PURPOSE:Rectal cancer treatment has a wide range of possible approaches from radical extirpative surgery to nonoperative watchful waiting following chemoradiotherapy, with or without, additional chemotherapy. Our goal was to assess the personal opinion of active practicing surgeons on rectal cancer treatment if he/she was the patient.METHODS:A panel of the International Society of University Colon and Rectal Surgeons (ISUCRS) selected 10 questions that were included in a questionnaire that included other items including demographics. The questionnaire was distributed electronically to ISUCRS fellows and other surgeons included in our database and remained open from April 16 to 28, 2020.RESULTS:One hundred sixty-three specialists completed the survey. The majority of surgeons (n=65, 39.9%) chose the minimally invasive (laparoscopic) surgery for their personal treatment of rectal cancer. For low-lying rectal cancer T1 and T2, the treatment choice was standard chemoradiation+local excision (n=60, 36.8%) followed by local excision±chemoradiotherapy if needed (n=55, 33.7%). In regards to locally advanced low rectal cancer T3 or greater, the preference of the responders was for laparoscopic surgery (n=65, 39.9%). We found a statistically significant relationship between surgeons' age and their preference for minimally invasive techniques demonstrating an age-based bias on senior surgeons' inclination toward open approach.CONCLUSION:Our survey reveals an age-based preference by surgeons for minimally invasive surgical techniques as well as organ-preserving techniques for personal treatment of treating rectal cancer. Only 1/4 of specialists do adhere to the international guidelines for treating early rectal cancer.

Department of Abdominal and General Surgery and Oncology, National Cancer Institute, Vilnius, Lithuania Faculty of Medicine, Institute of Clinical Medicine, Vilnius University, Vilnius, Lithuania Department of Surgery, University of Connecticut School of Medicine and Hartford Hospital, Hartford, Connecticut, USA Department of Colorectal Surgery, National Cancer Centre, National Clinical Research Centre for Cancer/Cancer Hospital, Chinese Academy ofMedical Science and Peking Union Medical College, Beijing, China Department of Colorectal Surgery, Allegheny General Hospital, Pittsburgh, Pennsylvania, USA Department of Colorectal Surgery, King’s College Hospital Foundation NHS Trust, London, UK Department of Surgery, Klaipeda University Hospital, Klaipeda, Lithuania Health Research and Innovation Science Centre Faculty of Health Sciences, Klaipeda University, Klaipeda, Lithuania

BackgroundThe novel severe acute respiratory syndrome coronavirus 2 virus that emerged in December 2019 causing coronavirus disease 2019 (COVID-19) has led to the sudden national reorganization of health care systems and changes in the delivery of health care globally. The purpose of our study was to use a survey to assess the global effects of COVID-19 on colorectal practice and surgery.Materials and MethodsA panel of International Society of University Colon and Rectal Surgeons (ISUCRS) selected 22 questions, which were included in the questionnaire. The questionnaire was distributed electronically to ISUCRS fellows and other surgeons included in the ISUCRS database and was advertised on social media sites. The questionnaire remained open from April 16 to 28, 2020.ResultsA total of 287 surgeons completed the survey. Of the 287 respondents, 90% were colorectal specialists or general surgeons with an interest in colorectal disease. COVID-19 had affected the practice of 96% of the surgeons, and 52% were now using telemedicine. Also, 66% reported that elective colorectal cancer surgery could proceed but with perioperative precautions. Of the 287 respondents, 19.5% reported that the use of personal protective equipment was the most important perioperative precaution. However, personal protective equipment was only provided by 9.1% of hospitals. In addition, 64% of surgeons were offering minimally invasive surgery. However, 44% reported that enough information was not available regarding the safety of the loss of intra-abdominal carbon dioxide gas during the COVID-19 pandemic. Finally, 61% of the surgeons were prepared to defer elective colorectal cancer surgery, with 29% willing to defer for ≤ 8 weeks.ConclusionThe results from our survey have demonstrated that, globally, COVID-19 has affected the ability of colorectal surgeons to offer care to their patients. We have also discussed suggestions for various practical adaptation strategies for use during the recovery period.

