Eric C. Poulin

Optimizing recovery after laparoscopic colon surgery (ORAL-CS): effect of intravenous ketorolac on length of hospital stay.

BackgroundThe objective of this study was to determine if intravenous ketorolac can reduce ileus following laparoscopic colorectal surgery, thus shortening hospital stay.MethodsThis was a prospective, randomized, double-blind, placebo-controlled, clinical trial of patients undergoing laparoscopic colorectal resection and receiving morphine patient controlled analgesia (PCA) and either intravenous ketorolac (group A) or placebo (group B), for 48 h after surgery. Daily assessments were made by a blinded assistant for level of pain control. Diet advancement and discharge were decided according to strictly defined criteria.ResultsFrom October 2002 to March 2005, 190 patients underwent laparoscopic colorectal surgery. Of this total, 84 patients were eligible for this study and 70 consented. Another 26 patients were excluded, leaving 22 patients in each group. Two patients who suffered anastomotic leaks in the early postoperative period were excluded from further analysis. Median length of stay for the entire study was 4.0 days, with significant correlation between milligrams of morphine consumed and time to first flatus (rxa0=xa00.422, pxa0=xa00.005), full diet (rxa0=xa00.522, pxa0<xa00.001), and discharge (rxa0=xa00.437, pxa0=xa00.004). There we no differences between groups in age, body mass index, or operating time. Patients in group A consumed less morphine (33xa0±xa031 mg versus 63xa0±xa041 mg, pxa0=xa00.011), and had less time to first flatus (median 2.0 days versus 3.0 days, pxa0<xa00.001) and full diet (median 2.5 days versus 3.0 days, pxa0=xa00.033). The reduction in length of stay was not significant (mean 3.6 days versus 4.5 days, median 4.0 days versus 4.0 days, pxa0=xa00.142). Pain control was superior in group A. Three patients required readmission for treatment of five anastomotic leaks (4 in group A versus 1 in group B, pxa0=xa00.15). Two of them underwent reoperation.ConclusionsIntravenous ketorolac was efficacious in improving pain control and reducing postoperative ileus when anastomotic leaks were excluded. This simple intervention shows promise in reducing hospital stay, although the outcome was not statistically significant. The high number of leaks is inconsistent with this group’s experience and is of concern.

Needlescopic surgery. A logical evolution from conventional laparoscopic surgery.

Background: The purpose of this study was to analyze the safety and feasibility of needlescopic surgery and to compare the short-term outcomes relative to conventional laparoscopic surgery. Methods: Needlescopic surgery patients were compared to matched cohorts of conventional laparoscopic surgery patients from the same prospective database for a variety of selected procedures. Results: A total of 101 needlescopic procedures were analyzed (30 cholecystectomy, 28 Nissen fundoplication, 12 bilateral sympathectomy, 10 splenectomy, 10 Heller myotomy, three adrenalectomy, two colon resection, two splenic cyst excision, four other). There was no significant difference between the needlescopic and conventional laparoscopic groups in conversion rates, morbidity, or mortality. A higher proportion of patients were in hospital <24 h for needlescopic splenectomies (40% vs 0%, p = 0.087), fundoplications (68% vs 42%, p = 0.107), and myotomies (90% vs 30%, p = 0.022) than for conventional laparoscopic surgery. Operative times were significantly shorter for needlescopic sympathectomy than for laparoscopic sympathectomy and Heller myotomy (p = 0.004 and 0.013, respectively), and they were equivalent for other procedures. Conclusion: Needlescopic surgery can be performed in a variety of procedures with no apparent increase in conversions, operative time, morbidity, or mortality. There is a trend toward reduced hospital stays for certain procedures. Randomized prospective trials comparing needlescopic to conventional laparoscopic surgery are still needed to confirm and/or extend our findings.

Early experience with laparoscopic ileal pouch-anal anastomosis for ulcerative colitis.

