Early rehabilitation versus conventional care after laparoscopic rectal surgery: a prospective, randomized, controlled trial

Background

Although early rehabilitation programs have been reported to be effective after laparoscopic colectomy, there is no report of the efficacy of rehabilitation programs after rectal cancer surgery. This study was designed to evaluate the efficacy of an early rehabilitation program after laparoscopic low anterior resection for mid or low rectal cancer in a randomized, controlled trial.

Methods

Ninety-eight patients who had undergone a laparoscopic low anterior resection with defunctioning ileostomy were randomized on a 1:1 basis to an early rehabilitation program (n = 52) or conventional care (n = 46). The primary endpoint was recovery rate at 4 days postoperatively. The secondary endpoints were recovery time, postoperative hospital stay, complications, readmission rates, pain on a visual analogue scale, and quality of life (QOL) according to Short Form 36.

Results

The recovery rates were not different in both groups (rehabilitation, 25 % vs. conventional, 13 %, p = 0.135). Recovery time and postoperative hospital stay was similar between the groups (rehabilitation, 137 h [107–188] vs. conventional, 146.5 h [115–183], p = 0.47; 7.5 days [7–11] vs. 8.0 days [7–10], p = 0.882). The complication rates did not differ between the two groups, but more complications were noted in the rehabilitation program group (42.3 vs. 24.0 %, p = 0.054), which was related to postoperative ileus (28.8 vs. 13.0 %, p = 0.057) and acute voiding difficulty (19.6 vs. 4.7 %, p = 0.032). There was no readmission within 1 month of surgery. Pain and QOL were similar in both groups.

Conclusions

This randomized trial did not show that an early rehabilitation program is beneficial after laparoscopic low anterior resection. Our results confirm that postoperative ileus and acute voiding difficulty are major obstacles to fast-track surgery for mid or low rectal cancer. This study was registered (registration number NCT00606944).     

Impact of a trimodal prehabilitation program on functional recovery after colorectal cancer surgery: a pilot study

Background

Patients undergoing colorectal cancer resections are at risk for delayed recovery. Prehabilitation aims to enhance functional capacity preoperatively for better toleration of surgery and to facilitate recovery. The authors previously demonstrated the limited impact of a prehabilitation program using exercise alone. They propose an expanded trimodal prehabilitation program that adds nutritional counseling, protein supplementation, and anxiety reduction to a moderate exercise program. This study aimed to estimate the impact of this trimodal program on the recovery of functional capacity compared with standard surgical care.

Methods

Consecutive patients were enrolled in this pre- and postintervention study over a 23-month period. The postoperative recovery for 42 consecutive patients enrolled in the prehabilitation program was compared with that of 45 patients assessed before the intervention began. The primary outcome was functional walking capacity (6-min walk test [6MWT]). The secondary outcomes included self-reported physical activity (CHAMPS questionnaire) and health-related quality of life (SF-36). Data are expressed as mean ± standard deviation or median (interquartile range [IQR]) and were analyzed using Chi-square and Student’s t test. All p values lower than 0.05 were considered significant.

Results

The prehabilitation and control groups were comparable in terms of age, gender, body mass index (BMI) and American Society of Anesthesiology (ASA) class. There was no difference in walking capacity at the first assessment (6MWT distance, 422 ± 87 vs 402 ± 57 m; p = 0.21). During the prehabilitation period lasting a median of 33 days (range, 21–46 days), functional walking capacity improved by 40 ± 40 m (p < 0.01). The postoperative complication rates and the hospital length of stay were similar. The patients in the prehabilitation program had better postoperative walking capacity at both 4 weeks (mean difference, 51.5 ± 93 m; p = 0.01) and 8 weeks (mean difference, 84.5 ± 83 m; p < 0.01). At 8 weeks, 81 % of the prehabilitated patients were recovered compared with 40 % of the control group (p < 0.01). The prehabilitation group also reported higher levels of physical activity before and after surgery.

Conclusion

In this pilot study, a 1-month trimodal prehabilitation program improved postoperative functional recovery. A randomized trial is ongoing (NCT01356264).     

Insights into fast-track colon surgery: a plea for a tailored program

Background

This retrospective study compared the fast-track colon surgery program to conventional perioperative care and assessed factors that influence postoperative length of stay.

