Charles M. Friel

Wound Infection after Elective Colorectal Resection

Introduction:Surgical site infection (SSI) is a potentially morbid and costly complication following major colorectal resection. In recent years, there has been growing attention placed on the accurate identification and monitoring of such surgical complications and their costs, measured in terms of increased morbidity to patients and increased financial costs to society. We hypothesize that incisional SSIs following elective colorectal resection are more frequent than is generally reported in the literature, that they can be predicated by measurable perioperative factors, and that they carry substantial morbidity and cost. Methods:Over a 2-year period at a university hospital, data on all elective colorectal resections performed by a single surgeon were retrospectively collected. The outcome of interest was a diagnosis of incisional SSI as defined by the Center of Disease Control and Prevention. Variables associated with infection, as identified in the literature or by experts, were collected and analyzed for their association with incisional SSI development in this patient cohort. Multivariate analysis by stepwise logistic regression was then performed on those variables associated with incisional SSI by univariate analysis to determine their prognostic significance. The incidence of SSI in this study was compared with the rates of incisional SSI in this patient population reported in the literature, predicted by a nationally based system monitoring nosocomial infection, and described in a prospectively acquired intradepartmental surgical infection data base at our institution. Results:One hundred seventy-six patients undergoing elective colorectal resection were identified for evaluation. The mean patient age was 62 ± 1.2 years, and 54% were men. Preoperative diagnoses included colorectal cancer (57%), inflammatory bowel disease (20%), diverticulitis (10%), and benign polyp disease (5%). SSIs were identified in 45 patients (26%). Twenty-two (49%) SSIs were detected in the outpatient setting following discharge. Of all preoperative and perioperative variables measured, increasing patient body mass index and intraoperative hypotension independently predicted incisional SSI. Although we could not measure statistically increased length of hospital stay associated with SSI, a representative population of patients with SSI accumulated a mean of

Expression, Localization, and Functional Activity of TL1A, a Novel Th1-Polarizing Cytokine in Inflammatory Bowel Disease

6200/patient of home health expenses related to wound care. Our rates of SSI were substantially higher than that reported generally in the literature, predicted by the National Nosocomial Infection System, or described by our own institutional surgical infection data base. Conclusions:The incidence of incisional SSI in patients undergoing elective colorectal resection in our cohort was substantially higher than generally reported in the literature, the NNIS or predicted by an institutional surgical infection complication registry. Although some of these differences may be attributable to patient population differences, we believe these discrepancies highlight the potential limitations of systematic outcomes measurement tools which are independent of the primary clinical care team. Accurate surgical complication documentation by the primary clinical team is critical to identify the true frequency and etiology of surgical complications such as incisional SSI, to rationally approach their reduction and decrease their associated costs to patients and the health care system.

Salvage Radical Surgery After Failed Local Excision for Early Rectal Cancer

TL1A is a novel TNF-like factor that acts as a costimulator of IFN-γ secretion through binding to the death domain-containing receptor, DR3. The aim of this study was to test the hypothesis that TL1A may play an important role in inflammatory bowel disease (IBD) by functioning as a Th1-polarizing cytokine. The expression, cellular localization, and functional activity of TL1A and DR3 were studied in intestinal tissue specimens as well as isolated lamina propria mononuclear cells from IBD patients and controls. TL1A mRNA and protein expression was up-regulated in IBD, particularly in involved areas of Crohn’s disease (CD; p < 0.03 vs control). TL1A production was localized to the intestinal lamina propria in macrophages and CD4+ and CD8+ lymphocytes from CD patients as well as in plasma cells from ulcerative colitis patients. The amount of TL1A protein and the number of TL1A-positive cells correlated with the severity of inflammation, most significantly in CD. Increased numbers of immunoreactive DR3-positive T lymphocytes were detected in the intestinal lamina propria from IBD patients. Addition of recombinant human TL1A to cultures of PHA-stimulated lamina propria mononuclear from CD patients significantly augmented IFN-γ production by 4-fold, whereas a minimal effect was observed in control patients. Our study provides evidence for the first time that the novel cytokine TL1A may play an important role in a Th1-mediated disease such as CD.

