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1.  Integrating Hospital Administrative Data to Improve Health Care Efficiency and Outcomes: “The Socrates Story” 
Evaluation of health care outcomes has become increasingly important as we strive to improve quality and efficiency while controlling cost. Many groups feel that analysis of large datasets will be useful in optimizing resource utilization; however, the ideal blend of clinical and administrative data points has not been developed. Hospitals and health care systems have several tools to measure cost and resource utilization, but the data are often housed in disparate systems that are not integrated and do not permit multisystem analysis. Systems Outcomes and Clinical Resources AdministraTive Efficiency Software (SOCRATES) is a novel data merging, warehousing, analysis, and reporting technology, which brings together disparate hospital administrative systems generating automated or customizable risk-adjusted reports. Used in combination with standardized enhanced care pathways, SOCRATES offers a mechanism to improve the quality and efficiency of care, with the ability to measure real-time changes in outcomes.
PMCID: PMC3699139  PMID: 24436649
costs; performance; technology
2.  Simulation and Its Role in Training 
Despite its short history, surgical simulation has been successfully introduced into surgical residency programs in an effort to augment training. A wide range of simulator types and levels of complexity have proven an effective teaching method for surgical trainees. They have been used for training in areas such as general surgery, urology, gynecology, and ophthalmology among others. Coincident with the introduction of simulators is the need for objective evaluation of skills learned on them, which has led to the development and validation of multiple evaluation tools. This article evaluates the drivers for simulation, types of simulators, training, and evaluation of them especially as it pertains to laparoscopic colorectal surgery.
PMCID: PMC3699140  PMID: 24436648
simulator; education; laparoscopic colorectal surgery
3.  Postoperative ileus: Impact of pharmacological treatment, laparoscopic surgery and enhanced recovery pathways 
Almost all patients develop postoperative ileus (POI) after abdominal surgery. POI represents the single largest factor influencing length of stay (LOS) after bowel resection, and has great implications for patients and resource utilization in health care. New methods to treat and decrease the length of POI are therefore of great importance. During the past decade, a substantial amount of research has been performed evaluating POI, and great progress has been made in our understanding and treatment of POI. Laparoscopic procedures, enhanced recovery pathways and pharmacologic treatment have been introduced. Each factor has substantially contributed to decreasing the length of POI and thus LOS after bowel resection. This editorial outlines resource utilization of POI, normal physiology of gut motility and pathogenesis of POI. Pharmacological treatment, fast track protocols and laparoscopic surgery can each have significant impact on pathways causing POI. The optimal integration of these treatment options continues to be assessed in prospective studies.
PMCID: PMC2864831  PMID: 20440846
Postoperative ileus; Pathophysiology; Cost utilization; Pharmacologic treatment; Laparoscopic surgery; Enhanced recovery pathways
4.  Laparoscopic Approaches to Rectal Cancer 
Laparoscopic colectomy has been proven oncologically equivalent to conventional surgery and is now generally agreed to offer patients a reduced length of stay, shorter recovery times, and improved cosmesis. In contrast, acceptance of laparoscopic proctectomy for rectal cancer has been much delayed and the enthusiasm of early studies has met considerable skepticism. For rectal cancer, it has been demonstrated that there is considerable variation between surgeons in disease-free survival and local pelvic recurrence after open proctectomy for rectal cancer. These differences are likely to be magnified when the technical challenge of laparoscopy is added to proctectomy. Minimally invasive approaches to rectal cancer need to demonstrate equivalent oncologic outcomes and maintenance or improvement in quality of life. This review will outline the current evidence for laparoscopy as a treatment option for patients with rectal cancer, emphasize the need for standardized approaches among multidisciplinary teams, and highlight the technical details of different laparoscopic operations for rectal cancer.
PMCID: PMC2789505  PMID: 20011205
Laparoscopy; rectal cancer; techniques; approaches
5.  Surgical treatment for rectal cancer: An international perspective on what the medical gastroenterologist needs to know 
Rectal cancer accounts for one third of all colorectal cancers. The age adjusted death rates from colorectal cancer have declined over recent decades due to a combination of colorectal cancer screening, improved diagnostic tests, improved standardized surgical technique, improved medical support, neoadjuvant chemotherapies and radiation treatment or combinations of these. Because of complex treatment algorithms, use of multidisciplinary teams in the management of rectal cancer patients has also been popularized. Medical gastroenterologists performing colonoscopies are frequently the first health care provider to raise the suspicion of a rectal cancer. Although the diagnosis depends on histological confirmation, the endoscopic presentation is almost diagnostic in many cases. In order to meet the patient’s immediate needs for information, it is important that the endoscopist has knowledge about the investigations and treatment options that will be required for their patient. The aim of this paper is to describe the modern preoperative investigations and operative procedures commonly offered to rectal cancer patients taking into account perspectives of three colorectal surgeons, practicing in the USA, Europe and Asia.
