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Objective. To assess outcome and safety of 571 hybrid natural orifice transluminal endoscopic surgery (NOTES) cholecystectomies. Methods. We retrospectively analyzed all consecutive NOTES cholecystectomies performed at our center between June 2009 and January 2018. All procedures were performed using a hybrid transvaginal technique, including an umbilical small-size trocar. End points, calculated at discharge, 30 and up to 90 days postoperatively, included intra- and postoperative morbidity assessed by the validated Clavien–Dindo classification and the Comprehensive Complication Index (CCI). Special focus was held on outcome and necessity of pre- and postoperative gynecological examinations. Results. We performed 571 hybrid NOTES cholecystectomies within 9 years. The vast majority were elective, 9.6% were emergency cholecystectomies. 6.7% of patients developed at least one complication until discharge, most of them minor (≤grade II). 30- and 90-day complication rates were 10.7% and 11%, respectively. Mean CCI at discharge and postoperative days 30 and 90 was 1.45 (±6.4), 2.3 (±7.7), and 2.4 (±7.8), respectively. Major complications (≥grade IIIa) occurred in 1.6% of patients, and 4 patients required emergency reoperation. No mortality was observed. In 9.8%, an additional abdominal trocar was placed. All patients underwent routine gynecological examination, whereof only 5 were rejected for transvaginal access preoperatively. In no case transvaginal access was discontinued intraoperatively due to gynecological disease. Conclusion. Hybrid NOTES transvaginal cholecystectomy represents a safe and feasible alternative to standard laparoscopic cholecystectomy. Preoperative gynecological examination is no longer routinely necessary, as intraoperative assessment is adequate.

IntroductionPostoperative urinary retention (POUR) is a common complication after inguinal hernia repair with a reported incidence up to 34%. It can be described as the inability to initiate urination or insufficient bladder emptying following surgery. It usually requires the use of catheterisation to empty the bladder in order to prevent further injury to the bladder or kidneys and to relief from pain. Tamsulosin is a medication that is commonly used in men with urinary symptoms related to an enlarged prostate. There is some evidence to suggest that it may also potentially be beneficial for preventing POUR.Methods and analysisThis is a multicentre, blinded, prospective, phase IV randomised controlled trial with parallel allocation. Six hundred and thirty-four patients scheduled for elective endoscopic inguinal hernia repair surgery will be recruited. There will be effective (concealed) randomisation of the subjects to the intervention/control groups. Group assignment will be performed using a covariate-adaptive allocation procedure to provide a balance for selected covariates. The interventional group receives 0.4 mg tamsulosin hydrochloride and the control-group receives one placebo capsule matching the active study drug, both daily, starting from 5 days prior to the day of surgery, at the day of surgery and for 1 day following surgery. The primary outcome is any need for urinary catheterisation postoperatively as a binary outcome. Secondary outcome measures include postoperative pain, change in International Prostate Symptom Score from baseline prior to surgery to after surgery and hospital stay.Ethics and disseminationThe study has been approved by the Northwestern and Central Switzerland Ethics Committee (2020–00569) and it is being conducted in accordance with the Declaration of Helsinki and Good Clinical Practice. Study results will be disseminated through peer-reviewed journals and national and international scientific conferences.Trial registration numbersSNCTP000003904. NCT04491526.

INTRODUCTION AND OBJECTIVE:Robot-assisted laparoscopic surgery relies on CO2 insufflation to establish the operative field. Most residual CO2 is expelled prior to port and incision closure. While s...

Postoperative ileus after colorectal surgery is a frequent problem that significantly prolongs hospital stay and increases perioperative costs.The aim was to evaluate the effect of standardized coffee intake on postoperative bowel movement after elective laparoscopic colorectal resection.This is a prospective randomized controlled trial that was conducted between September 2014 and December 2016.This study was performed in a public cantonal hospital in Switzerland with accreditation for colon and rectum cancer surgery.Patients who underwent elective colorectal surgery were included.Patients were randomly assigned either to the intervention group receiving coffee or the control group receiving tea. A total of 150 mL of the respective beverage was drunk 3 times per day every postoperative day until discharge.The primary end point was time to first bowel movement. Secondary end points included the use of laxative, insertion of a nasogastric tube, length of hospital stay, and postoperative complications.A total of 115 patients were randomly assigned: 56 were allocated to the coffee group and 59 to the tea group. After coffee intake, the first bowel movement occurred after a median of 65.2 hours versus 74.1 hours in the control group (intention-to-treat analysis; p = 0.008). The HR for earlier first bowel movement after coffee intake was 1.67 (p = 0.009). In the per-protocol analysis, hospital stay was shorter in the coffee group (6 d in the coffee group vs 7 d in the tea group; p = 0.043).The rate of protocol violation, mostly coffee consumption in the tea arm, was relatively high, even if patients were clearly instructed not to consume coffee if they were in the tea arm.Coffee intake after elective laparoscopic colorectal resection leads to faster recovery of bowel function. Therefore, coffee intake represents a simple and effective strategy to prevent postoperative ileus. See Video Abstract at http://links.lww.com/DCR/A955.clinicaltrials.gov identifier: NCT02469441.

