Current Challenges for Education and Training in Transanal Surgery.

Transanal endoscopic microsurgery (TEM) is a technique that was introduced in the 1980s for improved exposure to upper rectal polyps. This technique, though initially difficult to master due to new skill acquisition for surgeons, has spared many patients proctectomy. There are many benign indications for transanal endoscopic surgery which has led to in vivo operating room training with fewer undesirable effects to the patient. With the explosion of laparoscopic technology this transanal technique is no longer limited to intraluminal pathology, but is now being used to remove the entire rectum. In transanal total mesorectal excision (taTME), benign indications are less common, translating to potentially more severe oncologic patient consequences during the early phase of adoption. For this reason, strict training criteria consensus guidelines have been developed by the experts in taTME. The current consensus statements agree that training surgeons should have performed a minimum of 10 laparoscopic TME procedures and should have some experience with transanal surgery. Surgeons need to attend a formal training course and should start clinically on benign or early malignant pathology without threated circumferential resection margins. Surgeons also need to have their first cases proctored until deemed proficient by the proctor and monitor their morbidity, oncologic, and functional outcomes prospectively.

Pediatric Colorectal Surgery: A Collaborative Approach From a Single Institution.

BACKGROUND: Inflammatory bowel disease encompasses relapsing gastrointestinal disorders commonly presenting in pediatric patients, with 25% of diagnoses made before age 20 and 4% before age 5. Considering the need for life-long surgical follow-up, a collaborative system involving both pediatric and colorectal surgeons could improve overall patient experiences. We hypothesized that cases performed in collaboration with both pediatric and adult colorectal surgeons may lead to better outcomes. METHODS: Data were gathered retrospectively for 116 patients 18 y old or younger who underwent colorectal resections for inflammatory bowel disease between 2010 and 2017 at our institution. Data included patient demographics, type of procedure, surgical approach, specimen extraction site, surgeon involvement (pediatric, colorectal, or collaborative), operative time, and estimated blood loss. We analyzed days until passage of flatus and bowel movement, length of stay, type of surgical procedure, and surgical complications. RESULTS: Our data showed that days until flatus (2.27 ± 0.47, P = 0.049), first bowel movement (2.64 ± 0.67, P = 0.006), and length of stay (4.45 ± 1.51, P = 0.006) were the shortest in the collaborative group. We also found that single-incision laparoscopic surgery was significantly more common in the collaborative group (77.8%, P = 0.002). We did not see a difference in surgical complication rates among any of the groups. CONCLUSIONS: Our study showed short-term beneficial outcomes in a single institution associated with the collaboration of pediatric surgeons and colorectal surgeons on pediatric colorectal cases in comparison to those performed by pediatric surgeons or adult colorectal surgeons alone.

Case-Matched Comparison of Long-Term Functional and Quality of Life Outcomes Following Laparoscopic Versus Open Ileal Pouch-Anal Anastomosis.

BACKGROUND: Laparoscopic ileal pouch-anal anastomosis (IPAA) is associated with recovery benefits when compared with open IPAA. There is limited data on long-term quality of life and functional outcomes, which this study aimed to assess. METHODS: An IRB-approved, prospectively maintained database was queried to identify patients undergoing laparoscopic IPAA (L), case-matched with open IPAA (O) based on age ± 5 years, gender, body mass index (BMI) ± 5 kg/m2, diagnosis, date of surgery ± 3 years, stapled/handsewn anastomosis, omission of diverting loop ileostomy and length of follow-up ± 3 years. We assessed functional results, dietary, social, work, sexual restrictions and the Cleveland Clinic global quality of life score (CGQoL) at 1, 2, 3, 4, 5 and 10 years postoperatively. Functional outcomes were assessed based on number of stools (day/night) and seepage protection use (day/night). Variables were evaluated with Kaplan-Meier survival curves, uni- and multivariable analyses. RESULTS: Out of 4595 IPAAs, 529 patients underwent L, of whom 404 patients were well matched 1:1 to an equivalent number of O based on all criteria. Median follow-ups were 2 (0.5-17.8) versus 2.4 (0.5-22.2) years in L versus O, respectively (p = 0.18). L was associated with significantly decreased number of stools at night and less frequent pad usage at 1 year, both during the day and at night. Functional outcomes became similar during further follow-up. L was also associated with improved overall CGQoL, and energy scores at 1 year postoperatively, and decreased social restrictions for 1-2 years. There were no significant differences in quality of health, dietary, work or sexual restrictions. Laparoscopy was not associated with increased risk of pouch failure (p = 0.07) or significantly different causes of pouch failure when compared to O. CONCLUSIONS: Laparoscopic and open IPAA are associated with equivalent long-term functional outcomes, quality of life and pouch survival rates. Laparoscopic technique is associated with temporary benefits lasting 1 or 2 years.

