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Right colon diverticulitis is a rare disease process for which there are no established treatment guidelines, and outcomes following surgical management are underreported in the literature. We sought to describe the demographics of patients undergoing ileocecectomy for right colon diverticulitis and compare short-term postoperative outcomes between open and minimally invasive approaches. The American College of Surgeons National Surgical Quality Improvement Program (NSQIP) was queried for patients with diverticulitis of the colon who underwent ileocecectomy between 2012 and 2019. Patients with ascites, disseminated cancer, ASA class 5, and patients requiring mechanical ventilation were excluded. Preoperative, intraoperative, and 30-day postoperative outcomes were compared between the groups using both univariable chi-square or t-tests and multivariable logistical regression models. 484 patients met inclusion criteria, 150 (31%) of whom underwent open surgery and 334 (69%) who underwent minimally invasive surgery with an 18% conversion rate. 71% of patients were White, 11% of were Black, 7% were Hispanic, and 5% were Asian. The indication for surgery differed significantly by approach with acute diverticulitis representing 47% of indications for open cases and 25% for MIS cases (p

Since the introduction of Enhanced Recovery After Surgery (ERAS), early diet after surgery has been emphasized and clinical outcomes have improved, though vomiting has been reported frequently. We defined diet failure based on clinical manifestation and images after colon cancer surgery and attempted to analyze underlying risk factors by comparing the early diet group with the conventional diet group. All consecutive patients underwent colectomy with curative intent at a single institution between August 2015 and July 2017. The early diet group was started on soft diet on the second day after surgery, while the conventional group started the same after flatulence. The primary outcome was the difference in the incidence of diet failure between the two groups. Secondary outcomes were analyzed to determine risk factors for diet failure and readmission due to ileus. Overall, 293 patients were included in the conventional diet group and 231 in the early diet group. There were no significant differences between the two groups, except for shorter hospital stays in the early diet group (median 8 days, p

Background This was a retrospective, matching-adjusted indirect comparison of clinical outcomes between patients from a single-arm trial of the ECHELON CIRCULAR™ Powered Stapler (ECP) and those from a historical cohort of patients who underwent left-sided colorectal resection using conventional manual circular staplers, extracted from the Premier Healthcare Database. Methods Patients in the ECP trial cohort were propensity score matched to those in the historical cohort through nearest neighbor matching. Outcomes included 30-day readmission rates; length of stay (LOS) for the index admission; rates of anastomotic leak, pelvic abscess, ileus/small bowel obstruction, infection, bleeding, and stoma creation. Results The study included 168 patients in the ECP trial cohort and 4544 patients in the historical cohort; 165 ECP trial patients were matched to 1348 historical cohort patients. After matching, conversions were more prevalent in the historical cohort than the ECP trial cohort (4.2% ECP vs. 10.2% historical, p = 0.001). Relative to the historical cohort, the ECP trial cohort had statistically significant lower rates of 30-day inpatient readmission (6.1% vs. 10.8%, p = 0.019), anastomotic leak (1.8% vs. 6.9%, p p p = 0.001), and bleeding (1.8% vs. 9.2%, p Conclusions In this study, the ECP trial cohort had lower incidence proportions of several surgical complications as compared with the historical cohort. Further controlled prospective clinical studies are needed to confirm the validity of this finding.

Outcome studies have failed to show significant improvement related to formal fellowship training in different surgical specialties. We aimed to look whether laparoscopic fellowship-trained (FT) surgeons had better outcomes. This is an IRB approved retrospective review from a single institution (inner city hospital) on adults undergoing appendectomy from 2008 to 2017. Demographics and 30-day complications were analyzed with univariate and multivariate logistic regression analyses. Total of 558 appendectomies were reviewed. 151 (27.36%) appendectomies were performed by FT surgeons (MIS/CRS), 401 (72.64%) performed by GS. No difference in age, ASA, BMI, race, gender, insurance status, smoking, diabetes mellitus (DM), or hypertension was found. Also, similar rates of non-iatrogenic perforated appendicitis were seen (16.37% GS vs 20% FT, p = 0.318). For major complications, no difference was found between GS and FT (p = 0.63). However, appendectomies performed by GS showed higher rates of post-op ileus (3.99% vs 0.66%, p = 0.04), higher conversion to open (7.55% vs 2.67%, p = 0.039), higher rates of choosing an open approach (17.46% vs 0.66%, p =

Enhanced recovery after surgery (ERAS) programs for patients undergoing colorectal surgery has yielded promising results. However, there remains controversy regarding the application of ERAS protocols in an elderly population. The aim of this review is to compare the clinical outcomes between ERAS versus conventional peri-operative care (Non-ERAS) for colorectal surgery in patients aged ≥ 65 years old. The PRISMA guidelines were adhered to. A comprehensive search was performed using Medline, Embase and the Cochrane Library electronic databases and relevant articles were identified. Indications for the colorectal resections included both benign and malignant diseases, while emergency surgeries were excluded. Primary outcomes include post-operative morbidity, length of stay and re-admission rates. Data analysis was performed using Revman 5.3. A total of six studies were included, which involved a total of 1174 patients. ERAS was associated with a lower incidence of post-operative morbidity compared to Non-ERAS (OR 0.38, 95% CI 0.25–0.59), p

Background Long-term evaluations 10 years after Roux-en-Y gastric bypass (RYGB) are limited. We report the development in weight and cardiovascular risk factors during 10 years after laparoscopic RYGB, with evaluation of gastrointestinal symptoms and quality of life (QoL) at 10-year follow-up. Methods We performed a prospective longitudinal cohort study. Patients operated with laparoscopic RYGB from May 2004 to November 2006 were invited to 10-year follow-up consultations. Gastrointestinal Symptom Rating Scale (GSRS) questionnaire and two QoL questionnaires were used for analyses of gastrointestinal symptoms and QoL. Results A total of 203 patients were operated; nine (4.4%) died during follow-up. Of 194 eligible patients, 124 (63.9%) attended 10-year follow-up consultations. Percent excess weight loss (%EWL) and percent total weight loss (%TWL) at 10 years were 53.0% and 24.1%, respectively. %EWL > 50% was seen in 53.2%. Significant weight regain (≥15%) from 2 to 10 years was seen in 63.3%. Remission rates of type 2 diabetes, dyslipidemia, and hypertension were 56.8%, 46.0%, and 41.4%, respectively. Abdominal operations beyond 30 days after RYGB were reported in 33.9%. Internal hernia and ileus (13.7%) and gallstone-related disease (9.7%) were the most common causes. Vitamin D deficiency ( Conclusion We observed significant weight loss and remission of comorbidities 10 years after RYGB. Significant weight regain occurred in a substantial subset of patients. Gastrointestinal symptoms were common and negatively impacted QoL.

Post-operative ileus and delayed return of gastrointestinal function are complications seen frequently in patients undergoing colorectal surgery. Many enhanced recovery after surgery protocols include alvimopan to inhibit the effects of opiates in the gastrointestinal tract and lidocaine to augment analgesics. Limited data exist regarding alvimopan's efficacy in opiate-sparing regimens.This single-center, retrospective cohort analysis was conducted in a randomly selected population of adult patients undergoing colorectal resection between February 2018 and October 2019. Patients meeting inclusion criteria were divided into four groups dependent upon whether or not they received alvimopan (A or a) and/or lidocaine (L or l). The primary endpoint in this study was median time to first bowel movement or discharge, whichever came first. Our secondary endpoint was length of stay.Of the 430 patients evaluated, a total of 192 patients were included in the final evaluation in the following groups: AL (n = 93), Al (n = 34), aL (n = 44), and al (n = 21). A significant difference was found among the groups for the primary outcome of median time to bowel movement or discharge (p = 0.001). Three subsequent pair-wise comparisons resulted in a significant difference in the primary outcome: group AL 39.4 h vs. group aL 54.0 h (p = 0.003), group AL 39.4 h vs. group al 55.4 h (p = 0.001), and group Al 44.9 h vs. group al 55.4 h (p = 0.01). Length of stay was significantly reduced by 1.8 days in groups AL and Al compared to group aL (p 0.001).Treatment with alvimopan resulted in a significant improvement in time to GI recovery and decreased length of stay in an established ERAS program. While lidocaine's reduction in opiates was minimal, the group receiving both alvimopan and lidocaine had the greatest reduction in time to GI recovery and length of stay.

