Influence of laparoscopic surgery on the outcomes of radical cystectomy within a multimodal rehabilitation protocol.

INTRODUCTION AND OBJECTIVE: The implementation of Enhanced Recover After Surgery (ERAS) multimodal rehabilitation protocols in radical cystectomy has shown to improve outcomes in hospital stay and complications. The aim of this analysis is to evaluate the impact of laparoscopic surgery on radical cystectomy within a multimodal rehabilitation program. MATERIAL AND METHODS: The study was carried out in a third level center between 2011 and 2020 including patients with bladder cancer submitted to radical cystectomy according to an ERAS (Enhanced Recovery After Surgery) protocol and the Spanish Multimodal Rehabilitation Group (GERM) with 20 items to be fulfilled. RESULTS: A total of 250 radical cystectomies were performed throughout the study period, 42.8% by open surgery (OS) and 57.2% by laparoscopic surgery (LS). The groups are comparable in demographic and clinical variables (p > 0.05). Operative time was longer in the LS group (248.4 ±â€¯55.0 vs. 286.2 ±â€¯51.9 min; p < 0.001). However, bleeding was significantly lower in the LS group (417.5 ±â€¯365.7 vs. 877.9 ±â€¯529.7 cc; p < 0.001), as was the need for blood transfusion (33.6% vs. 58.9%; p < 0.001). Postoperative length of stay (11.5 ±â€¯10.5 vs. 20.1 ±â€¯17.2 days; p < 0.001), total and major complications were also significantly lower in this group (LS). The readmission rate was lower in the LS group but not significantly (36.4% vs. 29.4%; p = 0.237). The difference between 90-day mortality in both groups was not statistically significant (2.8% LS vs. 4.3% OS; p = 0.546). The differences were maintained in the multivariate models. CONCLUSIONS: Laparoscopic surgery within a multimodal rehabilitation program increases operative time but significantly decreases intraoperative bleeding, transfusion requirements, postoperative length of stay, and complications.

Enhanced Recovery after Surgery is Feasible and Beneficial and Should Be the Standard in Major Gynecological Surgeries.

BACKGROUND: Enhanced recovery after surgery (ERAS) protocols are evidence-based protocols designed to standardize medical care, improve outcomes, and lower healthcare costs. OBJECTIVES: To evaluate the implementation of the ERAS protocol and the effect on recovery during the hospitalization period after gynecological laparotomy surgeries. METHODS: We compared demographic and clinical data of consecutive patients at a single institute who underwent open gynecological surgeries before (August 2017 to December 2018) and after (January 2019 to March 2020) the implementation of the ERAS protocol. Eighty women were included in each group. RESULTS: The clinical and demographic characteristics were similar among the women operated before and after implementation of the ERAS protocol. Following implementation of the protocol, decreases were observed in post-surgical hospitalization (from 4.89 ± 2.56 to 4.09 ± 1.65 days, P = 0.01), in patients reporting nausea symptoms (from 18 (22.5%) to 7 (8.8%), P = 0.017), and in the use of postoperative opioids (from 77 (96.3%) to 47 (58.8%), P < 0.001). No significant changes were identified between the two periods regarding vomiting, 30-day re-hospitalization, and postoperative minor and major complications. CONCLUSIONS: Implementation of the ERAS protocol is feasible and was found to result in less postoperative opioid use, a faster return to normal feeding, and a shorter postoperative hospital stay. Implementation of the protocol implementation was not associated with an increased rate of complications or with re-admissions.

Time to conceive after myomectomy: should we advise a minimum time interval? A systematic review.

The optimal time interval between myomectomy and pregnancy is unclear and no specific guidelines exist. The aim of this review was to study the time interval from myomectomy to pregnancy and the occurrence of uterine rupture after myomectomy. Randomized controlled trials, cohort studies and retrospective studies were used to assess the primary objective, and case reports, cases series or letters to the editor for the secondary objective. Only articles reporting myomectomy performed via the vaginal route, laparotomy, laparoscopy or robot-assisted surgery were selected for inclusion. Among 3852 women who wanted to become pregnant after the surgery, 2889 became pregnant, accounting for 3000 pregnancies (77.9%) and 2097 live births (54.4%). Mean time between myomectomy and pregnancy was estimated at 17.6 months (SD 9.2) for 2451 pregnant women. Among 1016 women, a third were advised to delay attempting to conceive for between 3 and 6 months and another third for between 6 and 12 months. A total of 70 spontaneous uterine ruptures with a mean gestational age of 31 weeks at occurrence were identified. No linear relationship was found between gestational age at the event and time interval from myomectomy to conception (P = 0.706). There are insufficient data to advise a minimal time interval between myomectomy and conception.

