Essential articles: Colorectal

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Anal fistulas

Sugrue J, et al. Sphincter-Sparing Anal Fistula Repair: Are We Getting Better? Dis Colon Rectum. 2017 Oct;60(10):1071-1077. doi: 10.1097/DCR.0000000000000885. 

Vogel JD, et al. Clinical Practice Guideline for the Management of Anorectal Abscess, Fistula-in-Ano, and Rectovaginal Fistula Dis Colon Rectum. 2016 Dec;59(12):1117-1133. doi: 10.1097/DCR.0000000000000733. 

Sirany AM, et al. The ligation of the intersphincteric fistula tract procedure for anal fistula: a mixed bag of results Dis Colon Rectum. 2015 Jun;58(6):604-12. doi: 10.1097/DCR.0000000000000374. 


Diverticulitis:

Francis NK, et al. EAES and SAGES 2018 consensus conference on acute diverticulitis management: evidence-based recommendations for clinical practice Surg Endosc. 2019 Sep;33(9):2726-2741. doi: 10.1007/s00464-019-06882-z. 


Fissures

Murad-Regadas SM, et al. How much of the internal sphincter may be divided during lateral sphincterotomy for chronic anal fissure in women? Morphologic and functional evaluation after sphincterotomy Dis Colon Rectum. 2013 May;56(5):645-51. doi: 10.1097/DCR.0b013e31827a7416. 

Stewart DB Sr, et al. Clinical Practice Guideline for the Management of Anal Fissures Dis Colon Rectum. 2017 Jan;60(1):7-14. doi: 10.1097/DCR.0000000000000735. 

Thornton MJ, et al. Prospective manometric assessment of botulinum toxin and its correlation with healing of chronic anal fissure Dis Colon Rectum. 2005 Jul;48(7):1424-31. doi: 10.1007/s10350-005-0025-9. 


Hemorrhoids

Davis BR, et al. The American Society of Colon and Rectal Surgeons Clinical Practice Guidelines for the Management of Hemorrhoids Dis Colon Rectum. 2018 Mar;61(3):284-292. doi: 10.1097/DCR.0000000000001030. 

Nelson DW, et al. Prophylactic antibiotics for hemorrhoidectomy: are they really needed? Dis Colon Rectum. 2014 Mar;57(3):365-9. doi: 10.1097/DCR.0b013e3182a0e522. 

Nienhuijs S, et al. Conventional versus LigaSure hemorrhoidectomy for patients with symptomatic Hemorrhoids Cochrane Database Syst Rev. 2009 Jan 21;2009(1):CD006761. doi: 10.1002/14651858.CD006761.pub2. 


Rectal prolapse

Bordeianou L, et al. Clinical Practice Guidelines for the Treatment of Rectal Prolapse Dis Colon Rectum. 2017 Nov;60(11):1121-1131. doi: 10.1097/DCR.0000000000000889. 


Colon cancer

Allaix ME, Rebecchi F, Fichera A. The Landmark Series: Minimally Invasive (Laparoscopic and Robotic) Colorectal Cancer Surgery. Ann Surg Oncol. 2020 Oct;27(10):3704-3715.

Alonso S, Saltz L. The Landmark Series: Chemotherapy for Non-Metastatic Colon Cancer. Ann Surg Oncol. 2021 Feb;28(2):995-1001.

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Pneumatosis Intestinalis:

Sanford Z, et al Updates on the Utility of Diagnostic Laparoscopy in the Management of Pneumatosis Intestinalis: An Improvement to the Current Treatment Algorithm. Surg Innov. 2018 Dec;25(6):648-650.


Rectal Cancer

Peacock O, Chang GJ. The Landmark Series: Management of Lateral Lymph Nodes in Locally Advanced Rectal Cancer. Ann Surg Oncol. 2020 Aug;27(8):2723-2731.

