Sarcopenia is a Poor Predictor of Outcomes in Elective Colectomy for Diverticulitis.

BACKGROUND: Sarcopenia is associated with adverse perioperative outcomes in patients undergoing operations for malignancy, but its influence on patients undergoing elective colectomy for diverticulitis is unknown. We hypothesized that sarcopenia is associated with adverse perioperative events in patients undergoing elective colectomy for diverticulitis. METHODS: Comorbidities, operative characteristics, and postoperative complications were extrapolated from our institutional EMR in patients undergoing elective colectomy for diverticulitis from 2016 to 2020. Sarcopenia was calculated using perioperative imaging and defined by standard skeletal muscle index (SMI) and psoas muscle index (PMI) thresholds. Univariate analysis was used to compare sarcopenic and non-sarcopenic patients. RESULTS: 148 patients met inclusion criteria. Using SMI thresholds, 95 patients (64%) were sarcopenic. With SMI criteria, sarcopenic patients were older (67 vs 52 years old; P < .01) and had lower BMIs (26.2 vs 34.0, respectively; P < .001) than non-sarcopenic patients. There were no differences in baseline characteristics, postoperative complications, and non-home discharge between groups (P > .05 for all). Postoperative length of stay was greater in sarcopenic patients (3 IQR 2-5 vs 2 IQR 2-3 days; P < .01). Using PMI thresholds, 68 (46%) met criteria for sarcopenia. Using PMI thresholds, sarcopenic patients were older (68 vs 57.5 years old; P < .01) and had lower BMIs (25.8 vs 32.8; P < .01). There were no differences in comorbidities or measured operative outcomes between groups (P > .05 for all), other than postoperative length of stay which was longer in the sarcopenic group (3.5 IQR 3-5 vs 2 IQR 2-3; P < .01). CONCLUSIONS: Incidence of sarcopenia was high in patients undergoing elective colectomy for diverticulitis in our practice, but sarcopenia was not associated with adverse perioperative outcomes. In select patients, elective colectomy for diverticulitis can be safely performed in the presence of sarcopenia.

The effect of smoking status on inguinal hernia repair outcomes: An ACHQC analysis.

BACKGROUND: Smoking has been shown to negatively affect surgical outcomes, so smoking cessation prior to elective operations is often recommended. However, the effects of smoking status on inguinal hernia repair outcomes have not been extensively studied. Hence, we investigated the association between smoking status and short-term adverse outcomes following inguinal hernia repair. METHODS: Abdominal Core Health Quality Collaborative database was queried for elective, clean inguinal hernia repairs, excluding those with concomitant procedures or where length of stay > 30 days. The resulting cohort was divided into three groups: current smokers, former smokers, and never smokers. Baseline patient, hernia, operative characteristics, and 30-day outcomes were compared. Multivariable logistic regression was used to evaluate the association between smoking status and overall and wound complications. RESULTS: 19,866 inguinal hernia repairs were included (current smokers = 2239, former smokers = 4064 and never smokers = 13,563). Current smokers and former smokers, compared to never smokers, had slightly higher unadjusted rates of overall complication rates (9% and 9% versus 7%, p = 0.003) and surgical site occurrences/infection (6% and 6% versus 4%, p < 0.001). However, on multivariable analysis, compared to current smokers, neither the rates of overall complications nor surgical site occurrences were significantly different in former smokers (OR = 0.93, 95% CI [0.76, 1.13] and OR = 0.92, 95% CI [0.73, 1.17]) and never smokers (OR = 0.99, 95% CI [0.83, 1.18] and OR = 0.86, 95% CI [0.70,1.06]) respectively. CONCLUSIONS: Smoking status is not associated with short-term adverse outcomes following inguinal hernia repair. Mandating smoking cessation does not appear necessary to prevent short-term adverse outcomes.

S041-Trends and short-term outcomes of three approaches to minimally invasive repair of small ventral hernias. An ACHQC analysis.

