Pain control with continuous infusion preperitoneal wound catheters versus continuous epidural analgesia in colon and rectal surgery: A randomized controlled trial.

OBJECTIVE: To compare continuous infusion preperitoneal wound catheters (CPA) versus continuous epidural analgesia (CEA) after elective colorectal surgery. METHODS: An open-label equivalence trial randomizing patients to CPA or CEA. Primary outcomes were postoperative pain as determined by numeric pain scores and supplemental narcotic analgesia requirements. Secondary outcomes included incidence of complications and patient health status measured with the SF-36 Health Survey (Acute Form). RESULTS: 98 patients were randomized [CPA (N = 50, 51.0%); CEA (N = 48, 49.0%)]. 90 patients were included [ CPA 46 (51.1%); CEA 44 (48.9%)]. Pain scores were significantly higher in the CPA group in the PACU (p = 0.04) and on the day of surgery (p < 0.01) as well as supplemental narcotic requirements on POD 0 (p = 0.02). No significant differences were noted in postoperative complications between groups, aggregate SF-36 scores and SF-36 subscale scores. CONCLUSIONS: Continuous epidural analgesia provided superior pain control following colorectal surgery in the PACU and on the day of surgery. The secondary endpoints of return of bowel function, length of stay, and adjusted SF-36 were not affected by choice of peri-operative pain control.

A population-based study comparing laparoscopic and robotic outcomes in colorectal surgery.

BACKGROUND: Current data addressing the role of robotic surgery for the management of colorectal disease are primarily from single-institution and case-matched comparative studies as well as administrative database analyses. The purpose of this study was to compare minimally invasive surgery outcomes using a large regional protocol-driven database devoted to surgical quality, improvement in patient outcomes, and cost-effectiveness. METHODS: This is a retrospective cohort study from the prospectively collected Michigan Surgical Quality Collaborative registry designed to compare outcomes of patients who underwent elective laparoscopic, hand-assisted laparoscopic, and robotic colon and rectal operations between July 1, 2012 and October 7, 2014. We adjusted for differences in baseline covariates between cases with different surgical approaches using propensity score quintiles modeled on patient demographics, general health factors, diagnosis, and preoperative co-morbidities. The primary outcomes were conversion rates and hospital length of stay. Secondary outcomes included operative time, and postoperative morbidity and mortality. RESULTS: A total of 2735 minimally invasive colorectal operations met inclusion criteria. Conversion rates were lower with robotic as compared to laparoscopic operations, and this was statistically significant for rectal resections (colon 9.0 vs. 16.9%, p < 0.06; rectum 7.8 vs. 21.2%, p < 0.001). The adjusted length of stay for robotic colon operations (4.00 days, 95% CI 3.63-4.40) was significantly shorter compared to laparoscopic (4.41 days, 95% CI 4.17-4.66; p = 0.04) and hand-assisted laparoscopic cases (4.44 days, 95% CI 4.13-4.78; p = 0.008). There were no significant differences in overall postoperative complications among groups. CONCLUSIONS: When compared to conventional laparoscopy, the robotic platform is associated with significantly fewer conversions to open for rectal operations, and significantly shorter length of hospital stay for colon operations, without increasing overall postoperative morbidity. These findings and the recent upgrades in minimally invasive technology warrant continued evaluation of the role of the robotic platform in colorectal surgery.

Newly implemented enhanced recovery pathway positively impacts hospital length of stay.

BACKGROUND: Enhanced recovery pathways (ERPs) are thought to improve surgical outcomes by standardizing perioperative patient care established in evidence-based literature. The objective of this study was to determine the impact of a colorectal surgery ERP on hospital length of stay (LOS) and other patient outcomes. METHODS: This is a comparative effectiveness study of patients undergoing elective colorectal surgery 2 years prior (pre-ERP group) and 2 years after (ERP group) implementation of an ERP program. The primary outcome was hospital LOS. Secondary outcomes included postoperative complications, 30-day readmissions, and 30-day reoperations. Multivariable regression analyses were utilized to control for patient factors, general health factors, diagnosis, surgeon, colon versus rectal operations, and open versus minimally invasive operations-laparoscopic and robotic. An ERP checklist was developed to track adherence to components of the pathway. RESULTS: The study population included 1036 patients: 523 in the pre-ERP group and 513 in the ERP group. Unadjusted LOS was significantly shorter in the ERP group than the control pre-ERP group [3 (IQR 3.5) vs 5 days (IQR 4.6); p < 0.0001]. Multivariable regression analysis confirmed the reduction in LOS, controlling for age, colon/rectum procedure, open/laparoscopic/robotic approach, primary diagnosis, and alvimopan use. Postoperative outcomes were not significantly different between groups except for 30-day readmissions, which were unexpectedly higher in the ERP group (14.6 vs 8.7 %, p = 0.04). CONCLUSIONS: A newly implemented ERP on a dedicated colorectal surgery service in an academic non-university hospital setting resulted in shorter hospital LOS, but increased readmissions, for patients undergoing elective open and minimally invasive colon and rectal surgery. Future multi-institutional studies are needed to understand the impact of ERP on postoperative complications and readmissions.

