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Aim It is questioned whether all separate fast track elements are essential for enhanced postoperative recovery. We aimed to determine which baseline characteristics and which fast track elements are independent predictors of faster postoperative recovery in patients undergoing resection for colon cancer. Method Data from the LAFA trial database were used. In this trial, fast track care was compared with standard perioperative care in 400 patients undergoing laparoscopic or open surgery for colonic cancer. During admission 19 fast track elements per patient were prospectively evaluated and scored whether or not they were successfully applied. To identify predictive factors six baseline characteristics and those fast track items that were successfully achieved were entered in a univariate and multivariate linear regression analysis with total postoperative hospital stay (THS) as the primary outcome. Results In 400 patients, two baseline characteristics and two fast track elements were found to be significant independent predictors of THS: female sex [B = 0.85; 95% CI 0.75‐0.96; reduction of 15% (CI 14‐25%) in THS], laparoscopic resection [B = 0.85; 95% CI 0.75‐ 0.96; reduction of 15% (CI 14‐25%) in THS], ‘normal diet at postoperative days 1, 2 and 3’ [B = 0.70; 95% CI 0.61‐0.81; reduction of 30% (CI 19‐39%) in THS] and ‘enforced mobilization at postoperative days 1, 2 and 3’ [B = 0.68; 95% CI 0.59‐0.80; reduction of 32% (CI 20‐ 41%) in THS]. Conclusion Evaluating only those fast track elements that were successfully achieved, enforced advancement of oral intake, early mobilization, laparoscopic surgery and female sex were independent determinants of early recovery.

Circulating tumour cells (CTCs) have been presumed critical to the metastatic process since 1800. These epithelial cells are disseminated from the primary or metastatic tumor site and can be identified in the peripheral blood of patients. Nowadays, technical advances have rendered it easier to reproducibly and repeatedly sample this population of cells with an acceptable degree of accuracy. Therefore, these cells could become an attractive surrogate for phenotypic and genotypic markers in correlation with the development of molecular targeted therapies. In metastatic colorectal cancer several prospective studies have demonstrated the independent prognostic significance of CTCs and identified the number of CTCs before and during treatment as a predictor for overall survival and disease free survival. However, the underlying molecular characteristics of CTCs associated with outcome remain largely unknown. In this review, the role of CTCs in metastatic colorectal cancer is discussed. The variety of assays that can be used for enrichment and detection steps in CTC detection will be described and the clinical utility of these cells for assessing prognosis and monitoring response to therapy will be analyzed. We will also address the shortcomings of current detection methods that fail to identify a mesenchymal subgroup of CTCs, and briefly address how characterization of these cells can help elucidate the biology of cancer metastases.

The Dutch Society for Endoscopic Surgery together with the Dutch Society of Obstetrics and Gynecology initiated a multidisciplinary working group to develop a guideline on minimally invasive surgery to formulate multidisciplinary agreements for minimally invasive surgery aiming towards better patient care and safety. The guideline development group consisted of general surgeons, gynecologists, an anesthesiologist, and urologist authorized by their scientific professional association. Two advisors in evidence-based guideline development supported the group. The guideline was developed using the “Appraisal of Guidelines for Research and Evaluation” instrument. Clinically important aspects were identified and discussed. The best available evidence on these aspects was gathered by systematic review. Recommendations for clinical practice were formulated based on the evidence and a consensus of expert opinion. The guideline was externally reviewed by members of the participating scientific associations and their feedback was integrated. Identified important topics were: laparoscopic entry techniques, intra-abdominal pressure, trocar use, electrosurgical techniques, prevention of trocar site herniation, patient positioning, anesthesiology, perioperative care, patient information, multidisciplinary user consultation, and complication registration. The text of each topic contains an introduction with an explanation of the problem and a summary of the current literature. Each topic was discussed, considerations were evaluated and recommendations were formulated. The development of a guideline on a multidisciplinary level facilitated a broad and rich discussion, which resulted in a very complete and implementable guideline.

The clinical impact of sentinel lymph node (SN) biopsy in colorectal cancer is still controversial. The aim of our study was to determine the accuracy of this procedure from published data and to identify factors that contribute to the conflicting reports. A systematic search of the Medline, Embase, and Cochrane databases up to July 2011 revealed 98 potentially eligible studies, of which 57 were analyzed including 3,934 patients (3,944 specimens). The pooled SN identification rate was 90.7 % (95 % CI 88.2-93.3), with a significant higher identification rate in studies including more than 100 patients or studies using the ex vivo SN technique. The pooled sensitivity of the SN procedure was 69.6 % (95 % CI 64.7-74.6). Including the immunohistochemical findings increased the pooled sensitivity of SN procedure to 80.2 % (95 % CI 4.7-10.7). Subgroups with significantly higher sensitivity could be identified: a parts per thousand yen4 SNs versus

To investigate which perioperative treatment, ie, laparoscopic or open surgery combined with fast track (FT) or standard care, is the optimal approach for patients undergoing segmental resection for colon cancer. Important developments in elective colorectal surgery are the introduction of laparoscopy and implementation of FT care, both focusing on faster recovery. In a 9-center trial, patients eligible for segmental colectomy were randomized to laparoscopic or open colectomy, and to FT or standard care, resulting in 4 treatment groups. Primary outcome was total postoperative hospital stay (THS). Secondary outcomes were postoperative hospital stay (PHS), morbidity, reoperation rate, readmission rate, in-hospital mortality, quality of life at 2 and 4 weeks, patient satisfaction and in-hospital costs. Four hundred patients were required to find a minimum difference of 1 day in hospital stay. Median THS in the laparoscopic/FT group was 5 (interquar-tile range: 4-8) days; open/FT 7 (5-11) days; laparoscopic/standard 6 (4.5-9.5) days, and open/standard 7 (6-13) days (P < 0.001). Median PHS in the laparoscopic/FT group was 5 (4-7) days; open/FT 6 (4.5-10) days; laparoscopic/standard 6 (4-8.5) days and open/standard 7 (6-10.5) days (P < 0.001). Secondary outcomes did not differ significantly among the groups. Regression analysis showed that laparoscopy was the only independent predictive factor to reduce hospital stay and morbidity. Optimal perioperative treatment for patients requiring segmental colectomy for colon cancer is laparoscopic resection embedded in a FT program. If open surgery is applied, it is preferentially done in FT care. This study was registered under NTR222 (www.trialregister.nl)

Single port surgery of rectal tumors may be associated with a shorter learning curve and fewer costs than transanal endoscopic microsurgery. The authors aimed to select the most optimal single access port for transanal employment. Four single access ports (GelPOINT, TriPort, SSL Access System, and SILS) were tested in 2 pigs. Insertion feasibility and intraoperative features of each port were assessed. A rectal excision was attempted using the most suitable port. Insertion of GelPOINT was impossible. SILS and TriPort were easily inserted; however, insufficient stability demanded manual fixation. CO2 leaked through the TriPort trocar ports. Insertion of the 2-cm SSL Access System retractor was difficult, but pneumorectum and surgical circumstances were favorable. Single port transanal surgery may be a promising alternative for transanal endoscopic microsurgery. The SSL Access System was found the most suitable for this indication in a porcine model.

