Breast models: a useful tool for instruction

Comparative Analysis of Laparoscopic Versus Open Procedures in Specific General Surgical Interventions

Laparoscopic and open surgeries are two distinct surgical approaches with significantly different procedures and outcomes. Minimally invasive surgery, also known as laparoscopic surgery, utilizes small incisions and specialized instruments like the laparoscope to perform procedures. This contrasts with open surgery, which requires larger incisions to directly access the surgical site. Open surgery was the preferred approach for any invasive procedure until the introduction of new technological advances in the form of laparoscopy. While laparoscopy is still evolving, preliminary results demonstrate promise for various operations. Open surgery provides the healthcare professional with more liberty in the form of increased visualization, but it also increases tissue damage and hospital stays. Laparoscopic and open procedures are both valuable surgical methods with advantages and disadvantages. While open surgery is favored for difficult patients, laparoscopic surgery offers a quicker recovery and fewer scars. The choice between the two approaches depends on the patient's condition, surgical demands, and the surgeon's skills. As these methods develop, they become increasingly important for offering safe and efficient surgical treatments across a range of medical specialties.

Neo-Antigen-Reactive T Cells Immunotherapy for Colorectal Cancer: A More Personalized Cancer Therapy Approach

Colorectal cancer (CRC) is the second most common malignancy in women and the third most frequent cancer in men. Evidence has revealed that the survival of patients with metastatic CRC is very low, between one and three years. Neoantigens are known proteins encoded by mutations in tumor cells. It is theorized that recognizing neoantigens by T cells leads to T cell activation and further antitumor responses. Neoantigen-reactive T cells (NRTs) are designed against the mentioned neoantigens expressed by tumor cells. NRTs selectively kill tumor cells without damage to non-cancerous cells. Identifying patient-specific and high immunogen neoantigens is important in NRT immunotherapy of patients with CRC. However, the main challenges are the side effects and preparation of NRTs, as well as the effectiveness of these cells in vivo. This review summarized the properties of neoantigens as well as the preparation and therapeutic outcomes of NRTs for the treatment of CRC.

Cyanoacrylate in Colorectal Surgery: Is It Safe?

Anastomotic leakage (AL) of a gastrointestinal (GI) anastomosis continues to be an important complication in GI surgery. Since its introduction more than 60 years ago, Cyanoacrylate (CA) has gained popularity in colorectal surgery to provide "prophylaxis" against AL. However, although in surgical practice it is increasingly used, evidence on humans is still lacking. The aim of this study is to analyze in humans the safety of CA to seal colorectal anastomosis. All consecutive patients from Jannuary 2022 through December 2022 who underwent minimally invasive colorectal surgery were retrospectively analyzed from a prospectively maintained database. Inclusion criteria were a histological diagnosis of cancer, a totally minimally invasive procedure, and the absence of intraoperative complications. 103 patients were included in the study; N-butyl cyanoacrylate with metacryloxisulfolane (Glubran 2®) was used to seal colorectal anastomosis, no adverse reactions to CA or postoperative complications related to inflammation and adhesions occurred; and only one case of AL (0.9%) was recorded. We can consider this study an important proof of concept on the safety of CA to seal colorectal anastomosis. It opens the possibility of starting prospective and comparative studies in humans to evaluate the effectiveness of CA in preventing colorectal AL.

Design and Evaluation of a Balanced Compliant Laparoscopic Grasper

In laparoscopic surgery, quality of haptic feedback is reduced compared to conventional surgery, leading to unintentional tissue damage during grasping. From the perspective of haptics, poor mechanical design of laparoscopic instrument joints induces friction and a nonlinear actuation-tip force relation. In this study, a novel laparoscopic grasper using compliant joints and a magnetic balancer is presented, and the reduction in hysteresis and friction is evaluated. The hysteresis loop of the novel compliant grasper and two conventional laparoscopic graspers (high quality leading commercial brand and low quality unbranded grasper) were measured. In order to assess quality of haptic feedback, the lowest grasper tip load perceivable by instrument users was measured with the novel and the conventional laparoscopic graspers. The hysteresis loop measurement yielded a mechanical efficiency of 43% for the novel grasper, compared to- 25% and 23% for the Aesculap and the unbranded grasper, respectively. The forces perceivable by the user through the novel grasper were significantly lower (mean 1.37N, SD 0.44N) than those of conventional graspers (mean 2.15N, SD 0.71N and mean 2.65N, SD 1.20N, respectively). The balanced compliant grasper technology has the ability to improve the quality of haptic feedback compared to conventional laparoscopic graspers. Research is needed to relate these results to soft and delicate tissue grasping in a clinical setting, for which this instrument is intended.

Objective measurement of retention of laparoscopic skills: a prospective cohort study

INTRODUCTION

There has been an overall growth of 462% in laparoscopic procedures performed by surgical residents between 2000 and 2018. Therefore, training courses in laparoscopic surgery are advocated in many postgraduate programs. While the immediate effect is determined in some cases, the retention of acquired skills is rarely investigated. The objective of this study was to objectively measure the retention of laparoscopic technical skills to offer a more personalized training program.

METHODS

First year general surgery residents performed two fundamental laparoscopic skills tasks (Post and Sleeve and the ZigZag loop) on the Lapron box trainer. Assessment was performed before, directly after, and 4 months after completing the basic laparoscopy course. Force, motion, and time were the measured variables.

RESULTS

A total of 29 participants were included from 12 Dutch training hospitals and 174 trials were analyzed. The 4 months assessment of the Post and Sleeve showed a significant improvement in force ( P= 0.004), motion ( P ≤0.001), and time ( P ≤0.001) compared to the baseline assessment. The same was true for the ZigZag loop: force ( P ≤0.001), motion ( P= 0.005), and time ( P ≤0.001).Compared to the 4 months assessment, skill deterioration was present for the Post and Sleeve in the mean force ( P= 0.046), max impulse ( P= 0.12), and time ( P= 0.002). For the ZigZag loop, skill decay was observed for force ( P= 0.021), motion ( P= 0.015), and time ( P ≤0.001) parameters.

CONCLUSION

Acquired laparoscopic technical skills decreased 4 months after the basic laparoscopy course. Compared to baseline performance, participants showed significant improvement, however deterioration was observed compared to postcourse measurements. To preserve acquired laparoscopic skills, it is recommended to incorporate maintenance training, preferably with objective parameters, in training curricula.

Carbon black-containing self-healing adhesive hydrogels for endoscopic tattooing

Endoscopic tattooing with India ink is a popular method for identifying colonic lesions during minimally invasive surgery because it is highly challenging to localize lesions during laparoscopy. However, there is a perceived unmet need for the injection of India ink and carbon particle suspension due to various complications and inconstant durability during the perioperative period. In this study, carbon black-containing self-healing adhesive alginate/polyvinyl alcohol composite hydrogels were synthesized as endoscopic tattooing inks. Alginate (Alg) conjugated with phenylboronic acid (PBA) groups in the backbone was crosslinked with polyvinyl alcohol (PVA) because of the dynamic bonds between the phenylboronic acid in alginate and the cis-diol groups of PVA. The carbon black-incorporated Alg-PBA/PVA hydrogels exhibited self-healing and re-shapable properties, indicating that improved intraoperative localization could be achieved. In addition, the adhesive tattooing hydrogels were stably immobilized on the target regions in the intraperitoneal spaces. These carbon black-containing self-healing adhesive hydrogels are expected to be useful in various surgical procedures, including endoscopic tattooing.

Feasibility of robotic-assisted pancreatic resection in patients with previous minor abdominal surgeries: a single-center experience of the first three years

BACKGROUND

Robotic-assisted pancreatic surgery is limited to specialized high-volume centers and selected patient cohorts. Especially for patients with a history of previous abdominal surgeries, the standard procedure remains open surgery due to the fear of complications caused by abdominal adhesions.

METHODS

Clinical data of all consecutive patients undergoing robotic-assisted pancreatic surgery using the daVinci Xi system (Intuitive Surgical) at our center (Department of Surgery, Universitätsmedizin Berlin, Germany) were collected prospectively and further analyzed from October 2017 to October 2020. Prior abdominal surgeries were specified according to the surgical approach and localization. In univariate and multivariate analysis, baseline and perioperative parameters of patients with a history of prior abdominal surgeries (PS) were compared to those of patients with no history of prior abdominal surgeries (NPS).

