Kurt G. Davis

Effect of race on colon cancer treatment and outcomes in the department of defense healthcare system.

PURPOSE: The increase in mortality noted in African Americans with colon cancer is attributed to advanced stage at presentation and disparities in treatment received. The aim of this study was to assess the influence of race on the treatments and survival of colon cancer patients in an equal-access healthcare system. METHODS: This retrospective cohort study included African American and white patients with colon cancer treated at Department of Defense facilities. Disease stage, surgery performed, chemotherapy used, and overall survival were evaluated. RESULTS: Of the 6958 colon cancer patients identified, 1115 were African American. African Americans presented more frequently with stage IV disease, 23% vs 17% for whites (P < .001). There was no difference in surgical resection rates for African American or whites (85.8% vs 85.5%, respectively; &khgr;2, P > .05). There was no difference in the use of systemic chemotherapy for stage III colon cancer (73.5% for African Americans vs 72.2% for whites; &khgr;2, P > .05) or stage IV colon cancer (56.3% for African Americans vs 54.4% for whites; &khgr;2, P > .05). The overall 5-year survival rate was similar for African American and white patients (56.1% vs 58.5%, respectively; log-rank, P > .05). After adjusting for gender, age, tumor grade, and stage, African American race was not a risk factor for survival in Cox proportional hazard analysis (hazard ratio, 0.981; 95% confidence interval, 0.888–1.084). CONCLUSIONS: In an equal-access healthcare system, African American race is not associated with an increase in mortality. African American patients undergo surgery and chemotherapy is administered at rates equal to whites for all stages of colon cancer.

Controversies in the Care of the Enterocutaneous Fistula

Enterocutaneous fistula and its variations are some of the most difficult problems encountered in the practice of general surgery. Reliable evidence that can be used to direct the care of patients afflicted with this malady is limited. There are controversies in several areas of care. This article addresses some of the gray areas of care for the patient with enterocutaneous fistula. There is particular attention directed toward the phenomenon of enteroatmospheric fistula, as well as prevention and abdominal wall reconstruction, which is often required in these individuals.

The use of simvastatin for the prevention of gallstones in the lithogenic prairie dog model

Background: Surgery for morbid obesity is rapidly increasing. Patients undergoing bariatric surgery are prone to gallstone development during the rapid weight loss. These patients are often given medications such as ursodeoxycholic acid to prevent gallstone formation; however, these medications are often poorly tolerated by patients, who subsequently discontinue them. We performed a study in a lithogenic animal model to assess the effectiveness of a potential alternate medication for gallstone prevention. Methods: 20 male prairie dogs were randomly separated into 2 groups and fed a lithogenic diet for 28 days. The study group animals were given 2.5 mg of the HMG-CoA reductase inhibitor simvastatin. Total cholesterol and triglycerides were measured and an open cholecystectomy was performed on each animal at the conclusion of the study period. The gallbladder was visually inspected for gallstones and microscopic biliary cholesterol crystal formation. Results: There was a decrease of 36% in the total cholesterol of the study animals compared to controls. The animals treated with simvastatin showed gallstone formation in 5/10 (50%) of animals, compared with 6/10 (60%) of control animals. The study animals demonstrated microscopic cholesterol crystal formation in 80%, identical to the number found in the control animals. Conclusion: Despite a reduction in cholesterol, simvastatin prevented neither gallstone formation nor biliary cholesterol crystals in this animal model. Given the rapid increase in the number of bariatric surgical procedures coupled with the poor tolerance of ursodeoxycholic acid, viable alternatives should continue to be sought for these patients.

Implementation of sentinel lymph node biopsy for breast cancer by surgeons in the Department of Defense

BACKGROUND Sentinel lymph node biopsy (SLNB) for the evaluation of women with invasive breast cancer is rapidly gaining acceptance. The purpose of this study was to assess how surgeons in the Department of Defense (DOD) are incorporating SLNB into practice. METHODS Surgeons at all DOD hospitals were telephonically surveyed regarding their current practices with SLNB. RESULTS Of 66 DOD hospitals 23 (35%) are currently performing SLNB. Eleven hospitals (11 of 23, 48%) are academic centers, while 12 (12 of 23, 52%) are not teaching facilities. Seventeen (17 of 23, 77%) are in the learning phase of SLNB and follow SLNB with an axillary dissection. Eighteen (18 of 23, 78%) of facilities have surgeons who learned the procedure in residency/fellowship training. Sixteen (16 of 23, 70%) use a combination of isosulfan blue dye and sulfur colloid radioisotope. Surgeons performing SLNB are not aware of the method of examination of the sentinel node at their institution at 6 of 23 (26%) of hospitals. CONCLUSIONS Increasing numbers of surgeons in the DOD Healthcare System are performing SLNB. The majority learned the procedure in residency or fellowship and are using a combination of blue dye and radioisotope for the performance of SLNB.