Postoperative ileus (POI) is common after gastrointestinal surgery and is associated with significant morbidity and costs. However, POI is poorly defined. The I-FEED score is a novel outcome measure for POI, developed by expert consensus. It contains five elements (intake, response to nausea treatment, emesis, exam, and duration, each scored with 0, 1, or 3 points) and classifies patients into normal, postoperative gastrointestinal intolerance (POGI), and postoperative gastrointestinal dysfunction (POGD). However, it has not yet been validated in a clinical context. The objective was to provide validity evidence for the I-FEED score to measure the construct of POI in patients undergoing colorectal surgery. Data previously collected from a clinical trial investigating the impact of different perioperative fluid management strategies on primary POI in patients undergoing elective laparoscopic colectomy (2013–2015) were analyzed. Patients were managed by a longstanding Enhanced Recovery program (expected length of stay (LOS): 3 days). Daily I-FEED scores were generated (normal 0–2, POGI 3–5, POGD 6+ points) up to hospital discharge or postoperative day 7. Validity was assessed by testing the hypotheses that I-FEED score was higher (1) in patients with longer time to GI3 (tolerating diet + flatus/bowel movement), (2) with longer LOS (> 3 days vs shorter), (3) in patients with complications vs without, (4) in patients with poorer recovery (measured by Quality of Recovery-9 questionnaire). A total of 128 patients were included for analysis (mean age 61.7 years (SD 15.2), 57% male, 71% malignancy, and 39.1% rectal resection). Median LOS was 4 days [IQR3–5], and 32% experienced postoperative in-hospital morbidity. Overall, 48% of patients were categorized as normal, 22% POGI, and 30% POGD. The data supported all 4 hypotheses. This study contributes preliminary validity evidence for the I-FEED score as a measure for POI after colorectal surgery.

Postoperative ileus (POI) is regarded as the most clinically significant morbidity following loop ileostomy closure; however, its incidence remains poorly understood. Our objective was therefore to determine the pooled incidence of POI after loop ileostomy closure and identify risk factors associated with its development. We systematically searched MEDLINE (via Ovid and PubMed), Embase, the Cochrane Library, Biosis Previews, and Scopus to identify studies reporting the incidence of POI in patients who underwent loop ileostomy closure. Two independent reviewers extracted data and appraised study quality. Cumulative incidence proportions were pooled across studies using a random-effects meta-analytic model. Sixty-seven studies, including 9528 patients, met our inclusion criteria. The pooled estimate of POI was 8.0% (95% CI 6.9–9.3%; I2 = 74%). The estimated incidence varied by POI definition: studies with a robust definition of POI (n = 8) demonstrated the highest estimate of POI (12.4%, 95% CI 9.2–16.5%; I2 = 79%) while studies that did not report an explicit POI definition (n = 38) demonstrated the lowest estimate (6.7%, 95% CI 5.3–8.3%; I2 = 61%). Small bowel anastomosis technique (hand-sewn) and interval time from ileostomy creation to closure (longer time) were the factors most commonly associated with POI after loop ileostomy closure. However, most comparative studies were not powered to examine risk factors for POI. POI is an important complication after loop ileostomy closure, and its incidence is dependent on its definition. More research aimed at studying this complication is required to better understand risk factors for POI after loop ileostomy closure.

Over the last three decades, laparoscopic appendicectomy (LA) has become the routine treatment for uncomplicated acute appendicitis. The role of laparoscopic surgery for complicated appendicitis (gangrenous and/or perforated) remains controversial due to concerns of an increased incidence of post-operative intra-abdominal abscesses (IAA) in LA compared to open appendicectomy (OA). The aim of this study was to compare the outcomes of LA versus OA for complicated appendicitis. A systematic literature search following PRISMA guidelines was conducted using MEDLINE, EMBASE, PubMed and Cochrane Database for randomised controlled trials (RCT) and case–control studies (CCS) that compared LA with OA for complicated appendicitis. Data from three RCT and 30 CCS on 6428 patients (OA 3,254, LA 3,174) were analysed. There was no significant difference in the rate of IAA (LA = 6.1% vs. OA = 4.6%; OR = 1.02, 95% CI = 0.71–1.47, p = 0.91). LA for complicated appendicitis has decreased overall post-operative morbidity (LA = 15.5% vs. OA = 22.7%; OR = 0.43, 95% CI: 0.31–0.59, p

The hybrid approach to abdominal wall reconstruction (AWR) for abdominal wall hernias combines minimally invasive posterior component separation and retromuscular dissection with open fascial closure and mesh implantation. This combination may enhance patient outcomes and recovery compared to the open approach alone. The purpose of this study is to evaluate the operative outcomes of hybrid vs. open abdominal wall reconstruction.A retrospective review was conducted to compare patients who underwent open versus hybrid AWR between September 2015 and August of 2018 at Anne Arundel Medical Center. Patient demographics and perioperative data were collected and analyzed using univariate analysis.Sixty-five patients were included in the final analysis: 10 in the hybrid and 55 in the open groups. Mean age was higher in the hybrid vs. open group (65.1 vs. 56.2 years, p 0.05). The hybrid and open groups were statistically similar (p 0.05) in gender distribution, mean BMI, and ASA score. Intraoperative comparison found hybrid patients parallel to open patients (p 0.05) in mean operative time (294.5 vs. 267.5 min), defect size (14.4 vs. 13.6 cm), mesh area, and drain placement. The mean total hospital cost was lower in the hybrid group compared to the open group ($16,426 vs. $19,054, p = 0.43). The hybrid group had a shorter length of stay (5.3 vs. 3.6 days, p = 0.03) after surgery and was followed for a similar length of time (12.3 vs. 12.6 months, p = 0.91). The hybrid group showed a lower trend of seroma, hematoma, wound infection, ileus, and readmission rates after surgery.A review of patient outcomes after hybrid AWR highlights a trend towards shorter length of stay, lower hospital cost, and fewer complications without significant addition to operative time. Long-term studies on a larger number of patients are definitively needed to characterize the comprehensive benefits of this approach.

