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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. [ABSTRACT FROM AUTHOR]

Objective: To compare short term outcomes of patients undergoing laparoscopic or robotic rectal cancer surgery. Background: Significant benefits of robotic rectal cancer surgery over laparoscopy have yet to be demonstrated. Operative time and direct institutional cost seem in favor of the laparoscopic approach. Methods: We performed a retrospective review of consecutive patients operated on for rectal cancer with a mini-invasive approach at Mayo Clinic from 2005 to 2018. The primary aim of this study was to investigate the difference in postoperative morbidity between the laparoscopic and robotic approach. Multivariable models for odds to complications and prolonged (≥6 days) length of stay were built. Results: A total of 600 patients were included in the analysis. The number of patients undergoing robotic surgery was 317 (52.8%). The 2 groups were similar in respect to age, sex, and body mass index. Laparoscopic surgery was correlated to shorter operative time (214 vs 324 minutes; P < 0.001). Patients undergoing robotic surgery had a lower overall complications rate (37.2% vs 51.2%; P < 0.001). Robotic surgery was found to be the most protective factor [odds ratio (OR) 0.485; P = 0.006] for odds to complications. The event of a complication (OR 9.33; P < 0.001) and conversion to open surgery (OR 3.095; P = 0.002) were identified as risk factors for prolonged length of stay whereas robotic surgery (OR 0.62; P = 0.027) was the only independent protective factor. Conclusions: Robotic rectal cancer surgery is strongly associated with better short-term outcomes over laparoscopic surgery. [ABSTRACT FROM AUTHOR]

Objective: Surgeon workload, or human ''cost'' of performing a procedure, is not well understood in light of emerging surgical technologies. This pilot study quantified surgeon workload for colorectal procedures and identified patient, surgeon, and procedural factors impacting workload. Summary Background Data: Innovative technologies and procedures in surgery have generally been promoted for the advancement of patient care. The resulting surgeon workload is poorly studied with little knowledge of the contributing factors impacting workload. Methods: Surgeons completed NASA-Task Load Index (NASA-TLX) questionnaires to self-assess workload following abdominopelvic colon and rectal procedures. Corresponding patient data were retrieved from the medical record. Descriptive statistics, correlations, and ANOVA were performed to compare surgeon and patient factors, procedure type, and surgical approach on workload overall and by subscales. Results: Seven attending surgeons rated 238 surgeries, of which 218 (92%) had corresponding patient data. Surgeon experience and patient demographics had inconsistent effects on workload. A statistically significant 3-way interaction was identified among disease process, procedure type, and surgical approach on workload (F(9, 146) = 2.17, P = 0.027), but was limited to open procedures for neoplasia and inflammatory bowel disease patients. Proctectomy and colectomy procedures compared across open, laparoscopic, and robotic approaches showed significant differences in overall workload and subscales, where the robotic procedures required significantly less mental demand, physical demand, and effort, than open or laparoscopic (P < 0.05). Conclusions: Patient characteristics, disease process, and surgical experience had inconsistent effects on surgeon workload. Major differences in workload were identified for procedure type and surgical approach, where robotic procedures required less mental demand, physical demand, and effort. [ABSTRACT FROM AUTHOR]

Objective: Determine the safety of overlapping surgery in a tertiary care colorectal surgery practice. Summary: Although overlapping surgery is common in academic centers, reports on outcomes of this practice are limited. The primary aim of this study was to investigate the safety of overlapping surgery in a dedicated tertiary care academic colorectal practice by comparing groups of patients who did or did not have their surgery performed in an overlapping fashion. Methods: Retrospective review of 1270 colorectal patients undergoing inpatient colorectal surgery at our institution. Eligible participants were all patients undergoing elective inpatient colorectal surgery by one of the colorectal surgeons at the Mayo Clinic Rochester between January 1, 2012 and December 31, 2015. Patients under the age of 18 or who underwent an emergent procedure were excluded. Data were abstracted using the American College of Surgeons National Quality Improvement Program (ACS-NSQIP) database. Additionally, each subject's chart was reviewed and further abstracted. The safety of overlapping surgery on outcomes was assessed using multiple multivariable models. Results: One thousand two hundred seventy patients were included in the study cohort of whom 50.7% were female and the average age was 55.4 years. Overlapping surgery occurred in 576 patients (45%). There were no significant differences in demographic, surgical indications, procedures, or operative complexity between patients undergoing overlapping surgery and those who did not. Overall adverse events were significantly less likely in patients undergoing overlapping surgery compared with those who did not (18.4% vs 23.6%, P = 0.02). We found that overlapping surgery was associated with significantly less adverse events compared with patients not undergoing overlapping surgery using a model that controlled for the effect of the individual surgeon (OR 0.7, 95% CI 0.6 – 0.96; P  = .02) and a multivariable propensity score (OR 0.7, 95% CI 0.5– 0.9; P = 01). Conclusions: Overlapping surgery in a tertiary care colorectal practice is safe and not associated with adverse patient outcomes. [ABSTRACT FROM AUTHOR]

