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Readmission after ileostomy creation continues to be a major cause of morbidity with rates ranging from 15% to 30% due to dehydration and obstruction. Rural environments pose an added risk of readmission due to larger travel distances and lack of consistent home health services.This study aimed to reduce ileostomy-related readmission rates in a rural academic medical center.This is a rapid cycle quality improvement study.This single-center study was conducted in a rural academic medical center.Colorectal surgery patients receiving a new ileostomy were included in this study.Improvement initiatives were identified through Plan-Do-Study-Act cycles (enhanced team continuity, standardized rehydration, nursing/staff education).Thirty-day readmission, average length of stay, and average time to readmission served as main outcome measures.Roughly equal rates of ileostomy were created in each time point, consistent with a tertiary care colorectal practice. The preimplementation readmission rate was 29%. Over the course of the entire quality improvement initiative, re-admission rates decreased by more than 50% (29% to 14%). PDSA cycle 1, which involved integrating a service-specific physician assistant to the team, allowed for greater continuity of care and had the most dramatic effect, decreasing rates by 27.5% (29% to 21%). Standardization of oral rehydration therapy and the implementation of a patient-directed intake/output sheet during PDSA cycle 2 resulted in further improvement in readmission rates (21% to 15%). Finally, implementation of nurse and physician assistant (PA)-driven patient education on fiber supplementation resulted in an additional yet nominal decrease in readmissions (15% to 14%). Latency to readmission also significantly increased throughout the study period.This study was limited by its small sample size in a single-center study.Implementation of initiatives targeting enhanced team continuity, the standardization of rehydration therapies, and improved patient education decreased readmission rates in patients with new ileostomies. Rural centers, where outpatient resources are not as readily available or accessible, stand to benefit the most from these types of targeted interventions to decrease readmission rates. See Video Abstract at http://links.lww.com/DCR/B771.ANTECEDENTES:La readmisión después de la creación de una ileostomía sigue siendo una de las principales causas de morbilidad con tasas que oscilan entre el 15% y el 30% debido a la deshidratación y la oclusión. Un entorno rurale presenta un riesgo adicional de readmisión debido a las mayores distancias de viaje y la falta de servicios de salud domiciliarios adecuados.OBJETIVO:Reducir las tasas de reingreso por ileostomía en un centro médico académico rural.DISEÑO:Estudio de mejoría de la calidad de ciclo rápido.AJUSTE:Estudio unicéntrico en una unidad de servicio médico académico rural.PACIENTES:Pacientes de cirugía colorrectal a quienes se les confeccionó una ileostomía.INTERVENCIONES:Iniciativas de mejoría identificadas a través de los ciclos Planificar-Hacer-Estudiar-Actuar (Continuidad del equipo mejorada, rehidratación estandarizada, educación de enfermería / personal).PRINCIPALES MEDIDAS DE RESULTADO:30 días de readmisión, duración media de la estadía hospitalaria, tiempo medio de reingreso.RESULTADOS:Se crearon tasas aproximadamente iguales de ileostomías un momento dado de tiempo, subsecuentes en la práctica colorrectal de atención terciaria. La tasa de readmisión previa a la implementación del estudio fue del 29%. En el transcurso de toda la iniciativa de mejoría en la calidad, las tasas de readmisión disminuyeron en más del 50% (29% a 14%). El ciclo 1 de PDSA, que implicó la integración en el equipo de un asistente médico específico, lo que permitió una mayor continuidad en la atención y tuvo el mayor efecto disminuyendo las tasas en un 27,5% (29% a 21%). La estandarización de una terapia de rehidratación oral y la implementación de una hoja de ingresos / perdidas dirigida al paciente durante el ciclo 2 de PDSA resultó en una mejoría adicional en las tasas de readmisión (21% a 15%). Finalmente, la implementación de la educación del paciente impulsada por enfermeras y AF sobre el consumo suplementario de dietas con fibra dio como resultado una disminución adicional, aunque nominal, de las readmisiones (15% a 14%). La latencia hasta la readmisión también aumentó significativamente durante el período de estudio.LIMITACIONES:Estudio de un solo centro con un muestreo de pequeño tamaño.CONCLUSIONES:La implementación de iniciativas dirigidas a mejorar la continuidad en el equipo, la estandarización de las terapias de rehidratación y la mejoría en la información de los pacientes disminuyeron las tasas de readmisión en todos aquellas personas con nuevas ileostomías. Los centros rurales, donde los recursos para pacientes ambulatorios no están tan fácilmente disponibles o accesibles, son los que más beneficiaron de este tipo de intervenciones específicas para reducir las tasas de readmisión. Consulte Video Resumen en http://links.lww.com/DCR/B771. (Traducción-Dr. Xavier Delgadillo).

CASE SUMMARY A 59-year-old previously healthy, asymptomatic man initially presented for his first screening colonoscopy. At this time, a friable, partially obstructing tumor was encountered in his proximal rectum. Final workup demonstrated a mrT2N1M0 upper rectal cancer. The patient went on to successfully complete total neoadjuvant chemoradiation therapy and was taken to the operating room for an uncomplicated robotic-assisted low anterior resection with primary anastomosis. His final pathology revealed an ypT2N1M0 rectal cancer, and he was subsequently followed in surveillance per National Comprehensive Cancer Network guidelines. At long-term follow-up visits he continued to report significant depressive symptoms and functional impairment. Despite aggressive medical management with fiber supplementation and antidiarrheal medications, the patient continued to struggle with bowel movement frequency and urgency. He reported having 4 to 6 clustered bowel movements during the day and 1 to 2 stools at night that significantly limited his ability to perform normal day-to-day activities.

AIM We aimed to evaluate long-term changes in patient-reported bowel function from presentation of anal canal squamous cell carcinoma (SCC) successfully treated with the modified Nigro protocol using a patient-reported outcome measure for bowel function. METHOD This is a retrospective study of prospectively collected patient-reported outcomes for bowel function. We included patients that were successfully treated with the modified Nigro protocol for anal SCC and had completed the Colorectal Functional Outcomes (COREFO) questionnaire at presentation, following the modified Nigro treatment (post-Nigro), and at subsequent surveillance visits (medium and long term). We compared the differences in mean domain and total COREFO scores using a paired t test for each paired time point. RESULTS Twenty-seven patients met inclusion criteria. Time from completion of the modified Nigro was post-Nigro at 3-6 months, medium-length follow-up at 8-12 months and long-term follow-up at 12-18 months. There was significant improvement in the stool-related aspects domain (pain, bleeding and anal skin irritation) from presentation to our short- and medium-length follow-up (42.5 to 23.7, P = 0.01). There was worsening in the frequency domain in the medium term (7.23 to 14.5, P = 0.02). There were no differences in any other domain or time point. CONCLUSION Global bowel function does not appear to change following successful treatment of anal canal SCC with the modified Nigro protocol in the long term. There are some improvements in stool-related aspects and worsening in bowel movement frequency at medium-length follow-up. These findings should help surgeons counsel patients with regard to bowel function expectations for those with anal canal SCC in the long term.

