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Background Enhanced recovery after surgery (ERAS) is a multimodal perioperative care pathway designed to achieve early recovery by preserving preoperative organ function and minimizing the stress response following surgery. Few studies have assessed the association between ERAS and postoperative cardiac complications. The goal of this study is to evaluate the impact of ERAS on postoperative cardiac complications. Materials and Methods A retrospective review of a prospectively maintained database of colorectal patients who underwent surgery at a tertiary colorectal cancer referral center was carried out. Preoperative, intraoperative, and postoperative factors including demographics, comorbidities, medications, and fluid administration were recorded. The primary outcome was postoperative cardiac arrhythmia, and secondary outcomes included other postoperative complications. Results A total of 800 patients who underwent elective colorectal surgery were identified. Four hundred seventeen patients (52%) were in the control group and 383 patients (48%) were in the ERAS group. Patients in both groups were similar with regard to demographics and clinical characteristics. There were significantly higher rates of cardiac arrhythmia in the control group (5.3%) compared with the ERAS group (1.8%), p  = 0.009. Multivariable analysis revealed that ERAS was an independent predictor of decreased postoperative cardiac arrhythmia (OR 0.30, 95%CI 0.17–0.55, p  < 0.001) while older age was an independent predictor of increased postoperative cardiac arrhythmia (OR 1.08, 95%CI 1.02–1.13, p  = 0.008). Patients receiving lower amounts of intravenous fluids had significantly decreased postoperative cardiac arrhythmia (OR = 0.25, 95%CI 0.09–0.67, p  = 0.006). Conclusions ERAS and goal-directed fluid therapy are associated with significant reductions in postoperative cardiac arrhythmias.

INTRODUCTION:A 55-year-old male with history of Peutz-Jeghers syndrome was referred for a colonoscopy for management of a large ileal polyp. Surgical history was notable for two laparatomies for small bowel obstructions in the setting of intussusception as well as multiple enterotomies for removal of polyps.CASE DESCRIPTION/METHODS:Colonoscopy confirmed a polypoid mass in the distal ileum that was partially obstructing. Endoscopic submucosal dissection of the polyp stalk was performed but revealed two feeding arteries as well as a thick muscular band, concerning for muscularis propria, that precluded further safe dissection. Hemoclips were placed on the feeding arteries in an attempt to cause necrosis of the lesion. After discharge the patient developed hematochezia. Repeat colonoscopy did not show any ongoing bleeding but the mass appeared to be necrotic. Repeat colonoscopy was planned in the operating room to evaluate the mass. If the necrosis was not complete, dissection of the stalk would be re-attempted with plans to convert to surgical resection if needed. On endoscopy, the mass appeared to have revitalized. Another attempt at submucosal dissection of the polyp stalk was performed. However as the area had already been dissected through, the submucosal plane was not easily identified in the stalk and did not feel that it was safe to continue the submucosal dissection. Subsequently, the patient was converted to surgical resection of the ileal polyp, which also revealed multiple polyps more proximally throughout the small bowel. The bowel resection included the initial large polyp and another large polyp at a prior ileal anastomosis that could not be removed without a resection. Multiple other polyps were removed via enterotomies. To clear the remaining small bowel of residual polyps, we performed a clean sweep. A pediatric colonoscope was introduced orally and the scope was able to be advanced distally to the ileal anastomosis by plicating the bowel over the scope. Multiple further polypectomies were then performed using standard endoscopic mucosal resection technique. On 3 month follow up MR enterography, there were no convincing polyps identified in the entire small bowel.DISCUSSION:This case demonstrates the importance of a multi-disciplinary approach to the management of this patient's polyposis. The combination of endoscopic and surgical approach allowed for effective management of both the large ileal polyp as well as his overall polyp burden.Watch the video: http://bit.ly/2JWHRA2