RESULTS

Out of 131 patients undergoing robotic-assisted pancreatic surgery, 62 (47%) had a history of abdominal surgery. Previous procedures included most often appendectomy (32%) followed by gynecological surgery (29%) and cholecystectomy (27%). 24% of PS had received multiple surgeries prior to the robotic-assisted pancreatic resections. Baseline characteristics and comorbidities were comparable between the groups. We did not detect differences in the duration of surgery (262 min), conversion rates (10%), and postoperative complications between NPS and PS. Postoperative pancreatic fistula (POPF), postpancreatectomy hemorrhage (PPH), and in-house mortality showed no significant differences between the two groups. Multivariate analysis revealed male sex and high BMI as a potential predictive factor for severe postoperative complications. Other characteristics like the type of pancreatic resection, ASA, and underlying malignancy showed no difference in the multivariable analysis.

CONCLUSIONS

We propose robotic-assisted pancreatic surgery to be safe and feasible for patients with a history of minor prior abdominal surgery. Hence, each patient should individually be evaluated for a minimally invasive approach regardless of a history of previous operations.

Mid- and low-rectal cancer: laparoscopic vs open treatment-short- and long-term results. Meta-analysis of randomized controlled trials

BACKGROUND

The laparoscopic approach in the treatment of mid- or low-rectal cancer is still controversial. Compared with open surgery, laparoscopic resection of extraperitoneal cancer is associated with improved short-time non-oncological outcomes, although high-level evidence showing similar short- and long-term oncological outcomes is scarce.

OBJECTIVE

The aim of our paper is to study the oncological and non-oncological outcomes of laparoscopic versus open surgery for extraperitoneal rectal cancer.

DATA SOURCES

A systematic review of MedLine, EMBASE, and CENTRAL from January 1990 to October 2020 was performed by combining various key words.

STUDY SELECTION

Only randomized controlled trials (RCTs) comparing laparoscopic versus open surgery for extraperitoneal rectal cancer were included. The quality of RCTs was assessed using the Cochrane reviewer's handbook. This meta-analysis was based on the recommendation of the Preferred Reporting Items for Systematic Reviews and Meta-Analysis guidelines.

INTERVENTION(S)

This study analyzes laparoscopic versus open surgery for extraperitoneal rectal cancer.

MAIN OUTCOME MEASURES

Primary outcomes were oncological parameters.

RESULTS

Fifteen RCTs comprising 4,411 patients matched the selection criteria. Meta-analysis showed a significant difference between laparoscopic and open surgery in short-time non-oncological outcomes. Although laparoscopic approach increased operation time, it decreases significantly the blood loss and length of hospital stay. No significant difference was noted regarding short- and long-term oncological outcomes, but 4 and 5 years disease-free survival were statistically higher in the open group.

LIMITATIONS

There are still questions about the long-term oncological outcomes of laparoscopic surgery for extraperitoneal rectal cancer being comparable to the open technique.

CONCLUSIONS

Considering that all surgical resections have been performed in high volume centers by expert surgeons, the minimally invasive surgery in patients with extraperitoneal cancer could still be not considered equivalent to open surgery in terms of oncological radicality.

Colorectal Cancer Surgery Quality in Manitoba: A Population-Based Descriptive Analysis

Unwarranted clinical variation in healthcare impacts access, productivity, performance, and outcomes. A strategy proposed for reducing unwarranted clinical variation is to ensure that population-based data describing the current state of health care services are available to clinicians and healthcare decision-makers. The objective of this study was to measure variation in colorectal cancer surgical treatment patterns and surgical quality in Manitoba and identify areas for improvement. This descriptive study included individuals aged 20 years or older who were diagnosed with invasive cancer (adenocarcinoma) of the colon or rectum between 1 January 2010 and 31 December 2014. Laparoscopic surgery was higher in colon cancer (24.1%) compared to rectal cancer (13.6%). For colon cancer, the percentage of laparoscopic surgery ranged from 12.9% to 29.2%, with significant differences by regional health authority (RHA) of surgery. In 86.1% of colon cancers, ≥12 lymph nodes were removed. In Manitoba, the negative circumferential resection margin for rectal cancers was 96.9%, and ranged from 96.0% to 100.0% between RHAs. The median time between first colonoscopy and resection was 40 days for individuals with colon cancer. This study showed that high-quality colorectal cancer surgery is being conducted in Manitoba along with some variation and gaps in quality. As a result of this work, a formal structure for ongoing measuring and reporting surgical quality has been established in Manitoba. Quality improvement initiatives have been implemented based on these findings and periodic assessments of colorectal cancer surgery quality will continue.

Effects of analgesic and surgical modality on immune response in colorectal cancer surgery

BACKGROUND AND OBJECTIVE

Different surgical methods, anesthesia, and analgesia are known to modify the surgical stress response, especially in patients with malignancy. We compared the impact of patient-controlled intravenous (PCA) versus epidural analgesia (EDA) on tumor-related mucosal immune response in patients undergoing open or laparoscopic surgery for colorectal cancer.

METHODS

In a University Hospital subgroup (n = 43) of a larger cohort (n = 235) of patients undergoing open or laparoscopic surgery for colorectal carcinoma randomized to PCA or EDA, colorectal tissues were stained for interleukin-10 (IL-10), tumor necrosis factor (TNF), and mast cell tryptase and then examined by immunofluorescence microscopy.

RESULTS

More IL-10⁺-cells were found in patients undergoing open compared to laparoscopic surgery in the PCA (P < 0.05) and EDA group (P < 0.0005), respectively, and numbers of TNF⁺-cells were higher in the open surgery group who received PCA (P < 0.05). No differences in IL-10 or TNF expressions were detected between EDA/PCA within the open or laparoscopic surgery groups, respectively. Fewer mast cells were observed in patients undergoing laparoscopic compared to open surgery combined with PCA (P < 0.05). Within the open surgery group, EDA resulted in fewer mucosal mast cells compared to the PCA group (P < 0.05).

CONCLUSIONS

The surgical method, rather than type of analgesia, may have higher impact on peri-operative inflammation. Laparoscopic surgery when combined with EDA for colorectal cancer caused a decrease in the TNF and IL-10 expression and mast cells. EDA seems to have an anti-inflammatory effect on cancer-related inflammation during open surgery.

Neoantigen-reactive T cells exhibit effective anti-tumor activity against colorectal cancer

Neoantigens play a crucial role in cancer immunotherapy. However, the effectiveness and safety of neoantigen-based immunotherapies in patients with colorectal cancer (CRC), particularly in the Chinese population, have not been well studied. This study explored the feasibility and effectiveness of neoantigens in the treatment of CRC. Whole-exome sequencing (WES) and transcriptome sequencing were used to identify somatic mutations, RNA expression, and human leukocyte antigen (HLA) alleles. Neoantigen candidates were predicted, and immunogenicity was assessed. The neoantigens TSHZ3-L523P, RARA-R83H, TP53-R248W, EYA2-V333I, and NRAS-G12D from Patient 4 (PW4); TASP1-P161L, RAP1GAP-S215R, MOSPD1-V63I, and NAV2-D1973N from Patient 10 (PW10); and HAVCR2-F39V, SEC11A-R11L, SMPDL3B-T452M, LRFN3-R118Q, and ULK1-S248L from Patient 11 (HLA-A0201⁺PW11) induced a heightened neoantigen-reactive T cell (NRT) response as compared with the controls in peripheral blood lymphocytes (PBLs) isolated from patients with CRC. In addition, we identified neoantigen-containing peptides SEC11A-R11L and ULK1-S248L from HLA-A0201⁺PW11, which more effectively elicited specific CTL responses than the corresponding native peptides in PBLs isolated from HLA-A0201⁺PW11 as well as in HLA-A2.1/K^b transgenic mice. Importantly, adoptive transfer of NRTs induced by vaccination with two mutant peptides could effectively inhibit tumor growth in tumor-bearing mouse models. These data indicate that neoantigen-containing peptides with high immunogenicity represent promising candidates for peptide-mediated personalized therapy.

Abbreviations: CRC: colorectal cancer; DCs: dendritic cells; ELISPOT: enzyme-linked immunosorbent spot; E:T: effector:target; HLA: human leukocyte antigen; MHC: major histocompatibility complex; Mut: mutant type; NGS: next-generation sequencing; NRTs: neoantigen-reactive T cells; PBMCs: peripheral blood mononuclear cells; STR: short tandem repeat; PBLs: peripheral blood lymphocytes; PBS: phosphate-buffered saline; PD-1: programmed cell death protein 1; TILs: tumor-infiltrating lymphocytes; RNA-seq: RNA sequencing; Tg: transgenic; TMGs: tandem minigenes; WES: whole-exome sequencing; WT: wild-type.

