Search

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.

Utility of adjuvant chemotherapy for stage II cancer remains a matter of debate. Clinical guidelines suggest adjuvant chemotherapy for stage II tumors with high-risk features, in particular T4 tumors. However, limited consensus exists regarding the importance of other high-risk features (lymphovascular or perineural invasion, microsatellite instability). Our study aimed to investigate the impact of adjuvant chemotherapy for stage IIA (T3N0) colon cancer patients. Patients who underwent colectomy for stage IIA colon adenocarcinoma (2010-2015) were identified in the National Cancer Database (NCDB) and divided in two groups based on receipt of adjuvant chemotherapy vs observation. Inverse probability of treatment weighting (IPTW)-adjusted Kaplan-Meier and Cox proportional hazards regression analyses were performed to compare overall survival between the two groups. Subgroup analysis of patients with specific high-risk features LVI, PNI and MSI was performed. Among 46 688 surgical patients with stage IIA colon adenocarcinoma 5937 (12.7%) received adjuvant chemotherapy, while 40 751 (87.3%) were observed. Five-year IPTW-adjusted survival was higher in the adjuvant chemotherapy group (79.7% [95% CI 79.1, 80.2]) compared to the observation group (70.3% [95% CI 69.7, 70.9]). Patients with high-risk pathological features showed an estimated 5-year survival benefit of 11.3% (78.2% [95% CI 77.4, 79.1] vs 66.9% [95% CI 65.9, 67.8]) when treated with adjuvant chemotherapy. This NCDB analysis revealed a survival benefit for patients with stage IIA colon adenocarcinoma and high-risk features that were treated with adjuvant chemotherapy., (© 2020 Union for International Cancer Control.)

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: To understand how surgeon expectation of case difficulty relates to workload for colon and rectal procedures and to identify possible surgeon-perceived drivers contributing to case difficulty., Materials and Methods: For 3 mo, surgeons were asked to complete a modified NASA-Task Load Index (NASA-TLX) questionnaire following each surgical case. Questions included items on distractions, fatigue, procedural difficulty, and expectation plus the validated NASA-TLX items. All but expectation were rated on a 20-point scale (0 = low, 20 = high). Expectation was rated on a 3-point scale (i.e., more difficult than expected, as expected, less difficult than expected). Surgeons also reported perceived drivers contributing to case ease or difficulty. Patient and procedural data were analyzed for procedures with completed surveys., Results: Seven surgeons (three female) rated 122 procedures over the research period using a modified NASA-TLX survey. Mean surgeon-perceived workload was highest for effort (mean [M] = 10.83, standard deviation [SD] = 5.66) followed by mental demand (M = 10.18, SD = 5.17), and physical demand (M = 9.19, SD = 5.60). Procedural difficulty varied significantly by procedure type (P < 0.001). Thirty-five percent of cases were considered more difficult than expected. Surgeon-perceived workload and most subscales differed significantly according to expectation level. There was no significant difference in patient factors by expectation level. Surgeons most frequently reported patient anatomy, body habitus, and operative team characteristics as drivers to difficulty and ease of cases., Conclusions: Procedural difficulty significantly differed across procedure type. More than one-third of cases were more difficult than expected, during which surgeons attributed this to operative team characteristics as well as issues in patient anatomy and body habitus., (Copyright © 2019 Elsevier Inc. All rights reserved.)

