Kenneth A. Forde

Combined preoperative mechanical bowel preparation with oral antibiotics significantly reduces surgical site infection, anastomotic leak, and ileus after colorectal surgery.

OBJECTIVES To clarify whether bowel preparation use or its individual components [mechanical bowel preparation (MBP)/oral antibiotics] impact specific outcomes after colorectal surgery. METHODS National Surgical Quality Improvement Program-targeted colectomy data initiated in 2012 capture information on the use/type of bowel preparation and colorectal-specific complications. For patients undergoing elective colorectal resection, the impact of preoperative MBP and antibiotics (MBP+/ABX+), MBP alone (MBP+/ABX-), and no bowel preparation (no-prep) on outcomes, particularly anastomotic leak, surgical site infection (SSI), and ileus, were evaluated using unadjusted/adjusted logistic regression analysis. RESULTS Of 8442 patients, 2296 (27.2%) had no-prep, 3822 (45.3%) MBP+/ABX-, and 2324 (27.5%) MBP+/ABX+. Baseline characteristics were similar; however, there were marginally more patients with prior sepsis, ascites, steroid use, bleeding disorders, and disseminated cancer in no-prep. MBP with or without antibiotics was associated with reduced ileus [MBP+/ABX+: odds ratio (OR) = 0.57, 95% confidence interval (CI): 0.48-0.68; MBP+/ABX-: OR = 0.78, 95% CI: 0.68-0.91] and SSI [MBP+/ABX+: OR = 0.39, 95% CI: 0.32-0.48; MBP+/ABX-: OR = 0.80, 95% CI: 0.69-0.93] versus no-prep. MBP+/ABX+ was also associated with lower anastomotic leak rate than no-prep [OR = 0.45 (95% CI: 0.32-0.64)]. On multivariable analysis, MBP with antibiotics, but not without, was independently associated with reduced anastomotic leak (OR = 0.57, 95% CI: 0.35-0.94), SSI (OR = 0.40, 95% CI: 0.31-0.53), and postoperative ileus (OR = 0.71, 95% CI: 0.56-0.90). CONCLUSIONS These data clarify the near 50-year debate whether bowel preparation improves outcomes after colorectal resection. MBP with oral antibiotics reduces by nearly half, SSI, anastomotic leak, and ileus, the most common and troublesome complications after colorectal surgery.

History of endoscopy: what lessons have we learned from the past?

The ability to reflect light in deeply located organs was a central problem in designing open tubes to explore or retract tissues and allow the examiner to observe these structures. To address the problem, the light guide system was developed. Philipp Bozzinl, one of the critical workers in this field, was born in 1773 in Mainz, Germany, to an aristocratic Italian family. His father had been forced to flee his native country after coincidentally killing another aristocrat during a duel. In principle, Bozzini s light guide consisted of a housing in which a candle was placed. On one side, he attached open tubes in various sizes and configurations that could be introduced into orifices including the mouth and the rectum. He even devised one with a mirror to examine

Colonoscopic screening for neoplasms in asymptomatic first-degree relatives of colon cancer patients

Individuals with a family history of colorectal cancer are believed to be at an increased risk of developing colorectal neoplasia. To estimate this risk and the potential yield of screening colonoscopy in this population, we recruited and prospectively colonoscoped 181 asymptomatic first-degree relatives (FDR) of colorectal cancer patients and 83 asymptomatic controls (without a family history of colorectal cancer). The mean ages for the FDR and control groups were 48.2 ± 12.5 and 54.8 ± 11.0, respectively. Adenomatous polyps were detected in 14.4 percent of FDRs and 8.4 percent of controls. Although 92 percent of our FDRs had only one FDR afflicted with colon cancer, those subjects with two or more afflicted FDRs had an even higher risk of developing colonic adenomas (23.8 percent) than those with only one afflicted FDR (13.1 percent). A greater proportion of adenomas was found to be beyond the reach of flexible sigmoidoscopy in the FDR group than in the controls (48 percentvs.25 percent, respectively). Logistic regression analysis revealed that age, male sex, and FDR status were independent risk factors for the presence of colonic adenomatous polyps (RR=2.32, 2.86, and 3.49, respectively;P<0.001). Those at greatest risk for harboring an asymptomatic colonic adenoma are male FDRs over the age of 50 (40 percentts.20 percent for age-matched male controls). Based on probability curves, males with one FDR afflicted with colon cancer appear to have an increased risk of developing a colonic adenoma beginning at 40 years of age. Our results document, for the first time, an increased prevalence of colonoscopically detectable adenomas in asymptomatic first-degree relatives of colon cancer patients, as compared with asymptomatic controls, and support the use of colonoscopy as a routine screening tool in this high-risk group.

Colonoscopy in acute rectal bleeding

Twenty-five patients underwent colonoscopy during active rectal bleeding. Five patients bled from diverticula, three from unsuspected cancer, and two each from polyps, ischemic colitis, and arteriovenous malformation. Despite the difficulties, colonoscopy should be encouraged in these patients because of the positive impact on subsequent surgical management.