Considering Value in Rectal Cancer Surgery: An Analysis of Costs and Outcomes Based on the Open, Laparoscopic, and Robotic Approach for Proctectomy.

OBJECTIVE: The aim of the study was to compare value (outcomes/costs) of proctectomy in patients with rectal cancer by 3 approaches: open, laparoscopic, and robotic. BACKGROUND: The role of minimally invasive proctectomy in rectal cancer is controversial. In the era of value-based medicine, costs must be considered along with outcomes. METHODS: Primary rectal cancer patients undergoing curative intent proctectomy at our institution between 2010 and 2014 were included. Patients were grouped by approach [open surgery, laparoscopic surgery, and robotic surgery (RS)] on an intent-to-treat basis. Groups were compared by direct costs of hospitalization for the primary resection, 30-day readmissions, and ileostomy closure and for short-term outcomes. RESULTS: A total of 488 patients were evaluated; 327 were men (67%), median age was 59 (27-93) years, and restorative procedures were performed in 333 (68.2%). Groups were similar in demographics, tumor characteristics, and treatment details. Significant outcome differences between groups were found in operative and anesthesia times (longer in the RS group), and in estimated blood loss, intraoperative transfusion, length of stay, and postoperative complications (all higher in the open surgery group). No significant differences were found in short-term oncologic outcomes. Direct cost of the hospitalization for primary resection and total direct cost (including readmission/ileostomy closure hospitalizations) were significantly greater in the RS group. CONCLUSIONS: The laparoscopic and open approaches to proctectomy in patients with rectal cancer provide similar value. If robotic proctectomy is to be widely applied in the future, the costs of the procedure must be reduced.

Does stoma site specimen extraction increase postoperative ileostomy complication rates?

BACKGROUND: Minimizing incisions has the potential to decrease hernia formation and wound complications following laparoscopic surgery. It is currently unknown if using the stoma site for specimen extraction affects outcomes. This study aims to evaluate the impact of stoma site extraction on postoperative complication rates in laparoscopic colorectal surgery. METHODS: After IRB approval, a retrospective comparative review of 738 consecutive patients (405 M) who underwent laparoscopic colorectal surgery with ileostomy between January 2008 and December 2014 was performed. Patients who had a minimally invasive surgery that required an ileostomy were included. Patients were classified into two groups: stoma site extraction (SSE) or non-stoma site extraction (NSSE) and compared by body mass index (BMI), age, comorbidities, American Society of Anesthesiologists score, length of stay, estimated blood loss, parastomal complications, and hernia rate. RESULTS: The parastomal hernia rate was 10.1% for the SSE group (n = 14) and 4.2% for the NSSE group (n = 25) (p = 0.007). The need for additional surgeries was 7/139 (5.0%) for the SSE group and 27/599 (4.5%) for the NSSE group (p = 0.79). There was no difference in the hernia rate after stoma closure in either group. There was no difference in single incision laparoscopic surgery versus conventional laparoscopy or robotic-assisted laparoscopy on stoma site complications in patients with SSE. SSE, transfusion, and BMI >30 were found to be independent factors associated with increased stoma site complications. CONCLUSION: SSE does increase stoma site complications. SSE should be used with caution, or in conjunction with other techniques to reduce hernias in patients requiring a permanent stoma or with an elevated BMI. The increase in stoma site complications does not translate into additional surgeries or postoperative sequelae following stoma reversal and is a reasonable option in patients requiring a temporary stoma.