Chronic pelvic sepsis after ileoanal or coloanal anastomosis precludes ileostomy closure and, even if closure is ultimately possible, function of the neorectum is badly affected. Early closure of the anastomotic leak might prevent chronic pelvic sepsis and its adverse sequelae. In our experience of early closure in a consecutive group of six patients with a leaking low anastomosis (five with ileoanal pouch anastomosis and one after a low anterior resection), we were able to achieve anastomotic closure in five by means of initial endosponge therapy followed either by early suture (four patients) or endoscopic clip repair (one patient). Early minimally invasive closure of low anastomotic leaks is therefore possible provided that the para-anastomotic cavity is drained well prior to closure and the anastomosis is defunctioned.

Purpose Defunctioning ileostomies are widely performed in order to prevent or treat anastomotic leakage after colorectal surgery. The aim of the present study was to determine morbidity related to stoma closure and to identify predictive factors of a complicated postoperative course. Methods A consecutive series of 138 patients were retrospectively analyzed after stoma reversal. Data collection included general demographics and surgery-related aspects. Morbidity related to stoma closure was retrieved from our prospectively collected registry of complications. Results In 74 of 138 patients, defunctioning ileostomy was performed after restorative proctocolectomy and ileal pouch-anal anastomosis (IPAA). The remaining ileostomies (n = 64) were constructed after a low colorectal or coloanal anastomosis. A total of 46 complications were recorded in 28 patients resulting in an overall complication rate of 20.3%. Anastomotic leakage rate was 4.3%, and reoperation rate was 8.0%. The number of complications according to the Clavien–Dindo classification was 5 for grade I (10.9%), 26 for grade II (56.5%), 13 for grade III (28.3%), 1 for grade IV (2.2%), and 1 for grade V (2.2%). Multivariate analysis revealed a significantly higher ASA score in the complicated group (P = 0.015, odds ratio 2.6, 95% confidence interval 1.2–5.6). Conclusions Closure of a defunctioning ileostomy is associated with 20% morbidity and a reoperation rate of 8%. There is an urgent need for criteria on which a more selective use of a defunctioning ileostomy after low colonic anastomosis or IPAA can be based given its associated morbidity.

Background Clinical advantages of laparoscopic appendectomy have been shown in numerous trials and reviews. Most of these advantages are small and of limited clinical relevance, while laparoscopic operation costs are reported to be higher. The present study compares short- and long-term results of conventional appendectomy with or without diagnostic laparoscopy (OA), and laparoscopic appendectomy (LA). Methods All adult patients who underwent appendectomy in our institution from 1995 to 2005 were included retrospectively. Patient data were retrieved from medical records, questionnaires sent by mail, and records of general practitioners. Primary outcome parameters were long-term complications, readmissions, and reinterventions (>30 days postoperatively). Secondary outcome parameters were short-term complications, readmissions, and reinterventions (≤30 days postoperatively). Results A total of 755 patients were included, 545 of whom underwent OA, with the remaining 210 undergoing LA. In the long term there were few complications noted, and there were no significant differences in complications between the two groups. Within 30 days postoperatively, LA was associated with a significantly higher incidence of abdominal abscesses with consequent diagnostic investigations, interventions, and readmissions. Conclusions Although laparoscopic appendectomy is known to deliver clinical advantages, it is associated with a higher incidence of abdominal abscesses. Because the procedure is about to become the standard of care, future research must be directed at solving this issue. The expected lower incidence of incisional hernia and small bowel obstruction after laparoscopic appendectomy was not shown in the present study.

Traditionally, surgical training has been a matter of apprenticeship. The surgical trainee learned to perform surgery under the supervision of a trained surgeon until he or she was believed capable of performing surgery independently. The opinion of the supervising surgeon was about the only informal standard that had to be met—a standard hard to define, second to none, but the hand of God himself, as perceived both within and without surgical societies. This is illustrated by literature, in which a capital for “Surgeon” is allowed in both ancient and recent publications [1–3]. At the beginning of the new millennium, a paradigm shift in medical education thinking became apparent. Public opinion developed into a powerful force, a force affected by messages such as the rate of iatrogenic complications in U.S. hospitals. If extrapolated to the airline industry, this would be the equivalent of three large jet crashes every two days [4]. In addition, patient safety and quality-of-care movements together with forces from technological innovation and governmental attention demanded safer and more transparent health care systems, systems whose very foundation must be build on the principle of accountability, hence, systems able and actively seeking for self-reflection of performance. Consequently, these must be systems that actively seek for opportunities to improve medical education and thereby ultimately create optimal conditions for near-future patient care [5–7]. The combination of the aforementioned forces, all stressing the need to reform medical education, led to the development of standards for physician competence.

The short-term results of the Sigma trial show that laparoscopic sigmoid resection (LSR) used electively for diverticular disease offers advantages over open sigmoid resection (OSR). This study aimed to compare the overall mortality and morbidity rates after evaluation of the clinical outcomes at the 6-month follow-up evaluation. In a prospective, multicenter, double-blind, parallel-arm, randomized control trial, eligible patients were randomized to either LSR or OSR. The short-term results and methodologic details have been published previously. Follow-up evaluation was performed at the outpatient clinic 6 weeks and 6 months after surgery. In this trial, 104 patients were randomized for either LSR or OSR, and the conversion rate was 19.2%. The LSR approach was associated with short-term benefits such as a 15.4% reduction in the major complications rate, less pain, and a shorter hospital stay at the cost of a longer operating time. At the 6-month follow-up evaluation, no significant differences in morbidity or mortality rates were found. Two patients died of cardiac causes (overall mortality, 3%). Late complications (7 LSR vs. 12 OSR; p = 0.205) consisted of three incisional hernias, five small bowel obstructions, four enterocutaneous fistulas, one intraabdominal abscess, one retained gauze, two anastomotic strictures, and three recurrent episodes of diverticulitis. Nine of these patients underwent additional surgical interventions. Consideration of the major morbidity over the total follow-up period (0–6 months) shows that the LSR patients experienced significantly fewer complications than the OSR patients (9 LSR vs. 23 OSR; p = 0.003). The Short Form-36 (SF-36) questionnaire showed significantly better quality of life for LSR at the 6-week follow-up assessment. However, at the 6-month follow-up assessment, these differences were decreased. The late clinical outcomes did not differ between LSR and OSR during the 30-day to 6-month follow-up period. Consideration of total postoperative morbidity shows a 27% reduction in major morbidity for patients undergoing laparoscopic surgery for diverticular disease.