Hypothermia has been associated with an increase in the rate of infectious complications following colectomy. We hypothesized that a substantial fraction of temperature loss in patients undergoing elective colectomy occurs prior to operation.

BACKGROUND: Auscultation for bowel sounds has been advocated by some clinicians as a method to determine the resolution of postoperative ileus.OBJECTIVE: Our primary aim was to prospectively evaluate the relationships between bowel sounds and the ability to tolerate oral intake in patients after major abdominal surgery. Secondarily we aimed to evaluate relationships among bowel sounds, flatus and bowel movement, and oral intake.DESIGN: This was a prospective, blinded observational study.SETTINGS: The study was conducted at Western Pennsylvania Hospital.PATIENTS: A total of 124 adult patients undergoing major abdominal surgery were included.MAIN OUTCOME MEASURES: Data were collected by medical students blinded to the purpose of the study for 10 days postoperatively or until discharge, including the presence of bowel sounds (auscultation for 1 minute), flatus, bowel movement, and tolerance of oral intake (defined as ingestion of >= 1000 mL/24 h and each subsequent day without vomiting). Associations between paired variables were determined using. coefficient testing.RESULTS: The study population consisted of 51 men and 73 women, with a mean age of 64 years (range, 20-92 y). The majority of patients (78/124 (63%)) underwent colorectal resection. The median length of hospital was 6 days. Bowel sounds were not associated with flatus, bowel movement, or tolerance of oral intake throughout the study period. The positive predictive value of bowel sounds in predicting flatus and bowel movement was low in the early postoperative period and remained <25% in predicting tolerance of oral intake throughout the study period. The analysis was repeated, including only those patients undergoing colorectal procedures, and was essentially unchanged. Flatus correlated with bowel movement in the first 6 days postoperation, but neither flatus nor bowel movement was associated with tolerance of oral intake.LIMITATIONS: The rate of tolerance of oral intake was relatively modest throughout the study period.CONCLUSIONS: Bowel sounds are not associated with flatus, bowel movement, or tolerance of oral intake after major abdominal surgery.

Spilled gallstones have emerged as a new issue in the era of laparoscopic cholecystectomy. We treated a 77-year-old woman who underwent laparoscopic cholecystectomy. Subsequently, a right flank abscess developed. During the cholecystectomy, the gallbladder was perforated and stones were spilled. After a failed attempt to drain the abscess percutaneously, the patient required open drainage, which revealed retained gallstones in the right flank. The abscess resolved, although the patient continued to have intermittent drainage without evidence of sepsis. Review of the literature revealed 127 cases of spilled gallstones, of which 44.1% presented with intraperitoneal abscess, 18.1% with abdominal wall abscess, 11.8% with thoracic abscess, 10.2% with retroperitoneal abscess, and the rest with various clinical pictures. In case of gallstone spillage during laparoscopic cholecystectomy, every effort should be made to locate and retrieve the stones.

Background information about the variation in the risk for venous thromboembolism (VTE) and in prophylaxis practices around the world is scarce. The ENDORSE (Epidemiologic International Day for the Evaluation of Patients at Risk for Venous Thromboembolism in the Acute Hospital Care Setting) study is a multinational cross-sectional survey designed to assess the prevalence of VTE risk in the acute hospital care setting, and to determine the proportion of at-risk patients who receive effective prophylaxis.Methods All hospital inpatients aged 40 years or over admitted to a medical ward, or those aged 18 years or over admitted to a surgical ward, in 358 hospitals across 32 countries were assessed for risk of VTE on the basis of hospital chart review. The 2004 American College of Chest Physicians (ACCP) evidence-based consensus guidelines were used to assess VTE risk and to determine whether patients were receiving recommended prophylaxis.Findings 68183 patients were enrolled; 30 827 (45%) were categorised as surgical, and 37 356 (55%) as medical. On the basis of ACCP criteria, 35 329 (51.8%; 95% CI 51.4-52.2; between-country range 35.6-72.6) patients were judged to be at risk for VTE, including 19 842 (64.4%; 63.8-64.9; 44.1-80.2) surgical patients and 15 487 (41. 5%; 41.0-42. 0; 21.1-71.2) medical patients. Of the surgical patients at risk, 11613 (58.5%; 57.8-59.2; 0.2-92.1) received ACCP-recommended VTE prophylaxis, compared with 6119 (39.5%; 38.7-40.3; 3.1-70.4) at-risk medical patients.Interpretation A large proportion of hospitalised patients are at risk for VTE, but there is a low rate of appropriate prophylaxis. Our data reinforce the rationale for the use of hospital-wide strategies to assess patients' VTE risk and to implement measures that ensure that at-risk patients receive appropriate prophylaxis.

