Laparoscopic versus open colectomy for patients with American Society of Anesthesiology (ASA) classifications 3 and 4: the minimally invasive approach is associated with significantly quicker recovery and reduced costs

Laparoscopic colectomy for patients with poor American Society of Anesthesiology classifications

INTRODUCTION

The American Society of Anesthesiologists (ASA) classification is used to assess the fitness of a patient for surgery. Whether laparoscopic surgery is appropriate for colorectal cancer patients with poor ASA performance status (PS) remains unclear.

METHODS

Among 4585 patients who underwent colorectal surgery between 2016 and 2023, this study retrospectively reviewed all 458 patients with ASA-PS ≥3. Patients were divided into two groups: patients treated by open surgery (O group, n = 80); and patients treated by laparoscopic surgery (L group, n = 378). We investigated the impact of surgical approach on postoperative complications in patients with colorectal cancer and ASA-PS ≥3.

RESULTS

Operation time was longer (170 min vs. 233 min, p < .001), blood loss was less (156 mL vs. 23 mL, p < .001), postoperative complications were less frequent (40.0% vs. 25.1%, p = .008), and hospital stay was shorter (23 days vs. 14 days, p < .001) in L group. Univariate analysis revealed rectal cancer, open surgery, longer operation time, and blood loss as factors significantly associated with postoperative complications. Multivariate analysis revealed open surgery (odds ratio [OR] 2.100, 95% confidence interval [CI] 1.164-3.788; p = .013) and longer operation time (OR 1.747, 95% CI 1.098-2.778; p = .018) as independent predictors of postoperative complications.

CONCLUSION

Laparoscopic surgery provides favorable outcomes for colorectal cancer patients with poor ASA-PS.

Work-Related Musculoskeletal Disorders in Endoscopic Sinus and Skull Base Surgery: A Systematic Review With Meta-analysis

OBJECTIVE

Endoscopic sinus and skull base surgery has led to significant improvements in patient outcomes, yet may have come at a cost to surgeons' musculoskeletal (MSK) health. We aimed to determine the prevalence and characteristics of work-related MSK disorders (WRMDs) in endoscopic sinus and skull base surgeons; to investigate contributing factors for WRMD in this population; and to evaluate the effectiveness of ergonomic interventions on the severity or prevalence of WRMD in this population.

DATA SOURCES

Medline, Embase, CINAHL, Web of Science, and Scopus from inception to April 2, 2024. A bibliographic examination was performed for further papers.

REVIEW METHODS

Inclusion criteria included original peer-reviewed papers with work-related MSK outcomes (prevalence, contributing factors, and interventions) relating to endoscopic sinus and/or skull base surgeons in any language.

RESULTS

Of 25,772 unique citations, 37 studies met the inclusion criteria. The pooled lifetime, point, and 12-month prevalences of WRMD were 75.9% (95% confidence interval; I2, 67.2%-83.6%, I2 95.6%), 80.8% (77.0%-84.3%, I2 98.0%), and 82.0% (71.8%-90.3%, I2 60.96%) respectively. The neck, lumbar spine, and thoracic spine were the most commonly involved areas. One of 9 studies on contributing factors investigated discomfort as an outcome. The remainder focussed on surrogate outcomes (eg, posture, hand dysfunction). Two of the 13 intervention studies investigated pain or fatigue as an outcome. The remainder targeted posture, muscle activity, or workload.

CONCLUSION

WRMDs are highly prevalent in endoscopic sinus and skull base surgeons. Further studies focusing on the direct outcomes of WRMD such as pain are needed.

Comparing surgical outcomes of approaches to adrenalectomy - a systematic review and network meta-analysis of randomised clinical trials

BACKGROUND

No randomised clinical trials (RCTs) have simultaneously compared the safety of open (OA), transperitoneal laparoscopic (TLA), posterior retroperitoneal (PRA), and robotic adrenalectomy (RA) for resecting adrenal tumours.

AIM

To evaluate outcomes for OA, TLA, PRA, and RA from RCTs.

METHODS

A NMA was performed according to PRISMA-NMA guidelines. Analysis was performed using R packages and Shiny.

RESULTS

Eight RCTs with 488 patients were included (mean age: 48.9 years). Overall, 44.5% of patients underwent TLA (217/488), 37.3% underwent PRA (182/488), 16.4% underwent RA (80/488), and just 1.8% patients underwent OA (9/488). The mean tumour size was 35 mm in largest diameter with mean sizes of 44.3 mm for RA, 40.9 mm for OA, 35.5 mm for TLA, and 34.4 mm for PRA (P < 0.001). TLA had the lowest blood loss (mean: 50.6 ml), complication rates (12.4%, 14/113), and conversion to open rates (1.3%, 2/157), while PRA had the shortest intra-operative duration (mean: 94 min), length of hospital stay (mean: 3.7 days), lowest visual analogue scale pain scores post-operatively (mean: 3.7), and was most cost-effective (mean: 1728 euros per case). At NMA, there was a significant increase in blood loss for OA (mean difference (MD): 117.00 ml (95% confidence interval (CI): 1.41-230.00)) with similar blood loss observed for PRA (MD: - 10.50 (95% CI: - 83.40-65.90)) compared to TLA.

CONCLUSION

LTA and PRA are important contemporary options in achieving favourable outcomes following adrenalectomy. The next generation of RCTs may be more insightful for comparison surgical outcomes following RA, as this approach is likely to play a future role in minimally invasive adrenalectomy.

PROSPERO REGISTRATION

CRD42022301005.

Association between the proportion of laparoscopic approaches for digestive surgeries and the incidence of consequent surgical site infections, 2009-2019: A retrospective observational study based on national surveillance data in Japan

BACKGROUND

Surgical site infections (SSIs) are among the most common healthcare-associated infections. Laparoscopy is increasingly being used in various surgical procedures. However, no study has examined the association between the proportion of laparoscopic procedures and the incidence of SSIs in digestive surgery using nationwide surveillance data.

METHODS

We retrospectively investigated national SSI surveillance data from the Japan Nosocomial Infections Surveillance between 2009 and 2019. The annual trend of the SSI rate and the proportion of laparoscopic procedures were assessed, focusing on five major digestive surgeries. This was based on data from 109,544 (appendix surgery), 206,459 (gallbladder surgery), 60,225 (small bowel surgery), 363,677 (colon surgery), and 134,695 (rectal surgery) procedures. The effect of a 10% increase in the proportion of laparoscopic procedures on the reduction of the SSI rate was estimated using mixed-effect logistic regression.

FINDINGS

The average SSI rate of the five digestive surgeries decreased from 11.8% in 2009 to 8.1% in 2019. The proportion of laparoscopic procedures in each of the five digestive surgeries increased continuously (p<0.001). The SSI rate for laparoscopic procedures was always lower than that for open procedures. The results were consistent between all and core hospitals participating in the surveillance. The odds ratios of the 10% increase in the proportion of laparoscopic procedures for five digestive surgeries were always <0.950 (p<0.001).

CONCLUSION

An increase in the proportion of laparoscopic procedures was associated with a reduction in the SSI rate in digestive surgeries.

"Every minute counts": association between operative time and post-operative complications for patients undergoing minimally invasive sacrocolpopexy

INTRODUCTION AND HYPOTHESIS

Our aim was to assess whether operative time is independently associated with post-operative complications for minimally invasive sacrocolpopexy (MISCP).

