Background Enthusiasm is high for expansion of robotic assisted surgery into right hemicolectomy. But data on outcomes and cost is lacking. Our objective was to determine the association between surgical approach and cost for minimally invasive right hemicolectomy. We hypothesized that a robot approach would have increased costs (both economic and opportunity) while achieving similar short-term outcomes. Methods We performed a retrospective cohort analysis with a simulation of operating room utilization at a quaternary care, academic institution. We enrolled patients undergoing minimally invasive right hemicolectomy from November 2017 to August 2019. Patients were categorized by the intended approach- laparoscopic or robotic. The primary outcome was the technical variable direct cost. Secondary outcomes included total cost, supply cost, operating room utilization, operative time, conversion, length of stay and 30-day post-operative outcomes. Results 79 patients were included in the study. A robotic approach was used in 22% of the cohort. The groups differed significantly only in etiology of surgery. Robotic surgery was associated with a 1.5 times increase in the technical variable direct cost ( p < 0.001), increased supply cost (2.6 times; p < 0.001) and increased total cost (1.3 times; p < 0.001). Significant differences were observed in median room time (Robotic: 285 min vs. Laparoscopic: 170 min; p < 0.001) and procedure time (Robotic: 203 min vs. Laparoscopic: 118 min; p < 0.001). There were no differences observed in post-operative outcomes including length of stay or readmission. In a simulation of OR utilization, 45 laparoscopic right hemicolectomies could be performed in an OR in a month compared to 31 robotic cases. Conclusions Robotic right hemicolectomy was associated with increased costs with no improvement in post-operative outcomes. In a simulation of operating room efficiency, a robotic approach was associated with 14 fewer cases per month. Practitioners and administrators should be aware of the increased cost of a robotic approach.

The traditional morbidity and mortality associated with traditional management has stimulated exploration of endoscopic approaches. Success depends on patient selection, the location and etiology of obstruction, patient status, and the capability of the endoscopist. This article discusses techniques of intralumenal dilation and stent placement and results from systematic reviews.

More than a million patients in North America live with some type of intestinal stoma. These stomas are typically constructed as one of the last components of a long and challenging surgical procedure. Stomal construction is important because their function will have significant impact on the ostomate's life. Stomal creation is a technical exercise that if done correctly will result in good function and minimal complications for the remainder of the ostomate's life. Conversely, if created poorly, stoma complications are common and can lead to years of misery. Intestinal stomas are in fact enterocutaneous anastomoses, and all the principles that apply to creation of any anastomosis (i.e., using healthy intestine, avoiding ischemia and undue tension) are important in stoma creation. This chapter reviews construction and management of ileostomies and colostomies.

Margin negative resection of rectal cancer with minimally invasive techniques remains technically challenging. Robotic surgery has potential advantages over traditional laparoscopy. We hypothesize that the difference in the rate of negative margin status will be < 6% between laparoscopic and robotic approach. The National Cancer Database (2010–2014) was queried for adults with locally advanced rectal cancer who underwent neoadjuvant chemoradiation and curative resection to conduct an observational retrospective cohort study of a prospectively maintained database. Patients were grouped by either robotic (ROB) or laparoscopic (LAP) approach in an intent-to-treat analysis. Primary outcome was negative margin status, defined as a composite of circumferential resection margin and distal margin. Secondary outcomes included length of stay (LOS), readmission, 90-day mortality, and overall survival. 7616 patients with locally advanced rectal cancer who underwent minimally invasive resection were identified. 2472 (32%) underwent attempted robotic approach. The overall conversion rate was 13% and was increased in the laparoscopic group [LAP: 15% vs. ROB: 8%; OR 0.47; 95% CI (0.39, 0.57)]. Differences in margin negative resection rate were within the prespecified range of practical equivalence (LAP: 93% vs.: ROB 94%; 95% CI (0.69, 1.06); $$p_{\updelta}$$ = 1). For secondary outcomes, there was no difference in 30-day readmission [LAP: 9% vs.: ROB 8%; 95% CI (0.84, 1.24)] and 90-day mortality [LAP: 1% vs.: ROB 1%; 95% CI (0.38, 1.24)]. While the median LOS was 5 days in both groups, the mean LOS was 0.6 (95% CI: 0.24, 0.89) days shorter in the robotic group. This robust analysis supports either robotic or laparoscopic approach for resection of locally advanced rectal cancer from a margin perspective. Both have similar readmission and 5-year overall survival rates. Patients undergoing robotic surgery have a 0.6-day decrease in LOS and decreased conversion rate.

