1% had undergone third-line therapy of sacral nerve stimulator implantation. CONCLUSION: Major LARS is common yet seemingly underrecognized by clinicians because less than half of patients are on first-line therapy and practically none are on second- and third-line therapies. Long-term follow-up of patients after low anterior resection, improved preoperative and postoperative education, and continued symptom assessment is necessary to improve treatment of major LARS.

Avoiding Retained Surgical Items at an Academic Medical Center: Sustainability of a Surgical Quality Improvement Project.

Unintentionally retained surgical items (RSIs) are a serious complication representing a surgical "Never" event. The authors previously reported the process and significant improvement over a 3-year multiphased quality improvement RSI reduction effort that included sponge-counting technology. Herein, they report the sustainability of that effort over the decade following the formal quality improvement project conclusion. This retrospective analysis includes descriptive and qualitative data collected during RSI event root cause analysis. Between January 2009 and December 2019, 640 889 operations were performed with 24 RSIs reported. The resulting RSI rate of 1 per 26 704 operations represent a 486% performance improvement compared to the preintervention rate of 1 per 5500 operations. The interval, in days, between RSI events increased to 160 from 26 during the preintervention phase. Cotton sponges were the most retained RSI despite the use of sponge-counting technology. A significant and sustained reduction in RSI is possible after designing a sustainable comprehensive multidisciplinary effort.

A historical perspective on the problem of the retained surgical sponge: Have we really come that far?

Retained surgical items, particularly surgical sponges, are a considered a "never event." Unfortunately, they continued to be reported despite significant efforts to reduce them. Our goal was to identify some of the earliest reports of surgical items, particularly surgical sponges, to see how it was presented in the literature as well as any insights into contributing factors and processes to mitigate the event. We progress forward in time to look at how this issue has been addresses or changed as we enter the 21st century. After this review, it appears that our advances are not as significant as those efforts proposed over 100 years ago. We view this as a call to action for significant change in our operative safety processes and to incorporate available technology.

Tradition Versus Value: Is There Utility in Protocolized Postoperative Laboratory Testing After Elective Colorectal Surgery?

OBJECTIVE: Determine if routine ordering of postoperative day 1 (POD 1) serum laboratory tests after elective colorectal surgery are clinically warranted and valuable given the associated costs of these lab tests. SUMMARY OF BACKGROUND DATA: Routine postoperative serum laboratory tests are a part of many colorectal surgery order sets. Whether these protocolized lab tests represent cost-effective care is unknown. METHODS: Patients undergoing elective colorectal surgery between January 1, 2015 and December 31, 2017 at our institution were identified. The protocolized POD 1 lab tests obtained as part of the postoperative order set were reviewed to determine the rate of abnormal values and any intervention in response. Costs associated with protocolized laboratory testing were calculated using dollar amounts representing 2017 outpatient Medicare reimbursement. RESULTS: A total of 2252 patients were identified with 8205 total lab test values. Of these, only 4% were abnormal (3% of hemoglobin values, 6% of creatinine values, 3% of potassium of values, and 3% of glucose values), and only 1% were actively intervened upon. The total aggregate cost of the protocolized POD 1 laboratory tests in these years was $64,000 based on Medicare outpatient reimbursement dollars. CONCLUSIONS: Routine POD 1 lab tests after elective colorectal surgery are rarely abnormal, and they even less frequently require active intervention beyond rechecking. This results in increased resource utilization and cost of care without appreciable impact on clinical care, and is not cost-effective. Protocolized POD 1 laboratory testing should be replaced with clinically-based criteria to trigger serum laboratory investigations.

Challenges of Modeling Outcomes for Surgical Infections: A Word of Caution.