PMCID: PMC2716581  PMID: 18528924
Rectal cancer management; Evaluation; Staging; Neoadjuvant; Adjuvant; Surgical treatment; Surveillance
6.  Academic University Practice: Program Selection and the Interview Process 
The decision to go into academic surgery, rather than private practice, is often multifactorial and includes the opportunity to participate in research, education, and patient care. The current job market for academic colon and rectal surgeons can be described as favorable and growing as there is a push for major academic institutions to obtain fellowship-trained colorectal surgeons. In selecting a job, one should be familiar with the department characteristics. This requires obtaining the answers to multiple questions and negotiation of institutional commitment.
PMCID: PMC2780169  PMID: 20011372
Academic practice; mentoring; research; job market
7.  Current state of the art in laparoscopic colorectal surgery for cancer: Update on the multi-centric international trials 
Laparoscopic colectomy is now widely applied to cases of malignancy, supported by early data from several large randomized controlled trials. Long-term follow-up is now available from those trials, supporting equivalency of cancer-free and overall survival for open and laparoscopic resections. This promising data has inspired further exploration of other applications of laparoscopic techniques, including use of single incision laparoscopy. This article reviews recent reports of long-term data for colorectal cancer resection from four randomized, prospective international trials.
PMCID: PMC3444362  PMID: 22846394
Laparoscopy; Colorectal cancer; Cost; Classic; Color
8.  Laparoscopic versus open colectomy for colon cancer in an older population: a cohort study 
Laparoscopic colectomy for colon cancer has been compared with open colectomy in randomized controlled trials, but these studies may not be generalizable because of strict enrollment and exclusion criteria which may explicitly or inadvertently exclude older individuals due to associated comorbidities. Previous studies of older patients undergoing laparoscopic colectomy have generally focused on short-term outcomes. The goals of this cohort study were to identify predictors of laparoscopic colectomy in an older population in the United States and to compare short-term and long-term outcomes.
Patients aged 65 years or older with incident colorectal cancer diagnosed 1996-2002 who underwent colectomy within 6 months of cancer diagnosis were identified from the linked Surveillance, Epidemiology, and End Results-Medicare database. Laparoscopic and open colectomy patients were compared with respect to length of stay, blood transfusion requirements, intensive care unit monitoring, complications, 30-day mortality, and long-term survival. We adjusted for potential selection bias in surgical approach with propensity score matching.
Laparoscopic colectomy cases were associated with left-sided tumors; areas with higher population density, income, and education level; areas in the western United States; and National Cancer Institute-designated cancer centers. Laparoscopic colectomy cases had shorter length of stay and less intensive care unit monitoring. Although laparoscopic colectomy patients (n = 424) had fewer complications (21.5% versus 26.3%), lower 30-day mortality (3.3% versus 5.8%), and longer median survival (6.6 versus 4.8 years) compared with open colectomy patients (n = 27,012), after propensity score matching these differences disappeared.
In this older population, laparoscopic colectomy practice patterns were associated with factors which likely correlate with tertiary referral centers. Although short-term and long-term survival are comparable, laparoscopic colectomy offers shorter hospitalizations and less intensive care.
PMCID: PMC3296595  PMID: 22313593
9.  Prevention of Transplant Rejection 
Clinical immunotherapeutics  1996;6(2):89-96.
Successful solid organ transplantation is generally attributed to the increasingly precise ability of drugs to control rejection. However, it was recently shown that a few donor haematolymphoid cells can survive for decades in recipients of successful organ allografts, a phenomenon called microchimaerism. The association for decades of haematolymphoid chimaerism with allograft tolerance in experimental transplantation suggests that immunosuppressive drugs merely create a milieu that enables an allograft and its complement of passenger leucocytes to prime the recipient for graft acceptance.
Exploitation of this concept requires a fundamental shift in the classical view of passenger leucocytes only as initiators of rejection. Microchimaerism has taught us that solid organ transplantation involves the transfer of two donor organ systems to the recipient: the allograft parenchyma and the donor haematolymphoid system in the form of donor stem cells contained within the passenger leucocyte compartment. Each has the potential to integrate with the corresponding recipient system and carry out normal physiological functions, such as immunological self definition. Resistance to initial integration by mature T cells requires some form of immunosuppression, but maintenance of donor immune system function will depend on renewable supply of cells, which can be provided by engrafted progenitors. Successful clinical application will depend on the development of low morbidity methods to enhance engraftment of donor haemopoietic stem cells.
