M. Alexander Otto

VANCOUVER, B.C. – Bleeding from uterine arteriovenous malformations was stopped with a combination of tranexamic acid, gonadotropin-releasing hormone agonist, and an aromatase inhibitor in a small case series in Canada.

The cocktail appears to be a safe alternative to uterine artery embolization and hysterectomy, which allows women to remain fertile, said Dr. Angelos Vilos, an ob.gyn. at Western University in London, Ontario, and the study’ lead investigator.

Dr. Vilos and his team used uterine tamponade to control bleeding, then gave the women oral tranexamic acid for 5 days. Patients also received a GnRH agonist – usually one injection of leuprolide – with oral letrozole for 5 days after the injection. In all cases, the arteriovenous malformations resolved within 3 months.

In a video interview at the AAGL meeting, Dr. Vilos said the approach could be a “game changer” if it holds up in future testing.

[email protected]

VANCOUVER, B.C. – Bleeding from uterine arteriovenous malformations was stopped with a combination of tranexamic acid, gonadotropin-releasing hormone agonist, and an aromatase inhibitor in a small case series in Canada.

The cocktail appears to be a safe alternative to uterine artery embolization and hysterectomy, which allows women to remain fertile, said Dr. Angelos Vilos, an ob.gyn. at Western University in London, Ontario, and the study’ lead investigator.

Dr. Vilos and his team used uterine tamponade to control bleeding, then gave the women oral tranexamic acid for 5 days. Patients also received a GnRH agonist – usually one injection of leuprolide – with oral letrozole for 5 days after the injection. In all cases, the arteriovenous malformations resolved within 3 months.

In a video interview at the AAGL meeting, Dr. Vilos said the approach could be a “game changer” if it holds up in future testing.

[email protected]

VANCOUVER, B.C. – Bleeding from uterine arteriovenous malformations was stopped with a combination of tranexamic acid, gonadotropin-releasing hormone agonist, and an aromatase inhibitor in a small case series in Canada.

The cocktail appears to be a safe alternative to uterine artery embolization and hysterectomy, which allows women to remain fertile, said Dr. Angelos Vilos, an ob.gyn. at Western University in London, Ontario, and the study’ lead investigator.

Dr. Vilos and his team used uterine tamponade to control bleeding, then gave the women oral tranexamic acid for 5 days. Patients also received a GnRH agonist – usually one injection of leuprolide – with oral letrozole for 5 days after the injection. In all cases, the arteriovenous malformations resolved within 3 months.

In a video interview at the AAGL meeting, Dr. Vilos said the approach could be a “game changer” if it holds up in future testing.

[email protected]

SAN FRANCISCO – When naltrexone is not an option for alcohol use disorder, topiramate is a good choice for many patients, according to Dr. Steven L. Batki, psychiatry professor and addiction researcher at the University of California, San Francisco.

Naltrexone is often the first-line option, because it’s relatively inexpensive, simple to dose orally or by injection, and “probably has the greatest evidence” for reducing use and craving, he said at the American Psychiatric Association’s Institute on Psychiatric Services (JAMA 2014;311:1889-1900).

RTEmagicC_b7f0cb3_Batki_Steven_CA.jpg.jpg

But GI upset is common with the drug, and, like disulfiram, it can cause liver problems. It’s also contraindicated with recent opioid use.

When those are problems, “I would go to topiramate. It reliably reduces craving ... might reduce postwithdrawal dysphoria and anxiety,” and numb the reaction to drinking cues. “There’s quite an effect size for abstinence [versus] placebo.” In some studies, it “works even better than acamprosate or naltrexone,” Dr. Batki said.

The issue with topiramate (Topamax), however, is dose titration. If it’s too fast, the reason for the drug’s slang name – “dopamax” – becomes clear: “excessively rapid up-titration in some patients has led to word searching, and other memory and concentration problems. You can also get paresthesias,” he said.

Because of that, in a study Dr. Batki led that found topiramate reduces alcohol use and hyperarousal in veterans with posttraumatic stress disorder, “we increased the dose very slowly,” starting at 25 mg a day and going up over 6 weeks to 300 mg a day; 300 mg daily is the standard dose, but “I think much lower doses might be effective.” Several studies show as little as 200 mg and perhaps even less may be effective for alcohol use. “We really don’t know what the effective dose is,” he said (Alcohol Clin. Exp. Res. 2014;38:2169-77).

Kidney stones, metabolic acidosis, and narrow angle glaucoma are all possible side effects of the drug, “so anyone who gets eye pain on topiramate” must be taken off immediately. As with other renally excreted alcohol treatment drugs, “cut the dose in half if patients are renally impaired,” Dr. Batki said.

Dosing with another treatment option, gabapentin is generally 600 mg t.i.d., but its effective dose is also “not fully worked out yet.” It seems to increase abstinence and decrease craving but at the cost for some of sedation, dizziness, and edema. “It’s important to check for lower extremity edema. I’ve seen quite a bit of that, especially in women,” he said.

Meanwhile, “there hasn’t been an American study with intention-to-treat analysis where acamprosate has separated from placebo; on secondary analysis it did work. It probably does work.” Dosing is about 2 grams a day, however. “I just haven’t found very many patients who can remember to take two big pills three times a day,” he said.

Dr. Batki has no relevant disclosures.

[email protected]

SAN FRANCISCO – When naltrexone is not an option for alcohol use disorder, topiramate is a good choice for many patients, according to Dr. Steven L. Batki, psychiatry professor and addiction researcher at the University of California, San Francisco.

Naltrexone is often the first-line option, because it’s relatively inexpensive, simple to dose orally or by injection, and “probably has the greatest evidence” for reducing use and craving, he said at the American Psychiatric Association’s Institute on Psychiatric Services (JAMA 2014;311:1889-1900).

RTEmagicC_b7f0cb3_Batki_Steven_CA.jpg.jpg

But GI upset is common with the drug, and, like disulfiram, it can cause liver problems. It’s also contraindicated with recent opioid use.

