Is obesity a high-risk factor for laparoscopic colorectal surgery?

Association between body mass index and short-term outcomes of laparoscopic right hemicolectomy for colon cancer

BACKGROUND

Laparoscopic right hemicolectomy can be technically challenging in patients with increased body mass index, reportedly associated with higher surgical site infection (SSI) and incisional hernia rates. We aimed to assess the association between increased body mass index and short-term outcomes of laparoscopic right hemicolectomy.

METHODS

This retrospective cohort study included patients with colon cancer who underwent laparoscopic right hemicolectomy between 2011 and 2021. Patients were managed with a standardized care protocol that comprised preoperative, intraoperative, and postoperative measures and were divided according to body mass index-normal body mass index (18-24.9 kg/m2), overweight (25-29.9 kg/m2), and obesity (≥30 kg/m2). Body mass index groups were compared for baseline characteristics and outcomes. The main outcome measures were operative time, hospital stay, 30-day complications, reoperation, number of harvested lymph nodes, and resection status.

RESULTS

A total of 270 patients (50% male sex; mean age: 68.7 ± 13.5 years) were included-28.5% had normal body mass index, 47% were overweight, and 24.5% had obesity. Mean operative times in obese and overweight patients were significantly longer than patients with normal body mass index (172.1 and 168.8 versus 143.3 minutes, P = .01). Compared to normal body mass index, obesity was associated with significantly higher odds of incisional SSI (odds ratio: 9.29, P = .039). Body mass index had a significant positive correlation with operation time (r = 0.205, P = .004) and incisional SSI (r = 0.126, P = .04). Body mass index groups had similar hospital stays, 30-day complications and mortality, anastomotic leak, ileus, and reoperation.

CONCLUSION

Patients with increased body mass index had longer operative times and higher SSI rates, yet similar hospital stays and comparable 30-day complication rates, mortality, and reoperation to patients with normal body mass index.

The feasibility and outcomes of metabolic and bariatric surgery prior to neoplastic therapy

BACKGROUND

Metabolic and bariatric surgery (MBS) is a potent intervention for addressing obesity-related medical conditions and achieving sustainable weight loss. Beyond its conventional role, MBS has demonstrated potential to serve as a transitional step for patients requiring various interventions. However, the implications of MBS in the context of neoplasia remain understudied.

OBJECTIVES

To explore the feasibility of MBS as a possible attempt to reduce surgical and treatment risks in patients with benign tumors or low-grade cancers.

SETTING

Multicenter review from twelve tertiary referral centers spanning 8 countries.

METHODS

A retrospective review of patients with a diagnosis of primary neoplasia, deemed inoperable or high-risk due to obesity, and receiving primary MBS prior to neoplastic therapy. Data encompassed baseline characteristics, neoplasia characteristics, MBS outcomes, and neoplastic therapy outcomes.

RESULTS

Thirty-seven patients (median age 52 years, 75.7% female, median BMI of 49.1 kg/m2) were included. There were 9 distinct organs of origin of primary neoplasia, with the endometrium (43.2%) being the most common, followed by the pancreas, colon, kidney and breast. Sleeve gastrectomy (SG) was the most commonly performed MBS procedure (78.4%), with no MBS-related complications or mortalities reported over an average of 4.3 ± 3.9 years. Thirty-one patients (83.8%) eventually underwent neoplastic surgery, with a mean BMI decrease from 49.9 kg/m2 to 39.7 kg/m2 at surgery over an average of 5.8 ± 4.8 months. There were 2 (6.7%) documented mortalities associated with neoplastic surgical intervention.

CONCLUSIONS

This study highlights the potential feasibility of employing MBS prior to neoplastic therapy in patients with low-grade, less aggressive neoplasms in the context of obesity. This underscores the importance of providing a personalized, case-to-case multidisciplinary approach in the management of these patients.

Strategies to reduce ileus after colorectal surgery: A qualitative umbrella review of the collective evidence

BACKGROUND

Various strategies were proposed to reduce postoperative ileus after colorectal surgery. This umbrella review aimed to provide a comprehensive overview of current evidence on measures to reduce the incidence and severity of postoperative ileus after colorectal surgery.

METHODS

A Preferred Reporting Items for Systematic Reviews and Meta-Analyses-compliant systematic search was conducted in PubMed and Scopus to identify systematic reviews that assessed the efficacy of interventions used to prevent postoperative ileus after colorectal surgery. Data on study characteristics, interventions, and outcomes were summarized in a narrative manner.

RESULTS

A total of 26 systematic reviews incorporating various strategies like early oral feeding, gum chewing, coffee consumption, medications, and acupuncture were included. Early oral feeding reduced postoperative ileus and accelerated bowel function return. The most assessed intervention was chewing gum, which was associated with a median reduction of postoperative ileus by 45% (range, 11%-59%) and shortening of the time to first flatus and time to defecation by a median of 11.9 and 17.7 hours, respectively. Coffee intake showed inconsistent results, with a median shortening of time to flatus and time to defecation by 1.32 and 14.45 hours, respectively.

CONCLUSION

Early oral feeding, chewing gum, and alvimopan were the most commonly assessed and effective strategies for reducing postoperative ileus after colorectal surgery. Medications used to reduce postoperative ileus included alvimopan, intravenous lidocaine, dexamethasone, probiotics, and oral antibiotics. Intravenous dexamethasone and lidocaine and oral probiotics helped hasten bowel function return. Acupuncture positively impacted the recovery of bowel function.

Effect of Sevoflurane on the Deep Neuromuscular Blockade in Obese Patients Undergoing Laparoscopic Sleeve Gastrectomy: A Single Center Prospective Randomized Controlled Study

Objective

Our study aimed to demonstrate that the combination of sevoflurane inhalation with continuous intravenous anesthesia can effectively reduce the dosage of muscle relaxants, shorten extubation time under anesthesia while meeting the requirements of laparoscopic deep neuromuscular block (dNMB) in obese patients. Additionally, we sought to assess the potential reduction in postoperative residual muscle relaxants.

Methods

Fifty-nine patients were randomly assigned. Anesthesia-related variables, such as anesthetics dosages, muscle relaxant effective time, clinical muscle relaxant time, muscle relaxant in vivo action time, muscle relaxant recovery time, body movement times, and extubation duration were recorded. Surgery-related variables (the Leiden-Surgical Rating Scale (L-SRS), duration of the procedure) were recorded. Pain was measured using the visual analog scale (VAS) score before leaving the PACU. The duration of the PACU stay and patients' satisfaction levels in the PACU were also recorded.

Results

Patients who inhaled sevoflurane during the operation required a lower dosage of muscle relaxant to achieve the same deep neuromuscular block (dNMB) effect. The time from stopping the rocuronium pump to T1 recovery of 90% was shorter, and the time for T1 to recover from 25% to 75% was faster among patients who inhaled sevoflurane during the operation. Furthermore, the sevoflurane combined with continuous intravenous anesthesia group exhibited a shorter extubation time for obese patients undergoing laparoscopic bariatric surgery, along with a reduced risk of experiencing hypoxemia and a shorter observation time in the PACU.

Conclusion

Inhaling sevoflurane combined with continuous intravenous anesthesia during the operation effectively reduces the dosage of muscle relaxant required to achieve the same deep neuromuscular block (dNMB) effect. Additionally, this approach significantly shortens the extubation time for obese patients undergoing laparoscopic bariatric surgery and reduces the risk of experiencing hypoxemia, along with reducing the observation time in the PACU.

Body composition index obtained by using a bioelectrical impedance analysis device can be a predictor of prolonged operative time in patients undergoing minimally invasive colorectal surgery

PURPOSE

Obesity has been known to contribute to technical difficulties in surgery. Until now, body mass index (BMI) has been used to measure obesity. However, there are reports that BMI does not always correspond to the visceral fat. Recently, bioelectrical impedance analysis (BIA) has been used for body composition analysis. This study aimed to evaluate the usefulness of the body composition index obtained using a BIA device in predicting short-term postoperative outcomes.

METHODS

Data of patients who underwent elective major colorectal surgery using minimally invasive techniques were reviewed retrospectively. Body composition status was recorded using a commercial BIA device the day before surgery. The relationship between BMI, body composition index, and short-term postoperative outcomes, including operative time, was analyzed.

RESULTS

Sixty-six patients were enrolled in this study. In the correlation analysis, positive correlation was observed between BMI and body composition index. BMI and body composition index were not associated with short-term postoperative outcomes. Percent body fat (odds ratio, 4.226; 95% confidence interval [CI], 1.064-16.780; P=0.041) was found to be a statistically significant factor of prolonged operative time in the multivariate analysis. Correlation analysis showed that body fat mass was related to prolonged operative time (correlation coefficients, 0.245; P=0.048). In the area under curve analysis, body fat mass showed a statistically significant predictive probability for prolonged operative time (body fat mass: area, 0.662; 95% CI, 0.531-0.764; P=0.024).

CONCLUSION

The body composition index can be used as a predictive marker for prolonged operative time. Further studies are needed to determine its usefulness.

Effect of obesity on perioperative outcomes following gastrointestinal surgery: meta-analysis

BACKGROUND

Obesity can pose perioperative challenges related to obesity-associated co-morbidities and technical factors. However, the true impact of obesity on postoperative outcomes is not well established and reports are conflicting. The aim was to perform a systematic review and meta-analysis to explore the effect of obesity on perioperative outcomes for general surgery procedures in distinct obesity subtypes.

METHODS

A systematic review was performed for studies reporting postoperative outcomes in relation to BMI in upper gastrointestinal, hepatobiliary and colorectal based on an electronic search using the Cochrane Library, Science Direct, PubMed and Embase up to January 2022. The primary outcome was the incidence of 30-day postoperative mortality among patients with obesity undergoing general surgical procedures in comparison to patients with normal range BMI.