How well can surgeons perform colonoscopy

AbstractBackground: Little recent data exist relative to the efficacy or postprocedural complications of surgeons performing diagnostic or therapeutic colonoscopy. Therefore, the aim of this study was to retrospectively assess the outcome of colonoscopy performed by surgeons. Methods: The charts of 2,069 patients who underwent colonoscopy between January 1992 and April 1995 by one of four surgeons at one of two centers were reviewed. Parameters included demographics, indications, procedures and findings, pathology, major complications, length of procedures and dosage of medication. Results: 2,069 colonoscopies were performed for the following indications: 877 polyp surveillance, 509 cancer surveillance, 287 rectal bleeding, 282 family history of colon cancer, 127 change in bowel habits, 112 polyps found by flexible sigmoidoscope or barium enema, 92 inflammatory bowel disease, 48 preoperation, and 58 other indications. Some patients had more than one indication. The cecum could not be intubated in 73 cases (3.5%) due to narrowing and stricture [33] redundancy [18], poor preparation [14], and other miscellaneous conditions [8]. The average procedure time in the 1,023 cases in which it was measured was 34.7 min. Average sedation doses were 2.1 mg of midazolam and 75.2 mg of meperedine in these same cases.The 2,069 colonoscopies included 1,878 biopsies, 353 polypectomies, and 139 other procedures. Some patients had multiple therapeutic interventions. Findings included 2,107 polyps, the pathology of which included 907 tubular; 62 tubulovillous and 41 villous adenomas, 325 hyperplastic polyps, and 68 carcinomas. There were five major complications after polypectomies (0.2%) including two cases of bleeding and three perforations. The two patients with bleeding were admitted to hospital, one for observation for 2 days and the other for colonoscopy, coagulation, and transfusion of 3 units of blood. Of the three patients with perforation, one underwent hospitalization for intravenous antibiotics and the other two for surgery (0.01%). Surgery included one resection with primary closure of the sigmoid perforation and one colostomy. Conclusions: This study confirms the observation that colonoscopy performed by surgeons is safe and rapid whether performed as a therapeutic or as a diagnostic procedure.

The role of peritoneoscopy (laparoscopy) in the evaluation of the acute abdomen in critically ill patients

SummaryEmergency peritoneoscopy (laparoscopy) to evaluate a suspected intraabdominal catastrophe was performed in ten critically ill patients over a 3-year period. The examination was negative in six cases, thereby avoiding celiotomy in this high-risk group. The examination was positive in four cases and, on this basis, celiotomy was recommended. Verification of the peritoneoscopic findings by clinical follow-up, operative findings, or autopsy was obtained in eight out of the ten cases. Based on our experience, we feel that peritoneoscopy is of value in defining the indications for celiotomy in this high-risk group of patients.

Intraoperative colonoscopy: Preliminary report

ConclusionColonoscopy performed in the operating room at celiotomy, but prior to colotomy, is of definite value in the intraoperative assessment of colonic disease, especially with reference to the need for and extent of resection. By avoiding colotomies, contamination of the peritoneal cavity and wound can be obviated, with concomitant diminished morbidity.

Colonoscopy in complicated diverticular disease

Colonoscopy proved to be of significant value in the evaluation of 40 patients with extensive diverticular disease by averting operative intervention in some, by comfirming or clarifying radiologic suspicions in many and by discovering unsuspected lesions occasionally. Although no endoscopic complications were encountered in this series, it is generally recognized that the acutely or chronically inflamed bowel requires special caution in endoscopic manipulation.

Abdominal wall dimensions and umbilical position vary widely with BMI and should be taken into account when choosing port locations

BackgroundMany surgeons rely on the umbilicus when determining the location of ports for laparoscopic procedures and falsely assume that it is located in the vertical midline. The purpose of this study was to assess the degree of variation in umbilical position and abdominal dimensions in the general population.MethodsTorso length, abdominal girth, weight, and height were recorded for 259 patients over a 9-month period. Body mass index (BMI) was calculated and used to classify patients into four groups: underweight, normal, overweight, and obese.ResultsAverage umbilical position for all BMI groups was below the true vertical midpoint and dropped further caudally as BMI increased. In addition, average abdominal dimensions increased with increasing BMI. There was no statistical difference between males and females in each BMI group regarding umbilical position or abdominal dimensions.ConclusionThere is a clear relationship between increasing BMI and a drop in umbilical position as well as an increase in abdominal dimensions. We recommend determining umbilical position and abdominal dimensions prior to placing ports and shifting port positions toward target quadrants.

A preliminary prospective study of the usefulness of a magnetic endoscope locating device during colonoscopy

BackgroundAlthough magnetic endoscope imaging of the colonoscope via the Endoscope Positioning Detecting Unit (EPDU) has been studied to some extent in Europe, its application in the United States has been limited. The purposes of this study were to determine whether the technique enabled for accurate localization of the lesion and to determine if and how the device facilitated scope insertion and completion of the colonoscopic exam.MethodsOutpatient colonoscopies using the EPDU were performed by three experienced surgical endoscopists over a 5-month period. A specialized scope with electromagnetic coils or a regular scope with a magnetic probe insert in the instrument channel was used for the duration of the examination to identify loops and localize pathology.ResultsA total of 80 colonoscopies were performed with the device. In two patients, the probe insert was removed prior to completion of the procedure; thus, the total number of examinations included in the study was 78. The EPDU was used in conjunction with transillumination to estimate the location of polyps or cancers in the 33 patients (42%) in whom such lesions were found. In the four patients who subsequently underwent operation, the lesion’s location as estimated by EPDU was verified. In regard to the usefulness of the device during insertion, the EPDU led to the discovery of loops and to the application of pressure that resulted in prompt completion of the examination in 28% of cases (deemed most useful). In 33% of cases, the device identified loops and led to the application of abdominal wall pressure and early position changes, thus facilitating the examination; however it did not lead to its immediate or rapid completion. In 39% of cases, the device was not required or used for insertion due to the simple nature of the examination.ConclusionsThe EPDU was accurate in estimating lesion location. The device also holds promise as an aid in the completion of difficult exams (about 30% of cases in this study).