INTRODUCTION: Different approaches and mesh positions are used for minimally invasive ventral hernia repair (MIS-VHR). Our aim was to evaluate the trends and short-term outcomes of intraperitoneal onlay mesh (IPOM), preperitoneal, and retromuscular repairs for small ventral hernias. METHODS: We conducted a retrospective cohort study using the Abdominal Core Health Quality Collaborative (ACHQC). We included elective MIS-VHR in adults with hernia defect width < = 6 cm from 2012 to 2021. We compared patient/hernia characteristics, trends, and short-term outcomes between IPOM, preperitoneal, and retromuscular repairs. Inverse probability of treatment weighting (IPTW) was used to balance baseline characteristics. RESULTS: A total of 7261 patients were included (IPOM = 4484, preperitoneal = 1829, retromuscular = 948). Preperitoneal repair was associated with lower rates of incisional (preperitoneal = 37%, IPOM = 63%, retromuscular = 73%) and recurrent hernias (preperitoneal = 11%, IPOM = 21%, retromuscular = 22%) compared to IPOM and retromuscular. Median defect width was 3.0, 2.0, and 4.0 cm for IPOM, preperitoneal, and retromuscular, respectively. There has been a progressive increase in the proportion of preperitoneal and retromuscular repairs over time (10% in 2013-53% in 2021 of all MIS-VHR). Robotic approach was more frequently utilized in preperitoneal and retromuscular (both > 85%) compared to IPOM (47%). Transversus abdominis release was performed in 14% of retromuscular repairs. After IPTW, no clinically significant differences were noted in the short-term outcomes between IPOM versus preperitoneal. Retromuscular repairs were associated with higher risk of 30-day reoperation (OR = 3.54, 95%CI [1.67, 7.5] and OR = 5.29, 95%CI [1.23, 22.74]) compared to IPOM and preperitoneal repairs, respectively, and higher risk of 30-day readmission compared to preperitoneal repairs (OR = 2.6, 95%CI [2.6, 6.4]). CONCLUSION: Based on ACHQC data, preperitoneal and retromuscular approaches for MIS-VHR of small hernias have increased over time and are primarily performed robotically. Transversus abdominis release was performed in 14% of retromuscular repairs of these small hernias. Retromuscular repairs were associated with higher 30-day readmission and reoperation rates compared to the other approaches.

The Impact of a Narcotic-Sparing Enhanced Recovery Protocol on Postoperative Narcotic Use Following Colectomy.

BACKGROUND: In the United States, 37% of all opioids are prescribed in the surgical setting, many of which report initial exposure in the postoperative period. OBJECTIVE: This study aimed to assess the impact of a narcotic-sparing enhanced recovery after surgery protocol on postoperative narcotic use by patients and to assess its impact on the narcotic-prescribing practices of physicians. DESIGN: Data regarding consecutive narcotic-naïve patients who underwent a surgical procedure from January 2013 to August 2017 were retrospectively reviewed. SETTINGS: Patients were divided into 2 cohorts: preimplementation (2013-2015) and postimplementation (2015-2017) of the enhanced recovery after surgery protocol. PATIENTS: This study included patients who underwent elective inpatient abdominal colorectal surgery at the University of Florida Health. MAIN OUTCOME MEASURES: The primary outcome measure was 30-day postoperative narcotic use (inpatient and outpatient). Other outcomes measured included pain scores, time to diet institution, length of hospital stay, cost of hospitalization, and postoperative complications. RESULTS: Baseline characteristics were similar between the preprotocol group (n = 537) and postprotocol group (n = 790). Protocol implementation was associated with a decrease in the total 30-day postoperative narcotic amount used by patients (2481 vs 31 morphine milligram equivalents; p = 0.05), inpatient patient-controlled analgesia use (63% vs 0.5%; p < 0.00001; dosage 1254 vs 5 morphine milligram equivalents), inpatient on-demand oral narcotic use (90% vs 32%; p = 0.001; dosage 47 vs 5 morphine milligram equivalents), and outpatient narcotic amount used (46 vs 6 morphine milligram equivalents; p = 0.001). Average pain scores were similar. LIMITATIONS: Retrospective nature of the study and possible underestimation of pre- and postoperative narcotic use. CONCLUSIONS: Implementation of a narcotic-sparing enhanced recovery after surgery protocol was associated with a decrease in both inpatient and 30-day outpatient postoperative narcotic use. Variation in resident physician prescribing practices suggests the need for ongoing education to accompany these protocols. See Video Abstract at http://links.lww.com/DCR/B936 . EL IMPACTO DE UN PROTOCOLO DE RECUPERACIN MEJORADO CON AHORRO DE NARCTICOS EN EL USO POSTOPERATORIO DE NARCTICOS DESPUS DE UNA COLECTOMA: ANTECEDENTES:En los Estados Unidos, el 37 % de todos los opioides se prescriben en el entorno quirúrgico. Entre los adictos a los narcóticos, muchos reportan una exposición inicial en el período posoperatorio.OBJETIVO:Nuestro objetivo fue evaluar el impacto de un protocolo de recuperación mejorada después de la cirugía que ahorra narcóticos en el uso de narcóticos postoperatorios por parte de los pacientes y evaluar su impacto en las prácticas de prescripción de narcóticos de los médicos.DISEÑO:Se revisaron retrospectivamente los datos de pacientes consecutivos sin tratamiento previo con narcóticos que se sometieron a un procedimiento quirúrgico colorrectal abdominal electivo para pacientes hospitalizados desde enero de 2013 hasta agosto de 2017.AJUSTE:Los pacientes se dividieron en 2 cohortes: antes de la implementación (2013-2015) y después de la implementación (2015-2017) del protocolo de recuperación mejorada después de la cirugía.PACIENTES:Pacientes de cirugía colorrectal abdominal electiva para pacientes internados en University of Florida Health.MEDIDAS DE RESULTADO PRINCIPALES:La medida de resultado primaria fue el uso de narcóticos postoperatorios de 30 días (pacientes hospitalizados y ambulatorios). Otros resultados medidos incluyeron puntuaciones de dolor, tiempo hasta la institución de la dieta, duración de la estancia hospitalaria, costo de la hospitalización y complicaciones postoperatorias.RESULTADOS:Las características iniciales fueron similares entre los grupos antes (n = 537) y después del protocolo (n = 790). La implementación del protocolo se asoció con una disminución en la cantidad total de narcóticos postoperatorios de 30 días utilizada por los pacientes (2481 mg frente a 31 mg de equivalentes de morfina, p = 0,05), uso de analgesia controlada por pacientes hospitalizados (63 % frente a 0,5 %, p < 0,00001; dosis 1254 mg frente a 5 mg), uso de narcóticos orales a demanda en pacientes hospitalizados (90 % frente a 32 %, p = 0,001; dosis de 47 mg frente a 5 mg) y cantidad de narcóticos utilizados en pacientes ambulatorios (46 mg frente a 6 mg, p = 0,001). Las puntuaciones medias de dolor fueron similares.LIMITACIONES:La naturaleza retrospectiva del estudio y la posible sub estimación del uso de narcóticos antes y después de la operación fueron limitaciones de los hallazgos del estudio.CONCLUSIÓN:La implementación de un protocolo de recuperación mejorada después de la cirugía que ahorra narcóticos se asoció con una disminución en el uso de narcóticos en el postoperatorio de pacientes hospitalizados y ambulatorios de 30 días. La variación en las prácticas de prescripción de los médicos residentes sugiere la necesidad de una educación continua que acompañe a estos protocolos. Consulte Video Resumen en http://links.lww.com/DCR/B936 . (Traducción-Dr. Mauricio Santamaria ).

