Ultrasound-Guided Transversus Abdominis Plane (TAP) Block for Laparoscopic Gastric-Bypass Surgery:a Prospective Randomized Controlled Double-Blinded Trial

Background

Despite the laparoscopic approach, patients can suffer moderate to severe pain following bariatric surgery. This randomized controlled double-blinded trial investigated the analgesic efficacy of ultrasound-guided transversus abdominis plane (TAP) blocks for laparoscopic gastric-bypass surgery.

Methods

Seventy patients undergoing laparoscopic gastric-bypass surgery were randomized to receive either bilateral ultrasound-guided subcostal TAP block injections after induction of general anesthesia or none. All patients received trocar insertion site local anesthetic infiltration and systemic analgesia. The primary outcome was cumulative opioid consumption (IV morphine equivalent) during the first 24 h postoperatively. Interval opioid consumption, pain severity scores, rates of nausea or vomiting, and rates of pruritus were measured during phase I recovery, and at 24 and 48 h postoperatively.

Results

There was no difference in cumulative opioid consumption during the first 24 h postoperatively between the TAP (32.2 mg [95% CI, 27.6–36.7]) and control (35.6 mg [95% CI, 28.6–42.5]; P?=?0.41) groups. Postoperative opioid consumptions during phase I recovery and the 24–48-h interval were similar between groups, as were pain scores at rest and with movement during all measured intervals. The rates of nausea or vomiting and pruritus were equivalent.

Conclusions

Bilateral TAP blocks do not provide additional analgesic benefit when added to trocar insertion site local anesthetic infiltration and systemic analgesia for laparoscopic gastric-bypass surgery.     

Transversus abdominis plane blocks and enhanced recovery pathways: making the 23-h hospital stay a realistic goal after laparoscopic colorectal surgery

Background

Although enhanced recovery pathways (ERPs) may permit early recovery and discharge after laparoscopic colorectal surgery (LC), most publications report that the mean hospital stay is 4 and 6 days. This study evaluates the addition of a transversus abdominis plane (TAP) block to the standard ERP.

Methods

In this study, 35 consecutive elective patients received a TAP block at the end of LC. The patients were matched by operation, diagnosis, age, gender, and body mass index (BMI) with 35 recent cases and followed in a prospective institutional review board (IRB)-approved database. All the patients were managed with a standardized ERP. The surgeon placed TAP blocks under laparoscopic guidance that infiltrated 15 ml of 0.5 % Marcaine on both sides of the abdomen.

Results

The cases included 8 low pelvic anastomoses, 4 proctectomies with or without an ileal pouch anal anastomosis, 5 sigmoid/left colectomies, 13 ileocolic/right colectomies, 1 total colectomy, and 5 others. The mean age was 59 years for the TAP group and 64.1 years for the control group (p = 0.21). The mean hospital stay was 2 days for the TAP patients and 3 days for the control patients (p = 0.000013). Of the 35 TAP patients, 13 went home on postoperative day (POD) 1 (37 %), 12 on POD 2 (34 %), 8 on POD 3 (23 %), and the remainder on POD 4. Of the 35 control patients, 1 went home on POD 1 (3 %), 10 on POD 2 (29 %), 10 on POD 3 (29 %), 11 on POD 4 (31 %), and the remainder on POD 5 to 8. The TAP patients required fewer narcotics postoperatively than the control patients (respective mean morphine equivalents, 31.08 vs. 85.41; p = 0.01).

Discussion

A bilateral TAP block significantly improved the results of an established ERP for patients undergoing LC. Surgeon-administered TAP blocks may be an economical and efficient method for improving the results of LC.     

Transversus abdominis plane blocks for rescue analgesia following Cesarean delivery: a case series

Purpose

The role of routine transversus abdominis plane (TAP) blocks at the time of surgery for Cesarean delivery analgesia is uncertain. Previous studies have shown no additional analgesic benefit in patients receiving intrathecal morphine. We present a series of three cases where TAP blocks were used for rescue analgesia in patients who had severe post-Cesarean delivery pain after a standard spinal anesthetic containing bupivacaine 12 mg, fentanyl 10 μg, and morphine 200 μg.

