Major Bowel Resection Research Articles

Improving Gastrointestinal Cancer Care by Enhanced Recovery Protocol Implementation

Background: Enhanced recovery protocols (ERPs) have become the standard of care for patients undergoing elective small bowel surgeries but have not yet been adequately studied in community hospitals. In this study, a multidisciplinary ERP was developed and implemented at a community hospital to include minimal anesthesia, early ambulation and enteral alimentation, and multimodal analgesia. The aim of this study was to determine the effects of the ERP on postoperative length of stay (LOS), readmission (RA) rates following bowel surgery, and postoperative outcomes. Methods: The study design was a retrospective review of patients undergoing major bowel resection at Holy Cross Hospital (HCH) from January 1, 2017 to December 31, 2017. Patient charts for diagnostic-related group (DRG) 329, 330, and 331 were retrospectively reviewed at HCH in 2017 to compare outcomes in ERP versus non-ERP cases. The Medicare claims database (CMS) was also retrospectively reviewed to compare HCH data to the national average LOS and RA for the same DRG codes. Mean values for LOS and RA were statistically compared to determine significant differences between ERP versus non-ERP patients at HCH and national CMS data versus HCH patients. Results: LOS was analyzed for each DRG at HCH. At HCH, for DRG 329, the mean LOS for non-ERP was 13.0833 days (n = 12) versus 3.375 days (n = 8) (P ? 0.001) for ERP. For DRG 330, the mean LOS for non-ERP was 10.861 days (n = 36) versus 4.583 days (n = 24) (P ? 0.001) for ERP. For DRG 331, the mean LOS for non-ERP was 7.272 days (n = 11) versus 3.348 days (n = 23) (P = 0.004) for ERP. LOS was also compared to national CMS data. The LOS at HCH for DRG 329 improved from the 10th to 90th percentile (n = 238,907); DRG 330 improved from the 10th to the 72nd percentile (n = 285,423); DRG 331 improved from 10th to 54th percentile (n = 126,941) (P < 0.001). The RA at HCH in ERP and non-ERP cases was 3% at 30 and 90 days. CMS RA for DRG 329 was 25.1% at 90 days and 9.9% at 30 days; DRG 330 RA was 18.3% at 90 days and 6.6% at 30 days; DRG 331 RA was 11% at 90 days and 3.9% at 30 days. Conclusion: Implementation of ERP following bowel surgery at HCH significantly improved outcomes, in comparison to non-ERP cases, national CMS data, and Humana data. Further research on ERP for other fields and its impact on outcomes in other community settings is recommended. World J Oncol. 2023;14(2):135-144 doi: https://doi.org/10.14740/wjon1534

Actinomycosis Simulating Malignancy on CT: A Case of A Long-Forgotten IUD

Actinomyces Israelii is known to be commensal, particularly in the gums and tonsils, sometimes in the vagina. The diagnosis of actinomycosis is challenging owing to nonspecific clinical findings. First instance imaging often resembles inflammatory and infective pathologies like Crohn’s or intestinal tuberculosis, and in this case, abdominal malignancies [1]. Actinomycosis infectionsare complicated by their tendency to extend into surrounding structures and develop fistulae [2]. Our case report specifically looks at a fit-and-well female patient who had been referred under a suspected gastrointestinal cancer pathway after a recent change in bowel habit for CT imaging which was subsequently thought to be disseminative malignant growths. Our 56-year-old lady had an indurating mass in her abdomen draining pus which prompted her GP to discuss this case with the surgeons. On further MRI imaging and lab cultures, it was revealed that the sinister mass is found to be an Actinomyces Israelii colonised long-forgotten IUD placed 12 years ago. The unfortunate patient suffered widespread abdominal involvement which required extensive surgery involving major bowel resection, salpingo-oopherectomy, bilateral ureteric stents for hydronephrosis and a partial cystectomy.

Epidemiology and Natural History of Perianal Crohn's Disease: A Systematic Review and Meta-Analysis of Population-Based Cohorts.