Background: Postoperative ileus remains an issue after colorectal surgery delaying recovery and increasing the length of hospital stay and costs., Objective: The purpose of this study was to analyze the impact of perioperative fluid management on ileus occurrence after colorectal surgery within a fully implemented enhanced recovery pathway., Design: This was a retrospective cohort study of a prospectively maintained institutional database., Settings: The study was conducted at a tertiary academic facility with fully implemented standardized enhanced recovery pathway over the entire study period., Patients: All of the consecutive elective major colorectal resections for benign or malign indications between 2011 and 2016 were included., Main Outcome Measures: Postoperative ileus was defined as the need for nasogastric tube reinsertion. Perioperative fluid management and surgical outcome were compared between patients presenting with ileus and those without. Potential risk factors for ileus were identified through multinomial logistic regression., Results: Postoperative ileus occurred in 377 (9%) of 4205 included patients at day 4 (interquartile range, 2-5 d). Intraoperatively, ileus patients received 3.2 ± 2.6 L of fluids, whereas the remaining patients received 2.5 ± 1.7 L (p < 0.001). Weight gain was 3.8 ± 7.1 kg in ileus patients versus 3.0 ± 6.6 kg (p = 0.272) in the remaining patients at postoperative day 1, 4.4 ± 6.5 kg versus 3.1 ± 7.0 kg (p = 0.028) at postoperative day 2, and 1.8 ± 6.0 kg versus 0.0 ± 6.0 kg at discharge (p = 0.002). The multivariable model including all significant (p < 0.05) demographic, fluid management-related, and surgical parameters retained postoperative day 0 fluids of >3 L (OR = 1.65 (95% CI, 1.13-2.41); p = 0.009), postoperative day 2 weight gain of >2.5 kg (OR = 1.49 (95% CI, 1.01-2.21); p = 0.048), and occurrence of postoperative complications (OR = 2.00 (95% CI, 1.39-2.90); p < 0.001) as independent risk factors for ileus., Limitations: This study was limited by its retrospective design. Fluid management depends on patient-, disease-, and surgery-related factors and cannot be generalized and extrapolated., Conclusions: Fluid overload and occurrence of postoperative complications were independent risk factors for postoperative ileus. This calls for action to keep perioperative fluids below suggested thresholds. See Video Abstract at http://links.lww.com/DCR/B54. ASOCIACIÓN POTENCIAL ENTRE EL MANEJO DEL LÍQUIDO PERIOPERATORIO Y EL SUCESO DE ÍLEO POSTOPERATORIO: El íleo postoperatorio sigue siendo un problema después de una cirugía colorrectal que retrasa la recuperación y aumenta la duración de la estancia hospitalaria y los costos.Analizar el impacto del manejo del líquido perioperatorio en la incidencia de íleo después de la cirugía colorrectal dentro de una vía de recuperación mejorada totalmente implementada.Estudio de cohorte retrospectivo de una base de datos institucional mantenida prospectivamente.Centro académico terciario con una ruta de recuperación mejorada estandarizada completamente implementada durante todo el período del estudio.Se incluyeron todas las resecciones colorrectales mayores electivas consecutivas para indicaciones benignas o malignas entre 2011 y 2016.El íleo postoperatorio se definió como la necesidad de reinserción de la sonda nasogástrica. El manejo del líquido perioperatorio y el resultado quirúrgico se compararon entre los pacientes con íleo y los que no. Los posibles factores de riesgo para el íleo se identificaron mediante regresión logística multinominal.El íleo postoperatorio se ocurrió en 377 (9%) de los 4205 pacientes incluidos al cuarto día (RIC 2-5). Intraoperatoriamente, los pacientes con íleo recibieron 3.2 ± 2.6 L de líquidos, mientras que los pacientes restantes recibieron 2.5 ± 1.7 L (p < 0.001). El aumento de peso fue de 3.8 ± 7.1 kg en pacientes con íleo versus 3 ± 6.6 kg (p = 0.272) en los pacientes restantes en el día postoperatorio 1, 4.4 ± 6.5 kg vs. 3.1 ± 7 kg (p = 0.028) en el día postoperatorio 2 y 1.8 ± 6 kg versus a 0 ± 6 kg al tiempo de alta hospitalaria (p = 0.002). El modelo multivariable que incluye todos los parámetros demográficos, del manejo de líquidos y quirúrgicos significativos (p <0.05) mantuvo líquidos del día 0 después de la operación de> 3L (proporción de probabilidad 1.65, intervalo de confianza del 95% 1.13-2.41, p = 0.009), ganancia de peso de > 2.5 kg en el dia postoperatorio 2 (proporción de probabilidad 1.49, 95% intervalo de confianza 1.01-2.21, p = 0.048) y aparición de complicaciones postoperatorias (proporción de probabilidad 2, 95% intervalo de confianza 1.39-2.9, p <0.001) como factores de riesgo independientes para íleo.Diseño retrospectivo. El manejo de líquidos depende de factores relacionados con el paciente, la enfermedad y la cirugía, y no puede generalizarse ni extrapolarse.La sobrecarga de líquidos y la aparición de complicaciones postoperatorias fueron factores de riesgo independientes para el íleo postoperatorio. Esto requiere medidas para mantener los líquidos perioperatorios por debajo de los umbrales sugeridos. Vea el Video del Resumen en http://links.lww.com/DCR/B54.

Background: The present study aimed to evaluate safety of tranexamic acid (TA) administration and to assess bleeding risk in colorectal surgery (CRS)., Methods: Retrospective cohort study including consecutive patients undergoing elective CRS by a single surgeon between August 2014 and May 2015. All patients received 1 g of TA intravenously at induction and at closure. Demographics, operative and postoperative details were prospectively assessed and compared to a historical control cohort., Results: 213 patients were evaluated. TA did not increase complications, readmissions, or reoperation rates. Significant postoperative hemoglobin (Hgb) drop (≥3 g/dL) (TA: n = 6, 7.4%, Control: n = 22, 16.6%; p = 0.193) and transfusion rates (intraoperative: TA: n = 2, 2.5%, Control: n = 2, 1.5%; p = 0.586, postoperative: TA: n = 1, 1.2%, Control: 9, 6.8%; p = 0.065) were not statistically different., Conclusions: Postoperative hemoglobin drop and transfusion rates were not decreased statistically. Further study is warranted given the large clinical differences in favor of TA., (Copyright © 2019 Elsevier Inc. All rights reserved.)

