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Background: IPAA has become the criterion standard for treating ulcerative colitis, familial adenomatous polyposis, and selected cases of Crohn's colitis. Robotic surgery promises improved postoperative outcomes and decreased length of stay. However, few studies have evaluated the benefits of robotic IPAA compared to laparoscopy., Objective: To compare short-term 30-day postoperative outcomes of robotic versus laparoscopic proctectomy with IPAA and diverting loop ileostomy., Design: Retrospective observational study from a single, high-volume center., Settings: Mayo Clinic, Rochester, Minnesota (tertiary referral center for IBD)., Patients: All adult patients undergoing minimally invasive proctectomy with IPAA and diverting loop ileostomy between January 2015 and April 2023., Main Outcome Measures: Thirty-day complications, hospital length of stay, estimated blood loss, conversion rate, 30-day readmission, and 30-day reoperation., Results: Two hundred seventeen patients were included in the study; 107 underwent robotic proctectomy with IPAA and diverting loop ileostomy, whereas 110 had laparoscopic proctectomy with IPAA and diverting loop ileostomy. Operating time was significantly longer in the robotic group (263 ± 38 vs 228 ± 75 minutes, p < 0.0001). The robotic group also had lower estimated blood loss (81.5 ± 77.7 vs 126.8 ± 111.0 mL, p = 0.0006) as well as fewer conversions (0% vs 8.2%, p = 0.003). Patients in the robotic group received more intraoperative fluids (3099 ± 1140 vs 2472 ± 996 mL, p = 0.0001). However, there was no difference in length of stay, 30-day morbidity, 30-day readmission, 30-day reoperation, rate of diverting loop ileostomy closure at 3 months, and surgical IPAA complication rate after ileostomy closure., Limitations: Retrospective design, single-center study, potential bias because of the novelty of the robotic approach, and lack of long-term and quality-of-life outcomes., Conclusions: Robotic proctectomy with IPAA and diverting loop ileostomy may offer advantages in terms of estimated blood loss and conversion rate while maintaining the benefits of minimally invasive surgery. Further research is needed to evaluate long-term outcomes. See Video Abstract ., Navegando El Progreso Experiencia De Ocho Aos En Un Solo Centro Con Proctectoma Mnimamente Invasiva Y Anastomosis Analbolsa Ileal: ANTECEDENTES:La anastomosis anal-bolsa ileal (IPAA) se ha convertido en el estándar de oro para el tratamiento de la colitis ulcerosa, la poliposis adenomatosa familiar y casos seleccionados de colitis de Crohn. La cirugía robótica promete mejores resultados posoperatorios y una menor duración de la estancia hospitalaria. Sin embargo, pocos estudios han evaluado los beneficios de la IPAA robótica en comparación con la laparoscopia.OBJETIVO:Comparar los resultados postoperatorios a corto plazo a 30 días de la proctectomía robótica versus laparoscópica con IPAA e ileostomía en asa de derivación.DISEÑO:Estudio observacional retrospectivo de un único centro de gran volumen.AJUSTES:Mayo Clinic, Rochester, Minnesota (centro terciario de referencia para EII).PACIENTES:Todos los pacientes adultos sometidos a proctectomía mínimamente invasiva con IPAA y DLI entre Enero de 2015 y Abril de 2023.PRINCIPALES MEDIDAS DE RESULTADOS:Complicaciones a los 30 días, duración de la estancia hospitalaria, pérdida de sangre estimada, tasa de conversión, reingreso a los 30 días y reoperación a los 30 días.RESULTADOS:Se incluyeron en el estudio 217 pacientes; 107 se sometieron a proctectomía robótica con IPAA y DLI, mientras que 110 se sometieron a proctectomía laparoscópica con IPAA y DLI. El tiempo operatorio fue significativamente mayor en el grupo robótico (263 ± 38 minutos versus 228 ± 75 minutos, p < 0,0001); la pérdida de sangre estimada (EBL) fue menor en el grupo robótico (81,5 ± 77,7 ml versus 126,8 ± 111,0 ml, p = 0,0006), así como el número de conversiones (0% versus 8,2%, p = 0,003). Los pacientes del grupo robótico recibieron más líquidos intraoperatorios (3099 ± 1140 ml versus 2472 ± 996 ml, p = 0,0001). Sin embargo, no hubo diferencias en la duración de la estancia hospitalaria, la morbilidad a los 30 días, el reingreso a los 30 días, la reoperación a los 30 días, la tasa de cierre del DLI a los tres meses y la tasa de complicaciones quirúrgicas de la IPAA después del cierre de la ileostomía.LIMITACIONES:Diseño retrospectivo, estudio unicéntrico, posible sesgo debido a la novedad del enfoque robótico, falta de resultados a largo plazo y de calidad de vida.CONCLUSIONES:La proctectomía robótica con IPAA y DLI puede ofrecer ventajas en términos de EBL y tasa de conversión, manteniendo al mismo tiempo los beneficios de la cirugía mínimamente invasiva. Se necesita más investigación para evaluar los resultados a largo plazo. (Traducción-Dr. Yesenia Rojas-Khalil )., (Copyright © The ASCRS 2024.)

Background: Ulcerative colitis, total colectomy, and tofacitinib have all been associated with an increased risk of venous thromboembolism., Objective: To determine whether preoperative tofacitinib exposure increases venous thromboembolism or other postoperative complications among patients with ulcerative colitis undergoing subtotal colectomy, total colectomy, or total proctocolectomy., Design: Retrospective, case-controlled study at a single institution., Settings: A tertiary referral center., Patients: Adult patients with ulcerative colitis undergoing subtotal colectomy, total colectomy, or total proctocolectomy after 2018 who were taking tofacitinib within 30 days of surgery (n = 56) were compared to age- and sex-matched patients with ulcerative colitis undergoing the same surgeries but who were not exposed to tofacitinib (n = 56)., Main Outcome Measure: The primary outcome was differences in the incidence of venous thromboembolism within 90 days of surgery based on tofacitinib exposure. Secondary outcomes were 90-day postoperative complications., Results: Groups were well matched for age (non-tofacitinib: mean 35.2 years [SD 12.0], tofacitinib: 35.9 [SD 12.1], p = 0.36) and sex (41% women in each group, p = 1.00). Medical characteristics were similar between groups except for biological medication exposure 30 days before surgery (non-tofacitinib: 66%, tofacitinib: 36%, p = 0.004). Surgical characteristics did not differ between groups. Most patients were discharged on extended venous thromboembolism prophylaxis (non-tofacitinib: 80% and tofacitinib: 77%). Adjusted for biological exposure, there were no statistically significant differences in venous thromboembolism (non-tofacitinib exposed: 14%, tofacitinib exposed: 4%, p = 0.09) or other postoperative outcomes., Limitation: Retrospective, single institutional study., Conclusions: Among patients with ulcerative colitis undergoing total colectomy or proctocolectomy, exposure to tofacitinib was not associated with an increased risk of venous thromboembolism or other postoperative complications. See Video Abstract ., La Exposicin a Tofacitinib No Aumenta Las Complicaciones Posoperatorias Entre Pacientes Con Colitis Ulcerosa Sometidos a Colectoma Total Un Estudio Retrospectivo De Casos Y Controles: ANTECEDENTES:La colitis ulcerosa, la colectomía total y el tofacitinib han sido asociados con un mayor riesgo de tromboembolismo venoso.OBJETIVO:Determinar si la exposición preoperatoria a tofacitinib aumenta la tromboembolia venosa u otras complicaciones posoperatorias entre pacientes con colitis ulcerosa sometidos a colectomía subtotal, colectomía total o proctocolectomía total.DISEÑO:Estudio retrospectivo de casos y controles en una sola institución.AJUSTES:Un centro de referencia terciario.PACIENTES:Los pacientes adultos con colitis ulcerosa sometidos a colectomía subtotal, colectomía total o proctocolectomía total después del año 2018 que se encontraron consumiendo tofacitinib dentro de los 30 días posteriores a la cirugía (n = 56) fueron comparados con pacientes con colitis ulcerosa de la misma edad y sexo sometidos a las mismas cirugías pero que no estuvieron expuestos a tofacitinib (n = 56).MEDIDA DE RESULTADO PRINCIPAL:El resultado primario fueron las diferencias en las incidencias de tromboembolismo venoso dentro de los 90 días posteriores a la cirugía según la exposición a tofacitinib. Los resultados secundarios fueron las complicaciones posoperatorias a los 90 días.RESULTADOS:Los grupos se encontraban bien emparejados por edad (sin tofacitinib: media 35,2 años [DE 12,0], tofacitinib: 35,9 [DE 12,1], p = 0,36) y sexo (41% mujeres en cada grupo, p = 1,00). Las características médicas fueron similares entre los grupos, excepto por la exposición a medicamentos biológicos 30 días antes de la cirugía (sin tofacitinib: 66 %, tofacitinib: 36 %, p = 0,004). Las características quirúrgicas no difirieron entre los grupos. La mayoría de los pacientes fueron dados de alta con profilaxis extendida para tromboembolismo venoso (sin tofacitinib: 80% y tofacitinib: 77%). Ajustado a la exposición biológica, no hubo diferencias estadísticamente significativas en el tromboembolismo venoso (no expuestos a tofacitinib: 14%, expuestos a tofacitinib: 4%, p = 0,09) u otros resultados posoperatorios.LIMITACIÓN:Estudio institucional único, retrospectivo.CONCLUSIÓN:Entre los pacientes con colitis ulcerosa sometidos a colectomía total o proctocolectomía, la exposición a tofacitinib no se asoció con un mayor riesgo de tromboembolismo venoso u otras complicaciones posoperatorias. (Traducción-Dr Osvaldo Gauto )., (Copyright © 2024 The Author(s). Published by Wolters Kluwer Health, Inc. on behalf of the American Society of Colon and Rectal Surgeons.)

Objective: To compare robotic-assisted proctectomy with ileal pouch-anal anastomosis (R-IPAA) outcomes and laparoscopic proctectomy with ileal pouch-anal anastomosis (L-IPAA) within a specialized robotic surgery center, using matching techniques to minimize potential confounding factors., Summary Background Data: Minimally invasive approaches, particularly laparoscopy, have improved outcomes for IBD and FAP patients undergoing IPAA. Robotic-assisted surgery offers potential technical advantages, but its definitive superiority over laparoscopy in this context remains under debate., Methods: This retrospective, STROBE-compliant study analyzed 234 consecutive IPAA patients (117 robotic, 117 laparoscopic). Data encompassed patient demographics, intraoperative details, and postoperative outcomes. We employed various matching techniques to address potential bias. Primary endpoints focused on 30-day complications, readmissions, and reoperations, with secondary endpoints including hospital stay, blood loss, and stoma closure rates., Results: R-IPAA demonstrated a lower conversion rate to open surgery (P=0.02), a shorter hospital stay (P=0.04), and reduced blood loss (P=0.0003) compared to L-IPAA. While overall 30-day morbidity rates were similar (P=0.4), matched analyses suggested a trend towards fewer reoperations and 3-month IPAA-associated complications after diverting loop ileostomy closure in the robotic group. However, these differences did not reach statistical significance., Conclusions: In a high-volume robotic surgery center, R-IPAA reduced the risk of conversion to open surgery while reducing intraoperative blood loss and providing shorter length of stay with equivalent perioperative outcomes. Promising trends to reduce 30-day reoperations and surgical complications following DLI closure were observed after a matching analysis., Competing Interests: Conflicts of interest: The authors declare no conflict of interest., (Copyright © 2024 Wolters Kluwer Health, Inc. All rights reserved.)

