Publications by authors named "Theodore J Saclarides"

37 Publications

Surgical Residents' Perspective on Informed Consent-How Does It Compare With Attending Surgeons?

J Surg Res 2020 Dec 14;260:88-94. Epub 2020 Dec 14.

Rush University Medical Center, Division of Colon and Rectal Surgery, Department of Surgery, Chicago, Illinois. Electronic address:

Background: The informed consent discussion (ICD) is a compulsory element of clinical practice. Surgical residents are often tasked with obtaining informed consent, but formal instruction is not included in standard curricula. This study aims to examine attitudes of surgeons and residents concerning ICD.

Materials And Methods: A survey regarding ICD was administered to residents and attending surgeons at an academic medical center with an Accreditation Council for Graduate Medical Education-accredited general surgery residency.

Results: In total, 44 of 64 (68.75%) residents and 37 of 50 (72%) attending surgeons participated. Most residents felt comfortable consenting for elective (93%) and emergent (82%) cases, but attending surgeons were less comfortable with resident-led ICD (51% elective, 73% emergent). Resident comfort increased with postgraduate year (PGY) (PGY1 = 39%, PGY5 = 85%). A majority of participants (80% attending surgeons, 73% residents) believed resident ICD skills should be formally evaluated, and most residents in PGY1 (61%) requested formal instruction. High percentages of residents (86%) and attendings (100%) believed that ICD skills were best learned from direct observation of attending surgeons.

Conclusions: Resident comfort with ICD increases as residents advance through training. Residents acknowledge the importance of their participation in this process, and in particular, junior residents believe formal instruction is important. Attending surgeons are not universally comfortable with resident-led ICDs, particularly for elective surgeries. Efforts for improving ICD education including direct observation between attending surgeons and residents and formal evaluation may benefit the residency curriculum.
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http://dx.doi.org/10.1016/j.jss.2020.10.019DOI Listing
December 2020

I want to go home: should we abandon open surgery for treatment of rectal prolapse? Consideration of discharge destination following surgery for rectal prolapse.

Colorectal Dis 2020 Nov 28. Epub 2020 Nov 28.

Department of Surgery, Rush University Medical Center, Chicago, Illinois, USA.

Aim: Despite the financial and value-based implications associated with higher levels of care at discharge, few studies have evaluated modifiable treatment factors that may optimize postacute care. The aim of this work was to assess the association between operative approach and disposition to a higher level of care and other outcomes following surgery for rectal prolapse.

Method: Using a retrospective cohort study design, the database of the National Surgical Quality Improvement Program was used to identify patients with rectal prolapse who underwent perineal repair or open or laparoscopic rectopexy with or without resection between 2012 and 2017. Discharge destination and 30-day postoperative outcomes were compared using propensity score mathcing and weighting. Nomograms generated using multivariable regression calculated the risk of requiring higher levels of care upon discharge and morbidity.

Results: Propensity-score analysis included 3000 patients [1500 in the perineal group, 580 in the open abdominal group and 920 in the minimally invasive (MIS) group]. Patients who received open abdominal surgery were more likely to require elevation of care at destination compared with those who received perineal surgery (OR 1.65, 95% CI 1.22-1.24) and MIS abdominal surgery (OR 1.80, 95% CI 1.18-2.76). Similar effects were seen for overall morbidity. Increased age, higher American Society of Anesthesiologists class, congestive heart failure, dependent functional status and open surgery were independent predictors of discharge to higher level of care (c-statistic = 0.79).

Conclusion: Open surgery compared with MIS and perineal surgery was associated with higher levels of discharge disposition following rectal prolapse surgery. Future research should continue to identify modifiable treatment factors that reduce poor postoperative outcomes among patients with rectal prolapse.
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http://dx.doi.org/10.1111/codi.15466DOI Listing
November 2020

It Takes a Village: The First 100 Patients Seen in a Multidisciplinary Pelvic Floor Clinic.

Female Pelvic Med Reconstr Surg 2020 Apr 30. Epub 2020 Apr 30.

From the Department of Surgery.

Objective: This study aimed to assess the characteristics of patients assessed and treated at a multidisciplinary pelvic floor program that includes representatives from multiple specialties. Our goal is to describe the process from triaging patients to the actual collaborative delivery of care. This study examines the factors contributing to the success of our multidisciplinary clinic as evidenced by its ongoing viability.

Methods: This is a descriptive study retrospectively analyzing a prospectively maintained database that included the first 100 patients seen in the Program for Abdominal and Pelvic Health clinic between December 2017 and October 2018. We examined patient demographics, their concerns, and care plan including diagnostic tests, findings, treatments, referrals, and return visits.

Results: The clinic met twice monthly, and the first 100 patients were seen over the course of 10 months. The most common primary symptoms were pelvic pain (45), constipation (30), bladder incontinence (27), bowel incontinence (23), high tone pelvic floor dysfunction (23), and abdominal pain (23); most patients had more than one presenting symptom (76). The most common specialties seen at the first visit to the clinic included gastroenterology (56%), followed by physical medicine and rehabilitation (45%), physical therapy (31%), female pelvic medicine and reconstructive surgery (25%), behavioral health (19%), urology (18%), and colorectal surgery (13%). Eleven patients were entirely new to our hospital system. Most patients had diagnostic tests ordered and performed.

