Staging and surgical approaches in gastric cancer: a clinical practice guideline.

BACKGROUND: Resection is the cornerstone of cure for gastric adenocarcinoma; however, several aspects of surgical intervention remain controversial or are suboptimally applied at a population level, including staging, extent of lymphadenectomy (lnd), minimum number of lymph nodes that have to be assessed, gross resection margins, use of minimally invasive surgery, and relationship of surgical volumes with patient outcomes and resection in stage iv gastric cancer. METHODS: Literature searches were conducted in databases including medline (up to 10 June 2016), embase (up to week 24 of 2016), the Cochrane Library and various other practice guideline sites and guideline developer Web sites. A practice guideline was developed. RESULTS: One guideline, seven systematic reviews, and forty-eight primary studies were included in the evidence base for this guidance document. Seven recommendations are presented. CONCLUSIONS: All patients should be discussed at a multidisciplinary team meeting, and computed tomography (ct) imaging of chest and abdomen should always be performed when staging patients. Diagnostic laparoscopy is useful in the determination of M1 disease not visible on ct images. A D2 lnd is preferred for curative-intent resection of gastric cancer. At least 16 lymph nodes should be assessed for adequate staging of curative-resected gastric cancer. Gastric cancer surgery should aim to achieve an R0 resection margin. In the metastatic setting, surgery should be considered only for palliation of symptoms. Patients should be referred to higher-volume centres and those that have adequate support to manage potential complications. Laparoscopic resections should be performed to the same standards as those for open resections, by surgeons who are experienced in both advanced laparoscopic surgery and gastric cancer management.

Laparoscopy influences hiring practices within academic surgical departments.

BACKGROUND: This study aimed to determine whether the increasing emphasis on minimally invasive surgery (MIS) influences hiring practices within academic surgical departments. METHODS: A questionnaire was mailed to chairs of surgery departments and divisions of general surgery at the 16 Canadian academic institutions. Nonresponders were identified and contacted directly. The survey consisted of 34 questions, including Likert scales, single answers, and multiple-choice questions. Data were collected on demographics, perceptions of MIS, and recruitment/hiring. At the time of the survey, two department chair positions were vacant. RESULTS: A response rate of 87% (26/30) was obtained, with representation from 94% of departments (15/16). Of those surveyed, 88% intend to increase the importance of MIS at their institution within 5 years, and 87% intend to achieve this objective through new hirings. Networking (73%) and retention of recent graduates (89%) were cited most frequently as recruitment strategies. Strengthening the division, research, and education were considered important or extremely important by more than 90% of the respondents with respect to recruitment goals, whereas strengthening MIS was considered important or extremely important by 50%. Within 5 years, surgical departments intend to hire a median of four general surgeons, 50% of whom will have formal MIS training. In comparison, over the past 10 years, only 25% of new recruits had formal MIS training. More than 90% of the respondents considered formal MIS fellowship, MIS fellowship plus a second fellowship, and proctorship to be adequate training for performing advanced MIS, whereas traditional methods were considered inadequate. Lack of operative time and resource issues were considered most limiting in the hiring of new MIS surgeons. CONCLUSION: Minimally invasive surgery is growing in importance within academic surgical departments, but it remains an intermediate recruitment priority. Formal MIS training appears to be important in the recruiting of new surgeons, whereas traditional training methods are considered inadequate.

Optimizing recovery after laparoscopic colon surgery (ORAL-CS): effect of intravenous ketorolac on length of hospital stay.