RESULTS

Sixty-two studies, including 1 886 326 patients, were eligible for inclusion. Overall, patients with obesity (including class I/II/II) had lower 30-day mortality rates in comparison to patients with a normal BMI (odds ratio (OR) 0.75, 95 per cent c.i. 0.66 to 0.86, P < 0.0001, I2 = 71 per cent); this was also observed specifically in emergency general surgery (OR 0.83, 95 per cent c.i. 0.79 to 0.87, P < 0.0000001, I2 = 7 per cent). Compared with normal BMI, obesity was positively associated with an increased risk of 30-day postoperative morbidity (OR 1.11, 95 per cent c.i. 1.04 to 1.19, P = 0.002, I2 = 85 per cent). However, there was no significant difference in postoperative morbidity rates between the cohorts of patients with a normal BMI and class I/II obesity (OR 0.98, 95 per cent c.i. 0.92 to 1.04, P = 0.542, I2 = 92 per cent). Overall, the cohort with obesity had a higher rate of postoperative wound infections compared with the non-obese group (OR 1.40, 95 per cent c.i. 1.24 to 1.59, P < 0.0001, I2 = 82 per cent).

CONCLUSION

These data suggest a possible 'obesity paradox' and challenge the assumption that patients with obesity have higher postoperative mortality compared with patients with normal range BMI. Increased BMI alone is not associated with increased perioperative mortality in general surgery, highlighting the importance of more accurate body composition assessment, such as computed tomography anthropometrics, to support perioperative risk stratification and decision-making.

REGISTRATION NUMBER

CRD42022337442 (PROSPERO https://www.crd.york.ac.uk/prospero/).

The Extraperitoneal Approach to Left-Sided Colorectal Resections: A Human Cadaveric Study

INTRODUCTION

Technical challenges during laparoscopic and robotic anterior resection include identification of key retroperitoneal structures and obtaining clear views of the inferior mesenteric artery (IMA) pedicle and total mesorectal excision (TME) plane. Steep head-down position improves surgical exposure but is associated with cerebral oedema, high intrapulmonary pressures, and rare neurological complications. In this article we describe the key steps of an anterior resection performed via the extra-peritoneal (XP) space in the supine position.

METHODS

The technique of same-side lateral-to-medial XP dissection has been developed and refined in serial cadaveric workshops. A standard periumbilical port is inserted for initial laparoscopic exploration. Dissection is then performed in the left XP space via a 5 cm skin incision (later used as the extraction site) to allow for insertion of four (latterly three) working ports. The colon is mobilized along its lateral attachments, reflecting retroperitoneal structures down and away. The IMA pedicle is taken proximally, next to the duodenum. If required, TME dissection can be continued in the same plane. A short intraperitoneal phase is then required to complete the procedure.

RESULTS

Eight cadavers were studied (seven males; median 78 y). Four operations were performed laparoscopically and four robotically. Excellent views of the key retroperitoneal structures were achieved early in the procedure. Anatomical identification was performed sequentially for left-sided structures-psoas tendon, gonadal vessel, ureter, common iliac artery, IMA, and duodenum before ligation of the IMA pedicle. High ligation of IMA on the aorta and splenic flexure mobilization were performed in all eight procedures.

CONCLUSIONS

This novel study shows it is feasible to perform the key steps of an anterior resection using the XP space in the supine position. This will reduce the need for steep head-down positioning which may have meaningful clinical benefits. Prospective clinical studies are required to validate the technique within a patient population.

Association of hospital volume with conversion to open from minimally invasive colectomy in patients with diverticulitis: A national analysis

BACKGROUND

Despite the known advantages of minimally invasive surgery (MIS) for diverticular disease, the impact of conversions to open (CtO) colectomy remains understudied. The present study used a nationally representative database to characterize risk factors and outcomes associated with CtO in patients with diverticular disease.

METHODS

All elective adult hospitalizations entailing colectomy for diverticulitis were identified in the 2017-2019 Nationwide Readmissions Database. Annual institutional caseloads of MIS and open colectomy were independently tabulated. Restricted cubic splines were utilized to non-linearly estimate the risk-adjusted association between hospital volumes and CtO. Additional regression models were developed to evaluate the association of CtO with outcomes of interest.

RESULTS

Of an estimated 110,281 patients with diverticulitis who met study criteria, 39.3% underwent planned open colectomy, 53.3% completed MIS, and 7.4% had a CtO. Following adjustment, an inverse relationship between hospital MIS volume and risk of CtO was observed. In contrast, increasing hospital open volume was positively associated with greater risk of CtO. On multivariable analysis, CtO was associated with lower odds of mortality (AOR 0.3, p = 0.001) when compared to open approach, and similar risk of mortality when compared to completed MIS (AOR 0.7, p = 0.436).

CONCLUSION

In the present study, institutional MIS volume exhibited inverse correlation with adjusted rates of CtO, independent of open colectomy volume. CtO was associated with decreased rates of mortality compared to planned open approach but equivalence risk relative to completed MIS. Our findings highlight the importance of MIS experience and suggest that MIS may be safely pursued as the initial surgical approach among diverticulitis patients.

Effects of pneumoperitoneum and patient position on intracranial pressure in obese patients undergoing laparoscopic cholecystectomy

Background/Aim: Optic nerve sheath diameter (ONSD) measurement is one of the non-invasive techniques used for intracranial pressure (ICP) measurement. ICP changes have been evaluated based on ONSD measurements during many laparoscopic surgeries. However, such analyses in the obese patient populations are limited. This study aimed at investigating the effects of pneumoperitoneum and reverse Trendelenburg and head-up position on ICP based on ONSD measurements in obese patients undergoing laparoscopic cholecystectomy. Methods: This observational study included 60 female patients who were scheduled for laparoscopic cholecystectomy. Obese patients with a body mass index (BMI) of 30 and above were assigned to Group 1, while BMI < 30 patients were assigned to Group 2. The first ONSD measurement was performed just before insufflation (T1). The second measurement was taken 5 min after insufflation (T2), the third measurement 5 min after placing patients in the reverse Trendelenburg and head-up position (T3), and the last measurement 5 min after the deflation while the reverse Trendelenburg and head-up position was maintained (T4). Results: ONSD measurements at the T2 and T3 time points in Group 1 patients were higher than in Group 2 patients (P = 0.012 versus P = 0.020). Both measurement values were higher in obese patients. In Group 1 patients, T2 and T3 measurements were significantly higher than T1 and T4 measurements (T2 > T1; P < 0.001, T2 > T4; P < 0.001, T3 > T1; P < 0.001, and T3 > T4; P < 0.001). No significant difference between T2 and T3 and between T1 and T4 measurements were found. In Group 2 patients, T2 measurements were significantly higher than the T1, T3, and T4 measurements, while T3 measurements were significantly higher than T1 and T4 measurements (T2 > T1; P < 0.001, T2 > T3; P = 0.022, T2 > T4; P < 0.001, T3 > T1; P < 0.001, and T3 > T4; P = 0.048). No significant difference between T1 and T4 measurements was noted. Conclusion: Laparoscopic cholecystectomy does not cause an increase in ICP of obese patients with limited pneumoperitoneum pressure, reverse Trendelenburg and head-up position, and controlled anesthesia.

Routine placement of abdominal drainage in pouch surgery does not impact on surgical outcomes

The evidence does not support the routine use of abdominal drainage (AD) in colorectal surgery. However, there is no data on the usefulness of AD, specifically, after ileal pouch-anal anastomosis (IPAA). The aim of this study is to assess post-operative outcomes of patients undergoing IPAA with or without AD at a high volume referral center. A retrospective analysis of prospectively collected data of consecutive patients undergoing IPAA with AD (AD group) or without AD (NAD group) was performed. Baseline characteristics, operative, and postoperative data were analyzed and compared between the two groups. A total of 97 patients were included in the analysis, 46 were in AD group and 51 in NAD group. AD group had a higher BMI (23.9 ± 3.9 kg/m² vs 21.9 ± 3.0 kg/m²; p = 0.007) and more commonly underwent two-stage proctocolectomy with IPAA compared to the NAD group (50.0% vs 3.9%; p < 0.001). There was no difference in anastomotic leak rate (6.5% AD vs 5.9% NAD group; p = 1.000), major post-operative complication (8.6% vs 7.9%; p = 0.893); median length of stay [IQR] (5 [5-7] days vs 5 [4-7] days; p = 0.305) and readmission < 90 days (8.7% vs 3.9%; p = 0.418). The use of AD does not impact on surgical outcome after IPAA and question the actual benefit of its routine placement.

Robotic-assisted versus laparoscopic rectal surgery in obese and morbidly obese patients: ACS-NSQIP analysis

Laparoscopic rectal surgery within the confines of a narrow pelvis may be associated with a high rate of open conversion. In the obese and morbidly obese patient, the complexity of laparoscopic surgery increases substantially. Robotic technology is known to reduce the risk of conversion, but it is unclear if it can overcome the technical challenges associated with obesity. The ACS NSQIP database was used to identify obese patients who underwent elective laparoscopic or robotic-assisted rectal resection from 2015 to 2016. Obesity was defined as a body mass index (BMI) greater than or equal to 30 kg/m². Morbid obesity was defined as a BMI greater than or equal to 35 kg/m². The primary outcome was unplanned conversions to open. Other outcomes measures assessed included anastomotic leak, operative time, surgical site infections, length of hospital stay, readmissions and mortality. Statistical analyses were performed using SPSS 22.0 (IBM SPSS, USA). 1490 patients had robotic-assisted and 4967 patients had laparoscopic rectal resections between 2015 and 2016. Of those patients, 561 obese patients had robotic-assisted rectal resections and 1824 patients underwent laparoscopic rectal surgery. In the obese cohort, the rate of unplanned conversion to open in the robotic group was 14% compared to 24% in the laparoscopic group (P < 0.0001). Median operative time was significantly longer in the robotic group (248 min vs. 215 min, P < 0.0001). There was no difference in anastomotic leak or systemic sepsis between the laparoscopic and robotic rectal surgery groups. In morbidly obese patients (BMI ≥ 35 kg/m²), the rate of unplanned conversion to open in the robotic group was 19% compared to 26% in the laparoscopic group (P < 0.027). There was no difference in anastomotic leak, systemic sepsis or surgical site infection rates between robotic and laparoscopic rectal resection. Multivariate analysis showed that robotic-assisted surgery was associated with fewer unplanned conversions to open (OR 0.28, P < 0.0001). Robotic-assisted surgery is associated with a decreased risk of conversion to open in obese and morbidly obese patients when compared to conventional laparoscopic surgery. However, robotic surgery was associated with longer operative time and despite improvement in the rate of conversion to open, there was no difference in complications or length of stay. Our findings are limited by the retrospective non-randomised nature of the study, demographic differences between the two groups, and the likely difference in surgeon experience between the two groups. Large randomised controlled studies are needed to further explore the role of robotic rectal surgery in obese and morbidly obese patients.