Bacterial Communities and Midgut Microbiota Associated with Mosquito Populations from Waste Tires in East-Central Illinois.

Mosquito-microbe interactions tend to influence larval nutrition, immunity, and development, as well as fitness and vectorial capacity of adults. Understanding the role of different bacterial species not only improves our knowledge of the physiological and ecological consequences of these interactions, but also provides the basis for developing novel strategies for controlling mosquito-borne diseases. We used culture-dependent and culture-independent techniques to characterize the bacterial composition and abundance in water and midgut samples of larval and adult females of Aedes japonicus (Theobald), Aedes triseriatus (Say), and Culex restuans (Theobald) collected from waste tires at two wooded study sites in Urbana, IL. The phylum-specific real-time quantitative polymerase chain reaction assay revealed a higher proportion of Actinobacteria and a lower proportion of gamma-Proteobacteria and Bacteroidetes in water samples and larval midguts compared to adult female midguts. Only 15 of the 57 bacterial species isolated in this study occurred in both study sites. The number of bacterial species was highest in water samples (28 species from Trelease Woods; 25 species from South Farms), intermediate in larval midguts (13 species from Ae. japonicus; 12 species from Ae. triseriatus; 8 species from Cx. restuans), and lowest in adult female midguts (2 species from Ae. japonicus; 3 species from Ae. triseriatus). These findings suggest that the composition and richness of bacterial communities varies both between habitats and among mosquito species and that the reduction in bacteria diversity during metamorphosis is more evident among bacteria detected using the culture-dependent method.

Nonsteroidal Anti-inflammatory Drugs: Do They Increase the Risk of Anastomotic Leaks Following Colorectal Operations?

BACKGROUND: Nonsteroidal anti-inflammatory drugs have become an important component of narcotic-sparing postoperative pain management protocols. However, conflicting evidence exists regarding the adverse association of nonsteroidal anti-inflammatory drug use with intestinal anastomotic healing in colorectal surgery. OBJECTIVE: This study compares patients receiving nonsteroidal anti-inflammatory drugs on postoperative day 1 with patients who did not receive nonsteroidal anti-inflammatory drugs with regard to the occurrence of anastomotic leaks. DESIGN: This is a retrospective study from a protocol-driven prospectively collected statewide database. A propensity score model was used to adjust for differences between the groups in patient demographics, characteristics, comorbidities, and laboratory values. SETTINGS: The multicenter data set used in this analysis represents a variety of academic and community hospitals within the state of Michigan from July 2012 through February 2014. PATIENTS: Nonpregnant patients over the age of 18 who underwent colon and rectal surgery with bowel anastomosis were selected. MAIN OUTCOME MEASURES: Occurrence of anastomotic leak, composite surgical site infection, sepsis, and death within 30 days of surgery were the primary outcomes measured. RESULTS: A total of 4360 patients met inclusion criteria, of which 1297 (29.7%) received nonsteroidal anti-inflammatory drugs and 3063 (70.3%) did not receive nonsteroidal anti-inflammatory drugs. There was no statistically significant difference between the 2 groups in the proportion of cases with anastomotic leak (OR, 1.33; CI, 0.86-2.05; p = 0.20), composite surgical site infection (OR, 1.26; CI, 0.96-1.66; p = 0.09), or death within 30 days (OR, 0.58; CI, 0.28-1.19; p = 0.14). There was a significantly greater risk of sepsis for patients given nonsteroidal anti-inflammatory drugs than for those patients not given nonsteroidal anti-inflammatory drugs (OR, 1.47; CI, 1.05-2.06; p = 0.03). LIMITATIONS: This is a nonrandomized study performed retrospectively, and it is based on data collected only within a subset of hospitals in the state of Michigan. CONCLUSIONS: No statistically significant increase in the proportion of patients with anastomotic leak was observed when prescribing nonsteroidal anti-inflammatory drugs for analgesia in the early postoperative period for patients undergoing elective colorectal surgery. Unexpectedly, there was an increased risk of sepsis that warrants further investigation (see video, Supplemental Digital Content 1, http://links.lww.com/DCR/A192, for a synopsis of this study).