When those are problems, “I would go to topiramate. It reliably reduces craving ... might reduce postwithdrawal dysphoria and anxiety,” and numb the reaction to drinking cues. “There’s quite an effect size for abstinence [versus] placebo.” In some studies, it “works even better than acamprosate or naltrexone,” Dr. Batki said.

The issue with topiramate (Topamax), however, is dose titration. If it’s too fast, the reason for the drug’s slang name – “dopamax” – becomes clear: “excessively rapid up-titration in some patients has led to word searching, and other memory and concentration problems. You can also get paresthesias,” he said.

Because of that, in a study Dr. Batki led that found topiramate reduces alcohol use and hyperarousal in veterans with posttraumatic stress disorder, “we increased the dose very slowly,” starting at 25 mg a day and going up over 6 weeks to 300 mg a day; 300 mg daily is the standard dose, but “I think much lower doses might be effective.” Several studies show as little as 200 mg and perhaps even less may be effective for alcohol use. “We really don’t know what the effective dose is,” he said (Alcohol Clin. Exp. Res. 2014;38:2169-77).

Kidney stones, metabolic acidosis, and narrow angle glaucoma are all possible side effects of the drug, “so anyone who gets eye pain on topiramate” must be taken off immediately. As with other renally excreted alcohol treatment drugs, “cut the dose in half if patients are renally impaired,” Dr. Batki said.

Dosing with another treatment option, gabapentin is generally 600 mg t.i.d., but its effective dose is also “not fully worked out yet.” It seems to increase abstinence and decrease craving but at the cost for some of sedation, dizziness, and edema. “It’s important to check for lower extremity edema. I’ve seen quite a bit of that, especially in women,” he said.

Meanwhile, “there hasn’t been an American study with intention-to-treat analysis where acamprosate has separated from placebo; on secondary analysis it did work. It probably does work.” Dosing is about 2 grams a day, however. “I just haven’t found very many patients who can remember to take two big pills three times a day,” he said.

Dr. Batki has no relevant disclosures.

[email protected]

SAN FRANCISCO – When naltrexone is not an option for alcohol use disorder, topiramate is a good choice for many patients, according to Dr. Steven L. Batki, psychiatry professor and addiction researcher at the University of California, San Francisco.

Naltrexone is often the first-line option, because it’s relatively inexpensive, simple to dose orally or by injection, and “probably has the greatest evidence” for reducing use and craving, he said at the American Psychiatric Association’s Institute on Psychiatric Services (JAMA 2014;311:1889-1900).

RTEmagicC_b7f0cb3_Batki_Steven_CA.jpg.jpg

But GI upset is common with the drug, and, like disulfiram, it can cause liver problems. It’s also contraindicated with recent opioid use.

When those are problems, “I would go to topiramate. It reliably reduces craving ... might reduce postwithdrawal dysphoria and anxiety,” and numb the reaction to drinking cues. “There’s quite an effect size for abstinence [versus] placebo.” In some studies, it “works even better than acamprosate or naltrexone,” Dr. Batki said.

The issue with topiramate (Topamax), however, is dose titration. If it’s too fast, the reason for the drug’s slang name – “dopamax” – becomes clear: “excessively rapid up-titration in some patients has led to word searching, and other memory and concentration problems. You can also get paresthesias,” he said.

Because of that, in a study Dr. Batki led that found topiramate reduces alcohol use and hyperarousal in veterans with posttraumatic stress disorder, “we increased the dose very slowly,” starting at 25 mg a day and going up over 6 weeks to 300 mg a day; 300 mg daily is the standard dose, but “I think much lower doses might be effective.” Several studies show as little as 200 mg and perhaps even less may be effective for alcohol use. “We really don’t know what the effective dose is,” he said (Alcohol Clin. Exp. Res. 2014;38:2169-77).

Kidney stones, metabolic acidosis, and narrow angle glaucoma are all possible side effects of the drug, “so anyone who gets eye pain on topiramate” must be taken off immediately. As with other renally excreted alcohol treatment drugs, “cut the dose in half if patients are renally impaired,” Dr. Batki said.

Dosing with another treatment option, gabapentin is generally 600 mg t.i.d., but its effective dose is also “not fully worked out yet.” It seems to increase abstinence and decrease craving but at the cost for some of sedation, dizziness, and edema. “It’s important to check for lower extremity edema. I’ve seen quite a bit of that, especially in women,” he said.

Meanwhile, “there hasn’t been an American study with intention-to-treat analysis where acamprosate has separated from placebo; on secondary analysis it did work. It probably does work.” Dosing is about 2 grams a day, however. “I just haven’t found very many patients who can remember to take two big pills three times a day,” he said.

Dr. Batki has no relevant disclosures.

[email protected]

VANCOUVER, B.C.– A thorough preop work-up can just about eliminate the risk of accidentally morcellating an occult uterine sarcoma, according to a prospective series of 2,824 women referred for minimally invasive myomectomy to a French university hospital from 2002 to 2013.

The message came just days before the Food and Drug Administration’s Nov. 24 advice not to use power morcellationin the majority of women undergoing hysterectomy or myomectomy for uterine fibroids because “there is no reliable method for predicting whether a woman with fibroids may have a uterine sarcoma” that morcellation could spread. The agency estimated that about 1 in 350 fibroid patients actually have an occult sarcoma.

RTEmagicC_624a13d_Fazel_Afshin_FR.jpg.jpg

That’s close to the 1 in 400 incidence investigators at the Lariboisière Hospital in Paris found; the difference is that the French investigators detected all but one of the seven sarcomas in their series before entering the operating room, using a heightened screening protocol. “That’s the major difference between our series and the other series that the” FDA relied on for their advice, said lead investigator and gynecologic surgeon Dr. Afshin Fazel, an assistant professor of obstetrics and gynecology at Lariboisière Hospital.

