Enhanced recovery program implementation: an evidence-based review of the art and the science.

BACKGROUND: The benefits of enhanced recovery program (ERP) implementation include patient engagement, improved patient outcomes and satisfaction, better team relationships, lower per episode costs of care, lower public consumption of narcotic prescription pills, and the promise of greater access to quality surgical care. Despite these positive attributes, vast numbers of surgical patients are not treated on ERPs, and many of those considered "on pathway" are unlikely to be exposed to a majority of recommended ERP elements. METHODS: To explain the gap between ERP knowledge and action, this manuscript reviewed formal implementation strategies, proposed a novel change adoption model and focused on common barriers (and corollary solutions) that are encountered during the journey to a fully implemented and successful ERP. Given the nature of this review, IRB approval was not required/obtained. RESULTS: The information reviewed indicates that implementation of best practice is both a science and an art. What many surgeons have learned is that the "soft" skills of emotional intelligence, leadership, team dynamics, culture, buy-in, motivation, and sustainability are central to a successful ERP implementation. CONCLUSIONS: To lead teams toward achievement of pervasive and sustained adherence to best practices, surgeons need to learn new strategies, techniques, and skills.

Portomesenteric venous thrombosis following major colon and rectal surgery: incidence and risk factors.

BACKGROUND: Portomesenteric venous thrombosis (PMVT) is an uncommon complication of abdominal surgery. The objective of this study was to assess PMVT risk factor profiles and patient outcomes after colorectal surgery. METHODS: A single center retrospective review of patients undergoing colorectal surgery was performed (2007-2012). PMVT was defined as thrombus within the portal, splenic, or superior mesenteric vein on computed tomography (CT). Inferior mesenteric vein thrombosis was excluded. Independent samples t test was used to compare data variables between PMVT and non-PMVT patients. Univariate and multivariate logistic regression analyses were used to assess PMVT risk factors. RESULTS: There were 1,224 patients included (mean age 62 years, male = 566). Elective bowel resection was performed for colon carcinoma (n = 302), rectal carcinoma (n = 112), ulcerative colitis (n = 125), Crohn's disease (n = 78), polyps (n = 117), and diverticulitis (n = 215). Patients undergoing gynecological resections and emergent laparotomies were included (n = 275). Thirty-six patients (3%) were diagnosed with PMVT by CT: 17/36 on initial presentation and 19/36 by expert radiologist review. Patients with PMVT were younger (53 vs. 62 years, p = 0.001) with higher BMI (30.5 vs. 26.7, p < 0.001) and thrombocytosis (464 vs. 306, p < 0.001) compared to patients without PMVT. Univariate logistic regression identified younger age (p < 0.001), obesity (p < 0.001), ulcerative colitis (p < 0.001), thrombocytosis, (p < 0.001) and proctocolectomy as significant predictors of PMVT. Stepwise multivariate logistic regression identified that obesity (p < 0.001), thrombocytosis, (p < 0.001) and restorative proctocolectomy (p = 0.001) were still significant predictors. No patients in the PMVT group suffered bowel infarction and no related mortalities occurred. Thirty-day readmission rates were higher in the PMVT group (53% vs. 17%, p < 0.01). CONCLUSION: BMI ≥ 30 kg/m(2), thrombocytosis, and restorative proctocolectomy were significant predictors of PMVT. Initial diagnostic studies showed a PMVT rate of 1.4%; however, after expert focused radiologic review, the actual rate was 3%. Thus, the diagnosis of PMVT is difficult and readmission after colorectal surgery should prompt its consideration.

Patient survival after surgical treatment of rectal cancer: impact of surgeon and hospital characteristics.

