Cary B. Aarons

Management of malignant colon polyps:Current status and controversies

Colon cancer remains a significant clinical problem worldwide and in the United States it is the third most common cancer diagnosed in men and women. It is generally accepted that most malignant neoplasms of the colon arise from precursor adenomatous polyps. This stepwise progression of normal epithelium to carcinoma, often with intervening dysplasia, occurs as a result of multiple sequential, genetic mutations-some are inherited while others are acquired. Malignant polyps are defined by the presence of cancer cells invading through the muscularis mucosa into the underlying submucosa (T1). They can appear benign endoscopically but the presence of malignant invasion histologically poses a difficult and often controversial clinical scenario. Emphasis should be initially focused on the endoscopic assessment of these lesions. Suitable polyps should be resected en-bloc, if possible, to facilitate thorough evaluation by pathology. In these cases, proper attention must be given to the risks of residual cancer in the bowel wall or in the surrounding lymph nodes. If resection is not feasible endoscopically, then these patients should be referred for surgical resection. This review will discuss the important prognostic features of malignant polyps that will most profoundly affect this risk profile. Additionally, we will discuss effective strategies for their overall management.

Perioperative fluid restriction.

Perioperative fluid management of the colorectal surgical patient has evolved significantly over the last five decades. Older notions espousing aggressive hydration have been shown to be associated with increased complications. Newer data regarding fluid restriction has shown an association with improved outcomes. Management of perioperative fluid administration can be considered in three primary phases: In the preoperative phase, data suggests that avoidance of preoperative bowel preparation and avoidance of undue preoperative dehydration can improve outcomes. Although the type of intraoperative fluid given does not have a significant effect on outcome, data do suggest that a restrictive fluid regimen results in improved outcomes. Finally, in the postoperative phase of fluid management, a fluid-restrictive regimen, coupled with early enteral feeding also seems to result in improved outcomes.

Laparoscopic surgery for crohn disease: a brief review of the literature.

Crohn disease remains a challenging clinical entity, both medically and surgically. It frequently presents in early adulthood and imposes a lifetime exposure to chronic inflammation that can affect the entire gastrointestinal tract. Although the mainstay of therapy is treatment with immunomodulating drugs, ∼70 to 90% of patients with Crohn disease will ultimately require surgery. Furthermore, there are high rates of symptomatic recurrences that may also require surgical intervention over time. There is no definitive cure for Crohn disease and surgery is reserved for failed medical therapy or the complications of the disease, namely, obstruction, septic complications (abscess, perforation), and fistulas. However, the robust inflammatory environment during these periods is not always conducive to a minimally invasive surgical approach. Despite the inherent technical challenges, the literature has increasingly shown that laparoscopy for Crohn disease, in the appropriate setting, is feasible and safe. In fact, it offers many advantages, which are particularly beneficial to this subset of patients, such as fewer wound complications, a shortened hospital course, less tissue trauma and subsequent adhesion formation, and earlier resumption of oral intake and bowel function.

Lymph node identification following neoadjuvant therapy in rectal cancer: A stage-stratified analysis using the surveillance, epidemiology, and end results (SEER)-medicare database

Neoadjuvant chemoradiation (nCRT) for rectal adenocarcinoma reduces lymph node (LN) identification following surgical resection. We sought to evaluate the relationship between LN identification following nCRT and disease‐specific survival (DSS), stratified by pathologic stage.

Racial disparities in surgical outcomes of patients with Inflammatory Bowel Disease

BACKGROUNDnInflammatory Bowel Disease (IBD) has not historically been a focus of racial health disparities research. IBD has been increasing in the black community. We hypothesized that outcomes following surgery would be worse for black patients.nnnMETHODSnA retrospective cohort study of death and serious morbidity (DSM) of patients undergoing surgery for IBD was performed using data from the American College of Surgeons National Surgical Quality Improvement Program (NSQIP 2011-2014). Multivariable logistic regression modeling was performed to evaluate associations between race and outcomes.nnnRESULTSnAmong 14,679 IBD patients, the overall rate of DSM was 20.3% (white: 19.3%, black 27.0%, other 23.8%, pu202f<u202f0.001). After adjustment, black patients remained at increased risk of DSM compared white patients (OR: 1.37; 95% CI 1.14-1.64).nnnCONCLUSIONSnBlack patients are at increased risk of post-operative DSM following surgery for IBD. The elevated rates of DSM are not explained by traditional risk factors like obesity, ASA class, emergent surgery, or stoma creation.

Colon Cancer: Preoperative Evaluation and Staging

The preoperative assessment of patients with colorectal cancer (CRC) often requires a multidisciplinary approach, involving a complete endoscopic evaluation as well as both clinical and radiographic staging. In addition to providing a concrete diagnosis, histologic review by the pathologist imparts valuable information about tumor grade and other important prognostic features, which will be discussed in greater detail in this chapter. A thorough history and physical examination rounds out the initial evaluation and provides the surgeon with vital information that may influence operative planning.

Using community outreach to explore health-related beliefs and improve surgeon-patient engagement

BACKGROUNDnFostering surgeon engagement in community outreach was recently identified as a major priority toward reducing health care disparities in surgery. We aimed to increase surgeon engagement in the local community, understand prevalent beliefs, and identify educational opportunities in the local community regarding cancer screening and treatment using community outreach.nnnMATERIALS AND METHODSnIn collaboration with the universitys cancer center, the medical student surgical interest group, surgical faculty, and residents developed a community outreach program. The program consisted of networking time, a formal presentation, panel discussion, and question and answer time. A survey was distributed to all participants before the educational session, and a program assessment was distributed at the programs conclusion.nnnRESULTSnA total of 256 community members and 22 surgical volunteers attended at least one of the two events. Attendees were insured (175; 92.7%), female (151; 80%), and African-American (176; 93.1%), with a mean age of 61xa0y (standard deviation 14.0). About 56 participants (29.6%) were unwilling to undergo screening colonoscopy. Forty-eight respondents (25.4%) endorsed mistrust in doctors and 25% believed surgery causes cancer to spread; a significantly higher proportion of them aged <60xa0y old. About 113 (59.8%) and 87 (46.1%) misunderstood the definitions of malignant and metastatic, respectively. Males were more unsure than females (61% versus 55%, Pxa0=xa00.5 and 70% versus 55%; Pxa0=xa00.01).nnnCONCLUSIONSnRisk perceptions related to fatalism, mistrust, or lack of knowledge were prevalent. The ability of surgeons to reach at-risk populations in the prehospital setting is an important opportunity waiting to be capitalized upon.