Introduction: The purpose of this study was to evaluate the association of MIS approaches for rectal cancer with long-term postoperative bowel dysfunction., Materials and Methods: This was an Institutional Review Board-approved observational cohort study including consecutive patients with rectal or rectosigmoid cancer who underwent surgical resection between 2007 and 2017. The primary exposure was surgical approach, defined as open surgery or MIS (laparoscopy or robotic surgery). The primary outcome was major LARS, defined as a LARS score of ≥30. Subgroup analyses were performed by tumor height and type of MIS approach., Results: Among 749 potentially eligible patients, 514 (68.6 %) responded to the survey and were included for analysis. In total, 195 (37.9 %) patients underwent an MIS approach - 117 (60.0 %) laparoscopic and 78 (40.0 %) robotic. At a median follow-up of 6.1 (3.7-9.6) years from surgery, 222 patients (43.2 %) had major LARS (MIS: 41.0 % vs. open: 44.5 %, p = 0.44). On multivariable logistic regression, surgical approach had no association with major LARS (MIS, aOR: 1.21, 0.79-1.86). Older age (aOR: 1.03, 1.01-1.04), female sex (aOR: 1.75, 1.16-2.67), TME (aOR: 1.74, 1.01-3.02), diverting ileostomy (aOR: 2.74, 1.49-5.02) and radiation therapy (aOR: 2.63, 1.60-4.33) were all associated with major LARS. On subgroup analysis of patients with mid and low rectal cancers (n = 197), there remained no association between surgical approach and major LARS (MIS, aOR: 1.50, 0.68-3.33)., Conclusions: MIS approach to rectal cancer surgery was not associated with decreased risk of major LARS and should not be touted as a reason to offer MIS., (Copyright © 2024 Elsevier Ltd, BASO ~ The Association for Cancer Surgery, and the European Society of Surgical Oncology. All rights reserved.)

Parastomal hernia is a common occurrence following stoma construction, necessitating surgical intervention in symptomatic cases. This study presents a comprehensive analysis of Robotic-Assisted Parastomal Hernia Repair (r-PSHR), utilizing the Da Vinci Xi™ Surgical System. Retrospective analysis was conducted on patients undergoing r-PSHR at a high-volume center. Surgical variables, complications, and recurrence rates were assessed. The primary technique involved a modified Sugarbaker intraperitoneal onlay mesh. Eighty-six patients underwent r-PSHR, predominantly females (59.3%), with mean age 60.8 years. Mean BMI was 31.0. Most patients were classified as ASA 2 (31.4%) or ASA 3 (65.1), with 64.6% having no prior PSH repair. Index procedures primarily involved laparoscopic colonic resections (27.8%) and open abdominoperineal resections (27.8%). Parastomal hernias were mainly associated with end ileostomy (50%) and end colostomy (47.7%). A hybrid modification was required in 22.1% of cases, with only one conversion to open repair. Mean operative time was 257 min. Thirty-day morbidity was 40.7% and includes ileus (24.4%), deep surgical-site infections (7.0%), acute kidney injury (5.8%), and sepsis (5.8%). Grade IIIB complications occurred in 5.8% of cases. Thirty-day readmissions were observed in 19.8% of cases. There were five cases (5.8%) of recurrence within 15 months post-surgery. This study highlights the effectiveness of r-PSHR in managing parastomal hernia. R-PSHR shows promising outcomes with an acceptable post-operative occurrence profile and a favorable recurrence rate., (© 2024. Italian Society of Surgery (SIC).)

Background: Answering calls in the literature, we developed and introduced an evidence-based tool for surgeons facing errors in the operating room: the STOPS framework (stop, talk to you team, obtain help, plan, succeed). The purpose of this research was to assess the impact of presenting this psychological tool on resident coping in the operating room and the related outcome of burnout while examining sex differences., Methods: In a natural experiment, general surgery residents were invited to attend 2 separate educational conferences regarding coping with errors in the operating room. Three months later, all residents were asked to fill out a survey assessing their coping in the operating room, level of burnout, and demographics. We assessed the impact of the educational intervention by comparing those who attended the coping conferences with those who did not attend., Results: Thirty-five residents responded to the survey (65% response rate, 54% female respondents, 49% junior residents). Our hypothesized moderated mediation model was supported. Sex was found to moderate the impact of the STOPS framework-female residents who attended the coping educational conference reported higher coping self-efficacy, whereas attendance had no statistically significant impact on male levels of coping self-efficacy. In turn, higher coping self-efficacy was associated with lower levels of burnout., Conclusion: Our results suggest that there is evidence of efficacy in this instruction-female residents presented this material report higher levels of coping in the operating room compared to those who did not receive the framework. Further, increase in coping ability was associated with reduced levels of burnout for both genders., (Copyright © 2024 Elsevier Inc. All rights reserved.)

Background: The evolution of enhanced recovery pathways (ERPs) in colon and rectal surgery has led to the development of same-day discharge (SDD) procedures for selected patients. Early discharge after diverting loop ileostomy (DLI) closure was first described in 2003. However, its widespread adoption remains limited, with SDD accounting for only 3.2% of all DLI closures in 2005-2006, according to the American College of Surgeons National Surgical Quality Improvement Program database, and rising to just 4.1% by 2016. This study aimed to compare the outcomes of SDD DLI closure with those of DLI closure after the standard ERP., Methods: A retrospective case-matched study compared 125 patients undergoing SDD DLI closure with 250 patients undergoing DLI closure after the standard ERP based on age (±1 year), sex, American Society of Anesthesiologists score, body mass index, surgery date (±2 months), underlying disease, and hospital site. The primary outcome was comparative 30-day complication rates., Results: Patients in the traditional ERP group received more intraoperative fluids (1221.1 ± 416.6 vs 1039.0 ± 368.3 mL, P < .001) but had similar estimated blood loss. Ten patients (8%) in the SDD-ERP group failed SDD. The 30-day postoperative complication rate was significantly lower in the SDD group (14.8%) than the standard ERP group (25.7%, P = .025). This difference was primarily driven by a lower incidence of ileus in the SDD group (9.6% vs 14.8%, P = .034). There were no significant differences in readmission rate (9.6% of SDD-ERP vs 9.2% of standard ERP, P = .900) and reoperation rates (3.2% of SDD-ERP vs 2.4% of standard ERP, P = .650)., Conclusion: SDD ileostomy closure is a safe, feasible, and effective procedure associated with fewer complications than the present study's standard ERP. This could represent a new standard of care. Further prospective trials are required to confirm the findings of this study., (Copyright © 2024. Published by Elsevier Inc.)

Background: Up to 20% of patients with ileal pouch will develop pouch failure, ultimately requiring surgical reintervention. As a result of the complexity of reoperative pouch surgery, minimally invasive approaches were rarely utilized. In this series, we present the outcomes of the patients who underwent robotic-assisted pouch revision or excision to assess its feasibility and short-term results., Methods: All the patients affected by inflammatory bowel diseases and familial adenomatous polyposis who underwent robotic reoperative surgery of an existing ileal pouch were included., Results: Twenty-two patients were included; 54.6% were female. The average age at reoperation was 51 ± 16 years, with a mean body mass index of 26.1 ± 5.6 kg/m 2 . Fourteen (63.7%) had a diagnosis of ulcerative colitis at reoperation, and seven (31.8%) had Crohn's disease. The mean time to pouch reoperation was 12.8 ± 11.8 years. Seventeen (77.3%) patients underwent pouch excision, and five (22.7%) had pouch revision surgery. The mean operative time was 372 ± 131 min, and the estimated blood loss was 199 ± 196.7 ml. The conversion rate was 9.1%, the 30-day morbidity rate was 27.3% (with only one complication reaching Clavien-Dindo grade IIIB), and the mean length of stay was 5.8 ± 3.9 days. The readmission rate was 18.2%, the reoperation rate was 4.6%, and mortality was nihil. All patients in the pouch revisional group are stoma-free., Conclusion: Robotic reoperative pouch surgery in highly selected patients is technically feasible with acceptable outcomes., (© 2024. Springer Nature Switzerland AG.)

Background: Although laparoscopic Ileal pouch-anal anastomosis (IPAA) has become the gold standard in restorative proctocolectomy, surgical techniques have experienced minimal changes. In contrast, substantial shifts in perioperative care, marked by the enhanced recovery program (ERP), modifications in steroid use, and a shift to a 3-staged approach, have taken center stage., Methods: Data extracted from our prospective IPAA database focused on the first 100 laparoscopic IPAA cases (historic group) and the latest 100 cases (modern group), aiming to measure the effect of these evolutions on postoperative outcomes., Results: The historic IPAA group had more 2-staged procedures (92% proctocolectomy), whereas the modern group had a higher number of 3-staged procedures (86% proctectomy) (P < .001). Compared with patients in the modern group, patients in the historic group were more likely to be on steroids (5% vs 67%, respectively; P < .001) or immunomodulators (0% vs 31%, respectively; P < .001) at surgery. Compared with the historic group, the modern group had a shorter operative time (335.5 ± 78.4 vs 233.8 ± 81.6, respectively; P < .001) and length of stay (LOS; 5.4 ± 3.1 vs 4.2 ± 1.6 days, respectively; P < .001). Compared with the modern group, the historic group exhibited a higher 30-day morbidity rate (20% vs 33%, respectively; P = .04) and an elevated 30-day readmission rate (9% vs 21%, respectively; P = .02). Preoperative steroids use increased complications (odds ratio [OR], 3.4; P = .01), whereas 3-staged IPAA reduced complications (OR, 0.3; P = .03). ERP was identified as a factor that predicted shorter stays., Conclusion: Although ERP effectively reduced the LOS in IPAA surgery, it failed to reduce complications. Conversely, adopting a 3-staged IPAA approach proved beneficial in reducing morbidity, whereas preoperative steroid use increased complications., (Copyright © 2024 Society for Surgery of the Alimentary Tract. Published by Elsevier Inc. All rights reserved.)

Introduction: Patients with inflammatory bowel disease are reported to be at elevated risk for postoperative venous thromboembolism (VTE). The rate and location of these VTE complications is unclear., Methods: Patients with ulcerative colitis (UC) or Crohn's disease (CD) undergoing intestinal operations between January 2006 and March 2021 were identified from the medical record at a single institution. The overall incidence of VTEs and their anatomic location were determined to 90 days postoperatively., Results: In 2716 operations in patients with UC, VTE prevalence was 1.95% at 1-30 days, 0.74% at 31-60 days, and 0.48% at 90 days (P < 0.0001). Seventy two percent of VTEs within the first 30 days were in the portomesenteric system, and this remained the location for the majority of VTE events at 31-60 and 61-90 days postoperatively. In the first 30 days, proctectomies had the highest incidence of VTEs (2.5%) in patients with UC. In 2921 operations in patients with CD, VTE prevalence was 1.43%, 0.55%, and 0.41% at 1-30 days, 31-60 days, and 61-90 days, respectively (P < 0.0001). Portomesenteric VTEs accounted for 31% of all VTEs within 30 days postoperatively. In the first 30 days, total abdominal colectomies had the highest incidence of VTEs (2.5%) in patients with CD., Conclusions: The majority of VTEs within 90 days of surgery for UC and Crohn's are diagnosed within the first 30 days. The risk of a VTE varies by the extent of the operation performed, with portomesenteric VTE representing a substantial proportion of events., (Copyright © 2024 Elsevier Inc. All rights reserved.)

Background and Rationale: Recent research has called for further resident training in coping with errors and adverse events in the operating room. To the best of our knowledge, there currently exists no evidence-based curriculum or training on this topic., Materials and Methods: Synthesizing three prior studies on how experienced surgeons react to errors and adverse events, we developed the STOPS framework for handling surgical errors and adverse events (Stop, Talk to your team, Obtain help, Plan, Succeed). This material was presented to residents in two teaching sessions., Results and Conclusion: In this paper, we describe the presentation of, and the uniformly positive resident reaction to, the STOPS framework: an empirically based psychological tool for surgeons who experience operative errors or adverse events., (Copyright © 2023 Association of Program Directors in Surgery. Published by Elsevier Inc. All rights reserved.)

