H. David Vargas

Advances and Challenges in the Management of Acute Colonic Pseudo-Obstruction (Ogilvie Syndrome)

Although acute colonic pseudo-obstruction (ACPO), also known as Ogilvie syndrome, is a well-known clinical entity, in many respects it remains poorly understood and continues to challenge physicians and surgeons alike. Our understanding of ACPO continues to evolve and its epidemiology has changed as new conditions have been identified predisposing to ACPO with critical illness providing the common thread among them. A physician must keep ACPO high in the list of differential diagnoses when dealing with the patient experiencing abdominal distention, and one must be prepared to employ and interpret imaging studies to exclude mechanical obstruction. Rapid diagnosis is the key, and institution of conservative measures often will lead to resolution. Fortunately, when this fails pharmacologic intervention with neostigmine often proves effective. However, it is not a panacea: consensus on dosing does not exist, administration techniques vary and may impact efficacy, contraindications limit its use, and persistence and or recurrence of ACPO mandate continued search for additional medical therapies. When medical therapy fails or is contraindicated, endoscopy offers effective intervention with advanced techniques such as decompression tubes or percutaneous endoscopic cecostomy providing effective results. Operative intervention remains the treatment of last resort; surgical outcomes are associated with significant morbidity and mortality. Therefore, a surgeon should be aware of all options for decompression-conservative, pharmacologic, and endoscopic-and use them in best combination to the advantage of patients who often suffer from significant concurrent illnesses making them poor operative candidates.

Longer operative time: deterioration of clinical outcomes of laparoscopic colectomy versus open colectomy.

BACKGROUND: As laparoscopic surgery is applied to colorectal surgery procedures, it becomes imperative to delineate whether there is an operative duration where benefits diminish. OBJECTIVE: The purpose of this work was to determine whether benefits of a laparoscopic right colectomy compared with an open right colectomy are diminished by prolonged operative times. DESIGN: We performed a retrospective analysis comparing outcomes of patients undergoing laparoscopic right and open right colectomy for colon cancer with operative duration of less than and greater than 3 hours. SETTINGS: This study was based on data in the American College of Surgeons National Surgical Quality Improvement Program database. PATIENTS: We queried the database for patients with laparoscopic and open right colectomy with a diagnosis of colorectal cancer between 2005 and 2010. MAIN OUTCOME MEASURES: Patients were stratified by operative technique and duration. Forward multivariable logistic regression analysis was performed for mortality, cerebrovascular/cardiovascular complications, and infectious complications. Predictors of operative time >3 hours in the laparoscopic cohort were identified by logistic regression. RESULTS: Of 4273 patients, operative duration was >3 hours for 18.4% of patients with a laparoscopic right colectomy and 11.3% with an open right colectomy. There was no benefit of the laparoscopic right colectomy with an operative duration >3 hours over open right colectomy with respect to mortality and cardiopulmonary and cerebrovascular complications. An operative duration >3 hours was an independent risk factor for infectious complications in patients undergoing a laparoscopic right colectomy. LIMITATIONS: This was a retrospective study and not an intention-to-treat analysis. CONCLUSIONS: At an operative duration of ≥3 hours, laparoscopic right colectomy has higher infectious complications than open right colectomy. Reduced mortality and less cardiopulmonary and cerebrovascular complications seen in the laparoscopic cohort with shorter operative duration were lost with an operative duration >3 hours. In patients at risk for prolonged laparoscopic right colectomy, early conversion to an open technique may be warranted.

Timing and Perioperative Risk Factors for In-Hospital and Post-Discharge Venous Thromboembolism After Colorectal Cancer Resection

