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1.
J Surg Educ ; 77(6): 1473-1480, 2020.
Artigo em Inglês | MEDLINE | ID: mdl-32768381

RESUMO

OBJECTIVE: The purpose of this study is to identify perceptions of academic surgeons regarding academic productivity and assess its relationship to clinical productivity. We hypothesized that these perceptions would vary based on respondent characteristics including clinical activity and leadership roles. DESIGN: This retrospective, survey-based study was performed from August 26, 2019 to September 26, 2019. SETTING: The setting was academic surgical departments across the US. PARTICIPANTS: The survey instrument was administered to faculty members of the Association of Program Directors in Surgery. A total of 105 academic surgeons responded. RESULTS: Most respondents were Program Directors (59%) of general surgery programs. Of the participants, 30% identified as Professor, 36% as Associate Professor, and 15% as Assistant Professor. Respondents agreed that multiple academic pursuits or factors should count towards academic productivity including the following (in descending order): completing a first-authored manuscript (98.8%), completing a senior-authored manuscript (97.7%), chairing a national committee (94.1%), serving on a national committee (88.2%), completing a second-authored manuscript (88.0%), completing a first lecture (83.7%), completing a middle-authored manuscript (71.8%), completing a lecture (whether or not repeated) (70.9%), impact factor of journal (60.7%), and attendance at grand rounds (57.0%). Perspectives did not vary significantly based on surgeon demographics, clinical setting, or leadership role (p > 0.05). CONCLUSIONS: Perceptions regarding what constitutes academic productivity and merit a reduction in clinical expectation are remarkably similar across multiple surgeon characteristics including demographics, academic title, leadership role, and practice environment.

2.
JAMA ; 324(4): 350-358, 2020 07 28.
Artigo em Inglês | MEDLINE | ID: mdl-32721009

RESUMO

Importance: Opioid-induced ventilatory depression and hypoxemia is common, severe, and often unrecognized in postoperative patients. To the extent that nonopioid analgesics reduce opioid consumption, they may decrease postoperative hypoxemia. Objective: To test the hypothesis that duration of hypoxemia is less in patients given intravenous acetaminophen than those given placebo. Design, Setting, and Participants: Randomized, placebo-controlled, double-blind trial conducted at 2 US academic hospitals among 570 patients who were undergoing abdominal surgery, enrolled from February 2015 through October 2018 and followed up until February 2019. Interventions: Participants were randomized to receive either intravenous acetaminophen, 1 g (n = 289), or normal saline placebo (n = 291) starting at the beginning of surgery and repeated every 6 hours until 48 postoperative hours or hospital discharge, whichever occurred first. Main Outcomes and Measures: The primary outcome was the total duration of hypoxemia (hemoglobin oxygen saturation [Spo2] <90%) per hour, with oxygen saturation measured continuously for 48 postoperative hours. Secondary outcomes were postoperative opioid consumption, pain (0- 10-point scale; 0: no pain; 10: the most pain imaginable), nausea and vomiting, sedation, minimal alveolar concentration of volatile anesthetic, fatigue, active time, and respiratory function. Results: Among 580 patients randomized (mean age, 49 years; 48% women), 570 (98%) completed the trial. The primary outcome, median duration with Spo2 of less than 90%, was 0.7 (interquartile range [IQR], 0.1-5.1) minutes per hour among patients in the acetaminophen group and 1.1 (IQR, 0.1-6.6) minutes per hour among patients in the placebo group (P = .29), with an estimated median difference of -0.04 (95% CI,-0.18 to 0.11) minutes per hour. None of the 8 secondary end points differed significantly between the acetaminophen and placebo groups. Mean pain scores within initial 48 postoperative hours were 4.2 (SD, 1.8) in the acetaminophen group and 4.4 (SD, 1.8) in the placebo group (difference, -0.28; 95% CI, -0.71 to 0.15); median opioid use in morphine equivalents was 50 mg (IQR, 18-122 mg) and 58 mg (IQR, 24-151 mg) , respectively, with a ratio of geometric means of 0.86 (95% CI, 0.61-1.21). Conclusions and Relevance: Among patients who underwent abdominal surgery, use of postoperative intravenous acetaminophen, compared with placebo, did not significantly reduce the duration of postoperative hypoxemia over 48 hours. The study findings do not support the use of intravenous acetaminophen for this purpose. Trial Registration: ClinicalTrials.gov Identifier: NCT02156154.


