James W. Fleshman M.D.

https://bhslibrary-primo.hosted.exlibrisgroup.com/primo-explore/openurl?sid=Entrez:PubMed&id=pmid:34856589&vid=01TEXAM-HSC_V1&institution=01TEXAM-HSC&url_ctx_val=&url_ctx_fmt=null&isSerivcesPage=true

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BACKGROUND: Surgical site infections are a major preventable source of morbidity, mortality, and increased healthcare expenditure following colorectal surgery. Patients with penicillin allergy may not receive the recommended preoperative antibiotics, putting them at increased risk for surgical site infections. OBJECTIVE: This study aimed to evaluate the impact of patient-reported penicillin allergy on preoperative antibiotic prophylaxis and surgical site infection rates among patients undergoing major colon and rectal procedures. DESIGN: Retrospective observational study. SETTING: Tertiary teaching hospital in Dallas. PATIENTS: Adults undergoing colectomy or proctectomy between July 2012 to July 2019. MAIN OUTCOME MEASURES: Preoperative antibiotic choice and surgical site infection. RESULTS: Among 2198 patients included in the study, 12.26% (n=307) reported a penicillin allergy. Patients with penicillin allergy were more likely to be white (82%) and female (54%) (p<0.01). The most common type of allergic reaction reported was rash (36.5%), whereas 7.2% of patients reported anaphylaxis. Patients with self-reported penicillin allergy were less likely to receive beta-lactam antibiotics compared to patients who did not report a penicillin allergy (79.8% vs 96.7%, p<0.001). Overall, there were 143 (6.5%) patients with surgical site infections. On multivariable logistic regression there was no difference in rates of surgical site infection between patients with penicillin allergy vs. those without penicillin allergy (adjusted odds ratio 1.14; 95% confidence interval, 0.71-1.82). LIMITATIONS: Retrospective study design. CONCLUSIONS: Self-reported penicillin allergy among colorectal surgery patients is common, however only a small number of these patients report any serious adverse reactions. Patients with self-reported penicillin allergy are less likely to receive beta-lactam antibiotics and more likely to receive non beta-lactam antibiotics. However, this does not affect the rate of surgical site infection among these patients and patient's penicillin allergy can be safely prescribed non beta-lactam antibiotics without negatively impacting surgical site infection rates.

Stringfield, S. B., G. O. Ogola, R. Curran, K. O. Wells, A. Fichera and J. W. Fleshman (2021). “Colorectal Surgery in COVID-Negative Patients in the Early Phases of the Pandemic: Short-Term Outcomes.” J Gastrointest Surg Aug 17;1-4. [Epub ahead of print]. 1-4.

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Many elective operations were canceled early in the COVID-19 pandemic in order to conserve resources and to keep patients out of public settings. Our institution canceled elective cases except those that were considered “medically necessary to correct a serious medical condition or to preserve the life of a patient 1.” For colorectal patients, this included emergencies and selected cases such as cancer resections. We noticed that a high number of patients that underwent surgery during this time developed postoperative ileus (POI) and had a prolonged hospital stay. Our hypothesis was that patients undergoing surgery during the pandemic had worse short-term outcomes, despite being COVID-negative. [No abstract; excerpt from article].

Jafari, M. D., A. Pigazzi, E. C. McLemore, M. G. Mutch, E. Haas, S. H. Rasheid, A. D. Wait, I. M. Paquette, O. Bardakcioglu, B. Safar, R. G. Landmann, M. G. Varma, D. J. Maron, J. Martz, J. J. Bauer, V. V. George, J. W. Fleshman, Jr., S. R. Steele and M. J. Stamos (2021). “Perfusion Assessment in Left-Sided/Low Anterior Resection (PILLAR III): A Randomized, Controlled, Parallel, Multicenter Study Assessing Perfusion Outcomes With PINPOINT Near-Infrared Fluorescence Imaging in Low Anterior Resection.” Dis Colon Rectum 64(8): 995-1002.

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BACKGROUND: Indocyanine green fluoroscopy has been shown to improve anastomotic leak rates in early phase trials. OBJECTIVE: We hypothesized that the use of fluoroscopy to ensure anastomotic perfusion may decrease anastomotic leak after low anterior resection. DESIGN: We performed a 1:1 randomized controlled parallel study. Recruitment of 450 to 1000 patients was planned over 2 years. SETTINGS: This was a multicenter trial. PATIENTS: Included patients were those undergoing resection defined as anastomosis within 10 cm of the anal verge. INTERVENTION: Patients underwent standard evaluation of tissue perfusion versus standard in conjunction with perfusion evaluation using indocyanine green fluoroscopy. MAIN OUTCOME MEASURES: Primary outcome was anastomotic leak, with secondary outcomes of perfusion assessment and the rate of postoperative abscess requiring intervention. RESULTS: This study was concluded early because of decreasing accrual rates. A total of 25 centers recruited 347 patients, of whom 178 were randomly assigned to perfusion and 169 to standard. The groups had comparable tumor-specific and patient-specific demographics. Neoadjuvant chemoradiation was performed in 63.5% of perfusion and 65.7% of standard (p > 0.05). Mean level of anastomosis was 5.2 ± 3.1 cm in perfusion compared with 5.2 ± 3.3 cm in standard (p > 0.05). Sufficient visualization of perfusion was reported in 95.4% of patients in the perfusion group. Postoperative abscess requiring surgical management was reported in 5.7% of perfusion and 4.2% of standard (p = 0.75). Anastomotic leak was reported in 9.0% of perfusion compared with 9.6% of standard (p = 0.37). On multivariate regression analysis, there was no difference in anastomotic leak rates between perfusion and standard (OR = 0.845 (95% CI, 0.375-1.905); p = 0.34). LIMITATIONS: The predetermined sample size to adequately reduce the risk of type II error was not achieved. CONCLUSIONS: Successful visualization of perfusion can be achieved with indocyanine green fluoroscopy. However, no difference in anastomotic leak rates was observed between patients who underwent perfusion assessment versus standard surgical technique. In experienced hands, the addition of routine indocyanine green fluoroscopy to standard practice adds no evident clinical benefit.