Enhanced recovery (ERAS) guidelines do not differentiate between left- and right-sided colectomies, but differences in recovery have been reported for the two procedure types. We aimed to compare compliance with the ERAS protocol and outcomes after right versus left colectomy. Between June 2011 and September 2014, all patients undergoing elective colonic resection were treated according to a standardized ERAS protocol and entered a prospective database. This retrospective analysis compared right and left colectomy regarding application of the ERAS pathway, bowel recovery, complications, and hospital stay. Eighty-five patients with right colectomy matched well with 138 left-sided resections for baseline demographics. Overall compliance with the ERAS protocol was 76 % for right versus 77 % for left colectomy patients (p = 0.492). First flatus occurred at postoperative day 2 in both groups (p = 0.057); first stool was observed after a median of 3 (right) and 2 days (left), respectively (p = 0.189). Twenty patients (24 %) needed postoperative nasogastric tube after right colectomy compared to 11 patients (8 %) after left colectomy (p = 0.002). Overall complication rates were 49 and 37 % for right and left colectomy, respectively (p = 0.071). Median postoperative length of stay was 6 days (IQR 4-9) after right and 5 days (IQR 4-7.5) after left colectomy (p = 0.020). Overall compliance with the protocol was equally high in both groups showing that ERAS protocol was applicable for right and left colectomy. Functional recovery however, tended to be slower after right colectomy, and postoperative ileus rate was significantly higher. More cautious early feeding after right colectomy should be considered.

The success of enhanced recovery (ERAS) pathways depends on the actual application of the intended protocol (adherence), but its full implementation remains challenging. In order to potentially streamline the pathway, it is indispensable to know the impact of individual items and the entire protocol on clinical outcomes. Retrospective analysis including all consecutive colorectal ERAS patients since implementation (May 2011) until February 2014; demographics, adherence and outcomes were retrieved from a prospectively maintained database. Primary outcome was the impact of individual item and of the entire protocol on complications (overall and major) and length of hospital stay. Statistical analysis included logistic multivariate regression and adjustment for confounding factors. There were 328 patients with complete data sets analyzed. A minimally invasive approach [odd ratio (OR) 0.62; confidence interval (CI) 0.4-0.9] was significantly associated with less overall complications. In contrast, the use of prophylactic nasogastric tubes (OR 3.18; CI 1.4-7.4), prophylactic abdominal and pelvic drains (OR 1.96; 1.2-3.2) and intraoperative thoracic epidural analgesia (OR 1.76; CI 1.3-2.4) were associated with more overall complications. Minimal invasive approach was further associated with reduced hospital stay (OR 0.5; CI 0.4-0.7) and less major complications (OR 0.58; CI 0.4-0.8). Higher adherence to the entire ERAS protocol was associated with significantly less complications (P < 0.001) and shorter hospital stay (P < 0.001). Minimally invasive surgery was the single most important component of the ERAS pathway while nasogastric tubes, drains and epidurals should be avoided. Overall, increasing adherence with the protocol was associated with better outcomes and should be the goal.

Enhanced recovery after surgery (ERAS) protocols advocate no nasogastric tubes after colorectal surgery, but postoperative ileus (POI) remains a challenging clinical reality. The aim of this study was to assess incidence and risk factors of POI. This retrospective analysis included all consecutive colorectal surgical procedures since May 2011 until November 2014. Uni- and multivariate risk factors for POI were identified by multiple logistic regression and functional and surgical outcomes assessed. The study cohort consisted of 513 consecutive colorectal ERAS patients. One hundred twenty-eight patients (24.7%) needed postoperative reinsertion of nasogastric tube at the 3.9 ± 2.9 postoperative day. Multivariate analysis retained the American Society of Anesthesiologists group 3-4 (odds ratio (OR) 1.3; 95% CI 1-1.8, p = 0.043) and duration of surgery of >3 h (OR 1.3; 95% CI 1-1.7, p = 0.047) as independent risk factors for POI. Minimally invasive surgery (OR 0.6; 95% CI 0.5-0.8, p ≤ 0.001) and overall compliance of >70% to the ERAS protocol (OR 0.7; 95% CI 0.6-1, p = 0.031) represented independent protective factors. POI was associated with respiratory (23 vs. 5%, p ≤ 0.001) and cardiovascular (16 vs. 3%, p ≤ 0.001) complications. POI was frequent in the present study. Overall compliance to the ERAS protocol and minimally invasive surgery helped to prevent POI, which was significantly correlated with medical complications.

