RESUMO
BACKGROUND: Ileal Crohn's disease (CD) complicated by intraabdominal abscess, phlegmon, fistula, and/or microperforation is commonly treated with antibiotics, bowel rest, and percutaneous drainage followed by interval ileocolic resection (ICR). This "cool off" strategy is intended to facilitate the safe completion of a one-stage resection using a minimally invasive approach and minimize perioperative complications. There is limited data evaluating the benefits of delayed versus early resection. METHODS: A retrospective review of a prospectively maintained inflammatory bowel disease (IBD) database at a tertiary center was queried from 2013-2020 to identify patients who underwent ICR for complicated ileal CD confirmed on preoperative imaging. ICR cohorts were classified as early (≤ 7 days) vs delayed (> 7 days) based on the interval from diagnostic imaging to surgery. Operative approach and 30-day postoperative morbidity were analyzed. RESULTS: Out of 474 patients who underwent ICR over the 7-year period, 112 patients had complicated ileal CD including 99 patients (88%) with intraabdominal abscess. Early ICR was performed in 52 patients (46%) at a median of 3 days (IQR 2, 5) from diagnostic imaging. Delayed ICR was performed in 60 patients (54%) following a median "cool off" period of 23 days of non-operative treatment (IQR 14, 44), including preoperative percutaneous abscess drainage in 17 patients (28%). A higher proportion of patients with intraabdominal abscess underwent delayed vs early ICR (57% vs 43%, p = 0.19). Overall, there were no significant differences in the rate of laparoscopy (96% vs 90%), conversion to open surgery (12% vs 17%), rates of extended bowel resection (8% vs 13%), additional concurrent procedures (44% vs 52%), or fecal diversion (10% vs 2%) in the early vs delayed ICR groups. The median postoperative length of stay was 5 days in both groups with an overall 25% vs 17% (p = 0.39) 30-day postoperative complication rate and a 6% vs 5% 30-day readmission rate in early vs delayed ICR groups, respectively. Overall median follow-up time was 14.3 months (IQR 1.2, 24.1) with no difference in the rate of subsequent CD-related intestinal resection (4% vs 5%) between the two groups. CONCLUSIONS: In this contemporary series, at a high-volume tertiary referral center, a "cool off" delayed resectional approach was not found to reduce perioperative complications in patients undergoing ICR for complicated ileal Crohn's disease. Laparoscopic ICR can be performed within one week of diagnosis with low rates of conversion and postoperative complications.
Assuntos
Abscesso Abdominal , Doença de Crohn , Laparoscopia , Abscesso Abdominal/etiologia , Abscesso Abdominal/cirurgia , Abscesso/etiologia , Abscesso/cirurgia , Anastomose Cirúrgica/efeitos adversos , Colectomia/efeitos adversos , Doença de Crohn/complicações , Doença de Crohn/cirurgia , Humanos , Laparoscopia/métodos , Complicações Pós-Operatórias/epidemiologia , Complicações Pós-Operatórias/etiologia , Complicações Pós-Operatórias/cirurgia , Resultado do TratamentoRESUMO
OBJECTIVE: To identify risk factors for urethral and urologic injuries during transanal total mesorectal excision (taTME) and evaluate outcomes. BACKGROUND: Urethral injury is a rare complication of abdominoperineal resection (APR) that has not been reported during abdominal proctectomy. The Low Rectal Cancer Development Program international taTME registry recently reported a 0.8% incidence, but actual incidence and mechanisms of injury remain largely unknown. METHODS: A retrospective analysis of taTME cases complicated by urologic injury was conducted. Patient demographics, tumor characteristics, intraoperative details, and outcomes were analyzed, along with surgeons' experience and training in taTME. Surgeons' opinion of contributing factors and best approaches to avoid injuries were evaluated. RESULTS: Thirty-four urethral, 2 ureteral, and 3 bladder injuries were reported during taTME operations performed over 7 years by 32 surgical teams. Twenty injuries occurred during the teams' first 8 taTME cases ("early experience"), whereas the remainder occurred between the 12th to 101st case. Injuries resulted in a 22% conversion rate and 8% rate of unplanned APR or Hartmann procedure. At median follow-up of 27.6 months (range, 3-85), the urethral repair complication rate was 26% with a 9% rate of failed urethral repair requiring permanent urinary diversion. In patients with successful repair, 18% reported persistent urinary dysfunction. CONCLUSIONS: Urologic injuries result in substantial morbidity. Our survey indicated that those occurring in surgeons' early experience might best be reduced by implementation of structured taTME training and proctoring, whereas those occurring later relate to case complexity and may be avoided by more stringent case selection.