Background: We developed a novel analytic tool for colorectal deep organ/space surgical site infections (C-OSI) prediction utilizing both institutional and extra-institutional American College of Surgeons-National Surgical Quality Improvement Program (ACS-NSQIP) data. Methods: Elective colorectal resections (2006-2014) were included. The primary end point was C-OSI rate. A Bayesian-Probit regression model with multiple imputation (BPMI) via Dirichlet process handled missing data. The baseline model for comparison was a multivariable logistic regression model (generalized linear model; GLM) with indicator parameters for missing data and stepwise variable selection. Out-of-sample performance was evaluated with receiver operating characteristic (ROC) analysis of 10-fold cross-validated samples. Results: Among 2,376 resections, C-OSI rate was 4.6% (n = 108). The BPMI model identified (n = 57; 56% sensitivity) of these patients, when set at a threshold leading to 80% specificity (approximately a 20% false alarm rate). The BPMI model produced an area under the curve (AUC) = 0.78 via 10-fold cross- validation demonstrating high predictive accuracy. In contrast, the traditional GLM approach produced an AUC = 0.71 and a corresponding sensitivity of 0.47 at 80% specificity, both of which were statstically significant differences. In addition, when the model was built utilizing extra-institutional data via inclusion of all (non-Mayo Clinic) patients in ACS-NSQIP, C-OSI prediction was less accurate with AUC = 0.74 and sensitivity of 0.47 (i.e., a 19% relative performance decrease) when applied to patients at our institution. Conclusions: Although the statistical methodology associated with the BPMI model provides advantages over conventional handling of missing data, the tool should be built with data specific to the individual institution to optimize performance.

Assessing Malnutrition Before Major Oncologic Surgery: One Size Does Not Fit All.

BACKGROUND: There are multiple definitions for malnutrition, without evidence of superiority of any one definition to assess preoperative risk. Therefore, to aid in identification of patients that might warrant prehabilitation, we aimed to determine the optimal definition of malnutrition before major oncologic resection for 6 cancer types. METHODS: The American College of Surgeons NSQIP database was queried for patients undergoing elective major oncologic operations from 2005 to 2017. Nutritional status was evaluated using the European Society for Parenteral and Enteral Nutrition definitions, NSQIP's variable for >10% weight loss during the previous 6 months, and the WHO BMI classification system. Multivariable logistic regression was performed to evaluate the adjusted effect of nutritional status on mortality and major morbidity. RESULTS: We identified 205,840 operations (74% colorectal, 10% pancreatic, 9% lung, 3% gastric, 3% esophageal, and 2% liver). A minority (16%) of patients met criteria for malnutrition (0.6% severe malnutrition, 1% European Society for Parenteral and Enteral Nutrition 1, 2% European Society for Parenteral and Enteral Nutrition 2, 6% NSQIP, and 6% mild malnutrition), 31% were obese, and the remaining 54% had a normal nutrition status. Both mortality and major morbidity varied significantly between the nutrition groups (both p < 0.0001). An interaction between nutritional status and cancer type was observed in the models for mortality and major morbidity (interaction term p < 0.0001 for both), indicating the optimal definition of malnutrition varied by cancer type. CONCLUSIONS: The definition of malnutrition used to assess postoperative risk is specific to the type of cancer being treated. These findings can be used to enhance nutritional preparedness in the preoperative setting.

Development of a Risk Score to Predict Anastomotic Leak After Left-Sided Colectomy: Which Patients Warrant Diversion?

BACKGROUND: Anastomotic leak is a feared complication after left-sided colectomy, but its risk can potentially be reduced with the use of a diverting ostomy. However, an ostomy has its own associated negative sequelae; therefore, it is critical to appropriately identify patients to divert. This is difficult in practice since many risk factors for anastomotic leak exist and outside factors bias this decision. We aimed to develop and validate a risk score to predict an individual's risk of anastomotic leak and aid in the decision. METHODS: The American College of Surgeons National Surgical Quality Improvement Program Colectomy Targeted PUF was queried from 2012 to 2016 for patients undergoing elective left-sided resection for malignancy, benign neoplasm, or diverticular disease. Multivariable logistic regression identified predictors of anastomotic leak in non-diverted patients, and a risk score was developed and validated. RESULTS: 38,475 patients underwent resection with an overall anastomotic leak rate of 3%. Independent risk factors for anastomotic leak included younger age, male sex, tobacco use, and omission of combined bowel preparation. A risk score incorporating independent predictors demonstrated excellent calibration. There was strong visual correspondence between predicted and observed anastomotic leak rates. 3960 patients underwent resection with diversion, yet over half of these patients had a predicted leak rate of less than 4%. CONCLUSION: A novel risk score can be used to stratify patients according to anastomotic leak risk after elective left-sided resection. Intraoperative calculation of scores for patients can help guide surgical decision-making in both diverting the highest risk patients and avoiding diversion in low-risk patients.

Disparities influencing rates of urgent/emergent surgery for diverticulitis in the state of Florida.