Background Secure transluminal closure remains the most fundamental barrier to safe translation of transgastric natural orifice transluminal endoscopic surgery (NOTES) procedures to humans. Obtaining optimal critical view of safety (CVS) is a prerequisite to performing cholecystectomy avoiding common bile duct injury. Objectives (1) To evaluate feasibility and safety of hybrid transgastric NOTES cholecystectomy. (2) To evaluate feasibility and reliability of gastrotomy closure using a novel Over-The-Scope-Clip (OTSC; Ovesco) in survival porcine experiments. Methods Laparoscopic access to the abdominal cavity was obtained by two 2-mm and one umbilical optical trocar(s). Gastric access was created by balloon dilatation of a needle knife puncture up to 18 mm. Exposure of CVS was obtained and evaluated by aid of a 2-mm device. Subsequently the cystic duct and artery were clipped endoscopically. After laparoscopic dissection the specimen was extracted via the stomach. The gastrotomy was closed endoscopically using the OTSC. Necropsy was performed after 10 days with inspection of gastrotomy and peritoneal cavity for complications. Experiments were planned in 3 acute and 16 survival pigs. Main outcome parameters were documented exposure of CVS, successful cholecystectomy and closure, uncomplicated survival and histology-confirmed full-thickness closure. Results In all 16 survival experiments CVS was obtained satisfactorily and hybrid cholecystectomy was successfully performed [100%; 95% confidence interval (CI): 81–100%]. Transgastric closure was endoscopically successful in all experiments in mean time of 7 min [standard deviation (SD) 3 min]. At necropsy 10 days after surgery there were no signs of (infectious) complications. Histology confirmed full-thickness healing with 100% success (95% CI: 81–100%). Conclusion Hybrid transgastric NOTES cholecystectomy is feasible, safe and results in optimal CVS. Use of OTSC for gastrotomy closure is feasible, reliable and results in histology-proven full-thickness closure in survival porcine experiments. Electronic supplementary material The online version of this article (doi:10.1007/s00464-010-1242-4) contains supplementary material, which is available to authorized users.

Ileocecal Crohn's disease (CD) can be treated medically as well as surgically. Both treatment modalities have been improved markedly in the last two decades, making CD more manageable. However, multidisciplinary research, addressing issues such as timing of surgery or medical treatment versus surgery, is scarce. Particularly in limited ileocecal CD, ileocolic resection might be a good alternative to long-term medical therapy. This review discusses the evidence on medical and surgical treatment options for ileocecal CD. It provides an aid in decision-making by discussing a treatment algorithm that can be used until further evidence on treatment is available.

Background and Aims: Traditionally large, complex colorectal polyps were managed by surgical resection (SR), and in recent years endoscopic resection (ER) has progressed significantly. However, to what extent ER has replaced SR remains largely unknown. We performed a multicenter retrospective cohort study to assess the volume and volume changes of SR for benign colorectal polyps over the past decade. Methods: Patients who underwent SR for a benign colorectal polyp in the Netherlands between 2005 and 2015 were selected from the prospective nationwide Dutch Pathology Registry (PALGA database). Clinical characteristics were obtained from the charts of patients who underwent SR in the province of Noord-Holland. Results: A total of 5937 patients were treated with SR for a colorectal polyp and the absolute (454-739 per year) and relative volumes (0.20%-0.37% per colonoscopy per year) of SR remained stable. In the province of Noord-Holland, 928 patients (15.6%) underwent SR. In these patients, submucosal lifting and ER were attempted in 19.9% (n = 175) and 15.0% (n = 134). After 2010, patients were more likely to undergo lifting (27.7% vs 11.4%, P

Background Ileocolic resection for Crohn's disease can be performed entirely laparoscopically. However, an incision is needed for specimen extraction. This prospective observational study assessed the feasibility of endoscopic transcolonic specimen removal. Methods Endoscopic specimen removal was attempted in a consecutive series of ten patients scheduled for laparoscopic ileocolic resection. Primary outcomes were feasibility, operating time, reoperation rate, pain scores, morphine requirement and hospital stay. To assess applicability, outcomes were compared with previous data from patients who had laparoscopically assisted operations. Results Transcolonic removal was successful in eight of ten patients; it was considered not feasible in two patients because the inflammatory mass was too large (7–8 cm). Median operating time was 208 min and median postoperative hospital stay was 5 days. After surgery two patients developed an intra-abdominal abscess, drained laparoscopically or percutaneously, and one patient had another site-specific infection. The operation took longer than conventional laparoscopy, with no benefits perceived by patients in terms of cosmesis or body image. Conclusion Transcolonic removal of the specimen in ileocolic Crohn's disease is feasible in the absence of a large inflammatory mass but infection may be a problem. It is unclear whether the technique offers benefit compared with conventional laparoscopic surgery.

The Author(s) 2009. This article is published with open access at Springerlink.com Endoscopic surgery is known for its different eye–hand coordination and its learning curves. It encompasses complex and sensitive equipment that requires different maintenance and quality control. Despite the development of dedicated training programs and extensive research justifying the endoscopic revolution, the Dutch Health Care Inspectorate (DHI) [1] recently surprised endoscopic surgeons with its report entitled Risks of Minimally Invasive Surgery Underestimated [2]. In this report, the Inspectorate expressed its sincere concern regarding endoscopic surgery in The Netherlands. The DHI report was based on investigations done by the Inspectorate initiated by unusual observations of incidents associated with endoscopic surgery. The investigations consisted of questionnaires and on-site visits to hospitals and endoscopic surgeons. Such activity is part of DHI’s task to control the quality of health care in general.

Background Long-term results of laparoscopically assisted versus open ileocolic resection for Crohn's disease were evaluated in a randomized trial. Methods Sixty patients who underwent ileocolic resection between 1999 and 2003 were followed prospectively. Primary outcomes were reoperation, readmission and repeat resection rates for recurrent Crohn's disease. Secondary outcomes were quality of life (QOL), body image and cosmesis. Results Five patients were lost to follow-up. Median follow-up was 6·7 (interquartile range 5·7–7·9) years. Sixteen of 29 and 16 of 26 patients remained relapse free after ileocolic resection in the laparoscopic and open groups respectively (risk difference 6 (95 per cent confidence interval − 20 to 32) per cent). Resection of recurrent Crohn's disease was necessary in two of 29 versus three of 26 patients (risk difference 5 (−11 to 20) per cent). Overall reoperation rates for recurrent Crohn's disease, incisional hernia and adhesion-related problems were two of 29 versus six of 26 (risk difference 16 (−3 to 35) per cent). QOL was similar, whereas body image and cosmesis scores were significantly higher after laparoscopy (P = 0·029 and P < 0·001 respectively). Conclusion Laparoscopically assisted ileocolic resection results in better body image and cosmesis, whereas open surgery is more likely to produce incisional hernia and obstruction.

