Hernán Vaccarezza

Laparoscopic colorectal resections: a simple predictor model and a stratification risk for conversion to open surgery.

BACKGROUND: The advantages associated with the laparoscopic approach are lost when conversion is required. Available predictive models have failed to show external validation. Body surface area is a recently described risk factor not included in these models. OBJECTIVE: The aim of this study was to develop a clinical rule including body surface area for predicting conversion in patients undergoing elective laparoscopic colorectal surgery. DESIGN: This was a prospective cohort study. SETTING: This study was conducted at a single large tertiary care institution. PATIENTS: Nine hundred sixteen patients (mean age, 63.9; range, 14–91 years; 53.2% female) who underwent surgery between January 2004 and August 2011 were identified from a prospective database. MAIN OUTCOME MEASURES: Conversion rate was analyzed related to age, sex, obesity, disease location (colon vs rectum), type of disease (neoplastic vs nonneoplastic), history of previous surgery, and body surface area. A predictive model for conversion was developed with the use of logistic regression to identify independently associated variables, and a simple clinical prediction rule was derived. Internal validation of the model was performed by using bootstrapping. RESULTS: The conversion rate was 9.9% (91/916). Rectal disease, large patient size, and male sex were independently associated with higher odds of conversion (OR, 2.28 95%CI, 1.47–3.46]), 1.88 [1.1–3.44], and 1.87 [1.04–3.24]). The prediction rule identified 3 risk groups: low risk (women and nonlarge males), average risk (large males with colon disease), and high risk (large males with rectal disease). Conversion rates among these groups were 5.7%, 11.3%, and 27.8% (p < 0.001). Compared with the low-risk group, ORs for average- and high-risk groups were 2.17 (1.30–3.62, p = 0.004) and 6.38 (3.57–11.4, p < 0.0001). LIMITATIONS: The study was limited by the lack of external validation. CONCLUSION: This predictive model, including body surface area, stratifies patients with different conversion risks and may help to inform patients, to select cases in the early learning curve, and to evaluate the standard of care. However, this prediction rule needs to be externally validated in other samples (see Video, Supplemental Digital Content 1, http://links.lww.com/DCR/A137).

Body surface area: a new predictor factor for conversion and prolonged operative time in laparoscopic colorectal surgery.

BACKGROUND: Body surface area is a measurement of body size used in clinical settings. Its impact on laparoscopic colorectal surgery has not been previously studied. OBJECTIVE: The aim of this study was to assess the impact of body surface area on the conversion rate and laparoscopic operative time. DESIGN: This study was conducted as a retrospective analysis of prospectively collected data SETTING: This study was conducted at a single tertiary care institution. PATIENTS: Nine hundred sixteen consecutive patients operated on between January 2004 and August 2011 were identified from a prospective database. MAIN OUTCOME MEASURES: Conversion rate and laparoscopic operative time were analyzed related to age, sex, obesity, disease location (colon vs rectum), type of disease (neoplastic vs nonneoplastic), history of previous surgery, and body surface area; body surface area was calculated by the Mosteller formula. Body surface area was analyzed by the use of median and quartile cutoff values (1.6, 1.8, and 2.0). Multivariate models were adjusted for different confounders. Interaction between body surface area and BMI was ruled out. RESULTS: The conversion rate was 10%. Conversion rates for quartiles 1, 2, 3, and 4 were 4.4%, 8.3%, 12.7%, and 14.8%, p = 0.001. Patients with body surface area≥1.8 had a higher conversion rate than those with body surface area <1.8 (13.9% vs 5.3%, OR: 2.35 (95% CI: 1.45–3.86; p = 0.0001)). Multivariate analysis showed that body surface area ≥1.8 was associated with conversion (OR: 2, 95% CI: 1.1–3.7, p = 0.02) and a longer operative time after adjusting for sex, age, obesity, disease location (rectum vs colon), and type of laparoscopic approach. LIMITATION: This was a single-institution retrospective study. CONCLUSION: Body surface area is a predictor for conversion and longer laparoscopic operative time. It should be considered when informing patients, selecting cases in the early learning curve, and assessing standard of care.

Iliopsoas abscess: presentation, management, and outcomes.

