Marylise Boutros

Clostridium difficile colitis: Increasing incidence, risk factors, and outcomes in solid organ transplant recipients

Background Clostridium difficile-associated diarrhea (CDAD) is an increasingly important diagnosis in solid organ transplant recipients, with rising incidence and mortality. We describe the incidence, risk factors, and outcomes of colectomy for CDAD after solid organ transplantation. Methods Patients with CDAD were identified from a prospective transplant database. Complicated Clostridium difficile colitis (CCDC) was defined as CDAD associated with graft loss, total colectomy, or death. Results From 1999 to 2010, we performed solid organ transplants for 1331 recipients at our institution. The incidence of CDAD was 12.4% (165 patients); it increased from 4.5% (1999) to 21.1% (2005) and finally 9.5% (2010). The peak frequency of CDAD was between 6 and 10 days posttransplantation. Age more than 55 years (hazard ratio [HR]: 1.47, 95% confidence interval [CI]=1.16–1.81), induction with antithymocyte globulin (HR: 1.43, 95% CI=1.075–1.94), and transplant other than kidney alone (liver, heart, pancreas, or combined kidney organ) (HR: 1.41, 95% CI=1.05–1.92) were significant independent risk factors for CDAD. CCDC occurred in 15.8% of CDAD cases. Independent predictors of CCDC were white blood cell count more than 25,000/&mgr;L (HR: 1.08, 95% CI=1.025–1.15) and evidence of pancolitis on computed tomography scan (HR: 2.52, 95% CI=1.195–5.35). Six patients with CCDC underwent colectomy with 83% patient survival and 20% graft loss. Of the medically treated patients with CCDC (n=20), the patient survival was 35% with 100% graft loss. Conclusions We have identified significant risk factors for CDAD and predictors of progression to CCDC. Furthermore, we found that colectomy can be performed with excellent survival in selected patients.

Risk factors for mortality following emergency colectomy for fulminant Clostridium difficile infection.

PURPOSE: This study evaluated risk factors for mortality after emergency colectomy for fulminant Clostridium difficile infection. METHODS: Retrospective study of 130 cases of Clostridium difficile infection that required a colectomy between 1994 and 2007 in four hospitals of Quebec, Canada. Primary outcome was 30-day mortality. RESULTS: Twenty-five cases underwent colectomy in 1994 to 2002, 41 in 2003, 40 in 2004, and 24 in 2005 to 2007. Common indications were septic shock (41 percent) and nonresponse to medical treatment (39 percent). Overall, 30-day mortality was 37 percent. Mortality increased with age but was not influenced by comorbidities burden. Mortality correlated with preoperative lactate (≤2.1 mmol/L: 26 percent; 2.2-4.9 mmol/L: 52 percent; ≥5.0 mmol/L: 75 percent, P < 0.001), leukocytosis (<20.0 × 109/L: 32 percent; 20.0-49.9 × 109/L: 33 percent; ≥50.0 × 109/L: 73 percent, P = 0.008), albumin (≥25 g/L: 19 percent; 15-24 g/L: 38 percent; <15 g/L: 52 percent, P = 0.04) and renal failure. In multivariate analysis, risk factors for mortality were age (per year, adjusted odds ratio: 1.03, 95 percent confidence interval: 1.00-1.06), preoperative lactate greater than or equal to 5.0 mmol/L (adjusted odds ratio: 10.32, 95 percent confidence interval: 2.59-41.1), leukocytosis greater than or equal to 50.0 ×109/L (adjusted odds ratio: 3.68, 95 percent confidence interval: 0.92-14.8) and albumin less than 15 g/L (adjusted odds ratio, 6.57, 95 percent confidence interval: 1.31-33.1). CONCLUSIONS: Incidence of Clostridium difficile infection-related emergency colectomies increased 20-fold during the epidemic. Postoperative mortality can be predicted by simple laboratory parameters. Three-fourths of patients with leukocytosis greater or equal to 50.0 ×109/L or lactate greater or equal to 5.0 mmol/L died. When possible, emergency colectomy should be performed earlier.

Role of prophylactic ureteric stents in colorectal surgery

Ureteric injury is a feared complication in colorectal surgery, with a reported incidence of 0.2%–7.6%. Prophylactic ureteric catheter placement has the advantage of facilitating intraoperative ureter identification and assisting in immediate injury recognition and repair. However, its use has been controversial because of fear of ureteric damage during catheter insertion and postoperative urinary complications such as obstructive oliguria and urinary tract infection. Although the exact indications for prophylactic catheter placement are not clearly defined, it is generally used for reoperative cases, large tumors, previous radiation therapy, diverticulitis, fistulas, Crohns disease and obesity. Herein, we review the incidence and risk factors for ureteric injury, the role of prophylactic ureteric stents and the complications and costs associated with its use in both open and laparoscopic colorectal surgery.

