Koiana Trencheva

Long-term outcomes of patients undergoing curative laparoscopic surgery for mid and low rectal cancer.

PURPOSE: The use of laparoscopy surgery in the management of rectal cancer is controversial, especially in the mid and low rectum. The aim of this study was to determine oncologic and long-term outcomes after laparoscopic and hand-assisted laparoscopic surgery for mid and low rectal cancer. METHODS: Between January 1999 and December 2006, 185 patients had surgery for rectal cancer; 103 these patients had mid and low rectal cancer. The source of data was inpatient/outpatient medical records. Telephone interviews were conducted for all patients. Actuarial survival was calculated with use of the Kaplan-Meier method. RESULTS: Hand-assisted laparoscopic surgery was performed in 58 (56.3%) patients, and pure laparoscopic surgery in 45 (43.7%) patients. Mean follow-up time was 42.1 months. The conversion rate was 2.9%. All specimen margins were negative. The anastomotic leak rate was 7.8% (n = 8). There was no 30-day mortality. Local recurrence rate was 5% at five years. Overall survival was 91% and disease-free survival was 73.1% at five years. CONCLUSION: Laparoscopic surgical techniques for mid and low rectal cancer seem safe and feasible with acceptable oncologic and long-term outcomes. Further studies, comparing laparoscopic and open methods, are warranted.

Evaluation of the Safety, Efficacy, and Versatility of a New Surgical Energy Device (THUNDERBEAT) in Comparison with Harmonic ACE, LigaSure V, and EnSeal Devices in a Porcine Model

BACKGROUND THUNDERBEAT™ (TB) (Olympus, Japan) simultaneously delivers ultrasonically generated frictional heat energy and electrically generated bipolar energy. The aim of this study was to evaluate the versatility, bursting pressure, thermal spread, and dissection time of the TB compared with commercially available devices: Harmonic(®) ACE (HA) (Ethicon Endo-Surgery, USA), LigaSure™ V (LIG) (Covidien, USA), and EnSeal(®) (Ethicon). METHODS An acute study was done with 10 female Yorkshire pigs (weighing 30-35 kg). Samples 2 cm long of small (2-3 mm)-, medium (4-5 mm)-, and large (6-7 mm)-diameter vessels were created. One end of the sample was sent for histological evaluation, and the other was used for burst pressure testing in a blinded fashion. Versatility was defined as the performance of the surgical instrument based on the following five variables, using a score from 1 to 5 (1=worst, 5=best), adjusted by coefficient of variable importance with weighted distribution: hemostasis, 0.275; histologic sealing, 0.275; cutting, 0.2; dissection, 0.15; and tissue manipulation, 0.1. There were 80 trials per vessel group and 60 trials per instrument group, giving a total of 240 samples. RESULTS Versatility score was higher (P<.01) and dissection time was shorter (P<.01) using TB compared with the other three devices. Bursting pressure was similar among TB and the other three instruments. Thermal spread at surgery was similar between TB and HA (P=.4167), TB and EnSeal (P=.6817), and TB and LIG (P=.8254). Difference in thermal spread was noted between EnSeal and HA (P=.0087) and HA and LIG (P=.0167). CONCLUSION TB has a higher versatility compared with the other instruments tested with faster dissection speed, similar bursting pressure, and acceptable thermal spread. This new energy device is an appealing, safe alternative for cutting, coagulation, and tissue dissection during surgery and should decrease time and increase versatility during surgical procedures.