Sterile gloves: do they make a difference?

BACKGROUND Multiple studies have demonstrated that >10(5) organisms/mL are needed to cause a wound infection. The aim of this study was to determine if there was a difference in bacterial colony-forming units (CFUs) on sterile gloves versus clean gloves in an outpatient clinical setting. METHODS Volunteers self-gloved with pairs of clean gloves, and culture swabs were obtained from the palmar surface. Cultures were also obtained after volunteers self-donned sterile gloves and donned sterile gloves with the assistance of a surgical technician. RESULTS Twenty-five volunteers participated. Mean growths were as follows: clean gloves, 14.08 ± 15.45 CFUs/mL (range, 0-44 CFUs/mL); self-donned sterile gloves, 1.28 ± 4.28 CFUs/mL (range, 0-20 CFUs/mL); and technician-assisted sterile gloves, 1 positive with 8 CFUs/mL. CONCLUSIONS There was a statistically significant difference in bacterial load on clean gloves versus sterile gloves (P < .001). However, when comparing the bacterial contamination on clean gloves with that required to cause an infection, it appeared that this statistically significant difference was clinically irrelevant.

Crohn's Disease of the Foregut.

Crohns disease of the foregut is more common than previously recognized, with up to 40% of patients with Crohns disease in the distal intestine also having evidence of foregut disease. Esophageal disease is best managed medically with proton pump inhibition, steroids, thiopurines, methotrexate, and anti-tumor necrosis factor-α biologic medications. Esophageal strictures are dealt with using endoscopic dilation. Surgery is generally reserved of resistant strictures or esophageal fistulas. Patients with gastroduodenal disease more commonly come to surgery. The most commonly performed operations for gastroduodenal Crohns disease are intestinal bypass or strictureplasty. The concomitant use of vagotomy remains controversial.

Prevalence of teaching sentinel lymph node biopsy for breast cancer in general surgery residency programs

PURPOSE Sentinel lymphadenectomy (SLNB) for the evaluation of clinically negative lymph nodes in women with invasive breast cancer is rapidly gaining acceptance within the surgical community. The purpose of this study was to document the prevalence of teaching SLNB to residents in general surgery training programs in the United States. METHODS The Fellowship and Residency Electronic Interactive Database (FREIDA) was searched for a listing of all general surgery residency programs. A short questionnaire was mailed to the program director of each residency program listed. The program directors were asked whether general surgery residents are taught the technique of performing SLNB for breast cancer, and how the procedure is performed at their institutions. RESULTS Of the 255 surgical programs listed in FREIDA, 191 or 75% responded to the survey. Of responding programs, 92% are currently teaching surgical residents SLNB, whereas 4% plan on adding SLNB to the curriculum within the next academic year. A total of 74% of programs are performing SLNB as part of an organized hospital protocol, whereas 40% routinely follow SLNB with an axillary node dissection. A total of 89% of the programs use both sulfur colloid radioisotope and isosulfan blue dye, whereas 7% use dye alone, and 4% use only radioisotope. CONCLUSIONS The practice of performing SLNB for the purpose of detecting occult nodal metastases in breast cancer is being taught at most surgery training programs in this country. In the less than 6 years since the modification of this technique for the treatment of breast disease, it has become the standard of care for treating women with invasive breast cancer with clinically negative axillary lymph nodes at training hospitals in the United States.

Surgical management and associated complications of penetrating rectal injuries sustained in Iraq and Afghanistan.

