Impact of a Novel Preoperative Patient-centered Surgical Wellness Program.

OBJECTIVE: The objective of this study was to evaluate if a preoperative wellness bundle significantly decreases the risk of hospital acquired infections (HAI). BACKGROUND: HAI threaten patient outcomes and are a significant burden to the healthcare system. Preoperative wellness efforts may significantly decrease the risk of infections. METHODS: A group of 12,396 surgical patients received a wellness bundle in a roller bag during preoperative screening at an urban academic medical center. The wellness bundle consisted of a chlorhexidine bath solution, immuno-nutrition supplements, incentive spirometer, topical mupirocin for the nostrils, and smoking cessation information. Study staff performed structured patient interviews, observations, and standardized surveys at key intervals throughout the perioperative period. Statistics compare HAI outcomes of patients in the wellness program to a nonintervention group using the Fisher's exact test, logistic regression, and Poisson regression. RESULTS: Patients in the nonintervention and intervention groups were similar in demographics, comorbidity, and type of operations. Compliance with each element was high (80% mupirocin, 72% immuno-nutrition, 71% chlorhexidine bath, 67% spirometer). The intervention group had statistically significant reductions in surgical site infections, Clostridium difficile, catheter associated urinary tract infections, and patient safety indicator 90. CONCLUSIONS: A novel, preoperative, patient-centered wellness program dramatically reduced HAI in surgical patients at an urban academic medical center.

Delayed repeated intraperitoneal chemotherapy after cytoreductive surgery for colorectal and appendiceal carcinomatosis.

BACKGROUND: Delayed repeated intraperitoneal chemotherapy after cytoreductive surgery for carcinomatosis may be an alternative to intraoperative hyperthermic infusion. OBJECTIVE: The aim of this study was to evaluate the safety and feasibility of delayed repeated intraperitoneal chemotherapy after cytoreduction of colorectal and appendiceal carcinomatosis and pseudomyxoma peritonei. DESIGN: This study constitutes a retrospective case series. SETTING: This study was conducted at a single institution. PATIENTS: A total of 31 patients with peritoneal carcinomatosis (23) and pseudomyxoma peritonei (8) were included. INTERVENTIONS: Cytoreduction was followed by placement of an adhesion barrier and intraperitoneal catheters. Peritoneal scintigraphy preceded biweekly intraperitoneal 5-fluorouracil and systemic combination chemotherapy with leucovorin, fluorouracil, and oxaliplatin (FOLFOX). MAIN OUTCOME MEASURES: The primary outcomes measured are safety, feasibility, and short-term survival. RESULTS: Cytoreduction to a score of 0 to 1 was possible in 25 patients (80%). Complications occurred in 16 patients (51.6%) and were confined to grades I to III. There were no deaths, and no digestive fistulae occurred. Port malfunction or complication resulted in removal in 5 patients (16.1%). Intraperitoneal chemotherapy was possible in 83.8% of patients; 55% completed the full course. Peritoneal scintigraphy demonstrated free diffusion of tracer in 18 patients (58%), 4 (12.9%) had diffusion in each gutter with limited communication, 5 (16.1%) had limited diffusion around each catheter without communication, and 2 (6.5%) had no diffusion on scintigraphy. Overall survival for peritoneal carcinomatosis was 44.5% at 3 years (95% CI = 23%-65%). LIMITATIONS: The nonrandomized nature of this study and the early experience are limitations. CONCLUSIONS: Delayed repeated intraperitoneal and systemic chemotherapy after cytoreduction is feasible and has acceptable morbidity rates. Delayed intraperitoneal chemotherapy is possible in 83% of patients.

Evaluation of bioabsorbable seamguard for staple line reinforcement in stapled rectal anastomoses.

INTRODUCTION: The concept of staple line reinforcement is a growing area of interest. This study evaluated the feasibility and effect of using bioabsorbable Seamguard (BSG) to bolster end-to-end stapled rectal anastomoses in a porcine model. METHODS: Eleven female 45-kg Yucatan domestic pigs were used. Each animal served as its own control by creating a BSG and nonreinforced anastomosis using a 29-mm end-to-end anastomotic stapling device. Reinforced anastomoses were randomized to proximal and distal positions along the rectum. Each staple line reinforcement agent consisted of adding BSG to the stapling device according to the manufacturer's instructions. Barium enemas were then performed and the 2 anastomotic sites harvested. Each anastomosis underwent burst testing. The internal diameter of each anastomosis was measured and underwent pathologic review. RESULTS: Bolstered anastomoses offered no strength advantage as burst pressures were no different as compared with unbolstered anastomoses. There was also no difference in anastomotic internal or external diameters. Only 1 stapled anastomosis burst during testing and none in the bolstered group. On histological analysis, there was a significant increase in inflammatory infiltrate in the bolstered group as compared with the stapled group (P = .041), with a higher incidence of lymphocytes (P = .047) and giant cells (P = .037). There was no difference in mucosal loss at the anastomotic site, neovascularization, fibroblast presence, extent of fibrosis, muscle layer disruption, percentage of anastomosis replaced by collagen, and elastin deposition. CONCLUSIONS: The routine use of BSG bolsters in stapled rectal anastomoses is safe and results in equivalent anastomotic strength as traditional stapled anastomoses.