Introduction: Enhanced recovery after surgery (ERAS) pathways proved to reduce complications, length of hospital stay and costs after colorectal surgery. Standardized discharge criteria have been established that are fulfilled after complete medical recovery is achieved. This study aimed to assess the timing of complete medical recovery in relation to the timing of actual discharge, and to assess reasons for prolonged hospital stay within an ERAS pathway. Methods: One hundred fourteen consecutive patients undergoing elective colorectal surgery within an ERAS pathway were included in this prospective analysis. Fulfillment of discharge criteria was assessed daily and reasons for prolonged hospital stay were documented. Results: Thirty percent of patients went home on the day that all discharge criteria were met. Overall, patients were discharged at a median of 2 days (interquartile range 1-3) after fulfillment of discharge criteria. Reasons for delayed discharge were (1) organizational in 20%; (2) patient or surgeon unwilling in 29%; and (3) because the patient was deemed to be discharged too soon distance from the operation in 51%. Conclusion: In this observational study, only 30% of patients were discharged on the day all recovery criteria were met. The main reason for continued hospitalization was surgeon- or patient-related reluctance or ‘precaution'; thus, better and more of general information seems to be necessary.

Background. Serum procalcitonin (PCT) is a useful biomarker to tailor the duration of antibiotics in respiratory infections. The objective of this study was to determine whether PCT levels could tailor postoperative antibiotic therapy in patients operated for peritonitis. Method. Patients with peritonitis were randomized postoperatively. The control group received antibiotics for a defined duration according to institutional guidelines. In the study group, antibiotics were stopped based on serum PCT levels. Patients were stratified into three categories: (1) gastrointestinal perforation, (2) perforated appendicitis, and (3) postoperative complication. Primary outcome was duration of antibiotics. Results. We included 162 patients: 83 and 79 patients in the control group and study group, respectively. In the subgroup of patients with peritonitis due to gastrointestinal perforation, we found 7 days of antibiotics in the PCT group versus 10 days in the control group (p value 0.065). There was no difference in infectious complications, mortality, median length of hospital stay, and necessity to restart antibiotics. Conclusion. No significant differences were found in duration of antibiotics when applying PCT guidance. However, in the subgroup of primary perforation of the gastrointestinal tract, there was a difference in duration of antibiotics in favor of the PCT group without obtaining significance, as the study was not powered for subgroup analysis. Further studies including only this subgroup should be performed.

Item does not contain fulltext BACKGROUND: We aim to determine if C-reactive protein (CRP), lipopolysaccharide-binding protein (LBP), and procalcitonin (PCT) in drain fluid can serve as screening tools for colorectal anastomotic leakage (CAL). METHODS: Patients included in this multicenter prospective observational study underwent left hemicolectomy, sigmoid resection, high anterior resection, low anterior resection, or subtotal colectomy. During the first 5 postoperative days, CRP, LBP, and PCT were determined on drain fluid. RESULTS: In total 243 patients were included, of whom 19 (8%) developed CAL. CRP levels were higher in patients with leakage on day 3 and day 5, levels of LBP were higher on days 2, 3, and 4, and PCT levels were higher on day 5. Multivariate analysis showed LBP to be significantly related to CAL. An increase in the average initial value at the first postoperative day with 1 standard deviation increased the risk of leakage by 1.6 times. CONCLUSION: Increased concentrations of LBP in drain fluid are significantly associated to a higher chance of CAL and could contribute in a future prognostic model for CAL. 01 september 2014

Item does not contain fulltext PURPOSE: With current diagnostic methods, the majority of patients with symptomatic colorectal anastomotic leakage(CAL) is identified approximately 1 week after operation.The aim of this study is to determine whether real-time polymerase chain reaction (RT-PCR) for detection of Escherichia coli and Enterococcus faecalis on drain fluid can serve as a screening test for CAL in the early postoperative phase. METHODS: All patients included in this multicenter prospective observational study underwent left-sided colorectal resection for both malignant and benign diseases with construction of an anastomosis. In all patients, an intra-abdominal drain was placed during operation. During the first five postoperative days, drain fluid was processed for RT-PCR. The quantitative results of the RT-PCR on days 2 to 5 were compared to the results of day 1 in order to detect concentration changes. RESULTS: In total, 243 patients, with both benign and malignant diseases, were included of whom 19 (7.8 %) developed symptomatic CAL. An increase in E. coli concentration was found insignificantly more patients with CAL on day 4 and 5 [p =0.0004; diagnostic odds ratio (DOR) 7.9]. For E. faecalis, this result was found for days 2, 3, and 4 (p