Supplemental Digital Content is available in the text Objective: To determine the disease-free survival (DFS) and recurrence after the treatment of patients with rectal cancer with open (OPEN) or laparoscopic (LAP) resection. Background: This randomized clinical trial (ACOSOG [Alliance] Z6051), performed between 2008 and 2013, compared LAP and OPEN resection of stage II/III rectal cancer, within 12 cm of the anal verge (T1-3, N0-2, M0) in patients who received neoadjuvant chemoradiotherapy. The rectum and mesorectum were resected using open instruments for rectal dissection (included hybrid hand-assisted laparoscopic) or with laparoscopic instruments under pneumoperitoneum. The 2-year DFS and recurrence were secondary endpoints of Z6051. Methods: The DFS and recurrence were not powered, and are being assessed for superiority. Recurrence was determined at 3, 6, 9, 12, and every 6 months thereafter, using carcinoembryonic antigen, physical examination, computed tomography, and colonoscopy. In all, 486 patients were randomized to LAP (243) or OPEN (243), with 462 eligible for analysis (LAP = 240 and OPEN = 222). Median follow-up is 47.9 months. Results: The 2-year DFS was LAP 79.5% (95% confidence interval [CI] 74.4–84.9) and OPEN 83.2% (95% CI 78.3–88.3). Local and regional recurrence was 4.6% LAP and 4.5% OPEN. Distant recurrence was 14.6% LAP and 16.7% OPEN. Disease-free survival was impacted by unsuccessful resection (hazard ratio [HR] 1.87, 95% CI 1.21–2.91): composite of incomplete specimen (HR 1.65, 95% CI 0.85–3.18); positive circumferential resection margins (HR 2.31, 95% CI 1.40–3.79); positive distal margin (HR 2.53, 95% CI 1.30–3.77). Conclusion: Laparoscopic assisted resection of rectal cancer was not found to be significantly different to OPEN resection of rectal cancer based on the outcomes of DFS and recurrence. [ABSTRACT FROM AUTHOR]

This study was designed to compare short-term outcomes after laparoscopic ileal pouch-anal anastomosis with those of open ileal pouch-anal anastomosis in patients with both sclerosing cholangitis and ulcerative colitis. Sixteen patients with sclerosing cholangitis and ulcerative colitis undergoing laparoscopic ileal pouch-anal anastomosis were matched with 16 open ileal pouch control subjects by sex, American Society of Anesthesiologists’ score, age, and body mass index. Operative mortality was zero. Operative time was longer in the laparoscopic group (500 ± 125.8 vs. 381.8 ± 60.9 minutes, P = 0.03). Thirty-day complications were not significantly different between groups (laparoscopic 25 percent vs. open 43.7 percent, P = 0.26). Length of stay was significantly shorter in the laparoscopic group (5.3 ± 1.3 days vs. 9.9 ± 3.3 days open, P < 0.001). Average return of gastrointestinal function was 2.5 days in the laparoscopic group and 4.8 days in the open group ( P = 0.001). Time to soft diet was three days in the laparoscopic group and six days in the open group ( P < 0.001). All patients were alive and all pouches were intact at last follow-up. Laparoscopic ileal pouch-anal anastomosis is feasible with apparent safety in patients with primary sclerosing cholangitis, resulting in shorter duration of hospital stay and quicker return of gastrointestinal function compared with the open procedure with no difference in perioperative complications, reoperations, and readmissions. [ABSTRACT FROM AUTHOR]

This study was designed to compare self-reported sexual function, body image, and quality of life outcomes among ulcerative colitis patients undergoing laparoscopic or open ileal pouch-anal anastomosis. Between 1978 and 2004, 100 laparoscopic and 189 open operations were performed in patients who were identified from a previously published cohort. Patients were surveyed one year after operation to evaluate sexual function, body image, and quality of life. A total of 125 of 289 patients (43 percent) returned completed surveys. There were no significant differences in terms of demographics, complications, or long-term functional outcomes between those who completed the surveys and those who did not. There were no clinical differences in results between laparoscopic and open patients using the three survey instruments. Orgasmic function scores were lower in men who underwent laparoscopic ileal pouch-anal anastomosis ( P < 0.05) compared with open ileal pouch-anal anastomosis. Overall, sexual function scores were equal to or better than normal values for men but were lower in women. Finally, overall body image and quality of life scores were above the means published for the United States. After ileal pouch-anal anastomosis, men and women reported excellent body image and high cosmetic and quality of life scores regardless of operative approach. Female sexual function was more adversely affected after ileal pouch-anal anastomosis than was male sexual function. [ABSTRACT FROM AUTHOR]