Systematic review and meta-analysis: association between obesity/overweight and surgical complications in IBD

PURPOSE

While the prevalence of obesity in inflammatory bowel disease (IBD) patients is rapidly increasing, it is unclear whether obesity affects surgical outcomes in this population. This meta-analysis aims to assess the impact of obesity/overweight on patients undergoing surgery for IBD.

METHODS

Databases (PubMed, Web of Science, Cochrane Library, and Springer) were searched through September 2021. The meta-analysis included patients with surgically treated IBD to investigate the impact of obesity/overweight on this population. Primary outcomes included overall complications, infectious complications, noninfectious complications, and conversion to laparotomy.

RESULTS

Fifteen studies totaling 12,622 IBD patients were enrolled. Compared with nonobese (including overweight) patients, obese IBD patients have increased the risk in terms of overall complications (OR = 1.45, p < 0.001), infectious complications (OR = 1.48, p = 0.003) (especially wound complications), as well as conversion to laparotomy (OR = 1.90, p < 0.001). Among the noninfectious complications, only the incidence of visceral injury (OR = 2.36, p = 0.05) had significantly increased. Compared with non-overweight patients, the risk of developing wound complications (OR = 1.65, p = 0.01) and sepsis (OR = 1.73, p = 0.007) were increased in overweight patients, but the rates of overall complications (OR = 1.04, p = 0.81), infectious complications (OR = 1.31, p = 0.07), and conversion to laparotomy (OR = 1.33, p = 0.08) associated with body mass index (BMI) were not significantly different.

CONCLUSION

Obesity is a risk factor for surgical complications in IBD patients, mainly reflected in infectious complications. Moreover, obese patients seem to have a more common chance of developing surgical complications than overweight patients.

Outcomes in Obese vs Non-Obese Injured Patients at a Level 1 Trauma Center and Bariatric Surgery Center of Excellence

BACKGROUND

We hypothesized that the outcomes of trauma patients with a body mass index (BMI) equal to or greater than 30 compared to patients with BMI less than 30 would not differ at a level 1 trauma center that is also a Metabolic and Bariatric Surgery Center of Excellence in the Metabolic and Bariatric Surgery Accreditation Quality Improvement Program (MBSAQIP).

STUDY DESIGN

Patients equal to and greater than 18 years old treated between 1/1/2018 and 12/31/2020 were included. Demographics, BMI, comorbidities, and outcomes (hospital-LOS, ICU-LOS, blood products used, and mortality) were compared between 2 groups: obese (BMI ≥30) vs non-obese (BMI <30).

RESULTS

Of the 4192 patients identified, 3821 met the inclusion criteria; 3019 patients had a BMI <30, and 802 had a BMI ≥30. There was a statistically significant difference between the 2 groups with respect to gender (females: 57% vs 47%, P < .0001) and age (median: 80 [IQR: 63-88] vs 69 [IQR: 55-81], P < .0001). When adjusted for age, sex, DM, dementia, ISS, and ICU admission, there was no statistically significant difference in hospital-LOS (4.30 [95% CI: 4.10, 4.52] vs 4.48 [95% CI: 4.18, 4.79]) or mortality. No statistical differences were seen between the 2 groups in blood product use.

CONCLUSIONS

Obesity did not correlate with poorer outcomes at an ACS-verified level 1 Trauma Center and Bariatric Surgery Center of Excellence. Further studies are needed to determine whether outcomes vary at hospitals without both designations.

Impact of the Deep Neuromuscular Block on Oncologic Quality of Laparoscopic Surgery in Obese Gastric Cancer Patients: A Randomized Clinical Trial

BACKGROUND

Obesity can hinder laparoscopic procedures and impede oncological safety during laparoscopic cancer surgery. Deep neuromuscular block (NMB) reportedly improves laparoscopic surgical conditions, but its oncological benefits are unclear. We aimed to evaluate whether deep NMB improves the oncologic quality of laparoscopic cancer surgery in obese patients.

STUDY DESIGN

We conducted a double-blinded, parallel-group, randomized, phase 3 trial at 9 institutions in Korea. Clinical stage I and II gastric cancer patients with a BMI at or above 25 kg m -2 were eligible and randomized 1:1 ratio to the deep or moderate NMB groups, with continuous infusion of rocuronium (0.5-1.0 and 0.1-0.5 mg kg -1 h -1, respectively). The primary endpoint was the number of retrieved lymph nodes (LNs). The secondary endpoints included the surgeon's surgical rating score (SRS) and interrupted events.

RESULTS

Between August 2017 and July 2020, 196 patients were enrolled. Fifteen patients were excluded, and 181 patients were finally included in the study. There was no significant difference in the number of retrieved LNs between the deep (N = 88) and moderate NMB groups (N = 93; 44.6 ± 17.5 vs 41.5 ± 16.9, p = 0.239). However, deep NMB enabled retrieving more LNs in patients with a BMI at or above 28 kg/m2 than moderate NMB (49.2 ± 18.6 vs 39.2 ± 13.3, p = 0.026). Interrupted events during surgery were lower in the deep NMB group than in the moderate NMB group (21.6% vs 36.6%; p = 0.034). The SRS was not influenced by NMB depth.

CONCLUSION

Deep NMB provides potential oncologic benefits by retrieving more LNs in patients with BMI at or above 28 kg/m2 during laparoscopic gastrectomy.

Meta-analysis of transanal versus laparoscopic total mesorectal excision for rectal cancer: a 'New Health Technology' assessment in South Korea

Purpose

Under the South Korea's unique health insurance structure, any new surgical technology must be evaluated first by the government in order to consider whether that particular technology can be applied to patients for further clinical trials as categorized as 'New Health Technology,' then potentially covered by the insurance sometime later. The aim of this meta-analysis was to assess the safety and efficacy of transanal total mesorectal excision (TaTME) for rectal cancer, activated by the National Evidence-based Healthcare Collaborating Agency (NECA) TaTME committee.

Methods

We systematically searched Ovid-MEDLINE, Ovid-Embase, Cochrane, and Korean databases (from their inception until August 31, 2019) for studies published that compare TaTME with laparoscopic total mesorectal excision (LaTME). End-points included perioperative and pathological outcomes.

Results

Sixteen cohort studies (7 for case-matched studies) were identified, comprising 1,923 patients (938 TaTMEs and 985 LaTMEs). Regarding perioperative outcomes, the conversion rate was significantly lower in TaTME (risk ratio, 0.19; 95% confidence interval, 0.11-0.34; P < 0.001); whereas other perioperative outcomes were similar to LaTME. There were no statistically significant differences in pathological results between the 2 procedures.

Conclusion

Our meta-analysis showed comparable results in preoperative and pathologic outcomes between TaTME and LaTME, and indicated the benefit of TaTME with low conversion. Extensive evaluations of well-designed, multicenter randomized controlled trials are required to come to unequivocal conclusions, but the results showed that TaTME is a potentially beneficial technique in some specific cases. This meta-analysis suggests that TaTME can be performed for rectal cancer patients as a 'New Health Technology' endorsed by NECA in South Korea.

The influence and countermeasure of obesity in laparoscopic colorectal resection

BACKGROUND

The aim of this study was to investigate the influence of obesity and the usefulness of a preoperative weight loss program (PWLP) for obese patients undergoing laparoscopic colorectal resection (LCR).

METHODS

Study 1: 392 patients who underwent LCR for colorectal cancer were divided into two groups: those with a body mass index (BMI) ≥25 kg/m2 (n = 113) and those with a BMI <25 kg/m2 (n = 279). The influence of BMI on LCR was investigated. Study 2: Patients with a BMI ≥28 kg/m2 who were scheduled to undergo LCR (n = 7, mean body weight 87.0 kg, mean BMI 33.9 kg/m2) undertook a PWLP including caloric restriction and exercise for 29.6 (15-70) days. The effects of this program were evaluated.

RESULTS

Study 1: The BMI ≥25 kg/m2 group had a prolongation of operation time and hospital stay than the BMI <25 kg/m2 group. Study 2: The patients achieved a mean weight loss of 6.9% (-6.0 kg). The mean visceral fat area was significantly decreased by 18.0%, whereas the skeletal muscle mass was unaffected. The PWLP group had a significantly lower prevalence of postoperative complications compared with the BMI ≥25 kg/m2 group.

CONCLUSION

Obesity affected the surgical outcomes in LCR. A PWLP may be useful for obese patients undergoing LCR.

Robotic versus laparoscopic right hemicolectomy: a case-matched study

The current gold standard surgical treatment for right colonic malignancy is the laparoscopic right hemicolectomy (LRH). However, laparoscopic surgery has limitations which can be overcome by robotic surgery. The benefits of robotics for rectal cancer are widely accepted but its use for right hemicolectomy remains controversial. The aim of this study was to compare outcomes in patients undergoing robotic right hemicolectomy (RRH) and LRH in a university teaching hospital. Demographic, perioperative and postoperative data along with early oncological outcomes of patients who underwent RRH and LRH with extracorporeal anastomosis (ECA) were identified from a prospectively maintained database. A total of 70 patients (35 RRH, 35 LRH) were identified over a 4-year period. No statistically significant differences in estimated blood loss, conversion to open surgery, postoperative complications, anastomotic leak, 30-day reoperation, 30-day mortality, surgical site infection or lengths of stay were demonstrated. Surgical specimen quality in both groups was favourable. The mean duration of surgery was longer in RRH (p <  < 0.00001). A statistically significant proportion of RRH patients had a higher BMI and ASA grade. The results demonstrate that RRH is safe and feasible when compared to LRH, with no statistical difference in postoperative morbidity, mortality and early oncological outcomes. A difference was noted in operating time, however was influenced by training residents in docking the robot and a technically challenging cohort of patients. Operative time has shortened with further experience. Incorporating an intracorporeal anastomosis technique in RRH offers the potential to improve outcomes compared to LRH.