S-144 lack of association between glycated hemoglobin and adverse outcomes in diabetic patients undergoing ventral hernia repair: an ACHQC study.

INTRODUCTION: Elevated preoperative glycated hemoglobin (HbA1c) is believed to predict complications in diabetic patients undergoing ventral hernia repair (VHR). Our objective was to assess the association between HbA1c and outcomes of VHR in diabetic patients. METHODS: We conducted a retrospective cohort study using the Abdominal Core Health Quality Collaborative (ACHQC) database. We included adult diabetic patients who underwent elective VHR with an available HbA1c result. The patients were divided into two groups (HbA1c < 8% and HbA1c ≥ 8%). Patient demographics, comorbidities, hernia characteristics, operative details, and surgical outcomes were compared. Multivariable logistic regression analysis of complications was performed. Cox proportional hazard regression was used to assess probability of composite recurrence at different HbA1c levels. RESULTS: 2167 patients met the inclusion criteria (HbA1c < 8% = 1,776 and HbA1c ≥ 8% = 391). Median age was 61 years and median body mass index was 34 kg/m2. 75% had an American Society of Anesthesiology class of 3. The median HbA1c was 6.5% in the HbA1c < 8% group versus 8.7% in the HbA1c ≥ 8% group. 73% were incisional hernias, 34% were recurrent, and median hernia width was 6 cm. Open approach was used in 63% and myofascial release was performed in 46%. Median follow-up was 27 days. There were no clinically significant differences in the rates of overall 30-day complications, wound complications, reoperation, readmission, mortality, length of stay and quality of life and pain scores between the two groups. Regression analyses did not identify an association between HbA1c and the rates of complications, surgical site infection or composite recurrence across the spectrum of HbA1c values. CONCLUSION: Our study finds no evidence of an association between HbA1c and operative outcomes in diabetic patients undergoing elective VHR.

Safety of laparoscopic inguinal hernia repair in the setting of antithrombotic therapy.