Design

This retrospective study included 124 fast-track and 119 conventional care colon surgical patients. Exclusion criteria were primary rectal disease, stoma, American Society of Anesthesiologists score IV, and Association Française de Chirurgie index 3 or 4. Laparoscopy was the preferred approach. Variables influencing length of stay were analyzed by multivariate linear and logistic regression.

Results

Overall mortality and complication rates were not significantly different between groups (fast-track vs. controls 0 vs. 0.8 %, 30.6 vs. 38.6 % respectively). As expected, median length of stay was significantly reduced in fast-track patients (3 vs. 6 days, p < 0.001), but emergency readmission rate was higher (16.9 vs. 7.6 %, p = 0.026), although rehospitalization rates were similar (8 vs. 4.2 %, not significant). Independent risk factors of increased length of stay were identified as age >69 years (p = 0.001), laparotomy (p = 0.011), and conventional perioperative care (p < 0.001).

Conclusions

The introduction of a fast-track program reduced postoperative length of stay without increasing complication rate. This study proposes a modulation of the program according to patient age and surgical approach.     

Laparoscopic Versus Open Surgery for Stage I Rectal Cancer: Long-term Oncologic Outcomes

Background

Laparoscopic resection is increasingly being performed for rectal cancer. However, few data are available to compare long-term outcomes after open versus laparoscopic surgery for early-stage rectal cancer.

Methods

Included in this retrospective study were 160 patients who underwent surgery for stage I rectal cancer between 2001 and 2008. Perioperative outcomes, overall survival (OS), and disease-free survival (DFS) were compared for open versus laparoscopic surgery.

Results

Altogether, 85 patients were treated using open surgery and 80 with laparoscopic surgery. Postoperative mortality (0 vs. 1.3 %; p = 1.00), morbidity (31.3 vs. 25.0 %; p = 0.38), and harvested lymph nodes (22.5 vs. 20.0; p = 0.84) were similar for the two groups. However, operating time was longer (183.8 vs. 221.0 min; p = 0.008), volume of intraoperative bleeding was less (200.0 vs. 150.0 ml; p = 0.03), time to first bowel movement was shorter (3.54 vs. 2.44 days; p < 0.001), rate of superficial surgical-site infection was lower (7.5 vs. 0 %; p = 0.03), and postoperative hospital stay was shorter (11.0 vs. 8.0 days; p < 0.001) in the laparoscopy group than in the open surgery group. At 5 years, there was no difference in OS (98.6 vs. 97.1 %; p = 0.41) or DFS (98.2 vs. 96.4 %; p = 0.30) between the open and laparoscopy groups.

Conclusions

Long-term outcomes of laparoscopic surgery for stage I rectal cancer were comparable to those of open surgery. Laparoscopic surgery, however, produced more favourable short-term outcomes than open surgery.     

Deprivation and Colorectal Cancer Surgery: Longer-Term Survival Inequalities are Due to Differential Postoperative Mortality Between Socioeconomic Groups

Background

Deprivation is associated with poorer survival after surgery for colorectal cancer, but determinants of this socioeconomic inequality are poorly understood.

Methods

A total of 4,296 patients undergoing surgery for colorectal cancer in 16 hospitals in the West of Scotland between 2001 and 2004 were identified from a prospectively maintained regional audit database. Postoperative mortality (<30 days) and 5-year relative survival by socioeconomic circumstances, measured by the area-based Scottish Index of Multiple Deprivation 2006, were examined.

Results

There was no difference in age, gender, or tumor characteristics between socioeconomic groups. Compared with the most affluent group, patients from the most deprived group were more likely to present as an emergency (23.5 vs 19.5 %; p = .033), undergo palliative surgery (20.0 vs 14.5 %; p < .001), have higher levels of comorbidity (p = .03), have <12 lymph nodes examined (56.7 vs 53.1 %; p = .016) but were more likely to receive surgery under the care of a specialist surgeon (76.3 vs 72.0 %; p = .001). In multivariate analysis, deprivation was independently associated with increased postoperative mortality [adjusted odds ratio 2.26 (95 % CI, 1.45–3.53; p < .001)], and poorer 5-year relative survival [adjusted relative excess risk (RER) 1.25 (95 % CI, 1.03–1.51; p = .024)] but not after exclusion of postoperative deaths [adjusted RER 1.08 (95 %, CI .87–1.34; p = .472)].