Many different techniques of colorectal anastomosis have been described in search of the technique with the lowest incidence of anastomotic leak. A systematic review of leak rates of techniques of hand-sewn colorectal anastomosis was conducted to provide a guideline for surgical residents and promote standardization of its technique. Clinical and experimental articles on colorectal anastomotic techniques and anastomotic healing published in the past 4 decades were searched. We included evidence on suture material, suture format, single- vs double-layer sutures, interrupted vs continuous sutures, hand-sewn vs stapled and compression colorectal anastomosis, and anastomotic configuration. In total, 3 meta-analyses, 26 randomized controlled trials, 11 nonrandomized comparative studies, 20 cohort studies, and 57 experimental studies were found. Results show that, for many aspects of the hand-sewn colorectal anastomosis technique, evidence is lacking. A single-layer continuous technique using inverting sutures with slowly absorbable monofilament material seems preferable. However, in contrast to stapled and compression colorectal anastomoses, the technique for hand-sewn colorectal anastomoses is nonstandardized with regard to intersuture distance, suture distance to the anastomotic edge, and tension on the suture. We believe detailed documentation of the anastomotic technique of all colorectal operations is needed to determine the role of the hand-sewn colorectal anastomosis.

Anastomotic leakage after colorectal surgery is correlated with considerable morbidity and mortality. Although many studies focus on risk factors and detection, studies on the treatment strategy for colorectal anastomotic leakage are scarce. A national questionnaire amongst 350 members of the Dutch Society for Gastrointestinal Surgery was undertaken on the current treatment of colorectal anastomotic leakage. The response was 40% after two anonymous rounds. 27% of the respondents state that a leaking anastomosis above the level of the promontory should be salvaged in ASA 1-2 patients 80 years of age this percentage is 7.3%. For an anastomosis under the promontory, 50% of the respondents choose preserving the anastomosis for ASA 1-2 compared to 17% for ASA 3 and/or >80 years of age. In ASA 1-2 patients with a local abscess after a rectum resection without protective ileostomy, 31% of the respondents will create an protective ileostomy, 40% break down the anastomosis to create a definite colostomy, in ASA 3 and/or >80 years of age 14% of the respondents create a protective ileostomy and 63% a definitive colostomy. In ASA 1-2 patients with peritonitis after a rectum resection with deviating ileostomy, 31% prefer a laparotomy for lavage and repair of the anastomosis, 25% for lavage without repair and 36% of the respondents prefer to break down the anastomosis. When the patient is ASA 3 and/or >80 years of age, 13% prefer repair, 9% a lavage and 74% breaking down the anastomosis. This questionnaire shows that in contrast to older people, more surgeons make an effort to preserve the anastomosis in younger people.

Enhanced recovery after surgery (ERAS) pathway includes recovery goals requiring active participation of the patients; this may be perceived as "aggressive" care in older patients. The aim of the present study was to assess whether ERAS was feasible and beneficial in older patients. Since June 2011, all consecutive colorectal patients were included in an ERAS pathway and documented in a dedicated prospective database. This retrospective analysis included 513 patients, 311 younger patients (

Background Enhanced recovery after surgery (ERAS) guidelines for colorectal surgery suggest routine transurethral bladder drainage with early removal to prevent urinary tract infection (UTI). The aim of this study was to identify risk factors for urinary retention (UR). Methods This retrospective analysis included all colorectal patients since ERAS implementation in May 2011-November 2014. From the prospective ERAS database, over 100 items related to demographics, surgery, compliance, and outcome were analyzed. Risk factors for UR were identified by multiple logistic regressions; then, UR was correlated to functional outcomes and UTI and acute kidney injury rates. Results The study cohort consisted of 513 consecutive patients. Of these, 73 patients (14%) presented with UR. Multivariate analysis identified male gender (odds ratio 1.4; 95% CI, 1-1.8; P = 0.045) and postoperative thoracic epidural analgesia (EDA; odds ratio 2.6; 95% CI, 1.6-4.3; P ≤ 0.001) as independent risk factors for postoperative UR. Functional recovery was impeded in patients with UR, who were less mobile (mobilization day 1 >4 h: 57% versus 70%, P = 0.024) and gained more weight (2.8 ± 2.5 kg versus 1.6 ±3 kg on day 1, P = 0.001) due to fluid overload. Furthermore, patients with urinary catheters reported more pain (visual analog scales day 3: 3.1 ± 2.5 versus 2.2 ± 2.4, P = 0.002) and depended longer on intravenous fluid administration (termination of intravenous fluids later than day 1: 53% versus 39%, P = 0.021). Ten of 73 patients (14%) developed UTI in patients with UR and 42 of 440 (10%) in patients without UR (P = 0.276). Six of 73 patients (8%) developed acute kidney injury in patients with UR and 36 of 440 (8%) in patients without UR (P = 0.991). Conclusions Male gender and EDA were independent risk factors for postoperative UR which appeared to be a significant impediment for functional recovery.