Characteristics of learning curve in minimally invasive ileal pouch-anal anastomosis in a single institution.

BACKGROUND: Previous work from our institution has characterized the learning curve for open ileal pouch-anal anastomosis (IPAA). The purpose of the present study was to assess the learning curve of minimally invasive IPAA. METHODS: Perioperative outcomes of 372 minimally invasive IPAA by 20 surgeons (10 high-volume vs. 10 low-volume surgeons) during 2002-2013, included in a prospectively maintained database, were assessed. Predicted outcome models were constructed using perioperative variables selected by stepwise logistic regression, using Akaike's information criterion. Cumulative sums (CUSUM) of differences between observed and predicted outcomes were graphed over time to identify possible improvement patterns. RESULTS: Institutional pelvic sepsis and other pouch morbidity rates (hemorrhage, anastomotic separation, pouch failure, fistula) significantly decreased (18.2 vs. 7.0 %, CUSUM peak after 143 cases, p = 0.001; 18.4 vs. 5.3 %, CUSUM peak after 239 cases, respectively, p < 0.001). Institutional total proctocolectomy mean operative times significantly decreased (307 min vs. 253 min, CUSUM peak after 84 cases, p < 0.001), unlike completion proctectomy (p = 0.093) or conversion rates (10 vs. 5.4 %, p = 0.235). Similar learning curves were identified among high-volume surgeons but not among low-volume surgeons. Learning curves were identified in the two busiest individual surgeons for pelvic sepsis (peaks at 47 and 9 cases, p = 0.045 and p = 0.002) and in one surgeon for operative times (CUSUM peak after 16 and 13 cases for both total proctocolectomy and completion proctectomy (p < 0.001 and p = 0.006) but not for other pouch complications (peak at 49 and 41 cases, p = 0.199 and p = 0.094). CONCLUSION: Pouch complications, particularly pelvic sepsis, are the most consistent and relevant learning curve end points in laparoscopic IPAA.

Impact of the Specific Extraction-Site Location on the Risk of Incisional Hernia After Laparoscopic Colorectal Resection.

BACKGROUND: The impact of the specific incision used for specimen extraction during laparoscopic colorectal surgery on incisional hernia rates relative to other contributing factors remains unclear. OBJECTIVE: This study aimed to assess the relationship between extraction-site location and incisional hernia after laparoscopic colorectal surgery. DESIGN: This was a retrospective cohort study (January 2000 through December 2011). SETTINGS: The study was conducted at a high-volume, specialized colorectal surgery department. PATIENTS: All of the patients undergoing elective laparoscopic colorectal resection were identified from our prospectively maintained institutional database. MAIN OUTCOME MEASURES: Extraction-site and port-site incisional hernias clinically detected by physician or detected on CT scan were collected. Converted cases, defined as the use of a midline incision to perform the operation, were kept in the intent-to-treat analysis. Specific extraction-site groups were compared, and other relevant factors associated with incisional hernia rates were also evaluated with univariate and multivariate analyses. RESULTS: A total of 2148 patients (54.0% with abdominal and 46.0% with pelvic operations) with a mean age of 51.7 ± 18.2 years (52% women) were reviewed. Used extraction sites were infraumbilical midline (23.7%), stoma site/right or left lower quadrant (15%), periumbilical midline (22.5%), and Pfannenstiel (29.6%) and midline converted (9.2%). Overall crude extraction site incisional hernia rate during a mean follow-up of 5.9 ± 3.0 years was 7.2% (n = 155). Extraction-site incisional hernia crude rates were highest after periumbilical midline (12.6%) and a midline incision used for conversion to open surgery (12.0%). Independent factors associated with extraction-site incisional hernia were any extraction sites compared with Pfannenstiel (periumbilical midline HR = 12.7; midline converted HR = 13.1; stoma site HR = 28.4; p < 0.001 for each), increased BMI (HR = 1.23; p = 0.002), synchronous port-site hernias (HR = 3.66; p < 0.001), and postoperative superficial surgical-site infection (HR = 2.11; p < 0.001). LIMITATIONS: This study was limited by its retrospective nature, incisional hernia diagnoses based on clinical examination, and heterogeneous surgical population. CONCLUSIONS: Preferential extraction sites to minimize incisional hernia rates should be Pfannenstiel or incisions off the midline. Midline incisions should be avoided when possible.