Right hemicolectomy is a very common surgery. Many studies compare different options for laparoscopic ileocolic anastomoses: intra- or extracorporeal; handsewn or stapled; side-to-side or end-to-side. However, there are no studies about the influence that peristalsis could have on this anastomosis. The aim of this study is to compare safety and feasibility of isoperistaltic and antiperistaltic anastomosis in terms of postoperative morbidity and mortality between both groups. The secondary endpoint is to compare long-term functional outcomes (chronic diarrhoea) and quality of life (GIQLI questionnaire) after a 1-year follow-up period. A double-blind, randomised, prospective trial in patients undergoing scheduled surgery for right colon cancer with laparoscopic right hemicolectomy and isoperistaltic (ISO) or antiperistaltic (ANTI) ileocolic anastomoses. Hundred and eight patients were included in the study. Patients were randomised either to isoperistaltic or antiperistaltic configuration (54 ISO/ANTI). No significant differences in baseline variables were found. No differences in surgical time (130 [120–150] min ISO vs. 140 [127–160] ANTI, p = 0.481), nor in anastomotic time (19 [17–22] vs. 20 [16–25], p = 0.207) and nor in postoperative complications: 37.0% ISO versus 40.7% ANTI, (p = 0.693) were found. There were no differences in postoperative ileus (p = 0.112) nor in anastomotic leakage (3.7% vs. 5.56%, p = 1.00). Differences in “time to first flatus” and “time to first deposition” were found in favour of the antiperistaltic group (p = 0.004 and p = 0.017). Anastomotic configuration did not influence hospital stay (3 days [2–6] isoperistaltic vs. 3 [2–4] antiperistaltic, p = 0.236). During follow-up, there were no differences between the two groups at 1, 6 and 12 months (p = 0.154, p = 0.498 and p = 0.683), nor in chronic diarrhoea rates in GIQLI scores (24% ISO vs. 31.4% ANTI, p = 0.541). The isoperistaltic and antiperistaltic ileocolic anastomosis present similar results in terms of performance, safety and functionality. However, further studies must be carried out in order to assess relationship between postoperative ileus and anastomosis configuration. Randomised Clinical trial (Identifier: NCT02309931).

The robotic platform in pancreatic disease has gained popularity in the hepatobiliary community due to significant advantages it technically offers over conventional open and laparoscopic techniques. Despite promising initial studies, there remains scant literature on operative and oncologic outcomes of robotic pancreaticoduodenectomy (RPD) for pancreatic adenocarcinoma. A retrospective review evaluated all RPD performed for pancreatic adenocarcinoma from 2008 to 2019 in a single tertiary institution. RPD cases were matched to open cases (OPD) by demographic and oncologic characteristics and outcomes compared using Mann–Whitney U test, log rank tests, and Kaplan–Meier methods. Thirty-eight RPD cases were matched to 38 OPD. RPD had significantly higher lymph node (LN) yield (21.5 vs 13.5; p = 0.0036) and no difference in operative time or estimated blood loss (EBL). RPD had significantly lower rate of delayed gastric emptying (DGE) (3% vs 32%; p = 0.0009) but no difference in leaks, infections, hemorrhage, urinary retention ,or ileus. RPD had significantly shorter length of stay (LOS) (7.5 vs. 9; p = 0.0209). There were no differences in 30- or 90-day readmissions or 90-day mortality. There was an equivalent R0 resection rate and LN positivity ratio. There was a trend towards improved median overall survival in RPD (30.4 vs. 23.0 months; p = 0.1105) and longer time to recurrence (402 vs. 284 days; p = 0.7471). OPD had two times the local recurrent rate (16% vs. 8%) but no difference in distant recurrence. While the feasibility and safety of RPD has been demonstrated, the impact on oncologic outcomes had yet to be investigated. We demonstrate that RPD not only offers similar if not superior immediate post-operative benefit by decreasing DGE but more importantly may offer improved oncologic outcomes. The significantly higher LN yield and decreased inflammatory response demonstrated in robotic surgery may improve overall survival.

Background Although the use of laparoscopic resection for colon cancer (LRC) has been increasing, conversion to open surgery sometimes becomes necessary because of intraoperative difficulties. Although the Glasgow prognostic score (GPS) is well known to be a predictor of outcome in patients with various cancers, it is unclear whether the preoperative GPS can predict the need for conversion from laparoscopic to open surgery. Objective To investigate factors predictive of conversion from laparoscopic to open surgery in patients with colon cancer. Methods Data from 308 consecutive patients who underwent LRC between January 2006 and March 2017 were retrospectively enrolled. Preoperative clinical factors in patients who had undergone LRC were compared between conversion and non-conversion groups, and multivariate regression analysis was performed to identify preoperative factors that might predict conversion from laparoscopic to open surgery. Results Among 308 patients who had undergone LRC, conversion to open surgery was necessary in 28 (9.1%). Sixteen of the latter patients (6.8%) had GPS 0 (among a total of 234) and 6 (11.5%) had GPS 1 (among a total of 52). The proportion of patients with GPS 2 who required conversion was 27.2% (6/22), which was significantly higher than for those with GPS 0 or 1. Multivariate analysis demonstrated that GPS 2 (odds ratio [OR] 3.352; 95% confidence interval [CI] 1.049–10.71; p = 0.041) and preoperative ileus (OR 7.405; 95% CI 2.386–22.98; p = 0.001) were independent factors predictive of conversion from laparoscopic to open surgery. Conclusions A high preoperative GPS is an independent factor predictive of conversion from laparoscopic to open surgery in patients with colon cancer.

Prolonged postoperative ileus (PPOI) is a common complication after colorectal resection but data regarding PPOI risk factors after laparoscopic rectal cancer surgery is lacking. This study aimed to identify risk factors for PPOI after laparoscopic sphincter-saving total mesorectal excision (TME) for cancer.All patients who underwent a laparoscopic sphincter-saving TME for cancer from 2005 to 2014 were identified from our prospective database. PPOI was defined as abdominal distension, nausea, and/or vomiting, requiring a nasogastric tube insertion, during the postoperative period.Among 428 consecutive patients, 65 patients (15%) presented with POI. In multivariate analysis, male gender (Odds Ratio (OR) 2.3 [1.1-4.5]; p = 0.026, age70 years (OR: 2.0 [1.1-4.0]; p = 0.037)], conversion to open approach (OR 4.9 [1.5-15.4]; p = 0.007), and intra-abdominal surgical site infection (OR 3.8 [1.9-7.5]; p 0.001) were identified as independent risk factor for PPOI. PPOI risk was 5% in patients without any risk factor but raised to 11, 28, and 54% in patients with 1, 2, or ≥3 risk factors, respectively (p 0.001).PPOI is observed in 15% of the patients after laparoscopic sphincter-saving surgery for rectal cancer. We identified four independent factors for PPOI in multivariate analysis: male, gender, age70, conversion to open approach, and intra-abdominal surgical site infection, leading to the construction of a simple and pragmatic predictive score. This score might help the surgeon to assess patient at risk of PPOI.

Restoration of intestinal continuity after Hartmann’s procedure is a technically difficult surgery associated with significant morbidity and mortality. This study presents the short-term results of a new approach: a transanal Hartmann’s colostomy reversal assisted by laparoscopy. This is a retrospective analysis of data collected in one tertiary hospital, from October 2013 to November 2015. During the study period, there were ten cases of transanal Hartmann’s reversal. Reasons for Hartmann’s procedure were: complicated diverticulitis (4), anastomotic leak (3), and recto-sigmoid cancer (3). Rectal stump length was 10.4 ± 4.5 cm. Reconstruction was achieved in all patients. One low colorectal anastomosis was hand-sewn, the other 9 were stapled. Mean operative time was 204 ± 65 min. Diverting loop ileostomies were created in five patients and all were closed during the following year. One case required hand-assistance but there was no conversion to open surgery. Iatrogenic laparoscopic enterotomies occurred in four patients and all were repaired primarily without consequences. Three patients had a total of four post-operative complications: ileus (2), abdominal abscess and wound infection (1). None required reoperation. Mean length of stay was 7.2 ± 4.3 days. One required readmission. A transanal Hartmann’s reversal assisted by laparoscopy is a new approach for a difficult surgery. It has the potential to be an additional tool in the case of hostile pelvises or with a rectal stump difficult to identify. The surgery remains challenging and indications need to be clarified.

