https://www.thelancet.com/pdfs/journals/lancet/PIIS0140-6736(05)66545-2.pdf

Short-term endpoints of conventional versus laparoscopic-assisted surgery in patients with colorectal cancer (MRC CLASICC trial): multicentre, randomised controlled trial

https://www.thelancet.com/pdfs/journals/lancet/PIIS0140-6736(02)09290-5.pdf

Laparoscopy-assisted colectomy versus open colectomy for treatment of non-metastatic colon cancer: a randomised trial

[Crohn's disease].

This is the fourth updated Enhanced Recovery After Surgery (ERAS®) Society guideline presenting a consensus for optimal perioperative care in colorectal surgery and providing graded recommendations for each ERAS item within the ERAS® protocol. A wide database search on English literature publications was performed. Studies on each item within the protocol were selected with particular attention paid to meta-analyses, randomised controlled trials and large prospective cohorts and examined, reviewed and graded according to Grading of Recommendations, Assessment, Development and Evaluation (GRADE) system. All recommendations on ERAS® protocol items are based on best available evidence; good-quality trials; meta-analyses of good-quality trials; or large cohort studies. The level of evidence for the use of each item is presented accordingly. The evidence base and recommendation for items within the multimodal perioperative care pathway are presented by the ERAS® Society in this comprehensive consensus review.

/pdf/guidelines-for-perioperative-care-in-elective-colonic-1wl593eui2.pdf

Guidelines for perioperative care in elective colonic surgery: Enhanced recovery after surgery (ERAS®) society recommendations

MEDICAL LITERATURE has been deluged during the past few years with books and papers on penicillin; but a book which has been produced under the general editorship of Sir Alexander Fleming himself represents a complete and authoritative summary of penicillin therapy as it stands today.' The book contains a series of independent contributions by \"experienced and eminent men who have worked with penicillin in Great Britain\". Their opinions and practical methods differ slightly, and there is some overlapping; but these are not disadvantageous, comparison and contrast lending interest to the reading. In the first or general section of the book Fleming contributes two chapters, one on the history and development of penicillin, introducing some interesting sidelights in the romance of discovery, the other on the bacteriological control of penicillin therapy. In both chapters the information is set out in meticulous detail and with a clarity and simplicity which can be enjoyed by all readers. Fleming also gives the right perspective to the place of penicillin amongst the antibiotics and lays down the principles of treatment. Both chapters are well illustrated and are the most outstanding in the book. Included in this first section also are chapters on the chemistry and manufacture of penicillin and its pharmacy, pharmacology and methods of administration. The second section of the book is entirely clinical, giving each author's view on the use of penicillin therapy in a disease or an infection of some particular region of the body. The entire range of peniCillin-sensitive conditions is considered in twenty authoritative and clearly written chapters; these contain many references and illustrations. Dental and veterinary diseases are also given fairly full consideration. The final section is a condensed resume of much of the preceding chapters and is written for. the general practttioner. This chapter is superttuous: it does not contain enough detall to be of much practical value. The book as a Whole, however, will undoubtedly be considered a classical contribution to medical literature and is strongly recommended, not only because of the general interest of its topic, but as a reference book on penicillin therapy of hitherto unequalled excellence. The typography, although conforming to war economy standards, is clear and the paper is good. There is an excellent list of references and the index is satisfactory.

Gray's Anatomy

Endoscopic Submucosal Dissection of Large Pseudo-Polyps in the Right Colon Using a Novel Articulating Grasper With a Double-Balloon Endolumenal Surgical Platform: An Ex Vivo Study in a Porcine Colorectal Model.

