A laparoscopic approach reduces short‐term complications and length of stay following ileocolic resection in Crohn’s disease: an analysis of outcomes from the NSQIP database

Aim Studies to date examining the impact of laparoscopy in resection for Crohn's disease on short‐term morbidity have been limited by small study populations. The aim of this study was to establish the impact of the operative approach (laparoscopic or open) on outcomes after ileocolic resection for Crohn’s disease. Method Ileocolic resections for Crohn’s disease were identified using Current Procedural Terminology (CPT) and International Classification of Disease, Ninth Revision, Clinical Modification (ICD‐9‐CM) codes from the National Surgical Quality Improvement Program (NSQIP) database (2005–2009). Complications were categorized as major (organ system damage and systemic sepsis) or minor (incisional and urinary infections). Multivariate 30‐day outcomes and length of stay were determined using linear models adjusting for patient characteristics, comorbidities and operative approach. Results Of 1917 ileocolic resections, 644 (34%) were performed laparoscopically. At baseline, the open group was significantly older, had more comorbidities, higher American Society of Anesthesiology (ASA) classes, and more intra‐operative transfusions (all variables, P < 0.05). On multivariate analysis, laparoscopic ileocolic resections were associated with a decrease in major (OR = 0.629, 95% CI: 0.430–0.905, P = 0.014) and minor (OR = 0.576, 95% CI: 0.405–0.804, P = 0.002) complications compared with open resections. Laparoscopy was associated with a significant reduction in adjusted length of stay compared with the open approach (?1.08 ± 0.29 days, P = 0.0002). Conclusion After adjusting for comorbidities and perioperative factors, such as preoperative sepsis, higher ASA class and higher transfusion rates in the open group, laparoscopic ileocolic resection for Crohn’s disease was found to be a safer choice than the open approach, resulting in fewer complications and length of stay. All other things being equal, such patients should be offered the laparoscopic approach as a first‐choice option.     

Factors associated with complications of open versus laparoscopic sigmoid resection for diverticulitis.

BACKGROUND: This study critically reviews sigmoid colon resection for diverticulitis comparing open and laparoscopic techniques. METHODS: We conducted a retrospective review of all open and laparoscopic cases of diverticulitis between 1992 and 2001. Data analyzed included the following: indications for operation, postoperative complications, and incidence of laparoscopic conversion to laparotomy. Major and minor complications were analyzed in relation to patients' preoperative diagnosis, age, presence or absence of splenic flexure mobilization, length of stay, and laparoscopic sigmoid resection versus open sigmoid resection. RESULTS: Over a 10-year period, 166 resections for diverticulitis were performed including 126 open cases and 40 laparoscopic cases. No significant differences existed in patient characteristics between the groups. Major complications occurred in 14% of patients, and the laparoscopic conversion rate was 20%. The presence of abscess, fistula, or stricture preoperatively was associated with a higher complication rate only in patients > or =50 years old undergoing open sigmoid resection. The length of stay between patients undergoing laparoscopic resection was significantly less than in patients having open resection. CONCLUSION: Advanced laparoscopic sigmoid resection is an alternative to open sigmoid resection in patients with diverticulitis and its complications. Open sigmoid resection in patients >50 years may have a higher complication rate in complicated diverticulitis when compared with laparoscopic sigmoid resection (all patient ages) and open sigmoid resection (patients <50 years old). Regarding complications, no difference existed between the length of stay in patients with open vs. laparoscopic resection.     

Converted laparoscopic colorectal surgery

BACKGROUND: Conversion rates following laparoscopic colorectal surgery vary widely between studies, and the outcome of converted patients remains controversial. METHODS: A comprehensive search of the English-language literature was updated until May 1999. RESULTS: Twenty-eight studies on 3232 patients were considered for analysis. The overall conversion rate was 15.38%. Seventy nine percent of the studies did not include a definition for conversion; in these studies, the conversion rate was significantly lower than in the series where a specific definition was considered (13.7% vs 18.9%, chi-square test, p < 0.001). Converted patients had a prolonged hospital stay (11.38 vs 7.41 days) and operative time (209 vs 189 min) in comparison with laparoscopically completed patients (95% confidence interval (CI), 1.70-4.00 and 35.90-37.10, respectively). The factors associated with an increased rate for conversion were left colectomy (Odds Ratio [OR] = 1.061), anterior resection of the rectum (OR = 1.088), diverticulitis (OR = 1.302), and cancer (OR = 2.944) (for each parameter, Wald chi-square value, p < 0.001). CONCLUSIONS: In nonrandomized studies, the rate of laparoscopically completed colorectal resections is close to 85%. Because converted patients have a distinct outcome, a clear definition of conversion is required to compare the results of randomized trials. Such trials should also consider a 20% rate of conversion when estimating the sample size for the desired power level. It is likely that converted patients will have a significant impact on the results of future clinical research in laparoscopic colorectal surgery.     