INTRODUCTION: There are a paucity of data regarding the safety of laparoscopic inguinal hernia repair in patients on antiplatelet and anticoagulant therapy (APT/ACT). We aim to compare the postoperative outcomes of laparoscopic (LIHR) vs. open repair of inguinal hernias (OIHR) in patients on APT/ACT. METHOD: We conducted a retrospective cohort study using the Vizient Clinical DataBase. We included adults receiving APT/ACT who underwent outpatient, elective, and primary inguinal hernia repair between 2017 and 2019. Subgroup analysis was performed on patients receiving aspirin, non-aspirin antiplatelet, and anticoagulant therapy. Mixed-effects logistic regression was used to assess both the effect of APT/ACT on the probability of receiving LIHR vs OIHR and their respective outcomes. RESULT: A total of 142,052 repairs were included, of which 21,441 (15%) were performed on patients receiving APT/ACT. Mean age was 69 years (± 10.5) and 93% were male. 19% of hernias were bilateral. 40% of operations were performed at teaching hospitals. On multivariable analysis, patients on non-aspirin antiplatelet or anticoagulant therapy were more likely to receive an open procedure (Odds Ratio (OR) = 1.2; 95% Confidence Intervals (CI) [1.1, 1.4] and OR = 1.4; CI [1.3, 1.5], respectively). LIHR was associated with a lower rate of length of stay > 1 day (OR = 0.65; CI [0.5, 0.9]). Rates of 30-day postoperative hematoma, transfusions, stroke, myocardial infarction, deep venous thrombosis, pulmonary embolism, readmission, and emergency department visits were similar between the two operative approaches. CONCLUSION: Patients on APT/ACT represent a substantial proportion of those undergoing inguinal hernia repair. Non-aspirin antiplatelet or anticoagulant therapy are independent predictors of choosing an open repair. Laparoscopic repair appears to be safe in patients receiving APT/ACT under current perioperative management patterns.

Safety of Laparoscopic Appendectomy in the Setting of Coagulopathy: An ACS-NSQIP Study.

INTRODUCTION: Patients with coagulopathy requiring emergent appendectomy constitute a challenging patient population. It is unclear whether laparoscopic appendectomy (LA) is as safe as open appendectomy (OA) in these patients. METHODS: We queried the ACS-NSQIP database for adults with coagulopathy undergoing emergent appendectomy from 2014 to 2017. Demographic characteristics and operative outcomes were compared between the two groups. Propensity weighting for LA versus OA was estimated using augmented inverse probability of treatment weights (AIPW). RESULTS: A total of 137,429 patients were included, of which 7049 (5%) had coagulopathy. In patients with coagulopathy, LA was the most common approach (89%). After AIPW, there was no difference in the adjusted risk of either postoperative transfusion or 30-day reoperation between OA and LA. LA was associated with reduced operative time (56 versus 75 min), length of stay (3.5 versus 7.0 d), and surgical site infection rate (6% versus 13%) compared to OA. CONCLUSIONS: Patients with coagulopathy represent a significant proportion of those undergoing an appendectomy. The majority of patients with coagulopathy who require appendectomy undergo LA, and this approach appears to be safe with regard to transfusion requirement and reoperation.

Activity of Sorafenib Plus Capecitabine in Previously Treated Metastatic Colorectal Cancer.

LESSONS LEARNED: Treatment for patients with metastatic colorectal cancer (mCRC) typically involves multiple lines of therapy with eventual development of treatment resistance. In this single-arm, phase II study involving heavily pretreated patients, the combination of sorafenib and capecitabine yielded a clinically meaningful progression-free survival of 6.2 months with an acceptable toxicity profile. This oral doublet therapy is worthy of continued investigation for clinical use in patients with mCRC. BACKGROUND: Capecitabine (Cape) is an oral prodrug of the antimetabolite 5-fluorouracil. Sorafenib (Sor) inhibits multiple signaling pathways involved in angiogenesis and tumor proliferation. SorCape has been previously studied in metastatic breast cancer. METHODS: This single-arm, phase II study was designed to evaluate the activity of SorCape in refractory metastatic colorectal cancer (mCRC). Patients received Sor (200 mg p.o. b.i.d. max daily) and Cape (1,000 mg/m2 p.o. b.i.d. on days 1-14) on a 21-day treatment cycle. Primary endpoint was progression-free survival (PFS) with preplanned comparison with historical controls. RESULTS: Forty-two patients were treated for a median number of 3.5 cycles (range 1-39). Median PFS was 6.2 (95% confidence interval [CI], 4.3-7.9) months, and overall survival (OS) was 8.8 (95% CI, 4.3-12.2) months. One patient (2.4%) had partial response (PR), and 22 patients (52.4%) had stable disease (SD) for a clinical benefit rate of 54.8% (95% CI, 38.7%-70.2%). Hand-foot syndrome was the most common adverse event seen in 36 patients (85.7%) and was grade ≥ 3 in 16 patients (38.1%). One patient (2.4%) had a grade 4 sepsis, and one patient (2.4%) died while on treatment. CONCLUSION: SorCape in this heavily pretreated population yielded a reasonable PFS with manageable but notable toxicity. The combination should be investigated further.

Endoscopic Step Up: A Colon-Sparing Alternative to Colectomy to Improve Outcomes and Reduce Costs for Patients With Advanced Neoplastic Polyps.

