IMPORTANCE Evidence about the efficacy of laparoscopic resection of rectal cancer is incomplete, particularly for patients with more advanced-stage disease. OBJECTIVE To determine whether laparoscopic resection is noninferior to open resection, as determined by gross pathologic and histologic evaluation of the resected proctectomy specimen. DESIGN, SETTING, AND PARTICIPANTS A multicenter, balanced, noninferiority, randomized trial enrolled patients between October 2008 and September 2013. The trial was conducted by credentialed surgeons from 35 institutions in the United States and Canada. A total of 486 patients with clinical stage II or III rectal cancer within 12 cm of the anal verge were randomized after completion of neoadjuvant therapy to laparoscopic or open resection. INTERVENTIONS Standard laparoscopic and open approaches were performed by the credentialed surgeons. MAIN OUTCOMES AND MEASURES The primary outcome assessing efficacy was a composite of circumferential radial margin greater than 1 mm, distal margin without tumor, and completeness of total mesorectal excision. A 6%noninferiority margin was chosen according to clinical relevance estimation. RESULTS Two hundred forty patients with laparoscopic resection and 222 with open resection were evaluable for analysis of the 486 enrolled. Successful resection occurred in 81.7%of laparoscopic resection cases (95%CI, 76.8%–86.6%) and 86.9%of open resection cases (95%CI, 82.5%–91.4%) and did not support noninferiority (difference, −5.3%; 1-sided 95%CI, −10.8%to ∞; P for noninferiority = .41). Patients underwent low anterior resection (76.7%) or abdominoperineal resection (23.3%). Conversion to open resection occurred in 11.3%of patients. Operative time was significantly longer for laparoscopic resection (mean, 266.2 vs 220.6 minutes; mean difference, 45.5 minutes; 95%CI, 27.7–63.4; P < .001). Length of stay (7.3 vs 7.0 days; mean difference, 0.3 days; 95%CI, −0.6 to 1.1), readmission within 30 days (3.3%vs 4.1%; difference, −0.7%; 95%CI, −4.2%to 2.7%), and severe complications (22.5%vs 22.1%; difference, 0.4%; 95%CI, −4.2%to 2.7%) did not differ significantly. Quality of the total mesorectal excision specimen in 462 operated and analyzed surgeries was complete (77%) and nearly complete (16.5%) in 93.5%of the cases. Negative circumferential radial margin was observed in 90% of the overall group (87.9% laparoscopic resection and 92.3%open resection; P = .11). Distal margin result was negative in more than 98%of patients irrespective of type of surgery (P = .91). CONCLUSIONS AND RELEVANCE Among patients with stage II or III rectal cancer, the use of laparoscopic resection compared with open resection failed to meet the criterion for noninferiority for pathologic outcomes. Pending clinical oncologic outcomes, the findings do not support the use of laparoscopic resection in these patients. TRIAL REGISTRATION clinicaltrials.gov Identifier: NCT00726622

(Grade 2C) prophylaxis be used other than early ambulation. For patients at low risk for VTE ( ‫ف‬ 1.5%), we suggest mechanical prophylaxis, preferably with intermittent pneumatic compression (IPC), over no prophylaxis (Grade 2C). For patients at moderate risk for VTE ( ‫ف‬ 3%) who are not at high risk for major bleeding complications, we suggest low-molecular-weight heparin (LMWH) (Grade 2B), low-dose unfractionated heparin (Grade 2B), or mechanical prophylaxis with IPC (Grade 2C) over no prophylaxis. For patients at high risk for VTE ( ‫ف‬ 6%) who are not at high risk for major bleeding complications, we recommend pharmacologic prophylaxis with LMWH (Grade 1B) or low-dose unfractionated heparin (Grade 1B) over no prophylaxis. In these patients, we suggest adding mechanical prophylaxis with elastic stockings or IPC to pharmacologic prophylaxis (Grade 2C). For patients at high risk for VTE undergoing abdominal or pelvic surgery for cancer, we recommend extended-duration, postoperative, pharmacologic prophylaxis (4 weeks) with LMWH over limited-duration prophylaxis (Grade 1B). For patients at moderate to high risk for VTE who are at high risk for major bleeding complications or those in whom the consequences of bleeding are believed to be particularly severe, we suggest use of mechanical prophylaxis, preferably with IPC, over no prophylaxis until the risk of bleeding diminishes and pharmacologic prophylaxis may be initiated (Grade 2C). For patients in all risk groups, we suggest that an inferior vena cava fi lter not be used for primary VTE prevention (Grade 2C) and that surveillance with venous compression ultrasonography should not be performed (Grade 2C). We developed similar recommendations for other nonorthopedic surgical populations. Conclusions: Optimal thromboprophylaxis in nonorthopedic surgical patients will consider the risks of VTE and bleeding complications as well as the values and preferences of individual patients. CHEST 2012; 141(2)(Suppl):e227S-e277SAbbreviations: CABG 5 coronary artery bypass graft; ES 5 elastic stockings; ICH 5 intracranial hemorrhage; IPC 5 intermittent pneumatic compression; IVC 5 inferior vena cava; LDUH 5 low-dose unfractionated heparin; LMWH 5 low-molecular-weight heparin; PE 5 pulmonary embolism; QALY 5 quality-adjusted life year; RR 5 risk ratio; VCU 5 venous compression ultrasonography

Laparoscopic assisted resection of rectal cancer was not found to be significantly different to OPEN resection of rectal cancer based on the outcomes of DFS and recurrence.