Few series have reported on the impact of robotic right colectomy compared with conventional laparoscopy. Even fewer have reported on the outcomes of intracorporeal anastomoses. The aim of our study was to determine the impact of robotic surgery on short-term operative outcomes in patients undergoing right colectomy with intracorporeal anastomosis. One hundred and fourteen consecutive patients who underwent a right colectomy by two colorectal surgeons between 2012 and 2017 were included. Patients were separated into two groups: laparoscopic technique with extracorporeal anastomosis (n = 87) and robotic technique with intracorporeal anastomosis (n = 27). Univariate analysis was performed to determine differences in outcomes. Differences between cohorts were only identified with regard to gender (62 vs 37%, P = 0.022) and year of surgery. In comparison with laparoscopy, robotic colectomy resulted in a shorter time of GI recovery (1.3 ± 0.6 vs 3 ± 1.1, P < 0.0001), lower rates of postoperative ileus (4 vs 28%, P = 0.007), lower overall morbidity (26 vs 52%, P = 0.019), less blood loss ( P = 0.001), 50 per cent lower narcotic use, and longer operative time (255 ± 66 vs 139 ± 49, P < 0.001). Despite longer operative time, robotic surgery improved GI recovery, significantly lowered oral morphine equivalent usage, and decreased short-term complications.

Techniques for robotic resection of the right colon have not been extensively published or adopted. We report our initial experience of robotic right colectomy with intracorporeal anastomosis and specimen extraction through a Pfannenstiel incision retrospectively. Twenty-one consecutive patients with a right colon cancer (n = 18) or polyp too large to remove endoscopically (n = 3) were treated at Mayo Clinic Rochester, Minnesota. Main outcomes measured were estimated blood loss, operative time, conversion rate, return of gastrointestinal function, length of stay, overall and severe complications, discharge status, and pathology. All 21 procedures were technically successful without the need for conversion. The mean total operative time was 250 ± 56 min, estimated blood loss was less than 100 mL in 19 (90%), only 1 (5%) ileus occurred, mean length of stay and return of gastrointestinal function was 4 ± 1.3 and 1 ± 0.6 days, respectively, only 1 (5%) patient experienced a Dindo grade ≥ 3 complication, and 20 (95%) were discharged to home. Mean number of nodes resected was 26 ± 12. Tumors were diagnosed as stage 0 in 3 (14%), stage I in 7 (33%), stage II in 4 (19%), stage III in 6 (28%), and stage IV in 1 (5%). Main limitations were nonrandomized nature, single institution experience, small patient sample size, and procedures only being performed by two surgeons. Finally, we conclude that robotic right colectomy with central mesocolic excision, intracorporeal anastomosis, and extraction through a Pfannenstiel incision is technically feasible, efficacious, oncologically acceptable, and safe to perform.

Background: Clinical trials demonstrate that postresection chemotherapy conveys survival benefit to patients with stage III colon cancer. It is unclear whether this benefit can be extrapolated to the elderly, who are underenrolled in clinical trials., Objective: The purpose of this study was to determine outcomes of selected octogenarians with stage III colon cancer with/without postresection adjuvant therapy., Design: This was a retrospective cohort study (2006-2011) using unadjusted Kaplan-Meier and adjusted Cox proportional hazards analyses of overall survival., Setting: The study was conducted with the National Cancer Database., Patients: We included patients 80 to 89 years of age who were undergoing curative-intent surgery for stage III colon cancer and excluded patients who received neoadjuvant therapy, died within 6 weeks of surgery, or had high comorbidity., Main Outcome Measures: Overall survival was the main measure., Results: A total of 8141 octogenarians were included; 3483 (42.8%) received postresection chemotherapy, and 4658 (57.2%) underwent surgery alone. Patients receiving chemotherapy were younger (82.0 vs 84.0 years; p < 0.001), healthier (73.1% vs 70.4% with no comorbidities; p = 0.009), and more likely to have N2 disease (40.4% vs 32.8%; p < 0.001). Overall survival was improved in patients receiving adjuvant chemotherapy (median = 61.7 vs 35.0 months; p < 0.001). Subgroup analysis of patients offered chemotherapy but refusing (n = 1315) demonstrated overall survival worse than those receiving adjuvant chemotherapy (median = 42.7 vs 61.7 months; p < 0.001). Multivariable analysis adjusting for potential confounders showed therapy with surgery alone to be independently associated with increased mortality hazard (HR = 1.83; p < 0.001), and the mortality hazard remained elevated in patients who voluntarily refused adjuvant therapy (HR = 1.45; p < 0.001)., Limitations: The study was limited by its retrospective, nonrandomized design., Conclusions: In selected octogenarians with stage III colon cancer, postresection adjuvant chemotherapy was associated with superior overall survival. However, less than half of the octogenarians with stage III colon cancer in the National Cancer Database received it. The remaining majority, who were all fit and survived ≥6 weeks postsurgery, could have derived benefit from adjuvant chemotherapy. This represents a substantial opportunity for quality improvement in treating octogenarians with stage III colon cancer.