Potential importance of vital capacity for the safety of laparoscopic surgery for colorectal cancer in patients with pulmonary dysfunction

BACKGROUND

We examined the safety of laparoscopic surgery for colorectal cancer (CRC) in patients with pulmonary dysfunction, and evaluated risk factors (RF) for post-operative complications.

METHODS

We defined pulmonary dysfunction as having any diagnosed pulmonary disease with spirometry findings of obstructive or restrictive defects. Clinicopathological factors of 213 patients with pulmonary dysfunction who underwent laparoscopic surgery for CRC at Toranomon Hospital from 1999 to 2016 were evaluated to retrospectively identify RFs for any post-operative complications and major complications, namely post-operative pulmonary complications (PPCs). Examined preoperative factors included age, gender, body mass index, tumour location, smoking history, percentage vital capacity (%VC), forced expiratory volume in 1 s (FEV1.0), a ratio of FEV1.0 to forced vital capacity and American Society of Anesthesiologists physical status grade. Intraoperative factors, such as operative time, blood loss and blood transfusion, were also assessed.

RESULTS

Forty patients (18.8%) developed any complications including PPCs. Multivariate analysis revealed that male, rectal cancer and spirometry findings (both low FEV1.0 (0.8 L) and low %VC (<95)) were RFs (P = 0.026, 0.003 and 0.007, respectively). Six cases (2.8%) developed PPCs. The prevalence of PPCs was higher in patients with both low %VC (<95%) and low FEV1.0 (<0.8 L), with statistical significance (P = 0.006).

CONCLUSION

Our study suggested that not only low FEV1.0 but also low %VC was an important RF for post-operative complications after laparoscopic surgery for CRC.

The Introduction of Laparoscopic Colorectal Surgery: Can It Improve Hospital Economics?

INTRODUCTION

Clinical benefits of laparoscopic surgery are well established, but evidence for financial benefits is limited. This study aimed to compare the financial impact of the introduction of laparoscopic colorectal surgery.

METHODS

This study included patients who underwent colorectal surgery between January 2010 and 2015. We collected a range of financial data and divided the patients into 2 groups. Primary outcome was total cost defined by surgical-related costs.

RESULTS

A total of 1,246 patients were included, of which 440 surgeries were performed laparoscopically. The total median cost of laparoscopy was higher compared to open surgery (EUR 4,665 vs. EUR 4,268, p = 0.001). Laparoscopy was associated with higher equipment costs (EUR 857 vs. EUR 232, p < 0.001), longer operating time (3.2 vs. 2.5 hours, p < 0.001), and more readmissions (10.9 vs. 8.5%, p < 0.001). However, after adjusting for heterogeneity, no difference was found in total cost. Surgical-related costs were counterbalanced by lower costs associated with shorter median hospital stay (6 vs. 9 days, p < 0.001), less morbidity (37.3 vs. 55.1%, p < 0.001), and less mortality (1.8 vs. 5.6%, p = 0.013) for laparoscopy.

CONCLUSION

During the introduction of laparoscopy for colorectal surgery, no significant differences were found in total cost between laparoscopic and open colorectal surgery. However, favorable postoperative outcomes were achieved with laparoscopic surgery.

First-in-Human Assessment of cRGD-ZW800-1, a Zwitterionic, Integrin-Targeted, Near-Infrared Fluorescent Peptide in Colon Carcinoma

PURPOSE

Incomplete oncologic resections and damage to vital structures during colorectal cancer surgery increases morbidity and mortality. Moreover, neoadjuvant chemoradiotherapy has become the standard treatment modality for locally advanced rectal cancer, where subsequent downstaging can make identification of the primary tumor more challenging during surgery. Near-infrared (NIR) fluorescence imaging can aid surgeons by providing real-time visualization of tumors and vital structures during surgery.

EXPERIMENTAL DESIGN

We present the first-in-human clinical experience of a novel NIR fluorescent peptide, cRGD-ZW800-1, for the detection of colon cancer. cRGD-ZW800-1 was engineered to have an overall zwitterionic chemical structure and neutral charge to lower nonspecific uptake and thus background fluorescent signal. We performed a phase I study in 11 healthy volunteer as well as a phase II feasibility study in 12 patients undergoing an elective colon resection, assessing 0.005, 0.015, and 0.05 mg/kg cRGD-ZW800-1 for the intraoperative visualization of colon cancer.

RESULTS

cRGD-ZW800-1 appears safe, and exhibited rapid elimination into urine after a single low intravenous dose. Minimal invasive intraoperative visualization of colon cancer through full-thickness bowel wall was possible after an intravenous bolus injection of 0.05 mg/kg at least 2 hours prior to surgery. Longer intervals between injection and imaging improved the tumor-to-background ratio.

CONCLUSIONS

cRGD-ZW800-1 enabled fluorescence imaging of colon cancer in both open and minimal invasive surgeries. Further development of cRGD-ZW800-1 for widespread use in cancer surgery may be warranted given the ubiquitous overexpression of various integrins on different types of tumors and their vasculature.

Surgical treatment of primary gastrointestinal stromal tumors (GISTs): Management and prognostic role of R1 resections

BACKGROUND

Surgery represents the best treatment for primary gastrointestinal stromal tumors (GISTs). The aim of this study is to analyse outcomes of surgical management in order to evaluate the influence of microscopically R1 margins on survival and recurrence in patients affected by GISTs.

METHODS

The study reviewed retrospective data from 74 patients surgically treated for primary GISTs without metastasis at diagnosis. Clinical and pathological findings, surgical procedures, information about follow up and outcomes were analyzed.

RESULTS

Recurrence rate was low and no patients died in the R1 group during the follow up period. The difference in recurrence free survival for patients undergoing an R0 (n = 54) versus an R1 (n = 20) resections was not statistically significant (76% versus 85% at 3 years, logrank test p-value = 0,14; 63% versus 86% at 5 years, logrank test p-value = 0,48) CONCLUSIONS: Microscopically positive margin has no influence on overall and relapse-free survival in GIST patients. Thus, when R0 surgery implies major functional sequelae, it may be decided to accept possible R1 margins, especially for low risk tumors.

Effect of different carbon dioxide (CO2) insufflation for laparoscopic colorectal surgery in elderly patients: A randomized controlled trial

BACKGROUND

Evidence suggests that dry CO2 insufflation during laparoscopic colorectal surgery results in greater structural injury to the peritoneum and longer hospital stay than the use of warm, humidified CO2. We aimed to test the hypothesis that warm, humidified CO2 insufflation could reduce postoperative pain and improve recovery in laparoscopic colorectal surgery.

METHODS

One hundred fifty elderly patients undergoing laparoscopic colorectal surgery under general anesthesia from May 2017 to October 2018 were randomly divided into 3 groups. The primary outcomes were resting pain, cough pain, and consumption of sufentanil at 2, 4, 6, 12, 24, and 48 hours postoperatively. Quality of visual image, hemodynamic changes, esophageal temperature, mean skin temperature, mean body temperature, recovery time, days to first flatus and solid food intake, shivering, incidence of postoperative ileus, length of hospital stay, surgical site infections, patients and surgeon satisfaction scores, adverse events, prothrombin time, activated partial thromboplastin time, and thrombin time were recorded.

RESULTS

Group CE patients were associated with significantly higher early postoperative cough pain and sufentanil consumption than the other 2 groups (P < .05). Compared with group CE, patients in both groups WH and CF had significantly reduced intraoperative hypothermia, recovery time of PACU, days to first flatus and solid food intake, and length of hospital stay, while the satisfaction scores of both patients and surgeon were significantly higher (P < .05). Prothrombin time, activated partial thromboplastin time, and thrombin time were significantly higher in group CE from 60 minutes after pneumoperitoneum to the end of pneumoperitoneum than the other 2 groups (P < .05). The number of patients with a shivering grade of 0 was significantly lower and grade of 3 was significantly higher in group CE than in the other 2 groups (P < .05).

CONCLUSION

Use of either warm, humidified CO2 insufflations or 20°C, 0% relative humidity CO2 combined with forced-air warmer set to 38°C during insufflations can both reduce intraoperative hypothermia, dysfunction of coagulation, early postoperative cough pain, sufentanil consumption, days to first flatus, solid food intake, and length of hospital stay.

Laparoscopic Distal Pancreatectomy: Our Experience in a Tertiary Referral Center

BACKGROUND

Despite an increase in the number of laparoscopic distal pancreatectomy (LDP) procedures being performed, the long-term oncology and operative results are still unclear. The aim of this study was to present the surgical and long-term results of patients undergoing LDP for the treatment of distal pancreatic tumors.