Background: Open combined resections of colorectal primary tumors and synchronous liver metastases have become common in selected cases. However, evidences favoring a minimally invasive (MIS) approach are still limited. The aim of this study is to evaluate the outcomes of MIS vs. open synchronous liver and colorectal resections., Methods: 384 cases of synchronous colorectal and liver resections performed at one institution were identified during the study period. MIS vs open approach were compared after a propensity score matching; surgical outcomes were analyzed., Results: MIS cases featured longer operative time (399 vs 300 min, p < 0.001), fewer blood loss (200 vs 500 ml, p = 0.003), and shorter hospitalization (median LOS 4 vs 6 days, p = 0.001). No difference was observed between the two groups for use of Pringle maneuver (p = 0.083), intraoperative blood transfusion (p = 0.061), achievement of negative colorectal (p = 0.176) and liver margins (p = 1.000), postoperative complications (p = 1.000) and significant (Clavien-Dindo ≥ 3a) complications (p = 0.817), delay of adjuvant therapy due to complications (p = 0.555), 30- and 90-day mortality., Conclusion: Synchronous colorectal and liver metastases resections via a minimally-invasive approach in high-volume centers with appropriate expertise result in significantly lower blood loss and length of stay despite longer operative time in comparison to open, with no oncological inferiority., (Copyright © 2023 International Hepato-Pancreato-Biliary Association Inc. Published by Elsevier Ltd. All rights reserved.)

Laparoscopy is the first-line approach in ileocolic resection for Crohn's disease. Emerging data has shown better short-term outcomes with robotic right colectomy for cancer when compared to laparoscopic approach. However, robotic ileocolic resection for Crohn's disease has only shown faster return to bowel function. We aimed to evaluate short-term outcomes of ileocolic resection for Crohn's disease between robotic intracorporeal anastomosis (RICA) and laparoscopic extracorporeal anastomosis (LECA). Patients undergoing minimally invasive ileocolic resections for Crohn's disease were retrospectively identified using a prospectively maintained database between 2014 and 2021 in two referral centers. Among the 239 patients, 70 (29%) underwent RICA while 169 (71%) LECA. Both groups were similar according to baseline and preoperative characteristics. RICA was associated with more intraoperative adhesiolysis and longer operative time [RICA: 238 ± 79 min vs. LECA: 143 ± 52 min; p < 0.001]. 30-day postoperative complications were not different between the two groups [RICA: 17/70(24%) vs. LECA: 54/169(32%); p = 0.238]. Surgical site infections [RICA: 0/70 vs. LECA: 16/169(10%); p = 0.004], intra-abdominal septic complications [RICA: 0/70 vs. LECA: 14/169(8%); p = 0.012], and Clavien-Dindo ≥ III complications [RICA: 1/70(1%) vs. LECA: 15/169(9%); p = 0.044] were less frequent in RICA. Return to bowel function [RICA: 2.1 ± 1.1 vs. LECA: 2.6 ± 1.2 days; p = 0.002] and length of stay [RICA: 3.4 ± 2.2 vs. LECA: 4.2 ± 2.5 days; p = 0.015] were shorter after RICA, with similar readmission rates. RICA demonstrated better short-term postoperative outcomes than LECA, with reduced Clavien-Dindo ≥ III complications, surgical site infections, intra-abdominal septic complications, shorter length of stay, and faster return to bowel function, despite the longer operative time., (© 2023. The Author(s), under exclusive licence to Springer-Verlag London Ltd., part of Springer Nature.)

Minimally invasive surgery (MIS) is the first-line approach for ileocolic resection in Crohn's disease (CD), and it is safe and feasible, even with severe penetrating CD or redo surgery. While MIS indications are continually broadening, challenging CD cases might still require an open approach. This study aimed to report rate and indications for an upfront open approach in ileocolic resection for CD. Comprehensive perioperative data for all consecutive patients undergoing ileocolic resection for CD between 2014 and 2021 in a high-volume referral center for CD and MIS, were collected retrospectively. Indications for an upfront open approach were reviewed separately by two authors according to the preoperative visit. Among 319 ileocolic resections for CD, 45 (14%) were open and 274 (86%) MIS. Two or more of the below indications were present in 40 patients (89%) in the open group, while only in 6 patients (2%) in the MIS group (p < 0.0001). Indications for upfront open approach were severe penetrating disease (58%), adhesions at previous surgery (47%), history of abdominal sepsis (33%), multifocal and extensive disease (24%), abdominal wall involvement (22%), concomitant open procedures (9%), small bowel dilatation (9%), and anesthesiologic contraindications (4%). MIS was never performed in a patient with abdominal wall involvement, concomitant open procedure, and anesthesiologic contraindication to MIS. This study can help guide patients, physicians, and surgeons. An abdominal wall involvement or the presence of two of the above indications predicts a high surgical complexity and may be considered as a no-go for the MIS approach. These criteria should prompt surgeons to strongly consider an upfront open approach to optimize the perioperative planning and care of these complex patients., (© 2023. Italian Society of Surgery (SIC).)

Background: Although the safety of laparoscopic redo ileocolonic resection for Crohn's disease has been described before, the safety of robotic redo ileocolonic resection is still unelucidated., Objective: This study aimed to share our preliminary experience regarding the safety of robotic redo ileocolonic resection for Crohn's disease., Design: Retrospective analysis., Setting: Tertiary care center., Patients: All consecutive adult patients who underwent robotic ileocolonic resection for Crohn's disease at our institution between 2014 and 2021 were included. Patients were divided into redo ileocolonic resection and primary ileocolonic resection groups., Primary Outcome Measures: Baseline demographics, preoperative risk factors, and intraoperative details were compared between both groups. The primary outcome was conversion to an open approach, and secondary outcomes were 30-day postoperative complications., Results: A total of 98 patients were included. Of them, 18 (18.4%) had a redo ileocolonic resection. Patients who had a redo ileocolonic resection were more likely to have a longer duration of disease, associated anoperineal disease, a higher number of previous lines of medical treatments, received total parental nutrition before the operation for correction of malnutrition, and longer time for adhesiolysis. Patients who had redo ileocolonic resection had a higher risk for conversion to open ileocolonic resection [3 (16.7%) versus 2 (2.5%); p value = 0.04]. There was no statistically significant difference regarding the overall length of stay and the 30-day morbidity between both groups. No 30-day mortality or anastomotic leaks occurred in either group., Limitations: Retrospective nature of the analysis., Conclusions: Robotic redo ileocolonic resection showed similar short-term postoperative outcomes to robotic primary ileocolonic resection for Crohn's disease. However, conversion rates are higher in robotic redo ileocolonic resection yet seem lower than previously published results in laparoscopic surgery. See Video Abstract at http://links.lww.com/DCR/C77 ., Reseccin Ileoclica Robtica Redo Para La Enfermedad De Crohn Informe Preliminar De Un Centro De Atencin Terciaria: ANTECEDENTES:Si bien la seguridad de la resección ileocolónica laparoscópica para la enfermedad de Crohn se ha descrito antes, la seguridad de la resección ileocolónica robótica aún no se ha dilucidado.OBJETIVO:Este estudio tuvo como objetivo compartir nuestra experiencia preliminar con respecto a la seguridad de la resección ileocolónica robótica para la enfermedad de Crohn.DISEÑO:Análisis retrospectivo.AJUSTE:Centro de atención terciaria.PACIENTES:Se incluyeron todos los pacientes adultos consecutivos que se sometieron a resección ileocolónica robótica por enfermedad de Crohn en nuestra institución entre 2014 y 2021. Los pacientes se dividieron en grupos de resección ileocolónica reconfeccionada y resección ileocolónica primaria.MEDIDAS DE RESULTADO:Se compararon los datos demográficos iniciales, los factores de riesgo preoperatorios y los detalles intraoperatorios entre ambos grupos. El resultado primario fue la conversión a abierto y los resultados secundarios fueron las complicaciones posoperatorias a los treinta días.RESULTADOS:Se incluyeron un total de 98 pacientes. De ellos, 18 (18,4%) tuvieron resección ileocolónica. Los pacientes que se sometieron a una nueva resección ileocolónica tenían más probabilidades de tener una mayor duración de la enfermedad, enfermedad anoperineal asociada, un mayor número de líneas previas de tratamientos médicos, más probabilidades de haber recibido nutrición parental total antes de la operación para la corrección de la desnutrición y más tiempo tiempo de adhesiolisis. Los pacientes que se sometieron a una nueva resección ileocolónica tuvieron un mayor riesgo de conversión a cirugía abierta [3 (16,7 %) frente a 2 (2,5 %); valor p 0,04]. No hubo diferencia estadísticamente significativa con respecto a la duración total de la estancia y la morbilidad a los treinta días entre ambos grupos. No hubo mortalidad a los treinta días ni fugas anastomóticas en ninguno de los grupos.LIMITACIONES:Naturaleza retrospectiva del análisis.CONCLUSIÓN:La resección ileocolónica robótica mostró resultados postoperatorios a corto plazo similares a la resección ileocolónica primaria robótica para la enfermedad de Crohn. Sin embargo, las tasas de conversión son más altas en la resección ileocolónica robótica, pero parecen más bajas que los resultados publicados previamente en la cirugía laparoscópica. Consulte Video Resumen en http://links.lww.com/DCR/C77 . (Traducción-Dr Yolanda Colorado )., (Copyright © The ASCRS 2022.)

Purpose: One-third of patients with Crohn's disease (CD) require multiple surgeries during their lifetime. So, reducing the incisional hernia rate is crucial. We aimed to define incisional hernia rates after minimally invasive ileocolic resection for CD, comparing intracorporeal anastomosis with Pfannenstiel incision (ICA-P) versus extracorporeal anastomosis with midline vertical incision (ECA-M)., Methods: This retrospective cohort compares ICA-P versus ECA-M from a prospectively maintained database of consecutive minimally invasive ileocolic resections for CD performed between 2014 and 2021 in a referral center., Results: Of the 249 patients included: 59 were in the ICA-P group, 190 in the ECA-M group. Both groups were similar according to baseline and preoperative characteristics. Overall, 22 (8.8%) patients developed an imaging-proven incisional hernia: seven at the port-site and 15 at the extraction-site. All 15 extraction-site incisional hernias were midline vertical incisions [7.9%; p = 0.025], and 8 patients (53%) required surgical repair. Time-to-event analysis showed a 20% rate of extraction-site incisional hernia in the ECA-M group after 48 months (p = 0.037). The length of stay was lower in the intracorporeal anastomosis with Pfannenstiel incision group [ICA-P: 3.3 ± 2.5 vs. ECA-M: 4.1 ± 2.4 days; p = 0.02] with similar 30-day postoperative complication [11(18.6) vs. 59(31.1); p = 0.064] and readmission rates [7(11.9) vs. 18(9.5); p = 0.59]., Conclusion: Patients in the ICA-P group did not encounter any incisional hernias while having shorter hospital length of stay and similar 30-day postoperative complications or readmission compared to ECA-M. Therefore, more consideration should be given to performing intracorporeal anastomosis with Pfannenstiel incision during Ileocolic resection in patients with CD to reduce hernia risk., (© 2023. The Author(s), under exclusive licence to Springer-Verlag GmbH Germany, part of Springer Nature.)

For rectal cancer, MRI plays an important role in assessing extramural tumor spread and informs surgical planning. The contemporary standardized management of rectal cancer with total mesorectal excision guided by imaging-based risk stratification has dramatically improved patient outcomes. Colonoscopy and CT are utilized in surveillance after surgery to detect intraluminal and extramural recurrence, respectively; however, local recurrence of rectal cancer remains a challenge because postoperative changes such as fat necrosis and fibrosis can resemble tumor recurrence; additionally, mucinous adenocarcinoma recurrence may mimic fluid collection or abscess on CT. MRI and 18 F-FDG PET are problem-resolving modalities for equivocal imaging findings on CT. Treatment options for recurrent rectal cancer include pelvic exenteration to achieve radical (R0 resection) resection and intraoperative radiation therapy. After pathologic diagnosis of recurrence, imaging plays an essential role for evaluating the feasibility and approach of salvage surgery. Patterns of recurrence can be divided into axial/central, anterior, lateral, and posterior. Some lateral and posterior recurrence patterns especially in patients with neurogenic pain are associated with perineural invasion. Cross-sectional imaging, especially MRI and 18 F-FDG PET, permit direct visualization of perineural spread, and contribute to determining the extent of resection. Multidisciplinary discussion is essential for treatment planning of locally recurrent rectal cancer. This review article illustrates surveillance strategy after initial surgery, imaging patterns of rectal cancer recurrence based on anatomic classification, highlights imaging findings of perineural spread on each modality, and discusses how resectability and contemporary surgical approaches are determined based on imaging findings., (© 2023. The Author(s), under exclusive licence to Springer Science+Business Media, LLC, part of Springer Nature.)