Background Colon cancer patients often ask how surgery will affect bowel function. Current understanding is informed by conflicting data, making preoperative patient counseling difficult. We aimed to evaluate patient-reported bowel function changes after colectomy for colon malignancy. Material and methods This was a retrospective analysis of a prospectively collected institutional database from July 2015 to June 2019. The included patients underwent colectomy for adenocarcinoma of the colon, and completed the Colorectal Functional Outcome (COREFO) questionnaire at preoperative presentation and postoperative followup. Preoperative and postoperative scores were compared using paired t-tests. Multivariable analysis was performed using domains demonstrating statistical significance on bivariate analysis, assessing the factors that were associated with symptomatic bowel function. Results We identified 117 patients with a mean age of 64 ± 13 y. The median time between preoperative and postoperative questionnaire completion was 52 d (interquartile range 45-70). Bowel movement frequency increased significantly from a mean preoperative score of 9.72 to a mean postoperative score of 14.2 (P = 0.003). There were no significant differences in the remaining four domains of bowel function or global function. Multivariable analysis demonstrated higher likelihood of symptomatic postoperative frequency scores in male patients (OR 3.85, 95% CI 1.44-11.11, P = 0.007) and patients with symptomatic preoperative frequency (OR 5.56, 95% CI 1.62-19.02, P = 0.006). Conclusions Patient-reported bowel movement frequency worsens at postoperative follow-up after colectomy for colon cancer, while overall bowel function does not change. Men and patients with preoperative symptomatic frequency have an increased likelihood of reporting symptomatic postoperative frequency. These findings should guide more personalized and evidence-based preoperative patient counseling.

Fecal incontinence is a prevalent health problem that affects over 20% of healthy women. Many surgical treatment options exist for fecal incontinence after attempts at non-operative management. In this article, the authors discuss surgical treatment options for fecal incontinence other than sacral neuromodulation.

The aim of this work was to evaluate physicians' perceptions of ostomates' quality of life (QoL) and comfort of care among an international sample of physicians caring for ostomates.This was a cross-sectional survey study. We conducted a survey of primary care physicians (PCP), gastroenterologists (GI), and general surgeons (GS) from three continents using the SERMO online physician platform. We piloted the survey for content, clarity and domain development using a pilot sample of physicians from each speciality before use. We summarized responses to questions related to physician comfort of ostomate care with descriptive statistics. We conducted multiple logistic regression with the primary outcome of physician perception of ostomate QoL.A total of 617 physicians (PCP 264, GI 176, GS 177) completed the survey representing North America, Europe and Australia similarly. The average age was 46 years and 21% were women. Ninety per cent of physicians care for an ostomate at least once per month. Eighty eight per cent had access to enterostomal nurses. Eighty two per cent of physicians believed that ostomates have decreased QoL. Forty seven per cent believed that ostomates have decreased overall health. Almost half of respondents answered incorrectly to a 'bogus question' citing fake clinical evidence supporting a negative impact of ostomies on social relationships. Increased physician comfort in ostomy care (OR 1.30, p = 0.04) and US-based physicians (OR 1.75, p = 0.01) were associated with increased odds of answering that ostomates have no decreased QoL.Among a diverse international sample, most physicians believe that ostomates have decreased QoL but not overall health. Physician implicit bias, physician comfort and geographical variability account for these findings. Targeted efforts to increase physician comfort in ostomate care and establish universal best practices is needed.

Enhanced Recovery After Surgery protocols have demonstrated decreased complication rates and length of stay. However, the influence of mental health on Enhanced Recovery After Surgery success is unknown.A retrospective study of patient-reported outcomes for physical and mental health. We included patients who underwent elective minimally invasive colon resections, who completed the Patient-Reported Outcomes Measurement Information System 10 questionnaire preoperatively, and who had successful implementation of perioperative Enhanced Recovery After Surgery components. We evaluated the predictors of having successful expected Enhanced Recovery After Surgery outcomes using a multiple logistic regression, controlling for baseline patient characteristics, history of a mental health diagnosis, inpatient opiate use, and preoperative Patient-Reported Outcomes Measurement Information System 10 scores.In total, 163 patients met inclusion criteria, with 23% failing Enhanced Recovery After Surgery, and 32% having a preoperative mental health diagnosis. The most common reason for failure of expected Enhanced Recovery After Surgery outcomes was length of stay (55.3%) followed by postoperative ileus (31.6%). Age, sex, the American Society of Anesthesiologists physical status classification, and preoperative Patient-Reported Outcomes Measurement Information System 10 scores were not significantly different between those who failed or succeeded, whereas length of stay was typically longer for those who failed Enhanced Recovery After Surgery (5.7 days failure vs 2.2 days success, P.001). Patients with a previous mental health diagnosis, where depression and anxiety were most common, had significantly lower odds of successfully meeting expected Enhanced Recovery After Surgery outcomes (odds ratio of 0.23, 95% confidence interval: 0.09-0.55, P = .001).Patients with a mental health diagnosis have a lower likelihood of successfully meeting expected Enhanced Recovery After Surgery outcomes. The majority of these patients self-report normal mental and physical health preoperatively, indicating that even well-controlled mental health diagnoses have a negative impact on Enhanced Recovery After Surgery success.

A 59-year-old previously healthy, asymptomatic man initially presented for his first screening colonoscopy. At this time, a friable, partially obstructing tumor was encountered in his proximal rectum. Final workup demonstrated a mrT2N1M0 upper rectal cancer. The patient went on to successfully complete total neoadjuvant chemoradiation therapy and was taken to the operating room for an uncomplicated robotic-assisted low anterior resection with primary anastomosis. His final pathology revealed an ypT2N1M0 rectal cancer, and he was subsequently followed in surveillance per National Comprehensive Cancer Network guidelines. At long-term follow-up visits he continued to report significant depressive symptoms and functional impairment. Despite aggressive medical management with fiber supplementation and antidiarrheal medications, the patient continued to struggle with bowel movement frequency and urgency. He reported having 4 to 6 clustered bowel movements during the day and 1 to 2 stools at night that significantly limited his ability to perform normal day-to-day activities.

