Suela Sulo

Oncologic and Clinicopathologic Outcomes of Robot-Assisted Total Mesorectal Excision for Rectal Cancer

BACKGROUND: Minimally invasive rectal cancer surgery is challenging and technically difficult. Robotic technology offers a stable surgical platform with magnified 3-dimensional vision and endowristed instruments, which may facilitate the minimally invasive procedure. Data on short-term and long-term outcomes indicate results comparable to laparoscopic and open surgery. OBJECTIVE: We assessed the perioperative, clinicopathologic, and oncologic outcomes of robotic surgery for rectal cancer. DESIGN: This study was a review of a prospective database of patients over a 7-year period. SETTINGS: Procedures took place in the colorectal division at a tertiary hospital. PATIENTS: From August 2005 to October 2012, 101 patients with rectal cancer were operated on using the robotic approach. Rectal cancers were defined as tumors within 15 cm from the anal verge. INTERVENTIONS: Patients received either a totally robotic or a hybrid laparoscopic-robotic operation with rectal dissection performed robotically. MAIN OUTCOME MEASURES: Operative and perioperative data, pathologic outcomes, and disease-free and overall survival were examined. RESULTS: There were 63 men (62.4%) and 38 women (37.6%) in the study; the mean age was 61.5 years. Mid rectal and low rectal cancers composed 74.2% of cases. Preoperative chemoradiation was given to 74.3% of patients. Four conversions to open surgery occurred. Circumferential margin positivity was 5%, and median lymph node yield was 15. At a mean follow-up of 34.9 months, the disease-free survival was 79.2% and overall survival 90.1%. The mean cost of robotic surgery was

Extramedullary chronic lymphocytic leukemia: Systematic analysis of cases reported between 1975 and 2012

22,640 versus

Speaking up: teens voice their health information needs.

18,330 for the hand-assisted laparoscopic approach (p = 0.005). LIMITATIONS: This was a single-institution study with no head-to-head comparative group. CONCLUSIONS: Robotic surgery for rectal cancer extirpation is safe and feasible. It has a low conversion rate, satisfies all measures of pathologic adequacy, and offers acceptable oncologic outcomes. Robotic surgery is significantly more expensive than hand-assisted laparoscopic surgery. The absence of randomized data limits recommending it as the standard of care at present.

Diagnosing Pulmonary Embolism in Pregnancy: Are Biomarkers and Clinical Predictive Models Useful?

The prognostic significance of extra-medullary chronic lymphocytic leukemia (EM-CLL) is unknown. We conducted a Medline database systematic search analyzing English language articles published between 1975 and 2012 identifying 192 cases. Patients with EM-CLL were more commonly treated than not (p < .001). Skin and central nervous system (CNS) were the most commonly reported sites of organ involvement. Survival after diagnosis of EM-CLL appeared to depend on the site of EM involvement. Prospective evaluation and further studies of EM-CLL are warranted.

Robot-assisted Abdominoperineal Resection: Clinical, Pathologic, and Oncologic Outcomes

School nurses provide an important role in the continuity of health care especially for adolescents who are at high risk for significant health concerns. The purpose of this study was to assess adolescents’ health information needs and identify their preferences for accessing health information. Using an inductive qualitative research design, 11 focus groups were conducted with a convenience sample of 101 junior high and high school students in suburban northeastern Illinois. The students identified a variety of health concerns and emphasized the need for accessible, high-quality, and personally relevant information. Most students favored taking an active role in learning about their health. They preferred to directly access information from qualified individuals within comfortable, trusting, and respectful relationships or to indirectly retrieve information from reliable resources. Finally, students emphasized the need for privacy and a variety of learning options depending on the specific health topic.

Nutrition-Focused Quality Improvement Program Results in Significant Readmission and Length of Stay Reductions for Malnourished Surgical Patients

Objective The objective of this study was to evaluate whether trimester-specific D-dimer levels or the modified Wells score (MWS) is a useful risk stratification tool to exclude pregnant women at low risk of pulmonary embolism (PE) from diagnostic imaging. Study Design This is a prospective and retrospective cohort study. Pregnant women who underwent diagnostic imaging for suspected PE were prospectively enrolled. D-dimer serum levels were drawn, and a MWS was assigned. Pregnant women diagnosed with a PE before study launch who underwent diagnostic imaging and had a D-dimer level drawn were also evaluated. Results In this study, 17 patients were diagnosed with a PE and 42 patients had no PE on diagnostic imaging. Sixteen out of 17 patients with a PE versus 11 out of 42 without PE had an abnormal D-dimer level (p = 0.001). Four patients with a PE versus zero without a PE had an abnormal MWS (p = 0.005). The combination of a trimester-specific D-dimer level along with the MWS was abnormal in all 17 patients with a documented PE versus 11/42 (26.2%) patients without a documented PE (p = 0.001). Conclusion A combination of trimester-specific D-dimer levels along with a MWS can be used in pregnancy to triage women into a low-risk category for PE and thereby avoid radiation exposure in a majority of pregnant patients.

Weight-based contrast administration in the computerized tomography evaluation of acute pulmonary embolism: Challenges in optimizing imaging quality.