Although laparoscopic surgery significantly reduces surgical trauma compared to open surgery, postoperative ileus is a frequent and significant complication after abdominal surgery. Unlike laparoscopic colorectal surgery, the effects of epidural analgesia on postoperative recovery after laparoscopic gastrectomy are not well established. We compared the effects of epidural analgesia to those of conventional intravenous (IV) analgesia on the recovery of bowel function after laparoscopic gastrectomy. Eighty-six patients undergoing laparoscopic gastrectomy randomly received either patient-controlled epidural analgesia with ropivacaine and fentanyl (Epi PCA group) or patient-controlled IV analgesia with fentanyl (IV PCA group), beginning immediately before incision and continuing for 48 h thereafter. The primary endpoint was recovery of bowel function, evaluated by the time to first flatus. The balance of the autonomic nervous system, pain scores, duration of postoperative hospital stay, and complications were assessed. The time to first flatus was shorter in the epidural PCA group compared with the IV PCA group (61.3 ± 11.1 vs. 70.0 ± 12.3 h, P = 0.001). Low-frequency/high-frequency power ratios during surgery were significantly higher in the IV PCA group, compared with baseline and those in the epidural PCA group. The epidural PCA group had lower pain scores during the first 1 h postoperatively and required less analgesics during the first 6 h postoperatively. Compared with IV PCA, epidural PCA facilitated postoperative recovery of bowel function after laparoscopic gastrectomy without increasing the length of hospital stay or PCA-related complications. This beneficial effect of epidural analgesia might be attributed to attenuation of sympathetic hyperactivation, improved analgesia, and reduced opioid use.

The objective of this study was to determine whether right-sided colectomies (RC) were associated with a higher incidence of primary postoperative ileus (pPOI) compared to left-sided colectomies (LC).Patients who underwent elective colectomy for neoplastic disease between 2012 and 2016 were identified using the American College of Surgeons National Surgical Quality Improvement Program database. RC and LC were defined as having an ileocolic or colocolic/colorectal anastomosis, respectively. Coarsened Exact Matching (CEM) was used to balance the two groups (1:1) on important confounders. The association between type of colectomy and pPOI, defined as POI in the absence of intra-abdominal sepsis, was then assessed in a multiple logistic regression analysis of the matched data.Of 40,636 patients who underwent a colectomy for neoplastic disease, 15,231 underwent a RC and 25,405 a LC. After CEM, 12,949 matched patients remained in each group, and all important confounders were well balanced. The incidence of pPOI was higher in the RC group (11.5% vs. 8.8%, p 0.001). On multiple logistic regression, RC was associated with a 35% higher odds of developing pPOI compared to LC (OR 1.35, 95% CI 1.25-1.47). RC was also associated with increased risk for NSQIP-defined major morbidity (OR 1.10, 95% CI 1.01-1.20), 30-day readmission (OR 1.16, 95% CI 1.06-1.27), and increased length of stay (β = 0.16 days, 95% CI 0.11-0.22).pPOI is more common after RC than LC. Future research should aim at better understanding the pathophysiology behind this increased risk and identifying interventions to mitigate pPOI in this population.

Delayed gastrointestinal (GI) recovery remains a significant morbidity after colorectal surgery. Intracorporeal anastomosis for right colectomy may hasten GI recovery. Therefore, the objective of this study was to determine the effect of intracorporeal versus extracorporeal anastomosis on GI recovery after elective laparoscopic right colectomy within an established ERAS program. Adult patients undergoing elective laparoscopic right colectomy at a single high-volume institution from 07/2014 to 12/2018 were reviewed. Patients were divided into two groups: intracorporeal (IC) and extracorporeal (EC). The primary outcome was time to GI-3 defined as days to tolerance of solid diet and first flatus/bowel movement. Prolonged postoperative ileus (PPOI) was defined as GI-3 not met by postoperative day 4. Secondary outcomes were length of stay (LOS) and overall 30-day complications. Sensitivity analysis was performed using coarsened exact matching to account for unmeasured confounding. Multiple regression was performed using a Cox proportional hazard model to identify predictors of GI recovery. A total of 346 patients were reviewed, of which 226 were included (71IC, 155EC). Patient characteristics were well balanced between groups: mean age was 64.9 years (SD 15.9), BMI was 26.3 (SD 5.7), 38.1% of patients had ASA ≥ 3, and 78.3% underwent surgery for neoplasms. IC anastomosis was associated with longer operative duration (165 min (SD 40); 144 min (SD 48), p = 0.002). There was no difference in the median time to GI-3 (IC 2 days [IQR1-2]; EC 2 days [IQR2-3], p = 0.135). The incidence of PPOI (IC 8.5%; EC 10.3%, p = 0.659), superficial SSI (4.2% vs. 5.8%, p = 0.757), deep SSI (2.8% vs. 5.2%, p = 0.729), and median LOS (3 days [IQR 2–4] vs. 3 [IQR 3–5], p = 0.059) were also similar. On multivariate analysis, IC anastomosis did not independently predict faster GI recovery (HR 0.98, 95% CI 0.71–1.34). Similar results were observed in the matched cohort (185 patients (61IC, 124EC)). In this study, IC anastomosis was not associated with faster GI recovery or reduced complication rate compared to EC anastomosis. Longer term studies may be required to determine the potential benefits of IC anastomosis.

The aim of this study was to determine whether early laparoscopic cholecystectomy (LC) is safe and feasible for patients diagnosed with moderate (grade 2) and severe (grade 3) acute cholecystitis (AC) according to the Tokyo Guidelines 2013 (TG13). Early cholecystectomy is the current accepted standard of care for patients with mild (grade 1) and selected grade 2 AC based on TG13. For selected grade 2 and grade 3 AC, early percutaneous cholecystostomy (PC) followed by delayed cholecystectomy is recommended. Patients diagnosed with AC over a 14-month period were identified and divided into three grades of AC based upon chart review using the grading and severity indicators according to TG13. A total of 149 patients underwent emergency LC. Eighty-two (55 %) patients were male. Eighty-four (56.4 %) patients were classified as grade 1 AC, 49 (32.9 %) as grade 2, and 16 (10.7 %) as grade 3. Eighty-three (98.8 %) patients with grade 1 AC underwent emergency LC, and 1 patient (1.2 %) underwent PC followed by emergency LC. The median length of hospital stay for grade 1 AC patients was 2 (1–11) days. There were 2 (2.4 %) readmissions with fever and no additional complications. Among the 65 patients identified with grade 2 or 3 AC, 6 (9.2 %) underwent PC followed by emergency LC. Fifty-nine (90.8 %) patients underwent emergency cholecystectomy: 58 (98.3 %) LC and one (1.7 %) open cholecystectomy. Among the 58 patients with LC, 3 (5.2 %) patients had open conversion and 10 (17.2 %) patients required subtotal cholecystectomy. One patient was converted to open due to bile duct injury and had hepaticojejunostomy repair. Two other patients were converted due to dense adhesions and inability to safely dissect Calot’s triangle. The median length of hospital stay was 4 (1–28) days. There was one readmission for ileus. Severity grading of AC is not the sole determinant of early LC. Patient comorbidity also impacts clinical decision. Confirmation in a larger cohort is warranted.

The clinical outcomes for postoperative complications (PCs) after gastrectomy depend on early diagnosis and intensive treatment. The aim of this study was to investigate the role of C-reactive protein (CRP) as an early predictor of PCs after gastrectomy for gastric cancer.A total of 334 consecutive patients who underwent gastrectomy for gastric cancer in 2014 were enrolled in this study. Blood samples were obtained preoperatively, and at postoperative days 1 and 4 for the measurement of inflammatory markers (white blood cell, neutrophil, and platelet counts, and CRP). Patients were classified into groups of major and minor/no PCs, which were defined as patients with PCs of more than grade III and those with grade I/II or without PCs, respectively, according to the Clavien-Dindo classification.Twenty-five patients developed major PCs. The CRP on postoperative day 4 provided superior diagnostic accuracy in predicting major PCs compared to the other systematic inflammatory markers. Multivariate analysis identified a CRP level of 16.8 mg/dl or greater on postoperative day 4 as a significant predictive factor for major PCs.Among the various systemic inflammatory markers, CRP on postoperative day 4 is the most reliable predictor of PCs after gastrectomy for gastric cancer.