Perianal Crohn's disease (pCD) is a potentially severe phenotype of CD. We conducted a systematic review with meta-analysis to estimate cumulative incidence, risk factors, and outcomes of pCD in population-based cohort studies. Through a systematic literature review through March 1, 2021, we identified population-based inception cohort studies reporting cumulative incidence of perianal disease (primarily abscess and/or fistula) in patients with CD. We estimated the cumulative incidence of pCD at presentation and 1-, 5-, and 10-year follow-up, and risk factors for perianal disease and outcomes including risk of major (bowel resection, proctectomy, ostomy) and minor perianal (incision and drainage, seton placement, etc.) surgery. In 12 population-based studies, prevalence of pCD was 18.7% (95% confidence interval [CI], 12.5%-27.0%) with 1-, 5-, and 10-year risk of perianal disease being 14.3% (95% CI, 7.9%-24.6%), 17.6% (95% CI, 11.3%-26.5%), and 18.9% (95% CI, 15.0%-23.4%), respectively. Approximately 11.5% of patients (95% CI, 6.7%-19.0%) had perianal disease at or before CD diagnosis. Colonic disease location and rectal involvement were associated with higher risk of pCD. Overall, 63.3% of patients (95% CI, 53.3-72.3) required minor perianal surgery and 6.4% of patients (95% CI, 1.8%-20.6%) required major abdominal surgery for pCD. Use of biologic therapy for pCD is common and has steadily increased throughout the years. Approximately 1 in 5 patients with CD develops perianal disease within 10 years of CD diagnosis, including 11.5% who have perianal disease at presentation. Approximately two-thirds of patients require perianal surgery, with a smaller fraction requiring major abdominal surgery.

A phase II trial of short-course Hyperthermic IntraPEritoneal Chemotherapy (HIPEC) for high tumor burden ovarian cancer: updated report with preliminary survival outcomes

<h3>Objectives:</h3> To present an updated report with preliminary survival outcomes from our feasibility study. <h3>Methods:</h3> This study was a non-randomized, open-label, multi-center, single-arm trial on the safety and efficacy of neoadjuvant chemotherapy (NACT) followed by fast-track cytoreductive surgery (CRS) plus short-course HIPEC (i.e.: 30 min) in advanced ovarian cancer (NCT02249013). HIPEC was performed according to the closed-abdomen technique using a concentration-based regimen of cisplatin (25 mg/m²/L) or cisplatin plus doxorubicin (15mg/L) at 41–43°C. Dextrose perfusate was circulated using the Performer HT device (RAND Srl, Medolla, MO, Italy) at a flow rate of 700ml/min. Primary endpoint was PD9 (i.e.: proportion of patients with disease progression or death occurring within 9 months of interval CRS plus HIPEC) and secondary endpoints were morbidity (mortality and complication rates related to CRS plus HIPEC), time to start adjuvant chemotherapy, length of ICU and hospital stay, QoL over treatment (EORTC QLQ-C30), and ultimately progression-free (PFS) and overall (OS) survivals. Funding sources were from Decit/SCTIE/MS - CNPq/FACEPE/SES-PE (APQ:0187-4.01/13) and FAPE/IMIP. <h3>Results:</h3> A total of 15 patients with stage III epithelial malignancies were recruited from our public health system between February 2015 and July 2019 in four Brazilian centers. The median (range) age was 46 years (19–67), with preoperative serum CA125 levels of 737.7U/mL (161.6–6550). The median number of preoperative cycles of IV chemotherapy was 3 (2–4), resulting in PCI scores of 11 (3–18) at the time of interval CRS plus HIPEC performed after a median of 29 days (26–43) from the last neoadjuvant cycle. Time to restarts IV chemotherapy was 39 days (31–74) and fourteen (93.3%) patients completed all the six cycles of IV chemotherapy as planned. Only 1 patient did not start the systemic adjuvant therapy due to poor recovery after surgery. Median operation time was 490 minutes (235–865), with 9 (60%) patients requiring major bowel resection as rectosigmoidectomy (n=8) or partial colectomy (n=1), but with a nil rate of ostomies. Median length of hospital stay was 5 days (3–10), with ICU stay of 1 day (1–5). Four patients experienced no postoperative complications, whereas 5 suffered only minor G1/G2 complications, and 6 suffered major G3 complications, according to the NCI/CTCAE classification. The most common complications were electrolytes imbalance and anemia. Two patients experienced reoperation because of G3 postoperative hemorrhage or peritoneal infection, whereas no deaths were recorded. No significant difference over time in the QLQ-C30 summary scores was observed (p>0.05). With a median follow-up of 32 (18.2–61.2) months, PD9 and median PFS was 6.7% and 18 months, respectively. At this time, median OS was not reached and our 2y- PFS and OS was 30.8% and 92.8%, respectively. <h3>Conclusions:</h3> We confirm the preliminary hypothesis of safety and efficacy for our comprehensive approach involving the use of short-course HIPEC in high tumor burden ovarian cancer. Median overall survival is pending to confirm short-course HIPEC at the time of interval CRS as a promising approach in terms of survival outcomes.