Assuntos
Acetaminofen/administração & dosagem , Analgésicos não Entorpecentes/administração & dosagem , Hipóxia/tratamento farmacológico , Complicações Pós-Operatórias/tratamento farmacológico , Analgésicos Opioides/efeitos adversos , Analgésicos Opioides/uso terapêutico , Método Duplo-Cego , Feminino , Humanos , Infusões Intravenosas , Masculino , Pessoa de Meia-Idade , Medição da Dor , Dor Pós-Operatória/tratamento farmacológico , Falha de Tratamento
3.
Cancers (Basel) ; 12(8)2020 Jul 24.
Artigo em Inglês | MEDLINE | ID: mdl-32722082

RESUMO

(1) Background: The relatively poor expert restaging accuracy of MRI in rectal cancer after neoadjuvant chemoradiation may be due to the difficulties in visual assessment of residual tumor on post-treatment MRI. In order to capture underlying tissue alterations and morphologic changes in rectal structures occurring due to the treatment, we hypothesized that radiomics texture and shape descriptors of the rectal environment (e.g., wall, lumen) on post-chemoradiation T2-weighted (T2w) MRI may be associated with tumor regression after neoadjuvant chemoradiation therapy (nCRT). (2) Methods: A total of 94 rectal cancer patients were retrospectively identified from three collaborating institutions, for whom a 1.5 or 3T T2w MRI was available after nCRT and prior to surgical resection. The rectal wall and the lumen were annotated by an expert radiologist on all MRIs, based on which 191 texture descriptors and 198 shape descriptors were extracted for each patient. (3) Results: Top-ranked features associated with pathologic tumor-stage regression were identified via cross-validation on a discovery set (n = 52, 1 institution) and evaluated via discriminant analysis in hold-out validation (n = 42, 2 institutions). The best performing features for distinguishing low (ypT0-2) and high (ypT3-4) pathologic tumor stages after nCRT comprised directional gradient texture expression and morphologic shape differences in the entire rectal wall and lumen. Not only were these radiomic features found to be resilient to variations in magnetic field strength and expert segmentations, a quadratic discriminant model combining them yielded consistent performance across multiple institutions (hold-out AUC of 0.73). (4) Conclusions: Radiomic texture and shape descriptors of the rectal wall from post-treatment T2w MRIs may be associated with low and high pathologic tumor stage after neoadjuvant chemoradiation therapy and generalized across variations between scanners and institutions.

4.
Surg Endosc ; 2020 Jun 17.
Artigo em Inglês | MEDLINE | ID: mdl-32556770

RESUMO

BACKGROUND: Laparoscopic sigmoidectomy is the preferred approach in the elective surgical management of diverticulitis. However, it is unclear if the benefits of laparoscopy persist when operative times are prolonged. We aimed to investigate if the recovery benefits associated with laparoscopy are retained when operative times are long. METHODS: A retrospective review of a prospectively maintained database of patients who underwent elective laparoscopic sigmoidectomy from 2010-2015 at a single academic tertiary institution was performed. Operative times among laparoscopic completed cases were divided into quartiles, and patient outcomes were compared between the groups. RESULTS: A total of 466 patients (median age: 58 ± 11.6 years, 58% females) underwent sigmoidectomy: 430 completed laparoscopically and 36 (7.7%) converted. Median operative time in laparoscopically completed cases was 188 min (IQR 154-230). There were no differences in morbidity (P = 0.52) or readmission rates (P = 0.22) among the quartiles. The 2nd and 4th operative time quartiles were associated with significantly longer length of stay (LOS) when compared to the fastest quartile (P = 0.003 and P = 0.002, respectively), but there was no increase in LOS as operative times progressed between the 2nd, 3rd, and 4th quartiles. LOS after conversion was longer but did not reach statistical significance when compared to laparoscopically completed operations in the longest quartile (5.0 vs 6.5 days, P = 0.075) CONCLUSIONS: Our data do not support preemptive conversion of laparoscopic sigmoidectomy to avoid prolonged operative times. As long as progress is safely being made, surgeons are justified to continue pursuing laparoscopic completion.