Impact of obesity on short-term outcomes of laparoscopic colorectal surgery for Japanese patients with colorectal cancer: A multicenter study

INTRODUCTION

The impact of obesity on short-term outcomes after laparoscopic colorectal surgery (LAC) in Asian patients is unclear. The purpose of the present multicenter study was to evaluate the safety and feasibility of LAC in obese Japanese patients.

METHODS

We retrospectively reviewed 1705 patients who underwent LAC between April 2016 and February 2019. Patients were classified according to body mass index (BMI): non-obese (BMI < 25 kg/m² , n = 1335), obese I (BMI 25-29.9 kg/m² , n = 313), and obese II (BMI ≥30 kg/m² , n = 57). Clinical characteristics and surgical outcomes were compared among the three groups.

RESULTS

The proportion of patients with comorbidities (non-obese, 58.1%; obese I, 69.6%; obese II, 75.4%; P < .001) and median operation time (non-obese, 224 minutes; obese I, 235 minutes; obese II, 258 minutes; P = .004) increased significantly as BMI increased. The conversion rate was similar among the groups (P = .715). Infectious complications were significantly high in obese II patients (non-obese, 10.4%; obese I, 8.3%; obese II, 28.1%; P < .001). Multivariate analysis revealed that in obese II patients, BMI was an independent predictive factor of infectious postoperative complications (odds ratio 2.648; 95% confidence interval, 1.421-4.934; P = .002).

CONCLUSION

LAC has an increased risk of postoperative infectious complications in obese II patients, despite improvements in surgical technique. Management of obese II colorectal cancer patients requires meticulous perioperative management.

Differences in effectiveness and use of laparoscopic surgery in locally advanced colon cancer patients

Patients with locally advanced colon cancer have worse outcomes. Guidelines of various organizations are conflicting about the use of laparoscopic colectomy (LC) in locally advanced colon cancer. We determined whether patient outcomes of LC and open colectomy (OC) for locally advanced (T4) colon cancer are comparable in all colon cancer patients, T4a versus T4b patients, obese versus non-obese patients, and tumors located in the ascending, descending, and transverse colon. We used data from the 2013–2015 American College of Surgeons’ National Surgical Quality Improvement Program. Patients were diagnosed with nonmetastatic pT4 colon cancer, with or without obstruction, and underwent LC (n = 563) or OC (n = 807). We used a composite outcome score (mortality, readmission, re-operation, wound infection, bleeding transfusion, and prolonged postoperative ileus); length of stay; and length of operation. Patients undergoing LC exhibited a composite outcome score that was 9.5% lower (95% CI − 15.4; − 3.5) versus those undergoing OC. LC patients experienced a 11.3% reduction in postoperative ileus (95% CI − 16.0; − 6.5) and an average of 2 days shorter length of stay (95% CI − 2.9; − 1.0). Patients undergoing LC were in the operating room an average of 13.5 min longer (95% CI 1.5; 25.6). We found no evidence for treatment heterogeneity across subgroups (p > 0.05). Patients with locally advanced colon cancer who receive LC had better overall outcomes and shorter lengths of stay compared with OC patients. LC was equally effective in obese/nonobese patients, in T4a/T4b patients, and regardless of the location of the tumor.

Management of postoperative complications during laparoscopic anterior rectal resection

Laparoscopic anterior resection (LAR) is currently a routine practice in specialized high-volume centers, with equivalent oncological outcomes in historical, open surgery. Appropriate pelvic dissection can be measured by the adequacy of circumferential margin (CRM) and distal margin, both are risk factors of local recurrence. Among the various operative procedures for colorectal cancer, low anterior resection (LAR) for rectal cancer is one of the most demanding procedures because it requires resection of cancer with surrounding mesorectal tissue and reconstruction with anastomosis in the narrow pelvis while preserving the autonomic nerves of the urogenital organs particularly in the male pelvis. Low anterior resection is associated with a relatively high incidence of postoperative morbidities, including anastomotic leakage and other operative site infections, and asymptomatic patients infected with COVID-19 submitted to elective could be at higher risk which sometimes result in post operative mortality. Therefore, recognition of the incidence and risk factors of postoperative complications following low anterior resection is essential to prevent it. The importance of some risk factors such as age, nutrition status of the patient, experience of the surgeon and many other factors that influence outcome of colorectal surgery which could be modified pre operatively to prevent post operative complications. In the other hand long term post operative complications may promote tumor recurrence and decrease survival. The severity of these complications was evaluated by Clavien-Dindo classification (Table1) initiated in 1992 is based on the type of therapy needed to correct the complication. The principle of the classification is simple, reproducible, flexible, and applicable. The Clavien-Dindo Classification(1) appears reliable and may represent a compelling tool for quality assessment in surgery. Post-operative complications can also be classified according to time-line related to surgery as such, early postoperative complications can be defined where morbidity rates occurred within 30 days of the procedure (25%-32%)- (Table 2) or long-term as those that take place between the 30th post-operative day to 3 years following. The aims of this review are to provide an overview of the current literature on post operative complications of rectal surgery and to describe risk factors and strategies to prevent, treat or reduce complications.

The impact of body mass index on outcomes in robotic colorectal surgery: a single-centre experience

Obesity is an independent risk factor for postoperative morbidity and mortality in laparoscopic colorectal surgery (LCRS). The technological advantages of robotic colorectal surgery (RCRS) may allow surgeons to overcome the limitations of LCRS in obese patients, but it is largely unknown if this translates to superior outcomes. The aim of this study was to compare perioperative, postoperative and short-term oncological outcomes in obese (BMI ≥ 30.0 kg/m²) and non-obese (BMI < 30 kg/m²) patients undergoing RCRS in a university teaching hospital. Demographic, perioperative and postoperative data along with short-term oncological outcomes of obese and non-obese patients that underwent RCRS for both benign and malignant colorectal disease were identified from a prospectively maintained database. A total of 107 patients (34 obese, 73 non-obese) underwent RCRS over a 4-year period. No statistically significant differences in the incidence of complications, 30-day reoperation, 30-day mortality, conversion to open surgery, anastomotic leak or length of inpatient stay were demonstrated. Obese patients had a significantly higher rate of surgical site infection (SSI) (p < 0.0001). Short-term oncological outcomes in both groups were favourable. There was no statistically significant difference in median duration of surgery between the two cohorts. The results demonstrate that obese patients undergoing RCRS in this institution experience similar outcomes to non-obese patients. These results suggest that RCRS is safe and feasible in obese patients and may be superior to LCRS in this cohort, where the literature suggests a higher complication rate compared to non-obese patients. The inherent advantages of robotic surgical platforms, such as improved visualisation, dexterity and ergonomics likely contribute to the improved outcomes in this challenging patient population.

Wound infection in colorectal cancer resections through a laparoscopic approach: a single-center prospective observational study of over 3000 cases

OBJECTIVES

This prospective observational study aimed to clarify the incidence and independent risk factors of wound infection after laparoscopic surgery for primary colonic and rectal cancer.

METHODS

A prospective surveillance of surgical site infection (SSI) was conducted in consecutive patients with primary colorectal cancer, who underwent elective laparoscopic surgery in a single comprehensive cancer center between 2005 and 2014. The outcomes of interest were the incidence and risk factors of wound infection.

RESULTS

In total, 3170 patients were enrolled in the study. The overall incidence of wound infection was 3.0%. The incidence of wound infection was significantly higher in rectal surgery than in colonic surgery (4.7 vs. 2.1%, p < 0.001). In rectal surgery, independent risk factors for developing wound infection included abdominoperineal resection (p < 0.001, odds ratio [OR] = 11.4, 95% confidence interval [CI]: 5.04-24.8), body mass index (BMI) ≥ 25 kg/m2 (p = 0.041, OR = 1.97, 95% CI, 1.03-3.76), and chemoradiotherapy (p = 0.032, OR = 2.18, 95% CI, 1.07-4.45). In laparoscopic colonic surgery, no significant risk factors were identified.

CONCLUSIONS

Laparoscopic rectal surgery has a higher risk of wound infection than colonic surgery. Laparoscopic rectal surgery involving abdominoperineal resection, patients with higher BMI, and chemoradiotherapy requires careful observation in wound care and countermeasures against wound infection.

The Obesity Paradox in Emergency General Surgery Patients

Operative management of emergency general surgery (EGS) diagnoses involves a range of procedures which can carry high morbidity and mortality. Little is known about the impact of obesity on patient outcomes. The aim of this study was to examine the association between body mass index (BMI) >30 kg/m² and mortality for EGS patients. We hypothesized that obese patients would have increased mortality rates.

A regional integrated health system EGS registry derived from The American Association for the Surgery of Trauma EGS ICD-9 codes was analyzed from January 2013 to October 2015. Patients were stratified into BMI categories based on WHO classifications. The primary outcome was 30-day mortality. Longer-term mortality with linkage to the Social Security Death Index was also examined. Univariate and multivariable analyses were performed.

A total of 60 604 encounters were identified and 7183 (11.9%) underwent operative intervention. Patient characteristics include 53% women, mean age 58.2 ± 18.7 years, 64.2% >BMI 30 kg/m², 30.2% with chronic obstructive pulmonary disease, 19% with congestive heart failure, and 31.1% with diabetes. The most common procedure was laparoscopic cholecystectomy (36.4%). Overall, 90-day mortality was 10.9%. In multivariable analysis, all classes of obesity were protective against mortality compared to normal BMI. Underweight patients had increased risk of inpatient (OR = 1.9, CI = 1.7-2.3), 30-day (OR = 1.9, CI = 1.7-2.1), 90-day (OR = 1.8, CI 1.6-2.0), 1-year (OR = 1.8, CI = 1.7-2.0), and 3-year mortality (OR = 1.7, CI = 1.6-1.9).

When stratified by BMI, underweight EGS patients have the highest odds of death. Paradoxically, obesity appears protective against death, even when controlling for potentially confounding factors. Increased rates of nonoperative management in the obese population may impact these findings.

