Abstract
Enhanced Recovery after Surgery (ERAS) pathways have become popular in colorectal surgery due to their associated decrease in length of stay (LOS), complications, and readmission rate. ...However, it is unclear if these pathways are safe, feasible, or effective in unique patient populations such as elderly patients, urgent/emergent surgeries, patients with specific comorbidities, inflammatory bowel disease, or pediatric patients. Enhanced recovery pathways appear safe in elderly patients, associated with decreased complications, though with slightly lower rates of adherence and increased LOS and readmission rates. Modified ERAS pathways have been applied to urgent and emergent surgeries, resulting in decreased morbidity and LOS. There have been no studies that performed subgroup analyses of ERAS pathways in patients with specific comorbidities. Studies investigating patients with inflammatory bowel disease on enhanced recovery pathways are extremely limited, but suggest that they are safe and feasible. Data on ERAS pathways in pediatric patients are still emerging. Therefore, though data are sparse, enhanced recovery pathways appear to be safe in unique patient populations, with similar efficacy in decreasing LOS and complications. There is an urgent need for more studies investigating these specific patient groups to aid perioperative decision making by colorectal surgeons.
Management of Diverticulitis in 2017 Deery, Sarah E.; Hodin, Richard A.
Journal of gastrointestinal surgery,
10/2017, Volume:
21, Issue:
10
Journal Article
Peer reviewed
Open access
Diverticulitis has become increasingly more common in the 20
th
century and is now one of the most frequent indications for gastrointestinal tract-related hospitalizations. The spectrum of clinical ...presentation can vary widely from mild, uncomplicated disease that can be managed as an outpatient, to complicated diverticulitis with peritonitis and sepsis. Historically, all patients with diverticulitis were managed with, at a minimum, a course of antibiotics, with many patients undergoing urgent or emergent surgery with a sigmoid colectomy, end colostomy, and oversewn rectosigmoid “Hartmann’s” stump. However, the treatment paradigm has shifted away from more aggressive surgical management over the years, with recent literature supporting the notion that nonoperative management may lead to equivalent or even superior outcomes in many circumstances. Therefore, the purpose of this review is to summarize and interpret the existing literature on the management of uncomplicated and complicated left-sided diverticulitis in 2017.
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EMUNI, FZAB, GEOZS, IJS, IMTLJ, KILJ, KISLJ, MFDPS, NUK, OBVAL, OILJ, PNG, SAZU, SBCE, SBJE, SBMB, SBNM, UKNU, UL, UM, UPUK, VKSCE, ZAGLJ
While enhanced recovery pathways (ERAS) appear to be beneficial for post-operative outcomes, there have been no studies evaluating the specific role of patient education within an ERAS pathway.
We ...identified all colectomies performed at our institution since initiation of an ERAS protocol, excluding for mortality and length of stay >30 days. Patients who received preoperative education by a nurse practitioner via a scripted telephone call were compared to patients who did not receive education using the NSQIP database. We then evaluated differences in surgical complications and length of stay among these cohorts.
Patients who received scripted education phone calls had a significantly shorter mean length of stay when compared to patients that receiving usual care (3.0 ± 2.2 vs 3.7 ± 3.2 days; p = 0.005). Subgroup analysis demonstrates strongest benefit in patients undergoing left colectomy and laparoscopic surgery.
Scripted patient education modules may shorten length of stays and postoperative complications, even when added to an already existing ERAS bundle, which may translate into significant hospital cost savings.
•Colectomy patients receiving education had significantly shorter length of stay.•Subgroup analysis shows strongest benefit for laparoscopic and left colectomies.•No significant increase in readmission rate despite improved length of stay.
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GEOZS, IJS, IMTLJ, KILJ, KISLJ, NLZOH, NUK, OILJ, PNG, SAZU, SBCE, SBJE, UL, UM, UPCLJ, UPUK, ZRSKP
Intestinal homeostasis is a crucial factor for complication-free short- and long-term postoperative recovery. The brush border enzyme intestinal alkaline phosphatase (IAP) is an important regulator ...of gut barrier function and intestinal homeostasis and prevents endotoxemia by detoxifying lipopolysaccharides (LPSs). As IAP is predominantly secreted by enterocytes in the duodenum, we hypothesized that pancreaticoduodenectomy (PD) leads to a significantly stronger decrease in IAP than other major abdominal surgery.
Pre- and postoperative blood, stool, and intestinal samples were collected from patients undergoing PD, as well as other major surgical procedures without duodenectomy. The samples were analyzed using enzyme histochemistry, the para -nitrophenyl phosphate method for IAP, and the limulus amebocyte lysate assay for LPS.