The purpose of this study was to define clinical and radiographic variables associated with postoperative mortality after urgent colectomy for fulminant Clostridium difficile colitis. Data were obtained regarding patients undergoing colectomy for fulminant C. difficile colitis at two institutions (1997-2005). Univariate analysis of factors predicting 30-day mortality was performed using χ 2 and Student's t tests. Multivariable logistic regression was done to include all variables whose P value was < 0.20. Clinical variables analyzed included: age, gender, recent operation, comorbidities, preoperative multisystem organ failure, vasopressors, symptom duration, time to surgery, serum albumin, change in serum albumin, serum creatinine, white blood cell count, and extent of colectomy. Computed tomography variables included: ascites, megacolon, and extent of colitis. Thirty-five patients (mean age 70 years, 46% male) underwent urgent colectomy for C. difficile colitis. The 30-day mortality rate was 45.7 per cent (16/35). The only clinical variable associated with mortality was preoperative multisystem organ failure (non-survivors 9/16 vs survivors: 4/19; P = 0.037). None of the three patients undergoing partial colectomy survived, although the difference in survival versus those undergoing subtotal colectomy was not significant. Patients with fulminant C. difficile colitis undergoing colectomy have a high mortality rate. Preoperative presence of multisystem organ failure was independently predictive of mortality.

Selection of candidates for surgical fellowships has traditionally been based on subjective evaluations by the program directors and references from previous positions. The introduction of well-validated objective methods of assessment has allowed us to evaluate candidates’ technical skills and base the selection process on objective, reliable, and transparent criteria. The aim of the study was to assess the applicability of such methods in current practice.

BACKGROUND:This study aimed to assess the efficacy of a method for avoiding conversion to laparotomy in patients considered for laparoscopic colectomy. Patients deemed to be at high risk for conversion to laparotomy were initially approached via an 8-cm midline incision ("peek port") with the laparoscopic equipment unopened. If intraperitoneal conditions were favorable, the procedure was performed using hand-assisted laparoscopy. If intraperitoneal conditions were unfavorable, the incision was extended to a formal laparotomy. Patients deemed to be at low risk for conversion to laparotomy were approached laparoscopically from the outset.METHODS:Data from 241 consecutive patients brought to the operating room for intended laparoscopic colectomy were retrieved from a prospective database.RESULTS:The study population consisted of 132 men and 109 women with a mean age of 62 years and a mean body mass index (BMI) of 28. Prior abdominal surgery had been performed in 49% of these patients. Inflammatory conditions accounted for 38% of the diagnoses, and enteric fistulas were present in 7% of the cases. Of the 25 patients who underwent the initial "peek port," 8 (32%) underwent immediate incision extension to formal laparotomy. Hand-assisted laparoscopic colectomy was performed in 17 (68%) of these 25 patients, with one subsequent conversion to formal laparotomy. Of the 216 patients initially approached laparoscopically, 5 (2%) required conversion to laparotomy. The laparotomy rate for the "peek port" group (9/25, 36%) was higher than for the initial laparoscopy group (5/216, 2%) (p < 0.0001). Of the 233 patients from both groups who underwent laparoscopy, the overall rate for conversion to laparotomy was 3% (6/233).CONCLUSIONS:The "peek port" approach to the patient with a potentially hostile abdomen allows for rapid assessment of intraperitoneal conditions and is associated with an overall low rate of conversion from laparoscopy to laparotomy. This technique should reduce overall cost by avoiding the use of laparoscopic equipment as well as potential complications related to trocar placement and laparoscopic dissection in patients who will ultimately require formal laparotomy.

