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Background: Surgery induces a temporal change in the immune system, which might be modified by regional anesthesia. Applying a bilateral preoperative anterior quadratus lumborum block has proven to be a safe and effective technique in pain management after abdominal and retroperitoneal surgery, but the effect on the immune response is not thoroughly investigated., Methods: This study is a substudy of a randomized, controlled, double-blinded trial of patients undergoing laparoscopic hemicolectomy due to colon cancer. Twenty-two patients were randomized to undergo either a bilateral anterior quadratus lumborum nerve block with a total of 60 mL ropivacaine 0.375% or placebo with corresponding isotonic saline injections. The main objective of this exploratory substudy was to investigate the systemic immune response in the first postoperative day by examining changes in blood transcript levels (n=750) and stimulated secretion of cytokines (n=17) on ex vivo activation with microbial ligands and anti-CD3/CD28., Results: Using unsupervised data analysis tools, we observed no effect of the bilateral anterior quadratus lumborum nerve block on gene expression in immune cells (permutational multivariate analysis of variance using distance matrices: F=0.52, p=0.96), abundances of major immune cell populations (Wilcoxon rank-sum test: p>0.05), and stimulated cytokine secretion (Wilcoxon rank-sum test: p>0.05)., Conclusions: Our study provides evidence that administration of bilateral anterior quadratus lumborum nerve block as a part of a multimodal analgesic regimen in an enhanced recovery after surgery for laparoscopic hemicolectomy in this cohort does not alter the systemic immune response. Trial registration number NCT03570541., Competing Interests: Competing interests: None declared., (© American Society of Regional Anesthesia & Pain Medicine 2024. No commercial re-use. See rights and permissions. Published by BMJ.)

Background/objectives: L-RYGB and L-SG are the dominant bariatric procedures worldwide. While L-RYGB is an effective treatment of coexisting gastroesophageal reflux disease (GERD), L-SG is associated with an increased risk of de-novo or worsening of GERD. The study aimed to evaluate the long-term use of proton pump inhibitors (PPI) following laparoscopic Roux-en-Y gastric bypass (L-RYGB) and sleeve gastrectomy (L-SG)., Subjects/methods: This nationwide register-based study included all patients undergoing L-RYGB or L-SG in Denmark between 2008 and 2018. In total, 17,740 patients were included in the study, with 16,096 and 1671 undergoing L-RYGB and L-SG, respectively. The median follow up was 11 years after L-RYGB and 4 years after L-SG. Data were collected through Danish nationwide health registries. The development in PPI use was assessed through postoperative redeemed prescriptions. GERD development was defined by a relevant diagnosis code associated with gastroscopy, 24 h pH measurement, revisional surgery or anti-reflux surgery. The risk of initiation of PPI treatment or GERD diagnosis was evaluated using Kaplan-Meier plots and COX regression models. The risk of continuous PPI treatment was examined using logistic regression modeling., Results: The risk of initiating PPI treatment was significantly higher after L-SG compared with L-RYGB (HR 7.06, 95% CI 6.42-7.77, p < 0.0001). The risk of continuous PPI treatment was likewise significantly higher after L-SG (OR 1.45, 95% CI 1.36-1.54, p < 0.0001). The utilization of PPI consistently increased after both procedures. The risk of GERD diagnosis was also significantly higher after L-SG compared with L-RYGB (HR 1.93, 95% CI 1.27-2.93, p < 0.0001)., Conclusions: The risk of initiating and continuing PPI treatment was significantly higher after L-SG compared with L-RYGB, and a continuous increase in the utilization of PPI was observed after both procedures., (© 2024. The Author(s).)

Background: Acute appendicitis is the most common cause of abdominal pain requiring surgery, usually managed with laparoscopic appendectomy. In Denmark, the standard postoperative treatment for complicated cases involves intravenous antibiotics. This study compares peroral versus intravenous antibiotics in the context of fast-track surgery and Enhanced Recovery After Surgery (ERAS) protocols. Our objective is to evaluate the impact of peroral versus intravenous antibiotics on patient-reported outcomes following laparoscopic appendectomy for complicated appendicitis., Methods: This was a sub-study within a broader Danish cluster-randomized non-inferiority trial conducted at Zealand University Hospital, focusing on adult patients undergoing laparoscopic appendectomy for complicated appendicitis. Participants were randomized into two groups: one receiving a three-day course of peroral antibiotics and the other intravenous antibiotics after surgery. Recovery quality was assessed on the third postoperative day using the Quality of Recovery-15 (QoR-15) questionnaire., Results: The study included 54 patients, 23 in the peroral and 31 in the intravenous groups. The peroral group reported significantly better recovery outcomes, with higher QoR-15 scores (mean difference of 12 points, p < 0.001). They also experienced shorter hospital stays, averaging 47 h less than the intravenous group (p < 0.001). No significant differences between the groups were observed in readmissions or severe postoperative complications., Conclusions: Peroral antibiotic administration after laparoscopic appendectomy for complicated appendicitis significantly improves patient recovery and reduces hospital stay compared to intravenous antibiotics. These results advocate a potential shift towards peroral antibiotic use in postoperative care, aligning with ERAS principles., Trial Registration Number: ClinicalTrials.gov NCT04803422., (© 2024. The Author(s).)

Purpose: Bowel obstruction accounts for around 50% of all emergency laparotomies. A multidisciplinary (MDT) standardized intraoperative model was applied (definitive, palliative, or damage control surgery) to identify patients suitable for a one-step, definitive surgical procedure favoring anastomosis over stoma, when undergoing surgery for bowel obstruction. The objective was to present mortality according to the strategy applied and to compare the rate of laparoscopic interventions and stoma creations to a historic cohort in surgery for bowel obstruction., Methods: In a retrospective cohort study, we included patients undergoing emergency surgery for bowel obstruction during a 1-year period at two Copenhagen University Hospitals (2019 and 2021). The MDT model consisted of a 30- and 60-min time-out with variables such as functional and hemodynamic status, presence of malignancy, and surgical capabilities (lap/open). Pre-, intra-, and postoperative data were collected to investigate associations to postoperative complications and mortality. Stoma creation rates and laparoscopies were compared to a historic cohort (2009-2013)., Results: Three hundred sixty-nine patients underwent surgery for bowel obstruction. Intraoperative surgical strategy was definitive in 77.0%, palliative in 22.5%, and damage control surgery in 0.5%. Thirty-day mortality was significantly lower in the definitive patient population (4.6%) compared to the palliative population (21.7%) (p < 0.000). Compared to the historic cohort, laparoscopic surgery for bowel obstruction increased from 5.0 to 26.4% during the 10-year time span, the rate of stoma placements was reduced from 12.0 to 6.1%, p 0.014, and the 30-day mortality decreased from 12.9 to 4.6%, p < 0.000., Conclusion: An intraoperative improvement strategy can address the specific surgical interventions in patients undergoing surgery for bowel obstruction, favoring anastomosis over stoma whenever resection was needed, and help adjust specific postoperative interventions and care pathways in cases of palliative need., (© 2024. The Author(s), under exclusive licence to Springer-Verlag GmbH Germany, part of Springer Nature.)

Background: Evidence for the routine use of robotic technology and its impact on short-term outcomes in colon cancer surgery is lacking. The aim of this study was to compare the surgically induced systemic stress response and clinical and patient-reported outcomes for patients undergoing robot-assisted or laparoscopic colon cancer surgery., Methods: In this double-blinded superiority RCT completed between August 2021 and March 2023, patients with stage 1-3 colon cancer were randomized in a 1 : 1 ratio to undergo either robot-assisted or laparoscopic colon cancer surgery. The primary outcome was changes in the systemic stress response, characterized by C-reactive protein expression in the first three postoperative days. Secondary outcomes were intraoperative and postoperative complications and patient-reported outcomes. The latter included quality of recovery-15 and pain intensity using a visual analogue scale., Results: In total, 128 patients were screened for potential inclusion in this study; 50 patients (25 in the robot-assisted group and 25 in the laparoscopic group) were included in the final follow-up and analysis. The postoperative C-reactive protein response was higher on the first postoperative day in the laparoscopic group (mean difference = 19.88 mg/l, 95% c.i. 3.89-35.86; P = 0.045). No statistically significant differences were noted for C-reactive protein expression on the second and third postoperative days., Conclusion: Adopting robot-assisted surgery for stage 1-3 colon cancer is associated with a reduction in the surgical stress response., Registration Number: NCT04687384 (http://www.clinicaltrials.gov)., (© The Author(s) 2024. Published by Oxford University Press on behalf of BJS Foundation Ltd. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.)