Physicians at the hospital go further than some to rule out sarcomas prior to fibroid surgery. “Every single patient with a pelvic mass gets an MRI,” as well as a clinical exam and pelvic ultrasound. “If the endometrium is thicker than 4 mm, every patient older than 40 [years old] has endometrial sampling, and if there’s bleeding, every single patient has an office hysteroscopy.” A multidisciplinary team – oncologists, radiologists, gynecologists, and surgeons – review the results and select the appropriate surgical approach, Dr. Fazel said at a meeting sponsored by AAGL.

The screening protocol caught five of the seven sarcomas before surgery. A sixth case, a ruptured uterine sarcoma, presented emergently. All seven women had open surgeries, most had a hysterectomy as their initial operation, and none were morcellated. “The take-home message is that you need all the cards in your hand” to rule out sarcomas before myomectomy. No one screening test is sufficient. Some sarcomas, for instance, don’t have the usual MRI signs; of the three sarcomas the team had detected so far in 2014 – not included in the reported series – just one was found on MRI; the other two were found by endometrial sampling. “Preoperative diagnosis is the key to preventing [accidental] morcellation,” Dr. Fazel said.

The second message is that although “1 out of 400 fibroids in our series were actually sarcomas,” the extra screening meant that “the undiagnosed rate of sarcoma was” 0.035% (or 1 in 2,824), he said.

One of the sarcoma patients was from Taiwan, another was African, and the rest were French. Their age ranged from 38 to 78 years, with a mean age 50 years; two were postmenopausal. They had heavy bleeding and pain, and two had multiple masses. The average size of the uterus was 1,136 cc, and the average size of the mass 891 cc. Four of the seven patients died within 2 years of their surgery.

Among all 2,824 women, two-thirds had minimally invasive approaches, including 743 laparoscopic, 510 hysteroscopic, and 336 vaginal procedures; 262 had uterine artery embolization, which was pioneered by Lariboisière in the late 1980s.

Dr. Fazel said he has no disclosures.

[email protected]

VANCOUVER, B.C.– A thorough preop work-up can just about eliminate the risk of accidentally morcellating an occult uterine sarcoma, according to a prospective series of 2,824 women referred for minimally invasive myomectomy to a French university hospital from 2002 to 2013.

The message came just days before the Food and Drug Administration’s Nov. 24 advice not to use power morcellationin the majority of women undergoing hysterectomy or myomectomy for uterine fibroids because “there is no reliable method for predicting whether a woman with fibroids may have a uterine sarcoma” that morcellation could spread. The agency estimated that about 1 in 350 fibroid patients actually have an occult sarcoma.

RTEmagicC_624a13d_Fazel_Afshin_FR.jpg.jpg

That’s close to the 1 in 400 incidence investigators at the Lariboisière Hospital in Paris found; the difference is that the French investigators detected all but one of the seven sarcomas in their series before entering the operating room, using a heightened screening protocol. “That’s the major difference between our series and the other series that the” FDA relied on for their advice, said lead investigator and gynecologic surgeon Dr. Afshin Fazel, an assistant professor of obstetrics and gynecology at Lariboisière Hospital.

Physicians at the hospital go further than some to rule out sarcomas prior to fibroid surgery. “Every single patient with a pelvic mass gets an MRI,” as well as a clinical exam and pelvic ultrasound. “If the endometrium is thicker than 4 mm, every patient older than 40 [years old] has endometrial sampling, and if there’s bleeding, every single patient has an office hysteroscopy.” A multidisciplinary team – oncologists, radiologists, gynecologists, and surgeons – review the results and select the appropriate surgical approach, Dr. Fazel said at a meeting sponsored by AAGL.

The screening protocol caught five of the seven sarcomas before surgery. A sixth case, a ruptured uterine sarcoma, presented emergently. All seven women had open surgeries, most had a hysterectomy as their initial operation, and none were morcellated. “The take-home message is that you need all the cards in your hand” to rule out sarcomas before myomectomy. No one screening test is sufficient. Some sarcomas, for instance, don’t have the usual MRI signs; of the three sarcomas the team had detected so far in 2014 – not included in the reported series – just one was found on MRI; the other two were found by endometrial sampling. “Preoperative diagnosis is the key to preventing [accidental] morcellation,” Dr. Fazel said.

The second message is that although “1 out of 400 fibroids in our series were actually sarcomas,” the extra screening meant that “the undiagnosed rate of sarcoma was” 0.035% (or 1 in 2,824), he said.

One of the sarcoma patients was from Taiwan, another was African, and the rest were French. Their age ranged from 38 to 78 years, with a mean age 50 years; two were postmenopausal. They had heavy bleeding and pain, and two had multiple masses. The average size of the uterus was 1,136 cc, and the average size of the mass 891 cc. Four of the seven patients died within 2 years of their surgery.

Among all 2,824 women, two-thirds had minimally invasive approaches, including 743 laparoscopic, 510 hysteroscopic, and 336 vaginal procedures; 262 had uterine artery embolization, which was pioneered by Lariboisière in the late 1980s.

Dr. Fazel said he has no disclosures.

[email protected]

VANCOUVER, B.C.– A thorough preop work-up can just about eliminate the risk of accidentally morcellating an occult uterine sarcoma, according to a prospective series of 2,824 women referred for minimally invasive myomectomy to a French university hospital from 2002 to 2013.

The message came just days before the Food and Drug Administration’s Nov. 24 advice not to use power morcellationin the majority of women undergoing hysterectomy or myomectomy for uterine fibroids because “there is no reliable method for predicting whether a woman with fibroids may have a uterine sarcoma” that morcellation could spread. The agency estimated that about 1 in 350 fibroid patients actually have an occult sarcoma.

RTEmagicC_624a13d_Fazel_Afshin_FR.jpg.jpg

That’s close to the 1 in 400 incidence investigators at the Lariboisière Hospital in Paris found; the difference is that the French investigators detected all but one of the seven sarcomas in their series before entering the operating room, using a heightened screening protocol. “That’s the major difference between our series and the other series that the” FDA relied on for their advice, said lead investigator and gynecologic surgeon Dr. Afshin Fazel, an assistant professor of obstetrics and gynecology at Lariboisière Hospital.