Laparoscopic or open liver resection? Let systematic review decide it

BackgroundLaparoscopic liver resection is increasingly being used for the excision of benign and malignant hepatic lesions. The aim of this study was to perform meta-analysis on the compiled data from available observational studies.MethodsAll the studies comparing laparoscopic versus open liver resections were searched on the available databases. Data were analyzed using Review Manager software version 5.0 (The Cochrane Collaboration, Software Update, Oxford, UK).ResultsThere was a total of 2,466 patients: 1,161 (47.1%) in the laparoscopic group and 1,305 (52.9%) in the open group. The laparoscopic group was associated with a reduced overall complication rate (odds ratio = .35; 95% confidence interval [CI], .28–.45; P < .001; heterogeneity (HG): P = .51), fewer positive resection margins for malignant tumor resections (odds ratio = .38; CI, .20–.76; P = .006; HG: P = .52) and a decrease in the number of patients requiring blood transfusion (odds ratio = .36; CI, .23–.74; P < .001; HG: P = .30).ConclusionsLaparoscopic liver resection showed a reduced overall morbidity rate and favorable and comparable outcomes when compared with the open group. However, there is still a need for randomized controlled trials to compare laparoscopic versus open hepatic resection in benign and malignant lesions.     

Stellenwert der laparoskopischen Sigmaresektion bei der elektiven chirurgischen Therapie der Sigmadivertikulitis

The full significance of laparoscopic technique in elective surgery of sigmoid diverticulitis has yet to be determinated. However, it seems worthwhile to evaluate how minimally invasive surgery could be integrated into the surgical treatment of diverticulitis disease. Between January 1995 and August 1996, 26 patients with sigmoid diverticulitis underwent elective surgery. Following diagnostic laparoscopy, seven patients were treated with primary conventional resection, 15 patients with laparoscopic resection and four patients with laparoscopic-assisted surgery. One laparoscopic resection had to be converted to a median laparotomy. Postoperative complications (n=2) only appeared in the group of conventional resections. Conventional resections required less time than laparoscopic or laparoscopic-assisted resections, but postoperatively, patients with laparoscopic resection were able to defecate sooner and required a shorter hospital stay. For 60% of the patients with diverticulitis disease of the colon, elective laparoscopic resection may prove to be the best alternative of surgical treatment. In selected patients it is a sound technique with a low complication rate. We recommend that all patients with diverticulitis disease requiring elective surgery undergo diagnostic laparoscopy to determine whether or not laparoscopic resection is a viable option.     

Acute and Elective Laparoscopic Resection for Complicated Sigmoid Diverticulitis: Clinical and Histological Outcome

Background

Surgical treatment of acute complicated sigmoid diverticulitis is still under debate while elective treatment of recurrent diverticulitis has proven benefits. The aim of this study was to evaluate the clinical and histological outcome of acute and elective laparoscopic sigmoid colectomy in patients with diverticulitis.

Methods

A retrospective review was conducted where 197 patients were analyzed undergoing laparoscopic sigmoid resection for acute complicated diverticulitis and recurrent diverticulitis. Single-stage laparoscopic resection and primary anastomosis were routinely performed using a 3-trocar technique. Recorded data included age, sex, American Society of Anesthesiologists (ASA)-score, operative time, duration of hospital stay, complications, and histological results.