Background: The incidence of postprocedural bleeding in patients undergoing rubber band ligation (RBL) for symptomatic internal hemorrhoids while taking clopidogrel bisulfate is unknown. To determine the postprocedural bleeding risk of RBL for patients taking clopidogrel compared with age- and sex-matched controls. Materials and methods: This is a retrospective case-controlled cohort study analyzing data from 2005 to 2013 conducted at a single tertiary care academic center. The study included a total of 80 rubber bands placed on 41 patients taking clopidogrel bisulfate and 72 bands placed on 41 control patients not taking clopidogrel matched for age and sex. The 30-d rates of significant and insignificant bleeding events after RBL were recorded. A bleeding event was considered significant if the patient required admission to the hospital, transfusion of blood products, or additional procedures to stop the bleeding. Insignificant bleeding was defined as passage of blood or clots per rectum with spontaneous cessation and no need for additional intervention. Results: There was no significant difference in the number of bleeding events per band placed in the clopidogrel group when compared with the control group (3.75% versus 2.78%, P = 0.7387). The rate of significant (2.5% versus 1.39%, P = 0.6244) and insignificant bleeding events (1.25% versus 1.39%, P = 0.9399) was also similar between the two groups. Two significant bleeding events occurred in the clopidogrel group requiring intervention: cauterization in one patient and colonoscopy and transfusion in the other. Conclusions: The risk of a bleeding complication after RBL for hemorrhoids does not appear to be increased in patients taking clopidogrel. Our results support the practice of continuing clopidogrel bisulfate in the periprocedural period as the associated risk of thrombosis is greater than the risk of bleeding. (C) 2018 Elsevier Inc. All rights reserved.

BACKGROUND: Low rectal tumors are often treated with sphincter-preserving resection followed by coloanal anastomosis. OBJECTIVE: The purpose of this study was to compare the short-term complications following straight coloanal anastomosis vs colonic J-pouch anal anastomosis. DESIGN: Patients were identified who underwent proctectomy for rectal neoplasia followed by coloanal anastomosis in the 2008 to 2013 American College of Surgeons National Surgical Quality Improvement Program database. Demographic characteristics and 30-day postoperative complications were compared between groups. SETTINGS: A national sample was extracted from the American College of Surgeons National Surgical Quality Improvement Project database. PATIENTS: Inpatients following proctectomy and coloanal anastomosis for rectal cancer were selected. MAIN OUTCOME MEASURES: Demographic characteristics and 30-day postoperative complications were compared between the 2 groups. RESULTS: One thousand three hundred seventy patients were included, 624 in the straight anastomosis group and 746 in the colonic J-pouch group. Preoperative characteristics were similar between groups, with the exception of preoperative radiation therapy (straight anastomosis 35% vs colonic J-pouch 48%, p = 0.0004). Univariate analysis demonstrated that deep surgical site infection (3.7% vs 1.4%, p = 0.01), septic shock (2.25% vs 0.8%, p = 0.04), and return to the operating room (8.8% vs 5.0%, p = 0.0006) were more frequent in the straight anastomosis group vs the colonic J-pouch group. Major complications were also higher (23% vs 14%, p = 0.0001) and length of stay was longer in the straight anastomosis group vs the colonic J-pouch group (8.9 days vs 8.1 days, p = 0.02). After adjusting for covariates, major complications were less following colonic J-pouch vs straight anastomosis (OR, 0.57; CI, 0.38–0.84; p = 0.005). Subgroup analysis of patients who received preoperative radiation therapy demonstrated no difference in major complications between groups. LIMITATIONS: This study had those limitations inherent to a retrospective study using an inpatient database. CONCLUSION: Postoperative complications were less following colonic J-pouch anastomosis vs straight anastomosis. Patients who received preoperative radiation had similar rates of complications, regardless of the reconstructive technique used following low anterior resection. See Video Abstract at http://links.lww.com/DCR/A468.

