Timothy M. Geiger

Association of Perioperative Hypothermia During Colectomy With Surgical Site Infection

IMPORTANCE Maintaining perioperative normothermia has been shown to decrease the rate of surgical site infection (SSI) after segmental colectomy and is part of the World Health Organizations Guidelines for Safe Surgery. However, strong evidence supporting this association is lacking, and an exact definition of normothermia has not been described. OBJECTIVE To determine whether intraoperative hypothermia in patients who undergo segmental colectomy is associated with postoperative SSI. DESIGN, SETTING, AND PARTICIPANTS In a retrospective cohort study at a single tertiary-referral hospital, 296 adult patients who underwent elective segmental colectomy from January 1, 2005, through December 31, 2009, were included. Exclusion criteria included postoperative stoma, emergent or urgent operation, and diagnosis of inflammatory bowel disease. EXPOSURES Perioperative temperature was measured continuously, and 4 possible definitions of hypothermia were explored, including temperature nadir, mean intraoperative temperature, percentage of time at the temperature nadir, and percentage of time with a temperature of less than 36.0°C. MAIN OUTCOMES AND MEASURES The primary outcome measure was 30-day SSI. Secondary outcome measures included clinical leak, return to the operating room, and nasogastric tube placement (a surrogate for ileus). RESULTS The mean (SD) findings were as follows: intraoperative temperature, 35.9°C (0.6°C); temperature nadir, 34.3°C (2.8°C); percentage of time at the nadir, 4.7% (10.8%); and percentage of time with a temperature of less than 36.0°C, 49.9% (42.0%). The rate of SSI was 12.2% (n = 36). There was no statistically significant difference in temperature measurements between the patients who developed an SSI and those who did not. Logistic regression models evaluated each exposure measure and its effect on SSI, adjusting for body mass index, smoking status, and sex. The adjusted analyses revealed no association between intraoperative hypothermia and 30-day SSI (odds ratio, 1.17; 95% CI, 0.76-1.81; P = .48). Increased body mass index (odds ratio, 1.39; 95% CI, 1.10-1.76; P = .007) was significantly associated with SSI in all 4 logistic regression models. CONCLUSIONS AND RELEVANCE Patients who underwent segmental colectomy and sustained a period of intraoperative hypothermia were no more likely to develop an SSI than those who were normothermic.

Disruptive Education: Training the Future Generation of Perioperative Physicians.

<zdoi;10.1097/ALN.0000000000000978> Anesthesiology, V 125 • No 2 266 August 2016 T issue of Anesthesiology contains a collection of articles describing “care redesign” in health care. This term encompasses many interpretations of the goals and objectives for redesigning the perioperative or periprocedural health care. An example of a circumscribed care redesign initiative was the operating room (oR) of the Future Project from the last decade. The goal of the oR of the Future Project was to examine the operating room systems to make them more efficient and improve utilization. The project was notable because it analyzed, among other things, the impact on its stakeholders, including participants.1–5 healthcare organizations continue actively seeking solutions, such as the oR of the future, to improve the operational performance under the pressure of declining reimbursements. A prominent current care redesign initiative is the Perioperative surgical home (Psh). The Psh aims to transition focus from the intraoperative period to the entire perioperative period, expanding the role of the consultant anesthesiologist in assisting our surgical colleagues to provide higher-quality and more cost-effective care. The oR of the future, the Psh, and the projects described in this issue represent the substantial efforts to redesign how we provide care. These projects all represent significant departures from previous thought, and they provoke us to reflect whether the current content and structure of anesthesiology education is suited to facilitate such innovation. The implicit expectation is that care redesign will improve the value for patients by improving quality and/or reducing cost, but many questions are unanswered even as healthcare organizations scramble to adapt to face new pressures. For example, how and why do care redesign initiatives arise in healthcare organizations? how are they managed, evaluated, and concluded? how do clinicians learn to participate in and lead such projects? Change in a technological environment involves altering the way people, processes, and technology work together. Does our current system of education in anesthesiology prepare clinicians to be the agents (and subjects) of change in the complex healthcare environment as we focus on improving value? Are residency training programs responding to this paradigm shift by changing curricula? Are we training residents to actively embrace and manage change, and importantly, to evaluate the outcomes? We would assert, based on the experiences like the oR of the future, that until now there has been little formal medical education on the topics of initiating, leading, and assessing the outcomes of care redesign in medicine. training the next generation of anesthesiologists to participate in the planning and leadership of new innovations in a value-driven care must become an important element of our training programs. if the Psh is in fact the future of our specialty, how should anesthesiology residency programs teach concepts to move the specialty from current state to the Psh? Currently, anesthesiology training is largely conducted in silos; residents receive training in intensive care units, pain management clinics, and in the operating room, without a unifying experience to tie the arc of periprocedural patient care together. Furthermore, the skills needed Disruptive Education