1.5:1 meshed AlloDerm bolsters for stapled rectal anastomoses does not provide any advantage in anastomotic strength in a porcine model.

INTRODUCTION: The most feared complication of colorectal anastomoses is leaks resulting in severe morbidity. The concept of staple-line reinforcement is a growing area of interest. In this study, the authors evaluated the feasibility and effect of using 1.5:1 meshed AlloDerm to bolster end-to-end stapled rectal anastomoses in a porcine model. METHODS: A total of 30 female 45-kg domestic pigs were studied, and each served as its own control by creating a bolstered and unbolstered anastomosis in each animal. All anastomoses were created with a 29-mm end-to-end stapling device. Bolstered anastomoses were randomized to proximal and distal positions along the rectum, and each rectorectal anastomosis was separated by an average of 10 cm. The animals were survived to 3, 5, and 30 days. Barium enemas were then performed and the 2 anastomotic sites harvested. Each anastomosis underwent burst testing. The internal diameter of each anastomosis was measured, and a biochemical analysis was performed for elastin and collagen content. RESULTS: Bolstered anastomoses offered no strength advantage as burst pressures were no different when compared with unbolstered anastomoses. There was also no difference in anastomotic internal diameter, biochemical analysis of elastin or collagen, or presence of adhesions when comparing bolstered with unbolstered anastomoses. There were 4 subclinical leaks-1 in the unbolstered group and 3 in the bolstered group. CONCLUSIONS: The routine use of 1.5:1 meshed AlloDerm sandwich bolsters in stapled rectal anastomosis does not confer any detectable advantage in anastomotic strength. Further studies are needed to determine equivalence to traditional stapled anastomoses.

Single-port laparoscopic right hemicolectomy: a safe alternative to conventional laparoscopy.

PURPOSE: Single-port laparoscopic surgery has evolved from an effort to minimize tissue trauma, limit morbidity, and maximize cosmesis. Limited data exist comparing single-port with conventional laparoscopy for right colectomy. Our aim is to compare single-port with laparoscopic colectomy with regard to safety and feasibility. We assert that this approach can be adopted in a safe and efficacious manner while using standard laparoscopic instrumentation. METHODS: This is a retrospective analysis of prospectively gathered data regarding 16 single-port and 27 conventional laparoscopic right hemicolectomies performed by a single surgeon between January 2008 and February 2009. Demographics, operative outcomes, and morbidity were included and analyzed using either Student t test or Fisher exact probability test. RESULTS: Single-port and conventional laparoscopic groups were similar with regard to age, gender, body mass index, prior abdominal surgery, and co-morbidity. Seventy-five percent and 70% of the operations were performed for malignancy in the single-port and the conventional laparoscopy group, respectively (P = .69). Operative duration was 106 minutes in the single-port group vs 100 minutes in the conventional group (P = .64). Blood loss was 54 mL and 90 mL, respectively (P = .07). No conversions or additions of ports occurred. Hospital stay was 5.3 days in the single-port group vs 6 days in the conventional group (P = .53). Margins were negative in both groups. Mean lymph node number was 18 and 16 nodes (P = .92). There was one death in the conventional group (P = .44). Morbidity including wound infection was 18.8% and 14.9%, respectively (P = .73). CONCLUSIONS: These findings support single-port right colectomy as a safe and efficacious approach to right colon resections in patients eligible for laparoscopy with minimal additional equipment or learning curve for experienced laparoscopic colorectal surgeons. The single port was undertaken without an increase in morbidity or mortality. There was no increase in operative time with use of the single-port approach. Finally, adequate lymph node harvest and margin clearance was maintained.

Video. Transanal single-port low anterior resection in a cadaver model.