Introduction: We postulated that the risk of venous thromboembolic disease (VTE) may persist after discharge and tested this hypothesis in patients undergoing colorectal resection for cancer. Methods: The American College of Surgeons National Surgery Quality Improvement Program database was queried for patients undergoing colorectal resections for cancer from 2005 to 2009. The outcome analyzed was a 30-day deep vein thrombosis (DVT) and/or pulmonary embolism (PE). Multivariable forward stepwise regression was used to identify independent predictors of VTE. Results: The database contained 21 943 colorectal cancer resections. The 30-day DVT rate was 1.4% (306 of 21 943), 29% (89 of 306) were diagnosed post-discharge. The 30-day PE rate was 0.8% (180 of 21 943), 33% (60 of 180) was diagnosed post-discharge, the combined DVT/PE rate was 2.0% (446 of 21 943). The median time to diagnosis of VTE was 9 days (interquartile range 4-16) after surgery. Post-discharge VTE rates in patients with length of stay (LOS) less than 1 week (0.6%) were similar to patients with LOS greater than 1 week (0.7%, Fisher exact P not significant). Independent risk factors for post-discharge VTE were preoperative steroid use for chronic condition (odds ratio [OR] 2.90, 95% confidence interval [CI] 1.51-5.57, P = .001) and preoperative systemic inflammatory response syndrome (OR 2.26, 95% CI 1.24-4.10, P = .008). Conclusions: Diagnosis of almost one third of postoperative VTE in this patient population occurred after discharge. The duration of the prothrombotic stimulus of surgery is not well defined, and patients with malignancy are at high risk of VTE; thromboprophylaxis after discharge should be considered for these patients.

Acute Intestinal Pseudo-Obstruction (Ogilvie's Syndrome)

Acute colonic pseudo-obstruction (ACPO), also known as Ogilvies syndrome, is a condition characterized by massive colonic distension in the absence of mechanical obstruction. Patients presenting with Ogilvies syndrome have underlying medical and surgical conditions predisposing them to the syndrome. Ogilvies syndrome can often be managed by conservative therapy. However, unrecognized and untreated, the continued distension associated with Ogilvies syndrome can lead to perforation that is associated with a high mortality rate. In this article, the pathophysiology, epidemiology, and treatment options are reviewed.

Morbid obesity and diverticulitis: Results from the ACS Nsqip dataset

BACKGROUND We examined the relationship between morbid obesity, clinical presentation, and perioperative outcomes in patients offered surgery for diverticulitis. STUDY DESIGN We queried the ACS NSQIP dataset from 2005 to 2010 for patients undergoing surgery for nonhemorrhaging diverticulitis. Univariate comparisons were made between normal weight (NL) and morbidly obese (MO) patients in terms of demographics, clinical presentation, and perioperative and postoperative outcomes variables using chi-square or rank tests. Multivariable regression was used to adjust for age in assessing the impact of MO on the likelihood of emergent surgery (ES), ostomy creation, open surgery, and undergoing procedures without an anastomosis. RESULTS We identified 10,952 patients undergoing surgery for diverticulitis; morbidly obese (body mass index [BMI] ≥ 40 kg/m(2), n = 592, 5.7%), normal weight (BMI 18.5 to 25 kg/m(2), n = 2,530, 24.2%). Morbidly obese patients were younger than NL patients by an average of 9.4 years (p < 0.001). Morbidly obese patients underwent ES more frequently than NL patients (19.3% vs 15.4%; p = 0.025). Multivariable regression identified morbid obesity as an independent risk factor for ES (odds ratio [OR] 1.75, 95% CI 1.37 to 2.24, p < 0.001), ostomy creation (OR 1.67, 95% CI 1.34 to 2.08, p < 0.001), undergoing procedures without an anastomosis (OR 1.78, 95% CI 1.42 to 2.24, p < 0.001), and open surgery (OR 2.09, 95% CI 1.72 to 2.53, p < 0.001). Morbidly obese patients undergoing ES had more preoperative systemic inflammatory response syndrome/sepsis/septic shock than NL patients (72.8% vs 57.7%, p = 0.004). CONCLUSIONS Morbidly obese patients undergoing surgery for diverticulitis are nearly 10 years younger than NL patients and are more likely to require ES, ostomy creation, open surgery, and to undergo procedures without an anastomosis. Morbidly obese patients undergoing ES also have more preoperative systemic inflammatory response syndrome/sepsis/septic shock.