Aim: The use of robot-assisted surgery for left-sided colon cancer is increasing in Denmark; however, it is yet to be established if the robotic approach results in improved clinical outcomes compared with the corresponding laparoscopic approach. The aim of this study was to compare the intraoperative and short-term postoperative outcomes of robot-assisted surgery with laparoscopic surgery for left-sided colon cancer at a national level., Method: The study is a nationwide database study based on data from the Danish Colorectal Cancer Group database. Patients from all colorectal centres in Denmark treated with surgery with curative intent in an elective setting with either robotic or laparoscopic left colectomy or sigmoidectomy during the period 2014-2019 were included. To adjust for confounding, propensity score matching (PSM) was performed and the groups were compared for age, sex, body mass index, American Society of Anesthesiologists classification, performance score, year of diagnosis, neoadjuvant chemotherapy, left colectomy or sigmoidectomy, tumour localization, use of stoma or stenting and pathological T (pT) category., Results: A total of 5532 patients were available for analysis, and after PSM in a ratio of 2:1, 1392 laparoscopic and 696 robotic cases were identified. After matching we found a lower conversion rate and a higher lymph node yield in the robotic group compared with the laparoscopic group (5.8% vs. 11%, p < 0.001 and 27 vs. 24, p < 0.001, respectively). Further, we found a higher proportion of patients with a lymph node yield of 12 or more in the robotic group (97% vs. 94.8%, p = 0.02). Plane of dissection, radicality and pathological disease stages did not differ between the two groups. We found no difference in either overall surgical (13% vs. 11.1%, p = 0.23) or medical (5.6% vs. 6.5%, p = 0.49) postoperative complications and no difference in 30-day (p = 0.369) or 90-day mortality (p = 0.08)., Conclusion: Robot-assisted surgery for left-sided colon cancer was associated with a significantly lower conversion rate and a significantly higher lymph node yield than the laparoscopic approach. Postoperative morbidity and mortality were similar in the two groups., (© 2023 Association of Coloproctology of Great Britain and Ireland.)

Background: Local excision of early colon cancers could be an option in selected patients with high risk of complications and no sign of lymph node metastasis (LNM). The primary aim was to assess feasibility in high-risk patients with early colon cancer treated with Combined Endoscopic and Laparoscopic Surgery (CELS)., Methods: A non-randomized prospective feasibility study including 25 patients with Performance Status score ≥ 1 and/or American Society of Anesthesiologists score ≥ 3, and clinical Union of International Cancer Control stage-1 colon cancer suitable for CELS resection. The primary outcome was failure of CELS resection, defined as either: Incomplete resection (R1/R2), local recurrence within 3 months, complication related to CELS within 30 days (Clavien-Dindo grade ≥ 3), death within 30 days or death within 90 days due to complications to surgery., Results: Fifteen patients with clinical T1 (cT1) and ten with clinical T2 (cT2) colon cancer and without suspicion of metastases were included. Failure occurred in two patients due to incomplete resections. Histopathological examination classified seven patients as having pT1, nine as pT2, six as pT3 adenocarcinomas, and three as non-invasive tumors. In three patients, the surgical strategy was changed intraoperatively to conventional colectomy due to tumor location or size. Median length of stay was 1 day. Seven patients had completion colectomy performed due to histological high-risk factors. None had LNM., Conclusions: In selected patients, CELS resection was feasible, and could spare some patients large bowel resection., (© 2023. The Author(s).)

Purpose: The aim of this study was to evaluate the long-term surgical and oncological outcomes after transanal total mesorectal excision (TaTME) for rectal cancer during an implementation phase on a national level., Method: This is a retrospective review of prospectively recorded data. Registration was initiated by the Danish Colorectal Cancer Group in order to assess the quality of care during the implementation of TaTME in Denmark. Data from four centers were pooled for simultaneous analysis. Short-term data was available from a prior study, and long-term data regarding recurrences, chemotherapy, and mortality was collected., Results: From August 2016 to April 2019, 115 TaTME procedures were registered. Patients were predominantly male (n = 85, 74%) with mid-rectal (n = 88, 77%) tumors. The overall local recurrence rate was 7.8% (n = 9) of which six patients also had systemic recurrence. Mean long-term follow-up was 59.4 months, and median time to local recurrence was 24.9 months. Local recurrences occurred predominantly among initial implementation cases. The overall mortality rate was 13% (n = 15). Of the 17 patients with recurrence, 35% (n = 6) died and developed either solely distant recurrence (n = 2, 12%) or in combination with local recurrence (n = 4, 24%)., Conclusion: We found acceptable long-term oncological results after TaTME during the implementation phase in Denmark. There was an accumulation of local recurrences in the early phase of the study which emphasizes the importance of thorough training and proctoring when starting the approach., Competing Interests: Declaration of competing interest The authors declare they have no conflicts of interest., (Copyright © 2023 Elsevier Ltd. All rights reserved.)

Background: Securing sufficient blood perfusion to the anastomotic area after low-anterior resection is a crucial factor in preventing anastomotic leakage (AL). Intra-operative indocyanine green fluorescent imaging (ICG-FI) has been suggested as a tool to assess perfusion. However, knowledge of inter-observer variation among surgeons in the interpretation of ICG-FI is sparse. Our primary objective was to evaluate inter-observer variation among surgeons in the interpretation of bowel blood-perfusion assessed visually by ICG-FI. Our secondary objective was to compare the results both from the visual assessment of ICG and from computer-based quantitative analyses of ICG-FI between patients with and without the development of AL., Method: A multicenter study, including patients undergoing robot-assisted low anterior resection with stapled anastomosis. ICG-FI was evaluated visually by the surgeon intra-operatively. Postoperatively, recorded videos were anonymized and exchanged between centers for inter-observer evaluation. Time to visibility (TTV), time to maximum visibility (TMV), and time to wash-out (TWO) were visually assessed. In addition, the ICG-FI video-recordings were analyzed using validated pixel analysis software to quantify blood perfusion., Results: Fifty-five patients were included, and five developed clinical AL. Bland-Altman plots (BA plots) demonstrated wide inter-observer variation for visually assessed fluorescence on all parameters (TTV, TMV, and TWO). Comparing leak-group with no-leak group, we found no significant differences for TTV: Hazard Ratio; HR = 0.82 (CI 0.32; 2.08), TMV: HR = 0.62 (CI 0.24; 1.59), or TWO: HR = 1.11 (CI 0.40; 3.11). In the quantitative pixel analysis, a lower slope of the fluorescence time-curve was found in patients with a subsequent leak: median 0.08 (0.07;0.10) compared with non-leak patients: median 0.13 (0.10;0.17) (p = 0.04)., Conclusion: The surgeon's visual assessment of the ICG-FI demonstrated wide inter-observer variation, there were no differences between patients with and without AL. However, quantitative pixel analysis showed a significant difference between groups., Trial Registration: ClinicalTrials.gov Identifier: NCT04766060., (© 2023. The Author(s).)

Background and Aims: An opioid-sparing postoperative analgesic regimen following laparoscopic hemicolectomy is optimal to promote minimal postoperative pain, early mobilization, and improved quality of recovery. Various regional anesthesia techniques have been tested to improve postoperative pain management after laparoscopic hemicolectomy. In this study, we aimed to assess the effect of administering a preoperative bilateral ultrasound-guided anterior quadratus lumborum nerve block on postoperative opioid consumption after laparoscopic colon cancer surgery., Methods: In this randomized, controlled, double-blinded trial, 69 patients undergoing laparoscopic hemicolectomy due to colon cancer were randomized to receive an anterior quadratus lumborum block with ropivacaine 0.375% 30 mL on each side or isotonic saline (placebo). The primary outcome measure was total opioid consumption during the first 24 hours postsurgery. The secondary outcome measures were pain scores, accumulated opioid consumption in 6-hour intervals, nausea and vomiting, ability of postoperative ambulation, time to first opioid, orthostatic hypotension or intolerance, postoperative Quality of Recovery-15 scores, surgical complications, length of hospital stay, and adverse events., Results: The total opioid consumption in the first 24 hours postsurgery was not significantly reduced in the ropivacaine group compared with the saline group (mean 129 mg (SD 88.4) vs mean 127.2 mg (SD 89.9), p=0.93). In addition, no secondary outcome measures showed any statistically significant intergroup differences., Conclusion: The administration of a preoperative bilateral anterior quadratus lumborum nerve block as part of a multimodal analgesic regimen for laparoscopic hemicolectomy did not significantly reduce opioid consumption 24 hours postsurgery. Trial registration number NCT03570541., Competing Interests: Competing interests: None declared., (© American Society of Regional Anesthesia & Pain Medicine 2023. No commercial re-use. See rights and permissions. Published by BMJ.)

Background: Emergency abdominal surgery is associated with a high rate of postoperative complications and death. Pre- and immediate postoperative bundle-care strategies have improved outcome, but so far, no standardized intraoperative strategies have been proposed. We introduced a quality improvement model of specific intra- and postoperative strategies for the heterogenous group of patients undergoing emergency abdominal surgery. The objective was to evaluate a quality improvement strategy, using an intraoperative, multidisciplinary time-out model in emergency abdominal surgery to apply one of three surgical strategies; definitive-palliative-or damage control surgery., Methods: All patients scheduled for any gastrointestinal emergency procedure were stratified dynamically according to standardized criteria for performing definitive-palliative-or damage control surgery. Pre- intra- and postoperative data were collected according to the intraoperative strategy applied. Postoperative complications were displayed according to the Clavien-Dindo-score and the CCI (Comprehensive Complication Index). 30-90-day- and 1-year mortality was presented., Results: We included 436 consecutive patients undergoing emergency laparotomy or laparoscopy in 2019. Intraoperative strategy was definitive in 326(75%)-palliative in 90(21%) and damage control approach in 20(4%) patients. CCI was 21(0,45), 30(17,54) and 78(54,100) in the definitive-, the palliative-, and the damage control group, respectively. 30-day mortality was; 11.7%, 26.7% and 30%, and the 1-year mortality was 16.9%, 56.7% and 40% in the definitive- the palliative- and the damage control group, respectively., Conclusions: We present a multidisciplinary, intraoperative decision-making standard as a potential quality improvement tool of ensuring individualized intra- and postoperative treatment for every emergency surgical patient and for future research-protocols., (© 2022. The Author(s) under exclusive licence to Société Internationale de Chirurgie.)

