Surgical treatment of extensive and confluent anal condylomata results in large open wounds, whic... more Surgical treatment of extensive and confluent anal condylomata results in large open wounds, which in other contexts of anorectal surgery (e.g., hemorrhoidectomy), have been associated with a relevant risk of stricture formation. The aim of our study was therefore to revisit the issue and assess this risk and the general morbidity in patients undergoing extensive excision and fulguration of anal warts. Records of 41 consecutive patients undergoing with excision/fulguration of extensive, i.e., >50% confluent anal condylomata were retrospectively reviewed. Excluded were patients with a lesser degree of warts and patients lost to follow-up before complete wound healing. Data recorded included patient characteristics and evolution of the local area after the surgery. Forty-one patients (40 males and one female) underwent excision and fulguration of a large anal condyloma with an average follow-up of 6 months (range, 1-36 months). The majority of patients (97.6%) were HIV-positive with 80% taking antiretroviral medication. Half of the patients had not received any previous medical or surgical treatment, whereas one fourth had undergone surgical excisions or fulgurations before. Recurrent warts developed in 19 patients (46.3%). The surgical morbidity after the extensive excision consisted of bleeding (22%). However, none of the patients showed any evidence or complaints of postoperative stricturing and anal stenosis at follow-up. Excision of extensive anal condylomata has a known high probability of recurrences, but the risk of developing anal stenosis is low. Careful primary excision of even confluent warts can therefore be safely performed without major primary flap reconstructions.
This quality improvement study involves comparison of opioid prescription data before and after i... more This quality improvement study involves comparison of opioid prescription data before and after implementation of an opioid stewardship program in a safety-net medical system.
e15597 Background: Patients with locally advanced rectal cancer (LARC) typically receive chemorad... more e15597 Background: Patients with locally advanced rectal cancer (LARC) typically receive chemoradiation prior to surgery, followed by adjuvant chemotherapy (standard). Recently there has been a growing trend toward total neoadjuvant therapy (TNT), in which all chemotherapy is given in the neoadjuvant setting, having the advantage of higher chemotherapy completion rates. Data exploring adherence to both standard therapy and TNT within a vulnerable, underserved population is lacking. Within our safety-net hospital, we determined the chemotherapy completion rates for LARC patients who received TNT vs standard treatment. We also compared two populations within the standard treatment group- those who received all doses of prescribed adjuvant chemotherapy (AC) and those who did not. Methods: A retrospective chart review was performed for all patients with LARC (stage II or III) presenting to Los Angeles County + USC Medical Center from 2015 to 2020. Patients who progressed prior to receiv...
Improving patient safety is vital for all hospitals due to increasing public reporting and pay-fo... more Improving patient safety is vital for all hospitals due to increasing public reporting and pay-for-performance reimbursement. Venous thromboembolism (VTE) remains a leading cause of preventable mortality accounting for 5 per cent of inpatient deaths. The purpose of this study was to outline the process of implementing standard VTE prophylactic order sets in a 600-bed academic safety net hospital and assess the resulting change in patient outcomes. Outcomes were assessed by comparing the rate that eligible inpatients receive VTE prophylaxis and the rate of preventable VTE's compared with total VTE's. From 2011 to 2015, random samples of 60 Los Angeles County+University of Southern California inpatients were generated monthly to examine compliance rates by comparing ICD-9 diagnostic codes to ordered VTE prophylaxis. All inpatient VTE's are retrospectively analyzed. Baseline-ordered VTE prophylaxis was 37 per cent in 2010. The target of 85 per cent was exceeded by the secon...