Superior mesenteric artery syndrome (SMAS) is a rare condition caused by partial obstruction of the third portion of the duodenum by the SMA anteriorly and aorta posteriorly. Laparoscopic duodenojejunostomy has been described as a safe and feasible surgical intervention with favorable short-term outcomes. However, descriptions of intermediate outcomes are lacking in the literature. A retrospective chart review was performed on patients who underwent minimally invasive duodenojejunostomy from March 2005 to August 2015 at our healthcare system with greater than 6-month follow-up. Eighteen patients with mean age of 31.2 were identified. There were 4 men and 14 women. Patients’ diagnosis was made by clinical presentation with radiographic confirmation. Mean weight loss preoperatively was 13.9 kg, representing 24.1 % total body weight loss. There were no intraoperative complications. Postoperatively, 2 patients developed prolonged ileus. One underwent exploratory laparotomy and washout for presumed leak, but none was identified. Three patients were readmitted within 30 days; 2 for intolerance to enteral intake with dehydration, and 1 for closed-loop obstruction requiring laparoscopic lysis of adhesions. The average and median length of follow-up were 27.7 and 26.0 months, respectively. Patients gained an average of 2.2 kg with an increase in body mass index of from 19.6 to 20.4 m/kg2. Although 14 of 18 patients reported initial symptom improvement, at latest follow-up, only 6 patients reported symptomatic improvement or resolution. Three were diagnosed with global dysmotility, and 1 underwent intestinal transplant. Two were diagnosed with gastroparesis, and 1 underwent a laparoscopic gastric electric stimulator placement and pyloroplasty. There were no mortalities. Duodenojejunostomy is the most common surgical intervention in management of SMAS. Our intermediate follow-up reveals infrequent improvement and rare resolution of preoperative symptomatology. Patients had a modest average weight gain postoperatively. This may suggest that different preoperative workup and treatment is indicated.

Few data are available on TAP block in laparoscopic colorectal surgery and ERAS program. The aim of this prospective study was to evaluate local wound infiltration plus TAP block compared to local wound infiltration in the management of postoperative pain, nausea and vomiting, ileus and use of opioids in the context of laparoscopic colorectal surgery and ERAS program. From March 2014 to March 2015, 48 patients were treated by laparoscopic resection and ERAS program for colorectal cancer and diverticular disease at the Division of General and Hepatobiliary Surgery, University of Verona Hospital Trust. Among these, 24 patients received local wound infiltration plus TAP block (TAP block group) and 24 patients received local wound infiltration (control group). No differences were observed in baseline patient characteristics, clinical variables and surgical procedures between the two groups. Local wound infiltration plus TAP block allowed to achieve pain control despite a reduced use of opioid analgesics (P = 0.009). The adoption of TAP block resulted beneficial on the prevention of postoperative nausea (P = 0.002) and improvement of essential outcomes of ERAS program as recovery of bowel function (P = 0.005), urinary catheter removal (P = 0.003) and capability to tolerate oral diet (P = 0.027). TAP block plus local wound infiltration in the setting of laparoscopic colorectal surgery and ERAS program guarantees a reduced use of opioid analgesics and good pain control allowing the improvement of essential items of enhanced recovery pathways.

Laparoscopic right colectomy with intracorporeal anastomosis is a procedure of increasing popularity. This study aims to compare short- and long-term outcomes of intracorporeal and extracorporeal anastomoses. This is a comparative study of two anastomosis techniques for laparoscopic right hemicolectomy. A total of 191 consecutive patients, operated for neoplasm of the right colon, were identified. The intracorporeal group included 91 patients and the extracorporeal group 100 patients. Patient demographics and disease-related characteristics were similar. Mean operative time was longer in the intracorporeal group (155 vs. 142 min; P = 0.006). Intracorporeal anastomosis was associated with less overall postoperative complications (18.7 vs. 35 %, P = 0.011) and decreased rate of surgical site infections (4.4 vs. 14 %, P = 0.023). The need for postoperative intervention (Clavien–Dindo 3) was higher in the extracorporeal group (7 vs. 0 %; P = 0.015). There was no statistically significant difference in the incidence of postoperative leak, ileus and bleeding. Mean length of stay was significantly shorter in the intracorporeal group (5.9 ± 2.1 vs. 6.9 ± 3.0; P = 0.04). Moreover, more patients with intracorporeal anastomosis had a length of stay shorter than 4 days (28.6 vs. 14.1 %, P = 0.015). Extraction incision was periumbilical in 99 % of the patients in the extracorporeal group. In the intracorporeal group extraction, incision was transverse suprapubic (Pfannenstiel) in 85.7 %, transvaginal in 9.9 % and periumbilical in 3.3 % of the patients. The incidence rate of incisional hernia was lower in the intracorporeal group (2.2 vs. 17.0 %, P = 0.001). Laparoscopic right hemicolectomy with intracorporeal anastomosis is associated with improved short- and long-term outcomes. The rates of postoperative complications requiring intervention and incisional hernias are decreased.

Previous assessments of the impact of epidural analgesia (EA) on outcomes after colorectal surgery were related to the period before widespread implementation of the enhanced recovery after surgery (ERAS) protocols. This study evaluates the impact of EA on postoperative recovery after colectomy using recent multicenter data. Patients who underwent elective colectomy from the American College of Surgeons (ACS) National Surgical Quality Improvement Program (NSQIP) data (2014–2015) were identified. Demographics, comorbidities, diagnosis, procedure type and approach, and postoperative complications associated with EA were assessed. Impact of EA on postoperative ileus, length of stay (LOS), and prolonged LOS (defined as LOS > 75 percentile) was evaluated for all, open, and laparoscopic cases using univariable and multivariable analyses. Of 9045 elective colectomy procedures, 3081 (34.1%) received EA. Epidural analgesia was associated with greater rates of postoperative ileus (15.9% vs. 10.8%, p

LSG is widely accepted as a definitive treatment for obesity. Due to lack of large series with long-term follow-up, disagreement remains regarding its safety and efficacy. We present a series of 1020 consecutive LSGs performed with long-term follow-up.A retrospective review of a prospectively collected database was conducted on patients who underwent LSG from January 2005 to February 2014. Data included weight, height, BMI, ideal body weight, comorbid conditions, intraoperative complications, mean length of hospital stay (LOS), early (30 days) readmission, early and late (30 days) postoperative complications, and percentage of excess weight loss (%EWL).Of the 1020 patients, 66.6 % (n = 679) were female, with a mean age of 38.4 ± 16.5 years. Mean BMI at the time of first visit was 43.4 ± 5.8 kg/m(2). The most common comorbid conditions identified were diabetes mellitus (89.4 %), sleep apnea (86.4 %), hypertension (80.3 %), and hyperlipidemia (70 %). Over the entire follow-up period, 57 % of diabetic patients experienced significant improvement or remission. There was no mortality in this series. Early postoperative complications within 30 days of surgery included leak in 0.1 % (n = 1), stricture in 0.1 % (n = 1), emesis in 23 % (n = 234), dehydration in 19 % (n = 194), prolonged ileus in 18 % (183), and self-limited bleeding in 3 % (n = 30). Mean LOS was of 3.4 ± 2.1 days, with a 3.8 % overall rate of early readmissions. Long-term morbidity was found in 3.9 % of patients (n = 40) and included stricture in 0.49 % (n = 5) and GERD in 6 % (n = 61). The overall 30-day mortality rate was 0 %. Mean %EWL at 3 months to 1, 3, 5, and 8 years was 72 ± 16.8, 86 ± 22.3, 63 ± 19, 61 ± 11, and 52 ± 9.2, respectively.This study confirms that LSG is safe and has very low rates of early and long-term complications when compared to other well-established procedures. Additionally, LSG that appears results in significant improvement of obesity-related comorbid conditions.