Background Mechanical bowel preparation (MBP) has been shown to have no influence on the incidence of anastomotic leakage in overall colorectal surgery. The role of MBP in elective surgery in combination with an inflammatory component such as diverticulitis is yet unclear. This study evaluates the effects of MBP on anastomotic leakage and other septic complications in 190 patients who underwent elective surgery for colonic diverticulitis. Methods A subgroup analysis was performed in a prior multicenter (13 hospitals) randomized trial comparing clinical outcome of MBP versus no MBP in elective colorectal surgery. Primary endpoint was the occurrence of anastomotic leakage in patients operated on for diverticulitis, and secondary endpoints were septic complications and mortality. Results Out of a total of 1,354 patients, 190 underwent elective colorectal surgery (resection with primary anastomosis) for (recurrent or stenotic) diverticulitis. One hundred and three patients underwent MBP prior to surgery and 87 did not. Anastomotic leakage occurred in 7.8 % of patients treated with MBP and in 5.7 % of patients not treated with MBP (p = 0.79). There were no significant differences between the groups in septic complications and mortality. Conclusion Mechanical bowel preparation has no influence on the incidence of anastomotic leakage, or other septic complications, and may be safely omitted in case of elective colorectal surgery for diverticulitis.

Ischemic-type biliary lesions (ITBL) are the most frequent cause of nonanastomotic biliary strictures after liver transplantation. This complication develops in up to 25% of patients, with a 50% retransplantation rate in affected patients. Traditionally, ischemia-reperfusion injury to the biliary system is considered to be the major risk factor for ITBL. Several other risk factors for ITBL have been identified, including the use of liver grafts donated after cardiac death, prolonged cold and warm ischemic times and use of University of Wisconsin preservation solution. In recent years however, impaired microcirculation of the peribiliary plexus (PBP) has been implicated as a possible risk factor. It is widely accepted that the PBP is exclusively provided by blood from the hepatic artery, and therefore, the role of the portal venous blood supply has not been considered as a possible cause for the development of ITBL. In this short report, we present three patients with segmental portal vein thrombosis and subsequent development of ITBL in the affected segments in the presence of normal arterial blood flow. This suggests that portal blood flow may have an important contribution to the biliary microcirculation and that a compromised portal venous blood supply can predispose to the development of ITBL.

Item does not contain fulltext PURPOSE: Both "high tie" (HT) and "low tie" (LT) are well-known strategies in rectal surgery. The aim of this study was to compare colonic perfusion after HT to colonic perfusion after LT. METHODS: Patients undergoing rectal resection for malignancy were included. Colonic perfusion was measured with laser Doppler flowmetry, immediately after laparotomy on the antimesenterial side of the colon segment that was to become the afferent loop (measurement A). This measurement was repeated after rectal resection (measurement B). The blood flow ratios (B/A) were compared between the HT group and the LT group. RESULTS: Blood flow was measured in 33 patients, 16 undergoing HT and 17 undergoing LT. Colonic blood flow slightly decreased in the HT group whereas the flow increased in the LT group. The blood flow ratio was significantly higher in the LT group (1.48 vs. 0.91; p = 0.04), independent of the blood pressure. CONCLUSION: This study shows the blood flow ratio to be higher in the LT group. This suggests that anastomoses may benefit from better perfusion when LT is performed.

BACKGROUND:Respiratory variations in arterial pulse pressure (ΔPPman) are accurate predictors of fluid responsiveness in mechanically ventilated patients. However, they cannot be continuously monitored. In our study, we assessed the clinical utility of a novel algorithm for automatic estimation of Δ

Purpose Incisional hernia (IH) is one of the most frequent postoperative complications. Of all patients undergoing IH repair, a vast amount have a hernia which can be defined as a large incisional hernia (LIH). The aim of this study is to identify the preferred technique for LIH repair. Methods A systematic review of the literature was performed and studies describing patients with IH with a diameter of 10 cm or a surface of 100 cm 2 or more were included. Recurrence hazards per year were calculated for all techniques using a generalized linear model. Results Fifty-five articles were included, containing 3,945 LIH repairs. Mesh reinforced techniques displayed better recurrence rates and hazards than techniques without mesh reinforcement. Of all the mesh techniques, sublay repair, sandwich technique with sublay mesh and aponeuroplasty with intraperitoneal mesh displayed the best results (recurrence rates of