OBJECTIVE To assess the current barriers in robotic surgery training for general surgery residents. DESIGN Multi-institutional web-based survey. SETTING 9 academic medical centers with a general surgery residency. PARTICIPANTS General surgery residents of at least PGY-3 training level. RESULTS 163 general surgery residents were contacted with 80 responses (49.1%). The most common responders were PGY-3s (38.8%) followed by PGY-5s (27.5%). The Northeast represented 42.5% of responses. Colorectal cases were the most common robotic case residents were involved in (51.3%). Residents’ typical roles were assisting at the bedside (31.3%) and splitting time between assisting at the bedside and operating at the surgeon console (31.3%). 43% report to be either extremely or somewhat dissatisfied with their robotic surgery experience. 62.5% report they do not intend to integrate robotic surgery into their future practice. 93.8% of residents have a standardized robotic curriculum. 47.5% report using the simulator only during required didactic time with 52.5% having the robotic simulator conveniently located. The majority of residents report that the presence of dual consoles and first-assists in robotic cases enhance their robotic training (93% - 62%, respectively). 72.5% felt like they had more autonomy during laparoscopic cases and 96.8% of residents felt that an attendings’ lack of experience impacted their time operating at the surgeon console. CONCLUSIONS General surgery residents report lack of effective OR teaching, real clinical experience, and simulated experience as main barriers in their robotic surgery training. Dual consoles and first-assistants are favorably looked upon. Lack of attending experience and comfort were universally negatively associated with resident participation. For residents interested in robotic surgery, advocating for more robust investment in dual consoles, first-assistants, and faculty development would likely improve their robotic surgery training experience. However, residency programs should consider whether robotic surgery should be a core competency of an already time restricted training paradigm.

Postoperative bowel function is a common concern for patients undergoing a sigmoidectomy. We have previously demonstrated that patients with symptomatic bowel function preoperatively have substantial improvement at long-term follow-up. However, the effect of the operative approach on patient-reported bowel function is largely unknown. We aimed to evaluate the differences in long-term patient-reported bowel function after robotic or laparoscopic sigmoid colectomies for benign and malignant disease.A retrospective analysis of a prospectively collected institutional database from July 2015 to July 2020. Patients included underwent a sigmoid colectomy for benign or malignant disease and completed the Colorectal Functional Outcome (COREFO) questionnaire at preoperative presentation, postoperatively, and long-term follow-up. Differences between preoperative and postoperative scores, as well as differences between the robotic and laparoscopic cohorts, were compared using paired t-tests.A total of 169 patients met inclusion criteria with a median age of 61 y, and 55% of the patients underwent robotic sigmoid colectomy, with the most common diagnosis being diverticular disease (62%). There was no significant difference between the presentation, short-term, or long-term follow-up total COREFO scores or subdomains based on the surgical technique. Patients that present asymptomatic remain asymptomatic, while those that are symptomatic demonstrate improvements for both the robotic and laparoscopic groups.Patient-reported long-term global bowel function does not appear to differ between patients who underwent elective robotic or laparoscopic sigmoid colectomy for benign or malignant disease. Patients that present asymptomatic remain asymptomatic, while those that are symptomatic demonstrate improvements, regardless of surgical technique.

BACKGROUND/PURPOSE: Clinical trials in oncology evaluating the effects of patient reported outcomes (PRO) collection have found that monitoring of symptoms with PROs is associated with improved clinical care through reduced acute care utilization and decreased patient symptom burden. This educational review will evaluate strategies for systematic PRO integration into everyday oncology clinical practice. METHODS: We outline key considerations for using PROs in clinical practice, highlighting evidence from published studies. We also discuss the benefits and challenges of PRO implementation in oncology. RESULTS: Implementing PRO collection in clinical practice can improve care delivery and facilitate patient-centered clinical research. Considerations for using PROs in clinical practice include choice of instrument, method of delivery, and frequency of query. Challenges with implementing systematic PRO collection include the costs and resources needed for implementation, impact on clinical workflow, and controlling/monitoring physician burnout. DISCUSSION: While challenges exist in terms of financial resources and staff participation/burnout, patient reported outcomes in clinical practice provide a number of benefits including symptom monitoring, clinical research, and potential real-time personalized clinical decision support.

Supplemental Material, sj-pdf-1-sri-10.1177_1553350621998871 for Patient-Reported Outcome Measures in Colorectal Surgery: Construction of Core Measures Using Open-Source Research Method by Alaa El-Hussuna, Ines Rubio-Perez, Monica Millan, Gianluca Pellino, Ionut Negoi, Gaetano Gallo, Mostafa Shalaby, Valerio Celentano, Ryan Green, Ana Minaya-Bravo, Sameh Emile, Neil J. Smart, Yasuko Maeda, Srinivas J. Ivatury, Graham Mackenzie, Ali Yalçınkaya, Claudia Mellenthin, Nagendra N. Dudi-Venkata, Justin Davies, Angus McNair, Francesco Pata, Kasper Gymoese Berthelsen, David Rivadeneira, Antonino Spinelli, Pår Myrelid, Julio Mayol and Steven Wexner in Surgical Innovation

Supplemental Material, sj-pdf-1-sri-10.1177_1553350621998871 for Patient-Reported Outcome Measures in Colorectal Surgery: Construction of Core Measures Using Open-Source Research Method by Alaa El-Hussuna, Ines Rubio-Perez, Monica Millan, Gianluca Pellino, Ionut Negoi, Gaetano Gallo, Mostafa Shalaby, Valerio Celentano, Ryan Green, Ana Minaya-Bravo, Sameh Emile, Neil J. Smart, Yasuko Maeda, Srinivas J. Ivatury, Graham Mackenzie, Ali Yalçınkaya, Claudia Mellenthin, Nagendra N. Dudi-Venkata, Justin Davies, Angus McNair, Francesco Pata, Kasper Gymoese Berthelsen, David Rivadeneira, Antonino Spinelli, Pår Myrelid, Julio Mayol and Steven Wexner in Surgical Innovation

Background Many patients with inflammatory bowel disease (IBD) are referred to surgeons when medical treatments are ineffective, signifying poor disease control. We aimed to assess the association of IBD diagnosis with physical and mental health upon presentation to a colorectal surgeon. Methods We included all new patients presenting to colorectal surgery clinic over 1.5 years. During registration, patients completed the PROMIS Global-10, a validated outcome measure assessing physical and mental health. We grouped patients by diagnosis: IBD, anorectal, benign colorectal, and malignancy. Details on IBD patients were obtained via chart review. We evaluated the interaction between PROMIS scores and diagnosis through ANOVA analysis and post hoc Tukey–Kramer pairwise comparison. We estimated the strength of association of age, sex, and visit diagnosis with poor physical and mental health (PROMIS: −1 SD) through logistic regression. Results Eight hundred ninety-seven patients were included. The cohort was as follows: IBD (99) (Crohn = 73; ulcerative colitis = 26), anorectal (378), benign colorectal (224), and malignancy (196). The mean age of patients was 56 (±17) years. Fifty-seven percent were female. The IBD group was youngest (P < 0.001). IBD had significantly lower PROMIS scores on pairwise comparison; anorectal had the highest scores. Controlling for age and sex, the IBD group had 4.1× odds of poor physical health (95% confidence interval 2.46–6.76) and 2.9× odds of poor mental health (95% confidence interval 1.66–5.00). Conclusions Patients with IBD, specifically Crohn disease, have worse physical and mental health on presentation to a colorectal surgeon compared to patients presenting with other colorectal diagnoses. These patients considering surgery might benefit from added support during the perioperative period.