Jafari, M.D., Pigazzi, A., McLemore, E.C., Mutch, M.G., Haas, E., Rasheid, S., Wait, A.D., Paquette, I.M., Bardakcioglu, O., Safar, B., Landmann, R.G., Varma, M., Maron, D.J., Martz, J., Bauer, J., George, V.V., Fleshman, J.W., Steele, S.R. and Stamos, M.J. (2021). “Perfusion Assessment in Left-Sided/Low Anterior Resection (PILLAR III): A Randomized, Controlled, Parallel, Multicenter Study Assessing Perfusion Outcomes with PINPOINT Near-Infrared Fluorescence Imaging in Low Anterior Resection.” Dis Colon Rectum.

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BACKGROUND: Indocyanine green fluoroscopy has been shown to improve anastomotic leak rates in early phase trials. OBJECTIVE: We hypothesized that the use of fluoroscopy to ensure anastomotic perfusion may decrease anastomotic leak following low anterior resection. DESIGN: We performed a 1:1 randomized, controlled, parallel study. Recruitment of 450-1000 patients was planned over 2-years. SETTING: Multicenter. PATIENTS: Patients undergoing resection defined as anastomosis within 10cm of anal verge. INTERVENTION: Patients underwent standard evaluation of tissue perfusion versus standard in conjunction with perfusion evaluation using indocyanine green fluoroscopy. MAIN OUTCOME MEASURE: Primary outcome was anastomotic leak, with secondary outcomes of perfusion assessment and the rate of postoperative abscess requiring intervention. RESULTS: This study was concluded early due to decreasing accrual rates. A total of 25 centers recruited 347 patients, of which 178 were randomized to perfusion and 169 to standard. The groups had comparable tumor-specific and patient-specific demographics. Neoadjuvant chemoradiation was performed in 63.5% of perfusion and 65.7% of standard (p>0.05). Mean level of anastomosis was 5.2+3.1cm in perfusion compared to 5.2+3.3cm in standard (p>0.05). Sufficient visualization of perfusion was reported in 95.4% of patients in the perfusion group. Postoperative abscess requiring surgical management was reported in 5.7% of PFN and 4.2% of standard (p=0.75). Anastomotic leak was reported in 9.0% of perfusion compared to 9.6% of standard (p=0.37). On multivariate regression analysis, there was no difference in anastomotic leak rates between perfusion and standard (OR 0.845; 95% CI (0.375, 1.905); p=0.34). LIMITATIONS: The pre-determined sample size to adequately reduce the risk of type II error was not achieved. CONCLUSION: Successful visualization of perfusion can be achieved with ICG-F. However, no difference in anastomotic leak rates was observed between patients who underwent perfusion assessment versus standard surgical technique. In experienced hands, the addition of routine ICG-F to standard practice adds no evident clinical benefit. See Video Abstract at http://links.lww.com/DCR/B560

Fleshman, J. (2021). “Birth of the Board of Colon and Rectal Surgery: Curtice Rosser, J.D., M.D. (January 3, 1891, to October 23, 1969) Remembered at Baylor University Medical Center, Dallas, Texas.” Dis Colon Rectum 64(2): 157-162.

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Great leaders carry a vision with them that shapes and defines their life and their career. They believe in what can be, and, in so doing, bring the vision into reality. They motivate others and, by their effort and enthusiasm, drive the betterment of the institution or group with which they find themselves associated. Curtice Rosser, J.D., M.D., was such a man. The world of colon and rectal surgery owes Dr Rosser a great deal of gratitude for his vision and his leadership. Baylor University Medical Center (BUMC), Baylor College of Medicine, and Southwestern Medical College (now University of Texas Southwestern Medical School) also benefitted greatly from his presence during the early part of their existence. The American Board of Colon and Rectal Surgery exists directly because Dr Rosser and his colleagues envisioned colorectal surgery as a self-governing and credentialing subspecialty, equivalent to other strong surgical subspecialties, and invested time, energy, and political capital to realize their dream. [No abstract; excerpt from article].