BACKGROUND: Surgeon and hospital factors are associated with the survival of patients treated for rectal cancer. The relative contribution of each of these factors toward determining outcomes is poorly understood. METHODS: We used data from the Surveillance, Epidemiology, and End Results-Medicare database to analyze the outcomes of patients aged 65 years and older undergoing operative treatment for nonmetastatic rectal cancer, diagnosed in the United States between 1998 and 2007. These data were linked to a registry to identify whether the treating surgeon was a board-certified colorectal surgeon versus a noncolorectal surgeon. Hospital volume and hospital certification as a National Cancer Institute-designated Comprehensive Cancer Centers were also analyzed. The primary outcome of interest was long-term survival. RESULTS: Our data source yielded 6432 patients. Initial analysis demonstrated improved long-term survival in patients treated by higher-volume colorectal surgeons, higher-volume hospitals, teaching hospitals, and National Cancer Institute (NCI)-designated Comprehensive Cancer Centers. Based on an iterative approach to modeling the interactions between these various factors, we found a robust effect of surgeon subspecialty status, hospital volume, and NCI designation. Surgeon volume was not distinctly associated with long-term survival. CONCLUSIONS: Patients treated for rectal cancer by board-certified colorectal surgeons in centers that are higher volume and/or NCI-designated Comprehensive Cancer Centers experience better overall survival. These differences persist after adjustment for a broad range of patient and contextual risk factors, including surgeon volume. Patients and payers can use these results to identify surgeons and hospitals where outcomes are most favorable.

Dysplasia in ulcerative colitis as a predictor of unsuspected synchronous colorectal cancer.

BACKGROUND: Endoscopic surveillance of patients with ulcerative colitis aims to prevent cancer-related morbidity through the detection and treatment of dysplasia. The literature to date varies widely with regard to the importance of dysplasia as a marker for colorectal cancer at the time of colectomy. OBJECTIVE: The aim of this study was to accurately characterize the extent to which the preoperative detection of dysplasia is associated with undetected cancer in patients with ulcerative colitis. DESIGN/PATIENTS/SETTING: A retrospective chart review was conducted of patients undergoing surgery for colitis within the Mayo Clinic Health System between August 1993 and July 2012. MAIN OUTCOME MEASURES: Patient demographics and pre- and postoperative dysplasia were tabulated. The relationship between pre- and postoperative dysplasia/cancer in surgical pathology specimens was assessed. RESULTS: A total of 2130 patients underwent abdominal colectomy or proctocolectomy; 329 patients were identified (15%) as having at least 1 focus of dysplasia preoperatively. Of these 329 patients, the majority were male (69%) with a mean age of 49.7 years. Unsuspected cancer was found in 6 surgical specimens. Indeterminate dysplasia was not associated with cancer (0/50). Preoperative low-grade dysplasia was associated with a 2% (3/141) risk of undetected cancer when present in random surveillance biopsies and a 3% (2/79) risk if detected in endoscopically visible lesions. Similarly, 3% (1/33) of patients identified preoperatively with random surveillance biopsy high-grade dysplasia harbored undetected cancer. Unsuspected dysplasia was found in 62/1801 (3%) cases without preoperative dysplasia. LIMITATIONS: This study is limited by its retrospective nature and by its lack of evaluation of the natural history of dysplastic lesions that progress to cancer. CONCLUSIONS: The presence of dysplasia was associated with a low risk of unsuspected cancer at the time of colectomy. These findings will help inform the decision-making process for patients with ulcerative colitis who are considering intensive surveillance vs surgical intervention after a diagnosis of dysplasia.

Short and long-term oncologic outcomes of patients with colon cancer of the splenic flexure.

BACKGROUND: There is currently no consensus on surgical management of splenic flexure adenocarcinoma (SFA). METHODS: Patients undergoing surgical resection for SFA between 1993 and 2015 were identified. Postoperative outcomes were compared between patients who underwent segmental (SR) vs. anatomical resection (AR). RESULTS: One-hundred and thirteen patients underwent SR and 89 underwent AR. More patients in the SR group had open resections, but there were otherwise no differences in demographics or surgical characteristics between the two groups. There were no differences in overall (p = 0.29) or recurrence-free(p = 0.37) survival. On multivariable analysis, increased age (HR 1.04, 1.01-1.07, p = 0.005), higher American Society of Anesthesiology classification (HR 3.1, 1.7-5.71, p < 0.001), and higher tumor stage (HR 8.84, 3.76-20.82, p < 0.001) were predictive of mortality. CONCLUSIONS: Short and long-term outcomes after SR and AR for SFA are not different, making SR a viable option for SFA surgical management.

Single-incision versus standard multiport laparoscopic colectomy: a multicenter, case-controlled comparison.