Background: The aim of this study was to evaluate clinico-pathologic specific predictors of recurrence for stage II/III disease. Improving recurrence prediction for resected stage II/III colon cancer patients could alter surveillance strategies, providing opportunities for more informed use of chemotherapy for high risk individuals., Methods: 871 stage II and 265 stage III patients with colon cancers were included. Features studied included surgery date, age, gender, chemotherapy, tumor location, number of positive lymph nodes, tumor differentiation, and lymphovascular and perineural invasion. Time to recurrence was evaluated, using Cox's proportional hazards models. The predictive ability of the multivariable models was evaluated using the concordance (c) index., Results: For stage II cancer patients, estimated recurrence-free survival rates at one, three, five, and seven years following surgery were 98%, 92%, 90%, and 89%. Only T stage was significantly associated with recurrence. Estimated recurrence-free survival rates for stage III patients at one, three, five, and seven years following surgery were 94%, 78%, 70%, and 66%. Higher recurrence rates were seen in patients who didn't receive chemotherapy (p = 0.023), with a higher number of positive nodes (p < 0.001). The c-index for the stage II model was 0.55 and 0.68 for stage III., Conclusions: Current clinic-pathologic information is inadequate for prediction of colon cancer recurrence after resection for stage II and IIII patients. Identification and clinical use of molecular markers to identify the earlier stage II and III colon cancer patients at elevated risk of recurrence are needed to improve prognostication of early stage colon cancers.

Background: Enhanced recovery pathways have been shown to improve short-term outcomes after colorectal surgery. Occurrence of complications can lead to prolonged length of stay (LOS). The goal of this study was to examine whether shorter time to occurrence of complications was associated with a shorter hospital LOS in rectal cancer patients undergoing minimally invasive surgery, taking into account the perioperative pathway., Study Design: This retrospective study included consecutive patients undergoing rectal cancer resection from 2005 to 2011 at a single institution. Enhanced recovery pathway was introduced in 2009. Complications and date of occurrence were reviewed. The impact of perioperative care modalities and comorbidities was evaluated using competing risk models with occurrence of complications and LOS as time-dependent outcomes measured as time from surgery., Results: A total of 346 patients were included in the analysis with 78 patients treated with enhanced recovery pathway, and 268 with established care. The overall complication rate was 22.3% (77 patients with ileus, wound infection, leak, abscess, small bowel obstruction, reoperation for bleeding, and renal failure). Median time to occurrence of a complication was 3 days post operation. The time to complication diagnosis was associated with shorter time to discharge after the advent of the complication (hazard ratio = 0.84; 95% CI, 0.73-0.96; p = 0.01). Enhanced recovery pathway was associated with a shorter LOS for patients without complications compared with the established pathway (hazard ratio = 2.81; 95% CI, 2.09-3.78; p < 0.001) after adjusting for comorbidities in a competing risk model., Conclusions: Early diagnosis of postoperative complications is associated with a shorter LOS after rectal cancer surgery. Enhanced recovery pathway can facilitate a faster recovery in the presence of comorbidities., (Copyright © 2014 American College of Surgeons. Published by Elsevier Inc. All rights reserved.)

Intraoperative iatrogenic splenic injury during colorectal surgery is rare but may cause significant morbidity. We aimed to describe the anatomic mechanisms of iatrogenic injury to the spleen during colonic surgery. All adult surgical patients who sustained a splenic injury during colectomy at our institution from 1992 to 2007 were retrospectively identified. The operative and pathologic reports were reviewed, and anatomic details of the injuries were collected. Results are reported as a proportion or median, with range reported in brackets. Of 13,897 colectomies, 71 splenic injuries among 58 patients were identified. Splenic flexure colonic mobilization occurred in 53 (91%) of these patients. The median number of tears was 1 (1-3). The average length of tear was 4.59 cm. The distribution of injury location on the spleen was 24 (34%) inferior, 14 (20%) hilar, 3 (4%) posterior, 2 (3%) lateral, and 1 (1%) superior. Three (4%) patients suffered from splenic rupture. The location of 24 (34%) injuries was not described. Capsular tears were the cause of splenic injury in 55 (95%) patients. Intraoperative splenic injury ultimately resulted in splenectomy in 44 (76%) patients. Splenic injury was a delayed finding requiring reoperation in 4 (7%) patients. The primary mechanism of intraoperative splenic injury during colectomy is capsular tears and lacerations secondary to misplaced traction and tension on the spleen during colonic mobilization. Techniques to lessen these forces may decrease the number of injuries and subsequent splenectomy., (Copyright © 2011 Wiley-Liss, Inc.)

