Long-term ileoanal pouch survival after pouch urinary tract fistulae.

BACKGROUND: Ileoanal pouch is a demanding procedure with many potential technical complications including bladder or ureteral injury, while inflammation or stricture of the anastomosis or anal transition zone may lead to the formation of strictures and fistulae, including to the adjacent urethra. Pouch urinary tract fistulae are rare. We aimed to describe the presentation, diagnostic workup, and management of patients with pouch urinary at our center. METHODS: Our prospectively maintained pouch registry was queried using diagnostic codes and natural language processing free-text searches to identify ileoanal pouch patients diagnosed with any pouch-urinary tract fistula from 1997 to 2022. Descriptive statistics and pouch survival using Kaplan-Meier curves are presented. Numbers represent frequency (proportion) or median (range). RESULTS: Over 25 years, urinary fistulae were observed 27 pouch patients; of these, 16 of the index pouches were performed at our institution [rate 0.3% (16/5236)]. Overall median age was 42 (27-62) years, and 92.3% of the patients were male. Fistula locations included pouch-urethra in 13 patients (48.1%), pouch-bladder in 12 patients (44.4%), and anal-urethra in 2 (7.4%). The median time from pouch to fistula was 7.0 (0.3-38) years. Pouch excision and end ileostomy were performed in 12 patients (bladder fistula, n = 3; urethral fistula, n = 9), while redo ileal pouch-anal anastomosis (IPAA) was performed in 5 patients (bladder fistula, n = 3; urethral fistula, n = 2). The 5-year overall pouch survival after fistula to the bladder was 58.3% vs. 33.3% with urethral fistulae (p = 0.25). CONCLUSION: Pouch-urinary tract fistulae are a rare, morbid, and difficult to treat complication of ileoanal pouch that requires a multidisciplinary, often staged, surgical approach. In the long term, pouches with bladder fistulae were more likely to be salvaged than pouches with urethral fistulae.

A national analysis of the medical schools of training for merit award-winning laboratory medical doctors working in Britain.

AIMS: To inform the discussion regarding the origins of Laboratory Medical Consultant clinical merit award holders (LMC) whether the awards came from the Clinical Excellence Awards (CEA) or Distinction Awards (DA) schemes. METHODS: Setting - CEA is a scheme to financially reward senior doctors in England and Wales who are assessed to be working over and above the standard expected of their role. The DA scheme is the parallel and equivalent scheme in Scotland. Participants - All of the merit award holders in the 2019 round. Design - This involved a secondary analysis of the complete 2019 published dataset of award winners. Statistical analyses were performed with Chi-square tests set at p < 0.05 level for statistical significance. RESULTS: The top five medical schools (London University, Glasgow, Edinburgh, Aberdeen and Oxford) were responsible for 68.4% of the LMC merit award holders in the 2019 round. 97.9% of the LMC merit award holders were from European medical schools, whereas 90.9% of the non-LMC award holders were from European medical schools. The LMCs with A plus or platinum awards came from only six medical schools: Aberdeen, Edinburgh, London University, Oxford, Sheffield and Southampton. In contrast, the B or silver/bronze LMC award holders came from a more diverse background of 13 medical schools. CONCLUSIONS: The majority of LMC merit award holders originated from only five university medical schools. All the LMCs with A plus or platinum awards came from only six university medical schools. There is an apparent overrepresentation of a small number of medical schools of origin amongst those LMCs that hold national merit awards.

Medical school origins of award-winning surgeons; analysis of a complete national dataset.