Safety and Efficacy of Laparoscopic Liver Resection for Colorectal Liver Metastasis With Obesity

INTRODUCTION

Laparoscopic liver resection (LLR) in obese patients has been reported to be particularly challenging owing to technical difficulties and various comorbidities.

METHODS

The safety and efficacy outcomes in 314 patients who underwent laparoscopic or open nonanatomical liver resection for colorectal liver metastases (CRLM) were analyzed retrospectively with respect to the patients' body mass index (BMI) and visceral fat area (VFA).

RESULTS

Two hundred and four patients underwent LLR, and 110 patients underwent open liver resection (OLR). The rate of conversion from LLR to OLR was 4.4%, with no significant difference between the BMI and VFA groups (P = .647 and .136, respectively). In addition, there were no significant differences in terms of operative time and estimated blood loss in LLR (P = .226 and .368; .772 and .489, respectively). The incidence of Clavien-Dindo grade IIIa or higher complications was not significantly different between the BMI and VFA groups of LLR (P = .877 and .726, respectively). In obese patients, the operative time and estimated blood loss were significantly shorter and lower, respectively, in LLR than in OLR (P = .003 and < .001; < .001 and < .001, respectively). There was a significant difference in the incidence of postoperative complications, organ/space surgical site infections, and postoperative bile leakage between the LLR and OLR groups (P = .017, < .001, and < .001, respectively).

CONCLUSION

LLR for obese patients with CRLM can be performed safely using various surgical devices with no major difference in outcomes compared to those in nonobese patients. Moreover, LLR has better safety outcomes than OLR in obese patients.

Obese patients and robotic colorectal surgery: systematic review and meta-analysis

BACKGROUND

Obesity is a major health problem, demonstrated to double the risk of colorectal cancer. The benefits of robotic colorectal surgery in obese patients remain largely unknown. This meta-analysis evaluated the clinical and pathological outcomes of robotic colorectal surgery in obese and non-obese patients.

METHODS

MEDLINE, Embase, Global Health, Healthcare Management Information Consortium (HMIC) and Midwives Information and Resources Service (MIDIRS) databases were searched on 1 August 2018 with no language restriction. Meta-analysis was performed according to PRISMA guidelines. Obese patients (BMI 30 kg/m2 or above) undergoing robotic colorectal cancer resections were compared with non-obese patients. Included outcome measures were: operative outcomes (duration of surgery, conversion to laparotomy, blood loss), postoperative complications, hospital length of stay and pathological outcomes (number of retrieved lymph nodes, positive circumferential resection margins and length of distal margin in rectal surgery).

RESULTS

A total of 131 full-text articles were reviewed, of which 12 met the inclusion criteria and were included in the final analysis. There were 3166 non-obese and 1420 obese patients. A longer duration of surgery was documented in obese compared with non-obese patients (weighted mean difference -21·99 (95 per cent c.i. -31·52 to -12·46) min; P < 0·001). Obese patients had a higher rate of conversion to laparotomy than non-obese patients (odds ratio 1·99, 95 per cent c.i. 1·54 to 2·56; P < 0·001). Blood loss, postoperative complications, length of hospital stay and pathological outcomes were not significantly different in obese and non-obese patients.

CONCLUSION

Robotic surgery in obese patients results in a significantly longer duration of surgery and higher conversion rates than in non-obese patients. Further studies should focus on better stratification of the obese population with colorectal disease as candidates for robotic procedures.

Selective decontamination of the digestive tract in upper gastrointestinal surgery: systematic review with meta-analysis of randomized clinical trials

BACKGROUND

Infectious complications are common after gastrointestinal surgery. Selective decontamination of the digestive tract (SDD) might reduce their incidence. SDD is used widely in colorectal resections, but its role in upper gastrointestinal resection is less clear. The aim of this study was to investigate the impact of SDD on postoperative outcome in upper gastrointestinal surgery.

METHODS

Studies investigating SDD in upper gastrointestinal surgery were included after search of medical databases (PubMed, Ovid, Cochrane Library and Google Scholar). Results were analysed according to predefined criteria. The incidence of perioperative overall complications and death was pooled. Risk of bias was assessed using the revised Cochrane risk-of-bias tool.

RESULTS

Some 1384 studies were identified, of which four RCTs were included in the final analysis. These studies included 415 patients, of whom 213 (51·3 per cent) received standard treatment/placebo and 202 (48·7 per cent) had SDD. The incidence of anastomotic leakage (odds ratio (OR) 0·39, 95 per cent c.i. 0·19 to 0·80; P = 0·010) and pneumonia (OR 0·42, 0·23 to 0·78; P = 0·006) was reduced in patients receiving SDD. Rates of surgical-site infection (P = 0·750) and mortality (P = 0·130) were not affected by SDD.

CONCLUSION

SDD seems to be associated with reduction of anastomotic leakage and pneumonia following upper gastrointestinal resection, without affecting postoperative mortality.

Influence of Body Mass Index ≥30 on Pure Laparoscopic Donor Right Hepatectomy

Background

Pure laparoscopic donor right hepatectomy (PLDRH) for donors with obesity has not been previously investigated. This study aimed to investigate the influence of donor obesity (BMI ≥30 kg/m²) on and clinical outcomes after PLDRH.

Material/Methods

Records of all living donors who underwent PLDRH between November 2015 and May 2018 and open conventional donor right hepatectomy (CDRH) between January 2011 and October 2015 at Seoul National University Hospital were retrospectively reviewed. The donors were divided into 3 groups: PLDRH BMI ≥30, PLDRH BMI <30, and CDRH BMI ≥30.

Results

Donors in the PLDRH BMI ≥30 group (n=7) were compared with those in the PLDRH BMI <30 (n=65; control 1) and CDRH BMI ≥30 (n=8; control 2) groups. Graft weight was significantly heavier in PLDRH BMI ≥30 than in control 1 (P=0.012). The lowest hemoglobin (Hb) value was higher (P=0.014) and ΔHb% was lower (P=0.005) in PLDRH BMI ≥30 than in control 1. Similarly, the lowest Hb value was higher (P=0.021) and ΔHb% was lower (P<0.001) in PLDRH BMI ≥30 than in control 2. The peak alanine aminotransferase (ALT) (P=0.029) and ΔALT% were higher in PLDRH BMI ≥30 than in control 2. No significant differences in hospital stay and postoperative complications were found between PLDRH BMI ≥3 and control 1, as well as between PLDRH BMI ≥3 and control 2.

Conclusions

This study revealed that PLDRH is feasible in donors with obesity.

Intracorporeal hemi-hand-sewn technique for end-to-end anastomosis in laparoscopic left-side colectomy

BACKGROUND

Recently, complete laparoscopic procedures with intracorporeal reconstruction were performed in laparoscopic colectomies; however, they were scarcely reported in left-side colectomies because of the anatomical reasons. Since the descending colon is extensively fixed to the retroperitoneum, the dissection range required for resection cannot always be enough for a safe extracorporeal anastomosis. We devised an intracorporeal hemi-hand-sewn (IC-HHS) technique for end-to-end anastomosis in laparoscopic left-side colectomies.

MATERIALS AND METHODS

A total of 11 patients underwent IC-HHS anastomosis for the treatment of colon cancer around the sigmoid-descending (SD) junction. The posterior wall of the anastomosis was constructed with a linear stapler and subsequently, the anterior wall was sutured with an intracorporeal hand-sewn technique. Perioperative outcomes were evaluated.

RESULTS

IC-HHS reconstruction between the descending colon and sigmoid colon was performed in 11 cases. There were six males and five females with an average age of 66.5 years. The average body mass index was 26.1 kg/m². The averages of the operation time and intraoperative blood loss were 181.2 min (range, 154 to 210 min) and 13.9 ml (range 5-30 ml), respectively. There were no perioperative complications except for one patient with a superficial surgical site infection.

CONCLUSIONS

IC-HHS anastomosis was successfully performed for colon cancer around the SD junction with acceptable perioperative outcomes and there were no procedure-related complications, indicating its feasibility. IC-HHS anastomosis could eliminate unnecessary splenic flexure mobilization in left-side colectomies. IC-HHS anastomosis can be an optional reconstruction for totally laparoscopic colectomies.

Comparison Study of Patient Demographics, Risk Factors, and Lengths of Stay for Postoperative Ileus After Primary Total Knee Arthroplasty

BACKGROUND

Postoperative ileus is a potential complication after orthopedic surgery, which has not been well studied after total knee arthroplasty (TKA). The aims of this study were to analyze rates of postoperative ileus; patient demographic profiles; in-hospital lengths of stay (LOS); and patient-related risk factors for postoperative ileus after primary TKA.

METHODS

A query was performed from January 1, 2005 to March 31, 2014 using the Medicare Standard Analytical Files. Patients who underwent primary TKA and developed postoperative ileus within 3 days after their index procedure were identified. Patients who did not develop ileus represented controls. Primary outcomes analyzed and compared included patient demographics, risk factors, and in-hospital LOS. A P value less than .05 was considered statistically significant.

RESULTS

Ileus patients were older, more likely to be male, and had higher Elixhauser-Comorbidity Index scores (8 vs 6; P < .0001) compared with controls. Male patients (odds ratio [OR], 2.12; P < .0001), patients with preoperative electrolyte/fluid imbalance (OR, 3.40; P < .001), patients older than 70 years (OR, 1.62-2.33; P < .015), and body mass indices greater than 30 kg/m² (OR, 1.79-2.00; P < .001) were at the greatest risk of developing ileus. In addition, ileus patients had significantly longer in-hospital LOS (5.42 vs 3.22 days; P < .001).

CONCLUSION

The study demonstrated differences in patient demographics, patient-related risk factors, and an increased in-hospital LOS for ileus patients after primary TKA. The study is important as it can allow orthopedists to properly identify and optimize patients with certain risk factors to potentially mitigate this adverse event from occurring.