Conclusions

The observed socioeconomic gradient in long-term survival after surgery for colorectal cancer was due to higher early postoperative mortality among more deprived groups.     

Functional outcome and mortality in nonagenarians following hip fracture surgery

Introduction

The world’s population is ageing and the elderly population itself is growing older. This population shows a high incidence of hip fractures. We performed a retrospective study, reviewing the functional status, postoperative complications and mortality rate of nonagenarians who underwent surgery for hip fracture.

Methods and subjects

56 nonagenarian patients underwent hip fracture surgery in our institution between January 2000 and December 2010. Two of these patients had presented with hip fracture on separate occasions, giving a total of 58 hips for analysis. Patients with open fracture, subtrochanteric fracture, polytrauma and pathological fracture were excluded. The case notes, electronic records and X-rays for all those included in the study were reviewed. The main outcome measures were functional status, postoperative complications and mortality rate at 1 year.

Results

Patients with extracapsular hip fractures were associated with higher risks of postoperative complications (60.7 %; p = 0.037), mortality (25 %; p = 0.003) and more likely to be non-ambulant at 1 year (53.6 vs 16.7 %; p = 0.003). Females were more likely to suffer postoperative complications than males (p = 0.016). 46.6 % of the patients had immediate postoperative complications and most commonly due to urological complications (29.3 %). The 1-year mortality rate was 12.1 %. A notable proportion of patients (65.5 %) remained ambulant 1 year postoperatively, although almost half of the patients (48.3 %) who could ambulate independently pre-injury required a walking aid after hip fracture surgery.

Conclusion

Nonagenarians have good surgical outcomes after hip fracture surgery with low mortality rate. They should be treated similarly as their younger counterparts in terms of decision for surgery. Potential decline in functional status and rehabilitation options should be shared with the patient and family at an early stage.     

Intraoperative colonoscopy does not worsen the outcomes of laparoscopic colorectal surgery: a case-matched study

Background

Intraoperative colonoscopy is sometimes needed as an adjunct to colorectal surgery. When it is performed with laparoscopic surgery, there is the potential for prolonged bowel distension, obstructed surgical exposure, and increased morbidity. This study aimed to evaluate the overall safety and outcomes of laparoscopic colorectal procedures in which intraoperative colonoscopy was performed.

Methods

The study group consisted of patients who underwent intraoperative colonoscopy during laparoscopic intestinal resection at our institution between 1995 and 2011. They were individually matched for a number of factors including age, gender, diagnosis, American Society of Anesthesiologists (ASA) physical status score, and type of surgical procedure with a cohort of patients who underwent laparoscopic intestinal resection with no intraoperative colonoscopy during the same period. Early postoperative outcomes and time to flatus and first bowel movement were compared.

Results

For the study, 30 patients (18 females) and 30 matched control subjects were identified. The study and control groups did not differ in terms of operating time (132 vs 151 min; p = 0.5), estimated blood loss (216 vs 212 ml; p = 0.9), conversion to open surgery (n = 1 vs 5; p = 0.2), time to first flatus (3 vs 4 days; p = 0.4), time to first bowel movement (4 vs 4 days; p = 0.4), reoperation (n = 0 vs 1; p = 1), length of hospital stay (6 vs 9 days; p = 0.3), overall morbidity (n = 10 vs 14; p = 0.4), or readmission (n = 0 vs 1; p = 1). The complications that developed during or after surgery were similar in the two groups. No colonoscopy-related complications or deaths occurred.

Conclusions

Intraoperative colonoscopy does not complicate the application and outcomes of laparoscopic intestinal resection. Surgeons should perform an intraoperative colonoscopy when it is indicated during laparoscopic surgery.     

Comparison of minimally invasive fusion and instrumentation versus open surgery for severe stenotic spondylolisthesis with high-grade facet joint osteoarthritis

Purpose

The object of this study was to compare minimally invasive surgery (MIS) with open surgery in a severely affected subgroup of degenerative spondylolisthetic patients with severe stenosis (SDS) and high-grade facet osteoarthritis (FJO).

Methods

From January 2009 to February 2010, 49 patients with severe SDS and high-grade FJO were treated using either MIS or open TLIF. Intraoperative and diagnostic data, including perioperative complications and length of hospital stay (LOS), were collected, using retrospective chart review. Surgical short- and long-term outcomes were assessed according to the Oswestry disability index (ODI) and visual analog scale (VAS) for back and leg pain.