P256 High disease burden of CROHN’S DISEASE (CD) in a Latin American IBD reference center

Abstract Background CD is a multifactorial, heterogeneous, disabling condition, with high surgical rates and complications. Best knowledge of regional clinical features may favor awareness, evolution and healthcare resources. AIM: to describe by means a retrospective study in a Latin American IBD reference center, clinical characteristics of our CD casuistic, and the risk for surgery. Methods data of CD patients (pts) assisted from 1990-June 2020 (CD duration≥1 yr), registered in a database, were revised and reclassified (by Montreal) in Age at diagnosis (A)A1:≦16yrs, A2:17–40, A3:&amp;gt;40, Behavior (B) B1, stricturing (B2), penetrating (B3), perianal modifier (p), Location (L) L1: ileal, L2: colonic, L3: ileocolonic, L4: upper GI: isolated or combined. Incidence rates of progression and surgery (major abdominal surgery and/or bowel resection) were estimated (Kaplan Meier). Results 598 CD pts (M 313, F 285), CD median duration 13.9 yrs (IQR 7.1–21.2) were available for analysis. Montreal A1: n 93 (15.6%), A2: n 335 (56.0%), A3: n 170 (28.4%). Behavior patterns rates within 90 days from diagnosis were: B1: n 523 (87.5%), B2: n 52 (8.7%), B3: n 23 (3.8%). Location L1: n 52 (8.7%), L2: n 368 (61.5%) L3: n 176 (29.4), L4: n 2 (0.33%) and L4 combined with L1, L2, L3: n 47 (7.9%). Complicated initial behavior (or progression to complications) was observed in 252/598 (42.1%). Rates of cumulative incidence of developing either stricturing or penetrating complications at 1, 3, 5, 10 yrs were: 20.9% (95%CI 17.9–24.4), 31.4% (95%CI 27.7–35.4), 37.0% (95%CI 33.0–41.3), 48.4% (95%CI 43.5–53.4) respectively; by each complication were for B2: 15.22%, 22.9%, 27.0%, 34.1%, and B3: 6.7%, 11.1%, 14.6%, 21.9%, respectively. Both complications in same patient were present in 54 (9%) pts. B3 was more prevalent in L3 (40.8%), B2 in L1 (56.3%), (p=0.00001 for both) vs L2 (16.7%, 22.2% respectively). Perianal disease (p) was more frequent in L2 (53.2% p&amp;lt;0.024) vs. the rest of locations (L1: 39.6%, L3: 40.8%, half of L4). CD location progression was less frequent (5%, mainly progression on small bowel). Considerable proportions of pts needed early IV steroids, immunosuppressants (58%), Biologics (at least one: 44%) and optimization. Major surgery was performed in 304/598 pts (50.8%),≥1 in 20%; 9.8% needed permanent stoma. Cumulative incidence rates of major surgery at 90 days, 1, 3, 5, 10 yrs were 5.7%, 11.7%, 23.4%, 29.1%, 42.0%. Patterns B2, B3, L1, L3, L4, A2, also (unusual) A3 were substantial contributors. Conclusion We found high disease burden in this Latin American referral IBD cohort with a large proportion of patients presenting/developing a complicated disease behaviour, with high need for immunosupressive/biological therapy and high rates of major surgery.

Morbidity and mortality after major large bowel resection of non-malignant polyp among participants in a population-based screening program.

Background and aimsColonoscopy following positive fecal occult blood screening may detect non-malignant polyps deemed to require major large bowel resection. We aimed to estimate the major inpatient morbidity and mortality associated with major resection of non-malignant polyps detected at colonoscopy following positive guaiac fecal occult blood screening in Ontario's population-based colorectal screening program.MethodsWe identified those without a diagnosis of colorectal cancer in the Ontario Cancer Registry ≤24 months following the date of colonoscopy prompted by positive fecal occult blood screening between 2008 and 2017, who underwent a major large bowel resection ≤24 months after the colonoscopy, with a diagnosis code for non-malignant polyp, in the absence of a code for any other large bowel diagnosis. We extracted records of major inpatient complications and readmissions ≤30 days following resection. We computed mortality within 90 days following resection.ResultsFor those undergoing colonoscopy ≤6 months following positive guaiac fecal occult blood screening, 420/127,872 (0.03%) underwent major large bowel resection for a non-malignant polyp. In 50/420 (11.9%), the resection included one or more rectosigmoid or rectal polyps, with or without a colonic polyp. There were one or more major inpatient complications or readmissions within 30 days in 117/420 (27.9%). Death occurred within 90 days in 6/420 (1.4%).ConclusionsSerious inpatient complications and readmissions following major large bowel resection for non-malignant colorectal polyps are common, but mortality ≤90 days following resection is low. These outcomes should be considered as unintended adverse consequences of population-based colorectal screening programs.