Poor sleep leads to poor health outcomes. Inpatient sleep disturbance has been studied primarily in the ICU. Minimal research exists on sleep in surgical populations.We recruited patients undergoing elective, inpatient general surgery procedures. Participants wore Fitbit trackers while inpatient to measure total sleep time (CDC recommendation is 7 or more hours per night). At discharge, patients completed the Richards-Campbell Sleep Questionnaire (RCSQ) to measure inpatient sleep quality. The RCSQ combines 5 domains into a cumulative score (0 to 100); a higher score means better sleep quality. Patients also completed the outpatient Pittsburgh Sleep Quality Index preoperatively and postoperatively. The primary end point was percentage of patients with total sleep score ≥ 50. Secondary outcomes included mean RCSQ domain scores, Fitbit total sleep time, and percentage with Pittsburgh Sleep Quality Index Score indicating poor sleep.We included 64 patients (mean ± SD age 55.0 ± 14.1 years). Mean ± SD RCSQ total sleep score was 49 ± 20.5 and 53.1% with total sleep score50. Mean ± SD RCSQ domain scores were Awakenings: 40.4 ± 22.8, Sleep Quality: 49.1 ± 27.9, Sleep Latency: 49.2 ± 25.3, Sleep Depth: 50.2 ± 26.5, Returning to Sleep: 55.9 ± 28.1, and Noise Disturbance: 59.1 ± 27.9. On night one, 25 devices (40%) had recorded sleep data due to enough sleep. Mean ± SD total sleep time on night 1 was 4.7 ± 2.8 hours. Mean total sleep time for nights 2, 3, and 4 remained fewer than 7 hours. Percentages for each night that achieved the CDC goal of 7 or more hours were as follows: night one 10.9%, night two 32.8%, night three 35.3%, and night four 27.6%. Per the Pittsburgh Sleep Quality Index, 88.1% of patients were poor sleepers preoperatively and 84.5% were poor sleepers at follow-up (p = 0.6).Elective general surgery patients experience a severe inpatient sleep disturbance, worse than in similarly studied ICU cohorts. This disturbance is driven primarily by nighttime awakenings.

Background Surgery for anorectal disease is thought to cause significant postoperative pain. Our previous work demonstrated that most opioids prescribed after anorectal surgery are not used. We aimed to evaluate a standardized protocol for pain control after anorectal surgery. Methods We prospectively evaluated a standardized opioid reduction protocol over a 13-mo period for all patients undergoing elective anorectal surgery at our institution. Protocol components include preoperative query, procedural local-anesthetic blocks, first-line nonopioid analgesic use ± opioid prescription of five pills, and standardized postoperative instructions. Patients completed questionnaires at postoperative follow-up. Patients with history of opioid abuse or use within 30 d of operation, loss to follow-up, or surgical complications were excluded. Primary outcome was quality of pain control on a five-point scale. Secondary outcomes included use of nonopioid analgesics, opioids used, and need for refill. Results A total of 55 patients were included. Mean age was 47 ± 17 y with 23 women (42%). Anorectal abscess/fistula procedures were the most common (69%) followed by pilonidal procedures (11%) and hemorrhoidectomy (7%). Most had general anesthesia (60%) with the remainder local anesthesia ± sedation. Fifty-four (98%) had procedural local-anesthetic blocks. Twenty-six patients (47%) were prescribed opioids with a median of five pills. Forty-seven patients (85%) reported the use of nonopioid analgesics. Forty-six patients (84%) reported excellent to very good pain control. About 220 opioid pills were prescribed, and 122 were reported to be used. One patient (2%) received an opioid refill. Conclusions Satisfactory pain control after anorectal surgery can be achieved with multimodality therapy with little to no opioid use for most patients.

BACKGROUND Nonoperative management has been reported to decrease symptoms from common anorectal conditions such as chronic anal fissures and hemorrhoids. The effects of these interventions on bowel function are unknown. OBJECTIVE This study aims to perform a prospective evaluation of patient-reported outcomes of bowel function on nonoperative management for chronic anal fissures and hemorrhoid disease. DESIGN This is a prospective, observational study. SETTINGS Patient-reported outcome measures were collected from the clinical practice of the division of colon and rectal surgery at a tertiary colon and rectal surgery referral center. INTERVENTION All patients received standardized dietary counseling including fiber supplementation as well as toileting strategies. Those with chronic anal fissures were also prescribed topical calcium channel blockers. The Colorectal Functional Outcome questionnaire was administered at baseline and at first follow-up visit. MAIN OUTCOME MEASURES The primary outcomes measured were the mean change in patient-reported bowel function scores after nonoperative management for each disease and in aggregate. RESULTS A cohort of 64 patients was included, 37 patients (58%) with chronic anal fissure and 27 patients with hemorrhoid disease. Incontinence, social impact, stool-related aspects, and the global score were observed to have statistically significant improvement in the aggregate group. When analyzed by diagnosis, hemorrhoid disease demonstrated a statistically significant improvement in incontinence and stool-related aspects, whereas chronic anal fissure was associated with a statistically significant change in social impact, stool-related aspects, and the global score. LIMITATIONS This study was limited by the small cohort size and unclear patient adherence to medical management. CONCLUSIONS Nonoperative management of chronic anal fissures and hemorrhoid disease is associated with significant improvement in patient-reported outcome scores in several domains, suggesting that dietary counseling and medical therapy should be the first-line outpatient therapy for these diseases. See Video Abstract at http://links.lww.com/DCR/A726.

Background Surgery for anorectal diseases is thought to cause significant pain postoperatively. There is little known regarding standardized opioid-prescribing trends and patient use following surgery for anorectal diseases. We aimed to evaluate and analyze opioid-prescribing trends and patient use for outpatient anorectal operations. Materials and methods All patients who underwent outpatient anorectal surgery performed over a 1-y period at a single institution were eligible. Procedures included hemorrhoidectomy, anal fistula repair/seton, anal fissure treatment with sphincterotomy, and transanal excision of rectal tumors. Demographic, operative, and postoperative data were obtained. Patients were given a survey to determine postoperative pain control with opioid and non-narcotic analgesia use; respondents were included in analysis. Results Forty-two outpatient anorectal surgery patients were included: 13 had hemorrhoidectomy, 22 had anal fistula repair/seton, one had sphincterotomy, and six had transanal excisions. All patients had multimodality treatment with either an anal block and/or postoperative nonopioid analgesics. Ninety percent were prescribed opioids postoperatively with a median of 20 pills (range: 0-120 pills). Forty-three percent (18/42) did not fill their prescription. For those who used opioids, the median number of pills taken was four. Eighty percent of pills prescribed were not used. One patient required a refill. Greater than 60% of respondents reported good to excellent pain control on a five-point scale. Conclusions Most patients had adequate pain control after anorectal surgery with little to no use of opioids and that more than 80% of opioid pills prescribed were not consumed. We intend to standardize our prescribing opioid quantities for outpatient anorectal operations to reflect this reduced use.