Results

Comparing MIS and open surgery, the MIS group had lesser blood loss, significantly lesser need for transfusion (p = 0.02), more rapid improvement of postoperative back pain in the first 6 weeks of follow-up and a shorter LOS. On the other hand, we experienced in the MIS group a longer operative time. The distribution on the postoperative ODI (p = 0.841), VAS leg (p = 0.943) and back pain (p = 0.735) scores after a mean follow-up of 2 years were similar. The overall proportion of complications showed no significant difference between the groups (29 % in the MIS group vs. 28 % in the open group, p = 0.999).

Conclusion

Minimally invasive surgery for severe SDS leads to adequate and safe decompression of lumbar stenosis and results in a faster recovery of symptoms and disability in the early postoperative period.     

Structured Synchronous Implementation of an Enhanced Recovery Program in Elective Colonic Surgery in 33 Hospitals in The Netherlands

Background

It has been clearly shown that after elective colorectal surgery patients benefit from multimodal perioperative care programs. The Dutch Institute for Health Care Improvement started a breakthrough project to implement a multimodal perioperative care program of enhanced recovery after surgery (ERAS). This pre/post noncontrolled study evaluated the success of large-scale implementation of the ERAS program for elective colonic surgery using the breakthrough series.

Methods

A total of 33 hospitals participated in this breakthrough project during 2005–2009. Each hospital performed a retrospective chart review to gather information on traditionally treated patients (pre-ERAS group, n = 1,451). During the subsequent year patients were treated according to the ERAS program (ERAS group, n = 1 034). Outcomes were length of stay (LOS), functional recovery, adherence to the protocol, and determinants of reduced LOS.

Results

Median LOS decreased significantly from 9 to 6 days (p < 0.001). In the ERAS group, functional recovery was reached within 3 days. Adherence to the protocol elements was high during the preoperative and perioperative phases but slightly lower during the postoperative phase. Younger age, female sex, American Society of Anesthesiologists grades I/II, and laparoscopic surgery were associated with decreased LOS. Care elements that positively influenced LOS were cessation of intravenous fluids and mobilization on postoperative day 1 and administration of laxatives postoperatively.

Conclusions

The ERAS program was successfully implemented in one-third of all Dutch hospitals using the breakthrough series. Participating hospitals reduced the LOS by a median 3 days and were able to improve their standard of care in elective colonic surgery.     

Enhanced Recovery Pathway for Urgent Colectomy

Background

Enhanced recovery protocols have been proven to decrease complications and hospital stay following elective colorectal surgery. However, these principles have not yet been reported for urgent surgery procedures. We aimed to assess our initial experience with urgent colectomies performed within an established enhanced recovery pathway.

Methods

In a prospective cohort study, all patients undergoing colonic resection between April 2012 and March 2013 were treated according to a standardized enhanced recovery protocol. Urgent surgeries were compared with the elective procedures with regards to baseline characteristics, compliance with enhanced recovery items, and clinical outcome.

Results

Patients (N = 28) requiring urgent colonic resection were included and compared with patients undergoing elective colectomy (N = 63). Overall compliance with the protocol was 57 % for the urgent compared with 77 % for the elective procedures (p = 0.006). The pre-operative compliance was 64 versus 96 % (p < 0.001), the intra-operative compliance was 77 versus 86 % (p = 0.145), and the post-operative compliance was 49 versus 67 % (p = 0.015), for the urgent and elective resections, respectively. Overall, 18 urgent patients (64 %) and 32 elective patients (51 %) developed postoperative complications (p = 0.261). Median postoperative length of stay was 8 days in the urgent setting compared with 5 days in the elective setting (p = 0.006).

Conclusions

Many of the intra-operative and post-operative enhanced recovery items can also be applied to urgent colectomy, entailing outcomes that approach the results achieved in the elective setting.     

Less pain after transvaginal/transumbilical cholecystectomy than after the classical laparoscopic technique: short-term results of a matched-cohort study

Background

Natural orifice surgery (NOS) is gaining acceptance as an alternative to the traditional laparoscopic technique, especially for cholecystectomy through the transvaginal route. However, NOS remains controversial concerning expected advantages in terms of short- and long-term outcomes and potential side effects. This study was designed to compare short-term outcomes between transvaginal/transumbilical and classical laparoscopic cholecystectomy (LC).

