Food Insecurity in the Elective Enhanced Recovery After Surgery Colorectal Surgical Population: Prevalence and Implications for Surgical Outcomes.

BACKGROUND: Food insecurity is defined as having limited or uncertain availability of nutritionally adequate food. Approximately 10.5% of U.S. households are food-insecure. Our study aimed to determine the prevalence and postoperative implications of food insecurity in a diverse group of colorectal surgery patients admitted to a hospital in an area with a higher-than-average median income. METHODS: The 6-question Household Food Security Survey was added to the colorectal surgery ERAS program preoperative paperwork. Patient demographics, comorbidities, operative parameters, length of stay, and postoperative outcomes were collected by review of electronic medical records. RESULTS: A total of 294 ERAS patients (88.8%) completed the survey over an 11-month period. Thirty-three patients (11.2%) were identified as food-insecure. Food-insecure patients were more likely to be non-white (P = .003), younger (P = .009), smokers (P = .004), chronic narcotic users (P < .001), unmarried (P = .007), and have more comorbidities (P = .004). The food-insecure population had more frequent postoperative ileus (P = .044). Hospital length of stay was significantly longer in food-insecure patients (8.6 days vs 5.4 days, P < .001). Food-insecure patients also had higher rates of >30-day mortality (P = .049). DISCUSSION: Food insecurity was found to occur in patients that lived in communities deemed both affluent and distressed. These patients had longer hospital stays and higher mortality. A food insecurity questionnaire can easily identify patients at risk. Further investigations to mitigate these complications are warranted.

Prospective evaluation of an evidence-based decision tool to assess pediatric blunt abdominal trauma (BAT).

PURPOSE: Computed tomography (CT) is currently the standard for evaluation of intra-abdominal injury (IAI) after BAT. Pediatric patients receiving CT scans based on adult clinical protocols are potentially exposed to unnecessary radiation. The purpose of this study is to determine the rate of CT scans before and after implementation of a pediatric BAT decision tool. METHODS: We adapted and implemented an evidence-based decision tool for pediatric BAT based on five clinical variables. We reviewed patient charts 18 months pre- and post-implementation. Demographics and outcomes were compared using Chi-square and Fisher's exact test, accordingly. RESULTS: The pre and post-implementation groups were uniform when comparing age, sex, mechanism, and Injury Severity Score. The decision tool was utilized in 85% of patients post-implementation. Fewer CT scans were obtained in the post-implementation group (28 vs. 21%, p = 0.215) with no missed injuries or late diagnoses. CONCLUSION: Implementation of a pediatric BAT decision tool decreased CT usage and radiation exposure without an obvious compromise to patient care. This experience supports the utilization of these tools for the assessment of IAI after BAT and have resulted in more selective use of CT during pediatric BAT in our program.

Opioid Requirements in Laparoscopic Colectomies: Do Enhanced Recovery After Surgery Protocols Make a Difference?

BACKGROUND: With the growing opioid epidemic and recent focus on the quantity of opioids prescribed at discharge after surgery, enhanced recovery pathways provide another tool to counteract this epidemic. The aim of this current study is to analyze the differences in opioid requirements and pain scores in the immediate postoperative period for patients who underwent laparoscopic colectomies before and after the implementation of enhanced recovery after surgery (ERAS) protocols. MATERIALS AND METHODS: This study is a retrospective review of patients and was conducted at an academically affiliated tertiary care hospital. In patients undergoing elective laparoscopic colectomies before December 1, 2013-July 31, 2015 and after September 1, 2015-May 31, 2018, the implementation of enhanced recovery pathways was included. The primary end point was opioid consumption from the end of surgery until 48 hours after surgery. Secondary end points included pain scores, surgery length of time, and hospital length of stay after surgery. RESULTS: A total of 242 patients (122 pre- and 120 postimplementation) were analyzed. Patient characteristics were similar between groups. Pain scores were higher in the preimplementation patients for postoperative day (POD) 0 scores (P = .019). There was a decrease in the morphine milligram equivalents (MME) on POD 0-2 for the postimplementation patients. This decrease resulted in a 61% reduction in opioid requirements after implementation of ERAS protocols (32 vs. 12.5 MME, P < .0001). DISCUSSION: Enhanced recovery after surgery protocols can reduce opioid requirements after elective laparoscopic colectomies without negatively affecting pain scores.

Cost-Effective Approach to the Laparoscopic Appendectomy : Balancing Disposable Instrument Cost With Operative Time.

BACKGROUND: Surgeons can help reduce health care spending by selecting affordable and efficient instruments. The laparoscopic appendectomy (LA) is commonly performed and can serve as a model for improving health care cost. METHODS: We retrospectively reviewed all adult patients who underwent LA for non-perforated appendicitis from March 2015 to November 2017. Our objective was to determine which combination of disposable instruments afforded the lowest total operative cost without compromising postoperative outcomes. RESULTS: In total, 1857 consecutive patients were reviewed from 2 hospitals. After determining the 8 most commonly utilized combinations of disposable instruments, 846 patients were ultimately analyzed. The combination of a LigaSure, Endoloop, and an EndoBag (LEB) had the shortest median operative time (25 minutes, P < .001) and lowest median total operative cost ($1893, P < .001). CONCLUSIONS: The LEB instrument combination rendered the shortest operative time, lowest total operative cost, and can be used to maximize surgical value during LA.