Abstract Introduction Proctocolectomy with ileal pouch anal anastomosis (IPAA) was introduced over 40 years ago, prior to the era of laparoscopy. Since then, minimally invasive surgery (MIS) techniques have been applied to pelvic pouch surgery. One advantage of MIS is the reduction in adhesion-related complications. However, the lack of adhesions may result in a different set of complications. Specifically, when the pouch is not adherent in the pelvis, pouch volvulus can occur around the mesenteric axis. The aim of this study was to describe our experience with pelvic pouch volvulus. Methods Our prospectively maintained pelvic pouch registry and our enterprise wide electronic medical record were queried for keyword combinations of “pouch volvulus” between 1994 and 2020. Pouch volvulus was defined as torsion of the ileal pouch on its own mesenteric axis or around small bowel while maintaining the proper orientation of the ileo-anal anastomosis. Patients with pouches constructed with twisted mesenteric axis from ill-aligned anastomoses were excluded. Data for these patients was collected from the pouch registry and additional chart review. Results We identified 17 patients with pouch volvulus; of these, 11 patients did not meet our selection criteria and were excluded. Of the 6 patients (5 female; median age 25 range 20–33 yr at time of volvulus surgery) with true volvulus, the diagnosis at IPAA was ulcerative colitis (n=5) and Lynch syndrome with a rectal cancer. All pelvic pouches were constructed with MIS techniques, including standard laparoscopy (n=4) and single incision laparoscopic technique (n=2). All 6 patients presented with diffuse abdominal pain and abdominal distention. The average time from pouch construction to pouch volvulus was 2.5 years (range: 5.2 – 97.5 months). Computed tomography with or without rectal contrast was the initial diagnostic test in 4/6 with findings highly suspicious for pouch volvulus. Surgery was performed urgently in 5/6 of patients; all 6 had open surgery. At reoperation, all had minimal adhesions and a gap between the pouch mesentery and the retroperitoneum. Interventions included pouch-pexy (n=3), closure of gap between pouch and sacrum (n=2), and pouch excision and ileostomy (n=1). At a median of 9 months (IQR: 4–97) of follow up, pouch survival was 83%; functional outcomes included mild fecal incontinence (n=1) and paradox requiring intermittent pouch intubation for stool evacuation (n=1). Conclusions Pelvic pouches constructed by minimally invasive techniques may be at risk for pouch volvulus due to minimal adhesions. Surgeons should have a high index of suspicion for patients with unexplained abdominal pain, distension, and other obstructive symptoms. Cross-sectional imaging with rectal contrast, may help clarify the diagnosis. Immediate surgical care can allow for pouch salvage.

Purpose Physician wellness is important for delivering high-quality care. Initiatives to understand resident wellness often come in the form of surveys, and solutions are often implemented using a top-down approach with uncertain effects on wellness. Human-centered design (HCD) offers an alternative approach by drawing on the experiences of residents to provide relevant insights. We describe using HCD to understand the definition of wellness to our residents and create a wellness initiative. Methods A HCD framework was used to develop wellness initiatives. Residents created journey maps by graphing their relative levels of wellness over time, and then interviewed one another to discover what wellness means to their partner. Interview notes were collected and qualitatively analyzed for common themes. Two ideation sessions were held for residents to brainstorm ideas to answer a generative prompt “how might we…” improve one of the themes. Residents then tested their ideas via small-scale experiments. Results Twenty-five residents participated in the journey map and peer interview exercise. Common themes that emerged were camaraderie, fulfillment at work, protection of personal relationships, time usage, and general stressors. During the ideation sessions, over 100 possible experiments were generated based on these themes. Many of these experiments were then trialed on a small scale. Conclusions HCD provides an actionable framework for curriculum development, especially as it offers a resident-centered approach to improve wellness. The in-depth interviews identified themes that would not have been captured via survey. Insights generated by the HCD discussions helped guide our wellness program development with further iterations of projects planned.

Background Investigating the context of trauma and acute care surgery, the article aims at understanding the factors that can enhance some ethical aspects, namely the importance of patient consent, the perceptiveness of the ethical role of the trauma leader, and the perceived importance of ethics as an educational subject. Methods The article employs an international questionnaire promoted by the World Society of Emergency Surgery. Results Through the analysis of 402 fully filled questionnaires by surgeons from 72 different countries, the three main ethical topics are investigated through the lens of gender, membership of an academic or non-academic institution, an official trauma team, and a diverse group. In general terms, results highlight greater attention paid by surgeons belonging to academic institutions, official trauma teams, and diverse groups. Conclusions Our results underline that some organizational factors (e.g., the fact that the team belongs to a university context or is more diverse) might lead to the development of a higher sensibility on ethical matters. Embracing cultural diversity forces trauma teams to deal with different mindsets. Organizations should, therefore, consider those elements in defining their organizational procedures. Level of evidence Trauma and acute care teams work under tremendous pressure and complex circumstances, with their members needing to make ethical decisions quickly. The international survey allowed to shed light on how team assembly decisions might represent an opportunity to coordinate team member actions and increase performance.

Purpose: The proportions of select stem cells in term amniotic fluid have been shown to correlate with the type and size of experimental neural tube defects (NTDs). We sought to determine the impact of gestational age upon this form of targeted amniotic cell profiling. Methods: Sprague-Dawley fetuses with retinoic acid-induced NTDs (n = 110) underwent amniotic fluid procurement at four time points in gestation. Samples were analyzed by flow cytometry for the presence of cells concomitantly expressing Nestin and Sox-2 (neural stem cells, aNSCs) and cells concomitantly expressing CD29 and CD44 (mesenchymal stem cells, aMSCs). Statistical analysis was by nonparametric Kruskal-Wallis ANOVA (p < 0.05). Results: There was a statistically significant impact of gestational age on the proportions of both aMSCs (p = 0.01) and aNSCs (p < 0.01) in fetuses with isolated spina bifida. No such impact was noted in normal fetuses (p > 0.10 for both cells), in isolated exencephaly (p > 0.10 for both cells), or in combination defects (p > 0.10 for both cells). Gestational age had no effect on aNSC/aMSC ratios. Conclusions: Targeted quantitative amniotic cell profiling varies with gestational age in experimental isolated spina bifida. This finding should be considered prior to the eventual translation of this diagnostic adjunct into the prenatal evaluation of these anomalies.