Differing risk factors for incisional and organ/space surgical site infections following abdominal colorectal surgery

OBJECTIVE: Surgical site infections are a major source of morbidity after colorectal surgery. The aim of this study was to explore differences between incisional and organ/space surgical site infection types by evaluating risk factors, National Nosocomial Risk Index Scores, and clinical outcomes. DESIGN: A random sample of adults undergoing abdominal colorectal surgery between June 2001 and July 2008 was extracted from a colorectal surgery practice database. Patient factors, comorbidities, intraoperative factors, postoperative factors, and infection were collected; risk score (from −1 to 3 points) was calculated. Variables associated with surgical site infection by univariate analysis were incorporated in a multivariable model to identify risk factors by infection type. Infection risk by risk score was evaluated by logistic regression. Length of stay, readmission, and mortality were examined by infection type. RESULTS: Six hundred fifty subjects were identified: 312 were male, age was 59.8 (SD 17.8) years. Common preoperative diagnoses included colorectal cancer (36.9%) and inflammatory bowel disease (21.7%). Forty-five cases were emergencies, and 171 included rectal resections. Eighty-two patients developed incisional and 64 developed organ/space surgical site infections. Body mass index was associated with incisional infection (OR 1.05, 95% CI 1.00–1.09), whereas previous radiation (OR 4.49, 95% CI 1.53–13.18), postoperative hyperglycemia (OR 2.99, 95% CI 1.41–6.34), preoperative [albumin] (OR 0.52, 95% CI 0.36–0.76), and case length (OR 1.26, 95% CI 1.08–1.47) were associated with organ/space infection. A risk score of 2 and above, compared with a score of <2, predicted organ/space (OR 5.92, 95% CI 3.16–11.09) but not incisional infection (OR 0.95, 95% CI 0.41–2.16). Organ/space infections were associated with longer length of stay (P = .006) and higher readmission rates (P < .001) than incisional infections. CONCLUSIONS: Risk factors for surgical site infections differ by type of infection. Clinical outcomes and value of the risk index score are different by infection type. It may be prudent to consider incisional and organ/space surgical site infections as different entities for patients undergoing colorectal surgery.

Antibiotic Regimen and the Timing of Prophylaxis Are Important for Reducing Surgical Site Infection after Elective Abdominal Colorectal Surgery

BACKGROUND Surgical site infections (SSIs) cause morbidity after elective colorectal surgery, and antibiotic prophylaxis can decrease SSIs. The aim of this study was to determine compliance with an antibiotic administration protocol, including regimen, initial dose timing, and re-dosing, and determine the risk of SSI associated with each. We hypothesized that appropriate antibiotic administration reduces the risk of SSI. METHODS Retrospective review from a prospective database of a random sample of patients undergoing elective abdominal colorectal procedures with anastomosis. Antibiotic regimens, initial dose timing (IDT), and re-dosing were evaluated. Appropriate regimens covered gram-positive cocci, gram-negative bacilli, and anaerobes. The IDT was considered proper if completed within 30 min prior to incision; re-dosing parameters were determined pharmacokinetically for each agent. The main outcome was SSI. Sequential logistic models were generated: Model 1 assessed antibiotic administration factors, whereas Model 2 controlled for patient and clinical factors, including disease process, patient characteristics, intra-operative factors, and post-operative factors. RESULTS Six hundred five patients (mean age 59.7 [standard deviation 17.8] years, 42.8% male) were included. The most common diagnoses were cancer (38.8%) and inflammatory bowel disease (22.0%). Seventy-six patients (12.6%) had superficial or deep incisional SSI, and 54 (8.9%) had organ/space SSI. Regimens included cefazolin + metronidazole for 219 patients (36.2%), cefoxitin for 214 (35.4%), and levofloxacin + metronidazole for 48 (7.9%). One hundred fourteen patients (18.8%) received other/nonstandard regimens, and ten had no documented antibiotic prophylaxis. Fifty-five patients (9.1%) received insufficient coverage, whereas 361 patients (59.7%) had proper IDT, and 401 regimens (66.3%) were re-dosed properly. In Model 1, the use of other/nonstandard regimens (odds ratio [OR] 2.069; 95% confidence interval [CI] 1.078-1.868) and early administration of the initial prophylaxis dose (OR 1.725; 95% CI 1.147-2.596) were associated with greater odds of SSI. After adding clinical factors in Model 2, both of these factors remained significant (OR 2.505; 95% CI 1.066-5.886 and OR 1.733; 95% CI 1.017-2.954, respectively). CONCLUSIONS Appropriate antibiotic selection and timing of administration for prophylaxis are crucial to reduce the likelihood of SSI after elective colorectal surgery with intestinal anastomosis.