This study was designed to evaluate the long-term functional and quality-of-life outcomes of patients after coloanal anastomosis for distal rectal cancer. A total of 192 patients underwent coloanal anastomosis between 1982 and 2001 at two tertiary referral institutions. Standardized and validated questionnaires to assess functional and quality-of-life outcomes were mailed to 151 patients, of which 121 patients responded (median follow-up, 65 months). Patients receiving pelvic radiotherapy had more bowel function problems than patients who did not receive pelvic radiotherapy. No significant differences in relevant functional and quality-of-life outcomes were seen among patients who received preoperative or postoperative pelvic radiotherapy. Patients requiring permanent diversion as a result of complications of the surgery had decreased quality of life. Coloanal anastomosis for distal rectal cancer has favorable long-term outcomes. Pelvic radiotherapy has an adverse effect on subsequent bowel function (whether given preoperatively or postoperatively) in patients who maintain intestinal continuity. Loss of intestinal continuity after a coloanal anastomosis is associated with diminished quality of life. [ABSTRACT FROM AUTHOR]

PURPOSE: Functional outcomes in laparoscopic-assisted ileal pouch-anal anastomosis have been incompletely studied. More than one-year follow-up has rarely been reported in these patients. This study was designed to assess operative, functional, and quality of life outcomes in patients with ulcerative colitis or familial adenomatous polyposis a minimum of one year after. METHODS: Thirty-three laparoscopic-assisted ileal pouch-anal anastomosis and 33 open ileal pouch-anal anastomosis patients, with a median of 13 months and minimum of 12 months follow-up, were identified from a prospective, laparoscopic database. Functional outcome was prospectively assessed by using a standardized survey. These cohorts were matched by individual patient for year of surgery, age, gender, body mass index, and indication. RESULTS: Median age was 27 years (open) and 28 years (laparoscopic). There were 27 females and 6 males in each group. All operations occurred between 1999 and 2001. Median body mass index was 22.3 (open) and 21.7 (laparoscopic) groups. There were no significant differences in diagnosis, use of diversion, and anastomotic technique. Postoperative morbidity occurred in 6 percent of the laparoscopic cases and 12 percent of the open cases. Functional outcome after a minimum of one year revealed equivalent median day and median nocturnal number of stools of six to seven and one to two respectively. Consistency of stool, medication usage, and continence were no different between groups. Daytime and nocturnal incontinence was similar. Quality of life in regard to social, home life, family, travel, sports, recreation, and sex life were equivalent. CONCLUSIONS: The function and quality of life outcomes for patients undergoing laparoscopic-assisted ileal pouch-anal anastomosis seem to be equivalent to our open experience. Laparoscopic-assisted ileal pouch-anal anastomosis offers selected patients a safe, feasible, and durable alternative. [ABSTRACT FROM AUTHOR]

PURPOSE: Local excision for early-staged rectal cancers is controversial. Preoperative understaging is not uncommon and radical resection after local resection may be needed for a curative treatment. The aim of this study was to determine the frequency and outcome of radical resection (within 30 days) after local excision for rectal adenocarcinoma. METHODS: All locally excised rectal cancers (curative intent) that required radical surgery within 30 days were reviewed (1980-2000). T2-3N0-1 stage cancers were each matched to three primary radical surgery controls for stage, age (±5 years), gender, date (±1 years), and type (abdominoperineal resection or low anterior resection) of operation. T1N0-1 cancers were compared with stage-matched rectal cancers treated by either primary radical surgery (n = 78) or local excision alone (n = 77). RESULTS: Fifty-two locally excised rectal adenocarcinomas (29 transanal and 23 polypectomies) were followed by radical surgery (24 abdominoperineal resection and 28 low anterior resection) within 7 (range, 1-29) days. Radical surgery was performed because of a cancerous polyp (n = 42), positive margins (5), lymphovascular invasion (3), and T3-staged cancer (2). Twelve of 52 cancers (23 percent) were found to have nodal involvement and 15 of 52 (29 percent) showed residual cancer in the resected specimen. The T2-3N0-1 stage controls were well matched. No significant difference in tumor location, size, adjuvant therapy, or length of follow-up was noted. Local and distant recurrence occurred in 2 of 4 T2-3N1 tumors and in 2 of 11 T2-3N0 cancers and were comparable to the matched controls, as was survival, with the exception of shorter survival in T3N1 cases, but numbers were too small for a definitive conclusion. Length of follow- up was not different. For Ti cancers, the controls were also comparable regarding patient and tumor demographics and adjuvant therapy. Nodal involvement was 21 percent in T1 study cases and 15 percent in T1 primary radical-surgery controls, with a trend toward location in the lower third of the rectum in both groups (58 percent and 50 percent, respectively). Local recurrence rates were 3 percent in the study group, 5 percent for patients undergoing primary radical surgery, and 8 percent for local excision alone. Distant metastasis (11 percent, 12 percent, and 13 percent, respectively) and overall five-year survival were also not significantly different (78 percent, 89 percent, and 73 percent, respectively). CONCLUSIONS: Nodal involvement in attempted locally excised rectal cancers is not uncommon. Local excision of rectal tumors followed by radical surgery within 30 days in cancer patients does not compromise outcome compared with primary radical surgery. Even after radical surgery for superficial T1 rectal cancers, recurrence rates are not insignificant. Future improvements in preoperative staging may be helpful in selecting tumors for local excision only. [ABSTRACT FROM AUTHOR]