Functional outcomes of pediatric laparoscopic pyeloplasty: post-operative functional recovery is superior in infants compared to older children.

AIM: Laparoscopic pyeloplasty (LP) is less popular and considered less successful in infants compared to older children. There are few reports analyzing the functional results of LP in relation to age of surgery. The aim of this paper is to compare the functional results of LP in infants (group 1) with children over 1 year of age (group 2). MATERIAL AND METHODS: The data of all children undergoing LP between August 2016 and July 2019 were retrospectively analyzed for patient details and follow-up. Only children (n = 135) with at least 1-year follow-up and completed post-operative ultrasound and diuretic renogram were included. All children underwent pre-operative and post-operative ultrasound and diuretic renogram; pre-operative, operative and post-operative parameters were compared between both groups. Statistical analysis was done using software; Mann-Whitney U test, Student t test, and Fisher's exact test were applied. RESULTS: There were 71 infants (group 1) and 64 children > 1 year (group 2). Pre-operatively, all kidneys had SFU grade 3 or 4 HDN and 131/135 kidneys had a renal pelvic APD > 20 mm; all kidneys had unequivocal obstruction on DR. At surgery, the preferred drainage method was intra-operative antegrade placement of a JJ stent in 68 (96%) group 1 and 63 (98%) group 2 children. The remaining 4 cases (3 group 1, 1 group 2) had a nephrostomy with trans-anastomotic external stent placement, because the JJ stent could not be negotiated into the bladder. The demographic data and comparison of pre- and post-operative parameters between both groups are summarized in Tables 1 and 2, respectively. Group 1 had significantly more children with antenatal diagnosis of HDN (87% vs 56%, p = 0.0005). The 36 children with antenatal diagnosis in group 2 were initially followed expectantly; the indication for pyeloplasty was deterioration of SRF on serial DR, urinary infection, and pain, in 13, 14, and 9 children, respectively. The operating time was significantly longer in group 2 (p = 0.0001). There was no difference in the success of LP or complication rate in both groups. Group 2 had significantly more children with extrinsic obstruction (1.4% vs 17%, p = 0.001). All children underwent post-operative US and DR; a significant reduction in hydronephrosis (APD) on follow-up was noted in both groups (p = 0.0001). The mean pre-operative SRF in both groups was comparable (p = 0.088). The mean SRF in both groups improved significantly after LP; however, the mean post-operative SRF was significantly higher in group 1 when compared to group 2 (p = 0.0001). Furthermore, group 1 had significantly more kidneys demonstrating > 10% increase in SRF after LP (53% vs 26%, p = 0.0003). CONCLUSIONS: The safety profile and success of LP in infants was comparable to older children. Infant LP took shorter time to perform, while older children had increased incidence of extrinsic obstruction. Infant kidneys demonstrated better functional improvement than older children after LP. These findings should encourage more surgeons to utilize LP for pyeloplasty even in infants.

Operationalizing Postdischarge Recovery From Laparoscopic Sacrocolpopexy for the Preoperative Consultative Visit.

OBJECTIVE: The objective was to establish a threshold for postdischarge surgical recovery from laparoscopic sacrocolpopexy for the preoperative consultative visit to answer the "what is my recovery time?" question. METHODS: Study participants (N = 171) with stage 2 or worse pelvic organ prolapse undergoing laparoscopic sacrocolpopexy who completed postoperative surveys at 4 time points. Postdischarge Surgical Recovery 13 (PSR13) scores were anchored to a Global Surgical Recovery (GSR) tool (if 100% recovery is back to your usual health, what percentage of recovery are you now?). Weighted mean PSR13 scores were calculated as a sum of the products variable when patients considered themselves 80 to less than 85, 85 to less than 90, 90 to less than 95, or 95 to 100 percent recovered on the GSR tool. The percentage of study participants recovered at postdischarge day 7, 14, 42, and 90 was calculated based on a comparison between the GSR scores and weighted mean PSR13 scores. RESULTS: A PSR13 score of 80 or greater, corresponding to 85% or greater recovery, was seen in 55.6% (42 days) and 50.9% (90 days) of study participants, respectively, establishing this numeric threshold as representing "significant" postdischarge recovery after laparoscopic sacrocolpopexy. At 14 days after discharge, only 16.4% of the study population achieved this PSR13 score. CONCLUSIONS: Most study subjects were "significantly" recovered at 42 days after laparoscopic sacrocolpopexy using a PSR13 score of 80 or greater as a numeric threshold. There is a need to determine the population percentage of recovered study subjects at 30, 60, and beyond 90 days from laparoscopic sacrocolpopexy.

