IMPORTANCE Enhanced recovery after surgery (ERAS) colorectal programs have shown to be successful at reducing length of stay in many international and academic centers; however, their efficacy in a community hospital setting remains unclear. OBJECTIVE To determine if favorable results could be reproduced in a community hospital setting using our ERAS program, which was developed using core ERAS guidelines with the goal of accelerated recovery while also addressing other important outcomes affecting patient experience and safety. DESIGN, SETTING, AND PARTICIPANTS Prospective study of ERAS program, a multidisciplinary effort involving anesthesia, preadmission staff, nursing, and surgery staff at a community hospital. The program was initiated in 2010 and was in full practice by 2011. We assessed practice patterns and patient outcomes for all elective colon and rectal resection cases performed in 2009 (prior to ERAS implementation), 2011, and 2012. MAIN OUTCOMES AND MEASURES Laparoscopic approach, narcotic use, length of stay, 30-day readmission, ileus (defined as reinsertion of nasogastric tube), and intra-abdominal infection and association between colorectal cancer (CRC) diagnosis and these outcomes. RESULTS From 2009 to 2012, the use of laparoscopy increased from 57.4% to 88.8% (P < .001). Length of stay decreased significantly (6.7 days vs 3.7 days, P < .001), without an increase in 30-day readmission rate (17.6% vs 12.5%, P = .49). Use of patient-controlled narcotic analgesia and duration of use decreased (63.2% of patients vs 15%, P < .001; 67.8 hours vs 47.1 hours, P = .02). Ileus rate decreased from 13.2% to 2.5% (P = .02). Intra-abdominal infection decreased from 7.4% to 2.5% (P = .24). When comparing laparoscopic cases alone, similar results were observed. Following regression analysis, there were no statistically significant differences between CRC diagnosis and LOS, 30-day readmission rates, ileus, and intra-abdominal infection (all P's > .05). Length of stay reductions resulted in an estimated cost savings of $3202 per patient (2011) and $4803 per patient (2012). CONCLUSIONS AND RELEVANCE Implementation of this patient care-directed enhanced recovery program is feasible in a community hospital setting, and it is associated with decreased LOS without increased readmission or morbidity, as well as significant decreases in narcotic use and cost. Improved outcomes are independent of the laparoscopic approach and CRC diagnosis.

OBJECTIVE To evaluate the effect of routine anastomotic leak testing (performed to screen for leaks) vs selective testing (performed to evaluate for a suspected leak in a higher-risk or technically difficult anastomosis) on outcomes in colorectal surgery because the value of provocative testing of colorectal anastomoses as a quality improvement metric has yet to be determined. DESIGN Observational, prospectively designed cohort study. SETTING Data from Washington state's Surgical Care and Outcomes Assessment Program (SCOAP). PATIENTS Patients undergoing elective left-sided colon or rectal resections at 40 SCOAP hospitals from October 1, 2005, to December 31, 2009. INTERVENTIONS Use of leak testing, distinguishing procedures that were performed at hospitals where leak testing was selective (<90% use) or routine (≥ 90% use) in a given calendar quarter. MAIN OUTCOME MEASURE Adjusted odds ratio of a composite adverse event (CAE) (unplanned postoperative intervention and/or in-hospital death) at routine testing hospitals. RESULTS Among 3449 patients (mean [SD] age, 58.8 [14.8] years; 55.0% women), the CAE rate was 5.5%. Provocative leak testing increased (from 56% in the starting quarter to 76% in quarter 16) and overall rates of CAE decreased (from 7.0% in the starting quarter to 4.6% in quarter 16; both P ≤ .01) over time. Among patients at hospitals that performed routine leak testing, we found a reduction of more than 75% in the adjusted risk of CAEs (odds ratio, 0.23; 95% CI, 0.05-0.99). CONCLUSION Routine leak testing of left-sided colorectal anastomoses appears to be associated with a reduced rate of CAEs within the SCOAP network and meets many of the criteria of a worthwhile quality improvement metric.

