Conor Shields

Preoperative hypoalbuminemia is an independent risk factor for the development of surgical site infection following gastrointestinal surgery: a multi-institutional study.

Background:Surgical site infection (SSI) is an infection occurring in an incisional wound within 30 days of surgery and significantly effects patient recovery and hospital resources. Objective:This study sought to determine the relationship between preoperative serum albumin and SSI. Methods:A study of 524 patients who underwent gastrointestinal surgery in 4 institutions was performed. Patients were identified using a prospective SSI database and hospital records. Serum albumin was determined preoperatively in all patients. Hypoalbuminemia was defined as albumin <30 mg/dL. Data are presented as median (interquartile range) and a difference between groups was examined using Mann-Whitney U and Fisher exact test and multiple logistic regression analysis. Results:A total of 105 patients developed a SSI (20%). The median time to the development of SSI was 7 (5–10) days. Having an emergency procedure (P = 0.003), having a procedure over 3 hours in duration (P = 0.047), being American Society of Anaesthetics grade 3 (P = 0.03) and not receiving preoperative antibiotics (P = 0.007) were associated with SSI while having a laparoscopic procedure reduced the likelihood of SSI (P = 0.004). Patients who developed a SSI had a lower preoperative serum albumin (30 [25–34.5] vs. 36 [32–39], P < 0.001). On multivariate analysis, hypoalbuminemia was an independent risk factor for SSI development (relative risk, RR = 5.68, 95% confidence interval: 3.45–9.35, P < 0.001). Albumin <30 mg/dL was associated with an increased rate of deep versus superficial SSI (P = 0.002). The duration of inpatient stay was negatively correlated with preoperative albumin (R2 = −0.319, P < 0.001). Conclusions:Hypoalbuminemia is an independent risk factor for the development of SSI following gastrointestinal surgery and is associated with deeper SSI and prolonged inpatient stay.

Abdomino-perineal resection for anal cancer: impact of a vertical rectus abdominis myocutaneus flap on survival, recurrence, morbidity, and wound healing.

Objectives:To evaluate the results of a vertical rectus abdominis myocutaneus (VRAM) flap after abdomino-perineal resection (APR) for anal cancer (AC). Background Data:APR is the only curative treatment for AC that recurs or persists after radiochemotherapy. To obtain a clear surgical margin, APR frequently includes a significant perineal exenteration, leaving a large defect surrounded by irradiated tissue. VRAM may facilitate the healing of such a wound and, by providing tissue that can cover a large defect, can facilitate a wide resection and thus may influence survival. Methods:All patients who underwent APR for AC between 1996 and 2007 were included. Results:Ninety-five patients (70 women) underwent APR, including 43 patients who subsequently received a VRAM flap. The remaining patients had an omentoplasty. Indications for APR were recurrence of AC (n = 46), persistence of disease (n = 41), and contraindication to radiotherapy (n = 8). The groups (VRAM vs. No VRAM) differed in age at surgery (56.3 vs. 62.1; P = 0.0263); administration of chemotherapy in addition to radiotherapy (81% vs. 59%; P = 0.0218); and stage (ypT3-T4 67.6% vs. 38.4%; P = 0.0394). Five-year overall and disease-free survival did not differ between the 2 groups (58.1% vs. 54.5%; P = 0.6756; 41.1% vs. 48.9%; P = 0.2756). Perineal complications were significantly less frequent following VRAM (26.8% vs. 48.9%; P = 0.0336), with reduced time to healing (18.7 vs. 117 days; P = 0.0019) and the ratio of wound healing to survival time (5.6% vs. 19.4%; P = 0.0176). No difference was observed in the incidence of abdominal incisional hernias (9.3% vs. 9.6%), but patients who underwent a VRAM flap pelvic reconstruction had fewer perineal hernias (0% vs. 15.4%; P = 0.0072). Conclusions:Survival in the 2 groups was equivalent despite the presence of more advanced cancers in the VRAM flap cohort. This may be explained by the more extensive resections that were performed in this group. VRAM is an effective technique for reducing both the perineal complication rate and wound-healing delay in patients undergoing APR for AC that does not increase abdominal wall morbidity.

Carcinoid tumors of the rectum: a multi-institutional international collaboration.