Introduction: Synchronous robotic colorectal and liver resection for metastatic colorectal cancer (mCRC) is gaining popularity. This case series describes our initial institutional experience., Methods: A retrospective study of synchronous robotic colorectal and liver resections for metastatic colorectal cancer (March 2020 to December 2021)., Results: Eight patients underwent synchronous robotic resections. The median age was 59 (45-72), and the median body mass index was 29 (20-33). Seven received neoadjuvant chemotherapy, and five rectal cancers received neoadjuvant radiotherapy. One patient had a low anterior resection with major hepatectomy, two had low anterior resection with minor hepatectomy, and one had abdominoperineal resection with major hepatectomy. One patient had a left colectomy with minor hepatectomy, and two had right colectomies with minor hepatectomy. We used five robotic 8/12 mm ports in all cases. Extraction incisions were Pfannenstiel in four patients, colostomy site in two patients, one perineal incision, and one supra-umbilical incision. The median estimated blood loss was 200 mL (25-500), and the median operative time was 448 min (374-576). There were no intra-operative complications or conversions. Five patients had the liver resection first, and two of six anastomoses were performed before the liver resection. The Median length of stay was 4 days (3-14). There were two post-operative complications, prolonged ileus and DVT, with a Clavien-Dindo complication grade of I and II, respectively. There were no readmissions or reoperations. All colorectal and liver resection margins were negative., Conclusions: Synchronous robotic colorectal and liver resection can be performed effectively utilizing one port configuration with acceptable short-term outcomes and quality of oncologic resection.

Background: Existing venous thromboembolism (VTE) risk scores help identify patients at increased risk of postoperative VTE who warrant extended prophylaxis in the first 30 days. However, these methods do not address factors unique to colorectal surgery, wherein the tumor location and operation performed vary widely. VTE risk may extend past 30 days. Therefore, we aimed to determine the roles of tumor location and operation in VTE development and evaluate VTE incidence through 90 days postoperatively., Study Design: Adult patients undergoing surgery for colorectal cancer between January 1, 2005, and December 31, 2021, at a single institution were identified. Patients were then stratified by cancer location and by operative extent. VTEs were identified using diagnosis codes in the electronic medical record and consisted of extremity deep venous thromboses, portomesenteric venous thromboses, and pulmonary emboli., Results: A total of 6,844 operations were identified (72% segmental colectomy, 22% proctectomy, 6% total (procto)colectomy), and tumor location was most commonly in the ascending colon (32%), followed by the rectum (31%), with other locations less common (sigmoid 16%, rectosigmoid junction 9%, transverse colon 7%, descending colon 5%). The cumulative incidence of any VTE was 3.1% at 90 days with a relatively steady increase across the entire 90-day interval. Extremity deep venous thromboses were the most common VTE type, accounting for 37% of events, and pulmonary emboli and portomesenteric venous thromboses made up 33% and 30% of events, respectively. More distal tumor locations and more anatomically extensive operations had higher VTE rates., Conclusions: When considering extended VTE prophylaxis after colorectal surgery, clinicians should account for the operation performed and the location of the tumor. Further study is necessary to determine the optimal length of VTE prophylaxis in high-risk individuals., (Copyright © 2023 by the American College of Surgeons. Published by Wolters Kluwer Health, Inc. All rights reserved.)

Background: The efficacy of preoperative oral antibiotics alone compared with mechanical and oral antibiotic bowel preparation in minimally invasive surgery is still a matter of debate., Objective: This study aimed to assess the trend of surgical site infection rates in parallel to the utilization of bowel preparation modality over time for minimally invasive colorectal surgeries in the United States., Design: This study is a retrospective analysis., Settings: The American College of Surgeons National Surgical Quality Improvement Program database was the source of data for this study., Patients: Adult patients who underwent elective colorectal surgery and reported bowel preparation modality were included., Main Outcome Measures: The primary outcomes measured were the trends and the comparison of surgical site infection rates for mutually exclusive groups according to the underlying disease (colorectal cancer, IBD, and diverticular disease) who underwent bowel preparation using oral antibiotics or combined mechanical and oral antibiotic bowel preparation. Patients who underwent rectal surgery were analyzed separately., Results: A total of 30,939 patients were included. Of them, 12,417 (40%) had rectal resections. Over the 7-year study period, mechanical and oral antibiotic bowel preparation utilization increased from 29.3% in 2012 to 64.0% in 2018; p < 0.0001 at the expense of no preparation and mechanical bowel preparation alone. Similarly, oral antibiotics utilization increased from 2.3% in 2012 to 5.5% in 2018; p < 0.0001. For patients with colon cancer, patients who had oral antibiotics alone had higher superficial surgical site infection rates than patients who had combined mechanical and oral antibiotic bowel preparation (1.9% vs 1.1%; p = 0.043). Superficial, deep, and organ space surgical site infection rates were similar for all other comparative colon surgery groups (cancer, IBD, and diverticular disease). Patients with rectal cancer who had oral antibiotics had higher rates of deep surgical site infection (0.9% vs 0.1%; p = 0.004). However, superficial, deep, and organ space surgical site infection rates were similar for all other comparative rectal surgery groups., Limitations: This study was limited by the retrospective nature of the analysis., Conclusion: This study revealed widespread adoption of mechanical and oral antibiotic bowel preparation and increased adoption of oral antibiotics over the study period. Surgical site infection rates are similar from a clinical relevance standpoint among most comparative groups, questioning the systematic preoperative addition of mechanical bowel preparation to oral antibiotics alone in all patients for minimally invasive colorectal surgery. See Video Abstract at http://links.lww.com/DCR/B828 ., Preparacin Intestinal Con Antibiticos Orales Sin Preparacin Mecnica En Cirugas Colorrectales Mnimamente Invasivas Prctica Actual Y Perspectivas Futuras: ANTECEDENTES:La eficacia de los antibióticos orales preoperatorios solos en comparación con la preparación intestinal mecánica mas antibióticos orales en la cirugía mínimamente invasiva es un tema de debate que todavía esta en curso.OBJETIVO:Este estudio tuvo como objetivo evaluar la tendencia de las tasas de infección del sitio quirúrgico en relacion a la utilización de la modalidad de preparación intestinal a lo largo del tiempo en cirugías colorrectales mínimamente invasivas en los Estados Unidos.DISEÑO:Análisis retrospectivo.ENTORNO CLINICO:Base de datos del Programa Nacional de Mejoramiento de la Calidad Quirúrgica del Colegio Estadounidense de Cirujanos.PACIENTES:Pacientes adultos sometidos a cirugía colorrectal electiva y reportados con modalidad de preparación intestinal.PRINCIPALES MEDIDAS DE VALORACIÓN:Tendencias y comparacion de las tasas de infección del sitio quirúrgico para grupos mutuamente excluyentes según la enfermedad subyacente (cáncer colorrectal, enfermedad inflamatoria intestinal y enfermedad diverticular) que se sometieron a preparación intestinal usando antibióticos orales exclusivamente o preparación intestinal mecánica combinada con antibióticos orales. Los pacientes que se sometieron a cirugía rectal se analizaron por separado.RESULTADOS:Se incluyeron un total de 30.939 pacientes. De ellos, 12.417 (40%) se sometieron a resecciones rectales. Durante el período de estudio de siete años, la preparación mecánica del intestino y la utilización de antibióticos orales aumentó del 29,3% en 2012 al 64,0% en 2018; p < 0,0001 sobre la no preparación y de la preparación intestinal mecánica exclusivamente. De manera similar, la utilización de antibióticos orales ha aumentado del 2,3% en 2012 al 5,5% en 2018; p < 0,0001. Para los pacientes con cáncer de colon, los pacientes que recibieron antibióticos orales solos tuvieron mayores tasas de infección superficial del sitio quirúrgico en comparación con los pacientes que recibieron una preparación intestinal mecánica combinada con antibióticos orales (1,9% frente a 1,1%; p = 0,043). Las tasas de infección superficial, profundo del sitio quirúrgico y de los compartimientos intraabdominales fueron similares para todos los demás grupos de cirugía de colon (cáncer, enfermedad inflamatoria intestinal y enfermedad diverticular). Los pacientes con cáncer de recto que recibieron antibióticos orales tuvieron tasas más altas de infección profunda del sitio quirúrgico (0,9% frente a 0,1%; p = 0,004). Sin embargo, las tasas de infección del sitio quirúrgico superficial, profundo y de los compartimientos intraabdominales fueron similares comparativamente para todos los demás grupos de cirugía rectal.LIMITACIONES:Carácter retrospectivo del análisis.CONCLUSIONES:Este estudio reveló la adopción generalizada de preparación intestinal mecánica y antibióticos orales y una mayor aceptación de antibióticos orales durante el período de estudio. Las tasas de infección del sitio quirúrgico parecen ser similares desde un punto de vista de relevancia clínica entre la mayoría de los grupos comparados, lo que cuestiona la adición preoperatoria sistemática de preparación intestinal mecánica a antibióticos orales solos en todos los pacientes para cirugía colorrectal mínimamente invasiva. Consulte Video Resumen en http://links.lww.com/DCR/B828 . (Traducción- Dr. Ingrid Melo )., (Copyright © The ASCRS 2021.)

Study Objective: To highlight different surgical approaches for managing deep infiltrating endometriosis involving the rectosigmoid colon., Design: Demonstration of specific surgical techniques with educational narrated video footage., Setting: Bowel endometriosis is reported in 3.8% to 37% of patients with endometriosis [1]. Most commonly, the rectosigmoid colon is involved. Pelvic ultrasound and magnetic resonance imaging may be useful in diagnosis and for surgical planning [2]. Treatment options include observation, medications, or surgery. There are various surgical techniques that can be used for excision of deep infiltrating endometriosis involving the rectosigmoid colon. Serosal shaving, discoid resection, and complete resection are the possible types of surgical interventions that are demonstrated in this surgical education video at an academic medical center. Serosal shaving is used for lesions with minimal involvement of the muscularis. It can be done sharply or with electrosurgery and it is imperative to assess bowel integrity after shaving. Discoid resection is used for lesions with muscularis involvement, <3 cm in size, and encompassing less than one-third to a half of the bowel circumference. Full-thickness discoid bowel resection can be done in various ways including manual resection with primary suture closure, regular stapler transabdominally, or EEA stapler (Medtronic EEA Circular Stapler, Minneapolis, MN) transrectally. Segmental resection is used for lesions >3 cm in size, involving >50% of the bowel circumference, or for multifocal lesions. Various suture and stapler methods exist for this technique., Interventions: Based on the imaging and intraoperative findings, a surgical technique was chosen and demonstrated. The types of surgical techniques demonstrated include laparoscopic serosal shaving, discoid resection with manual resection and primary suture closure, discoid resection with EEA stapler, and segmental resection., Conclusion: Knowledge of different surgical approaches to excise endometriosis is essential to appropriately address a patient's unique pathology. The choice of which surgical technique to use should include consideration of the location of the lesion, depth and circumference of involvement, and the number of nodules present., (Published by Elsevier Inc.)

Background: During COVID-19 pandemic, hospitals changed visitation policy to limit the infection spread. We aimed to evaluate the impact of evolving visitation policy on short-term surgical outcomes., Methods: All adult patients who underwent colorectal surgery between January 1 st , 2020, and May 12 th , 2020, at our institution were included. Patients were divided into: before implementing the no visitor allowed policy (VA) or no visitor allowed policy (NVA) groups, based on the hospital admission date.. The primary outcomes were 30-day readmission rate and length of stay (LOS)., Results: A total of 439 patients were included. Of them, 128 (29.2%) patients had surgery during the NVA policy, and 311 (70.8%) patients underwent surgery during VA policy. Patients who had surgery during the NVA policy were more likely to have emergency surgery and a longer operation time. However, the other baseline characteristics, surgical approach, underlying disease, extent of resection, and the need for intraoperative blood transfusion were comparable between the two groups. There was no difference between both groups regarding the 30-day readmission rate (10.3% vs. 7.8% in the NVA group; P>0.05) and median LOS (4 days vs. 3 days in the NVA group; P>0.05)., Conclusions: Restricting inpatient visitors for patients undergoing colorectal surgery was not associated with increased postoperative complications and readmission rates. LOS was similar between the two groups. This strategy can be safely implemented in cases of crisis. Further studies are needed to confirm these findings.