Background/aim: Laparotomy has been the approach of choice for re-operations in patients with surgical complications. The aim of this retrospective analysis was to evaluate the feasibility and the safety of laparoscopic approach for the management of general abdominal surgery complications. Materials and methods: We report a retrospective review of 75 patients who underwent laparoscopic evaluation for postoperative complications over a 4-year period. Primary outcomes (resolution rate by exclusive laparoscopic approach, conversion rate, further surgery rate) and secondary outcomes (mortality, hospitalization, prolonged ileus, wounds problems and median operative time) were evaluated. Results: Sixty-six patients (88 %) were managed with laparoscopic approach without conversion; of these, sixty-three patients (84 %) had no more or further complications and were discharged from hospital between 4 ± 3 days after “second-look” surgery; three patients (4 %) developed postoperative complications requiring a third surgery. Nine cases (12 %) underwent conversion in open surgery after laparoscopic approach. Two elderly patients (2.7 %) died in intensive care unit, because of multi-organ failure syndrome. Median time elapsed between an intervention and another was about 2.5 ± 9.5 days. Mean operative time was 90 ± 150 min. Postoperative hospital stay was between 4.5 and 18 days. Discussion and conclusion: Laparoscopy has begun to be the preferred method to manage postoperative problems, but only few reports are available actually. Our experience in “relaparoscopic” management of surgical complications seems to suggest that laparoscopy “second look” is an effective tool after open or laparoscopic surgery for the management of postoperative complications and it may avoid diagnostic delay and further laparotomy and related problems.

Although enhanced recovery programs (ERPs) have been proven to be beneficial after laparoscopic colon surgery, they may result in adverse clinical outcomes following failure. This study analyzed risk factors associated with ERP failure after laparoscopic colon cancer surgery. We analyzed the outcomes of 208 patients who underwent ERPs following laparoscopic colon cancer surgery between June 2007 and April 2013. The ERP included early oral feeding, early ambulation, and regular laxative administration. ERP failure was defined as postoperative hospital stay of more than 5 days related to postoperative complications, unplanned readmission within 30 days of surgery, or death. Surgical procedures included anterior resection (n = 101), right hemicolectomy (n = 90), and left hemicolectomy (n = 17). The mean postoperative hospital stay was 6.5 ± 2.3 days (range 3–24 days). ERP failure occurred in 36 patients (17.3 %), with no mortality; reasons included ileus (n = 14), wound infection (n = 4), chylous drainage (n = 3), anastomotic bleeding (n = 3), pneumonia (n = 1), or readmission (n = 11) owing to delayed complications. Univariable analysis showed that ERP failure was associated with proximal colon cancer, side-to-side anastomosis, longer operation time, increased blood loss, and longer resected specimen length. Multivariable analysis showed that side-to-side anastomosis [odds ratio (OR) 4.534; 95 % confidence interval (CI) 1.902–10.811; P = 0.001] and increased blood loss (OR 1.004; 95 % CI 1.001–1.008; P = 0.041) were independent risk factors for ERP failure. We showed that increased blood loss and side-to-side anastomosis in comparison with end-to-end anastomosis were independent risk factors associated with ERP failure after laparoscopic colon cancer surgery. This suggests that intraoperative elements may be important determinants to obtain successful postoperative recovery in the era of ERP.

The ideal incision for laparoscopic specimen extraction is not known. There has been no randomised study thus far evaluating extraction site in laparoscopic colorectal surgery. The aim of our study was to compare post-operative outcomes, pain scores and quality of life scores of vertical periumbilical (VW) versus transverse left iliac fossa (TW) incisions for specimen extraction in laparoscopic anterior resections. Using an assumption of pain score of 5 in the VW group versus pain score of 2 in the TW group, on day one post-operatively, and based on a 80 % statistical power of analysis to achieve a statistical difference with reduction in pain scores, the sample size per arm calculated was 16. Forty patients undergoing laparoscopic anterior resection were randomised to VW (n = 20) or TW (n = 20). Primary endpoint was post-operative pain. Secondary endpoints were post-operative outcomes, wound cosmesis using Hollander Cosmesis Score and quality of life assessment using EQ-5D at 2 weeks and 2 months post-operatively. Median pain score on the first post-operative day was 2 in both groups (p = 0.360). There was no significant difference in wound infection rates, operative time or post-operative recovery. Cosmesis scores and EQ-5D scores were also similar in both groups. At a median follow-up of 30 months, the incidence of extraction site incisional hernia was similar. Transverse and vertical incisions in laparoscopic colorectal surgery have similar post-operative outcomes, with similar pain scores, cosmesis scores, quality of life scores and incisional hernia rates.

We hypothesized that administration of IV acetaminophen alone would reduce the opioid consumption in post-operative colorectal surgery and reduce the side effects of narcotics. Patients were randomized to receive either IV acetaminophen or placebo in addition to opioid PCA. Primary endpoints evaluated were opioid consumption and pain visual analogue scale score (PVASS) during first 48 h post-operatively. Secondary endpoints evaluated were time of return of GI function (ROGIF), time to diet ordered (TTDO), length of hospital stay (LOHS), and occurrence of ileus. 105 patients were enrolled and 97 remained in the study after exclusion (control group n = 50; study group n = 47). Mean ± SEs of opioid consumption in the study group was 21.5 ± 1.8 mg of morphine equivalent (ME) and 35.0 ± 3.3 mg ME at 24 and 48 h, respectively, versus 36.4 ± 4.1 mg ME and 59.7 ± 6.7 mg ME in the control group (p = 0.002 and 0.002). PVASS levels were lower in the study group at all intervals at 3, 8, 24, and 48 h (p = 0.02, 0.006

The enhanced recovery after surgery (ERAS) pathway and laparoscopic approach had been proven beneficial for patients and should now be considered as a standard of care in colorectal surgery. Multimodal analgesia is the gold standard in the ERAS program with the use of thoracic epidural analgesia (TEA). Few data are available on Transversus abdominis plane (TAP) blocks in laparoscopic colorectal surgery and ERAS pathway. The aim of this study is to evaluate the efficacy of TAP block compared to TEA in the management of postoperative pain and the impact on the recurrence of postoperative nausea, vomiting and ileus in laparoscopic colorectal surgery in the ERAS program. From October 2014 to October 2016, 182 patients underwent elective colon surgical interventions in enhanced recovery after surgery pathway. The patients were divided into two groups: Group 1 (n = 92) and Group 2 (n = 91) who received TEA and TAP block, respectively, with a standardized postoperative analgesic regimen consisting of regular 1 g of paracetamol every 8 h and a rescue dose with intravenous non-steroidal anti-inflammatory drugs infusion for both groups. No differences were observed in baseline patient characteristics, clinical variables and surgical procedures between the two groups, as well as in the postoperative complications rate (p = 0.515) in accordance with Clavien–Dindo classification, 90-day mortality (p = 0.319), hospital stay (p = 0.469) and 30-day readmission rate (p = 0.711). Patients in the TAP block group showed lower postoperative nausea and vomiting rates (p = 0.025), as well as lower ileus (p = 0.031) and paraesthesia rates (p = 0.024). No differences were found in urinary retention (p = 0.157). Despite the “opioid-free” analgesia protocol in the TAP block group, pain intensity was comparable between the two groups (p = 0.651). TAP block combined with an opioid-sparing analgesia in the setting of the laparoscopic colorectal surgery and ERAS program is feasible and effective in postoperative pain control.

