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Background: Scoliosis is a complex three-dimensional deformity with limited treatment options. Current treatments present potential problems that may be addressed with use of fusionless techniques for the correction of scoliosis. However, there are few data comparing the efficacy of different fusionless implant strategies in controlling scoliosis or on the integrity of rigid compared with flexible devices in an in vivo setting over time. The objective of this study was to compare the efficacy and integrity of rigid and flexible anterior thoracic tethers used to treat experimental scoliosis.Methods: Experimental scoliosis was created in twenty-four Spanish Cross-X female goats and was subsequently treated with either anterior shape memory alloy staples or anterior ligament tethers attached to bone anchors. Serial radiographs were analyzed to determine the efficacy of the implants in controlling scoliosis progression as well as the integrity of the implants at study completion. After the goats were killed, the implants were analyzed with use of three quantitative indices of implant integrity and implant pullout testing.Results: Over the treatment period, scoliosis progressed from 77.3 degrees to 94.3 degrees in the goats treated with staples and was corrected from 73.4 degrees to 69.9 degrees in the goats treated with bone anchors, with loosening of eighteen of forty-two staples (two of the eighteen dislodged) and evidence of drift in two of forty-nine anchors. Histologic sections revealed a consistent halo of fibrous tissue around the staple tines but well-fixed bone anchors at all sites. Pullout testing demonstrated that bone anchors had greater strength than staples initially and at the study completion, with an increase in bone anchor fixation over the course of the study.Conclusions: In this scoliosis model, the flexible ligament tethers attached to bone anchors demonstrated greater efficacy and integrity than the more rigid shape memory alloy staples. [ABSTRACT FROM AUTHOR]

An economic model was developed to compare costs of stand-alone anterior lumbar interbody fusion with recombinant human bone morphogenetic protein 2 on an absorbable collagen sponge versus autogenous iliac crest bone graft in a tapered cylindrical cage or a threaded cortical bone dowel. The economic model was developed from clinical trial data, peer-reviewed literature, and clinical expert opinion. The upfront price of bone morphogenetic protein (3380 dollars) is likely to be offset to a significant extent by reductions in the use of other medical resources, particularly if costs incurred during the 2 year period following the index hospitalization are taken into account. [ABSTRACT FROM AUTHOR]

Competing Interests: Disclosure: The Disclosure of Potential Conflicts of Interest form is provided with the online version of the article (http://links.lww.com/JBJS/I6).

Background: Surgical treatment of recurrent rectal prolapse is associated with unique technical challenges, partially determined by the surgical approach used for the index operation. Success rates are variable, and data to determine the best approach in patients with recurring prolapse are lacking., Objective: The study aimed to assess current surgical approaches to patients with prior rectal prolapse repairs and to compare short-term outcomes of de novo and redo procedures, including recurrence of rectal prolapse., Design: Retrospective analysis of a prospective database., Settings: The Multicenter Pelvic Floor Disorders Consortium Prospective Quality Improvement database. De-identified surgeons at more than 25 sites (81% high volume) self-reported patient demographics, prior repairs, symptoms of incontinence and obstructed defecation, and operative details, including history of concomitant repairs and prior prolapse repairs., Patients: Patients who were offered surgery for full thickness rectal prolapse., Interventions: Incidence and type of repair used for prior rectal prolapse surgery were recorded. Primary and secondary outcomes of index and redo operations were calculated. Patients undergoing rectal prolapse re-repair (redo) were compared with patients undergoing first (de novo) rectal prolapse repair. The incidence of rectal prolapse recurrence in de novo and redo operations was quantified., Outcomes: The primary outcome of rectal prolapse recurrence in de novo and redo settings., Results: Eighty-nine (19.3%) of 461 patients underwent redo rectal prolapse repair. On short-term follow-up, redo patients had prolapse recurrence rates similar to those undergoing de novo repair. However, patients undergoing redo procedures rarely had the same operation as their index procedure., Limitations: Self-reported, de-identified data., Conclusion: Our results suggest that recurrent rectal prolapse surgery is feasible and can offer adequate rates of rectal prolapse durability in the short term but may argue for a change in surgical approach for redo procedures when clinically feasible. See Video Abstract ., Los Enfoques Duraderos Para La Reparacin Del Prolapso Rectal Recurrente Pueden Requerir Evitar El Procedimiento Ndice: ANTECEDENTES:El tratamiento quirúrgico del prolapso rectal recurrente se asocia con desafíos técnicos únicos, determinados en parte por el abordaje quirúrgico utilizado para la operación inicial. Las tasas de éxito son variables y faltan datos para determinar el mejor abordaje en pacientes con prolapso recurrente.OBJETIVO:Evaluar los enfoques quirúrgicos actuales para pacientes con reparaciones previas de prolapso rectal y comparar los resultados a corto plazo de los procedimientos de novo y rehacer, incluida la recurrencia del prolapso rectal.DISEÑO:Análisis retrospectivo de una base de datos prospectiva.AJUSTE:Base de datos de mejora prospectiva de la calidad del Consorcio multicéntrico de trastornos del suelo pélvico. Cirujanos no identificados en más de 25 sitios (81% de alto volumen) informaron datos demográficos de los pacientes, reparaciones previas, síntomas de incontinencia y defecación obstruida y detalles operativos, incluido el historial de reparaciones concomitantes y reparaciones previas de prolapso.INTERVENCIONES:Se registro la incidencia y el tipo de reparación utilizada para la cirugía de prolapso rectal previa. Se calcularon los resultados primarios y secundarios de las operaciones de índice y reoperacion. Se compararon los pacientes sometidos a una nueva reparación (reoperacion) de prolapso rectal con pacientes sometidos a una primera reparación (de novo) de prolapso rectal. Se cuantificó la incidencia de recurrencia del prolapso rectal en operaciones de novo y rehacer.RESULTADOS:El resultado primario de recurrencia del prolapso rectal en entornos de novo y redo. Ochenta y nueve (19,3%) de 461 pacientes se sometieron a una nueva reparación del prolapso rectal. En el seguimiento a corto plazo, los pacientes reoperados tuvieron tasas de recurrencia de prolapso similares a los de los sometidos a reparación de novo. Sin embargo, los pacientes sometidos a procedimientos de rehacer rara vez tuvieron la misma operación que su procedimiento índice.LIMITACIONES:Datos no identificados y autoinformados.CONCLUSIONES/DISCUSIÓN:Nuestros resultados sugieren que la cirugía de prolapso rectal recurrente es factible y puede ofrecer tasas adecuadas de durabilidad del prolapso rectal en el corto plazo, pero puede abogar por un cambio en el enfoque quirúrgico para rehacer los procedimientos cuando sea clínicamente factible. (Traducción-Dr. Mauricio Santamaria )., (Copyright © The ASCRS 2024.)