Physicians at the hospital go further than some to rule out sarcomas prior to fibroid surgery. “Every single patient with a pelvic mass gets an MRI,” as well as a clinical exam and pelvic ultrasound. “If the endometrium is thicker than 4 mm, every patient older than 40 [years old] has endometrial sampling, and if there’s bleeding, every single patient has an office hysteroscopy.” A multidisciplinary team – oncologists, radiologists, gynecologists, and surgeons – review the results and select the appropriate surgical approach, Dr. Fazel said at a meeting sponsored by AAGL.

The screening protocol caught five of the seven sarcomas before surgery. A sixth case, a ruptured uterine sarcoma, presented emergently. All seven women had open surgeries, most had a hysterectomy as their initial operation, and none were morcellated. “The take-home message is that you need all the cards in your hand” to rule out sarcomas before myomectomy. No one screening test is sufficient. Some sarcomas, for instance, don’t have the usual MRI signs; of the three sarcomas the team had detected so far in 2014 – not included in the reported series – just one was found on MRI; the other two were found by endometrial sampling. “Preoperative diagnosis is the key to preventing [accidental] morcellation,” Dr. Fazel said.

The second message is that although “1 out of 400 fibroids in our series were actually sarcomas,” the extra screening meant that “the undiagnosed rate of sarcoma was” 0.035% (or 1 in 2,824), he said.

One of the sarcoma patients was from Taiwan, another was African, and the rest were French. Their age ranged from 38 to 78 years, with a mean age 50 years; two were postmenopausal. They had heavy bleeding and pain, and two had multiple masses. The average size of the uterus was 1,136 cc, and the average size of the mass 891 cc. Four of the seven patients died within 2 years of their surgery.

Among all 2,824 women, two-thirds had minimally invasive approaches, including 743 laparoscopic, 510 hysteroscopic, and 336 vaginal procedures; 262 had uterine artery embolization, which was pioneered by Lariboisière in the late 1980s.

Dr. Fazel said he has no disclosures.

[email protected]

SAN FRANCISCO – Oral antibiotics with mechanical bowel preparation significantly reduce surgical site infections, length of hospital stay, and readmissions in both open and laparoscopic elective colorectal surgery, according to a review of 8,415 cases in the National Surgery Quality Improvement Program.

It “should be adopted for elective colorectal surgery,” concluded the investigators, led by colorectal surgeon Melanie Morris of the University of Alabama at Birmingham.

RTEmagicC_782569a_Morris_Melanie_AL.jpg.jpg

A quarter of the patients had no bowel prep, 45% had mechanical prep alone – GoLytely or another laxative, and 30% received both oral antibiotics and mechanical prep. Partial colectomy and sigmoid resections were the most common procedures, generally for neoplasms or diverticulitis.

Overall, 15% of the no-prep group, 12% of the mechanical prep group, and 6.5% of the oral antibiotic plus mechanical prep group developed subsequent surgical site infections (SSIs), a statistically significant difference. Results were similar when broken down into superficial, deep wound, and organ space infections (J. Am. Coll. Surg. 2014:219;S18-19).

On multivariate analysis and after adjusting for diabetes, smoking, age, and other potential confounders, the antibiotic group was 54% less likely than the no-prep group to develop an SSI (odds ratio 0.46), 26% less likely to be readmitted (OR 0.74), and more likely to leave the hospital earlier, at about 4 days instead of 5 (OR 0.90). SSIs and readmissions were only slightly less likely in the mechanical prep–only group, compared with the no-prep group, and there was no difference in length of stay.

There were fewer anastomotic leaks, fewer cases of sepsis, less significant bleeding, and other benefits for oral antibiotics with mechanical preparation. In addition, there was a protective effect against 30-day mortality in open procedures.

“Even in the minimally invasive group,” about two-thirds of patients, “oral antibiotic prep … was protective for surgical site infections,” Dr. Morris said at the annual clinical congress of the American College of Surgeons.

Still, bowel prep remains “a very controversial topic.” Nationwide some surgeons prep, some don’t. “People have very strong beliefs that may or may not be rooted in the data,” she said.

There are concerns about fluid and electrolyte disturbances, Clostridium difficile overgrowth, and other potential problems. Plus, mechanical preparation hasn’t worked any better than placebo in recent studies, but many of those studies didn’t include oral antibiotics. Effective bowel prep includes both, Dr. Morris said.

It’s possible that confounders might have been at work in the Alabama study. Perhaps surgeons shied away from bowel prep in older, sicker patients, but the rate of acute renal injury was the same in all three study groups at about 0.9%, suggesting similar background comorbidities.

“I don’t think confounding issues” explain the findings. Previously, “we’ve shown the benefit of oral antibiotic bowel prep in a [Veterans Affairs] cohort, and now we’ve shown it in this national cohort,” Dr. Morris said (Dis. Colon. Rectum 2012;55:1160-6).

After a marked reduction in surgical site infections in the VA study, “we changed our practices. We now do mechanical and oral antibiotic preps and have seen a 50% reduction in our SSI rate. We don’t feel like we are doing anything else differently,” she said.

Dr. Morris has no disclosures.

[email protected]

SAN FRANCISCO – Oral antibiotics with mechanical bowel preparation significantly reduce surgical site infections, length of hospital stay, and readmissions in both open and laparoscopic elective colorectal surgery, according to a review of 8,415 cases in the National Surgery Quality Improvement Program.

It “should be adopted for elective colorectal surgery,” concluded the investigators, led by colorectal surgeon Melanie Morris of the University of Alabama at Birmingham.

RTEmagicC_782569a_Morris_Melanie_AL.jpg.jpg

A quarter of the patients had no bowel prep, 45% had mechanical prep alone – GoLytely or another laxative, and 30% received both oral antibiotics and mechanical prep. Partial colectomy and sigmoid resections were the most common procedures, generally for neoplasms or diverticulitis.