Purpose: Previous studies have shown that intracorporeal anastomosis (ICA) in minimally invasive right colectomy may improve postoperative recovery compared with extracorporeal anastomosis (ECA). It has been hypothesized that creating the anastomosis extracorporeally may cause mesenteric traction and compromised intestinal perfusion. The purpose of this study was to investigate the effect of either ICA or ECA on intestinal perfusion., Method: This was a substudy to a multicenter, triple-blind randomized clinical trial comparing ICA with ECA in patients undergoing robotic right colectomy for colonic cancer. Videos from intraoperative Indocyanine Green (ICG) fluorescence imaging were analyzed with quantitative ICG perfusion assessment (q-ICG). q-ICG was performed by extracting perfusion metrics from a time-intensity curve generated from an image analysis software: F MAX : maximal fluorescence intensity, T MAX : time until maximal fluorescent signal, T 1/2MAX : time until half-maximal fluorescent signal, time ratio (T 1/2MAX /T MAX ) and slope., Results: A total of 68 patients (33 ICA and 35 ECA) were available for analysis. Demographics were similar between the groups, except for mean arterial blood pressure at the time of ICG infusion, which was significantly lower in the ICA group. We found a significantly steeper slope in the ICA group compared to the ECA group (6.3 vs. 4.7 AU/sec, P = .048). There were no significant differences in F MAX , T MAX , T 1/2MAX , and time ratio., Conclusion: We found evidence of an improved intestinal perfusion following ICA compared with ECA. This finding may be related to patient outcomes and should be explored further in the future., Clinicaltrials: gov NCT03130166., (© 2022. The Author(s), under exclusive licence to Springer-Verlag GmbH Germany, part of Springer Nature.)

Objective: To determine if minimally invasive right colectomy with intra-corporeal anastomosis improves postoperative recovery compared to extra-corporeal anastomosis., Background: Previous trials have shown that intracorporeal anastomosis improves postoperative recovery; however, it has not yet been evaluated in a setting with optimized perioperative care or with patient-related outcome measures., Methods: This was a multicenter, triple-blind, randomized clinical trial at two high-volume colorectal centers with strict adherence to optimized perioperative care pathways. The patients underwent robotic right colectomy with either intracorporeal or extracorporeal anastomosis. The primary outcome was patient-reported postoperative recovery measured using the "Quality of Recovery-15" questionnaire. ClinicalTrials.gov NCT03130166., Results: A total of 89 patients were randomized and analyzed according to the "Intention-to-treat"-principle. We found no statistically significant differences in patient-reported recovery between the groups. Postoperative pain, nausea, time to ambulation, time to first passage of flatus/stool, length of hospital stay, and pathophysiological tests showed no differences either. The duration of time to create the anastomosis was significantly longer with intracorporeal anastomosis (17 vs 13 min, P = 0.003), while all other intraoperative, postoperative, and pathology variables showed no difference., Conclusion: There were no significant differences in postoperative recovery between the two groups., Competing Interests: Conflicts of Interest and Sources of Funding: ND received unrestricted funding from the Louis-Hansen Foundation, Jacob & Olga Madsen’s foundation, Trigon Foundation, Toyota Foundation, Dagmar Marshalls Foundation, Vissing Foundation, the Kjaer Foundation, and the Nyegaard Foundation. The funding sources had no role in the design and conduct of the study; data collection, analysis, and interpretation of data; the preparation, review or approval of the manuscript or the decision to submit for publication. For the remaining authors none were declared. The study did not receive funding from National Institutes of Health (NIH); Wellcome Trust; or Howard Hughes Medical Institute (HHMI). The authors report no conflicts of interest., (Copyright © 2021 Wolters Kluwer Health, Inc. All rights reserved.)

High-level evidence now strongly supports the use of a minimally invasive approach in most abdominal surgical procedures. Minimally invasive surgery is performed with either a laparoscopic or a robotic approach, and the robotic approach has been implemented to overcome some of the inherent limitations of the conventional laparoscopic approach. In Denmark, robotic surgery is widely adopted, and this review describes the application and rationale of a robotic approach in different subspecialties, while also presenting the available high-level evidence.

Introduction: Asking participants to rate their own performance during unsupervised training in laparoscopy is reliable and may be cost-effective. The objective of the study was to explore the reliability of self-rated examinations where participants rate their own performance and decide themselves when they have passed tasks in basic laparoscopic skills., Methods: This prospective observational study was conducted at the Copenhagen Academy for Medical Education and Simulation where simulation-based laparoscopic skill training is offered. Here, participants taking part in a basic laparoscopic skills course were asked to rate their own performance and decide when they had passed the Training and Assessment of Basic Laparoscopic Techniques test. To explore reliability, all examinations were video recorded and rated by a blinded rater after the end of the course., Results: Thirty-two surgical trainees participated in the course, and 28 completed the study. We found a high reliability when comparing self-rated scores and blinded ratings with an intraclass correlation coefficient of 0.89 ( P < 0.001); self-rated scores compared with blinded ratings were not significantly different (mean = 451 vs. 455, P = 0.28), and the participants did not underestimate nor overestimate their performance., Conclusions: Ratings from self-rated examinations in a basic laparoscopic skills course are reliable, and participants neither underestimate nor overestimate their performance. Self-rated examinations may also be beneficial because they also can offer a cost-effective approach to assessment of surgical trainees., Competing Interests: E.T. reports nonrestricted educational grants from Johnson & Johnson during the conduct of the submitted work. The other authors declare no conflict of interest., (Copyright © 2021 Society for Simulation in Healthcare.)

Aim: To estimate the effect of laparoscopy versus laparotomy on recurrence status in patients undergoing intended curative resection for stage I-III colon cancer using nationwide data., Method: A retrospective cohort study using prospectively collected nationwide quality assurance data on all patients undergoing elective, intended curative surgery for UICC stage I-III colon cancer in Denmark from 1 January 2010, through 31 December 2013. The association between laparoscopic versus open surgery and recurrence status was investigated using cause-specific hazard and subdistribution hazard models with death from any cause as a competing event., Results: In total, 4369 patients undergoing elective intended curative surgery for colon cancer were included in the analysis. Overall, 3243 (74.2%) patients underwent laparoscopic surgery. During a median follow-up time of 84 months, 1191 (27.2%) patients experienced recurrence, and 1304 (29.8%) patients died. The cause-specific hazard of recurrence following laparoscopic versus open surgery was HR CS  = 1.08, 95% CI: 0.90-1.28, p = 0.422. The subdistribution hazard of recurrence following laparoscopic versus open surgery was HR SD =0.99, 95% CI: 0.84-1.16, p = 0.880., Conclusion: Elective laparoscopic resection for UICC stage I-III colon cancer is oncologically safe and comparable with open resection. These results confirm the external validity of previous RCTs in everyday clinical settings., (© 2021 The Association of Coloproctology of Great Britain and Ireland.)

Background and Objective: During the last decades, laparoscopic surgery has been introduced as an alternative to open surgery. We aimed to examine to what extent laparoscopic surgery has replaced open surgery for appendicitis in an entire nation during the last two decades. Second, we examined the effects of shifting to laparoscopic surgery for appendicitis on different quality indicators such as length of postoperative stay and mortality. We also examined age as a predictor of 30-day mortality., Methods: During the period 2000 to 2015, all adult patients with appendicitis and surgical removal of the appendix were identified in the Danish National Patient Register. Demographics, type of surgery, time of surgery, and duration of postoperative stay were retrieved form Danish National Patient Register. Vital status was retrieved from the Danish Civil Registration System., Results: A total of 58,093 patients underwent surgery for appendicitis. In 2000, a total of 274 out of 3717 (7.4%) had a laparoscopic appendectomy, and the postoperative stay was 55 (iqr: 35-88) h and 30-day mortality was 0.91%. In 2015, a total of 3995 out of 4296 (93.0%) had a laparoscopic appendectomy, and the postoperative stay was 16 (iqr: 9-56) h and 30-day mortality was 0.40%. Age as a predictor of 30-day postoperative mortality had an area under the curve of 0.93 (95% confidence interval: 0.92; 0.94)., Conclusions: In Denmark, the standard surgical procedure for appendicitis has changed from open surgery to laparoscopic surgery during the period 2000-2015. At the same time, duration of postoperative stay and 30-day mortality has decreased.