Is there anything we can modify among factors associated with morbidity following elective laparoscopic sigmoidectomy for diverticulitis?

BACKGROUND: Laparoscopic sigmoidectomy for diverticulitis is widely accepted, using either endolinear staplers or traditional linear staplers under direct vision through the extraction site to transect the rectum. The aim of this study was to assess modifiable factors affecting perioperative morbidity after elective laparoscopic sigmoidectomy for diverticulitis. METHODS: Potential associations between perioperative morbidity and demographic, disease-related, and treatment-related factors were assessed on all consecutive patients included in a prospectively collected database undergoing elective laparoscopic sigmoidectomy for diverticulitis between 1992 and 2013. Rectal transection with a linear stapler under direct vision through the extraction site was considered compatible with laparoscopic technique. RESULTS: There were two deaths out of 1059 patients (0.19 %). Conversion rate was 13.1 %, overall morbidity 28 %, and anastomotic leak 3.7 %. Independent factors associated with morbidity in an intent-to-treat analysis were ASA 3 (OR 1.53, p = 0.006), conversion (OR 1.71, p = 0.015), and rectal transection without endolinear stapling (traditional linear stapler: OR 1.75, p = 0.003; surgical knife: OR 2.09, p = 0.002). The same factors along with complicated diverticulitis (OR 1.56, p = 0.013) were independently associated with overall morbidity among laparoscopically completed cases. BMI ≥ 35 (OR 2.3, p = 0.017), complicated diverticulitis (OR 2.37, p = 0.002), and rectal transection with a traditional linear stapler (OR 2.19, p = 0.018) were independently associated with abdomino-pelvic infections, both in an intent-to-treat analysis and among laparoscopically completed cases. The number of endolinear stapler firings was not associated with morbidity. CONCLUSIONS: Most factors associated with morbidity of laparoscopic sigmoidectomy for diverticulitis cannot be easily modified. With the limitation of a retrospective analysis, modifiable factors to minimize morbidity are laparoscopic completion and endolinear stapling.

Impact of tumor location on lymph node metastasis in T1 colorectal cancer.

PURPOSE: Data evaluating the risk of lymph node metastasis depending upon the location of the primary tumor are limited in patients with T1 colorectal cancer. We aimed to evaluate the impact of tumor location on lymph node metastasis in T1 colorectal cancer. METHODS: Patients who underwent an oncologic resection with curative intent for T1 adenocarcinoma of the colon and rectum between January 1997 and October 2014 were assessed. Exclusion criteria were distant organ metastases, previous or concurrent cancer, past history of surgical or medical cancer treatment, preoperative chemoradiation, and patients with inflammatory bowel disease or polyposis syndromes. RESULTS: Out of 232 (56 % male) patients fulfilling the study criteria, 24 (10 %) had lymph node metastasis. Age (65 vs 61 years, p = 0.1), gender (55 vs 63 % male, p = 0.5), tumor size (2 vs 2 cm, p = 0.49), and lymphovascular invasion (5 vs 8 %, p = 0.46) were not associated with lymph node metastasis. While there was no statistical significance (p = 0.2), lymph node positivity was higher in rectal cancer (14 %, n = 11/79) compared to colon cancer (9 %, n = 13/153). CONCLUSIONS: Although it was not statistically significant, lymph node positivity varies based on tumor location of T1 colorectal adenocarcinoma regardless of fundamental tumor characteristics including size, differentiation, and lymphovascular invasion.