Background: Iliopsoas abscess remains a rare condition. Together with a decreasing incidence of tuberculosis infection, pyogenic iliopsoas abscess (PIPA) has become relatively more frequent and represents more than half of iliopsoas abscesses. Objective: To analyze presentation, treatment, and outcomes in a series of patients with diagnosis of PIPA. Design: Retrospective. Settings: A single tertiary care institution. Patients: A series of 34 consecutive patients with diagnosis of PIPA treated between 2001 and 2010 at the Hospital Italiano de Buenos Aires. Main Outcome Measures: Analyzed variables were: age, sex, diagnostic modality, clinical presentation, and treatment outcomes. Results: Primary and secondary abscess occurred in 20.6% and 79.4%, respectively. The leading cause of PIPA was spondylodiscitis (38%) and computed tomography was the preferred diagnostic modality (87%). Most common presentation was left unilateral abscess in 66% of patients and most frequent isolated bacteria were Staphylococcus aureus. Fifteen patients (44%) received antibiotics as initial treatment with an initial failure rate of 80%; 11 of 15 patients required a second treatment. Sixteen patients (47%) underwent percutaneous drainage (PD) as first line treatment with a success rate of 50%. However, success rate of PD, increased to 100% after 2 drainages. Three patients were surgically drained without success (0 of 3 patients). Compared with the rest of the population, PD showed a lower hospital stay (25 vs. 14 d, respectively, P=0.08) whereas surgery had a higher mortality rate (8% vs. 22%, respectively, P=0.03). Limitations: A single institutional retrospective study. Conclusions: Our series showed a higher proportion of unilateral and secondary abscess. Spondylodiscitis was the first cause of PIPA. PD seems to be the best treatment option for PIPA and compared with surgery it is associated with a higher success rate and lower hospital stay and mortality rate.

Two-day hospital stay after laparoscopic colorectal surgery, is enhanced recovery program a healthcare system specific issue? Reply.

We greatly appreciate the opportunity to reply to the letter from Wang et al. asking whether an enhanced recovery after surgery (ERAS) program is a healthcare systemspecific issue. According to the comparison they made with our patients and Asian customs in terms of postoperative recovery, we consider that there are a few points to discuss. First, we certainly agree with Wang et al. that our findings in terms of morbidity and readmission rates were within our ERAS group. We also agree that our findings may not be the same as in other countries. In fact, they may even be different for the other institutions of our country. Secondly, as it has been previously reported, length of stay (LOS) is an indicator of healthcare efficiency and may be useful in assessing healthcare quality [1, 2], while laparoscopy has shown to impact favorably on this postoperative outcome [3]. However, Wang et al. not only did not find any significant difference in terms of LOS between patients operated on by laparoscopy versus open surgery under a fast track program, but also their overall LOS was around 13 days. This seems to show that in West China Hospital, patients are generally admitted several days before surgery. These two findings reflect the likelihood that the compliance with the various components of ERAS in their institution was not so high, as expected. Moreover, the delay in discharging the patient from the hospital until stitch removal conspires against the essence of ERAS. In fact, if we should wait for stitch removal in all our surgical patients, our institution would collapse (logistically and economically speaking). On the other hand, it seems that there are at least two key factors that suggest higher chances of success with ERAS. Firstly, the greater the adherence to the guidelines, the better the outcome. Two, we must know what we are doing. This means that we need to audit the whole process. Very frequently, the amount of single ‘‘therapeutic measures’’ (removal of tubes and drains, opioid-free analgesia, minimally invasive approach, etc.,) is overestimated. In other words, it is very common to believe that ‘‘we are doing ERAS’’ but that is not really the truth. With reference to this, a group from Canada recently reported that the main barriers to the implementation of an ERAS program include the need for patient education, the optimization of communication, and, finally, better evidence for ERAS interventions [4]. Another important aspect of perioperative care is related to cost. It has also been reported that with decreasing hospital resources and increasing medical costs, a safe reduction in postoperative hospital stays has become a major concern to optimize utilization of healthcare resources including the availability of beds [5]. Because of that, despite every medical institution (public health or private) has different economic needs, effort should also be focused on a rational use of economic resources. There is no doubt that each country has its own idiosyncrasies that will surely influence postoperative care. However, whenever any surgical group intends to implement an ERAS program, these issues need to be addressed. Returning to the initial question posed by the G. Rossi (&) H. Vaccarezza Section of Colorectal Surgery, Department of Surgery, Hospital Italiano de Buenos Aires, Buenos Aires, Argentina e-mail: gustavo.rossi@hospitalitaliano.org.ar

Hand-assisted laparoscopic colorectal surgery with double-glove technique

The hand‐assisted laparoscopic colorectal surgery (HALS) preserves the advantages of the minimally‐invasive approach. However, its application has faced resistance due to the need of hand port devices and its increased costs. The aim of the present study was to assess the feasibility of an original technique using a double glove to keep pneumoperitoneum.