Background: Despite its introduction in 1991, laparoscopic colectomy is performed in <10% of United States patients requiring colectomy. Laparoscopic colectomy is avoided principally because of its technical difficulty, steep learning curve, and increased operative times. Hand-assisted laparoscopic colectomy is an alternative technique that addresses these problems while preserving the short-term benefits of laparoscopic colectomy., Objective: To describe the utility and short-term outcomes, we evaluated 1103 patients who underwent hand-assisted laparoscopic colorectal resections over a 5-year period., Design: This study was a retrospective analysis of prospectively collected data., Settings: The setting was a single tertiary care institution., Patients: A total of 1103 consecutive hand-assisted laparoscopic colorectal resections from 2004 to 2009 were identified using a prospectively maintained database., Main Outcome Measures: Demographics, perioperative variables, and 30-day outcomes were reported. Data are presented as frequency (proportion) or median (interquartile range)., Results: A total of 1103 hand-assisted laparoscopic colorectal resections were documented. Median age of patients was 55 years; 47% were women, and median body mass index was 26.5 (range, 23-34) kg/m. Diagnoses included inflammatory bowel disease (35%), colorectal cancer (31%), diverticular disease (23%), and "other" (11%). Forty-two percent of patients had prior abdominal surgery. Segmental colectomies were performed in 533 (48%) patients, proctocolectomy with ileal pouch-anal anastomosis in 229 (21%), proctocolectomy with end ileostomy in 114 (10%), and "other" in 227 (21%). The conversion rate was 9%. Overall median operative time was 201 (range, 145-269) minutes, and the median postoperative length of stay was 5 (range, 4-7) days. Postoperative complications occurred in 27% and readmissions in 7%; mortality was 0.3%., Limitations: This was a single institutional retrospective study., Conclusions: Hand-assisted laparoscopic colorectal resection can be performed for numerous indications. It preserves nearly all the benefits of laparoscopic colectomy reported in the literature. With experience, it is associated with significantly reduced operative times. Wider adoption of hand-assisted laparoscopic colorectal surgery would increase the number of patients benefiting from minimal access colorectal surgery.

Background: Minimally invasive surgery for Crohn's ileocolitis is well established but few data exist regarding laparoscopic techniques for Crohn's colitis. We aimed to describe outcomes associated with minimally invasive surgery for Crohn's colitis, including predictors of conversion to laparotomy and postoperative complications., Methods: We identified all Crohn's patients who underwent minimal invasive colectomy at our institution from 1997-2008. Data represent frequency (proportion) or median (interquartile range). Multivariate regression identified factors associated with conversion and 30-day complications (odds ratio [95% confidence interval])., Results: Over 11 years we identified 92 patients, median age 40 (26-51) years, body mass index (BMI) 22.9 (19.3-26.4) kg/m(2); 61% were women. Median Crohn's duration was 6.5 (4-15) years, 11% had prior intestinal resection; medications included immunomodulators (62%), corticosteroids (54%), infliximab (35%). Forty-three cases (47%) were total colectomy, 17 (18%) subtotal colectomy, 32 (35%) were segmental. Straight laparoscopy was used in 57%; 43% were hand-assisted. Median operative time was 248 (190-292) minutes. There were 15 (16%) conversions; only small bowel disease predicted conversion (OR 7 [1.6-35]). Conversion was not associated with increased length of stay or with postoperative complications. Overall postoperative length of stay was 5 (4-7) days. Short-term complications occurred in 34% with reoperation in 5: obstruction n = 3, anastomotic leak n = 2. Only perianal disease predicted complications (2.6 [1.0-6.6]). There was no 30-day mortality., Conclusions: Minimally invasive colectomy in patients with Crohn's colitis can be safely accomplished with reasonable operative times, conversion rates, and excellent postoperative outcomes.

Background: Fast-track (FT) postoperative protocols have been shown to be highly beneficial in open colectomy. Some have questioned the necessity of an FT protocol in the setting of laparoscopic colectomy because hospital stays are short and morbidity is low compared with open surgery. We set out to determine whether an FT protocol has any utility in the setting of elective laparoscopic colectomy., Study Design: A retrospective review was conducted on a cohort of 334 patients who underwent elective laparoscopic sigmoid resection for diverticulitis from 1998 to 2008, at Mayo Clinic, a tertiary care center in Rochester, MN. There were 235 patients who were managed with traditional postoperative care, and 99 who were managed with an FT protocol initiated in 2006. The main outcomes measures were time to soft diet, length of stay, overall morbidity, and readmission rate., Results: Times to soft diet (mean 2.3 vs 3.6 days), and first bowel movement (mean 2.6 vs 3.5 days) were shorter in the FT group (p < 0.001). The median lengths of stay were 3 days (interquartile range 3 to 4 days) and 5 days (interquartile range 4 to 6 days) for the FT and non-FT groups, respectively (p < 0.001). Morbidity was significantly lower in the FT group compared with the non-FT group (15.2% vs 25.5%, p < 0.03). The 30-day readmission rate was 2.9% for the FT group and 7.6% for the non-FT group (p = NS). There were no deaths in either group., Conclusions: Even in patients undergoing laparoscopic colectomy, FT protocols further improve the speed of gastrointestinal recovery, shorten the length of stay, and decrease morbidity., (Copyright © 2010 American College of Surgeons. Published by Elsevier Inc. All rights reserved.)