BACKGROUND: The objective of this study was to determine if intravenous ketorolac can reduce ileus following laparoscopic colorectal surgery, thus shortening hospital stay. METHODS: This was a prospective, randomized, double-blind, placebo-controlled, clinical trial of patients undergoing laparoscopic colorectal resection and receiving morphine patient controlled analgesia (PCA) and either intravenous ketorolac (group A) or placebo (group B), for 48 h after surgery. Daily assessments were made by a blinded assistant for level of pain control. Diet advancement and discharge were decided according to strictly defined criteria. RESULTS: From October 2002 to March 2005, 190 patients underwent laparoscopic colorectal surgery. Of this total, 84 patients were eligible for this study and 70 consented. Another 26 patients were excluded, leaving 22 patients in each group. Two patients who suffered anastomotic leaks in the early postoperative period were excluded from further analysis. Median length of stay for the entire study was 4.0 days, with significant correlation between milligrams of morphine consumed and time to first flatus (r = 0.422, p = 0.005), full diet (r = 0.522, p < 0.001), and discharge (r = 0.437, p = 0.004). There we no differences between groups in age, body mass index, or operating time. Patients in group A consumed less morphine (33 +/- 31 mg versus 63 +/- 41 mg, p = 0.011), and had less time to first flatus (median 2.0 days versus 3.0 days, p < 0.001) and full diet (median 2.5 days versus 3.0 days, p = 0.033). The reduction in length of stay was not significant (mean 3.6 days versus 4.5 days, median 4.0 days versus 4.0 days, p = 0.142). Pain control was superior in group A. Three patients required readmission for treatment of five anastomotic leaks (4 in group A versus 1 in group B, p = 0.15). Two of them underwent reoperation. CONCLUSIONS: Intravenous ketorolac was efficacious in improving pain control and reducing postoperative ileus when anastomotic leaks were excluded. This simple intervention shows promise in reducing hospital stay, although the outcome was not statistically significant. The high number of leaks is inconsistent with this group's experience and is of concern.

Laparoscopic resection of gastrointestinal stromal tumors: not all tumors are created equal.

BACKGROUND: Laparoscopic resection has become an accepted approach to gastrointestinal stromal tumors (GISTs), with acceptable early results published in the literature. Long-term recurrence rates, however, are still unclear, and the management of tumors in challenging locations requires exploration. METHODS: A retrospective analysis of all patients undergoing a laparoscopic resection of gastric GIST in our institution between November 1997 and July 2004 was performed. RESULTS: A total of 14 patients with 15 tumors were evaluated, 5 of which were located high on the lesser curve. All the patients had an attempted laparoscopic approach, with the following procedures performed: stapled wedge excision (n = 8), excision and manual sewing technique (n = 4), and distal gastrectomy (n = 1). Overall, there was a 15% (n = 2) conversion rate. Lesions found in the fundus and greater curvature areas were easily resected via simple stapled wedge excision. High lesser curve tumors were more difficult to manage and required a combination of methods for complete excision and preservation of the gastrointestinal junction including intraoperative gastroscopy, excision and manual sewing technique, and reconstruction over an esophageal bougie. There were no postoperative complications, and the length of hospital stay was 4.6 +/- 1.9 days. At a median follow-up period of 46.5 months (mean, 37.4 +/- 26 months), one patient experienced a recurrence (18 months postoperatively), with eventual disease-related death. CONCLUSION: The laparoscopic approach to gastric GIST tumors is safe and associated with acceptable short- and intermediate-term results. High lesser curve GISTs can be safely approached laparoscopically using various techniques to ensure an adequate resection margin without compromise of the GE junction.

Objective analysis of gastroesophageal reflux after laparoscopic heller myotomy: an anti-reflux procedure is required.

BACKGROUND: Controversy exists over the necessity of performing a concurrent antireflux procedure with a Heller myotomy. We therefore sought to objectively analyze gastroesophageal reflux following laparoscopic Heller myotomy where an antireflux procedure was not performed. METHODS: A prospective database of 66 cases of laparoscopic Heller myotomy performed between November 1996 and June 2002 was reviewed. Previous, concurrent, or subsequent fundoplication was performed in 12 patients; therefore 54 patients without antireflux procedures were available for analysis. Follow-up included symptomatic assessment in 50 patients (93%). Heartburn was assessed on a four-point scale with clinical significance defined as >2 episodes/week. Objective testing, including endoscopy, esophagogram, manometry, and 24-h pH monitoring, was offered to all patients. Objective evidence of reflux was defined as the composite endpoint of positive 24-h pH monitoring or esophagitis on endoscopy. RESULTS: Significant heartburn was reported in 15 of 50 patients (30%). Positive 24-h pH recordings were seen in 11 of 22 patients tested while esophagitis was seen in 13 of 21 patients tested, resulting in objective evidence of reflux in 18 of 30 patients tested (60%). Of these 18 patients, seven did not have significant heartburn. All 12 patients without objective reflux did not have significant heartburn. Therefore, of the 30 patients with objective testing, seven (23%) had objective reflux without subjective heartburn (silent reflux). CONCLUSION: Objective analysis reveals an unacceptable rate of gastroesophageal reflux in laparoscopic Heller myotomy without an antireflux procedure. We therefore recommend performing a concurrent antireflux procedure.