BACKGROUND:Obesity is a risk factor for cancer and is associated with increased mortality from a number of malignancies. We describe our experience with bariatric surgery patients with a history of malignancy and review the safety and outcomes of bariatric surgery in patients with a history of cancer.METHODS:We performed a retrospective review of prospectively collected data from all patients diagnosed with a malignancy before, during, or after bariatric surgery. Data on weight loss, co-morbidities, and recurrence were collected.RESULTS:From July 1999 to February 2008, 1566 patients underwent bariatric surgery. Of these 1566 patients, 36 (2.3%) had a history of malignancy before they underwent bariatric evaluation and surgery, 4 (0.26%) were diagnosed with a malignancy during their preoperative evaluation, 2 of whom subsequently underwent bariatric surgery, and 2 had intraoperative findings suspicious for malignancy; bariatric surgery was completed in both cases. The evaluation revealed renal cell carcinoma and low-grade lymphoma, respectively. No procedures were aborted because of a suspicion of malignancy. Postoperatively, 16 patients (0.9%) were diagnosed with cancer, 3 of whom had a history of malignancy: 1 with metastatic renal cell, 1 with recurrent melanoma, and 1, who had had prostate cancer, with bladder cancer.CONCLUSION:A history of malignancy does not appear to be a contraindication for bariatric surgery as long as the life expectancy is reasonable. Screening for bariatric surgery might reveal the malignancy. Bariatric surgery does not seem to have a negative effect on the treatment of malignancies that are discovered in the postoperative period.

Purpose: Our objective was to evaluate their clinical presentation and management of patients under 45 years with acute diverticulitis. Methods: Retrospective, single institution study with review of the literature. We reviewed all charts of patients under 45 years that were discharged from the hospital with a diagnosis of diverticular disease (ER-GI lab-Inpatient). Our inclusion criteria were those patients with CT scan diagnosis and/or operative report of left sided diverticulitis. We excluded all patients in which symptoms were not due to diverticular disease and those with right side diverticulitis. Patient data, including demographics, Hinchey classification, non-operative and operative procedures performed, length of hospital stay, complications and recurrence were collected and studied. Results: 153 patients under 45 years were discharged with diagnosis of diverticular disease. In 80 patients the main complaint was not due to diverticular disease and in 3 patients there was a right-sided diverticulitis and were exclude from the study. Seventy patients had one or more episodes of acute diverticulitis. The mean age was 35 years (Median 36 years- Range 22–43 years) and the male-female ratio was 46/24. Fifty patients (71%) were admitted to the hospital whereas 20 patients (29%) were treated as outpatients. Sixty two patients (89%) had a non-complicated or Hinchey I diverticulitis, 6 patients (9%) Hinchey II and 2 patients (2%) Hinchey III-IV. Sixteen patients (23%) had a recurrence in a mean time of 8 months, (Median 4.5 Month, Range 1 week–4 years) and only two needed emergency surgery. All patients were non-complicated diverticulitis or Hinchey I in the first episode and all except one that recurred with a Hinchey III had the same stage at the recurrent episode. Recurrence was based on readmission to the hospital. Overall, 17 patients (23%) with diverticulitis had surgery; Ten surgeries (59%) were elective and 7 (41%) urgently. Conclusion: Reviewing the literature and based in our experience, acute diverticulitis does not appear to be a more virulent disease in patients under 45 year of age than in older patients

Immunosuppression is considered by some surgeons to be a relative contraindication for weight loss surgery. We describe our experience with immunosuppressed patients undergoing weight loss surgery.