BACKGROUND & AIMS: The importance of nursing for surgical patients has been frequently underestimated. The success of enhanced recovery programs after surgery (ERAS) depends on preferably complete fulfilment of the protocol and nurses are an important part of it. Due to the additional nursing action required, such protocols are suspected to increase the nursing workload. The aim of the present study was to observe and measure objectively nursing workload before, during and after systematic implementation of a comprehensive enhanced recovery pathway in colorectal surgery. METHODS: The program ERAS was introduced systematically in our tertiary academic centre 2011, since then our experience is based on more than 1500 ERAS patients. Nursing workload was prospectively assessed for all patients on a routine basis by means of a standardized and validated point system (PRN). In a retrospective cohort study, we compared nursing workload based on prospective data before, during and after ERAS implementation and correlated nursing workload to the compliance with the ERAS protocol. RESULTS: The study cohort included 50 patients before ERAS implementation (2010) and 69 (2011) and 148 (2012) consecutive patients after implementation; the baseline characteristics of the 3 groups were similar. Mean PRN values were 61.2 ± 19.7 per day in 2010 and decreased to 52.3 ± 13.7 (P = 0.005) and 51.6 ± 18.6 (P < 0.002) in 2011 and 2012, respectively. Increasing compliance with the ERAS protocol was significantly correlated to decreasing nursing workload (ρ = -0.42; P < 0.001). CONCLUSIONS: Nursing workload is - against a common belief - decreased by systematic implementation of enhance recovery protocol. The higher the compliance with the pathway, the lower the burden for the nurses!

Background In colorectal surgery, anastomotic leakage (AL) is the most significant complication. Sealants applied around the colon anastomosis may help prevent AL by giving the anastomosis time to heal by mechanically supporting the anastomosis and preventing bacteria leaking into the peritoneal cavity. The aim of this study is to compare commercially available sealants on their efficacy of preventing leakage in a validated mouse model for AL. Methods Six sealants (Evicel, Omnex, VascuSeal, PleuraSeal, BioGlue, and Colle Chirurgicale Cardial) were applied around an anastomosis constructed with five interrupted sutures in mice, and compared with a control group without sealant. Outcome measures were AL, anastomotic bursting pressure, and death. Results In the control group there was a 40% death rate with a 50% rate of AL. None of the sealants were able to diminish the rate of AL. Furthermore, use of the majority of sealants resulted in failure to thrive, increased rates of ileus, and higher mortality rates. Conclusions If sealing of a colorectal anastomosis could achieve a reduction of incidence of clinical AL, this would be a promising tool for prevention of leakage in colorectal surgery. In this study, we found no evidence that sealants reduce leakage rates in a mouse model for AL. However, the negative results of this study make us emphasize the need of systemic research, investigating histologic tissue reaction of the bowel to different sealants, the capacity of sealants to form a watertight barrier, their time of degradation, and finally their results in large animal models for AL.

Adequate working space is a prerequisite for safe and efficient minimal access surgery. No objective data exist in literature about the effect of mechanical bowel preparation (MBP) on working space in laparoscopic surgery. We objectively measured this effect with computed tomography in a porcine laparoscopy model. Using standardized anesthesia, twelve 20-kg pigs without MBP and eight 20-kg pigs with MBP were studied with computed tomography at intra-abdominal pressure (IAP) levels of 0, 5, 10, and 15 mmHg. Volumes and dimensions of the pneumoperitoneum were measured on reconstructed CT images and compared between the pigs with and those without MBP. A reproducible and statistically significant increase of approximately 500 ml in pneumoperitoneum volume was found in the MBP group at all levels of IAP. This represents a 43 % relative increase at a pneumoperitoneum pressure of 5 mmHg, 21 % at IAP 10 mmHg, and 18 % at IAP 15 mmHg. Peak inspiratory pressure was lower at IAP 0 and 5 mmHg in the MBP group. Anteroposterior diameter in the group with MBP was lower at 0 mmHg, but abdominal dimensions were similar in both groups at all other IAPs. This shows that the gain in working space is due to a diminished volume of the intra-abdominal content and not to compression or displacement of the bowel. MBP increases working space by reducing bowel content. Especially at low intra-abdominal working pressures, the increase in working space associated with MBP could represent an important benefit in challenging laparoscopic surgery.

Background: Adhesion formation after surgery for peritonitis-related conditions, with such associated complications as intestinal obstruction, pain, and infertility, remains an important problem. Applying a liquid barrier intra-peritoneally might reduce initial adhesion formation. Methods: A combination of the cecal ligation and puncture model of peritonitis with the side-wall defect (SWD) model of adhesion formation was performed. Forty rats were assigned randomly to receive no barrier or 1 mL or 2 mL of the cross-linked polyvinyl alcohol and carboxymethylcellulose (PVA/CMC) hydrogel A-Part (R) Gel (B. Braun Aesculap AG, Tuttlingen, Germany). After 14 days, the animals were sacrificed, and adhesion formation and abscess formation were scored. Results: Thirty animals survived, distributed equally among the groups. There were significantly fewer adhesions to the SWD in the PVA/CMC groups (median 0) than in the control group (median 26%-50%) (p < 0.05). The median tenacity of the adhesions was significantly higher in the control group (Zuhlke score 2) than in the PVA/CMC groups (Zuhlke score 0) (p < 0.05). The amount and size of intra-abdominal abscesses were not significantly different in the three groups. Conclusion: In this experiment, PVA/CMC hydrogel reduced the amount of adhesions to the SWD and between viscera significantly with equal risk of abscess formation.