BACKGROUND: The optimal strategy for colonic polyps not amenable to traditional endoscopic polypectomy is unknown. Endoscopic step up is a promising strategy for definitive treatment. OBJECTIVE: The purpose of this study was to determine whether endoscopic step up leads to improved outcomes and decreased costs compared with planned colectomy for endoscopically unresectable colon polyps. DESIGN: This was a retrospective review of a prospective database. SETTING: The study was conducted at a tertiary referral center. PATIENTS: Consecutive patients referred for endoscopically unresectable colon polyps 15 to 50 mm in size were included. INTERVENTIONS: Patients underwent planned colectomy or endoscopic step up at the surgeon's discretion. Endoscopic step up began with diagnostic colonoscopy in the operating room. If the polyp was amenable to endoscopic removal, endoscopic mucosal resection or endoscopic submucosal dissection was performed with progression to combined endoscopic-laparoscopic surgery or laparoscopic colectomy, as indicated. MAIN OUTCOME MEASURES: The primary outcome was 30-day adverse events. We also examined length of stay, hospital charges, insurer payments, and polyp recurrence. RESULTS: A total of 52 patients underwent planned colectomy (48 laparoscopic), and 38 underwent endoscopic step up (28 endoscopic mucosal resection, 2 endoscopic submucosal dissection, 6 combined endoscopic-laparoscopic surgery, and 2 colectomy). Compared with planned colectomy, endoscopic step-up patients had fewer complications (13% vs 33%; p = 0.03) and shorter length of stay (median, 0 vs 4 d; p < 0.001). There was 1 readmission in the endoscopic step-up group and 5 in the planned colectomy group. Endoscopic step-up patients had lower hospital costs ($4790 vs $13,004; p < 0.001) and insurer payments ($2431 vs $19,951; p < 0.001). One-year polyp recurrence-free survival was 84% (95% CI, 67%-93%) in endoscopic step-up patients. All of the recurrences were benign, <1 cm, and managed endoscopically. LIMITATIONS: The study was limited by its nonrandomized design and short follow-up. CONCLUSIONS: An endoscopic step-up approach to colon polyps is associated with less morbidity, decreased healthcare costs, and colon preservation in 95% of patients. Additional studies are needed to evaluate long-term quality of life and polyp recurrence in this group. See Video Abstract at http://links.lww.com/DCR/B188. ENDOSCOPIC STEP UP: UNA ALTERNATIVA A COLECTOMíA PARA PRESERVACIóN DE COLON CON LOS PROPóSITOS DE MEJORAR RESULTADOS Y REDUCIR COSTOS EN PACIENTES CON PóLIPOS NEOPLáSICOS AVANZADOS: Se desconoce la estrategia óptima para los pólipos de colon no susceptibles a la polipectomia endoscópica tradicional. Endoscopic Step Up es una estrategia prometedora para el tratamiento definitivo.Determinar si Endoscopic Step Up produce mejores resultados y menores costos en comparación con la colectomía programada para pólipos de colon endoscópicamente no resecables.Revisión retrospectiva de una base de datos prospectiva.Centro de referencia de tercer nivel.Pacientes consecutivos remitidos para pólipos de colon endoscópicamente irresecables de tamaño 15-50 mm.Los pacientes se sometieron a colectomía programada o Endoscópico Step Up a discreción del cirujano. Endoscopic Step Up comenzó con una colonoscopia diagnóstica en el quirófano. Si el pólipo era susceptible de extirpación endoscópica, la resección endoscópica de la mucosa o la disección submucosa endoscópica se realizaba con progresión a cirugía endoscópica-laparoscópica combinada o colectomía laparoscópica, según a cosnideraciones clínicas en el transoperatorio.El resultado primario fue los eventos adversos a 30 días. Duración de la estadía hospitalaria, los cargos hospitalarios, los pagos de las aseguradoras y la recurrencia de pólipos también fueron examinados.Un total de 52 pacientes se sometieron a colectomía programada (48 laparoscópicas) y 38 se sometieron a Endoscopic Step Up (28 resección endoscópica de la mucosa, 2 disección submucosa endoscópica, 6 cirugía endoscópica-laparoscópica combinada y 2 colectomía). En comparación con la colectomía programada los pacientes endoscópicos Step Up tuvieron menos complicaciones (13% versus 33%, p = 0.03) y una estadía hospitalaria más corta (mediana 0 versus 4 días, p <0.001). Hubo 1 reingreso hospitalario en el grupo Endoscopic Step Up y 5 en el grupo de colectomía programada. Los pacientes endoscópicos Step Up tuvieron costos hospitalarios más bajos ($ 4,790 versus $ 13,004, p <0,001) y pagos de la aseguradora ($ 2,431 versus $ 19,951, p <0,001). La supervivencia libre de recurrencia de pólipos a un año fue del 84% (IC 95% 67-93) en pacientes endoscópicos Step Up. Todas las recurrencias fueron benignas, <1 cm, y manejadas endoscópicamente.Diseño no aleatorizado y seguimiento corto.El abordaje endoscópico Step Up para pólipos de colon se asocia con menos morbilidad, disminución de los costos de atención médica y preservación del colon en el 95% de los pacientes. Se ocupan más estudios para evaluar la calidad de vida a largo plazo y la recurrencia de pólipos en este grupo. Consulte Video Resumen en http://links.lww.com/DCR/B188. (Traducción-Dr Adrián Ortega Robles).

