The Impact of Transversus Abdominis Plane Block Within an Enhanced Recovery After Surgery Protocol on Length of Stay.

BACKGROUND: Multimodal, narcotic-sparing analgesic strategies are an important part of enhanced recovery after surgery protocols. Within such protocols, regional anesthetics have proven to be superior to narcotics. OBJECTIVE: This study aimed to evaluate the impact of the transversus abdominis plane block within an enhanced recovery after surgery protocol on length of stay. DESIGN: A retrospective analysis of patients who underwent colorectal surgery in 2015 to 2016 was completed. The primary end points for this analysis were total length of stay and total narcotics consumed during hospitalization. Length of stay and total narcotic use were compared for patients who received a transversus abdominis plane block versus those that did not. DATA SOURCE: The data were obtained from the data warehouse of a university teaching hospital. SETTINGS: This study took place at a university teaching hospital. PATIENTS: The patients were 18 years or older. MAIN OUTCOME MEASURES: The primary outcomes measured were length of stay and the total narcotics used. RESULTS: A total of 347 patients underwent colorectal procedures under the enhanced recovery protocol. Among these, 186 (54%) received a transversus abdominis plane block. Overall, the mean length of stay was 5.8 days (SD ±5.6), and median length of stay was 4 days. These values compare to a mean length of stay of 9.6 days and median length of stay of 7 days before implementing the enhanced recovery protocol. Patients who received a transversus abdominis plane block had a mean length of stay of 5.1 days compared to 6.6 days for those who did not receive one (p < 0.01). Patients who received a transversus abdominis plane block consumed 736.5 morphine milligram equivalents of opioids compared to 1150.3 morphine milligram equivalents of opioid consumed by those without a transversus abdominis plane block (p < 0.05), a 36% decrease in opioid use. When comparing patients who had a mean length of stay of 4 days with those whose length of stay was >4 days, there was an 80% decrease in opioid use. The readmission rate was 7.8%. LIMITATIONS: The lack of randomization of patients was a limitation of this study. CONCLUSION: The use of transversus abdominis plane block in the setting of a well-structured enhanced recovery protocol was associated with a statistically significant decrease in length of stay by 1.5 days and a 36% decrease in narcotic use. See Video Abstract at http://links.lww.com/DCR/B432. IMPACTO DE LA ANESTESIA DEL PLANO MUSCULAR DE LOS TRANSVERSOS ABDOMINALES EN LA ESTADA DENTRO UN PROTOCOLO ERAS: ANTECEDENTES:La estrategia analgésica multimodal que consume poco medicamento de tipo narcótico es parte importante en los protocolos de recuperación mejorada postoperatoria. Dentro de dichos protocolos, los anestésicos regionales han demostrado ser superiores a la administración de medicamentos narcóticos.OBJETIVO:Estudiar el impacto del bloqueo del plano muscular de los transversos del abdomen sobre la duración de la estadía dentro de un protocolo de recuperación mejorada postoperatoria.DISEÑO:Se realizó un análisis retrospectivo de los pacientes que se sometieron a cirugía colorrectal entre 2015-2016. Los criterios principales de valoración en el presente análisis fueron la duración total de la estadía y el total de medicamentos narcóticos consumidos durante la hospitalización. Se comparó la duración de la estadía y el uso total de narcóticos en los pacientes que recibieron un bloqueo anestésico del plano muscular de los transversos del abdomen con los que no lo recibieron.FUENTE DE DATOS:Banco de datos de un hospital universitario docente.AMBIENTE:Hospital Universitario Docente.PACIENTES:Adultos desde los 18 años o mayores.PRINCIPALES MEDIDAS DE RESULTADO:Duración de la estadía, cantidad total de medicamentos narcóticos administrados.RESULTADOS:Un total de 347 pacientes se sometieron a procedimientos colorrectales bajo el protocolo ERAS. Entre ellos, 186 (54%) recibieron un bloqueo del plano muscular de los transversos del abdomen. En la globalidad, la duración media de la estadía fué de 5,8 días (DE ± 5,6) y la duración media de la estadía fué de 4 días. Estos resultados fueron comparados con la estadía media de 9,6 días y una estadía media de 7 días antes de implementar el protocolo ERAS. Los pacientes que recibieron un bloqueo del plano muscular de los transversos del abdomen tuvieron una estadía media de 5,1 días en comparación con los 6,6 días de los que no recibieron el mencionado bloqueo (p <0,01). Los pacientes que recibieron el bloqueo del plano muscular consumieron 736,5 miligramos de morfina o su equivalente en opioides, comparados con los 1150,3 de aquellos sin bloqueo del plano muscular (p <0,05) lo que significó una disminución del 36% en la administración de opioides. Al comparar los pacientes que tuvieron una estadía media de 4 días con aquellos cuya estadía fue mayor a 4 días, se evidenció una disminución en el 80% de la administración de opioides. La tasa de reingreso fue del 7,8%.LIMITACIONES:Estudio sin sin aleatorización de pacientes.CONCLUSIÓN:El bloqueo anestésico del plano muscular de los transversos del abdomen dentro un contexto protocolar tipo ERAS o de recuperación mejorada bien estructurada, se asoció con la disminución estadísticamente significativa de la duración de la estadía en 1,5 días y una disminución del 36% en la administración de medicamentos narcóticos. Consulte Video Resumen en http://links.lww.com/DCR/B432.