Introduction: The value of provocative testing of colorectal anastomoses to reduce morbidity and mortality has yet to be determined. Part of the challenge of determining its use as a quality improvement (QI) metric is that leak testing at the time of operation can be done to screen for leak as well as to confirm a suspected leak. If used for confirmation of a suspected leak then leak testing might actually appear to be associated with increased risk of leak. Methods: The Surgical Care and Outcomes Assessment Program (SCOAP) is a Washington State QI benchmarking tool based on chart-abstracted process of care and risk-adjusted outcomes data. We evaluated leak testing, death and/or adverse events requiring reintervention as a composite adverse event (CAE) for patients undergoing elective left-sided colon or rectal resections at 40 SCOAP hospitals from October 1, 2005 to December 31, 2009. To account for use of leak testing among patients where there was a suspected leak, we distinguished procedures that were performed at hospitals where leak testing was “selective” (<90% use) separate from those where leak testing was greater than 90% (routine) in a given calendar quarter. Results: Of 3,449 (58.8±14.8 yrs; 55.0% women) patients the CAE rate was 5.5% and in-hospital mortality 0.5%. Provocative leak testing increased (56.0% in Q0 to 75.8% in Q16) and rates of CAE decreased (7.0% in Q0 to 4.6% in Q16) over time (test for trend p-value≤0.01 for both). Male sex, low albumin levels (<3.0 g/dL), use of an immunosuppressant, increased operating time, and higher comorbidity score were associated with an increased rate of CAE. Among all patients at routine testing hospitals, those undergoing leak testing had a CAE rate of 5.8% compared to 11.1% among untested (p-value=0.18) with a>75% reduction in risk after adjustment for patient characteristics (OR 0.23, 95% CI 0.06-0.95). For example, leak testing among patients with adequate nutritional status (albumin>3g/dL) was associated with sharp reductions in CAE from 20% to 5.8% when testing was used (p-value=0.02). Conclusions: Routine leak testing appears to be associated with better outcomes and was part of the reason the SCOAP network reduced the rates of CAE. Tabled 1 Operations done at routine centers: all patients All patients (n=1,267) Tested group (n=36) Untested group (n=1,230) P-value Deaths 8 (0.6%) 8 (0.7%) 0 (0%) 0.63 Composite Adverse Event 75 (5.9%) 71 (5.8%) 4 (11.1%) 0.18 Operations done at routine centers: Patients with albumin level greater than 3 mg/dL All patients (n = 535) Tested group (n = 520) Untested group (n = 15) P value Deaths 4 (0.8%) 4 (0.8%) 0 (0%) 0.73 Composite Adverse Event 33(6.2%) 30 (5.8%) 3 (20.0%) 0.02 Open table in a new tab

BACKGROUND:Microsatellite instability (MSI) is a genetic aberration associated with less aggressive tumor biology. Some tumors with MSI also have lymphocytic infiltrate (LI), which suggests a heightened immune response against the tumor.OBJECTIVE:To evaluate the combined prognostic significance of MSI and LI in a colon cancer population.DESIGN:Colon cancers were prospectively evaluated for MSI by assessing 11 satellite markers and were classified as MSI+ if 2 or more satellite markers displayed instability. Tumors were classified as LI+ if at least 5 lymphocytes were observed per 10 high-power fields.SETTING:Community hospital system.PATIENTS:Individuals undergoing definitive surgery for colon cancer.MAIN OUTCOME MEASURES:Overall and disease-free survival were compared according to combined MSI and LI status.RESULTS:In 150 patients, tumors were classified as follows: 95 were MSI-/LI-, 9 were MSI-/LI+, 30 were MSI+/LI-, and 16 were MSI+/LI+. Median follow-up was 40.6 months. Five-year disease-free survival was 56.7% for patients with MSI-/LI- tumors and 88.9% for those with MSI+/LI+ tumors (P = .01). Patients with MSI+/LI- and MSI-/LI+ tumors had 5-year survival of 75.4% and 75.0%, respectively.CONCLUSIONS:Patients with colon cancer and MSI-/LI- tumors have worse disease-free survival rate regardless of stage at diagnosis. Patients exhibiting both MSI+ and LI+ tumors have more favorable disease-free survival rates. Both MSI and LI show promise as a combined prognostic marker and with further study may prove to be particularly useful in selecting patients with stage II disease for adjunctive therapy.

