Sergio Ibarra

Pelvic Muscle Rehabilitation: A Standardized Protocol for Pelvic Floor Dysfunction

Introduction. Pelvic floor dysfunction syndromes present with voiding, sexual, and anorectal disturbances, which may be associated with one another, resulting in complex presentation. Thus, an integrated diagnosis and management approach may be required. Pelvic muscle rehabilitation (PMR) is a noninvasive modality involving cognitive reeducation, modification, and retraining of the pelvic floor and associated musculature. We describe our standardized PMR protocol for the management of pelvic floor dysfunction syndromes. Pelvic Muscle Rehabilitation Program. The diagnostic assessment includes electromyography and manometry analyzed in 4 phases: (1) initial baseline phase; (2) rapid contraction phase; (3) tonic contraction and endurance phase; and (4) late baseline phase. This evaluation is performed at the onset of every session. PMR management consists of 6 possible therapeutic modalities, employed depending on the diagnostic evaluation: (1) down-training; (2) accessory muscle isolation; (3) discrimination training; (4) muscle strengthening; (5) endurance training; and (6) electrical stimulation. Eight to ten sessions are performed at one-week intervals with integration of home exercises and lifestyle modifications. Conclusions. The PMR protocol offers a standardized approach to diagnose and manage pelvic floor dysfunction syndromes with potential advantages over traditional biofeedback, involving additional interventions and a continuous pelvic floor assessment with management modifications over the clinical course.

Review of 500 single incision laparoscopic colorectal surgery cases - Lessons learned

Single incision laparoscopic surgery (SILS) is a minimally invasive platform with specific benefits over traditional multiport laparoscopic surgery. The safety and feasibility of SILS has been proven, and the applications continue to grow with experience. After 500 cases at a high-volume, single-institution, we were able to standardize instrumentation and operative steps, as well as develop adaptations in technique to help overcome technical and ergonomic challenges. These technical adaptations have allowed the successful application of SILS to technically difficult patient populations, such as pelvic cases, inflammatory bowel disease cases, and high body mass index patients. This review is a frame of reference for the application and wider integration of the single incision laparoscopic platform in colorectal surgery.

867 Effect of BMI on Short-Term Outcomes With Robotic-Assisted Laparoscopic Surgery: A Case-Matched Study

Background Many benefits of minimally invasive surgery are lost in the obese, but robotic-assisted laparoscopic surgery (RALS) may offer advantages in this population. Our goal was to compare outcomes for RALS in obese and non-obese patients.

Surgery for Tumors of the Heart

Most surgeons will encounter only a handful of primary cardiac tumors outside of myxomas. Approximately 3 quarters of primary cardiac tumors are benign and 1 quarter is malignant. In most cases, cardiac tumors are silent but when symptoms do occur, they are primarily determined by tumor size and anatomical location, not by histopathology. The diagnosis and preoperative imaging relies heavily on multimodal imaging including echocardiography, computed tomography, magnetic resonance imaging, and coronary angiography. Surgical resection is the most common treatment for most simple primary cardiac tumors and for some complex benign tumors. Surgical resection of primary cardiac tumors frequently involves the need for complex cardiac reconstruction, particularly when malignant. Secondary tumors to the heart are 30 times more frequent than primary cardiac tumors, and their incidence is increasing, largely as a result of advances in cancer diagnosis and therapy. Surgical resection is feasible in only a small fraction of highly-selected patients with secondary tumors to the heart. For complex benign tumors-such as paraganglioma or large fibromas-and all primary and secondary malignant tumors, a multidisciplinary cardiac tumor team review in experienced centers of excellence is recommended.

Letter to the editor regarding “Colorectal surgery and surgical site infection: is a change of attitude necessary?”