AIM This systematic review aimed to evaluate the efficacy, morbidity and mortality of laparoscopic peritoneal lavage for patients with perforated diverticulitis. METHOD We searched PubMed, EMBASE, Web of Science, the Cochrane Library and CINAHL databases, Google Scholar and five major publisher websites without language restriction. All articles which reported the use of laparoscopic peritoneal lavage for patients with perforated diverticulitis were included. RESULTS Two prospective cohort studies, nine retrospective case series and two case reports reporting 231 patients were selected for data extraction. Most (77%) patients had purulent peritonitis (Hinchey III). Laparoscopic peritoneal lavage successfully controlled abdominal and systemic sepsis in 95.7% of patients. Mortality was 1.7%, morbidity 10.4% and only four (1.7%) of the 231 patients received a colostomy. CONCLUSION There have been no publications of high methodological quality on laparoscopic peritoneal lavage for patients with perforated colonic diverticulitis. The published papers do, however, show promising results, with high efficacy, low mortality, low morbidity and a minimal need for a colostomy.

Infliximab (IFX), an anti-TNF biologic agent, has been demonstrated to offer benefits for the treatment of autoimmune disorders, such as rheumatoid arthritis and Crohn's disease. Several trials have also investigated the efficacy of IFX for the treatment of ulcerative colitis (UC). IFX was found to be well tolerated. In most trials, IFX treatment was more effective than placebo for patients with moderate, moderate-to-severe or severe UC. However, its place in the treatment algorithms for UC remains to be defined and, to this end, clinical trials comparing IFX treatment to conventional therapies are needed.

Background Laparoscopic surgery has become popular during the last decade, mainly because it is associated with fewer postoperative complications than the conventional open approach. It remains unclear, however, if this benefit is observed after laparoscopic correction of perforated peptic ulcer (PPU). The goal of the present study was to evaluate whether laparoscopic closure of a PPU is as safe as conventional open correction. Methods The study was based on a randomized controlled trial in which nine medical centers from the Netherlands participated. A total of 109 patients with symptoms of PPU and evidence of air under the diaphragm were scheduled to receive a PPU repair. After exclusion of 8 patients during the operation, outcomes were analyzed for laparotomy (n = 49) and for the laparoscopic procedure (n = 52). Results Operating time in the laparoscopy group was significantly longer than in the open group (75 min versus 50 min). Differences regarding postoperative dosage of opiates and the visual analog scale (VAS) for pain scoring system were in favor of the laparoscopic procedure. The VAS score on postoperative days 1, 3, and 7 was significant lower (P

Background: No randomized controlled trial has compared laparoscopic sigmoid resection (LSR) to open sigmoid resection (OSR) for symptomatic diverticulitis of the sigmoid colon. This study tested the hypothesis that LSR is associated with decreased postoperative complication rates as compared with OSR. Methods: This was a prospective, multicenter, double-blind, parallel-arm, randomized controlled trial. Eligible patients were randomized to either LSR or OSR. Endpoints included postoperative mortality, and complications were classified as major and minor. The generator of the allocation sequence was separated from the executor. Blinding was ensured using an opaque Wound dressing to cover the abdomen. Symptomatic diverticulitis of the sigmoid colon was defined as recurrent disease Hinchey I, IIa, IIb, symptomatic stricture, or severe rectal bleeding. The decision to discharge patients was made by independent physicians blind to the allocation sequence. Data were analyzed according to the intention to treat principle. Results: From 2002 to 2006, 104 patients were randomized in 5 centers. All patients underwent the allocated intervention. Fifty-two LSR patients were comparable to 52 OSR patients for gender, age, BMI, ASA grade, comorbid conditions, previous abdominal surgery, and indication for surgery. LSR took longer (P = 0.0001) but caused less blood loss (P = 0.033). Conversion rate was 19.2%. Mortality rate was 1%. There were significantly more major complications in OSR patients (9.6% vs. 25.0%; P = 0,038). Minor complication rates were similar (LSR 36.5% vs. OSR 38.5%; P = 0.839). LSR patients had less pain (Visual Analog Scale 1.6; P = 0.0003), systemic analgesia requirement (P = 0.029), and returned home earlier (P = 0.046). The short form-36 questionnaire showed significantly better quality of life for LSR. Conclusions: LSR was associated with a 15.4% reduction in major complication rates, less pain, improved quality of life, and shorter hospitalization at the cost of a longer operating time

The aim of this prospective double-cohort pilot study is to evaluate the feasibility and desirability of laparoscopic Nissen fundoplication (LNF) performed in day-care when compared with laparoscopic cholecystectomy (LC) in day-care. Patients who underwent a LNF in day-care were prospectively evaluated. LNF patients were treated according to LC in day-care protocol. Outcome parameters were EQ-5D, visual analogue scale (VAS), and patient satisfaction. From October 2005 to March 2008, 22 patients underwent LNF and 48 patients LC in day-care. After LNF, 21 out of 22 (95%) patients were discharged the same day. Seven (32%) patients were seen postoperatively in the Emergency Department with dysphagia or pain and two (9%) patients were readmitted. After LC, 45 out of 48 (94%) patients were discharged the same day. Six (12.5%) patients were seen postoperatively in the Emergency Department because of wound infection or pain and three (6%) were readmitted. EQ-5D and VAS scores were significantly worse after LNF in day-care (repeated measurements, p

OBJECTIVES: Preoperative radiotherapy followed by rectal resection with total mesorectal excision (TME) and colo-anal anastomosis severely compromises anorectal function, which has been attributed to a decrease in neorectal capacity and neorectal compliance. However, to what extent altered motility of the neorectum is involved, is still unknown. The aim of the study was to compare the motor response to (prolonged) filling of the (neo-) rectum in patients after preoperative radiotherapy and rectal resection with that in healthy volunteers (HV). METHODS: Neorectal function (J-pouch or side-to-end anastomosis) was studied in 15 patients (median age 61 years, 10 males) 5 months after short-term preoperative radiotherapy (5 x 5 Gy) and rectal resection with TME for rectal cancer and compared with that of 10 volunteers (median age 41 years, 7 males). Furthermore, patients with a colonic J-pouch anastomosis (n = 6) were compared with patients with a side-to-end anastomosis (n = 9). (Neo-) rectal sensitivity was assessed using a stepwise isovolumetric and isobaric distension protocol. (Neo-) rectal motility was determined during prolonged distension at the threshold of the urge to defecate. RESULTS: The neorectal volume of patients at the threshold of the urge to defecate (125 +/- 45 ml) was significantly lower when compared with that of HV (272 +/- 87 ml, P