5.
Surg Endosc ; 2020 May 29.
Artigo em Inglês | MEDLINE | ID: mdl-32472496

RESUMO

BACKGROUND: In the West, piecemeal endoscopic resection remains the primary treatment for large colon polyps (LCP), as most recurrences are believed to be benign and resectable with follow-up endoscopy. However, invasive malignancy at the site of prior piecemeal endoscopic mucosal resection has been reported in the Asian literature. This study aims to identify the incidence of and the risk factors for local recurrence with malignancy after endoscopic resection of LCP with high-grade dysplasia (HGD). METHODS: In this retrospective cohort study, we identified patients undergoing complete endoscopic resection of LCPs (≥ 20 mm) with HGD at the Cleveland Clinic between January 2000 and December 2016. Demographic, endoscopic, and pathologic data were collected. All subsequent endoscopic and pathology reports were reviewed to identify recurrence. The cumulative incidence of malignancy at the polypectomy site was determined and univariate analysis was performed to assess risk factors. RESULTS: A total of 254 LCPs with HGD were resected in 229 patients. Mean polyp size was 29.2 mm. There were 138 lesions resected in piecemeal fashion and 116 en-bloc. After a median follow-up of 28.7 months for the entire cohort, local recurrence with malignancy was diagnosed in six cases. Median time to malignancy diagnosis was 28.5 months. All malignant cases occurred after piecemeal resection and none after en-bloc resection (HR 11.4; 95% CI 0.48-273). CONCLUSION: Malignancy after endoscopic resection of LCPs with HGD is uncommon and may be associated with piecemeal resection. When possible, en-bloc resection should be the goal for the management of LCPs.

6.
Surg Endosc ; 2020 May 28.
Artigo em Inglês | MEDLINE | ID: mdl-32468260

RESUMO

BACKGROUND: The aims of this study were to determine risk factors for morbidity associated with laparoscopic ileocolic resection (LICR) for Crohn's disease (CD) and whether the addition of a diverting ileostomy is associated with reduced morbidity. METHODS: Patients undergoing LICR for primary CD at our institution from 2005 to 2015 included in a prospectively maintained database were assessed. The decision to perform a diverting ileostomy was left at the discretion of the operating surgeon. Demographics, disease-related, and treatment-related variables were evaluated using univariate and multivariate analyses as possible factors associated with diverting ileostomy creation and 30-day perioperative septic complications (anastomotic leaks and/or abscess). Use of any immunosuppressive medication was defined as use of steroids, biologics, and immunomodulators either alone or in combination. RESULTS: For 409 patients, mortality was nil, overall morbidity rate was 40.6%, conversion rate 9.3%, and septic morbidity rate 7.6%. A diverting stoma was created in 22% of cases and was independently associated with BMI < 18.5 kg/m2 (P = 0.001), low serum albumin levels (P = 0.006), and longer operative time (P = 0.003). Use of any immunosuppressive medication was the only variable independently associated with septic complications, both in the overall population (OR 2.7, P = 0.036) and in the subgroup of undiverted patients (OR 3.1, P = 0.031). There was no association between septic morbidity and ileostomy creation, anastomotic configuration, penetrating disease, combined procedures (other resection or strictureplasty), BMI, albumin levels, and operative times. CONCLUSIONS: LICR is safe in selected cases of complex penetrating disease, including when combined procedures are necessary. Our data are unable to prove that a diverting stoma is associated with reduced morbidity.

8.
Eur J Surg Oncol ; 46(6): 955-966, 2020 06.
Artigo em Inglês | MEDLINE | ID: mdl-32147426

RESUMO

The liver is the most common anatomical site for hematogenous metastases from colorectal cancer. Therefore effective treatment of liver metastases is one of the most challenging elements in the management of colorectal cancer. However, there is rare available clinical consensus or guideline only focusing on colorectal liver metastases. After six rounds of discussion by 195 clinical experts of the Shanghai International Consensus Expert Group on Colorectal Liver Metastases (SINCE) from 29 countries or regions, the Shanghai Consensus has been finally completed, based on current research and expert experience. The consensus emphasized the principle of multidisciplinary team, provided detailed diagnosis approaches, and guided precise local and systemic treatments. This Shanghai Consensus might be of great significance to standardized diagnosis and treatment of colorectal liver metastases all over the world.

9.
Ann Surg ; 272(1): e27-e29, 2020 07.
Artigo em Inglês | MEDLINE | ID: mdl-32221117

RESUMO

: Little is known about surgical practice in the initial phase of coronavirus disease 2019 (COVID-19) global crisis. This is a retrospective case series of 4 surgical patients (cholecystectomy, hernia repair, gastric bypass, and hysterectomy) who developed perioperative complications in the first few weeks of COVID-19 outbreak in Tehran, Iran in the month of February 2020. COVID-19 can complicate the perioperative course with diagnostic challenge and a high potential fatality rate. In locations with widespread infections and limited resources, the risk of elective surgical procedures for index patient and community may outweigh the benefit.