BACKGROUND: Britain attracts doctors from all over the world to work in the National Health Service. Elucidating the educational backgrounds of award-winning doctors working in the country is potentially an important medical education issue and merit award audit. Using the British clinical merit award schemes as outcome measures, we identify medical school origins of award-winning doctors who have been identified as having achieved national or international prominence. METHODS: The Clinical Excellence Awards/Distinction Awards schemes select doctors in Britain who are classified as high achievers, with categories for national prominence and above. We used this outcome measure in a quantitative observational analysis of the 2019 dataset of all 901 award-winning doctors. Pearson's Chi-Square test was used where appropriate. RESULTS: Seven medical schools (London university medical schools, Glasgow, Edinburgh, Aberdeen, Oxford, Cambridge and Manchester) accounted for 52.7% of the surgical award-winning doctors in the 2019 round, despite the dataset representing 85 medical schools. Surgeons with the lower grade national awards came from a more diverse educational background of 43 medical schools. International medical graduates accounted for 16.1% of the award-winning surgeons and 9.8% of the award-winning non-surgeons. 87.1% of the surgical award-winners were from European medical schools, whereas 93.2% of the non-surgical award-winners were from European medical schools. CONCLUSIONS: The majority of the award-winning surgeons originated from only seven, overrepresented, medical schools. A greater diversity of medical school origin existed for the lowest grade national merit awards. These comprised 43 medical schools and indicated greater globalization effects in this category. International medical graduates contributed substantially to these award holders; surgical award-winners were more likely to be international medical graduates (16.1%) than non-surgical award-winners (9.8%). This study not only indicates educational centres associated with the production of award-winners but also provides students with a roadmap for rational decision making when selecting medical schools.

Defining the safety of early ileostomy closure after ileal pouch anal anastomosis.

PURPOSE: The safety of early ileostomy reversal after ileal pouch anal anastomosis (IPAA) has not been established. Our hypothesis was that ileostomy reversal before 8 weeks is associated with negative outcomes. METHODS: This was a retrospective cohort study from a prospectively maintained institutional database. Patients who underwent primary IPAA with ileostomy reversal between 2000 and 2021 from a Pouch Registry were stratified on the basis of timing of reversal. Those reversed before 8 weeks (early) and those reversed from 8 weeks to 116 days (routine) were compared. The primary outcome was overall complications according to timing and reason for closure. RESULTS: Ileostomy reversal was performed early in 92 patients and routinely in 1908. Median time to closure was 49 days in the early group and 93 days in the routine group. Reasons for early reversal were stoma-related morbidity in 43.3% (n = 39) and scheduled closure in 56.7% (n = 51). The complication rate in the early group was 17.4% versus 11% in the routine group (p = 0.085). When early patients were stratified according to reason for reversal, those reversed early for stoma-related morbidity had an increased complication rate compared to the routine group (25.6% vs. 11%, p = 0.006). Patients undergoing scheduled reversal in the early group did not have increased complications (11.8% vs. 11%, p = 0.9). There was a higher likelihood of pouch anastomotic leak when reversal was performed early for stoma complications compared to routinely (OR 5.13, 95% CI 1.01-16.57, p = 0.049). CONCLUSIONS: Early closure is safe but could be delayed in stoma morbidity as patients may experience increased complications.

Effects of acute dietary nitrate supplementation on cold-induced vasodilation in healthy males.

PURPOSE: Cold-induced vasodilation (CIVD) is a paradoxical rise in blood flow to the digits that occur during prolonged cold exposure. CIVD is thought to occur through active vasodilation and/or sympathetic withdrawal, where nitric oxide (NO) may play a key role in mediating these mechanisms. Beetroot juice (BRJ) is high in dietary nitrate (NO3-) which undergoes sequential reduction to nitrite (NO2-) and subsequently NO. Using a double-blind, randomized, crossover design, we examined the effect of acute BRJ supplementation on the CIVD response in 10 healthy males. METHODS: Participants had a resting blood pressure measurement taken prior to ingesting 140 mL of nitrate-rich BRJ (13 mmol NO3-) or a NO3--free placebo (PLA). After 2 h, participants immersed their hand in neutral water (~ 35 °C) for 10 min of baseline before cold water immersion (~ 8 °C) for 30 min. Laser-Doppler fluxmetry and skin temperature were measured continuously on the digits. RESULTS: Compared to PLA (100 ± 3 mmHg), acute BRJ supplementation significantly reduced mean arterial pressure at -30 min (96 ± 2 mmHg; p = 0.007) and 0 min (94 ± 2 mmHg; p = 0.008). Acute BRJ supplementation had no effect on Laser-Doppler fluxmetry during CIVD (expressed as cutaneous vascular conductance) measured as area under the curve (BRJ: 843 ± 148 PU mmHg-1 s; PLA: 1086 ± 333 PU mmHg-1 s), amplitude (BRJ: 0.60 ± 0.12 PU mmHg-1; PLA: 0.69 ± 0.14 PU mmHg-1), and duration (BRJ: 895 ± 60 s; PLA: 894 ± 46 s). CONCLUSION: Acute BRJ supplementation does not augment the CIVD response in healthy males.