Should antibiotic prophylaxis be used routinely in clean surgical procedures: a tentative yes.

BACKGROUND: The incidence of surgical site infection (SSI) after clean surgical procedure has traditionally been regarded as too low for routine antibiotic prophylaxis. But we now know that host factors may increase the risk of SSI to as high as 20%. We assessed the value of prophylactic cefotaxime in patients stratified for risk of SSI in a randomized double-blind trial. METHODS: Patients admitted for clean elective operations were enrolled, stratified for risk by National Nosocomial Infection Survey criteria, and randomized to receive intravenous cefotaxime 2 gm or placebo on call for operation. They were followed for 4 to 6 weeks for SSI diagnosed by Centers for Disease Control and Prevention criteria. RESULTS: Analysis of 775 patients showed that the 378 evaluable patients who received cefotaxime had 70% fewer SSI than those who did not--Mantel-Haenszel risk ratio (MH-RR) 0.31; 95% confidence intervals (CI) 0.11 to 0.83. Benefit was clear in the 616 low risk patients--0.97% versus 3.9% SSI (MH-RR 0.25, CI 0.07 to 0.87, p = 0.018), but only a trend was seen in 136 high risk patients--2.8% versus 6.1% SSI (MH-RR 0.48, CI 0.09 to 2.5). CONCLUSIONS: The results indicate clear benefit for routine antibiotic prophylaxis in clean surgical procedures. High risk patients need more study.

Achalasia developing years after surgery for reflux disease: case reports, laparoscopic treatment, and review of achalasia syndromes following antireflux surgery.

Two case reports demonstrate the paradoxical occurrence of achalasia many years after the successful surgical treatment of gastroesophageal reflux disease (GERD). These patients had remedial surgery laparoscopically. The three types of achalasia syndromes that can follow antireflux surgery are discussed. In type 1, primary achalasia is misdiagnosed as GERD and inappropriate antireflux surgery causes worsening dysphagia immediately after surgery without any symptom-free interval. In type 2, secondary iatrogenic achalasia is seen early after antireflux surgery and is characterized by the presence of stenosis and scar formation at the site of the fundic wrap. Although the motility studies resemble achalasia, the repair needs only to be taken down and refashioned when there is no response to balloon dilatation. In type 3, illustrated by the case reports, primary achalasia follows antireflux surgery after a significant symptom-free interval. There is complete absence of any stenosis or fibrosis of the esophagus and periesophageal tissues at remedial surgery. Moreover, surgical treatment of this condition needs to include esophageal myotomy.

Laparoscopic gastroenterostomy for duodenal obstruction.

BACKGROUND: It is not yet clear where laparoscopic procedures will fit into the armamentarium of the surgeon. Over the past decade, there has been a clear trend toward minimally invasive procedures for palliation of inoperable cancer. Traditionally, when duodenal obstruction occurs secondary to a disease process, gastric bypass through laparotomy is required. PATIENTS AND METHODS: Between November 13, 1992 and September 13, 1994, 10 patients underwent laparoscopic gastroenterostomy for duodenal obstruction. In 9 patients, the procedure was carried out for malignant obstruction; in 1 patient, duodenal obstruction was secondary to chronic scarring from benign peptic ulcer disease. Eight of these patients already had biliary decompression through radiologic or endoscopic means. One patient underwent laparoscopic cholecystenterostomy for biliary obstruction in addition to the laparoscopic gastroenterostomy. RESULTS: Laparoscopic gastroenterostomy was successfully completed in 8 of the 10 patients. In 2, conversion to open surgery was necessary. There was no mortality related to this operative approach. CONCLUSIONS: Laparoscopic gastroenterostomy is a safe procedure for treatment of duodenal obstruction. Good palliation can be expected in patients with obstruction of the duodenum secondary to advanced malignancies.

