Thomas Anthony

Practice parameters for the management of rectal cancer (revised).

The American Society of Colon and Rectal Surgeons is dedicated to assuring high-quality patient care by advancing the science, prevention, and management of disorders and diseases of the colon, rectum, and anus. The Standards Committee is composed of Society members who are chosen because they have demonstrated expertise in the specialty of colon and rectal surgery. This Committee was created to lead international efforts in defining quality care for conditions related to the colon, rectum, and anus. This is accompanied by developing Clinical Practice Guidelines based on the best available evidence. These guidelines are inclusive, and not prescriptive. Their purpose is to provide information on which decisions can be made, rather than dictate a specific form of treatment. These guidelines are intended for the use of all practitioners, health care workers, and patients who desire information about the management of the conditions addressed by the topics covered in these guidelines. It should be recognized that these guidelines should not be deemed inclusive of all proper methods of care or exclusive of methods of care reasonably directed to obtaining the same results. The ultimate judgment regarding the propriety of any specific procedure must be made by the physician in light of all of the circumstances presented by the individual patient.

Factors Affecting Recurrence following Incisional Herniorrhaphy

The purpose of this study was to determine the influence of chronic illness, obesity, and type of repair on the likelihood of recurrence following incisional herniorrhaphy. The medical records of 77 patients who underwent elective repair of a midline incisional hernia at the Dallas Veterans Affairs Medical Center between 1991 and 1995 were reviewed. Demographic data, presence of chronic illnesses, type of repair, and presence of recurrence were noted. Ninety-six percent of the patients were men, with an average age of 59 years. More than 50% of the patients had chronic lung or cardiac diseases and more than 40% weighed ≥120% of their ideal body weight and had a body mass index (BMI) ≥30. Sixty-two percent of the patients underwent primary reapproximation of the fascia (tissue repair), whereas 38% underwent repair with prosthetic material (prosthetic repair). The overall recurrence rate was 45%, with a median follow-up of 45 months (range 6–73). Seventy-four percent of the recurrences presented within 3 years of repair. The recurrence rate for those patients undergoing a tissue repair was 54%, whereas the recurrence rate following prosthetic repair was 29%. The incidence of recurrence for patients with pulmonary or cardiac disease or diabetes mellitus was similar to that of patients without these illnesses. The percent ideal body weight and BMI of patients who developed a recurrent hernia, particularly following a prosthetic repair, were significantly greater than those of patients whose repairs remained intact. These data strongly support the use of prosthetic repairs for incisional hernias, particularly in patients who are overweight.

Emergency Surgery for Colon Carcinoma

AbstractPURPOSE: Emergency surgery for colon cancer is widely thought to be associated with increased likelihood of surgical morbidity and mortality; however, other coexistent factors such as advanced disease, the age of the patient, and medical comorbid conditions may also influence these outcomes. The primary purpose of this study was to identify the relative risk for surgical morbidity and/or mortality conferred by emergency surgery compared with elective surgery for patients with colon cancer. METHODS: An Institutional Review Board-approved, case-control study was performed. During the period from January 1, 1995, to June 30, 2001, a total of 184 primary surgeries for colon cancer were performed. Emergency indications for surgery were defined as peritonitis, intra-abdominal abscess, or complete bowel obstruction at presentation (defined as emesis, distention on examination, and confirmatory plain radiograph films). By this definition, 29 patients (15.7 percent) met the criteria for inclusion. These patients were age and stage matched with 29 patients derived from the remaining 155 patients. Information was collected on surgical morbidity and mortality, length of stay, and survival. RESULTS: Age, medical comorbidities, and stage of disease were well matched between groups. The indications for the 29 emergency surgeries were as follows: 6 for peritonitis, 2 for abscesses, and 21 for complete obstructions. Nine patients did not have their primary tumor removed. Sixteen patients underwent resection and anastomosis; the remaining four patients underwent a Hartmann’s procedure. Overall surgical morbidity (64 vs. 24 percent; odds ratio, 5.1; 95 percent confidence interval, 1.7–16) and mortality (34 vs. 7 percent; odds ratio, 7.1; 95 percent confidence interval, 1.4–36.2) were significantly higher for patients undergoing emergency surgery. Among patients surviving surgery, there was no difference in overall survival between patients undergoing emergency compared with elective operation. CONCLUSIONS: Emergency surgery has a strong negative influence (beyond that which is expected based on stage of disease) on immediate surgical morbidity and mortality. The similarity between the two groups in overall survival for patients surviving the perioperative period suggests that the negative impact of emergency surgery is confined to the immediate postoperative period.

