Brad Champagne

Considerations and complications in patients undergoing ileal pouch anal anastomosis.

Total proctocolectomy with ileal pouch anal anastomosis (IPAA) preserves fecal continence as an alternative to permanent end ileostomy in select patients with ulcerative colitis and familial adenomatous polyposis. The procedure is technically demanding, and surgical complications may arise. This article outlines both the early and late complications that can occur after IPAA, as well as the workup and management of these potentially morbid conditions.

Endoscopic mucosal resection with full-thickness closure for difficult polyps: a prospective clinical trial

BACKGROUND Large flat polyps may be more amenable to endoscopic resection if an endoluminal method for full-thickness closure were available. OBJECTIVE Assessment of feasibility of endoluminal full-thickness closure. DESIGN Prospective, open-label, interventional study. SETTING Tertiary referral center. PATIENTS Patients referred to surgery for endoscopically unresectable polyps. INTERVENTIONS Endoscopic resection of colon polyps with full-thickness closure of the resection site under laparoscopic observation by using a novel needle and T-tag tissue apposition system. MAIN OUTCOME MEASUREMENTS Feasibility and efficacy of tissue apposition with the TAS during procedure and safety at 3-month follow-up. RESULTS Nineteen patients referred with unresectable polyps at initial colonoscopy were enrolled. Five patients had successful endoscopic polypectomy and did not require closure of the resulting defect. In 6 patients, the polyp could not be resected endoscopically and surgical resection was performed. Use of the TAS was attempted in 8 and successfully deployed in 7 patients; there was 1 device malfunction. Deployment of the tags through the needle could be performed more safely under laparoscopic guidance when the resection site was visible from the peritoneal cavity. The location of the tags could not be safely determined when the needle was directed toward the retroperitoneal or mesenteric site. There were no long-term complications. Colonoscopy at a 3-month follow-up showed normal healed mucosa with the sutures and anchoring devices in place. LIMITATIONS Small number of patients, single-center feasibility study without control arm. CONCLUSIONS Full-thickness endoluminal closure of large polypectomy sites in humans is feasible for selected difficult polyps. Closure should be performed with concurrent laparoscopic guidance to maximize safety. ( CLINICAL TRIAL REGISTRATION NUMBER NCT00553436.).

Emergency laparoscopic colectomy: does it measure up to open?

BACKGROUND Laparoscopic colectomy has become the standard of care for elective resections; however, there are few data regarding laparoscopy in the emergency setting. METHODS By using a database with prospectively collected data, we identified 94 patients who underwent an emergency colectomy between August 2005 and July 2008. Laparoscopic surgeries were performed in 42 patients and were compared with 25 patients who were suitable for laparoscopy but received open colectomy. RESULTS The groups had similar demographics with no differences in age, sex, or surgical indications. Blood loss was lower (118 vs 205 mL; P < 0.01) and the postoperative stay was shorter (8 vs 11 d; P = 0.02) in the laparoscopic patients, and perioperative mortality rates were similar between the 2 groups (1 vs 3; P = 0.29). CONCLUSIONS With increasing experience, laparoscopic colectomy is a feasible option in certain emergency situations and is associated with shorter hospital stay, less morbidity, and similar mortality to that of open surgery.

Clinical results of intraoperative radiation therapy for patients with locally recurrent and advanced tumors having colorectal involvement.

BACKGROUND Intraoperative radiation therapy (IORT) may be useful in the treatment of patients who have a locally advanced primary and recurrent abdominopelvic neoplasm with colorectal involvement. METHODS A retrospective review of colorectal cancer patients treated since 1999 with IORT using the Mobetron device. RESULTS Forty patients underwent colectomy or proctectomy with IORT. All patients had evidence of local extension to contiguous structures and based on preoperative staging were deemed by the operating surgeon as being likely to have incomplete resection. IORT was selected as an alternative to sacrectomy or exenteration for an expected close margin in 10 patients. Mean survival was 35 +/- 26 months, and 1 patient had local recurrence. CONCLUSIONS The introduction of IORT has allowed a selective treatment approach to locally advanced primary and recurrent neoplasms, which traditionally would have been deemed unresectable. Using IORT, extended resections may be avoided in selected high-risk patients with low risk of local recurrence and minimal morbidity.

The impact of race on outcomes following emergency surgery: an American College of Surgeons National Surgical Quality Improvement Program assessment

BACKGROUND Despite significant evolutions in health care, outcome discrepancies exist among demographic cohorts. We sought to determine the impact of race on emergency surgery outcomes. METHODS This is a retrospective review of the American College of Surgeons National Surgical Quality Improvement Program database (2005 through 2009) for all patients aged ≥16 years undergoing emergency abdominal surgery. Primary outcomes included morbidity and mortality. RESULTS We identified 75,280 patients (mean age 48.2 ± 19.9 years, 51.7% female; 79% white, 9.9% black, 5.0% Hispanic, 3.7% Asian, 1.3% American Indian or Alaskan, .2% Pacific Islander). Annual rates of emergency operations ranged from 7.3% to 8.5% (P = .22). The overall complication (18.6%) and mortality rate (4.6%) was highest in the black population (24.3%, 5.3%) followed by whites (18.7%, 4.6%), with the lowest rate in Hispanic (11.7%, 1.8%) and Pacific Islander populations (10.2%, 1.8%; P < .001). Compared with whites, blacks had a 1.25-fold (1.17 to 1.34; P < .001) increased risk of complications, but similar mortality (P = .168). When combining minorities, overall complications were 1.059-fold (1.004 to 1.12; P = .034) higher, however, mortality was reduced 1.7-fold (1.07 to 1.34; P = .001). CONCLUSIONS Following emergency abdominal surgery, minority race is independently associated with increased complications and reduced mortality.