Background: Pretransplant donor-organ immunomodulation may attenuate allograft rejection by changing the redox state of donor cells. This study explored impact of donor-cell redox-state alteration by glutathione (GSH) depletion on graft immunogenicity.Methods: Splenic and heart endothelial cells from Balb/c mice were treated with diethylmaleate (a GSH-depleting agent) and/or lipopolysaccharide to assess the impact of GSH depletion on alloreactivity by mixed lymphocyte reaction, endothelial cell adhesion by T-cell adhesion assay, intracellular adhesion molecule-1 expression by reverse transcriptionase-polymerase chain reaction, and nuclear factor-kappa B upregulation by electrophoretic mobility shift assay. Heterotopic heart transplants were performed as in vivo correlate.Results: GSH depletion decreased endothelial cell and splenic cell alloreactivity, decreased endothelial-cell intracellular adhesion molecule-1 expression through attenuation of nuclear factor-kappa B activity, decreased endothelial cell adhesion, and prolonged heterotopic heart transplant graft survival.Conclusions: GSH depletion may represent a significant immunomodulator of donor antigenicity to prevent transplant rejection. (c) 2006 Excerpta Medica Inc. All rights reserved.

Inferior vena cava (IVC) injuries continue to be associated with mortality rates of 21 to 66 per cent despite advances in prehospital, surgical, and critical care. The purpose of this study was to evaluate outcome of patients with IVC injury after treatment at a major urban trauma center and to identify factors predictive of survival. Between 1989 and 1995, 158 patients presented to the Los Angeles County + University of Southern California Medical Center with IVC injuries. One hundred thirty-six patient records were available for review, and 69 data points were collected and analyzed. Mean age was 26 years (range, 6–54), and 122 (90%) patients were male. Mechanism of injury included gunshot in 88 (65%) patients, stab in 23 (17%) patients, shotgun in 7 (5%) patients, and blunt trauma in 18 (13%) patients. The mean Injury Severity Score was 25. Seventy (52%) patients were hypotensive. Eleven (8%) patients died before surgical intervention, and 25 (18%) patients died before operative repair. Repair (79), ligation (20), or observation (1) was accomplished in 100 (74%) patients. Overall survival was 48 per cent and 65 per cent in the 100 patients surviving to operative repair, including 5 of 20 patients requiring IVC ligation. Significant differences (P < 0.001) between survivors and nonsurvivors included Injury Severity Score, Glasgow Coma Score, hematocrit, hypotension, emergent thoracotomy, blood loss, level of injury, tamponade, and associated aortic injury. Logistic regression analysis identified hypotension, anatomic level of injury, and associated aortic injury as significant predictors of outcome (P = 0.001). Survival is predominantly determined by severity and anatomic accessibility of the IVC injury and by the absence of associated major vascular injuries. Ligation may control otherwise exsanguinating injuries and should be considered early in the management of complex injuries.