Standardization of Care: Impact of an Enhanced Recovery Protocol on Length of Stay, Complications, and Direct Costs after Colorectal Surgery

AbstractOBJECTIVES: Local recurrence after transanal excision of rectal cancer is often amenable to salvage radical proctectomy, but the long-term results remain unknown. This study was designed to determine the outcome of salvage radical surgery after failed local excision in patients with early rectal cancer. METHODS: We retrospectively reviewed the charts of 29 patients who underwent salvage radical surgery for local recurrence after a full-thickness transanal excision for Stage I rectal cancer. End points included local and distant recurrences and disease-free survival after salvage radical surgery. Comparisons between groups were performed by chi-squared test. RESULTS: Recurrence involved the rectal wall in 26 patients (90 percent) and was purely extrarectal in only 3 (10 percent). Mean time between local excision and radical operation was 26 months. The resection was considered curative in 23 patients (79 percent). The stage of the recurrent tumor was more advanced than the primary tumor in 27 patients (93 percent). At a mean follow-up of 39 (range, 2–147) months after radical surgery, 17 patients (59 percent) remained free of disease. The disease-free survival rate was 68 percent for patients with tumors with favorable histology vs. 29 percent for patients with tumors with unfavorable histology. CONCLUSION: Salvage surgery for recurrence after local excision of rectal cancers may not provide results equivalent to those of initial radical treatment. In the present study the poor results of salvage surgery emphasize the importance of appropriate selection of the initial treatment of Stage I rectal cancer.

Intravenous lidocaine is as effective as epidural bupivacaine in reducing ileus duration, hospital stay, and pain after open colon resection: a randomized clinical trial.

BACKGROUND Colorectal surgery is associated with considerable morbidity and prolonged length of stay (LOS). Recognizing the need for improvement, we implemented an enhanced recovery (ER) protocol for all patients undergoing elective colorectal surgery at an academic institution. STUDY DESIGN A multidisciplinary team implemented an ER protocol based on: preoperative counseling with active patient participation, carbohydrate loading, multimodal analgesia with avoidance of intravenous opioids, intraoperative goal-directed fluid resuscitation, immediate postoperative feeding, and ambulation. Discharge requirements remained identical throughout. A before and after study design was undertaken comparing patients before (August 2012 to February 2013) and after implementation of an ER protocol (August 2013 to February 2014). Risk stratification was performed using the NSQIP risk calculator to calculate the predicted LOS for each patient based on 23 variables. RESULTS One hundred and nine consecutive patients underwent surgery within the ER protocol compared with 98 consecutive historical controls (conventional). The risk-adjusted predicted LOS was similar for each group at 5.1 and 5.2 days. Substantial reductions were seen in LOS, morphine equivalents, intravenous fluids, return of bowel function, and overall complications with the ER group. There was a

Anastomotic Leak and the Loop Ileostomy: Friend or Foe?

7,129/patient reduction in direct cost, corresponding to a cost savings of

Morbidity, Mortality, Cost, and Survival Estimates of Gastrointestinal Anastomotic Leaks

777,061 in the ER group. Patient satisfaction as measured by Press Ganey improved considerably during the study period. CONCLUSIONS Implementation of an ER protocol led to improved patient satisfaction and substantial reduction in LOS, complication rates, and costs for patients undergoing both open and laparoscopic colorectal surgery. These data demonstrate that small investments in the perioperative environment can lead to large returns.

A method for estimating the risk of surgical site infection in patients with abdominal colorectal procedures.

Background: Both postoperative epidural analgesia and intravenous (IV) infusion of local anesthetic have been shown to shorten ileus duration and hospital stay after colon surgery when compared with the use of systemic narcotics alone. However, they have not been compared directly with each other. Methods: Prospective, randomized clinical trial was conducted comparing the 2 treatments in open colon surgery patients. Before induction of general anesthesia, patients were randomized either to epidural analgesia (bupivacaine 0.125% and hydromorphone 6 &mgr;g/mL were started at 10 mL/hr within 1 hr of the end of surgery) or IV lidocaine (1 mg/min in patients <70 kg, 2 mg/min in patients ≥70 kg). Markers of return of bowel function, length of stay, postoperative pain scores, systemic analgesic requirements, and adverse events were recorded and compared between the 2 groups in an intent-to-treat analysis. Results: Study enrollment took place from April 2005 to July 2006. Twenty-two patients were randomized to IV lidocaine therapy and 20 patients to epidural therapy. No statistically significant differences were found between groups in time to return of bowel function or hospital length of stay. The median pain score difference was not statistically significant. No statistically significant differences were found in pain scores for any specific postoperative day or in analgesic consumption. Conclusions: No differences were observed between groups in terms of return of bowel function, duration of hospital stay, and postoperative pain control, suggesting that IV infusion of local anesthetic may be an effective alternative to epidural therapy in patients in whom epidural anesthesia is contraindicated or not desired.

