Protocol-based intravenous fluid hydration for newly created ileostomies decreases readmissions secondary to dehydration

Background: Newly created ileostomies often result in patient readmission due to dehydration secondary to high ostomy output. Implementation of a mandatory home intravenous hydration protocol can avoid this. We aim to evaluate the impact of mandatory home intravenous hydration for patients with newly created ileostomies. Materials and methods: All patients at a single, tertiary care center who underwent ileostomy creation during a period of sporadic home intravenous hydration (February 2011-December 2013) and mandatory protocol hydration (March 2016-December 2018) were reviewed for incidence of dehydration, readmissions, and emergency department visits. Results: 241 patients were evaluated. 119 were in the sporadic group and 122 were in the protocol group. Operative approach differed among both groups, with hydration protocol patients undergoing 15% less open procedures and 4.9% more hand-assisted laparoscopic procedures (P = .0017). Prior to protocol implementation, 23.5% of patients were sent home with intravenous hydration. Length of hospital stay after index ileostomy creation was shorter for protocol patients by 3.3 days (P \u3c .0001). 15.1% of sporadic patients experienced dehydration as compared to 7.4% of protocol patients (P = .0283). Following protocol implementation, the number of patients readmitted due to dehydration increased from 13 to 14 (P = .01). Discussion: Standardized, mandatory at-home intravenous hydration following ileostomy creation leads to a significant reduction in postoperative incidence of dehydration and dehydration-associated readmissions. This protocol should be followed for all patients with newly created ileostomies, so long as adequate home health nursing support and active surveillance are available

Current status of robotic surgery for rectal cancer: A bird′s eye view

Minimally invasive surgery for rectal cancer is now widely performed via the laparoscopic approach and has been validated in randomized controlled trials to be oncologically safe with better perioperative outcomes than open surgery including shorter length of stay, earlier return of bowel function, better cosmesis, and less analgesic requirement. Laparoscopic surgery, however, has inherent limitations due to two-dimensional vision, restricted instrument motion and a very long learning curve. Robotic surgery with its superb three-dimensional magnified optics, stable retraction platform and 7 degrees of freedom of instrument movement offers significant benefits during Total Mesorectal Excision (TME) including ease of operation, markedly lower conversion rates and better quality of the specimen in addition to shorter (steeper) learning curves. This review summarizes the current evidence for the adoption of robotic TME for rectal cancer with supporting data from the literature and from the authors′ own experience. All relevant articles from PubMed using the search terms listed below and published between 2000 and 2014 including randomized trials, meta-analyses, prospective studies, and retrospective reviews with substantial numbers were included

The Impact of Obesity on the Perioperative, Clinicopathologic, and Oncologic Outcomes of Robot Assisted Total Mesorectal Excision for Rectal Cancer

Purpose: To analyze the feasibility and outcomes of robotic rectal cancer surgery in obese patients. Methods: From 2005 to 2012, 101 consecutive rectal cancers operated robotically were enrolled in a prospective database. Patients were stratified into obese (BMI ≥ 30 kg/m2) and non-obese (BMI < 30 kg/m2) groups. Operative, perioperative parameters, and pathologic outcomes were compared. Data were analyzed using SPSS 22.0, while statistical significance was defined as a p value ≤ .05. Results: There were 33 obese patients (mean BMI 33.8 kg/m2). Patients were comparable regarding gender, T stage, and type of operation. Operative time and blood loss were higher in the obese group; only operative time was statistically significant. The conversion rate, length of stay, and anastomotic leak rates were similar. Circumferential margin positivity and lymph node yield were comparable. Disease free and overall survivals at 3 years were 75.8% versus 80.9% and 84.8% versus 92.6%, respectively for obese and non-obese subgroups. Conclusions: Robotic surgery for curative treatment of rectal cancer in the obese is safe and feasible. BMI does not influence conversion rates, length of stay, postoperative complications, and quality of the specimen or survival when the robotic platform is used

Wpływ otyłości na wyniki okołooperacyjne, klinicznopatologiczne oraz onkologiczne całkowitego wycięcia mezorektum w nowotworze odbytnicy metodą chirurgii wspomaganej robotowo