Impact of visceral obesity and sarcobesity on surgical outcomes and recovery after laparoscopic resection for colorectal cancer

BACKGROUND & AIMS

Studies analyzing the impact of visceral fat excess on surgical outcomes after resection for colorectal cancer (CRC) have yielded conflicting results. Visceral obesity (VO) and sarcobesity (SO) have been recently addressed as risk factors for poor short-term results while no data are available for recovery goals after surgery. No data are available on the protective effect of ERAS in VO and SO patients. The aim of this study was to assess clinical implications of computed tomography (CT) assessed VO and SO on surgical and recovery outcomes after minimally invasive resection for CRC before and after ERAS protocol implementation.

METHODS

Visceral adipose tissue (VAT) and skeletal muscle area (SMA) were retrospectively assessed using pre-operative CT studies of 261 patients who underwent laparoscopic resection for CRC between January 2012 and April 2019; ERAS protocol was adopted in 160 patients operated on after March 2014. Patients' surgical and recovery outcomes were compared according to BMI categories, VO and SO which was defined using the VAT/SMA ratio (Sarcobesity Index). Predictive factors for poor surgical and recovery outcomes were evaluated by univariate and multivariate analyses.

RESULTS

Of the 261 patients, 12.6% were BMI obese while 68.6% presented visceral obesity. BMI was not associated to any of the outcomes considered. No differences in intra-operative results were found except for a lower number of retrieved lymph nodes both in VO and SO patients. While VO showed no impact on post-operative course, SO resulted an independent risk factor for cardiac complications and prolonged post-operative ileus (PPOI) at logistic regression analysis. Furthermore, sarcobese patients showed delayed recovery after surgery. Patients enrolled in the ERAS protocol showed improved recovery outcomes for both VO and SO groups, although ERAS did not result to be a protective factor for cardiac complications and PPOI.

CONCLUSIONS

A high Sarcobesity Index is a risk factor for developing cardiac complications and PPOI after laparoscopic resection for CRC. A reduced number of lymph nodes retrieved is associated to VO and SO. These conditions should then be considered in clinical practice for the risk of down staging the N stage. Effect of VO and SO on recovery items after surgery should be further investigated. ERAS protocol application should be implemented to improve recovery outcomes in VO and SO patients undergoing laparoscopic colorectal resection.

What influences conversion to open surgery during laparoscopic colorectal resection?

INTRODUCTION

We analyzed the risk of morbidity and mortality in laparoscopic (Lap) conversion for colorectal surgery across a group of subspecialist surgeons with expertise in minimally invasive techniques.

METHODS

We reviewed prospective data patients who underwent abdominopelvic procedures from 7/1/2007 to 12/31/2016 at a tertiary care facility. We identified procedures that were converted from Lap to open (Lap converted). Lap converted procedures were matched to Lap completed and open procedures based on elective versus urgent and surgeon. We also abstracted patient demographics and outcomes at 30 days using the American College of Surgeons National Surgical Quality Improvement Program defined adverse event list. We analyzed outcomes across these groups (Lap converted, Lap completed, open procedures) with x² and t tests and used the Bonferroni Correction to account for multiple statistical testing.

RESULTS

From a database of 12,454 procedures, we identified 100 Lap converted procedures and matched them to 305 open procedures and 339 Lap completed procedures. In our dataset of abdominopelvic procedures, Lap techniques were attempted in 49 ± 1%. We noted a higher risk of aggerate morbidity following open procedures (33 ± 10) as compared to Lap converted (29 ± 17%) and the matched Lap completed procedures (18 ± 8%; p < 0.001). Converted cases had the longest operative time (222 ± 102 min), compared to lap completed (177 ± 110), and open procedures (183 ± 89). There were no differences in mortality, sepsis complications, anastomotic leaks, or unplanned returns to the operating room across the three operative groups.

CONCLUSIONS

Although aggregate morbidity of Lap converted procedures is higher than in Lap completed procedures, it remains less than in matched open procedures. Compared to Lap completed procedures, the additional morbidity of Lap converted procedures appears to be related to additional surgical site infection risk. Our data suggest that surgeons should not necessarily be influenced by additional complications associated with conversion when contemplating complex laparoscopic colorectal procedures.

Which obesity-associated parameters can better reflect the risk of the occurrence of the anastomotic leakage?

Purpose: We investigated which obesity-associated parameters can better predict the risk of anastomotic leakage (AL) in rectal cancer patients that underwent anterior resection of the rectum.Method: Patients (n = 589) who underwent anterior resection of the rectum with a primary anastomosis were included in this study, including 44 patients with AL and 545 without AL. Univariate analysis was used to compare demographic characteristics and to select risk factors that were used in one-to-one propensity score matching (PSM). Obesity-associated parameters, including preoperative body mass index (BMI), visceral fat area (VFA), subcutaneous fat area (SFA), total fat area (TFA), VFA/TFA ratio, serum cholesterol, and triglycerides, were compared between the two groups after PSM.Results: Sex, neoadjuvant chemotherapy, operation time, and anastomosis level from the anal verge were risk factors for AL (p < .05). After the PSM, BMI, VFA, SFA, TFA, VFA/TFA, and serum cholesterol showed no significant difference between the two group (p > .05). However, the level of serum triglycerides was an independent risk factor for AL (p = .024, odds ratio = 2.95).Conclusions: Serum triglycerides have potential as a predictive indicator for AL, which may improve the treatment and outcomes of patients with AL.

A systematic review and meta-analysis of baseline risk factors for the development of postoperative ileus in patients undergoing gastrointestinal surgery

INTRODUCTION

Postoperative ileus occurs frequently following abdominal surgery. Identification of groups at high risk of developing ileus before surgery may allow targeted interventions. This review aimed to identify baseline risk factors for ileus.

METHODS

A systematic review was conducted with reference to PRISMA and MOOSE guidelines. It was registered on PROSPERO (CRD42017068697). Searches of MEDLINE, EMBASE and CENTRAL were undertaken. Studies reporting baseline risk factors for the development of postoperative ileus based on cohort or trial data and published in English were eligible for inclusion. Dual screening of abstracts and full texts was undertaken. Independent dual extraction was performed. Bias assessment was undertaken using the quality in prognostic studies tool. Meta-analysis using a random effects model was undertaken where two or more studies assessed the same variable.

FINDINGS

Searches identified 2,430 papers, of which 28 were included in qualitative analysis and 12 in quantitative analysis. Definitions and incidence of ileus varied between studies. No consistent significant effect was found for association between prior abdominal surgery, age, body mass index, medical comorbidities or smoking status. Male sex was associated with ileus on meta-analysis (odds ratio 1.12, 95% confidence interval 1.02-1.23), although this may reflect unmeasured factors. The literature shows inconsistent effects of baseline factors on the development of postoperative ileus. A large cohort study using consistent definitions of ileus and factors should be undertaken.

Outcomes of inflammatory bowel disease surgery in obese versus non-obese patients: a meta-analysis

BACKGROUND

Obesity is considered a risk factor for many chronic diseases and obese patients are often considered higher risk surgical candidates. The aim of this meta-analysis was to evaluate the outcomes of obese (body mass index ≥ 30 kg/m²) versus non-obese patients undergoing surgery for inflammatory bowel disease (IBD).

METHODS

PubMed, Scopus, and Embase libraries were searched up to March 2019 for studies comparing outcomes of obese with non-obese patients undergoing surgery for IBD. A meta-analysis was conducted using Review Manager software to create forest plots and calculate odds ratios and mean differences.

RESULTS

Four thousand three hundred and eleven patients from five observational studies were included. Obese patients were older at the time of surgery and more likely to have diabetes. Obese patients had longer operative times (MD 23.28, 95% CI 14.63-31.93, p < 0.001), higher intra-operative blood loss (MD 45.32, 95% CI 5.89-84.76, p = 0.02), longer length of stay (MD 0.90, 95% CI 0.60-1.20, p < 0.001), higher wound infection rates (OR 1.76, 95% CI 1.39-2.23, p < 0.001), and higher total postoperative complication rates (OR 1.33, 95% CI 1.04-1.70, p = 0.02).

CONCLUSIONS

Obesity is associated with significantly worse outcomes following IBD-specific surgery, including longer operative times, greater blood loss, longer length of stay, higher wound infection rates, and higher total postoperative complication rates. Clinicians should be mindful of these increased risks when counselling patients and consider weight reduction strategies where possible.

The impact of body mass index on perioperative outcomes after robotic liver resection

High body mass index (BMI) is associated with other multiple comorbidities such as non-alcoholic fatty liver disease, steatohepatitis, liver cirrhosis, and cardiopulmonary diseases, which can impact the perioperative outcomes following liver resection. We aimed to study the impact of BMI on perioperative outcomes after robotic liver resection. All the patients undergoing robotic liver resection between 2013 and 2017 were prospectively followed. The patients were divided into three groups (BMI < 25, BMI 25-35, BMI > 35 kg/m²) for illustrative purposes. Demographic and perioperative outcome data were compared. Data are presented as median (mean ± SD). Thirty-eight patients underwent robotic hepatectomy, 73% were women, age was 58 (57 ± 17.6) years, and ASA class was 3 (3 ± 0.5). Indications for surgery were neoplastic lesions in 34 patients (89%), hemangioma in two patients (6%), fibrous mass in one patient (2.5%), and focal nodular hyperplasia in one patient (2.5%). 32% of the patients underwent right or left hemihepatectomy, 21% underwent sectionectomy, 5% underwent central hepatectomy and the reminder underwent non-anatomical liver resection. Operative time was 261 (254.6 ± 94.3) min. Estimated blood loss was 175 (276 ± 294.8) ml. Length of hospital stay was 3 (5 ± 4.9) days. By regression analysis of the three BMI groups, estimated blood loss, rate of postoperative complication, rate of conversion, need for transfusion, length of ICU stay, and length of hospital stay did not have a significant relationship with BMI. A total of five patients (13%) experience complications. Four patients had complications that were nonspecific to liver resection, including acute renal injury, respiratory failure, and enterocutaneous fistula. One patient had bile leak, treated with ERCP stenting. No mortality was seen in this study. Obesity should not dissuade surgeons from utilizing minimally invasive robotic approach for liver resection. Robotic technique is a safe and feasible in patients with high BMI. The impact of BMI on outcomes is insignificant.

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.