BACKGROUND: Natural orifice transluminal endoscopic surgery (NOTES), a recent development in the field of minimally invasive surgery, provides theoretical advantages over open and laparoscopic surgery. Challenges with the use of NOTES for colon resections include the need to extract a large specimen and perform an intestinal anastomosis. A transanal single-port laparoscopic proctectomy uses the potential advantages of NOTES yet provides easy specimen extraction and anastomosis. METHODS: Fresh frozen then thawed human cadavers were used. Access was obtained via transanal mucosectomy, and a transanal endoscopic microsurgery (TEM) system was used to perform the proctectomy once the procedure was above the pelvic floor. After the peritoneal cavity was entered, a hand port was placed through the sphincter and above the pelvic floor. The left colon was mobilized using two 5-mm working ports and a 10-mm camera port for the flexible-tipped laparoscope that were placed through the hand port. The specimen was removed transanally. RESULTS: The critical steps for an oncologic resection of the rectum were achieved using a combination of TEM and laparoscopic instrumentation transanally. The rectum and mesorectum were mobilized. The left ureter was identified and preserved, the inferior mesenteric artery (IMA) ligated at its origin, the inferior mesenteric vein ligated near the ligament of Treitz, the proximal colon mobilized for transanal extraction, the specimen resected proximal to the ligated IMA, and a hand-sewn coloanal anastomosis performed. Postresection examination showed preservation of the hypogastric nerves and an intact mesorectum. Challenges included maneuverability around the sacral promontory and length of the instruments. However, this was easily overcome by the use of long reticulating instruments and a flexible-tipped laparoscope. CONCLUSIONS: Transanal single-port low anterior resection using TEM and laparoscopic techniques is feasible and can maintain the principles of an oncologic resection.

Perioperative Management of Patients with Colovesical Fistula.

BACKGROUND: Colovesical fistula (CVF) is an uncommon complication of diverticulitis. Substantial heterogeneity exists in the perioperative management of this condition. We seek to evaluate the role of bladder leak testing, closed suction drainage, prolonged bladder catheter usage, and routine postoperative cystogram in the management of CVF. STUDY DESIGN: This is a retrospective study from a single academic health center investigation patients undergoing operation for diverticular CVF from 2005 to 2015 (n = 89). RESULTS: Patients undergoing operative repair for diverticular CVF resection had a mortality of 4% and overall morbidity of 46%. Intraoperative bladder leak test was performed in 36 patients (40%) and demonstrated a leak in 4 patients (11%). No patients with a negative intraoperative bladder leak test developed a urinary leak. Overall, five (6%) patients developed postoperative bladder leak. Three were identified by elevated drain creatinine and two by cystogram. The diagnostic yield of routine cystogram was 3%. All bladder leaks were diagnosed between postoperative day 3 and 7. Of patients with a postoperative bladder leak, none required reoperation and all resolved within 2 months. CONCLUSIONS: There is significant variability in the management of patients undergoing operation for CVF. Routine intraoperative bladder leak test should be performed. Cystogram may add cost and is low yield for routine evaluation for bladder leak after operation for CVF. Urinary catheter removal before postoperative day 7 should be considered.

Contemporary Management of Sigmoid Volvulus.

BACKGROUND: Sigmoid volvulus is an uncommon cause of bowel obstruction that is historically associated with high morbidity and mortality. The objective of this study was to evaluate contemporary management of sigmoid volvulus and the safety of primary anastomosis in patients with sigmoid volvulus. METHODS: The National Surgical Quality Improvement Project from 2012 to 2015 was queried for patients with colonic volvulus who underwent left-sided colonic resection. A propensity score-matched analysis was performed to compare patients with sigmoid volvulus undergoing colectomy with primary anastomosis without proximal diversion to colectomy with end colostomy. RESULTS: Two thousand five hundred thirty-eight patients with sigmoid volvulus were included for analysis. Patients had a median age of 68 years (interquartile range, 55-80) and 79% were fully independent preoperatively. Fifty-one percent of operations were performed emergently. One thousand eight hundred thirteen (71%) patients underwent colectomy with anastomosis, 240 (10%) colectomy with anastomosis and proximal diversion, and 485 (19%) colectomy with end colostomy. Overall, 30-day mortality and morbidity were 5 and 40%, respectively. After propensity score matching, mortality, overall morbidity, and serious morbidity were similar between groups. CONCLUSIONS: Sigmoid volvulus occurs in elderly and debilitated patients with significant morbidity, mortality, and lifestyle implications. In selected patients, anastomosis without proximal diversion in patients with sigmoid volvulus results in similar outcomes to colectomy with end colostomy.

Bowel Preparation Is Associated with Reduced Morbidity in Elderly Patients Undergoing Elective Colectomy.