PURPOSE The aim of this study was to analyze the surgical management and associated complications of penetrating rectal injuries sustained in Operation Iraqi Freedom and Operation Enduring Freedom. METHODS A retrospective review was performed using the Joint Theater Trauma Registry. U.S. military personnel injured in Iraq and Afghanistan from October 2003 to November 2008 were included. The surgical management of rectal injuries was evaluated, specifically looking at the utilization of diversion with ostomy, distal washout, and presacral drainage. Complications were compared between the treatment groups. RESULTS 57 patients who sustained a penetrating rectal injury were included in this study. Surgical management included diversion and ostomy alone in 34 patients (60%), diversion and distal washout in 11 patients (19%), diversion and drainage in 8 patients (14%), and diversion, distal washout, and drainage in 4 patients (7%). Complications were identified in 21% of patients. There were no deaths in the study group. Logistical regression failed to show a correlation between postoperative complications with either distal washout (p = 0.33) or presacral drainage (p = 0.9). CONCLUSIONS The majority of patients were successfully managed with fecal diversion alone, suggesting that drainage and distal washout may be unnecessary steps in the management of high-velocity, penetrating rectal injuries.

Cellular changes of the colon after mechanical bowel preparation

BACKGROUND The purpose of this study was to evaluate the effect of mechanical bowel preparation (MBP) on the intracellular environment, specifically evaluating butyrate transport, within the colon of the Sprague-Dawley rat. METHODS Sixty-eight Sprague-Dawley rats were randomized to either an MBP group (n = 34) or a control group (n = 34). Twenty-four hours after the completion of the MBP, both groups were euthanized, and the colons were harvested. The level of cellular apoptosis was investigated after DNA fragmentation, poly(ADP-ribose) polymerase cleavage, and caspase assays. Western blot analysis was performed to measure the expression of the butyrate transporter protein, monocarboxylate transporters 1, and proliferating cell nuclear antigen (a marker for tissue proliferation). Immunohistochemical staining was performed to further investigate cellular proliferation. Statistical significance (P < 0.05) was determined using two-tailed t-test. RESULTS Apoptosis was detected without significant differences in both groups. Western Blot analysis demonstrated that the expression of the monocarboxylate transporters 1 protein is downregulated in the MBP group (10.18 ± 3.09) compared with the control group (16.73 ± 7.39, P = 0.001), and proliferating cell nuclear antigen levels showed a decrease in cellular proliferation in the MBP group (13.35 ± 5.88) compared with the control (20.07 ± 7.55, P = 0.018). Immunohistochemistry confirmed a decrease in cellular proliferation after MBP with 23.4 ± 7.8% of the cells staining positive for Ki-67 in the MBP group versus 28.6 ± 7.9% in the control group (P = 0.006). CONCLUSIONS MBP has a negative impact on cellular proliferation and intracellular transport of butyrate within the rat colon, not related to apoptosis. This is the first study to demonstrate the intracellular effects that MBP has on the rat colon.

Equivalence in colonoscopy results between gastroenterologists and general surgery residents following an endoscopy simulation curriculum.

BACKGROUND In 2011, multiple gastroenterology societies published a position statement expressing concern over the American Board of Surgery guidelines regarding endoscopy education. Their position asserted that the American Board of Surgerys guidelines were inadequate to produce competency and the requirements should be similar to those adopted by the American Society for Gastrointestinal Endoscopy. This assertion failed to take into account the increasing use of simulation in surgical and endoscopic education. METHODS Surgery residents were required to complete a self-paced endoscopy simulation curriculum. A retrospective review of all patients undergoing colonoscopy at a single institution over a 6-month period was then undertaken. Specifically, the quality measures associated with colonoscopy including the cecal intubation rate and the adenoma detection rate (ADR) were compared between those colonoscopies that were performed by faculty gastroenterologists and general surgery residents. RESULTS In total, 818 colonoscopies were performed during the study period-598 were performed by the gastroenterology service (GI) and 220 were performed by general surgery residents on the surgery service (GS). Baseline characteristics of the groups were similar. Cecal intubation rates for GI and GS were 98.4% and 93.5% respectively. ADRs were similar between the groups (GI-29.8% in men and 15.3% in women; GS-26.8% in men and 18.7% in women). GI was found to perform biopsies at a higher rate than GS: 0.92 vs 0.62 (not significant, NS). GS had a higher rate of adenomas biopsied: 0.42 vs 0.32 (NS). CONCLUSIONS Following endoscopy simulation training, general surgery residents, under the supervision of surgical staff, are capable of achieving quality measures equivalent to those of staff gastroenterologists at a single institution. The ADRs and cecal intubation rates seen in this study are consistent with those previously identified in the literature.