To date, solid organ and bone marrow transplantation between genetically disparate individuals has depended upon nonspecific immunosuppressive agents to control chronic rejection. Although these agents are vital to suppression of graft rejection, they have their own associated toxicities, including susceptibility to opportunistic infections, osteoporosis, impaired hepatic or renal function, and an increased incidence of neoplasms. Chronic rejection, in varying degrees of severity, often persists despite the use of these agents.Numerous methods have been attempted to induce specific transplantation tolerance. Experimental animal models have included neonatal bone marrow inoculation (1) and whole body irradiation, or fractionated total lymphoid irradiation coincident with bone marrow transplantation and immediate or deferred solid organ transplantation in adult recipients (2-4). As a preparation for subsequent organ allografts, these methods have the advantage of induction of specific, rather than nonspecific tolerance. However, bone marrow transplantation is currently limited by graft-vs.-host disease (GVHD) 1 (5), and a level of immunoincompetence probably resulting from failure of appropriate immune cell interactions in the reconstituted host (6-8). We have attempted to overcome these limitations in the murine system by reconstituting the lethally irradiated host with T cell-depleted syngeneic plus allogeneic bone marrow components (9). Such animals were specifically tolerant to donor-type, full-thickness tail skin grafts, and exhibited stable hematopoietic chimerism. In addition, survival rates were excellent, with no evidence for GVHD or wasting.We have presumed that such mixed reconstituted animals are superior to fully allogeneic chimeras because the presence of the syngeneic components overcomes the immunoincompetence that results from restriction of immune cell interactions in fully ailogeneic chimeras, while the allogeneic elements provide conditioning for induction of specific tolerance. We have now examined in detail patterns of reconstitution, immunocompetence, and in vitro reactivity of such l Abbreviations used in this paper: CML. cell-mediated lympholysis; Con A, concanavalin A; FITC fluorescein isothiocyanate; GVHD, graft-vs.-host disease; MEM, minimum essential medium; MHC, major histocompatibility complex; MLR, mixed lymphocyte reaction; MST, median survival time; PBL, peripheral blood lymphocyte; PFC, plaque-forming cell; RAMB, rabbit anti-mouse brain; SRBC, sheep red blood cell. J. ExP. MED.

Telehealth can be safely used in selected ambulatory patients as a substitute for the standard postoperative clinic visit with a high degree of patient satisfaction. Time and expense for travel (7-866 miles) were reduced and the freed clinic time was used to schedule new patients.

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IMPORTANCEThe COVID-19 pandemic has affected every aspect of medical care, including surgical treatment. It is critical to understand the association of government policies and infection burden with surgical access across the United States. OBJECTIVE To describe the change in surgical procedure volume in the US after the governmentsuggested shutdown and subsequent peak surge in volume of patients with COVID-19. DESIGN, SETTING, AND PARTICIPANTS This retrospective cohort study was conducted using administrative claims from a nationwide health care technology clearinghouse. Claims from pediatric and adult patients undergoing surgical procedures in 49 US states within the Change Healthcare network of health care institutions were used. Surgical procedure volume during the 2020 initial COVID-19-related shutdown and subsequent fall and winter infection surge were compared with volume in 2019. Data were analyzed from November 2020 through July 2021. EXPOSURES 2020 policies to curtail elective surgical procedures and the incidence rate of patients with COVID-19. MAIN OUTCOMES AND MEASURES Incidence rate ratios (IRRs) were estimated from a Poisson regression comparing total procedure counts during the initial shutdown (March 15 to May 2, 2020)

ObjectiveTo assess the treatment of peripancreatic fluid collections or abscess with percutaneous catheter drainage (PCD). Summary Background DataSurgical intervention has been the mainstay of treatment for infected peripancreatic fluid collections and abscesses. Increasingly, PCD has been used, with mixed results reported in the literature. MethodsA retrospective chart review of 1993 to 1997 was performed on 82 patients at a tertiary care public teaching hospital who had computed tomography-guided aspiration for suspected infected pancreatic fluid collection or abscess. Culture results, need for subsequent surgical intervention, length of stay, and death rate were assessed. ResultsOne hundred thirty-five aspirations were performed in 82 patients (57 male patients, 25 female patients) with a mean age of 40 years (range 17-68). The etiologies were alcohol (41), gallstones (32), and other (9). The mean number of Ranson's criteria was four (range 0 -9). All patients received antibiotics. Forty-eight patients had evidence of pancreatic necrosis on computed tomography scan. Cultures were negative in 40 patients and positive in 42. Twenty-five of the 42 culture-positive patients had PCD as primary therapy, and 6 required subsequent surgery. Eleven patients had primary surgical therapy, and five required subsequent surgery. Six patients were treated with only antibiotics. The death rates were 12% for culture-positive patients and 8% for the entire 82 patients. ConclusionsHistorically, patients with positive peripancreatic aspirate culture have required operation. This series reports an evolving strategy of reliance on catheter drainage. PCD should be considered as the initial therapy for culture-positive patients, with surgical intervention reserved for patients in whom treatment fails.Historically, the presence of an infected peripancreatic fluid collection or pancreatic abscess has mandated operation. Primary surgical treatment is successful for most patients, but the death rate is reportedly 15% to 80%, and surgery is associated with reoperation and prolonged lengths of stay.1 It has been more than 20 years since the treatment of pancreatic abscess was reviewed at our institution.2 In that report, Holden et al identified a death rate of 50% among 28 patients treated operatively and a complication rate of 93%.The availability of percutaneous catheter drainage (PCD) under radiologic guidance has replaced surgical drainage as the primary treatment of intraabdominal and hepatic abscesses. 3 A natural progression of the use of PCD has been its application for peripancreatic fluid collections and abscess. To ascertain the relative merits of PCD and to guide patient selection, we performed a retrospective chart review of patients with peripancreatic fluid collections or pancreatic abscess who had computed tomography (CT)-guided aspiration.