Methods

A prospective matched-cohort study compared the authors’ first 50 transvaginal/transumbilical cholecystectomies (TVC) with a group of 50 classical LCs from the corresponding period matched in terms of age, body mass index, and American Society of Anesthesiology classification. In both groups, elective surgery was performed for symptomatic cholecystolithiasis. In the NOS group, a hybrid procedure was performed with one transumbilical rigid instrument and two transvaginal rigid instruments. A numeric rating scale was used for daily pain assessment, initiated postoperatively in the recovery room. Both groups were compared with regard to length of surgery, intra- and postoperative complications, length of hospital stay, postoperative pain, and consumption of analgesics.

Results

The length of surgery and the rate of complications were similar in the two groups. But significant advantages were found for the transvaginal access in terms of pain using Numeric Rating Scale (NRS) on the day of surgery (NRS, 1.5/10 vs 3.1/10; p = 0.003) as well as in the morning (NRS, 1.9/10 vs 2.8/10; p = 0.047) and in the evening (NRS, 1.1/10 vs 1.8/10; p = 0.025) of postoperative day 1, and with regard to the length of the postoperative hospital stay (2.7 vs 3.4 days; p = 0.035).

Conclusions

The findings show that TVC is a safe procedure for female patients. It has a risk comparable with that of classic LC, causes significantly less pain in the early postoperative period, and leads to a significantly shorter hospital stay. Prospective randomized trials are necessary to confirm these results.     

Single-port cholecystectomy in obese patients: our experience and a review of the literature

Purpose

The objective of the present study was to compare the postoperative outcomes between obese and normal-weight patients undergoing single-port cholecystectomy (SPC) for gallstone disease.

Methods

A prospectively maintained SPC-database was retrospectively analyzed, and the outcomes of obese [body mass index (BMI) ≥30 kg/m²] and normal-weight patients were compared. All patients underwent SPC using the reusable X-Cone? device.

Results

A total of 100 patients underwent SPC between July 2009 and September 2011. Seventeen obese patients (17 %) (median BMI 33.9 kg/m², range 30.0–38.8) were compared to 83 normal-weight patients (median BMI 24.1 kg/m², range 17.3–29.5). The length of the operation (median 75.5 min, range 42–156 vs. median 72.0 min, range 42–129; p = 0.51), conversion rate (N = 2 vs. N = 0; p = 1), postoperative complication rate (9.6 vs. 11.8%; p = 0.68), and postoperative hospital stay (median 3 days, range 1–14 vs. median 3 days, range 2–5; p = 0.74), were comparable for the normal-weight and obese patients.

Conclusion

The postoperative outcome of obese patients after SPC is not inferior to that of normal-weight patients undergoing the same operation. Therefore, the BMI should not be considered a key criterion in the patient selection for single-port surgery.     

Two-day Hospital Stay After Laparoscopic Colorectal Surgery under an Enhanced Recovery after Surgery (ERAS) Pathway

Background

The present study aims to examine the feasibility and safety of a two-day hospital stay after laparoscopic colorectal resection (LCR) under an enhanced recovery after surgery (ERAS) pathway.

Methods

Between 2003 and 2010, 882 consecutive patients undergoing LCR were analyzed. Patients were grouped and analyzed according to whether their hospital stay was 2 days (group A) or longer (group B). Demographic, surgical, and postoperative data were compared. To identify independent predictive factors related to a short hospital stay, a multivariate analysis was also performed.

Results

Group A represented 10.3 % of this series (91 patients). There were no differences regarding age, gender, BMI, ASA, and previous abdominal surgeries between groups. Group A had a lower incidence of rectal cancer and anterior resections than group B (6.6 vs. 17.7 % [p = 0.006] and 14.3 vs. 23.4 % [p = 0.048]), respectively, and a lower mean operative time (170 min vs. 192 min; p = 0.002). Group A had a lower overall morbidity rate than group B (5.5 vs. 16.9 %; p = 0.004) and a lower incidence of surgery-related complications (5.5 vs. 14.9 %; p = 0.001). The overall conversion rate was 10 % (only one patient in group A required conversion), and the difference in conversion rate between groups was statistically significant (1.2 vs. 10.7 %; p = 0.003). Group A had a lower readmission rate (0 vs. 4.9 %; p = 0.089). Multivariate analysis showed that conversion, postoperative morbidity, and rectal prolapse were independently associated with the length of hospital stay.