Background: Robot-assisted surgery is being increasingly adopted in treating colorectal cancer, and the transition from laparoscopic surgery to robot-assisted surgery is a trend. The evidence of the benefits of robot-assisted surgery is sparse. However, findings are associated with improved patient-related outcomes and overall morbidity rates compared to laparoscopic surgery. This induction is unclear, considering both surgical modalities are characterized as minimally invasive. This study aims to evaluate the systemic and peritoneal inflammatory stress response induced by robot-assisted surgery compared with laparoscopic surgery for elective colon cancer resections in a prospective, randomized controlled clinical trial., Methods: This study is a single-centre randomized controlled superiority trial with 50 colon cancer participants. The primary endpoint is the level of systemic inflammatory response expressed as serum C-reactive protein (CRP) and interleukin 6 (IL-6) levels between postoperative days one and three. Secondary endpoints include (i) levels of systemic inflammation in serum expressed by a panel of inflammatory and pro-inflammatory cytokines measured during the first three postoperative days, (ii) postoperative surgical and medical complications (30 days) according to Clavien-Dindo classification and Comprehensive Complication Index, (iii) intraoperative blood loss, (iv) conversion rate to open surgery, (v) length of surgery, (vi) operative time, (vii) the number of harvested lymph nodes, and (viii) length of hospital stay. The exploratory endpoints are (i) levels of peritoneal inflammatory response in peritoneal fluid expressed by inflammatory and pro-inflammatory cytokines between postoperative day one and three, (ii) patient-reported health-related quality of recovery-15 (QoR-15), (iii) 30 days mortality rate, (iv) heart rate variability and (v) gene transcript (mRNA) analysis., Discussion: To our knowledge, this is the first clinical randomized controlled trial to clarify the inflammatory stress response induced by robot-assisted or laparoscopic surgery for colon cancer resections. Trial registration This trial is registered at Clinicaltrials.gov (Identifier: NCT04687384) on December, 29, 2020, Regional committee on health research ethics, Region of Southern Denmark (N75709) and Data Protection Agency, Hospital Sønderjylland, University Hospital of Southern Denmark (N20/46179)., (© 2021. The Author(s).)

Purpose: On a national level, the minimally invasive approach is widely adopted in Denmark. The adoption of robotic colorectal surgery is increasing; however, the advantage of a robotic approach in right colectomy is still uncertain. The purpose of this study was to compare robotic right colectomy with laparoscopic right colectomy on a national level., Methods: This was a nationwide database study based on data from the Danish Colorectal Cancer Group database. Patients from all colorectal centers in Denmark in the period 2014-2018 treated with curative intend in an elective setting with either robotic or laparoscopic right colectomy were identified. Propensity score matching was performed to adjust for confounding, and the groups were compared on demographics, disease characteristics, operative data, and postoperative and pathology outcomes. Reporting was done in accordance with the STROBE statement., Results: In total, 4002 patients were available for analysis. Propensity score matching in ratio 2:1 identified 718 laparoscopic and 359 robotic cases. After matching, we found a higher lymph node yield in the robotic group compared to the laparoscopic group, (32.5 vs. 28.4, P < 0.001), while radicality, plane of dissection, and pathological disease stages showed no differences. There were no statistical differences in morbidity and mortality. Intracorporeal anastomosis (23.7% vs. 4.5%, P < 0.001) was more commonly performed with a robotic approach., Conclusions: Robotic approach was associated with a significant higher lymph node yield and with similar postoperative morbidity compared to a laparoscopic approach for right colectomy., (© 2021. The Author(s), under exclusive licence to Springer-Verlag GmbH Germany, part of Springer Nature.)

Aim: Objective and reproducible quality measures of complete mesocolic excision (CME) for colon cancer are not currently available. This study aimed to measure the inferior mesenteric stump length following CME for sigmoid colon cancer and explore surgical, pathological and oncological outcomes in patients with a stump length of <10 mm vs. ≥10 mm., Method: This was a single-centre, retrospective cohort study including patients undergoing minimally invasive surgery for sigmoid colon cancer between May 2013 and May 2015. Follow-up CT scans were reviewed, and a vascular stump cut-off of <10 mm for adequate central ligation of the inferior mesenteric artery was applied. Differences in perioperative, histopathological and oncological outcome parameters (overall, disease-free and recurrence-free survival) were explored between <10 mm vs. ≥10 mm groups., Results: A total of 127 patients (43% female) with a median age of 68 years were included. The median follow-up time was 68 months. CT measurements showed good interrater agreement (90% absolute agreement) and reliability among raters (kappa = 0.77, 95% CI 0.53-1.00, p < 0.001). A stump length ≥10 mm was associated with longer operating time (150 vs. 180 min, p = 0.021), intramesocolic resection (p = 0.008), and a shorter distance from the bowel wall to vascular tie (120 vs. 102 mm, p = 0.005)., Conclusion: An arterial stump length ≥10 mm in sigmoid resection for colon cancer was associated with key clinical quality measures. Measurement of arterial stump length using routine follow-up CT may serve as a quality indicator of vascular ligation in CME surgery., (© 2021 The Association of Coloproctology of Great Britain and Ireland.)

Introduction: A minimally invasive approach in colorectal surgery reduces surgical stress compared with open surgery. Today, the gold standard in the treatment of right-sided colonic cancer is a minimally invasive approach, which can be performed with either a "minimally invasive assisted" technique - a combination of open and minimally invasive surgery with an extracorporeal anastomosis (ECA) or with a "totally minimally invasive" technique with intracorporeal anastomosis (ICA). The prevailing technique is ECA, but there is no conclusive evidence on the superiority of one technique over the other, and randomised trials comparing ICA with ECA are warranted. We hypothesised that ICA will yield improved recovery compared with ECA., Methods: This is a triple blind, multicentre, randomised controlled trial comparing robotic right colectomy with ECA with robotic right colectomy with ICA. We plan to include 100 patients undergoing elective minimally invasive right colectomies in two colorectal centres in Denmark. The primary outcome is patient-reported post-operative recovery, and secondary outcomes are additional measures of post-operative recovery (pain, analgesics, nausea and vomiting, time to first flatus/bowel movement, length of hospital stay), operative time, intraoperative complications, conversions, readmissions, reoperations, 30- and 90-day morbidity and mortality., Conclusion: The results of this randomised controlled trial will contribute with valuable knowledge on the best surgical management of right-sided colonic cancer., Funding: The study has received unrestricted grants from the Louis-Hansen Foundation, Jacob & Olga Madsen's foundation, Trigon Foundation, Toyota Foundation, Dagmar Marshalls Foundation, Vissing Foundation, The Kjaer Foundation and the Nyegaard foundation., Trial Registration: Clinicaltrials.gov identifier: NCT03130166., (Articles published in the DMJ are “open access”. This means that the articles are distributed under the terms of the Creative Commons Attribution Non-commercial License, which permits any non-commercial use, distribution, and reproduction in any medium, provided the original author(s) and source are credited.)

Aim: The aim of this study was to evaluate the short-term surgical and oncological outcomes after transanal total mesorectal excision (TaTME) for rectal cancer during the implementation phase of this procedure in Denmark., Method: This is a retrospective review of prospectively recorded data. Registration was initiated by the Scientific Council of the Danish Colorectal Cancer Group (DCCG.dk) in order to assess the quality of care during the implementation of TaTME. Pre-, intra- and postoperative data including early recurrences were recorded at the operating centres., Results: From August 2016 to April 2019, 115 TaTME procedures were registered. Patients were predominantly male (74%) with mid-rectal (88%) tumours. The level of surgical complications was comparable to previous nationwide results. Anastomotic leakage occurred in 6/109 (5.5%). One urethral injury occurred. The plane of dissection was mesorectal in 60% of cases, intramesorectal in 28% and muscularis in 12%. Nonmicroradicality was seen in 8% (R1, 6%; R2, 2%). Four local recurrences occurred after a median of 23 months of follow-up. One of these was multifocal., Conclusion: In an implementation phase where patient selection is expected, surgical and oncological results after TaTME were comparable to those of other approaches reported in the literature., (© 2020 The Association of Coloproctology of Great Britain and Ireland.)

Surgical stress is followed by oxidative stress, where reactive oxygene species may act as regulators of pathways related to cancer cell survival and metastatic ability. Furthermore, reactive oxygene species may cause DNA and RNA damage. The aim of this study was to examine whether laparoscopic colon cancer surgery causes oxidative stress and dysregulation of related pathways., Methods: Patients undergoing elective laparoscopic surgery for colon cancer were included. Blood and urine samples were drawn on the day prior to surgery and on day 1 and 10 after surgery., Results: Twenty-six patients were included. Out of 140 genes previously identified as sensitive to regulation by reactive oxygene species, 46 were significantly differentially expressed on day 1 after surgery (FDR < 0.05). Upregulated genes were related to cellular immune suppression, proliferation, migration and epithelial to mesenchymal transition. Downregulated genes were related to IFN pathways and cytotoxic immunological reactions. Genes related to DNA repair were primarily downregulated on day one after surgery, and urinary excretion of 8oxdG was decreased on day two after (p = 0.004), and increased on day 10 after surgery (p = 0.01)., Conclusion: Laparoscopic colon cancer surgery causes oxidative stress, and impaired DNA repair. Gene expression profiling indicates that reactive oxygen species may act as regulators of pathways related to increased risk of metastasis and cellular immune suppression after surgery. Measures of intracellular oxidative stress, indicates impaired DNA repair on day two after surgery, and sustained oxidative stress on day 10 after surgery., (Copyright © 2020. Published by Elsevier Ltd.)

