Uma R. Phatak

Facilitators and barriers of implementing enhanced recovery in colorectal surgery at a safety net hospital: A provider and patient perspective.

BACKGROUND Enhanced Recovery After Surgery (ERAS) pathways are known to decrease complications and duration of stay in colorectal surgery patients. However, it is unclear whether an ERAS pathway would be feasible and effective at a safety-net hospital. The aim of this study was to identify local barriers and facilitators before the adoption of an ERAS pathway for patients undergoing colorectal operations at a safety-net hospital. METHODS Semistructured interviews were conducted to assess the perceived barriers and facilitators before ERAS adoption. Stratified purposive sampling was used. Interviews were audiotaped, transcribed verbatim, and analyzed using content analysis. Analytic and investigator triangulation were used to establish credibility. RESULTS Interviewees included 8 anesthesiologists, 5 surgeons, 6 nurses, and 18 patients. Facilitators identified across the different medical professions were (1) feasibility and alignment with current practice, (2) standardization of care, (3) smallness of community, (4) good teamwork and communication, and (5) caring for patients. The barriers were (1) difficulty in adapting to change, (2) lack of coordination between different departments, (3) special needs of a highly comorbid and socioeconomically disadvantaged patient population, (4) limited resources, and (5) rotating residents. Facilitators identified by the patients were (1) welcoming a speedy recovery, (2) being well-cared for and satisfied with treatment, (3) adequate social support, (4) welcoming early mobilization, and (5) effective pain management. The barriers were (1) lack of quiet and private space, (2) need for more patient education and counseling, and (3) unforeseen complications. CONCLUSION Although limited hospital resources are perceived as a barrier to ERAS implementation at a safety-net hospital, there is strong support for such pathways and multiple factors were identified that may facilitate change. Inclusion of patient perspectives is critical to identifying challenges and facilitators to implementing ERAS changes focused on optimizing patient perioperative health and outcomes.

Is Nighttime the Right Time? Risk of Complications after Laparoscopic Cholecystectomy at Night

BACKGROUND Laparoscopic cholecystectomies can be performed at night in high-volume acute care hospitals. We hypothesized that nonelective nighttime laparoscopic cholecystectomies are associated with increased postoperative complications. STUDY DESIGN We conducted a single-center retrospective review of consecutive laparoscopic cholecystectomy patients between October 2010 and May 2011 at a safety-net hospital in Houston, Texas. Data were collected on demographics, operative time, time of incision, length of stay, 30-day postoperative complications (ie, bile leak/biloma, common bile duct injury, retained stone, superficial surgical site infection, organ space abscess, and bleeding) and death. Statistical analyses were performed using STATA software (version 12; Stata Corp). RESULTS During 8 months, 356 patients had nonelective laparoscopic cholecystectomies. A majority were female (n = 289 [81.1%]) and Hispanic (n = 299 [84%]). There were 108 (30%) nighttime operations. There were 29 complications in 18 patients; there were fewer daytime than nighttime patients who had at least 1 complication (4.0% vs 7.4%; p = 0.18). On multivariate analysis, age (odds ratio = 1.06 per year; 95% CI, 1.02-1.10; p = 0.002), case duration (odds ratio = 1.02 per minute; 95% CI, 1.01-1.02; p = 0.001), and nighttime surgery (odds ratio = 3.33; 95% CI, 1.14-9.74; p = 0.001) were associated with an increased risk of 30-day surgical complications. Length of stay was significantly longer for daytime than nighttime patients (median 3 vs 2 days; p < 0.001). CONCLUSIONS Age, case duration, and nighttime laparoscopic cholecystectomy were predictive of increased 30-day surgical complications at a high-volume safety-net hospital. The small but increased risk of complications with nighttime laparoscopic cholecystectomy must be balanced against improved efficiency at a high-volume, resource-poor hospital.

Glycemic control and prevention of surgical site infection.

BACKGROUND Stress hyperglycemia is associated with increased risk of surgical site infections (SSIs). Use of strict or tight glycemic control with intensive insulin therapy to prevent SSIs is controversial. METHODS Review of pertinent English-language literature. RESULTS There is a large body of literature supporting an association between stress hyperglycemia and SSIs. The quality of evidence from randomized controlled trials and meta-analyses that strict glycemic control reduces SSIs or any infections is low, and the strength of recommendation for strict glycemic control is weak due to the associated increase in moderate and severe hypoglycemia. CONCLUSION Current recommendations for glycemic control in surgical patients are informed primarily by trials using intensive insulin therapy in critically ill patients. Further research is necessary to ascertain the optimal glycemic target for non-critically ill patients, to determine if subsets of patients may benefit from strict glycemic control, and to identify alternative methods for treating stress hyperglycemia and explaining the mechanisms by which it increases infectious risk.