Postoperative hyperglycemia and adverse outcomes in patients undergoing colorectal surgery: results from the Michigan surgical quality collaborative database.

PURPOSE: Our objective was to assess the relationship between high blood glucose levels (BG) in the early postoperative period and the incidence of surgical site infections (SSIs), sepsis, and death following colorectal operations. METHODS: The Michigan Surgical Quality Collaborative database was queried for colorectal operations from July 2012 to December 2013. Normoglycemic (BG < 180 mg/dL) and hyperglycemic (BG ≥ 180 mg/dL) groups were defined by using the highest BG within the first 72 h postoperatively. Outcomes of interest included the incidence of superficial, deep, and organ/space SSIs, sepsis, and death within 30 days. Initial unadjusted analysis was followed by propensity score matching and multiple logistic regression modeling after adjusting for significant predictors. Separate analyses were performed for previously diagnosed diabetic and non-diabetic patients. RESULTS: A total of 5145 cases met inclusion criteria, of which 1072 were diabetic. For diabetic patients, there was a marginally significant association between high BG and superficial SSI in the unadjusted analysis (OR = 1.75, p = 0.056), but not in the adjusted analysis (OR = 1.35, p = 0.39). There was no significant relationship between elevated BG and deep SSI, organ/space SSI, sepsis, or death among diabetic patients. For non-diabetic patients, there was a significant association between high BG and superficial SSI (OR = 1.53, p = 0.03), sepsis (OR = 1.61, p < 0.01), and death (OR = 2.26, p < 0.01), but not deep or organ/space SSI. CONCLUSIONS: Following colorectal operations, superficial SSI, sepsis, and death are associated with postoperative serum hyperglycemia in patients without diabetes, but not those with diabetes. Vigilant postoperative BG monitoring is critical for all patients undergoing colorectal surgery.

Is hepato-imino diacetic acid scan a better imaging modality than abdominal ultrasound for diagnosing acute cholecystitis?

BACKGROUND: The role of hepato-imino diacetic acid scan (HIDA) in the diagnosis of acute cholecystitis remains controversial when compared with the more commonly used abdominal ultrasound (AUS). METHODS: The diagnostic imaging workup of 1,217 patients who presented to the emergency department at a single hospital with acute abdominal pain and suspicion of acute cholecystitis was reviewed to calculate the sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) of AUS and HIDA. RESULTS: In patients undergoing both imaging modalities, HIDA had significantly higher sensitivity (90.7% vs 64.0%, P < .001) and specificity (71.4% vs 58.4%, P = .005) than AUS for the diagnosis of acute cholecystitis. Additionally, PPV and NPV of HIDA (56.2% and 95.0%, respectively) were higher than PPV and NPV of AUS (38.4% and 80.0%, respectively) when both imaging modalities were used for the same patient. CONCLUSION: In adults with acute abdominal pain, HIDA significantly increases the accuracy of the correct diagnosis.

Chlorhexidine with isopropyl alcohol versus iodine povacrylex with isopropyl alcohol and alcohol- versus nonalcohol-based skin preparations: the incidence of and readmissions for surgical site infections after colorectal operations.