Background With an increasing percentage of colorectal resections performed laparoscopically nowadays, there is more emphasis on training “before the job” on operative skills, including the comprehension of specific laparoscopic surgical anatomy. As integration of technical skills with correct interpretation of the anatomical image must be incorporated in laparoscopic training, a human specimen training model with special emphasis on surgical anatomy was developed. Methods The new embalming method Anubifix™ combines long-term high-quality embalming of human bodies with almost normal flexibility and plasticity, and the body can be kept operational as long as conventionally embalmed human specimens. A colorectal training model was created in a specimen in which anatomical landmarks of colorectal anatomy were permanently colored to explore laparoscopic colorectal anatomy in a skills training setting. Airtight closure of the abdominal wall permits the creation of pneumoperitoneum. Residents were asked to test the model by mobilizing the small and large bowels and expose the central vessels and ureters. Afterward they were asked to fill out an eight-item questionnaire about the model. Results Eleven surgical residents in their first and second year of training participated. Responses to the questionnaire showed that a majority of residents considered the model to be representative of the real situation and superior to animal models or virtual reality simulators, and helped to improve the knowledge of three-dimensional anatomy and laparoscopic skills. Conclusion The new training model for laparoscopic colorectal surgery proved to be a high-quality tool, concentrating on laparoscopic colorectal anatomy in a skills training setting. We believe it may be a valuable adjunct to residency training programs based on the principle of “training before the job.”

Adhesions follow abdominal surgery with an incidence as high as 95%, resulting in invalidating complications such as bowel obstruction, female infertility, and chronic pain. Searches have been performed for a safe and effective adhesion barrier; however, such barriers have impaired anastomotic site healing. The primary aim of this study was to investigate the effect of a new adhesion barrier, polyvinyl alcohol gel, on healing of colonic anastomoses using a rat model.Thirty-two Wistar rats were divided in two groups. In all animals, an anastomosis was constructed in the ascending colon. The first group received no adhesion barrier, whereas in the second group, 2 mL of polyvinyl alcohol gel (A-Part Gel(®); Aesculap AG, Tuttlingen, Germany) was applied circularly around the anastomosis. All animals were sacrificed on the seventh post-operative day, and the abdomen was inspected for signs of anastomotic leakage. The anastomotic bursting pressure, the adhesions around the anastomosis, and the collagen content of the excised anastomosis were measured.No significant differences were observed between the two groups in the incidence of anastomotic leakage, the anastomotic bursting pressure (p=0.08), or the collagen concentration (p=0.91). No significant reduction in amount of adhesions was observed in the rats receiving polyvinyl alcohol gel.This experimental study showed no significant differences in anastomotic leakage, anastomotic bursting pressure, or collagen content of the anastomosis when using the adhesion barrier polyvinyl alcohol around colonic anastomoses. The barrier did not prevent adhesion formation.

Objective: The aim of this study was to determine the contribution of the hepatic artery, gastroduodenal artery, and portal vein to the microvascular blood flow in the common bile duct (CBD). Background: Biliary complications are a common cause of graft loss after liver transplantation. The occurrence is, partly, attributed to hepatic artery thrombosis, which is considered to be the sole provider of blood flow to the bile ducts. However, the contribution of the portal vein and the gastroduodenal artery to the bile ducts is unknown. Methods: Microvascular blood flow in the CBD was determined in 15 patients who underwent a pancreaticoduodenectomy with a combination of laser Doppler flowmetry and reflectance spectrophotometry. Microvascular blood flow was measured at baseline, during clamping the portal vein, during clamping the hepatic artery, and during clamping both. After transection of the CBD, these 4 measurements were repeated. Results: Compared with baseline measurements, the microvascular blood flow through the CBD decreased to 62% after clamping the portal vein, 51% after clamping the hepatic artery, and 31% after clamping both. After the CBD was transected, these 3 measurements were 60%, 31%, and 20%, respectively. Conclusions: Historically, the hepatic artery has been considered mainly responsible for biliary blood flow. We show that after transection of the CBD, mimicking the situation after liver transplantation, the contribution of the portal vein to the microvascular blood flow through the CBD is 40%. This study emphasizes the importance of the portal vein, and disturbances in portal venous blood flow could contribute to the formation of biliary complications after liver transplantation.