Laparoscopic IPAA is not associated with decreased rates of incisional hernia and small-bowel obstruction when compared with open technique: long-term follow-up of a case-matched study.

BACKGROUND: There are scant data on the presumed reduction of small-bowel obstruction and incisional hernia rates associated with laparoscopic IPAA. OBJECTIVE: The aim of this study was to compare long-term outcomes after open vs laparoscopic IPAA based on a previous study from our institution. DESIGN: This was a retrospective cohort study (from January 1992 through December 2007). SETTINGS: The study was conducted in a high-volume, specialized colorectal surgery department. PATIENTS: Patients included those who were enrolled in a previous institutional case-matched (2:1) study that examined 238 open and 119 laparoscopic IPAAs. MAIN OUTCOME MEASURES: Long-term complications, including incisional hernia clinically detected by physician, adhesive small-bowel obstruction requiring hospital admission and surgery, pouch excision, and pouchitis rates, were collected. Laparoscopic abdominal colectomy followed by rectal dissection under direct vision (lower midline or Pfannenstiel incision) and converted cases were analyzed within the laparoscopic group. RESULTS: Groups were comparable with respect to age, sex, BMI, and extent of resection (completion proctectomy vs proctocolectomy), consistent with the original case matching. Mean follow-up was significantly longer in the open group (9.6 vs 8.1 years; p = 0.008). Open and laparoscopic operations were associated with similar incidences of incisional hernia (8.4% vs 5.9%; p = 0.40), small-bowel obstruction requiring hospital admission (26.1% vs 29.4%; p = 0.50), and small-bowel obstruction requiring surgery (8.4% vs 11.8%; p = 0.31). A subgroup analysis comparing 50 patients with laparoscopic rectal dissection versus 69 patients with rectal dissection under direct vision confirmed statistically similar incidences of incisional hernia, hospital admission, and surgery for small-bowel obstruction. LIMITATIONS: This study was limited by its retrospective nature. CONCLUSIONS: Some of the anticipated long-term benefits of laparoscopic IPAA could not be demonstrated in this cohort. The lack of such long-term benefits should be discussed with patients when proposing a laparoscopic approach.

Does laparoscopy reduce splenic injuries during colorectal resections? An assessment from the ACS-NSQIP database.

BACKGROUND: Nearly half of all incidental splenectomies caused by iatrogenic splenic injury occur during colorectal surgery. This study evaluates factors associated with incidental splenic procedures during colorectal surgery and their impact on short-term outcomes using a nationwide database. METHODS: Patients who underwent colorectal resections between 2005 and 2012 were identified from the American College of Surgeons National Surgical Quality Improvement Program database according to Current Procedural Terminology codes. Patients were classified into two groups based on whether they underwent a concurrent incidental splenic procedure at the time of the colorectal procedure. All splenic procedures except a preoperatively intended splenectomy performed in conjunction with colon or rectal resections were considered as incidental. Perioperative and short-term (30 day) outcomes were compared between the groups. RESULTS: In total, 93633 patients who underwent colon and/or rectal resection were identified. Among these, 215 patients had incidental splenic procedures (153 open splenectomy, 17 laparoscopic splenectomy, 36 splenorraphy, and 9 partial splenectomy). Open colorectal resections were associated with a significantly increased likelihood of incidental splenic procedures (OR 6.58, p < 0.001) compared to laparoscopic surgery. Incidental splenic procedures were associated with increased length of total hospital stay (OR 1.25, p < 0.001), mechanical ventilation dependency (OR 1.62, p = 0.02), transfusion requirement (OR: 3.84, p < 0.001), re-operation requirement (OR 1.7, p = 0.005), and sepsis (OR: 2.03, p = 0.001). Short-term advantages of splenic salvage (splenorraphy or partial splenectomy) included shorter length of total hospital stay (p = 0.001) and decreased need for re-operation (p < 0.001). CONCLUSIONS: Incidental splenic procedures during colorectal resections are associated with worse short-term outcomes. Use of the laparoscopic technique decreases the need for incidental splenic procedures.

