Role of single-ring oval disposable wound protecting device in preventing surgical site infection in laparoscopic colorectal resections.

CONTEXT: Surgical site infections (SSI) continue to be a major cause of morbidity, mortality, prolonged hospital stays and a major reason of financial burden to health-care providers and patients after major abdominal surgeries. Along with infection control practices and care bundles, additional use of devices which protect the wound from contamination is believed to decrease the burden of SSI. AIMS: This study aims to assess the benefit of single-ring disposable wound protector in preventing SSI, overall complications, hospitals stay and morbidity data in laparoscopic colorectal resection. SETTINGS AND DESIGN: The study design involves case-control study, retrospective. SUBJECTS AND METHODS: A case-control study comparing single ring oval wound protector versus conventional wound protectors retrospectively between August 2019 and December 2021. The ease of use of the device, rate of SSI, overall complications, hospitals stay and morbidity data were analysed. STATISTICAL ANALYSIS USED: The statistical analysis was performed by IBM SPSS Statistics 20 version. All Categorical Variables will be described as frequency and percentage. Continuous variables will be described as mean ± standard deviation. Continuous variables were analysed using t-test and categorical parameters using Fisher's exact test. RESULTS: Of the 110 patients studied, wound Protecting devices were used in 58 patients Wound Protector Group (WPG group) and 62 patients did not use such devices (no WPG). The groups were comparable in demographic features, risk features, systemic illness, type of surgeries undertaken and the specimen extraction wound used. There was a significant decrease in the incidence of SSI (1.7% vs. 16% P ≤ 0.008) and the hospital stay (P ≤ 0.03) when WPG was used compared to the group in which it was not used. CONCLUSIONS: Apart from the use of infection control practices and care bundles, the use of oval-shaped single-ring wound protector is likely to reduce SSI.

Voluntary perioperative colorectal cancer registry from Kerala-An initial overview.

BACKGROUND: Although colorectal cancer (CRC) may not be uncommon in India, accurate data regarding its demographics and surgical outcomes is sparse. METHODS: With an aim to assess demographics and perioperative outcomes of CRC in Kerala, all members of Association of Surgical Gastroenterologists of Kerala (ASGK) were invited to participate in a registry. Data of operated cases of CRC were entered on a web-based questionnaire by participating members from January 2016. Analysis of accrued data until March 2018 was performed. RESULTS: From 25 gastrointestinal surgical centers in Kerala, 15 ASGK member hospitals contributed 1018 CRC cases to the database (M:F 621:397; median age-63.5 years [15-95 years]). Rectum (39.88%) and rectosigmoid (20.33%) cancers comprised the majority of the patients. Among them, preoperative bowel preparation was given to 37.68%, minimally invasive surgery (MIS) was performed in 73%, covering stoma in 47% and had an overall leak rate of 3.58%. In colonic malignancies, MIS was performed in 56.74%, covering stoma created in 13% and had a leak rate of 2.71%. Of 406 patients with rectal cancers, neo-adjuvant radiotherapy/chemoradiotherapy was given to 51.23%. The mean hospital stay for MIS in both rectal and colonic cancer patients was significantly shorter than open approach (10.46 ± 5.08 vs. 12.26 ± 6.03 days; p = 0.001and 10.29 ± 4.58 vs. 12.46 ± 6.014 days; p = <0.001). Mortality occurred in 2.2% patients. CONCLUSION: A voluntary non-funded registry for CRC surgery was successfully created. Initial data suggest that MIS was performed in majority, which was associated with shorter hospital stay than open approach. Overall mortality and leak rate appeared to be low.

Oncological adequacy of laparoscopic rectal cancer resection: An audit in Indian perspective.