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Neoplasias Retais/cirurgia , Cirurgia Endoscópica Transanal/efeitos adversos , Sistema Urinário/lesões , Adulto , Idoso , Idoso de 80 Anos ou mais , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Protectomia/efeitos adversos , Estudos Retrospectivos , Uretra/lesõesRESUMO
PURPOSE: Our aim was to evaluate factors leading to ostomy reversal among a group of 44 patients with Crohn's disease (CD) who underwent subtotal colectomy (STC) between June 2011 and September 2018. METHODS: Our study design was a retrospective chart review. Patients with CD who underwent STC were included. Logistic regression analysis was used to evaluate several risk factors for non-reversal including medications received prior to surgery and indication for STC. RESULTS: Of 44 STCs performed, 31 (70.5%) were completed laparoscopically and 13 required an open approach (29.5%). Nine patients (20.4%) underwent ostomy reversal, and the mean time to reversal was 8.4 months. Preoperative therapy with an immunomodulator or biologic was associated with ostomy reversal (OR and CI: 0.43, 0.09-0.93; 0.47, 0.10-0.96), as was a diagnosis of intraabdominal abscess (0.43, 0.09-0.93). CONCLUSION: Ileostomy reversal after STC in Crohn's disease is uncommon. Certain treatment regimens and diagnostic factors may impact the likelihood of ostomy reversal. Based on the available data, patients with CD whose disease is severe enough to require STC should be counseled that their ostomy will most likely be permanent. However, due to the low incidence of this procedure for CD, more data is needed.
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Colectomia , Doença de Crohn , Ileostomia , Doença de Crohn/tratamento farmacológico , Doença de Crohn/cirurgia , Humanos , Ileostomia/efeitos adversos , Estudos Retrospectivos , Fatores de RiscoRESUMO
BACKGROUND: The use of transanal total mesorectal excision (taTME) for treatment of rectal cancer is growing, but anatomic constraints prevent access to the proximal rectum with rigid instruments. The articulated instrumentation of current surgical robots is promising in overcoming these limitations, but the bulky size of current platforms inhibits the proximal reach of dissection. Flexible robotic systems could overcome these constraints while maintaining a stable platform for dissection. The goal of this study was to evaluate feasibility of performing taTME using the semi-robotic Flex® System (Medrobotics Corp., Raynham, MA) in human cadavers. METHODS: taTME was performed by two surgeons in six fresh human cadaveric specimens using the Flex® System, with or without transabdominal laparoscopic assistance. Both mid- and low-rectal lesions were simulated. Metrics including quality of visualization, maintenance of pneumorectum, maneuverability of instruments, effectiveness of pursestring suture placement, and dissection in an anatomically correct plane were evaluated. RESULTS: The semi-robotic endoluminal platform allowed for excellent visualization, insufflation, and dissection during taTME. Adequate pursestring occlusion of the rectum was achieved in all six cases. In cadavers with simulated mid-rectal lesions (N = 4), dissection and anterior peritoneal entry was achieved in all cases, with abdominal assistance utilized in two of four cases. In cadavers with simulated low-rectal lesions (N = 2), dissection was incomplete and aborted due to difficulty maneuvering instruments in close proximity to the rigid transanal port. CONCLUSIONS: Use of the Flex® system for taTME is feasible for mid-rectal dissection. Advantages over the traditional multi-armed robot include longer reach of instruments with the ability to dissect up to 17 cm from the anal verge, as well as tactile feedback. The current design of the flexible platform does not permit safe dissection in the distal rectum, although this constraint may be resolved with future adjustments to the equipment.