Response of metastatic mucosal melanoma to immunotherapy: It can get worse before it gets better.

Immune therapy with checkpoint inhibitors has revolutionized the management of metastatic melanoma. Ipilimumab, nivolumab, and pembrolizumab are all FDA-approved immune checkpoint inhibitors to treat metastatic melanoma. Responses to immune checkpoint inhibitors are usually delayed. An interim progression on restaging computed tomography scans "pseudo-progression" may be observed before response to treatment occur. In this case, we report a significant interim progression of metastatic mucosal melanoma before meaningful responses to immunotherapy occurred. The patient developed significant immune therapy-related colitis and new onset vitiligo. Further restaging computed tomography scans showed sustained tumor response despite stopping the immune therapy.

Mobile spaced education for surgery rotation improves National Board of Medical Examiners scores.

BACKGROUND: Use of mobile devices for medical education is increasing. The aim of this study was to describe the implementation of a spaced education-based app study program in a third year medical school surgery rotation and examine its effects on National Board of Medical Examiners (NBME) examination performance. MATERIALS AND METHODS: Case-based questions were created and distributed to students on a voluntary basis via a mobile app. Questions were repeated in a spaced based manner until mastered. Students completed surveys regarding study habits and app use. NBME examination scores and prior academic measures were obtained. Users of the app were compared to non-users of the app and the previous years' class. RESULTS: One hundred fifty-two students were offered the app; 121 (80%) used it. App users had a final NBME score of 77.5% compared with 68.8% (P < 0.01) in non-users, although their prior academic achievement was better. Categorizing them by their academic achievement and intensity of app use demonstrated significantly higher scores in regular users of the app as compared with casual and non-users in mid (78 versus 75 versus 71.2%, P < 0.01) and low-achieving students (71.4 versus 70 versus 64.6, P < 0.01), but not high-achieving students (85.3 versus 81.1 versus 79.7, P = 0.09). Stepwise linear regression modeling revealed intensity of app use accounted for 6% of the variance in NBME scores. CONCLUSIONS: Use of the app-based program was an effective tool associated with higher scores on standardized tests in lower level achieving students.

Rectal perforation at the time of vaginal mesh placement and subsequent abdominal mesh removal.

INTRODUCTION: We present an uncommon complication of vaginally placed synthetic prolapse mesh and demonstrate repair of rectal mesh perforation. METHODS: A 41-year-old was referred with multiple complaints following rectocele repair using a posterior vaginal mesh kit 5 months earlier. In the immediate postoperative period, she experienced severe pain radiating down her right leg, pelvic pain, dyspareunia, dyschezia, diarrhea, and new onset fecal incontinence. Our examination revealed tight, tender mesh arms palpable at the vaginal apex with no evidence of erosion or rectovaginal fistula. Rectal examination revealed intrarectal mesh traversing the rectal lumen 6 cm from the anal verge. Pelvic MRI demonstrated a possible rectovaginal fistula with inflammation surrounding the right sciatic nerve plexus. The patient underwent exploratory laparotomy, removal of the mesh, primary repair of two perforating rectal defects and diverting loop ileostomy. Postoperatively she experienced immediate improvement in pain and later underwent successful take-down of her ileostomy. She did well with improvement of bowel function, continence of feces, improvement of pain, and no recurrence of prolapse. CONCLUSION: Our video shows an abdominal approach for mesh removal and repair of rectal mesh injury occurring from vaginal mesh placement. We discuss the rationale for the abdominal approach and review techniques for proper placement of posterior vaginal mesh.