Enhanced Recovery and Surgical Optimization Protocol for Minimally Invasive Gynecologic Surgery: An AAGL White Paper.

This is the first Enhanced Recovery After Surgery (ERAS) guideline dedicated to standardizing and optimizing perioperative care for women undergoing minimally invasive gynecologic surgery. The guideline was rigorously formulated by an American Association of Gynecologic Laparoscopists Task Force of US and Canadian gynecologic surgeons with special interest and experience in adapting ERAS practices for patients requiring minimally invasive gynecologic surgery. It builds on the 2016 ERAS Society recommendations for perioperative care in gynecologic/oncologic surgery by serving as a more comprehensive reference for minimally invasive endoscopic and vaginal surgery for both benign and malignant gynecologic conditions. For example, the section on preoperative optimization provides more specific recommendations derived from the ambulatory surgery and anesthesia literature for the management of anemia, hyperglycemia, and obstructive sleep apnea. Recommendations pertaining to multimodal analgesia account for the recent Food and Drug Administration warnings about respiratory depression from gabapentinoids. The guideline focuses on workflows important to high-value care in minimally invasive surgery, such as same-day discharge, and tackles controversial issues in minimally invasive surgery, such as thromboprophylaxis. In these ways, the guideline supports the American Association of Gynecologic Laparoscopists and our collective mission to elevate the quality and safety of healthcare for women through excellence in clinical practice.

Perioperative breathing training to prevent postoperative pulmonary complications in patients undergoing laparoscopic colorectal surgery: A randomized controlled trial.

OBJECTIVE: The aim of this study was to determine whether perioperative breathing training reduces the incidence of postoperative pulmonary complications in patients undergoing laparoscopic colorectal surgery. DESIGN: A randomized controlled trial. SETTING: University hospital. SUBJECTS: A total of 240 patients undergoing laparoscopic colorectal surgery participated in this study. INTERVENTION: The enrolled patients were randomized into an intervention or control group. Patients in the intervention group received perioperative breathing training, including deep breathing and coughing exercise, balloon-blowing exercise, and pursed lip breathing exercise. The control group received standard perioperative care without any breathing training. MAIN MEASURES: The primary endpoint was the incidence of postoperative pulmonary complications. The secondary objectives were to evaluate the effect of perioperative breathing training on arterial oxygenation, incidence of other postoperative complications, patient satisfaction, length of stay, and hospital charges. RESULTS: The incidence of postoperative pulmonary complications in the breathing training group was lower than that in the control group (5/120 [4%] vs 14/120 [12%]; RR 0.357, 95%CI 0.133-0.960; P = 0.031). In addition, PaO2 and arterial oxygenation index on the first and fourth days after surgery were significantly higher in the breathing training group than in the control group (P < 0.001). In addition, patients with breathing training had shorter length of stay (6d [IQR 5-7] vs 8d [IQR 7-9]), lower hospital charges (7761 ± 1679 vs 8212 ± 1326), and higher patient satisfaction (9.46 ± 0.65 vs 9.21 ± 0.47) than those without. CONCLUSION: Perioperative breathing training may reduce the incidence of postoperative pulmonary complications and preserve of arterial oxygenation after laparoscopic colorectal surgery.

Novel Technology to Capture Objective Data from Patients' Recovery from Laparoscopic Endometriosis Surgery.