METHODS

Using the National Surgical Quality Improvement Program (NSQIP) database, patients undergoing MISCP from 2015 to 2020 were identified by CPT code. The following data were extracted: demographics, concomitant procedures (hysterectomies, midurethral sling, and anterior or posterior repair), and post-operative complications. Complications were categorized into minor, major, and composite, modeled after the Clavien-Dindo classification. For analysis, covariates associated with operative time and composite complications were identified using a general linear model and Chi-squared or Fisher's exact test as appropriate. Then, adjusted spline regression was performed as a test of nonlinearity between operative time and composite complications. Adjusted relative risks of complications by 60-min increments were estimated using Poisson regression with robust error variance.

RESULTS

A total of 13,239 patients who underwent MISCP were analyzed. Overall, mean operative time (SD) was 189.5 (78.3) min. Post-operative complication rates were 2.6% for minor, 4.7% for major, and 7.3% for composite complications. Age, smoking, and sling were the only covariates associated with both operative time and post-operative complications. Adjusted spline regression demonstrated linearity (p<0.0001). With each 60-min increase in operative time, adjusted relative risks (95% CI) were 1.14 for composite (1.09, 1.19), 1.16 for minor (1.10, 1.21), and 1.11 (1.03, 1.20) for major complications.

CONCLUSIONS

Operative time is independently and linearly associated with post-operative complications for patients undergoing MISCP, even when adjusted for demographic variables and concomitant procedures.

Trends in Same-Day Discharge Rate After Minimally Invasive Sacrocolpopexy and Propensity Score-Matched Analysis of Postoperative Complication Rates Using the National Surgical Quality Improvement Program Database

OBJECTIVE

The primary aim of this study was to review trends in the same-day discharge (SDD) rate after minimally invasive sacrocolpopexy (MISCP). The secondary aim was to compare the composite 30-day postoperative complication rates between propensity score-matched SDD and admitted cohorts.

METHODS

This was a retrospective cohort study using the American College of Surgeons National Surgical Quality Improvement Program database from 2015 to 2019. Patients who underwent MISCP were identified by Current Procedural Terminology codes. Concurrent hysterectomy, anterior or posterior repairs, rectopexy, and midurethral sling were also identified. Multivariable logistic regression and propensity score matching were performed.

RESULTS

A total of 12,762 MISCP patients were captured: 3,968 underwent MISCP only, 4,065 underwent MISCP with total laparoscopic hysterectomy, 734 underwent MISCP with laparoscopically assisted vaginal hysterectomy, and 3,995 underwent MISCP with laparoscopic supracervical hysterectomy. Overall, the SDD rate was 16.3%, with an increase from 12.3% in 2015 to 23.1% in 2019. Multivariable logistic regression showed that admitted patients were more likely to be older, to be of Black race, have an American Society of Anesthesiologists classification of 3 or 4, have hypertension requiring medication, have longer operative time, and have undergone concurrent anterior or posterior repair, rectopexy, or sling. After propensity score matching, the composite postoperative complication rates were similar between the 2 cohorts (5.7% vs 6.4%, P = 0.818). However, superficial surgical site infection was more likely in the SDD cohort (adjusted odds ratio, 2.3; P < 0.001) and blood transfusion in the admitted cohort (adjusted odds ratio, 11.9; P = 0.0.34).

CONCLUSIONS

The rate of SDD after MISCP seems to be increasing. Composite postoperative complication rates are similar between SDD and admitted cohorts.

Optimizing Patient Selection for Laparoscopic and Open Colorectal Cancer Resections: A National Surgical Quality Improvement Program–Matched Analysis

The aim of this study was to identify patients undergoing colorectal cancer (CRC) resection who might benefit specifically from either an open or laparoscopic approach. From the NSQIP database (2012–2013), patients who underwent laparoscopic colectomy (LC) or open colectomy (OC) for CRC were identified. The two groups were matched and compared in terms of any, medical, and surgical complications. A wide range of patient characteristics were collected and analyzed. Interaction analysis was performed in a multivariable regression model to identify risk factors that may make LC or OC more beneficial in certain subgroups of patients. Overall, OC (n = 6593) was associated with a significantly higher risk of any [odds ratio (OR) 2.03, 95% confidence interval (CI) 1.87–2.20], surgical (OR 1.98, 95% CI 1.82–2.16), and medical (OR 1.71, 95% CI 1.51–1.94) complications than LC (n = 6593). No subgroup of patients benefited from an open approach. Patients with obesity (BMI > 30) (P = 0.03) and older age (>65 years) (P = 0.01) benefited more than average from a laparoscopic approach. For obese patients, LC was associated with less overall complications (OC vs LC: OR 1.92 obese vs 1.21 nonobese patients). For elderly patients, LC was more preferable regarding the risk of medical complications (OC vs LC OR of 1.91 vs 1.34 for younger patients). No subgroup of CRC patients benefited specifically more from an open colorectal resection. This supports that the laparoscopic technique should be performed whenever feasible. For the obese and elderly patients, the benefits of the laparoscopic approach were more pronounced.

With widespread adoption of MIS colectomy for colon cancer, does hospital type matter?

BACKGROUND

Recent studies have shown that hospital type impacts patient outcomes, but no studies have examined hospital differences in outcomes for patients undergoing minimally invasive surgery (MIS) for segmental colectomies.

METHODS

The 2010-2014 National Cancer Data Base was queried for patients undergoing segmental colectomy for non-metastatic colon adenocarcinoma. Descriptive statistics characterized MIS utilization by hospital type. Multivariable models were used to examine the effect of hospital type on outcomes after MIS. Survival probability was plotted using the Kaplan-Meier method.

RESULTS

80,922 patients underwent MIS segmental colectomy for colon cancer from 2010 to 2014. From 2010 to 2014, the number of MIS segmental colectomies increased by 157% at academic hospitals, 151% at comprehensive hospitals, and 153% at community hospitals. Compared to academic hospitals, community and comprehensive hospitals had greater adjusted odds of positive margins (Community OR 1.525, 95% Confidence Interval 1.233-1.885; Comprehensive OR 1.216, 95% CI 1.041-1.42), incomplete number of lymph nodes analyzed (< 12 LNs) from surgery (Community OR 2.15, 95% CI 1.98-2.32; Comprehensive OR 1.42, 95% CI 1.34-1.51), and greater 30-day mortality (Community OR 1.43, 95% CI 1.14-1.78; Comprehensive OR 1.36, 95% CI 1.17-1.59). Patient survival probability was higher at academic hospitals at 5 years (Academic 69% vs. Comprehensive 66% vs. Community 63%, p < 0.001). Community hospitals and comprehensive hospitals had significantly higher risk of adjusted long-term mortality (Community HR 1.28; 95% CI 1.19-1.37; p < 0.001; Comprehensive HR 1.14; 95% CI 1.09-1.20; p < 0.001).

CONCLUSIONS

Despite widespread use of laparoscopic oncologic surgery, short- and long-term outcomes from MIS for segmental colectomy are superior at academic hospitals. This difference may be due to superior perioperative oncologic technique and surgical outcomes at academic hospitals. Our data provide important information for patients, referring physicians, and surgeons about the significance of hospital type in management of colon cancer.

A Comparison of Open and Minimally Invasive Surgery for Hepatic and Pancreatic Resections Among the Medicare Population

INTRODUCTION

Minimally invasive surgery (MIS) has become standard of care for many gastrointestinal surgical procedures. Despite possible clinical benefits, MIS may be underutilized in some populations. The aim of this study was to access the utilization of MIS among Medicare patients undergoing hepatopancreatic procedures and define clinical outcomes, as well as costs, of minimally invasive techniques compared with the conventional open approach.