To prospectively evaluate the ability of radio frequency detection (RFD) system-embedded sponges ... more To prospectively evaluate the ability of radio frequency detection (RFD) system-embedded sponges to mitigate the incidence of retained surgical sponges (RSS) after emergency surgery. Emergency surgery patients are at high risk for retained foreign bodies. All emergent trauma and nontrauma cavitary operations over a 5-year period (January 2010-December 2014) were prospectively enrolled. For damage-control procedures, only the definitive closure was included. RFD sponges were used exclusively throughout the study period. Before closure, the sponge and instrument count was followed by RFD scanning and x-ray evaluation for retained sponges. RSS and near-misses averted using the RFD system were analyzed. In all, 2051 patients [median (range)], aged 41 (1-101) years, 72.2% male, 46.8% trauma patients, underwent 2148 operations (1824 laparotomy, 100 thoracotomy, 30 sternotomy, and 97 combined). RFD detected retained sponges in 11 (0.5%) patients (81.8%laparotomy, 18.2% sternotomy) before c...
After surgical debridement, the use of fecal diversion systems (such as an endo-rectal tube or su... more After surgical debridement, the use of fecal diversion systems (such as an endo-rectal tube or surgical colostomy) in Fournier's Gangrene (FG) to assist with wound healing remains controversial. A 6-y retrospective review of a tertiary medical center emergency surgery database was conducted. Variables abstracted from the database include patient demographics, laboratory and physiological profiles, hospital length-of-stay, intensive care unit length-of-stay, operative data, time to healing, morbidity, and mortality. Thirty-five patients were treated. Seventy-seven percent (n = 27) required some form of fecal diversion (21 patients using an endo-rectal tube and six patients undergoing construction of a surgical colostomy). One patient had a pre-existing colostomy before the development of FG. The remaining seven patients underwent conservative wound care with multiple daily dressing changes (no diversion system). Twenty-eight of the 35 patients (80.0%) had long-term follow-up with 100% having completely healed surgical wounds at the final clinic visit. Average time to complete wound healing was 4.8 ± 1.0 mo (range, 1.0-31.0). Of the six patients who underwent colostomy formation, two had their colostomies reversed, two were unacceptable surgical risk and did not undergo reversal (due to uncontrolled diabetes and cardiovascular disease), and two were lost to follow-up. Of the two patients who had their colostomies reversed both had complications from their reversal (leak and urinary retention). Surgical colostomy may not be mandatory (and might be associated with a high additional morbidity) in FG. With appropriate patient selection, it may be possible to avoid colostomy formation using a less-invasive diversion technology without compromising patient outcomes.
Journal of the American College of Surgeons, Jan 13, 2017
Outpatient laparoscopic appendectomy is being used increasingly as a treatment option for acute, ... more Outpatient laparoscopic appendectomy is being used increasingly as a treatment option for acute, uncomplicated appendicitis. This was a prospective validation study in a large, urban, public safety-net hospital. From 2014 to 2016, all patients undergoing laparoscopic appendectomy for acute, uncomplicated appendicitis were enrolled in a prospective observational trial. Standard baseline perioperative practice (control group) was documented for 1 year. An outpatient appendectomy protocol was then introduced. Inclusion criteria required intraoperative confirmation of uncomplicated appendicitis and strict discharge criteria, including physician assessment before discharge. Data collection then continued for 1 year (outpatient group). The outcomes measures examined included complications, length of stay, nursing transitions, emergency department visits, readmissions, and patient satisfaction. The study enrolled 351 patients (178 control, 173 outpatient). Of the 173 candidates for outpati...
Diverticulitis has become a medically managed disease process; the indications and timing of surg... more Diverticulitis has become a medically managed disease process; the indications and timing of surgical intervention have evolved. We retrospectively reviewed all patients who underwent surgical intervention due to diverticular disease by the Division of Colon and Rectal Surgery from 2012 to 2014. Ninety-eight surgeries were performed. Indications included colovesicular fistula, multiple recurrences of diverticulitis, medically refractory diverticulitis, stricture, abscess, colocutaneous fistula, and colovaginal fistula. Average length of stay was 5.7 ± 5.9 days (range, 1 to 51). Eighteen patients (18%) required an ostomy. Postoperative complications occurred in 18% of patients, including anastomotic leak (3.3%), wound infection (7.1%), acute kidney injury (5.1%), and urinary tract infection (2.0%). Thirty-day readmission rate was 7.2%; unplanned 30-day reoperation rate was 3.1%. There were no deaths. The type of patient undergoing surgery for diverticulitis has changed, with selection bias toward chronic, advanced disease due to the proliferation of medical management strategies.