The Foker process is a method of esophageal lengthening through axial tension-induced growth, allowing for subsequent primary reconstruction of the esophagus in esophageal atresia (EA). In this unique case, the Foker process was used to grow the remaining esophageal segment long enough to attain esophageal continuity following failed colonic interpositions for long-gap esophageal atresia (LGEA). Initially developed for the treatment of LGEA in neonates, this case demonstrates that (i) an active esophageal lengthening response may still be present beyond the neonate time-period; and, (ii) the Foker process can be used to restore esophageal continuity following a failed colonic interposition if the lower esophageal segment is still present.

Colorectal cancer (CRC) diagnosed before age 50 years (early-onset CRC, EO-CRC) is rising at an alarming rate, yet its molecular and microenvironmental drivers remain poorly understood. EO-CRC is highly heterogeneous, and while subtle differences from late-onset CRC (LO-CRC) have been reported, their full extent remains unresolved due to the limited scope of previous studies. Here, we integrate public data with in-house clinical samples profiled by single-cell RNA sequencing (scRNA-seq) and multiplex immunofluorescence (mIF) to compare EO-CRC and LO-CRC. Additionally, we employ gene regulatory network-based protein activity inference (VIPER), enabling a more precise characterization of key regulatory proteins driving tumor-stroma interactions. Our analysis reveals that EO-CRC and LO-CRC have a largely similar immune composition, challenging previous reports of an \"immune-cold\" phenotype in EO-CRC. However, we identify distinct stromal differences, including a significant enrichment of fibroblasts in EO-CRC. Notably, we define a previously unrecognized epithelial subpopulation in EO-CRC, marked by high expression of toll-like receptor 4 (TLR4) and C-C chemokine receptor type 5 (CCR5)-key mediators of inflammation-driven tumor progression and fibroblast recruitment. These findings suggest that EO-CRC may be driven by a tumor-intrinsic inflammatory phenotype with enhanced stromagenesis, providing new insights into potential mechanisms underlying its increasing incidence in young adults.Colorectal cancer (CRC) diagnosed before age 50 years (early-onset CRC, EO-CRC) is rising at an alarming rate, yet its molecular and microenvironmental drivers remain poorly understood. EO-CRC is highly heterogeneous, and while subtle differences from late-onset CRC (LO-CRC) have been reported, their full extent remains unresolved due to the limited scope of previous studies. Here, we integrate public data with in-house clinical samples profiled by single-cell RNA sequencing (scRNA-seq) and multiplex immunofluorescence (mIF) to compare EO-CRC and LO-CRC. Additionally, we employ gene regulatory network-based protein activity inference (VIPER), enabling a more precise characterization of key regulatory proteins driving tumor-stroma interactions. Our analysis reveals that EO-CRC and LO-CRC have a largely similar immune composition, challenging previous reports of an \"immune-cold\" phenotype in EO-CRC. However, we identify distinct stromal differences, including a significant enrichment of fibroblasts in EO-CRC. Notably, we define a previously unrecognized epithelial subpopulation in EO-CRC, marked by high expression of toll-like receptor 4 (TLR4) and C-C chemokine receptor type 5 (CCR5)-key mediators of inflammation-driven tumor progression and fibroblast recruitment. These findings suggest that EO-CRC may be driven by a tumor-intrinsic inflammatory phenotype with enhanced stromagenesis, providing new insights into potential mechanisms underlying its increasing incidence in young adults.

Vitamin D exerts a role in the maintenance of cognitive abilities and in frailty. Although several studies evaluated the interactions between vitamin D and cognitive impairment, results were conflicting. In a cohort of community-dwelling older persons, we described the association between vitamin D levels and cognitive decline and all-cause dementia evaluating frailty’s contribution. Our cohort included 509 adults, aged 64–92 years: 176 patients with mild cognitive impairment (MCI), 59 with Alzheimer’s Disease (AD), 26 with idiopathic Normal Pressure Hydrocephalus (iNPH), 133 with mixed dementia (MD) and 115 without cognitive decline. Frailty was measured by frailty index, and serum 25-hydroxyvitamin D concentrations through electrochemiluminescence immunoassays. We found a significant association between vitamin D levels and Mini Mental State Examination independently of cognitive impairment, age, sex and frailty. The patients with dementia (AD and MD) showed the lowest vitamin D levels, while MCI patients showed higher levels than the other groups. The most severe deficiency was observed in MD patients, the most aged as well as cognitively and functionally impaired. In conclusion, in our community-dwelling older persons investigated for a suspected cognitive impairment, we observed an association between vitamin D levels and cognitive decline, regardless of the frailty status.