Background: Until now, no detailed long-term data regarding patients with declining quality of life or occupational status after laparoscopic Roux-en-Y gastric bypass surgery have been presented. The aim of this study was to evaluate the long-term effect of laparoscopic Roux-en-Y gastric bypass surgery on quality of life and occupational status., Methods: The study was a single-center register-based cohort study including all patients who underwent laparoscopic Roux-en-Y gastric bypass surgery from 2010 through 2014. Quality of life was based on the validated Moorehead-Ardelt questionnaire, measured preoperatively and postoperatively after 12, 24, and median 63 months. Longitudinal trends of occupational status were created and compared with overall trends in the Danish population. Subgroup analyses were conducted, investigating associations between declining quality of life, declining occupational status, and postoperative chronic abdominal pain., Results: In total, 749 patients were included in the study. All aspects of quality of life improved after laparoscopic Roux-en-Y gastric bypass surgery. After a median follow-up of 63 months, quality of life was significantly reduced in 14% of the patients compared with the preoperative baseline. Lower quality of life was associated with a decline in occupational status (P = .008) and postoperative chronic abdominal pain (P < .0001). Overall, occupational status was unchanged compared with before surgery. Throughout the study period occupational status declined in 21% of the patients. Declining occupational status was associated with declining quality of life (P = .008) and development of chronic abdominal pain (P = .009)., Conclusion: In general, quality of life and occupational status improved after laparoscopic Roux-en-Y gastric bypass surgery. Subgroups of patients had declining quality of life and declining occupational status both being associated with postoperative chronic abdominal pain., (Copyright © 2020 Elsevier Inc. All rights reserved.)

Background: Right colectomy is the standard surgical treatment for tumors in the right colon and surgical complications are reduced with minimally-invasive laparoscopy compared with open surgery, with potential further benefits achieved with robotic assistance. The anastomotic technique used can also have an impact on patient outcomes. However, there are no large, prospective studies that have compared all techniques., Methods/design: MIRCAST is the Minimally-Invasive Right Colectomy Anastomosis Study that will compare laparoscopy with robot-assisted surgery, using either intracorporeal or extracorporeal anastomosis, in a large prospective, observational, multicenter, parallel, four-cohort study in patients with a benign or malignant, non-metastatic tumor of the right colon. Over 2 years of follow-up, the study will prospectively evaluate peri- and postoperative complications, postoperative recovery, hospital stay, and mid-term results including survival, local recurrence, metastases rate, and conversion rate. The primary composite endpoint will be the efficacy of the surgical method regarding surgical wound infections and postoperative complications (Clavien-Dindo grade III-IV complications at 30 days post-surgery). Secondary endpoints include long-term oncologic results, conversion rate, operative time, length of stay, and quality of life., Discussion: This will be the first large, international study to prospectively evaluate the use of minimally-invasive laparoscopy or robot-assisted surgery during right hemicolectomy and to control for the impact of the anastomotic technique. The research will contribute to current knowledge regarding the medical care of patients with malignant or benign tumors of the right colon, and enable physicians to determine which technique may be the most appropriate for their patients., Trial Registration: This study was registered on Clinicaltrials.gov (clinicaltrials.gov identifier: NCT03650517 ) on August 28th 2018 (study protocol version CI18/02 revision A, 21 February 2018).

Background: Colon cancer is one of the most commonly diagnosed types of cancer with surgical resection of the tumor being the primary choice of treatment. However, the surgical stress response induced during treatment may be related to a higher risk of recurrence. The aim of this study was to examine the effect of surgery on adhesion of cultured colon cancer cells with or without expression of the tumour suppressor CDX2., Method: We enrolled 30 patients undergoing elective, curatively intended laparoscopic surgery for colon cancer in this study. Blood samples were drawn 1 day prior to surgery and 24 h after surgery. The samples of pre- and postoperative serum was applied to wild type colon cancer LS174T cells and CDX2 inducible LS174T cells and adhesion was measured with Real-Time Cell-Analysis iCELLigence using electrical impedance as a readout to monitor changes in the cellular adhesion., Results: Adhesion abilities of wild type LS174T cells seeded in postoperative serum was significantly increased compared to cells seeded in preoperative serum. When seeding the CDX2 inducible LS174T cells without CDX2 expression in pre- and postoperative serum, no significant difference in adhesion was found. However, when inducing CDX2 expression in these cells, the adhesion abilities in pre- and postoperative serum resembled those of the LS174T wild type cell line., Conclusions: We found that the adhesion of colon cancer cells was significantly increased in postoperative versus preoperative serum, and that CDX2 expression affected the adhesive ability of cancer cells. The results of this study may help to elucidate the pro-metastatic mechanisms in the perioperative phase and the role of CDX2 in colon cancer metastasis.

Background: Recent studies suggest better oncological results after open versus laparoscopic rectal resection for cancer. The external validity of these results has not been tested on a nationwide basis., Objective: This study aimed to identify risk factors for positive circumferential resection margin in patients undergoing surgery for rectal cancer with special emphasis on surgical approach., Design: This database study was based on the Danish nationwide colorectal cancer database. To identify risk factors for positive circumferential resection margin, we performed uni- and multivariate logistic regression analyses. To assess the role of surgical approach, a propensity score-matched analysis was performed., Settings: This study was conducted at public hospitals across Denmark., Patients: Patients undergoing elective rectal resection from October 2009 through December 2013 were included., Main Outcome Measures: The primary outcome measured was the risk of a positive circumferential resection margin., Results: Included in the final analyses were 2721 cases (745 operated on by an open approach; 1976 by laparoscopy). On direct comparison, positive circumferential resection margin occurred more often after open resection (6.3% vs 4.7%; p = 0.047). After multivariate analyses, tumors located low in the rectum, neoadjuvant chemoradiation therapy, increasing T and N stage, tumor fixated in the pelvis, and dissection in the muscularis plane increased the risk of a positive circumferential resection margin. In the propensity score-matched sample (541 exact matched pairs), the laparoscopic approach did not influence the risk of a positive circumferential resection margin (OR, 0.9; 95% CI, 0.6-1.5; p = 0.77)., Limitations: This was a retrospective review of prospectively collected data, and thereby contained possible selection bias., Conclusions: Based on this nationwide database study, and after multivariate and propensity score-matched analyses, there was no increased risk of positive circumferential resection margin after laparoscopic vs open rectal resection. See Video Abstract at http://links.lww.com/DCR/A996. MARGEN DE RESECCIÓN CIRCUNFERENCIAL DESPUÉS DE LA RESECCIÓN RECTAL LAPAROSCÓPICA Y ABIERTA: UN ESTUDIO DE COHORTE DE PUNTUACIÓN DE PROPENSIÓN A NIVEL NACIONAL: Estudios recientes sugieren mejores resultados oncológicos después de la resección rectal abierta versus laparoscópica. La validez de estos resultados no se ha probado a nivel nacional., Objetivo: Identificar los factores de riesgo del margen de resección circunferencial positivo en pacientes sometidos a cirugía por cáncer de recto con especial énfasis en el abordaje quirúrgico. DISEÑO:: Estudio de la base de datos nacional de Dinamarca de cáncer colorrectal. Para identificar los factores de riesgo del margen de resección circunferencial positivo, realizamos análisis de regresión logística uni y multivariable. Para evaluar el papel del abordaje quirúrgico, se realizó un análisis emparejado de puntuación de propensión., Ajustes: Hospitales públicos en toda Dinamarca., Pacientes: Pacientes sometidos a resección rectal electiva en el período comprendido entre octubre de 2009 y diciembre de 2013., Principales Medidas De Resultados: Riesgo del margen de resección circunferencial positivo., Resultados: 2721 casos (745 operados por abordaje abierto; 1976 por laparoscopia) se incluyeron en el análisis final. En la comparación directa, el margen de resección circunferencial positivo ocurrió más a frecuentemente, después de la resección abierta (6.3 vs 4.7%; p = 0.047). Posterior a los análisis multivariados, tumores localizados en el recto bajo, quimioterapia con radioterapia neoadyuvante, incremento de etapas T y la N, tumor fijo en pelvis y la disección en el plano muscular, aumentaron el riesgo del margen de resección circunferencial positivo. En la muestra emparejada del puntaje de propensión (541 pares coincidentes exactos), el abordaje laparoscópico no influyó en el riesgo del margen de resección circunferencial positivo (razón de probabilidades (IC 95%) 0.9 (0.6-1.5); p = 0.77)., Limitaciones: Revisión retrospectiva de los datos recopilados prospectivamente y por lo tanto, posible sesgo de selección., Conclusiones: El estudio de la base de datos a nivel nacional y después de los análisis emparejados multivariados y de puntuación de propensión, no hubo un mayor riesgo del margen de resección circunferencial positivo después de la resección laparoscópica versus resección abierta. Vea el Resumen del video en http://links.lww.com/DCR/A996.

