Edward C. Lee

Single-incision versus standard multiport laparoscopic colectomy: a multicenter, case-controlled comparison.

Objective:The aim of this study was to compare single-incision laparoscopic colectomy (SILC) to multiport laparoscopic colectomy (MLC) when performed by experienced laparoscopic surgeons. Background:Recent case reports and single institution series have demonstrated the feasibility of SILC. Few comparative studies for MLC and SILC have been reported. Methods:Patients from 5 institutions undergoing SILC were entered into an IRB approved database from November 2008 to March 2010. SILC patients were matched with those undergoing MLC for gender, age, disease, surgery, BMI, and surgeon. The primary endpoint was length of stay and secondary endpoints included operative time, conversion, complications and postoperative pain scores. Results:Three hundred thirty patients (SILC = 165, MLC = 165) were evaluated. Operative time (135 ± 45 min vs. 133 ± 56 min; P = 0.85) and length of stay (4.6 ± 1.6 vs. 4.3 ± 1.4; P = 0.35) were not significantly different. Maximum postoperative day one pain scores were significantly less for SILC (4.9 vs. 5.6; P = 0.005). Eighteen (11%) patients undergoing SILC were converted to multiport laparoscopy. There was no statistical difference between groups for conversions to laparotomy, complications, re-operations, or re-admissions. Conclusions:SILC is feasible when performed on select patients by surgeons with extensive laparoscopic experience. Outcomes were similar to MLC, except for a reduction in peak pain score on the first postoperative day. Prospective randomized trials should be performed before incorporation of this technology into routine surgical care.

Single-incision vs straight laparoscopic segmental colectomy: a case-controlled study.

PURPOSE: Single-incision laparoscopic surgery is gaining momentum in general surgery but it is essentially unstudied for laparoscopic colectomy. The aim of our study was to compare outcomes for single-incision laparoscopic colectomy with laparoscopic-assisted colectomy. METHODS: Patients undergoing laparoscopic colectomy were prospectively entered into an institutional review board-approved database. Those that underwent single-incision laparoscopic colectomy were case matched for sex, age, disease, surgery, body mass index, previous surgeries, and surgeon with patients undergoing LAC. RESULTS: Twenty-nine single-incision laparoscopic segmental colectomies were performed for polyps (4), adenocarcinoma (12), diverticulitis (6), and Crohns disease (7) and were case matched to laparoscopic-assisted colectomy for the same indications. Mean body mass index was 28.8 ± 3 kg/m2. Operative time was longer for single-incision laparoscopic colectomy (134.4 ± 40 vs 103.8 ± 54 min; P = .0002). Four single-incision laparoscopic colectomies were converted to LAC requiring either one extra port (2) or 2 extra ports (2), and there was one conversion to laparotomy. Extraction scar length (millimeters) was similar (38 ± 6.0 vs 45 ± 6.2; P = .746). Postoperative morbidity (5/29 vs 7/29; P = .284) and length of stay (day) (3.7 ± 1.1 vs 3.9 ± 1.1; P = .445) were similar between groups. CONCLUSIONS: Single-incision laparoscopic colectomy is feasible and safe but takes more time than laparoscopic-assisted colectomy. Although results approximate those for laparoscopic-assisted colectomy, an additional learning curve is involved, and extra incisions are sometimes required. Single-incision laparoscopic colectomy requires further prospective validation so that the cost of the device can be justified by an improved clinical outcome.

Complicated diverticulitis following renal transplantation

PURPOSE: Colonic perforations in renal transplant recipients have historically been associated with mortality rates as high as 50 to 100 percent. However, these previous series generally predate the use of cyclosporine-based immuno-suppressive protocols. METHODS: We retrospectively reviewed all patients who had undergone renal transplant from our institution and who developed complicated diverticulitis. Complicated diverticulitis was defined as diverticulitis involving free perforation, abscess, phlegmon, or fistula. Factors analyzed included the time interval since transplantation, use of cyclosporine, living-relatedvs. cadaveric donor, cause of renal failure, and presenting signs and symptoms. RESULTS: Between August 1969 and September 1996, 1,211 kidney transplants were performed in 1,137 patients. The first 388 patients (1969–1984) received prednisone and azathioprine, with cyclosporine added to the immunosuppressive regimen for the subsequent 823 recipients (1984–1996). Thirteen (1.1 percent) patients had episodes of complicated diverticulitis, occurring from 25 days to 14 years after transplant; all required surgical therapy. Clinical presentation was highly variable, ranging from asymptomatic pneumoperitoneum (2 patients) to generalized peritonitis. There was one perioperative mortality (7.7 percent). Patients with polycystic kidney disease as the cause of renal failure had a significantly higher rate of complicated diverticulitis. Specifically, patients with polycystic kidney disease (9 percent of the total transplant population) accounted for 46 percent of the cases of diverticulitis (P < 0.001, Fishers exact probability test). Neither treatment with cyclosporine nor donor source had a significant effect on the rate of diverticular complications (P=0.36 andP=0.99, respectively, Fishers exact probability test). CONCLUSION: Complicated diverticulitis following renal transplantation is rare, and the clinical presentation may be atypical in the immunosuppressed transplant recipient. Patients with polycystic kidney disease experience a significantly higher rate of complicated diverticulitis than do other transplant patients and, therefore, warrant aggressive diagnostic evaluation of even vague abdominal symptoms. In addition, pretransplant screening and prophylactic sigmoid resection in this high-risk population deserve consideration and further study.