Conclusions: A multidisciplinary clinic for abdominal and pelvic health proves a sustainable model for comprehensive treatment for patients with pelvic floor dysfunction, including difficulties with defecation, urination, sexual dysfunction, and pain.
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http://dx.doi.org/10.1097/SPV.0000000000000884DOI Listing
April 2020

Early feeding in colorectal surgery patients: safe and cost effective.

Int J Colorectal Dis 2020 Mar 4;35(3):465-469. Epub 2020 Jan 4.

Department of Surgery, Division of Colon and Rectal Surgery, Boston Medical Center, FGH Building, 820 Harrison Avenue, Room 5008, Boston, MA, 02118, USA.

Purpose: Enhanced recovery after surgery (ERAS) pathways has demonstrated improved outcomes in colorectal surgery. An important component of ERAS is early oral intake. The aim of this study is to determine the impact of early oral intake in patients following colorectal surgery.

Methods: A retrospective analysis of patients who underwent colectomy and proctectomy at an academic institution from January 2015 to November 2018 was performed. Postoperative outcomes were compared between patients who had postoperative day 0 (POD 0) oral intake and those who did not.

Results: A total of 436 ERAS patients had oral intake timing documented. The majority of patients were women (241, 55.3%) and white (313, 71.8%). The mean age was 57 ± 15.09. Patients who had early intake were found to have lower 30-day overall morbidity and length of stay (p < 0.05), and no difference in serious adverse events. Additionally, hospital costs were lower in the POD 0 feeding group for all patients (p < 0.05).

Conclusion: We have demonstrated that early oral feeding in an established ERAS pathway is associated with improved clinical outcomes as well as decreased total hospital costs. Early postoperative feeding is safe in colorectal patients and should be prioritized to decrease complications and healthcare costs.
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http://dx.doi.org/10.1007/s00384-019-03500-1DOI Listing
March 2020

A national analysis of operative treatment of adult patients with Hirschsprung's disease.

Int J Colorectal Dis 2020 Jan 21;35(1):169-172. Epub 2019 Nov 21.

Department of Surgery, Rush University Medical Center, 1725 West Harrison Suite 1138, Chicago, IL, 60612, USA.

Purpose: Hirschsprung's disease is primarily a disease of infancy, but in rare cases, adults with this condition require surgery. The aim of this study is to identify the types of operations and postoperative outcomes in adults with Hirschsprung's disease on a national level.

Methods: The National Surgical Quality Improvement Program database was used to perform a retrospective review of all adult patients diagnosed with Hirschsprung's disease. Patients were divided into two groups depending on the type of operation: restoration of bowel continuity or diversion of fecal stream; clinicopathologic data and 30-day outcomes were compared between the two groups.

Results: A total of 32 patients were analyzed. Fourteen patients (43.8%) underwent diversion and 18 (56.2%) underwent restorative procedures. The median age was 49.5 years old for the diversion group and 23.5 years old for the reconstructive group (p = 0.001). The restorative surgery group was more likely to have an ASA 1-2 while the diversion group had a higher frequency of ASA 3-5 (p = 0.011). The median length of stay for the diversion surgery was 9.5 days and 5 days for the restoration group (p = 0.045). Complications occurred in 57% of patients in the diversion group and in 22% of patients in the restoration group (p = 0.049). There were otherwise no statistically significant differences in intraoperative data and postoperative complications.

Conclusion: This is the first study using a national database to evaluate the surgical treatment of Hirschsprung's disease in adult patients. Complications are common and were more frequent in the older, sicker diversion group, with restoration of continuity being better tolerated in the younger, healthier patient population.
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http://dx.doi.org/10.1007/s00384-019-03442-8DOI Listing
January 2020

Excision of a Presacral Ganglioneuroma in a Young Man.

Am Surg 2017 Jul;83(7):e228-230

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July 2017

Clinical Practice Guideline for the Management of Anorectal Abscess, Fistula-in-Ano, and Rectovaginal Fistula.

Dis Colon Rectum 2016 Dec;59(12):1117-1133

Prepared on behalf of The Clinical Practice Guidelines Committee of the American Society of Colon and Rectal Surgeons.

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http://dx.doi.org/10.1097/DCR.0000000000000733DOI Listing
December 2016

Patient factors may predict anastomotic complications after rectal cancer surgery: Anastomotic complications in rectal cancer.

Ann Med Surg (Lond) 2015 Mar 13;4(1):11-6. Epub 2014 Dec 13.

Department of Colorectal Surgery, Loyola University Medical Center, Maywood, IL 60153, USA.

