Latest Updates

Surgical Management of Fecal Incontinence

Asya Ofshteyn , MD, MPH, Daniel Popowich, MD, FACS, FASCRS
    • MRI defecography is obtained in real time as patient passes contrast during defecation. It is a noninvasive functional test, which can reveal anatomic defects including rectocele and rectal prolapse, the structure of surrounding pelvic organs and sphincter muscle anatomy. It is superior to endoanal ultrasonography in visualizing sphincter atrophy, which correlates with poor outcomes after sphincteroplasty, and can significantly influence surgical approach in patients who are operative candidates.
    • Sacral nerve stimulation (SNS) has been shown to have excellent results in terms of improvement in fecal incontinence in up to 90% of patients and achievement of complete continence in 1/3 of patients after multiple years of follow-up. Additionally, SNS improves fecal incontinence in patients with external sphincter tears, pudendal neuropathy and preceding sphincteroplasty. Because of these encouraging results, SNS is becoming the first-line surgical therapy for patient’s refractory to medical management. As SNS has gained traction, some colorectal surgeons proceed directly to the first stage of SNS placement as a combined diagnostic and therapeutic modality.
    • The Fenix system is an implantable device consisting of a ring of magnetized titanium beads that help keep the sphincter closed during defecation and can be forced open by bearing down during normal defecation. This device is currently under investigation, comparing its effectiveness with SNS in a large multicenter randomized controlled trial.

Anal Cancer

David Shibata, MD, Miriam Tsao, MD
    • Response to chemoradiation should be assessed for up to 26 weeks, provided there is no evidence of progression.
    • Varying regimens for chemoradiation, including capecitabine, as an alternative to 5-fluorouracil and the introduction of intensity-modulated radiation therapy
    • Nivolumab as a potential second- or third-line treatment in refractory metastatic squamous cell carcinoma

Morbid Obesity

Megan Adams, DO, MBA, Breck Finzer, MD, John P Lawrence, MD, MEd, MBA
    • The use of suggamadex versus traditional neuromuscular blockade reversal may lead to improved postoperative pulmonary outcomes in obese patients.
    • The advent and use of less fat-soluble volatile anesthetics, such as desflurane, leads to faster emergence and return of airway reflexes and may improve postoperative pulmonary outcomes in the obese patient.
    • Creation of obesity-specific perioperative guidelines from the Society of Bariatric Anesthesia
    • Creation of specific operative equipment to assist with the transportation and positioning of obese patients

Spine and Spinal Cord Injury

Miguel Arribas, MD, Michael A. Cole, MD
    • Blood pressure management is essential in spinal injury management: IV Crystalloid, blood products and/or norepinephrine should be used to maintain SBP >90 mmHg and MAP between 85-90 mm Hg
    • Intravenous steroid administration may be considered in the first 8 hours after blunt spinal cord injury in consultation with a spinal specialist and with patient and/or family understanding the risks and benefits.
    • If required, surgical intervention within 24 hours of injury is associated with improved long-term outcomes in spinal cord injury.

Spine and Spinal Cord Injury

Miguel Arribas, MD, Michael A. Cole, MD
    • Blood pressure management is essential in spinal injury management: IV Crystalloid, blood products and/or norepinephrine should be used to maintain SBP >90 mmHg and MAP between 85-90 mm Hg
    • Intravenous steroid administration may be considered in the first 8 hours after blunt spinal cord injury in consultation with a spinal specialist and with patient and/or family understanding the risks and benefits.
    • If required, surgical intervention within 24 hours of injury is associated with improved long-term outcomes in spinal cord injury.

Anal Cancer

David Shibata, MD, Miriam Tsao, MD
    • Response to chemoradiation should be assessed for up to 26 weeks, provided there is no evidence of progression.
    • Varying regimens for chemoradiation, including capecitabine, as an alternative to 5-fluorouracil and the introduction of intensity-modulated radiation therapy
    • Nivolumab as a potential second- or third-line treatment in refractory metastatic squamous cell carcinoma

Traumatic Spinal Cord Injury

Kee D. Kim, MD, Ryan Martin, MD, Kiarash Shahlaie, MD, PhD, Lara Zimmermann, MD, Marike Zwienenberg, MD
    • Maintain a mean arterial blood pressure 85-90 mmHg for 7 days following injury.
    • Methylprednisolone is not recommended for treatment of traumatic spinal cord injury.
    • Obtain MRI if incomplete neurologic deficit or findings that do not correlate with CT.

Management of Drug Interactions between Anti-infective and Common Anesthetics 

Kevin McLaughlin, PharmD, BCPS, James Schurr, PharmD, BCPS, MD, Craig A Stevens, PharmD, BCPS
    • Rocuronium-induced neuromuscular blockade is potentiated by a synergistic effect of gentamicin and clindamycin, which may delay recovery.
    • Penicillins form a complex with sugammadex, which may interfere with the therapeutically intended sugammadex-rocuronium complex.
    • Ondansetron can decrease the analgesic efficacy of acetaminophen at high doses.
    • Anesthesiologists are positioned to manage interactions between anesthetic agents and antimicrobials in the operating room.
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