Objective: To analyze potential benefits with regards to infectious complications with combined use of mechanical bowel preparation (MBP) and ABP in elective colorectal resections. Background: Despite recent literature suggesting that MBP does not reduce infection rate, it still is commonly used. The use of oral antibiotic bowel preparation (ABP) has been practiced for decades but its use is also controversial. Methods: Patients undergoing elective colorectal resection in the 2012 to 2015 American College of Surgeons National Surgical Quality Improvement Program cohorts were selected. Doubly robust propensity score–adjusted multivariable regression was conducted for infectious and other postoperative complications. Results: A total of 27,804 subjects were analyzed; 5471 (23.46%) received no preparation, 7617 (32.67%) received MBP only, 1374 (5.89%) received ABP only, and 8855 (37.98%) received both preparations. Compared to patients receiving no preparation, those receiving dual preparation had less surgical site infection (SSI) [odds ratio (OR)1⁄4 0.39, P < 0.001], organ space infection (OR1⁄4 0.56, P 0.001), wound dehiscence (OR1⁄4 0.43, P1⁄4 0.001), and anastomotic leak (OR 1⁄4 0.53, P < 0.001). ABP alone compared to no prep resulted in significantly lower rates of surgical site infection (OR1⁄4 0.63, P 1⁄4 0.001), organ space infection (OR 1⁄4 0.59, P 1⁄4 0.005), anastomotic leak (OR 1⁄4 0.53, P 1⁄4 0.002). MBP showed no significant benefit to infectious complications when used as monotherapy. Conclusions: Combined MBP/ABP results in significantly lower rates of SSI, organ space infection, wound dehiscence, and anastomotic leak than no preparation and a lower rate of SSI than ABP alone. Combined bowel preparation significantly reduces the rates of infectious complications in colon and rectal procedures without increased risk of Clostridium difficile infection. For patients undergoing elective colon or rectal resection we recommend bowel preparation with both mechanical agents and oral antibiotics whenever feasible.

Background A diverting loop ileostomy is commonly constructed to protect a distal anastomosis after proctectomy for rectal cancer. Little data are available on whether closing the ileostomy before or after adjuvant chemotherapy affects survival. Methods We conducted a retrospective review of patients with rectal cancer who underwent a low anterior resection with diverting loop ileostomy followed by adjuvant chemotherapy at Ochsner Medical Center. The primary outcome was the long-term survival in patients who had their loop ileostomies closed before chemotherapy (BC) vs after chemotherapy (AC). Results Seventy-two patients were identified (22 in the BC group vs 50 in the AC group). No difference in mean age (BC 59.5 ± 9.8 vs AC 59.2 ± 12.6, P=0.9) or preoperative clinical stage was seen between study groups. The mean interval from ileostomy creation to closure was significantly shorter in the BC group vs AC group (16.9 ± 14.5 weeks vs 33.6 ± 18.1 weeks, P=0.0001). Follow-up data revealed a similar mean duration from surgery to last contact (BC 50.6 ± 23.6 months vs AC 43.5 ± 22.1 months, P=0.23) and similar overall survival (BC 86% vs AC 70%, P=0.23) between groups. Conclusion Long-term survival was similar in patients who underwent ileostomy closure before and after adjuvant therapy following low anterior resection for rectal cancer. While this study was underpowered, it adds additional insight to an area of surgery lacking significant data. The timing of ileostomy closure should be individualized for each patient.