Impact of previous midline laparotomy on the outcomes of laparoscopic intestinal resections: a case-matched study.

The effectiveness of laparoscopic intestinal resection in patients with previous midline laparotomy (PML) is controversial. The aim of this study was to assess the feasibility of laparoscopic surgery and identify possible factors associated with postoperative outcomes in patients with PML. Patients with PML (at least an infraumbilical incision or longer) undergoing elective laparoscopic intestinal resection between 1997 and 2011 were case matched with patients without PML undergoing laparoscopic surgery based on age, gender, body mass index, ASA score, surgical procedure, and diagnosis. Fifty patients with PML undergoing laparoscopic intestinal resection were well matched to 50 counterparts. Conversion to open surgery (n = 8 vs. n = 4, p = 0.22), operating time (211 vs. 192 min, p = 0.22), and estimated blood loss (158 vs. 184 ml, p = 0.95) were similar between the groups. Intraabdominal adhesions (either disease related or from previous operations) were significantly more common in patients with PML (n = 24 vs. n = 11, p = 0.01). Intraoperative complications included inadvertent enterotomy and hemorrhage and were comparable between the groups (n = 1 vs. n = 0, p = 1 and n = 1 vs. n = 2, p = 1 for PML vs. no PML, respectively). One patient without PML died postoperatively from aspiration pneumonia. Overall morbidity (n = 26 vs. n = 10, p = 0.001) and particularly postoperative ileus (n = 10 vs. n = 3, p = 0.04) were significantly increased in the PML group when compared to laparoscopy without PML, unlike the respective differences in postoperative return of bowel function (4 vs. 3 days, p = 0.15), reoperations (n = 5 vs. n = 3, p = 0.72), length of hospital stay (9 vs. 6 days, p = 0.09), and readmissions (n = 5 vs. n = 4, p = 0.73). Intestinal resections in patients with PML can be frequently completed laparoscopically but are associated with worse postoperative outcomes when compared to laparoscopy on a virgin abdomen.

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/m(2)) 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.

Transanal endoscopic surgery using a single access port: a practical tool in the surgeon's toybox.

BACKGROUND: Large polyps and early carcinomas of the rectum may be excised with transanal endoscopic surgery (TES). Single-port techniques are emerging in the field of colorectal surgery and have been adapted to many colorectal procedures so far. In this article, we aimed to present our initial experience with TES using a single access port with its technical details. PATIENTS AND METHODS: Patients undergoing TES using a single access port between July 2010 and January 2013 were included in the study. Patient demographics, operative technique, and both operative and postoperative outcomes were evaluated and presented. RESULTS: A total of 12 patients (ten males) were included in our study. The median age was 63.5 years (50-84), median American Society of Anesthesiologists (ASA) score was 3 (2-4), and median body mass index was 28.8 kg/m(2) (17.4-55.6). Median operating time was 79 min (43-261). Histopathological diagnoses were as follows: tubulovillous adenoma (n = 6), tubular adenoma (n = 4), adenocarcinoma (n = 1), and neuroendocrine tumor (n = 1). Five patients were sent home on the day of surgery and the median postoperative hospital stay was 1 day (0-38). Median estimated blood loss was 22.5 ml (5-150). A transient urinary retention was developed in one patient postoperatively, and two patients had postoperative bleeding. The first of these patients with a long history of anticoagulant usage had rectal bleeding 13 days after surgery, which was successfully managed with medical treatment. The second patient was morbidly obese, had multiple comorbidities, and had rectal bleeding on postoperative day 7 which was managed with local epinephrine injection. He suffered unrelated cardiac death on postoperative day 38. CONCLUSIONS: TES is safe and feasible when using a single port and in the standard laparoscopic setting. The single-port technique may play a major role in the widespread utilization of TES as a treatment for large adenomas and early rectal cancers.

Impact of stress dose steroids on the outcomes of restorative proctocolectomy in patients with ulcerative colitis.