PURPOSE: This study assessed long-term functional outcome and explored risk factors for fistula recurrence in patients surgically treated for cryptoglandular fistulas. METHODS: Three hundred ten consecutive patients were surgically treated for perianal fistulas. After exclusion of patients with inflammatory bowel disease or HIV, 179 patients remained. Patients were divided into two groups: those who received fistulotomy for low perianal fistulas and those who received rectal advancement flap for high perianal fistulas. Time to fistula recurrence was the main outcome and Cox proportional hazard models were used to assess the importance of various risk factors. Functional outcome was assessed using the Vaizey and colorectal functional outcome (COREFO) questionnaires. RESULTS: The median follow-up duration was 76 months (range, 7-134). The 3-year recurrence rate for low perianal fistulas treated by fistulotomy (n = 109) was 7 percent (95 percent confidence interval, 1-13 percent). In high transsphincteric fistulas treated by rectal advancement flap (n = 70), the recurrence rate was 21 percent (95 percent confidence interval, 9-33 percent). In both groups, soiling was reported at 40 percent. None of the seven potential risk factors examined were statistically significant. CONCLUSIONS: Fistula recurrence rate after fistulotomy was low. No clear risk factors were found. Overall functional outcome in terms of continence was good. However, a substantial amount of patients reported soiling.

Komplexe hohe und rezidivierende Fisteln sind nach wie vor eine chirurgische Herausforderung. Einfache Spaltung, z.B. durch eine Fistulotomie, resultiert mit hoher Wahrscheinlichkeit in einer Stuhlinkontinenz. Verschiedene chirurgische Behandlungsoptionen bei diesen Fisteln haben enttauschende Ergebnisse gezeigt. Kurzlich wurde ein biologischer analer Fistelplug zur Behandlung der genannten hohen transsphinktaren Fisteln entwickelt. Um die Ergebnisse dieses analen Fistelplugs bei Patienten mit komplexen hohen perianalen Fisteln zu beurteilen, wurde eine prospektive, dizentrische, klinische Studie durchgefuhrt. Zwischen April 2006 und Oktober 2006 wurde eine konsekutive Serie von Patienten mit komplizierten therapieresistenten hohen Fisteln in die Studie aufgenommen. Wahrend der Operation wurde die innere Offnung des Fistelgangs primar identifiziert. Durch den Fistelgang wurde ein konisch geformter Kollagenplug gezogen. Der uberstehende Teil des Fistelplugs, der nicht im Gang platziert werden konnte, wurde entfernt. Der Fistelplug wurde an der inneren Offnung mit einer tiefen 3/0-Polydioxanon-Naht befestigt. Eingeschlossen wurden 17 Patienten mit einem medianen Alter von 45 Jahren (27–75 Jahre). 71% dieser Patienten (12/17) waren mannlich. Bei einer medianen Nachuntersuchungsdauer von 7 Monaten (3–9 Monate) waren sieben von 17 Fisteln geheilt (41%). Bei zehn Patienten rezidivierte die Fistel. In dieser kleinen Serie von 17 Patienten mit komplizierten hohen perianalen Fisteln betrug die Erfolgsrate 41%. Grosere Serien mussen vorzugsweise im Rahmen einer Studie untersucht werden, um die Wirksamkeit des Analfistelplugs bei perianalen Fisteln zu belegen.

BACKGROUND: Evidence of benefits of laparoscopic and laparoscopic-assisted colectomies (LAC) over open procedures in gastrointestinal surgery has continued to accumulate. With its wide implementation, technical difficulties and limitations of LAC have become clear. Hand-assisted laparoscopic surgery (HALS) was introduced in an attempt to facilitate the transition from open techniques to minimally invasive procedures. Continuing debate exists about which approach is to be preferred, HALS or LAC. Several studies have compared these two techniques in colorectal surgery, but no single study provided evidence which procedure is superior. Therefore, a systematic review was carried out comparing HALS with LAC colorectal resection. METHODS: Eligible studies were identified from electronic databases (Medline, Embase Cochrane) and cross-reference search. The database search, quality assessment, and data extraction were independently performed by two reviewers. Minimal outcome criteria for inclusion were operating time, conversion rate, hospital stay, and morbidity. RESULTS: Out of 468 studies a total of 13 studies were selected for comprehensive review. Two randomized controlled trials (RCT) and 11 non-RCTs, comprising 1017 patients, met the inclusion criteria. Because of possible clinical heterogeneity two groups of procedures were created: segmental colectomies and total (procto)colectomies. In the segmental colectomy group significant differences in favor of the HALS group were seen in operating time (WMD 19 min) and conversion rate (OR of 0.3 conversions). In the total (procto)colectomy group a significant difference in favor of the HALS group was seen in operating time (WMD 61 min). CONCLUSIONS: This systematic review indicates that HALS provides a more efficient segmental colectomy regarding operating time and conversion rate, particularly accounting for diverticulitis. A significant operating time advantage exists for HALS total (procto)colectomy. HALS must therefore be considered a valuable addition to the laparoscopic armamentarium to avoid conversion and speed up complicated colectomies

Objectives: Although the advent of (hand-assisted) laparoscopic donor nephrectomy has had a positive effect on the donor pool, there is still some concern about the increased morbidity and safety of the laparoscopic donor nephrectomy. The aim of this study was to compare the results of hand-assisted laparoscopic donor nephrectomy (HALD) with open donor nephrectomy (ODN). Methods: A single-center non-randomized analysis of 202 living donor kidney transplantations (44 ODN, 158 HALD) between January 1995 and April 2006 was conducted. Results: The left kidney was harvested in 75% in the ODN group and 53% in the HALD group (P = 0.009). There was no conversion in the HALD group. Mean donor operative time for HALD (174 min) was longer than for ODN (124 min, P

Background Older living kidney donors remain controversial because of their physiological decline in glomerular filtration rate and their increased susceptibility of surgical complications. Little is known about the quality of life (QOL) of this elderly group. The purpose of this study is to examine surgical outcome and the QOL in older living donors. Patients and methods All 105 consecutive living donors who underwent a laparoscopic donor nephrectomy between June 2002 and February 2006 were prospectively included in the study. Intra- and postoperative complications were measured. Quality of life was recorded preoperatively and at several endpoints postoperatively. Older donors were defined as 55 years and older. Results There were no significant differences in intra- and postoperative complication rates and 1-year graft survival rate between both groups. Elderly donors (n=34) had both a significant lower postoperative pain at rest at day 1 compared with the younger group (P=0.019) and a lower total pain score in the analysis for the whole follow-up period (P=0.002). Although small solitary significant differences in Short Form-36 Health Survey, Multidimensional Fatigue Inventory-20 and visual analogue scale measuring pain, between both groups were detected, in general QOL of older donors was not different than of younger donors. Conclusion Although small solitary significant differences exist with respect to pain, social functioning and mental health older donors, in general, have similar surgical outcome and quality of life when compared with younger donors. There is no need to exclude older donors in screening programs for transplantation.