Overall, 88 patients were prospectively enrolled in the study. Fecal IAP activity negatively correlated with serum LPS (r = -0.3603, p = 0.0006). PD led to a significant decline in IAP compared to preoperative baseline levels (p < 0.0001). The decline in IAP correlated with the length of proximal small intestinal resection (r = 0.4271, p = 0.0034). Compared to controls, PD was associated with a much more pronounced reduction in IAP-also after adjusting for surgical trauma (operative time, blood loss; r = 0.4598, p = 0.0086). Simultaneously, PD triggered a clearly more prominent increase in serum LPS compared to controls (p = 0.0001). Increased postoperative LPS was associated with an elongated hospitalization (r = 0.7534, p = 0.0062) and more prominent in pancreatic cancer (p = 0.0009).
Based upon the functional roles for IAP, supplementation with exogenous IAP might be a new treatment option to improve short- and long-term outcome after PD.
OBJECTIVE:The goal of this study was to examine a multi-institutional experience with adrenal metastases to describe survival outcomes and identify subpopulations who benefit from adrenal ...metastasectomy.
BACKGROUND:Adrenalectomy for metastatic disease is well-described, although indications and outcomes are incompletely defined.
METHODS:A retrospective cohort study was performed of patients undergoing adrenalectomy for secondary malignancy (2002–2015) at 6 institutions. The primary outcomes were disease free survival (DFS) and overall survival (OS). Analysis methods included Kaplan-Meier and Cox proportional hazards.
RESULTS:Of 269 patients, mean age was 60.1 years; 50% were male. The most common primary malignancies were lung (n = 125, 47%), renal cell (n = 38, 14%), melanoma (n = 33, 12%), sarcoma (n = 18, 7%), and colorectal (n = 12, 5%). The median time to detection of adrenal metastasis after initial diagnosis of the primary tumor was 17 months (interquartile range6–41). Post-adrenalectomy, the median DFS was 18 months (1-year DFS54%, 5-year DFS31%). On multivariable analysis, lung primary was associated with longer DFS hazard ratio (HR)0.49, P = 0.008). Extra-adrenal oligometastatic disease at initial presentation (HR1.84, P = 0.016), larger tumor size (HR1.07, P = 0.013), chemotherapy as treatment of the primary tumor (HR2.07 P = 0.027) and adjuvant chemotherapy (HR1.95, P = 0.009) were associated with shorter DFS. Median OS was 53 months (1-year OS83%, 5-year OS43%). On multivariable analysis, extra-adrenal oligometastatic disease at adrenalectomy (HR1.74, P = 0.031), and incomplete resection of adrenal metastasis (R1 margins; HR1.62, P = 0.034; R2 margins; HR5.45, P = 0.002) were associated with shorter OS.
CONCLUSIONS:Durable survival is observed in patients undergoing adrenal metastasectomy and should be considered for subjects with isolated adrenal metastases.
Abstract Introduction Hypocalcemia is a common complication following thyroid surgery. We seek to report on our experience in pediatric thyroidectomy in a high volume thyroid surgery center and ...accurately assess the incidence of postoperative hypocalcemia. Materials and methods A retrospective review of patients aged 18 and younger who underwent thyroid surgery between 1992 and 2013. The primary endpoints were the occurrence of postoperative hypocalcemia as by defined as a nadir calcium < 8.0 mg/dL and being discharged on oral calcium supplementation, need for intravenous calcium and the occurrence of permanent hypoparathyroidism. Results 171 patients who underwent 186 thyroid operations were analyzed. The average age was 15.4 years with 82.3% female. The most common indications for surgery were nodular disease (74.7%) and hyperthyroidism (12.4%). 24 patients (12.9%) experienced postoperative hypocalcemia with 13 (7.0%) requiring intravenous calcium infusion. One patient (0.9%) experienced permanent hypoparathyroidism. Risk factors for postoperative hypocalcemia included total thyroidectomy (OR 7.39, p < 0.01), central and bilateral lateral neck dissection (OR 22.26, p = 0.01), Graves’ disease (OR 3.99, p = 0.02), and malignancy (OR 2.96, p = 0.03). Conclusions Pediatric patients who undergo total thyroidectomy for underlying malignancy or Graves’ disease and those who have more extensive nodal dissections are at increased risk of developing this postoperative hypocalcemia. These patients may benefit from more vigilant preoperative preparation and postoperative calcium and vitamin D supplementation.
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GEOZS, IJS, IMTLJ, KILJ, KISLJ, NUK, OILJ, PNG, SAZU, SBCE, SBJE, UL, UM, UPCLJ, UPUK
Background
Adrenal metastasectomy is associated with increased survival in non-small cell lung cancer (NSCLC) with isolated adrenal metastases. Although clinical use of adrenal metastasectomy has ...expanded, indications remain poorly defined. The aim of this study was to evaluate the clinical benefit of adrenal metastasectomy for all lung cancer subtypes.
