Abstract


Introduction: Interest in microscopic margin positivity during surgical resection of medical-refractory Crohn’s disease has been renewed with multiple recent studies showing an association between microscopic margin positivity with disease recurrence. Our aim was to determine risk factors for microscopic margin disease positivity following ileocolic resection (ICR).
Materials and Methods: A prospectively-maintained database of patients with Crohn’s disease undergoing ICR at a tertiary-referral center was queried. Margin positivity was defined as the presence of cryptitis, erosion, transmural inflammation with lymphoid aggregates, or architectural distortion at either ileal (proximal) or colonic (distal) margins.
Results: Amongst 584 patients, 97 patients had a positive microscopic margin (17%) of which 46% had a positive proximal margin, 17% had a positive distal margin, and 13% had both positive and distal margins. Using multivariable logistic regression analysis, index ICR was associated with less odds of positive margin (odds ratio [OR] 0.46, 95% confidence interval [CI] 0.24-0.89, p=0.02), and granuloma presence was associated with increased odds (OR 2.26, 95% CI 1.23–4.21, p=0.01).
Conclusion: We found that repeat ileocolic resection and granuloma presence were predictors of microscopic margin disease.

Abstract


Background: Pancreatoduodenectomy is a highly complex surgical procedure associated with high postoperative morbidity and mortality. Treatment of postoperative pain is crucial to preventing chronic pain and further complications. Opioids are the leading treatment modality for acute postoperative pain for all surgical procedures in the US, contributing to the opioid epidemic, a crisis causing death and lifelong impairment in many patients. Multimodal analgesia techniques, such as the transversus abdominis plane (TAP) block, are suggested to reduce perioperative opioid usage. This exploratory literature review aims to investigate the use of TAP block in postoperative pain and opioid use in patients undergoing pancreatoduodenectomy.
Materials and Methods: A search strategy developed from Cochrane best practice recommendations was applied to a comprehensive search of PubMed, Scopus, and PsycINFO databases, yielding three articles of relevance in patients having pancreatic surgery.
Results: Previous research demonstrates TAP block efficacy in decreasing opiate consumption after major abdominal surgery; however, there is a paucity of data regarding opioid consumption in pancreatoduodenectomy patients.
Conclusion: Research in relation to TAP block analgesia is varied given the variety of approaches, techniques, and timing of the TAP block procedure. Future research should seek to elucidate the role of TAP blocks in reducing postoperative pain and opioid consumption in pancreatoduodenectomy patients.

Abstract


Surgical stapling has evolved significantly over time, with the primary goal of improving patient outcomes. This study describes the technological advancements in surgical stapling from the perspective of staple and cartridge design, assessing the impact of staple design when it changes from the traditional B form (also known as 2D staple form) to a three-dimensional form (known as 3D staple form). The change in configuration helps compress a larger surface area of the tissue. The 3D configuration is designed to optimize compression not only underneath each staple but also across staples and multiple staple lines, including both stapled and unstapled regions of the tissue. By achieving more evenly distributed compression throughout the staple line, there is potential for reduced leak paths. The study demonstrates that the 3D staple form in surgical stapling results in more evenly distributed compression. In the future, this advanced technology should seamlessly integrate into emerging systems such as the surgical robot, enabling continued progress in surgical instrumentation and ultimately in surgical care.

Abstract


Transanal minimally invasive surgery (TAMIS) is an effective procedure that plays an important role in the care of patients with significant rectal neoplasia and polyps including early-stage cancers. However, it is perhaps underutilised and under threat from both advanced flexible endoscopic procedures and proceduralists (who often act as gatekeepers for referral to colorectal surgeons), as well as from robotic surgery proponents. TAMIS advocates can learn and adopt practice insights from both these fields and incorporate available technological innovations building on the huge accomplishments already delivered in this area. Evolved practice through technology has the potential to offset current limitations regarding technical constraints and indeed patient selection (via artificial intelligence methods). Potential target areas for advances are considered in this review from different perspectives: (1) Access (2) Insufflation (3) Visualisation (4) Disease Characterization in situ, and (5) Tissue Handling and Suturing. While a bundle approach may be most useful, the advances for each component are potentially useful in their own right and could be applied without depending on the other practices detailed so that more accurate (and perhaps even numerically more) TAMIS procedures can be performed globally to improve patient care.

Abstract


Introduction: This study aimed to ascertain the risk factors contributing to in-patient mortality in elderly patients 65 years and older who were admitted emergently, diagnosed with intestinal fistula, and underwent surgery.
Materials and Methods: Data were extracted from the National Inpatient Sample (NIS) spanning the years 2005–2014. Multivariable logistic regression and a generalized additive model (GAM) were employed to investigate predictors of mortality. Continuous variables are presented as mean values with standard deviations (SD).
Results: The study encompassed 34,853 patients with a mean age of 77.7 years—56.5% were female and 79.4% were White. Patients were categorized into three groups based on the time elapsed between admission and surgery: less than two days (17,761), two to three days (8,407), and more than three days (4,233). Mortality rates were 2.7%, 6%, and 6.1% for patients who underwent surgery within two to three days, within two days, and after more than three days of admission, respectively. Notably, the group that operated more than three days from admission experienced nearly double the hospital length of stay (12 days, SD: 7.2) compared to the other two groups (6.3, SD: 6 and 6.1, SD: 4.8). Furthermore, the association between mortality and time to operation, as indicated by the GAM model, revealed a significant non-linear relationship after adjusting for age, gender, race, zip code, hospital location, and comorbidities (p<0.001).
Conclusion: Elderly patients diagnosed with intestinal fistula should undergo operative treatment as soon as possible, once they are resuscitated. Delaying the operation more than three days after admission substantially increases the risk of mortality.

Abstract


Purpose: Rib fixation procedures are being performed more frequently as they have shown multiple advantages over traditional non-operative management in well-selected patients. We have developed a rib-fixation simulation on cadavers for use by surgical residents in attempt to improve their comfort, knowledge and ability to use this new technology.
Methods: Residents in years 3 through 5 of training attended a rib-fixation simulation course with cadavers. Trauma faculty and representatives of manufacturers of rib-fixation hardware participated. The simulation consisted of groups of residents reviewing anatomy and creating adequate exposure for the entire procedure. Each group created rib fractures in the cadaver, determined which materials were needed, and then performed the rib-fixation procedure. Following the simulation, we surveyed the residents to determine the impact of the structured cadaveric rib fixation-based course on their comfort level. The survey was performed using a four- and five-level Likert questionnaire. The results were analyzed using paired t-tests.
Results: Of the participating residents, 72% of residents had performed five or fewer rib-fixation procedures in their training in the first cohort, while in the cohort for the following year, 65% had performed 5-10 procedures. The simulation had a statistically significant benefit to the residents’ comfort level with rib plating (2.5 versus 3.6, p-value: 0.003). The greatest impact on the comfort level was seen in year 3 of training (2 versus 4, p-value 0.02). One hundred percent of residents found that having faculty and representatives present for the simulation was very helpful. The survey demonstrated that most residents gained new knowledge regarding the anatomy and technical dissection. In 20 of 25 encounters, residents strongly agreed that this simulation was beneficial for their surgical education, when used in addition to real operative experience. Every resident reported that they would recommend the simulation to younger resident classes.
Conclusion: Rib-fixation simulations on cadavers were beneficial for surgical residents’ self-assessed comfort level. The simulation increased residents’ knowledge, comfort, and ability to perform rib-fixation procedures. We have seen a significant increase in resident participation in these cases after simulation training. Based on these findings, we will continue to incorporate these simulations into our program’s curriculum.