Audrey L. Stokes

Liposomal Bupivacaine Use in Transversus Abdominis Plane Blocks Reduces Pain and Postoperative Intravenous Opioid Requirement After Colorectal Surgery.

BACKGROUND: Enhanced recovery protocols frequently use multimodal postoperative analgesia to improve postoperative outcomes in patients undergoing colorectal surgery. OBJECTIVE: The purpose of this study was to evaluate liposomal bupivacaine use in transversus abdominis plane blocks on postoperative pain scores and opioid use after colorectal surgery. DESIGN: This was a retrospective cohort study comparing outcomes between patients receiving nonliposomal anesthetic (n = 104) and liposomal bupivacaine (n = 303) blocks. SETTINGS: The study was conducted at a single tertiary care center. PATIENTS: Patients included those identified within an institutional database as inpatients undergoing colorectal procedures between 2013 and 2015 who underwent transversus abdominis plane block for perioperative analgesia. MAIN OUTCOME MEASURES: The study measured postoperative pain scores and opioid requirements. RESULTS: Patients receiving liposomal bupivacaine had significantly lower pain scores for the first 24 to 36 postoperative hours. Pain scores were similar after 36 hours. The use of intravenous opioids among the liposomal bupivacaine group decreased by more than one third during the hospitalization (99.1 vs 64.5 mg; p = 0.040). The use of ketorolac was also decreased (49.0 vs 18.3 mg; p < 0.001). In subgroup analysis, the decrease in opioid use was observed between laparoscopic and robotic procedures but not with laparotomies. No significant differences were noted in the use of oral opioids, acetaminophen, or ibuprofen. Postoperative length of stay and total cost were decreased in the liposomal bupivacaine group but did not achieve statistical significance. LIMITATIONS: The study was limited by its retrospective, single-center design and heterogeneity of block administration. CONCLUSIONS: Attenuated pain scores observed with liposomal bupivacaine use were associated with significantly lower intravenous opioid and ketorolac use, suggesting that liposomal bupivacaine-containing transversus abdominis plane blocks are well aligned with the opioid-reducing goals of many enhanced recovery protocols.

Overall survival by pattern of recurrence following curative intent surgery for colorectal liver metastasis.

Following curative intent surgery (CIS) for colorectal liver metastasis (CRLM), patterns of recurrence and subsequent survival outcomes are not widely reported.

Clostridium difficile Infection Is Associated With Lower Inpatient Mortality When Managed by GI Surgeons.

BACKGROUND: Patients admitted with Clostridium difficile infection are managed in a variety of settings. If their care is inadequate, these patients can rapidly deteriorate. OBJECTIVE: The purpose of this study was to evaluate whether mortality for patients admitted with C difficile differed between medical and general/colorectal surgery services. DESIGN: This was a retrospective cohort study with multivariable logistic regression used to evaluate the effect of admitting service on in-hospital mortality rates, with propensity score matching used to validate this relationship. SETTINGS: The study was conducted at a single, tertiary care center. PATIENTS: Inpatients with a positive C difficile stool test within 24 hours of admission to medical or surgical services were identified (2005–2015) using institutional electronic data sources. MAIN OUTCOME MEASURE: We measured inpatient mortality rate. RESULTS: Of 1175 patients, 985 (83%) were admitted to medical services, whereas 190 (17%) were admitted by surgeons. Medical patients were older (63.9 vs 58.9 years; p = 0.001) and had a mean of 0.6 additional comorbidities (p < 0.001); cohorts were similar regarding vasopressors, peak white blood cell counts, and rate of intensive care unit admissions. Mortality was lower among surgery patients (2.6% vs 6.8%; p = 0.028), and logistic regression demonstrated lower odds of mortality for this group OR = 0.18 (95% CI, 0.05–0.58)). After propensity score matching for age, comorbidities, and severity of disease, this difference was confirmed (2.6% vs. 9.5%). A higher incidence of total colectomy for surgery patients (14.2% vs 0.4%) was a causal factor in their longer lengths of stay and higher total hospital costs. The time between orders for stool testing and metronidazole therapy was shorter in the surgery group (1.8 vs 3.8 hours; p = 0.002), although this trend was not observed with vancomycin therapy. LIMITATIONS: This was a retrospective study from a single institution, thereby limiting generalizability, with a lack of information regarding premorbid creatinine levels, ileus, or megacolon. CONCLUSIONS: In-hospital mortality rates for patients admitted with C difficile were lower on surgery services, perhaps in part related to higher colectomy rates.

An unexpected presentation: minimal change disease in an adult with treatment-naïve hepatitis C

Minimal change disease is the most common glomerular disease affecting children; its prevalence among adults, however, is eclipsed by other glomerular pathologies. Each of these diseases has a number of classic associations, such as membranoproliferative glomerulonephritis with hepatitis C. We report the case of a middle-aged African-American male who presented with the nephrotic syndrome and acute renal failure and was concomitantly diagnosed with a new hepatitis C infection. He also had a history of urethral strictures with potential reflux nephropathy, which—in combination with his African-American race—also made focal segmental glomerulosclerosis a diagnostic possibility. Full laboratory evaluation did not distinguish the cause of his massive proteinuria; subsequent renal biopsy ultimately revealed minimal change disease. A full course of high-dose steroids eventually reduced his proteinuria, after which his renal failure resolved as well without need for hemodialysis.

Institution of a Preoperative Stoma Education Group Class Decreases Rate of Peristomal Complications in New Stoma Patients

PURPOSE: The purpose of this study was to compare selected postoperative complications (including stomal and peristomal complications), hospital length of stay, and readmission rates in a group of patients who attended a preoperative educational intervention to a retrospective group of patients who did not receive the intervention. DESIGN: Retrospective, comparison cohort study. SUBJECTS AND SETTING: The intervention group comprised 124 patients who attended an educational session for persons with fecal ostomies at a single tertiary care center in the Northeastern United States. They were compared to findings from a group of 94 individuals who underwent ostomy surgery during a 1-year period before initiation of the class. Patients undergoing emergent procedures or who had previous stomas were excluded. We found no significant differences between the 2 cohorts with respect to age, gender, comorbidities, open versus minimally invasive procedures, or colorectal diagnoses. METHODS: A preoperative 2-hour stoma education class was led by certified WOC nurses for all patients undergoing colorectal surgeries in which the creation of a stoma was anticipated. This session included a didactic portion outlining postoperative expectations in the management of new ostomies (including dietary changes, prevention of dehydration, and an overview of ostomy supplies), as well as a hands-on portion to practice stoma care skills. We compared postoperative complications within 30 days (particularly stoma-related complications, including pouch leakage due to loss of seal, and peristomal skin irritation) between the group attending the education session and the control group. We also compared length of stay and 30-day readmission rates. RESULTS: Patients who participated in the educational intervention experienced significantly fewer peristomal complications than did patients in the historic control group (44.7% vs 20.2%, P = .002). Logistic regression analysis revealed that participation in the group was associated with a lower likelihood of peristomal skin complications (odds ratio = 0.35; 95% confidence interval, 0.18-0.67). Their length of stay (median 6 days vs 5 days, P = NS), and the proportion who experienced 30-day readmission (20.2% vs 15.3%, P = NS), did not significantly differ. CONCLUSIONS: A preoperative stoma education group class significantly reduced the likelihood of frequent leakage from the ostomy pouching system and peristomal skin irritation.