Objective: To develop and analyze a risk-adjusted cumulative sum (RA-CUSUM) chart as a potential method to monitor individual surgeon performance in robotic total mesorectal excision (TME) for rectal cancer., Summary Background Data: Currently, surgeons lack real-time tools to monitor and enhance their performance beyond residency completion. While national quality programs exist, granular, individual-level data is crucial for continuous improvement. Previous studies suggest CUSUM charts hold promise in identifying performance trends and outliers., Methods: This retrospective study analyzed data from 640 robotic TME cases performed by 12 surgeons at two institutions. RA-CUSUM charts were generated for three outcomes: complications, operative time, and length of stay., Results: The overall RA-CUSUM curves for operative time and complications showed an initial learning phase followed by a plateau or downward slope, indicating proficiency or improvement. However, individual surgeon curves revealed significant heterogeneity. Three surgeons consistently excelled in operative time, while five minimized complications most effectively. Potential quality improvement could be implemented to drive performance toward positive outliers. No differences were found in unadjusted outcomes, including conversion, number of lymph nodes harvested, and positive circumferential margins., Conclusions: The RA-CUSUM chart is a promising method for identifying individual surgeon performance in robotic TME. It could help surgeons, teams, and leaders identify improvement areas and benchmark themselves against positive outliers. Further studies are needed to explore the potential of RA-CUSUM for implementing interventions to improve surgical quality., Competing Interests: Conflicts of interest: The authors declare no conflict of interest., (Copyright © 2024 Wolters Kluwer Health, Inc. All rights reserved.)

Objective: This study aims to assess the costs of a Same-Day Discharge Enhanced Recovery Pathway (SDD) for diverting loop ileostomy closure compared to a standard institutional enhanced recovery protocol (ERP)., Summary Background Data: Every year, 50,155 patients in the United States undergo temporary stoma reversal. While ambulatory stoma closure has shown promise, widespread adoption remains slow. This study builds on previous research, focusing on the costs of a novel SDD protocol introduced in 2020., Methods: A retrospective case-control study was conducted at Mayo Clinic, Rochester, Minnesota, and Mayo Clinic, Jacksonville, Florida, comparing patients undergoing same-day discharge diverting loop ileostomy closure (SDD) from August 2020 to February 2023 to those in a matched cohort receiving standard inpatient ERP. Patients were matched based on age, sex, ASA score, surgery period, and hospital. Primary outcomes included direct hospitalization and additional costs in the 30 days post-discharge., Results: The SDD group (n=118) demonstrated a significant reduction in median index episode hospitalization and 30-day post-operative costs compared to the inpatient group (n=236), with savings of $4,827 per patient. Complication rates were similar, and so were readmission and reoperation rates., Conclusions: Implementation of the SDD for diverting loop ileostomy closure is associated with substantial cost savings without compromising patient outcomes. The study advocates for a shift towards same-day discharge protocols, offering economic benefits and potential improvements in healthcare resource utilization., Competing Interests: Conflicts of interest: The authors declare no conflict of interest., (Copyright © 2024 Wolters Kluwer Health, Inc. All rights reserved.)

