Routine endoscopic surveillance for local recurrence of rectal cancer is futile.

BACKGROUND: National Comprehensive Cancer Network guidelines for rectal adenocarcinoma regarding routine surveillance with proctoscopy for local recurrence have been evolving. The purpose of this study was to examine the utility of rectal surveillance. METHODS: This is a single-center, retrospective review of patients (2004 to 2011) who underwent total mesorectal excision for rectal cancer. The primary end point was cancer recurrence, with detection method(s) noted. The number of surveillance procedures was collected. RESULTS: The study included 112 patients. There were no local recurrences identified by rectal surveillance. There were 1 local recurrence and 17 distant recurrences (16%). The local recurrence was identified by carcinoembryonic antigen and symptoms. There were 20 anoscopies, 44 proctoscopies, and 495 flexible sigmoidoscopies performed, with estimated charges of $266,000. CONCLUSIONS: Rectal surveillance at this center was not beneficial. This study supports the recent (2015) change in the National Comprehensive Cancer Network guidelines, which no longer recommend routine rectal surveillance and challenge other society guidelines.

The importance of extended postoperative venous thromboembolism prophylaxis in IBD: a National Surgical Quality Improvement Program analysis.

BACKGROUND: The National Comprehensive Cancer Network recommends that patients who have colorectal cancer receive up to 4 weeks of postoperative out-of-hospital venous thromboembolism prophylaxis. Patients with IBD are at high risk for venous thromboembolism, but there are no recommendations for routine postdischarge prophylaxis. OBJECTIVE: The purpose of this study was to compare the postoperative venous thromboembolism rate in IBD patients versus patients who have colorectal cancer to determine if IBD patients warrant postdischarge thromboembolism prophylaxis. DESIGN: This study is a retrospective review of IBD patients and patients who had colorectal cancer who underwent major abdominal and pelvic surgery. PATIENTS: Data were collected from the American College of Surgeons National Surgical Quality Improvement Program (2005-2010). MAIN OUTCOME MEASURES: The primary outcome was 30-day postoperative venous thromboembolism in IBD patients and patients who had colorectal cancer. Risk factors for venous thromboembolism were analyzed with the use of univariate testing and stepwise logistic regression. RESULTS: A total of 45,964 patients were identified with IBD (8888) and colorectal cancer (37,076). The 30-day postoperative rate of venous thromboembolism in IBD patients was significantly higher than in patients who had colorectal cancer (2.7% vs 2.1%, p < 0.001). In a model with 15 significant covariates, the OR for venous thromboembolism was 1.26 (95% CI, 1.021-1.56; p = 0.03) for the IBD patients in comparison with the patients who have colorectal cancer. LIMITATIONS: This study was limited by the retrospective design and the limitations of the data included in the database. CONCLUSIONS: Patients with IBD had a significantly increased risk for postoperative venous thromboembolism in comparison with patients who had colorectal cancer. Therefore, postdischarge venous thromboembolism prophylaxis recommendations for IBD patients should mirror that for patients who have colorectal cancer. This would suggest a change in clinical practice to extend out-of-hospital prophylaxis for 4 weeks in postoperative IBD patients.

A survey of American College of Surgery fellows evaluating their use of antibiotic prophylaxis in the placement of subcutaneously implanted central venous access ports.

BACKGROUND: Currently, there is no standard of care for prophylactic antibiotics (PABX) at the time of placement of fully implanted central venous access ports (CVAPs). A survey of fellows of the American College of Surgeons was undertaken to determine the current practice pattern of PABX in CVAP placement. METHODS: A survey was mailed to 5,000 fellows of the American College of Surgeons. RESULTS: The response rate was 21.7%, with 73.1% of respondents nonacademic surgeons. PABX were given by 88.2% of the respondents. Of those who did not use PABX, the primary reasons were "not justified" or "not standard of care." General comments regarding reasons for use of PABX included "medicolegal," "required by hospital," and "liability." CONCLUSIONS: In this survey, the overwhelming majority of responding American College of Surgeons fellows indicated that they use preoperative antibiotic prophylaxis for CVAP placement, despite there being no accepted standard of care or definitive evidence regarding PABX use for fully implanted CVAPs.

A comparison of postoperative outcomes utilizing a continuous preperitoneal infusion versus epidural for midline laparotomy.

BACKGROUND: Postoperative pain management with a continuous preperitoneal infusion (CPI) for locoregional anesthesia has been shown to have improved postoperative outcomes. This is the first direct comparison of CPI versus epidural infusion (EPI), both in conjunction with systemic analgesia. METHODS: A retrospective review was performed of midline laparotomy cases, comparing the use of CPI with systemic patient-controlled analgesia to EPI with systemic patient-controlled analgesia for postoperative outcomes. RESULTS: A total of 240 cases from 2007 to 2009 were reviewed. There were 41.3% using CPI and 58.7% with EPI. There were no differences with respect to age, body mass index, or American Society of Anesthesiologists score between CPI and EPI cases. In a multivariate model, total hospital stay was 2 days shorter for the CPI group (P < .001), and the total admission cost was less for CPI (by $6,164; P < .001). CONCLUSIONS: The use of CPI results in decreased length of hospital stay, decreased number of days with a Foley catheter, and lower hospital costs, compared with EPI use. These findings show that the routine use of CPI for pain management after laparotomy is a safe alternative to EPI.

Antibiotic prophylaxis in the placement of totally implanted central venous access ports.

BACKGROUND: Antibiotic prophylaxis during placement of implanted central venous access ports (CVAP) has not been studied. This retrospective review compared the rate of catheter-related infections (CRIs) with and without perioperative antibiotics. METHODS: This was a single-center study that compared patients treated with and without a single dose of antibiotics during CVAP placement. CRIs were defined as a patient treated with antibiotics for port site induration, positive blood cultures, or suspicion of infection that led to port removal within 30 days of placement. RESULTS: CVAP were placed in 459 patients, 103 of whom (22.4%) received antibiotic prophylaxis. Surgical technique and patient demographics were similar to those patients not receiving antibiotics (356). All 9 (2%) CRIs occurred in the non-prophylactic antibiotic group (P = .218), with 5 infections resulting in port removal. CONCLUSIONS: Single-dose perioperative antibiotics may decrease CVAP infection rates and should be studied further in a prospective randomized trial.