Backgrounds and aim In recent decades, fibrin glue has appeared as an alternative treatment for high perianal fistulas. Early results seemed promising, with high success rates being reported. However, with increasing follow-up, the enthusiasm was tempered because of disappointing results. The aim of this retrospective study was to assess the additional value of fibrin glue in combination with transanal advancement flap, compared to advancement flap alone, for the treatment of high transsphincteric fistulas of cryptoglandular origin. Materials and methods Between January 1995 and January 2006, 127 patients were operated for high perianal fistulas with an advancement flap. After exclusion of patients with inflammatory bowel disease or HIV, 80 patients remained. A consecutive series of 26 patients had an advancement flap combined with obliteration of the fistula tract with fibrin glue. Patients were matched for prior fistula surgery, and the advancement was performed identically in all patients. In the fibrin glue group, glue was installed retrogradely in the fistula tract after the advancement was completed and the fistula tract had been curetted. Results Minimal follow-up after surgery was 13 months [median of 67 months (range, 13–127)]. The overall recurrence rate was 26% (n = 21). Recurrence rates for advancement flap alone vs the combination with glue were 13% vs 56% (p = 0.014) in the group without previous fistula surgery and 23% vs 41% (p = 0.216) in the group with previous fistula surgery. Conclusion Obliterating the fistula tract with fibrin glue was associated with worse outcome after rectal advancement flap for high perianal fistulas.

PURPOSE: An incomplete linear staple line that was discovered during the stapling of an ileal pouch alerted us to evaluate potential usage concerns with linear cutters. This study was designed to assess the integrity of the staple line of three different sizes of linear staplers. METHODS: In an animal model three different lengths of linear cutters (Proximate (R), Ethicon Endo-Surgery) were used to cross-staple and transect the large bowel of one pig to check for the integrity of the proximal end of the staple line. RESULTS: Cross-stapling and transecting across the pig's large bowel demonstrated that if the tissue is advanced up to the highest number on the scale of the 100 mm stapling device, insufficient overlap between the proximal end of the staple line and the proximal end of the cut line occur. CONCLUSIONS: Although a more than 100 mm staple line is delivered, the 100 mm cutter may not produce a double-staggered row of staples at the most proximal end of the staple line if the tissue is advanced past the 9.5 cm mark. Ethicon Endo-Surgery has agreed to add indicator markers to the scale label on the instrument to provide the user with additional guidance for tissue placement

Dendritic cells (DCs) are key cells in innate and adaptive immune responses that determine the pathophysiology of Crohn's disease. Intestinal DCs migrate from the mucosa into mesenteric lymph nodes (MLNs). A number of different markers are described to define the DC populations. In this study we have identified the phenotype and localization of intestinal and MLN DCs in patients with Crohn's disease and non-IBD patients based on these markers. We used immunohistochemistry to demonstrate that all markers (S-100, CD83, DC-SIGN, BDCA1-4, and CD1a) showed a different staining pattern varying from localization in T-cell areas of lymph follicles around blood vessels or single cells in the lamina propria and in the MLN in the medullary cords and in the subcapsular sinuses around blood vessels and in the T-cell areas. In conclusion, all different DC markers give variable staining patterns so there is no marker for the DC. (J Histochem Cytochem 56:233–241, 2008)

The most frequently described laparoscopic operations for the management of patients with IBD are restorative proctocolectomy for ulcerative colitis and ileocolic resection for Crohn's disease. For patients with Crohn's disease, there is level 1b evidence that, in experienced hands, laparoscopic ileocolic resection enhances recovery and leads to a shorter hospital stay compared with conventional ileocolic resection. The demonstrated advantages of laparoscopic ileocolic resection with regard to cost and cosmesis, and the acceptable long-term results achieved (which are at least comparable to those achieved by conventional ileocolic resection) favor the use of laparoscopic ileocolic resection over conventional ileocolic resection in patients with ileocolic Crohn's disease. For patients with ulcerative colitis, the expected advantages of laparoscopic restorative proctocolectomy over conventional restorative proctocolectomy have yet to be clearly shown. Although there is a trend towards a reduced hospital stay (of only 1.6 days) when laparoscopic restorative proctocolectomy is performed, operating times are disproportionably prolonged. The most important argument for offering patients with IBD the chance to undergo a laparoscopic procedure, rather than conventional open surgery, is (particularly for women) the long-term superior cosmesis and body image it confers.

Background: Installation of the pneumoperitoneum is an essential part of laparoscopic surgery. Creation can be performed by either the open or a closed technique. The aim of this study was to assess the number of and contributing factors to entry-related complications in medical liability insurance claims in the Netherlands. Methods: A retrospective chart review was performed, including all malpractice claims filed at MediRisk, which is presently the largest medical liability mutual insurance company for institutions, mainly hospitals, in healthcare in the Netherlands. Results: From January 1993 to December 2005, 41 claims were identified as entry-related complications which comprised 18% of all laparoscopy-related complications leading to claims. Most were young (median age = 35 years) female patients who had routine, non-advanced, laparoscopic procedures planned as short-stay or day-care procedures. The claims were equally divided between general surgery (n = 20) and gynecology (n = 21). A total of 51 structures were injured. There were 18 vascular structure injuries, 30 bowel injuries, and three other injuries. An open entry technique was used in only two (5%) patients. Vascular injury was exclusively associated with closed entry. In only 19 (46%) patients the entry-related complication was diagnosed peroperatively, consisting of 70% of the vascular and 25% of the bowel injuries. Twenty-six patients (64%) were admitted to the intensive care unit for a median of five days. There was no mortality. Besides conversion, the majority of the patients filed a claim to compensate for a longer hospital stay and related costs. A payment was made in 17 (57%) of the 30 settled claims. Conclusions: Medical liability claims concerning laparoscopic entry-related complications comprised a fifth of all laparoscopy-related claims. Claims concerning entry-related complications occurred in young patients who had routine, nonadvanced procedures. In the investigated cases most claims involved the closed-entry technique