BACKGROUND: Stress dose steroids are administered during the perioperative period to prevent complications of secondary hypoadrenalism, which can occur after long-term steroid treatment. Steroids also increase postoperative morbidity. Patients with ulcerative colitis often require steroid therapy before definitive surgery and often receive perioperative steroids in a variety of doses. OBJECTIVE: The aim of this study was to evaluate the impact of stress dose steroid administration on short-term postoperative outcomes after restorative proctocolectomy in patients with ulcerative colitis. DESIGN: This was a retrospective cohort study. SETTING: The investigation took place in a high-volume, specialized colorectal surgery department. PATIENTS: Patients who had been treated with steroids for ulcerative colitis and underwent a restorative proctocolectomy from January 2009 to July 2011 were identified and categorized into 2 groups based on whether they received stress dose steroids. MAIN OUTCOME MEASURES: Both cohorts were compared for patient demographics, duration of steroid treatment before surgery, and operative and postoperative outcomes. RESULTS: Eighty-nine patients received stress dose steroids and 146 patients did not. Stress dose steroids were more frequently administered to patients who were under steroid treatment immediately before restorative proctocolectomy (37.1% versus 10.3%; p < 0.001). A sinus tachycardia developed more frequently in patients who received stress dose steroids during surgery (p = 0.03). One patient in the stress dose steroid group died on postoperative day 25 because of anastomotic leak. Although no patients in either group had an adrenal crisis during surgery, 1 patient in the stress dose steroid group was diagnosed with adrenal insufficiency postoperatively. LIMITATIONS: This study was limited by its retrospective and nonrandomized nature. CONCLUSIONS: Although administration of stress dose steroids is not related to increased postoperative complications, the steroids do not appear to affect adrenal insufficiency outcomes. Patients who were treated with steroids for ulcerative colitis should be monitored carefully in the perioperative and early postoperative periods for signs of adrenal insufficiency, regardless of the steroid regimen used.

Reduced port versus conventional laparoscopic total proctocolectomy and ileal J pouch-anal anastomosis.

BACKGROUND: The feasibility and safety of single-incision laparoscopic total proctocolectomy (TPC) and ileal pouch anal anastomosis (IPAA) were first reported in 2010. To improve accuracy and efficiency while maintaining the cosmetic advantages of single-incision laparoscopic surgery, we have since modified the technique to include the use of a 5-mm instrument placed through the eventual drain site. The aim of this study is to compare reduced port laparoscopic (RPL) IPAA with conventional laparoscopic IPAA with respect to short-term outcomes to assess safety. METHODS: RPL cases were matched to conventional laparoscopy cases for patient age (±5 years), body mass index, gender, diagnosis, type and number of stages of surgical procedure, American Society of Anesthesiologists (ASA) classification, and year of surgery (±3 years). Groups were compared using χ(2) or Fisher exact tests for categorical and Wilcoxon rank-sum test for quantitative data. RESULTS: Twenty-four RPL patients were case-matched to an equal number of patients who underwent conventional laparoscopic IPAA. Short-term outcomes including postoperative complications, length of hospital stay, and time to first bowel movement were similar between groups. Despite similar diagnosis, previous surgery, and comorbidity, operative blood loss (p < 0.001) and operating time (p = 0.02) were lower for the RPL group. CONCLUSION: RPL IPAA can be safely performed with short-term outcomes comparable to conventional laparoscopy.

Malfunction and failure of robotic systems during general surgical procedures.

BACKGROUND: There has been recent interest in using robots for general surgical procedures. This shift in technique raises the issue of patient safety with automated instrumentation. Although the safety of robotics has been established for urologic procedures, there are scant data on its use in general surgical procedures. The aim of this study is to analyze the incidence of robotic malfunction and its consequences for general surgical procedures. METHODS: All robotic general surgical procedures performed at a tertiary center between 2008 and 2011 were reviewed from institutional review board (IRB)-approved prospective databases. RESULTS: A total of 223 cases were done robotically, including 102 endocrine, 83 hepatopancreaticobiliary, 17 upper gastrointestinal, and 21 lower gastrointestinal colorectal procedures. There were 10 cases of robotic malfunction (4.5%). These failures were related to robotic instruments (n = 4), optical system (n = 3), robotic arms (n = 2), and robotic console (n = 1). None of these failures led to adverse patient consequences or conversion to open. Six (2.7%) cases were converted to open due to bleeding (n = 3), difficult dissection plane (n = 1), invasion of tumor to surrounding structures (n = 1), and intolerance of pneumoperitoneum due to CO(2) retention (n = 1). There was no mortality, and morbidity was 1% (n = 2). CONCLUSION: To our knowledge, this is the largest North American report to date on robotic general surgical procedures. Our results show that robotic malfunction occurs in a minority of cases, with no adverse consequences. We believe that awareness of these failures and knowing how to troubleshoot are important to maintain the efficiency of these procedures.