OBJECTIVE: The aim of this study was to compare single-incision laparoscopic colectomy (SILC) to multiport laparoscopic colectomy (MLC) when performed by experienced laparoscopic surgeons. BACKGROUND: Recent case reports and single institution series have demonstrated the feasibility of SILC. Few comparative studies for MLC and SILC have been reported. METHODS: Patients from 5 institutions undergoing SILC were entered into an IRB approved database from November 2008 to March 2010. SILC patients were matched with those undergoing MLC for gender, age, disease, surgery, BMI, and surgeon. The primary endpoint was length of stay and secondary endpoints included operative time, conversion, complications and postoperative pain scores. RESULTS: Three hundred thirty patients (SILC = 165, MLC = 165) were evaluated. Operative time (135 ± 45 min vs. 133 ± 56 min; P = 0.85) and length of stay (4.6 ± 1.6 vs. 4.3 ± 1.4; P = 0.35) were not significantly different. Maximum postoperative day one pain scores were significantly less for SILC (4.9 vs. 5.6; P = 0.005). Eighteen (11%) patients undergoing SILC were converted to multiport laparoscopy. There was no statistical difference between groups for conversions to laparotomy, complications, re-operations, or re-admissions. CONCLUSIONS: SILC is feasible when performed on select patients by surgeons with extensive laparoscopic experience. Outcomes were similar to MLC, except for a reduction in peak pain score on the first postoperative day. Prospective randomized trials should be performed before incorporation of this technology into routine surgical care.

Colectomy for endoscopically unresectable polyps: how often is it cancer?

BACKGROUND: Colonoscopy has an established role in reducing the burden of colorectal cancer through early detection and removal of polyps. For endoscopically unresectable polyps, colectomy is generally indicated to prevent malignant transformation or to remove cancer already present. OBJECTIVE: This study aimed to determine the incidence of malignancy and the factors predictive of malignancy in surgically resected benign polyps. DESIGN/PATIENTS/SETTING: This study was a retrospective chart review of patients undergoing a colectomy for a colonic polyp (no preoperative diagnosis of cancer) in 4 hospitals within the Mayo Clinic Health System. MAIN OUTCOME MEASURES: Patient characteristics, endoscopic location and size, and preoperative and operative polyp pathology were tabulated. Correlations between these features and the finding of invasive carcinoma on surgical pathology were assessed. RESULTS: A total of 750 patients met our inclusion criteria. Patients were predominantly male (55.2%) with an average age of 69.4 ± 9.8 years. A majority of polyps were located in the right colon (70.9%). Invasive cancer was identified in 133 patients (17.7%). Multivariate analysis revealed polyps in the left colon (adjusted OR 2.13, 95% CI (1.22-3.72)), and those with high-grade dysplasia (adjusted OR 4.60, 95% CI (2.91-7.27)) were more likely to harbor carcinoma. Age, sex, polyp dimension, and villous features were not predictive of malignancy. Of the patients with cancer, 31 (23.3%) had nodal disease. LIMITATIONS: This study is limited by its retrospective nature, the change in terminology and technique over time, and the partially subjective nature of an endoscopically unresectable polyp. CONCLUSIONS: The finding that polyp size and villous features do not strongly predict malignancy differs from previous endoscopic studies. This study confirms that polyps located in the left colon or with high-grade dysplasia are more likely to harbor cancer. The results of this study suggest that endoscopically unresectable polyps are best treated by radical oncologic resection.

Impact of minimally invasive techniques in colorectal surgery.

Minimally invasive techniques have had a marked impact on colorectal surgery despite the limited adoption of such techniques. Patients stay in the hospital a shorter time, experience less pain, and have less chance of developing a wound infection, an incisional hernia, a bowel obstruction, or difficulty becoming pregnant. Training courses have undergone metamorphosis from ad hoc animate courses to highly defined educational opportunities, and fellowships have had to respond to the educational demands of trainees demanding to be exposed to minimally invasive techniques.

Laparoscopic ileal pouch-anal anastomosis reduces abdominal and pelvic adhesions.