Background: Much has been published on the role of mechanical bowel preparation (MBP) in open colorectal resection; however, the current study shows little evidence on the use of MBP prior to laparoscopic colorectal resections. In contrast to open procedures, MBP could influence the diameter of the bowel and thus the exposure of the surgical field in laparoscopy. This study aimed to assess the current practice of Dutch laparoscopic surgeons regarding MBP prior to colorectal resections. Methods: In January 2010, members of the Dutch Association for Endoscopic Surgery were invited to fill out an online questionnaire investigating whether MBP is prescribed prior to laparoscopic colorectal surgery, and which considerations are taken into account when choosing or omitting MBP. Results: The 82 (49%) returned questionnaires showed that 20% of respondents prescribe MBP prior to colonic resections, while 63% prescribe MBP prior to rectal resections. The most common reasons for giving MBP were the construction of a protective ileostoma (22%), improvement of the surgical field exposure (16%), and "other reasons" specified by free text (21%). The three most common reasons for conversion were inadequate surgical field exposure (88%), locally advanced tumor (68%), and adhesions (29%). Concerning the question which stages of the operation are influenced by MBP, 29% of respondents believed that the diameter of the small bowel was influenced by MBP, 29% indicated that the exposure of the surgical field was influenced by MBP, and 52% did not believe that any of the stages of the operation were influenced by MBP. Conclusion: The results of this questionnaire indicate that the implementation of MBP in laparoscopic colorectal surgery is based on individual preferences in the Netherlands. This emphasizes the need of new studies investigating the role of MBP on surgical field exposure in colorectal laparoscopic surgery.

BACKGROUND: Anastomotic leakage (AL) is the most feared complication of colorectal surgery. Atherosclerosis is suggested to have a detrimental effect on anastomotic healing. This study aimed to analyze the calcium score, a measure for atherosclerosis, as a risk factor for AL.STUDY DESIGN: The calcium scores of colorectal patients operated on in 2 Dutch university medical centers were determined using a computed tomography scan and calcium scoring software. The aorta, common iliac arteries, internal and external iliac arteries were studied. Additionally, patient- and operation-related factors were scored.RESULTS: A total of 122 patients were included. In patients with AL, calcium scores were significantly higher in the left common iliac artery (561.4 vs 156.0, P = .028), right common iliac artery (542.0 vs 144.4, P = .041), both common iliac arteries together (1,103.3 vs 301.9, P = .046), and the left internal iliac artery (716.3 vs 35.3, P = .044).CONCLUSIONS: Patients with higher calcium scores in the iliacal arteries have an increased leakage risk. (C) 2011 Elsevier Inc. All rights reserved.

Left ventricular stroke area by transoesophageal echocardiographic automated border detection has been shown to be strongly correlated to left ventricular stroke volume. Respiratory variations in left ventricular stroke volume or its surrogates are good predictors of fluid responsiveness in mechanically ventilated patients. We hypothesised that respiratory variations in left ventricular stroke area (ΔSA) can predict fluid responsiveness. Eighteen mechanically ventilated patients undergoing coronary artery bypass grafting were studied immediately after induction of anaesthesia. Stroke area was measured on a beat-to-beat basis using transoesophageal echocardiographic automated border detection. Haemodynamic and echocardiographic data were measured at baseline and after volume expansion induced by a passive leg raising manoeuvre. Responders to passive leg raising manoeuvre were defined as patients presenting a more than 15% increase in cardiac output. Cardiac output increased significantly in response to volume expansion induced by passive leg raising (from 2.16 ± 0.79 litres per minute to 2.78 ± 1.08 litres per minute; p < 0.01). ΔSA decreased significantly in response to volume expansion (from 17% ± 7% to 8% ± 6%; p < 0.01). ΔSA was higher in responders than in non-responders (20% ± 5% versus 10% ± 5%; p < 0.01). A cutoff ΔSA value of 16% allowed fluid responsiveness prediction with a sensitivity of 92% and a specificity of 83%. ΔSA at baseline was related to the percentage increase in cardiac output in response to volume expansion (r = 0.53, p < 0.01). ΔSA by transoesophageal echocardiographic automated border detection is sensitive to changes in preload, can predict fluid responsiveness, and can quantify the effects of volume expansion on cardiac output. It has potential clinical applications.

Erratum to: Int J Colorectal Dis DOI 10.1007/s00384-011-1188-6 Due to an oversight on the part of the authors, N. Komen, J. Slieker, P. de Kort, J. H. W. de Wilt, E. van der Harst, P.P Coene, M. Gosselink, G. Tetteroo, E. de Graaf, T. van Beek, R. den Toom, W. van Bockel, C. Verhoef, J.F. Lange, an incorrect name of one of the co-authors was published in the manuscript entitled “High tie versus low tie in rectal surgery: comparison of anastomotic perfusion”, Int J Colorectal Dis DOI 10.1007/s00384-011-1188-6. The correct name of the author is M.P. Gosselink instead of M. Gosselink.