Glenn T. Ault

The Management of Complicated Diverticulitis and the Role of Computed Tomography

PURPOSE:Acute diverticulitis is a disease with a wide clinical spectrum, ranging from a phlegmon (stage Ia), to localized abscesses (stages Ib and II), to free perforation with purulent (stage III) or feculent peritonitis (stage IV). While there is little debate about the best treatment for mild episodes and/or very severe episodes, uncertainty persists about the optimal management for intermediate stages (Ib and II). The aim of our study was therefore to define the role of computed tomography (CT) and to analyze its impact on the management of acute diverticulitis.METHODS:We retrospectively analyzed 511 patients (296 males, 215 females) admitted for acute diverticulitis between January 1994 and December 2003. Excluded were patients with stoma reversal only, “diverticulitis” mimicked by cancer, or significantly deficient patient records. Patients were analyzed either as a whole or subgrouped according to age (<40 yr, >40 yr). A modified Hinchey classification was used to stage the severity of acute diverticulitis.RESULTS:In 99 patients (19.4%), an abscess was found (74 pericolic, 25 pelvic, median diameter: 4.0 cm). CT-guided drainage was performed in 16 patients, one failure requiring a two-stage operation. Whereas conservative treatment failed in 6.8% in patients without abscess or perforation, 22.2% of patients with an abscess required an urgent resection (68.2%, one-stage, 31.8%, two-stage). Recurrence rates were 13% for mild cases, as compared to 41.2% in patients with a pelvic abscess (stage II) treated conservatively with/without CT-guided drainage. Of all surgical cases, resection/primary anastomosis was achieved in 73.6% with perioperative mortality of 1.1% and leak rate was 2.1%.CONCLUSIONS:CT evidence of a diverticular abscess has a prognostic impact as it correlates with a high risk of failure from nonoperative management regardless of the patients age. After treatment of diverticulitis with CT evidence of an abscess, physicians should strongly consider elective surgery in order to prevent recurrent diverticulitis.

Exporting a technical skills evaluation technology to other sites

BACKGROUND The Objective Structured Assessment of Technical Skill (OSATS) is a multistation performance-based examination that assesses the technical skills of surgery residents. This study explores the implementation issues involved in remote administration of the OSATS focusing on feasibility and the psychometric properties of the examination. METHODS An eight-station OSATS was administered to surgical residents in Los Angeles and Chicago. The University of Toronto and the local institutions shared responsibility for organization and administration of the examination. RESULTS There was good reliability for both the checklist (alpha = 0.68 for LA, 0.73 for Chicago) and global rating forms (alpha = 0.82 for both sites). Both iterations also showed evidence of construct validity, with a significant effect of training year for the checklist and global rating forms at both sites (analysis of variance: F = 8.66 to 19.93, P <0.01). Despite some challenges, the model of central organization and peripheral delivery was effective for the administration of the examinations. CONCLUSIONS Two iterations of the OSATS at remote sites demonstrated psychometric properties that are highly consistent with previously reported data suggesting that the examination is portable. Both faculty and residents indicated satisfaction with the examination experience. A model of central administration with peripheral delivery was feasible and effective.

Impact of the Aging Population on the Demand for Colorectal Procedures

PURPOSE: With the baby boomers entering retirement age, the United States population is seeing a dramatic increase in the number of elderly individuals. We hypothesized that as a result, during the next 20 years, the demand for colorectal procedures will grow rapidly. METHODS: We used the 2005 Nationwide Inpatient Sample and the Florida State Ambulatory Surgery Database as source data. From these two data sources, we identified commonly performed inpatient and outpatient colorectal procedures, as well as associated diagnoses. These data were combined with census projections to generate projected volumes for the selected procedures and diagnoses. RESULTS: Between 2005 and 2025, the United States population is expected to grow by 18 percent, with disproportionate growth in individuals aged 65 to 74 years (92 percent) and those aged 75+ years (54 percent). We forecast that growth in outpatient procedures and inpatient procedures will be 21.3 percent and 40.6 percent, respectively. Inpatient operations for colon cancer and rectal cancer show the greatest growth. CONCLUSIONS: During the next two decades, demographic changes in the United States population will lead to a marked increase in the use of colorectal surgical services, especially inpatient and oncologic procedures. The ability of the surgical workforce to meet this projected growth in demand should be assessed.