Clinical features

All three women experienced severe incisional pain in the postanesthetic care unit (PACU) after offset of spinal anesthesia. When the pain did not subside with intravenous opioids, the women were offered either additional intravenous opioids or a TAP block. They chose the latter. Bilateral TAP blocks were performed in a sterile posterior approach under ultrasound guidance with 0.375% ropivacaine 20 mL with epinephrine 1:400,000. All three patients experienced significant pain relief that lasted 10-19 hr and allowed for a timely discharge from the PACU.

Conclusion

These cases show that TAP blocks may play a valuable role as a rescue analgesic technique rather than as a routine preemptive block for all Cesarean delivery patients. Use of TAP blocks reduced the need for escalating intravenous opioid doses and potential maternal opioid-related side effects. Rescue TAP blocks should be considered after Cesarean delivery when intrathecal morphine does not provide adequate pain relief or for early breakthrough pain after offset of spinal anesthesia.     

Effects of preoperative ultrasound-guided transversus abdominis plane block on pain after laparoscopic surgery for colorectal cancer: a double-blind randomized controlled trial

Background

Although laparoscopic colorectal surgery decreases postoperative pain and facilitates a speedier recovery compared with laparotomy, postoperative pain at trocar insertion sites remains a clinical concern. The objective of this study was to assess the effects of a preoperative ultrasound-guided transversus abdominis plane (TAP) block on pain after laparoscopic surgery for colorectal cancer.

Methods

In total, 58 patients scheduled to undergo laparoscopic surgery following a diagnosis of colorectal cancer were included in this study. The patients were randomized into TAP and control groups; the TAP group patients received a preoperative ultrasound-guided bilateral TAP block with 0.5 mL/kg of 0.25 % bupivacaine, while the control patients received the block with an equal amount of saline. Pain on coughing and at rest was assessed during postanesthetic recovery (PAR; 1 h after surgery) and on postoperative days (PODs) 1 (24 h), 2 (48 h), and 3 (72 h) by an investigator blinded to group allocations using the numeric rating scale (NRS). The primary outcome was pain on coughing on postoperative day (POD) 1.

Results

Fifty-five patients were included in the final analysis, including 28 in the TAP and 27 in the control groups. The pain intensity on coughing and at rest during PAR and on PODs 1, 2, and 3 showed no significant differences between groups. Furthermore, there was no significant difference in postoperative opioid consumption, sedation scores, nausea scores at the four time points, complication rates, and length of hospital stay between groups.

Conclusions

In colorectal cancer patients undergoing laparoscopic colorectal surgery, a TAP block did not offer enough benefit for clinical efficacy in terms of postoperative pain or analgesic consumption.

     

Analgesic efficacy and outcome of transversus-abdominis plane block versus low thoracic-epidural analgesia after laparotomy in ischemic heart disease patients

Background

Tranversus-abdominis plane (TAP) block is a novel technique alternative to central neural blockade in providing analgesia to the anterior abdominal wall. As such, we compared the analgesic efficacy of TAP block with low thoracic-epidural analgesia (TEA) in ischemic heart disease patients after abdominal laparotomy.

Methods

Forty-four American Society of Anesthesiologists physical status (ASA) III patients, 59–75 years of age and undergoing elective upper abdominal surgery under general anesthesia, were assigned randomly to receive either continuous low TEA or intermittent administration of local anesthetic in TAP block. Supplemental analgesia was provided with intravenous morphine with patient-controlled-analgesia. Morphine consumption and pain intensity using verbal rating scale (VRS) at rest and coughing over the first 48 h were recorded.

Results

Whereas all patients in the TAP group required morphine, 16 (72.2 %) patients in TEA group received morphine postoperatively (p = 0.021). Morphine consumed on day 1 and day 2 was 11.5 mg (7.5–12.3 mg) and 7mg (4.5–8 mg) for the TEA group, while in the TAP group, it was 18 mg (16–19 mg) and 11 mg (10–13 mg), respectively (p < 0.001). Time for first request of morphine was 311.2 ± 18.5 min in the TEA group versus 210 ± 22.2 min in the TAP group (p < 0.001). VRS at rest and cough were lower in the TEA group compared with the TAP group at 1, 6, 12, 18, 24, 36 and 48 h (p < 0.001). Incidence of hypotension and ephedrine administration were significantly higher in the TEA group than in the TAP group (p = 0.007).

Conclusion

Low TEA reduced morphine consumption and provided a higher analgesic efficacy compared with TAP block after laparotomy in ischemic heart disease patients.     