STUDY OBJECTIVE: To assess the feasibility of a noncontact radio sensor as an objective measurement tool to study postoperative recovery from endometriosis surgery. DESIGN: Prospective cohort pilot study. SETTING: Center for minimally invasive gynecologic surgery at an academically affiliated community hospital in conjunction with in-home monitoring. PATIENTS: Patients aged above 18 years who sleep independently and were scheduled to have laparoscopy for the diagnosis and treatment of suspected endometriosis. INTERVENTIONS: A wireless, noncontact sensor, Emerald, was installed in the subjects' home and used to capture physiologic signals without body contact. The device captured objective data about the patients' movement and sleep in their home for 5 weeks before surgery and approximately 5 weeks postoperatively. The subjects were concurrently asked to complete a daily pain assessment using a numeric rating scale and a free text survey about their daily symptoms. MEASUREMENTS AND MAIN RESULTS: Three women aged 23 years to 39 years and with mild to moderate endometriosis participated in the study. Emerald-derived sleep and wake times were contextualized and corroborated by select participant comments from retrospective surveys. In addition, self-reported pain levels and 1 sleep variable, sleep onset to deep sleep time, showed a significant (p <.01), positive correlation with next-day-pain scores in all 3 subjects: r = 0.45, 0.50, and 0.55. In other words, the longer it took the subject to go from sleep onset to deep sleep, the higher their pain score the following day. CONCLUSION: A patient's experience with pain is challenging to meaningfully quantify. This study highlights Emerald's unique ability to capture objective data in both preoperative functioning and postoperative recovery in an endometriosis population. The utility of this uniquely objective data for the clinician-patient relationship is just beginning to be explored.

Recovery after enhanced versus conventional care laparoscopic hysterectomy performed in the afternoon: A randomized controlled trial.

OBJECTIVE: To compare enhanced recovery after surgery (ERAS) and conventional care (CC) protocols on outcomes of laparoscopic hysterectomy (LH) performed in the afternoon. METHODS: A single-center randomized controlled trial was conducted on 120 women undergoing LH who were randomly divided into the intervention group (IG; n=60) and control group (CG; n=60). Women in the IG were treated according to the ERAS protocol and those in the CG according to the CC protocol. The primary outcome was the length of hospitalization. Secondary outcomes were postoperative opioid use, postoperative pain and emesis, complications, operative bleeding, and time. RESULTS: More women discharged during 24 hours in the IG than in the CG (88% vs 55%, P<0.001). The time to actual discharge (19 vs 22 hours, P<0.001) and ready-to-discharge time (15 vs 21 hours, P<0.001) were shorter and the use of oxycodone was lower (0 mg [0-0 vs 2.5 mg [0-10], P<0.001) in the IG than in the CG, respectively. Otherwise, no other significant differences between the groups were observed. The follow-up time was one month. CONCLUSION: The ERAS protocol reduces hospital stay and decreases the use of opioids with no impairment in surgical outcome of LH. ClinicalTrials.gov: NCT03828981.

Altura del tumor en el cáncer de recto: resultados postoperatorios y oncológicos en cirugía laparoscópica / Tumor height in rectal cancer: oncological and post surgery results in laparoscopic surgery

RESUMEN Existe pobre evidencia del impacto de la altura de los tumores de recto extraperitoneal en los resultados postoperatorios y oncológicos. No obstante, se ha reportado que aquellos tumores de recto inferior tendrían peor pronóstico oncológico y mayor tasa de complicaciones. Sin embargo, se desconoce si la laparoscopía podría disminuir dichas dificultades en tumores bajos. El objetivo de este trabajo fue revisar artículos bibliográficos actualizados relacionados con los tumores de recto extraperitoneal y los resultados utilizando un abordaje laparoscópico. Se incluyeron 22 artículos sobre tumores de recto extraperitoneal operados por vía laparoscópica. Se compararon variables demográficas, resultados quirúrgicos, histopatológicos y oncológicos entre los artículos revisados. No hubo diferencias en variables demográficas en la revisión. La incidencia de complicaciones tempranas fue muy baja y las complicaciones tardías fueron más anatomopatológicas (escisión total del mesorrecto, margen de resección circunferencial). Las variables y estadios patológicos no presentaron diferencias. Con una mediana de seguimiento de 41,8 meses (rango: 6-120), las tasas de recurrencia y sobrevida fueron comparables. La altura de los tumores de recto extraperitoneal no afectaría los resultados quirúrgicos ni oncológicos en la escisión total del mesorrecto laparoscópica (AU).

SUMMARY There is little evidence of the impact of the extra peritoneal rectal tumors height in the oncological and post surgery results. Nevertheless, it has been reported that inferior rectal tumors would have a worse oncological prognosis and a bigger rate of complications. But it is unknown if laparoscopy could reduce those difficulties in low tumors. The aim of this work was reviewing up-dated bibliographic articles dealing with tumors of the extra peritoneal rectum and the results obtained using a laparoscopic approach. 22 articles on tumors of extra peritoneal rectum that underwent laparoscopic surgery were included. Demographic variables and oncological, histopathologic surgical results were compared between the reviewed articles. Differences in demographic variables were not found in the review. The incidence of early complications was low and late complications were more anatomopathologic ones (total mesorectal resection, circumferential resection margin). Variables and pathological stages did not show differences. With an average follow up of 41.8 months (range 6-120), the recurrence rates and survival were similar. The height of extra peritoneal rectum tumors would not affect surgical nor oncologic results in the total laparoscopic mesorectal resection (AU).