Purpose: Anastomotic complications following rectal cancer surgery occur with varying frequency. Preoperative radiation, BMI, and low anastomoses have been implicated as predictors in previous studies, but their definitive role is still under review. The objective of our study was to identify patient and operative factors that may be predictive of anastomotic complications.

Methods: A retrospective review was performed on patients who had sphincter-preservation surgery performed for rectal cancer at a tertiary medical center between 2005 and 2011.

Results: 123 patients were included in this study, mean age was 59 (26-86), 58% were male. There were 33 complications in 32 patients (27%). Stenosis was the most frequent complication (24 of 33). 11 patients required mechanical dilatation, and 4 had operative revision of the anastomosis. Leak or pelvic abscess were present in 9 patients (7.3%); 4 were explored, 2 were drained and 3 were managed conservatively. 4 patients had permanent colostomy created due to anastomotic complications. Laparoscopy approach, BMI, age, smoking and tumor distance from anal verge were not significantly associated with anastomotic complications. After a multivariate analysis chemoradiation was significantly associated with overall anastomotic complications (Wall = 0.35, p = 0.05), and hemoglobin levels were associated with anastomotic leak (Wald = 4.09, p = 0.04).

Conclusion: Our study identifies preoperative anemia as possible risk factor for anastomotic leak and neoadjuvant chemoradiation may lead to increased risk of complications overall. Further prospective studies will help to elucidate these findings as well as identify amenable factors that may decrease risk of anastomotic complications after rectal cancer surgery.
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http://dx.doi.org/10.1016/j.amsu.2014.12.002DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4323762PMC
March 2015

Are our publications failing the inspection?: a review of the publications in rectal cancer surgery between 2002 and 2012.

Dis Colon Rectum 2014 Aug;57(8):983-92

Division of Colon and Rectum Surgery, Department of Surgery, Loyola University Medical Center, Maywood, Illinois.

Background: Quality of publications is considered a subjective measurement, and more weight is placed on prospective studies, especially randomized clinical trials and meta-analyses.

Objective: This study describes the type of publications and evaluates the quality of randomized clinical trials and review articles using an objective measurement.

Data Sources: Medline (PubMed) is the data source for this work.

Study Selection: We used the terms "rectal neoplasms/surgery" and the filters "10 years," "humans," and "English."

Main Outcome Measures: We measured compliance with checklist items. Randomized clinical trials were reviewed using the Consolidates Standards of Reporting Trials statement; systematic reviews/meta-analyses were reviewed using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement.

Results: A total of 3603 articles were identified: 20.8% were case report/series, 20.5% were retrospective cohorts, 14.0% were reviews or meta-analyses, 16.4% were prospective cohorts, 14.0% were other types of articles (comments, letters, or editorials), 5.5% were clinical trials (phase I/II), 4.2% were randomized clinical trials, and 4.4% were cross-sectional studies. We reviewed 108 randomized clinical trials; the maximum score possible was 74.0, the average score was 44.6 (range, 20.0-64.0), 4 (3.7%) were graded as "excellent," 21 (19.4%) were "good," 44 (40.7%) were "deficient," and 39 (36.1%) were graded as "fail." The predictors of higher scores for randomized clinical trials were year of publication after 2007 (p = 0.00), higher impact factor (p = 0.03), and declared funding (p = 0.01). Twenty-nine meta-analyses were reviewed; the average score was 19.64 (range, 12.0-25.0); 5 articles (17.2%) were graded as "excellent," 12 (41.4%) were "good," 10 (34.5%) were "deficient," and 2 (6.9%) were "fail."

Limitations: Only 1 electronic database was used, so we lacked a validated score. In addition, the search terms did not include "colorectal."

Conclusions: A total of 20.8% of the articles published were case reports and 25.0% of the articles were prospective or clinical trials. Although randomized clinical trials and systematic reviews provide the highest level of evidence, publications with missing data limit replication of the study and affect the generalizability of results to other populations. To improve the quality of our publications, authors, reviewers, and journal editors should consider the endorsement of standardize checklists.
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http://dx.doi.org/10.1097/DCR.0000000000000169DOI Listing
August 2014

Hospital readmission for fluid and electrolyte abnormalities following ileostomy construction: preventable or unpredictable?

J Gastrointest Surg 2013 Feb 29;17(2):298-303. Epub 2012 Nov 29.

Division of Colon and Rectal Surgery, Loyola University Medical Center, 2160 South First Ave, Maywood, IL 60153, USA.

Background: Ileostomy creation has complications, including rehospitalization for fluid and electrolyte abnormalities. Although studies have identified predictors of this morbidity, readmission rates remain high.

Methods: The researchers conducted a retrospective chart review of all patients with ileostomy creation at a tertiary institution from January 2008 to June 2011.