METHODS

The Medicare Provider Analysis and Review (MEDPAR) Inpatient Files were reviewed to identify Medicare patients who underwent pancreatic and liver procedures between 2013 and 2015. Primary outcomes of the analysis included perioperative clinical outcomes such as rates of complications, index hospitalization length-of-stay (LOS), failure-to-rescue, rates, and causes of 90-day readmission, as well as 90-day mortality. Secondary outcomes were Medicare payments for index hospitalization and readmission. Multivariable logistic regression was used to investigate the impact of MIS on clinical outcomes and health expenditures.

RESULTS

A total of 13,716 (90.6%) patients underwent open resection, while MIS was performed in 1424 (9.4%) patients. LOS was shorter among patients undergoing MIS (mean 7.3 ± SD 7.3) versus open (mean 9.3 ± SD 9.1) surgery (p < 0.001). The incidence of perioperative complications was lower following MIS (open 25.5%, n = 3492 vs. MIS 17.2%, n = 245) (p < 0.001). Rates of failure-to-rescue were similar among patients undergoing an open versus MIS pancreatic procedure (open 19.4%, n = 271 vs. MIS 13.4%, n = 17) (p = 0.09). In contrast, 90-day readmission (open 31.1%, n = 1630 vs. MIS 24.1%, n = 201, p < 0.001), as well as 90-day mortality (open 7.7%, n = 404 vs. MIS 4.2%, n = 35, p < 0.001) were lower among patients undergoing pancreatic resections via an MIS approach. In contrast, failure-to-rescue and readmission, as well as mortality, were all comparable among patients undergoing a liver resection, regardless as to whether the operation was performed open or via an MIS approach (all p > 0.05). Mean total payments for open pancreatic surgery were on average $1421 higher in the open versus MIS pancreatic group (p = 0.01); in contrast, there was no difference in the overall payment for hepatic resection (p > 0.05).

CONCLUSION

The MIS approach was underutilized among patients undergoing liver and pancreatic procedures. MIS was associated with lower complication and readmission and shorter LOS, as well as comparable/slightly lower Medicare payments, compared with the open approach. The MIS approach should strongly be considered among older patients undergoing liver and pancreatic procedures.

The Balance Between Surgical Resident Education and Patient Safety in Laparoscopic Colorectal Surgery: Surgical Resident's Performance has No Negative Impact

OBJECTIVE

This study aimed to evaluate the feasibility and effectiveness of a comprehensive theoretical and hands-on training program in performing laparoscopic colonic resections under supervision of an expert surgeon.

MATERIALS AND METHODS

Laparoscopic right colectomy was performed in 78 patients (10 with benign disease, 68 with carcinoma). Demographic, intraoperative, pathologic examination, and short-term outcome data were retrospectively compared between 25 patients operated by surgical residents (R group) and 53 patients operated by senior surgeons (S group). The residents who performed surgeries in the R group had between 1 and 6 years after graduation; no experience with open or laparoscopic colorectal surgery was necessary. The residents completed a training program under supervision of a single expert laparoscopic colorectal surgeon, which included 6 steps, from basic skills to certification.

RESULTS

There were no differences in patient age, sex, and body mass index between the R and S groups. Significantly more patients in the R group had early cancer and benign lesions (P<0.05). Thirteen of the 16 residents (81.2 %) had not had prior experience with colonic resection. The time of suturing and knot tying in the dry box did not differ between residents and senior surgeons (68 and 69 s, respectively). All the residents performed laparoscopic right colectomy without intraoperative complications. There were no significant differences in operating time (R group: 173±34 min, S group: 172±52 min), mean estimated blood loss (50±111 vs. 49±100 mL), number of lymph nodes dissected (20.8±12.8 vs. 17.1±9.0), and mean postoperative hospital stay (9.1±3.3 vs. 10.7±4.1 d). On the basis of the year of their residency period, all 3 residents at 6 years after graduation had far greater experience than the other residents and therefore performed the surgery with minor verbal support from the expert. However, residents with 1 or 2 years after graduation had to receive guidance provision by the expert during surgery.

CONCLUSIONS

When supervised and led by an expert laparoscopic surgeon, surgical residents are capable of performing laparoscopic surgery without negative effects on outcomes.

Minimally invasive versus open surgery in the Medicare population: a comparison of post-operative and economic outcomes

BACKGROUND

Despite strong evidence demonstrating the clinical and economic benefits of minimally invasive surgery (MIS), utilization of MIS in the Medicare population is highly variable and tends to be lower than in the general population. We sought to compare the post-operative and economic outcomes of MIS versus open surgery for seven common surgical procedures in the Medicare population.

METHODS

Using the 2014 Medicare Provider Analysis and Review Inpatient Limited Data Set, patients undergoing bariatric, cholecystectomy, colectomy, hysterectomy, inguinal hernia, thoracic, and ventral hernia procedures were identified using DRG and ICD-9 codes. Adjusting for patient demographics and comorbidities, the odds of complication and all-cause 30-day re-admission were compared among patients undergoing MIS versus open surgery stratified by operation type. A generalized linear model was used to calculate the estimated difference in length of stay (LOS), Medicare claim cost, and Medicare reimbursement.

RESULTS

Among 233,984 patients, 102,729 patients underwent an open procedure versus 131,255 who underwent an MIS procedure. The incidence of complication after MIS was lower for 5 out of the 7 procedures examined (OR 0.36-0.69). Re-admission was lower for MIS for 6 out of 7 procedures (OR 0.43-0.87). MIS was associated with shorter LOS for 6 procedures (point estimate range 0.35-2.47 days shorter). Medicare claim costs for MIS were lower for 4 (range $3010.23-$4832.74 less per procedure) and Medicare reimbursements were lower for 3 (range $841.10-$939.69 less per procedure).

CONCLUSIONS

MIS benefited Medicare patients undergoing a range of surgical procedures. MIS was associated with fewer complications and re-admissions as well as shorter LOS and lower Medicare costs and reimbursements versus open surgery. MIS may represent a better quality and cost proposition in the Medicare population.

Trends in laparoscopic colorectal surgery over time from 2005-2014 using the NSQIP database

BACKGROUND

Laparoscopy, originally pioneered by gynecologists, was first adopted by general surgeons in the late 1980s. Since then, laparoscopy has been adopted in the surgical specialties and colorectal surgery for treatment of benign and malignant disease. Formal laparoscopic training became a required component of surgery residency programs as validated by the Fundamentals of Laparoscopic Surgery curriculum; however, some surgeons may be more apprehensive of widespread adoption of minimally invasive techniques. Although an overall increase in the use of laparoscopy in colorectal surgery is anticipated over a 10-year period, it is unknown if a similar increase will be seen in higher risk or more acutely ill patients.

METHODS

Using the American College of Surgeons (ACS) National Surgical Quality Improvement Program (NSQIP) database from 2005-2014, colorectal procedures were identified by Current Procedural Terminology codes and categorized to open or laparoscopic surgery. The proportion of colorectal surgeries performed laparoscopically was calculated for each year. Separate descriptive statistics was performed and categorized by age and body mass index (BMI). American Society of Anesthesiology (ASA) classification and emergency case status variables were added to the project to help assess complexity of cases.

RESULTS

During the 10-year study period, the number of colorectal cases increased from 3114 in 2005 to 51,611 in 2014 as more hospitals joined NSQIP. A total of 277,376 colorectal cases were identified; of which, 114,359 (41.2%) were performed laparoscopically. The use of laparoscopy gradually increased each year, from 22.7% in 2005 to 49.8% in 2014. Laparoscopic procedures were most commonly performed in the youngest age group (18-49 years), overweight and obese patients (BMI 25-34.9), and in ASA class 1-2 patients. Over the 10-year period, there was a noted increase in the use of laparoscopy in every age, BMI, and ASA category, except ASA 5. The percent of emergency cases receiving laparoscopic surgery also doubled from 5.5% in 2005 to 11.5% in 2014.