Results

Ninety-one patients received laparoscopy for acute diverticular disease (group I) and 93 patients underwent elective laparoscopic sigmoid resection for diverticulitis (group II). M/F ratio was 49:42 for group I and 37:56 for group II. Mean operative time and hospital stay was similar in both groups. Majority of patients were ASA II in both groups. Rate of minor complications was 14.3 % in group I and 7.5 % in group II. Major complications were 2.2 % for acute treatment and 4.3 % for elective resections. No anastomotic leakage and no mortality occurred. In 32.3 % of the patients of elective group II, destruction of the colonic wall with pericolic abscess, fistulization, or fibrinoid purulent peritonitis were identified.

Conclusions

Laparoscopic surgery for acute diverticular disease is safe and effective. Continuing bowl inflammations in histological specimens justify sigmoid resection in elective patients, but more effective pre-operative parameters need to be found to identify patients that would benefit from surgery during the initial episode.     

Laparoscopic versus open approach for solitary insulinoma

Background In recent years, advances in laparoscopic techniques have allowed surgeons to treat pancreatic lesions laparoscopically. Insulinoma, the most prevalent pancreatic endocrine tumor, is mostly benign and curable with surgical resection. This study aimed to assess the results from laparoscopic resection (LG) of insulinomas and to compare them with the results from open surgery (OG). Methods From September 1999 to December 2005, 56 laparoscopic pancreatic resections were performed for selected patients, including 12 laparoscopic resections of insulinomas. The results were compared with those of patients who underwent open resection of insulinomas selected from the authors’ pancreatic database. Results Three conversions to the open approach were required because of inability to identify the tumor. There were no deaths in either group, and the morbidity rates were 25% (3/12) for LG and 55% (5/9) for OG (nonsignificant difference). The pancreatic fistula rate after laparoscopic enucleation was statistically lower than after open enucleation (14% vs 100%; p = 0.015). The mean postoperative hospital stay was 13 ± 5.9 days for LG and 17.6 ± 7.5 days for OG (nonsignificant difference). After exclusion of the patients who underwent conversion to laparotomy, the mean postoperative hospital stay was 11.5 ± 5.8 days for LG and 17.6 ± 7.5 days for OG (p = 0.04). Conclusion This study demonstrates the feasibility and safety of laparoscopic resection of insulinomas. The laparoscopic approach was associated with a decrease in hospital stay and pancreatic fistula after enucleation. Preoperative localization tests and laparoscopic ultrasonography seem necessary to prevent conversion.     

Use of laparoscopy in general surgical operations at academic centers

BackgroundLaparoscopy is commonly being used in many different types of general surgical procedures. The aim of the present study was to examine the use of laparoscopy and perioperative outcomes in 7 general surgical operations commonly performed at U.S. academic medical centers.MethodsThe clinical data of patients who underwent 1 of the 7 general surgical operations from 2008 to 2012 were obtained from the University HealthSystem Consortium database. The University HealthSystem Consortium database contains data from all major teaching hospitals in the United States. The 7 analyzed operations included only elective, inpatient procedures (except for appendectomy): open and laparoscopic antireflux surgery for gastroesophageal reflux, colectomy for colon cancer or diverticulitis, bariatric surgery for morbid obesity, ventral hernia repair for incisional hernia, appendectomy for acute appendicitis, rectal resection for rectal cancer, and cholecystectomy for cholelithiasis. The outcome measures included the number of procedures, rate of laparoscopy, rate of conversion to laparotomy, and in-hospital mortality.ResultsDuring the 3.5-year period, 53,958 patients underwent bariatric surgery, 13,918 patients underwent antireflux surgery, 8654 patients underwent appendectomy, 8512 patients underwent cholecystectomy, 29,934 patients underwent colectomy, 17,746 patients underwent ventral hernia repair, and 4729 patients underwent rectal resection. The present rate of laparoscopic use was 94.0% for bariatric surgery, 83.7% for antireflux surgery, 79.2% for appendectomy, 77.1% for cholecystectomy, 52.4% for colectomy, 28.1% for ventral hernia repair, and 18.3% for rectal resection. In-hospital mortality was greatest for colorectal resection (.38%–.58%). In-hospital mortality for bariatric surgery (.06%) was comparable to that for appendectomy (.01%), cholecystectomy (.27%), antireflux surgery (.15%), and ventral hernia repair (.20%). The rate of laparoscopic conversion to open surgery was lowest for bariatric surgery (.89%) and greatest for rectal resection (16.4%).ConclusionWithin the context of academic centers and elective, inpatient procedures, bariatric surgery had the greatest use of laparoscopy and the lowest rate of laparoscopic conversion to open surgery. The mortality for laparoscopic bariatric surgery is now comparable to that of laparoscopic cholecystectomy, ventral hernia repair, appendectomy, and antireflux surgery.     