Results: One hundred fifty-four patients (154) were included in this study; 71 (46.1 %) were female. Mean age was 49 ± 17.64 (range 16-91), and mean BMI was 26.9 ± 6.44 (range 13-52). The readmission rate for fluid and electrolyte abnormalities was 20.1 % for the study population; of those readmitted for all diagnoses, dehydration accounted for 40.7 % of all readmissions. Cancer was associated with readmission (χ(2) = 4.73, p = 0.03) as was neoadjuvant therapy (χ(2) = 9.20, p = 0.01). After multivariate analysis, only the use of anti-diarrheals and neoadjuvant therapy remained significant. High stoma output, adjuvant treatment, and postoperative complications were not significant.

Conclusions: Our study found that the use of anti-diarrheals and neoadjuvant therapy for rectal cancer were associated with readmission. Our findings imply that the use of anti-diarrheals may be a marker for patients at risk for fluid and electrolyte abnormalities; these patients should be strictly monitored at home. Our study also suggests consideration of avoidance of ileostomy creation or different discharge criteria for at-risk patients. Prospective studies focused on stoma monitoring after discharge may help reduce rehospitalizations for fluid and electrolyte abnormalities after ileostomy creation.
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http://dx.doi.org/10.1007/s11605-012-2073-5DOI Listing
February 2013

Tumor scatter after neoadjuvant therapy for rectal cancer: are we dealing with an invisible margin?

Dis Colon Rectum 2012 Dec;55(12):1206-12

Department of General Surgery, Section of Colon and Rectal Surgery, Rush University Medical Center, Chicago, Illinois, USA.

Background: After the impressive response of rectal cancers to neoadjuvant therapy, it seems reasonable to ask: can we can excise the small ulcer locally or avoid a radical resection if there is no gross residual tumor? Does gross response reflect what happens to tumor cells microscopically after radiation?

Objective: The aim of this study was to identify microscopic tumor cell response to radiation.

Design: This study is a retrospective review of a prospectively collected database.

Setting: This investigation was conducted at a single tertiary medical center.

Patients: Patients were selected who had elective radical resection for rectal cancer after preoperative chemotherapy and radiation performed by 2 colorectal surgeons between 2006 and 2011.

Main Outcome Measures: The primary outcome measured was tumor presence after radiation therapy

Results: Of the 75 patients, 20 patients were complete responders and 55 had residual cancer. Of these patients, 28 had no tumor cells seen outside the gross ulcer, and 27 (49.1%) had tumor outside the visible ulcer or microscopic tumor present with no overlying ulcer. Of these tumors, 81.5% were skewed away from the ulcer center. The mean distance of distal scatter was 1.0 cm from the visible ulcer edge to a maximum of 3 cm; 3 patients had tumor cells more than 2 cm distal to the visible ulcer edge. Tumor scatter outside the ulcer was not associated with poor prognostic factors, such as nodal and distant disease, perineural invasion, or mucin; however, it was associated with lymphovascular invasion (χ2 = 4.12, p = 0.038)

Limitations: There was limited access to clinical information gathered outside our institution.

Conclusions: Our study suggests that 1) after radiation, the gross ulcer cannot be used to determine the sole area of potential residual tumor, 2) cancer cells may be found up to 3 cm distally from the gross ulcer, so the traditional 2-cm margin may not be adequate, and 3) local excision of the ulcer or no excision after apparent complete response appears to be insufficient treatment for rectal cancer.
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http://dx.doi.org/10.1097/DCR.0b013e318269fdb3DOI Listing
December 2012

Unusual thrombotic complications.

Am Surg 2012 Jun;78(6):728-9

Department of General Surgery, Section of Colon & Rectal Surgery, Rush University Medical Center, Chicago, Illinois, USA.

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June 2012

Surgery after colonic stenting.

Am Surg 2012 Jun;78(6):722-7

Department of General Surgery, Rush University Medical Center, Chicago, Illinois, USA.

Colonic stenting is an accepted treatment of large bowel obstruction. The literature is sparse regarding surgical difficulties associated with an indwelling stent. We report our experience focusing on outcomes, complications, and whether the stent created intraoperative concerns. In this retrospective review, 6 patients were identified between 2007 and 2010 that had surgery after colonic stents were placed. Their charts were reviewed to compare clinical variables, surgical procedures, outcomes, and complications. One obstruction was due to diverticulitis. The stent reobstructed, leading to emergent transverse loop colostomy, and subsequent sigmoidectomy with stoma reversal. Four patients' obstructing masses were malignant. The final patient's stent was placed through a Hartmann's stump to drain a pelvic abscess. These 5 patients had no stent complications. Surgery occurred an average of 9.8 weeks after stent placement; four had low anterior resections and one underwent Hartmann's reversal. All 6 patients had colorectal anastomoses and five underwent laparoscopic surgery; one had an anastomotic leak requiring reoperation. Colonic stenting allows for the immediate relief of obstruction while permitting diagnosis and treatment of coexisting medical problems. The colon can be prepared for an elective rather than emergency operation, and a colostomy may be avoided.
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June 2012

Pelvic sepsis after transanal endoscopic microsurgical excision of rectal polyps.

Am Surg 2011 Aug;77(8):E154-5

Section of Colon & Rectal Surgery, Department of General Surgery, Rush University Medical Center, Chicago, Illinois, USA.