Effect of epidural analgesia on bowel function in laparoscopic colorectal surgery: a systematic review and meta-analysis

Purpose

Use of thoracic epidural analgesia (TEA) with local anesthetic and adjuncts, such as opioids, are cornerstones of ERAS (Enhanced Recovery After Surgery) and are considered to play a key role in recovery after colorectal surgery. However, its effect on bowel function may lead to prolong hospital stay and is still a matter of debate. The purpose of this systemic review was to assess whether epidural analgesia could have a detrimental effect on bowel function in laparoscopic colorectal surgery with a subsequent effect on hospital stay duration, leading to failure of ERAS in colorectal surgery.

Methods

A systematic review of randomized, controlled trials for the effect of epidural analgesia on laparoscopic colorectal surgery was performed. The effect on postoperative recovery was evaluated in terms of return of bowel function as the primary outcome, whereas length of stay (LOS), pain score on visual analogue scale, operative time, and incidence of postoperative complications and side-effects of analgesia were recorded as secondary outcomes.

Results

Six trials published between 1999 and 2011 were included in the final analysis. TEA significantly improves return of bowel function assessed by time to first bowel motion [WMD ?0.62 (?1.11, ?0.12) with Z = 2.43; P = 0.02, 95 % confidence interval (CI)], and pain scores [WMD ?1.23 (?2.4, ?0.07)] with Z = 2.07; P = 0.04, 95 % CI]. TEA did not influence duration of hospital stay [WMD ?0.47 (?1.55, 0.61)] with Z = 0.85 (P = 0.39, 95 % CI). No significant increase in operative time or side effects was associated with TEA.

Conclusions

Despite of some beneficial effect of epidural analgesia on return of bowel function and pain in laparoscopic surgery, it does not affect LOS, which is multifactorial.     

The efficacy of continuous subcostal transversus abdominis plane block for analgesia after living liver donation: a retrospective study

Purpose

Postoperative pain management for living liver donors has become a major concern as a result of the increasing number of living liver donations. Transversus abdominis plane (TAP) block has been known to provide effective analgesia for abdominal surgery. The aim of this study was to evaluate the efficacy of ultrasound-guided continuous subcostal TAP block as a part of a multimodal analgesic regimen in comparison with conventional intravenous (IV) fentanyl-based analgesia in living liver donors.

Methods

Thirty-two donors were retrospectively classified into either the continuous subcostal TAP block group (TAP group) or the IV fentanyl-based analgesia group (control group). TAP group donors received bilateral continuous subcostal TAP infusion of 0.125 % levobupivacaine at 6 ml/h. Control group donors did not receive any neural blockade.

Results

Cumulative fentanyl consumption was significantly lower in the TAP group for 48 h (P < 0.01) as compared to the control group. Further, the donors in the TAP group had significantly lower incidence of nausea and vomiting during 24–48 h postoperatively (P < 0.01) and fewer delays in the initiation of oral intake than those in the control group (P = 0.02).

Conclusions

In conclusion, continuous subcostal TAP block provided an effective opioid-sparing analgesia for living liver donors.

     

Skin as marker for collagen type I/III ratio in abdominal wall fascia

Purpose

An altered collagen metabolism could play an important role in hernia development. This study compared collagen type I/III ratio and organisation between hernia and control patients, and analysed the correlation in collagen type I/III ratio between skin and abdominal wall fascia.

Methods

Collagen organisation was analysed in Haematoxylin–Eosin sections of anterior rectus sheath fascia, and collagen type I/III ratio, by crosspolarisation microscopy, in Sirius-Red sections of skin and anterior rectus sheath fascia, of 19 control, 10 primary inguinal, 10 recurrent inguinal, 13 primary incisional and 8 recurrent incisional hernia patients.

Results

Compared to control patients [7.2 (IQR = 6.8–7.7) and 7.2 (IQR = 5.8–7.9)], collagen type I/III ratio was significantly lower in skin and anterior rectus sheath fascia of primary inguinal [5.2 (IQR = 3.8–6.3) and 4.2 (IQR = 3.8–4.7)], recurrent inguinal [3.2 (IQR = 3.1–3.6) and 3.3 (IQR = 3–3.7)], primary incisional [3.5 (IQR = 3–3.9) and 3.4 (IQR = 3.3–3.6)] and recurrent incisional hernia [3.2 (IQR = 3.1–3.9) and 3.2 (IQR = 2.9–3.2)] patients; also incisional and recurrent inguinal hernia had lower ratio than primary inguinal hernia patients. Furthermore, collagen type I/III ratio was significantly correlated (r = 0.81; P < 0.001) between skin and anterior rectus sheath fascia. Finally, collagen organisation was comparable between hernia and control patients.