Surgery for peptic strictures.

Benign peptic stricture of the esophagus is a complex disorder which results from persistent gastroesophageal reflux. Its successful management depends on an accurate preoperative evaluation of the stricture and the patient. Surgical management of peptic strictures can be quite effective in relieving the symptoms and halting the pathologic gastroesophageal reflux that accompanies this disorder. This article reviews the general principles of evaluation and surgical treatment of benign peptic esophageal strictures.

Operative treatment of malignancy.

The overall prognosis of patients afflicted with cancer of the esophagus is dismal and has not changed greatly over the last few decades. Improvements have largely been due to better perioperative care rather than new surgical techniques. There remain, about the optimal treatment of these patients, and these differences are summarized in this article. The principal elements required to make an appropriate surgical decision also are outlined. Until new markers for early detection and effective systematic therapy emerge, improvement is likely to occur only in subsets of patients referred early and treated in an environment that guarantees low operative mortality.

Laparoscopic nephrectomy for autosomal dominant polycystic kidney disease.

BACKGROUND: The authors reviewed their experience with laparoscopic nephrectomy for autosomal dominant polycystic kidney disease to evaluate whether patient-related or surgery-related factors influence operative outcomes. METHODS: A retrospective review was carried out of 22 consecutive laparoscopic nephrectomies performed by one surgeon in a university setting between March 1998 and March 2003. The impact of patient factors (body mass index, preoperative hemoglobin level, preoperative blood urea nitrogen and creatinine, kidney size and side, prior abdominal surgery, dialysis) and surgical factors (surgeon experience and preoperative embolization) on short-term outcomes (estimated blood loss, transfusion requirements, operative time, conversion, intra- and postoperative complications and length of stay) was analyzed using the Student's t-test, Pearson correlation, and Mann-Whitney and Fisher tests. RESULTS: A total of 19 patients underwent 22 nephrectomies. The average patient age was 49 years (range, 36-65 years) and the average body mass index was 31.4 kg/m2 (range, 20.4-64.5 kg/m2). Fourteen patients (68%) were receiving dialysis. Fifteen right (68%) and 7 left (32%) nephrectomies were performed. The median kidney size was 22 cm (range, 8-50 cm). Five patients (23%) had preoperative embolization. The median operative time was 255 min (range, 95-415 min). There were no mortalities. The intraoperative complication rate was 18% (1 vena cava laceration, 1 cecal perforation, 1 dialysis fistula thrombosis, 1 intrarenal bleeding requiring conversion), and the postoperative complication rate was 32% (1 myocardial infarction, 1 urgent laparotomy for clinical peritonitis, 1 minor bile fistula, 1 AV fistula thrombosis, 2 incisional hernias, 1 urinary retention). Four procedures (18%) were converted (1 for vena cava laceration, 1 for cecal perforation, 1 for intrarenal bleeding, 1 for adhesions). The median blood loss was 400 ml (range, 100-5000 ml). Eight patients (36%) received transfusions (median, 2 units). The median length of stay was 4 days. The patients who required blood transfusions had lower preoperative hemoglobin levels. Preoperative embolization did not affect surgical outcome. However, surgeon experience significantly reduced operative time. CONCLUSIONS: Laparoscopic nephrectomy for autosomal dominant polycystic kidney disease is a safe procedure, providing patients with a short hospital stay. Complication and conversion rates are relatively high.

Does a laparoscopic approach to total abdominal colectomy and proctocolectomy offer advantages?