Introduction: A subgroup of patients with benign colonic neoplasia is unsuitable for standard endoscopic treatment modalities. These patients may benefit from a combined endoscopic and laparoscopic surgical (CELS) approach. A CELS procedure may even be an option for some patients with a small malignant lesion where resection of the colon may be associated with an excessively high risk of proced-ure-related morbidity and mortality., Methods: All patients considered for a CELS procedure were evaluated at a multidisciplinary team conference. The CELS procedures were performed as laparoscopy-assisted endoscopic mucosal resections or endoscopy-assisted laparoscopic resections., Results: A total of 25 patients were included. Five patients had a malignant and 20 patients had a benign lesion. Two patients with histologically verified malignant lesions pre-operatively had CELS performed due to severe co-morbidity. In one patient with initially benign biopsies, the resected CELS specimen revealed adenocarcinoma. This patient subsequently underwent oncological resection (no residual disease). In the last two cases, the lesions were assessed during CELS and they exhibited endoscopically malignant features. Consequently, both patients underwent immediate oncological segmental colon resection., Conclusions: CELS is a feasible treatment for colonic neoplasia where endoscopic resection alone is not technically possible. In case of severe co-morbidity ruling out segmental resection in patients diagnosed with T1 or T2 colorectal cancer, CELS treatment may be considered., Funding: none., Trial Registration: This study was assessed by The National Committee on Health Research Ethics (SJ-593), which concluded that the study required no approval from the Committee. The study was approved by the Danish Data Protection Agency (REG-126-2017). ., (Articles published in the DMJ are “open access”. This means that the articles are distributed under the terms of the Creative Commons Attribution Non-commercial License, which permits any non-commercial use, distribution, and reproduction in any medium, provided the original author(s) and source are credited.)

Background: High-quality surgical resection of colonic cancer, including dissection along the embryologic mesocolic plane, translates into improved long-term oncological outcomes., Objective: This study aimed to identify risk factors for compromised specimen quality and to evaluate the specimen quality of patients undergoing laparoscopic and open resection for colonic cancer., Design: This is a retrospective observational study., Settings: This database study is based on the prospective national Danish Colorectal Cancer Database including patients undergoing intended curative elective colonic cancer surgery from January 1, 2010 through December 2013., Patients: A total of 5143 patients (1602 open resections; 3541 laparoscopic resections) with colonic cancer were included., Main Outcome Measures: Risk factors for poor resection quality were identified through uni- and multivariate logistic regression analysis. The surgical approach was assessed by propensity score-matched regression analysis. Poor resection quality was defined as resections in the muscularis plane accompanied by R0 resection, or resections in any resection plane accompanied by R1 resection., Results: Overall, 4415 (85.8%) of the resections were considered good and 728 (14.2%) were considered poor. After multivariate analysis, neoadjuvant oncological treatment, advanced tumor stage (T3-4), advancing N stage (N1-2), open tumor perforation, and open surgery significantly increased the risk of poor resection quality. In a propensity score-matched sample (n = 1508 matched pairs), matched for age, sex, ASA score, BMI, neoadjuvant treatment, tumor stage, and tumor location, open resection was still associated with a higher risk of poor resection quality compared with laparoscopic resection (OR, 1.4; 95% CI, 1.1-1.8; p = 0.002)., Limitations: Retrospective design was a limitation of this study., Conclusions: In this nationwide propensity score-matched database study, laparoscopic resection was associated with a higher probability of good resection quality compared with open resection for colonic cancer. Risk factors for compromised specimen quality were neoadjuvant oncological treatment, locally advanced tumor stage (T3-4), advanced N stage (N1-2), open tumor perforation, and open surgery. See Video Abstract at http://links.lww.com/DCR/A830.

Background: Orthostatic hypotension (OH) and intolerance (OI) are common findings in the early postoperative period after major surgery and may delay early mobilization. The mechanism of impaired orthostatic competence and OI symptoms is not fully understood, and specific data after colorectal surgery with well-defined perioperative care regimens and mobilization protocols are lacking. The aim of this study was to investigate the prevalence, possible risk factors and the impact of OI in patients undergoing elective minimal invasive colorectal cancer resection., Methods: A prospective single-centre study with an optimal enhanced recovery program and multimodal analgesic treatment. OI and OH were evaluated using a well-defined mobilization protocol preoperatively and 6 hour and 24 hour postoperatively., Results: A total of 100 patients were included in the data analysis. The overall median length of stay was 3 days (1-38). OI was observed in 53% of the patients 6 hour postoperatively and in 24% at 24 hour. OI at 6 hour postoperatively was associated with younger age, lower BMI, and female gender. At 24 hour postoperatively, female gender and ASA class >1 was associated with OI. Opioid consumption and intravenous fluid during the first 24 hour was not associated with OI. Postoperative complications were equally observed between patients with and without OI. Although not statistically significant, patients with OI at 24 hour postoperatively had prolonged LOS (mean 4.0 vs 7.5 days, P = 0.069) compared with patients without OI., Conclusion: Postoperative orthostatic intolerance is a common problem during the first 24 hour following laparoscopic colorectal resection and may be followed by delayed recovery., (© 2018 The Acta Anaesthesiologica Scandinavica Foundation. Published by John Wiley & Sons Ltd.)

Introduction: Simulation-based training in surgery helps trainees master laparoscopic skills, and training at home on mobile box trainers may allow trainees to reach proficiency faster. The aim of this study was to examine the added effects of training at home., Methods: Participants were trainees from departments of surgery, gynaecology and urology who were recruited while taking part in a laparoscopic training course. The interven-tion consisted of added access to a mobile box trainer allowing participants to train at home., Results: During a one-year study period, 36 participants completed the trial. There was no statistically significant difference in the number of days it took to complete the course (86 days versus 89 days, p = 0.89) or in the final test scores of the two groups (493 versus 460, p = 0.07). A sig-nificant difference in the number of training sessions at-tended was found (5.8 versus 2.3, p < 0.001). Participants were able to reliably rate their own performance; the intraclass correlation coefficient was 0.86, p < 0.001., Conclusions: Trainees who had access to training at home did not pass a test earlier or achieve a higher score at the end of a course than trainees who had no such access. Improved access to training at home allowed for shorter and more frequent sessions; however, testing and mandatory training requirements apparently determine training patterns. Trainees were able to reliably rate their own performance., Funding: Equipment for the study was provided by the Copenhagen Academy for Medical Education and Simulation, Capital Region of Denmark, Copenhagen, Denmark., Trial Registration: The study was exempt from ethical approval according to Danish legislation (H-3-2014-FSP31). The trial protocol was registered with www.clinicaltrials.gov prior to commencing the trial (NCT02243215)., (Articles published in the DMJ are “open access”. This means that the articles are distributed under the terms of the Creative Commons Attribution Non-commercial License, which permits any non-commercial use, distribution, and reproduction in any medium, provided the original author(s) and source are credited.)

Background: Robotic technology has been proven to be a safe alternative to conventional laparoscopy with regards to the peri- and postoperative clinical outcomes. Oncological outcomes have been scarcely examined. The purpose of this study was to examine the disease-free survival in relation to the two surgical approaches: robot-assisted surgery and conventional laparoscopy. In addition, all-cause mortality and recurrence-free survival were investigated., Methods: Between January 2010 and December 2015, patients, undergoing either laparoscopic or robot-assisted elective, curative-intended surgery for colorectal cancer were included., Results: A total of 9184 patients underwent surgery in the study period: 5978 patients for colon cancer and 3206 patients for rectal cancer. Among patients with colon cancer, 331 patients (5.5%) underwent robot-assisted surgery, and 449 patients (14.0%) underwent robot-assisted surgery in the rectal cancer group. In the adjusted analyses, the hazard ratio (HR) for disease-free survival, for patients with colon cancer was 0.91 [95% confidence interval (CI) 0.71-1.18]. For patients with rectal cancer, the adjusted HR was 0.83 (95% CI 0.65-1.06). No difference in all-cause mortality and recurrence-free survival were observed., Conclusions: The study demonstrated comparable rates of disease-free survival, all-cause mortality, and recurrence-free survival when comparing robot-assisted surgery with conventional laparoscopy in patients with colorectal cancer.

Background: Resection quality after robot-assisted surgery for colorectal cancer have not previously been investigated in a nationwide study. The aim of the study was to examine the resection quality in robot-assisted versus laparoscopic surgery for colorectal cancer. Furthermore, 30-day mortality, postoperative complications, and conversion to open surgery were investigated., Methods: Patients undergoing either laparoscopic or robot-assisted surgery for colorectal cancer between 1 January 2010 and 31 December 2015 were included. The primary outcome was whether R0 resection was achieved. Secondary outcomes were 30-day mortality, postoperative complications, and conversions to laparotomy., Results: A total of 8615 and 3934 patients had a diagnosis of colon cancer and rectal cancer respectively. Of the patients with colon cancer, 511 patients underwent robot-assisted surgery and of the patients with rectal cancer, 706 patients underwent robot-assisted surgery. In the multivariate analysis, patients with colon cancer had an odds ratio (OR) = 0.63 (95%CI 0.45-0.88) for receiving R0 resection in the robot-assisted group compared to laparoscopy. For patients with rectal cancer, the OR was 1.20 (95%CI 0.89-1.61). No difference in 30-day mortality or postoperative complications were observed. The OR of conversion to laparotomy was lower in the robot-assisted group compared to the laparoscopic group in both patients with colon - and rectal cancer., Conclusions: The study showed significant lower odds of receiving R0 resection in patients with colon cancer undergoing robot-assisted surgery. In patients with rectal cancer the robot-assisted surgery non-significantly increased the odds of receiving R0 resection., (Copyright © 2018 Elsevier Ltd. All rights reserved.)