CONCLUSIONS

Over a 10-year period, there was a gradual increase in the use of laparoscopy in colorectal surgery. Further, there was a consistent increase of laparoscopic surgery in all age groups, including the elderly, in all BMI classes, including the obese and morbidly obese, and in most ASA classes, including ASA 3-4, as well as in emergency surgeries. These trends suggest that minimally invasive colorectal surgery appears to be widely adopted and performed on more complex or higher risk patients.

Open Colectomies of Shorter Operative Time Do Not Result in Improved Outcomes Compared With Prolonged Laparoscopic Operations

BACKGROUND

Laparoscopic colectomies are associated with reduced perioperative morbidity and mortality compared with open surgery. Nevertheless, many surgeons continue to utilize an open surgical approach due to the perceived benefits of shorter operative times. This study aims to compare the outcomes of laparoscopic versus open colectomies of equal or shorter operative duration.

METHODS

All patients undergoing elective laparoscopic or open colectomy in the American College of Surgeons National Surgical Quality Improvement Project (ACS-NSQIP) were identified from the years 2005 through 2012. Patients were stratified first by operative procedure including partial colectomy, total colectomy, or low anterior resection. Each surgical group was then divided into 4 groups according to operative time: <90 minutes, ≥90 minutes and <3 hours, ≥3 hours and <6 hours, and ≥6 hours. In total, 30-day outcomes were compared between laparoscopic operations and open procedures of shorter or equivalent durations within each surgical group. Multivariate logistic regression was utilized to account for differences in patient demographics and comorbidities between the surgical groups.

RESULTS

In total, 156,503 patients met inclusion criteria; 112,053 (71.6%) patients underwent a partial colectomy, 13,838 (8.8%) patients underwent a total colectomy, and 30,612 (19.6%) patients underwent a low anterior resection. A laparoscopic approach was used in 34% (37,789 patients) of the partial colectomies performed, 31% (4285 patients) of the total colectomies performed, and 45% (13,850 patients) of the low anterior resections performed. For all procedures, laparoscopic operations <6 hours were associated with superior outcomes compared with shorter open procedures. The benefit of laparoscopic operations was lost when operative time exceeded 6 hours.

CONCLUSIONS

Laparoscopic colectomies are associated with improved outcomes compared with open operations that do not exceed an operative time of 6 hours. Given the potential to improve patient outcomes, consideration should be given to the laparoscopic approach for all colon surgeries expected to be completed in <6 hours.

Validation of the three web quality dimensions of a minimally invasive surgery e-learning platform

INTRODUCTION

E-learning web environments, including the new TELMA platform, are increasingly being used to provide cognitive training in minimally invasive surgery (MIS) to surgeons. A complete validation of this MIS e-learning platform has been performed to determine whether it complies with the three web quality dimensions: usability, content and functionality.

METHODS

21 Surgeons participated in the validation trials. They performed a set of tasks in the TELMA platform, where an e-MIS validity approach was followed. Subjective (questionnaires and checklists) and objective (web analytics) metrics were analysed to achieve the complete validation of usability, content and functionality.

RESULTS

The TELMA platform allowed access to didactic content with easy and intuitive navigation. Surgeons performed all tasks with a close-to-ideal number of clicks and amount of time. They considered the design of the website to be consistent (95.24%), organised (90.48%) and attractive (85.71%). Moreover, they gave the content a high score (4.06 out of 5) and considered it adequate for teaching purposes. The surgeons scored the professional language and content (4.35), logo (4.24) and recommendations (4.20) the highest. Regarding functionality, the TELMA platform received an acceptance of 95.24% for navigation and 90.48% for interactivity.

CONCLUSIONS

According to the study, it seems that TELMA had an attractive design, innovative content and interactive navigation, which are three key features of an e-learning platform. TELMA successfully met the three criteria necessary for consideration as a website of quality by achieving more than 70% of agreements regarding all usability, content and functionality items validated; this constitutes a preliminary requirement for an effective e-learning platform. However, the content completeness, authoring tool and registration process required improvement. Finally, the e-MIS validity methodology used to measure the three dimensions of web quality in this work can be applied to other clinical areas or training fields.

Internal hernia after laparoscopic right hemicolectomy, report of a case

Mesenteric defects are often not closed in laparoscopic colectomy. We herein report a case of an internal hernia projecting through a mesenteric defect following laparoscopy-assisted right hemicolectomy. A 74-year-old woman was hospitalized for the surgical treatment of double colon cancer. Preoperative colonoscopy demonstrated the presence of ascending colon and transverse colon cancers. A laparoscopic-assisted right hemicolectomy was performed. The mesenteric defect resulting from the colectomy was not closed. Three months after the surgery, the patient developed a bowel obstruction. Under a diagnosis of strangulated bowel obstruction, we performed a laparotomy, and found a necrotic small bowel, which had passed into the bursa omentalis through the mesenteric defect. We removed the necrotic small bowel and closed the mesenteric defect by suturing. The patient's postoperative course was uneventful. An internal hernia projecting through a mesenteric defect following laparoscopy-assisted right hemicolectomy developed a severe strangulated bowel obstruction.

Safety of Laparoscopic Colorectal Resection in Patients With Severe Comorbidities

We aimed to assess the safety of laparoscopic colorectal resection in patients with severe comorbidities. High operative risk was defined as an American Society of Anesthesiologists (ASA) class 3 score. Outcomes in 34 patients with an ASA score of 3 undergoing laparoscopic surgery (LAP3) were compared with 172 laparoscopic surgery patients with an ASA score ≤2 (LAP2) and 32 laparotomy patients with an ASA score of 3 (OP3). The postoperative complication rate in LAP3 was similar to that seen in LAP2 and significantly lower than that seen in OP3 (LAP2, 4.0%; LAP3, 5.9%; OP3, 31.2%). The incidence of postoperative hemorrhage, infection, ileus, and anastomotic leakage was similar between LAP3 and LAP2 and between LAP3 and OP3. However, the systemic complication rate in LAP3 was similar to that seen in LAP2 and significantly lower than that seen in OP3. Laparoscopic colorectal resection can be performed safely in patients with severe comorbidities.

Laparoscopy-assisted distal gastrectomy for early gastric cancer poses few limitations for selected elderly patients: a single-center experience

Background

The safety and efficacy of laparoscopy-assisted distal gastrectomy (LADG) for early gastric cancer have been demonstrated in clinical studies. The aim of this study was to clarify the safety and efficacy of LADG in patients ≥80 years of age with early gastric cancer, an American Society of Anesthesiologists (ASA) classification of 1–2, and a performance status (PS) of 0–1.

Case presentation

From April 2009 to July 2011, 12 elderly patients aged ≥80 years and 43 younger patients underwent LADG for early gastric cancer. Seven of the 55 patients underwent LADG and simultaneous surgery including surgery for colorectal cancer, cholecystectomy, or other conditions. Forty-eight of the 55 patients who underwent only LADG were studied. Demographics and postoperative outcomes were compared.

Results

The postoperative complication rate, time to first ambulation, time to first flatus, time to first fluid intake, and postoperative hospital stay were similar in these two groups. Nutritional status as assessed by body weight, serum albumin, and total protein at 1 and 3 months after surgery was also similar in these two groups.

Conclusions

Postoperative outcomes were acceptable in the elderly patients included in the study. LADG for early gastric cancer is a safe and effective treatment in elderly patients aged ≥80 years with an ASA status of 1–2 and PS of 0–1.