Conclusions

Furthermore, in both skin and abdominal wall fascia of hernia patients, collagen type I/III ratio was lower compared to control patients, with more pronounced abnormalities in incisional and recurrent inguinal hernia patients. Importantly, collagen type I/III ratio in skin was representative for that in abdominal wall fascia.     

Outpatient inguinal hernia repair under local anaesthesia: feasibility and efficacy of ultrasound-guided transversus abdominis plane block

Background

The aim of this prospective randomized study was to determine the utility of transversus abdominis plane (TAP) block to improve the efficacy of conventional local anaesthesia for hernia repair in order to achieve an adequate anaesthesia and to evaluate its post-operative analgesic effectiveness.

Method

Hundred and fifty consecutive male patients undergoing outpatient hernia repair (Lichtenstein technique) were enrolled in this study. Patients were randomly allocated to undergo a combined TAP block and local anaesthesia (case group) or single conventional local anaesthesia (control group). The study was designed to obtain a 1:2 case–control ratio. The primary outcome was the evaluation of the proportion of patients achieving an adequate anaesthesia. The secondary outcome was the evaluation of pain on movement, pain at rest, rescue analgesia need, nausea and satisfaction.

Results

An adequate anaesthesia was achieved in 8 % case and in 36 % control subjects (p = 0.001). At the 6 and 12 h post-operative evaluations, patients enrolled in the case group reported significantly less pain (evaluated by VAS score) both at rest and on movement (p always = 0.001). Moreover, the need of rescue analgesia resulted significantly higher in the control group (14 vs. 32 %, p = 0.01).

Conclusion

Our results demonstrated that, as compared with conventional local anaesthesia, the combination of TAP block with local anaesthesia showed a higher efficacy in the obtainment of an adequate anaesthesia and in the post-operative pain control for hernia repair.     

Successful total shift from multiport to single-port laparoscopic surgery in low anterior resection of colorectal cancer

Objective

To assess the possibility of using single-port low anterior resection (LAR) in place of conventional laparoscopic LAR.

Background

Though single-port LS is gradually evolving, the application of single-port LS techniques in LAR have been viewed with skepticism due to technical difficulties.

Methods

Data from patients who had undergone either conventional laparoscopic LAR (n = 49) or single-port LAR (n = 67) for colorectal cancers between March 2006 and March 2013 were analyzed retrospectively.

Results

In single-port LAR group, oncologic outcomes were satisfactory with respect to attainment of lymph nodes (23.4 ± 15.3) and surgical margins (proximal cut margin: 7.1 ± 4.6 cm, distal cut margin: 7.7 ± 5.7 cm). Single-port LAR showed acceptable clinical outcomes manifested by comparable outcomes of post-operative analgesics requirement and length of hospital stay, and by low incidence of post-operative complications (conventional laparoscopic LAR group: 30.6 % vs. single-port LAR group: 14.9 %; P < 0.01). Operative time was comparable between groups (conventional laparoscopic LAR group: 309 ± 93 min vs. single-port LAR group: 277 ± 106 min; P = 0.097). Throughout a series of 67 consecutive single-port LARs, no conversion to multiport or open surgery was occurred.

Conclusion

This study shows that single-port LAR is both safe and feasible for use in resection of colorectal cancer when performed by surgeons who are trained in conventional laparoscopic technique. If further and more extensive studies support our results, then single-port LAR can be an acceptable alternative to conventional laparoscopic LAR for treatment of colorectal cancer.     

Transvaginal specimen extraction versus conventional minilaparotomy after laparoscopic anterior resection for colorectal cancer: mid-term results of a case-matched study

Background

Although the vagina is considered a viable route during laparoscopic surgery, a number of concerns have led to a need to demonstrate the safety of a transvaginal approach in colorectal surgery. However, the data for transvaginal access in left-sided colorectal cancer are extremely limited, and no study has compared the clinical outcomes with a conventional laparoscopic procedure.

Objective

We compared the clinical outcomes of totally laparoscopic anterior resection with transvaginal specimen extraction (TVSE) with those of the conventional laparoscopic approach with minilaparotomy (LAP) for anastomosis construction and specimen retrieval in left-sided colorectal cancer.