Assuntos
Infecções por Coronavirus/epidemiologia , Procedimentos Cirúrgicos Eletivos/efeitos adversos , Pandemias , Pneumonia Viral/epidemiologia , Complicações Pós-Operatórias , Betacoronavirus , Colecistectomia/efeitos adversos , Técnicas de Laboratório Clínico , Infecções por Coronavirus/diagnóstico , Infecções por Coronavirus/transmissão , Diagnóstico Diferencial , Feminino , Derivação Gástrica/efeitos adversos , Herniorrafia/efeitos adversos , Humanos , Histerectomia/efeitos adversos , Irã (Geográfico)/epidemiologia , Pneumonia Viral/diagnóstico , Pneumonia Viral/transmissão , Complicações Pós-Operatórias/diagnóstico , Complicações Pós-Operatórias/virologia , Estudos Retrospectivos
10.
Int J Colorectal Dis ; 35(1): 95-100, 2020 Jan.
Artigo em Inglês | MEDLINE | ID: mdl-31781841

RESUMO

PURPOSE: Most preoperative assessment tools to evaluate risk for postoperative complications require multiple data points to be collected and can be logistically burdensome. This study evaluated if umbilical contamination, a simple bedside assessment, correlated with surgical outcomes. METHODS: A 6-point score to measure umbilical contamination was developed and applied prospectively to patients undergoing colorectal surgery at an academic medical center. RESULTS: There were 200 patients enrolled (mean age 58.1 ± 14.8; 56% female). The mean BMI was 28.6 ± 7.4. Indications for surgery included colon cancer (24%), rectal cancer (18%), diverticulitis (13.5%), and Crohn's disease (12.5%). Umbilical contamination scores were 0 (23%, cleanest), 1 (26%), 2 (21%), 3 (24%), 4 (6%), and 5 (0%, dirtiest). Umbilical contamination did not correlate with preoperative functional status (p > 0.2). Umbilical contamination correlated with increased length of stay (rho = 0.19, p = 0.007) and postoperative complications (OR 1.3, 1.02-1.7, p = 0.04), but not readmission (p = 0.3) or discharge disposition (p > 0.2). CONCLUSION: Sterile preparation of the abdomen is an important component of proper surgical technique and umbilical contamination correlates with increased postoperative complications.


Assuntos
Cirurgia Colorretal , Umbigo/cirurgia , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Complicações Pós-Operatórias/etiologia , Resultado do Tratamento
11.
Int J Colorectal Dis ; 35(1): 77-84, 2020 Jan.
Artigo em Inglês | MEDLINE | ID: mdl-31776698

RESUMO

BACKGROUND: Controversial data exists in the current literature in regard to the use of neoadjuvant chemoradiation (nCRT) in patients with clinical T3N0 (cT3N0) rectal cancers, specifically based on location and relation to peritoneal reflection. We aimed to analyze the impact of nCRT on oncologic outcomes among cT3N0 rectal cancers, depending on the tumor height from anal verge (AV). METHODS: A retrospective analysis of patients with cT3N0 rectal cancers was included from a query of a prospectively maintained rectal cancer database from 1980 to 2016. Patients were divided into 3 groups based on the tumor height: low (1-5 cm from AV), mid (6-10 cm from AV), and upper (11-15 cm from AV). Patients were stratified by use of nCRT. MAIN OUTCOMES: 5-year overall survival (OS), disease-free survival (DFS), cancer-specific survival (CSS), and local recurrence (LR) using Kaplan-Meier curves. RESULTS: Five hundred ninety-two patients were included. Overall, 364 (61.4%) patients received nCRT and 228 (38.6%) patients did not. There were 251 (43%) patients with low, 302 (51%) with mid, and 39 (7%) with upper rectal cancer. Patients with low and mid rectal cancers received nCRT more frequently than those with upper rectal cancers (68.5% and 61.2% vs 43.6%, p = 0.007). The 5-year OS was 78% and 63%, DFS-88% and 73%, LR-1% and 8% in nCRT followed by resection vs. surgery alone (p < 0.001). In regard to cancer location after nCRT compared with surgery alone, low and mid cancers had better OS, DFS, and CSS, compared with upper ones. CONCLUSION: nCRT prolongs survival among patients with rectal cancer below 10 cm from AV; however, it has no effect on 5-year oncologic survival of patients with upper rectal cancer located below peritoneal reflection.


