Just the gastrointestinal stromal tumor: A case report of medical modeling of a rectal gastrointestinal stromal tumor.

A 54-year-old African-American male presented to the colorectal surgery clinic with the chief complaint of a painful anal swelling that had been ongoing for several weeks. An adequate rectal examination was not possible due to severe pain. Therefore, he was taken to the operating room for an exam under anesthesia where a presacral mass was identified. A transgluteal core needle biopsy was performed which was consistent with gastrointestinal stromal tumor. Computed tomography imaging identified a 16 cm ×10 cm ×9 cmrectal gastrointestinal stromal tumor. Given the size and location, the patient began treatment with neoadjuvant Imatinib. His progress was followed with serial computed tomography scans and clinic visits. A 3D model was created the tumor and surrounding structures to aide in pre- and intraoperative planning. The model was utilized during patient education and found to valuable in describing the potential for levator invasion and framing potential post-operative outcomes. The patient was able to undergo rectal preservation via a robotic low anterior resection with a transanal total mesorectal excision, coloanal anastomosis, and diverting ileostomy.

Comparing Outcomes in Patients Undergoing Colectomy at Veteran Affairs Hospitals and Non-Veteran Affairs Hospitals: A Multiinstitutional Study.

INTRODUCTION: The Veteran Affairs Surgical Quality Improvement Program (VASQIP) and National Surgical Quality Improvement Program (NSQIP) are large databases designed to measure surgical outcomes for their respective populations. We sought to compare surgical outcomes in patients undergoing colectomies at Veterans Affairs (VA) hospitals versus non-VA hospitals. METHODS: After institutional review baord approval, records for 271,523 colectomies from NSQIP and 11,597 from VASQIP between the years 2015 and 2019 were compiled. Demographics, comorbidity, 30-d mortality, and other outcomes were examined using Chi-squared, analysis of variance, Mann Whitney U, and Fisher's Exact Test within SPSS version 26. RESULTS: VASQIP patients were more likely to be male (94.3% versus 48.4%, P < 0.001) and older (median 63, 52-72 versus 67, 60-72 P < 0.001). Veterans were also more likely to have diabetes (25.3% versus 15.8%, P < 0.001), chronic obstructive pulmonary disease (15.4% versus 5.5%, P < 0.001), and congestive heart failure (17.0% versus 1.3%, P < 0.001). Veterans had slightly better 30-d mortality (2.4% versus 2.8%, P = 0.003), less organ space infections (2.8% versus 5.8%, P < 0.001), or postoperative sepsis (3.4% versus 5.3%). Non-VA patients were more likely to be having emergent surgery (13.4% versus 9.6%, P < 0.001) or undergo a laparoscopic approach (57.9% versus 50.2%, P < 0.001). Non-VA patients had shorter postoperative length of stay (5.99 d versus 7.32 d, P < 0.001) and were less likely to return to the operating room (5.3% versus 8.4%, P < 0.001) CONCLUSIONS: Despite increased comorbidity, VA hospitals and hospitals enrolled in NSQIP have managed to achieve markedly similar rates of 30-d mortality following colectomy. Further study is needed to better understand the differences between both the populations and surgical outcomes between VA hospitals and non-VA hospitals.

Trends in Resident Supervision and Patient Outcomes of Laparoscopic Cholecystectomies Within the Veterans Affairs Healthcare System.

OBJECTIVE: We sought to use the Veterans Affairs Surgical Quality Improvement Program (VASQIP) database to determine if there is an increase in morbidity or mortality when resident physicians independently perform laparoscopic cholecystectomy compared to when an attending surgeon is scrubbed. DESIGN: We performed a retrospective review of 54,144 cases of laparoscopic cholecystectomy performed within the Veterans Affairs (VA) Healthcare system from 2000 to 2020. Cases were divided into groups based on if the attending was scrubbed or not scrubbed. We then performed 1:1 case matching without replacement based on sex, race, and major comorbidities. PARTICIPANTS: Veterans over age 18 undergoing laparoscopic cholecystectomy within the VA healthcare system between 2000 and 2020. Cases were excluded if a resident was not involved in the surgery or if the level of autonomy was not defined. RESULTS: Significantly more operative cases were performed without the attending scrubbed before 2003 than after (14.6% vs 1.60%, p < 0.01). After matching, in 1464 (48.6%) cases the attending physician was scrubbed, and in 1549 (51.4%) the attending physician was not scrubbed. Patients were statistically similar in all measured comorbidities between the groups. Operative time was noted to be slightly longer when the attending was scrubbed (1.86 hours ± 0.79 vs 1.72 ± 0.67, p < 0.01) as well as increased complication rates (9.0% vs 6.1%, p < 0.01). No differences existed for 30-day mortality (0.8% vs 0.5%, p = 0.416), postoperative length of stay (2.7 days vs 2.96 days, p = 0.43), or superficial infection (1.9% vs 1.7%, p = 0.73). CONCLUSIONS: Our analysis of the VASQIP database indicates that decreased resident supervision during laparoscopic cholecystectomy has minimal impact on patient outcomes. Rates of resident independent operating have declined 10-fold since the early 2000's. Further research is required to better define the changes in resident surgical education and their impact on patient outcomes.

Penetration of the inferior vena cava and adjacent organs after filter placement is associated with retrievable filter type and length of time in place.

OBJECTIVE: Concern over local complications of inferior vena cava (IVC) filters exists, but little long-term data are available. Referrals for filter penetrations on computed tomography (CT) have increased with no standards for management. We reviewed postfilter CT findings in our institution. METHODS: All patients receiving IVC filters between January 1, 2006 and December 31, 2009 with a postfilter CT were reviewed. Penetration was graded with a previously published scale. Filter indication, type, and subsequent encounters for abdominal or back pain were recorded. RESULTS: A total of 591 patients had a filter during the study period. Of these, 262 had an adequate postfilter CT, comprising the study group. Indications were prophylaxis in 16.4% and venous thromboembolism in 83.6%. Of filters placed for venous thromboembolism, indications were absolute (inability/failure of anticoagulation) in 44.7% and relative in 55.3%. Retrievable filters made up 92.7% of the filters, and 7.3% were permanent type. Of the retrievable filters, 1.6% were retrieved. One hundred twenty (45.8%) filters had grade 2 or 3 penetration. Another 38.2% (100) had struts immediately adjacent to the external aspect of the IVC, which may represent tenting of the cava. Grade 2 or 3 penetration occurred in 49.0% of retrievable filters but only 5.3% of permanent filters (P = .0001). Grade 2 or 3 penetration occurred in 18.2% of filters less than 30 days old but in 57.3% of filters 30 days old or older (P < .0001). Thirty-two patients had subsequent encounters for abdominal or back pain, but none was conclusively related to penetration. CONCLUSIONS: A majority of filters were placed for prophylaxis or relative indications and were retrievable type. Retrieval rate was low. Penetration of the IVC and adjacent organs was common and associated with retrievable type and length of time in place. It is unclear if most penetrations cause problems. Monitoring of penetrations with CT may be important to understand the natural history of this condition.