Overall, 15% of the no-prep group, 12% of the mechanical prep group, and 6.5% of the oral antibiotic plus mechanical prep group developed subsequent surgical site infections (SSIs), a statistically significant difference. Results were similar when broken down into superficial, deep wound, and organ space infections (J. Am. Coll. Surg. 2014:219;S18-19).

On multivariate analysis and after adjusting for diabetes, smoking, age, and other potential confounders, the antibiotic group was 54% less likely than the no-prep group to develop an SSI (odds ratio 0.46), 26% less likely to be readmitted (OR 0.74), and more likely to leave the hospital earlier, at about 4 days instead of 5 (OR 0.90). SSIs and readmissions were only slightly less likely in the mechanical prep–only group, compared with the no-prep group, and there was no difference in length of stay.

There were fewer anastomotic leaks, fewer cases of sepsis, less significant bleeding, and other benefits for oral antibiotics with mechanical preparation. In addition, there was a protective effect against 30-day mortality in open procedures.

“Even in the minimally invasive group,” about two-thirds of patients, “oral antibiotic prep … was protective for surgical site infections,” Dr. Morris said at the annual clinical congress of the American College of Surgeons.

Still, bowel prep remains “a very controversial topic.” Nationwide some surgeons prep, some don’t. “People have very strong beliefs that may or may not be rooted in the data,” she said.

There are concerns about fluid and electrolyte disturbances, Clostridium difficile overgrowth, and other potential problems. Plus, mechanical preparation hasn’t worked any better than placebo in recent studies, but many of those studies didn’t include oral antibiotics. Effective bowel prep includes both, Dr. Morris said.

It’s possible that confounders might have been at work in the Alabama study. Perhaps surgeons shied away from bowel prep in older, sicker patients, but the rate of acute renal injury was the same in all three study groups at about 0.9%, suggesting similar background comorbidities.

“I don’t think confounding issues” explain the findings. Previously, “we’ve shown the benefit of oral antibiotic bowel prep in a [Veterans Affairs] cohort, and now we’ve shown it in this national cohort,” Dr. Morris said (Dis. Colon. Rectum 2012;55:1160-6).

After a marked reduction in surgical site infections in the VA study, “we changed our practices. We now do mechanical and oral antibiotic preps and have seen a 50% reduction in our SSI rate. We don’t feel like we are doing anything else differently,” she said.

Dr. Morris has no disclosures.

[email protected]

SAN FRANCISCO – Oral antibiotics with mechanical bowel preparation significantly reduce surgical site infections, length of hospital stay, and readmissions in both open and laparoscopic elective colorectal surgery, according to a review of 8,415 cases in the National Surgery Quality Improvement Program.

It “should be adopted for elective colorectal surgery,” concluded the investigators, led by colorectal surgeon Melanie Morris of the University of Alabama at Birmingham.

RTEmagicC_782569a_Morris_Melanie_AL.jpg.jpg

A quarter of the patients had no bowel prep, 45% had mechanical prep alone – GoLytely or another laxative, and 30% received both oral antibiotics and mechanical prep. Partial colectomy and sigmoid resections were the most common procedures, generally for neoplasms or diverticulitis.

Overall, 15% of the no-prep group, 12% of the mechanical prep group, and 6.5% of the oral antibiotic plus mechanical prep group developed subsequent surgical site infections (SSIs), a statistically significant difference. Results were similar when broken down into superficial, deep wound, and organ space infections (J. Am. Coll. Surg. 2014:219;S18-19).

On multivariate analysis and after adjusting for diabetes, smoking, age, and other potential confounders, the antibiotic group was 54% less likely than the no-prep group to develop an SSI (odds ratio 0.46), 26% less likely to be readmitted (OR 0.74), and more likely to leave the hospital earlier, at about 4 days instead of 5 (OR 0.90). SSIs and readmissions were only slightly less likely in the mechanical prep–only group, compared with the no-prep group, and there was no difference in length of stay.

There were fewer anastomotic leaks, fewer cases of sepsis, less significant bleeding, and other benefits for oral antibiotics with mechanical preparation. In addition, there was a protective effect against 30-day mortality in open procedures.

“Even in the minimally invasive group,” about two-thirds of patients, “oral antibiotic prep … was protective for surgical site infections,” Dr. Morris said at the annual clinical congress of the American College of Surgeons.

Still, bowel prep remains “a very controversial topic.” Nationwide some surgeons prep, some don’t. “People have very strong beliefs that may or may not be rooted in the data,” she said.

There are concerns about fluid and electrolyte disturbances, Clostridium difficile overgrowth, and other potential problems. Plus, mechanical preparation hasn’t worked any better than placebo in recent studies, but many of those studies didn’t include oral antibiotics. Effective bowel prep includes both, Dr. Morris said.

It’s possible that confounders might have been at work in the Alabama study. Perhaps surgeons shied away from bowel prep in older, sicker patients, but the rate of acute renal injury was the same in all three study groups at about 0.9%, suggesting similar background comorbidities.

“I don’t think confounding issues” explain the findings. Previously, “we’ve shown the benefit of oral antibiotic bowel prep in a [Veterans Affairs] cohort, and now we’ve shown it in this national cohort,” Dr. Morris said (Dis. Colon. Rectum 2012;55:1160-6).

After a marked reduction in surgical site infections in the VA study, “we changed our practices. We now do mechanical and oral antibiotic preps and have seen a 50% reduction in our SSI rate. We don’t feel like we are doing anything else differently,” she said.

Dr. Morris has no disclosures.

[email protected]

SAN FRANCISCO – Patients with stage I colorectal cancer should be followed as closely as patients with higher-stage primary tumors after resection, according to a prospective 6-year surveillance study of 1,202 British patients.