BACKGROUND: Controversy exists regarding the feasibility, safety, and outcomes of laparoscopic total abdominal colectomy (LTAC) and laparoscopic total proctocolectomy (LTPC). The object of this study was to assess the outcomes of LTAC and LTPC and compare them with those of institutional open procedure used as controls. METHODS: Perioperative data and surgical outcomes of patients who underwent TAC or TPC were analyzed and compared retrospectively at a single institution between 1991 and 1999. RESULTS: A total of 73 TACs performed during a 9-year period were evenly distributed between laparoscopic (n = 37) and open (n = 36) approaches. There were no significant differences between patient groups with respect to genders, age, weight, proportion of patients with inflammatory bowel disease, and the number of patients undergoing ileorectal anastomosis. The median operative time was longer with the laparoscopic method (270 vs 178 min; p = 0.001), but the median length of hospital stay was significantly shorter (6 vs 9 days; p = 0.001). The short-term postoperative complication rate up to 30 days from surgery was not statistically different (25% vs 44%; p = 0.137), although there was a clear trend toward a reduced number of overall complications in the laparoscopic group (9 vs 24). Wound complications were significantly fewer (0% vs 19%; p = 0.015) and postoperative pneumonia was nonexistent in laparoscopic patients. Long-term complications also were less common in the laparoscopic group (20% vs 64%; p = 0.002), largely because of reduced incidence of impotence, incisional hernia, and ileostomy complications. Total proctocolectomy was performed laparoscopically in 15 patients and with an open procedure in 13 patients over the same period. There were no statistically significant differences between the two groups with respect to gender, age, weight, and diagnosis. Median operating time was longer for the laparoscopic patients (400 vs 235 min; p = 0.001), whereas the length of hospital stay, morbidity, and mortality were not significantly different. CONCLUSIONS: The results indicate that LTAC can be performed safely with a statistically significant reduction in wound and long-term postoperative complications, as compared with its open counterpart. Operating time is increased, but there is a marked reduction in length of hospital stay. Preliminary results demonstrate that LTPC also is technically feasible and safe, with equal morbidity, mortality, and hospital stay, as compared with open procedures. Studies with larger numbers of patients and a randomized controlled trial giving special attention to patient quality-of-life issues are needed to elucidate the real advantages of this minimally invasive technique.

Laparoscopic colorectal resection in octogenarians.

BACKGROUND: The number and proportion of patients aged ?80 years are increasing. These patients often require surgical care and suffer subsequent high rates of morbidity and mortality. However, the surgical outcomes of laparoscopic colorectal resection in octogenarians are not well documented. METHODS: Octogenarians were identified from a large prospective database comprising 507 consecutive laparoscopic colorectal resections performed between 1991 and 1999 in a university setting. Preoperative comorbidity and surgical outcomes were analyzed. RESULTS: Sixty-two patients (30 men, 32 women) aged ?80 years were identified. Their mean age and weight were 85 years and 63 kg, respectively. Seven patients (11%) were converted to an open procedure. Four (6%) intraoperative complications occurred in four patients (one colon perforation, one small bowel perforation, one burned gallbladder serosa, and one missed lesion), necessitating two conversions. Twenty -four postoperative complications occurred in 19 patients (31%) (six ileus [10%], five wound infections [8%], five cardiac problems [8%], two urinary retentions [3%], two hemorrhages [3%], one abscess [2%], one pneumonia [2%], and two other [3%]). Intraoperative complications did not increase postoperative morbidity. Three patients (5%) died within 30 days of surgery. When the procedure was completed laparoscopically, the overall median postoperative hospital stay was 10.0 days; occurrence of a postoperative complication increased the median length of stay to 15.0 days. CONCLUSIONS: These results are superior to published historical controls involving open colorectal resection in octogenarians. Overall mortality, lung, and urinary tract complications were decreased, and there were no reoperations for small bowel obstruction. Laparoscopic colorectal resection is technically feasible and can be done safely in elderly patients. Results require randomization against those for open surgery to elucida te the real advantages of this technique.

Laparoscopic splenectomy does the training of minimally invasive surgical fellows affect outcomes?