Background: Despite guidelines suggesting the use of extended prophylaxis for prevention of venous thromboembolism in patients with colorectal cancer and perhaps IBD, routine use is low and scant data exist regarding oral forms of therapy., Objective: The purpose was to compare the incidence of postdischarge venous thromboembolism in patients given extended prophylaxis with low-dose rivaroxaban., Design: We used propensity matching to compare pre- and postintervention analyses from a 2-year period before instituting extended prophylaxis., Setting: All colorectal patients at a single institution were prospectively considered for extended prophylaxis., Patients: Patients with a diagnosis of IBD or colorectal cancer who underwent operative resection were included., Interventions: Those considered for extended prophylaxis were prescribed 10 mg of rivaroxaban for 30 days postsurgery., Main Outcome Measures: The primary outcome was venous thromboembolism incidence 30 days postdischarge. The secondary outcome was bleeding rates, major or minor., Results: Of the 498 patients considered for extended prophylaxis, 363 were discharged with rivaroxaban, 81 on baseline anticoagulation, and 54 without anticoagulation. Propensity-matched cohorts based on stoma creation, operative approach, procedure type, and BMI were made to 174 historical controls. After excluding cases of inpatient venous thromboembolism, postoperative rates were lower in the prospective cohort (4.8% vs 0.6%, p = 0.019). In the prospective group, 36 episodes of bleeding occurred, 26 (7.2%) were discharged with rivaroxaban, 8 (9.9%) discharged on other anticoagulants, and 2 (3.7%) with no postoperative anticoagulation. Cases of major bleeding were 1.1% (4/363) in the rivaroxaban group, and each required intervention., Limitations: The study was limited to a single institution and did not include a placebo arm., Conclusions: Among patients with IBD and colorectal cancer, extended prophylaxis with low-dose rivaroxaban led to a significant decrease in postdischarge thromboembolic events with a low bleeding risk profile. See Video Abstract ., Rivaroxabn En Dosis Bajas Como Profilaxis Prolongada Reduce La Tromboembolia Venosa Posterior Al Alta, En Pacientes Con Neoplasias Malignas Y Enfermedad Inflamatoria Intestinal: ANTECEDENTES:A pesar de las normas que sugieren el uso de profilaxis extendida para la prevención del tromboembolismo venoso en pacientes con cáncer colorrectal y tal vez enfermedad inflamatoria intestinal, el uso rutinario es bajo y existen escasos datos sobre las formas orales de terapia.OBJETIVO:Comparar la incidencia de tromboembolismo venoso posterior al alta, en pacientes que recibieron profilaxis prolongada con dosis bajas de rivaroxabán.DISEÑO:Utilizamos el emparejamiento de propensión para comparar un análisis previo y posterior a la intervención de un período de 2 años antes de instituir la profilaxis extendida.AJUSTE:Todos los pacientes colorrectales en una sola institución fueron considerados prospectivamente para profilaxis extendida.PACIENTES:Incluidos pacientes con diagnóstico de enfermedad inflamatoria intestinal o cáncer colorrectal sometidos a resección quirúrgica.INTERVENCIONES:A los considerados para profilaxis extendida se les prescribió 10 mg de rivaroxabán durante 30 días postoperatorios.PRINCIPALES MEDIDAS DE RESULTADO:El resultado primario fue la incidencia de tromboembolismo venoso 30 días después del alta. El resultado secundario fueron las tasas de hemorragia, mayor o menor.RESULTADOS:De los 498 pacientes considerados para profilaxis extendida, 363 fueron dados de alta con rivaroxabán, 81 con anticoagulación inicial y 54 sin anticoagulación. Se realizaron cohortes emparejadas por propensión basadas en la creación de la estoma, abordaje quirúrgico, tipo de procedimiento y el índice de masa corporal en 174 controles históricos. Después de excluir los casos de tromboembolismo venoso hospitalizado, las tasas posoperatorias fueron más bajas en la cohorte prospectiva (4,8% frente a 0,6%, p = 0,019). En el grupo prospectivo ocurrieron 36 episodios de hemorragia, 26 (7,2%) fueron dados de alta con rivaroxaban, 8 (9,9%) fueron dados de alta con otros anticoagulantes y 2 (3,7%) sin anticoagulación posoperatoria. Los casos de hemorragia mayor fueron del 1,1% (4/363) en el grupo de rivaroxabán y cada uno requirió intervención.LIMITACIONES:Limitado a una sola institución y no incluyó un grupo de placebo.CONCLUSIONES:Entre los pacientes con enfermedad inflamatoria intestinal y cáncer colorrectal, la profilaxis extendida con dosis bajas de rivaroxabán condujo a una disminución significativa de los eventos tromboembólicos posteriores al alta, con un perfil de riesgo de hemorragia bajo. (Traducción-Dr. Fidel Ruiz Healy)., (Copyright © The ASCRS 2023.)

Objective: There is a lack of consensus regarding the optimal approach for patients with full-thickness rectal prolapse. The aim of this international survey was to assess the patterns in treatment of rectal prolapse., Design: A 23-question survey was distributed to the Pelvic Floor Consortium of the American Society of Colorectal Surgeons, the Colorectal Surgical Society of Australia and New Zealand, and the Pelvic Floor Society. Questions pertained to surgeon and practice demographics, preoperative evaluation, procedural preferences, and educational needs., Setting: Electronic survey distributed to colorectal surgeons of diverse practice settings., Participants: 249 colorectal surgeons responded to the survey, 65% of which were male. There was wide variability in age, years in practice, and practice setting., Main Outcome Measures: Responses to questions regarding preoperative workup preferences and clinical scenarios., Results: In preoperative evaluation, 19% would perform anorectal physiology testing and 70% would evaluate for concomitant pelvic organ prolapse. In a healthy patient, 90% would perform a minimally invasive abdominal approach, including ventral rectopexy (56%), suture rectopexy (31%), mesh rectopexy (6%) and resection rectopexy (5%). In terms of ventral rectopexy, surgeons in the Americas preferred a synthetic mesh (61.9% vs 38.1%, p=0.59) whereas surgeons from Australasia preferred biologic grafts (75% vs 25%, p<0.01). In an older patient with comorbidities 81% would perform a perineal approach. Procedure preference (Delormes vs Altmeier) varied according to location (Australasia, 85.9% vs 14.1%; Europe, 75.3% vs 24.7%; Americas, 14.1% vs 85.9%). Most participants were interested in education regarding surgical approaches, however there is wide variability in preferred methods., Conclusion: There is significant variability in the preoperative evaluation and surgery performed for rectal prolapse. Given the lack of consensus, it is not surprising that most surgeons desire further education on the topic., Competing Interests: Competing interests: BG has speaking disclosures for Intuitive. ARLS has speaking disclosures for Intuitive, Cook Biotech, and Stryker. JKK, ERH, and JWO have no competing interests to disclose., (© Author(s) (or their employer(s)) 2023. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Background: Post-hemorrhoidectomy bleeding is a serious complication after hemorrhoidectomy. In the setting of a new wave of anticoagulants, we aimed to investigate the relationship of post-operative anticoagulation timing and delayed bleeding., Methods: We performed a retrospective analysis of all patients undergoing hemorrhoidectomy at a single institution over a 10-year period. Fisher's exact and Wilcoxon Rank Sum tests were utilized to test for association between delayed bleeding and anticoagulation use., Results: Between January 2011 and October 2020, 1469 hemorrhoidectomies were performed. A total of 216 (14.7%) were taking platelet inhibitors and 56 (3.8%) other anticoagulants. Delayed bleeding occurred in 5.2% (n = 76) of which 47% (n = 36) required operative intervention. Mean time to bleeding was 8.7 days (SD ±5.9). Time to bleeding was longer in those taking antiplatelet inhibitors vs. non-platelet inhibitors vs. none (11 vs. 8 vs. 7 days, P = .05). Among anticoagulants (n = 56), novel oral anticoagulants were more common than warfarin (57% vs 43%) and had a nonsignificant increase in delayed bleeding (31% vs 16%, P = .21). Later restart (>3 days) of novel anticoagulants after surgery was associated with increased bleeding (10.5% vs 61.5%, P=.005). On multivariable analysis, only anticoagulation use (OR 4.5, 95% CI: 2.1-10.0), male sex (OR 1.8, 95% CI: 1.1-2.9), and operative oversewing (OR 3.5, 95% CI: 1.8-6.9) were associated with delayed bleeding., Conclusion: Post-hemorrhoidectomy bleeding is more likely to occur with patients on anticoagulation. Later restart times within the first week after surgery was not associated with a decrease in bleeding., Competing Interests: Declaration of Conflicting InterestsThe author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Competing Interests: Disclosure: The Disclosure of Potential Conflicts of Interest form is provided with the online version of the article (http://links.lww.com/JBJS/H209).

Background: Chronic pouchitis and Crohn's disease after Ileal pouch anal anastomosis (IPAA) for ulcerative colitis could be a larger issue than previously reported., Methods: All patients receiving care for their IPAA over a 10-year period at a community hospital were included. Primary outcomes were incidence of Crohn's disease and pouchitis., Results: The study included 380 IPAA patients. Indication for pouch creation was either UC (n = 362) or indeterminate colitis (n = 18). Cumulative incidence of Crohn's was 19.5%. Five-, 10- and 20-year incidence of Crohn's was 3.4%, 8.4% and 16.9%. Chronic pouchitis occurred in 28.7%. Mean time to pouchitis and Crohn's diagnosis was 8.4 (SD ± 8.0) and 11.6 (SD ± 7.5) years. Pouch failure occurred in 12.4%. Patients who developed Crohn's were more likely to suffer pouchitis and pouch failure (OR 3.5, 95%CI 2.0-6.0 and 5.3, 95%CI 2.8-10.1)., Conclusion: During long term follow up, almost 20% are diagnosed with Crohn's contributing significantly to pouch failure., (Copyright © 2022 Elsevier Inc. All rights reserved.)

Purpose: Elevated CRP has been associated with infectious complications after colorectal surgery but has not been evaluated in a prospective fashion as part of a discharge checklist. The objective of this study was to evaluate the effectiveness of a multi-component "discharge criteria checklist" that included daily use of CRP in decreasing hospital readmission rates after colorectal surgery., Methods: This is a prospective before and after study design that included consecutive patients undergoing major colorectal operations at a single university-affiliated community hospital over a 2-year period. The primary outcome was inpatient or emergency department readmission after 30 days. Selected pre- and peri-operative factors associated with readmissions were then examined in a multivariate analysis model., Results: The study included a total of 1546 patients. Surgical indications were inflammatory bowel disease (15%), colorectal cancer (24%), and benign disease (60%); 9.5% were emergencies. The readmission rates for each group were similar, 17.3% and 17.0%, for the control and discharge checklist groups, respectively (p=0.88). On multivariate analysis of the discharge checklist group dataset, only age, sex, surgical acuity and operating time were statistically significant risk factors. The difference of median CRP values on the day of discharge of those readmitted compared to those not readmitted (35 vs 32 mg/L) was not statistically significant (p=0.28)., Conclusions: The institution of a "discharge checklist" did not impact post-operative hospital readmissions. Not only were readmissions unchanged by the use of a CRP threshold at discharge, but CRP levels at the time of discharge were not associated with readmissions.