The benefits of an enhanced recovery protocol (ERP) in colorectal surgery have been well describe... more The benefits of an enhanced recovery protocol (ERP) in colorectal surgery have been well described; however, data on the implementation process is minimal, especially in a resource-limited institution. The purpose of this study was to evaluate outcomes during implementation of a physician-driven ERP at a public-funded institution. We retrospectively reviewed all elective colorectal surgery during a transition from standard care to an ERP (implemented via a standard order sheet). Data regarding use of care plan, length of stay (LOS), and rates of postoperative complications and readmission were recorded. One hundred eleven patients were included in the study; however, complete use of the ERP after its introduction occurred in a total of 50 patients for a compliance rate of 60 per cent (95% confidence interval [CI], 49 to 70). Late implementation of ERP diet, analgesics, and activity were the most common process errors. Full application of the ERP reduced mean LOS by 3 days (P = 0.002...
Rectal foreign bodies represent a challenging and unique field of colorectal trauma. The approach... more Rectal foreign bodies represent a challenging and unique field of colorectal trauma. The approach includes a careful history and physical examination, a high index of suspicion for any evidence of perforation, a creative approach to nonoperative removal, and appropriate short-term follow-up to detect any delayed perforation.
Purpose: To investigate the effectiveness of a standardized vascular clinic (SVC) in teaching dia... more Purpose: To investigate the effectiveness of a standardized vascular clinic (SVC) in teaching diagnostic and management skills for common vascular problems, as compared with that of the traditional ambulatory setting.Methods: Third-year medical students participating in the required surgical clerkship participated in this study. Students were randomly assigned to attend either a 4-hour SVC experience (group 1, n = 64) or
Surgical treatment of extensive and confluent anal condylomata results in large open wounds, whic... more Surgical treatment of extensive and confluent anal condylomata results in large open wounds, which in other contexts of anorectal surgery (e.g., hemorrhoidectomy), have been associated with a relevant risk of stricture formation. The aim of our study was therefore to revisit the issue and assess this risk and the general morbidity in patients undergoing extensive excision and fulguration of anal warts. Records of 41 consecutive patients undergoing with excision/fulguration of extensive, i.e., >50% confluent anal condylomata were retrospectively reviewed. Excluded were patients with a lesser degree of warts and patients lost to follow-up before complete wound healing. Data recorded included patient characteristics and evolution of the local area after the surgery. Forty-one patients (40 males and one female) underwent excision and fulguration of a large anal condyloma with an average follow-up of 6 months (range, 1-36 months). The majority of patients (97.6%) were HIV-positive with 80% taking antiretroviral medication. Half of the patients had not received any previous medical or surgical treatment, whereas one fourth had undergone surgical excisions or fulgurations before. Recurrent warts developed in 19 patients (46.3%). The surgical morbidity after the extensive excision consisted of bleeding (22%). However, none of the patients showed any evidence or complaints of postoperative stricturing and anal stenosis at follow-up. Excision of extensive anal condylomata has a known high probability of recurrences, but the risk of developing anal stenosis is low. Careful primary excision of even confluent warts can therefore be safely performed without major primary flap reconstructions.