Assuntos
Quimiorradioterapia , Terapia Neoadjuvante , Neoplasias Retais/terapia , Idoso , Feminino , Humanos , Estimativa de Kaplan-Meier , Masculino , Pessoa de Meia-Idade , Análise Multivariada , Estadiamento de Neoplasias , Neoplasias Retais/patologia , Resultado do Tratamento
12.
Am J Surg ; 219(3): 515-520, 2020 03.
Artigo em Inglês | MEDLINE | ID: mdl-31703835

RESUMO

INTRODUCTION: Our aim was to develop a nomogram taking into account factors such as tumor biology to predict overall and disease-free survival for patients with primary rectal adenocarcinoma undergoing curative intent surgical resection. METHODS: Patients undergoing resection for primary rectal adenocarcinoma (2007-2017) were included. Factors reflecting tumor biology and important clinical prognosticators were included in nomogram development. Prognostic factors were assessed with multivariable analysis using Cox regression. The impact of each was assessed using Kaplan Meier survival curves. RESULTS: Overall, 1688 patients (male, 61%) with a mean age of 59.8 years (±13.5) and a median follow-up of 34.8 months (range, 12-132) were included. The only significant factors affecting the overall and disease-free survival were age at diagnosis, pathological staging, regression grade, resection margin, and tumor deposits. CONCLUSION: The current model incorporates histopathological and clinical factors. It emphasizes the importance of tumor biological factors like tumor deposits in predicting overall and disease-free survival in rectal cancer. SUMMARY: Rectal cancer outcomes are associated with certain clinical and pathological factors that can be evaluated. Tumor deposits are one such factor that can affect overall and disease-free survival.


Assuntos
Adenocarcinoma/mortalidade , Adenocarcinoma/cirurgia , Neoplasias Retais/mortalidade , Neoplasias Retais/cirurgia , Sobrevivência , Adenocarcinoma/patologia , Fatores Etários , Feminino , Humanos , Masculino , Margens de Excisão , Pessoa de Meia-Idade , Gradação de Tumores , Estadiamento de Neoplasias , Nomogramas , Valor Preditivo dos Testes , Prognóstico , Neoplasias Retais/patologia
13.
Am J Surg ; 220(1): 187-190, 2020 07.
Artigo em Inglês | MEDLINE | ID: mdl-31735257

RESUMO

BACKGROUND: Modified frailty index (mFI) has been proposed as a reliable tool in predicting postoperative outcomes after surgery. This study aims to evaluate whether mFI could be utilized to predict readmissions after colorectal resection for patients with cancer by using nationwide cohort. METHODS: Patients undergoing elective abdominal colorectal resection for colorectal cancer were reviewed from the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) procedure-targeted database (2010-2012). A previously described mFI was calculated. Demographics, comorbidities, and 30-day postoperative complications were compared between patients who were readmitted or not after colorectal surgery. RESULTS: A total of 7337 patients were identified with a mean age of 65.8(±13.6) years. Eight hundred seventy-one (11.8%) patients were readmitted at least once within 30 days. Age, gender, BMI, and other comorbidities were comparable between the groups. O approach, current smoking, mFI(>3/11), disseminating cancer, bleeding disorder and longer operative time were found to independently associated with readmission. CONCLUSIONS: An 11-point modified frailty index as measured in NSQIP correlates with readmissions after colorectal resection in patients with colon and rectal cancer.


Assuntos
Neoplasias Colorretais/cirurgia , Cirurgia Colorretal/métodos , Fragilidade/diagnóstico , Readmissão do Paciente/tendências , Melhoria de Qualidade , Medição de Risco , Idoso , Neoplasias Colorretais/epidemiologia , Comorbidade , Bases de Dados Factuais , Feminino , Fragilidade/epidemiologia , Humanos , Incidência , Masculino , Pessoa de Meia-Idade , Complicações Pós-Operatórias/epidemiologia , Estudos Retrospectivos , Fatores de Risco , Taxa de Sobrevida/tendências , Estados Unidos/epidemiologia
14.
Int J Colorectal Dis ; 35(1): 41-49, 2020 Jan.
Artigo em Inglês | MEDLINE | ID: mdl-31760437