Surveillance pouchoscopy for dysplasia: Cleveland Clinic Ileoanal Pouch Anastomosis Database.

BACKGROUND: No formal guidelines exist for surveillance pouchoscopy following ileal pouch-anal anastomosis (IPAA) for ulcerative colitis. METHODS: All adults who had previously had IPAA for ulcerative colitis, and underwent a pouchoscopy between 1 January 2010 and 1 January 2020, were included. RESULTS: A total of 9398 pouchoscopy procedures were performed in 3672 patients. The majority of the examinations were diagnostic (8082, 86·0 per cent; 3260 patients) and the remainder were for routine surveillance (1316, 14·0 per cent; 412 patients). Thirteen patients (0·14 per cent of procedures) were found to have biopsy-proven neoplasia at the time of pouchoscopy; seven had low-grade dysplasia (LGD) (0·07 per cent; all located in the anal transition zone), none had high-grade dysplasia (HGD) and six (0·06 per cent) had invasive adenocarcinoma (4 in anal transition zone and 6 in pouch). Of the six patients with adenocarcinoma, four had neoplasia at the time of proctocolectomy (2 adenocarcinoma, 1 LGD, 1 HGD); all six were symptomatic with anal bleeding or pelvic pain at the time of pouchoscopy, had a negative surveillance pouchoscopy examination within 2 years of diagnosis of adenocarcinoma, had palpable masses on digital rectal examination, and had visible lesions at the time of pouchoscopy. CONCLUSION: Surveillance pouchoscopy is not recommended in asymptomatic patients because significant neoplasia following IPAA for ulcerative colitis is rare.

ANTECEDENTES: No existen unas recomendaciones formales para vigilancia endoscópica en pacientes a los que se les ha realizado un reservorio ileoanal (ileal pouch anal anastomosis, IPAA) por una colitis ulcerosa (ulcerative colitis, UC). MÉTODOS: Se incluyeron todos los pacientes adultos a los que se les había realizado previamente un IPAA por UC y se sometieron a una endoscopia del reservorio. RESULTADOS: Se realizaron un total de 9.398 procedimientos endoscópicos en 3.672 pacientes entre el 1/1/2010 y el 1/1/2020. La mayoría de las exploraciones fueron diagnósticas (n = 8.082; 86%; 3.260 pacientes) y el resto fueron de seguimiento (n = 1.316; 14%; 412 pacientes). Se descubrió que 13 pacientes tenían una neoplasia demostrada por biopsia (0,14%) en el momento de la endoscopia; siete pacientes tenían displasia de bajo grado (low-grade displasia, LGD) (0,074%; localizada en todos los casos en la zona de transición anal), ninguno tenía displasia de alto grado (high-grade displasia, HGD) y seis (0,064%) tenían un adenocarcinoma invasivo (cuatro en la zona de transición anal) y dos en el reservorio). De los seis pacientes con adenocarcinoma, 4 tenían neoplasia en el momento de la proctocolectomía (2 adenocarcinoma, uno LGD, uno HGD). Todos estos pacientes tenían síntomas de hemorragia anal o dolor pélvico en el momento de la endoscopia, se les había practicado una endoscopia previa reciente del reservorio en los dos años anteriores, presentaban una masa palpable en la exploración digital rectal, así como lesiones visibles en la endoscopia del reservorio. CONCLUSIÓN: La vigilancia endoscópica del reservorio no se recomienda en pacientes asintomáticos porque es raro que aparezca una neoplasia después del IPAA por UC.

Excisional haemorrhoidectomy: is it safe in patients with an ileal pouch-anal anastomosis?