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August 2011

Incisionless laparoscopic total proctocolectomy with ileal J-pouch anal anastomosis.

Am Surg 2011 Jul;77(7):929-32

Section of Colon and Rectal Surgery, Department of General Surgery, Rush University Medical Center, Chicago, Illinois, USA.

Minimally invasive surgery continues to evolve. Recent innovations have included single-incision access, robotic technology, and natural orifice dissection and/or specimen extraction. Many argue that there is minimal patient benefit to these advanced techniques. We report 39 patients undergoing laparoscopic ileal J-pouch anal anastomosis surgery, 17 of whom did not have a separate specimen extraction incision (Group 1). The specimen for this group was extracted through the circular incision made for the ileostomy; the pouch was constructed extracorporeally and returned to the abdomen through the stoma site. For the remaining 22 patients, a suprapubic Pfannenstiel incision was made (Group 2). No hand-assistance was used for either group. Group 1 showed a 45-minute reduction in operative time, a 1-day reduction in hospital stay, and a reduction in complications. Although these differences are modest, it shows that minimally invasive surgery is an evolving process. Small modifications may translate into significant advantages.
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July 2011

Neoadjuvant treatment of rectal gastrointestinal stromal tumors with imatinib.

Am Surg 2010 Aug;76(8):E110-2

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August 2010

Laparoscopic colectomy: complications causing reoperation or emergency room/hospital readmissions.

Am Surg 2011 Jan;77(1):65-9

Rush University Medical Center, Chicago, Illinois 60612, USA.

The purpose of this study was to determine the incidence of complications causing reoperation or emergency room(ER)/hospital readmission after laparoscopic colectomy (LC). We retrospectively reviewed a prospectively managed database of 358 patients undergoing LC. Nonhand assisted LC was jointly performed by two surgeons assisted by a general surgery resident. Trochar site fascial wounds larger than 5 millimeters were not closed for the first 283 cases, mesenteric defects were not closed. Forty-one patients (11%) required reoperation. Of the 19 hernias (17 incisional, 2 mesenteric), seven caused early postoperative obstructions either within the first week of surgery or within 4 days after discharge. Twelve hernias presented in a delayed fashion and were repaired months later. Eight hernias occurred at trochar sites, nine at specimen extraction sites, and two were in the mesenteric defect. There were eight adhesive small bowel obstructions, five were treated with early reoperation. Other causes included perforations in six cases (2%), anastomotic leak in seven cases (2%) and bleeding in two cases (0.5%). Fifty-nine (16%) separate patients required evaluation in the ER. Fifty-three patients had one ER visit, six patients had two. Causes included nausea and vomiting in 19 cases (5%), wound infection in 16 cases (4%), pain in 13 cases (4%), fever in five cases (1%), thrombosis in four cases (1%); 46 were admitted to the hospital, 70 per cent were discharged within 4 days. Eleven per cent of patients required reoperation after LC, usually for hernias or adhesive small bowel obstruction. Fifty-three per cent of the hernias could have been avoided by routine closure of the fascia. An additional 16 per cent of patients required ER evaluation for complications. Of these, 78 per cent were admitted, 70 per cent were discharged within 4 days. LC is not without potential complications and is not necessarily a less morbid operation.
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January 2011

Neoadjuvant Treatment of Rectal Gastrointestinal Stromal Tumors with Imatinib.

Am Surg 2010 Aug;76(8):110-112

Rush University Medical Center Chicago, Illinois, USA.

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August 2010

Endobronchial colorectal metastasis versus primary lung cancer: a tale of two sleeve right upper lobectomies.

Interact Cardiovasc Thorac Surg 2009 Aug 8;9(2):379-81. Epub 2009 May 8.

Division of Thoracic Surgery, Rush University Medical Center, Chicago, IL, USA.

Endobronchial metastasis from colorectal carcinoma is relatively uncommon whereas primary bronchogenic carcinoma is more common. These two disease entities can both appear to be similar clinically and radiographically. Palliative treatment rather than a curative-intent anatomic resection is typically employed in the setting of endobronchial metastatic disease. We compare two cases of patients with a history of colorectal carcinoma with endobronchial lesions of which one was truly a metastatic lesion.
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http://dx.doi.org/10.1510/icvts.2009.207555DOI Listing
August 2009

Morbidity and mortality in octogenarians and older undergoing major intestinal surgery.

Dis Colon Rectum 2009 Jan;52(1):59-63

Section of Colon and Rectal Surgery, Department of General Surgery, Rush University Medical Center, Chicago, Illinois, USA.

Purpose: The elderly constitute an increasing portion of the world's population. Our study assessed morbidity, mortality, and outcome in octogenarians who have undergone lower intestinal operations, and compared outcome between subsequent decades.

Methods: A total of 138 octogenarians who underwent 157 operations were retrospectively studied (1995-2005). The American Society of Anesthesiologists Physical Status classification, blood loss, length of surgery, surgical intensive care unit admission, length of surgical intensive care unit and hospital stay, and complications were recorded. Emergency vs. elective and cancer vs. noncancer cases were compared. Results were compared for the years 1985 to 1994.