RESUMO

BACKGROUND: It is unknown if ulcerative colitis (UC) duration has an impact on outcomes of ileal pouch anal anastomosis (IPAA). The aim of the study was to compare the long-term IPAA outcomes based on preoperative UC duration. METHODS: All patients with pathologically confirmed UC who underwent IPAA were included from a prospectively maintained pouch database (1983-2017).Patient's cohort was stratified according to UC duration:< 5 years,5-10 years,10-20 years,> 20 years. UC duration was defined as time interval from date of preoperative diagnosis to colectomy date. The main outcome was Kaplan-Meier pouch survival. Secondary outcomes were pouch function and quality of life. RESULTS: Out of 4502 IPAAs (1983-2016), 2797 patients were included. Treated with biologics versus 12% with UC duration > 20 years were 41% patients with UC duration < 5 years. Treated with steroids compared to shortest (34%,p < 0.001) were 54% patients with the longest disease. A total of 65% of patients with shortest disease had IPAAs performed mostly in 3 stages. Anastomotic separation and pelvic sepsis were more prevalent among shortest compared to longest disease groups. Rates of pouch-targeted fistulas, anastomotic strictures, and pouchitis were highest in longest disease group. Pouch survival was similar between groups. Multivariate analysis did not show a significant association between UC duration and pouch failure [1.05(0.97-1.1), p = 0.23].Longer UC duration was associated with increased odds of pouchitis [1.2(1.1, 1.3), p < 0.001]. Biologics agents were shown to be protective against pouchitis. CONCLUSIONS: Preoperative UC duration does not increase pouch failure risk. Longer preoperative UC duration increases the pouchitis risk. Biologic agents and three-staged IPAA are protective against pouchitis and septic complications in long-term among patients with UC.


Assuntos
Colite Ulcerativa/cirurgia , Cuidados Pré-Operatórios , Proctocolectomia Restauradora , Adulto , Fezes , Feminino , Humanos , Estimativa de Kaplan-Meier , Masculino , Análise Multivariada , Complicações Pós-Operatórias/etiologia , Modelos de Riscos Proporcionais , Qualidade de Vida , Fatores de Tempo , Resultado do Tratamento
15.
Am J Surg ; 219(3): 527-529, 2020 03.
Artigo em Inglês | MEDLINE | ID: mdl-31604485

RESUMO

BACKGROUND: Ileus following colorectal surgery is a significant burden for healthcare and can be challenging to manage. This study aims to evaluate risk factors for postoperative ileus in patients undergoing colorectal surgery. METHODS: Patients who underwent colorectal resections for any diagnosis were identified from our institutional database between 2009 and 2014. Patient demographics, pre-operative comorbidities, and operation-related variables were compared in patients with and without ileus within 30 days after surgery. RESULTS: A total of 5369 patients were identified with a mean age of 53 years. 892 patients (16.6%) developed postoperative ileus. Males were twice as likely (p < 0.001) and patients with anastomosis were 1.4 times more likely to develop ileus compared to those without (p < 0.001). Laparoscopic surgery and younger age were associated with lower ileus risk. Patients with colorectal cancer, Crohn's disease, and ulcerative colitis diagnoses were all more likely to develop postoperative ileus compared to patients with diverticular disease. CONCLUSIONS: Evaluation of factors such as male gender, older age, anastomosis formation, diagnosis of cancer and inflammatory bowel disease, can help facilitate earlier diagnosis of postoperative ileus and may require consideration of prophylactic therapy.


Assuntos
Doenças do Colo/cirurgia , Íleus/etiologia , Complicações Pós-Operatórias/etiologia , Doenças Retais/cirurgia , Fatores Etários , Feminino , Humanos , Laparoscopia , Masculino , Pessoa de Meia-Idade , Fatores de Risco , Fatores Sexuais
16.
Am J Surg ; 219(3): 419-423, 2020 03.
Artigo em Inglês | MEDLINE | ID: mdl-31640851