Au cours d'une periode de 62 mois, nous avons utilise le dioxyde de carbone pour completer ou remplacer les produits de contraste iodes au cours de la realisation de 27 angioplasties transluminales chez 26 malades. Les differentes arteres interessees etaient les suivantes : renales dans deux cas, iliaques dans cinq cas, femorales ou poplitees dans 15 cas, sous-poplitees dans deux cas et l'association de plusieurs arteres dans trois cas. L'indication de la procedure etait une gangrene du membre inferieur dans 11 cas, une ulceration ischemique dans 10 cas, des douleurs de decubitus dans trois cas, une claudication intermittente dans un cas et une nephropathie ischemique dans deux cas. La contre-indication a l'utilisation de produits de contraste iodes etait une insuffisance renale d'origine diabetique (20 cas) ou en rapport avec une nephropathie ischemique (deux cas) ou une insuffisance cardiaque (quatre cas). Huit procedures n'ont utilise que du dioxyde de carbone comme produit de contraste alors que 19 ont necessite de completer le dioxyde de carbone par du produit de contraste non ionique (en moyenne 39 ml). Nous avons obtenu un succes technique au cours de 25 procedures avec une amelioration hemodynamique significative chez 20 malades. Les complications observees ont ete une degradation transitoire de la fonction renale chez deux malades et un infarctus du myocarde chez deux malades. A 30 jours, 18 malades avaient une amelioration clinique significative. Les malades a haut risque de complications en rapport avec les produits iodes peuvent avoir une angioplastie transluminale sous arteriographie digitalisee en soustraction au dioxyde de carbone afin de diminuer ou eliminer le besoin en produit de contraste iode

Although the renin-angiotensin system has been implicated in the pathogenesis of renovascular hypertension (RVH), blood pressure does not parallel serum levels of renin or angiotensin II (AII) in chronic RVH. Upregulation of angiotensin II type 1 receptor (AT1) gene expression may explain this paradox and clarify the pathogenesis of chronic hypertension in RVH. To investigate this hypothesis, we studied changes in AT1 mRNA levels in rat kidney in a two-kidney, one-clip (2K1C) rat model of RVH. Animals were sacrificed at 1 or 10 weeks postoperatively. Blood pressure was measured with a tail cuff photosensor. Relative gene expression was quantitated by dot blotting total RNA, hybridizing with a cDNA probe for AT1, and quantitating signal intensity with scanning densitometry. A significant increase in blood pressure (BP) was observed at 1 week postoperatively (ΔBP: 2K1C = +24 mm Hg, n = 3; controls = +7 mm Hg, n = 3; P < 0.05), and at this time relative AT1 mRNA levels actually decreased in the clipped kidney (P < 0.05). Hypertension intensified 10 weeks postoperatively (ΔBP: 2K1C = +46 mm Hg, n = 20; controls = -17 mm Hg, n = 7; P < 0.005) and, remarkably, was paralleled by an almost sevenfold upregulation of AT1 mRNA levels in the clipped kidney (P < 0.005) and more than eightfold in the unclipped kidney (P < 0.005) of 2K1C animals. Upregulation of renal AT1 gene expression could lead to increased AT1 receptor production, hypersensitivity to AII, and chronic hypertension in RVH.

During a 62-month period, carbon dioxide was used to supplement or completely replace iodinated contrast agents in performing 27 transluminal angioplasties in 26 patients. The arterial segments addressed included the following: renal in two cases, iliac in five, femoral/popliteal in 15, infrapopliteal in two, and combined in three. Indications for intervention included lower extremity gangrene in 11 cases, ischemic ulceration in 10, rest pain in three, claudication in one, and ischemic nephropathy in two. Contraindications to iodinated contrast agents included renal insufficiency resulting from diabetes (n = 20) or ischemic nephropathy (n = 2) and congestive heart failure (n = 4). Eight procedures used carbon dioxide as the sole contrast agent, whereas 19 required supplementation of carbon dioxide with a mean of 39 ml of nonionic contrast medium. Technical success was achieved in 25 procedures with significant hemodynamic improvement in 20 patients. Complications included transient deterioration in renal function in two patients and myocardial infarctions in two. At 30 days 18 patients had demonstrated significant clinical improvement. Patients at high risk for iodinated contrast-related complications may undergo transluminal angioplasty using carbon dioxide/digital subtraction arteriography to reduce or eliminate the need for iodinated contrast agents.