BACKGROUND: Postoperative adhesions are an expected outcome for the majority of open abdominal operations, occurring in more than 90% of cases. Adhesions are responsible for more than 75% of small bowel obstruction cases. This study aimed to evaluate adhesions to the anterior abdominal wall and adnexal organs after laparoscopic ileal-pouch anal anastomosis (IPAA). METHODS: Patients who underwent laparoscopic IPAA for ulcerative colitis had laparoscopic evaluation of adhesions at loop ileostomy closure for assessment of adhesions to the anterior abdominal wall and for adhesions to the adnexae in the case of women. Adhesions to the adnexae were quantified using the American Fertility Society adhesion score. Data were maintained prospectively. RESULTS: In this study, 34 patients (21 women) ranging in age from 19 to 78 years (median, 36 years) underwent laparoscopic IPAA. With regard to anterior abdominal wall adhesions, 23 patients (68%) had no adhesions to the anterior abdominal wall, and the remaining 11 patients had few adhesions (filmy, avascular). No patients had dense adhesions to the abdominal wall. Of the 21 women, 15 (71%) had no adnexal adhesions, 5 had filmy adhesions enclosing less than one-third one adnexa, and 1 had filmy adhesions enclosing one-third to two-thirds of one adnexa. No patient had adhesions affecting both adnexae. CONCLUSIONS: Laparoscopic IPAA results in few adhesions to the anterior abdominal wall or to gynecologic organs. These adhesions were significantly fewer than previously reported for open operations with or without the use of a glycerol hyaluronate/carboxymethylcellulose bioresorbable (GHA/CMC) adhesion barrier.

Safety, feasibility, and short-term outcomes of laparoscopically assisted primary ileocolic resection for Crohn's disease.

BACKGROUND: Outcomes of laparoscopic resection for ileocecal Crohn's disease have been reported previously in smaller studies, suggesting its short-term advantages over open surgery. This study assessed the safety and recovery parameters in the largest, consecutive, single-institution series to date. METHODS: Consecutive patients undergoing laparoscopically assisted primary ileocolic resection for Crohn's disease between 1994 and 2006 were identified in an institutional prospectively collected database. Operative and postoperative outcomes at 30 days were studied. RESULTS: In this study, 109 patients (35 men) with a mean age of 35 +/- 14 years and a mean body mass index (BMI) of 25 +/- 6 kg/m(2) were identified. The main indications for surgery were medically refractory disease (63%) and fibrous stenosis (27%). In 41% of the cases, previous abdominal surgery had been performed. The surgery had a mean duration of 150 +/- 45 min and a conversion rate of 6%. The overall 30-day morbidity rate was 11%, and the reoperation rate was 1%. The mortality rate was 0%. The median postoperative hospital stay was 4 days (range, 2-15 days). CONCLUSIONS: This series, the largest reported to date, concurs with recent metaanalyses findings that laparoscopically assisted primary ileocecal resection for Crohn's disease is safe and feasible, resulting in better short-terms outcomes than open resection. This operation is therefore the procedure of choice for Crohn's disease at our institutions.

Surgeon volume does not predict outcomes in the setting of technical credentialing: results from a randomized trial in colon cancer.

OBJECTIVE: To test the hypothesis that surgeon volume would not predict short- and long-term outcomes when evaluated in the setting of technical credentialing. SUMMARY BACKGROUND DATA: Surgical volume is a known predictor of outcomes; the importance of technical credentialing has not been evaluated. METHODS: Fifty-three credentialed surgeons operated on 871 patients in the Clinical Outcomes of Surgical Therapy Study (NCT00002575), investigating laparoscopic versus open surgery for colon cancer. Credentialing required that each surgeon document performance of at least 20 laparoscopic colon cases and demonstrate oncologic techniques on a video-recorded case. Surgeons were separated based on volume entered into the trial (low, < or =5 cases (n = 39); medium, 6-10 cases (n = 9); or high, >10 cases (n = 5)) and compared by outcomes. RESULTS: Patients treated by high volume compared with medium or low volume surgeons were older (70, 66, and 68 years; P < 0.001), more often had right-sided tumors (63%, 46%, and 53%; P < 0.001) and had more previous operations (48%, 38% and 45%; P < 0.004), respectively. Mean operative times were shorter (123, 147 and 145 minutes; P < 0.001), distal margins longer (13.4, 12.4 and 11.6 cm; P = 0.005), and lymph node harvest greater (14.8, 12.8, 12.6; P = 0.05) for high versus medium versus low volume surgeons. However, rates of conversion, complications, 5-year survival, and disease-free survival showed no significant differences. CONCLUSION: When tested in a randomized controlled trial with case-specific surgical technical credentialing and auditing, surgeon volume did not predict differences in rates of conversion, complications, or long-term cancer outcomes. Case-specific technical credentialing should be further studied specific to the role it could play in creating consistent, high quality outcomes.