"Peek port": avoiding conversion during laparoscopic colectomy-an update.

PURPOSE: To assess the efficacy of a method to avoid conversion to laparotomy in patients considered for laparoscopic colectomy. Patients considered being at high risk for conversion to formal laparotomy were initially approached via a small midline incision ("peek port") with the laparoscopic equipment readily available but unopened. If intraperitoneal conditions were favorable, the procedure was performed using hand-assisted laparoscopy (HALS); if intraperitoneal conditions were unfavorable, the incision was extended to a formal laparotomy. METHODS: Data from 664 patients from a single surgeon brought to the operating room with the intention of proceeding with laparoscopic colectomy (either via straight laparoscopy or HALS) were retrieved from a prospective database. Comparison of conversion rates between groups was performed using χ2 analysis. RESULTS: The study population consisted of 361 men and 303 women with a mean age of 61 years. Inflammatory conditions accounted for 40% of the diagnoses and enteric fistulas were present in 12%. Of the 79 patients who underwent initial "peek port" exploration, 38 (48%) underwent immediate extension to formal laparotomy, whereas 41 (52%) underwent HALS colectomy, with one subsequent conversion from HALS to formal laparotomy. Of the 585 patients initially approached laparoscopically, 14 (2%) required conversion to laparotomy. Of the 626 patients from both groups who underwent laparoscopy, the overall conversion to laparotomy rate was 15/626 (2%). DISCUSSION: The "peek port" approach to the patients with a potentially hostile abdomen allows for prompt assessment of intraperitoneal conditions and is associated with an overall low rate of conversion from laparoscopy to laparotomy during colectomy. This technique may reduce expense and morbidity for patients who ultimately require laparotomy, while allowing some patients with complex disease to be managed laparoscopically who would not normally be considered for a minimally invasive procedure.

Sigmoido-rectal intussusception.

Rectal prolapse is usually of benign etiology. Rarely, sigmoido-rectal intussusception results from a malignant lead-point. We report the case of a patient with a partially obstructing sigmoid cancer causing a full thickness rectal prolapse requiring surgical intervention. An 82-year-old woman presented with 1 week of rectal bleeding, fecal incontinence, and weight loss. Computed tomography identified sigmoido-rectal intussusception. Colonoscopic biopsy revealed high-grade dysplasia. Magnetic resonance imaging demonstrated a 6-cm mass forming the lead point of the intussusceptum with epiploic appendages seen within the rectal lumen. She underwent laparoscopic low anterior resection with final pathology consistent with T2N0 adenocarcinoma, and recovered well. Among adult patients with rectal prolapse, suspicion for underlying malignancy should prompt a thorough investigation to inform the decision for resection, which may be safely performed by minimally invasive techniques.

Should They Stay or Should They Go? The Utility of C-Reactive Protein in Predicting Readmission and Anastomotic Leak After Colorectal Resection.

BACKGROUND: Hospital readmission and anastomotic leak following colorectal resection have a negative impact on patients, surgeons, and the health care system. Novel markers of patients unlikely to experience these complications are of value in avoiding readmission. OBJECTIVE: This study aimed to determine the predictive value of C-reactive protein for readmission and anastomotic leak within 30 days following colorectal resection. DESIGN: This is a retrospective review of a prospectively compiled single-institution database. PATIENTS: From January 1, 2013, to July 20, 2017, consecutive patients undergoing elective colorectal resection with anastomosis without the presence of proximal intestinal stoma, who had C-reactive protein measured on postoperative day 3, were included. MAIN OUTCOME MEASURES: The primary outcome measured was the predictive value of C-reactive protein measured on postoperative day 3 for readmission or anastomotic leak within 30 days after colorectal resection. RESULTS: Of the 752 patients examined, 73 (10%) were readmitted within 30 days of surgery and 17 (2%) had an anastomotic leak. Mean C-reactive protein in patients who neither had an anastomotic leak nor were readmitted (127 ± 77 mg/L) was lower than for patients who were readmitted (157 ± 96 mg/L, p = 0.002) and lower than for patients who had an anastomotic leak (228 ± 123 mg/L, p = 0.0000002). The area under the receiver operating characteristic curve for the diagnostic accuracy of C-reactive protein for readmission was 0.59, with a cutoff value of 145 mg/L, generating a 93% negative predictive value. The area under the curve for the diagnostic accuracy of C-reactive protein for anastomotic leak was 0.76, with a cutoff value of 147 mg/L generating a 99% negative predictive value. LIMITATIONS: This study was limited by its retrospective design and because all patients were treated at a single center. CONCLUSIONS: Patients with a C-reactive protein below 145 mg/L on postoperative day 3 after colorectal resection have a low likelihood of readmission within 30 days, and a very low likelihood of anastomotic leak. See Video Abstract at http://links.lww.com/DCR/A761.