Background: Minimally invasive ileocolic resection for complicated Crohn disease, defined as penetrating Crohn disease associated with intra-abdominal fistula, abscess, or phlegmon, is challenging. In addition, the impact of the minimally invasive approach on postoperative outcomes is still debated. This study aimed to compare the intraoperative and postoperative outcomes of minimally invasive ileocolic resection for complicated versus uncomplicated Crohn disease., Methods: A retrospective analysis of all consecutive adult patients with Crohn disease undergoing minimally invasive ileocolic resection from 2014 to 2021 was performed. Perioperative outcomes were compared between patients with complicated Crohn disease (complicated group) and patients without these lesions (uncomplicated group)., Results: Among the 274 patients undergoing minimally invasive ileocolic resection for Crohn disease, 101 (36.9%) had a robotic approach, and 84 (30.7%) had complicated Crohn disease. Complicated patients were more frequently malnourished (32.1% vs 16.1%, P = .004) and had more frequent previous bowel resections for Crohn disease (22.1% vs 9.5%, P = .002). There were no differences between both groups regarding intraoperative complications (1.1% uncomplicated group vs 2.4% complicated group, P = .463), conversion rate (2.6% uncomplicated group vs 4.8% complicated group, P = .463), postoperative morbidity (27.4% uncomplicated group vs 34.5% complicated group, P = .231), intra-abdominal septic complications (4.2% uncomplicated group vs 7.1% complicated group, P = .309), and length of stay (3.8 ± 2.0 days uncomplicated group vs 4.2 ± 3.0 complicated group, P = .188)., Conclusion: Minimally invasive ileocolic resection for complicated Crohn disease is safe and feasible. Future prospective studies are needed to confirm these results., (Copyright © 2022 Elsevier Inc. All rights reserved.)

To date, there is no cohort in the literature focusing on the impact of the type of anastomosis in robotic ileocolonic resections for Crohn's Disease (CD). We aimed to compare short-term postoperative outcomes of robotic ileocolic resection for CD between patients who had intracorporeal (ICA) or extracorporeal anastomosis (ECA). We retrospectively included all consecutive robotic ileocolonic resections for CD at our institution between 2014 and 2020. We compared baseline, perioperative characteristics, and postoperative outcomes between ICA and ECA. The analysis included 89 patients: 71% underwent ICA and 29% ECA. Groups were similar in age, sex, body mass index, smoking, CD duration, Montreal classification, surgical history, and previous CD medical treatments. Return to bowel function was achieved sooner in the ICA group (ICA 1.6 ± 0.7 day, ECA 2.1 ± 0.8 days; p = 0.026) despite longer operative time (ICA 235 ± 79 min, ECA 172 ± 51 min; p < 0.001), but no statistical difference was found regarding ileus rate and length of stay. Overall, 30-day postoperative complication rate was 23.6% (ICA 22.2%, ECA 26.9%; p = 0.635). There were no abdominal septic complications, anastomotic leaks, or severe postoperative complications. In conclusion, robotic ileocolic resection for CD shows acceptable 30 days outcomes for both ICA and ECA. ICA was associated with a faster return to bowel function without impact on the length of stay or 30-day complications. Further studies are needed to confirm the benefits of ICA in the setting of ileocolic resections for CD., (© 2021. The Author(s), under exclusive licence to Springer-Verlag London Ltd., part of Springer Nature.)

Objective: We aimed to determine a safe zone of intraoperative fluid management associated with the lowest postoperative complication rates without increased acute kidney injury (AKi) risk for elective colorectal surgery patients., Background: To date, standard practice within institutions, let alone national expectations related to fluid administration, are limited. This fact has perpetuated a quality gap., Methods: Elective colorectal surgeries between 2018 and 2020 were included. Unadjusted odds ratios (ORs) for postoperative ileus, prolonged LOS, and AKi were plotted against the rate of intraoperative RL infusion (mL/ kg/h) and total intraoperative volume. Binary logistic regression analysis, including fluid volumes as a confounder, was used to identify risk factors for postoperative complications., Results: A total of 2900 patients were identified. Of them, 503 (17.3%) patients had ileus, 772 (26.6%) patients had prolonged LOS, and 240 (8.3%) patients had AKI. The intraoperative fluid resuscitation rate (mg/kg/h) was less impactful on postoperative ileus, LOS, and AKI than the total amount of intraoperative fluid. A total fluid administration range between 300 mL and 2.7 L was associated with the lowest complication rate. Total intraoperative RL ≥2.7 L was independently associated with a higher risk of ileus (adjusted OR 1.465; 95% confidence interval 1.154-1.858) and prolonged LOS (adjusted OR 1.300; 95% confidence interval 1.047-1.613), but not AKI. Intraoperative RL ≤300 mL was not associated with an increased risk of AKI., Conclusion: Total intraoperative RL ≥2.7 L was independently associated with postoperative ileus and prolonged LOS in elective colorectal surgery patients. A new potential standard for intraoperative fluids will require anesthesia case planning (complexity and duration) to ensure total fluid volume meets this new opportunity to improve care., Competing Interests: The authors report no conflicts of interest., (Copyright © 2022 Wolters Kluwer Health, Inc. All rights reserved.)

Aim: The aim of this study was to describe the surgical management, outcomes and risk of malignancy of presacral tailgut cysts., Method: A retrospective analysis of all patients who underwent resection of tailgut cyst at Mayo Clinic in Arizona, Florida and Minnesota between 2008 and 2020 was performed. Demographics, presentation, evaluation, surgical approach, postoperative complications, pathology and recurrence rates were reviewed., Results: Seventy-three patients were identified (81% female) with a mean age of 45 years. Thirty-nine patients (53%) were symptomatic, most commonly with pelvic pain (26 patients). Digital rectal examination identified a palpable mass in 68%. Mean tumour size was 6 cm. Resection was primarily performed through a posterior approach (77%, n = 56), followed by a transabdominal approach (18%, n = 13) and a combined approach (5%, n = 4). Six patients underwent a minimally invasive resection (laparoscopic/robotic). Coccygectomy or distal sacrectomy was performed in 41 patients (56%). Complete resection was achieved in 94% of patients. Thirty-day morbidity occurred in 18% and was most commonly wound related; there was no mortality. Malignancy was identified in six patients (8%). For the 30 patients with follow-up greater than 1 year, the median follow-up was 39 months (range 1.0-11.1 years). Local recurrence was identified in three patients and distant metastatic disease in one patient., Conclusion: The rate of malignancy in presacral tailgut cysts based on this current review was 8%. Overall recurrence was 5% at a median of 24 months., (© 2021 The Association of Coloproctology of Great Britain and Ireland.)

Objective: Prior to 2015 residents in our Accreditation Council for Graduation Medical Education (ACGME) colon and rectal surgery training program were in charge of managing, with faculty oversight, the outpatient anorectal clinic at our institution. Starting in 2015 advanced practice providers (APPs) working in the division assumed management of the clinic. The effect of APPs on ACGME resident index diagnostic case volumes has not been explored. Herein we examine ACGME case log graduate statistics to determine if the inclusion of APPs into our anorectal clinic practice has negatively affected resident index diagnostic anorectal case volumes., Design: ACGME year-end program reports were obtained for the years 2011 to 2019. Program anorectal diagnostic index volumes were recorded and compared to division volumes. Analysis of variance (ANOVA) and analysis of covariance (ANCOVA) tests were conducted to assess whether the number of cases per year (for each respective case type) prior to the introduction of APPs into the anorectal clinic (2011-2014) differed from the number of cases per year with the APP clinic in place (2015-2018). A p-value <0.05 was considered statistically significant., Setting: Mayo Clinic, Rochester, Minnesota (quaternary referral center)., Participants: Colon and rectal surgery resident year-end ACGME reports (2011-2019)., Results: ANOVAs revealed a marginally significant (p = 0.007) downtrend for hemorrhoid diagnostic codes, and a significant uptrend (p = 0.000) for fistula cases. Controlling for overall division volume, ANCOVA only reveled significance for fistula cases (p = 0.004) with the involvement of APPs., Conclusions: At our institution we found the inclusion of APPs into our anorectal clinic practice did not negatively affect colon and rectal surgery resident ACGME index diagnostic anorectal case volumes. Inclusion of APPs into a multidisciplinary practice can promote resident education by allowing trainees to pursue other educational opportunities without hindering ACGME index case volumes., Competing Interests: Declarations of Interest None for all authors., (Copyright © 2021 Association of Program Directors in Surgery. Published by Elsevier Inc. All rights reserved.)

Background: Avoiding unnecessary inpatient stay may decrease hospital-acquired complications and costs while increasing patient satisfaction. This study aimed to develop and validate a score to identify patients eligible for safe same-day discharge after colorectal resections., Methods: This bi-institutional retrospective cohort study included consecutive patients undergoing elective colon and rectal resections (2011-2018) for benign and malignant indications. Two multivariable logistic models were developed based on demographic and surgical risk factors to predict a combined endpoint (ileus, anastomotic leak, intra-abdominal abscess, and readmission). Development and validation datasets were randomly sampled from the entire cohort. Areas under the receiver operating characteristic curves (AUC) were evaluated, and Hosmer-Lemeshow goodness-of-fit tests were used to assess validation model fit., Results: Of 5,389 patients, 1,182 (21.9%) experienced at least one complication of the combined endpoint. Male gender, open surgery, ASA ≥3, wound class ≥3, ileostomy, surgical duration >3 hours, and perioperative IV fluids >3 L all had significantly greater odds of the combined endpoint in the parsimonious multivariable model (all P < .05). The reduced model considering only the 4 variables with the highest OR (>1.5) contained open surgery, ASA ≥3, wound class ≥3, and surgical duration ≥3 hours as predictors (all P < .05, AUC of 0.65; 95% CI 0.63, 0.68). Both the parsimonious model and the reduced model demonstrated no lack of fit in the validation cohort., Conclusion: The suggested score composed of preand intraoperative items may help physicians decide on patients' same-day discharge after colorectal resection., (Copyright © 2021. Published by Elsevier Inc.)

Background: The aim of this study was to identify national utilization trends of robotic surgery for elective colectomy, conversion rates over time, and the specific impact of conversion on postoperative morbidity. Conversion to open represents a hard endpoint for minimally invasive surgery (MIS) and is associated with worse outcomes when compared to MIS or even traditional open procedures., Methods: All adult patients who underwent either laparoscopic or robotic elective colectomy from 2013 to 2018 as reported in the American College of Surgeons Quality Improvement Program (ACS-NSQIP) database were included. National trends of both robotic utilization and conversion rates were analyzed, overall and according to underlying disease (benign disease, inflammatory bowel disease (IBD), cancer), or the presence of obesity (body mass index (BMI) ≥ 30 kg/m 2 ). Demographic and surgical risk factors for surgical conversion to open were identified through multivariable regression analysis. Further assessed were overall and specific postoperative 30-day complications, which were risk adjusted and compared between converted patients and the remaining cohort., Results: Of 66,652 included procedures, 5353 (8.0%) were converted to open. Conversion rates were 8.5% for laparoscopic and 4.9% for robotic surgery (p < 0.0001). A decline in conversion rates over the 6-year inclusion period was observed overall and for patients with obesity. This trend paralleled an increased utilization of the robotic platform. Several surrogates for advanced disease stages for cancer, diverticulitis, and IBD and prolonged surgical duration were identified as independent risk factors for unplanned conversion, while robotic approach was an independent protective factor (OR 0.44, p < 0.0001). Patients who had unplanned conversion were more likely to experience postoperative complications (OR 2.36; 95% CI [2.21-2.51]), length of hospital stay ≥ 6 days (OR 2.86; 95% CI [2.67-3.05], and 30-day mortality (OR 2.28; 95% CI [1.72-3.02])., Conclusion: This nationwide study identified a decreasing trend in conversion rates over the 6-year inclusion period, both overall and in patients with obesity, paralleling increased utilization of the robotic platform. Unplanned conversion to open was associated with a higher risk of postoperative complications., (© 2021. The Author(s), under exclusive licence to Springer Science+Business Media, LLC part of Springer Nature.)

