Ahmet Rencuzogullari

Predictors of anastomotic leak in elderly patients after colectomy: nomogram-based assessment from the American College of Surgeons National Surgical Quality Program Procedure-Targeted Cohort

BACKGROUND: Elderly patients undergoing colorectal surgery have increasingly become under scrutiny by accounting for the largest fraction of geriatric postoperative deaths and a significant proportion of all postoperative complications, including anastomotic leak. OBJECTIVE: This study aimed to determine predictors of anastomotic leak in elderly patients undergoing colectomy by creating a novel nomogram for simplistic prediction of anastomotic leak risk in a given patient. DESIGN: This study was a retrospective review. SETTINGS: The database review of the American College of Surgeons National Surgical Quality Improvement Program was conducted at a single institution. PATIENTS: Patients aged ≥65 years who underwent elective segmental colectomy with an anastomosis at different levels (abdominal or low pelvic) in 2012–2013 were identified from the multi-institutional procedure-targeted database. MAIN OUTCOME MEASURES: We constructed a stepwise multiple logistic regression model for anastomotic leak as an outcome; predictors were selected in a stepwise fashion using the Akaike information criterion. The validity of the nomogram was externally tested on elderly patients (≥65 years of age) from the 2014 American College of Surgeons National Surgical Quality Improvement Program colectomy-targeted database. RESULTS: A total of 10,392 patients were analyzed, and anastomotic leak occurred in 332 (3.2%). Of the patients who developed anastomotic leak, 192 (57.8%) were men (p < 0.001). Based on unadjusted analysis, factors associated with an increased risk of anastomotic leak were ASA score III and IV (p < 0.001), chronic obstructive pulmonary disease (p = 0.004), diabetes mellitus (p = 0.003), smoking history (p = 0.014), weight loss (p = 0.013), previously infected wound (p = 0.005), omitting mechanical bowel preparation (p = 0.005) and/or preoperative oral antibiotic use (p < 0.001), and wounds classified as contaminated or dirty/infected (p = 0.008). Patients who developed anastomotic leak had a longer length of hospital stay (17 vs 7 d; p < 0.001) and operative time (191 vs 162 min; p < 0.001). A multivariate model and nomogram were created. LIMITATIONS: This study was limited by its retrospective nature and short-term follow-up (30 d). CONCLUSIONS: An accurate prediction of anastomotic leak affecting morbidity and mortality after colorectal surgery using the proposed nomogram may facilitate decision making in elderly patients for healthcare providers.

Robotic rectal surgery

Robotic technology is increasingly used in colorectal surgery during last decade. Whether this technology will translate into clinical efficiency and value of care remains to be determined. This review aims to discuss current data in robotic rectal surgery with emphasize on ergonomics, cost, and learning curve aspects. All relevant articles are reviewed in addition to published and unpublished work from the authors’ own experience. J. Surg. Oncol. 2015; 112:326–331.

Case-matched Comparison of Robotic Versus Laparoscopic Proctectomy for Inflammatory Bowel Disease.

The present study reports an early institutional experience with robotic proctectomy (RP) and outcome comparison with laparoscopic proctectomy (LP) in patients with inflammatory bowel disease (IBD). Patients who underwent either RP or LP during proctocolectomy for IBD between January 2010 and June 2014 were matched (1:1) and reviewed. Twenty-one patients undergoing RP fulfilled the study criteria and were matched with an equal number of patients who had LP. Operative time was longer (304 vs. 213 min, P=0.008) and estimated blood loss was higher in the RP group (360 vs. 188 mL, P=0.002). Conversion rates (9.5% vs. 14.3%, P>0.99), time to first bowel movement(2.29±1.53 vs. 2.79±2.26, P=0.620), and hospital length stay(7.85±6.41 vs. 9.19±7.47 d, P=0.390) were similar in both groups. No difference was noted in postoperative complications, ileal pouch to anal canal anastomosis-related outcomes, Cleveland Global Quality of Life, and Short Form-12 health survey outcomes between RP and LP. Our good results with standard laparoscopy are unlikely to be improved with robotics in proctectomy cases. Potential benefits of robotic approach for completion proctectomy warrant further investigation as experience grows with robotics.

An Effective Bundled Approach Reduces Surgical Site Infections in a High-Outlier Colorectal Unit