RESUMO

BACKGROUND: Locoregional colon cancer recurrence occurs in around 10% of patients following initial curative intent primary resection. We hypothesized oncological results can vary based on the recurrence site. Our aim was to determine outcomes for patients undergoing resection with curative intent for locally recurrent colon cancer. METHODS: Patients with locoregional recurrence after curative intent resection for colon cancer were identified (1999-2017). Demographics, operative details and outcome data were recorded. Kaplan-Meier method was used to compare survival differences. RESULTS: Fifty-two patients (mean age, 62) were included. The most common recurrence site was primary anastomosis (48%). R0 resection was obtained in 68%. Major morbidity occurred in 37%. Patients with anastomotic recurrence had a statistically significant overall survival compared to other sites (71.6 vs. 40.8 months respectively with a P value of 0.05). CONCLUSIONS: Excellent outcomes are possible for curative intent recurrent colon cancer surgery. The site of loco-regional recurrence plays a significant role in outcomes. Table of Contents Summary: Colon cancer recurrence can be treated surgically with optimal outcomes. Anastomotic recurrence is associated with improved survival.


Assuntos
Neoplasias do Colo/cirurgia , Recidiva Local de Neoplasia/cirurgia , Idoso , Anastomose Cirúrgica , Neoplasias do Colo/mortalidade , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Recidiva Local de Neoplasia/mortalidade , Ohio , Taxa de Sobrevida
17.
Am J Surg ; 219(3): 406-410, 2020 03.
Artigo em Inglês | MEDLINE | ID: mdl-31672306

RESUMO

BACKGROUND: Neoadjuvant chemoradiotherapy (nCRT) has become the standard of care for locally advanced rectal cancer, decreasing locoregional recurrence, yet with an unclear survival advantage. We aimed to assess the benefit of nCRT on oncologic and perioperative outcomes of patients with clinical stage IIA rectal adenocarcinoma treated with abdominoperineal resection (APR). METHODS: Patients with clinical T3N0 rectal adenocarcinoma that underwent APR between 1995 and 2014 were included. Patients who received nCRT were compared with patients who did not. Multivariate analysis was conducted to compare oncological and perioperative outcomes between the groups. RESULTS: 127 patients were included, of which 94 received nCRT. Median follow-up was 11.9 years. There was no difference in circumferential margins, postoperative morbidity, and complication rates between the groups. There was no difference in 5-year oncological outcomes between the groups. CONCLUSIONS: No difference was found in 5-year oncological outcomes between patients with clinical T3N0 rectal adenocarcinoma necessitating an APR who received nCRT and those not receiving nCRT, with similar overall complication rates.


Assuntos
Adenocarcinoma/terapia , Quimiorradioterapia Adjuvante , Protectomia , Neoplasias Retais/terapia , Adenocarcinoma/mortalidade , Adenocarcinoma/patologia , Idoso , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Terapia Neoadjuvante , Recidiva Local de Neoplasia , Estadiamento de Neoplasias , Complicações Pós-Operatórias , Neoplasias Retais/mortalidade , Neoplasias Retais/patologia , Medição de Risco , Análise de Sobrevida
18.
Inflamm Bowel Dis ; 26(3): 476-483, 2020 02 11.
Artigo em Inglês | MEDLINE | ID: mdl-31372647

RESUMO

BACKGROUND: Enhanced recovery pathways (ERPs) have been shown to reduce length of stay (LOS), complications, and costs after colorectal surgery; yet, little data exists regarding patients with inflammatory bowel disease (IBD). We hypothesized that implementation of ERP for IBD patients is associated with shorter LOS and improved economic outcomes. METHODS: An IRB-approved prospective clinical database was used to identify consecutive patients from 2015 to 2017. Patients were grouped as "pre-ERP" and "post-ERP" based on the date of implementation of a comprehensive ERP. Ileostomy closures, redo pouch operations, and outpatient operations were excluded. The relationship between ERP, LOS, and secondary outcomes was assessed using univariate and multivariate analysis. RESULTS: Overall, a total of 671 patients were included: 345 (51.4%) with Crohn's disease (CD) and 326 (48.6%) with ulcerative colitis (UC). Of these, 425 were pre-ERP (63.4%), and 246 were post-ERP (36.6%). The groups did not differ in terms of age, gender, American Society of Anesthesiologist (ASA) scores, comorbidities, estimated blood loss, or ostomy construction. The post-ERP group had a significantly higher mean body mass index (BMI), more patients with CD, longer operative time, and more minimally invasive surgery (MIS; all P < 0.05). The post-ERP group had a significantly shorter LOS (6 vs 4.5 days, median), whereas mean hospital costs decreased by 15.7%. There was no difference in readmissions or complications. On multivariate analysis, MIS and ERP use were both associated with a shorter LOS. CONCLUSION: Inflammatory bowel disease patients benefit from the use of ERP, demonstrating decreased LOS and costs without an increase in complications and readmissions. Enhanced recovery pathways should be routinely implemented in this often challenging patient population.