Autoimmune enteropathy with a CD8 + CD7 - T-cell small bowel intraepithelial lymphocytosis: case report and literature review

BackgroundAdult onset autoimmune enteropathy (AIE) is a rare condition characterized by diarrhea refractory to dietary therapy diagnosed in patients with evidence of autoimmune conditions. Auto-antibodies to gut epithelial cells and other tissues are commonly demonstrated. Despite increasing awareness, the pathogenesis, histologic, immunologic and clinical features of AIE remain uncertain. There remains controversy regarding the diagnostic criteria, the frequency and types of auto-antibodies and associated autoimmune conditions, and the extent and types of histologic and immunologic abnormalities. CD4+ T-cells are thought to at least responsible for this condition; whether other cell types, including B- and other T-cell subsets are involved, are uncertain. We present a unique case of AIE associated with a CD8+CD7- lymphocytosis and review the literature to characterize the histologic and immunologic abnormalities, and the autoantibodies and autoimmune conditions associated with AIE.Case PresentationWe present a case of immune mediated enteropathy distinguished by the CD8+CD7- intra-epithelial and lamina propria lymphocytosis. Twenty-nine cases of AIE have been reported. The majority of patients had auto-antibodies (typically anti-enterocyte), preferential small bowel involvement, and predominately CD3+ CD4+ infiltrates. Common therapies included steroids or immuno-suppressive agents and clinical response with associated with histologic improvement.ConclusionsAIE is most often characterized (1) IgG subclass anti-epithelial cell antibodies, (2) preferential small bowel involvement, and (3) CD3+ alphabeta TCR+ infiltrates; there is insufficient evidence to conclude CD4+ T-cells are solely responsible in all cases of AIE.

Lower Gastrointestinal Hemorrhage

Lower gastrointestinal bleeding refers to bleeding from a source distal to the ligament of Treitz. Presentation ranges from occult bleeding with anemia to frank hemorrhage with cardiovascular collapse. Management hinges on volume resuscitation and restoration of hemodynamic stability, followed by a search for the source of bleeding. Investigative measures include colonoscopy, nuclear scintigraphy, CT angiography, and mesenteric angiography. If an active source of bleeding is identified, therapeutic angiography and embolization should be attempted. Active bleeding identified during colonoscopy should be controlled endoscopically. Surgery is reserved for patients with ongoing hemorrhage and hemodynamic instability or for those who fail nonsurgical management.

Current State of Colorectal Surgery Training: A Survey of Program Directors, Current and Recently Matched Colorectal Residents, and Recent Colorectal Graduates.

BACKGROUND: Colorectal residency has become one of the more competitive postgraduate training opportunities; however, little information is available to guide potential applicants in gauging their competitiveness. OBJECTIVE: The aim of this study was to identify the current trends colorectal residency training and to identify what factors are considered most important in ranking a candidate highly. We hypothesized that there was a difference in what program directors, current and recently matched colorectal residents, and recent graduates consider most important in making a candidate competitive for a colorectal residency position. DESIGN: Three 10-question anonymous surveys were sent to 59 program directors, 87 current and recently matched colorectal residents, and 119 recent graduates in March 2015. SETTINGS: The study was conducted as an anonymous internet survey. MAIN OUTCOME MEASURES: Current trends in applying for a colorectal residency, competitiveness of recent colorectal residents, factors considered most important in ranking a candidate highly, and what future colorectal surgeons can expect after finishing their training were measured. RESULTS: The study had an overall response rate of 43%, with 28 (47%) of 59 program directors, 46 (53%) of 87 current and recently matched colorectal residents, and 39 (33%) of 119 recent graduates responding. The majority of program directors felt that a candidate’s performance during the interview process was the most important factor in making a candidate competitive, followed by contact from a colleague, letters of recommendation, American Board of Surgery In-Training Exam scores, and number of publications/presentations. The majority of current and recently matched colorectal residents felt that a recommendation/telephone call from a colleague was the most important factor, whereas the majority of recent graduates favored letters of recommendation as the most important factor in ranking a candidate highly. LIMITATIONS: Limitations to the study include its small sample size, selection bias, responder bias, and misclassification bias. CONCLUSIONS: There are differences in what program directors and current/recent residents consider most important in making an applicant competitive for colorectal residency.