Money matters: a resident curriculum for financial management.

BACKGROUND: A 2005 survey reported 87% of surgery program directors believed practice management training should occur during residency. However, only 8% of program directors believed residents received adequate training in practice management [1]. In addition to the gap in practice financial management knowledge, we recognized the need for training in personal finance among residents. A literature review and needs assessment led to the development of a novel curriculum for surgery residents combining principles of practice management and personal finance. METHODS: An 18-h curriculum was administered over the 2012 academic year to 28 post graduate year 1-5 surgery residents and faculty. A self-assessment survey was given at the onset and conclusion of the curriculum [2]. Pre-tests and post-tests were given to objectively evaluate each twice monthly session's content. Self-perception of learning, interest, and acquired knowledge were analyzed using the Wilcoxon signed ranks test. RESULTS: Initial self-assessment data revealed high interest in practice management and personal finance principles but a deficiency in knowledge of and exposure to these topics. Throughout the curriculum, interest increased. Residents believed their knowledge of these topics increased after completing the curriculum, and objective data revealed various impacts on knowledge. CONCLUSIONS: Although surgery residents receive less exposure to these topics than residents in other specialties, their need to know is no less. We developed, implemented, and evaluated a curriculum that bridged this gap in surgery education. After the curriculum, residents reported an increase in interest, knowledge, and responsible behavior relating to personal and practice financial management.

What Do Medical Students Actually Want from Learning Communities? A Comprehensive Needs Assessment.

This article was migrated. The article was marked as recommended. Purpose: The demanding nature of medical education has been well-described. Learning Communities (LCs) have been formed in a number of medical schools to address unmet needs such as wellness, social support, and academic/career counseling. However, there is limited information regarding the student perspective in shaping LC goals and activities. This study examined that perspective using a needs assessment survey. Methods: A formal needs assessment survey was completed by 510 medical students. The survey included 16 Likert-scale items and one open response item. Topics focused on student well-being, career planning, meaningful professional relationships, and academic success. Results: As expected, residency success and academic performance were the domains ranked as most important. Of note, the domain of wellness was ranked as less important overall. Results also varied by medical school year and gender. Conclusion: Formal assessment of student needs can serve as a guide to the development of LC programming, hopefully increasing student engagement.

Overexpression of CXCR4 in primary tumor of patients with HER-2 negative breast cancer was predictive of a poor disease-free survival: a validation study.

BACKGROUND: Although HER-2 negative tumors are thought to be less aggressive than their counterpart, there is a subset that behaves poorly. The molecular mechanism to account for this is unknown. The chemokine receptor CXCR4 is often upregulated in a wide array of cancers. Using a training dataset, we previously reported that high CXCR4 overexpression portends a poor outcome among patients with HER-2 negative breast tumors. This study aims to validate these findings, using our validation dataset. METHODS: There were 115 patients with stages I-III, HER-2 negative breast cancers who were prospectively accrued and analyzed. CXCR4 levels from primary tumors were detected using Western blots, and results were quantified against 1 microg of HeLa cells. CXCR4 expression was defined as low (<6.6 fold) or high (> or =6.6 fold). Primary endpoint was cancer recurrence. Statistical analysis performed included Spearman correlation, Fisher exact test, Kaplan-Meier survival analysis, Cox proportional hazard ratio model, and log-rank test. RESULTS: There were 13 patients in the high (> or =6.6 fold) and 102 patients in the low CXCR4 group (<6.6 fold). Overall survival (OS) and disease-free survival (DFS) for the cohort was 84 and 71%, respectively. The 5-year OS for the high CXCR4 group was 52% and for the low CXCR4 group was 86% (P = 0.08). The 5-year DFS for the high CXCR4 and low CXCR4 group was 38 and 74%, respectively (P = 0.01). CONCLUSION: We validated that high CXCR4 overexpression in primary tumors of patients with HER-2 negative tumors portend a poor outcome. These findings should be confirmed with either a prospective clinical trial and/or an external validation study.

Lessons Learned From the Creation of a Business of Medicine Course.

This article was migrated. The article was marked as recommended. Knowledge, attitudes, and skills required to successfully manage business and personal finances are rarely taught within traditional medical education. This has contributed to low financial literacy, high stress related to educational debt, and burnout among physicians. To address this deficiency, we created the Business of Medicine course for fourth-year medical students which teaches basic business and personal finance topics. As we have reflected on lessons learned in the creation and implementation of this course, we have recorded them for the benefit of others who desire to partner with us in teaching this important topic to the next generation of physicians.

