Vriti Advani

Does resident involvement effect surgical times and complication rates during laparoscopic appendectomy for uncomplicated appendicitis? An analysis of 16,849 cases from the ACS-NSQIP

BACKGROUND Controversy exists regarding whether resident involvement during surgery impacts patient outcomes. We compared surgical times and perioperative complications of patients undergoing laparoscopic appendectomy with and without residents. METHODS Patients undergoing laparoscopic appendectomy for uncomplicated acute appendicitis during 2005 to 2008 were identified from the American College of Surgeons National Surgical Quality Improvement Program database. RESULTS During the study period, 16,849 patients underwent laparoscopic appendectomy for uncomplicated appendicitis (residents participated in 68% of procedures). There were no statistical and/or clinically meaningful differences between median age, sex, body mass index, American Society of Anesthesiology score, and morbidity probability between the 2 groups, suggesting that case mix was not a significant confounder. Patients undergoing laparoscopic appendectomy with residents compared with patients undergoing laparoscopic appendectomy without residents had a higher incidence of serious and overall morbidity and longer surgical times. However, surgical times and complications were similar between residents in postgraduate years 1 to 5. CONCLUSIONS Regardless of the postgraduate year level, resident involvement resulted in a clinically appreciable increase in surgical times and a statistically significant increase in certain complications.

Single incision laparoscopic colon surgery. Is the ride worth the curve

Single incision laparoscopic (SIL) colectomy is currently regarded as the next major advance in the progress of minimally invasive techniques in colorectal surgery. It is also viewed as a step forward in the development of NOTES (natural orifice transluminal endoscopic surgery) and surgery without scars. The primary advantage of SILS (single incision laparoscopic surgery) over conventional laparoscopy is considered to be cosmesis, as well as the potential for decreased incisional pain and complications as a result of fewer incisions. By now all major colorectal resections including segmental colonic resections, ileo-anal pouches and rectal dissections for benign and malignant disease have been performed using this technique. The experience from the literature with SIL colectomy suggests that this is a safe and viable approach and, in the case of malignancy, allows for adequate oncologic resection. However, the published reports are limited by follow-up beyond hospital discharge and lack of long-term clinical and oncologic outcome. Using the keywords ‘single incision colectomy’, ‘single incision laparoscopic surgery’, ‘right’, ‘sigmoid’, ‘left’ and ‘hemicolectomy’ in PubMed, we identified seven reports with 19 patients who underwent a SIL right hemicolectomy and seven with 10 patients who had undergone left sided resection (including three patients who had an extended colonic resection), using a variety of techniques and devices. Among the reported cases reviewed, all but three patients had no reported follow-up beyond hospital discharge (two patients were followed for 1 month and one patient for 1 year). Another observation notable from the published experience is the case selection. A key factor in the ease or difficulty of laparoscopic surgery is the body habitus of the patient, in particular the pattern of obesity. The highest BMI reported was 35 kg ⁄ m in a patient undergoing a SIL right colectomy; however, in all the other reports in which the BMI was mentioned, the mean BMI was less than 25 kg ⁄ m. While laparoscopic colorectal surgery has been shown to be feasible in obese individuals, it certainly adds to the challenge of the procedure, as most would agree. Experience with SIL colectomy also suggests that the skill required for SILS is different from conventional laparoscopy. In particular, traction and counter-traction achieved by instrument triangulation in conventional laparoscopy (and open surgery) is not possible in SILS. This therefore requires the surgeon to learn to use instruments without triangulation and to perform hand manoeuvres that are not usually recommended in conventional laparoscopy. Thus SIL colectomy is not necessarily a technical progression of current laparoscopic techniques but is rather a modification or an adaptation of another approach, the merits of which are unknown at this time. As a result of a consumer-driven health market, an increasing number of patients will seek to have this type of surgery based on hype and publicity and not necessarily scientific evidence. This situation is likely to be further compounded by commercial manufacturers with an obvious conflict of interest. Proponents of SILS are likely to draw parallels between SIL colectomy and laparoscopic cholecystectomy and may argue that SILS will be judged in a similar manner as was laparoscopic cholecystectomy when it was introduced in the early 1990s. It is important, however, to remember that many bile ducts were injured and difficult lessons were also learnt about adopting a new technology from the laparoscopic cholecystectomy experience. Conventional laparoscopic approaches for colorectal surgery, despite being around for almost two decades and now known to have scientifically proven patient benefits, still have not become the standard of care but instead are considered an acceptable alternative. The major factors contributing to this include the question of oncologic adequacy and the steep learning curve to achieve proficiency in advanced minimally invasive techniques. While the issues regarding oncologic equivalence have been appropriately addressed, the widespread dissemination of complex laparoscopic skills has been challenging. As a result, less than twenty per cent of colorectal resections are being performed by minimally invasive approaches in the United States and the United Kingdom. Undoubtedly, SIL colectomy represents an important advance in the evolution of minimally invasive surgery. It has the potential to contribute towards improved patient outcomes and therefore deserves the surgical community’s consideration and attention. But it is also essential that its application and implementation should be judicious and well thought-out. If SIL colectomy is to be the next step in the march of minimally invasive techniques, it would make sense to achieve the necessary precursor of the widespread application of conventional minimally invasive colorectal surgery. It is also imperative that before we again embark on another long and arduous learning curve, patient