AIM: Excisional haemorrhoidectomy in patients with ulcerative colitis (UC), especially those undergoing an ileal pouch-anal anastomosis (IPAA), remains controversial. The aim of our study was to determine the safety of excisional haemorrhoidectomy in UC patients with and without an IPAA. METHOD: A retrospective review of all adult UC patients undergoing excisional haemorrhoidectomy between 1 January 1995 and 1 January 2019 at a tertiary inflammatory bowel disease referral centre was performed. Data collected included patient demographics, clinical characteristics of UC, prior surgical intervention for UC (colectomy, IPAA) and complications after haemorrhoidectomy. RESULTS: Forty-one adult patients [50% male; median age 52 (range 25-79) years] with UC underwent excisional haemorrhoidectomy between 1 January 1995 and 1 January 2019. The majority (n = 23) had not previously undergone surgery for UC. However, eight had already undergone construction of an IPAA at the time of haemorrhoidectomy, seven had IPAA at the time of haemorrhoidectomy and three had an IPAA constructed subsequent to haemorrhoidectomy. Two (4.9%) patients need to go back to theatre for postoperative bleeding. There were no further 30-day complications or long-term nonhealing of the surgical site. There were no pouch complications in those who had haemorrhoidectomy at the time of IPAA construction or in the presence of an IPAA. CONCLUSION: Our data suggest that excisional haemorrhoidectomy may be performed safely in carefully selected UC patients with symptomatic haemorrhoids with or without IPAA and even at the time of IPAA construction.

Self-reported access to health care, communicable diseases, violence and perception of legal status among online transgender identifying sex workers in the UK.

OBJECTIVES: Transgender-identifying sex workers (TGISWs) are among the most vulnerable groups but are rarely the focus of health research. Here we evaluated perceived barriers to healthcare access, risky sexual behaviours and exposure to violence in the United Kingdom (UK), based on a survey of all workers on BirchPlace, the main transgender sex commerce website in the UK. STUDY DESIGN: The study design used in the study is an opt-in text-message 12-item questionnaire. METHODS: Telephone contacts were harvested from BirchPlace's website (n = 592 unique and active numbers). The questionnaire was distributed with Qualtrics software, resulting in 53 responses. RESULTS: Our survey revealed significant reported barriers to healthcare access, exposure to risky sexual behaviours and to physical violence. Many transgender sex workers reportedly did not receive a sexual screening, and 28% engaged in condomless penetrative sex within the preceding six months, and 68% engaged in condomless oral sex. 17% responded that they felt unable to access health care they believed medically necessary. Half of the participants suggested their quality of life would be improved by law reform. CONCLUSIONS: TGISWs report experiencing a high level of risky sexual behaviour, physical violence and inadequate healthcare access. Despite a National Health System, additional outreach may be needed to ensure access to services by this population.

Colectomy for caecal and sigmoid volvulus: a national analysis of outcomes and risk factors for postoperative complications.

AIM: Colonic volvulus is a common entity encountered by colorectal surgeons, but there are few reports of national data regarding postoperative outcomes. The aim of this study was to describe the volvulus population, 30-day outcomes following right- and left-sided colectomy and risk factors for postoperative complications. METHOD: The American College of Surgeons National Surgical Quality Improvement Program Database from 2012 to 2015 was utilized to identify patients with the diagnosis of 'volvulus' who underwent right- or left-sided colectomy. Primary outcomes were overall morbidity and mortality. RESULTS: A total of 2175 patients were identified (661 right colectomy and 1514 left colectomy). Risk factors for complications following right-sided colectomy included: age, male gender, smoker, systemic inflammatory response syndrome, sepsis, septic shock and American Society of Anesthesiologsts class ≥ 4. Risk factors for complications following left-sided colectomy included: age, male gender, systemic inflammatory response syndrome, sepsis and septic shock. CONCLUSION: Several nonmodifiable risk factors were identified for complications following colectomy for volvulus. These risk factors can be used in patient/family counselling and discharge planning.

Ileal pouch revision vs excision: short-term (30-day) outcomes from the National Surgical Quality Improvement Program.