Purpose: The purpose of this study is to assess the impact routine blood cultures have on the management / outcome of patients admitted with the working diagnosis of acute diverticulitis. Methods: Retrospective chart review of all patients admitted to the Western Pennsylvania Hospital Main and Forbes Regional campuses from June 1, 2004 to June 30, 2007 with the diagnosis of acute diverticulitis and whom had blood cultures performed upon admission. Results: The charts of 30 patients admitted with the diagnosis of acute diverticulitis in whom blood cultures were obtained were reviewed. Cultures were followed for a minimum of 5 days before reports were finalized. None of the cultures obtained yielded growth of any organisms. This is irrespective of severity of illness based upon: temperature, WBC count, presence of bandemia, and CT scan findings at presentation, as well as, the need for surgical intervention during their primary admission. There were no changes in antibiotic regimens until the patients were able to tolerate oral intake and prepared for discharge. Conclusion: There is no evidence to support the notion that blood cultures alter the decision making or care of patients with acute diverticulitis. This is a clearly a misappropriation of hospital and patient financial resources. Based upon the results of this study it is suggested that blood cultures no longer be obtained as routine admission orders for patients with acute diverticulitis.

Patients undergoing bariatric surgery while on anticoagulation are considered high risk. We describe our experience with bariatric surgery on patients on active anticoagulation.

Aim: To review trends in incidence and treatment of thermal injuries among the elderly.Method: A 3-year retrospective review of medical records of people aged 65 years and older admitted to our burn centre over July 2003-June 2006.Results: Elderly people with burns continued to have significant comorbidities. They were often burned because they were inappropriately trying to live alone. Thus discharge was often complicated.Conclusions: At our burn centre, survival among elderly people with burns has increased, probably as a result of more sophisticated medical, surgical and nursing care, as well as more extensive rehabilitation. (c) 2007 Elsevier Ltd and ISBI. All rights reserved.

Purpose: To assess the efficacy of a method to avoid conversion to laparotomy in patients considered for laparoscopic colectomy. Methods: Data from a single surgeon's consecutive series of 189 patients brought to the operating room with the intention of proceeding with laparoscopic colectomy were retrieved from a prospective database and supplemented by chart review. Patients deemed high risk for conversion had an 8 cm midline incision (“peek port”) made with the laparoscopic equipment unopened. If intraperitoneal conditions were favorable, a hand-assist device was placed through this incision and the procedure performed laparoscopically; if unfavorable, the midline incision was extended. Patients deemed low risk for conversion were approached laparoscopically from the outset. Results: Study population was 103 men and 86 women, mean age 62 years (range 17–94), mean BMI 28 (18–53). Operative procedures were right colectomy (N = 85), left colectomy/restorative proctectomy (N = 73), APR (N = 6), subtotal/total colectomy/proctocolectomy (N = 25). Of the 19 patients who underwent initial “peek port”, 7 (37%) underwent immediate extension to formal laparotomy. 12/19 (63%) underwent hand-assisted laparoscopic colectomy, with one subsequent conversion to formal laparotomy secondary to severe diverticulitis with enterocolic fistula. Of the 170 patients initially approached laparoscopically, 87 (51%) were attempted with standard laparoscopic techniques and 83 (49%) were attempted with a hand-assisted technique. 4/170 (2%) required conversion to laparotomy because of dense adhesions (N = 1), enterocolic fistula (1), ureteral injury (1), morbid obesity with pulmonary compromise (1). Overall, 5/182 patients (3%) in whom laparoscopic access was established by either method underwent conversion to laparotomy using this paradigm. In addition, we were able to identify those patients at high risk for conversion to laparotomy preoperatively (7/19 in the “peek port” group vs. 4/170 in those approached laparoscopically from the outset, P < 0.0001, Chi square). Conclusion: This approach to the patient with a potentially hostile abdomen allows for rapid assessment of intraperitoneal conditions that would preclude successful laparoscopic colectomy, and is associated with a low rate of conversion from laparoscopy to laparotomy. Adoption of this technique should reduce overall cost by avoiding the utilization of laparoscopic equipment in patients who will ultimately require formal laparotomy, and avoid potential trocar-related complications.