Conclusions

A two-day hospital stay after LCR is safe and feasible under an ERAS pathway, without compromising the readmission or complication rate.     

Validation of the SF-36 as a measure of postoperative recovery after colorectal surgery

Introduction

Surgery is evolving, and new techniques are introduced to improve “recovery.” Postoperative recovery is complex, and evaluating the effectiveness of surgical innovations requires assessment of patient-reported outcomes. The Short-Form-36 (SF-36), a generic health-related quality of life questionnaire, is the most commonly used instrument in this context. The objective of this study was to contribute evidence for the validity of the SF-36 as a metric of postoperative recovery.

Methods

Data from 128 patients undergoing planned colorectal surgery at one university hospital between 2005 and 2010 were analyzed. In the absence of a gold standard, the responsiveness and construct validity (known groups and convergent) of the SF-36 were evaluated. Standardized response means were computed for the former and non-parametric tests were used to assess the statistical significance of the changes observed. Multiple linear regression was used to determine whether the SF-36 discriminates between patients with versus without complications and between laparoscopic and open surgery (known groups); correlations between the SF-36 and the 6-min walk test, a measure of functional walking capacity (convergent) was investigated with Spearman’s rank correlation.

Results

The SF-36 was sensitive to clinically important changes. Scores on six of eight domains and the physical component summary score deteriorated postoperatively (SRM 0.86 for the PCS, p < 0.01) and improved to baseline thereafter. Patients with complications had significantly lower scores on five SF-36 domains (with differences from ?9 (?18, ?1), p = 0.04 to ?18 (?32, ?2), p = 0.03), and scores on all subscales were lower than those in a healthy population (p < 0.01 to p = 0.04). The SF-36 did not differentiate between laparoscopic and open surgery. Physical functioning scores correlated with 6MWT distance at 1 and 2 months (Spearman’s r = 0.31 and 0.36, p < 0.01).

Conclusions

The SF-36 is responsive to expected physiological changes in the postoperative period, demonstrates construct validity, and thus constitutes a valid measure of postoperative recovery after planned colorectal surgery. The SF-36 did not, however, discriminate between recovery after laparoscopic and open surgery.     

Reoperative Surgery After Repair of Postcholecystectomy Bile Duct Injuries: Is it Worthwhile?

Background

Repeat repair of bile duct injuries (BDIs) after cholecystectomy is technically challenging, and its success remains uncertain. We retrospectively evaluated the short- and long-term outcomes of patients requiring reoperative surgery for BDI at a major referral center for hepatobiliary surgery.

Methods

Between January 1991 and May 2011, we performed surgical BDI repairs in 46 patients. Among them, 22 patients had undergone a previous surgical repair elsewhere (group 1), and 24 patients had no previous repair (group 2). We compared the early and late outcomes in the two groups.

Results

The patients in group 1 were younger (48.6 vs. 54.8 years, p = 0.0001) and were referred after a longer interval (>1 month) from BDI (72.7 vs. 41.7 %, p = 0.042). Intraoperative diagnosis of BDI (59.1 vs. 12.5 %, p = 0.001), ongoing cholangitis (45.4 vs. 12.5 %; p = 0.02), and delay of repair after referral to our institution (116 ± 34 days vs. 23 ± 9 days; p = 0.001) were significantly more frequent in group 1 than in group 2. No significant differences were found for postoperative mortality, morbidity, or length of stay between the groups. Patients with associated vascular injuries had a higher postoperative morbidity rate (p = 0.01) and associated hepatectomy rate (p = 0.045). After a mean follow-up of 96.6 ± 9.7 months (range 5–237.2 months, median 96 months), the rate of recurrent cholangitis (6.5 %) was comparable in the two groups.

Conclusions

This study demonstrates that short- and long-term outcomes after surgical repair of BDI are comparable regardless of whether the patient requires reoperative surgery for a failed primary repair. Associated vascular injuries increase postoperative morbidity and the need for liver resection.     