As robotic surgery continues to disseminate into the field of colon and rectal surgery, there is a growing interest in the utilization of intracorporeal anastomosis to potentially improve surgical outcomes. The purpoe of this study was to compare feasibility, safety, and short-term outcomes of robotic sigmoid and low anterior resections performed with completely intracorporeal anastomosis (CICA) technique to the traditional extracorporeal assisted anastomosis (ECAA) technique. Consecutive series of patients who underwent elective robotic sigmoid or low anterior resections for benign or malignant disease utilizes either CICA or ECAA between August 2017 and November 2019. Surgical complications were assessed until 30 postoperative days and compared between the two groups. A total of 160 patients were identified; 73 (45.6%) in the CICA group and 87 (54.4%) in the ECAA group. Most of the procedures were performed for malignancy (76%). Estimated blood loss was lower in the CICA group (80.7 mL vs. 110.2 mL; p = 0.048), while operative times were longer (5.9 ± SD hours vs. 4.9 ± SD hours; p =  < 0.001). Overall conversion rate was 1.9%, with no conversions in the CICA group. Overall complications occurred in 54 patients (33.8%) with 13 (8.3%) representing major complications. There were no significant differences in 30 day outcomes between the two groups. This study demonstrates the feasibility and safety of robotic sigmoid and low anterior resections with CICA. Outcomes for robotic sigmoid and low anterior resections are encouraging regardless of anastomotic technique (CICA vs ECAA)., (© 2021. Italian Society of Surgery (SIC).)

Although much focus is placed on oncological outcomes for rectal cancer, it is important to assess quality of life after surgery of which sexual function is an important component. This study set about to describe the prevalence of sexual dysfunction by resection type and gender among patients undergoing surgery for rectal cancer, usingretrospective analysis. All English-speaking living patients who underwent surgery for stage I-III rectal cancer with curative intent between 2012 and 2016 were identified from a prospectively maintained database at our institution. Eligible patients were invited to complete either the Female Sexual Function Index (FSFI) or the International Index of Erectile Function (IIEF). Primary outcomes were overall rates of sexual dysfunction, defined as more than one standard deviation below the mean of the normal population for each tool. A total of 147 patients responded, yielding a response rate of 38%. The overall sexual dysfunction rate was 70% at a median time from surgery of 38 months. Sixty-two men (62%) and 41 women (87%) reported overall scores that fell below one standard deviation of the population mean. There was no significant difference in sexual dysfunction for both male and female patients between low anterior resection, coloanal anastomosis, or abdominoperineal resection.. The present study revealed a high rate of sexual dysfunction after rectal cancer surgery, particularly in female patients. This study serves as a reminder to surgeons and their teams to openly discuss the impact of surgery on sexual function and ensure adequate consent and appropriate peri-operative management strategies. The retrospective nature of the analysis is the limitation of this study., (© 2021. Italian Society of Surgery (SIC).)

Background: Obesity is a risk factor for failure of pouch surgery completion. However, little is known about the impact of obesity on short-term outcomes after minimally invasive (MIS) ileal pouch-anal anastomosis (IPAA). This study aimed to assess short-term postoperative outcomes in patients undergoing MIS total proctocolectomy (TPC) with IPAA in patients with and without obesity., Materials and Methods: All adult patients (≥ 18 years old) who underwent MIS IPAA as reported in the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) Participant User Files 2007 to 2018 were included. Patients were divided according to their body mass index (BMI) into two groups (BMI ≥ 30 kg/m 2 vs. BMI < 30 kg/m 2 ). Baseline demographics, preoperative risk factors including comorbidities, American Society of Anesthesiologists Class, smoking, different preoperative laboratory parameters, and operation time were compared between the two groups. Propensity score matching (1:1) based on logistic regression with a caliber distance of 0.2 of the standard deviation of the logit of the propensity score was used to overcome biases due to different distributions of the covariates. Thirty-day postoperative complications including overall surgical and medical complications, surgical site infection (SSI), organ space infection, systemic sepsis, 30-day mortality, and length of stay were compared between both groups., Results: Initially, a total of 2158 patients (402 (18.6%) obese and 1756 (81.4%) nonobese patients) were identified. After 1:1 matching, 402 patients remained in each group. Patients with obesity had a higher risk of postoperative organ/space infection (12.9%; vs. 6.5%; p-value 0.002) compared to nonobese patients. There was no difference between the groups regarding the risk of postoperative sepsis, septic shock, need for blood transfusion, wound disruption, superficial SSI, deep SSI, respiratory, renal, major adverse cardiovascular events (myocardial infarction, stroke, cardiac arrest requiring cardiopulmonary resuscitation), venous thromboembolism, 30-day mortality, and length of stay., Conclusion: MIS IPAA can be safely performed in patients with obesity. However, patients with obesity have a 2-fold risk of organ space infection compared to patients without obesity. Loss of weight before MIS IPAA is recommended not only to allow for pouch creation but also to decrease organ space infections., (© 2021. The Author(s), under exclusive licence to Springer-Verlag GmbH Germany, part of Springer Nature.)

There is limited data about the safety of colorectal surgery after immune checkpoint inhibitors (ICI). We aimed to share our experience about postoperative outcomes of colorectal surgery for patients treated with ICI. Overall, 31 patients were identified, 22 (71%) underwent elective and nine (29%) underwent emergent/urgent surgery. The 30-day Clavien Dindo class ≥ III complication rates were 27.3% (n = 6) for elective and 55.5% (n = 5) for emergent/urgent cases. Four patients underwent emergency surgery for immune-related colonic perforation and developed postoperative septic shock; two died. Considering patients' comorbidities, cancer stage, and surgical complexity, elective colorectal surgery after ICI seems relatively safe. However, emergent/urgent colorectal surgery was associated with high postoperative morbidity. Indeed, colonic perforation in the setting of ICI treatment has a significant risk of postoperative mortality. Therefore, for patients on ICI with any acute abdominal symptoms, surgical consult should be involved, and colon perforation should be ruled out., Competing Interests: Declaration of competing interest This research did not receive external funding. Authors declare no conflict of interest., (Copyright © 2021 Elsevier Ltd, BASO ~ The Association for Cancer Surgery, and the European Society of Surgical Oncology. All rights reserved.)

Objective: There is limited literature on the impact of the extent of resection on short-term outcomes in patients with ulcerative colitis (UC) in an elective setting. The aim of this study was to better understand the impact of approach and extent of resection on short-term outcomes for patients undergoing total proctocolectomy (TPC) and subtotal colectomy (STC) for UC., Methods: Patients with UC who underwent elective TPC or STC were captured from the ACS-NSQIP® 2011-2018 database and divided into four cohorts: Open TPC (O-TPC), Laparoscopic TPC (L-STC), Open STC (O-STC), and Laparoscopic STC (L-STC). Baseline and perioperative variables were compared between the four groups alongside 30-day mortality and 30-day complication rates., Results: Of 3387 patients, 368 (10.9%) underwent O-STC, 406 (12%) underwent O-TPC, 1958 (58%) underwent L-STC, and 655 (19%) underwent L-TPC. Overall rate of prolonged length of stay (LOS) was 27% and 9% needed a blood transfusion. There was no difference in the risk of complications between open TPC and open STC. Those who had open surgery had a higher risk of complications and prolonged LOS. Patients who had L-TPC had prolonged LOS compared to patients who had L-STC, but less compared to those who had O-STC., Conclusion: Elective surgery for UC is associated with high rates of prolonged LOS and blood transfusion despite MIS approaches. Short-term outcomes and LOS are more impacted by the operative approach than the extent of resection. Despite this laparoscopic TPC has higher rates of prolonged LOS when compared to laparoscopic STC., (© 2021. Italian Society of Surgery (SIC).)

Background: Characteristics and indications for discharging patients to home or a specific facility type have been studied; however, critical evaluation of these facilities through analysis of post-discharge complications and readmission rates is mandatory. The aim of this study was to compare complications occurring after discharge to home, skilled, and unskilled care facilities to identify potential pitfalls., Methods: All adult (≥18 years) patients who underwent surgery for colon or rectal cancer from 2012 to 2017 as reported in the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database were included. Patients were categorized according to the discharge destination into: home, skilled care (rehabilitation center, separate acute care, skilled facility), and unskilled care (multilevel senior community, facility which is home, unskilled facility). Demographics, surgical risk factors and predischarge complications were compared between the three groups. Primary endpoints were overall, major, surgical, and medical complications occurring post-discharge, within 30 days of surgery. Further assessed were specific complications, readmission, length of stay, and 30-day mortality., Results: A total of 108,617 patients were identified. Of them, 100,478 (92%) discharged to home, 7313 (7%) to skilled, and 826 (1%) to unskilled care. Of patients discharged to skilled care, 1928 (26%) discharged to rehabilitation centers, 368 (5%) to separate acute care, and 5017 (69%) to skilled facilities. Adjusted overall, major, surgical, and medical post-discharge complications were highest among patients discharged to skilled care destinations. Subgroup analysis revealed separate acute care (inter-hospital transfer) to be associated with the highest morbidity. Main reasons for readmission were primarily related to surgical site infection and intestinal obstruction among the three main destinations, whereas readmissions for systemic sepsis and medical complications were more frequent in patients admitted to skilled care., Conclusion: This study identified higher rates of post-discharge complications associated with skilled care destinations, despite risk adjustment. This over-morbidity is potentially related to prevailing medical complications and inter-hospital transfers. Further studies are needed to better understand those findings and to improve quality of post-acute care and related outcomes., Competing Interests: Declaration of competing interest None., (Copyright © 2020. Published by Elsevier Inc.)