Impact of enhanced recovery after surgery on postoperative neutrophil-lymphocyte ratio in patients with colorectal cancer.

OBJECTIVE: To investigate the impact of enhanced recovery after surgery (ERAS) on the postoperative neutrophil-lymphocyte ratio (NLR) in patients with colorectal cancer. METHODS: A total of 200 patients with colorectal cancer who underwent surgery between January 2015 and November 2018 were enrolled in the study. They were divided into a traditional treatment group (n=100) and an ERAS group (n=100). The traditional treatment group underwent radical laparoscopic colorectal surgery, and the ERAS group underwent traditional treatment plus the ERAS protocol (preoperative improvement of glucose tolerance, unconventional indwelling stomach and urinary tubes, intraoperative body temperature management, fluid management, postoperative pain management, early oral feeding, and early activities). Clinical data were collected for all patients. NLR levels before and after surgery, and complications were compared between the two groups. RESULTS: Postoperative NLR was significantly lower in the ERAS compared with the traditional treatment group. The incidence of complications, including anastomotic leakage, pulmonary infection, urinary tract infection, and cardiopulmonary dysfunction were also significantly lower in the ERAS group. CONCLUSION: Enhanced recovery after surgery can reduce the increase in postoperative NLR and reduce the occurrence of postoperative complications, which results will be of clinical value.

Analysis of hidden blood loss and its influential factors in myomectomy.

OBJECTIVE: This study was performed to quantify hidden blood loss (HBL) and explore its influential factors in myomectomy. METHODS: Two hundred nine patients who underwent myomectomy by laparotomy or laparoscopy from 1 January 2017 to 31 December 2018 were analyzed. Each patient's estimated blood volume and total blood loss (TBL) were calculated by the Nadler formula and Gross formula, respectively. The HBL was calculated by subtracting the visible blood loss (VBL) from the TBL. A multivariate linear stepwise analysis was applied to identify the influential factors of HBL in myomectomy. RESULTS: The mean perioperative VBL and estimated TBL during myomectomy were 137.81 ±104.43 and 492.24 ± 225.00 mL, respectively. The mean HBL was 354.39 ± 177.69 mL, which accounted for 71.52% ± 15.75% of the TBL and was two to three times higher than the VBL. The duration of surgery, number of removed leiomyomas, and location of removed leiomyomas were independent risk factors for HBL in myomectomy. CONCLUSIONS: HBL accounted for a significant percentage of TBL in myomectomy. A full understanding of the HBL in perioperative blood management may improve patients' postoperative rehabilitation.

Impact of visceral obesity and sarcobesity on surgical outcomes and recovery after laparoscopic resection for colorectal cancer.

BACKGROUND & AIMS: Studies analyzing the impact of visceral fat excess on surgical outcomes after resection for colorectal cancer (CRC) have yielded conflicting results. Visceral obesity (VO) and sarcobesity (SO) have been recently addressed as risk factors for poor short-term results while no data are available for recovery goals after surgery. No data are available on the protective effect of ERAS in VO and SO patients. The aim of this study was to assess clinical implications of computed tomography (CT) assessed VO and SO on surgical and recovery outcomes after minimally invasive resection for CRC before and after ERAS protocol implementation. METHODS: Visceral adipose tissue (VAT) and skeletal muscle area (SMA) were retrospectively assessed using pre-operative CT studies of 261 patients who underwent laparoscopic resection for CRC between January 2012 and April 2019; ERAS protocol was adopted in 160 patients operated on after March 2014. Patients' surgical and recovery outcomes were compared according to BMI categories, VO and SO which was defined using the VAT/SMA ratio (Sarcobesity Index). Predictive factors for poor surgical and recovery outcomes were evaluated by univariate and multivariate analyses. RESULTS: Of the 261 patients, 12.6% were BMI obese while 68.6% presented visceral obesity. BMI was not associated to any of the outcomes considered. No differences in intra-operative results were found except for a lower number of retrieved lymph nodes both in VO and SO patients. While VO showed no impact on post-operative course, SO resulted an independent risk factor for cardiac complications and prolonged post-operative ileus (PPOI) at logistic regression analysis. Furthermore, sarcobese patients showed delayed recovery after surgery. Patients enrolled in the ERAS protocol showed improved recovery outcomes for both VO and SO groups, although ERAS did not result to be a protective factor for cardiac complications and PPOI. CONCLUSIONS: A high Sarcobesity Index is a risk factor for developing cardiac complications and PPOI after laparoscopic resection for CRC. A reduced number of lymph nodes retrieved is associated to VO and SO. These conditions should then be considered in clinical practice for the risk of down staging the N stage. Effect of VO and SO on recovery items after surgery should be further investigated. ERAS protocol application should be implemented to improve recovery outcomes in VO and SO patients undergoing laparoscopic colorectal resection.