BACKGROUND: This study aimed to compare quality of life (QOL), functional outcome, body image, and cosmesis after hand-assisted laparoscopic (LRP) versus open restorative proctocolectomy (ORP). The potential long-term advantages of LRP over ORP remain to be determined. The most likely advantage of LRP is the superior cosmetic result. It is, however, unclear whether the size and location of incisions affect body image and QOL. METHODS: In a previously conducted randomized trial comparing LRP with ORP, 60 patients were prospectively evaluated. The primary end points were body image and cosmesis. The secondary end points were morbidity, QOL, and functional outcome. A body image questionnaire was used to evaluate body image and cosmesis. The Short Form-36 Health Survey and the Gastrointestinal Quality of Life Inventory were used to assess QOL. Body image and QOL also were assessed preoperatively. RESULTS: A total of 53 patients completed the QOL and functional outcome questionnaires. There were no differences in functional outcome, morbidity, or QOL between LRP and ORP. At a median of 2.7 years after surgery, 46 patients returned the questionnaires regarding body image, cosmesis, and morbidity. The body image and cosmesis scores of female patients were significantly higher in the LRP group than in the ORP group (body image, 17.4 vs 14.9; cosmesis, 19.1 vs 13.0, respectively). The female patients in the ORP group had significantly lower body image scores than the male patients (14.9 vs 18.3). CONCLUSIONS: This study is the first to show that ORP has a negative impact on body image and cosmesis as compared with LRP. Functional outcome, QOL, and morbidity are similar for the two approaches. The advantages of a long-lasting improved body image and cosmesis for this relatively young patient population may compensate for the longer operating times and higher costs, particularly for women

PURPOSE: Complex high and recurrent fistulas remain a surgical challenge. Simple division, i.e., fistulotomy, will likely result in fecal incontinence. Various surgical treatment options for these fistulas have shown disappointing results. Recently a biologic anal fistula plug was developed to treat these high transsphincteric fistulas. To assess the results of the anal fistula plug in patients with complex high perianal fistulas, a prospective, two-center, clinical study was undertaken. METHODS: Between April 2006 and October 2006, a consecutive series of patients with difficult therapy-resistant high fistulas were enrolled. During surgery, the internal fistula tract opening was identified. A conical shaped collagen plug was pulled through the fistula tract. Any remaining portion of the plug that was not implanted in the tract was removed. The plug was fixed at the internal opening with a deep 3/0 polydioxanone suture. RESULTS: Seventeen patients with a median age of 45 (range, 27-75) years were included. Of these patients, 71 percent (12/17) were male. At a median length of follow-up of 7 (range, 3-9) months, 7 of 17 fistulas had healed (41 percent). In ten patients, the fistula recurred. CONCLUSIONS: In these small series of 17 patients with difficult high perianal fistulas, a success rate of 41 percent is noted. Larger series, preferably in trial setting, must be performed to establish the efficacy of the anal fistula plug in perianal fistula.

For two years, every 6 weeks a 23-year-old man presented with episodes of severe abdominal pain and fever. After an extensive diagnostic workup, showing only slightly increased infectious parameters during the pain attacks and infiltration around the terminal ileum, a diagnostic laparoscopy diagnosed 'chronic recurrent appendicitis'. A 40-year-old female had severe attacks of abdominal pain and fever every 4-6 weeks for 1.5 years. Some inflammation around the appendix was seen on colonoscopy, and a diagnostic laparoscopy finally confirmed the same diagnosis 'chronic recurrent appendicitis'. Patients with recurrent abdominal pain often are a diagnostic challenge for the clinician. The appendix is rarely recognized as the causative factor and the diagnosis 'chronic recurrent appendicitis' is not widely accepted. This disease entity often has an atypical presentation and well-defined criteria are lacking. In this article we plea for a broader acceptance of this diagnosis, which, in our opinion, deserves to be included in the differential diagnosis of longstanding or recurrent abdominal pain attacks.

Background: Laparoscopic sigmoidectomy for diverticulitis has initially been confined to the elective setting. However, open acute sigmoidectomy for perforated diverticulitis is associated with high morbidity rates that might be reduced after laparoscopic surgery. The aim of this systematic review was to assess the feasibility of emergency laparoscopic sigmoidectomy for perforated diverticulitis. Methods: We performed a systematic search of PubMed, EMBASE and CENTRAL. All studies reporting on patients with perforated diverticulitis (Hinchey III-IV) treated by laparoscopic sigmoidectomy in the acute phase were included, regardless of design. Results: We included 4 case series and one cohort study (total of 104 patients) out of 1,706 references. Hartmann's procedure (HP) was performed in 84 patients and primary anastomosis in 20. The mean operating time varied between 115 and 200 min. The conversion rate varied from 0 to 19%. The mean length of hospital stay ranged between 6 and 16 days. Surgical re-intervention was necessary in 2 patients. In 20 patients operated upon without defunctioning ileostomy, no anastomotic leakage was reported. Three patients died during the postoperative period. Stoma reversal after HP was performed in 60 out of 79 evaluable patients (76%). Conclusions: Acute laparoscopic sigmoidectomy for the treatment of perforated diverticulitis is feasible in selected patients provided they are handled by experienced hands.

BACKGROUND: This experimental study investigates infectious complications and functional outcome of biological meshes in a contaminated environment. METHODS: In 90 rats peritonitis was induced, and after 24 hours, a biological mesh was implanted intraperitoneally including 2 non-crosslinked mesh groups (Strattice and Surgisis) and 2 crosslinked mesh groups (CollaMendFM and Permacol). Sacrifice was after 90 and 180 days. RESULTS: More mesh infections occurred in crosslinked meshes compared with non-crosslinked meshes (70% vs 4%; P < .001). Mesh infection was the highest in crosslinked CollaMendFM (81.2%) and lowest in non-crosslinked Strattice groups (0%). Incorporation into the abdominal wall was poor in all meshes (0% to 39%). After 180 days no residue of non-crosslinked Surgisis mesh was found. After 180 days, shrinkage was .8% in crosslinked Permacol and 20% in Strattice groups. Strattice showed the least adhesion formation (median 5%). CONCLUSIONS: Infection rate of biological meshes in a contaminated field was the highest in crosslinked meshes. All biological meshes showed poor incorporation, which makes long-term abdominal wall repair questionable. (C) 2015 Elsevier Inc. All rights reserved.