Laparoscopic Resection of Chronic Sigmoid Diverticulitis with Fistula

Background and Objectives:

A growing number of operations for sigmoid diverticulitis are being done laparoscopically. There is a paucity of data on the outcome of laparoscopy for sigmoid diverticulitis complicated by colonic fistula. The aim of this study was to compare the results of laparoscopic resection of sigmoid diverticulitis with and without colonic fistula.

Methods:

A retrospective review was conducted of all patients who underwent laparoscopic resection of sigmoid diverticulitis complicated by fistula at a single tertiary care institution over a 7-year period. Comparison was made with a group of patients who underwent resection for diverticulitis without fistula during the same study period.

Results:

Forty-two patients were analyzed (group 1: diverticular fistula, group 2: no fistula). The median age was similar (49 vs. 50 years, P = .68). A chronic abscess was present in 24% of patients in group 1 and 10% in group 2 (P = .40). Fistula types were colovesical (71%), colovaginal (19%), and colocutaneous (10%). Operation types were sigmoidectomy (57% vs. 81%) and anterior resection (43% vs. 19%) in groups 1 and 2, respectively (P = .18). Ureteral catheters were used more frequently in group 1 (67% vs. 33% [P = .06]). No difference was noted in operative time, blood loss, conversion rate, length of stay, overall complications, wound infection rate, readmission rate, reoperation rate, and mortality. All patients healed without fistula recurrence.

Conclusions:

Patients with sigmoid diverticulitis with fistula can be successfully treated with laparoscopic excision, with similar outcomes for patients without fistula.     

Laparoscopic vs. open liver resection for malignant liver disease. A systematic review

IntroductionSince the introduction of minimally invasive techniques, there is little agreement about use of laparoscopic surgery for malignant liver lesions as compared to open resection. We aim to analyse all available data comparing both these groups.MethodsAll the studies that compared laparoscopic and open liver resections for malignant lesions were searched on various databases. Data were collected and analysed in Review Manager RevMan (version 5.0).ResultsThere were total of 10 studies (n = 700) that compared laparoscopic (296/700) and open (404/700) hepatic resections for malignant lesions. Laparoscopic group was associated with reduced number of patients requiring blood transfusion [Odds ratio 0.35 CI 0.20, 0.60 P<0.001 HG 0.85], decreased number of positive resection margin [Odds ratio 0.34 CI 0.16, P0.006 HG 0.73] and decrease in overall complication rate [Odds ratio 0.43, CI 0.26, 0.73 P0.002 HG 0.22]. Laparoscopic group was associated with less operative blood loss [WMD 162.6 ml CI ?261.79, 73.45 P<0.001] and reduced hospital stay [WMD 4.28 days CI ?6.33, ?2.23 P<0.001]; however, there was significant heterogeneity [HG <0.001] between the studies for these parameters.ConclusionThe laparoscopic group was associated with reduce overall complication rate, positive resection margins and number of patients requiring blood transfusion. There is still need for level I and II data to compare laparoscopic versus open hepatic resection in malignant lesions.     

Dexmedetomidine reduces postoperative pain and speeds recovery after bariatric surgery: a meta-analysis of randomized controlled trials