Choosing the most appropriate minimally invasive approach to treat gynecologic cancers in the context of an enhanced recovery program: Insights from a comprehensive cancer center.

OBJECTIVE: The aim of the study was to compare the characteristics of procedures for gynecologic cancers conducted with conventional laparoscopy (CL) or robotically assisted laparoscopy (RAL) in the context of an enhanced recovery program (ERP). METHODS: This is a secondary analysis of prospectively collected data from a cohort study conducted between 2016 (when the ERP was first implemented at the Institut Paoli-Calmettes, a comprehensive cancer center in France) and 2018. We included patients who had undergone minimally invasive surgery for gynecological cancers and followed our ERP. The endpoints were the analysis of postoperative complications, the length of postoperative hospitalization (LPO), and the proportion of combined procedures depending on the approach (RAL or CL). Combined procedures were defined by the association of at least two of the following operative items: hysterectomy, pelvic lymphadenectomy, and para-aortic lymphadenectomy. RESULTS: A total of 362 women underwent either CL (n = 187) or RAL (n = 175) for gynecologic cancers and followed our ERP. The proportion of combined procedures performed by RAL was significantly higher (85/175 [48.6%]) than that performed by CL (23/187 [12.3%]; p < 0.001). The proportions of postoperative complications were similar between the two groups (19.4% versus 17.1%; p = 0.59). Logistic regression analysis revealed a statistically insignificant trend in the association of RAL with a reduced likelihood of an LPO > 3 days after adjusting for predictors of prolonged hospitalization (adjusted OR = 0.573 [0.236-1.388]; p = 0.217). CONCLUSION: Experts from our cancer center preferentially choose RAL to perform gynecologic oncological procedures that present elements of complexity. More studies are needed to determine whether this strategy is efficient in managing complex procedures in the framework of an ERP.

Preliminary Results of an Exercise Program After Laparoscopic Resective Colorectal Cancer Surgery in Non-Metastatic Adenocarcinoma: A Pilot Study of a Randomized Control Trial.

Performing physical exercise after a colorectal cancer diagnosis is associated with lower mortality related to the tumor itself. In order to improve physical recovery after elective surgery, there are no specific exercise protocols after discharge from the hospital. The purpose of this study is to show the preliminary results of an exercise program after colorectal cancer surgery. Six patients with non-metastatic colorectal adenocarcinoma addressed to respective laparoscopic were randomly assigned to a mixed supervised/home-based exercise program for six months and compared to a control group without exercise. To assess the effectiveness of the program, functional and body composition parameters were evaluated. Three months after surgery, the exercise group increased flexibility (p < 0.01, ES = 0.33), strength of lower limbs (p < 0.01, ES = 0.42) and aerobic capacity (p < 0.01, ES = 0.28). After surgery, the six patients experienced a significant reduction in body mass index (BMI) and free fat mass. More specifically, fat mass reached the lowest values, with a concomitant increase in cell mass after six months (p < 0.01, ES = 0.33). This did not occur in the control group. Colorectal cancer treatment induces a reduction in physical function, particularly during the first six months after treatment. A mixed exercise approach appears promising in countering this process after colorectal cancer surgery.

Sexual Function following Laparoscopic versus Transvaginal Closure of the Vaginal Vault after Laparoscopic Hysterectomy: Secondary Analysis of a Randomized Trial by the Italian Society of Gynecological Endoscopy Using a Validated Questionnaire.