Assuntos
Reto/cirurgia , Procedimentos Cirúrgicos Robóticos/instrumentação , Cirurgia Endoscópica Transanal , Cadáver , Estudos de Viabilidade , HumanosRESUMO
BACKGROUND: Transanal total mesorectal excision (taTME) is a surgical approach for low rectal cancer with a learning curve estimated at 40-50 cases. The experience among taTME surgeons beyond their learning curve is limited. METHODS: A retrospective analysis of all taTME cases performed for rectal cancer at two tertiary care hospitals from 2014 to 2019 was conducted. Transanal surgeons had previously performed > 50 taTME cases. Demographic, perioperative, and short-term outcomes were analyzed. RESULTS: Among 54 taTME patients, 74.1% were male and 27.8% had a BMI ≥ 30. Tumors were stage I (8), II (13), III (29), and IV (4). Complex cases included 4 local recurrences, 4 prior liver resections, and 2 with prior prostate cancer. Thirty tumors were located ≤ 6 cm from the anal verge. On staging MRI, 12 had a positive predicted circumferential radial margin (+CRM), and 4 had internal anal sphincter involvement (+IAS). Forty-seven patients received neoadjuvant therapy. A 2-team approach was used in 51 patients with laparoscopic (83.3%) or robotic (16.7%) abdominal assistance with a 9.2% conversion rate. Low anterior resection with sphincter salvage was achieved in 87% with 8 patients requiring intersphincteric resection. Anastomoses were hand-sewn in 57.4% and all patients were diverted. Median LOS was 5 days with a 42.6% 30-day morbidity rate and 3 postoperative mortalities (ARDS, pulmonary embolism and pseudomembranous colitis). Complete and near complete TME grade was achieved in 94.4% with a 3.7% rate of +CRM. At a median follow-up of 28 months, local and distant recurrence rates were 3.9% and 17.6%, respectively, with no cancer-related mortality. CONCLUSION: Indications for taTME at experienced centers have expanded to include complex reoperative cases, local recurrences, metastatic cancer, and tumors with threatened CRM or IAS with evidence of post-treatment tumor regression. In the latter cases, taTME achieves good short-term outcomes and may facilitate R0 resection.
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Curva de Aprendizado , Neoplasias Retais/cirurgia , Reto/cirurgia , Cirurgia Endoscópica Transanal , Idoso , Canal Anal/cirurgia , Feminino , Humanos , Laparoscopia , Tempo de Internação , Imageamento por Ressonância Magnética , Masculino , Margens de Excisão , Pessoa de Meia-Idade , Recidiva Local de Neoplasia/cirurgia , Estadiamento de Neoplasias , Complicações Pós-Operatórias , Neoplasias Retais/diagnóstico por imagem , Neoplasias Retais/patologia , Estudos Retrospectivos , Cirurgia Endoscópica Transanal/efeitos adversos , Resultado do TratamentoAssuntos
Procedimentos Cirúrgicos do Sistema Digestório , Laparoscopia , Neoplasias Retais , Humanos , Procedimentos Cirúrgicos do Sistema Digestório/métodos , Laparoscopia/métodos , Anastomose Cirúrgica/métodos , Intestinos/cirurgia , Canal Anal/cirurgia , Neoplasias Retais/cirurgia , Colo/cirurgiaRESUMO
Based on an in-depth study with 56 informants (25 women and 31 men), across the ICT (information and communication technology), creative and academic sectors in one city/regional hub in Ireland, this article investigates the so-called revolution in work/life practices associated with the post-Fordist labour processes of the Knowledge Economy from the perspectives of workers themselves. Recent theorizations of post-Fordist work patterns emphasize a rearranging of work and life place boundaries; a reconfiguring of work and life time boundaries; and a dissolving of the gendered boundaries of work and life (production and social reproduction) (Adkins and Dever ; Morini and Fumagalli ; Gill and Pratt ; Weeks ; Hardt and Negri ). Our findings suggest that, instead of dissolving boundaries, workers constantly struggle to draw boundaries between what counts as work and as life, and that this varies primarily in relation to gender and stage in a gendered life trajectory. Work extensification is compensated for via a perceived freedom to shape one's own life, which is articulated in terms of individualized boundary-drawing. While younger men embraced 'always on' work, they also articulated anxieties about how these work habits might interfere with family aspirations. This was also true for younger women who also struggled to make time for life in the present. For mothers, boundary drawing was articulated as a necessity but was framed more in terms of personal choice by fathers. Although all participants distinguished between paid work and life as distinct sites of value, boundaries were individually drawn and resist any easy mapping of masculinity and femininity onto the domains of work and life. Instead, we argue that it is the process of boundary drawing that reveals gendered patterns. The personalized struggles of these relatively privileged middle-class workers centre on improving the quality of their lives, but raise important questions about the political possibilities within and beyond the world of post-Fordist labour.
