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Silvestre J, Singh GP, Weldeslase TA, Bleier JIS. Supply and Demand for Colon and Rectal Surgery Training in the United States. Dis Colon Rectum 2024; 67:739-742. [PMID: 38354059 DOI: 10.1097/dcr.0000000000003227] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/05/2024]
Affiliation(s)
- Jason Silvestre
- Department of Orthopaedic Surgery, Medical University of South Carolina, Charleston, South Carolina
| | - Gagan P Singh
- Department of Surgery, Howard University College of Medicine, Washington, District of Columbia
| | - Terhas A Weldeslase
- Department of Surgery, Howard University College of Medicine, Washington, District of Columbia
| | - Joshua I S Bleier
- Department of Surgery, Perelman School of Medicine, Philadelphia, Pennsylvania
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Abstract
Ileostomy or colostomy formation is an important component of many surgical procedures performed for a wide range of disorders of the gastrointestinal tract. Despite the frequency with which intestinal stomas are created, stoma-related complications remain common and are associated with significant morbidity as well as cost. Some of the most prevalent complications of stoma formation which will be detailed in this article include peristomal skin complications, retraction, stomal necrosis, stomal stenosis, prolapse, bleeding, dehydration from high ostomy output, and parastomal hernia. The authors will review these common complications, detail means to avoid or prevent them, and outline recommendations for management.
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Affiliation(s)
- Douglas R Murken
- Department of Surgery, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Joshua I S Bleier
- Division of Colon and Rectal Surgery, Department of Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
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Abstract
With increased use of explosive devices in warfare, anal trauma is often seen coupled with more complex pelviperineal injury. While the associated mortality is high, casualties that survive are often left with disabling fecal incontinence from damage to the anosphincteric complex. After resolution of the acute insult, the initial evaluation mandates a thorough physical exam, including endoscopic evaluation with rigid proctoscopy and flexible sigmoidoscopy, as well as adjunctive testing, specifically anal manometry and endoanal ultrasound. First-line therapy favors bulking agents and antidiarrheals, in conjunction with biofeedback, due to a minimal risk profile. Surgical options range from direct sphincter repairs to complex anosphincteric reconstruction with widely variable results. Most recently, burgeoning therapies in the treatment of fecal incontinence, including sacral nerve stimulation and magnetic anal sphincters, offer excellent alternatives with promising long-term outcomes. In summation, the goal of all interventions is the re-establishment of bowel continence, but, in its absence, permanent fecal diversion for devastating fecal incontinence is a reasonable option with excellent patient satisfaction scores.
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Affiliation(s)
- Arjun N Jeganathan
- Department of Surgery, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Jeremy W Cannon
- Division of Traumatology, Critical Care and Emergency Surgery, Department of Surgery, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Joshua I S Bleier
- Division of Colon and Rectal Surgery, Department of Surgery, University of Pennsylvania, Philadelphia, Pennsylvania
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4
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Abstract
Transanal endoscopic surgery (TES) techniques encompass a variety of approaches, including transanal endoscopic microsurgery and transanal minimally invasive surgery. These allow a surgeon to perform local excision of rectal lesions with minimal morbidity and the potential to spare the need for proctectomy. As understanding of the long-term outcomes from these procedures has evolved, so have the indications for TES. In this study, we review the development of TES, its early results, and the evolution of new surgical techniques. In addition, we evaluate the most recent research on indications and outcomes in rectal cancer.