STUDY OBJECTIVE: The effect of the different types of vaginal cuff closures on posthysterectomy sexual function has not been investigated in depth. We evaluated if there is a difference between transvaginal versus a laparoscopic closure after total laparoscopic hysterectomy (TLH) on female sexual function, using a validated questionnaire. DESIGN: Secondary analysis of a prospective randomized controlled trial. SETTING: Three academic research centers. PATIENTS: Women consenting to telephone interviews on their sexual life before and after undergoing TLH were included. INTERVENTIONS: Patients were randomly assigned to a laparoscopic or transvaginal approach for vaginal cuff closure at the end of TLH for benign indications. MEASUREMENTS AND MAIN RESULTS: A validated questionnaire (the Female Sexual Function Index [FSFI]) was used to explore sexuality before and after the operation. Of the 1408 patients enrolled in the primary study, 400 patients were asked to complete the questionnaire. Of them, 182 (41.4%) were eligible and accepted enrollment in the present analysis. No difference was found in terms of pre- and postoperative FSFI scores between groups. Patients with a low preoperative FSFI score (<26.55) had a significantly higher likelihood of having a postoperative sexual disorder (p <.001). Women who received bilateral adnexectomy before menopause and those with postoperative vaginal cuff hematoma had a significantly lower postoperative FSFI score (p = .001 and p = .04, respectively). After multivariable analysis, both variables maintained at least a tendency toward an association with a lower postoperative FSFI score (odds ratio, 2.696; 95% confidence interval, 1.010-7.194; p = 0.048 and p = 0.053; odds ratio, 13.2; 95% confidence interval, .966-180.5, respectively). CONCLUSION: Transvaginal and laparoscopic cuff closures after TLH have similar sexual postoperative outcomes. A patient with sexual problems before TLH is more likely to have a low FSFI score postoperatively. Premenopausal patients undergoing bilateral ovariectomy and those with postoperative vaginal cuff hematoma have a worse postoperative sexual life. (Clinicaltrials.gov, protocol number NCT02453165, registration date May 25, 2015.).

Predictors of Postdischarge Surgical Recovery Following Laparoscopic Sacrocolpopexy: A Prospective Cohort Study.

OBJECTIVES: Our aim was to identify sociodemographic/clinical, surgical, and psychosocial predictors of postdischarge surgical recovery after laparoscopic sacrocolpopexy. METHODS: Study participants (N = 171) with at least stage 2 pelvic organ prolapse completed a preoperative survey measuring hypothesized sociodemographic/clinical, surgical, and psychosocial recovery predictors followed by a postoperative survey at 4 time points (days 7, 14, 42, and 90) that included the Postdischarge Surgical Recovery 13 scale. One multivariate linear regression model was constructed for each time point to regress Postdischarge Surgical Recovery 13 scores on an a priori set of hypothesized predictors. All variables that had P < 0.1 were considered significant predictors of recovery because of the exploratory nature of this study and focus on model building rather than model testing. RESULTS: Predictors of recovery at 1 or more time points included the following: sociodemographic/clinical predictors: older age, higher body mass index, fewer comorbidities, and greater preoperative pain predicted greater recovery; surgical predictors: fewer perioperative complications and greater change in the leading edge of prolapse after surgery predicted greater recovery; psychosocial predictors: less endorsement of doctor's locus of control, greater endorsement of other's locus of control, and less sick role investment predicted greater recovery. CONCLUSIONS: Identified sociodemographic/clinical, surgical, and psychosocial predictors should provide physicians with evidence-based guidance on recovery times for patients and family members. This knowledge is critical for informing future research to determine if these predictors are modifiable by changes to our narrative during the preoperative consultation visit. These efforts may reduce the postdischarge surgical recovery for patients with pelvic organ prolapse after laparoscopic sacrocolpopexy, accepting the unique demands on each individual's time.

Feasibility of perioperative volatile organic compound breath testing for prediction of paralytic ileus following laparoscopic colorectal resection.

BACKGROUND: Despite implementation of enhanced recovery after surgery (ERAS) and laparoscopic techniques, postoperative ileus (POI) remains frequent after colorectal surgery, impacting the patient, their recovery and health-care resources. Presently there are no tests that reliably predict or enable early POI diagnosis. Volatile organic compounds (VC) are products of human and microbiota cellular metabolism and we hypothesised that a detectable alteration occurs in POI. METHOD: This was a prospective observational study of patients undergoing laparoscopic colorectal resection within an established ERAS programme. Standardized end-expiratory breath sampling was performed on the morning of surgery and on the first three postoperative mornings. The concentrations of VCs commonly found in intestinal gas were analysed using selected ion flow tube mass spectrometry and GastroCH4 ECK®. Feasibility data, bowel preparation, postoperative oral intake, POI and 30-day morbidity were recorded. RESULTS: Of the 75 potentially eligible patients, 58 (77%) agreed to participate. Per-protocol breath sampling was successfully completed in 94%. There were no analytical failures. Baseline and postoperative concentrations of VCs were broadly comparable and were not altered by bowel preparation or postoperative oral intake. POI developed in 14 (29%) patients. Preoperative ammonia concentration was higher in patients who developed POI [830 parts per billion (ppb) vs 510 ppb, P = 0.027]. There was an increase in the concentration of acetic acid detected on day 2 in patients who developed POI (99 ppb vs 171 ppb, P = 0.021). CONCLUSION: Repeated VC breath sampling and analysis is feasible in the perioperative setting. An elevated ammonia concentration on the morning of surgery may be a potential predictor of POI.