Background To optimize responsible opioid prescribing after inpatient operation, we implemented a clinical trial with the following objectives: prospectively validate patient-centered opioid prescription guidelines and increase the FDA-compliant disposal rate of leftover opioid pills to higher than currently reported rates of 20% to 30%. Study Design We prospectively enrolled 229 patients admitted for 48 hours or longer after elective general, colorectal, urologic, gynecologic, or thoracic operation. At discharge, patients received a prescription for both nonopioid analgesics and opioids based on their opioid usage the day before discharge: if 0 oral morphine milligram equivalents (MME) were used, then five 5-mg oxycodone pill-equivalents were prescribed; if 1 to 29 MME were used, then fifteen 5-mg oxycodone pill-equivalents were prescribed; if 30 or more MME were used, then thirty 5-mg oxycodone pill-equivalents were prescribed. We considered patients’ opioid pain medication needs to be satisfied if no opioid refills were obtained. To improve FDA-compliant disposal of leftover pills, we implemented patient education, convenient drop-box, reminder phone call, and questionnaire. Results Our opioid guideline satisfied 93% (213 of 229) of patients. Satisfaction was significantly higher in lower opioid usage groups (p = 0.001): 99% (99 of 100) in the 0 MME group, 90% (91 of 101) in the 1 to 29 MME group, and 82% (23 of 28) in the 30 or more MME group. Overall, 95% (217 of 229) of patients used nonopioid analgesics. Sixty percent (138 of 229) had leftover pills; 83% (114 of 138) disposed of them using an FDA-compliant method and 51% (58 of 114) used the convenient drop-box. Of 2,604 prescribed pills, only 187 (7%) were kept by patients. Conclusions This clinical trial prospectively validated a patient-centered opioid discharge prescription guideline that satisfied 93% of patients. FDA-compliant disposal of excess pills was achieved in 83% of patients with easily actionable interventions.

ObjectiveTo (1) characterise (A) the lived experiences and (B) information needs of patients with rectal cancer; and (2) compare to the perceived lived experiences and information needs of colorectal surgeons.DesignWe conducted 1-hour semistructured qualitative interviews, dual independent transcript coding and thematic analysis.Setting/participantsInterviews included rectal cancer survivors (stages I–III), some accompanied by caregivers, at Dartmouth-Hitchcock Medical Center and experienced colorectal surgeons.ResultsWe performed 25 interviews involving 30 participants, including 15 patients with 5 caregivers, plus 10 physicians. Two major themes emerged. First, patients reported major impacts on their lives following rectal cancer, including on their everyday lives and leisure activities; identity, self-confidence and intimacy; mental health, especially anxiety. These impacts were mediated by their medical experiences, lifestyle and attitudes. Second, the diversity of effects on patients’ lives means that care, counselling and information needs should be personalised for a better medical experience and outcomes. Surgeons did not report knowledge of the full range of patient experiences and reported limited counselling in key areas, particularly concerning intimacy and mental health.ConclusionRectal cancer diagnosis, treatment and survivorship dramatically affect all people, regardless of which surgical treatment they undergo. Effects are varied and necessitate customised care, counselling and information, which surgeons are not currently providing. Because rectal cancer affects every part of patients’ lives, they need holistic support and information. Patients would benefit from substantial support after treatment as they establish a new normal.

Introduction Diverticular disease is common worldwide. A subset of these patients will choose to undergo elective surgical resection because of symptoms or complicated disease. The aim of this study was to evaluate changes in bowel function after elective sigmoid resection for diverticular disease. Materials and methods We retrospectively reviewed patients seen at our institution from May 2015 to July 2018 who underwent elective sigmoid resection for diverticular disease. We used the Colorectal Functional Outcome (COREFO) questionnaire, a validated questionnaire that assesses bowel function in five domains and a global function score (scores 0-100, with higher score indicating worse function). We obtained questionnaire data at baseline, as well as at postoperative follow-up, and a paired t-test was used to compare. Results Forty-nine patients met criteria for inclusion in this study. The median time between questionnaire completion was 70 days (interquartile range: 56 to 85). The mean age was 60 ± 12 years, with 57% female patients. Thirty-six (73%) patients underwent sigmoidectomy alone and 13 (27%) underwent sigmoidectomy with fistula repair. Six patients (12%) had a diverting loop ileostomy in addition to sigmoidectomy and underwent a subsequent reversal. Overall, there were no differences in any of the five domains or the total Colorectal Functional Outcome score from baseline to postintervention. Conclusions In our cohort, bowel function did not significantly change in the early postoperative period after elective sigmoid resection for diverticular disease. Surgeons should counsel patients, especially symptomatic ones, that bowel function will likely be no different at time of postoperative follow-up.

2064 Background: A standardized, validated tool for capturing symptoms from cancer patients, PRO-CTCAE, has been used to reduce symptom burden, decrease acute care needs, and preserve quality of life. The association between specific PRO-CTCAE symptom scores and single item measures of OWb and PFn were characterized to understand symptom constellations. Methods: A novel Epic-based symptom management program (eSyM) was deployed for GI, GYN, and thoracic cancer patients starting chemotherapy (Memphis Baptist) or having surgery (WVU Medicine). Patients received automated prompts to complete surveys via the patient portal (MyChart) on a fixed schedule, approximately twice/week. Each survey included one OWb item, one PFn item, and at least 6 PRO-CTCAE items (pain, nausea, vomiting, fatigue, anxiety, insomnia). The OWb and PFn items, which were created de novo, included 5 ordinal response options with corresponding pictograms (emojis from very happy to very sad for OWb; a figure walking to one prone in bed for PFn). Composite scores were generated: 0 for no symptoms, 1-2 for mild/moderate symptoms, and 3 for severe symptoms. We describe OWb and PFn and analyze associations between these items and PRO-CTCAE symptom scores. Results: Between 9/10/19-1/22/20, we collected 908 eSyM responses from 166 chemotherapy patients at Baptist (Age, M = 65), and 480 eSyM responses from 97 postoperative patients at WVU (Age, M = 57). The OWb and PFn scores demonstrated moderate correlation with PRO-CTCAE symptom scores (Baptist r = 0.63; WVU r = 0.75), and moderate correlation with mean symptom scores among surgery patients at WVU (r = 0.74); but lower correlation among chemotherapy patients at Baptist (r = 0.53-0.55). Scores improved over time following surgery, but not after initiation of chemotherapy. Among the 730 eSyM responses with none/mild values for both OWb and PFn (52.9% of all responses), only 4.5% reported any severe symptom; among 651 responses with impairment of OWb and/or PFn, 45.2% reported at least one severe symptom. Conclusions: Integration of eSyM into the Epic EHR enabled tracking of OWb, PFn, and PRO-CTCAE items. When asked alongside PRO-CTCAE symptom items, two single item OWb and PFn measures provided distinct information and correlated with symptom burden. These results demonstrate the feasibility of integrating ePRO collection into routine post-operative and medical oncology care and that PRO-CTCAE items provide information that is distinct from that obtained from global metrics of well-being. Clinical trial information: NCT03850912.