Risk of readmission after laparoscopic vs. open colorectal surgery

PURPOSE

Laparoscopic colorectal resection (LC) is associated with known recovery benefits and earlier discharge when compared to open colorectal resection (OC). Whether earlier discharge leads to a paradoxical increase in readmission has not been well characterized. The aim of this study is to compare the risk of readmission after the two procedures in a large, nationally representative sample.

METHODS

Patients who underwent colorectal resection in 2011 were identified from the American College of Surgeons (ACS) National Surgical Quality Improvement Program (NSQIP) database. LC and OC patients were compared for patient factors, complications, and readmission rates. A multivariable analysis controlling for significant factors was performed to evaluate factors associated with readmission.

RESULTS

Of 30,428 patients who underwent colorectal resection, 40.2% underwent LC. Length of stay (LOS) after LC was shorter than after OC (5.7 vs. 9.7 days, p < 0.001). LC was associated with a significantly lower rate of surgical site infections (SSI), bleeding, reoperation, 30-day mortality, and complications. Risk of readmission was greater for patients undergoing proctectomy than colectomy (12.7 vs. 10.6 %, p < 0.001), but was lower after laparoscopic than open for both procedures after controlling for confounding factors. Obesity, DM, operating time ≥180 min, steroid use, and ASA class 3-5 were found to be associated with readmission.

CONCLUSION

Despite its technical complexity, LC can be performed without concerns for increased complications or readmission. The shorter length of stay and the lower risk of readmissions underline the true benefits of the laparoscopic approach for colorectal resection.

Short-term results of a randomized study between laparoscopic and open surgery in elderly colorectal cancer patients

BACKGROUND

In surgical treatment of elderly patients, securing the safety of surgery and radical cure must be balanced. Our purpose was to verify the safety and validity of laparoscopic surgery for the treatment of colorectal cancer in elderly patients.

METHODS

Patients with cTis–T4a colorectal cancer who were 75 years or older were randomized to receive open or laparoscopic surgery. Exclusion criteria were patients who had a bulky tumor, rectal cancer that required pelvic side wall lymphadenectomy, and history of colon resection. Patients were divided according to tumor location (right colon, left colon, and rectum). The short-term outcomes were compared between the two groups.

RESULTS

One hundred patients (right 43, left 28, and rectum 29) were registered in each group from August 2008 to August 2012. There were no differences in patient characteristics between the two groups. Three patients were converted from laparoscopic to open, because of bleeding, excision of peritoneum metastasis, and patient’s desire, respectively. In the short-term results (open:laparoscopic), there were significant differences in the rates of complications (36:23 %) and ileus (12:4 %), amount of blood loss (157:63 mL), and duration of surgery (150:172 min). There were no significant differences in the pathological margins, and the number of dissected lymph nodes. In the subgroup analysis according to the tumor location, there were significant differences in the rate of complications (39.4:22.5 %), amount of blood loss (135:42 mL), duration of surgery (139:160 min), and length of postoperative stay (13.0:10.0 days) in the colon cancer. There were no significant differences in short-term results in the rectal cancer.

CONCLUSIONS

Laparoscopic surgery in elderly colorectal cancer patients did not result in a difference in radical cure compared with open surgery, and the short-term results except the duration of surgery were excellent. It is an effective procedure for elderly patients with colorectal cancer, especially colon cancer.

Laparoscopic colorectal surgery in learning curve: Role of implementation of a standardized technique and recovery protocol. A cohort study

Background

Despite the proven benefits, laparoscopic colorectal surgery is still under utilized among surgeons. A steep learning is one of the causes of its limited adoption. Aim of the study is to determine the feasibility and morbidity rate after laparoscopic colorectal surgery in a single institution, “learning curve” experience, implementing a well standardized operative technique and recovery protocol.

Methods

The first 50 patients treated laparoscopically were included. All the procedures were performed by a trainee surgeon, supervised by a consultant surgeon, according to the principle of complete mesocolic excision with central vascular ligation or TME. Patients underwent a fast track recovery programme. Recovery parameters, short-term outcomes, morbidity and mortality have been assessed.

Results

Type of resections: 20 left side resections, 8 right side resections, 14 low anterior resection/TME, 5 total colectomy and IRA, 3 total panproctocolectomy and pouch. Mean operative time: 227 min; mean number of lymph-nodes: 18.7. Conversion rate: 8%. Mean time to flatus: 1.3 days; Mean time to solid stool: 2.3 days. Mean length of hospital stay: 7.2 days. Overall morbidity: 24%; major morbidity (Dindo–Clavien III): 4%. No anastomotic leak, no mortality, no 30-days readmission.

Conclusion

Proper laparoscopic colorectal surgery is safe and leads to excellent results in terms of recovery and short term outcomes, even in a learning curve setting. Key factors for better outcomes and shortening the learning curve seem to be the adoption of a standardized technique and training model along with the strict supervision of an expert colorectal surgeon.

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Benefits from laparoscopic colorectal surgery have been widely demonstrated.

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A steep learning curve is considered the main limitation to its adoption.

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We present short-term outcomes in a learning curve prospective series.

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A modular, stepwise approach leads to excellent results.

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Even trainees can safely learn both laparoscopic and open surgery, when strictly supervised.

Identification of process measures to reduce postoperative readmission

BACKGROUND

Readmission rates after intestinal surgery have been notably high, ranging from 10 % for elective surgery to 21 % for urgent/emergent surgery. Other than adherence to established strategies for decreasing individual postoperative complications, there is little guidance available for providers to work toward reducing their postoperative readmission rates.

STUDY DESIGN

Processes of care that may affect postoperative readmissions were identified through a systematic literature review, assessment of existing guidelines, and semi-structured interviews with individuals who have expertise in hospital readmissions and surgical quality improvement. Eleven experts ranked potential process measures for validity on the basis of the RAND/University of California, Los Angeles Appropriateness Methodology.

RESULTS

Of 49 proposed process measures, 34 (69 %) were rated as valid. Of the 34 valid measures, two measures addressed care in the preoperative period. These included evaluation of patient's comorbidities, providing written instruction detailing the anticipated perioperative course, and communication with the patient's referring or primary care doctor. A measure addressing perioperative care stated that institutions should have a standardized perioperative care protocol. Additional measures focused on discharge instructions and communication.

CONCLUSIONS

An expert panel identified several aspects of care that are considered essential to quality patient care and important to reducing postoperative readmissions.

The application of McBurney's single-incision laparoscopic colectomy alleviates the response of patients to postoperative wound pain

BACKGROUND

Single-incision laparoscopic colectomy (SILC) is one of several promising operation choices. Our previous study demonstrated that SILC with a self-made glove-port system both improves the feasibility of SILC and decreases the cost expense of surgery. Because the incision site for SILC could be made at either the umbilicus or McBurney's point, we are interested in whether the incision site affects the outcomes of patients, which is a less explored topic. The purpose of this study is not only to show the results of SILC with a self-made glove-port system for supporting its feasibility, but also to compare the short-term surgical outcomes between SILC with the incision made at the umbilicus and at McBurney's point.

SUBJECTS AND METHODS

We collected and reviewed the medical records of patients who received SILC with a self-made glove-port system for tumors in the left side of the colon from August 2009 to March 2011. All operations were performed by a single surgeon. Comparisons of the demographic characteristics, perioperative data, and clinical outcomes between umbilical and McBurney's SILCs were performed. Postoperative pain was assessed by a visual analog scale and opiate demand.