Comparison of short-term and long-term efficacy of laparoscopic and open gastrectomy in high-risk patients with gastric cancer: a propensity score-matching analysis

BACKGROUND

To determine whether laparoscopic surgery can be used in high-risk patients with gastric cancer.

METHODS

The clinicopathological data of 3743 patients with primary gastric adenocarcinoma, collected from January 2007 to December 2014, were retrospectively analyzed. Patients who had ≥ 1 of the following conditions were defined as high-risk patients: (1) age ≥ 80 years; (2) BMI ≥ 30 kg/m²; (3) ASA (American Society of Anesthesiologists) grade ≥ 3; or (4) clinical T stage 4 (cT4). Propensity score matching (PSM) was used to reduce confounding bias; then, we compared the short-term and long-term efficacy of laparoscopic gastrectomy (LG) with open gastrectomy (OG) in high-risk patients with gastric cancer.

RESULTS

A total of 1296 patients were included in PSM. After PSM, no significant difference in clinicopathological data was observed between the LG group (n = 341) and the OG group (n = 341). The operative time (181.70 vs. 266.71 min, p < 0.001) and blood loss during the operation (68.11 vs. 225.54 ml, p < 0.001) in the LG group were significantly lower than those in the OG group. In the LG and OG groups, postoperative complications occurred in 39 (11.4%) and 63 (18.5%) patients, respectively, p = 0.010. Multivariate analysis showed that laparoscopic surgery was an independent protective factor against postoperative complications (p = 0.019). The number of risk factors was an independent risk factor for postoperative complications (p = 0.021). The 5-year overall survival rate in the LG group was comparable to that in the OG group (55.0 vs. 52.0%, p = 0.086). Hierarchical analysis further confirmed that the LG and OG groups exhibited comparable survival rates among patients with stages cI, pI, cII, pII, cIII, and pIII (all p > 0.05).

CONCLUSIONS

For high-risk patients with gastric cancer, LG not only exhibits better short-term efficacy than OG but also has a comparable 5-year survival rate to OG.

Comparison of oncological benefits of deep neuromuscular block in obese patients with gastric cancer (DEBLOQS_GC study): A study protocol for a double-blind, randomized controlled trial

PURPOSE

Many studies have demonstrated the advantage of maintaining intraoperative deep neuromuscular block (NMB) with sugammadex. This trial is designed to evaluate the impact of muscle relaxation during laparoscopic subtotal gastrectomy on the oncological benefits, particularly in obese patients with gastric cancer.

MATERIALS AND METHODS

This is a double-blind, randomized controlled multicenter prospective trial. Patients with clinical stage I-II gastric cancer with a body mass index of 25 and over, who undergo laparoscopic subtotal gastrectomy will be eligible for trial inclusion. The patients will be randomized into a deep NMB group or a moderate NMB group with a 1:1 ratio. A total of 196 patients (98 per group) are required. The primary endpoint is the number of harvested lymph nodes, which is a critical index of the quality of surgery in gastric cancer treatment. The secondary endpoints are surgeon's surgical condition score, patient's sedation score, and surgical outcomes including peak inspiratory pressure, operation time, postoperative pain, and morbidity.

DISCUSSION

This is the first study that compares deep NMB with moderate NMB during laparoscopic gastrectomy in obese patients with gastric cancer. We hope to show the oncologic benefits of deep NMB compared with moderate NMB during subtotal gastrectomy.

TRIAL REGISTRATION NUMBER

ClinicalTrials.gov (NCT03196791), date of registration: October 10, 2017.

Electrical Stimulation and Recovery of Gastrointestinal Function Following Surgery: A Systematic Review

OBJECTIVES

Postoperative ileus occurs in approximately 5-15% of patients following major abdominal surgery, and poses a substantial clinical and economic burden. Electrical stimulation has been proposed as a means to aid postoperative gastrointestinal (GI) recovery, but no methods have entered routine clinical practice. A systematic review was undertaken to assess electrical stimulation techniques and to evaluate their clinical efficacy in order to identify promising areas for future research.

MATERIALS AND METHODS

Literature was searched using MEDLINE, EMBASE, Google Scholar and by assessing relevant clinical trial databases. Studies investigating the use of electrical stimulation for postoperative GI recovery were included, regardless of methods used or outcomes measured. A critical review was constructed encompassing all included studies and evaluating and synthesizing stimulation techniques, protocols, and clinical outcomes.

RESULTS

A broad range of neuromodulation strategies and protocols were identified and assessed. Improved postoperative GI recovery following electrical stimulation was reported by 55% of studies (10/18), most commonly those assessing transcutaneous electrical nerve stimulation and electroacupuncture therapy (7/10). Several studies reported shorter time to first flatus and stool, shorter duration of hospital stay, and reduced postoperative pain. However, inconsistent reporting and limitations in trial design were common, compromising a definitive determination of electrical stimulation efficacy.

CONCLUSIONS

Electrical stimulation appears to be a promising methodology to aid postoperative GI recovery, but greater attention to mechanisms of action and clinical trial quality is necessary for progress. Future research should also aim to apply validated and standardized gut recovery outcomes and consistent neuromodulation methodologies.

Risk Factors for Complications following Introduction of Radical Surgery for Colon Cancer: A Consecutive Patient Series

BACKGROUND

Rectal cancer surgery is standardized, resulting in improved survival. Colon cancer has fallen behind and therefore more radical surgical techniques have been introduced. One technique is complete mesocolic excision. The aim of this article was to study the complications after the introduction of standardized complete mesocolic excision in a single center.

METHODS

Complete mesocolic excision was introduced in 2007, and data were collected from 286 patients prior to surgery (2007-2010). The surgeon decided on open or laparoscopic surgery. Follow-up information was recorded until 31 December 2015. Complications were classified according to a modified Clavien-Dindo classification.

RESULTS

Complications occurred in 47%, severe complications (grade III and IV) in 15%. In-hospital mortality was 3.5%. A total of 142 patients (49.7%) were operated by open surgery. Logistic regression revealed anemia (p = 0.001), open surgery (p < 0.001), and long operating time (p < 0.001) as significant factors for complications in general. Multinomial logistic regression revealed that severe complications occurred more often in males (odds ratio: 2.56; 95% confidence interval: 0.98-6.68), patients with anemia (odds ratio: 3.49; 95% confidence interval: 1.27-9.60), elevated body mass index (odds ratio: 1.14; 95% confidence interval: 1.02-1.28), and in open surgery (odds ratio: 9.95; 95% confidence interval: 2.58-38.35). Age was not associated with severe complications. Survival was not significantly influenced by complications. Overall survival (5 years) was 90% among patients with complications and 92% among those without complications.

CONCLUSION

Severe complications following the introduction of complete mesocolic excision are patient dependent and related to open surgery. Patients selected for laparoscopy had less number of complications; therefore, introducing complete mesocolic excision by laparoscopy is justified. Identification of these factors can improve selection of appropriate surgical approach and postoperative patient safety.

Robotic rectal cancer surgery in obese patients may lead to better short-term outcomes when compared to laparoscopy: a comparative propensity scored match study

PURPOSE

Laparoscopic rectal surgery in obese patients is technically challenging. The technological advantages of robotic instruments can help overcome some of those challenges, but whether this translates to superior short-term outcomes is largely unknown. The aim of this study is to compare the short-term surgical outcomes of obese (BMI ≥ 30) robotic and laparoscopic rectal cancer surgery patients.

METHODS

All consecutive obese patients receiving laparoscopic and robotic rectal cancer resection surgery from three centres, two from the UK and one from Portugal, between 2006 and 2017 were identified from prospectively collated databases. Robotic surgery patients were propensity score matched with laparoscopic patients for ASA grade, neoadjuvant radiotherapy and pathological T stage. Their short-term outcomes were examined.

RESULTS

A total of 222 patients were identified (63 robotic, 159 laparoscopic). The 63 patients who received robotic surgery were matched with 61 laparoscopic patients. Cohort characteristics were similar between the two groups. In the robotic group, operative time was longer (260 vs 215 min; p = 0.000), but length of stay was shorter (6 vs 8 days; p = 0.014), and thirty-day readmission rate was lower (6.3% vs 19.7%; p = 0.033).

CONCLUSIONS

In this study population, robotic rectal surgery in obese patients resulted in a shorter length of stay and lower 30-day readmission rate but longer operative time when compared to laparoscopic surgery. Robotic rectal surgery in the obese may be associated with a quicker post-operative recovery and reduced morbidity profile. Larger-scale multi-centre prospective observational studies are required to validate these results.

Surgical site infection in overweight and obese Total Knee Arthroplasty patients

Purpose

This aim of this study was to evaluate the rate of surgical site infection (SSI) in patients undergoing Total Knee Arthroplasty (TKA), to improve our understanding of the associations between infection rate and obesity.

Methods

Data was reviewed for 839 primary TKA procedures performed at a National Arthroplasty Centre over one year (April 2007-March 2008). SSI data was collected at 30 days and one year post-operatively. Patients were grouped guided by the WHO classifications of obesity; normal (BMI < 25.0), overweight (BMI 25.00-29.99), obese class I (BMI 30.00-34.99), obese class II (BMI 35.00-39.99), obese class III (BMI ≥ 40.00). Statistical significance was assessed by Fisher's Exact Test.

Results

When grouped by BMI, 30.9% of patients were obese class I, 19.0% obese class II and 8.7% obese class III. Of the total cohort, 22 patients (2.6%) had superficial SSI and 13 (1.5%) had deep SSI. When comparing the obese class III cohort to all other cohorts (non-obese class III), the odds ratios for superficial SSI was 4.20 (95% CI [1.59, 11.09]; p = 0.009) and deep SSI was 6.97 (95% CI [2.22, 21.89]; p = 0.003). In the obese class III cohort, superficial SSI rate was higher in females (8.9%) than males (5.9%), yet deep SSI demonstrated the opposite, with a higher occurrence in males (11.8%) compared to females (5.4%).

Conclusion

This study suggests that obese class III TKA patients are at increased odds of superficial and deep SSI compared to other BMI cohorts. Interestingly, male obese class III patients demonstrated a higher rate of deep infection compared to their female counterparts. However, it must be noted that study findings are limited as confounders were unable to be accounted for in this retrospective study design.