Methods

Fifty-eight patients underwent TVSE between October 2006 and July 2011 and were matched by age, surgery date, tumor location, and tumor stage with patients who underwent conventional LAP for left-sided colorectal cancer.

Results

Operative time was significantly longer in the TVSE group (149.3 ± 39.8 vs. 131.9 ± 41.4 min; p = 0.023). Patients in the TVSE group experienced less pain (pain score 4.9 ± 1.6 vs. 5.8 ± 1.9; p = 0.008), shorter time to passage of flatus (2.2 ± 1.1 vs. 2.7 ± 1.2 days; p = 0.026), and higher satisfaction with the cosmetic results (cosmetic score 8.0 ± 1.4 vs. 6.3 ± 1.5; p = 0.001). More endolinear staplers for rectal transection were used in the LAP group (1.2 ± 0.5 vs. 1.1 ± 0.2; p = 0.021). Overall morbidities were similar in both groups; however, three wound infections only occurred in the LAP group. After a median follow-up of 34.4 (range 11–60) months, no transvaginal access-site recurrence occurred. The 3-year disease-free survival was similar between groups (91.5 vs. 90.8 %; p = 0.746).

Conclusions

Transvaginal access after totally laparoscopic anterior resection is safe and feasible for left-sided colorectal cancer in selected patients with better short-term outcomes.     

The addition of epidural local anesthetic to systemic multimodal analgesia following lumbar spinal fusion: a randomized controlled trial

Purpose

This randomized trial aimed to evaluate the effects of adding continuous epidural analgesia with a bupivacaine and hydromorphone solution to systemic multimodal analgesia following one- or two-level lumbar spinal fusion.

Methods

Thirty-nine patients undergoing lumbar spinal fusion, stratified for sex and one- or two-level fusion, were randomized to receive a continuous postoperative epidural infusion of either 0.1% bupivacaine with 15 μg·mL^?1 hydromorphone (LA group) or 0.9% saline (NS group) at 6 mL·hr^?1 for 48 hr through an epidural catheter placed intraoperatively. All patients received a standardized postoperative multimodal analgesia regimen. Patients, healthcare providers, and research staff were blinded. The primary outcome measure was cumulative opioid consumption (oral morphine equivalent) during the first 48 hr postoperatively.

Results

The mean (SD) cumulative opioid consumption 48 hours postoperatively was 249.3 (143.3) mg in the NS group and 184.7 (208.1) mg in the LA group (mean difference 64.6 mg; 95% confidence interval ?54.3 to 183.5; P = 0.27). There were no adverse events in either group.

Conclusion

Continuous epidural infusion combined with systemic multimodal analgesia resulted in a mean reduction in 48-hr cumulative opioid consumption of 64.6 mg (95% confidence interval ?54.3 to 183.5) following one- or two-level lumbar spinal fusion. This estimate of effect is imprecise, and the routine use of continuous epidural analgesia in this surgical population is not yet warranted. This trial was registered at www.clinicaltrials.gov: NCT00644111.     

Survival following laparoscopic and open colorectal surgery

Background

Laparoscopic colorectal surgery is known to provide increased benefits to patients during the postoperative recovery period. Initial scepticism over the oncological adequacy of resection has been dismissed by a number of major randomized trials. Emerging evidence indicates that laparoscopic surgery may provide a potential survival benefit in colorectal cancer.

Methods

Patients undergoing elective laparoscopic or open resection for colorectal cancer between October 2003 and December 2010 were analyzed. Data were collated and a database compiled. Survival analysis was calculated by using the Kaplan–Meier method.

Results

A total of 665 resections were performed with 457 laparoscopically and 208 open. The median length of stay was 4 days following laparoscopic resection and 7 days following open (p < 0.0005). There was no significant difference between the two groups apart from gender (p = 0.03), ASA (p = 0.03), and the number of patients with extranodal metastatic disease (p = 0.01). The 5-year overall survival (OS) in the completed laparoscopic group was 75.8 versus 72.5 % in the open group (p = 0.12). The 5-year OS in patients who were converted was 52 %. The 5-year OS for nonmetastatic disease in the completed laparoscopic group was significantly greater at 79.4 versus 74 % in the open group (p = 0.03). There was no difference between the groups in OS for rectal cancer (p = 0.66), but there was an OS advantage for laparoscopically resected colon cancer (p = 0.02).