The reason is that the incidence of recurrences that can be treated surgically with curative intent is the same in stage I patients as it is in patients with stage II and III primaries, about 6% (J. Am. Coll. Surg. 2014:219;e46-47).

Following resection with clear margins, the patients were randomized about 300 per group to either serial CT surveillance, serial carcinoembryonic antigen (CEA) monitoring, both, or minimum surveillance, and followed for a median of 4.4 years. About a quarter of the subjects had Dukes’ A primaries and a quarter Dukes’ C primaries, and about half had Dukes’ B primaries. The A, B, C designations are similar to the stage I, II, and III designations more common in the United States.

On both sides of the Atlantic, guidelines focus on active surveillance for higher-stage primaries, but are ambivalent about monitoring stage I tumors because they are less likely to recur and the benefit of follow-up has been uncertain.

RTEmagicC_9b64cd3_Pugh_Sian_UK_2.jpg.jpg

That needs to change because treatable recurrences are what matters, and they are as likely in low-stage disease as in high-stage disease, lead investigator Dr. Sian Pugh, a colorectal surgeon at the University of Southampton (England), said at the annual clinical congress of the American College of Surgeons.

“Picking up recurrences that are not treatable doesn’t help anyone; it just gives you bad news earlier,” she said. The benefit of follow-up is “finding treatable disease, and that’s independent of the stage of the primary tumor. We recommend equivalent follow-up for all patients with resected Dukes’ A-C colorectal cancer. The guidelines [should] be reconsidered,” she asserted.

Her team also thinks that the most cost-effective way to monitor patients is probably with CEA monitoring every 3 months for the first 2 years, CEA monitoring every 6 months thereafter until year 5, and a single CT at 12-18 months to catch recurrences that don’t express CEA. That strategy was three times more likely than minimal surveillance to find treatable recurrences, about the same as serial CTs and serial CTs with regular CEA monitoring.

“We don’t think patients need to be followed up quite as intensively as the guidelines suggest,” – for instance, CT scans every 6 months – “but we are waiting for more health economic analysis,” Dr. Pugh said.

Although treatable recurrences were equally likely in all the groups, they were more common in patients with lower-stage primary cancers. Among recurrences in patients with Dukes’ A primary tumors, 50% (13/26) were treated surgically with curative intent, compared with 40% (32/81) in patients with Dukes’ B primaries and 24% (20/82) in those with Dukes’ C.

Pulmonary recurrence was most frequent with rectal primary tumors, and multisite recurrence was most common from right-colonic cancers. Median survival following recurrence was 2.28 years and was influenced by stage and site of primary. Following recurrence, survival was highest in those with lower-stage and rectal primaries, and lowest in patients with higher-stage primaries and recurrence from the right colon.

Dr. Pugh had no disclosures. The work was funded by the U.K. National Health Service.

[email protected]

SAN FRANCISCO – Patients with stage I colorectal cancer should be followed as closely as patients with higher-stage primary tumors after resection, according to a prospective 6-year surveillance study of 1,202 British patients.

The reason is that the incidence of recurrences that can be treated surgically with curative intent is the same in stage I patients as it is in patients with stage II and III primaries, about 6% (J. Am. Coll. Surg. 2014:219;e46-47).

Following resection with clear margins, the patients were randomized about 300 per group to either serial CT surveillance, serial carcinoembryonic antigen (CEA) monitoring, both, or minimum surveillance, and followed for a median of 4.4 years. About a quarter of the subjects had Dukes’ A primaries and a quarter Dukes’ C primaries, and about half had Dukes’ B primaries. The A, B, C designations are similar to the stage I, II, and III designations more common in the United States.

On both sides of the Atlantic, guidelines focus on active surveillance for higher-stage primaries, but are ambivalent about monitoring stage I tumors because they are less likely to recur and the benefit of follow-up has been uncertain.

RTEmagicC_9b64cd3_Pugh_Sian_UK_2.jpg.jpg

That needs to change because treatable recurrences are what matters, and they are as likely in low-stage disease as in high-stage disease, lead investigator Dr. Sian Pugh, a colorectal surgeon at the University of Southampton (England), said at the annual clinical congress of the American College of Surgeons.

“Picking up recurrences that are not treatable doesn’t help anyone; it just gives you bad news earlier,” she said. The benefit of follow-up is “finding treatable disease, and that’s independent of the stage of the primary tumor. We recommend equivalent follow-up for all patients with resected Dukes’ A-C colorectal cancer. The guidelines [should] be reconsidered,” she asserted.

Her team also thinks that the most cost-effective way to monitor patients is probably with CEA monitoring every 3 months for the first 2 years, CEA monitoring every 6 months thereafter until year 5, and a single CT at 12-18 months to catch recurrences that don’t express CEA. That strategy was three times more likely than minimal surveillance to find treatable recurrences, about the same as serial CTs and serial CTs with regular CEA monitoring.

“We don’t think patients need to be followed up quite as intensively as the guidelines suggest,” – for instance, CT scans every 6 months – “but we are waiting for more health economic analysis,” Dr. Pugh said.

Although treatable recurrences were equally likely in all the groups, they were more common in patients with lower-stage primary cancers. Among recurrences in patients with Dukes’ A primary tumors, 50% (13/26) were treated surgically with curative intent, compared with 40% (32/81) in patients with Dukes’ B primaries and 24% (20/82) in those with Dukes’ C.

Pulmonary recurrence was most frequent with rectal primary tumors, and multisite recurrence was most common from right-colonic cancers. Median survival following recurrence was 2.28 years and was influenced by stage and site of primary. Following recurrence, survival was highest in those with lower-stage and rectal primaries, and lowest in patients with higher-stage primaries and recurrence from the right colon.

Dr. Pugh had no disclosures. The work was funded by the U.K. National Health Service.

[email protected]

SAN FRANCISCO – Patients with stage I colorectal cancer should be followed as closely as patients with higher-stage primary tumors after resection, according to a prospective 6-year surveillance study of 1,202 British patients.