Cel pracy: Analiza możliwości przeprowadzenia oraz wyników operacji robotowej w nowotworze odbytnicy u otyłych pacjentów. Metody: Od 2005 do 2012 roku do rejestru prospektywnej bazy danych wpisano 101 kolejnych przypadków nowotworów odbytnicy operowanych metodą chirurgii robotowej. Pacjentów rozdzielono do grup z otyłością (BMI≥30 kg/m2) oraz bez otyłości (BMI<30 kg/m2). Porównano parametry operacyjne, okołooperacyjne oraz wyniki patologiczne. Dane analizowano przy użyciu programu SPSS 22.0, zaś istotność statystyczną zdefiniowano jako wartość p≤0,05. Wyniki: W badaniu uczestniczyło 33 otyłych pacjentów (średnia wartość BMI – 33,8 kg/m2). Pacjentów porównano, biorąc pod uwagę płeć, stopień zaawansowania nowotworu (faza T) oraz typ operacji. Czas trwania zabiegu i utrata krwi były większe w grupie pacjentów otyłych; jedynie czas trwania zabiegu był istotny statystycznie. Częstotliwość konwersji, czas trwania hospitalizacji oraz częstotliwość występowania przecieków zespolenia były podobne. Dodatni margines obwodowy oraz liczba usuniętych węzłów chłonny były porównywalne. Odsetek pacjentów wolnych od choroby oraz odsetek przeżyć po okresie 3 lat wyniosły odpowiednio w grupach z otyłością i bez: 75,8% vs 80,9% oraz 84,8% vs 92,6%. Wnioski: Zabieg chirurgii robotowej w leczeniu nowotworu odbytnicy u osób otyłych jest bezpieczny i możliwy do przeprowadzenia. W zabiegach z użyciem zautomatyzowanej platformy BMI nie wpływało na częstotliwość konwersji, czas trwania hospitalizacji, powikłania pooperacyjne oraz jakość preparatu lub przeżywalność

The Impact of Obesity on the Perioperative, Clinicopathologic, and Oncologic Outcomes of Robot Assisted Total Mesorectal Excision for Rectal Cancer

Purpose: To analyze the feasibility and outcomes of robotic rectal cancer surgery in obese patients. Methods: From 2005 to 2012, 101 consecutive rectal cancers operated robotically were enrolled in a prospective database. Patients were stratified into obese (BMI ≥ 30 kg/m2) and non-obese (BMI < 30 kg/m2) groups. Operative, perioperative parameters, and pathologic outcomes were compared. Data were analyzed using SPSS 22.0, while statistical significance was defined as a p value ≤ .05. Results: There were 33 obese patients (mean BMI 33.8 kg/m2). Patients were comparable regarding gender, T stage, and type of operation. Operative time and blood loss were higher in the obese group; only operative time was statistically significant. The conversion rate, length of stay, and anastomotic leak rates were similar. Circumferential margin positivity and lymph node yield were comparable. Disease free and overall survivals at 3 years were 75.8% versus 80.9% and 84.8% versus 92.6%, respectively for obese and non-obese subgroups. Conclusions: Robotic surgery for curative treatment of rectal cancer in the obese is safe and feasible. BMI does not influence conversion rates, length of stay, postoperative complications, and quality of the specimen or survival when the robotic platform is used

Use of botulinum toxin injections for the treatment of chronic anal fissure: Results from an American Society of Colon and Rectal Surgeons survey