Results: Cancer comprised 63 percent of cases. The most common causes of mortality were sepsis and multiorgan failure. Differences (P < 0.05) were found for elective vs. emergent surgeries according to age, length of stay, complications, surgical intensive care unit admission, American Society of Anesthesiologists Physical Status classification, and mortality. Noncancer cases were more likely to be emergent, have a higher American Society of Anesthesiologists Physical Status classification, and a higher mortality rate. When emergency operations were excluded, there were no significant differences between cancer vs. noncancer cases. In a comparison of two decades (1985-1994 vs. 1995-2005), we found that the mortality rate in patients younger than aged 85 years decreased by more than 10 percent (P < 0.05). Patients older than aged 85 years demonstrated no significant differences between decades. The strongest determinants of outcome are emergency status and the presence of comorbid conditions.

Conclusions: Elective surgery in the elderly is safe. Emergency surgery is accompanied by significant morbidity and mortality.
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http://dx.doi.org/10.1007/DCR.0b013e31819754d4DOI Listing
January 2009

Repeat pulmonary resection for metachronous colorectal carcinoma is beneficial.

Surgery 2008 Oct 29;144(4):712-7; discussion 717-8. Epub 2008 Aug 29.

Division of Thoracic Surgery, Rush University Medical Center, Chicago, IL, USA.

Background: Initial pulmonary metastatectomy for limited colorectal carcinoma metastases is associated with improved survival. The role of repeat thoracic interventions is less well defined. The purpose of this study is to clarify the role of repeat pulmonary resection for metastatic colorectal carcinoma.

Methods: A retrospective study was performed using patients who underwent pulmonary metastatectomy for colorectal carcinoma at a single academic institution between January 1, 1985, and December 31, 2007. Sex, age at colorectal operation, colorectal TNM stage, and operative procedures for pulmonary metastases were recorded. Intervals between the original colorectal operation and thoracic operation and between the first pulmonary metastatectomy and repeat thoracic interventions were calculated. Log-rank comparison of Kaplan-Meier survival curves and covariate analysis were performed.

Results: A total of 69 patients were identified as having undergone at least 1 pulmonary metastatectomy. There were 32 female and 37 male patients with a mean age of 57 +/- 11 years. The median disease-free interval from original colorectal operation to first pulmonary metastatectomy for all the patients was 27 months. A total of 125 pulmonary resections were performed: 64 wedge resections, 27 segmentectomies, 30 lobectomies, and 4 pneumonectomies. Of the 69 patients, 41 underwent a single thoracic metastatectomy, whereas 28 underwent at least 1 second thoracic metastatectomy (2nd, 17 patients; 3rd, 6; 4th, 4; 5th, 1). There were no perioperative mortalities. From the original colorectal resection, the 5-year survival was 59% (median, 52 months). From the initial pulmonary metastatectomy, the 5-year survival for all patients was 25% (median, 36 months). The 5-year survival for patients undergoing only 1 thoracic resection was 23% (median, 24 months), which was not significantly different compared to patients undergoing repeat thoracic resections, 29% (median: 42 months). In the covariate analysis, no parameters significantly impacted survival.

Conclusions: Patients undergoing multiple pulmonary resections have the same survival as patients undergoing a single pulmonary resection for metachronous colorectal carcinoma. These findings indicate pulmonary metastases may be favorably treated with repeat thoracic interventions.
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http://dx.doi.org/10.1016/j.surg.2008.07.007DOI Listing
October 2008

Primary extramedullary plasmacytomas of the colon.

Am Surg 2008 Sep;74(9):873-4

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September 2008

What's new in ACS surgery: principles and practice. Transanal endoscopic microsurgery.

Bull Am Coll Surg 2004 Dec;89(12):36-7

Rush University Medical Center, Chicago, IL, USA.

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December 2004

TEM/local excision: indications, techniques, outcomes, and the future.

J Surg Oncol 2007 Dec;96(8):644-50

Rush Medical College Head, Section of Colon and Rectal Surgery, Rush University Medical Center, Chicago, Illinois, USA.

Transanal endoscopic microsurgery (TEM) has emerged as a safe method for excising virtually any rectal adenoma and carefully selected cancers. Extended applications include treatment of extra- and supra-sphincteric fistulae, rectovaginal fistulae, anastomotic strictures, and sinus tracts. The procedure utilizes an air-tight system, long shafted instruments, high-quality magnifying optics, and constant carbon dioxide insufflation, all of which facilitate a precise excision and closure with clear margins. Complications are few, most patients can be treated as an outpatient.
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http://dx.doi.org/10.1002/jso.20922DOI Listing
December 2007

Laparoscopic rectopexy without resection: a worthwhile treatment for rectal prolapse in patients without prior constipation.