Background: Circular staplers perform a critical function for creation of anastomoses in colorectal surgeries. Powered stapling systems allow for reduced force required by surgeons to fire the device and may provide advantages for creating a secure anastomosis. The objective of this study was to evaluate the clinical performance of a novel circular powered stapler in a post-market setting, during left-sided colectomy procedures., Materials and Methods: Consecutive subjects underwent left-sided colorectal resections that included anastomosis performed with the ECHELON CIRCULAR™ Powered Stapler (ECP). The primary endpoint was the frequency in which a stapler performance issue was observed. Secondary endpoints included evaluation of ease of use of the device via a surgeon satisfaction questionnaire, and monitoring/recording of procedure-related adverse events (AEs)., Results: A total of 168 anastomoses were performed with the ECP. Surgical approaches included robotic-assisted (n = 74, 44.0%), laparoscopic (n = 71, 42.3%), open (n = 20, 11.9%), and hand-assisted minimally invasive (n = 3, 1.8%) procedures. There were 22 occurrences of device performance issues in 20 (11.9%) subjects during surgery. No positive intraoperative leak tests were observed, and only 1 issue was related to a procedure-related AE or surgical complication, which was an instance of incomplete surgical donut necessitating re-anastomosis. Postoperative anastomotic leaks were experienced in 4 (2.4%) subjects. Clavien-Dindo classification of all AEs indicated that 92.0% were Grades I or II. Participating surgeons rated the ECP as easier to use compared to previously used manual circular staplers in 85.7% of procedures., Conclusion: The circular powered stapler exhibited few clinically relevant performance issues, an overall favorable safety profile, and ease of use for creation of left-sided colon anastomoses., (Copyright © 2020 IJS Publishing Group Ltd. Published by Elsevier Ltd. All rights reserved.)

Background: Chronic opioid use in the United States is a well-recognized public health concern with many negative downstream consequences. Few data exist regarding the use of preoperative opioids in relation to outcomes after elective colorectal surgery., Objective: The purpose of this study was to determine if chronic opioid use before colorectal surgery is associated with a detriment in postoperative outcomes., Design: This is a retrospective review of administrative data supplemented by individual chart review., Setting: This study was conducted in a single-institution, multisurgeon, community colorectal training practice., Patients: All patients undergoing elective colorectal surgery over a 3-year time frame (2011-2014) were selected., Main Outcome Measures: Opioid use was stratified based on total dose of morphine milligram equivalents (naive, sporadic use (>0-15 mg/day), regular use (>15-45 mg/day), and frequent use (>45 mg/day)). Primary outcomes were surgical site infections, length of hospital stay, and readmissions., Results: Of the 923 patients, 23% (n = 213) were using opioids preoperatively. The preoperative opioid group contained more women (p = 0.047), underwent more open surgery (p = 0.003), had more nonmalignant indications (p = 0.013), and had a higher ASA classification (p = 0.003). Although median hospital stay was longer (4.7 days vs 4.0, p < 0.001), there was no difference in any surgical site infections (10.3% vs 7.1%, p = 0.123) or readmissions (14.2% vs 14.1%, p=0.954). Multivariable analysis identified preoperative opioid use (17.0% longer length of stay; 95% CI, 6.8%-28.2%) and ASA 3 or 4 (27.2% longer length of stay; 95% CI, 17.1-38.3) to be associated with an increase in length of stay., Limitations: Retrospectively abstracted opioid use and small numbers limit the conclusions regarding any dose-related responses on outcomes., Conclusions: Although preoperative opioid use was not associated with an increased rate of surgical site infections or readmissions, it was independently associated with an increased hospital length of stay. Innovative perioperative strategies will be necessary to eliminate these differences for patients on chronic opioids. See Video Abstract at http://links.lww.com/DCR/B280. EFECTOS DEL CONSUMO CRÓNICO DE OPIOIDES EN EL PREOPERATORIO CON RELACIÓN A LAS INFECCIONES DE LA HERIDA QUIRÚRGICA, LA DURACIÓN DE LA ESTADÍA Y LA READMISIÓN: El consumo crónico de opioides en los Estados Unidos es un problema de salud pública bien reconocido a causa de sus multiples consecuencias negativas ulteriores. Existen pocos datos sobre el consumo de opioides en el preoperatorio relacionado con los resultados consecuentes a una cirugía colorrectal electiva.El propósito es determinar si el consumo crónico de opioides antes de la cirugía colorrectal se asocia con un detrimento en los resultados postoperatorios.Revisión retrospectiva de datos administrativos complementada por la revisión de un gráfico individual.Ejercicio durante la formación de multiples residentes en cirugía colorrectal enTodos los pacientes de cirugía colorrectal electiva durante un período de 3 años (2011-2014).El uso de opioides se estratificó en función de la dosis total de equivalentes de miligramos de morfínicos (uso previo, uso esporádico [> 0-15 mg / día], uso regular (> 15-45 mg / día) y uso frecuente (> 45 mg / día)). Los resultados primarios fueron las infecciones de la herida quirúrgica, la duración de la estadía hospitalaria y la readmisión.De los 923 pacientes, el 23% (n = 213) consumían opioides antes de la operación. El grupo con opioides preoperatorios tenía más mujeres (p = 0.047), se sometió a una cirugía abierta (p = 0.003), tenía mas indicaciones no malignas (p = 0.013) y tenía una clasificación ASA más alta (p = 0.003). Aunque la mediana de la estadía hospitalaria fue más larga (4,7 días frente a 4,0; p <0,001), no hubo diferencia en ninguna infección de la herida quirúrgica (10,3% frente a 7,1%, p = 0,123) o las readmisiones (14,2% frente a 14,1%, p = 0,954). El análisis multivariable identificó que el uso de opioides preoperatorios (17.0% más larga LOS; IC 95%: 6.8%, 28.2%) y ASA 3 o 4 (27.2% más larga LOS; IC 95%: 17.1, 38.3) se asocia con un aumento en LOS.La evaluación retrospectiva poco precisa del consumo de opioides y el pequeño número de casos limitan las conclusiones sobre cualquier respuesta relacionada con la dosis - resultado.Si bien el consumo de opioides preoperatorios no se asoció con un aumento en la tasa de infecciones de la herida quirúrgica o las readmisiones, ella se asoció de forma independiente con un aumento de la LOS hospitalaria. Serán necesarias estrategias perioperatorias innovadoras para eliminar estas diferencias en los pacientes consumidores cronicos de opioides. Consulte Video Resumen en http://links.lww.com/DCR/B280.

Background: Prevention of venous thromboembolism after colorectal surgery remains challenging. National guidelines endorse thromboembolism prophylaxis for 4 weeks after colorectal cancer resection. Expert consensus favors extended prophylaxis after IBD surgery. The actual frequency of prescription after resection remains unknown., Objective: This study aimed to assess prescription of extended, postdischarge venous thromboembolism prophylaxis after resection in Michigan., Design: This is a retrospective review of elective colorectal resections within a statewide collaborative receiving postdischarge, extended-duration prophylaxis., Setting: This study was conducted between October 2015 and February 2018 at an academic center., Patients: A total of 5722 patients (2171 with colorectal cancer, 266 with IBD, and 3285 with other)., Main Outcome Measures: We compared the prescription of extended, postdischarge prophylaxis over time, between hospitals and by indication., Results: Of 5722 patients, 373 (6.5%) received extended-duration prophylaxis after discharge. Use was similar between patients undergoing surgery for cancer (282/2171, 13.0%) or IBD (31/266, 11.7%, p = 0.54), but was significantly more common for both patients undergoing surgery for cancer or IBD in comparison with patients with other indications (60/3285, 1.8%, p < 0.001). Use increased significantly among patients with cancer (6.8%-16.8%, p < 0.001) and patients with IBD (0%-15.1%, p < 0.05) over the study period. For patients with other diagnoses, use was rare and did not vary significantly (1.5%-2.3%, p = 0.49). Academic centers and large hospitals (>300 beds) were significantly more likely to prescribe extended-duration prophylaxis for all conditions (both p < 0.001), with the majority of prophylaxis concentrated at only a few hospitals., Limitations: This study was limited by the lack of assessment of actual adherence, small number of observed venous thromboembolism events, small sample of patients with IBD, and restriction to the state of Michigan., Conclusions: The use of extended-duration venous thromboembolism prophylaxis after discharge is increasing, but remains uncommon in most hospitals. Efforts to improve adherence may require quality implementation initiatives or targeted payment incentives. See Video Abstract at http://links.lww.com/DCR/B193. ANÁLISIS POBLACIONAL DE LA ADHERENCIA A LA PROFILAXIS ANTI-TROMBÓTICA EXTENDIDA (TEV) EN PACIENTES DE ALTA LUEGO DE UNA RESECCIÓN COLORECTAL.: La prevención del tromboembolismo venoso después de cirugía colorrectal sigue siendo un desafío. Las guías nacionales han aprobado la profilaxia del tromboembolismo durante cuatro semanas luego de una resección de cáncer colorrectal. El consenso de expertos favorece la profilaxia extendida solamente después de la cirugía por enfermedad inflamatoria intestinal. La frecuencia real de prescripción después de la resección colorrectal sigue siendo desconocida.Evaluar la prescripción de profilaxia prolongada de tromboembolismo venoso después del alta luego de una resección colorrectal en Michigan.Revisión retrospectiva de las resecciones colorrectales electivas seguidas de una profilaxia de larga duración con el apoyo de todo el estado (MI).Este estudio se realizó entre octubre de 2015 y febrero de 2018 en un solo centro académico.Un universo de 5722 pacientes operados (2171 por cáncer colorrectal, 266 por enfermedad inflamatoria intestinal, 3285 por otros diagnósticos).Se comparó la prescripción de profilaxia prolongada después del alta según la duración, los hospitales y la indicación.De 5722 pacientes, 373 (6.5%) recibieron profilaxia de duración prolongada después del alta. El uso fue similar entre pacientes sometidos a cirugía por cáncer (282/2171, 13.0%) o enfermedad inflamatoria intestinal (31/266, 11.7%, p = 0.54), pero fue significativamente más común para ambos en comparación con pacientes con otras indicaciones (60/3285, 1.8%, p < 0.001). El uso aumentó significativamente entre pacientes con cáncer (6.8% a 16.8% (p < 0.001)) y en pacientes con enfermedad inflamatoria intestinal (0% a 15.1%, p < 0.05) durante el período de estudio. Para pacientes con otros diagnósticos, su utilización fue rara y no varió significativamente (1.5% a 2.3%, p = 0.49). Los centros académicos y los grandes hospitales (>300 camas) tenían mayor probabilidad de prescribir la profilaxia de duración extendida en todas las afecciones (ambas p < 0.001), pero la mayoría de las profilaxis se concentraron el algunos pocos grandes hospitales.Este estudio estuvo limitado por la falta de evaluación de actuales adherentes, por el pequeño número de eventos tromboembólicos venosos observados, por la pequeña muestra de pacientes con enfermedad inflamatoria intestinal y debido a ciertas restricciones en el estado de Michigan.El uso de profilaxia para el tromboembolismo venoso de duración prolongada después del alta está en aumento, pero su uso sigue siendo poco frecuente en la mayoría de los hospitales. Los esfuerzos para mejorar la adherencia al tratamiento pueden requerir iniciativas de mejoría en la calidad o incentivos específicos de reembolso. Consulte Video Resumen en http://links.lww.com/DCR/B193. (Traducción-Dr. Xavier Delgadillo).