Longterm Complications of Hand-Assisted Versus Laparoscopic Colectomy

BACKGROUND Hand-assisted laparoscopic surgery (HALS) requires a larger incision compared with standard laparoscopic surgery (SLS). Whether this leads to more longterm complications, such as incisional hernia (IH) and small bowel obstruction (SBO), has not been studied to date. This study compares the rates of SBO and IH after HALS and SLS in patients undergoing operations for colon and rectal diseases. STUDY DESIGN From a colorectal database, 536 consecutive patients were identified who underwent bowel resection using HALS (n = 266) and SLS (n = 270) between 2001 to 2006. All medical records were reviewed, and all subjects were contacted by telephone for accurate followup. Statistical analysis was performed using chi-square, Fishers exact, and Mann-Whitney U tests, where appropriate. RESULTS Median followup was 27 months (range 1 to 72 months). Overall conversion rate was 2.2% (SLS, n = 4; HALS, n = 8). Median incision size in HALS (75 mm; range 60 to 140 mm) was larger than SLS (45 mm; range 30 to 130 mm; p < 0.01). Despite the larger wound, the incidence of IH was similar between both approaches (HALS, n = 16 [6.0%] versus SLS, n = 13 [4.8%]; p < 0.54). Rate of SBO was also comparable (HALS, n = 11 [4.1%] versus SLS, n = 20 [7.4%]; p = 0.11). Wound infections occurred similarly between both groups (HALS, n = 18 [6.8%]; SLS, n = 13 [4.8%]; p = 0.33). Converted patients had a higher rate of IH compared with nonconverted ones (25% versus 5%; p = 0.02), although the rate of SBO was similar (8.3% versus 5.7%; p = 0.51). CONCLUSIONS HALS does not lead to more longterm complications of IH and SBO when compared with SLS for resections of the colon and rectum.

Treatment for right colon polyps not removable using standard colonoscopy: combined laparoscopic-colonoscopic approach.

BACKGROUND: For complex right colon polyps, not removable using colonoscopy, right colon resection is considered the optimal treatment. Combined endoscopic-laparoscopic surgery, using both laparoscopy and CO2 colonoscopy, has been introduced as a new approach for these complex colon polyps with intent to avoid bowel resection. OBJECTIVE: This study aimed to evaluate the safety and outcomes of combined endoscopic-laparoscopic surgery used for treatment of complex right colon polyps. DESIGN: This is a retrospective study of patients undergoing combined endoscopic-laparoscopic surgery for treatment of benign right colon polyps from 2003 to 2008. SETTINGS: This is a single-institution study. PATIENTS: Twenty-three patients with complex right colon polyps were included. MAIN OUTCOME MEASURES: The main outcome measures included the length of hospital stay, postoperative complications, and polyp recurrence. RESULTS: Of 23 patients, 20 (87%) patients had their polyp removed successfully by combined endoscopic-laparoscopic surgery and 3 (13%) needed laparoscopic resection, after laparoendoscopic evaluation. The median length of hospital stay was 2 days (range, 1–5), and there were no postoperative complications. Median follow-up time was 12 months. Three patients had recurrent polyps, and the recurrence-free interval at 36 months was 55.7% (95% CI = 8.6%, 87.0%). All recurrences were benign polyps and were removed by colonoscopic snaring. CONCLUSIONS: Combined endoscopic-laparoscopic surgery can be safely offered to selected patients with benign right colon polyps that can not be removed by colonoscopy. This combined approach may provide a viable alternative to right colon resection for complex benign colon lesions and warrants future investigation.

