Avery S. Walker

Future directions for the early detection of colorectal cancer recurrence.

Surgical resection remains a mainstay of treatment and is highly effective for localized colorectal cancer. However, ~30-40% of patients develop recurrence following surgery and 40-50% of recurrences are apparent within the first few years after initial surgical resection. Several variables factor into the ultimate outcome of these patients, including the extent of disease, tumor biology, and patient co-morbidities. Additionally, the time from initial treatment to the development of recurrence is strongly associated with overall survival, particularly in patients who recur within one year of their surgical resection. Current post-resection surveillance strategies involve physical examination, laboratory, endoscopic and imaging studies utilizing various high and low-intensity protocols. Ultimately, the goal is to detect recurrence as early as possible, and ideally in the asymptomatic localized phase, to allow initiation of treatment that may still result in cure. While current strategies have been effective, several efforts are evolving to improve our ability to identify recurrent disease at its earliest phase. Our aim with this article is to briefly review the options available and, more importantly, examine emerging and future options to assist in the early detection of colon and rectal cancer recurrence.

An evaluation of colonoscopy surveillance guidelines: are we actually adhering to the guidelines?

BACKGROUND National guidelines put forth by the American Cancer Society, the US Multi-Society Task Force on Colorectal Cancer, and the American College of Gastroenterology provide recommendations regarding colorectal cancer screening and follow-up surveillance. Practice patterns may differ from these guidelines. This study analyzes the concordance between a tertiary equal access system and national guidelines for colorectal cancer and polyp surveillance. METHODS We performed a retrospective database review of all patients at a single institution undergoing screening colonoscopy from 2010 to 2011. Patient demographics, indication for colonoscopy, pathologic findings, and follow-up recommendations documented by the provider were analyzed. Multivariate analysis was performed in an attempt to identify predictors of discordant recommendations. RESULTS One thousand four hundred twenty patients were identified (mean age, 54.3 ± 7.7 years, 48.6% women). The gastroenterology service performed the majority of colonoscopies (87.2%) compared with the surgery service (11.6%). The major indications were routine screening (84.4%) and a strong family history of colorectal cancer (12.2%). The adenoma detection rate for the entire cohort was 27.4%. Other pathologic conditions identified included hyperplastic polyps (16%), lymphoid aggregates (3.5%), and invasive adenocarcinoma (0.1%). Overall, follow-up recommendations correlated with established guidelines in 97% of cases. By multivariate analysis, only the final pathologic finding of lymphoid aggregates was associated with discordant recommendations (odds ratio [OR], 4.62; 95% confidence interval [CI], 1.64 to 12.99; P = .004). When comparing discordant recommendations between specialties, there was a statistically significant difference between gastroenterology (1.6%) and surgery (7.6%) (P < .0001) providers; surgeons trended toward recommending earlier follow-up examinations (P = .37). CONCLUSIONS Overall, surveillance recommendations correlated well with current national guidelines. Concordance rates were higher with gastroenterologists in this cohort. Alterations based on final pathologic examination and individual cases remain clinically important.

Cefazolin-Induced Neutropenia and Thrombocytopenia Following Trauma: A Case Report

Cefazolin, a first generation cephalosporin, is a rare cause of cyclical fevers, neutropenia, and thrombocytopenia following surgical prophylaxis. We present the case of an otherwise healthy 21-year-old male who sustained a 50-cm laceration to his chest and abdomen. He received emergency department prophylaxis with cefazolin and surgical repair. Subsequently, he developed cyclical fevers, neutropenia, and thrombocytopenia, all of which resolved after antibiotic discontinuation. This is the first case report in which the perioperative administration of cefazolin following trauma resulted in significant neutropenia and thrombocytopenia. Also discussed in this report are the etiology, workup, and treatment of cefazolin-induced neutropenia.

Predictors of appendiceal perforation in an equal access system

BACKGROUND Discrepancies in socioeconomic factors have been associated with higher rates of perforated appendicitis. As an equal-access health care system theoretically removes these barriers, we aimed to determine if remaining differences in demographics, education, and pay result in disparate outcomes in the rate of perforated appendicitis. MATERIALS AND METHODS All patients undergoing appendectomy for acute appendicitis (November 2004-October 2009) at a tertiary care equal access institution were categorized by demographics and perioperative data. Rank of the sponsor was used as a surrogate for economic status. A multivariate logistic regression model was performed to determine patient and clinical characteristics associated with perforated appendicitis. RESULTS A total of 680 patients (mean age 30±16 y; 37% female) were included. The majority were Caucasian (56.4% [n=384]; African Americans 5.6% [n=38]; Asians 1.9% [n=13]; and other 48.9% [n=245]) and enlisted (87.2%). Overall, 6.4% presented with perforation, with rates of 6.6%, 5.8%, and 6.7% (P=0.96) for officers, enlisted soldiers, and contractors, respectively. There was no difference in perforation when stratified by junior or senior status for either officers or enlisted (9.3% junior versus 4.40% senior officers, P=0.273; 6.60% junior versus 5.50% senior enlisted, P=0.369). On multivariate analysis, parameters such as leukocytosis and temperature, as well as race and rank were not associated with perforation (P=0.7). Only age had a correlation, with individuals aged 66-75 y having higher perforation rates (odds ratio, 1.04; 95% confidence interval, 1.02-1.05; P<0.001). CONCLUSIONS In an equal-access health care system, older age, not socioeconomic factors, correlated with increased appendiceal perforation rates.