BACKGROUND: The extralevator approach to abdominoperineal resection is associated with a decreased incidence of rectal perforation and circumferential resection margin positivity translating to lower recurrence rates. The abdominoperineal resection, as such, is an operation associated with poorer outcomes in comparison with low anterior resections, and any improvements in short-term outcomes are likely to be related to surgical technique. Robot assistance in extralevator abdominoperineal resection has shown improvement in these pathologic outcomes. Because these are surrogate markers for local recurrence and disease-free survival, long-term survival data are needed to assess the efficacy of this robot-assisted technique, exclusively in a dedicated abdominoperineal resection cohort. OBJECTIVE: We assessed the perioperative, pathologic, and oncologic outcomes of the robot-assisted extralevator abdominoperineal resection for rectal cancer. DESIGN: This study was a review of a prospective database of patients over a 5-year period. SETTING: Procedures were performed in the colorectal division of a tertiary hospital from April 2007 to July 2012. PATIENTS: Patients with rectal cancer were operated on robotically. Indications for abdominoperineal resection were low rectal cancers invading the sphincter complex or location in the anal canal precluding anastomosis. INTERVENTIONS: All patients received a robot-assisted extralevator abdominoperineal resection. MAIN OUTCOME MEASURES: Operative and perioperative measures, pathologic outcomes, and disease-free survival and overall survival were documented and assessed. RESULTS: Twenty-two patients (15 men) with a mean age of 65.5 years and mean BMI of 28.6 kg/m2 underwent robotic abdominoperineal resection. Circumferential resection margin was positive in 13.6%. There was 1 tumor/rectal perforation. At a mean follow-up of 33.9 months, overall survival was 81.8% with a disease-free survival of 72.7%. Local recurrence was 4.5%. LIMITATIONS: This was a single-institution study with no comparative open or laparoscopic group. CONCLUSION: Robot-assisted abdominoperineal resection is safe, feasible, and oncologically sound with short-term and long-term outcomes comparable to open and laparoscopic surgery.

The Impact of Obesity on the Perioperative, Clinicopathologic, and Oncologic Outcomes of Robot Assisted Total Mesorectal Excision for Rectal Cancer

BACKGROUND Addressing nutrition needs of inpatients results in improved health outcomes. We conducted a post hoc analysis of previously published data. The aim of this analysis was to evaluate the clinical benefits of a nutrition quality improvement program (QIP) in surgical patients when compared with medical patients. METHODS Data were collected from 1269 QIP patients and 1319 historical controls. These combined 2588 patients were categorized into surgical (390, 15%) and medical (2198, 85%) patient subgroups. RESULTS Readmission rate relative risk reductions were significantly higher among surgical patients when compared with the medical patients (46.9% vs 20.6%, P < .001). Average length of stay decreased significantly for both groups (29.0% and 29.6%, P = .8). CONCLUSION Malnourished hospitalized surgical and medical patients experienced improved readmission rates and length of stay. However, surgical patients saw a significantly greater reduction in the readmission rate when compared with the medical patients, thus highlighting the importance of nutrition on surgical outcomes. The ClinicalTrials.gov Identifier for this study is NCT02262429.

Perinatal and Neonatal Outcomes of Triplet Gestations Based on Chorionicity

Abstract Compare individualized contrast protocol, or weight-based protocol, to standard methodology in evaluating acute pulmonary embolism. Retrospective chart review was performed on patients undergoing computed tomography angiography with standard contrast protocol (n = 50) or individualized protocol (n = 50). Computerized tomography images were assessed for vascular enhancement and image quality. Demographics were comparable, however, more patients in the individualized group were admitted to intensive care unit (48% vs 16%, P = 0.004). Vascular enhancement and image quality were also comparable, although individualized protocol had significantly fewer contrast and motion artifact limitations (28% vs 48%, P = 0.039). Fifteen percent decrease in intravenous contrast volume was identified in individualized group with no compromise in image quality. Individualized contrast protocol provided comparable vascular enhancement and image quality to the standard, yet with fewer limitations and lower intravenous contrast volume. Catheter-gauge flow rate restrictions resulting in inconsistent technologist exam execution were identified, supporting the need for further investigation of this regimen.

Perinatal and Neonatal Outcomes of Triplet Gestations Based on Chorionicity [19K]

PURPOSE To analyze the feasibility and outcomes of robotic rectal cancer surgery in obese patients. METHODS From 2005 to 2012, 101 consecutive rectal cancers operated robotically were enrolled in a prospective database. Patients were stratified into obese (BMI ≥ 30 kg/m2) and non-obese (BMI < 30 kg/m2) groups. Operative, perioperative parameters, and pathologic outcomes were compared. Data were analyzed using SPSS 22.0, while statistical significance was defined as a p value ≤ .05. RESULTS There were 33 obese patients (mean BMI 33.8 kg/m2). Patients were comparable regarding gender, T stage, and type of operation. Operative time and blood loss were higher in the obese group; only operative time was statistically significant. The conversion rate, length of stay, and anastomotic leak rates were similar. Circumferential margin positivity and lymph node yield were comparable. Disease free and overall survivals at 3 years were 75.8% versus 80.9% and 84.8% versus 92.6%, respectively for obese and non-obese subgroups. CONCLUSIONS Robotic surgery for curative treatment of rectal cancer in the obese is safe and feasible. BMI does not influence conversion rates, length of stay, postoperative complications, and quality of the specimen or survival when the robotic platform is used.