RESULTS

In total, 61 patients were enrolled in this retrospective study. Five of 48 (10.4%) tumors in the umbilical SILC group and 5 of 13 (38.5%) tumors in the McBurney's SILC group were located below the peritoneal reflection. The tumor location was significantly different between these two groups (P=.015). Patients in the umbilical SILC group had significantly higher frequency of opiate demand than those in the McBurney's SILC group (0.4±0.7 versus 1.4±1.8, respectively; P=.002).

CONCLUSIONS

This study further provides evidence for supporting the safety and feasibility of SILC in treating colorectal diseases. More important is that McBurney's SILC not only alleviates the patient response to wound pain, but also provides the same site for a diverting enterostomy to avoid creating an additional wound.

Short- and mid-term outcomes after early surgical training in laparoscopic colorectal cancer surgery: trainees' performance has no negative impact

BACKGROUND

This study aimed to evaluate the safety and quality of laparoscopic colorectal cancer surgery undertaken by trainees.

PATIENTS AND METHODS

From a prospectively maintained database, we identified 456 consecutive patients who underwent laparoscopic resection for colorectal cancer between 2006 and 2010. Short-term operative outcomes, relapse-free survival (RFS), and overall survival (OS) were compared between operations undertaken by the experts (E group) and trainees (T group). Multivariate analyses were performed for RFS and OS in stage II/III disease.

RESULTS

Trainees performed 313 surgeries (68.6%) and completed the procedure by themselves in 297 cases (94.9%). Short-term outcomes, including operative time, blood loss, conversion, complication, mortality, and retrieval of less than 12 lymph nodes, were comparable between the E group and the T group. After a median follow-up period of 35 months, RFS and OS were similar between the two groups, with the exception of OS for stage II (3-year OS for E group versus T group, 96.9% versus 87.0%; P=.029); however, this difference disappeared after multivariate analyses. Multivariate analyses showed that positive resection margin and higher log carcinoembryonic antigen (CEA) levels were associated with lower RFS. Furthermore, increasing age, positive resection margin, higher log CEA levels, intraoperative surgeon exchange, rectal cancer, postoperative complications, absence of postoperative chemotherapy, and shorter operative time were associated with poor OS.

CONCLUSIONS

Laparoscopic operations undertaken by trainees did not negatively affect short-term outcomes and were not associated with impaired mid-term oncologic outcomes. Our findings support early initiation of training in laparoscopic surgery for colorectal cancer treatment.

Comparison of respiratory mechanics between sevoflurane and propofol-remifentanil anesthesia for laparoscopic colectomy

BACKGROUND

The creation of pneumoperitoneum and Trendelenburg positioning during laparoscopic surgery are associated with respiratory changes. We aimed to compare respiratory mechanics while using intravenous propofol and remifentanil vs. sevoflurane during laparoscopic colectomy.

METHODS

SIXTY PATIENTS UNDERGOING LAPAROSCOPIC COLECTOMY WERE RANDOMLY ALLOCATED TO ONE OF THE TWO GROUPS: group PR (propofol-remifentanil group; n = 30), and group S (sevoflurane group; n = 30). Peak inspiratory pressure (PIP), dynamic lung compliance (Cdyn), and respiratory resistance (Rrs) values at five different time points: 5 minutes after induction of anesthesia (supine position, T1), 3 minutes after pneumoperitoneum (lithotomy position, T2), 3 minutes after pneumoperitoneum while in the lithotomy-Trendelenburg position (T3), 30 minutes after pneumoperitoneum (T4), and 3 minutes after deflation of pneumoperitoneum (T5).

RESULTS

In both groups, there were significant increases in PIP and Rrs while Cdyn decreased at times T2, T3, and T4 compared to T1 (P < 0.001). The Rrs of group PR for T2, T3, and T4 were significantly higher than those measured in group S for the corresponding time points (P < 0.05).

CONCLUSIONS

Respiratory mechanics can be adversely affected during laparoscopic colectomy. Respiratory resistance was significantly higher during propofol-remifentanil anesthesia than sevoflurane anesthesia.

Laparoscopy for colorectal cancer

The laparoscopic approach for colorectal cancer resection has been evolved from an experimental procedure with oncological concerns to routine daily practice within a period of two decades. Numerous randomized controlled trials and meta-analyses have shown that laparoscopic resection results in faster recovery with similar oncological outcome compared to an open approach, both for colon and rectal cancer. Besides improved cosmesis, other long-term advantages seem to be less adhesion related small bowel obstruction and reduced incisional hernia rate. Adequate patient selection and surgical experience are of crucial importance. Experience can be gradually expanded step by step, by increasing the complexity of the procedure. A decision to convert should be made early in the procedure, because the outcome after a reactive conversion is worse than initial open resection or strategic conversion. The additive value of new techniques such as robotic surgery has to be proven in randomized studies including a cost-effectiveness assessment.

Experts reviews of the multidisciplinary consensus conference colon and rectal cancer 2012: science, opinions and experiences from the experts of surgery

The first multidisciplinary consensus conference on colon and rectal cancer was held in December 2012, achieving a majority of consensus for diagnostic and treatment decisions using the Delphi Method. This article will give a critical appraisal of the topics discussed during the meeting and in the consensus document by well-known leaders in surgery that were involved in this multidisciplinary consensus process. Scientific evidence, experience and opinions are collected to support multidisciplinary teams (MDT) with arguments for medical decision-making in diagnosis, staging and treatment strategies for patients with colon or rectal cancer. Surgery is the cornerstone of curative treatment for colon and rectal cancer. Standardizing treatment is an effective instrument to improve outcome of multidisciplinary cancer care for patients with colon and rectal cancer. In this article, a review of the following focuses; Perioperative care, age and colorectal surgery, obstructive colorectal cancer, stenting, surgical anatomical considerations, total mesorectal excision (TME) surgery and training, surgical considerations for locally advanced rectal cancer (LARC) and local recurrent rectal cancer (LRRC), surgery in stage IV colorectal cancer, definitions of quality of surgery, transanal endoscopic microsurgery (TEM), laparoscopic colon and rectal surgery, preoperative radiotherapy and chemoradiotherapy, and how about functional outcome after surgery?

Total abdominal colectomy for severe ulcerative colitis: does the laparoscopic approach really have benefit?

BACKGROUND

It is still unknown to what extent the reported morbidity and recovery benefits of laparoscopic total abdominal colectomy (TAC) for severe ulcerative colitis (UC) are associated with patient selection bias. This study aimed to evaluate whether laparoscopic TAC has any advantages over open surgery after control for perioperative confounding factors.

METHODS

Patients undergoing TAC for UC during 2006-2010 were identified. Demographics, disease characteristics, and perioperative outcomes were compared between laparoscopic and open TAC. Postoperative recovery and 30-day complications were further assessed by covariate-adjusted multivariate regression models. The outcomes of different laparoscopic techniques were compared. A subgroup analysis including surgeons who routinely used both laparoscopic and open techniques was also performed.

RESULTS

Of the 412 eligible patients, the 197 patients undergoing laparoscopic TAC were significantly younger and had a decreased Charlson Comorbidity Index and ASA score, increased hemoglobin and serum albumin levels, and a smaller proportion of extensive colitis and urgent cases. Unadjusted analyses showed that intraoperative morbidity, postoperative mortality, and rates for readmission and reoperation were similar. Laparoscopic TAC was associated with a longer operative time but a decrease in blood loss, overall morbidity, ileus, and thromboembolism, as well as a faster return to bowel function and a shorter hospital stay. After covariate adjustments, laparoscopic surgery remained associated with a reduction in the time to stoma function, incidence of postoperative ileus, and hospital stay compared with open TAC. The rates of postoperative morbidity, readmission, and reoperation did not differ regardless whether the conventional multitrocar technique, hand-assisted procedure, or single-incision technique was used. Laparoscopic TAC among surgeons using both open and laparoscopic techniques was associated with recovery benefits similar to those observed in the overall study population.