The script concordance test as a measure of clinical reasoning: a national validation study

INTRODUCTION The script concordance test (SCT) is an innovative tool for clinical reasoning assessment. It has previously been shown to be a reliable and valid measure of clinical reasoning among general surgical residents. PURPOSE To determine if the SCT maintained its validity and reliability when administered on a national level. METHODS The test was administered to 202 residents (51 R1, 45 R2, 45 R3, 28 R4, and 33 R5) in 9 general surgery programs across Canada. RESULTS The optimized version of the test had a reliability (Cronbach alpha) of .85. Scores increased progressively from R1 (64.5 ± 7.6) to R2 (69.5 ± 5.8) to R3 (69.9 ± 6.7) to R4 (72.0 ± 6.2) with a dip in the R5s (68.3 ± 8.6). The test was able to differentiate junior (R1+ R2 = 66.8 ± 7.2) from senior residents (R3 + R4 + R5 = 70.0 ± 7.3, P = .001) across all the programs. CONCLUSIONS The SCT maintained its reliability and validity as a measure of intraoperative clinical reasoning among general surgical residents when administered across multiple centers. We believe that the SCT can be developed to measure clinical reasoning in high-stakes national examinations.

Inflammatory Bowel Disease in the Obese Patient

Obesity is becoming increasingly more common among patients with inflammatory bowel disease. In this review, we will explore the epidemiological trends of inflammatory bowel disease, the complex interplay between the proinflammatory state of obesity and inflammatory bowel disease, outcomes of surgery for inflammatory bowel disease in obese as compared with non-obese patients, and technical concerns pertaining to restorative proctocolectomy and ileoanal pouch reservoir, stoma creation and laparoscopic surgery for inflammatory bowel disease in obese patients.

The Molecular Basis of Cystinuria: An Update

Cystinuria is a hereditary disorder of cystine and dibasic amino acid transport across the luminal membrane of renal proximal tubule and small intestine. In 1992, a cDNA (rBAT) was isolated from kidney which induced high-affinity, sodium-independent uptake of cystine and dibasic amino acids when expressed in Xenopus oocytes. The rBAT gene was mapped to a region of chromosome 2p known to contain a cystinuria locus, and rBAT expression was demonstrated in the straight (S3) portion of renal proximal tubule and small intestine. Over 30 distinct rBAT mutations have been described in patients who inherit two fully recessive (type I) cystinuria genes. Recently, the second cystinuria gene (SLC7A9) on chromosome 19q was identified; SLC7A9 mutations were shown to cause the incompletely recessive form of cystinuria (types II and III). Patients who inherit two mutant SLC7A9 genes have recurrent nephrolithiasis comparable to those with two rBAT mutations. In some cystinuria families, patients inherit a fully recessive allele from one parent and an incompletely recessive allele from the other parent; patients with this ‘mixed type’ of cystinuria have somewhat milder disease. It is not yet clear whether this form of cystinuria involves rBAT as well as SLC7A9 mutations. Current evidence suggests that the transmembrane channel mediating uptake of cystine and dibasic amino acids at the luminal surface is encoded by SLC7A9; the smaller rBAT protein forms a heterodimeric complex with this channel and is critical for its targetting to the luminal membrane.

Small bowel adenocarcinoma and Crohn's disease: Any further ahead than 50 years ago?

This review of the literature on small bowel carcinoma associated with Crohns disease specifically addresses the incidence, risk factors, and protective factors which have been identified. It also reviews the clinical presentation, the current modalities of diagnosis, the pathology, treatment, and surveillance. Finally, the prognosis and future direction are addressed. Our experience with small bowel adenocarcinoma in Crohns disease is reported. Readers will be provided with a better understanding of this rare and often poorly recognized complication of Crohns disease.

Laparoscopic resection of rectal cancer results in higher lymph node yield and better short-term outcomes than open surgery: a large single-center comparative study.