Background: Fast-track (FT) recovery protocols have demonstrated advantages over historical recovery routines after open colectomy; however, their impact in recovery after laparoscopic colectomy is not clearly defined. This study was designed to determine whether patients who recover on FT protocol after laparoscopic colectomy have a shorter length of stay (LOS) and fewer complications compared with patients who recover on standard (non-FT) protocol., Methods: A cohort of consecutive patients with colon cancer who underwent completed laparoscopic-assisted right hemicolectomy from 2005-2007 was identified. Univariate and multivariate logistic analyses were performed to identify risk factors for increased LOS and postoperative complications with recovery protocol as the primary predictor., Results: A total of 197 patients were included: 115 (58%) patients recovered on a non-FT protocol, and 82 (42%) patients on FT protocol. Univariate analysis showed no differences with respect to age, gender, body mass index, or American Society of Anesthesiologists (ASA) class between groups. The median (interquartile range) LOS was 4 (range, 3-6) days and 3 (range, 3-4) days for the non-FT and FT recovery patients, respectively (p < 0.001). On multivariate analysis, independent risk factors for increased LOS were complications (p < 0.001) and non-FT recovery (p = 0.007). Non-FT recovery also was associated with increased complications (56 vs. 29%, p = 0.0002); this remained significant on multivariate analysis (p < 0.001). Readmissions were similar (p = 1.0) between recovery groups. No mortalities were observed at 30 days., Conclusions: Fast-track recovery is independently associated with a shorter LOS and decreased morbidity after laparoscopic right hemicolectomy.

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: To determine the optimal surgical management of splenic injury encountered during colectomy., Design: Retrospective review from 1992 to 2007., Setting: Mayo Clinic in Rochester, Minnesota, a tertiary care center., Patients: A cohort of patients who sustained splenic injury during colectomy from 1992 to 2007., Main Outcome Measures: Overall 30-day major morbidity and mortality and overall 5-year survival., Results: Of 13,897 colectomies, we identified 59 splenic injuries (0.42%). Of these, 33 (56%) were in men; there was a median age of 68 years (range, 30-93 years) and a median body mass index of 25.5 (range, 15-54). Thirty-seven injuries (63%) occurred during elective surgery, 6 (10%) occurred without splenic flexure mobilization, and 5 (8.4%) occurred during minimally invasive surgery. Injury was successfully managed by primary repair in 10 (17%), splenorrhaphy in 4 (7%), and splenectomy in 45 cases (76%). Four injuries (7%) were unrecognized and resulted in reoperation and splenectomy. Multiple attempts at splenic salvage were performed in 30 (51%); of these, 21 (70%) required splenectomy. More than 2 attempts at salvage was associated with splenectomy (P = .03). The 30-day major morbidity and mortality rates were 34% and 17%, respectively. Sepsis was the most common complication, with no confirmed episodes of postsplenectomy sepsis. Median survival after splenic injury was 7.25 years. There was no significant association between the surgical management of splenic injuries and short- or long-term outcomes., Conclusions: Splenic injury is an infrequent but morbid complication. Splenic salvage is frequently unsuccessful; our data suggest that surgeons should not be reluctant to perform splenectomy when initial repair attempts fail.

Background: Total proctocolectomy with Brooke ileostomy remains the optimal surgical procedure for select ulcerative colitis patients. However, few studies describe outcomes of minimally invasive total proctocolectomy with Brooke ileostomy. Our aim was to describe the safety and feasibility of these procedures by examining short-term (30-day) outcomes., Methods: Using a prospective database, we identified a cohort of patients who underwent laparoscopic total proctocolectomy with Brooke ileostomy at our institution from 2000-2007. Results are reported as median (range) or frequency (proportion)., Results: Forty-four patients were included; age 65 years (54-73), 24 were male (55%), body mass index was 26.5 (22.1-30.2) kg/m(2). Colitis duration was 66 months (24-240), and 40% had prior surgery. The indication for surgery was refractory colitis (82%) and neoplasia (18%). Factors influencing choice of total proctocolectomy with permanent ileostomy were advanced age in 18 (41%), lifestyle in 13 (30%), medical comorbidities in 11 (25%), fecal incontinence in 10 (23%), oncologic reasons in 3 (6.8%), and obesity in 3 (6.8%). Twenty-three (52%) operations were hand-assisted laparoscopic surgery, 13 (30%) were laparoscopic-assisted, and 8 (18%) were "laparoscopic-incisionless" with transanal specimen extraction. Two laparoscopic-assisted cases (4.6%) were converted. Operative time was 329 (272-402) minutes, and length of stay 5 (4-6) days. Major post-operative complications occurred in 4 (9%); there were no perioperative mortalities., Conclusions: Minimally invasive total proctocolectomy with Brooke ileostomy is a safe, feasible option for the surgical treatment of chronic ulcerative colitis, and is the procedure of choice for select patients.