Conclusions

Laparoscopic resection for nonmetastatic colon cancer may provide an overall survival advantage.     

Comparison of the analgesic effect between continuous wound infiltration and single-injection transversus abdominis plane block after gynecologic laparotomy

Purpose

Both single-injection transversus abdominis plane (TAP) block and continuous wound infiltration (CWI) provide postoperative analgesia, but no study has compared the two regional techniques. We tested the hypothesis that CWI is more effective for controlling postoperative pain compared with single-injection TAP block after laparotomy.

Methods

We conducted a prospective randomized study of patients undergoing gynecologic laparotomy with midline incision through the umbilicus under general anesthesia. The patients were allocated to receive either single-injection TAP block (TAP group) or CWI (CWI group) for postoperative analgesia. All patients received intravenous patient-controlled analgesia with morphine and intravenous flurbiprofen twice daily after surgery. Postoperative pain at rest and on coughing, postoperative morphine consumption, incidence of postoperative nausea and vomiting (PONV), pruritus and urinary retention, ambulation, and satisfaction score were recorded. Patients were assessed at 3 h after surgery and twice daily on postoperative days (POD) 1 and 2.

Results

Data of 54 patients were analyzed. Compared to the TAP group (n = 27), pain score on coughing was significantly lower in the CWI group (n = 27) on POD1 and POD2 (P < 0.05). Pain score on coughing at 3 h after surgery, pain score at rest at all assessed time points, morphine consumption, incidence of PONV, pruritus and urinary retention, ambulation, and satisfaction score were not different between the two groups.

Conclusion

CWI reduced pain on coughing after the day of surgery compared with single-injection TAP block when performed as part of multimodal analgesia in patients undergoing gynecologic laparotomy.

     

Effect of pre-emptive pregabalin on pain intensity and postoperative morphine consumption after laparoscopic cholecystectomy

Background

Postoperative pain is the dominant complaint and the most common cause of delayed discharge after laparoscopic cholecystectomy. The aim of this study is to evaluate the potential of preoperative administration of pregabalin to reduce postoperative pain and opioid consumption.

Methods

Fifty American Society of Anesthesiologists (ASA) I and II adult patients with symptomatic gallstone disease scheduled for elective laparoscopic cholecystectomy were randomized into two groups: group I patients (n = 25) were given 600 mg pregabalin per os divided in two doses, the night before surgery and 1 h preoperatively, respectively, while group II patients (n = 25) received a matching to pregabalin placebo at the same scheme. Postoperative pain, morphine consumption, and complications were compared between the two groups.

Results

Postoperative pain (static and dynamic assessment) was significantly less at 0, 1, 8, 16, and 24 h (p < 0.001) after the procedure for group I (pregabalin) compared with the placebo group. Postoperative patient-controlled morphine consumption during hospital stay was also significantly less in the pregabalin group compared with the placebo group. Side-effects were similar in both groups expect for dizziness, which was significantly higher (p < 0.0001) in the pregabalin group.

Conclusions

Administration of 600 mg pregabalin per os, divided in two preoperative doses, significantly reduces postoperative pain as well as opioid consumption in patients undergoing laparoscopic cholecystectomy, at the cost of increased incidence of dizziness.     

Laparoscopic surgery improves postoperative outcomes in high-risk patients with colorectal cancer

Background

Patients with significant comorbidities often are denied laparoscopic colorectal resections, because they are thought to be too “high-risk.” This study was designed to examine the feasibility and safety of laparoscopic colorectal resections in high-risk colorectal cancer patients and to compare them with a similar cohort of patients undergoing open resections in the same time period.

Methods

This was a single-center, prospective, cohort study conducted at a high-volume, nonuniversity, tertiary care hospital. From a database of 616 patients submitted to elective colorectal surgery for cancer within a fast-track protocol (January 2005 to November 2011), 188 patients who met at least one minor (age >80 years and body mass index (BMI) >30 m/kg²) and one major (cardiac, pulmonary, renal or liver disease, diabetes mellitus) criterion were classified as high-risk. Differences in baseline characteristics, intraoperative outcomes, and short-term (30-day) postoperative outcomes, as well as the pathology findings and the readmission and reoperation rates, were compared between the open and laparoscopic cohorts in both high- and low-risk groups and between high- and low-risk groups.