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Affiliation(s)
- Earl V Thompson
- Department of Surgery, University of Pennsylvania Health System, Philadelphia, Pennsylvania
| | - Joshua I S Bleier
- Department of Surgery, University of Pennsylvania Health System, Philadelphia, Pennsylvania
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Jeganathan AN, Shanmugan S, Bleier JIS, Hall GM, Paulson EC. Colorectal Specialization Increases Lymph Node Yield: Evidence from a National Database. Ann Surg Oncol 2016; 23:2258-65. [DOI: 10.1245/s10434-016-5122-6] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2015] [Indexed: 11/18/2022]
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Hall GM, Shanmugan S, Bleier JIS, Jeganathan AN, Epstein AJ, Paulson EC. Colorectal specialization and survival in colorectal cancer. Colorectal Dis 2016; 18:O51-60. [PMID: 26708838 DOI: 10.1111/codi.13246] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/26/2015] [Accepted: 10/16/2015] [Indexed: 12/12/2022]
Abstract
AIM It is recognized that higher surgeon volume is associated with improved survival in colorectal cancer. However, there is a paucity of national studies that have evaluated the relationship between surgical specialization and survival. METHOD We used the Surveillance, Epidemiology, and End Results Medicare cancer registry to examine the association between colorectal specialization (CRS) and disease-specific survival (DSS) between 2001 and 2009. A total of 21,432 colon cancer and 5893 rectal cancer patients who underwent elective surgical resection between 2001 and 2009 were evaluated. Univariate and multivariate Cox survival analysis was used to identify the association between surgical specialization and cancer-specific survival. RESULTS Colorectal specialists performed 16.3% of the colon and 27% of the rectal resections. On univariate analysis, specialization was associated with improved survival in Stage II and Stage III colon cancer and Stage II rectal cancer. In multivariate analysis, however, CRS was associated with significantly improved DSS only in Stage II rectal cancer [hazard ratio (HR) 0.70, P = 0.03]. CRS was not significantly associated with DSS in either Stage I (colon HR 1.14, P = 0.39; rectal HR 0.1.26, P = 0.23) or Stage III (colon HR 1.06, P = 0.52; rectal HR 1.08, P = 0.55) disease. When analysis was limited to high volume surgeons only, the relationship between CRS and DSS was unchanged. CONCLUSIONS CRS is associated with improved DSS following resection of Stage II rectal cancer. A combination of factors may contribute to long-term survival in these patients, including appropriate surgical technique, multidisciplinary treatment decisions and guideline-adherent surveillance. CRS probably contributes positively to these factors resulting in improved survival.
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Affiliation(s)
- G M Hall
- Division of Colon and Rectal Surgery, Department of General Surgery, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - S Shanmugan
- Division of Colon and Rectal Surgery, Department of General Surgery, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - J I S Bleier
- Division of Colon and Rectal Surgery, Department of General Surgery, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - A N Jeganathan
- Department of General Surgery, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - A J Epstein
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, Pennsylvania, USA.,Division of General Internal Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - E C Paulson
- Division of Colon and Rectal Surgery, Department of General Surgery, University of Pennsylvania, Philadelphia, Pennsylvania, USA.,Department of General Surgery, Philadelphia VA Medical Center, Philadelphia, Pennsylvania, USA
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Steele SR, Varma MG, Prichard D, Bharucha AE, Vogler SA, Erdogan A, Rao SSC, Lowry AC, Lange EO, Hall GM, Bleier JIS, Senagore AJ, Maykel J, Chan SY, Paquette IM, Audett MC, Bastawrous A, Umamaheswaran P, Fleshman JW, Caton G, O'Brien BS, Nelson JM, Steiner A, Garely A, Noor N, Desrosiers L, Kelley R, Jacobson NS. The evolution of evaluation and management of urinary or fecal incontinence and pelvic organ prolapse. Curr Probl Surg 2015; 52:17-75. [PMID: 25919203 DOI: 10.1067/j.cpsurg.2015.01.001] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2014] [Accepted: 01/29/2015] [Indexed: 12/13/2022]
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Abstract
Parastomal hernia is a prevalent problem and treatment can pose difficulties due to significant rates of recurrence and morbidities of the repair. The current standard of care is to perform parastomal hernia repair with mesh whenever possible. There exist multiple options for mesh reinforcement (biologic and synthetic) as well as surgical techniques, to include type of repair (keyhole and Sugarbaker) and position of mesh placement (onlay, sublay, or intraperitoneal). The sublay and intraperitoneal positions have been shown to be superior with a lower incidence of recurrence. This procedure may be performed open or laparoscopically, both having similar recurrence and morbidity results. Prophylactic mesh placement at the time of stoma formation has been shown to significantly decrease the rates of parastomal hernia formation.
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Affiliation(s)
- Suzanne Gillern
- Division of Colon and Rectal Surgery, Department of Surgery, University of Pennsylvania Health System, Philadelphia, Pennsylvania
| | - Joshua I S Bleier
- Division of Colon and Rectal Surgery, Department of Surgery, University of Pennsylvania Health System, Philadelphia, Pennsylvania
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Abstract
Perioperative fluid management of the colorectal surgical patient has evolved significantly over the last five decades. Older notions espousing aggressive hydration have been shown to be associated with increased complications. Newer data regarding fluid restriction has shown an association with improved outcomes. Management of perioperative fluid administration can be considered in three primary phases: In the preoperative phase, data suggests that avoidance of preoperative bowel preparation and avoidance of undue preoperative dehydration can improve outcomes. Although the type of intraoperative fluid given does not have a significant effect on outcome, data do suggest that a restrictive fluid regimen results in improved outcomes. Finally, in the postoperative phase of fluid management, a fluid-restrictive regimen, coupled with early enteral feeding also seems to result in improved outcomes.