Background/Aims: The prematurely closed Stent-In II trial in patients with left-sided obstructive colon cancer may have influenced clinical decision making in The Netherlands. The aim of this study was to evaluate treatment of left-sided malignant colon obstruction at a population level since then. Methods: Short-term outcomes of all patients who underwent resection for left-sided obstructive colon cancer between 2009 and 2012 were assessed based on a prospective national registry. Results: In total, 1,816 evaluable patients were included; acute resection was performed in 1,485 (81.8%), and endoscopic stent or decompressing stoma followed by resection in 196 (10.8%) and 135 (7.4%), respectively. The use of endoscopic stenting significantly decreased from 18% (2009) to 6% (2012). Overall 30-day or in-hospital mortality rate was 6.9, 5.6, and 3.7%, respectively (p = 0.107). Mortality rate after acute resection was 2.9% in patients >70 years, but mortality rates up to 32.2% were observed in high-risk elderly patients. Conclusion: Acute resection as first choice treatment seems justified for patients >70 years of age given a mortality rate of 3%. For the elderly frail patients, mortality rates over 30% after acute resection stress the need for alternative treatment strategies.

OBJECTIVE: The aim of the study was to compare laparoscopic-assisted and open ileocolic resection for primary Crohn's disease in a randomized controlled trial. METHODS: Sixty patients were randomized for laparoscopic-assisted or open surgery. Primary outcome parameter was postoperative quality of life (QoL) during 3 months of follow-up, measured by SF-36 and GIQLI questionnaire. Secondary parameters were operating time, morbidity, hospital stay, postoperative morphine requirement, pain, and costs. RESULTS: Patient characteristics were not different. Conversion rate was 10% (n=3). Median operating time was longer in laparoscopic compared with open surgery (115 versus 90 minutes; P

Background Fast track (FT) programmes optimize perioperative care in an attempt to accelerate recovery, reduce morbidity and shorten hospital stay. The aim of this review was to assess FT programmes for elective segmental colonic resections. Methods A systematic review was performed of all randomized controlled trials and controlled clinical trials on FT colonic surgery. The main endpoints were number of applied FT elements, hospital stay, readmission rate, morbidity and mortality. Quality assessment and data extraction were performed independently by three observers. Results Six papers were eligible for analysis (three randomized controlled and three controlled clinical trials), including 512 patients. FT programmes contained a mean of nine (range four to 12) of the 17 FT elements as defined in the literature. Primary hospital stay (weighted mean difference − 1·56 days, 95 per cent confidence interval (c.i.) − 2·61 to − 0·50 days) and morbidity (relative risk 0·54, 95 per cent c.i. 0·42 to 0·69) were significantly lower for FT programmes. Readmission rates were not significantly different (relative risk 1·17, 95 per cent c.i. 0·73 to 1·86). No increase in mortality was found. Conclusions FT appears to be safe and shortens hospital stay after elective colorectal surgery. However, as the evidence is limited, a multicentre randomized trial seems justified.

Background: After colorectal surgery, patients often experience impaired functional outcome. Faecal incontinence grading systems and self-assessment questionnaires are frequently used to assess these complaints. The available faecal incontinence grading systems have been validated, but have a limited focus, while more comprehensive questionnaires, which have been developed, have not been validated. Aims: To investigate the reliability and validity of a newly developed, colorectal functional outcome (COREFO) questionnaire and of Dutch translations of the Hallböök questionnaire and an adapted version of the Vaizey questionnaire. Patient/methods: Two hundred fifty-seven patients with and without impaired functional outcome after (colorectal) surgery received a booklet containing the three questionnaires in random order by mail. One hundred seventy-nine (70%) completed them, and 160 patients (90%) completed a retest within, on average, 18 days. Results/findings: Reliability and validity were adequate for the COREFO and Hallböök questionnaire, with slight differences in the psychometric analyses in favour of the COREFO questionnaire. Significantly more patients found the COREFO questionnaire to reflect their problems best. The reliability of the Vaizey questionnaire was not sufficient. Interpretation/conclusions: The newly developed COREFO ques tionnaire and the previously unvalidated Hallböök questionnaire are both suitable instruments to evaluate functional outcome after colorectal surgery. The psychometric analyses showed a slight difference in favour of the COREFO questionnaire and significantly more patients preferred the COREFO questionnaire to the other questionnaires. Therefore, we prefer to use the COREFO questionnaire in future research.

Objective: The aim of the study was to evaluate postoperative recovery after hand-assisted laparoscopic or open restorative proctocolectomy with ileal pouch anal anastomosis for ulcerative colitis and familial adenomatous polyposis in a randomized controlled trial. Methods: Sixty patients were randomized for hand-assisted laparoscopic (n = 30) or open surgery (n = 30). Primary outcome parameter was postoperative recovery in the 3 months after surgery, measured by quality of life questionnaires (SF-36 and GIQLI). Secondary parameters were postoperative morphine requirement and surgical parameters, viz. operating time, morbidity, hospital stay, and costs. Results: There was no difference between the 2 procedures in quality of life assessment in the 3 months after surgery. There was a significant decline in quality of life on all scales of the SF-36 (P < 0.001) and total GIQLI score (P < 0.001) in the first 2 weeks in both groups (no significant difference between the groups). Quality of life returned to baseline levels after 4 weeks. Operating times were longer in the laparoscopic group compared with the open group (210 and 133 minutes, respectively; P < 0.001). No significant differences were found in morphine requirement. Neither morbidity nor postoperative hospital stay differed between the laparoscopic and open group (20% versus 17%, in 10 versus 11 days, respectively). Median overall costs were? 16.728 for the hand-assisted laparoscopic procedure and? 13.406 for the open procedure (P = 0.095). Conclusions: Recovery measured using quality of life questionnaires is comparable for hand-assisted laparoscopic or open restorative proctocolectomy with ileal pouch anal anastomosis. The laparoscopic approach is as safe, but more costly than the open procedure.

Study Objective To evaluate clinical outcome in terms of pain and quality of life after laparoscopic adhesiolysis. Design Prospective observational study (Canadian Task Force II-3). Setting University-affiliated medical center. Patients Twenty-three patients (22 women). Intervention Laparoscopic adhesiolysis for chronic abdominal pain. Measurements and Main Results Pain was assessed by validated McGill score. Patients with an intraindividual decrease in pain score of 5 points or more were considered successes. Quality of life was assessed by the SF-36 and gastrointestinal quality of life index. Patients were evaluated before and at intervals until 2 years after adhesiolysis. The mean pain score before adhesiolysis was 30.5 (range: 17–40). At 2 years of follow-up, 10 (45%) of 22 patients (95% CI 0.244–0.678) were considered successes. They reported significant improvement in quality of life on scales physical, role physical, and social function, and fewer gastrointestinal symptoms. Twelve women (55%) had a complete relapse, and most were not motivated to visit the pain clinic after 6 months. Conclusion Laparoscopic adhesiolysis for chronic abdominal pain was successful in only 45% of patients.