Structured Abstract Background There is a continuing debate on the best approach for endoscopically benign large polyps that are unsuitable for conventional endoscopic resection. This study aims to ...estimate the cancer risk in patients with endoscopically benign unresectable colonic polyps referred for surgery. Study Design Patients with an endoscopic diagnosis of benign adenoma deemed not amenable for endoscopic removal who underwent colectomy between 1997- 2012 were accessed. Patients with preoperative diagnoses of cancer, inherited polyposis syndrome, inflammatory bowel disease, and synchronous pathology requiring surgery were excluded. Results 439 patients 220(50.1%) men; median age 67(27-97) years underwent colectomy. Of 439 patients, 346(79%) underwent preoperative endoscopy at our institution for all polyps preoperative biopsy was benign. Most of the polyps were located in the right colon (394/439, 89.7%) with majority being in the cecum (199/394, 45.3%). Polyp morphology was as follows: sessile (n=252, 57.4 %), pedunculated (n=109, 24.8%) and flat (n=78, 17.8%). Endoscopic pathology revealed high-grade dysplasia in 88 (20%) patients. Mean colonoscopic and postoperative polyp sizes were 3.0 cm (range, 0.3-10) and 2.7 cm (range, 0-11) cm, respectively (p<0.001). Final surgical pathology revealed cancer in 37 patients (8%). Polyp location, morphology and histologic types were similar between the benign and malignant polyps. Cancer stages were: stage I (23 patients), stage II (11), and stage III (3). Conclusions For the majority of endoscopically benign colonic polyps an oncologic colonic resection may be unnecessary hence adaption of advanced endoscopic resection techniques or laparoscopic assisted polypectomy should be considered. When bowel resection is needed, the resection should be performed obeying oncologic principles and techniques.
Purpose The aim of this study is to determine if resident involvement in a large cohort of laparoscopic colorectal surgery (LCS) cases negatively impacts outcomes and ultimately increases costs. ...Methods The American College of Surgeons National Surgical Quality Improvement Program database was queried for patients who underwent LCS between 2005 and 2010. Patients were classified into two groups: postgraduate year (PGY; resident involvement) or Attending Only. A subgroup analysis was then conducted among the individual PGY levels (1–2, 3–5, ≥6) and Attending Only group. Results A total of 4,836 patients were included in the PGY group and 2,418 in the Attending Only group. Mean operative time (163.9 ± 66.7 vs. 140.7 ± 67.2 minutes, P < .001) and length of hospital stay (5.8 ± 5.4 vs. 5.6 ± 5.4 days, P = .015) were significantly longer in the PGY group. Surgical and nonsurgical complications and overall morbidity and mortality rates were similar between the two groups. Each individual PGY group was associated with longer operative time ( P < .001), and PGY ≥ 6 was associated with an increased length of stay ( P < .001). Conclusion Although resident participation in LCS does not affect overall mortality or morbidity, it may negatively impact hospital costs through increased operative time and length of hospital stay. Early and intensive laparoscopy training may be necessary for improving residents' laparoscopy skills before their involvement in LCS.
Abstract Prevention of surgical site infection (SSI) has become one of the primary objectives of national quality improvement programs in U.S. hospitals. This article would discuss the impact of ...participation in the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) on the outcomes and our experience for SSI reduction. Since 2005, our institution has been an active participant of the ACS-NSQIP, and our SSI rates have been compared with other NSQIP centers; in 2006, we were found to be a high outlier institution for SSI. ACS-NSQIP greatly facilitated our understanding of the reasons for high SSI rates and patient profile that is associated with high risks for SSIs and how we can make improvements. Thus, our department initiated an SSI reduction strategy program called the “CORS SSI Prevention Bundle Project” in 2014. This effort was resulted in a statistically significant decrease in overall SSI rates from 11.8% to 6.5% after colorectal surgery. In conclusion, participation in the ACS-NSQIP offers the opportunity to compare institutional SSI rates with those of other and recognize the facts for improvement. By using this data, a bundled approach improved clinical outcomes in our experience and this was attributed to multifaceted initiatives stemming from multiple team members and comprehensive data utilization.