Morbidity and mortality following major large bowel resection for colorectal cancer detected by a population-based screening program

In 2008, Ontario initiated a population-based colorectal screening program using guaiac fecal occult blood testing. This work was undertaken to fill a major gap in knowledge by estimating serious post-operative complications and mortality following major large bowel resection of colorectal cancer detected by a population-based screening program. We identified persons with a first positive fecal occult blood result between 2008 and 2016, at the age of 50-74 years, who underwent a colonoscopy within 6 months, and proceeded to major large bowel resection for colon cancer within 6 months or rectosigmoid/rectal cancer within 12 months, and identified an unscreened cohort of resected cases diagnosed during the same years at the age of 50-74 years. We identified serious postoperative complications and readmissions ≤30 days following resection, and postoperative mortality ≤30 days, and between 31 and 90 days among the screen-detected and the unscreened cohorts. Serious post-operative complications or readmissions within 30 days were observed among 1476/4999 (29.5%) cases in the screen-detected cohort, and among 3060/8848 (34.6%) unscreened cases. Mortality within 30 days was 43/4999 (0.9%) among the screen-detected cohort, and 208/8848 (2.4%) among the unscreened cohort. Among 30 day survivors, mortality between 31 and 90 days was 28/4956 (0.6%) and 111/8640 (1.3%), respectively. Serious post-operative complications, readmissions, and mortality may be more common following major large bowel resection for colorectal cancer between the ages of 50 and 74 among unscreened compared to screen-detected cases.

Revising the definition of vertical margin involvement following endoscopic polypectomy may reduce unnecessary surgery in patients with malignant colorectal polyps.

Background and Study AimsEndoscopically resected malignant colorectal polyps (MCPs) present a dilemma regarding whether the risk of residual disease justifies a major bowel resection. Overtreatment is common, and the vast majority of patients who undergo resection have no residual tumor. The aim of this study was to investigate whether revising the definition of vertical margin involvement following MCP polypectomy could reduce unnecessary surgery.Patients and MethodsThis was a cohort study of consecutive patients with MCPs treated at a tertiary hospital between 2004 and 2018. Data on demographics, index colonoscopy, polyp pathology, and any subsequent surgical resection were analyzed. Polypectomy resection margins were reviewed and measured to the nearest decimal place. The ability of existing guidelines (requiring a margin clearance of ≥ 1 mm) to predict residual disease was compared to a revised version requiring a margin clearance of ≥ 0.1 mm.ResultsA total of 129 patients with an MCP were included. Of these 129 patients, 77 (60%) underwent surgical resection, of which 62 (81%) had no residual tumor. Existing guidelines, requiring a margin clearance of ≥ 1 mm, classified 28 patients as being at “low risk” for residual disease. Of these, four underwent surgery, but none had residual tumor (P = 0.031). Revised guidelines, requiring a margin clearance of ≥ 0.1 mm, classified 44 patients as “low risk.” Of these, in the 13 that had surgery, no residual tumor was found (P = 0.003).ConclusionsRevising the definition of vertical margin involvement leads to more patients being correctly classified as being at low risk of residual disease. This has the potential to reduce unnecessary surgery in patients with MCPs.