Liposome Bupivacaine for Postsurgical Analgesia in Adult Patients Undergoing Laparoscopic Colectomy: Results from Prospective Phase IV Sequential Cohort Studies Assessing Health Economic Outcomes

Background Opioid-based postsurgical analgesia exposes patients undergoing laparoscopic colectomy to elevated risk for gastrointestinal motility problems and other opioid-related adverse events (ORAEs). The purpose of our research was to investigate postsurgical outcomes, including opioid consumption, hospital length of stay, and ORAE risk associated with a multimodal analgesia regimen, employing a single administration of liposome bupivacaine as well as other analgesics that act by different mechanisms. Methods We analyzed combined results from 6 Phase IV, prospective, single-center studies in which patients undergoing laparoscopic colectomy received opioid-based intravenous patient-controlled analgesia (PCA) or multimodal analgesia incorporating intraoperative administration of liposome bupivacaine. As-needed rescue therapy was available to all patients. Primary outcome measures were postsurgical opioid consumption, hospital length of stay, and hospitalization costs. Secondary measures included time to first rescue opioid use, patient satisfaction with analgesia (assessed using a 5-point Likert scale), and ORAEs. Results Eighty-two patients underwent laparoscopic colectomy and did not meet intraoperative exclusion criteria (PCA n = 56; multimodal analgesia n = 26). Compared with the PCA group, the multimodal analgesia group had significantly lower mean total postsurgical opioid consumption (96 vs 32 mg, respectively; P < 0.0001) and shorter median postsurgical hospital length of stay (3.0 vs 4.0 days; P = 0.0019). Geometric mean costs were

Bioabsorbable staple line reinforcement in restorative proctectomy and anterior resection: a randomized study.

11,234 and

Local and systemic Th17 immune response associated with advanced stage colon cancer

13,018 in the multimodal analgesia and PCA groups, respectively (P = 0.2612). Median time to first rescue opioid use was longer in the multimodal analgesia group versus PCA group (1.1 hours vs 0.6 hours, respectively; P=0.0003). ORAEs were experienced by 41% of patients receiving intravenous opioid PCA and 8% of patients receiving multimodal analgesia (P = 0.0019). Study limitations included use of an open-label, nonrandomized design; small population size; and the inability to isolate treatment-related effects specifically attributable to liposome bupivacaine. Conclusions Compared with intravenous opioid PCA, a liposome bupivacaine-based multimodal analgesia regimen reduced postsurgical opioid use, hospital length of stay, and ORAEs, and may lead to improved postsurgical outcomes following laparoscopic colectomy.

Complications and surgical outcomes after interhospital transfer vs direct admission in colorectal surgery: a National Surgical Quality Improvement Program analysis

BACKGROUND: Anastomotic complications, including leaks, strictures/stenoses, and bleeding, cause considerable mortality and morbidity after colorectal surgery. OBJECTIVE: The aim of this study was to assess whether the use of a synthetic, bioabsorbable staple line reinforcement material with circular staplers would reduce postoperative anastomotic leakage in patients with a colorectal, coloanal, or ileoanal anastomosis. DESIGN: This was a randomized study that compared outcomes in patients in whom the reinforcement material was used with those in patients who were not given the material. SETTINGS: This study was conducted at several centers in the United States. PATIENTS: The 258 patients (123 in the reinforcement group and 135 control subjects) underwent surgery for a variety of conditions, but most (n = 200) were treated for rectal cancer. MAIN OUTCOME MEASURES: The main outcome measures were occurrence of anastomotic leaks and other complications according to the study protocol. RESULTS: There were no significant differences in the 2 study groups with respect to age, BMI, ASA physical status, operating time, diagnosis, previous chemoradiotherapy, surgical technique, or 30-day complications, except for a higher rate of small-bowel obstruction (p = 0.03) and anastomotic stricture (p = 0.006) in the control group. The overall anastomotic leak rate was 12% (bioabsorbable staple line reinforcement, 11.4%; no bioabsorbable staple line reinforcement, 12.6%). LIMITATIONS: The study was nonblinded and was terminated at the first planned interim analysis because of insufficient power to detect an intergroup difference in anastomotic leak rate in the time allotted for the investigation. CONCLUSIONS: Reinforcing the circular staple line in colorectal anastomoses with bioabsorbable material did not significantly affect the anastomotic leak rate but may have reduced anastomotic strictures. Most strictures did not require an anastomotic revision or delay in stoma closure. The bioabsorbable material may positively affect some aspects of the healing of circular stapled colorectal anastomoses; however, additional research on factors associated with anastomotic leakage is needed.