Background: The quality of recovery-15 (QoR-15) is a patient-reported outcome measurement measuring QoR after surgery and anesthesia. The scale is arbitrary and ranges from 0 to 150. We aimed to classify the QoR-15 score into four severity classes; excellent, good, moderate, and poor recovery., Materials and Methods: Data from one prospective observational cohort study and two randomized clinical trials were merged and comprised 276 adult patients with an American Society of Anesthesiologists class of I-III undergoing acute laparoscopic surgery for suspected appendicitis. Merged data were split into a "training" set and a "validation" set. Optimal cutoff points for classifying the QoR-15 into excellent, good, moderate, and poor recovery were identified in the "training" set. The four severity classes according to the QoR-15 score were validated in the "validation" set using prespecified hypotheses., Results: The QoR-15 scores for excellent, good, moderate, and poor recovery were 136-150, 122-135, 90-121, and 0-89, respectively. A better severity class of recovery based on the QoR-15 score measured repeatedly six times over 30 d was associated with an increased chance of resuming recreational and occupational activities (P < 0.001). Patients with a better severity class of recovery on the first postoperative day had a lower incidence of postoperative complications within 30 d of surgery (P = 0.001)., Conclusions: After surgery and anesthesia, patients can be classified as being in poor, moderate, good, or excellent recovery based on the QoR-15 score., (Copyright © 2018 Elsevier Inc. All rights reserved.)

Background: Methylprednisolone administered intravenously preoperatively has been shown to reduce pain, nausea, and fatigue after elective surgery. We aimed to show that 125 mg of methylprednisolone given intravenously 30 minutes before laparoscopic surgery for suspected appendicitis would reduce pain at rest during the first 3 postoperative days., Methods: A multicenter, parallel-group, double-blind, placebo-controlled study was conducted including patients 18 years of age and older with an American Society of Anesthesiologist class of I-III undergoing laparoscopic surgery for suspected appendicitis. The primary outcome was pain at rest measured on the 11-point numerical rating scale 5 times during the first 3 days after surgery. The effect of 125 mg of methylprednisolone on postoperative pain at rest during the first 3 days was assessed using a mixed-effects model with time and intervention as main effects., Results: From April 2016 to August 2016, 78 patients were included, and all were eligible for analysis of the primary outcome. The estimated effect of 125 mg of methylprednisolone on pain at rest during the first 3 days after surgery was a nonsignificant increase of 0.2 (95% confidence interval, -0.5 to 0.9; P = .571) on the 11-point numerical rating scale. There was no difference between the 2 groups regarding the need for opioid agonists during hospital stay on the first postoperative day (P = .381)., Conclusions: A 125-mg dose of methylprednisolone given intravenously 30 minutes before laparoscopic surgery for appendicitis seemed no better than placebo at providing a clinical meaningful reduction in postoperative pain at rest.

Introduction: Recent studies have described the benefits of performing bowel resections for benign and malignant diseases as a total laparoscopic procedure with intra-corporeal anastomosis. We describe our preliminary experience with total laparoscopic surgery for benign lower gastrointestinal diseases., Methods: All patients (n = 32) who had received elective bowel surgery with intra-corporeal anastomosis for benign diseases between November 2013 and August 2015 were included in this retrospective study., Results: A total of 15 patients (47%) had a primary anastomosis, 17 patients (53%) had a stoma reversal. The median length of stay was five days (range: 3-16). Surgical complications requiring re-operation were present in five patients (Clavien-Dindo grade IIIb) of whom two presented with anastomotic leaks (6%; 95% confidence interval: 2-20%). No post-operative medical complications according to the Clavien-Dindo Classification were seen. The median duration of surgery was 127 min. (range: 61-211 min.). No deaths occurred., Conclusion: A total laparoscopic approach to benign lower gastrointestinal diseases with intra-corporeal ana-stomosis was feasible., Funding: none., Trial Registration: The trial is registered with the Danish Data Protection Agency., (Articles published in the DMJ are “open access”. This means that the articles are distributed under the terms of the Creative Commons Attribution Non-commercial License, which permits any non-commercial use, distribution, and reproduction in any medium, provided the original author(s) and source are credited.)

Introduction: Adaptive process triage (ADAPT) is a triage tool developed to assess the severity and address the priority of emergency patients. In 2009-2011, ADAPT was the most frequently used triage system in Denmark. Until now, no Danish triage system has been evaluated based on a selective group of patients in need of acute abdominal surgery. Gastrointestinal perforation (GIP) is acknowledged as one of the surgical conditions with the highest mortality rates. The aim of this study was to evaluate whether ADAPT can identify patients with GIP., Methods: All abdominal emergency laparoscopies and laparotomies performed over a one-year period at Herlev Hospital, Denmark, were included. Patient data and triage levels were collected from medical records. We defined patients suspected of less severe surgical illness as green-yellow and patients suspected of severe/life-threatening illness as orange-red., Results: A total of 803 patients with a known triage level were identified: 47% green, 38% yellow, 13% orange and 2% red. Of these patients, 136 were identified with a GIP. The negative predictive value was 83.2% (95% confidence interval: 80.1-85.7), meaning that one out of six abdominal surgery patients triaged as green or yellow had a GIP that was not identified by the triage system., Conclusion: ADAPT is incapable of identifying one of the most critically ill patient groups in need of emergency abdominal surgery., Funding: none., Trial Registration: HEH-2013-034 I-Suite: 02336., (Articles published in the DMJ are “open access”. This means that the articles are distributed under the terms of the Creative Commons Attribution Non-commercial License, which permits any non-commercial use, distribution, and reproduction in any medium, provided the original author(s) and source are credited.)

Purpose: Emergency abdominal surgery results in a high rate of post-operative complications and death. There are limited data describing the emergency surgical population in details. We aimed to give a detailed analyses of complications and mortality in a consecutive group of patients undergoing acute abdominal surgery over a 4-year period., Methods: This observational study was conducted between 2009 and 2013 at Copenhagen University Hospital Herlev, Denmark. All patients scheduled for emergency laparotomy or laparoscopy were included. Pre-, intra-, and post-operative data were collected from medical records. Complications were registered according to the Clavien-Dindo classification. Cox regression analysis was performed to identify risk factors for mortality., Results: A total of 4,346 patients underwent emergency surgery, of whom 14 % had surgical complications and 23 % medical complications. The overall 30-day mortality was 8 % with 50 % of those in this group over 80 years of age. The 30-day mortality rates were 0.8 % (95 % CI 0.5-1.1) and 17 % (95 % CI 15.5-18.9), respectively, for the laparoscopy and the laparotomy groups. The overall death rate within 24 h of surgery was 21 %. Several risk factors for 30- and 90-day mortality were identified: age, ASA ≥3 (American Society of Anaesthesiologists physical status classification), performance score (Zubroed/WHOclassification), cirrhosis of the liver, chronic nephropathy, several medical conditions, and malignancy., Conclusion: Almost one in five patients died after emergency laparotomy, of whom one in five died within 24 h of surgery. Predictors for poor outcome were identified.

Background: Simulation training can prepare trainees for clinical practice in laparoscopic surgery. Training on box trainers allows for simulation training at home, which studies have shown to be a feasible method of training. However, little research has been conducted into how to make it a more efficient method of training. Our aim was to investigate how box trainers are used in take-home training to help guide the design of take-home training courses., Methods: This study was designed using a mixed methods approach. Junior doctors participating in a laparoscopy curriculum, which included practising at home on box trainers, were invited. Quantitative data on training patterns was collected from logbooks. Qualitative data on the use of box trainers was retrieved from focus groups and individual interviews., Results: From logbooks, we found that 14 out of 18 junior doctors mixed their training modalities, and four practised first on box trainers then on virtual reality simulators. Twelve practised only at home, while five practised at both places and one practised solely at the simulation centre. After a delayed start, most practised for some time, then had a period without training and then started training again towards the end of the course. We found that the themes of the interviews were: training method, training pattern, feedback and self-regulation. Participants identified the lack of feedback as challenging but described how self-rating provided direction during unsupervised training. Mandatory training elements affected when and how much participants practised., Conclusions: When participants practised at home, they took an individualised approach to training. They mixed their training at home with training at the simulation centre. Participants practised at the beginning and towards the end of the course. Self-rating helped to guide unsupervised training where feedback was not accessible. Curricular requirements and testing determined when and how much participants practised.