Increasing Lynch syndrome identification through establishment of a hereditary colorectal cancer registry.

BACKGROUND: Lynch syndrome contributes to 5% of all colorectal cancers. Patients seen in most surgical clinics have limited or no family histories documented and are rarely assessed for hereditary syndromes. In 2007 a clinic-based hereditary colorectal cancer registry was established to screen for Lynch syndrome and facilitate genetic counseling/testing. OBJECTIVE: To evaluate the effectiveness of the hereditary colorectal cancer registry to identify high-risk colorectal cancer patients and have them referred for genetic counseling/testing for Lynch syndrome. DESIGN: A retrospective review and cohort comparison of both prospectively collected and retrospective data. SETTING: The colorectal surgical clinic at Vanderbilt University Medical Center. PATIENTS: All newly diagnosed colorectal cancer patients seen between January 2006 and October 2010. MAIN OUTCOME MEASURES: To assess the identification of colorectal cancer patients at high risk for Lynch syndrome and for the occurrence of genetic counseling/testing before and after the establishment of a hereditary registry by comparing the results from the colorectal cancer patients seen the year prior to the establishment of the registry (January – December 2006, “control period”) with those patients seen after initiation of the registry (January 2007 – October 2010, “registry period”). RESULTS: During the “registry period,” 495 colorectal cancer patients were seen in the clinic and 257 (51.9%) were high risk for Lynch syndrome. Forty-nine patients (9.8%) underwent genetic testing, with 27 (5.4%) positive for a gene mutation, of which half were >50 years old. By comparison, in 2006, 115 colorectal cancer patients were seen in the clinic but only 4 patients (3.5%) went on for further assessment, and only 1 had genetic testing. Retrospective assessment showed that at least 22 patients (19.1%) had warranted further investigation in 2006. LIMITATIONS: This was a single-institution, retrospective review. CONCLUSION: Establishment of a hereditary colorectal cancer registry with a clinic-based protocol improves identification of Lynch syndrome.

Human alpha defensin 5 is a candidate biomarker to delineate inflammatory bowel disease

Inability to distinguish Crohns colitis from ulcerative colitis leads to the diagnosis of indeterminate colitis. This greatly effects medical and surgical care of the patient because treatments for the two diseases vary. Approximately 30 percent of inflammatory bowel disease patients cannot be accurately diagnosed, increasing their risk of inappropriate treatment. We sought to determine whether transcriptomic patterns could be used to develop diagnostic biomarker(s) to delineate inflammatory bowel disease more accurately. Four patients groups were assessed via whole-transcriptome microarray, qPCR, Western blot, and immunohistochemistry for differential expression of Human α-Defensin-5. In addition, immunohistochemistry for Paneth cells and Lysozyme, a Paneth cell marker, was also performed. Aberrant expression of Human α-Defensin-5 levels using transcript, Western blot, and immunohistochemistry staining levels was significantly upregulated in Crohns colitis, p< 0.0001. Among patients with indeterminate colitis, Human α-Defensin-5 is a reliable differentiator with a positive predictive value of 96 percent. We also observed abundant ectopic crypt Paneth cells in all colectomy tissue samples of Crohns colitis patients. In a retrospective study, we show that Human α-Defensin-5 could be used in indeterminate colitis patients to determine if they have either ulcerative colitis (low levels of Human α-Defensin-5) or Crohns colitis (high levels of Human α-Defensin-5). Twenty of 67 patients (30 percent) who underwent restorative proctocolectomy for definitive ulcerative colitis were clinically changed to de novo Crohns disease. These patients were profiled by Human α-Defensin-5 immunohistochemistry. All patients tested strongly positive. In addition, we observed by both hematoxylin and eosin and Lysozyme staining, a large number of ectopic Paneth cells in the colonic crypt of Crohns colitis patient samples. Our experiments are the first to show that Human α-Defensin-5 is a potential candidate biomarker to molecularly differentiate Crohns colitis from ulcerative colitis, to our knowledge. These data give us both a potential diagnostic marker in Human α-Defensin-5 and insight to develop future mechanistic studies to better understand crypt biology in Crohns colitis.