BACKGROUND: The training of surgeons and residents in laparoscopic surgery has become an important issue. The purpose of this study is to determine if the training of a laparoscopic fellow affects outcomes in patients undergoing laparoscopic splenectomy (LS). METHODS: Data were obtained from a prospectively collected database of patients who underwent LS from August 1994 to November 1999. Outcomes of the last 25 cases, performed by fellows under supervision, were compared to 25 cases performed by staff surgeons prior to the introduction of fellows. RESULTS: Patient demographics, preoperative platelet count, and splenic size were similar for the two groups. Outcome measures comparing the staff and the fellows group including operative time (151 vs 178 min, p = 0.055), blood loss (214 vs 162 ml, p = 0.40), intraoperative complications (3 vs 2, p = 1.0), need for transfusion (2 vs 3, p = 1.0), conversions (1 vs 0, p = 1.0), length of hospital stay (3.3 vs 2.5 days, p = 0.13), and postoperative complications (1 vs 2, p = 1.0) were similar for the two groups. CONCLUSION: When performed by a fellow under supervision, LS has the same outcomes as when the procedure is performed by the teaching staff surgeon.

Local recurrence and survival after laparoscopic mesorectal resection forrectal adenocarcinoma.

BACKGROUND: Laparoscopic resection for rectal cancer is controversial. Actuarial survival and local recurrence rates have not been determined. METHODS: A prospective database containing 80 consecutive unselected laparoscopic resections of rectal cancers performed between November 1991 and 1999 was reviewed. Local recurrence was defined as any detectable local disease at follow-up assessment occurring either alone or in conjunction with generalized recurrence. The tumor node metastases (TNM) classification for colorectal cancers and the Kaplan-Meier method were used to determine staging and survival curves. The mesorectal excision technique was used during surgery. RESULTS: The median follow-up period was 31 months for patients with stages I, II, and III cancer, and 15.5 months for patients with stage IV cancer. The overall 5-year survival rate was 65.1% for all cancer stages and 72.1% for stages I, II, and III cancer. No trocar-site recurrence was observed. The overall local recurrence rate was 3.75% (3/80) for all cancer stages, and 4.3% (3/70) for stages I, II, and III cancer. CONCLUSIONS: The survival and local recurrence rates for patients with rectal cancer treated by laparoscopic mesorectal excision do not differ negatively from those in the literature for open mesorectal excision. Further validation is needed.

Needlescopic surgery. A logical evolution from conventional laparoscopic surgery.

BACKGROUND: The purpose of this study was to analyze the safety and feasibility of needlescopic surgery and to compare the short-term outcomes relative to conventional laparoscopic surgery. METHODS: Needlescopic surgery patients were compared to matched cohorts of conventional laparoscopic surgery patients from the same prospective database for a variety of selected procedures. RESULTS: A total of 101 needlescopic procedures were analyzed (30 cholecystectomy, 28 Nissen fundoplication, 12 bilateral sympathectomy, 10 splenectomy, 10 Heller myotomy, three adrenalectomy, two colon resection, two splenic cyst excision, four other). There was no significant difference between the needlescopic and conventional laparoscopic groups in conversion rates, morbidity, or mortality. A higher proportion of patients were in hospital

Laparoscopic splenectomy for idiopathic thrombocytopenic purpura (ITP).

BACKGROUND: Although the short-term benefits of laparoscopic splenectomy (LS) have been well documented, long-term follow-up data of patients who have undergone LS for ITP are scarce. We report our long-term follow-up data in patients who underwent LS for idiopathic thrombocytopenic purpura (ITP). METHODS: Data were obtained from a prospectively collected computer database of 52 patients who underwent LS between October 1992 and December 2000 for medically refractory ITP. Patients and their referring hematologist were contacted, and follow-up information was obtained for 45 patients. RESULTS: Fifty-two patients (27 women and 25 men) underwent LS for ITP. Median operative time was 160 min (range, 70-335); and median blood loss was 100 cc (range, 20-1500). There were seven cases of intraoperative hemorrhage (13.7%), resulting in one conversion. A second case was converted due to inadequate working space in a patient with a 26-cm spleen. Accessory spleens were found in 17 patients (32.7%). Postoperative complications occurred in three patients (5.9%). There were no deaths. Median length of hospital stay was 2 days (range, 1-12). Follow-up data were obtained in 45 patients (86.5%), with a median follow-up of 51 months. Six patients did not respond to surgery initially, and another two patients developed recurrent disease, for a remission rate of 82.2%. Nine patients underwent a damaged red blood cell scan. This group included the two patients who suffered recurrences. A positive scan was obtained in three patients (33%), one of whom was a patient with recurrent disease. This patient underwent an uneventful laparoscopic excision of residual splenic tissue but continues to require intermittent steroids to maintain platelet counts. The two other patients with a positive scan remain in remission. CONCLUSIONS: Laparoscopic splenectomy for ITP is safe and associated with low morbidity and a short hospital stay. Long-term follow-up showed that remission rates of ITP following LS are comparable to those reported in the literature on open surgery.