BACKGROUND: Laparoscopic resection for rectal cancer (LRR) has gained popularity because of better short-term outcomes and less post-operative morbidity. However, LRR is still not endorsed as a standard of care mainly due to concerns centred on oncological safety in comparison with open approach. Moreover, two recent randomised trials (Australian Laparoscopic Cancer of the Rectum [ALaCaRT] and the American College of Surgeons Oncology Group [ACOSOG] Z6051) have failed to prove that LRR is non-inferior to open resection. Studies on oncological adequacy of LRR in the Indian population in terms of quality of mesorectal excision are scarce. In this article, we aim to audit the oncological adequacy of LRR in our centre and thereby critically analyse the reliability of extrapolation of results of ALaCaRT and ACOSOG trials to the Indian population. METHODS: We retrospectively analysed the oncological adequacy of LRR in terms of completeness of total mesorectal excision (TME), distal and circumferential resection margin (CRM) status and nodal harvest in patients with rectal cancer who underwent LRR between January 2016 and June 2018 at our centre. RESULTS: Of 157 patients included in this study, a complete TME was achieved in 148 (94.26%) patients and nearly complete in 7 (4.46%) patients. A safe CRM (≥1 mm) was obtained in 151 (96.18%) patients. Distal margin results were negative in 155 (98.73%) patients. Average nodal harvest was 19.86 ± 9.28. Overall surgical success, calculated as a composite measure of negative distal margin and negative CRM and complete TME was 95.54%. CONCLUSION: Good quality rectal cancer resection can be achieved by experienced laparoscopic surgeons without compromising oncological safety.

Exploring minimally invasive options: Laparoscopic transabdominal levator transection for low rectal cancers.

Extralevator abdominoperineal excision (ELAPE) of the rectum offers wider circumferential margin and decreased rate of intraoperative tumour perforation. However, the need to change the position of the patient in between abdominal and perineal stages of the procedure and extended perineal resection result in increased morbidity and operative time. Evolving technique of laparoscopic transabdominal controlled division of levator ani muscles under direct vision could address these issues while providing all benefits of ELAPE for patients with low rectal cancers.

Sexual and urinary dysfunction following laparoscopic total mesorectal excision in male patients: A prospective study.

AIMS: Even with the use of nerve-sparing techniques, there is a risk of bladder and sexual dysfunction after total mesorectal excision (TME). Laparoscopic TME is believed to improve this autonomic nerve dysfunction, but this is not demonstrated conclusively in the literature. In Indian patients generally, the stage at which the patients present is late and presumably the risk of autonomic nerve injury is more; however, there is no published data in this respect. MATERIALS AND METHODS: This prospective study in male patients who underwent laparoscopic TME evaluated the bladder and sexual dysfunction using objective standardised scores, measuring residual urine and post-voided volume. The International Prostatic Symptom Score (IPSS) and International Index of Erectile Function score were used respectively to assess the bladder and sexual dysfunction preoperatively at 1, 3, 6 months and at 1 year. RESULTS: Mean age of the study group was 58 years. After laparoscopic TME in male patients, the moderate to severe bladder dysfunction (IPSS <8) is observed in 20.4% of patients at 3 months, and at mean follow-up of 9.2 months, it was seen only in 2.9%. There is more bladder and sexual dysfunction in low rectal tumours compared to mid-rectal tumours. At 3 months, 75% had sexual dysfunction, 55% at median follow-up of the group at 9.2 months. CONCLUSION: After laparoscopic TME, bladder dysfunction is seen in one-fifth of the patients, which recovers in the next 6 months to 1 year. Sexual dysfunction is observed in 75% of patients immediately after TME which improves to 55% over 9.2 months.

Laparoscopic Management of Colonic Diverticular Disease and its Complications: an Analysis.