Objective: The aim of this study was to perform an external validation of 2 institutionally derived predictive models of laparoscopic conversion in colorectal surgery using the Mayo Clinic, Rochester (MCR) laparoscopic colon and rectal surgery experience., Summary of Background Data: Two different predictive scoring systems of conversion in laparoscopic colorectal surgery were developed and published based upon single institution experiences. Neither model was validated on an independent data set. Thus, the utility of these models outside of their respective institutions is unknown., Methods: A prospectively collected data set of 998 laparoscopic colorectal procedures from MCR was analyzed. All patient-, procedure-, and surgeon-related factors used in both models were present in our data set. Logistic regression was used to evaluate their ability to predict conversion in our cohort. Model effectiveness was assessed by area under the curve from the logistic regression model, 95% confidence intervals for the observed number of conversions, and a goodness-of-fit test to compare the observed number of conversions with the predicted conversion rates for each score., Results: The cohort mean age of 552 women was 53, with a median body mass index of 25.2 kg/m. There were 382 right-sided, 251 left-sided, 46 rectal resections, and 151 proctocolectomies. Major diagnoses were inflammatory bowel disease 34%, cancer 18%, polyps 17%, and diverticular disease 13%. The overall MCR conversion rate was 15%. Several variables from the models were statistically significant predictors of conversion in our data set. However, both models performed similarly with an area under the curve of 0.62, suggesting that these models are of limited predictive value in our independent cohort with a performance closer to chance. The numbers of actual conversions were significantly different from the predicted number for both scoring systems., Conclusion: Patient and clinical factors associated with laparoscopic conversion in colorectal surgery may be institution dependent. This finding cautions surgeons on the applicability of institution-based surgical predictive models. Independent data set validation is recommended before surgical predictive models are applied to general clinical practice.

Objective: Evaluate outcomes of patients with an original diagnosis of ulcerative colitis (UC) who required partial or complete ileal pouch reconstruction due to poor function or infectious complications., Methods: A prospectively collected ileal pouch-anal anastomosis (IPAA) database was reviewed retrospectively to identify UC patients undergoing major reconstructive revisions of their IPAA at our institution between 1981 and 2005. Functional results were derived from continued surveys of patients., Results: Fifty-one UC patients were identified but 22 subsequently proved to have Crohns disease (CD). The initial IPAA was constructed at our institution in 32 patients and elsewhere in 19 patients. Indications for revision included infectious/inflammatory complications (65%) and mechanical difficulties (35%). Pouch revision was partial in 57% of patients and complete in 43%. There were no postoperative deaths. Following reconstruction, patients reported on average 5 daytime and 1 nighttime bowel movements. Daytime incontinence was occasional in 43% and frequent in 4%. Nighttime incontinence was occasional in 54% and frequent in 7%. The probability of pouch survival after reconstruction was 93% at 1 year and 89% at 5 years. Of the pouches that subsequently failed, 75% occurred in patients with a later diagnosis of CD. Postreconstruction abscess was a significant risk factor for ultimate pouch failure., Conclusions: In UC patients with failing IPAA, partial or complete pouch reconstruction can be done safely with good functional results, and may avoid pouch excision and permanent ileostomy in carefully selected patients, especially those with definite UC.

Objective: To test the hypothesis that surgeon volume would not predict short- and long-term outcomes when evaluated in the setting of technical credentialing., Summary Background Data: Surgical volume is a known predictor of outcomes; the importance of technical credentialing has not been evaluated., Methods: Fifty-three credentialed surgeons operated on 871 patients in the Clinical Outcomes of Surgical Therapy Study (NCT00002575), investigating laparoscopic versus open surgery for colon cancer. Credentialing required that each surgeon document performance of at least 20 laparoscopic colon cases and demonstrate oncologic techniques on a video-recorded case. Surgeons were separated based on volume entered into the trial (low, < or =5 cases (n = 39); medium, 6-10 cases (n = 9); or high, >10 cases (n = 5)) and compared by outcomes., Results: Patients treated by high volume compared with medium or low volume surgeons were older (70, 66, and 68 years; P < 0.001), more often had right-sided tumors (63%, 46%, and 53%; P < 0.001) and had more previous operations (48%, 38% and 45%; P < 0.004), respectively. Mean operative times were shorter (123, 147 and 145 minutes; P < 0.001), distal margins longer (13.4, 12.4 and 11.6 cm; P = 0.005), and lymph node harvest greater (14.8, 12.8, 12.6; P = 0.05) for high versus medium versus low volume surgeons. However, rates of conversion, complications, 5-year survival, and disease-free survival showed no significant differences., Conclusion: When tested in a randomized controlled trial with case-specific surgical technical credentialing and auditing, surgeon volume did not predict differences in rates of conversion, complications, or long-term cancer outcomes. Case-specific technical credentialing should be further studied specific to the role it could play in creating consistent, high quality outcomes.