Background: Outcomes of laparoscopic resection for ileocecal Crohn's disease have been reported previously in smaller studies, suggesting its short-term advantages over open surgery. This study assessed the safety and recovery parameters in the largest, consecutive, single-institution series to date., Methods: Consecutive patients undergoing laparoscopically assisted primary ileocolic resection for Crohn's disease between 1994 and 2006 were identified in an institutional prospectively collected database. Operative and postoperative outcomes at 30 days were studied., Results: In this study, 109 patients (35 men) with a mean age of 35 +/- 14 years and a mean body mass index (BMI) of 25 +/- 6 kg/m(2) were identified. The main indications for surgery were medically refractory disease (63%) and fibrous stenosis (27%). In 41% of the cases, previous abdominal surgery had been performed. The surgery had a mean duration of 150 +/- 45 min and a conversion rate of 6%. The overall 30-day morbidity rate was 11%, and the reoperation rate was 1%. The mortality rate was 0%. The median postoperative hospital stay was 4 days (range, 2-15 days)., Conclusions: This series, the largest reported to date, concurs with recent metaanalyses findings that laparoscopically assisted primary ileocecal resection for Crohn's disease is safe and feasible, resulting in better short-terms outcomes than open resection. This operation is therefore the procedure of choice for Crohn's disease at our institutions.

Purpose: This study was designed to evaluate the safety, feasibility, and short-term outcomes of three-stage minimally invasive surgery for fulminant ulcerative colitis., Methods: Using a prospective database, we identified all patients with ulcerative colitis who underwent minimally invasive surgery for both subtotal colectomy and subsequent ileal pouch-anal anastomosis at our institution from 2000 to 2007. Demographics and short-term outcomes were retrospectively evaluated., Results: During seven years, 50 patients underwent minimally invasive subtotal colectomy for fulminant ulcerative colitis; 50 percent were male, with a median age of 34 years. All patients had refractory colitis: 96 percent were taking steroids, 76 percent were recently hospitalized, 59 percent had >/=5 kg weight loss, 57 percent had anemia that required transfusions, 30 percent were on biologic-based therapy, and 96 percent had >/=1 severe Truelove & Witts' criteria. Of these 50 procedures, 72 percent were performed by using laparoscopic-assisted and 28 percent with hand-assisted techniques. The conversion rate was 6 percent. Subsequently, minimally invasive completion proctectomy with ileal pouch-anal anastomosis was performed in 42 patients with a 2.3 percent conversion rate. Median length of stay after each procedure was four days. There was one anastomotic leak and no mortality., Conclusions: A staged, minimally invasive approach for patients with fulminant ulcerative colitis is technically feasible, safe, and reasonable operative strategy, which yields short postoperative length of stay.

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.

Background: Laparoscopic-assisted colectomy (LAC) is not performed widely despite numerous patient benefits. LAC is difficult to perform and the learning curve is steep. Hand-assisted laparoscopy (HALS) permits placement of a hand into the abdomen to assist the dissection. Our aim was to analyze the impact of HALS on a minimal access colectomy (MAC) practice., Study Design: A prospectively maintained database was retrospectively reviewed for all LAC and HALS colectomies. HALS was introduced in November 2003, and analysis was performed for the ensuing 3-year period. Procedure types, conversion rates, operation duration, complications, and length of stay were determined., Results: During the study period, 969 MACs were performed (373 HALS, 596 LAC). Although HALS was used for all types of colorectal resection, it was most commonly used for complex colectomies (left-sided and total colectomies). HALS complex colectomies increased 44% from 2004 to 2005, and 24% from 2005 to 2006. Conversely, LAC complex colectomies decreased 29% (2004 to 2005) and then increased 27% (2005 to 2006). There were no demographic differences between patient groups. For complex colectomies, HALS substantially reduced operative time (mean +/- SD; LAC, 258+/-90 minutes; HALS, 242+/-89 minutes; p=0.037) and conversion rate (LAC, 15.3% versus HALS, 3.4%, p < 0.001), with the same complication rate (LAC, 13.6%; HALS, 15.4%; p=0.629). The average length of stay (mean +/- SD) was increased 1 day in the HALS group (LAC, 5.0+/-3.0 days; HALS, 6.0+/-3.4 days; p < 0.001), likely because of the higher proportion of total colectomies., Conclusions: HALS increased the number of MACs performed. More notably, HALS was used preferentially for complex colectomies. HALS effectively bridges the complexity divide between minimal access and open procedures. HALS may serve as a technology to expand MAC.