Five Anabolic Steroids in the Treatment of Inflammatory Bowel Disease

Abstract Crohn's disease (CD) and ulcerative colitis (UC), the constituents of Inflammatory Bowel Disease (IBD), are the most destructive benign diseases of young adults. Two-hundred thousand young men and women in North America will have major bowel resection annually, half to experience a premature death and many an increased risk of colorectal cancer. New cases in the youngest quadrille are appearing at a 0.5 percent rate per year. Adalimumab, the last pharmaceutical TNF-inhibitor drug approved for IBD was 17 years ago. Adalimumab's failure rate is 40 percent by year two, 60 percent by year five, and the 12-year German study questions whether there is any long-term gain in quality of life at all. The problems to date in understanding and treating IBD are that no one has identified the cause, no specific biomarkers are recognized, no alternatives to overtly toxic medications and no alternatives exist for inevitable surgical resections. That has changed. There are now serum hormonal biomarkers that are highly predictive of flairs in Crohn's diseases; the first being the nuclear membrane Estrogen Receptor-beta/Estrogen Receptor-alpha ratio. The second being bioavailable testosterone measured as the Free Androgen Index. Causation is clearly demarcated to hormonal dysregulation at the Hypothalamic-Pituitary-Gonadal Axis suppressing testosterone production. Five inexpensive, generic, FDA approved anabolic steroid medications have been successfully used to treat IBD, albeit, not the recognized standard of care. Here is the future of medicine: After initial medical information intake, measure Gender Specific Medicine biomarkers of gonadal hormones (causation) and then treat to normalize these biomarkers. Admixtures of anabolic steroids should reset the biomarkers and reduce the autoimmune, inflammatory, and systemic aspects of disease. Remission may be attainable with even the most resistant Crohn's and Ulcerative Colitis patients as observed in the Case Reports.

Prognostic implications of lymph node metastasis in advanced ovarian cancer: Analysis of the National Cancer Database 2006 to 2014.

e17042 Background: During debulking surgery (Surg) for advanced ovarian cancer (OvCa), lymph node (LN) sampling is not routinely performed. Hence, prognostic implications of LN involvement following debulking surg and chemotherapy (ChemoRx) were analyzed from the National Cancer Database (NCDB). Methods: Only Stage III and IV patients (pts) from NCDB 2006–2014 undergoing debulking surg and ChemoRx were included. Group A: pts with debulking surg without bowel resection; Group B: pts with major bowel resection and Group C: pts with bowel and bladder resection. Pts were further subdivided according to the use of 1) NeoAdjuvant (NeoAdj) 2) Adjuvant (Adj) and 3) NeoAdj and Adj ChemoRx. Survival analysis was done based on -ve or +ve LN status. Pearson Chi Square testing was used to evaluate the survival between -ve and +ve LN pts. Results: A total of 13839 Pts were included. There were 5757 Pts (41.59%) with -ve LN status, versus 8082 Pts (68.4%) with +ve LN status. Out of 10,737 Stage III and 3,102 Stage IV pts, there were 6,828 in Group A, 6,413 in Group B and 598 in Group C pts. For all patients in Groups A, B, and C, the 5 yr overall survival was better in LN -ve than LN +ve pts. The overall survival for both LN -ve and LN +ve pts was better in Adjuvant chemoRx in all 3 groups, except for Stage III Group C LN-ve pts, where NeoAdj was better (75% vs 37.5%). Overall survival was also slightly better in Stage III vs Stage IV pts. (Table-1). Conclusions: Even though LN dissection is not routinely done during debulking surgery, overall pts with LN metastasis do worse than LN -ve pts irrespective of the timing of ChemoRx. Hence, LN sampling during debulking surg should be strongly considered, as it may provide important prognostic information. Table-1: 5 yr Survival by LN status [Table: see text]

Prognostic implications of lymph node metastasis in advanced ovarian cancer: Analysis of National Cancer Database.

5567 Background: During debulking surgery (Surg) for advanced ovarian cancer (OvCa), lymph node (LN) sampling are not routinely performed. Hence, prognostic implications of LN involvement following debulking surg and chemotherapy (ChemoRx) were analyzed from National Cancer Database (NCDB). Methods: Only Stage III and Stage IV patients (pts) from 2004 –2014 NCDB pts undergoing Debulking surg. and ChemoRx were included. Group A included pts with debulking surg without bowel resection; Group B with major bowel resection and Group C with bowel and bladder resection. Pts were further subdivided according to the use of 1) NeoAdjuvant (NeoAdj) 2) Adjuvant (Adj) and 3) Neo Adj and Adj ChemoRx. Survival analysis was done based on -ve or +ve LN status. using Pearson Chi Square testing. Results: Out of 10,737 Stage III and 3,102 Stage IV pts, there were 6828 Group A, 6413 Group B and 598 Group C pts. Five year overall survival (OS) for all pts in Stage III with LN-ve vs LN +ve was 59.9% vs 53.9% and Stage IV was 48.7% vs 41.2%. In Group A, B, and C, the 5 yr OS was better in LN – ve than LN +ve pts (Table1). The OS for both LN –ve and LN +ve groups were better in Adjuvant chemoRx in all 3 groups. OS was slightly better in Stage III vs Stage IV pts. Conclusions: Even though LN dissection are not routinely done during debulking surg, overall pts with LN metastasis do worse than LN –ve pts irrespective of the timing of ChemoRx. Hence, LN sampling during debulking surg should be strongly considered as it may provide important prognostic information. [Table: see text]