Abstract Background Perioperative outcomes of patients who underwent hand-assisted colorectal laparoscopic (HALS) versus open colectomy were compared using recently released procedure-targeted ...database. Methods Review was conducted using the 2012 colectomy-targeted ACS-NSQIP database. Patients were classified into two groups according to final surgical approach: HALS vs. Open (Planned). Groups were matched (1:1) based on age, gender, BMI, surgical procedure, diagnosis, ASA score, and wound classification. Multivariate logistic regression analysis was conducted for group comparison. Results Out of 7303 patients, 1740 patients were matched in each group. Open group had higher proportion of patients with preoperative dyspnea (p=0.01), ascites(p=0.01), weight loss(p<0.001), smoking history(p=0.04), and increased work relative value units(p<0.001). After adjusting for difference in baseline co-morbidities, overall morbidity, superficial, deep, and organ-space SSI, UTI, ileus, reoperation, readmission, and hospital stay were significantly higher in Open group(p<0.05). Conclusion NSQIP targeted-data demonstrated several advantages of HALS compared to open colonic resection including shorter hospital stay and lower complication rate. Further adoption of HALS technique as a bridge to straight laparoscopy or tool in difficult cases, can positively impact the short-term outcomes following colectomy when compared with open technique.
Surgical management of splenic flexure carcinoma remains controversial.
This study aimed to establish an expert international consensus on splenic flexure carcinoma management.
A 3-round online-based ...Delphi study was conducted between September 2020 and April 2021.
The first round included 18 experts from 12 different countries. For the second and third rounds, each expert in the first round was asked to invite 2 more colorectal surgeons (n = 47). Out of 47 invited experts, 89% (n = 42) participated in the second and third rounds of the consensus.
A total of 35 questions were created and sent via the online questionnaire tool.
Levels of recommendation based on voting concordance were graded as follows: more than 75% agreement was defined as strong, between 50% and 75% as moderate, and below 50% as weak.
There was moderate consensus on the definition of splenic flexure (55%) as 10 cm from either side where the distal transverse colon turns into the proximal descending colon. Also, experts recommended an abdominopelvic CT scan plus intraoperative exploration (moderate consensus, 72%) for tumor localization and cancer registry. Segmental colectomy was the preferred technique for the management of splenic flexure carcinoma in the elective setting (72%). Moderate consensus was achieved on the technique of complete mesocolic excision and central vascular ligation principles for splenic flexure carcinoma (74%). Only strong consensus was achieved on the surgical approach for minimally invasive surgery (88%).
Subjective decisions are based on individual expert clinical experience and not evidence based.
This is the first internationally conducted Delphi consensus study regarding splenic flexure carcinoma. The definition of splenic flexure remains ambiguous. To more effectively compare oncologic outcomes among different cancer registries, guidelines need to be developed to standardize each domain and avoid arbitrary definitions. See Video Abstract at http://links.lww.com/DCR/C143 .