The purpose of this study was to describe our minimally invasive technique and outline perioperative and medium-term outcomes in patients undergoing laparoscopic ileal pouch-anal anastomosis (LIPAA) for ulcerative colitis. Data were obtained from a prospectively collected database of 13 LIPPA procedures performed for ulcerative colitis between May 1994 and November 2000. Medium-term quality-of-life follow-up was obtained by telephone interview. Eight males and five females had an LIPAA performed, all of whom had previously undergone total abdominal colectomy with ileostomy. Median operative time was 255 minutes (range, 200–398 minutes) with one conversion (8%) due to adhesions. There were no deaths or intraoperative complications; however, six patients experienced seven postoperative complications within 30 days of final closure of defunctioning ileostomy (two leaks, two wound infections, one pulmonary embolus, and two reoperations for small bowel obstruction). Median length of stay was 7 days (range, 5–13 days). Median follow-up was 24 months (range, 6–66 months). The median number of day and night bowel movements was 6.0 (range, 3–10) and 1.0 (range, 0–3), respectively, with five patients requiring medication to control frequency. None had incontinence of stool or retrograde ejaculation; however, one had occasional incontinence of gas, three had occasional nocturnal soiling, and one was impotent. Three patients (23%) had pouchitis, all treated successfully with oral antibiotics. All patients were satisfied with the outcome of their operation and all preferred their pouch to previous ileostomy. Patients reported their overall social, emotional, and physical well being to be satisfactory to excellent. Results of the SF-36, a generic quality-of-life survey, were similar to those from studies of patients following an open pelvic pouch procedure. The LIPAA is technically feasible in experienced centers. We believe that the technique is still evolving and that more time and experience is required to refine the procedure.

Neoadjuvant therapy and anastomotic leak after tumor-specific mesorectal excision for rectal cancer.

PurposeThis study was designed to evaluate whether neoadjuvant therapy is a risk factor for anastomotic leakage after rectal cancer surgery.MethodsA retrospective review of 220 patients who underwent tumor-specific mesorectal excision for rectal cancer from 2000 to 2005 was performed. Risk factors for leak were identified by using a multivariable regression model.ResultsA total of 54 patients received neoadjuvant chemoradiation therapy and surgery, whereas 166 received surgery alone. No difference in clinically significant leaks was observed between the two groups (5.6 vs. 6.6 percent, Pu2009=u20091). A diverting ileostomy was performed in 26.4 percent of patients who received neoadjuvant therapy compared with 9.7 percent for surgery alone (Pu2009=u20090.0021). Neoadjuvant patients were more likely to have ultralow anastomoses (17.6 vs. 2.5 percent, Pu2009<u20090.0001). On multivariate analysis, smoking (odds ratio, 6.37 (1.8, 22.2), Pu2009=u20090.004), difficult anastomosis (odds ratio, 7.66 (1.8, 31.5), Pu2009=u20090.0048), and low level of anastomosis (≤4xa0cm from the verge; odds ratio, 5.28 (1.05, 26.6), Pu2009=u20090.044) were independently associated with anastomotic leakage.ConclusionsSignificant predictors of anastomotic leak include smoking, difficult anastomosis, and level of anastomosis (≤4xa0cm). Neoadjuvant chemoradiation therapy was not found to be significantly associated with leakage after tumor-specific mesorectal excision for rectal cancer.

Are transverse colon cancers suitable for laparoscopic resection

BackgroundThe large randomized trials reporting on laparoscopic versus open colon surgery for cancer have all excluded patients with transverse colon cancer lesions. This study was undertaken to review our experience with surgery for curable transverse colon cancer.MethodsA database of 938 laparoscopic colon resections performed between April 1991 and September 2004 was reviewed. Of 514 procedures for cancer, stage IV disease, mid to low rectal cancers, and total colectomies were excluded. On an intent-to-treat basis, outcomes of surgery for transverse colon lesions (TC) were compared with outcomes of segmental colon resections for other lesions (OC).ResultsA total of 22 TC were resected compared with 285 OC. Patients with TC were similar to patients with OC in age, gender, weight, and body mass index (BMI). Cancer stage was equivalent between patients with TC (9 Stage I, 7 Stage II, 6 Stage III) and OC (66 Stage I, 126 Stage II, 93 Stage III, pxa0=xa00.170) as was tumor size. Patients with TC underwent 9 transverse colectomies, 12 extended right hemicolectomies, and 1 extended left hemicolectomy. Patients with OC underwent 126 right hemicolectomies, 24 left hemicolectomies, and 135 sigmoid colectomies or anterior resections. There were no differences in conversion rate (18.2% vs. 13.3%, pxa0=xa00.752) or in intraoperative (9% vs. 8%, pxa0=xa00.814) or postoperative (41% vs. 30%, pxa0=xa00.418) complications. Operating time was longer with TC (209xa0±xa063 min vs. 176xa0±xa060 min, pxa0=xa00.042) and lymph node harvest was higher (15.3xa0±xa011.6 vs. 10.8xa0±xa07.6, pxa0=xa00.011). At a median followup of 17.2 months and 17.1 months, respectively, there were two (9%) recurrences after resection of TC and 17 (6%) recurrences after resection of OC.ConclusionsLaparoscopic resection of transverse colon cancers is technically feasible and not associated with a significantly higher rate of complications or conversions or with impaired oncologic outcomes compared with patients having segmental laparoscopic resections for other colon cancers. Operating time is longer.