Background: Surgical treatment for transverse colon cancer involves either extended colectomy or segmental resection, depending on the location of the tumor and surgeon perspective. However, the oncological safety of segmental resection has not yet been established in large cohort studies., Objective: This study aims to compare segmental resection versus extended colectomy for transverse colon cancer in terms of oncological outcomes., Design: This was a retrospective cohort study., Settings: This study was conducted using a nationwide cohort., Patients: A total of 66,062 patients who underwent colectomy with curative intent for transverse stage I to III adenocarcinoma were identified in the National Cancer Database (2004-2015)., Main Outcome Measures: Patients were divided in 2 groups based on the type of surgery received (extended versus segmental resection). The primary outcome was overall survival. Secondary outcomes were 30- and 90-day mortality, length of hospital stay, and readmission rate within 30 days of surgical discharge., Results: Extended colectomy was performed in 44,417 (67.2%) patients, whereas 21,645 (32.8%) patients underwent segmental resection. Extended colectomy was associated with lower survival at multivariate analysis (HR, 1.07; 95% CI, 1.04-1.10; p < 0.001). The subgroup analysis showed that extended resection was independently associated with poorer survival in mid transverse colon cancers (HR, 1.08; 95% CI, 1.04-1.12; p < 0.001) and in stage III tumors (HR, 1.11; 95% CI, 1.04-1.18; p < 0.001). The number of at least 12 harvested lymph nodes was an independent predictor of improved survival in both overall and subgroup analyses., Limitations: This study was limited by its retrospective design., Conclusion: Extended colectomy was not associated with a survival advantage compared with segmental resection. On the contrary, extended colectomy was associated with slightly poorer survival in mid transverse cancers and locally advanced tumors. Segmental resection was found to be safe when appropriate margins and adequate lymph node harvest were achieved. See Video Abstract at http://links.lww.com/DCR/B454., Abordaje Quirrgico Del Cncer De Colon Transverso Anlisis De La Prctica Actual Y Los Resultados Oncolgicos Utilizando La Base De Datos Nacional De Cncer: ANTECEDENTES:El tratamiento quirúrgico para el cáncer de colon transverso implica colectomía extendida o resección segmentaria, según la ubicación del tumor y la perspectiva del cirujano. Sin embargo, la seguridad oncológica de la resección segmentaria aún no se ha establecido en estudios de cohortes grandes.OBJETIVO:Este estudio tiene como objetivo comparar la resección segmentaria versus la colectomía extendida para el cáncer de colon transverso en términos de resultados oncológicos.DISEÑO:Este fue un estudio de cohorte retrospectivo.ESCENARIO:Este estudio se realizó utilizando una cohorte a nivel nacional.PACIENTES:Un total de 66,062 pacientes que se sometieron a colectomía con intención curativa por adenocarcinoma de colon transverso en estadio I-III fueron identificados en la Base de Datos Nacional del Cáncer (2004-2015).PRINCIPALES MEDIDAS DE RESULTADO:Los pacientes se dividieron en dos grupos según el tipo de cirugía recibida (resección extendida versus resección segmentaria). El resultado primario fue la supervivencia global. Los resultados secundarios fueron la mortalidad a los 30 y 90 días, la duración de la estancia hospitalaria y la tasa de reingreso dentro de los 30 días posteriores al alta quirúrgica.RESULTADOS:Se realizó colectomía extendida en 44,417 (67.2%) casos, mientras que 21,645 (32.8%) pacientes fueron sometidos a resección segmentaria. La colectomía extendida se asoció con una menor supervivencia en el análisis multivariado (HR 1.07 IC 95% 1.04-1.10; p <0.001). El análisis de subgrupos mostró que la resección extendida se asoció de forma independiente con una menor supervivencia en los cánceres de colon transverso medio (HR 1.08 IC 95% 1.04-1.12; p <0.001) y en tumores en estadio III (HR 1.11 IC 95% 1.04-1.18; p <0.001). Un número de al menos 12 ganglios linfáticos cosechados fue un predictor independiente de una mejor supervivencia en los análisis general y de subgrupos.LIMITACIONES:Este estudio estuvo limitado por su diseño retrospectivo.CONCLUSIÓN:La colectomía extendida no se asoció con una ventaja de supervivencia en comparación con la resección segmentaria. Por el contrario, la colectomía extendida se asoció con una supervivencia levemente menor en cánceres de colon transverso medio y tumores localmente avanzados. Se encontró que la resección segmentaria es segura cuando se logran los márgenes apropiados y la cosecha adecuada de ganglios linfáticos. Consulte Video Resumen en http://links.lww.com/DCR/B454., (Copyright © The ASCRS 2021.)

Despite an increasing trend towards utilization of minimally invasive approaches (MIS), results regarding their safety profile are contradictory. All patients who underwent elective colectomy for any underlying disease with an identifiable operative approach available from the targeted colectomy files of the ACS-NSQIP PUFs 2013 to 2018 were included. The trend of utilization and complication rates of the different operative approaches (open, laparoscopic, robotic) were assessed during the inclusion period. Furthermore, overall, surgical, and medical complications were compared between the three approaches. The study cohort included 78,987 patients. Of them, 12,335 (15.6%) patients underwent open, 57,874 (73.3%) laparoscopic, and 8,778 (11.1%) robotic surgery. There was an increasing trend towards the utilization of robotic surgery (2.5% increase per year) at the expense of the other approaches. With the increasing trend toward the utilization of the robotic approach, a decreasing trend in overall and surgical complications and length of stay was observed. After adjusting for the baseline confounders, robotic surgery was associated with shorter length of stay, lower rate of overall (OR 0.397; p < 0.05 compared to open and OR: 0.763; p < 0.05 compared to laparoscopy) and surgical complications (OR: 0.464; p < 0.05 compared to open and OR: 0.734; p < 0.05 compared to laparoscopy). This study revealed an increasing trend toward the utilization of MIS for elective colectomy in the US. Robotic surgery was associated with a decreasing trend in overall and surgical morbidity and length of stay.

Background: Circumferential resection margin (CRM) involvement is widely considered the strongest predictor of local recurrence after TME. This study aimed to determine preoperative factors associated with a higher risk of pathological CRM involvement in robotic rectal cancer surgery., Methods: This was a retrospective review of a prospectively maintained database of consecutive adult patients who underwent elective, curative robotic low anterior or abdominoperineal resection with curative intent for primary rectal adenocarcinoma in a tertiary referral cancer center from March 2012 to September 2019. Pretreatment magnetic resonance imaging (MRI) reports were reviewed for all the patients. Risk factors for pathological CRM involvement were investigated using Firth's logistic regression and a predictive model based on preoperative radiological features was formulated., Results: A total of 305 patients were included, and 14 (4.6%) had CRM involvement. Multivariable logistic regression found both T3 >5 mm (OR 6.12, CI 1.35-36.44) and threatened or involved mesorectal fascia (OR 4.54, CI 1.33-17.55) on baseline MRI to be preoperative predictors of pathologic CRM positivity, while anterior location (OR 3.44, CI 0.72-33.13) was significant only on univariate analysis. The predictive model showed good discrimination (area under the receiver-operating characteristic curve >0.80) and predicted a 32% risk of positive CRM if all risk factors were present., Conclusion: Patients with pre-operatively assessed threatened radiological margin, T3 tumors with greater than 5 mm extension and anterior location are at risk for a positive CRM. The predictive model can preoperatively estimate the CRM positivity risk for each patient, allowing surgeons to tailor management to improve oncological outcomes., Competing Interests: Declaration of competing interest The authors declare that they have no conflicts of interest., (Copyright © 2020 Elsevier Ltd, BASO ~ The Association for Cancer Surgery, and the European Society of Surgical Oncology. All rights reserved.)

Background and Objectives: The goal of this study was to compare disease-specific risk factors and 30-day outcomes between patients with Crohn's disease (CD) and colon cancer (CC) undergoing right-sided surgical resection., Methods: The American College of Surgeons-National Surgical Quality Improvement Program (ACS-NSQIP®) was interrogated to extract all patients ≥18 years undergoing elective right-sided resection for CD versus CC. Independent risk factors for surgical complications were identified through multivariable logistic regression for both groups. In a second step, surgical and medical 30-day morbidity was compared after risk adjustment., Results: The cohort consisted of 17,516 patients, of which 2,899 (16.6%) underwent surgery for CD versus 14,617 (83.4%) for CC. Independent risk factors for surgical complications in patients with CD were male gender, African American race, ASA score (III or IV), active smoking, prolonged surgery, and preoperative anemia. Independent risk factors for surgical complications in the cancer group were age ≥70 years, male gender, ASA score (III or IV), respiratory and cardiovascular comorbidities, and preoperative hypoalbuminemia (<3.5 g/dL). After risk adjustment, surgical complications (OR 1.25, p = 0.002), sepsis (OR 1.64, p = 0.012), and unplanned readmissions (OR 1.39, p = 0.004) were more common in patients with CD. Thirty-day mortality was higher in cancer patients (1.1 vs. 0.1%, p < 0.0001)., Conclusions: Patients with Crohn's disease were more prone to surgical complications and postoperative sepsis compared to the cancer group undergoing the same procedure. Careful evaluation and correction of disease-specific modifiable risk factors of patients with CD and CC, respectively, are important., (© 2021 The Author(s). Published by S. Karger AG, Basel.)

Objective: To determine the risk factors for developing primary postoperative pulmonary complications (PPC) in patients undergoing minimally invasive colorectal surgery (MIS) for the treatment of cancer and to identify the potential indicators for more extensive preoperative evaluation., Materials and Methods: The ACS-NSQIP ® database was interrogated to capture patients who had elective colon or rectal cancer and underwent MIS between 2012 and 2017. Patients who had primary PPC including pneumonia, unplanned intubation and/or failure to wean from mechanical ventilation for > 48 h were compared to patients without PPC. Significant risk factors for PPC were retained to build a predictive risk model through logistic regression analysis. The model was then internally validated using 2018 data., Results: Of 50,150 patients identified, 637 (1.3%) had PPC. The final risk prediction model included six variables: history of chronic obstructive pulmonary disease, age, smoking status, functional health status, pre-operative congestive heart failure, and American Society of Anesthesiology class ≥ 3. The model achieved good calibration (Hosmer-Lemeshow goodness-of-fit test, p = 0.614) and discrimination (c statistics = 0.757). Internal validation achieved similar discrimination (c statistics = 0.798)., Conclusion: Primary postoperative pulmonary complications affected 1.3% of patients undergoing MIS for colon or rectal cancer. The novel predictive risk score showed good discrimination and may help to identify patients who may benefit from perioperative optimization.

Background: While minimally invasive surgery contributed to improved outcomes in bariatric surgery, less is known about current utilization trends and outcomes related to surgical technique for colorectal resections in super-obese patients (body mass index ≥50 kg/m 2 )., Objective: The aim of this study was to compare surgical modalities and short-term outcomes of patients with super obesity who underwent elective colectomy in the United States., Setting: A retrospective review was performed of patients with super obesity who underwent elective colectomy between 2012 to 2018 using the American College of Surgeons National Quality Improvement Program data pool., Methods: Patients were categorized into an open, laparoscopic, or robotic group. Baseline characteristics and perioperative outcomes including 30-day complications and length of stay were compared between the 3 groups. Furthermore, utilization trends of surgical modalities were assessed., Results: Of 1199 patients, 338 (28.2%) had open, 735 (61.3%) laparoscopic, and 126 (10.5%) robotic colectomy during the study period, primarily for colon cancer (50.8%). Patients in the open group tended to have more baseline co-morbidities. Laparoscopic approach showed better risk-adjusted outcomes compared with open for postoperative ileus (adjusted odds ratio [aOR]: .6, 95% confidence interval [CI; .383-.965]), overall medical complications (aOR: .4, 95%CI [.3-.8]), and length of stay (OR .6, 95% CI [.394-.968]). Trend utilization showed increasing utilization of the robotic platform over the study period, which was associated with less unplanned conversion to open (aOR .417, 95%CI [.199-.872])., Conclusion: Laparoscopic colectomy provides advantageous outcomes over open surgery for colectomy in super-obese patients. The robotic platform has been increasingly used over time, and potential benefits need to be further studied., (Copyright © 2020 American Society for Bariatric Surgery. Published by Elsevier Inc. All rights reserved.)