BackgroundDexmedetomidine in opioid-sparing analgesia promotes enhanced recovery and improves postoperative outcomes.ObjectivesThis study aimed to explore the safety and efficacy of dexmedetomidine in bariatric surgery.SettingMeta-analysis.MethodsWe selected studies from Pubmed, Embase, Web of Science, and the Cochrane Central Registry of Controlled Trials before 20 April, 2021. The primary outcomes were pain scores and intravenous morphine equivalents (IVME) in the post anesthesia care unit (PACU) and postoperative day 1 (POD1). The secondary outcomes included postoperative nausea and vomiting (PONV), the length of hospital stay (LOS), intraoperative mean arterial pressure (MAP) and heart rate (HR).ResultsWe extracted 697 participants from 10 randomized controlled trials. Dexmedetomidine reduced PACU pain scores (MD = ?1.51, 95% confidence interval [CI]: ?2.60 to ?.42) after bariatric surgery, especially laparoscopic Roux-en-Y gastric bypass (MD = ?3.05, 95%CI: ?3.77 to ?2.33), but it did not affect POD1 pain scores (MD = .20, 95%CI: ?.85 to 1.26). Dexmedetomidine can reduce PACU IVME (MD = ?4.29, 95%CI: ?6.59 to ?1.99), but does not reduce POD1 IVME (MD = ?.36, 95%CI: ?2.41 to 1.68). In addition, dexmedetomidine significantly reduced PONV both in PACU (OR = .28, 95%CI: .14–.54) and POD1 (OR = .24, 95%CI: .14–.4), shortened LOS (MD = ?.29, 95%CI: ?.49 to ?.10), and had little effect on intraoperative MAP (MD = ?6.64, 95%CI: ?9.52 to ?3.76) and HR (MD = ?4.8, 95%CI: ?11.55 to 1.94).ConclusionIn conclusion, the use of dexmedetomidine in opioid-sparing analgesia contributes to postoperative analgesia after bariatric surgery, but the heterogeneity was high. In addition, dexmedetomidine is beneficial for enhanced recovery.     

Short- and Long-term Outcomes After Laparoscopic Versus Open Emergency Resection for Colon Cancer: An Observational Propensity Score-matched Study

Background

Case series suggest the feasibility and safety of emergency resection of colon cancer by laparoscopy. The present study compares short- and long-term outcomes of laparoscopic and open resection for colon cancers treated as emergencies.

Methods

The study was a propensity score-matched design based on a prospective database. From October 2006 to December 2011, emergency laparoscopic colon cancer resections were 1:2 propensity score-matched to open cases. Covariates for match-estimation were age, gender, American Society of Anesthesiologists grade, procedure type, tumor site, and reason for emergency surgery. Short-term outcomes included oncological quality surrogates (lymph node harvest and R stage), need for a stoma, length of hospital stay, and postoperative complications. For long-term outcomes, overall and recurrence-free survival rates were analyzed with Kaplan–Meier curves.

Results

During the study period, a total of 217 colon cancers were resected (181 open and 36 laparoscopic) as emergencies. The laparoscopic cases were matched to 72 open cases. Median follow-up was 3.6 [95 % confidence interval (CI) 2.3–4.3] years. The overall 3-year survival rate was 51 % (95 % CI 35–76) in the laparoscopic group versus 43 % (95 % CI 32–58) in the open group (p = 0.24). The 3-year recurrence-free survival rate in the laparoscopic group was 35 % (95 % CI 20–60) versus 37 % (95 % CI 27–50) in the open group (p = 0.53). Median lymph node harvest (17 vs. 13 nodes; p = 0.041) and median length of hospital stay (7.5 vs. 11.0 days; p = 0.019) favored laparoscopy.

Conclusions

Our data suggest that selective emergency laparoscopy for colon cancer is not inferior to open surgery with regard to short- and long-term outcomes. Laparoscopy resulted in a shorter length of hospital stay.     

Laparoscopic colectomy for recurrent and complicated diverticulitis: a prospective study of 396 patients