In surgical treatment of elderly patients, securing the safety of surgery and radical cure must be balanced. Our purpose was to verify the safety and validity of laparoscopic surgery for the treatment of colorectal cancer in elderly patients. Patients with cTis–T4a colorectal cancer who were 75 years or older were randomized to receive open or laparoscopic surgery. Exclusion criteria were patients who had a bulky tumor, rectal cancer that required pelvic side wall lymphadenectomy, and history of colon resection. Patients were divided according to tumor location (right colon, left colon, and rectum). The short-term outcomes were compared between the two groups. One hundred patients (right 43, left 28, and rectum 29) were registered in each group from August 2008 to August 2012. There were no differences in patient characteristics between the two groups. Three patients were converted from laparoscopic to open, because of bleeding, excision of peritoneum metastasis, and patient’s desire, respectively. In the short-term results (open:laparoscopic), there were significant differences in the rates of complications (36:23 %) and ileus (12:4 %), amount of blood loss (157:63 mL), and duration of surgery (150:172 min). There were no significant differences in the pathological margins, and the number of dissected lymph nodes. In the subgroup analysis according to the tumor location, there were significant differences in the rate of complications (39.4:22.5 %), amount of blood loss (135:42 mL), duration of surgery (139:160 min), and length of postoperative stay (13.0:10.0 days) in the colon cancer. There were no significant differences in short-term results in the rectal cancer. Laparoscopic surgery in elderly colorectal cancer patients did not result in a difference in radical cure compared with open surgery, and the short-term results except the duration of surgery were excellent. It is an effective procedure for elderly patients with colorectal cancer, especially colon cancer.

It is still unknown to what extent the reported morbidity and recovery benefits of laparoscopic total abdominal colectomy (TAC) for severe ulcerative colitis (UC) are associated with patient selection bias. This study aimed to evaluate whether laparoscopic TAC has any advantages over open surgery after control for perioperative confounding factors. Patients undergoing TAC for UC during 2006–2010 were identified. Demographics, disease characteristics, and perioperative outcomes were compared between laparoscopic and open TAC. Postoperative recovery and 30-day complications were further assessed by covariate-adjusted multivariate regression models. The outcomes of different laparoscopic techniques were compared. A subgroup analysis including surgeons who routinely used both laparoscopic and open techniques was also performed. Of the 412 eligible patients, the 197 patients undergoing laparoscopic TAC were significantly younger and had a decreased Charlson Comorbidity Index and ASA score, increased hemoglobin and serum albumin levels, and a smaller proportion of extensive colitis and urgent cases. Unadjusted analyses showed that intraoperative morbidity, postoperative mortality, and rates for readmission and reoperation were similar. Laparoscopic TAC was associated with a longer operative time but a decrease in blood loss, overall morbidity, ileus, and thromboembolism, as well as a faster return to bowel function and a shorter hospital stay. After covariate adjustments, laparoscopic surgery remained associated with a reduction in the time to stoma function, incidence of postoperative ileus, and hospital stay compared with open TAC. The rates of postoperative morbidity, readmission, and reoperation did not differ regardless whether the conventional multitrocar technique, hand-assisted procedure, or single-incision technique was used. Laparoscopic TAC among surgeons using both open and laparoscopic techniques was associated with recovery benefits similar to those observed in the overall study population. The data suggest that laparoscopic TAC retains recovery advantages over open surgery even after adjustments for confounders.

Single-incision laparoscopic colectomy (SILC) is touted to be an improved approach for minimally invasive surgery although no data currently exists regarding the acquisition of skills for the safe performance of this technique. The authors report their early experience with proctoring of surgical residents in SILC by experienced colorectal surgeons.Data regarding patient demographics, operative data, and short-term outcomes were prospectively collected at two surgical training hospitals. Residents and staff independently rated individual components of this technique to compare them with learning standard multiport colectomy (MP).A total of 31 SILC cases (15 men; mean age 53 years) were managed. The average BMI was 26.5 kg/m(2) (range 16-39 kg/m(2)). The surgical indications included cancer (n = 13), polyps (n = 8), diverticular disease (n = 4), Crohn's disease (n = 2), familial adenomatous polyposis (n = 2), volvulus (n = 1), and rectal prolapse (n = 1). The average operative time was 164 ± 86 min, and the mean blood loss was 80 ± 83 mL. The mean incision length was 4.1 ± 1.1 cm. One case required additional trocar placement (stoma creation), and three cases required conversion to open procedure because of failure to progress, difficult colorectal anastomosis, or poor visualization. The median hospital stay was 5.7 ± 1.3 days. The 30-day morbidity included minor wound infections (9.7 %), ileus (6.5 %), blood transfusion (3.2 %), and intraabdominal abscess (3.2 %). No deaths occurred. Residents rated vascular pedicle isolation, mobilization, critical structure exposure, instrument conflict/handling, and ergonomics as significantly more difficult with SILC.Senior-level residents can safely perform SILC under appropriate experienced supervision. The required advanced skills reflect complex laparoscopic training occurring during residency. Opportunities exist for better preparation and training of surgical residents to perform this complex surgery independently and safely at completion of residency.

Recent American College of Surgeons National Surgical Quality Improvement Project (ACS-NSQIP)-based evidence indicates that laparoscopic (LAP) colectomy results in improved outcomes compared to hand-assisted laparoscopic (HAL) colectomy in the general population. Previous comparative studies demonstrated that the HAL technique offers distinct advantages for obese patients. The aim of this study was to perform comparative analyses of HAL and LAP colectomy and low anterior resection (LAR) in obese patients. The ACS-NSQIP public use file and targeted colectomy dataset, 2012-2014, were utilized for patients undergoing colectomy and LAR. Only obese patients (BMI > 30) and laparoscopic or hand-assisted operations were included. Patient, operation, and outcome variables were compared in two separate cohorts: colectomy and LAR. Bivariate analysis compared the approaches, followed by multivariable regression. Of 9610 obese patients included, HAL and LAP colectomy were performed in 3126 and 3793 patients and LAR in 1431 and 1260 patients, respectively. In comparison to LAP colectomy, HAL colectomy patients had increased comorbidities including class 2 and 3 obesity. HAL colectomy was associated with higher overall morbidity (20 vs. 16%, p

Postoperative ileus (POI) is a major cause of morbidity, increased length of stay (LOS) and hospital cost after colorectal surgery. Alvimopan is a µ-opioid antagonist used to accelerate upper and lower gastrointestinal function after bowel resection. We hypothesized that alvimopan would reduce LOS in patients undergoing colorectal resection with stoma, a situation that has not been evaluated. A retrospective review (2010–2015) identified 58 patients who underwent colorectal resection for benign or malignant disease with stoma creation and received alvimopan. They were case-matched to 58 non-alvimopan patients based on age, BMI, baseline comorbidities, stoma type created and surgical approach. We compared overall LOS, incidence of POI and other postoperative complications. There were equal numbers of laparoscopic (N = 18) and open resections (N = 40) in the alvimopan group and non-alvimopan group. There were also equal numbers of patients with an ileostomy (N = 37) or colostomy (N = 21) in each group. Overall, 41 patients underwent resection for malignant disease in the alvimopan group compared to 37 in the non-alvimopan group. There was a significant reduction in median LOS overall (alvimopan 5 (4–7) versus control 6 (4.75–9.25) days, P = 0.03). While the 6-day median LOS was similar for patients undergoing ileostomy creation (P = 0.25), alvimopan patients had a 3-day decreased median LOS that approached statistical significance (P = 0.06). The overall 30-day complication rate was higher in the control group (41.4 vs. 51.7%, P = 0.26), but the readmission rate within 30 days was higher in the alvimopan group (19 vs. 13.8%, P = 0.45). Neither of these differences reached statistically significance. The use of alvimopan in patients undergoing colorectal resection with stoma is associated with a significantly shorter LOS, but the increased readmission rate warrants further study. Based on these data, alvimopan should be evaluated in a controlled setting for patients undergoing colorectal resection with colostomy creation.