Knowledge and Attitudes Regarding Colorectal Cancer Screening Among Medical Students: A Tale of Two Schools

Colorectal cancer (CRC) screening has been shown to decrease the incidence of CRC cancers and decrease mortality. Studies show that the most important predictor of patient compliance with CRC screening is physician recommendation. We assessed the knowledge and attitudes of medical students regarding cancer screening. A study-specific questionnaire was distributed to medical students (MS) at two medical schools. There was a significant difference in the percentage of correctly answered questions regarding screening recommendations between first year MS and all other years for both schools. However, MS attitudes towards CRC screening were consistent between classes and schools. Although most MS had positive attitudes regarding cancer screening our survey identified several important deficits in knowledge.

Single Incision Laparoscopic Right Hemicolectomy for Colon Cancer Less Is More

Single incision laparoscopic colectomy has been reported to be safe and feasible using several techniques and devices. The authors’ report their experience with a single incision laparoscopic colectomy performed in a lateral to medical fashion using a commercially developed access device with standard laparoscopic instruments.

Meta-analysis of Survival of Patients with Stage 4 Colorectal Cancer Managed with Resection versus Chemotherapy Alone: Letter to the Editor

In their article Stillwell et al. conclude that, to avoid tumorrelated complications, asymptomatic patients presenting with metastatic colorectal cancer should undergo resection of the primary tumor [1]. While this observation may once have been correct, we believe that recent advances in medical oncology warrant re-examination of this assertion. In the last decade five new chemotherapeutic agents (irinotecan, capecitabine, oxaliplatin, bevacizumab, and cetuximab) have been approved, and a number of effective regimens have been developed, broadening the armamentarium against metastatic colorectal cancer. Clinical trials have demonstrated an increase in median survival in patients with metastatic colorectal cancer from 6–8 months with supportive care alone to more than 20 months with the use of combination chemotherapy [2]. As a result, the view of metastatic colorectal cancer has changed from an acute condition and a certain death sentence to, potentially, a chronic condition, that patients live with but do not die from [2]. Furthermore, complications from an asymptomatic primary tumor being left in situ in a patient with unresectable synchronous metastatic disease receiving newer chemotherapy agents may not be of such concern as suggested in a recent article by Poultsides et al. [3]. In their experience, they managed 233 consecutive patients with synchronous metastatic colorectal cancer and an unresected primary tumor with up-front modern chemotherapy (oxaliplatinor irinotecan-based, triple-drug chemotherapy) between 2000 and 2006. They observed that 213 (89%) patients never required any direct symptomatic management for the intact primary tumor, and the median overall survival for the entire patient cohort was 18 months from the initiation of systemic chemotherapy. The fundamental issue is that comparisons of treatment strategies in the literature have been retrospective and uncontrolled, and they are thus subject to a significant selection bias. Therefore any evaluation is akin to comparing apples and oranges, and to paraphrase a renowned North American surgeon, this makes for an unappetizing fruit salad. Compelling arguments for both approaches can be made, but in the end they are just that ... arguments and not scientific evidence. The Halstedian principles for managing breast cancer were also convincing until welldesigned controlled trials like the National Surgical Adjuvant Breast and Bowel Project (NSABP) B-04 proved otherwise [4]. The meta-analysis of Stillwell et al. unfortunately raises more questions than it answers, foremost of which is whether the time has come for a randomized trial to determine the optimal treatment strategy for patients with asymptomatic metastatic colorectal cancer in the twentyfirst century. With an estimated 148,000 new cases of colorectal cancer diagnosed in the United States alone each year, and with nearly one-fourth of patients having metastatic disease at diagnosis [5], the numbers certainly suggest so.