BACKGROUND: Bowel preparation in elderly patients is associated with physiologic derangements that may result in postoperative complications. The aim of this study is to determine the impact of bowel preparation on postoperative outcomes in elderly patients. METHODS: Patients age 75 years and older who underwent elective colectomy were identified from the 2012-2014 American College of National Surgical Quality Improvement Program (ACS-NSQIP database). Patients were grouped into no bowel preparation, mechanical bowel preparation (MBP), oral antibiotic preparation (OABP), or combined MBP + OABP. Logistic regression modeling was conducted to calculate risk-adjusted 30-day outcomes. RESULTS: There were 4829 patients included in the analysis. Morbidity was 34.3% in no bowel prep, 32.4% in MBP, 24.8% in OABP, and 24.6% in MBP + OABP groups (p < 0.001). The MBP + OABP group compared with no bowel prep was associated with reduced rates of anastomotic leak, ileus, superficial surgical site infection (SSI), organ space SSI, respiratory compromise, and reduced length of stay. There was no difference in the rate of acute kidney injury between the groups. CONCLUSION: MBP + OABP was associated with reduced morbidity compared with no bowel preparation in elderly patients undergoing elective colorectal resection. MBP alone was not associated with differences in outcomes compared with no bowel preparation. The use of MBP + OABP is safe and effective in elderly patients undergoing elective colectomy.

Clinically enlarged lateral pelvic lymph nodes do not influence prognosis after neoadjuvant therapy and TME in stage III rectal cancer.

PURPOSE: The significance of lateral pelvic lymph nodes (LPLN) in rectal cancer remains unclear. The purpose of this study was to determine the outcome of patients with LPLNs identified on pretherapy imaging who were treated with neoadjuvant therapy followed by proctectomy without LPLN dissection. METHODS: Pretherapy imaging of patients with stage III rectal cancer was reviewed to determine perirectal and LPLN enlargement. Data were collected on preoperative therapy, operative resection, adjuvant therapy, and patient outcomes and were correlated to the presence or absence of preoperatively identified LPLNs (LPLN+ and LPLN-). RESULTS: Of the 53 patients identified who were treated between 2000 and 2005, 30 (57%) were LPLN+ on preoperative imaging. All patients received preoperative radiation therapy and total mesorectal excision. The local recurrence was 13%, and there was no difference related to LPLN status. A comparison of the overall and disease-free survival in patients with and without enlarged LPLNs revealed no difference. CONCLUSIONS: The LPLNs that were identified on pretherapy imaging do not affect the overall or disease-free survival after the neoadjuvant therapy and proctectomy in stage III rectal cancer. A lateral pelvic lymph node dissection does not appear to be justified in stage III patients with LPLNs on pretherapy imaging who receive neoadjuvant therapy.

Laparoscopic versus open 2-stage ileal pouch: laparoscopic approach allows for faster restoration of intestinal continuity.

BACKGROUND: Restorative proctocolectomy with ileal pouch-anal anastomosis (IPAA) is the treatment of choice for patients with ulcerative colitis and familial adenomatous. This study examined the impact of the surgical approach (laparoscopic versus open) to IPAA on short-term outcomes and time to ileostomy closure in 2-stage restorative proctocolectomies. STUDY DESIGN: A retrospective review was performed on a prospectively maintained database at Washington University School of Medicine for patients undergoing elective 2-stage restorative proctocolectomy and IPAA from April of 1999 through July of 2008. Outcomes for patients were analyzed according to laparoscopic versus open technique. RESULTS: A total of 124 patients (55 laparoscopy, 69 open) were included in this study. Laparoscopic IPAA took, on average, 79.2 minutes longer to complete than open IPAA (p < 0.0001) and required significantly more intravenous fluid administration (p = 0.0004). There was no significant difference between laparoscopic and open IPAA with respect to estimated blood loss, blood transfusions, postoperative narcotic usage, return of bowel function, length of stay, and hospital readmission rates. Total complications were not statistically significant between the 2 groups. Patients in the laparoscopic IPAA group underwent ileostomy closure an average of 24.1 days sooner than patients in the open group (p = 0.045). Multivariate analysis revealed that surgical approach (p = 0.018) and length of stay (p = 0.004) were associated with faster time to closure of loop ileostomy. CONCLUSIONS: Laparoscopic IPAA is safe, with postoperative morbidity comparable with open IPAA. Laparoscopic IPAA can lead to faster recovery and result in faster progression to restoration of intestinal continuity in patients undergoing 2-stage restorative proctocolectomy.

Chemoprevention for colorectal neoplasia.

Colorectal cancer is a major cause of morbidity and mortality in industrialized societies and leads to significant treatment costs. Currently there are screening programs with fecal occult blood testing, radiographic, and endoscopic evaluation. Despite this, mortality from colorectal cancer has not improved dramatically. As such, attention has turned to finding agents to prevent carcinogenesis. The emerging field known as chemoprevention studies agents that target multiple steps in the development of adenomas and their subsequent transformation to colorectal carcinoma. There are multiple case control, cohort, and randomized controlled trials investigating the efficacy of fiber, calcium, vitamin D, folate, and nonsteroidal antiinflammatory drugs as chemopreventive agents against colorectal cancer.