The myth of informed consent in rectal cancer surgery: what do patients retain?

BACKGROUND: Previous research in colorectal cancer has focused on survival, recurrence, and functional outcomes. Few have assessed the decisional needs of patients or the information patients are retaining from the informed consent process. OBJECTIVES: The aims of this study were to describe the decisional needs of adult patients with rectal cancer when deciding on the surgical treatment of their disease and to identify gaps in patients’ recollection of the informed consent discussion. DESIGN: Face-to-face interviews were conducted with the use of a questionnaire based on the validated Ottawa Decision Support Framework Needs Assessment. SETTING: This study was performed at a university-based academic Cancer Assessment Center, in Ottawa, Ontario, Canada. PATIENTS: Adult patients with rectal cancer treated with low anterior resection or abdominoperineal resection were included. MAIN OUTCOME MEASURES: The primary outcomes measured were patients knowledge and understanding of decision and their decisional needs. RESULTS: Thirty patients were interviewed between November 2009 and July 2010. Eighty percent were male, with a median age of 65. None of the patients perceived having a choice of surgical options. When questioned about the main outcomes of rectal cancer surgery, 47% could not recall a preoperative discussion of risks to bowel function, 47% could not recall a preoperative discussion of risks to sexual function, and 57% could not recall a preoperative discussion of risks to urinary function. Patients would like information regarding functional outcomes, body image, and the immediate postoperative period. A minority of patients desire information regarding cure rate, need for a second surgery, or the ability of surgery to treat their symptoms. Patients would like information that is portable and trusted by their health care team that they can review at their own time. LIMITATIONS: To avoid introducing decisional conflict before surgery, patients were interviewed at the first postoperative visit. Preoperative informed consent discussions were not standardized. CONCLUSION: Despite a comprehensive educational oncology pathway, patients retain little of the informed consent discussion. This study highlights the dichotomy between the outcomes that surgeons and patients value most. The results of this study will guide future efforts to improve informed consent.

Laparoscopic splenectomy does the training of minimally invasive surgical fellows affect outcomes

BackgroundThe training of surgeons and residents in laparoscopic surgery has become an important issue. The purpose of this study is to determine if the training of a laparoscopic fellow affects outcomes in patients undergoing laparoscopic splenectomy (LS).MethodsData were obtained from a prospectively collected database of patients who underwent LS from August 1994 to November 1999. Outcomes of the last 25 cases, performed by fellows under supervision, were compared to 25 cases performed by staff surgeons prior to the introduction of fellows.ResultsPatient demographics, preoperative platelet count, and splenic size were similar for the two groups. Outcome measures comparing the staff and the fellows group including operative time (151 vs 178 min, p=0.055), blood loss (214 vs 162 ml, p=0.40), intraoperative complications (3 vs 2, p=1.0), need for transfusion (2 vs 3, p=1.0), conversions (1 vs 0, p=1.0), length of hospital stay (3.3 vs 2.5 days, p=0.13), and postoperative complications (1 vs 2, p=1.0) were similar for the two groups.ConclusionWhen performed by a fellow under supervision, LS has the same outcomes as when the procedure is performed by the teaching staff surgeon.

Does experience with laparoscopic colorectal surgery influence intraoperative outcomes