BACKGROUND: Patients with diverticulitis have a 20% risk of requiring urgent/emergent treatment. Since morbidity and mortality rates differ between elective and urgent/emergent care, understanding associated disparities is critical. We compared factors associated with treatment setting for diverticulitis and evaluated disparities regarding access to Minimally Invasive Surgery (MIS) and development of complications. METHODS: The Florida Inpatient Discharge Dataset was queried for patients diagnosed with diverticulitis. Three multivariate models were utilized: 1) elective vs urgent/emergent surgery, 2) MIS vs open and 3) presence of complications. RESULTS: The analysis included 12,654 patients. Factors associated with increased odds of urgent/emergent care included being uninsured or covered by Medicaid, African American, obese, or more comorbid. MIS was associated with reduced odds of complications. Patients treated by high-volume or colorectal surgeons had increased odds of receiving MIS. CONCLUSIONS: Patients were more likely to receive MIS if they were treated by a colorectal surgeon, or a high-volume surgeon (colorectal, or general surgeon). Additionally, patients that were older, had increased comorbidities, or did not have health insurance were less likely to receive MIS.

microRNA overexpression in slow transit constipation leads to reduced NaV1.5 current and altered smooth muscle contractility.

OBJECTIVE: This study was designed to evaluate the roles of microRNAs (miRNAs) in slow transit constipation (STC). DESIGN: All human tissue samples were from the muscularis externa of the colon. Expression of 372 miRNAs was examined in a discovery cohort of four patients with STC versus three age/sex-matched controls by a quantitative PCR array. Upregulated miRNAs were examined by quantitative reverse transcription qPCR (RT-qPCR) in a validation cohort of seven patients with STC and age/sex-matched controls. The effect of a highly differentially expressed miRNA on a custom human smooth muscle cell line was examined in vitro by RT-qPCR, electrophysiology, traction force microscopy, and ex vivo by lentiviral transduction in rat muscularis externa organotypic cultures. RESULTS: The expression of 13 miRNAs was increased in STC samples. Of those miRNAs, four were predicted to target SCN5A, the gene that encodes the Na+ channel NaV1.5. The expression of SCN5A mRNA was decreased in STC samples. Let-7f significantly decreased Na+ current density in vitro in human smooth muscle cells. In rat muscularis externa organotypic cultures, overexpression of let-7f resulted in reduced frequency and amplitude of contraction. CONCLUSIONS: A small group of miRNAs is upregulated in STC, and many of these miRNAs target the SCN5A-encoded Na+ channel NaV1.5. Within this set, a novel NaV1.5 regulator, let-7f, resulted in decreased NaV1.5 expression, current density and reduced motility of GI smooth muscle. These results suggest NaV1.5 and miRNAs as novel diagnostic and potential therapeutic targets in STC.

Improving the rate of surgical normothermia in gynecologic surgery.

OBJECTIVE: To increase the rate of normothermia (core temperature ≥ 36 °C) in patients undergoing gynecologic surgery. METHODS: The rate of surgical normothermia was evaluated in a single institution. A two-phase quality improvement project was undertaken; Phase 1 included the use of intra-operative room temperature regulation and intra-operative patient warming and Phase 2 included pre-operative patient warming. Clinical characteristics, median temperatures, and rate of normothermia were abstracted for patients in each phase. Cohorts were compared using chi-square and t-tests. RESULTS: The project was performed in two phases, each with a historic and intervention cohort. There were 503 patients in the historical cohort and 636 patients in the intervention cohort in phase 1; there were 291 patients in the historical cohort and 259 patients in the intervention cohort for Phase 2. Patient characteristics and anesthetic type and duration did not differ between cohorts. After intra-operative temperature regulation and patient warming in Phase 1, significantly more patients achieved normothermia (79% versus 68%, P < 0.0001). However operating room staff were more likely to rate the temperature as very hot in 40% of cases post-intervention, compared to only 2% historically. In Phase 2, after the intervention of pre-warming patients, there was no difference in achieving normothermia, 78% versus 83%, P = 0.09. Staff had no statistical difference in personal comfort with the temperature, however did feel efforts were very effective more frequently, 7.7% historic versus 32.7% post-intervention, P < 0.0001. CONCLUSIONS: Quality improvement methodology can be applied to pre- and intra-operative decision making to improve rates of surgical patient normothermia.