PMCID: PMC3091025  PMID: 21566684
Transplantation  1995;60(2):158-171.
The bidirectional paradigm of tolerance involving reciprocal host vs. graft and graft vs. host reactions was examined after Lewis (LEW) → Brown Norway (BN) transplantation of different whole organs (liver, intestine, heart, and kidney) or of 2.5×108 LEW leukocytes obtained from bone marrow, spleen, lymph nodes, and thymus. The experiments were performed without immunosuppression or under 14 daily doses of postoperative tacrolimus, which were continued in weekly doses to 100 days in a “continuous treatment” subgroup, and to 27 days in a short treatment group. Without immunosuppression, all organs and cell suspensions failed to engraft or were acutely rejected. GVHD (usually fatal) was always caused when either the long or short treatment was used for recipients of intestinal grafts and cell suspensions of spleen and lymph nodes. In contrast, both immunosuppressive protocols allowed engraftment of bone marrow cells, liver, heart, and kidney without clinical GVHD, whereas thymus cell suspensions and small doses of whole blood neither engrafted nor caused GVHD. At 100 days, now drug-free for 73 days, the liver, bone marrow, and heart recipients were tolerant in that they accepted all challenge LEW heart and/or liver grafts for 100 more days despite in vitro evidence of donor-specific reactivity (split tolerance). At 200 days, histopathologic studies of the challenge livers were normal no matter what the priming graft. However, the still-beating challenge hearts had a spectrum from normal to severe chronic rejection that defined the tolerogenicity of the original primary grafts: liver best → bone marrow next → heart least. Both the GVHD propensity and tolerogenicity in these experiments were closely associated with recipient tissue chimerism 30 and 100 days after the experiments began. The tissue chimerism was invariably multilineage, but the GVHD outcome was associated with T cell over-representation. These observations provide guidelines that should be considered in devising leukocyte augmentation protocols for human whole organ recipients. The results are discussed in relation to the historical tolerance studies of Billingham, Brent, and Medawar; Good; Monaco; and Calne.
PMCID: PMC3003921  PMID: 7624958
11.  International Preoperative Rectal Cancer Management: Staging, Neoadjuvant Treatment, and Impact of Multidisciplinary Teams 
World Journal of Surgery  2010;34(11):2689-2700.
Little is known regarding variations in preoperative treatment and practice for rectal cancer (RC) on an international level, yet practice variation may result in differences in recurrence and survival rates.
One hundred seventy-three international colorectal centers were invited to participate in a survey of preoperative management of rectal cancer.
One hundred twenty-three (71%) responded, with a majority of respondents from North America, Europe, and Asia. Ninety-three percent have more than 5 years’ experience with rectal cancer surgery. Fifty-five percent use CT scan, 35% MRI, 29% ERUS, 12% digital rectal examination and 1% PET scan in all RC cases. Seventy-four percent consider threatened circumferential margin (CRM) an indication for neoadjuvant treatment. Ninety-two percent prefer 5-FU-based long-course neoadjuvant chemoradiation therapy (CRT). A significant difference in practice exists between the US and non-US surgeons: poor histological differentiation as an indication for CRT (25% vs. 7.0%, p = 0.008), CRT for stage II and III rectal cancer (92% vs. 43%, p = 0.0001), MRI for all RC patients (20% vs. 42%, p = 0.03), and ERUS for all RC patients (43% vs. 21%, p = 0.01). Multidisciplinary team meetings significantly influence decisions for MRI (RR = 3.62), neoadjuvant treatment (threatened CRM, RR = 5.67, stage II + III RR = 2.98), quality of pathology report (RR = 4.85), and sphincter-saving surgery (RR = 3.81).
There was little consensus on staging, neoadjuvant treatment, and preoperative management of rectal cancer. Regular multidisciplinary team meetings influence decisions about neoadjuvant treatment and staging methods.
PMCID: PMC2949570  PMID: 20703471
12.  Alvimopan for the Management of Postoperative Ileus After Bowel Resection: Characterization of Clinical Benefit by Pooled Responder Analysis 
World Journal of Surgery  2010;34(9):2185-2190.
A pooled post hoc responder analysis was performed to assess the clinical benefit of alvimopan, a peripherally acting mu-opioid receptor (PAM-OR) antagonist, for the management of postoperative ileus after bowel resection.