Background It was the aim of this prospective study to evaluate the outcome of laparoscopic surgery for diverticular disease.Methods All patients who underwent elective laparoscopic colectomy for diverticular disease within a 10-year period were prospectively entered into a PC database registry. Indications for laparoscopic surgery were acute complicated diverticulitis (Hinchey stages I and IIa), chronically recurrent diverticulitis, sigmoid stenosis or outlet obstruction caused by chronic diverticulitis. Surgical procedures (sigmoid and anterior resection, left colectomy and resection rectopexy) included intracorporeal dissection and colorectal anastomosis. Parameters studied included age, gender, stage of disease, procedure, duration of surgery, intraoperative technical variables, transfusion requirements, conversion rate, total complication rate including major (requiring re-operation), minor (conservative treatment) and late-onset (post-discharge) complication rates, stay on ICU, hospitalisation, mortality, and recurrence. For objective evaluation, only laparoscopically completed procedures were analysed. Comparative outcome analysis was performed with respect to stage of disease and experience.Results A total of 396 patients underwent laparoscopic colectomy. Conversion rate was 6.8% (n=27), so that laparoscopic completion rate was 93.2% (n=369). Most common reasons for conversion were directly related to the inflammatory process, abscess or fistulas. The most common procedure was sigmoid resection (n=279), followed by anterior resection (n=36) and left colectomy (n=29). Total complication rate was 18.4% (n=68). Major complication rate was 7.6% (n=28), whereas the most common complication requiring re-operation was haemorrhage in 3.3% (n=12). Anastomotic leakage occurred in 1.6% (n=6). Minor complications were noted in 10.7% (n=40), late-onset complications occurred in 2.7% (n=10). Mortality was 0.5% (n=2). Mean duration of surgery was 193 (range 75–400) min, return to normal diet was completed after 6.8 (range 3–19) days. Mean hospital stay was 11.8 (range 4–71) days. No recurrence of diverticulitis occurred.Conclusion Laparoscopic surgery for diverticular disease is safe, feasible and effective. Therefore, laparoscopic colectomy has replaced open resection as standard surgery for recurrent and complicated diverticulitis at our institution.     

Short- and Long-Term Oncological Outcome After Rectal Cancer Surgery: a Systematic Review and Meta-Analysis Comparing Open Versus Laparoscopic Rectal Cancer Surgery

Background

While several trials have compared laparoscopic to open surgery for colon cancer showing similar oncological results, oncological quality of laparoscopic versus open rectal resection is not well investigated.

Methods

A systematic literature search for randomized controlled trials was conducted in MEDLINE, the Cochrane Library, and Embase. Qualitative and quantitative meta-analyses of short-term (rate of complete resections, number of harvested lymph nodes, circumferential resection margin positivity) and long-term (recurrence, disease-free and overall survival) oncologic results were conducted.

Results

Fourteen randomized controlled trials were identified including 3528 patients. Patients in the open resection group had significantly more complete resections (OR 0.70; 95% CI 0.51–0.97; p?=?0.03) and a higher number of resected lymph nodes (mean difference ??0.92; 95% CI ??1.08 to 0.75; p?<?0.001). No differences were detected in the frequency of positive circumferential resection margins (OR 0.82; 95% CI 0.62–1.10; p?=?0.18). Furthermore, no significant differences of long-term oncologic outcome parameters after 5 years including locoregional recurrence (OR 0.95; 95% CI 0.44–2.05; p?=?0.89), disease-free survival (OR 1.16; 95% CI 0.84–1.58; p?=?0.36), and overall survival (OR 1.04; 95% CI 0.76–1.41; p?=?0.82) were found. Most trials exhibited a relevant risk of bias and several studies provided no information on the surgical expertise of the participating surgeons.

Conclusion

Differences in oncologic outcome between laparoscopic and open rectal surgery for rectal cancer were detected for the complete resection rate and the number of resected lymph nodes in favor of the open approach. No statistically significant differences were found in oncologic long-term outcome parameters.

     

Laparoscopic vs open hepatic resection: a comparative study

Background: Although the feasibility of minor laparoscopic liver resections (LLR) has been demonstrated, data comparing the open vs the laparoscopic approach to liver resection are lacking. Methods: We compared 30 LLR with 30 open liver resections (OLR) in a pair-matched analysis. The indications for resection were malignant disease in 47% of the LLR and 83% of the OLR. The average size of the lesions was 42 mm for LLR and 41 mm for OLR. Five wedge resections, 12 segmentectomies, and 13 bisegmentectomies were performed in each group. Results: The conversion rate for LLR was nil. The mean operative time was 148 min for LLR and 142 min for OLR. Mean blood loss was minimal in the LLR group (320 vs 479 ml; p < 0.05). Postoperative complications occurred in 6.6% of the patients in each group; there were no deaths. The mean postoperative hospital stay was shorter for LLR patients (6.4 vs 8.7 days; p < 0.05). In tumors, the resection margin was <1 cm in 43% of the LLR patients and 40% of the OLR patients (p = NS). Conclusions: Minor LLR of the anterior segments has the same rates of mortality and morbidity as OLR. However, the laparoscopic approach reduces blood loss and postoperative hospital stay.     