Mucosal serotonin signaling is altered in chronic constipation but not in opiate-induced constipation.

OBJECTIVES: Changes in mucosal serotonin (5-HT) signaling have been detected in a number of functional and inflammatory disorders of the gastrointestinal (GI) tract. This study was undertaken to determine whether chronic constipation (CC) is associated with disordered 5-HT signaling and to evaluate whether constipation caused by opiate use causes such changes. METHODS: Human rectal biopsy samples were obtained from healthy volunteers, individuals with idiopathic CC, and individuals taking opiate medication with or without occurrence of constipation. EC cells were identified by 5-HT immunohistochemistry. 5-HT content and release levels were determined by enzyme immunoassay, and mRNA levels for the synthetic enzyme tryptophan hydroxylase-1 (TpH-1) and serotonin-selective reuptake transporter (SERT) were assessed by quantitative real-time reverse transcription PCR. RESULTS: CC was associated with increases in TpH-1 transcript, 5-HT content, and 5-HT release under basal and stimulated conditions, whereas EC cell numbers and SERT transcript levels were not altered. No changes in these elements of 5-HT signaling were detected in opiate-induced constipation (OIC). CONCLUSIONS: These findings demonstrate that CC is associated with a pattern of altered 5-HT signaling that leads to increased 5-HT availability but does not involve a decrease in SERT expression. It is possible that increased 5-HT availability due to increased synthesis and release contributes to constipation due to receptor desensitization. Furthermore, the finding that elements of 5-HT signaling were not altered in the mucosa of individuals with OIC indicates that constipation as a condition does not lead to compensatory changes in 5-HT synthesis, release, or signal termination.

Outcome Comparison of Single-port Versus Multiport Versus Under Direct View Completion Proctectomy With Ileal-Pouch Anal Anastomosis for Patients With Ulcerative Colitis.

PURPOSE: Whether the reported theoretical benefits of single-port laparoscopic (SPL) approach can be converted to superior clinical outcomes is still unknown for ulcerative colitis (UC) patients undergoing second-stage proctectomy. This study aimed to compare the short-term postoperative and long-term pouch-related functional outcomes of SPL, multiport laparoscopic (MPL), and direct view (DV) completion proctectomy with ileal-pouch anal anastomosis (CP/IPAA). MATERIALS AND METHODS: Patients who underwent either SPL, MPL, or under DV CP/IPAA for UC between August 2009 and August 2014 were identified from an institutional review board-approved, prospectively maintained institutional database and reviewed. Demographics, patient characteristics, short-term and long-term complications, and morbidity were compared between the 3 groups. Multivariate logistic or Cox regression analysis was conducted for covariate adjustments. RESULTS: Groups (SPL: n=36; MPL: n=67; DV: n=97) were comparable in terms of preoperative characteristics and demographics except for age. The SPL group was associated with reduced estimated blood loss, reduced length of stay compared with the MPL and DV groups, and shorter operating time compared with the MPL group (P<0.001). Similar short-term postoperative and long-term pouch-related functional outcomes were noted without significant differences in quality of life scores among the 3 groups. CONCLUSIONS: SPL CP/IPAA for UC can be safely performed with superior short-term outcomes such as reduced intraoperative blood loss and length of hospital stay compared with MPL and under direct view approaches, and shorter operating time compared with MPL.