Adult patients who underwent laparotomy for bowel resection scheduled for opioid-based intravenous patient-controlled analgesia received oral alvimopan or placebo preoperatively and twice daily postoperatively until hospital discharge or for 7 postoperative days. The proportion of responders and numbers needed to treat (NNT) were examined on postoperative days (POD) 3–8 for GI-2 recovery (first bowel movement, toleration of solid food) and hospital discharge order (DCO) written.
Alvimopan significantly increased the proportion of patients with GI-2 recovery and DCO written by each POD (P < 0.001 for all). More patients who received alvimopan achieved GI-2 recovery on or before POD 5 (alvimopan, 80%; placebo, 66%) and DCO written before POD 7 (alvimopan, 87%; placebo, 72%), with corresponding NNTs equal to 7.
On each POD analyzed, alvimopan significantly increased the proportion of patients who achieved GI-2 recovery and DCO written versus placebo and was associated with relatively low NNTs. The results of these analyses provide additional characterization and support for the overall clinical benefit of alvimopan in patients undergoing bowel resection.
PMCID: PMC2917559  PMID: 20526599
13.  Emergency Laparoscopic Colectomy: Does it Measure Up to Open? 
American journal of surgery  2009;197(3):296-301.
Laparoscopic colectomy has become the standard of care for elective resections; however, there are few data regarding laparoscopy in the emergency setting.
Using a prospectively collected database, we identified 94 patients who underwent an emergency colectomy between August 2005 and July 2008. Laparoscopic operations were performed in 42 patients and were compared to 25 who were suitable for laparoscopy but received open colectomy.
The groups had similar demographics with no difference in age, gender or surgical indications. Blood loss was lower (118ml vs. 205ml, p <0.01) and postoperative stay shorter (8 vs. 11 days, p = 0.02) in the laparoscopic patients, and perioperative mortality rates were similar between the two groups (1 vs. 3, p = 0.29).
With increasing experience, laparoscopic colectomy is a feasible option in certain emergency situations and is associated with shorter hospital stay, less morbidity, and similar mortality to that of open operation.
Laparoscopic colectomy has become the standard of care for elective resections; however, there are few data regarding laparoscopy in the emergency setting. We demonstrate that increasing experience, laparoscopic colectomy is a feasible option in certain emergency situations and is associated with shorter hospital stay, less morbidity, and similar mortality to that of open operation.
PMCID: PMC2681486  PMID: 19245904
laparoscopic emergency colectomy; emergent colectomy; urgent colectomy laparoscopy; colectomy
14.  Pharmacological management of postoperative ileus 
Canadian Journal of Surgery  2009;52(2):153-157.
The duration of postoperative ileus following abdominal surgery is quite variable, and prolonged postoperative ileus is an iatrogenic phenomenon with important influence on patient morbidity, hospital costs and length of stay in hospital. Adequate treatment for prolonged postoperative ileus is important to improve patient morbidity and clinical efficiency. Both clinical and pharmacological management strategies have improved rapidly over the last decade, and appropriate and timely management using multimodal techniques should be used for optimal care. In this review, we define postoperative ileus, describe the pathogenesis and briefly discuss clinical management before detailing potential pharmacologic management options.
PMCID: PMC2663489  PMID: 19399212
15.  Management of postoperative ileus: focus on alvimopan 
Postoperative ileus (POI) is a transient loss of coordinated peristalsis precipitated by surgery and exacerbated by opioid pain medication. Ileus causes a variety of symptoms including bloating, pain, nausea, and vomiting, but particularly delays tolerance of oral diet and liquids. Thus POI is a primary determinant of hospital stay after surgery. ‘Fast-track’ recovery protocols, opioid sparing analgesia, and laparoscopic surgery reduce but do not eliminate postoperative ileus. Alvimopan is a mu opioid receptor antagonist that blocks the effects of opioids on the intestine, while not interfering with their centrally mediated analgesic effect. Several large randomized clinical trials have demonstrated that alvimopan accelerates the return of gastrointestinal function after surgery and subsequent hospital discharge by approximately 20 hours after elective open segmental colectomy. However, it has not been tested in patients undergoing laparoscopic surgery and is less effective in patients receiving nonsteroidal anti-inflammatory agents in a narcotic sparing postoperative pain control regimen. Safety concerns seen with chronic low dose administration of alvimopan for opioid bowel dysfunction have not been noted with its acute use for POI.
PMCID: PMC2621409  PMID: 19209278
alvimopan; postoperative ileus; gastrointestinal surgery

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