AIM: Ileal pouch-anal anastomosis (IPAA) failure occurs in approximately 5%-10% of patients. We aimed to compare short-term (30-day) postoperative outcomes associated with pouch revision and pouch excision using a large international database. Our null hypothesis was that there is no statistically significant difference in overall postoperative complications between patients selected for pouch revision vs pouch excision. METHODS: Using the American College of Surgeons National Surgical Quality Improvement Program Participant User File from 2005 to 2016 we identified patients who underwent either IPAA revision via the combined abdominoperineal approach [Current Procedural Terminology (CPT) 46712] or IPAA excision (CPT 45136). Differences in baseline characteristics and short-term outcomes between groups were assessed with univariate and matched analyses. RESULTS: We identified 593 reoperative IPAA procedures: revision group 78 (13%) and excision group 515 (86%). The groups had similar age and body mass index (kg/m2 ), but the revision group had more women (65.4% vs 51.8%, P = 0.02) and fewer were on chronic steroids (3.9% vs 17.9%, P = 0.0008) relative to the excision group. Revision IPAA patients were more likely to have received a preoperative transfusion (5.1% vs 0.97%, P = 0.02). Revision and excision were associated with similar postoperative length of stay (9.3 vs 8.6 days, 0.44), mortality (nil vs 0.58%, respectively; P = 0.99) and short-term morbidity (34.6% vs 40.2%, respectively; P = 0.88) at 30 days. CONCLUSIONS: Pouch revision and excision have comparable short-term postoperative outcomes, but pouch excision appears to be more commonly utilized. Increased awareness of the indications for pouch revision or referral to specialized centres may improve pouch revision rates.

The relationship between mesorectal grading and oncological outcome in rectal adenocarcinoma.

AIM: The prognostic association between mesorectal grading and oncological outcome in patients undergoing resection for rectal adenocarcinoma is controversial. The aim of this retrospective chart review was to determine the individual impact of mesorectal grading on rectal cancer outcomes. METHOD: We compared oncological outcomes in patients with complete, near-complete and incomplete mesorectum who underwent rectal excision with curative intent from 2009 to 2014 for Stage cI-III rectal adenocarcinoma. We also assessed the independent association of mesorectal grading and oncological outcome using multivariate models including other relevant variables. RESULTS: Out of 505 patients (339 men, median age of 60 years), 347 (69%) underwent a restorative procedure. There were 452 (89.5%), 33 (6.5%) and 20 (4%) patients with a complete, near-complete and incomplete mesorectum, respectively. Local recurrence was seen in 2.4% (n = 12) patients after a mean follow-up of 3.1 ± 1.7 years. Unadjusted 3-year Kaplan-Meier analysis by mesorectal grade showed decreased rates of overall, disease-free and cancer-specific survival and increased rates of overall and distant recurrence with a near-complete mesorectum, while local recurrence was increased in cases of an incomplete mesorectum (all P < 0.05). On multivariate analyses, a near-complete mesorectum was independently associated with decreased cancer-specific survival (hazard ratio 0.26, 95% CI 0.1-0.7; P = 0.007). There were no associations between mesorectal grading and overall survival, disease-free survival, overall recurrence or distant recurrence (all P > 0.05). CONCLUSION: Mesorectal grading is independently associated with oncological outcome. It provides unique information for optimizing surgical quality in rectal cancer.

Less is more: creation and validation of a novel, affordable suturing simulator for anorectal surgery.

BACKGROUND: Duty hour restrictions have increased the role of simulation in surgical education. A simulation that recreates the unique visual, anatomic, and ergonomic challenges of anorectal surgery has yet to be described. The aim of this study was to develop a low-cost, low-fidelity anorectal surgery simulator and provide validity evidence for the model. METHODS: A novel, low-fidelity simulator was constructed, and anorectal surgery workshops were implemented for general surgery interns at a single institution. Face and content validity were assessed with separate questionnaires using a 5-point Likert scale. Participants performed a simulated hemorrhoid excision with longitudinal wound closure, and transverse wound closure. Time-to-task completion and quality of suturing/knot tying were evaluated by a blinded observer to assess construct validity. RESULTS: Material cost was US $11 per simulator. We recruited 20 first-year surgery residents (novices) and 4 practicing colorectal surgeons (experts), and conducted 3 workshops in 2014-2016. All face and content validity measures achieved a median score greater than 4 (range 4.0-5.0). Time-to-task completion was significantly lower in the expert cohort (hemorrhoid excision with longitudinal wound closure: 195 vs. 477 s and transverse closure: 79 vs. 192 s, p < 0.001 for both). Suturing and knot-tying scores were significantly higher in the expert cohort for both tasks (p < 0.05 for all comparisons). CONCLUSIONS: Our low-fidelity, low-cost anorectal surgery model demonstrated evidence of face, content, and construct validity. We believe that this simulator could be a useful instrument in the education of junior surgical trainees and will allow residents to obtain proficiency in anorectal suturing tasks in conjunction with traditional surgical training.