Predicting time to full enteral nutrition in children after significant bowel resection

PurposeParenteral nutrition (PN) contributes to considerable morbidity in children after significant bowel resection. This study evaluates the utility of clinical variables in predicting time to independence from PN. MethodsAfter IRB approval, a retrospective review (1999–2012) of 71 children who were on PN for >6weeks after intestinal resection and successfully weaned was performed. Clinical characteristics were evaluated to determine the relationship to time to full enteral nutrition. P-values<0.05 were significant. ResultsMost children had necrotizing enterocolitis (56%), intestinal atresia (20%), or gastroschisis (11%) with a median small bowel length of 55cm (IQR, 35–92cm). The duration of PN was independent of the etiology of intestinal loss, presence of the ileocecal valve or colon, or location of anastomosis, but was strongly associated with small bowel length (<0.01) and percent of expected small bowel based on gestational age (GA) (median 50%, <0.01). In general, children who had 25–50% of their small bowel were dependent on PN for at least 2years compared to approximately 1year for those with 51–75%. ConclusionThe duration of PN dependence in children after major bowel resection is best predicted by remaining small bowel length and can be estimated using a linear regression model. Level of evidence2b.

Minimal Invasive Urologic Surgery and Postoperative Ileus

Postoperative ileus (POI) is the most common cause of prolonged length of hospital stays (LOS) and associated healthcare costs. The advent of minimal invasive technique was a major breakthrough in the urologic landscape with great potential to progress in the future. In the field of gastrointestinal surgery, several studies had reported lower incidence rates for POI following minimal invasive surgery compared to conventional open procedures. In contrast, little is known about the effect of minimal invasive approach on the recovery of bowel motility after urologic surgery. We performed an overview of the potential benefit of minimal invasive approach on POI for urologic procedures. The mechanisms and risk factors responsible for the onset of POI are discussed with emphasis on the advantages of minimal invasive approach. In the urologic field, POI is the main complication following radical cystectomy but it is rarely of clinical significance for other minimal invasive interventions. Laparoscopy or robotic assisted laparoscopic techniques when studied individually may reduce to their own the duration and prevent the onset of POI in a subset of procedures. The potential influence of age and urinary diversion type on postoperative ileus is contradictory in the literature. There is some evidence suggesting that BMI, blood loss, urinary extravasation, existence of a major complication, bowel resection, operative time and transperitoneal approach are independent risk factors for POI. Treatment of POI remains elusive. One of the most important and effective management strategies for patients undergoing radical cystectomy has been the development and use of enhanced recovery programs. An optimal rational strategy to shorten the duration of POI should incorporate minimal invasive approach when appropriate into multimodal fast track programs designed to reduce POI and shorten LOS.

Citrulline levels following proximal versus distal small bowel resection

PurposeCitrulline, a nonprotein amino acid synthesized by enterocytes, is a biomarker of bowel length and the capacity to wean from parenteral nutrition. However, the potentially variant effect of jejunal versus ileal excision on plasma citrulline concentration [CIT] has not been studied. This investigation compared serial serum [CIT] and mucosal adaptive potential after proximal versus distal small bowel resection. MethodsEnterally fed Sprague-Dawley rats underwent sham operation or 50% small bowel resection, either proximal (PR) or distal (DR). [CIT] was measured at operation and weekly for 8 weeks. At necropsy, histologic features reflecting bowel adaptation were evaluated. ResultsBy weeks 6–7, [CIT] in both resection groups significantly decreased from baseline (P<0.05) and was significantly lower than the concentration in sham animals (P<0.05). There was no difference in [CIT] between PR and DR at any point. Villus height and crypt density were higher in the PR than in the DR group (P≤0.02). Conclusion[CIT] effectively differentiates animals undergoing major bowel resection from those with preserved intestinal length. The region of intestinal resection was not a determinant of [CIT]. The remaining bowel in the PR group demonstrated greater adaptive potential histologically. [CIT] is a robust biomarker for intestinal length, irrespective of location of small intestine lost.