A novel approach to assessing technical competence of colorectal surgery residents: The development and evaluation of the colorectal objective structured assessment of technical skill (COSATS)

Objective: To develop and evaluate an objective method of technical skills assessment for graduating subspecialists in colorectal (CR) surgery—the Colorectal Objective Structured Assessment of Technical Skill (COSATS). Background: It may be reasonable for the public to assume that surgeons certified as competent have had their technical skills assessed. However, technical skill, despite being the hallmark of a surgeon, is not directly assessed at the time of certification by surgical boards. Methods: A procedure-based, multistation technical skills examination was developed to reflect a sample of the range of skills necessary for CR surgical practice. These consisted of bench, virtual reality, and cadaveric models. Reliability and construct validity were evaluated by comparing 10 graduating CR residents with 10 graduating general surgery (GS) residents from across North America. Expert CR surgeons, blinded to level of training, evaluated performance using a task-specific checklist and a global rating scale. The mean global rating score was used as the overall examination score and a passing score was set at “borderline competent for CR practice.” Results: The global rating scale demonstrated acceptable interstation reliability (0.69) for a homogeneous group of examinees. Both the overall checklist and global rating scores effectively discriminated between CR and GS residents (P < 0.01), with 27% of the variance attributed to level of training. Nine CR residents but only 3 GS residents were deemed competent. Conclusions: The Colorectal Objective Structured Assessment of Technical Skill effectively discriminated between CR and GS residents. With further validation, the Colorectal Objective Structured Assessment of Technical Skill could be incorporated into the colorectal board examination where it would be the first attempt of a surgical specialty to formally assess technical skill at the time of certification.

Adenocarcinoma Arising in the Middle of Ileoanal Pouches : Report of Five Cases

Restorative proctocolectomy with ileal pouch-anal anastomosis with or without mucosectomy has become the procedure of choice in patients with long-standing ulcerative colitis complicated by malignancy or medically refractory disease and for familial polyposis syndrome. Some reports have demonstrated the development of malignancy at the ileoanal anastomosis. We present a recent series of five patients who developed adenocarcinoma in the middle of their ileal pouch including the first case of pouch carcinoma in a patient who underwent pouch formation for ulcerative colitis. We discuss their presentation and management. Development of ileal pouch cancers, while rare, has been seen with increasing frequency in our practice. Patients with long-standing ileal pouches may benefit from routine surveillance of the pouch as often as every six months, which can be performed quickly and easily in the office using flexible endoscopy.

Elective versus emergency surgery for ulcerative colitis: a National Surgical Quality Improvement Program analysis

BACKGROUND It is unclear whether advances in the medical management of ulcerative colitis (UC) have altered outcomes for medically intractable disease. Therefore, it is essential to understand the current impact of elective versus emergency surgery for UC. METHODS The American College of Surgeons National Surgical Quality Improvement Program database was used to compare outcomes for elective versus emergency UC surgery between 2005 and 2010. RESULTS Four thousand nine hundred sixty-two patients were eligible for study (94% elective and 6% emergent). Emergency surgery patients were significantly older and frequently underwent open surgery. Emergency cases were associated with a higher frequency of cardiac, pulmonary, and renal comorbidities; postoperative complications; longer hospital stays; and higher rates of return to the operating room. CONCLUSIONS In the era of advanced UC medical therapy, the need for emergency surgery still exists and is associated with substantial morbidity and mortality. Data are needed to determine if earlier selection of surgery would be beneficial.

Rectal Foreign Bodies: What Is the Current Standard?

Rectal foreign bodies represent a challenging and unique field of colorectal trauma. The approach includes a careful history and physical examination, a high index of suspicion for any evidence of perforation, a creative approach to nonoperative removal, and appropriate short-term follow-up to detect any delayed perforation.

Cost-saving effect of treatment algorithm for chronic anal fissure: A prospective analysis

Evidence-based medicine suggests that in the management of chronic anal fissure (CAF), lateral internal sphincterotomy (LIS) is far more effective than medical treatment in lowering the anal sphincter tone and curing the fissure. In the current study, we developed a treatment algorithm from topical nitroglycerin (NTG) to botulinum toxin type A (Botox [BTX]) to LIS and analyzed its cost benefit by calculating the effective and potential costs based on the treatment success and the rate of avoided surgeries. Patients presenting between November 2003 and December 2004 with CAF and symptoms for greater than 3 months were prospectively treated according to a treatment algorithm which started with (1) topical NTG, in case of failure (2) injection of BTX, thus limiting (3) surgery to those who failed both nonsurgical options or at any point chose the surgical approach. Based on the primary end points of fissure healing or surgery, we calculated the true cost (algorithm) and the potential incremental cost (BTX plus surgery or surgery in all patients, respectively). Sixty-seven patients with CAF (25 men and 42 women; median duration of symptoms, 16 weeks) were treated according to the algorithm. NTG alone was successful in fissure healing in 31 of 67 patients (46.2%). Two developed a recurrent fissure and then received BTX as part of the protocol. Of the 36 patients who failed NTG trial, 3 requested surgery; the others were treated with BTX, which was successful in 84.8%. Five patients (15.2%) failed BTX and subsequently required surgery. The overall surgery rate in the whole study group was 11.9%, whereas CAF healed in 88.1% of our patients with medical treatment alone. Cost for NTG is

Colorectal procedures: What proportion is performed by American board of Colon and rectal surgery-certified surgeons?

10; for 100 units BTX,

A Novel Classification, Evaluation, and Treatment Strategy for Supralevator Abscesses.

528; and for outpatient surgery,