Laparoscopy reduces iatrogenic splenic injuries during colorectal surgery.

BACKGROUND: Splenic injury can occur during colorectal surgery especially in cases, where the splenic flexure is mobilized. The aim of this study was to analyze whether the operative approach (laparoscopic vs. open) was associated with an increased risk for splenic injury during colorectal surgery and to compare the outcomes of different management options. METHODS: All accidental injuries that occurred during colorectal resections performed in our department between January 2010 and June 2013 were identified from an administrative database. All patients with iatrogenic splenic injuries were classified into two groups according to the operative approach. Only procedures that required splenic flexure mobilization were included. Splenic injury management options and outcomes were compared. RESULTS: There were 2336 colorectal resections (1520 open, 816 laparoscopic) performed during the study period. There were 25 (1.1%) iatrogenic splenic injuries. 23 out of 25 splenic injuries occurred during open colorectal surgery. Overall, 16 (64%) patients were managed with topical hemostatic methods, 5 (20%) with splenectomy, and 4 (16%) with splenorrhaphy. It was possible to salvage the spleen in both laparoscopic patients. The laparoscopic approach was associated with a lower splenic injury rate (0.25% vs. 1.5%, p = 0.005) and a lower need for splenectomy/splenorrhaphy (p = 0.03). CONCLUSIONS: Our data suggest that laparoscopic colorectal surgery may be associated with a lower risk of iatrogenic splenic injury, and that most splenic injuries can be managed with spleen-preserving approaches.

Gender violence, poverty and HIV infection risk among persons engaged in the sex industry: cross-national analysis of the political economy of sex markets in 30 European and Central Asian countries.

OBJECTIVES: Persons engaged in the sex industry are at greater risk of HIV and other sexually transmitted infections than the general population. One major factor is exposure to higher levels of risky sexual activity. Expanding condom use is a critical prevention strategy, but this requires negotiation with those buying sex, which takes place in the context of cultural and economic constraints. Impoverished individuals who fear violence are more likely to forego condoms. METHODS: Here we tested the hypotheses that poverty and fear of violence are two structural drivers of HIV infection risk in the sex industry. Using data from the European Centre for Disease Prevention and Control and the World Bank for 30 countries, we evaluated poverty, measured using the average income per day per person in the bottom 40% of the income distribution, and gender violence, measured using homicide rates in women and the proportion of women exposed to violence in the last 12 months and/or since age 16 years. RESULTS: We found that HIV prevalence among those in the sex industry was higher in countries where there were greater female homicide rates (ß = 0.86; P = 0.018) and there was some evidence that self-reported exposure to violence was also associated with higher HIV prevalence (ß = 1.37; P = 0.043). Conversely, HIV prevalence was lower in countries where average incomes among the poorest were greater (ß = -1.05; P = 0.046). CONCLUSIONS: Our results are consistent with the theory that reducing poverty and exposure to violence may help reduce HIV infection risk among persons engaged in the sex industry.

Factors associated with hospital readmission following diverting ileostomy creation.

BACKGROUND: The creation of a diverting loop ileostomy is associated with the risk of readmission due to stoma-related complications. We hypothesized that the assessment of our institution-specific readmissions following ileostomy creation would help identifying at-risk groups which should be the focus of future preventative strategies. METHODS: Patients who underwent loop ileostomy formation from 2009 to 2013 were reviewed. We evaluated readmissions within 30 days after discharge following loop ileostomy construction. Possible associations between readmission and demographic, disease-related and treatment-related factors were assessed using univariate and multivariate analyses. RESULTS: Out of 1267 patients undergoing loop ileostomy construction, 163 patients (12.9%) were readmitted. The main causes of readmissions were organ/space infections (43, 3.4%), small bowel obstruction/ileus (42, 3.3%) and dehydration (38, 3%). Independent factors associated with overall readmission were cardiovascular (OR = 2.0) and renal comorbidity (OR = 2.9), preoperative chemo/radiotherapy (OR = 4.0), laparoscopic approach (OR = 1.7) and longer operative time (OR = 1.2). Cancer diagnosis was associated with reduced readmission rates (OR = 0.2). Independent factors associated with readmission due to dehydration were chemo/radiotherapy (OR = 4.7) and laparoscopic approach (OR = 2.6). CONCLUSIONS: Dehydration associated with diverting ileostomy creation was relevant as an individual cause of readmission, but its overall incidence was relatively rare. Dedicated strategies to prevent dehydration should be directed to patients who received chemoradiotherapy and/or laparoscopic surgery.