The impact of Model for End-Stage Liver Disease-Na in predicting morbidity and mortality following elective colon cancer surgery irrespective of underlying liver disease.

BACKGROUND The Model for End-Stage Liver Disease Sodium Model (MELD-Na) is a validated scoring system that uses bilirubin, international normalized ratio, serum creatinine, and sodium to predict mortality in cirrhotic patients awaiting liver transplantation. The aim of this study was to identify the utility of MELD-Na to predict patient outcomes, with and without liver disease, after elective colon cancer surgery. METHODS A review of the American College of Surgeons National Surgical Quality Improvement Program database (2005 to 2010) was conducted to calculate risk-adjusted 30-day outcomes using regression modeling. RESULTS A total of 10,842 patients (mean age, 68 years; 51% women) were included. MELD-Na scores were higher in men (10.2 vs 9.1, P < .001) and in open procedures (9.9 vs 9.1, P < .001). The overall complication and mortality rates were 26.3% and 3.3%, respectively. Incremental increases in MELD-Na score correlated with a 1.2% increase in mortality and a 1.1% increase in complications. On multivariate analysis, complications increased with MELD-Na score (odds ratio [OR], 1.05 per 1 point increase; 95% confidence interval [CI], 1.038 to 1.066). MELD-Na score was also associated with increased mortality (OR, 1.13; 95% CI, 1.1 to 1.16), along with ascites (OR, 5.7; 95% CI, 3.7 to 8.8) and corticosteroids (OR, 2.1; 95% CI, 1.3 to 3.3). CONCLUSIONS Elevated preoperative MELD-Na score is significantly associated with worse outcomes after elective resection for colon cancer.

Validation of a novel postoperative quality-of-life scoring system.

BACKGROUND No specific scoring system exists for the assessment of postoperative quality of life (QOL) after major abdominal surgery. This study prospectively validates PQL, a novel prospective scoring system in patients having laparoscopic or open major abdominal colorectal surgery. METHODS Six experienced surgeons developed the questionnaire. Twenty patients reviewed and selected the most relevant questions, yielding 14 questions. One hundred patients undergoing a variety of colorectal procedures completed the questionnaire preoperatively, and on postoperative days (POD) 1, 2, 4, 8, 12, 30, and 60. Internal validation was assessed by Cronbachs alpha and factor analysis. RESULTS Cronbachs alpha revealed excellent internal consistency, ranging from .84 to .94 at all time points, even at POD 1 when Cronbachs alpha was .79, demonstrating that the items in the questionnaire measured the same underlying construct. Factor analysis consistently loaded at each follow-up time on the same 2 factors. CONCLUSIONS Factor analysis consistently loaded at each follow-up time on the same 2 factors, designated the PQL Symptom Score and the PQL Recover Score.

Improving Outcomes and Cost-Effectiveness of Colorectal Surgery

In order to truly make an impact on improving the cost effectiveness, and most importantly, the outcomes of patients undergoing colorectal surgery, all aspects of care need to be scrutinized, re-evaluated, and refined. To accomplish this, everything from the way we train surgeons to the adoption of a minimally invasive approach for colorectal disease, along with the use of adjunct intraoperative measures to decrease morbidity and mortality, may all need to be incorporated within an ERAS program. Only then will this approach lead the provider to a patient-centric care plan which can successfully reduce metrics such as morbidity, mortality, and length of stay (even with the obligatory readmission rate) and provide it all at a lower cost of care.

Acute Management of Stoma-Related Colocutaneous Fistula by Temporary Placement of a Self-Expanding Plastic Stent

Colocutaneous fistulas are frequently the result of complications related to previous operative procedures and are a major cause of morbidity. Most are initially treated conservatively, with a large percentage eventually requiring further surgery for definitive treatment. The use of a temporary colonic stent for the management of colostomy-related colocutaneous fistula has not been previously described. Two patients with colocutaneous fistula related to end colostomies and opening into midline laparotomy wounds were treated by temporary plastic stenting. A removable Polyflex silicone stent was inserted into the stoma. Stent redeployment was needed on several occasions following partial stent expulsion. Midline wound healing was achieved in both cases by 6 weeks post—stent insertion, and complete fistula closure occurred in 1 case. Temporary stent placement in certain cases may aid in the management of a colocutaneous fistula associated with a colostomy to allow fecal diversion from wounds and aid fistula closure.

A nationwide assessment comparing nonelective open with minimally invasive complex colorectal procedures.

The use of minimally invasive colorectal surgery has increased greatly for both benign and malignant disease. Studies evaluating complex procedures have been largely limited to elective indications. We aimed to compare the outcome of a laparoscopic with an open transverse (TC) and total abdominal colectomy (TAC) in the nonelective setting.