This quality improvement study involves comparison of opioid prescription data before and after i... more This quality improvement study involves comparison of opioid prescription data before and after implementation of an opioid stewardship program in a safety-net medical system.
e15597 Background: Patients with locally advanced rectal cancer (LARC) typically receive chemorad... more e15597 Background: Patients with locally advanced rectal cancer (LARC) typically receive chemoradiation prior to surgery, followed by adjuvant chemotherapy (standard). Recently there has been a growing trend toward total neoadjuvant therapy (TNT), in which all chemotherapy is given in the neoadjuvant setting, having the advantage of higher chemotherapy completion rates. Data exploring adherence to both standard therapy and TNT within a vulnerable, underserved population is lacking. Within our safety-net hospital, we determined the chemotherapy completion rates for LARC patients who received TNT vs standard treatment. We also compared two populations within the standard treatment group- those who received all doses of prescribed adjuvant chemotherapy (AC) and those who did not. Methods: A retrospective chart review was performed for all patients with LARC (stage II or III) presenting to Los Angeles County + USC Medical Center from 2015 to 2020. Patients who progressed prior to receiv...
Improving patient safety is vital for all hospitals due to increasing public reporting and pay-fo... more Improving patient safety is vital for all hospitals due to increasing public reporting and pay-for-performance reimbursement. Venous thromboembolism (VTE) remains a leading cause of preventable mortality accounting for 5 per cent of inpatient deaths. The purpose of this study was to outline the process of implementing standard VTE prophylactic order sets in a 600-bed academic safety net hospital and assess the resulting change in patient outcomes. Outcomes were assessed by comparing the rate that eligible inpatients receive VTE prophylaxis and the rate of preventable VTE's compared with total VTE's. From 2011 to 2015, random samples of 60 Los Angeles County+University of Southern California inpatients were generated monthly to examine compliance rates by comparing ICD-9 diagnostic codes to ordered VTE prophylaxis. All inpatient VTE's are retrospectively analyzed. Baseline-ordered VTE prophylaxis was 37 per cent in 2010. The target of 85 per cent was exceeded by the secon...
To prospectively evaluate the ability of radio frequency detection (RFD) system-embedded sponges ... more To prospectively evaluate the ability of radio frequency detection (RFD) system-embedded sponges to mitigate the incidence of retained surgical sponges (RSS) after emergency surgery. Emergency surgery patients are at high risk for retained foreign bodies. All emergent trauma and nontrauma cavitary operations over a 5-year period (January 2010-December 2014) were prospectively enrolled. For damage-control procedures, only the definitive closure was included. RFD sponges were used exclusively throughout the study period. Before closure, the sponge and instrument count was followed by RFD scanning and x-ray evaluation for retained sponges. RSS and near-misses averted using the RFD system were analyzed. In all, 2051 patients [median (range)], aged 41 (1-101) years, 72.2% male, 46.8% trauma patients, underwent 2148 operations (1824 laparotomy, 100 thoracotomy, 30 sternotomy, and 97 combined). RFD detected retained sponges in 11 (0.5%) patients (81.8%laparotomy, 18.2% sternotomy) before c...
After surgical debridement, the use of fecal diversion systems (such as an endo-rectal tube or su... more After surgical debridement, the use of fecal diversion systems (such as an endo-rectal tube or surgical colostomy) in Fournier's Gangrene (FG) to assist with wound healing remains controversial. A 6-y retrospective review of a tertiary medical center emergency surgery database was conducted. Variables abstracted from the database include patient demographics, laboratory and physiological profiles, hospital length-of-stay, intensive care unit length-of-stay, operative data, time to healing, morbidity, and mortality. Thirty-five patients were treated. Seventy-seven percent (n = 27) required some form of fecal diversion (21 patients using an endo-rectal tube and six patients undergoing construction of a surgical colostomy). One patient had a pre-existing colostomy before the development of FG. The remaining seven patients underwent conservative wound care with multiple daily dressing changes (no diversion system). Twenty-eight of the 35 patients (80.0%) had long-term follow-up with 100% having completely healed surgical wounds at the final clinic visit. Average time to complete wound healing was 4.8 ± 1.0 mo (range, 1.0-31.0). Of the six patients who underwent colostomy formation, two had their colostomies reversed, two were unacceptable surgical risk and did not undergo reversal (due to uncontrolled diabetes and cardiovascular disease), and two were lost to follow-up. Of the two patients who had their colostomies reversed both had complications from their reversal (leak and urinary retention). Surgical colostomy may not be mandatory (and might be associated with a high additional morbidity) in FG. With appropriate patient selection, it may be possible to avoid colostomy formation using a less-invasive diversion technology without compromising patient outcomes.
