Conor P. Delaney

Postoperative ileus (POI) is a major cause of morbidity, increased length of stay (LOS) and hospital cost after colorectal surgery. Alvimopan is a µ-opioid antagonist used to accelerate upper and lower gastrointestinal function after bowel resection. We hypothesized that alvimopan would reduce LOS in patients undergoing colorectal resection with stoma, a situation that has not been evaluated.

Transient ileus is a normal physiologic process after surgery. When prolonged, it is an important contributor to postoperative complications, increased length of stay and increased healthcare costs. Efforts have been made to prevent and manage postoperative ileus; alvimopan is an oral, peripheral μ-opioid receptor antagonist, and the only currently US FDA-approved medication to accelerate the return of gastrointestinal function postoperatively.

We report our initial clinical experience from a pilot study to compare the diagnostic accuracy of hybrid PET/MRI with PET/CT in colorectal cancer and discuss potential PET/MRI workflow solutions for colorectal cancer. Patients underwent both FDG PET/CT and PET/MRI (Ingenuity TF PET/MRI, Philips Healthcare) for rectal cancer staging or colorectal cancer restaging. The PET acquisition of PET/MRI was similar to that of PET/CT whereas the MRI protocol was selected individually based on the patient’s medical history. One nuclear medicine physician reviewed the PET/CT studies and one radiologist reviewed the PET/MRI studies independently. The diagnostic accuracy of each modality was determined in consensus, using available medical records as a reference. Of the 12 patients enrolled, two were for initial staging and ten for restaging. The median scan delay between the two modalities was 60 min. The initial imaging was PET/CT in nine patients and PET/MRI in three patients. When PET/CT was performed first, the SUV values of the 16 FDG avid lesions were greater at PET/MRI than at PET/CT. In contrast, when PET/MRI was performed first, the SUV values of the seven FDG avid lesions were greater at PET/CT than at PET/MRI. PET/MRI provided more detailed T staging than PET/CT. On a per-patient basis, with both patient groups combined for the evaluation of N and M staging/restaging, the true positive rate was 5/7 (71%) for PET/CT and 6/7 (86%) for PET/MRI, and true negative rate was 5/5 (100%) for both modalities. On a per-lesion basis, PET/CT identified 26 of 29 (90%) tumor lesions that were correctly detected by PET/MRI. Our proposed workflow allows for comprehensive cancer staging including integrated local and whole-body assessment. Our initial experience shows a high diagnostic accuracy of PET/MRI in T staging of rectal cancer compared with PET/CT. In addition, PET/MRI shows at least comparable accuracy in N and M staging as well as restaging to PET/CT. However, the small sample size limits the generalizability of the results. It is expected that PET/MRI would yield higher diagnostic accuracy than PET/CT considering the high soft tissue contrast provided by MRI compared with CT, but larger studies are necessary to fully assess the benefit of PET/MRI in colorectal cancer.

Unexpected variations in postoperative length of stay (LOS) negatively impact resources and patient outcomes. Statistical process control (SPC) measures performance, evaluates productivity, and modifies processes for optimal performance. The goal of this study was to initiate SPC to identify LOS outliers and evaluate its feasibility to improve outcomes in colorectal surgery. Review of a prospective database identified colorectal procedures performed by a single surgeon. Patients were grouped into elective and emergent categories and then stratified by laparoscopic and open approaches. All followed a standardized enhanced recovery protocol. SPC was applied to identify outliers and evaluate causes within each group. A total of 1294 cases were analyzed—83 % elective (n = 1074) and 17 % emergent (n = 220). Emergent cases were 70.5 % open and 29.5 % laparoscopic; elective cases were 36.8 % open and 63.2 % laparoscopic. All groups had a wide range in LOS. LOS outliers ranged from 8.6 % (elective laparoscopic) to 10.8 % (emergent laparoscopic). Evaluation of outliers demonstrated patient characteristics of higher ASA scores, longer operating times, ICU requirement, and temporary nursing at discharge. Outliers had higher postoperative complication rates in elective open (57.1 vs. 20.0 %) and elective lap groups (77.6 vs. 26.1 %). Outliers also had higher readmission rates for emergent open (11.4 vs. 5.4 %), emergent lap (14.3 vs. 9.2 %), and elective lap (32.8 vs. 6.9 %). Elective open outliers did not follow trends of longer LOS or higher reoperation rates. SPC is feasible and promising for improving colorectal surgery outcomes. SPC identified patient and process characteristics associated with increased LOS. SPC may allow real-time outlier identification, during quality improvement efforts, and reevaluation of outcomes after introducing process change. SPC has clinical implications for improving patient outcomes and resource utilization.

Quality improvement in colorectal surgery (CRS) requires implementation of tools to improve patient and financial outcomes, and assessment of results. Our objective was to evaluate the durability of transversus abdominis plane (TAP) blocks and a standardized enhanced recovery protocol (ERP) on a large series of laparoscopic colorectal resections. Two hundred consecutive laparoscopic CRS patients received TAP blocks under laparoscopic guidance at the end of their operation. All were managed with a standardized ERP. Demographic, perioperative, and postoperative outcomes variables were analyzed. The main outcomes measures were length of stay (LOS), readmission, reoperation, morbidity, and mortality rates. Of 200 cases, 194 were elective and 6 emergent. The main diagnosis was colorectal cancer (45%). The mean patient age was 61.2 years, mean body mass index was 29.2 kg/m(2), and the majority (63%) were American Society of Anesthesiologists (ASA) class III. The main procedure performed was a segmental colectomy (64%). Mean operative time was 181 minutes. Nine cases (4.5%) were converted to open. The median LOS was 2 days (range 1 to 8 days). Twenty-one percent were discharged by postoperative day (POD) 1, 41% by POD 2, and 77% by POD 3. By POD 7, 99% were discharged. Twelve percent (n = 24) had complications, and 6.5% (n = 13) were readmitted. There were 3 unplanned reoperations and no mortalities. Comparing the first and second groups of 100 consecutive patients further tested the consistency of the TAP block benefit. With comparable demographics, there were no significant differences in readmission, complication, or reoperation rates over the entire series. Adding TAP blocks to an ERP facilitated shorter LOS with low readmission and reoperation rates when compared to previously published series. The effect appears durable and consistent in a large case series. Transversus abdominis plane blocks may be an efficient, cost-effective method for improving laparoscopic CRS results.