Dear Editor: Surgical site infection (SSI) is a burdening issue in the surgery units for both the patients and the health care system. According to the statistics of Centers for Disease Control and Prevention, 20,916 SSIs have been reported by 3,654 US hospitals among 2,417,933 surgical procedures performed in 2014 [1]. The SSI is associated with increased morbidity andmortality, with a larger burden in colorectal surgery (CRS) units due to the higher incidence rate. The paper by Elia-Guedea et al. entitled BColorectal surgery and surgical site infection: is a change of attitude necessary?^ published in Int J Colorectal Dis, compares the effectiveness of an implemented preventive bundle for SSI after colorectal surgery with a conventional treatment plan in reducing postoperative SSI [2]. The authors attempted to define a set of simple preventive measures in their CRS unit, which included proper antibiotic prophylaxis administration, change of operative room (OR) location, restriction of staff transit in the operating room (OR), and training sessions for surgical and clinical staff in their unit. Data analysis revealed that their preventive measures have led to a significant reduction in SSI rate and the length of hospital stay. Early inclusion of patients who underwent surgery under the new preventive bundle, which had been implemented only for 3 months, is a source of concern in that the new measures such as clinical training and OR traffic control had not been matured yet to result in a maintained behavioral change or risk reduction attitude. This can mean that the observed benefit of the bundle is not going to last beyond the study period. Moreover, such an early analysis of the data for the experimental group, when the hospital staff are still new to the preventive bundle, can increase the risk of the Hawthorne bias. Despite the authors’ motivation to diminish their own SSI rate in the CRS unit, this study does not discuss the major barriers, which already exist in their daily practice. A preventive measure is most effective in reducing the SSI incidence when the plan is tailored based on the clinical, surgical, and environmental characteristics of that specific service. In other words, how can we boost our infection prevention protocol when we are not aware of the system flaws? Another point worthy of consideration is the dissimilarity between the intervention and control groups in terms of preoperative characteristics such as body mass index (BMI), risk of SSI (SENIC score), and comorbidities as well as intraoperative measures such as procedure types and proportion of open vs. laparoscopic approaches. While the BMI in the experimental group with the new preventive bundle was significantly higher, patients in the control group who received the traditional plan had higher comorbidity (90 vs. 78.5%) and a larger proportion of higher risk categories (38.6 vs. 26.6%, for SENIC scores ≥3). According to a systematic review on risk factors for SSI after the surgery, postoperative infections were associated with comorbidities, advanced age, risk indices, frailty scores, and complexity of the procedure [3]. Also, notable in the study of Elia-Guedea et al., 61.4% of the pre-bundle patients had an open procedure compared to 45.6% of the post-bundle group. On the other hand, patients of the post-bundle group more commonly had a left or sub-total colectomy for which the leak rate, and subsequently, the deep SSI rate may be higher [4]. This is especially true when their results show a higher rate of anastomotic leak and related peritonitis in the pre-bundle group. * Saeed Shoar saeedshoar@gmail.com

Mo1624 Comparative Analysis of Single Incision Colorectal Surgery in Obese and Non-Obese Patients: A Case-Matched Study

S A T A b st ra ct s therapy to treat LRRC remains controversial. Therefore, we retrospectively analyzed patients who underwent surgical treatment for LRRC, to evaluate the perioperative outcome and the prognosis. Methods: Forty-five patients (male-female ratio, 25:20), who underwent surgical treatment for LRRC in a single institution between 1990 and 2014, were clinicopathologically analyzed. Results: The mean age at surgical treatment for LRRC was 60 years old (range 36-87). Thirty-four patients (76%) were diagnosed as LRRC within three years after surgery for the primary tumor. Total pelvic exenteration, abdominoperineal resection or low anterior resection, and simple tumor excision were performed in 7, 27, and 11 patients, respectively. The median operative time, blood loss and hospital stay were 530 min, 2213 ml and 53 days, respectively. Out of 45 patients, 32 patients (71%) had curative (R0) resection and 13 patients (29%) had non-curative resection. The complications, such as intrapelvic abscess, urinary tract dysfunction, wound infection, and intestinal obstruction, were observed in 35 patients (75%) after surgical treatment for LRRC. There was no surgery-related death. Threeyear survival rate of all 45 patients and 35 patients with R0 resection were 53% and 73%, respectively. No three-year survivors were observed in the patients with non-curative resection. Conclusions: Although surgical treatment for LRRC is highly invasive, curative (R0) resection improves the outcome of the patients with LRRC.