Trends of robotic-assisted surgery for thyroid,colorectal, stomach and hepatopancreaticobiliary cancer: 10 year Korea trend investigation

BackgroundThe current position of robotic surgery in the field of minimally invasive surgery remains ambiguous. We evaluated long-term trends of robotic general surgery and the future direction of its development.MethodsData on robotic cancer surgeries between 2005 and 2014 were retrospectively collected by volunteer institutions in the Republic of Korea. Spearman's correlation and logistic regression analyses were used to compare robotic and laparoscopic surgery trends in general surgery.ResultsThe odds that robotic surgery was performed instead of laparoscopic surgery significantly decreased in the fields of colorectal, stomach, and hepato-biliary-pancreatic surgery (odds ratio [OR]: 0.95, 95% confidence interval [CI]: 0.93–0.97; OR: 0.90, 95% CI: 0.88–0.92; and OR: 0.71, 95% CI: 0.65–0.78, respectively), except for thyroid surgery (OR: 1.28, 95% CI: 1.25–1.30). Of the total numbers of each procedure, proportions of robotic intersphincteric resections, abdominoperineal resections, and pylorus-preserving surgery performed significantly increased (r = 0.98, P < .001; r = 0.78, P = .01; and r = 0.86, P = .007, respectively).ConclusionsThe use of robotic surgery failed to preponderate that of laparoscopic surgery, except for thyroid surgery. Robotic surgery is increasingly preferred for limited fields or complex surgeries, but the use of robotics in simple surgeries has decreased.     

Can we predict immediate outcome after laparoscopic rectal surgery? Multivariate analysis of clinical, anatomic, and pathologic features after 3-dimensional reconstruction of the pelvic anatomy

OBJECTIVES: The laparoscopic approach for colon resection is widely accepted but its definitive role in rectal tumors is controversial due to the technical difficulties associated with this procedure. Tumor size and volume, and pelvic dimensions may influence intraoperative and/or immediate outcome. This study aimed to evaluate the predictive value of anatomic and pathologic features on immediate outcome after laparoscopic rectal resection. MATERIAL AND METHODS: The study included a prospective series of 60 patients submitted to laparoscopic resection for rectal tumors. A preoperative computed tomography was performed in all patients. Three-dimension reconstruction of the pelvis, rectal tumor, and prostate was computed. Tumor and prostate volume and diameters were calculated, as were main pelvic diameters (subsacrum-retropubic, coccyx pubis, and promontorium coccyx), and lateral diameters, at the tumor level (3D Doctor Software package). Age, sex, body mass index (BMI), tumor height, previous radiotherapy treatment, and type of procedure (anterior resection, low anterior resection, and abdominoperineal resection) were recorded. Immediate outcome (morbidity, mortality, and stay) was also collected. Dependent variables were operative time, intraoperative difficulty, conversion, and postoperative morbidity. Univariate and multivariate analyses were performed (SPSS package). RESULTS: The series included 36 men and 24 women, with a mean age of 72 years (range, 38-87). Surgical procedures were 10 anterior resections, 31 low anterior resections, and 19 abdominoperineal resections. Conversion rate was 9 of 60 (15%), operative time: 172 minutes (range, 90-360), morbidity: 31% and stay: 9 days (range, 6-43). Multivariate analysis showed tumor craniocaudal length was an independent predictive factor for conversion (P < 0.04, odds ratio [OR]: 1.5, confidence interval [CI]95%: 1-2.2). Pubic coccyx axis (P < 0.005) and sex (P < 0.009) showed independent values for operative time, and BMI (P < 0.02, OR: 1.2, CI 95%:1-1.5) was related to postoperative morbidity. When a subanalysis was performed in relation to sex, independent factors differed between males and females, with a predominance of anatomic and tumor measures in men. CONCLUSION: Local anatomy and pathologic features directly affect surgical outcome in the laparoscopic approach to the rectum. Sex, BMI, lower pelvis diameter, and tumor size are independent predictors for conversion, operative time, and morbidity. These data should be taken into account when planning this kind of procedure.     