BackgroundThis study aimed to define the management and risk factors for intraoperative complications (IOC) and conversion in laparoscopic colorectal surgery, and to assess whether surgeon experience influences intraoperative outcomes.MethodsConsecutive patients undergoing laparoscopic colorectal procedures from 1991 to 2005 were analyzed from a longitudinal prospectively collected database. All patients referred to the four surgeons involved in this study were offered a minimally invasive approach. Patient characteristics, perioperative variables, and surgeon experience data were analyzed and compared.ResultsA total of 991 consecutive laparoscopic colorectal procedures were studied. The majority of operations were performed for malignant disease (nxa0=xa0526, 53%), and most frequently consisted of segmental colonic resections (nxa0=xa0718, 72%). A total of 85 patients (8.6%) had an IOC. Patients experiencing an IOC had a significantly higher median body weight (75 versus 68xa0kg, pxa0=xa00.0047) and had a higher proportion of previous abdominal surgery (31% versus 20%, pxa0=xa00.029). Only 39% of patients suffering an IOC required conversion to open surgery. A total of 126 (13%) cases were converted to open surgery. On multivariable analysis, previous abdominal surgery [odds ratio (OR) 3.40, 95% confidence interval (CI) 1.39–8.35, pxa0=xa00.0076] was independently associated with having an IOC and a conversion to open within the same procedure. With increasing experience, individual surgeons were found to operate on heavier patients (pxa0=xa00.025), and on patients who had a higher rate of previous intra-abdominal surgery (pxa0<xa00.0001). Despite these risk factors, the early and late experience demonstrated no significant difference in terms of IOCs (pxa0=xa00.54) and conversion to open surgery (pxa0=xa00.40).ConclusionsThe majority of IOCs can be managed laparoscopically. With increasing experience surgeons can perform laparoscopic colorectal surgery on a patient population with a greater proportion of previous abdominal surgery and a higher mean body weight without adversely affecting their rates of intraoperative complications or conversion.

Laparoscopic colectomy for complex diverticular disease: a justifiable choice?

BackgroundSurgery is increasingly reserved for complicated diverticulitis. The role of laparoscopy in this context is ill defined. This study aimed to evaluate the safety, feasibility, and outcomes associated with the application of laparoscopy to an unrestricted spectrum of diverticular pathologies, with an emphasis on complicated disease.MethodsConsecutive patients who underwent elective, urgent, or emergent laparoscopic colectomy for diverticular disease from 1991 to 2007 were analyzed from a prospectively collected database. Laparoscopy was offered to all patients presenting for surgical attention, thus minimizing selection bias. Complicated cases had abscesses, perforations, fistulas, or strictures. Uncomplicated cases had chronic or recurrent diverticulitis. Summary statistics and univariate comparisons were generated.ResultsA total of 183 patients were analyzed, including 39 complicated cases. The complicated cohort included 12 abscesses or perforations (31%), 18 fistulas (46%), and 11 strictures (28%). Intraoperative complications were comparable between the two groups (7.7 vs. 9.7%), although the complicated cases resulted in more conversions (23 vs. 4.2%; pxa0=xa00.0007). More than 79% of the complicated patients and 96% of the uncomplicated patients underwent unprotected primary anastomosis. Medical (23 vs. 1.4%; pxa0<xa00.0001) and surgical (28 vs. 14%; pxa0=xa00.035) complications were more frequent in the complicated group. Leak rates were acceptably low (6.5 vs. 2.2%; pxa0=xa00.23). There were no recorded deaths. Finally, the time until discharge from hospital was significantly longer in the complicated group by a median of 1xa0day.ConclusionsThe laparoscopic management of complicated diverticular disease is feasible and appears to be safe in the hands of experts. Despite a high rate of conversion to open surgery, laparoscopy was the sole operative intervention for the majority of patients with complicated diverticular disease. Further studies are needed to allow rigorous comparison with an open control group.

Resident training in minimally invasive surgery: a survey of Canadian department and division chairs

BackgroundThis study aimed to seek the opinions of academic surgical chairs on minimally invasive surgery (MIS) education for general surgery residents and to identify perceived gaps and trends in educational strategies.MethodsA national survey on attitudes toward MIS was sent to the chairs of departments of surgery and divisions of general surgery across the 16 Canadian academic centers. The survey contained 34 questions consisting of Likert scales, single answers, and multiple-choice questions. Nonresponders were contacted directly. At the time of the survey, two department chair positions were vacant.ResultsThe response rate was 87% (26/30). The majority of the centers used early operating room exposure to basic MIS cases (92%) and animal labs (85%). Two-thirds of the institutions used early operating room exposure to advanced MIS cases (69%) and didactic lectures (65%). Half of the academic centers used MIS video (54%) and the laparoscopic virtual reality simulator (54%). The least used method was computer software (19%). The surgical division and department chairs believed the most effective teaching method was early operating room exposure to basic MIS cases (100%), followed by the laparoscopic virtual reality simulator (91%) and animal labs (88%). Computer software was considered 42% useful, and the least useful method was didactic lectures (16%). In the next 5xa0years, 62% of academic centers plan to add laparoscopic virtual reality simulators to their MIS curriculum.ConclusionThe chairs’ opinion on the most effective MIS teaching method for residents is basic MIS cases followed by laparoscopic virtual reality simulators. The majority of academic institutions plan to add laparoscopic virtual reality simulators to the curriculum in the next 5xa0years.