MATERIALS AND METHODS

A retrospective review was made of patients who underwent LDP in our clinic, between 2006 and 2018, and who were diagnosed with pancreas tail, neck, and corpus tumors. For the purposes of this study, the data related to the preoperative, operative, and postoperative characteristics of the patients were determined.

RESULTS

A total of 46 patients were identified as suitable for inclusion in the study. Of these, 52.1% were female individuals, and the average age of the whole group was 63 years. Previous surgery for malignant diseases was recorded for 54.3% of the patients, due to premalignant diseases in 13% and benign diseases in 32.7%. On average, 10 lymph nodes were removed from patients diagnosed with malignant tumors. The conversion rate was found to be 2.1%. The postoperative pancreatic fistula rate was 26%, and there was 1 complication each of grades III and IV according to the Clavien-Dindo classification. The mortality rate was 0%.

CONCLUSIONS

It was concluded that LDP of distal pancreas tumors seems to be both safe and effective in respect of the long-term results in addition to the early results of the operation.

Economic Disparities in Patients Undergoing Sigmoidectomy

Background and Objectives:

Disparities in health care outcomes and resources utilized are present in the treatment of many conditions and represent an area for targeted improvement. This study analyzes the differences in outcomes and total hospital charges between the highest and lowest income quartiles of patients undergoing sigmoid colectomy.

Methods:

This retrospective cohort study included patients undergoing sigmoid colectomy from 2013 to 2014 queried from the Agency for Healthcare Research and Quality National Inpatient Sample Database who were categorized as the lowest and highest income quartile based on average income of the patient's ZIP code. Patients were grouped into income quartiles, as defined by average income in the ZIP code of residence. In-hospital complications were the primary outcome of this study. We hypothesized that patients in the lowest income quartile would have poorer outcomes than those in the highest income quartile prior to data collection.

Results:

The lowest (n = 40,995) and highest (n = 40,940) income quartiles are not significantly different based on age or gender. The lowest income quartile was sicker, with higher mean scores for the All Patient Refined Diagnosis Related Group Severity Index and All Patient Refined Diagnosis Related Group Risk of Mortality Index. The lowest income quartile cohort had higher rates of postoperative complications and higher total charges than those in the highest income quartile. Adjusted regression analysis showed significantly lower total charges for the lowest income quartile but no significant differences in overall complications, mortality rates, or nonhome discharge.

Conclusions:

Patients in the highest income quartile utilize more hospital resources than the lowest income quartile. Additional study is required to understand why these differences exist.

Key Points:

1. Significant differences in outcomes and hospital charges exist between socioeconomic groups undergoing sigmoidectomy. 2. There does not seem to be a difference in outcomes after sigmoidectomy among different socioeconomic groups. 3. Elective and laparoscopic sigmoid colectomy is more frequently applied to higher socioeconomic groups. 4. Hospital charges are also greater among patients of higher socioeconomic groups undergoing sigmoid colectomy.

Question:

Does socioeconomic status affect outcomes and total charges in patients undergoing sigmoid colectomy?

Findings:

Unadjusted analysis showed significant disparities between the highest and lowest income quartile in outcomes after sigmoid colon resection. Adjusted analysis showed no difference in outcomes, with patients in the highest income quartile having higher total charges.

Meaning:

There is a value difference between high-income and low-income patients undergoing sigmoid colectomy.

Biomarkers in colorectal cancer: Current clinical utility and future perspectives

Colorectal cancer (CRC) is a major cause of cancer death worldwide. CRC has poor prognosis and there is a crucial need for new diagnostic and prognostic biomarkers to avoid CRC-related deaths. CRC can be considered a sporadic disease in most cases (75%-80%), but it has been suggested that crosstalk between gene mutations (i.e., mutations of BRAF, KRAS, and p53 as well as microsatellite instability) and epigenetic alterations (i.e., DNA methylation of CpG island promoter regions) could play a pivotal role in cancer development. A number of studies have focused on molecular testing to guide targeted and conventional treatments for patients with CRC, sometimes with contrasting results. Some of the most useful innovations in the management of CRC include the possibility to detect the absence of KRAS, BRAF, NRAS and PIK3CA gene mutations with the subsequent choice to administer targeted adjuvant therapy with anti-epidermal growth factor receptor antibodies. Moreover, CRC patients can benefit from tests for microsatellite instability and for the detection of loss of heterozygosity of chromosome 18q that can be helpful in guiding therapeutic decisions as regards the administration of 5-FU. The aim of this review was to summarize the most recent evidence on the possible use of genetic or epigenetic biomarkers for diagnosis, prognosis and response to therapy in CRC patients.

Propensity score matching comparison of laparoscopic versus open surgery for rectal cancer in a middle-income country: short-term outcomes and cost analysis

Background

Laparoscopic surgery for rectal cancer is associated with improved postoperative outcomes compared to open surgery; however, economic studies have yielded contradictory results. The aim of this study was to compare the clinical and economic outcomes of laparoscopic versus open surgery for patients with rectal cancer.

Methods

Propensity score matching analysis was performed in a retrospective cohort of patients who underwent elective low anterior resection for rectal cancer treatment by laparoscopic and open surgery in a single Brazilian cancer center. Matched covariates included age, gender, body mass index, pTNM stage, American Society of Anesthesiologists score, type of anesthesia, neoadjuvant chemoradiotherapy, and interval between neoadjuvant chemoradiotherapy and index surgery. The clinical and economic outcomes were evaluated. The follow-up period was within 30 days of the index procedure. The clinical outcomes were reoperation, postoperative complications, operative time, length of stay in the intensive care unit, and postoperative hospital stay. For economic outcomes, a cost analysis was used to compare the costs.

Results

Initially, 220 patients were evaluated. After propensity score matching, 100 patients were included in the analysis (50 patients in the open surgery group and 50 patients in the laparoscopic surgery group). There were no differences in patients' baseline characteristics. Operative time was longer for laparoscopic surgery (247 minutes vs 285 minutes, P=0.006). There were no significant differences in other clinical outcomes. The hospital costs were similar between the two groups (Brazilian reais 21,233.15 vs Brazilian reais 21,529.28, P=0.115), although the intraoperative costs were higher for laparoscopic surgery, mainly owing to the surgical devices and the theater-related costs. The postoperative costs were lower for laparoscopic surgery, owing to lower intensive care unit, ward, and reoperation costs.

Conclusion

Laparoscopic surgery for rectal cancer is not costlier than open surgery from the health care provider's perspective, since the intraoperative costs were offset by lower postoperative costs. Open surgery tends to have a longer length of stay.

Patient Perceptions and Quality of Life After Colon and Rectal Surgery: What Do Patients Really Want?

BACKGROUND

Colorectal surgery outcomes must be accurately assessed and aligned with patient priorities. No study to date has investigated the patient's subjective assessment of outcomes most important to them during and following their surgical recovery. Although surgeons greatly value the benefits of laparoscopy, patient priorities remain understudied.

OBJECTIVE

This study aimed to assess what aspects of patients' perioperative care and recovery they value most when queried in the postoperative period.

DESIGN

This study is an exploratory cross-sectional investigation of a defined retrospective patient population. Enrollees were stratified into subcategories and analyzed, with statistical analysis performed via χ test and unpaired t test.

SETTINGS

This study was conducted at a single academic medical center in New England.

PATIENTS

Patients who underwent a colorectal surgical resection between 2009 and 2015 were selected.

INTERVENTIONS

Patients within a preidentified population were asked to voluntarily complete a 32-item questionnaire regarding their surgical care.

MAIN OUTCOME MEASURES

The primary outcomes measured were patient perioperative and postoperative quality of life and satisfaction on selected areas of functioning.

RESULTS

Of 167 queried respondents, 92.2% were satisfied with their recovery. Factors considered most important included being cured of colorectal cancer (76%), not having a permanent stoma (78%), and avoiding complications (74%). Least important included length of stay (13%), utilization of laparoscopy (14%), and incision appearance and length (2%, 4%).

LIMITATIONS

The study had a relatively low response rate, the study is susceptible to responder's bias, and there is temporal variability from surgery to questionnaire within the patient population.

CONCLUSIONS

Overall, patients reported high satisfaction with their care. Most important priorities included being free of cancer, stoma, and surgical complications. In contrast, outcomes traditionally important to surgeons such as laparoscopy, incision appearance, and length of stay were deemed less important. This research helps elucidate the outcomes patients truly consider valuable, and surgeons should focus on these outcomes when making surgical decisions. See Video Abstract at http://links.lww.com/DCR/A596. See Visual Abstract at https://tinyurl.com/yb25xl66.