Genomic variation as a marker of response to neoadjuvant therapy in locally advanced rectal cancer.

There is variation in the responsiveness of locally advanced rectal cancer to neoadjuvant chemoradiation, from complete response to total resistance. This study compared genetic variation in rectal cancer patients who had a complete response to chemoradiation versus poor response, using tumor tissue samples sequenced with genomics analysis software. Rectal cancer patients treated with chemoradiation and proctectomy June 2006-March 2017 were grouped based on response to chemoradiation: those with no residual tumor after surgery (CR, complete responders, AJCC-CPR tumor grade 0, n = 8), and those with poor response (PR, AJCC-CPR tumor grade two or three on surgical resection, n = 8). We identified 195 variants in 83 genes in tissue specimens implicated in colorectal cancer biopathways. PR patients showed mutations in four genes not mutated in complete responders: KDM6A, ABL1, DAXX-ZBTB22, and KRAS. Ten genes were mutated only in the CR group, including ARID1A, PMS2, JAK1, CREBBP, MTOR, RB1, PRKAR1A, FBXW7, ATM C11orf65, and KMT2D, with specific discriminating variants noted in DMNT3A, KDM6A, MTOR, APC, and TP53. Although conclusions may be limited by small sample size in this pilot study, we identified multiple genetic variations in tumor DNA from rectal cancer patients who are poor responders to neoadjuvant chemoradiation, compared to complete responders.

Recurrence pattern and outcomes in T4 colon cancer: A single institution analysis.

BACKGROUND AND OBJECTIVES: Patients with T4 colon adenocarcinoma have an increased risk of locoregional and distant recurrence. This study defines the metastatic pattern, predictors of recurrence, and efficacy of adjuvant treatment in T4 colon cancer. METHODS: A retrospective review was performed of patients with T4 colon adenocarcinoma from May 2005 to November 2015 at a tertiary care hospital. Baseline factors, follow-up, recurrence, and survival were collected and analyzed. RESULTS: Locoregional recurrence (LR) rates for N0, N1, and N2 were 21/85 (24.7%), 14/50 (28%), and 21/46 (45.7%), respectively (P = .014). Multivariate analysis for distant recurrence was significant for positive nodes (hazard ratio [HR], 3.3; 95% confidence interval [CI], 1.1-9.9). Multivariate analysis for LR was significant for the following variables: perforation (HR, 2.7; 95% CI, 1.2-6.2), lymphovascular invasion (HR, 2.7; 95% CI, 1.1-6.7), positive nodes (HR, 2.8; 95% CI, 1.2-6.9), and positive margins (HR, 5.0; 95% CI, 2.1-12.1). Multivariate analysis for overall survival was significant for: signet ring histology (HR, 2.5; 95% CI, 1.2-5.8), positive nodes (HR, 2.3; 95% CI, 1.2-4.4), and positive margin (HR, 2.8; 95% CI, 1.4-5.8). CONCLUSION: T4 colon adenocarcinoma has a high risk of LR and mortality. Clinical trials utilizing the aforementioned high-risk features may increase the ability to demonstrate beneficial intervention.

Hidradenitis Suppurativa.

CASE SUMMARY: A 66-year-old obese (BMI 34) diabetic man, a former smoker who had quit 4 months ago, had a 20-year history of perianal, inguinal, and gluteal hidradenitis suppurativa. He presented to the office with persistent perianal and gluteal inflammation and drainage. He had had various surgical excisions of the affected area over the preceding 10 years. The patient was also following up with dermatology and was previously on doxycycline and infliximab with little improvement in his symptoms. On physical examination of his gluteal and perianal region, he had multiple areas of scarring and draining sinus tracts with significant induration ( and ). The patient underwent extensive unroofing of the sinus tracts and excision of active disease ().(Figure is included in full-text article.)(Figure is included in full-text article.)(Figure is included in full-text article.).

Transanal stricturoplasty: a minimally-invasive approach to a challenging problem.

Despite the advances in the surgical techniques and technology in colorectal surgery, the development of rectal anastomotic stricture is a common problem. In some case series, the incidence is estimated to be as high as 30%. Some of the known risk factors for developing a stricture include anastomotic leak and ischemia. Treatment options range from frequent dilations using digital rectal examinations and dilators if the stricture is low or endoscopic balloon dilations for higher strictures. Unfortunately, multiple sessions are typically required to achieve adequate results. We present a case report of a benign anastomotic stricture and describe a novel approach, transanal stricturoplasty, for this challenging problem.