Dedifferentiated Liposarcoma Mimicking a Primary Colon Mass.

Dedifferentiated liposarcoma is typically a nonlipogenic high-grade sarcoma that arises from well-differentiated liposarcoma. It most commonly presents as a large mass in the retroperitoneum. Significant involvement of the gastrointestinal tract by dedifferentiated liposarcoma is uncommon. We present a unique case of dedifferentiated liposarcoma radiographically mimicking a primary colon mass with resulting intussusception; stranding of the adjacent adipose tissue was presumed to be a secondary reactive change. On histopathologic analysis of the hemicolectomy specimen, a high-grade sarcoma was seen growing through the colonic wall, and the majority of the surrounding pericolonic adipose tissue was actually composed of well-differentiated liposarcoma with characteristic fibrous bands rather than benign fat with reactive fibrosis. This case raises awareness that well-differentiated liposarcoma and dedifferentiated liposarcoma can rarely present as a primary intestinal mass mimicking colon cancer or other more common entities. When radiographic examination shows a perigastrointestinal or retroperitoneal fatty mass and/or stranding of the fat adjacent to a solid gastrointestinal mass, this unusual scenario should be considered in the radiologic differential diagnosis. Pathologists should keep dedifferentiated liposarcoma in the initial histologic differential diagnosis for any high-grade spindle cell tumor of the retroperitoneum or intra-abdominal visceral organs.

Multidisciplinary surgical treatment of presacral meningocele and teratoma in an adult with Currarino triad.

BACKGROUND: Currarino syndrome (CS) is a rare genetic condition that presents with the defining triad of anorectal malformations, sacral bone deformations, and presacral masses, which may include teratoma. Neurosurgeons are involved in the surgical treatment of anterior meningoceles, which are often associated with this condition. The accepted surgical treatment is a staged anterior-posterior resection of the presacral mass and obliteration of the anterior meningocele. CASE DESCRIPTION: This case involved a 36-year-old female who presented with late onset of symptoms attributed to CS (e.g., presacral mass, anterior sacral meningocele, and sacral agenesis). She successfully underwent multidisciplinary single-stage approach for treatment of the anterior sacral meningocele and resection of the presacral mass. This required obliteration of the meningocele and closure of the dural defect. One year later, her meningocele had fully resolved. CONCLUSION: While late presentations with CS are rare, early detection and multidisciplinary treatment including single-state anterior may be successful for managing these patients.

Fluorescein as a topical fluorescent contrast agent for quantitative microendoscopic inspection of colorectal epithelium.

Fiber bundle microendoscopic imaging of colorectal tissue has shown promising results, for both qualitative and quantitative analysis. A quantitative image quality control and image feature extraction algorithm was previously designed for quantitative image feature analysis of proflavine-stained ex vivo colorectal tissue. We investigated fluorescein as an alternative topical stain. Images of ex vivo porcine, caprine, and human colorectal tissue were used to compare microendoscopic images of tissue topically stained with fluorescein and proflavine solutions. Fluorescein was shown to be comparable for automated crypt detection, with an average crypt detection sensitivity exceeding 90% using a combination of three contrast limit pairs.

Rectal gastrointestinal stromal tumor with metastasis to the penis: Case report and review of literature.

We report the case of a 51-year-old gentleman with previously diagnosed gastrointestinal stromal tumor (GIST) of the rectum with metastasis to the penis. The patient underwent abdominoperineal resection of the primary tumor with negative margins and completed a three-year course of imatinib mesylate (Gleevec). Forty months after resection of his rectal tumor, the patient presented to his urologist with worsening testicular pain, mild lower urinary tract obstructive symptoms, and nocturia. A pelvic MRI revealed the presence of an ill-defined mass in the right perineum extending from the base of the penis to the penoscrotal junction. Biopsy of this mass was consistent with metastatic GIST. To our knowledge, this is the first report of metastatic GIST to the penis.

Quantitative analysis of ex vivo colorectal epithelium using an automated feature extraction algorithm for microendoscopy image data.