Component separation for complex congenital abdominal wall defects: not just for adults anymore.

PURPOSE Operative repair of large abdominal wall defects in infants and children can be challenging. Component separation technique (CST) is utilized in adults to repair large abdominal wall defects but rarely used in children. The purpose of this report is to describe our experience with the CST in pediatric patients including the first description of CST use in newborns. METHODS After IRB approval, we reviewed all patients who underwent CST between June 1, 2010 and December 31, 2012 at a large childrens hospital. CST included dissection of abdominal wall subcutaneous tissue from the muscle and fascia and an incision of the external oblique aponeurosis one centimeter lateral to the rectus sheath. Biologic mesh onlay or underlay was used to reinforce this closure. Patients were followed for complications. RESULTS Nine children, two patients with gastroschisis and seven with omphalocele, were repaired with CST at median (range) 1.1 years (5 days-10.1 years) of age. CST was the first surgical intervention for five children. There were minor wound complications and no recurrences after a median (range) follow up of 16 months (3-34 months). CONCLUSION CST can be a very useful technique to repair large abdominal wall defects in children with a loss of abdominal domain.

Review of stoma site and midline incisional hernias after stoma reversal

BACKGROUND The incidence of incisional hernias after stoma reversal is not well reported. The aim of this study was to systematically review the literature reporting data on incisional hernias after stoma reversal. We evaluated both the incidence of stoma site and midline incisional hernias. METHODS A systematic review identified studies published between January 1, 1980, and December 31, 2012, reporting the incidence of incisional hernia after stoma reversal at either the stoma site or at the midline incision (in cases requiring laparotomy). Pediatric studies were excluded. Assessment of risk of bias, detection method, and essential study-specific characteristics (follow-up duration, stoma type, age, body mass index, and so forth) was done. RESULTS Sixteen studies were included in the analysis; 1613 patients had 1613 stomas formed. Fifteen studies assessed stoma site hernias and five studies assessed midline incisional hernias. The median (range) incidence of stoma site incisional hernias was 8.3% (range 0%-33.9%) and for midline incisional hernias was 44.1% (range 8.7%-58.1%). When evaluating only studies with a low risk of bias, the incidence for stoma site incisional hernias is closer to one in three and for midline incisional hernias is closer to one in two. CONCLUSION Stoma site and midline incisional hernias are significant clinical complications of stoma reversals. The quality of studies available is poor and heterogeneous. Future prospective randomized controlled trials or observational studies with standardized follow-up and outcome definitions/measurements are needed.

Comparative effectiveness of primary tumor resection in patients with stage IV colon cancer

Although the safety of combination chemotherapy without primary tumor resection (PTR) in patients with stage IV colon cancer has been established, questions remain regarding a potential survival benefit with PTR. The objective of this study was to compare mortality rates in patients who had colon cancer with unresectable metastases who did and did not undergo PTR.

Systematic review of educational interventions for ostomates.

BACKGROUND: Stoma-related complications lead to increased hospital length of stay and readmissions. Although education of new ostomates is widely recommended, there is a lack of data regarding effective evidence-based educational interventions to prevent or decrease these complications. OBJECTIVE: The aim of this study was to systematically review the literature for educational interventions for new ostomates designed to decrease stoma-related complications. DATA SOURCES: PubMed was searched for studies on educational interventions for new ostomates. STUDY SELECTION: Studies were included if they were in English, targeted adult stoma patients, and evaluated an educational intervention at the time of stoma creation. INTERVENTION: Educational interventions were performed. MAIN OUTCOME MEASURES: The outcomes of interest were length of stay, complications, and readmissions. RESULTS: We found 1706 articles of which 7 met the inclusion criteria. Two were randomized controlled trials, and the rest were cohort studies. The overall quality of the studies was low. Each study used a unique intervention. However, all incorporated a specialized colorectal or ostomy nurse. Of the 5 studies that evaluated length of stay, 2 found a reduction in length of stay associated with the intervention, but 3 found no difference. Two studies found a reduction in complications, but 2 found no difference. Of the 3 studies that evaluated readmissions, none found a difference in the intervention group compared with the control group. LIMITATIONS: This study is limited by the search of a single database and the inclusion of only English language studies. CONCLUSION: Education is a key component of patient care; however, evidence to support an improvement in clinical outcomes is lacking. Further study is needed by the use of rigorous designs to craft a feasible educational intervention that will lead to improved patient care and outcomes.