Objective:This study aims to describe recent experience with rectal carcinoids in European and North American centers. Background:While considered indolent, the propensity of carcinoids to metastasize can be significant. Methods:Rectal carcinoid patients were identified from prospective databases maintained at 9 institutions between 1999 and 2008. Demographic, clinical, and histologic data were collated. Median follow-up was 5 years (range, 0.5–10 years). Results:Two hundred two patients were identified. The median age was 55 years (range, 31–81 years). The majority of tumors were an incidental finding (n = 115, 56.9%). The median tumor size was 10 mm (range, 2–120 mm). Overall, 93 (49%) tumors were limited to the mucosa or submucosa, 45 (24%) involved the muscularis propria, 29 (15%) extended into the perirectal fat, and 6 (3%) reached the visceral peritoneum. The primary treatment modalities were endoscopic resection (n = 86, 43%) and surgical extirpation (n = 102, 50%). Forty-one patients (40%) underwent a high anterior resection, whereas 45 (44%) underwent anterior resection with total mesorectal excision. Seven patients (7%) underwent Hartmans procedure, 7 (7%) underwent abdomino-perineal resection, and 6 (6%) had transanal endoscopic microsurgery, whereas 4 (4%) patients underwent a transanal excision. Multiple variable logistic regression analysis demonstrated that tumor size greater than 10 mm and lymphovascular invasion were predictors of nodal involvement (P = 0.006 and < 0.001, respectively), whereas the presence of lymph node metastases and lymphovascular invasion was associated with subsequent development of distant metastases (P = 0.033 and 0.022, respectively). The presence of nodal metastases has a profound effect upon survival, with a 5-year survival rate of 70%, and 10-year survival of 60% for node positive tumors. Patients with distant metastases have a 4-year survival of 38%. Conclusion:Tumor size greater than 10 mm and lymphovascular invasion are significantly associated with the presence of nodal disease, rendering mesorectal excision advisable. Transanal excision is adequate for smaller tumors.

Lung injury in acute pancreatitis: mechanisms, prevention, and therapy

Lung injury is the most pertinent manifestation of extra-abdominal organ dysfunction in pancreatitis. The propensity of this retroperitoneal inflammatory condition to engender a diffuse and life-threatening lung injury is significant. Approximately one third of patients will develop acute lung injur

Hypertonic saline enhances host response to bacterial challenge by augmenting receptor-independent neutrophil intracellular superoxide formation.

Objective This study sought to determine whether hypertonic saline (HTS) infusion modulates the host response to bacterial challenge. Methods Sepsis was induced in 30 Balb-C mice by intraperitoneal injection of Escherichia coli (5 × 107 organisms per animal). In 10 mice, resuscitation was performed at 0 and 24 hours with a 4 mL/kg bolus of HTS (7.5% NaCl), 10 animals received 4 mL/kg of normal saline (0.9% NaCl), and the remaining animals received 30 mL/kg of normal saline. Samples of blood, spleen, and lung were cultured at 8 and 36 hours. Polymorphonucleocytes were incubated in isotonic or hypertonic medium before culture with E. coli. Phagocytosis was assessed by flow cytometry, whereas intracellular bacterial killing was measured after inhibition of phagocytosis with cytochalasin B. Intracellular formation of free radicals was assessed by the molecular probe CM-H2DCFDA. Mitogen-activated protein (MAP) kinase p38 and ERK-1 phosphorylation, and nuclear factor &kgr; B (NF&kgr;B) activation were determined. Data are represented as means (SEM), and an analysis of variance test was performed to gauge statistical significance. Results Significantly reduced bacterial culture was observed in the animals resuscitated with HTS when compared with their NS counterparts, in blood (51.8 ± 4.3 vs. 82.0 ± 3.3 and 78.4 ± 4.8, P = 0.005), lung (40.0 ± 4.1 vs. 93.2 ± 2.1 and 80.9 ± 4.7, P = 0.002), and spleen (56.4 ± 3.8 vs. 85.4 ± 4.2 and 90.1 ± 5.9, P = 0.05). Intracellular killing of bacteria increased markedly (P = 0.026) and superoxide generation was enhanced upon exposure to HTS (775.78 ± 23.6 vs. 696.57 ± 42.2, P = 0.017) despite inhibition of MAP kinase and NF&kgr;B activation. Conclusions HTS significantly enhances intracellular killing of bacteria while attenuating receptor-mediated activation of proinflammatory cascades.

Surgical resection of retrorectal tumours in adults: long‐term results in 47 patients

Retrorectal tumours (RT) are uncommon, and diagnosis and management remain difficult. The aim of this study was to evaluate the results of the surgical management of RT in our institution.

Attenuation of Pancreatitis-Induced Pulmonary Injury by Aerosolized Hypertonic Saline

BACKGROUND The immunomodulatory effects of hypertonic saline (HTS) provide potential strategies to attenuate inappropriate inflammatory reactions. This study tested the hypothesis that administration of intratracheal aerosolized HTS modulates the development of lung injury in pancreatitis. METHODS Pancreatitis was induced in 24 male Sprague-Dawley rats by intraperitoneal injection of 20% L-arginine (500 mg/100 g body weight). At 24 and 48 h, intratracheal aerosolized HTS (7.5% NaCl, 0.5 mL) was administered to 8 rats, while a further 8 received 0.5 mL of aerosolized normal saline (NS). At 72 hours, pulmonary neutrophil infiltration (myeloperoxidase activity) and endothelial permeability (bronchoalveolar lavage and wet:dry weight ratios) were assessed. In addition, histological assessment of representative lung tissue was performed by a blinded assessor. In a separate experiment, polymorphonucleocytes (PMN) were isolated from human donors, and exposed to increments of HTS. Neutrophil transmigration across an endothelial cell layer, VEGF release, and apoptosis at 1, 6, 12, 18, and 24 h were assessed. RESULTS Histopathological lung injury scores were significantly reduced in the HTS group (4.78 +/- 1.43 vs. 8.64 +/- 0.86); p < 0.001). Pulmonary neutrophil sequestration (1.40 +/- 0.2) and increased endothelial permeability (6.77 +/- 1.14) were evident in the animals resuscitated with normal saline when compared with HTS (0.70 +/- 0.1 and 3.57 +/- 1.32), respectively; p < 0.04). HTS significantly reduced PMN transmigration (by 97.1, p = 0.002, and induced PMN apoptosis (p < 0.03). HTS did not impact significantly upon neutrophil VEGF release (p > 0.05). CONCLUSIONS Intratracheal aerosolized HTS attenuates the neutrophil-mediated pulmonary insult subsequent to pancreatitis. This may represent a novel therapeutic strategy.