Evaluating an Evidence-Based Bundle for Preventing Surgical Site Infection: A Randomized Trial

OBJECTIVE To determine if an evidence-based practice bundle would result in a significantly lower rate of surgical site infections (SSIs) when compared with standard practice. DESIGN Single-institution, randomized controlled trial with blinded assessment of main outcome. The trial opened in April 2007 and was closed in January 2010. SETTING Veterans Administration teaching hospital. PATIENTS Patients who required elective transabdominal colorectal surgery were eligible. A total of 241 subjects were approached, 211 subjects were randomly allocated to 1 of 2 interventions, and 197 were included in an intention-to-treat analysis. INTERVENTIONS Subjects received either a combination of 5 evidenced-based practices (extended arm) or were treated according to our current practice (standard arm). The interventions in the extended arm included (1) omission of mechanical bowel preparation; (2) preoperative and intraoperative warming; (3) supplemental oxygen during and immediately after surgery; (4) intraoperative intravenous fluid restriction; and (5) use of a surgical wound protector. MAIN OUTCOME MEASURE Overall SSI rate at 30 days assessed by blinded infection control coordinators using standardized definitions. RESULTS The overall rate of SSI was 45% in the extended arm of the study and 24% in the standard arm (P = .003). Most of the increased number of infections in the extended arm were superficial incisional SSIs (36% extended arm vs 19% standard arm; P = .004). Multivariate analysis suggested that allocation to the extended arm of the trial conferred a 2.49-fold risk (95% confidence interval, 1.36-4.56; P = .003) independent of other factors traditionally associated with SSI. CONCLUSIONS An evidence-based intervention bundle did not reduce SSIs. The bundling of interventions, even when the constituent interventions have been individually tested, does not have a predictable effect on outcome. Formal testing of bundled approaches should occur prior to implementation.

Comparison of Laparoscopic and Open Repair With Mesh for the Treatment of Ventral Incisional Hernia A Randomized Trial

BACKGROUND Laparoscopic repair of ventral incisional hernias has not been proved to be safer than open mesh repair. DESIGN Prospective randomized trial conducted between February 1, 2004, to January 31, 2007. SETTING Four Veterans Affairs medical centers. PARTICIPANTS One hundred sixty-two patients with ventral incisional hernias. INTERVENTIONS Standardized laparoscopic or open repair. MAIN OUTCOME MEASURES Overall complication rates at 8 weeks and the odds of complications, adjusted for study site, body mass index, and hernia type. RESULTS Of the 162 randomized patients, 146 underwent surgery (73 open and 73 laparoscopic repairs). Complications were less common in the laparoscopic group (23 patients [31.5%]) compared with the open repair group (35 patients [47.9%]; adjusted odds ratio [AOR], 0.45; 95% confidence interval [CI], 0.22-0.91; P = .03). Surgical site infection through 8 weeks was less common in the laparoscopic group (5.6% vs 23.3%; AOR, 0.2; 95% CI, 0.1-0.6). The mean worst pain score in the laparoscopic group was 15.2 mm lower on a visual analog scale at 52 weeks (95% CI, 1.0-29.3; P = .04). Time to resume work activities was shorter for the laparoscopic group than for the open repair group (median, 23.0 days vs 28.5 days), with an adjusted hazard ratio of 0.54 (95% CI, 0.28-1.04; P = .06). Overall recurrence at 2 years was 12.5% in the laparoscopic group and 8.2% in the open repair group (AOR, 1.6; 95% CI, 0.5-4.7; adjusted P = .44). CONCLUSIONS Laparoscopic repair was associated with fewer, albeit more severe, complications and improved some patient-centered outcomes. Trial Registration clinicaltrials.gov Identifier: NCT00240188.

The diagnostic accuracy of mammography in the evaluation of male breast disease

BACKGROUND The role of mammography in the evaluation of male patients presenting with breast disease is controversial. This controversy is a function of the lack of specific data concerning the diagnostic accuracy of mammography when used in this clinical setting. The purpose of this study was to define the diagnostic accuracy of mammography in the evaluation of male breast disease. METHODS One hundred and four prebiopsy mammograms from 100 patients with tissue diagnoses were read blindly by two independent radiologists, and placed into one of five predetermined categories: definitely malignant, possibly malignant, gynecomastia, benign mass, and normal. Radiologic/pathologic correlation was performed and the sensitivity (Sn), specificity (Sp), positive (Ppv) and negative predictive value (Npv), and accuracy (Ac) for each of the mammographic diagnostic category determined. RESULTS The pathologic diagnoses were 12 cancers, including 1 patient with bilateral breast cancer, 70 cases of gynecomastia, 16 benign masses, and 6 normals. The accuracy data for the mammographic diagnostic categories are as follows: malignant (combined definitely and possibly malignant), Sn 92%, Sp 90%, Ppv 55%, Npv 99%, Ac 90%; and overall benignity (combined gynecomastia, benign mass, and normal), Sn 90%, Sp 92%, Ppv 99%, Npv 55%, Ac 90%. Six cancers (50%) coexisted with gynecomastia. CONCLUSIONS Mammography can accurately distinguish between malignant and benign male breast disease. Although not a replacement for clinical examination, its routine use could substantially reduce the need for biopsy in patients whose mammograms and clinical examination suggest benign disease.