19.
Ann Surg ; 271(4): 663-670, 2020 04.
Artigo em Inglês | MEDLINE | ID: mdl-31663970

RESUMO

OBJECTIVE: The aim of this study was to determine characteristics of the most cited publications in the history of the American Surgical Association (ASA). SUMMARY BACKGROUND DATA: The Annals of Surgery has served as the journal of record for the ASA since 1928, with a special issue each year dedicated to papers presented before the ASA Annual Meeting. METHODS: The top 100 most cited ASA publications in the Annals of Surgery were identified from the Scopus database and evaluated for key characteristics. RESULTS: The 100 most cited papers from the ASA were published between 1955 and 2010 with an average of 609 citations (range: 333-2304) and are included among the 322 most cited papers in the Annals of Surgery. The most common subjects of study included clinical cancer (n = 43), gastrointestinal (n = 13), cardiothoracic/vascular (n = 9), and transplant (n = 9). Ninety-three institutions were included lead by Johns Hopkins University (n = 9), University of Pittsburgh (n = 8), Memorial Sloan-Kettering (n = 7), John Wayne Cancer Institute (n = 7), University of Texas (n = 7), and 5 each from Brigham and Women's Hospital, Mayo Clinic, and University of Chicago. The majority of manuscripts came from the United States (n = 85), followed by Canada (n = 7), Germany (n = 5), and Italy (n = 5). Study design included randomized controlled trials (n = 19), retrospective matched cohort studies (n = 11), retrospective nonmatched studies (n = 46), and other (n = 24). CONCLUSIONS: The top 100 most cited publications from the ASA are highly impactful, landmark studies representing a diverse array of subject matter, investigators, study design, institutions, and countries. These influential publications have immensely advanced surgical science over the decades and should serve as inspiration for all surgeons and surgical investigators.


Assuntos
Bibliometria/história , Cirurgia Geral/história , Publicações Periódicas como Assunto/história , Editoração/história , Sociedades Médicas/história , História do Século XX , História do Século XXI , Humanos , Estados Unidos
20.
J Crohns Colitis ; 13(7): 856-863, 2019 Jul 25.
Artigo em Inglês | MEDLINE | ID: mdl-31329836

RESUMO

BACKGROUND AND AIMS: Patients with Crohn's disease undergoing ileocolectomy and primary anastomosis are often at increased risk of anastomotic leak. We aimed to determine whether diverting ileostomy was protective against anastomotic leak after ileocolic resection for Crohn's disease using a large international registry. METHODS: We analysed the National Surgical Quality Improvement Program Colectomy Module from 2012 to 2016. Multivariable logistic regression analysis and propensity-score matching were used to identify independent risk factors for leak, and to test the hypothesis that diverting ileostomy was protective against anastomotic leakage. RESULTS: A total of 4172 [92%] patients underwent primary anastomosis, and 365 [8%] underwent anastomosis plus ileostomy. The leak rates in the two groups were 4.5% and 2.7%, [p = 0.12], respectively. Multivariate analysis indicated ileostomy omission, emergency surgery, smoking, inpatient status, wound classification 3 or 4, weight loss, steroid use, and prolonged operative time were independently associated with leak. Patients with 0-6 risk factors had leak rates of 1.6%, 2.7%, 4.3%, 6.7%, 8.8%, 11.5%, and 14.3% [p ≤ 0.001], respectively. Following propensity-score matching, ileostomy reduced the risk of leak rate by 55% [p = 0.005]. Patients with primary anastomosis who leaked most frequently required reoperation [57.8%], but anastomosis plus ileostomy patients who leaked most frequently were managed by percutaneous drainage [70%], p = 0.04. CONCLUSIONS: After ileocolic resection for Crohn's disease, anastomotic leak may be predicted by simple addition of risk factors. We found that diverting ileostomy mitigated against leak, reducing both the leak rate and the likelihood of unplanned reoperations. Faecal diversion should be considered when ≥3 risk factors are present.


Assuntos
Anastomose Cirúrgica , Fístula Anastomótica/prevenção & controle , Colectomia , Doença de Crohn/cirurgia , Ileostomia , Adulto , Feminino , Humanos , Masculino , Pontuação de Propensão , Sistema de Registros , Fatores de Risco
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