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Affiliation(s)
- Joshua I S Bleier
- Division of Colon and Rectal Surgery, Department of Surgery, University of Pennsylvania Health System, Philadelphia, Pennsylvania
| | - Cary B Aarons
- Division of Colon and Rectal Surgery, Department of Surgery, University of Pennsylvania Health System, Philadelphia, Pennsylvania
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Abstract
The surgical approach to treating fecal incontinence is complex. After optimal medical management has failed, surgery remains the best option for restoring function. Patient factors, such as prior surgery, anatomic derangements, and degree of incontinence, help inform the astute surgeon regarding the most appropriate option. Many varied approaches to surgical management are available, ranging from more conservative approaches, such as anal canal bulking agents and neuromodulation, to more aggressive approaches, including sphincter repair, anal cerclage techniques, and muscle transposition. Efficacy and morbidity of these approaches also range widely, and this article presents the data and operative considerations for these approaches.
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Affiliation(s)
- Joshua I S Bleier
- Division of Colon and Rectal Surgery, Pennsylvania Hospital/Hospital of the University of Pennsylvania, University of Pennsylvania, 800 Walnut Street, 20th Floor, Philadelphia, PA 19106, USA.
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Abstract
The development of an academic surgical career can be an overwhelming prospect, and one that is not intuitive. Establishing a structured plan and support structure is critical to success. Starting a successful academic surgical career begins with defining one's academic goals within several broad categories: personal goals, academic goals, research goals, educational goals, and financial goals. Learning the art of self-promotion is the means by which many of these goals are achieved. It is important to realize that achieving these goals requires a delicate personal balance between work and home life, and the key ways in which to achieve success require establishment of well thought-out goals, a reliable support structure, realistic and clear expectations, and frequent re-evaluation.
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Affiliation(s)
- Joshua I. S. Bleier
- Division of Colon and Rectal Surgery, Department of Surgery, University of Pennsylvania Health System, Philadelphia, Pennsylvania
| | - Brian Kann
- Division of Colon and Rectal Surgery, Department of Surgery, University of Pennsylvania Health System, Philadelphia, Pennsylvania
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Abstract
Crohn disease involves the perineum and rectum in approximately one-third of patients. Symptoms can range from mild, including skin tags and hemorrhoids, to unremitting and severe, requiring a proctectomy in a small, but significant, portion. Fistula-in-ano and perineal sepsis are the most frequent manifestation seen on presentation. Careful diagnosis, including magnetic resonance imaging or endorectal ultrasound with examination under anesthesia and aggressive medical management, usually with a tumor necrosis factor-alpha, is critical to success. Several options for definitive surgical repair are discussed, including fistulotomy, fibrin glue, anal fistula plug, endorectal advancement flap, and ligation of intersphincteric fistula tract procedure. All suffer from decreased efficacy in patients with Crohn disease. In the presence of active proctitis or perineal disease, no surgical therapy other than drainage of abscesses and loose seton placement is recommended, as iatrogenic injury and poor wound healing are common in that scenario.
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Affiliation(s)
- Robert T. Lewis
- Division of Colon and Rectal Surgery, Department of Surgery, University of Minnesota, Minneapolis, Minnesota
| | - Joshua I. S. Bleier
- Division of Colon and Rectal Surgery, Department of Surgery, University of Pennsylvania Health System, Philadelphia, Pennsylvania
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Glasgow SC, Bleier JIS, Burgart LJ, Finne CO, Lowry AC. Meta-analysis of histopathological features of primary colorectal cancers that predict lymph node metastases. J Gastrointest Surg 2012; 16:1019-28. [PMID: 22258880 DOI: 10.1007/s11605-012-1827-4] [Citation(s) in RCA: 75] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/04/2011] [Accepted: 01/05/2012] [Indexed: 01/31/2023]
Abstract
BACKGROUND Treatment decisions for colorectal cancer vary based on lymph node status. While some histopathological features of the primary tumor correlate with lymph node spread, the relative influences of these risk factors are not well quantified. OBJECTIVE This study aims to systematically review published studies relating histopathological features of primary colorectal cancer to the presence of lymph node metastases and to determine how reliable certain factors might be at predicting nodal metastasis when only the primary lesion is available for study. DATA SOURCES Inclusive literature search using EMBASE and Ovid MEDLINE databases plus manual reference checks of all articles correlating lymphatic spread with colorectal cancer (any T stage) from 1984 to mid-2008 was performed. STUDY SELECTION This search generated two levels of screening utilized on 602 citations, yielding 123 articles for full review. Data reported from 76 articles were chosen. MAIN OUTCOME MEASURES The relative influence of each histopathological feature on the likelihood of lymphatic metastases was determined. Fixed-effects meta-analysis was performed, and results were reported as Mantel-Haenszel odds ratios (OR). RESULTS Of 42 histopathological features analyzed, only 40.4% were reported in >2 articles. The positive predictive values for the top quartile of most frequently reported risk factors were 25.5-86.4%. Among the commonly reported histopathological findings, lymphatic invasion (OR, 8.62) significantly outperformed tumor depth (T2 vs. T1; OR, 2.62) and overall differentiation (OR, 2.38) in predicting nodal spread. For the rectal cancer subset, risk factors differed from the overall colorectal group in predictive ability; poor differentiation at the invasive front (OR, 6.08) and tumor budding (OR, 5.82) were the most predictive. LIMITATIONS This literature search is limited by the small number of studies examining only rectal cancers and the potential changes in histological and/or surgical techniques over the study period. CONCLUSIONS No single histopathological feature of colorectal cancer reliably predicted lymph node metastases. Several risk factors that correlate highly with nodal disease are not routine components of standard pathology reports. Until further research establishes histopathological or molecular patterns for predicting lymph node spread, caution should be exercised when basing treatment decisions solely on these factors.