In laparoscopic surgery, abdominal tissues are dissected using a combination of cutting and coagulation, often with specialized electrosurgical instruments or ultrasonic devices. Precise dissection with minimal bleeding is especially important in laparoscopic surgery. Even minor oozing compromises the laparoscopic view and clearing blood from the fi eld of vision with suction and irrigation may be tedious. Therefore, dissection must be performed with tools that optimize precise tissue cutting and coagulation. Although many different coagulation and dissection devices are available, they all divide and coagulate tissue by converting various types of energy into heat. Therefore, the effect on tissue is thermal and depends on exposure time and the amount of energy applied to the tissue. Before embarking on a specifi c discussion of each instrument used to cut or coagulate tissue, reviewing some basic concepts about thermal alteration of tissue is worthwhile. Tissue reaction to thermal injury depends primarily on the temperature used (Figure 3.1). An increase in tissue temperature up to 60°C results in almost indiscernible changes to the naked eye. Coagulation begins at temperatures above 60°C; it is characterized by shrinkage and blanching caused by the denaturation of proteins, particularly collagen. When the tissue temperature reaches 100°C, the cell water boils, water is converted to steam, and the cell wall ruptures. When the water has evaporated and heat is still applied, the tissue temperature increases rapidly until it reaches 200°–300°C. At this point, the tissue carbonizes and begins to vaporize and smoke. At temperatures more than 500°C, tissue burns and evaporates. The effect of heat on tissue depends not only on the absolute amount of heat applied to tissue but also on the exposure time to heat. If heat is applied over a very short time (less than 1–2 seconds), the effect is localized because the heat is not conducted to surrounding tissues; even when the heat is great enough to vaporize the tissue, the vaporization is localized. If, however, the same amount of heat is applied for a longer period (greater than 2 seconds), the heat is conducted to the

Surgical Energy Sources

The preoperative evaluation and preparation procedures for patients undergoing laparoscopic colorectal surgery are identical to those for conventional surgery – only the access to the operative site differs. Patients should have preoperative blood testing, endoscopic and radiographic examinations, bowel preparation, and receive perioperative antibiotics exactly as if they were undergoing conventional surgery. We usually administer 90 mL of sodium phosphate solution in two divided doses (45 mL each), each mixed with a large glass of water, the day before surgery, to cleanse the bowel. In patients with colorectal cancer, the liver should be thoroughly examined, either using preoperative computed tomography with both intravenous and oral contrast dye or using intraoperative ultrasonography, because liver palpation cannot be performed during laparoscopic surgery. We also recommend endoluminal ultrasonography be done in all patients with rectal cancer. The size, depth of wall penetration, and precise relationship of the tumor to other organs can be accurately determined in almost 90% of patients. Additionally, larger pelvic or presacral vessels can sometimes be identifi ed by preoperative endoluminal ultrasonography and avoided during pelvic dissection.

Patient Preparation and Operating Room Setup

This chapter outlines the principal indications and contraindications for laparoscopic surgery to treat diseases of the small intestine, the colon, and the rectum. Indications and contraindications may vary somewhat depending on the laparoscopic team’s experience and the patient being treated. Nonetheless, this chapter should be a helpful guide to surgeons at all levels of experience in laparoscopic surgery.

Indications and Contraindications

BACKGROUND Fecal incontinence (FI) represents a large source of morbidity and is a challenging clinical problem to manage. InterStim was approved to treat FI in 2011. Little is known about its adoption. We sought to characterize patterns of use of Interstim since Food and Drug Administration approval for FI. METHODS The New York State SPARCS database was used to evaluate InterStim use for FI from 2011 to 2014. The primary endpoint was the number of successful implantations of InterStim. Secondary endpoints included device removal, median time to removal of device, 90-day infection rates, and percentage of procedures performed by surgeon specialty and geographic location. RESULTS A total of 369 patients with FI underwent "Stage 1" of InterStim from 2011 to 2014. A total of 302 patients underwent "Stage 2," yielding a trial period failure rate of 18.2%. The majority of patients who underwent successful implantation were female (87.7%) and White (78.8%). Twenty-nine patients underwent device removal after a median duration of 147 days. Estimated risk of removal at median follow-up of 2 years was 11.8%. Colorectal surgeons comprised 51.1% of all providers followed by gynecologic (24.4%) and urologic surgeons (17.8%). A total of 71.7% of providers performed <5 procedures, while 3 of the highest volume providers performed 50.7% of all procedures. CONCLUSIONS InterStim for FI has been used by a wide variety of providers in New York State although only a few high-volume providers have performed the majority of procedures. White, female patients with Medicare are the most common recipients of InterStim. Further work must be done to develop strategies for improving access to this technology and to determine whether volume relates to outcomes.

Jeffrey W. Milsom

Papers

Endoscopic Submucosal Dissection of Large Pseudo-Polyps in the Right Colon Using a Novel Articulating Grasper With a Double-Balloon Endolumenal Surgical Platform: An Ex Vivo Study in a Porcine Colorectal Model.

Surgical Energy Sources

Patient Preparation and Operating Room Setup

Indications and Contraindications

Evaluation of Trends in the Use of InterStim for Fecal Incontinence.