Primary colonic lymphoma

The colon is a rare location for gastrointestinal non‐Hodgkins lymphoma (NHL). This study was undertaken to identify risk factors, presentation, treatment, and prognosis for primary colonic lymphoma (PCL) through review of a large tertiary care hospital system experience.

The impact of surgical site infection on the development of incisional hernia and small bowel obstruction in colorectal surgery

INTRODUCTION The purpose of this study was to evaluate the long-term complications of surgical site infection (SSI) in the colorectal population, specifically its association with incisional hernia and small bowel obstruction. METHODS Using standardized definitions of SSI, a retrospective review of patients undergoing transabdominal colorectal surgery from January 2002 to December 2005 was performed. Primary outcomes included incisional hernia and small bowel obstruction in patients with SSIs. RESULTS A total of 443 patients were analyzed. The median surgical follow-up was 12 months (2-3,091 days). Infections were identified in 101 (23%) cases. There were 99 cases (22%) of incisional hernia and 32 cases (7%) of small bowel obstruction. Logistic regression revealed SSI to be independently associated with incisional hernia after adjusting for clinical covariates (adjusted odds ratio = 2.23, P = .003; 95% confidence interval, 1.3-3.8). Patients with incisional hernia were 1.9 times more likely to have had an SSI (36.3% vs 18.8%, P ≤ .01). They required a longer operative time (224 minutes vs 198 minutes, P = .03), had an increased body mass index (29.0 vs 26.8, P ≤ .01), and had increased estimated blood loss (363 vs 289, mL, P = .03). Small bowel obstruction was significantly associated with operations involving the rectum (11.5% in operations involving the rectum vs 5.9% in nonrectal operations, P = .05), increased estimated blood loss (409 ml vs 297 ml, P = .04), and red blood cell transfusion (15.5% with transfusion vs 5.7% without, P = .01). SSI was not an independent predictor of small bowel obstruction (adjusted odds ratio = 1.05, P = .91; 95% confidence interval, .45-2.5). CONCLUSIONS Patients with an SSI were 1.9 times more likely to have an incisional hernia than those without an SSI. An SSI after colorectal surgery was a risk factor for the development of incisional hernia but was not a risk factor for small bowel obstruction in our population.

The effect of treatment for colorectal cancer on long-term health-related quality of life.

Background: Little information is available on the impact that therapies used in the treatment of colorectal cancer (CRC) have on long-term, health-related quality of life (HRQL). Knowledge of how HRQL is affected by these therapies is essential in properly selecting patients for treatment. The purpose of this study was to determine the long-term impact that surgical and adjuvant therapy for resectable CRC has on patient-reported HRQL in a male veteran population through a case-control design.Methods: All participating patients had completed therapy at least 6 months before enrollment. One hundred fifty-eight patients were accrued over a 3-year period (January 1, 1997 to December 31, 1999) at a single institution. The impact of CRC surgery on HRQL was measured by comparing a cohort of 61 patients undergoing surgery alone for the treatment of CRC (CRC-S group) with 44 patients undergoing surgery for benign colonic disease (BCD group). To study the effect of adjuvant therapy for CRC on HRQL, a third cohort of 53 patients undergoing both surgical and adjuvant treatment (CRC-S/A group) was compared with the CRC-S group. For each group, health status was measured by a health survey questionnaire, SHORT FORM 36 (SF36). For patients treated for CRC, an additional disease-specific supplemental questionnaire also was used.Results: Self-reported health status, as measured by mean SF36 score, was significantly reduced for the BCD group compared with CRC-S patients on general health perception (41.9 ± 3.9 vs. 52.2 ± 3.0, P = .04) and the standardized physical component score (31.2 ± 1.7 vs. 37.5 ± 1.5, P < .005). Despite an increased number of distally located tumors, later stage cancers, and an increased number of recurrences in the CRC-S/A group compared with the CRC-S cohort, no significant differences were identified between these groups on any of the subscales or standardized scores of SF36. Using the supplemental questions, no differences were identified between the CRC groups with respect to appetite, weight, or gastrointestinal or urinary functioning.Conclusions: Surgical therapy for CRC probably has minimal impact on long-term HRQL when compared with surgery for benign colonic processes. Similarly, there does not appear to be a measurable, lasting impact of CRC adjuvant therapy on HRQL when compared with surgery alone. Although overall impact of therapies for CRC on HRQL appears to be limited, measurement of therapeutic influence on an individual level and identification of selection criteria based on estimated impact on HRQL for these therapies requires prospective validation.

Surgical site infection in colorectal surgery: a review of the nonpharmacologic tools of prevention.

P S c a d o a c e o v a h s c t t t c t urgical site infections (SSI) are among the most common ource of nosocomial morbidity for patients undergoing surical procedures. SSIs are associated with increased hospital ength of stay, increased risk of mortality, and decreased ealth-related quality of life. SSIsalso increasehospital costsby 1,300to