Introduction: Laparoscopic assisted (LA) colectomy has significant patient benefits but is technically challenging. Hand-assisted laparoscopic surgery (HALS) allows tactile feedback because the surgeon's hand assists in retraction and dissection. This may decrease the technical difficulty and shorten the learning curve associated with performing laparoscopic colectomy. We investigated the patient selection and short-term clinical outcomes of HALS and LA since the introduction of HALS to our minimally invasive colorectal practice., Methods: Prospectively collected data on 258 patients undergoing HALS (n = 109) or LA colectomy (n = 149) during a calendar year (2004) were analyzed. Patient and disease characteristics, operative parameters, and perioperative outcomes were compared., Results: HALS patients were similar to LA patients in age (51 vs. 54 yrs), gender (56 vs. 52% male), body mass index (26 vs. 26 kg/m2), comorbidities (84 vs. 85% with one or more), and diagnosis (83 vs. 80% benign), but differed in incidence of previous surgery (49 vs. 30%; P = 0.008). A significantly greater proportion of HALS patients underwent complex procedures and extensive resections. Conversion rates (15 vs. 11%, P = 0.44), intraoperative complications (4 vs. 1%, P = 0.17), 30-day morbidity (18 vs. 11%, P = 0.12) and surgical reinterventions (2 vs. 1%, P = 0.58) did not differ. Recovery measured by days to flatus was not different [mean (standard deviation) 3(2) vs. 3(2) days, P = 0.26], however HALS patients had longer operative times [276(96) vs. 211(107) minutes P < 0.0001] and 1 day longer stay in hospital [6(3) vs. 5 (3) days, P = 0.0009)]., Conclusions: Patients undergoing HALS underwent more-complex procedures than LA patients but retained the short-term benefits associated with LA colectomy. HALS facilitates expansion of a minimally invasive colectomy practice to include more challenging procedures while maintaining short-term patient benefits.

Laparoscopic segmental colectomy has been widely accepted as a surgical procedure for benign colonic disease. With improving technology and surgeon experience, more complex procedures have been performed. However, a minimal invasive approach may not be justified for all colonic diseases. The use of laparoscopic surgery for colonic cancer, for example, has been controversial and the results of our national and international trials are yet unknown. We anticipate, given the positive findings of multiple small randomized and nonrandomized trials, that laparoscopic colectomy for cancer may soon prove to be appropriate in this setting. Our aim in this paper is to explore the indications, contraindications, and techniques regarding laparoscopic surgery that we have used in the treatment of colon cancer for patients enrolled in the national trial.

Surgery improves the quality of life in patients with Crohn's disease (CD) and cures patients with chronic ulcerative colitis (CUC). There are several surgical controversies primarily involving techniques and long-term outcomes. Some debates are long standing; whether to perform a double-stapled ileal pouch-anal anastomosis (IPAA) or a mucosectomy and hand-sewn anastomosis, and whether to divert or not to divert in patients with CUC undergoing an IPAA. Other issues are more recent, such as the effects of age, pregnancy, pouch salvage, and laparoscopic IPAA. In patients with Crohn's disease the anastomosis technique, the management of perianal disease, and the role of laparoscopic surgery are topics of debate. This review shows the current concepts and controversies in the surgical management of patients with CUC or CD.

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. [ABSTRACT FROM AUTHOR]

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/m2). 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. 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. 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. 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]). 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. [ABSTRACT FROM AUTHOR]

Background: The aim of this analysis was to determine the impact of complicated and uncomplicated diverticulitis on conversion rates and complications in patients undergoing laparoscopic surgery (LS) for diverticular disease.Methods: Between 1993 and 2004, 125 patients underwent LS [91 laparoscopic-assisted (LA) and 34 hand-assisted (HA) colectomy for diverticular disease, 79 uncomplicated and 46 complicated]. Cases not completed laparoscopically were considered converted. Complicated diverticulitis was defined as diverticular disease associated with abscess, fistula, bleeding or stricture.Results: The mean age was 59 years with 67 (54%) men with a mean follow-up of 23 months. The conversion rate was 26% (33 patients). The only factor independently associated with conversion was a history of previous abdominal surgery (37% vs. 14%, p = 0.004). Among the subset of patients undergoing surgery for uncomplicated diverticulitis, the number of diverticulitis episodes (DE), the time between the first and last DE, and the time between the last DE and surgery, were not significantly associated with conversion. Early complications (<30 days from surgery) occurred in 30 (25%) patients. Twenty-one long-term complications (>30 days from surgery) occurred in 20 patients and the one and two-year cumulative probabilities of these complications were 14% and 22%, respectively. Early complications were significantly higher among patients requiring conversion (44% vs. 24%, p = 0.04) but were not significantly higher among patients with complicated diverticulitis (39% vs. 24%, p = 0.11). The rates of long-term complications were not significantly higher among patients that required conversion or had complicated diverticulitis (one-year rate 23% vs. 11%, p = 0.47; 18% vs. 13%, p = 0.70).Conclusions: A previous history of abdominal surgery was associated with a higher conversion rate in patients undergoing laparoscopic surgery for diverticular disease. Long-term patient outcomes are not adversely impacted by laparoscopic surgery for complicated diverticulitis or laparoscopic surgery requiring conversion to an open procedure. [ABSTRACT FROM AUTHOR]