Short- and Long-Term Oncological Outcome After Rectal Cancer Surgery: a Systematic Review and Meta-Analysis Comparing Open Versus Laparoscopic Rectal Cancer Surgery

BACKGROUND

While several trials have compared laparoscopic to open surgery for colon cancer showing similar oncological results, oncological quality of laparoscopic versus open rectal resection is not well investigated.

METHODS

A systematic literature search for randomized controlled trials was conducted in MEDLINE, the Cochrane Library, and Embase. Qualitative and quantitative meta-analyses of short-term (rate of complete resections, number of harvested lymph nodes, circumferential resection margin positivity) and long-term (recurrence, disease-free and overall survival) oncologic results were conducted.

RESULTS

Fourteen randomized controlled trials were identified including 3528 patients. Patients in the open resection group had significantly more complete resections (OR 0.70; 95% CI 0.51-0.97; p = 0.03) and a higher number of resected lymph nodes (mean difference - 0.92; 95% CI - 1.08 to 0.75; p < 0.001). No differences were detected in the frequency of positive circumferential resection margins (OR 0.82; 95% CI 0.62-1.10; p = 0.18). Furthermore, no significant differences of long-term oncologic outcome parameters after 5 years including locoregional recurrence (OR 0.95; 95% CI 0.44-2.05; p = 0.89), disease-free survival (OR 1.16; 95% CI 0.84-1.58; p = 0.36), and overall survival (OR 1.04; 95% CI 0.76-1.41; p = 0.82) were found. Most trials exhibited a relevant risk of bias and several studies provided no information on the surgical expertise of the participating surgeons.

CONCLUSION

Differences in oncologic outcome between laparoscopic and open rectal surgery for rectal cancer were detected for the complete resection rate and the number of resected lymph nodes in favor of the open approach. No statistically significant differences were found in oncologic long-term outcome parameters.

What to consider when designing a laparoscopic colorectal training curriculum: a review of the literature

Multiple studies have demonstrated the benefits of laparoscopic colorectal surgery (LCS), but in several countries it has still not been widely adopted. LCS training is associated with several challenges, such as patient safety concerns and a steep learning curve. Current evidence may facilitate designing of efficient training curricula to overcome these challenges. Basic training with virtual reality simulators has witnessed meteoric advances and may be essential during the early parts of the learning curve. Cadaveric and animal model training still constitutes an indispensable training tool, due to a higher degree of difficulty and greater resemblance to real operative conditions. In addition, recent evidence favors the use of novel training paradigms, such as proficiency-based training, case selection and modular training. This review summarizes the recent advances in LCS training and provides the evidence for designing an efficient training curriculum to overcome the challenges of LCS training.

C-reactive protein as a marker of the surgical stress reduction within an ERAS protocol (Enhanced Recovery After Surgery) in colorectal surgery: A prospective cohort study

BACKGROUND

The aim of this study is to evaluate the effectiveness of an Enhanced Recovery After Surgery Protocol (ERAS) in relation to reduce the Systemic Inflammatory Response (SIR) to surgery using C-reactive protein (CRP) in the first (POD1), second (POD2) and third (POD3) postoperative day.

METHODS

We enrolled 121 patients (ERAS group) that underwent elective colorectal surgery with ERAS, and compared them with 135 patients (preERAS group) that had undergone surgery prior to the implementation. We made a univariate analysis to compare the CRP values in POD1, POD2, and POD3 between preERAS/ERAS group, laparoscopic/open surgery and the presence or not of Clavien Dindo complications. Multivariable lineal regression was used to assess if the ERAS had a decreasing effect on the CRP in POD1, POD2, and POD3, and was adjusted by age, male sex, use of laparoscopy, and complications.

RESULTS

The presence of complications was independently associated with an increase in CRP values ​​in POD1, POD2, and POD3. Laparoscopy in POD1 and POD2, and ERAS in POD2 was independently associated with a decrease in CRP values.

CONCLUSION

The analysis shows an increase in SIR measured as a CRP value in those patients that had complications. The SIR decreased with laparoscopy in POD1 and POD2 and with ERAS in POD2.

Impact of medial-to-lateral vs lateral-to-medial approach on short-term and cancer-related outcomes in laparoscopic colorectal surgery: A retrospective cohort study

Background

Laparoscopic surgery is the favoured method of colorectal cancer resections. It is surgeon expertise and discretion to choose whether to mobilize colon lateral-to-medial or medial-to-lateral. We aim to identify the advantage of one approach over the other in short-term and cancerrelated outcomes.

Methods

A retrospective review of a prospectively maintained database of all laparoscopic colorectal resections with curative-intent, in a single unit, from March 2013 to October 2014. Data was collected on patient demographics, method of laparoscopic mobilisation, operating time, length-of-stay, post-operative complications, clearance of circumferential resection margins lymph node harvest and follow-up.

Results

137 patients with comparable patient demographics had laparoscopic colorectal cancer resection. 76 (60.3%) male and 50 (39.7%) female patients. 58(46.0%) of resections were performed using medial-to-lateral approach, while 68(54.0%) lateral-to-medial. Lateral group had on average 14(0–38) lymph nodes with specimen compared to 17 (6–45) in medial group. There was a statistically significant difference in the major complication rate (Clavien-Dindo IV) between the groups with 1(1.7%) in the medial-to-lateral group compared to 7 (10.2%) in the lateral-to-medial group, (p .035). Patients in the medial-to-lateral group had median length-of-stay of 7 days (range 2–55) compared to 7 days (range 2–75) in the lateral-to-medial group. There was no statistically significant difference in survival between both groups up-to 1334 days p=.413.

Conclusion

Our study shows that mobilising the colon medially in laparoscopic colorectal cancer resection increases the lymph node harvest, gives comparable CRM clearance, similar length of hospital stay and complications. It makes no statistically significant difference in the overall patient survival.

•

This study reports that no one approach is superior to the other but the patient having surgery using medial-to-lateral approach have less post operative complications and higher number of lymph node harvest.

•

There is no long-term advantage to report.

•

Meta-analysis by Ding and colleagues reported that medial-to-lateral approach is better in terms of conversion rate and complications but give less number of lymph nodes in the specimen.

Selection Bias in Colorectal Surgery in a Non-Tertiary Hospital: Laparoscopic Versus Open Surgery

INTRODUCTION

Laparoscopy is used increasingly to treat malignant and benign colorectal surgical diseases. However, this practice is still not offered to all patients. Many barriers halt the widespread use of laparoscopic colorectal surgery. Both surgeon's and patient's factors contribute to limit a wider use of laparoscopy in colorectal surgery.

MATERIALS AND METHODS

We retrospectively analyzed 408 consecutive colorectal resections in a 4-year period, to find out if a selection bias exists in using laparotomy or laparoscopy for colorectal surgical diseases, and which factors are associated with a poor use of laparoscopy or to a preferred laparotomy.

RESULTS

In our practice, advanced disease, American Society of Anesthesiologist class III and IV, and emergency status are all patient-related factors associated with laparotomy. Surgeon's age more than 52 years and lack of laparoscopic training are surgeon-related factors that negatively affect the chance of being operated on with the laparoscopic technique.

CONCLUSIONS

An extensive laparoscopic colorectal training and a supporting environment, especially during the night shift, are needed to facilitate the use of laparoscopy in colorectal surgery avoiding a bias in selecting surgical candidates to one technique or another.

Hand-assisted laparoscopic surgery versus laparoscopic right colectomy: a meta-analysis

Objective

The objective of this study is to systematically assess the clinical efficacy of hand-assisted laparoscopic surgery (HALS) and laparoscopic right colectomy (LRC).

Methods

The randomized controlled trials (RCTs) and non-RCTs were collected by searching electronic databases (Pubmed, Embase, and the Cochrane Library). The outcomes included intraoperative outcomes, postoperative outcomes, postoperative morbidity, and oncologic outcomes. Meta-analysis was performed using of RevMan 5.3 software.

Results

A total of five studies involving 438 patients were finally included, with 202 cases in HALS group and 236 cases in LRC group. Results of meta-analysis showed that there was no statistical difference between HALS and LRC in terms of conversion rate, length of hospital stay, reoperation rate, postoperative morbidity, and oncologic outcomes. The operative time was 6.5 min shorter in HALS group; however, it was not a clinically significant difference. Although the incision length was longer in HALS, it did not influence the postoperative recovery.

Conclusions

HALS can be considered an alternative to LRC which combines the advantages of open as well as laparoscopic surgery.