The reason is that the incidence of recurrences that can be treated surgically with curative intent is the same in stage I patients as it is in patients with stage II and III primaries, about 6% (J. Am. Coll. Surg. 2014:219;e46-47).

Following resection with clear margins, the patients were randomized about 300 per group to either serial CT surveillance, serial carcinoembryonic antigen (CEA) monitoring, both, or minimum surveillance, and followed for a median of 4.4 years. About a quarter of the subjects had Dukes’ A primaries and a quarter Dukes’ C primaries, and about half had Dukes’ B primaries. The A, B, C designations are similar to the stage I, II, and III designations more common in the United States.

On both sides of the Atlantic, guidelines focus on active surveillance for higher-stage primaries, but are ambivalent about monitoring stage I tumors because they are less likely to recur and the benefit of follow-up has been uncertain.

RTEmagicC_9b64cd3_Pugh_Sian_UK_2.jpg.jpg

That needs to change because treatable recurrences are what matters, and they are as likely in low-stage disease as in high-stage disease, lead investigator Dr. Sian Pugh, a colorectal surgeon at the University of Southampton (England), said at the annual clinical congress of the American College of Surgeons.

“Picking up recurrences that are not treatable doesn’t help anyone; it just gives you bad news earlier,” she said. The benefit of follow-up is “finding treatable disease, and that’s independent of the stage of the primary tumor. We recommend equivalent follow-up for all patients with resected Dukes’ A-C colorectal cancer. The guidelines [should] be reconsidered,” she asserted.

Her team also thinks that the most cost-effective way to monitor patients is probably with CEA monitoring every 3 months for the first 2 years, CEA monitoring every 6 months thereafter until year 5, and a single CT at 12-18 months to catch recurrences that don’t express CEA. That strategy was three times more likely than minimal surveillance to find treatable recurrences, about the same as serial CTs and serial CTs with regular CEA monitoring.

“We don’t think patients need to be followed up quite as intensively as the guidelines suggest,” – for instance, CT scans every 6 months – “but we are waiting for more health economic analysis,” Dr. Pugh said.

Although treatable recurrences were equally likely in all the groups, they were more common in patients with lower-stage primary cancers. Among recurrences in patients with Dukes’ A primary tumors, 50% (13/26) were treated surgically with curative intent, compared with 40% (32/81) in patients with Dukes’ B primaries and 24% (20/82) in those with Dukes’ C.

Pulmonary recurrence was most frequent with rectal primary tumors, and multisite recurrence was most common from right-colonic cancers. Median survival following recurrence was 2.28 years and was influenced by stage and site of primary. Following recurrence, survival was highest in those with lower-stage and rectal primaries, and lowest in patients with higher-stage primaries and recurrence from the right colon.

Dr. Pugh had no disclosures. The work was funded by the U.K. National Health Service.

[email protected]

SAN FRANCISCO– Little steps, when added together, lead to big reductions in serious reportable events in the operating room, according to investigators from the Phoenix-based Banner Health system.

After slight modifications to the count, timeout, and other OR procedures, Banner saw a 52% reduction in serious reportable events (SREs), including a 70% reduction in wrong-site surgeries, across its 22 hospitals and 8 ambulatory surgery centers (J. Am. Coll. Surg. 2014 Oct. 4 [doi:http://dx.doi.org/10.1016/j.jamcollsurg.2014.09.018]).

In an interview at the annual clinical congress of the American College of Surgeons, lead investigator Dr. Terrence Loftus, the health system’s medical director of surgery services and clinical resources, explained how they did it. He also explained why surgical SREs are seven times more common in the system’s robotic surgery program, despite overall improvements, and what Banner is planning to do about it.

[email protected]

SAN FRANCISCO– Little steps, when added together, lead to big reductions in serious reportable events in the operating room, according to investigators from the Phoenix-based Banner Health system.

After slight modifications to the count, timeout, and other OR procedures, Banner saw a 52% reduction in serious reportable events (SREs), including a 70% reduction in wrong-site surgeries, across its 22 hospitals and 8 ambulatory surgery centers (J. Am. Coll. Surg. 2014 Oct. 4 [doi:http://dx.doi.org/10.1016/j.jamcollsurg.2014.09.018]).

In an interview at the annual clinical congress of the American College of Surgeons, lead investigator Dr. Terrence Loftus, the health system’s medical director of surgery services and clinical resources, explained how they did it. He also explained why surgical SREs are seven times more common in the system’s robotic surgery program, despite overall improvements, and what Banner is planning to do about it.

[email protected]

SAN FRANCISCO– Little steps, when added together, lead to big reductions in serious reportable events in the operating room, according to investigators from the Phoenix-based Banner Health system.

After slight modifications to the count, timeout, and other OR procedures, Banner saw a 52% reduction in serious reportable events (SREs), including a 70% reduction in wrong-site surgeries, across its 22 hospitals and 8 ambulatory surgery centers (J. Am. Coll. Surg. 2014 Oct. 4 [doi:http://dx.doi.org/10.1016/j.jamcollsurg.2014.09.018]).

In an interview at the annual clinical congress of the American College of Surgeons, lead investigator Dr. Terrence Loftus, the health system’s medical director of surgery services and clinical resources, explained how they did it. He also explained why surgical SREs are seven times more common in the system’s robotic surgery program, despite overall improvements, and what Banner is planning to do about it.

[email protected]

SAN FRANCISCO – To meet the Affordable Care Act’s goal of integrated health care, access to mental health services is going to have to improve, according to Dr. Roderick E. Shaner, medical director of the Los Angeles County Department of Mental Health.

That’s going to mean more electronic consultations with primary care providers needing advice, in addition to traditional face-to-face meetings with patients.

At the American Psychiatric Association’s Institute on Psychiatric Services meeting, Dr. Shaner shared what his county has learned so far about implementing the ACA, and insights about how his psychiatrists are paid for their electronic consultations.