Bahadoer RR, Dijkstra EA, van Etten B, et al. Short-course radiotherapy followed by chemotherapy before total mesorectal excision (TME) versus preoperative chemoradiotherapy, TME, and optional adjuvant chemotherapy in locally advanced rectal cancer (RAPIDO): a randomised, open-label, phase 3 trial. Lancet Oncol. 2021 Jan;22(1):29-42. doi: 10.1016/S1470-2045(20)30555-6. Epub 2020 Dec 7. Erratum in: Lancet Oncol. 2021 Feb;22(2):e42. PMID: 33301740.

Conroy T, Lamfichekh N, Etienne P, Rio E, Francois E, Mesgouez-Nebout N, et al. Total neoadjuvant therapy with mFOLFIRINOX versus preoperative chemoradiation in patients with locally advanced rectal cancer: final results of PRODIGE 23 phase III trial, a UNICANCER GI trial. J Clin Oncol 2020;38(15 Suppl.):4007.

Iatrogenic urologic injuries 

Ferrara M, Kann BR. Urological injuries during colorectal surgery. Clin Colon Rectal Surg. 2019 May;32(3):196-203.

“A recent retrospective population-based study of patients in the United States undergoing colorectal surgery found the overall incidence of ureteral injury to be 0.28%. The incidence was found to be significantly higher in patients with stage 3 or 4 cancer, malnutrition, steroid use, and in operations done at teaching hospitals. Rectal cancer cases were found to have the highest rates of ureteral injuries (7.1/1,000), followed by Crohn’s disease and diverticular disease (2.9/1,000 each). In this review, laparoscopic surgery was associated with a lower incidence of ureteral injuries when compared with open (1.1 vs. 2.8/1,000, p  < 0.001). Of the specific operations reviewed, abdominoperineal resection (APR) was found to have the highest rate of ureteral injury at 7.1/1,000 cases.” (Ferrara, 2019, p. 196)

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Essential Articles for Surgical Residents (2022-2023)

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We are excited to share a new section titled “Essential Articles for Surgical Residents.”

Keeping up with surgical literature in residency can be challenging. This list was created to serve as an easily accessible, up-to-date, and evidence-based resource for residents.

The content has been curated by faculty from each department and is intended to supplement the standard educational curriculum of each rotation with current and relevant literature.

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Resource Highlight: Surgical Anatomy Apps for Liver, Lung, and Male Pelvis

These were created by Emory University and are available for Apple devices.

Download here.

Surgical Anatomy of the Liver

“This app is for trainees, medical students, instructors, and anyone that needs a quick way to learn or teach liver anatomy.This hands-on tool allows you to mentally map the 3D anatomy of the liver in a way that was never possible with illustrations or imaging studies.

Emory Surgical Oncologist Shishir Maithel, MD, FACS, guided a certified medical illustrator in the process of digitally sculpting the anatomy to be both clear and accurate. The anatomy is a synthesis of radiographic, cadaveric, and surgical references, as well as hundreds of hours of liver surgery.”

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Surgical treatment and risk of recurrence of horseshoe anorectal abscess

Gaertner WB, et al. The American Society of Colon and Rectal Surgeons Clinical Practice Guidelines for the Management of Anorectal Abscess, Fistula-in-Ano, and Rectovaginal Fistula. Dis Colon Rectum. 2022 Aug 1;65(8):964-985. Full-text for Emory users.

Patients with acute anorectal abscess should be treated promptly with incision and drainage. Grade of recommendation: strong recommendation based on low-quality evidence, 1C.

“Abscesses that cross the midline (ie, horseshoe) can be challenging to manage. These abscesses most often involve the deep postanal space and extend laterally into the ischiorectal spaces. [40,71] Under these circumstances, primary lay-open fistulotomy should typically be avoided because these fistulas tend to be transsphincteric. The Hanley procedure, a technique that drains the deep postanal space and uses counter incisions to address the ischiorectal spaces, is effective in the setting of a horseshoe abscess, [71] although it may negatively impact anal sphincter function. [40,71] A modified Hanley technique using a posterior midline partial sphincterotomy to unroof the postanal space plus seton placement has a high rate of abscess resolution and has been reported to better preserve anorectal function compared to other operative interventions. [40,72,73]” (p. 969)