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Equilíbrio Trabalho-Vida , Emprego/psicologia , Emprego/estatística & dados numéricos , Família , Feminino , Identidade de Gênero , Humanos , Tecnologia da Informação , Irlanda , Masculino , Fatores SexuaisRESUMO
BACKGROUND: Relative contraindications for transanal endoscopic microsurgery include high, anterior-based lesions for full-thickness excisions because of worries about entering the peritoneal cavity. Concerns exist regarding safety and oncological outcome. OBJECTIVE: We examined the outcomes of transanal endoscopic microsurgery excisions with entry into the peritoneal cavity and compared them with those that did not to address our hypothesis that entry is safe with no ill infectious or oncological consequences. DESIGN: This single-institution retrospective review uses a prospectively maintained database. SETTINGS: This study was conducted at a tertiary colorectal surgery referral center. PATIENTS: From 1997 to 2012, we identified 303 patients who underwent transanal endoscopic microsurgery resections, with 26 patients having entrance into the peritoneal cavity. MAIN OUTCOME MEASURES: Perioperative data, postoperative morbidities, delayed morbidities, and oncological outcomes were the primary outcomes measured. RESULTS: Of 26 patients, there were 8 women with a mean age of 67.5 years. Mean BMI was 31 kg/m, and ASA class was III or IV in 69%. Mean superior border of the lesion was 10.4 cm (4.5-16). Forty-eight percent had anterior-based lesions. Anterior location, level from anorectal ring, and diagnosis of cancer were significantly higher in the peritoneal entry group (p = 0.003, p = 0.007, and p = 0.007). Preoperative diagnoses included 16 adenocarcinomas, 8 polyps, and 2 carcinoid tumors. Thirteen patients had preoperative chemoradiation. Median estimated blood loss was 15 mL (5-400), and 3 patients underwent diversions. Median time to discharge was 3 days (2-10). There were no perioperative mortalities. Median follow-up time was 21.0 months. There was 1 local recurrence (3.8%), and there was no development of carcinomatosis. LIMITATIONS: This review was limited by its retrospective nature. CONCLUSIONS: High anterior location rectal lesions should be considered candidates for transanal endoscopic microsurgery excision in experienced hands. After obtaining considerable transanal endoscopic microsurgery experience, our use of transanal endoscopic microsurgery in a high-risk patient population allowed us to definitively treat 88% of patients without an abdominal operation and the need for a temporary or permanent colostomy. Theoretic concerns of abscess or carcinomatosis were not experienced (see Video, Supplemental Digital Content 1, http://links.lww.com/DCR/A154).