BACKGROUND: Surgical site infections are a major cause of morbidity and mortality after colorectal operations. Preparation of the surgical site with antiseptic solutions is an essential part of wound infection prevention. To date, there is no universal consensus regarding which preparation is most efficacious. OBJECTIVE: This study compared 2.0% chlorhexidine with 70.0% isopropyl alcohol versus 0.7% iodine povacrylex with 74.0% isopropyl alcohol and alcohol-based versus nonalcohol-based skin preparations with regard to efficacy in preventing postoperative wound infections. DESIGN: This is a retrospective study from 2 prospectively collected statewide databases combined. A propensity score model was used to adjust for differences between the groups in patient demographics, characteristics, comorbidities, and laboratory values. SETTINGS: The multicenter data set used in this analysis represents a variety of academic and community hospitals within the state of Michigan from January 2010 through June 2012. PATIENTS: Patients over the age of 18 years who underwent clean-contaminated colorectal operations were included. MAIN OUTCOME MEASURES: The incidence of superficial surgical site infections, any surgical site infection, any wound complication, and readmission within 30 days for surgical site infection were measured. RESULTS: When 2.0% chlorhexidine with 70.0% isopropyl alcohol (n = 425) and 0.7% iodine povacrylex with 74.0% isopropyl alcohol (n = 115) were compared, a total of 540 colorectal cases met inclusion criteria. When alcohol-based (n = 610) and nonalcohol-based (n = 177) skin preparations were compared, a total of 787 colorectal cases met inclusion criteria. There was no significant difference in the propensity-adjusted odds for having any of the 4 outcomes of interest when comparing 2.0% chlorhexidine with 70.0% isopropyl alcohol to 0.7% iodine povacrylex with 74.0% isopropyl alcohol and when comparing alcohol-based with nonalcohol-based skin preparations. LIMITATIONS: This was a nonrandomized study performed retrospectively based on data collected within the state of Michigan. CONCLUSIONS: The use of 2.0% chlorhexidine with 70.0% isopropyl alcohol versus 0.7% iodine povacrylex with 74.0% isopropyl alcohol or alcohol-based versus nonalcohol-based skin preparations does not significantly influence the incidence of surgical site infections or readmission within 30 days for surgical site infection after clean-contaminated colorectal operations.

Land use patterns and the risk of West Nile virus transmission in central Illinois.

Understanding how human land use patterns influence mosquito ecology and the risk of mosquito-borne pathogens is critical for the development of disease management strategies. We examined how different environments influenced mosquito species composition, abundance, and West Nile virus (WNV) infection rates in central Illinois. Using a combination of gravid traps and CDC light traps, adult mosquitoes were collected every other week from June 24 to September 16, 2012, in four major land use categories-row crops, prairies, forest fragments, and residential neighborhoods. The mosquitoes were identified to species morphologically, and pools of pure and mixed Culex mosquitoes (primarily Culex pipiens and Culex restuans) were tested for WNV-RNA by qRT-PCR. Mosquito species diversity was significantly higher in forest habitats compared to residential, agricultural, and prairie land use categories. All the four landscape types were equally important habitats for WNV vectors Cx. pipiens and Cx. restuans, contrary to previous findings that these species principally inhabit the residential areas. WNV-infected mosquito pools were observed in all land use types, and the infection rates overlapped among land use categories. Although our findings support the importance of residential habitats for WNV transmission to humans, they also establish that prairie, row crops, and wood lots are potentially important refuges for enzootic transmission. This is particularly important in urban ecosystems where these land use categories are small, interspersed fragments serving as potential refuge sites during periods of low rainfall.

The importance of oxidases in the tolerance of deciduous leaf infusions by Aedes (Stegomyia) aegypti and Aedes (Stegomyia) albopictus (Diptera: Culicidae).

Aedes (Stegomyia) aegypti (L.) and Aedes (Stegomyia) albopictus (Skuse) larvae rely on oxidases to reduce toxicity of water soluble toxins from some senescent tree leaf infusions. The mortality of third instar Ae. aegypti larvae in live oak and pin oak leaf infusions increased significantly in the presence of piperonyl butoxide (PBO), a broad inhibitor of cytochrome P450s (CYPs). In contrast, PBO treatment did not increase mortality in water controls or infusions of northern red oak or sugar maple leaf infusions for Ae. aegypti larvae. A similar pattern was observed for Ae. albopictus larvae, that is, an increase in mortality when CYPs were inhibited in live oak leaf infusions and no increase in sugar maple leaf infusions or water controls. However, the fresh live oak leaf infusion (5 d old) was the most toxic infusion to Ae. aegypti, but appeared less toxic to Ae. albopictus than the older infusions. A direct comparison of survival between the two Aedes species revealed Ae. aegypti exhibited a greater mortality than Ae. albopictus in PBO-treated live oak leaf infusions. These findings suggest that toxic components of some leaf litter in larval habitats may impose cryptic energy costs (detoxification).