Failing to Prepare Is Preparing to Fail: A Single-Blinded, Randomized Controlled Trial to Determine the Impact of a Preoperative Instructional Video on the Ability of Residents to Perform Laparoscopic Right Colectomy.

BACKGROUND Little is known about how the immunologic microenvironment changes during tumor progression and metastatic spread. Recently, murine models have shown the T-helper 17 (Th17) pathway to play an important role in promoting colorectal cancer (CRC). The purpose of this study was to compare cytokine profiles in the tumor microenvironment of CRC between local disease (stages I/II) and advanced disease (stages III/IV), and to determine whether these changes were manifest in the systemic circulation of patients with advanced disease. MATERIALS AND METHODS Serum and tissue cytokine profiles were assayed among patients with documented adenocarcinoma before surgical resection at a single institution from September 2014 to February 2015. Using the Bio-Plex Pro Human Th17 Cytokine Assay Kit (Bio-Rad Laboratories), the concentrations of multiple cytokines were determined. Multiple logistic regression analyses were used to evaluate the association between TNM staging and cytokine levels. RESULTS A total of 33 patients with documented adenocarcinoma were included. None of the patients received neoadjuvant chemotherapy. American Joint Commission on Cancer TNM classification was used. Advanced disease was associated with elevated tumor levels of tumor necrosis factor-alpha, interleukin (IL)-4, IL-10, IL-17A, and IL-17F, and only stage IV showed elevated systemic levels of Th17-associated cytokines IL-17F, IL-23, and IL-25. CONCLUSIONS The Th17 pathway likely has important mechanistic implications in human CRC. Metastatic disease was associated with elevated Th17-associated cytokines both in colonic tissue and systemically. These changes in systemic expression of Th17-associated cytokines could establish novel pathways for CRC and warrant further investigation.

A novel histologic grading scheme based on poorly differentiated clusters is applicable to treated rectal cancer and is associated with established histopathological prognosticators

BACKGROUND Interhospital transfer is common among patients undergoing colorectal surgery. The purpose of this study was to determine surgical outcomes after transfer vs direct admission in patients undergoing colorectal surgery. METHODS The American College of Surgeons National Surgical Quality Improvement Program database from 2010 to 2012 was used. Colorectal operations were selected, including both emergency and nonemergency cases. Transfers were compared with direct admissions using a complex comorbidity analysis model. Primary outcomes of interest were mortality, extended hospital length of stay, and complication rates. RESULTS The study included 121,040 admissions. After adjusting for multiple patient factors and comorbidities, nonemergency transfers still had higher mortality rates (RR = 1.20; P < .05), longer length of hospital stay (RR = 1.24; P < .05), and higher complication rates (RR = 1.18; P < .05). CONCLUSIONS Preoperative hospital transfer is common among patients requiring colorectal surgery. Despite extensive propensity score matching, nonemergency transfers have higher rates of mortality, longer length of hospital stay, and higher overall complication rates compared with direct admissions. Transfer status is an important variable in hospital performance models and should be taken into consideration when analyzing hospital outcomes.

Single Surgeon Experience with Laparoscopic Surgery in Pediatric Patients with Inflammatory Bowel Disease

BACKGROUND: Laparoscopic colorectal resection is an index case for advanced skills training, yet many residents struggle to reach proficiency by graduation. Current methods to reduce the learning curve for residents remain expensive, time consuming, and poorly validated. OBJECTIVE: The purpose of this study was to assess the impact of the addition of a preprocedural instructional video to improve the ability of a general surgery resident to perform laparoscopic right colectomy when compared with standard preparation. DESIGN: This was a single-blinded, randomized control study. SETTINGS: Four university-affiliated teaching hospitals were included in the study. PARTICIPANTS: General surgery residents in postgraduation years 2 through 5 participated. INTERVENTION: Residents were randomly assigned to preparation with a narrated instructional video versus standard preparation. MAIN OUTCOME MEASURES: Resident performance, scored by a previously validated global assessment scale, was measured. RESULTS: Fifty-four residents were included. Half (n = 27) were randomly assigned to view the training video and half (n = 27) to standard preparation. There were no differences between groups in terms of training level or previous operative experience or in patient demographics (all p > 0.05). Groups were similar in the percentage of the case completed by residents (p = 0.39) and operative time (p = 0.74). Residents in the video group scored significantly higher in total score (mean: 46.8 vs 42.3; p = 0.002), as well as subsections directly measuring laparoscopic skill (vascular control mean: 11.3 vs 9.7, p < 0.001; mobilization mean: 7.6 vs. 7.0, p = 0.03) and overall performance score (mean: 4.0 vs 3.1; p < 0.001). Statistical significance persisted across training levels. LIMITATIONS: There is potential for Hawthorne effect, and the study is underpowered at the individual postgraduate year level. CONCLUSIONS: The simple addition of a brief, narrated preprocedural video to general surgery resident case preparation significantly increased trainee ability to successfully perform a laparoscopic right colectomy. In an era of shortened hours and less exposure to cases, incorporating a brief but effective instructional video before surgery may improve the learning curve of trainees and ultimately improve safety.