“After drainage, abscesses may recur in up to 44% of patients, most often within 1 year of initial treatment. [2,10,70] Inadequate drainage, the presence of loculations or a horseshoe-type abscess, and not performing a primary fistulotomy are risk factors for recurrent abscess (primary fistulotomy is further addressed in recommendation no. 4). [10,71,72]” (p. 969)

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Urinary retention in thoracic epidural patients

Choi S, Mahon P, Awad IT. Neuraxial anesthesia and bladder dysfunction in the perioperative period: a systematic review. Can J Anaesth. 2012 Jul;59(7):681-703. Erratum in: Can J Anaesth. 2017 Dec 18. Full-text for Emory users.

Principal findings: Our search yielded 94 studies, and in 16 of these studies, the authors reported time to micturition after intrathecal anesthesia of varying local anesthetics and doses. Intrathecal injections were performed in 41 of these studies, epidural anesthesia/analgesia was used in 39 studies, and five studies involved both the intrathecal and epidural routes. Meta-analysis was not possible because of the heterogeneity of interventions and reported outcomes. The duration of detrusor dysfunction after intrathecal anesthesia is correlated with local anesthetic dose and potency. The incidence of urinary retention displays a similar trend and is further increased by the presence of neuraxial opioids, particularly long-acting variants. Urinary tract infection secondary to catheterization occurred rarely.

Conclusions: Neuraxial anesthesia/analgesia results in transient detrusor dysfunction. The duration of dysfunction depends on the potency and dose of medication used; however, it does not appear to result in significant morbidity.


Allen MS, et al. Optimal Timing of Urinary Catheter Removal After Thoracic Operations: A Randomized Controlled Study. Ann Thorac Surg. 2016 Sep;102(3):925-930. Full-text for Emory users.

Results: The study enrolled 374 patients, 217 men (58%) and 157 women (42%). The 247 eligible and evaluated patients, 141 (57.1%) men and 106 (42.9%) women, were a median age of 61.5 years (range, 21 to 87 years). There were no statistically significant differences in any of the preoperative or operative categories between the two groups. Median length of stay was 5 days (range, 2 to 42 days) for all patients, and there was no difference between the two groups. Postoperatively, 19 patients (7.7%) required urinary catheter reinsertion after it was removed. A significantly greater number of patients in the early removal group required reinsertion of the urinary catheter (15 [12.4%] vs 4 [3.2%]); p = 0.0065). Patients whose urinary catheter was removed within 48 hours of the operation had a much higher rate of bladder scans postoperatively (59.5% [n = 72]) and required more in-and-out catheterization than those whose urinary catheter was removed 6 hours after the epidural analgesia was discontinued (31.0% [n = 39]; p < 0.0001). The only documented urinary tract infection in the entire cohort occurred in a patient whose urinary catheter was removed within 48 hours after the operation. No urinary tract infections developed in the 126 patients whose urinary catheter remained in place until the epidural catheter was removed.

Conclusions: In a randomized control trial, patients with an epidural catheter in place after a general thoracic surgical operation have a higher rate of urinary problems when the urinary catheter is removed early, while the epidural catheter is still in place, compared with patients whose urinary catheter is removed after the epidural analgesia is discontinued.

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Article of interest: Role of antibiotic prophylaxis for the prevention of intravascular catheter-related infection

Carratalà J. Role of antibiotic prophylaxis for the prevention of intravascular catheter-related infection. Clin Microbiol Infect. 2001;7 Suppl 4:83-90. Free full-text.

“A plausible explanation for the failure to reduce catheter-related bacteremia with this prophylactic approach probably lies in the mechanism by which catheter-related infection occurs. Thus, it is known that in long-term central venous catheters, bacteria are more likely to be introduced during and following catheter hub manipulation than via spread from the skin insertion site or from tunnel infection. On the other hand, the systemic administration of prophylactic glycopeptides may lead to the emergence of resistant organisms, and Centers for Disease Control and Prevention guidelines recommend against its use [55]. Therefore, the use of systemic glycopeptides to prevent intravascular catheter-related infections is not recommended.” (p. 85)

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