Background: The focus of research in simulation-based laparoscopic training has changed from examining whether simulation training works to examining how best to implement it. In laparoscopic skills training, portable and affordable box trainers allow for off-site training. Training outside simulation centers and hospitals can increase access to training, but also poses new challenges to implementation. This review aims to guide implementation of off-site training of laparoscopic skills by critically reviewing the existing literature., Methods: An iterative systematic search was carried out in MEDLINE, EMBASE, ERIC, Scopus, and PsychINFO, following a scoping review methodology. The included literature was analyzed iteratively using a thematic analysis approach. The study was reported in accordance with the STructured apprOach to the Reporting In healthcare education of Evidence Synthesis statement., Results: From the search, 22 records were identified and included for analysis. A thematic analysis revealed the themes: access to training, protected training time, distribution of training, goal setting and testing, task design, and unsupervised training. The identified themes were based on learning theories including proficiency-based learning, deliberate practice, and self-regulated learning., Conclusions: Methods of instructional design vary widely in off-site training of laparoscopic skills. Implementation can be facilitated by organizing courses and training curricula following sound education theories such as proficiency-based learning and deliberate practice. Directed self-regulated learning has the potential to improve off-site laparoscopic skills training; however, further studies are needed to demonstrate the effect of this type of instructional design.

Objective: Simulation-based assessment tools have been developed to allow for proficiency-based simulator training in laparoscopy. However, few studies have examined the consequences of different standard setting methods or examined what level of proficiency is considered adequate for trainees. The objectives of the present study were to explore the consequences of different standard setting methods and to examine the proficiency level that surgical trainees are expected to reach, before performing supervised surgery on patients., Design: Study participants undertook the Training and Assessment of Basic Laparoscopic Techniques test. The tests were video-recorded and rated using a simple scoring system based on number of errors and time. Participants were then asked to assess how high a score a novice should reach before performing supervised surgery on a patient. We then compared 3 methods of standard setting: expert performance level, contrasting groups method, and a modified Angoff method., Setting: The study was conducted at the Copenhagen Academy for Medical Education and Simulation. The academy provides surgical simulation training in laparoscopy for trainees at the hospitals in the Capital Region and the Zealand Region of Denmark., Participants: Participants were recruited among surgical trainees in their first year of specialty training from surgery, gynecology, and urology departments. A total of 40 participants were included and completed the trial., Results: The different standard setting methods resulted in different pass/fail levels. At the expert performance level, the pass/fail level was 474 points-the contrasting groups method resulted in 358 points and the modified Angoff method resulted in 311 points among experienced surgeons, and 386 points among trainees. The different proficiency levels resulted in a failure rate of 0% to 50% of experienced surgeons and a pass rate of 0% to 25% of novices. Novice laparoscopic surgeons set a higher pass/fail level than experienced surgeons did (p = 0.008)., Conclusion: Required proficiency levels varies depending on the standard setting method used, which highlights the importance of using an established standard setting method to set the pass/fail level., (Copyright © 2016 Association of Program Directors in Surgery. Published by Elsevier Inc. All rights reserved.)

Background: Information about predictors for the duration of convalescence and the overall general wellbeing after laparoscopic surgery for suspected appendicitis is missing in the scientific literature. We aimed to describe and identify predictors for the duration of convalescence and the quality of recovery for patients undergoing laparoscopic surgery for suspected appendicitis., Methods: A prospective cohort of adult patients undergoing laparoscopic surgery for suspected appendicitis was performed between July 2014 and December 2014. Patients completed a QoR-15 questionnaire six times during the 30-d postoperative period. Time until resumption of recreational and occupational activities was recorded. Potential predictors for the duration of convalescence and the quality of recovery measured by the QoR-15 score were identified., Results: A total of 108 patients were included, and 95 patients were eligible for analysis. The median duration of convalescence was 13 d. Disease, depressive mood, level of recreational activities, age, and pain at rest on the first postoperative day were significant predictors of the duration of convalescence. Gender, postoperative complications, disease, and anxiety were significant predictors of the quality of recovery during the 30-d postoperative period. A 10% increase in the QoR-15 score increased the hazard ratio of 1.24 (95% confidence interval, 1.08-1.43, P = 0.002) for ending the period of convalescence., Conclusions: Duration of convalescence after laparoscopic surgery for appendicitis seems long. Psychological factors, demographical factors, and perioperative outcomes were important predictors for the quality of recovery and the duration of convalescence. Increased quality of recovery is associated with a shorter period of convalescence., (Copyright © 2016 Elsevier Inc. All rights reserved.)

Purpose: Our objective was to report postoperative urogenital dysfunction after rectal cancer surgery, identifying possible predictors including conventional laparoscopic total mesorectal excision and robot-assisted total mesorectal excision laparoscopic surgery., Materials and Methods: Questionnaires were mailed to 184 patients who underwent laparoscopic rectal cancer surgery between January 2009 and May 2013. Single questions were used to retrospectively assess preoperative urogenital dysfunction. Surgical data were collected from hospital records. Postoperative urinary and sexual function was measured with validated questionnaires and the results were statistically analyzed., Results: A total of 97 questionnaires were included in the study. Of those sexually active before the operation, 81% reported some degree of erectile dysfunction (ED). In total, 73% reported some degree of orgasmic dysfunction (OD). On multivariate analyses, older age was the only predictor for ED (P=0.0012). Older age (P=0.007) and having a rectal extirpation procedure (P=0.013) were predictors of OD., Conclusions: ED and OD are common after rectal cancer surgery. Robotic surgery was seemingly not associated with ED or OD.

Deep vein thrombosis and pulmonary embolism are well-known complications after surgery. Despite the widespread use of graduated elastic compression stockings as a mechanical prophylaxis method against thromboembolic complications, data supporting their use for patients under-going laparoscopic surgery for benign conditions are sparse. In this paper, we address the evidence for the effectiveness of the stockings as a method of prophylaxis in laparoscopic day surgery.

Laparoscopic colorectal cancer surgery results in a reduced impact on the immune system compared with open surgery. This is important when taken into consideration that the immune system may have an instrumental role in the advancement of cancer in the perioperative period. Several studies have shown that the perioperative period is characterized by an immune incompetent period, which is believed to favour tumour metastasis. In this paper factors associated with the cellular and innate immune response in relation to laparoscopic and open colorectal cancer surgery are reviewed.

Introduction: Abdominal adhesions are a frequent reason for chronic abdominal pain. The purpose of this systematic review was to investigate the evidence of performing laparoscopic adhesiolysis as a treatment for patients with chronic abdominal pain., Methods: Medline, Embase, and The Cochrane Central Register of Controlled Trials were searched for trials performing lysis of adhesions on patients suffering from chronic abdominal pain. Clinical studies on patients being treated for chronic abdominal pain with surgical adhesiolysis were included. The main outcome of the study was the postoperative assessment of symptoms. The Newcastle-Ottawa scale was used for bias assessment of non-randomized studies while the Jadad score was used for the randomized controlled trials., Results: A total of 25 studies were identified evaluating the efficacy of adhesiolysis in 1281 patients suffering from chronic abdominal pain. A total of 22 trials were identified as case-series and included no control group. Three studies were identified as randomized controlled trials (RCT). A benefit of the intervention varied from 16 to 88 % in the non-randomized studies, with the majority reporting pain relief in more than 50 % of their patients. However, analysis indicated a high risk of bias in most of the studies. The RCTs also showed variance, with one study showing benefit, one study showing benefit only in a subgroup in which the patients had dense and vascularized adhesions, and one study showed no difference between the intervention and control group., Conclusion: The identified studies showed promising but preliminary results of laparoscopic adhesiolysis as a treatment of chronic abdominal pain. The evidence for laparoscopic adhesiolysis is not sufficient to make definitive conclusions.

Objective: To monitor surgeons' performance and cognition during night shifts., Design: Surgeons were monitored before call and on call (17-hour shift). Psychomotor performance was assessed by laparoscopic simulation and cognition by the d2 test of attention. The surgeons performed the laparoscopic simulation and the d2 test of attention at 8 a.m. before call and at 4 a.m. on call. Sleep was measured by wrist actigraphy and sleepiness by the Karolinska sleepiness scale., Setting: Department of Surgery at Herlev Hospital, Denmark., Participants: Overall, 30 interns, residents, and attending surgeons were included and completed the study. One participant was subsequently excluded owing to myxedema., Results: The surgeons slept significantly less on call than before call. There was increasing sleepiness on call; however, no significant differences were found in the precall laparoscopic simulation values compared with on-call values. The d2 test of attention showed significantly improved values on call compared with before call., Conclusion: Sleep deprivation during a 17-hour night shift did not impair surgeons' psychomotor or cognitive performance., (Copyright © 2014 Association of Program Directors in Surgery. Published by Elsevier Inc. All rights reserved.)

This review aimed to present an overview of the randomized controlled trials investigating analgesic regimens used in laparoscopic Roux-en-Y gastric bypass (LRYGB) surgery. Literature search was performed in PubMed and EMBASE databases in August 2013 in accordance to PRISMA guidelines. The literature search identified nine studies eligible for inclusion. The administration of nonsteroidal anti-inflammatory drugs, local anesthetics (intraperitoneally or subfascially/subcutaneously), transversus abdominis plane block, dexmedetomidine, and ketamine may improve analgesia compared to placebo/controls in LRYGB. None of the studies incorporated multimodal procedure-specific analgesic regimens. The Oxford quality scoring system scores indicated a generally limited methodological quality of the included studies. This review documents a need for high-quality, procedure-specific literature concerning analgesic treatment in LRYGB surgery.