ANTECEDENTES:El tratamiento quirúrgico del cáncer de ángulo esplénico sigue siendo controvertido.OBJETIVO:Establecer un consenso internacional de expertos sobre el manejo del cáncer del ángulo esplénico.DISEÑO:Se condujo un estudio Delphi en línea de 3 rondas entre septiembre de 2020 y febrero de 2021.ESCENARIO:La primera ronda incluyó a 18 expertos de 12 países distintos. Para la segunda y tercera rondas, a cada experto de la primera ronda se le pidió que invitara a 2 cirujanos colorrectales más de su región (n = 47). De los 47 expertos invitados, el 89% (n = 42) participó en la segunda y tercera ronda del consenso.INTERVENCIONES:Se crearon y enviaron un total de 35 preguntas a través de la herramienta de cuestionario en línea.PRINCIPALES MEDIDAS DE RESULTADO:Los niveles de recomendación basados en la concordancia de votos fueron jerarquizados de la siguiente manera: más del 75% de acuerdo se definió como fuerte, entre 50 y 75% como moderado y por debajo del 50% como débil.RESULTADOS:Hubo un consenso moderado sobre la definición de ángulo esplénico (55%) como 10 cm desde cualquier lado donde el colon transverso distal se convierte en el colon descendente proximal. Así también, los expertos recomendaron la tomografía computarizada abdominopélvica más la exploración intraoperatoria (consenso moderado, 72%) para la localización del tumor y el registro del ángulo esplénico. La colectomía segmentaria fue la técnica preferida para el tratamiento del cáncer de ángulo esplénico en el caso de ser electivo (72%). Se logró un consenso moderado sobre la técnica de escisión completa del mesocolon y los principios de ligadura vascular a nivel central para el cáncer de ángulo esplénico (74%). Solo se logró un fuerte consenso sobre el abordaje quirúrgico para la cirugía mínimamente invasiva (88%).LIMITACIONES:Decisiones subjetivas basadas en la experiencia clínica de expertos individuales y no basadas en evidencia.CONCLUSIONES:Este es el primer estudio internacional de consenso Delphi realizado sobre el cáncer de ángulo esplénico. Si bien encontramos un consenso moderado sobre las modalidades de diagnóstico preoperatorio y el manejo quirúrgico, la definición de ángulo esplénico sigue siendo ambigua. Para comparar de manera más efectiva los resultados oncológicos entre diferentes registros de cáncer, se deben desarrollar pautas para estandarizar cada dominio y evitar definiciones arbitrarias. Consulte Video Resumen en http://links.lww.com/DCR/C143 . (Traducción-Dr. Osvaldo Gauto ).
Identification of risk factors for postoperative venous thromboembolism is an important step to reduce the morbidity associated with this potentially preventable complication after elective surgery ...for patients with IBD.
This study aimed to determine the risk factors for 30-day venous thromboembolism after abdominal surgery for patients with venous thromboembolism, identify potential indications for extended thromboprophylaxis, and develop a nomogram for prediction of risk.
This is a retrospective cohort study from a prospectively collected database.
The American College of Surgeons National Surgical Quality Improvement Program Participant User File from 2005 to 2016 was used for data analysis.
All patients with IBD undergoing elective abdominopelvic bowel surgery were included.
The primary outcomes were the incidence of in-hospital and postdischarge venous thromboembolism within 30 days of the index abdominopelvic surgery.
A total of 24,182 patients met the inclusion criteria. Thirty-day total and postdischarge rates of venous thromboembolism were 2.5% (n = 614) and 1% (n =252). Forty-one percent (252/614) of venous thromboembolism events occurred after hospital discharge. Univariate analysis assessed 37 variables for association with study outcomes. On multivariate logistic regression analysis, older age, steroid use, bleeding disorders, open surgery, hypertension, longer operative time, and preoperative hospitalization were associated with venous thromboembolism before discharge and also postoperative transfusion, steroid use, pelvic and enterocutaneous fistula surgery, and longer operative time were associated with venous thromboembolism after discharge. A nomogram was constructed for each outcome, translating multivariate model parameter estimates into a visual scoring system where the estimated probability of venous thromboembolism can be calculated.
This study was limited by its retrospective nature and the limitations inherent to a database.
Given the higher risk of venous thromboembolism in patients with IBD after elective abdominopelvic surgery compared with other indications, an accurate prediction of venous thromboembolism before and after discharge using the proposed nomogram can facilitate decision making for individualized extended thromboprophylaxis in the preoperative setting as a screening tool. See Video Abstract at http://links.lww.com/DCR/A711.