Background: As the availability and use of robotic surgery increases, current data suggest comparable outcomes to laparoscopic surgery but at an increased cost. Elective sigmoid resection for diverticular disease is the most common colorectal application of robotic surgery and there is limited comparative data specifically for this indication., Methods: We identified all elective cases of laparoscopic- and robot-assisted surgery for diverticular disease among a practice of 7 colorectal surgeons within an established enhanced recovery protocol. We performed propensity matching based on surgical indications (recurrent disease, ongoing symptoms, or fistula), stoma creation, and body mass index to create a matched cohort. Our primary outcomes were return of bowel function, length of stay, opioid use, and pain scores during the first 72 h postoperatively. Secondary outcomes were operative room and hospital charges., Results: From 2011 to 2016, 69 robotic cases were propensity matched from a group of 222 laparoscopic cases to create a 1:1 case ratio that was equivalent in terms of patient demographics and operative indications. Time to first bowel movement was slightly quicker in the robotic group (1 [1] versus 2 [1.5], P = 0.09), while length of stay (3.5 [1.6] versus 3.6 [1.4] d, P = 0.64) was equivalent. Pain scores were lower in the robotic group on day 0 (4.6 versus 6.1, P = 0.0001), but similar on day 1 and day 2 (4.3 versus 4.1, P = 0.62 and 3.8 versus 3.3, P = 0.19). There was no difference in postoperative 72-h opioid use between groups (110.8 MME [144.5] versus 97.4 MME [101.5], P = 0.70). In the robotic arm operating room charges were slightly more ($2835 ± $394 versus $2196 ± $359, P < 0.0001), but total hospital charges were over significantly increased ($41,159 [$7840] versus $25,761 [$11,689], P < 0.0001)., Conclusions: Via a carefully matched cohort of elective sigmoid resection for diverticular disease at a single community institution, we have demonstrated that laparoscopic- and robotic-assisted surgery result in clinically equivalent return of bowel function, length of stay, postoperative pain, and opioid use., (Copyright © 2019 Elsevier Inc. All rights reserved.)

Purpose: Recurrent diverticulitis has been reported in 30-50% of patients who recover from an episode of diverticular-associated abscess. Our aim was to review the outcomes of patients who underwent non-operative management after percutaneous drainage (PD) of colonic diverticular abscess., Methods: All patients with a diverticular-associated abscess were identified between 2001 and 2012. Individual charts were queried for peri-procedural data and follow-up. The most recent follow-up data were acquired via the electronic medical record or telephone call., Results: A total of 165 patients underwent PD of diverticular-associated abscesses. Abscess locations were pelvic (n = 122), abdominal (n = 36), and both (n = 7), while median abscess size was 6.1 ± 2.2 cm. One hundred eighteen patients clinically improved following non-operative management, and 81 of these patients did not undergo subsequent colonic resection within 4 months of PD. Of these, 8 died within 12 months. Among the remaining 73 patients, there were no significant differences in demographics or abscess variables compared to those who underwent elective surgery within 4 months. Only 7 of 73 patients had documented episodes of recurrences, while 22 patients later had elective surgery (1.1 ± 1.2 years from the index case). Five-year colectomy-free survival was 55% (95%CI 42-66%), while the recurrence-free survival at 5 years was 77% (95%CI 65-86%). All recurrences were managed non-operatively initially and one patient went on to have elective resection., Conclusion: A sizable number of patients successfully recover from complicated diverticulitis following PD. Subsequent non-operative management carries an acceptable risk for recurrent episodes and may be considered as a reasonable management option.

Background: Accurate preoperative prediction of lymph node status would be a revolutionary adjunct in treating colorectal cancer. The immunohistochemical marker CD10 has been suggested recently to have a predictive capacity for lymph node involvement in colorectal cancer., Objective: The aim of our study was to evaluate the relationship between the presence of the CD10 molecular marker and lymph node metastasis in a US patient population using previously banked colorectal cancer specimens., Design: This was a retrospective study., Settings: The study was conducted at a single academic institution., Patients: Included were specimens from 191 patients, with cancer stages ranging from T1N0 to T3N2., Main Outcome Measures: The relationship between CD10 and different clinicopathologic parameters was assessed, as well as the ability to predict lymph node metastasis by itself and in conjunction with lymphovascular invasion., Results: CD10 was significantly correlated with left-sided colon cancers (p = 0.01) and the presence of mucinous histology and had a relatively high specificity (75.7%) for lymph node metastasis. CD10 did not correlate with lymph node status (p = 0.33) or enhance the ability of lymphovascular invasion to predict lymphatic metastasis in our patient population. Sensitivity and specificity of lymphovascular invasion alone for lymph node metastasis were 62.8% and 93.6%, whereas adding CD10 status resulted in a sensitivity of 70.6% and specificity of 69.3%. Multivariate analysis revealed only lymphovascular invasion as a predictor of lymph node metastasis in our patient population., Limitations: This study was primarily limited by its small sample size and retrospective nature., Conclusions: In our patient population, CD10 status was not significantly associated with lymph node metastasis, and it was no better than lymphovascular invasion alone when predicting lymph node status.

Adolescent idiopathic scoliosis (AIS) is a clinically significant disorder with high heritability that affects 2-4% of the population. Genome-wide association studies have identified LBX1 as a strong susceptibility locus for AIS in Asian and Caucasian populations. Here we further dissect the genetic association with AIS in a Caucasian population. To identify genetic markers associated with AIS we employed a genome-wide association study (GWAS) design comparing 620 female Caucasian patients who developed idiopathic scoliosis during adolescence with 1,287 ethnically matched females who had normal spinal curves by skeletal maturity. The genomic region around LBX1 was imputed and haplotypes investigated for genetic signals under different inheritance models. The strongest signal was identified upstream of LBX1 (rs11190878, P(trend) = 4.18 × 10(-9), OR = 0.63[0.54-0.74]). None of the remaining SNPs pass the genome-wide significance threshold. We found rs11190870, downstream of LBX1 and previously associated with AIS in Asian populations, to be in modest linkage disequilibrium (LD) with rs11190878 (r(2) = 0.40, D' = 0.81). Haplotype analysis shows that rs11190870 and rs11190878 track a single risk factor that resides on the ancestral haplotype and is shared across ethnic groups. We identify six haplotypes at the LBX1 locus including two strongly associated haplotypes; a recessive risk haplotype (TTA, Control(freq) = 0.52, P = 1.25 × 10(-9), OR = 1.56), and a co-dominant protective haplotype (CCG, Control(freq) = 0.28, P = 2.75 × 10(-7), OR = 0.65). Together the association signals from LBX1 explain 1.4% of phenotypic variance. Our results identify two clinically relevant haplotypes in the LBX1-region with opposite effects on AIS risk. The study demonstrates the utility of haplotypes over un-phased SNPs for individualized risk assessment by more strongly delineating individuals at risk for AIS without compromising the effect size.