Converted laparoscopic colectomy

Background The safety and benefits of laparoscopic colon resection are well documented. However, few reports have addressed the safety and comparative outcome of laparoscopic colon operations that necessitated conversion. Methods All consecutive laparoscopic colon resections performed by a single surgeon from July 1996 to October 2003 were assessed. Data obtained from a prospective computerized database included demographics, diagnosis, reason and time to conversion, length of stay, morbidity, and mortality. Additionally, all laparoscopic-converted colectomies were then matched with open colectomies by diagnosis and severity of disease and analyzed with respect to morbidity, mortality, and clinical outcome. Results A total of 143 laparoscopic colon resections were analyzed, 78 of which were left colon resections and 65 were right colon resections. The overall conversion rate was 19.6% (28 patients). The disease entities of the 28 converted patients were diverticulitis (16), polyps (four), Crohn’s disease (three), metastatic cancer (three), and others (two). Conversion was higher in the left-sided (24 patients, 30.8%) versus right-sided (four patients, 6.1%) procedures. There were no differences regarding age, gender, and comorbidities among the laparoscopic, open, and converted groups; the median follow-up was 39 months. The median length of stay was 6, 8, and 12 days for the laparoscopic, open, and converted groups, respectively. Right-sided conversions were due to the size of the inflammatory mass in three patients and intraoperative bleeding in one patient. Left-sided conversions were due to the inflammatory process extending beyond the sigmoid colon in 12 patients, adhesions in five, obesity in four, pericolonic abscess in two, and fixed mass in one patient. Postoperative morbidity was significantly higher for laparoscopic procedures that were converted to open procedures more than 30 min into the operation. Preoperative predictors of conversion were extent of inflammatory process beyond the sigmoid colon and obesity, whereas intraoperative predictors were adhesions and bleeding. Conclusions Laparoscopic-converted colon resection is associated with significantly greater morbidity, particularly wound complications and greater length of hospital stay, compared to open or laparoscopic colectomies. Prompt conversion (<30 min) may reduce the overall morbidity associated with converted procedures. Furthermore, thoughtful patient selection may decrease the conversion rate and thereby prevent the inherent morbidity associated with converted procedures.     

Racial and Socioeconomic Disparities in the Surgical Management and Outcomes of Patients with Colorectal Carcinoma

Introduction

Colorectal cancer (CRC) is the second leading cause of cancer mortality in the USA. We aimed to determine racial and socioeconomic disparities in the surgical management and outcomes of patients with CRC in a contemporary, national cohort.

Methods

We performed a retrospective analysis of the National Inpatient Sample for the period 2009–2015. Adult patients diagnosed with CRC and who underwent colorectal resection were included. Multivariable linear and logistic regressions were used to assess the effect of race, insurance type, and household income on patient outcomes.

Results

A total of 100,515 patients were included: 72,552 (72%) had elective admissions and 27,963 (28%) underwent laparoscopic surgery. Patients with private insurance and higher household income were consistently more likely to have laparoscopic procedures, compared to other insurance types and income levels, p < 0.0001. Black patients, compared to white patients, were more likely to have postoperative complications (OR 1.23, 95% CI, 1.17, 1.29). Patients with Medicare and Medicaid, compared to private insurance, were also more likely to have postoperative complications (OR 1.30, 95% CI, 1.24, 1.37 and OR 1.40, 95% CI, 1.31, 1.50). Patients in low-household-income areas had higher rates of any complication (OR 1.11, 95% CI 1.06, 1.16).

Conclusions

The use of laparoscopic surgery in patients with CRC is strongly influenced by insurance type and household income, with Medicare, Medicaid and low-income patients being less likely to undergo laparoscopic surgery. In addition, black patients, patients with public insurance, and patients with low household income have significant worse surgical outcomes.

     

Surgical treatment of diverticulitis and its complications: A systematic review and meta-analysis of randomized control trials

Purpose

The surgical interventions of diverticulitis vary according to its grade and severity. There is a controversy about the best of these different surgical procedures. We aimed to systematically review and meta-analyze randomized controlled trials (RCTs) comparing outcomes and complications between different surgical approaches for acute diverticulitis and its complications.