Perioperative Topical Nitrate and Sphincter Function in Patients Undergoing Transanal Stapled Anastomosis: A Randomized, Placebo-Controlled, Double-Blinded Trial

PURPOSEThe use of transanal stapling devices may impair continence because of digital dilatation and/or instrumentation. This study assessed the effect of pharmacological dilatation of the sphincter prior to stapler insertion.METHODSA randomized, placebo-controlled, double-blinded study of 60 patients undergoing transanal stapled anastomosis was undertaken. Consenting patients were randomly assigned to receive a single intraoperative dose of topical 0.2 percent nitroglycerin (glyceryl trinitrate) ointment or nitroglycerin-free placebo. All patients were assessed preoperatively and postoperatively by clinical methods (Wexner incontinence scores and examination), anorectal manometry by a station pull-through technique, and endoanal ultrasonography.RESULTSIntraoperative mean (±SEM) resting pressures (mmHg) were significantly reduced by nitroglycerin compared with prenitroglycerin levels (9.9 ± 0.9 vs. 50.5 ± 2.7; P = 0.002) or controls (56.0 ± 3.2; P = 0.001). Twenty-one of the 28 controls (75 percent) but only 4 of the 32 patients in the nitroglycerin group (12.5 percent) required digital dilatation to insert the stapling instrument (P = 0.003). Squeeze pressures were unaltered by the intervention but mean resting pressures were higher in the nitroglycerin group postoperatively (52.9 ± 3.2 − 31.6 ± 1.3 = 21.3 mmHg; 95 percent confidence interval, 14–27). Incontinence scores were lower in the nitroglycerin group at the 3-month (1.1 ± 0.2 vs. 4.6 ± 0.3; P = 0.003) and 12-month (0.9 ± 0.1 vs. 4.4 ± 0.3; P = 0.002) clinic visits.CONCLUSIONPreoperative nitroglycerin dilatation protects sphincter function in patients undergoing transanal stapled anastomoses.

R1 rectal resection: look up and don't look down.

Background:After rectal resection for adenocarcinoma, pathological examination may reveal invasion of the distal margin (DM) and/or a circumferential resection margin of the tumor (CRM-T) or of involved nodes (CRM-N) less than or equal to 1 mm. Such findings transform a planned R0 resection to R1. Aim:The aim was to analyze the impact of an R1 resection on prognosis, recurrence rate, and choice of adjuvant treatment. Patients and Methods:All R1 resections observed between 2006 and 2011 were retrospectively collected. Patients were matched with 80 patients with R0 resections according to age, body mass index, gender, neoadjuvant treatment, type of resection, ypT/pT stages, and N stage. Results:Among 472 rectal resections performed, 40 (8.5%) were R1 (CRM-T = 34; CRM-N = 11; invaded DM = 4). Among the 4 patients with invaded DM, 3 underwent salvage abdominoperineal resection. Of the 12 patients who had not received neoadjuvant treatment, 5 received adjuvant radiotherapy. Mean follow-up was 49.3 ± 29.3 months for the 120 patients; 5-year overall survival (OS) and disease-free survival (DFS) were 72% and 56%. Comparison between R0 and R1 resections showed a trend toward worse OS in R1 resections: 62% versus 79% (P = 0.0954), a significantly worse DFS: 41% versus 65% (P = 0.0267). Local recurrence rates were similar: 12% versus 13% (P = 0.9177), whereas distant recurrence was significantly more frequent after R1 resection: 56% versus 26% (P = 0.0040). Conclusions:R1 resection is associated with a worse prognosis, but local recurrence rate does not differ significantly from matched R0 resections. The difference was observed for distant recurrences, especially lung, favoring the use of chemotherapy and close surveillance of the thorax.

The immunohistochemical demonstration of Helicobacter pylori in rectal ectopia.

The finding of heterotopic gastric mucosa in the rectum is rare, with less than 40 reported cases in the literature. A condition of unknown etiology, several hypotheses exist including infectious and congenital. We report a case of ectopic gastric tissue in the rectum of a 47-year-old female, and her subsequent clinical course. Furthermore for the first time, we present immunohistologic evidence of the presence of Helicobacter pylori in rectal ectopic gastric tissue.