Background: Discharge on postoperative day 3 after laparoscopic colorectal resections is now common, and same-day discharge has been proposed recently as an option., Objective: The purpose of this study was to determine the safety of same-day and next-day discharge after laparoscopic colorectal surgery and to delineate which characteristics may make a patient eligible for this pathway., Design: This was a retrospective cohort study., Settings: The American College of Surgeons National Surgical Quality Improvement Project Targeted Colectomy Participant User File was used., Patients: Patients underwent elective laparoscopic colorectal resection and were discharged without complications on or before postoperative day 5 (early discharge: postoperative day 0 or 1, intermediate: postoperative day 2, standard: postoperative day 3 to 5)., Main Outcome Measures: Early readmission (on or before postoperative day 7), anastomotic leak, ileus, and overall readmission were measured., Results: Of 36,526 patients total, 906 (2.5%) were discharged on postoperative day 0 or 1. Patients discharged on postoperative day 0/1 tended to have shorter-duration operations, a diagnostic indication more commonly of benign neoplasm, and underwent less low pelvic anastomoses. The readmission rate within 7 days was only 2%. Overall rates of anastomotic leak (0.6% early, 1.0% intermediate, 1.2% standard), ileus (1.9% early, 1.5% intermediate, 2.1% standard), and readmission (early 4.8%, intermediate 5.1%, standard 5.8%) were equivalent to decreased in patients discharged early versus those discharged in the intermediate or standard discharge groups. On multivariable analysis, dismissal day remained a noncontributory-to-protective factor against anastomotic leak, ileus, and readmission., Limitations: Specific follow-up pathways used were unknown, and selection bias exists in deciding what day patients can be discharged., Conclusions: Discharge on the same day or next day after surgery was not associated with increased risk compared with discharge on postoperative day 3 to 5, and it did not result in a high rate of early readmissions. Increased use of expedited discharge pathways would reduce hospital costs and resource use. See Video Abstract at http://links.lww.com/DCR/B331. ¿ES RAZONABLE EL ALTA EL MISMO DíA O AL DíA SIGUIENTE, DESPUéS DE LA COLECTOMíA LAPAROSCóPICA EN PACIENTES SELECCIONADOS: Es común el alta hospitalaria en el 3er día postoperatorio, después de resecciones colorrectales laparoscópicas. Recientemente se ha propuesto como una opción, el alta el mismo día.Determinar la seguridad de alta el mismo día o al día siguiente después de la cirugía colorrectal laparoscópica, y delinear qué características pueden hacer que un paciente sea elegible para esta vía.Estudio de cohorte retrospectivo.American College of Surgeons National Surgical Quality Improvement Project Targeted Colectomy Participant User File.Se sometieron a resección colorrectal laparoscópica electiva, y se dieron de alta sin complicaciones durante el 5° día postoperatorio o antes (alta temprana: día 0 o 1 postoperatorio; intermedia: día 2 postoperatorio; estándar: día 3-5 postoperatorio).Reingreso temprano (en o antes del día 7 postoperatorio), fuga anastomótica, íleo y reingreso general.De 36,526 pacientes en total, 906 (2.5%) fueron dados de alta en el día 0 o 1 postoperatorio. Los pacientes dados de alta en el día 0/1 postoperatorio, tendieron a presentar operaciones de menor duración, indicación diagnóstica más frecuente de neoplasia benigna, y sometidos a menos anastomosis de pelvis baja. La tasa de readmisión dentro de los siete días, fue del 2%. Las tasas generales de fuga anastomótica (0.6% temprana, 1.0% intermedia, 1.2% estándar), íleo (1.9% temprana, 1.5% intermedia, 2.1% estándar) y reingreso (temprana 4.8%, intermedia 5.1%, estándar 5.8%) fueron equivalentes a la disminución en pacientes dados de alta temprana, versus aquellos dados de alta en los grupos intermedia o estándar. En el análisis multivariable, el día de alta no contribuyó al factor protector contra la fuga anastomótica, el íleo y el reingreso.Se desconocen las vías de seguimiento específicas utilizadas y existe un sesgo de selección al decidir en qué día se puede dar de alta a los pacientes.El alta el mismo día o al día siguiente después de la cirugía, no se asoció con un mayor riesgo, en comparación con el alta en el postoperatorio en los días 3-5, y no dio lugar a una alta tasa de reingresos tempranos. Mayor utilización de las vías de alta acelerada, reducirían costos hospitalarios y utilización de recursos. Consulte Video Resumen en http://links.lww.com/DCR/B331. (Traducción-Dr Fidel Ruiz Healy).

Background: Hospital readmission rate is an important quality metric and has been recognized as a key measure of hospital value-based purchasing programs., Objective: This study aimed to assess the risk factors for hospital readmission with a focus on potentially preventable early readmissions within 48 hours of discharge., Design: This is a retrospective cohort study., Settings: This study was conducted at a tertiary academic facility with a standardized enhanced recovery pathway., Patients: Consecutive patients undergoing elective major colorectal resections between 2011 and 2016 were included., Main Outcome Measures: Univariable and multivariable risk factors for overall and early (<48 hours) readmissions were identified. Specific surgical and medical reasons for readmission were compared between early and late readmissions., Results: In total, 526 of 4204 patients (12.5%) were readmitted within 30 days of discharge. Independent risk factors were ASA score (≥3; OR, 1.5; 95% CI, 1.1-2), excess perioperative weight gain (OR, 1.7; 95% CI, 1.3-2.3), ileostomy (OR, 1.4; 95% CI, 1-2), and transfusion (OR, 2; 95% CI, 1.4-3), or reoperation (OR, 11.4; 95% CI, 7.4-17.5) during the index stay. No potentially preventable risk factor for early readmission (128 patients, 24.3% of all readmissions, 3% of total cohort) was identified, and index hospital stay of ≤3 days was not associated with increased readmission (OR, 0.9; 95% CI, 0.7-1.2). Although ileus and small-bowel obstruction (early: 43.8% vs late: 15.5%, p < 0.001) were leading causes for early readmissions, deep infections (3.9% vs 16.3%, p < 0.001) and acute kidney injury (0% vs 5%, p = 0.006) were mainly observed during readmissions after 48 hours., Limitations: Risk of underreporting due to loss of follow-up and the potential co-occurrence of complications were limitations of this study., Conclusions: Early hospital readmission was mainly due to ileus or bowel obstruction, whereas late readmissions were related to deep infections and acute kidney injury. A suspicious attitude toward potential ileus-related symptoms before discharge and dedicated education for ostomy patients are important. A short index hospital stay was not associated with increased readmission rates. See Video Abstract at http://links.lww.com/DCR/B237. REINGRESOS DENTRO DE LAS 48 HORAS POSTERIORES AL ALTA: RAZONES, FACTORES DE RIESGO Y POSIBLES MEJORAS: La tasa de reingreso hospitalario es una métrica de calidad importante y ha sido reconocida como una medida clave de los programas hospitalarios de compras basadas en el valor.Evaluar los factores de riesgo para el reingreso hospitalario con énfasis en reingresos tempranos potencialmente prevenibles dentro de las 48 horas posteriores al alta.Estudio de cohorte retrospectivo.Institución académica terciaria con programa de recuperación mejorada estandarizado.Pacientes consecutivos sometidos a resecciones colorrectales mayores electivas entre 2011 y 2016.Se identificaron factores de riesgo uni y multivariables para reingresos totales y tempranos (<48 horas). Se compararon razones médicas y quirúrgicas específicas para el reingreso entre reingresos tempranos y tardíos.En total, 526/4204 pacientes (12,5%) fueron readmitidos dentro de los 30 días posteriores al alta. Los factores de riesgo independientes fueron puntuación ASA (≥3, OR 1.5; IC 95% 1.1-2), aumento de peso perioperatorio excesivo (OR 1.7; IC 95% 1.3-2.3), ileostomía (OR 1.4, IC 95%: 1-2) y transfusión (OR 2, IC 95% 1.4-3) o reoperación (OR 11.4; IC 95% 7.4-17.5) durante la estadía índice. No se identificó ningún factor de riesgo potencialmente prevenible para el reingreso temprano (128 pacientes, 24.3% de todos los reingresos, 3% de la cohorte total), y la estadía hospitalaria índice de ≤ 3 días no se asoció con un aumento en el reingreso (OR 0.9; IC 95% 0.7-1.2) Mientras que el íleo / obstrucción del intestino delgado (temprano: 43.8% vs. tardío: 15.5%, p < 0.001) fueron las principales causas de reingresos tempranos, infecciones profundas (3.9% vs 16.3%, p < 0.001) y lesión renal aguda (0 vs 5%, p = 0.006) se observaron principalmente durante los reingresos después de 48 horas.Riesgo de subregistro debido a la pérdida en el seguimiento, posible co-ocurrencia de complicaciones.El reingreso hospitalario temprano se debió principalmente a íleo u obstrucción intestinal, mientras que los reingresos tardíos se relacionaron con infecciones profundas y lesión renal aguda. Es importante tener una actitud suspicaz hacia los posibles síntomas relacionados con el íleo antes del alta y una educación específica para los pacientes con ostomía. La estadía hospitalaria índice corta no se asoció con mayores tasas de reingreso. Consulte Video Resumen en http://links.lww.com/DCR/B237.

Background: Transanal excision is the surgical treatment of choice for low-risk rectal pathology such as endoscopically unresectable polyps, very select early rectal cancers, as well as other benign and low-risk tumors. Robotic transanal minimally invasive surgery enhances the surgeon's ability to work in the confined space of the rectum and helps overcome the limitations of other modalities for transanal excision. Large lesions that extend to the dentate line and cannot be excised transanally impart a particular challenge. Herein, we describe a hybrid robotic transanal minimally invasive surgery approach for excising large rectal lesions that extend to the dentate line and cannot be excised by utilizing traditional transanal techniques., Technique: With the use of a standard transanal approach, the distal margin of the lesion is marked and lifted off of the internal sphincter muscle. The dissection is continued until above the anorectal ring, and a 5.5-cm transanal platform is introduced transanally. Insufflation with an 8-mm trocar is initiated and the robotic platform is docked transanally. A 1-cm circumferential proximal margin is marked, and the excision is continued robotically until en bloc resection of the lesion is completed. The defect is closed in a transverse fashion using barbed suture. For rare cases of circumferential or nearly circumferential full-thickness defects, interrupted barbed sutures are placed equidistant, the robot is undocked, the transanal platform is removed, and a handsewn coloanal anastomosis is performed allowing complete closure of the defect., Results: A hybrid robotic transanal minimally invasive surgery approach to large and low-lying rectal lesions is feasible and safe, and it has advantages over standard transanal excision including enhanced ergonomics, dexterity, and optics, as well as reduced rates of specimen fragmentation., Conclusion: A hybrid robotic transanal minimally invasive surgery approach allows for complete resection of very large polyps, which would otherwise be extremely challenging with standard transanal approaches. See Video at http://links.lww.com/DCR/B231.

Purpose: To assess the impact of delay from diagnosis to curative surgery on survival in patients with non-metastatic colon cancer., Methods: National Cancer database (NCDB) analysis (2004-2013) including all consecutive patients diagnosed with stage I-III colon cancer and treated with primary elective curative surgery. Short and long delays were defined as lower and upper quartiles of time from diagnosis to treatment, respectively. Age-, sex-, race-, tumor stage and location-, adjuvant treatment-, comorbidity- and socioeconomic factors-adjusted overall survival (OS) was compared between the two groups (short vs. long delay). A multivariable Cox regression model was used to identify the independent impact of each factor on OS., Results: Time to treatment was <16 days in the short delay group (31,171 patients) and ≥37 days in the long delay group (29,617 patients). OS was 75.4 vs. 71.9% at 5 years and 56.6 vs. 49.7% at 10 years in short and long delay groups, respectively (both p < 0.0001). Besides demographic (comorbidities, advanced age) and pathological factors (transverse and right-vs. left-sided location, advanced tumor stage, poor differentiation, positive microscopic margins), treatment delay had a significant impact on OS (HR 1.06, 95% CI 1.05-1.07 per 14 day-delay) upon multivariable analysis. The adjusted hazard ratio for death increased continuously with delay times of longer than 30 days, to become significant after a delay of 40 days., Conclusion: This analysis using a national cancer database revealed a significant impact on OS when surgeries for resectable colon cancer were delayed beyond 40 days from time of diagnosis., Competing Interests: Declaration of competing interest None., (Copyright © 2019 Elsevier Ltd, BASO ~ The Association for Cancer Surgery, and the European Society of Surgical Oncology. All rights reserved.)

Objective: To determine the relative or combined effects of Crohn disease (CD) and ulcerative colitis (UC) and the operation performed on postoperative venous thromboembolism (VTE) to better guide recommendations on extended VTE prophylaxis., Summary Background Data: There is growing evidence to suggest patients with inflammatory bowel disease have an increased risk of postoperative VTE, but prior studies have not accounted for the operation performed nor acknowledged differences between CD and UC., Methods: The American College of Surgeons National Surgical Quality Improvement Project database from 2005 to 2016 was queried for patients with a diagnosis of CD, UC, malignancy, or benign disease (diverticular disease, Clostridium difficile) undergoing major abdominal surgery. Operations with a VTE rate >3% were designated high risk. Operation-specific univariate and multivariable logistic regression analyses were conducted., Results: A total of 231,718 operations were analyzed with 4426 patients experiencing a VTE (1.9%). The overall rate of VTE ranged widely based on the operation performed from 0.7% for enterostomy closure to 5.3% for open subtotal colectomy. Seven operations met our threshold of 3% to be considered high risk. For each operation, postoperative VTE rates were similar regardless of diagnostic indication when performed in the elective setting. However, when performed emergently, the same operations had significantly higher VTE rates. Compared with the malignancy and benign disease groups, neither CD nor UC was associated with increased odds of VTE after any operation., Conclusions: Postoperative VTE risk varies widely by the operation performed, and a diagnostic indication of CD or UC does not play a role. Extended duration VTE prophylaxis should be considered in all patients undergoing high-risk operations, regardless of their underlying diagnosis.