Laparoscopic-Assisted Resection for Advanced Colorectal Cancer in Solid Organ Transplant Recipients

AIM

To evaluate the feasibility, short- and long-term outcomes, and safety of laparoscopic resection for advanced colorectal cancer (CRC) in solid organ transplant recipients.

METHODS

Between September 2001 and April 2016, five patients who underwent laparoscopic-assisted resection for CRC after solid organ transplantation were included in this study. Their clinical data were retrospectively analyzed with regard to patient demographics, immunosuppressive therapy, tumor characteristics, surgical outcomes, and follow-up data.

RESULTS

Four kidney and one heart transplant recipients were included. Laparoscopic-assisted low anterior resection was performed in four patients with rectal or rectosigmoid junction cancer, and sigmoidectomy was done in one with sigmoid colon cancer. One kidney transplant patient received a protective loop transverse colostomy. All resections achieved complete tumor removal with tumor-free margins and total mesorectal excision, with an average number of 14 lymph nodes harvested. Most tumors were in stage III (n = 3), one was in stage II, and one in stage IV. The mean duration of surgery, intraoperative blood loss, and postoperative hospital stay were 144 min, 105 mL, and 8.8 days, respectively. No major complications occurred and graft function stayed well. During a mean follow-up period of 62 months, two patients developed metastasis and died eventually.

CONCLUSION

Laparoscopic resection for advanced CRC in organ transplant recipients is technically feasible and therapeutically safe, and seems to have the advantages of few postoperative complications, short recovery time, and acceptable oncological outcomes.

Accelerated enhanced Recovery following Minimally Invasive colorectal cancer surgery (RecoverMI): a study protocol for a novel randomised controlled trial

INTRODUCTION

Definitive treatment of localised colorectal cancer involves surgical resection of the primary tumour. Short-stay colectomies (eg, 23-hours) would have important implications for optimising the efficiency of inpatient care with reduced resource utilisation while improving the overall recovery experience with earlier return to normalcy. It could permit surgical treatment of colorectal cancer in a wider variety of settings, including hospital-based ambulatory surgery environments. While a few studies have shown that discharge within the first 24 hours after minimally invasive colectomy is possible, the safety, feasibility and patient acceptability of a protocol for short-stay colectomy for colorectal cancer have not previously been evaluated in a prospective randomised study. Moreover, given the potential for some patients to experience a delay in recovery of bowel function after colectomy, close outpatient monitoring may be necessary to ensure safe implementation.

METHODS AND ANALYSIS

In order to address this gap, we propose a prospective randomised trial of accelerated enhanced Recovery following Minimally Invasive colorectal cancer surgery (RecoverMI) that leverages the combination of minimally invasive surgery with enhanced recovery protocols and early coordinated outpatient remote televideo conferencing technology (TeleRecovery) to improve postoperative patien-provider communication, enhance postoperative treatment navigation and optimise postdischarge care. We hypothesise that RecoverMI can be safely incorporated into multidisciplinary practice to improve patient outcomes and reduce the overall 30-day duration of hospitalisation while preserving the quality of the patient experience. ETHICS AND DISSEMINATION: RecoverMI has received institutional review board approval and funding from the American Society of Colorectal Surgeons (ASCRS; LPG103). Results from RecoverMI will be published in a peer-reviewed publication and be used to inform a multisite trial.

TRIAL REGISTRATION NUMBER

NCT02613728; Pre-results.

Cost comparison of laparoscopic colectomy versus open colectomy in colon cancer

BACKGROUND

Laparoscopic colectomy has been shown to be safe, oncologically comparable, and clinically beneficial over open colectomy for colon cancer, but utilization remains low. Objectives To evaluate the cost of laparoscopic colectomy vs open colectomy for colon cancer.

METHODS

The authors conducted a retrospective claims data analysis using the 2012 and 2013 Truven Health Analytics MarketScan Commercial Claims and Encounter Database. The denominator population consisted of individuals who had commercial insurance coverage in all months of 2012 and >1 month in 2013 and pharmacy coverage throughout eligibility. The study population included individuals aged 18-64 years who were identified with colon cancer in 2013 and underwent an elective inpatient open colectomy or laparoscopic colectomy between January and November 2013. The cost and re-admission rate of open vs laparoscopic colectomy were compared after risk, adjusting for comorbidities, demographics, and geographic region.

RESULTS

During the study period, 1299 elective inpatient colon cancer colectomies were performed (open, n = 558; laparoscopic, n = 741). After risk adjustment, the laparoscopic vs open group was shown to have lower re-admission rates (6.61 and 10.93 per 100 cases, respectively, p = .0165), lower average re-admission costs ($1676 and $3151, respectively, p = .0309), and lower 30-day post-discharge healthcare utilization costs ($4842 and $7121, respectively, p = .0047). Average allowed cost for the combined inpatient and 30-day post-discharge period was lower for laparoscopic vs open colectomy cases ($36,395 and $44,226, respectively, p < .001).

CONCLUSIONS

The cost of laparoscopic colectomy was found to be statistically significantly less than that of open colectomy in patients undergoing elective surgery for colon cancer.

Insurance Status, Not Race, is Associated With Use of Minimally Invasive Surgical Approach for Rectal Cancer

OBJECTIVE

To determine the impact of race and insurance on use of minimally invasive (MIS) compared with open techniques for rectal cancer in the United States.

BACKGROUND

Race and socioeconomic status have been implicated in disparities of rectal cancer treatment.

METHODS

Adults undergoing MIS (laparoscopic or robotic) or open rectal resections for stage I to III rectal adenocarcinoma were included from the National Cancer Database (2010-2012). Multivariate analyses were employed to examine the adjusted association of race and insurance with use of MIS versus open surgery.

RESULTS

Among 23,274 patients, 39% underwent MIS and 61% open surgery. Overall, 86% were white, 8% black, and 3% Asian. Factors associated with use of open versus MIS were black race, Medicare/Medicaid insurance, and lack of insurance. However, after adjustment for patient demographic, clinical, and treatment characteristics, black race was not associated with use of MIS versus open surgery [odds ratio [OR] 0.90, P = 0.07). Compared with privately insured patients, uninsured patients (OR 0.52, P < 0.01) and those with Medicare/Medicaid (OR 0.79, P < 0.01) were less likely to receive minimally invasive resections. Lack of insurance was significantly associated with less use of MIS in black (OR 0.59, P = 0.02) or white patients (OR 0.51, P < 0.01). However, among uninsured patients, black race was not associated with lower use of MIS (OR 0.96, P = 0.59).

CONCLUSIONS

Insurance status, not race, is associated with utilization of minimally invasive techniques for oncologic rectal resections. Due to the short-term benefits and cost-effectiveness of minimally invasive techniques, hospitals may need to improve access to these techniques, especially for uninsured patients.

The Role of Laparoscopy in the Treatment of Anastomotic Leaks After Minimally Invasive Colorectal Resections for Cancer

AIM OF THE STUDY

The aim of this study was to describe the role of laparoscopy in the treatment of leaks occurring after minimally invasive colorectal resections.

MATERIALS AND METHODS

Thirty-four of 566 consecutive patients who underwent minimally invasive colorectal resection for cancer between January 2004 and December 2012 and who showed signs of anastomotic leakage (6%) requiring reoperation were studied using a prospectively maintained database. Patient characteristics, clinical signs, the surgical approach, the role of laparoscopy, operative and postoperative results, and the rate of permanent stoma were analyzed.

RESULTS

The median time to diagnosis of an anastomotic leak after surgery was 5.5 days. The median time to reoperation from the diagnosis of leakage was 2 days. Leaks were treated laparoscopically in 21 of 34 (61.8%) patients. Anastomoses were dismantled in 14 patients (41.2%) and the procedure was performed laparoscopically in 28.6% of the cases. The postoperative morbidity was 55.9%, the perioperative mortality 5.7%, and the rate of permanent stoma was 8.8%.

CONCLUSIONS

Laparoscopic reoperation can be performed in most cases of anastomotic leaks occurring after minimally invasive colorectal resection for cancer. Anastomosis can be dismantled laparoscopically in 28.6% of the cases. A permanent stoma was necessary only in patients with terminal stomas.

Evaluation of short-term outcomes of laparoscopic-assisted surgery for colorectal cancer in elderly patients aged over 75 years old: a multi-institutional study (YSURG1401)

BACKGROUND

The short-term outcomes of laparoscopic-assisted surgery for colorectal cancer (LAC) have not been fully evaluated in elderly patients. The aim of this study was to compare the short term surgical outcomes of LAC between the patients older than 75 years and those with non-elderly patients.