Nodal disease in rectal cancer patients with complete tumor response after neoadjuvant chemoradiation: Danger below calm waters

BACKGROUND: A subset of patients with rectal cancer who undergo neoadjuvant chemoradiation therapy will develop a complete pathologic tumor response. Complete nodal response is not universal in these patients and is difficult to assess clinically. Quantifying the risk of nodal disease would allow for targeted therapy with either radical resection or “watchful waiting.” OBJECTIVE: This study aimed to identify risk factors for residual nodal disease in ypT0 rectal adenocarcinoma. DESIGN: This is a retrospective case control study. SETTINGS: The National Cancer Database 2006 to 2014 was used to identify patients for this study. PATIENTS: Patients with stage II/III rectal adenocarcinoma who completed chemoradiation therapy followed by resection and who had ypT0 tumors were included. Patients with metastatic disease and <2 lymph nodes evaluated were excluded. Patients were divided into 2 groups: node positive and node negative. MAIN OUTCOME MEASURES: The main outcome was nodal disease. The secondary outcome was overall survival. RESULTS: A total of 42,257 patients with stage II/III rectal cancer underwent chemoradiation therapy and radical resection; 4170 (9.9%) patients had ypT0 tumors and 395 (9.5%) were node positive. Of patients with clinically node-negative disease (ie, pretreatment imaging), 6.2% were node positive after chemoradiation therapy and resection. In multivariable analysis, factors predictive of nodal disease included increasing (pretreatment) clinical N-stage, high tumor grade (3/4), perineural invasion, and lymphovascular invasion. Higher clinical T-stage was inversely associated with residual nodal disease. Overall 5-year survival was significantly different between patients with ypN0, ypN1, and ypN2 disease (87.4%, 82.2%, and 62.5%, p = 0.002). LIMITATIONS: This study was limited by the lack of clinical detail in the database and the inability to assess recurrence. CONCLUSIONS: Ten percent of patients with ypT0 tumors had positive nodes after chemoradiation therapy and resection. Factors associated with residual nodal disease included clinical nodal disease at diagnosis and poor histologic features. Patients with any of these features should consider radical resection regardless of tumor response. Others could be suitable for “watchful waiting” strategies. See Video Abstract at http://links.lww.com/DCR/A458.

Management of colonoscopic perforations: A systematic review

BACKGROUND Perforation during colonoscopy is a rare but well recognized complication with significant morbidity and mortality. We aim to systematically review the currently available literature concerning care and outcomes of colonic perforation. An algorithm is created to guide the practitioner in management of this challenging clinical scenario. DATA SOURCES A systematic review of the literature based on PRISMA-P guidelines was performed. We evaluate 31 articles focusing on findings over the past 10 years. CONCLUSION Colonoscopic perforation is a rare event and published management techniques are marked by their heterogeneity. Reliable conclusions are limited by the nature of the data available - mainly single institution, retrospective studies. Consensus conclusions include a higher rate of perforation from therapeutic colonoscopy when compared to diagnostic colonoscopy and the sigmoid as the most common site of perforation. Mortality appears driven by pre-existing conditions. Treatment must be tailored according to the patients comorbidities and clinical status as well as the specific conditions during the colonoscopy that led to the perforation.