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Adenocarcinoma/cirurgia , Tumor Carcinoide/cirurgia , Endoscopia Gastrointestinal/métodos , Microcirurgia/métodos , Cavidade Peritoneal/cirurgia , Neoplasias Retais/cirurgia , Adenocarcinoma/terapia , Idoso , Idoso de 80 Anos ou mais , Canal Anal , Antimetabólitos Antineoplásicos/uso terapêutico , Perda Sanguínea Cirúrgica , Tumor Carcinoide/terapia , Quimiorradioterapia Adjuvante , Endoscopia Gastrointestinal/efeitos adversos , Feminino , Fluoruracila/uso terapêutico , Humanos , Pólipos Intestinais/cirurgia , Tempo de Internação , Masculino , Microcirurgia/efeitos adversos , Pessoa de Meia-Idade , Cirurgia Endoscópica por Orifício Natural/efeitos adversos , Duração da Cirurgia , Neoplasias Retais/terapia , Estudos RetrospectivosRESUMO
INTRODUCTION: Physical inactivity is a risk factor for cancer morbidity and mortality, but its influence in colorectal cancer (CRC) survivors is understudied. We investigated sociodemographic, physically limiting, and behavioral predictors influencing leisure time physical activity (LTPA) among CRC survivors. METHODS: Pooled 1997-2010 National Health Interview Survey data (N=2378) were used to evaluate LTPA compliance in CRC survivors according to Healthy People 2010 recommendations. Univariate and multivariable logistic regression analyses were performed to identify predictors of LTPA compliance among CRC survivors. Independent variables included: age, gender, race/ethnicity, education, health insurance, body mass index (BMI), ≥2 chronic conditions limiting physical activity, time since cancer diagnosis, and poverty, marital, smoking and alcohol status. RESULTS: Multivariable regression models reveal that Hispanics, non-Hispanic Blacks, those with ≥2 physically limiting chronic conditions, and current smokers were less likely to comply with LTPA recommendations. CRC survivors who were of "other" race, more than one race, those with some college degree or college degree, and current drinkers were more likely to comply. DISCUSSION: Hispanics, non-Hispanic Blacks, those with >2 physically limiting chronic conditions and current smokers warrant additional efforts to encourage physical activity and to determine the impact of regular physical activity on CRC survivorship.
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Atividades de Lazer , Cooperação do Paciente , Sobreviventes/psicologia , Negro ou Afro-Americano/psicologia , Negro ou Afro-Americano/estatística & dados numéricos , Análise de Variância , Doença Crônica , Neoplasias Colorretais/epidemiologia , Neoplasias Colorretais/prevenção & controle , Feminino , Comportamentos Relacionados com a Saúde , Inquéritos Epidemiológicos , Hispânico ou Latino/psicologia , Hispânico ou Latino/estatística & dados numéricos , Humanos , Entrevistas como Assunto , Modelos Logísticos , Masculino , Pessoa de Meia-Idade , Atividade Motora , Fatores de Risco , Fumar , Classe Social , Sobreviventes/estatística & dados numéricosRESUMO
OBJECTIVE: To compare 30-day postoperative complications in patients with inflammatory bowel disease (IBD) undergoing colorectal resection before and after implementation of a hospital-wide surgical care bundle (SCB) to prevent surgical site infection (SSI) followed by enhanced recovery protocol (ERP). BACKGROUND: Perioperative SCBs to prevent SSI after colectomy have evolved to include ERPs demonstrating reduced rates of SSI, ileus, and length of stay in colorectal surgical patients. IBD patients often present with more risk factors for postoperative complication like malnutrition or immunosuppression, and the impact of SCBs and ERPs in this population is understudied. METHODS: Crohn's disease and ulcerative colitis patients undergoing elective bowel resection at a tertiary-level referral center from 2013 to 2018 were retrospectively evaluated. Postoperative complications at 30 days including SSI, ileus, and anastomotic leak were compared between pre-SCB/ERP, post-SCB, and post-SCB + ERP time periods using institutional ACS-NSQIP data. Pediatric (age < 18 years) and emergent cases were excluded. RESULTS: Out of 977 patients, 224 were pre-SCB/ERP, 517 post-SCB, and 236 post-SCB + ERP. Gender (P = 0.01), race (P = 0.02), body mass index (P = 0.04), immunosuppressant use (P = 0.01), wound classification (P < 0.001), malnutrition (P < 0.001), duration of procedure (P = 0.04), and procedure performed (P = 0.01) were significantly different between the three cohorts. A significant decrease in the rates of SSI (14.7% to 5.5%), ileus (20.1% to 8.9%), and anastomotic leak (4.7% to 0.0%) was demonstrated after implementation of SCB and ERP (P ≤ 0.01). On multivariable regression, the risk for postoperative SSI and ileus decreased significantly post-SCB + ERP (OR 0.39, CI 0.19-0.82 and OR 0.45, CI 0.24-0.84, respectively). CONCLUSION: SCB and ERP implementation was associated with decreased rates of postoperative SSI, ileus, and anastomotic leak for IBD patients undergoing elective bowel resection.