Colonic decompression and direct intraluminal medical therapy for Clostridium difficile‐associated megacolon using a tube placed endoscopically in the proximal colon

Urgent colectomy for severe Clostridium difficile infection can be associated with increased morbidity and mortality. We aimed to use endoscopic methods for treatment.

Biomaterials in the treatment of anal fistula: hope or hype?

Anal fistula (AF) presents a chronic problem for patients and colorectal surgeons alike. Surgical treatment may result in impairment of continence and long-term risk of recurrence. Treatment options for AFs vary according to their location and complexity. The ideal approach should result in low recurrence rates and minimal impact on continence. New technical approaches involving biologically derived products such as biological mesh, fibrin glue, fistula plug, and stem cells have been applied in the treatment of AF to improve outcomes and decrease recurrence rates and the risk of fecal incontinence. In this review, we will highlight the current evidence and describe our personal experience with these novel approaches.

Mesenteric irritation as a means to prevent internal hernia formation after laparoscopic gastric bypass surgery

INTRODUCTION Internal hernias (IHs) occur more frequently in laparoscopic gastric bypass (LGB) surgery than in the classic open procedure. The incidence of small bowel obstruction after LGB ranges from 1.8% and 9.7%. Some have theorized that this occurs because of decreased adhesion formation. METHODS The mesenteric irritation technique is performed after closure of the jejunojejunal mesenteric defect with a running 2-0 silk suture. A sponge is then rubbed against the closed visceral peritoneal mesentery until petechiae are visualized on the surface of the mesentery. RESULTS In all, 338 LGBs were performed using the standard closure technique with an IH incidence of 5.3% (range 1.7% to 7.8%). When using the mesenteric irritation technique, 72 LGBs were performed with an IH rate of 1.4% (P = .13). CONCLUSIONS Mesenteric irritation is a novel technique performed with minimal additional time and no additional equipment. This technique may prove beneficial in reducing the incidence of IHs.

The weekend effect: does time of admission impact management and outcomes of small bowel obstruction?

Aims: To determine whether day and time of admission influences the practice patterns of the admitting general surgeon and subsequent outcomes for patients diagnosed with small bowel obstruction. Methods: A retrospective database review was carried out, covering patients admitted with the presumed diagnosis of partial small bowel obstruction from 2004–2011. Results: A total of 404 patients met the inclusion criteria. One hundred and thirty-nine were admitted during the day, 93 at night and 172 on the weekend. Overall 30.2% of the patients were managed operatively with no significant difference between the groups (P = 0.89); however, of patients taken to the operating room, patients admitted during the day received operative intervention over 24 hours earlier than those admitted at a weekend, 0.79 days vs 1.90 days, respectively (P = 0.05). Overall mortality was low at 1.7%, with no difference noted between the groups (P = 0.35). Likewise there was no difference in morbidity rates between the three groups (P = 0.90). Conclusions: Despite a faster time to operative intervention in those patients admitted during the day, our study revealed that time of admission does not appear to correlate to patient outcome or mortality.

What is the Real Cost of an Overnight Stay After an Ambulatory General Surgical Procedure

INTRODUCTION Outpatient surgery is performed widely throughout the Army Medical Command (MEDCOM). It is common practice throughout Medical Command to admit barracks dwelling active duty service members (ADSMs) undergoing ambulatory surgical procedures for overnight observation. We hypothesized that overnight observation of these individuals has not prevented adverse outcomes that would have otherwise occurred if the patient had been discharged to the barracks. METHODS We reviewed the postoperative course of all ADSMs undergoing ambulatory surgery with subsequent overnight hospital stay because of primary barracks residence. Procedures included hernia repair, lipoma excisions, and pilonidal cystectomies. Inclusion criteria were ADSMs who stayed overnight purely on the basis of their military barracks residence. RESULTS 145 patients met our inclusion criteria. Their mean age was 23 ± 3.2, 90.9% were males. The mean hospital length of stay was 24 ± 11.4 hours. There were four (2.78%) postoperative complications, three patients with postoperative urinary retention, and one patient with mild bleeding from a pilonidal excision site, all within 8 hours postoperatively. No adverse outcomes were noted during the period of their hospitalization. CONCLUSION Barracks dwelling ADSMs do not have adverse outcomes during their inpatient observational hospitalization. An outpatient escort would be sufficient to ensure adequate observation.

Quality Improvement: Are Fast Track Pathways for Laparoscopic Surgery Needed?

Multiple studies have been performed demonstrating the benefits of an enhanced recovery program following a wide breadth of surgical disciplines, including more recent reports showing significant benefits of enhanced recovery protocols for patients undergoing a laparoscopic colectomy. This has held true in both comparisons of an open versus minimally invasive approach, as well as when comparing enhanced recovery pathways to traditional perioperative care strategies. While most providers are now well versed in the concept of enhanced recovery, the individual practice and components often vary in number and nature. However, the basic principles of ensuring this program spans the preoperative, intraoperative, and postoperative settings, along with a multidisciplinary mandated “buy-in”, are necessary to ensure maximal effectiveness regardless of the institution or procedure.