BACKGROUND: Surgical site infections are the most common hospital-acquired infection after colorectal surgery, increasing morbidity, mortality, and hospital costs. OBJECTIVE: The purpose of this study was to investigate the impact of preventive measures on colorectal surgical site infection rates in a high-volume institution that performs inherent high-risk procedures. DESIGN: This was a prospective cohort study. SETTINGS: The study was conducted at a high-volume, specialized colorectal surgery department. PATIENTS: The Prospective Surgical Site Infection Prevention Bundle Project included 14 preoperative, intraoperative, and postoperative measures to reduce surgical site infection occurrence after colorectal surgery. Surgical site infections within 30 days of the index operation were examined for patients during the 1-year period after the surgical site infection prevention bundle was implemented. The data collection and outcomes for this period were compared with the year immediately before the implementation of bundle elements. All of the patients who underwent elective colorectal surgery by a total of 17 surgeons were included. The following procedures were excluded from the analysis to obtain a homogeneous patient population: ileostomy closure and anorectal and enterocutaneous fistula repair. MAIN OUTCOME MEASURES: Surgical site infection occurring within 30 days of the index operation was measured. Surgical site infection–related outcomes after implementation of the bundle (bundle February 2014 to February 2015) were compared with same period a year before the implementation of bundle elements (prebundle February 2013 to February 2014). RESULTS: Between 2013 and 2015, 2250 abdominal colorectal surgical procedures were performed, including 986 (43.8%) during the prebundle period and 1264 (56.2%) after the bundle project. Patient characteristics and comorbidities were similar in both periods. Compliance with preventive measures ranged between 75% and 99% during the bundle period. The overall surgical site infection rate decreased from 11.8% prebundle to 6.6% at the bundle period (P < 0.001). Although a decrease for all types of surgical site infections was observed after the bundle implementation, a significant reduction was achieved in the organ-space subgroup (5.5%–1.7%; P < 0.001). LIMITATION: We were unable to predict the specific contributions the constituent bundle interventions made to the surgical site infection reduction. CONCLUSIONS: The prospective Surgical Site Infection Prevention Bundle Project resulted in a substantial decline in surgical site infection rates in our department. Collaborative and enduring efforts among multiple providers are critical to achieve a sustained reduction See Video Abstract at http://links.lww.com/DCR/A438.

Superficial Surgical Site Infection after Colorectal Surgery: Targeting High-Risk Patients Increases the Efficacy of Prevention Bundles

Amaç: Kolorektal cerrahi sonrası cerrahi alan enfeksiyonlarını (CAE) azaltmak için hazırlanan önlem paketlerinin tüm hastalara uygulanması pahalı olup minimal başarıya sahiptir. Bu çalışmada yüksek riskli yüzeyel CAE’leri ile ilişkili faktörler ve koruyucu önlemlerin yüksek riskli hastalardaki etkinliğini değerlendirmek amaçlanmıştır. Yöntem: 2010-Ocak ve 2014-Şubat tarihleri arasında kolorektal eksizyon uygunlanan hastalar önlem demeti öncesi (2010 Ocak-2012 Ağustos) ve demet dönemi (2012 Ağustos-2014 Şubat) olmak üzere identifiye edildi. Yüzeyel CAE riski ile ilişkili faktörler değerlendirildi. Demeti öncesi ve demet dönemi periyoduna ait hastalar risk modeli oluşturularak 1/10’luk gruplar şeklinde düşük riskten yüksek riske doğru kategorize edildi. Demet dönemi periyoduna ait hastalara prospektif olarak uygulanan koruyucu önlemlerin etkisi çok değişkenli modelleme ve frekans-eşlemeli analiz ile değerlendirildi. Bulgular: İleokolik (%19,1), sol taraflı (%46) ve pelvik prosedür (%34,9) yapılan 2535 demeti öncesi hasta analiz edildi. Ortalama yüzeyel CAE oranı %10,7 idi. Ayarlanmamış analize göre 4 hasta ilişkili ve 5 prosedür ilişkili faktör yüzeyel CAE ile anlamlı düzeyde ilişkili bulundu. Üzerinde risk modellemesi yapılandırılan demeti öncesi ve koruyucu önlemlerin uygulandığı risk değerlendirilmesinde kullanılan demet dönemi periyodu hastaları kıyaslandığında yüzeyel CAE oranlarında anlamlı düşme sağlandı (%10,6’dan %3,2’e, p<0,001). Frekans-eşlemeli analizinde demet dönemi periyodu hastalarında demeti öncesine kıyasla yüzeyel CAE’de anlamlı azalma tespit edildi (%13’ten %4,2’e, p<0,001). Demet dönemi hastalarına ait her 1/10’luk grupta, predikte edilen ve gözlenen yüzeyel CAE oranlarındaki düşme en belirgin şeklilde yüksek riskli gruplarda mecuttu. Sonuç: Koruyucu stratejilerin kolorektal cerrahi sonrası yüzeyel CAE için yüksek risk barındıran hastaları hedeflemesi CAE oranında en fazla oranda azalma ile sonuçlanmıştır. CAE’lerin karmaşık natürü düşünüldüğünde işbirliği ile yapılan ve hedeflenmiş tedbirlerin uygulanması, etkili ve potansiyel olarak maliyet etkin stratejilerin sağlanmasında kritik öneme sahiptir. Anahtar Kelimeler: Yüzeyel cerrahi alan enfeksyonları, önlem demeti, kolorektal cerrahi, yüksek riskli hastalar ÖZ ABSTRACT

Virtual reality training in laparoscopic colorectal surgery

Due to the critical balance between patient safety and long learning curves for new surgical techniques, there has been rising interest in ex vivo surgical training models using simulators.