Enhanced Recovery After Surgery Pathway in Patients Undergoing Pancreaticoduodenectomy

Background

Enhanced recovery after surgery (ERAS^®) pathways have reduced morbidity and length of hospital stay (LOS) in orthopedics, bariatric, and colorectal surgery. New perioperative care protocols have been tested in patients undergoing pancreaticoduodenectomy (PD), with controversial results on morbidity. Incomplete data about ERAS items compliance have been reported. The aim of this study was to assess compliance with an ERAS protocol and its impact on short-term outcome in patients undergoing PD.

Methods

A comprehensive ERAS protocol was applied in 115 consecutive patients undergoing PD. Each ERAS patient was matched with one patient who received standard perioperative care. Match criteria were age, gender, malignant/benign disease, and PD-specific prognostic score.

Results

No adverse effect related to ERAS items occurred. Compliance with postoperative items ranged between 38 and 66 %. The ERAS group had an earlier recovery of mobilization (p < 0.001), oral feeding (p < 0.001), gut motility (p < 0.001), and an earlier suspension of intravenous fluids (p = 0.041). No difference between ERAS and control group was found in mortality, overall morbidity, and major complication rates. Subgroup analysis showed that 43/60 (71 %) patients with early postoperative low compliance with the ERAS pathway had complications. The ERAS pathway significantly shortened LOS in uneventful patients or those with minor complications (11.2 vs. 13.7 days, p = 0.001).

Conclusion

The ERAS pathway was feasible and safe, yielding an earlier postoperative recovery. An ERAS protocol should be implemented in patients undergoing PD; however, patients with early postoperative low compliance should be carefully managed.     

Laparoscopic resection for hepatocellular carcinoma: a matched-pair comparative study

Background

Only a few series have demonstrated the safety of laparoscopic resection for hepatocellular carcinoma (HCC) and the benefits of this approach. Moreover, these studies reported mostly minor and nonanatomic hepatic resections. This report describes the results of a pair-matched comparative study between open and laparoscopic liver resections for HCC in a series of essentially anatomic resections.

Methods

Patients were retrospectively matched in pairs for the following criteria: sex, age, American Society of Anesthesiology (ASA) score, severity of liver disease, tumor size, and type of resection. A total of 42 patients undergoing laparoscopy were compared with patients undergoing laparotomy during the same period. Surgeons from the authors’ department not trained in laparoscopy performed open resections. Operative, postoperative, and oncologic outcomes were compared.

Results

The mean duration of surgery was similar in the two groups. Significantly less bleeding was observed in the laparoscopic group (364.3 vs. 723.7 ml; p < 0.0001). Transfusion was required for four patients (9.5%) in the laparoscopic group and seven patients (16.7%) in the open surgery group (p = 0.51). Postoperative ascites was less frequent after laparoscopic resections (7.1 vs. 26.1%; p = 0.03). General morbidity was similar in the two groups (9.5 vs. 11.9%; p = 1.00). The mean hospital stay was significantly shorter for the patients undergoing laparoscopy (6.7 vs. 9.6 days; p < 0.0001). The surgical margin and local recurrence adjacent to the liver stump were not affected by laparoscopy. The overall postoperative survival rates in the laparoscopic group were 93.1% at 1 year, 74.4% at 3 years, and 59.5% at 5 years and, respectively, 81.8, 73, and 47.4% in the open surgery group (p = 0.25). The postoperative disease-free survival rates in the laparoscopic group were at 81.6% at 1 year, 60.9% at 3 years, and 45.6% at 5 years, respectively, 70.2, 54.3, and 37.2% in the open surgery group (p = 0.29).

Conclusions

Laparoscopic resection of HCC for selected patients gave a better postoperative outcome without oncologic consequences. Prospective trials are required to confirm these results.     

Single-port laparoscopic colorectal resections in obese patients are as safe and effective as conventional laparoscopy

Background

Obese patients pose additional operative technical difficulties, and it is unclear if the outcomes of single-port colorectal surgery are equivalent to those of conventional laparoscopy in such patients. The aim of this study was to compare perioperative variables and short-term outcomes of single-port versus conventional laparoscopy in obese patients undergoing colorectal surgery.

Patients and methods

Obese patients (BMI ≥ 30 kg/m²) undergoing single-port laparoscopic colorectal resections between March 2009 and September 2012 were case matched 1:1 with obese counterparts undergoing conventional (multi-port) laparoscopic surgery based on diagnosis and operation type.