Improving Access to Care: Breast Surgeons, the Gatekeepers to Breast Reconstruction

BACKGROUND Fewer than half of patients undergo reconstruction after breast cancer treatment, despite its quality of life benefits. Earlier studies demonstrated that most general surgeons do not discuss reconstructive options with patients. The aim of this study was to examine the likelihood of reconstruction within a cohort of mastectomy patients and compare rates of reconstruction between those referred and not referred for plastic surgery evaluation. STUDY DESIGN Retrospective review of the records of 471 consecutive patients between the ages of 19 and 94 years who underwent mastectomy between 2003 and 2007. Variables evaluated were age, body mass index, diabetes, laterality (unilateral vs bilateral), TNM staging, history of radiation, smoking history, insurance type, and race. RESULTS Of 471 patients, 313 were referred for consultation with a plastic surgeon and 158 were not; 91.7% of those referred were reconstructed and 100% of those not referred were not reconstructed. The 2 groups differed considerably in terms of age (mean age 61.84 years in the nonreferred group vs 51.83 years in the referred group), body mass index (25.9 in referred group, 27 in nonreferred group), diabetes (15% in nonreferred group vs 3.5% in referred group), and laterality (14% of nonreferred group underwent bilateral mastectomies vs 26% of those referred). The groups did not differ significantly in terms of race or tobacco use. Those with private insurance were more likely to be reconstructed, but no independent effect of insurance type was seen on multivariate analysis. CONCLUSIONS The breast surgeons decision to refer a patient for reconstruction significantly affects whether the patient will receive breast reconstruction. Factors that appear to influence the referral decision are age, diabetes, body mass index, and laterality of mastectomy (bilateral more than unilateral).

Dynamic article: long-term outcomes of patients undergoing combined endolaparoscopic surgery for benign colon polyps.

BACKGROUND: Patients with large benign colon polyps not amenable to endoscopic removal commonly undergo resections. Polyp removal using combined endolaparoscopic surgery may be an effective alternative to bowel resection in select patients. OBJECTIVE: The aim of this study was to evaluate short-term and long-term outcomes of patients who underwent endolaparoscopy at our institution. DATA SOURCES: Medical records and a prospectively maintained database were reviewed. STUDY SELECTION: This study constituted a retrospective review of consecutive patients who underwent endolaparoscopy for benign polyps from 2003 to 2012. INTERVENTIONS: Combined endolaparoscopic surgery was performed. MAIN OUTCOME MEASURES: The primary outcomes measured were success rate, rate of recurrence, rate of malignancy, length of stay, and complication rate. RESULTS: A total of 75 patients were taken to the operating room with the intention of endolaparoscopy. The most common indications were large polyp size and difficult location. Based on intraoperative findings, 10 patients were suspected of having cancer and underwent immediate laparoscopic colectomy. Of 65 attempted cases, 48 patients (74%) underwent successful combined endolaparoscopic surgery. Median follow-up time was 65 (8–87) months. Patients in whom combined endolaparoscopic surgery was unsuccessful were converted to colectomy (2 open, 15 laparoscopic). Two patients were converted because of concerns of cancer and 15 because of technical difficulties. Median operative time for successful endolaparoscopy was 145 (50–249) minutes. The complication rate was 4.4% (2/48). Median length of stay was 1 (0–6) day for endolaparoscopy vs 5 (3–19) days for those converted to colectomy. Median polyp size was 3 (1.0–7.0) cm. One patient was found to have cancer on final pathology, but refused to have further surgery. Sensitivity and specificity of predicting malignancy based on clinical findings were 33% (4/12) and 98.5% (64/65). Four of 5 patients who had recurrence (10%) after endolaparoscopy had complete endoscopic polypectomy. One patient required delayed laparoscopic colectomy for a second recurrence. LIMITATIONS: This study was limited by its retrospective nature. CONCLUSIONS: Combined endolaparoscopic surgery appears to be a safe and effective alternative to colectomy in all parts of the colon in patients who have benign polyps not removable with colonoscopy alone.

Laparoscopic resection of t4 colon cancers: is it feasible?