Disease-free Survival and Local Recurrence for Laparoscopic Resection Compared With Open Resection of Stage II to III Rectal Cancer: Follow-up Results of the ACOSOG Z6051 Randomized Controlled Trial.

OBJECTIVE: To determine the disease-free survival (DFS) and recurrence after the treatment of patients with rectal cancer with open (OPEN) or laparoscopic (LAP) resection. BACKGROUND: This randomized clinical trial (ACOSOG [Alliance] Z6051), performed between 2008 and 2013, compared LAP and OPEN resection of stage II/III rectal cancer, within 12 cm of the anal verge (T1-3, N0-2, M0) in patients who received neoadjuvant chemoradiotherapy. The rectum and mesorectum were resected using open instruments for rectal dissection (included hybrid hand-assisted laparoscopic) or with laparoscopic instruments under pneumoperitoneum. The 2-year DFS and recurrence were secondary endpoints of Z6051. METHODS: The DFS and recurrence were not powered, and are being assessed for superiority. Recurrence was determined at 3, 6, 9, 12, and every 6 months thereafter, using carcinoembryonic antigen, physical examination, computed tomography, and colonoscopy. In all, 486 patients were randomized to LAP (243) or OPEN (243), with 462 eligible for analysis (LAP = 240 and OPEN = 222). Median follow-up is 47.9 months. RESULTS: The 2-year DFS was LAP 79.5% (95% confidence interval [CI] 74.4-84.9) and OPEN 83.2% (95% CI 78.3-88.3). Local and regional recurrence was 4.6% LAP and 4.5% OPEN. Distant recurrence was 14.6% LAP and 16.7% OPEN.Disease-free survival was impacted by unsuccessful resection (hazard ratio [HR] 1.87, 95% CI 1.21-2.91): composite of incomplete specimen (HR 1.65, 95% CI 0.85-3.18); positive circumferential resection margins (HR 2.31, 95% CI 1.40-3.79); positive distal margin (HR 2.53, 95% CI 1.30-3.77). CONCLUSION: Laparoscopic assisted resection of rectal cancer was not found to be significantly different to OPEN resection of rectal cancer based on the outcomes of DFS and recurrence.

What do Young Colorectal Surgeons Value From Their CRS Residency Training?

OBJECTIVE: Colorectal surgery (CRS) training has seen many changes over the years. This study sought to identify aspects of CRS residency curriculum that were most valued by recent graduates and what changes could be made to improve training. DESIGN: Semistructured interviews were performed with board-certified colorectal surgeons 2 to 7years removed from their CRS residency. Interview responses were qualitatively analyzed and converted to coded, categorizable data. Subjects were recruited via a snowball sampling method. SETTING: Interviews were conducted in person and via telephone with surgeons in a variety of practices across the United States and Canada. Analysis was performed by a team at Lahey Clinic, Burlington, MA, an academic, tertiary care center. PARTICIPANTS: Board certified colorectal surgeons 2 to 7years removed from CRS residency. RESULTS: Twenty surgeons from 11 different CRS residencies were interviewed. At the time of the interview, surgeons were employed in 13 states and 1 foreign country. When asked what aspects of their CRS residency were of value, surgeons produced 74 comments emphasizing: volume of cases (65% of subjects), variety of cases (55%), development of technical skills (40%), management of specific diseases (35%), faculty (30%), mentorship (30%), and practice management (15%). With regard to technical skills, surgeons cited pelvic surgery (40%) and minimally invasive techniques (45%) as the exposures that helped them become successful. When discussing what could be added to training, subjects made 54 comments identifying: more robotic exposure (35%), more anorectal disease (30%), more pelvic floor exposure (25%), and practice management/billing (35%) as items to incorporate. Sixty five percent of subjects believed that "nothing" should be eliminated from their training. CONCLUSIONS: Young colon and rectal surgeons valued their training highly and strongly declined to eliminate any substantial part of the existing curriculum. They also expressed a strong desire to add more elements to the CRS residency including further robotic training, more anorectal, more pelvic floor, and further training in practice management.