METHODS

This retrospective multi-institutional study selected patients who underwent LAC between April 2013 and March 2014 at Yokohama City University Hospital and its related general hospitals. The patients were categorized into two groups: elderly patients (>75 years of age: group A) and non-elderly patients (<75 years of age: group B). Surgical outcomes and post operative complications were compared between the two groups.

RESULTS

A total of 237 patients were evaluated in the present study. Eighty-four patients were classified into group A, and 153 into group B. Preoperative clinicopathological outcomes demonstrated no significant differences except for the ASA score. When comparing the surgical outcomes between group A and group B, the rate of conversion to open procedure (3.6% vs 5.2%, P = 0.750), median operation time (232 min vs 232 min, P = 0.320), median blood loss (20 ml vs 12 ml, P = 0.350). The differences were not significantly different in the surgical outcomes. The incidences of > grade 2 post operative surgical complications were similar between two groups ((19.0% vs 15.7%, p = 0.587). No mortality was observed in this study. The length of postoperative hospital stay was also similar (10 days vs 10 days, p = 0.350).

CONCLUSIONS

The present study suggested that LAC is safe and feasible, regardless of the age of the patient, especially for elderly patients who may be candidates for colon cancer surgery.

Minimally Invasive Distal Pancreatectomy: Review of the English Literature

BACKGROUND

Recently, the superiority of the minimally invasive approach, which results in a better cosmetic result, faster recovery, and shorter length of hospital stay, is a technique that has been progressively recognized as it has developed. And the minimally invasive approach has been applied to distal pancreatectomy (DP), which is a standard method for the treatment of benign, borderline, and part of malignant lesions of the pancreatic body and tail. This article aims to analyze the types, postoperative recovery, and outcomes of laparoscopic distal pancreatectomy (LDP).

MATERIALS AND METHODS

A systematic search of the scientific literature was performed using PubMed, EMBASE, online journals, and the Internet for all publications on LDP. Articles were selected if the abstract contained patients who underwent LDP for pancreatic diseases. All selected articles were reviewed and analyzed.

RESULTS

If there were no contraindications for LDP, this operation is suitable for benign, borderline, or malignant tumors of the pancreatic body and tail, which should try to be performed with preservation of the spleen. LDP is safe and feasible under some conditions to experienced surgeon. Single-incision laparoscopic distal pancreatectomy (S-LDP) and robotic laparoscopic distal pancreatectomy (R-LDP) perioperative outcomes are similar with conventional multi-incision laparoscopic distal pancreatectomy (C-LDP). And the advantages of S-LDP and R-LDP require further exploration. With the application of enhanced recovery program (ERP), length of hospital stay and costs are reduced.

CONCLUSIONS

LDP is safe and feasible under some conditions. Compared with open distal pancreatectomy, LDP has a lot of advantages; a trend was observed for LDP to replace traditional open surgery. LDP combined with ERP is expected to become standard in the treatment of pancreatic body and tail lesions.

Impact of laparoscopic versus open surgery on hospital costs for colon cancer: a population-based retrospective cohort study

OBJECTIVE

Laparoscopy is increasingly being used as an alternative to open surgery in the treatment of patients with colon cancer. The study objective is to estimate the difference in hospital costs between laparoscopic and open colon cancer surgery.

DESIGN

Population-based retrospective cohort study.

SETTINGS

All acute hospitals of the National Health System in England.

POPULATION

A total of 55 358 patients aged 30 and over with a primary diagnosis of colon cancer admitted for planned (elective) open or laparoscopic major resection between April 2006 and March 2013.

PRIMARY OUTCOMES

Inpatient hospital costs during index admission and after 30 and 90 days following the index admission.

RESULTS

Propensity score matching was used to create comparable exposed and control groups. The hospital cost of an index admission was estimated to be £1933 (95% CI 1834 to 2027; p<0.01) lower among patients who underwent laparoscopic resection. After including the first unplanned readmission following index admission, laparoscopy was £2107 (95% CI 2000 to 2215; p<0.01) less expensive at 30 days and £2202 (95% CI 2092 to 2316; p<0.01) less expensive at 90 days. The difference in cost was explained by shorter hospital stay and lower readmission rates in patients undergoing minimal access surgery. The use of laparoscopic colon cancer surgery increased 4-fold between 2006 and 2012 resulting in a total cost saving in excess of £29.3 million for the National Health Service (NHS).

CONCLUSIONS

Laparoscopy is associated with lower hospital costs than open surgery in elective patients with colon cancer suitable for both interventions.

Reducing liver metastases of colon cancer in the context of extensive and minor surgeries through β-adrenoceptors blockade and COX2 inhibition

Liver metastases are a major cause of colorectal cancer death, and the perioperative period is believed to critically affect the metastatic process. Here we tested whether blocking excess release of catecholamines and prostaglandins during surgical procedures of different extent can reduce experimental liver metastasis of the syngeneic CT26 colon cancer in female and male BALB/c mice. Animals were either treated with the beta-blocker, propranolol, the COX-2 inhibitor, etodolac, both drugs, or vehicle. The role of NK cells in controlling CT26 hepatic metastasis and in mediating the effect of the drugs was assessed by in vivo depletion or stimulation of NK cells, using anti-asialo GM1 or CpG-C, respectively. Surgical extent was manipulated by adding laparotomy to small incision, extending surgical duration, and enabling hypothermia. The results indicated that combined administration of propranolol and etodolac, but neither drug alone, significantly improved host resistance to metastasis. These beneficial effects occurred in both minor and extensive surgeries, in both sexes, and in two tumor inoculation approaches. NK cell-mediated anti-CT26 activity is involved in mediating the beneficial effects of the drugs. Specifically, CpG-C treatment, known to profoundly activate mice marginating-hepatic NK cytotoxicity, reduced CT26 hepatic metastases; and NK-depletion increased metastases and prevented the beneficial effects of the drugs. Overall, given prevalent perioperative psychological and physiological stress responses in patients, and ample prostaglandin release by colorectal tumors and injured tissue, propranolol and etodolac could be tested clinically in laparoscopic and open colorectal surgeries, attempting to reduce patients' metastatic disease.

Role of surgery for colorectal cancer in the elderly

The prevalence of subjects with colorectal cancer is expected to grow in the next future decades and surgery represents the most successful treatment modality for these patients. Anyway, currently elderly subjects undergo less elective surgical procedures than younger patients mainly due to the high rates of postoperative morbidity and mortality. Some authors suggest extensive surgery, including multistage procedures, as carried out in younger patients while others promote less aggressive surgery. In older patients, laparoscopic-assisted colectomy showed a number of advantages compared to conventional open surgery that include lower stress, higher rate of independency after surgery, quicker return to prior activities and a decrease in costs. The recent advances in chemotherapy and the introduction of new surgical procedures such as the endoluminal stenting, suggest the need for a revisitation of surgical practice patterns and the role of palliative surgery, mainly for patients with advanced disease. In this article, we discuss the current role of surgery for elderly patients with colorectal cancer.

Laparoscopic versus open appendectomy: a retrospective cohort study assessing outcomes and cost-effectiveness

BACKGROUND

Appendectomy is the most common surgical procedure performed in emergency surgery. Because of lack of consensus about the most appropriate technique, appendectomy is still being performed by both open (OA) and laparoscopic (LA) methods. In this retrospective analysis, we aimed to compare the laparoscopic approach and the conventional technique in the treatment of acute appendicitis.

METHODS

Retrospectively collected data from 593 consecutive patients with acute appendicitis were studied. These comprised 310 patients who underwent conventional appendectomy and 283 patients treated laparoscopically. The two groups were compared for operative time, length of hospital stay, postoperative pain, complication rate, return to normal activity and cost.

RESULTS

Laparoscopic appendectomy was associated with a shorter hospital stay (2.7 ± 2.5 days in LA and 1.4 ± 0.6 days in OA), with a less need for analgesia and with a faster return to daily activities (11.5 ± 3.1 days in LA and 16.1 ± 3.3 in OA). Operative time was significantly shorter in the open group (31.36 ± 11.13 min in OA and 54.9 ± 14.2 in LA). Total number of complications was less in the LA group with a significantly lower incidence of wound infection (1.4 % vs 10.6 %, P <0.001). The total cost of treatment was higher by 150 € in the laparoscopic group.

CONCLUSION

The laparoscopic approach is a safe and efficient operative procedure in appendectomy and it provides clinically beneficial advantages over open method (including shorter hospital stay, decreased need for postoperative analgesia, early food tolerance, earlier return to work, lower rate of wound infection) against only marginally higher hospital costs.

TRIAL REGISTRATION

NCT02867072 Registered 10 August 2016. Retrospectively registered.