[email protected]

SAN FRANCISCO – To meet the Affordable Care Act’s goal of integrated health care, access to mental health services is going to have to improve, according to Dr. Roderick E. Shaner, medical director of the Los Angeles County Department of Mental Health.

That’s going to mean more electronic consultations with primary care providers needing advice, in addition to traditional face-to-face meetings with patients.

At the American Psychiatric Association’s Institute on Psychiatric Services meeting, Dr. Shaner shared what his county has learned so far about implementing the ACA, and insights about how his psychiatrists are paid for their electronic consultations.

[email protected]

SAN FRANCISCO – To meet the Affordable Care Act’s goal of integrated health care, access to mental health services is going to have to improve, according to Dr. Roderick E. Shaner, medical director of the Los Angeles County Department of Mental Health.

That’s going to mean more electronic consultations with primary care providers needing advice, in addition to traditional face-to-face meetings with patients.

At the American Psychiatric Association’s Institute on Psychiatric Services meeting, Dr. Shaner shared what his county has learned so far about implementing the ACA, and insights about how his psychiatrists are paid for their electronic consultations.

[email protected]

SAN FRANCISCO – If current trends continue, vagotomy and gastrectomy for bleeding peptic ulcers will be mostly a thing of the past, according to Dr. Mikhail Kryzhanouski, a surgery resident at the University of Illinois, Chicago.

Their use is quickly fading, eclipsed by better techniques and a steady drop in adverse outcomes, even though patients are presenting with more comorbidities, Dr. Kryzhanouski found in a review of patients in the U.S. Nationwide Inpatient Sample who were hospitalized for peptic ulcers from 1998 to 2011 (J. Am. Coll. Surg. 2014;219:e142).

Dr. Kryzhanouski shared the results of his study – and the reasons for his prediction – at the American College of Surgeons Clinical Congress.

[email protected]

SAN FRANCISCO – If current trends continue, vagotomy and gastrectomy for bleeding peptic ulcers will be mostly a thing of the past, according to Dr. Mikhail Kryzhanouski, a surgery resident at the University of Illinois, Chicago.

Their use is quickly fading, eclipsed by better techniques and a steady drop in adverse outcomes, even though patients are presenting with more comorbidities, Dr. Kryzhanouski found in a review of patients in the U.S. Nationwide Inpatient Sample who were hospitalized for peptic ulcers from 1998 to 2011 (J. Am. Coll. Surg. 2014;219:e142).

Dr. Kryzhanouski shared the results of his study – and the reasons for his prediction – at the American College of Surgeons Clinical Congress.

[email protected]

SAN FRANCISCO – If current trends continue, vagotomy and gastrectomy for bleeding peptic ulcers will be mostly a thing of the past, according to Dr. Mikhail Kryzhanouski, a surgery resident at the University of Illinois, Chicago.

Their use is quickly fading, eclipsed by better techniques and a steady drop in adverse outcomes, even though patients are presenting with more comorbidities, Dr. Kryzhanouski found in a review of patients in the U.S. Nationwide Inpatient Sample who were hospitalized for peptic ulcers from 1998 to 2011 (J. Am. Coll. Surg. 2014;219:e142).

Dr. Kryzhanouski shared the results of his study – and the reasons for his prediction – at the American College of Surgeons Clinical Congress.

[email protected]

SAN FRANCISCO – Surgeons improve if they know they are behind the curve, according to Dr. Judy A. Tjoe, a breast cancer surgeon with Milwaukee-based Aurora Health Care.

She and her colleagues used that principle to significantly increase Aurora’s use of minimally invasive breast biopsies, the gold standard to diagnose breast cancer.

Although Dr. Tjoe and the system’s other three dedicated breast surgeons were using MIBB as appropriate, they found that 9 of 42 general surgeons (21%) were not, opting instead for open biopsies.

All it took to fix the problem was letting those surgeons know that minimally invasive breast biopsies was the preferred method, and that most of their peers were using it.

In a video interview at the American College of Surgeons Clinical Congress, Dr. Tjoe, also chair of Aurora’s quality committee for breast cancer care, explained why that message was so powerful, and how, in an era of pay for performance, the project is a model for improving health care without punitive measures.

[email protected]

SAN FRANCISCO – Surgeons improve if they know they are behind the curve, according to Dr. Judy A. Tjoe, a breast cancer surgeon with Milwaukee-based Aurora Health Care.

She and her colleagues used that principle to significantly increase Aurora’s use of minimally invasive breast biopsies, the gold standard to diagnose breast cancer.

Although Dr. Tjoe and the system’s other three dedicated breast surgeons were using MIBB as appropriate, they found that 9 of 42 general surgeons (21%) were not, opting instead for open biopsies.

All it took to fix the problem was letting those surgeons know that minimally invasive breast biopsies was the preferred method, and that most of their peers were using it.

In a video interview at the American College of Surgeons Clinical Congress, Dr. Tjoe, also chair of Aurora’s quality committee for breast cancer care, explained why that message was so powerful, and how, in an era of pay for performance, the project is a model for improving health care without punitive measures.

[email protected]

SAN FRANCISCO – Surgeons improve if they know they are behind the curve, according to Dr. Judy A. Tjoe, a breast cancer surgeon with Milwaukee-based Aurora Health Care.

She and her colleagues used that principle to significantly increase Aurora’s use of minimally invasive breast biopsies, the gold standard to diagnose breast cancer.

Although Dr. Tjoe and the system’s other three dedicated breast surgeons were using MIBB as appropriate, they found that 9 of 42 general surgeons (21%) were not, opting instead for open biopsies.

All it took to fix the problem was letting those surgeons know that minimally invasive breast biopsies was the preferred method, and that most of their peers were using it.

In a video interview at the American College of Surgeons Clinical Congress, Dr. Tjoe, also chair of Aurora’s quality committee for breast cancer care, explained why that message was so powerful, and how, in an era of pay for performance, the project is a model for improving health care without punitive measures.

[email protected]