Purpose: Laparoscopic ventral mesh rectopexy (LVR) is an emerging technique for selected patients with rectal prolapse and obstructed defaecation syndrome. Data are insufficient to conclude which type of mesh affords the greatest benefit. Our aim was to compare the outcomes of LVR using a non-cross-linked biologic versus a permanent mesh., Methods: Twenty nine cases of LVR with permanent mesh were matched based on age and surgical indication with an equal number of patients using biologic mesh. Cases were retrospectively reviewed from a prospectively maintained database. Symptom resolution, patient satisfaction and recurrence of prolapse were measured among those who underwent LVR with either a biologic (Biodesign(®), Cook Medical) or polypropylene mesh., Results: Age, American Society of Anesthesiologists (ASA) class, surgical indication and primary symptoms were not different between the two groups. After a median follow-up of 15.4 months, all patients reported being either completely or partially satisfied. Rates of complete or partial symptom resolution (p = 0.26) or satisfaction (p = 0.27) did not differ between groups. After LVR, similar rates of additional procedures were performed in the biologic (21 %) and the permanent (28 %) mesh group. Among patients with full-thickness prolapse (n = 33), there were five cases (15 %) of recurrence, one in the biologic group and four in the permanent mesh group (p = 0.37). There were no mesh-related complications in either group., Conclusions: LVR using a non-cross-linked biologic mesh appears to have comparable rates of symptom improvement and patient satisfaction in the short term. Longer follow-up will be required to determine if prolapse recurrence depends on mesh type.

Aim: Laparoscopic ventral rectopexy (LVR) is a non-resectional technique for selected patients with full-thickness rectal prolapse and obstructed defaecation syndrome. Despite its challenges, LVR can be performed with relatively minimal patient trauma thus creating the potential for same-day discharge. Our aim was to assess the safety of day-case LVR and identify factors associated with same-day discharge., Method: Data were prospectively collected on all patients (n = 120) from June 2008 to October 2011. Variables included demographics, perioperative details and postoperative course. Primary outcome was length of stay and secondary outcome was symptom improvement at the latest outpatient follow-up. Patients discharged the same day after LVR were compared with those who stayed overnight or longer., Results: Indications included rectocele and internal prolapse (47%), full-thickness rectal prolapse (44%) and other (9%). Mean operative time was 97 min, same-day discharge occurred with 23% (n = 27) and 67% (n = 80) were discharged on postoperative day 1. In terms of complications, 89% had none, 8% minor and 3% major, including one 24-h readmission for pain. Logistic regression identified younger age (P = 0.054) and private insurance status (P < 0.001) as being significantly associated with same-day discharge. Although surgical indication (P < 0.001), no prior hysterectomy (P = 0.012) and use of biological mesh (P = 0.012) had significant association they were probably confounded by age., Conclusion: In selected patients with rectal prolapse or obstructed defaecation, same-day discharge after LVR is feasible and safe. Our analysis identified quicker discharge in the private system with younger patients. Nevertheless, in unselected patients 90% were discharged by the first operative day., (© 2013 The Authors Colorectal Disease © 2013 The Association of Coloproctology of Great Britain and Ireland.)

Objective: The objective of this study is to identify rates and factors associated with permanent diversion following restorative proctosigmoidectomy for rectal cancer when complicated by an anastomotic leak., Design: This study is a retrospective review., Setting: The setting of this study is a tertiary referral hospital, Patients: Patients involved in this study were those who underwent restorative rectal cancer surgery from 1997 through 2008 identified from an institutional cancer database., Interventions: No interventions were performed in this study., Main Outcome Measures: Factors associated with time to ostomy closure and rates of permanent diversion following anastomotic leaks, Results: One hundred and thirty patients (mean age 59.7 years) were identified, 111 (85%) of whom had stoma diversion at the index surgery. Asymptomatic occult radiological leaks occurred in 52 patients (40%). Seventy-eight patients (60%) underwent ultimate ostomy closure at a median time of 6.3 months after the index surgery, which was not significantly affected by previous radiotherapy (p = 0.08). Twelve patients (9%) underwent anastomotic reconstruction. Pathologic stage II or greater (OR 4.42; 1.95-10.04), symptomatic presentation (OR 4.13; 1.86-9.19) and anastomotic disruption >5 mm (OR 4.42; 2.01-9.74) were independently associated with permanent diversion. Among all survivors, 33% did not have their ostomy reversed. Stoma diversion constructed after leak detection in 19 patients (15%) did not affect permanent stoma rate (OR 0.86; 0.31-2.34) or time to stoma closure (p = 0.29)., Conclusions: The majority of anastomotic leaks after restorative rectal cancer surgery can be salvaged without anastomotic reconstruction. However, in one third of the patients, an anastomotic leak results in a permanent stoma.

Study Design: Genetic association study investigating the association of genetic markers of melatonin signaling and biosynthesis with adolescent idiopathic scoliosis (AIS)., Objective: To determine whether gene polymorphisms related to the melatonin signaling or biosynthesis pathways are associated with AIS., Summary of Background Data: Data have been published on the potential role of gene polymorphisms for melatonin receptor (MTNR) 1B in predicting AIS. Other genes in the melatonin pathways have been tested for association with AIS., Methods: The following genes involved in melatonin synthesis were evaluated herein: tryptophan 5-hyroxylase 1 (TPH1), serotonin N-acetyltransferase (SNAT), and hydroxyindoleo-methyltransferase (HIOMT). In addition, proteins involved in melatonin signaling were also included in this study: MTNR1A, MTNR1B, and protein kinase C delta (PKCd). High throughput microarray-based single nucleotide polymorphism (SNP) genotyping was performed for these seven genes using DNA samples from 589 AIS subjects and 1533 ethnically matched controls. Chi-square analyses of allele frequency between AIS cases and controls were performed and odds ratios were calculated for all SNP markers., Results: Three SNPs were tested for both MTNR1A and HIOMT, 4 for TPH1 and SNAT, 12 for PKCd, and 7 for MTNR1B. The minor allele frequencies were not significantly different between AIS cases and controls. No association was thus found between AIS and the investigated SNPs., Conclusions: Genetic polymorphisms associated with either melatonin synthesis or its signaling pathway are unlikely to be commonly associated with AIS.

Study Design: Validation of a prognostic DNA marker panel., Objective: The goals of this study were to develop and test the negative predictive value of a prognostic DNA test for adolescent idiopathic scoliosis (AIS) and to establish clinically meaningful endpoints for the test., Summary of Background Data: Clinical features do not adequately predict which children diagnosed with minimal or mild AIS will have the progressive form of the disease; genetic markers associated with curve progression might offer clinically useful prognostic insights., Methods: Logistic regression was used to develop an algorithm to predict spinal curve progression incorporating genotypes for 53 single nucleotide polymorphisms and the patient's presenting spinal curve (Cobb angle). Three cohorts with known AIS outcomes were selected to reflect intended-use populations with various rates of AIS progression: 277 low-risk females representing a screening cohort, 257 females representing higher risk patients followed at referral centers, and 163 high risk males. DNA was extracted from saliva, and genotypes were determined using TaqMan assays. AIS Prognostic Test scores ranging from 1 to 200 were calculated., Results: Low-risk scores (<41) had negative predictive values of 100%, 99%, and 97%, respectively, in the tested populations. In the risk model, we used cutoff scores of 50 and 180 to identify 75% of patients as low-risk (<1% risk of progressing to a surgical curve), 24% as intermediate-risk, and 1% as high-risk., Conclusion: Prognostic testing for AIS has the potential to reduce psychological trauma, serial exposure to diagnostic radiation, unnecessary treatments, and direct and indirect costs-of-care related to scoliosis monitoring in low-risk patients. Further improvements in test performance are expected as the optimal markers for each locus are identified and the underlying biologic pathways are better understood. The validity of the test applies only to white AIS patients; versions of the test optimized for AIS patients of other races have yet to be developed.

In the first part of this 2-part historical review, the authors outlined the early diagnostic and therapeutic strategies used in the management of spinal deformity. In this second part, they expand upon those early innovations and further detail the advances from 1990 to the modern era.

Hunter syndrome is a rare, X-linked disorder caused by a deficiency of the lysosomal enzyme iduronate-2-sulfatase. In the absence of sufficient enzyme activity, glycosaminoglycans accumulate in the lysosomes of many tissues and organs and contribute to the multisystem, progressive pathologies seen in Hunter syndrome. The nervous, cardiovascular, respiratory, and musculoskeletal systems can be involved in individuals with Hunter syndrome. Although the management of some clinical problems associated with the disease may seem routine, the management is typically complex and requires the physician to be aware of the special issues surrounding the patient with Hunter syndrome, and a multidisciplinary approach should be taken. Subspecialties such as otorhinolaryngology, neurosurgery, orthopedics, cardiology, anesthesiology, pulmonology, and neurodevelopment will all have a role in management, as will specialty areas such as physiotherapy, audiology, and others. The important management topics are discussed in this review, and the use of enzyme-replacement therapy with recombinant human iduronate-2-sulfatase as a specific treatment for Hunter syndrome is presented.