Neoadjuvant radiation for clinical T4 colon cancer: A potential improvement to overall survival

Background: Resection of T4 colon cancer remains challenging compared to lower T stages. Data on the effect of neoadjuvant radiation to improve resectability and survival are lacking. The purpose of this study is to describe the use and outcomes of neoadjuvant radiation therapy in clinical T4 colon cancer. Methods: Adults with clinical evidence of T4 locally advanced colon cancer were included from the National Cancer Database (2004–2014). Bivariate and multivariable analyses were used to examine the association between neoadjuvant radiation therapy and R0 resection rate, multivisceral resection, and overall survival. Results: Fifteen thousand two hundred and seven patients with clinical T4 disease who underwent resection were identified over the study period. One hundred ninety‐five (1.3%) underwent neoadjuvant radiation therapy. Factors associated with the use of neoadjuvant radiation therapy included younger age, male sex, private insurance, lower Charlson Comorbidity Index score, and treatment at an academic research program. Neoadjuvant radiation therapy was associated with superior R0 resection rates (87.2% neoadjuvant radiation therapy vs 79.8% no neoadjuvant radiation therapy; P = .009). Five‐year overall survival was increased in the neoadjuvant radiation therapy group (62.0% neoadjuvant radiation therapy vs 45.7% no neoadjuvant radiation therapy; P < .001). The benefit of neoadjuvant radiation therapy persisted in a Cox proportional hazards multivariable model containing a number of confounding variables, including comorbidity and postoperative chemotherapy (odds ratio 1.37; 95% confidence interval 1.05–1.77; P = .01). In a subgroup analysis of T4b patients, there was an even greater size effect in adjusted overall survival (odds ratio 1.71; 95% confidence interval 1.07–2.72; P = .02). Conclusion: Although radiation is rarely used in locally advanced colon cancer, this National Cancer Database analysis suggests that the use of neoadjuvant radiation for clinical T4 disease may be associated with superior R0 resection rates and improved overall survival. Patients with clinical T4b disease may benefit the most from treatment. Neoadjuvant radiation therapy should be considered on a case‐by‐case basis in locally advanced colon cancer.

Resection for anal melanoma: Is there an optimal approach?

Background: Anal melanoma is a lethal disease, but its rarity makes understanding the behavior and effects of intervention challenging. Local resection and abdominal perineal resection are the proposed treatments for nonmetastatic disease. We hypothesize that there is no difference in overall survival between surgical therapies. Methods: The National Cancer Database (2004–2014) was queried for adults with a diagnosis of anal melanoma who underwent curative resection. Patients with metastatic disease were excluded. Patients were divided into 2 groups based on surgical approach (local resection versus abdominal perineal resection). Unadjusted and adjusted analyses were used to examine the association between surgical approach and R0 resection rate, short‐term survival, and overall survival. Results: A total of 570 patients with anal melanoma who underwent resection were identified. The median age was 68 and 59% of patients were female. A total of 383 (67%) underwent local resection. Abdominal perineal resection was associated with higher rates of R0 resection rates (abdominal perineal resection 91% versus local resection 73%; P < .001). Overall 5‐year survival for the entire cohort was 20%. There was no significant difference in 5‐year overall survival (abdominal perineal resection 21% vs local resection 17%; P = .31). This persisted in a Cox proportional hazard multivariable model (odds ratio 0.84; 95% confidence interval 0.66–1.06; P = .15). Additionally, there was no improvement in overall survival for patients who underwent R0 resection (odds ratio 1.18; 95% confidence interval 0.90–1.56; P = .22). Conclusion: Anal melanoma has a very poor prognosis, with only 1 of 5 patients alive at 5 years. Although local resection was associated with lower rates of R0 resection, there was no discernable difference in overall survival in both unadjusted and adjusted analysis.

Commentary on “Perioperative hypothermia: turning up the heat on the conversation”

We appreciate the thoughtful commentary by Dr. Mehta (1) reviewing our publication “Association of perioperative hypothermia during colectomy with surgical site infections (SSI)” (2). His commentary brings up some excellent discussion topics on the subject of hypothermia in the operating room.