Journal of the American College of Surgeons, Jan 13, 2017
Outpatient laparoscopic appendectomy is being used increasingly as a treatment option for acute, ... more Outpatient laparoscopic appendectomy is being used increasingly as a treatment option for acute, uncomplicated appendicitis. This was a prospective validation study in a large, urban, public safety-net hospital. From 2014 to 2016, all patients undergoing laparoscopic appendectomy for acute, uncomplicated appendicitis were enrolled in a prospective observational trial. Standard baseline perioperative practice (control group) was documented for 1 year. An outpatient appendectomy protocol was then introduced. Inclusion criteria required intraoperative confirmation of uncomplicated appendicitis and strict discharge criteria, including physician assessment before discharge. Data collection then continued for 1 year (outpatient group). The outcomes measures examined included complications, length of stay, nursing transitions, emergency department visits, readmissions, and patient satisfaction. The study enrolled 351 patients (178 control, 173 outpatient). Of the 173 candidates for outpati...
Diverticulitis has become a medically managed disease process; the indications and timing of surg... more Diverticulitis has become a medically managed disease process; the indications and timing of surgical intervention have evolved. We retrospectively reviewed all patients who underwent surgical intervention due to diverticular disease by the Division of Colon and Rectal Surgery from 2012 to 2014. Ninety-eight surgeries were performed. Indications included colovesicular fistula, multiple recurrences of diverticulitis, medically refractory diverticulitis, stricture, abscess, colocutaneous fistula, and colovaginal fistula. Average length of stay was 5.7 ± 5.9 days (range, 1 to 51). Eighteen patients (18%) required an ostomy. Postoperative complications occurred in 18% of patients, including anastomotic leak (3.3%), wound infection (7.1%), acute kidney injury (5.1%), and urinary tract infection (2.0%). Thirty-day readmission rate was 7.2%; unplanned 30-day reoperation rate was 3.1%. There were no deaths. The type of patient undergoing surgery for diverticulitis has changed, with selection bias toward chronic, advanced disease due to the proliferation of medical management strategies.
The benefits of an enhanced recovery protocol (ERP) in colorectal surgery have been well describe... more The benefits of an enhanced recovery protocol (ERP) in colorectal surgery have been well described; however, data on the implementation process is minimal, especially in a resource-limited institution. The purpose of this study was to evaluate outcomes during implementation of a physician-driven ERP at a public-funded institution. We retrospectively reviewed all elective colorectal surgery during a transition from standard care to an ERP (implemented via a standard order sheet). Data regarding use of care plan, length of stay (LOS), and rates of postoperative complications and readmission were recorded. One hundred eleven patients were included in the study; however, complete use of the ERP after its introduction occurred in a total of 50 patients for a compliance rate of 60 per cent (95% confidence interval [CI], 49 to 70). Late implementation of ERP diet, analgesics, and activity were the most common process errors. Full application of the ERP reduced mean LOS by 3 days (P = 0.002...
Rectal foreign bodies represent a challenging and unique field of colorectal trauma. The approach... more Rectal foreign bodies represent a challenging and unique field of colorectal trauma. The approach includes a careful history and physical examination, a high index of suspicion for any evidence of perforation, a creative approach to nonoperative removal, and appropriate short-term follow-up to detect any delayed perforation.
Purpose: To investigate the effectiveness of a standardized vascular clinic (SVC) in teaching dia... more Purpose: To investigate the effectiveness of a standardized vascular clinic (SVC) in teaching diagnostic and management skills for common vascular problems, as compared with that of the traditional ambulatory setting.Methods: Third-year medical students participating in the required surgical clerkship participated in this study. Students were randomly assigned to attend either a 4-hour SVC experience (group 1, n = 64) or
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