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Affiliation(s)
- Sean C Glasgow
- Department of Surgery, San Antonio Military Medical Center, 3551 Roger Brooke Drive, Ft. Sam Houston, San Antonio, TX 78234-6200, USA.
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Abstract
Enterocutaneous fistula (ECF) is a challenging clinical problem with many etiologies; however, the most common cause is iatrogenic, complicating abdominal surgery. Advances in the overall care of the ECF patient have resulted in dramatic reductions in morbidity and mortality over the last five decades. A structured approach to the management of ECF has been shown to result in improved outcomes. Initial physiologic stabilization of the postoperative patient, focused on hemodynamic and fluid support as well as aggressive sepsis control are the critical initial maneuvers. Subsequent optimization of nutrition and wound care allows the patient to regain a positive nitrogen balance, and allow for healing. Judicious use of antimotility agents as well as advanced wound care techniques helps to maximize healing as well as quality of life, and prepare patients for subsequent definitive surgery.
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Affiliation(s)
- Joshua I. S. Bleier
- Department of Surgery, Division of Colorectal Surgery, Pennsylvania Hospital/Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Traci Hedrick
- Department of Surgery, University of Virginia, Charlottesville, Virginia
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Marshall MB, Deeb ME, Bleier JIS, Kucharczuk JC, Friedberg JS, Kaiser LR, Shrager JB. Suction vs water seal after pulmonary resection: a randomized prospective study. Chest 2002; 121:831-5. [PMID: 11888968 DOI: 10.1378/chest.121.3.831] [Citation(s) in RCA: 138] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
Abstract
STUDY OBJECTIVE To evaluate whether suction or water seal is superior in the management of chest tubes after pulmonary resection. DESIGN A prospective, randomized, controlled trial. After an initial, brief period of suction, patients were randomized to water seal or - 20 cm H(2)O suction. SETTING University hospital. PATIENTS Sixty-eight patients who underwent wedge resection, segmentectomy, or lobectomy were included in the study. Those patients who underwent reoperative surgery or lung volume reduction surgery were excluded. RESULTS There were 34 patients in each group. The two groups were evenly matched for age, sex, operation performed, severity of lung disease, and nutritional status. Fifteen patients in each group (44%) had an air leak at the completion of surgery. The duration of the air leak was shorter in the water seal group than in the suction group (mean +/- SEM, 1.50 +/- 0.32 days vs 3.27 +/- 0.80 days, respectively; p = 0.05). The mean times to removal of chest tubes were 3.33 +/- 0.35 days in the water seal group and 5.47 +/- 0.98 days in the suction group (p = 0.06). The length of stapled parenchyma was measured for each patient and averaged 24.9 cm for the water seal group and 18.5 cm for the suction group (p = 0.18). When corrected for the length of staple lines, the duration of air leaks and days with chest tube were dramatically lower in the water seal group (p = 0.02 and p = 0.02, respectively). CONCLUSION Placing chest tubes on water seal after a brief period of suction after pulmonary resection shortens the duration of the air leak and likely decreases the time that the chest tubes remain in place. Adoption of this practice may result in lower morbidity and lower hospital costs.
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Affiliation(s)
- M Blair Marshall
- Section of General Thoracic Surgery, Division of Cardiothoracic Surgery, Department of Surgery, University of Pennsylvania School of Medicine, Philadelphia, PA 19104, USA
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