Am Surg 2007 Sep;73(9):858-61

Department of General Surgery, Section of Colon and Rectal Surgery, Rush University Medical Center, Chicago, Illinois 60612, USA.

Anterior resection with rectopexy is considered by many to be the best operation for rectal prolapse. It is feared that if sigmoid redundancy created by rectal mobilization is not resected, colonic motility (specifically constipation) could be disabling. We contend that resection is not necessary in patients without preexisting constipation. We tested this hypothesis using a laparoscopic approach to minimize hospital stay. Twelve patients were treated (eight women); mean age was 45 years (range, 25-82 years). No patient had preexisting constipation; one had irritable bowel syndrome. Three patients had prior prolapse operations. Full rectal mobilization was undertaken down to the levator hiatus; neither the mesenteric vessels nor the lateral ligaments were divided. Rectopexy to the presacral fascia was done with one to two Nurolon sutures on either side of the rectum. There were no complications; mean hospital stay was 4 days. Mean follow up was 32 months (range; 3-75 months); there have been no recurrences. Only the patient with irritable bowel syndrome developed significant constipation. We conclude: 1) rectopexy can be safely done laparoscopically, 2) resection is not required in the absence of prior constipation, and 3) rectal mobilization and rectopexy does not predispose to future constipation in these selected patients.
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September 2007

Morbidity and mortality of the Confederate generals during the American Civil War.

Am Surg 2007 Aug;73(8):760-3; discussion 763-4

Department of Surgery, Section of Colon and Rectal Surgery, Rush University Medical Center, Chicago, Illinois, USA.

During the American Civil War (1861-1865), 426 men were commissioned generals by Jefferson Davis and the Confederate Congress. Eighty (19%) died of battle wounds (versus 8% in the Union army) and 3 per cent died of disease. During the war, 211 (49%) were wounded; of these, each was wounded a mean 1.9 times. When noncombatants are excluded, 52 per cent sustained wounds. Of those who served in five or more major engagements, 62 per cent were wounded; of those who fought in more than 10, 71 per cent sustained wounds. Sixty-five per cent of battlefield deaths were immediate and 85 per cent were from gunshot wounds. Mortality did not vary by state of birth, age group, rank (brigadier, major, lieutenant, full), formal military education, or prewar profession. Professional soldiers fared no better or worse than prewar civilians appointed to the rank of general. Of those who survived the war, mean age at death was 68.0 years.
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August 2007

Hartmann's colostomy reversal: outcome of patients undergoing surgery with the intention of eliminating fecal diversion.

Am Surg 2007 Jul;73(7):664-7; discussion 668

Department of General Surgery, Section of Colon and Rectal Surgery, Rush University Medical Center, Chicago, Illinois, USA.

Reversal of a Hartmann's operation can be a morbid undertaking; successful restoration of intestinal continuity cannot be guaranteed. Between June 2001 and July 2006, 35 Hartmann's reversals were undertaken. There were 19 males (54%). Mean age was 54.7 years (range, 14-82 years). Twenty-one (60%) patients had their Hartmann's for diverticular disease, 7 (20%) for anorectal cancer, 4 (11%) for volvulus, and 3 for miscellaneous reasons. Mean length of stay was 7.7 days (range, 3-16 days); 23 per cent required intensive care for a mean 2.3 days (range, 1-4 days). Blood loss was 470 mL, and mean operative time was 4.28 hours (range, 1-8.3 hours). The mean time interval between the original operation and its reversal was 8.9 months (range, 1.4-55 months). Extensive lysis of adhesions was required in 69 per cent, 40 per cent experienced minor complications (urinary tract infections, ileus, and so on), and 38 per cent had major complications (myocardial infarction, leak, hernias, respiratory failure). There was one death (3%). The operation failed because of intraoperative circumstances in three patients (8%). Ten patients (26%) had stomas at the time of discharge of which 3 were intended to be permanent and 7 were temporary. Of the latter, 3 were successfully closed, 3 are awaiting closure, and 1 had complete anastomotic failure requiring permanent diversion. Total failure rate was 10.3 per cent; contributing factors included prior radiation and ultra-low anastomoses.
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July 2007

Patient attitudes toward medical students in an outpatient colorectal surgery clinic.

Dis Colon Rectum 2007 Aug;50(8):1255-8

Department of General Surgery, Section of Colon and Rectal Surgery, Rush University Medical Center, Chicago, IL 60162, USA.

Purpose: Patients with colorectal diseases may be reluctant to have medical students present during their outpatient clinic visit, especially when significant disrobing and embarrassing examinations are performed. This study examines patient attitudes in this regard.

Methods: One hundred consecutive patients completed a questionnaire after the conclusion of their office visit. Patient age, gender, race, diagnosis, level of disease, socioeconomic status, and education level were recorded as well as attitudes toward the presence of students in the examination room. Responses were analyzed by using two-sample Z tests or chi-squared tests for comparison of proportions among groups. The pooled-variance t-test was used to compare the difference of means when appropriate.