Perioperative hypothermia during colectomy: when do patients get cold?

BACKGROUND: Hypothermia has been associated with an increase in the rate of infectious complications following colectomy. We hypothesized that a substantial fraction of temperature loss in patients undergoing elective colectomy occurs prior to operation. METHODS: Temperature data were collected from 105 consecutive patients undergoing elective colectomy at a single institution. RESULTS: The study population consisted of 105 patients; 67(64%) male, median age 59 years (range 17-95 years), median body mass index 27 kg/m2 (range 15-48 kg/m2). Median preoperative temperature was 36.7 °C (range 35.2-39.2 °C), dropping to 35.7 °C (range 34.0-37.3 °C) immediately following intubation and then rising to 36.2 °C (range 34.0-38.0 °C) prior to leaving the operating room. The median first postoperative temperature was 36.3 °C (range 34.4-37.7 °C). Temperatures were significantly different from one another (p < 0.05, ANOVA), except for the last operative and first postoperative temperature. A first postoperative temperature of ≥ 36.0 °C (meeting Surgical Care Improvement criteria Inf-10) was achieved in 78 (74%) of patients. A preoperative temperature of ≥ 36.5 °C was associated with a first postoperative temperature of ≥ 36.0 °C, but operative approach (laparoscopic versus open) was not. CONCLUSIONS: Most temperature loss occurs prior to operation in patients undergoing colectomy. Patients are rewarmed during the operative procedure. The time period prior to operation should be the focus of efforts designed to ensure normothermia.

Should classification as an ACS-NSQIP high outlier be used to direct hospital quality improvement efforts?

BACKGROUND: ACS-NSQIP classifies hospitals as "high outliers" if their performance is significantly worse than expected. We determined how often hospitals return to as-expected performance after being newly identified as outliers. METHODS: Outlier status was identified in ACS-NSQIP semi-annual reports (SARs) 2008-2011 for 13 postoperative adverse events. Pearson correlation and R2 measured the relationship between frequency of changes in outlier status, frequency of outlier identification, and adverse event rate. RESULTS: Among 284 hospitals, 75% were classified as high outliers for an adverse event at least once. New high outliers frequently did not remain outliers in the next SAR. Of new outliers, mortality had the highest percentage return to as-expected performance (62.7%), while surgical site infection had the lowest (20.5%). The likelihood of an outlier hospital returning to as-expected performance was inversely related to the percentage of hospitals classified as outliers. The percentage of hospitals classified as outliers for an event explained 60% of variation in outlier hospitals returning to as-expected performance. CONCLUSIONS: Outlier status may be less meaningful for adverse events with relatively few outlier hospitals.

What Is the Risk of Anastomotic Leak After Repeat Intestinal Resection in Patients With Crohn's Disease?

BACKGROUND: Approximately half of Crohn's patients require intestinal resection, and many need repeat resections. OBJECTIVE: The purpose of this study was to evaluate the increased risk of clinical anastomotic leak in patients with a history of previous intestinal resection undergoing repeat resection with anastomosis for Crohn's disease. DESIGN: This was a retrospective analysis of prospectively collected departmental data with 100% capture. SETTINGS: The study was conducted at the department of colorectal surgery in a tertiary care teaching hospital between July 2007 and March 2016. PATIENTS: A cohort of consecutive patients with Crohn's disease who were treated with intestinal resection and anastomosis, excluding patients with proximal fecal diversion, were included. The cohort was divided into 2 groups, those with no previous resection compared with those with previous resection. MAIN OUTCOME MEASURES: Clinical anastomotic leak within 30 days of surgery was measured. RESULTS: Of the 206 patients who met criteria, 83 patients had previous intestinal resection (40%). The 2 groups were similar in terms of patient factors, immune-suppressing medication use, and procedural factors. Overall, 20 clinical anastomotic leaks were identified (10% leak rate). There were 6 leaks (5%) detected in patients with no previous intestinal resection and 14 leaks (17%) detected in patients with a history of previous intestinal resection (p < 0.005). The OR of anastomotic leak in patients with Crohn's disease with previous resection compared with no previous resection was 3.5 (95% CI, 1.3-9.4). Patients with 1 previous resection (n = 53) had a leak rate of 13%, whereas patients with ≥2 previous resections (n = 30) had a leak rate of 23%. The number of previous resections correlated with increasing risk for clinical anastomotic leak (correlation coefficient = 0.998). LIMITATIONS: This was a retrospective study with limited data to perform a multivariate analysis. CONCLUSIONS: Repeat intestinal resection in patients with Crohn's disease is associated with an increased rate of anastomotic leakage when compared with initial resection despite similar patient, medication, and procedural factors. See Video Abstract at http://links.lww.com/DCR/A459.