Subtotal colectomy with antiperistaltic cecorectal anastomosis (SCCRA) has proved to be an effective alternative to total colectomy for the treatment of severe slow-transit constipation. The laparoscopic approach has made this procedure even more attractive. This is the first controlled trial on laparoscopic SCCRA. The study compares the laparoscopic and the open approach. Since 2001, all SCCRAs have been performed laparoscopically at our institution. Only severely symptomatic patients are offered surgery, after stringent patient selection. Laparoscopic SCCRA was performed following the same steps that we first described for the open approach, by utilizing a five-trocar technique. Outcome parameters were prospectively collected every 3 and 6 months. Wexner constipation and incontinence scales (WCS, WI) and gastrointestinal quality of life index (GIQLI) were adopted for functional results. We conducted a case–control study of 15 consecutive patients who underwent laparoscopic SCCRA (VL) and 15 patients previously operated on by the open approach (Op) to compare postoperative and functional outcomes. The VL group had better postoperative outcomes (pain, ileus) while complication rates were similar. Resolution of constipation was impressive in both groups, with no significant difference at follow-up. The VL group presented with a higher number of bowel movements at 3 months (3.8 vs. 2.8, p = 0.039), resulting in a significantly higher incontinence rate at 3 months (WI 6.4 vs. 2.73, p = 0.004), although the difference was no longer significant at 1-year follow-up. The quality of life was good for both groups; the VL group showed a significant improvement at 1-year follow-up (64.18 vs. 114.79, p

Over the past few years, surgeons have been able to obtain training in advanced minimally invasive surgery (MIS) for hepatic, pancreatic, and biliary (HPB) cases instead of having to teach themselves these complex techniques. As a result, the initial experience of a surgeon with advanced MIS HPB training at a national cancer center was reviewed. The experience of a surgeon with the first 50 laparoscopic hepatectomies for cancer was reviewed retrospectively. All cases begun with the intention to complete the hepatectomy laparoscopically were included in the laparoscopic group. From November 2008 to October 2010, a total of 57 hepatectomies were performed, with 53 attempted laparoscopically. Of these 57 hepatectomies, 46 (87%) were completed laparoscopically, 4 (7%) required hand assistance, and 3 (6%) were converted to an open approach. Laparoscopic minor hepatectomies were performed for 28 patients and laparoscopic major hepatectomies for 25 patients. The mean operative time was 265 min, and the mean estimated blood loss was 300 ml. The mean hospital stay was 7 days. Complications occurred for six patients (11%) (2 bile leaks, 2 hemorrhages requiring conversion, 1 hernia requiring a hernia repair on postoperative day 7, and 1 ileus managed nonoperatively). Surgeons with advanced MIS HPB training may be able to perform a higher percentage of their hepatectomies laparoscopically. Training in both open and laparoscopic HPB surgery is advisable before these techniques are performed.

Anastomotic complications such as leakage and bleeding remain among the most serious complications of laparoscopic colorectal surgery. No perfect method exists for accurate and reliable avoidance of these catastrophes. This study aimed to study the usefulness of routine intraoperative endoscopy (RIOE) by comparing the surgical outcomes for RIOE patients with those for selective intraoperative endoscopy (SIOE) patients. A retrospective chart review was performed for consecutive patients who underwent elective laparoscopic colorectal resections with distal anastomosis between January 2004 and May 2007. One surgeon performed RIOE, whereas the other three surgeons performed SIOE as necessary. All the abnormalities of IOE patients were managed with a subsequent salvage procedure, and the postoperative outcomes were compared between the RIOE and SIOE groups. The study included 107 patients in the RIOE group and 137 patients in the SIOE group. Abnormalities were detected in 11 RIOE patients (10.3%) (six with staple line bleeding, three with positive air leak test results, and two with additional pathology identified). All but one abnormality was laparoscopically managed without conversion to laparotomy. Whereas one patient experienced postoperative staple line bleeding that required a second operation, the remaining 10 patients recovered uneventfully. The mean hospital stay was 6 days (range, 4–9) days. The RIOE group had overall rates of 0% for anastomotic leakage and 0.9% for staple line bleeding. Intraoperative endoscopies were performed for 30 (21.9%) of the 137 patients in the SIOE group. The postoperative outcomes comparison between the RIOE and SIOE groups showed a tendency toward more overall anastomotic complications (0.9% vs. 5.1%) in the SIOE group, which due to the small sample size did not translate into significant differences in terms of staple line bleeding and anastomotic leakage. There also were no significant differences in other outcomes such as ileus, abdominal or pelvic sepsis, reoperation, positive distal margin, distance from distal margins, length of hospital stay, or mortality. Routine IOE for patients undergoing elective laparoscopic colorectal surgery with distal anastomosis can detect abnormalities at or around the anastomosis. Although the RIOE group had fewer postoperative anastomotic complications, due to the small sample size, the 5.7-fold increase in anastomotic failure did not translate into significantly better postoperative outcomes than the SIOE group experienced. A larger-scale single or multicenter prospective randomized study or a metaanalysis including similar studies is necessary for further investigation of this issue.

Postoperative wound complications are minimized after laparoscopic ventral hernia repair (LVHR) while maintaining low recurrence rates and acceptable morbidity. The purpose of this study is to evaluate efficacy and safety of LVHR in patients after organ transplantation in comparison to a large cohort of nontransplantation patients after LVHR. A retrospective, institutional review board (IRB)-approved review was performed on 347 patients who underwent LVHR between July 2000 and December 2007. LVHR was successfully completed in 38/38 transplantation patients (n = 21 liver, n = 5 cardiac, n = 8 kidney, n = 1 lung/kidney, n = 2 kidney/pancreas, n = 1 double lung) without conversion and in 301/309 (97.4%) nontransplant patients. Previous hernia repairs were attempted in 5/38 (13.2%) of the transplant patients and 108/309 (35.0%) of nontransplantation patients. Mean defect size was 256 cm2 (p

This study aimed to assess the feasibility, safety, and immediate postoperative outcome of laparoscopically assisted ileocolic resection for Crohn’s disease. Data were collected retrospectively from a database of 50 consecutive patients with Crohn’s disease who underwent ileocolic resection between 1997 and 2007. The mean age of the patients was 40 years (range, 20–74 years), and 21 of the patients were men. Of the 50 patients, 18 had a history of abdominal surgery. The mean time from diagnosis to operation was 6.4 years (range, 1–31 years). The indications for surgery included subobstruction (48%), failure of medical treatment (20%), and internal fistulas (32%). The mean operating time was 150 min (range, 80–360 min), and the blood loss was 130 ml (0–400 ml). Only 1 of the 50 patients underwent conversion to laparotomy. Return of bowel movement occurred at a mean of 3 days (range, 1–7 days). The median hospital stay was 8 days (range, 5–130 days). There was no 30-day mortality. The minor complication rate was 20%. The complications included wound infection, pneumonia, urinary infection, postoperative bleeding, prolonged ileus, and fever of unknown origin. Major complications occurred for four patients, with three patients experiencing an anastomotic leak and one patient a leak after fistulectomy. The laparoscopically assisted approach to ileocolic Crohn’s disease seems to be feasible and safe, with acceptable immediate postoperative outcomes.