Can We Predict Technical Aptitude?: A Systematic Review

OBJECTIVE

To identify background characteristics and cognitive tests that may predict surgical trainees' future technical performance, and therefore be used to supplement existing surgical residency selection criteria.

BACKGROUND

Assessment of technical skills is not commonly incorporated as part of the selection process for surgical trainees in North America. Emerging evidence, however, suggests that not all trainees are capable of reaching technical competence. Therefore, incorporating technical aptitude into selection processes may prove useful.

METHODS

A systematic search was carried out of the MEDLINE, PsycINFO, and Embase online databases to identify all studies that assessed associations between surrogate markers of innate technical abilities in surgical trainees, and whether these abilities correlate with technical performance. The quality of each study was evaluated using the Grading of Recommendations, Assessment, Development, and Evaluation system.

RESULTS

A total of 8035 records were identified. After screening by title, abstract, and full text, 52 studies were included. Very few surrogate markers were found to predict technical performance. Significant associations with technical performance were seen for 1 of 23 participant-reported surrogate markers, 2 of 25 visual spatial tests, and 2 of 19 dexterity tests. The assessment of trainee Basic Performance Resources predicted technical performance in 62% and 75% of participants.

CONCLUSIONS

To date, no single test has been shown to reliably predict the technical performance of surgical trainees. Strategies that rely on assessing multiple innate abilities, their interaction, and their relationship with technical skill may ultimately be more likely to serve as reliable predictors of future surgical performance.

The feasibility of single-port laparoscopic appendectomy using a solo approach: a comparative study

Purpose

To investigate the feasibility and safety of solo surgery with single-port laparoscopic appendectomy, which is termed herein solo-SPLA (solo-single-port laparoscopic appendectomy).

Methods

This study prospectively collected and retrospectively analyzed data from patients who had undergone either non-solo-SPLA (n = 150) or solo-SPLA (n = 150). Several devices were utilized for complete, skin-to-skin solo-SPSA, including a Lone Star Retractor System and an adjustable mechanical camera holder.

Results

Operating times were not significantly different between solo- and non-solo-SPLA (45.0 ± 21.0 minutes vs. 46.7 ± 26.1 minutes, P = 0.646). Most postoperative variables were also comparable between groups, including the necessity for intravenous analgesics (0.7 ± 1.2 ampules [solo-SPLA] vs. 0.9 ± 1.5 ampules [non-solo-SPLA], P = 0.092), time interval to gas passing (1.3 ± 1.0 days vs. 1.4 ± 1.0 days, P = 0.182), and the incidence of postoperative complications (4.0% vs. 8.7%, P = 0.153). Moreover, solo-SPLA effectively lowered the operating cost by reducing surgical personnel expenses.

Conclusion

Solo-SPLA economized staff numbers and thus lowered hospital costs without lengthening of operating time. Therefore, solo-SPLA could be considered a safe and feasible alternative to non-solo-SPLA.

Recurrent colorectal cancer after endoscopic resection when additional surgery was recommended

AIM: To evaluate the type of recurrence after endoscopic resection in colorectal cancer patients and whether rescue was possible by salvage operation.

METHODS: Among 4972 patients who underwent surgical resection at our institution for primary or recurrent colorectal cancers from January 2005 to February 2015, we experienced eight recurrent colorectal cancers after endoscopic resection when additional surgical resection was recommended.

RESULTS: The recurrence patterns were: intramural local recurrence (five cases), regional lymph node recurrence (three cases), and associated with simultaneous distant metastasis (three cases). Among five cases with lymphatic invasion observed histologically in endoscopic resected specimens, four cases recurred with lymph node metastasis or distant metastasis. All cases were treated laparoscopically and curative surgery was achieved in six cases. Among four cases located in the rectum, three cases achieved preservation of the anus. Postoperative complications occurred in two cases (enteritis).

CONCLUSION: For high-risk submucosal invasive colorectal cancers after endoscopic resection, additional surgical resection with lymphadenectomy is recommended, particularly in cases with lymphovascular invasion.

Enhanced recovery care after colorectal surgery in elderly patients. Compliance and outcomes of a multicenter study from the Spanish working group on ERAS

PURPOSE

ERAS (enhanced recovery after surgery) programs have proven to reduce morbidity and hospital stay in colorectal surgery. However, the feasibility of these programs in elderly patients has been questioned. The aim of this study is to assess the implementation and outcomes of an ERAS program for colorectal cancer in elderly patients.

METHODS

This is a multicenter observational study of a cohort of elderly patients undergoing colorectal surgery within an ERAS program. A total of 188 consecutive patients over 70 years who underwent elective colorectal surgery within an ERAS program at three institutions during a 2-year period were included. The compliance with the ERAS protocol interventions was measure. Complications were evaluated according to Clavien-Dindo classification. Data on length of stay and readmission rates were analyzed.

RESULTS

Early intake and early mobilization were the most successfully carried out interventions. There was a global compliance rate of 56 % of patients for whom compliance was achieved with all measured interventions. The median hospital length of stay was 6 days. Almost 60 % of patients had no complications, 24 % had minor complications while 13 % had major complications; of them, 8 % patients were reoperated. The readmission rate was 6.4 %.

CONCLUSIONS

ERAS after colorectal surgery in elderly patients presents as safe and feasible based on good reported outcomes of compliance rates, complications, readmissions, and needs for reoperation.

A national evaluation of clinical and economic outcomes in open versus laparoscopic colorectal surgery

BACKGROUND

Surgical value is based on optimizing clinical and financial outcomes. The clinical benefits of laparoscopic surgery are well established; however, many patients are still not offered a laparoscopic procedure. Our objective was to compare the modern clinical and financial outcomes of laparoscopic and open colorectal surgery.

METHODS

The Premier Perspective database identified patients undergoing elective colorectal resections from January 1, 2013 to December 31, 2013. Cases were stratified by operative approach into laparoscopic and open cohorts. Groups were controlled on all demographics, diagnosis, procedural, hospital characteristics, surgeon volume, and surgeon specialty and then compared for clinical and financial outcomes. The main outcome measures were length of stay (LOS), complications, readmission rates, and cost by surgical approach.

RESULTS

A total of 6343 patients were matched and analyzed in each cohort. The most common diagnosis was diverticulitis (p = 0.0835) and the most common procedure a sigmoidectomy (p = 0.0962). The LOS was significantly shorter in laparoscopic compared to open (mean 5.78 vs. 7.80 days, p < 0.0001). The laparoscopic group had significantly lower readmission (5.82 vs. 7.68 %, p < 0.0001), complication (32.60 vs. 42.28 %, p < 0.0001), and mortality rates (0.52 vs. 1.28 %, p < 0.0001). The total cost was significantly lower in laparoscopic than in open (mean $17,269 vs. $20,552, p < 0.0001). By category, laparoscopy was significantly more cost-effective for pharmacy (p < 0.0001), room and board (p < 0.0001), recovery room (p = 0.0058), ICU (p < 0.0001), and laboratory and imaging services (both p < 0.0001). Surgical supplies (p < 0.0001), surgery (p < 0.0001), and anesthesia (p = 0.0053) were higher for the laparoscopic group.

CONCLUSIONS

Laparoscopy is more cost-effective and produces better patient outcomes than open colorectal surgery. Minimally invasive colorectal surgery is now the standard that should be offered to patients, providing value to both patient and provider.

Surgery for synchronous colorectal cancers with double colonic anastomoses: A comparison of laparoscopic and open approaches

INTRODUCTION

The aim of this study was to evaluate the safety of laparoscopic double colon resection and synchronous anastomosis for synchronous colorectal cancer.

METHODS

We reviewed 42 consecutive patients who underwent double colon resection and synchronous anastomosis for synchronous colorectal cancer between 2000 and 2014. Clinical characteristics and short-term outcomes were compared between laparoscopic (n = 27) and open (n = 15) groups.

RESULTS

There was no conversion to open surgery in the laparoscopic group. Operating time in the laparoscopic group was significantly longer than in the open group (373 vs 292 min), but estimated blood loss was significantly lower (40 vs 179 mL). Time to first flatus (1 vs 3 days) and length of hospital stay (12 vs 17 days) were significantly shorter in the laparoscopic group. The rate of postoperative complications was similar in both groups (19% vs 27%). The anastomotic leakage rate was 3.7% in the laparoscopic group and 20.0% in the open group.

CONCLUSION

Laparoscopic surgery with double colon resection and synchronous anastomosis for synchronous colorectal cancers is safe and has greater short-term benefits than open surgery. It should be considered as a treatment option under optimal conditions.