Implications of laparoscopy on surgery residency training

PurposeAnastomotic disruption is an uncommon but morbid complication of colon and rectal surgery. This study was designed to evaluate the use of proximal diversion and surgical drainage as an alternative to anastomotic resection in the operative management of patients with anastomotic complications.MethodsA retrospective chart review was undertaken of all patients on the colon and rectal surgery service at an academic medical center requiring operative intervention for an anastomotic complication between 1998 and 2005. Demographic data, operative management, morbidity, and mortality were collected and analyzed for each patient.ResultsTwenty-seven patients with anastomotic leaks were included in the study. Nineteen patients were managed with proximal diversion and surgical drainage, six patients had resection of their anastomosis and creation of an end colostomy, and two patients were treated by primary reanastomosis. There was 0 percent mortality. Sixty-three percent of the patients treated with proximal diversion had restoration of intestinal continuity vs. 33 percent of the patients who had the anastomosis resected. Of the 13 patients treated with proximal diversion who underwent fluoroscopic evaluation, 92 percent were normal without evidence of persistent leak or stricture.ConclusionsBased on this retrospective study, proximal diversion without resection of the anastomosis seems to be a safe and effective alternative for the treatment of anastomotic complications. Sepsis is well controlled with limited mortality and there is a high rate of anastomotic salvage. Prospective studies are needed to further delineate the optimal management for this complicated patient population.

Integrating Cultural Competency and Humility Training into Clinical Clerkships: Surgery as a Model

BACKGROUND Anastomotic leak, a potentially deadly postoperative occurrence, particularly interests surgeons performing gastrointestinal procedures. We investigated incidence, cost, and impact on survival of anastomotic leak in gastrointestinal surgical procedures at an academic center. STUDY DESIGN We conducted a chart review of American College of Surgeons NSQIP operative procedures with gastrointestinal anastomosis from January 1, 2003 through April 30, 2006. Each case with an American College of Surgeons NSQIP 30-day postoperative complication was systematically reviewed for evidence of anastomotic leak for 12 months after the operative date. We tracked patients for up to 10 years to determine survival. Morbidity, mortality, and cost for patients with gastrointestinal anastomotic leaks were compared with patients with anastomoses that remained intact. RESULTS Unadjusted analyses revealed significant differences between patients who had anastomotic leaks develop and those who did not: morbidity (98.0% vs. 28.4%; p < 0.0001), length of stay (13 vs. 5 days; p ≤ 0.0001), 30-day mortality (8.4% vs. 2.5%; p < 0.0001), long-term mortality (36.4% vs. 20.0%; p ≤ 0.0001), and hospital costs (chi-square [2] = 359.8; p < 0.0001). Multivariable regression demonstrated that anastomotic leak was associated with congestive heart failure (odds ratio [OR] = 31.5; 95% CI, 2.6-381.4; p = 0.007), peripheral vascular disease (OR = 4.6; 95% CI, 1.0-20.5; p = 0.048), alcohol abuse (OR = 3.7; 95% CI, 1.6-8.3; p = 0.002), steroid use (OR = 2.3; 95% CI: 1.1-5.0; p = 0.027), abnormal sodium (OR = 0.4; 95% CI, 0.2-0.7; p = 0.002), weight loss (OR = 0.2; 95% CI, 0.06-0.7; p = 0.011), and location of anastomosis: rectum (OR = 14.0; 95% CI, 2.6-75.5; p = 0.002), esophagus (OR = 13.0; 95% CI, 3.6-46.2; p < 0.0001), pancreas (OR = 12.4; 95% CI, 3.3-46.2; p < 0.0001), small intestine (OR = 6.9; 95% CI, 1.8-26.4; p = 0.005), and colon (OR = 5.2; 95% CI, 1.5-17.7; p = 0.009). CONCLUSIONS Significant morbidity, mortality, and cost accompany gastrointestinal anastomotic leaks. Patients who experience an anastomotic leak have lower rates of survival at 30 days and long term.