Results

During the study period, 68 high-risk patients underwent laparoscopic resections and 120 had open surgeries. A shorter length of postoperative stay (6 vs. 9 days, p < 0.0001) and fewer postoperative nonsurgical complications (4 % vs. 19 %, p = 0.003) were observed among the laparoscopic group. Postoperative major (p = 0.774) and minor complications (p = 0.3) and reoperations (p = 0.196) were similar between the two groups, and a significantly lower rate of mortality (1.5 vs. 7.5 %, p = 0.038) was observed in the laparoscopic group than in the open group.

Conclusions

Laparoscopic colorectal resection can be safely performed on “high-risk” surgical patients with better results than a similar group of high-risk patients undergoing open colon resections.     

Volumetric Changes after 90Y Radioembolization for Hepatocellular Carcinoma in Cirrhosis: An Option to Portal Vein Embolization in a Preoperative Setting?

Background

Contralateral hypertrophy after ⁹⁰Y radioembolization has been described in case reports, but the incidence and quantitative extent of liver volume modifications after this therapy are unknown.

Methods

This retrospective study examined patients with hepatocellular carcinoma and underlying cirrhosis treated by ⁹⁰Y radioembolization. The main inclusion criteria were unilateral treatment, no prior liver surgery, and computed tomographic scans allowing for volumetric assessments. Treated, tumor, and contralateral liver volumes were measured. Whole liver volume and the ratio of contralateral to total functional liver volume after a virtual hepatectomy were calculated.

Results

Data of 34 patients were analyzed. Response rates were 26 % according to Response Evaluation Criteria in Solid Tumors (RECIST) and 63 % according to modified RECIST. Median overall survival was 13.5 months. Median treated volume decreased from 938 mL (interquartile range [IQR] = 719) to 702 mL (IQR = 656) (p < 0.001), while median contralateral volume increased from 724 mL (IQR = 541) to 920 mL (IQR = 530) (p < 0.001). The whole liver volume remained stable, with a median volume of 1,702 mL (IQR = 568) versus 1,577 mL (IQR 670), respectively (p = 0.55). The mean maximal increase in contralateral volume was 42 % (95 % confidence interval 16–67). Overall, 13 patients (38.2 %) exhibited increases greater than 30 %, while 13 patients (38.2 %) showed no increase or showed increases less than 10 %. The median ratio of contralateral to total functional liver volume increased from 48.5 to 64.9 % (p < 0.001), with the proportion of patients with a ratio of ≥50 % increasing from 47.1 to 67.6 % (p = 0.013).

Conclusions

⁹⁰Y radioembolization induced frequent and similar increases in functional liver remnant volume compared with portal vein embolization. This technique should be tested in a prospective study phase 2 study before liver resection.     

Initial experience of a surgical fellow in laparoscopic colorectal cancer surgery under training protocol and supervision: comparison of short-term results for 70 early cases (under supervision) and 73 late cases (without supervision)

Purpose

Laparoscopic colorectal surgery is a technically challenging procedure for beginners, such as surgical fellows. The purpose of this study was to assess the safety, feasibility, and short-term surgical outcomes of laparoscopic colorectal cancer surgery by a single surgical fellow.

Methods

The study analyzed the data from 143 consecutive patients who underwent laparoscopic colorectal resection by a single surgical fellow between August 2009 and October 2010. The patients were divided into two groups: the early group—the first 70 patients (under supervision of experienced surgeon), and the late group—the last 73 patients (without supervision). The short-term surgical results were compared between two groups.

Results

The operations were 24 right colon resections, two transverse colectomies, six left colectomies, 36 anterior resections, 57 low anterior resections, 12 intersphincteric resections, two abdominoperineal resections, three Hartmann’s operations, and 1 total colectomy. The mean operating time, mean amounts of blood loss, and conversion rate were similar between the two groups. The morbidity rate, anastomosis leak rate, and mortality rate within 30 days of surgery did not differ significantly. The mean number of lymph nodes was larger in the late group (23.8 vs. 31.7, P = 0.017). In terms of low anterior resection, the mean number of endo-linear staplers used was smaller in the late group (2.46 ± 0.81 vs. 1.97 ± 0.83, P = 0.028). The anastomosis leakage rate in rectal cancer surgery was not significantly different between the two groups.

Conclusions

This study demonstrates that laparoscopic colorectal resections can be independently performed safely after a period of supervision and training by an experienced surgeon.