Chronic constipation.

Chronic constipation is a prevalent condition that severely impacts the quality of life of those affected. Several types of primary chronic constipation, which show substantial overlap, have been described, including normal-transit constipation, rectal evacuation disorders and slow-transit constipation. Diagnosis of primary chronic constipation involves a multistep process initiated by the exclusion of 'alarm' features (for example, unintentional weight loss or rectal bleeding) that might indicate organic diseases (such as polyps or tumours) and a therapeutic trial with first-line treatments such as dietary changes, lifestyle modifications and over-the-counter laxatives. If symptoms do not improve, investigations to diagnose rectal evacuation disorders and slow-transit constipation are performed, such as digital rectal examination, anorectal structure and function testing (including the balloon expulsion test, anorectal manometry or defecography) or colonic transit tests (such as the radiopaque marker test, wireless motility capsule test, scintigraphy or colonic manometry). The mainstays of treatment are diet and lifestyle interventions, pharmacological therapy and, rarely, surgery. This Primer provides an introduction to the epidemiology, pathophysiological mechanisms, diagnosis, management and quality of life associated with the commonly encountered clinical problem of chronic constipation in adults unrelated to opioid abuse.

Ileorectal anastomosis for slow transit constipation: long-term functional and quality of life results.

The results of colectomy and ileorectal anastomosis (IRA) in patients diagnosed by physiologic testing as having slow transit constipation (STC) have been reported. The durability of functional results and long-term quality of life (QoL) in these patients, however, has not been established. Between 1987 and 2002, 3670 patients were evaluated for constipation at our institution; 110 (3%) fulfilled the criteria for STC and underwent an IRA. Patients were prospectively followed and functional outcomes assessed annually by standardized questionnaires. After a median follow-up of 11 years, 104 eligible patients were mailed validated questionnaires to assess functional outcomes and QoL (Knowles-Eccersley-Scott Symptom [KESS] score, the Irritable Bowel Syndrome Quality of Life [IBS-QOL], and the SF-12 health survey). Prospectively assessed functional data was available on 85 of 104 (82%) eligible patients. At last follow-up, improvement of constipation and satisfaction with bowel function was reported by 98% and 85% of patients, respectively. Performance measures including social activity, household work, sexual life, and family relationships were reported to have improved or were not affected as a result of surgery by 75%, 86%, 81%, and 86% of the patients respectively. Fifty-nine patients (57%) responded to the study questionnaires. All 59 patients reported their constipation to be better since IRA, 83% did not require any medication, and 85% reported being satisfied with bowel function. The KESS scores of patients undergoing IRA for STC (median 6, range 0-35) were lower than reported scores of STC patients not operated upon (median 21, range 11-35, P<0.001) indicating symptomatic improvement after surgery. Mean IBS-QOL scores were similar to reported scores of patients undergoing IRA for other conditions [80 (23) versus 84 (16)], P=0.7). Mean SF-12 physical and mental summary scores were similar to reported SF-12 scores of the normal population (49.5 versus 50 and P=0.70, 48.7 versus 50, P=0.42, respectively). Ileorectal anastomosis in appropriately selected patients with slow transit constipation results in durable symptomatic relief and a long-term quality of life indistinguishable from the general population.

Influence of postoperative acute-phase response on angiogenesis and tumor growth: open vs. laparoscopic-assisted surgery in mice.