BACKGROUND:Loop ileostomy is a common adjunct to surgical procedures for low rectal cancers and inflammatory bowel disease. Ileostomy closure through a limited incision can be technically challenging. We hypothesized that placing a sodium hyaluronate/carboxymethylcellulose (SH/CMC) bioresorbable membrane at loop ileostomy creation would decrease stoma closure time without increasing morbidity.METHODS:In a retrospective review at a single institution with 6 board-certified colorectal surgeons, patients with loop ileostomy creation and closure between September 1999 and December 2011 were grouped based on SH/CMC placement at ileostomy creation. Data were abstracted for age, sex, body mass index (BMI), primary diagnosis, length of surgery, staff surgeon, interval between surgeries, and postoperative morbidity. The primary endpoint was the length of the surgery for ileostomy closure. Secondary outcome measures were length of stay, wound infection rate, and other complications.RESULTS:A total of 293 patients were identified. Group 1 (with SH/CMC) included 146 patients, and Group 2 (without SH/CMC) included 147 patients. The groups were matched according to age, sex, BMI, interval between creation and closure, and indication for surgery. The average surgical time for closure was significantly shorter in Group 1 (46.4 minutes ± 2.7) compared to Group 2 (60 minutes ± 2.3) (P=0.0001). We found no difference between the groups in length of stay, wound infection rate, or complication rate.CONCLUSION:The use of SH/CMC in loop ileostomy creation significantly decreases the operative time required for stoma closure with no increase in the complication rate.

Physician reimbursement and the coding to support it are critically important to the sustained health of any physician's practice. This article reviews the recent history of physician reimbursement from the government and third-party payers and physician coding to support reimbursement. Explanations of terminology and documentation requirements are included.

BACKGROUND: Colorectal residency has become one of the more competitive postgraduate training opportunities; however, little information is available to guide potential applicants in gauging their competitiveness.OBJECTIVE: The aim of this study was to identify the current trends colorectal residency training and to identify what factors are considered most important in ranking a candidate highly. We hypothesized that there was a difference in what program directors, current and recently matched colorectal residents, and recent graduates consider most important in making a candidate competitive for a colorectal residency position.DESIGN: Three 10-question anonymous surveys were sent to 59 program directors, 87 current and recently matched colorectal residents, and 119 recent graduates in March 2015.SETTINGS: The study was conducted as an anonymous internet survey.MAIN OUTCOME MEASURES: Current trends in applying for a colorectal residency, competitiveness of recent colorectal residents, factors considered most important in ranking a candidate highly, and what future colorectal surgeons can expect after finishing their training were measured.RESULTS: The study had an overall response rate of 43%, with 28 (47%) of 59 program directors, 46 (53%) of 87 current and recently matched colorectal residents, and 39 (33%) of 119 recent graduates responding. The majority of program directors felt that a candidate's performance during the interview process was the most important factor in making a candidate competitive, followed by contact from a colleague, letters of recommendation, American Board of Surgery In-Training Exam scores, and number of publications/presentations. The majority of current and recently matched colorectal residents felt that a recommendation/telephone call from a colleague was the most important factor, whereas the majority of recent graduates favored letters of recommendation as the most important factor in ranking a candidate highly.LIMITATIONS: Limitations to the study include its small sample size, selection bias, responder bias, and misclassification bias.CONCLUSIONS: There are differences in what program directors and current/recent residents consider most important in making an applicant competitive for colorectal residency.

BACKGROUND Upper extremity surgery is commonly performed in the ambulatory setting and is associated with moderate to severe postoperative pain. METHODS Patients scheduled for upper extremity orthopedic surgery with a peripheral nerve block were randomized to receive either an ultrasound-guided single-injection supraclavicular block or ultrasound-guided median, ulnar, and radial nerve blocks (forearm blocks) performed at the level of the mid to proximal forearm with liposomal bupivacaine (Exparel) combined with a short-acting supraclavicular block. A sham block was performed in an attempt to blind enrollees in the control group. We administered the EuroQol 5D-5L questionnaire preoperatively and on postoperative days 1-3 and considered the results the primary outcome of our investigation. Block procedure times, postanesthesia care unit (PACU) length of stay, instances of nausea/vomiting, need for narcotic administration, and patient satisfaction were also assessed. RESULTS We observed no significant differences in postoperative EuroQol scores between the 2 groups and no significant differences in patient demographics, PACU length of stay, or side effects in the PACU. In some instances, the short-acting supraclavicular block resolved in the PACU, and these patients reported higher pain scores and required titration of analgesics prior to discharge. CONCLUSION Larger prospective studies are needed to determine the safety and efficacy of liposomal bupivacaine in patients undergoing upper extremity surgery. Liposomal bupivacaine is currently only approved for local anesthetic infiltration use.