Objectives: Describe the type-specific prevalence of anal HPV infection in women with lower genital tract intraepithelial neoplasia and cancer. Describe the prevalence of abnormal anal cytology and identify risk factors for anal HPV infection and abnormal anal cytology in this population., Methods: We performed a cross-sectional study of women attending 2 university-based colposcopy clinics with high-grade lower genital tract intraepithelial neoplasia or cancer. Participants received anal HPV testing/typing, anal cytology and completed a questionnaire detailing medical history and sexual behavior., Results: Of the 102 women enrolled, 92 (90%) had adequate beta-globin for analysis of HPV DNA status, and 47/92 women (51%) had detectable anal HPV. Of the 15 HPV types identified, 9 (60%) were oncogenic types and 6 (40%) were non-oncogenic or undetermined risk types. Overall, 9 women (9%) had abnormal anal cytology, and 7 of those had corresponding anal intraepithelial neoplasia grade I (AIN I). Women with vulvar disease had the highest proportion of abnormal anal cytology (21%) compared to women with cervical disease alone (7%), but this difference was not statistically significant (p=0.10). Neither anal HPV infection nor abnormal cytology was significantly associated with anal sex practices, smoking or number of sexual partners., Conclusions: Anal infection with high-risk HPV types is common in women with high-grade genital neoplasia, but was not associated with known risk factors for genital HPV infection. Other unidentified risk factors may play a role in the anal HPV infection in this population. Abnormal anal cytology was rare and larger studies are needed to identify risk factors associated with abnormal cytology and anal intraepithelial neoplasia in this population.

Anorectal procedures are associated with significant morbidity and include complications of the perineum, which can cause substantial difficulty for the patient. Prevention of perineal complications is key, but many anorectal procedures are performed in difficult situations such as large bulky tumors or inflammatory bowel diseases. In this review, the authors outline many of the complications encountered following both simple and complex anorectal procedures while highlighting best evidence for treatment.

Purpose: A notable increase in-hospital admissions for Clostridium difficile colitis has occurred in the United States. In this paper we evaluate changes in the epidemiology of Clostridium difficile colitis in a subset of hospitalized patients with inflammatory bowel diseases., Methods: A retrospective cohort analysis was conducted for all inflammatory bowel disease patients with Clostridium difficile colitis in the Nationwide Inpatient Sample, a 20 percent stratified random sample of national hospital discharge abstracts from 1993 through 2003. Using standard diagnostic codes, we identified yearly admissions for Clostridium difficile, other bacterial infections, and parasitic infections in inflammatory bowel disease patients. Next, we calculated prevalence, case fatality, and operative mortality for inflammatory bowel disease patients diagnosed with Clostridium difficile., Results: We found that the prevalence of Clostridium difficile rose significantly in patients with ulcerative colitis and in those Crohn's disease patients with some component of large bowel involvement but not in patients with Crohn's disease limited to the small bowel alone. During the study period, case fatality also rose significantly in patients with ulcerative colitis and Clostridium difficile but not in patients with Crohn's disease and Clostridium difficile. Operative mortality for ulcerative colitis patients with Clostridium difficile reached 25.7 percent., Conclusions: The prevalence and case fatality of patients with inflammatory bowel disease and Clostridium difficile rose significantly during the study period. Changes in Clostridium difficile epidemiology were particularly noteworthy for those patients with ulcerative colitis, who experienced elevated rates of hospitalization and case fatality.

Background: Although the risk of anal cancer in immunosuppressed individuals is significantly higher than in the general population, methods for detecting precancerous anal dysplasia have not been well studied in solid-organ transplant recipients. We sought to identify the incidence of anal dysplasia in kidney transplant recipients and associated factors that increase the likelihood of dysplasia., Study Design: We prospectively analyzed kidney transplant recipients who had been immunosuppressed for at least 6 months with a functioning allograft. We interviewed willing participants and performed anal cytology sampling and high-resolution anoscopy; if we found microscopic abnormalities, we performed biopsies. We used univariate analysis to measure the association between variables and anal dysplasia., Results: Of the 40 participants, 15 were women and 25 were men; their mean age was 61 years. Their median duration of immunosuppression was 5.6 years; 23 (59%) had fewer than 5 lifetime sexual partners, and 2 (5%) reported ever practicing anal intercourse. Of all cytology specimens, 35 (88%) had sufficient cells for interpretation and 2 (6%) demonstrated dysplasia. We performed biopsies in 11 patients; 6 had dysplasia (4 low-grade, 2 high-grade). Of these patients, five had normal anal cytology. The sensitivity of cytology to predict histologic evidence of dysplasia was 17%. Overall, seven (18%) had dysplasia according to either cytology or histology specimens; two (5%) had high-grade dysplasia. We found no significant associations between the tested variables and the presence of dysplasia., Conclusions: A significant proportion of kidney transplant recipients harbor anal dysplasia. One time anal cytology sampling was not predictive of histologic findings. Although these findings confirm their high risk for dysplasia, a larger sample is required to more accurately quantify risk factors for dysplasia and progression to cancer.

Background: The aim was to measure female sexual function after total proctocolectomy with ileal pouch-anal anastomosis for ulcerative colitis using a validated scoring system and to determine the impact of pouch function on sexual function., Methods: A cross-sectional survey was performed using a modified version of the Female Sexual Function Index (FSFI-m). Measures of pouch function, including the Faecal Incontinence Severity Index, were also evaluated., Results: Of 166 women eligible for inclusion, 90 responded to the questionnaires and 83 of these reported sexual activity. The mean age of the 83 women was 38.4 years and the mean time since pouch formation was 6.2 years. Thirty-nine women (47.0 per cent) had an FSFI-m score of 26 or less, indicating sexual dysfunction. The association between sexual dysfunction and stool leakage interfering with the ability to enjoy sexual activity tended toward significance (P = 0.071), but other measures of pouch function were not associated with sexual dysfunction. Some 55-80 per cent of respondents perceived no change or improved performance in the six domains of sexual function., Conclusion: Almost half of the respondents reported having sexual dysfunction. Although poor pouch function was not identified as an important predictor of sexual dysfunction in this series, larger studies may be required to identify associated prognostic factors clearly., ((c) 2008 British Journal of Surgery Society Ltd. Published by John Wiley & Sons, Ltd.)

Hypothesis: We hypothesized that the recent reduction in procedure volume for coronary artery bypass grafting (CABG) has led to an increase in the in-hospital mortality rate., Design: Hospital discharge data from the Nationwide Inpatient Sample from January 1, 1988, through December 31, 2003., Setting: A 20% random sample of patients admitted to US hospitals., Patients: All patients who underwent CABG or percutaneous transluminal coronary interventions. Facilities performing CABG were assigned to standard volume cutoffs., Main Outcome Measures: Rates of cardiac procedures and the proportion of hospitals meeting standard volume cutoffs, as well as the CABG mortality rate., Results: During our 16-year study period, the rate of CABG increased from 7.2 cases per 1000 discharges in 1988 to 12.2 cases in 1997 but then decreased to 9.1 cases in 2003, while the rate of percutaneous interventions tripled. For CABG, the proportion of high-volume hospitals declined from 32.5% in 1997 to 15.5% in 2003. Despite shifts between high- and low-volume hospitals, the CABG mortality rate steadily declined from 5.4% in 1988 to 3.3% in 2003. Hospitals performing the lowest volume of CABG experienced the largest decrease in the in-hospital mortality rate., Conclusions: Since 1997, CABG volume has declined in the setting of a decrease in in-hospital mortality. A lower mortality rate in the setting of reduced CABG volume is a counterintuitive finding, suggesting that procedure volume is an insufficient predictor of outcome on which to base regionalization strategies.