Inflammatory responses and tumor growth are increased after laparotomy compared with laparoscopy in some animal models. Proinflammatory cytokines interleukin-6 (IL-6) and interleukin-1 beta (IL-1 beta) upregulate the expression of vascular endothelial growth factor (VEGF). Our aim was to investigate the influence of postoperative inflammatory responses on angiogenesis and tumor growth. 5 x 10(6) B51LiM cells were injected into the cecal wall of Balb/c mice. After 2 weeks, the animals were randomized into the following three groups: open cecectomy (OC), CO(2)-laparoscopic-assisted cecectomy (LC), and helium-laparoscopic-assisted cecectomy (LH). On postoperative day 12, the mice were killed. Tumor load scores and weight were significantly greater after laparotomy than after laparoscopy. Serum IL-6 levels 6 hours after surgery (OC: 4157+/-1297 pg/ml vs. LC: 2514+/-1417 pg/ml vs. LH: 2255+/-1714 pg/ml) and VEGF levels on postoperative day 12 (OC: 231+/-125 pg/ml vs. LC: 45+/-9 pg/ml vs. LH: 49+/-8 pg/ml), measured by enzyme-linked immunosorbent assay, were significantly higher in the laparotomy group. Microvessel density was also significantly higher in the OC group (OC: 34.3+/-11.5 vs. LC: 15.5+/-12.5 vs. LH: 18.5+/-11.9). There was a positive correlation between IL-6 and VEGF postoperative serum levels (rho=0.67; P<0.001). We concluded that increased systemic levels of proinflammatory cytokines and VEGF are associated with increased angiogenesis and tumor growth after laparotomy compared to laparoscopy in mice.

Case report: misdiagnosis of tailgut cyst presenting as recurrent perianal fistula with pelvic abscess.

Tailgut cysts are uncommon lesions that usually occur within the presacral space. The relative rarity and nonspecific complaints associated with these lesions often lead to misdiagnosis or unnecessary procedures before the correct diagnosis is made. We describe a case of a 16-year-old female who presented with pelvic pain. She had previously undergone several procedures at an outside institution for recurrent perianal fistula and perirectal abscess. Subsequent evaluation under anesthesia revealed a presacral cystic mass with a well-developed tract within the anorectal ring in the posterior midline. This mass was surgically removed using a combined transanal and posterior sagittal excision technique and was found to be a tailgut cyst upon pathologic evaluation. Tailgut cysts and other presacral masses should be included in the differential for patients with recurrent abscess in the presacral space or fistula within the anal canal. A variety of surgical approaches are available depending on the anatomy of the lesion.

Reduced acute bowel toxicity in patients treated with intensity-modulated radiotherapy for rectal cancer.

PURPOSE: We have previously shown that intensity-modulated radiotherapy (IMRT) can reduce dose to small bowel, bladder, and bone marrow compared with three-field conventional radiotherapy (CRT) technique in the treatment of rectal cancer. The purpose of this study was to review our experience using IMRT to treat rectal cancer and report patient clinical outcomes. METHODS AND MATERIALS: A retrospective review was conducted of patients with rectal cancer who were treated at Mayo Clinic Arizona with pelvic radiotherapy (RT). Data regarding patient and tumor characteristics, treatment, acute toxicity according to the Common Terminology Criteria for Adverse Events v 3.0, tumor response, and perioperative morbidity were collected. RESULTS: From 2004 to August 2009, 92 consecutive patients were treated. Sixty-one (66%) patients were treated with CRT, and 31 (34%) patients were treated with IMRT. All but 2 patients received concurrent chemotherapy. There was no significant difference in median dose (50.4 Gy, CRT; 50 Gy, IMRT), preoperative vs. postoperative treatment, type of concurrent chemotherapy, or history of previous pelvic RT between the CRT and IMRT patient groups. Patients who received IMRT had significantly less gastrointestinal (GI) toxicity. Sixty-two percent of patients undergoing CRT experienced ≥Grade 2 acute GI side effects, compared with 32% among IMRT patients (p = 0.006). The reduction in overall GI toxicity was attributable to fewer symptoms from the lower GI tract. Among CRT patients, ≥Grade 2 diarrhea and enteritis was experienced among 48% and 30% of patients, respectively, compared with 23% (p = 0.02) and 10% (p = 0.015) among IMRT patients. There was no significant difference in hematologic or genitourinary acute toxicity between groups. In addition, pathologic complete response rates and postoperative morbidity between treatment groups did not differ significantly. CONCLUSIONS: In the management of rectal cancer, IMRT is associated with a clinically significant reduction in lower GI toxicity compared with CRT. Further study is needed to evaluate differences in late toxicity and long-term efficacy.