The impact of PICC Lines on Venous Thromboembolism (VTE) rates in patients who undergo bowel major bowel resection

The impact of PICC Lines on Venous Thromboembolism (VTE) rates in patients who undergo bowel major bowel resection

Complications Among Colorectal Cancer Survivors

Societal preference-weighted health-related quality of life (HRQOL) scores enable comparing multidimensional health states across diseases and treatments for research and policy. To assess the effects of living with a permanent intestinal stoma, compared with a major bowel resection, among colorectal cancer (CRC) survivors. Cross-sectional multivariate linear regression analysis to explain preference-weighted HRQOL scores. In all, 640 CRC survivors (≥ 5 years) from 3 group model health maintenance organizations; ostomates and nonostomates with colorectal resections for CRC were matched on gender, age (± 5 years), time since diagnosis, and tumor site (rectum vs. colon). SF-6D scoring system was applied to Medical Outcomes Study Short Form-36 version 2 (SF-36v2); City of Hope Quality of Life-Ostomy; and Charlson-Deyo comorbidity index. Survey of CRC survivors linked to respondents' clinical data extracted from health maintenance organization files. Response rate was 52%. Ostomates and nonostomates had similar sociodemographic characteristics. Mean SF-6D score was 0.69 for ostomates, compared with 0.73 for nonostomates (P < 0.001), but other factors explained this difference. Complications of initial cancer surgery, and previous year comorbidity burden, and hospital use were negatively associated with SF-6D scores, whereas household income was positively associated. CRC survivors' SF-6D scores were not associated with living with a permanent ostomy after other factors were taken into account. Surgical complications, comorbidities, and metastatic disease lowered the preference-weighted HRQOL of CRC survivors with and without ostomies. Further research to understand and reduce late complications from CRC surgeries as well as associated depression is warranted.

Responsive Measures to Prehabilitation in Patients Undergoing Bowel Resection Surgery

Surgical patients often show physiological and metabolic distress, muscle weakness, and long hospital stays. Physical conditioning might help recovery. We attempted to identify the most responsive measure of aerobic fitness from a four-week pre-surgical aerobic exercise program (prehabilitation) in patients undergoing major bowel resection. Twenty-one subjects randomized two to one (exercise: control) scheduled for colorectal surgery. Fourteen subjects [Body Mass Index (BMI) = 27 +/- 6 kg/m(2); maximal oxygen uptake (VO(2max)) = 22 +/- 10 ml/kg/min] underwent 3.8 +/- 1.2 weeks (27 +/- 8 sessions) of progressive, structured pre-surgical aerobic exercise training at 40 to 65% of heart rate reserve (%HRR). Peak power output was the only maximal measure that was responsive to training [26 +/- 27%, Effects Size (ES) = 0.24; Standardized Response Mean (SRM) = 1.05; p < 0.05]. For the submaximal measures, heart rate and oxygen uptake during submaximal exercise was most responsive to training (decrease by 13% +/- 15%, ES = -0.24; SRM = -0.57; and 7% +/- 6%, ES = -0.40; SRM -0.97; p < 0.05) at an exercise intensity of 76 +/- 47 W. There was no change to maximal or submaximal measures in the control group. The distance walked over six minutes improved in both groups (by approximately 30 m), but the effect size and t-statistic were higher in the exercise group. Heart rate and oxygen uptake during submaximal exercise, and peak power output are the most responsive measures to four weeks of prehabilitation in subjects with low initial fitness.

Reoperation following Minimally Invasive Surgery: Are the “Rules” Different?

This article discusses various indications for reoperation and how employing laparoscopy at primary operation might affect the incidence, presentation, and treatment of common complications. The abdomen is likely to be far less hostile after laparoscopic surgery than after laparotomy. Adhesions to the anterior abdominal wall are minimal or absent. As a result, relaparoscopy is a reasonable diagnostic and often successful treatment modality in patients suspected of having intra-abdominal complications following laparoscopic operation. Laparoscopic success in dealing with acute bowel obstruction after laparoscopic surgery is related to the paucity of adhesions and unique mechanisms of obstruction that are localized and amenable to minimal dissection. The same mechanisms are also responsible for the increased risk of bowel necrosis associated with bowel obstruction after laparoscopic surgery. Limited experience with successful laparoscopic management of bleeding and anastomotic leak has been reported with the caveat that if the bleeding or contamination is excessive, cannot be identified and controlled quickly, or is unresponsive to a reasonable and brief effort using laparoscopy, a prompt laparotomy is indicated. Based on the current literature, it is reasonable to conclude that laparoscopic approaches to primary Crohn's disease and relaparoscopy for recurrence are an appropriate (perhaps the most appropriate) management strategy. Also, laparoscopic restorative proctocolectomy and ileal pouch-anal anastomosis after laparoscopic subtotal colectomy is the preferred treatment for toxic ulcerative colitis. We conclude that laparoscopic reoperative surgery is feasible for the treatment of many complications following laparoscopic major abdominal surgery and bowel resection.