BACKGROUND: Prognosis in rectal cancer is closely related to mesorectal integrity, margin status, and adequate lymph node dissection. The impact of laparoscopy on the pathologic and short-term outcomes remains controversial. OBJECTIVE: We aim to compare the pathologic and short-term outcomes of laparoscopic and open resections for rectal cancer. DESIGN: This is a large single-center retrospective comparative study using a prospective database. PATIENTS: All patients who underwent primary resections for rectal cancer from January 2007 to September 2011 were identified. MAIN OUTCOME MEASURES: Pathologic (nodal harvest, mesorectal integrity, circumferential, and distal margins) and operative outcomes were measured. RESULTS: Two hundred thirty-four (mean age, 61 years; 65% male) patients underwent resections for primary rectal cancer, including 118 laparoscopic (99 restorative proctectomies, 19 abdominoperineal resections) and 116 open (69 restorative proctectomies, 47 abdominoperineal resections) resections. Both groups were similar in demographics, comorbidities, and tumor characteristics. The laparoscopic group had significantly more lymph nodes (26 vs 21, p = 0.02) than the open group, with no differences in circumferential margins, proportion of distal resection margins <l cm, and completeness of total mesorectal excision. The impact of laparoscopic resection on lymph nodes was also observed for restorative proctectomy (27 vs 21, p = 0.03). Furthermore, obese and laparoscopic-converted patients had equivalent pathologic outcomes for laparoscopic and open resection. Laparoscopy was associated with longer operative time (245 vs 213 minutes, p = 0.002); less blood loss (284 vs 388 mL, p = 0.0l); shorter incisions (8 vs 20 cm, p = 0.0001) and hospital stay (7 vs 8 days, p = 0.05); and lower rates of 30-day morbidity (25% vs 43%, p = 0.04) and wound infections (9 vs 20%, p = 0.04). On multivariate regression, laparoscopic resection and year of surgery were the only independent predictors of greater lymph node harvest. CONCLUSIONS: Laparoscopy for primary rectal cancer is associated with a greater number of lymph nodes as well as short-term benefits.

Clinical Practice Guidelines for Enhanced Recovery After Colon and Rectal Surgery From the American Society of Colon and Rectal Surgeons and Society of American Gastrointestinal and Endoscopic Surgeons.

This clinical practice guideline represents a collaborative effort between the American Society of Colon and Rectal Surgeons (ASCRS) and the Society of American Gastrointestinal and Endoscopic Surgeons (SAGES). The ASCRS Clinical Practice Guidelines Committee is composed of society members who are c

Is There a Role for Oral Antibiotic Preparation Alone Before Colorectal Surgery? Acs-nsqip Analysis by Coarsened Exact Matching

BACKGROUND: Recent studies demonstrated reduced postoperative complications using combined mechanical bowel and oral antibiotic preparation before elective colorectal surgery. OBJECTIVE: The aim of this study was to assess the impact of these 2 interventions on surgical site infections, anastomotic leak, ileus, major morbidity, and 30-day mortality in a large cohort of elective colectomies. DESIGN: This is a retrospective comparison of 30-day outcomes using the American College of Surgeons National Surgical Quality Improvement Program colectomy-targeted database with coarsened exact matching. SETTINGS: Interventions were performed in hospitals participating in the national surgical database. PATIENTS: Adult patients who underwent elective colectomy from 2012 to 2014 were included. INTERVENTIONS: Preoperative bowel preparations were evaluated. MAIN OUTCOME MEASURES: The primary outcomes measured were surgical site infections, anastomotic leak, postoperative ileus, major morbidity, and 30-day mortality. RESULTS: A total of 40,446 patients were analyzed: 13,219 (32.7%), 13,935 (34.5%), and 1572 (3.9%) in the no-preparation, mechanical bowel preparation alone, and oral antibiotic preparation alone groups, and 11,720 (29.0%) in the combined preparation group. After matching, 9800, 1461, and 8819 patients remained in the mechanical preparation, oral antibiotic preparation, and combined preparation groups for comparison with patients without preparation. On conditional logistic regression of matched patients, oral antibiotic preparation alone was protective of surgical site infection (OR, 0.63; 95% CI, 0.45–0.87), anastomotic leak (OR, 0.60; 95% CI, 0.34–0.97), ileus (OR, 0.79; 95% CI, 0.59–0.98), and major morbidity (OR, 0.73; 95% CI, 0.55–0.96), but not mortality (OR, 0.32; 95% CI, 0.08–1.18), whereas a regimen of combined oral antibiotics and mechanical bowel preparation was protective for all 5 major outcomes. When directly compared with oral antibiotic preparation alone, the combined regimen was not associated with any difference in any of the 5 postoperative outcomes. LIMITATIONS: This study was limited by its retrospective design with heterogeneous data. CONCLUSIONS: Oral antibiotic preparation alone significantly reduced surgical site infection, anastomotic leak, postoperative ileus, and major morbidity after elective colorectal surgery. A combined regimen of oral antibiotics and mechanical bowel preparation offered no superiority when compared with oral antibiotics alone for these outcomes. See Video Abstract at http://links.lww.com/DCR/A358.