Race not rural residency is predictive of surgical treatment for hepatocellular carcinoma: Analysis of the Texas Cancer Registry

Rural patients have poor access to specialists and are less likely to receive evidence‐based cancer care. We hypothesized that hepatocellular carcinoma(HCC) patients from rural counties in Texas would be less likely to receive surgical therapy than those from urban areas.

Initiation of a Transanal Total Mesorectal Excision Program at an Academic Training Program: Evaluating Patient Safety and Quality Outcomes.

BACKGROUND: Short-term results have shown that transanal total mesorectal excision is safe and effective for patients with mid to low rectal cancers. Transanal total mesorectal excision is considered technically challenging; thus, adoption has been limited to a few academic centers in the United States. OBJECTIVE: The aim of this study is to describe outcomes after the initiation of a transanal total mesorectal excision program in the setting of an academic colorectal training program. DESIGN: This is a single-center retrospective review of consecutive patients who underwent transanal total mesorectal excision from December 2014 to August 2016. SETTING: This study was conducted at an academic center with a colorectal residency program. PATIENTS: Patients with benign and malignant diseases were selected. INTERVENTION: All transanal total mesorectal excisions were performed with abdominal and perineal teams working simultaneously. OUTCOME MEASURES: The primary outcomes measured were pathologic quality, length of hospital stay, 30-day morbidity, and 30-day mortality. RESULTS: There were 40 patients (24 male). The median age was 55 years (interquartile range, 46.7–63.4) with a median BMI of 29 kg/m2 (interquartile range, 24.6–32.4). The primary indication was cancer (n = 30), and tumor height from the anal verge ranged from 0.5 to 15 cm. Eighty percent (n = 24) of the patients who had rectal cancer received preoperative chemoradiation. The most common procedures were low anterior resection (67.5%), total proctocolectomy (15%), and abdominoperineal resection (12.5%). Median operative time was 380 minutes (interquartile range, 306–454.4), with no change over time. For patients with malignancy, the mesorectum was complete or nearly complete in 100% of the specimens. A median of 14 lymph nodes (interquartile range, 12–17) were harvested, and 100% of the rectal cancer specimens achieved R0 status. Median length of stay was 4.5 days (interquartile range, 4–7), and there were 6 readmissions (15%). There were no deaths or intraoperative complications. LIMITATIONS: This study’s limitations derive from its retrospective nature and single-center location. CONCLUSIONS: A transanal total mesorectal excision program can be safely implemented in a major academic medical center. Quality outcomes and patient safety depend on a comprehensive training program and a coordinated team approach. See Video Abstract at http://links.lww.com/DCR/A448.

624 Implementation of Best Practices in Colorectal Surgery at a Safety Net Hospital: Facilitators and Barriers

S A T A b st ra ct s females (age 62.0±10.8 years). Median follow up period was 67.3+/-17.8months (range:12.3102.2months). CT scans were available in 651 patients (CT follow up duration : median 44.6months, range 12.3-82.8months). Preoperative VAT obesity was observed in 323 patients (49.4%) and SAT obesity in 266 (47%). Preoperative VAT obesity was associated with earlier TNM stage (p=0.042) and negative venous invasion (p=0.02). After surgery, 266 patients (53%) showed increase in VAT, and 358 patients (63.3%) in SAT after surgery. Chemotherapy did not influence in VAT or SAT changes (p=0.086). Increase in VAT amount after surgery was associated with pathologic differentiation and increase in SAT with T stage and TNM stage. By Kaplan Meier analysis, increased VAT and SAT after surgery showed higher OS (p=0.001, 0.03) and DFS (p=0.004, 0.02) in stage 3. On univariate analysis, TNM stage, pathologic differentiation, perineural invasion, preoperative CEA level, postoperative VAT and SAT change were significant predictors of OS and DFS. Preoperative VAT obesity was not associated with OS (p=0.148) and DFS (p=0.615). By multivariate Cox regression analysis, TNM stage (p=0.049), differentiation (p=0.006), perineural invasion (p=0.000) and postoperative VAT change (HR, decrease : increase = 1 : 0.493, p=0.012) were significant predictors for OS and DFS. Conclusions> In contrary to other studies, preoperative visceral obesity was not a predictor for poor prognosis in our cohort of patients. Instead, the increase in visceral fat amount after surgery was a significant positive predictor of overall and disease free survival in CRC patients undergoing curative resection.