Health-Related Quality of Life, Sexuality and Hormone Status after Laparoscopic Roux-En-Y Gastric Bypass in Women.

OBJECTIVE: Few studies have been carried out concerning the influence of bariatric surgery on female sexuality and hormones, particularly utilizing hormone-based questionnaires. The effect of bariatric surgery on sex hormone levels, sexual function and health-related quality of life (HRQL) in women was analyzed in this study. Participants were included in a single-center study at a regional hospital in Sweden, with a duration of one-year follow-up. METHODS: One hundred non-smoking women, undergoing laparoscopic Roux-en-Y gastric bypass, were included in the study. Blood assay for sex-hormone binding globulin (SHBG), testosterone, estrogen, progesterone, follicle-stimulating hormone (FSH) and luteinizing hormone (LH) was analyzed. Participants completed the Female Sexual Function Index (FSFI), Women's Health Questionnaire (WHQ) and Psychological General Well-being Inventory (PGWB) parallel to lab testing. RESULTS: At one-year follow-up, several significant results were found concerning hormones and questionnaires. Testosterone decreased and SHBG increased, N = 68/100. Desire, arousal, orgasm, satisfaction and total score domains for the FSFI increased after one year, N = 53/100. WHQ domains concerning depressed mood, somatic symptoms, memory, anxiety, sexual behavior and attractiveness improved after one year, N = 47/100. All domains in the PGWB (N = 52), including anxiety, depressed mood, positive well-being, self-control, general health, vitality and total score improved at follow-up. Spearman's Rho coefficient analysis found correlation between testosterone/WHQ-sexual problems (0.3), SHBG/WHQ-general health (0.3) and SHBG/FSFI-arousal (-0.3). CONCLUSIONS: Bariatric surgery normalizes levels of sex-hormones in women, and results in improved sexual function, health-related quality of life and psychological well-being.

Association of Serum Zinc Concentration with Preservation of Renal Function After Bariatric Surgery: a Retrospective Pilot Study.

BACKGROUND: Although serum zinc level (Zn) is known to impact renal function in patients with diabetes, their correlation following bariatric surgery remains unknown. This study aimed at assessing the association of Zn with estimated glomerular filtration rate (eGFR) after laparoscopic sleeve gastrectomy (LSG). METHODS: One hundred and twenty-nine patients in total (mean age, 38.1 ± 10.8; body mass index, 39.1 ± 5.1 kg/m2) with normal preoperative kidney function undergoing LSG at a single tertiary referral center were reviewed. The primary study endpoint was the relationship between Zn and post-LSG eGFR at 12-month follow-up. The secondary outcomes were the associations of percentage weight loss (%WL) with changes in Zn (△Zn) and eGFR (△eGFR). RESULTS: The incidence of zinc deficiency was 8.5%, 8.1%, and 29.9% at baseline, post-LSG and one- and 12-month follow-up, respectively. At 12-month follow-up, Zn dropped from 104.1 ± 19.2 to 85.3 ± 38.9 µg/dL (p = 0.001), while eGFR levels decreased from 106.6 ± 10.3 to 102.1 ± 19.4 mL/min per 1.73 m2 (p = 0.025). Zn correlated positively with eGFR at 6-month (r = 0.252, p = 0.037) and 12-month (r = 0.41, p = 0.001) follow-ups. Multiple linear regression analyses including baseline variables of age, sex, BMI, %WL, and diabetes identified Zn and %WL as independent predictors of eGFR at 12-month follow-up. There was no evidence of multicollinearity among these variables. Despite positive association between %WL and △eGFR (r = 0.222, p = 0.031), no correlation was noted between %WL and △Zn (r = - 0.129, p = 0.40). CONCLUSION: The results demonstrated a positive relationship between post-LSG serum zinc levels and preservation of renal function among patients with obesity in a surgical setting. Large-scale studies are warranted to support the findings.