Results: Overall, 81 percent of patients accepted students' presence. Females were less likely than males (77 vs. 86 percent; P = 0.03) and blacks less likely than whites (61 vs. 88 percent; P = 0.004) to accept students. Higher compliance was demonstrated in patients with greater perceived severity of disease (P = 0.03). We found no significant correlation between patient level of education or income and their comfort level with respect to teaching in the examination room. However, racial differences were seen in this category (P = 0.01). Females were more likely to prefer the same gender student, but this was not statistically significant.

Conclusions: Students are generally accepted in outpatient colorectal clinics (81 percent). Reasons for acceptance of students included being able to contribute to the teaching of future doctors. Reasons for refusal included perceived increased length of the office visit and patient privacy. We noticed significant differences in compliance by gender, race, and severity of disease, but not age, patient level of income, or education.
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http://dx.doi.org/10.1007/s10350-007-0274-xDOI Listing
August 2007

Current choices--good or bad--for the proactive management of postoperative ileus: A surgeon's view.

J Perianesth Nurs 2006 Apr;21(2A Suppl):S7-15

Rush Medical College, Section of Colon and Rectal Surgery, Rush University Medical Center, Chicago, IL 60612, USA.

Postoperative ileus (POI) is frequently experienced by many patients undergoing abdominal operations and other surgical procedures. Postoperative ileus causes physical discomfort and may increase risk for prolonged hospital length of stay. Despite its prevalence, there is currently no accepted standard definition of POI and, consequently, no standardized mode of prevention or treatment; it is no wonder that a variety of management approaches for POI have been developed. Some of these include alternative surgical techniques such as laparoscopic or endoscopic procedures to minimize trauma and help lessen the release of endogenous mediators of POI. Others have evaluated alternate analgesic regimens such as thoracic epidural anesthetics to avoid stimulating opioid receptors in the gut. These approaches have had varying results. Other pharmacologic attempts to reduce POI have focused on the blockade of opioid receptors to prevent opioid-induced GI-related adverse effects. A new class of agents, peripherally acting mu-opioid-receptor antagonists such as methylnaltrexone and alvimopan, may improve the pharmacologic management of POI and reshape the current paradigm of multimodal management of POI. Protocols that incorporate these agents may offer yet another avenue to mitigate the adverse effects of POI, and thus help improve surgical outcomes. To date, alvimopan has been shown in phase 3 clinical trials to significantly reduce the duration of POI while maintaining satisfactory analgesia and reducing length of hospital stay. Combinations of strategies with demonstrated effectiveness such as early feeding, epidural analgesia, laparoscopic surgery, and peripherally acting mu-opioid-receptor antagonists may help transform the management of POI into an effective multimodal paradigm that targets the diverse etiologic factors leading to this common clinical problem. Clearly, all surgical team members are crucial in the optimal implementation of such multimodal approaches.
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http://dx.doi.org/10.1016/j.jopan.2006.01.008DOI Listing
April 2006

Transanal endoscopic microsurgical resection of pT1 rectal tumors.

Dis Colon Rectum 2006 Feb;49(2):164-8

Section of Colon and Rectal Surgery, Department of General Surgery, Rush University Medical Center, Chicago, Illinois 60612, USA.

Purpose: Transanal endoscopic microsurgery has emerged as an improved method of transanal excision of neoplasms because its enhanced visibility, superior optics, and longer reach permit a more complete excision and precise closure. This study will show that transanal endoscopic microsurgical treatment of pT1 rectal cancers is safe and achieves low local recurrence and high survival rates.

Methods: Retrospective review performed of all pT1 rectal cancers treated by a single surgeon (TS) using transanal endoscopic microsurgery between 1991 and 2003. Patient age, gender, tumor distance from the anal verge, lesion size, operative time, blood loss, complications, recurrence, and survival rates were prospectively recorded.

Results: Fifty-three patients (average age, 65.6 (range, 31-89) years) were studied. Forty-nine percent were male. Average tumor distance from the anal verge was 7 (range, 0-13) cm; average size was 2.4 (range, 1-10) cm. Radiation and/or chemotherapy were not administered. Sixteen patients had pT1 lesions removed piecemeal during colonoscopy; there was no residual tumor after transanal endoscopic microsurgical resection of the polyp site. Mean follow-up was 2.84 years. Fifty-one percent had longer than two-year follow-up. For the entire group, there were four recurrences (7.5 percent) occurring at 9 months, 15 months, 16 months, and 11 years. Two were treated with abdominoperineal resection, one with low anterior resection, and one with fulguration alone. There were no recurrences in the 16 patients who had excision of the polypectomy site. If excluded, recurrence was 11 percent (4/37). Patients were examined at three-month intervals for the first two years and every six months thereafter. There have been no cancer-related deaths.

Conclusions: Transanal endoscopic microsurgical resection of pT1 rectal cancers yields low recurrence rates. Close follow-up permits curative salvage for those that do recur. Transanal excision remains a viable option.
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http://dx.doi.org/10.1007/s10350-005-0269-4DOI Listing
February 2006