Patients and Methods
We performed a retrospective cohort study of patients who underwent adrenal metastasectomy for metastatic lung cancer at six institutions between 2001 and 2015. The primary outcomes were disease-free survival (DFS) and overall survival (OS). Cox proportional hazards regressions and Kaplan–Meier survival analysis were performed.
Results
For 122 patients, the mean age was 60.5 years and 49.2% were female. Median time to detection of the metastasis was 11 months, and 41.8% were ipsilateral to the primary lung cancer. Median DFS was 40 months (1 year: 64.8%; 5 year: 42.9%). Factors associated with longer DFS included primary tumor resection hazard ratio (HR): 0.001;
p
= 0.005, longer time to adrenal metastasis (HR: 0.94;
p
= 0.005), and ipsilateral metastases (HR: 0.13;
p
= 0.004). Shorter DFS corresponded with older age (HR: 1.11;
p
= 0.01), R1 resection (HR: 8.94;
p
= 0.01), adjuvant radiation (HR: 9.45;
p
= 0.02), and open adrenal metastasectomy (HR: 10.0;
p
= 0.03). Median OS was 47 months (1 year: 80.2%; 5 year: 35.2%). Longer OS was associated with ipsilateral metastasis (HR: 0.55;
p
= 0.02) and adjuvant chemotherapy (HR: 0.35;
p
= 0.02). Shorter OS was associated with extra-adrenal metastases at adrenalectomy (HR: 3.52;
p
= 0.007), small cell histology (HR: 15.0;
p
= 0.04), and lung radiation (HR: 3.37;
p
= 0.002).
Discussion
Durable survival was observed in patients undergoing adrenal metastasectomy and should be considered for isolated adrenal metastases of NSCLC. Small cell histology and extra-adrenal metastases are relative contraindications to adrenal metastasectomy.
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EMUNI, FIS, FZAB, GEOZS, GIS, IJS, IMTLJ, KILJ, KISLJ, MFDPS, NLZOH, NUK, OILJ, PNG, SAZU, SBCE, SBJE, SBMB, SBNM, UKNU, UL, UM, UPUK, VKSCE, ZAGLJ
Liver fibrosis is frequently associated with gut barrier dysfunction, and the lipopolysaccharides (LPS) -TLR4 pathway is common to the development of both. Intestinal alkaline phosphatase (IAP) has ...the ability to detoxify LPS, as well as maintain intestinal tight junction proteins and gut barrier integrity. Therefore, we hypothesized that IAP may function as a novel therapy to prevent liver fibrosis.
Stool IAP activity from cirrhotic patients were determined. Common bile duct ligation (CBDL) and Carbon Tetrachloride-4 (CCl4)-induced liver fibrosis models were used in WT, IAP knockout (KO), and TLR4 KO mice supplemented with or without exogenous IAP in their drinking water. The gut barrier function and liver fibrosis markers were tested.
Human stool IAP activity was decreased in the setting of liver cirrhosis. In mice, IAP activity and genes expression decreased after CBDL and CCl4 exposure. Intestinal tight junction related genes and gut barrier function were impaired in both models of liver fibrosis. Oral IAP supplementation attenuated the decrease in small intestine tight junction protein gene expression and gut barrier function. Liver fibrosis markers were significantly higher in IAP KO compared to WT mice in both models, while oral IAP rescued liver fibrosis in both WT and IAP KO mice. In contrast, IAP supplementation did not attenuate fibrosis in TLR4 KO mice in either model.
Endogenous IAP is decreased during liver fibrosis, perhaps contributing to the gut barrier dysfunction and worsening fibrosis. Oral IAP protects the gut barrier and further prevents the development of liver fibrosis via a TLR4-mediated mechanism.
Preclinical human IBD mechanisms is part of five focus areas of the Challenges in IBD research document, which also include environmental triggers, novel technologies, precision medicine and ...pragmatic clinical research. The Challenges in IBD research document provides a comprehensive overview of current gaps in inflammatory bowel diseases (IBD) research and delivers actionable approaches to address them. It is the result of a multidisciplinary input from scientists, clinicians, patients, and funders, and represents a valuable resource for patient centric research prioritization. In particular, the preclinical human IBD mechanisms manuscript is focused on highlighting the main research gaps in the pathophysiological understanding of human IBD. These research gap areas include: 1) triggers of immune responses; 2) intestinal epithelial homeostasis and wound repair; 3) age-specific pathophysiology; 4) disease complications; 5) heterogeneous response to treatments; and 6) determination of disease location. As an approach to address these research gaps, the prioritization of reverse translation studies is proposed in which clinical observations are the foundation for experimental IBD research in the lab, and for the identification of new therapeutic targets and biomarkers. The use of human samples in validating basic research findings and development of precision medicine solutions is also proposed. This prioritization aims to put emphasis on relevant biochemical pathways and humanized in vitro and in vivo models that extrapolate meaningfully to human IBD, to eventually yield first-in-class and effective therapies.
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