e19139 Background: Rectal cancer surgery drastically changes the lives of patients. Decision aids available to guide patients on this decision are limited and of poor quality. We aimed to identify the content and delivery preferences of rectal cancer survivors who have faced this surgical decision and colorectal surgeons to guide future decision aid creation. Methods: We performed semi-structured interviews of survivors and their caregivers, as well as colorectal surgeons from April through August 2019. We purposively sampled patients treated surgically for rectal cancer and colorectal surgeons to include different demographics, surgical experiences, and practice types. We achieved thematic saturation in both groups. We performed dual coding and inductive thematic analysis. Results: A total of 30 participants were interviewed, 15 patients with 5 caregivers, and 10 colorectal surgeons. Patient demographics demonstrated an equal distribution of sex, age categories, and operative type. Physician demographics demonstrated a mean of 10±7 years in practice with 70% academic and 30% private practice. Main themes for both groups stated that a massive patient educational need exists throughout the continuum of disease into survivorship. Participants emphasized the need for a comprehensive educational tool to address these needs rather than a decision aid. Both wanted a tool that was personalized, simple, understandable, visually appealing, interactive, and delivered in a combination of modalities to capture the broadest audience. Patients also desired specific features like care timelines and resources. Surgeons felt than an educational tool would enhance patient/provider interaction by reinforcing material covered in clinic. Conclusions: A surgical decision aid for rectal cancer is not enough. Patients and surgeons acknowledged the need for a comprehensive tool to address the educational gap that exists through the continuum of rectal cancer care.

PURPOSE: Stoma reversal sites are a common location for incisional hernias. We aim to evaluate fascial defects at previous stoma sites in patients with a history of colorectal cancer. METHODS: This was a retrospective cohort study from a single center. We included adult patients diagnosed with colorectal cancer, who underwent stoma reversal from 2011 to 2018 with at least one postoperative computed tomography scan. RESULTS: Of 92 patients, 40 (43%) were female, with a mean age of 58 years. Fascial defects were noted in 45 (49%) patients, with stoma-site hernias present in 24 (26%) patients. Posterior sheath defects were not associated with subsequent hernia development, and most hernias occurred within 2 years. Body mass index >30 was associated with increased risk of stoma-site hernia (odds ratio 11.9, P = 0.002), but smoking, hypertension, stoma type, pathologic stage, and chemotherapy within 90 days were not found to be significant. CONCLUSIONS: The incidence of stoma-site hernias is high. Obesity appears to be a significant risk factor for the development of these hernias and most hernias occur quickly following surgery.

IMPORTANCE: Increasing regionalization of cancer surgery has the inadvertent potential to lead to fragmentation of care if readmissions occur at a facility other than the index hospital. The magnitude and adverse effects of readmission to a facility other than the one where the surgery was performed are unclear. OBJECTIVES: To assess rates of readmission to nonindex hospitals after major cancer surgery and to compare outcomes between index and nonindex hospital readmissions. DESIGN, SETTING, AND PARTICIPANTS: In this multicenter, population-based, nationally representative study of adult patients undergoing a major cancer operation (defined as esophagectomies or gastrectomies, hepaticobiliary resections, pancreatectomies, colorectal resections, or cystectomies), retrospective analyses were performed using the Nationwide Readmissions Database (admissions from January 1 through September 30, 2013). Descriptive analyses were performed to determine 90-day readmission characteristics, including timing, cost, and outcomes. Adjusting for clustering by facility, the study used multivariate logistic regression to identify factors associated with nonindex vs index readmissions. The study also used regression models to identify differences in mortality, major complications, and subsequent readmissions between the 2 groups. Data analysis was performed from January 1 through December 31, 2013. EXPOSURES: Readmission to index vs nonindex hospitals (defined as any hospital other than the hospital where the major cancer operation was performed). MAIN OUTCOMES AND MEASURES: Proportion of 90-day readmissions and nonindex readmissions after major cancer surgery, factors associated with nonindex readmissions, and difference between in-hospital mortality, hospital costs, and subsequent readmissions for patients admitted to index vs nonindex hospitals. RESULTS: A total of 60 970 patients were included in the study (mean [SD] age, 67 [13] years; 7619 [55.6%] male and 6075 [44.4%] female). The 90-day readmission rate was 23.0%. Of the 13 695 first readmissions, 20.1% were to a nonindex hospital. Independent factors associated with readmission to a nonindex hospital included type of procedure, comorbidities (OR, 1.40; 95% CI, 1.15-1.70), elective admission (OR, 1.21; 95% CI, 1.06-1.37), discharge to a nursing facility (OR, 1.20; 95% CI, 1.07-1.36), and surgery at a teaching hospital (OR, 1.16; 95% CI, 1.00-1.34) (all P

Complicated diverticulitis is associated with a postoperative mortality rate of 20%. We hypothesized that age ≥80 was an independent risk factor for mortality after Hartmann's procedure for diverticular disease when controlling for baseline comorbidities.Patients who underwent an urgent or emergent Hartmann's procedure (Current Procedural Terminology codes 44143 and 44206) for diverticular disease (International Classification of Diseases-9:562.xx) were identified using the American College of Surgeons National Surgical Quality Improvement Project 2005-2013 user file. Using propensity score matching to control for baseline comorbidities, a group of patients ≥80 years old was matched to a group of those80 years old. Univariate and multivariable logistic regression were performed. A P value0.05 was considered statistically significant with a confidence interval (CI) of 95%.From a total of 2986 patients, 464 patients (15.5%) were ≥80 years old. Two groups of 284 patients in each study arm were matched using propensity-matching. The mean age of the ≥80 group and80 group was 84.4 ± 3.3 versus 63.77 ± 911.8; P 0.0001, respectively. There was no statistical difference in baseline comorbidities or operative time between the groups. There was a significant difference in mortality with 19% and 9.2% in the80 group versus80 groups, respectively (P = 0.001). Factors associated with mortality included ascites (odds ratio [OR] 4.95, confidence interval [CI] 1.64-14.93, P = 0.005), previous cardiac surgery (OR 3.68, CI 1.46-9.26, P = 0.006), partially dependent or fully dependent functional status (OR 2.51, CI 1.12-5.56, P = 0.02), albumin3 (OR 2.49, CI 1.18-5.29, P = 0.01), and American Society of Anesthesiologist class3 (OR 2.10, CI 1.10-4.46, P = 0.05).Octogenarians presenting with complicated diverticulitis requiring an emergent Hartmann's procedure have a higher mortality rate compared to those80, even after controlling for baseline comorbidities.This is a retrospective, descriptive study.