CONCLUSION

The data suggest that laparoscopic TAC retains recovery advantages over open surgery even after adjustments for confounders.

Impact of operative duration on postoperative pulmonary complications in laparoscopic versus open colectomy

BACKGROUND

Prolonged operative duration is associated with increased postoperative morbidity and mortality. Although laparoscopic colectomy (LC) is associated with longer operative duration compared with open colectomy (OC), research shows paradoxically decreased morbidity following LC versus OC. The direct impact of operative duration on postoperative pulmonary complications (PPC) following LC versus OC has not been analyzed.

METHODS

We queried the ACS/NSQIP 2009-2010 Public Use File for patients who underwent elective LC and OC. The associations between operative duration and a PPC (pneumonia, intubation >48 h, and unplanned intubation) were evaluated. Multivariable regression models were created to determine the independent effect of operative time on the development of PPC controlling for LC versus OC.

RESULTS

A total of 25,419 colectomies (13,741 laparoscopic and 11,678 open) were reviewed; 765 (3 %) patients experienced at least one PPC. Regression modeling demonstrated that for both LC and OC each 60-min increase in operative time up to 480 min was associated with 13 % increased odds of PPC [odds ratio (OR) 1.13; 95 % confidence interval (CI) 1.07-1.19]. Beyond 480 min, each additional 60-min interval was associated with 33 % increased risk of PPC (OR 1.33; 95 % CI 1.12-1.58). Overall, PPCs occurred half as often following LC [270 (2 %) laparoscopic vs. 497 (4.3 %) open; OR 0.45; 95 % CI 0.39-0.53].

CONCLUSIONS

Operative duration is independently associated with increased risk of PPC in patients undergoing LC and OC. However, a laparoscopic approach carries half the absolute risk of PPC and, when safe, should be preferentially utilized despite a potential for prolonged operative duration.

E-Learning and Multimedia Contents for Minimally Invasive Surgery Learning

Background: Minimally Invasive Surgery has revolutionized the surgical practice for the last years but it presents specific training processes. At the same time, e-Learning platforms and multimedia contents are now having great success within teaching processes in different fields. Purpose: to determine perception of surgeons towards e-MIS: e-Learning and multimedia contents for minimally invasive surgery. Methods: A 19-item online survey was sent. Statistical and descriptive analyses were performed. Results: 307 surgeons responded to the survey. 99% of participants agree to include new technologies in surgical learning and 99.3% consider surgical videos as a good training tool. Conclusion: The widespread use and capabilities of e-Learning together with the use of surgical videos within the surgical learning process makes possible creating new technological systems and tools that address current problems in surgical training derived from time constraints and patient safety concerns.

Safe laparoscopic colorectal surgery performed by trainees

OBJECTIVES

Laparoscopic surgery for colorectal cancer is safe, but there have been hesitations to implement the technique in all departments. One of the reasons for this may be suboptimal learning possibilities since supervised trainees have not been allowed to do the operations to an adequate extent for the technique to spread. We routinely plan all operations as laparoscopic procedures and most cases are done by supervised trainees. The present study therefore presents the results of operations performed by trainees compared with results obtained by experienced laparoscopic surgeons.

DESIGN

Data for all patients who underwent elective colorectal cancer surgery in 2009 were recorded. Surgeries performed by laparoscopic inexperienced surgeons were compared with the outcome of surgery performed by laparoscopic experienced surgeons. These results were also compared with nationwide data extracted from the national database.

SETTING

A university teaching department of surgery.

PARTICIPANTS

A total of 131 patients underwent colorectal elective surgery in 2009 in the department.

RESULTS

Of the 131 operations, 60% were performed by trainees supervised by experienced laparoscopic colorectal surgeons. The trainees performed a total of 70% of all colonic procedures and 43% of all rectal resections. There were no statistically significant differences between the inexperienced and experienced laparoscopic surgeons with regards to short-term outcome other than increased duration of surgery for colonic resections (198 vs 140 min, p = 0.005). Thus, we found no difference regarding length of stay, conversion to laparotomy, intraoperative bleeding or complications, postoperative complications, or 30-day mortality.

CONCLUSIONS

Our data suggest that laparoscopic surgery for colorectal cancer can be performed safely by supervised trainees with good short term results. Therefore, a high volume of operations with an educational potential can easily be maintained when going from open to laparoscopic surgery as the standard operative technique for colorectal cancer in a university department of surgery.

Laparoscopic approach to acute abdomen from the Consensus Development Conference of the Società Italiana di Chirurgia Endoscopica e nuove tecnologie (SICE), Associazione Chirurghi Ospedalieri Italiani (ACOI), Società Italiana di Chirurgia (SIC), Società Italiana di Chirurgia d'Urgenza e del Trauma (SICUT), Società Italiana di Chirurgia nell'Ospedalità Privata (SICOP), and the European Association for Endoscopic Surgery (EAES)

BACKGROUND

In January 2010, the SICE (Italian Society of Endoscopic Surgery), under the auspices of the EAES, decided to revisit the clinical recommendations for the role of laparoscopy in abdominal emergencies in adults, with the primary intent being to update the 2006 EAES indications and supplement the existing guidelines on specific diseases.

METHODS

Other Italian surgical societies were invited into the Consensus to form a panel of 12 expert surgeons. In order to get a multidisciplinary panel, other stakeholders involved in abdominal emergencies were invited along with a patient's association. In November 2010, the panel met in Rome to discuss each chapter according to the Delphi method, producing key statements with a grade of recommendations followed by commentary to explain the rationale and the level of evidence behind the statements. Thereafter, the statements were presented to the Annual Congress of the EAES in June 2011.

RESULTS

A thorough literature review was necessary to assess whether the recommendations issued in 2006 are still current. In many cases new studies allowed us to better clarify some issues (such as for diverticulitis, small bowel obstruction, pancreatitis, hernias, trauma), to confirm the key role of laparoscopy (such as for cholecystitis, gynecological disorders, nonspecific abdominal pain, appendicitis), but occasionally previous strong recommendations have to be challenged after review of recent research (such as for perforated peptic ulcer).

CONCLUSIONS

Every surgeon has to develop his or her own approach, taking into account the clinical situation, her/his proficiency (and the experience of the team) with the various techniques, and the specific organizational setting in which she/he is working. This guideline has been developed bearing in mind that every surgeon could use the data reported to support her/his judgment.

Complement activation and interleukin response in major abdominal surgery

The objective of this study was to evaluate whether major abdominal surgery leads to complement activation and interleukin response and whether the kind of anaesthesia influence complement activation and the release of inflammatory interleukins. The study design was prospective and randomised. Fifty patients undergoing open major colorectal surgery due to cancer disease or inflammatory bowel disease were studied. Twenty-five patients were given total intravenous anaesthesia (TIVA) with propofol and remifentanil, and 25 patients were given inhalational anaesthesia with sevoflurane and fentanyl. To determine complement activation (C3a and SC5b-9) and the release of pro- and anti-inflammatory interleukins (tumour necrosis factor-a (TNF-a)), interleukin-1b (IL-1b), IL-6, IL-8, IL-4 and IL-10), blood samples were drawn preoperatively, 60 minutes after start of surgery, 30 minutes after end of surgery and 24 hours postoperatively. Complement was activated and pro-inflammatory interleukins (IL-6 and IL-8) and anti-inflammatory interleukins (IL-10) were released during major colorectal surgery. There was no significant difference between TIVA and inhalational anaesthesia regarding complement activation and cytokine release. Major colorectal surgery leads to activation of the complement cascade and the release of both pro-inflammatory and anti-inflammatory cytokines. There are no significant differences between total intravenous anaesthesia (TIVA) with propofol and remifentanil and inhalational anaesthesia with sevoflurane and fentanyl regarding complement activation and the release of pro- and anti-inflammatory interleukins.