BACKGROUND: Laparoscopic surgical treatment of T4 cancers remains a concern that is mostly associated with technical feasibility, high conversion rate, inadequate oncologic clearance, and surgical outcome. OBJECTIVE: The purpose of this work was to evaluate the short- and long-term clinical and oncologic outcomes after laparoscopic and open surgeries for T4 colon cancers. DESIGN: This was a retrospective study of patients with T4 colon cancer without metastasis (M0) who had laparoscopic or open surgery from 2003 to 2011. SETTING: The study was conducted at a single institution. PATIENTS: A total of 83 patients with pT4 colon cancer were included. MAIN OUTCOME MEASURES: R0 resection rate, morbidity and mortality within 30 postoperative days, overall survival, and disease-free survival were measured. RESULTS: Laparoscopic surgery was performed on 61 and open surgery on 22 patients. The groups were similar in overall staging (p = 0.461), with 35 (42%) of the patients at stage 2 and 48 (58%) at stage 3. A complete R0 resection was achieved in 61 (100%) of the patients who underwent laparoscopic surgery and in 21 (96%) of the patients who underwent open surgery (p = 0.265). The average number of lymph nodes harvested was 21 in the laparoscopic group and 24 in the open group (p = 0.202). Thirty-day morbidity rate was similar between the groups (p = 0.467), and the mortality rate was 0. The length of hospital and postsurgical stay was significantly shorter in the laparoscopic group (p = 0.002 and p = 0.008). The 3-year overall survival rates between the groups were 82% (range, 71%–93%) for patients who underwent laparoscopic surgery and 81% (range, 61%–100%) for those who underwent open surgery (p = 0.525), and disease-free survival was 67% (range, 54%–79%) for laparoscopic surgery and 64% (range, 43%–86%) for open surgery (p = 0.848). The follow-up time was 40 ± 25 in months in the laparoscopic group and 34 ± 26 months in the open surgery group (p = 0.325). LIMITATIONS: This was a retrospective study at a single institution. CONCLUSIONS: The study shows that laparoscopic surgery is feasible in T4 colon cancers. With comparable clinical and oncologic outcomes, this study suggests that laparoscopy may be considered as an alternative approach for T4 colon cancers with the advantage of faster recovery (see Video, Supplemental Digital Content 1, http://links.lww.com/DCR/A156).

Surgical adhesive increases burst pressure and seals leaks in stapled gastrojejunostomy

BACKGROUND Leakage from a gastrointestinal anastomosis in bariatric surgery is a catastrophic complication and is the second-most preventable cause of death after Roux-en-Y gastric bypass. Several adjuncts for staple line reinforcement have been investigated to reduce the incidence of this complication. The purpose of our study was to determine whether a commercially available tissue sealant (BioGlue) could reinforce a stapled gastrojejunal anastomosis and whether it could seal an artificially created anastomotic leak. METHODS Circular-stapled gastrojejunostomies were performed on freshly explanted porcine stomach and intestine. Experiment 1 consisted of 10 control nonreinforced gastrojejunostomies and 10 gastrojejunostomies reinforced with BioGlue. The staple lines were submerged in saline and exposed to increased pressure using constant-rate infusion of air. The burst pressures were recorded at the point of visible leakage from the anastomosis. In experiment 2, a small defect was created in 10 gastrojejunostomies. The burst pressures were recorded before and after application of BioGlue to the anastomosis. The data were analyzed using the 2-tailed paired t test. RESULTS In experiment 1, the burst pressure was significantly increased in the reinforced gastrojejunostomies, from 27.4 ± 8.4 mm Hg to 59.1 ± 19.2 mm Hg (P <.001). In experiment 2, the defective gastrojejunostomies had an average burst pressure of 1.2 ± 0.8 mm Hg. After application of BioGlue, the burst pressure increased to 42.8 ± 15.9 mm Hg (P <.001). CONCLUSION These ex vivo findings suggest that the surgical adhesive BioGlue can reinforce both intact and defective stapled gastrojejunal anastomoses. Additional in vivo study is warranted to determine whether BioGlue can prevent or help seal gastrojejunal leaks.