Background Machining using vertical CNC end mill is popular in the modern material removal industries because of its ability to remove the material at a fast rate with a reasonably good surface quality. Methods In this work, the influence of important common machining process variables like feed, cutting speed and axial depth of cut on the output parameters such as surface roughness and amplitude of tool vibration levels in Al-6061 workpieces has been studied. With the use of experimental result analysis and mathematical modelling, correlations between the cutting process conditions and process outputs are studied in detail. The cutting experiments are planned with response surface methodology (RSM) using Box-Behnken design (BBD). Results This work proposes a multi-objective optimization approach based on genetic algorithms using experimental data so as to simultaneously minimize the tool vibration amplitudes and work-piece surface roughness. The optimum combination of process variable is further verified by the radial basis neural network model. Conclusions Finally, based on the multi-objective optimization approach and neural network models an interactive platform is developed to obtain the correct combination of process parameters.

This paper describes the design, fabrication and analysis a five axes articulated robotic manipulator. The current work is undertaken by considering various commercially available robotic kits to design and fabricate a five degree of freedom (D.O.F) arm. Forward kinematic model has been presented in order to determine the end effectors position and orientation. Although this work is still in primary level, this analysis is useful for path tracking of an industrial manipulator with pick-and-place application. Based on this analysis, a researcher can develop path tracking behaviour of an end effector in complicated work space.

ObjectivesOur aim was to conduct a systematic review of the literature to determine the impact of patient decision aids (PDA) on patients facing treatment decisions for colorectal cancer.DesignSystematic review.Data sourcesSources included Embase, Medline, Web of Science, CINAHL and the Cochrane Library from inception to June, 20, 2019.Eligibility criteriaWe included randomised controlled trials (RCTs), cohort studies, mixed methods and case series in which a PDA for colorectal cancer treatment was used. Qualitative studies were excluded from our review.Data extraction and synthesisFollowing execution of the search strategy by a medical librarian, two blinded independent reviewers identified articles for inclusion. Two blinded reviewers were also responsible for data extraction, risk of bias and study quality assessments. Any conflict in article inclusion or extraction was resolved by discussion.ResultsOut of 3773 articles identified, three met our inclusion criteria: one RCT, one before-and-after study and one mixed-method study. In these studies, the use of a PDA for colorectal cancer treatment was associated with increased patient knowledge, satisfaction and preparation for making a decision. On quality assessment, two of three studies were judged to be of low quality.ConclusionA paucity of evidence exists on the effect of PDA for colorectal cancer treatment with existing evidence being largely of low quality. Further investigation is required to determine the effect of decision aids for colorectal cancer treatment as well as reasons for the lack of PDA development and implementation in this area.Prospero registration numberCRD42018095153.

Background Colostomy creation is a common procedure performed in colon and rectal surgery. Outcomes by technique have not been well studied. Objective This study evaluated outcomes related to open versus laparoscopic colostomy creation. Design This was a retrospective review of patients undergoing colostomy creation using univariate and multivariate propensity score analyses. Settings Hospitals participating in the American College of Surgeons National Surgical Quality Improvement Program database were included. Patients Data on patients were obtained from the American College of Surgeons National Surgical Quality Improvement Program 2005-2011 Participant Use Data Files. Main outcome measures We measured 30-day mortality, 30-day complications, and predictors of 30-day mortality. Results A total of 2179 subjects were in the open group and 1132 in the laparoscopic group. The open group had increased age (open, 64 years vs laparoscopic, 60 years), admission from facility (17.0% vs 14.9%), and disseminated cancer (26.1% vs 21.4%). All were statistically significant. The open group had a significantly higher percentage of emergency operations (24.9% vs 7.9%). Operative time was statistically different (81 vs 86 minutes). Thirty-day mortality was significantly higher in the open group (8.7% vs 3.5%), as was any 30-day complication (25.4% vs 17.0%). Propensity-matching analysis on elective patients only revealed that postoperative length of stay and rate of any wound complication were statistically higher in the open group. Multivariate analysis for mortality was performed on the full, elective, and propensity-matched cohorts; age >65 years and dependent functional status were associated with an increased risk of mortality in all of the models. Limitations This study has the potential for selection bias and limited generalizability. Conclusions Colostomy creation at American College of Surgeons National Surgical Quality Improvement Program hospitals is more commonly performed open rather than laparoscopically. Patient age >65 years and dependent functional status are associated with an increased risk of 30-day mortality.

This study indicates that patients undergoing laparoscopic cholecystectomy have discernable characteristics that can contribute in a major way to postoperative length of stay., Background: Laparoscopic cholecystectomy for gallbladder disease is a common surgical procedure performed in hospitals throughout the world. This study evaluates the major factors that contribute to postoperative length of stay for patients undergoing laparoscopic cholecystectomy. Methods: We analyzed data for patients undergoing laparoscopic cholecystectomy in a 5-hospital community health system from December 1, 2008 to January 31, 2009. The natural logarithm of postoperative length of stay was modeled to evaluate significant factors and contributions. Results: Included in the analysis were 232 patients. Three preoperative patient factors were significant contributors: body mass index was associated with decreased postoperative length of stay, while white blood cell count and the presence of biliary pancreatitis were associated with increased postoperative length of stay. The operative factors of fluids administered and ASA class were significant contributors to increased postoperative length of stay, with an increasing contribution with a higher ASA class. The utilization factor of nonelective status was a significant contributor to increased postoperative length of stay. Conclusion: Several factors were major contributors to postoperative length of stay, with ASA class and nonelective status having the most significant increased contribution. Efforts to optimize efficient elective care delivery for patients with symptomatic gallbladder disease may demonstrate a benefit of decreased hospital utilization.

The role intestinal epithelial cells play in the pathogenesis of amebic colitis is poorly understood. Herein, we demonstrate that secreted and soluble ameba ( Entamoeba histolytica ) proteins (SAP) induce expression of the chemoattractant monocyte chemotactic protein (MCP) in the colonic epithelial cell lines Caco-2, T84, and LS174T. MCP-1 mRNA induction was both dose and time dependent, with peak induction occurring at 8 h and with 100 μg/ml of SAP. Significant increase in MCP-1 protein expression was observed after 12 h. SAP failed to activate any of the mitogen-activated protein kinase pathways or IκB kinase activity. Moreover, inhibiting the classical pathway of NF-κB activation did not affect SAP-induced MCP-1 expression. Instead, we find that SAP-induced MCP-1 expression is dependent on posttranslational modification of the NFκB p65 subunit. SAP induced phosphorylation of p65 and enhanced NF-κB transcriptional activity, which are phosphatidylinositol 3-kinase (PI3 kinase) dependent. Treatment with PI3 kinase inhibitor LY290004 significantly abrogated the activation of Akt, p65, and MCP-1 mRNA induction. We conclude that colonic epithelial cells play a role in the initiation of inflammation by secreting chemokines in response to soluble ameba components.