Study Design: Absolute and relative growth modulation of apical spinal segments were measured during creation and correction of an experimental scoliosis in a goat model., Objective: To differentiate relative and absolute changes in growth on the concavity and convexity of an experimental scoliosis treated with anterior vertebral stapling., Summary of Background Data: The creation and correction of vertebral wedge deformities have been previously described in a rat tail model using external fixation as well as in a goat model using anterior vertebral body stapling., Methods: Progressive, structural, scoliotic curves convex to the right in the thoracic spine were created in 14 Spanish Cross-X female goats using a posterior asymmetric tether. After 7-13 weeks, all tethers were removed, and goats were randomized into stapled (n = 8) and untreated (n = 6) groups. Stapled goats underwent anterior vertebral stapling with 4 shape memory alloy staples (Medtronic Sofamor Danek, Memphis, TN) along the convexity of the maximal curvature. All goats were observed for an additional 7-13 weeks. There were 12 additional goats matched for age, sex, and weight used as growth controls throughout the study. Serial radiographs were used to document progression or correction of the maximal scoliotic deformity, and changes in relative and absolute growth at the apical spinal segment T9-10 (2 adjacent vertebrae and the intervening disc)., Results: All tethered goats had progressive, structural, scoliotic curves of significant magnitude during the tethering period (average 61.4 degrees, range 49 degrees to 73 degrees) (P = 0.001). There was 1 goat from each group eliminated from the study because its apical spinal segment did not match the T9-10 level used to establish normal growth in controls. During the treatment period, stapled goats had a correction of -6.9 degrees (P = 0.03), whereas untreated goats had little change (-1.4 degrees). Apical spinal segment wedging progressed in all tethered goats, from 11.1 degrees to 22.4 degrees, during the tethering period (P = 0.001). During the treatment period, wedging corrected -2.2 degrees (range 22.5 degrees to 20.3 degrees) in the stapled goats but progressed +3.5 degrees (range 22.3 degrees to 25.8 degrees) in the untreated goats (P < 0.05). Apical spinal segment growth in all tethered goats was decreased on the concavity by 78% and increased on the convexity by 33% when compared to growth controls (P < 0.001). During the treatment period, growth on the concavity of the apical spinal segment of the stapled goats was decreased by 10% but increased in the untreated goats by 37% when compared to growth controls. On the convexity, apical spinal segment growth at T9-10 was decreased in the stapled goats by 18% and increased in the untreated goats by 29% when compared to growth controls (P < 0.04)., Conclusions: Data in this study show the ability to modulate relative and absolute growth, according to the Hueter-Volkmann law, at the apical spinal segment of a progressive experimental scoliosis. However, anterior vertebral stapling, although able to control progressive wedging and scoliosis at the apical spinal segment, was not able to reverse fully the Hueter-Volkmann effect.

Study Design: Longitudinal follow-up of animals after a surgically initiated scoliosis., Objective: To create a progressive, structural, idiopathic-type, lordoscoliotic curve convex to the right in the thoracic spine of the immature goat using a flexible posterior asymmetric tether with minimal disruption of the spinal elements along the curve., Summary of Background Data: Our previous work created an experimental scoliosis model using a rigid posterior asymmetric tether to study the safety and efficacy of fusionless scoliosis treatments. Posterior asymmetric tethers, whether rigid or flexible, represent the most reliable method of creating an experimental deformity that approximates idiopathic scoliosis. Although our initial rigid model was unique in creating progressive structural scolioses without violation of the essential spinal elements along the curve, there were a number of shortcomings associated with the model. These included substantially stiff curves and unpredictability of curve progression., Methods: Scoliosis was created in 24 Spanish Cross X female goats (age, 6-8 weeks; weight, 8-12 kg) using a braided synthetic ligament as a left posterior asymmetric tether from T5 to L1. Convex rib resection and concave rib tethering from ribs 8 to 13 were performed without disruption of the spinal elements before tensioning of the posterior tether. All goats were followed over an 8-week period with serial radiographs to document progression of the deformity. At the end of 8 weeks, the 20 goats with progressive curves were randomized into treatment groups for a separate study. However, 6 of these 20 remained untreated in the subsequent study and, therefore, were followed for an additional 12 to 16 weeks., Results: There were two deaths in the early postoperative period due to pulmonary complications. Of the remaining 22 goats, 20 (91%) developed progressive, structural, idiopathic-type, lordoscoliotic curves convex to the right in the thoracic spine. Initial scoliosis after tethering measured 55.4 degrees on average (range, 37 degrees-75 degrees) and progressed to 74.4 degrees on average (range, 42 degrees-93 degrees) over 8 weeks. The average progression of 19.0 degrees (range, 5 degrees-33 degrees) was statistically significant (P < 0.001). The average initial lordosis after tethering measured -18.9 degrees (range, -13 degrees to -27 degrees) and progressed to -40.7 degrees on average (range, -28 degrees to -56 degrees) over 8 weeks. The average progression in lordosis of -21.8 degrees (range, -5 degrees to -43 degrees) was significant (P < 0.001)., Conclusions: This study demonstrated the effectiveness of a flexible posterior asymmetric tether in creating idiopathic-type deformities in a shorter tethering period than previously described. With substantial remaining spinal growth after the 8-week tethering period and preservation of the essential spinal elements in an undisturbed state, this model is suitable for the study of scoliosis progression and various fusionless scoliosis treatment methods.

Study Design: Wedging of apical spinal segments was measured during creation and correction of an experimental scoliosis in a goat model., Objectives: To create and correct apical vertebral wedge deformities in a progressive experimental scoliosis model by purely mechanical means., Summary of Background Data: The creation and correction of vertebral wedge deformities has been previously described in a rat tail model using external fixation., Methods: Experimental scoliosis was created in 14 goats using a posterior asymmetric tether with convex rib resection and concave rib tethering. After a period of up to 13 weeks, all tethers were removed and goats were randomized into treated (n = 8) and untreated (n = 6) groups. Treated goats underwent anterior thoracic stapling with four shape memory alloy staples along the convexity of the maximal curvature. Goats were followed for an additional 7 to 13 weeks during treatment. Serial radiographs were used to document progression or correction of the maximal scoliotic deformity as well as to measure the wedging of the apical spinal segment (two adjacent vertebrae and the intervening disc)., Results: During the tethering period, all goats achieved a progressive, structural, lordoscoliotic curve of significant magnitude (mean: 61 degrees, range: 49 to 73 degrees). Wedging of the apical spinal segment measured 11.1 degrees at the beginning and 22.4 degrees at the end of the tethering period. The increase in apical spinal segment wedging of +11.3 degrees (10.7 degrees vertebral/0.6-degree disc) was significant (P = 0.001). During the treatment period, the scoliosis in the stapled goats measured 56.8 degrees at the beginning and 43.4 degrees at the end for an average correction of -13.4 degrees (range: 0 to-22 degrees) (P = 0.001), whereas the untreated goats measured 67.0 degrees at the beginning and 59.8 degrees at the end for an average correction of -7.2 degrees (range: +7 to -21 degrees) (P = 0.19). Additionally, wedging of the apical spinal segment in the stapled goats measured 22.5 degrees at the beginning and 20.3 degrees at the end for an average correction of -2.2 degrees (-0.6 degrees vertebral/-1.6-degree disc); wedging of the apical vertebral segment in the untreated goats measured 22.3 degrees at the beginning and 25.8 degrees at the end of the treatment period for an average progression of +3.5 degrees (3.5 degrees vertebral/0.0-degree disc). The difference in apical spinal segment correction versus progression in the stapled (-2.2 degrees) versus control (+3.5 degrees) goats was significant (P < 0.05)., Conclusions: This study demonstrates the ability to create wedge deformities at the apex of an experimental scoliosis in a large animal model and to control the progression of these deformities using anterior thoracic staples.

Study Design: A cohort of 145 patients with adolescent idiopathic scoliosis (AIS) were identified and contacted to determine whether they had a family history of scoliosis. These results were submitted to an internal genealogical database to screen for potential connections to other AIS families. The severity and incidence of AIS in extended family groups were also analyzed., Objectives: Our objectives were to quantify the genetic effect in AIS, determine the expressivity and penetrance of AIS in large family groupings, and examine larger scoliosis pedigrees for evidence of multiple genes., Summary of Background Data: Previous reports have suggested an 80% connectedness among scoliosis families, but no clear evidence of multiple genes. It is not known if there are major gene(s)., Methods: A cohort of 145 AIS probands were identified and contacted to ascertain whether they had a family history of AIS. Their medical records and spine radiographs were reviewed to confirm the diagnosis and determine the disease severity. Using an internal genealogical database, the cases were screened for potential connections that would produce larger extended pedigrees., Results: Overall, 131 of the probands were in the database and 127 showed connections to other scoliosis families, a 97% connectedness. These results suggest a major scoliosis gene, as more than 50% of the probands were connected by founders that all resided in England in the mid 1500s. The differences in penetrance (41% vs. 34%) and expressivity (38% vs. 61%) between seemingly unrelated large family groupings might suggest that two different genes are a major influence for AIS in these families., Conclusions: Nearly all (97%) AIS patients have familial origins. There appears to be at least one major gene, and the differences in penetrance and expressivity in two large unconnected pedigrees might suggest the presence of more than one gene.