A nationwide assessment comparing nonelective open with minimally invasive complex colorectal procedures.

AIM: The use of minimally invasive colorectal surgery has increased greatly for both benign and malignant disease. Studies evaluating complex procedures have been largely limited to elective indications. We aimed to compare the outcome of a laparoscopic with an open transverse (TC) and total abdominal colectomy (TAC) in the nonelective setting. METHOD: Comparative analysis was made using the Nationwide Inpatient Sample (2008-11) of patients undergoing a nonelective TC or TAC identified by ICD-9-CM procedure codes. The risk-adjusted 30-day outcome was assessed using regression modelling accounting for patient characteristics, comorbidity and surgical procedure. RESULTS: We identified 7261 admissions including 818 laparoscopic and 6443 open procedures. The mean age of the population was 65 ± 17 years and patients in the laparoscopic group were younger (56 ± 20 vs. 66 ± 17 years; P < 0.05). The rate of a single complication was lower in the laparoscopic group (26% vs. 38%; P < 0.01), but this did not remain significant following a logistic regression analysis. Mortality was significantly lower in the laparoscopic group (3.1% vs. 17%; P < 0.01) and this remained true after adjusting for covariates (OR = 0.62; P < 0.05). Laparoscopic cases were associated with a shorter median length of stay (10 vs. 13 days; P < 0.01) and hospital charge ($75,758 vs. $98,833; P < 0.01). CONCLUSION: A nonelective laparoscopic TC or TAC is associated with an equivalent complication rate and lower mortality compared with an open operation. The results should encourage surgeons with the appropriate skills to consider a laparoscopic approach for nonelective pathology requiring a complex colectomy.

Identifying Francisella tularensis genes required for growth in host cells.

Francisella tularensis is a highly virulent Gram-negative intracellular pathogen capable of infecting a vast diversity of hosts, ranging from amoebae to humans. A hallmark of F. tularensis virulence is its ability to quickly grow to high densities within a diverse set of host cells, including, but not limited to, macrophages and epithelial cells. We developed a luminescence reporter system to facilitate a large-scale transposon mutagenesis screen to identify genes required for growth in macrophage and epithelial cell lines. We screened 7,454 individual mutants, 269 of which exhibited reduced intracellular growth. Transposon insertions in the 269 growth-defective strains mapped to 68 different genes. FTT_0924, a gene of unknown function but highly conserved among Francisella species, was identified in this screen to be defective for intracellular growth within both macrophage and epithelial cell lines. FTT_0924 was required for full Schu S4 virulence in a murine pulmonary infection model. The ΔFTT_0924 mutant bacterial membrane is permeable when replicating in hypotonic solution and within macrophages, resulting in strongly reduced viability. The permeability and reduced viability were rescued when the mutant was grown in a hypertonic solution, indicating that FTT_0924 is required for resisting osmotic stress. The ΔFTT_0924 mutant was also significantly more sensitive to ß-lactam antibiotics than Schu S4. Taken together, the data strongly suggest that FTT_0924 is required for maintaining peptidoglycan integrity and virulence.

Colonic decompression and direct intraluminal medical therapy for Clostridium difficile-associated megacolon using a tube placed endoscopically in the proximal colon.

AIM: Urgent colectomy for severe Clostridium difficile infection can be associated with increased morbidity and mortality. We aimed to use endoscopic methods for treatment. METHOD: We describe a technique of placing an intracolonic tube facilitating decompression and direct delivery of vancomycin to the proximal colon along with enemas on a regular and frequent basis that may not be possible with vancomycin enemas alone. RESULTS: Successful resolution of the C. difficile infection and avoidance of surgery. CONCLUSION: While further long-term evaluation is required, our initial results have shown it to be effective in treating select patients with recalcitrant Clostridium difficile-associated megacolon.