Background: Chronic anal fissure (CAF) is commonly treated by colorectal surgeons. Pharmacological treatment is considered first-line therapy. An alternative treatment modality is chemical sphincterotomy with injection of botulinum toxin (BT). However, there is a lack of a consensus on the BT administration procedure among colorectal surgeons. Methods: A national survey approved by the American Society of Colon and Rectal Surgeons (ASCRS) Executive Council was sent to all members. An eight-question survey was sent via ASCRS email correspondence between December 2019 and February 2020. Questions were derived from available meta-analyses and expert opinions on BT use in CAF patients and included topics such as BT dose, injection technique, and concomitant therapies. The survey was voluntary and anonymous, and all ASCRS members were eligible to complete it. Responses were recorded and analyzed via an online survey platform. Results: 216 ASCRS members responded to the survey and 90% inject 50-100U of BT. Most procedures are performed under MAC anesthesia (56%). A majority of respondents (64%) inject into the internal sphincter and a majority (53%) inject into 4 quadrants in the anal canal circumference. Some respondents perform concomitant manual dilatation (34%) or fissurectomy (38%). Concomitant topical muscle relaxing agents are not used uniformly among respondents. Discussion: Injection of BT for CAF is used commonly by colorectal surgeons. There is consensus on BT dosage, administration site, technique, and the use of monitored anesthesia care

Disparities in screening for colorectal cancer based on limited language proficiency

Background:This study analyzes the association between limited language proficiency and screening for colorectal cancer. Methods:This is a retrospective cohort study from the 2015 sample of the National Health Interview Survey database utilizing univariate and multivariate regression analysis. The study population includes subjects between 50 and 75 years of age. The main outcome analyzed was rates of screening colonoscopies between limited English-language proficiency (LEP) subjects and those fluent in English. Secondary outcomes included analysis of baseline, socioeconomic, access to health care variables, and other modalities for colorectal cancer screening between the groups. Results:Incidence of limited language proficiency was 4.8% (n = 1978, count = 4 453 599). They reported lower rates of screening colonoscopies (61% vs 34%, P \u3c .001), less physician recommendation for a colonoscopy (87 vs 60%, P \u3c .001), fewer polyps removed in the previous 3 years (24% vs 9.1%; P \u3c .001), and fewer fecal occult blood samples overall (P \u3c .001). Additionally, Hispanic non-LEP subjects have higher rates of colonoscopies compared to those with language barriers (50% vs 33%, P \u3c .001). On multivariate analysis, LEP was associated with a lower likelihood to have a screening colonoscopy (OR .67 95% CI .49-.91). A second regression model with Spanish language and other language variables included, associated Spanish speakers with a lower likelihood for a screening colonoscopy (OR .71 95% CI .52-.97) when controlling for baseline, socioeconomic, and access to health care covariates. Discussion:Patients with limited English-language proficiency are associated with lower rates of screening for colorectal cancer, in particular the Spanish speaking subgroup

Correlation of tumor response between flexible sigmoidoscopy and magnetic resonance imaging in patients undergoing neoadjuvant therapy for locally advanced rectal cancer: A retrospective review

Background:The National Accreditation Program for Rectal Cancer recommends a pelvic MRI to assess the response to neoadjuvant therapy for advanced rectal cancers. However, there is no single restaging modality that can identify all patients with complete tumor response. At our institution, we perform both a pelvic MRI and a flexible sigmoidoscopy (FS) after neoadjuvant therapy prior to surgical resection. Objective: The objective is to elucidate the correlation of tumor response between FS and MRI in patients undergoing neoadjuvant therapy for locally advanced rectal cancer. Design: Single institution from 2010 to 2019. Retrospective cohort study comparing local tumor response on FS to MRI utilizing final pathology as the gold standard for comparison. Patients: Patients with confirmed locally advanced rectal adenocarcinoma (stage II or III) who underwent neoadjuvant therapy prior to surgical intervention and underwent flexible endoscopy and a standardized rectal cancer protocol MRI to evaluate tumor response. Results: A total of 48 patients were evaluated. Seven (14%) patients had a complete pathological response. MRI adequately reported 1 (14%), while FS found 4 (57.14%) out of the 7 complete responders. Nevertheless, this did not reach statistical significance ( P = .06). On logistic regression analysis, flexible sigmoidoscopy had a 5.5 higher likelihood to report an accurate complete response (OR 5.5, 95% CI: 1.02-29.64; P = .047). Conclusions: Flexible sigmoidoscopy should be used in conjunction with MRI in the work up of patients who have received neoadjuvant therapy for advanced rectal cancer prior to surgical resection