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Colectomia/efeitos adversos , Recuperação Pós-Cirúrgica Melhorada , Doenças Inflamatórias Intestinais/cirurgia , Pacotes de Assistência ao Paciente , Protectomia/efeitos adversos , Infecção da Ferida Cirúrgica/prevenção & controle , Adulto , Fístula Anastomótica/etiologia , Colite Ulcerativa/cirurgia , Doença de Crohn/cirurgia , Procedimentos Cirúrgicos Eletivos/efeitos adversos , Feminino , Humanos , Íleus/etiologia , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos , Fatores de Risco , Infecção da Ferida Cirúrgica/etiologia , Adulto JovemRESUMO
BACKGROUND: Advanced Life Support (ALS) providers may perform more invasive prehospital procedures, while Basic Life Support (BLS) providers offer stabilisation care and often "scoop and run". We hypothesised that prehospital interventions by urban ALS providers prolong prehospital time and decrease survival in penetrating trauma victims. STUDY DESIGN: We prospectively analysed 236 consecutive ambulance-transported, penetrating trauma patients an our urban Level-1 trauma centre (6/2008-12/2009). Inclusion criteria included ICU admission, length of stay >/=2 days, or in-hospital death. Demographics, clinical characteristics, and outcomes were compared between ALS and BLS patients. Single and multiple variable logistic regression analysis determined predictors of hospital survival. RESULTS: Of 236 patients, 71% were transported by ALS and 29% by BLS. When ALS and BLS patients were compared, no differences in age, penetrating mechanism, scene GCS score, Injury Severity Score, or need for emergency surgery were detected (p>0.05). Patients transported by ALS units more often underwent prehospital interventions (97% vs. 17%; p<0.01), including endotracheal intubation, needle thoracostomy, cervical collar, IV placement, and crystalloid resuscitation. While ALS ambulance on-scene time was significantly longer than that of BLS (p<0.01), total prehospital time was not (p=0.98) despite these prehospital interventions (1.8 ± 1.0 per ALS patient vs. 0.2 ± 0.5 per BLS patient; p<0.01). Overall, 69.5% ALS patients and 88.4% of BLS patients (p<0.01) survived to hospital discharge. CONCLUSION: Prehospital resuscitative interventions by ALS units performed on penetrating trauma patients may lengthen on-scene time but do not significantly increase total prehospital time. Regardless, these interventions did not appear to benefit our rapidly transported, urban penetrating trauma patients.
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Serviços Médicos de Emergência/organização & administração , Cuidados para Prolongar a Vida/organização & administração , Triagem/organização & administração , Ferimentos Penetrantes/mortalidade , Adolescente , Adulto , Cuidados de Suporte Avançado de Vida no Trauma/organização & administração , Ambulâncias , Feminino , Humanos , Escala de Gravidade do Ferimento , Tempo de Internação/estatística & dados numéricos , Cuidados para Prolongar a Vida/métodos , Masculino , Pessoa de Meia-Idade , Estudos Prospectivos , Fatores de Tempo , Centros de Traumatologia , Resultado do Tratamento , Estados Unidos/epidemiologia , Ferimentos Penetrantes/terapiaRESUMO
Rectal cancer management benefits from a multidisciplinary approach involving medical and radiation oncology as well as surgery. Presented are the current dominant issues in rectal cancer management with an emphasis on our treatment algorithm at the Lankenau Medical Center. By basing surgical decisions on the downstaged rectal cancer we explore how sphincter preservation can be extended even for cancers of the distal 3 cm of the rectum. TATA and TEM techniques can be used to effectively treat cancer from an oncologic standpoint while maintaining a high quality of life through sphincter preservation and avoidance of a permanent colostomy. We review the results of our efforts, including the use of advanced laparoscopy in the surgical management of low rectal cancers.