The outcome of transanal endoscopic microsurgery in obese patients

BACKGROUND

The prevalence of obesity is as high as one-third of the adult population in the ultrasound. Obese patients operated for rectal cancer are less likely to undergo sphincter-preserving surgery, and have an increased morbidity and mortality. We aim to report the outcomes of transanal-endoscopic-microsurgery (TEM) in obese patients with benign and malignant neoplasms.

MATERIALS AND METHODS

An analysis was carried out of all patients undergoing TEM at a single institution between 2004 and 2015. Clinical, demographic, and pathologic data were analyzed in respect to BMI; a dichotomous variable was created categorizing the patients in this retrospective case series as either obese (BMI≥30) or nonobese (BMI<30).

RESULTS

Of the 158 patients who underwent TEM during the study period, 51 (32%) were obese and 107 (68%) were nonobese. No significant differences were found in terms of patients' demographics and tumor characteristics. There were no significant differences in operative time [105 min (range: 75-170) and 98 (range: 56-170), respectively, P=0.2], hospital length of stay [3 days (range: 2-6) and 4 (range: 2-12), respectively, P=0.48], or complication rates (20 and 23%, respectively, P=0.68).

CONCLUSION

TEM is a safe procedure for rectal neoplasms in the obese population. We found no difference in surgical time and completeness of specimen resection, and no increase in complications or length of stay in the hospital in obese versus nonobese patients. As for selected high risk patients, the TEM may be of benefit in obese patients with T1/T2N0M0 rectal cancer.

Outcomes according to body mass index following laparoscopic surgery in patients with colorectal cancer

Purpose:

Body mass index (BMI) may not be appropriate for different populations. Therefore, the World Health Organization (WHO) suggested 25 kg/m² as a measure of obesity for Asian populations. The purpose of this report was to compare the oncologic outcomes of laparoscopic colorectal resection with BMI classified from the WHO Asia-Pacific perspective.

Patients and Methods:

All patients underwent laparoscopic colorectal resection from September 2006 to March 2015 at a tertiary referral hospital. A total of 2408 patients were included and classified into four groups: underweight (n = 112, BMI <18.5 kg/m²), normal (n = 886, 18.5–22.9 kg/m²), pre-obese (n = 655, 23–24.9 kg/m²) and obese (n = 755, >25 kg/m²). Perioperative parameters and oncologic outcomes were analysed amongst groups.

Results:

Conversion rate was the highest in the underweight group (2.7%, P < 0.001), whereas the obese group had the fewest harvested lymph nodes (21.7, P < 0.001). Comparing oncologic outcomes except Stage IV, the underweight group was lowest for overall (P = 0.007) and cancer-specific survival (P = 0.002). The underweight group had the lowest proportion of national health insurance but the highest rate of medical care (P = 0.012).

Conclusion:

The obese group had the fewest harvested lymph nodes, whereas the underweight group had the highest estimated blood loss, conversion rate to open approaches and the poorest overall and cancer-specific survivals.

Impact of radiofrequency energy on intraoperative outcomes of laparoscopic colectomy for cancer in obese patients

Nowadays laparoscopic approach is accepted as a valid alternative to open surgery for the treatment of colorectal cancer. Several studies consider this approach to be safe and feasible also in obese patients, even if dissection in these patients may require a longer operative time and involve higher blood loss. To facilitate laparoscopic approach, more difficult in these patients, several energy sources for laparoscopic dissection and sealing, has been adopted recently. The aim of this study is to investigate the possible intraoperative advantages of radiofrequency energy in terms of blood loss and operative time in obese patients undergoing laparoscopic resection for cancer. All patients who underwent laparoscopic surgery for colorectal cancer from January 2010 to December 2015 were registered in a prospective database. Patients with a body mass index BMI (kg/m²) ≥30 were defined as obese, and patients with a BMI (kg/m²) <30 were defined as non-obese. All 136 obese patients observed were divided retrospectively into 2 groups according to the devices used for dissection: 83 patients (Historical group: B) on whom dissection and coagulation were performed using other energy sources (monopolar electrocautery scissors, bipolar electrical energy, ultrasonic coagulating shears) and 53 patients who were treated with electrothermal bipolar vessel sealing (Caiman group: A). In group A, the Laparoscopic Caiman 5 (Aesculap AG, Tuttlingen, Germany) was the only instrument employed in the whole procedure. The study examined only three types of operation: right colectomy (RC), left colectomy (LC), and anterior resection (AR). Preoperative data were similar for RC, LC, and AR in both groups (A and B). The mean operative time was statistically shorter in the Caiman group than in the Historical group [104 vs 124 min (p 0.004), 116 vs 140 min (p 0.004), and 125 vs 151 min (p 0.003) for RC, LC, and AR between group A and B, respectively]. Also intraoperative blood loss results significantly lower in the Caiman group than in the historical one [52 ml vs 93 for RC (p 0.003); 65 vs 120 ml for LC (p 0.001); 93 vs 145 ml for AR (p 0.002) between group A and B, respectively]. No intraoperative complications were recorded in either group. The mean conversion rate was 4.4% (6 patients). There were no statistical differences in intensive care unit (ICU) stay, functional outcomes, mean hospital stay and overall morbidity rate between the two groups. There was no mortality in either group. The use of the Caiman EBVS instrument shows significant advantages with respect to a small number of intraoperative parameters. We can conclude that use of this radiofrequency device, in the laparoscopic approach, offers advantages in terms of lower intraoperative blood loss and shorter operative time in obese patients with colorectal cancer.

Enhanced Recovery Pathway for Right and Left Colectomy: Comparison of Functional Recovery

BACKGROUND

Enhanced recovery (ERAS) guidelines do not differentiate between left- and right-sided colectomies, but differences in recovery have been reported for the two procedure types. We aimed to compare compliance with the ERAS protocol and outcomes after right versus left colectomy.

METHODS

Between June 2011 and September 2014, all patients undergoing elective colonic resection were treated according to a standardized ERAS protocol and entered a prospective database. This retrospective analysis compared right and left colectomy regarding application of the ERAS pathway, bowel recovery, complications, and hospital stay.

RESULTS

Eighty-five patients with right colectomy matched well with 138 left-sided resections for baseline demographics. Overall compliance with the ERAS protocol was 76 % for right versus 77 % for left colectomy patients (p = 0.492). First flatus occurred at postoperative day 2 in both groups (p = 0.057); first stool was observed after a median of 3 (right) and 2 days (left), respectively (p = 0.189). Twenty patients (24 %) needed postoperative nasogastric tube after right colectomy compared to 11 patients (8 %) after left colectomy (p = 0.002). Overall complication rates were 49 and 37 % for right and left colectomy, respectively (p = 0.071). Median postoperative length of stay was 6 days (IQR 4-9) after right and 5 days (IQR 4-7.5) after left colectomy (p = 0.020).

CONCLUSION

Overall compliance with the protocol was equally high in both groups showing that ERAS protocol was applicable for right and left colectomy. Functional recovery however, tended to be slower after right colectomy, and postoperative ileus rate was significantly higher. More cautious early feeding after right colectomy should be considered.

Association Between Obesity and Wound Infection Following Colorectal Surgery: Systematic Review and Meta-Analysis

BACKGROUND

The aim of this meta-analysis is to comprehensively review and quantify the excess risk of surgical site infections (SSI) in obese patients following colorectal surgery.

METHODS

A systematic electronic search of the MEDLINE and EMBASE databases identified studies that investigated the association of obesity, defined by body mass index (BMI) with SSI among colorectal surgery patients.

RESULTS

Twelve studies were included in the final analysis. Patients with BMI ≥30 kg/m² were at 1.5 times (pooled OR 1.51, 95% CI: 1.39, 1.63, p < 0.001) higher odds of developing SSI after colorectal surgery when compared to BMI <30 kg/m². Subgroup analysis of the eight studies that investigated only elective procedures showed that the odds of developing SSI when BMI ≥30 kg/m² is 1.6 times that of those with BMI <30 kg/m² (pooled OR 1.60; 95% CI 1.34, 1.86; p < 0.001). The odds of having SSI when BMI is 25-29.9 kg/m² are 1.2 times than those with BMI <25 kg/m² (pooled OR 1.17; 95% CI 1.07, 1.28; p < 0.001).

CONCLUSION

Overweight and obese patients carry at least 20% and 50% higher odds of developing SSI after colorectal surgery compared to normal weight patients, respectively.

Laparoscopic colectomy in the obese, morbidly obese, and super morbidly obese: when does weight matter?

PURPOSE

Previous studies have demonstrated that obese patients (BMI >30) undergoing laparoscopic colectomy have longer operative times and increased complications when compared to non-obese cohorts. However, there is little data that specifically evaluates the outcomes of obese patients based on the degree of their obesity. The aim of this study was to evaluate the impact of increasing severity of obesity on patients undergoing laparoscopic colectomy.

METHODS

A retrospective review was performed of all patients undergoing laparoscopic colectomy between 1996 and 2013. Patients were classified according to their BMI as obese (BMI 30.0-39.9), morbidly obese (BMI 40.0-49.9), and super obese (BMI >50). Main outcome measures included conversion rate, operative time, estimated blood loss, post-operative complications, and length of stay.

RESULTS

There were 923 patients who met inclusion criteria. Overall, 604 (65.4%), 257 (27.9%), and 62 (6.7%) were classified as obese (O), morbidly obese (MO), and super obese (SO), respectively. Clinicopathologic characteristics were similar among the three groups. The SO group had significantly higher conversion rates (17.7 vs. 7 vs. 4.8%; P = 0.031), longer average hospital stays (7.1 days vs. 4.9 vs. 3.4; P = 0.001), higher morbidity (40.3 vs. 16.3 vs. 12.4%; P = 0.001), and longer operative times (206 min vs. 184 vs. 163; P = 0.04) compared to the MO and O groups, respectively. The anastomotic leak rate in the SO (4.8%; P = 0.027) and MO males (4.1%; P = 0.033) was significantly higher than MO females (2.2%) and all obese patients (1.8%).

CONCLUSION

Increasing severity of obesity is associated with worse perioperative outcomes following laparoscopic colectomy.