Qualitative screening for colorectal polyps via fiber bundle microendoscopy imaging has shown promising results, with studies reporting high rates of sensitivity and specificity, as well as low interobserver variability with trained clinicians. A quantitative image quality control and image feature extraction algorithm (QFEA) was designed to lessen the burden of training and provide objective data for improved clinical efficacy of this method. After a quantitative image quality control step, QFEA extracts field-of-view area, crypt area, crypt circularity, and crypt number per image. To develop and validate this QFEA, a training set of microendoscopy images was collected from freshly resected porcine colon epithelium. The algorithm was then further validated on ex vivo image data collected from eight human subjects, selected from clinically normal appearing regions distant from grossly visible tumor in surgically resected colorectal tissue. QFEA has proven flexible in application to both mosaics and individual images, and its automated crypt detection sensitivity ranges from 71 to 94% despite intensity and contrast variation within the field of view. It also demonstrates the ability to detect and quantify differences in grossly normal regions among different subjects, suggesting the potential efficacy of this approach in detecting occult regions of dysplasia.

Neoadjuvant chemotherapy in stage III breast cancer.

Neoadjuvant chemotherapy in advanced breast cancer can potentially downstage disease prior to definitive surgery. In this study, a doxorubicin-based neoadjuvant regimen was administered to stage III breast cancer patients to assess 1) primary tumor response, 2) tumor involvement of resection margins, and 3) predictive value in cancer outcome. Eighty-two patients with stage IIIA and IIIB breast cancer diagnosed between 1990 and 2003 were studied. All patients received similar chemotherapy regimens, consisting of doxorubicin, cisplatin, and 5-fluorouracil, plus surgery and radiation therapy. End points measured include primary tumor response [complete response (CR) = 100%, partial response (PR) > 50%, or no response (NR) < or = 50%], resection margins for tumor, disease-free, and overall survival. Kaplan-Meier and log-rank tests were performed. Of the 82 patients studied, 34 received neoadjuvant therapy, 48 received conventional postoperative treatment. Seventy-two per cent of the stage IIIB and 22 per cent of the stage IIIA patients received neoadjuvant therapy. In the neoadjuvant group, 29 (85%) patients demonstrated tumor response, 9 (26%) of which were CR. Tumor-free resection margins were achieved in 94 per cent of the neoadjuvant group. Survival analysis demonstrated no benefit comparing neoadjuvant versus postoperative adjuvant therapy but hints at improved disease-free survival in neoadjuvant CR patients (log-rank test, P = 0.07). Eighty-five per cent of patients with stage III breast cancer treated with neoadjuvant chemotherapy experienced clinical response, with 26 per cent CR, and 97 per cent tumor-free resection margins. CR may portend a better cancer outcome.

Qualitative and quantitative comparison of colonic microendoscopy image features to histopathology.

Colorectal cancer is the second leading cause of cancer deaths in the United States, affecting more than 130,000 Americans every year1. Determining tumor margins prior to surgical resection is essential to providing optimal treatment and reducing recurrence rates. Colorectal cancer recurrence can occur in up to 20% of cases, commonly within three years after curative treatment. Typically, when colorectal cancers are resected, a margin of normal tissue on both sides of the tumor is required. The minimum margin required for colon cancer is 5 cm and for the lower rectum 2 cm. However, usually more normal tissue is taken on both sides of the tumor because the blood supply to the entire segment is removed with the surgery and therefore the entire segment must be removed. Anastomotic recurrences may result from inadequate margins. Pathologists look at the margins to ensure that there is no residual tumor and this is usually documented in the pathology report. We have developed a portable, point-of-care fiber bundle microendoscopy imaging system for detection of abnormalities in colonic epithelial microstructure. The system comprises a laptop, a modified fiber bundle image guide with a 1mm active area diameter and custom Lab VIEW interface, and is approved for imaging surgically resected colon tissue at the University of Arkansas for Medical Sciences. The microendoscopy probe provides high-resolution images of superficial epithelial histology in real-time to assist surgical guidance and to localize occult regions of dysplasia which may not be visible. Microendoscopy images of freshly resected human colonic epithelium were acquired using the microendoscopy device and subsequently mosaicked using custom post-processing software. Architectural changes in the glands were mapped to histopathology H&E slides taken from the precise location of the microendoscopy images. Qualitatively, glandular distortion and placement of image guide was used to map normal and dysplastic areas of the colonic tumor and surrounding region from microendoscopy images to H&E slides. Quantitative metrics for correlating images were also explored and were obtained by analyzing glandular diameter and spatial distribution as well as image texture.