Study Design: Experimental scoliosis was created and subsequently corrected in goats. The 3-dimensional (3-D) effects of the treatments were analyzed., Objective: To analyze the 3-D effect of 2 different fusionless scoliosis treatment techniques on an experimental idiopathic-type scoliosis using plain radiographs and computerized tomography., Summary of Background Data: Scoliosis is a complex 3-D spinal deformity with limited treatment options. By preserving growth, motion, and function of the spine, fusionless scoliosis surgery provides theoretical advantages over current forms of treatment., Methods: Scoliosis was created in 24 Spanish cross-X female goats using a flexible, left posterior asymmetric tether from the T5 to L1 laminae, with convex rib resection and concave rib tethering from T8 to T13. After 8 weeks of posterior tethering, goats were randomized into 3 treatment groups: group 1, no treatment; group 2, anterior-shape memory alloy staple; and group 3, anterior ligament tether with bone anchor. The 6 levels of maximal curvature were instrumented in groups 2 and 3. All goats were observed for an additional 12-16 weeks. Serial radiographs and computerized tomography were used to document progression/correction of coronal, sagittal, and transverse plane deformities throughout the study., Results: There were 20 goats that had progressive, structural, idiopathic-type, lordoscoliotic curves convex to the right in the thoracic spine over the 8-week tethering period. An overall deformity score equaling the sum of the scoliosis, lordosis, and axial rotation measurements was calculated for each goat at 3 times., Conclusion: The data in this study show the ability of a ligament tether attached to a bone anchor to correct scoliosis modestly in the coronal plane, but not in the sagittal or transverse plane. In addition, although a significant decrease in the deformity score was shown initially in this group (P < 0.001), the effect was lost over time. The final deformity in the bone anchor/ligament tether group wassignificantly less than either the stapled or untreated groups (P < 0.03). Further study is warranted to provide a better understanding of the 3-D effects of fusionless scoliosis treatments.

Study Design: Review article of current knowledge of animal models used in the investigations of fusionless scoliosis surgery., Objective: To provide a summary of available data on animal studies in the area of fusionless scoliosis surgery., Summary of Background Data: Fusionless scoliosis surgery is an emerging treatment for patients with idiopathic scoliosis as it offers theoretical advantages over current forms of treatment. These advantages include correction of spinal deformity while preserving growth, motion, and function of the spine., Methods: Literature review of animal models used in the investigation of fusionless scoliosis surgery., Results: At present, the theoretical advantages of fusionless scoliosis surgery in the treatment of idiopathic scoliosis are unproven clinically. However, investigations using animal models have demonstrated promise for this new form of treatment. These studies have demonstrated the safety and efficacy of a variety of fusionless scoliosis implants in treating experimental scoliosis and in modulating spinal growth., Conclusion: Fusionless scoliosis surgery offers theoretical advantages over brace treatment and surgery. Like bracing, fusionless treatments preserve growth, motion, and function of the spine. Like surgery, these treatments offer substantial correction of deformity. However, minimally invasive fusionless scoliosis surgery is less extensive than fusion surgery and may avoid adjacent segment degeneration and other complications related to fusion. Additional investigations are required to identify optimal implant strategies, to evaluate the effects of these implants of the spine and surrounding structures, and to define the appropriate patient population for these interventions.

Study Design: Selected references are cited to illustrate the current status of approaches to surgical complications in isthmic spondylolisthesis surgery., Objective: To minimize untoward events and outcomes in the surgical treatment of spondylolisthesis, an awareness of complications and pitfalls specific to spondylolisthesis surgery is necessary., Summary of Background Data: Pseudarthrosis is the most common complication, and factors that contribute are vertebral geometry, bone grafting options and technique, and immobilization with instrumentation constructs or an orthosis. There has been an increase in neurologic deficits associated with spondylolisthesis surgery during the period of 1996 to 2002. Neurologic sequelae can include cauda equina syndrome, root lesions, autonomic dysfunction, and chronic pain. These can result from reduction maneuvers, instrumentation, and after surgery, although neurologic deficit can occur without identifiable causes. Restoring or maintaining the physiologic sagittal contour of the lumbar spine is a necessary component of surgical planning., Methods: Literature review., Results: Problems and complications associated with the surgical treatment of spondylolisthesis are well documented in the medical literature., Conclusions: The occurrence of pseudarthrosis, neurologic deficits, and transition syndromes such as spondylolisthesis acquisita, S1-S2 deformity, and adjacent segment syndrome can be minimized with proper planning and attention to surgical technique.

Objective: Vacuum-assisted wound closure (VAC) exposes the wound bed to negative pressure, resulting in removal of edema fluid, improvement of blood supply, and stimulation of cellular proliferation of reparative granulation tissue. It has been used to treat open wounds in the extremities, open sternal wounds, pressure ulcers, and abdominal wall wounds. This study retrospectively reviewed instrumented spine fusions complicated by surgical wound infection and managed by a protocol including the use of VAC in order to evaluate the efficacy of applying vacuum therapy on patients with deep spine infections and exposed instrumentation., Methods: Twenty consecutive patients with deep wound infections after undergoing spinal fusion procedures were studied. There were 12 men and 8 women with an average age of 55 years (31-81 years). Eight patients had undergone concomitant anterior and posterior arthrodesis, nine patients had a posterior spinal fusion, and three patients had a transforaminal lumbar interbody fusion. Seven patients had a decompression with exposed dura. Sixteen patients presented with a draining wound within the first 6 weeks postoperatively (average 24 days). There were four patients who presented with back pain and temperature after 1 year postoperatively (average 3 years). All patients were taken to the operating room for irrigation and debridement followed by placement of the VAC with subsequent delayed closure of the wound., Results: There was an average of 1.8 (1-8) irrigation and debridement procedures prior to placement of the VAC. Once the VAC was initiated, there was an average of 2.2 (2-3) procedures until and including closure of the wound. The wound was closed an average of 7 days (5-14 days) after the placement of the initial VAC in the wound. All patients tolerated the VAC without adverse effects. All patients were kept on a 6-week course of intravenous antibiotic therapy. The average follow-up was 10 months (6-24 months). There were no cases of uncontrolled sepsis once the VAC was initiated. All patients achieved a clean closed wound without removal of instrumentation at a minimum follow-up of 6 months., Conclusion: VAC therapy is an effective adjunct in closing complex deep spinal wounds with exposed instrumentation.

Study Design: Experimental scoliosis was created in goats and then treated using anterior thoracic stapling., Objective: To correct, without fusion, a progressive idiopathic-type scoliotic deformity in an immature goat model using a shape memory alloy staple., Summary of Background Data: Fusionless scoliosis treatment techniques, using minimally invasive approaches to the anterior thoracic spine, provide theoretical advantages over currently available forms of treatment., Methods: Experimental scoliosis was created in 40 goats using a posterior asymmetric tether with convex rib resection and concave rib tethering for a period of up to 15 weeks. Twenty-seven goats with progressive deformities were used for subsequent study and randomized into 4 treatment groups: group I, anterior thoracic stapling with removal of the posterior tether; group II, removal of the posterior tether only; group III, anterior thoracic stapling with persistent posterior tethering; and group IV, persistent posterior tethering with no treatment. The treatment period lasted an additional 6 to 14 weeks. Staple backout was graded radiographically. After killing the goats, histology and disc biochemistry analyses were conducted., Results: The goats in group I corrected from an initial 57 degrees of curvature to 43 degrees over the duration of the treatment period. Group II goats, which served as a control for group I, corrected from 67 degrees to 60 degrees during the treatment period. Group III goats demonstrated a modest correction from 65 degrees to 63 degrees with the stapling procedure, whereas group IV goats (controls for group III) progressed from 55 degrees to 67 degrees with a persistent posterior tether during the treatment period. The difference between the correction in group III and progression in group IV was statistically significant (P = 0.002). Complications were limited to partial staple backout in 27% of 56 staples., Conclusions: The results of this study support the efficacy of an anterior thoracic staple in correcting moderately severe scoliosis and halting the progression of more malignant scoliosis without fusion in a goat model.

Study Design: Experimental scoliosis was created in an immature goat model., Objectives: To create a progressive, structural, idiopathic-type, lordoscoliotic curve convex to the right in the thoracic spine of the immature goat while maintaining the anterior and posterior elements of the spine along the maximal curve in a pristine state., Summary of Background Data: Progressive scoliotic curves in a small animal model have been created using a posterior asymmetric tether. However, attempts in larger animal models have had less success and typically required violation of the spinal elements., Methods: Scoliosis was created in 40 Spanish Cross X female goats (age 1-2 months, weight 8-12 kg) using a left posterior asymmetric tether from T5 to L1. Convex rib resection and concave rib tethering from T8 to T13 were performed before compression across the rigid construct. Goats were followed over a 6- to 15-week period with serial radiographs to document progression of the deformity., Results: Of the 40 goats that underwent posterior assymetric tethering with rib procedures, 7 (18%) encountered substantial complications (five deaths and two neurologic injuries). Of the 33 available for analysis, 27 goats (82%) developed progressive, structural, idiopathic-type, lordoscoliotic curves in convex to the right in the thoracic spine. All curves demonstrated characteristic radiographic features of idiopathic scoliosis including significant displacement of the apical vertebra from the midline, wedging of both the vertebral bodies and discs, rotation, and decreased flexibility. Initial scoliosis after posterior asymmetric tethering measured 42 degrees on average (range 33-50 degrees ) and progressed to 60 degrees on average (range 44-73 degrees ) over 6 to 15 weeks. The average progression of +18 degrees (range 6-37 degrees ) was statistically significant (P < 0.001)., Conclusions: This study establishes an experimental model for scoliosis that creates progressive, structural, idiopathic-type, lordoscoliotic curves convex to the right in the thoracic spine of the immature goat with high statistical significance (P < 0.001). In addition, this method of experimental scoliosis creation avoids violation of the spinal elements throughout the maximal portion of the curve providing an ideal opportunity subsequent study of the deformity.