Evaluating operative risk in colorectal cancer surgery: ASA and POSSUM-based predictive models

To review two predictive models, based on the American Society of Anaesthesiologists (ASA) and the Physiological and Operative Severity Score for the enumeration of Mortality and morbidity (POSSUM)-used for estimating postoperative mortality in patients, undergoing surgery for colorectal disease, in the UK. Data was derived from three multicentre, UK-based studies involving a total of 16,006 patients with malignant or non-malignant bowel pathologies. Data sources were: The Colorectal-POSSUM (CR-POSSUM) Study population, comprising 6883 patients undergoing colorectal surgery in 15 UK hospitals between 1993 and 2001; The Association of Coloproctology of Great Britain and Ireland (ACPGBI) Colorectal Cancer (CRC) Database, encompassing 8077 newly diagnosed CRC patients, undergoing surgical resections in 79 hospitals, between April 2000 and March 2002; The ACPGBI Malignant Bowel Obstruction (MBO) Study, encompassing 1046 patients with MBO in 148 hospitals, treated between April 1998 and March 1999. Multifactorial logistic regression analyses were used to adjust for case-mix, identify risk factors for in-hospital/30-day operative mortality and to accommodate the variability of outcomes between hospitals. In the ACPGBI CRC study, 7374 patients had surgery, 6622(89.8%) a major bowel resection and 1465(19.9%) emergency surgery. Nine hundred and eighty-nine (94.6%) patients with MBO had surgery and 854(86.3%) underwent bowel resection. In the CR-POSSUM study, of the 6790(98.6%) patients undergoing surgery, 3451(50.8%) had a major colorectal resection, including 2107(31.0%) as an emergency. The operative mortality was 7.5% for the ACPGBI CRC study, 15.7% for patients with MBO and 5.7% for patients in the CR-POSSUM study. When tested, the predictive models showed good discrimination, with an area under the receiver-operator characteristic curve of 77.5% for the ACPGBI CRC, 80.1% for the MBO and 89.8% for the CR-POSSUM. Prediction of postoperative death can be made by the clinician using simple, numerical, tables derived from the ACPGBI CRC, MBO and CR-POSSUM models. The models can be used in everyday practice for pre-operative counselling of patients and their carers, as a part of the process of informed consent. They may also be used to compare the outcomes between multidisciplinary CRC teams.

Laparoscopic-assisted bowel resection in pediatric/adolescent inflammatory bowel disease: laparoscopic bowel resection in children.

The purpose of this study is to discuss indications, technical approach, and morbidity of laparoscopic approaches to major bowel resection in the pediatric/adolescent population with inflammatory bowel disease and familial polyposis. Retrospective review of laparoscopic-assisted bowel procedures between May 1991 and January 2002 was performed. Laparoscopic-assisted bowel resection is defined as complete intracorporeal mobilization and devascularization of a segment of colon or rectum. The indications for extracorporeal vs. intracorporeal anastomosis will be discussed. Clinically unstable, septic, or massively bleeding patients were not candidates for this technique. The decision to attempt the laparoscopic approach was based on the experience of the consulting surgeon. There were 31 patients, including 14 females. Five patients had undergone prior surgery. Twenty-nine patients had inflammatory bowel disease, one had familial polyposis, and one had a cavernous hemangioma. We included all pediatric/adolescent patients in our practice undergoing laparoscopic resection. Twenty-nine patients had 33 laparoscopic operations, including proctocolectomy with ileal pouch-anal anastomosis (n = 14), proctocolectomy with ileostomy (n = 3), ileocolectomy with ileocolic anastomosis (n = 13), and small-bowel obstruction (n = 1). Average operating time was 158 (range, 30-400) minutes, with average blood loss of 159 ml. Average wound length was 4.9 cm. The complication rate was 16 percent (n = 5), with one anastomotic leak. The rate of conversion to open operations was 5.8 percent. Liquid diet was begun on Day 3, and the average length of stay was 5.9 days. Major laparoscopic bowel surgery can be performed safely in the pediatric/adolescent population, with reasonable operative times, low conversion to open operations, and low morbidity.