Little is known about the pathogenesis of Entamoeba histolytica and how epithelial cells respond to the parasite. Herein, we characterized the interactions between E. histolytica and colonic epithelial cells and the role macrophages play in modulating epithelial cell responses. The human colonic epithelial cell lines Caco-2 and T84 were grown either as monoculture or co-cultured in transwell plates with differentiated human THP-1 macrophages for 24 h before stimulation with soluble amebic proteins (SAP). In naive epithelial cells, prolonged stimulation with SAP reduced the levels of heat shock protein (Hsp) 27 and 72. However in THP-1 conditioned intestinal epithelial cells SAP enhanced Hsp27 and Hsp72, which was dependent on the activation of ERK MAP kinase. Hsp synthesis induced by SAP conferred protection against oxidative and apoptotic injuries. Treatment with SAP inhibited NF-kappaB activation induced by interleukin-1beta; specifically, the NF-kappaB-DNA binding, nuclear translocation of p65 subunit, and phosphorylation of IkappaB-alpha were reduced. Gene silencing by small interfering RNA confirmed the role of Hsp27 in suppressing NF-kappaB activation at IkappaB kinase (IKK) level. By co-immunoprecipitation studies, we found that Hsp27 interacts with IKK-alpha and IKK-beta, and this association was increased in SAP-treated conditioned epithelial cells. Overexpression of wild type Hsp27 amplified the effects of SAP, whereas a phosphorylation-deficient mutant of Hsp27 abrogated SAP-induced NF-kappaB inhibition. In conditioned epithelial cells, Hsp27 was phosphorylated at serine 15 after prolonged exposure to SAP. This mechanism may explain the absence of colonic inflammation seen in the majority of individuals infected with E. histolytica.

Early in the 21st century, postoperative venous thromboembolism (VTE), deep vein thrombosis (DVT), and pulmonary embolism (PE) continue to plague roughly 2.5– 10 % of abdominopelvic cancer patients. Cancer patients are an especially high-risk group, and VTE is the most common cause of early postoperative mortality, accounting for half of all deaths within 30 days after abdominopelvic cancer surgery. Given that half of all VTE events occur after hospital discharge, there has been long-standing interest in extended chemoprophylaxis (ECP), typically for 28 days postoperatively. The hypothesis that ECP is more efficacious in preventing VTE than traditional hospital-only based prophylaxis has proven true; ECP also has been proven safe. Both randomized and large observation studies have shown that ECP after abdominopelvic cancer surgery significantly decreases VTE events but does not significantly increasing the risk of bleeding. Moreover, major organizations, such as the American Society of Chest Physicians (ACCP), American Society of Clinical Oncology (ASCO), and the National Comprehensive Cancer Network (NCCN), have published practice guidelines that recommend ECP. Despite this unified expert consensus regarding the benefit of ECP nationally, these recommendations have not been embraced and adoption of ECP has been poor. For example, Merkow et al. examined the adherence to postdischarge VTE prophylaxis in Medicare beneficiaries undergoing colorectal cancer surgery and found a compliance rate of a paltry 1.5 % overall. In this issue of Annals of Surgical Oncology, we are presented with two studies examining issues integral to the implementation of ECP into clinical practice. The first, by Fagarasanu et al., is a meta-analysis reexamining the efficacy and potential risk of ECP and represents the highestquality level of evidence supporting ECP to date. The second, by Krell et al., examines the operationalization of ECP using a Michigan statewide registry, highlighting that ECP has not been widely adopted. Fagarasanu et al. reported the results of a well-performed systematic review and meta-analysis examining the efficacy of ECP. The authors, not surprisingly, found a significant reduction of proximal DVT, and all VTE, with ECP, with no increased rate of major bleeding. The three randomized control trials referenced in the Fagarasanu et al. meta-analysis are summarized below. The ENOXACAN-II study, by Bergqvist et al., randomized patients to ECP with low molecular weight heparin (LMWH), enoxaparin, or standard duration LMWH prophylaxis and found a lower rate of VTE in the ECP group of 4.8 versus 12.0 % in controls. Of note, there was persistence of the protective effect at 3 months. In the European multinational CANBESURE study by Kakkar et al., patients were randomized to ECP with bemiparin, an ultraLMWH associated with a lower risk of bleeding than LMWH, or standard duration bemiparin prophylaxis, and similarly found a lower rate of major VTE in the ECP group of 0.8 versus 4.6 % in controls; however, there was no difference in a composite outcome of DVT, nonfatal PE, and all-cause mortality. Finally, in Vedovati et al., patients Society of Surgical Oncology 2016

Gastrointestinal mucin is a constituent of luminal barrier function and is the first line of host defense against invading pathogens. Mucin carbohydrates and amino acids, as well as trapped soluble host defense molecules, serve as substrates for colonization and control or deter pathogen invasion to the underlying mucosal epithelial cells. Toll-like receptors on the surface of epithelial cells act as sensors for invading pathogens, and the ensuing host response limits parasite invasion and leads to adaptive immunity. The latest work in the field and the use of parasite model systems to illustrate the delicate host-parasite interaction at the mucosal surface of the gut are discussed here.

Hamano et al. have recently reported that in murine models of amebiasis, innate resistance is associated with nonhemopoietic cells and depends on the activity of interleukin-10. This article raises the issue of the importance of predisposition to amebic colitis and discusses which host factors have a role in innate resistance to invasive disease. Resistance studies that elucidate the mechanisms involved in parasite clearance or parasite invasion are essential to understanding the incidence of amebiasis in humans.

Background Virtual reality (VR) and physical model (PM) simulators differ in terms of whether the trainee is manipulating actual 3-dimensional objects (PM) or computer-generated 3-dimensional objects (VR). Much like video games (VG), VR simulators utilize computer-generated graphics. These differences may have profound effects on the utility of VR and PM training platforms. In this study, we aimed to determine whether a relationship exists between VR, PM, and VG platforms. Methods VR and PM simulators for laparoscopic camera navigation ([LCN], experiment 1) and flexible endoscopy ([FE] experiment 2) were used in this study. In experiment 1, 20 laparoscopic novices played VG and performed 0° and 30° LCN exercises on VR and PM simulators. In experiment 2, 20 FE novices played VG and performed colonoscopy exercises on VR and PM simulators. Results In both experiments, VG performance was correlated with VR performance but not with PM performance. Performance on VR simulators did not correlate with performance on respective PM models. Conclusions VR environments may be more like VG than previously thought.