Results

Thirty-seven patients who underwent single-port surgery were matched with 37 conventional laparoscopic counterparts. Male gender predominated in the single-port group (26 vs 15, p = 0.02). The number of patients with a history of previous abdominal operations (17 vs 13, p = 0.48) and ASA score (3 vs 2, p = 0.6) were similar between the groups. No differences were observed with respect to conversion rate (2 vs 5, p = 0.43), operative time (146 vs 150 min, p = 0.48), estimated blood loss (159 vs 183 ml, p = 0.99), time to first flatus (3 vs 3 days, p = 0.91), time to first bowel movement (3 vs 4 days, p = 0.62), length of hospital stay (7 vs 6 days, p = 0.37), or reoperation (2 vs 1, p > 0.99), and readmission rates (2 vs 2, p > 0.99). There were no deaths.

Conclusion

For obese patients undergoing colorectal resections, single-port laparoscopy appears to be as safe and effective as conventional laparoscopy.     

Safety of Liver Resection for Hepatocellular Carcinoma After Sorafenib Therapy: A Multicenter Case-Matched Study

Background

Liver resection can be considered in some hepatocellular carcinoma (HCC) patients who received sorafenib. The lack of clinical data about safety of resection after sorafenib treatment led us to assess its potential impact on perioperative course in a multicentric study.

Methods

From 2008 to 2011, a total of 23 HCC patients who underwent liver resection after treatment with sorafenib (sorafenib group) were compared with 46 HCC patients (control group) matched for age, gender, underlying liver disease, tumor characteristics and type of resection. Patients received sorafenib for a median duration of 1 (range 0.2–11) months and drug was interrupted at least 7 days before surgery. End points were intraoperative (operative time, vascular clamping, blood loss and transfusion), and postoperative outcomes focusing on recovery of liver function.

Results

In the sorafenib group, HCC was developed on F4 cirrhosis in 48 % and the rate of major resection was 44 %. Surgical procedure duration (280 vs. 240 min), transfusion rate (26 vs. 15 %), blood loss (400 vs. 300 mL) and vascular clamping (70 vs. 74 %) were similar in the two groups. Mortality was zero in the sorafenib group and one (2.1 %) in the control group (p = 1.000). The incidence of postoperative complications was 44 % in the sorafenib group and 59 % in the control group (p = 0.307). Recovery of liver function was similar in the two groups in terms of prothrombin time (90 vs. 81 %, p = 0.429) and bilirubin level (16 vs. 24 μmol/L, p = 102) at postoperative day 5.

Conclusions

No adverse effect of preoperative administration of sorafenib was observed during and immediately after liver resection for HCC.     

Aluminum Overload Hampers Symptom Improvement Following Parathyroidectomy for Secondary Hyperparathyroidism

Background

Aluminum overload and accumulation in tissues may lead to skeletal, hematological, and neurological toxicity. The aim of this study was to assess the effects of serum aluminum levels on presentations, postoperative recovery, and symptom improvement in patients undergoing parathyroidectomy for secondary hyperparathyroidism.

Methods

From 2008 to 2013, all patients with end-stage renal disease undergoing initial parathyroidectomy were included in the study. Serum aluminum level was measured preoperatively and/or within 1 week after surgery. Preoperative and postoperative biochemical profile and symptoms were compared between the low and high aluminum groups.

Results

A total of 176 patients were included in the study. Of these, 38 (22 %) patients had serum aluminum levels higher than 20 μg/L. A higher percentage of patients in the high aluminum group were on peritoneal dialysis than in the low aluminum group (24 vs. 4 %, p = 0.001). Both groups had similar bone mineral density and changes in biochemical profiles. The preoperative parathyroidectomy assessment of symptoms (PAS) score was not associated with serum aluminum levels (p = 0.349), whereas the postoperative PAS score showed positive association (p = 0.005). There was a negative association between serum aluminum levels and the improvement of total PAS scores (p = 0.001). The high aluminum group had more residual symptoms in three aspects: bone pain (p = 0.038), difficulty getting out of a chair or car (p = 0.045), and pruritus (p = 0.041).

Conclusions

A high serum aluminum level was associated with reduced symptom improvement in patients undergoing parathyroidectomy for secondary hyperparathyroidism.