Dense inflammatory reactions, loss of tissue planes and sepsis make surgical treatment of diverticulitis complex and difficult. Experience with laparoscopic management of this disease is scanty in our country. This study aims to assess the pattern of presentation, the site of involvement and complications of diverticulitis coli. This study also aims to audit the results of laparoscopic approach for complicated colonic diverticulitis. A retrospective analysis of all patients who had laparoscopic management of complicated diverticulitis patients from August 2007 to October 2014 was done from the database. The site of involvement, extent and presence or absence of complications of diverticular disease was noted. The surgical approach, intraoperative parameters and short-term outcome measures were analysed. There were 38 (8.8 %) patients with diverticular disease out of 427 patients who had laparoscopic colorectal surgery in the study period with a median age of 59 years. Out of 38 patients, 50 % had comorbid conditions. Internal fistulae were seen in 9 (23.6 %) patients, 6 with colovesical and 3 with colovaginal fistulae. Elective laparoscopic colectomy with primary anastomosis was done in 34 (89 %) cases of which, and 10 (26 %) patients had abscess on presentation requiring drainage. Four patients required emergency laparoscopic surgery of which primary resection and anastomosis was done in 3 (7.8 %), and Hartmann's operation was done in 1 (2.6 %) patient. Two patients required stoma. The morbidity was seen in 15 % cases, and the mean hospital stay was 9.54 days. Laparoscopic approach for diverticular disease and its complication is feasible and safe. Careful selection of patients, judicious use of diverting stoma and appropriate selection of the procedure help to achieve good results even in those with septic complications and fistulising disease.

Octreotide Does Not Prevent Pancreatic Fistula Following Pancreatoduodenectomy in Patients with Soft Pancreas and Non-dilated Duct: A Prospective Randomized Controlled Trial.

BACKGROUND: Whether octreotide prevents pancreatic fistula following pancreatoduodenectomy is controversial and it is believed to be beneficial in soft glands and normal-sized ducts. The aim of this study is to assess the potential value of octreotide in reducing the incidence of pancreatic fistula, postoperative complications, morbidity and hospital stay in patients with soft pancreas and non-dilated ducts. METHODS: A total of 109 patients undergoing elective pancreatoduodenectomy with soft pancreas and non-dilated duct were randomized to octreotide group versus no octreotide-the control group. Surgical steps were standardized and incidences of pancreatic fistula, complications, death and hospital stay were assessed. RESULTS: There were 55 patients in octreotide group and 54 in the control group. Demographic features and pancreatic duct diameter of the groups were comparable. The rates of clinically significant pancreatic fistulae (grades B and C) were 10.9 and 18.5 % (p = ns), and morbidity was 18 and 29.6 % (p = ns), respectively. Patients who received octreotide resumed oral diet early and had a shorter hospital stay. CONCLUSION: This study demonstrated no statistical difference in pancreatic fistulae with the use of octreotide, though there was a trend towards fewer incidences of pancreatic fistulae, morbidity and shorter hospital stay. ClinicalTrials.gov Identifier: NCT01301222.

Outcome of pancreatic ascites in patients with tropical calcific pancreatitis managed using a uniform treatment protocol.

Pancreatic ascites or internal pancreatic fistula is a known complication of chronic pancreatitis. This condition is associated with considerable morbidity and mortality. The management approach of pancreatic ascites in tropical calcific pancreatitis is infrequently reported owing to the low incidence of this condition. Between December 2005 and June 2007, 11 patients with pancreatic ascites with tropical calcific pancreatitis (male:female 7:4, mean age 29.5 [14.2] years) were treated. A retrospective analysis of patients who underwent endotherapy and surgery for this condition based on an institutional protocol was performed. The end point was resolution of pancreatic ascites and relief of symptoms. All patients had pancreatic ascites, and one patient also had pancreatic pleural effusion. Endoscopic transpapillary stenting was possible in nine patients (81%). Identification of site of leak and placement of an endoscopic stent across the PD disruption was possible in five (45%) patients. All these patients had relief of ascites. Mean number of endotherapy sessions required before control of ascites was 1.8. Among the remaining four (36.6%) patients who had ERCP, placement of stent across the leak was unsuccessful; however stenting helped stabilize the general condition and nutritional status. These four patients and two patients who failed ERP underwent lateral pancreatojejunostomy surgery. Morbidity was observed in three patients who underwent surgery and one patient died due to sepsis and hemorrhage. All patients who had surgical drainage had complete relief of ascites and symptoms. In patients with pancreatic ascites in tropical calcific pancreatitis endotherapy and transpapillary stenting helps in resolution of ascites in nearly half of the patients. In the remaining patients preliminary conservative management followed by surgical pancreatic ductal drainage provides good relief of symptoms.