Minimally invasive surgery training in Canada: a survey of general surgery.

BACKGROUND: The purpose of this study was to assess the state of surgical training in minimally invasive surgery (MIS) within Canadian academic surgical departments. METHODS: A pretested questionnaire was distributed to the general surgery residents of participating Canadian academic surgical departments. RESULTS: Fourteen of 16 residency programs participated and 235 of 388 residents (60%) responded to the survey. Residents expect to perform both basic (217/235 [92%]) and advanced (123/234 [53%]) MIS procedures on completion of their residency. However, only 41 of 233 (18%) believed that their advanced MIS training would be adequate. On a Likert scale, the most important factors influencing their training included limited advanced case volume (median, 5), limited opportunity in the operating room (OR) (median, 5), lack of attending surgeon interest (median, 4), limited OR time (median, 4), and a lack of surgical department support (median, 4). Residents were concerned about their ability to acquire these skills once they finished their training (median, 4), and 231 of 234 (99%) thought that there was an important role for a MIS surgeon within the academic setting (median, 5). CONCLUSION: The rapid development of MIS has generated complex issues for resident training within the present Canadian academic surgical environment.

Predicting conversion in laparoscopic colorectal surgery. Fellowship training may be an advantage.

BACKGROUND: Laparoscopic colorectal surgery has clear advantages over open surgery; however, the effectiveness of the approach depends on the conversion rate. The objective of this work was to prospectively validate a model that would predict conversion in laparoscopic colorectal surgery. METHODS: A simple clinical model for predicting conversion in laparoscopic colorectal surgery was previously developed based on a multivariable logistic regression analysis of 367 procedures. This model was applied prospectively to a follow-up group of 248 procedures by the same team, including 54 procedures performed by one new fellowship-trained surgeon. RESULTS: Patients in the follow-up group were more likely to have cancer (56% vs 44%, p = 0.007) and were more obese (median, 71.0 vs 66.0 kg; p < 0.001). The rate of conversion in the follow-up group was unchanged (8.9% vs 9.0%, p > 0.05). Despite expected trends toward increasing risk of conversion with weight level (<60 kg, 6.8%; 60-<90 kg, 9.0%; >90 kg, 12.1%; p > 0.05) and malignancy (10.1% vs 7.3%, p > 0.05), the model did not distinguish well between groups at risk for conversion. Contrary to the model, however, the fellowship-trained surgeon had a conversion rate that was not higher than that of the other, more experienced surgeons (7.3% vs 9.3%, p > 0.05) even though he was less experienced, and operating on patients who were more obese (median, 75.0 vs 70 kg; p = 0.02) and more likely to have cancer (59% vs 55%, p > 0.05). Recalculated conversion scores that excluded the inexperience point for the fellowship-trained surgeon showed a good fit for the model. Considering the original and follow-up experience together (615 cases), the model clearly stratifies patients into low (0 points), medium (1-2 points), and high risk (3-4 points) for conversion, with respective rates of 2.9%, 8.1%, and 20% ( p = 0.001). CONCLUSION: This model appears to be a valid predictor of conversion to open surgery. Fellowship training may provide sufficient experience so that learning curve issues are redundant in early practice. This model now requires validation by other centers.