Background: Emergent resection for complications of colon cancer has worse short-term outcomes compared to elective resections of colon cancer.However, there is little data on the long-term outcomes of emergently resected patients.The purpose of this study was to examine the long term overall survival (OS) of colon cancer patients who underwent emergent resection versus patients who were resected electively in a national hospital based cancer registry.Methods: The 2006-2011 National Cancer Data Base was queried for all colon cancer patients who underwent surgical resection.An emergent resection was defined as any resection that occurred within 24 hours of diagnosis.A mixed-effects logistic regression model was used to identify independent factors associated with undergoing an emergent resection versus an elective resection.Mixed-effect Cox proportional-hazards models were subsequently used to estimate the adjusted effect of emergent versus elective resection on 5-year overall survival.Results: A total of 208,636 patients met inclusion criteria, of which, 32% of the cohort had an emergent resection.Factors and outcomes associated with emergent resection are presented in the table.Patients who underwent emergent resection had a lower 5-year overall survival rate compared to those who underwent elective resection (63.5% vs 69.5%, Log-Rank P<0.0001).After controlling for patient factors, pathological stage, lymph node yield, positive margin status, receipt of adjuvant chemotherapy, and hospital factors, emergent resection was independently associated with an increased odds of 30-day mortality (OR=1.58,95% CI=1.47-1.73)and increased hazard of death at 5 years (HR=1.27,95% CI=1.25-1.29)compared to elective resections.Conclusion: Emergent resection for colon cancer is independently associated with poor short-term outcomes and decreased 5-year overall survival compared to elective resection, irrespective of patient factors, pathological stage, adequate lymph node yield, positive margin status, receipt of adjuvant chemotherapy, and hospital factors.With almost one third of cases in this study being performed emergently, these findings underlie the importance of adherence to colon cancer screening guidelines to limit the need for emergent resections and potentially improve overall survival for colon cancer in the U.S.

Dr. James W. Fleshman is the Helen Buchanan and Stanley Joseph Seeger Endowed Professor and Chairman—Department of Surgery, Baylor University Medical Center, and Chief of Surgery at Baylor University Medical Center, Dallas, Texas. James was born in New Orleans, Louisiana, and received an MD degree from Washington University School of Medicine, St. Louis, MO. His general surgery training, which included a year of research, was conducted at The Jewish Hospital of St. Louis, Washington University School of Medicine, St. Louis, MO. He then performed a fellowship in Colon and Rectal Surgery at the University of Toronto, Toronto, Canada. In 1987, he joined the colorectal staff at Washington University School of Medicine, St. Louis, MO, and eventually became professor and section head of the division of colon and rectal surgery. In 2012, he moved to Dallas, TX, to assume his current position.

Dr. Garrett Nash is an Associate Attending Colon and Rectal Surgeon at the Memorial Sloan Kettering Cancer Center in New York, NY. Garrett was born in Ireland and moved to the United States in 1990. He received a bachelor's degree in political science from Brown University, Providence, RI, and an MD degree from Columbia University in New York, NY. He started his General Surgery Residency training at the University of Massachusetts Medical School in Worcester, MA and then did 3 years of research at Memorial Sloan Kettering Cancer Center. His residency was completed at the New York Presbyterian Hospital-Weill Cornell in New York, NY. His colorectal surgery residency training was performed at New York Presbyterian Hospital-Cornell/Columbia. Then, he completed a colorectal oncology fellowship at Memorial Sloan Kettering Cancer Center, and in 2008 he joined the staff at this institution. In addition in 2010, Dr. Nash obtained a Masters of Public Health from Harvard University in Boston, MA.