Laparoscopic versus open distal gastrectomy for gastric cancer: a meta-analysis of randomized controlled trials and high-quality nonrandomized studies

OBJECTIVE

To perform a meta-analysis of high-quality published trials, randomized and observational, comparing laparoscopic distal gastrectomy (LDG) and open distal gastrectomy (ODG) for gastric cancer.

BACKGROUND

Controversy persists about the clinical utility of minimally invasive techniques for the treatment of gastric cancer. Prospective data is limited to a few small randomized trails.

METHODS

: Studies published from January 1992 to March 2010 that compare LDG and ODG were identified. No restrictions in pathologic stage were applied. All randomized controlled trials (RCTs) were included. Selection of high-quality, nonrandomized comparative studies (NRCTs) was based on a validated tool (Methodological Index for Nonrandomized Studies). Mortality, complications, harvested lymph nodes, operative time, blood loss, and hospital stay were compared using weighted mean differences (WMDs) and odds ratios (ORs).

RESULTS

Twenty-five studies were included in the analyses, 6 RCTs and 19 NRCTs, compromising 3055 patients (1658 LDG, 1397 ODG). LDG was associated with longer operative times (WMD 48.3 minutes; P < 0.001) and lower overall complications (OR 0.59; P < 0.001), medical complications (OR 0.49; P = 0.002), minor surgical complications (OR 0.62; P = 0.001), estimated blood loss (WMD -118.9 mL; P < 0.001), and hospital stay (WMD -3.6 days; P < 0.001). Mortality and major complications were similar. Patients in the ODG group had a significantly higher number of lymph nodes harvested (WMD 3.9 nodes; P < 0.001), although the estimated proportion of patients with less than 15 retrieved nodes was similar (OR 1.26, P = 0.09).

CONCLUSIONS

LDG can be performed safely with a shorter hospital stay and fewer complications than open surgery. The long-term significance of a difference of less than 5 nodes in the number of harvested lymph nodes remains unclear. Lymph node staging appears to be unaffected. These results need to be validated in Western patients with advanced gastric cancer.

Laparoscopic colorectal cancer surgery by a colon lifting-up technique that decreases the number of access ports: comparison by propensity scoring of short-term and long-term outcomes with standard multiport laparoscopic surgery

BACKGROUND

Laparoscopic colectomy for colorectal cancer has become established as a minimally invasive surgical approach. However, many disposable instruments are required, and there is an associated disadvantage of cost. We have developed a new technique, which uses a suture string to lift up the colon. This method is expected to reduce the number of access ports required without compromising the radical cure.

OPERATIVE PROCEDURE

A suture string piercing the abdominal wall is passed through the mesocolon. The colon is retracted anteriorly and is fixed at the abdominal wall. The main mesenteric vessels are under tension, and lymph node dissection is performed easily by a medial approach. The working space is more stable because the colon is fixed to the abdominal wall.

METHODS

This study examined the short-term and long-term surgical outcomes of laparoscopic resection for colorectal cancer using our colon lifting-up technique (CLT), compared with the standard multiport technique. The study design was a case-matched control by propensity scoring. Analyzed variables were sex, age, American Society of Anesthesiologists score, cancer in a different organ, multiple colorectal cancer, operator, operative year, tumor location, operative procedure, adjuvant chemotherapy, and International Union Against Cancer TNM stage.

RESULTS

From 2000 to 2010, 301 patients underwent CLT and 436 standard multiport technique, 148 patients were matched by propensity score and analyzed. Regarding short-term outcomes, there was no difference between the 2 groups. The mean number of ports needed was 3.37±0.48 for CLT (93 with 3 ports, 55 with 4). There were no differences in recurrence-free survival and overall survival in long-term follow-up results for each stage. There were neither recurrences nor complications due to CLT.

CONCLUSIONS

The CLT facilitated laparoscopic colectomy without compromising cure rates. It is a useful method to keep a stable view and to conserve medical resources.

Laparoscopic surgery for colorectal cancer

BACKGROUND

Laparoscopic surgery for colorectal cancer has undergone tremendous advancement in the last two decades, with maturation of techniques and integration into current practice.

SOURCES OF DATA

Worldwide English-language literature on laparoscopic surgery for the management of colon and rectal cancer was reviewed.

AREAS OF AGREEMENT

A large body of evidence has attested to the improved short-term outcomes and long-term oncological safety of laparoscopic surgery for colon cancer. Laparoscopic colectomy can be recommended to suitable patients where expertise is available. Laparoscopic resection for rectal cancer is feasible, with good evidence of faster post-operative recovery and adequate surgical quality, but requires more data on long-term oncological outcomes. This review examines the evidence and current practice of laparoscopic surgery for colorectal cancer.

AREAS OF CONTROVERSY

Does laparoscopic surgery confer a survival advantage for colorectal cancer patients?

GROWING POINTS

The role of single-incision laparoscopic surgery and robotic surgery in colorectal cancer.

AREAS TIMELY FOR DEVELOPING RESEARCH

Barriers to the adoption of the laparoscopic technique.

Staged restorative proctocolectomy: laparoscopic or open completion proctectomy after laparoscopic subtotal colectomy?

BACKGROUND

The aim of this study was to compare outcomes of laparoscopic and open completion proctectomy (CP) and ileal-pouch anal anastomosis (IPAA) after a previous laparoscopic subtotal colectomy (STC).

METHODS

From a prospectively maintained ileal pouch database, outcomes for patients who underwent laparoscopic CP after laparoscopic STC (LSTC-LCP group) for ulcerative or indeterminate colitis were compared to those for patients who underwent open CP (LSTC-OCP group). A control group of open CP after open STC (OSTC-OCP group) was case-matched to LSTC-OCP at a ratio of 1:2 for age at surgery, gender, body mass index (BMI), year of operation, and American Society of Anesthesiologists (ASA) classification. Demographics, perioperative data, and pouch function were compared. Quality of life was evaluated using the Cleveland Global Quality of Life Scale (CGQL).

RESULTS

Between 1997 and 2009, 47 patients underwent LSTC followed by LCP (LSTC-LCP), and 48 patients underwent OCP after LSTC (LSTC-OCP); the latter group was matched to 96 open-open patients (OSTC-OCP). There were no significant differences in demographic and preoperative data among the three groups, except that the OSTC-OCP group patients were younger. Postoperative morbidity, pouch function, and CGQL were similar. LSTC-LCP patients had lower estimated blood loss (EBL) (p < 0.001), less commonly described intraoperative adhesiolysis (p < 0.001), reduced length of hospital stay (LOS) (p = 0.002) but longer operating time (p = 0.001) at CP/IPAA when compared with open-open patients. For patients with previous LSTC, LCP was associated with less commonly described intraoperative adhesiolysis (p = 0.003) and shorter LOS (p = 0.003) than OCP but a longer operating time (p = 0.036).

CONCLUSIONS

Laparoscopic CP and IPAA can be performed with safety comparable to that of open surgery after previous laparoscopic STC. The laparoscopic approach is associated with advantages including reduced intraoperative blood loss and earlier recovery as demonstrated by shorter length of hospital stay.